bluuebunny/crossref_metadata_2025 huggingface dataset:
Should Pediatric Emergency Care Be Decentralized ?: An Out‐of‐hospital Destination Model for Critically III Children
Authors: Sacchetti Alfred , Brennan John , Kelly‐Goodstein Nancy , Graff Diane
Published: January 2008

Abstract. Objectives: A time‐to‐initial‐stabilization model for out‐of‐hospital destinations of critically ill children (CICs) was developed. Application of this model to assess the impact of changes in different parameters of an emergency medical services for children (EMSC) system is described. Methods: A computer model created a 2,500‐square‐mile community containing ten community hospitals (CHs) and one pediatric critical care center (PCC). Community hospitals capable of providing initial immediate stabilization of CICs were defined as emergency departments accepting pediatrics (EDAPs). Critically ill children were randomly selected in proportion to population densities across the modeled community. Time to initial stabilization (TIS) was defined as the time to arrival at either an EDAP or a PCC or time to arrival at a non‐EDAP CH + travel time for a team from the PCC to the non‐EDAP CH + preparation/dispatch (P/D) time. The following parameters of the model were varied and their effect on TIS was evaluated: location of CHs, location of PCC, primary destinations for CICs, percent of CHs meeting EDAP standards, out‐of‐hospital compliance with designated hospitals for CICs, P/D time, and ambulance speed. Results: The computer model selected 1,000 CICs in accordance with the population densities of the community. The scenario with the shortest TIS was one in which every CH achieved EDAP designation (9.8 ± 0.5 minutes). The scenario with the longest TIS involved a model in which every CIC was transported directly to the PCC (28.6 ± 0.33 minutes). The number of EDAPs in a community and out‐of‐hospital compliance with use of EDAPs produced comparable effects on the TIS. Travel speeds had a direct effect on TIS but also exaggerated inefficiencies between scenarios. The P/D time had little effect on the TIS. Conclusions: An out‐of‐hospital destination model has been developed with the ability to modify multiple EMSC system variables. Application of this model demonstrates the shortest times to stabilization of critically ill children occur in systems that maximize the number of hospitals that meet EDAP standards and decentralize pediatric emergency care.
Ruptured Ectopic Pregnancy after Elective Termination of Intrauterine Pregnancy Discovered by Use of Ultrasonography in the Emergency Department
Authors: Burnette Robert E , Butler Richard C
Published: January 2008

Abstract. The authors report a case of a 27‐year‐old female who was diagnosed as having a ruptured ectopic pregnancy approximately 12 hours after an elective termination of an intrauterine pregnancy (IUP) was performed. Multiple previous evaluations by an obstetrician for a chief complaint of abdominal pain revealed an IUP but did not disclose the underlying pathology. The ectopic pregnancy was identified by the emergency physician's use of ultrasound in the emergency department.
A Comparison of Two Bedside Tests for the Detection of Salicylates in Urine
Authors: Weiner Alan L , Ko Carlyn , McKay Charles A
Published: January 2008

Abstract. Objective: Ferric chloride (FC) and Trinder reagent (TR) have both been used to identify salicylates (ASA) in the urine of patients presenting with possible drug overdose. The authors sought to compare the sensitivities and specificities of these two reagents in detecting ASA in the urine of patients presenting to an emergency department (ED) with suspected drug overdose. Methods: Patients were eligible for inclusion in this study if they presented to the ED with either suspected overdose or unexplained metabolic acidosis. One milliliter of the patient's urine was added to 1 mL of each of the two reagents. A positive test was defined as any darkening of the color of the reagent. Each patient had a quantitative serum ASA measured. Results: Twenty of 180 patients (11%) had quantitative serum ASA levels above 5 mg/dL. Both reagents were 100% sensitive in identifying these patients. The specificity of FC was 71% compared with 73% for TR. The two reagents gave similar results in 91% of cases. Conclusion: Both FC and TR are reliable in detecting ASA in the urine of patients presenting with suspected drug overdose. A negative result with either test eliminates the need for a quantitative serum ASA level. Because FC has a longer shelf life than TR, it is the more practical reagent for use in the ED.
A Porcine Model for Instruction of Lateral Canthotomy
Authors: Suner Selim , Simmons Walter , Savitt Daniel L
Published: January 2008

Abstract. Objectives: Retrobulbar hemorrhage is a rare condition often necessitating immediate lateral canthotomy for preservation of vision. It is performed infrequently in emergency departments (EDs); therefore, a laboratory‐based curriculum using a swine model was developed to teach emergency medicine (EM) residents and pediatric emergency medicine (PEM) fellows the proper technique of lateral canthotomy and to provide them with hands‐on training. Methods: Anesthetized adult swine are used due to similarity with human anatomy and availability from other concurrent procedure laboratories. Fifteen to twenty milliliters of saline is injected behind the orbit to produce proptosis and mimic retrobulbar hemorrhage. A dissection is performed on one orbit to demonstrate the technique and to illustrate the lateral canthal ligaments. The resident then performs a rapid lateral canthotomy on the contralateral orbit under faculty supervision. Results: Over one year, 19 EM residents and 3 PEM fellows were trained using this model. During the same period no lateral canthotomies were performed in the EDs. A post‐laboratory survey demonstrated a high subjective level of comfort with this procedure. Video‐based demonstration of this laboratory is publicity available on the World Wide Web. Conclusion: Adult swine can effectively serve as a model for resident training in lateral canthotomy, a rarely performed sight‐saving procedure.
Prediction of Hyperkalemia in Dogs from Electrocardiographic Parameters Using an Artificial Neural Network
Authors: Porter Robert S. , Kaplan Justin , Zhao Ning , de Garavilla Lawrence , Eynon C. Andrew , Wenger Fred G. , Dalsey William C.
Published: January 2008

Abstract. Objective: To predict severe hyperkalemia from single electrocardiogram (ECG) tracings. Methods: Ten conditioned dogs each underwent this protocol three times: Under isoflurane anesthesia, 2 mEq/kg/hr of potassium chloride was given intravenously until P‐waves were absent from the ECG and ventricular rates decreased ≥20% in ≤5 minutes. Serum potassium levels (K+) were measured at regular intervals with concurrent digital storage of lead II of the surface ECG. A three‐layer artificial neural network with four hidden nodes was trained to predict K+ from 15 separate elements of corresponding ECG data. Data were divided into a training set and a test set. Sensitivity, specificity, and diagnostic accuracy for recognizing hyperkalemia were calculated for the test set based on a prospectively defined K+= 7.5. Results: The model produced data for 189 events; 139 were placed in the training set and 50 in the test set. The test set had 37 potassium levels at or above 7.5 mmol/L. The neural network had a sensitivity of 89% (95% CI = 75% to 97%) and a specificity of 77% (95% CI = 46% to 95%) in recognizing these. The positive likelihood ratio was 3.87. Overall accuracy of this model was 86% (95% CI = 73% to 94%). Mean (±SD) difference between predicted and actual K+ values was 0.4 ± 2.0 (95% CI = ‐0.2 to 1.0). Conclusions: An artificial neural network can accurately diagnose experimental hyperkalemia using ECG parameters. Further work could potentially demonstrate its usefulness in bedside diagnosis of human subjects.
Emergency Medicine Standardized Letter of Recommendation: Predictors of Guaranteed Match
Authors: Girzadas Daniel V. , Harwood Robert C. , Delis Steve N. , Stevison Kathleen , Keng George , Cipparrone Nancy , Carlson Andrea , Tsonis George D.
Published: January 2008

Abstract. Objective: The Council of Emergency Medicine Residency Directors (CORD) standardized letter of recommendation (SLOR) has become a common, reliable, and useful tool in the evaluation of emergency medicine (EM) applicants. A “guaranteed match” (GM) is the SLOR's bottom‐line superlative response. It is also the SLOR's least common superlative response. Because candidates receiving a GM are a select group, the authors thought it would be useful to identify SLOR information that predicts a GM recommendation. Methods: This was a secondary analysis of a database of all EM SLORs submitted to a single EM residency during the 1998‐1999 application cycle to one EM residency program. Response to GM and 16 data points in the background/qualification sections were analyzed by chi‐square, univariate analysis, and logistic regression. Results: Four hundred eleven SLORs were analyzed. Qualification information was more predictive than background information for applicants receiving a GM. The highest univariate odds ratios for background information were “staff author” (OR = 1.7, 1.0‐2.8), “extended contact” (OR = 2.2, 1.0‐4.5), “clinical contact outside the ED” (OR = 3.0, 1.5‐5.9), and “honors on EM rotation” (OR = 5.4, 3.0‐9.8). The highest univariate odds ratios for qualification information were “outstanding differential diagnosis ability” (OR = 10.1, 5.8‐17.4), “outstanding work ethic” (OR = 13.1, 5.2‐33.3), and “outstanding global assessment” (OR = 58, 24.2‐139). Logistic regression analysis demonstrated “outstanding global assessment” (p < 0.000; r= 0.92) and “outstanding work ethic” (p = 0.028; r= 0.71) to be statistically predictive of GM. Conclusions: There were both background and qualification data points predictive of a “guaranteed match.” Qualification information had a greater predictive value than background information. Medical student applicants, letter writers, and letter evaluators may find this information useful when dealing with SLORs.
Online Medical Control and Initial Refusal of Care: Does It Help to Talk with the Patient?
Authors: Hoyt Brian T. , Norton Robert L.
Published: January 2008

The use of online medical control (OLMC) for initial refusal of care is time‐consuming and has medical—legal risks. Objectives: This study attempted to answer the following: Does physician—patient communication (PPC) increase the rate of transport and at what cost in terms of increased physician time? Do altered mental status (AMS) patients agree to transport more frequently and do they require more physician time? Can senior emergency medicine resident (RES) and emergency medicine faculty (FAC) physicians be equally efficient in handling refusal calls?Methods: The study evaluated a retrospective cohort for six months at a single base station, university hospital. Online medical control audiotapes and written records of radio and telephone communications were reviewed. Results: One hundred forty‐seven refusal cases were analyzed, PPC was used 70 times, and 37 patients were transported. Twenty‐four of 70 (34%) patients with PPC agreed to be transported, while ten of 77 (13%) patients without PPC agreed to be transported (p = 0.002). Sixteen of 30 (53%) patients with AMS were transported compared with 21 of 117 (18%) patients with normal mental status (p = 0.00007). Call times were longer with PPC utilization [406.3 sec PPC vs 230.1 sec no PPC (p < 0.001)] and with AMS patients [411.2 sec AMS vs 289.1 sec no AMS (p = 0.028)]. The RES and FAC physicians did not differ in transport rates [21% RES vs 26% FAC (p = 0.612)] and call times [329.4 sec RES vs 310.4 sec FAC (p = 0.659)]. Conclusions: Although time‐consuming, the use of PPC is associated with more patients' agreeing to be transported. Patients with AMS are transported more frequently and they use more physician time. Emergency medicine RES and FAC physicians have equal efficiency and efficacy in handling these calls.
Redefining Emergency Medicine Procedures: Canadian Competence and Frequency Survey
Authors: Farion Ken , Morrison Laurie J.
Published: January 2008

Objective: To redefine the Royal College of Physicians and Surgeons (RCPS) procedural skills list for Canadian emergency medicine (EM) residents through a national survey of EM specialists to determine procedural performance frequency and self‐assessment of competence. Methods: The survey instrument was developed in three phases: 1) an EM program directors survey identified inappropriate or dated procedures, endorsing 127 skills; 2) a search of EM literature added 98 skills; and 3) an expert panel designed the survey instrument and finalized a list of 150 skills. The survey instrument measured the frequency of procedure performance or supervision, self‐reported competence (yes/no), and endorsement of one of four training levels for each skill: undergraduate (UG), postgraduate (PG), knowledge only, or un‐necessary (i.e., too infrequently performed to maintain competence). Results: All 289 Canadian EM specialists were surveyed by mail; 231 (80%) responded, 221 completed surveys, and 10 were inactive. More than 60% reported competence in 125 (83%) procedures, and 55 procedures were performed at least three times a year. The mean competence score was 121 (SD ± 17.7, median = 122) procedures. Competence score correlation with patient volume was r= 0.16 (p = 0.02) and with hours worked was r= 0.19 (p = 0.01). Competence score was not associated with year or route (residency vs grandfather) of certification. Each procedure was assigned to a training level using response consensus and decision rules (UG: 1%; PG: 82%; unnecessary: 17%). Conclusions: A survey of EM clinicians reporting competence and frequency of skill performance defined 127 procedural skills appropriate for Canadian RCPS postgraduate training and EM certification.
Patient and Provider Attitudes toward Commercial Television Film Crews in the Emergency Department
Authors: Rodriguez Robert M. , Dresden Graham M. , Young Justin C.
Published: January 2008

One of the most successful reality‐based television shows is The Learning Channel's “Trauma—Life in the ER,” in which patients are filmed prior to being consented and camera crews are intimately intertwined in resuscitations. Objective: To assess provider and patient attitudes regarding privacy and satisfaction during filming. Methods: This was a prospective survey of patients and providers working in an urban, county teaching emergency department (ED). Scores of visual analog scales (VASs) for satisfaction, privacy, and willingness to return to the ED were accessed. Results: Eighty patients, 39 physicians and 39 nurses, were interviewed. On a 10‐cm VAS where 0 = no invasion of patient privacy and 10 = extreme privacy invasion, the mean (±SD) rating by physicians was 5.4 (±2.6), by nurses was 4.9 (±3.1), and by patients was 2.3 (±3.2). There was no significant difference between physician and nurse ratings (p = 0.69), but patients rated invasion of privacy significantly lower (p < 0.0001). Filmed patients rated significantly higher invasion of privacy (3.8 ± 4.1) than patients not filmed or those unsure whether they had been filmed (1.6 ± 2.5); p < 0.01). On a 10‐cm VAS where ‐5 = extreme decrease in satisfaction and 5 = extreme increase in satisfaction, the mean rating by physicians was ‐0.25 (±1.6), by nurses was ‐0.32 (±1.3), and by patients was 0.02 (±1.4). There was no statistical difference between the satisfaction levels of providers and patients (p = 0.19). Conclusions: Providers rated invasion of patient privacy higher than patients rated their own invasion of privacy. Patients who were filmed rated invasion of privacy higher than patients who were not filmed. Filming had no significant effect on the satisfaction of providers or patients.
Adrenal Insufficiency in Critically Ill Emergency Department Patients: A Taiwan Preliminary Study
Authors: Chang Shy‐Shin , Liaw Shiumn‐Jen , Bullard Michael J. , Chiu Te‐Fa , Chen Jih‐Chang , Liao How‐Chin
Published: January 2008

Objective: Unrecognized adrenal insufficiency can have serious consequences in critically ill emergency department (ED) patients. This prospective pilot study of adrenal function in patients with severe illness was undertaken to determine the prevalence of adrenal dysfunction and any relation to prior herbal drug use. Methods: In a high‐volume urban tertiary care ED, adult patients with sepsis or acute myocardial infarction (AMI) were eligible for the study. Over a two‐month period, a convenience sample was enrolled by the authors on arrival to the ED. Inclusion criteria were systemic inflammatory response syndrome (SIRS) criteria plus evidence of at least one organ dysfunction or cardiac marker plus electrocardiogram‐proven AMI. Exclusion criteria included known corticosteroid use. Serum cortisol was measured on arrival and for those patients with a level of <15 μg/dL (<414 nmol/L), an adrenocorticotropic hormone (ACTH) stimulation test was performed. Results: Of the 30 enrolled patients, 23 (77%) were suffering from severe sepsis and the other seven (23%) had an AMI. Thirteen of the 30 patients (43%; 95% CI = 25% to 65%) had serum cortisol levels of <15 μg/dL, consistent with adrenal insufficiency, nine with severe sepsis and four with an AMI. Eight (62%; 95% CI = 32% to 86%) of the 13 patients with low cortisol levels reported using herbal medications, while only two (12%; 95% CI = 1% to 36%) of the 17 with normal cortisol levels reported taking herb drugs (p = 0.01). Only two (15%; 95% CI = 2% to 45%) of the patients with low cortisol levels failed their corticotropin stimulation test, suggestive of true adrenocortical insufficiency. Both reported using herbal preparations. Conclusions: These results indicate that adrenal dysfunction is common among a group of critically ill patients seen in this Taiwanese ED. Moreover, the use of herbal drugs was high in the patients with low serum cortisols. Further studies are required to both confirm these findings and clarify whether a number of herbal medications contain corticosteroids.
Handbook of Medical Photography
Authors: Schauer Bobbie Ann
Published: January 2008

Handbook of Medical Photography. BY LAWRENCE B. STACK, ALAN B. STORROW, MICHAEL A. MORRIS, AND DAN R. PATTON.
Predicting Postconcussion Syndrome after Minor Traumatic Brain Injury
Authors: Bazarian Jeffrey J. , Atabaki Shireen
Published: January 2008

Background: Up to 50% of patients with minor traumatic brain injury (mTBI) develop postconcussion syndrome (PCS). A decision rule to stratify risk for PCS is needed. Objective: To identify mTBI patients at low and high risk of PCS by comparing the predictive values of variables generated by logistic regression (LR) and recursive partitioning (RP). Methods: This was a prospective, observational study of 69 mTBI patients aged >16 years presenting to the emergency department of a university teaching hospital. Minor TBI was defined as loss of consciousness <10 minutes or amnesia, Glasgow Coma Scale score (GCS) of 15, no skull fracture on physical examination, nonfocal neurologic exam, and no brain injury on computed tomography if one was done. Clinical/demographic data and the results of a brief neurobehavioral test battery were collected for all patients. The presence of PCS was determined by a validated telephone questionnaire at one month after initial presentation. All variables were subjected to both LR and RP. Results: Fifty‐eight percent had PCS at one month after initial presentation. Low risk: PCS occurred in 9% of men scoring >24 on the Hopkins Verbal Learning A (HVLA) (by LR) and in 9% of those injured in sports scoring >22 on HVLA (RP). High risk: PCS occurred in 89% of women scoring <9 on the Digit Span test (LR) and in 92% of those injured via falls or motor vehicle collision scoring <11.5 on HVLB2 (RP). Conclusions: Despite the high incidence of PCS, we were able to identify a low‐risk subgroup with an average PCS risk of <10% and a high‐risk subgroup with a PCS risk of ∼90%. Combining results from LR and RP expanded the number of patients able to be classified as high/low risk. Prospective validation is necessary.
Impact of a Resident Strike on Emergency Department Quality Indicators at an Urban Teaching Hospital
Authors: Salazar Albert , Corbella Xavier , Onaga Hisao , Ramon Rosa , Pallares Roman , Escarrabill Joan
Published: January 2008

Objective: To evaluate the indicators of activity and quality within the emergency department (ED) during a resident physicians' strike. Methods: This was an observational study comparing a strike period (SP) and a non‐strike period (NSP) in the ED of a 1,000‐bed tertiary care teaching hospital in Barcelona, Spain, with an annual census of 100,000 emergency visits. During a period of nine nonconsecutive days, the resident physicians were on strike. Emergency visits were handled by staff members. Data were compared between all patients treated in the ED during the SP and those treated during the NSP, matched by the weekday. The authors compared lengths of stay (LOSs), rates of use of laboratory tests and radiology procedures, numbers of patient walkouts, patient/physician ratios, emergency hospital admission rates, home discharge rates, unscheduled return rates, and mortality rates. Results: The two groups (SP 2,610 patients and NSP 3,634 patients) were comparable in terms of average daily attendance rate (SP: 290 ± 12 vs NSP: 302 ± 21; p = 0.13), elective hospital admission rate, and severity of illness. Statistically significant differences were found in terms of mean total patients' LOS (SP: 206.75 ± 12.27 vs NSP: 235.10 ± 27.08 minutes; p < 0.001), number of laboratory tests per patient (SP: 0.30 ± 0.05 vs NSP: 0.38 ± 0.04; p < 0.001), and radiographs per patient (SP: 0.78 ± 0.06 vs NSP: 0.88 ± 0.09; p = 0.021). Conclusions: This study demonstrated that replacing residents with staff physicians resulted in fewer laboratory tests ordered, fewer radiographs ordered, and shorter lengths of stays in the ED.
Initial Experience of Emergency Physicians Using the Intubating Laryngeal Mask Airway: A Case Series
Authors: Martel Marc , Reardon Robert F. , Cochrane Josh
Published: January 2008

Objective: Although the intubating laryngeal mask airway (ILMA) is widely available, its use by emergency physicians (EPs) has not been reported. The authors report the initial experience of EPs using the ILMA. A review of their experience and the relevant anesthesia literature provides a basis for EPs to use the ILMA more confidently and effectively. Methods: Between January 2000 and January 2001, the ILMA was used on a convenience sample of emergency department (ED) patients undergoing “routine” intubations, and “rescue” situations, after failed rapid‐sequence intubation (RSI). Patients were identified from the ED resuscitation case database. Chart review and intubating physician interviews focused on success of the device, complications encountered, and “pearls” of the device's use as perceived by the intubating physician. Results: Ventilation with the appropriate‐size ILMA occurred in less than 15 seconds in all “routine” intubations; tracheal intubation was subsequently accomplished in less than 1 minute. Eight of nine “routine” patients had blind tracheal intubation through the ILMA. One patient required fiberoptic bronchoscopy to guide the endotracheal tube into the trachea. Of the “rescue” intubations, all patients (n= 7) were successfully ventilated and five were successfully intubated using the ILMA. Conclusions: In this case series, the ILMA was easy to use in acute resuscitations, and proved to be invaluable in cases of failed RSI.
Research Fundamentals: Choosing an Appropriate Journal, Manuscript Preparation, and Interactions with Editors
Authors: DeBehnke Daniel J. , Kline Jeffrey A. , Shih Richard D.
Published: January 2008

This article, the last in a series on research methodology prepared by the Research Committee of the Society for Academic Emergency Medicine (SAEM), describes the process of journal selection, manuscript preparation, manuscript submission, and responding to editorial and reviewer comments. Methods for completing each step of this process are described. Following these methods will increase the chance of publishing one's work in the highest‐quality and most appropriate journal.
Surrogate Consent by Family Members for Out‐of‐hospital Cardiac Arrest Research
Authors: Hsieh Margaret , Dailey Michael W. , Callaway Clifton W.
Published: January 2008

Objectives: To evaluate the availability of family members of potential subjects to provide consent for participation in out‐of‐hospital cardiac arrest (OOHCA) research and to estimate the time required to contact a family member. Methods: This study was a prospective observational study of adult patients (>18 years old) with nontraumatic OOHCA treated by an urban emergency medical service. Emergency medicine resident physicians responded to each scene and noted the presence of family members. A subsequent convenience sample of family members answered standardized questions about their ability to provide consent for research participation on behalf of the patient. Results: Physicians were present at 100 of the 112 adult medical cardiac arrests during the study period. A family member was present at 57% of the scenes (95% CI = 47% to 67%). Patients with family present were older and were less likely to have bystander cardiopulmonary resuscitation (CPR) or live in a nursing home. The mean time (±SE) from emergency dispatch to family contact was 24.40 (±2.60) minutes and from physician arrival to family contact was 2.45 (±0.87) minutes (n= 20). Eight of 13 family members were willing to enroll the patient into a resuscitation study, but five family members were unable to understand the explanation of informed consent. Conclusions: Family members were present for an unrepresentative subset of OOHCA cases, and were contacted after the therapeutic window for many interventions. The emotional nature of the emergency situation also limited the reliability of surrogate consent for OOHCA research.
Adrenocortical Dysfunction Following Etomidate Induction in Emergency Department Patients
Authors: Schenarts Christina L. , Burton John H. , Riker Richard R.
Published: January 2008

Abstract. Objective: To assess adrenocortical function following intravenous etomidate use in emergency department (ED) patients requiring intubation. Methods: This was a prospective, randomized, controlled trial of consecutive patients presenting to the ED requiring intubation. Patients were randomized to receive a single bolus induction dose of either 0.05‐0.1 mg/kg midazolam (control group) or 0.3 mg/kg etomidate (etomidate group) during a standardized rapid‐sequence intubation (RSI) with succinylcholine. The primary outcome variable was adrenocortical function at 4, 12, and 24 hours post‐induction as assessed by measured serum cortisol response to exogenous cosyntropin (cosyntropin stimulation test, CST). Fisher's exact test was used to compare CST results between groups. Results: Thirty‐one patients were enrolled: 8 control, 10 etomidate, and 13 excluded from analysis for either incomplete data or steroid use during the study period. The 4‐hour CST results were significantly different between study groups, with a normal response in 100% of control patients vs 30% of etomidate patients (p = 0.004). The 12‐ and 24‐hour CSTs did not differ significantly between groups: normal CST in 100% of control patients at 12 and 24 hours vs 100% and 90% among etomidate patients at 12 and 24 hours, respectively (p = 1.0 at 12 and 24 hours). Measured cortisol levels of patients with abnormal CSTs remained within normal laboratory reference ranges. Conclusion: Use of etomidate in ED patients requiring RSI results in adrenocortical dysfunction. However, cortisol levels remain within normal laboratory levels during this period of dysfunction. Adrenocortical dysfunction appears to resolve within 12 hours of a single bolus dose of 0.3 mg/kg etomidate.
Intravenous Etomidate for Procedural Sedation in Emergency Department Patients
Authors: Ruth William J. , Burton John H. , Bock Anthony J.
Published: January 2008

Abstract. Objective: To determine the safety and effectiveness of intravenous (IV) etomidate for the sedation of patients undergoing painful procedures in the emergency department (ED). Methods: A two‐part feasibility study for ED patients receiving IV etomidate for painful ED procedures was undertaken. In the initial phase, a retrospective series of patients receiving etomidate for ED procedural sedation was considered. This phase served as the basis for a descriptive, prospective feasibility study of consecutive ED patients. During the second phase, patients were evaluated for complications related to IV etomidate sedation or the procedure performed. Immediately following the procedure, the physician was asked to complete a data collection sheet documenting the patient's etomidate dose, the number of doses required to complete the procedure, the analgesic used, the complications of the procedure, and the patient's procedural recall. Results: Intravenous etomidate was administered to nine patients during the initial study phase and 51 during the prospective, descriptive phase. Indications for sedation included dislocation reduction (25), cardioversion (7), fracture reduction (20), abscess incision and drainage (4), foreign body removal (3), and chest thoracostomy (1). Physicians used 0.1‐mg/kg IV bolus etomidate. A mean of 1.6 doses of etomidate was used to complete procedures (range 1‐3 doses). Of the 60 patients in both study groups, 59 (98%) achieved adequate sedation by physician's assessment. Procedural success was documented for 56 patients (93%). There were 12 complications reported: oxygen desaturation below 90% (5), myoclonus (4), vomiting (1), pain with injection (1), and a brief bradycardic episode (1). No patient required assistance with ventilation or endotracheal intubation. Conclusions: Intravenous etomidate can be administered safely and effectively to provide appropriate conscious sedation for short, painful ED procedures.
The Efficacy of Esmolol versus Lidocaine to Attenuate the Hemodynamic Response to Intubation in Isolated Head Trauma Patients
Authors: Levitt M. Andrew , Dresden Graham M.
Published: January 2008

Abstract. Objective: To assess the effect of esmolol vs lidocaine to attenuate the detrimental rise in heart rate and blood pressure during intubation of patients with isolated head trauma. Methods: This was a prospective, double‐blind, randomized study, performed at an urban, county teaching emergency department. Participants were 30 patients with isolated head trauma. Each underwent a standardized intubation protocol including esmolol or lidocaine, both at 2 mg/kg. Results: Esmolol was used in 16 patients and lidocaine in 14. Mechanisms of injury included 12 assaults, 6 motor vehicle collisions, 6 falls, 4 auto‐vs‐pedestrian crashes, and 2 bicycle incidents. Mean ethanol level was 0.116 ± 0.133 SD (range 0‐0.482). Mean Glasgow Coma Scale (GCS) score was 7.9 ± 4.0 SD. Cranial computed tomography (CT) hemorrhagic findings included 9 subdural/epidural hematomas, 6 cortex hemorrhages, and 2 multi‐hemorrhages. Eleven patients received surgical intervention: 9 patients received a craniotomy, and 2 a ventricular catheter. The 2‐minute time interval around intubation was used to assess each drug's efficacy. The mean difference change between groups for heart rate was 4.0 beats/min (95% CI = ‐17.7 to 9.7 beats/min), for systolic blood pressure was 1.3 mm Hg (95% CI = ‐27.8 to 30.4 mm Hg), and for diastolic blood pressure was 2.6 mm Hg (95% CI = ‐27.1 to 21.9 mm Hg). The power of this study was 90% to detect a 20‐beat/min difference in heart rate, a 35‐mm Hg difference in systolic blood pressure, and a 20‐mm Hg difference in diastolic blood pressure. Conclusions: Esmolol and lidocaine have similar efficacies to attenuate moderate hemodynamic response to intubation of patients with isolated head trauma.
Etomidate for Pediatric Sedation Prior to Fracture Reduction
Authors: Dickinson Richard , Singer Adam J. , Carrion Wesley
Published: January 2008

Abstract. Objective: While etomidate is reported as a procedural sedative in adults, its use in children has not been extensively reported. The authors describe their experience with etomidate for procedural sedation in children with extremity fractures and major joint dislocations. Methods: This was a retrospective descriptive chart review. The setting was a university‐based emergency department (ED) that follows national guidelines for procedural sedation. Subjects were children less than 18 years old who received etomidate prior to fracture reduction or major joint dislocations. Standardized data were abstracted from the medical records, including patient demographics, diagnosis, weight, types and doses of sedative and analgesic agents used, number of boluses of etomidate, attempts at reduction, complications encountered, vitals signs before, during, and after the reduction, disposition, and the time from procedure to discharge. Descriptive statistics calculated included means and proportions with 95% confidence intervals. Results: Fifty‐three children received etomidate for fracture reduction. Their mean age was 9.7; 41.5% were females. Indications for reduction included forearm fractures (38), ankle fractures (12), upper arm fractures (2), and hip dislocations (1). In most cases (83%) reduction was successful after one attempt only. The mean initial and total doses of etomidate were 0.20 mg/kg (range, 0.1 to 0.4) and 0.24 mg/kg (range, 0.13 to 0.52), respectively. Thirteen patients required a second bolus of etomidate or midazolam. Thirty‐four patients (64%) were discharged from the ED after a mean observation of 94 minutes (range, 35 to 255). There were no major adverse events (95% CI = 0% to 5.7%). One patient reported nausea and one required a fluid bolus for hypotension. One patient receiving multiple sedatives and opioid analgesics was admitted for observation due to prolonged sedation. No patient required assisted ventilation or intubation. Conclusions: These results suggest that etomidate is a safe and effective agent for procedural sedation in children requiring fracture and major joint reductions.
Functional Decline in Independent Elders after Minor Traumatic Injury
Authors: Shapiro Marc J. , Partridge Robert A. , Jenouri Ilse , Micalone Maria , Gifford David
Published: January 2008

Abstract. Objectives: To describe injury types, patterns, and health status in independently functioning elder patients presenting to the emergency department (ED) after a minor traumatic injury; and 2) to assess short‐term functional decline in this population at three‐month follow‐up. Methods: This was a prospective observational study of elder patients (age > 65 years) discharged home from the ED after evaluation and treatment for an acute traumatic injury. Patients were excluded if they were not independently functioning or had an acute delirium. Type and mechanism of injury sustained during the ED visit were recorded. Functional status was assessed during the visit and three months later using activities of daily living (ADL) and instrumental activities of daily living (IADL) scores. Results: One hundred six subjects were enrolled in the study. Mean age was 74.8 years. The most common injuries observed were contusion (n= 35, 33%, 95% CI = 24% to 42%), fractures (n= 28, 26%, 95% CI = 18% to 36%), lacerations (n= 20, 19%, 95% CI = 12% to 28%), and sprains (n= 12, 11%, 95% CI = 6% to 19%), which represented more than 90% of the injuries. Eighty‐eight (83%) patients completed three‐month follow up. Of these, 6 of 88 (6.82%, 95% CI = 3% to 14%) declined in their ADL scores and 20 of 88 (22.73%, 95% CI = 14% to 33%) declined in their IADL scores at three months. Primary injury type, specifically contusion, was more prevalent in patients who had a decline in ADL score, as compared with those who did not have a decline in ADL score (chi‐square p < 0.001). In addition, anatomic locations of injury were different between those patients with and without a decline in IADL scores (chi‐square p = 0.008). Gender differences were also found; females were more likely to be injured by a slip, trip, or fall indoors (36 of 58, 62%) than outdoors (22 of 58, 38%); males injured by this mechanism were more likely to be injured outdoors (14 of 20, 70%) as opposed to indoors (6 of 20, 30%), chi‐square p = 0.013. Conclusions: A significant proportion of functional elder patients with minor traumatic injury are at risk for short‐term functional decline. Decline in ADL is related to injury type, while IADL decline is related to anatomic location of injury. Emergency physicians should consider initiating follow‐up evaluation and possible intervention in highly functioning elders after minor traumatic injury.
Emergency Evaluation of Patients Presenting with Acute Scrotum Using Bedside Ultrasonography
Authors: Blaivas Michael , Sierzenski Paul , Lambert Michael
Published: January 2008

Abstract. Acute scrotal pain is not a rare emergency department (ED) complaint. Traditional reliance on medical history and physical examination can be precarious as signs and symptoms can overlap in various etiologies of acute scrotal pain. Objective: To determine the accuracy with which emergency physicians (EPs) using bedside ultrasonography are able to evaluate patients presenting to the ED with acute scrotal pain. Methods: The study was performed at an urban community hospital ED with a residency program and an annual census of 70,000. A retrospective chart review identified 36 patients who presented with complaints of acute scrotal pain and were evaluated by EPs using bedside ultrasound. A 5.0‐ or 7.5‐MHz linear‐array transducer with color and power Doppler capability was used to scan the scrotum. Patients were seen between July 1998 and September 1999. Diagnoses were verified by radiology or surgery. Sensitivity and specificity with 95% confidence intervals were calculated. Results: The EP ultrasound examinations agreed with confirmatory studies for 35 of 36 patients, resulting in a sensitivity of 95% (95% CI = 0.78 to 0.99) and a specificity of 94% (95% CI = 0.72 to 0.99). Diagnoses included three testicular torsions, six cases of epididymitis, four cases of orchitis, one testicular fracture, three hernias, three hydroceles, and 15 normal examinations. One case of epididymitis was misdiagnosed as an epididymal mass. Conclusions: This study suggests that EPs using bedside ultrasonography are able to accurately diagnose patients presenting with acute scrotal pain. In addition, they appear able to differentiate between surgical emergencies, such as testicular torsion, and other etiologies.
Attenuation of Verapamil‐induced Myocardial Toxicity in an Ex‐vivo Rat Model Using a Verapamil‐specific Ovine Immunoglobin
Authors: Hill Robert E. , Heard Kennon , Bogdan Gregory M. , Cairns Charles B. , Dart Richard C.
Published: January 2008

Objective: To determine whether an ovine verapamil‐specific immunoglobin G (V‐IgG) attenuates verapamil toxicity in an ex‐vivo rat left ventricular papillary muscle model. Methods: The authors dissected left ventricular papillary muscle strips from male Sprague‐Dawley rats (350‐410 g) and suspended them in an oxygen‐perfused Tyrode buffer bath at 37.5°C. Muscle strips equilibrated for 90 minutes under electrical stimulation of 1 Hz. Resting and developed tension (mg) were monitored continuously. A concentration—response trial was performed with verapamil concentrations ranging from 31 to 1,020 nM; 510 nM produced consistent reduction in developed tension. A trial of V‐IgG was then conducted by administering the following treatments to papillary muscle strips in a randomized manner: V‐IgG + 510 nM verapamil, nonspecific ovine IgG (N‐IgG) + 510 nM verapamil (protein control), and 510 nM verapamil alone. Immunoglobin G was administered in equimolar concentrations to verapamil. Attenuation was expressed as inhibition of the verapamil‐induced reduction of developed tension. Results: The V‐IgG comparative trial indicated the V‐IgG + verapamil treatment had a mean reduction in developed tension of 14.1% (SD ± 12.2) compared with 36.2% (SD ± 14.9) for N‐IgG + verapamil and 34.9% (SD ± 8.1) for verapamil alone (p < 0.05). There was no difference between the two control groups. Conclusion: Verapamil‐specific IgG attenuated verapamil‐induced reduction of developed tension in an ex‐vivo rat model.
The Effect of Written Informed Consent on Detection of Violence in the Home
Authors: Hollander Judd E. , Schears Raquel M. , Shofer Frances S. , Baren Jill M. , Moretti Lisa M. , Datner Elizabeth M.
Published: January 2008

Studies of programmatic interventions for victims of violence in the home may require the use of informed consent. The use of informed consent may result in ascertainment bias, with victims of violence being less likely to participate. Objective: To investigate the effect of written informed consent on the detection of violence in the home during emergency department (ED) screening. Methods: The authors performed a nonrandomized, controlled trial of 3,466 patients at an urban university ED. On odd days, patients (n? 1,857) were read a brief scripted statement and screened using standardized questions. On even days, patients (n? 1,609) received standard written informed consent prior to the same screening questions (writ‐IC). The main outcome was the number of cases of violence in the home detected using each screening protocol. Results: Fewer writ‐IC patients participated in screening (82% vs 92%; p < 0.001). Despite a higher refusal rate in the writ‐IC group, there was no difference in the number of victims detected by each screening method: choked/kicked/bit/punched? (writ‐IC, 7.3 vs routine screen, 6.5%; p ? 0.3); slapped/grabbed/shoved? (7.3 vs 6.7%; p ? 0.4); threatened/actually used knife/gun to scare/hurt you? (8.3 vs 9.4%; p ? 0.3); thrown object to harmyou? (5.2 vs 4.6%; p ? 0.4); forced sex? (5.8 vs 4.7%; p ? 0.15); or afraid current/former intimate partner would hurt you physically? (13.9 vs 11.9%; p ? 0.9). Conclusions: A written informed consent process in screening for violence in the home is associated with a higher refusal rate than routine screening, but use of written informed consent does not result in a lower rate of detection for multiple forms of violence. The authors did not find any support for the hypothesis that the use of written informed consent would decrease detection of violence in the home.
A Comprehensive Set of Coded Chief Complaints for the Emergency Department
Authors: Aronsky Dominik , Kendall Diane , Merkley Kathleen , James Brent C. , Haug Peter J.
Published: January 2008

Objective: To develop a generally applicable set of coded chief complaints for the computerized patient records of emergency departments (EDs). Methods: At an urban teaching ED the chief complaints of more than 50,000 patients were analyzed retrospectively during a 29‐month period (June 1995—October 1997). Applying continuous quality improvement methods, a multidisciplinary team examined the current process documenting the patient's chief complaint. During two prospective periods (November 1997—December 1998; January 1999—June 1999), more than 34,000 chief complaints were analyzed. To reduce free‐text charting practices, a variety of interventions on individual and team level were applied. Quantitative analysis was performed with statistical process control charts, and a qualitative evaluation was performed with a questionnaire. Results: The charting of chief complaint in free‐text format decreased from 23% to 1%. The range among individual ED staff members narrowed from 45% to 9%. During the refinement of the set of coded chief complaints, six infrequently charted items were removed. Five new chief complaints identified by analysis of free‐text entries during the second study period were added. The current set of chief complaints consists of 54 codable and the three original free‐text items. The ED staff members perceived all the interventions beneficial. A poster displaying all available terms as a visual aid, however, had the largest impact on charting the patient's chief complaint in coded format. Conclusions: Applying continuous quality improvement methods, the authors created a clinically developed and applicable set of codable chief complaints that can be easily integrated into a computerized patient record of an ED.
Safety Net Research in Emergency Medicine Proceedings of the Academic Emergency Medicine Consensus Conference on “The Unraveling Safety Net”
Authors: Gordon James A. , Billings John , Asplin Brent R. , Rhodes Karin V.
Published: January 2008

A primary goal of the Academic Emergency Medicine Consensus Conference, “The Unraveling Safety Net: Research Opportunities and Priorities,” was to explore a formal research agenda for safety net research in emergency medicine. This paper represents the thoughts of active health services researchers regarding the structure and direction of such work, including some examples from their own research. The current system for safety net care is described, and the emergency department is conceptualized as a window on safety net patients and systems, uniquely positioned to help study and coordinate integrated processes of care.
The Epidemiology of the Homeless Population and Its Impact on an Urban Emergency Department
Authors: D'Amore Jason , Hung Oliver , Chiang William , Goldfrank Lewis
Published: January 2008

Objectives: To characterize the homeless adult population of an urban emergency department (ED) and study the medical, psychiatric, and social factors that contribute to homelessness. Methods: A prospective, case—control survey of all homeless adult patients presenting to an urban, tertiary care ED and a random set of non‐homeless controls over an eight‐week period during summer 1999. Research assistants administered a 50‐item questionnaire and were trained in assessing dentition and triceps skin‐fold thickness. Inclusion criteria: all homeless adults who consented to participate. Homelessness was defined as being present for any person not residing at a private address, group home, or drug treatment program. Randomly selected controls were concurrently enrolled with a 3:1 homeless:control rate. Exclusion criteria: critically ill, injured, or incapacitated patients, or patients <21 years of age. Univariate analysis with appropriate statistical tests was used. The Mantel‐Haenszel test was used to adjust for population differences. Results: Two hundred fifty‐two homeless subjects and 88 controls were enrolled. Data are presented for homeless vs control patients, and all p‐values were <0.01. Odds ratios (ORs) with 95% confidence intervals (95% CIs) are given where appropriate: mean age (±SD) ? 42 ± 10 vs 48 ± 13; male gender 95% vs 54% (OR ? 17; 95% CI ? 8 to 37); history of (hx) tuberculosis 49% vs 15% (OR ? 2.5; 95% CI ? 1.2 to 3); hx HIV infection 35% vs 13% (OR ? 3.8; 95% CI ? 1.8 to 8); hx penetrating trauma 62% vs 16% (OR ? 8.62; 95% CI ? 4.4 to 17.1); hx depression 70% vs 15% (OR ? 13.4; 95% CI ? 6.7 to 27); hx schizophrenia 27% vs 7% (OR ? 5.1; 95% CI ? 2.0 to 14); hx alcoholism 81% vs 15% (OR ? 24; 95% CI ? 12 to 49); significant tooth loss (>3) 43% vs 18% (OR ? 3.3; 95% CI ? 1.8 to 6.4); percentage of body fat 16.5% vs 19.7%; hx social isolation (no weekly social contacts) 81% vs 11% (OR ? 33.3; 95% CI ? 14 to 100); mean number of ED visits/year 6.0 vs 1.6. Conclusions: In the study population homelessness was associated with a history of significantly higher rates of infectious disease, ethanol and substance use, psychiatric illness, social isolation, and rates of ED utilization.