Matthew D. Sztajnkrycer

Valproic acid toxicity: overview and management

Acute valproic acid intoxication is an increasing problem, accounting for more than 5000 calls to the American Association of Poison Control Centers in 2000. The purpose of this paper is to review the pharmacology and toxicology of valproic acid toxicity. Unlike earlier antiepileptic agents, valproic acid appears to function neither through sodium channel inhibition nor through direct γ-aminobutyric acid agonism, but through an indirect increase in regional brain γ-aminobutyric acid levels. Manifestations of acute valproic acid toxicity are myriad, and reflect both exaggerated therapeutic effect and impaired intermediary metabolism. Central nervous system depression is the most common finding noted in overdose, and may progress to coma and respiratory depression. Cerebral edema has also been observed. Although hepatotoxicity is rare in the acute overdose setting, pancreatitis and hyperammonemia have been reported. Metabolic and hematologic derangements have also been described. Management of acute valproic acid ingestion requires supportive care and close attention to the airway. The use of controversial adjunctive therapies, including extracorporeal drug elimination and l-carnitine supplementation, will be discussed.

Injury patterns related to use of less-lethal weapons during a period of civil unrest

This case series documents injury patterns related to beanbag and other less-lethal (LL) weapons during a period of civil unrest in a major U.S. city. A retrospective review of injuries related to LL weapons usage presenting to an urban Emergency Department (ED) from April 10, 2001 to April 18, 2001 was performed. Patients under 18 years of age and those without signed consent to treat were excluded. Twenty-seven patients were identified. Two were excluded due to lack of signed consent for treatment. Mean age was 28.4 +/- 11.7 years; 76% of patients were male. Significant morbidity was found in 7 (28%) cases with no fatalities. Three (12%) individuals, with the diagnoses of pulmonary contusion, liver laceration, and Achilles tendon rupture, required admission. Two (8%) individuals had delayed complications of pneumonia and post-concussive syndrome. Reports of injury patterns associated with beanbag munitions in the medical literature are limited. Physicians should be aware of the injuries and delayed sequelae associated with their use.

FAST Ultrasound as an Adjunct to Triage Using the START Mass Casualty Triage System

Objective. To determine whether the FAST examination might be a useful adjunct to simple triage andrapid treatment (START) in the secondary triage of mass-casualty victims already classified as delayed (Yellow). Methods. A retrospective chart review was conducted of all adult trauma patients evaluated by the trauma surgery service at a level 1 trauma center between January 1 andDecember 31, 2003. Patients were retrospectively triaged to one of three START categories: immediate (Red), delayed (Yellow), or expectant (Black). The FAST results were obtained from the medical records. Results. FAST results were available for 359 patients, of which 27 were classified as positive. Twenty (6.9%) of 286 patients retrospectively triaged as delayed (Yellow) had positive FAST studies. Of these, six underwent operative intervention within 24 hours of arrival. A total of 232 patients had both FAST andcomputed tomography (CT) studies performed, of which 19 FAST studies were inconclusive. In the remaining 213 patients, six of 27 had falsely positive studies, while 24 of 186 had falsely negative studies. Conclusions. Portable ultrasound technology might have identified 20 delayed (Yellow) patients with evidence of hemoperitoneum, thereby expediting evacuation to definitive care. However, only 30% of these patients subsequently underwent an operative intervention within 24 hours of arrival. Both over- andundertriage were significant problems. As such, the current study does not support the routine use of FAST ultrasound as a secondary triage tool.

Mitigation of Pennyroyal Oil Hepatotoxicity in the Mouse

OBJECTIVES Pennyroyal oil ingestion has been associated with severe hepatotoxicity and death. The primary constituent, R-(+)-pulegone, is metabolized via hepatic cytochrome P450 to toxic intermediates. The purpose of this study was to assess the ability of the specific cytochrome P450 inhibitors disulfiram and cimetidine to mitigate hepatotoxicity in mice exposed to toxic levels of R-(+)-pulegone. METHODS 20-g female BALB/c mice were pretreated with either 150 mg/kg of cimetidine intraperitoneal (IP), 100 mg/kg of disulfiram IP, or both. After one hour, mice were administered 300 mg/kg of pulegone IP and were killed 24 hours later. Data were analyzed using ANOVA. Post-hoc t-tests used Bonferroni correction. RESULTS There was a tendency for lower serum glutamate pyruvate transaminase in the disulfiram and cimetidine groups compared with the R-(+)-pulegone group. The differences were significant for both the cimetidine and the combined disulfram and cimetidine groups compared with the R-(+)-pulegone group. Pretreatment with the combination of disulfiram and cimetidine most effectively mitigated R-(+)-pulegone-induced hepatotoxicity. CONCLUSIONS Within the limitations of a pretreatment animal model, the combination of cimetidine and disulfiram significantly mitigates the effects of pennyroyal toxicity and does so more effectively than either agent alone. These data suggest that R-(+)-pulegone metabolism through CYP1A2 appears to be more important in the development of a hepatotoxic metabolite than does metabolism via CYP2E1.

Law Enforcement-applied Tourniquets: A Case Series of Life-saving Interventions

Abstract Although the epidemiology of civilian trauma is distinct from that encountered in combat, in both settings, extremity hemorrhage remains a major preventable cause of potential mortality. The current paper describes the largest case series in the literature in which police officers arriving prior to emergency medical services applied commercially available field tourniquets to civilian victims of violent trauma. Although all 3 patients with vascular injury arrived at the receiving emergency department in extremis, they were successfully resuscitated and survived to discharge without major morbidity. While this outcome is likely multifactorial and highlights the exceptional care delivered by the modern trauma system, tourniquet application appears to have kept critically injured patients alive long enough to reach definitive trauma care. No patient had a tourniquet-related complication. This case series suggests that law enforcement officers can effectively identify indications for tourniquets and rapidly apply such life-saving interventions.

Effectiveness of a Simple Internet-Based Disaster Triage Educational Tool Directed Toward Latin-American EMS Providers

Background. A previous survey demonstrated a lack of standardization related to disaster triage among Latin-American providers. Objective. To assess the effectiveness of a short Internet-based educational intervention in disaster andmass-casualty triage. Using three Spanish Internet emergency medical services (EMS) forums, Latin-American providers were invited to participate in the study. The tool consisted of two educational modules: an introduction to disaster triage module anda START (simple triage andrapid treatment) module. Pre- andpostintervention tests were administered, each consisting of five standardized scenarios. Factorial analysis was used to measure the weight of each scenario. The first andfifth scenarios were identical for intraclass correlation. Skill retention was assessed through a one-month follow-up survey. Statistical analysis was performed using chi-square andFishers exact test. A total of 55 EMS providers participated in the study. Five of 55 (9.1%) participants correctly answered four or more scenarios on the pretest intervention, compared with 53 of 55 (96.4%) on the posttest [p < 0.001, relative risk 10.60 (95% CI 4.59–24.49)]. Similar findings were obtained for those accurately triaging all five scenarios, with zero of 55 (0%) in the pretest compared with 49 of 55 in the posttest (p < 0.001). Follow-up at one month was 69%. Four or more scenarios were correctly answered at follow-up by 34 of 38 (89.5%) respondents. No significant difference was noted compared with the immediate postcourse survey (p = 0.18). Although initial ability of the cohort to accurately triage patients was suboptimal, a short Internet-based educational tool significantly impacted the cohorts ability to perform triage in a simulated patient environment. This improvement was maintained after one month. Key words. disaster; traum; triage; Internet; education; prehospital; Latin America.

Language Barriers as a Reported Cause of Prehospital Care Delay in Minnesota

Objective. Although anecdotal reports exist, the frequency of language barriers encountered between EMS providers andpatients/families in the prehospital environment remains unknown. The purpose of this study was to determine the frequency of EMS provider-reported perceived delays in care due to language barrier andto characterize the nature of calls involved.Methods. Retrospective analysis of the Minnesota State Ambulance Reporting system (MNSTAR) database, a mandated statewide EMS data collection tool. All EMS run reports submitted between January 1, 2004, andJune 30, 2005, were reviewed to identify instances of reported treatment delay secondary to a language barrier.Results. During the 18-month study period, 629,738 patient encounter reports were submitted to MNSTAR, of which 2,052 identified treatment delays secondary to language. The rate of language barrier care delays in the state of Minnesota is 3.3 per 1,000 prehospital patient encounters.Conclusion. EMS responses troubled by delays in care secondary to language barriers represent a small percentage of total runs in Minnesota. However, approximately 1,370 cases per year occur.

Police Officer Response to the Injured Officer: A Survey-Based Analysis of Medical Care Decisions

INTRODUCTION No widely accepted, specialized medical training exists for police officers confronted with medical emergencies while under conditions of active threat. The purpose of this study was to assess medical decision-making capabilities of law enforcement personnel under these circumstances. METHODS Web-based surveys were administered to all sworn officers within the county jurisdiction. Thirty-eight key actions were predetermined for nine injured officer scenarios, with each correct action worth one point. Descriptive statistics and t-tests were used to analyze results. RESULTS Ninety-seven officers (65.1% response rate) responded to the survey. The majority of officers (68.0%) were trained to the first-responder level. Overall mean score for the scenarios was 15.5 +/- 3.6 (range 7-25). A higher level of medical training (EMT-B/P versus first responder) was associated with a higher mean score (16.6 +/- 3.4, p = 0.05 vs. 15.0 +/- 3.6, p = 0.05). Tactical unit assignment was associated with a lower score compared with non-assigned officers (13.5 +/- 2.9 vs. 16.0 +/- 3.6, p = 0.0085). No difference was noted based upon previous military experience. Ninety-two percent of respondents expressed interest in a law enforcement-oriented advanced first-aid course. CONCLUSIONS Tactical medical decision-making capability, as assessed through the nine scenarios, was sub-optimal. In this post 9/11 era, development of law enforcement-specific medical training appears appropriate.

Tactical medical skill requirements for law enforcement officers: a 10-year analysis of line-of-duty deaths.

INTRODUCTION In the absence of other data, military Tactical Combat Casualty Care (TCCC) precepts are increasingly being adapted to law enforcement needs. The purpose of this study is to better describe the nature of potentially preventable law enforcement Line-of-Duty Deaths (LODDs) occurring as a result of felonious assaults. METHODS A retrospective analysis was performed of open source data available through the US Federal Bureau of Investigation Uniform Crime Reporting (UCR) Law Enforcement Officers Killed and Assaulted (LEOKA) program for the years 1998-2007 inclusive. RESULTS After applying exclusion criteria, 341 victim officers were included in the study. The most common cause of death was head trauma (n=198), followed by chest trauma (n=90). There were 123 victim officers that suffered potentially preventable deaths; the majority of these injuries involved the chest. Over the 10-year study period, only two officers (0.6%) died from isolated extremity hemorrhage. CONCLUSIONS The current emphasis of TCCC on control of exsanguinating extremity hemorrhage may not meet the needs of law enforcement personnel in an environment with expedited access to well-developed trauma systems. Further study is needed to better examine the causes of preventable deaths in law enforcement officers, as well as the most appropriate law enforcement tactical medical skill set and treatment priorities.

Needle Thoracostomy by Non-Medical Law Enforcement Personnel: Preliminary Data on Knowledge Retention

INTRODUCTION Tension pneumothorax is the second leading cause of preventable combat death. Although relatively simple, the management of tension pneumothorax is considered an advanced life support skill set. The purpose of this study was to assess the ability of non-medical law enforcement personnel to learn this skill set and to determine long-term knowledge and skill retention. METHODS After completing a pre-intervention questionnaire, a total of 22 tactical team operators completed a 90-minute-long training session in recognition and management of tension pneumothorax. Post-intervention testing was performed immediately post-training, and at one- and six-months post-training. RESULTS Initial training resulted in a significant increase in knowledge (pre: 1.3 +/- 1.35, max score 7; post: 6.8 +/- 0.62, p < 0.0001). Knowledge retention persisted at one- and six-months post-training, without significant decrement. CONCLUSIONS Non-medical law enforcement personnel are capable of learning needle decompression, and retain this knowledge without significant deterioration for at least six months.