Jason Bothwell

Evaluation and Management of Traumatic Knee Injuries in the Emergency Department

Posttraumatic knee pain is a common presentation in the emergency department (ED). The use of clinical decision rules can rule out reliably fractures of the knee and reduce the unnecessary cost and radiation exposure associated with plain radiographs. If ligamentous or meniscal injury to the knee is suspected, the ED physician should arrange for expedited follow- up with the patients primary care physician or an orthopedic specialist for consideration of an MRI and further management. Patients presenting after high-energy mechanisms are at risk for occult fracture and vascular injuries. ED providers must consider these injuries in the proper clinical setting.

Clinical Effects and Antivenom Use for Snake Bite Victims Treated at Three US Hospitals in Afghanistan

OBJECTIVE Annually, more than 100,000 US and international military and civilian personnel work in Afghanistan within terrain harboring venomous snakes. Current literature insufficiently supports Afghan antivenom treatment and stocking guidelines. We report the clinical course and treatments for snakebite victims presenting to US military hospitals in Afghanistan. METHODS All snakebite victims presenting to 3 US military emergency departments between July 2010 and August 2011 in northern and southern Afghanistan were examined via chart review. Case information included patient demographics, snake description, bite details and complications, laboratory results, antivenom use and adverse effects, procedures performed, and hospital course. RESULTS Of 17 cases, median patient age was 20 years (interquartile range [IQR], 12-30), 16 were male, and 82% were Afghans. All bites were to an extremity, and median time to care was 2.8 hours (IQR, 2-5.8). On arrival, 8 had tachycardia and none had hypotension or hypoxia. A viper was implicated in 5 cases. Ten cases received at least 1 dose of polyvalent antivenom, most commonly for coagulopathy, without adverse effects. Six received additional antivenom, 6 had an international normalized ratio (INR) > 10, and none developed delayed coagulopathy. Three received blood transfusions. Hospital stay ranged from 1 to 4 days. None required vasopressors, fasciotomy, or other surgery, and none died. All had resolution of marked coagulopathies and improved swelling and pain on discharge. CONCLUSIONS We report the largest series of snake envenomations treated by US physicians in Afghanistan. Antivenom was tolerated well with improvement of coagulopathy and symptoms. All patients survived with minimal advanced interventions other than blood transfusion.

Impact of Decontamination Therapy on Ultrasound Visualization of Ingested Pills

Introduction Acute toxic ingestion is a common cause of morbidity and mortality. Emergency physicians (EP) caring for overdose (OD) patients are often required to make critical decisions with incomplete information. Point of care ultrasound (POCUS) may have a role in assisting EPs manage OD patients. We evaluated the impact of different liquid adjuncts used for gastric decontamination on examiners’ ability to identify the presence of tablets using POCUS, and assessed examiners’ ability to quantify the numbers of tablets in a simulated massive OD. Methods This prospective, blinded, pilot study was performed at an academic emergency department. Study participants were volunteer resident and staff EPs trained in POCUS. Five nontransparent, sealed bags were prepared with the following contents: 1 liter (L) of water, 1 L of water with 50 regular aspirin (ASA) tablets, 1 L of water with 50 enteric-coated aspirin tablets (ECA), 1 L of polyethylene glycol (PEG) with 50 ECA, and 1 L of activated charcoal (AC) with 50 ECA. After performing POCUS on each of the bags using a 10-5 MHz linear array transducer, participants completed a standardized questionnaire composed of the following questions: (1) Were pills present? YES/NO; (2) If tablets were identified, estimate the number (1–10, 11–25, >25). We used a single test on proportions using the binomial distribution to determine if the number of EPs who identified tablets differed from 50% chance. For those tablets identified in the different solutions, another test on proportions was used to determine whether the type of solution made a difference. Since 3 options were available, we used a probability of 33.3%. Results Thirty-seven EPs completed the study. All (37/37) EP’s correctly identified the absence of tablets in the bag containing only water, and the presence of ECA in the bags containing water and PEG. For Part 2 of the study, most participants - 25/37 (67.5%) using water, 23/37 (62.1%) using PEG, and all 37 (100%) using AC - underestimated the number of ECA pills in solution by at least 50%. Conclusion There may be a potential role for POCUS in the evaluation of patients suspected of acute, massive ingested OD. EPs accurately identified the presence of ECA in water and PEG, but underestimated the number of tablets in all tested solutions.

Comparison of Intubation Using Personal Protective Equipment and Standard Uniform in Simulated Cadaveric Models

Introduction The use of personal protection equipment (PPE) for patient care can have an impact on the delivery of effective patient care. The purpose of this study is to examine the effects of basic PPE on intubation times and corresponding success rates in cadaver models. Methods A prospective crossover design using a single cohort of emergency medicine residents was used for this study. The primary objective is to compare time with intubation in standard uniform (e.g., scrubs without PPE) and using PPE. The secondary objectives are measuring success rates of intubation and the perceived difficulty of intubation when using PPE. Results The mean time to intubation in the standard uniform group was 18.85 s, whereas the mean time to intubation in the PPE group was 19.29. The overall success rate in the standard uniform group was 83% compared with the PPE group, which was 72%. The perceived difficulty was higher in the PPE group (3.38) when compared with the standard uniform. Conclusion Although the mean intubation times between the groups were not significantly different, the overall success rate was significantly higher in the standard uniform group when compared with PPE group. The perceived difficulty rating was also noted to be significantly higher in the PPE group when compared with the standard uniform group.

52 Procedures in 52 Weeks: An innovative curriculum for emergency medicine residents

The specialty of Emergency Medicine (EM) requires that providers are as competent in rare procedures as they are in common ones. This creates a challenge for EM educators, who are charged with graduating competent physicians who have the mental and technical expertise to perform such a breadth of procedures. To facilitate this instruction, we have created a weekly procedure curriculum that utilizes videos coupled with hands on instruction to teach 52 EM procedures. We have found this curriculum to be very effective and easy to implement into our residency training schedule.

Safely Managing Acute Osteoarthritis in the Emergency Department: An Evidence-Based Review

BACKGROUND Joint pain caused by acute osteoarthritis (OA) is a common finding in the emergency department. Patients with OA often have debilitating pain that limits their function and ability to complete their activities of daily living. In addition, OA has been associated with a high percentage of arthritis-related hospital admissions and an increased risk of all-cause mortality. Safely managing OA symptoms in these patients can present many challenges to the emergency provider. OBJECTIVES We review the risks and benefits of available treatment options for acute OA-related pain in the emergency department. In addition, evidence-based recommendations will be made for safely managing pain and disability associated with OA in patients with comorbidities, including cardiovascular disease, renal insufficiency, and risk factors for gastrointestinal bleeding. DISCUSSION Commonly used treatments for OA include acetaminophen, oral nonsteroidal anti-inflammatory drugs, and opioids, each with varying degrees of efficacy and risk depending on the patients underlying comorbidities. Effective alternative therapies, such as topical preparations, intra-articular corticosteroid injections, bracing, and rehabilitation are likely underused in this setting. CONCLUSIONS Emergency providers should be aware of the risks and benefits of all treatment options available for acute OA pain, including oral medications, topical preparations, corticosteroid injections, bracing, and physical therapy.

Accuracy of trans-abdominal ultrasound in a simulated massive acute overdose

INTRODUCTION Toxic ingestions are a common cause of morbidity and mortality in the United States. In 2013, there were nearly 2 million reported ingestions and nearly 1000 deaths from poisonings. There is no well-validated imaging study for confirming the presence of pills in the stomach of an overdose patient. There are case reports of ultrasound used for confirmation of pills in the stomach, and we are aware of one prospective trial to evaluate sonography for this application. OBJECTIVE To determine the sensitivity and specificity of transabdominal ultrasound for visualization of ingested pills. METHODS Randomized, blinded, placebo-controlled study. Twenty Subjects were randomized to one of two groups. The experimental group ingested 50 enteric-coated placebo capsules with 1 liter of fluid. The control group ingested only 1 liter of fluid. At time 0, 60, and 90 minutes after ingestion, expert sonographers performed transabdominal ultrasound in an attempt to visualize pills in the stomach. RESULTS At time 0, 60, and 90 minutes post-ingestion, ultrasound had a sensitivity of 62.5% (41.1%, 81.9%), 20.8% (4.6%, 37.1%), and 25% (7.7%, 42.3%) respectively. The specificity at time 0, 60, and 90 minutes post-ingestion were 58.3% (21.9%, 61.4%), 79.1% (62.9%, 95.5%), and 70.8% (52.6%, 89.0%) respectively. CONCLUSION There is poor sensitivity and specificity for ultrasound detection of pills in the stomach at time 0; these values fell substantially at 60 and 90 minutes post-ingestion. In this pilot study, we did not find ultrasound to be a useful screening tool for detecting pills in the stomach.