Physiological Effects of a Spit Restraint Device Saturated With Artificial Saliva.

BACKGROUND: Spit restraint devices, also referred to as spit hoods, spit masks, or spit socks, are used by law enforcement and medical personnel to minimize transmission of communicable disease from bodily fluids from agitated individuals. Several lawsuits have implicated spit restraint devices as contributing to the death of individuals who are physically restrained by means of asphyxiation due to saturation of the mesh restraint device with saliva. OBJECTIVES: This study aims to evaluate whether a saturated spit restraint device has any clinically significant effects on the ventilatory or circulatory parameters of healthy adult subjects. METHODS: Subjects wore a spit restraint device dampened with 0.5% carboxymethylcellulose, an artificial saliva. Baseline vitals were taken, and a wet spit restraint device was then placed over the subject's head, and repeat measurements were taken at 10, 20, 30, and 45 min. A second spit restraint device was placed 15 min after the first. Measurements at 10, 20, 30, and 45 min were compared with baseline using paired t-tests. RESULTS: The mean age of 10 subjects was 33.8 years, and 50% were female. There was no significant difference between baseline and while wearing the spit sock for 10, 20, 30, and 45 min for the measured parameters including heart rate, oxygen saturation, end-tidal CO2, respiratory rate, or blood pressure. No subject indicated respiratory distress or had to terminate the study. CONCLUSIONS: In healthy adult subjects, there were no statistically or clinically significant differences in ventilatory or circulatory parameters while wearing the saturated spit restraint.

Frequency and Outcomes of Cervical Spine Computed Tomography Imaging on Alcohol-Intoxicated Patients in the Emergency Department.

BACKGROUND: Cervical spinal (c-spine) injuries range greatly in severity from minor ligamentous injuries to osteoligamentous instability with spinal cord injuries. Initial evaluation begins with stabilization as needed and immediate immobilization. Current practice as to whether the c-spine can be cleared clinically without radiographic evaluation is often guided by using the National Emergency X-Radiography Utilization Study Low-Risk Criteria and the Canadian C-Spine Rule. Under these clinical decision guidelines, stable trauma patients presenting with alcohol intoxication cannot have the c-spine cleared clinically and imaging should be "considered." OBJECTIVE: This study aimed to assess the frequency of computed tomography (CT) c-spine scans ordered for patients presenting with alcohol intoxication to the emergency department (ED), the timing of the studies, and subsequently determine the proportion of which showed a clinically significant result that required intervention. METHODS: In this retrospective medical record review, all clinically alcohol-intoxicated patients presenting to two academic EDs were included. Overall demographic characteristics, time to order of CT imaging, radiology reads, and outcomes of patient visits were determined. RESULTS: There were 8008 patient visits included in the study. Of these visits, 5 patients scanned in ≤3 h had acute findings on CT scan and no patients with a deferred timing of CT scan after patients metabolized had an acute finding on CT scan. No patients required operative management. CONCLUSIONS: This study's results suggest that it is a safe clinical practice to defer CT imaging for patients presenting to the ED with alcohol intoxication and low suspicion for c-spine injury per history and examination.

Perinatal Carbon Monoxide Poisoning: Treatment of a 2-Hour-Old Neonate with Hyperbaric Oxygen.

A 41-year-old gravida 4 para 3 (G4P3) and 38 5/7 weeks pregnant woman presented to labor and delivery with dizziness, headache, and decreased fetal movement after 12 hours of exposure to carbon monoxide (CO) from a grill that was used inside for heat. The mother was hemodynamically stable, and her neurologic examination was intact. Her carboxyhemoglobin level, which was obtained 12 hours after removal from the CO exposure, was 7.4%. The fetus's heart rate was 173 beats per minute with moderate variability and one late appearing deceleration, not associated with contractions. The biophysical profile score was 2 of 8. The obstetrics team performed a routine cesarean section. The 1- and 5-minute Apgar's scores were 7 and 8, respectively. The arterial cord gas result was as follows: pH = 7.05, PCO 2 = 71 mm Hg, pO 2 = 19 mm Hg, bicarbonate = 14 mmol/L, and carboxyhemoglobin = 11.9%. The mother and infant were treated with hyperbaric oxygen therapy consisting of 100% oxygen at 2.4 atmosphere absolutes (ATA) for 90 minutes at 2.5 hours after delivery. Following one hyperbaric oxygen treatment, the infant was transitioned to room air and routine postpartum treatment and was discharged 3 days later in good condition. Hyperbaric oxygen treatment was well tolerated in this neonate.

Massive Nonfatal Hydroxychloroquine Ingestion in a Pediatric Patient.

BACKGROUND: Hydroxychloroquine overdose is rare but potentially lethal. Hydroxychloroquine overdose symptoms are characterized by central nervous system toxicity, cardiac toxicity, and hypokalemia. Recommended treatment consists of epinephrine, high-dose diazepam, and careful potassium repletion. Few pediatric hydroxychloroquine overdoses have been reported. CASE REPORT: We describe a 14-year-old girl who ingested 10 g (172 mg/kg) of hydroxychloroquine. She developed tachycardia, hypotension, and hypokalemia. She was intubated and treated with diazepam and epinephrine infusions and potassium supplementation. Her serum hydroxychloroquine concentration obtained 10 h after ingestion was 13,000 ng/mL (reference range 500-2000 ng/mL). The patient made a full medical recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pediatric hydroxychloroquine overdoses are reported rarely, and the toxic and lethal doses of hydroxychloroquine ingestion have not been established. This case of a teenaged patient who ingested 10 g of hydroxychloroquine and survived provides additional information that may be used to help establish toxic and lethal doses of ingestion.

Qua-Alluding to the Past: A Case of Methaqualone Analog Ingestion.

Methaqualone, known previously under the brand name Quaalude, is a Schedule I sedative hypnotic drug that may cause neurotoxicity in overdose, characterized by somnolence, hyperreflexia and muscular hyperactivity. We present a case of a 21-year-old male who reportedly ingested methaqualone in addition to insufflation of street cocaine. He subsequently developed hypoxia, hyperreflexia, myoclonus, and altered mental status. His laboratory results were notable for the presence of methemoglobinemia, which was most likely due to a cocaine contaminant. Laboratory analysis of the alleged methaqualone pills identified the substance as SL-164, a dichlorinated methaqualone analog. Urine toxicology results were positive for SL-164 (and presumed metabolites) as well as for cocaine and tetrahydrocannabinol metabolites. The patient was treated with supplemental oxygen and a benzodiazepine (lorazepam) and observed in the Emergency Department (ED) until his symptoms resolved. This case highlights current community access to methaqualone analogs. The case also focuses on laboratory techniques used to identify the methaqualone analog.

Severe Perampanel Toxicity in a Pediatric Patient With Prolonged Symptoms.

BACKGROUND: Perampanel is a new antiepileptic used to treat partial-onset seizures and generalized tonic-clonic seizures in people older than 12 years old. Perampanel is a selective, non-competitive α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor antagonist, with a prolonged half-life of approximately 105 hours. Few cases of significant toxicity have been reported, and effects in overdose are poorly understood. CASE REPORT: This case describes a 20-month-old healthy female who ingested 8 mg of perampanel. She presented to a pediatric emergency department 1 hour after ingestion with ataxia, irritability, and somnolence. Vital signs were: heart rate 130 beats per minute, blood pressure 112/97 mmHg, temperature 99°F, respiratory rate 30 breaths per minute. She was admitted to the pediatric intensive care unit. During the hospitalization, she developed hypotension and bradycardia which improved with stimulation and fluid resuscitation. Intermittent bradycardia persisted for 32 hours after ingestion. Physical examination was notable for somnolence and truncal ataxia with irritability when aroused, all of which improved throughout the hospitalization. A quantitative level obtained on hospital day 3 (HD) was 750ng/ml. On HD 3 the patient was noted to be ataxic but otherwise had an age-appropriate neurologic examination. She was discharged on HD 4 with normal vital signs, return to baseline mental status, and baseline gait. The patient's cardiovascular, neurologic, and behavioral symptoms were attributed to perampanel toxicity. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS ?: Toxicity from a perampanel overdose is poorly understood both in adults and pediatric patients with significant cardiovascular, behavioral, and central nervous system abnormalities.

Patients Who Leave the Emergency Department Without Being Seen and Their Follow-Up Behavior: A Retrospective Descriptive Analysis.

BACKGROUND: Past studies suggest that patients who leave without being seen (LWBS) by a physician from a hospital's emergency department (ED) represent a quality and safety concern, and thus LWBS rates have often been used as an ED performance metric. There are few recent studies, however, that have examined the characteristics of the LWBS population at hospitals in the United States. OBJECTIVE: This study describes the LWBS population at a multi-hospital academic health system. METHODS: This was a retrospective study of electronic medical record data from EDs at two academic hospitals with a shared patient population that analyzed all LWBS visits during the 45-month period between July 2012 and March 2016. Demographic and clinical variables, including patient characteristics, chief complaint, acuity, and evidence of ongoing medical care, were assessed. RESULTS: During the study period, 2.4% of patients presenting to the study EDs left without being seen. This population tended to have lower-acuity chief complaints and nearly triple the number of ED visits as the general ED patient; 7.8% sought follow-up care from outpatient clinics and 24.8% returned to the ED within 7 days. Of this latter group, 11.5% were subsequently admitted for inpatient care, representing 0.068% of the total ED census during the study period. CONCLUSIONS: LWBS patients are high ED utilizers who may be effectively targeted by "hotspotting." Our 11.5% admission rate at return after LWBS compares favorably with the overall 20.9% admission rate at the study EDs and represents a small minority of all LWBS visits. Given the paucity of return ED visits after interval clinic encounters, our data suggest that patients who were seen in clinic had their medical complaint adequately resolved on a non-emergent outpatient basis, and that increased LWBS rates may reflect poor access to timely clinic-based care rather than intrinsic systemic issues within the ED.

Effect of a Computerized Alert on Emergency Department Hepatitis A Vaccination in Homeless Patients During a Large Regional Outbreak.

BACKGROUND: While the overall incidence of hepatitis A has declined markedly since the introduction of a vaccine, sporadic cases and outbreaks of the disease continue to occur. OBJECTIVE: Our aim was to evaluate the effectiveness of an electronic health record (EHR) provider alert as part of an outbreak-control vaccination program implemented in the emergency department (ED). METHODS: We conducted a retrospective study assessing the impact of a Best Practice Alert (BPA) built into an EHR to prompt providers when a patient was homeless to consider hepatitis A vaccination in the ED. Data were collected over three 6-month time periods: a historical control period, a pre-intervention period, and an intervention period. RESULTS: There were no vaccinations given in the ED in the historical period, which increased to 465 after the implementation of the BPA. During the implementation period, there were 1,482 visits identified among 1,131 patients that met the inclusion criteria. Of these, there were 1,147 (77.5%) visits where the patient either received the vaccine in the ED, had already received the vaccine, or it was not indicated due to the current medical issue. There were also 333 (22.5%) visits where the BPA was active for potential vaccination eligibility, but did not receive it in the ED. CONCLUSIONS: We leveraged an informatics tool developed within our EHR to identify high-risk patients and remind providers of the availability of vaccination in the ED. Using these tools enabled providers to increase vaccination efforts within our ED to help control the community-wide outbreak.

A Description of a Health System's Emergency Department Patients Who Were Part of a Large Hepatitis A Outbreak.

BACKGROUND: A recent hepatitis A virus (HAV) outbreak in San Diego, California represents one of the largest HAV outbreaks in the United States. The County of San Diego Health and Human Services Agency identified homelessness and illicit or injection drug use as risk factors for contracting HAV during this outbreak. OBJECTIVE: We describe those patients who presented to our Emergency Department (ED) and were identified as HAV positive. METHODS: This was a retrospective descriptive study conducted at a tertiary care university health system's EDs from November 2016 to February 2018. Included were those of all ages who tested positive for HAV immunoglobulin M antibody. Outcome measures included: 1) demographic data; 2) number of patients testing positive for HAV by week and month of the outbreak; 3) homeless status, illicit and injection drug use, and alcohol use; 4) ED chief complaint; 5) initial liver function and coagulopathy test results, hepatitis B and C test results, and initial vital signs; 6) admission status; 7) death; and 8) the 7-day ED revisit rate for nonadmitted patients and the 30-day all-cause readmission rate for admitted patients. RESULTS: We identified 57,721 patients with at least one ED visit, and 1,453 of these were tested for HAV; 133 patients (9.2%) tested positive. Average age was 45.1 years, and 91 (68.4%) were male. Eighty-six patients (64.7%) were homeless and 53 patients (39.8%) reported illicit or injection drug use; 64 patients (48.1%) had chief complaints consistent with typical HAV symptoms. Most patients (112 or 84.2%) were admitted. Nine patients (6.8%) were admitted to a critical care setting; 8 patients (6%) died. CONCLUSIONS: During this large HAV outbreak, 9% of those screened for HAV tested positive. The majority were homeless, and 40% reported illicit or injection drug use. Most required hospitalization, and 6% of patients died.

A Multidisciplinary Bootcamp as an Educational Launch to a Geriatric Emergency Department.

BACKGROUND: Emergency department (ED) visits are increasing among patients ≥65 years of age. Geriatric EDs (GED) provide specialized emergency care for this older population. Interdisciplinary education of GED staff and providers is needed as part of the development of a GED. OBJECTIVES: We sought to describe the effective use of a GED bootcamp as an educational mechanism for the introduction of a GED to a health system. METHODS: An all-day, in-person GED bootcamp was held on the campus of our health system's medical school campus and was led by experts in geriatric emergency care. Participants in the bootcamp were professionals from a variety of health care fields and medical specialties as well as health care administrators and health policy professionals. Bootcamp attendees were administered a survey at the completion of the bootcamp. The survey asked about knowledge and interest in concepts relating to GEDs that the participants had both before and after attending the bootcamp. RESULTS: A total of 100 participants from a range of health care fields and medical specialties were present for the GED bootcamp. Fifty percent of bootcamp participants completed both before and after bootcamp survey questions. Among these, there was a significant increase in the level of high knowledge and interest in concepts relating to GEDs when comparing pre- and postbootcamp survey results (p < 0.001). CONCLUSIONS: An all-day, in-person GED bootcamp was an effective forum to bring together an interdisciplinary health care group and provide meaningful emergency geriatric care education.

The accuracy of emergency department medication history as determined by mass spectrometry analysis of urine: a pilot study.

BACKGROUND: Emergency Department (ED) medication lists (ML) are considered inaccurate based on previous comparisons of ED ML with patients' self-reporting of medications and reviews of patients' pharmacy and medical records. OBJECTIVE: To determine the accuracy of ED ML using mass spectrometry analysis of urine samples. METHODS: This was a prospective observational study conducted at an urban tertiary care university hospital. Convenience sampling of patients who underwent ED triage was done. Included were patients 18 years or older who were capable of providing informed consent and who reported use of at least one medication. Excluded were patients unable to consent, prisoners, non-English-speaking patients, and patients unwilling or unable to provide a urine sample. Mass spectrometry analysis was performed on enrolled patients' urine, and their ED triage ML were recorded. Urinalysis results were compared to ED triage ML. Concordance between respective ED triage ML and urinalysis results was determined. Medications were grouped by medication class. The top five discrepant medication classes were identified. RESULTS: There were 100 patients enrolled; 21 patients, although eligible, did not provide a urine sample and were excluded, and one patient withdrew. Mean age was 51 years, and 54 patients were male. Twenty-two medication classes were identified. No patient had 100% concordance of ED triage ML and urinalysis results. Opioid analgesic, sedative hypnotics, cardiac, psychiatric, and nonopioid analgesic medications were the top discrepant medication classes. CONCLUSIONS: ED triage ML obtained by patient recall are inaccurate when compared to medications detected in urine using mass spectrometry analysis.

Crotaline Fab antivenom reverses platelet dysfunction induced by Crotalus scutulatus venom: an in vitro study.

BACKGROUND: Patients sustaining rattlesnake envenomation often develop thrombocytopenia, the etiology of which is not clear. Laboratory studies have demonstrated that venom from several species, including the Mojave rattlesnake (Crotalus scutulatus scutulatus), can inhibit platelet aggregation. In humans, administration of crotaline Fab antivenom has been shown to result in transient improvement of platelet levels; however, it is not known whether platelet aggregation also improves after antivenom administration. OBJECTIVES: The objective was to determine the effect of C. scutulatus venom on platelet aggregation in vitro in the presence and absence of crotaline Fab antivenom. METHODS: Blood was obtained from four healthy male adult volunteers not currently using aspirin, nonsteroidal anti-inflammatory drugs, or other platelet-inhibiting agents. C. scutulatus venom from a single snake with known type B (hemorrhagic) activity was obtained from the National Natural Toxins Research Center. Measurement of platelet aggregation by an aggregometer was performed using five standard concentrations of epinephrine (a known platelet aggregator) on platelet-rich plasma over time, and a mean area under the curve (AUC) was calculated. Five different sample groups were measured: 1) blood alone, 2) blood + C. scutulatus venom (0.3 mg/mL), 3) blood + crotaline Fab antivenom (100 mg/mL), 4) blood + venom + antivenom (100 mg/mL), and 5) blood + venom + antivenom (4 mg/mL). Standard errors of the mean (SEM) were calculated for each group, and paired t-tests were used to measure differences between groups. RESULTS: Antivenom administration by itself (group 2) did not significantly affect platelet aggregation compared to baseline (103.8%, SEM ± 3.4%, p = 0.47). Administration of venom (group 3) decreased platelet aggregation (72.0%, SEM ± 8.5%, p < 0.05). Concentrated antivenom administration in the presence of venom (group 4) normalized platelet aggregation (101.4%, SEM ± 6.8%) and in the presence of diluted antivenom (group 5) significantly increased aggregation (133.9%, SEM ± 9.0%; p < 0.05 for both groups when compared to the venom-only group). To further assess the effects of the venom and antivenom, each was run independently in platelet-rich plasma without epinephrine; neither was found to significantly alter platelet aggregation in the absence of epinephrine. CONCLUSIONS: Crotaline Fab antivenom improved platelet aggregation in an in vitro model of platelet dysfunction induced by venom from C. scutulatus. It is unclear at this time whether this improvement in platelet dysfunction translates into improved clinical outcomes in envenomated patients.

A poison center's ten-year experience with flumazenil administration to acutely poisoned adults.

BACKGROUND: The frequency of seizures among acutely poisoned adults who are administered flumazenil has not been well established. STUDY OBJECTIVE: The objectives of the study were: to determine the frequency of seizures among acutely poisoned adults administered flumazenil; to identify factors associated with seizures; and to determine the mental status of subjects before and after administration of flumazenil. METHODS: This study was a historical case series of acutely poisoned adults reported to a poison control system from 1999 to 2008. Included cases were those involving administration of flumazenil to subjects who were ≥ 18 years of age. Both genders were included. Variables collected included: presence of seizure or death, exposure to a pro-convulsant drug, and mental status before and after flumazenil administration. RESULTS: Over the 10-year period studied, 904 cases were identified that met inclusion criteria. Thirteen subjects (1.4%) developed seizures after flumazenil was administered. One death occurred. There were 293 subjects exposed to a pro-convulsant drug, and 8 of these had seizures after flumazenil administration. Development of seizures after flumazenil administration was significantly associated with exposure to a pro-convulsant drug (odds ratio 3.41; 95% confidence interval 1.13-10.72). Mental status before and after flumazenil administration was available for 546 subjects (60.3%). Of these, 291 (53.3%) became awake after administration of flumazenil. CONCLUSIONS: Flumazenil administration to acutely poisoned adults resulted in a low frequency of seizures and death. Development of seizures was associated with exposure to a pro-convulsant drug. More than half of the subjects for whom mental status was recorded became awake after receiving flumazenil.

Flumazenil administration in poisoned pediatric patients.

OBJECTIVE: The goal of this retrospective cohort study of pediatric patients exposed to flumazenil was to identify the frequency of seizures. METHODS: Included patient were those aged 12 years or younger who received flumazenil, who had evidence of clinical poisoning as defined by an altered mental status, and who were reported to the California Poison Control System for the period 1999 to 2008. Data variables were age, sex, seizure, death, acute exposure to a benzodiazepine, drugs of exposure, long-term use of benzodiazepines, history of a seizure disorder, mental status before flumazenil administration, and poison center recommendation of flumazenil (yes/no). RESULTS: Eighty-three patients were included. Forty-eight (58%) of this subset were female. Median age was 2 years (range, 3 months-12 years). Seventy (84%) patients were younger than 5 years. Of the 83 patients, 68 (82%) were allegedly exposed to a benzodiazepine; whereas, 12 (15%) had been allegedly exposed to a proconvulsant drug. No flumazenil-related seizures occurred (0% with 95% confidence interval, 0%-4%). The California Poison Control System recommended flumazenil use in 60 (72%) of the 83 cases, and 48 of these had been allegedly exposed to a benzodiazepine. CONCLUSIONS: No flumazenil-associated seizures occurred among allegedly benzodiazepine- and non-benzodiazepine-poisoned pediatric patients aged 12 years or younger.

A retrospective poison center review of varenicline-exposed patients.

BACKGROUND: Varenicline was approved by the Food and Drug Administration (FDA) as a prescription smoking cessation aid in May 2006. Varenicline is both a partial nicotine agonist and an antagonist. Recent reports by the Institute of Safe Medication Practices identified safety problems associated with varenicline use, and the FDA recently issued a boxed warning. These safety concerns regarding varenicline use prompted this study. OBJECTIVE: To characterize varenicline-exposed patients as reported to a poison control system. METHODS: We performed a retrospective search of the California Poison Control System electronic database from August 2006 through August 2008, using the term varenicline or Chantix. Cases matching these results were reviewed. All ages were included. Excluded were patients with coingestants and unknown outcomes. Clinical parameters and medical outcomes were extracted from the database. RESULTS: Thirty-six cases met inclusion criteria and 17 cases were excluded, Ten cases involved nonpediatric patients; 9 cases involved patients less than 6 years old, which were defined as pediatric patients. The median duration of poison center follow-up for pediatric patients was 253 minutes; median duration of follow-up for nonpediatric patients with unintentional exposures was 28.5 minutes. The majority of exposures were unintentional and included all the pediatric patients and 6 nonpediatric patients who had unintentional medication errors. Gastrointestinal and neuropsychiatric adverse events were most frequently reported. The majority of these patients were managed at home. Among those evaluated at a healthcare facility, only 1 pediatric patient was admitted. Of the remaining patients, 1 nonpediatric patient reported a deliberate exposure and 3 nonpediatric patients experienced adverse effects at therapeutic doses. Median duration of follow-up for these patients was 308 minutes. CONCLUSIONS: Patients exposed to varenicline in our study had favorable outcomes. Gastrointestinal and neuropsychiatric effects were the most commonly reported adverse events. A dose-response relationship could not be determined and triage criteria to a healthcare facility remain undetermined.

L-arginine levels are diminished in adult acute vaso-occlusive sickle cell crisis in the emergency department.

Paediatric studies have demonstrated that l-arginine (l-arg), the precursor to nitric oxide, is diminished in vaso-occlusive crisis (VOC). This study aimed to determine whether l-arginine levels are altered in adult VOC in the emergency department. Plasma l-arg and nitric oxide metabolite (NOx) levels were obtained in adult VOC patients presenting to the emergency department. Fifty patients had significantly low plasma l-arg (29.78 micromol/l +/- 11.21, P < 0.05 vs steady-state control = 41.16 micromol/l +/- 5.04) and significantly low plasma NOx (12.33 micromol/l +/- 10.28, P < 0.05 vs steady-state control = 25.2 +/- 2.6 micro mol/l). Neither l-arg nor NOx levels could predict VOC clinical course.