There is more to the mechanism of unconsciousness from vascular neck restraint than simply carotid compression.

Vascular neck restraint (VNR), an effective technique practiced within police and military combatives and in mixed martial arts and grappling sports, is of both interest and controversy. In any context the goal of VNR (referred to as a choke within combat sports) is to restrict brain blood flow enough to threaten or result in unconsciousness. The physiologic basis for the resultant unconsciousness has been depicted as being solely because of restriction of carotid blood flow due to direct external compression. This view is likely simpler than what is actually going on, but it's an area not well explored in the medical literature. Brain blood flow is maintained through mechanisms that allow for a relatively wide acceptable cerebral perfusion pressure (CPP). If CPP drops below the threshold of this auto-regulation, blood flow and brain oxygen delivery begin to decline. CPP is the difference of the mean arterial pressure (MAP) coming into the brain and the intracranial pressure (ICP). Lowering the MAP and/or raising the ICP reduce the CPP. The best literature-established physiologic component of VNR is carotid compression and resultant reduction in functional carotid MAP, thus lowering the CPP. Most studies have looked at this essentially to the exclusion of two other contributing entities: jugular compression resulting in increased ICP from reduction of outflow, and reduction of actual whole body MAP due to reduced cardiac output from vagal stimulation coming from a pressure affected carotid body. This article fleshes out some of these physiologic variables and discusses the related available literature.

Toxicity following laundry detergent pod ingestion.

Laundry detergent pods (LDPs) have only recently become available in the United States, and there has been increasing concern regarding pediatric ingestions of them. We describe a 15-month-old female infant who ingested an LDP and had a depressed level of consciousness, metabolic acidosis, pulmonary toxicity, and swallowing difficulties. It is currently unclear what the exact etiologic agent(s) is responsible for the toxicity associated with LDPs. The case demonstrates the potential for significant toxicity following the ingestion of an LDP. Clearly, measures should be taken to avoid ingestions of these products.

Death caused by ingestion of an ethanol-based hand sanitizer.

BACKGROUND: The use of hand sanitizer is effective in preventing the transmission of disease. Many hand sanitizers are alcohol-based, and significant intoxications have occurred, often in health care facilities, including the emergency department (ED). OBJECTIVES: We present this case to highlight potential toxicity after the ingestion of an ethanol-based hand sanitizer. CASE REPORT: A 36-year-old man presented to the ED with ethanol intoxication. Ethanol breath analysis was measured at 278 mg/dL. After 4 h, the patient was less intoxicated and left the ED. Thirty minutes later, he was found apneic and pulseless in the ED waiting room bathroom after having ingested an ethanol-based hand sanitizer. Soon after a brief resuscitation, his serum ethanol was 526 mg/dL. He never regained consciousness and died 7 days later. No other cause of death was found. CONCLUSION: The case highlights the potential for significant toxicity after the ingestion of a product found throughout health care facilities. Balancing the benefit of hand sanitizers for preventing disease transmission and their potential misuse remains a challenge.

A case of necrotizing fasciitis with a LRINEC score of zero: clinical suspicion should trump scoring systems.

BACKGROUND: Necrotizing fasciitis (NF) is a potentially lethal infection involving the skin, subcutaneous tissue, and fascia. The Laboratory Risk Indicator for Necrotizing fasciitis (LRINEC) score has been proposed as a way of using abnormal laboratory values to distinguish between severe cellulitis and necrotizing fasciitis. OBJECTIVES: The utility of the LRINEC system, including a review of current literature on this scoring system, is discussed. CASE REPORT: A case of a 37-year-old man is presented. As part of the diagnostic work-up, appropriate laboratory tests necessary to calculate a LRINEC score were obtained. Despite a LRINEC score of 0, NF was later confirmed at surgery. CONCLUSIONS: Although the LRINEC score has been proposed as a robust way of identifying patients with early NF, it failed to detect NF in the patient reported here. NF should thus remain primarily a disease of clinical suspicion, and this suspicion should trump the LRINEC score.

Convulsions associated with the use of a synthetic cannabinoid product.

INTRODUCTION: Clinical presentations following the use of various "spice" or synthetic cannabinoids have included agitation, anxiety, emesis, hallucinations, psychosis, tachycardia, and unresponsiveness. Convulsions were described in a one report although there was not laboratory confirmation for synthetic cannabinoids. In another published report laboratory confirmation for a synthetic cannabinoid was done in which the patient manifested activity that was interpreted as a possible convulsion. CASE REPORT: We describe a patient who had two witnessed generalized convulsions soon after smoking a "spice" product that we later confirmed to have four different synthetic cannabinoids. DISCUSSION: Convulsions have only rarely been associated with marijuana exposures. Recreational use of synthetic cannabinoids is a very recent phenomenon and there is a very limited, albeit burgeoning, literature detailing the associated complications including convulsions we have reported here. The absence of anticonvulsant phytocannabinoids in spice products could potentially be one of multiple unknown mechanisms contributing to convulsions.

"Spice" girls: synthetic cannabinoid intoxication.

BACKGROUND: "Spice" refers to various synthetic cannabinoid-containing products that seem to have rapidly become popular recreational drugs of abuse. Very little medical literature currently exists detailing the adverse effects and emergency department (ED) presentations associated with "spice" use. OBJECTIVES: To describe the presentation of 2 patients who recreationally used a "spice" product and to briefly summarize what is known about "spice" and synthetic cannabinoids. CASE REPORT: Two patients presented to the ED with, predominantly, anxiety after recreationally using a "spice" product that we subsequently confirmed to contain the synthetic cannabinoids, JWH-018 and JWH-073. CONCLUSION: We suspect that use of "spice" products may increase. Although anxiety was a prominent presentation in both of the patients described here, undoubtedly, future studies will describe the manifestations of intoxication and toxicity with the various synthetic cannabinoids.

Report of the Task Force on National Fourth Year Medical Student Emergency Medicine Curriculum Guide.

This manuscript reports recommendations of the National Fourth Year Medical Student Emergency Medicine Curriculum Guide Task Force. This task force was convened by 6 major emergency medicine organizations to develop a standardized curriculum for fourth year medical students. The structure of the curriculum is based on clerkship curricula from other specialties such as internal medicine and pediatrics. The report contains a historical context, global and targeted needs assessment, goals and objectives, recommended educational strategies, implementation guidelines, and suggestions on feedback and evaluation.

Effect of whole bowel irrigation on the pharmacokinetics of an acetaminophen formulation and progression of radiopaque markers through the gastrointestinal tract.

STUDY OBJECTIVES: We describe the effects of whole bowel irrigation on a delayed-release acetaminophen preparation. We compare the mechanical effect of whole bowel irrigation on the progression of radiopaque markers through the gastrointestinal tract between an experimental and a control group. METHODS: We performed a 2-armed, prospective, randomized, crossover volunteer study. In the experimental phase, subjects were administered a delayed-release acetaminophen preparation (75 mg/kg) along with a capsule containing radiopaque markers. We initiated whole bowel irrigation at 30 minutes after ingestion and continued until the rectal effluent was clear. Serum acetaminophen concentrations were measured at baseline and from 0.5 to 8 hours. Abdominal radiographs were obtained at the completion of whole bowel irrigation. In the control phase, whole bowel irrigation was not performed. The primary outcome measure was the effect on the area under the acetaminophen concentration versus time curve (AUC) between the 2 groups. RESULTS: Ten subjects participated in the study. We found an 11.5% reduction in the AUC, with the majority of the effect occurring in the delayed-release portion of the curve after the 2-hour mark. This reduction, however, was not statistically significant. Radiographs obtained at the end of whole bowel irrigation revealed radiopaque markers sequestered in the right hemicolon in 8 of 10 subjects. No discernible pattern was noted in the control arm. CONCLUSION: The effect of whole bowel irrigation on reduction of AUC for delayed-release acetaminophen preparation was not statistically significant. Whole bowel irrigation did appear to have a mechanical effect on the progression of radiopaque markers through the gastrointestinal tract, but the clinical significance of this finding is not clear.

Complications of diagnostic physostigmine administration to emergency department patients.

STUDY OBJECTIVES: Literature exists describing the complications associated with therapeutic physostigmine administration. No series exists detailing strictly diagnostic use. Our objective was to document the complications associated with diagnostic physostigmine administration in emergency department (ED) patients suspected of having antimuscarinic delirium. METHODS: Two reviewers blinded to the study purpose performed a retrospective chart review on all adult patients administered physostigmine diagnostically over a 79-month period at a tertiary-care hospital. Twenty percent of charts were reviewed by both abstractors. The data abstracted from the chart included total dose of physostigmine, effect on mental status, any subsequent complications, or any use of atropine. Discharge summaries, toxicology consultations, and urine drug screens were used to determine the cause of the altered mental status. RESULTS: Thirty-nine adult patients were administered varying doses of physostigmine (range 0.5 to 2 mg). The reviewers were able to determine the cause of the altered mental status in 35 patients. The cause was purely antimuscarinic in 19 patients, purely nonantimuscarinic in 10 patients, mixed antimuscarinic and nonantimuscarinic in 2 patients, psychiatric in 4 patients, and unknown in 4 patients. A total of 22 patients had full reversal of delirium, and this group comprised all 19 patients with a purely antimuscarinic cause and 3 patients in whom a cause was never determined. One (2.6%) in 39 patients had a brief convulsion without adverse sequelae. This patient was poisoned with an antimuscarinic drug. No patient had dysrhythmias, had signs of cholinergic excess, or was administered atropine. CONCLUSION: Diagnostic physostigmine administration was without significant complication when given to ED patients suspected of having antimuscarinic delirium. Although a relatively small series, it contributes to the safety profile of physostigmine.

Droperidol in the emergency department: is it safe?

Droperidol is an antipsychotic and antiemetic drug that has been used extensively by emergency physicians, psychiatrists, and anesthesiologists worldwide since 1967. It also has been used effectively for other diverse conditions, such as treatment of headache and vertigo. As of January 2001, Droperidol was no longer available in Europe after its founder, Janssen-Cilag Pharmaceuticals, discontinued its distribution. In December 2001, the United States Food and Drug Administration (FDA) placed a black box warning on the use of Droperidol in response to an association between Droperidol and fatal cardiac dysrhythmias, such as torsade de pointes, resulting from prolongation of the QT interval. In this review we closely examine the pharmacology, indications, use, and complications associated with Droperidol, and speculate on its future use in the Emergency Department.

The effects of the FDA warning on the use of droperidol by u.s. Emergency physicians.

OBJECTIVES: To determine if emergency physicians' (EP) use of droperidol has changed since the United States Food and Drag Administration (FDA) warning of December 2001 concerning QT interval prolongation, torsade de pointes, and sudden death; and to query EP opinions regarding droperidol before and after the FDA warning and regarding potential alternative drugs. METHODS: An internet-based survey was designed with questions regarding droperidol use in the emergency department (ED). Data collected included EP demographics, use of droperidol before and after the FDA warning, use of alternative drugs, and incidence of arrhythmias. A representative sample of EPs were contacted by e-mail and asked to complete the survey. RESULTS: A total of 2,000 e-mails resulted in 506 (25%) completed surveys. There was no second mailing. Responders' average years practicing was 12.6 ± 9.2. EP responders worked in private/community (n=278, 55%), academic/county (n=187, 37%), and HMO (n=41, 8%) hospitals. The. majority (n=455, 90%) used droperidol and were aware of the FDA warning (n=460, 91%). Droperidol was no longer available at 122 (24%) of the respondents' EDs as a result of the FDA warning. Prior to the FDA warning, EPs who had used droperidol used it as an antiemetic (n=408, 90%), for control of agitation (n=330, 73%), for treatment of headache (n=247, 54%), and for treatment of vertigo (n=106, 23%). After the FDA warning, 387 (85%) of EPs reported their use of droperidol had decreased or ceased altogether, and 68 (15%) always obtained an electrocardiogram prior to administration. Of those who used droperidol for agitation, 137 (42%) felt there were no other drugs with greater efficacy. Haloperidol was the most cited alternative agent (n=260, 79%) followed by benzodiazepines (n=223, 68%). Of those who used droperidol for antiemesis, 116 (28%) felt there were no other drugs with greater efficacy than droperidol; promethazine was the most cited alternative agent (n=260, 64%). Two (0.4%) EPs reported arrhythmias in patients who received droperidol. Only 37 (8%) EPs reported they were unconcerned with potential loss of droperidol from the market. CONCLUSION: Based on this survey, EP use of droperidol has decreased dramatically as a result of the FDA warning. However, EPs believe that there are few or no alternative antiemetic drugs that have an improved adverse effect profile.

Massive OxyContin ingestion refractory to naloxone therapy.

OxyContin (oxycodone hydrochloride controlled release) is a long-acting preparation of oxycodone that is used as an opioid analgesic to treat chronic pain conditions. We report a patient who ingested a massive quantity of OxyContin and had altered mental status, noncardiogenic pulmonary edema, and hypoventilation that proved refractory to naloxone administration. She required mechanical ventilation for 3 days before recovering completely. The severity and length of poisoning was likely related both to the quantity and formulation of the oxycodone ingested.