Showing papers in "Journal of Emergency Medicine in 2014"

Case Report of Electronic Cigarettes Possibly Associated with Eosinophilic Pneumonitis in a Previously Healthy Active-duty Sailor

Abstract: Background Electronic cigarettes (e-cigarettes) are a technology that has been touted as a safe and effective alternative to traditional cigarettes. There is, however, a paucity of literature showing the adverse outcomes of e-cigarettes and a correlation with acute eosinophilic pneumonia (AEP). Objective To present a possible association between e-cigarettes and AEP. Case Report A 20-year-old previously healthy man was found to develop AEP after smoking an e-cigarette. He was treated with antibiotics and steroids and his symptoms improved. Conclusion Though an alternative to traditional cigarettes, e-cigarettes can have unpredictable and potentially serious adverse effects. More research needs to be conducted to determine their safety. If seeing a patient in the ED with pulmonary symptoms after use of e-cigarettes, AEP should be considered in the differential.

Synthetic cathinones ("bath salts").

Abstract: Background Synthetic cathinones are popularly referred to in the media as “bath salts.” Through the direct and indirect activation of the sympathetic nervous system, smoking, snorting, or injecting synthetic cathinones can result in tachycardia, hypertension, hyperthermia, myocardial infarction, and death. Objective The chemical structures and names of bath salts identified by the Ohio Attorney General's Bureau of Criminal Investigation are presented. Based on their common pharmacophores, we review the history, pharmacology, toxicology, detection methods, and clinical implications of synthetic cathinones. Through the integration of this information, the pharmacological basis for the management of patients using synthetic cathinones is presented. Discussion Synthetic cathinones activate central serotonergic and dopaminergic systems contributing to acute psychosis and the peripheral activation of the sympathetic nervous system. The overstimulation of the sympathetic nervous system contributes to the many toxicities reported with bath salt use. The pharmacological basis for managing these patients is targeted at attenuating the activation of these systems. Conclusions Treatment of patients presenting after using bath salts should be focused on reducing agitation and psychosis and supporting renal perfusion. The majority of successfully treated synthetic cathinones cases have used benzodiazepines and antipsychotics along with general supportive care.

Bedside Ultrasound Maximizes Patient Satisfaction

Abstract: Background Bedside ultrasound (US) is associated with improved patient satisfaction, perhaps as a consequence of improved time to diagnosis and decreased length of stay (LOS). Objectives Our study aimed to quantify the association between beside US and patient satisfaction and to assess patient attitudes toward US and perception of their interaction with the clinician performing the examination. Methods We enrolled a convenience sample of adult patients who received a bedside US. The control group had similar LOS and presenting complaints but did not have a bedside US. Both groups answered survey questions during their emergency department (ED) visit and again by telephone 1 week later. The questionnaire assessed patient perceptions and satisfaction on a 5-point Likert scale. Results Seventy patients were enrolled over 10 months. The intervention group had significantly higher scores on overall ED satisfaction (4.69 vs. 4.23; mean difference 0.46; 95% confidence interval [CI] 0.17–0.75), diagnostic testing (4.54 vs. 4.09; mean difference 0.46; 95% CI 0.16–0.76), and skills/abilities of the emergency physician (4.77 vs. 4.14; mean difference 0.63; 95% CI 0.29–0.96). A trend to higher scores for the intervention group persisted on follow-up survey. Conclusions Patients who had a bedside US had statistically significant higher satisfaction scores with overall ED care, diagnostic testing, and with their perception of the emergency physician. Bedside US has the potential not only to expedite care and diagnosis, but also to maximize satisfaction scores and improve the patient–physician relationship, which has increasing relevance to health care organizations and hospitals that rely on satisfaction surveys.

Ultrasound exposure during gross anatomy.

Abstract: Background As medical schools seek to standardize ultrasound training and incorporate clinical correlations into the basic science years, we proposed that ultrasonography should have a greater role in the anatomy curriculum. Objectives To describe the introduction of ultrasound into the curriculum of a first-year medical student anatomy course and evaluate the utility of this introduction. Methods First-year medical students attended two ultrasound lectures and three small-group hands-on sessions that focused on selected aspects of musculoskeletal, thoracic, abdominal, and neck anatomy. Pre and post surveys were administered to assess student perception of their ability to obtain and interpret ultrasound images and the utility of ultrasound in the anatomy course. Understanding of basic ultrasound techniques and imaging was tested in the practical examinations. Results Of the 269 first-year medical students who completed the course, 144 students completed both surveys entirely, with a response rate of 53%. Students' interest and self-perceived experience, comfort, and confidence in ultrasound skills significantly increased (p Conclusions Ultrasound can be effectively incorporated into an anatomy course for first-year medical students by utilizing didactics and hands-on exposure. Medical students found the addition of ultrasound training to be valuable, not only in enhancing their understanding of anatomy, but also in increasing their interest and experience in ultrasound imaging.

A Review of Methylene Blue Treatment for Cardiovascular Collapse

Abstract: Background Historically, methylene blue (MB) has been used for multiple purposes, including as an antidote for toxin-induced and hereditary methemoglobinemia, ifosfamide-induced encephalopathy, and ackee fruit and cyanide poisoning; as an aniline dye derivative, antimalarial agent, and antidepressant. Discussion Most recently, the use of MB has been advocated as a potential adjunct in the treatment of shock states. Our article reviews the role of MB in septic shock, anaphylactic shock, and toxin-induced shock. MB is proposed to increase blood pressure in these shock states by interfering with guanylate cyclase activity, and preventing cyclic guanosine monophosphate production and vasodilatation. Summary MB may be an adjunct in the treatment of septic shock, anaphylactic shock, and toxin-induced shock.

Pain management: association with patient satisfaction among emergency department patients.

Abstract: Background Patient satisfaction with emergency care is associated with timeliness of care, empathy, technical competence, and information delivery. Previous studies have demonstrated inconsistent findings regarding the association between pain management and patient satisfaction. Objectives This study was undertaken to determine the association between pain management and patient satisfaction among Emergency Department (ED) patients presenting with acute painful conditions. Methods In this survey study, a standardized interview was conducted at the Emergency Department at the University of Toledo Medical Center in May–July 2011. Participants were asked to answer 18 questions pertaining to patient satisfaction. Additional data collected included demographic information, pain scores, and clinical management. Results Among 328 eligible participants, 289 (88%) participated. The mean triage pain score on the verbal numeric rating scale was 8.2 and the mean discharge score was 6.0. The majority of patients (52%) experienced a reduction in pain of 2 or more points. Participants received one pain medication dose (44%), two medication doses (14%), three medication doses (5%), or four medication doses (2%). Reduction in pain scores of 2 or more points was associated with a higher number of medications administered. Reduction in pain scores was associated with higher satisfaction as scored on questions of patient perceptions of adequate assessment and response to pain, and treatment of pain. Conclusions There was a significant association between patient satisfaction and a reduction in pain of 2 or more points and number of medications administered. Effective pain management is associated with improved patient satisfaction among ED patients with painful conditions.

Crush Syndrome: A Case Report and Review of the Literature

Abstract: Background Crush trauma to the extremities, even if not involving vital organs, can be life threatening. Crush syndrome, the systemic manifestation of the breakdown of muscle cells with release of contents into the circulation, leads to metabolic derangement and acute kidney injury. Although common in disaster scenarios, emergency physicians also see the syndrome in patients after motor-vehicle collisions and patients "found down" due to intoxication. Objective The objectives of this review are to discuss the pathophysiology of crush syndrome, report on prehospital and emergency department treatment, and discuss the relationship between crush syndrome and compartment syndrome. Discussion We present the case of a young man found down after an episode of intoxication, with compartment syndrome of his lower extremity and crush syndrome. Although he eventually required an amputation, aggressive fluid resuscitation prevented further kidney injury and metabolic derangement. Conclusions Early, aggressive resuscitation in the prehospital setting, before extrication if possible, is recommended to reduce the complications of crush syndrome. Providers must be aware of the risk of hyperkalemia shortly after extrication. Ongoing resuscitation with i.v. fluids is the mainstay of treatment. Compartment syndrome is a common complication, and prompt fasciotomies should be performed when compartment syndrome is present.

Cannabis-associated Myocardial Infarction in a Young Man with Normal Coronary Arteries

Abstract: Background The use of cannabis is not usually regarded as a risk factor for acute coronary syndrome. However, several cases of myocardial infarction (MI) associated with cannabis use have been reported in the scientific literature. The etiology of this phenomenon is not known. Objectives To present a case of cannabis-associated MI in which atherosclerotic coronary disease was excluded as a potential etiology by intravascular ultrasound examination, and briefly review the other possible mechanisms by which this effect may be mediated. Case Report We present the case of a previously healthy 21-year-old man who regularly smoked cannabis and presented to the Emergency Department with ST-elevation myocardial infarction after participating in a sport. He was also a cigarette smoker, but had no other conventional cardiovascular risk factors. At coronary angiography, a large amount of thrombus was found in the left anterior descending coronary artery. He recovered with medical treatment, and subsequent intravascular ultrasound examination showed no evidence of atherosclerosis at the site of the thrombus. Conclusion Cannabis-associated MI is increasingly recognized. The etiology is unclear, but we believe this is the first report of the phenomenon where atherosclerotic plaque rupture has been excluded as the cause with a high degree of confidence.

Integration of palliative care into emergency medicine: the Improving Palliative Care in Emergency Medicine (IPAL-EM) collaboration.

Abstract: Background Emergency department (ED) providers commonly care for seriously ill patients who suffer from advanced, chronic, life-limiting illnesses in addition to those that are acutely ill or injured. Both the chronically ill and those who present in extremis may benefit from application of palliative care principles. Case report We present a case highlighting the opportunities and need for better integration of emergency medicine and palliative care. Discussion We offer practical guidelines to the ED faculty/administrators who seek to enhance the quality of patient care in their own unique ED setting by starting an initiative that better integrates palliative principles into daily practice. Specifically, we outline four things to do to jumpstart this collaborative effort. Conclusion The Improving Palliative Care in Emergency Medicine project sponsored by the Center to Advance Palliative Care is a resource that assists ED health care providers with the process and structure needed to integrate palliative care into the ED setting.

Prospective evaluation of prehospital trauma ultrasound during aeromedical transport.

Abstract: Background Ultrasound is widely considered the initial diagnostic imaging modality for trauma. Preliminary studies have explored the use of trauma ultrasound in the prehospital setting, but the accuracy and potential utility is not well understood. Objective We sought to determine the accuracy of trauma ultrasound performed by helicopter emergency medical service (HEMS) providers. Methods Trauma ultrasound was performed in flight on adult patients during a 7-month period. Accuracy of the abdominal, cardiac, and lung components was determined by comparison to the presence of injury, primarily determined by computed tomography, and to required interventions. Results HEMS providers performed ultrasound on 293 patients during a 7-month period, completing 211 full extended Focused Assessment with Sonography for Trauma (EFAST) studies. HEMS providers interpreted 11% of studies as indeterminate. Sensitivity and specificity for hemoperitoneum was 46% (95% confidence interval [CI] 27.1%–94.1%) and 94.1% (95% CI 89.2%–97%), and for laparotomy 64.7% (95% CI 38.6%–84.7%) and 94% (95% CI 89.2%–96.8%), respectively. Sensitivity and specificity for pneumothorax were 18.7% (95% CI 8.9%–33.9%) and 99.5% (95% CI 98.2%–99.9%), and for thoracostomy were 50% (95% CI 22.3%–58.7%) and 99.8% (98.6%–100%), respectively. The positive likelihood ratio for laparotomy was 10.7 (95% CI 5.5–21) and for thoracostomy 235 (95% CI 31−1758), and the negative likelihood ratios were 0.4 (95% CI 0.2–0.7) and 0.5 (95% CI 0.3–0.8), respectively. Of 240 cardiac studies, there was one false-positive and three false-negative interpretations (none requiring intervention). Conclusions HEMS providers performed EFAST with moderate accuracy. Specificity was high and positive interpretations raised the probability of injury requiring intervention. Negative interpretations were predictive, but sensitivity was not sufficient for ruling out injury.

A Randomized Controlled Trial to Reduce Prehospital Delay Time in Patients With Acute Coronary Syndrome (ACS)

Abstract: Background The literature suggests that people delay too long prior to attending emergency departments with acute coronary syndrome (ACS) symptoms. This delay is referred to as prehospital delay. Patient decision delay contributes most significantly to prehospital delay. Objectives Using a randomized controlled trial, we tested an educational intervention to reduce patient prehospital delay in ACS and promote appropriate responses to symptoms. Methods Eligible patients who were admitted across five emergency departments (EDs) in Dublin were recruited to the study (n = 1944; control: 972, intervention: 972). Results Median baseline prehospital delay times did not differ significantly between the groups at baseline (Mann-Whitney U, p = 0.34) (Control: 4.28 h, 25th percentile = 1.71, 75th percentile = 17.37; Intervention 3.96 h, 25th percentile = 1.53, 75th percentile = 18.51). Both groups received usual in-hospital care. In addition, patients randomized to the intervention group received a 40-min individualized education session using motivational techniques. This was reinforced 1 month later by telephone. Of the 1944, 314 (16.2%) were readmitted with ACS symptoms: 177 (18.2%) and 137 (14.1%) of the intervention and control groups, respectively. Prehospital delay times were again measured. Median delay time was significantly lower in the intervention compared to the control group (1.7 h vs. 7.1 h; p ≤ 0.001). Appropriately, those in the intervention group reported their symptoms more promptly to another person (p = 0.01) and fewer consulted a general practitioner (p = 0.02). There was no significant difference in ambulance use (p = 0.51) or nitrate use (p = 0.06) between the groups. Conclusion It is possible to reduce prehospital delay time in ACS, but the need for renewed emphasis on ambulance use is important.

Short-term unscheduled return visits of adult patients to the emergency department

Abstract: Background Emergency department (ED) crowding is a major international concern that affects patients and providers. Study Objective We describe the characteristics of patients who had an unscheduled related return visit to the ED and investigate its relation to ED crowding. Methods Retrospective medical record review of all unscheduled related ED return visits by patients older than 16 years of age over a 1-year period. The top quartile of ED occupancy rates was defined as ED crowding. Results Eight hundred thirty-seven patients (1.9%) made an unscheduled related return visit. Length of stay (LOS) at the ED for the index visit and the LOS for the return visit (5 h, 54 min vs. 6 h, 51 min) were significantly different, as were the percent admitted (11.6% vs. 46.1%). Of these patients, 85.1% and 12.0% returned due to persistence or a wrong initial diagnosis, of their initial illness, respectively, and 2.9% returned due to an adverse event related to the treatment initially received. Patients presented the least frequently with an alcohol-related complaint during the index visit (480 patients), but they had the highest number of unscheduled return visits (45 patients; 9.4%). Unscheduled related return visits were not associated with ED crowding. Conclusion Return visits impose additional pressure on the ED, because return patients have a significantly longer LOS at the ED. However, the rate of unscheduled return visits and ED crowding was not related. Because this parameter serves as an essential quality assurance tool, we can assume that the studied hospital scores well on this particular parameter.

A systematic review of vapocoolants for reducing pain from venipuncture and venous cannulation in children and adults.

Abstract: Background Studies of vapocoolants for pain reduction from venipuncture have demonstrated conflicting results. Objective Our aim was to systematically review the literature regarding the analgesic effectiveness of vapocoolants in children and adults. Methods We searched MEDLINE, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane Central Register of Trials using key words: vapocoolant, pain, venipuncture, and cannulation. We included randomized or quasi-randomized studies comparing vapocoolants to placebo or no treatment. Two authors reviewed titles and abstracts and extracted data. Quality was assessed by consensus using the Cochrane risk of bias tool. The primary outcome was self-reported pain using a 100-mm visual analog scale, a 0- to 10-point numerical scale, or observational scale for preverbal children. Data were pooled using a random effects model. Results Twelve studies including 1266 patients (509 children, 757 adults) were identified. No significant pain reduction was found in children receiving vapocoolants vs. placebo or no treatment (mean difference −10 mm; 95% confidence interval [CI] −26 to 6). In adults, less pain was reported when vapocoolants were compared with no treatment: −10 mm on a 100-mm scale (95% CI −17 to −4); but not when compared to placebo (−12 mm; 95% CI −26 to 2). Pain from application of vapocoolants was greater than placebo (8 mm; 95% CI 4 to 2). Conclusions Vapocoolants were ineffective in children and adults when compared to placebo, and effective in adults only when compared to no treatment. The magnitude of effect was low and was offset by increased pain from application. They cannot be recommended for routine use in children or adults.

Location of the Appendix in the Gravid Patient

Abstract: Background Several studies have attempted to support or dispel the teaching of appendix movement away from the right lower quadrant (RLQ) during pregnancy with contradictory results. Objective This study investigated the location of the appendix in the gravid patient in an emergency department (ED) setting using computed tomography (CT). Methods This was a retrospective chart review of consecutive gravid patients presenting to the ED for trauma who required abdominal CT. The patient population was obtained using the Vidant Medical Center Trauma Registry from January 1, 2000 to December 31, 2006. The abdomen was divided into nine regions using the mid-clavicular lines, superior anterior iliac spine, and umbilicus. A single Board-certified radiologist determined the region location of the appendix. Results Forty-five patients were identified and 35 were studied. Ten patients were excluded due to appendix not identified, unknown gestational age, or inability to review the CT study. In 21 of 22 third-trimester pregnancies, the appendix was not found in the right lower region (RLR), which corresponded to the RLQ. All 11 patients in the second trimester did not have the appendix in the RLR. Two patients were identified in the first trimester and neither appendix was found in the RLR. Conclusions The appendix in the gravid patient was not found in the RLR with increasing frequency as pregnancy progressed.