Vicken Y. Totten

Respiratory effects of spinal immobillzatlon

OBJECTIVE To evaluate the effect of whole-body spinal immobilization on respiration. METHODS This was a randomized, crossover laboratory study with 39 human volunteer subjects (20 males; 19 females) ranging in age from 7 to 85 years. Respiratory function was measured three times: at baseline (seated or lying), immobilized with a Philadelphia collar on a hard wooden backboard, and on a Scandinavian vacuum mattress with a vacuum collar. The comfort levels of each of the two methods were assessed on a forced Likert scale. RESULTS Both immobilization methods restricted respiration, 15% on the average. The effects were similar under the two immobilization conditions, although the FEV1 was lower on the vacuum mattress. Respiratory restriction was more pronounced at the extremes of age. The vacuum mattress was significantly more comfortable. CONCLUSION This study confirmed the previously reported respiratory restriction caused by spinal immobilization. Vacuum mattresses are more comfortable than wooden backboards.

Opioid Prescribing in a Cross Section of US Emergency Departments

STUDY OBJECTIVE Opioid pain reliever prescribing at emergency department (ED) discharge has increased in the past decade but specific prescription details are lacking. Previous ED opioid pain reliever prescribing estimates relied on national survey extrapolation or prescription databases. The main goal of this study is to use a research consortium to analyze the characteristics of patients and opioid prescriptions, using a national sample of ED patients. We also aim to examine the indications for opioid pain reliever prescribing, characteristics of opioids prescribed both in the ED and at discharge, and characteristics of patients who received opioid pain relievers compared with those who did not. METHODS This observational, multicenter, retrospective, cohort study assessed opioid pain reliever prescribing to consecutive patients presenting to the consortium EDs during 1 week in October 2012. The consortium study sites consisted of 19 EDs representing 1.4 million annual visits, varied geographically, and were predominantly academic centers. Medical records of all patients aged 18 to 90 years and discharged with an opioid pain reliever (excluding tramadol) were individually abstracted by standardized chart review by investigators for detailed analysis. Descriptive statistics were generated. RESULTS During the study week, 27,516 patient visits were evaluated in the consortium EDs; 19,321 patients (70.2%) were discharged and 3,284 (11.9% of all patients and 17.0% of discharged patients) received an opioid pain reliever prescription. For patients prescribed an opioid pain reliever, mean age was 41 years (SD 14 years) and 1,694 (51.6%) were women. Mean initial pain score was 7.7 (SD 2.4). The most common diagnoses associated with opioid pain reliever prescribing were back pain (10.2%), abdominal pain (10.1%), and extremity fracture (7.1%) or sprain (6.5%). The most common opioid pain relievers prescribed were oxycodone (52.3%), hydrocodone (40.9%), and codeine (4.8%). Greater than 99% of pain relievers were immediate release and 90.0% were combination preparations, and the mean and median number of pills was 16.6 (SD 7.6) and 15 (interquartile range 12 to 20), respectively. CONCLUSION In a study of ED patients treated during a single week across the country, 17% of discharged patients were prescribed opioid pain relievers. The majority of the prescriptions had small pill counts and almost exclusively immediate-release formulations.

Managing ankle injuries in the emergency department

We review the anatomy and physiology of the ankle joint with attention to the structures most likely to be injured. We discuss the epidemiology of ankle injuries and their physical and radiographic evaluation, including the Ottawa Ankle Rules. Treatment, consultation, and pitfalls are followed by more specific discussions of tendonitis, Achilles tendon injury, tendonous subluxations, tarsal tunnel syndrome, sonovial impingement, and injury to the os trigonum. The references provide a guide for further reading.

Hypermagnesemia-induced fatality following epsom salt gargles

Hypermagnesemia is a rare cause of coma in a patient with normal renal function. When present, it is often because of iatrogenic medication overdose. We report a fatal case of chronic Epsom salt gargles for halitosis that produced a serum magnesium of 23.6 mg/dL (9.8 mmol/L) and resulted in coma. We review the wide presentation of hypermagnesemia from subtle neurologic and cardiovascular signs to the major life-threatening clinical manifestations of shock, dysrhythmias, coma, and cardiopulmonary arrest despite emergency dialysis.

A Comparison of Patient and Staff Attitudes About Emergency Department–Based HIV Testing in 2 Urban Hospitals

OBJECTIVE This study compares and contrasts emergency department (ED) patient and staff attitudes towards ED-based HIV testing in 2 major hospitals in a single city, with an attempt to answer the following: Should routine ED-based HIV testing be offered? If so, who should be responsible for disclosing HIV test results? And what barriers might prevent ED-based HIV testing? METHODS Paper-based surveys were presented to a convenience sample of ED patients and staff at 2 urban, academic, tertiary care hospitals between December 2007 and June 2009. Descriptive statistics were derived with SAS and MicroSoft Excel. Data are reported in percentages, fractions, and graphs. RESULTS A total of 457 patients and 85 staff completed the surveys. The majority of patients favor ED-based HIV testing. Only a minority of ED staff support ED-based HIV testing. In both hospitals, patients prefer to have HIV test results delivered by a physician. This was true for both positive and negative results. However, only about one third of attending physicians feel comfortable disclosing a positive HIV test result. Patients and staff both view privacy and confidentiality as significant barriers to ED-based HIV testing. CONCLUSION Although ED patients are overwhelmingly in favor of ED-based HIV testing, the staff is not. Patients and staff agree that physicians should deliver HIV test results to patients, but a significant number of physicians are not comfortable doing so. Historical barriers continue to hinder ED-based HIV testing programs.

NEUROLEPTIC MALIGNANT SYNDROME PRESENTING WITHOUT INITIAL FEVER: A CASE REPORT

Neuroleptic malignant syndrome (NMS) is a rare but potentially fatal complication of the use of neuroleptic medications. It is of interest to emergency physicians because rapid recognition of NMS will improve patient outcome and prevent inappropriate treatment. NMS shares features with malignant hyperthermia, serotonin syndrome, lethal catatonia, and heat stroke. We describe a patient with NMS who presented to our institution without initial fever. We review the literature, the classic presentation of NMS, the risk factors, and the morbidity. We discuss the differential diagnosis and the treatment recommendations from the literature.

The cost of decontaminating an ED after finding a bed bug: results from a single academic medical center

The common bed bug, Cimex lectularius L, is a resurgent problem in industrialized nations, including the United States. The US National Electronic Injury Surveillance System–All Injury Program showed that emergency department (ED) visits related to bed bugs rose from 2156 in 2007 to 15945 in 2010, a 7-fold increase in 3 years [1]. In 2013, Orkin Inc listed the Cleveland/Akron/Canton area as the 13th most bed bug-infested city in the United States. Terminix, another large pest management company, estimated that between 2012 and 2013, bed bug infestations rose 36% in the Cleveland area [2,3]. There have been few published epidemiologic investigations of bed bugs in hospitals and no reports on the costs of bed bugs in the ED [1,4]. The objective of this study was to identify the financial burden of bed bugs in our ED. The study took place between June 15, 2013, andNovember 16, 2013, at an academic, tertiary care, urban ED in Cleveland, OH. The ED treats 55,664 adults of 44 ED treatment rooms. We recorded the number times a room was out of service because a bed bug was confirmed or suspected on a patient who had used that room. We noted the length of time the roomwas out of service, if the roomwas treatedwith residual pesticides and steam cleaned or steam cleaned only. We calculated the direct costs associated with spraying and steam cleaning each room based on the number of documented room closures multiplied by a direct bill from the pest management professional (PMP). We added up the number of hours of closure for the study period and extrapolated to 1 year, assuming no change in bed bug frequency for the year. In our hospital, a patients is confirmed for having bed bugs if one is captured and identified by both hospital environmental services (ES) and by a PMP. A bed bug is suspected if a bed bug was seen by ED staff but not captured. A confirmed bed bug resulted in the affected room being treated with pesticides by a PMP, followed by 12 hours of closure, and then steam cleaned by ES before being reopened for new ED patients. A room in which a bed bug was suspected but not confirmedwas only steamcleaned by ES andnot treatedwith pesticides by a PMP. Patients in our EDwere not asked if they had bed bugs as part of their routine clinical care, and hospital staff did not specifically look to find bed bugs on their patients. During 22 weeks, 41 rooms were closed for a total of 720.5 hours due to bed bugs. On average, an ED room was closed per bed bug incident for an average of 17.57 hours every 3.75 days. A total of 35 rooms were both sprayed and steamed. Six rooms were only steamed (Table 1). The average time that an ED room was taken out of service to be treated with pesticides and steamed was 20.14 hours (range, 8.5-32 hours). The average time that an ED room was taken out of service for steaming was 2.42 hours (range, 0.5-4.5 hours). The direct cost to treat a room with pesticides was

Development of emergency medicine in Europe.

325 per room. Steam cleaning a room was estimated to cost

Families' and Victims' Characteristics Influencing Child Sexual Abuse

27.74 per room. Our ED spent

A model for predicting angiographically normal coronary arteries in survivors of out-of-hospital cardiac arrest

12512 for 22 weeks in direct costs related to bed bugs (Table 2) or an estimated