bluuebunny/crossref_metadata_2025 huggingface dataset:
Can Clinical Parameters Predict Fractures in Acute Pediatric Wrist Injuries?
Authors: Pershad Jay , Monroe Kathy , King William , Bartle Sam , Hardin Elizabeth , Zinkan Lyn
Published: January 2008

Abstract. Objective: Fractures around the wrist are common in pediatric patients presenting to the emergency department (ED). This pilot study was aimed at identifying clinical variables that are most likely to be associated with a fracture. Methods: This was a prospective blinded case series of patients 3‐18 years of age presenting with an acute (<3 days) wrist injury, without obvious deformity. A team of five investigators blinded to the eventual radiographic findings evaluated patients. Physical examination variables included range of motion (ROM), site of maximal tenderness, and functional deficit. The latter was determined objectively, by recording any difference in grip strength between the injured and noninjured hands. Diagnostic radiographs were obtained for all patients. Univariate analysis using Wilks log likelihood ratio test was performed to identify clinical variables associated with confirmed wrist fractures. Sample size was determined based on the ability to detect a difference of 15 degrees in the ROM variables, 20% point differences in grip strength, and 30% proportion differences in categorical variables using a power of 0.8 and a two‐tailed of 0.05. Results: The ROMs were not significantly different between the fracture (Fx) and nonfracture (NFx) group. There was significant change in the grip strength between the Fx and NFx groups (t = 3.3, p = 0.0019). Tenderness over the distal radius was also associated with a greater likelihood of a fracture (G2= 5.0, p = 0.02). Sensitivity of clinical prediction was found to be 79%, and specificity was 63%. The false‐negative rate was 0.21 and the false‐positive rate was 0.37, while the positive predictive value was found to be 0.68 and negative predictive value 0.75. Conclusions: Distal radius point tenderness and a 20% or more decrease in grip strength were predictive of fractures.
Bilateral Tubal Ectopic Pregnancy: A Tale of Caution
Authors: Ryan Mary T. , Saldana Benjamin
Published: January 2008

Abstract. Diagnosis of ectopic pregnancy continues to be an important challenge facing emergency physicians. The authors present a case of bilateral tubal ectopic pregnency and discuss its clinical features and diagnositc difficulties. A review of the English‐language literature on the subject is discussed. Suggestions are made on ways to increase diagnostic accuracy, reduce complications, and preserve future fertility in this group of patients.
Predicting Recovery from Acute Asthma in an Emergency Diagnostic and Treatment Unit
Authors: McCarren Madeline , Zalenski Robert J. , McDermott Michael , Kaur Kulvinder
Published: January 2008

Abstract: Objective: Optimal use of emergency diagnostic and treatment unit (EDTU) resources for treatment of acute asthma should be facilitated by the selection of patients with a high probability of discharge from the EDTU. The study goal was to identify characteristics of the patient or exacerbation that could be used to predict recovery of pulmonary function within 12 hours. Methods: Comprehensive cohort design in an urban public hospital. The subjects were 269 patients with moderately severe asthma exacerbations. Data were collected for historical and presenting features and response to treatment over 12 hours. Two outcomes were examined: 1) discharge from the EDTU and 2) achieving 50% predicted peak expiratory flow rate (PEFR) within 12 hours. Results: The two outcomes showed good concordance. The third‐treatment PEFR was found to be predictive of both discharge and reaching 50% predicted PEFR within 12 hours. Since the objective measure of reaching 50% predicted PEFR is more readily defined and thus more generalizable, the authors focused on this outcome when describing prediction zones. Patients with 40% or higher PEFR after third treatment had an 89% probability of reaching 50% predicted in 12 hours, while those with a third‐treatment PEFR lower than 32% predicted had only a 22% probability. Conclusions: A simple objective measure of pulmonary function early in treatment discriminated among those with high, low, and intermediate probabilities of achieving a specified level of PEFR within 12 hours. Awareness of this probability could assist clinicians attempting to predict discharge from the EDTU and facilitate decision making regarding utilization of EDTU resources.
Selection Criteria for Emergency Medicine Residency Applicants
Authors: Crane Joseph T. , Ferraro Carl M.
Published: January 2008

Abstract: Objectives: To determine the criteria used by emergency medicine (EM) residency selection committees to select their residents, to determine whether there is a consensus among residency programs, to inform programs of areas of possible inconsistency, and to better educate applicants pursuing careers in EM. Methods: A questionnaire consisting of 20 items based on the current Electronic Residency Application Service (ERAS) guidelines was mailed to the program directors of all 118 EM residencies in existence in February 1998. The program directors were instructed to rank each item on a five‐point scale (5 = most important, 1 = least important) as to its importance in the selection of residents. Followup was done in the form of e‐mail and facsimile. Results: The overall response rate was 79.7%, with 94 of 118 programs responding. Items ranking as most important (4.0‐5.0) in the selection process included: EM rotation grade (mean ± SD = 4.79 ± 0.50), interview (4.62 ± 0.63), clinical grades (4.36 ± 0.70), and recommendations (4.11 ± 0.85). Moderate emphasis (3.0‐4.0) was placed on: elective done at program director's institution (3.75 ± 1.25), U.S. Medical Licensing Examination (USMLE) step II (3.34 ± 0.93), interest expressed in program director's institution (3.30 ± 1.19), USMLE step I (3.28 ± 0.86), and awards/achievements (3.16 ± 0.88). Less emphasis (<3.0) was placed on Alpha Omega Alpha Honor Society (AOA) status (3.01 ± 1.09), medical school attended (3.00 ± 0.85), extracurricular activities (2.99 ± 0.87), basic science grades (2.88 ± 0.93), publications (2.87 ± 0.99), and personal statement (2.75 ± 0.96). Items most agreed upon by respondents (lowest standard deviation, SD) included EM rotation grade (SD 0.50), interview (SD 0.63), and clinical grades (SD 0.70). Of the 94 respondents, 37 (39.4%) replied they had minimum requirements for USMLE step I (195.11 ± 13.10), while 30 (31.9%) replied they had minimum requirements for USMLE step II (194.27 ± 14.96). Open‐ended responses to “other” were related to personal characteristics, career/goals, and medical school performance. Conclusions: The selection criteria with the highest mean values as reported by the program directors were EM rotation grade, interview, clinical grades, and recommendations. Criteria showing the most consistency (lowest SD) included EM rotation grade, interview, and clinical grades. Results are compared with those from previous multispecialty studies.
Epidemiologic Analysis of an Urban, Public Emergency Department's Frequent Users
Authors: Mandelberg Joshua H. , Kuhn Robert E. , Kohn Michael A.
Published: January 2008

Abstract. Objectives: To determine how the demographic, clinical, and utilization characteristics of emergency department (ED) frequent users differ from those of other ED patients. Methods: A cross‐sectional and retrospective cohort study was performed using a database of all 348,858 visits to the San Francisco General Hospital ED during a five‐year period (July 1, 1993, to June 30, 1998). A “frequent user” visited the ED five or more times in a 12‐month period. Results: Frequent users constituted 3.9% of ED patients but accounted for 20.5% of ED visits. The relative risk (RR) of frequent use was high among patients who were homeless (RR = 4.5), African American (RR = 1.8), and Medi‐Cal sponsored (RR = 2.1). Frequent users were more likely to be seen for alcohol withdrawal (RR = 4.4), alcohol dependence (RR = 3.4), and alcohol intoxication (RR = 2.4). Frequent users were also more likely to visit for exacerbations of chronic conditions, including sickle cell anemia (RR = 8.0), renal failure (RR = 3.6), and chronic obstructive pulmonary disease (RR = 3.3). They were less likely to visit for all forms of trauma (RR = 0.43). Survival analysis showed that only 38% of frequent users for one year remained frequent users the next year. However, 56% of frequent users for two consecutive years remained frequent users in the third year. Conclusions: Frequent use of the ED reflects the urban social problems of homelessness, poverty, alcohol abuse, and chronic illness. Frequent use of the ED shows a high rate of decline from one year to the next. This rate of decline slows after the first year and suggests the existence of a smaller group of chronic frequent users.
Evaluation of Protocols Allowing Emergency Medical Technicians to Determine Need for Treatment and Transport
Authors: Schmidt Terri , Atcheson Regina , Federiuk Carol , Mann N. Clay , Pinney Tannert , Fuller Dave , Colbry Kyran
Published: January 2008

Abstract. Objective: To determine whether emergency medical technicians (EMTs) can safely apply protocols to assign transport options and to assess agreement between groups of providers on application of the protocols. Methods: Developed protocols categorized patients as: 1) needs ambulance; 2) go to the emergency department (ED) by alternative means; 3) contact primary care provider (PCP); or 4) treat and release. After education on the application of the protocols, first responders and ambulance EMTs categorized patients at the scene prior to transport but did not change current practice. Ambulance reports were reviewed using a predetermined list of critical events that signified the need for an ambulance. Results: The EMTs categorized 1,300 study patients as follows: 1,023 (79%) needed ambulance transport, 200 (15%) could go to the ED by alternative means, 63 (5%) could contact a PCP, 14 (1%) could be treated and released. Categorizations by a first responder and the transporting EMT were compared for 209 patients. Collapsing categories to “need ambulance/do not need ambulance” showed fair concordance (kappa = 0.51). Initially, 30 of 277 (11%) patients determined not to need an ambulance appeared to experience a critical event. After review, 23 patients had events that may not warrant advanced life support transport. Seven (3%) had critical events in the ambulance warranting ambulance transport. Most were miscategorized by the EMT. Overall sensitivity and specificity for identifying patients needing ambulance transport were 94.5% and 32.8%, respectively. Conclusions: From 3% to 11% of patients determined on scene not to need an ambulance had a critical event. Emergency medical services systems need to determine an acceptable rate of undertriage. Further study is needed to determine whether better adherence to the protocols might increase safety.
Emergency Medicine Residents' Shiftwork Tolerance and Preference
Authors: Steele Mark T. , Ma O. John , Watson William A. , Thomas Harold A.
Published: January 2008

Abstract. Objectives: To determine the shift lengths currently worked by emergency medicine (EM) residents and their shift length preferences, and to determine factors associated with EM residents' subjective tolerance of shiftwork. Methods: A survey was sent to EM‐2 through EM‐4 allopathic EM residents in May 1996. This questionnaire assessed the residents' shift length worked, shift length preferences, night shift schedules, and self‐reported ability to overcome drowsiness, sleep flexibility, and morningness‐eveningness tendencies. When providing shift length preferences, the residents were asked to assume a constant total number of hours scheduled per month. Results: Seventy‐eight programs participated, and 62% of 1,554 eligible residents returned usable surveys. Current shift lengths worked were 8 hours (12%), 10 hours (13%), 12 hours (37%), combinations of 8‐hour, 10‐hour, or 12‐hour (34%) shifts, and other combinations (4%). Seventy‐three percent of the respondents indicated that they preferred to work 8‐hour or 10‐hour shifts, and only 21% preferred a 12‐hour shift. Shifwork tolerance was recorded as: not well at all (2%), not very well (14%), fairly well (70%), and very well (14%). The EM residents' eveningness preference, ability to overcome drowsiness, sleep flexibility, younger age, and having no children at home were all associated with greater shiftwork tolerance. Conclusions: Emergency medicine residents generally tolerate shiftwork well and prefer 8‐hour or 10‐hour shift lengths compared with 12‐hour shift lengths. Emergency medicine residencies with 12‐hour shifts should consider changing residents' shifts to shorter shifts.
Unique Curriculum for Emergency Medicine Residents as Medical Directors for Rural Out‐of‐hospital Agencies
Authors: Custalow Catherine B. , Armacost Michael , Honigman Benjamin
Published: January 2008

Abstract. Background: Many rural communities have difficulty maintaining a medical director for their emergency medical services (EMS). Local physicians may be overwhelmed, be hesitant to take on additional responsibilities, and feel unskilled in providing the necessary leadership. Without a medical director, rural EMS agencies are frequently forced to shut down, thus depriving the community of local out‐of‐hospital care. Objectives: To meet the needs of rural EMS agencies for medical direction, to provide a unique opportunity for emergency medicine (EM) residents to acquire EMS medical direction skills, and to fulfill the obligation of EM residencies to provide both didactic and experiential training in EMS. Program Description: This article describes a curriculum, now being used in Colorado, for placing EM residents as EMS medical directors for rural out‐of‐hospital agencies that have lost their medical directors. Residents visit these rural communities 6‐12 times a year, provide continuing education through interactive lectures, develop or revise EMS protocols and policies, perform quality assurance reviews, troubleshoot problems, and assist in EMS planning for the community. Residents are supervised by the Colorado state EMS medical director. Conclusions: This unique program enables local EMS agencies to continue their service while providing clear educational benefit for the EM residents. This paper demonstrates how this program has been working successfully in the state of Colorado by placing residents in four distinct rural and mountainous communities.
Patient Satisfaction Investigations and the Emergency Department: What Does the Literature Say?
Authors: Trout Andrew , Magnusson A. Roy , Hedges Jerris R.
Published: January 2008

Abstract. Background: Patient satisfaction is an indicator of the quality of care provided by emergency department (ED) personnel. It is this perception of satisfaction that becomes the basis for future ED choice or the recommendation of a specific ED to other potential patients. Objective: To perform an evidence‐based literature review to: 1) characterize measures of “patient satisfaction” 2) identify factors that have been associated with overall ED patient satisfaction; 3) critique the methods used to assess patient satisfaction in the literature; and 4) address how this information can be beneficial to those reading the satisfaction literature or designing a satisfaction survey instrument. Methods: The MEDLINE database was searched for studies addressing ED patient satisfaction, from January 1976 through July 1999, using MeSH terms and a text word search. Bibliographies of manuscripts also were searched for additional relevant articles and each clinical study was used as a search criterion in Science Citation Index, from the date of publication through July 1999. Results: Multiple measures have been used to evaluate overall patient satisfaction. Sixteen studies were found associating ED patient satisfaction with service and patient factors. Most studies are observational and of these, most are cross‐sectional. Hence, cause‐and‐effect determination of factors responsible for patient satisfaction cannot be resolved using the current literature. Conclusions: Despite considerable methodologic variability, key themes (e.g., association of satisfaction with patient information, provider—patient interpersonal factors, and perceived waiting time) emerge from review of the ED patient satisfaction literature. To standardize future investigations, clinicians and investigators should use a common definition for the state of overall patient satisfaction, e.g., when the patient's own expectations for treatment and care are met (or exceeded). This common definition should be incorporated into the instrument used to measure overall ED patient satisfaction.
Clinical Presentations and Prognostic Factors of a Glyphosate — Surfactant Herbicide Intoxication A Review of 131 Cases
Authors: Lee Hsin‐Ling , Chen Kuan‐Wen , Chi Chih‐Hsien , Huang Jeng‐Jong , Tsai Liang‐Miin
Published: January 2008

Abstract. Objective: Suicide attempts with agricultural chemicals are common in southern Taiwan. Among them, glyphosate—surfactant herbicide (GlySH) intoxication has been encountered with increasing frequency. Although a number of reports have described the clinical course and outcomes following ingestion, predictors of serious complications and mortality have not been elucidated. The purpose of this study was to define predictors of serious complications and probable mortality. Methods: This was a retrospective study of 131 GlySH‐intoxicated patients treated at the National Cheng Kung University Hospital from 1988 to 1995. Medical charts were reviewed and clinical and laboratory variables were abstracted, looking for predictors of mortality. Results: The most common symptoms included sore throat (79.5%), and nausea with or without vomiting (73.8%). The most common laboratory findings were leukocytosis (68.0%), low serum bicarbonate (48.1%), and acidosis (35.8%). Overall, 11 of 131 patients (8.4%) died; the mean ± SEM time to death was 2.8 ± 0.8 days after presentation. When comparing the clinical and laboratory characteristics among the survivor and fatality groups, significant differences were identified. Respiratory distress, pulmonary edema, respiratory distress necessitating intubation, shock (systolic blood pressure less than 90 mm Hg), altered consciousness, abnormal chest x‐ray, renal failure necessitating hemodialysis, larger amount of ingestion (>200 mL), and hyperkalemia were predictors highly associated with poor outcomes and mortality. Using multiple logistic regression, three predictors were identified, which may predict mortality in severely intoxicated patients. Conclusions: In managing patients who have larger amount of GlySH ingestion, airway protection, early detection of pulmonary edema, and prevention of further pulmonary damage and renal damage appear to be of critical importance.
Mucormycosis Manifesting as Proptosis and Unilateral Blindness
Authors: Doty Christopher I. , Lucchesi Michael
Published: January 2008

Abstract. A 51‐year‐old woman presented to the emergency department (ED) of another institution with sudden onset of blindness in the left eye. The patient was found to have no light perception in the left eye and a marked chemosis occurring several days after a fall. She was transferred to the hospital for ophthalmologic evaluation. Upon careful history and physical examination, the diagnosis of rhinocerebral mucormycosis was considered and urgent ophthalmology and otolaryngology consults were obtained. The patient underwent extensive surgical debridement and pharmacologic treatment. The diagnosis was confirmed by pathological specimens. In this case report, the clinical presentation, pathogenesis, diagnostic workup, and ED management of mucormycosis are discussed, highlighting the possible diagnostic and therapeutic pitfalls that are most pertinent to the emergency physician.
Prospective Evaluation of Two‐dimensional Transthoracic Echocardiography in Emergency Department Patients with Suspected Pulmonary Embolism
Authors: Jackson Raymond E. , Rudoni Raymond R. , Hauser Andrew M. , Pascual Rebecca G. , Hussey Mary E.
Published: January 2008

Abstract. Objective: To prospectively examine the diagnostic accuracy of two‐dimensional transthoracic echocardiography (2‐D echo) in emergency department (ED) patients being evaluated for acute pulmonary embolism (PE). Methods: This was a 14‐month prospective observational trial of a convenience sample of ED patients undergoing evaluation for suspected PE at a suburban teaching hospital. The 2‐D echo was defined as positive if any two of the following were noted: right ventricular dilation, abnormal septal motion, loss of right ventricular contractility, elevated pulmonary artery or right ventricular pressures, moderate to severe tricuspid regurgitation, or visualization of a clot seen in the right ventricle or pulmonary artery. The patient was considered to have a PE if one of the following was positive: a pulmonary angiogram, contrast helical computed tomography, a magnetic resonance angiogram, a high‐probability ventilation/perfusion (V/Q) scan without contradictory evidence, or an intermediate‐probability V/Q scan with ultrasonic evidence of deep venous thrombosis. Results: Of 225 cases identified, 39 met the defined criteria for PE (17%). A 2‐D echo was performed on 124 patients (55%), of whom 27 (22%) had PE. In 20 patients the 2‐D echo had at least two indicators of right ventricular strain; however, only 11 of these patients had confirmed pulmonary embolus. The 2‐D echo had a sensitivity of 0.41 (95% CI = 0.32 to 0.49) and a specificity of 0.91 (95% CI = 0.86 to 0.96). The likelihood ratio positive was a moderately strong 4.4, with a weak likelihood ratio negative of 0.6. Conclusions: Bedside 2‐D echo is not a sensitive test for the diagnosis of PE in ED patients. Positive findings moderately increase the suspicion for PE but are not diagnostic.
The Accuracy of Oral Predictive and Infrared Emission Detection Tympanic Thermometers in an Emergency Department Setting
Authors: O'Brien Debra L. , Rogers Ian R. , Holden Warren , Jacobs Ian , Mellett Steven , Wall Erin J. , Davies Derin
Published: January 2008

Abstract. Objective: To assess the accuracy of an oral predictive thermometer and an infrared emission detection (IRED) tympanic thermometer in detecting fever in an adult emergency department (ED) population, using an oral glass mercury thermometer as the criterion standard. Methods: This was a single‐center, nonrandomized trial performed in the ED of a metropolitan tertiary referral hospital with a convenience sample of 500 subjects. The temperature of each subject was taken by an oral predictive thermometer, an IRED tympanic thermometer set to “oral” equivalent, and an oral glass mercury thermometer (used as the criterion standard). A fever was defined as a temperature of 37.8°C or higher. The subject's age, sex, triage category, and diagnostic group were also recorded. Sensitivity, specificity, positive and negative likelihood ratios, positive and negative predictive values, and corresponding 95% confidence intervals were calculated. Logistic regression was used to identify predictors of fever. Results: The sensitivities and specificities for detection of fever of the predictive and the IRED tympanic thermometers were similar (sensitivity 85.7%/88.1% and specificity 98.7%/95.8%, respectively). The predictive thermometer had a better positive predictive value (85.7%) compared with the IRED tympanic thermometer (66.1%). The positive and negative likelihood ratios for the predictive oral thermometer were 65 and 0.14, respectively, and for the IRED tympanic thermometer 21 and 0.12, respectively, indicating that the predictive thermometer will “miss” 1 in about 7 fevers and the IRED tympanic thermometer will “miss” 1 in about 8 fevers. Conclusions: Although quick and convenient, oral predictive and IRED tympanic thermometers give readings that cannot always be relied on in the detection of fever. If we are to continue using electronic thermometers in the ED setting, we need to recognize their limitations and maintain the importance of our clinical judgment.
Massive Pneumocephalus Following Merocel Nasal Tamponade for Epistaxis
Authors: Hollis Gregory John
Published: January 2008

Abstract. Anterior epistaxis is commonly treated with Merocel nasal tampon insertion in preference to gauze packing. An 89‐year‐old patient was found to have cerebrospinal fluid rhinorrhea and massive pneumocephalus immediately after removal of a Merocel tampon used for spontaneous anterior epistaxis. She later developed fever and mild confusion, but was well at three‐month follow‐up. The advantages and complications of Merocel nasal tamponade are briefly reviewed and compared with those of other methods of control of anterior epistaxis.
Isolated Intraperitoneal Fluid on Abdominal Computed Tomography in Children with Blunt Trauma
Authors: Holmes James F. , London Keri L. , Brant William E. , Kuppermann Nathan
Published: January 2008

Abstract. Objective: To determine the frequency of isolated intraperitoneal fluid (IIF) on abdominal computed tomography (CT) in pediatric blunt trauma patients and the association between IIF and clinically identifiable intra‐abdominal injuries (IAIs) in these patients. Methods: The authors conducted a prospective observational study of consecutive children <16 years old with blunt torso trauma who underwent abdominal CT scanning while in the emergency department (ED). All patients were evaluated by a faculty emergency physician who documented the patient's physical examination. All CTs were interpreted by a single faculty radiologist masked to clinical data. The volume of intraperitoneal fluid was quantified (small, moderate, large) and the presence of organ injury visible on CT was noted. Patients were considered to have IIF if the CT demonstrated intraperitoneal fluid and no solid organ injury. Patients with IIF were followed through their hospitalizations or telephoned in one week if discharged home from the ED. Results: Five hundred twenty‐seven children with blunt trauma were enrolled into the study. The mean age (±SD) was 7.4 ± 4.7 years, and the median pediatric trauma score was 10 (range ‐2 to 12). Eighty‐eight patients (17%; 95% CI = 14% to 20%) had intraperitoneal fluid on CT scan and 42 (48%; 95% CI = 37% to 59%) of these patients had IIF. Of the 42 patients with IIF, five patients (all without abdominal tenderness and with a small amount of IIF on CT scan) were discharged to home from the ED and were well at telephone follow‐up; the remaining 37 patients were hospitalized. Of the 42 patients with IIF, 7 patients (17%, 95% CI = 7 to 31%) had IAIs subsequently identified (all gastrointestinal injuries) during their evaluations. Six of the seven patients with IIF and subsequently identified IAIs had abdominal tenderness on examination in the ED. The remaining patient had a decreased level of consciousness. Conclusions: Isolated intraperitoneal fluid occurs in 8% of pediatric blunt trauma patients undergoing abdominal CT, and IAIs are subsequently identified in 17% of these patients. Patients with a small amount of IIF on CT who lack abdominal tenderness and have a normal level of consciousness are at low risk for subsequently identified IAIs.
Variation in Utilization of Computed Tomography Scanning for the Investigation of Minor Head Trauma in Children: A Canadian Experience
Authors: Klassen Terry P , Reed Martin H , Stiell Ian G , Nijssen‐Jordan Cheri , Tenenbein Milton , Joubert Gary , Jarvis Anna , Baldwin Gregory , St‐Vil Dickens , Pitters Carrol , Belanger Franc¸ois , McConnell Don , Vandemheen Kathy , Hamilton Mark G , Sutcliffe Terry , Colbourne Margaret , Pham Ba
Published: January 2008

Abstract. Objectives: To compare the utilization rates of CT scans in investigating minor head trauma in children in Canada, to identify the injuries determined by these scans, and to identify clinical findings that are highly associated with its diagnosis and the injury itself. Methods: A retrospective cohort study involving nine pediatric hospitals in Canada was conducted. A structured data collection method was used. Inclusion criteria included age 16 years or less, history of blunt head trauma, and a Glasgow Coma Scale score (GCS) greater than or equal to 13. Data collected included demographic information, type of injury, relevant clinical information, computed tomography (CT) scan data, and clinical outcome. Clinical findings associated with CT scan and positive CT scan were identified using logistic regression. Results: One thousand one hundred sixty‐four children were included in the study. One hundred seventy‐one (15%) had a CT scan, of which 60 (35%) were abnormal. There was a significant difference in the rate of ordering of CT scans among the participating hospitals, but no significant difference in the rate of abnormal CT scans. Mechanism of injury, GCS, and loss of consciousness were significantly related to the presence of an abnormal CT scan. Conclusions: Although there is a significant difference in the utilization of CT scans to investigate minor head trauma in children across Canada, there is no significant difference in the frequency of head injuries in these patients. This suggests that it may be possible to determine clinical criteria that are predictive of a head injury in these patients.
Care and Outcome of Out‐of‐hospital Deliveries
Authors: Moscovitz Harry C , Magriples Urania , Keissling Mark , Schriver John A
Published: January 2008

Abstract. Objectives: To identify interventions by paramedics in out‐of‐hospital deliveries and predictors of neonatal outcome. Methods: A prospective case series of consecutive out‐of‐hospital deliveries at Yale‐New Haven Hospital from January 1991 to January 1994. Data describing out‐of‐hospital interventions, demographics, maternal risk factors, and neonatal outcomes were collected from out‐of‐hospital, emergency department (ED), and hospital records. Subgroups defined by source of prenatal care were compared using a multiple logistic regression model to determine predictors of poor neonatal outcome. Results: Ninety‐one patients presented to the hospital after delivery. Paramedics attended 78 (86%) of the cases. Paramedics performed endotracheal intubation in one neonate and supported ventilation in four others. Suctioning and warming of the neonate were documented in 58% and 76%, respectively, and hypothermia was common (47%) in the paramedicattended deliveries. There were 9 neonatal deaths. Eight (89%) of the neonatal deaths were in the group with no prenatal care (p < 0.0001). Lack of prenatal care (RR 304, 95% CI = 5.0 to 18,472) and history of poor prenatal care (RR 22.5, 95% CI = 1.19 to 427) were significant predictors of poor neonatal outcome. Sixteen percent of all study patients and 43% of those with no prenatal care were treated in the ED during their pregnancies. Eighteen percent of the patients had had no prenatal care during previous pregnancies. Conclusions: Paramedics manage labor and delivery of a high‐risk population. Fundamental aspects of care were not universally documented. Lack of prenatal care was associated with high neonatal morbidity and mortality. Nearly half of the mothers who went on to deliver without prenatal obstetric care saw emergency physicians during their pregnancies.
A Randomized Controlled Trial to Assess Decay in Acquired Knowledge among Paramedics Completing a Pediatric Resuscitation Course
Authors: Su Eustacia , Schmidt Terri A , Mann N Clay , Zechnich Andrew D
Published: January 2008

Abstract. Background: Critical pediatric illness or injury occurs infrequently in out‐of‐hospital settings, making it difficult for paramedics to maintain physical assessment, treatment, and procedure skills. Objectives: To document the ability of paramedics to retain clinical knowledge over a one‐year interval after completing a pediatric resuscitation course and to determine whether clinical experience or retesting improves retention. Methods: This was a randomized controlled study assessing retention of knowledge in pediatric resuscitation soon after, six months after, and 12 months following completion of a pediatric anvanced life support course. Forty‐three parmedics participated in pre‐ and post‐pediatric resuscitation course testing and were randomly assigned to one of four groups. Group 1 received a knowledge examination (KE) and mock resuscitation scenarios (MR) at six months. Group 2 received only the KE at six months. Groups 3 received the MR only at six months. Group 4 received no intermediate testing. All groups were reassessed at 12 months. Results; Pediatric clinical knowledge (as measured by KE) rose sharply immediately after the course but returned to baseline levels within six months. There was no difference between the groups in knowledge scores at 12 months, despite the interventions at six months. Conclusions: Although intensive out‐of‐hospital pediatric education enhances knowledge, that knowledge rapidly decays. Emergency medical services programs need to find novel ways to increase retention and ensure paramedic readiness.
State of the Art: Therapeutic Controversies in Severe Acute Asthma
Authors: Gibbs Michael A , Camargo Carlos A , Rowe Brian H , Silverman Robert A
Published: January 2008

Abstract. This is a transcript of the 1999 SAEM State‐of‐the‐Art session on “Therapeutic Controversies in Severe Acute Asthma,” presented at the 1999 SAEM annual meeting in Boston. The aim of this session was to address some of the current controversies in the management of acute asthma exacerbations, a major issue in emergency medicine. Despite many recent advances in asthma management, morbidity and mortality remain high. While many of us have strong feelings on how asthma patients should be treated, many of our assertions are not based on good science, and there are numerous areas of controversy. This discussion focuses on the controversy over beta agonist treatment for acute asthma, the physiology of corticosteroids in asthma, and the emergency use of leukotriene‐modifying agents.
Variation in Institutional Review Board Responses to a Standard Protocol for a Multicenter Clinical Trial
Authors: Stair Thomas O. , Reed Caitlin R. , Radeos Michael S. , Koski Greg , Camargo Carlos A. , THE MARC*
Published: January 2008

Abstract. Multicenter clinical trials require approval by multiple local institutional review boards (IRBs). The Multicenter Airway Research Collaboration mailed a clinical trial protocol to its U.S. investigators and 44 IRBs ultimately reviewed it. Objective: To describe IRB responses to one standard protocol and thereby gain insight into the advantages and disadvantages of local IRB review. Methods: Two surveys were mailed to participants, with telephone follow‐up of nonrespondents. Survey 1 was mailed to 82 investigators across North America. Survey 2 was mailed to investigators from 44 medical centers in 17 U.S. states. Survey 1 asked about each investigator's local IRB (e.g., frequency of meetings, membership), whereas survey 2 asked about IRB queries and concerns related to the submitted clinical trial. Results: Both surveys had 100% response rate. Investigators submitted applications a median of 58 days (interquartile range [IQR], 40‐83) after receipt of the protocol, and IRB approval took an additional 38 days (IQR, 26‐62). Although eight applications were approved with little or no changes, IRBs requested an average of 3.5 changes per site. Changes involved study logistics and supervision for 45%, the research process for 43%, and the consent form for 91%. Despite these numerous requests, all eventually approved the basic protocol, including inclusion criteria, intervention, and data collection. Conclusions: The IRBs showed extreme variability in their initial responses to a standard protocol, but ultimately all gave approval. Almost all IRBs changed the consent form. A national, multicenter IRB process might streamline ethical review and warrants further consideration.
Monthly, Weekly, and Daily Patterns in the Incidence of Congestive Heart Failure
Authors: Allegra John R. , Cochrane Dennis G. , Biglow Rodney
Published: January 2008

Abstract. Objective: To determine whether there are patterns in the incidence of emergency department (ED) visits for congestive heart failure (CHF) by month of the year, day of the week, or hour of the day. Methods: This was a retrospective analysis of a computerized billing database of ED visits, involving seven northern New Jersey hospitals EDs. Consecutive patients seen by emergency physicians over an 11‐year period (January 1, 1988‐December 31, 1998) were included. Chi‐square tests were used to evaluate for significant differences (p < 0.05). Results: There were a total of 2,370,233 patients in the database, of whom 26,224 had a primary ED diagnosis of CHF. The chi‐square test rejected uniformity for month of the year, for day of the week, and for hour of the day (p < 0.0001). Visits for CHF were increased in the winter months. Compared with the average of the other months, December was the highest (14.3% above, p < 0.0001) and August was the lowest (15.5% below, p < 0.0001). There was also a day‐of‐the‐week variation. Compared with the average of the other days, Monday was the highest (14.5% above, p < 0.0001) and Saturday was the lowest (9.6% below, p < 0.0001). There was also an hour‐of‐the‐day pattern, with a rapid rise after 8 AM and a downtrend after 3 PM. Conclusions: These data revealed a higher incidence of ED visits for CHF in the winter months, on Mondays, and during the hours of 8 AM to 3 PM. In comparison with previous studies, these data revealed a similar pattern by month of the year and a different pattern by hour of the day.
Imaging of Mandibular Trauma: ROC Analysis
Authors: Nair Madhu K. , Nair Uma P.
Published: January 2008

Objectives: To compare the diagnostic efficacies of panoramic radiographs, mandibular trauma series, and digitized radiographs for detection of fractures of the mandible. Methods: Fractures were induced using blunt trauma in 25 cadaver mandibles. Panoramic radiographs, digitized radiographs, and mandibular series comprising an anteroposterior view, two lateral oblique, and a reverse Towne's were used. Six observers recorded their diagnoses using a five‐point confidence rating scale. The data were analyzed using receiver operating characteristic (ROC) curve analysis. Results: Significant differences based on imaging modalities were found (p < 0.0015) in the area under the curves (Az): panoramic radiograph, 0.8762; mandibular series, 0.7521; panoramic plus anteroposterior radiographs combination, 0.8886; and digitized mandibular series, 0.7723. No observer‐based differences were noted. Condylar and coronoid fractures were difficult to detect than those in other areas of the mandible (p < 0.033). Intra‐ and inter‐observer agreements were high (κw= 0.81 and 0.76, respectively). Conclusions: Panoramic radiographs are adequate for detection of mandibular fractures. Addition of an anteroposterior view augments diagnostic accuracy.
Combination of Goldman Risk and Initial Cardiac Troponin I for Emergency Department Chest Pain Patient Risk Stratification
Authors: Limkakeng Alex , Gibler W. Brian , Pollack Charles , Hoekstra James W. , Sites Frank , Shofer Frances S. , Tiffany Brian , Wilke Eric , Hollander Judd E.
Published: January 2008

Background: Accurate identification of low‐risk emergency department (ED) chest pain patients who may be safe for discharge has not been well defined. Goldman criteria have reliably risk‐stratified patients but have not identified any subset safe for ED release. Cardiac troponin I (cTnI) values have also been shown to risk‐stratify patients but have not identified a subset safe for ED release. Objective: To test the hypothesis that ED chest pain patients with a Goldman risk of ≤4% and a single negative cTnI (≤0.3 ng/mL) at the time of ED presentation would be safe for discharge [<1% risk for death, acute myocardial infarction (AMI), revascularization]. Methods: A prospective cohort study was performed in which consecutive ED chest pain patients were enrolled from July 1999 to November 2000. Data collected included patient demographics, medical and cardiac history, electrocardiogram, and creatine kinase—MB and cTnI. Goldman risk stratification score was calculated while patients were still in the ED. Hospital course was followed daily. Telephone follow‐up occurred at 30 days. The main outcome was death, AMI, or revascularization (percutaneous transluminal coronary angioplasty/stents/coronary artery bypass grafting) within 30 days. Results: Of 2,322 patients evaluated, 998 had both a Goldman risk ≤4% and a cTnI ≤0.3 ng/mL. During the initial hospitalization, 37 patients met the composite endpoint (3.7%): 6 deaths (0.7%), 17 AMIs (1.7%), 18 revascularizations (1.8%). Between the time of hospital discharge and 30‐day follow‐up, 15 patients met the composite endpoint: 4 deaths (0.4%), 6 AMIs (0.6%), and 5 revascularizations (0.5%). Overall, 49 patients met the composite endpoint (4.9%; 95% CI = 3.6% to 6.2%): 10 deaths (1.0%; 95% CI = 0.4% to 1.6%); 23 AMIs (2.3%; 95% CI = 1.4% to 3.2%), and 23 revascularizations (2.3%; 95% CI = 1.4% to 3.2%) within 30 days of presentation. Conclusions: The combination of two risk stratification modalities for ED chest pain patients (Goldman risk ≤4% and cTnI ≤0.3 ng/mL) did not identify a subgroup of chest pain patients at <1% risk for death, AMI, or revascularization within 30 days.
Characteristics and Outcomes of Young Adults Who Present to the Emergency Department with Chest Pain
Authors: Walker Nicole J. , Sites Frank D. , Shofer Frances S. , Hollander Judd E.
Published: January 2008

Background: Most studies of emergency department (ED) chest pain patients exclude patients <30‐40 years old. As a result, the clinical course of these patients is poorly described. Objective: To study the clinical characteristics, hospital course, and 30‐day outcomes of ED chest pain patients <40 years old. The hypothesis was that patients <40 years old without a cardiac history and with normal electro‐cardiograms (ECGs) or no cardiac risk factors would be at a <1% risk for acute coronary syndromes (ACSs) and 30‐day adverse cardiovascular (CV) events. Methods: This was a prospective cohort study of non‐cocaine‐using ED patients, 24‐39 years old, who received an ECG for chest pain between July 9, 1999, and October 23, 2000. Structured data collection at presentation included demographics, chest pain description, history, laboratory, and ECG data. Hospital course was followed daily. Thirty‐day follow‐up was performed by telephone. The main outcomes were discharge diagnosis and 30‐day adverse CV events [acute myocardial infarction (AMI), death, percutaneous intervention (PCI), or coronary artery bypass grafting (CABG)]. Results: A total of 487 patients presented 527 times and comprised the study group. Patients were most often 30‐39 years old (71%), female (60%), and African‐American (73%). Thirty‐two percent were admitted. Five hundred seven of 527 patient visits (96%) had 30‐day follow‐up. Patients had the following cardiac risk factors: tobacco, 37%; hypertension, 22%; family history, 19%; diabetes mellitus, 6%; cholesterol, 6%; prior angina, 3%; known coronary artery disease, 3%; and prior AMI, 2%. Patients usually had unremarkable ECGs (61% normal, 98% nonischemic). Overall, 11 of 527 patients had adverse CV events (2.1%; 95% CI = 0.9% to 3.3%): 8 AMIs (1.5%), 4 deaths (0.8%), 5 PCIs (0.9%), and no CABG. Twenty‐five patients had a final diagnosis of ACS (4.7%; 95% CI = 2.9% to 6.5%). The incidence of ACS in the 210 patients without a cardiac history and without cardiac risk factors was 0.5% (95% CI = 0% to 1.4%). At 30 days, none of these 210 patients had AMI, PCI, CABG, or death (0%, 95% CI = 0% to 1.4%). The incidence of ACS in the 312 patients with normal ECGs and a negative cardiac history was 0.3% (95% CI = 0% to 0.9%). At 30 days, there was no AMI, PCI, or CABG in these 312 patients, and one patient with metastatic cancer died (adverse CV event 0.3%, 95% CI = 0% to 0.9%). Conclusions: Although young patients, as a whole, have a 4.7% risk of ACSs and a 2.1% risk of adverse CV events at 30 days, those without known cardiac disease or any cardiac risk factors had a <1% risk of ACSs and were free from adverse CV events over 30 days. Likewise, young patients without a cardiac history and with a normal ECG had a <1% risk of ACSs and adverse CV events at 30 days. It may be reasonable to expedite outpatient management and limit unnecessary admissions in these cohorts.
Risk Factors for Infection in Patients with Traumatic Lacerations
Authors: Hollander Judd E. , Singer Adam J. , Valentine Sharon M. , Shofer Frances S.
Published: January 2008

Background: Most of our knowledge of laceration management comes from studies in animal models or patients with closure of sterile postoperative surgical incisions. Traumatic laceration management has not been well studied. Objective: To determine which characteristics of traumatic lacerations were associated with the development of wound infection. Methods: A cross‐sectional study of consecutive patients with traumatic lacerations repaired over a four‐year period was conducted. Structured closed‐question data sheets were prospectively completed at the time of laceration repair and suture removal. Infection was determined at the time of suture removal. Multivariate modeling was used to determine the adjusted odds ratio (OR) of infection. Results: Five thousand five hundred twenty‐one patients were enrolled; 195 patients developed an infection (3.5%). An increased likelihood of wound infection was associated with age (adjusted OR per year, 1.01; 95% CI = 1.0 to 1.02); history of diabetes mellitus (adjusted OR 6.7; 95% CI = 1.7 to 26.4); laceration width (adjusted OR 1.05 per mm; 95% CI = 1.02 to 1.08); and presence of foreign body (adjusted OR 2.6; 95% CI = 1.3 to 5.2). Laceration location on the head/neck was associated with a decreased risk of infection (adjusted OR 0.28; 95% CI = 0.18 to 0.45). Conclusions: Both patient and wound characteristics of traumatic lacerations have an influence on the likelihood of infection. This knowledge may be valuable for determining whether various methods of wound cleansing, debridement, and repair can improve the outcome of patients with traumatic lacerations.