Gerard DeMers

Excited delirium syndrome (ExDS): Treatment options and considerations

The term Excited Delirium Syndrome (ExDS) has traditionally been used in the forensic literature to describe findings in a subgroup of patients with delirium who suffered lethal consequences from their untreated severe agitation.(1-5) Excited delirium syndrome, also known as agitated delirium, is generally defined as altered mental status and combativeness or aggressiveness. Although the exact signs and symptoms are difficult to define precisely, clinical findings often include many of the following: tolerance to significant pain, rapid breathing, sweating, severe agitation, elevated temperature, delirium, non-compliance or poor awareness to direction from police or medical personnel, lack of fatiguing, unusual or superhuman strength, and inappropriate clothing for the current environment. It has become increasingly recognized that individuals displaying ExDS are at high risk for sudden death, and ExDS therefore represents a true medical emergency. Recently the American College of Emergency Physicians (ACEP) published the findings of a white paper on the topic of ExDS to better find consensus on the issues of definition, diagnosis, and treatment.(6) In so doing, ACEP joined the National Association of Medical Examiners (NAME) in recognizing ExDS as a medical condition. For both paramedics and physicians, the difficulty in diagnosing the underlying cause of ExDS in an individual patient is that the presenting clinical signs and symptoms of ExDS can be produced by a wide variety of clinical disease processes. For example, agitation, combativeness, and altered mental status can be produced by hypoglycemia, thyroid storm, certain kinds of seizures, and these conditions can be difficult to distinguish from those produced by cocaine or methamphetamine intoxication.(7) Prehospital personnel are generally not expected to differentiate between the multiple possible causes of the patients presentation, but rather simply to recognize that the patient has a medical emergency and initiate appropriate stabilizing treatment. ExDS patients will generally require transfer to an emergency department (ED) for further management, evaluation, and definitive care. In this paper, we present a typical ExDS case and then review existing literature for current treatment options.

Secure scalable disaster electronic medical record and tracking system.

Introduction: Electronic medical records (EMR) are considered superior in documentation of care for medical practice. Current disaster medical response involves paper tracking systems and radio communication for mass casualty incidents (MCIs). These systems are prone to errors, may be compromised by local conditions, and are labor intensive. Communication infrastructure may be impacted, overwhelmed by call volume, or destroyed by the disaster, making self-contained and secure EMR response a critical capability. As the prehospital disaster EMR allows for more robust content including Protected Health Information (PHI), security measures must be instituted to safeguard these data. Objectives: To develop a secure prehospital disaster triage/EMR system that prevents unintentional disclosure of private information, may be used by prehospital personnel during the MCI triage process, and can be relayed via wireless system to local and distant medical assets. Methods: The Wireless Information System for medicAl Response in Disasters (WIISARD) Research Group developed a handheld linked wireless EMR system utilizing current technology platforms. Smart phones connected to radio frequency identification (RFID) readers may be utilized to efficiently track casualties resulting from the incident. Medical information may be transmitted on an encrypted network to fellow prehospital team members, medical dispatch, and receiving medical centers. Results: This system has been field tested in a number of exercises with excellent results and future iterations will incorporate robust security measures. Conclusions: A secure prehospital triage EMR improves documentation quality during disaster drills.

American Academy of Emergency Medicine Position Statement: Safety of Droperidol Use in the Emergency Department

BACKGROUND Droperidol (Inapsine®, Glaxosmithkline, Brent, UK) is a butyrophenone used in emergency medicine practice for a variety of uses. QT prolongation is a well-known adverse effect of this class of medications. Of importance to note, QT prolongation is noted with multiple medication classes, and droperidol increases QT interval in a dose-dependent fashion among susceptible individuals. The primary goal of this literature search was to determine the reported safety issues of droperidol in emergency department management of patients. METHODS A MEDLINE literature search was conducted from January 1995 to January 2014 and limited to human studies written in English for articles with keywords of droperidol/Inapsine. Guideline statements and nonsystematic reviews were excluded. Studies identified then underwent a structured review from which results could be evaluated. RESULTS There were 542 papers on droperidol screened, and 35 appropriate articles were rigorously reviewed in detail and recommendations given. CONCLUSION Droperidol is an effective and safe medication in the treatment of nausea, headache, and agitation. The literature search did not support mandating an electrocardiogram or telemetry monitoring for doses < 2.5 mg given either intramuscularly or intravenously. Intramuscular doses of up to 10 mg of droperidol seem to be as safe and as effective as other medications used for sedation of agitated patients.

Pneumomediastinum caused by isolated oral-facial trauma

Pneumomediastinum from isolated blunt or penetrating oral-facial trauma is a rare occurrence, which can be associated with facial fractures or may be iatrogenic. We present two cases caused by high-pressure-induced facial injuries that had very different management and outcomes. The first patient had asymptomatic pneumomediastinum and an uncomplicated recovery, whereas the second had a complicated clinical course requiring extensive surgical debridement. Neither patient developed mediastinitis as a complication of pneumomediastinum. This case series illustrates isolated facial trauma causing pneumomediastinum and reviews the literature over last 20 years for similar cases. The authors advocate emergency department management of pneumomediastinum from facial trauma.

Secure scalable disaster electronic medical record and tracking system

Introduction: Electronic medical records (EMR) are considered superior in documentation of care for medical practice. Current disaster medical response involves paper tracking systems and radio communication for mass casualty incidents (MCIs). These systems are prone to errors, may be compromised by local conditions, and are labor intensive. Communication infrastructure may be impacted, overwhelmed by call volume, or destroyed by the disaster, making self-contained and secure EMR response a critical capability. As the prehospital disaster EMR allows for more robust content including Protected Health Information (PHI), security measures must be instituted to safeguard these data. Objectives: To develop a secure prehospital disaster triage/EMR system that prevents unintentional disclosure of private information, may be used by prehospital personnel during the MCI triage process, and can be relayed via wireless system to local and distant medical assets. Methods: The Wireless Information System for medicAl Response in Disasters (WIISARD) Research Group developed a handheld linked wireless EMR system utilizing current technology platforms. Smart phones connected to radio frequency identification (RFID) readers may be utilized to efficiently track casualties resulting from the incident. Medical information may be transmitted on an encrypted network to fellow prehospital team members, medical dispatch, and receiving medical centers. Results: This system has been field tested in a number of exercises with excellent results and future iterations will incorporate robust security measures. Conclusions: A secure prehospital triage EMR improves documentation quality during disaster drills.

Navy En Route Care: A 3-Year Review of 428 Navy Air Evacuations

BACKGROUND Navy medical personnel have been recording en route care (ERC) missions through Search and Rescue (SAR) reports since the 1970s. Our objective was to report clinical ERC cases treated by Navy operational assets from January 2012 to January 2015. METHODS The Search and Rescue Model Manager office collects SAR reports for all patient transports involving Navy personnel and equipment. From these reports, descriptive statistics to include total number of patients transported, percentages of Advanced Life Support versus Basic Life Support transports, time of transport, and type of ERC provider for the transport were collected. Data reported as median (interquartile range) or percentages. RESULTS During a 3-year period, 428 patients were transported. Transport time was 54 (30-78) minutes. Missions were staffed by more than one provider 22% of the time. Individual providers included 76% Search and Rescue Medical Technicians, 25% Flight Surgeons, and 21% Other. Patients required ALS transport 54% of the time. Less than half (48%) of the patients were trauma related. CONCLUSION In our review of 428 SAR reports from Navy ERC (2012-2015), we found that 76% of the missions were performed by Search and Rescue Medical Technicians and 54% met Advanced Life Support transport criteria.

Paraganglioma causing a myocardial infarction.

Paragangliomas, extra-adrenal pheochromocytomas, are rare and classically associated with sustained or paroxysmal hypertension, headache, perspiration, palpitations, and anxiety. A 49-year-old male, parachute instructor, likely developed a hypertensive emergency when deploying his parachute leading to a myocardial infarction. A para-aortic tumor was incidentally discovered during the patients emergency department work-up and was eventually surgically resected. He had no evidence of coronary disease during his evaluation. This case shows that a myocardial infarction may be the initial manifestation of these neuroendocrine tumors. Hypertensive emergency, much less elevated blood pressure may not be present at time of presentation.