Alcohol-Related Metabolic Emergencies.

Patients with alcohol use disorders are commonly identified and managed in the emergency department. Although the alcohol-intoxicated patient has a high risk for significant injury and diseases, the majority will be allowed to sober in the emergency department and can be discharged without incident. However, there are metabolic derangements in these patients, such as alcoholic ketoacidosis, Wernicke-Korsakoff, and potomania that very commonly present similar to intoxication and can be misdiagnosed by emergency clinicians.

Don't Forget What You Can't See: A Case of Ocular Syphilis.

This case describes an emergency department (ED) presentation of ocular syphilis in a human immunodeficiency virus (HIV) infected patient. This is an unusual presentation of syphilis and one that emergency physicians should be aware of. The prevalence of syphilis has reached epidemic proportions since 2001 with occurrences primarily among men who have sex with men (MSM). This is a case of a 24-year-old male who presented to our ED with bilateral painless vision loss. The patient's history and ED workup were notable for MSM, positive rapid plasmin reagin (RPR) and HIV tests and fundus exam consistent with ocular syphilis, specifically uveitis. Ocular manifestations of syphilis can present at any stage of syphilis. The 2010 Centers for Disease Control and Prevention guidelines now recommend that ocular syphilis be treated as neurosyphilis regardless of the lumbar puncture results. There is a paucity of emergency medicine literature on ocular syphilis. For emergency physicians it is important to be aware of iritis, uveitis, or chorioretinitis as ocular manifestations of neurosyphilis especially in this high-risk population and to obtain RPR and HIV tests in the ED to facilitate early diagnosis, and treatment and to prevent irreversible vision loss.

The "syringe" technique: a hands-free approach for the reduction of acute nontraumatic temporomandibular dislocations in the emergency department.

BACKGROUND: The traditional intraoral manual reduction of temporomandibular joint (TMJ) dislocations is time consuming, difficult, and at times ineffective, and commonly requires conscious sedation. OBJECTIVES: We describe a novel technique for the reduction of acute nontraumatic TMJ dislocations in the emergency department (ED). METHODS: This study was a prospective convenience sample population during a 3-year period at two university teaching-hospital EDs where acute nontraumatic TMJ dislocations were reduced utilizing our syringe technique. Demographics, mechanism, duration of dislocation, and reduction time were collected. Briefly, the "syringe" technique is a hands-free technique that requires a syringe to be placed between the posterior molars as they slide over the syringe to glide the anteriorly displaced condyle back into its normal anatomical position. Procedural sedation or intravenous analgesia is not required. RESULTS: Of the 31 patients, the mean age was 38 years. Thirty patients had a successful reduction (97%). The majority of dislocations were reduced in <1 min (77%). The two most common mechanisms for acute TMJ dislocations were due to chewing (n = 19; 61%) and yawning (n = 8; 29%). There were no recurrent dislocations at 3-day follow-up. CONCLUSION: We describe a novel technique for the reduction of the acutely nontraumatic TMJ dislocation in the ED. It is simple, fast, safe, and effective.

The routine utilization of procedural pain management for pediatric lumbar punctures: are we there yet?

BACKGROUND: The objective of this study was to assess the utilization of local anesthetics by emergency physicians (EP) and pediatric physicians (PP) who performed a lumbar puncture (LP) in pediatric patients from birth to 24 months of age. METHODS: We conducted a prospective study of children that received an LP at a university tertiary referring hospital. A convenience sample included children from birth to 24 months that received an LP for suspected meningitis in the ED or pediatric units during a one-year period. Physicians performing the LP were blinded to the objectives of the study. Data was collected using a standardized procedure form developed for this study. RESULTS: Three hundred nine LPs were performed during the study period. Excluded patients consisted of 29 subjects who underwent moderate procedural sedation and 57 subjects that had incomplete procedural data forms. From our sample population of 223 subjects, 146 subjects received a local anesthetic prior to the LP. One hundred twenty six subjects received 1% lidocaine, 20 subjects received EMLA cream (with one subject that received both 1% lidocaine and EMLA), while 77 received no pre-procedural local anesthetic. The use of local anesthetics differed greatly with the age of the patient. Pre-procedural local anesthetics were administered in 65 of 120 subjects less than 12 months of age and in 81 of 82 patients 12 to 24 months of age. Interestingly, the neonatal subject population did not receive any procedural anesthetic by EP or PP. PP and EP differed in the type of local anesthetic utilized prior to performing a LP. EP exclusively used 1% lidocaine while PP preferentially administered EMLA. A subset analysis demonstrated that only PP utilized moderate sedation (Midazolam and Fentanyl) in 41/309 (13%) of the study population. CONCLUSIONS: This is the first study to demonstrate that EPs and PPs differ in their preference in the use of local anesthetics prior to LP and that procedural anesthetic is not universal within this pediatric age group and that utilization of a local anesthetic varies by patient age, with younger children less likely to receive a local anesthetic. KEYWORDS: Local anesthetic; Lumbar puncture; Emergency physician; Pediatric physician.

Vascular pedicle width on chest radiograph as a measure of volume overload: meta-analysis.

INTRODUCTION: Vascular pedicle width (VPW), a measurement obtained from a chest radiograph (CR), is thought to be an indicator of circulating blood volume. To date there are only a handful of studies that demonstrate a correlation between high VPW and volume overload, each utilizing different VPW values and CR techniques. Our objective was to determine a mean VPW measurement from erect and supine CRs and to determine whether VPW correlates with volume overload. METHODS: MEDLINE database, Web of Science, and the Cochrane Central Register of Controlled Trials were searched electronically for relevant articles. References from the original and review publications selected electronically were manually searched for additional relevant articles. Two investigators independently reviewed relevant articles for inclusion criteria and data extraction. Mean VPW measurements from both supine and erect CRs and their correlation with volume overload were calculated. RESULTS: Data from 8 studies with a total of 363 subjects were included, resulting in mean VPW measurements of 71 mm (95% confidence interval [CI] 64.9-77.3) and 62 mm (95% CI 49.3-75.1) for supine and erect CRs, respectively. The correlation coefficients for volume overload and VPW were 0.81 (95% CI 0.74-0.86) for both CR techniques and 0.81 (95% CI 0.72-0.87) for supine CR and 0.80 (95% CI 0.69-0.87) for erect CR, respectively. CONCLUSION: There is a clinical and statistical correlation between VPW and volume overload. VPW may be used to evaluate the volume status of a patient regardless of the CR technique used.

Analysis of urobilinogen and urine bilirubin for intra-abdominal injury in blunt trauma patients.

OBJECTIVE: To determine the point prevalence of urine bilirubin, urine hemoglobin and urobilinogen in blunt trauma patients, and to evaluate its utility as a screening tool for intra-abdominal injury. METHODS: Data analysis of 986 consecutive trauma patients of which 698 were adult blunt trauma patients. Five-hundred sixteen subjects had a urinalysis and a CT scan of the abdomen/pelvis or exploratory laparotomy. We reviewed initial urinalysis results from trauma patients in the emergency department (ED) for the presence of urine hemoglobin, uroblinogen and urine bilirubin. Computed tomography (CT) scan results and operative reports were reviewed from the trauma registry for evidence of liver laceration, spleen laceration, bowel or mesenteric injuries. RESULTS: There were 73 injuries and 57/516 patients (11%) with intra-abdominal injury. Urinalysis was positive for urobilinogen in 28/516 (5.4%) patients, urine bilirubin in 15/516 (2.9%) patients and urine hemoglobin in 313/516 (61%) patients. Nineteen/forty-seven (4%) subjects had liver lacerations, 28/56 (5%) splenic lacerations, and 15/5 (3%) bowel or mesenteric injury. Comparing the proportion of patients that had urobilinogen detected in the group with and without intra-abdominal injury, 8/28 (29%) subjects with urobilinogen, 5/15 (33%) subjects with bilirubin and 47/313 (15%) subjects with urine hemoglobin were found to have liver lacerations, spleen lacerations, or bowel/mesenteric injuries. Preexisting liver or biliary conditions were not statistically associated with elevation of urine bilirubin, urine hemoglobin or urobilinogen on initial urinalysis after blunt abdominal trauma. Point prevalence for urobilinogen, urine bilirubin and urine hemoglobin are 5.43% (28/516), 2.91% (15/516) and 60.7% (313/516) respectively. CONCLUSIONS: The utility of the initial routine urinalysis in the ED for adult blunt abdominal trauma patients should not be used as a screening tool for the evaluation of intra-abdominal injury.

A methicillin-resistant Staphylococcus aureus-positive holospinal epidural abscess.

Spinal epidural abscess is a rare debilitating disease that if left untreated may result in serious morbidity and mortality. Most cases involve the level of 3 or 4 vertebrae, but in very rare cases may affect the whole spine. The most common pathogen found in spinal abscesses is Staphylococcus aureus, which involves approximately two thirds of cases. The recent introduction of methicillin-resistant strains of S aureus has left physicians with the challenging task of identifying and treating this serious condition.We present the only case reported of a methicillin-resistant S aureus holospinal epidural abscess with subsequent neurological follow-up over a 1-year period.

Under Utilization of local anesthetics in infant lumbar punctures.

BACKGROUND: Lumbar Puncture (LP) is an invasive procedure frequently used to diagnose meningitis among the pediatric population. Neonates and infants have not routinely received local anesthesia prior to LP. STUDY OBJECTIVE: To determine whether emergency medicine physicians and pediatricians use local analgesics on neonates and infants prior to performing an LP and to identify which local anesthetics, if any, were used. METHODS: Prospective, cohort study of all infants, six months of age or less, that received an LP in the emergency department (ED) or inpatient pediatric units for suspected meningitis during a period of year at a university tertiary care hospital. RESULTS: A total sample population of 111 infants that received an LP within the study period. A control population of 42 adults received an LP. Only 40.4% (45/111) of the infants received local analgesia prior to LP: either 1% lidocaine, EMLA or a combination of the two. Infants were less likely to receive lidocaine or EMLA prior to LP compared to adult subjects (OR= 0.27; 95% CI0.12 to 0.62). No neonates that were less than one month of age received local procedural anesthesia by emergency medicine or pediatric physicians. ED physicians' use of local anesthesia prior to LP increased with increasing age of the infant. The pediatricians in this study used local anesthesia prior to LP when the infant was at least five months of age. DISCUSSION: The data objectively support recent literature regarding the under use or lack of use of analgesia prior to LP among neonates and infants. Local anesthetics should be used routinely without exception prior to performing an LP in the pediatric population.

Complications of MRSA Treatment: Linezolid-induced Myelosuppression Presenting with Pancytopenia.

Methicillin-resistant Staphylococcus aureus (MRSA) infections have grown to epidemic proportions in the United States. With the development of increasing drug resistance of MRSA to traditional antimicrobials, there has been a search for a more effective antibiotic treatment. Linezolid is one of the most effective oral medications used for outpatient treatment of MRSA infections. We present a case of pancytopenia after outpatient treatment with linezolid. Myelosuppression is a rare but serious side effect of linezolid of which emergency physicians need to be aware in order to provide early intervention.

Acute ischemic stroke in a pediatric patient.

Acute ischemic stroke in a pediatric patient is a complex disease with a variety of etiologies that differ from adults. Though rare, they are a real phenomenon with potentially devastating consequences. Some treating institutions are using anti-thrombotic drug therapy with unclear benefits. Available literature, which is limited to case reports and retrospective reviews of databases, clouds this topic with both positive and negative outcomes. Emergency department management should focus on stabilization and resuscitation with immediate involvement of a pediatric neurologist and intensivist. The decision to use anti-thrombotic drug therapy, including anti-platelet drugs and thrombolytics, should be in consult with the specialists involved until randomized controlled trials determine their safety and efficacy in the pediatric population.

Access to Firearms among Orange County Youth: A School-Based Study.

OBJECTIVE: School-associated firearm violence among children and adolescents is a national public concern. The objective of this study was to determine the accessibility of firearms, methods of firearm access and firearm safety knowledge among middle and high school students in Orange County, California. METHODS: After permission from school officials and parents was obtained, a 24-question survey was distributed to 176 students in grades 6 through 12 at four schools in Orange County. Data was collected over a 12-month period beginning in February 2003. Data analysis was presented in proportions. In addition, cross tabulations were performed to determine which factors were associated with access to guns, having fired a gun, and firearm possession at school. RESULTS: The mean age of participants was 16.1 years. Seventy-seven (45%) were male, 121 (69%) Hispanic, and 171 (94%) were of middle income. Four participants (2.3%) admitted to gang involvement, 47 (26.7%) had fired a gun. Those more likely to have fired a gun appeared to be non-Hispanic males (p= 0.001). Seventy-five (43%) reported access to a gun. Older students and those in grades 9 to 12 were more likely to have access to a gun (p= 0.01), which they stated could be obtained from their homes, friends or relatives (4.5% to 22%). No students admitted to bringing a gun to school. Two (1.1%) students stated that they had thought of using a gun at school. One hundred one students (62%) were taught firearm safety by their parent(s). CONCLUSION: Almost half of the students in this study acknowledged that they could gain access to a gun and two students had thought about using a gun at school. Firearm education, safety and counseling are of paramount importance to ensure safety among school youths.

Conscious sedation and emergency department length of stay: a comparison of propofol, ketamine, and fentanyl/versed.

STUDY OBJECTIVES: Three of the most commonly used agents for conscious sedation in the Emergency Department (ED) are ketamine, fentanyl/versed, and propofol. In this study, we measured and compared the total times spent in the ED with each of these agents. Our objective was to determine whether the use of propofol for conscious sedation was associated with a shorter length of ED stay as compared to the other two agents. METHODS: This was a consecutive case series. All patients who required procedural conscious sedation who presented to the ED at University of California, Irvine Medical Center from January 2003 through April 2004 were included in the study. The attending ED physician evaluated the patient and determined which medication(s) would be administered. All patients underwent procedural sedation according to the ED's standardized sedation protocol. The times and dosages of administered medications and the sedation/consciousness level (SCL) scores were recorded by ED nurses at 3-5 minute intervals. Data was abstracted prospectively. The time to sedation (first dose of agent to SCL score of 2 or less) and time to recovery (last dose of agent to SCL score of 4) of the different regimens were then analyzed and compared. RESULTS: Thirty-eight patients received propofol, 38 received ketamine, and 14 received fentanyl/versed. The mean times to sedation (minutes) were: propofol 4.5 (95% CI: 3.3-5.7), ketamine 10.6 (95% CI: 5.8-15.4), fentanyl/versed 11.5 (95% CI: 3.5-19.4). The mean times to recovery were: propofol 21.6 (95% CI: 16.1-27.1), ketamine 55.4 (95% CI: 46.2-64.5), fentanyl/versed 59.9 (95% CI: 20.3-99.5). Propofol had a statistically significant shorter time to sedation than both ketamine (p<.001) and fentanyl/versed (p=.022). Propofol also produced shorter recovery times than both ketamine (p<.001) and fentanyl/versed (p=.002). CONCLUSION: In this study, sedation and recovery times were shorter with propofol than with ketamine or fentanyl/versed. The use of propofol for conscious sedation in this non-randomized study was associated with a shorter ED length of stay.

Analgesia and addiction in emergency department patients with acute pain exacerbations.

INTRODUCTION: There is ongoing controversy regarding the appropriate use of narcotic analgesia for patients presenting frequently to the emergency department (ED) with subjective acute exacerbations of pain. "Are we treating pain or enabling addiction?" OBJECTIVES: To determine whether the presence of specific factors could be used to identify adults complaining of acute exacerbations of pain for suspected drug addiction, to estimate the percentage of drag addicted patients, to assess the physicians' ability to detect drug addiction and to evaluate Interrater reliability. METHODS: A Drug Abuse Screening Test (DAST-20) was administered to 76 ED patients who presented with acute exacerbations of pain and either multiple ED visits for similar pain complaints, specific narcotic requests, or "allergies" to non-narcotics. The DAST-20 was also administered to 74 age-matched controls. Treating ED physicians rated their suspicion for drug addiction using a visual analog scale (VAS). RESULTS: The overall estimation of drug addiction based on the DAST-20 survey was 17.3% (26/150). Twenty-one percent (16/76) of the analgesia subjects and 13.5% (10/74) of the control subjects scored positive for drug addiction as measured by the DAST-20. Of the analgesia subjects with positive DAST-20 scores for drug addiction, 43.8% (7/16) had multiple ED visits, 43.8% (7/16) requested specific narcotics and 6.3% (1/16) reported "allergies" to non-narcotics. There was no correlation between the VAS scores and the DAST-20 scores. There was a significant correlation between resident and attending VAS scores for their suspicion for drug addiction. CONCLUSION: There exists a clinically significant drug addiction problem among ED patients presenting with acute exacerbations of pain and among low-acuity patients who do not present to the ED for pain management.

Intimate partner violence among women presenting to a university emergency department.

OBJECTIVE: To establish point and one-year prevalence data regarding partner violence (PV) for women presenting to a university teaching hospital, University of California, Irvine Medical Center (UCIMC), one of 15 emergency departments in Orange County, and to determine differences in partner violence rates when comparing descriptive variables such as race, income and education. METHODS: An anonymous, written survey was administered to a convenience sample of 370 women presenting to University of California Irvine Emergency Department over a 12 month period. RESULTS: Partner violence has a point prevalence of 6.7% and a one-year prevalence of 37.0%. Women who have experienced previous abuse are more likely to present with complaints related to PV acutely. Lower income levels correlate with a higher incidence of physical, emotional, and sexual abuse. We found no correlation between race and likelihood of PV. CONCLUSION: PV in Orange County, California occurs quite frequently. The one-year prevalence compares to that of the entire state of California, but is at the higher limit when other areas are compared. Detection rates among EPs should be improved, and services to women who have suffered PV will need to be enhanced within Orange County.

Intimate partner violence among men presenting to a university emergency department.

OBJECTIVE: We sought to investigate the one-year point prevalence for male intimate partner violence (IPV) in men presenting to a university emergency department, to identify types of violence, to examine differences in male IPV rates based on patient demographics, and to identify any differences in prevalence based on types of partnership. METHODS: This survey study was conducted from September 2001 until January 2002 at a tertiary, academic, Level I Trauma Center with an emergency department (ED) that has 40,000 visits per year. The anonymous written survey consisted of 16 questions previously validated in the Colorado Partner Violence Study, Index of Spouse Abuse and the Conflict Tactics Scale. This survey was administered to all consenting adult men who presented to the ED. Odds ratios (OR) with 95% CI were calculated when appropriate and a p-value of 0.05 was set for significance. RESULTS: The one-year point prevalence rate of male IPV was 24% in our study population (82/346). Among the men who experienced some form of abuse specified as either physical, emotional, or sexual, the prevalence was calculated to be 15.6% (54/346), 13.6% (47/346), and 2.6% (9/346), respectively. Education, income, age, and race did not demonstrate an association for any one variable to be associated with intimate partner abuse (p>0.05) with the exception of increased risk of IPV among unemployed men in the relationship (p<0.04, OR 0.592). IPV towards men was found to affect both heterosexual as well as homosexual relationships. Overall, 2% (8/346) of the men surveyed had received medical treatment as a result of IPV by their intimate partner within the past year. Three percent (11/344) of those men reporting abuse were abusers themselves. CONCLUSION: The point prevalence of IPV among our study population was 24%. In our study of 346 men, male IPV crossed all socioeconomic boundaries, racial differences, and educational levels regardless of the sex of the partner.