bluuebunny/crossref_metadata_2025 huggingface dataset:
Emergency Procedures Important to the Training of Emergency Medicine Residents: Who Performs Them in the Emergency Department?
Authors: Gallagher E. John , Coffey John , Lombardi Gary , Saef Steven
Published: September 2008

Objective: To quantify one aspect of emergency medicine (EM) training by determining the proportion of emergency procedures performed by emergency physicians (EPs) in EDs with EM residency programs (EMRPs).

Methods: Cross‐sectional descriptive survey of all allopathic EMRPs accredited by the EM Residency Review Committee (RRC‐EM) as of July 1, 1993. Using a modified visual analog scale, program directors indicated the proportion of ten index procedures performed in the ED by EPs vs all other physicians.

Results: All 98 EMRPs meeting entry criteria responded to the survey. The medians for the percentage of times index procedures were performed in the ED by an EP were as follows (parentheses following percentages enclose 95% CIs): endotracheal intubation, 97% (95%, 100%); reduction of anterior shoulder dislocation, 93% (88%, 97%); thoracostomy, 63% (50%, 75%); transvenous pacer insertion, 60% (50%, 75%); cricothyrotomy, 50% (50%, 75%); thoracotomy, 50% (25%, 50%); diagnostic peritoneal lavage, 50% (25%, 50%); fiberoptic laryngoscopy, 22% (6%, 25%); sigmoidoscopy, 0% (0%, 6%); and pelvic sonography, 0% (0%, 0%).

Conclusion: EPs in EDs of institutions that have EMRPs perform, on average, 50% of all index procedures (95% CI 47%, 52%). This information may assist EM programs experiencing difficulty in ensuring that their residents receive an equitable share of those procedures that are critical to their training.
Efficacy of Ipratropium Bromide in Acute Childhood Asthma: A Meta‐analysis
Authors: Osmond Martin H. , Klassen Terry P.
Published: September 2008

Purpose: To determine whether inhaled ipratropium bromide provides an additive, clinically important improvement in children with acute asthma who are being treated with β2‐agonists.

Methods: An English‐language literature search was conducted employing MEDLINE (1966 to 1992), Science Citation Index (1986 to 1992) using key citations, bibliographic reviews of primary research and review articles, and correspondence with authors of recent articles. After independent review by two observers, six studies were selected on the basis of prespecified selection criteria. Two observers independently assessed the selected papers by using explicit methodologic criteria for evaluating the quality of studies dealing with therapeutic intervention.

Results: None of the six studies found a significant difference in clinical rating score, admission rate, or length of stay in hospital between the ipratropium bromide and the control groups. The three studies with the highest methodologic validity measured the change in percentage predicted forced expiratory volume in 1 second (FEV1) from baseline to 60 minutes. The pooled effect size (95% CI) for these studies was 0.88 (0.42–1.34), which translates to an improvement in percentage predicted FEV1 over the control group of 12.5% (95% CI, 6.6–18.4). In a subset of 23 children who had severe airway obstruction, peak expiratory flow rate (PEFR) responded better to a β2‐agonist alone (p = 0.007).

Conclusion: The existing evidence reveals that the addition of ipratropium bromide to a β2‐agonist offers a statistically significant improvement in percentage predicted FEV1 but no clinical improvement. As it may cause deterioration in PEFR in severely asthmatic children, ipratropium bromide should not be used universally for acute childhood asthma until further research determines the clinical significance of these spirometric changes.
Biochemical Markers of Cerebral Injury in Patients with Minor Head Trauma and Ethanol Intoxication
Authors: Levitt M. Andrew , Cook Laura Ann Staffeld , Simon Barry C. , Williams Virgil
Published: September 2008

Objective: To determine whether biochemical markers can selectively identify those intoxicated patients with presumed minor head injuries who are likely to have CT evidence of intracranial injury.

Methods: Patients presenting to the ED with simultaneous presumed minor head trauma and ethanol intoxication were prospectively entered into this cross‐sectional study. Following phlebotomy, all patients received cranial CT. Associations between the presence of an abnormal CT scan for injury and serum levels of the following biochemical markers were sought: serum catecholamines, creatine kinase‐brain band (CK‐BB), and serum amylase. Serum levels are reported as mean ± SEM.

Results: Nine of the 107 patients (8.4%; 95% CI 3.9–15.4%) had evidence of intracranial injury on CT. Mean serum CK‐BB (16.1 ± 3.7 vs 13.2 ± 9.6 ng/mL), serum norepinephrine (913 ± 117 vs 1,089 ± 76 pg/mL), and serum amylase (64.9 ± 14.8 vs 84 ± 4.7 U/L) levels were not significantly different in patients with and without CT evidence of intracranial injury, respectively. Mean serum epinephrine (298 ± 54 vs 167 ± 18 pg/mL; p = 0.03) and serum dopamine (218 ± 50 vs 130 ± 9 pg/mL; p = 0.014) levels were significantly elevated in the group with intracranial injury on CT. A threshold level of serum dopamine ±140 pg/mL yields a sensitivity of 89% (95% CI 52–100%) and a specificity of 80% (95% CI 70–87%) for CT‐evident injury. A threshold level of serum epinephrine ±218 pg/mL yields a sensitivity of 89% (95% CI 52–100%) and a specificity of 80% (95% CI 70–87%) for CT‐evident injury.

Conclusion: Elevated serum epinephrine and dopamine levels are associated with intracranial CT‐evident injury for ethanol‐intoxicated patients with presumed minor head injuries. The potential use of these biochemical markers to guide a more selective approach to cranial CT scanning warrants further evaluation.
Dehydration and Orthostatic Vital Signs in Women with Hyperemesis Gravidarum
Authors: Johnson David R. , Douglas Daniel , Hauswald Mark , Tandberg Dan
Published: September 2008

Objectives: To assess the hydration status of women presenting to an ED with hyperemesis gravidarum and to determine whether clinically relevant changes in orthostatic vital signs occur.

Methods: A convenience sample of 23 pregnant women who had hyperemesis gravidarum, with each patient serving as her own control. The study took place in the ED observation unit of an urban teaching hospital. Women who had pregnancies of ≤16 weeks' gestation who had been vomiting for at least 24 hours were included. Supine and standing pulse rates and blood pressures (BPs) were measured sequentially after 5 minutes in each position. Patient weight and urine specific gravity (SG) also were recorded. After 6 L of lactated Ringer's solution was infused over a 12‐hour period, the same measurements were repeated. Pre‐ and posthydration changes were analyzed using the paired t‐test.

Results: The mean treatment weight gain as a percentage of the total body weight was 5.6% ± 2.2% (mean ± SD). The urine SG decreased from 1.027 ± 0.004 to 1.008 ± 0.003 (p < 0.001). The mean change in systolic BP upon assuming the standing position was ‐8.3 ± 12.7 mm Hg before hydration vs 2.9 ± 7.8 mm Hg after hydration (p < 0.001). The corresponding change in mean diastolic BP was 3.7 ± 10.9 mm Hg before hydration vs 8.6 ± 10.9 mm Hg after hydration (p = 0.12). The mean change in pulse rate upon standing was 26.8 ± 14.5 beats/min before hydration vs 14.5 ± 10.1 beats/min after hydration (p = 0.002).

Conclusions: Women who present to the ED with hyperemesis gravidarum are significantly dehydrated and experience measurable improvement in postural pulse rate and systolic BP changes with rehydration. However, the presenting orthostatic changes lack sufficient sensitivity to be effectively used as quantitative screening tests for dehydration.
Theoretically Optimal Duty Cycles for Chest and Abdominal Compression during External Cardiopulmonary Resuscitation
Authors: Babbs Charles F. , Thelander Keir
Published: September 2008

Objective: To use an electronic model of human circulation to compare the hemodynamic effects of different durations of chest compression during external CPR, both with and without interposed abdominal compression (IAC).

Methods: An electrical analog model of human circulation was studied on digital computer workstations using SPICE, a general‐purpose circuit simulation program. In the model the heart and blood vessels were represented as resistive‐capacitive networks, pressures as voltages, blood flow as electric current, blood inertia as inductance, and cardiac and venous valves as diodes. External pressurization of the heart and great vessels, as would occur in IAC‐CPR, was simulated by the alternate application of damped rectangular voltage pulses, first between intrathoracic vascular capacitances and ground, and then between intra‐abdominal vascular capacitances and ground. With this model compression frequencies of 60, 80, and 100 cycles/min and duty cycles ranging from 10% to 90%, both with and without IAC, were compared.

Results: There was little difference in hemodynamics when the overall compression frequency was varied between 60 and 100 cycles/min, but the effects of duty cycle were substantial. During both standard CPR and IAC‐CPR, total flow and coronary flow were greatest at chest compression durations equal to 30% of cycle time. Interposed abdominal compression substantially improved simulated systemic blood flow and perfusion pressure at all duty cycles, compared with standard CPR without abdominal compression. Mean arterial pressure > 75 mm Hg and artificial cardiac output > 2.0 L/min could be generated by 30% duty cycle compression with IAC. Coronary perfusion in the model is clearly optimized at 30% chest compression (i.e., high‐impulse chest compression technique).

Conclusion: Combined high‐impulse chest compressions and IACs maximize blood flow during CPR in the electrical analog model of human circulation.
Bi‐level Positive Airway Pressure Support System Use in Acute Congestive Heart Failure: Preliminary Case Series
Authors: Sacchetti Alfred D. , Harris Russell H. , Paston Carrie , Hernandez Zaida
Published: September 2008

Objective: To describe the use of a noninvasive bi‐level positive airway pressure (PAP) support system for ED patients with acute congestive heart failure (CHF).

Methods: Retrospective case series analysis of ED patients presenting with acute CHF in imminent need of endotracheal intubation (ETI) managed with a bi‐level PAP system. The bi‐level PAP system was applied at the discretion of the treating emergency physician. Management of the bi‐level PAP system, including setting of inspiratory PAP (IPAP) and expiratory PAP (EPAP), weaning, adjunct pharmacologic therapy, and failure of bi‐level PAP support, was determined by the treating physician.

Results: Only two (9%) of 22 patient presentations necessitated ETI. The mean duration of bi‐level PAP therapy was 7.9 hours. The mean maximum IPAP and EPAP settings were 10.8 and 5.8 cm H2O, respectively. Mean intensive care unit length of stay (LOS) was 2.4 days, with a median LOS of only 1 day. There were three deaths in the series; none were attributed to the bi‐level PAP system. No technical difficulty with the bi‐level PAP system was noted.

Conclusion: Noninvasive pressure support ventilation with a bi‐level PAP support system may avert ETI in acute CHF patients. This device can be effectively used by ED personnel.
Padded vs Unpadded Spine Board for Cervical Spine Immobilization
Authors: Walton Ross , DeSalvo Jay F. , Ernst Amy A. , Shahane Aditi
Published: September 2008

Objectives: To determine whether padding the long spine board improves patient comfort, affects cervical spine (c‐spine) immobilization, or increases sacral transcutaneous O2 tension.

Methods: A prospective randomized, controlled crossover study of healthy volunteers was conducted over a two‐week period. Participants included 30 volunteers with no previous history of c‐spine injury or disease. The subjects were randomized to either padded or unpadded long spine board immobilization with serial measurements of discomfort (using a visual analog scale) and transcutaneous tissue O2 tension obtained at zero and 30 minutes. Measurements of ability to flex, extend, rotate, and laterally bend the c‐spine were made using a goniometer. The subjects then returned a minimum of three days later to complete the opposite half of the study (padded vs unpadded boards).

Results: Subject discomfort was significantly reduced in the padded group compared with the unpadded group (p = 0.024). There was no significant difference in flexion (p = 0.410), extension (p = 0.231), rotation (p = 0.891), or lateral bending (p = 0.230) for the two groups. There was no significant difference in the actual drop in sacral transcutaneous O2 tension from time zero to 30 minutes for the padded and the unpadded groups (mean drop = 14.8% ± 17.5% vs 12.2% ± 16.8%, respectively; p = 0.906).

Conclusion: Adding closed‐cell foam padding to a long spine board significantly improves comfort without compromising c‐spine immobilization. Sacral tissue oxygenation does not appear affected by such padding for healthy volunteers.
Stiff‐man Syndrome: Case Report
Authors: Kuhn Walter F. , Light Peter J. , Kuhn Sharon C.
Published: September 2008

Stiff‐man syndrome is a rare neurologic disorder characterized by progressive, fluctuating muscle rigidity with painful muscle contractions affecting predominantly the back and proximal extremities. In the ED, the diagnosis can be easily overlooked and misdiagnosed as acute or chronic low back pain and muscle spasm. This syndrome is often associated with diabetes, autoimmune diseases, and cancer. This report describes an illustrative case of a 39‐year‐old woman who presented to the ED with a two‐year history of right leg spasms and low back pain that had become so severe in the preceding two days that she was unable to ambulate. Clues to the patient's proper diagnosis coincide with the diagnostic criteria for stiff‐man syndrome: the presence of a slowly progressive stiffness of the axial muscles and proximal limb muscles, making ambulation difficult; hyperlordosis of the lumbar spine; episodic spasms precipitated by jarring or sudden movement; a normal intellectual, sensory, and motor examination when not in spasm; and a marked amelioration of symptoms with the IV administration of diazepam. High‐dose oral diazepam is the maintenance drug of choice.
The Use of a Break‐even Analysis: Financial Analysis of a Fast‐track Program
Authors: Saywell Robert M. , Cordell William H. , Nyhuis Allen W. , Giles Beverly K. , Culler Steven D. , Woods John R. , Chu David K. W. , McKinzie Jeffry P. , Rodman George H.
Published: September 2008

Objective: To calculate the financial break‐even point and illustrate how changes in third‐party reimbursement and eligibility could affect a program's fiscal standing.

Methods: Demographic, clinical, and financial data were collected retrospectively for 446 patients treated in a fast‐track program during June 1993. The fast‐track program is located within the confines of the emergency medicine and trauma center at a 1,050‐bed tertiary care Midwestern teaching hospital and provides urgent treatment to minimally ill patients. A financial break‐even analysis was performed to determine the point where the program generated enough revenue to cover its total variable and fixed costs, both direct and indirect.

Results: Given the relatively low average collection rate (62%) and high percentage of uninsured patients (31%), the analysis showed that the program's revenues covered its direct costs but not all of the indirect costs.

Conclusions: Examining collection rates or payer class mix without examining both costs and revenues may lead to an erroneous conclusion about a program's fiscal viability. Sensitivity analysis also shows that relatively small changes in third‐party coverage or eligibility (income) requirements can have a large impact on the program's financial solvency and break‐even volumes.
Sensitivity of New‐generation Computed Tomography in Subarachnoid Hemorrhage
Authors: Sames Thomas A. , Storrow Alan B. , Finkelstein Jeff A. , Magoon Michael R.
Published: September 2008

Objective: To determine the sensitivity of the initial new‐generation CT (NGCT) scan interpretation for detection of acute nontraumatic subarachnoid hemorrhage (SAH) and to decide whether lumbar puncture (LP) should follow a “normal” NGCT scan.

Methods: A retrospective chart review was performed of patients admitted between March 1988 and July 1994 with proven SAH. Exclusion criteria were age <2 years, diagnosis other than acute SAH, history of head trauma within 24 hours before symptom onset, NGCT scan not done before diagnosis, and records not available. Patients were placed into two groups: symptom duration <24 hours (group 1) and >24 hours (group 2) prior to CT scan. The resolution of each NGCT scanner was recorded. An NGCT sceinner was defined as a third‐generation scanner or more recent.

Results: Of 349 SAH patients, 181 met inclusion criteria. The sensitivity of NGCT scans for SAH was 93.1% for the group 1 patients (n = 144) and 83.8% for the group 2 patients (n = 37). The overall sensitivity was 91.2%. All the patients who had SAH not detected by NGCT scans were diagnosed by LP. There was no significant relationship between NGCT scanner resolution and sensitivity for SAH.

Conclusion: Initial interpretation of NGCT scans to detect SAH does not approach 100% sensitivity. A “normal” NGCT scan does not reliably exclude the need for LP in patients who have symptoms suggestive of SAH.
Out‐of‐hospital Rapid‐sequence Induction for Intubation of the Pediatric Patient
Authors: Sing Ronald F. , Reilly Patrick M. , Rotondo Michael F. , Lynch Michael J. , McCans James P. , Schwab C. William
Published: September 2008

Objective:To determine the effectiveness and morbidity of out‐of‐hospital rapid‐sequence induction (RSI) for endotracheal intubation (ETI) in the pediatric population.

Methods: The medical records were retrospectively reviewed for a consecutive series of pediatric patients undergoing out‐of‐hospital RSI by flight paramedics from July 1990 through July 1994. Patient demographics, pharmacologic agents, ED arterial blood gas data, pulmonary complications, and RSI‐related complications were abstracted.

Results: Forty patients (31 injured, 9 medical) with a mean age of 8.1 years (range 0.5–17 years) underwent out‐of‐hospital RSI. Indications for intubation included hyperventilation (n = 20), combativeness (n = 16), apnea (n = 5), and unknown (n = 5). Intubation mishaps occurred in 13 patients (33%); these included multiple attempts (n = 9), aspiration (n = 8), and esophageal intubation (n = 1). The success rate of ETI was 97.5% (one failed attempt). Hemodynamic side effects occurred in three patients (8%); all three had bradycardia, with one developing hypotension. Bradycardia was associated with failure to pretreat with atropine (p < 0.05). Sixteen pulmonary complications, seven pneumonia (18%) and nine atelectasis (22.5%), occurred in 13 patients within the first ten hospital days. Intubation mishaps were not associated with pulmonary complications. There were six deaths, none associated with RSI.

Conclusions: 1) Rapid‐sequence induction is an effective method for obtaining airway control in the critically ill pediatric patient. 2) Intubation mishaps did not influence the rate of pulmonary complications. 3) Omission of atropine was associated with bradycardia during RSI in pediatric patients.
Ethanol Ingestion and Related Hypoglycemia in a Pediatric and Adolescent Emergency Department Population
Authors: Ernst Amy A. , Jones Kathleen , Nick Todd G. , Sanchez Julie
Published: September 2008

Objective:To estimate the frequency of associated hypoglycemia in an ethanol‐ingesting pediatric and adolescent population.

Methods: The study was a retrospective review of nondiabetic pediatric and adolescent patients with measurable ethanol levels (i.e., >2 mmol/L) who had an ED serum glucose level determined.

Results: Over the four‐and‐a‐half‐year study period, there were 254,234 pediatric visits. One hundred eleven had ethanol levels determined (0.044% of patients) due to suspected ingestion. Of these 111, 88 had glucose levels determined. The mean age of the 88 patients was 14 years, with a mean glucose level of 5.6 mmol/ L [101 mg/dL; interquartile range (IQR) 4.7‐6.3 mmol/L] and a mean ethanol level of 30 mmol/L (IQR 15–43 mmol/L). Glucose levels were < 67 mg/dL (hypoglycemia) in three of the 88 (3.4%) ethanol‐positive patients; all the hypoglycemic patients had significant behavioral changes.

Conclusion: In this large retrospective series, the number of patients for whom the clinical suspicion of ethanol ingestion was confirmed was quite small. Hypoglycemia occurred in only 3.4% of these selected patients; all had altered behavior. Pediatric patients with presentations suggesting ethanol intoxication with altered behavior should be assessed for concurrent hypoglycemia.
Advance Directives in the Emergency Department: Too Few, Too Late
Authors: Ishihara Kristina K. , Wrenn Keith , Wright Seth W. , Socha Cawlynn M. , Cross Marya
Published: September 2008

Objective:To determine: 1) the number of patients arriving at the ED who had executed an advance directive (AD), 2) how many of the patients who had an AD brought the AD with them, and 3) whether those patients who did not have an AD had ever discussed ADs with their primary care providers (PCPs) or had ever heard of an AD.

Methods: A cross‐sectional, observational survey of a convenience sample of high‐risk patients presenting to the ED of a university hospital was performed. Patients presenting to the ED for acute complaints who were elderly or had an underlying disease that suggested a risk of death in the near future were considered high risk.

Results: Of the 238 patients surveyed, 90% had PCPs. However, only 22% had ADs. Of these, only 23% brought the AD to the ED. Of the patients who did not have ADs, 95% had never discussed ADs with their PCPs, and 42% did not know what an AD was. Blacks were less likely than whites to have ADs (p < 0.0002) or to know about them (p < 0.004).

Conclusion: The majority of high‐risk patients presenting to this ED do not have ADs. Among those high‐risk patients who did have ADs, fewer than 25% brought the ADs with them. The development of ADs for high‐risk patients and the availability of ADs in the ED are woefully inadequate. Emergency physicians need to collaborate with PCPs to remedy these deficiencies.
Effects of Parental Presence during Children's Venipuncture
Authors: Wolfram R. Wayne , Turner Edwin D.
Published: September 2008

Objective:To determine whether parental presence during venipuncture (VP) altered self‐reported distress of the child, the parent, or the health professional (HP) performing VP.

Methods: During nine consecutive months, 130 nonconsecutive 8–18‐year‐old children having VP in an urban pediatric ED were prospectively randomized into two groups of 65 patients each. Before VP, every child, parent, and HP completed a questionnaire developed to measure epidemiologic variables believed to influence distress during VP. The patients were randomized to have either a parent present or both parents absent during VP. The patients, the parents, and the HPs privately self‐reported their distress during VP on a visual analog scale (VAS). Statistical significance was determined by the Mann‐Whitney U (rank‐sum) test.

Results: In the parent‐present group, distress scores were lower for the parent (p < 0.01) and for the child (p < 0.04) than they were in the parents‐absent group. The HP performing VP had no difference in distress scores with and without parental presence (p < 0.55).

Conclusions: Parents and children having VP have less distress with parental presence. Health professional distress is not affected by parental presence.
Prospective Evaluation of Emergency Medicine Instruction for Rotating First–postgraduate–year Residents
Authors: Wyte Collate Ditz , Adams Stephen L. , Cabel Jennifer A. , Pearlman Kenneth , Yarnold Paul R. , Morkin Michael , Hott Kimberly A. , Mathews James J.
Published: September 2008

Objective:To determine whether either bedside teaching alone (group A) or bedside teaching with written course materials (group B) improved written examination scores, satisfaction with the rotation, or clinical grades of rotating PGY1 residents.

Methods: A prospective, controlled educational trial was conducted. Sixty–five PGY1 residents from diverse specialties rotated in the ED for one month over a ten–month study period, and were included in the study. The PGY1 residents were assigned to group by month of rotation. All the PGY1 residents received unstructured bedside teaching by emergency medicine (EM) residents and faculty. In addition, group B received written course materials on day 1.

Results: Mean posttest scores were higher than mean pretest scores for the interns considered as a whole (p < 0.0001), but mean pretest, posttest, and clinical grades were comparable across instructional groups. Mean satisfaction ratings were higher for group A than for group B (p < 0.015). The interns specializing in EM achieved higher mean test scores (p < 0.013) and clinical grades (p < 0.003) than did the interns specializing in another medical specialty.

Conclusion: Both instructional methods were associated with improved written test performance. Written course materials did not augment bedside teaching in terms of test scores, clinical grades, or satisfaction. with the rotation. At a university–based, high–volume ED, bedside teaching offers educational benefit to rotating PGY1 residents that may not be augmented by written course materials.
Injury in West Virginia: A Statewide Survey
Authors: Williams Janet M. , Derk Susan J. , Furbee Paul M.
Published: September 2008

Objective: To determine an estimate of the period prevalence of medically attended injury in West Virginia via a statewide random telephone survey.

Methods: A statewide random telephone survey, the West Virginia Social Indicator Survey (WVSIS), was modified to incorporate questions regarding the incidence and mechanisms of injury. The WVSIS is periodically conducted on a representative cross‐section of West Virginians to gather information about their social and economic conditions as well as to monitor change in the quality of their lives over time.

Results: Of the 1,498 households interviewed, 412 (28%) reported having sustained injuries for which medical care had been obtained. This translates to a conservative estimate of 231,000 medically attended injuries within West Virginia in 1993. The average age of those injured was 35 years. Falls were the most frequently reported causes of injury, with motor vehicle crashes being the second most reported cause. Most injury victims (70%) were treated in an ED. Most respondents (67%) were able to suggest ways in which the injuries might have been avoided. Only 37% of the respondents with children 13 years of age reported ever having received injury prevention information from a physician. The most commonly reported physician advice concerned childhood poisoning (34%).

Conclusions: Injury questions added to ongoing state health surveillance surveys provide valuable insight into population‐based injury rates and potential preventive measures.
Effect of Permissive Hypotension in Continuous Uncontrolled Intra‐abdominal Hemorrhage
Authors: Silbergleit Robert , Satz Wayne , McNarnara Robert M. , Lee David C. , Schoffstall John M.
Published: September 2008

Objective: To determine the effects of aggressive fluid administration vs permissive hypotension on survival, blood loss, and hemodynamics in a model of uncontrolled hemorrhage in which bleeding has been shown to be continuous.

Methods: In this porcine model, 10 animals were bled through a flow‐monitored shunt placed between the femoral artery and the peritoneal cavity. The animals received either no fluid (n = 5) or 80 mug lactated Ringer's solution (n = 5) during a resuscitation phase between 10 and 20 minutes postinjury, followed by a 40‐minute evaluation phase. Arterial pressures, cardiac output (CO), and hemorrhage rate were measured, Survival and blood loss were calculated outcome measures.

Results: The difference in survival between the animals left hypotensive (40%) and those receiving normotensive resuscitation (20%) was not significant (p = 0.49). In the animals receiving fluid resuscitation, mean arterial pressure (MAP) and CO increased during the resuscitative phase, but all the animals suffered the same pattern of hemodynamic deterioration in the evaluation phase. Rate of hemorrhage during the resuscitative phase was 20 ± 5 mL/min in the animals not receiving fluid and 56 ± 9 mL/min in the animals receiving fluids. Total blood loss was subsequently 20 mL/kg greater in the animals receiving fluids than in the animals without fluid resuscitation.

Conclusions: In this model of continuous uncontrolled hemorrhage, the difference in survival between the animals left hypotensive and the animals receiving fluid resuscitation was not statistically significant. Increases in MAP and CO with fluid resuscitation were transient and were offset by larger volumes of blood loss. In contrast to the aortotomy model (where thrombosis is likely and hypotensive resuscitation has proven beneficial), this model suggests that in continuous bleeding, avoiding fluid resuscitation has a much smaller effect on outcome. Much of the benefit from hypotensive resuscitation may depend on having an injury that can stop bleeding.
Emergency Physician Use of Ultrasonography in Blunt Abdominal Trauma
Authors: Ingeman Jeffrey E. , Plewa Michael C. , Okasinski Robert E. , King Randall W. , Knotts F. Barry
Published: September 2008

Objective: To evaluate the diagnostic utility of abdominal diagnostic ultrasonography (DUS) performed by emergency physicians for intraperitoneal fluid caused by blunt abdominal trauma (BAT).

Methods: The design was a prospective, blind, observational study. During a 15‐month period, a convenience sample of patients presenting to the ED with BAT necessitating CT scan of the abdomen, diagnostic peritoneal lavage (DPL), or laparotomy was studied. Scans were performed by an emergency medicine (EM) attending, or a resident supervised by an attending, using a real‐time sector ultrasound scanner with a 3.5‐MHz probe. Training in DUS included a 1‐hour didactic session and 1 hour of practice on human volunteers. Free intraperitoneal fluid was defined as an anechoic stripe in the hepatorenal, bladder‐rectal, or splenorenal space, and constituted a positive DUS study. Free intraperitoneal fluid detected on abdominal CT scan, DPL, and/or laparotomy was the criterion standard.

Results: Of 110 patients scanned, 13 were excluded secondary to technical difficulty or lack of diagnostic follow‐up modalities. Of the remaining 97 patients, there were 24 females and 73 males, ranging from ages 2 to 78 years. DUS detected intraperitoneal fluid in 21 subjects, including 3 false positives. There were 6 false‐negative DUS examinations. DUS had a sensitivity of 75% (95% CI 53–90%), a specificity 96% of (95% CI 89–99%), and an accuracy of 91% (95% CI 83–96%). No false‐positive or false‐negative DUS study occurred after the first 67 cases. The mean interval for a DUS scan was 4.9 ± 2.9 minutes, ranging from 0.5 to 16 minutes, and the mean intervals were not different between the positive and the negative studies. The accuracies of DUS were similar in the pediatric patients, 97% (95% CI 83–100%), and in the adults, 88% (95% CI 78–95%). The hepatorenal view provided the highest sensitivity as well as the least number of uninterpretable scans of the 3 DUS views.

Conclusion: Emergency physicians with minimal training can use DUS with fair sensitivity and good specificity and accuracy to detect free intraperitoneal fluid in both pediatric and adult BAT victims. The hepatorenal view provides the highest sensitivity for intraperitoneal fluid, although the 3‐view series (with hepatorenal, bladder‐rectal, and splenorenal spaces) can typically be performed within 5 minutes and may increase the specificity and accuracy.
Patient Refusal of Care in the Out‐of‐hospital Setting
Authors: Adams James , Verdile Vince , Arnold Robert , JK R. Jack Ayres , Kosowsky Joshua
Published: September 2008

A case vignette of out‐of‐hospital refusal of emergency care is reported with accompanying discussion. This case illustrates the challenges faced by out‐of‐hospital emergency care personnel in these scenarios and provides guidance to the emergency physician and emergency medical technician. Recommendations are provided for preparing the emergency medical services system to handle these cases.
Use of Practice Tracks in the Medical Specialties
Authors: Melanson Scott W. , Sexton Joseph D. , Heller Michael B.
Published: September 2008

Objectives: To evaluate the use of practice tracks by each of the 24 medical specialty boards and to compare this with the experience in emergency medicine (EM).

Methods: Scripted telephone surveys were conducted with representatives of each of the specialty boards.

Results: Of 24 specialties currently recognized by the American Board of Medical Specialties (ABMS), 14 (58%) reported a history of a practice track. Eight boards reported never having a practice track and 2 were unsure. All practice tracks have been limited in duration, most commonly closing after a specified period. The mean duration of the practice tracks was 9.8 years, the median was 7.5 years, and the range was 3–27 years. The practice track in EM was open for 9 years.

Conclusions: Practice tracks were common in the early years of most specialties and most were limited by duration. The history of the practice track in EM is not dissimilar to those of other specialties.
Topical Tetracaine Attenuates the Pain of Infiltration of Buffered Lidocaine
Authors: Bartfield Joel M. , Lee Fayzel S. , Raccio‐Robak Nancy , Salluzzo Richard F. , Asher Shellie L.
Published: September 2008

Objective: To determine whether topical tetracaine attenuates the pain of buffered lidocaine infiltration.

Methods: A prospective, randomized, double‐blind trial was conducted involving adults with lacerations being repaired following local anesthesia. Two 0.5‐mL injections of buffered lidocaine were given in a standardized manner. Injection 1 was given prior to application of topical study solution. Injection 2 was given on the opposite side of the laceration after topical application of a study solution that was 4 mL of either tetracaine or normal saline. Pain of each infiltration was measured using a visual analog pain scale. Pain score differences (injection 1 ‐ injection 2) were compared for the 2 study solutions using a Wilcoxon 2‐sample signed‐rank test.

Results: Of 57 subjects studied, 29 received tetracaine and 28 received saline. The groups were similar in age, gender, wound length, wound location, and initial pain score. Pain scores decreased significantly in the tetracaine group as compared with the saline group. The median pain score difference for tetracaine was 12.0 mm, with an interquartile range (IQR) of 2 to 43 mm, as compared with 2 mm, with an IQR of —17 to 21 mm for saline (p = 0.048).

Conclusion: Topical tetracaine attenuates the pain of infiltration of buffered lidocaine.
Evidence for and Impact of Selective Reporting of Trauma Triage Mechanism Criteria
Authors: Burstein Jonathan L. , Henry Mark C. , Alicandro Jeanne M. , McFadden Kim , Jr. Henry C. Thode , Hollander Judd E.
Published: September 2008

Objective: To determine whether out‐of‐hospital care charts selectively report trauma triage criteria, and the impact of such documentation on triage guideline development.

Methods: A special structured data instrument that requested the presence or absence of the American College of Surgeons (ACS) trauma triage criteria was completed by emergency medical services (EMS) personnel transporting victims of motor vehicle crashes. The standard written EMS report forms for a subset of 199 patients with at least 1 ACS trauma triage mechanism criterion were reviewed by the investigators. Outcome data were obtained from medical record review. The structured data instrument and the standard EMS report were compared for concordance. The impact of method of data collection on the ability of the ACS criteria to predict patient outcome was determined.

Results: EMS reports and structured data instruments similarly noted the presence of anatomic, physiologic, and “other” trauma triage criteria (p > 0.07 for all individual comparisons). Most mechanism‐of‐injury criteria noted on the data instrument (pedestrian struck >20 mph; crash speed >20 mph; vehicle deformity; compartment intrusion; rollover; and ejection) were infrequently documented on the standard EMS report (median 28.5% noted, range 0–100%). Patients who had mechanism criteria noted on the EMS report were more likely to be admitted to the hospital (44% vs 13%; p = 0.006). to require major operative procedures (10% vs 0%; p = 0.005), and to have prolonged lengths of stay (26% vs 9%; p = 0.02) and injury severity scores ±16 (15% vs 3%; p = 0.03) than were patients who had mechanism criteria documented only on the structured data instrument.

Conclusions: In the authors' EMS system, standard EMS report documentation underreports ACS trauma triage mechanism criteria. This underreporting appears to bias outcome analysis in the direction of a worse outcome and more resource utilization. Reporting of mechanism‐of‐injury criteria improves with use of a structured data instrument.
Computed Tomography Screens Stable Patients at Risk for Penetrating Cardiac Injury
Authors: Nagy Kimberly K. , Gilkey Susan H. , Roberts Roxanne R. , Fildes John J. , Barrett John
Published: September 2008

Objective: To determine the accuracy of CT of the chest in diagnosing the presence of cardiac injury in stable pitients with penetrating chest injuries.

Methods: A retrospective chart review of a convenience sample of stable patients with penetrating thoracic wounds evaluated for hemopericardium using chest CT at an urban level I trauma center.

Results: 60 stable patients with penetrating wounds in proximity to the heart underwent CT. Three patients had radiographic evidence of pericardial fluid, and 1 had an equivocal study. These 4 patients underwent subxiphoid pericardial window exploration: 2 had only clear fluid present, the other 2 had hemopericardium. The latter patients had a total of 3 cardiac and 1 diaphragmatic injuries, which were repaired at subsequent sternotomy. None of the 56 patients who had negative CTs had further clinical evidence of cardiac injury. The sensitivity, specificity, and accuracy of CT in this setting for hemopericardium are 100% (95% CI 18–100%). 96.6% (95% CI 88–100%). and 96.7% (95% CI 89–100%), respectively.

Conclusion: Chest CT may be a useful test for diagnosing the presence of hemopericardium in the setting of penetrating thoracic injury. With the caveat that the patient must be removed from a closely monitored environment, the authors advocate the use of CT in stable patients with penetrating chest wounds whenever echocardiography is unavailable.
Agreement between Emergency Physicians and Psychiatrists Regarding Admission Decisions
Authors: Garbrick Lisa , Levitt M. Andrew , Barrett Michelle , Graham Leslie
Published: September 2008

Objective: To determine the level of agreement between emergency physicians (EPs) and psychiatrists regarding the need for acute psychiatric hospitalization and treatment for patients presenting with alleged psychiatric complaints.

Methods: A prospective, cross‐sectional assessment of concordance between EPs and psychiatrists in psychiatric admission decisions was performed at an urban county, teaching hospital ED. The participants had been brought to the ED for psychiatric evaluation. The patients were interviewed by an attending EP or a senior‐level resident, and a tentative impression and disposition were determined pfior to an independent examination and final disposition by a psychiatrist. Strength of physician group agrement was determined using the k statistic.

Results: The patient mean age was 37.5 ± 15 years; 51% were men. The most common reasons for evaluation were disruptive behavior (28%), overdose (24%), and danger to self (23%). Of the 156 patients, 47 (28.7%) were sent home without treatment, 10 (6.3%) were determined to need only medical treatment, and 6 (3.7%) were released with outpatient psychiatric treatment. There were 84 (55.7%) patients admitted for psychiatric treatment. The EPs and psychiatrists had only moderate agreement regarding danger to self (k = 0.44), danger to others (k = 0.40). substance abuse as the primary problem (k = 0.50), and need for psychiatric hospitalization (k = 0.54).

Conclusion: Moderate agreement between EPs and psychiatrists in key impressions and admission decisions suggests that shared training in psychiatric decision making, especially during residency training, is desired in this setting.
Acute Bilateral Blindness
Authors: Hoover Bradley W. , Stack Lawrence B.
Published: September 2008

Acute bilateral blindness is an emergent condition that may signal life‐threatening disease. This article details an emergency medicine approach to the patient with acute bilateral blindness, and reports a case of an elderly woman whose sole presenting complaint was acute loss of vision. She was ultimately diagnosed as having pulmonary embolism. The approach focuses on identification of life‐threatening disease processes, while differentiating between ocular. psychogenic, and cortical etiologies.
Intravenous Morphine for Early Pain Relief in Patients with Acute Abdominal Pain
Authors: Pace Steven , Burke Thomas E
Published: September 2008

Objective: To determine whether morphine affects evaluation or outcome for patients with acute abdominal pain.

Methods: Prospective, double‐blind, placebo‐controlled administration of morphine sulfate (MS) or normal saline (NS) in the setting of acute abdominal pain. The study was performed at a military ED with an annual census of 60, 000 visits. Patients ±18 years old who had abdominal pain for ± 48 hours were included. Patients who were allergic to MS or who had systolic blood pressures < 90 mm Hg were excluded. The physicians indicated a provisional diagnosis, a differential diagnosis, and a provisional disposition. Study solution was titrated to the patient's assessment of adequate analgesia (up to a volume equivalent of 20 mg of MS); pain response was monitored using a visual analog scale (VAS). The patients were followed until diagnosis occurred or symptoms resolved.

Results: Of 75 patients enrolled, 71 completed the study; 35 patients received MS and 36 received NS. More than half (44; 62%) of the patients were admitted from the ED: 28 patients underwent surgery. The VAS pain level improved more for the MS group, 3.9 2 2.8 cm, than it did for the NS group, 0.8 ± 1.5 cm (p < 0.01). Study solution dose was less in the MS group than it was in the NS group, 1.5 ± 0.5 mL vs 1.8 ± 0.4 mL (p <0.01). There was no difference between the groups when comparing accuracy of provisional or differential diagnosis with that of final diagnosis. Differences between provisional and actual dispositions were the same in all groups. There were 3 diagnostic or management errors in each group.

Conclusions: When compared with saline placebo, the administration of MS to patients with acute abdominal pain effectively relieved pain and did not alter the ability of physicians to accurately evaluate and treat patients. Key words: abdominal pain; analgesia; analgesics; emergency department; morphine; opiates; pain.
Nitric Oxide Metabolite Levels in Acute Vaso‐occlusive Sickle‐cell Crisis
Authors: Lopez Bernard L. , Barnett Jordan , Ballas Samir K. , Christopher Theodore A. , Davis‐Moon Linda , Ma Xin‐liang
Published: September 2008

Objectives: 1) To measure nitric oxide (NO) metabolite levels in patients presenting to the ED in acute vasoocclusive sickle‐cell crisis (SCC), and 2) to determine whether a relationship exists between NO metabolite levels and pain.

Methods: A prospective, observational study of patients with documented sickle‐cell anemia (SCA), aged ±18 years, presenting in typical, acute SCC was conducted in an urban, university teaching hospital. Excluded were those with atypical pain or acute, coexistent disease (as evidenced by fever, tachycardia, tachyon, or hypotension). Pain scores were measured by a 10‐cm visual analog scale (VAS). Blood NO metabolite levels for SCC patients and control subjects (healthy volunteers, n = 9; SCA control subjects not in SCC, n = 10) were determined using an NO‐specific chemiluminescence technique that measured plasma nitrite and nitrate, the stable end‐products of NO. The acute SCC patients were divided into 3 groups, with the range for the SCC‐normal (n = 5) group defined as within 2 SD of the healthy volunteer control patients. The SCC‐low patients (n = 21) had NO metabolite levels below this range and the SCC‐high (n = 21) patients had levels above this range.

Results: The SCA and healthy volunteer control groups had similar NO metabolite levels (25.3 vs 22.6 μmol; p = 0.10). The 3 acute SCC groups had the following mean NO levels: 1) SCC‐normal = 21.3 ± 1.6 μmol; 2) SCC‐low = 7.2 ± 1.1 μmol; and 3) SCC‐high = 43.7 ± 3.5 μmol. The SCC‐high NO‐level group had significantly lower VAS pain scores when compared with the SCC‐low and SCC‐normal NO‐level groups (6.52 ± 1.85 cm vs 8.76 ± 0.83 cm, and 8.62 ± 1.29 cm, p = 0.02).

Conclusion: NO metabolite levels vary in SCC patients. Elevated levels are associated with lower pain scores, while lower levels are associated with higher pain scores, indicating that NO metabolites may potentially represent a marker for compensatory mechanisms in SCC tissue ischemia. Further work is needed to delineate the usefulness of NO metabolites in assessing the seventy of SCC.
Tetrodotoxin Infusion: Nonventilatory Effects and Role in Toxicity Models
Authors: Mackenzie Colin E , Smalley Arthur J. , Barnas George M. , Park Sun G.
Published: September 2008

Objectives: To determine the cardiovascular, autonomic, and neuromuscular effects of an IV infusion of tetrodotoxin (TTX) when ventilation is supporte'd.

Methods:TTX was infused in 18 anesthetized beagles during conventional mechanical ventilation. TTX infusion continued at a rate of 9.3 μg/kg/hr until apnea occurred with 1 minute of ventilator disconnection. Measurements included intravascular pressures, heart rate (HR), cardiac output, blood gases, displacements of the rib cage and abdomen, O2delivery, and responses to train‐of‐four and tetanic peripheral nerve stimulation. Results are expressed as mean ± SD.

Results:During TTX infusion, all the dogs had discoordinate movements of the rib cage, abdomen, and limbs. Vomiting, urination, defecation, and increased salivation occurred. Nicotinic and muscarinic effects, neuromuscular blockade, and cardiovascular depression were produced by TTX. Apnea occurred in 72.0 ± 17.0 minutes when a total of 119.0 ± 17.4 μg of TTX was infused. At apnea, decreases in arterial pressure, cardiac index, HR, O2delivery, and systemic vascular resistance occurred, while pulmonary artery pressure and pulmonary vascular resistance increased. Loss of response to titanic stimulation was closely correlated with the dose of TTX that produced apnea.

Conclusion:The clinical symptoms and signs of TTX poisoning are similar to those of anticholinesterase poisons, and TTX dosing as described by this model may serve as a surrogate for organophosphorus poisoning. The model may be useful to determine optimum therapies for TTX poisoning and, since TTX prevents sodium influx into cells, to investigate enhanced survival in animals suffering from ischemia.