Baclofen and ethanol ingestion: a case report.

The number of reported cases of skeletal muscle relaxant ingestion has been increasing in the United States, although fatalities are rare. A 30-year-old women ingested 300 mg of baclofen and ethanol. She was able to ambulate into the Emergency Department (ED) 50 min later, but within 30 min post-arrival had a Glasgow Coma Score of 3. She was treated with supportive care including mechanical ventilation for 36 h. Her neurologic status returned to her previous state. Coma may occur rapidly after baclofen overdose, and the respiratory depression may be exacerbated by the co-ingestion of ethanol. Primary importance in the treatment of such ingestions should be placed on maintenance of an airway and respiratory support.

Emergency department impact of the Oklahoma City terrorist bombing.

STUDY OBJECTIVE: To collect descriptive epidemiologic injury data on patients who suffered acute injuries after the April 19, 1995, Oklahoma City bombing and to describe the effect on metropolitan emergency departments. METHODS: A retrospective review of the medical records of victims seen for injury or illness related to the bombing at 1 of the 13 study hospitals from 9:02 AM to midnight April 19, 1995. Rescue workers and nontransported fatalities were excluded. RESULTS: Three hundred eighty-eight patients met inclusion criteria; 72 (18.6%) were admitted, 312 (80.4%) were treated and released, 3 (.7%) were dead on arrival, and 1 had undocumented disposition. Patients requiring admission took longer to arrive to EDs than patients treated and released (P =.0065). The EDs geographically closest to the blast site (1.5 radial miles) received significantly more victims than more distant EDs (P <.0001). Among the 90 patients with documented prehospital care, the most common interventions were spinal immobilization (964/90, 71.1%), field dressings (40/90, 44.4%), and intravenous fluids (32/90, 35.5%). No patients requiring prehospital CPR survived. Patients transported by EMS had higher admission rates than those arriving by any other mode (P <.0001). The most common procedures performed were wound care and intravenous infusion lines. The most common diagnoses were lacerations/contusion, fractures, strains, head injury, abrasions, and soft tissue foreign bodies. Tetanus toxoid, antibiotics, and analgesics were the most common pharmaceutical agents used. Plain radiology, computed tomographic radiology, and the hospital laboratory were the most significantly utilized ancillary services. CONCLUSION: EMS providers tended to transport the more seriously injured patients, who tended to arrive in a second wave at EDs. The closest hospitals received the greatest number of victims by all transport methods. The effects on pharmaceutical use and ancillary service were consistent with the care of penetrating and blunt trauma. The diagnoses in the ED support previous reports of the complex but often nonlethal nature of bombing injuries.

Comparison of arterial and venous blood gas values in the initial emergency department evaluation of patients with diabetic ketoacidosis.

STUDY OBJECTIVE: To determine whether venous blood gas values can replace arterial gas values in the initial emergency department evaluation of patients with suspected diabetic ketoacidosis. METHODS: This prospective comparison was performed in an adult university teaching hospital ED. Samples for arterial and venous blood gas analysis were obtained during initial ED evaluations. The venous gas samples were collected with samples for other blood tests at the time of intravenous line insertion. Both arterial and venous samples were obtained before the initiation of treatment. RESULT: Data from 44 episodes of diabetic ketoacidosis in 38 patients were analyzed. Laboratory findings of those patients with diabetic ketoacidosis were as follows (mean +/- SD): arterial pH, 7.20 +/- 14; venous pH, 7.17 +/- 13; serum glucose, 33.8 +/- 16 mmol/L (609 +/- 288 mg/dL); arterial HCO3-, 11.0 +/- 6.0 mmol; venous HCO3-, 12.8 +/- 5.5 mmol/L; serum CO2, 11.8 +/- 5.0 mmol/L; and anion gap, 26.7 +/- 7.6 mmol/L. The mean difference between arterial and venous pH values was 0.03 (range 0.0 to 0.11). Arterial and venous pH results (r = .9689) and arterial and venous HCO3- results (r = .9543) were highly correlated and showed a high measure of agreement. CONCLUSION: Venous blood gas measurements accurately demonstrate the degree of acidosis of adult ED patients presenting with diabetic ketoacidosis.

Vascular abdominal emergencies.

Vascular emergencies are an uncommon but significant cause of abdominal pain, back pain, hemorrhagic shock, and death in adults. This article reviews abdominal vascular anatomy, risk factors, signs and symptoms, abdominal vascular thrombosis, mesenteric ischemia and infarction, and abdominal vascular emboli and aneurysms.

A prospective survey of procedures performed by emergency medicine residents during a 36-month residency.

Future specialty training requirements for emergency medicine may include adequately documented records of procedures and resuscitations performed. A computer database was developed to track these data and to report the experience of one graduating class of nine emergency medicine residents. This study was a prospective survey conducted at a community hospital with a fully accredited (PGY 1-3) emergency medicine residency program. This study showed that data on resident procedures can be adequately documented using a computer database to determine whether requirements for emergency medicine resident training are met. The problems of resident data entry compliance and determining procedural competence are discussed briefly.

Prospective evaluation of topical antibiotics for preventing infections in uncomplicated soft-tissue wounds repaired in the ED.

OBJECTIVE: To determine differences in infection rates among uncomplicated, repaired wounds managed with: topical bacitracin zinc (BAC); neomycin sulfate, bacitracin zinc, and polymyxin B sulfate combination (NEO); silver sulfadiazine (SIL); and petrolatum (PTR). METHODS: This was a prospective, randomized, double-blind, placebo-controlled study conducted at a military community hospital with an emergency medicine residency program. Patients were enrolled if they: presented to the ED within 12 hours of injury and did not have puncture wounds, allergies to the agents used, or a history of immunocompromise; were not receiving antibiotics, chemotherapy, or steroids at the time of presentation; had not taken antibiotics within the preceding seven days; did not have an underlying fracture; and were not pregnant as determined by history. Local anesthetics without epinephrine and high-pressure irrigation with normal saline were used for all patients. Wound scrubbing, débridement, and polyglactin subcutaneous (SQ) suture placement were carried out when necessary. Interrupted simple sutures using a monofilament, nonabsorbable material were used for skin closure. Numbered, randomized vials were given to all patients, with standardized instructions to inspect, clean, and redress their wounds three times a day. The wounds were evaluated for clinical infection at the time of follow-up. RESULTS: Among the groups, there was no difference in patient ages; gender; wound location, type, length, or depth; time elapsed from injury to ED treatment; number of wounds scrubbed or necessitating débridement; number of SQ and cutaneous sutures used; and rate of compliance with returning the used vial of dispensed topical agent. The wound infection rates for the treatment groups were: BAC, six of 109 (5.5%); NEO, five of 110 (4.5%); SIL, 12 of 99 (12.1%); and PTR, 19 of 108 (17.6%) (p = 0.0034). CONCLUSION: The use of topical antibiotics resulted in significantly lower infection rates than did the use of a petrolatum control. BAC and NEO had the lowest wound infection rates.

A prospective evaluation of risk factors for infections from dog-bite wounds.

OBJECTIVE: To define risk factors for infections from dog- bite wounds and to model the probability of wound infection in patients presenting without infection who are treated as outpatients. METHODS: A prospective survey of 769 consecutive dog-bite victims presenting over a two-year period to a community hospital emergency department (ED) with an emergency medicine residency program. A standardized wound-cleaning protocol was used, which included debridement and wound closure when indicated. Wounds were examined for infection at follow-up. Variables analyzed included demographic data (patient age, gender, race); wound information (wound age, type, number, location, depth); and treatment (prior to hospital, ED debridement, suturing, tetanus or rabies shots, antibiotics). RESULTS: There were 734 patients with complete records. These patients had a mean age of 13.4 +/- 13.2 years (range, 4 months to 71 years). Infection was evident in 2.5% of the wounds upon presentation. There were 704 patients (765 wounds) managed as outpatients and without wound infection upon presentation. Wounds were distributed as follows: 26.7% head/neck, 20.4% hand, 15.7% arm, 10.1% trunk, 9.5% thigh, 15.9% leg, and 1.7% foot. There were 32.9% puncture, 39.9% full-thickness, and 60.1% partial-thickness wounds. Wound infections were diagnosed in 2.1% Of these wounds at follow-up. Wounds requiring surgical debridement had a sevenfold higher infection rate (p = 0.01). Patients more than 50 years of age had a sixfold higher infection rate than younger patients (p = 0.05). Stepwise logistic regression found the following variables to be the best predictors for wound infection: full-thickness [p = 0.006, odds ratio (OR) = 6.23], female gender (p = 0.048, OR = 2.88), and wound debridement (p = 0.024, OR = 5.01). Combinations of these three variables predict infection rates from 0.35% to 23.9%. CONCLUSION: A low wound infection rate was seen in this cohort of dog-bite victims who were treated on an outpatient basis. Wound depth, patient gender, and wound debridement were the clinical variables that best predicted the likelihood of developing infection. Future interventional studies should concentrate on wounds with high probabilities of infection.

Double-blinded comparison of diphenhydramine versus lidocaine as a local anesthetic.

STUDY OBJECTIVE: To evaluate the efficacy, onset of action, duration of action, and side effects of 1% diphenhydramine compared with 1% lidocaine when used as a local anesthetic agent. DESIGN: Prospective, double-blinded, cross-over study. SETTING: Emergency medicine residency program, research section. PARTICIPANTS: Ten healthy male volunteers, aged 26 to 38 years old. INTERVENTIONS: Baseline levels of sensation to pinprick (18-gauge needle) within a 2.4-cm-diameter midvolar forearm area and levels of sedation were recorded on 10.2-cm visual analog scales. Subjects then underwent subcutaneous infiltration of 20 mg (2 mL) of the study agent using a 27-gauge needle. Visual analog scale sensation and sedation scores were recorded at five, ten, and 15 minutes and then every 15 minutes until return to baseline. Subjects were studied one week later with the alternate agent. Nonparametric data were analyzed using the Mann-Whitney U test with significance at P < .05. RESULTS: No significant differences in mean pinprick sensation were seen from baseline to 30 minutes. Significant differences were seen at 45 (P = .036) and 60 minutes (P = .036). The mean duration of effective anesthesia was significantly longer for lidocaine than diphenhydramine (81 versus 42 minutes, P = .028). No significant differences were seen in the sedation scores or in the frequencies of local reactions. One subject developed skin necrosis at the injection site with diphenhydramine. CONCLUSION: The duration of local anesthesia for 1% lidocaine was significantly longer and the depth of anesthesia after 30 minutes was significantly higher than that of 1% diphenhydramine. Diphenhydramine resulted in skin necrosis in one test subject.

Comparison of intramuscular meperidine and promethazine with and without chlorpromazine: a randomized, prospective, double-blind trial.

STUDY OBJECTIVES: To compare the effectiveness of intramuscular meperidine (2 mg/kg) and promethazine (1 mg/kg) with chlorpromazine (MPC) or without chlorpromazine (MP) (1 mg/kg) for sedation of children undergoing emergency department procedures. DESIGN: Randomized, double-blind trial. SETTING: A community and university hospital ED. TYPE OF PARTICIPANTS: Eighty-seven hemodynamically and neurologically stable children less than 16 years old. INTERVENTIONS: IM sedation followed by intended procedure. MEASUREMENTS AND MAIN RESULTS: Children receiving either combination were not significantly different with regard to age, sex, weight, chronic illness, and indications. Procedures included laceration repair (46), fracture reduction (25), and others (16). Mean onset of action was similar (16 +/- 12 minutes), whereas the duration of action was significantly longer after MPC (63 +/- 57 minutes [mean +/- SD] compared with MP 29 +/- 36 minutes; P < .05, Student's t-test). Paradoxical hyperactivity occurred only after MP (three of 43 cases; P = NS, Fisher's exact test), whereas transient oxygen desaturation occurred only after MPC (one of 44 cases; P = NS). No other serious complications were observed. Three observers rated the effectiveness of sedation and analgesia on separate 10.2-cm visual-analog scales. Overall, MPC received significantly better ratings (7.4 +/- 2.1 cm) than MP (5.7 +/- 3.0 cm; P < .05, Mann-Whitney U test). Parents believed sedation worked well in 90% of cases. Their children had bad memories of the procedure in only 9% of cases. CONCLUSION: Elimination of chlorpromazine from the IM combination of meperidine and promethazine for pediatric sedation during ED procedures results in a significant reduction in efficacy.

Emergency management of dog and cat bite wounds.

Most dog and cat bite injuries are minor wounds that require only local wound care as well a patient evaluation for tetanus and rabies postexposure immunoprophylaxis. For larger wounds, primary or delayed primary closure can be performed safely where indicated. When antimicrobial agents are necessary, inexpensive penicillins or cephalosporins are adequate for initial therapy. Large-scale, prospective, controlled clinical studies are needed to define further the role of prophylactic antimicrobial therapy for uninfected wounds.

Cutaneous nocardiosis associated with insect bites.

We report the first case of cutaneous nocardiosis associated with insect bites. The patient received these insect bites while camping a few days before he presented to the emergency room. The patient was a healthy twenty-six-year-old man, who was asplenic as a result of a motor vehicle accident. He presented to the emergency room with fever, multiple insect bites to his left lower extremity with pustules, lymphangitis, and left inguinal adenopathy. He was hospitalized but his condition failed to improve despite treatment with intravenous nafcillin for three days. Wound and blood cultures subsequently grew Nocardia brasiliensis. Treatment with intravenous amikacin (5 mg/kg every eight hours) was instituted along with oral trimethoprim-sulfamethoxazole double strength twice a day. The patient recovered with minimal scarring of the extremity. The amikacin was stopped after seven days and the patient was discharged to receive oral trimethoprim-sulfamethoxazole. This disease should be kept in mind when cutaneous infections do not respond to standard antibiotics, especially in the southwestern United States.

Prophylactic oral antibiotics for low-risk dog bite wounds.

The use of prophylactic antibiotics in the initial treatment of noninfected dog bite wounds is controversial. All patients with noninfected dog bite wounds who presented to our emergency department (ED) over a two-year period were considered for entry into a randomized prospective study. Patients were excluded from the study if they had any high-risk criteria for infection: puncture wounds, hand or foot wounds, wounds greater than 12 hours old, a history of immunocompromising disorders, or the use of immunosuppressive drugs. Patients in the antibiotic group (n = 89) were treated with local wound care and given either dicloxacillin, cephalexin, or erythromycin orally for seven days. Patients in the control group (n = 96) received local wound care only. All patients had their wounds irrigated with a 1% povidone-iodine solution and debrided and sutured if clinically indicated. All patients were subsequently reevaluated for clinical signs of wound infection. The groups were similar in age, sex, time of delay in seeking treatment, anatomic sites of wounds, depths and types of wounds, and number of wounds requiring suturing. The wound infection rates for the antibiotic and control groups were 1.1 and 5.1%, respectively. This difference was not significant (P = 0.212). There were 36 wounds in the antibiotic group and 37 wounds in the control group that were full thickness. The infection rates for these wounds were 2.8 and 13.5%, respectively. This was not statistically significant (P = 0.132). This study suggests that prophylactic oral antibiotics in low-risk dog bite wounds are not indicated.

Neurocysticercosis presenting to the emergency department as a pure motor hemiparesis.

We report the case of a 23-year-old male who presented to the emergency department (ED) with an isolated right-sided pure motor hemiparesis (PMH). An unenhanced computed tomography (CT scan) revealed a hypodensity in the area of the left parasagittal motor strip. The patient then experienced a Jacksonian type of seizure involving his right leg and was treated with intravenous phenytoin and dexamethasone. A second CT scan performed with contrast was thought to be consistent with a cerebral abscess with surrounding white matter edema. Surgical findings were consistent with neurocysticercosis. The patient was treated with praziquantel with nearly full recovery. Worldwide, cysticercosis is the most common CNS parasite. Because of immigration from endemic areas, cysticercosis has become more common in the United States. Patients with neurocysticercosis may arrive in the ED with a wide variety of unusual presentations. In this case, the PMH syndrome was caused by a solitary lesion in the motor strip. This report describes a case of PMH due to neurocysticercosis secondary to local mass affect alone. The literature of neurocysticercosis and PMH is reviewed and the pathogenesis, clinical presentation, and therapy are discussed.

Cat bite wounds: risk factors for infection.

STUDY OBJECTIVE: In the last ten years, many emergency medicine specialists have studied animal bite wounds. The majority of these studies have addressed the controversies of prescribing prophylactic antibiotics or suturing wounds. This study was undertaken to determine risk factors for cat bite wound infections. DESIGN: Prospective survey. SETTING: Community hospital emergency medicine residency program. TYPE OF PARTICIPANTS: One hundred eighty-six consecutive patients with 216 cat bite/scratch wounds over a two-year period. INTERVENTIONS: A standardized wound cleaning protocol with debridement and suturing, if indicated, was used. Variables analyzed included patient age and gender; wound age, type, number, location, and depth; prehospital therapy; emergency department therapy; and antibiotics used. RESULTS: The mean patient age was 19.5 +/- 15.9 years. The mean time interval from wounding to ED treatment was 10.2 +/- 39.2 hours. By anatomical sites, there were 33 (15%) head/neck, 48 (22%) arm, 97 (45%) hand, ten (5%) truncal, and 28 (13%) lower extremity wounds. By wound type, there were 122 (56%) punctures, 54 (25%) abrasions, 37 (17%) lacerations, and two (1%) avulsions. One hundred fifty (71%) of the wounds were partial thickness, and 62 (29%) were full thickness. Twenty-four (12.9%) of the patients had clinical evidence of wound infection on arrival to the ED. Five (2.7%) developed clinical evidence of infection despite ED treatment. None of the 14 (7.5%) patients with only "claw" injuries developed infection. The overall patient infection rate for those with cat "bites" was 15.6%. Factors associated with wound infections included older age (P less than .001), longer time intervals until ED treatment (P less than .0001), wounds inflicted by "pet" cats (P = .001), attempting wound care at home (P = .0004), having a more severe wound (P = .01), and having a deeper wound (P = .0001). Data from 148 patients who had only "bite" wounds and did not have clinical evidence of infection on initial presentation to the ED also were analyzed for wound infection risk factors. Wound infections were more likely to develop in patients with lower extremity wounds who did not receive prophylactic oral antibiotics (P = .071) and those with puncture wounds who did not receive prophylactic oral antibiotics (P = .085). CONCLUSION: In this study, wound type and wound depth were the most important factors in determining the likelihood of developing wound infection regardless of whether the patient was prescribed prophylactic oral antibiotics.

A prospective analysis of intramuscular meperidine, promethazine, and chlorpromazine in pediatric emergency department patients.

STUDY OBJECTIVE: To examine physiologic responses and efficacy of 2, 1, and 1 mg/kg IM meperidine, promethazine, and chlorpromazine (MPC), respectively, in children. DESIGN: Prospective, unblinded trial. SETTING: A university and community emergency department. PATIENTS: Sixty-three hemodynamically and neurologically stable children. INTERVENTION: Single dose of IM MPC. MEASUREMENTS AND MAIN RESULTS: Serial respirations, heart rate, arterial systolic blood pressure, oxygen saturation, and Glasgow Coma Scale were measured at 30-minute intervals. Effectiveness was assessed by two independent observers using separate visual analog scales for cooperation and sedation. Times to sleep (27 +/- 24 minutes), sitting upright (103 +/- 87 minutes), ED discharge (4.7 +/- 2.4 hours), eating (11 +/- 7.9 hours), and normal behavior (19 +/- 15 hours) were acceptable. Minor, but statistically significant, changes in respiration rate (-1.9 +/- 0.4), heart rate (+4.5 +/- 1.8), oxygen saturation (-0.7 +/- 0.3%), and Glasgow Coma Scale (-2.5 +/- 0.6) occurred for 120 minutes after MPC. No serious complications or resuscitation were required. Mean visual analog scale scores were 5.0/10.4 or more in 71% of cases, with interobserver agreement very good (cooperation, r = .79; effectiveness, r = .80). Twenty-nine percent of children were judged insufficiently sedated. CONCLUSION: IM MPC is a safe and generally effective agent for ED procedures in selected children.

Anaphylactic shock secondary to rattlesnake bite.

Anaphylactic reactions to Crotalidae envenomation are extremely rare. The presentation of anaphylaxis after envenomation can be a confusing variable in the timely diagnosis of both problems. The therapy of this dual disorder involves combining treatment of the obvious shock from the allergic reaction with a standard approach to Crotalidae envenomation. We present the case of a 22-year-old man who presented to the emergency department with urticaria, hypotension, and bronchospasm that developed immediately after his second envenomation from a rattlesnake. His symptoms resolved after administration of 0.8 mg SQ epinephrine, 100 mg IV diphenhydramine, 2,000 mL normal saline IV, and 250 mg IV methylprednisolone. Only one previous case report of anaphylactic shock from a rattlesnake bite could be found in the medical literature.

A comparison of wound irrigation solutions used in the emergency department.

The purpose of our study was to examine which of the wound irrigants commonly used in the emergency department is the most efficacious in reducing the risk of wound infection. Five hundred thirty-one patients were randomized into three groups. All patients had their wounds irrigated using a 20-mL syringe with a 20-gauge IV catheter. Patients received irrigation with normal saline (NS), 1% povidone-iodine solution (PI), or pluronic F-68 (Shur-Clens) (SC). Treatment was assigned by month; all wounds were treated with one solution during each of the three months of the study. The wounds were closed with interrupted, simple nylon sutures. The number of wound infections was 13 (6.9%), eight (4.3%), and nine (5.6%) for groups receiving NS, PI, and SC, respectively. This was not statistically significant. We conclude that there is not a significant difference in infection rates among sutured wounds irrigated with NS, PI, or SC. The cost of NS was the lowest of the three treatments in our ED.

Movement disorders as a manifestation of nonketotic hyperglycemia.

Movement disorders are well-known presenting signs of metabolic disorders. Focal motor abnormalities may be the chief initial presentation of diabetes mellitus in the nonketotic hyperglycemic state in 6% of patients. Nonketotic hyperglycemia (NKH), in particular, may manifest any of a wide variety of movement disorders. These have been described as focal seizures, epilepsia partialis continua, myoclonus, and opsoclonia. There are descriptions of movement disorders in hyperglycemia that are similar to the coarse flapping tremor of asterixis, the posturing of paroxysmal kinetogenic choreoathetosis, and of "fencing (stance) seizures." Disorders of facial motor function including aphasia, facial muscle twitching and jerking, and disorders of muscular tone have been described. These may include hemiparesis and hemiplegias as well as increased tone, in some cases mimicking the nuchal rigidity of meningitis. The movement disorders in NKH may mimic cerebral vascular accidents, meningitis, or psychiatric disorders, as well as various types of seizures. Clinicians may be able to avoid expensive and time-consuming diagnostic evaluations to rule out NKH in patients with movement disorders. We present two patients with focal motor abnormalities associated with nonketonic hyperglycemia and review the pertinent literature.