bluuebunny/crossref_metadata_2025 huggingface dataset:
Suspected Conversion Disorder Foreseeable Risks and Avoidable Errors
Authors: Glick Thomas H. , Workman Tom P. , Gaufberg Slava V.
Published: January 2008

Abstract. The authors reviewed the occurrence in their emergency department of cases of serious neurologic problems initially thought to be conversion disorders or similar psychogenic conditions. Their aim is to indicate the significance of this issue for emergency physicians (EPs) because of its contribution to the incidence of medical errors. Although there are no national statistics, the authors estimate by extrapolation that thousands of such cases probably have occurred and large numbers may still occur each year in the United States, sometimes resulting in patient injury. They have identified ways of anticipating and attempting to prevent such occurrences. Proposed interventions focus on education regarding the difficulty of diagnosis, patient‐based risk factors, and physician‐based attitudes and thought processes. The authors also include suggestions for systemic “safety nets” that will help to ensure quality of care, such as appropriate imaging and consultation. Review of texts and journals readily accessible to EPs revealed little attention to this subject.
Reducing Medication Errors Potential Benefits of Bolus Thrombolytic Agents
Authors: Richards Christopher F. , Cannon Christopher P.
Published: January 2008

Abstract. A recent Institute of Medicine report highlighted the high incidence of medical errors in clinical practice, and the important fact that errors are associated with increased mortality. The administration of thrombolytic therapy for acute myocardial infarction is a particularly high‐risk situation for emergency physicians. The combination of extreme time pressure with a narrow “therapeutic window” increases the potential for adverse outcomes due to dosing errors. Numerous trials have found that the dose of thrombolytic therapy is closely related to outcomes, with too low a dose associated with lower rates of infarct‐related artery patency and higher doses associated with increased bleeding and intracranial hemorrhage. In the GUSTO‐I trial, 13.5% of patients treated with streptokinase and 11.5% of patients treated with tissue plasminogen activator (t‐PA) had a medication error (i.e., incorrect dose or infusion length). Most importantly, 30‐day mortality was significantly higher in patients with medication errors: for t‐PA dosing errors mortality was 7.7% vs 5.5% for patients who received the correct t‐PA dose (p < 0.001), with similar findings for streptokinase. More recent data from the InTIME2 trial and other studies showed that use of a bolus thrombolytic agent reduced the rate of medication errors. Thus, use of the simpler bolus thrombolytic agents may reduce emergency department medication errors, and thus improve overall clinical outcome.
A Comparison of Succinylcholine and Rocuronium for Rapid‐sequence Intubation of Emergency Department Patients
Authors: Laurin Erik G. , Sakles John C. , Panacek Edward A. , Rantapaa Aaron A. , Redd Jason
Published: January 2008

Abstract. Objective: To compare rocuronium and succinylcholine for rapid‐sequence intubation (RSI) in the emergency department (ED). Methods: A one‐year prospective cohort comparison study was performed using a data collection form completed at the time of intubation. Data collected included the reason for the neuromuscular‐blocking agent (NMBA) chosen, the time to onset of paralysis, and any complications encountered. Three ten‐point numerical descriptor scales recorded the degree of body movement, vocal cord movement, and the physician's overall satisfaction with the extent of paralysis. Results: Succinylcholine was used in 382 patients and rocuronium was used in 138 (26% of all RSI) patients. The mean (± SD) times of onset of succinylcholine and rocuronium were 39 ± 13 sec and 44 ± 20 sec, respectively (p = 0.04). No patient desaturated and required assisted ventilations while waiting for paralysis to occur. Types of body movements were similar with the two agents, but less frequent with succinylcholine (median = 10, mean = 9.5 ± 1.1) than rocuronium (median = 10, mean = 9.1 ± 1.5) (p = 0.01). Vocal cord movements were similar for succinylcholine (median = 10, mean = 9.2 ± 1.6) and rocuronium (median = 9, mean = 9.0 ± 1.6) (p = 0.15). The physician's overall satisfaction with the extent of paralysis was also higher for succinylcholine (median = 10, mean = 9.4 ± 1.3) than rocuronium (median = 10, mean = 8.8 ± 2.0) (p < 0.01). Only one complication, widening of the QRS complex secondary to succinylcholine use in a patient with unsuspected hyperkalemia, could be attributed to the choice of NMBA. Conclusions: Both succinylcholine and rocuronium produced fast and reliable paralysis for RSI. Although succinylcholine had a faster onset and provided more relaxation, the difference had no clinical significance. Approximately a fourth of ED RSI patients qualified for use of rocuronium using these high‐risk criteria.
Sports‐related Injuries in Children
Authors: Taylor Bambi L. , Attia Magdy W.
Published: January 2008

Abstract. Objective: To describe the demographics and types of sports‐related injuries (SRIs) in children. Methods: The authors performed a retrospective chart review of children 5‐18 years of age diagnosed as having an SRI in a pediatric emergency department (ED) during a two‐year period. Patients were identified by ICD‐9 codes. Data collected were age, sex, sport, ED interventions, consultations, mechanism, location, and injury type. Pairwise comparisons were reported as odds ratios with 95% confidence intervals. Results: Six hundred seventy‐seven SRIs fit the inclusion criteria; 480 of the patients were male (71%). The mean ages of the males and females were 13.0 years (SD ± 3.0 yr) and 12.4 years (SD ± 2.9 yr), respectively. The six most common sports implicated were basketball (19.5%), football (17.1%), baseball/softball (14.9%), soccer (14.2%), in‐line skating (Rollerblading)/skating (5.7%), and hockey (4.6%). Sprains/strains (32.0%), fractures (29.4%), contusions/abrasions (19.3%), and lacerations (9.7%) accounted for 90% of injury types. Pairwise comparison of the four injury types in the six sports listed showed significant associations for contusions/abrasions in baseball, sprains/strains in basketball, fractures in Rollerblading/skating, and lacerations in hockey. Age variance, including all sports, of the younger group (5‐11 yr) in fractures and the older group (12‐18 yr) in sprains was significant. The most common injury location was wrist/hand (28%), followed by head/face (22%) and ankle/foot (18%). Each had significant sport‐specific predilections. Contact with person or object was the mechanism for >50% of the SRIs. Sport‐specific mechanisms followed lines drawn from the sport‐specific injury types and locations. Conclusions: The pediatric age group incurs a variety of injuries in numerous sports with diverse sex, age, mechanism, location, injury type, and sport‐specific differences.
Emergency Department Use by Adult Medicaid Patients after Implementation of Managed Care
Authors: Powers Robert D.
Published: January 2008

Abstract. Objective: To determine whether the advent of a mandatory Medicaid managed care (MMC) plan had any effect on emergency department (ED) utilization by adult Medicaid patients at an urban teaching hospital. Methods: This was a retrospective cohort study using four years of ED records encompassing the year prior to initiation of MMC (1994‐95), the enrollment year (1995‐96), and two years after the program had matured (1996‐98). Results: Total ED census declined slightly, then returned to 1995 levels. Emergency department use by MMC patients declined steadily, with the 1998 figure of 5,888 representing a 40% decline over the pre‐MMC volume of 9,849. Visits by MMC patients with acute illness or injury declined by 29%; MMC low‐acuity visits decreased by 43%. Medicaid managed care low‐acuitye after‐hours/weekend visits declined by 19%, then leveled off. The MMC enrollment was stable throughout the study period. Conclusions: Mandatory managed care can be associated with considerable diminution in ED use by Medicaid patients. This decline is most pronounced in low‐acuity triage categories, and least evident after hours and on weekends.
The Effects of Epidermal Debridement of Partial‐thickness Burns on Infection and Reepithelialization in Swine
Authors: Singer Adam J. , Thode Henry C. , McClain Steve A.
Published: January 2008

Abstract. Objective: Early postburn debridement of burn blisters is controversial. This study was conducted to compare rates of infection and reepithelialization in debrided vs nondebrided second‐degree burns in swine. Methods: This was a prospective, blinded, controlled, experimental trial using isoflurane‐anesthetized swine. Standardized partial‐thickness burns were inflicted by applying an aluminum bar preheated to 80°C to the backs and flanks of two young pigs for 20 seconds. In half of the burns the necrotic epidermis was manually debrided. All burns were randomly treated with octylcyanoacrylate spray (OCA) or dry gauze (C). Full‐thickness biopsies were taken at 7, 10, and 14 days for blinded histopathologic evaluation. The primary outcomes were the proportions of infected burns at days 7 and 10 and the proportion of completely reepithelialized burns at day 14. Burns were considered infected in the presence of intradermal neutrophils containing bacteria (intraobserver agreement, κ= 1.00). A secondary outcome was the proportion of burns with the presence of scar tissue (abnormal collagen under polarized light; intraobserver correlation, κ= 0.93). Chi‐square tests were used for group comparisons. This study had 90% power to detect a 40‐percentage‐point difference in infection rates (α= 0.05). Results: A total of 126 biopsies from 42 burns were available for review. Infection rates were higher in the debrided burns both at day 7 (55% vs 4.5%, p < 0.001) and at day 10 (65% vs 9%, p < 0.001) after injury. The proportion of nondebrided burns that were completely reepithelialized was higher at days 10 (68% vs 0%, p < 0.001) and 14 (100% vs 65%, p = 0.003). The presence of scar tissue was more common in debrided burns (75% vs 4.5%, p < 0.001). Burns treated with OCA had fewer infections than controls (4% vs 55%, p < 0.001). Fewer OCA‐treated debrided burns were reepithelialized at 14 days than those that were not debrided (30% vs 100%, p = 0.001). Conclusions: Under the current study conditions, early postburn epidermal debridement of second‐degree burns resulted in more infections and slower reepithelialization rates in swine. The effects of early postburn epidermal debridement in humans should be explored.
Primary Closure of Mammalian Bites
Authors: Chen Esther , Horing Sarah , Shepherd Suzanne M. , Hollander Judd E.
Published: January 2008

Abstract. Objective: Suturing of bite wounds remains controversial. The authors evaluated the incidence of wound infection in 145 mammalian bite wounds treated with primary closure. Methods: Consecutive patients with bite wounds receiving primary closure at a university hospital ED had structured closed‐question data sheets completed at the time of wound management and suture removal. Infection was determined at the time of suture removal using a previously validated definition. Data included demographics; medical history; time from injury to evaluation; wound characteristics and location; details of wound cleansing methods, debridement, foreign body removal, and wound closure methods; use of antibiotics; and follow‐up wound evaluation. Proportions and 95% confidence intervals were calculated. Results: One hundred forty‐five mammalian bite patients were enrolled: 88 dog, 45 cat, and 12 human bites. Patients had a mean (±SD) age of 21 ± 20 years; 58% were male; 86% were white; and they presented a mean (±SD) of 1.8 ± 1.2 hours after injury. Bites occurred on the head and neck (57%), upper extremity (36%), and lower extremity (6%). Wounds had a mean length and width of 2.5 cm and 4.8 mm, respectively. Twelve percent involved structures deep to subcutaneous tissue. After primary wound closure, wound infections occurred in eight patients (5.5%; 95% confidence interval = 1.8% to 9.2%). Conclusions: The data suggest that carefully selected mammalian bite wounds can be sutured with approximately a 6% rate of infection. This infection rate may be acceptable in lacerations where cosmesis is a primary concern.
Research Fundamentals: Statistical Considerations in Research Design: A Simple Person's Approach
Authors: Jones James B.
Published: January 2008

Abstract. A basic understanding of statistical methodology is essential, both for designing quality research projects and for evaluating the medical literature. Careful statistical planning, including the selection of study endpoints, the determination of the required sample size, and the selection of statistical tests to be used in the data analysis, is important to ensure a successful research project. The purpose of this article is to provide a basic review of statistical terms and methods for both the researcher and the clinician, as well as to clarify questions that need to be answered prior to embarking on an experimental study. The advantages of collaborating with stastical consultants, and some guidelines for such collaborations, are discussed as well.
Octylcyanoacrylate for the Treatment of Contaminated Partial‐thickness Burns in Swine A Randomized Controlled Experiment
Authors: Singer Adam J. , Mohammad Mazhar , Tortora George , Thode Henry C. , McClain Steve A.
Published: January 2008

Objective: To compare infection and reepithelialization rates of contaminated second‐degree burns treated with octylcyanoacrylate (OCA), silver sulfadiazine (SSD), polyurethane (PU) film, and dry gauze (control; C) in swine. Methods: Eighty standardized burns were created by applying an aluminum bar preheated to 80°C to the backs and flanks of young pigs for 20 seconds. All burns were immediately contaminated with 0.1 mL of Staphylococcus aureus 105/mL and randomly treated with OCA spray, SSD, PU, or dry gauze (C). Full‐thickness biopsies were taken at 3, 7, and 14 days for blinded histopathologic evaluation using hematoxylin and eosin (H&E)‐stained slides. Burns were considered infected in the presence of interstitial reticular dermal neutrophils containing bacteria (intraobserver agreement, κ= 1.00). Quantitative wound cultures were performed on a second day‐3 specimen. Results: At day 3, wound infection rates were 30% (OCA), 50% (SSD), 55% (PU), and 50% (C); p = 0.40 (Kruskal‐Wallis test). At day 7, infection rates were 35% (OCA), 85% (SSD), 70% (PU), and 65% (C); p = 0.01. Median bacterial counts at day 3 were 6,500 (OCA), 20,000 (SSD), 1,000,000 (PU), and 650,000 (C); p = 0.29. The proportion of completely reepithelialized wounds at day 14 were 75% (OCA), 90% (SSD), 85% (PU), and 90% (C); p = 0.50. Conclusions: Treatment of contaminated partial‐thickness burns with OCA spray resulted in fewer infections at one week than with the other three treatments.
A Combination of Midazolam and Ketamine for Procedural Sedation and Analgesia in Adult Emergency Department Patients
Authors: Chudnofsky Carl R. , Weber James E. , Stoyanoff Peter J. , Colone Pino D. , Wilkerson Mark D. , Hallinen Diane L. , Jaggi F. Michael , Boczar Michael E. , Perry Marcia A.
Published: January 2008

Objective: To describe the clinical characteristics of a combination of midazolam and ketamine for procedural sedation and analgesia in adult emergency department (ED) patients. Methods: This was a prospective, observational trial, conducted in the ED of an urban level II trauma center. Patients ≥ 18 years of age requiring procedural sedation and analgesia were eligible, and enrolled patients received 0.07 mg/kg of intravenous midazolam followed by 2 mg/kg of intravenous ketamine. Vital signs were recorded at regular intervals. The adequacy of sedation, adverse effects, patient satisfaction, and time to reach discharge alertness were determined. Descriptive statistics were calculated using statistical analysis software. Results: Seventy‐seven patients were enrolled. Three were excluded due to protocol violations, three due to lack of documentation, and one due to subcutaneous infiltration of ketamine, leaving 70 patients for analysis. The average age was 31 years, and 41 (59%) were female. Indications for procedural sedation and analgesia included abscess incision and drainage (66%), fracture/joint reduction (26%), and other (8%). The mean dose of midazolam was 5.6 ± 1.4 mg and the mean dose of ketamine was 159 ± 42 mg. The mean time to achieve discharge criteria was 64 ± 24 minutes. Fivepatients experienced mild emergence reactions, but there were no episodes of hallucinations, delirium, or other serious emergence reactions. Eighteen (25%) patients recalled dreaming while sedated; twelve (17%) were described as pleasant, two (3%) unpleasant, three (4%) both pleasant and unpleasant, and one (1%) neither pleasant nor unpleasant. There were four (6%) cases of respiratory compromise, two (3%) episodes of emesis, and one (1%) case of myoclonia. All of these were transient and did not result in a change in the patient's disposition. Only one (1%) patient indicated that she was not satisfied with the sedation regimen. Conclusions: The combination of midazolam and ketamine provides effective procedural sedation and analgesia in adult ED patients, and appears to be safe.
Prospective Confirmation of Low Arrest Rates among Intoxicated Drivers in Motor Vehicle Crashes
Authors: Lahn Michael , Gallagher E. John , Li Siu Fai , Touger Michael , Olmedo Ruben
Published: January 2008

Objective: Several states have legally sanctioned or mandated physician reporting of drivers who were driving while intoxicated (DWI). Valid prospective evidence demonstrating extremely poor performance of the criminal justice system seems ethically and scientifically essential if overriding public health considerations are to abrogate the fundamental principles of patient—physician confidentiality. No such evidence is available. The authors reasoned that poor performance of the judicial system would be most evident if drivers who were DWI were not arrested under conditions selected to optimize legal intervention. The authors therefore wished to estimate the unbiased proportion of DWI drivers brought to an emergency department (ED) under these optimized conditions who escape detection by law enforcement officials. Methods: Prospective, consecutive cohort of drivers transported to an urban ED following a motor vehicle crash (MVC). Conditions selected to optimize legal intervention included: police at scene; inebriation of driver clinically evident to out‐of‐hospital personnel; and confirmatory blood ethanol level ≥100 mg/dL (≥22 mmol/L). Main outcome measure was arrest for DWI. Results: Of 294 drivers in MVCs, 270 had ethanol levels, of whom 18 met criteria for optimum likelihood of legal intervention. Of these, 22% were arrested for DWI (95% CI = 6% to 48%). Adjustment for missing data, under assumptions designed to maximize arrest frequency for DWI, did not materially alter these findings. No patients were lost to follow‐up. Conclusion: These findings prospectively confirm that, even under conditions selected to optimize detection by law enforcement officials, only about one of every five drivers who were DWI and were brought to an ED following an MVC—and almost certainly no more than a minority—comes to the attention of the criminal justice system.
Do Diabetic Patients Have Higher In‐hospital Complication Rates When Admitted from the Emergency Department for Possible Myocardial Ischemia?
Authors: Richman Peter B. , Brogan Gerard X. , Nashed Ashraf H. , Hollander Judd E. , Thode Henry C.
Published: January 2008

Objective: To compare in‐hospital complication rates for diabetic and nondiabetic patients admitted from the emergency department (ED) for possible myocardial ischemia. Methods: This was a prospective, observational study of consecutive consenting patients presenting to a suburban university hospital ED during study hours with typical and atypical symptoms consistent with cardiac ischemia. Demographic, historical, and clinical data were recorded by trained research assistants using a standardized, closed‐question, data collection instrument. Inpatient records were reviewed by trained data abstractors to ascertain hospital course and occurrence of complications. Final discharge diagnosis of acute myocardial infarction (AMI) was assigned by World Health Organization criteria. Categorical and continuous data were analyzed by chi‐square and t‐tests, respectively. All tests were two‐tailed with alpha set at 0.05. Results: There were 1,543 patients enrolled who did not have complications at initial presentation; 283 were diabetic. The rule‐in rate for AMI was 13.8% for nondiabetic patients and 17.7% for diabetic patients (p = 0.09). Times to presentation were similar for nondiabetic vs diabetic patients [248 minutes (95% CI = 231 to 266) vs 235 minutes (95% CI = 202 to 269); p = 0.32]. Nondiabetic patients tended to be younger [56.6 years (95% CI = 55.8 to 57.4) vs 61.6 years (95% CI = 60.2 to 63.1); p = 0.001] and were less likely to be female (34.3% vs 48.1%; p = 0.001). The two groups had similar prevalences for initial electrocardiograms diagnostic for AMI (5.5% vs 7.4%; p = 0.21). There was no significant difference between nondiabetic and diabetic patients for the occurrence of the following complications after admission to the hospital: congestive heart failure (1.3% vs 1.1%, p = 0.77); nonsustained ventricular tachycardia (VT) (1.3% vs 1.2%, p = 0.93); sustained VT (1.2% vs 1.1%, p = 0.85); supraventricular tachycardia (1.7% vs 3.2%, p = 0.12); bradydysrhythmias (1.9% vs 1.1%, p = 0.33); hypotension necessitating the use of pressors (0.9% vs 1.1%, p = 0.76); cardiopulmonary resuscitation (0.2% vs 0.7%, p = 0.10); and death (0.3% vs 0.7%, p = 0.34). One or more complications occurred with similar frequencies for patients in the two groups (6.3% vs 5.7%; p = 0.70). Conclusions: No statistically significant difference was found in the post‐admission complication rates for initially stable diabetic vs nondiabetic patients admitted for possible myocardial ischemia. Based on these results, the presence or absence of diabetes as a comorbid condition does not indicate a need to alter admitting decisions with respect to risk for inpatient complications.
A Continuous Quality Improvement Approach to IL‐372 Documentation Compliance in an Academic Emergency Department, and Its Impact on Dictation Costs, Billing Practices, and Average Patient Length of Stay
Authors: Higgins III George L. , Becker Mary H.
Published: January 2008

Objective: To determine whether continuous quality improvement (CQI) methodology could improve and maintain IL‐372 documentation compliance in an academic emergency department (ED). The impact on transcription costs, billing practices, and average patient length of stay was also analyzed. Methods: Baseline IL‐372 compliance data were collected and shared with staff during a multidisciplinary educational session. Faculty dictation became mandatory. Pocket‐sized dictation templates were provided. A Documentation Improvement Committee monitored outcomes. Each month of the study period, a compliance officer reviewed approximately 100 records. The following indicators were monitored: IL‐372 compliance rates, dictation rates, transcription costs, down‐coding rates, percentage of billable records, and average patient length of stay. Individualized results were provided to faculty. Results: During the ten‐month study period, compliance rates increased from 60% to 100% (p‐trend < 0.001), while dictation rates increased from 69% to 100% (p < 0.001). Rates of down‐coding adjustments improved from 54% to 2% (p‐trend < 0.001). The percentage of billable records increased from 65% to 100% (p‐trend < 0.001). Transcription costs increased a modest 16%. The average patient length of stay remained unchanged. Conclusion: The application of CQI methodology, combined with the availability of dictation, resulted in sustained improvement in IL‐372 compliance. This was associated with a parallel increase in dictation rates, although concurrent transcription costs increased only modestly. The percentage of billable records increased, while the number of charts requiring down‐coding decreased, both beneficial outcomes. Average length of stay was not adversely impacted by this added documentation requirement.
Maximizing the Sensitivity and Specificity of Pediatric Trauma Team Activation Criteria
Authors: Dowd M. Denise , McAneney Constance , Lacher Mary , Ruddy Richard M.
Published: January 2008

Abstract. Background: Care of the severely injured child requires the rapid assembly of personnel trained in pediatric trauma care. Trauma team activation criteria, which are highly sensitive and maximally specific for identifying the child who requires resuscitation, are necessary to provide rapid care to all who need it, while using resources efficiently. Objective: To determine the sensitivity and specificity of the standard trauma team activation (TTA) criteria for identifying patients who receive resuscitation in the emergency department. Methods: A one‐year study was conducted of all patients transported by emergency medical out‐of‐hospital services for a trauma‐related complaint. For all patients, out‐of‐hospital medical control operators recorded whether patients met TTA criteria and, if so, which criteria were met. Criteria included standard physiologic, anatomic, and mechanism parameters. Sensitivity and specificity for the outcome of resuscitation (volume restoration, assisted ventilation or intubation, chest tube insertion/needle decompression, operative intervention) were calcuated. Results: A total of 492 patients met the case definition. Two‐thirds were male, the mean age was 8 years (±4.8 SD), and the Injury Severity Score was ≥15 in 9.3%. Trauma team activation criteria were met by 179 patients (36.4%) and, of these, 107 met mechanism criteria only. A resuscitative intervention was received by 54 (10.9%) of the total and none in the mechanism‐only group. Sensitivity and specificity of the TTA criteria for predicting receipt of a resuscitation procedure were 98.1% and 71.2%, respectively. When mechanism criteria were excluded, the sensitivity remained 98.1% and the specificity increased to 95.7%. Conclusions: Criteria for TTA that include patients who meet mechanism criteria only are not specific for identifying patients who receive a resuscitative intervention. Use of anatomic and physiologic criteria only results in an increase in specificity, thereby reducing overtriage while retaining a high sensitivity.
Low Plasma Thiamine Levels in Elder Patients Admitted through the Emergency Department
Authors: Lee David C. , Chu Jason , Satz Wayne , Silbergleit Robert
Published: January 2008

Abstract. Objectives: To determine the prevalence of thiamine deficiency in a high‐risk group of elder emergency department (ED) patients who reside in nursing homes and need admission to the hospital, and to determine the effect of patients diets on this prevalence. Methods: This was an observational pilot study of 75 consecutive ED patients aged 65 years or older who lived in a nursing home and were admitted to the hospital. Plasma thiamine levels were measured by high‐pressure liquid chromatography on serum samples collected within 24 hours of hospital admission. Nursing home records were reviewed to determine whether patients received nutritional supplementation or enteral tube feedings. Results: Seventy patients participated and had a mean plasma thiamine level of 27.3 μ/dL (95% CI = 20.2 to 34.4). Fourteen percent (n= 10, 95% CI = 8% to 24%) were thiamine‐deficient (<10 μg/dL). Patients not receiving dietary supplements or tube feedings (n= 26) had lower mean thiamine levels (20.3 μg/dL, 95% CI = 12.7 to 27.9) and were thiamine‐deficient more often (27%) than patients receiving dietary support (n= 44, 31.5 μg/dL, 95% CI = 24.7 to 38.3, 7% thiamine‐deficient). Conclusions: Elder nursing home patients seen in the ED and admitted to the hospital are frequently thiamine‐deficient. Empiric thiamine supplementation is often used in the ED for other high‐risk patients, such as alcoholic individuals, and may be appropriate for high‐risk elder patients. Further research is needed to determine whether thiamine supplementation in these patients can improve their clinical outcomes.
Repeat Ambulance Use by Pediatric Patients
Authors: Broxterman Kimberly , Sapien Robert , Fullerton Lynne , Olson Lenora , Sklar David
Published: January 2008

Abstract: Objective: To compare pediatric patients transported by ambulance on more than one occasion (repeat) with those transported only once. Methods: The authors analyzed pediatric (patient < 21 years old) transports for 1992‐1995 by the ambulance service that provides 99% of transports for a non‐innercity metropolitan area. Repeat transports were compared with single transports with regard to patient age, gender, chief complaint, and payment source. Results: There were 17,448 transports involving 15,168 patients. Nearly half (49.0%) of the repeat transports involved patients in the oldest age category, 17 to 20.9 years, contrasted with 38.0% of single transports (p < 0.00001). Females comprised 51.4% of the repeat transports and 48.5% of the single transports (p = 0.0008). Traumatic complaints accounted for one‐third (33.0%) of the repeat transports and half (51.1%) of the single transports (p < 0.0001). Chief complaints of the patients with repeat transports were more likely to be seizure, assault, abdominal pain, and respiratory problems, and less likely to be falls and motor vehicle‐related complaints, than chief complaints of the patients with single transports (p < 0.0001). More than one‐third (39.0%) of the repeat transports were funded by Medicaid, in contrast with 19.8% of the single transports (p < 0.0001). Conclusions: Compared with single transports, repeat transports were more likely to involve patients more than 16 years of age, female, and with a chief complaint of seizure, assault, abdominal pain, or respiratory distress, and more likely to be funded by public insurance (Medicaid). Repeat pediatric transports warrant further investigation. This information may be useful in designing interventions targeted at reducing emergencies and hence ambulance use.
Alveolar Dead Space as a Predictor of Severity of Pulmonary Embolism
Authors: Kline Jeffrey A. , Kubin Anita K. , Patel Manish M. , Easton Edward J. , Seupal Rawle A.
Published: January 2008

Abstract. Objective: To determine whether the alveolar dead space volume (VDalv), expressed as a percentage of the alveolar tidal volume (VDalv/VTalv), can predict the degree of vascular occlusion caused by pulmonary embolism (PE). Methods: Fifty‐three subjects with suspected PE were prospectively studied. Pulmonary embolism was diagnosed in 33 by high‐probability ventilation/perfusion (V/Q) scan (n = 19) or by pulmonary arteriography (PAG, n = 14). Pulmonary embolism was excluded by PAG in 20 subjects. The VDalv/VTalv was determined from volumetric capnography and arterial blood gas analysis, which permits measurement of the physiologic dead space, VDphys (mL) = [PaCO2— PeCO2)/PaCO2]. tidal volume. Airway dead space (VDaw) was subtracted to yield the alveolar dead space [(VDphys — VDaw) = VDalv (mL)]; the percentage of alveolar volume occupied by alveolar dead space per breath = VDalv/VTalv · 100%. Percentage perfusion defect was determined from V/Q scans by a radiologist blinded to other data. Regression analysis was performed to show correlation between VDalv/VTalv and defect on V/Q scan or systolic pulmonary arterial pressure (SPAP). Results: For subjects with PE, the mean perfusion defect on lung scan was 38 ± 22%; the mean VDalv = 208 ± 115 mL, VTalv = 452 ± 251 mL, and VDalv/VTalv = 43 ± 18%. Regression of VDalv/VTalv vs perfusion defect yielded r2= 0.41. Regression of VDalv/VTalv vs pulmonary artery pressures yielded r2= 0.59. For subjects without PE, VDalv/VTalv = 27 ± 14% and VDalv = 89 ± 66 mL. Conclusions: The VDalv/VTalv correlates with the lung perfusion defect and the pulmonary artery pressures in subjects with PE. These findings show the potential for VDalv/VTalv to quantify the embolic burden of PE.
Antagonism of the Cardiodepressant Effects of Adenosine during Acute Hypoxia
Authors: Cummings Jennifer , Kaplan Justin L. , Gao Erhe , Clas Dawn , Dalsey William C. , De Garavilla Lawrence
Published: January 2008

Abstract.Objective: To determine whether pharmacologic antagonism of adenosine A1‐receptor‐mediated cardiovascular changes can improve cardiac function and prolong survival during systemic hypoxia. Methods: Rats were anesthetized with ketamine, instrumented [including left ventricular (LV) pressure transducing catheters], paralyzed with vecuronium, then ventilated to pCO2= 35‐40 torr. After 10 minutes of equilibration (baseline), treatment commenced with saline (n = 7), NPC‐205, an adenosine A1receptor selective antagonist, at doses of 1 mg/kg (n= 10) or 10 mg/kg (n= 10), or drug vehicle (n= 9). Ten minutes later, inspired oxygen was reduced to 5%. Results: Survival duration (min) post‐hypoxia increased in a dose‐dependent fashion from 10.4 ± 1.4 (mean ± SEM) with vehicle control to 23.0 ± 4.7 and 41.1 ± 5.7 with 1 and 10 mg/kg NPC‐205, respectively (p < 0.000). Five minutes post‐hypoxia, dose‐dependent increases were also seen in the percentage of pre‐hypoxic values of LV contractility [25.9 ± 8.1 (vehicle), 39.5 ± 9.6 (1 mg/kg NPC‐205), and 56.5 ± 8.7 (10 mg/kg NPC‐205), p = 0.01], heart rate [60.6 ± 8.3 (vehicle), 74.7 ± 8.2 (1 mg/kg NPC‐205), and 90.4 ± 24.1 (10 mg/kg NPC‐205), p = 0.02], and blood pressure [16.1 ± 4.8 (vehicle), 28.8 ± 8.6 (1 mg/kg NPC‐205), and 51.7 ± 8.2 (10 mg/kg NPC‐205), p = 0.004]. Conclusions: The adenosine A1selective antagonist prolonged survival in this model. This prolongation was attributed to inhibition of adenosine A1receptor‐mediated decline in cardiac inotropy and chronotropy. Adenosine A1receptor‐selective antagonists show promise as adjunctive therapy for hypoxia‐induced cardiac insufficiency by prolonging the treatment window until more definitive resuscitation measures are taken.
Myoglobin for Early Risk Stratification of Emergency Department Patients with Possible Myocardial Ischemia
Authors: Green Gary B. , Skarbek‐Borowski George W. , Chan Daniel W. , Kelen Gabor D.
Published: January 2008

Abstract. Objectives: To determine and compare the prognostic abilities of early, single‐sample myoglobin measurement with that of creatine kinase‐MB (CK‐MB), with cardiac troponin T (cTnT), and with physician judgment in the absence of marker results among emergency department (ED) patients with possible myocardial ischemia. Methods: Prospective collection of clinical and serologic data using an identity‐unlinked technique from patients with possible myocardial ischemia at two urban EDs. Outcome data concerning the occurrence of adverse events (AEs) during the 14 days after enrollment were used to calculate and compare the relative risks (RRs) and predictive values (with 95% confidence intervals) of the various markers for predicting AEs. Results: Among 396 analyzed patients, 65 (16.4%) accrued 104 AEs, including 13 deaths (3.3%) and 31 (7.8%) myocardial infarctions. Myoglobin predicted AEs (RR = 3.36 [95% CI = 2.19 to 5.15]) with significantly higher sensitivity (50.8% [95% CI = 38.6 to 62.9]) than either CK‐MB (15.4% [95% CI = 6.6 to 24.2]) or cTnT (24.6% [95% CI = 14.1 to 35.1]), but with lower specificity (81.9% [95% CI = 77.7 to 86.0]; CK‐MB = 99.7% [95% CI = 99.1 to 100]; cTnT = 93.1% [95% CI = 90.3 to 95.8]). Myoglobin had prognostic ability among patients with chest pain (3.86 [95% CI = 2.39 to 6.22]) and atypical (non‐chest pain) presentations (2.71 [95% CI = 1.09 to 6.71]), including those with a non‐diagnostic electrocardiogram (3.11 [95% CI = 1.44 to 6.69]). The combination of myoglobin and physician decision making identified 63 of the 65 patients (96.9% [95% CI = 92.7 to 100]) with subsequent AEs. Conclusions: The early prognostic sensitivity of myoglobin may allow identification of some high‐risk patients missed by physician judgment, CK‐MB, and cTnT. Myoglobin should be considered for use in the ED based on both its diagnostic and prognostic abilities.
Continuous Electrocardiographic Monitoring and Cardiac Arrest Outcomes in 8,932 Telemetry Ward Patients
Authors: Schull Michael J. , Redelmeier Donald A.
Published: January 2008

Abstract. Objective: To estimate the benefit of routine electrocardiographic (ECG) telemetry monitoring on in‐hospital cardiac arrest survival. Methods: In a tertiary care hospital, all telemetry ward admissions and cardiac arrests occurring over a five‐year period were reviewed. Ward location and survival to discharge were determined for all patients outside of critical care areas. Results: During the study period, 8,932 patients were admitted to the telemetry ward, and 20 suffered cardiac arrest (0.2%; 95% CI = 0.1 to 0.3). Telemetry monitors signaled the onset of cardiac arrest in only 56% (95% CI = 30 to 80) of monitored arrests. Three patients survived to discharge, and in two of these three patients the arrest onset was signaled by the monitor. This yields a monitor‐signaled survival rate among telemetry ward patients of 0.02% (95% CI = 0 to 0.05). All survivors suffered significant arrhythmias prior to their cardiac arrests. Conclusions: Cardiac arrest is an uncommon event among telemetry ward patients, and monitor‐signaled survivors are extremely rare. Routine telemetry offers little cardiac arrest survival benefit to most monitored patients, and a more selective policy for telemetry use might safely avoid ECG monitoring for many patients.
Research Ethics: Ethical Issues of Data Reporting and the Quest for Authenticity
Authors: Marco Catherine A. , Larkin Gregory L.
Published: January 2008

Abstract. The search for truth and its unbiased reporting are ultimate goals of conducting scientific research. Ideally, the reporting of research data ought to be an objective task. In practice, however, it is fraught with numerous statistical and ethical pitfalls, seldom addressed in formal emergency medicine training. The lure of academic celebrity and related influences may persuade researchers to report results in ways that make data appear more interesting, or worthy of publication. Several examples of potentially misleading data reporting are illustrated, including using inappropriate statistical tests, neglecting negative results, omitting missing data points, failing to report actual numbers of eligible subjects, using inappropriate graph labels or terminology, data dredging, and others. Although potentially inaccurate or inflated methods of data reporting may not constitute overt scientific misconduct, the intentional misrepresentation of data is a form of fraud or deception. Publicly funded academic inquiry is a privilege and honor enjoyed by a trusted few. Regardless of outcome, every effort should be made to report data in the most scientifically accurate method. To this end, the Society for Academic Emergency Medicine Code of Conduct and American College of Emergency Physicians Code of Ethics provide important guidance toward the accurate, compassionate, competent, impartial, and honest conduct of scientific research. Accuracy and authenticity in data reporting are first and foremost a matter of individual integrity, and are crucial to the preservation of academic credibility, the protection of future patients, and the public's trust in the medical research enterprise.
Patient Education in the Emergency Department
Authors: Wei Henry G. , Camargo Carlos A.
Published: January 2008

Abstract. The emergency department (ED) visit provides an opportunity for patient education. Many ED patients have poor access to regular health care, including patient education. Accreditation standards, legal considerations, and cost‐efficiency concerns encourage the clinician to implement formal patient education in the ED. More importantly, published clinical studies evaluating patient education in both the ED and comparable settings support the hypothesis that ED‐based patient education improves outcomes. The article discusses considerations for instructional material, highlights challenges to ED‐based patient education, and suggests possibilities for future research.
Resuscitation of Severe Uncontrolled Hemorrhage 7.5% Sodium Chloride/6% Dextran 70 vs 0.9% Sodium Chloride
Authors: Stern Susan A. , Jwayyed Sharhabeel , Dronen Steven C. , Wang XU
Published: January 2008

Abstract. Objectives: Resuscitation studies of hypertonic saline using controlled and uncontrolled hemorrhage models yield conflicting results with regard to efficacy. These disparate results reflect the use of models and resuscitation regimens that are not comparable between studies. This study evaluated the effects of comparable and clinically relevant resuscitation regimens of 7.5% sodium chloride/6% dextran 70 (HSD) and 0.9% sodium chloride (NS) in a near‐fatal uncontrolled hemorrhage model. Methods: Thirty‐six swine (14.2 to 21.4 kg) with 4‐mm aortic tears were bled to a pulse pressure of 5 mm Hg (40‐45 mL/kg). The animals were resuscitated with either NS or HSD administered in volumes that provided equivalent sodium loads at similar rates. Group II (n = 12) was resuscitated with 80 mL/kg of NS at a rate of 4 mL/kg/min. Group III (n = 12) received 9.6 mL/kg of HSD at a rate of 0.48 mL/kg/min. In both groups, crystalloid resuscitation was followed by shed blood infusion (30 mL/kg) at a rate of 2 mL/kg/min. Group I (controls; n = 12) were not resuscitated. Results: One‐hour mortality was significantly greater in group I (92%) as compared with group II (33%) and group III (33%) (Fisher's exact test; p = 0.004). Intraperitoneal hemorrhage was significantly greater in group II (34 ± 20 mL/kg) and group III (31 ± 13 mL/kg) as compared with group I (5 ± 2 mL/kg) (ANOVA; p < 0.05). There was no significant difference in hemodynamic parameters between groups II and III. Conclusion: In this model of severe uncontrolled hemorrhage, resuscitation with HSD or NS, administered in volumes that provided equivalent sodium loads at similar rates, had similar effects on mortality, hemodynamic parameters, and hemorrhage from the injury site.
A Comparison of Data Sources for Motor Vehicle Crash Characteristic Accuracy
Authors: Grant Robert J. , Gregor Mary Ann , Beck Paul W. , Maio Ronald F.
Published: January 2008

Abstract. Objective: To determine the accuracy of police reports (PRs), ambulance reports (ARs), and emergency department records (EDRs) in describing motor vehicle crash (MVC) characteristics when compared with an investigation performed by an experienced crash investigator trained in impact biomechanics. Methods: This was a cross‐sectional, observational study. Ninety‐one patients transported by ambulance to a university emergency department (ED) directly from the scene of an MVC from August 1997 to April 1998 were enrolled. Potential patients were identified from the ED log and consent was obtained to investigate the crash vehicle. Data describing MVC characteristics were abstracted from the PR, AR, and medical record. Variables of interest included restraint use (RU), air bag deployment (AD), and type of impact (TI). Agreements between the variables and the independent crash investigation were compared using kappa. Interrater reliability was determined using kappa by comparing a random sample of 20 abstracted reports for each data source with the originally abstracted data. Results: Agreement using kappa between the crash investigation and each data source was 0.588 (95% CI = 0.508 to 0.667) for the PR, 0.330 (95% CI = 0.252 to 0.407) for the AR, and 0.492 (95% CI = 0.413 to 0.572) for the EDR. Variable agreement was 0.239 (95% CI = 0.164 to 0.314) for RU, 0.350 (95% CI = 0.268 to 0.432) for AD, and 0.631 (95%= 0.563 to 0.698) for TI. Interrater reliability was excellent (kappa > 0.8) for all data sources. Conclusions: The strength of the agreement between the independent crash investigation and the data sources that were measured by kappa was fair to moderate, indicating inaccuracies. This presents ramifications for researchers and necessitates consideration of the validity and accuracy of crash characteristics contained in these data sources.
Planning Recommendations for International Emergency Medicine and Out‐of‐hospital Care System Development
Authors: Holliman C. James , VanRooyen Michael J. , Green Gary B. , Kirsch Thomas D. , Delooz Herman H. , Clem Kathleen J. , Thomas Tamara L. , Davis Mark A. , Wang Ewen , Wolfson Allan B.
Published: January 2008

Abstract. Objectives: To present suggestions on planning for development of emergency medicine (EM) and out‐of‐hospital care in countries that are in an early phase of this process, and to provide basic background information for planners not already familiar with EM. Methods: The techniques and programs used by the authors and others in assisting in EM development in other countries to date are described. Conclusions: Some aspects of EM system development have applicability to most countries, but other aspects must be decided by planners based on country‐specific factors. Because of the very recent initiation of many EM system development efforts in other countries, to the authors' knowledge there have not yet been extensive evaluative reports of the efficacy of these efforts. Further studies are needed on the relative effectiveness and cost‐benefit of different EM development efforts.
Bench to Bedside Tumor Necrosis Factor‐alpha: From Inflammation to Resuscitation
Authors: Cairns Charles B. , Panacek Edward A. , Harken Alden H. , Banerjee Anirban
Published: January 2008

Abstract. Proinflammatory mediators such as tumor necrosis factor‐alpha (TNF) have been implicated in the pathophysiology in a number of acute disease states. Tumor necrosis factor‐alpha can contribute to cell death, apoptosis, and organ dysfunction. Tumor necrosis factor‐alpha can be generated with sepsis or ischemia‐reperfusion by activation of cell mitogen‐activated protein kinases and nuclear factor kappa B, leading to TNF production. A number of strategies to modulate TNF have been recently explored, including factors directed toward mitogen‐activated protein kinases, TNF transcription, anti‐inflammatory ligands, heat shock proteins, and TNF‐binding proteins. However, TNF may also play an important role in the adaptive response to injury and inflammation. Control of the deleterious effects of TNF and other proinflamatory cytokines represents a realistic goal for clinical emergency medicine. The purpose of this article is to provide a background of relevance to emergency medicine academicians on the production and regulation of TNF, the acute effects of TNF on pathophysiology, and the rationale for therapeutic interventions directed toward TNF and the clinical experience with these strategies.
Home Care and Emergency Medicine A Pilot Project to Discharge Patients Safely from the Emergency Department
Authors: Sinclair Douglas , Ackroyd‐Stolarz Stacy
Published: January 2008

Abstract. Objectives: To describe in detail the implementation of an acute care home care program (quick response program; QRP) for the emergency department (ED). Methods: A prospective observational study with key process and outcome indicators, including number of referrals, time to initiate service, type of home care provided, number of return patients to the ED, and outcome for all patients, defined at the beginning of the project. Patients are identified for the QRP and services are in place within four hours of patient discharge. Results: Of 177 eligible patients, 121 were entered into the program. Sixty‐eight percent were more than 65 years old, and 54% lived alone. All patients met the time target of services in place within four hours of discharge from the ED. Patient satisfaction was high as measured by an independent survey instrument. Fifty percent of the patients required no further service after the QRP, but 20% were admitted to hospital within 30 days. Conclusions: A QRP can be successfully implemented in the ED to discharge patients home, most of whom would have been admitted to hospital.