bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of a Statewide Trauma System on Rural Emergency Department Patient Assessment Documentation
Authors: Hedges Jerris R. , Mann N. Clay , Mullins Richard J. , Rowland Donna , Worrall William , Zechnich Andrew D. ,   For the OHSU Rural Trauma Research Group
Published: September 2008

Objective: To determine the association of rural ED patient assessment documentation with state trauma system implementation, hospital trauma categorization level (i.e., Level‐3 vs Level‐4), injury diagnosis, and patient demographics.

Methods: A pre‐ vs post‐system implementation (historical control) analysis of trauma documentation was performed using a sample of rural ED trauma patients from 4 Level‐3 and 5 Level‐4 trauma hospitals. The medical records of patients with specific index diagnoses in 4 anatomic regions (head, chest, liver/spleen, and femur/open‐tibia) were reviewed for 3‐year periods before statewide trauma system implementation and after hospital categorization. Vital sign, % inspired O2, and O2 saturation determinations were identified relative to the first and the last vital signs documented on the ED record. If not documented in the medical chart within 5 minutes of the first or last ED vital sign assessment, these measurements were considered missing. Separately, neurologic documentation (initial and final) also was sought for patients meeting criteria for an index head injury.

Results: Of 1,057 patients entered into the database, 532 were evaluated during the pre‐system period and 525 were evaluated during the post‐system period. Overall, 47% had a head injury, 34% had a chest injury, 23% had a femur/open‐tibia injury, and 12% had a spleen/liver injury. There were 142 (13%) patients with an injury in >1 index area. Except for initial systolic blood pressure, documentation of all other initial and final patient vital signs increased significantly (p < 0.05). Documentation of the Glasgow Coma Scale score (initial and final; p = 0.0001) and a final pupil examination on head‐injured patients (p = 0.025) also increased. The effects of hospital level, injury diagnosis, and patient demographics on documentation rate were minimal.

Conclusion: The study found overall improved ED documentation of trauma patient status in association with implementation of a statewide trauma system. This improvement in documentation suggests an enhanced process of care with trauma system participation.
The Potential of Using Billing Data for Emergency Department Injury Surveillance
Authors: Weiss Harold B. , Dill Susan M. , Garrison Herbert G. , Coben Jeffrey H.
Published: September 2008

Objective: To determine the availability of and sample statewide ED injury information obtained from hospital billing data for the purpose of demonstrating the feasibility of information acquisition for subsequent data linkage.

Methods: A retrospective, database investigation was conducted to obtain data describing a statewide stratified sample of ED patients. The aim was to collect a computerized billing summary record for each injured ED patient seen at each sampled hospital over a 1‐year period. All 215 Pennsylvania acute care hospitals in 1991 were eligible for sample selection. Data collection for the project was conducted in 1993. Participants included directors of hospital medical records and billing departments.

Results: Twenty‐four hospitals contributed data sets from the original target goal of 31 strata. The final combined data set contained 187,404 records with injury diagnoses from approximately 616,000 ED patient visits, representing a 12% sample of all annual statewide ED visits. Age, sex, date of visit, and primary diagnosis fields were completed from the retrieved data >99% of the time. More than two‐thirds of the sampled records had a social security number, and total charges were recorded >90% of the time. Other variables such as name and address were contained in <50% of the records submitted. E‐codes were usually not available.

Conclusions: Retrospective compilation of multihospital ED billing data to create a statewide ED data sample—with the potential for injury research and probabilistic database linkage—can be accomplished; there are, however, important limitations.
Is Closed Diagnostic Peritoneal Lavage Contraindicated in Patients with Previous Abdominal Surgery?
Authors: Moore Gregory P. , Alden Andrew W. , Rodman George H.
Published: September 2008

Objective: To compare the accuracies and complication rates of diagnostic peritoneal lavage (DPL) in trauma patients with and without previous abdominal surgery.

Methods: A retrospective review of DPL accuracy and complication rate was performed using all ED trauma patients who underwent DPL during 1993 as identified by the trauma registry. Care was provided at a Level‐1 trauma center, a 1,100‐bed, central‐city teaching hospital with an annual ED census of 84,000. Records were reviewed for a history of previous surgery, DPL results, complications, mechanism of injury, and location of abdominal scars. DPL was performed using the Seldinger technique with a standard Arrow Diagnostic Peritoneal Lavage Kit using an 8‐Fr catheter. Rates for patient groups with and without previous abdominal surgery were compared using Fisher's exact test. A “misclassified” DPL was defined as either a positive DPL with negative laparotomy or a negative DPL with subsequent need for laparotomy. “Complications” were defined as iatrogenic injury during the procedure or inability to obtain return of fluid during the lavage.

Results: A total of 372 DPLs were performed; 42 in patients with previous surgery and 330 in patients without prior surgery. The groups were similar with respect to proportion with blunt trauma (95% vs 97%), positive DPL (19% vs 19%), misclassified rate (2.4% vs 1.8%), and complication rate (2.4% vs 0.9%); no significant difference was found between groups. The previous abdominal surgeries were appendectomy (n = 20), tubal ligation (n = 5), abdominal hysterectomy (n = 4), cholecystectomy (nonlaparoscopic) (n = 4), pyloric stenosis (n = 1), uterine prolapse (n = 1), undescended testis (n = 1), partial gastrectomy (n = 1), and unknown (n = 5). The analysis had a 90% power of detecting a 10% difference between the 2 groups.

Conclusion: The complication rate and accuracy of closed DPL in patients with previous abdominal surgery were similar to those for DPL performed in patients without previous abdominal surgery.
Violence against Women: Provider Barriers to Intervention in Emergency Departments
Authors: McGrath Meghan E. , Bettacchi Andrea , Duffy Susan J. , Peipert Jeffrey F. , Becker Bruce M. , Angelo Linda St.
Published: September 2008

Objective: To determine: 1) provider behavior in screening for domestic violence (DV) and sexual assault (SA); 2) provider training in DV and SA; 3) provider knowledge of available protocols for DV and SA; and 4) provider perception of barriers to intervention.

Methods: Anonymous, structured surveys were distributed to physicians, nurses, and social workers at an adult ED trauma center, an affiliated pediatric ED, and a women's urgent care center between July and September 1995.

Results: Of 207 staff members (59%) responding, 54% and 68% indicated that they never/rarely screen for DV or SA, respectively. Thirty‐five percent had received no DV training and 27% had received no SA training. Thirty‐one percent of the staff had knowledge of existing protocols for DV and 63% had knowledge of existing protocols for SA. Providers trained in DV were more likely to screen for DV (RR 1.5, 95% CI 1.27–1.92, p ≤ 0.001) and SA (RR 1.49, 95% CI 1.24–1.79, p ≤ 0.0018), and providers trained in SA were more likely to screen for SA (RR 1.32, 95% CI 1.13–1.54, p = 0.0019) and DV (RR 1.35, 95% CI 1.13–1.60, p = 0.0007). Barriers that the majority of staff experienced in the care of DV/SA victims included: frustration that the victim would return to an abusive partner, concerns about misdiagnosis, lack of time, personal discomfort, reluctance to intrude into familial privacy, and lack of 24‐hour social service support.

Conclusion: Providers surveyed had received little training in and rarely screen for violence, and there are a range of personal and institutional barriers impeding intervention with victims of SA and DV. Institutional changes to enhance training and support providers working in the front line of this epidemic may improve services for victims of violence.
Injury Prevention: Is There a Role for Out‐of‐hospital Emergency Medical Services?
Authors: Kinnane Janet M. , Garrison Herbert G. , Coben Jeffrey H. , Alonso‐Serra Hector M.
Published: September 2008

Objective: To review the literature for options for integrating injury prevention into the role of out‐of‐hospital emergency medical services (EMS).

Data Sources: Computerized searches of the English‐language literature from 1966 through 1994 were conducted using the MEDLINE and National Association of EMS Physicians (NAEMSP) databases. These were supplemented by hand searches of pertinent journals not indexed on MEDLINE or by NAEMSP and the reference lists of retrieved articles. Key words searched included emergency medical services, accident, injury, prevention, and safety.

Article Selection: The review included all articles that described the experience of EMS organizations or individuals providing primary injury prevention (PIP) services or that proposed EMS PIP activities. Synthesis: PIP EMS experiences and PIP activities proposed for EMS included: preventing injuries in EMS providers, serving as role models, identifying persons at risk for injury, providing prevention counseling, collecting injury data, surveying residences and institutions for injury risks and hazards, conducting educational programs and media campaigns, and advocating legislative changes that promote injury prevention. Few studies have evaluated the effectiveness of EMS PIP activities.

Conclusion: As changes in the market compel health care systems to focus more on prevention, EMS organizations and individual providers may be assuming new injury prevention roles. Some EMS systems in many parts of the country have incorporated PIP into their work. It is necessary, however, to determine which PIP roles are effective and how they will be supported.
The Effect of Hypertonic Sodium and Dantrolene on Propranolol Cardiotoxicity
Authors: Kerns William , Ransom Mary , Tomaszewski Christian , Raymond Richard
Published: September 2008

Objective:To evaluate whether measures that lower cytosolic calcium (Ca) can reverse propranolol (prop) toxicity in the isolated, perfused rat heart.

Methods:Isolated rat hearts were perfused on a Langendorff apparatus with Krebs‐Henseleit‐bicarbonate (KHB) buffer solution. Toxicity was produced by perfusing the hearts with prop (5 (μg/mL) for 30 minutes. Subsequently, the hearts were treated for 30 minutes with buffer containing prop plus experimental treatment. Three treatments were chosen: hypertonic sodium (Na) (160 mmol), to stimulate Na‐Ca exchange, dantrolene (dan) (10 μmol), to inhibit Ca release from sarcoplasmic reticulum, and combined hypertonic Na and dan. The hearts were paced after 20 minutes of treatment. Heart rate (HR), left ventricular peak systolic pressure (LVP), the first derivative of LVP (dP/dt), and coronary flow were measured.

Results:prop decreased HR and rendered the hearts refractory to pacing, prop did not alter dP/dt. prop increased LVP consistent with increased cytosolic Ca. Combined hypertonic Na and dan treatment restored the ability to pace PROP‐toxic hearts to the basal HR. Individually, hypertonic Na or dan treatment partially restored the ability to pace toxic hearts. As experimental treatments increased HR, dP/dt and LVP decreased, consistent with decreased cytosolic Ca availability.

Conclusion:These data are consistent with the hypothesis that bradycardia during β‐blocker cardiotoxicity is mediated by altered Ca homeostasis.
Out‐of‐hospital Experience with the Syringe Esophageal Detector Device
Authors: Pelucio Maria , Halligan Luanne , Dhindsa Harinder
Published: September 2008

Objective: To determine the accuracy of a syringe esophageal detector device (EDD) for detecting esophageal intubations in an out‐of‐hospital setting.

Methods: Prospective, observational study of adult (age ≥18 years) patients intubated by paramedics from October 1993 through May 1994 in an urban emergency medical services (EMS) system. Paramedics were instructed to record the EDD reading after endotracheal tube placement. However, paramedics were instructed not to modify their tube locations based on the EDD reading. Tube placement was evaluated by a physician upon patient arrival at a local ED.

Results: Paramedics performed 374 intubations during the study period, and in 213, the EDD was used. Of these 213 patients, 45 were excluded from analysis (32—tube placement not confirmed, 11—paramedic uncertain of EDD reading, 2—too young). In the remaining 168 intubations, the EDD correctly identified 5 of 10 esophageal intubations (sensitivity 50%; 95% CI: 19%, 81%). The EDD correctly identified 156 of 158 tracheal intubations (specificity 99%; 95% CI: 96%, 100%).

Conclusions: In this paramedic field study, the EDD demonstrated poor sensitivity for esophageal intubations. Further EMS studies of the EDD are needed to clarify the value of the device in out‐of‐hospital emergent clinical intubations.
Bioimpedance Cardiac Output Measurements in Patients with Presumed Congestive Heart Failure
Authors: Weiss Steven J. , Kulik James P. , Calloway Edward
Published: September 2008

Objective: To describe preliminary ED experience with thoracic electrical bioimpedance (TEB) for evaluation of patients with complaints suggestive of congestive heart failure (CHF).

Methods: A 6‐month, prospective, observational study was performed using a convenience sample of patients with signs and symptoms consistent with CHF. Patients were excluded if they had received medication prior to arrival in the ED, if they were obese, and if they had unstable vital signs. They also were excluded if they were combative, refused to sign consent, or had invasive lines that did not allow for TEB lead placement. Patients also were excluded if the study could not be completed because the patient was taken from the department for a diagnostic test, or if there were no good follow‐up records available 6–12 months after the patient's visit. The patient's physician was blinded to the output of the TEB monitor. Cardiac output (CO), stroke volume (SV), end‐diastolic volume (EDV), thoracic fluid index (TFI), and acceleration index (ACI) were recorded at 5‐minute intervals. Results were evaluated for the time intervals 0–5 minutes, 30–35 minutes, and 60–65 minutes.

Results: Seven patients were included in the study. The echocardiographic diagnoses were hypertrophic car‐diomyopathy (2 cases), dilated cardiomyopathy (2 cases), ischemic cardiomyopathy (1 case), right ventricular hypertrophy (1 case), and pericardial effusion (1 case). Significant changes were seen in all cardiac parameters, with variance from individual to individual.

Conclusions: Significant differences in TEB variables exist between patients who appear similar on initial examination in the ED. Changes noted on TEB may help to further elucidate physiologic differences. The clinical use of TEB‐based hemodynamic measurements to guide presumed CHF patient management remains speculative.
Predictors of Repeat Emergency Department Visits by Elders
Authors: McCusker Jane , Healey Elizabeth , Bellavance François , Connolly Brian
Published: September 2008

Objective: To determine which characteristics of older patients who use a hospital ED are associated with repeat visits during the 90 days following the index visit.

Methods: The study was conducted in the ED of a 400‐bed university‐affiliated acute care community hospital in Montreal. Patients aged ≥75 years who visited the ED between 08:00 and and 16:00 on a convenience sample of days over an 8‐week period (July and August 1994) were assessed using a questionnaire, physical and cognitive status instruments, and a functional problem checklist. The hospital's administrative database was used to identify repeat visits during the 90 days following the ED visit. The representativeness of the sample was assessed by analyses of ED visits made by 4,466 persons aged ≥65 years during a 12‐month period (September 1993 to August 1994) using the hospital's administrative database.

Results: 256 patients aged ≥75 years visited the ED during the study period and 167 were assessed. Of these, 54 (32%) were admitted to the hospital. Among the 113 patients released from the ED, 27 (24%) made repeat visits during the next 90 days. In univariate analyses, repeat visits were significantly associated with the number of functional problems, cognitive impairment, and previous ED visits. In multiple logistic regression, male gender, living alone, and number of functional problems were independent predictors of repeat visits. In the administrative data analyses, nighttime arrival to the ED for the index visit was significantly associated with repeat visits.

Conclusions: Self‐reported risk factors can help to identify a group of elders likely to make repeated ED visits; the development of a screening instrument incorporating questions on these problems and implementation of appropriate interventions might improve these patients' quality of life and reduce the demand for further ED care in this age group.
Early Diagnostic Efficiency of Cardiac Troponin I and Troponin T for Acute Myocardial Infarction
Authors: Tucker John F. , Collins Richard A. , Anderson Alfred J. , Hauser Jacqueline , Kalas John , Apple Fred S.
Published: September 2008

Objective: To compare the early diagnostic efficiency of the cardiac troponin I (cTn‐I) level with that of the cardiac troponin T (cTn‐T) level, as well as the creatine kinase (CK), CK‐MB, and myoglobin levels, for acute myocardial infarction (AMI) in patients without an initially diagnostic ECG presenting to the ED within 24 hours of the onset of their symptoms.

Methods: A prospective, observational, cohort study was performed involving chest pain patients admitted to a large urban community hospital. Participants were consecutive consenting ED chest pain patients ≥30 years of age. Exclusions included duration of symptoms >24 hours, inability to complete data collection, receipt of CPR, and ST‐segment elevation on the initial ECG. Measurements included levels of cTn‐I, cTn‐T, CK, CK‐MB, and myoglobin at the time of presentation and 1, 2, 6, and 12–24 hours after presentation as well as presenting ECG and clinical follow‐up. Confirmation of the diagnosis of AMI was based on World Health Organization criteria.

Results: Of the 177 patients included in the study, 27 (15%) were diagnosed as having AMIs. The sensitivities of all 5 biochemical markers for AMI were poor at the time of ED presentation (3.7–33.3%) but rose significantly over the study period. The sensitivity of cTn‐T was significantly better than that of cTn‐I over the initial 2 hours, but both markers' sensitivities were low (<60%) during this time frame. The cTn‐I was significantly more specific for AMI than was the cTn‐T, but not significantly better than CK‐MB or myoglobin. Likelihood ratio analysis showed that the biochemical markers with the highest positive likelihood ratios for AMI during the first 2 hours following ED presentation were myoglobin and CK‐MB. From 6 through 24 hours, the positive likelihood ratios for cTn‐I, CK‐MB, and myoglobin were superior to those of CK and cTn‐T.

Conclusions: cTn‐I, CK‐MB, and myoglobin are significantly more specific for AMI than are CK and cTn‐T. Myoglobin is the biochemical marker having the highest combination of sensitivity, specificity, and negative predictive value for AMI within 2 hours of ED presentation. Neither cTn‐I nor cTn‐T offers significant advantages over myoglobin and CK‐MB in the early (≤2 hours) initial screening for AMI. The cardiac troponins are of benefit in identifying AMI ≤6 hours after presentation.
Thermal Effects of Neutralization Therapy and Water Dilution for Acute Alkali Exposure in Canines
Authors: Homan Clark S. , Singer Adam J. , Henry Mark C. , Thode Henry C.
Published: September 2008

Objective: To evaluate the change in temperature of the gastric mucosa and lumen contents when a weak acid or water is used to manage acute alkali exposure.

Methods: A prospective in‐vivo canine model was used in a university‐based animal laboratory setting. Eighteen adult canines weighing 20–25 kg were placed under a surgical plane of anesthesia and a laparotomy was performed. A gastrotomy was then made after ligation of the distal esophagus and proximal duodenum. Separate mucosa and lumen temperature probes were placed. Then 25 mL of room‐temperature (24–26°C) 50% sodium hydroxide (NaOH) was instilled in the gastric lumen. After 5 minutes, each canine was given treatment. Group 1 (n = 10) was treated with 75 mL of room‐temperature orange juice. Group 2 (n = 8) was treated with 75 mL of room‐temperature water. Continuous mucosa and lumen temperatures were observed and recorded at baseline and at specified intervals for 35 minutes after the alkali insult. Repeated‐measures analysis of variance was used to evaluate the overall temperature profile. Signed‐rank tests were used to compare the changes in temperature immediately following neutralization treatment.

Results: Significant temperature decreases of 1.1°C and 2.1°C were observed for both mucosa (p = 0.002) and lumen (p < 0.001) temperatures, respectively, following neutralization therapy with room‐temperature orange juice. In the group treated with room‐temperature water, significant temperature decreases of 2.1°C for mucosa (p = 0.01) and 2.4°C for lumen (p = 0.01) were observed. Posttreatment temperatures did not exceed baseline for the entire observation period.

Conclusion: Neutralization therapy with room‐temperature orange juice or water dilution for acute gastric injuries by liquid alkali does not cause a rise in mucosal or intraluminal temperatures in an in‐vivo canine model.
Effect of Hypothermia, Dichloroacetate, and Deferoxamine in the Treatment for Cortical Edema and Functional Recovery after Experimental Cortical Impact in the Rat
Authors: Heegaard William , Biros Michelle , Zink Julie
Published: September 2008

Objective: To investigate the effects of hypothermia alone or in combination with dichloroacetic acid (DCA) and/or deferoxamine (DFO) in reducing cortical edema (CE) and improving neurologic functional recovery after moderate closed head trauma with controlled cortical impact (CCI).

Methods: Anesthetized rats were randomized to receive right parietal moderate CCI (impact depth 2 mm, speed 3.5 m/sec) or sham operations. Immediately after trauma, the animals underwent selective brain cooling to 30°C (temporalis muscle temperatures). Ten minutes after trauma, the randomized animals received intra‐peritoneal doses of DCA (25 mg/kg), DFO (50 mg/kg), both DCA and DFO, or equivolume normal saline. For evaluation of cortical edema, some animals (n = 42) were sacrificed 4 hours after trauma and cortical specific gravity (SpG) was determined gravimetrically. The other animals (n = 47) were evaluated for functional recovery beginning 6 days posttrauma. Neurobehavioral performance was assessed in the Morris water maze.

Results: Cortical edema was significantly less in the animals treated with hypothermia (SpG = 1.041 ± 0.001, p < 0.05) compared with the untreated traumatized animals (SpG = 1.037 ± 0.001). Combination treatment with hypothermia and drug treatment did not reduce cortical edema when compared with no treatment. Hypothermia with and without drug treatment did not improve neurobehavioral performance when compared with no treatment.

Conclusions: In this pilot study with a relatively small sample size, hypothermia alone significantly reduced post‐CCI cortical edema as measured by SpG. Hypothermia combined with drug treatment did not reduce posttraumatic cortical edema. Hypothermia with and without drug therapy did not improve functional neurologic recovery in the rats subjected to CCI.
A Pilot Study of the Predictive Value of Plasma Tumor Necrosis Factor α. and Interleukin 1β for Streptococcus pneumoniae Bacteremia in Febrile Children
Authors: Strait Richard T. , Ruddy Richard M. , Friedland Leonard R. , Duncan Kathy M. , Wilmott Robert W.
Published: September 2008

Objective: To determine the value of tumor necrosis factor α (TNF) and interleukin 1β (IL1) levels in predicting Streptococcus pneumoniae bacteremia in nontoxic‐appearing, febrile children who do not have a bacterial source for their fever on physical examination.

Methods: A prospective, nested case‐control study was conducted in a children's hospital ED. All febrile children <3 years old who were believed to be immunocompetent and not in shock, had no obvious bacterial source for their fever on physical examination, and had a blood culture obtained were eligible. Plasma obtained at the time of the blood culture was available for analysis by enzyme‐linked immunosorbent assays for TNF and ILL Children who had positive blood cultures for Streptococcus pneumoniae were the cases. The controls were selected from children who had negative blood cultures.

Results: During a 1‐year period, 12 cases and 65 controls were identified. There was no significant difference in age, height or duration of fever, or illness acuity between the groups. The following were used as threshold values for a positive test: white blood cell (WBC) count >15.0 × 109 cells/L, TNF >21.5 ng/mL, and IL1 >9.0 ng/mL. Using an estimated prior probability of bacteremia of 4%, the positive predictive value (PPV) and the negative predictive value (NPV) for bacteremia were 11.7% and 98.6% using the WBC count, 11.1% and 98.6% using the IL1 level, and 9.0% and 98.9% using the TNF level. The combination of WBC count with either TNF or IL1 gave an NPV of 100%, with PPVs of 8.5% for TNF and 9.9% for ILL

Conclusions: Like the WBC count, TNF and IL1 are good negative but poor positive predictors of Streptococcus pneumoniae bacteremia in nontoxic‐appearing, febrile children. At present, the addition of plasma TNF or IL1 levels would add little to emergency physicians' ability to predict Streptococcus pneumoniae bacteremia. However, as the quantification of these cytokines becomes more rapid, available, and standardized, and more knowledge of TNF and IL1 levels during various illnesses is gained, their utility in the clinical setting for ruling out bacteremia should be further assessed.
Left Bundle Branch Block Pattern Complicating the Electrocardiographc Evaluation of Acute Myocardial Infarction
Authors: Brady William J. , Aufderheide Tom P.
Published: September 2008

The ECG diagnosis of ischemic heart disease is made more difficult in the setting of left bundle branch block (LBBB). The ECG diagnosis of prior or remote myocardial infarction (MI) is extremely difficult in this setting. Furthermore, the associated—and expected—ST‐segment‐T‐wave abnormalities of LBBB may mimic acute ischemic change. However, ECG detection of abnormalities arising from acute ischemic cardiac disease in the setting of LBBB can be valuable. Several strategies are available to the emergency physician (EP) to assist in the correct interpretation of this ECG pattern, including: a knowledge of the anticipated ST‐segment‐T‐wave changes of LBBB and, consequently, the ability to recognize ischemic morphologies; the performance of serial ECGs demonstrating dynamic changes encountered in ischemic patients; and a comparison with previous ECGs. Three cases are reported in which an analysis of the 12‐lead ECG in the setting of LBBB assisted the EP in establishing the correct diagnosis of acute Ml and applying timely, appropriate therapy.
Safety and Efficacy of Flumazenil in Reversing Conscious Sedation in the Emergency Department
Authors: Chudnofsky Carl R.
Published: September 2008

Objectives: To evaluate the safety and efficacy of flumazenil vs placebo in reversing fentanyl and midazolam‐induced conscious sedation in ED patients undergoing a short, painful procedure.

Methods: This was a multicenter, randomized, parallel, double‐blind, placebo‐controlled study conducted at 9 university‐affiliated teaching hospitals. Patients >18 years of age requiring conscious sedation for a painful procedure expected to last <20 minutes were eligible for inclusion in the study. Patients received 2 μg/kg of fentanyl, followed by midazolam titrated to the desired level of sedation. Patients were then randomized to receive either flumazenil or placebo in a 3:1 ratio (flumazenihplacebo). Vital signs, O2 saturation, and alertness were recorded at regular intervals. Prior to ED release, patients were asked to rate the amount of discomfort they experienced and the level of relaxation achieved on a 10‐cm visual analog scale (VAS). They also were questioned about their recall for the procedure and satisfaction with the drug regimen. Physicians also rated their satisfaction with the drug regimen on a 10‐cm VAS.

Results: Overall, 133 patients received flumazenil and 46 patients received placebo. Patients in the 2 groups received similar doses of midazolam. The patients who received flumazenil returned to baseline alertness earlier (11.1 min vs 24.8 min, p < 0.001) and at a faster rate than did the patients given placebo. Actual intervals from procedure completion until release from the ED did not differ between the 2 groups (98.2 ± 3.6 min flumazenil vs 96.9 ± 5.8 min placebo; p = 0.89). The amounts of discomfort experienced, levels of relaxation achieved, recalls for the procedure, and both patient and physician satisfactions were also similar for the 2 groups. There were no serious adverse effects related to the study drug, and minor adverse effects were similar for the 2 groups.

Conclusion: Flumazenil is safe and efficacious in reversing midazolam‐induced sedation in ED patients given a combination of fentanyl and midazolam to facilitate the performance of a short, painful procedure. The patients given flumazenil returned to baseline alertness earlier and at a faster rate than did the patients given placebo. However, flumazenil did not alter the actual interval from procedure completion until ED release.
Normal Intrauterine Pregnancy Is Unlikely in Emergency Department Patients with Either Menstrual Days >38 Days or β‐hCG >3,000 mlU/mL, but without a Gestational Sac on Ultrasonography
Authors: Dart Robert , Kaplan Beth , Ortiz Luis , Cloherty John , Lavoie Thomas
Published: September 2008

Objective: To determine whether the absence of a gestational sac on transvaginal ultrasonography in patients with a quantitative beta‐human chorionic gonadotropin (β‐hCG) >3,000 mIU/mL and/or menstrual days >38 excludes the diagnosis of a normal intrauterine pregnancy (IUP).

Methods: A retrospective analysis was performed of ED patients evaluated from August 1991 to December 1994 at an urban teaching hospital. Patients presented with abdominal pain and/or vaginal bleeding and had a positive serum β‐hCG test. Patients who had transvaginal ultrasonographies performed during the ED visit that were read as indeterminate were reviewed. Menstrual days were determined by subtracting the date of the last normal menstrual period (LMP) from the ED visit date. ED β‐hCGs were quantified. Patients were excluded if the LMP or quantitative β‐hCG result was not available or if the final diagnosis could not be definitively determined.

Results: 248 patients met eligibility criteria; of these, 54 were excluded. Therefore, 194 patients were enrolled. Menstrual days ranged from 5 to 151, with a median of 54 days. Of 143 patients with menstrual days >38 and no gestational sac by ultrasonography, only 4 (2.8%) had a final diagnosis of normal IUP. The menstrual days for the 4 normal IUPs were 39, 41, 42, and 59 days. β‐hCGs ranged from 19 to 151,926 mIU/mL, with a median of 2,410 mIU/mL. None of the 74 patients with a β‐hCG >3,000 mIU/mL and no gestational sac by ultrasonography had a final diagnosis of normal IUP.

Conclusion: In patients with either a β‐hCG >3,000 mIU/mL or menstrual days >38 and no gestational sac by transvaginal ultrasonography, the likelihood of a normal IUP is low.
Are Emergency Department Patients Thinking about Advance Directives?
Authors: Llovera Ingrid , Mandel Francine S. , Ryan James G. , Ward Mary F. , Sama Andrew
Published: September 2008

Objectives: To assess the percentage of adult patients presenting to an urban ED who have a written advance directive (AD) and to determine whether age, sex, a patient's perception of his or her health status, and having a regular physician are associated with the patient's having an AD.

Methods: This was a cross‐sectional patient survey performed at a community teaching hospital ED. Surveys were completed by 511 adult ED patients during representative shifts over a 3‐month period. The questions included age, sex, “self‐reported” health status, whether the patient had a “regular” physician, a patient‐generated list of medical problems, and whether the patient had a written AD. For this study, ADs included health care proxies, living wills, and do‐not‐attempt‐resuscitation (DNAR) orders.

Results: Of the patients surveyed, 27% reported having an AD. Males and females were equally likely to have an AD. Factors associated with an increased likelihood of having an AD were older age, having a “regular” physician, and the patient's perception of his or her health status as ill. Most patients who had an AD (82%) discussed it with their families, but only 48% discussed it with their physicians.

Conclusion: Only 27% of the adult patients presenting to the ED had an AD. Older age, the patient's perception of his or her health status as ill, and having a “regular” physician increased the likelihood of having an AD.
Vertebral Artery Dissection
Authors: Showalter William , Esekogwu Victor , Newton Kim I. , Henderson Sean O.
Published: September 2008

ABSTRACT

Vertebral artery dissections (VADs) following a variety of minor traumatic mechanisms have been previously reported. This article reports 2 cases of VAD with delayed recognition following motor vehicle collisions (MVCs). The first VAD patient developed major neurologic abnormalities 28 hours after an MVC. The second VAD patient presented with 3 weeks of neck and head pain beginning 8 weeks after an MVC and subsequent chiropractic manipulation. The anatomy and pathophysiology of VAD are reviewed. Early ED recognition prior to the onset of major neurologic deficits (e.g., paresis, dysarthria, ataxia, or altered mental status) is emphasized. An algorithm for the ED management of the entity is suggeste
Tumor Necrosis Factor Activity Increases in the Early Response to Trauma
Authors: Ferguson Kevin L. , Taheri Paul , Rodriguez Jorge , Tonapi Vijay , Cardellio Anthony , Dechert Ron
Published: September 2008

Objectives: 1) To determine whether tumor necrosis factor (TNF) up‐regulation occurs in the first hours following severe injury. 2) To determine whether the time from injury to blood sampling affects the probability of detecting TNF.

Methods: A prospective, cross‐sectional study was performed using a convenience sample of adult major trauma patients (“patients”) treated at a university hospital ED (Level‐1 trauma center) and 20 healthy volunteers (“controls”). The time interval from injury to specimen collection (ΔT), the injury severity scale (ISS) score, patient demographics, and quantitative cytokine [TNF and interleukin (IL‐6, IL‐8)] levels were measured. In the patients, cytokine levels were analyzed as a function of ΔT (using first hourly cutoff points and then the median T as an arbitrary cutoff point) with and without potential confounders (e.g., ISS, age, gender).

Results: The mean ΔT was 92.8 ± 49.2 min (range 10–210 min, median 82 min). In the controls, TNF activity was present in 96%, with a mean level of 125 pg/mL. The controls showed no baseline IL‐6 activity and only 10% had a measurable baseline IL‐8 level. In the patients, TNF was present in 93%, with a mean level of 628 ±138 pg/mL. When the patients' specimens were divided at the median to obtain roughly equal‐sized groups, more TNF levels were elevated >2.5 SD above the controls in the early vs late group (51% vs 30%; p = 0.07). The mean levels of TNF and IL‐8 also were higher in the early vs late group (756 vs 530 and 287 vs 135, respectively; p < 0.05).

Conclusions: TNF levels are elevated in the immediate 4 hours post‐injury. Previous investigators' inability to detect TNF activity increases may be related to delays in sampling. These results are consistent with the theory that increased TNF activity occurs early after major trauma and may initiate subsequent cytokine activity.
Pediatric Gamma Hydroxybutyrate Intoxication
Authors: Suner Selim , Szlatenyi C. Stephen , Wang Richard Y.
Published: September 2008

Reported are 2 uncommon cases of childhood gamma hydroxybutyrate (GHB) toxicity and the surreptitious manner in which GHB was made. Two children unintentionally ingested a soft drink containing GHB and were found comatose. Both had been well 1 hour earlier. The parent had made GHB by combining gamma butyrolactone with caustic soda (sodium hydroxide). Symptoms were early in onset and resolved in 24 hours. The ECG changes in one case are unique to GHB toxicity and are unexplained. GHB‐toxic children appear similar to adults who have this poisoning. Supportive management remains the mainstay of therapy. Health care providers should be aware of GHB's clandestine production and its increasing presence on the streets and in the home. This agent is not detected with common drug screens.
Linking Large Administrative Databases: A Method for Conducting Emergency Medical Services Cohort Studies Using Existing Data
Authors: Waien Sohail A.
Published: September 2008

Objective: To evaluate probabilistic matching for linking a cohort of cardiac arrest (CA) patients identified in the Metro Toronto Ambulance (MTA) database in Toronto, Ontario, Canada, to their appropriate record in either the Vital Statistics Information System (VSIS) or the Canadian Institute of Health Information (CIHI) databases and thus establish their clinical outcomes.

Methods: A linkage of a large administrative database was performed. A cohort of patients who suffered an out‐of‐hospital CA during the calendar years 1988 — 1993 was identified. To determine the patients' outcomes, the cohort was probabilistically linked to patient records in the VSIS and CIHI databases. Identifying variables used during the process of linking records included: names (first and last); New York State Identification and Intelligence System (NYSIIS) code; date of event; date of death; city; admitting hospital number; mode of admission to hospital; age; and sex.

Results: A cohort of 7,079 CA patients was identified from the MTA database; 6,448 (91%) patients were accurately linked to records in 1 of the 2 outcome databases (CIHI, VSIS). Missing data for ≥1 of the linking variables were responsible for unlinked records. Using these longitudinal data, it was possible to determine the number of patients surviving their out‐of‐hospital CAs to be admitted to hospital (n = 833) (16%). No differences in survival rates (p = 0.06) or median lengths of hospital stay among the survivors (p = 0.15) were observed between admitting hospitals.

Conclusions: Probabilistic matching is an effective method by which researchers can use existing administrative data to determine outcomes of population cohorts. This is especially valuable in situations where controlled intervention studies are not feasible or may be inappropriate. In this analysis, in‐hospital management of admitted CA patients, as determined by hospital‐specific survival rates and length of stay, suggests no measurable differences in the care provided to these patients by hospitals in Toronto.
Computed Tomography Scanning and Delirium in Elder Patients
Authors: Naughton Bruce J. , Moran Maureen , Ghaly Youssef , Michalakes Chris
Published: September 2008

Objective: 1) To examine the ordering of head CT scans in elder patients with delirium and cognitive impairment; and 2) to report CT scan findings associated with these conditions.

Methods: This was a 2‐part study. Part 1 was a prospective, observational study of 560 adults >70 years of age evaluated at 3 separate EDs using a 200‐hour stratified sampling process at each ED. During Part 1, the frequencies of specific findings (i.e., delirium, impaired consciousness, and impaired cognition) and CT scan rates for these groups were determined. Part 2 was a retrospective analysis of CT scan reports and medical records (n = 279) for patients >70 years of age in the prospective sample (n = 79) and from a sample (n = 200) of CT scans obtained at a fourth ED. Part 2 examined clinical findings detected in the ED to determine those factors that were associated with acute findings on CT scan.

Results: Part 1: There were 333 (59.4%) patients prospectively classified as having impaired cognition, impaired consciousness, or delirium; 79 (23.7%) of these patients had a head CT scan. Of these 3 groups, delirious patients were more frequently scanned (p < 0.001). Part 2: Of 279 CT scans, 42 (15.0%) were positive for an acute condition (hemorrhage, hematoma, space‐occupying lesion, infarct). Of 42 positive scans, 40 (95.1%) were found in the 102 (36.6%) patients with either impaired consciousness or a new focal neurologic finding detected in the ED.

Conclusions: Considerable variability in ED CT scan ordering exists for elder patients with neurologic findings. Impaired consciousness and/or new focal neurologic signs are associated with acute findings on CT scan in elder patients. Acute CT abnormalities are uncommon in elder ED patients with other neurologic findings. Additional prospective evaluation is warranted prior to guideline development for CT scans in this patient population.
Analysis of the Treatment of Spontaneous Sustained Stable Ventricular Tachycardia
Authors: Marill Keith A. , Greenberg Gary M. , Kay Darren , Nelson Brian K.
Published: September 2008

Objectives: To determine the termination rate of spontaneous sustained stable ventricular tachycardia (SSSVT) as a function of the first and second therapeutic interventions used, and to determine factors associated with successful termination.

Methods: A multihospital, retrospective analysis of the treatment of patients with SSSVT was performed. The setting included 2 urban county hospitals, 2 urban private hospitals, and a Veterans Affairs hospital. Cases were identified by discharge diagnosis and ECG characteristics, and confirmed by electrophysiology study or ECG criteria.

Results: There were 40 cases of SSSVT identified. Excluding adenosine, 35 patients were treated with lidocaine as a first intervention. The rate of termination with lidocaine bolus was 17% (6 of 35) (95% CI 7–34%). Regarding the 35 patients initially treated with lidocaine, the odds of termination of SSSVT were 11 times greater in those without a history of previous myocardial infarction (MI) than in those with a history of MI (95% CI 0.96–551). Of the 29 patients who failed initial lidocaine treatment, 23 were treated with a second lidocaine bolus, with a termination rate of 18% (4 of 22) (95% CI 5–40%). Only 2 patients with sustained ventricular tachycardia had a concurrent MI, and the tachycardia was unresponsive to initial lidocaine bolus in both cases. Fifteen patients received adenosine with no tachycardia terminations and no significant adverse effects.

Conclusions: The rate of SSSVT termination with lidocaine was low, particularly in patients with a history of MI.
Adverse Outcomes of Managed Care Gatekeeping
Authors: Young Gary P. , Lowe Robert A.
Published: September 2008

Objectives: To determine whether telephone preauthorization for reimbursement of ED care (medical “gate‐keeping”) by managed care organizations (MCOs) is associated with adverse outcomes.

Methods: A structured review was performed of case reports solicited during 1994 and 1995 with possible adverse outcomes related to managed care gatekeeping. Gatekeeping was defined as the requirement imposed by an MCO that ED staff contact on‐call gatekeepers (i.e., clinical or nonclinical MCO personnel) to request preauthorization for ED treatment (a requirement that such MCOs enforce by refusing payment for the ED care unless preauthorization is obtained). Cases in which gatekeeper denial of preauthorization occurred were sought. Two physicians agreed on patient eligibility and classification criteria, then independently, retrospectively classified case reports identified as MCO ED payment denials into 1 of 4 categories: 1) adverse outcome; 2) patient placed at increased risk of death or disability; 3) “near miss” (emergency physicians prevented adverse outcome by caring for patient despite denial); and 4) none of the above.

Results: Of the 143 cases reviewed, 29 reports represented MCO ED payment denial. Of these 29 eligible cases, there were 4 (14%) patients with adverse outcomes, 4 (14%) patients placed at increased risk, and 21 (72%) near misses. All of the 29 cases came from different EDs, representing 9 different states, with the majority from California. Adverse outcomes included respiratory failure from fulminant meningococcemia, hypovolemic syncope from ruptured ectopic pregnancy, hypovolemic arrest from vascular fibroid hemorrhage necessitating emergency hysterectomy, and prolonged postoperative course following ruptured duodenal ulcer. Patients placed at increased risk were diagnosed as having epiglottitis, myocardial infarction, ruptured ectopic pregnancy, and delayed treatment of hip septic arthritis. Near misses included diagnoses of ectopic pregnancy (n = 2), pneumothorax (n = 2), alcohol withdrawal seizures and pancreatitis necessitating intensive care unit admission, appendicitis, bacterial meningitis, cerebrovascular accident, cryptococcal meningitis in immuno‐compromised host, endocarditis, incarcerated inguinal hernia, meningococcemia, meningococcal meningitis, peritonsillar abscess, pneumococcal meningitis, ruptured abdominal aortic aneurysm, shock from gastrointestinal bleeding, small bowel obstruction, schizophrenic crisis resulting in psychiatric hospitalization, suicidal depression resulting in psychiatric hospitalization, and unstable angina.

Conclusion: Adverse outcomes occur with MCO gatekeeping. Although the present study cannot ascertain whether this is a frequent event or a rare one, the safety of MCO gatekeeping deserves further study.
Confidentiality and Privacy Breaches in a University Hospital Emergency Department
Authors: Mlinek Edward J. , Pierce Jessica
Published: September 2008

Objective: To determine the frequency of visual and auditory confidentiality and privacy breaches in a university ED.

Methods: A prospective, observational study of medical personnel behavior was performed using participant and direct observation techniques. Observations were made in a university tertiary referral and trauma center emergency facility. Observers recorded auditory and visual confidentiality and privacy breaches in various patient care areas during 1‐hour periods. Information collected included patient name or room number, complaint/diagnosis, diagnostic tests, past medical history, and personal information. It was then determined whether a clear identification of the patient's name or face and/or an association to his or her clinical course could be made.

Results: All members of the health care team committed confidentiality and privacy breaches. Frequency of breaches was dependent on room location and design. Breaches in the triage/waiting area occurred for >53% of the patients. Breaches near the physician/nursing station ranged from 3 to 24 per hour and 1.5 to 3.4 per patient hour. Other inappropriate comments also were noted. One hundred consecutive patients and family members were interviewed at ED release, with only 2/100 having noticed the status board, although neither could recall any specific details.

Conclusion: Confidentiality and privacy breaches occur in a university ED by all members of the health care team. The ED architecture and floor plan affect patient confidentiality and privacy.