‘Mules’ or body packers are people who transport illegal drugs by packet ingestion into the gastrointestinal tract. A large study of body packers apprehended by United State Customs officials at JFK International Airport, New York describes experience with body packers and an algorithm for conservative and surgical management.
Of 56 patients requiring admission out of a total of 1250 subjects confirmed to be body packers, 25 patients (45%) required surgical intervention, whereas 31 patients (55%) were successfully managed conservatively.
Diagnosis:
Plain abdominal x-ray was diagnostic in 49 patients (88% of all hospitalised patients).
Non-contrast CT of the abdomen and pelvis is required if AXR is negative
Forty-eight per cent of body packers had positive urine toxicology for illicit substances.
Management:
Indications for intervention included:
bowel obstruction
packet rupture/toxicity
delayed progression of packet transit on conservative management.
Patients with packets found predominantly in the proximal gastrointestinal tract failed conservative management more frequently than those with packets found in the distal gastrointestinal tract.
Multiple intraoperative manoeuvres were used to remove the foreign bodies:
gastrotomy
enterotomy
colotomy.
Wound infection was the most common complication and is associated with distal enterotomy and colotomy.
The authors recommend a confirmatory radiological study to demonstrate complete clearance of packets Establishment of a definitive protocol for the diagnosis and management of body packers (drug mules). Emerg Med J 2011;28:98-10
You come across a patient in the community who has taken an overdose of pills. The ambulance is on its way and you have no medical equipment. Is there any first aid that might help? How should you position the patient if they are unconscious?
Authors of a BestBet in the EMJ searched the literature to answer the three-part question:
In [orally poisoned patients] does [a specific body position] result in [a better outcome for the patient]?
The limited evidence they found from just two papers suggests that drug absorption is lowest in patients lying on their left side, so you might want to consider placing an unconscious overdose patient in the left-sided recovery position prior to definitively managing them in hospital. The theoretical increased risk of pulmonary aspiration on the left side should be considered however. The table shows just how limited this evidence base is – but the idea is an interesting one. Optimal body position in oral poisoning cases Emerg Med J 2010;27:952-953 Full text from the BestBets site
The National Tracheostomy Safety Project at www.tracheostomy.org.uk in the UK aims to allow patients with tracheostomies or laryngectomies to be safely cared for in hospitals.
The site contains a wealth of educational resources of use to the critical care practitioner. For example, have you thought about what do with a laryngectomy patient who presents with dyspnoea, or even apnoea? Remember that although applying oxygen to the face & neck is a default emergency action for all patients with a tracheostomy, these patients cannot be intubated and ventilated through the normal oral route since their tracheostomy is an end stoma – it does not communicate with the mouth:
Compare this with the algorithm for other patients with a tracheostomy, in whom attempts to oxygenate and ventilate, including intubation, can be made in an emergency either from the ‘top end’ (mouth) or via the stoma:
There are also a number of multimedia resources and a link to the UK Intensive Care Society’s Tracheostomy Guidelines
How can you not love those guys at hqmeded.com?
Here’s a great case of theirs demonstrating the echocardiographic appearance of ventricular fibrillation – something we talk about on the BEAM course.
One infrequently used option for refractory status epilepticus is isoflurane anaesthesia. A report of two cases demonstrates progressive MRI changes suggestive of neurotoxicity, that improved after discontinuation of isoflurane. Impossible to prove cause and effect here, since the both patients had status for weeks and were on multiple anticonvulsant medications, for example lorazepam, fosphenytoin, levetiracetam, valproate, and subsequent infusions of midazolam, pentobarbital, and ketamine. Neither patient recovered beyond a minimally conscious state. This article serves as a reminder that:
Persistent status epilepticus may be associated with a poor neurologic outcome
Some cases are extremely refractory to treatment
Isoflurane is one of many options to try when standard anticonvulsant regimens are failing
Dr WFS Sellers and colleagues describe several cases that demonstrate convincingly a protective effect of intravenous magnesium sulphate against the tachycardia produced by intravenous salbutamol in patients with asthma. This effect was observed both when magnesium was given before and when given after the salbutamol. It was seen in critically ill asthmatic patients and in a volunteer with well-controlled asthma.
Intravenous magnesium sulphate increases atrial contraction time and refractory times. It is used to treat atrial tachyarrhythmias and has a negative chronotropic and dromotropic effect. Intravenous magnesium sulphate prevents intravenous salbutamol tachycardia in asthma Br J Anaesth. 2010 Dec;105(6):869-70
Made a radiologist go red with rage recently? If not, you could try showing them this paper1 in this month’s Annals of Emergency Medicine that describes accurate emergency physician ultrasound diagnosis of deep vein thrombosis after just ten minutes training!
ED patients with a suspected lower extremity deep venous thrombosis were assessed using a bedside 2-point compression technique by emergency physicians using a portable US machine and all patients subsequently underwent duplex ultrasonography performed by the Department of Radiology.
The emergency physicians had a 10-minute training session before enrolling patients
The techinque involved 2 specific points: the common femoral and popliteal vessels, with subsequent compression of the common femoral and popliteal veins. The study result was considered positive for proximal lower extremity deep venous thrombosis if either vein was incompressible or a thrombus was visualised. Free DVT ultrasound tutorial at Sonoguide.com
A total of 47 physicians performed 199 2-point compression ultrasonographic examinations in the ED.
There were 45 proximal lower extremity deep venous thromboses observed on Department of Radiology evaluation, all correctly identified by ED 2-point compression ultrasonography. The 153 patients without proximal lower extremity deep venous thrombosis all had a negative ED compression ultrasonographic result. One patient with a negative Department of Radiology ultrasonographic result was found to have decreased compression of the popliteal vein on ED compression ultrasonography, giving a single false-positive result, yet repeated ultrasonography by the Department of Radiology 1 week later showed a popliteal deep venous thrombosis. The sensitivity and specificity of ED 2-point compression ultrasonography for deep venous thrombosis were 100% (95% confidence interval 92% to 100%) and 99% (95% confidence interval 96% to 100%), respectively.
These figures may appear to fail the ‘sniff test’, ie. seem too good to be true. Not surprisingly Annals acknowledge this by providing an accompanying editorial2 by emergency ultrasound heavyweight Michael Blaivas, MD, who is healthily skeptical of such a minimal training program but is overwhelmingly supportive of the principle. Dr Blaivas also provides a fantastic summary of the existing evidence base on ED ultrasound for DVT. To me he hits the nail on the head when with a philosophical point on the practice of EM: ‘One common challenge proponents of any new application or procedure face in emergency medicine is overcoming the inertia of comfort with the status quo.’ Spot on, Dr B.
1. Compression Ultrasonography of the Lower Extremity With Portable Vascular Ultrasonography Can Accurately Detect Deep Venous Thrombosis in the Emergency Department Annals of Emergency Medicine 2010;56(6):601-10
2. Point-of-Care Ultrasonographic Deep Venous Thrombosis Evaluation After Just Ten Minutes’ Training: Is This Offer Too Good to Be True? Annals of Emergency Medicine 2010;56(6):611-3
The guys at ‘EM Live’ have a short video on how to do DVT ultrasound:
Another stab at assessing noninvasive ventilation in cardiogenic pulmonary oedema has been made by Italian researchers who compared CPAP with noninvasive pressure support ventilation (nPSV – similar to BiPAP) in a randomised trial of 80 patients. The primary outcome was endotracheal intubation rates. There was no significant difference between the two modalities. This result is in keeping with the much larger 3CPO trial. Continuous Positive Airway Pressure vs. Pressure Support Ventilation in Acute Cardiogenic Pulmonary Edema: A Randomized Trial J Emerg Med. 2010 Nov;39(5):676-84
Certain chemical burns require a little extra thought than just irrigation and good wound care – which may even be contraindicated. An article in The Journal of Emergency Medicine addresses these, and some of the points are summarised below, with some additional information from Toxbase: Hot tar (bitumen)
Immerse contaminated area in cool water until the bitumen has hardened and cooled.
Adherent material may be left in place to avoid causing further injury by removal attempts, and will spontaneously detach after a few days.
If a finger or limb is completely surrounded, split the bitumen to prevent a tourniquet effect.
To remove bitumen, apply a lipid or polysorbate based agent and a clean non-adherent dressing. Suitable products include melted butter, sunflower oil, liquid paraffin, and petroleum or polysorbate based antibiotic ointments. Solvents such as alcohol, acetone, kerosene, ether or gasoline are not suitable.
Change the dressing frequently, and reapply the product as necessary, until the bitumen is completely removed. This may take up to 72 hours.
Treat as a thermal burn.
Elemental sodium
– utilised in the manufacturing of methamphetamine.
will spontaneously ignite above 115°C
Contact with water releases sodium hydroxide and hydrogen gas. It is the heat released in the reaction with the water in air that then ignites locally produced hydrogen gas.
Burns involving the metallic forms of sodium, potassium, and lithium (alkali metals) produce both thermal and chemical injury to the tissue. The thermal tissue damage is due to the extreme exothermic reaction that metallic sodium undergoes when exposed to water.
At times, water, when mixed with either elemental sodium or potassium, undergoes an explosive reaction.
Avoid water irrigation; if metal is still present in the tissues, the added water could ignite it.
All clothing should first be removed from the victim. If retained metal exists, the affected area should be covered in mineral oil. Removal of embedded sodium should then be undertaken with forceps.
Mineral oil is a practical, and potentially safer, alternative to isopropyl alcohol for the storage of elemental sodium.
Chromic acid
– a corrosive, oxidizing acid. After skin has been exposed to chromium, burns covering as little as 10% of body surface area (BSA) have proven fatal.
Burns involving as little as 1% of total BSA have resulted in acute renal failure.
Wash thoroughly with copious amounts of water and treat as a thermal burn.
Application of 10% ascorbic acid solution at least three times per day may improve the rate of healing
Prompt excision of burned, contaminated areas is recommended to prevent absorption of the chemical.
White phosphorus
– will ignite spontaneously in 30°C air temperature; typically stored in water.
burns of > 10% can have associated mortality.
Three stages of systemic toxicity exist: (1) gastrointestinal symptoms (nausea, vomiting and “smoking stool”). Symptoms of headache, seizures, and coma, as well as the potential for cardiovascular collapse, may occur in the initial phase. Decreasing serum calcium concentrations; (2) symptom-free period; (3) (4 to 8 days post-exposure) neurological toxicity, bleeding diathesis, hepatic failure, renal failure, and shock.
Continuous coverage with water will protect both the patient and staff from ignition and fumes that result from white phosphorus’s contact with air.
Brushing particulate not incorporated in wounds can accomplish a significant amount of decontamination. This brushing should be followed by continuous irrigation until all particles are removed. Those debriding and decontaminating an exposed patient should have a safe method of disposing of particles: a container of cold water would suffice.
A way to identify phosphorous particles for removal is the use of a Wood’s lamp, which will cause the white phosphorous to fluoresce.
Excision may be necessary to remove the chemical if deeply entrenched in fascia.
Phenol
– a corrosive aromatic hydrocarbon that can be absorbed at toxic levels through all routes of absorption
causes extensive denaturisation of tissue proteins, producing an eschar with shallow ulcers
Rescue personnel should use butyl rubber gloves and aprons, and conduct decontamination in a well-ventilated area.
wipe exposed areas immediately with low-molecular-weight polytheylene glycol (PEG 300 or 400)
however Toxbase states: “The use of solvents (such as glycerol, polyethylene glycol and isopropanol) has been suggested. One (animal) study (Hunter et al, 1992) indicated that isopropanol was more effective than water, but there is no evidence in humans that solvents are more effective than washing with copious amounts of water.”
if the burn covers a large skin area, high pressure shower irrigation before PEG application is preferable
Any water applied must be applied in high pressure, as small amounts might dilute the phenol present on the skin and thus expand not only the involved area but also the amount of phenol absorbed.
Hydrofluoric acid
HF is highly corrosive and causes damage by two mechanisms. It produces a corrosive burn from the high concentration of hydrogen ions. It also penetrates tissues due to the lipophilic nature of fluoride, and causes liquefactive necrosis.
Tissue penetration leads to systemic reactions with effects on the cardiac, respiratory, nervous, and gastrointestinal systems. The fluoride ion precipitates calcium, leading to hypocalcemia, and may interfere with enzyme systems by binding magnesium and manganese, as well as important nerve conduction functions that depend on calcium.
Copious irrigation of HF-burned skin with water should begin immediately. Most HF burns will respond well to this.
Pain that persists after irrigation is a marker that the fluoride ion needs detoxification. This can be accomplished through superficial topical treatment, infiltrative treatment, or intra-arterial treatment.
The preferred topical agent is calcium gluconate gel.
