Teresa M. Ross, MD
Zachary Repanshek, MD
Leana Wen, MD MSc
Immediate Past President
Ryan Shanahan, MD
At-large Board Members
Ali Farzad, MD
Stephanie Gardner, MD
Sarah Terez Malka, MD
Taylor McCormick, MD
Ketan Patel, MD
Medical Student Council President
Copy Editor: Taylor McCormick, MD
Managing Editor: Jody Bath, AAEM/RSA Staff
Special thanks to this issue's contributors: Casey Grover, MD; Michael Pulia, MD FAAEM; Veronica Tucci, MD JD; Cathy Carrubba, MD; Robert Redwood, MD; Meaghan Mercer, MSIV; and Mary Calderone, MSII.
Opinions expressed are those of the authors and do not necessarily represent the official views of AAEM or AAEM/RSA.
Tox Talks: Bath Salts
Meaghan Mercer, MSIV
Western University of Health Sciences
AAEM/RSA Medical Student Council President
Walking onto my shift a few days ago, I heard shrieking coming from my pod, and I knew this would be an interesting night. I rushed over to find a female restrained by four police officers screaming that demons were out to get her. Witnesses reported that after snorting an unknown substance, the patient began running down the street, topless, yelling that something was after her. It required all four officers to control her and get her to the ED. She was agitated and combative, unwilling to answer questions, with a HR: 130, RR: 20, BP: 190/115, temp: 103, and an O2 saturation of 95% on room air. This was it, what I have been hearing so much about...a bath salt ingestion.
There has been a recent insurgency of patients presenting to emergency departments across the country in an agitated delirium caused by a new designer drug called bath salts. On October 21st, the DEA issued a temporary one-year ban on methylenedioxypyrovalerone (MDPV), the main component of bath salts, classifying it as a schedule 1 substance. Manufacturers evade the restriction with minor alterations in the chemical structure, and bath salts are still available in gas stations, head shops and online.1
MDPV is a sympathomimetic that inhibits dopamine and norepinephrine reuptake causing a toxidrome similar to a PCP. The effects of this drug include hyperthermia, diaphoresis, mydriasis, tachycardia, HTN, arrhythmias, rhabdomyolysis and possibly cardiovascular collapse; more prominently though, they cause anxiety, agitation, paranoid delusions and combativeness, and self-destructive behavior is the predominate cause of death.2
There is no specific antidote for bath salts, and the treatment is supportive. After the ABC's have been addressed, the cornerstone of management is aggressive benzodiazepines to dampen the sympathetic effects and reverse life-threatening tachycardia and hyperthermia. If the tachycardia persists, consider an alpha-blocker, but avoid unopposed beta blockade.3 Patients often require aggressive intravenous fluid administration to prevent kidney damage from rhabdomyolysis. Hyperthermia is common, with temperatures reportedly reaching 107 degrees, and cooling measures should be initiated.4 Finally, keeping these patients in a dark, quiet area can help decrease agitation.
- Gussow, Leon MD. Toxicology Rounds: Giving New Meaning to 'Bed, Bath, and Beyond.' Emergency Medicine News: March 2011.
- United States Drug Enforcement Administration. Methylenedioxypyrovalerone, December 2010.
- Emergency department visits after use of a drug sold as "bath salts" -- Michigan, November 13, 2010-March 31, 2011. Morb Mortal Wkly Rep 2011.
- Scott Weingart: Bath Salts with Leon Gussow - EMCrit podcasts October 25, 2011.
Clinical Pearls from Intern Year
Casey Grover, MD
Stanford/Kaiser Emergency Medicine
Looking back after finishing a year as an emergency medicine intern, the lessons that I remember the most come from the mistakes that I have made. I had one particularly rough month late in my internship that was filled with bounce backs and mismanaged cases. I learned six important lessons that will hopefully help to avoid another such month in the future.
- Review every study that you order. While you may have ordered a chemistry panel just to check the creatinine, it's embarrassing to miss a sodium of 121.
- Document your discharge decision process. If a patient has a problem or bounces back, it is extremely helpful to have documented everything (i.e., normal vitals, well appearance, consultant recommendations) that you considered when sending that patient home.
- Review discharge vital signs. Vital signs are actually important – they reflect the patient's underlying physiology. Document normal vital signs when sending patients home; and when discharging someone with abnormal vitals, document your rationale and plan.
- Document your discussions with consultants. Record at what time and to whom you spoke, as well as what they recommended. This allows others to see the basis of your decisions, which is essential if an adverse outcome occurs.
- Be suspicious of patients signed out to you. Review the labs and vital signs of the patient you will be taking care of, and address all of their medical issues. Approach the case with fresh eyes and be willing to consider other diagnoses than those billed to you in sign out.
- Approach procedures carefully. While it's fun to do procedures, be aware that complications may arise – particularly in a patient who is high risk for bleeding. Review labs and history, particularly for things like coagulopathy, that may make procedures difficult.
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Management of MRSA Skin and Soft Tissue Infections in the ED
Mary Calderone, MSII
Michael Pulia, MD
Loyola University Chicago, Stritch School of Medicine
Community-acquired Methicillin Resistant Staphylococcus Aureus (CA-MRSA) has emerged as the most common etiology of skin and soft tissue infections (SSTIs) seen in the emergency department (ED). Simultaneously, a great deal of controversy has surfaced in the literature regarding optimal management of this condition. Understanding the risk factors for CA-MRSA and the basic management steps is essential for approaching this commonly encountered pathology effectively.
Patients with SSTIs caused by CA-MRSA most commonly present with abscesses, frequently accompanied by cellulitis, and a chief complaint of "spider bite" or "boil." Several risk factors for CA-MRSA have been indentified, including playing contact sports, IV drug use, having a family member with MRSA, having a history of incarceration, living in crowded conditions, low socioeconomic status, antibiotic use within the past year, pregnant/postpartum women, working in a health care setting, and nasal colonization.
Incision and drainage (I&D) is the primary treatment for uncomplicated MRSA abscesses. This procedure is indicated for those infections with signs of purulence, such as fluctuance, compressibility, central point or "head" and visually draining pus. Purulent material and loculations within the abscess are usually cleared by blunt dissection with a hemostat. Although packing is traditionally recommended after I&D, some clinicians believe it might actually prevent complete drainage of purulent material, thereby increasing complications. The CDC encourages collection of a wound culture in order to distinguish MRSA from other common SSTI pathogens and determine antibiotic susceptibilities.
Given the emerging problem of antibiotic resistance and the lack of new antibiotic development, it is critical that ED clinicians safely and accurately target antibiotic therapy in the treatment of SSTIs. Whether antibiotic therapy following I&D of uncomplicated abscesses actually improves clinical outcomes remains controversial, but in most cases trimethoprim-sulfamethoxazole (TMP-SMX) is the antibiotic of choice when CA-MRSA is suspected. TMP-SMX has been shown to have the highest efficacy against CA-MRSA compared with other oral antibiotics, although it should be avoided in patients with sulfa allergies, in pregnant women in their third trimester and in infants less than three months of age.
Appropriate wound care should be executed by the physician and explained to the patient. Current guidelines recommend covering the abscess with sterile, non-adherent dressing and removal of any packing two days later by a clinician. Patients should be counseled to return immediately upon signs of worsening infection or the development of systemic symptoms. A follow-up visit should be scheduled within 48 hours of the initial visit to confirm adequate response to therapy.
- Hansra NK, Shinkai K. Cutaneous community-acquired and hospital-acquired methicillin-resistant Staphylococcus aureus. Dermatologic Therapy 2011: 24L 263-272.
- Estes, K. Methicillin-Resistant Staphylococcus aureus Skin and Soft Tissue Infections. Crit Care Nurs Q 2011: 34: 101-209.
- Gorwitz R, Jernigan D, Powers J, Jernigan J. Participants in the CDC convened experts' meeting on management of MRSA in the community. Strategies for clinical management of MRSA in the community: summary of an experts' meeting convened by the CDC. Published 2006.
EMS Board Review
Veronica Tucci, MD JD
Cathy Carrubba, MD
University of South Florida College of Medicine
Q1. Which of the following helmets may be safely removed on the scene by EMTs/paramedics following trauma to the head or neck?
- football helmet
- lacrosse helmet
- ice hockey helmet
- motorcycle helmet
Q2. Which of the following is an example of direct medical control or oversight during a mass casualty incident?
- written protocol of medications that may be administered by providers
- a physician or qualified provider who is onsite to answer questions and provide direction to first responders and other providers
- a physician or qualified provider who is either onsite or otherwise available to communicate in real-time with first responders and other providers on scene
- direction given only by the EMS medical director
Q3. Which of the following is an example of a primary blast injury?
- ruptured eardrum
- shrapnel embedded in patient's leg
- smoke inhalation
- clavicle fracture from being slammed against a wall by the explosion
A1. Choice D is the correct answer. Motorcycle helmets do not fit snugly on the head, are not worn with shoulder pads, and do not maintain a neutral position when patients lie supine. Choice A is incorrect. Although the National Athletic Trainer's association recommends removal of football helmets at the earliest opportunity, properly fitted equipment, including shoulder pads, maintains neutral head and spinal alignment, and Tintinalli currently endorses leaving the helmet and shoulder pads in place as the athlete is immobilized with removal after clinical evaluation in the ED. Choices B and C are incorrect. The principles of spinal immobilization have been extrapolated to these sports in various studies, and Tintinalli recommends that they remain in place pending hospital and radiographic evaluation. See Tintinalli, 7th edition, pg 9.
A2. Choice C is correct. Direct medical oversight involves a way to communicate directly, in real-time with on scene personnel. Choice A is incorrect. Written protocols give providers a standardized set of directions and are classified as indirect medical oversight. Choice B is incorrect. Physicians are not required to be onsite to offer direct medical oversight but must be able to communicate directly with personnel. This may include radio, video or internet transmissions as encompassed in the correct answer. Choice D is incorrect. While the medical director should be an experienced emergency physician with experience in directing EMS personnel and providing care at a mass casualty event, other physicians may be able to give medical direction to EMS personnel at the medical director's discretion and as agreed between various hospital and EMS agencies. See Tintinalli, 7th edition, pg 21.
A3. Choice A is correct. Primary blast injuries affect hollow or air-filled organs including the tympanic membrane and eardrum, lungs and GI tract. Choice B is incorrect and an example of a secondary blast injury from flying debris from an explosion. Choice C is incorrect. Smoke inhalation along with burns and chemical agent release is considered a quaternary blast injury. Choice D is also incorrect. Fractures that occur when a patient is propelled into a stationary object are classified as a tertiary blast injury. See Tintinalli, 7th edition, pg 38.
PPACA: A Chance to Advocate For Emergency Medicine
Robert Redwood, MD
University of Wisconsin Hospitals and Clinics
As advocates for our patients and for our specialty, it's important to be aware of the health care policy changes taking effect under the Patient Protection and Affordable Care Act (PPACA)(Public Law 111-148) and how emergency medicine is affected. This article presents an overview and offers starting points for being a PPACA advocate at your institution/city/state.
As you may have heard, the law is 906 pages long, so I have taken the liberty of summarizing the reform to what I regard as its five core components:
- Insurers must offer the same premium to all applicants of the same age and geographical location without regard to pre-existing conditions.
- An individual mandate requires that nearly all persons not covered by Medicaid, Medicare or other insurance programs purchase an approved insurance policy or pay a tax penalty.
- Medicaid eligibility is expanded to include all individuals and families with incomes up to 133% of the poverty level.
- Health insurance exchanges will offer a marketplace where individuals and small businesses can compare/purchase policies and premiums.
- Focusing on quality and efficiency of care, the law allows restructuring of incentives that will likely move Medicare reimbursement from "fee-for-service" to "bundled payments."
For EPs these reforms represent an expansion of the national health care safety net (primarily composed of emergency departments) and also a shift in the way hospitals and physicians function. For example, the new Center for Medicare and Medicaid Innovation (CMMI) is charged with identifying, testing and disseminating innovative models of care and payment that deliver better health care at a lower cost.
Focusing on improving health, and not just delivering health care, PPACA also addresses patient behaviors, emphasizing wellness and prevention by funding programs for smoking cessation, childhood obesity, nutritional services and immunizations. For our uninsured patients, it is unclear whether they will be getting the same care they receive now. Section 9007, for example, obligates charitable hospitals to "limit amounts charged for emergency...care provided to individuals eligible for assistance under the financial assistance policy...to not more than the amounts generally billed to individuals who have insurance covering such care" and "prohibits the use of gross charges." One can only speculate how this will be interpreted and how our uninsured patients will be affected.
So what can we do as residents? Below is a list of questions/topics that directly relate to residents; in other words, opportunities for AAEM members to be advocates!
- Will the reform include developing and improving emergency department efficiencies, including EMRs and nationwide prescription databases?
- Are bundled payments appropriate for emergency department billing?
- Will the government fund additional residents to emergency medicine training programs?
- In these formative years, will the National Health Care Workforce Commission emphasize the education and training needs of emergency medicine residents?
- Is emergency medicine research a priority in the CMMI's long-term plan of establishing a national research agenda?
Let's not stop there either; email your ideas, concerns and questions so that AAEM/RSA can continue the discussion and brainstorm ideas on being better advocates for our patients and our specialty.