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Background The indications for prehospital hydroxocobalamin are not well defined. The aim of this study was to evaluate prehospital signs and symptoms in patients who received hydroxocobalamin to improve future use. Methods In this retrospective study, all patients who received prehospital Hydroxocobalamin at a tertiary care burn center from December 2012 to March 2018 were reviewed. Each case was evaluated for evidence of suspected cyanide toxicity: hypotension, syncope, CNS depression/altered mentation, seizures, respiratory or cardiac arrest. A determination was made whether or not hydroxocobalamin was indicated. Results In this study, EMS providers administered hydroxocobalamin to 42 patients between December 2012 and March 2018. The majority (71%) of suspected cyanide exposures were from house fires. The most common prehospital findings were coma or depressed CNS (36%), followed by hypotension (16%) and cardiac arrest (12%). Sixty percent of patients treated with hydroxocobalamin had none of the six clinical indicators for potential cyanide toxicity. Carboxyhemoglobin and serum lactate were significantly different in patients that had a clinical indication for hydroxocobalamin compared to those who did not. Conclusions Prehospital hydroxocobalamin was used empirically however, indications are unclear. Using defined clinical indications may provide greater clarity for providers and reduce unnecessary use of hydroxocobalamin.

Introduction Cricothyrotomy may be necessary for airway management when a patient's airway cannot be maintained through standard techniques such as oral airway placement, blind insertion airway device, or endotracheal intubation. Wire-guided cricothyrotomy is one of many techniques used to perform a cricothyrotomy. Although there is some controversy over which cricothyrotomy technique is superior, there is no published data regarding long term retention rates. The purpose of this study is to determine whether ground based paramedics can be taught and are able to retain the skills necessary to successfully perform a wire-guided cricothyrotomy. Methods This retrospective study was performed in a suburban county with a population of 160,000 with 23,000 EMS calls per year. Participants were ground-based paramedics who were taught wire-guided cricothyrotomy as part of a standardized paramedic educational update program. After viewing an instructional video, the paramedics were shown each the steps of the procedure on a simulation model, using a low fidelity task trainer previously developed to train emergency medicine residents. Using a 16 step procedural checklist, participants were allowed open-ended practice using the task trainer. Critical steps in the checklist were marked in bold lettering indicating automatic failure. Each paramedic was then individually supervised performing a minimum of 5 successful simulations. Retention was assessed using the same 16 step checklist 6 to 12 weeks following the initial training. Results A total of 55 paramedics completed both the initial training and reassessment during the time period studied. During the initial training phase 100% (55 of 55) of the paramedics were successful in performing all 16 steps of the wire-guided cricothyrotomy. During the retention phase, 87.3% (48 of 55) of paramedics retained the skills necessary to successfully perform the wire-guided cricothyrotomy. On the 16 step checklist, most steps were performed successfully by all the paramedics or missed by only 1 of the 55 paramedics. The step involving removal of the needle prior to advancing the airway device over the guide wire was missed by 34.5% (19 of 55) of the participants. This was not an automatic failure since most participants immediately self-corrected and completed the procedure successfully. Conclusion Paramedics can be taught and can retain the skills necessary to successfully perform a wire-guided cricothyrotomy on a simulator. Future research is necessary to determine if paramedics can successfully transfer these skills to real patients.

Background Ketamine is a cyclohexamine derivative that acts as a noncompetitive N-methyl D-aspartate receptor antagonist. Its use for procedural sedation is recommended by national clinical policy. However, its immunogenic potential is not well documented. Case Report We report a case of allergic reaction associated with the administration of intravenous ketamine for procedural sedation in a 16-year-old male. Minutes after administration, the patient developed a morbilliform, erythematous rash that extended to the upper and lower torso and resolved with intravenous diphenhydramine. It is most likely that this allergic reaction was caused by a ketamine-induced histamine release that has been described in vitro. Why Should an Emergency Physician be Aware of This? This is the first case report in which ketamine was used as monotherapy in the emergency department for the facilitation of procedural sedation that resulted in an allergic reaction. Supportive measures, including advanced airway procedures and hemodynamic support, may be necessary in more severe anaphylactic cases. Providers should be aware of this potential adverse effect when using ketamine for procedural sedation.

Crush injuries have the potential to cause life-threatening systemic effects such as hyperkalemia, dysrhythmias, acute kidney injury, and renal failure. Systemic involvement is known as crush syndrome (CS) and results from tissue ischemia and muscle necrosis. This is a report of a 76-year-old female who developed a fatal dysrhythmia following release of her extremity from prolonged entrapment in bathroom safety equipment. Hyperkalemia should be presumed in any crush injury and be treated empirically and aggressively. Although tourniquet application prior to extrication is not widely recommended to prevent CS, it should be considered in prolonged extremity entrapment.

Objective The deployment of video laryngoscopy devices that include recording capability presents a new and unique opportunity for medical directors to review prehospital patient encounters. We sought to evaluate the effect of introducing a video laryngoscope and video quality assurance program to an air medical program on measures of intubation success including overall success, first-pass success, success within 2 attempts, and the total number of attempts. Methods This was a retrospective review of data collected on intubations by nurses and paramedics of the Virginia State Police Med-Flight 1 air medical program. Results After introduction of the video laryngoscope and quality assurance program, the overall intubation success improved to 100% but did not reach statistical significance (95% confidence interval [CI], −4.40 to 12.57; P = .25). First-pass success improved from 76.19% to 92.86% (CI, 1.14-33.14; P = .02), whereas the average attempts declined from 1.31 to 1.09 per patient encounter (CI, −.41 to −.03; P = .02). Success within 2 attempts was 92.86% before the intervention and 98.21% after (CI, 4.25-17.82; P = .19). Conclusion Video laryngoscopy and a robust means for medical director oversight are important components of a high-performance airway management program and demonstrably improve intubation first-pass success.

In an effort to decrease door-to-needle times for patients with acute ischemic stroke, some hospitals have begun taking stable EMS patients with suspected stroke directly from the ambulance to the CT scanner, then to an emergency department (ED) bed for evaluation. Minimal data exist regarding the potential for time savings with such a protocol. The study hypothesis was that a direct-to-CT protocol would be associated with decreases in both door-to-CT-ordered and door-to-needle times.An observational, multicenter before/after study was conducted of time/process measures at hospitals that have implemented direct-to-CT protocols for patients transported by EMS with suspected stroke. Participating hospitals submitted data on at least the last 50 "EMS stroke alert" patients before the launch of the direct-to-CT protocol, and at least the first 50 patients after. Time elements studied were arrival at the ED, time the head CT was ordered, and time tPA was started. Data were submitted in blinded fashion (patient and hospital identifiers removed); at the time of data analysis, the lead investigator was unaware of which data came from which hospital. Simple descriptive statistics were used, along with the Mann-Whitney test to compare time medians.Seven hospitals contributed data on 1040 patients (529 "before" and 511 "after"); 512 were male, and 627 had final diagnoses of ischemic stroke, of whom 275 received tPA. The median door-to-CT-ordered time for all patients was 7 minutes in the before phase, and 4 minutes after (difference 3 minutes, p =0.0001); similarly, the median door-to-CT-started time was 6 minutes "before" and 10 minutes after (p0.0001). The median door-to-needle time for all patients given tPA was 42 minutes before, and 44 minutes after (p = 0.78). Four hospitals had modest decreases in door-to-CT-ordered time (of 2, 4, 2, and 5 minutes), and only one hospital had a decrease in door-to-needle time (32 min vs 26 min, p = 0.012).In this sample from seven hospitals, a minimal reduction in door-to-CT-ordered and door-to-CT-started time, but no change in door-to-needle time, was found for EMS patients with suspected stroke taken directly to the CT scanner, compared to those evaluated in the ED prior to CT.

OBJECTIVES Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infection is an increasing problem in athletic populations, with outbreaks spreading among team members. Due to this elevated risk, several strategies have been adopted from nonsports settings to avoid and to control CA-MRSA outbreaks within athletic teams, including the use of surveillance nasal cultures to identify CA-MRSA carriers for decolonization. We sought to assess the effectiveness of such a surveillance program in reducing CA-MRSA infections over 1 season in a professional football team. In addition, we measured the prevalence of CA-MRSA carriage in players with active CA-MRSA infections and conducted a review of the literature for studies, including CA-MRSA nasal carriage surveys in athletic teams. DESIGN Prospective cohort. SETTING Professional football team, San Francisco 49ers. PARTICIPANTS Players and staff of the 2007 San Francisco 49ers (n = 108). INTERVENTIONS Preseason nasal cultures for CA-MRSA were obtained on players and staff of the San Francisco 49ers. Wound and nasal cultures were performed for all participants with suspected CA-MRSA infections throughout the season. MAIN OUTCOME MEASURES Nasal and wound cultures positive for CA-MRSA. RESULTS Of 108 total subjects screened on the first day of the 2007 season, 0 cultures were positive for methicillin-resistant Staphylococcus aureus (MRSA). A total of 5 culture-confirmed CA-MRSA infections occurred during the course of the season. Zero of these 5 players had positive MRSA nasal cultures at the time of infection. CONCLUSIONS Despite the success of surveillance nasal screening in controlling MRSA outbreaks in hospital settings, this strategy is ineffective in athletic populations.

The International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force was formed in 2013 to review and evaluate the scientific literature on first aid in preparation for development of international first aid guidelines, including the 2015 American Heart Association (AHA) and American Red Cross Guidelines Update for First Aid . The 14 members of the task force represent 6 of the international member organizations of ILCOR. Before 2015, evidence evaluation for first aid was conducted by the International First Aid Science Advisory Board and the National First Aid Advisory Board. Although the group responsible for evidence evaluation has changed, the goals remain the same: to reduce morbidity and mortality due to emergency events by making recommendations based on an analysis of the scientific evidence. A critical review of the scientific literature by appointed ILCOR First Aid Task Force members and evidence evaluators resulted in consensus on science statements with treatment recommendations for 22 selected questions addressing first aid interventions. These findings are presented in “Part 9: First Aid” of the 2015 ILCOR International Consensus on First Aid Science With Treatment Recommendations ,1,2 and they include a list of identified knowledge gaps that may be filled through future research. The ILCOR treatment recommendations are intended for the international first aid community, with the understanding that local, state, or provincial regulatory requirements may limit the ability to implement recommended first aid interventions. The current AHA/American Red Cross First Aid guidelines are derived from this work. New topics found in the 2015 First Aid Guidelines Update include first aid education, recognition of stroke, recognition of concussion, treatment of mild symptomatic hypoglycemia, and management of open chest wounds. Other topics have been updated based on findings from the corresponding ILCOR reviews. The roots of first aid have been recorded throughout …

In the past, some moonshine products contained potentially toxic contaminants. Although moonshine production continues in the United States, no studies have analyzed the content of moonshine since the early 1960s. We hypothesize that moonshine continues to contain potentially toxic concentrations of contaminants.Forty-eight samples of illicitly distilled moonshine were obtained from law enforcement agencies. An independent laboratory, blinded to both the moonshine source and a control sample of ethanol, conducted the analysis. Lead content was determined using atomic absorption spectrophotometry with a graphite tube atomizer. Alcohol content, including ethanol, acetone, isopropanol, methanol, and ethylene glycol, was determined using gas liquid chromatography with flame ionization detection.Ethanol content ranged from 10.5% to 66.0% with a mean value of 41.2%. Lead was found in measurable quantities in 43 of 48 samples with values ranging from 5 to 599 parts per billion (ppb) with a mean value of 80.7 ppb. A total of 29 of 48 (60%) of samples contained lead concentrations above or equal to the EPA water guideline of 15 ppb. Methanol was found in only one sample at a concentration of 0.11%. No samples contained detectable concentrations of acetone, isopropanol, or ethylene glycol.Many moonshine samples contain detectable concentrations of lead. Extrapolations based on the described moonshine lead content suggest that chronic consumers of moonshine may develop elevated lead concentrations. Physicians should consider lead toxicity in the differential diagnosis when evaluating patients consuming moonshine.

Purpose: To determine whether the stroke alert process results in improved outcomes, as reflected in door to lytic times and other outcome measures. Introduction: The diagnosis and treatment of stroke is time-sensitive and should be inclusive of all seven D’s in the “chain of survival” - Detection, Dispatch, Delivery, Door, Data, Decision and Drug (Adams, Stroke, 2007). Early stroke activation is part of the “Delivery” which incorporates transport and management by Emergency Medical Services (EMS). Clinical suspicion of stroke by EMS resulted in a process of early activation which was labeled “Stroke Alert.” This expedited the code stroke process upon arrival, preparing the hospital based stroke team to provide immediate triage and evaluation. The goal was to improve clinical efficiency and possibly clinical outcomes. Methods: • Implementation of a notification process from EMS to ED - Stroke Alert • Incorporated Stroke Alert to include Stroke Response Team (SRT) nurses January 22, 2011 • Retrospective review of internal stroke database (January 22, 2011 to July 2013) for comparative analysis of Stroke Alerts called versus those where no stroke alert was called • Evaluate clinical outcomes directly related to Stroke Alert process Results: From January 22, 2011 to July 2013: Stroke Alert Called: • 37 t-PA patients and 14 of those, 37.8%, met the 60 minute benchmark • Average Door to Lytic time - 65 minutes Stroke Alert NOT Called: • 35 t-PA patients and 10 of those, 28.6% met the 60 minute benchmark • Average Door to Lytic time - 79 minutes Conclusions: The ability for a SRT to meet the golden hour of stroke benchmark occurs more frequently when a Stroke Alert is called to the SRT nurse. Future plans include review of stroke severity scores, length of stay (LOS), and discharge disposition, to determine the impact a Stroke Alert may have on clinical outcomes.

The American Heart Association (AHA) and the American Red Cross (Red Cross) cofounded the National First Aid Science Advisory Board to review and evaluate the scientific literature on first aid in preparation for the 2005 American Heart Association (AHA) and American Red Cross Guidelines for First Aid. 1 In preparation for the 2010 evidence evaluation process, the National First Aid Advisory Board was expanded to become the International First Aid Science Advisory Board with the addition of representatives from a number of international first aid organizations (see Table). The goal of the board is to reduce morbidity and mortality due to emergency events by making treatment recommendations based on an analysis of the scientific evidence that answers the following questions: View this table: Table. International First Aid Science Advisory Board Member Organizations A critical review of the scientific literature by members of the International First Aid Science Advisory Board is summarized in the 2010 International Consensus on First Aid Science With Treatment Recommendations ( ILCOR 2010 CPR Consensus ), from which these guidelines are derived.2 That critical review evaluates the literature and identifies knowledge gaps that might be filled through future scientific research. The history of first aid can be traced to the dawn of organized human societies. For example, Native American Sioux medicine men of the Bear Society were noted for treating battle injuries, fixing fractures, controlling bleeding, removing arrows, and using a sharp flint to cut around wounds and inflammation.3 Modern, organized first aid evolved from military experiences when surgeons taught soldiers how to splint and bandage battlefield wounds. Two British officers, Peter Shepherd and …

Myocarditis is an acute inflammatory syndrome involving the heart and related structures. In many instances, the presentation is obvious, and appropriate treatment and disposition follow accordingly. In other situations, patients present with viral illness of the respiratory or gastrointestinal tracts (or both) or nonspecific symptoms such as fatigue and weakness,leading the clinician astray. Management is largely supportive, including aggressive cardiorespiratory support.

The electrocardiogram (ECG), when applied in the prehospital setting, has a significant effect on the patient with chest pain. The potential effect on the patient includes both diagnostic and therapeutic issues, including the diagnosis of acute myocardial infarction (AMI) and the indication for thrombolysis. The prehospital ECG may also detect an ischemic change that has resolved with treatment delivered by emergency medical services (EMS) prior to the patient's arrival in the emergency department (ED). Perhaps the most significant issue in the management of chest-pain patients involves the effect of the out-of-hospital ECG on the ED-based delivery of reperfusion therapy, such as thrombolysis. In AMI patients with ST-segment elevations, it has been conclusively demonstrated that information obtained from the prehospital ECG reduces the time to hospital-based reperfusion treatment. Importantly, these benefits are encountered with little increase in EMS resource use or on-scene time.

A previously documented CFD methodology is further generalized and applied to realistic turbine airfoil film cooling test cases. First, a series of fundamental test cases are examined in order to document the ability of the robust and practical CFD methodology to deal with the effects of the individually isolated key physics mechanisms on film cooling. These include: (1) favorable and adverse pressure gradients; (2) convex curvature; (3) horseshoe vortex; (4) profile losses with and without coolant jets; (5) laminar-to-turbulent boundary layer transition; and (6) discontinuities. Second, in addition to the fundamental flow test cases, two turbine airfoil cascade, one low subsonic and another transonic, configurations were modeled. The subsonic cascade case was designed to study the aerodynamics losses with and without film cooling jets, as well as, the adiabatic effectiveness for a range of parameters. The transonic turbine cascade represents a truly modern design at realistic engine conditions. A total of 18 test configurations, corresponding to compound-round, axial-shaped, and compound-shaped film holes, are simulated in order to document in detail the current state of the readily available robust and practical CFD technology for use by the gas turbine design community.

State-of-the-art experimental and computational techniques are used to study film cooling on the suction and pressure surfaces of a modern turbine blade under realistic engine conditions. Measured data and predicted results are compared for coolant jets injected through a row of three fundamentally different configurations: (1) Compound-angle round (CAR) holes; (2) Axial shaped holes (ASH); and (3) Compound-angle shaped holes (CASH). Experiments employ a single-passage cascade for validation-quality adiabatic film effectiveness measurements using a gas analysis technique. Computations use a novel combination of geometry and grid generation techniques, discretization scheme, turbulence modeling, and numerical solvers to evaluate a “best practice” standard for use in the gas turbine industry. The gridding procedure uses a super-block, multi-topology, unstructured/adaptive, non-conformal, near-wall resolved mesh to accurately capture all of the mean flow features of the 3-D jet-in-crossflow interaction. The effects of blowing ratio (M) are examined, with M = 1.0, 1.5, and 2.0 on the suction surface and M = 1.5, 3.0, and 4.5 on the pressure surface. All simulations are run with a density ratio of 1.52. The simulations model the three-way coupling between a transonic blade passage flow, subsonic film-hole flow, and creeping plenum flow; high pressure gradients; high rates of curvature; and large strain-rates found in actual engines. Computed results are compared to experimental data in terms of aerodynamic loading and spanwise-averaged adiabatic effectiveness on the blade surfaces in order to validate the computational methodology for this class of problems and to explain the mechanisms responsible for the performance of CAR, ASH, and CASH configurations.Copyright © 2002 by ASME

A well-tested computational methodology and high-quality data from a companion experimental study are used to analyze the physics of axial-injected, shaped-hole film cooling on the pressure and suction surfaces of a modern high-pressure turbine blade. Realistic engine conditions, including transonic flow, high turbulence levels, and a nominal density ratio of 1.52, are used to examine blowing ratios of 1.0, 1.5, and 2.0 on the suction surface (SS) and 1.5, 3.0, and 4.5 on the pressure surface (PS). SS results show excellent film-cooling performance with the hole shaping, but massive hot crossflow ingestion is found using similar hole shaping on the PS. Primary mechanisms governing the near and far-field cooling effectiveness and crossflow ingestion are identified, including: (1) the nature of the coolant entry into the film hole; (2) location of hole shaping relative to major coolant flow characteristics; and (3) susceptibility of low-momentum fluid to pressure gradients. Changes in blowing ratio, while not introducing new physical mechanisms, significantly alter the extent to which the mechanisms already present affect the flow. These effects are highly non-linear for both SS and PS geometries, highlighting the inadequacy of one-dimensional design practices and the potential usefulness of CFD as a predictive tool.Copyright © 2002 by ASME

For the first time in the open literature, code validation quality data and a well-tested, highly reliable computational methodology are employed to isolate the true performance of seven turbulence treatments in discrete jet film cooling. The present research examines both computational and high quality experimental data for two length-to-diameter ratios of a row of streamwise injected, cylindrical film holes. These two cases are used to document the performance of the following turbulence treatments: 1) standard k-e model with generalized wall functions; 2) standard k-e model with non-equilibrium wall functions: 3) Renormalization Group k-e (RNG) model with generalized wall functions; 4) RNG model with non-equilibrium wall functions: 51 standard k-e model with two-layer turbulence wall treatment; 6) Reynolds Stress Model (RSM) with generalized wall functions; and 7) RSM with non-equilibrium wall functions. Overall, the standard k-e turbulence model with the two-layer near-wall treatment, which resolves the viscous sublayer, produces results that are more consistent with experimental data.Copyright © 1998 by ASME