Retrobulbar hematoma from warfarin toxicity and the limitations of bedside ocular sonography.

The following case describes a 26-year-old female who presented to the emergency department with a nontrauamtic retrobulbar hematoma associated with warfarin toxicity. The application and limitations of focused bedside ocular sonography for this condition are discussed.

Intranasal naloxone delivery is an alternative to intravenous naloxone for opioid overdoses.

INTRODUCTION: This study proposes that intranasal (IN) naloxone administration is preferable to intravenous (IV) naloxone by emergency medical services for opioid overdoses. Our study attempts to establish that IN naloxone is as effective as IV naloxone but without the risk of needle exposure. We also attempt to validate the use of the Glasgow Coma Scale (GCS) in opioid intoxication. METHODS: A retrospective chart review of prehospital advanced life support patients was performed on confirmed opioid overdose patients. Initial and final unassisted respiratory rates (RR) and GCS, recorded by paramedics, were used as indicators of naloxone effectiveness. The median changes in RR and GCS were determined. RESULTS: Three hundred forty-four patients who received naloxone by paramedics from January 1, 2005, until December 31, 2007, were evaluated. Of confirmed opioid overdoses, change in RR was 6 for the IV group and 4 for the IN group (P = .08). Change in GCS was 4 for the IV group and 3 for the IN group (P = .19). Correlations between RR and GCS for initial, final, and change were significant at the 0.01 level (rho = 0.577, 0.462, 0.568, respectively). CONCLUSION: Intranasal naloxone is statistically as effective as IV naloxone at reversing the effects of opioid overdose. The IV and IN groups had similar average increases in RR and GCS. Based on our results, IN naloxone is a viable alternative to IV naloxone while posing less risk of needle stick injury. Additionally, we demonstrated that GCS is correlated with RR in opioid intoxication.

External blood loss estimation using the MAR Method.

BACKGROUND: An element lacking in medical education is training to estimate blood volumes. Therefore, health care workers currently use visual estimation as their only means of determining blood volumes, which has shown to be highly inaccurate. This study proposes and tests a new method using one's fist to determine external blood loss. METHODS: Increments of human whole blood were measured and used to compare fist size to surface area of blood present. A formula was created averaging blood per fist, hereafter known as the MAR Method. Two scenarios were staged using set quantities of blood (75 and 750 mL). Participants estimated blood volumes before and after being taught the MAR Method in a 1-minute session. Errors in estimation before and after using the MAR Method were compared. RESULTS: The MAR Method was created using a fist to cover a surface area of blood that equals 20 mL. A total of 74 participants had errors of 120% and 73% for visualization of the small and large pools, respectively. For the smaller volume, the average error from the mean decreased by 76% (P < .0001), and the interquartile range of errors decreased by 60%. For the larger volume, the average error from the mean reduced by 40% (P < .0001), and the interquartile range of errors reduced by 45%. CONCLUSION: Use of the MAR Method improves blood volume estimations. After less than 1 minute of instruction, participants were able to determine blood volumes with improved accuracy and precision.

Prevalence of methicillin-resistant Staphylococcus aureus on the stethoscopes of emergency medical services providers.

OBJECTIVE: The investigation seeks to determine the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) on the stethoscopes of emergency medical services (EMS) providers. While stethoscopes are known fomites for MRSA, the prevalence of MRSA in the prehospital setting is not well documented in the literature. METHODS: This was a prospective, observational cohort study of 50 stethoscopes provided by consecutive, consenting EMS providers at our academic emergency department (ED). Stethoscopes were swabbed with saline culture applicators and samples were cultured on a commercial MRSA test kit containing mannitol salt agar with oxacillin. After 72 hours of incubation at 37 degrees C, two emergency physicians and one microbiologist analyzed the plates independently. MRSA colonization was recorded as positive if all three reviewers agreed that colonization had occurred. RESULTS: Of 50 stethoscopes, 16 had MRSA colonization, and 16 (32%) EMS professionals had no recollection of when their stethoscopes had been cleaned last. Reported length of time since last cleaning was grouped into six categories: one to seven days, eight to 14 days, 15 to 30 days, 31 to 180 days, 181 days to 365 days, and unknown. The median time frame reported since the last cleaning was one to seven days. In the model, an increase from one time category to the next increased the odds of MRSA colonization by 1.86 (odds ratio = 1.86, p = 0.038). CONCLUSIONS: In this ED setting, MRSA was found on approximately one in three stethoscopes of EMS professionals. A longer length of time since the last stethoscope cleaning increased the odds of MRSA colonization.