Near-Fatal Spice Intoxication of a Toddler.

Synthetic cannabinoids are a heterogenous group of novel, legally regulated psychoactive substances that can result in broad, multisystemic, dangerous effects. Despite growing literature regarding synthetic cannabinoid toxicity, little is known about the extent of these effects in young children. Caregivers of drug-endangered children may not provide an accurate history of exposure when children present with symptoms of intoxication, and lack of swift detection on routine urine drug screens may further obscure and delay the diagnosis. Clinical recognition carries forensic relevance that may support interventions to aid in protecting vulnerable children. We describe a case of near-fatal child maltreatment due to supervisory neglect resulting from ingestion of an increasingly common synthetic cannabinoid. Furthermore, we highlight clinical findings that should increase a physician's index of suspicion for synthetic cannabinoid toxicity, even in the absence of a history of exposure.

Angioedema and Dual Nurse Flight Crew Cricothyrotomy After Envenomation by a Severed Rattlesnake Head.

Crotalid envenomation may result in airway compromise from angioedema, anaphylaxis, or an anaphylactoid reaction. A 57-year-old man was transported by helicopter to the emergency department (ED) after a bite to his hand from a severed rattlesnake head. He rapidly developed facial and oropharyngeal edema that did not respond to standard treatment. After 2 unsuccessful attempts at intubation, the dual flight nurse team performed a cricothyrotomy. They notified the ED team en route, and antivenom was prepared before arrival. Angioedema was suspected because there was no concomitant urticaria, bronchoconstriction, or persistent hypotension. Edema and ecchymosis of the affected extremity were mild. Severe coagulopathy ensued, which was treated with bolus doses of antivenom and continuous infusion. This case report is significant for several reasons. It is the first detailing a prehospital cricothyrotomy performed by flight crew nurses for life-threatening airway edema caused by snakebite envenomation. In-flight notification enabled the ED staff to prepare and administer antivenom immediately after arrival. Despite the use of antivenom in bolus dosing, crotalid envenomation may be complicated by persistent or recurring coagulopathy, and continuous antivenom infusion may be useful. Finally, it highlights the danger of snakebite envenomation even after the death and decapitation of a snake.

Acute and Chronic Carbon Monoxide Toxicity from Tobacco Smoking.

INTRODUCTION: Carbon monoxide (CO) is produced from incomplete combustion of hydrocarbons and is a by-product of tobacco smoking. Chronic cigarette smokers often have carboxyhemoglobin (COHb) concentrations as high as 10%. We report a case of severely elevated COHb and polycythemia because of tobacco smoking and provide a review of the literature regarding elevated COHb in smokers. MATERIALS AND METHODS: A comprehensive search of PubMed and Google Scholar was performed looking for articles on tobacco smoking and CO, COHb, CO poisoning, cigarettes, pipes, cigars and water pipes/hookah smokers. RESULT: COHb levels in frequent cigarette smokers generally range from 4.2% presmoking to 8.6% postsmoking. A heavy cigarette smoker presented twice with symptoms of CO toxicity and was found to have levels 21.8 to 24.2%. Cigar smokers have been found to have COHb ranging as high as 13.0 to 38.6% in case reports. Waterpipe or "hookah" smokers generally have COHb levels 10.1% +/-2.5% and case reports, and series of even higher levels associated with CO toxicity symptoms are common. Waterpipe smokers have been found to have COHb levels as high as 39.2% after smoking. CONCLUSIONS: Many active duty military and military veterans are tobacco smokers and these patients and their health care providers should be aware of the adverse effects of CO toxicity from tobacco smoking. Patients may have symptoms such as headaches, syncope, and ataxia in the setting of acute CO toxicity; however, the chronic effects of CO may not be completely understood. Future work could explore chronic CO toxicity and its effects on strength and exercise tolerance in military personnel and provide education to service members, veterans, and health care providers.

Are Emergency Medicine Residents Prepared to Meet the Ethical Challenges of Clinical Practice? Findings from an Exploratory National Survey.

BACKGROUND: Although the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine require clinical ethics education in residency training, instruction varies widely. We assessed the educational preparedness of trainees in emergency medicine to address ethics challenges common to their field. METHODS: The survey assessed two outcomes: 1) knowledge of specific ethical challenges and 2) perceived educational preparedness, across five ethics areas: 1) informed consent and decisional-capacity assessment, 2) surrogate decision making, 3) interpretation of advanced directives, 4) withdrawing and/or withholding life support, and 5) presumed consent for emergency treatment. Clinical vignettes, revised through expert panel review and pilot testing, were utilized to evaluate these areas. The final instrument was administered via Web link to emergency medicine residents and recent graduates through adverts within Emergency Medicine Residency Association and Society for Academic Emergency Medicine (SAEM) newsletters and social media platforms. Additionally, targeted e-mails through the Council of Residency Directors in Emergency Medicine, the Clerkship Directors of Emergency Medicine, and the SAEM Ethics Committee listservs encouraged survey distribution. Analyses involved one-way analysis of variance for overall knowledge scores and chi-square tests for categorical outcomes. Multivariable regression models tested associations between respondent characteristics and outcomes. RESULTS: There were 302 participants of which 34% reported having a dedicated ethics module within their residency curriculum. The mean (±SD) knowledge score was 59.7% (±12.8%); assessing decisional capacity was the most difficult topic for respondents as only 1% both correctly addressed the general issue and identified the correct plan of action. Participants having a dedicated ethics module perceived themselves better prepared, although there was no association between having a dedicated ethics module and knowledge scores. CONCLUSIONS: Gaps in clinical ethics knowledge appear prevalent among emergency medicine trainees, and few programs have dedicated ethics modules. Greater study is needed to understand and remedy clinical ethics knowledge shortfalls.

Number of Weeks Rotating in the Emergency Department Has a Greater Effect on Ultrasound Milestone Competency Than a Dedicated Ultrasound Rotation.

OBJECTIVES: Ultrasound (US) is vital to modern emergency medicine (EM). Across residencies, there is marked variability in US training. The "goal-directed focused US" part of the Milestones Project states that trainees must correctly acquire and interpret images to achieve a level 3 milestone. Standardized methods by which programs teach these skills have not been established. Our goal was to determine whether residents could achieve level 3 with or without a dedicated US rotation. METHODS: Thirty-three first- and second-year residents were assigned to control (no rotation) and intervention (US rotation) groups. The intervention group underwent a 2-week curriculum in vascular access, the aorta, echocardiography, focused assessment with sonography for trauma, and pregnancy. To test acquisition, US-trained emergency medicine physicians administered an objective structured clinical examination. To test interpretation, residents had to identify normal versus abnormal findings. Mixed-model logistic regression tested the association of a US rotation while controlling for confounders: weeks in the emergency department (ED) as a resident, medical school US rotation, and postgraduate years. RESULTS: For image acquisition, medical school US rotation and weeks in the ED as a resident were significant (P = .03; P = .04) whereas completion of a US rotation and postgraduate years were not significant. For image interpretation, weeks in the ED as a resident was the only significant predictor of performance (P = .002) whereas completion of a US rotation and medical school US rotation were not significant. CONCLUSIONS: To achieve a level 3 milestone, weeks in the ED as a resident were significant for mastering image acquisition and interpretation. A dedicated US rotation did not have a significant effect. A medical school US rotation had a significant effect on image acquisition but not interpretation. Further studies are needed to best assess methods to meet US milestones.

A Survey of Ultrasound Milestone Incorporation Into Emergency Medicine Training Programs.

OBJECTIVES: With the introduction of the Emergency Medicine Milestone Project in 2013, residencies now assess emergency ultrasound (US) skills at regular intervals. However, it is unclear how programs are implementing the emergency US milestones and assessing competency. With the use of the milestone tool, a survey was distributed to emergency US educators to determine when programs are providing emergency US education, when residents are expected to attain competency, and whether the milestones reflect their expectations of trainees. METHODS: We conducted a prospective cross-sectional survey study distributed electronically to designated emergency US experts at 169 programs. Participants were queried on education and competency evaluation within the context of the milestones by designating a postgraduate year when the 5 milestone levels were taught and competency was expected. Survey findings were reported as percentages of total respondents from descriptive statistics. RESULTS: Responses were received from 53% of programs, and 99% were familiar with the milestones. Most programs provide level 1 (88%) and 2 (85%) instruction during postgraduate year 1. Most programs expect level 1 competency before residency (61%) and expect mastery of level 2 by the end of postgraduate year 1 (60%). Sixty-two percent believe the milestones do not accurately reflect their expectations, citing insufficient minimum scan numbers, lack of specificity, and unattainable level 5 requirements. CONCLUSIONS: There is substantial variability in the frequency and methods of competency evaluation using the emergency US milestones. However, most responders agree that residents should obtain level 2 competency by postgraduate year 1. Variation exists regarding what year and what skills define level 3 or greater competency.

Therapeutic effects of exercise: wheel running reverses stress-induced interference with shuttle box escape.

Exercise can reduce symptoms of depression and anxiety in humans, but therapeutic effects of exercise in an animal model of stress-related mood disorders have yet to be demonstrated. In the current study, the authors investigated the ability of wheel running to reverse a long-lasting interference with shuttle box escape produced by uncontrollable stress. Rats who remained sedentary following uncontrollable foot shock demonstrated robust conditioned freezing behavior to the stressor environment and deficits in shuttle box escape learning. Voluntary access to running wheels for 6 weeks, but not 2 weeks, following uncontrollable foot shock reduced the expression of conditioned freezing and reversed the escape deficit. Results demonstrate a long-lasting interference with shuttle box escape that can be reversed by exercise in a duration-dependent fashion.