Four Loko Intoxication

From Lancaster Online:

For each of the past two weekends, emergency room doctors at Lancaster General have treated anywhere from four to six people who have passed out after drinking a beverage called Four Loko.

“They’re nearly comatose from alcohol poisoning,” said Dr. Mike Reihart, an LGH emergency physician who has treated some of the young people.

“I’ve been practicing emergency medicine for 13 years in Lancaster,” he said, “and I have yet to see one alcoholic beverage that has caused so much intoxication in such a short amount of time.”

Emergency crews are noticing it, too.

“We are seeing a dramatic increase in calls related to Four Loko,” said Stephanie Brown, operations director for the Lancaster Emergency Medical Services Association, which has ambulances and medic units in the county.

Last weekend, LEMSA crews responded to nine calls related to people drinking Four Loko.

Four Loko is a mix of a caffeinated energy drink and a high-alcohol beverage. It comes in a colorful, tall can and in fruity flavors, such as blue raspberry and watermelon.

It has a 12 percent alcohol content, more than twice that of most beers.

In Marion, a battle among the ERs

From  Ocala.com:

The emergency department, despite the chaos that can ensue there, is the front door of any hospital.

“Insist on Munroe Regional,” one ad reads.

“Call 9-1-1 and ask to go to Ocala,” reads a competing ad.

With the main emergency rooms just across the street from each other, the ER is where the battle for market share dominance in Ocala has centered in recent months.

Ocala Health System, the HCA-owned system that includes Ocala Regional Medical Center and West Marion Community, launched an aggressive marketing blitz in the spring touting low wait times at its emergency rooms.

At Munroe Regional Medical Center, which also has an additional emergency department at TimberRidge, staffers have done everything they can to make sure patients who want to go to a Munroe ER can go to a Munroe ER. In the past year, the hospital hasn’t had to divert any ER patients to other hospitals due to ER overcrowding.

Out-of-Hospital Hypertonic Resuscitation Following Severe Traumatic Brain Injury

From JAMA:

Context: Hypertonic fluids restore cerebral perfusion with reduced cerebral edema and modulate inflammatory response to reduce subsequent neuronal injury and thus have potential benefit in resuscitation of patients with traumatic brain injury (TBI).

Objective:  To determine whether out-of-hospital administration of hypertonic fluids improves neurologic outcome following severe TBI.

Design, Setting, and Participants: Multicenter, double-blind, randomized, placebo-controlled clinical trial involving 114 North American emergency medical services agencies within the Resuscitation Outcomes Consortium, conducted between May 2006 and May 2009 among patients 15 years or older with blunt trauma and a prehospital Glasgow Coma Scale score of 8 or less who did not meet criteria for hypovolemic shock. Planned enrollment was 2122 patients.

Intervention: A single 250-mL bolus of 7.5% saline/6% dextran 70 (hypertonic saline/dextran), 7.5% saline (hypertonic saline), or 0.9% saline (normal saline) initiated in the out-of-hospital setting.

Main Outcome Measure: Six-month neurologic outcome based on the Extended Glasgow Outcome Scale (GOSE) (dichotomized as >4 or 4).

Results: The study was terminated by the data and safety monitoring board after randomization of 1331 patients, having met prespecified futility criteria. Among the 1282 patients enrolled, 6-month outcomes data were available for 1087 (85%). Baseline characteristics of the groups were equivalent. There was no difference in 6-month neurologic outcome among groups with regard to proportions of patients with severe TBI (GOSE 4) (hypertonic saline/dextran vs normal saline: 53.7% vs 51.5%; difference, 2.2% [95% CI, –4.5% to 9.0%]; hypertonic saline vs normal saline: 54.3% vs 51.5%; difference, 2.9% [95% CI, –4.0% to 9.7%]; P = .67). There were no statistically significant differences in distribution of GOSE category or Disability Rating Score by treatment group. Survival at 28 days was 74.3% with hypertonic saline/dextran, 75.7% with hypertonic saline, and 75.1% with normal saline (P = .88).

Conclusion: Among patients with severe TBI not in hypovolemic shock, initial resuscitation with either hypertonic saline or hypertonic saline/dextran, compared with normal saline, did not result in superior 6-month neurologic outcome or survival.

An evaluation of echo in life support (ELS): is it feasible? What does it add?

From the Emergency Medicine Journal:

Background: Emergency physicians were trained to perform echo in life support (ELS)—that is, limited transthoracic echocardiography during advanced life support (ALS) management of cardiac arrest.

Methods: Data were collected on the adequacy of views obtained and timing of the scan, as well as the clinical findings of pericardial effusion and ventricular wall motion. Any intervention performed as a result of the scan was also noted. ELS was performed on 50 patients during cardiac arrest.

Results: Adequate views were obtained in 47 (94%) scans, and 45 (90%) were obtained within the 10 s rhythm check. Twenty patients (40%) had ventricular wall motion (VWM), three (6%) had pericardial effusions and six patients (12%) had an intervention performed as a direct result of the scan. These included pericardiocentesis, thrombolysis and insertion of a chest drain. The presence of VWM had a positive predictive value of 55%. The absence of VWM resulted in a negative predictive value of 97% for predicting return of spontaneous circulation (ROSC).

Conclusion: It is concluded that ELS is feasible and that the scan findings may guide further interventions.

Use of Advanced Radiology During Visits to US Emergency Departments for Injury-Related Conditions, 1998-2007

Ed. This made a splash in the popular press. Here’s a link to the abstract.

From JAMA:

Context Excessive use of medical imaging increases health care costs and exposure to ionizing radiation (a potential carcinogen) without yielding significant benefits to all patients.

Objective To determine whether there has been a change in the prevalence of emergency department visits for injury-related conditions for which computed tomography (CT) or magnetic resonance imaging (MRI) was obtained and whether there has been a change in the diagnosis of life-threatening conditions and patient disposition.

Design, Setting, and Participants Retrospective cross-sectional analysis of emergency department visits using data from the National Hospital Ambulatory Medical Care Survey (1998-2007). Sampled visits were weighted to produce estimates for the United States.

Main Outcomes Measures Proportion of visits for injury-related conditions during which a CT or MRI was obtained, a life-threatening condition was diagnosed (eg, cervical spine fracture, skull fracture, intracranial bleeding, liver and spleen laceration), and which resulted in hospital and intensive care unit admission.

Results The prevalence of CT or MRI use during emergency department visits for injury-related conditions increased from 6% (95% confidence interval [CI], 5%-7%) (257 of 5237 visits) in 1998 to 15% (95% CI, 14%-17%) (981 of 6567 visits) in 2007 (P < .001 for trend). There was a small increase in the prevalence of life-threatening conditions (1.7% [95% CI, 1.2%-2.2%; 59 of 5237 visits] in 1998 and 2.0% [95% CI, 1.6%-2.5%; 142 of 6567 visits] in 2007; P = .04 for trend). There was no change in prevalence of visits during which patients were either admitted to the hospital (5.9% [95% CI, 4.9%-6.9%] in 1998 and 5.5% [95% CI, 4.7%-6.5%] in 2007; P = .50 for trend) or to an intensive care unit (0.62% [95% CI, 0.40%-1.00%] in 1998 and 0.80% [95% CI, 0.53%-1.21%] in 2007; P = .14 for trend). Visits during which CT or MRI was obtained lasted 126 minutes (95% CI, 123-131 minutes) longer than those for which CT or MRI was not obtained.

Conclusion From 1998 to 2007, the prevalence of CT or MRI use during emergency department visits for injury-related conditions increased significantly, without an equal increase in the prevalence of life-threatening conditions.