Ketamine's love story with the heart: A Takotsubo twist.

INTRODUCTION: Ketamine is a dissociative anesthetic with N-methyl-d-aspartate and glutamate receptor antagonist properties. It has been the most popular agent to facilitate emergency department procedures for three decades. Considered a safe and effective option for procedural sedation, ketamine has rapid onset, short effective sedation time, and a low risk profile. Ketamine's sympathomimetic effects could theoretically induce stress-related cardiac dysfunction, including cardiomyopathy. A review of the literature demonstrates one prior report of stress (Takotsubo) cardiomyopathy after ketamine sedation. CASE REPORT: In this case report, we present a case of Takotsubo cardiomyopathy after ketamine sedation for distal radius fracture reduction. The patient presented hemodynamically normal with an unremarkable cardiac ultrasound and progressed to hypoxia from bilateral pulmonary edema, eventually requiring intubation. Inpatient evaluation revealed elevated high sensitivity troponin, non-obstructive coronary arteries on catheterization, and echocardiogram findings of Takotsubo cardiomyopathy. She received operative fixation of her radius fracture by orthopedics and was discharged home on hospital day 9. She had an unremarkable follow up with cardiology but had no echocardiogram to determine full resolution. CONCLUSION: Although ketamine has robust evidence of safety and efficacy, physicians should be aware of the potential complications of its sympathomimetic effects, from hypertension and tachycardia to overt Takotsubo cardiomyopathy.

Case Report of Malignant Hyperthermia in the Emergency Department.

INTRODUCTION: Malignant hyperthermia (MH) is a rare but deadly condition that may be encountered in the emergency department (ED). This report highlights a case of a patient who initially presented for acute agitation with hypertension and tachycardia and provides explanation for how to manage MH. CASE REPORT: A 44-year-old male presented to the ED with altered mental status, eventually requiring intubation with etomidate and succinylcholine. Despite being afebrile initially, the patient developed a rectal temperature of 105.3° Fahrenheit (F) with significantly elevated arterial carbon dioxide levels after intubation. The treating team initiated cooling measures and dantrolene, leading to a positive outcome. CONCLUSION: Clinicians should strive for expeditious recognition of MH and treatment with an updated institutional protocol.

Data linkage for crash outcome assessment: Linking police-reported crashes, emergency response data, and trauma registry records.

INTRODUCTION: Traffic crash reports lack detailed information about emergency medical service (EMS) responses, the injuries, and the associated treatments, limiting the ability of safety analysts to account for that information. Integrating data from other sources can enable a better understanding of characteristics of serious crashes and further explain variance in injury outcomes. In this research, an approach is proposed and implemented to link crash data to EMS run data, patient care reports, and trauma registry data. METHOD: A heuristic framework is developed to match EMS run reports to crashes through time, location, and other indicators present in both datasets. Types of matches between EMS and crashes were classified. To investigate the fidelity of the match approach, a manual review of a sample of data was conducted. A comparative bias analysis was implemented on several key variables. RESULTS: 72.2% of EMS run reports matched to a crash record and 69.3% of trauma registry records matched with a crash record. Females, individuals between 11 and 20 years old, and individuals involved in single vehicle or head on crashes were more likely to be present in linked data sets. Using the linked data sets, relationships between EMS response time and reported injury in the crash report, and between police-reported injury and injury severity score were examined. CONCLUSION: Linking data from other sources can greatly enhance the information available to address road safety issues, data quality issues, and more. Linking data has the potential to result in biases that must be investigated as they relate to the use-case for the data. PRACTICAL IMPLICATIONS: This research resulted in a transferable heuristic approach that can be used to link data sets that are commonly collected by agencies across the world. It also provides guidance on how to check the linked data for biases and errors.

Opioid Overdoses for Recently Incarcerated Individuals: Toxicology Results and Risk Evaluations.

Background: The opioid epidemic continues to challenge the United States, fueled by illicitly manufactured fentanyl. All stakeholders involved in fighting the opioid epidemic, from medical providers to policy makers, will benefit from understanding what contributes to overdoses. Recently incarcerated individuals represent a particularly vulnerable population. Methods: We performed a retrospective review of Jefferson County Coroner data for overdose deaths by postmortem toxicology between January 2017 and December 2018. Patients were cross-referenced with Jefferson County Department of Corrections (DOC) records, with inclusion of individuals with violations after January 2016 to focus on recently incarcerated individuals. We analyzed substances found in toxicology reports and substance risk level assigned based on screening by the DOC. Results: A total of 575 opioid overdose deaths occurred in Jefferson County from 2017-2018, with 55 of these individuals having interaction with the DOC after January 1, 2016. DOC population individuals had statistically significant higher findings of amphetamines/methamphetamines. Individuals from the DOC population had higher frequencies of fentanyl, heroin, cocaine, and cannabinoid/THC; however, these differences were not statistically significant. Prisoners with substance risk assessment scores of high or very high had fewer days from release to overdose death. Conclusion: Fentanyl remains a major contributor to overdose death, including those recently incarcerated. Substance risk assessment tools should drive referral for treatment while in prison and at time of release. These results provide better insight into the opioid epidemic and may help guide medical care, specifically for recently incarcerated individuals.