Jeffrey D. Ho

Failure of Adjunctive Bicarbonate to Improve Outcome in Severe Pediatric Diabetic Ketoacidosis

STUDY OBJECTIVEnAlthough adjunctive intravenous bicarbonate therapy is commonly recommended for children with severe diabetic ketoacidosis (DKA), no studies assessing clinical outcome with this therapy have ever been performed. Our objective was to determine whether bicarbonate therapy influenced outcome for pediatric DKA.nnnMETHODSnThe study was a retrospective consecutive case series of 147 admissions for severe DKA (initial pH < or = 7.15 and glucose concentration > or = 300 mg/dL [16.7 mmol/L]) in 106 children during a 16-year period at a tertiary university medical center. Descriptive statistics were applied to the 147 admissions. The first patient admitted with DKA was then selected for each of the 106 children, and clinical and laboratory data were compared between subjects who did and did not receive bicarbonate. Multivariate and matched pair analyses were performed to control potentially confounding variables.nnnRESULTSnFifty-seven of the 147 patients admitted with DKA (39%) were successfully treated without bicarbonate, including 9 with a pH of 7.00 or less and one with a pH of 6.73. The frequency of complications was comparable between bicarbonate and nonbicarbonate groups (4% versus 2%, P = 1.00). The mean duration of hospitalization for children receiving bicarbonate was 23% (16 hours) longer than children who did not receive bicarbonate in the multivariate analysis (P = .07) and 37% (22 hours) longer in the matched pair analysis (P = .01). The mean rate of metabolic recovery by three distinct measures was similar between groups, and the sample had 80% power to detect differences of 14% to 29% in these measures.nnnCONCLUSIONnWe found no evidence that adjunctive bicarbonate improved clinical outcome in children with severe DKA. The rate of metabolic recovery and complications were similar in patients treated with and without bicarbonate, and prolonged hospitalizations were noted in the bicarbonate group. We conclude that adjunctive bicarbonate is unnecessary and potentially disadvantageous in severe pediatric DKA.

Excited Delirium Syndrome (ExDS): Defining Based on a Review of the Literature

BACKGROUNDnPatients present to police, Emergency Medical Services, and the emergency department with aggressive behavior, altered sensorium, and a host of other signs that may include hyperthermia, superhuman strength, diaphoresis, and lack of willingness to yield to overwhelming force. A certain percentage of these individuals will go on to expire from a sudden cardiac arrest and death, despite optimal therapy. Traditionally, the forensic community would often classify these as Excited Delirium deaths.nnnOBJECTIVESnThis article will review selected examples of the literature on this topic to determine if it is definable as a discrete medical entity, has a recognizable history, epidemiology, clinical presentation, pathophysiology, and treatment recommendations.nnnDISCUSSIONnExcited delirium syndrome is characterized by delirium, agitation, acidosis, and hyperadrenergic autonomic dysfunction, typically in the setting of acute-on-chronic drug abuse or serious mental illness or a combination of both.nnnCONCLUSIONSnBased upon available evidence, it is the consensus of an American College of Emergency Physicians Task Force that Excited Delirium Syndrome is a real syndrome with uncertain, likely multiple, etiologies.

Prehospital Ultrasound by Paramedics: Results of Field Trial

OBJECTIVESnThe objective was to determine if 9-1-1 paramedics trained in ultrasound (US) could adequately perform and interpret the Focused Assessment Sonography in Trauma (FAST) and the abdominal aortic (AA) exams in the prehospital care environment.nnnMETHODSnParamedics at two emergency medical services (EMS) agencies received a 6-hour training program in US with ongoing refresher education. Paramedics collected US in the field using a prospective convenience methodology. All US were performed in the ambulance without scene delay. US exams were reviewed in a blinded fashion by an emergency sonographer physician overreader (PO).nnnRESULTSnA total of 104 patients had an US performed between January 1, 2008, and January 1, 2009. Twenty AA exams were performed and all were interpreted as negative by the paramedics and the PO. Paramedics were unable to obtain adequate images in 7.7% (8/104) of the patients. Eighty-four patients had the FAST exam performed. Six exams (6/84, 7.1%) were read as positive for free intraperitoneal/pericardial fluid by both the paramedics and the PO. FAST and AA US exam interpretation by the paramedics had a 100% proportion of agreement with the PO.nnnCONCLUSIONSnThis pilot study shows that with close supervision, paramedics can adequately obtain and interpret prehospital FAST and AA US images under protocol. These results support a growing body of literature that indicates US may be feasible and useful in the prehospital setting.

Human cardiovascular effects of a new generation conducted electrical weapon

OBJECTIVESnThe conducted electrical weapon (CEW) is used by law enforcement to control potentially violent people. Much of the research in CEW safety has focused on the TASER X26, which uses a single deployment cartridge. New Generation CEW (NGCEW) technology has been developed that uses a different circuit and multiple cartridges that can be simultaneously deployed. The objective of this study is to examine the cardiovascular effects of the NGCEW in different deployment possibilities.nnnMETHODSnThis was a prospective study of human subjects during NGCEW training courses. Subjects received a NGCEW probe deployment to the frontal torso in 1 of 3 configurations: 2, 3,or 4 embedded probes and then underwent a 10-s exposure. Before and after vital signs, electrocardiograms (ECGs), and serum troponin I values were obtained. Real-time echocardiography was utilized before, during and after the exposure to evaluate heart rate and rhythm.nnnRESULTSnInitially, a 1st version NGCEW (NGCEWv1) that was in the final stages of manufacturer verification was used at the training courses. It had not been publicly released. During a NGCEWv1 exposure with 2 probes, there was an apparent brief episode of cardiac capture. Testing was halted and the manufacturer was notified. The device was redesigned and the study continued when a redesigned, 2nd version (NGCEWv2) was used. The NGCEW1 was studied in 8 subjects. The NGCEWv2 was studied in 45 subjects with no evidence of cardiac capture. There were no important post-exposure vital sign, troponin I or ECG changes found in any volunteers.nnnCONCLUSIONSnAn apparent brief myocardial capture event occurred with the NGCEWv1. This device was not released and was redesigned. The NGCEWv2 appears to exhibit a reasonable degree of cardiac safety with frontal torso exposures and multiple probe combination configurations.

Time Saved With Use of Emergency Warning Lights and Sirens During Response to Requests for Emergency Medical Aid in an Urban Environment

STUDY OBJECTIVEnTo determine whether the use of warning lights and sirens saves a significant amount of time for ambulances responding to requests for medical aid in an urban, 2-tiered EMS setting.nnnMETHODSnA prospective design was used to determine run times for ambulances responding to calls with lights and sirens (Code 3), and for a similarly equipped chase vehicle traveling to the same call on the same route without lights and sirens (Code 2). Data were collected for run times, distance traveled, visibility, road surface condition, time of day, and day of the week. Simple statistics and analysis of variance were used to test for significant differences between Code 3 and Code 2 operation, as well as the other variables listed above.nnnRESULTSnSixty-four runs were timed during a 9-month period. The average Code 3 response interval was 4.46 minutes. The average Code 2 response interval was 7.48 minutes. The 3.02 minutes saved on average represents a significant time savings of 38.5% (P < .01). Run distance was the only variable that was statistically significant in affecting time saved during a Code 3 response.nnnCONCLUSIONnCode 3 operation by EMS personnel in an urban, 2-tiered EMS setting saved significant time over Code 2 operation when traveling to a call.

Acidosis and catecholamine evaluation following simulated law enforcement "use of force" encounters.

OBJECTIVESnLaw enforcement authorities are often charged with controlling resisting suspects. These encounters sometimes result in the sudden and unexpected death of the suspect. Drug intoxication, excited delirium syndrome, or excessive uses of force are factors that are often blamed, but sometimes the mechanism of these deaths is not fully understood. It is possible that worsening acidosis or excessive catecholamine release play a part. The objective of this study was to determine the effect on markers of acidosis and catecholamines of various tasks intended to simulate common arrest-related situations.nnnMETHODSnSubjects were assigned to one of five task groups: 1) a 150-meter sprint and wall hurdle (simulated flight from arrest); 2) 45 seconds of striking a heavy bag (simulated physical resistance); 3) a 10-second TASER X26 electronic control device exposure; 4) a fleeing and resistance exercise involving a law enforcement dog (K-9); or 5) an oleoresin capsicum (OC) exposure to the face and neck. Baseline serum pH, lactate, potassium, troponin I, catecholamines, and creatine kinase (CK) were evaluated. Serum catecholamines, pH, lactate, and potassium were sampled immediately after the task and every 2 minutes for 10 minutes posttask. Vital signs were repeated immediately after the task. Serum CK and troponin I were evaluated again at 24 hours posttask.nnnRESULTSnSixty-six subjects were enrolled; four did not complete their assigned task. One subject lost the intravenous (IV) access after completing the task and did not have data collected, and one subject only received a 5-second TASER device exposure and was excluded from the study, leaving 12 subjects in each task group. The greatest changes in acidosis markers occurred in the sprint and heavy bag groups. Catecholamines increased the most in the heavy bag group and the sprint group and increased to a lesser degree in the TASER, OC, and K-9 groups. Only the sprint group showed an increase in CK at 24 hours. There were no elevations in troponin I in any group, nor any clinically important changes in potassium.nnnCONCLUSIONSnThe simulations of physical resistance and fleeing on foot led to the greatest changes in markers of acidosis and catecholamines. These changes may be contributing or causal mechanisms in sudden custodial arrest-related deaths (ARDs). This initial work may have implications in guiding applications of force for law enforcement authorities (LEAs) when apprehending resisting subjects.

Time saved with the use of emergency warning lights and siren while responding to requests for emergency medical aid in a rural environment

Objective. To determine whether the use of warning lights and siren saves a significant amount of time for ambulances responding to requests for emergency medical aid in a rural emergency medical services (EMS) setting. Methods. A prospective design was used to determine run times for ambulances responding to calls with lights and siren (code 3) and for a similarly equipped “chase” ambulance traveling to the same destination via the same route without lights and siren, while obeying all traffic laws (code 2) within a rural setting. Data were collected for run time intervals, distance traveled, visibility, road surface conditions, time of day, and day of the week. Descriptive statistics, a paired Students t-test, and analysis of variance were used to test for significant differences between code 2 and code 3 operations, as well as the other variables listed above. Results. Sixty-seven runs were timed during a 21-month period. The average code 3 response interval was 8.51 minutes. The average code 2 response interval was 12.14 minutes. The 3.63 minutes saved on average represents significant time savings of 30.9% (p < 0.01). Shorter runs had higher time savings per mile than the longer runs. Run distance was the only variable that was statistically significant in affecting time saved during a code 3 response. Conclusion. Code 3 operation by EMS personnel in a rural EMS setting saved significant time over code 2 operation when traveling to a call.

Successful Management of Excited Delirium Syndrome with Prehospital Ketamine: Two Case Examples

Abstract Excited delirium syndrome (ExDS) is a medical emergency usually presenting first in the prehospital environment. Untreated ExDS is associated with a high mortality rate and is gaining recognition within organized medicine as an emerging public safety problem. It is highly associated with male gender, middle age, chronic illicit stimulant abuse, and mental illness. Management of ExDS often begins in the field when first responders, law enforcement personnel, and emergency medical services (EMS) personnel respond to requests from witnesses who observe subjects exhibiting bizarre, agitated behavior. Although appropriate prehospital management of subjects with ExDS is still under study, there is increasing awareness of the danger of untreated ExDS, and the danger associated with the need for subject restraint, whether physical or chemical. We describe two ExDS patients who were successfully chemically restrained with ketamine in the prehospital environment, and who had good outcomes without complication. These are among the first case reports in the literature of ExDS survival without complication using this novel prehospital sedation management protocol. This strategy bears further study and surveillance by the prehospital care community for evaluation of side effects and unintended complications.

An Incident-Level Profile of TASER Device Deployments in Arrest-Related Deaths

While a considerable body of research has investigated the physiological risks associated with the TASER device, much less research attention has been devoted to examining the nearly 400 police–citizen encounters in which a suspect has died after the device was used. As a result, there are numerous unanswered questions regarding officer, suspect, and incident-level characteristics of these arrest-related deaths (ARDs), as well as the extent to which patterns in these characteristics may have changed over time. The current study seeks to inform the discourse surrounding these death cases through a descriptive analysis of the near-universe of ARDs involving a TASER device deployment from 2001-2008 (n = 392). Using a unique data triangulation methodology that captures both media (n = 392) and medical examiner reports (n = 213), the authors characterize the geographic distribution of ARDs and find parallels between that distribution, state population, the number of officers per state, crime levels per state, and TASER device sales patterns. Also, an incident-level analysis shows that these ARDs were dynamic encounters between suspects who were frequently intoxicated and who actively and aggressively resisted police, and officers who were drawing deeply into their arsenal of force options in an attempt to control and arrest them. Cause of death was most commonly identified as drugs, heart problems, or Excited Delirium Syndrome. Last, longitudinal analysis showed consistency in most incident, suspect and officer characteristics, though key aspects of suspect resistance, including level of aggression and persistence after TASER device exposure, changed notably over time. The article concludes with a discussion of implications for policy and practice with regard to these rare but fatal police–citizen encounters.

Relationship Between Blood Alcohol Concentration and Observable Symptoms of Intoxication in Patients Presenting to an Emergency Department

AIMSnClinical and medico-legal decisions often require knowledge of alcohol impairment that is not necessarily revealed by an individuals appearance, and in turn, may not necessarily reflect level of blood alcohol. This study compares clinical signs and symptoms with measured and estimated blood alcohol concentrations (BACs).nnnMETHODnIndividuals (n = 384) perceived to be under the influence of alcohol at presentation to an emergency department were assessed by physicians and nurses for clinical features of alcohol intoxication (alcohol symptom checklist, ASC), who were asked to estimate the patients BAC. Relation to measured BACs was assessed by correlation.nnnRESULTSnBACs ranged from 0 to 418 mg/100 ml. The correlation between the estimated BAC and measured BAC was r = 0.513. Measured BAC correlated with ASC r = 0.250. In subjects without a history of chronic drinking (n = 134) there was a better (P < 0.05) correlation with the ASC score (r = 0.363) versus measured BAC compared with that for chronic drinkers (r = 0.154). The positive predictive value of estimating BAC at or above a particular BAC cut-off decreased from 93.2% at 100 mg/100 ml to 37.7% at 300 mg/100 ml (P < 0.05).nnnCONCLUSIONSnMeasured BAC does not correlate well with the outward physical signs of intoxication, especially for chronic drinkers. There is a need for further education on how tolerance masks clinical signs of intoxication for the chronic drinker. BACs should be measured especially in the obtunded where no history (symptoms) can be given by the patient.