bluuebunny/crossref_metadata_2025 huggingface dataset:
Do Admitted Patients Held in the Emergency Department Impact the Throughput of Treat‐and‐release Patients?
Authors: Bazarian Jeffrey J. , Schneider Sandra M. , Newman Valerie J. , Chodosh Joshua
Published: September 2008

Objective: To examine the impact of reducing ED “boarders” (through the use of a short‐stay inpatient medicine unit) on the amount of time that treat‐and‐release patients spend in the ED.

Methods: A retrospective analysis of hours spent in the ED was made at a university hospital teaching ED for treat‐and‐release patients in 4 clinical categories: chest pain, asthma exacerbation, sickle‐cell crisis, and seizure. The average hours per patient spent in the ED during the 4‐month intervals before (August‐November 1993) and after (August‐November 1994) the establishment of the short‐stay medicine unit were compared. Data were analyzed using the 2‐tailed, unpaired t‐test.

Results: This short‐stay inpatient medicine unit received on average 135 patients per month from the ED, with an average length of stay of 2.4 days. The mean (±SD) number of admitted patients per day waiting in the ED >8 hours for an inpatient bed dropped from 9.6 ± 4.2, before the institution of this unit, to 2.3 ± 2.6. There was a significant reduction in the average number of hours spent in the ED by treat‐and‐release patients with chest pain (from 7.3 ± 6.0 to 5.5 ± 4.8 hr/patient, p c 0.001) and asthma exacerbation (from 5.0 ± 3.6 to 4.2 ± 2.9 hdpatient, p < 0.05), but not with sickle‐cell crisis or seizure, after the implementation of the short‐stay unit.

Conclusion: Reducing the number of admitted patients waiting in the ED for inpatient beds, in this case by establishment of a short‐stay medicine unit, is associated with a decrease in the interval that treat‐and‐release patients spend in the ED.
Reliability of Performance‐based Clinical Skill Assessment of Emergency Medicine Residents
Authors: Burdick William P. , Ben‐David Miriam Friedman , Swishel Loice , Bechel John , Magee Douglas , McNamara Robert , Zwanger Mark
Published: September 2008

Objective: To test the overall reliability of a performance‐based clinical skill assessment for entering emergency medicine (EM) residents. Also, to investigate the reliability of separate reporting of diagnostic and management scores for a standardized patient case, subjective scoring of patient notes, and interstation exercise scores.

Methods: Thirty‐four first‐year EM residents were tested using a 10‐station standardized patient (SP) examination. Following each 10‐minute encounter, the residents completed a patient note that included differential diagnosis and management. The residents also were asked to read an ECG or chest x‐ray (CXR) associated with each case. History, physical examination, and interpersonal skills were scored by the SPs. The patient note, CXR, and ECG readings were scored by faculty emergency physicians. Intercase reliability was determined for the residents.

Results: Global score reliability, Cronbach's α = 0.85. Reliabilities for the other components were: history, 0.77; physical examination, 0.83; and interpersonal skills, 0.80. Differential diagnosis and management reliabilities were 0.61 and 0.66, respectively. Subjective scoring of the patient note resulted in acceptable reliability for legibility (0.80), history completeness (0.80), and history organization (0.81). Physical examination completeness and organization reliabilities were 0.74 and 0.73. For ECG and CXR readings, α = 0.74 and 0.34, respectively.

Conclusions: SPs can be used to reliably assess bedside clinical skills of EM residents. While component reliability levels are slightly lower than the global clinical skill reliability coefficient, they are still high enough to use for identification of individual strengths and weaknesses.
The Psychological Effects of a Four‐week Emergency Medicine Rotation on Residents in Training
Authors: Alagappan Kumar , Steinberg Maurice , Mancherje Noel , Pollack Simcha , Carpentel Kenneth
Published: September 2008

Objective: To prospectively evaluate psychological stress reactions among residents in an emergency medicine (EM) rotation during a 4‐week period.

Methods: Pre‐ and postrotation psychological distress levels were assessed over a 4‐week EM rotation. Subjects were evaluated by several psychometric measures. These included the assessment of anxiety, depressive, and other psychological symptoms by the Brief Symptom Inventory (BSI), and the occurrence of traumatic anxiety via the Dissociative Experience Scale (DES). Also assessed were the Impact of Events Scale and the Holmes Social Readjustment Ratings Scale (Holmes), a baseline life‐change measure. Demographic data were obtained. The study occurred in a university‐affiliated teaching hospital ED. The 45 EM residents and 27 non‐EM residents were analyzed as a group, followed by subgroup analysis comparing EM vs non‐EM residents.

Results: An increase in psychological distress over the 4‐week rotation was found in the non‐EM group, but not in the EM group. For the non‐EM residents, all 10 BSI scales worsened and 3 of 4 DES scales worsened (p = 0.002), indicative of increased psychological distress. In contrast, analysis of the 45 EM residents showed improvement in 8 of 10 BSI scales and 3 of 4 DES scales (p = 0.057).

Conclusion: A significant increase in psychologic distress was found among the non‐EM residents during an EM rotation. The EM residents showed a trend for a decrease in psychological distress over the same 4‐week period.
Spontaneous Rupture of a Vesicourachal Diverticulum Manifesting as Acute Abdominal Pain
Authors: Lewis Jack B. , Morse Jeffrey W. , Eyolfson Michael F. , Schwartz Stephen L.
Published: September 2008

Urachal abnormalities are rare clinical entities. This article reports a case of a spontaneously ruptured vesicourachal diverticulum manifesting as acute abdominal pain in a healthy 38‐year‐old man. The embryology, clinical diagnosis, and management of urachal abnormalities are discussed. Emergency physicians should include this clinical entity in their differential diagnoses of patients who develop acute abdominal pain in the absence of trauma, especially when the pain immediately follows a maneuver that increases intra‐abdominal pressure.
Alcohol Use and Medical Care Utilization among Health Maintenance Organization Patients in the Emergency Department
Authors: Cherpitel Cheryl J. , Hurley Leo B. , Fireman Bruce H. , Soghikian Krikor
Published: September 2008

Objective: To determine the association of an alcohol–related ED visit with medical care utilization during a two–year period surrounding the ED visit in an HMO.

Methods: A probability sample of ED patients were interviewed and underwent breath analysis in a large HMO in a Northern California county. Based on recent alcohol intake or documentation of an alcohol–related ED visit, the patients were assigned to an alcohol group (n = 91) or a non–alcohol group (n = 897). A 10% random sample of the health plan membership of the same county (n = 19, 968) served as a comparison group. Utilization data were obtained from computerized files. Multiple linear regression was used to determine differences in subsequent outpatient visit rates between the alcohol and the non–alcohol groups. Logistic regression was used to compare the risks of hospitalization in the two groups.

Results: Annual outpatient visit rates were 7. 8 in the alcohol group and 8. 3 in the non–alcohol group (p = 0. 65), controlling for gender, age, and injury status, and were significantly different from the visit rate of 5. 5 for the random health plan sample (p = 0. 0001). No difference was found between the alcohol and the non–alcohol groups for risk of hospitalization; however, those in the health plan sample were less than half as likely to be hospitalized as were those in the non–alcohol group (odds ratio 0. 44, p = 0. 002).

Conclusions: No difference was found in utilization of medical services between the alcohol and the nonalcohol groups in this predominantly white, well–educated HMO ED population. However, both groups used significantly more inpatient and outpatient services than did the general HMO membership.
Serum Neuron–specific Enolase as a Prognostic Marker for Irreversible Brain Damage in Comatose Cardiac Arrest Survivors
Authors: Martens Patrick
Published: September 2008

Objective: To assess the use of serum neuron–specific enolase (S–NSE) level as a noninvasive predictor of CNS injury irreversibility in comatose cardiac arrest survivors.

Methods: An observational, prospective clinical study was performed in a community hospital ED and intensive care unit. All cardiac arrest survivors (n = 52) with impaired neurologic status admitted between February 1994 and May 1995 were followed until return of consciousness (1) or death due to CNS failure (0). Serum samples for S–NSE determination (ng/mL) using the radioimmunoassay technique were obtained 24 hours after cardiac arrest. Data were analyzed using stepwise logistic regression with dichotomized predictors to validate the correlation between S–NSE (X) and outcome (Y), where X = 0 if < median and 1 if > median S–NSE level. Adjustment was made for the following variables: glucose level on admission, total epinephrine dose used before return of spontaneous circulation, and best Glasgow Coma Scale score on admission. These data were all available in 34 cases. In 16 cases, CSF enzymes at 48 hours postarrest were obtained and compared with S–NSE.

Results: The logistic equation determining the influence of S–NSE (X) on outcome (Y) was: Y = 0. 606–1. 785X (odds ratio = 6; p = 0. 020). There was no confounding effect of the other variables related to survival. The mean S–NSE value for all the patients was 34 (7. 9–188). All the patients recovering consciousness (n = 15) had an S–NSE mean ± SEM value of 17. 5 ± 2. 4, with a maximum of 47.

Conclusion: These data support the conclusion that measurement of S–NSE at 24 hours post–cardiac arrest may supplement clinical assessment of hypoxic–ischemic encephalopathy after cardiac arrest.
The Effects of Endothelin–1 on Coronary Perfusion Pressure during Cardiopulmonary Resuscitation in a Canine Model
Authors: DeBehnke Daniel J. , Spreng David , Wickman Laurie L. , Crowe Dennis T.
Published: September 2008

Objective: To study the hemodynamic effects of exogenously administered endothelin–1 (ET–1), a peptide produced by endothelial cells with potent non–adrenergically mediated vasoconstrictor properties.

Methods: A prospective drug intervention study was carried out in a resuscitation research laboratory.

Fifteen mixed–breed dogs were anesthetized and instrumented for hemodynamic monitoring. Asphyxia arrest was produced by clamping the endotracheal tube. Hemodynamic data were collected continuously.

Following loss of aortic fluctuations monitored by thoracic aortic catheter, the animals remained in pulseless electrical activity (PEA) for 10 minutes. After 10 minutes of no–flow PEA, closed–chest CPR was begun and the animals were randomized to one of three treatment groups (epi, 0. 02 mg/kg epinephrine IV every 3 minutes; endo, 100 μg ET–1 IV at 0 minutes; and epi/endo, a combination of the epi and endo treatments).

Results: endo and epi alone produced similar coronary perfusion pressures (CPPs). The epi/endo combination produced significantly improved CPP compared with that of either epi or endo alone. In the epi group, the best mean CPP was 16 ± 14 mm Hg and occurred 7 minutes after drug administration. In the endo group, the best mean CPP was 28 ± 7 mm Hg and occurred 13 minutes after drug administration. In the epi/endo combination group, the best mean CPP was 61 ± 37 mm Hg and occurred 7 minutes after drug administration (p < 0. 05 compared with the epi and endo groups alone).

Conclusion: ET–1 is a potent vasoconstrictor. The combination of epi and endo significantly improved CPP compared with that for either agent alone. ET–1 should be investigated further as a vasoconstrictor in cardiac arrest.
Identification of Hazardous/Harmful Drinking among Subcritically Injured Patients
Authors: Clifford Patrick R. , Sparadeo Frank , Minugh P. Allison , Nirenberg Ted D , Woolard Robert , Longabaugh Richard , Becker Bruce
Published: September 2008

Objectives: To examine the relationship between a saliva alcohol test (SAT) and hazardous/harmful drinking, as measured by the Alcohol Use Disorders Identification Test (AUDIT), among a sample of subcritically injured patients.

Methods: Patients (n = 78) seeking treatment for a subcritical injury were saliva‐tested for alcohol and interviewed regarding their drinking behaviors and related difficulties. Associations of SAT values with AUDIT results were determined.

Results: SAT results and hazardous/harmful drinking were not independent events (p < 0. 001). Estimates of sensitivity and specificity (using a dichotomous SAT result [≥ 4 mmol/L] to identify positive AUDIT patients) were 65. 2% and 83. 6%, respectively. SAT‐positive people had significantly higher AUDIT scores than did SAT‐negative individuals (p < 0. 0001). Patients experiencing assault‐type injuries were much more likely to be SAT‐positive than were patients incurring other types of injury. Discriminant function analysis suggests that AUDIT scores can successfully identify SAT‐positive and SAT‐negative patients; the analysis accounted for 42. 5% of the variance and correctly classified 84. 6% of the sample.

Conclusions: The use of an easy‐to‐administer, noninvasive, routine SAT, among patients presenting for a subcritical injury in a hospital ED, provides a mechanism for the identification of individuals with a history of hazardous/harmful drinking. However, since discrimination of hazardous/harmful drinking is imperfect, some caution is warranted when conducting such screening activities.
“Inappropriate” Emergency Department Use: A Comparison of Three Methodologies for Identification
Authors: O'Brien Gail M. , Shapiro Marc J. , Woolard Robert W. , O'Sullivan Patricia S. , Stein Michael D.
Published: September 2008

Objective: To determine the level of agreement between the rates of “inappropriate” ED visits assigned to a cohort of ambulatory patients based on three methods of defining ED use appropriateness.

Methods: Ambulatory adult patients seen at one urban, university‐based teaching hospital ED between 8 am and midnight during select days from April to June 1994 were assessed regarding‐the appropriateness of their ED visits. Patients triaged to acute resuscitation rooms in the ED were excluded. Eligible patients were asked to complete a 90–question survey including demographics and health service use (response rate 81%). The appropriateness of ED use was assessed for consenting respondents by 1) application of a list of 51 nonemergent complaints that have been used by managed care providers and previously published (triage), 2) use of ten explicit criteria (e. g., need for parenteral medication) from prior publications (explicit), and 3) the consensus of two emergency physicians (EPs) reviewing the records of ED patients (phys). All three methods were applied at the time of retrospective chart review. The agreement between methods was evaluated using kappa scores.

Results: Of the 892 eligible respondents, 64% were white, 54% were employed, 50% were female, and 29% were uninsured. Of the respondents, 26% had no regular source of ambulatory care and 25% considered the ED their regular source of care. The assigned rates of “inappropriate” visits using the three definitions were triage, 58%; phys, 47%; and explicit, 42%. Of those deemed “inappropriate” by the explicit criteria, 81% also were judged as “inappropriate” by the triage criteria, and 72%, by the phys criteria. Of those patients deemed “inappropriate” by the triage criteria, 59% also were judged as “inappropriate” by the explicit criteria, and 66%, by the phys criteria. Levels of agreement (kappas) were triage/explicit, 0.39; triage/phys, 0.42; and explicit/phys, 0.42.

Conclusion: There is only moderate agreement between different methods of determining appropriateness of ED use. Until further refinement is made in triage assessment, managed care organizations and EPs should remain cautious when implementing a protocol that defines and restricts “inappropriate” ED visits.
Drive–by Shootings by Violent Street Gangs in Los Angeles: A Five–year Review from 1989 to 1993
Authors: Hutson H. Range , Anglin Deirdre , Eckstein Marc
Published: September 2008

Objective: To determine trends in the numbers of drive–by shootings, individuals shot at, innocent bystanders shot at, and homicides by drive–by shootings in the city of Los Angeles from 1989 to 1993.

Methods: A retrospective analysis of police records was performed for all gang–related drive–by shootings that occurred in the city of Los Angeles between 1989 and 1993.

Results: From 1989 to 1993, there were 6,327 drive–by shootings, 9,053 people shot at, and 590 homicides. There was an increase in drive–by shootings, people shot at, and homicides between 1989 and 1991, followed by a decrease between 1991 and 1993. The case fatality ratio of individuals killed to individuals shot at increased from 1989 to 1993 (p = 0.0011). Forty–seven percent of the people shot at, and 23% of the homicide victims, were innocent bystanders.

Conclusion: Drive–by shootings are a major public health problem in Los Angeles. While the rate of drive–by shootings decreased in 1992 and 1993, the proportion of fatal cases increased. To prevent drive–by shootings, the root causes of violent street gang formation must be addressed.
Sodium Polystyrene Sulfonate Treatment for Lithium Toxicity: Effects on Serum Potassium Concentrations
Authors: Linakis James G. , Hull Keith M. , Lacouture Peter G. , Lockhart Gregory R. , Lewander William J. , Maher Timothy J.
Published: September 2008

Objective: To examine the effects of sodium polystyrene sulfonate (SPS) on serum potassium (K) concentrations in mice pretreated with parenteral lithium (Li).

Methods: A placebo–controlled murine model trial of SPS therapy following IV Li was performed. Sixty male CD–I mice weighing 18–22 g were administered either IV LiCl (125 mg/kg) or a control solution (normal saline). Half of the mice in each of these groups were then given orogastric water 20, 40, 90, 150, and 210 minutes after LiCl or normal saline; the other half received SPS (5 g/kg/dose) at equivalent times. Subgroups of each of these four groups were sacrificed at one, two, and six hours after pretreatment and the serum was analyzed for K concentration. Serum K concentrations for the various groups were compared with analysis of variance and Newman–Keuls tests for the comparison of multiple means.

Results: A statistically significant reduction of serum K concentrations occurred in the animals that received SPS treatment following either IV saline or LiCl solutions. The degree of K reduction that resulted from the combination of LiCl and SPS treatment (35% reduction at six hours, compared with the placebo–treated controls) was larger than that which resulted from eimer IV Li with oral water (15% reduction) or IV saline with oral SPS (20% reduction).

Conclusions: These findings suggest that development of hypokalemia may represent a potential limitation in the use of SPS in the treatment for Li toxicity.
Managing Law Enforcement (K–9) Dog Bites in the Emergency Department
Authors: Pineda Gilbert V. , Hutson H. Range , Anglin Deirdre , Flynn Christopher J. , Russell Marie A.
Published: September 2008

Objective: To review the types of injuries due to law enforcement (K–9) dog bites and address related management issues.

Methods: A case series of law enforcement dog bite victims is reported and related literature reviewed.

Results: Law enforcement dogs are taught a bite–and–hold technique for subduing individuals suspected of felony crimes. This bite–and–hold technique's greater applied force results in a unique spectrum of injuries, including deep puncture wounds, severe crush injuries, large tissue avulsions and lacerations, wounds necessitating surgical debridement, bony injuries ranging from cortical violations to displaced fractures, neurovascular damage, and other wounds at high risk for infection. The four reported cases highlight the types of injuries and complications associated with law enforcement dog bites.

Conclusion: Attention to potential deep injuries of nerves, vessels, and the musculoskeletal system is essential with law enforcement dog bites. Injuries associated both with pursuit and arrest and with the bites themselves must be identified and assessed. Guidelines for the ED treatment of patients with law enforcement dog bite injuries are proposed.
The Efficacy of a Standard Training Program for Transillumination–guided Endotracheal Intubation
Authors: Margolis Gregg S. , Menegazzi James , Abdlelhak Mervat , Delbridge Theodore R.
Published: September 2008

Objective: To evaluate the success rate, intubation time, and complication rate of transillumination–guided intubation following two hours of instruction in the use of the Trachlight (TL) device.

Methods: A prospective, randomized crossover laboratory trial was conducted at an emergency medical service training site with 30 nonpaid volunteer paramedic students, one month prior to their graduation. The students were instructed in the use of the TL in a standardized curriculum consisting of didactic, video, and demonstration sessions. Each student was required to successfully intubate a training manikin with the TL five times. Approximately three weeks later, the students were asked to intubate the manikin 20 times, alternating between direct laryngoscopy (DL) and TL.

Results: The success rates were 94% for DL and 63% for TL (p < 0.0001). The mean intubation times were 14.6 seconds for DL and 16.8 seconds for TL (p < 0.001). The incidences of trauma were 7.3% for DL and 1.4% for TL (p < 0.001).

Conclusion: A two–hour training session, including five successful light–guided intubations using the TL, was inadequate for producing acceptable success rates during manikin intubations by paramedic students. While TL intubation intervals were shorter when successful, the 2.2–second difference was not clinically meaningful. The incidence of trauma in our manikin model during TL intubations was significantly lower than that with DL.
Effect of Time of Day and Duration into Shift on Hazardous Exposures to Biological Fluids
Authors: Marias Darryl J. , II John Hafner , Brillman Judith C. , Tandberg Dan
Published: September 2008

Objective: To determine whether hospital employee biological hazardous exposure rates varied with time of day or increased with time interval'into shift.

Methods: This was a retrospective occurrence report review conducted at a university hospital with an emergency medicine residency program. Health care worker biological hazardous exposure data over a 30–month period were reviewed. Professional status, date, time, and type of exposure (needlestick, laceration, splash), time interval into shift of exposure, and hospital location of exposure were recorded. Hourly employee counts and risky procedure counts were matched by location with each reported exposure, to determine hourly rates of biological hazardous exposures.

Results: Analysis of 411 recorded exposures demonstrated that more people were exposed between 9:00 am and 1:00 am (p < 0.05), yet the exposure risk did not vary significantly when expressed as the number of exposures per worker or per procedure. Of the 393 exposures with data describing time interval into shift when the exposure occurred, significant numbers of exposures occurred during the first hour and at shift's end [when corrected for exposures per worker (p < 0.05) or exposures per procedure (p < 0.05)].

Conclusion: While the number of exposures are increased in the am hours, the exposure rate (as a function of workers or procedures) does not vary with time of the day. However, the exposure rate is increased during the first hour and last 2 hours of a shift. Efforts to increase worker precautions at the beginning and end of shifts are warranted.
Reducing the Rate of Paramedic Needlesticks in Emergency Medical Services: The Role of Self‐capping Intravenous Catheters
Authors: O'Connor Robert E. , Krall Scott P , Megargel Ross E. , Tan Lawrence E. , Bouzoukis James K.
Published: September 2008

Objective: To determine whether the frequency of unintentional needlesticks can be reduced by replacing conventional IV catheters with self‐capping ones.

Methods: Retrospective cohort, historically controlled study, conducted in an emergency medical services advanced life support (ALS) service. The ALS service annually transports 12,000 patients, for whom IV therapy is attempted in about 65% of cases. The needlestick rate per 1,000 patients receiving attempts at IV access was examined during the 2 10‐month periods, before and after introduction of a self‐capping IV catheter.

Results: For the 2 periods, the percentage of patients for whom IV access was attempted remained constant at 65%. The success rate for IV access was statistically unchanged from 88% to 90% (p > 0.5, power = 0.995). During the period prior to use of the new datheter, 44 injuries were reported overall. Of these, 15 were due to unintentional needlesticks, 11 associated with contaminated needles. Following the system‐wide introduction of the new catheter, only 1 of 31 reported injuries was due to needlestick (uncontaminated). The extrapolated annual incidence of contaminated needlesticks decreased from 169 (95% CI; 85, 253) to 0 (95% CI; 0, 46) per 100,000 IV attempts. The extrapolated incidence for all needlesticks decreased from 231 (95% CI; 132, 330) to 15 (95% CI; 0, 40) per 100,000 IV attempts. The absolute number of needlesticks and the proportion of injuries due to needlesticks decreased significantly (p < 0.005).

Conclusion: The use of IV catheters with self‐capping needles was associated with a significant reduction in the absolute number of inadvertent needlesticks as well as the proportion of injuries due to needlesticks among ALS providers. The use of self‐capping IV catheters was feasible and did not appear to be a deterrent to initiating IV therapy in the out‐of‐hospital environment.
Noninvasive Hemodynamic Monitoring of Critical Patients in the Emergency Department
Authors: Shoemaker William C. , Wo Charles C. J. , Bishop Michael H. , Thangathurai D. , Patil Ramish S.
Published: September 2008

Objective: To evaluate the feasibility of multicomponent noninvasive hemodynamic monitoring in critical emergency patients and to compare this technique with simultaneous invasive monitoring by the pulmonary artery thermodilution catheter.

Methods: A prospective observational study was done comparing invasive monitoring and noninvasive monitoring in 60 critically ill or injured patients who required hemodynamic monitoring shortly after entering the ED of a university‐affiliated county hospital. Cardiac output (CO) values measured by the standard thennodilution pulmonary artery catheter technique were compared with simultaneously obtained measurements using a noninvasive bioimpedance method. Concurrent measurements were made of pulse oximetry to screen pulmonary function and transcutaneous oximetry to assess tissue perfusion.

Results: The impedance CO values closely approximated those for the thermodilution method; r 0.81, p < 0.001. Significant circulatory abnormalities, including hypotension, reduced cardiac index, arterial hemoglobin desaturation, tissue hypoxia, reduced O2 delivery, and consumption, were found in 54 of the 60 (90%) patients. The cardiac index decreased in 44% of the patients, the transcutaneous O2 decreased in 39%. and the O2 saturation by pulse oximetry fell in 22% during the observation period in the ED (commonly lasting 2–8 hours).

Conclusions: Noninvasive monitoring can provide hemodynamic and perfusion information previously available only by invasive thermodilution catheters. Such noninvasive monitoring can display continuous on‐line real‐time data, allowing immediate recognition of circulatory abnormalities and providing a means to titrate therapy to appropriate therapeutic goals.
Noninvasive Cardiac Index Monitoring in Gunshot Wound Victims
Authors: Bishop Michael H. , Shoemaker William C. , Shuleshko Julia , Wo Charles C. J.
Published: September 2008

Objective: To evaluate a bioimpedance device for the noninvasive measurement of cardiac index (CI) against standard thermodilution measurements in patients with gunshot wounds.

Methods: A prospective open‐label performance evaluation was done using a convenience sample of gunshot wound victims initially treated in the resuscitation area of a high‐volume, urban ED. After initial resuscitation, patients had a flow‐directed pulmonary artery catheter placed for thermodilution cardiac output (CO) measurements. The CO measurements were made in triplicate and averaged. Estimates of body surface area were used to convert these measurements to CI estimates. Electrodes for bioimpedance measurements were placed as soon as practical after ED arrival. Simultaneous measurements of CI using the bioimpedance device were made as clinically indicated during each patient's hospital course.

Results: There were 54 patients studied, with an overall mean (± SEM) age of 32 ± 3 years, Revised Trauma Score of 6.7 ± 0.4, and Injury Severity Scale score of 22 ± 3. There were 42 survivors and 12 nonsurvivors. The CI as estimated by bioimpedance correlated well with that measured by thermodilution (r = 0.79, ± 0.02). The precision of the invasive and noninvasive measurements was 1.1 L/min/m2; the bias was ‐0.011 L/min/m2. In 24 patients with thoracic injuries requiring tube thoracostomy or thoracic surgery, the correlation of the 2 devices was r = 0.71 with precision and bias of 1.4 L/min/m2 and ‐0.018 L/min/m2, respectively.

Conclusions: Cardiac index can be noninvasively estimated in acutely injured patients with gunshot wounds using a bioimpedance device. Further study of bioimpedance measurements as a guide to volume therapy is warranted.
Emergency Department Utilization by the Elderly: Analysis of the National Hospital Ambulatory Medical Care Survey
Authors: Woford James L. , Schwartz Earl , Timerding Beverly L. , Folmar Steven , Ellis Shellie D. , Messick Catherine H.
Published: September 2008

Objective: To characterize the ED utilization patterns of the elderly population using nationally representative data.

Methods: A secondary analysis was performed using the National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationwide, stratified probability sample of ED encounters. Using these physician‐reported data, the demographics, patient complaints, physician diagnoses, and dispositions were compared by age group, i.e., young‐old (age 65–84 years) vs old‐old (age ±85 years).

Results: The elderly (age ±65 years) represented 5,038 (19.6%) of 25,646 ED encounters for all adults (age ±18 years). The geriatric age groups (ages 65–74, 75–84, and ±85 years) accounted for 45.3%, 37.4%, and 17.2% of all the encounters by the elderly. The proportions of female patients and white patients were higher with increasing age. The proportion of elderly patients hospitalized was 4 times that of younger adults and reflected monotonic increase with increasing age among elders. Patient complaints and physician diagnoses were generally similar for the young‐old (65–84 years) and the old‐old (±85 years).

Conclusions: These findings are consistent with previous single‐center studies of geriatric ED patients. This data source may be useful for investigation of clinical issues related to the care of elderly ED patients.
Model Curriculum in Emergency Medical Services for Emergency Medicine Residency Programs
Authors: Verdile Vincent P , Krohmer Jon R. , Swor Robert A. , Spaite Daniel W ,   for the SAEM Emergency Medical Services Committee
Published: September 2008

An emergency medical services (EMS) curriculum, as developed by the SAEM Emergency Medical Services Committee, is provided for the training of emergency medicine residents in EMS.
Disaster Nomenclature–A Functional Impact Approach: The PICE System
Authors: Koenig Kristi L. , Dinerman Norm , Kuehl Alexander E.
Published: September 2008

A standard nomenclature that concisely describes any disaster is currently lacking. This article describes a model taxonomy system. Instead of the term “disaster,” a root word “PICE,”“potential injury‐creating event,” is used. Descriptive modifiers to account for all possible scenarios surround this root word, as illustrated.

A modifier is chosen from each column and a stage is assigned to each PICE. Column A describes the potential for additional casualties. Column B describes whether resources are overwhelmed and, if so, whether they must simply be augmented (disruptive) or they must first be reconstituted (paralytic). Column C describes the extent of geographic involvement. “Stage” refers strictly to the likelihood that outside medical assistance will be needed. Stage 0 means there is little chance, stage I means there is a small chance (place outside help on “alert”), stage II means there is a moderate chance (place on “standby”), and stage III means local medical resources are clearly overwhelmed (immediately dispatch outside resources, commit personnel, prepare remote hospitals). For example, a multiple vehicle crash in a large city would be a ”static, controlled, local PICE, stage 0.” In conclusion, a new nomenclature for describing disasters is reported. A short phrase describes the incident and communicates the need for outside assistance. The model may be useful for disaster planning, management, and research.
A Pharmacokinetic Comparison of Acetaminophen Products (Tylenol Extended Relief vs Regular Tylenol)
Authors: Douglas Daniel R. , Sholal James B. , Smilkstein Martin J.
Published: September 2008

Obiedive:To compare the pharmacokinetics of Tylenol Extended Relief (ER APAP) with those of immediate‐release acetaminophen (IR APAP) at supratherapeutic doses.

Methods:A prospective, double‐blind, randomized, crossover comparison trial involving 14 adult volunteers. Each subject ingested 75 mgkg of either ER APAP or IR APAP and 1 week later received the other APAP preparation. On both occasions plasma APAP concentration ([APAP]) was determined 0.5, 1, 2, 3, 4, 6, 8, 12, and 16 hours after ingestion. The times to maximum [APAP] (Tmax); the maximum [APAP] values (Cmax); the elimination half‐lives 4–16 hours postingestion (t1/2), and the areas under the [APAP] vs time curve (AUC) for ER APAP and IR APAP were compared using the paired t‐test.

Results:All the subjects completed both study phases. The mean APAP dose ingested was 5.6 g (range, 4.2–7.8 g). Both the AUC and the Cmaxwere less after ER APAP than after IR APAP; otherwise, there was no evident difference in any measure. Graphically, ER APAP yielded a flatter, plateau‐shaped curve initially, but after 4 hours the curve was nearly identical to that for IR APAP. Results are summarized in the table:

Conclusion:In this model involving a single supratherapeutic dose, ER APAP evidenced no pharmacokinetic features that would suggest the need for an alternate poisoning screening strategy. When compared with IR APAP, ER APAP had a lower AUC, all peak [APAP] occurred in <4 hours, and terminal eliminations were identical. The data suggest that, in most cases, the diagnostic approach to an overdose of ER APAP need not deviate from that used for an IR APAP overdose.
Direct Detection of Epstein‐Barr Viral Antigen in Nasopharyngeal Swabs from Patients with Infectious Mononucleosis
Authors: Bills Nathan D. , Hinrichs Steven H. , Morse Jeffrey W
Published: September 2008

Objective: To determine whether direct immunologic detection of Epstein‐Barr virus (EBV) early antigen diffuse component (EA‐D) from nasopharyngeal swabs is a feasible approach to the development of a rapid diagnostic test for infectious mononucleosis (IM).

Methods: Nasopharyngeal swabs from 20 patients presenting with a presumptive diagnosis of IM (having the classic triad of symptoms‐acute pharyngitis, fever, and lymphadenopathy) and 5 controls were assayed for EA‐D. EBV serologic testing and a heterophil antibody titer (HAT) test also were performed. EA‐D was assayed by polyacrylamide gel electrophoresis and subsequent transfer to a nylon membrane, followed by immunoblotting with a monoclonal antibody.

Results: EA‐D was detected in 17 of 20 patients (85%) with presumptive diagnoses of IM and in 1 of 5 normal subjects and was highly significant in predicting IM (p < 0.01). There was no significant difference in numbers of positive and negative results using either EA‐D assay or HAT test in patients with IM (p < 0.35). Pharyngeal exudate in the 17 pharyngitis patients with this variable documented was significantly correlated with positive EA‐D (p< 0.01). but not with the HAT test (p < 1.00).

Conclusions: Immunologic detection of EBV‐derived antigens from nasopharyngeal swabs is a potential early diagnostic tool for clinically suspected IM. Sensitivity and specificity in pediatric and adult populations, patients with other viral etiologies, and patients with streptoccocal pharyngitis should be determined in subsequent investigations.
Priapism: Etiology and Management
Authors: Mulhall John P. , Honig Stanton C.
Published: September 2008

Priapism is a urologic emergency. All patients should receive prompt urologic consultation. Management is based on prompt recognition, differentiation between low‐ and high‐flow priapism, reversal of any potential precipitating factors, and the use of corporal aspirationhigation combined with intracavernosal α‐agonist injection therapy. It cannot be overemphasized that severely prolonged erections are associated with the development of irreversible problems with erectile function and, therefore, immediate and aggressive management is mandatory.
Delayed Diagnosis of Thoracolumbar Fractures in Multiple‐trauma Patients
Authors: Anderson Stephen , Biros Michelle H. , Reardon Robert F.
Published: September 2008

Objectives: To determine the frequency of delayed diagnosis of major thoracolumbar vertebral fractures (T‐L Fxs) in ED multiple‐trauma patients, and to determine the differences between cases of delayed and nondelayed diagnoses of T‐L Fx.

Methods: A retrospective chart review was conducted of 181 trauma patients with 310 major T‐L Fxs (compression, burst, or chance Fxs or dislocations). Data collected included the time of the diagnosis of T‐L Fx, the patient's clinical presentation in the ED, the mechanism of injury, and the outcome.

Results: Of the 181 patients with major T‐L Fxs, 138 were diagnosed in the ED (nondelayed group), and 43 were diagnosed after the patient left the ED (delayed group). Of these, 33 cases occurred in unstable patients requiring emergent medical imaging and/or operation, 7 occurred when emergency physicians failed to detect subtle compression Fxs on ED radiographs, and 3 occurred in stable patients who were not radiographed in the ED. The delayed group were more often critical, and hypotensive, and had lower Glasgow Coma Scale (GCS) scores than did the nondelayed group. The delayed group patients also had more cervical spine injuries, multiple noncontiguous spinal Fxs, high‐energy mechanisms of injury, and direct blunt assaults to the back than did the nondelayed group patients. There were 13 patients with T‐L Fxs, GCS scores = 15, and normal back examinations. There were 43 patients who had neurologic deficits associated with their injuries; 11 patients with incomplete cord lesions progressed, including 3 in the delayed group.

Conclusions: A delay in the diagnosis of T‐L Fx in hospitalized trauma patients is frequently associated with an unstable patient condition that necessitates higher‐priority procedures than ED T‐L spine radiographs. Such patients should receive spinal precautions until more complete evaluation can be performed. The decision to selectively radiograph T‐L spines in multiple‐trauma patients should consider the mechanism of injury, the presence of possible confounders to physical examination, and clinical signs and symptoms of back injury.
Out‐of‐hospital Administration of Mannitol to Head‐injured Patients Does Not Change Systolic Blood Pressure
Authors: Sayre Michael R. , Daily Stephen W. , Stern Susan A. , Storer Daniel L. , van Loveren Harry R. , Hurst James M.
Published: September 2008

Objective: To determine the effect of out‐of‐hospital mannitol administration on systolic blood pressure (BP) in the head‐injured multiple‐trauma patient.

Methods: This was a prospective, randomized, double‐blind, placebo‐controlled clinical trial involving a university‐based helicopter air medical service and level‐1 trauma center hospital. Endotracheally intubated head‐trauma victims with Glasgow Coma Scale (GCS) scores < 12 were enrolled from November 22, 1991, to November 20, 1992, if evaluated by the participating aeromedical transport team within 6 hours of injury. Patients were excluded if they were <18 years old, had already received mannitol or another diuretic, were potentially pregnant, or were receiving CPR. All patients were intubated prior to study drug (mannitol [1 g/ kg] or normal saline) use. Pulse and BP were measured every 15 minutes for 2 hours following study drug administration.

Results: A total of 44 patients were enrolled. After exclusion of 3 patients who did not meet all inclusion criteria, there were 20 patients in the mannitol group and 21 patients in the placebo group. The groups were similar at baseline in age, pulse, systolic BP (baseline mannitol: 124 ± 47 mm Hg; placebo: 128 ± 32 mm Hg), GCS score, and Injury Severity Scale score. Systolic BP did not change significantly throughout the observation period in either group. This study had 83% power to detect a mean systolic BP drop to <90 mm Hg.

Conclusion: Out‐of‐hospital administration of mannitol did not significantly change systolic BP in this group of head‐injured multiple‐trauma patients.
Intrasound Vibration Testing in Acute Ankle Injuries
Authors: Plewa Michael C. , Otto Raymond , Verbrugge John , Buderer Nancy M. Fenn , Vaughn Glen , Mattevi Patricia
Published: September 2008

Objectives: To determine the accuracy of intrasound vibration testing (IVT) in comparison with plain radiography in the diagnosis of acute ankle fractures.

Methods: A group‐sequential, nonrandomized, double‐blind, observational study design was used. A convenience sample of patients were studied, aged <10 years, with acute ankle injuries, undergoing ankle radiography, evaluated at a community teaching hospital ED. Excluded were cases involving injuries of <24 hours' duration, inadequate documentation, protocol violation, or positive IVT on the uninjured ankle. IVT was performed with the intrasound apparatus placed on the anterior and posterior aspects of the medial and lateral malleoli of the uninjured and injured ankles; positive IVT was defined as patient withdrawal secondary to pain.

Results: Of 105 patients enrolled, 8 were excluded; 1 for inadequate documentation, 5 for protocol violation, and 2 for positive IVT of the uninjured ankle. Of the 97 patients analyzed, 13 had fractures identified by radiography, including 9 lateral malleolar, 1 medial malleolar, 1 bimalleolar, and 2 talar fractures. Only 5 of the 13 fractures were detected with IVT (sensitivity = 39%; 95% CI: 14–68%). Seventy of 84 nonfractured ankles hadnegative IVT (specificity = 83%; 95% CI: 74–91%). Of the 19 with positive IVT, 5 had fractures (positive predictive value of 26%; 95% CI: 9–51%). Of the 78 with negative IVT, 70 had no fracture (negative predictive value of 90%; 95% CI: 81–96%). Overall, 75 of 97 IVTs were correct (77%), most of which were among patients without fractures.

Conclusion: IVT was not a useful test for predicting fractures in patients with acute ankle injuries.
Management of Nontraumatic Subarachnoid Hemorrhage in a Patient with Sickle‐cell Disease: A Case Report
Authors: Rinnert Stephan , Scalea Thomas , Sinert Richard
Published: September 2008

Subarachnoid hemorrhage (SAH) due to sickle‐cell anemia is rare, but potentially devastating. However, with early recognition of SAH, aggressive support with exchange transfusion, cerebral angiography, and neurosurgical intervention, a positive outcome may be achieved. A case report of SAH managed in this fashion is reported. Based on similar cases in the literature, a suggested treatment protocol is provided for the management of nontraumatic SAH in sickle‐cell patients presenting to the ED.
Raeder's Paratrigeminal Syndrome: A Case Report
Authors: Murnane Matthew , Proano Lawrence
Published: September 2008

Raeder's paratrigeminal syndrome is an uncommon neurologic disorder characterized by oculosympathetic paralysis, including ptosis and miosis. In the ED, this syndrome can be easily confused with Horner's syndrome, although with Raeder's syndrome trigeminal nerve irritation and preservation of facial sweating are noted. This report reviews a case of a 62‐year‐old man who presented to the ED with signs and symptoms consistent with Raeder's syndrome. MRI with angiography revealed a carotid artery dissection, and the patient was admitted and anticoagulated. The syndrome has been associated with head trauma, hypertension, vasculitis, migraine headaches, parasellar mass lesions, and internal carotid artery dissections. Hence, treatment of the patient who has Raeder's syndrome is dependent on the specific underlying lesion.
Statistical Methodology: I. Incorporating the Prevalence of Disease into the Sample Size Calculation for Sensitivity and Specificity
Authors: Buderer Nancy M. Fenn
Published: September 2008

Careful consideration of statistical issues related to the choice of a sample size is critical for achieving meaningful results in research studies designed to evaluate diagnostic tests. When assessing the ability of a diagnostic test to screen for disease, the parameters sensitivity, specificity, and predictive values are of interest. Study sample size requirements can be calculated based on a clinically acceptable degree of precision, the hypothesized values of sensitivity and specificity, and the estimated prevalence of disease in the target population. The simple methods and tables in this paper guide the researcher when deciding how many subjects to sample in a study designed to estimate both the sensitivity and the specificity of a diagnostic test, given a specified precision and estimated disease prevalence.
Alcohol Abuse/Dependence in Motor Vehicle Crash Victims Presenting to the Emergency Department
Authors: Maio Ronald F. , Waller Patricia F. , Blow Frederic C. , Hill Elizabeth M. , Singer Kathleen M.
Published: September 2008

Objective: 1) To determine the prevalence of current alcohol abuse/alcohol dependence (AA/AD) among the full injury range of ED motor vehicle crash (MVC) patients; and 2) compare AA/AD and non‐AA/AD patient characteristics.

Methods: This was a prospective cohort study using a stratified random sample of MVC patients aged ≥18 years presenting to a university hospital and university‐affiliated community hospital ED from May 1, 1992, to August 30, 1994. A diagnosis of current AA/AD was based on the alcohol section of the Diagnostic Interview Survey (DIS). Other measurements included the presence of blood alcohol (BAC +), Injury Severity Score (ISS‐85), occupant status (driver/passenger), age, gender, seat belt use, culpability for crash, and ED disposition (admitted vs released). A weighted prevalence was determined; subgroups were compared using t‐tests, χ2. 2‐factor analysis, and logistic regression modeling; α = 0.05.

Results: 1,161 patients were studied. The weighted prevalence of current AA/AD was 22.5%; 53% of these patients were released from the ED. Almost 45% of the patients with current AA/AD were BAC —. When controlling for BAC and AA/AD, greater injury severity and culpability were associated with a BAC +, but not with current AA/AD.

Conclusion: Almost 23% of ED MVC patients have current AA/AD; BAC testing does not accurately identify these patients. Intervention strategies must be directed to both admitted and released patients.