Systemic loxoscelism in the age of community-acquired methicillin-resistant Staphylococcus aureus.

The increase in cases of community-acquired methicillin-resistant Staphylococcus aureus (MRSA), as well as its isolation from the majority of skin and soft tissue abscesses in the emergency department, requires the emergency physician to consider this diagnosis in all skin or soft tissue infections. However, making the diagnosis of MRSA when the wound is actually a cutaneous lesion of a brown recluse spider bite may have untoward consequences. Furthermore, the clinical manifestations of systemic loxoscelism may be misdiagnosed as a systemic staphylococcal infection. We present a patient with systemic loxoscelism who was diagnosed with a systemic infection and received an unnecessary surgical procedure.

A randomized, placebo-controlled trial of ondansetron, metoclopramide, and promethazine in adults.

OBJECTIVES: The objective of the study was to assess whether ondansetron has superior nausea reduction compared with metoclopramide, promethazine, or saline placebo in emergency department (ED) adults. METHODS: This randomized, placebo-controlled, double-blinded superiority trial was intended to enroll a convenience sample of 600 patients. Nausea was evaluated on a 100-mm visual analog scale (VAS) at baseline and 30 minutes after treatment. Patients with a minimum preenrollment VAS of 40 mm were randomized to intravenous ondansetron 4 mg, metoclopramide 10 mg, promethazine 12.5 mg, or saline placebo. A 12-mm VAS improvement in nausea severity was deemed clinically important. We measured potential drug adverse effects at baseline and 30 minutes. Patients received approximately 500 mL of saline hydration during the initial 30 minutes. RESULTS: Of 180 subjects who consented, 163 completed the study. The median age was 32 years (interquartile range, 23-47), and 68% were female. The median 30-minute VAS reductions (95% confidence intervals) and saline volume given for ondansetron, metoclopramide, promethazine, and saline were -22 (-32 to -15), -30 (-38 to -25.5), -29 (-40 to -21), and -16 (-25 to -3), and 500, 500, 500, and 450, respectively. The median 30-minute VAS differences (95% confidence intervals) between ondansetron and metoclopramide, promethazine, and saline were -8 (-18.5 to 3), -7 (-21 to -5.5), and 6 (-7 to 20), respectively. We compared the antiemetic efficacy across all treatments with the Kruskal-Wallis test (P = .16). CONCLUSIONS: Our study shows no evidence that ondansetron is superior to metoclopramide and promethazine in reducing nausea in ED adults. Early study termination may have limited detection of ondansetron's superior nausea reduction over saline.

Emergency airway management in critically injured patients: a survey of U.S. aero-medical transport programs.

OBJECTIVE: Pre-hospital airway management represents the intervention most likely to impact outcomes in critically injured patients. As such, airway management issues dominate quality improvement (QI) reviews of aero-medical programs. The purpose of this study was to evaluate current practice patterns of airway management in trauma among U.S. aero-medical service (AMS) programs. METHODS: The Association of Air Medical Services (AAMS) Resource Guide from 2005 to 2006 was utilized to identify the e-mail addresses of all directors of U.S. aero-medical transport programs. Program directors from 182 U.S. aero-medical programs were asked to participate in an anonymous, web-based survey of emergency airway management protocols and practices. Non-responders to the initial request were contacted a second time by e-mail. RESULTS: 89 programs responded. 98.9% have rapid sequence intubation (RSI) protocols. 90% use succinylcholine, 70% use long-acting neuromuscular blockers (NMB) within their RSI protocol. 77% have protocols for mandatory in-flight sedation but only 13% have similar protocols for maintenance paralytics. 60% administer long-acting NMB immediately after RSI, 13% after confirmation of neurological activity. Given clinical scenarios, however, 97% administer long-acting NMB to patients with scene and in-flight Glasgow Coma Scale (GCS) of 3, even for brief transport times. CONCLUSIONS: The majority of AMS programs have well defined RSI and in-flight sedation protocols, while protocols for in-flight NMB are uncommon. Despite this, nearly all programs administer long-acting NMB following RSI, irrespective of GCS or flight time. Given the impact of in-flight NMB on initial assessment, early intervention, and injury severity scoring, a critical appraisal of current AMS airway management practices appears warranted.