Robert L. Galli

Cervical collar-induced changes in intracranial pressure.

Placement of a protective cervical collar is common in cases of acute head trauma. However, the effect of this collar on intracranial pressure is uncertain. This prospective study examined the change in measured cerebrospinal fluid pressure (CSFP) after the application of a rigid Philadelphia collar in 20 adult patients undergoing lumbar puncture. CSFP averaged 176.8 mm H2O initially and increased to an average of 201.5 mm H2O after collar placement (range 0 to 120). Although this difference of 24.8 mm H2O is statistically significant (P = .001), it is uncertain if this would be clinically important. Nonetheless, this small increment in pressure could be significant in patients who already have an elevated intracranial pressure.

Severe Illness Associated with Reported Use of Synthetic Cannabinoids - Mississippi, April 2015.

On April 2, 2015, four patients were evaluated at the University of Mississippi Medical Center (UMMC) in Jackson, Mississippi, for agitated delirium after using synthetic cannabinoids. Over the next 3 days, 24 additional persons went to UMMC with illnesses suspected to be related to synthetic cannabinoid use; one patient died. UMMC notified the Mississippi State Department of Health, which issued a statewide alert via the Health Alert Network on April 5, requesting that health care providers report suspected cases of synthetic cannabinoid intoxication to the Mississippi Poison Control Center (MPCC). A suspected case was defined as the occurrence of at least two of the following symptoms: sweating, severe agitation, or psychosis in a person with known or suspected synthetic cannabinoid use. A second statewide alert was issued on April 13, instructing all Mississippi emergency departments to submit line lists of suspected patients to MPCC each day. By April 21, 16 days after the first alert was issued, MPCC had received reports of approximately 400 cases, including eight deaths possibly linked to synthetic cannabinoid use; in contrast, during April 2012–March 2015, the median number of telephone calls to MPCC regarding synthetic cannabinoid use was one per month (range = 0–11). The Mississippi State Department of Health, with the assistance of CDC, initiated an investigation to better characterize the outbreak, identify risk factors associated with severe illness, and prevent additional illnesses and deaths.

Relief of acute migraine headache with intravenous oxytocin: report of two cases.

We present 2 cases, one adult and one pédiatrie, of acute migraine headache promptly relieved by intravenous oxytocin. Both cases were typical flares of a chronic intermittent headache pattern with classic vascular symptoms. Pain relief in both cases was rapid and temporally related to oxytocin administration. Vascular headache pathophysiology and possible oxytocin mechanisms of action are discussed.

A national survey of the air medical transport of high-risk obstetric patients

INTRODUCTION Air medical transport of high-risk obstetric (HROB) patients can be accomplished and advantageous for neonate survival and maternal morbidity. A survey of U.S. helicopter air medical programs was conducted to determine the frequency and current practices of HROB transport. METHODS Each program was contacted by telephone, and air medical personnel were asked to answer 12 questions based on personal experience and statistics compiled by their programs. RESULTS Of the 203 programs surveyed, 133 (66%) provided responses. The mean number of HROB transports was 45.6 per year (4.6% of the mean 995 total transports). Although 83% of the responding programs used the standard flight crew during the HROB transport, only 52% required crew members to maintain neonatal resuscitation certification. Only 56% of the aircraft allow pelvic access in the normal patient configuration. While only 22% of programs have specific HROB launch (dispatch) protocols, 50% reported having obstetricians involved in dispatching flights, and 84% carry tocolytic agents in their drug kit. The greatest concerns included in-flight delivery (60%), inadequate fetal monitoring (6%), and inexperience (5%). CONCLUSION While HROBs account for 5% of air medical flights, many programs appear to be poorly prepared for these patients.

Innovation possibilities for prehospital providers.

The national interest in disaster management anda burgeoning technology field are leading to the development of new approaches to emergency evaluation, triage, andtreatment in prehospital andall hospital arenas. The ability to bring “hands-on” expertise, both physically andtechnologically, as quickly as possible to the trauma patient brings the potential for real advancement in the field. This descriptive report presents several such concepts that are moving into reality.

Effect of routine pulse oximetry measurements on ED triage classification.

Pulse oximetry is commonly used to rapidly determine oxygen saturation and is incorporated in emergency triage as a screening for potential cardiopulmonary complications. This study examined the effect of routine pulse oximetry measurements on emergency department (ED) triage classification. Using a portable pulse oximeter, oxygen saturation of 1,235 adults presenting to a university-based, urban ED was obtained and each patient was assigned a classification of severity based on a standard 1-to-4 scale before and after the measurement. According to data obtained, a small but statistically significant group (2.8%) benefitted from the routine use of pulse oximetry in an emergency triage system and only 40% of these patients required admission or extended care. Although this group is small in number, the potential consequences of missing a hypoxic condition could be devastating for the individual patient. Since pulse oximetry is presently an inexpensive technology, it would seem to be a worthwhile screening tool for emergency triage.

Evaluation of potential adverse health effects resulting from chronic domestic exposure to the organophosphate insecticide methyl parathion.

Methyl parathion (MP) was used illegally to spray homes for insect control over approximately an 8-yr period. In an attempt to determine if there were any adverse health effects from this, health-screening evaluations were performed on 353 individuals living in homes that were illegally sprayed. The average subject spent 15.5 h a day in the home. Subjects from homes with high levels of MP (exposure group) were compared to controls that lived in homes with minimal or no MP. Subjects were aware of the levels of MP found in their homes and recall bias was likely. There were no significant differences in the symptoms reported or by the physician assessment of subacute or chronic toxicity between those in the exposure group and controls. No significant differences were found in growth and developmental evaluations. Three subjects were identified who most likely suffered acute toxicity from the initial exposure and were not appropriately diagnosed and treated. Cholinesterase determinations also did not differ between those in the exposure group and controls. When subjects from the exposure group were stratified by the level of MP in their home, those from homes with the highest levels appeared to have an increased likelihood of subacute toxicity and reported an increased number of neuropsychiatric symptoms (OR 2 for both evaluations).

The use of chemical restraint in helicopter transport

INTRODUCTION Helicopter transport of the combative patient is a major safety hazard facing air medical teams. Although physical restraints alone are helpful, the addition of chemical restraint (CR) often is necessary to control these patients while in flight. METHODS A survey was conducted to determine the current practices of using nonparalyzing CR in air medical transport programs nationwide. The survey consisted of 24 questions on the use of CR during transport. Each U.S. program belonging to the Association of Air Medical Services was contacted by telephone, and a flight nurse or paramedic provided answers based on personal experience and statistics compiled by his or her individual program. RESULTS Of the 100 programs responding, benzodiazepines were used most commonly to control agitation with 51% using micazolam. Patients with a head injury required CR more frequently than any other condition (73%). Crews flying larger aircraft reported less need for CR. A physician order was required by only 30% of the programs, but delays infrequently endangered the patient (2%). Only 7% of the responding programs had a patient whose condition deteriorated because of CR. CONCLUSION CR is necessary in air medical transport. Most programs use short-acting benzodiazepines. Crews in smaller aircraft use CR more frequently, and head injury is the most common condition requiring such restraint.

The impact of the TelEmergency program on rural emergency care: An implementation study

Introduction Timely, appropriate intervention is key to improving outcomes in many emergent conditions. In rural areas, it is particularly challenging to assure quality, timely emergency care. The TelEmergency (TE) program, which utilizes a dual nurse practitioner and emergency medicine-trained, board-certified physician model, has the potential to improve access to quality emergency care in rural areas. The objective of this study was to examine how the implementation of the TE program impacts rural hospital Emergency Department (ED) operations. Methods Methods included a before and after study of the effect of the TE program on participating rural hospitals between January 2007 and December 2008. Data on ED and hospital operations were collected one year prior to and one year following the implementation of TE. Data from participating hospitals were combined and compared for the two time periods. Results Nine hospitals met criteria for inclusion and participated in the study. Total ED volumes did not significantly change with TE implementation, but ED admissions to the same rural hospital significantly increased following TE implementation (6.7% to 8.1%, p-value = 0.02). Likewise, discharge rates from the ED declined post-initiation (87.1% to 80.0%, p-value = 0.003). ED deaths and transfer rates showed no significant change, while the rate of patient discharge against medical advice significantly increased with TE use. Discussion In this analysis, we found a significant increase in the rate of ED admissions to rural hospitals with TE use. These findings may have important implications for the quality of emergency care in rural areas and the sustainability of rural hospitals’ EDs.

Testicle ischemia resulting from an inguinal hernia.

BACKGROUND Scrotal pain in the emergency department (ED) should be evaluated rapidly for sources that may cause irreversible testicular ischemia. OBJECTIVES This case report discusses a patient presenting with a large inguinal hernia causing testicle ischemia. CASE REPORT A 48-year-old man with a 1-year history of a large right-sided indirect inguinal hernia was transferred to the ED from the ultrasound laboratory after the patient experienced acute onset of severe right-sided testicular pain. The radiologist urgently called the attending emergency physician to notify him of ultrasound findings that showed compromised vascular flow to the right testicle. Urology and General Surgery were consulted immediately. The patient was placed in a supine position and reduction of the large hernia was attempted. After approximately 15 min of manual pressure, the herniated bowel was reduced back into the abdominal cavity and the patient experienced immediate relief of his symptoms. CONCLUSIONS Scrotal ultrasound was repeated, and vascular flow to his right testicle was found to be re-established. This case highlights a rare presentation of acute onset of testicular ischemia caused by vascular compression from a large indirect inguinal hernia in an adult male.