Brad S Selden

THE INCIDENCE OF WOUND INFECTION FOLLOWING CROTALID ENVENOMATION

Many sources advocate the empiric use of antibiotics to prevent wound infection (WI) following crotalid (rattlesnake) envenomations. We undertook a prospective observational study to examine the incidence of infections following crotalid envenomation. We studied crotalid envenomations presenting to our institution with follow-up by direct examination or telephone consultation. All patients presenting to our institution from June 1990 to October 1991 with history and clinical evidence of crotalid envenomation were included in the analysis. Routine management of crotalid envenomation was undertaken in each case, including the use of antivenin, surgical debridement, and antibiotics only when indicated by signs and symptoms of infection. A total of 54 patients were observed during the study period. Twelve patients received prophylactic antibiotics begun either prior to transfer to our institution or following a surgical procedure, and were evaluated separately. Follow-up was obtained on 32 patients 7 or more days following envenomation. Only 1 patient from the study group developed clinical evidence of WI during the study period. We conclude that because of a low incidence of WI in this series, the routine use of prophylactic antibiotics in such patients may not be warranted.

Adolescent epidemic hysteria presenting as a mass casualty, toxic exposure incident

Discussed is a case of explosive epidemic hysteria presenting as a mass casualty, toxic inhalation incident. Fifteen adolescent female students were triaged from a school of 700 persons exposed to sewer gas and arrived simultaneously at the emergency department complaining of a variety of nonspecific symptoms without physical findings. These symptoms quickly remitted with reassurance and dispersion of the group. Factors important in the recognition and treatment of epidemic hysteria are presented.

The “No-Patient” Run: 2,698 Patients Evaluated but Not Transported by Paramedics

Patients evaluated by paramedics but not transported by ambulance to the hospital (“no-patient” runs or NPR) form a large part of the volume of ambulance runs in many emergency medical service (EMS) systems and account for 50–90 % of litigation brought against paramedics. Since there are no published studies of this important population, this paper provides a demographic description of the encounters and the prehospital patient disposition in one EMS system. Of all EMS runs for 1987 in the system studied, 2,698 (26.1 %) met NPR criteria. Mean run time for the NPR was 18.5±10.5 min versus 43.1 min for patients transported. The proportion of NPR was unrelated to sex or EMS response type, but was increased in those over age 40 years (p This is the first study of NPR in an EMS system. It describes patient demographics, disposition, and differences from transported patients. Emergency Medical Services providers specifically should examine this population in their systems to maintain patient care standards and decrease medicolegal risks.

Medicolegal documentation of prehospital triage

Patients evaluated by paramedics but not transported to the hospital account for 50% to 90% of emergency medical services lawsuits. We reviewed 2,698 consecutive paramedic run reports to examine documentation in these cases. Documentation criteria for prehospital patient release were history, physical examination, vital signs, mental status, lack of significant mental impairment, and for patients refusing care, that risks of refusing were understood. Criteria for appropriate release were met in 65.2% of cases. Criteria omitted in inappropriate releases were risks of refusing care in 481 (51.3% of inappropriate releases), vitals in 320 (34.1%), mental status in 188 (20.0%), lack of impairment in 120 (12.8%), and history or physical in 19 (2.0%) cases. Age from 0 to 14 and 65 or more years and prehospital assessment of hyperventilation, psychiatric emergency, choking, infection, and patient deceased were significantly associated with appropriate release. Age from 35 to 54 years and prehospital diagnosis of no injury, head injury, seizure, minor trauma, and ethanol use were significantly associated with inappropriate releases. There was no association of appropriate release or inappropriate release with patient sex, contact with medical control, length of encounter, or time of day. Only one patient complication was believed due to inappropriate triage; this could be improved by implementation of standardized criteria.

Complete maternal and fetal recovery after prolonged cardiac arrest

A case of complete maternal and fetal recovery after prolonged cardiac arrest from massive lidocaine overdose is presented. A 27-year-old woman at 15 weeks gestation had a complete neurologic recovery after 22 minutes of CPR, including 19 minutes of electromechanical dissociation and asystole, with normal fetal heart function and fetal motion confirmed by ultrasound immediately after resuscitation. The patient delivered a healthy and neurologically normal infant at 40 weeks gestation. This is the longest cardiac arrest in early pregnancy reported in the medical literature with normal maternal and fetal outcome.

Optimal patient position for transport and initial management of toxic ingestions

STUDY OBJECTIVES Many factors influence the rate of gastric emptying and therefore the rate of drug absorption in the orally poisoned patient. Limited studies have evaluated the effect of body position on the rate of gastric emptying of radiographically marked foods and contrast media, but effects on drug absorption have not been studied previously. Our hypothesis was that body position would have an effect on the rate of drug absorption in an oral overdose model. DESIGN A blinded, within-subjects (crossover) design. PARTICIPANTS Six male and six female healthy, adult volunteer subjects with no concurrent drug use or medications affecting gastrointestinal function. INTERVENTIONS Five body positions commonly used in prehospital and emergency department settings were examined: left lateral decubitus, right lateral decubitus, supine, prone, and sitting. All were performed by all subjects in random order with a three-day washout phase between trials. To simulate an acute overdose, fasted subjects ingested 80 mg/kg acetaminophen in the form of 160-mg pediatric tablets. Each subject then remained in the body position for that trial for two hours. Acetaminophen levels were obtained at 15-minute intervals, and a two-hour area under the curve (AUC) was calculated for each subject trial to represent total drug absorption during each study period. Investigators were blinded to all results until all trials were completed. MEASUREMENTS AND MAIN RESULTS All subjects completed the study. Group mean drug absorption as represented by two-hour AUC (mg.L.min) was calculated for each body position. AUC for left lateral decubitus (6,006 +/- 2,614) was lowest but did not significantly differ from that for supine (6,649 +/- 2,761). Both were significantly less than those for prone (7,432 +/- 1,809), right lateral decubitus (8,950 +/- 1,405), and sitting (8,608 +/- 1,725) positions (P less than .05 by one-way analysis of variance and follow-up paired t tests). CONCLUSION Initial drug absorption as determined by two-hour AUC was lowest in the left lateral decubitus position. Although the difference between the left lateral decubitus and supine positions did not reach statistical significance, both left lateral decubitus and supine were significantly lower than three other common patient body positions tested. Because the left lateral decubitus position has other advantages (eg, prevention of aspiration) in addition to minimizing drug absorption, we recommend that orally poisoned patients be placed in the left lateral decubitus position for prehospital and initial ED management.

Relief by naloxone of morphine-induced spasm of the sphincter of Oddi in a post-cholecystectomy patient.

Spasm of the sphincter of Oddi is a well-recognized effect of the narcotic class of drugs. Although it is usually clinically silent, such spasm occasionally causes debilitating pain that may be mistaken for more serious disorders. We present the case of a patient who had undergone cholecystectomy previously, but in whom morphine given in the Emergency Department precipitated pain consistent with biliary colic; the pain resolved promptly after administration of naloxone. This entity may considered in the differential diagnosis of acute onset of colicky abdominal pain in the patient given narcotics.