Daniel Lasoff

Loperamide Trends in Abuse and Misuse Over 13 Years: 2002–2015

With the increasing amount of information available on the Internet describing techniques for using loperamide either for self‐treatment of opioid withdrawal syndromes or for recreational use (so‐called legal highs), the objective was to describe a statewide poison control systems experience with loperamide misuse and abuse, with specific interest in cases of cardiotoxicity, and to determine if reported loperamide misuse or abuse cases have recently increased.

The Treatment of Acute Pain in the Emergency Department: A White Paper Position Statement Prepared for the American Academy of Emergency Medicine

BACKGROUND Pain is one of the most common reasons patients present to the emergency department (ED). Emergency physicians should be aware of the numerous opioid and nonopioid alternatives available for the treatment of pain. OBJECTIVES To provide expert consensus guidelines for the safe and effective treatment of acute pain in the ED. METHODS Multiple independent literature searches using PubMed were performed regarding treatment of acute pain. A multidisciplinary panel of experts in Pharmacology and Emergency Medicine reviewed and discussed the literature to develop consensus guidelines. RECOMMENDATIONS The guidelines provide resources for the safe use of opioids in the ED as well as pharmacological and nonpharmacological alternatives to opioid analgesia. Care should be tailored to the patient based on their specific acute painful condition and underlying risk factors and comorbidities. CONCLUSIONS Analgesia in the ED should be provided in the most safe and judicious manner, with the goals of relieving acute pain while decreasing the risk of complications and opioid dependence.

An Unusual Case of an Icteric Infant with Abdominal Distention

BACKGROUND Jaundiced infants are uncommon in most emergency departments (EDs). Biliary rupture remains one of the more rare and less described causes of this condition. CASE REPORT A 5-month-old male presented to our ED with scleral icterus, increasing abdominal distention, and increased irritability. A bedside ultrasound revealed a moderate amount of ascites and further imaging suggested he had a rupture of his common bile duct. Surgical exploration confirmed this and revealed the presence of choledocholithiasis, which was the likely cause of the rupture. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Biliary rupture remains a rare but serious condition in very young patients. Emergency physicians should consider bedside ultrasound as an adjunct in undifferentiated abdominal distention or jaundice in this patient population.

Perampanel overdose causing a prolonged coma

Wen-Loung Lin Taichung Wildlife Conservation Group, Taichung, Taiwan Yan-Chiao Mao Division of Clinical Toxicology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan School of Medicine, National Defense Medical Center, Taipei, Taiwan Division of Clinical Toxicology and Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan doc1385e@gmail.com

Death associated with intravenous turmeric (Curcumin) preparation

Dear Editor,Curcumin, the principal curcuminoid present in turmeric, has been touted as having therapeutic effects on several pathways involved in inflammation and cancer [1]. Because of this, many...

Factors and outcomes associated with inpatient cardiac arrest following emergent endotracheal intubation

BACKGROUND Inpatient peri-intubation cardiac arrest (PICA) following emergent endotracheal intubation (ETI) is an uncommon but potentially preventable type of cardiac arrest (CA). Limited published data exist describing factors associated with inpatient PICA and patient outcomes. This study identifies risk factors associated with PICA among hospitalized patients emergently intubated out of the operating room and compares PICA to other types of inpatient CA. METHODS Retrospective case-control study of patients at our institution over a five-year period. Cases were defined as inpatients emergently intubated outside of the operating room that experienced cardiac arrest within 20min after ETI. The control group consisted of inpatients emergently intubated out of the operating room without CA. Predictors of PICA were identified through univariate and multivariate analysis. Clinical outcomes were compared between PICA and other inpatient CAs, identified through a prospectively enrolled CA registry at our institution. RESULTS 29 episodes of PICA occurred over 5 years, accounting for 5% of all inpatient arrests. Shock index ≥1.0, intubation within one hour of nursing shift change, and use of succinylcholine were independently associated with PICA. Sustained ROSC, survival to discharge, and neurocognitive outcome did not differ significantly between groups. CONCLUSION Patients outcomes following PICA were comparable to other causes of inpatient CA. Potentially modifiable factors were associated with PICA. Hemodynamic resuscitation, optimized staffing strategies, and possible avoidance of succinylcholine were associated with decreased risk of PICA. Clinical trials testing targeted strategies to optimize peri-intubation care are needed to identify effective interventions to prevent this potentially avoidable type of CA.

Proning: Outcomes of Use of Force Followed With Prone Restraint

Background: EMS and police are often faced with violent subjects that require the use of force and the application of restraints. After gaining control and restraining subjects, he or she can be physically placed into a number of positions including prone, supine, on their side or sitting. However, due to cases of sudden death of restrained individuals, there has been increased scrutiny towards the positions in which a subject is left after he is restrained. Methods: This was an evaluation of prospectively collected data from a single law enforcement agency for all subjects in which a use of force was utilized during a one year study period. Data collected includes whether the patient was agitated, resisting arrest, the level of resistance the subject demonstrated and how long the subject resisted for after being placed in his final restraining position. Results: Of 2431 use of force incidents, 1535 (63.1%) patients ended up being placed in a prone restraint position, 43 (1.7%) were restrained lying face up, 64 (2.7%) were placed on their sides and 224 (9.2%) were placed in a sitting position. Of all of the subjects who were restrained, 1863 (76.6%) incurred no injuries. 354 (14.6%) subjects were treated at a hospital and then cleared for discharge. No fatalities were noted in any subjects of the research population. Conclusion: Use of force incidents commonly result in individuals placed in a prone restraint position, however, we found no fatalities of individuals placed in a prone restraint position.

Anti-N-Methyl-D-Aspartate Receptor Encephalitis, an Underappreciated Disease in the Emergency Department.

Anti-N-Methyl-D-Aspartate Receptor (NMDAR) Encephalitis is a novel disease discovered within the past 10 years. Antibodies directed at the NMDAR cause the patient to develop a characteristic syndrome of neuropsychiatric symptoms. Patients go on to develop autonomic dysregulation and often have prolonged hospitalizations and intensive care unit stays. There is little literature in the emergency medicine community regarding this disease process, so we report on a case we encountered in our emergency department to help raise awareness of this disease process.

Psychiatric Emergencies for Clinicians: Detection and Management of Anti−N-Methyl-D-Asparate Receptor Encephalitis

A 19-year-old female college freshman presented to the emergency department (ED) for exhibiting bizarre behavior. She presented with her roommate after complaining that her boyfriend was poisoning her food. Before this episode, she was a healthy woman with no medical or psychiatric history. She denied any history of drug use, alcohol use, and she had been on no medications in the past. Collateral history provided by her roommate revealed that she was normal when they started college, but had since become ‘‘really weird’’ over the past 2 weeks. On examination, her vital signs were a temperature of 37.3 C (99.1 F), heart rate of 87 beats/min, respiratory rate of 18 breaths/ min, blood pressure of 125/85 mm Hg, and oxygen saturation of 100% on room air. She repeatedly stated that her food was poisoned and was making her sick. She was slightly disheveled, had pressured speech, and she appeared to be delusional with regard to being poisoned. The remainder of the physical and neurologic examination was normal. She had no nuchal rigidity, nystagmus, tremor, ataxia, rashes, or petechiae. Her gait was normal. Shortly after finishing the physical examination, she had a witnessed tonicclonic seizure.

An Unusual Case of Dysphagia

A previously healthy 38-year-old female pregnant at 6 weeks (first pregnancy) presented to our emergency department (ED) for the second time in 5 days with a chief complaint of a sore throat. Her medical history was significant only for the pregnancy and, besides prenatal vitamins, she did not take any other medications. During her initial visit, she stated she had pain on swallowing, which was located anterior and just left of midline around her thyroid. Her vital signs were unremarkable and her examination revealed a well-developed female without any obvious pharyngitis, uvular deviation, or swelling of the neck. She did exhibit minimal tenderness to the left side of her thyroid gland. No masses or asymmetry were noted on palpation while she swallowed. There were no bruits or erythematous regions noted near the thyroid. On her second visit, she described a progressively worsening pain in the same region, along with an increased fullness on the left side of her neck. She also noted that her voice sounded muffled. She denied any fever, chills, weight changes, cough or trauma to the region. Her vital signs at this visit were temperature of 97.4 F, heart rate of 76 beats/min, and blood pressure of 126/76 mm Hg. Her examination revealed a patent airway with tenderness on the left side of her neck, and a mobile mass that moved with swallowing was noted just lateral to her thyroid, as depicted in Figure 1. Her review of