A lightning multiple casualty incident in Sequoia and Kings Canyon National Parks.

Multiple casualty incidents (MCIs) are uncommon in remote wilderness settings. This is a case report of a lightning strike on a Boy Scout troop hiking through Sequoia and Kings Canyon National Parks (SEKI), in which the lightning storm hindered rescue efforts. The purpose of this study was to review the response to a lightning-caused MCI in a wilderness setting, address lightning injury as it relates to field management, and discuss evacuation options in inclement weather incidents occurring in remote locations. An analysis of SEKI search and rescue data and a review of current literature were performed. A lightning strike at 10,600 feet elevation in the Sierra Nevada Mountains affected a party of 5 adults and 7 Boy Scouts (age range 12 to 17 years old). Resources mobilized for the rescue included 5 helicopters, 2 ambulances, 2 hospitals, and 15 field and 14 logistical support personnel. The incident was managed from strike to scene clearance in 4 hours and 20 minutes. There were 2 fatalities, 1 on scene and 1 in the hospital. Storm conditions complicated on-scene communication and evacuation efforts. Exposure to ongoing lightning and a remote wilderness location affected both victims and rescuers in a lightning MCI. Helicopters, the main vehicles of wilderness rescue in SEKI, can be limited by weather, daylight, and terrain. Redundancies in communication systems are vital for episodes of radio failure. Reverse triage should be implemented in lightning injury MCIs. Education of both wilderness travelers and rescuers regarding these issues should be pursued.

Intranasal naloxone is a viable alternative to intravenous naloxone for prehospital narcotic overdose.

OBJECTIVE: To compare the prehospital time intervals from patient contact and medication administration to clinical response for intranasal (IN) versus intravenous (IV) naloxone in patients with suspected narcotic overdose. METHODS: This was a retrospective review of emergency medical services (EMS) and hospital records, before and after implementation of a protocol for administration of intranasal naloxone by the Central California EMS Agency. We included patients with suspected narcotic overdose treated in the prehospital setting over 17 months, between March 2003 and July 2004. Paramedics documented dose, route of administration, and positive response times using an electronic record. Clinical response was defined as an increase in respiratory rate (breaths/min) or Glasgow Coma Scale score of at least 6. Main outcome variables included time from medication to clinical response and time from patient contact to clinical response. Secondary variables included numbers of doses administered and rescue doses given by an alternate route. Between-group comparisons were accomplished using t-tests and chi-square tests as appropriate. RESULTS: One hundred fifty-four patients met the inclusion criteria, including 104 treated with IV and 50 treated with IN naloxone. Clinical response was noted in 33 (66%) and 58 (56%) of the IN and IV groups, respectively (p = 0.3). The mean time between naloxone administration and clinical response was longer for the IN group (12.9 vs. 8.1 min, p = 0.02). However, the mean times from patient contact to clinical response were not significantly different between the IN and IV groups (20.3 vs. 20.7 min, p = 0.9). More patients in the IN group received two doses of naloxone (34% vs. 18%, p = 0.05), and three patients in the IN group received a subsequent dose of IV or IM naloxone. CONCLUSIONS: The time from dose administration to clinical response for naloxone was longer for the IN route, but the overall time from patient contact to response was the same for the IV and IN routes. Given the difficulty and potential hazards in obtaining IV access in many patients with narcotic overdose, IN naloxone appears to be a useful and potentially safer alternative.

Biphasic defibrillation does not improve outcomes compared to monophasic defibrillation in out-of-hospital cardiac arrest.

STUDY OBJECTIVE: To compare the outcomes of out-of hospital cardiac arrest (OHCA) victims treated with monophasic truncated exponential (MTE) versus biphasic truncated exponential (BTE) defibrillation in an urban EMS system. METHODS: We conducted a retrospective review of electronic prehospital and hospital records for victims of OHCA between August 2000 and July 2004, including two years before and after implementation of biphasic defibrillators by the Fresno County EMS agency. Main outcome measures included: return of spontaneous circulation (ROSC), number of defibrillations required for ROSC, survival to hospital discharge, and discharge to home versus an extended care facility. RESULTS: There were 485 cases of cardiac arrest included. Baseline characteristics between the monophasic and biphasic groups were similar. ROSC was achieved in 77 (30.6%, 95% CI 25.2-36.5%) of 252 patients in the monophasic group, and in 70 (30.0% 95% CI 24.5-36.2%) of 233 in the biphasic group (p= .92). Survival to hospital discharge was 12.3% (95% CI 8.8-17%) for monophasic and 10.3% (95% CI 7.0-14.9%) for biphasic (p= .57). Discharge to home was accomplished in 20 (7.9%, 95% CI 5.1-12.0%) of the monophasic, and in 15 (6.4%, 95% CI 3.9-10.4%) of the biphasic group (p= .60). More defibrillations were required to achieve ROSC (3.5 vs. 2.6, p= .015) in the monophasic group. CONCLUSIONS: We found no difference in ROSC or survival to hospital discharge between MTE and BTE defibrillation in the treatment of OHCA, although fewer defibrillations were required to achieve ROSC in those treated with biphasic defibrillation.

A novel approach to enhance visualization during drainage of peritonsillar abscess.

Routine emergency department care for uncomplicated peritonsillar abscess involves needle aspiration or incision and drainage. Standard technique involves use of a tongue blade and auxiliary light source. We describe the novel use of a disassembled disposable vaginal speculum with fiberoptic light, a device becoming commonplace in many emergency departments. This novel approach to managing peritonsillar abscess greatly enhances visualization and facilitates peritonsillar abscess drainage.

An experimental study of warming intravenous fluid in a cold environment.

OBJECTIVE: Numerous studies support the use of warmed intravenous fluids in hypothermic patients. The most effective method to accomplish this goal in a cold prehospital, wilderness, or combat setting is unknown. We evaluated various methods of warming intravenous fluids for a bolus infusion in a cold remote environment. METHODS: One liter and 500 mL bags of intravenous fluid at 5 degrees C were heated using various methods in a 5 degrees C cold room. Methods included attachment of 3 types of chemical heat packs and heating the fluid in a pot on a camping stove. For all methods, fluids were run at a wide-open rate through an intravenous line with an 18-gauge catheter attached to the end to simulate a bolus infusion. The temperature of the fluid at the end of the intravenous line was measured. Each method was tested twice. Equipment weight and setup times are reported. Mean infusion temperatures for the various methods are compared. RESULTS: Equipment weights ranged from 19 to 665 gm. Setup times ranged from 5 to 11 minutes. The 2 methods which achieved the desired mean infusion temperature of 35 to 42 degrees C without excessive maximum temperatures were 1) 2 Meal Ready to Eat hot packs attached to a 500 mL bag of fluid for 10 minutes prior to infusion, and 2) a camping stove heating the surface of a 500 mL bag of fluid to 75 degrees C prior to infusion. Other methods, including the use of commonly available heat packs and a commercially available IV fluid warmer were ineffective, with mean infusion temperatures ranging from 7 to 12 degrees C. CONCLUSIONS: Heating of cold intravenous fluids in a cold environment is possible using either Meal Ready to Eat heat packs or a camping stove. Further study is needed to evaluate the ability of either method to consistently produce an appropriate fluid temperature given various ambient and initial fluid temperatures.

An unusual case of subterfuge in the emergency department: covert administration of antipsychotic and anxiolytic medications to control an agitated patient.

Pediatric, nursing home, and institutionalized psychiatric patients frequently receive medications covertly or against their will. Surreptitious medicating of emergency department (ED) psychiatric patients may occur but has not been reported. We discuss competing ethical, therapeutic, and legal issues in potential conflict during the treatment of an acutely psychotic patient who had homicidal and suicidal ideation and presented to a busy, urban ED. The practice of covertly medicating may not be uncommon in EDs, but fear of professional censure probably inhibits open discussion and documentation of such events. No specific statutory, ethical, or case law in the United States seems to control this type of situation.

Patient transport via private vehicle in Sequoia and Kings Canyon National Parks.

OBJECTIVE: Emergency medical service providers frequently encounter patients with low acuity. Because of liability and safety concerns, emergency medical service systems often prohibit privately owned vehicle (POV) transport. Thus, prehospital resources are used with questionable benefit. In Sequoia and Kings Canyon National Parks, our primary objective was to determine the feasibility of POV. We assessed patient compliance, satisfaction, and safety. Our hypothesis was that POV is feasible with online physician medical control. METHODS: This study was a prospective observational analysis of outcomes from POV during a 1-year period. All POV patients were advised to seek medical attention at a hospital. POV patients were asked questions about their medical complaint and the events during transport and at the hospital. RESULTS: No documented admissions or patient deterioration was noted. During the survey, all patients were either "all better" (86%) or "somewhat better" (14%). CONCLUSION: We conclude that POV with carefully selected patients and online physician medical control is feasible and deserves further study in other systems.

Use of the Gamow Bag by EMT-basic park rangers for treatment of high-altitude pulmonary edema and high-altitude cerebral edema.

As part of an emergency medical system protocol, national park service rangers certified at the level of an emergency medical technician-basic (EMT-B) are taught to recognize and treat high-altitude pulmonary edema and high-altitude cerebral edema. In Sequoia and Kings Canyon National Parks, this is done with the assistance of physician on-line medical control as a backup. High-altitude pulmonary edema and high-altitude cerebral edema are both potentially fatal altitude illnesses that can be particularly problematic in the backcountry, where evacuation may be delayed. We report a case of high-altitude pulmonary edema and high-altitude cerebral edema occurring at moderate altitude that was successfully treated by park rangers with the Gamow Bag.

Suction for venomous snakebite: a study of "mock venom" extraction in a human model.

STUDY OBJECTIVE: We determine the percentage of mock venom recovered by a suction device (Sawyer Extractor pump) in a simulated snakebite in human volunteers. METHODS: A mock venom (1 mL normal saline solution, 5.0 mg albumin, 2.5 mg aggregated albumin) radioactively labeled with 1 mCi of technetium was injected with a curved 16-gauge hypodermic needle 1 cm into the right lateral lower leg of 8 supine male volunteers aged 28 to 51 years. The Sawyer Extractor pump was applied after a 3-minute delay, and the blood removed by suction was collected after an additional 15 minutes. A 1991 Siemens Diacam was used to take measurements of the radioactive counts extracted and those remaining in the leg and body. RESULTS: The "envenomation load," as measured by mean radioactivity in the leg after injection, was 89,895 counts/min. The mean radioactivity found in the blood extracted in the 15 minutes of suction was 38.5 counts/min (95% confidence interval [CI] -33 to 110 counts/min), representing 0.04% of the envenomation load. The postextraction leg count was less than the envenomation load by 1,832 counts/min (95% CI -3,863 to 200 counts/min), representing a 2.0% decrease in the total body venom load. CONCLUSION: The Sawyer Extractor pump removed bloody fluid from our simulated snakebite wounds but removed virtually no mock venom, which suggests that suction is unlikely to be an effective treatment for reducing the total body venom burden after a venomous snakebite.

The esophageal detector bulb in the aeromedical setting.

To determine the accuracy of the Esophageal Detector Bulb (EDB) in the aeromedical setting, we conducted a prospective, observational study of all intubated patients transported by an aeromedical program over two years. Flight personnel recorded the results of the EDB, clinical examination, pulse oximetry, and capnography (ETCO(2)). Endotracheal tube position was confirmed by prehospital ETCO(2) or by the receiving emergency physician. There were 104 EDB assessments in 53 patients. The EDB correctly identified four of five esophageal intubations and 96 of 99 tracheal intubations. The sensitivity and specificity of the EDB in the detection of an esophageal intubation were 80% (95% CI, 38-96%) and 97% (95% CI, 92-99%), respectively, and the overall accuracy was 96% (95% CI, 90-98%). The EDB augments the ability of an aeromedical crew to determine endotracheal tube position, but its results must be carefully interpreted in the context of other available means of confirmation of endotracheal tube position.