Toxicology

AEM Early Access 14: Cannabis and Mental Health ED Visits in Colorado

Welcome to the fourteenth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

  A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

DISCUSSING:(Click title for open access through may 31, 2018)

Mental Health-Related Emergency Department Visits Associated with Cannabis in Colorado. Katelyn E. Hall MPH, Andrew A. Monte MD, Tae Chang, Jacob Fox, Cody Brevik, Daniel I. Vigil MD, MPH,  Mike Van Dyke PhD, CIH,  Katherine A. James PhD, MSPH. Academic Emergency Medicine, 2018.

LISTEN NOW: AUTHOR INTERVIEW

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Andrew A. Monte, MD

Associate Professor, Departments of Emergency Medicine & PharmaceuticaLSciences
University of Colorado Denver-Anschutz Medical Center Aurora, CO and Rocky Mountain Poison & Drug Center
Denver Health & Hospital Authority
Denver, CO

ARTICLE SUMMARY: 

Objectives:
Across the United States, the liberalization of marijuana use has resulted in a rapid increase in the social acceptability of its use.  Colorado has been at the forefront of marijuana legalization, allowing recreational use beginning in 2014.  Since then, Colorado has positioned itself as the optimal environment to study health-related impacts from marijuana use.  Cannabis use is well-known to exacerbate mental health illness such as schizophrenia, mood disorders, anxiety, and depression.  Since legalization in Colorado, increased healthcare utilization has been associated with acute and chronic marijuana use.  It is currently unknown if cannabis use is associated with increased ED visits in patients with mental illness.  The primary objective of this study was to determine the prevalence ratios of mental health diagnoses among ED visits with cannabis-associated diagnosis compared to those without cannabis-associated diagnoses in Colorado.

Methods:
The study was cross-sectional in design, with discharge diagnostic codes collected from Colorado emergency departments from 2012 to 2014.  Diagnosis codes identified visits associated with both mental health conditions and cannabis.  Prevalence ratios of mental health ED discharges were calculated to compare cannabis-associated visits to those without cannabis.  Rates of mental health and cannabis-associated ED discharges were examined of the study period.  

Results:
State-wide data demonstrated a five-fold higher prevalence of mental health diagnoses in cannabis-associated ED visits (PR: 5.35, 95% CI: 5.27-5.43) compared to visits without cannabis. In the study’s secondary outcome, state-wide rates of ED visits associated with both cannabis and mental health significantly increased from 2012 to 2014 from 224.5 to 268.4 per 100,000 (p<0.0001).

Conclusion:
In Colorado from 2012 to 2014 the prevalence of mental health conditions in ED visits with cannabis-associated diagnostic codes is higher than in those without cannabis.  Due to the nature of the study design, it is unclear if these findings are attributable to cannabis or coincident with increased use and availability.  Per the authors of the paper, ED physicians nationwide should be aware of the detriments of marijuana use on pre-existing mental health conditions and ED management should include counseling on cessation and rehabilitation.
 

AEM Early Access 10: Air Ambulance Delivery and Administration of 4-Factor PCC

Welcome to the tenth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

  &nbsp; &nbsp; &nbsp; &nbsp; A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

        A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

DISCUSSING:

Air Ambulance Delivery and Administration of Four-Factor Prothrombin Complex Concentrate is Feasible and Decreases Time to Anticoagulation Reversal. Claire Vines, PharmD, Stephanie J. Tesseneer, PharmD, Robert D. Cox, MD, PhD,
Damon A. Darsey, MD, Kristin Carbrey, PharmD, BCPS and Michael A. Puskarich, MD

(click on title for full text; open access through February 1, 2018)     

LISTEN NOW: INTERVIEW WITH corresponding AUTHOR DR.michael puskarich

Dr. Michael Puskarich

Michael Puskarich, MD

Associate Professor and Research Director

Department of Emergency Medicine

University of Mississippi Medical Center

ARTICLE SUMMARY:

Objectives: The objective was to evaluate the feasibility, safety, and preliminary efficacy of four-factor prothrombin complex concentrate (4-factor PCC) administration by an air ambulance service prior to or during transfer of patients with warfarin-associated major hemorrhage to a tertiary care center for definitive management (interventional arm) compared to patients receiving 4-factor PCC following transfer by air ambulance or ground without 4-factor PCC treatment (conventional arm).

Methods: This was a retrospective chart review of patients presenting to a large academic medical center. All patients presenting to the emergency department (ED) treated with 4-factor PCC from April 1, 2014, through June 30, 2016, were identified. For this study, only transfer patients with an International Normalized Ratio (INR) > 1.5 actively treated with warfarin were included. The primary outcome was the proportion of patients with an INR ≤ 1.5 upon tertiary care hospital arrival, and the secondary efficacy outcome was difference in time to achievement of INR ≤ 1.5. Additional safety and efficacy objectives included difference in thromboembolic complications, length of stay, intensive care unit length of stay, and inpatient mortality between groups.

Results: Of the 72 included patients, a higher proportion of patients in the interventional group had an INR ≤ 1.5 on ED arrival (proportion difference = 0.82, 95% confidence interval = 0.64–0.92, p < 0.0001) and significantly reduced time to observed INR ≤ 1.5 (181 minutes vs. 541 minutes, p = 0.001). No differences were observed in thromboembolic complications or patient-centered outcomes with the exception of mortality, which was significantly higher in patients in the interventional group. This group was also observed to have lower Glasgow Coma Scale score and higher intubation rates prior to transfer and treatment.

Conclusions: Dispatch of an air ambulance carrying 4-factor PCC with administration prior to transfer is feasible and leads to more rapid improvement in INR among patients with warfarin-associated major hemorrhage.

FURTHER READING:

Race against the clock: overcoming challenges in the management of anticoagulant-associated intracerebral hemorrhageJ Neurosurg. 2014 Aug;121 Suppl:1-20. doi: 10.3171/2014.


 

AEM Early Access 09: The Hack's Impairment Index (HII) Score

Welcome to the ninth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners. This one is a mid-month bonus!

Find this podcast series on iTunes here.

  A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

DISCUSSING:

Performance of the Hack’s Impairment Index Score: A Novel Tool to Assess Impairment from Alcohol in Emergency Department Patients Jason B. Hack, MD, Eric J. Goldlust, MD, Dennis Ferrante and Brian J. Zink, MD

(click on title for full text; open access through January 5, 2018)     

listen now: interview with lead author Dr. Jason Hack

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Jason Hack, MD, FACEP, FACMT
Director,  Division of Medical Toxicology. Brown University
Professor, Department of Emergency Medicine
Warren Alpert Medical School, 
Brown University

 

Background: Over 35 million alcohol-impaired (AI) patients are cared for in emergency departments (EDs) annually. Emergency physicians are charged with ensuring AI patients’ safety by identifying resolution of alcohol induced impairment. The most common standard evaluation is an extemporized clinical examination, as ethanol levels are not reliable or predictive of clinical symptoms. There is no standard assessment of ED AI patients.

Objective: The objective was to evaluate a novel standardized ED assessment of alcohol impairment, Hack’s Impairment Index (HII score), in a busy urban ED.

Methods: A retrospective chart review was performed for all AI patients seen in our busy urban ED over 24 months. Trained nurses evaluated AI patients with both “usual” and HII score every 2 hours. Patients were stratified by frequency of visits for AI during this time: high (≥ 6), medium (2–5), and low (1). Within each category, comparisons were made between HII scores, measured ethanol levels, and usual nursing assessment of AI. Changes in HII scores over time were also evaluated. Results: A total of 8,074 visits from 3,219 unique patients were eligible for study, including 7,973 (98.7%) with ethanol levels, 5,061 (62.7%) with complete HII scores, and 3,646 (45.2%) with health care provider assessments. Correlations between HII scores and ethanol levels were poor (Pearson’s R2 = 0.09, 0.09, and 0.17 for high-, medium-, and low-frequency strata). HII scores were excellent at discriminating nursing assessment of AI, while ethanol levels were less effective. Omitting extrema, HII scores fell consistently an average 0.062 points per hour, throughout patients’ visits.

Conclusions: The HII score applied a quantitative, objective assessment of alcohol impairment. HII scores were superior to ethanol levels as an objective clinical measure of impairment. The HII declines in a reasonably predictable manner over time, with serial evaluations corresponding well with health care provider evaluations.

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CORRECTIVE NOTE: Dr. Hack would like to note a correction in the podcast audio, in which he states the HII sections are scored 'up to five'; rather, there are five sections/tasks, with a score of zero to four in each. 

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Further reading:

1.    Hack JB, Goldlust D, Ferrante D, Zink B.  The HII Score – A Novel Tool to Assess Impairment from Alcohol in Emergency Department Patients. Acad Emerg Med. 2017 Oct; 24(10):1193-1203.

2.   Hack JB, Goldlust EJ, Gibbs F, Zink B. The H-Impairment Index (HII): a standardized assessment of alcohol induced impairment in the emergency department. Am J Drug Alcohol Abuse 2014;40:111–7.

3.   Benoit JL, Hart KW, Soliman AA, et al. Developing a standardized measurement of alcohol intoxication. Am J Emerg Med 2017;35:725–30.

4.   Todd K, Berk WA, Welch RD, et al. Prospective analysis of mental status progression in ethanol-intoxicated patients. Am J Emerg Med 1992;10:271– 3. 5.    

5.   Galbraith S. Misdiagnosis and delayed diagnosis in traumatic intracranial haematoma. Br Med J 1976;1:1438– 9.