bluuebunny/crossref_metadata_2025 huggingface dataset:
The Effect of Soft Cervical Collars on Persistent Neck Pain in Patients with Whiplash Injury
Authors: Gennis Paul , Miller Leslie , Gallagher E. John , Giglio James , Carter Wallace , Nathanson Noel
Published: September 2008

Objective: To assess the efficacy of soft cervical collars in the early management of whiplash‐injury‐related pain.

Methods: A controlled, clinical trial was conducted in an urban ED. Adults with neck pain following automobile crashes indicated their initial degrees of pain on a visual analog scale. Patients with cervical spine fractures or subluxation, focal neurologic deficits, or other major distracting injuries were excluded. Patients were assigned to receive a soft cervical collar or no collar based on their medical record numbers. Pain at ≥ 6 weeks postinjury was coded as none, better, same, or worse, and analyzed as 3 dichotomous outcomes: recovered (pain = none); improved (pain = none or better); and deteriorated (pain = worse).

Results: Of 250 patients enrolled, 196 (78%) were available for follow‐up. Of these patients, 104 (53%) were assigned to the soft cervical collar group, and 92 (47%) to the control group. These groups were similar in age, gender, seat position in the car, seat belt use, and initial pain score. Pain persisted at ≥ 6 weeks in 122 (62%) patients. The groups showed no difference in follow‐up pain category (p = 0.59). There was no significant difference between the 2 groups in complete recovery (p = 0.34), improvement (p = 0.34), or deterioration (p = 0.60). The study had a power of 80% to detect an absolute difference of at least 20% in recovery, 17% in improvement, and 7% in deterioration (2–tailed, ex = 0.05).

Conclusions: Most patients with whiplash injuries have persistent pain for at least 6 weeks. Soft cervical collars do not influence the duration or degree of persistent pain.
Treatment of Out‐of‐hospital Supraventricular Tachycardia: Adenosine vs Verapamil
Authors: Jr. William J. Brady , DeBehnke Daniel J. , Wickman Lauri L. , Lindbeck George
Published: September 2008

Objective: To compare the use of adenosine and the use of verapamil as out‐of‐hospital therapy for supraventricular tachycardia (SVT).

Methods: A period of prospective adenosine use (March 1993 to February 1994) was compared with a historical control period of verapamil use (March 1990 to February 1991) for SVT. Data were obtained for SVT patients treated in a metropolitan, fire‐department‐based paramedic system serving a population of approximately 1 million persons. Standard drug protocols were used and patient outcomes (i.e., conversion rates, complications, and recurrences) were monitored.

Results: During the adenosine treatment period, 105 patients had SVT; 87 (83%) received adenosine, of whom 60(69%) converted to a sinus rhythm (SR). Vagal maneuvers (VM) resulted in restoration of SR in 8 patients (7.6%). Some patients received adenosine for non‐SVT rhythms: 7 sinus tachycardia, 18 atrial fibrillation, 7 wide‐complex tachycardia (WCT), and 2 ventricular tachycardia; no non‐SVT rhythm converted to SR and none of these patients experienced an adverse effect. Twenty‐five patients were hemodynamically unstable (systolic blood pressure < 90 mm Hg), with 20 receiving drug and 13 converting to SR; 8 patients required electrical cardioversion. Four patients experienced adverse effects related to adenosine (chest pain, dyspnea, prolonged bradycardia, and ventricular tachycardia). In the verapamil period, 106 patients had SVT; 52 (49%) received verapamil (p < 0.001, compared with the adenosine period), of whom 43 (88%) converted to SR (p = 0.11). Two patients received verapamil for WCT; neither converted to SR and both experienced cardiovascular collapse. VM resulted in restoration of SR in 12 patients (11.0%) (p = 0.52). Sixteen patients were hemodynamically unstable, with 5 receiving drug (p = 0.005) and 5 converting to SR; 9 patients required electrical cardioversion (p = 0.48). Four patients experienced adverse effects related to verapamil (hypotension, ventricular tachycardia, ventricular fibrillation). Recurrence of SVT was noted in 2 adenosine patients and 2 verapamil patients in the out‐of‐hospital setting and in 23 adenosine patients and 15 verapamil patients after ED arrival, necessitating additional therapy (p = 0.48 and 0.88, for recurrence rates and types of additional merapies, respectively). Hospital diagnoses, outcomes, and ED dispositions were similar for the 2 groups.

Conclusion: Adenosine and verapamil were equally successful in converting out‐of‐hospital SVT in patients with similar etiologies responsible for the SVT. Recurrence of SVT occurred at similar rates for the 2 medications. Rhythm misidentification remains a common issue in out‐of‐hospital cardiac care in this emergency medical services system.
Directional‐tip Endotracheal Tubes for Blind Nasotracheal Intubation
Authors: Hooker Edmond A. , Hagan Stuart , Coleman Royce , Heine Michael F. , Greenwood Patrick
Published: September 2008

Objectives: To compare initial success rates of blind nasotracheal intubation using directional‐tip endotracheal tubes vs standard endotracheal tubes.

Methods: A prospective trial comparing directional‐tip and standard endotracheal tubes during initial attempts at blind nasotracheal intubation (BNTI) at a university hospital ED. Using an alternating schedule, the directional‐tip or standard tube was used for the first attempt at BNTI. An attempt was defined as beginning when the tube was placed through the nose into the posterior pharynx and ending when the patient was intubated or the tube was removed from the nares. After the intubation, the physician graded the difficulty of the technique (i.e., easy/routine, intermediate, difficult, or unable to intubate nasally).

Results: There were 49 patients entered over 5 months. Patient presentations for the intubations were trauma (45.8%), overdose (33.3%), respiratory/cardiac event (12.5%), seizure (2.1%), and other (6.3%). Intubation was successful on the first attempt in 18 of 21 patients (86%; 95% CI, 64% to 97%) for the directional‐tip tube vs 16 of 28 patients (57%; 95% CI, 37% to 76%) for the standard tube (p = 0.03). The groups did not differ in age, sex, clinical presentation, or perceived difficulty of intubation. Only 1 patient could not be intubated nasally and was subsequently intubated orally.

Conclusion: The use of directional‐tip tubes may improve the success rate of the first attempt at BNTI.
Emergency Medicine Expeditions to the Developing World: The Loma Linda University Experience in Papua New Guinea
Authors: Clem Kathleen J. , Green Steven M.
Published: September 2008

Emergency physicians (EPs) are increasingly participating in international medicine in regions that are chronically medically underserved. In August 1994, a ten‐member emergency medicine team from the Loma Linda University School of Medicine staffed a 70‐bed bush hospital in the primitive highlands of Papua New Guinea, providing both outpatient and inpatient medical care. Typhoid fever, malaria, polio, and numerous other infectious diseases were encountered. Rampant local tribal warfare resulted in regular penetrating injuries from arrows, spears, and machetes. The expedition was judged highly successful, in that 1) substantial medical service was provided to tribespeople accustomed to minimal care, 2) education was provided to local health care providers, and 3) team participants became adept at managing medical conditions uncommon in industrialized societies, and gained valuable ethical and utilitarian perspectives regarding health care delivery in underserved areas. In this article the objectives, organization, and experiences of the team members are described. This information may encourage other EPs to participate in medical expeditions to the developing world, and to provide general principles to assist in their organization and implementation.
Out‐of‐hospital Treatment of Opioid Overdoses in an Urban Setting
Authors: Sporer Karl A. , Firestone Jennifer , Isaacs S. Marshal
Published: September 2008

Objectives: To investigate clinical outcomes in a cohort of opioid overdose patients treated in an out‐of‐hospital urban setting noted for a high prevalence of IV opioid use.

Methods: A retrospective review was performed of presumed opioid overdoses that were managed in 1993 by the emergency medical services (EMS) system in a single‐tiered, urban advanced life support (ALS) EMS system. Specifically. all patients administered naloxone by the county paramedics were reviewed. Those patients with at least 3 of 5 objective criteria of an opioid overdose [respiratory rate <6/min, pinpoint pupils, evidence of IV drug use, Glasgow Coma Scale (GCS) score <12, or cyanosis] were included. A response to naloxone was defined as improvement to a GCS 14 and a respiratory rate 10/min within 5 minutes of naloxone administration. ED dispositions of opioid‐overdose patients brought to the county hospital were reviewed. All medical examiner's cases deemed to be opioid‐overdose‐related deaths by postmortem toxicologic levels also were reviewed.

Results: There were 726 patients identified with presumed opioid overdoses. Most patients (609/726, 85.4%) had an initial pulse and blood pressure (BP). Most (94%) of this group responded to naloxone and all were transported. Of the remainder, 101 (14%) had obvious signs of death and 16 (2.2%) were in cardiopulmonary arrest without obvious signs of death. Of the patients in full arrest, 2 had return of spontaneous circulation but neither survived. Of the 609 patients who had initial BPs, 487 (80%) received naloxone IM (plus bag‐valve‐mask ventilation) and 122 (20%) received the drug IV. Responses to naloxone were similar; 94% IM vs 90% IV. Of 443 patients transported to the county hospital, 12 (2.7%) were admitted. The admitted patients had noncardiogenic pulmonary edema (n = 4). pneumonia (n = 2), other infections (n = 2), persistent respiratory depression (n = 2). and persistent alteration in mental status (n = 2). The patients with pulmonary edema were clinically obvious upon ED arrival. Hypotension was never noted and bradycardia was seen in only 2% of our presumed‐opioid:overdose population.

Conclusions: The majority of the opioid‐overdose patients who had initial BPs responded readily to naloxone, with few patients requiring admission. Noncardiogenic pulmonary edema was uncommon and when present, hypoxia was evident upon arrival to the ED. Naloxone administered IM in conjunction with bag‐valve‐mask ventilation was effective in this patient population. The opioid‐overdose patients in cardiopulmonary arrest did not survive.
Criteria‐based Expert System for Cardiac Ischemia Evaluation in the Emergency Department
Authors: Hirshberg Alan J.
Published: September 2008

Objective: To develop and evaluate a cardiac ischemia computer expert system using a criteria‐based expert shell for assessment of chest pain patients in a community hospital ED setting.

Methods: A retrospective, comparison study of the expert system against the clinical judgment of board‐certified emergency physicians (EPs) was performed in 1 community hospital ED. All chest pain patients had either a cardiac catheterization, Persantine stress testing, or both within 1 month of ED presentation. A final diagnosis of acute myocardial infarction or unstable angina by a consultant cardiologist represented the criterion standard for cardiac ischemia.

Results: Of the 59 patients meeting study criteria, 28 (47%) had cardiac ischemia. The expert system had equal sensitivity (100%) and was more than twice as specific (39% vs 16%) in diagnosing ischemic cardiac disease as were the board‐certified EPs (p < 0.001; McNemar's chi‐square with Yates' correction).

Conclusions: The criteria‐based system built around a system of findings ordered by Bayes' rule has potential to augment the ability of the EP to accurately diagnose ischemic heart disease.
Hypoglycemia Manifested by Sinus Bradycardia: A Report of Three Cases
Authors: Pollock Gary , Brady William J. , Hargarten Steve , DeSilvey Dennis , Carter C. Tom
Published: September 2008

Three cases are reported of hypoglycemia manifested by profound sinus bradycardia and fatigue, which responded to IV dextrose with prompt normalization of the cardiac rhythm. The cases involved 3 different patients and disease processes: a young female who had anorexia nervosa and profound malnutrition; an elderly, nondiabetic male who subsequently experienced a transient ischemic attack; and a patient who had diabetes mellitus managed with chronic, subcutaneous insulin administration. It is vitally important that the emergency physician recognize unusual clinical manifestations of hypoglycemia and fully evaluate such scenarios when hypoglycemia may occur. Untreated, hypoglycemia may result in significant chronic morbidity, and rarely, in death. Bradyarrhythmias–particularly sinus bradycardia–should be added to the list of potential clinical manifestations of hypoglycemia.
Informed Consent for Medical Research: Common Discrepancies and Readability
Authors: White Lynn J. , Jones Jeffrey S. , Felton Christopher W , Pool Linda C.
Published: September 2008

Objective: To identify common discrepancies and average reading grade levels for informed consent forms (ICFs) us submitted to institutional review boards (IRBs) by medical researchers.

Methods: A retrospective evaluation of ICFs as submitted to IRBs of 3 university‐affiliated hospitals during a I‐year period. ICF content was evaluated using a checklist of 23 requirements specified in the federal regulations governing human research. Documents then were computer‐analyzed to determine the readability scores using 2 common indexes of comprehension. A discrepancy was defined as any instance in which an ICF did not address an applicable requirement in the Code of Federal Regulations.

Results: Eighty‐two ICFs representing 16 medical specialties were evaluated; 8 (10%) were from emergency medicine. Eighteen ICFs (22%) were conspicuously incomplete, lacking 29 federal requirements. The mean number of discrepancies was 4.7 (95% CI, 3.9–5.5) Common omissions included: a statement about who is doing the research, number of subjects in the study, circumstances when a subject's participation may be terminated, disclosure of alternative procedures, and notice to subjects regarding new findings. The mean Flesch grade level required to read all ICFs was 13.8 (95% CI, 13.5–14.2), implying that the majority of the U.S. adult population would be unable to comprehend these forms.

Conclusion: Designing a consent form to meet all of the federal requirements while maintaining a level of reading comprehension suitable for the general population is a difficult task for investigators.
The Complete Blood Count and Reticulocyte Count–Are They Necessary in the Evaluation of Acute Vasoocclusive Sickle‐cell Crisis?
Authors: Lopez Bernard L. , Griswold. Sharon K. , Navek Anke , Urbanski Linda
Published: September 2008

Objective: To assess the usefulness of the complete blood count (CBC) and the reticulocyte count in the evaluation of adult patients with acute vasoocclusive sickle‐cell crisis (SCC) presenting to the ED.

Methods: A 2‐part study was performed. Part 1 was a retrospective chart review of patients with a sole ED diagnosis of acute SCC. Part 2 was a prospective evaluation of consecutive patients presenting in SCC. In both parts of the study, patients with coexisting acute disease were excluded. The remaining patients were divided into 2 groups: admitted and released. The mean values for white blood cell (WBC) count, hemoglobin (Hb) level, and reticulocyte count were compared. In Part 2. the change (Δ) from the patient's baseline in WBC count, Hb level, and reticulocyte count also was determined. Data were analyzed by 2‐tailed Student's t‐test.

Results: Part 1: There was no difference between the admitted (n = 33) and the released (n = 86) groups in mean WBC count (p = 0.10), Hb level (p = 0.25), or reticulocyte count (p = 0.08). Part 2: There was no difference between the admitted (n = 44) and the released (n = 160) groups in mean Hb level (p = 0.88). reticulocyte count (p = 0.47). AHb level (p = 0.88). and Areticulocyte count (p = 0.76). There was a difference in mean WBC counts (15.8 ± 4.9 × 109/L admitted vs 12.8 ± 4.9 × 109/L released, p = 0.003) and ΔWBC counts (5.1 ± 4.6 × 109/L admitted vs 1.8 ± 4.6 × 109/L released, p < 0.002).

Conclusion: Determination of the Hb level and the reticulocyte count do not appear useful in the evaluation of acute SCC in the ED. Admission decisions appear associated with elevations in the WBC count. Further study is required to determine the true value of the WBC count in such decisions.
Comparison of Hyperbaric Oxygen and Dapsone Therapy for Loxosceles Envenomation
Authors: Hobbs Gregory D. , Anderson Alena R. , Greene Thomas J. , Yealy Donald M.
Published: September 2008

Objective: To determine whether hyperbaric O2 (HBO), dapsone, or HBO plus dapsone affects lesion size in a swine model of Loxosceles envenomation.

Methods: In a randomized controlled animal laboratory experiment, 32 piglets were assigned to 1 of 4 equal groups. Each piglet received 15 μL of purified venom intradermally on day zero. Group 1 received no treatment; group 2 received HBO at 2 atm for 2 hours on days 1–3; group 3 received 50 mg of dapsone orally on days 1–3; and group 4 received dapsone 50 mg orally and HBO at 2 atm for 2 hours on days 1–3. On days 1–7, 14, and 21, an investigator blinded to the treatment groups measured necrosis and induration. Mean necrosis and induration rates were compared using analysis of variance for repeated measures.

Results: Comparing groups on any day, no significant difference was noted in necrosis, induration, reduction in necrosis from day 1, or rate of change in lesion size from days 1–7. A difference was seen in the reduction of induration between all 3 treatment groups and the control group on days 7 and 14 only. The sample size permitted a power of 0.8 to detect a 12‐mm mean change in lesion size.

Conclusion: Compared with the control, neither dapsone, HBO, nor the combination of dapsone and HBO reduced necrosis from Loxosceles envenomation on days 3–21. An increase was seen in the rate of reduction in induration between all 3 treatment groups and the control group on days 7–21. However, the magnitude of this effect was clinically insignificant. In this animal model, treatment with either dapsone or HBO or a combination offers little clinical benefit in Loxosceles envenomation.
Amrinone as an Antidote in Experimental Veraparnil Overdose
Authors: Koury Shaheed I. , Stone C. Keith , Thomas Stephen H.
Published: September 2008

Objective: To evaluate the effect of amrinone as a treatment for the hemodynamic effects of verapamil overdose in a canine model.

Methods: This nonblind interventional study was performed in an established canine model of verapamil toxicity, without concurrent control animals. Pentobarbital‐anesthetized and instrumented dogs (n = 8) were maintained and observed for 60 minutes or until death. The animals were overdosed with verapamil, 15 mg/kg IV, over 30 minutes. Hemodynamic parameters, including cardiac index (CI), heart rate (HR), and mean arterial pressure (MAP), were monitored. Completion of the verapamil infusion represented the defined point of toxicity; at that point, all the animals received an amrinone bolus of 2 mgkg IV over 2 minutes followed by an amrinone drip at 10 μg/kg/min. The hemodynamic values at the defined point of toxicity were compared with those obtained postinitiation of the amrinone infusion.

Conclusion: Amrinone appears to reverse the depressed cardiac index associated with verapamil overdose in a canine model while having no significant effect on the hypotension or bradycardia.
The Rate of Clinically Significant Plain Radiograph Misinterpretation by Faculty in an Emergency Medicine Residency Program
Authors: Nitowski Leonard A. , O'Connor Robert E. , Reese Charles L.
Published: September 2008

Objective: To estimate the rate of clinically significant discrepancies between radiograph interpretations by attending radiologists and emergency medicine (EM) faculty in 2 academic EDs, using a unique scoring system.

Methods: A retrospective comparison of radiographic agreement between EM and radiology faculty members was performed. All plain films initially interpreted by EM faculty or by EM residents with immediate rein‐terpretation by EM faculty were subsequently reviewed by attending radiologists. All discrepancies between these readings were reported to the ED on the following day for review by an EM faculty member (usually different from the initial EM faculty reader) who determined the need for treatment or follow‐up changes. A secondary chart review by a quality assurance faculty member determined whether radiographic findings not noted on the x‐ray log were present on the ED record. All discrepancies from February to June 1994 were reviewed. A severity score was assigned based on the following criteria. Q‐0: There was no change in treatment or follow‐up; or the initial interpretation by EM faculty was validated by repeat or additional views. Q‐1: Discrepancy is minor. Q‐2: Discrepancy is significant, with potential for injury or bad outcome. 4–3: Discrepancy is significant, with actual injury or bad outcome.

Results: Of 14,046 radiographic studies eligible for enrollment, there were 134 discrepancies (0.95%). Only 28 cases (0.2%) were found to be clinically significant. Of these, 25 were scored Q‐1, 3 were scored Q‐2, and 0 were scored 4–3. These clinically significant discrepancy rates were highest for the finger, skull, elbow, hand, and lumbar spine.

Conclusion: Emergency medicine faculty provide highly accurate rates of plain radiograph interpretation, particularly when adjusted for clinical significance and actual impact on patient care.
Emergency Medicine Resident Interpretation of Pediatric Radiographs
Authors: Brunswick J. Eric , Ilkhanipour Kaveh , Fuchs Susan , Seaberg David
Published: September 2008

Objective: To examine the concordance of pediatric radiograph interpretation between emergency medicine residents (EMRs) and radiologists.

Methods: A prospective, observational study was performed in a university pediatric ED with an annual census of 60,000 visits. Radiographs ordered by EMRs from December 1993 through October 1994 were initially interpreted solely by the EMR, with subsequent unmasked final review by attending radiology staff. Misinterpreted radiographs were placed into 3 categories. The groupings included overreads, underreads with no change in treatment, and underreads that required a change in treatment.

Results: A total of 415 radiographs were interpreted by PGY1–3 residents. Overall concordance was found for 371 radiographs (89.4%). There were 44 misinterpretations (10.6%), with 24 (5.78%) overreads, 13 (3.13%) underreads, and 7 (1.69%) underreads that required follow‐up interventions. Misinterpretations were similar for the different levels of training:

The 5 most frequently ordered radiographs were chest (28%), ankle (7%), foot (6%), wrist (5%), and hand (5%). The most frequently misinterpreted radiographs were sinus, foot, shoulder, facial, and hand.

Conclusion: 89.4% of all the radiographs interpreted by PGY1–3 residents were read correctly. Only 1.69% of the misinterpreted radiographs led to a change in management. Level of training did not significantly correlate with radiograph misinterpretation rates.
Structure and Practice of Institutional Review Boards in the United States
Authors: Jones Jeffrey S. , White Lynn J. , Pool Linda C. , Dougherty James M.
Published: September 2008

Objective: The institutional review board (IRB) is a critical element in the protection of patients' and subjects' rights with regard to their participation in research protocols. The purpose of this study was to describe the structure and current practices of IRBs in the United States.

Methods: A self‐administered questionnaire was mailed to the IRB chair of each U.S. hospital with a capacity of at least 400 beds (n = 907). The survey contained 21 questions outlining committee size and structure, review of research proposals, and policies concerning scientific misconduct. Chairs also were asked what advice they would offer a young investigator preparing a proposal for submission.

Results: A total of 488 surveys (54%) were returned; 447 of the responding institutions had an IRB committee. Committees had an average of 14 members, representing 27 medical specialties. Orthopedics had the least IRB representation (10% of committees), followed by emergency medicine (12%) and ophthalmology (15%). The majority of research proposals go through 5 specific steps once submitted for review. Common reasons for proposal rejection were improperly designed consent form (54%), poor study design (44%), unacceptable risk to subjects (34%), ethical or legal reasons (24%). and scientific merit (14%). When a research proposal is rejected, 86% of the responding IRBs assist the investigator in making appropriate revisions. Although a number of IRBs (17%) have dealt with scientific misconduct allegations, only 58% have a written policy regarding research integrity.

Conclusion: Despite variations in committee structure and representation, IRBs have similar procedures for governing research. Investigators should be familiar with these procedures and are encouraged to discuss their proposal with an IRB representative prior to formal review.
Emergency Medicine Journal Clubs
Authors: Jouriles Nicholas J. , Cordell William H. , Martin Daniel R. , Wolfe Richard , Emerman Charles L. , Avery Ann
Published: September 2008

Objective: To ascertain the status of journal club within emergency medicine (EM) residency programs and to describe 3 currently used formats.

Methods: The directors of U.S. Residency Review Committee for Emergency Medicine (RRC‐EM)‐approved residency programs were surveyed to determine the features of their programs' journal clubs. Responses to 3 questions assessing the degree of satisfaction (5‐item scales from very good to very poor) with the “current format,” “resident participation,” and “faculty participation” from the survey were grouped according to the program director's impressions of resident and faculty “enjoyment” (2 3‐item scales) and whether the journal club is a “success” (3‐item scale) to develop an overall satisfaction index. Three journal club formats currently in use at EM residencies are described in detail.

Results: Of the 101 directors surveyed, 91 (90%) responded. The respondents' overall satisfaction index was highest when the journal club was held in the evening (p < 0.008) or at a faculty member's home (p < 0.0004). The format of the journal club (e.g., by topic, with a statistical focus, with a research design focus, or as a clinical practice update) was not associated with the overall satisfaction index.

Conclusion: Journal clubs associated with EM residencies vary in format and perceived success. The 3 representative journal clubs illustrate different format options.
Thrombolytic Therapy for Cerebral Infarction
Authors: Kothari Rashmi , Pancioli Arthur , Brott Thomas , Broderick Joseph
Published: September 2008

Until recently, no clinically effective therapy for acute ischemic stroke has been available. Recent advances in the use of thrombolytic therapy for ischemic stroke appear promising in clinical care. As the use of thrombolytic therapy in acute stroke progresses, emergency physicians (EPs) will become increasingly involved in its implementation. The EP must be cognizant of both prior and ongoing investigations in acute ischemic stroke therapy. To that end, this article reviews research in the field of thrombolytic therapy for acute ischemic stroke.
Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993
Authors: Crandall Cameron , Olson Lenora , Fullerton Lynne , Sklar David , Zumwalt Ross
Published: September 2008

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.

Methods: The authors retrospectively sampled in 5‐year intervals all victims of penetrating trauma who presented to either the state Level‐1 trauma center or the state medical examiner from a 16‐year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.

Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person‐years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.

Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.
A Truncated E‐code System for Injury Surveillance in the Emergency Department: Description and Clinometric Testing
Authors: Bota Gary W. , Therrien Sandra A. , Rowe Brian H.
Published: September 2008

Objectives: ED injury surveillance requires accurate information about mechanism. This study explored the clinometric properties of an E‐code system specifically designed to track ED injuries.

Methods: All patients assessed in the ED had cause‐of‐injury information documented using a truncated E‐code system. Patient records were hand‐searched to determine coding compliance. A selection of 98 charts (50 injury/48 noninjury) were coded by 7 physicians, 2 nurses, and 2 nosologists. Agreements (interrater and intrarater) on the diagnosis of trauma and exact E‐codes were determined (using kappa; κ).

Results: E‐coding compliance was high (overall 90%: 95% CI: 85–93%), and accuracy of injury classification was 99%. Compared with an expert's coding, agreement on injury classification was excellent for physicians (κ = 0.91; 95% CI: 0.80–1.0), nurses (κ = 0.88; 95% CI: 0.75–1.0), and nosologists (κ = 0.92; 95% CI: 0.81–1.0). Agreement was substantial for the exact E‐codes between physicians (κ = 0.77; 95% CI: 0.60‐ 0.94) and nurses (κ = 0.72; 95% CI: 0.54–0.90). Recode reliability was also excellent for physicians (κ = 0.88; 95% CI: 0.75–1.0) and nurses (κ = 0.96; 95% CI: 0.88–1.0).

Conclusions: Injury coding using a truncated E‐code system can provide valid and reliable data from the ED. Differences between nurses, physicians, and nosologists in the ability to accurately code using this system were minimal, thus eliminating the need for additional staff and resources.
Telephone Follow‐up for Case Finding of Domestic Violence in an Emergency Department
Authors: Sixsmith Diane M. , Weissman Laurie , Constant Florence
Published: September 2008

Objective: To determine whether telephone follow‐up of selected female patients seen in an urban ED would improve domestic violence (DV) case finding.

Methods: A prospective, cross‐sectional study was conducted on consecutive female patients between the ages of 16 and 65 years treated in an urban trauma center during July and August 1995. Record review identified those patients with conditions suggesting increased risk for DV: injury; substance abuse; complaints or diagnoses related to stress, anxiety, depression, or panic attack; or complaints of headache, nonspecific abdominal pain, generalized fatigue, or numbness lasting >] week. Attempts were made to telephone all patients who had high‐risk presentations within 3 days of their emergency visits. Patients were contacted by a trained interviewer regarding the circumstances of their visits.

Results: There were 142 (9%) high‐risk presentations out of 1,500 ED visits by women. Of these high‐risk visits, 68 patients denied DV, 19 patients did not speak English, 16 patients gave an incorrect telephone number, 18 patients could not be reached after 3 telephone calls, and 6 patients did not give a telephone number. Of the remaining 15 patients, 5 were diagnosed at the initial visit as having experienced DV, and 10 admitted on the follow‐up call that the visit had been related to DV or emotional stress at home.

Conclusion: A structured interview, conducted via telephone in follow‐up of released ED patients, identified an additional 10 victims out of 142 high‐risk presentations and 1,500 total ED presentations. This approach is labor‐intensive, with a relatively low yield. Nonetheless, prospective identification of selective high‐risk cases by physicians, coupled with subsequent social service telephone contact, may be a complement in department case finding.
Who Gets Bystander Cardiopulmonary Resuscitation in a Witnessed Arrest?
Authors: Jackson Raymond E. , Swor Robert A.
Published: September 2008

Objective: To identify characteristics associated with provision of bystander CPR in witnessed out‐of‐hospital cardiac arrest cases.

Methods: An observational, prospective, cohort study was performed using cardiac arrest cases as identified by emergency medical services (EMS) agencies in Oakland County, MI, from July 1, 1989, to December 31, 1993. All patients who sustained a witnessed arrest prior to arrival of EMS personnel were reviewed.

Results: Of the 927 patients meeting entry criteria, the 229 patients receiving bystander CPR were younger: 60.9 ± 14.7 vs 67.9 ± 14.7 years (p < 0.01). Most (76.6%) cardiac arrests occurred in the home. In a multivariate logistic model, only the location of arrest outside the home was a significant predictor of receiving bystander CPR [odds ratio (OR) 3.8; 99% CI 2.5, 5.9]. Arrests outside the home were associated with significantly improved outcome, with 18.2% of out‐of‐home and 8.2% of in‐home victims discharged from the hospital alive (OR 2.5; 99% CI 1.4, 4.4).

Conclusion: Patients who have had witnessed cardiac arrests outside the home are nearly 4 times more likely to receive bystander CPR, and are twice as likely to survive. This observation emphasizes the need for CPR training of family members in the authors' locale. This phenomenon may also represent a significant con‐founder in studies of out‐of‐hospital cardiac arrest and resuscitation.
Population Density, Automated External Defibrillator Use, and Survival in Rural Cardiac Arrest
Authors: Stapczynski J. Stephan , Svenson James E. , Stone C. Keith
Published: September 2008

Objective: To determine whether population density is an independent predictor of survival from out‐of‐hospital cardiac arrest managed by basic life support (BLS) services using automated external defibrillators (AEDs).

Methods: A retrospective, observational study in Kentucky of 34 BLS services covering 22 counties during the years 1992 to 1994 who used AEDs to treat patients who had out‐of‐hospital cardiac arrests.

Results: Of 311 patients who had out‐of‐hospital cardiac arrests, 110 (35%) were defibrillated, 46 (15%) were resuscitated to hospital admission, and 19 (6%) survived to hospital discharge. Univariate predictors for survival to hospital discharge were emergency medical services response interval (from call receipt to ambulance arrival) <8 minutes, defibrillation by the AED, initial rhythm of ventricular fibrillation or ventricular tachycardia (VF/VT), and population density >100/square mile (sq mi) for the BLS service area (p < 0.001). A forced logistic regression model of survival to hospital discharge, using these 4 factors plus the presence of a witnessed arrest or bystander CPR, demonstrated that population density >100/sq mi was highly significant (OR 9.4, 95% CI: 1.7 to 51.4, p < 0.01). Stepwise logistic regression models with combinations of these 6 factors found that survival to hospital discharge was best predicted by an initial rhythm of VF/VT (p = 0.004) and population density >100/sq mi (p = 0.011).

Conclusions: Population density is strongly associated with survival from out‐of‐hospital cardiac arrest. BLS services within areas with population densities ≤100/sq mi sustained little benefit from the addition of AEDs to their treatment of patients who had out‐of‐hospital cardiac arrests.
Frequent Users of the Emergency Department: Can We Intervene?
Authors: Spillane Linda L , Lumb Eileen W. , Cobaugh Daniel J. , Wilcox Susan Riley , Clark John S. , Schneider Sandra M.
Published: September 2008

Objective: To determine whether the use of individualized patient care plans and multidisciplinary case management would decrease ED utilization by frequent ED users.

Methods: The authors performed a prospective, randomized clinical trial of the impact of a care plan on ED use by adults with frequent ED visits. Patients with >10 ED visits to a university hospital in 1993 were identified. Patients were matched for age, sex, and number of visits and then randomized into 2 groups. The control group received standard emergency care. The treatment group was managed by a multidisciplinary team and treated in the ED according to individualized care plans. ED use was tracked at the university hospital and at the other 5 community hospitals in the city.

Results: Of the 70 enrolled patients, 25 of 37 control patients and 27 of 33 treatment patients made visits to the university hospital during the 1‐year study period. Only those patients with follow‐up visits were included in the data analysis. Patients remaining in the control group made 247 total visits (range 1–65) to the university hospital and 179 total visits (range 0–38) to the community hospitals during the study period. Patients in the treatment group made 320 total visits (range 1–72) to the university hospital and 254 total visits (range 0–135) to the community hospitals during the study period. There was no significant difference in the median number of visits made to either the university hospital or the community hospitals by the patients in the control group and those in the treatment group.

Conclusions: The use of individualized care plans and case management did not significantly decrease ED utilization by frequent ED users. However, the impact of individualized care plans and case management on other quality‐of‐care measures (e.g., patient satisfaction, ED length of stay, hospitalizations, primary care visits, and health care costs) remains to be determined.
Evaluation of a New Assay for Cardiac Troponin I vs Creatine Kinase‐MB for the Diagnosis of Acute Myocardial Infarction
Authors: Brogan Gerard X. , Hollander Judd E. , McCuskey Charles F. , Thode Henry C. , Snow Jeffrey , Sama Andrew , Bock Jay L. ,   Biochemical Markers for Acute Myocardial Ischemia (BAMI) Study Group
Published: September 2008

Objective: To compare a new assay for cardiac troponin I (cTn‐I) with an assay for creatine kinase‐MB (CK‐MB) for the diagnosis of acute myocardial infarction (AMI).

Methods: A prospective cross‐sectional study of patients presenting with symptoms consistent with cardiac ischemia was performed at a university teaching hospital. Serum sampling for cTn‐I and CK‐MB was performed at 0, 1, 3, 8, and 16 hours after presentation. Normal values were defined as CK‐MB ≤ 7 ng/mL and a relative index ≤ 2%, cTn‐I ≤ 1.4 ng/mL. Final diagnosis was made using World Health Organization criteria, including standard enzyme sampling. Consecutive patients with AMI were compared with a randomly selected subset of patients without AMI to determine the sensitivity and specificity of the cTn‐I and CK‐MB assays for AMI, stratified by time from symptom onset. The ability of the biochemical cardiac markers obtained within 6 hours of symptom onset to predict later complications or need for interventions was assessed using odds ratios (ORs).

Results: Thirty‐five patients who had AMI were compared with 136 patients who did not have AMI. The sensitivities and specificities of the cTn‐I and CK‐MB assays, stratified by time from symptom onset, were: Patients who had elevations in either CK‐MB or cTn‐I within 6 hours of symptom onset were at increased risk for cardiovascular complications and/or interventions (CK‐MB, OR 5.8; cTn‐I, OR 6.3).

Conclusion: cTn‐I was as sensitive and specific for AMI as was CK‐MB in ED patients who presented within 24 hours of symptom onset. However, cTn‐I was more sensitive in patients who presented ≥ 24 hours after symptom onset. Elevations of either marker within 6 hours of symptom onset predict an increased risk of complications and/or need for interventions.
Evaluation of Ketorolac in Children with Forearm Fractures
Authors: Pierce Mary Clyde , Fuchs Susan
Published: September 2008

Objectives: To evaluate ketorolac for pain relief and an opioid‐sparing effect in children with forearm fractures necessitating reduction.

Methods: A prospective, randomized, double‐blind study was conducted at an urban children's hospital ED. A convenience sample of children aged 3–18 years with isolated forearm fractures was studied. None received prior pain medication. A 10‐point visual analog scale (VAS) was used to assess pain at the time of study entry and prior to sedation/analgesia. The Children's Hospital of Eastern Ontario's Pain Score (CHEOPS), a 13‐point behavioral score, was used to assess pain during sedation. Patients received either IV ketorolac (K), 1 mg/kg, or saline (S) after entry into the study. After a minimum of 20 minutes, pain was reassessed and supplemental analgesia/sedation administered. A standard dose of midazolam, 0.1 mg/kg to a maximum of 6 mg, was given to all patients, and fentanyl was titrated at 1‐μg/kg increments based on patient need. Once the patient was comfortable, reduction was performed and a reduction CHEOPS score assigned.

Results: For the 34 study children (17 K, 17 S), there was no difference in sex or mean age between the groups. Mean total doses of fentanyl were 2.26 μg/kg in the K group and 2.85 μg/kg in the S group (p = 0.07). The median changes in VAS score before and after receiving the study drug were —1.13 K and ‐0.18 S (p = 0.06). The median CHEOPS score was 10 for both groups. Seven of the 17 patients in the S group required the maximum fentanyl dose (4 μg/kg), compared with 2 of 17 in the K group (p = 0.06).

Conclusions: Although ketorolac seems to add to patient comfort in children with forearm fractures, it does not have a significant opioid‐sparing effect. Ketorolac showed a trend toward pain relief, but statistical significance was not reached.
Alcohol Use among Injured Patients Aged 12 to 18 Years
Authors: Mannenbach Mark S. , Hargarten Stephen W. , Phelan Mary Beth
Published: September 2008

Objective: To examine the scope of alcohol use among a population of injured adolescents.

Methods: A convenience sample of injured patients aged 12–18 years seen at a pediatric ED was tested for the presence of alcohol. Injured patients seen within 6 hours of their injuries were asked to submit urine samples for testing using reagent strips. Data were collected from the patient, out‐of‐hospital emergency care personnel, and parents regarding the circumstances of the injury.

Results: Of the 243 injured patients who were tested during an 8‐month period, 231 were included in the final analysis. Ninety patients (39%) were alcohol‐positive. The mean age of the alcohol‐positive group was 16.0 ± 1.64 years, compared with 15.3 ± 1.8 years for the alcohol‐negative group (p < 0.003). There was no significant difference between the 2 groups based on race, gender, or injury characteristics. A positive urine alcohol test was found for 18 (33%) of the motor vehicle crash victims, 9 (38%) of the motor vehicle drivers, 10 (37%) of the patients who attempted suicide, and 49 (44%) of the assault victims.

Conclusions: A substantial percentage of injured adolescent patients were alcohol‐positive. The authors recommend the use of alcohol screening when treating injured adolescents.
Rotating Shiftwork Schedules: Can We Enhance Physician Adaptation to Night Shifts?
Authors: Smith‐Coggins Rebecca , Rosekind Mark R. , Buccino Kenneth R. , Dinges David F. , Moser Richard P.
Published: September 2008

Objectives: To evaluate the effectiveness of a broad, literature‐based night shiftwork intervention for enhancement of emergency physicians' (EPs') adaptation to night rotations.

Methods: A prospective, double‐blind, active placebo‐controlled study was conducted on 6 attending physicians in a university hospital ED. Three data sets were collected under the following conditions: baseline, after active placebo intervention, and after experimental intervention. In each condition, data were collected when the physicians worked both night and day shifts. Measurements included ambulatory polysomnographic recordings of the main sleep periods, objective performance tests administered several times during the subjects' shifts, and daily subjective ratings of the subjects' sleep, moods, and intervention use.

Results: The subjects slept an average of 5 hr 42 min across all conditions. After night shifts, the subjects slept significantly less than they did after day shifts (5 hr 13 min vs 6 hr 20 min; p < 0.05). The physicians' vigilance reaction times and times for intubation of a mannequin were significantly slower during night shifts than they were during day shifts (p = 0.007 and p < 0.04, respectively), but performances on ECG analysis did not significantly differ between night and day shifts. Mood ratings were significantly more negative during night shifts than they were during day shifts (more sluggish p < 0.04, less motivated p < 0.03, and less clear thinking p < 0.04). The strategies in the experimental intervention were used 85% of the time according to logbook entries. The experimental and active placebo interventions did not significantly improve the physician's performance, or mood on the night shift, although the subjects slept more after both interventions.

Conclusions: Although the experimental intervention was successfully implemented, it failed to significantly improve attending physicians' sleep, performance, or mood on night shifts. A decrease in speed of intubation, vigilance reaction times, and subjective alertness was evident each time the physicians rotated through the night shift. These findings plus the limited sleep across all conditions and shifts suggest that circadian‐mediated disruptions of waking neurobehavioral functions and sleep deprivation are problems in EPs.