bluuebunny/crossref_metadata_2025 huggingface dataset:
Mock Drug Delivery to the Proximal Aorta during Cardiopulmonary Resuscitation: Central vs Peripheral Intravenous Infusion with Varying Flush Volumes
Authors: Gaddis Gary M. , Dolister Michael , Gaddis Monica L.
Published: September 2008

Objective: To compare mock drug deliveries to the proximal aorta during CPR after peripheral vs central IV administration when the mock drug is followed by different postinfusion flush volumes.

Methods: Delivery of indocyanine green (ICG) dye to the proximal aorta of an instrumented 20‐kg canine cardiac arrest model was examined. The ICG administration (2.5 mg) preceded either a 2‐mL or a 10‐mL saline flush, for either a central or a peripheral IV route of dye administration. Five dogs each underwent three sets of the four possible route/flush‐volume combinations in a stratified randomized order. Real‐time dye‐absorbance‐vs‐time curves, as sampled from the proximal aorta, modeled central‐circulation drug delivery. Systolic and diastolic blood pressures (BPs) were monitored, and the absorbance‐vs‐time curve upstroke phases were used to estimate cardiac output during arrest.

Results: Times (mean ± SD) to onset of dye appearance did not differ significantly between peripheral/10 mL (126 ± 35 sec) and central/10 mL (108 ± 35 sec), or between central/2 mL (123 ± 31 sec) and central/10 mL. Times to onset of dye appearance did differ between peripheral/2 mL (161 ± 70 sec) and central/10 mL [analysis of variance (ANOVA) p = 0.032]. Times to peak dye concentration did not differ significantly between peripheral/10 mL (230 ± 88 sec) and either central/10 mL (202 ± 88 sec) or central/2 mL (215 ± 83 sec), but differed between peripheral/2 mL (326 ± 134 sec) and every other route/flush‐volume combination (ANOVA p = 0.009). Peak dye concentrations and systolic/diastolic BPs (averaging 23/10 for all route/flush‐volume combinations) did not differ significantly between any route/flush‐volume combinations.

Conclusion: An adequately sized post infusion crystalloid flush (0.5 mug) permits peripherally administered model drug to reach the central circulation as quickly and in equivalent concentration as centrally administered drug during CPR in a canine cardiac arrest model.
Standard and Higher Doses of Atropine in a Canine Model of Pulse less Electrical Activity
Authors: Behnke Daniel J. De , Swart Gary L. , Spreng David , Aufderheide Tom P.
Published: September 2008

Objective:To determine whether standard or increased doses of atropine improve the return of spontaneous circulation (ROSC) rate in a canine model of pulseless electrical activity (PEA).

Methods:A prospective, controlled, blinded laboratory investigation was performed using an asphyxial canine cardiac arrest model. After the production of asphyxial PEA, 75 dogs remained in untreated PEA for 10 minutes and then were randomized to receive placebo (group 1) or one of four doses of atropine (group 2, 0.04 mg/kg; group 3, 0.1 mg/kg; group 4, 0.2 mg/kg; group 5, 0.4 mg/kg). All the animals received mechanical external CPR and epinephrine (0.02 mg/kg every 3 minutes) throughout resuscitation.

Results:The ROSC rates were not significantly different between the groups (group 1, 73%; group 2, 67%; group 3. 40%; group 4, 47%; group 5, 27%; p = 0.06). The heart rates and hemodynamics during resuscitation were not significantly different between the groups.

Conclusion:In this canine model of asphyxial PEA cardiac arrest, standard‐dose atropine did not improve ROSC rates, compared with placebo. Increasing doses of atropine tended to decrease ROSC rates, compared with placebo and standard‐dose atropine.
Applying the Trauma Triage Rule to Blunt Trauma Patients
Authors: Mechanic Andrew D. , Hedges Jeri's R. , Sparkman Kent , Jui Jon , Mullins Richard J.
Published: September 2008

Objective: To determine the accuracy of the Baxt Trauma Triage Rule (TTR: systolic blood pressure < 85 mm Hg; Glasgow Coma Scale‐motor score < 5; or penetrating trauma to head, neck, or trunk) for prediction of major trauma in an independent data set of blunt trauma patients.

Methods: Retrospective evaluation of the TTR in a cohort of patients identified by Oregon Trauma System entry criteria. Accuracy for prediction of “major trauma” victims was measured using resource‐based definitions of major trauma. Participants included 626 adult, blunt trauma patients at a level‐I trauma center serving a metropolitan center of more than one million people.

Results: Of 524 patients with sufficient registry data to apply the TTR, 95 (18%) and 63 (12%) patients met the criteria for major trauma suggested by Baxt et al. and Emerman et al., respectively. Using the Baxt definition of major trauma, the TTR had a sensitivity of 74% (95% CI: 0.65–0.83) and a specificity of 84% (95% CI: 0.81–0.88). There were 25 significant false‐negative results, including 12 patients requiring urgent laparoscopy and four patients requiring emergency airway procedures. Using the Emerman definition of major trauma, sensitivity improved modestly to 76% (95% CI: 0.65–0.87) and specificity decreased slightly to 80% (95% CI: 0.77–0.84).

Conclusions: In this blunt trauma population, the Baxt TTR failed to identify a significant number of severely injured patients. Slight alterations in the definition of “major trauma” can significantly affect the performance characteristics of triage instruments.
Spontaneous Agonal Respiration in a Swine Model of Out‐of‐hospital Cardiac Arrest
Authors: Menegazzi James J. , Check Brian D.
Published: September 2008

Objective: To describe ventilator dynamics following the onset of ventricular fibrillation (VF) in an experimental swine model.

Methods: Twelve female mixed‐breed domestic swine (mean mass 21.3 2 1.7 kg) were sedated with IM ketamine (10 mag) and xylazine (1 mgntg), anesthetized with α‐chloralose (40 mgkg loading dose, 10 mg/kg/hr rnaintenance infusion), incubated, and mechanically ventilated on room air. ECG, and aortic and pulmonary artery pressures were monitored continuously. VF was induced with a 3‐sec, 60‐Hz, 100‐mA Tran thoracic shock, and left untreated for 8 minutes. Respiratory rate, tidal volume, and minute ventilation were recorded until respiratory activity ceased.

Results: All 12 animals (100%) had agonal respirations through the first 2 minutes of arrest. This decreased to 11 (92%) at minute 3, five (42%) at minute 4, and two (17%) at minute 7. Mean respiratory rates ranged from 6 to 11 breathdmin. Mean tidal volumes ranged from 502 to 852 mL. Mean minute ventilations ranged from 3.3 to 5.8 L.

Conclusion: In this swine model, 11 of 12 (92%) continued to have spontaneous agonal respirations for the first 3 minutes of VF cardiac arrest. Many animals had supernormal tidal volumes, and near‐normal minute ventilations. These findings have potential implications for lay‐rescuer and first‐responder contributions to resuscitation of victims of out‐of‐hospital cardiac arrest.
Qualitative Research Methodologies in Emergency Medicine
Authors: Binder Louis S. , Chapman Dane M.
Published: September 2008

Qualitative research methodologies, though often used in other fields and in medical educational investigations, have not been used to study problems in emergency medicine (EM). These methodologies address qualitative data and provide a process of describing, interpreting, and explaining the dynamics of a population or phenomenon. The stages of a qualitative investigation include initial narrative description, interpretation, theory development, assessment of generalization, and evaluation. Important differences between this framework and those of quantitative research methods are described. These methods may be applied to systematic investigation of virtually any observable phenomenon or process in EM in which a better understanding of process would be valuable, such as patient flow, patient satisfaction issues, patient turnover and sign‐out processes, bedside teaching. EM teamwork dynamics, and development of the career interests of students and residents. As with quantitative research, EM academicians should seek collaboration and appropriate training with guidance by established qualitative investigators when applying these methods.
Does Topical Lidocaine Attenuate the Pain of Infiltration of Buffered Lidocaine?
Authors: Bartfield Joel M. , Raccio‐Robak Nancy , Salluzzo Richard F.
Published: September 2008

Objective: To determine whether topical lidocaine attenuates the pain of buffered lidocaine infiltration.

Methods: This was a prospective, randomized, double‐blind, placebo‐controlled trial conducted at a university‐based ED. The subjects were adults who had lacerations being repaired using local anesthesia. Two 0.5‐mL injections of buffered lidocaine were given in a standardized manner. The first was given prior to application of topical study solution. The second was given on the opposite side of the laceration after topical application of study solution, which was 5 mL of either 2% lidocaine or saline placebo. The pain of each infiltration was measured using a visual analog pain scale. Pain scores were calculated and compared using a Wilcoxon test with significance defined as p 0.05.

Results: A total of 54 subjects participated; 29 received lidocaine topically and 25 received placebo. The groups were similar with respect to age, gender, wound length, wound location, and initial pain score. Pain scores decreased by 11.6 ± 18.6 mm for lidocaine and 10.9 ± 20.9 mm for placebo (p > 0.5). The study had the power to detect a 15‐mm pain score difference (α = 0.05 and β = 0.20) on a 100‐mm scale.

Conclusion: Topical 2% lidocaine does not attenuate the pain of infiltration of buffered lidocaine more than does topical normal saline. Investigation of other topical anesthetics with and without epinephrine in conjunction with buffered lidocaine is warranted.
Emergency Department Presentation of Patients with Conversion Disorder
Authors: Dula David J. , DeNaples Louis
Published: September 2008

Objective: To describe the presenting symptoms and other features of ED patients diagnosed as having conversion disorder.

Methods: A retrospective chart review was carried out on the records of ED patients who had had final ED or in‐hospital diagnoses of conversion disorder. Cases from 1982 to 1992 at a 566‐bed rural tertiary care hospital with a residency program in emergency medicine were reviewed for patient age and gender, presenting signs and symptoms, ED diagnostic evaluation, disposition, and comorbidity.

Results: Of 42 patients who had conversion disorder diagnoses, 24 were women and 18 were men. Twenty‐one (50%) of the patients were diagnosed in the ED, and of those patients, ten were released home from the ED. Patient age ranged from 5 to 70 years, with a mean age of 33 years for women and 34 years for men. Most clinical symptoms mimicked neurologic disorders (weakness, pain, seizurelike activity, loss of consciousness, etc). Thirty patients (71%) received laboratory studies in the ED and two others received laboratory studies on admission. Seventeen (40%) patients had computed tomography of the head and five (12%) patients had magnetic resonance imaging of the head. Twelve (29%) patients had previous histories of psychiatric disorders, four (10%) had histories of alcohol and drug abuse, two (5%) had prior conversion reactions, three (7%) had chronic illnesses, and four (10%) had been victims of previous head trauma.

Conclusion: Patients with conversion disorder in the ED usually present with neurologic symptoms and undergo multiple diagnostic tests. Comorbidity is common. Early psychiatric evaluation may assist in the diagnosis and evaluation of patients with suspected conversion disorder in the ED.
Violence and General Security in the Emergency Department
Authors: Ordog Gary J. , Wasserberger Jonathan , Ordog Cindy , Ackroyd Syama Atluri, Greg
Published: September 2008

Objective: To describe cases of violence related to weapons in a university hospital and urban county ED and to provide related recommendations for ED staff security.

Methods: Descriptive analysis and case examples of weapons‐related assaults in one urban ED for the period 1979–1993.

Results: Over a 14‐year period, 115 “incidents” of weapons‐related violence were identified during the management of approximately 980,000 patients. Examples of ED violence are described.

Conclusion: Emergency department staff should prepare for the possibility of violence by 1) recognizing the danger, 2) rehearsing response mechanisms, and 3) debriefing after incidents. In particular, plans must be made and practiced for the time when external violence follows the surviving victims of gang activity through the “sacrosanct” hospital doors. Protection of patients and ED personnel must be ensured. In many urban settings, appropriately armed security guards must be immediately accessible to the ED staff. Other suggestions for ED protection are given.
Evaluation of a Portable Clinical Blood Analyzer in the Emergency Department
Authors: Sands Vicki M. , Auerbach Paul S. , Birnbaum Jonathan , Green Maurice
Published: September 2008

Objective: To assess the potential effects of rapid bedside blood analysis on patient management in the ED.

Methods: A prospective, nonrandomized clinical study was conducted over a consecutive ten‐month period (August 1992 to May 1993). Blood samples drawn from a convenience sample of 960 patients for analysis of Na +, K +, Cl‐, BUN, glucose, and/or hematocrit (Hct) were simultaneously analyzed by portable clinical analyzer (PCA) and by routine methods in the central laboratory. Caregivers were blinded to the PCA values; patient care was based solely on central laboratory results. Physicians were surveyed after the completion of patient care.

Results: The PCA results were available 31 minutes (mean) sooner than were the central laboratory results for Hct, 43 minutes faster for Na +, K+, and Cl‐, and 44 minutes faster for BUN and glucose. Except for Hct and glucose, the values obtained from the PCA were not significantly different from the central clinical blood analyzer laboratory values. When surveyed, the physicians caring for the patients reported that had the PCA results been available, a different or an earlier therapeutic approach would have resulted in 9.5% of the cases. The decision to release or admit the patient was based on one or more of the laboratory values for 10.7% of patients sampled. In no case in this series did a physician report that final ED clinical outcome would have been affected.

Conclusions: In our ED, the PCA yielded faster reporting of laboratory values. These earlier results might have reduced the length of stay in the ED for 17.3% of patients studied. Selective use of a handheld portable analyzer might decrease time to therapeutic interventions and time to disposition.
Utility of Routine Admission Serum Chemistry Panels in Adult Trauma Patients
Authors: Tortella Bartholomew J. , Lavery Robert F. , Rekant Mark
Published: September 2008

Objectives: To determine the frequency of abnormal serum chemistries and whether they provide clinically useful information regarding trauma patients. To identify clinical criteria associated with critical serum chemistry values (CSCVs).

Methods: The records of all trauma patients admitted to one urban, Level I Trauma Center were retrospectively reviewed for the period (July 1‐December 31, 1989). All trauma patients who had had serum chemistry determinations at hospital admission and at least once more prior to discharge were studied. The CSCVs were determined by a panel of experts prior to record review. Serum chemistry values, patient demographics, mechanisms of injury, and outcomes were statistically analyzed.

Results: Most (814/913; 89%) trauma patients had abnormal serum chemistry values. However, only 54/913 (6%) had CSCVs and only six of these CSCVs had prompted a change in resuscitation or treatment (therapeutic K+ infusions). Age > 50 years, a history of hypertension therapy, and a Glasgow Coma Scale score ± 10 were associated with CSCVs; and CSCVs were correlated with increased mortality and critical care unit admission.

Conclusion: Routine‐admission serum chemistry values, while frequently abnormal for major trauma patients, generally do not provide clinically useful information in the resuscitation and treatment of trauma patients. Hypoglycemia and metabolic acidosis were more rapidly determined using bedside glucose determination and arterial blood gas evaluation. The routine‐admission serum chemistry panel described in the study lacked utility for most trauma patients. Selective chemistry panel ordering should be used at the time of hospital admission for major trauma patients.
Noninvasive Evaluation of the Collateral Circulation to the Hand
Authors: Fuhrman Thomas M. , McSweeney Elaine
Published: September 2008

Objective: To compare four methods of evaluating collateral blood flow to the hand.

Methods: The hands of 74 volunteers on the faculty or staff of a university hospital were studied prospectively. Only subjects without known peripheral vascular disease were included. Four tests were used in random order to assess radial and ulnar artery flow. Results of the assessments using the modified Allen's test, pulse oximetry, plethysmography, and laser Doppler perfusion monitoring were compared.

Results: No interrupted palmar arch was found. The modified Allen's test was normal in all cases. Pulse oximetry detected a 5% incidence of noticeably reduced blood flow in one artery compared with the other artery. This dominance of one artery was identified in 69% of the hands by plethysmography. The laser Doppler noted a dominant artery in 64% of the hands. Plethysmography and the laser Doppler disagreed in their findings in only 9% of the hands evaluated. Numerical values of blood flow, attainable only by the laser Doppler, were significantly lower upon occlusion of the radial vs the ulnar arteries (p < 0.05; paired t‐test).

Conclusion: All of the tests provide information about the collateral circulation to the hand. Only the laser Doppler provides quantitative blood flow. Further studies involving subjects most at risk for post‐cannulation ischemic injury are needed to guide the clinical application of these findings.
Artificial Surfactant Administration in an Animal Model of Near Drowning
Authors: Anker Anthony L. , Santora Thomas , Spivey William
Published: September 2008

Objective: To study the use of exogenous surfactant in a rabbit freshwater near‐drowning model.

Methods: In a randomized, placebo‐controlled experiment, 21 rabbits were anesthetized, paralyzed, and subjected to near drowning with 6 mL/kg of distilled water. Vital signs, arterial blood gases, and pulmonary compliance were measured at predetermined intervals. The animals were randomized into two groups: a normal O2 group that had their pO2 levels adjusted to 75–150 torr using supplemental O2 as needed, and a high O2 group ventilated with an FiO2 = 100%. Ventilator settings were further adjusted to normalize pH and pCO2 levels prior to instillation of distilled water. The two groups were further divided and 15 minutes after simulated near drowning, the animals were either treated with surfactant (5 mL/kg instilled en‐dotracheally) or not treated. Data were analyzed by repeated‐measures analysis of variance.

Results: Near drowning had no significant effect on heart rate or blood pressure. Acidosis was not changed by surfactant; hypoxia was worsened by surfactant: 158 ± 54 torr before and 66 ± 19 torr after administration (p < 0.01). Compliance did not change as a result of surfactant administration. Only the animals (n = 3) in the normal O2 plus surfactant group died during the 90‐minute post‐near‐drowning period of the study.

Conclusions: Surfactant administration (5 mL/kg) in this animal model of freshwater near drowning offers no benefit over simple ventilation. Assessment of the merit of smaller volumes of surfactant should be investigated because administration of this solution may represent a second pulmonary insult, given current volume recommendations.
Efficacy of Tissue Glue for Laceration Repair in an Animal Model
Authors: Yawn Michael , Halperin Michael , Huffer William , Cairns Charles
Published: September 2008

Objective: To compare the efficacy of butyl‐2‐cyanoacrylate tissue glue (TG) for the repair of skin lacerations in rats with the efficacy of standard closure with sutures.

Methods: In a prospective study, eight rats were anesthetized and an 8‐cm dorsal incision was made on each side of the midline. One wound was closed with a single layer of interrupted 5–0 Prolene suture and one by application of TG. The time required to close each wound was recorded. Sutures were removed at seven days; the TG was allowed to fall off spontaneously. The animals were sacrificed after 20 days and the wounds were judged for cosmetic outcome. Four 1 ± 3‐cm strips of skin were excised from each wound; one strip for histologic analysis and three for load extension testing using a tensiometer. Specimens were loaded to wound failure while displacement (D) and energy absorption (EA) were recorded. The paired t‐test was used for comparisons and reported as mean ± SE.

Results: No significant difference between TG and suture was found in D (6.5 ± 0.4 vs 5.2 ± 0.4 mm), EA (0.18 ± 0.01 vs 0.17 ± 0.03 kg mm/cm2), or histologic features. The closure time was significantly less using TG (66 ± 5 vs 401 ± 17 sec; p < 0.0001).

Conclusions: 1) Sutures and TG in rat skin repair result in similar wound strengths (EA), amounts of stretch (D), and histologic fea‐sures. 2) Wound closure is accomplished much more rapidly with TG.
Physician Medical Direction and Advanced Life Support in the United States
Authors: Tortella Bartholomew J. , Lavery Robert F. , Cody Ronald P. , Doran James
Published: September 2008

Objective: To determine the specialty training and responsibilities of urban U.S. emergency medical service (EMS) medical directors and how these factors relate to the type of service involved (fire, hospital, private, municipal).

Methods: A single mailed survey of training officers—field supervisors of 211 urban advanced life support (ALS) services in the United States. The survey also requested information about medications carried, approved procedures, and who set these standards. Respondents also rated the EMS medical director's involvement in various activities (quality assurance, administrative, executive, run reviews, and in‐service/education).

Results: Eighty‐five percent (n = 179) of the forms were returned, with 165 (78%) usable. The physician EMS medical directors were primarily trained in emergency medicine (77%) and were paid (75%) for EMS responsibilities. The number of medications carried and the number of approved procedures were not related to either the number of hours the physicians commit weekly to the EMS service or their degree of involvement in ALS activities. The physician EMS medical directors were most often involved in quality assurance and education and were less likely to devote time to executive or other administrative functions of ALS units, with the exception of fire‐based EMS physician medical directors, who contributed significantly to executive and administrative functions (p < 0.05). Overall practice standards were established by the medical director (46%), the state department of health (24%), and local/regional health authorities (23%).

Conclusions: EMS training officers believe that urban ALS medical directors in the United States primarily provide quality assurance and educational support. With the exception of fire‐based EMS systems, physicians appear to have limited involvement in other EMS administrative and executive functions.
Exertional Heat Stroke in a Young Woman: Gender Differences in Response to Thermal Stress
Authors: Sidman Robert D. , Gallagher E. John
Published: September 2008

Exertional heat stroke (EHS) is an acute life‐threatening emergency that necessitates the immediate institution of cooling measures. Reported here is a case of EHS in a nonacclimatized young woman who was undergoing strenuous exercise. The patient developed many of the characteristic features of EHS, including central nervous system disturbances, lactic acidosis, rhabdomyolysis, coagulopathy, and abnormal myocardial conduction. While EHS is relatively common in young men, the condition is rare in women. This case presentation addresses gender differences in the response to the thermal stress of intense physical activity.
Falsely Elevated Serum Digoxin Levels Secondary to Endogenous Digoxin‐like Immunoreactive Substances
Authors: Koobatian Thomas J. , Roberts James R.
Published: September 2008

Endogenous digoxin‐like immunoreactive substances (DLIS) are produced by the human body and can be significantly elevated in specific clinical conditions. Commercially available digoxin assays do not have the specificity to fully distinguish DLIS from exogenous digoxin, though DLIS do not possess the same therapeutic properties as do the drug. The resultant artificial elevation of a reported digoxin level or a completely factitious level in a patient not taking the drug can have clinically significant consequences.
Nonhemorrhagic Pontine Infarct in a Child Following Mild Head Trauma
Authors: Tannebaum Ross D. , Sloan Edward P.
Published: September 2008

A child who presented with hemiparesis secondary to a delayed nonhemorrhagic pontine infarction following mild head trauma is described. The results of the child's workup, including computed tomography (CT), were negative. The diagnosis of nonhemorrhagic pontine infarct was made by magnetic resonance imaging (MRI). The diagnostic evaluation excluded other possible etiologies of cerebral infarction, including vasculitides, CNS infection, congenital heart disease, hypercoagulable states, and demyelinating diseases. Although trauma cannot be proven as the cause of the infarct, other known causes of infarct were excluded. There are few cases of traumatic nonhemorrhagic cerebral infarction among children in the literature; none describes diagnostic MRI findings. MRI is important in these cases, because it may reveal delayed infarction from small–vessel injury, which is not apparent on CT. This article discusses the etiology of and the diagnostic evaluation of pediatric cerebrovascular accidents and suggests the need for emergency physicians to consider trauma as a potential cause of delayed nonhemorrhagic cerebral infarct in children.
The Health Consequences of Injury Questionnaire
Authors: McClure Roderick J.
Published: September 2008

Objective: To study the properties of a new survey instrument, the Health Consequences of Injury Questionnaire (HCIQ), for measuring the impact of injury on health and to compare the new instrument with the more detailed, previously developed Quality of Well–being (QWB) scale.

Methods: The HCIQ is a three–page health status questionnaire, suitable for self–administration. Similar to the QWB scale, the HCIQ measures health on a unitary scale where 1 represents optimum health and 0, death. The HCIQ was developed and studied in representative samples of injured adults from an Australian population. The HCIQ was administered concurrently with the QWB instrument to a sample of injured subjects, and the QWB scale scores were compared with estimated scores from the HCIQ using QWB scale weightings. The reliability of the HCIQ was tested on a further sample of injured subjects using a mailed test–retest design.

Results: Of the 211 subjects in the validity sample, 98 completed both the HCIQ and the QWB scales. The intraclass correlation coefficient for the scores obtained from the two questionnaires was 0.86 (95% CI = 0.66–1.00). The mean difference between the scores was 0.04 ± 0.09 (SD). The HCIQ had a median completion time of 15 minutes. Of the 129 subjects in the reliability study, 53 completed the HCIQ on both postal administrations. The reliability coefficient was 0.90 (95% CI = 0.62–1.00).

Conclusion: The HCIQ is a practical and reliable questionnaire for identifying the health consequences of injury that, when used with QWB weights, successfully predicts the QWB score.
The Minor Injury Scale
Authors: McClure Roderick J.
Published: September 2008

Objective: To develop an injury scoring system suitable for non–life–threatening injuries.

Methods: A prospective cohort study was conducted using a representative sample of 1,396 injured adults to identify the outcomes of a range of injuries. Data were collected between March 12, 1992, and March 11,1993, in the Australian Capital Territory, a geographically circumscribed urban community of 296,000 people served by two hospital EDs. Outcomes included “injury–related health status immediately following injury occurrence” and “accumulated health loss over the period of recovery.” The injury–related health status of each subject at the time of the injury occurrence was measured using the Health Consequences of Injury Questionnaire (HCIQ), which records this outcome as a value on a unitary scale. Injuries were then stratified by injury type, as identified by the Abbreviated Injury Scale numerical identifiers. The median health index value for each type of injury was designated the injury severity score for that injury type. The “accumulated health loss over time until recovery” for each injury was calculated from repeated administrations of the HCIQ over a six–month follow–up period, and the median outcome value for each injury type was designated the injury morbidity score for that injury.

Results: Injury severity scores for 46 types of minor injury and injury morbidity scores for 39 types of minor injury were tabulated to form the Minor Injury Scale.

Conclusion: This new injury scoring system provides a means of categorizing minor injury according to properties relevant to a public health approach to injury control. Expansion of the number of injury types scored requires further work, as does the testing of the results obtained to confirm the predictive power of the scales.
Practice Satisfaction, Occupational Stress, and Attrition of Emergency Physicians
Authors: Doan–Wiggins Lynnette , Zun Leslie , Cooper Mary Ann , Meyers David L. , Chen Edwin H. , Force For the Wellness Task
Published: September 2008

Objective: To define sources of job satisfaction and stress among emergency physicians and assess self–projected career longevity.

Design: A survey containing questions regarding emergency medicine (EM) practice satisfaction was mailed to 1,317 diplomates of the American Board of Emergency Medicine (ABEM). Specific sources of practice satisfaction and dissatisfaction, self–reported burnout or impairment, and plans for remaining in the specialty were assessed. Data were compared between two groups of physicians, namely, those residency–trained in EM and those attaining certification through the practice or special category tracts.

Results: Of the physicians returning the survey, 25.2% stated that they felt burned out or impaired and 23.1% planned to leave the practice of EM within five years. Perceptions of burnout/impairment and plans to stop practice were associated with less overall practice satisfaction but were not significantly different between the two groups of physicians. Burnout/impairment was linked with psychiatric, drug, or alcohol problems and the feeling that EM had contributed to that problem.

Conclusion: This study confirms the relatively high levels of projected attrition in EM and supports the perception that stress and burnout are associated with the specialty. Differences in job satisfaction and stress between those ABEM diplomates who were residency–trained in EM and those who became eligible for the board examination through practice or special–category eligibility appear minor.
HIV Seroprevalence in Emergency Department Patients: Portland, Oregon, 1988–1991
Authors: Jui Jon , Stevens Penny , Hedberg Katrina , Modesitt Steve
Published: September 2008

Objectives: In Portland, OR: 1) to determine the changes in HIV seroprevalence for ED patients from 1988 to 1991, 2) to define the characteristics of the HIV‐positive ED patient. 3) to determine the hepatitis B seroprevalence of HIV‐seropositive ED patients, and 4) to demonstrate the feasibility of an ED population‐based surveillance investigation.

Methods: A prospective, multiyear observational, cross‐sectional, multicenter, population‐based seroprevalence study was performed using seven urban hospital EDs. Serologic testing for HIV and hepatitis B was performed on excess blood obtained from ED patients. Four sampling periods were used at each hospital at 14‐month inlervals starting June 1988 and ending December 1991. The blood specimens were obtained concurrently at all the participating hospitals.

Results: Of 1,681 patients, 17 (1.0%) were HIV‐positive. The HIV seroprevalence rate was relatively stable over time: 0.5% (2/444) in 1988, 1.7% (7/396) in 1989, 1% (3/296) in 1990, and 0.9% (51545) in 1991. Most (94%) HIV patients were men, 100% were white, 81% were≥230 years old. Most (59%) of the HIV‐positive patients also were positive for hepatitis B core antibody. Many (76%) of the HIV‐positive patients were known to be positive by the emergency health care worker.

Conclusion: HIV seroprevalence among the ED patients in Portland, OR, was generally stable from 1988 to 1991. Many HIV‐positive patients also were hepatitis‐B‐positive, thus representing a double occupational infectious disease risk to ED personnel. A significant minority (24%) of the HIV‐positive patients were not known to be HIV‐positive by the ED personnel. Universal precautions and hepatitis B immunization are paramount for reducing the risk of infectious disease due to exposure to body fluids.
Alcohol Use among Subcritically Injured Emergency Department Patients
Authors: Becker Bruce , Woolard Robert , Nirenberg Ted D. , Minugh P. Allison , Longabaugh Richard , Clifford Patrick R.
Published: September 2008

Objectives: To determine the incidence of alcohol use in subcritically injured patients presenting to the ED, by using a saliva alcohol test (SAT) at ED triage during the ED initial assessment; to compare the incidence of alcohol use revealed by the SAT with documentation of alcohol use by ED nurses and emergency physicians (EPs) blinded to the SAT results; and to describe the demographics of the SAT‐positive, subcritically injured population.

Methods:A blinded, prospective, observational evaluation of ED patients presenting with subcritical injuries was performed. The patients were tested for alcohol use with an SAT, and a subsequent record review was conducted for extraction of demographic data and evidence of documentation of alcohol use by ED nurses and EPs blinded to the SAT results.

Results:During the study. 791 subcritically injured patients had SATs performed. Twenty‐one percent of these patients were found to be alcohol‐positive by SAT. Either the ED nurse or the EP documented a clinical impression of alcohol use for 52% of the SAT‐positive patients. There were higher SAT‐positive rates among men (24%), victims of assault (47%), and patients arriving at night (41%).

Conclusions:While the SAT identified 21% of the subcritically injured patient population as alcohol‐positive, ED nurse and EP documentation did not identify half of these alcohol‐positive patients. Many of these patients may be at risk for additional injuries related to their drinking behavior.
The Dextromethorphan Defense: Dextromethorphan and the Opioid Screen
Authors: Storrow Alan B. , Magoon Michael Raynard , Norton John
Published: September 2008

Objective: To determine whether a single oral dose of dextromethorphan produces a falsely positive qualitative urine opioid screen.

Methods:A prospective, randomized, triple‐blind, placebo‐controlled, crossover exposure study design was used. Twenty adult volunteers participated. All were without routine medications, not pregnant or lactating, without known sensitivity to dextromethorphan, and negative for urine toxicologic screening immediately prior to testing. These volunteers underwent three separate urine Enzyme‐Multiplied Immunoassay Technique (EMIT) opioid screens. Each screen was performed six hours after the subject had ingested a single liquid medication, either dextromethorphan, codeine, or placebo. Each volunteer took all three medications randomly, at least 72 hours apart. Half of the volunteers took the standard adult dose of dextromethorphan (20 mg). while the other half ingested twice this amount (40 mg). The amounts of codeine (30 mg) and sucrose placebo (10 mL) remained constant.

Results:For these young adults (mean age & SD = 30.7 ±2.8 years), all urine EMIT assays six hours after ingestion of dextromethorphan, at both dosage levels, were negative for opioids and all other drugs. All assays after codeine and placebo ingestion were positive and negative for opioids, respectively.

Conclusion:Although dextromethorphan is structurally similar to opioid drugs, the ingestion of a single normal (or even twice normal) dose of dextromethorphan is not likely to produce a falsely positive six‐hour urine opioid EMIT screen.
Hematologic Safety of Intraosseous Blood Transfusion in a Swine Model of Pediatric Hemorrhagic Hypovolemia
Authors: Plewa Michael C. , King Randall W. , Fenn‐Buderer Nancy , Gretzinger Karl , Renuart Donald , Cruz Rafael
Published: September 2008

Objective: To assess the risk of hemolysis, disseminated intravascular coagulation (DIC), or fat embolism syndrome (FES) with pressurized intraosseous (10) blood transfusion following hemorrhage.

Methods: A controlled, repeated‐measures, randomized animal study with blinded pathologic evaluations was conducted. Sixteen pento‐barbital‐anesthetized, instrumented immature swine underwent a 20‐mL/kg hemorrhage into citrate‐phosphate‐dextrose bags, then received autologous blood transfusion via a 16‐ga IV catheter (eight), or via a 15‐ga 10 needle in the proximal tibia (eight) under maximal manual pressure using a 30‐mL syringe. At baseline and at one hour and 48 hours posttransfusion, blood samples were assayed for hemoglobin (Hb), schistocytes, free Hb in plasma, bilirubin, lactate de‐hydrogenase, platelets, fibrinogen, and alveolar‐arteriolar O2 gradient. Lung sections were examined for inflammation after hematoxylid eosin stain, and for fat emboli after oil red‐O‐stain. Kidney sections were examined for inflammation using hematoxylin/eosin stain.

Results: Though the 10 transfusion rate of 21 ± 6 mumin was slower than the IV rate of 35 ± 5 mL/min (p = 0.0012), all the animals returned to baseline blood pressure within 15 minutes and survived. The presence of schistocytes and mildly elevated free Hb in plasma was noted in both groups at baseline and each time period, and was presumed to be due to sampling from the arterial catheter. All other laboratory values remained within normal limits and without inter‐group differences at any time period. No fat embolus was noted, and all lung and kidney specimens were free of inflammation.

Conclusions: In this model, pressurized 10 blood transfusion appears to be hematologically safe, i.e., without risk of appreciable hemolysis, DIC, or FES.
Injury as a Motivator to Reduce Drinking
Authors: Longabaugh Richard , Minugh P. Allison , Nirenberg Ted D. , Clifford Patrick R. , Becker Bruce , Woolard Robert
Published: September 2008

Objectives: To identify predictors of readiness to change drinking behavior by minor‐injury patients who had positive saliva alcohol tests (SATs) in the ED. To develop and test a model intended to be prognostic of readiness to change, which included predispositional and injury‐event‐related variables.

Methods: An on‐site survey was conducted of minor‐injury ED patients sampled consecutively during predesignated periods. Patients were identified as SAT‐positive during their screening evaluations. After giving their consent, they were administered a self‐report battery that assessed predispositional and injury‐event‐related variables as well as readiness to change their drinking. Predictors of readiness to change drinking were tested with regression analyses.

Results: Twenty‐four SAT‐positive patients participated; there were 18 men and six women (average age 34 years). Preinjury predispositional variables were by themselves unrelated to the patient's readiness to change while in the ED. Aversiveness of the injury and perception of degree of alcohol involvement were injury‐event‐related variables predictive of readiness to change (p <0.008). Negative consequences attributed to drinking prior to the injury event strengthened the association of injury aversiveness and alcohol involvement with readiness to change (p <0.0075).

Conclusion: Interventions to decrease drinking in this population should focus on increasing patient awareness of the association between drinking, injuries, and other alcohol‐related negative consequences.
Agreement in the Interpretation of Extremity Radiographs of Injured Children and Adolescents
Authors: Minnes Bruce G. , Sutcliffe Terry , Klassen Terry P.
Published: September 2008

Objectives: To measure agreement beyond chance (kappa) for comparison interpretations of extremity radiographs by pediatric radiologists and emergency physicians (EPs) and to identify factors associated with disagreement.

Methods: A random sample of 205 radiographs was selected from 1,016 patients having x‐rays of their extremities in the emergency and radiology departments of a tertiary care pediatric hospital. Interpretations by the “official” reporting pediatric radiologist (ORPR), the treating EP, and a pediatric radiologist blinded to all clinical information (BPR) were compared for three categories: “abnormal” (one or more of fracture, dislocation, or effusion); “possibly abnormal”; and “normal.”

Results: The overall weighted kappa (K,) for the ORPRs and the EPs was 0.55. For fractures alone, the K, for the ORPRs vs the EPs was 0.77; and for effusions alone, the value was 0.34. The K, for the ORPRs vs the BPR was 0.63 (range 0.43–0.83 for individual ORPRs). The main areas of disagreement were in the identification of joint effusions and of nondisplaced fractures of the phalanges, elbow joint. tarsals, or metatarsals.

Conclusions:There is good agreement between EPs and pediatric radiologists in interpreting extremity radiographs of injured children and adolescents. Disagreement occurs mainly for effusions or minor fractures and for the elbow region. Because of the importance of recognizing abnormalities in this region, an educational intervention to improve this area of deficiency is recommended.
Histopathologic Evaluation of the Therapeutic Efficacy of Water and Milk Dilution for Esophageal Acid Injury
Authors: Homan Clark S. , Maitra Subir R. , Lane Bernard P. , Thode Henry C. , Davidson Lev
Published: September 2008

Objective: To determine whether acid‐induced injury to the esophagus is decreased by early dilutional therapy with water or milk.

Methods: A controlled in‐vitro animal model for acid injury to the esophagus was carried out using esophagi harvested from 70 Sprague‐Dawley rats of both sexes and weighing 250–350 g. One control and six experimental groups each containing ten esophagi were instilled with 1 mL of 0.5 normal solution of hydrogen chloride (N HCl). Dilution with water or milk was performed at 0, 5, or 30 minutes postinjury in the experimental groups. No dilution was performed with the control group. Specimens were maintained in an oxygenated saline bath for a 60‐minute experimental period and then fixed in 10% formalin for histologic evaluation. Injury severity was rated by blinded histopathologic examination using scores of 0 (no injury), 1 (minor), 2 (moderate), and 3 (severe) for the histopathologic categories: cornified epithelial cells (CEs), granular cells (GCs), granular cell nuclei (GNs), and basal cells (BCs). Red blood cells were scored as positive or negative for lysis.

Results: The controls showed the most severe outcomes. Significant differences in injury occurred for all time periods and histopathologic categories, except for the GN/water and BC/milk histopathologic category/treatment groups. However, a linear trend analysis was significant for all histopathologic categories except BC. These analyses support decreased injury in the earlier treated groups. Injury severity was highest in the most superficial cell layer (CE).

Conclusions: Emergency therapy with water or milk reduces acute acid injury to the esophagus. Earlier treatment is associated with decreased injury severity. This research supports the use of dilutional therapy with water or milk for acute acid injury to the esophagus.
Visualization of C7‐T1 on Portable Lateral Cervical Spine Radiographs Using a Lead‐lined Acrylic Filter
Authors: Quinn James V. , Cwinn Adam , Carr Brendan , Grahovac Steven , Stiell Ian , Pelland Pierre
Published: September 2008

Objective: To determine whether lead‐lined acrylic cervical filters can improve the quality of portable lateral cervical spine (c‐spine) radiographs for trauma patients.

Methods: Twenty trauma patients who required portable c‐spine x‐rays had these taken with a lead filter attached to the collimator of the portable x‐ray machine to improve penetration and visualization of lower cervical structures without overpenetrating upper cervical structures. The radiographs of these patients were compared with the first portable c‐spine radiographs without filters for 20 controls matched for gender and injury severity. The comparison of radiographs was done by an experienced emergency physician and a neuroradiologist blinded to whether the filter was used.

Results: The two groups were similar for demographic and clinical characteristics. There was a significant improvement in the ability to visualize the C7‐T1 level for the filter group compared with the control group (65% vs 30%, p < 0.05). Agreement between the physicians was excellent (kappa = 0.79, 95% CI = 0.60‐0.99).

Conclusions: Lead‐lined acrylic filters improve the ability to visualize the lower c‐spine in trauma patients.
Accuracy of E‐codes Assigned to Emergency Department Records
Authors: Schwartz Robert J. , Nightingale Bonnie S. , Boisoneau David , Jacobs Lenworth M.
Published: September 2008

Objective: To determine the accuracy of ICD‐9‐CM external‐cause‐of‐injury codes (e‐codes) assigned to the medical records of injured patients treated in an ED and released.

Methods: A comparison was made of routine coding and expert recoding of medical records generated in the ED for a convenience sample of patients treated for injuries within 24 hours of injury occurrence and subsequently released from the ED. The medical record was handwritten and subsequently coded by three medical records coders (MRCs). The e‐coded charts were sent to an external medical record consultant (expert), who was blinded to the codes previously assigned. The expert reading was used as the criterion standard. Accuracy was measured using a kappa statistic, and errors were described.

Results: Of 126 available patient charts, 108 (85.7%) were assigned e‐codes by MRCs. The expert assigned two codes to (double‐coded) 67 patients, while the MRCs double‐coded only one patient. The additional code was usually a “place of occurrence code.” In 60 cases (55.6%), the expert code exactly matched the MRC code; kappa = 0.462. Of the 48 mismatches (44.4%), 20 (41.7%) were e‐coded in the wrong category, 20 (41.7%) were e‐coded in the correct category but with incorrect specificity of information, either too specific or not specific enough, and eight (16.6%) had combined coding errors.

Conclusion: The accuracy of e‐codes assigned to ED records was moderate in this single institution analysis. Errors were predominantly related to the specificity of the code, but some e‐codes were in the wrong category. There are implications for injury surveillance and research. E‐code assignment must be standardized and applied uniformly to obtain accurate codes. Automation of e‐coding could improve accuracy and consistency of codes. National and international epidemiologic studies of cause of injury among ED patients will be severely hampered until e‐code assignment can be better standardized.