Study ObjectivesNausea and vomiting are common chief complaints when presenting to the emergency department (ED). Ondansetron has become a first-line antiemetic in the ED due to perceived efficacy, safety, and low risk of adverse side-effects despite a lack of substantive evidence of superiority. Haloperidol is a typical antipsychotic medication, acting as a dopamine (D2) antagonist that has efficacy in treating nausea, vomiting, and headache in a variety of ED conditions including migraine headache, cannabis hyperemesis syndrome and diabetic gastroparesis. Our objective is to evaluate the efficacy of haloperidol and ondansetron on undifferentiated nausea and vomiting in ED patients. Secondary outcomes include comparisons of analgesic effects, QT prolongation, efficacy in cannabis users, and adverse side-effects.MethodsThis study is a randomized, double-blind, non-inferiority trial of patients aged 18-55 between April 2021 and March 2022. A convenience sampling of patients meeting inclusion criteria were randomly assigned to either the haloperidol or ondansetron groups. Patients were excluded if any of the following were present: abnormal blood pressure (>200/100mmHg or <90/40mmHg), fever (>100.4F), acute trauma, QT > 450ms on cardiac monitor, altered mental status (GCS < 15), chest pain, allergy to haloperidol or ondansetron, Parkinson's disease, pregnancy or lactation, use of any antiemetic in the previous 8 hours, nausea and vomiting associated with vertigo, prisoners or any wards of the state. Patients were randomized to receive either 2.5mg of haloperidol intravenous (IV) or 4mg IV ondansetron. Symptoms were evaluated at time of enrollment and at 30-, 60-, and 90-minutes post-treatment using a validated Visual Analogue Scale (VAS) with side-effects evaluated concurrently. QT interval was evaluated at enrollment and 90 minutes post- treatment. After 90 minutes, all further treatment was determined by the primary ED physician at their discretion. Patients were contacted after 24 hours to collect follow-up data. Alpha value was set at 0.025 and all results showing non-inferiority were tested for superiority.ResultsOf 384 patients evaluated for inclusion, 312 were excluded due to screening criteria and 48 completed the study. 22 patients were randomized to haloperidol and 26 to ondansetron. Background data, initial nausea, and initial pain scores were statistically similar between groups at enrollment. Haloperidol was found to be superior to ondansetron in treatment of nausea at 90 minutes (p= 0.0178) with reduction in median nausea VAS of 6.5 (7 to 0.5) compared to 3 (6 to 3) in the ondansetron group. Haloperidol was also found to be superior to ondansetron in treatment of abdominal pain at 90 minutes (p = 0.0006) with reduction in median VAS pain score of 5 (5 to 0) compared to 2.5 (6 to 3.5). No difference in QT interval change was found between haloperidol and ondansetron groups (p=0.45). Haloperidol was not found to be superior to ondansetron in reducing nausea in cannabis users (p = 0.0385) at 90 minutes post-treatment.ConclusionThis study presents novel data that haloperidol 2.5mg IV is effective and superior to ondansetron at treating nausea and pain in undifferentiated adult patients in the emergency department. This study also shows that there is no difference in QT prolongation among the two medications.No, authors do not have interests to disclose Study ObjectivesNausea and vomiting are common chief complaints when presenting to the emergency department (ED). Ondansetron has become a first-line antiemetic in the ED due to perceived efficacy, safety, and low risk of adverse side-effects despite a lack of substantive evidence of superiority. Haloperidol is a typical antipsychotic medication, acting as a dopamine (D2) antagonist that has efficacy in treating nausea, vomiting, and headache in a variety of ED conditions including migraine headache, cannabis hyperemesis syndrome and diabetic gastroparesis. Our objective is to evaluate the efficacy of haloperidol and ondansetron on undifferentiated nausea and vomiting in ED patients. Secondary outcomes include comparisons of analgesic effects, QT prolongation, efficacy in cannabis users, and adverse side-effects. Nausea and vomiting are common chief complaints when presenting to the emergency department (ED). Ondansetron has become a first-line antiemetic in the ED due to perceived efficacy, safety, and low risk of adverse side-effects despite a lack of substantive evidence of superiority. Haloperidol is a typical antipsychotic medication, acting as a dopamine (D2) antagonist that has efficacy in treating nausea, vomiting, and headache in a variety of ED conditions including migraine headache, cannabis hyperemesis syndrome and diabetic gastroparesis. Our objective is to evaluate the efficacy of haloperidol and ondansetron on undifferentiated nausea and vomiting in ED patients. Secondary outcomes include comparisons of analgesic effects, QT prolongation, efficacy in cannabis users, and adverse side-effects. MethodsThis study is a randomized, double-blind, non-inferiority trial of patients aged 18-55 between April 2021 and March 2022. A convenience sampling of patients meeting inclusion criteria were randomly assigned to either the haloperidol or ondansetron groups. Patients were excluded if any of the following were present: abnormal blood pressure (>200/100mmHg or <90/40mmHg), fever (>100.4F), acute trauma, QT > 450ms on cardiac monitor, altered mental status (GCS < 15), chest pain, allergy to haloperidol or ondansetron, Parkinson's disease, pregnancy or lactation, use of any antiemetic in the previous 8 hours, nausea and vomiting associated with vertigo, prisoners or any wards of the state. Patients were randomized to receive either 2.5mg of haloperidol intravenous (IV) or 4mg IV ondansetron. Symptoms were evaluated at time of enrollment and at 30-, 60-, and 90-minutes post-treatment using a validated Visual Analogue Scale (VAS) with side-effects evaluated concurrently. QT interval was evaluated at enrollment and 90 minutes post- treatment. After 90 minutes, all further treatment was determined by the primary ED physician at their discretion. Patients were contacted after 24 hours to collect follow-up data. Alpha value was set at 0.025 and all results showing non-inferiority were tested for superiority. This study is a randomized, double-blind, non-inferiority trial of patients aged 18-55 between April 2021 and March 2022. A convenience sampling of patients meeting inclusion criteria were randomly assigned to either the haloperidol or ondansetron groups. Patients were excluded if any of the following were present: abnormal blood pressure (>200/100mmHg or <90/40mmHg), fever (>100.4F), acute trauma, QT > 450ms on cardiac monitor, altered mental status (GCS < 15), chest pain, allergy to haloperidol or ondansetron, Parkinson's disease, pregnancy or lactation, use of any antiemetic in the previous 8 hours, nausea and vomiting associated with vertigo, prisoners or any wards of the state. Patients were randomized to receive either 2.5mg of haloperidol intravenous (IV) or 4mg IV ondansetron. Symptoms were evaluated at time of enrollment and at 30-, 60-, and 90-minutes post-treatment using a validated Visual Analogue Scale (VAS) with side-effects evaluated concurrently. QT interval was evaluated at enrollment and 90 minutes post- treatment. After 90 minutes, all further treatment was determined by the primary ED physician at their discretion. Patients were contacted after 24 hours to collect follow-up data. Alpha value was set at 0.025 and all results showing non-inferiority were tested for superiority. ResultsOf 384 patients evaluated for inclusion, 312 were excluded due to screening criteria and 48 completed the study. 22 patients were randomized to haloperidol and 26 to ondansetron. Background data, initial nausea, and initial pain scores were statistically similar between groups at enrollment. Haloperidol was found to be superior to ondansetron in treatment of nausea at 90 minutes (p= 0.0178) with reduction in median nausea VAS of 6.5 (7 to 0.5) compared to 3 (6 to 3) in the ondansetron group. Haloperidol was also found to be superior to ondansetron in treatment of abdominal pain at 90 minutes (p = 0.0006) with reduction in median VAS pain score of 5 (5 to 0) compared to 2.5 (6 to 3.5). No difference in QT interval change was found between haloperidol and ondansetron groups (p=0.45). Haloperidol was not found to be superior to ondansetron in reducing nausea in cannabis users (p = 0.0385) at 90 minutes post-treatment. Of 384 patients evaluated for inclusion, 312 were excluded due to screening criteria and 48 completed the study. 22 patients were randomized to haloperidol and 26 to ondansetron. Background data, initial nausea, and initial pain scores were statistically similar between groups at enrollment. Haloperidol was found to be superior to ondansetron in treatment of nausea at 90 minutes (p= 0.0178) with reduction in median nausea VAS of 6.5 (7 to 0.5) compared to 3 (6 to 3) in the ondansetron group. Haloperidol was also found to be superior to ondansetron in treatment of abdominal pain at 90 minutes (p = 0.0006) with reduction in median VAS pain score of 5 (5 to 0) compared to 2.5 (6 to 3.5). No difference in QT interval change was found between haloperidol and ondansetron groups (p=0.45). Haloperidol was not found to be superior to ondansetron in reducing nausea in cannabis users (p = 0.0385) at 90 minutes post-treatment. ConclusionThis study presents novel data that haloperidol 2.5mg IV is effective and superior to ondansetron at treating nausea and pain in undifferentiated adult patients in the emergency department. This study also shows that there is no difference in QT prolongation among the two medications.No, authors do not have interests to disclose This study presents novel data that haloperidol 2.5mg IV is effective and superior to ondansetron at treating nausea and pain in undifferentiated adult patients in the emergency department. This study also shows that there is no difference in QT prolongation among the two medications.

Secondary brain injury impacts patient prognosis and can lead to long-term morbidity and mortality in cases of trauma. Continuous monitoring of secondary injury in acute clinical settings is primarily limited to intracranial pressure (ICP); however, ICP is unable to identify essential underlying etiologies of injury needed to guide treatment (e.g. immediate surgical intervention vs medical management). Here we show that a novel intracranial bioimpedance monitor (BIM) can detect onset of secondary injury, differentiate focal (e.g. hemorrhage) from global (e.g. edema) events, identify underlying etiology and provide localization of an intracranial mass effect. We found in an in vivo porcine model that the BIM detected changes in intracranial volume down to 0.38 mL, differentiated high impedance (e.g. ischemic) from low impedance (e.g. hemorrhagic) injuries (p < 0.001), separated focal from global events (p < 0.001) and provided coarse ‘imaging’ through localization of the mass effect. This work presents for the first time the full design, development, characterization and successful implementation of an intracranial bioimpedance monitor. This BIM technology could be further translated to clinical pathologies including but not limited to traumatic brain injury, intracerebral hemorrhage, stroke, hydrocephalus and post-surgical monitoring.

INTRODUCTION:As the prevalence of obesity continues to rise, there is a growing need to identify practices that protect overweight patients from injury during spine surgery. Intraoperative neurophysiological monitoring (IONM) has been recommended for complex spine surgery, but its use in obese and morbidly obese patients is understudied.CASE REPORT:This case report describes a patient with morbid obesity and ankylosing spondylitis who was treated for a T9-T10 3-column fracture with a planned, minimally invasive approach. Forty minutes after positioning the patient to prone, the IONM team identified a positive change in the patient's motor responses in the bilateral lower extremities and alerted the surgical team in a timely manner. It turned out that the pressure exerted by gravity on the patient's large pannus resulted in further dislocation of the fracture and narrowing of the spinal canal. The surgical team acknowledged the serious risk of spinal cord compression and, hence, immediately changed the surgical plan to an urgent, open approach for decompression and reduction of the fracture. The patient's lower extremities' motor responses improved after decompression. The patient was ambulatory on post-operative day 2 and pain-free at six-weeks with no other neurologic symptoms.SIGNIFICANCE:The use of IONM in this planned minimally invasive spine surgery for a patient with morbid obesity prevented potentially serious iatrogenic injury. The authors include a literature review that situates this case study in the existing literature and highlights a gap in current knowledge. There are few studies that have examined the use of IONM during spine surgery for morbidly obese patients. More research is needed to elucidate best practices for the use of IONM in spine surgery for morbidly obese patients.

Abstract Objective The management of mild traumatic brain injury (mTBI) with minor radiographic findings traditionally involves hospital admission for monitoring, although this practice is expensive with unclear benefit. We implemented a protocol to manage these patients in our emergency department observation unit (EDOU), hypothesizing that this pathway was cost effective and not associated with any difference in clinical outcome. Methods mTBI patients with minor radiographic findings were managed under the EDOU protocol over a 3‐year period from May 1, 2015 to April 30, 2018 (inclusions: ≥19 years old, isolated acute head trauma, normal neurological exam [except transient alteration in consciousness], and a computed tomography [CT] scan of the head with at least 1 of the following: cerebral contusions <1 cm in maximum extent, convexity subarachnoid hemorrhage, or closed, non‐displaced skull fractures). These patients were retrospectively analyzed; clinical outcomes and charges were compared to a control cohort of matched mTBI hospital admissions over the preceding 3 years. Results Sixty patients were observed in the EDOU over the 3‐year period, and 85 patients were identified for the control cohort. There were no differences in rate of radiographic progression, neurological exam change, or surgical intervention, and the overall incidence of hemorrhagic expansion was low in both groups. The EDOU group had a significantly faster time to interval CT scan (Mean Difference (MD) 3.92 hours, [95%CI 1.65, 6.19]), P = 0.001), shorter length of stay (MD 0.59 days [95% CI 0.29, 0.89], P = 0.001), and lower encounter charges (MD $3428.51 [95%CI 925.60, 5931.42], P = 0.008). There were no differences in 30‐day re‐admission, 30‐day mortality, or delayed chronic subdural formation, although there was a high rate of loss to follow‐up in both groups. Conclusions Compared to hospital admission, observing mTBI patients with minor radiographic findings in the EDOU was associated with significantly shorter time to interval scanning, shorter length of stay, and lower encounter charges, but no difference in observed clinical outcome. The overall risk of hemorrhagic progression in this subset of mTBI was very low. Using this approach can reduce unnecessary admissions while potentially yielding patient care and economic benefits. When designing a protocol, close attention should be given to clear inclusion criteria and a formal mechanism for patient follow‐up.

Everitt, Alicia; Root, Brandon K MD; Calnan, Daniel R MD, PhD; Bauer, David F MD, MPH; Halter, Ryan Author Information

Calnan, Daniel R MD, PhD; Everitt, Alicia; Root, Brandon K MD; Jaleel, Naser MD, PhD; Bauer, David F MD, MPH; Halter, Ryan Author Information

Introduction: Traumatic brain injury (TBI) contributes to nearly a third of injury-related deaths, is the fourth leading cause of death in the U.S., and costs the U.S. similar to$60 billion annually. There are two types of TBI, focal and diffuse, each requiring drastically different treatments. The current clinical standard for monitoring severe TBI is through intracranial pressure (ICP) sensing; however, significant limitations in the ICP response have motivated investigation into more multi-modal monitoring approaches. Electrical impedance has been shown to be sensitive to pathological changes within tissue including ischemia and stroke lesions. We hypothesize that by correlating electrical impedance to intracranial volume (ICV) changes we will be able to identify onset of a focal injury and localize it within the intracerebral space, overcoming many of the current limitations in TBI monitoring. Methods: A saline phantom and porcine animal model were used with controlled volume inflation steps of a Fogarty catheter. Impedance was collected across 8 electrode sectors and spatial localization capabilities compared to inclusion location. Autologous blood was then injected to simulate an intracerebral hemorrhage and the same protocol applied. Results: The phantom successfully detected inclusion presence, volume change and location. The animal model detected inclusion change with moderate success in accurately specifying location. Conclusion: Electrical impedance was successfully able to detect changes in intracranial volume in both a phantom and animal model. Additionally, initial results show potential spatial localization capabilities enabling differentiation of focal events from diffuse injury in monitoring of traumatic brain injury.

Patients with mild traumatic head injury with intracranial hemorrhage (mTBI) have low neurosurgical intervention rates. Inpatient admission for monitoring is common; this practice is costly and may be unnecessary. We developed and implemented a protocol to co-manage mTBI in our ED observation unit (OU) with Neurosurgery. The objective of this study is to review the safety and efficacy of an observation protocol for patients with mTBI

INTRODUCTION:Spinal epidural hematomas are uncommon in children. The diagnosis can be elusive as most cases present without a history of trauma, while symptoms can be atypical.CASE REPORT:We encountered a 35-month-old male presenting with nonspecific symptoms and no history of trauma. He later developed unilateral miosis and ptosis; MRI discovered a subacute cervicothoracic epidural which was promptly evacuated. The patient made an excellent recovery.COCLUSIONS:We emphasize the frequent absence of identifiable trauma and the importance of thorough imaging when this entity is suspected. Miosis and ptosis, likely representing a partial Horner syndrome, is an extremely rare presentation, this being one of the only reported cases.

BACKGROUND: Multiple external ventricular drain (EVD) simulators have been created, yet their cost, bulky size, and nonreusable components limit their accessibility to residency programs.OBJECTIVE: To create and validate an animated EVD simulator that is accessible on a mobile device.METHODS: We developed a mobile-based EVD simulator that is compatible with iOS (Apple Inc., Cupertino, California) and Android-based devices (Google, Mountain View, California) and can be downloaded from the Apple App and Google Play Store. Our simulator consists of a learn mode, which teaches users the procedure, and a test mode, which assesses users'procedural knowledge. Twenty-eight participants, who were divided into expert and novice categories, completed the simulator in test mode and answered a postmodule survey. This was graded using a 5-point Likert scale, with 5 representing the highest score. Using the survey results, we assessed the module's face and content validity, whereas construct validity was evaluated by comparing the expert and novice test scores.RESULTS: Participants rated individual survey questions pertaining to face and content validity a median score of 4 out of 5. When comparing test scores, generated by the participants completing the test mode, the experts scored higher than the novices (mean, 71.5; 95% confidence interval, 69.2 to 73.8 vs mean, 48; 95% confidence interval, 44.2 to 51.6; P < .001).CONCLUSION: We created a mobile-based EVD simulator that is inexpensive, reusable, and accessible. Our results demonstrate that this simulator is face, content, and construct valid.

Introduction: The pterional craniotomy is used to access numerous skull base lesions yet no pterional craniotomy simulators have been designed. Our objective was to design a novel, interactive simulator that users could complete on a mobile device. Additionally, we sought to create a simulator with three-dimensional graphics allowing users to immerse themselves in a realistic environment.

OBJECTIVE: To determine whether antibiotic impregnated external ventricular drains (AI-EVDs) are effective in preventing ventriculostomy associated infection (VAI), and to examine their cost effectiveness.METHODS: A comprehensive literature search was performed for published data through May 2014, including randomized controlled trials and observational cohort studies comparing AI-EVDs with nonimpregnated controls. A meta-analysis of included studies was performed using a random effects model. Historical data at the authors' institution were used to estimate both the incremental price of AI-EVDs and the hospital expenses associated with VAI.RESULTS: Three randomized controlled trials and 5 observational studies met inclusion criteria. The analysis demonstrated a statistically significant protective effect of AI-EVDs against VAI (risk ratio = 0.31 [0.15-0.64]; P = 0.002), although there was significant heterogeneity (chi(2) = 18.08; P = 0.01; I-2 = 61%). The number of AI-EVDs needed to prevent one infection (Number needed to treat [NNT]) was 19. Based on $100 as the incremental price, and $30,000 as the estimated expense of one episode of VAI, AI-EVDs would result in an overall savings estimate of $28,100 (range, $26,400-$28,500) per NNT. If a hospital places 150 AI-EVDs annually, savings could range from $109,292 to $278,577 per year.CONCLUSIONS: Meta-analysis demonstrated a significant protective benefit of AI-EVDs against VAI, and this benefit is likely associated with cost savings. However, current data on AI-EVDs are limited, and overall hospital costs will vary among institutions. Although both the efficacy and cost effectiveness of AI-EVDs are supported by this analysis, further study of AI-EVDs is clearly warranted.

INTRODUCTION:The ability to record and stream neurosurgery is an unprecedented opportunity to further research, medical education, and quality improvement. Here, we appraise the ease of implementation of existing point-of-view devices when capturing and sharing procedures from the neurosurgical operating room and detail their potential utility in this context.METHODS:Our neurosurgical team tested and critically evaluated features of the Google Glass and Panasonic HX-A500 cameras, including ergonomics, media quality, and media sharing in both the operating theater and the angiography suite.RESULTS:Existing devices boast several features that facilitate live recording and streaming of neurosurgical procedures. Given that their primary application is not intended for the surgical environment, we identified a number of concrete, yet improvable, limitations.CONCLUSION:The present study suggests that neurosurgical video capture and live streaming represents an opportunity to contribute to research, education, and quality improvement. Despite this promise, shortcomings render existing devices impractical for serious consideration. We describe the features that future recording platforms should possess to improve upon existing technology.