Christopher Sampson

Life-threatening diphenhydramine toxicity presenting with seizures and a wide complex tachycardia improved with intravenous fat emulsion.

Diphenhydramine toxicity manifests with signs of anticholinergic toxicity; therapy is generally supportive. In rare cases, patients can also present with a wide complex tachycardia due to sodium channel blockade. Treatment involves sodium bicarbonate. Lidocaine and hypertonic saline are used for arrhythmias refractory to sodium bicarbonate. Although intravenous fat emulsion (IFE) therapy is proposed as an adjunctive therapy due to the lipophilicity of diphenhydramine (octanol/water partition coefficient of 3.3), successful use of IFE after a confirmed sole ingestion of diphenhydramine is not previously reported. We present the case of a 30-year-old woman presenting with seizures, a wide complex tachycardia, and cardiovascular collapse after an ingestion of diphenhydramine refractory to other therapies with rapid improvement after IFE administration.

Withdrawal Seizures Seen In the Setting of Synthetic Cannabinoid Abuse

The recent rise in the abuse of synthetic cannabinoid receptor agonists (Spice, K2) has led to an increase of patients presenting to emergency departments (EDs) with complications stemming from their abuse. We present a case of withdrawal seizures seen in a chronic abuser of these herbal mixtures who stopped using them abruptly. Seizures have been reported in the literature in the setting of abuse, but not during withdrawal [1]. A 29-year-old man with a history of depression and polysubstance abuse presented to our ED with the complaint of a seizure. The patient reported getting dressed that morning and the next event he could remember was awakening inside the ambulance. Paramedics reported witnessing full body shaking consistent with a tonic-clonic seizure. The seizure activity resolved spontaneously, and this was followed by a postictal state. The patient denied any bladder or bowel incontinence or tongue biting. He did although report his tongue being sore. The patient admitted to smoking “K2” on at least a daily basis. The patient also admitted to drinking a large quantity of gin the previous night and woke up with “hangover” symptoms. The patient’ sl ast K2 use was more than than 24 hours before the seizure. The patient denied any previous seizures history other than 2 months ago when he last stopped abruptly usingsynthetic cannabinoids.Atthat time,the patient had stopped the synthetic cannabinoid abuse for approximately 24 to 36 hours and had onset of seizure-like activity, which led to injuries resulting in compression fractures of multiple thoracic vertebrae (T3 and T4). He presented to our ED then to be evaluated for back pain, but received no investigations for his seizure activity. While in the ED for this current evaluation, the patient proceeded to have 3 witnessedepisodes of generalized tonic-clonic activityin back to back fashion without return of consciousness. These episodes were preceded by profuse diaphoresis. Intravenous lorazepam was given, and no further seizure activity was witnessed. The patient was loaded with 15mg/kg of fosphenytoin. Bloodwork obtained in the ED was notable for an elevated white blood cell count of 13.4 × 10 9 /L. A urine

High-pressure water injection injury

Patients that present with high-pressure injection injuries most often have hand or digital involvement. Overall, high-pressure injection injuries to the hand are uncommon and tend to be occupation related. The usual cause is industrial equipment, with machinery such as grease guns, spray guns and diesel engine injectors accounting for most of these injuries. Materials injected include the following reported substances: paint, paint thinner, grease, oil, hydraulic fluid, plastic, wax, water and semifluid cement. The extent of damage from high-pressure injection injuries depends on a number of physical, chemical and biological factors, including the type, amount and velocity of injected material and the anatomical location of the injury. For any injury that results in a significant depth of penetration, the most important determinant of the extent of injury is the chemical composition of the injected material. This determines the likely tissue inflammatory response and the resulting fibrosis that develops during healing. Paint and paint thinner produce a large, early inflammatory response and result in a high percentage of amputations. In contrast, grease injuries cause a small inflammatory response and have a lower amputation rate but are associated with oleogranuloma formation, fistulas, scarring and loss of digit function. The amount of material injected into the confined space of the digits or palm determines the degree of mechanical distention and the potential for vascular compromise. The velocity of the injected material and the site of tissue penetration determine anatomical dispersion, which for upper extremity injuries may include the digit, hand and forearm [1]. The patient who seeks treatment early after injury may have minimal symptoms with either an innocuous entrance wound or no visible break in the skin. Fusiform swelling resulting from mechanical distention of the tissue by the injectant will usually be apparent. Several hours later, the involved digit or palm may become extremely painful, swollen and pale because of vascular compromise and tissue necrosis [1]. The incidence of high-pressure water injection injury to the mouth or oral cavity appears to be quite rare. A literature search of MEDLINE yielded no reports of high-pressure injuries to this region. The only literature detailing an oral water injury was described by Duplechain et al. in 1993 [2]. They reported on a 5-year-old girl who suffered an injury from a much lower pressure bathtub water spout. Here we describe a recent oral injury from a high power pressure washer.

Lipid emulsion therapy given intraosseously in massive verapamil overdose

Intravenous fat emulsion (IFE) therapy has been widely used in the emergency department (ED) for treating various medication overdoses. The standard recommended route to administer IFE therapy is intravenously through a peripheral or central vein. No reports of intraosseous (IO) administration in humans could be found in the literature after a brief search. We report of a patient emergently receiving IFE through the IO route. A 24-year-old woman presented to ED after a massive deliberate verapamil overdose. A decision was then made to start both vasopressors and 20% IFE therapy. Central access was established, and a norepinephrine drip was started. Intravenous fat emulsion was to be started, but peripheral access was lost at that time and not able to be reestablished. An IO line was then placed without difficulty in the left proximal tibia using an EZ-IO system. Approximately half way during the bolus administration, the intravenous pump began to alarm that the infusion was not flowing adequately. At this point, peripheral access was obtained, and IFE infusion was moved to that site. We believe that this is the first report of IFE administered via the IO route in a human. This case report illustrates a novel way of administering IFE therapy in an emergency situation where intravenous access may be difficult to obtain.

Academic Primer Series: Key Papers About Peer Review

Introduction Peer review, a cornerstone of academia, promotes rigor and relevance in scientific publishing. As educators are encouraged to adopt a more scholarly approach to medical education, peer review is becoming increasingly important. Junior educators both receive the reviews of their peers, and are also asked to participate as reviewers themselves. As such, it is imperative for junior clinician educators to be well-versed in the art of peer reviewing their colleagues’ work. In this article, our goal was to identify and summarize key papers that may be helpful for faculty members interested in learning more about the peer-review process and how to improve their reviewing skills. Methods The online discussions of the 2016–17 Academic Life in Emergency Medicine (ALiEM) Faculty Incubator program included a robust discussion about peer review, which highlighted a number of papers on that topic. We sought to augment this list with further suggestions by guest experts and by an open call on Twitter for other important papers. Via this process, we created a list of 24 total papers on the topic of peer review. After gathering these papers, our authorship group engaged in a consensus-building process incorporating Delphi methods to identify the papers that best described peer review, and also highlighted important tips for new reviewers. Results We found and reviewed 24 papers. In our results section, we present our authorship group’s top five most highly rated papers on the topic of peer review. We also summarize these papers with respect to their relevance to junior faculty members and to faculty developers. Conclusion We present five key papers on peer review that can be used for faculty development for novice writers and reviewers. These papers represent a mix of foundational and explanatory papers that may provide some basis from which junior faculty members might build upon as they both undergo the peer-review process and act as reviewers in turn.

Curated Collections for Educators: Five Key Papers on Evaluating Digital Scholarship

Traditionally, scholarship that was recognized for promotion and tenure consisted of clinical research, bench research, and grant funding. Recent trends have allowed for differing approaches to scholarship, including digital publication. As increasing numbers of trainees and faculty turn to online educational resources, it is imperative to critically evaluate these resources. This article summarizes five key papers that address the appraisal of digital scholarship and describes their relevance to junior clinician educators and faculty developers. In May 2017, the Academic Life in Emergency Medicine Faculty Incubator program focused on the topic of digital scholarship, providing and discussing papers relevant to the topic. We augmented this list of papers with further suggestions by guest experts and by an open call via Twitter for other important papers. Through this process, we created a list of 38 papers in total on the topic of evaluating digital scholarship. In order to determine which of these papers best describe how to evaluate digital scholarship, the authorship group assessed the papers using a modified Delphi approach to build consensus. In this paper we present the five most highly rated papers from our process about evaluating digital scholarship. We summarize each paper and discuss its specific relevance to junior faculty members and to faculty developers. These papers provide a framework for assessing the quality of digital scholarship, so that junior faculty can recommend high-quality educational resources to their trainees. These papers help guide educators on how to produce high quality digital scholarship and maximize recognition and credit in respect to receiving promotion and tenure.

Effect of Commuter Time on Emergency Medicine Residents

Background The impact of resident work hours on resident well-being and patient safety has long been a controversial issue. Objectives What has not been considered in resident work hour limitations is whether resident commuting time has any impact on a residents total work hours or well-being. Methods A self-administered electronic survey was distributed to emergency medicine residents in 2016. Results The survey response was 8% (569/6828). Commuter time was 30 minutes or less in 70%. Two residents reported a commuter time of 76 to 90 minutes and one resident had a commuter time of 91 to 105 minutes. None reported commuter times greater than 105 minutes. Of most concern was that 29.3% of the residents reported falling asleep while driving their car home from work. We found 12% of respondents reporting being involved in a car collision while commuting. For residents with commute times greater than one hour, 66% reported they had fallen asleep while driving. When asked their opinion on the effect of commute time, those with commute times greater than one hour (75% of residents) responded that it was detrimental. Conclusions While the majority of emergency medicine residents in this survey have commuter times of 30 minutes or less, there is a small population of residents with commuter times of 76 to 105 minutes. At times, residents whose commute is up to 105 minutes each way could be traveling a total of more than 3.5 hours for each round trip. Given that these residents often work 12-hour shifts, these extended commuter times may be having detrimental effects on their health and well-being.