Eschmann introducer through laryngeal mask airway: a cadaveric trial of an alternate means of rescue intubation.

STUDY OBJECTIVE: Laryngeal mask airways (LMAs) are often used as airway rescue devices where laryngoscopy is difficult. The LMA does not protect the airway and is preferably replaced with a cuffed endotracheal tube. There are reports of cases where an Eschmann tracheal tube introducer (ETTI) was successfully used to bridge between a standard LMA and an endotracheal tube. This project was designed to determine whether an Eschmann stylet can reliably be passed through an LMA into the trachea as a means of rescue intubation. METHODS: Nineteen emergency medicine residents and attending physicians, who were participants in a cadaveric airway course, placed and inflated a size 4 LMA (The Laryngeal Mask Company Ltd., San Diego, CA) on each of six unembalmed human cadavers in the usual fashion. They then attempted to pass a lubricated, 15 Fr, reusable, coude-tipped ETTI (Portex, Smiths Medical, Keene, NH)) through the airspace/handle of the inflated LMA. The LMA was then deflated and removed while the ETTI was held in place. Investigators then determined the location of the ETTI by laryngoscopy. RESULTS: Of 114 attempts at the rescue procedure, 59 resulted in placement of the bougie into the trachea, yielding an overall success rate of 52% (95% CI 48%-56%). There were no significant differences in performance based on level of training of residents or years of experience of attending physicians. CONCLUSIONS: While not a primary difficult airway option, the use of a ETTI as a bridge device between LMA and endotracheal tube was successful about 50% of the time.

Randomized evaluation of octreotide vs prochlorperazine for ED treatment of migraine headache.

UNLABELLED: Patients with headaches account for approximately 2% of all ED visits, with migraines being the most common defined primary headache syndrome. Our goals were to evaluate the efficacy of intravenous octreotide (OC) for the treatment of migraines, when compared to standard therapy with prochlorperazine. METHODS: The study was conducted as a double-blinded, randomized controlled trial. Each subject received either 100 microg of octreotide or 10 mg of prochlorperazine intravenously for a 2-minute period. RESULTS: Comparison of the change in median visual analog scale scores for 60 minutes demonstrated that octreotide was less effective at reducing pain (P = .03) and producing clinical success (P < .01). Restlessness consistent with akathisia was noted by 35% of the PC group and 8% of the OC group (P < .01). At 60 minutes, rescue medication was required by 48% of the patients in the OC group, whereas 10% of the PC group required such therapy (P < .01). All 44 patients were contacted for follow-up at 48 to 72 hours after enrollment. At that time, 10% of the prochlorperazine and 25% of the octreotide patients had experienced some headache recurrence (P = .1). CONCLUSION: Prochlorperazine was statistically superior to octreotide in clinical success rate and decrease in pain in migraine patients but caused more restlessness and sedation.

Bedside ultrasound for the detection of soft tissue foreign bodies: a cadaveric study.

The objective of this study was to evaluate the sensitivity and specificity of bedside ultrasound, as performed by emergency physicians with typical equipment, in detecting small, soft tissue foreign bodies, using a cadaveric model. This was a prospective study, using 6 unembalmed human cadavers and 6 ultrasound-credentialed, emergency medicine residency-trained physicians as sonographers. Incisions were made in 150 total sites of the extremities and each site was randomly assigned one of five groups: wood, metal, plastic, glass, or no foreign body. All foreign bodies were 2.5 mm3 in total volume or less, no longer than 5 mm in any dimension, and inserted to a depth of up to 3 cm. Ultrasound was performed with a SonoSite TITAN (SonoSite, Inc., Bothell, WA) ultrasound system using a L38/10-5 broadband linear array transducer. Sonographers were blinded to the number, type, and location of foreign bodies. A total of 900 ultrasound examinations were recorded. Overall sensitivity of ultrasound for foreign body detection was 52.6% (95% confidence interval [CI] 48.9%-56.2%), and overall specificity was 47.2% (95% CI 39.9%-54.5%). Positive predictive value was 79.9% (95% CI 76.3%-83.5%), and negative predictive value was 20.0% (95% CI 16.2%-23.7%). Sensitivity for individual sonographers ranged from 40.8% to 72.3% (average 52.6% +/- 13.3%), and specificity ranged from 30% to 66.7% (average 47.2% +/- 15.1%). Inter-observer reliability was poor. In our model, bedside ultrasound performed by emergency physicians was neither sensitive nor specific for the presence of small soft tissue foreign bodies.

Chest injury while wearing a bullet-proof vest.

Ballistic protective vests and garments have evolved into important life-saving measures for members of police forces and militaries. Although effectively reducing morbidity and mortality from projectile injuries, significant injuries still do occur. We report a case demonstrating an example of the effects of transmitted forces through a protective vest resulting in a significant chest contusion.

Transdermal patch medication delivery systems and pediatric poisonings, 2002-2006.

Transdermal drug delivery systems are an increasingly popular method of medication delivery containing large quantities of medication and presenting new opportunities for toxicity. To provide a description of exposures to transdermal medications in a pediatric population, we studied exposures in individuals less than 12 years of age. This is a retrospective database study in which the Texas Poison Center Network database from 2002 to 2006 was reviewed. In all, 336 poison control center records of patch exposures over the 5-year period were identified. Of those, 110 cases involved children less than 12 years old. A majority of cases resulted in no significant clinical effects. One death resulted from opioid toxicity. Although a majority of patch exposures in children less than 12 years of age resulted in no significant clinical toxicity, practitioners and the public must be made aware of the available patch-based medications and their potential for toxicity in children.

Colchicine exposures: the Texas experience.

OBJECTIVES: Colchicine is a relatively uncommon toxin, but is known to precipitate severe multiorgan failure in overdose. Little is known about exposure patterns and outcomes in cases of colchicine ingestion. Our goal was to add to toxicologic knowledge through a database review and descriptive study of colchicine exposures. METHODS: Texas Poison Center Network Data was reviewed for the years 2000 to 2005, and all reports of colchicine exposures were reviewed. RESULTS: A total of 79 cases were found in the time period studied. The most common exposure reasons were unintentional-therapeutic error (33%), unintentional-general (28%), and intentional-suspected suicide (18%). Medical outcomes included no effect (24%), minor effect (20%), moderate effect (15%), and major effect (3%). The most common clinical findings included vomiting (20%), diarrhea (17%), and abdominal pain (7%). The most commonly employed therapies were dilution (28%), single-dose activated charcoal (26%), cathartics (16%), and gastrointestinal lavage (15%). CONCLUSION: The majority of cases of exposure produced no significant effects, and fatality was uncommon in this sample. Colchicine is a relatively uncommon toxin among therapeutic drugs, and though capable of it, is rarely responsible for significant morbidity or mortality. Meticulous exposure record keeping at poison centers is a key to the study of patterns of toxicity with uncommon toxins such as colchicine.

Two cases of contact dermatitis resulting from use of body wash as a skin moisturizer.

The use of liquid skin cleanser or body wash has become common in the United States. We report 2 cases of contact dermatitis secondary to the application of Dove Body Wash (Unilever US, Inc., Englewood Cliffs, NJ) with the consumer misconception that the product was a skin moisturizing cream.

The effects of an accelerated triage and treatment protocol on left without being seen rates and wait times of urgent patients at a military emergency department.

To combat increasing wait times and left without being seen (LWOBS) rates, our emergency department (ED) implemented an accelerated triage and treatment (TNT) protocol. A TNT team was allocated treatment rooms to begin management of urgent patients if a bed in the main ED was not available. A retrospective database study was performed using three separate 6-month periods: two control periods before the intervention (P1, P2) and one period after the intervention (P3). The primary outcome measures were LWOBS rate, time to evaluation, and total ED time for urgent patients. The time to be seen for EC3 patients improved from P1 to P3 by an average of 12.6 minutes (18.5%, p < 0.0001) and from P2 to P3 by an average of 12.0 minutes (17.6%, p < 0.0001). The EC3 LWOBS rate decreased from 2.0% in P1 and 1.9% in P2 to 0.8% in P3 (p < 0.0001 for both). The use of an accelerated TNT protocol was associated with a significant reduction in EC3 patient LWOBS rates and time to evaluation.

Trauma-induced pneumothorax after "bear-hug back crack" home remedy: attempted spinal manipulation by a layperson.

Spinal manipulation, as practiced by US-trained osteopathic physicians, is a safe and effective method of resolving patient pain and encouraging desirable physiologic improvement--often without pharmacologic intervention. Though novices, laypeople, and other clinicians also use manual techniques with similar goals in mind, their results are varied and sometimes dangerous to those they would help. The authors describe a case in which a layperson attempted spinal manipulation on a 20-year-old woman who later required a chest tube thoracostomy and hospitalization as a result of a pneumothorax. Osteopathic physicians are encouraged to consider patient risk factors for pneumothorax as a contraindication for the use of thoracic thrust techniques.

A procedure for soft tissue foreign body removal under real-time ultrasound guidance.

A 16-year-old, dependant, female patient presented to the emergency department complaining of a sewing needle stuck in her right great toe. The needle was removed with real-time ultrasound guidance, with no complications. The use of ultrasonography for localization of foreign bodies is discussed.

Isopropyl alcohol pad use for blood ethanol sampling does not cause false-positive results.

This was a retrospective analysis of prospective data collected from a study of blood ethanol levels after the use of the alcohol-based hand sanitizer (ABHS). A total of 5 male volunteers were enrolled. Eight of the 10 total blood ethanol level measurements were drawn after skin preparation with Kendall WEBCOL Alcohol Preps (APP) containing 70% isopropyl alcohol. All had an initial and post-ABHS application blood alcohol level (BAL) drawn, for a total of 10 BAL measurements. Measurements upon completion of the study were <5 mg/dL in all 5 study participants and in each of the 10 blood draws regardless of skin preparation technique. This study demonstrates that the use of isopropyl skin prep pads is unlikely to cause significant false-positive blood ethanol levels.

Experience with bandage contact lenses for the treatment of corneal abrasions in a combat environment.

Corneal abrasions are a common result of eye trauma. Although they usually heal well with conservative therapy, they still tend to be a source of morbidity, in terms of pain and lost work time. We reviewed 15 cases in which a bandage contact lens was used as the primary treatment for corneal abrasions in an austere environment. We found that the lenses performed well, except for patients who had undisclosed risk factors for corneal ulcers at the outset. When used for carefully selected patients, bandage contact lenses may be a highly effective treatment modality that allows for rapid return to duty.

A descriptive analysis of authorship within medical journals, 1995-2005.

INTRODUCTION: The emphasis on publications for promotion in academic medicine would lead one to the theory that authorship numbers would increase proportionally with this emphasis. To investigate authorship trends across a number of periodicals, we performed a descriptive study comparing two full years of published articles spaced ten years apart from five medical journals. METHODS: Physician reviewers each reviewed all articles of one medical journal for the 1995 and 2005 publication years. Reviewed journals included Academic Emergency Medicine (AEM), Annals of Emergency Medicine (AnnEM), Annals of Internal Medicine (AIM), Journal of Trauma (JT), and New England Journal of Medicine (NEJM). Data collected for each article were number of authors, ordinal number of the corresponding author, type of study described, whether the described study was a multicenter trial, whether authorship listed included a "study group," and whether any author was also an editor of the journal. RESULTS: A total of 2927 articles were published in the five journals in 1995, and of these, 1401 (47.9%) were analyzed after the exclusion criteria had been applied; for 2005 a total of 3630 articles were published and of these, 1351 (37.2%) were included in the analysis. Across all five journals the mean number of authors per article increased from 4.66 to 5.73 between 1995 and 2005 (P < 0.0001), and four of the five journals individually had statistically significant increases in the number of authors per article. More articles had a journal editor as an author in 2005 (increased from 7.8% to 11.0%, P = 0.004), though no single journal had a statistically significant increase. CONCLUSION: We describe a trend of increasing mean authors, editorial authorship, study groups, and multicenter trials over time with fewer solo authors now publishing original research or case reports. The academic medical community must pursue an authorship requirement consensus to assure that a standard of contribution for all authors on a given paper is met.

Does the clinical use of ethanol-based hand sanitizer elevate blood alcohol levels? A prospective study.

BACKGROUND: Ethanol-based hand sanitizers (EBHSs) are used in most health care facilities in the United States. Infection control personnel advocate the use of generous quantities of EBHS before and after contact with patients. Although it is assumed that little systemic absorption of ethanol occurs during EBHS use, many alcohols are absorbed to varying degrees via the transdermal route. Ethanol intoxication by employees in the medical workplace is a potentially serious finding, and it is of forensic and medical-legal importance to elucidate the effects of frequent use of EBHS upon serum blood ethanol levels (BELs). To investigate the effect of frequent use of EBHS upon serum blood ethanol concentrations, we prospectively studied 5 volunteers undergoing frequent application of EBHS. METHODS: Enrolled subjects applied 5 mL of the product (62% denatured ethyl alcohol manufactured by Kimberley-Clark, Roswell, GA) to both hands and rubbed until dry. This activity was repeated 50 times over 4 hours. Participants had their blood drawn before as well as after completing the study. Each participant was without alcohol exposure during the 12 hours preceding the study. RESULTS: Five volunteers were enrolled. All had an initial blood ethanol level of less than 5 mg/dL. All 5 participants completed the 4-hour study. There were no noted adverse reactions during the study. Blood ethanol level upon completion of the 50 applications of EBHS was less than 5 mg/dL in all 5 study participants. CONCLUSION: The results of this study demonstrate that use of ethanol-based hand sanitizers, when frequently used in accordance with labeling, do not raise serum blood ethanol levels.

Cardiovascular collapse from low dose bupivacaine.

Bupivacaine is a long-acting local anesthetic agent that is very widely used for cutaneous infiltration, peripheral nerve blocks, epidural anesthesia, and spinal anesthesia. Well-described cardiotoxic effects of bupivacaine and other members of its class include dysrhythmias, hypotension, and depression of cardiac output. The minimum IV dose of bupivacaine previously associated with significant toxicity in humans is 1.6 mg/kg. A case is reported of bradyasystolic arrest with post resuscitation shock, without significant central nervous system (CNS) toxicity, following the injection of less than 1.1 mg/kg bupivacaine in an adult.