bluuebunny/crossref_metadata_2025 huggingface dataset:
Influence of Preliminary Damage on the Load‐Bearing Capacity of Zirconia Fixed Dental Prostheses
Authors: Kohorst Philipp , Butzheinen Lutz Oliver , Dittmer Marc Philipp , Heuer Wieland , Borchers Lothar , Stiesch Meike
Published: August 2010

Purpose:The objective of this investigation was to evaluate the influence of differently shaped preliminary cuts in combination with artificial aging on the load‐bearing capacity of four‐unit zirconia fixed dental prostheses (FDPs).

Materials and Methods:Forty frameworks were fabricated from white‐stage zirconia blanks (InCeram YZ, Vita) by means of a computer‐aided design/computer‐aided manufacturing system (Cerec inLab, Sirona). Frameworks were divided into four homogeneous groups with ten specimens each. Prior to veneering, frameworks of two groups were “damaged” by defined saw cuts of different dimensions, to simulate accidental flaws generated during shape cutting. After the veneering process, FDPs, with the exception of a control group without preliminary damage, were subjected to thermal and mechanical cycling (TMC) during 200 days storage in distilled water at 36°C. Following the aging procedure, all specimens were loaded until fracture, and forces at fracture were recorded. The statistical analysis of force at fracture data was performed using two‐way ANOVA, with the level of significance chosen at 0.05.

Results:Neither type of preliminary mechanical damage significantly affected the load‐bearing capacity of FDPs. In contrast, artificial aging by TMC proved to have a significant influence on the load‐bearing capacity of both the undamaged and the predamaged zirconia restorations (p< 0.001); however, even though load‐bearing capacity decreased by about 20% due to simulated aging, the FDPs still showed mean load‐bearing capacities of about 1600 N.

Conclusions:The results of this study reveal that zirconia restorations have a high tolerance regarding mechanical damages. Irrespective of these findings, damage to zirconia ceramics during production or finishing should be avoided, as this may nevertheless lead to subcritical crack growth and, eventually, catastrophic failure. Furthermore, to ensure long‐term clinical success, the design of zirconia restorations has to accommodate the decrease in load‐bearing capacity due to TMC in the oral environment.
Incidence and transfusion risk factors for transfusion‐associated circulatory overload among medical intensive care unit patients
Authors: Li Guangxi , Rachmale Sonal , Kojicic Marija , Shahjehan Khurram , Malinchoc Michael , Kor Daryl J. , Gajic Ognjen
Published: August 2010

BACKGROUND: Transfusion‐associated circulatory overload (TACO) is a frequent complication of blood transfusion. Investigations identifying risk factors for TACO in critically ill patients are lacking.

STUDY DESIGN AND METHODS: We performed a 2‐year prospective cohort study of consecutive patients receiving blood product transfusion in the medical intensive care unit (ICU) of the tertiary care institution. Patients were followed for development of transfusion‐related complications. TACO was defined as acute hydrostatic pulmonary edema occurring within 6 hours of transfusion. In a nested case‐control design, transfusion characteristics were compared between cases (TACO) and controls after matching by age, sex, and ICU admission diagnostic category. In a secondary analysis, patient characteristics before transfusion were compared between cases (TACO) and randomly selected controls.

RESULTS: Fifty‐one of 901 (6%) transfused patients developed TACO. Compared with matched controls, TACO cases had a more positive fluid balance (1.4 L vs. 0.8 L, p = 0.003), larger amount of plasma transfused (0.4 L vs. 0.07 L, p = 0.007), and faster rate of blood component transfusion (225 mL/hr vs. 168 mL/hr, p = 0.031). In a secondary analysis comparing TACO cases and random controls, left ventricular dysfunction before transfusion (odds ratio [OR], 8.23; 95% confidence interval [CI], 3.36‐21.97) and plasma ordered for the reversal of anticoagulant (OR, 4.31; 95% CI, 1.45‐14.30) were significantly related to the development of TACO.

CONCLUSION: Volume of transfused plasma and the rate of transfusion were identified as transfusion‐specific risk factors for TACO. Left ventricular dysfunction and fresh‐frozen plasma ordered for the reversal of anticoagulant were strong predictors of TACO before the onset of transfusion.
Variability and Uncertainty in Swedish Exposure Factors for Use in Quantitative Exposure Assessments
Authors: Filipsson Monika , Öberg Tomas , Bergbäck Bo
Published: August 2010

Information of exposure factors used in quantitative risk assessments has previously been compiled and reported for U.S. and European populations. However, due to the advancement of science and knowledge, these reports are in continuous need of updating with new data. Equally important is the change over time of many exposure factors related to both physiological characteristics and human behavior. Body weight, skin surface, time use, and dietary habits are some of the most obvious examples covered here. A wealth of data is available from literature not primarily gathered for the purpose of risk assessment. Here we review a number of key exposure factors and compare these factors between northern Europe—here represented by Sweden—and the United States. Many previous compilations of exposure factor data focus on interindividual variability and variability between sexes and age groups, while uncertainty is mainly dealt with in a qualitative way. In this article variability is assessed along with uncertainty. As estimates of central tendency and interindividual variability, mean, standard deviation, skewness, kurtosis, and multiple percentiles were calculated, while uncertainty was characterized using 95% confidence intervals for these parameters. The presented statistics are appropriate for use in deterministic analyses using point estimates for each input parameter as well as in probabilistic assessments.
The Effectiveness of Risk Management: An Analysis of Project Risk Planning Across Industries and Countries
Authors: Zwikael Ofer , Ahn Mark
Published: August 2010

This article examines the effectiveness of current risk management practices to reduce project risk using a multinational, multi‐industry study across different scenarios and cultures. A survey was administered to 701 project managers, and their supervisors, in seven industries and three diverse countries (New Zealand, Israel, and Japan), in multiple languages during the 2002–2007 period. Results of this study show that project context—industry and country where a project is executed—significantly impacts perceived levels of project risk, and the intensity of risk management processes. Our findings also suggest that risk management moderates the relationship between risk level and project success. Specifically, we found that even moderate levels of risk management planning are sufficient to reduce the negative effect risk levels have on project success.
Incorporating Equity in Regulatory and Benefit‐Cost Analysis Using Risk‐Based Preferences
Authors: Farrow Scott
Published: August 2010

The analysis of federal regulations focuses on the analysis of economic efficiency through standard benefit‐cost analysis in which reductions in risk tend to represent benefits and variability may be investigated through sensitivity or simulation methods. Such analyses typically ignore distributional consequences that can affect decisions. Although analytical guidance from the Office of Management and Budget (OMB) mentions distributional consequences, there is little specificity regarding how it might be analyzed. Specificity might be improved by OMB: (1) communicating and enforcing distributional impacts as more central to the process, (2) identifying default types of descriptive distributional statistics, (3) identifying whether legislation has created a constraint to not harm a subgroup, and (4) requesting a distributional sensitivity test of the net benefits along with a standard benefit‐cost analysis. Although such actions have a data collection and analysis cost, they may make the results of regulatory analysis more relevant by investigating both efficiency and equity measures.
Loss Reduction Through Worker Satisfaction: The Case of Workers’ Compensation
Authors: Butler Richard J. , Johnson William G.
Published: August 2010

Abstract

A prospective study of occupational low back pain (LBP) indicates loss reduction efforts in workers’ compensation that improve workers satisfaction with the treatment of their claim significantly improves levels of recovery (reduces losses) and lowers workers’ compensation insurance costs. The improved outcomes associated with greater worker satisfaction with the firm's treatment of their injury claim, as well as with the treatment from their health care provider, are robust to five alternative measures of back problems, including leg pain and back pain scales, measures of functional limitation, and quality of life scales. Satisfaction with effectiveness of the health care is more important in recovery than satisfaction with the provider's bedside manner. While satisfaction with health care provider significantly improves back pain and functionality at 6 months, satisfaction with the employer's treatment of the claim is equally important at 6 months and grows in quantitative importance at 1 year. Overall, higher satisfaction with claim treatment reduces the likelihood that an injury becomes an indemnity claim and results in almost a 30 percent reduction in claim costs.
Implantation of a Fully Subcutaneous ICD in Children
Authors: McLEOD KAREN A. , McLEAN ANDREW
Published: August 2010

The subcutaneous implantable cardioverter defibrillator (S‐ICD) from Cameron Health (San Clemente, CA, USA) does not require a lead to be placed on or in the heart. Such a device, being subcutaneous, has potential benefits in children who require ICDs where problems largely relate to transvenous or epicardial leads and inappropriate shocks. The S‐ICD was approved for use in Europe in June 2009 and recently a study commenced to acquire data in 330 patients in order to submit to the FDA. We shall describe the implantation of the S‐ICD in two children aged 10 and 12 years at our institution. (PACE 2012; 35:e20–e23)
Oregon Trauma System: Change in Initial Admission Site and Post‐admission Transfer of Injured Patients
Authors: Hedges Jerris R. , Mullins Richard J. , Zimmer‐Gembeck Melanie , Helfand Mark , Southard Patricia
Published: August 2010

Objective:Associate statewide trauma system development with a change in the percentage of injured patients initially hospitalized at Levels I and II categorized trauma hospitals and a change in the length of stay (LOS) prior to arrival at a Level I or II hospital (PRE‐LOS) and total LOS (T‐LOS) for post‐admission transfer patients.

Methods:A retrospective analysis was performed using a hospital discharge database of 235,395 discharges with codes for acute injury managed at 74 acute care hospitals in Oregon State from 1983 to 1991. Primary outcome measures were admission site and transfer patient PRE‐LOS and T‐LOS. Predictor variables included category of initial hospital admission site, injury severity scale (ISS) score, head injury, age, and status of trauma system (pre‐system, 1983 to 1987; transitional, 1988 to 1989; and post‐system, 1991 to 1992).

Results:There was a significant increase in the percentage of initial admissions to hospitals with Level I or II categorization (17.6%, 26.2%, and 27.6% for the three periods of development, respectively; p < 0.00001). The percentage of patients with ISS scores greater than 15 admitted initially to Level I or II hospitals increased from 33.4% to 52.6% and 57.3%; p < 0.00001). Only 1,059 (0.57%) of 185,321 patients initially admitted to Level III, Level IV, or noncategorized hospitals were transferred to a Level I or II hospital. Mean PRE‐LOS for the 1,059 transferred patients showed a significant decrease with system development (2.3, 1.9, and 1.8 days, respectively; p < 0.02). When adjusted for age, ISS score, and head injury effects, mean T‐LOS was significantly reduced for the transitional and post‐system periods (p < 0.05).

Conclusions:In Oregon, development of a statewide trauma system was associated with increased initial admissions to Level I and II trauma hospitals. For those patients transferred to higher levels of care post‐admission, hospital LOSs were decreased with trauma system development.
Stress Levels in EMS Personnel: A Longitudinal Study with Work‐schedule Modification
Authors: Cydulka Rita K. , Emerman Charles L. , Shade Bruce , Kubincanek John
Published: August 2010

Objective:To determine if stress levels of emergency medical services (EMS) personnel can be reduced by adjusting work schedules to personnel preferences.

Methods:A prospective, longitudinal, cohort study with a work‐schedule modification intervention was performed. All EMS personnel employed by the City of Cleveland EMS were eligible for participation. EMS employees voluntarily completed an abbreviated medical personnel stress survey (MPSS‐R), a 20‐question validated stress‐assessment tool, in September 1989, February 1991, and September 1991. A new scheduling pattern was introduced March 1991. At that time, 27 EMS employees volunteered to work the new schedule (12 hours/shift: 3 days on/2 days off/2 days on/3 days off). The remaining 109 EMS employees remained on the old schedule (8 hours/shift: 6 days on/2 days off).

Results:Mean MPSS‐R stress scores increased significantly from September 1990 (61.9 ± 7.87) to September 1991 (65.08± 7.23) (p < 0.05). In September 1991, mean stress scores of EMS personnel working the new schedule (64.39± 7.82) were not significantly lower than stress scores of EMS personnel working the old schedule (65.25 ± 7.10).

Conclusion:Stress in EMS personnel increased despite a new schedule pattern designed to accommodate the preferences of EMS personnel.
Social‐work Services in an Emergency Department: An Integral Part of the Health Care Safety Net
Authors: Wrenn Keith , Rice Nancy
Published: August 2010

Objective:To quantify and describe the activities of social workers dedicated to a large urban emergency department (ED).

Methods:A retrospective case series of all patients seen by social workers in an urban university hospital ED over a period of six weeks.

Results:Social‐work service was provided to 5% of ED patients. Three distinct groups of patients were usually seen by social workers: the elderly, young adults, and children less than 5 years of age. The median age of the group referred for social work services was greater than that of the ED population as a whole; triage acuity also was greater in the referred group. The types of services provided varied with age. Among those patients with social‐work consultations, the average time spent with each patient was over one hour and did not vary according to the age, sex, race, or insurance status of the patient. More than 60% of the social worker's time was spent with patients or their significant others.

Conclusion:Social workers provide valuable services to ED patients. The availability of social workers in the ED reduces the demands for emergency physicians and nurses to arrange home health care, nursing home placement, and other social‐service functions. Cost savings through diversion of nonacute social admissions are possible. The types of services provided vary and depend to a large extent on patient age. The availability of dedicated social‐work personnel in the ED and the education of emergency personnel regarding the services that they can provide should be beneficial for patients, staff, and the hospital served.
A Prospective Evaluation of Risk Factors for Infections from Dog‐bite Wounds
Authors: Dire Daniel J. , Hogan David E. , Riggs Mark W.
Published: August 2010

Objective:To define risk factors for infections from dog‐bite wounds and to model the probability of wound infection in patients presenting without infection who are treated as outpatients.

Methods:A prospective survey of 769 consecutive dog‐bite victims presenting over a two‐year period to a community hospital emergency department (ED) with an emergency medicine residency program. A standardized wound‐cleaning protocol was used, which included debride‐ment and wound closure when indicated. Wounds were examined for infection at follow‐up. Variables analyzed included demographic data (patient age, gender, race); wound information (wound age, type, number, location, depth); and treatment (prior to hospital, ED debridement, suturing, tetanus or rabies shots, antibiotics).

Results:There were 734 patients with complete records. These patients had a mean age of 13.4 ± 13.2 years (range, 4 months to 71 years). Infection was evident in 2.5% of the wounds upon presentation. There were 704 patients (765 wounds) managed as outpatients and without wound infection at initial presentation. Wounds were distributed as follows: 26.7% head/neck, 20.4% hand, 15.7% arm, 10.1% trunk, 9.5% thigh, 15.9% leg, and 1.7% foot. There were 32.9% puncture, 39.9% full‐thickness, and 60.1% partial‐thickness wounds. Wound infections were diagnosed in 2.1% of these wounds at follow‐up. Wounds requiring surgical debridement had a sevenfold higher infection rate (p = 0.01). Patients more than 50 years of age had a sixfold higher infection rate than younger patients (p = 0.05). Stepwise logistic regression found the following variables to be the best predictors for wound infection: full‐thickness [p = 0.006, odds ratio (OR) = 6.23], female gender (p = 0.048, OR = 2.88), and wound debridement (p = 0.024, OR = 5.01). Combinations of these three variables predict infection rates from 0.35% to 23.9%.

Conclusion:A low wound infection rate was seen in this cohort of dog‐bite victims who were treated on an outpatient basts. Wound depth, patient gender, and wound debridement were the clinical variables that best predicted the likelihood of developing infection. Future intervention‐al studies should concentrate on wounds with high probabilities of infection.
Closed Reduction of a Traumatically Dislocated Testicle
Authors: Madden John F.
Published: August 2010

Traumatic testicular dislocation is an uncommon event, with fewer than 60 cases having been reported in the literature. It is imperative that the emergency physician be aware of the possibility of testicular dislocation following perineal trauma and either seek emergent urologic consultation or attempt relocation of the testicle immediately. Testicular dislocation (following a motorcycle crash) that was successfully managed by closed reduction in the emergency department (ED) is presented. Following a benign course during subsequent observation, the patient was released with close urologic follow‐up.
A Public Health Approach to Emergency Medicine: Preparing for the Twenty‐first Century
Authors: Bernstein Edward , Goldrank Lewis R. , Kellerman Arthur L. , Hargarten Stephen W. , Jui Jonathon , Fish Susan S. , Herbert Barbara H. , Flores Carlos , Caravati Martin E. , Krishel Scott , Stevens Carl D. , Kirsch Thomas D. , Lowe Robert A. , Lowenstein S. R. , Baraff Larry J. , Mueller‐Orsay Elizabeth J. , Ling Louis J. , Sklar David P.
Published: August 2010

This paper focuses on the implications of an inadequate public health/ preventive health care system for emergency medicine (EM), the role that EM providers can play in remedying critical health problems, and the benefits gained from a public health approach to EM. A broad definition of public health is adopted, suggesting shared goals of public health and EM. Critical problems posed for EM include alcohol, tobacco, and other drug abuse; injury; violence; sexually transmitted diseases and human immunodeficiency virus (HIV) infection; occupational and environmental exposures; and the unmet health needs of minorities and women. A blueprint for future merging of public health issues with EM is presented that includes the application of public health principles to 1) clinical practice; 2) public education, community involvement, and public policy advocacy; 3) development of medical school and residency public health/ prevention curricula and teaching methods; and 4) research opportunities and surveillance. Finally, recommendations are proposed that require restructuring the present health care system to provide resources, incentives, and organizational changes that promote an integration of public health and preventive services in the practice of EM.
Methodology‐dependent Variation in Documentation of Outcome Predictors in Out‐of‐hospital Cardiac Arrest
Authors: Gallagher E. John , Lombardi Gary , Gennis Paul , Treiber Marsha
Published: August 2010

Objective: To identify variation in outcome predictor documentation in out‐of‐hospital cardiac arrest associated with two different methods of data collection: concurrent questioning of personnel following a resuscitation attempt and archival report review.

Methods: All patients ≤ 18 years old who had had out‐of‐hospital cardiac arrests, verified using the New York City 911 telephone system, between October 1, 1990, and April 1, 1991, were eligible for inclusion. The authors reviewed the first 200 cases of presumed primary cardiac arrest involving a resuscitation attempt from among 3,243 consecutive ambulance call reports for cardiac arrest occurring during the study period. This archival data set was compared with data for the same 200 cases gathered through direct interview of field personnel by trained paramedics. The two data sets had been compiled independently by different individuals, using the same data collection instrument, which conformed to the Utstein template.

Results: Comparison of the data obtained from ambulance records with the data obtained from interviews of prehospital personnel revealed several areas of variance. Of note was a significantly lower proportion of bystander‐witnessed ventricular fibrillation (VF) in the data set gathered from written reports (7% vs 18%; 95% CI for the difference 4–18%; p = 0.001).

Conclusion: Differences in methods of collection of out‐of‐hospital cardiac arrest data are associated with a more than twofold variation in the reported incidences of witnessed cardiac arrests manifesting as VF. Methodology‐dependent variation in this important “denominator” may produce substantially different estimates of survival within the same cohort of patients.
Abdominal Pumping
Authors: Hillman Harold
Published: August 2010

This article reviews the author's experience with a form of interposed abdominal compression cardiopulmonary resuscitation (IAC‐CPR) in the United Kingdom. The development of the technique based upon animal resuscitation, including the use of phasic compression (abdominal pumping) for the resuscitation of rats from 30 minutes of cardiac arrest due to hypothermia, is reviewed. A simple technique for clinical use is described. The technique uses a hard‐covered book or bean‐shaped board applied to the abdomen below the umbilicus and compressed alternately with cardiac massage while respiration is assisted. Anecdotal clinical results suggest that further controlled clinical investigation is warranted.
Hemodynamics, Survival Benefits, and Complications of Interposed Abdominal Compression during Cardiopulmonary Resuscitation
Authors: Sack Jeffrey B. , Kesselbrenner Michael B.
Published: August 2010

Objective: To review and describe the hemodynamics and mechanism of benefit of interposed abdominal compression cardiopulmonary resuscitation (IAC‐CPR) as well as the current complications and survival data withtheuseoflAC‐CPR.

Methods: Critical review of selected, published English‐language studies analyzing IAC‐CPR. Overview of hemodynamic effects, complications, and survival data of IAC‐CPR vs standard CPR.

Results: Several investigators have demonstrated improvements in coronary perfusion pressure, carotid and cerebral blood flows, and augmented venous return using IAC‐CPR compared with standard CPR. Recently, IAC‐CPR has been shown to improve survival from in‐hospital cardiac arrest. To date, there has been no increase in complications seen with the use of abdominal compression during CPR.

Recommendations: IAC‐CPR should be considered an adjunct to standard CPR for adult patients experiencing in‐hospital cardiac arrest, after an adequate airway has been secured. More research is needed before IAC‐CPR can be recommended for out‐of‐hospital cardiac arrest, for patients who have not been intubated, or for children.
Comparison of Hydromorphone and Meperidine for Ureteral Colic
Authors: Jasani Neil B. , O'Connor Robert E. , Bouzoukis James K.
Published: August 2010

Objective:To compare the efficacies of meperidine and hydromorphone in the treatment for ureteral colic in the emergency department (ED).

Methods:A prospective, double‐blind, randomized clinical trial was conducted over six months at a tertiary referral center with 93,000 annual ED visits. Seventy‐three patients completed the study. The patients received either 1 mg of hydromorphone or 50 mg of meperidine IV at t = 0. Pain intensity was determined using a 10‐cm visual analog scale at t = 0, 15, 30, 60, and 120 minutes. A second dose of the study drug could be given between t = 15 and t = 120 minutes when the clinician believed the initial dose was ineffective. Patients requiring more than one additional dose of analgesia were treated as nonresponders and were removed from the study.

Results:Thirty‐six patients received hydromorphone and 37 received meperidine. The initial pain intensities (hydromorphone group = 8.4 ± 1.5; meperidine group = 8.5 ± 2.1), age distributions, sex distributions, and side effects of the two groups were comparable. Pain relief was better (p < 0.05) with hydromorphone at t = 15, 30, 60, and 120 minutes. The hydromorphone group required rescue analgesia less often (31% vs 68%, p < 0.01), had fewer IV pyelographies (IVPs) (28% vs 54%, p < 0.05), and had a lower proportion of hospital admissions (25% vs 49%, p = 0.08).

Conclusions:For the fixed doses used in this study, the adult ureteral colic patients receiving hydromorphone achieved more pain relief, required less rescue medication, underwent fewer IVPs, and avoided hospital admission more frequently than did those receiving meperidine.
Referral and Consultation in Emergency Medicine Practice
Authors: Guertler Andrew T. , Cortazzo Jeffrey M. , Rice Matthew M.
Published: August 2010

Since emergency physicians (EPs) frequently initiate referrals and consultations, accept patients in referral, and may provide consultation services, it is imperative that EPs fully understand these processes. Such an understanding improves communication and facilitates professional interactions and patient care. There is little published information concerning the significance and practice of referrals and consultations as they pertain to the EP. This article addresses referrals and consultations in relation to EPs. Specific recommendations are made for consultation initiation and execution. The dynamics and ethical/legal issues associated with initiating and accepting referrals and consultations are discussed.
An Argument for Colloid Resuscitation for Shock
Authors: Rady Mohamed
Published: August 2010

A focused review of the physiologic mechanisms of colloid and crystalloid fluid resuscitations for acute critical illness is presented. This review suggests that postresuscitation plasma volume, cardiac output, left ventricular mechanical performance, and global and microcirculatory O2 supplies are more favorable with colloid therapy. Conversely, crystalloid may adversely affect microcirculatory blood flow and resultant O2 supply and use by ischemic tissues in shock. Poor relief of global and regional hypoxia may persist in critically ill patients after resuscitation with crystalloid.
Prospective Multicenter Evaluation of Cocaine‐associated Chest Pain
Authors: Hollander Judd E. , Hoffman Robert S. , Gennis Paul , Fairweather Phillip , DiSano Michael J. , Schumb David A. , Feldman James A. , Fish Susan S. , Dyer Sophia , Wax Paul , Whelan Chris , Schwarzwald Evan
Published: August 2010

Objective: To describe a large cohort of patients who had chest pain following cocaine use, and to determine the incidence of and clinical characteristics predictive for myocardial infarction in this group of patients.

Methods: A prospective observational cohort study of consecutive patients with cocaine‐associated chest pain was conducted in six municipal hospital emergency departments (EDs). Demographic variables, drug abuse patterns, medical histories, chest pain characteristics, ECG results, and laboratory data were recorded. Myocardial infarction was the primary endpoint.

Results: Fourteen of 246 patients (5.7%; 95% confidence interval [CI], 2.7–8.7%) had myocardial infarction, as diagnosed by elevated CK‐MB isoenzyme levels. There were two deaths (0.8%). The patients had a median age of 33 years. The majority were male (71.5%), non‐white (83.3%), cigarette smokers (83.3%) who used cocaine regularly. Chest pain began a median of 60 minutes after cocaine use and persisted for a median of 120 minutes. Chest pain was most frequently described as substernal (71.3%) and pressure‐like (46.7%). Shortness of breath (59.3%) and diaphoresis (38.6%) were common. There was no clinical difference between patients who had myocardial infarctions and those who did not. Twelve patients had arrhythmias and four had congestive heart failure. All cases requiring intervention were evident upon presentation. An ECG revealing ischemia or infarction had a sensitivity of 35.7% for predicting a myocardial infarction. The specificity, positive predictive value, and negative predictive value of the ECGs were 89.9%, 17.9%, and 95.8%, respectively.

Conclusions: Myocardial infarction in patients who have cocaine‐associated chest pain is not uncommon. No clinical parameter available to the physician can adequately identify patients at very low risk for myocardial infarction. Therefore, all patients with cocaine‐associated chest pain should be evaluated for myocardial infarction.
Inspiratory‐cycle Instillation of Endotracheal Epinephrine in Porcine Arrest
Authors: Jasani Melinda S. , Nadkarni Vinay M. , Finkelstein Mark S. , Hofmann William T. , Salzman Steven K.
Published: August 2010

Objective: To compare timed inspiratory‐cycle endotracheal (ET) instillation of epinephrine (EPI) with instillation during apnea during CPR.

Methods: Prospective randomized laboratory comparison of two ET‐EPI instillation techniques in 24 preadolescent anesthetized and paralyzed Yucatan swine (mean weight 10.3 ± 1.5 kg) with apnea‐induced hypoxic and hypercarbic cardiopulmonary arrest. After 8 minutes of cardiopulmonary arrest and 1 minute of CPR, 500 μg (50 ± 7 μg/kg) of radiolabeled ET EPI was either administered timed to a ventilator inspira‐tory cycle (IN, n= 15) or injected during apnea (DA, n= 9) using a monitoring lumen built into the sidewall of the ET tube. Injection technique was carefully controlled regarding ET‐tube position, dilution, flush, and pressure‐limited mechanical ventilations. CPR was resumed and continued for 5 minutes. If resuscitation occurred, monitoring was continued for one hour. Outcome variables included pulmonary EPI distribution pattern (DIST), plasma exogenous and total EPI levels, successful resuscitation, and hemodynamic response.

Results: Bilateral DIST occurred in 58% of the pigs, with significantly more bilateral DISTs for IN versus DA pigs (p = 0.01). Plasma radio‐labeled exogenous EPI counts were significantly greater for IN versus DA pigs(p = 0.03). Total plasma EPI levels rose significantly above baseline over time within each group, but showed no difference between the IN and DA groups at any time point. Successful resuscitation occurred in 21% of the pigs, with no difference between IN and DA pigs (p = 0.38).

Conclusion: When other aspects of ET EPI instillation are optimized and controlled during porcine hypoxic‐hypercarbic arrest, timed inspiratory‐cycle instillation of ET EPI (50 μg/kg) results in an improved bilateral DIST and greater exogenous EPI absorption. However, in this severe pediatric asphyxial arrest model using a 50‐ μg/kg dose, inspiratory‐cycle instillation does not improve the resuscitation rate or hemodynamic response over currently recommended instillation during apnea.
The Efficacy of TAC (Tetracaine, Adrenaline, and Cocaine) with Various Wound‐application Durations
Authors: Ordog Gary J. , Ordog Cindy
Published: August 2010

Objective: To associate the efficacy of topical anesthesia of a tetracaine‐adrenaline‐cocaine solution (TAC) with the duration of skin contact.

Methods: A prospective, physician‐blinded, observational study of anesthetic efficacy as a function of TAC application duration in pediatric patients (age range 1–12 years) who had superficial lacerations was performed. Patients who had lacerations less than 5 cm long were eligible for the study. Patients who had lacerations of the finger, toe, penis, nose, or pinna were excluded. Patients with histories of allergies to any of the topical anesthetic components also were excluded. Nursing staff measured the duration of TAC application (always > 5 min). Effectiveness of anesthesia was rated by the single treating physician blinded to TAC application duration.

Results: For the 400 patients enrolled in the study, TAC provided better anesthesia when the wound‐application duration was more than 20 minutes (p = 0.0001). This commonly was evidenced by complete blanching of the skin within 1 cm of the wound's edges. The percentage of patients having good anesthesia at 5–10 minutes was 62% (95% CI = 46–76%) versus 97% (95% CI = 93–99%) at 31–40 minutes. No side effect was observed in any group.

Conclusion: TAC is most effective as a topical anesthetic when applied for more than 20 minutes prior to suturing.
Pediatric Pain Control and Conscious Sedation: A Survey of Emergency Medicine Residencies
Authors: Ilkhanipour Kaveh , Juels Christopher R. , Langdorf Mark I.
Published: August 2010

Objective: To determine the availability and relative use of pediatric analgesia and sedation at sites of U.S. emergency medicine residency training programs.

Methods: A mail/telephone survey of residency directors at 80 U.S. emergency medicine residencies regarding resident experience with pediatric analgesia and sedation for painful procedures conducted during November 1991.

Results: Sixty of 80 surveys (75%) were completed and available for analysis. Emergency medicine faculty supervised conscious sedation and analgesia in 87% of responding programs, while pediatrics faculty and pediatrics‐emergency medicine fellows supervised in the remainder. Ninety‐three percent of the programs had sedating agents available in the emergency department; only four programs needed to have drugs brought from the pharmacy. Thirty‐four programs (57%) had formal protocols for the administration of these drugs. Seventy‐seven percent of the programs had airway resuscitation equipment at the bedside, while only 63% brought resuscitation drugs. However, 60% of the programs reported complications of sedation, including respiratory depression, prolonged sedation, agitation, and vomiting. The most commonly used agents were midazolam (82%), meperidine alone (68%) and with promethazine and chlorpromazine (67%), and chloral hydrate (67%). Only 25% of the programs used nitrous oxide, and 30% used ketamine.

Conclusions: Emergency medicine residencies generally have available agents for pain control and conscious sedation in children, although the agents used vary widely. Appropriate instruction by trained faculty should enhance resident experience with pediatric pain control and sedation.
Evaluation of an Emergency‐procedure Teaching Laboratory for the Development of Proficiency in Tube Thoracostomy
Authors: Homan Clark S. , Viccellio Peter , Thode Henry C. , Fisher Warren
Published: August 2010

Objective: Emergency‐procedure laboratories are not a standardized part of the curriculum for emergency medicine residency programs. The authors evaluated the efficacy of an emergency‐procedure laboratory to teach medical students and residents the performance of tube thoracostomy.

Methods: A prospective repeated‐measures study of tube thoracostomy placement training was performed in an animal‐laboratory setting. Participants were six first‐postgraduate‐year emergency medicine residents and six fourth‐year medical students. Each participant was given a written pretest on tube thoracostomies followed by lectures on tube thoracostomy, venous cutdown, peritoneal lavage, and surgical airway. The procedure laboratory, using an anesthetized canine model (20–25 kg), was then conducted. Tube thoracostomies were timed from skin incision to passage of the tube into the thoracic cavity with subsequent tube fogging. Four attempts per participant were documented. Eighteen days later, an identical procedure laboratory was conducted for the same students including a written posttest identical to the pretest.

Results: The written test scores improved for every participant (p < 0.0001). Mean times for procedures completion improved from 121 sec to 39 sec (p = 0<.001) during the first session and improved from 58 sec to 28 sec (p = 0.005) during the second session. Retention of skills was indicated by significant shortening of the time to completion from the first attempt of the first session to that of the second session (121 sec to 58 sec, p = 0.002).

Conclusions: This procedure laboratory, which emphasized skill repetition, led to improvement in procedural speed and retention of tube thoracostomy skills over time. This approach to teaching clinical procedures should be considered for emergency medicine residency programs and for continuing medical education courses that emphasize acquisition of clinical procedural skills.
Suction Catheter‐assisted Nasotracheal Intubation
Authors: Sloan Edward P. , VanRooyen Michael J.
Published: August 2010

This case series illustrates the use of a suction catheter to guide the passage of an endotracheal (ET) tube through the glottis, a technique modification which can be used when standard nasotracheal intubation is unsuccessful. The technique is appropriate for patients in whom airway management is urgent, but not emergent. Catheter‐assisted nasotracheal intubation is useful when intubation is difficult because of excessive patient resistance to movement of the ET tube within the oropharynx. The clinical use of this technique is described for the following scenarios: overdose with obtundation, multiple trauma with agitation, and respiratory failure from pneumonia and pulmonary edema.
Use of Computer‐based Technologies in Teaching Emergency Procedural Skills
Authors: Chapman Dane M.
Published: August 2010

Use of Computer‐based Technologies in Teaching Emergency Procedural Skills
Emergency‐department Diagnosis of Acute Myocardial Infarction and Ischemia: A Cost Analysis of Two Diagnostic Protocols
Authors: Hoekstra James W. , Gibler W. Brian , Levy Richard C. , Sayre Michael , Naber William , Chandra Abhinav , Kacich Raymond , Magorien Raymond , Walsh Richard
Published: August 2010

Objective:To assess the potential cost savings of the emergency‐department (ED) diagnosis of acute myocardial infarction (AMI) and other myocardial ischemia using a nine‐hour ED evaluation protocol.

Methods:This one‐year study of chest‐pain evaluation unit (CPEU) patient charges was undertaken at two midwestern urban university hospital EDs. Included in the study were 447 patients presenting to the EDs with chest pain consistent with myocardial ischemia, nondiagnostic electrocardiograms (ECGs), and stable vital signs. Following initial ED evaluation, CPEU patients underwent nine hours of continuous ECG ST‐segment monitoring with serum CK‐MB levels determined at zero, three, six, and nine hours. Nonrandomized concurrent chest pain patients with routine ED evaluation and hospital admission without CPEU workup served as controls. At Center 1, patients with negative CPEU evaluations underwent immediate echocardiography (echo) and graded exercise testing (GXT) followed by ED release (CPEU;REL). At Center 2, CPEU patients were released from the ED for outpatient stress thallium testing (CPEU; REL). At Center 2, CPEU patients with positive workups as indicated by elevated CK‐MB levels, ischemia by ST‐segment monitoring, or positive echo/GXT/stress thallium testing were admitted to the hospital for further testing. Control patients were admitted directly to the hospital to evaluate for AMI. Hospital charges for CPEU and control groups were compared.

Results:(Total charges in dollars, mean ± SD, Student's t‐test):

Conclusion:At both centers, hospital charges related to the acute evaluation of chest pain were significantly lower with this ED diagnostic protocol for AMI and myocardial ischemia.
Home Observation for Asymptomatic Coin Ingestion: Acceptance and Outcomes
Authors: Conners Gregory P. , Cobaugh Daniel J. , Feinberg Rebecca , Lucanie Ralph , Caraccio Thomas , Stork Christine M. ,   THE New York State Poison Control Center Coin Ingestion Study Group
Published: August 2010

Objectives: To obtain preliminary estimates of the acceptance rate and the frequency of adverse outcomes, and to identify issues related to acceptance, associated with management of asymptomatic pediatric coin ingestion by home observation, in preparation for a large‐scale prospective study. Methods: Scripted telephone follow‐up of callers who had reported asymptomatic pediatric coin ingestions to one of five poison control centers six to 36 months previously, which had been managed by home observation. Results: Of the 67 callers enrolled, 41 (67%) reported contacting a physician regarding the coin ingestion, despite home observation instruction by poison control center personnel. Those who did not recall being instructed in home observation were more likely to have contacted a physician than those who did. Nearly all, however, were satisfied with the advice they had been given. One child developed subsequent symptoms; as per the instructions that had been given by poison control center personnel, his parent sought physician evaluation, revealing an esophageal coin, which was removed uneventfully. No other child developed complications. Conclusions: Although all of the 67 children managed by home observation did well, most of their caretakers had not accepted this management strategy. Acceptance, while unrelated to satisfaction, may be related to comprehension of the instructions caregivers are given. A prospective study of home observation for asymptomatic pediatric coin ingestion would be safe and would allow further examination of factors affecting acceptance.
Emergency Center Categorization Standards
Authors: Goldfrank Lewis , Henneman Philip L. , Ling Louis J. , Prescott John E. , Rosen Carlo , Sama Andrew ,   the EC Categorization Task Force
Published: August 2010

Abstract. The SAEM EC Categorization Task Force was developed in response to the 1994 Macy Foundation's recommendation that emergency medicine (EM) organizations “should revise the classification of emergency departments…to reflect the level of care available in emergency departments, and indicate whether or not facilities are adequate and whether appropriately qualified and credentialed emergency physicians are available 24 hours a day.” By holding Level 1 emergency centers (ECs) to objective standards based on the quality of care delivered as well as administrative, research, and educational efforts, SAEM hopes to improve patient care. The SAEM EC Categorization Task Force is now beginning the process of reviewing ECs that provide comprehensive emergency care and serve as regional resources for education, research, and administration in EM. This standards document describes relative and critical criteria to be met in order to receive designation as a Level 1 emergency center. Such centers must meet all critical criteria, and be in sufficient compliance with most or all relative criteria, in order to achieve this designation. This process is entirely voluntary. Any EC is eligible for review. Any institution can initiate the review process by applying. Application materials and further information, including the policies and procedures of the SAEM EC Categorization Task Force, are available from SAEM.
Academic Emergency Medicine's Future
Authors:   The SAEM Task Force on Emergency Medicine's Future:, Iserson Kenneth V. , Adams James , Cordell William H. , Graff Louis , Halamka John , Ling Louis , Peacock W. Frank , Sklar David , Stair Tom
Published: August 2010

Emergency medicine (EM) will change over the next 20 years more than any other specialty. Its proximity to and interrelationships with the community, nearly all other clinicians (physicians and nonphysicians), and scientific/technologic developments guarantee this. While emergency physicians (EPs) will continue to treat both emergent and nonemergent patients, over the next decades our interventions, methods, and place in the medical care system will probably become unrecognizable from the EM we now practice and deliver. This paper, developed by the Society for Academic Emergency Medicine (SAEM) Task Force on Academic Emergency Medicine's Future, was designed to promote discussions about and actions to optimize our specialty's future. After briefly discussing the importance of futures planning, it suggests “best‐case,”“worst‐case,” and most probable future courses for academic EM over the next decades. The authors predict that EPs will practice a much more technologic and accurate form of medicine, with diagnostic, patient, reference, and consultant information rapidly available to them. They will be at the center of an extensive consultation network stemming from major medical centers and the purveyors of a sophisticated home health system, very similar to or even more advanced than what is now delivered on hospital wards. The key to planning for our specialty is for EM organizations, academic centers, and individuals to act now to optimize our possible future.
Fenoldopam, a Dopamine Agonist, for Hypertensive Emergency: A Multicenter Randomized Trial
Authors: Tumlin James A. , Dunbar Lala M. , Oparil Suzanne , Buckalew Vardaman , Ram C. Venkata , Mathur Vandana , Ellis David , McGuire Dawn , Fellmann Jere , Luther Robert R. ,   The Fenoldopam Study Group
Published: August 2010

Abstract. Despite successful therapies for chronic hypertension, hospital admissions for hypertensive emergency more than tripled between 1983 and 1992. Objective: To examine the safety and efficacy of fenoldopam, the first antihypertensive with selective and specific action on vascular dopamine (DA1) receptors, in a clinical trial involving emergency department patients with true hypertensive emergencies. Methods: Patients with a sustained diastolic blood pressure (DBP) of ≥120 mm Hg and evidence of target organ compromise were randomized in a double‐blinded manner to one of four fixed doses of intravenous fenoldopam (0.01, 0.03, 0.1, or 0.3 μg/kg/min) for 24 hours. The primary endpoint was the magnitude of DBP reduction in each of the three higher‐dose groups after four hours of fenoldopam treatment compared with the lowest‐dose group. Results: One hundred seven participants from 21 centers were enrolled, and 94 patients received fenoldopam. Evidence of acute target‐organ damage included new renal dysfunction or hematuria (50%), acute congestive heart failure or myocardial ischemia (48%), and papilledema or grade III‐IV hypertensive retinopathy (34%). The DBP decreased in a dose‐dependent fashion, with significant differences between the 0.1‐ and 0.3‐μg/kg/min groups compared with the lowest‐dose group. Treatment was well tolerated, and there were no deaths or serious adverse events during follow‐up, up to 48 hours. All patients were successfully transitioned to oral or transdermal antihypertensives with maintenance of blood pressure control. Conclusions: Fenoldopam safely and effectively lowers blood pressure in a dose‐dependent manner in patients with hypertensive emergencies. Observations supporting potential risk factors for hypertensive emergency are discussed.