Volume 35 Number 3: March 2021

Brainchild External and internal stressors can quickly overwhelm a young person’s ability to cope, a problem that can result in anxiety, depression, personality changes, aggression, or even hallucinations. Although emergency clinicians are frequently challenged to differentiate medical etiologies from underlying psychiatric disorders, this can be particularly difficult when assessing pediatric patients, whose normal moods can sometimes mimic potentially abnormal behavior.

High Life Synthetic drugs of abuse are more popular and widely available than ever before; in 2017, more than half of opioid-related deaths in the US were attributed to synthetic varieties. Dangerous and hard to detect, these xenobiotics can have unpredictable physiological effects. This is especially true of synthetic cannabinoids and cathinones, which can lead to a variety of potentially dangerous symptoms, ranging from tachycardia and agitation to stroke and acute coronary syndrome.

THE OFFICIAL CME PUBLICATION OF THE AMERICAN COLLEGE OF EMERGENCY PHYSICIANS IN THIS ISSUE Lesson 5 n Pediatric Psychiatric Emergencies ...... 3

Critical Image ...... 8 Critical Decisions in Emergency Medicine is the official Critical Procedure ...... 9 CME publication of the American College of Emergency Physicians. Additional volumes are available. Clinical Pediatrics ...... 10 Critical Cases in Orthopedics and Trauma ...... 12 EDITOR-IN-CHIEF Critical ECG ...... 14 Michael S. Beeson, MD, MBA, FACEP Northeastern Ohio Universities, Lesson 6 n Synthetic Drugs of Abuse ...... 15 Rootstown, OH LLSA Literature Review ...... 21 SECTION EDITORS CME Questions ...... 22 Joshua S. Broder, MD, FACEP Drug Box/Tox Box ...... 24 Duke University, Durham, NC

Contributor Disclosures. In accordance with the ACCME Standards for Commercial Andrew J. Eyre, MD, MHPEd Support and policy of the American College of Emergency Physicians, all individuals with Brigham & Women’s Hospital/ control over CME content (including but not limited to staff, planners, reviewers, and Harvard Medical School, Boston, MA authors) must disclose whether or not they have any relevant financial relationship(s) to John Kiel, DO, MPH learners prior to the start of the activity . These individuals have indicated that they have University of Florida College of Medicine, a relationship which, in the context of their involvement in the CME activity, could be Jacksonville, FL perceived by some as a real or apparent conflict of interest (eg, ownership of stock, grants, honoraria, or consulting fees), but these individuals do not consider that it will influence the Frank LoVecchio, DO, MPH, FACEP CME activity . Joshua S . Broder, MD, FACEP, is a founder and shareholder of OmniSono Inc, Maricopa Medical Center/Banner Phoenix Poison an ultrasound technology company; his wife is employed by GlaxoSmithKline as a research and Drug Information Center, Phoenix, AZ organic chemist . Sharon E . Mace, MD, FACEP, performs contracted research that is funded by Biofire Corporation . All remaining individuals with control over CME content have no Amal Mattu, MD, FACEP significant financial interests or relationships to disclose . University of Maryland, Baltimore, MD This educational activity consists of two lessons, a post-test, and evaluation questions; Lynn P. Roppolo, MD, FACEP as designed, the activity should take approximately 5 hours to complete . The participant UT Southwestern Medical Center, should, in order, review the learning objectives, read the lessons as published in the print Dallas, TX or online version, and complete the online post-test (a minimum score of 75% is required) and evaluation questions . Release date March 1, 2021 . Expiration date February 29, 2024 . Christian A. Tomaszewski, MD, MS, MBA, FACEP Accreditation Statement. The American College of Emergency Physicians is accredited by University of California Health Sciences, San Diego, CA the Accreditation Council for Continuing Medical Education to provide continuing medical Steven J. Warrington, MD, MEd education for physicians . Orange Park Medical Center, Orange Park, FL The American College of Emergency Physicians designates this enduring material for a maximum of 5 AMA PRA Category 1 Credits™ . Physicians should claim only the credit ASSOCIATE EDITORS commensurate with the extent of their participation in the activity . Wan-Tsu W. Chang, MD Each issue of Critical Decisions in Emergency Medicine is approved by ACEP for 5 ACEP University of Maryland, Baltimore, MD Category I credits . Approved by the AOA for 5 Category 2-B credits . Kelsey Drake, MD, MPH, FACEP Commercial Support. There was no commercial support for this CME activity . St . Anthony Hospital, Lakewood CO Target Audience. This educational activity has been developed for emergency physicians . Walter L. Green, MD, FACEP UT Southwestern Medical Center, Dallas, TX Critical Decisions in Emergency Medicine is a trademark owned and published monthly by the American College of Emergency Physicians, PO Box 619911, Dallas, TX 75261-9911. Send address changes and John C. Greenwood, MD comments to Critical Decisions in Emergency Medicine, PO Box 619911, Dallas, TX 75261-9911, or to University of Pennsylvania, Philadelphia, PA [email protected]; call toll-free 800-798-1822, or 972-550-0911. Danya Khoujah, MBBS Copyright 2021 © by the American College of Emergency Physicians. All rights reserved. No part of University of Maryland, Baltimore, MD this publication may be reproduced, stored, or transmitted in any form or by any means, electronic or mechanical, including storage and retrieval systems, without permission in writing from the Publisher. Sharon E. Mace, MD, FACEP Printed in the USA. Cleveland Clinic Lerner College of Medicine/

The American College of Emergency Physicians (ACEP) makes every effort to ensure that contributors Case Western Reserve University, Cleveland, OH to its publications are knowledgeable subject matter experts. Readers are nevertheless advised that the Nathaniel Mann, MD statements and opinions expressed in this publication are provided as the contributors’ recommendations Greenville Health System, Greenville, SC at the time of publication and should not be construed as official College policy. ACEP recognizes the complexity of emergency medicine and makes no representation that this publication serves as an George Sternbach, MD, FACEP authoritative resource for the prevention, diagnosis, treatment, or intervention for any medical condition, Stanford University Medical Center, Stanford, CA nor should it be the basis for the definition of or standard of care that should be practiced by all health care providers at any particular time or place. Drugs are generally referred to by generic names. In some Joseph F. Waeckerle, MD, FACEP instances, brand names are added for easier recognition. Device manufacturer information is provided University of Missouri-Kansas City School of Medicine, according to style conventions of the American Medical Association. ACEP received no commercial support Kansas City, MO for this publication. To the fullest extent permitted by law, and without EDITORIAL STAFF limitation, ACEP expressly disclaims all liability for Rachel Donihoo, Managing Editor errors or omissions contained within this publication, and for damages of any kind or nature, arising out of [email protected] use, reference to, reliance on, or performance of such ISSN2325-0186 (Print) ISSN2325-8365 (Online) information. Brainchild Pediatric Psychiatric Emergencies

LESSON 5

By Purva Grover, MD, MBA, FACEP; and Onyinyechi I. Ukwuoma, MD, MPH Dr . Grover is the medical director of the Pediatric Emergency Department at the Cleveland Clinic in Cleveland, Ohio . Dr . Ukwuoma is a pediatric emergency specialist at Hillcrest Hospital in Mayfield Heights, Ohio . Reviewed by Sharon E. Mace, MD, FACEP OBJECTIVES On completion of this lesson, you should be able to: CRITICAL DECISIONS 1. Approach and stabilize pediatric patients with psychiatric n How should pediatric psychiatric patients be emergencies. evaluated in the emergency department? 2. Evaluate common psychiatric diagnoses. n What is the best way to differentiate a medical 3. Use diagnostic adjuncts available in the emergency department. condition from a psychiatric disorder? 4. Administer pharmacological treatment for pediatric n How should suicidal pediatric patients be psychiatric patients. managed? 5. Discuss medicolegal issues involving pediatric patients. n When are physical or chemical restraints FROM THE EM MODEL appropriate? 19.0 Procedures and Skills Integral to the Practice n What medicolegal issues must be considered when of Emergency Medicine managing pediatric psychiatric patients? 19.4.9 Psychobehavioral

External and internal stressors can quickly overwhelm a young person’s ability to cope, a problem that can result in anxiety, depression, personality changes, aggression, or even hallucinations. Although emergency clinicians are frequently challenged to differentiate medical etiologies from underlying psychiatric disorders, this can be particularly difficult when assessing pediatric patients, whose normal moods can sometimes mimic potentially abnormal behavior.

March 2021 n Volume 35 Number 3 3 CASE PRESENTATIONS ■ CASE ONE emergency department, where he also confides that she been using is now growling and spitting at the a razor to cut herself and has been A 9-year-old boy presents medical staff. He has a history of smoking marijuana daily to cope via ambulance in 4-point leather attention deficit hyperactivity disorder with her feelings. She reports restraints after an outburst in for which he takes methylphenidate. further “spiraling” after breaking school. The teaching staff reports He is tachycardic and tachypneic; his up with her boyfriend last week. that after recess — where no blood pressure cannot be obtained. Her vital signs are within normal untoward incidents were reported range, and the physical examination — the boy began banging his ■ CASE TWO is unremarkable. head against the table, resulting A 16-year-old girl is sent to the After a discussion with the in a forehead bleed. When staff emergency department after disclosing hospital psychiatrist, the emergency attempted first aid, he attacked to her counselor that she has thoughts physician recommends admitting them, scratching one teacher in of hurting herself. She was hospitalized the girl to the psychiatric unit. the face and bending another’s 2 months ago after deliberately slitting However, her mother refuses and finger to the point of deformity. her wrists. She says she was diagnosed threatens to take her home, insisting The child was subsequently with depression 3 years ago after her the patient’s suicidal thoughts are a restrained and transported the father committed suicide. The patient fabricated bid for attention.

National trends demonstrate an of Mental Disorders (DSM-5) to help buttons” have been introduced by increase (up to 5%) in emergency diagnose mental health disorders in many hospitals to help with safety as department visits for pediatric children. situations warrant. mental health issues.1,2 In spite of the Clinicians should attempt to gain nationwide demand for mental health CRITICAL DECISION rapport with the patient, interacting in services, there is a shortage of trained How should pediatric psychiatric a developmentally appropriate manner pediatric psychiatry personnel and patients be evaluated in the and explaining the evaluation process limited accessibility to mental health (unless the child is uncooperative). A emergency department? and community-based services. These parent or guardian can be an invaluable deficiencies have forced emergency Ensuring a safe environment for resource in calming a pediatric departments to meet these critical needs. patients, their parents or guardians, psychiatric patient; however, they A psychiatric emergency refers and hospital staff is key (Figure 1). may also be a trigger. Read the room to a relatively sudden situation in Patients must be screened for dangerous carefully and observe the interaction which there is an impending risk weapons prior to evaluation; typically, between children and their caregivers. of harm to oneself or others. The security personnel use metal detectors The evaluation of pediatric two most common pediatric mental or physically search patients and their psychiatric patients involves obtaining health emergencies are suicidality and belongings. In most centers, psychiatric a medical history, performing a physical aggression. Even when a psychiatric patients are asked to undress and are examination, and conducting a brief consultant is available, it is vital for provided with hospital gowns and but comprehensive interview of the emergency physicians to be armed with socks, and their belongings are kept in child and their parents or guardians. the knowledge to appropriately screen a secure location pending disposition. Psychiatric evaluations of children and children and adolescents with mental Dedicated rooms for mental health adolescents tend to take longer than health complaints and differentiate true patients should be devoid of objects those of adults, as the process typically psychiatric crises from behavioral issues that can be used as weapons, including involves additional interviews with that can be managed on an outpatient cutlery, medical tubes, electrical cords, collateral contacts. basis. and bandages. Speaking with parents or guardians All pediatric patients should A serene setting, preferably separate provides an opportunity to collect be approached in a culturally and from the hectic environment of the valuable information about a child’s developmentally appropriate manner main emergency department, is ideal; history, behavioral changes, potential with consideration for special needs or patients who are exposed to as little risk factors, and any treatments that developmental delays. Unfortunately, stimulus as possible are more likely to have been tried in the past. These family and social issues can further cooperate with treatment. These rooms discussions can help clarify whether complicate the assessment, treatment, should be easily accessible to medical the patient may be a risk to themselves and disposition of pediatric psychiatric and security staff, and high-risk patients or others, if there are any available patients. The CDC recommends using must be constantly observed by sitters resources in the community that can be the Diagnostic and Statistical Manual or continuous video monitoring. “Panic used in the patient’s care, and whether

4 Critical Decisions in Emergency Medicine the parent or guardian is willing and Acute-onset psychosis is more likely are to keep the patient safe, recognize able to supervise the child and follow- have a medical etiology than a psychiatric and manage any possible medical up with recommendations. origin, but the presence of subacute or complications, and decide upon a suitable A complete physical examination chronic symptoms (known psychiatric disposition. The physical examination includes a mental status assessment and diagnosis) or a family history of mental may reveal signs of self-injury, such as thorough neurologic exam. Routine illness should raise suspicion for the cuts or ligature marks, and the presence lab tests have shown limited utility and latter. Managing an acute psychotic of altered mental status warrants a are not recommended unless there is episode due to psychiatric illness involves toxicology screening, including ethanol suspicion for a specific medical illness; the administration of antipsychotic measurements. An organic etiology however, some mental health facilities medication. In cases of chronic psychosis, should also be ruled out. require lab work prior to accepting inpatient management is warranted if the The greatest risk factor for suicide transferred patients. patient is suicidal, homicidal, or unable to in an adolescent is a previous attempt. CRITICAL DECISION sustain activities of daily living. Other risk factors include a recent psychiatric admission, dysphoric mood, What is the best way to CRITICAL DECISION hopelessness, impulsive behavior, differentiate a medical condition How should suicidal pediatric substance abuse, access to lethal means, from a psychiatric disorder? recent stressors (eg, personal, relational, patients be managed? All patients presenting with mental etc), homosexual or transgender identity, Suicide is one of the leading causes health complaints should be medically and a family history of suicide. A 3 evaluated for possible underlying or of death in the adolescent population. thorough medical history includes an comorbid pathologies. Clues to the In the emergency setting, the main inquiry about these risk factors, as well possibility of an organic (medical) objectives when managing a suicidal child as further discussion about the reason etiology include abnormal vital signs or physical examination findings, a history FIGURE 1. Assessing Pediatric Psychiatric Emergencies of substance abuse, and an acute change in baseline neurologic or psychiatric Start here status. A broad range of medical Care Pathway Elements illnesses can manifest psychiatric symptoms, including endocrine, Environmental elements to consider neurologic, systemic, toxicologic, and • Calm setting • Trauma-informed Acute Medical • Specific rooms or hallways approach Yes metabolic conditions. Furthermore, it medical care stabilization • Dedicated care team • Use of triage scales can be difficult to differentiate between Triage required? of patient availability • Need for chemical or manipulative behaviors and true physical restraints psychiatric disorders when managing No Screenings to consider these cases. Pediatric patients often • Suicidal ideation, • Exposure to violence present with dissociative disorders, behavior, and self-harm • General mental health Initiate which occur most commonly in girls; • Violence/aggressive • Telepsychiatry and crisis screening behavior teams sexual abuse as a common original Screening • Depression • Drug and alcohol trauma. • Psychosis

Psychosis Assessments to consider Psychosis is characterized by • Mental assessment delusions, hallucinations, and Ongoing • Safety assessment assessment • Acute agitation and behavioral escalation disorganized thoughts and speech. Although it is a common manifestation of schizophrenia, psychosis can be AssessmentOngoing present in other psychiatric conditions, Linkages to primary care including depression and bipolar Inpatient or Outpatient Linkages to community mental health services disorder. It is also a symptom of a outpatient Home resources broad range of medical conditions, Telepsychiatry and eHealth so a thorough history must be Inpatient obtained to rule out life-threatening Disposition causes like hypoglycemia, hypoxia, Inpatient Transfer to admission central nervous system abnormalities, another Follow-up (psychiatric unit facility infection, endocrine and metabolic or other) disease, lupus, medication toxicity, and drug overdose. ADAPTED FROM THE US DEPARTMENT OF HEALTH AND HUMAN SERVICES

March 2021 n Volume 35 Number 3 5 for current suicidal thoughts and any Chemical Restraints plan of carrying out a suicide attempt. TABLE 1. Pediatric Chemical If this fails, the next step typically Restraint Medications The age and cognitive ability of the involves the use of medications patient influences the concept of suicide. Medication Initial Dose (chemical restraints), including Younger children, for example, may antipsychotic agents, benzodiazepines, 0.05–0.15 mg/kg Haloperidol not understand the finality of death, Teen: 2–5mg or a combination of both (Table 1). and some patients may not necessarily Patients already taking any of these 0.05–0.1 mg/kg want to die but express suicidal ideation Lorazepam Teen: 2–4 mg medications should be given their usual due to overwhelming sadness or or an increased dose of the same drug. 0.05–0.15 mg/kg hopelessness. Midazolam All cooperative patients should be given Teen: 2–4mg The emergency physician must the option to take the medication orally. <12 years: 2.5 mg work with mental health clinicians to Olanzapine Keep in mind the respective arrange a disposition that is beneficial Teen: 5–10 mg adverse effects of these medications: to the patient. When managing these 1.25 mg/kg Diphenhydramine first-generation antipsychotics cases, it is imperative to avoid dismissing Teen: 50 mg (haloperidol) and second-generation the need for a psychiatry consultation Risperidone <12 years: 0.5 mg antipsychotics (olanzapine, risperidone, if the patient or parent denies or (oral) Teen: 1 mg and ziprasidone) can cause cardiac downplays thoughts of suicide. Criteria <12 years: 5 mg arrhythmias, hypoventilation, CNS Ziprasidone for inpatient psychiatry management Teen: 10–20 mg depression, and extrapyramidal include a persistent desire to die, severe symptoms. Neuroleptic malignant <12 years: 1–2 mg hopelessness, a failure to establish safety Aripiprazole Teen: 2–5 mg syndrome. a rare adverse effect of plans, a poor support system with antipsychotic agents, is characterized unreliable monitoring and follow-up, by fever and muscle rigidity. Benzo­ and a suicide attempt using a highly include ensuring the safety of everyone diazepines can cause respiratory lethal means. involved, helping the patient manage depression, and paradoxical reactions Low-risk children and adolescents their emotions, averting physical or can occur between benzodiazepines and who have appropriate supervision at chemical restraints whenever possible, antihistamines. home and adequate access to mental and avoiding interventions that might Physical Restraints health care may be managed on an increase agitation.4 Physical restraints can result in outpatient basis. Although safety When an acutely agitated patient is both physical and psychological harm. contracts are sometimes employed, their at risk of harming themselves or others, Such tools are only indicated in cases of usefulness is debatable. If the patient the use of restraints may be necessary. severe disruptiveness with an impending is to be discharged home, a discussion Verbal restraints and de-escalation risk of harm — and only after other, must be had with caregivers regarding should be attempted first: Patients less-restrictive de-escalation measures restricting their means to self-harm (eg, should be approached in a reassuring, have failed. The Joint Commission and limiting access to potentially dangerous nonhostile manner, and the physician the Centers for Medicare and Medicaid instruments like knives, firearms, and should stay more than an arm’s length Services have both developed guidelines medications). away to avoid harm and appear less and regulations regarding the use of CRITICAL DECISION threatening. While giving patients some physical restraints.5,6 Notable safety autonomy helps with cooperation, it considerations include involving enough When are physical or chemical is necessary to set limits in a firm but personnel to immobilize the patient, restraints appropriate? respectful tone and avoid bargaining. using safe restraint material, securing Agitation or violent behavior may be the result of a medical, toxicological, or psychiatric condition — or a combination of any. It is important to ascertain the etiology of each patient’s symptoms to inform the management strategy. Manifestations of agitation n A parent or guardian can be an invaluable resource for calming a pediatric may range from restlessness or verbal psychiatric patient; however, they may also be a trigger. Read the room assaults to the destruction of property, carefully, and observe the interaction between the patient and guardian. self-harm, or physical violence. Identified n Pediatric patients often present with dissociative disorders, which occur most triggers amenable to intervention commonly in girls who have suffered sexual abuse. (eg, the presence of a specific family n Work to gain rapport with the child or adolescent, interacting in a member) should be addressed. The developmentally appropriate manner while explaining the evaluation process. goals of managing an agitated child

6 Critical Decisions in Emergency Medicine CASE RESOLUTIONS ■ CASE ONE staff’s attempt to administer first aid attempt and family history. Concerned The restrained boy received a dose had angered and frustrated him. about the patient’s welfare and her of midazolam; within 30 minutes, The patient had not previously mother’s refusal to allow inpatient he was calm. The restraints were shared anything about hearing voices treatment, the emergency physician promptly removed, and he was with his family, who expressed great reported the case to Child Protective placed under continuous observation. concern. He was admitted to the Services. Head CT was negative for any acute inpatient psychiatric unit for further After several long conversations intracranial process, and his blood treatment and assessment. with the emergency clinician and work was clinically insignificant. case worker, the mother acquiesced. The patient said that he began ■ CASE TWO The girl was admitted to the banging his head after “a voice” told The teenage girl was determined psychiatry unit, where she received a him he was “stupid and bad.” He to be at a particularly high risk of comprehensive evaluation and long- further explained that the school self-harm based on her previous suicide term treatment plan. restraints to the bed frame to avoid treatment without the involvement of Summary falls, and reducing the risk of aspiration a legal custodian. In some instances, The rate of emergency department by placing the patient in a supine a patient may meet the criteria for cases for pediatric mental health position. Pillows should be avoided psychiatric hospitalization despite the complaints has significantly increased, to avoid the risk of suffocation. The objection of their patients or guardians. and the evaluation of these patients can medical team should include at least The laws on involuntary hospitalization be taxing. Nevertheless, it is imperative five members, including a designated vary from state to state, thus familiarity for emergency physicians to be adept leader who can explain the process to in conducting basic interviews and with state laws is prudent. the patient in clear language. It is crucial pursuing the best level of care. The Attention should be paid to the to continuously monitor patients in acute evaluation of pediatric psychiatric interaction between the patient and their chemical or physical restraints for the patients incorporates triage and medical development of possible side effects. parents or guardians, and a report must clearance, observance of safety measures, be made to the appropriate authorities a thorough medical history, involvement CRITICAL DECISION whenever child abuse or neglect is of the family and caregivers, a mental What medicolegal issues must suspected or witnessed. Furthermore, if a health consultation, and disposition be considered when managing parent or guardian refuses treatment for planning. It is crucial that final treatment pediatric psychiatric patients? a child who is in imminent danger, Child plans include input and approval from Protective Services must be consulted. As members of the hospital’s psychiatry Consent to treat should be mandated reporters, it is important that team prior to discharge. obtained prior to the initial physicians understand how to recognize evaluation. Unless the patient has a REFERENCES child abuse and make comprehensive, life-threatening condition requiring 1 . Grupp-Phelan J, Harman JS, Kelleher KJ . Trends in accurate reports in a timely manner. mental health and chronic condition visits by children medical stabilization, waived consent presenting for care at U .S . emergency departments . Similarly, if it is determined that a patient Public Health Rep . 2007 Jan-Feb;122(1):55-61 . is not applicable. Consent is typically 2 . Mahajan P, Alpern ER, Grupp-Phelan J, et al; Pediatric obtained from a parent or guardian; poses a danger to another individual, Emergency Care Applied Research Network (PECARN) . Epidemiology of psychiatric-related however, some states do allow children the clinician is obligated to warn the visits to emergency departments in a multicenter collaborative research pediatric network . Pediatr to provide consent for mental health intended victim against violence. Emerg Care . 2009 Nov;25(11):715-720 . 3 . Shain BN; American Academy of Pediatrics Committee on Adolescence . Suicide and suicide attempts in adolescents . Pediatrics . 2016 Jul;138(1):e20161420 . 4 . Richmond JS, Berlin JS, Fishkind AB, et al . Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup . West J Emergency Med. 2012 Feb;13(1):17-25 . 5 . Centers for Medicare and Medicaid Services; Department of Health and Human Services . n Dismissing the need for psychiatry consultation if the patient denies or Medicare and Medicaid programs; hospital downplays thoughts of suicide. conditions of participation: patients’ rights . Final rule . Fed Regist . 2006 Dec;71(236):71377–71428 . n Neglecting to consider organic causes of mental status changes. 6 . The Joint Commission . Standards on restraint and seclusion . Crisis Prevention Institute website . Published 2009 . Accessed February 17, 2021 . https://www . n Failing to attempt low-risk de-escalation measures before implementing crisisprevention .com/CPI/media/Media/Resources/ chemical or physical restraints. alignments/Joint-Commission-Restraint-Seclusion- Alignment-2011 .pdf .

March 2021 n Volume 35 Number 3 7 The Critical Image A 12-kg girl (estimated age, 1 year) presents via ambulance following a By Joshua S. Broder, MD, FACEP high-speed, head-on motor vehicle collision. EMS found the child restrained Dr . Broder is a professor and the residency program director in the Division of in a rear-row infant seat; she was pulseless and asystolic, and CPR was Emergency Medicine at Duke University initiated . Paramedics placed a supraglottic airway and tibial intraosseous Medical Center in Durham, North Carolina . catheter and achieved return of spontaneous circulation before transport . Case contributor: John Hoff, MD On arrival, the infant’s vital signs are blood pressure 107/65, heart rate 114,

respiratory rate 28 via bag-valve-mask, temperature 37°C (98 .6°F), and SpO2 97% on 100% FiO2 . No visible or palpable traumatic findings are found on the physical exam, but the patient is neurologically unresponsive and apneic . Her supraglottic airway is replaced with an endotracheal tube . Axial CT images reveal no injuries, and she is transferred to the pediatric ICU .

Widened Basion B atlanto- A C occipital Widened interval basion-dens Spinal interval epidural C1-C2 fluid distraction Dens collection

C5-C6 distraction C5-C6 distraction

Abnormal Prevertebral cord signal fluid collection intensity A. Sagittal CT reconstruction demonstra­ B. 3D CT reconstructions viewed from anterior and lateral perspectives demonstrate a ting a multilevel distraction injury of the distraction injury at the C5-C6 level. cervical spine. Axial images alone (not shown) C. T2-weighted MRI demonstrating distraction of the vertebral bodies at C5-C6 and missed the injury, which is evident only as an an associated spinal cord injury with an increased T2 signal within the cord. The large unexpectedly large interval between bony prevertebral and epidural fluid collections are additional clues to the spinal injury . structures . In addition to a widened C5-C6 intervertebral space, the distances between the occipital condyles and atlas (C1) and KEY POINTS the basion (anterior aspect of the foramen n Pediatric cervical spine injuries are magnum) and dens are increased . distances may reveal subtle and rare (0 .66%-0 98%),. and injuries in rare injuries . The basion-dens young children and infants are even interval (distance between the tip of rarer (0 1%. in patients <9 years) 1,2. the dens of C2 and the basion, or n The ACR Appropriateness Criteria anterior-most midline point of the rate plain radiography as usually foramen magnum) is increased in appropriate and CT as usually atlanto-occipital injuries . The normal inappropriate as the initial imaging value on CT is reported to be below modality for children younger 8 .5 mm in adults; in the patient than 3 years who meet high-risk above, the value was 11 mm 4. The criteria for cervical spine trauma 3. normal atlanto-occipital interval REFERENCES However, in cases of polytrauma with is less than 1 .4 mm in adults and 1 . Viccellio P, Simon H, Pressman BD, et al . A prospective abnormal neurologic status, CT is varies in children, with a value less multicenter study of cervical spine injury in children . Pediatrics. 2001;108:E20 . the pragmatic choice because of its than 1 7 mm. in children under 12 2 . Pieretti-Vanmarcke R, Velmahos GC, Nance ML, et al . 5 Clinical clearance of the cervical spine in blunt trauma ability to rapidly assess for multi­ months of age . In this patient, it was patients younger than 3 years: a multi-center study of the system trauma . When performed, 2 .8 mm . american association for the surgery of trauma . J Trauma. 2009;67:543-549; discussion 9-50 . multiple CT planes should be 3 . Expert Panel on Pediatric I, Kadom N, Palasis S, et al . ACR reviewed to enable the detection of Appropriateness Criteria((R)) Suspected Spine Trauma- CASE RESOLUTION Child . J Am Coll Radiol. 2019;16:S286-S99 . subluxation and distraction injuries . 4 . Rojas CA, Bertozzi JC, Martinez CR, Whitlow J . The patient remained neurologically Reassessment of the craniocervical junction: normal n While attention should be directed values on CT . AJNR Am J Neuroradiol. 2007;28: to common areas of injury, subtle unresponsive. Brain death criteria 1819-1823 . 5 . Smith P, Linscott LL, Vadivelu S, Zhang B, Leach JL . clues like increased intervals were met, and she died after life Normal Development and Measurements of the Occipital between bony landmarks and support was withdrawn. Condyle-C1 Interval in Children and Young Adults . Am J Neuroradiol. 2016;37:952-957 . increased prevertebral soft-tissue

8 Critical Decisions in Emergency Medicine The Critical Procedure Ultrasound-Guided Serratus Anterior Plane Block By Lauren Karsh, MD Orange Park Medical Center, Orange Park, Florida Reviewed by Steven J. Warrington, MD, MEd The effective management of pain associated with acute chest wall pathologies, such as rib fractures, postoperative conditions, and herpes zoster, is vital for patient comfort. A serratus anterior plane block with ultrasound guidance provides optimal analgesia for localized pain control in the emergency department.

D Contraindications patient’s breathing and movement when This research was supported (in whole n Overlying infection manipulating the needle. Discomfort or in part) by HCA Healthcare and/or an n Allergy to the anesthetic during the procedure can be reduced HCA Healthcare affiliated entity. The views expressed in this publication represent by warming or buffering the anesthetic; Benefits and Risks those of the author(s) and do not necessarily topical or superficial anesthesia should Serratus anterior plane blocks represent the official views of HCA provide both localized and prolonged be considered prior to the procedure. Healthcare or any of its affiliated entities. analgesia (when used continuously); this approach is an ideal alternative or TECHNIQUE adjunct to systemic narcotic analgesia. Additionally, the procedure may provide relief when traditional regimens have failed, as in patients with intractable herpes zoster pain. The technique can be used in both children and adults. In addition to the potential complications associated with the anesthetic used, risks of the technique include pneumothorax,­ hematoma formation, infection, inadvertent intravascular injection, nerve injury, and procedure failure. Alternatives Alternative approaches include erector spinae plane, paravertebral, and intercostal blocks. Consider the location of the injury when determining which procedure would be most effective to 1. Place the patient in either the supine position (with the arm on the affected side help control the patient’s symptoms. raised) or lateral decubitus position (with the arm out of the way) (Figure A). Clinicans may also consider placing 2. Identify the planned injection site using a linear high-frequency ultrasound a catheter to provide a continuous transducer in the sagittal position at the midaxillary line (Figure B). Slowly move infusion of medication, but this the transducer posteriorly to identify the latissimus dorsi and serratus anterior approach is generally used for ongoing muscles and the fascial plane. management in collaboration with other 3. Prepare the site after identifying the pertinent structures. departments (eg, anesthesia). Other Introduce alternatives include systemic and topical 4. and advance the needle until it is underneath the fascial plane (Figure C). Carefully aspirate and inject a small amount of solution under real- medications. time ultrasound, using hydrodissection to confirm the position of the needle tip. Special Considerations 5. Inject the anesthetic solution slowly, readjusting the location of the needle tip Ultrasound guidance may reduce the if necessary. risk of complications like pneumothorax 6. Remove the needle and apply dressing to the site; consider applying an ice and vascular injury. Potential risks may pack as well. be mitigated by closely monitoring the

March 2021 n Volume 35 Number 3 9 Critical Pediatrics Primary Spontaneous Pneumothorax By David Foster, MD, MS Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York Reviewed by Sharon E. Mace, MD, FACEPH

An otherwise healthy 16-year-old boy presents with sudden-onset chest pain and shortness of breath. He describes 5 hours of constant, mild “stabbing” pain in his left chest, which began while he was getting dressed and is worse with deep inspiration. Breath sounds are present on examination but are decreased in the left chest compared to the right.

His vital signs are blood pressure 110/75, heart rate 110, respiratory rate 24, temperature 37ºC (98.6ºF), and SpO2 97% on room air. He has no other symptoms, and his vaccinations are up to date. He denies smoking, alcohol or drug use, and sexual activity. His parents are healthy with no history of connective tissue disorders or pulmonary disease.

The emergency physician orders with underlying lung conditions like common in males than females, with upright periapical and lateral x-rays asthma, pneumonia, cystic fibrosis, and an annual incidence of 4 per 100,000 of the patient’s chest, which reveal a connective tissue disorders. For example, children. moderate-sized pneumothorax of the left vaping is associated with PSP, and status Complications lung (Figure 1). asthmaticus is associated with SSP. Tension pneumothorax is a life- Case Discussion Pathophysiology threatening complication of PSP and SSP A spontaneous pneumothorax Alveolar rupture can cause air to in which increasing positing pressure occurs without an inciting event like enter the pleural space and lead to in the pleural space compromises the trauma or an iatrogenic complication. lung collapse. Increased alveolar and patient’s cardiopulmonary function. Spontaneous pneumothoraces can be transpulmonary pressures are the basis Initial signs of the disorder include subdivided based on the presence of for alveolar rupture in patients with hypotension, tachycardia, jugular venous underlying pulmonary disease. Primary PSP. Underlying pulmonary disease distension, and tracheal deviation away spontaneous pneumothoraces (PSPs) leading to weakness and the disruption from the pneumothorax side. Immediate occur in the absence of pulmonary of visceral pleural is associated with gas decompression of the pneumothorax is a disease, whereas secondary spontaneous leaking into the pleural space in children critical action to precent cardiovascular pneumothoraces (SSPs) are associated with SSP. PSP is two to four times more collapse and death.

FIGURE 1. Left-Sided Pneumothorax, Moderately Sized FIGURE 2. Pleural Line (Orange Arrows)

10 Critical Decisions in Emergency Medicine Diagnosis Pneumothorax is both a clinical FIGURE 3. Left-Sided Pigtail Catheter and radiographic diagnosis. The presentation of sudden-onset pleuritic chest pain, dyspnea, or abnormal vital signs should prompt further investigation. Clinical context, associated symptoms, and underlying disease help prompt the evaluation for SSP. Patients with signs and symptoms of a tension pneumothorax warrant immediate treatment, often before imaging studies are obtained. Plain chest radiographs are the imaging modality of choice for diagnosing pneumothorax. In such cases, a thin pleural line can typically be observed (Figure 2). In addition, there will be an absence of lung marking between the pleural line and the chest wall. Ultrasound (US) has a sensitivity of 94% and a specificity of 100% for diagnosing pneumothorax. Diagnostic findings include the absence of lung sliding and presence of a lung point. Chest CT is extremely sensitive and specific for diagnosing and evaluating nonrebreather mask and is thought to need for these treatments is determined the size of a pneumothorax. However, increase the reabsorption of air in the by surgery, the patient’s history and the exposure to ionizing radiation pleural space. Oxygen therapy should be presentation, and the success or failure and detection of radiographically paired with observation and monitoring, of other treatment modalities. present but clinically insignificant and repeat radiographs should be diagnoses should factor into imaging obtained after 6 to 12 hours. decisions. Laboratory studies are CASE RESOLUTION Invasive treatment for pneumothorax generally unhelpful for diagnosing A pigtail catheter was inserted is a continuum that begins with needle pneumothorax. into the patient’s left chest, aspiration and includes small pigtail and he was admitted for close Management catheter insertion, larger thoracostomy monitoring and repeat imaging. There is no standardized policy for (chest) tube insertion, and finally surgical The catheter was transitioned managing pneumothorax in pediatric intervention. from suction to water seal after patients. Many treatment strategies Chest tube insertion, either with 12 hours and removed after 24 are adapted from the adult literature a small pigtail catheter (Figure 3) hours, as repeat radiographs and policy guidelines. Factors that or larger thoracostomy tube, allows showed complete resolution of guide management include the size for prolonged active suction and the pneumothorax. of the pneumothorax, stability of the continuous monitoring for air leaks. If patient, any associated conditions, and no air leak is found after 12 hours of presence of an underlying pathology. continuous low suction or water seal REFERENCES 1 . Miscia ME, Lauriti G, Lisi G, Riccio A, Chiesa PL . Success is defined as positive lung re- and the patient is stable with improved Management of Spontaneous Pneumothorax in Children: A Systematic Review and Meta-Analysis . Eur expansion. Secondary outcomes of lung expansion on repeat radiographs, J Pediatr Surg 2020; 30(01): 002-012 . success can be measured by hospital the chest tube can be clamped and 2 . Glenn Yang Han Ng, Nah SA, Teoh OH, Ong LY . Primary spontaneous pneumothorax in children: admission and length of stay, future turned off. Additional observation for factors predicting recurrence and contralateral occurrence . Pediatr Surg Int. 2020 Mar;36(3):383-389 . recurrence, and ultimate need for continued stability and no signs of 3 . Meng MG, Beaunoyer M, Miron MC, Gravel J . surgical intervention. complications or re-expansion should Management and recurrence of spontaneous pneumothorax in children . Paediatr Child Health . 2020 The least-invasive treatment for be performed prior to chest tube Mar;25(2):86-92 . 4 . Skertich NJ, Sullivan GA, Madonna MB, Shah AN . a clinically stable pediatric patient removal and discharge. Vaping is a risk factor for spontaneous pneumothorax: two cases . Journal of Pediatric Surgery Case Reports, with a small or moderately sized Surgical intervention includes 50, 101305 . pneumothorax is oxygen therapy. pleurodesis, video-assisted thoracoscopic 5 . PSP Investigators et al . Conservative versus interventional treatment for spontaneous Oxygen is often administered via a surgery, and open thoracotomy; the pneumothorax . N Engl J Med 2020; 382:405-415 .

March 2021 n Volume 35 Number 3 11 Critical Cases in Orthopedics and Trauma Sternoclavicular Joint Dislocation By Jeremy Riekena, MD; and Victor Huang, MD, CAQ-SM NewYork-Presbyterian Queens Hospital Reviewed by John Kiel, DO, MPH A 23-year-old woman presents with right shoulder pain. She explains that she fell onto the affected shoulder while playing soccer and has taken ibuprofen for pain with minimal relief. A physical examination reveals tenderness over the medial aspect of her right clavicle. Her vital signs are stable, and her respiratory, cardiovascular, and neurological exams are normal.

The sternoclavicular (SC) joint is The associated risk of injury to the displaced medial clavicle, while a posterior the only joint that directly articulates subclavian vasculature, trachea, esophagus, dislocation demonstrates a depressed between the upper extremities and and brachial plexus makes posterior medial clavicle relative to the sternum.2 torso. This saddle-type structure has dislocations a true orthopedic emergency. Posterior dislocations are more subtle inherent stability and flexibility due to its As many as 30% of posterior dislocations and may be missed without a high index articulating surfaces and four ligamentous are associated with a life-threatening of suspicion and thorough evaluation. attachments: the anterior and posterior SC concomitant complication, and 3% to 4% Diagnostic imaging is recommended, as ligaments, interclavicular ligament, and of these cases result in death.2,3 the physical exam may be hindered by a 1 delayed presentation.6 costoclavicular ligament. Presentation SC joint dislocations are rare, Patients with SC dislocations Imaging comprising less than 1% of all dislocations commonly present after a traumatic event Due to overlying bony structures and and 3% of shoulder girdle injuries. Injuries with complaints of chest or shoulder pain soft tissues, standard radiographs of the to the joint can be categorized as sprains that is exacerbated when supine and with shoulder and clavicle may be inadequate (grade I), subluxations (grade II), and arm movement.4,5 It is critical to perform for evaluating the SC joint; notably, the 2 dislocations (grade III). Anterior SC thorough neurovascular, pulmonary, serendipity view, which is taken with a joint dislocations are the most common cardiac, and GI exams to assess for 40˚ cephalic tilt, can be used to perform of these injuries and can be caused by trauma to underlying structures. a more thorough assessment.4 X-ray lateral compression of the anterolateral In such cases, the SC joint findings may demonstrate widening of shoulder with force transmitted medially.2 demonstrates localized swelling with the SC joint space and displacement of Posterior SC dislocations represent about tenderness; pain may be worsened the affected clavicle above or below the 10% of SC dislocations and may occur with glenohumeral or scapulothoracic contralateral clavicle. Chest x-rays can from direct force to the medial clavicle or movement. An anterior dislocation is be useful when evaluating for associated posterolateral compression of the shoulder.3 evidenced by a prominent, anteriorly hemo- and pneumothorax. Bedside ultrasound can help expedite FIGURE 1. Axial CT, Posterior Dislocation of the Right SC Joint diagnosis and treatment. By comparing the contralateral side, ultrasonography may demonstrate the direction of the injury and reveal a posterior dislocation that would be difficult to detect based on physical findings alone. The ability of CT to illuminate the relationship between the sternum and clavicle makes it the gold standard for assessing suspected SC joint and associated thoracic injuries.5 CT angiography has the added advantage of identifying vascular injuries associated with posterior dislocations.6

12 Critical Decisions in Emergency Medicine FIGURE 2. AP View of the Right Clavicle FIGURE 3. 3D CT, Posterior Dislocation/Right SC Joint

Anterior Dislocation Posterior Dislocation • Towel clip: If the classic technique Grade I and II anterior dislocations Indications for the emergent closed is unsuccessful, the skin over the are not typically associated with reduction of a posterior dislocation clavicle should be prepared under significant morbidity, and patients include airway obstruction, stridor, sterile conditions. Using a metal can routinely be discharged without labored breathing, dysphagia, and towel clip, the medial clavicle 2,6 complications. These injuries are neurovascular compromise. Orthopedic is grasped percutaneously and surgery should be consulted regarding 2,6 sufficiently treated with analgesia, rest, placed in anterolateral traction. closed vs open reduction in the OR. immobilization with a sling or figure-of- • Buckerfield and Castle: The Thoracic and vascular surgery should eight splint, and outpatient orthopedic ipsilateral arm is adducted with also be made available, as reduction can follow-up.2,5 caudal traction while an assistant damage the surrounding neurovascular An orthopedic surgeon should be places posterior pressure on the and aerodigestive structures.5 When 3 consulted about patients with grade III performing a closed reduction, there are bilateral shoulders. 5 anterior dislocations. Closed reduction several techniques to consider: All patients with posterior SC in the emergency department or operating • Classic: The affected arm is abducted dislocations should be admitted for room (OR) may be required for these and extended with inline traction, operative management and kept for cases and can be performed within 7 and anterior traction is applied to observation, as vascular injuries may to 10 days of the inciting event. To the medial clavicle.2 occur after reduction.7 perform the reduction, the patient should be placed in the supine position with CASE RESOLUTION a sandbag or rolled-up towel between X-rays revealed that the patient’s right clavicle was inferior to the left clavicle, their scapulae. The affected arm should and CT angiography confirmed a posterior SC dislocation without associated be abducted to 90˚ and extended to 15˚ intrathoracic injuries. Orthopedic and vascular surgery were consulted, and with inline traction applied. Additional she was admitted for open reduction and internal fixation. The procedure was anterior-to-posterior pressure may need successful, and the patient was discharged after an observation period with to be applied to the medial clavicle.2,6 clavicular splinting and orthopedic follow-up. Reduced joints should be stabilized REFERENCES with a figure-of-eight brace, sling 1 . Roepke C, Kleiner M, Jhun P, Bright A, Herbert M . Chest pain bounce-back: posterior sternoclavicular dislocation . Ann 5,6 Emerg Med. 2015;66(5):559-561 . support, or a Velpeau bandage. Return 2 . Bengtzen RR, Daya MR . Shoulder . In Walls RM, Hockberger RS, Gausche-Hill, et al, eds . Rosen’s Emergency Medicine: Concepts and Clinical Practice. Vol 1 . 9th ed . Elsevier; 2018: 2014:549-569 . precautions and appropriate follow- 3 . Sewell MD, Al-Hadithy N, Le Leu A, Lambert SM . Instability of the sternoclavicular joint: current concepts in classification, treatment, and outcomes . Bone Joint J. 2013 Jun;95-B(6):721-731 . up should be clearly explained to the 4 . Balcik BJ, Monseau AJ, Krantz W . Evaluation and treatment of sternoclavicular, clavicular, and acromioclavicular injuries . patient, as up to 50% of these injuries re- Prim Care . 2013 Dec;40(4):911-923 . 5 . Deren ME, Behrens SB, Vopat BG, Blaine TA . Posterior sternoclavicular dislocations: a brief review and technique for dislocate. Pain typically resolves within 2 closed management of a rare but serious injury . Orthop Rev (Pavia) . 2014 Jan;6(1):5245 . 6 . Kiel J, Ponnarasu S, Kaiser K . Sternoclavicular joint injury . StatPearls website . Updated September 7, 2020 . Accessed to 3 weeks, and most patients can return February 8, 2021 . https://www .ncbi .nlm .nih gov/books/NBK507894. / . 7 . Burg MD . Sternoclavicular joint dislocation reduction . In: Reichman EF, ed . Reichman’s Emergency Medicine Procedures . to full physical activity after 3 months.3.5 3rd ed . McGraw Hill; 2019: 864-870

March 2021 n Volume 35 Number 3 13 A 20-year-old pregnant woman with 12 hours of persistent nausea and vomiting. The Critical ECG

Sinus rhythm, rate 60, T-wave abnormality suggestive of hypokalemia. By Amal Mattu, MD, FACEP ECG findings typically associated with hypokalemia include U waves, Dr . Mattu is a professor, vice chair, and director of the Emergency Cardiology ventricular ectopy, ST-segment depression, and T-wave flattening . In the Fellowship in the Department of author’s experience, moderate-to-severe hypokalemia often induces an unusual Emergency Medicine at the University biphasic T-wave appearance in the mid-precordial leads as noted in this of Maryland School of Medicine in Baltimore . example . The ST segment sags downward, often producing frank ST-segment depression, then rises into an upright T wave with a slightly prolonged overall QT interval .

It may be that this upright T wave is actually a U wave following an inverted T wave . Regardless, this biphasic complex is characteristic of hypokalemia and resolves with appropriate treatment . This patient’s serum potassium level was 2 .9 mEq/L (normal 3 .5-5 .3 mEq/L) . The biphasic T wave of hypokalemia should not be confused with the biphasic T wave found in Wellen syndrome, in which the initial portion of the T wave rises and the terminal portion inverts . Essentially, they are mirror images of each other .

From Mattu A, Brady W. ECGs for the Emergency Physician 2 . BMJ Publishing; 2008 . Reprinted with permission .

14 Critical Decisions in Emergency Medicine High Life Synthetic Drugs of Abuse

LESSON 6

By Aaron Trautmann, DO; Bradford E Schwartz, MD; and Anthony J. Hackett, DO, FAAEM, FACEP Dr . Trautmann is a physician in the Department of Emergency Medicine at the Carl R . Darnall Army Medical Center in Ft . Hood, Texas . Dr . Schwartz is an adjunct assistant professor of emergency medicine at the University of Maryland in Baltimore . Dr . Hackett is an assistant professor of emergency medicine at Texas A&M University in College Station . Reviewed by George Sternbach, MD, FACEP OBJECTIVES On completion of this lesson, you should be able to: CRITICAL DECISIONS 1. Identify two common classes of synthetic drugs of abuse. n What unique dangers are posed by synthetic 2. Identify the common physiologic effects of each of these cannabinoids? drug classes. n How should a patient who has abused SCs be 3. Identify the warning signs and symptoms of patients suffering the effects of synthetic drugs of abuse. assessed? 4. Discuss the management of synthetic drugs of abuse. n What treatments should be employed for 5. Describe treatment resources for patients suffering from patients who have ingested SCs? drug dependency. n What unique dangers are posed by synthetic cathinones? FROM THE EM MODEL n How should synthetic cathinone ingestions be 17 .0 Toxicologic disorders evaluated and managed? 17 1. .24 Recreational drugs

Synthetic drugs of abuse are more popular and widely available than ever before; in 2017, more than half of opioid-related deaths in the US were attributed to synthetic varieties.1 Dangerous and hard to detect, these xenobiotics can have unpredictable physiological effects. This is especially true of synthetic cannabinoids and cathinones, which can lead to a variety of potentially dangerous symptoms, ranging from tachycardia and agitation to stroke and acute coronary syndrome.

March 2021 n Volume 35 Number 3 15 CASE PRESENTATIONS ■ CASE ONE from the restraints and seems to have Paramedics were able to administer 5 mg of droperidol and 5 mg of A 48-year-old woman arrives via bitten her tongue in the struggle, as ambulance with agitation and altered evidenced by profuse bleeding from midazolam intramuscularly, and mental status (AMS). A neighbor her mouth. the patient was transferred to the called 911 after seeing her pounding stretcher, where physical restraints ■ CASE TWO on car windows in the parking lot were placed. of her apartment complex while A 24-year-old man presents Upon arrival, he is appropriately screaming incoherently about being via ambulance as a “danger to the sedated and maintaining his airway. “chased by cats.” EMS notes finding public.” He is agitated, hallucinating, Intravenous (IV) access is established, “incense paraphernalia” at the scene. and acting erratically. Paramedics and the patient is placed on a cardiac Once the patient has been were called to the scene after a monitor. He is tachycardic with vital chemically and physically restrained, bystander found him wandering down signs that include blood pressure her vital signs are obtained: blood the middle of the highway naked, 180/90, respiratory rate 145, rectal pressure 150/90, heart rate 150, covered in blood, and waving a temperature 39.4˚C (103˚F), and

respiratory rate 25, and SpO2 98% knife. When EMS and police arrived SpO2 98%. The physical exam is on room air. She has prominent on scene, the patient refused to significant for lacerations and dried bruising over both wrists and ankles follow police orders and was tased. blood across his forearms and thighs.

CRITICAL DECISION being discovered by German authorities. CRITICAL DECISION What unique dangers Much to the dismay of law enforcement, How should a patient who has another variant (JWH-073) rapidly took are posed by synthetic its place. The subsequent development of abused SCs be assessed? cannabinoids? second- and third-generation SCs, such as The effects of SCs differ from those Synthetic cannabinoids (SCs) AM-2201 and XLR-11, soon followed. of naturally occurring marijuana. generate much more potent effects Most recently, fourth-generation While marijuana use typically causes than their natural counterparts. “indazole” SCs have emerged. These tachycardia, conjunctival irritation, and These exacerbated reactions are often agents use an indazole ring containing sometimes slurred speech, the effects of attributed to the direct binding of a fused benzene and pyrene ring — a SCs can be more alarming and variable CB1 (central cannabinoid) and CB2 modification of the indole backbone (Table 1). Patients who have used SCs 3 (peripheral cannabinoid) receptors, found in earlier generations. may present with severe mood changes which have 5 and 10 times the binding Largely due to the variety of chemical (eg, euphoria, anxiety, agitation), 1 affinity, respectively, of marijuana. By compounds that can be synthesized cognition changes (eg, psychosis, slightly altering the chemical structure of and the quandary it creates for law delusions, confusion), and physiologic enforcement, SC variants have become the SC compound, clandestine chemists effects (eg, tachycardia, hypertension, have generated a range of similar particularly difficult to track and vomiting, and seizures).4 chemicals that can enumerate a variety criminalize. In July of 2012, the federal Small modifications in the chemical of different clinical symptoms. government took stricter measures to structure of the cannabinoid during Many users believe SCs (or “synthetic outlaw SC use by passing the Synthetic synthesis can produce drastic differences marijuana”) produce a legal high, as Drug Abuse Prevention Act, which in its clinical effects; for example, while these substances are often packaged, permanently placed 26 synthetic one package of “spice” may produce rebranded, and sold as nonillicit items cannabinoids and cathinones into Schedule agitation, delirium, and tachycardia, like incense. Additionally, the constantly I of the Controlled Substances Act. evolving chemical structure of these Often marketed as incense or another may cause lethargy and 5 compounds makes it difficult for them potpourri and labeled “not for human vomiting. Two users smoking from to be identified by urine drug screening consumption,” SCs can commonly be the same package may even experience assays, thus providing users a way to found in head shops and gas stations different clinical effects. The production avoid detection.2 (Figure 1). The burgeoning problem of SCs involves dissolving the substance Since initially hitting the market of these substances is evidenced by in a solvent — often acetone — and as “spice” in the UK and Europe and increased calls to the poison center: In allowing the solution to dry on plant “K2” in the US, the popularity of SCs 2015, the number of these calls related material. The amount of solvent left on has exploded. Although JWH-018 to SCs over a period of three months the plant material is highly variable, a was the first compound to be widely was four times that of all calls placed to factor that causes significant disparities abused, it was quickly outlawed after poison control in 2014. in the potencies of each product.6

16 Critical Decisions in Emergency Medicine Additionally, SCs contain a variety sympathomimetic, anticholinergic, of active metabolites that may have cholinergic, etc). SC abuse is often TABLE 1. Signs and Symptoms other, higher-affinity binding properties strongly suggested by the patient’s history of SC and Cathinone Toxicity to the CB receptors. Although agitation, or found paraphernalia. In addition Physical exam • Tremor tachycardia, and sympathomimetic to the dangers intrinsic to these drugs findings • Cold extremities effects dominate SC generations one and their variable potency, SCs are • Dry mouth through three, fourth-generation SCs often adulterated with other dangerous • Dry skin often have central-depressant effects substances. In March 2018, there was an • Conjunctival injection and can cause bradycardia. Possible outbreak of coagulopathies noted in SC • Nystagmus mechanisms for the cardiotoxicity and users due to the adulteration of the drug • Sweating neurotoxicity of SCs include binding to with brodifacoum, a potent anticoagulant • Dilated pupils cardiac potassium channels and central ingredient found in rat poison. In an early • Mydriasis serotonergic and dopaminergic activity, case series of 34 patients who ingested • Hypertonia respectively.7,8 these laced SCs, the most common • Myoclonus Fourth-generation indazole SCs manifestations included mucocutaneous • Muscle jerking were recently reported to have caused bleeding, hematuria, and bruising.11 • Shortness of breath Vital signs • Hyperpyrexia an outbreak of “zombie” intoxications Adulteration with brodifacoum is • Hypertension in New York City characterized by a not unique to this drug class; it was • Tachycardia blank stare, groaning, and purposeless reported as early as 1997 in a 21-year- • Tachypnea gestures. The culprit was a synthetic old man who developed a year-long Lab findings • Metabolic acidosis cannabinoid called “AK 47 Karat coagulopathy after smoking laced • Hypokalemia Gold,” which was found to contain a marijuana.12 The rationale behind • Hyponatremia fourth-generation SC known as AMB- the adulteration is unclear, but it is • Hypermagnesemia FUBINACA, a parent compound that likely an attempt to prolong the high; • Elevated creatinine kinase was developed by Pfizer for use as a additionally, superwarfarin may act as a Cardiovascular • Chest pain novel analgesic. CB-receptor modulator. • Palpitations A similar compound was • Ventricular described in Georgia in 2013, and in CRITICAL DECISION tachycardia 2020, another fourth-generation SC What treatments should be • Ventricular (5F-MDMB-PINACA) was discovered employed for patients who fibrillation as an adulterant in heroin.9 The Hallucinations 11% toxidrome reported in this case is of have ingested SCs? Delusions 11% clinical importance, as these patients There are no antidotes for SC Seizures 4% received naloxone and developed a ingestion; the management of these Headaches 3% paradoxical syndrome of anticholinergic cases is supportive. Patients with symptoms and severe agitation. Analysis unexplained bleeding abnormalities after of the confiscated drugs revealed suspected SC use should be evaluated with sympathomimetic, agitated states. that the heroin was laced with the for coagulopathy due to the adulterant Rarely, a more aggressive sedation aforementioned SC.10 brodifacoum: a long-acting, vitamin regimen that warrants propofol and The primary assessment of patients K-dependent antagonist.13 dexmedetomidine may be required; with suspected SC intoxication should Benzodiazepines are useful for the in such cases, intubation should be include a thorough history and evaluation treatment of anxiety and agitation and considered. Hyperthermia can be treated for specific clinical toxidromes (eg, can be used to resolve seizures associated with evaporative cooling; there is no role

FIGURE 1. Common Synthetic Cannabinoid Packaging

March 2021 n Volume 35 Number 3 17 FIGURE 2. Structural Similarity of Cathinone and Amphetamine

Phenylethylamine Amphetamine Cathinone

for antipyretic agents, as the source of predominantly found in East Africa, has produce unpredictable results.16 Some drug-induced hyperthermia is unrelated been used for its stimulant properties of the earliest synthetic cathinones to the hypothalamic set point. for centuries.15 included mephedrone, methylone, Rhabdomyolysis may occur and Cathinone derivatives have been and 3,4-methylenedioxypyrovalerone is treated supportively with aggressive developed into numerous illicit drugs, (MDPV). Like many synthetic drugs, IV hydration. Seizures should be resulting in an ever-evolving milieu of these substances initially emerged managed with benzodiazepines as a novel substances that are difficult to as either experimental medicinal first-line treatment, and those who detect on drug screening. Cathinones are compounds or obscure synthetic require second-line medications should actually part of a larger family of products in the early- to mid-20th receive phenobarbital. Sodium channel- substitu­ted phenylethylamines. Mescaline century and were later rediscovered.17 blocking agents like phenytoin should (from the peyote cactus) is an example Although their mechanism is not be avoided due to their potential for of a currently abused natural substituted completely understood, model cathinones worsening complications associated with phenylethylamine, and synthetic like methylone and mephedrone are polypharmacy overdose. substituted phenylethylamines include monoamine oxidase inhibitors, which Discharge Decisions well-known drugs like ampheta­mine, likely modulate the reuptake of biogenic methamphetamine, and 3,4-methylene­ amines and produce various mixtures Most patients can be discharged dioxy­methamphetamine (MDMA). of serotonergic and stimulant effects. As once symptoms resolve, typically Although it is difficult to catalog the with other amphetamines, the effects of within 6 hours of arrival. Patients with present number of cathinone derivatives the drug can be somewhat predicted by more complex symptoms may require currently in use, a 2018 analysis the substitution of the phenylethylamine admission. Emergency clinicians should documented at least 30 different itself.18 also consider consulting the poison variants, and a more recent DEA report In contrast to the typical cathinone, control center (1-800-222-1222), identified six new cathinone substances MDPV use tends to result in more which can offer valuable guidance for in 2019 alone. These substances have adrenergic effects, causing experiences managing these cases. many street names, including “Flakka,” more closely related to cocaine abuse; CRITICAL DECISION “Meow Meow,” “Vanilla Sky,” and in fact, MDPV is estimated to be about 19 What unique dangers “Bloom” — each with different 10 times more powerful than cocaine. pharmacokinetic properties that can Given their structural similarity to other are posed by synthetic cathinones? Synthetic cathinones have burst onto the drug scene in the past decade as a new “legal” designer drug class. These products are chemically related to their parent compound, cathinone, n SCs can cause various clinical symptoms, the most common being which is structurally similar to tachycardia and agitation; less-common symptoms include seizures, kidney amphetamine with one exception: injury, and even stroke and acute coronary syndrome. Synthetic cathinones contain a ketone n Synthetic cathinones like methedrone and methylone cause agitation, sympathomimetic symptoms, and various serotonergic effects. moiety (Figure 2).14 Cathinone is a n Cathinones like MDPV, N-ethylpentylone, and eutylone have effects similar phenylethylamine alkaloid that was to cocaine and can cause significant, dangerous psychiatric symptoms. originally obtained from the leaves n The management of patients who have ingested synthetic drugs of abuse is of the Catha Edulis plant, also called largely supportive. “qat” or “khat.” The plant, which is

18 Critical Decisions in Emergency Medicine forms of abused stimulants, synthetic cathinones are often used in illicit drug TABLE 2. Common Adverse Neuropsychiatric Effects of SC and manufacturing to dilute the product. Cathinone Intoxication In more recent years, two predominant Estimated prevalence Estimated prevalence of formulations have become abused — Psychiatric symptoms of SC reactions synthetic cathinone reactions N-ethylpentylone (MDEVP, bk-EPDP, Agitation/irritability 25% 40% bk-EBDP) and eutylone (bk-EBDB) — Lethargy 14% 7% both of which were initially discovered Altered mental status 12% 13% on the illicit market in 2014. Hallucinations 11% 18% Like MDPV, the effects of Delusions 11% 18% N-ethylpentylone are similar to those Seizures 4% 3% of cocaine; the drug is sometimes Headaches 3% 3% misrepresented as MDMA in club culture.20 Although drugs like methylone and mephedrone are designated illicit production techniques. Tragic spectrum of symptoms, ranging from consequences from the contamination Schedule I substances, many novel minor complaints like nausea, vomiting, of methcathinone resulted in a agents and analogues are advertised and hypertension, and hyperthermia to more Parkinsonian syndrome that was sold as “plant foods” or “bath salts” serious complications, including renal described in Europe in 2008. These with explicit warnings that they are not insufficiency, rhabdomyolysis, significant patients demonstrated stereotypical for human consumption. acidosis, seizures, acute psychosis, and Parkinsonian movements that were It should be noted that not all suicidal or homicidal ideation (Table 2). refractory to traditional treatments.22 synthetic cathinones are illicit. One of The initial assessment of these patients Astute researchers recognized that the most widespread synthetic cathinone should be focused on addressing any the unique symptoms that developed in pharmaceuticals is bupropion, which signs of hemodynamic instability these patients mimicked those seen in has a similar structure to MDPV and (eg, hypotension, significant hypertension, cases of heavy metal toxicity, specifically other phenylethylamine derivatives. tachycardia, and hyperpyrexia). Changes manganese toxicity in welders. Thus, Due to these similarities, bupropion in temperature have been found to be dose this syndrome was determined to be has recently found a niche as drug of dependent and are associated with the due to the toxic buildup of manganese abuse that can be insufflated and even chronicity of use. in the synthetic product rather than injected by users. As expected of other Acute cathinone use primarily causes the cathinone itself. Unfortunately, the cathinones, its stimulant effects have led hyperthermia, agitation, and adrenergic neurotoxicity of the contaminating some to call it “poor man’s cocaine.” symptoms. A thorough neurologic exam manganese was likely exacerbated by the Unlike the other nonpharmaceutical should include an evaluation for clonus, a cathinone itself.23 cathinones, bupropion can lead to finding that suggests serotonin syndrome. seizures and QTc prolongation. CRITICAL DECISION In a potentially undifferentiated toxic ingestion, it is important to obtain an ECG Arrhythmias associated with overdose How should synthetic can be difficult to treat with traditional early to evaluate the QRS and QT intervals means.21 cathinone ingestions be for evidence of arrhythmia and ischemia. Much like the adulterants found evaluated and managed? A detailed laboratory evaluation should be in SC products, cathinones can also Patients who have ingested synthetic undertaken to look for end-organ damage, contain unwanted byproducts of cathinones can present with a wide evidence of rhabdomyolysis, and other possible ingestions. Patient Management Supportive management is the main treatment for synthetic cathinone ingestion. Benzodiazepines should be used for acute agitation secondary to n Believing the same clinical effects apply to all patients who have abused SCs; a sympathetic surge from overdose these presentations vary, even across the same batch of drug. and are also the first-line treatment for n Failing to consider coagulopathy due to adulteration with brodifacoum or patients with acute seizures. Second-line other anticoagulants. antiepileptic agents should be employed n Neglecting to consider synthetic cathinones in any “club drug” overdose. It is for refractory seizures; however, important to remember that these substances are popular party drugs. phenytoin should be avoided due to n Failing to recognize that synthetic drugs of abuse can be used to “cut” other the increased risk of sodium-channel substances with similar effects, thus obscuring the parent drug’s toxidrome. blockade it poses in patients with other possible ingestions.

March 2021 n Volume 35 Number 3 19 CASE RESOLUTIONS ■ CASE ONE a PTT level above 50, an INR of 6, and for continued sedation. His lab tests The agitated woman required a hemoglobin of 10. The emergency were remarkable for leukocytosis, a additional sedation with 10 mg of physician ordered 10 units of IV vitamin CK of 47,500, and a lactate of 3.2. midazolam before she became calm. K and consulted poison control, which The patient was given 2 L of lactated An ECG and basic lab tests, including recommended treating the patient with Ringer’s solution, which improved his a CBC, CK, and a basic metabolic prothrombin complex concentrate. She CK and lactate levels, and cooled via panel, were ordered. Aggressive IV was admitted to the hospital under evaporative measures. fluid hydration was initiated using telemetry status and discharged 2 days His vital signs improved, and 3 L of lactated Ringer’s solution, and later after her hemoglobin, INR, and his ECG was unremarkable. A drug the patient’s CK level decreased from creatinine level stabilized. She was screen was negative for all tested 15,000 to 10,000. Her creatinine referred to an outpatient substance abuse substances, including alcohol. He level was 0.5, and no acute kidney program. was admitted to the intermediate injury was noted. care unit, where he remained Based on her profuse bleeding ■ CASE TWO hemodynamically stable and showed and scattered bruising, a coagulation The man suspected of synthetic improvement in his mental status via workup was ordered, which revealed cathinone abuse received ziprasidone a psychiatric evaluation.

Atypical antipsychotic agents Summary synthetic cannabinoid, 5F-MDMB-PINACA: a case series . Clin Pract Cases Emerg Med . 2020;4(2):121-125 . can also be used to manage agitation Synthetic drugs of abuse are more 12 . Kelkar AH, Smith NA, Martial A, Moole H, Tarantino MD, Roberts JC . An outbreak of synthetic cannabinoid– and have been found to be effective widely available than ever before. These associated coagulopathy in Illinois . N Engl J Med. 2018 for treating acute psychosis related xenobiotics are dangerous, hard to Sep;379(13):1216-1223 . 13 . La Rosa FG, Clarke SH, Lefkowitz JB . Brodifacoum to the ingestion of cathinones and detect, and have unpredictable effects on intoxication with marijuana smoking . Arch Pathol Lab other substituted phenylethylamines. Med . 1997 Jan;121(1):67-69 . patient physiology. Due to the explosion 14 . Gunja N, Coggins A, Bidny S . Management of Hyperpyrexia is a concern that should of xenobiotic abuse, emergency intentional superwarfarin poisoning with long-term vitamin K and brodifacoum levels . Clin Toxicol (Phila) . be managed with cooling measures physicians must have an understanding 2011 Jun;49(5):385-390 . as opposed to antipyretic agents. 15 . Majchrzak M, Celiński R, Kuś P, Kowalska T, Sajewicz M . of the effects and presenting symptoms The newest cathinone derivatives as designer drugs: Aggressive fluid resuscitation should be these potential lethal drugs. an analytical and toxicological review . Forensic Toxicol . 2017 Sep;36(1):33-50 . employed in cases of rhabdomyolysis 16 . Khullar V, Jain A, Sattari M . Emergence of new classes from agitated delirium secondary to REFERENCES of recreational drugs—synthetic cannabinoids and cathinones . J Gen Intern Med . 2014 Aug;29(8):1200- overdose. 1 . UNODC Research . Executive summary: conclusions 1204 . and policy implications . World Drug Report 2019 . 17 . Drug Enforcement Administration . 1-(1,3-Benzodioxol- A widened QRS detected on ECG is https://wdr .unodc .org/wdr2019/prelaunch/WDR19_ 5-yl)-2-(ethylamino)butan-1-one (Eutylone) . DEA likely due to a mixed ingestion and may Booklet_1_EXECUTIVE_SUMMARY . Accessed 2 Diversion Control Division website . https://www . June 2020 . deadiversion .usdoj .gov/drug_chem_info/eutylone .pdf . not be solely blamed on the cathinone. 2 . Richardson JB, St . Vil C, Wish E, Cooper C . “On Published 2020 . Accessed May 25, 2020 . papers”: perceptions of synthetic cannabinoid use 18 . German CL, Fleckenstein AE, Hanson GR . Bath salts A widened QRS or QT interval can be among black males under criminal justice supervision . and synthetic cathinones: an emerging designer drug treated with sodium bicarbonate and Health Justice . 2017 Jan;4(1) . phenomenon . Life Sci . 2014 Feb;97(1):2-8 . 3 . Lapoint JM . Cannabinoids . In: Nelson LS, Howland 19 . Gregg RA, Rawls SM . Behavioral pharmacology MA, Lewin NA, et al, eds . Goldfrank’s Toxicologic of designer cathinones: a review of the preclinical magnesium, respectively. th emergencies . 11 edition . McGraw-Hill; 2019: 1111- literature . Life Sci . 2014 Feb;97(1):27-30 . 1123 . 20 . Baumann MH, Partilla JS, Lehner KR, et al . Powerful Discharge Decisions 4 . Mills B, Yepes A, Nugent K . Synthetic cannabinoids . cocaine-like actions of 3,4-methylenedioxypyrovalerone Given the wide variety of synthetic Am J Med Sci . 2015;350(1):59-62 . (MDPV), a principal constituent of psychoactive 5 . Phillips J, Lim F, Hsu R . The emerging threat ‘bath salts’ products . Neuropsychopharmacol . 2013 cathinones available, the effects of of synthetic cannabinoids . Nurs Manage . 2017 Mar;38(4):552-562 . Mar;48(3):22-30 . 21 . Expert Committee on Drug Dependence . Critical these substances are variable and can 6 . Mills B, Yepes A, Nugent K . Synthetic cannabinoids . review report: N-ethylnorpentylone . World Health potentially last for days. Observation Am J Med Sci . 2015;350(1):59-62 . Organization website . https://www .who .int/medicines/ 7 . Trecki J, Gerona RR, Schwartz MD . Synthetic access/controlled-substances/N-Ethylnorpentylone .pdf . in the emergency department is cannabinoid–related illnesses and deaths . N Engl J Published 2018 . Accessed 2020 . Med . 2015 Jul;373(2):103-107 . 22 . Stepens A, Logina , Liguts V, Aldinš P, Ekštenia reasonable for minor symptoms. If the 8 . Wiley JL, Lefever TW, Marusich JA, et al . Evaluation of I, Platkājis A, et al . A parkinsonian syndrome in patient shows improvement in mental first generation synthetic cannabinoids on binding at methcathinone users and the role of manganese . non-cannabinoid receptors and in a battery of in vivo N Engl J Med. 2008 Mar;358(10):1009-1017 . status and is not deemed a danger assays in mice . Neuropharmacology . 2016 Nov;110(Pt 23 . Stall N, Godwin J, Juurlink D . Bupropion abuse and A):143-153 . overdose . CMAJ . 2014 Sep;186(13):1015 . to themselves or others, discharge 9 . Rominger A, Cumming P, Xiong G, Koller G . Effects may be reasonable. Admission to the of acute detoxification of the herbal blend ‘spice gold’ on dopamine D2/3 receptor availability: a [F-18] hospital is necessary for those with fallypride PET study . Eur Neuropsychopharmacol . 2013 Feb;23(11):1606-1610 . signs of more significant symptoms, 10 . Schwartz MD, Trecki J, Edison LA, Steck AR, Arnold including renal insufficiency, seizures, JK, Gerona RR . A common source outbreak of severe delirium associated with exposure to the novel rhabdomyolysis, serotonin syndrome, synthetic cannabinoid ADB-PINACA. J Emerg Med . 2015 May;48(5):573-580 . acute psychosis, and suicidal or 11 . Ershad M, Dela Cruz M, Mostafa A, Khalid MM, Arnold homicidal ideation. R, Hamilton R . Heroin adulterated with the novel

20 Critical Decisions in Emergency Medicine The LLSA Literature Review Bag-Valve-Mask Ventilation By Rmaah Memon, MD; and Andrew Eyre, MD, MHPEd Harvard-Affiliated Emergency Medicine Residency, Boston, Massachusetts

Casey JD, Janz DR, Russell DW, et al; PreVent Investigators and the Pragmatic Critical Care Research Group. Bag-mask ventilation during tracheal intubation of critically ill adults. N Engl J Med. 2019 Feb 28;380(9):811-821.

Hypoxemia during tracheal intubation is a common but serious complication that can lead to poor patient outcomes and even death. During rapid-sequence intubation, there is typically a delay of 45 to 90 seconds between medication administration and laryngoscopy. The use of bag-valve-mask (BVM) ventilation after induction and prior to laryngoscopy has remained controversial, and the risks of aspiration associated with this approach are widely debated.

The multicenter PreVent trial For participants in the was 4.7%, and the difference in studied adults (18+ years) undergoing “no-ventilation” group, BVM lowest oxygen saturation was greater induction and tracheal intubation in ventilation could be used only after for participants with a lower oxygen participating ICUs. Patients were split a failed attempt at laryngoscopy as a saturation at induction (P=0.01). into two groups: those who received treatment for hypoxemia. Noninvasive In addition, 10.9% of patients ventilation with a BVM device ventilation was not allowed in either in the BVM ventilation group and between induction and laryngoscopy, group during the interval between 22.8% in the no-ventilation group had and those who received none. induction and intubation; however, an oxygen saturation less than 80%; Researchers focused on two preoxygenation using any method, furthermore, 29.5% of those in the outcomes: the lowest oxygen including noninvasive ventilation, BVM ventilation group and 40.1% of saturation observed during the interval was permitted prior to induction in those in the no-ventilation cohort had an oxygen saturation less than 90%. between induction and 2 minutes both groups. There was no significant difference in after tracheal intubation, and the The two groups were analyzed the presence of new opacities on chest incidence of hypoxemia (oxygen using an intention-to-treat x-ray in the 48 hours after intubation saturation <80%) during the period comparison. The median lowest in either group and no significant between induction and 2 minutes oxygen saturation was 96% in the difference when looking at operator- after intubation. Additional outcomes BVM ventilation cohort and 93% reported aspiration. included new opacities on chest x-ray in the no-ventilation group. The Overall, the study illustrates within 48 hours after intubation and mean difference in the lowest oxygen the benefit of BVM ventilation for operator-reported aspiration events. saturation between the two groups preventing hypoxemia in patients undergoing tracheal intubation. A KEY POINTS larger study population is needed to fully evaluate for operator-reported n Critically ill adults undergoing intubation who receive BVM ventilation after aspiration, as the incidence was low in induction appear to have higher oxygen saturations and lower rates of severe hypoxemia than those who do not. this trial. Further research is needed before these results can be generalized n The incidence of operator-reported aspiration was lower in the BVM ventilation group than in the no-ventilation group. to patients in the emergency department.

Critical Decisions in Emergency Medicine’s series of LLSA reviews features articles from ABEM’s 2021 Lifelong Learning and Self-Assessment Reading List . Available online at acep .org/moc/llsa and on the ABEM website .

March 2021 n Volume 35 Number 3 21 Reviewed by Lynn Roppolo, MD, FACEP

Qualified, paid subscribers toCritical Decisions in Emergency Medicine may receive CME certificates for up to 5 ACEP Category I credits, 5AMA PRA Category 1 CME Credits™, and 5 AOA Category 2-B credits for completing this activity in its entirety. Submit your answers online at acep .org/cdem; a score of 75% or better QUESTIONS is required. You may receive credit for completing the CME activity any time within 3 years of its publication date. Answers to this month’s questions will be published in next month’s issue.

While waiting in the triage area, a 15-year-old girl Which life-threatening medical condition can 1 threatens the staff with profanity and physical 5 manifest signs of psychosis? violence. Security is held up in another part of the A . Alcohol poisoning hospital and is unable to attend immediately. What B . Attention deficit disorder should be your first step? C . Hyperglycemia A . Administer oral olanzapine D . Hypoxia B . Establish authority by engaging her with similar A 14-year-old girl presents with thoughts of “street” language hurting herself following a fight at home. She C . Obtain a detailed history, including any gang 6 confides that she has been having suicidal affiliations thoughts for several months and has also been D . Use de-escalation techniques, speak calmly, and cutting herself with a razor blade. After a maintain a safe distance from the patient discussion with the psychiatrist, you recommend What is a criterion for inpatient psychiatric inpatient psychiatric admission, but her father 2 management? refuses and threatens to take her home. What is A . All acute psychiatric conditions in children warrant your next best step? inpatient admission A . Allow the patient to go home after instructing B . Consent of the parent or guardian her to return if suicidal thoughts persist C . Failure to establish a safety plan B . Consult local Child Protective Services D . General feelings of sadness C . Enter a mental capacity note in the patient’s chart and refuse to discharge What measure should be taken when discharging a D . Prescribe an antidepressant and discharge her 3 pediatric patient with suicidal ideation? A . Consult Child Protective Services so the agency can Which life-threatening complication of provide ongoing monitoring 7 antipsychotic use is characterized by severe B . Counsel parents and caregivers to restrict the child’s rigidity? access to instruments that can be used for self-harm A . Cardiac arrhythmia C . Encourage the child to return to the emergency B . Neuroleptic malignant syndrome department if their “sad thoughts” persist C . Overdose D . No pediatric patient with suicidal ideation should be D . Serotonin syndrome discharged What potential side effect should be considered A 17-year-old boy with a history of schizophrenia is 8 when prescribing a first- or second-generation 4 brought in by his parents after rambling nonsensically antipsychotic? at home. In the emergency department, he continues to A . CNS depression yell and appears frantic. His parents report that he has B . Hyperventilation had similar episodes in the past. He is otherwise healthy C . Paradoxical reactions and is compliant with his daily dose of olanzapine. He is D . Worsening psychosis alert and well groomed, and his vital signs and physical Which factor places an adolescent at greatest exam are normal. What is the best medication to risk for suicide? administer next? 9 A . Family history of suicide A . Intramuscular lorazepam B . History of depression B . Intramuscular risperidone C . Marijuana use C . Oral benztropine D . Previous suicide attempt D . Oral olanzapine

22 Critical Decisions in Emergency Medicine Which action is appropriate when managing a Which treatment should be avoided in patients 10 patient with physical restraints? 15 with SC ingestion? A . Ensure that at least three trained staff A . Benzodiazepines members are available to help B . Dexmedetomidine B . Ensure that the patient’s head is supported C . Phenytoin by a pillow D . Propofol C . Monitor the patient in 30- to 45-minute What is the first-line agent for managing the blood intervals pressure of an agitated, hypertensive patient with D . Place the patient in the supine position to 16 an acute ingestion of a synthetic cathinone? reduce the likelihood of airway obstruction A . Hydralazine 10 mg IV Which effect of SC use can be predicted by the B . Metoprolol 10 mg IV 11 substance’s chemical structure? C . Midazolam 5 mg IV A . Psychosis is determined by the drug’s ability D . Therapy is unnecessary if the patient has no chest to bind to the CB1 and CB2 receptors pain B . SCs have variable effects that can be EMS responds to a 24-year-old man who appears to unpredictable based on each formulation be in a state of excited delirium. He is aggressive and user 17 and fighting with the police officers on scene. What C . Sedation is the most common effect is the best way to manage his agitation? D . The effects of these drugs are similar to those A . Lorazepam 4 mg IV of marijuana B . Midazolam 10 mg IM What is the most common method of SC C . Use physical four-point restraints to secure the 12 ingestion? patient to the gurney during transport to the A . Any plant-like material can be used hospital B . Marijuana bud D . Ziprasidone 10 mg IM C . Package labeled “Scooby Snacks” A patient presents with paranoia after using D . Powder that can be snorted or smoked 18 “bath salts.” What would you expect to see on What unique complication of recreational his drug screen? 13 bupropion overdose can be particularly A . It is impossible to predict the results difficult to treat? B . Negative results A . Acute urinary retention C . Positive for cannabinoids B . QRS and QTc prolongation that cannot be D . Positive for cocaine attributed to sodium-channel blockade What is the natural origin of cathinone? C . Severe aggression and agitation with acute A . Castor bean psychosis 19 B . Khat plant D . Significant vomiting and hemorrhagic C . Peyote cactus gastritis D . Psilocybin mushrooms What change in the chemical structure of A 27-year-old man presents after smoking an synthetic cathinones can cause sympathomimetic 14 unknown substance. He is hypotensive and peripheral effects like tachycardia and 20 vomiting blood. What is the likely etiology of hypertension? his symptoms? A . Methylation on the benzene ring A . Bath salts B . The addition of a ketone group B . MDMA adulterated with N-ethylpentalone C . The addition of a methyl group to the C . Opioids adulterated with fentantyl terminal amine portion of the structure D . SCs adulterated with brodifacoum D . The addition of a sulfur group anticoagulants

ANSWER KEY FOR FEBRUARY 2021, VOLUME 35, NUMBER 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 C D B B A A B B C B D C B C B C C C D D

March 2021 n Volume 35 Number 3 23 Drug Box Tox Box

DELAFLOXACIN CYCLOPEPTIDE MUSHROOMS By Frank LoVecchio, DO, MPH, FACEP By Christian A. Tomaszewski, MD, MS, MBA, FACEP Valleywise, University of Arizona, and Creighton College of Medicine, University of California, San Diego Phoenix, Arizona Cyclopeptide-containing mushrooms are found Delafloxacin is an intravenous and oral fluoroquinolone indicated throughout the US, mainly in northern bicoastal regions. for the treatment of acute skin and skin-structure infections caused Thousands of exposures are reported annually, usually by susceptible bacteria. It is the only oral antibiotic with in-vitro due to mushroom misidentification, some of which may activity against methicillin-resistant Staphylococcus aureus (MRSA), result in liver failure or death. Late GI symptoms can be Pseudomonas aeruginosa, and most Gram-positive pathogens, followed by terminal hepatic failure. including quinolone-resistant strains. Pathophysiology

Mechanism of Action • Species — Amanita phalloides, A. virosa, A. verna Inhibition of both bacterial topoisomerase IV and DNA gyrase — Galerina species (topoisomerase II) enzymes, which are required for bacterial DNA — Lepiota species replication, transcription, repair, and recombination • Amatoxins (cyclic peptides) Susceptible Organisms — Heat stable Gram-positive organisms: S. aureus (including MRSA and — High oral bioavailability methicillin-susceptible isolates), S. haemolyticus, S. lugdunensis, — Suppress protein synthesis by inhibiting RNA Streptococcus agalactiae, S. anginosus group (including S. anginosus, polymerase II S. intermedius, and S. constellatus), S. pyogenes, and Enterococcus Clinical Effects faecalis. • Phase I: (5-24 hours post ingestion) Gram-negative organisms: Escherichia coli, Enterobacter cloacae, — GI: diarrhea Klebsiella pneumoniae, and P. aeruginosa. — Nausea and vomiting Adult Dosing • Phase II: (12-36 hours post ingestion) • 300 mg every 12 hours over 60 minutes via IV infusion for 5 to — Liver injury (LFTs↑, INR↑) 14 days, OR • Phase III: (2-6 days post ingestion) • 300 mg every 12 hours over 60 minutes via IV infusion, then switch — Hypoglycemia to an oral 450-mg delafloxacin tablet every 12 hours for a total of — Jaundice 5 to 14 days, OR — Kidney failure • 450-mg tablet given orally every 12 hours for a total of 5 to 14 days — Hepatic coma Dosage adjustment is required for patients with severe renal Treatment 2 impairment (eGFR 15-29 mL/min/1.73m ). Delafloxacin is not • Decontamination with oral activated charcoal recommended in patients with end-stage renal disease. (1 gm/kg) to absorb amatoxins Precautions • Fluid and electrolyte repletion The most common side effects are nausea, vomiting, headache, • No proven antidote and diarrhea. Serious adverse reactions include tendonitis, tendon — N-acetylcysteine 150 mg/kg IV — potential rupture, peripheral neuropathy, CNS alteration, and seizures. hepatic protection Fluoroquinolones may exacerbate muscle weakness in patients — Benzylpenicillin 0.5-1.0 MU/kg/day IV — no with myasthenia gravis and should be avoided. As with other consistent data fluoroquinolones, QTc prolongation andClostridium difficile- — Silymarin (milk thistle extract) — investigational associated diarrhea may occur. agent Pregnancy and lactation risks are not well studied. • Liver transplantation if prognosis is dire