bluuebunny/crossref_metadata_2025 huggingface dataset:
Noninvasive Cerebral Cooling in a Swine Model of Cardiac Arrest
Authors: Tadler Scott C. , Callaway Clifton W. , Menegazzi James J.
Published: March 2010

Objective: Mild cerebral hypothermia improves neurologic outcome in animals resuscitated from cardiac arrest. This study examined whether one practical external cooling method, i.e., local application of ice to the heads and necks of swine, during resuscitation induces cerebral cooling.

Methods: Local external cerebral cooling was examined in a prospective laboratory investigation using 24 female swine in a model of cardiac arrest. The swine were randomized into hypothermia and normothermia groups. Intracerebral temperature was measured in the parietal cortex. Eight minutes after induction of ventricular fibrillation, chest compressions and mechanical ventilation were initiated. The hypothermia group was treated with 1,500 mL of ice in plastic bags applied to the head and neck, while the normothermia group received no extra interventions. Data were analyzed using repeated‐measures ANOVA.

Results: In the normothermia group, there was no significant change in nasopharyngeal (‐0.8 ± 0.6°C), intracerebral (‐0.6 ± 0.8°C), or esophageal (‐0.2 ± 0.6°C) temperatures during 20 minutes of resuscitation. However, in the hypothermia group, application of ice during resuscitation significantly reduced nasopharyngeal (‐2.9 ± 1.4°C), intracerebral (‐2.1 ± 0.6°C), and esophageal (‐1.4 ± 0.8°C) temperatures.

Conclusions: External application of ice packs during resuscitation effectively reduced intracerebral temperatures in swine by an amount that improved neurologic outcomes in previous large animal studies. These data suggest that clinically significant cerebral cooling could be accomplished with a noninvasive, inexpensive, and universally available intervention. Further studies are required to assess the clinical feasibility and therapeutic efficacy of this intervention.
Causes and Patterns of Injury from Ladder Falls
Authors: Partridge Robert A. , Virk Alamjit S. , Antosia Robert E.
Published: March 2010

Objectives: To review all ladder fall injuries seen in a community ED and to identify patterns of injury, factors that contribute to falls, and what pre‐event and event factors could have reduced the likelihood of a fall or a resulting injury.

Methods: This was a retrospective, observational study involving patients who presented to a community hospital ED from January 1993 through December 1995 with injuries from a ladder fall. The medical records of all patients were reviewed. Patients then underwent a structured telephone interview to provide additional information about the circumstances of the fall.

Results: There were 59 patients who sustained injuries relating to ladder falls. All were adults, aged >18 years (mean 42.9 ± 16.2 years), were predominantly male (93%), and had fallen a distance of 1–15 feet (mean 7.2 ± 3.6 feet). Thirteen percent were admitted to the hospital, and there was 1 death. Fractures were observed in 21 patients (36%) and usually involved an extremity (77%). There was no relationship between the distance fallen and the occurrence of fracture. Other primary injuries included sprain (27%), contusion (24%), laceration (10%), abrasion (3%), and subdural hematoma (2%). Of the 59 patients, 42 (71%) were contacted directly. Most falls (79%) resulted from excessive reaching or incorrect ladder placement. Fifty percent of the described falls were occupationally related.

Conclusions: Falls from ladders, both in the occupational and nonoccupational settings, often result in significant injury. Simple safety measures may have prevented the majority of falls in this study. Public health efforts should emphasize education on safe ladder practices and techniques to reduce the possibility of injury in the event of a fall.
Rapid Response to Stroke Symptoms: The Delay in Accessing Stroke Healthcare (DASH) Study
Authors: Rosamond Wayne D. , Gorton Rebecca A. , Hinn Albert R. , Hohenhaus Susan M. , Morris Dexter L.
Published: March 2010

Objective: To assess the determinants of prehospital delay for patients with presumed acute cerebral ischemia (ACI) in order to provide the background necessary to develop interventions to shorten such delays.

Methods: A prospective registry of patients presenting to the ED with signs and symptoms of stroke was established at a university hospital from July 1995 to March 1996. Trained nurses performed a structured ED interview, which assessed prehospital delay and potential confounders.

Results: The median delay (interquartile range) from symptom onset to ED arrival for all patients seeking care for stroke‐like symptoms (n= 152) was 3.0 hours (1.5–7.8 hr). The median delay from symptom onset to ED arrival was less in cases where a witness first recognized that there was a serious problem than it was when the patient first identified the problem. A heightened sense of urgency by the patient about his or her symptoms, and use of 911/emergency medical services (EMS) transport were also associated with rapid arrival in the ED within 3 hours of symptom onset. After adjusting for all predictor variables in a multivariable logistic regression model, only recognition of symptoms by a witness and calling 911/EMS transport remained statistically significant.

Conclusions: These data suggest that future efforts to intervene on prolonged prehospital delay for patients with ACI should include strategies for the community as a whole as well as persons at risk for stroke and should reinforce the use of 911 and EMS transport.
Domestic Violence Awareness and Prevalence in a First‐year Medical School Class*
Authors: Ernst Amy A. , Houry Debra , Nick Todd G. , Weiss Steven J.
Published: March 2010

Objective: To determine knowledge about domestic violence (DV), the effectiveness of formal instruction about DV, and the prevalence of DV in a first‐year medical school class.

Methods: A general‐knowledge survey of DV was given before and approximately 1 month after 3 hours of instruction provided by emergency medicine and internal medicine faculty. A previously validated scale, the Index of Spouse Abuse (ISA), was offered to determine baseline levels of DV within the group. Differences in first‐year medical student knowledge of facts about DV and differences in responses by men vs women were determined before and after the instruction.

Results: In the pre‐instruction series, 144 of 148 (97%) participated. After the instruction, 141 of the same 148 students participated (95%). The prevalence of DV against women was correctly identified by 45% of the students as “15–30%” prior to instruction, and 65% after instruction. The prevalence of DV against males was correctly identified as “0–15%” by 48% of the students prior to instruction, and 70% after instruction. Before instruction, 29% of the students knew that “DV rates are equal in different socioeconomic groups,” vs 72% after instruction. Similarly, prior to instruction 58% of the students knew that the victim is not responsible for the abuse, and 84% knew this after instruction. Before instruction 14 (10%) of the students believed they were victims of DV in the past, representing 7% of the men and 13% of the women. Before instruction neither group believed they were present victims of DV. However, according to ISA scoring, 6% of the women were positive for violence in the past, and approximately 5% were positive for present violence. No men were positive for ISA‐determined past or present violence.

Conclusion: Improvement in awareness was demonstrated after 3 hours of instruction in a first‐year medical school class. There was DV among female medical students in this first‐year class and self‐reporting was not reliable. These results support instruction on DV for medical students.
Carbon Monoxide Poisoning from Spray Paint Inhalation
Authors: Nager Eric C. , O'Connor Robert E.
Published: March 2010

This case report emphasizes the varied manifestation of CO poisoning and its genesis from methylene chloride. Because DCM is now an ingredient in many popular spray paints, the ingredients should be checked routinely in toxic exposures. Manufacturer's suggestions concerning the use these products in ventilated areas to avoid harmful effects do not always protect the consumer, and the public should be well informed regarding this issue.
Prospective, Randomized, Controlled Trial of Tissue Adhesive (2‐Octylcyanoacrylate) vs Standard Wound Closure Techniques for Laceration Repair
Authors: Singer Adam J. , Hollander Judd E. , Valentine Sharon M. , Turque Theo W. , McCuskey Charles F. , Quinn James V. ,   for the Stony Brook Octylcyanoacrylate Study Group
Published: March 2010

Objective: To compare a new tissue adhesive, 2‐octylcyanoacrylate, with standard wound closure techniques for the repair of traumatic lacerations.

Methods: A prospective, randomized, controlled clinical trial enrolled consecutive patients >1 year of age with non‐bite, non‐crush‐induced lacerations who presented <6 hours after injury. Structured closed‐question data sheets were completed at the time of laceration repair and suture removal. Patients were randomly assigned to treatment with either 2‐octylcyanoacrylate or standard wound closure. Infection was determined at the time of suture removal. Long‐term cosmetic appearance (>3 months) was assessed by physicians using a previously validated categorical cosmetic scale and by patients using a 100‐mm visual analog scale.

Results: There were 63 patients randomized to the octylcyanoacrylate group and 61 patients treated with standard wound closure techniques. The 2 treatment groups were similar with respect to age, gender, race, medical history, and wound characteristics. At the 5‐to‐10‐day follow‐up, only 1 wound was infected and only 2 wounds required reclosure due to dehiscence. These 3 patients received treatment with octylcyanoacrylate. At long‐term follow‐up, the cosmetic appearances were similar according to the patients (octylcyanoacrylate, 83.8 ± 19.4 mm vs standard techniques, 82.5 ± 17.6 mm; p = 0.72) and the physicians (optimal cosmetic appearance, 77% vs 80%; p = 0.67).

Conclusions: Wounds treated with octylcyanoacrylate and standard wound closure techniques have similar cosmetic appearances 3 months later.
Intubation Difficulty in Poisoned Patients: Association with Initial Glasgow Coma Scale Score
Authors: Adnet Frédéric , Borron Stephen W. , Finot Marie‐Agnès , Lapandry Claude , Baud Frédéric J.
Published: March 2010

Objective: To determine whether the initial Glasgow Coma Scale (GCS) score is predictive of intubation difficulty in out‐of‐hospital airway management of poisoned patients.

Methods: A prospective, observational study was performed in a toxicological intensive care unit of a university hospital and in a physician‐based out‐of‐hospital care system. Subjects included consecutive poisoned patients intubated during their airway management by out‐of‐hospital medical teams before hospitalization. The intubating operator (emergency physician or nurse anesthetist) completed a 1‐page checklist concerning the clinical parameters and circumstances (nature of sedation and difficulty) of endotracheal intubation upon hospital arrival.

Results: Forms were completed for all 394 consecutive out‐of‐hospital intubations. The patients ranged from 15 to 95 years of age (median age 38 years). Most (96%) of the intubations were via the oral route. Intubation difficulty was related to GCS values. Intubation difficulty was seen more often in patients with 7≤ GCS ≤9 (36%) than in patients with GCS <7 (15%) or >9 (10%). Not surprisingly, perceived intubation difficulty was least for those patients undergoing rapid‐sequence intubation rather than administration of sedation alone.

Conclusion: Maximum difficulty of intubation is encountered in poisoned patients with 7≤ GCS ≤9. Intubation of such patients appears to be facilitated by appropriate sedation and/or neuromuscular blockade.
Strategies for Improving Information Management in Emergency Medicine to Meet Clinical, Research, and Administrative Needs
Authors: Cordell William H. , Overhage J. Marc , Waeckerle Joseph F. ,   for the Information Management Work Group
Published: March 2010

The ED of the future will require the effective integration of information technologies into clinical care. This article proposes strategies for improving information management in emergency medicine to facilitate patient care, public health surveillance, clinical research, medical education, and health care management.
Supporting Emergency Medicine Research: Developing the Infrastructure
Authors: Biros Michelle H. , Barsan William G. , Lewis Roger J. , Sanders Arthur B.
Published: March 2010

The long‐term goals of developing research within the specialty of emergency medicine (EM) include the following: 1) to continue to improve the quality and quantity of EM research in order to ultimately improve emergency patient care; 2) to maximize the research potential of emergency health care professionals in order to develop new emergency research talent and enthusiasm; and 3) to establish the academic research credentials of the specialty of EM in order to become competitive for federal research funding, and further improve emergency patient care. This article addresses the process by which the infrastructure for EM research can be developed at academic medical centers and provides recommendations. The roles of the academic chair, research director, senior researcher, and departmental faculty are discussed.
LETTERS TO THE EDITOR
Authors: Hawlev Rollin James
Published: March 2010

Seizure‐like Symptoms and Complete Heart Block
Out‐of‐hospital Spinal Immobilization: Its Effect on Neurologic Injury
Authors: Hauswald Mark , Ong Grade , Tandberg Dan , Omar Zaliha
Published: March 2010

Objective: To examine the effect of emergency immobilization on neurologic outcome of patients who have blunt traumatic spinal injuries.

Methods: A 5‐year retrospective chart review was carried out at 2 university hospitals. All patients with acute blunt traumatic spinal or spinal cord injuries transported directly from the injury site to the hospital were entered. None of the 120 patients seen at the University of Malaya had spinal immobilization during transport, whereas all 334 patients seen at the University of New Mexico did. The 2 hospitals were comparable in physician training and clinical resources. Neurologic injuries were assigned to 2 categories, disabling or not disabling, by 2 physicians acting independently and blinded to the hospital of origin. Data were analyzed using multivariate logistic regression, with hospital location, patient age, gender, anatomic level of injury, and injury mechanism serving as explanatory variables.

Results: There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03–3.99; p = 0.04). This corresponds to a <2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64–3.62; p = 0.34).

Conclusion: Out‐of‐hospital immobilization has little or no effect on neurologic outcome in patients with blunt spinal injuries.
N‐Acetylcysteine Reduces Methemoglobin in an In‐vitro Model of Glucose‐6‐phosphate Dehydrogenase Deficiency
Authors: Wright Robert O. , Woolf Alan D. , Shannon Michael W. , Magnani Barbarajean
Published: March 2010

Objective:To determine whether N‐acetylcysteine (NAC) reduces methemoglobin (MHB) in an in‐vitro model of glucose‐6‐phosphate dehydrogenase (G6PD) deficiency, given that methylene blue is an ineffective MHB antidote in G6PD deficiency.

Methods:Five volunteers donated blood, which was divided equally into 2 test tubes, centrifuged, and washed with Tris‐Mopps buffer (pH 7.4, 15 mmol/L glucose). Both tubes were incubated with epiandrosterone (EA) (400 μmol), a specific inhibitor of G6PD. After 75 μL of 0.18 mol hydroxylamine (HA) was added to induce MHB formation, 150 μL of NAC (20 mg/mL) was added to tube 1 and 150 μL of phosphate‐buffered saline (PBS) was added to tube 2 as a volume control. Serial MHB levels are reported as a percentage of total hemoglobin (Hb). G6PD activity was measured at baseline, 15 minutes after EA, and at 5 hours.

Results:Mean G6PD activity at baseline was 9.2 ± 2.9 U/g Hb (normal >4.6 U/g Hb); 15 minutes after EA was 3.0 ± 1.0 U/g Hb; and at experiment's end was 2.3 ± 0.7 U/g Hb. The mean (±SD) areas under the concentration‐time curves (AUCs) of NAC‐EA‐HA and PBS‐EA‐HA samples were compared using an unpaired t‐test and were significantly different: PBS‐EA‐HA, 20,400 ± 1,100 % min, vs NAC‐EA‐HA, 10,400 ± 1,000 % min, respectively (p < 0.05).

Conclusion:In this in‐vitro model of G6PD deficiency, NAC efficiently reduced MHB.
Predictive Validity of the Emergency Physician and Global Job Satisfaction Instruments
Authors: Lloyd Stephen , Streiner David , Shannon Sue
Published: March 2010

Objective: To evaluate the predictive validity of the Emergency Physician Job Satisfaction (EPJS) and Global Job Satisfaction (GJS) instruments.

Methods: Prospective mail survey of 223 Canadian emergency physicians (EPs) using a 42‐item questionnaire, including 14 items evaluating their reasons for leaving emergency medicine (EM). Original (1990) EPJS and GJS scores were analyzed using 1‐way ANOVA and Scheffe's test comparing the physicians who left EM with those still in their original jobs, and those who had left their original jobs but who stayed in EM. Mean scores on the 14 “reason for leaving” items were compared with scores from an earlier sample of U.S. physicians using a t‐test for independent means. Criteria for statistical significance were set at a = 0.05 for all analyses.

Results: The response rate for the primary study questions was 99.1%. Of the respondents, 29.4% had left their original jobs, and 10.4% had left EM altogether. The GJS scores for the physicians who left EM were significantly different from those for the physicians who stayed (p = 0.004). The EPJS scores for the physicians who left EM were not significantly different from those for the physicians who stayed (p = 0.56). There was no significant difference in scores between the Canadian and U.S. physicians' reasons for leaving EM (all p‐values > 0.05). Shiftwork scored the highest as a reason to leave EM.

Conclusions: A low GJS score is associated with physicians' leaving EM, but not with changing jobs. The EPJS instrument was not associated with either outcome. Canadian and U.S. EPs place similar levels of importance on potential reasons for leaving EM.
Declining Rate of Cricothyrotomy in Trauma Patients with an Emergency Medicine Residency: Implications for Skills Training
Authors: Chang Robert S. , Hamilton Richard J. , Carter Wallace A.
Published: March 2010

Objective: To report the change in cricothyrotomy rate with emergency medicine (EM) residency development and to address the implications for training in this skill.

Methods: A retrospective chart review was used to determine the cricothyrotomy rate at a 1,000‐bed urban Level‐1 trauma center with EM, surgery, and anesthesiology residencies. All adult trauma patient visits to the ED between July 1, 1985, and June 30, 1995, were reviewed. The cricothyrotomy rate was defined as the total number of cricothyrotomies per trauma admissions during a study phase.

Results: The study period was divided into 3 phases. Phase 1 (academic years 1985–1989): prior to the inception of the EM residency; phase 2 (academic years 1990–1992): initiation and establishment of the residency; and phase 3 (academic years 1993–1994): full implementation of the EM residency. The cricothyrotomy rate during phase 1 was 1.8% (95% CI: 1.6 to 2.0), vs 1.1% (95% CI: 0.0 to 2.8) and 0.2% (95% CI: 0.0 to 0.2) during phases 2 and 3, respectively.

Conclusions: The cricothyrotomy rate decreased with the full implementation of the EM residency. Whether this trend was an effect of the presence of an EM faculty and residency training program, a parallel approach to airway management nationwide, or another unidentified factor will require further investigation. Nonetheless, given the increasing rarity of this procedure, it is likely that many EM, surgical, and anesthesiology residents will not acquire clinical experience with this technique during training.
Statistical Methodology: IV. Analysis of Variance, Analysis of Co variance, and Multivariate Analysis of Variance
Authors: Gaddis Monica L.
Published: March 2010

Medical research frequently involves the statistical comparison of >2 groups, often using data obtained through the application of complex experimental designs. Fortunately, inferential statistical methodologies exist to address these situations. Analysis of variance (ANOVA) in its many forms is used to simultaneously test the equality of all groups in a study. One‐way (with 1 independent variable), 2‐way (with 2 independent variables), and repeated‐measures (patients serve as their own controls) ANOVAs are forms of this technique. Each form has been developed to analyze data from a specific experimental design. Analysis of covariance (ANCOVA) allows the researcher to control for confounding variables that may influence the response of the dependent variable. Finally, multivariate analysis of variance (MANOVA) evaluates the simultaneous responses of multiple dependent variables to s 1 independent variable. Whereas ANOVA is the correct alternative to statistically inappropriate multiple t‐tests, MANOVA is the correct alternative to statistically inappropriate multiple uni‐variate ANOVA calculations. Use of each of these statistical methods requires an appropriate experimental design and data meeting a number of assumptions. When used properly, each of these methods provides a powerful statistical analysis technique.
Further Thoughts on Research Funding
Authors: Mulholland Michael W.
Published: March 2010

A research‐based department is developed from a specific intentional process. It requires a commitment of time and money from the leadership and desire from the faculty. Faculty need to be taught and mentored. Research funding is achieved only through a careful, deliberate plan.
Subcutaneous Buffered Lidocaine for Intravenous Cannulation: Is There a Role in Emergency Medicine?
Authors: Burgher Stephen W. , McGuirk Timothy D.
Published: March 2010

Abstract. Objective: To prospectively evaluate whether subcutaneous buffered lidocaine (SQBL) significantly reduces the pain or adversely affects the success rate of IV cannulation (IVC) in adult ED patients.

Methods: A convenience sample of patients a 18 years old requiring IVC in a regional military ED were prospectively randomized to receive SQBL, SQ normal saline with 0.9% benzyl alcohol (SQNS), or no pretreatment (NPTx), prior to IVC with an 18‐gauge angiocatheter. SQ infiltration was accomplished using a 27‐gauge insulin syringe. Investigators and patients were blinded to SQBL and SQNS in the pretreatment groups. The number of attempts at IVC was recorded for each patient. A 100‐mm visual analog pain scale (VAPS) was used to record pain scores for both SQ infiltration and IVC. Comparisons of the mean numbers of attempts to achieve IVC and of the VAPS scores were accomplished by analysis of variance followed by Duncan's multiple range test if significance was found.

Results: A total of 103 patients (SQBL‐34, SQNS‐30, and NPTx‐39) were enrolled between November 15, 1996, and June 13, 1997. There were no significant differences among the groups in either the mean number of attempts (SQBL = 1.35, 95% CI ± 0.260; SQNS = 1.13, 95% CI ± 0.124; and NPTx = 1.28, 95% CI ± 0.203) (p = 0.367) or the success rate on the first attempt (SQBL = 79.4%, SQNS = 86.7%, NPTx = 79.5%) (p = 0.533). The median VAPS score of rVC without pretreatment (21 mm, 95% CI ± 7.97) was greater than that for SQBL infiltration alone (10 mm, 95% CI ± 9.11), SQNS infiltration alone (9 mm, 95% CI ± 7.37), and IVC after SQBL (6 mm, 95% CI ± 9.18) (p < 0.009 for each group). SQNS infiltration had no significant effect on the VAPS score of subsequent rVC (20 mm, 95% CI ± 10.5) compared with IVC without pretreatment (21 mm).

Conclusions: SQBL significantly reduced the pain, while not adversely affecting the success rate, of IVC in adult patients in the ED.
Wound Irrigation with Tap Water
Authors: Moscati Ronald M. , Reardon Robert F. , Lerner E. Brooke , Mayrose James
Published: March 2010

Abstract. Objective: The study hypothesis was that irrigation with tap water is as efficacious as irrigation with sterile saline in removing bacteria from simple lacerations in preparation for wound closure.

Methods: The study was conducted in a laboratory rat model previously described in the literature for evaluating wound irrigation techniques. The study used a randomized, blinded crossover design using 10 animals. Two full‐thickness skin lacerations were made on each animal and each wound was inoculated with standardized concentrations of a Staphylococcus aureus broth. Wounds were irrigated for 4 minutes with normal saline from a syringe or 4 minutes with tap water from a faucet. Tissue specimens were sampled from each laceration prior to and following irrigation. Bacterial counts per gram of tissue were determined for each specimen and compared pre‐ and postirrigation.

Results: Preirrigation bacterial counts were not significantly different for saline vs tap water specimens. The wounds irrigated with saline had a mean reduction in bacterial count of 54.7% (SD =±28%), while the wounds irrigated with tap water had a mean reduction in bacterial count of 80.6% (SD =±20%) (p < 0.05, 2‐tailed, paired t‐test).

Conclusions: In this animal model, bacterial decontamination of simple lacerations was not compromised, and was actually improved using tap water irrigation. This is most likely due to the mechanical differences in the types of irrigation. In certain instances, such as with upper‐extremity lacerations, tap water irrigation would likely be cheaper and less labor‐intensive than irrigation with normal saline from a syringe.
Undergraduate Curriculum
Authors: DeBehnke Daniel J. , Restifo Karen M. , Mahoney John F. , Coates Wendy C. ,   For the SAEM Education Committee, Undergraduate Subcommittee
Published: March 2010

Abstract. The specialty of emergency medicine (EM) is becoming more and more involved in medical school education. The previous article discusses the integration of EM in medical school curricula. This outline was developed by the SAEM Undergraduate Education Committee to offer specific goals and objectives as well as suggestions for implementation of EM concepts into medical school curricula.
Research Fundamentals: II. Choosing and Defining a Research Question
Authors: Kwiatkowski Thomas , Silverman Robert
Published: March 2010

Abstract. This is the second in a series of articles developed by members of the SAEM Research Committee to describe a stepwise approach to the research process. This series is aimed at junior academic emergency physicians (EPs), as well as nonacademic EPs with an interest in the research process. This article describes the development of a testable research hypothesis. While a multitude of sources provide interesting questions for consideration, choosing and refining the research question, so that it can be tested adequately and answered completely, are difficult tasks.
Testicular Infarction in a Patient with Epididymitis
Authors: Sue Sean R. , Pelucio Maria , Gibbs Michael
Published: March 2010

To the authors' knowledge, this case is unique to the emergency medicine literature. Although testicular infarction from epididymitis is rare, it should be considered as a complication of severe or unresolving epididymitis. These patients should be Dlaced on broad spectrum antibiotcs, i.e., quinolones; color flow Dopp‐er of the testes should be obtained; md urologic consultation should be onsidered for possible admission ind surgical exploration.
Abdominal Pain in Geriatric Emergency Patients: Variables Associated with Adverse Outcomes
Authors: Marco Catherine A. , Schoenfeld Charles N. , Keyl Penelope M. , Menkes Edana D. , Doehring Marla C.
Published: March 2010

Abstract. Objective: To determine the diagnoses and outcomes of geriatric patients with abdominal pain, and to identify variables associated with adverse outcomes.

Methods: Geriatric emergency patients (aged 65 years and older) with a complaint of abdominal pain were participants in this longitudinal case series. Eligible patients were followed by telephone contact and chart review, to determine outcomes and final diagnoses.

Results: Of 380 eligible patients, follow‐up information was available for 375 (97%), for the two months following the ED visit. Final diagnoses included infection (19.2%), mechanical‐obstructive disorders (15.7%), ulcers/hypersecre‐tory states (7.7%), urinary tract disease (7.7%), malignancy (7.2%), and others. Although 5.3% of the patients died (related to presenting condition), most (61.3%) patients ultimately recovered. Surgical intervention was required for 22.1% of the patients. Variables associated with adverse outcomes (death, and need for surgical intervention) included hypotension, abnormalities on abdominal radiography, leukocytosis, abnormal bowel sounds, and advanced age. Most physical examination findings were not helpful in identifying patients with adverse outcomes. This study demonstrated a higher incidence of malignancy (7.2%) and a lower incidence of disease necessitating surgical intervention (22.1%) than previously reported.

Conclusions: The majority of geriatric emergency patients with abdominal pain have significant disease necessitating hospital admission. Morbidity and mortality among these patients are high, and specific variables are strongly associated with death and the need for surgical intervention. Absence of these variables does not preclude significant disease. Physical examination findings cannot reliably predict or exclude significant disease. These patients should be strongly considered for hospital admission, particularly when fever, hypotension, leukocytosis, or abnormal bowel sounds are present.
Severe Sepsis in the Emergency Department and Its Association with a Complicated Clinical Course
Authors: Smith Stephen W. , Pheley Alfred , Collier Robert , Rahmatullah Amin , Johnson Lori , Peterson Phillip K.
Published: March 2010

Abstract. Objective Infection severity as determined by clinical criteria has been recently classified and studied in hospitalized inpatients. The objective of the study was to use modified criteria to determine the clinical course associated with three levels of infection severity in infected patients admitted from the ED.

Methods: This was a retrospective cohort study involving all patients 18 years of age and older admitted through the ED of an urban teaching hospital during a four‐month period whose primary reason for requiring hospitalization was an infection that was recognized in the ED. ED records were reviewed for criteria used to classify patients by three levels of infection severity: no systemic inflammatory response syndrome, sepsis, and severe sepsis (SS). The relationships between these classifications as well as certain clinical characteristics and any complicated clinical course as measured by death and/or admission to an intensive care unit (ICU), and/or prolonged hospitalization, were analyzed.

Results: Of 408 patients entered into the study, 138 (33.8%) fulfilled the criteria of SS in the ED. Patients with SS in the ED had a mortality of only 4.3%, though with an increased risk of dying compared with that of the other groups combined [relative risk (RR) = 11.64, 95% confidence interval (CI) = 1.43 to 96.53], an increased risk of ICU stay (RR = 7.65, 95% CI = 4.08 to 14.36), and an increased risk of prolonged hospitalization (RR = 1.99, 95% CI = 1.38 to 2.88). Although age over 60 years and several comorbid conditions also were identified by univariate analysis as risk factors, multivariate analysis revealed that only SS and diabetes mellitus (DM) were independent predictors of a complicated course. In the authors' institution, the positive predictive value (PPV) of SS for complicated clinical course was 0.48 and the negative predictive value (NPV) of no SS for no complicated course was 0.77. The PPV of [SS + DM] was 0.83, and the NPV of [SS, DM, or both] was also 0.83.

Conclusion: Although the strongest correlate of a complicated clinical course identified in the ED is SS as defined by the study criteria, its specificity and PPV are low. The mortality of ED patients with SS is much lower than the mortality rates reported for inpatients with SS. SS as defined by the study criteria is too sensitive and therefore lacks utility in the ED setting.
Research Fundamentals: III. Elements of a Research Protocol for Clinical Trials
Authors: Silverman Robert , Kwiatkowski Thomas
Published: March 2010

Abstract. A clinical trial is a powerful technique for evaluating the effectiveness of an experimental intervention. The initial stages of planning a clinical trial involve choosing and refining a research question, selecting a study design, and deciding on appropriate statistical tests and sample sizes. The success of the study depends upon how well these issues are thought out in advance, and how they can be put into practice. The protocol is the written document that allows the investigator to communicate details of how the research question will be answered. In the following article, the basic components of the research protocol are described. Issues related to quality control, data entry, and pilot testing are discussed. This is the third in a series of research fundamental concept papers, written by members of the SAEM Research Committee.
Intravenous vs Subcutaneous Naloxone for Out‐of‐hospital Management of Presumed Opioid Overdose
Authors: Wanger Karen , Brough Laura , Macmillan Ian , Goulding Jim , MacPhail Iain , Christenson James M.
Published: March 2010

Objective: To determine whether naloxone administered IV to out‐of‐hospital patients with suspected opioid overdose would have a more rapid therapeutic onset than naloxone given subcutaneously (SQ).

Methods: A prospective, sequential, observational cohort study of 196 consecutive patients with suspected opioid overdose was conducted in an urban out‐of‐hospital setting, comparing time intervals from arrival at the patient's side to development of a respiratory rate ≥10 breaths/min, and durations of bag‐valve‐mask ventilation. Subjects received either naloxone 0.4 mg IV (n= 74) or naloxone 0.8 mg SQ (n= 122), for respiratory depression of <10 breaths/min.

Results: Mean interval from crew arrival to respiratory rate ≥ 10 breaths/min was 9.3 ± 4.2 min for the IV group vs 9.6 ± 4.58 min for the SQ group (95% CI of the difference ‐1.55, 1.00). Mean duration of bag‐valve‐mask ventilation was 8.1 ± 6.0 min for the IV group vs 9.1 ± 4.8 min for the SQ group. Cost of materials for administering naloxone 0.4 mg IV was $12.30/patient, compared with $10.70/patient for naloxone 0.8 mg SQ.

Conclusion: There was no clinical difference in the time interval to respiratory rate ≥10 breaths/min between naloxone 0.8 mg SQ and naloxone 0.4 mg IV for the out‐of‐hospital management of patients with suspected opioid overdose. The slower rate of absorption via the SQ route was offset by the delay in establishing an IV.
Serum Creatine Kinase Is an Unreliable Predictor of Ectopic Pregnancy
Authors: Plewa Michael C. , Ledrick David , Buderer Nancy Fenn , King Randall W.
Published: March 2010

Objective: To compare serum creatine kinase (CK) values in patients with ectopic pregnancy vs patients with threatened miscarriage or normal pregnancy.

Methods: An observational case‐control study was performed at an urban teaching hospital. Pregnant women with a quantitative β‐hCG obtained for suspicion of ectopic pregnancy were evaluated. Excluded were cases with recent trauma, IM injections, surgery, or history of heart, liver, or muscle disease. The serum β‐hCG and CK values were recorded and compared between groups with 1‐way ANOVA and Tukey's multiple comparison procedure at the overall 0.05 level.

Results: The 15 ectopic, 28 threatened miscarriage, and 21 normal pregnancy cases were of similar gestational ages (p = 0.2), ranging from 3 to 12 weeks. Although the CK values for ectopic pregnancy (88.8 ± 33.6 IU/L) exceeded those for threatened miscarriage (65.9 ± 59.0 IU/L) and normal pregnancy (56.0 ± 38.1 U/L) (p = 0.02), there was significant overlap between groups. CK values were at or above a cutoff of 74 IU/L in 80% (95% confidence interval: 52–96%) of ectopic pregnancies, 25% (11–45%) of threatened miscarriages, and 14% (3–36%) of normal pregnancies.

Conclusions: Although the ectopic pregnancy population is characterized by a higher mean CK than are patients with threatened miscarriage or a normal pregnancy, a significant overlap in CK values makes use of this serum marker unreliable for detecting ectopic pregnancy.
University and Community Hospital Medical Student Emergency Medicine Clerkship Experiences
Authors: DeLahunta Elizabeth A. , Bazarian Jeffrey
Published: March 2010

Objective: To determine whether there is a significant difference between educational opportunities for fourth‐year medical students rotating at a university hospital (UH) compared with several community hospitals (CHs) during a mandatory emergency medicine (EM) clerkship.

Methods: A self‐reported clinical tool was completed in real time by each student rotating for 2 weeks at the UH and 2 weeks at 1 of 4 CHs (3 affiliated and 1 unaffiliated). Students are required to document the number of patients seen and the number of procedures performed on each of 20 six‐hour shifts. They rated the EM attending clinical teaching by site using a 5‐point scale at the end of the clerkship.

Results: Most (95%) of the 87 students in the 7 clerkship blocks of the 1996–97 academic year rotated at the UH and a CH. Most (71%) students rated both the UH and the CH for the quality of teaching by attendings. There was a significant difference in the mean number of patients evaluated/shift (2.2 ± 0.10 vs 2.8 ± 0.10, UH vs CH; p < 0.001) and the mean number of procedures performed/shift (0.36 ± 0.04 vs 0.56 ± 0.05, UH vs CH; p < 0.001). Attending clinical teaching scores were significantly higher (p = 0.03) at the CHs.

Conclusions: The educational opportunities for students in an EM clerkship to evaluate patients and perform procedures were significantly greater at the community hospitals. Inclusion of community hospital settings in a medical student EM clerkship may optimize the clinical experience.
Effect of Skin Pigmentation on Pulse Oximetry Accuracy in the Emergency Department
Authors: Adler Jonathan N. , Hughes Lori A. , Vtvilecchia Robert , Jr. Carlos A. Camargo
Published: March 2010

Abstract. Objective:To determine whether pulse oximeter (PO) accuracy and signal quality are affected by level of skin pigmentation.

Methods:Observational study in a community hospital ED. Consecutive adult patients undergoing arterial blood gas determination were enrolled into the study. Skin pigmentation was determined by comparison with standardized color swatches under controlled lighting; assigned values were used to stratify patients into 3 groups (light, intermediate, and dark) using predetermined criteria. Simultaneous with arterial blood sampling, staff recorded PO reading of O2 saturation using the Nellcor D‐25 oximeter. PO values were compared with criterion standard values measured using a 4‐wavelength spectrophotometer or cooximeter. PO signal quality also was recorded. Bias (the mean difference between PO and co‐oximeter‐measured values of hemoglobin saturation) and precision (the standard deviation of the bias) were calculated. Groups were compared using one‐way ANOVA, Bart‐lett's test for variances, and x2 test.

Results:O2 saturation data were obtained for 284 patients. Bias values did not differ between the 3 skin pigment groups (p = 0.79). Precision was of borderline significance (p = 0.05), but there was no dose‐response relation between skin pigmentation and precision. Study personnel reported suboptimal PO function most often among patients in the dark group (p = 0.003), but this finding was of no clinical significance. PO signal failure was rare (<1% of all patients).

Conclusions:Although several prior studies suggest the contrary, this study found that skin pigmentation does not affect the bias or precision of pulse oximetry. Furthermore, skin pigmentation has no clinically significant effect on PO signal quality.
A Comparison of Demand‐valve and Bag‐Valve Ventilations in a Swine Pneumothorax Model
Authors: Jr. Hervy B. Kornegay , Carroll Robert G. , Brown Lawrence H. , Whitehurst Marvin E.
Published: March 2010

Abstract. Objective:Two means of delivering artificial ventilation readily available to out‐of‐hospita] personnel are the bag‐valve (BV) and the empowered demand‐valve (OPDV). However, use of the OPDV has been limited because of concerns that it may worsen an underlying pneumothorax. This study compared the changes in size of pneumothorax in swine ventilated with the 2 devices.

Methods:Three swine were anesthetized, intubated, and instrumented with a femoral arterial line and a pediatric Swan‐Ganz catheter. A chest tube was placed, the chest was opened, and the lung parenchyma was visualized. The lung was disrupted by a single stab with a #10 scalpel; the chest was then sealed; and a pneumothorax was created by injecting 30 mL of air through the chest tube. The animals were ventilated by 12 emergency medical technicians using either BV or OPDV. After 10 minutes of ventilation, the pneumothorax volume was measured.

Results:When comparing final pneumothorax volumes after 10 minutes of ventilation with the 2 devices, there was no significant difference (mean ± SD = 40.8 ± 28.2 mL vs 52.3 ± 23.1 mL, p = 0.286).

Conclusion:There is no difference in final pneumothorax volumes after OPDV or BV ventilation.
How Often Do Women in the Emergency Department without Intimate Violence Injuries Return with Such Injuries?
Authors: Muelleman Robert L. , Liewer Joseph D.
Published: March 2010

Abstract. Objective:lb determine the rate at which a group of women visiting the ED for reasons other than intimate violence return to the ED at a later time for intimate‐violence‐related injuries.

Methods:Retrospective cohort study of a group of women with intimate‐violence‐related injuries on an index visit and a matched comparison group. Return visit rates to the ED for intimate violence injuries over the next 5 years were then compared.

Results:The 95 women in each group were followed an average of 57 months. The return rates in the positive index case group and matched comparison group, respectively, for any reason were 74.9% vs 77.9% (p = 0.463) and for intimate violence injuries were 29.5% vs 18.9% (p = 0.118).

Conclusion:Women in the ED without intimate violence injuries often return to the ED later with such injuries. This suggests the ED may play an important role in identifying women at risk for future intimate‐violence‐related injury.
A Method for Assessing Emergency Department Performance Using Patient Outcomes
Authors: Chamberlain James M. , Pollack Murray M.
Published: March 2010

Abstract. Objective:TO determine the rates of correct patient disposition after an ED evaluation.

Methods:In a university pediatric hospital, a 25% random sample of ED patients for 4 consecutive months was reviewed, after exclusion of minor injuries and patients triaged to the nonurgent clinic. Patients were categorized into one of 4 outcomes on the basis of inpatient resource use: appropriate admission, inappropriate admission, appropriate release, or inappropriate release. A 10% random sample of released patients was contacted by telephone to detect patients who sought care elsewhere after ED release.

Results:642 of 2,682 ED patients (23.9%) were admitted; 159 (24.7%) were inappropriately admitted, and 26 (1.3%) were inappropriately released. The correct identification of the need for hospitalization (sensitivity) was 94.9%, and for release (specificity) 92.7%. Overall, the correct classification rate was 93.1%. Inappropriate admissions were associated with diagnoses of trauma, seizures, and burns.

Conclusion:Inappropriate admissions occur at a substantial rate and occur more commonly than inappropriate releases. The correct disposition of patients is a practical and meaningful outcome‐based measure of the quality of ED care. This methodology is suitable for use in other EDs.
Carbon Monoxide Mass Exposure in a Pediatric Population
Authors: Klasner Ann E. , Smith Sharon R. , Thompson Michael W. , Scalzo Anthony J.
Published: March 2010

Abstract. Objectives:To describe the outcomes of a mass carbon monoxide (CO) intoxication, and to calculate the CO half‐life in a pediatric school‐aged population.

Methods:A retrospective chart review was performed based on Regional Poison Center database information, hospital laboratory data, and medical records of the pediatric patients who sought care at one of 3 St. Louis area hospitals, after exposure to high levels of CO. Exposures occurred on January 5, 1996, after evidence of a CO leak was discovered at an area elementary school. Charts were reviewed for major demographics, symptoms reported, carboxyhemoglobin (COHb) levels and times, and level of effect.

Results:Information about 177 (35%) of the 504 children in attendance at school that day was available. Mean age was 8.7 ± 1.8 years (range 4–12 years). Symptoms were present in 155 (88%) of the 177 children for whom data were available. Initial COHb levels were obtained for 147 (83.1%) of the 177 children. First mean COHb level was 7.0% (95% CI = 6.6–7.5%). Second COHb level was obtained for 26 children with a mean of 2.7% (95% CI = 2.2–3.2%). Calculated half‐life of COHb, on 100% 02 at 1 atm, was 44.0 minutes (95% CI = 39.6–48.2 minutes).

Conclusion:Some children had symptoms at COHb levels that traditionally have been considered nontoxic. The elimination of COHb was found to be more rapid in this population of children than reported in other studies.
Follow‐up Compliance in Febrile Children: A Comparison of Two Systems
Authors: Hemphill Robin R. , Santen Sally A. , Howell John M. , Altieri Michael F.
Published: March 2010

Abstract. Objectives:Follow‐up compliance is critical in febrile children because they may harbor unrecognized life‐threatening illnesses. This study compares follow‐up rates between 2 systems: Wilford Hall Medical Center (WHMC), with preset appointments after ED release, and free medical care; and Fairfax Hospital (FFX), where parents must arrange follow‐up appointments after ED release, and are responsible for payment for their follow‐up visits. The study also investigated factors associated with follow‐up compliance.

Methods:This was a prospective, observational study of febrile children seen in 2 EDs with different systems for patient follow‐up. From ED records and parental phone calls, diagnosis, follow‐up compliance, and demographics were collected. Data were analyzed using logistic regression and χ2.

Results:423 children met entrance criteria, and 330 parents were successfully contacted after the child's ED release (146 from WHMC; 184 from FFX). The WHMC children were more likely to comply with follow‐up than were the children in the FFX system (92% vs 67% follow‐up, odds ratio 2.5, 95% CI 1.1–5.3). Other factors associated with noncompliance with recommended follow‐up were: Hispanic ethnicity, non‐English‐speaking parents, and follow‐up suggested for <24 hours after ED release. For FFX, self‐pay, lack of a follow‐up physician, parents' dissatisfaction with the ED medical care, and diagnosis of otitis media were also significant factors found associated with noncompliance.

Conclusion:Febrile children evaluated in a medical system with prearranged follow‐up appointments and free medical care are more likely to comply with recommended follow‐up than are those evaluated in a system where payment and appointments are the responsibility of the parents. Efforts should be made to improve follow‐up compliance by modeling the WHMC system.