bluuebunny/crossref_metadata_2025 huggingface dataset:
EMCyberSchool An Evaluation of Computer‐assisted Instruction on the Internet
Authors: Baumlin Kevin M. , Bessette Michael J. , Lewis Carol , Richardson Lynne D.
Published: January 2008

Abstract. Objectives: To test the hypothesis that integration of the EMCyberSchool, a computer‐assisted instruction (CAI) tool available on the Internet, into the curriculum of a senior medical student subinternship in emergency medicine (EM) would improve exam scores and course satisfaction. Methods: Students were prospectively randomized, by four‐week blocks, into a CAI group and a no‐CAI group. All students were surveyed on previous computer experience and their use and opinion of the EMCyberSchool. Results: Completed data were obtained from 100 of 120 students. Sixty‐five percent of the students said they wanted CAI as an adjunct to their course curricula; only 28% actually used the educational tool. The students who used the site rated it useful (4.2/5), easy to use (4.4/5), and easy to access (4.1/5). Of the students who had access, and chose not to use the EMCyberSchool, 77.8% reported not having enough time as the reason for not using the site. The mean exam scores were 72.8% for the students in the CAI group and 68.2% for those in the no‐CAI group (p = 0.058). In the CAI group, 77.5% (31/40) of the students rated the course as outstanding or excellent; compared with 66% (33/50) in the no‐CAI group (p = 0.23). Conclusions: Although desired, it remains unclear whether CAI on the Internet is a useful adjunct for teaching EM to medical students.
Hypertonic Saline Treatment of Severe Hyperkalemia in Nonnephrectomized Dogs
Authors: Kaplan Justin L. , Eynon C. Andrew , Dalsey William C. , Braitman Leonard E. , Clas Dawn , de Garavilla Lawrence
Published: January 2008

Abstract.Objectives:To determine whether a hypertonic saline bolus improves cardiac conduction or plasma potassium levels more than normal saline infusion within 15 minutes of treatment for severe hyperkalemia. Previously with this model, 8.4% sodium chloride (NaCl) and 8.4% sodium bicarbonate (NaHCO3) lowered plasma potassium equally effectively.Methods:This was a crossover study using ten conditioned dogs (14‐20 kg) that received, in random order, each of three intravenous (IV) treatments in separate experiments at least one week apart: 1) 2 mmol/kg of 8.4% NaCl over 5 minutes (bolus); 2) 2 mmol/kg of 0.9% NaCl over one hour (infusion); or 3) no treatment (control). Using isoflurane anesthesia and ventilation (pCO2= 35‐40 torr), 2 mmol/kg/hr of IV potassium chloride (KCl) was infused until conduction delays (both absent p‐waves and ≥20% decrease in ventricular rate in ≤5 minutes) were sustained for 15 minutes. The KCl was then decreased to 1 mmol/kg/hr (maintenance) for 2 hours and 45 minutes. Treatment (0 minutes) began after 45 minutes of maintenance KCl.Results:From 0 to 15 minutes, mean heart rate increased 29.6 (95% CI = 12.2 to 46; p < 0.005) beats/min more with bolus than infusion and 23.4 (95% CI = 2.6 to 43.5; p < 0.03) beats/min more with bolus than control. No clinically or statistically significant difference was seen in heart rate changes from 0 to 30 minutes. Decreases in potassium from 0 to 15 minutes were similar with bolus, infusion, and control.Conclusions:In this model, 8.4% NaCl bolus reversed cardiac conduction abnormalities within the first 15 minutes after treatment, more rapidly than did the 0.9% NaCl infusion or control. This reversal occurred despite similar reductions in potassium levels.
The Effect of Hyperglycemia on Cocaine Neurotoxicity and Death in Mice
Authors: Bania Theodore C. , Perez Christopher , Carey Patricia M. , Almond Gregory L. , Ingram Christopher
Published: January 2008

Abstract. Objective: Cocaine toxicity frequently manifests as seizures and status epilepticus. Frequently, dextrose is administered to patients with cocaine‐induced seizures. The objective of this study was to examine the effect of pre‐existing hyperglycemia on cocaine neurotoxicity and death in mice. Methods: Swiss albino mice received intraperitoneal dextrose at a dose of 1 g/kg (12.5%) (hyperglycemic group, n= 98). The euglycemic group (n= 98) received an equal volume of 0.9% saline. After 60 minutes, all the animals received intraperitoneal cocaine at a dose of 90 mg/kg. The times to onset of ataxia, seizure, and death were recorded in seconds. Times to events were compared using a Kaplan‐Meier method and results were compared using the logrank test. The overall percentage outcomes were compared using chi‐square. Results: The ataxia rates (hyperglycemic 97%, euglycemic 97%, χ2= 0, p = 1), seizure rates (hyperglycemic 85%, euglycemic 82%, χ2= 0.292, p = 0.589), and survival rates (hyperglycemic 62%, euglycemic 51%, χ2= 0.2514, p = 0.113) were similar between the groups. The survival following a seizure was significantly higher in the hyperglycemic group (hyperglycemic 57%, euglycemic 41%, χ2= 4.439, p = 0.035). The median ataxia time was earlier in the hyperglycemic group (190 sec) than in the euglycemic group (166 sec) (p = 0.031). Seizures occurred no earlier in the hyperglycemic group (331 sec) than in the euglycemic group (342 sec) (p = 0.207). Survival times were not different for the hyperglycemic group (9,133 sec) and the euglycemic group (7,593 sec) (p = 0.394). Survival times following seizures were not different for the hyperglycemic group (8,095 sec) and the euglycemic group (5,816 sec) (p = 0.0752). Conclusions: In mice with pre‐existing hyperglycemia, ataxia occurred earlier and survival following cocaine‐induced seizures was longer than for euglycemic mice. No significant difference in the overall percentage of seizures and death was detected. Pre‐existing hyperglycemia had minimal effect on worsening cocaine toxicity in mice.
The Emergency Department Presentation of Patients with Active Pulmonary Tuberculosis
Authors: Sokolove Peter E. , Rossman Lorca , Cohen Stuart H.
Published: January 2008

Abstract. Objective: To determine the clinical presentation of emergency department (ED) patients with active pulmonary tuberculosis (TB). Methods: This was a retrospective medical record review of adult patients, identified through infection control records, diagnosed as having active pulmonary TB by sputum culture over a 30‐month period at an urban teaching hospital. The ED visits by these patients from one year before to one year after the initial positive sputum culture were categorized as contagious or noncontagious, using defined clinical and radiographic criteria. The medical records of patients with contagious visits to the ED were reviewed to determine chief complaint, presence of TB risk factors and symptoms, and physical examination and chest radiograph findings. Results: During the study period, 44 patients with active pulmonary TB made 66 contagious ED visits. Multiple contagious ED visits were made by 12 patients (27%; 95% CI = 15% to 43%). Chief complaints were pulmonary 33% (95% CI = 22% to 46%), medical but nonpulmonary 41% (95% CI = 29% to 54%), infectious but nonpulmonary 14% (95% CI = 6% to 24%), and traumatic/orthopedic 12% (95% CI = 5% to 22%). At least one TB risk factor was identified in 57 (86%; 95% CI%= 76 to 94%) patient visits and at least one TB symptom in 51 (77%; 95% CI = 65% to 87%) patient visits. Cough was present during only 64% (95% CI = 51% to 75%) of the patient visits and hemoptysis during 8% (95% CI = 3% to 17%). Risk factors and symptoms that, if present, were likely to be detected at triage were foreign birth, homelessness, HIV positivity, hemoptysis, and chest pain. Conclusions: Patients with active pulmonary TB may have multiple ED visits, and often have nonpulmonary complaints. Tuberculosis risk factors and symptoms are usually present in these patients but often missed at ED triage. The diversity of clinical presentations among ED patients with pulmonary TB will likely make it difficult to develop and implement high‐yield triage screening criteria.
Use of Bilevel Positive Airway Pressure in Out‐of‐hospital Patients
Authors: Craven Richard A. , Singletary Nici , Bosken Lois , Sewell Eric , Payne Martin , Lipsey Rebecca
Published: January 2008

Abstract. Objective: To evaluate the utility of bilevel positive airway pressure (BiPAP) in the out‐of‐hospital treatment of patients with presumed congestive heart failure (CHF). Methods: This was a prospective, sequential, parallel trial in an urban setting served by a single emergency medical services (EMS) system between January 4 and April 15, 1999. A convenience sampling of adults who were transported by rescue units judged to be in CHF by treating emergency medical technicians trained in advanced life support (ALS EMTs) was included. Rescue squads were divided into demographically matched pairs, and one of each was equipped with a BiPAP ventilatory support unit. Bilevel positive airway pressure therapy was added to the existing treatment protocols for eligible study patients. Main outcome measures were out‐of‐hospital treatment time, oxygen saturation changes, hospitalization length, need for endotracheal intubation, mortality rate, and ease of use of the device by EMS personnel. Results: Sixty‐two of 71 enrolled patients completed the study. Out‐of‐hospital treatment times did not differ between groups (31.2 minutes vs 31.4 minutes; p = 0.931). The difference between pre‐ and post‐treatment oxygen saturation levels was greater for the BiPAP group (13.71%) than the control group (6.69%) (p < 0.05). There was no statistical difference between groups in the length of hospital stay [control: 7.63 days, vs BiPAP: 6.33 days, p = 0.48], the intubation rate [control: 7 of 25 (28%) vs BiPAP: 4 of 37 (11%), p = 0.10], or death rate [control: 2 of 24, vs BiPAP: 6 of 37, p = 0.46]. All of the ALS EMTs who used BiPAP thought that it was safe to use, and 97% thought it was easy and appeared to improve patients' dyspnea and respiratory distress. Conclusions: ALS EMTs can be trained to deliver noninvasive ventilation with BiPAP, find it easy to apply, and believe that it helps relieve dyspnea in patients with suspected CHF.
“Preconditioning at a Distance” in the Isolated Rabbit Heart
Authors: Dickson Eric W. , Porcaro William A. , Fenton Richard A. , Heard Stephen O. , Reindhardt Christopher P. , Renzi Francis P. , Przyklenk Karin
Published: January 2008

Abstract. Objective: Brief myocardial ischemia evokes a cardioprotective response, referred to as “ischemic preconditioning” (IP), that limits injury caused by a subsequent prolonged ischemic insult. The myocardial IP effect can be induced by ischemia of “distant” cardiac and noncardiac tissue, implicating the involvement of an as‐yet‐unidentified humoral trigger. If a preconditioning hormone exists, the authors hypothesize that the IP effect should be transferable, via administration of coronary effluent, from a preconditioned donor heart to a virgin non‐preconditioned acceptor heart. Methods: Isolated buffer‐perfused rabbit hearts were assigned to one of four treatment groups in a donor/acceptor sequence. Donor hearts underwent either three IP cycles or a matched period of uninterrupted perfusion (control donors). Coronary perfusate collected from IP and control donor hearts was reoxygenated and transfused to virgin acceptor hearts. All hearts then underwent 30 minutes of global ischemia followed by 30 minutes of reperfusion. Left ventricular developed pressure (LVDP) (the authors’ index of cardioprotection) was monitored throughout the protocol by a left ventricular (LV) balloon. Results: In donor controls, LVDP assessed at 30 minutes post‐reflow was restored to only 49 ± 5% of baseline values. Recovery of LV function was significantly enhanced in both IP donor hearts (69 ± 4%*) and IP acceptor hearts (70 ± 6%*) vs donor controls (*p < 0.05), while, in acceptor controls, intermediate values of LVDP (62 ± 7%) were obtained. Conclusion: The IP effect can be transferred between rabbit hearts, suggesting the presence of a humoral trigger signal for distant preconditioning. Isolating this hormone may have therapeutic and diagnostic implications in the management of acute myocardial ischemia.
The Effect of Hypertension on the Response to Blood Loss in a Rodent Model
Authors: Sinert Richard , Guerrero Pilar , Quintana Eileen , Zehtabchi Shariar , Kim Chi‐Na , Agbemadzo Addison , Baron Bonny J.
Published: January 2008

Abstract. Objective: Hypertensive patients having higher baseline peripheral resistance and sympathetic tone than normotensive patients may have aberrant responses to hemorrhage. In an attempt to further characterize this clinical observation, the authors compared the hemodynamic and metabolic responses to hemorrhage between spontaneously hypertensive rats (SHR) and normotensive rats (NTR). Methods: Twenty adult rats (10 NTR and 10 SHR) were anesthetized with althesin via the intraperitoneal route. Femoral arteries were cannulated by cutdown. Twelve (6 SHR and 6 NTR) rats underwent controlled catheter hemorrhage of 25% of their total blood volumes. Eight rats (4 SHR and 4 NTR) served as nonhemorrhage controls. Mean arterial pressure (MAP) and base excess (BE) were measured prehemorrhage and then every 15 minutes for the next 120 minutes. Data were reported as mean ± standard error of the mean (SEM). Group comparisons were analyzed by ANOVA with repeated values post‐hoc by Bonferroni. Statistical significance was defined by an alpha = 0.05. Results: Immediately after hemorrhage, the SHR group experienced a significantly (p < 0.001) greater drop in MAP of 70 ± 4% in the SHR vs 40 ± 6% in the NTR. Blood pressure in the NTR returned to control values 15 minutes after hemorrhage, but the SHR remained relatively hypotensive for the entire length of the experiment. Base excess in the SHR decreased significantly (p < 0.004) by 8.2 ± 2 mmol/L from control values, as compared with no changes in BE for the NTR. Conclusions: The authors observed significant differences in the response to hemorrhage between hypertensive and normotensive rats. Hypertensive rats experienced a more profound hemorrhagic shock insult than normotensives for the same degree of blood loss.
Clinically Meaningful Changes in Quantitative Measures of Asthma Severity
Authors: Karras David J. , Sammon Maura E. , Terregino Carol A. , Lopez Bernard L. , Griswold Sharon K. , Arnold Gerald K.
Published: January 2008

Abstract. Objective: To determine minimum clinically meaningful improvements in peak expiratory flow rate (PEFR) and dyspnea visual analog score (VAS) in patients with acute asthma exacerbation. Methods: Patients presenting to the emergency department (ED) with acute asthma exacerbation were eligible. The PEFR and VAS were assessed at presentation and after initial asthma therapy. During reassessment, subjects were asked to describe their asthma symptoms as “much better,”“a little better,”“no change,”“a little worse,” or “much worse.” Correspondence between self‐reported improvement and changes in PEFR and VAS was assessed. The “minimum clinically significant change” in either index was defined as the difference between pre‐ and post‐treatment measures in subjects reporting their symptoms “a little better.” Results: One hundred fifty‐six subjects were included. Asthma symptoms were “much better” in 99 (64%), “a little better” in 41 (26%), and “unimproved” (composed of patients describing symptoms as “no change,”“a little worse,” or “much worse”) in 16 (10%). The mean VAS change among the “a little better” subjects was 2.2 cm (95% CI = 1.1 to 3.4), significantly greater than the ‐0.4 cm (95% CI = ‐2.1 to 1.4) change in the “unimproved” subjects. The mean change in percent predicted PEFR among the “a little better” subjects was 11.9 (95% CI = 7.3 to 16.1), not statistically different from the change of 6.1 (95% CI = 1.1 to 11.3) in the “no change” subjects. The “much better” group showed significantly greater changes in both measures than either of the other groups. A VAS change of ≥0.5 cm reliably discriminated between subjects with and without symptom improvement. Conclusions: Improvements in VAS of 2.2 cm and in predicted PEFR of about 12 percentage points are minimal clinically significant improvements during ED asthma therapy. The dyspnea VAS is valid in assessing symptomatic changes and may detect small subjective improvements better than the PEFR.
Vaccination of Emergency Department Patients at High Risk for Influenza
Authors: Kapur Atul K. , Tenenbein Milton
Published: January 2008

Abstract. Objective: To determine the proportion of Canadian emergency department (ED) patients who are at risk for increased morbidity from influenza but were not vaccinated and to determine emergency physicians’ (EPs') willingness to screen for and prescribe influenza vaccination. Methods: The authors surveyed a convenience sample of patients presenting during a one‐week period at each of four EDs in Winnipeg, Manitoba, Canada, after the end of the seasonal period for vaccination. They also surveyed all full‐time EPs in Winnipeg. Results: Fifty‐three percent of emergency patients at risk for increased morbidity from influenza had not been vaccinated and 59.3% of them were willing to be vaccinated during an emergency visit. This represents 31.6% (±3.1%) of all high‐risk patients and 15% of all emergency patients. High‐risk patients who did not have a regular physician were less likely to have been vaccinated (OR 0.165, p = 0.018). Most EPs rarely or never offer influenza vaccination (30% and 57%, respectively). Seventy‐six percent of them were willing to prescribe vaccination. Conclusion: Many ED patients are at risk for increased morbidity from influenza and have not been vaccinated. The majority of them are willing to be vaccinated during an emergency visit and the majority of EPs are willing to prescribe vaccination. Emergency department vaccination for influenza should be considered as a strategy to increase vaccination among high‐risk groups.
Research Fundamentals: Selection and Development of Clinical Outcome Measures
Authors: Singer Adam J. , Thode Henry C. , Hollander Judd E.
Published: January 2008

Abstract. Clinical outcomes measure patient health or well‐being. The choice of an outcome measure for use in a clinical trial or study is complex. It is even more difficult when no appropriate outcome measure exists, necessitating the development of a novel one. The ideal clinical outcome should be credible, comprehensive, sensitive to change, accurate, biologically sensible, and feasible. This paper describes the attributes of clinical outcomes and illustrates how to develop novel outcomes, using as an example the authors’ eperience in developing a wound cosmesis outcome measure.
Use of Out‐of‐hospital Interventions for the Pediatric Patient in an Urban Emergency Medical Services System
Authors: Scribano Philip V , Baker M Douglas , Holmes John , Shaw Kathy N
Published: January 2008

Abstract. Objective: To determine appropriateness of out‐of‐hospital interventions by emergency medical services (EMS) personnel on children with respiratory illnesses. Methods: A retrospective, cross‐sectional study was performed on a random sample of 304 children transported by an urban EMS system during 1994. Data were abstracted from EMScan (a computerized database of all EMS dispatches) and the EMS narrative records. Appropriate utilization of interventions was determined by comparison with the standard EMS protocol for respiratory complaints in this system. An assessment of whether interventions were inappropriately underutilized or inappropriately underutilized or inappropriately overutilized was made. Effect of severity of illness, patient age, transport times, and use of medical command on the use of interventions was evaluated. Results: Two hundred three patients (67%) were classified as having respiratory distress. Overall, 56% of the patients received appropriate interventions, 39% received one or two inappropriate interventions, and 5% received three or more inappropriate interventions. Rates of inappropriate utilization with 95% CI for each intervention were: oxygen 16% (95% CI = 12 to 20), assisted ventilation 2% (95% CI = 0.5 to 4), medication use 9% (95% CI = 6 to 13), vascular access 11% (95% CI = 7 to 14), phlebotomy 9% (95% CI = 6 to 13), and cardiac monitoring 18% (95% CI = 14 to 22). Oxygen and medications were underutilized (p < 0.005), whereas vascular access, cardiac monitoring, and phlebotomy were over‐utilized (p < 0.005). Online medical command (used in 9% of transports) improved appropriate use of vascular access [OR 8.3 (95% CI = 3 to 25) (p < 0.001)] and cardiac monitoring [OR = 3 (95% CI = 1 to 8) (p < 0.05)]. Conclusions: Emergency medical services personnel underutilized oxygen and medications and overutilized vascular access, phlebotomy, and cardiac monitoring in children with respiratory illness in this urban setting. Increasing patient age, transport times, and illness severity tend to increase the use of certain interventions, while contact with online medical direction seems to improve appropriate use of interventions.
Pretreatment of Lacerations with Lidocaine, Epinephrine, and Tetracaine at Triage: A Randomized Double‐blind Trial
Authors: Singer Adam J , Stark Mary Jo
Published: January 2008

Abstract. Objective: Pretreatment of lacerations with topical anesthetics reduces the pain of subsequent anesthetic injection yet requires time. This study was conducted to determine the ability of triage nurses to identify lacerations necessitating closure and pretreat them with a topical anesthetic and to compare the pain levels of lidocaine injection in lacerations pretreated with LET (lidocaine 2%, epinephrine 1:1,000, tetracaine 2%) vs a placebo. Methods: This was a double‐blind, randomized clinical trial that included consecutive emergency department patients aged ≥ 1 year with clean, non‐bite lacerations ≤ 6 hours old. At triage the lacerations were randomized to LET solution or a placebo containing epinephrine 1:1,000. At examination an emergency practitioner assessed the laceration edges for the presence of blanching and adequacy of anesthesia to a 27‐gauge needlestick. At the practitioner's discretion, supplemental lidocaine was infiltrated through the wound and the patient (or guardian) recorded the pain of infiltration on a 100‐mm visual analog scale marked “most pain” at the high end. The mean levels of pain of lidocaine infiltration were compared between groups with a t‐test and the proportions of adequately anesthetized wounds were compared with a χ2 test. A sample of 40 patients had 80% power to detect a 20‐mm between‐group difference in the pain of injection (α= 0.05). Results: Of 43 patients enrolled (mostly children and males), 22 received LET and 21 placebo. The groups were similar for baseline characteristics. Lacerations in the LET group were more frequently adequately anesthetized (46% vs 14%, p = 0.03), and LET patients experienced less pain from injection than controls (22 mm vs 42 mm, p = 0.02). Conclusions: Application of LET by triage nurses is more effective than placebo in adequately anesthetizing simple lacerations in normal hosts and decreases the pain of local anesthetic infiltration.
Does Advanced Age Matter in Outcomes after Out‐of‐hospital Cardiac Arrest in Community‐dwelling Adults ?
Authors: Swor Robert A , Jackson Raymond E , Tintinalli Judith E , Pirrallo Ronald G
Published: January 2008

Abstract. Objective: To assess whether advanced age is an independent predictor of survival to hospital discharge in community‐dwelling adult patients who sustained an out‐of‐hospital cardiac arrest in a suburban county. Methods: A prospective cohort study was conducted in a suburban county emergency medical services system of community‐dwelling adults who had an arrest from a presumed cardiac cause and who received out‐of‐hospital resuscitative efforts from July 1989 to December 1993. The cohorts were defined by grouping ages by decade: 19‐39, 40‐49, 50‐59, 60‐69, 70‐79, and 80 or more. The variables measured included age, gender, witnessed arrest, response intervals, location of arrest, documented by‐stander cardiopulmonary resuscitation, and initial rhythms. The primary outcome was survival to hospital discharge. Results are reported using analysis of variance, chi square, and adjusted odds ratios from a logistic regression model. Age group 50‐59 served as the reference group for the regression model. Results: Of the 2,608 total presumed cardiac arrests, the overall survival rate to hospital discharge was 7.25%. Patients in age groups 40‐49 and 50‐59 experienced the best rate of successful resuscitation (10%). Each subsequent decade had a steady decline in successful outcome: 8.1% for ages 60‐69; 7.1% for ages 70‐79; and 3.3% for age 80+. In a post‐hoc analysis, further seperation of the older age group revealed a successful outcome in 3.9% of patients ages 80‐89 and 1% in patients 90 and older. Patients aged 80 years or more were more likely to arrest at home, were more likely to have an initial bradyasystolic rhythm, yet had a similar rate of resuscitation to hospital admission. In the regression model, age 80 or older was associated with a significantly worse survival to hospital discharge (OR = 0.4, 95% CI = 0.20 to 0.82). Conclusions: There was a twofold decrease in survival following out‐of‐hospital cardiac arrest to discharge in patients aged 80 or more when compared with the reference group in this suburban county setting. However, resuscitation for community‐dwelling elders aged 65‐89 is not futile. These data support that out‐of‐hospital resuscitation of elders up to age 90 years is not associated with a universal dismal outcome.
Serum Neuron‐specific Enolase as a Predictor of Intracranial Lesions in Children with Head Trauma: A Pilot Study
Authors: Fridriksson Theodore , Kini Narendra , Walsh‐Kelly Christine , Hennes Halim
Published: January 2008

Abstract. Objective: To determine the reliability of serum neuronspecific enolase (NSE) levels in predicting intracranial lesions (ICL) in children with blunt head trauma (HT). Methods: A prospective pilot study was conducted of patients 0 to 18 years of age presenting to a children's hospital emergency department (ED) between December 1997 and October 1998. Children presenting within 24 hours of injury who required head computed tomography (CT) were eligible. Blood samples were obtained to measure serum NSE level. Data collected included patient demographics, historical information, Glasgow Coma Scale score (GCS), physical examinatioin, head CT results, and outcome. Patients were assigned to one of two groups based on the head CT results (PICL; presence of intracranial lesion, or NICL; no intracranial lesion). Data were analyzed using Student's t‐test and chisquare. The 95% confidence interval (95% CI) was calculated when appropriate. A receiver operating characteristic curve was constructed to determine the NSE level that yielded the highest sensitivity and specificity for predicting ICL. Results: Fifty patients were enrolled; 22 (45%) had abnormal head CT. No difference in demographics or mechanism of injury was observed between those with abnormal or normal CT scans. The mean GCS level was 11.9 ± 4.2 for PICL and 13.9 ± 2.6 for NICL (p = 0.045; 95% CI = ‐0.05 to ‐3.9). The mean NSE level was 26.7 ± 21.4 for PICL and 17.7 ± 7.8 for NICL (p = 0.048; 95% CI = 0.1 to 17.9). An NSE level ≥15.3 ng/mL yielded a sensitivity of 77%, a specificity of 52%, and a negative predictive value of 74%. Conclusions: These results suggest that serum NSE may be a useful screening tool for predicting ICL in children with blunt head trauma. However, the NSE alone was neither sensitive nor specific in predicting all patients with ICL.
Serious Toxicity in a Young Child Due to Ibuprofen
Authors: Öker Elif E , Hermann Luke , Baum Carl R , Fentzke Kathleen M , Sigg Todd , Leikin Jerrold B
Published: January 2008

Abstract. An 18‐month‐old male presented to the emergency department (ED) for evaluation of lethargy and apnea. Four hours before presentation, the patient was found with an empty bottle of ibuprofen, an ingestion of as much as 7.2 grams (600 mg/kg). The ED course was remarkable for a 30‐second tonic‐clonic seizure. Laboratory analysis was notable for metabolic acidosis. Four‐hour and 7.5‐hour serum ibuprofen levels were 640 and 39 μg/mL, respectively. Following treatment, the patient improved and was extubated the next morning.While metabolic acidosis has been frequently described at doses exceeding 400 mg/kg, seizures occurring early in the course of ibuprofen toxicity have been rarely noted.
Abortifacients: Toxidromes, Ancient to Modern—A Case Series and Review of the Literature
Authors: Netland Karin E , Martinez Jorge
Published: January 2008

Abstract. Between 1998 and 1999, four women presented to an emergency department after having attempted a nonmedical abortion. All four reported turning to pharmacologically induced abortion because their access to health care was limited by lack of insurance and resources. These cases serve as a reminder that self‐induced abortion remains a significant health problem for women, a problem that emergency physicians as toxicologists should be aware of.
Can Cardiac Sonography and Capnography Be Used Independently and in Combination to Predict Resuscitation Outcomes?
Authors: Salen Philip , O'Connor Robert , Sierzenski Paul , Passarello Brent , Pancu Diana , Melanson Scott , Arcona Steven , Reed James , Heller Michael
Published: January 2008

Abstract. Objective: To measure the ability of cardiac sonography and capnography to predict survival of cardiac arrest patients in the emergency department (ED). Methods: Nonconsecutive cardiac arrest patients prospectively underwent either cardiac ultrasonography alone or in conjunction with capnography during cardiopulmonary resuscitation at two community hospital EDs with emergency medicine residency programs. Cardiac ultrasonography was carried out using the subxiphoid view during pauses for central pulse evaluation and end‐tidal carbon dioxide (ETCO2) levels were monitored by a mainstream capnograph. A post‐resuscitation data collection form was completed by each of the participating clinicians in order to assess their impressions of the facility of performance and benefit of cardiac sonography during nontraumatic cardiac resuscitation. Results: One hundred two patients were enrolled over a 12‐month period. All patients underwent cardiac sonographic evaluation, ranging from one to five scans, during the cardiac resuscitation. Fifty‐three patients also had capnography measurements recorded. The presence of sonographically identified cardiac activity at any point during the resuscitation was associated with survival to hospital admission, 11/41 or 27%, in contrast to those without cardiac activity, 2/61 or 3% (p < 0.001). Higher median ETCO2 levels, 35 torr, were associated with improved chances of survival than the median ETCO2 levels for nonsurvivors, 13.7 torr (p < 0.01). The multivariate logistic regression model, which evaluated the combination of cardiac ultrasonography and capnography, was able to correctly classify 92.4% of the subjects; however, of the two diagnostic tests, only capnography was a significant predictor of survival. The stepwise logistic regression model, summarized by the area under the receiver operator curve of 0.9, furthermore demonstrated that capnography is an outstanding predictor of survival. Conclusions: Both the sonographic detection of cardiac activity and ETCO2 levels higher than 16 torr were significantly associated with survival from ED resuscitation; however, logistic regression analysis demonstrated that prediction of survival using capnography was not enhanced by the addition of cardiac sonography.
Emergency Department Management of Patients with Seizures: A Multicenter Study
Authors: Huff J. Stephen , Morris Dexter L. , Kothari Rashmi U. , Gibbs Michael A. , THE Emergency Medicine Seizure Study Group (EMSSG)*
Published: January 2008

Abstract. Objectives: Patients with seizure disorders are common in the emergency department (ED), yet little is known regarding the management of these patients. This study was performed to define the frequency of patients with seizure disorders in the ED patient population and to determine possible seizure etiologies, characteristics of diagnostic activities, treatments, and dispositions. Methods: Twelve EDs monitored all patients with a chief complaint related to seizure disorders presenting over 18.25 days (5% of the calender year) in late 1997. Retrospective chart review was used to gather specific data regarding these consecutive cases. Results: Of the 31,508 patients who presented to these 12 EDs during the study period, 368 (1.2%) had complaints related to seizures. Three hundred sixty‐two charts were available for analysis and make up the study population. Two hundred fifty‐seven (71%) utilized emergency medical services (EMS) for transport and care. Advanced care, including intravenous access, laboratory work, cardiac monitoring, or oxygen administration, was utilized in 304 (84%) patients. Antiepileptic drugs were given in 199 (55%) patients. Ethanol withdrawal or low antiepileptic drug levels were implicated as contributing factors in 177 (49%) of patients. New‐onset seizures were thought to be present in 94 (26%) patients. Status epilepticus occurred in only 21 (6%) patients. Ninety‐eight (27%) of all patients were admitted to the hospital. Conclusions: Patients with presenting complaints related to seizures are frequent in the ED population and make considerable demands on EMS and ED resources. Six percent of patients with seizure‐related presentations were in status epilepticus and more than a fourth of all patients required hospitalization.
Sledding Injuries in Patients Presenting to the Emergency Department in a Northern City
Authors: Voaklander Donald C. , Kelly Karen D. , Sukrani Nina , Sher Andy , Rowe Brian H.
Published: January 2008

Abstract. Objectives: Sledding is a common recreational activity in northern communities. The objective of this study was to examine the frequency and nature of sledding injuries (SIs) in patients presenting to emergency departments (EDs). Methods: The data were derived from a cohort of patients treated at all five EDs in an urban Canadian health region over a two‐year period. Following chart review, consenting patients were interviewed by telephone about their sledding activities and the circumstances surrounding the injury. Results: Three hundred twenty‐eight patients were correctly coded as having SIs, with 212 patients (65%) reached during the follow‐up survey. The median age of those with SIs was 12 years (IQR = 8, 21), and 206 (59%) were male. Injury rates peaked in the 10‐14‐year age group (87/100,000) for boys and in the 5‐9‐year age group (75/100,000) for girls. Most patients stated they were drivers (75%), fewer than half were thrown from the sled (42%), and fewer than half (44%) were sledding on community‐designated sledding hills at the time of injury. Injuries to the lower extremity (32%), upper extremity (31%), and head (13%) were most common. Thirty‐seven (11%) patients with SIs were admitted to hospital vs 4% of patients with other sports/recreation injuries (p < 0.05). Conclusions: Sledding injuries are common and potentially serious wintertime injuries in northern communities, involving primarily younger patients, with a large pre‐adolescent group. However, older sledders (>20 years) have poorer outcomes (hospitalization, lost time from work/school) than their younger counterparts. The SIs treated in the ED appear to lead to hospitalization more frequently than other types of sport/recreation injury, and injury prevention strategies appear warranted.
Effect of Changes in Graduate Medical Education Funding on Emergency Medicine Residency Programs
Authors: Stead Latha , Schafermeyer Robert W. , Counselman Francis L. , Blackburn Paul , Perina Debra
Published: January 2008

Abstract. Objective: To determine whether changes in graduate medical education (GME) funding have had an impact on emergency medicine (EM) residency training programs. Methods: A 34‐question survey was mailed to the program directors (PDs) of all 115 Accreditation Council for Graduate Medical Education (ACGME)‐accredited EM residency programs in the United States in the fall of 1998, requesting information concerning the impact of changes in GME funding on various aspects of the EM training. The results were then compared with a similar unpublished survey conducted in the fall of 1996. Results: One hundred one completed surveys were returned (88% response rate). Seventy‐one (70%) of the responding EM residency programs were PGY‐I through PGY‐III, compared with 55 (61%) of the responding programs in 1996. The number of PGY‐II through PGY‐IV programs decreased from 25 (28%) of responding programs in 1996 to 17 (16%). The number of PGY‐I through PGY‐IV programs increased slightly (13 vs 10); the number of EM residency positions remained relatively stable. Fifteen programs projected an increase in their number of training positions in the next two years, while only three predicted a decrease. Of the respondents, 56 programs reported reductions in non‐EM residency positions and 35 programs reported elimination of fellowship positions at their institutions. Only four of these were EM fellowships. Forty‐six respondents reported a reduction in the number of non‐EM residents rotating through their EDs, and of these, 11 programs reported this had a moderate to significant effect on their ability to adequately staff the ED with resident physicians. Sixteen programs limited resident recruitment to only those eligible for the full three years of GME funding. Eighty‐seven EM programs reported no change in faculty size due to funding issues. Sixty‐two programs reported no change in the total number of hours of faculty coverage in the ED, while 34 programs reported an increase. Three EM programs reported recommendations being made to close their residency programs in the near future. Conclusions: Changes in GME funding have not caused a decrease in the number of existing EM residency and fellowship training positions, but may have had an impact in other areas, including: an increase in the number of EM programs structured in a PGY‐I through PGY‐III format (with a corresponding decrease in the number of PGY‐II through PGY‐IV programs); a decrease in the number of non‐EM residents rotating through the ED; restriction of resident applicants who are ineligible for full GME funding from consideration by some EM training programs; and an increase in the total number of faculty clinical hours without an increase in faculty size.
Dedicated Asthma Center Improves the Quality of Care and Resource Utilization for Pediatric Asthma: A Multicenter Study
Authors: Battleman David S. , Callahan Mark A. , Silber Steven , Mun˜oz Cynthia I. , Santiago Lucia , Abularrage Joseph , Jabbar Hadi
Published: January 2008

Objectives: To determine the relative effectiveness of pediatric asthma care among patients treated by a dedicated asthma center (AC) vs children who use the emergency department (ED) as a site of primary asthma care. Methods: A retrospective case—control design was used. A random sample of AC cases was selected from a designated comprehensive AC over a 12‐month period. Concurrent ED control patients were identified from all cases of pediatric asthma from five urban hospitals based on two or more ED visits. Cases and controls were matched (1:2) based on age and National Heart, Lung, and Blood Institute (NHLBI) asthma severity of illness classification. A telephone survey was administered to the caregivers of all enrolled patients in the study sample. Results: Four elements of pediatric asthma care were examined: quality, access, hospital utilization, and functional impact of disease. Demographic data were similar between the ED cases and the AC controls. In terms of quality of care, the AC patients were more likely to use maintenance antiinflammatory medications, 60.2% vs 22.5% (OR = 5.3; 95% CI = 2.9 to 9.7) and more likely to be taking medications at school, 71.4% vs 48.1% (OR = 2.7; 95% CI = 1.5 to 4.7). In terms of access to care, the AC families were more likely to have a physician to call to assist with outpatient management, 98.2% vs 65.0% (OR = 25.3; 95% CI = 9.0 to 76.9). Frequent ED utilization (≥ 1 visit/month) was less likely in the AC patients, 9.2% vs 22.0% (OR = 0.35; 95% CI = 0.16 to 0.79) and school absenteeism was lower as well (9.5 ± 6.7 days vs 16.6 ± 10.3, p < 0.001). Additionally, the caregivers of the AC patients missed fewer workdays (4.7 ± 2.8 vs 7.4 ± 4.1; p = 0.03). Conclusions: Significant disparities in quality, access, resource utilization, and functional impact exist between AC and ED patients. Emergency physicians have a unique opportunity to improve the public health by directing ED patients toward pediatric AC treatment.
The Golden Hour: Scientific Fact or Medical “Urban Legend”?
Authors: Lerner E. Brooke , Moscati Ronald M.
Published: January 2008

The term “golden hour” is commonly used to characterize the urgent need for the care of trauma patients. This term implies that morbidity and mortality are affected if care is not instituted within the first hour after injury. This concept justifies much of our current trauma system. However, definitive references are generally not provided when this concept is discussed. It remains unclear whether objective data exist. This article discusses a detailed literature and historical record search for support of the “golden hour” concept. None is identified.
Evaluation of a Residency Program's Experience with a One‐week Emergency Medicine Resident Rotation at a Medical Liability Insurance Company
Authors: Houry Debra , Shockley Lee W.
Published: January 2008

Introduction: The authors' residency program implemented a one‐week rotation at the office of a medical liability insurance company. Residents examined 30 closed malpractice claims cases and sat in on settlement discussions. Objective: To review the residents' evaluations of their experiences and to determine whether this was a worthwhile addition to the emergency medicine (EM) residency curriculum. Methods: This was a five‐year retrospective study that reviewed residents' annual evaluations from 1994 to 1999 regarding the medical liability rotation. A five‐point scale was used to score specific categories in the rotation and an open‐ended section was used to collect general comments. Results: A total of 179 resident evaluations were reviewed. The quality of teaching ranked in the 80th percentile, the clinical caseload ranked in the 85th percentile, and level of responsibility ranked in the 79th percentile for all EM rotations. Specific comments included “All MDs should do this in their training”; “Quite an eye opener”; and “Good exposure to legal aspects of EM.”Conclusions: Overall, EM residents found the one‐week rotation to be invaluable and a good learning experience. This rotation ranked above average when compared with all of our other EM residency rotations.
Effects of Biphasic vs Monophasic Defibrillation on the Scaling Exponent in a Swine Model of Prolonged Ventricular Fibrillation
Authors: Wang Henry E. , Menegazzi James J. , Lightfoot Christopher B. , Callaway Clifton W. , Fertig Kristofer C. , Sherman Lawrence D. , Hsieh Margaret
Published: January 2008

Objective: Mathematical analyses of ventricular fibrillation (VF) have resulted in the derivation of a measure termed the scaling exponent (ScE) that characterizes the duration of VF and probability of defibrillation success. The purpose of this study was to compare the effects of biphasic defibrillation waveform (BDW) and monophasic defibrillation waveform (MDW) rescue shocks on ScE in a swine model of prolonged VF. Methods: Utstein guidelines for the laboratory study of cardiopulmonary resuscitation were followed. Twenty mixed‐breed domestic swine (mass range 20.5‐26.8 kg) were instrumented and randomized to receive either MDW or BDW rescue shocks. Ventricular fibrillation was induced and untreated for a nonintervention interval of 8 minutes. Rescue shocks were delivered at 8, 10, and 12 minutes of elapsed VF time. The energy sequence for the three MDW shocks was 70, 100, and 150 J (approximately 3, 4, and 6 J/kg). All BDW shocks were delivered at 50 J (approximately 2.5 J/kg). Only VF was shocked. Chest compressions and drugs were not provided. Rhythm analysis and ScE calculation were performed offline. Continuous and discontinuous linear regression models were fit to plots of ScE vs time. Defibrillation success and progression of ScE slope were analyzed using Fisher's exact test, paired t‐tests, and repeated‐measures analysis of variance (ANOVA). Results: Baseline characteristics were similar for both groups. Successful termination of VF occurred on the first rescue shock in 1 of 10 (10%) in the MDW group and 3 of 10 (30%) in the BDW group; this difference was not statistically significant (p = 0.58). No other defibrillation successes were observed. No animals achieved return of spontaneous circulation. The ScE values during the protocol progressed from 1.330 (95% CI = 1.287 to 1.373) to 1.724 (95% CI = 1.603 to 1.845) for MDW and 1.338 (95% CI = 1.261 to 1.415) to 1.639 (95% CI = 1.530 to 1.745) for BDW. Both groups showed a trend toward increasing ScE values with successive rescue shocks. Repeated‐measures ANOVA using both continuous and discontinuous models demonstrated no difference in overall ScE slope progression between study groups. Conclusions: Mode of defibrillation waveform (BDW vs MDW) does not appear to impact ScE trends. Additional studies must be performed to better evaluate the clinical implications of this finding.
Report from the Council of Emergency Medicine Residency Directors Subcommittee on Graduate Medical Education Funding: Effects of Decreased Medicare Support
Authors: Martin Daniel R. , Kazzi A. Antoine , Wolford Robert , Holliman C. James
Published: January 2008

Introduction: Recent changes by the Health Care Financing Administration (HCFA) have resulted in decreased Medicare support for emergency medicine (EM) residencies. Objective: To determine the effects of reduced graduate medical education (GME) funding support on residency size, resident rotations, and support for a fourth postgraduate year (PGY) of training and for residents with previous training. Methods: A 36‐question survey was developed by the Council of Emergency Medicine Residency Directors (CORD) committee on GME funding and sent to all 122 EM program directors (PDs). Responses were collected by the Society for Academic Emergency Medicine (SAEM) office and blinded with respect to the institution. Results: Of 122 programs, 109 (89%) responded, of which 78 were PGY 1‐3 programs, 19 were PGY 2‐4, and 12 were PGY 1‐4. The PDs were asked specifically whether there were changes in program size due to changes in Medicare reimbursement. Although few programs (12%) decreased their size or planned to decrease their size, 39% had discussions regarding decreasing their size. Thirty percent of the PDs responded that other programs at their institution had already decreased their size; 26% of the PDs had problems with financing outside rotations; and 24% had a decrease in off‐service residents in their emergency departments (EDs). Only seven (6%) of programs paid residents from practice plan dollars, while most (82%) were fully supported by federal GME funding. Nearly all four‐year programs (97%) received full resident salary support from their institutions and 77% of programs accept residents with previous training. Conclusions: Nearly all EM programs are fully supported by their institutions, including the fourth postgraduate year. Most programs take residents with previous training. Although few programs have reduced their size, many are discussing this. Many programs have had difficulty with funding off‐service rotations and many have had decreased numbers of off‐service residents in their EDs. Recent GME funding changes have had adverse effects on EM residency programs.