bluuebunny/crossref_metadata_2025 huggingface dataset:
Rapid Induction of Mild Cerebral Hypothermia by Cold Aortic Flush Achieves Normal Recovery in a Dog Outcome Model with 20‐minute Exsanguination Cardiac Arrest
Authors: Behringer Wilhelm , Prueckner Stephan , Safar Peter , Radovsky Ann , Kentner Rainer , Stezoski S. William , Henchir Jeremy , Tisherman Samuel A.
Published: January 2008

Abstract. Objectives: Resuscitation attempts in trauma victims who suffer cardiac arrest (CA) from exsanguination almost always fail. The authors hypothesized that an aortic arch flush with cold normal saline solution (NSS) at the start of exsanguination CA can preserve cerebral viability during 20‐minute no‐flow. Methods: Twelve dogs were exsanguinated over 5 minutes to CA of 20‐minute no‐flow, resuscitated by cardiopulmonary bypass, followed by post‐CA mild hypothermia (34°C) continued to 12 hours, controlled ventilation to 20 hours, and intensive care to 72 hours. At CA 2 minutes, the dogs received a 500‐mL flush of NSS at either 24°C (group 1,n= 6) or 4°C (group 2, n= 6), using a balloon‐tipped catheter inserted via the femoral artery into the descending thoracic aorta. Results: The flush at 24°C (group 1) decreased tympanic membrane temperature [mean (±SD)] from 37.5°C (±0.1) to 35.7°C (±0.2); the flush at 4°C (group 2) to 34.0°C (±1.1) (p = 0.005). In group 1, one dog achieved overall performance category (OPC) 2 (moderate disability), one OPC 3 (severe disability), and four OPC 4 (coma). In group 2, four dogs achieved OPC 1 (normal), one OPC 2, and one OPC 3 (p = 0.008). Neurologic deficit scores (0‐10% normal, 100% brain death) [median (25th‐75th percentile)] were 62% (40‐66) in group 1 and 5% (0‐19) in group 2 (p = 0.01). Total brain histologic damage scores were 130 (62‐137) in group 1 and 24 (10‐55) in group 2 (p = 0.008). Conclusions: Aortic arch flush of 4°C at the start of CA of 20 minutes rapidly induces mild cerebral hypothermia and can lead to normal functional recovery with minimal histologic brain damage. The same model with aortic arch flush of 24°C results in survival with brain damage in all dogs, which makes it suitable for testing other (e.g., pharmacologic) preservation potentials.
Breast Cancer Knowledge and Preventive Behaviors An Urban Emergency Department‐based Survey
Authors: Takakuwa Kevin M. , Ernst Amy A. , Weiss Steven J. , Nick Todd G.
Published: January 2008

Abstract. Objective: To assess general knowledge and preventive behaviors regarding breast cancer among women who present to an urban emergency department. Methods: During a six‐month study period, a convenience sampling of women aged 21 years and older who were in treatment and waiting areas was surveyed. The anonymous written survey asked about demographic variables, knowledge, and preventive behaviors regarding breast cancer. Knowledge was assessed with questions about the recommended frequency of breast self‐examination and the recommended age for first mammography. Performance was assessed by questions about breast self‐exam and mammography. Subgroup analysis was done by age (above and below 40 years old), race, income (above and below the median), insurance type, history of breast lump, and family history (FH) of breast cancer. Results: Four hundred women completed surveys. Two hundred twelve (53%) correctly knew the answers to the two knowledge questions. Knowledge was greater in women with private insurance. Knowledge of the frequency of breast self‐exam was significantly greater among whites and Native Americans than among African Americans, Asians, or Hispanics. Stated performance of preventive behaviors was 72% (288) for breast self‐exam and for mammography. Preventive behaviors were significantly more likely to be performed by higher‐income and privately‐insured women. Breast self‐exam was more likely to be done in older women, those with a history of a breast lump, and those with a FH of breast cancer. Conclusions: Women with lower income and without private insurance were less likely to be knowledgeable and practice preventive measures for detecting breast disease.
Emergency Medicine Residency Applicant Educational Debt Relationship with Attitude toward Training and Moonlighting
Authors: Kazzi A. Antoine , Langdorf Mark I. , Brillman Judith , Handly Neal , Munden Susan
Published: January 2008

Abstract. Objectives: Heated debate persists regarding the role of resident moonlighting in emergency medicine (EM). The attitudes of EM residency applicants have not been assessed. The objectives of this study were to assess: 1) the level of educational debt among EM residency applicants, 2) their perception of increased risk potential to patients from unsupervised EM resident practice, and 3) their opposition to laws restricting moonlighting. The authors then report the relationship between the degree of indebtedness and these stated positions. Methods: Fifty‐four EM residency programs returned 393 responses to a 1996 anonymous survey. Applicants recorded: 1) their indebtedness, 2) whether they believed that EDs should hire only physicians who have completed full training in an EM residency, and 3) whether they believed that unsupervised EM practice prior to completing EM training carries a higher risk of adverse patient outcomes. The authors used a t‐test and logistic regression to determine whether there was any significant difference in debt between responders who answered yes and those who answered no to the various questions. A p‐value < 0.05 was considered significant. Results: The mean ± SD debt was $72,290 ± 48,683 (median $70,000). Most EM applicants (84.8%) agreed that unsupervised medical care by EM residents carries a higher risk of adverse patient outcomes. Paradoxically, only half the applicants opposed a moonlighting ban. Responses did not statistically correlate with educational debt. Conclusions: Emergency medicine residency applicant debt is large. The EM applicants' opposition to laws that would restrict moonlighting was mixed. This was inconsistent with the majority acknowledging an increased risk potential to patients. Nearly all EM applicants would still select EM as a career, even if moonlighting were to be banned.
Resident Perception of Academic Skills Training and Impact on Academic Career Choice
Authors: Neacy Kathleen , Stern Susan A. , Kim Hyungjin Myra , Dronen Steven C.
Published: January 2008

Abstract. Objectives: 1) To evaluate residents' perceptions of the quality of training in basic academic skills and the availability and quality of research resources during residency; 2) to evaluate the association between these attitudes and choice of an academic career; and 3) to assess residents' attitudes toward the importance of postgraduate fellowship training for success in an academic career. Methods: A 15‐item survey was administered to all U.S. emergency medicine (EM) residents in conjunction with the February 1997 American Board of Emergency Medicine (ABEM) In‐service Examination. The survey assessed resident interest in a career in academic EM, and resident perception of the general quality of training in academic (research and teaching) skills. Residents were also asked to rate the quality of their training in the following specific academic skills: medical and grant writing, bedside teaching, lecturing, the use of computers, study design, statistics, and the use of audiovisual aids. Resident perceptions of the availability of the following resources were also assessed: teaching and research role models, data collection and analysis support, laboratory facilities, financial support of research, research fundamentals lectures, and computers. Results: The response rate was 93%. Forty‐four percent of the respondents were interested in academic EM, 36.6% were undecided, and 19.6% were not interested in an academic career. On a scale of 1 (unprepared) to 5 (well prepared), the residents rated their overall preparedness for an academic career fairly high (3.97 [0.86]). In contrast, they perceived the quality of their training in the specific academic skill areas assessed and research resource availability to be only fair. Despite resident perception of relatively inadequate training in basic academic skills, only 24% of the respondents indicated that they believed fellowship training was important for success in an academic career. Logistic regression analyses demonstrated that participation in a research project in medical school, the length of the training program (4‐ vs 3‐year), being a first‐year resident, and a better perception of one's overall academic skill preparation were factors independently associated with having a greater interest in an academic career. Conclusions: A relatively high percentage of residents initially express an interest in an academic career, but this interest wanes as residency progresses. A minority of residents believe that their training provides them with the specific skills needed to succeed in academics, or with adequate exposure to research resources or mentors. Emergency medicine may be able to increase the number of qualified academic faculty by recruiting medical students with prior research experience, and providing residents with better research training and role models.
Teaching Patient Empathy The ED Visit Program
Authors: Seaberg David C. , Godwin Steven A. , Perry Shawna J.
Published: January 2008

Abstract. Objective: Residency programs only are not challenged with developing competent emergency clinicians, but should strive to develop caring, empathetic, and community‐minded physicians. An exercise was designed to help residents experience emergency department (ED) visits from the patient's perspective. Methods: This study occurred in emergency medicine residency program at an urban teaching institution with an annual ED census of 94,000. On the first day of residency orientation, each resident was given a clinical scenario and registered through triage into the ED. Nurses were blinded to the study. The study concluded when the examining physician entered the exam room. Residents were then presented with a simulated bill based on their scenario. Residents completed a survey initially and at six months. Survey ratings were measured using a 100‐mm visual analog scale (VAS) (0 = not at all; 100 = a great deal). Results: Twenty‐five residents participated over two years. Sixty‐four percent had never been an ED patient before. Median length of stay was 139 minutes. This exercise was found to improve resident empathy for patients on initial survey, 66 mm (range 16‐71), and at follow‐up, 66 mm (range 23‐91). Residents found the exercise useful both initially, 50 mm (range 4‐86), and at follow‐up, 49 mm (range 15‐81). Ninety‐two percent of the residents thought the goals of the exercise had been met. Residents also stated the study changed their approach to patient care (45 mm, range 4‐76) and made them a better physician (49 mm, range 5‐80). Conclusions: The ED visit study enhanced patient empathy within residents and was useful in improving patient care attitude.
Pantomography vs Mandibular Series for the Detection of Mandibular Fractures
Authors: Guss David A. , Clark Richard F. , Peitz Tom , Taub Marc
Published: January 2008

Abstract. Objective: The two primary radiographic techniques used for the evaluation of mandible injury are a pantomographic series (PS) and the standard four‐view mandibular series (MS). Despite a tenuous foundation, there is apparent bias in favor of PS compared with MS. Many emergency departments do not have ready access to the specialized equipment necessary to perform a pantomographic study. The hypothesis of this study was that a high‐quality standard MS is as sensitive and specific as a PS in the detection of mandibular fractures. Methods: This was a prospective, blinded study of 54 patients presenting with acute mandibular injury comparing MS and PS. The study design used two board‐certified emergency physicians and a single staff radiologist who read a series of MS and PS films in a randomized fashion without access to clinical information or identifying patient data. The absolute number of fractures present was determined by a neuroradiologist with access to both MS and PS simultaneously as well as pertinent clinical information. Results: Thirty patients had 47 mandibular fractures. The sensitivity for fracture detection for each physician was 0.85, 0.77, and 0.89 with MS and 0.79, 0.74, and 0.83 with PS (p ≥ 0.51, p ≥ 1.00, and p ≥ 0.51, respectively, McNemar's binomial test). The specificity for fracture detection for each physician was 0.88, 0.92, and 0.96 for MS and 0.96, 1.00, and 0.92 for PS (p > 0.625, p > 0.50, and p = 1.00, respectively, McNemar's binomial test). Conclusions: A standard mandibular series is as sensitive and specific as pantomography in the detection of mandibular fractures.
Rattlesnake Venom‐induced Thrombocytopenia Response to Antivenin (Crotalidae) Polyvalent: A Case Series
Authors: Bush Sean P. , Wu Victor H. , Corbett Stephen W.
Published: January 2008

Abstract. Objective: To test the hypothesis that rattlesnake venom‐induced thrombocytopenia would improve following Antivenin (Crotalidae) Polyvalent administration, and that the degree of platelet increase would correlate with the dosage of antivenom. Methods: The authors conducted a retrospective review of all patients admitted for rattlesnake envenomation at two southern California hospitals between 1980 and 1998. Patients were included if platelet count was less than 150 × 109/L following a rattlesnake bite. Patients were excluded if they received platelet transfusion. The relationship between Antivenin (Crotalidae) Polyvalent administration and venom‐induced thrombocytopenia was evaluated by linear regression and paired t‐test. Results: The authors identified 103 cases of rattlesnake envenomation. Seventeen cases met inclusion criteria for thrombocytopenia. Two patients were excluded because they received platelet transfusions. One additional patient was excluded from paired t‐test only because no antivenom was given. Thrombocytopenia usually improved between presentation and discharge (mean difference, 44 × 109/L), although complete resolution was often not achieved. A statistically significant partial improvement in platelet counts immediately after antivenom administration was observed in a subset of patients with severe thrombocytopenia (platelet count <100 × 109/L) (mean difference, 64 × 109/L). Using regression analysis, the authors did not detect a linear relationship between the amount of Antivenin (Crotalidae) Polyvalent administered and the degree of improvement. Conclusions: Although rattlesnake venom‐induced thrombocytopenia usually improves immediately after Antivenin (Crotalidae) Polyvalent administration and by the time of discharge, the degree of improvement is frequently incomplete and of uncertain clinical significance in the absence of life‐threatening bleeding. The authors found no correlation between the degree of improvement and the dosage of Antivenin (Crotalidae) Polyvalent.
The Effects of Graded Doses of Endothelin‐1 on Coronary Perfusion Pressure and Vital Organ Blood Flow during Cardiac Arrest
Authors: DeBehnke Daniel
Published: January 2008

Background: Endothelin‐1 (ET‐1) is a potent vasoconstrictor and has been shown to improve coronary perfusion pressure (CPP) during arrest. The effects of ET‐1 on organ blood flow during arrest have not been extensively studied. Objective: To investigate the effects of ET‐1 on myocardial and cerebral blood flow during cardiac arrest. Methods: Sixty immature swine were anesthetized and instrumented. The animals were randomized to receive one of three doses of ET‐1 (50, 150, or 300 μg) or placebo with/without standard‐dose epinephrine (SDE) during cardiac arrest. After a 10‐minute period of no‐flow ventricular fibrillation (VF), cardiopulmonary resuscitation (CPR) was performed for 3 minutes, followed by drug administration. Placebo or SDE was given every 3 minutes. Myocardial and cerebral blood flow was measured using a fluorescent microsphere technique. Results: Prearrest and CPR variables were not different between groups. Beginning 4 minutes after giving 300 μg ET‐1 with or without SDE, CPP was significantly increased compared with SDE alone. Total myocardial blood flow following ET‐1 administration was no different than myocardial blood flow following SDE alone. Cerebral blood flow increased 3.5 minutes after administration of 300 μg ET‐1 with SDE and reached significance 9.5 minutes after drug administration when compared with SDE alone [92.5 (48.8‐117.9) vs 15.6 (7.7‐23) mL/min/100 g]. Conclusions: Three hundred μg ET‐1 with SDE increases CPP and improves cerebral blood flow but does not improve myocardial blood flow during cardiac arrest. The peripheral effects of ET‐1 significantly improve CPP and cerebral blood flow, but myocardial blood flow is not increased due to coronary vasoconstriction.
Two‐thumb vs Two‐finger Chest Compression in an Infant Model of Prolonged Cardiopulmonary Resuscitation
Authors: Dorfsman Michele L. , Menegazzi James J. , Wadas Richard J. , Auble Thomas E.
Published: January 2008

Abstract. Objective: Previous experiments in the authors swine lab have shown that cardiopulmonary resuscitation (CPR) using two‐thumb chest compression with a thoracic squeeze (TT) produces higher blood and perfusion pressures when compared with the American Heart Association (AHA)‐recommended two‐finger (TF) technique. Previous studies were of short duration (1‐2 minutes). The hypothesis was that TT would be superior to TF during prolonged CPR in an infant model. Methods: This was a prospective, randomized crossover experiment in a laboratory setting. Twenty‐one AHA‐certified rescuers performed basic CPR for two 10‐minute periods, one with TT and the other with TF. Trials were separated by 2‐14 days, and the order was randomly assigned. The experimental circuit consisted of a modified manikin with a fixed‐volume arterial system attached to a neonatal monitor via an arterial pressure transducer. The arterial circuit was composed of a 50‐mL bag of normal saline solution (air removed) attached to the manikin chest plate and connected to the transducer with a 20‐gauge intravenous catheter and tubing. Rescuers were blinded to the arterial pressure tracing. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were recorded in mm Hg, and pulse pressures (PPs) were calculated. Data were analyzed with two‐way repeated‐measures analysis of variance. Sphericity assumed modeling, with Greenhouse‐Geisser and Huynh‐Feldt adjustments, was applied. Results: Marginal means for TT SBP (68.9), DBP (17.6), MAP (35.3), and PP (51.4) were higher than for TF SBP (44.8), DBP (12.5), MAP (23.3), and PP (32.2). All four pressures were significantly different between the two techniques (p ≤ 0.001). Conclusion: In this infant CPR model, TT chest compression produced higher MAP, SBP, DBP, and PP when compared with TF chest compression during a clinically relevant duration of prolonged CPR.
Calcium and Digoxin vs Calcium Alone for Severe Verapamil Toxicity
Authors: Bania Theodore C. , Blaufeux Brian , Hughes Sidney , Almond Gregory L. , Homel Peter
Published: January 2008

Abstract. Calcium chloride (CaCl2) is ineffective in severe calcium channel antagonist overdoses. Digoxin increases intracellular calcium by inhibiting the sodium—potassium adenosine triphosphatase enzymes. Objective: To examine the effect of calcium and digoxin on the treatment of verapamil toxicity. Methods: Sixteen dogs were instrumented to monitor hemodynamics. Verapamil toxicity (50% decrease in mean arterial pressure) was induced with verapamil (VER) at 6 mg/kg/hr and maintained for 30 minutes by titrating the VER rate. Following toxicity, the dogs received either digoxin (0.018 mg/kg) (DIG) (n= 8) or saline (No‐DIG) (n= 8). Both groups received VER at three sequential rates (1 mg/kg/hr from 0 to 90 min, 6 mg/kg/hr from 90 to 130 min, and 18 mg/kg/hr from 130 to 170 min). Calcium boluses were given (500 mg at 0 and 15 min; 1 g at 140, 150, and 160 min). Data were analyzed using a repeated‐measures analysis of covariance comparing DIG vs No‐DIG across the infusion rates and time. Animal weight, does of VER administered during the toxicity phase, and baseline values were included as covariates. Mortality rates were compared at 230 minutes following a total dose of 500 mg of VER. Results: The DIG group had a higher systolic blood pressure (SBP) than the No‐DIG group during the 1‐mg/kg/hr (early p = 0.028, late p = 0.01), 6‐mg/kg/hr (p = 0.051), and 18‐mg/kg/hr (p = 0.038) VER infusion rates. There were no deaths in the DIG group and four deaths in the No‐DIG group (Fisher = 0.08). Neither ventricular tachycardia nor ventricular fibrillation developed in either group. Other hemodynamic parameters did not show significant changes. Conclusions: In a model of severe verapamil toxicity, digoxin plus calcium raised SBP and did not result in ventricular arrhythmias when compared with calcium alone.
Concordance of Clinical Findings and Clinical Judgment in the Diagnosis of Streptococcal Pharyngitis
Authors: Nawaz Haq , Smith David S. , Mazhari Ramesh , Katz David L.
Published: January 2008

Abstract. Objective: It is uncertain how reliably clinicians apply clinical predictors of group A beta hemolytic streptococcal pharyngitis (GABHSP) to form a clinical impression, and how reliably this impression predicts culture results. The objective was to study clinician accuracy in diagnosing GABHSP. Methods: This was a prospective cohort study, conducted at an urgent care center of a major university. A convenience sample of 218 patients, aged 9‐83 years, presenting with sore throat, was enrolled. Symptoms and signs of pharyngitis were documented on a standardized form; the likelihood of GABHSP was plotted on a visual analog scale; and throat culture was obtained. A comparison was then made between the clinical impression on presentation and the throat culture result. Results: Throat cultures were positive for GABHSP in 41 patients (19%). The probability of GABHSP was related to node size and tenderness, tonsillar exudate and hypertrophy, and pharyngeal erythema (p < 0.05); but not throat soreness, degree of fever, or cough. A strong clinical impression of GABHSP (>50% on the visual analog scale) was associated with tonsillar exudate and hypertrophy, tender nodes, and pharyngeal erythema. Together, these four predictors had a sensitivity of 71%, a specificity of 77%, and a positive predictive value of 46%. Conclusions: Clinicians in this study based their impression of GABHSP on the most reliable symptoms and signs. While a strong clinical suspicion of GABHSP predicted a greater probability of positive culture, the clinicians consistently overestimated the probability of GABHSP. Symptoms and signs predict GABHSP unreliably when used alone; they are helpful in modifying estimates of disease probability to facilitate optimal use of laboratory tests and antibiotics.
Early Discharge of Patients with Presumed Opioid Overdose: Development of a Clinical Prediction Rule
Authors: Christenson Jim , Etherington Jeremy , Grafstein Eric , Innes Grant , Pennington Sarah , Wanger Karen , Fernandes Chris , Spinelli John J. , Gao Min
Published: January 2008

Abstract. Objective: To develop a clinical prediction rule to identify patients who can be safely discharged one hour after the administration of naloxone for presumed opioid overdose. Methods: Patients who received naloxone for known or presumed opioid overdose were formally evaluated one hour later for multiple potential predictor variables. Patients were classified into two groups: those with adverse events within 24 hours and those without. Using classification and regression tree methodology, a decision rule was developed to predict safe discharge. Results: Clinical findings from 573 patients allowed us to develop a clinical prediction rule with a sensitivity of 99% (95% CI = 96% to 100%) and a specificity of 40% (95% CI = 36% to 45%). Patients with presumed opioid overdose can be safely discharged one hour after naloxone administration if they: 1) can mobilize as usual; 2) have oxygen saturation on room air of >92%; 3) have a respiratory rate >10 breaths/min and <20 breaths/min; 4) have a temperature of >35.0°C and <37.5°C; 5) have a heart rate >50 beats/min and <100 beats/min; and 6) have a Glasgow Coma Scale score of 15. Conclusions: This prediction rule for safe early discharge of patients with presumed opioid overdose performs well in this derivation set but requires validation followed by confirmation of safe implementation.
Ethics Seminars:Case Studies in “Futility”—Challenges for Academic Emergency Medicine
Authors: Marco Catherine A. , Larkin Gregory L.
Published: January 2008

Abstract. The concept of “futility” and its determination in emergency medicine pose unique challenges to emergency physicians, patients, and society. The term “futility,” although commonly used, is problematic in its scope, meaning, and interpretation. To bridge this gap in understanding, the authors suggest the construct of clinically nonbeneficial interventions (CNBI), instead of “futility.” This language better informs discussions of nonbeneficial interventions across the risk spectrum of emergency medical practice, while retaining the focus on the patient's interests. Two cases are presented, which underscore the need for prudence and empathetic communication when addressing issues of CNBI. Determinations of expected benefit should be based on established scientific evidence, and the goals and values of patients, not on individual biases regarding quality of life or other subjective matters. While physicians are under no ethical obligation to provide treatments that they judge have no realistic likelihood of clinical benefit, the context in which these determinations take place is of critical importance. When certain interventions are appropriately withheld, concerted efforts should be made to maintain effective communication, comfort, support, and counseling for patients, friends, and families. In all aspects of clinical decision making, the value of various interventions and therapies must be based on expected risks and benefits to the patients, first and foremost.
Effects of Alcohol on the Geographic Variation of Driver Fatalities in Motor Vehicle Crashes
Authors: Borgialli Dominic A. , Hill Elizabeth M. , Maio Ronald F. , Compton Charles P. , Gregor Mary Ann
Published: January 2008

Abstract: Objective: To determine whether the increased risk of dying in a rural vs nonrural motor vehicle crash (MVC) can be attributed to driver demographics, crash characteristics, or police‐reported alcohol use. Methods: A retrospective cohort study was conducted, comparing all rural (116,242) and a 20% random sample of nonrural (104,197) Michigan drivers involved in an MVC during 1994‐1996. Data consisted of all police‐reported traffic crashes on public roadways. A logistic regression model was created, using survival as the dependent variable and gender, age, crash characteristics, and rural or nonrural county as independent variables. Driver alcohol use, as reported by the investigating officer, was introduced into the model, and the effect was analyzed. Results: Nonsurvivors represented 0.2% of the total; 99.8% were survivors. Police‐reported alcohol use was reported for 3.9% of drivers. Drivers in rural MVCs were more likely to be male, to be more than 50 years of age, to have been drinking alcohol, and to have more severe vehicle deformation as a result of the MVC. The relative risk (RR) for MVC nonsurvivors was 1.69 [95% confidence interval (CI) = 1.3 to 2.1] times higher for drivers in rural than nonrural counties. After adjusting for demographic and crash characteristics, the RR was 1.56 (95% CI = 1.2 to 1.9). Controlling for alcohol and its interactions decreased the RR to 1.26 (95% CI = 0.6 to 2.4), a nonsignificant difference between rural and nonrural MVC mortalities. Conclusions: Alcohol use by drivers in Michigan was a significant contributor for nonsurvivors of rural crashes. Efforts to decrease rural MVC mortality must address alcohol use.
Association of Naphthalene with Acute Hemolytic Anemia
Authors: Sanctucci Karen , Shah Binita
Published: January 2008

Abstract: Objectives: To describe the prevalence and severity of naphthalene‐associated hemolysis (NAH) and infection‐associated hemolysis (IAH) in children with glucose‐6‐phosphate dehydrogenase (G‐6‐PD) deficiency. To survey the rationale for naphthalene‐containing moth repellent (mothball) use in the study population and to compare this with that of a more diverse population. Methods: A ten‐year retrospective chart review of 160 patients with G‐6‐PD deficiency and/or anemia and an analysis of 24 hospitalized African‐American children with an episode of acute hemolysis associated with G‐6‐PD deficiency were conducted. The parents of 330 children cared for in the pediatric emergency departments (EDs) of two tertiary care centers were questioned regarding domestic mothball (naphthalene) use. Results: Fourteen of 24 (58.3%) of the children identified with G‐6‐PD deficiency presented with hemolysis associated with exposure to naphthalene‐containing moth repellents. The remaining ten had IAH. Seventy‐nine percent of the NAH group required transfusion, compared with 60% of the IAH group. Mothballs were reportedly used by 27% of the families surveyed in one inner‐city population with a 2‐13% incidence of G‐6‐PD deficiency and by 15% in a more culturally diverse city. The main reported motivation for use was the fresh scent, not as a moth repellent. Conclusions: Mothballs are used for previously unrecognized reasons. Naphthalene‐containing mothballs can pose a hematologic threat to vulnerable populations.
Public Expectations of Survival Following Cardiopulmonary Resuscitation
Authors: Jones G. Kirk , Brewer Kori L. , Garrison Herbert G.
Published: January 2008

Abstract: Previous studies have demonstrated that the public maintains unrealistic expectations of the potential for successful recovery following administration of cardiopulmonary resuscitation (CPR). Others have attributed this phenomenon to misrepresentation of CPR outcomes on television and other sources of public information. Objectives: To determine public expectations of CPR and correlate these expectations with various sources of information regarding CPR, including age, television, personal medical training, public programs, friends/family with medical training, and personal experience with CPR. Methods: A written survey was randomly distributed to local church congregations and completed on a voluntary basis. Results: Ninety‐six percent of the respondents expected CPR to be unrealistically effective. Those factors found to increase predicted CPR survival rate were as follows: 1) being under 50 years of age, 2) use of television as a source of information regarding CPR, 3) personal medical training, and 4) use of public programs about CPR. Neither exposure to friends or family with medical training nor personal experience with CPR resulted in increased CPR survival predictions. Conclusions: Regardless of the source, the public is not accurately informed about the effectiveness of CPR. This creates a situation in which people may elect CPR for themselves or for family members when survival, not to mention recovery, is unlikely. Without dissemination of realistic statistics regarding survival and recovery following CPR, the public will maintain unrealistic expectations of CPR, and be unable to make well‐informed decisions concerning its use.
A Survey of Nonphysician Medical Screening Examinations in Academic Emergency Medicine
Authors: Beddingfield Frederick C. , Üner Atilla B. , Kwon Heejung , Baraff Larry J.
Published: January 2008

Abstract: Objectives: To determine the proportions of U.S. emergency medicine (EM) residency programs that use nonphysicians to perform medical screening examinations (MSEs) in lieu of a physician evaluation. Methods: This was a cross‐sectional observational study consisting of a mail survey of the 109 base hospitals of accredited U.S. EM residency programs. Follow‐up letters were sent twice to nonrespondents. Questions regarding ED demographics, the performance and structure of MSEs by physicians and nonphysicians, and the exact nature and purpose of such examinations were included. Results: Ninety of 109 (83%) programs responded. Eighty‐seven of the 90 programs (97%) perform MSEs on all patients presenting to the ED prior to discharge. Thirty‐seven percent (33/90) perform nonphysician MSEs (NPMSEs) at least some of the time. Fifty percent (16/32) refer patients to an outside facility based on the result of the screening, and in 32% of cases the patient is not offered the choice of an ED evaluation. Seventy percent (19/27) at times refer patients, including uninsured patients, to a same‐day clinic within their hospital system. Seven of 27 (26%) programs performing NPMSEs reported occasional adverse events, defined as two to 11 per year. Eight of 22 (36%) reported poorer clinical outcomes than expected from ED care as a result of the NPMSE, and 18 of 25 (72%) reported some degree of patient dissatisfaction. Two programs reported death as a result of NPMSEs. Conclusions: The use of NPMSEs is common and is frequently used as a basis for referring patients away from the ED without a physician examination. Using NPMSEs may be associated with adverse events, including patient dissatisfaction, morbidity, and possibly, mortality.
On the Future of Reanimatology*
Authors: Safar Peter
Published: January 2008

Abstract: This article is adapted from a presentation given at the 1999 SAEM annual meeting by Dr. Peter Safar. Dr. Safar has been involved in resuscitation research for 44 years, and is a distinguished professor and past initiating chairman of the Department of Anesthesiology and Critical Care Medicine at the University of Pittsburgh. He is the founder and director of the Safar Center for Resuscitation Research at the University of Pittsburgh, and has been the research mentor of many critical care and emergency medicine research fellows. Here he presents a brief history of past accomplishments, recent findings, and future potentials for resuscitation research. Additional advances in resuscitation, from acute terminal states and clinical death, will build upon the lessons learned from the history of reanimatology, including optimal delivery by emergency medical services of already documented cardiopulmonary cerebral resuscitation, basic‐advanced—prolonged life support, and future scientific breakthroughs. Current controversies, such as how to best educate the public in life‐supporting first aid, how to restore normotensive spontaneous circulation after cardiac arrest, how to rapidly induce mild hypothermia for cerebral protection, and how to minimize secondary insult after cerebral ischemia, are discussed, and must be resolved if advances are to be made. Dr. Safar also summarizes future technologies already under preliminary investigation, such as ultra‐advanced life support for reversing prolonged cardiac arrest, extending the “golden hour” of shock tolerance, and suspended animation for delayed resuscitation.
Media Reviews
Authors: Bair Aaron E.
Published: January 2008

Abstract: Grave Words: Notifying Survivors about Sudden, Unexpected Deaths. By Kenneth V. Iserson

Review and Self‐Assessment to Accompany Emergency Medi‐cine. BY JOHN M. HOWELL, JUDITH LINDEN, DONALD BARTON, and SHEREE GIVRE
Patients' Perceptions of Route of Nonsteroidal Anti‐inflammatory Drug Administration and Its Effect on Analgesia
Authors: Schwartz Nicholas A. , Turturro Michael A. , Istvan David J. , Larkin Gregory L.
Published: January 2008

Abstract. Objective: There is a commonly held belief among health care providers that patients respond better to parenteral nonsteroidal anti‐inflammatory drugs (NSAIDs) than to oral forms by virtue of the patients' belief that getting an injection means they are receiving “stronger” medicine. To the authors' knowledge, this effect has never been adequately documented in the literature. The objective of this study was to compare the effects of a placebo analgesic injection vs placebo oral analgesia on patients with acute musculoskeletal pain. Methods: A convenience sample of emergency department (ED) patients with acute musculoskeletal pain secondary to trauma were enrolled. Patients received 225 mL of orange‐flavored drink containing 800 mg of ibuprofen. Patients then received either a physiologically inactive starch tablet resembling ibuprofen 800 mg in taste and appearance or a physiologically inactive saline intramuscular (IM) injection resembling ketorolac 60 mg. Both patients and research nurses were blinded to the addition of ibuprofen to the drink and the inactive nature of subsequent medication. Pain was evaluated at time 0 and at 30, 60, 90, and 120 minutes on a 10‐mm visual analog scale (VAS). Results: Sixty‐four patients completed the study protocol. The VAS scores between groups did not differ significantly at baseline or at each subsequent interval (p = 0.86). Conclusions: These results contradict the belief that parenteral medications confer a selective placebo effect stemming from patients' beliefs regarding route of administration and efficacy. Therefore, the routine use of IM administration of NSAIDs for suspected enhanced analgesia appears unwarranted.
Cocaine‐associated Chest Pain How Common Is Myocardial Infarction?
Authors: Weber Jim Edward , Chudnofsky Carl R. , Boczar Michael , Boyer Edward W. , Wilkerson Mark D. , Hollander Judd E.
Published: January 2008

Abstract. Objective: Prior studies addressing the incidence of acute myocardial infarction (AMI) in patients with cocaine‐associated chest pain have found divergent results. Previous prospective studies, which found approximately a 6% incidence of AMI, have been criticized for selection bias. This study sought to determine the rate of AMI in patients with cocaine‐associated chest pain. Methods: All patients seen in an urban university‐affiliated hospital between July 1996 and February 1998 were identified by ICD‐9 medical records search for cocaine use and chest pain/acute coronary syndromes. In this system, all faculty admit all patients with cocaine‐associated chest pain for at least 23‐hour observation periods. Data collected included demographics, medical and cocaine use history, presenting characteristics, hospital course, cardiovascular complications, and diagnostic tests using a 119‐item closed‐question data instrument with high interrater reliability. The main outcome measure was AMI according to World Health Organization (WHO) criteria. Results: There were 250 patients identified with a mean age of 33.5 ± 8.5 years; 77% were male; 84% were African American. Of 196 patients tested, 185 had cocaine or cocaine metabolites in the urine (94%). The incidence of cardiac risk factors were: hypercholesterolemia, 8%; diabetes, 6%; family history, 34%; hypertension, 26%; tobacco use, 77%; prior MI, 6%; and prior chest pain, 40%. Seventy‐seven percent admitted to cocaine use in the preceding 24 hours: crack, 85%; IV, 2%; nasal, 6%. Twenty‐five patients (10%) had electrocardiographic evidence of ischemia. A total of 15 patients experienced an AMI (6%; 95% CI = 4.1% to 8.9%) using WHO criteria. Complications were infrequent: bradydysrrhythmias, 0.4%; congestive heart failure, 0.4%; supraventricular tachycardia, 1.2%; sustained ventricular tachycardia, 0.8%. Conclusion: The incidence of AMI was 6% in patients with cocaine‐associated chest pain. This result is identical to that found in prior prospective studies.
Randomized, Double‐blind, Placebo‐controlled Trial of Diazepam, Nitroglycerin, or Both for Treatment of Patients with Potential Cocaine‐associated Acute Coronary Syndromes
Authors: Baumann Brigitte M. , Perrone Jeanmarie , Hornig Sarah E. , Shofer Frances S. , Hollander Judd E.
Published: January 2008

Abstract. Introduction: To the authors' knowledge, treatment of patients with cocaine‐associated acute coronary syndromes has not been rigorously investigated in symptomatic patients. Objective: To perform a randomized double‐blind trial of diazepam, nitroglycerin, or both for treatment of patients with potential cocaine‐associated acute coronary syndromes. Methods: Patients with potential cocaine‐associated acute coronary syndromes were randomized to treatment with either diazepam, nitroglycerin, or both every 5 minutes or until symptom resolution. Outcomes were chest pain resolution (measured by visual analog scale), and changes in blood pressure, pulse rate, cardiac output (L/min), cardiac index (L/min/m2), stroke volume (mL/beat), and stroke index (mL/beat/m2) over the 15‐minute treatment period. To adjust for seven outcomes using the Bonferroni correction, alpha was set at 0.007. Results: Forty patients were enrolled (diazepam, 12; nitroglycerin, 13; both, 15). Patients had a mean age (±SD) of 35.4 (±7.5) years; 75% were male. They presented a mean of 5 hours and 37 minutes after cocaine use. Baseline demographics, cocaine use patterns, chest pain characteristics, and initial electrocardiograms were similar for all groups. Chest pain severity improved similarly in the threev groups [‐33.3 mm (±8.0); ‐30.7 mm (±7.1); ‐33.0 mm (±7.9); p = 0.6]. The stroke index decreased during the 15‐minute treatment period for all groups (diazepam, ‐8.7 (±3.3); nitroglycerin, ‐3.1 ± 2.8; both, ‐1.8 (±3.1) mL/beat/m2; p = 0.03). After adjustment for differences between baseline hemodynamic and cardiac profiles and multiple comparisons, there was no difference in any response to therapy over time for the different treatments. Conclusions: For treatment of patients with potential cocaine‐associated acute coronary syndromes, chest pain resolutions and changes in cardiac performance are not different in patients treated with diazepam or nitroglycerin. In this study, the use of both agents did not offer any advantage over either agent alone.
Effect of Exogenous Melatonin on Mood and Sleep Efficiency in Emergency Medicine Residents Working Night Shifts
Authors: Jockovich Milan , Cosentino David , Cosentino Lynn , Wears Robert L. , Seaberg David C.
Published: January 2008

Abstract. Objective: To determine whether melatonin taken prior to attempted daytime sleep sessions will improve daytime sleep quality, nighttime sleepiness, and mood state in emergency medicine (EM) residents, changing from daytime to nighttime work schedules. Methods: A prospective, randomized, double‐blind crossover design was used in an urban emergency department. Emergency medicine residents who worked two strings of nights, of at least three nights' duration each, and separated by at least one week of days were eligible. Subjects were randomized to receive either melatonin 1 mg or placebo, 30 to 60 minutes prior to their daytime sleep session, for three consecutive days after each night shift. Crossover to the other agent occurred during their subsequent night shifts. Objective measures of quality of daytime sleep were obtained using the Actigraph 1000. This device measures sleep motion and correlates with sleep efficiency, total sleep time, time in bed, and sleep latency. The Profile of Mood States (POMS) and the Stanford Sleepiness Scale (SSS) were also used to quantify nighttime mood and sleepiness. Results: Among the 19 volunteers studied, there was no difference in sleep efficiency (91.16% vs 90.98%, NS), sleep duration (379.6 min vs 342.7 min, NS), or sleep latency (7.59 min vs 6.80 min, NS), between melatonin and placebo, respectively. In addition, neither the POMS total mood disturbance (5.769 baseline vs 12.212 melatonin vs 5.585 placebo, NS) nor the SSS (1.8846 baseline vs 2.2571 melatonin vs 2.1282 placebo, NS) demonstrated a statistical difference in nighttime mood and sleepiness between melatonin and placebo. Conclusions: There are no beneficial effects of a 1‐mg melatonin dose on sleep quality, alertness, or mood state during night shift work among EM residents.
Adverse Outcomes and Opioid Analgesic Administration in Acute Abdominal Pain
Authors: Lee Jacques S. , Stiell Ian G. , Wells George A. , Elder Brian R. , Vandemheen Katherine , Shapiro Stanley
Published: January 2008

Abstract. To the authors' knowledge, no outcome‐based, randomized clinical trial of the safety of opioid analgesics in acute abdominal pain exists. Objectives: 1) To assess the feasibility of a randomized clinical trial of opioid safety by estimating the adverse outcome rate among patients with abdominal pain severe enough to necessitate opioid analgesics. 2) To explore the association of opioid administration with adverse outcomes in acute abdominal pain. Methods: The authors conducted a prospective observational study of emergency department (ED) abdominal pain patients, and followed them by telephone at three weeks to determine whether an adverse outcome occurred (defined as obstruction, perforation, ischemia, hemorrhage, peritonitis, sepsis, or death). A logistic regression of factors predicting adverse outcome was performed. Results: Adverse outcomes occurred in 67 of 860 abdominal pain patients (7.8%, 95% CI = 6.1% to 9.8%), and 252 of 860 (29%) received opioids. The adverse outcome rate was 12.7% (95% CI = 9.0% to 17.0%) among patients who received opioids. Variables predictive of adverse outcome in logistic regression included: ED diagnosis of adverse outcome (OR 12.4), age (OR 1.6 per decade), fever (OR 4.6), received opioids (OR 2.1), pain duration (OR 1.5 per day), and leukocytosis (OR 2.0). Conclusions: A clinical trial would need to randomize more than 1,500 patients to establish the equivalent adverse outcome rates of opioids and placebo: the sample size of all existing studies combined is insufficient to make such a conclusion. Although opioids were associated with a higher adverse outcome rate in this logistic regression, the authors believe this may be due to confounding by pain severity. They emphasize that the study's design precludes conclusion of a causal link. No change in clinical practice is warranted. A randomized clinical trial of sufficient size to definitively resolve this issue is needed.
Do Emergency Physicians Save Time When Locating a Live Intrauterine Pregnancy with Bedside Ultrasonography?
Authors: Blaivas Michael , Sierzenski Paul , Plecque David , Lambert Michael
Published: January 2008

Abstract. Objective: To determine whether patients presenting to the emergency department (ED) with first‐trimester pregnancy complications have a decreased length of stay (LOS) when a live intrauterine pregnancy (IUP) is diagnosed by emergency physicians (EPs). Methods: This study was performed at an urban community ED with a residency program and an annual census of 65,000. A retrospective chart review from October 1995 to August 1998 identified 1,419 patients who received ultrasound examinations confirming live IUP in the first trimester with pain and/or bleeding. Two hundred seventy‐seven of these patients received their ultrasound examinations from EPs; 1,142 patients received a study from radiology and were not scanned by EPs. The LOSs for the two groups were compared and defined as the time from being placed into a room to discharge from the ED. Significance was determined using a two‐tailed t‐test. Median times with confidence intervals were calculated. Results: When patients had a live IUP confirmed by an EP, the median LOS was 21% (59 min) less than those who received an ultrasound examination by radiology (p = 0.0001; 95% CI = 49 min to 1 hr 17 min). When evaluated by time of day, patients who presented after hours (6 PM to 6 AM) and were scanned by EPs spent 28% (1 hr 17 min) less time in the ED (p = 0.0001; 95% CI = 55 min to 1 hr 37 min). Conclusions: Emergency physicians identifying live IUP with bedside ultrasonography significantly decreased patients' LOSs in the ED. The decrease in LOS was most apparent for patients presenting during evening and nighttime hours.