Joshua Bucher

Intubation of the Neurologically Injured Patient

BACKGROUND Intubation of the neurologically injured patient is a critical procedure that must be done in a manner to prevent further neurologic injury. Although many different medications and techniques have been used to meet specific needs, there is little to no evidence to support many claims. OBJECTIVE To review the literature regarding important topics relating to intubating patients with neurologic injury. DISCUSSION Airway management requires ideal preoxygenation and airway maneuvers to minimize manipulation of the larynx and to maximize first-pass success. There is no evidence that lidocaine pretreatment decreases intracerebral pressure (ICP). Fentanyl can be used to help blunt the hemodynamic response to intubation. Esmolol is another medication that can blunt the hemodynamic response. Ketamine can be used and is possibly the ideal agent, having a neutral hemodynamic profile. A prefasciculation dose for neuromuscular blockade has not been shown to have any effect on ICP. CONCLUSIONS Ideal intubation conditions should be obtained through the use of airway manipulation techniques and appropriate medication choice for rapid sequence intubation in patients who are neurologically injured.

A Fish Tale: Flushing and Pruritis after Tuna Ingestion

A 65-year-old woman presented with the sudden onset of feeling ‘‘hot,’’ accompanied by a diffuse, blanching red rash, conjunctival injection, and one episode of nonbloody diarrhea. It happened suddenly about 90 min after consuming a dinner that included fully cooked tuna. It was also associated with mild diffuse pruritus, and the patient reported feeling restless. The patient reported that her husband had similar but milder symptoms, including flushing and diarrhea. She denied any prior similar episodes, and had eaten tuna many times before without any adverse reactions. She denied shortness of breath, wheezing, itching in her throat, mouth, or eyes, or perioral paresthesias. The patient’s only medications were montelukast and mometasone nasal spray. The patient had drug allergies to penicillin and sulfa compounds. Due to the patient’s history of seasonal allergies, in the context of what she presumed was an allergic reaction, she immediately took 50 mg by mouth (PO) of diphenhydramine and 300 mg PO of cimetidine while at home right after the incident. On presentation, the patient was awake, alert, and comfortable. Her vital signs were: temperature 37.0 C, pulse 92 beats/min, respiration 20 breaths/min, blood pressure 150/74 mm Hg, and SpO2 99% on room air. The patient was not in distress. The patient’s skin had a diffuse erythematous, blanching rash of her arms, legs, back, chest, and feet. There were no noticeable focal lesions or discharge. No other rash was noted. The patient also had mild conjunctival injection bilaterally but no facial swelling. The patient’s cardiovascular examination was normal. The patient’s lungs were clear bilaterally and there were no upper airway sounds. The patient’s abdominal examination was benign. The patient remained stable throughout the Emergency Department (ED) visit. The patient was instructed to continue her self-treatment with diphenhydramine and cimetidine for her symptoms and to follow-up to the ED if she had any difficulty breathing, wheezing, or intractable diarrhea. Given the patient’s classic presentation in the context of recent ingestion of tuna, which also sickened her husband, the diagnosis of scombroid poisoning was made.

Hand Washing Practices Among Emergency Medical Services Providers

Introduction Hand hygiene is an important component of infection control efforts. Our primary and secondary goals were to determine the reported rates of hand washing and stethoscope cleaning in emergency medical services (EMS) workers, respectively. Methods We designed a survey about hand hygiene practices. The survey was distributed to various national EMS organizations through e-mail. Descriptive statistics were calculated for survey items (responses on a Likert scale) and subpopulations of survey respondents to identify relationships between variables. We used analysis of variance to test differences in means between the subgroups. Results There were 1,494 responses. Overall, reported hand hygiene practices were poor among pre-hospital providers in all clinical situations. Women reported that they washed their hands more frequently than men overall, although the differences were unlikely to be clinically significant. Hygiene after invasive procedures was reported to be poor. The presence of available hand sanitizer in the ambulance did not improve reported hygiene rates but improved reported rates of cleaning the stethoscope (absolute difference 0.4, p=0.0003). Providers who brought their own sanitizer were more likely to clean their hands. Conclusion Reported hand hygiene is poor amongst pre-hospital providers. There is a need for future intervention to improve reported performance in pre-hospital provider hand washing.

EMS Dispatches during Hurricanes Irene and Sandy in New Jersey

Abstract Background: Hurricanes Irene and Sandy heavily impacted New Jersey. Investigating EMS dispatch trends during these storms may allow us to prepare for future disasters. Objectives: Our objectives to characterize the types of EMS dispatches immediately before, during, and after landfall compared to a control period. Methods: This retrospective study was conducted at a large EMS dispatch center that provides first responders, Basic Life Support (BLS), Advanced Life Support (ALS), and critical care transport services to an area with approximately 20 receiving hospitals including a Level I Trauma Center. At peak staffing, there are 8–10 ALS vehicles, 25 BLS vehicles, and 3 critical care transport vehicles deployed. We included of the day of landfall and seven days before and after. We compared dispatch data to a control period in 2010 that mirrored Hurricane Sandy the dates of. Descriptive statistics and two way ANOVA were used to assess dispatch, gender and age differences. Results: We found Hurricane Sandy dispatches peaked 2 days after landfall. Both ALS and BLS had an increase in age in the post-Sandy period compared to the pre-Sandy (ALS 58.5 to 64.2, p = 0.005, ANOVA p = 0.078; BLS 47.4 to 56.3, p < 0.001, ANOVA p = 0.001). There were 17 “hurricane related” (loss of power related issues, oxygen supply depleted, evacuation) and 15 carbon monoxide dispatches in the post-Sandy period and none in the others, including peri-Irene. The average age of cardiac arrest dispatches was lower in the post-Irene group compared to pre-Irene (74.3 to 47.8, p = 0.023). There were no critical care requests before or after Hurricane Sandy, but there were 14 around Hurricane Irene and 10 surrounding the control period. Conclusions: Dispatch data can inform natural disaster planning. Education efforts can focus on geriatric patients, as well as resource distribution planning for an increase in geriatric populations. However, pattern variability between storms shows further study is needed to clarify exactly which resources should be utilized in order to maintain an ideal response to a natural disaster.

Emergent Complications of Rheumatoid Arthritis

BACKGROUND Rheumatoid arthritis (RA) is an autoimmune disease resulting in polyarthritis and systemic effects that may result in morbidity and mortality. OBJECTIVE This review provides the emergency physician with an updated analysis of acute complications seen with RA, as well as an evidence-based approach to the management of these complications. DISCUSSION While the joint characteristics of RA are commonly recognized, the extra-articular manifestations may be overlooked. Of most concern to the emergency clinician is the involvement of the airway, cardiovascular, and pulmonary systems; however, RA can affect all organ systems. In addition, complications can arise from the specific therapies used to treat RA. Certain patient populations can have atypical presentations of the disease or may have an exaggerated response to the medications. An understanding of the involvement of these organ systems and complications can direct physicians to a broader differential that can identify disease processes that may have otherwise gone unnoticed. It is not necessarily the role of the clinician to diagnose RA in its earliest phases or initiate long-term immunosuppressive therapy from the emergency department; however, detection of some of the diseases characteristics can lead to earlier referral to specialists to begin therapy and potentially avoid life-threatening complications. If those problems are encountered in the emergency department, this review aims to provide insight into management of those conditions. CONCLUSIONS Prompt recognition of the acute complications of RA is crucial to treat these conditions. This review investigates these issues in a succinct manner for emergency clinicians.

EMS providers do not use FOAM for education

BackgroundFree open access to medical education (FOAM, #FOAM) is the free availability of educational materials on various medicine topics. We hope to evaluate the use of social media and FOAM by emergency medical services (EMS) providers.MethodsWe designed an online survey distributed to EMS providers with questions about demographics and social media/FOAM use by providers. The survey was sent to the American College of Emergency Physicians (ACEP) EMS Listserv of medical directors and was asked to be distributed to their respective agencies. The survey was designed to inquire about the providers’ knowledge of FOAM and social media and their use of the above for EMS education.ResultsThere were 169 respondents out of a total of 523 providers yielding a response rate of 32.3%. Fifty-three percent of respondents are paramedics, 37% are EMT-Basic trained, and the remainder (16%) were “other.”The minority (20%) of respondents had heard of FOAM. However, 54% of respondents had heard of “free medical education online” regarding pertinent topics. Of the total respondents who used social media for education, 31% used Facebook and 23% used blogs and podcasts as resources for online education.Only 4% of respondents stated they produced FOAM content. Seventy-six percent of respondents said they were “interested” or “very interested” in using FOAM for medical education. If FOAM provided continuing medical education (CME), 83% of respondents would be interested in using it.ConclusionSocial media is not used frequently by EMS providers for the purposes of FOAM. There is interest within EMS providers to use FOAM for education, even if CME was not provided. FOAM can provide a novel area of education for EMS.

Organization and Operations Management at the Explosive Incident Scene

INTRODUCTION The scene of a mass casualty incident is a chaotic, stressful environment. Explosive incident scenes, especially those related to terrorism, add increased levels of fear and potential injury to both civilians and health care providers. They frequently destabilize infrastructure in multiple ways. This article discusses best practices for management of the out-of-hospital explosion scene. The majority of the recommendations are based on expert panel consensus as described in the introductory article. On completion of this article, the reader will have been introduced to several key concepts that may be applied to his or her system in planning for an explosive incident. Because health care and emergency response systems vary considerably from region to region, we do not provide detailed incident plans, but offer a strategic base on which a more specific plan may be built. In the world of disaster management, the Incident Command System is widely used and provides a common language for health care providers. The system is a framework developed to coordinate response to mass casualty incidents. The branches of the Incident Command System are divided into operations, logistics, planning, and finance/ administration. The Federal Emergency Management Agency (FEMA) Incident Command System for emergency medical services (EMS) introduces 6 stages of incident management: planning and training, initial response, operations, stabilization, demobilization, and termination. We will use these 6 stages in this article as a framework for the discussion of management at the explosive incident scene. Furthermore, the National Incident Management System is a standard approach to disaster management that implements the Incident Command System. It was designed to help integrate and coordinate between all levels of responding, from the municipal government through the

Management of Explosive Incidents: Overview of the Project and Summary of Best Practices Consensus Statements of the Expert Panel

INTRODUCTION The project was conducted by the University Center for Disaster Preparedness and Emergency Response at Robert Wood Johnson University Hospital under a grant from the US ArmyTelemedicine andAdvancedTechnologyResearchCenter of the US Army Medical Research and Materiel Command. The project team compiled information fromopen-source publications and from subject matter experts reflecting the US military experience in Operation Iraqi Freedom and Operation Enduring Freedom, US civilian experience from civilian out-of-hospital and hospital health care systems, and Israeli civilian and military experience. A table top exercise, conducted in 2 phases during 2 days, was held to probe for omissions and inconsistencies in the planning effort. The final recommendations were presented at an international symposium in Washington, DC.

Medical Management at the Explosive Incident Scene

INTRODUCTION Blast scene medical management requires out-of-hospital personnel to perform several roles for their patients, including rapid triage, direct patient care, and transport. They must also practice constant vigilance and situational awareness and attempt to preserve evidence when possible. Below we present a brief summary for out-of-hospital providers to remember when responding to an incident scene.

Spontaneous renal artery dissection presenting as an aortic dissection: a case report

BackgroundRenal artery dissection is a condition that has been associated with traumatic injuries and connective tissue disorders. It has been managed in the past by multiple methods because there is no standard treatment, including vascular intervention with angioplasty and stenting, anticoagulation/antiplatelet therapy, and hypertension management.Case presentationWe present a case of a spontaneous renal artery dissection in a 55-year-old white man with no traditional risk factors who presented twice to our emergency department in a 2-day period with different symptoms; on his first presentation he presented with symptoms consistent with renal colic and on the second visit he presented with symptoms consistent with aortic dissection.ConclusionsOur patient was treated with endovascular stent placement by interventional radiology, heparin infusion, and admission to our medical intensive care unit. Our review here highlights the varied management of this diagnosis for which there is no standard treatment and decisions are made in conjunction with consultants.