Robert L Norris Jr

All Publications

• Civil-Military Collaboration in the Initial Medical Response to the Earthquake in Haiti NEW ENGLAND JOURNAL OF MEDICINE Auerbach, P. S., Norris, R. L., Menon, A. S., Brown, I. P., Kuah, S., Schwieger, J., Kinyon, J., Helderman, T. N., Lawry, L. 2010; 362 (10)

  View details for DOI 10.1056/NEJMp1001555

  View details for PubMedID 20181962

• Pain control in disaster settings: a role for ultrasound-guided nerve blocks. Annals of emergency medicine Lippert, S. C., Nagdev, A., Stone, M. B., Herring, A., Norris, R. 2013; 61 (6): 690-696

  View details for DOI 10.1016/j.annemergmed.2012.03.028

  View details for PubMedID 22579123

• The expanded scope of emergency medical practice necessary for initial disaster response: lessons from Haiti. Journal of special operations medicine : a peer reviewed journal for SOF medical professionals Menon, A. S., Norris, R. L., Racciopi, J., Tilson, H., Gardner, J., McAdoo, G., Brown, I. P., Auerbach, P. S. 2012; 12 (1): 31-36

  Abstract

  A team of emergency physicians and nurses from Stanford University responded to the devastating January 2010 earthquake in Haiti. Because of the extreme nature of the situation, combined with limited resources, the team provided not only acute medical and surgical care to critically injured and ill victims, but was required to uniquely expand its scope of practice. Using a narrative format and discussion, it is the purpose of this paper to highlight our experience in Haiti and use these to estimate some of the skills and capabilities that will be useful for physicians who respond to similar future disasters.

  View details for PubMedID 22427047

• Editor's Response to "Rescuing the Physical Exam" WILDERNESS & ENVIRONMENTAL MEDICINE Norris, R. L. 2010; 21 (2): 174-174

  View details for Web of Science ID 000279235900019

  View details for PubMedID 20591385

• Death following coral snake bite in the United States - First documented case (with ELISA confirmation of envenomation) in over 40 years TOXICON Norris, R. L., Pfalzgraf, R. R., Laing, G. 2009; 53 (6): 693-697

  Abstract

  We report the first documented death due to a coral snake (Micrurus species) in the United States (U.S.) in over 40 years. The victim failed to seek medical care following the bite of an eastern coral snake (Micrurus fulvius) and succumbed within hours. Post-mortem proof of envenomation was obtained using an ELISA (enzyme-linked immunosorbent assay) developed specifically for this investigation. U.S. coral snakes are briefly reviewed in terms of their venom compositions, their clinical effects, and proper pre-hospital and hospital management. The clinical significance of the impending absence of commercially available antivenom for coral snake bites in the U.S. is highlighted.

  View details for DOI 10.1016/j.toxicon.2009.01.032

  View details for Web of Science ID 000265358600014

  View details for PubMedID 19673084

• The Global Snakebite Crisis-A Public Health Issue Misunderstood, Not Neglected WILDERNESS & ENVIRONMENTAL MEDICINE Simpson, I. D., Norris, R. L. 2009; 20 (1): 43-56

  Abstract

  The global problem of venomous snakebite continues to attract attention despite it being described as a "neglected" issue. The current focus of the World Health Organization (WHO) remains anti-snake venom quality, although "availability and sustainability" of supply are consistently described as the key issues. Sustainability of antivenom supply has been elusive, with cost and pricing in developing countries being cited as the major reasons. The current WHO approach fails to explore the cost issue, but rather focuses on quality improvements, which may well adversely affect the costs of a product already perceived to be 'unaffordable.' The reference to cost and price indicates a marketing-based perspective may well give more relevant solutions to the snakebite crisis. This paper introduces a marketing model to examine global snakebite and to identify if the current approach is relevant and effective. The "4 Ps" model examines if the correct products are available, whether sufficient information exists concerning estimated market size, whether the assumptions frequently made about the costs of the product are correct and fully understood, if the product is promoted properly, and whether the method by which the product reaches the end user is optimum. The resulting analysis demonstrates that the current approach is characterized by a misunderstanding of the nature of the global snakebite problem. Further, a lack of implementation of key solutions, such as training doctors in developing countries with relevant protocols, has inevitably led to a lack of improvement in the snakebite arena over the last 30 years.

  View details for Web of Science ID 000264280300008

  View details for PubMedID 19364169

• The Ebbinghaus retention curve: training does not increase the ability to apply pressure immobilisation in simulated snake bite - implications for snake bite first aid in the developing world Meeting of the Royal-Society-of-Tropical-Medicine-and-Hygiene Simpson, I. D., Tanwar, P. D., Andrade, C., Kochar, D. K., Norris, R. L. ELSEVIER SCIENCE INC. 2008: 451–59

  Abstract

  Pressure immobilisation (PIM) has been recommended for field management of bites by some venomous snakes. A narrow range of pressures under the encompassing wrap is necessary for PIM to limit venom spread. This study sought to evaluate the effect of focused training on volunteers' ability to apply PIM and to retain such skill over time. Forty volunteers were randomly divided into two groups: Group 1 (N=20; controls) received standard written instructions in PIM application; and Group 2 (N=20) received focused instruction during a 4-h training session (including hands-on practice and real-time feedback regarding pressures achieved). After voicing confidence with the technique, volunteers were tested at 1h, 1 day, 3 days and 3 months post training. One-hour post training, no volunteers in the control group were successful in applying PIM with the correct pressure. Twelve volunteers (60%) in Group 2 achieved target pressures 1h after training. However, there was rapid loss of ability to apply PIM correctly by Group 2, falling to just 25% success at 3 days, with little further deterioration at 3 months. Neither written instructions nor intense training with feedback adequately prepares individuals to apply PIM with correct pressures under the wrap.

  View details for DOI 10.1016/j.trstmh.2008.01.014

  View details for Web of Science ID 000256558800010

  View details for PubMedID 18339412

• A Case of Elevated Liver Function Tests After Crown-of-Thorns (Acanthaster planci) Envenomation WILDERNESS & ENVIRONMENTAL MEDICINE Lin, B., Norris, R. L., Auerbach, P. S. 2008; 19 (4): 275-279

  Abstract

  The crown-of-thorns starfish (Acanthaster planci) inhabits coral reefs, largely throughout the Indo-Pacific region. Its dorsal surface is covered with stout thorn-like spines. When handled or stepped on by humans, the spines can puncture the skin, causing an immediate painful reaction, followed by inflammation and possible infection. Initial pain and swelling may last for days. Effects of envenomation on the liver have been demonstrated previously in animal models, but hepatic toxicity has not previously been described in humans. We describe elevated liver enzymes in a 19-year-old female associated with A planci spine puncture wounds. To our knowledge, this is the first documented report of transaminitis in a human after A planci envenomation.

  View details for PubMedID 19099322

• Snake antivenom product guidelines in India: "The devil is in the details" WILDERNESS & ENVIRONMENTAL MEDICINE Simpson, I. D., Norris, R. L. 2007; 18 (3): 163-168

  Abstract

  Venomous snakebite continues to exact a tremendous toll in human suffering and mortality in India. Contributing to this problem is the fact that all of the current Indian snake antivenom manufacturers include a great deal of misinformation in the package inserts and guidelines that accompany their products. Examples include erroneous recommendations regarding first aid, misleading information regarding the signs and symptoms to be anticipated after Indian snakebite, and misleading and ambiguous recommendations as to initial dosing and repeat dosing of antivenom. In addition, the significant problem of acute adverse reactions to Indian antivenoms is compounded by a lack of appropriate recommendations regarding prevention, diagnosis, and management of such reactions. It is the intent of this article to point out problems with the current Indian antivenom product guidelines and to encourage these manufacturers to produce new literature to accompany their products based on the best available evidence.

  View details for Web of Science ID 000249792200001

  View details for PubMedID 17896852

• Venomous snakebite in mountainous terrain: Prevention and management WILDERNESS & ENVIRONMENTAL MEDICINE Boyd, J. J., Agazzi, G., Svajda, D., Morgan, A. J., Ferrandis, S., Norris, R. L. 2007; 18 (3): 190-202

  Abstract

  The prevention and management of venomous snakebite in the world's mountains present unique challenges. This paper presents a series of practical, clinically sound recommendations for management of venomous snakebite in a mountain environment. The authors performed an extensive review of current literature using search engines and manual searches. They then fused the abundant knowledge of snakebite with the realities of remote first aid and mountain rescue to develop recommendations. A summary is provided of the world's most troublesome mountain snakes and the mechanisms of toxicity from their bites. Preventive measures are described. Expected symptoms and signs are reviewed in lay and medical terms. A review of currently recommended first-aid measures and advanced medical management for physicians, paramedics, and other clinicians is included. Venomous snakebites in mountainous environments present unique challenges for management. This paper offers practical recommendations for managing such cases and summarizes the approach to first aid and advanced management in 2 algorithms.

  View details for Web of Science ID 000249792200005

  View details for PubMedID 17896851

• Syncope, massive aspiration, and sudden death following rattlesnake bite WILDERNESS & ENVIRONMENTAL MEDICINE Norris, R. L., Wilkerson, J. A., Feldman, J. 2007; 18 (3): 206-208

  Abstract

  Fatalities following rattlesnake bite are rare in the United States, usually occur some hours following the bite, and are generally secondary to direct venom effects. We report a patient with acute syncope and subsequent massive aspiration resulting in airway obstruction and rapid death following a probable Northern Pacific rattlesnake (Crotalus oreganus oreganus) bite.

  View details for Web of Science ID 000249792200007

  View details for PubMedID 17896845

• Rediscovery of severe saw-scaled viper (Echis sochureki) envenoming in the thar desert region of Rajasthan, India WILDERNESS & ENVIRONMENTAL MEDICINE Kochar, D. K., Tanwar, P. D., Norris, R. L., Sabir, M., Nayak, K. C., Agrawal, T. D., Purohit, V. P., Kochar, A., Simpson, I. D. 2007; 18 (2): 75-85

  Abstract

  In India, venomous snakebite remains an enigma. Although ineffective first aid treatments that are centuries old continue to be used by people bitten by snakes, important factual information, such as the importance and uniqueness of bites by the northern saw-scaled viper (Echis sochureki), has been largely lost and forgotten. In this paper, we report the first systematically gathered data on the clinical course of envenoming by E sochureki in Rajasthan, India. Clinical information is reported on 12 victims bitten by definitively identified E sochureki, and 2 clinical cases are described in greater detail to illustrate the severity of envenoming by this snake.A data collection form was developed and used to prospectively gather clinical information regarding patients who were bitten by E sochureki and who brought the dead snake with them to hospital. All snakes were definitively identified by an experienced herpetologist. Information on symptoms and signs, management (both first aid and hospital), and outcomes was collected.All 12 victims had evidence of systemic envenoming, including abnormal 20-minute whole blood clotting tests (with systemic bleeding in 7). All received polyvalent antivenom made, in part, with Echis carinatus venom from southern India. Antivenom was relatively ineffective in restoring coagulation to these patients. All patients survived, although 1 patient suffered an intracranial bleed with residual hemiparesis.Echis sochureki causes severe bites in Rajasthan. Work needs to be done to alter the first aid practices used for snakebites in this area, to encourage more rapid presentation to hospital, and to develop antivenom that is more effective against E sochureki.

  View details for Web of Science ID 000247641100001

  View details for PubMedID 17590073

• Effects of implementing a rapid admission policy in the ED AMERICAN JOURNAL OF EMERGENCY MEDICINE Quinn, J. V., Mahadevan, S. V., Eggers, G., Ouyang, H., Norris, R. 2007; 25 (5): 559-563

  Abstract

  The purpose of this study is to determine the impact of a new rapid admission policy (RAP) on emergency department (ED) length of stay (EDLOS) and time spent on ambulance diversion (AD).The RAP, instituted in January 2005, allows attending emergency physicians to send stable patients, requiring admission to the general medicine service, directly to available inpatient beds. The RAP thereby eliminates 2 conventional preadmission practices: having admitting physicians evaluate the patient in the ED and requiring all diagnostic testing to be complete before admission. We compared patient characteristics, percentage of patients leaving without being seen, EDLOS for admitted patients, time on AD, and total adjusted facility charge for a 3-month period after the RAP implementation to the same period of the prior year.There was a 1.1% increase in census with no difference in patient demographics, acuity, or disposition categories for the 2 periods. The EDLOS decreased on average by 10.1 minutes (95% confidence interval [CI], 3.3-17.0 minutes), resulting in an average of 4.2 hours of extra bed availability per day. Weekly minutes of AD decreased 169 minutes (95% CI, 29-310 minutes). There was also a 3.2% increase (95% CI, 3.1%-3.3%) in adjusted facility charge between these periods in 2005 compared with 2004.The RAP resulted in a small decrease in the EDLOS, which likely decreased AD time. The resulting small increase in ED volume and higher acuity ambulance patients significantly improved ED revenue. Wider implementation of the policy and more uniform use among emergency physicians may further improve these measures.

  View details for DOI 10.1016/j.ajem.2006.11.034

  View details for PubMedID 17543661

• Snakes of medical importance in India: Is the concept of the "Big 4" still relevant and useful? WILDERNESS & ENVIRONMENTAL MEDICINE Simpson, I. D., Norris, R. L. 2007; 18 (1): 2-9

  Abstract

  Snakebites continue to be a major medical concern in India. However, there is very little hard evidence of a numerical nature to enable us to understand which species are responsible for mortality and morbidity. For many decades, the concept of the "Big 4" Snakes of Medical Importance has reflected the view that 4 species are responsible for Indian snakebite mortality--the Indian cobra (Naja naja), the common krait (Bungarus caeruleus), the Russell's viper (Daboia russelii) and the saw-scaled viper (Echis carinatus). However, a recent discovery that another species, the hump-nosed pit viper (Hypnale hypnale), is capable of causing lethal envenomation, and that this problem was being concealed by systematic misidentification of this species as the saw-scaled viper, has necessitated a review of the concept of the "Big 4." The concept of the "Big 4" snakes is reviewed to demonstrate its failure to include all currently known snakes of medical significance in India, and its negative effects related to clinical management of snakebite. The emergence of the hump-nosed pit viper (Hypnale hypnale) as a snake of medical significance has rendered the "Big 4" obsolete in terms of completeness. The concept of the "Big 4" is restricting sound epidemiological work and the development of effective snake antivenoms. It should be replaced by the model introduced in the 1980s by the World Health Organization, which has not received adequate circulation and implementation.

  View details for Web of Science ID 000245403500002

  View details for PubMedID 17447706

• Digital necrosis necessitating amputation after tube gauze dressing application in the ED AMERICAN JOURNAL OF EMERGENCY MEDICINE Norris, R. L., Gilbert, G. H. 2006; 24 (5): 618-621

  View details for DOI 10.1016/j.ajem.2005.12.009

  View details for PubMedID 16938605

• First report of a bite by the mottled rock rattlesnake (Crotalus lepidus lepidus) TOXICON Norris, R. L. 2005; 46 (4): 414-417

  Abstract

  Bites by the mottled rock rattlesnake (Crotalus lepidus lepidus) are rare. There appear to be no reports of bites by this subspecies in the literature. This is a case report of a bite by a captive specimen of this diminutive pit viper, and includes a review of what is known regarding its venom.

  View details for DOI 10.1016/j.toxicon.2005.06.003

  View details for Web of Science ID 000232127100007

  View details for PubMedID 16051298

• Physicians and lay people are unable to apply pressure immobilization properly in a simulated snakebite scenario WILDERNESS & ENVIRONMENTAL MEDICINE Norris, R. L., Ngo, J., Nolan, K., Hooker, G. 2005; 16 (1): 16-21

  Abstract

  To determine whether volunteers (with or without prior medical training) can correctly apply pressure immobilization (PI) in a simulated snakebite scenario after receiving standard instructions describing the technique.Twenty emergency medicine physicians (residents and attendings) and 20 lay volunteers without prior formal medical training were given standard printed instructions describing the application of PI for field management of snakebite. They were then supplied with appropriate materials and asked to apply the technique five separate times (twice to another individual [one upper and one lower extremity] and three times to themselves [nondominant upper extremity, dominant upper extremity, and one lower extremity]). Successful application was defined a priori by four criteria previously published in the literature: wrap begins at the bite site, entire extremity is wrapped, splint or sling is applied, and pressures under the dressing are between 40 and 70 mm Hg in upper-extremity application and between 55 and 70 mm Hg in lower-extremity use. Pressures were determined using a specially designed skin interface pressure-measuring device placed at the simulated bite site.The technique was correctly applied as judged by the preset criteria in only 13 out of 100 applications by emergency medicine physicians and in only 5 out of 100 applications by lay people. There was no significant difference in success rates between physicians and lay volunteers. Likewise, there was no significant difference in success based on which extremity was being wrapped. More detailed analysis revealed that the major contributor to failure was inability to achieve recommended target pressures.Volunteers in a simulated snakebite scenario have difficulty applying PI correctly, as defined in the literature. The major source of failure is an inability to achieve recommended pressure levels under the dressing. New methods of instructing people in the proper use of PI or new technologies to guide or automate application are needed if this technique is to be used consistently in an effective manner for field management of bites by venomous snakes not known to cause significant local wound necrosis.

  View details for Web of Science ID 000227979400004

  View details for PubMedID 15813142

• Regional vs systemic antivenom administration in the treatment of snake venom poisoning in a rabbit model: A pilot study Research Forum of the American-College-of-Emergency-Physicians Norris, R. L., Dery, R., Johnson, C., Williams, S., Rose, K., Young, L., McDougal, L. R., Bouley, D., Oehlert, J., Thompson, R. C. ALLIANCE COMMUNICATIONS GROUP DIVISION ALLEN PRESS. 2003: 231–35

  Abstract

  To develop a model that compares 2 different routes of antivenom administration (standard intravenous [IV] administration vs regional administration below a tourniquet) to assess their ability to limit muscle necrosis in a rabbit model of rattlesnake venom poisoning.New Zealand white rabbits were randomly assigned to 4 groups. All animals underwent general anesthesia and were then injected intramuscularly (IM) with a sublethal dose of western diamond-back rattlesnake (Crotalus atrox) venom in the right thigh and a similar volume of normal saline (NS) control in the left thigh. Thirty minutes later, standard treatment group animals (n = 4) received 1 vial of reconstituted Antivenin (Crotalidae) Polyvalent (ACP) and 10 mL of NS through an ear vein. Experimental treatment group animals (n = 4) had their lower extremities exsanguinated and isolated by arterial tourniquets. One vial of ACP was then given through a distal IV in the envenomed extremity, and 10 mL of NS was given through an IV in the sham extremity. Tourniquets were removed 30 minutes later. Positive control group animals (n = 2) similarly had their lower extremities exsanguinated and isolated by tourniquets. They then received 10 mL of NS through distal IVs in each lower extremity. Tourniquets were again removed after 30 minutes. Negative control group animals (n = 2) received 2 doses of NS only (10 mL each) through an ear vein. Serum creatinine phosphokinase (CPK) levels were drawn at baseline and 48 hours following venom injection. At 48 hours, the animals were injected with technetium pyrophosphate. Two hours later, they were euthanized, and the lower extremities were scanned to determine levels of radionucleotide uptake in envenomed muscles compared to contralateral sham-injected muscles. The anterior thigh muscle groups were then removed, fixed, stained, sectioned, and analyzed in a blinded fashion by a veterinary pathologist for muscle necrosis grading.There was no evidence of statistically significant differences in changes in serum CPK levels (from baseline to 48 hours), technetium pyrophosphate uptake ratios (right leg/left leg), or muscle necrosis indices in any 2-group analysis.Results of this pilot study do not suggest any beneficial effect of ACP, in the dose and routes used, in limiting local muscle necrosis following IM rattlesnake venom poisoning in the rabbit model.

  View details for PubMedID 14719857

• Airway management for the sports physician - Part 2: Advanced techniques PHYSICIAN AND SPORTSMEDICINE Norris, R. L., Peterson, J. 2001; 29 (11): 15-?

  Abstract

  Airway emergencies sometimes require techniques other than basic management methods. Advanced techniques are needed to manage laryngeal edema or fracture, upper-airway hemorrhage, or other injuries that make ventilation or intubation from above impossible. Placing various endotracheal devices and performing surgical techniques such as needle cricothyrotomy and tracheostomy can be done by physicians who have training and the necessary equipment. Surgical techniques can be performed with medical bag components, but commercial kits are available for those who are uncomfortable performing techniques using bag equipment.

  View details for Web of Science ID 000172050800005

  View details for PubMedID 20086554

• Airway management for the sports physician part 1: Basic techniques PHYSICIAN AND SPORTSMEDICINE Norris, R. L., Peterson, J. 2001; 29 (10): 23-29

  Abstract

  Airway emergencies are, fortunately, rare in sports medicine, but when they occur, they must be addressed quickly and effectively. Various techniques can be applied by a trained team physician to optimize oxygenation and ventilation for an acutely ill or injured athlete. Initial management of airway emergencies on the field can be guided using a simple algorithm. Basic maneuvers include methods to clear airways, place ventilation devices, and assist with breathing. More advanced techniques include placing various endotracheal tube devices and performing surgical techniques; these will be discussed in a subsequent article.

  View details for Web of Science ID 000171559300003

  View details for PubMedID 20086548

• Centipede envenomation WILDERNESS & ENVIRONMENTAL MEDICINE Bush, S. P., King, B. O., Norris, R. L., Stockwell, S. A. 2001; 12 (2): 93-99

  Abstract

  Five episodes of envenomation by centipedes in 2 patients are reported. These arthropods are fast-moving, frightening in appearance to some, and may display aggressive behavior. However, stings from these centipedes, like most found worldwide, caused no serious morbidity or mortality. Common effects included intense local pain, erythema, induration, and necrosis, as well as mild constitutional symptoms. All resolved without sequelae. Treatment included pain control, wound care, and tetanus immunization.

  View details for Web of Science ID 000169377300005

  View details for PubMedID 11434497

• A call for snakebite research WILDERNESS & ENVIRONMENTAL MEDICINE Norris, R. L. 2000; 11 (3): 149-151

  View details for Web of Science ID 000089963300001

  View details for PubMedID 11055558

• Snakes as an overlooked natural vector control resource WILDERNESS & ENVIRONMENTAL MEDICINE Norris, R. L. 1999; 10 (2): 132-132

  View details for Web of Science ID 000081796100013

  View details for PubMedID 10442163

• Snakebite scenario WILDERNESS & ENVIRONMENTAL MEDICINE Norris, R. L. 1999; 10 (1): 55-56

  View details for Web of Science ID 000079896900012

  View details for PubMedID 10347681

• Managing arthropod bites and stings PHYSICIAN AND SPORTSMEDICINE Norris, R. L. 1998; 26 (7): 47-?

  Abstract

  Most arthropod bites and stings cause limited swelling, itching, pain, and redness and can be managed by ice application and tetanus prophylaxis as necessary. Stings by bees, wasps, and stinging ants can cause anaphylaxis that may require treatment with epinephrine and antihistamines and respiratory and cardiac maintenance measures. Widow spider bite management is controversial, but interventions for systemic reactions include calcium gluconate, methocarbamol, diazepam, narcotics, and antivenom. Victims of brown spider bites may need hospitalization if lesions enlarge rapidly or there are signs of systemic poisoning. Those stung by a bark scorpion may require oxygen, an intravenous line, pulse oximetry, and cardiac monitoring.

  View details for Web of Science ID 000074815200018

  View details for PubMedID 20086833

• DELAYED USE OF WIDOW SPIDER ANTIVENIN ANNALS OF EMERGENCY MEDICINE Allen, R. C., Norris, R. L. 1995; 26 (3): 393-394

  View details for Web of Science ID A1995RR24600031

  View details for PubMedID 7661442

• BITE MARKS AND THE DIAGNOSIS OF VENOMOUS SNAKEBITE WILDERNESS & ENVIRONMENTAL MEDICINE Norris, R. L. 1995; 6 (2): 159-161

  View details for Web of Science ID A1995RA05300001

  View details for PubMedID 11995902

• Ovarian hyperstimulation syndrome in the emergency department: a case report. journal of emergency medicine Martin, R. A., Edraki, B., Norris, R. L. 1994; 12 (4): 481-484

  Abstract

  The Ovarian Hyperstimulation Syndrome (OHSS) is a complication of ovulation enhancing technologies that is becoming more prevalent with increasing use of these techniques in infertile women. In this report, we describe a 36-year-old woman who presented to the Emergency Department with hemodynamic compromise secondary to OHSS. The OHSS is characterized by ovarian enlargement, ascites, electrolyte disturbances, hypotension, and thromboembolic events. This case illustrates a serious complication of techniques used to enhance fertility.

  View details for PubMedID 7963394

• Local anesthetics. Emergency medicine clinics of North America Norris, R. L. 1992; 10 (4): 707-718

  Abstract

  Emergency physicians often rely on the use of local anesthetic agents to relieve patient discomfort, and research continues in an effort to develop new agents with improved anesthetic qualities. Eventually, a nontoxic, rapidly acting agent may become available that could provide profound anesthesia of long duration when applied topically to intact skin or wounds. Until the "perfect" agent is developed, physicians can help the patient by making knowledgeable choices regarding local anesthetic techniques. By choosing topical agents when appropriate and buffering agents to be infiltrated, using courteous techniques of injection, and being cognizant of potential adverse reactions, the physician can turn a potentially unpleasant and frightening situation for the patient into a positive experience that promotes satisfaction and cooperation.

  View details for PubMedID 1425399

• KETOROLAC FOR SICKLE-CELL VASOOCCLUSIVE CRISIS PAIN IN THE EMERGENCY DEPARTMENT - LACK OF A NARCOTIC-SPARING EFFECT ANNALS OF EMERGENCY MEDICINE Wright, S. W., Norris, R. L., Mitchell, T. R. 1992; 21 (8): 925-928

  Abstract

  To determine if a single dose of intramuscular ketorolac given on presentation to the emergency department has a narcotic-sparing effect in adult patients with sickle cell vaso-occlusive crisis pain.A prospective, randomized, single-dose, double-blind study.ED of a university hospital and an affiliated county hospital.Eighteen adult patients who presented to the ED with sickle cell crisis pain a total of 24 times.Patients were randomized to receive either ketorolac 60 mg IM or placebo on presentation to the ED. Subjects were administered meperidine on presentation and then received a standardized dose of meperidine every 30 minutes during the four-hour observation period based on the severity of pain.The 12 subjects in the ketorolac group received an average of 231 +/- 92 mg meperidine, whereas the 12 subjects in the placebo group received an average meperidine dose of 250 +/- 85 mg (P = .61).The use of intramuscular ketorolac did not lead to a clinically significant reduction in the requirement for narcotics during the four-hour ED treatment period.

  View details for Web of Science ID A1992JF12900007

  View details for PubMedID 1497158

• DELAYED USE OF ANTIVENIN IN BLACK-WIDOW SPIDER (LATRODECTUS-MACTANS) ENVENOMATION JOURNAL OF WILDERNESS MEDICINE Allen, R. C., Norris, R. L. 1991; 2 (3): 187-192

  View details for Web of Science ID A1991GA63100006

• APPARENT CORAL SNAKE ENVENOMATION IN A PATIENT WITHOUT VISIBLE FANG MARKS AMERICAN JOURNAL OF EMERGENCY MEDICINE Norris, R. L., Dart, R. C. 1989; 7 (4): 402-405

  Abstract

  Envenomation by the North American coral snake is an uncommon entity in the United States. In most cases fang marks will be present, although they may be quite small and difficult to see. The case of a young man who demonstrated evidence of envenomation following the bite of a Texas coral snake (Micrurus fulvius tenere), despite the absence of any apparent fang marks on close examination, is reported. The problems associated with coral snake envenomation in terms of diagnosis and management are reviewed.

  View details for Web of Science ID A1989AE00100011

  View details for PubMedID 2735987

• Deep vein thrombosis in an adolescent. Pediatric emergency care Berman, D. A., Norris, R. L., Crow, T., Scatamacchia, S. 1989; 5 (2): 102-104

  Abstract

  We report an unusual case of deep vein thrombosis following minor trauma in an adolescent who presented with a swollen, tender, lower extremity. Work-up consisted of a venogram which demonstrated occlusion of the deep venous system in the proximal leg. The patient was hospitalized for intravenous heparin followed by oral anticoagulation therapy. The problem of deep venous thrombosis in adolescents and the approach to diagnosis are discussed.

  View details for PubMedID 2748400