bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of a Prototype Esophageal Detection Device
Authors: Marley Charles D. , Eitel David R. , Anderson Thomas E. , Mum Alvin J. , Patterson Geraldine A.
Published: September 2008

Objective: To determine the ability of a prototype esophageal detection device (EDD) to identify esophageal misplacement of an endotracheal (ET) tube.

Methods: A prospective, randomized, blinded study of detection of esophageal intubation was conducted using 51 elective surgical patients who met inclusion criteria. A squeeze–bulb aspirator that creates a negative pressure of – 80 to – 90 torr was used for detection of esophageal intubation. The bulb should reinflate rapidly if the tube is in the noncollapsible trachea, but should not reinflate if the tube is in the collapsible esophagus. Each patient was prepared for surgery in the usual manner. The anesthesiologist placed an ET tube into the trachea. An identical tube was advanced the same distance into the esophagus. The tubes were labeled “A” or “B” according to a computer–generated random number list. An evaluator, who was blinded to the placement of the tubes, assessed one tube with the EDD. For most patients, a second evaluator, who was blinded to both tube placement and the results of the first evaluator, assessed the other tube. During evaluation, the tube cuffs were deflated. After data collection, the esophageal tube was removed and surgery was completed.

Results: All 45 esophageal tube placements were correctly identified. Thirty–five of the 40 ET tubes were correctly identified. Of the five ET tubes mislabeled, three were found in a mainstem bronchus. All had delayed bulb re–expansion.

Conclusion: This prototype EDD is a useful method of identifying esophageal misplacement of an ET tube in anesthetized adult surgical patients.
Family Response to Out–of–hospital Death
Authors: Schmidt Terri A. , Harrahill Maureen A.
Published: September 2008

Objective: To better understand the perceptions, needs, and responses of family members after an out–of–hospital death.

Methods: Over an 18–month period, phone interviews were conducted using a structured interview schedule modified from a similar study of survivors of in–hospital death. Subjects included 31 survivors of urban out–of–hospital deaths attended by paramedics from one ambulance company. Subjects were eligible if paramedics had arrived and death had been determined at the scene without transport. Survivors were interviewed 11 to 15 months after the death (mean = 12 months) to evaluate how well they coped with their loss, how they managed the experience of their loved ones' out–of–hospital deaths, and their feelings and beliefs about their loved ones' not being transported to a hospital.

Results: None of the survivors believed their loved ones should have been transported to a hospital, and only one believed that something more could have been done for the individual. Although many of the survivors had suspected their loved ones had died, 64% had been informed of the death by emergency medical technicians (EMTs) or firefighters. Most thought the EMTs had informed them in a professional (81%) and gentle/supportive manner (74%). Some (29%) still had unanswered questions about the death, but most (58%) were adjusting well and no one had a “poor” adjustment.

Conclusion: In this small sample, survivors of out–of–hospital death were generally satisfied with the care their loved ones had received. None of the survivors believed their loved ones should have been transported to the hospital. They also believed the paramedics had been supportive and met their needs at the time of death. It appears that paramedics may be able to meet the needs of a patient's survivors by terminating out–of–hospital resuscitation efforts on the patient.
Validation of a Rapid Urine Screening Assay for Cocaine Use among Pregnant Emergency Patients
Authors: Westdorp Ellen J. , Salomone Joseph A. , Roberts David K. , Mclntyre Malcolm K. , Watson William A.
Published: September 2008

Objectives: To determine the accuracy of the OnTrak rapid urine latex agglutination immunoassay (AIA) for testing pregnant ED patients for the cocaine metabolite benzoylecgonine (BE), and to determine the frequency of urine BE in pregnant ED patients and the association of test results with patient demographics.

Methods: A test performance evaluation was conducted using an inception cohort of pregnant patients at an urban teaching hospital ED. Patients with positive urine chorionic gonadotropin tests who had adequate remaining urine samples were studied. Patient demographics, ED diagnoses, and assay results were recorded without patient identifiers. Urine was tested using the rapid AIA. The first 150 samples were confirmed using a second immunoassay and gas chromatography with a nitrogen phosphorus detector. All positive samples also were confirmed with thin‐layer chromatography, and quantification by gas chromatography‐mass spectrometry.

Results: Twenty of 342 (5.9%, 95% CI 3.4–8.4%) pregnant patients had urine samples positive by AIA testing for BE. Confirmation testing demonstrated no false‐positive or ‐negative AIA result. Positive test results were not associated with specific patient diagnoses or demographics.

Conclusions: ED screening for cocaine use among pregnant patients can be accurately performed using the On Trak AIA for BE. In the ED population screened, 5.9% of the pregnant women had urine samples positive for BE.
A New Model for Teaching Corneal Foreign Body Removal
Authors: Austin Paul E. , Ljung Martha , Dunn Kathleen A.
Published: September 2008

Objective:To determine whether a skills laboratory for corneal foreign body and rust ring removal improves self‐assessed skill and confidence.

Methods: A prospective trial was conducted as part of the didactic curriculum of a university‐based residency program in emergency medicine (EM). A convenience sample of 26 EM residents and five fourth‐year medical students participated. The skills laboratory used model corneas made by coating 3.2‐cm glass spheres with a 1–2‐mm film of paraffin. Foreign bodies were simulated by embedding small pieces of metal into the paraffin. Rust rings were simulated by dipping a hot, straightened paper clip into a rust‐colored crayon and then into the paraffin. The model eyes fit into a life‐sized model of a human head. Participants removed the foreign bodies and rust rings under supervision, using the slit lamp. Each participant anonymously completed a questionnaire before and after participating in the skills laboratory. The questionnaire recorded educational level, previous experience, and self‐assessed comfort and skill levels (0 = lowest, 10 = highest).

Results: Most (66%) of the participants had not previously removed a corneal foreign body; 86% had not previously removed a rust ring. On a ten‐point scale, the median comfort level for removing a foreign body rose from 2 to 7, and the self‐assessed skill level rose from 1 to 7 (p = 0.0001). Similar improvements in self‐assessed comfort and skill levels were seen for rust ring removal.

Conclusions: Participation in this skills laboratory significantly improved the self‐reported comfort and self‐assessed skill levels in removing corneal foreign bodies and rust rings. This technique provides useful practice of a fine‐motor procedural skill requiring eye‐hand coordination prior to supervised application of these skills in clinical practice.
Evaluation of Hemoperitoneum Using a Single‐ vs Multiple‐view Ultrasonographic Examination
Authors: Ma O. John , Kefer Michael P. , Mateer James R. , Thoma Beth
Published: September 2008

Objective: To compare the sensitivities, specificities, and accuracies between a single‐view ultrasonography (US) technique and a multiple‐view technique for identifying hemoperitoneum in multiple‐trauma patients.

Methods: Data from a prior prospective study of US for trauma diagnosis at a level I trauma center were retrospectively analyzed. A convenience sample of adult patients (≥ 18 years of age) who had presented with major blunt or penetrating torso trauma and had undergone rapid trauma US examinations to detect hemoperitoneum were reviewed. The US interpretations by emergency physicians had been recorded prior to obtaining other diagnostic tests. Five views were evaluated, including the right intercostal oblique view examining Morison's pouch. Evidence of free intraperitoneal fluid by exploratory laparotomy, CT, or diagnostic peritoneal lavage (DPL) was used as the criterion standard.

Results: Of the 245 patients entered into the study, 37 had free intraperitoneal fluid, confirmed by CT, DPL, or exploratory laparotomy. With the multiple‐view technique, US was 87% (95% CI = 71%, 96%) sensitive, 100% (95% CI = 97%, 100%) specific, and 98% (95% CI = 95%, 100%) accurate. The single‐view technique, evaluating only Morison's pouch, was 51% (95% CI = 34%, 68%) sensitive, 100% (95% CI = 98%, 100%) specific, and 93% (95%. CI = 89%, 96%) accurate.

Conclusions: An initial trauma US examination using a multiple‐view technique is more sensitive than that using a single‐view technique for detecting hemoperitoneum in trauma patients.
Multicenter Study of Case Finding in Elderly Emergency Department Patients
Authors: Gerson Lowell W. , Rousseau Elaine W. , Hogan Teresita M. , Bernstein Edward , Kalbfleisch Norman
Published: September 2008

Objectives: To assess the feasibility of a brief comprehensive case‐finding program for detecting functional, cognitive, and social impairments among elderly ED patients and to estimate the prevalence of unknown, undetected, or untreated impairments elderly patients may have.

Methods: A multicenter prospective study conducted at five private and public hospital EDs in five different communities across the country. Patients aged 60 years and older released to their homes during 52 randomly selected evening and weekend shifts between February 1 and April 30, 1993, were eligible for the case‐finding program. They were evaluated by medical students who received special training (instructional videotape, supervised examinations, and conference calls) in the administration of a standardized 17‐item protocol that included an interview and simple tests of function. The patients' physicians were notified of the screening results and were asked to return a one‐month follow‐up questionnaire. The physicians answered whether the presumed problem had been confirmed and whether a treatment plan for a new problem had been developed.

Results: Patient acceptance of the case‐finding program was good; 252 of 338 eligible patients (75%) agreed to participate, and 281 conditions were detected for 242 screened patients (96%). The most frequently reported problems were with: performing the activities of daily living (79%); vision (55%); lack of influenza vaccination (54%); home environment (49%); mental status (46%); general health (41%); falls (40%); and depression (36%). The physicians returned questionnaires for 153 patients (63%); 76 patients (50%) were evaluated at follow‐up visits, during which 47 newly identified problems (62%) were confirmed and treatment plans were developed for 25 problems (53%) among 21 patients. A mean time of 17.7 ± 10.2 minutes was required to complete the screen.

Conclusions: A brief comprehensive case‐finding program for functional, cognitive, and social impairment among elderly ED patients is feasible. The screening uncovered a significant amount of morbidity among older patients visiting EDs.
Case Conference: Complete Heart Block in a Young Man
Authors: Huff J. Stephen , Syverud Scott A. , Tucci Mary Anne
Published: September 2008

A previously healthy 32‐year‐old man presented to the ED in complete heart block. Ischemic, infectious, and inflammatory conditions were considered in the differential diagnosis. Management options for complete heart block, the etiology of heart block in young adults, and treatment guidelines are reviewed.
Oral Intubation Using a Lighted Stylet vs Direct Laryngoscopy in Older Children with Cervical Immobilization
Authors: Berns Scott D. , Patel Ramesh I. , Chamberlain James M.
Published: September 2008

Objective:To compare the tracheal intubation success rates of blind oral intubation using a lighted stylet vs standard of direct laryngoscopy in anesthetized pediatric patients wearing rigid cervical collars

Methods: Seventy–eight children were randomly assigned to method of intubation (lighted stylet or direct laryngoscopy) and intubator; five patients were excluded after randomization. After sedation and paralysis, the patients were placed in rigid cervical spine collars to simulate intubating conditions for trauma patients. Three attempts at intubation were allowed. An observer recorded the following parameters during the procedure: 1) number of intubation attempts, 2) duration of each intubation attempt, and 3) complications. The intubators had limited prior experience with the lighted stylet technique.

Results: Thirty–three patients were in the lighted stylet group and 40 were in the laryngoscopy group. The patients in the lighted stylet group required more attempts prior to successful intubation (2.2 vs 1.5, p < 0.01), and the success rate was higher for the laryngoscopy group (26/33 vs 39/40, p < 0.05).

Conclusions: Blind oral intubation using a lighted stylet under controlled conditions took longer than direct laryngoscopy. However, among those successful on the first intubation attempt, the times to intubation were not significantly different between groups (44.5 vs 52.9 sec). The lighted stylet technique is a viable alternative technique for intubating children who have concurrent cervical spine immobilization.
Renal Gluconeogenesis and Blood Flow during Endotoxic Shock
Authors: Maitra Subir R. , Homan Clark S. , Pan Wansong , Geller Evan R. , Henry Mark C. , Jr. Henry C. Thode
Published: September 2008

Objectives: To determine whether endotoxic shock decreases the renal gluconeogenic capacity and the renal artery blood flow.

Methods: An in‐vivo, murine, nonrecirculating kidney perfusion model was studied in a trauma research laboratory. Each of 12 fasted, male Holtzman rats (shock n = 6, control n = 6) was injected with 1 mL of normal saline or endotoxin (20 mg/kg). Five hours after the injection, all the rats were anesthetized and blood samples were obtained for the determination of the plasma glucose. Right renal artery blood flow was measured by an ultrasonic small‐animal flow meter. The kidney was then perfused via the renal artery with 37°C, oxygenated, glucose‐free Krebs‐Henseleit solution in the presence of 100 μmol of phloridzin to inhibit the cellular uptake of glucose. Renal glucose production was determined by measuring glucose in both renal vein effluent and urine. After 30 minutes of equilibration, 5 mmol of lactate and 0.5 mmol of pyruvate were added to the perfusate as a gluconeogenic substrate. Renal vein and ureteral effluent samples were collected after 5, 10, and 15 minutes.

Results: The endotoxic shock group showed hypoglycemia (p < 0.05) as well as a decrease in renal artery blood flow (p < 0.05). Gluconeogenic stimulation was demonstrable in both the control and the endotoxic shock groups after 15 minutes of perfusion with substrate (p < 0.05). However, renal gluconeogenesis was significantly attenuated in the endotoxic shock group compared with the control.

Conclusions: Renal glucose production in response to a gluconeogenic substrate is significantly attenuated during the hypoglycemic phase of endotoxic shock. Endotoxic shock also causes a significant decrease of renal artery blood flow
Leukocytosis: A New Look at an Old Marker for Acute Myocardial Infarction
Authors: Green Steven M. , Vowels John , Waterman Bruce , Rothrock Steven G. , Kuniyoshi Gary
Published: September 2008

Objective: To determine the test performance of leukocytosis for identifying acute myocardial infarction (AMI) in patients with nondiagnostic ECGs, admitted to rule out AMI.

Methods: A retrospective, comparative test performance study was conducted using patients admitted to a university teaching hospital to rule out AMI. Clinical and laboratory information was reviewed and hospital laboratory ranges were used to define threshold elevations: total creatine kinase (CK), 275 U/L; CK‐MB, 7.5 μg/L; white blood cell (WBC) count, 11.5 × 109/L; and absolute neutrophil count (ANC), 8.0 × 109. Sensitivity, specificity, and predictive values of the total CK, CK‐MB, WBC count, and ANC were calculated, and receiver operating characteristic (ROC) curves constructed. Test performances of marker combinations also were determined.

Results: The initial WBC count was significantly higher for the subjects who had AMI (11.1 vs 8.8 × 109/L, p < 0.001). For the 688 subjects who had nondiagnostic ECGs, sensitivities for the initial total CK, CK‐MB, WBC, and ANC were 39%, 73%, 35%, and 36%, respectively, while the corresponding specificities were 94%, 93%, 85%, and 86%. Logistic regression analysis confirmed leukocytosis as an independent predictor of AMI (adjusted odds ratio 4.08, 95% CI 1.73–9.63). While CK‐MB alone was 73% sensitive for AMI, the decision rule of either an elevated CK‐MB or an elevated WBC count increased this sensitivity to 88% (corresponding specificity 79%). Similarly, while CK‐MB alone was 93% specific for AMI, the combination of an elevated CK‐MB and an elevated WBC count increased this specificity to 99% (corresponding sensitivity 20%).

Conclusions: Leukocytosis is significantly associated with AMI, and is a weak but independent laboratory predictor of this condition. In this preliminary study of admitted patients suspected of AMI, the combination of the WBC and the CK‐MB may have, additional diagnostic value over an isolated CK‐MB result. Neither parameter in isolation was satisfactorily sensitive for AMI. Prognostic assessment of the role of the WBC count in clinical decision making should address its complementary role to that of other clinical and ancillary test parameters.
Assessment of Visual Acuity in the Supine Position
Authors: Rees Sean M. , Goldfrank Lewis R.
Published: September 2008

Objective: To determine whether a modified Snellen eye chart could be used to accurately assess visual acuity (VA) in the supine position.

Method: This was a prospective study involving ED staff volunteers comparing VA on a standard Snellen eye chart with VA on a size‐reduced ceiling‐mounted modified Snellen eye chart.

Results: Fifty‐six volunteers participated. VA ranged from 20/10 to 20/200 on both of the cham, but 87% of the volunteers had VA of 20/50 or better. The VA results for the 2 charts were highly correlated; right eye r = 0.931 and left eye r = 0.953. Weighted ks showed substantial agreement for both eyes; k = 0.63 and 0.79 for the right and left eyes, respectively. In only 4 of 112 paired measurements did the VA recorded with the ceiling chart differ by >1 line from that recorded on the Snellen chart.

Conclusion: There is an excellent correlation between VAs determined in the erect and the supine positions using the standard Snellen eye chart and the modified ceiling‐mounted version. Substantial agreement exists between readings using the 2 charts. Although, additional testing is warranted in an ophthalmologically diverse patient population, use of this chart for the assessment of VA in the supine ED patient may allow for earlier VA evaluation.
An Easy Cricothyrotomy Approach: The Rapid Four‐step Technique
Authors: Brofeldt Bo Tomas , Panacek Edward A. , Richards John R.
Published: September 2008

A simplified 4‐step cricothyrotomy technique is described. The procedure can be completed in <30 seconds without use of suction or additional light source. The only equipment needed is a #20 scalpel, a tracheal hook with a large radius, and a cuffed tracheostomy tube. The 4 steps are: 1) palpation, 2) stab incision, 3) inferior traction, and 4) tube insertion. This streamlined method is simple and quick. Because the operator's body position and hand movements (steps 3 and 4) are similar to those in orotracheal intubation, there is a feeling of familiarity that enhances retention of the procedure. The steps are illustrated and 4 cases using this technique are reported. Since the hands at each step are stabilized on the patient and no special equipment is needed, this technique also may be ideal for the out‐of‐hospital environment.
Funding Avenues for Research in Emergency Medicine at the National Institutes of Health and the National Heart, Lung, and Blood Institute
Authors: Simons‐Morton Denise G.
Published: September 2008

There are opportunities for research in EM at the NIH, which may be appropriate for a variety of Institutes, depending on the topic area. Most NIH‐funded research is through investigator‐initiated grant applications, and the PHS 398 application packet is a source of more information. RFAs and RFPs, which have set‐aside funding, are released for specific topic areas when an Institute identifies an area requiring multiple studies or multicenter research. PAs, which do not have set‐aside funding, announce areas of interest for an Institute. The NIH Guide to Grants and Contracts announces RFAs, RFPs, and PAs. It is important to become expert in a field of research to be successful in achieving research funding, whether investigator‐ or institute‐initiated.
Comparison Trial of Four Injectable Anesthetics for Laceration Repair
Authors: Ernst Amy A. , Marvez‐Valls Eduardo , Nick Todd G. , Wahle Mark
Published: September 2008

Objectives: To compare four injectable anesthetics (buffered 1% lidocaine, buffered 1% lidocaine with epinephrine, plain 1% lidocaine with epinephrine, and 0. 5% diphenhydramine with epinephrine) for pain of infiltration and effectiveness of anesthesia during suturing of minor lacerations.

Methods: A prospective, randomized, double‐blind, comparison trial of the above agents was performed in an urban ED; adults with simple linear lacerations without vascular compromise were enrolled. Physicians and patients ranked the pain of injection and suturing according to a 10‐cm visual analog scale (VAS). Fisher's exact and Kruskal‐Wallis tests were used to compare demographic data, and Kruskal‐Wallis and Newman‐Keuls tests were used in analysis of VAS rankings. The power of the study was 0. 8 to detect a 1. 4‐cm difference in VAS readings, and 0. 9 to detect a 1. 7‐cm difference.

Results: Seven of 200 enrolled patients were excluded due to improper data collection and 13 were removed from final statistical analysis due to need for additional anesthetic (treatment failures), leaving 180 subjects for final analysis. Demographic data were similar for the four groups (p > 0.05). Diphenhydramine with epinephrine was significantly more painful to inject than was buffered lidocaine or buffered lidocaine with epinephrine, according to both the patients (p = 0.0003) and the physicians (p = 0.0037). The two buffered compounds were slightly less painful to inject than was lidocaine with epinephrine, but statistical comparisons did not reach significance. For anesthesia effectiveness, lidocaine with epinephrine and buffered lidocaine with epinephrine were statistically better than buffered lidocaine or diphenhydramine with epinephrine (p = 0.0001 for the patients and the physicians).

Conclusions: Buffered lidocaine with epinephrine and lidocaine with epinephrine were more effective anesthetics during suturing, according to both the physicians and the patients. There was a tendency toward less pain with infiltration in buffered solutions, compared with plain lidocaine with epinephrine, but the comparisons did not reach statistical significance. Diphenhydramine with epinephrine was more painful to inject than were buffered lidocaine with epinephrine and lidocaine with epinephrine, and was less effective anesthetically than the other three solutions.
The Use of Propofol for Sedation in the Emergency Department
Authors: Swanson Eric R. , Seaberg David C. , Mathias Susan
Published: September 2008

Objective: To evaluate the effectiveness of propofol and fentanyl when used by emergency physicians (EPs) for systemic sedation and analgesia in the ED.

Methods: Over an eight‐month period, a convenience sample of consenting patients at an urban teaching hospital ED who required sedation for painful procedures were enrolled in a descriptive study of therapeutic propofol sedation. After receiving 2μ‐g/kg of fentanyl IV, the patients received a continuous infusion of propofol at 0. 21 mg/kg/min IV to the desired level of sedation. A maintenance infusion of 3–6 mg/kg/hr was administered during the remainder of the procedure. Sedation time, total procedure time, and recovery time were recorded and the presence of side effects was noted. The patients and the physicians rated their satisfaction with the technique on a 100–mm visual analog scale. The patients were contacted at 24 hours for follow‐up information.

Results: Twenty patients (aged 19–62 years) received propofol infusion for procedures that included ten abscess incision and drainages, eight orthopedic reductions, one chest tube placement, and one wound exploration. The mean (±SD) total dose of propofol was 200 ± 160 mg. The mean time to onset of sedation was 6. 6 ± 3. 2 min, the mean procedure interval was 9. 6± 6. 3 min, and the mean interval until recovery was 6. 1 ± 4. 1 min. The median patient satisfaction score was 97 mm (range 40–100 mm); the median rating by physicians was 88 mm (range 4–100 mm). Side effects were noted in six patients: three had pain on injection, one had pain on injection and brief (<1 min) hypotension (systolic blood pressure = 80 mm Hg), and two had apnea (<30 sec). Seven patients had some recall of the procedure immediately afterwards, but only five had any recall at 24 hours. All 20 patients stated they would be willing to receive the same sedation again for a future procedure.

Conclusion: Propofol appears to be an effective agent to provide systemic sedation and analgesia when used in conjunction with fentanyl for procedures in the ED. Given its rapidity of onset and elimination, it may become a useful agent to EPs for IV sedation in the ED.
The Emergency Department Electrocardiogram and Hospital Complications in Myocardial Infarction Patients
Authors: Zalenski Robert J. , Rydman Robert J. , Sloan Edward P. , Caceres Luis , Murphy Daniel G. , Cooke David
Published: September 2008

Objective: To determine whether acute myocardial infarction (AMI) patients who have negative ECGs on presentation have significantly lower complication rates than do those AMI patients who have positive ECGs on presentation.

Methods: Retrospective, cohort analysis comparing rates of hospital complications (ventricular fibrillation or tachycardia, shock, atrial arrhythmia or bradyarrhythmia with systolic blood pressure 90 mm Hg, pulmonary edema) or interventions among patients with a final hospital diagnosis of AMI and an initially negative vs positive ECG. A negative ECG was normal or had nonspecific ST–segment and/or T–wave abnormalities (upright, flattened T waves; an isolated inverted T wave; ST depression <0.1 mV; tall T waves with J–point elevation) or minor nonischemic abnormalities. Sample size was adequate to detect a 30% between–group difference in complication rates [α = 0.05, 1 —‐ β (power) = 0.80].

Results: The 27 negative–ECG AMI patients differed from the 38 control patients in (mean X SD) age [57 X 12 vs 66 X 12 years, p < 0.01] but not in gender or history of AMI. The negative– and positive–ECG groups had similar rates of hospital complications [30% (95% CI: 13–47%) vs 42% (95% CI: 26–58%), p = 0.44] and intensive procedures [19% (95% CI: 4–34%) vs 29% (95% CI: 15–43%), p = 0.50], respectively. The negative–ECG patients with hospital complications had ECG evolution precede the event in 83% (95% CI: 69–97%) of cases; persistently negative–ECG patients had no complication [(95% CI: 0–33%), p = 0.06].

Conclusions: Negative– and positive–ECG AMI patients do not have moderate or large differences in the rates of in–hospital complications. Most negative–ECG patients who suffer complications evolve ECG changes prior to the event and such changes indicate the potential need for a higher level of care.
Association of Training Level and Short–term Cosmetic Appearance of Repaired Lacerations
Authors: Singer Adam J. , Hollander Judd E. , Valentine Sharon M. , Jr. Henry C. Thode , Henry Mark C.
Published: September 2008

Objective: To determine the association between emergency practitioner level of training and cosmetic appearance of primarily closed wounds as evaluated at the time of suture removal.

Methods: A retrospective analysis of wound registry data was performed. At the time of wound closure, standard data were collected including details of patient demographics, wound characteristics, preparation, closure, and postoperative care, for consecutive patients sutured in the ED. Follow–up data were obtained at the time of the return visit using a previously described cosmetic scale. With the scale, all lacerations were assigned 0 or 1 point each for the presence or absence of six items: a step–off of borders; contour irregularities; margin separation; edge inversion; excessive distortion; and overall appearance. For analysis, the proportion of wounds with a score of 6 (optimal cosmetic appearance in all categories) was associated with practitioner level of training.

Results: Five hundred fifty–two patients' wounds were evaluated. The percentages of various practitioners' achieving an optimal cosmetic score were: medical students (MSs), 50%; first–year residents (EMls), 54%; second–year residents (EM2s), 66%; third–year residents (EM3s), 68%; physician assistants (PAs), 70%; and attending physicians (APs), 66%. The senior practitioners (EM2s, EM3s, PAs, APs) were significantly more likely to obtain a maximal cosmetic score than were the junior practitioners (MSs, EMls) (68% vs 52%, p = 0.016).

Conclusion: Significant improvement in short–term cosmetic results following wound repair is associated with a training level beyond PGY1. These data reinforce the need for careful patient selection and close supervision of wound repair by trainees, especially of wound repair by medical students and interns.
Emergency Physicians' Obligations to Managed Care Patients under COBRA
Authors: Wood Joseph Patrick
Published: September 2008

In 1986 the federal government enacted a statute, the Consolidated Omnibus Budget Reconciliation Act (COBRA), intended to address the perceived problem of patients being denied essential emergency medical care, or being transferred in an unstable condition, because of the patient's lack of an adequate payer source. Compliance with COBRA has been a concern among hospitals and emergency physicians (EPs). Indeed, by the end of 1993, the federal government investigated δ1,500 allegations of COBRA violations. Since COBRA was enacted to address the problem of “economically motivated” transfers of indigent patients, many EPs are unaware of the potential for COBRA violations inherent in the accommodations currently being sought by some managed care organizations. This paper reviews hospitals' and physicians' obligations to managed care patients under COBRA.
Systemic Toxicity from Ocular Homatropine
Authors: Reilly Kevin M. , Chan Lisa , Mehta Nalin J. , Salluzzo Richard F.
Published: September 2008

Toxidromes are well known to emergency physicians. An unclear or incomplete history and subtle findings on physical examination make the diagnosis of poisonings challenging. This article reports a patient who had an acute onset of visual hallucinations, pressured speech, and mania. Although she denied taking any medications, she was ultimately diagnosed as having anticholinergic toxicity. On further questioning of family members, it was discovered that she was being treated for anterior uveitis with 5% homatropine. This case illustrates the potential role of ocular medications in systemic toxicity. Patients often do not consider eyedrops to be medications, and their use may be overlooked in the medical history. It also is important to educate patients and medical staff in methods to minimize systemic toxicity when using ocular medication.
A Population‐based Study of Fatal and Nonfatal Firearm‐related Injuries
Authors: Coben Jeffrey H. , Dearwater Stephen R. , Forjuoh Samuel N. , Dixon Bruce W.
Published: September 2008

Objective: To determine population‐based firearm‐related morbidity and mortality for Allegheny County, PA (population = 1.3 million), for the year 1994.

Methods: Fatalities were identified from a review of death certificates. To identify nonfatal cases, an active surveillance was conducted at all 24 acute care EDs in the county. The ED surveillance used 2 existing sources of case identification from each hospital to minimize undercount.

Results: Firearms were the leading cause of injury death to county residents, accounting for 155 deaths. The crude mortality rate from firearms was 11.7/100,000. Black males aged 15–19 years were most at risk for a firearm fatality (293/100,000). There were 514 nonfatal firearm injuries, producing a case fatality rate of 23%. The highest age‐specific rate for nonfatal firearm‐related injuries treated in the county EDs was observed for black males aged 15–19 years (2,245/100,000), which is 58 times higher than the firearm‐related injury rate for the entire county population (38.7/100,000).

Conclusion: Firearm‐related injury and death are a significant public health problem in Allegheny County. Although the crude mortality rate from firearms in the county is lower than the reported national rate, the observed rate for nonfatal injuries in the black youth of this community is the highest firearm injury incidence rate ever reported. Local surveillance of firearm‐related injuries, including nonfatal events, is needed to more accurately demonstrate the magnitude of this problem.
Work‐related Injuries in a Rural Emergency Department Population
Authors: Williams Janet M. , Higgins Doloris , Furbee Paul M. , Prescott John E.
Published: September 2008

Objective: To describe the spectrum of work‐related injury evaluated in a rural ED population. Methods: An ED‐based injury surveillance system (EDBISS) was used to collect injury data for all ED patients seen over a 1‐year period. A patient was classified as injured if his or her record contained an ED log injury code, an ICD‐9 N‐code between 800 and 995 in any diagnostic field, an E‐code, or an entry in the trauma registry. An injury was considered work‐related if the patient reported that the injury had occurred while at work.

Results: Work‐related injuries accounted for 1,539/12,321 (12.5%) of all injuries. The mean age of patients injured on the job was 33.8 years (range, 16–77 years), compared with a mean age of 27.7 years for all the injured patients. Males accounted for 1,026/1,537 (67%) of the work‐related injury visits, compared with 57% of all the injury visits. The most common mechanisms of work‐related injuries were: overexertion (313; 20%); cut or pierced by sharp implements (248; 16%); falls (250; 16%); struck by object (202; 13%); and transportation‐related injuries (71; 5%). Sprains and strains were the most common type of injury sustained (415; 27%), followed by wounds to upper limbs (283; 18%), contusions (182; 12%), and fractures (151; 10%). Of the 1,539 patients presenting with occupational injuries, 178 (12%) presented to the ED via ambulance. Most (1,401; 91%) were treated and released from the ED, with the remainder (136; 9%) hospitalized. The mechanisms of injury that most commonly resulted in hospitalization included struck by an object (28; 21%), transportation (26; 19%), falls (27; 20%), crushing mechanism (13; 10%), and machinery (20; 15%). Of those requiring hospitalization, 132/136 (97)% were male, and the average length of stay was 4.4 days. Four of the hospitalized persons died of their work‐related injuries. Known medical charges incurred by patients injured at work were as high as $62,622. The average charge for those treated and released was $273; the average charge for those who required hospitalization was $10,910.

Conclusions: Occupational injuries contribute significantly to the overall incidence of injuries seen in this ED and are responsible for significant medical charges each year.
Calcium, Magnesium, and Phosphorus: Emergency Department Testing Yield
Authors: Rose William D. , Martin Julia E. , Abraham F. Matthew , Jackson Rebecca L. , Williams Janet M. , Gunel Erdogan
Published: September 2008

Objectives: To investigate how often the ED ordering of stat serum calcium (Ca+2), magnesium (Mg+2), and phosphorus (PO4‐3) levels affected clinical treatment; to define the diagnoses of patients for whom Ca+2, Mg+2, and PO4‐3 measurements did affect clinical therapy; and to suggest guidelines for more appropriate ordering of these laboratory tests.

Methods: A retrospective chart review was performed in an academic teaching hospital. All adult ED patients who had Ca+2, Mg+2, or PO4‐3 laboratory testing during the 9‐month study period were included and evaluated for potential clinical impact of an abnormal Ca+2, Mg+2, or PO4‐3 laboratory test.

Results: 1,477 patients had Ca+2, Mg+2, or PO4‐3 measured while in the ED during the study period. Of these, 260 patients (17.6%) had a total of 312 abnormal Ca+2, Mg+2, or PO4‐3 values as defined by results exceeding ±15% of normal reference values. Of these, only 5 patients (0.3%) received treatment for abnormal values in the ED, while 75 patients (5.1%) were treated once admitted to the hospital. In this study, the only diagnostic groups to whom significant treatment was administered were diabetic patients (Ca+2 and PO4‐3); alcoholic patients (Mg+2); and renal failure patients (Ca+2, Mg+2, and PO4‐3).

Conclusion: These results suggest that stat Ca+2, Mg+2, and PO4‐3 levels seldom affect clinical treatment in the ED. The frequency of ordering these tests may be reduced by obtaining Ca+2, Mg+2, or PO4‐3 measurements only for patients known to be at risk for such abnormalities, based on their existing or suspected diagnoses. The authors suggest obtaining these tests, when indicated, on a “non‐stat” basis, with the subsequent laboratory results becoming available in‐hospital, where treatment is more likely to occur.
Psychosocial Difficulties and Emergency Department Use
Authors: Pilossoph‐Gelb Susan , Mower William R. , Ajaelo Ikem , Yang Sherry C.
Published: September 2008

Objective: To determine whether psychosocial difficulties are more prevalent among ambulatory patients using the ED for nonemergent complaints as compared with ambulatory patients having emergent complaints.

Methods: A survey of noncritical ED patients was performed using anonymous questionnaires addressing psychosocial difficulties: psychiatric illness, educational level, homelessness, alcohol and/or drug dependency (CAGE and DAST surveys), and depression (DSM‐III criteria). Three independent physicians ranked each patient's chief complaint as either emergent or appropriate for primary care. The majority ranking was used to determine whether the complaint was emergent. Groups with and without specific psychosocial difficulties were compared for their proportion of emergent vs primary care complaints.

Results: Of 700 patients, 367 (52%) met criteria for ≥1 psychosocial difficulty [acute psychosis—36 (5%), illiteracy—139 (20%), homelessness—45 (6%), alcohol dependency—111 (16%), drug dependency—66 (9%), and depression—130 (19%)]. There were 379 (54%) ED visits considered emergent. Patient groups with vs without ≥ psychosocial difficulty had similar rates of emergent visits (58% vs 50%, p = 0.04). Emergent visit rates also were similar for subgroups with vs without specific psychosocial difficulties: psychosis (56% vs 54%, p = 1.00), illiteracy (58% vs 53%, p = 0.89), homelessness (62% vs 54%, p = 0.33), alcohol dependency (62% vs 53%, p = 0.08), drug dependency (59% vs 54%, p = 0.47), or depression (58% vs 53%, p = 0.42).

Conclusion: Psychosocial difficulties are common among ED patients; however, emergent complaints are just as common in these patients as they are in those without psychosocial difficulties.
Emergency Department Evaluation of Geriatric Patients with Acute Cholecystitis
Authors: Parker L. Joseph , Vukov Larry F. , Wollan Peter C.
Published: September 2008

Objective: To estimate the frequency of abnormal clinical symptoms, laboratory tests, and diagnostic imaging studies in the ED assessment of elderly (≥65 yr) patients with acute cholecystitis, and to compare these factors in the young‐old (65–74 yr), middle‐old (75–84 yr), and old‐old (≥85 yr) population groups.

Methods: A retrospective, cross‐sectional study was performed by review of ED records, hospital charts, and surgical operative reports of consecutive elderly ED patients determined at surgery to have acute cholecystitis. Records were reviewed between April 1990 and April 1995 at a large Midwestern tertiary care facility with 65,000 annual ED patient visits. Clinical signs and symptoms were compared in the young‐old, middle‐old, and old‐old population groups.

Results: Of the 168 patients reviewed, 141 (84%) had either epigastric or right upper quadrant abdominal pain, and 8 (5%) had no pain whatsoever. Only 61 patients (36%) had back or flank pain radiation. Ninety‐six (57%) experienced nausea, 64 (38%) had emesis, and 13 (8%) had visible jaundice. Ninety‐four (56%) patients were afebrile and 69 (41%) had no increase of white blood cell count. Twenty‐two (13%) patients had no fever and all tests were normal. No statistical difference was noted in any symptom or laboratory factor for the 3 age groups, except jaundice was more common among the patients aged ≥85 years. Ultra‐sonography was diagnostic for 91%, and CT was beneficial for only 1 patient. Eight patients had normal results on their ultrasonographic and CT studies.

Conclusion: Classic symptoms and abnormal blood test results are frequently not present in geriatric patients with acute cholecystitis. Increasing age does not appear to affect the clinical and test markers used by clinicians to diagnose this illness. A high degree of awareness is essential for correct diagnosis of acute cholecystitis in geriatric patients.
Assessing Bedside Cardiologic Examination Skills Using “Harvey,” a Cardiology Patient Simulator
Authors: Jones Jeffrey S. , Hunt Stephen J. , Carlson Scott A. , Seamon Jason P.
Published: September 2008

Objective: To assess the cardiovascular physical examination skills of emergency medicine (EM) housestaff and attending physicians.

Methods: Prospective, cohort assessment of EM housestaff and faculty performance on 3 valvular abnormality simulations (mitral regurgitation, mitral stenosis, and aortic regurgitation) conducted on the cardiology patient simulator, “Harvey.” Participants examined each of the 3 study disease simulations and proposed a diagnosis (session I). They were then given a cardiac examination form and repeated the programmed simulations (session II). The examination form was used to prompt physicians to interpret 23 separate cardiac findings for each simulation in a multiple‐choice format.

Results: Forty‐six EM housestaff (PGY1–3) and attending physicians were tested over a 2‐month study period. Physician responses did not differ significantly among the different levels of postgraduate training. The overall correct response rates for participants were 59% for aortic regurgitation, 48% for mitral regurgitation, and 17% for mitral stenosis. For aortic regurgitation, recognition of a widened pulse pressure and recognition of diastolic decrescendo murmur were associated with a correct diagnosis (p < 0.01). For mitral regurgitation, correct assessment of the contour of the holosystolic murmur predicted a correct diagnosis (p < 0.001). For mitral stenosis, proper characterization of the mitral area diastolic murmur predicted a correct diagnosis (p < 0.001).

Conclusion: Housestaff and faculty had difficulty establishing a correct diagnosis for simulations of 3 common valvular heart diseases. However, accurate recognition of a few critical signs was associated with a correct diagnosis in each simulation. Training programs may need to focus attention on selected key components of the cardiovascular examination to facilitate teaching of physical diagnosis.
Comparison of Types of Research Articles Published in Emergency Medicine and Non‐Emergency Medicine Journals
Authors: Singer Adam J. , Homan Clark S. , Stark Mary Jo , Werblud Marc C. , Jr. Henry C. Thode , Hollander Judd E.
Published: September 2008

Introduction: As the specialty of emergency medicine (EM) matures, its journals should be publishing research of a quality similar to that which appears in other premier journals.

Objective: To compare the types of original research published in 4 EM vs 3 non‐EM journals.

Methods: Retrospective review of all 1995 articles published in Academic Emergency Medicine, American Journal of Emergency Medicine, Annals of Emergency Medicine, Journal of Emergency Medicine, Annals of Internal Medicine, JAMA, and New England Journal of Medicine. Research articles were classified as longitudinal vs cross‐sectional, prospective vs retrospective, and interventional vs observational. Other characteristics noted were number of subjects, randomization, blinding, control, and power calculations. Journals were reviewed by 4 investigators who received specific training in research classification, adhering to previously reported criteria for retrospective reviews. Interobserver reliability was independently validated.

Results: The authors reviewed 3,524 articles, of which 874 (24.8%) were original research. Compared with research reported in non‐EM journals, EM journals contained fewer longitudinal studies (40.5% vs 60.4%, p < 0.0001) and fewer prospective studies (70.8% vs 78.7%, p = 0.008). Fewer EM journals had studies that were blinded (13.7% vs 18.9%, p = 0.047) or controlled (36.3% vs 50.0%, p = 0.003). Studies reported in EM journals had fewer subjects (138 vs 300, p < 0.001). Research reports in EM journals were less likely to have been funded, even after adjustment for the differences in study designs (adjusted odds ratio 7.0, 95% CI 5.1–9.7).

Conclusion: Significant differences in types of research published in EM and non‐EM journals were identified.
Brown Recluse Spider Envenomation: A Prospective Trial of Hyperbaric Oxygen Therapy
Authors: Maynor Michael L. , Moon Richard E. , Klitzman Bruce , Fracica Philip J. , Canada Andrew
Published: September 2008

Objectives: Loxosceles reclusa (brown recluse) spider bites can produce severe skin lesions that may necessitate extensive surgical repair. This study delineated the effects of hyperbaric oxygen (HBO) therapy on these lesions by performing a prospective controlled animal study.

Methods: After approval by the Institutional Animal Care and Use Committee, 41 New Zealand white rabbits received 64 intradermal injections of 73 μL of raw venom extract mixed with physiologic buffered saline (Dulbecco's solution). Control injections were made with buffer. The animals were divided into 5 groups: 1) venom and no HBO; 2) venom and 1 immediate HBO treatment (100% O2); 3) venom and immediate HBO with 10 treatments (100% O2); 4) venom and then delayed (48 hr) HBO therapy with 10 treatments (100% O2); and 5) venom and immediate hyperbaric treatment with normal inspired Po2 for 10 treatments (8.4% O2). Three animals in group 2 also received a control sodium citrate buffer injection. HBO treatments were at 2.5 atm absolute (ATA) for 90 minutes twice daily. Daily measurements were made of the lesion diameter, and skin blood flow using a laser Doppler probe.

Results: There was no significant effect of HBO on blood flow at the wound center or 1–2 cm from the wound center. Standard HBO significantly decreased wound diameter at 10 days (p < 0.0001; ANOVA), whereas hyperbaric treatment with normoxic gas had no effect. Histologic preparations from 2 animals in each group revealed that there were more polymorphonuclear leukocytes in the dermis of all the HBO‐treated animals when compared with the venom‐alone and sodium‐citrate controls.

Conclusion: HBO treatment within 48 hours of a simulated bite from L. reclusa reduces skin necrosis and results in a significantly smaller wound in this model. The mechanism appears unrelated to augmented local blood flow between treatments.