bluuebunny/crossref_metadata_2025_split huggingface dataset:
Referral and Consultation in Emergency Medicine Practice
Authors: Guertler Andrew T. , Cortazzo Jeffrey M. , Rice Matthew M. 
Published: August 2010

ABSTRACTSince emergency physicians (EPs) frequently initiate referrals and consultations, accept patients in referral, and may provide consultation services, it is imperative that EPs fully understand these processes. Such an understanding improves communication and facilitates professional interactions and patient care. There is little published information concerning the significance and practice of referrals and consultations as they pertain to the EP. This article addresses referrals and consultations in relation to EPs. Specific recommendations are made for consultation initiation and execution. The dynamics and ethical/legal issues associated with initiating and accepting referrals and consultations are discussed.
An Argument for Colloid Resuscitation for Shock
Authors: Rady Mohamed 
Published: August 2010

ABSTRACTA focused review of the physiologic mechanisms of colloid and crystalloid fluid resuscitations for acute critical illness is presented. This review suggests that postresuscitation plasma volume, cardiac output, left ventricular mechanical performance, and global and microcirculatory O2 supplies are more favorable with colloid therapy. Conversely, crystalloid may adversely affect microcirculatory blood flow and resultant O2 supply and use by ischemic tissues in shock. Poor relief of global and regional hypoxia may persist in critically ill patients after resuscitation with crystalloid.
Prospective Multicenter Evaluation of Cocaine‐associated Chest Pain
Authors: Hollander Judd E. , Hoffman Robert S. , Gennis Paul , Fairweather Phillip , DiSano Michael J. , Schumb David A. , Feldman James A. , Fish Susan S. , Dyer Sophia , Wax Paul , Whelan Chris , Schwarzwald Evan 
Published: August 2010

ABSTRACT Objective: To describe a large cohort of patients who had chest pain following cocaine use, and to determine the incidence of and clinical characteristics predictive for myocardial infarction in this group of patients. Methods: A prospective observational cohort study of consecutive patients with cocaine‐associated chest pain was conducted in six municipal hospital emergency departments (EDs). Demographic variables, drug abuse patterns, medical histories, chest pain characteristics, ECG results, and laboratory data were recorded. Myocardial infarction was the primary endpoint. Results: Fourteen of 246 patients (5.7%; 95% confidence interval [CI], 2.7–8.7%) had myocardial infarction, as diagnosed by elevated CK‐MB isoenzyme levels. There were two deaths (0.8%). The patients had a median age of 33 years. The majority were male (71.5%), non‐white (83.3%), cigarette smokers (83.3%) who used cocaine regularly. Chest pain began a median of 60 minutes after cocaine use and persisted for a median of 120 minutes. Chest pain was most frequently described as substernal (71.3%) and pressure‐like (46.7%). Shortness of breath (59.3%) and diaphoresis (38.6%) were common. There was no clinical difference between patients who had myocardial infarctions and those who did not. Twelve patients had arrhythmias and four had congestive heart failure. All cases requiring intervention were evident upon presentation. An ECG revealing ischemia or infarction had a sensitivity of 35.7% for predicting a myocardial infarction. The specificity, positive predictive value, and negative predictive value of the ECGs were 89.9%, 17.9%, and 95.8%, respectively. Conclusions: Myocardial infarction in patients who have cocaine‐associated chest pain is not uncommon. No clinical parameter available to the physician can adequately identify patients at very low risk for myocardial infarction. Therefore, all patients with cocaine‐associated chest pain should be evaluated for myocardial infarction.
Inspiratory‐cycle Instillation of Endotracheal Epinephrine in Porcine Arrest
Authors: Jasani Melinda S. , Nadkarni Vinay M. , Finkelstein Mark S. , Hofmann William T. , Salzman Steven K. 
Published: August 2010

ABSTRACT Objective: To compare timed inspiratory‐cycle endotracheal (ET) instillation of epinephrine (EPI) with instillation during apnea during CPR. Methods: Prospective randomized laboratory comparison of two ET‐EPI instillation techniques in 24 preadolescent anesthetized and paralyzed Yucatan swine (mean weight 10.3 ± 1.5 kg) with apnea‐induced hypoxic and hypercarbic cardiopulmonary arrest. After 8 minutes of cardiopulmonary arrest and 1 minute of CPR, 500 μg (50 ± 7 μg/kg) of radiolabeled ET EPI was either administered timed to a ventilator inspira‐tory cycle (IN, n= 15) or injected during apnea (DA, n= 9) using a monitoring lumen built into the sidewall of the ET tube. Injection technique was carefully controlled regarding ET‐tube position, dilution, flush, and pressure‐limited mechanical ventilations. CPR was resumed and continued for 5 minutes. If resuscitation occurred, monitoring was continued for one hour. Outcome variables included pulmonary EPI distribution pattern (DIST), plasma exogenous and total EPI levels, successful resuscitation, and hemodynamic response. Results: Bilateral DIST occurred in 58% of the pigs, with significantly more bilateral DISTs for IN versus DA pigs (p = 0.01). Plasma radio‐labeled exogenous EPI counts were significantly greater for IN versus DA pigs(p = 0.03). Total plasma EPI levels rose significantly above baseline over time within each group, but showed no difference between the IN and DA groups at any time point. Successful resuscitation occurred in 21% of the pigs, with no difference between IN and DA pigs (p = 0.38). Conclusion: When other aspects of ET EPI instillation are optimized and controlled during porcine hypoxic‐hypercarbic arrest, timed inspiratory‐cycle instillation of ET EPI (50 μg/kg) results in an improved bilateral DIST and greater exogenous EPI absorption. However, in this severe pediatric asphyxial arrest model using a 50‐ μg/kg dose, inspiratory‐cycle instillation does not improve the resuscitation rate or hemodynamic response over currently recommended instillation during apnea.
The Efficacy of TAC (Tetracaine, Adrenaline, and Cocaine) with Various Wound‐application Durations
Authors: Ordog Gary J. , Ordog Cindy 
Published: August 2010

ABSTRACT Objective: To associate the efficacy of topical anesthesia of a tetracaine‐adrenaline‐cocaine solution (TAC) with the duration of skin contact. Methods: A prospective, physician‐blinded, observational study of anesthetic efficacy as a function of TAC application duration in pediatric patients (age range 1–12 years) who had superficial lacerations was performed. Patients who had lacerations less than 5 cm long were eligible for the study. Patients who had lacerations of the finger, toe, penis, nose, or pinna were excluded. Patients with histories of allergies to any of the topical anesthetic components also were excluded. Nursing staff measured the duration of TAC application (always > 5 min). Effectiveness of anesthesia was rated by the single treating physician blinded to TAC application duration. Results: For the 400 patients enrolled in the study, TAC provided better anesthesia when the wound‐application duration was more than 20 minutes (p = 0.0001). This commonly was evidenced by complete blanching of the skin within 1 cm of the wound's edges. The percentage of patients having good anesthesia at 5–10 minutes was 62% (95% CI = 46–76%) versus 97% (95% CI = 93–99%) at 31–40 minutes. No side effect was observed in any group. Conclusion: TAC is most effective as a topical anesthetic when applied for more than 20 minutes prior to suturing.
Pediatric Pain Control and Conscious Sedation: A Survey of Emergency Medicine Residencies
Authors: Ilkhanipour Kaveh , Juels Christopher R. , Langdorf Mark I. 
Published: August 2010

ABSTRACT Objective: To determine the availability and relative use of pediatric analgesia and sedation at sites of U.S. emergency medicine residency training programs. Methods: A mail/telephone survey of residency directors at 80 U.S. emergency medicine residencies regarding resident experience with pediatric analgesia and sedation for painful procedures conducted during November 1991. Results: Sixty of 80 surveys (75%) were completed and available for analysis. Emergency medicine faculty supervised conscious sedation and analgesia in 87% of responding programs, while pediatrics faculty and pediatrics‐emergency medicine fellows supervised in the remainder. Ninety‐three percent of the programs had sedating agents available in the emergency department; only four programs needed to have drugs brought from the pharmacy. Thirty‐four programs (57%) had formal protocols for the administration of these drugs. Seventy‐seven percent of the programs had airway resuscitation equipment at the bedside, while only 63% brought resuscitation drugs. However, 60% of the programs reported complications of sedation, including respiratory depression, prolonged sedation, agitation, and vomiting. The most commonly used agents were midazolam (82%), meperidine alone (68%) and with promethazine and chlorpromazine (67%), and chloral hydrate (67%). Only 25% of the programs used nitrous oxide, and 30% used ketamine. Conclusions: Emergency medicine residencies generally have available agents for pain control and conscious sedation in children, although the agents used vary widely. Appropriate instruction by trained faculty should enhance resident experience with pediatric pain control and sedation.
Evaluation of an Emergency‐procedure Teaching Laboratory for the Development of Proficiency in Tube Thoracostomy
Authors: Homan Clark S. , Viccellio Peter , Thode Henry C. , Fisher Warren 
Published: August 2010

ABSTRACT Objective: Emergency‐procedure laboratories are not a standardized part of the curriculum for emergency medicine residency programs. The authors evaluated the efficacy of an emergency‐procedure laboratory to teach medical students and residents the performance of tube thoracostomy. Methods: A prospective repeated‐measures study of tube thoracostomy placement training was performed in an animal‐laboratory setting. Participants were six first‐postgraduate‐year emergency medicine residents and six fourth‐year medical students. Each participant was given a written pretest on tube thoracostomies followed by lectures on tube thoracostomy, venous cutdown, peritoneal lavage, and surgical airway. The procedure laboratory, using an anesthetized canine model (20–25 kg), was then conducted. Tube thoracostomies were timed from skin incision to passage of the tube into the thoracic cavity with subsequent tube fogging. Four attempts per participant were documented. Eighteen days later, an identical procedure laboratory was conducted for the same students including a written posttest identical to the pretest. Results: The written test scores improved for every participant (p < 0.0001). Mean times for procedures completion improved from 121 sec to 39 sec (p = 0<.001) during the first session and improved from 58 sec to 28 sec (p = 0.005) during the second session. Retention of skills was indicated by significant shortening of the time to completion from the first attempt of the first session to that of the second session (121 sec to 58 sec, p = 0.002). Conclusions: This procedure laboratory, which emphasized skill repetition, led to improvement in procedural speed and retention of tube thoracostomy skills over time. This approach to teaching clinical procedures should be considered for emergency medicine residency programs and for continuing medical education courses that emphasize acquisition of clinical procedural skills.
Suction Catheter‐assisted Nasotracheal Intubation
Authors: Sloan Edward P. , VanRooyen Michael J. 
Published: August 2010

ABSTRACTThis case series illustrates the use of a suction catheter to guide the passage of an endotracheal (ET) tube through the glottis, a technique modification which can be used when standard nasotracheal intubation is unsuccessful. The technique is appropriate for patients in whom airway management is urgent, but not emergent. Catheter‐assisted nasotracheal intubation is useful when intubation is difficult because of excessive patient resistance to movement of the ET tube within the oropharynx. The clinical use of this technique is described for the following scenarios: overdose with obtundation, multiple trauma with agitation, and respiratory failure from pneumonia and pulmonary edema.
Emergency‐department Diagnosis of Acute Myocardial Infarction and Ischemia: A Cost Analysis of Two Diagnostic Protocols
Authors: Hoekstra James W. , Gibler W. Brian , Levy Richard C. , Sayre Michael , Naber William , Chandra Abhinav , Kacich Raymond , Magorien Raymond , Walsh Richard 
Published: August 2010

ABSTRACTObjective:To assess the potential cost savings of the emergency‐department (ED) diagnosis of acute myocardial infarction (AMI) and other myocardial ischemia using a nine‐hour ED evaluation protocol.Methods:This one‐year study of chest‐pain evaluation unit (CPEU) patient charges was undertaken at two midwestern urban university hospital EDs. Included in the study were 447 patients presenting to the EDs with chest pain consistent with myocardial ischemia, nondiagnostic electrocardiograms (ECGs), and stable vital signs. Following initial ED evaluation, CPEU patients underwent nine hours of continuous ECG ST‐segment monitoring with serum CK‐MB levels determined at zero, three, six, and nine hours. Nonrandomized concurrent chest pain patients with routine ED evaluation and hospital admission without CPEU workup served as controls. At Center 1, patients with negative CPEU evaluations underwent immediate echocardiography (echo) and graded exercise testing (GXT) followed by ED release (CPEU;REL). At Center 2, CPEU patients were released from the ED for outpatient stress thallium testing (CPEU; REL). At Center 2, CPEU patients with positive workups as indicated by elevated CK‐MB levels, ischemia by ST‐segment monitoring, or positive echo/GXT/stress thallium testing were admitted to the hospital for further testing. Control patients were admitted directly to the hospital to evaluate for AMI. Hospital charges for CPEU and control groups were compared.Results:(Total charges in dollars, mean ± SD, Student's t‐test): Conclusion:At both centers, hospital charges related to the acute evaluation of chest pain were significantly lower with this ED diagnostic protocol for AMI and myocardial ischemia.
Academic Emergency Medicine's Future
Authors:   The SAEM Task Force on Emergency Medicine's Future:, Iserson Kenneth V. , Adams James , Cordell William H. , Graff Louis , Halamka John , Ling Louis , Peacock W. Frank , Sklar David , Stair Tom 
Published: August 2010

AbstractEmergency medicine (EM) will change over the next 20 years more than any other specialty. Its proximity to and interrelationships with the community, nearly all other clinicians (physicians and nonphysicians), and scientific/technologic developments guarantee this. While emergency physicians (EPs) will continue to treat both emergent and nonemergent patients, over the next decades our interventions, methods, and place in the medical care system will probably become unrecognizable from the EM we now practice and deliver. This paper, developed by the Society for Academic Emergency Medicine (SAEM) Task Force on Academic Emergency Medicine's Future, was designed to promote discussions about and actions to optimize our specialty's future. After briefly discussing the importance of futures planning, it suggests “best‐case,”“worst‐case,” and most probable future courses for academic EM over the next decades. The authors predict that EPs will practice a much more technologic and accurate form of medicine, with diagnostic, patient, reference, and consultant information rapidly available to them. They will be at the center of an extensive consultation network stemming from major medical centers and the purveyors of a sophisticated home health system, very similar to or even more advanced than what is now delivered on hospital wards. The key to planning for our specialty is for EM organizations, academic centers, and individuals to act now to optimize our possible future.
Does the Sedative Agent Facilitate Emergency Rapid Sequence Intubation?
Authors: Sivilotti Marco L. A. , Filbin Michael R. , Murray Heather E. , Slasor Peter , Walls Ron M. ,   On behalf of the NEAR Investigators
Published: August 2010

AbstractObjectives:To ascertain whether the sedative agent administered during neuromuscular‐blocking agent‐facilitated intubation (rapid sequence intubation [RSI]) influences the number of attempts and overall success at RSI.Methods:Records were drawn from an ongoing, prospective multicenter registry of emergency department intubations. Conditional logistic regression stratified by institution was used to identify factors associated with multiple intubation attempts and unsuccessful RSI.Results:Of 3,407 intubations over 33 months in 22 institutions, 2,380 involved RSI. After correcting for the specialty and experience of the intubator and for the presence of airway aberrancy, the sedative agent was significantly associated with the number of attempts at intubation (p = 0.002). Specifically, the use of etomidate (adjusted odds ratio [OR] 0.35 [95% CI = 0.17 to 0.72]), ketamine (OR 0.27 [95% CI = 0.11 to 0.65]), a benzodiazepine (OR 0.47 [95% CI = 0.23 to 0.95]), or no sedative agent (OR 0.51 [95% CI = 0.23 to 1.13]) prior to neuromuscular blockade was associated with a lower likelihood of successful intubation on the first attempt, as compared with thiopental, methohexital, or propofol. The adjusted odds ratios for the likelihood of overall success had similar point estimates, but did not reach statistical significance due to lack of power (p = 0.2, with 36 unsuccessful intubations). Among patients receiving etomidate, intubation was more likely to be successful on the first attempt with increasing doses of either etomidate or succinylcholine.Conclusions:Thiopental, methohexital, and propofol appear to facilitate RSI in emergency department patients, independent of patient characteristics or intubator training. A deeper plane of anesthesia may improve intubating conditions in emergency patients undergoing RSI by complementing incomplete muscle paralysis.
Attending and Resident Satisfaction with Feedback in the Emergency Department
Authors: Yarris Lalena M , Linden Judith A. , Gene Hern H. , Lefebvre Cedric , Nestler David M. , Fu Rongwei , Choo Esther , LaMantia Joseph , Brunett Patrick ,   on behalf of the Emergency Medicine Education Research Group (EMERGe)
Published: August 2010

AbstractObjectives:  Effective feedback is critical to medical education. Little is known about emergency medicine (EM) attending and resident physician perceptions of feedback. The focus of this study was to examine perceptions of the educational feedback that attending physicians give to residents in the clinical environment of the emergency department (ED). The authors compared attending and resident satisfaction with real‐time feedback and hypothesized that the two groups would report different overall satisfaction with the feedback they currently give and receive in the ED.Methods:  This observational study surveyed attending and resident physicians at 17 EM residency programs through web‐based surveys. The primary outcome was overall satisfaction with feedback in the ED, ranked on a 10‐point scale. Additional survey items addressed specific aspects of feedback. Responses were compared using a linear generalized estimating equation (GEE) model for overall satisfaction, a logistic GEE model for dichotomized responses, and an ordinal logistic GEE model for ordinal responses.Results:  Three hundred seventy‐three of 525 (71%) attending physicians and 356 of 596 (60%) residents completed the survey. Attending physicians were more satisfied with overall feedback (mean score 5.97 vs. 5.29, p < 0.001) and with timeliness of feedback (odds ratio [OR] = 1.56, 95% confidence interval [CI] = 1.23 to 2.00; p < 0.001) than residents. Attending physicians were also more likely to rate the quality of feedback as very good or excellent for positive feedback, constructive feedback, feedback on procedures, documentation, management of ED flow, and evidence‐based decision‐making. Attending physicians reported time constraints as the top obstacle to giving feedback and were more likely than residents to report that feedback is usually attending initiated (OR = 7.09, 95% CI = 3.53 to 14.31; p < 0.001).Conclusions:  Attending physician satisfaction with the quality, timeliness, and frequency of feedback given is higher than resident physician satisfaction with feedback received. Attending and resident physicians have differing perceptions of who initiates feedback and how long it takes to provide effective feedback. Knowledge of these differences in perceptions about feedback may be used to direct future educational efforts to improve feedback in the ED.
Real‐Time Inter‐Rater Reliability of the Council of Emergency Medicine Residency Directors Standardized Direct Observation Assessment Tool
Authors: LaMantia Joseph , Kane Bryan , Yarris Lalena , Tadros Anthony , Ward Mary Frances , Lesser Martin , Shayne Philip ,   The SDOT Study Group II
Published: August 2010

AbstractObjectives:  Developed by the Council of Emergency Medicine Residency Directors (CORD), the standardized direct observation assessment tool (SDOT) is an evaluation instrument used to assess residents’ clinical skills in the emergency department (ED). In a previous study examining the inter‐rater agreement of the tool, faculty scored simulated resident–patient encounters. The objective of the present study was to evaluate the inter‐rater agreement of the SDOT in real‐time evaluations of residents in the ED.Methods:  This was a multi‐center, prospective, observational study in which faculty raters were paired to simultaneously observe and independently evaluate a resident’s clinical performance using the SDOT. Data collected from eight emergency medicine (EM) residency programs produced 99 unique resident–patient encounters and reported on 26 individual behaviors related to specific core competencies, global evaluation scores for each core competency, and an overall clinical competency score. Inter‐rater agreement was assessed using percentage agreement analyses with three constructs: exact agreement, liberal agreement, and binary (pass/fail) agreement.Results:  Inter‐rater agreement between faculty raters varied according to category of measure used. Exact agreement ranged from poor to good, depending on the measure: the overall competency score (good), the competency score for each of the six core competencies (poor to good), and the individual item scores (fair to very good). Liberal agreement and binary agreement were excellent for the overall competency score and the competency score for each of the six core competencies and very good to excellent for the individual item scores.Conclusions:  The SDOT demonstrated excellent inter‐rater agreement when analyzed with liberal agreement and when dichotomized as a pass/fail measure and fair to good agreement for most measures with exact agreement. The SDOT can be useful and reliable when evaluating residents’ clinical skills in the ED, particularly as it relates to marginal performance.