bluuebunny/crossref_metadata_2025 huggingface dataset:
Cocaine‐associated Chest Pain: One‐year Follow‐up
Authors: Hollander Judd E. , Hoffman Robert S. , Gennis Paul , Fairweather Phillip , Feldman James A. , Fish Susan S. , DiSano Michael J. , Schumb David A. , Dyer Sophia
Published: September 2008

Objective: To determine the one‐year mortality and incidence of myocardial infarction (MI) post‐hospital discharge or ED release for patients with cocaine‐associated chest pain.

Methods: A prospective, observational study of an inception cohort of consecutive patients who presented to one of four municipal hospital EDs with cocaine‐associated chest pain. Patients were followed for one year from the end of the enrollment period. Main outcome parameters were the one‐year actuarial survival and the frequency of nonfatal MI.

Results: Mortality data were available for all 203 patients at a mean of 408 days. Additional clinical information was available for 185 patients (91%). There were six deaths (one‐year actuarial survival 98%; 95% CI, 95–100%); none from MI. Nonfatal MI occurred in two patients (1%; 95% CI, 0–2%). Continued cocaine use was common (60%; 95% CI, 52–68%) and was associated with recurrent chest pain (75% vs 31%, p < 0.0001). No MI or death was reported for patients who claimed to have ceased cocaine use.

Conclusions: Patients who presented with cocaine‐associated chest pain commonly continued to use cocaine after discharge. Urgent evaluation of coronary anatomy or cardiac stress tests may not be necessary for patients for whom MI is ruled out and who do not have recurrent potentially ischemic pain. The subsequent risk for MI and death in this group appears to be low. Intervention strategies should emphasize cessation of cocaine use.
The Effects of Warming and Buffering on Pain of Infiltration of Lidocaine
Authors: Bartfield Joel M. , Crisafulli Kathleen M. , Raccio‐Robak Nancy , Salluzzo Richard F.
Published: September 2008

Objectives: To investigate the effects of warming vs buffering, and warming with buffering, on the pain of lidocaine infiltration.

Methods: A randomized, double‐blind clinical trial was conducted using volunteers aged 18 years or more and without an allergy to lidocaine. The study consisted of two parts, each comparing two solutions. The solutions for Part I were warm (38.9°C; 102°F) plain lidocaine and room‐temperature buffered lidocaine. Warm buffered lidocaine and room‐temperature buffered lidocaine were used for Part II. The subjects received two standardized 0.5‐mL intradermal injections, one study solution in each forearm. Immediately after each injection, pain was assessed using a 100‐mm visual analog pain scale. Pain scores were analyzed by the sign test, with significance defined as p < 0.05.

Results: Part I (n = 10): Nine subjects reported room‐temperature buffered lidocaine to be less painful than warm plain lidocaine. Mean pain scores were 28 mm lower for room‐temperature buffered lidocaine than they were for warm plain lidocaine (p < 0.01). Part II (n = 24): Eleven subjects found warm buffered lidocaine to be the least painful, 11 reported room‐temperature buffered lidocaine to be the least painful, and two reported no difference. A mean pain score difference of 2.1 mm favoring warm buffered lidocaine was not statistically significant. Part II had a power of 80% to detect a 10‐mm difference between the two solutions at a = 0.05.

Conclusion: To reduce the pain of lidocane infiltration, buffering is more effective than warming. Warming does not enhance buffering.
Association of Drug Therapy with Survival in Cardiac Arrest: Limited Role of Advanced Cardiac Life Support Drugs
Authors: Stiell Ian G. , Wells George A. , Hebert Paul C. , Laupacis Andreas , Weitzman Brian N.
Published: September 2008

Objective: To generate hypotheses regarding the association of standard Advanced Cardiac Life Support (ACLS) drugs with human cardiac arrest survival.

Methods: This observational cohort study was conducted over a two‐year period in the wards, intensive care units, and EDs of two tertiary care hospitals. Included were adult patients who suffered cardiac arrest either inside or outside the hospital and who required epinephrine according to standard ACLS guidelines. Six standard ACLS drugs (given while CPR was in progress) were assessed for association with survival from resuscitation to one hour and to hospital discharge by univariate and multivariate logistic regression analyses.

Results: In the 529 patients studied, initial cardiac rhythm had no impact on the association between drug administration and survival. The time of drug administration (quartile of ACLS period) was associated with resuscitation for atropine (p < 0.05) and lidocaine (p < 0.01). The odds ratios (95% CIs) for successful resuscitation, after multivariate adjustment for potential confounders, were: a respiratory initiating cause, 3.7 (2.1–6.4); each 5‐minute increase in CPR‐ACLS interval, 0.5 (0.4–0.7); each 5‐minute duration of ACLS, 0.9 (0.8–1.0); atropine, 1.2 (1.0–1.3); bretylium, 0.4 (0.1–1.1); calcium, 0.8 (0.2–2.4); lidocaine, 0.9 (0.7–1.1); procainamide, 21.0 (5.2–84.0); and sodium bicarbonate 1.2 (1.0–1.6). All other potential confounding variables entered into the model were not significantly associated with resuscitation.

Conclusion: Initiating cause of arrest, time to ACLS, and duration of ACLS were important correlates of survival. Other than procainamide, standard ACLS drugs had relatively little association with survival, but timing of administration may be an important factor. Further research using definitive large randomized controlled trials is warranted to assess the role of drug therapy in improving cardiac arrest survival.
On‐line Telemetry: Prospective Assessment of Accuracy in an All‐volunteer Emergency Medical Service System
Authors: Hollander Judd E. , Delagi Robert , Sciammarella Joseph , Viccellio Peter , Ortiz Joe , Henry Mark C.
Published: September 2008

Objective: To evaluate the need for on‐line telemetry control in an all‐volunteer, predominantly advanced emergency medical technician (A‐EMT) ambulance system.

Methods: Emergency medical service (EMS) advanced life support (ALS) providers were asked to transmit the ECG rhythms of monitored patients over a six‐month period in 1993. The ECG rhythm interpretations of volunteer EMS personnel were compared with those of the on‐line medical control physician. All discordant readings were reviewed by a panel of physicians to decide whether the misdiagnosis would have resulted in treatment aberrations had transmission been unavailable.

Results: Patients were monitored and rhythms were transmitted in 1,825 cases. 1,642 of 1,825 rhythms were correctly interpreted by the EMS providers (90%; 95% CI 89–91%). The accuracy of the EMS providers was dependent on the patient's rhythm (chi‐square, p < 0.00001), the chief complaint (chi‐square, p = 0.0001), and the provider's level of training (chi‐square, p = 0.02). Correct ECG rhythm interpretations were more common when the out‐of‐hospital interpretation was sinus rhythm (95%), ventricular fibrillation (87%), paced rhythm (94%), or agonal rhythm (96%). The EMS providers were frequently incorrect when the out‐of‐hospital rhythm interpretation was atrial fibrillation/flutter (71%), supraventricular tachycardia (46%), ventricular tachycardia (59%), or atrioventricular block (50%). Of the 183 discordant cases, 124 (68%) involved missing a diagnosis of, or incorrectly diagnosing, atrial fibrillation/flutter. Review of the discordant readings identified 11 cases that could have resulted in treatment errors had the rhythms not been transmitted, one of which might have resulted in an adverse outcome.

Conclusions: In this all‐volunteer, predominantly A‐EMT ALS system, patients with a field interpretation of a sinus rhythm do not require ECG rhythm transmission. Field interpretations of atrial fibrillation/flutter, supraventricular tachycardia, ventricular tachycardia, and atrioventricular blocks are frequently incorrect and should continue to be transmitted.
Effect of Nitrous Oxide Analgesia on Pneumothorax
Authors: Seaberg David C. , Yealy Donald M. , Ilkhanipour Kaveh
Published: September 2008

Objective: To address whether spontaneous inhalation of 50% nitrous oxide (N2O) for up to 30 minutes adversely affects swine with pneumothorax (PNTX).

Methods: Five fasted, female swine (13–17 kg) were sedated with IV ketamine, intubated, and allowed to spontaneously inhale either 50% N2O or room air (RA) in a sequential crossover design in which each animal served as its own RA control. Small (group I, 150 mL), medium (group II, 300 mL), and large (group III, 500 mL) PNTXs were created by instilling air into the left pleural space via an 18‐Fr three‐way Foley catheter. Changes in PNTX volume, heart rate (HR), central venous pressure (CVP), blood pressure (BP), ECG, and arterial blood gas (ABG) parameters were recorded in separate 10‐and 30‐minute trials. A 15‐minute washout period was given between each trial. Data were analyzed using repeated‐measures analysis of variance with post‐hoc Tukey's tests.

Results: No significant increase in PNTX size was seen during the 10‐minute trials. In the 30‐minute trials, a statistically significant increase in absolute PNTX size was seen with NzO compared with RA for group I (44 ± 17 vs 16 ± 5 mL, p = 0.02), group II (61 ± 21 vs 26 ± 4 mL, p = 0.01), and group III (62 ± 32 vs 40 ± 5 mL, p = 0.06). No difference in HR, CVP, MAP, ABGs, or ECG were observed between the N2O and RA trials for any size PNTX. No animal developed hemodynamic signs of tension pneumothorax.

Conclusion: In this model, spontaneous inhalation of 50% N2O for up to 30 minutes is associated with little risk of hemodynamic or respiratory compromise. Although PNTX size increases with 50% N2O use, the magnitude observed in this animal model is less than previously reported.
The Extent and Effects of Abuse and Harassment of Emergency Medicine Residents
Authors: McNamara Robert M. , Whitley Theodore W. , Sanders Arthur B. , Andrew Louise B. , Force For the SAEM In‐service Survey Task
Published: September 2008

Objective: To determine the extent and effects of abuse and harassment, including sexual harassment and racial or ethnic discrimination, experienced by residents in emergency medicine (EM).

Method: The study instrument was an anonymous, self‐report survey administered to a national sample of EM residents. The survey was timed to coordinate with the American Board of Emergency Medicine's annual In‐Service Examination in February 1993. The residents reported whether they had experienced nine types of abuse or harassment during their residency training, the sources of these incidents, the effects on the residents, and whether they chose to file a formal complaint regarding these events.

Results: Surveys were returned by 1,774 (80%) of the 2,229 residents who sat for the examination—74.4% men and 24.6% women. Overall, 98% reported at least one occurrence of abuse or harassment, with patients being the most frequent source. More than half of the more senior residents reported having been physically hit or pushed. Other health care professionals were a frequent source of verbal abuse and sexual harassment. Women were significantly more likely than men to report unwanted sexual advances (63% vs 32%, p < 0.001), discomfort from sexual humor (66% vs 27%, p < 0.001), and unfair treatment because of gender (71% vs 15%, p < 0.001). Non‐Caucasians reported a higher rate of racial or ethnic discrimination than did Caucasians (51% vs 23%, p < 0.001). As a result of these episodes, 19% of the respondents had questioned their decision to become a physician, 20% had questioned entering the specialty of EM, 11% had experienced emotional effects lasting over one month, and 11% had experienced disruption of their family lives. Only 56 (3.2%) had filed formal complaints.

Conclusions: Residents frequently encounter abuse or harassment, particularly from patients. They also report adverse consequences from these episodes.
Emergency Medicine Resident Moonlighting: A Survey of Program Directors
Authors: Langdorf Mark I. , Bearie Brian , Ritter Michael S. , Ferkich Anthony , Moonlighting For the CORD Task Force on Resident
Published: September 2008

Objectives: 1) To systematically describe emergency medicine (EM) program directors' perceptions of the benefits and risks of resident moonlighting. 2) To assess moonlighting policies of EM residencies, the degree of compliance with these policies, and the methods of dealing with residents who are out of compliance.

Methods: A written survey was mailed or hand‐delivered to all allopathic and osteopathic EM residency directors in the United States in 1992–93. Incomplete and ambiguous surveys were completed by phone.

Results: There was a 96% response rate (113/118). The average EM resident clinical workweek ranged from 38 to 50 hours while the resident was assigned to ED rotations. Most (90%) of the program directors believe moonlighting interferes with residency duties to some degree. Few (10%) programs prohibit moonlighting altogether, although 44% limit moonlighting to an average of 41.5 hours per month. Program directors believe residents moonlight primarily for financial reasons. Most (60%) of the program directors believe moonlighting offers experience not available in the residency, primarily related to autonomous practice. Fifteen programs reported residents who had been sued for malpractice while moonlighting, with one program director named along with the resident. One third of program directors have penalized residents for abuse of moonlighting privileges.

Conclusions: EM residency directors are concerned about the effect of moonlighting on resident education. The directors' concerns regarding litigation, excessive work hours, and interference with residency duties are balanced by a general acceptance of the financial need to supplement residency income.
National Survey of Emergency Medicine Resident Moonlighting
Authors: Langdorf Mark I. , Ritter Michael S. , Bearie Brian , Ferkich Anthony , Bryan James , Force For the SAEM Inservice Examination Survey Task
Published: September 2008

Objectives: To survey emergency medicine (EM) residents regarding moonlighting practices and perceptions for clarifying: 1) resident moonlighting remuneration; 2) any association of perceived educational debt with moonlighting income and hours; and 3) perceptions related to moonlighting (including motivations, impact on resident training, and potential medicolegal difficulties).

Methods: A confidential, voluntary survey was administered to all allopathic EM residents in the United States. This written survey was provided to residents at their in‐service examinations. Completed forms were anonymously returned by residents or local administrative staff to a central site where all identifiers were removed prior to mailing en mass to the investigators. Comparisons between groups were made using chi‐square tests and correlations were assessed using the Pearson correlation coefficient.

Results: Seventy‐six percent (1,826/2,407) of the surveys were returned. There was a weak correlation (r = 0.11) between educational debt and moonlighting hours for residents in the second year and above, but no association of debt with moonlighting income. Most (88%) of the residents reported that their programs permitted moonlighting. Nearly half (49%) reported that they did moonlight in some way. Most (82%) thought moonlighting provided experience not available in the residency. Only 13 (2%) respondents stated they had been sued for malpractice while moonlighting. Most (66%) moonlighting respondents stated that they moonlighted for financial reasons, with educational debt the primary motivating factor. Of the moonlighting residents, 28% were unsure of their type of malpractice insurance coverage, and 9% had no coverage at all.

Conclusions: Education about EM practice matters including the risks of moonlighting should begin early in residency, because moonlighting is widespread. Residents are vulnerable to medicolegal action while moonlighting and have insufficient knowledge of their malpractice insurance coverage. Although educational debt is perceived as a strong motivating factor for moonlighting, there is only a weak relationship between educational debt and moonlighting hours.
Impact of Interventions for Patients Refusing Emergency Medical Services Transport
Authors: Alicandro Jeanne , Hollander Judd E. , Henry Mark C. , Sciammarella Joseph , Stapleton Edward , Gentile David
Published: September 2008

Objective: To evaluate the effect of a documentation checklist and on–line medical control contact on ambulance transport of out–of–hospital patients refusing medical assistance.

Methods: Consecutive patients served by four suburban ambulance services who initially refused emergency medical services (EMS) transport to the hospital were prospectively enrolled. In phase 1 (control phase), all patients who initially refused medical attention or transport had an identifying data card completed. In phase 2 (documentation phase), out–of–hospital providers completed a similar data card that contained a checklist of high–risk criteria for a poor outcome if not transported. In phase 3 (intervention phase), a data card similar to that used in phase 2 was completed, and on–line medical control was contacted for all patients with high–risk criteria who refused transport. The primary endpoint was the percentage of patients transported to the hospital.

Results: A total of 361 patients were enrolled. Transport rate varied by phase: control, 17 of 144 (12%); documentation, 11 of 150 (7%); and intervention, 12 of 67 (18%) (chi–square, p = 0. 023). Transport of high–risk patients improved with each intervention: control, two of 60 (3%); documentation, seven of 70 (10%); and intervention, 12 of 34 (35%) (chi–square, p = 0. 00003). Transport of patients without high–risk criteria decreased with each intervention: control, 15 of 84 (18%); documentation, four of 80 (5%); and intervention, 0 of 33 (0%) (p = 0. 0025). Of the 28 patients for whom medical control was contacted, 12 (43%) were transported to the hospital, and only three of these 12 patients (25%) were released from the ED.

Conclusion: Contact with on–line medical control increased the likelihood of transport of high–risk patients who initially refused medical assistance. The appropriateness of the decreased transport rate of patients not meeting high–risk criteria needs further evaluation.
Bystander vs EMS First–responder CPR: Initial Rhythm and Outcome in Witnessed Nonmonitored Out–of–hospital Cardiac Arrest
Authors: Swor Robert A. , Boji Bernice , Cynar Mark , Sadler Edward , Basse Eliezer , Dalbec Dean L. , Grubb William , Jacobson Ronald , Jackson Raymond E. , Maher Ann , Rivera–Rivera Edgardo J.
Published: September 2008

Objectives: To assess whether outcome and first–monitored rhythm for patients who sustain a witnessed, nonmonitored, out–of–hospital cardiac arrest are associated with on–scene CPR provider group.

Methods: A retrospective, cohort analysis was conducted in a suburban, heterogeneous EMS system. Patients studied were ± 19 years of age, had had an arrest of presumed cardiac origin between July 1989 and January 1993, had gone into cardiac arrest prior to ALS arrival, and had received CPR on collapse. First–monitored rhythms and survival rates were compared for two patient groups who on collapse either: 1) had received CPR by nonprofessional bystanders (BCPR) or 2) had received CPR by on–scene EMS system first responders (FRCPR).

Results: Of 217 cardiac arrest victims, 153 (71%) had received BCPR and 64 (29%) had received FRCPR. The BCPR patients were slightly younger (62. 4 vs 68. 4 years, p = 0. 01) and had slightly shorter ALS response intervals (6. 4 vs 7. 7 minutes, p = 0. 02). There was no difference in BLS response time intervals or automatic external defibrillator (AED) use rates. The percentage of patients with a first–monitored rhythm of pulseless ventricular tachycardia/ventricular fibrillation (VT/VF) and the percentage of patients grouped by CPR provider who survived to hospital admission or to hospital discharge were:

Controlling for age, the odds ratio for VT/VF with BCPR was 5. 45 (95% CI 2. 8, 10. 3).

Conclusion: Patients who receive BCPR more often have a first–monitored rhythm of VT/VF than do FRCPR patients, despite both CPR–provider groups' initiating CPR essentially immediately after patient collapse. Hence, BCPR and FRCPR groups have different first–monitored arrest rhythms, which may affect survival rate. These patient populations should not be considered to be homogeneous groups in CPR research.
Incidence, Source, and Nature of Complaints Received in a Large, Urban Emergency Medical Services System
Authors: Curka Peter A. , Pepe Paul E. , Zachariah Brian S. , Gray Don , Matsumoto Cory
Published: September 2008

Objective: To document the incidence, source, and reasons for all complaints received by a large municipal emergency medical services (EMS) program.

Methods: A retrospective review of all complaints received during three consecutive years (1990–1992) in a centralized EMS system serving a large municipality (population 2 million). All cases were categorized by year, source, and nature of the complaint.

Results: In the three study years, EMS responded to 416, 892 incidents with nearly a half–million patient contacts. Concurrently, 371 complaints were received (incidence of 1. 12 per thousand); 132 in 1990, 129 in 1991, and 110 in 1992. Most complaints involved either: 1) allegations of “rude or unprofessional conduct” (34%), 2) “didn't take patient to the hospital” (19%), or 3) “problems with medical treatment” (13%). Only 1. 6% (n = 6) were response–time complaints. Other complaints included “lost/damaged property,” “taken to the wrong hospital,” “inappropriate billing,” and “poor driving habits.” The most common sources were patient's families (39%) and the patients themselves (30%). Only 7. 8% were from health care providers.

Conclusion: Reviews of complaints provide information regarding EMS system performance and reveal targets for quality improvement. For the EMS system examined, this study suggests a future training focus on interpersonal skills and heightened sensitivities, not only toward patients, but also toward bystanders and family members.
The Australian Capital Territory Injury Surveillance and Prevention Project
Authors: McClure Roderick J. , Burnside Joan
Published: September 2008

Objective: To identify the representativeness and sensitivity of the data collected by the Australian Capital Territory Injury Surveillance and Prevention Project (ACTISPP) for ED injury cases seen in the Australian Capital Territory (ACT).

Methods: A retrospective descriptive study was conducted using a systematic sample of people injured in the ACT between January 20 and September 19, 1992, and who received their first treatment for this injury in an ACT ED. The ACTISPP surveillance system is dependent on ED patient or family completion and return of a comprehensive injury survey. The following population variables in the ACTISPP database were compared with those of the injured ED population, as determined by ED and hospital record review: age, gender, postal code of residence, nature of injury, body part injured, and whether the patient had been admitted to hospital.

Results: The sensitivity of the surveillance system for injuries seen in the ED was 31% (95% CI = 30–32%). The distribution of the ACTISPP sample did not differ from the expected distribution for sex or socioeconomic status. The distributions differed by age only in the 5–14–year age group (p < 0.001). With respect to the nature of injury and body part injured, the difference was significant (p < 0.001) but was no greater than 7% for any of the categories. Two percent of the surveillance sample were admitted to hospital, compared with an estimated 4% of the target population (p < 0.001).

Conclusions: Approximately one–third of all incident injuries managed in the EDs of the ACT are included in the ACTISPP database. Although some sampling bias is introduced in the surveillance process, it does not appear to be of sufficient magnitude to compromise the project's goals.
Out‐of‐hospital Provider Use of Epinephrine for Allergic Reactions: Pilot Program
Authors: Lindbeck George H. , Burns Donna M. , Rockwell Diana D.
Published: September 2008

Objective: To describe experience with an out‐of‐hospital provider program for the recognition and field management of allergic reactions by advanced life support (ALS) and basic life support (BLS) providers.

Methods: Data sheets completed between June 1, 1988, and August 31, 1993, and records from receiving sites (physicians' offices or EDs) were reviewed for information regarding the presentation of the allergic reaction, the time course and treatment provided out of hospital, and the clinical outcome at the receiving health care facility.

Results: Thirty‐seven data sheets were completed during the study period. Fourteen (38%) of the providers were BLS providers. The epinephrine was supplied from the emergency medical services (EMS) provider's personal kit in 35% of the cases, from an EMS vehicle in 57% of the cases, and by the patient in 8% of the cases. Availability of the kits allowed administration of epinephrine prior to the arrival of the first EMS vehicle in 41 % of the instances and prior to physician on‐line medical command in 65% of all the instances (predominantly by BLS providers). Overall, 77% of the patients experienced alleviation of their symptoms of respiratory difficulty, swelling, or rash after epinephrine administration, while 20% were unchanged and 3% worsened. All patients receiving epinephrine had an ED diagnosis of allergic reaction, and no adverse event was encountered on follow‐up of the patients treated.

Conclusions: Severe allergic reactions can be reliably identified and safely managed by out‐of‐hospital providers, including BLS providers. Providing personal anaphylactic treatment kits and increasing the pool of providers trained to manage allergic reactions (including BLS providers) can often decrease the time to treatment.
Intravenous Chlorpromazine vs Intravenous Metoclopramide in Acute Migraine Headache
Authors: Cameron James D. , Lane Peter L. , Speechley Mark
Published: September 2008

Objective: To compare the efficacy of IV chlorpromazine with that of IV metoclopramide in the treatment for acute migraine headache in the ED.

Methods: A prospective randomized double‐blind trial was undertaken at two university‐affiliated urban EDs with a combined annual census of more than 85,000 patients. Included in the study were patients presenting to the ED with a diagnosis of migraine headache. The subjects were randomized to receive 0.1 mg/kg/dose IV of either chlorpromazine (CPZ) or metoclopramide (MC), up to a total of three doses.

Results: Ninety‐one patients completed the protocol; 44 received MC and 47 received CPZ. The demographics of the two groups were similar. Both drugs provided, for the majority of patients, adequate pain relief as measured on a visual analog scale (VAS) completed every 15 minutes from T = 0 minutes to T = 45 minutes. The average pain relief over 45 minutes (ΔVAS) for CPZ was 4.87 cm, vs 4.34 cm for MC (p = 0.35). There also was no statistically significant difference in blood pressure (BP) changes (ΔBP < 2 mm Hg for both systolic and diastolic BPs, p = 0.47 and 0.33) or numbers of patients reporting adverse effects (AEs) (CPZ: 16 of 35; MC: 13 of 29, p = 0.43). There was no severe AE with either study drug.

Conclusions: Metoclopramide and chlorpromazine administered IV are both effective in the management of acute migraine headache. They are associated with similar minor side‐effect profiles.
Ultrasonography to Evaluate Adults for Appendicitis: Decision Making Based on Meta‐analysis and Probabilistic Reasoning
Authors: Orr Richard K. , Porter Deborah , Hartman Daniel
Published: September 2008

Objectives: To review ultrasonography (US) test performance and to develop recommendations for the use of US to aid in the evaluation of potential appendicitis.

Methods: A meta‐analysis was conducted using all English‐language articles published since 1986 (17 studies; 3,358 patients) to ascertain sensitivity and specificity of US for diagnosing appendicitis in adults and teenagers. Calculation of the predictive value of US was performed for three groups of patients: group I—usually operated on (prevalence of appendicitis = 80%); group II—usually observed in hospital (prevalence = 40%); and group III—usually released home (prevalence 2%).

Results: Overall sensitivity was 84.7% (95% CI: 81.0–87.8%), and specificity 92.1% (88.0–95.2). The accuracy and usefulness of US were related to the likelihood of appendicitis. In group I, a positive test was accurate [positive predictive value (PPV) = 97.6%], but a negative study could not rule out appendicitis [negative predictive value (NPV) = 59.5%]. The converse was true for group III patients (PPV = 19.5%, NPV = 99.7%). Test performance accuracy was balanced only for group II patients (PPV = 87.3%, NPV = 89.9%).

Conclusions: 1) US should not be used to exclude appendicitis for patients who have “classic” signs/symptoms, due to the underlying high false‐negative rate. 2) US is most useful for patients who have an indeterminate probability of disease after the initial evaluation—if US is positive, the patient should have an operation; otherwise, he or she should be observed. 3) US is not recommended for screening patients who have a low probability of appendicitis, due to the low prevalence of disease and high false‐positive rate in this group.
Effect of Delayed Treatment with Sodium Polystyrene Sulfonate on Serum Lithium Concentrations in Mice
Authors: Linakis James G. , Hull Keith M. , Lee Calvin M. , Maher Timothy J. , Lewander William J. , Lacouture Peter G.
Published: September 2008

Objectives: To determine the efficacy of sodium polystyrene sulfonate (SPS) in lowering serum lithium (Li) concentrations. Specifically, to determine the effects of both different doses of SPS and different times to treatment with SPS on serum Li levels.

Methods: The study was a controlled, single‐dose murine trial of SPS on serum Li levels. Male CD‐I mice (n = 525) were given orogastric LiCl and then divided into three main treatment groups: group SPS received a single orogastric administration of SPS in a dose of 5 gm/kg body weight at either 0, 15, 30, 45, or 90 minutes after LiCl; group half‐SPS received a single orogastric administration of SPS in a dose of 2.5 gm/kg body weight at times equivalent to those of group SPS; and the control group received orogastric deionized water in a volume equivalent to that of group SPS at 0, 15, 30, 45, or 90 minutes after LiCl. Subgroups of seven to ten mice in each of the four treatment groups were sacrificed at one, two, four, and eight hours after administration of LiCl, and their blood was analyzed for Li concentration.

Results: 1) Single doses of SPS significantly lowered serum Li concentrations; 2) this effect was dose‐related; 3) the delays in administration of SPS used in this study did not significantly reduce its ability to lower serum Li concentrations; and 4) even when administered after peak serum Li concentrations had been achieved, a single dose of SPS was effective in lowering serum Li levels.

Conclusions: SPS may be efficacious in the treatment for Li toxicity under certain circumstances, even when there is delay to treatment. Additional study is warranted to further characterize the ability of SPS to alter Li kinetics.
Chest Compression and Ventilation Rates during Cardiopulmonary Resuscitation: The Effects of Audible Tone Guidance
Authors: Milander Melinda M. , Hiscok Perry S. , Sanders Arthur B. , Kern Karl B. , Berg Robert A. , Ewy Gordon A.
Published: September 2008

Objectives: To determine: 1) whether chest compressions during CPR are being performed according to American Heart Association (AHA) guidelines during cardiac arrest; and 2) the effect of an audio prompt to guide chest compressions on compliance with AHA guidelines and hemodynamic parameters associated with successful resuscitation.

Methods: An observational clinical report and laboratory study was conducted. A research observer responded to a convenience sample of cardiac arrests within a 300‐bed hospital and counted the rate of chest compressions and ventilations during CPR. To evaluate the effect of an audio prompt on CPR, health care providers performed chest compression without guidance using a porcine cardiac arrest model for 1 minute, followed by a second minute in which audio guidance was added. Chest compression rates, arterial and venous blood pressures, end‐tidal CO2 (ETCO2) levels, and coronary perfusion pressures were measured and compared for the two periods.

Results: Twelve in‐hospital cardiac arrests were observed in the clinical part of the study. Only two of 12 patients had chest compressions performed within AHA guidelines. No patient had respirations performed within AHA guidelines. In the laboratory, 41 volunteers were tested, with 66% performing chest compressions outside the AHA standards for compression rate without audible tone guidance. With guided chest compressions, the mean (± SD) chest compression rate increased from 74 ± 22 to 100 ± 3/min (p < 0.01). End‐tidal CO2 levels increased from 15 ± 7 to 17 ± 7 torr (p < 0.01). Coronary perfusion pressure increased minimally with audible tone‐guided chest compressions.

Conclusions: The majority of Basic Cardiac Life Support‐certified health care professionals did not perform CPR according to AHA‐recommended guidelines. The use of audible tones to guide chest compression resulted in significantly higher chest compression rates and ETCO2 levels.
Out‐of‐hospital Ventilation: Bag‐Valve Device vs Transport Ventilator
Authors: Johannigman Jay A. , Branson Richard D. , Johnson Daniel J. , Davis Kenneth , Hurst James M.
Published: September 2008

Objective: To examine the patterns of out‐of‐hospital airway management and to compare the efficacy of bag‐valve ventilation with that of the use of a transport ventilator for intubated patients.

Methods: A prospective, nonrandomized, convenience sample of 160 patients requiring airway management in the out‐of‐hospital urban setting was analyzed. A survey inquiring about airway and ventilatory management was completed by emergency medical services (EMS) personnel, and arterial blood gas (ABG) samples were obtained within 5 minutes of patient arrival in the ED. The ABG parameters were compared for patients grouped by different airway techniques and presence or absence of cardiac arrest (systolic blood pressure <50 mm Hg) upon ED presentation.

Results: Over a one‐year period, 160 surveys were returned. The majority (62%) of the patients were men; the population mean age was 61 ± 19 years. Presenting ABGs were obtained for 76 patients; 17% (13/76) had systemic perfusion and 83% (63/76) were in cardiac arrest. There was no difference in ABG parameters between the intubated cardiac arrest patients ventilated with a transport ventilator (pH 7.17 ± 0.17, Paco2 37 ± 20 torr, and Pao2 257 ± 142 torr) and those ventilated with a bag‐valve device (pH 7.20 ± 0.16, PaCO2 42 ± 21 torr, and Pao2 217 ± 138 torr). The patients ventilated via an esophageal obturator airway (EOA) device had impaired gas exchange, compared with the groups who had endotracheal (ET) intubation (pH 7.09 ± 0.13, Paco2 76 ± 30 torr, and Pao2 75 ± 35 torr). The intubated patients not in cardiac arrest had similar ABG parameters whether ventilated manually with a bag‐valve device or with a transport ventilator. Endotracheal intubation was successfully accomplished in 93% (123/132) of attempted cases.

Conclusions: In this sample, ET intubation was the most frequently used airway by EMS providers. When ET intubation was accomplished, adequate ventilation could be achieved using either bag‐valve ventilation or a transport ventilator. Ventilation via the EOA proved inadequate.
Multicenter Study of Creatine Kinase‐MB Use: Effect on Chest Pain Clinical Decision Making
Authors: Hedges Jerris R. , Gibler W. Brian , Young Gary P. , Hoekstra James W. , Slovis Corey , Aghababian Richard , Smith Mark , Rubison Mike ,   For the EMCREG II Study Group
Published: September 2008

Objective: To determine whether creatine kinase‐MB isomer (CK‐MB) levels affect initial physician decisions regarding patients with potential cardiac chest pain.

Methods: A prospective, multicenter, observational cohort study was performed at seven university teaching hospital EDs. Hemodynamically stable chest pain patients >25 years old and without ST‐segment elevation on their ECGs were observed with one to two sets of CK‐MB level determinations obtained three hours apart prior to disposition. The physicians committed to a dichotomous (yes/no) absolute decision regarding the diagnosis of myocardial infarction (MI), need for hospital admission, and need for coronary care unit (CCU) admission both before and after enzyme results were obtained. The physicians ranked the perceived importance of initial history and physical, serial clinical observation, initial ECG, and CK‐MB level to their decision making (rank score: 1 = most important, 4 = least important).

Results: Of the 1,042 patients enrolled, 777 (74.6%) were admitted to the hospital. For the 67 MI patients (8.6% of the admissions), changes in absolute decisions about the diagnosis of MI and planned CCU admission were associated with increased CK‐MB importance (p = 0.04 and p = 0.02, respectively). Of the 146 patients who had new‐onset angina or unstable angina, changes in absolute decisions were not associated with CK‐MB importance. No patient who had MI or unstable angina was released from the ED. There were three of 67 (4%) MI patients and one of 146 (1%) unstable/new‐onset angina patients initially slated for release home who were admitted to the hospital.

Conclusions: For a minority of the patients who had subsequently proven MI, the CK‐MB result helped guide disposition decisions. The CK‐MB availability did not adversely impact the disposition of the patients who had unstable or new‐onset angina.
Cognitive Deficits in Presumed Minor Head‐injured Patients
Authors: Stewart Daniel P. , Kaylor Jeffrey , Koutanis Elaine
Published: September 2008

Objective:To determine the frequency of cognitive deficits in ED patients with presumed minor head injury and to identify factors in the initial history and physical examination predictive of cognitive deficits in these patients.

Methods: A prospective clinical study was performed over a nine‐month period at a large community‐based ED (60,000 patient annual census). Consecutive patients between 16 and 50 years of age who presented to the ED with a history of blunt trauma or a deceleration injury to the head and a Glasgow Coma Scale (GCS) score of 14 or 15 were included. Patients who had previous head injury, mental retardation, or psychiatric problems were excluded. Patients who were admitted to the hospital or who had an abnormal imaging study of the skull or brain also were excluded. Detailed history and physical examination findings were collected using a standardized data form. Cognitive testing was done at one week postinjury (Halstead‐Reitan Neuropsychological Test Battery).

Results: Seventy patients were originally entered into the study, and 36 completed the follow‐up. Those completing the study were more commonly employed and less likely to have used sensorium‐altering drugs or ethanol. Of the 36 patients who completed the study, 42% had either mild or moderate cognitive deficits at one week postinjury. Abnormal cerebellar function during the initial visit was associated with the presence of cognitive deficits at follow‐up (p = 0.004). However, only four of 15 (27%; 95% CI 8–55%) patients with a cognitive deficit had an abnormal cerebellar finding.

Conclusion: Many patients with minor head injuries have cognitive deficits one week after injury. History and physical examination features are poor predictors of these deficits. Further studies are needed to evaluate the duration and final outcome of these cognitive deficits.
Improved Pediatric Patient Flow in a General Emergency Department by Altering Triage Criteria
Authors: Cain Patrick , Waldrop Ron D. , Jones John
Published: September 2008

Objective:To evaluate the effect of altering pediatric triage criteria on ED triage scoring and patient flow.

Methods: A prospective observational study of a pediatric triage modification was performed. Data for all pediatric patients presenting to an urban general ED during a six‐month study period were collected. After the first three months, pediatric triage criteria were altered by elevating the acuity of several historical items and specifically listing abnormal signs and symptoms. Outcome measures included triage score assignment, criteria making the patient emergent, proportion of emergent or urgent triage assignments, and times to examination, disposition, and admission.

Results: Altering pediatric triage criteria resulted in a significant (p < 0.05) increase in the number of patients triaged as emergent (2% vs 15%) or urgent (48% vs 55%). In addition, for emergent and urgent patients there was a significant decrease (p < 0.05) in the mean times to ED examination (50 vs 44 min), floor admission (355 vs 245 min), and intensive care unit admission (221 vs 132 min). The triage changes that had a significant impact on these results were a history of color change, decreased activity, and prematurity with complications.

Conclusions: A significant improvement in pediatric patient flow occurred after posting age‐specific abnormal signs and symptoms as well as elevating triage acuity for specific historical clues.
De‐Solv‐It for Hot Paving Asphalt Burn: Case Report
Authors: Tsou Thomas J. , Hutson H. Range , Bear Michael , Glenn Casper , Hardin Eugene
Published: September 2008

Removal of tar or paving asphalt from skin specifically to evaluate underlying burn injuries and to facilitate their treatment can be a difficult problem. We report the successful use of De‐Solv‐It Multi‐Use solvent for cutaneous removal of adherent asphalt cement. This product should be considered for ED use. Controlled trials of this agent and further evaluation of any cutaneous or mucous membrane toxicity should be undertaken to further validate our experience.
A New Model of Uncontrolled Hemorrhage That Allows Correlation of Blood Pressure and Hemorrhage
Authors: Silbergleit Robert , Satz Wayne , McNamara Robert M. , Lee David C. , Schoffstall John M.
Published: September 2008

Objective: To compare hemodynamics, mortality rates, and bleeding rates at 3 severities of hemorrhage in a new model of uncontrolled intra‐abdominal bleeding that uses an injury of varying severity and geometry unfavorable to thrombosis.

Methods: Ten swine were bled through a flow‐monitored shunt placed between the femoral artery and the peritoneal cavity. The shunt was connected to catheters of varying diameters placed in the femoral artery to create 3 rates of hemorrhage. Blood flow through the shunt was measured with an in‐line Doppler probe. Arterial pressures, cardiac output (CO), and ECGs were monitored. Survival and blood loss were calculated.

Results: The model successfully produced 3 hemorrhage severities. At all 3 rates of bleeding, blood flow was linearly related to mean arterial pressure, with R2 > 0.72. Bleeding was continuous in all groups. The mean numbers of minutes until death were 53, 45, and 25, respectively, at the increasing shock severities. Blood pressure (BP) and CO decreased continuously in all groups, but did so more rapidly with increasing severity of hemorrhage.

Conclusions: In this model of uncontrolled hemorrhage, bleeding was continuous and linearly related to BP. The hemodynamic response to uncontrolled bleeding in this model differs markedly from those in previous wire aortotomy models where wound geometry is favorable to thrombosis. Hence, when injury geometry is favorable to thrombosis (as in aortotomy), thrombosis formation affects hemorrhage rates and hemodynamic responses.
Orthostatic Change in Shock Index: Comparison with Traditional Tilt Test Definitions
Authors: Witting Michael D. , Smithline Howard A.
Published: September 2008

Objective: To determine whether the orthostatic change in the shock index or published tilt test criteria better discriminated normal individuals from those with moderate acute blood loss.

Methods: Postural vital signs were recorded in a standardized manner before and after an elective 450‐mL phlebotomy associated with blood donation in healthy volunteers. Paired comparisons of the sensitivity of each of 3 published tilt test criteria were made against the sensitivity of an orthostatic change in shock index (OCSI) at the threshold for OCSI yielding the same specificity. Subjects were prospectively divided into group 1 (age < 65 years) and group 2 (age ≥ 65 years).

Results: A total of 336 healthy euvolemic adult blood donors were studied over a 1‐year period (group 1 = 292; group 2 = 44). For each published criterion for a positive tilt test (for both groups), OCSI had the same or higher sensitivity for a chosen specificity. No sensitivity difference was statistically significant. An OCSI ≥ 0 was 99%/98% sensitive and 10%/10% specific (group l/group 2) for a 450‐mL blood loss; whereas an OCSI 2 0.25 was 28%/23% sensitive and 92%/100% specific (group l/group 2).

Conclusion: The OCSI discriminates normal individuals from those with acute moderate blood loss as well as previously published tilt test definitions do.
Oregon Emergency Physicians' Experiences with, Attitudes toward, and Concerns about Physician‐assisted Suicide
Authors: Schmidt Terri A. , Zechnich Andrew D. , Tilden Virginia P. , Lee Melinda A. , Ganzini Linda , Nelson Heidi D. , Tolle Susan W.
Published: September 2008

Objective: To determine emergency physicians' (EPs') attitudes toward physician‐assisted suicide (PAS), factors associated with those attitudes, current experiences with attempted suicides in terminally ill persons, and concerns about the impact of legalizing PAS on emergency medicine practice.

Methods: A cross‐sectional, anonymous mailed survey was taken of EPs in the state of Oregon.

Results: Of 356 eligible physicians, 248 (70%) returned the survey. Of the respondents, 69% indicated that PAS should be legal, 65% considered PAS consistent with the physician's role, and 19% believed that it is immoral. The respondents were concerned that patients might feel pressure if they perceived themselves to be either a care burden on others (82%) or a financial stress to others (69%). Only 37% indicated that the Oregon initiative has enough safeguards to protect vulnerable persons. Support for legalization was not associated with gender, age, or practice location. Respondents with no religious affiliation were most supportive of PAS (p < 0.001), and Catholic respondents were least supportive (p = 0.03). A majority (58%) had treated at least 1 terminally ill patient after an apparent overdose. Most respondents (97%) indicated at least 1 circumstance for which they would sometimes be willing to let a terminally ill patient die without resuscitation after PAS if the Oregon initiative becomes law: if verified with an advance directive from the patient (81%), with documentation in writing from the physician (73%), after speaking to the primary physician (64%), if a competent patient verbally confirmed intent (60%). or if the family verbally confirmed intent (52%).

Conclusions: Although the majority of Oregon EPs favor the concept of legalization of PAS, most have concerns that safeguards in the Oregon initiative are inadequate to protect vulnerable patients. These physicians would consider not resuscitating terminally ill patients who have attempted suicide under the law's provisions, only in the setting of documentation of the patient's intent.
Splenic Rupture Manifesting Two Years after Diagnosis of Injury
Authors: Fernandes Christopher M. B.
Published: September 2008

The entity of delayed splenic rupture is often challenged. This case report describes a patient who presented with splenic rupture 2 years after a prior splenic injury from blunt trauma. The pathology report confirmed previous splenic injury. Delayed splenic rupture is possible for extended periods following splenic injury managed conservatively.