August 16, 2018

Background: Alcohol and drug intoxication is common in trauma patients and a significant proportion of cervical spine (c-spine) injuries occur in patients with intoxication. A standard approach to both intoxicated and sober patients with suspected c-spine injury in many trauma centers includes the placement of a rigid cervical collar for spinal immobilization until the c-spine can be “cleared.”  Even after a negative CT, intoxicated patients often are immobilized for prolonged periods of time until a reliable exam can be performed due to concern for missed findings on CT scan, specifically unstable ligamentous injuries.  This practice is less than ideal, as prolonged c-spine immobilization is associated with DVT, atelectasis, aspiration pneumonia, and elevated intracranial pressures.  In 2015, the Eastern Association for the Surgery of Trauma (EAST) demonstrated that CT imaging of obtunded patients due to any cause would miss approximately 9% of cervical spine injuries, most of which are clinically insignificant. They additionally found no benefit to prolonged immobilization.

May 17, 2018

Definition: Salicylate toxicity is characterized by a constellation of symptoms caused by acute or chronic overdose of salicylate containing compounds. The most common salicylate is aspirin, but the group also includes topical forms of salicylates, methyl salicylate (Oil of Wintergreen), and bismuth subsalicylate (such as in Pepto-Bismol).

May 7, 2018

Background: Visits to the ED for alcohol intoxication can create quite the clinical conundrum both for acute medical and traumatic reasons.  Acutely intoxicated patients, just like young kids, don’t always have the ability to communicate due to sedation, agitation, or some other critical medical/traumatic process that is ongoing.  This makes getting a complete history or depending on the physical exam unreliable at best.

October 9, 2017

Background: North America’s current opioid crisis, much of it iatrogenic (2), has led to significant increases in ED visits associated with opioids (3). These patients often present after poisoning, in withdrawal, or with other health issues associated with their disease. It is well accepted that Opioid Replacement Therapy (ORT), namely, methadone and buprenorphine/naloxone, are successful harm reduction agents shown to improve health and social outcomes (4). Several individual providers, and even large academic institutions, have started initiating ORT, specifically buprenorphine/naloxone, in the ED when dependent patients present in withdrawal. D’Onofrio et al., in 2015, published outcomes after 30-days from a clinical trial of patients who met criteria for opioid dependence in the ED that were randomized to one of three interventions: referral, brief intervention or ED-initiated buprenorphine followed by 10 weeks of continued buprenorphine treatment in a primary care setting (5). They found that patients receiving ED initiated buprenorphine with continuation in primary care were more likely to be engaged in formal addiction treatment at 30 days (p < 0.001). More recently, they have published follow-up outcomes on a subset from the original study at 2, 6 and 12 months.