Carbon Monoxide Levels Produced by Propane/Isobutane Canister Stoves inside a Tent.

INTRODUCTION: Improper use of camp stoves in enclosed spaces has resulted in fatalities from carbon monoxide (CO) poisoning. Prior research has focused on the CO output of stoves burning white gas, unleaded gas, or kerosene. Stoves burning an isobutane/propane fuel have not been investigated and are the focus of this study. METHODS: Three stoves utilizing isobutane/propane fuel were used to heat a pot of water inside a 3-season tent under controlled settings. Multiple runs with each stove were performed, and CO measurements, in parts per million (ppm), were recorded at 1-min intervals for a total of 15 min using a RAE Systems gas monitor. Data are reported as mean with SD. Repeated measures analysis of variance was utilized to examine changes over time. Statistical significance was set at P<0.05. RESULTS: There was a statistically significant main effect of time and CO level, F (14, 168)=7.6, P<0.001. There was a statistically significant difference between-subjects effect of stove group F (2, 12)=8.6, P=0.005, indicating that CO levels were different depending on the stove. Tukey's post-hoc analyses revealed that stove A had the highest CO levels. The average level of stove A was statistically significantly higher than that of stove B and stove C, with a mean CO level difference of 79 ppm (95% CI, 3-156), P=0.043 and 117 ppm (95% CI, 40-194), P=0.004, respectively. CONCLUSIONS: Stoves utilizing isobutane/propane fuel can produce unsafe CO levels and should not be used in enclosed spaces.

The COVID-19 pandemic and opioid use disorder: Expanding treatment with buprenorphine, and combining safety precautions with telehealth.

BACKGROUND: This study investigated the efficacy and safety of providing medication for opioid use disorder (MOUD) and individualized telehealth in Kentucky, a state severely impacted simultaneously by the opioid epidemic and the COVID-19 pandemic. METHODS: The investigation analyzed pre- and post-COVID-19 characteristics in 191 opioid use disorder (OUD) buprenorphine outpatients who completed an 18-question survey in late 2020 related to COVID testing, OUD relapses, obstacles to maintaining abstinence, and treatment resources. RESULTS: The study revealed no statistically significant changes in drug use before and after the onset of the COVID-19 pandemic despite monthly volume increases. Results further demonstrated statistically significant barriers to treatment, including loss of housing and transportation, food insecurity, and onset of depression. No patients required hospitalization or succumbed to OUD or COVID-19. Potentially effective resource utilization findings included clinic transportation and 24/7 crisis intervention. Respondents rated telehealth as helpful when used in an individualized hybrid model matching patient's need to available resources based on COVID-19 safety guidelines. CONCLUSION: This report yields key clinical insights into providing outpatient MOUD care during the COVID-19 pandemic, validating in-person care as both safe and effective. Patients' experiences proved helpful in identifying and quantifying obstacles to abstinence in conjunction with facilitating continued patient access to essential clinical resources. Notably, telehealth can supplement rather than replace in-person treatment.

Retrospective Review of Need for Delayed Naloxone or Oxygen in Emergency Department Patients Receiving Naloxone for Heroin Reversal.

BACKGROUND: Emergency departments (EDs) are experiencing an increasing number of heroin overdose visits. Currently, there is no generally agreed upon ED observation period for heroin overdose patients who receive naloxone. OBJECTIVES: We aimed to determine the safety of a 2-h observation period for heroin overdose patients who receive naloxone. METHODS: We performed a chart review of all patients who presented with any opioid-related complaint between 2009 and 2014 to our urban academic trauma center. Subset analysis of patients with isolated heroin overdose who received naloxone was performed, with the intent of excluding patients intoxicated with long-acting/enteral opioids. The primary outcome was the number of patients who required delayed intervention-specifically, additional naloxone or supplemental oxygen. RESULTS: Between 2009 and 2014, we recorded 806 visits to our ED for heroin use after receiving naloxone. Twenty-nine patients (3.6%) received a repeat dose of naloxone, and 17 patients (2%) received oxygen ≥2 h after initial naloxone administration. Our 2-h intervention rate was 4.6% (N = 37). This decreased to 1.9% (N = 15) after 3 h and 0.9% (N = 7) after 4 h. Patients with polysubstance use were more likely to receive repeat naloxone (p < 0.01), but not oxygen (p = 0.10). Preexisting cardiopulmonary conditions did not correlate with a need for supplemental oxygen (p = 0.24) or repeat naloxone (p = 0.30). CONCLUSIONS: A 2-h ED observation period for heroin overdose patients reversed with naloxone resulted in a delayed intervention rate of 5%. Clinicians may consider a 3-h observation period, with extra scrutiny in polysubstance abuse.

Prevalence of Emergency Department Patients Presenting with Heroin or Prescription Opioid Abuse Residing in Urban, Suburban, and Rural Jefferson County.

BACKGROUND: Heroin and prescription opioid abuse in the United States is exhibiting a growing geographic ubiquity. OBJECTIVES: This study characterizes the changing geographic distribution of patients presenting with heroin and prescription opioid abuse to one urban emergency department (ED). METHODS: A retrospective review of patients with heroin and prescription opioid abuse from 2009-2014 was conducted in one adult urban ED. The primary outcome was the prevalence of heroin and prescription opioid patients residing in urban, suburban, and rural ZIP codes over time. RESULTS: From 2009 to 2014, 2695 patients presented for either heroin (N = 1436; 53%) or prescription opioid (N = 1259; 47%) abuse from 32 Jefferson County ZIP codes. Of the 32 ZIP codes, 15 were urban (47%), 13 suburban (41%), and 4 rural (12%). The prevalence of heroin patients (per 10,000 population) increased in each ZIP code from 2009-2014. After 2011, prescription opioid prevalence decreased in urban and suburban ZIP codes but increased in rural ones. Using segmented regression analysis, the increase in patients who used heroin residing in all ZIP codes and the decrease in patients abusing prescription opioids residing in urban areas was statistically significant after 2011. CONCLUSION: From 2009 to 2014, there was an increasing trend in ED patients using heroin who resided in urban, suburban, and rural ZIP codes. There was an increasing trend in prescription opioid prevalence in all regions from 2009 to 2011. After 2011, prescription opioid prevalence decreased in urban and suburban ZIP codes but not rural ZIP codes.

Alteplase Causing Cardiac Tamponade after Recent Cardiac Pacemaker Placement.

A 56-year-old female presented to the emergency department with evolving cardiac tamponade after receiving alteplase for acute ischemic stroke. This is the first case report of cardiac tamponade from thrombolytics in the setting of recent pacemaker placement. Point-of-care ultrasound was used to make the diagnosis quickly and expedite the patient to the operating room where a pericardial window was performed.

Remember the Drive Home? An Assessment of Emergency Providers' Sleep Deficit.

OBJECTIVE: Sleep deprivation decreases work performance and predisposes workers to deleterious health outcomes. We sought to evaluate sleep hygiene and fatigue among emergency physicians. METHODS: In March-June 2016, physicians and residents at an academic emergency medicine program were invited to complete a survey evaluating sleep and alertness. RESULTS: Six attending physicians and 26 residents completed the survey. Among six personal priorities, sleep ranked fourth behind family, work, and leisure. 75% stated poor sleep impedes effectiveness as a physician while 53% noted difficulty falling asleep before a night shift. In the last three months, 39% of subjects forgot driving home from a shift, and 34% had fallen asleep while driving. 34% used medications to assist with sleep (including melatonin (36%), alcohol (27%), and prescription drugs (9%)). Most providers attested to phone (88%) and television exposure (69%) immediately prior to goal sleep onset. CONCLUSION: Despite sleep being identified as a priority among EM physicians, deleterious habits remain. Poor sleep affects perceived effectiveness and personal safety, as evidenced by a significant portion of providers falling asleep on the commute home. Night shift is the chief obstacle to optimal sleep hygiene.

The Effects of Kentucky's Comprehensive Opioid Legislation on Patients Presenting with Prescription Opioid or Heroin Abuse to One Urban Emergency Department.

BACKGROUND: Prescription opioid abuse has increased to epidemic proportions in the United States. Kentucky, along with other states, passed comprehensive legislation to monitor and curb opioid prescribing. OBJECTIVES: This paper characterizes patients who presented to the emergency department (ED) after abusing prescription opioids and heroin prior to and after the passage of House Bill 1 (HB1) in April 2012. METHODS: Based on a retrospective review of ED visits from 2009-2014 in one urban adult facility, patients were included if the chief complaint or diagnosis was directly related to prescription opioid or heroin abuse. The primary outcome is the number and type of substance abused by each ED patient. RESULTS: From 2009-2014, 2945 patients presented to the ED after prescription opioid or heroin abuse. The number of prescription opioid patients decreased from 215 (of 276 patients) in 2009 to 203 (of 697 patients) in 2014; 77.9% of patients abused opioids in 2009, vs. 29% in 2014 (a 63% decrease). The number of heroin patients increased from 61 in 2009 to 494 in 2014; 22% of patients in 2009 abused heroin, vs. 71% in 2014 (a 221% increase). Both piecewise regression and autoregressive integrated moving average trend models showed an increased trend in patient heroin abuse beginning in 2011-2012. CONCLUSIONS: Our facility experienced a decrease in the number of patients who abused prescription opioids and an increase in the number of patients who abused heroin over the study period. The transition seemed to occur just prior to, or concurrent with, enforcement of statewide opioid legislation.

Compartment and Crush Syndromes After Sleep Deprivation and a Therapeutic Dose of Zolpidem.

Despite extensive review in the literature, compartment syndrome and crush syndrome remain difficult to diagnose. Trauma, toxins and reperfusion have been associated with these syndromes. Cases involving alcohol and drug abuse have described patients "found down" compressing an extremity. We present a case of a registered nurse who developed compartment syndrome in multiple limbs due to prolonged sleep after sleep deprivation and zolpidem use. To our knowledge, this is the first case of compartment syndrome or crush syndrome to have occurred in the setting of zolpidem use. Sleep disruption in healthcare workers represents a public health issue with dangerous sequelae, both acute and chronic.