Do mnemonics help healthcare professionals learn and recall cholinergic toxidromes?

BACKGROUND: The U.S. National Library of Medicine and Department of Homeland Security assembled subject matter experts (SMEs) for the Toxic Chemical Syndrome Definitions and Nomenclature Workshop. The SMEs at this meeting identified a lack of research evaluating the effectiveness of field recognition of toxidromes to guide treatment. They suggested that mnemonics may be helpful for remembering and recognizing toxidromes and further, that rapid toxidrome recognition, through use of a mnemonic or otherwise, leads to rapid action and urgent intervention. OBJECTIVES: (1) Determine if published studies demonstrate HPs can learn and recall hazardous materials (hazmat) toxidromes. (2) Determine if Healthcare Professionals (HPs) can learn mnemonics for muscarinic and nicotinic toxidromes during the Advanced Hazmat Life Support (AHLS) Provider Course (PC) and recall these cholinergic mnemonics when retested years later. Our hypothesis is HPs can learn these mnemonics and recall them up to four years later. METHODS: We analyzed results of HPs who completed AHLS PC pre-tests and post-tests during their initial AHLS PC between March 1, 2007 and March 1, 2010, and then, within four years, took either an online retest or a pre-test for a second AHLS PC. We compared pre- and post-test answers for questions regarding muscarinic and nicotinic mnemonics to assess if HPs can learn these mnemonics during an initial AHLS PC and then recall these mnemonics later, during retesting. We compared the percentage of HPs who correctly identified each cholinergic mnemonic on the pre-test, post-test, and retest using McNemar's test for paired, nominal data. We searched six literature databases to see if there were any previous similar studies. RESULTS: Our literature search found no similar published studies. The mean time to re-testing was 3.6 years (SD 0.8 year). The percentage of respondents correctly answering the question for the muscarinic toxidrome was 53% on the pre-test, 100% on the post-test, and 75% on the retest. The percentage of respondents correctly answering the nicotinic toxidrome question was 52% on the pre-test, 100% on the post-test, and 77% on the retest. CONCLUSION: All studied healthcare professionals learned the cholinergic toxidrome mnemonics during their initial AHLS PC. Mnemonic recall declined somewhat on retesting; however, recall was evident in 75-77% of retest takers compared to their pre-test results up to four years earlier, a statistically significant difference (p < .001) for both mnemonics. This supports our study hypothesis that HPs can learn these mnemonics and recall them up to 4 years later.

Intravenous Ondansetron and the QT Interval in Adult Emergency Department Patients: An Observational Study.

OBJECTIVES: Ondansetron is known to cause QT interval prolongation, but this effect and clinical significance has not been prospectively studied in adult emergency department (ED) patients. The primary objective was to determine the mean maximal corrected QT interval (QTc) prolongation after intravenous (IV) administration of 4 mg of ondansetron. The secondary objective was to report any serious adverse cardiac electrical events. METHODS: This was a prospective, observational, single-center cohort study conducted between 2012 and 2013 in an academic, military hospital ED. Adult patients ordered to receive 4 mg of IV ondansetron were eligible for the study. A six-lead electrocardiogram was recorded at baseline and every 2 minutes after ondansetron administration for 20 minutes. The QTc was calculated using the Bazett formula. Serious adverse cardiac electrical events (nonsinus rhythm, severe bradycardia, and sudden cardiac death) were also recorded. RESULTS: Twenty-two adult ED patients were enrolled. Ondansetron caused a mean prolongation of the QTc by 20 ms (95% confidence interval [CI] = 14 to 26 ms), with a mean proportion change from baseline of 5.2% (95% CI = 3.8% to 6.6%). There were zero (95% CI = 0 to 13%) reported serious adverse cardiac electrical events. CONCLUSIONS: While QTc prolongation does occur in adult ED patients receiving IV ondansetron, the clinical impact is questionable.

Acceptable differences in sensory and motor latencies between the median and ulnar nerves.

The median and ulnar nerves are often studied during the same electrodiagnostic examination. The sensory and motor latencies of these nerves have been compared to detect a common electrodiagnostic entity: median neuropathy at the wrist. However, this comparison could also be used to diagnose less common ulnar pathology. For this reason, it is important to establish normal values for comparing median and ulnar sensory and motor latencies. Previous research deriving these differences in latency has had some limitations. The purpose of this study was to derive an improved normative database for the acceptable differences in latency between the median and ulnar sensory and motor nerves of the same limb. Median and ulnar sensory and motor latencies were obtained from 219 and 238 asymptomatic risk-factor-free subjects, respectively. An analysis of variance was performed to determine whether physical characteristics, specifically age, race, gender, height, or body mass index (as an indicator of obesity), correlated with differences in latency. Differences in sensory latencies were unaffected by physical characteristics. The upper limit of normal difference between median and ulnar (median longer than ulnar) onset latency was 0.5 ms (97th percentile), whereas the peak latency value was 0.4 ms (97th percentile). The upper limit of normal difference between ulnar-versus-median (ulnar longer than median) onset latency was 0.3 ms (97th percentile), whereas the peak-latency value was 0.5 ms (97th percentile). The mean difference in motor latencies correlated with age, with older subjects having a greater variability. In subjects aged 50 and over, the mean difference in median-versus-ulnar latency was 0.9 ms +/- 0.4 ms. The upper limit of normal difference (median longer than ulnar) was 1.7 ms (97th percentile). The upper limit of normal ulnar motor latency is attained if the ulnar latency comes within 0.3 ms of the median latency. In individuals less than 50 years of age, the mean difference in latency was 0.6 ms +/- 0.4 ms, with the median latency usually being greater than the ulnar. The upper limit of normal difference (median longer than ulnar) was 1.4 ms (97th percentile), whereas the upper limit of ulnar latency relative to median latency was attained if the ulnar latency was equal to median latency.