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Study Objectives: Although other specialties have examined the role of the chief resident (CR), the role and training of the emergency medicine (EM) CR has largely been undefined.Methods: A survey was mailed to all EM CRs and their respective program directors (PD) in 124 EM residency programs. The survey consisted of questions defining demographics, duties of the typical CR, and opinions regarding the level of support and training received. Multiple choice, Likert scale (1 strong agreement, 5 strong disagreement) and short-answer responses were used. We analyzed associations between CR and PD responses using Chi-square, Student’s T and Mann-Whitney U tests.Results: Seventy-six percent of CRs and 65% of PDs responded and were similar except for age (31 vs. 42 years; p

Context: All-terrain vehicles' (ATVs) popularity and associated injuries among children are increasing in the United States. Currently, most known ATV use pattern data are obtained from injured youth and little documented data exist characterizing the typical ATV use patterns and safety practices among American children in general. Purpose: To describe the typical ATV safety and use patterns of rural youth. Methods: A cross-sectional anonymous mail survey was conducted of youth participants (ages 8-18) in the 4-H Club of America in four Central Illinois counties. Questions examined ATV use patterns, safety knowledge, safety equipment usage, crashes, and injuries. Findings: Of 1,850 mailed surveys, 634 were returned (34% response rate) with 280 surveys (44% of respondents) eligible for analysis. Respondents were principally adolescent males from farms or rural locations. Most drove less than or equal to 1 day per week (60.2%) and used ATVs for recreation (36%) or work (22.6%) on farms and/or private property (53.4%). Most never used safety gear, including helmets (61.4%), and few (14.6%) had received safety education. Of the 67% who experienced an ATV crash, almost half (44%) were injured. Children with safety training had fewer crashes (P = 0.01), and those riding after dark (P = 0.13) or without adult supervision (P = 0.042) were more likely injured. Conclusions: ATV use is common in a rural 4-H population. Most child ATV users were adolescent boys, had little safety training and did not use safety equipment or helmets. ATV injury prevention efforts should focus on these areas.

The importance of real-time, quantitative toxicology data available for physicians treating poisoned patients was illustrated during the 2018 outbreak in Illinois of severe coagulopathy caused by inhaling illicit synthetic cannabinoids products contaminated with commercially-available brodifacoum, difenacoum, and bromadiolone, three potent, long-acting anticoagulant rodenticides (LAARs). Identification and quantification of these life-threatening toxins in blood samples of hospitalized patients required toxicology testing with liquid chromatography-tandem mass spectrometry (LC-MS/MS) that was not available in clinical laboratories of hospitals at the time of the outbreak. This highly-sensitive, quantitative assay can provide critical information to guide patient care during and after hospitalization, including identification of offending LAARs, estimates of the ingested dose, and dosage and discontinuation of oral vitamin K1 therapy after hospital discharge once plasma LAARs concentrations decreased to a safe level (<10 ng/mL). Accordingly, we propose an action plan to enable treating physicians to quantify plasma concentrations of several LAARs simultaneously in poisoned patients. It involves rapid (<15 min), sensitive, and validated LC-MS/MS methods developed, tested and validated in our laboratory. This will allow treating physicians to request quantitative plasma LAARs testing, report test results in the patient's hospital discharge summary, and recommend regular monitoring of plasma LAARs concentrations in the outpatient setting. [ABSTRACT FROM AUTHOR]

Introduction: Synthetic cannabinoids are a rapidly expanding subset of designer drugs widely available in the United States since 2008. In Illinois during the spring of 2018, over 160 documented cases of bleeding and prolonged coagulopathy occurred secondary to contaminated synthetic cannabinoids. Methods: We conducted a retrospective cohort study consisting of 38 patients to describe the initial emergency department (ED) presentation, diagnosis, and treatment. Results: Through serum testing we found that three long-acting anticoagulant rodenticides (LAAR) were detected in patients who had inhaled these tainted products: brodifacoum, difenacoum, and bromodialone. Discussion: This study encompasses the largest ED presentation of LAAR poisoning via the inhalational route known to date. Conclusion: The emergency physician should be aware of the potential for tainted coingestants as the cause of undifferentiated coagulopathy. [ABSTRACT FROM AUTHOR]

Background: An outbreak of synthetic cannabinoid (SC)-associated coagulopathy and bleeding in Illinois, USA was determined to be due to inhalation of SC contaminated with brodifacoum (BDF), difenacoum (DiF), and bromadiolone (BDL), highly potent long-acting anticoagulant rodenticides (LAARs). Treatment with high-dose vitamin K1 (VK1) prevented mortality; however, plasma LAAR levels were not measured risking recurrence of coagulopathy and bleeding due to premature discontinuation. The goal of this study was to determine if plasma LAAR levels were reduced following standard of care treatment to normalize coagulopathy. Methods: Blood samples were collected from a cohort of 32 patients, and ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) analysis used to quantify plasma LAAR levels including enantiomers. Results: BDF was detected in 31 samples; 30 also contained DiF and 18 contained BDL. Initial plasma levels were 581 ± 87, 11.0 ± 1.9, and 14.9 ± 5.9 ng/mL for BDF, DiF, and BDL, respectively (mean ± SE). At discharge plasma, BDF levels remained elevated at 453 ± 68 ng/mL. Plasma half-lives for BDF, DiF, and BDL were 7.5 ± 1.3, 7.2 ± 1.9, and 1.8 ± 0.3 days, respectively. The half-life for trans-BDF enantiomers (5.7 ± 0.8 days) was shorter than for cis-enantiomers (7.6 ± 1.9 days). BDF half-lives were shorter, and coagulopathy normalized faster in patients receiving intravenous VK1 as compared to oral VK1. Patients prescribed VK1 at discharge had fewer re-admittances. Conclusions: These results demonstrate that plasma LAAR levels at discharge were elevated in poisoned patients despite normal coagulation, and that the route of VK1 administration affected LAAR pharmacokinetics and INR normalization. We propose plasma LAAR levels and coagulation be monitored concomitantly during follow-up of patients with LAAR poisoning. In patients treated with high-dose vitamin K1 for LAAR poisoning, plasma levels remained 40-fold above safe levels upon discharge from hospital. LAAR half-lives, normalization of coagulopathy, and readmittances were reduced by treatment with intravenous vitamin K1. [ABSTRACT FROM AUTHOR]

Background: Extracorporeal membrane oxygenation (ECMO) therapy has supported critically ill pediatric patients in the intensive care unit setting with cardiac and respiratory failure. This therapy is beginning to transition to the emergency department setting.Objective Of Review: This article describes the fundamentals of ECMO and familiarizes the emergency medicine physician with its use in critically ill pediatric patients.Discussion: ECMO can be utilized as either venoarterial (VA) or venovenous (VV), to support oxygenation and perfusion in respiratory failure, sepsis, cardiac arrest, and environmental hypothermia. [ABSTRACT FROM AUTHOR]

Background A novel musical memory aid has been proposed for aiding laypersons in complying with the American Heart Association (AHA) cardiopulmonary resuscitation (CPR) guidelines of 100 compressions per minute (cpm). Objective This study tested usefulness of such a memory aid to improve layperson long-term compliance with CPR compression rate guidelines. Methods A prospective randomized controlled trial was conducted using CPR-untrained laypersons. Subjects received either a standard CPR educational experience (AHA Heartsaver® CPR class) or an experimental CPR educational experience (AHA Heartsaver® CPR class augmented with a musical metronome). Experimental group subjects were taught to perform compressions to the cadence of a pop music song (The Bee Gees “Stayin’ Alive”; Saturday Night Fever, The Original Movie Soundtrack; Polygram International Music, 1977) with a tempo of 100 beats/min. Compression rates, depth of compressions, and correct compressions were measured initially and upon retesting ≥6 weeks post-training. Results Control subjects had a higher mean compression rate both immediately (121 [standard deviation {SD} = 21] vs. 109 [SD = 15] cpm; 95% confidence interval [CI] of mean difference 4−19; p = 0.002) and at follow-up (120 [SD = 20] vs. 111 [SD = 13] cpm; 95% CI of mean difference 2−16; p = 0.014). Compression rates stratified to 100−120 cpm demonstrated no difference between groups initially (39% vs. 48%; p = 0.382), but more experimental subjects maintained these rates at follow-up (43% vs. 74%; p = 0.003). Conclusions Subjects trained to use a musical metronome more often maintained a compression rate of 100−120 cpm at ≥6-week follow-up, suggesting the memory aid may improve long-term guideline adherence. [ABSTRACT FROM AUTHOR]

Background: Core Practical Objectives (CPOs) are clinical emergency medicine (EM) experiences (including suggested number of patient encounters) that students use to self-direct clerkship progress. Purpose: This study investigates feasibility of implementing EM clerkship CPOs, describes characteristics of students fulfilling CPO guidelines, and relates CPO completion to outcome measures (exam scores and grades). Methods: Cross-sectional research was conducted comparing students completing and not completing CPOs by gender, month of rotation, total patients evaluated, clerkship exam score, and final grade. Results: Over 4 years, 117 students completed an EM clerkship utilizing CPO guidelines. Gender and clerkship month were not associated with fulfilling CPOs. Total CPOs completed correlated positively with percent score on written exam and grade for rotation. Completion of specific CPOs was associated with exam scores and final grade. Conclusions: CPOs were successfully integrated into an EM clerkship. Preliminary data suggest that CPO guidelines can be used to standardize EM clerkships. [ABSTRACT FROM AUTHOR]

The article explores the pharmaceutical industry and its contact with the individual physician. It examines how industry-related activities affect prescribing practices. It shows that general practitioners who were visited more frequently by drug representatives were more likely to express views that led to unnecessary prescribing patterns. It discusses concerns for interactions between industry and physicians.

Abstract: Background: A novel and yet untested memory aid has anecdotally been proposed for aiding practitioners in complying with American Heart Association (AHA) cardiopulmonary resuscitation (CPR) compression rate guidelines (at least 100 compressions per minute). Objectives: This study investigates how subjects using this memory aid adhered to current CPR guidelines in the short and long term. Methods: A prospective observational study was conducted with medical providers certified in 2005 AHA guideline CPR. Subjects were randomly paired and alternated administering CPR compressions on a mannequin during a standardized cardiac arrest scenario. While performing compressions, subjects listened to a digital recording of the Bee Gees song “Stayin'' Alive,” and were asked to time compressions to the musical beat. After at least 5 weeks, the participants were retested without directly listening to the recorded music. Attitudinal views were gathered using a post-session questionnaire. Results: Fifteen subjects (mean age 29.3 years, 66.7% resident physicians and 80% male) were enrolled. The mean compression rate during the primary assessment (with music) was 109.1, and during the secondary assessment (without music) the rate was 113.2. Mean CPR compression rates did not vary by training level, CPR experience, or time to secondary assessment. Subjects felt that utilizing the music improved their ability to provide CPR and they felt more confident in performing CPR. Conclusions: Medical providers trained to use a novel musical memory aid effectively maintained AHA guideline CPR compression rates initially and in long-term follow-up. Subjects felt that the aid improved their technical abilities and confidence in providing CPR. [Copyright &y& Elsevier]

Internuclear ophthalmoplegia (INO) is characterized by pathognomonic findings on neurological examination. It results from a lesion in the medial longitudinal fasciculus (MLF) and is rarely caused by head trauma. The neuroanatomy of INO is complex and the mechanism by which trauma causes this syndrome is controversial. In the context of trauma, INO occurs frequently in association with other neurological findings and should prompt a thorough investigation and ICU admission. A case of an individual with acute post-traumatic INO is reported and discussed. [Copyright &y& Elsevier]