bluuebunny/crossref_metadata_2025_split huggingface dataset:
Left Bundle Branch Block Pattern Complicating the Electrocardiographc Evaluation of Acute Myocardial Infarction
Authors: Brady William J. , Aufderheide Tom P. 
Published: September 2008

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

ABSTRACTObjectives: To evaluate the safety and efficacy of flumazenil vs placebo in reversing fentanyl and midazolam‐induced conscious sedation in ED patients undergoing a short, painful procedure.Methods: This was a multicenter, randomized, parallel, double‐blind, placebo‐controlled study conducted at 9 university‐affiliated teaching hospitals. Patients >18 years of age requiring conscious sedation for a painful procedure expected to last <20 minutes were eligible for inclusion in the study. Patients received 2 μg/kg of fentanyl, followed by midazolam titrated to the desired level of sedation. Patients were then randomized to receive either flumazenil or placebo in a 3:1 ratio (flumazenihplacebo). Vital signs, O2 saturation, and alertness were recorded at regular intervals. Prior to ED release, patients were asked to rate the amount of discomfort they experienced and the level of relaxation achieved on a 10‐cm visual analog scale (VAS). They also were questioned about their recall for the procedure and satisfaction with the drug regimen. Physicians also rated their satisfaction with the drug regimen on a 10‐cm VAS.Results: Overall, 133 patients received flumazenil and 46 patients received placebo. Patients in the 2 groups received similar doses of midazolam. The patients who received flumazenil returned to baseline alertness earlier (11.1 min vs 24.8 min, p < 0.001) and at a faster rate than did the patients given placebo. Actual intervals from procedure completion until release from the ED did not differ between the 2 groups (98.2 ± 3.6 min flumazenil vs 96.9 ± 5.8 min placebo; p = 0.89). The amounts of discomfort experienced, levels of relaxation achieved, recalls for the procedure, and both patient and physician satisfactions were also similar for the 2 groups. There were no serious adverse effects related to the study drug, and minor adverse effects were similar for the 2 groups.Conclusion: Flumazenil is safe and efficacious in reversing midazolam‐induced sedation in ED patients given a combination of fentanyl and midazolam to facilitate the performance of a short, painful procedure. The patients given flumazenil returned to baseline alertness earlier and at a faster rate than did the patients given placebo. However, flumazenil did not alter the actual interval from procedure completion until ED release.
Normal Intrauterine Pregnancy Is Unlikely in Emergency Department Patients with Either Menstrual Days >38 Days or β‐hCG >3,000 mlU/mL, but without a Gestational Sac on Ultrasonography
Authors: Dart Robert , Kaplan Beth , Ortiz Luis , Cloherty John , Lavoie Thomas 
Published: September 2008

ABSTRACTObjective: To determine whether the absence of a gestational sac on transvaginal ultrasonography in patients with a quantitative beta‐human chorionic gonadotropin (β‐hCG) >3,000 mIU/mL and/or menstrual days >38 excludes the diagnosis of a normal intrauterine pregnancy (IUP).Methods: A retrospective analysis was performed of ED patients evaluated from August 1991 to December 1994 at an urban teaching hospital. Patients presented with abdominal pain and/or vaginal bleeding and had a positive serum β‐hCG test. Patients who had transvaginal ultrasonographies performed during the ED visit that were read as indeterminate were reviewed. Menstrual days were determined by subtracting the date of the last normal menstrual period (LMP) from the ED visit date. ED β‐hCGs were quantified. Patients were excluded if the LMP or quantitative β‐hCG result was not available or if the final diagnosis could not be definitively determined.Results: 248 patients met eligibility criteria; of these, 54 were excluded. Therefore, 194 patients were enrolled. Menstrual days ranged from 5 to 151, with a median of 54 days. Of 143 patients with menstrual days >38 and no gestational sac by ultrasonography, only 4 (2.8%) had a final diagnosis of normal IUP. The menstrual days for the 4 normal IUPs were 39, 41, 42, and 59 days. β‐hCGs ranged from 19 to 151,926 mIU/mL, with a median of 2,410 mIU/mL. None of the 74 patients with a β‐hCG >3,000 mIU/mL and no gestational sac by ultrasonography had a final diagnosis of normal IUP.Conclusion: In patients with either a β‐hCG >3,000 mIU/mL or menstrual days >38 and no gestational sac by transvaginal ultrasonography, the likelihood of a normal IUP is low.
Are Emergency Department Patients Thinking about Advance Directives?
Authors: Llovera Ingrid , Mandel Francine S. , Ryan James G. , Ward Mary F. , Sama Andrew 
Published: September 2008

ABSTRACTObjectives: To assess the percentage of adult patients presenting to an urban ED who have a written advance directive (AD) and to determine whether age, sex, a patient's perception of his or her health status, and having a regular physician are associated with the patient's having an AD.Methods: This was a cross‐sectional patient survey performed at a community teaching hospital ED. Surveys were completed by 511 adult ED patients during representative shifts over a 3‐month period. The questions included age, sex, “self‐reported” health status, whether the patient had a “regular” physician, a patient‐generated list of medical problems, and whether the patient had a written AD. For this study, ADs included health care proxies, living wills, and do‐not‐attempt‐resuscitation (DNAR) orders.Results: Of the patients surveyed, 27% reported having an AD. Males and females were equally likely to have an AD. Factors associated with an increased likelihood of having an AD were older age, having a “regular” physician, and the patient's perception of his or her health status as ill. Most patients who had an AD (82%) discussed it with their families, but only 48% discussed it with their physicians.Conclusion: Only 27% of the adult patients presenting to the ED had an AD. Older age, the patient's perception of his or her health status as ill, and having a “regular” physician increased the likelihood of having an AD.
Vertebral Artery Dissection
Authors: Showalter William , Esekogwu Victor , Newton Kim I. , Henderson Sean O. 
Published: September 2008

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

ABSTRACTObjectives: 1) To determine whether tumor necrosis factor (TNF) up‐regulation occurs in the first hours following severe injury. 2) To determine whether the time from injury to blood sampling affects the probability of detecting TNF.Methods: A prospective, cross‐sectional study was performed using a convenience sample of adult major trauma patients (“patients”) treated at a university hospital ED (Level‐1 trauma center) and 20 healthy volunteers (“controls”). The time interval from injury to specimen collection (ΔT), the injury severity scale (ISS) score, patient demographics, and quantitative cytokine [TNF and interleukin (IL‐6, IL‐8)] levels were measured. In the patients, cytokine levels were analyzed as a function of ΔT (using first hourly cutoff points and then the median T as an arbitrary cutoff point) with and without potential confounders (e.g., ISS, age, gender).Results: The mean ΔT was 92.8 ± 49.2 min (range 10–210 min, median 82 min). In the controls, TNF activity was present in 96%, with a mean level of 125 pg/mL. The controls showed no baseline IL‐6 activity and only 10% had a measurable baseline IL‐8 level. In the patients, TNF was present in 93%, with a mean level of 628 ±138 pg/mL. When the patients' specimens were divided at the median to obtain roughly equal‐sized groups, more TNF levels were elevated >2.5 SD above the controls in the early vs late group (51% vs 30%; p = 0.07). The mean levels of TNF and IL‐8 also were higher in the early vs late group (756 vs 530 and 287 vs 135, respectively; p < 0.05).Conclusions: TNF levels are elevated in the immediate 4 hours post‐injury. Previous investigators' inability to detect TNF activity increases may be related to delays in sampling. These results are consistent with the theory that increased TNF activity occurs early after major trauma and may initiate subsequent cytokine activity.
Pediatric Gamma Hydroxybutyrate Intoxication
Authors: Suner Selim , Szlatenyi C. Stephen , Wang Richard Y. 
Published: September 2008

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

ABSTRACTObjective: To evaluate probabilistic matching for linking a cohort of cardiac arrest (CA) patients identified in the Metro Toronto Ambulance (MTA) database in Toronto, Ontario, Canada, to their appropriate record in either the Vital Statistics Information System (VSIS) or the Canadian Institute of Health Information (CIHI) databases and thus establish their clinical outcomes.Methods: A linkage of a large administrative database was performed. A cohort of patients who suffered an out‐of‐hospital CA during the calendar years 1988 — 1993 was identified. To determine the patients' outcomes, the cohort was probabilistically linked to patient records in the VSIS and CIHI databases. Identifying variables used during the process of linking records included: names (first and last); New York State Identification and Intelligence System (NYSIIS) code; date of event; date of death; city; admitting hospital number; mode of admission to hospital; age; and sex.Results: A cohort of 7,079 CA patients was identified from the MTA database; 6,448 (91%) patients were accurately linked to records in 1 of the 2 outcome databases (CIHI, VSIS). Missing data for ≥1 of the linking variables were responsible for unlinked records. Using these longitudinal data, it was possible to determine the number of patients surviving their out‐of‐hospital CAs to be admitted to hospital (n = 833) (16%). No differences in survival rates (p = 0.06) or median lengths of hospital stay among the survivors (p = 0.15) were observed between admitting hospitals.Conclusions: Probabilistic matching is an effective method by which researchers can use existing administrative data to determine outcomes of population cohorts. This is especially valuable in situations where controlled intervention studies are not feasible or may be inappropriate. In this analysis, in‐hospital management of admitted CA patients, as determined by hospital‐specific survival rates and length of stay, suggests no measurable differences in the care provided to these patients by hospitals in Toronto.
Computed Tomography Scanning and Delirium in Elder Patients
Authors: Naughton Bruce J. , Moran Maureen , Ghaly Youssef , Michalakes Chris 
Published: September 2008

ABSTRACTObjective: 1) To examine the ordering of head CT scans in elder patients with delirium and cognitive impairment; and 2) to report CT scan findings associated with these conditions.Methods: This was a 2‐part study. Part 1 was a prospective, observational study of 560 adults >70 years of age evaluated at 3 separate EDs using a 200‐hour stratified sampling process at each ED. During Part 1, the frequencies of specific findings (i.e., delirium, impaired consciousness, and impaired cognition) and CT scan rates for these groups were determined. Part 2 was a retrospective analysis of CT scan reports and medical records (n = 279) for patients >70 years of age in the prospective sample (n = 79) and from a sample (n = 200) of CT scans obtained at a fourth ED. Part 2 examined clinical findings detected in the ED to determine those factors that were associated with acute findings on CT scan.Results: Part 1: There were 333 (59.4%) patients prospectively classified as having impaired cognition, impaired consciousness, or delirium; 79 (23.7%) of these patients had a head CT scan. Of these 3 groups, delirious patients were more frequently scanned (p < 0.001). Part 2: Of 279 CT scans, 42 (15.0%) were positive for an acute condition (hemorrhage, hematoma, space‐occupying lesion, infarct). Of 42 positive scans, 40 (95.1%) were found in the 102 (36.6%) patients with either impaired consciousness or a new focal neurologic finding detected in the ED.Conclusions: Considerable variability in ED CT scan ordering exists for elder patients with neurologic findings. Impaired consciousness and/or new focal neurologic signs are associated with acute findings on CT scan in elder patients. Acute CT abnormalities are uncommon in elder ED patients with other neurologic findings. Additional prospective evaluation is warranted prior to guideline development for CT scans in this patient population.
Analysis of the Treatment of Spontaneous Sustained Stable Ventricular Tachycardia
Authors: Marill Keith A. , Greenberg Gary M. , Kay Darren , Nelson Brian K. 
Published: September 2008

ABSTRACTObjectives: To determine the termination rate of spontaneous sustained stable ventricular tachycardia (SSSVT) as a function of the first and second therapeutic interventions used, and to determine factors associated with successful termination.Methods: A multihospital, retrospective analysis of the treatment of patients with SSSVT was performed. The setting included 2 urban county hospitals, 2 urban private hospitals, and a Veterans Affairs hospital. Cases were identified by discharge diagnosis and ECG characteristics, and confirmed by electrophysiology study or ECG criteria.Results: There were 40 cases of SSSVT identified. Excluding adenosine, 35 patients were treated with lidocaine as a first intervention. The rate of termination with lidocaine bolus was 17% (6 of 35) (95% CI 7–34%). Regarding the 35 patients initially treated with lidocaine, the odds of termination of SSSVT were 11 times greater in those without a history of previous myocardial infarction (MI) than in those with a history of MI (95% CI 0.96–551). Of the 29 patients who failed initial lidocaine treatment, 23 were treated with a second lidocaine bolus, with a termination rate of 18% (4 of 22) (95% CI 5–40%). Only 2 patients with sustained ventricular tachycardia had a concurrent MI, and the tachycardia was unresponsive to initial lidocaine bolus in both cases. Fifteen patients received adenosine with no tachycardia terminations and no significant adverse effects.Conclusions: The rate of SSSVT termination with lidocaine was low, particularly in patients with a history of MI.
Adverse Outcomes of Managed Care Gatekeeping
Authors: Young Gary P. , Lowe Robert A. 
Published: September 2008

ABSTRACTObjectives: To determine whether telephone preauthorization for reimbursement of ED care (medical “gate‐keeping”) by managed care organizations (MCOs) is associated with adverse outcomes.Methods: A structured review was performed of case reports solicited during 1994 and 1995 with possible adverse outcomes related to managed care gatekeeping. Gatekeeping was defined as the requirement imposed by an MCO that ED staff contact on‐call gatekeepers (i.e., clinical or nonclinical MCO personnel) to request preauthorization for ED treatment (a requirement that such MCOs enforce by refusing payment for the ED care unless preauthorization is obtained). Cases in which gatekeeper denial of preauthorization occurred were sought. Two physicians agreed on patient eligibility and classification criteria, then independently, retrospectively classified case reports identified as MCO ED payment denials into 1 of 4 categories: 1) adverse outcome; 2) patient placed at increased risk of death or disability; 3) “near miss” (emergency physicians prevented adverse outcome by caring for patient despite denial); and 4) none of the above.Results: Of the 143 cases reviewed, 29 reports represented MCO ED payment denial. Of these 29 eligible cases, there were 4 (14%) patients with adverse outcomes, 4 (14%) patients placed at increased risk, and 21 (72%) near misses. All of the 29 cases came from different EDs, representing 9 different states, with the majority from California. Adverse outcomes included respiratory failure from fulminant meningococcemia, hypovolemic syncope from ruptured ectopic pregnancy, hypovolemic arrest from vascular fibroid hemorrhage necessitating emergency hysterectomy, and prolonged postoperative course following ruptured duodenal ulcer. Patients placed at increased risk were diagnosed as having epiglottitis, myocardial infarction, ruptured ectopic pregnancy, and delayed treatment of hip septic arthritis. Near misses included diagnoses of ectopic pregnancy (n = 2), pneumothorax (n = 2), alcohol withdrawal seizures and pancreatitis necessitating intensive care unit admission, appendicitis, bacterial meningitis, cerebrovascular accident, cryptococcal meningitis in immuno‐compromised host, endocarditis, incarcerated inguinal hernia, meningococcemia, meningococcal meningitis, peritonsillar abscess, pneumococcal meningitis, ruptured abdominal aortic aneurysm, shock from gastrointestinal bleeding, small bowel obstruction, schizophrenic crisis resulting in psychiatric hospitalization, suicidal depression resulting in psychiatric hospitalization, and unstable angina.Conclusion: Adverse outcomes occur with MCO gatekeeping. Although the present study cannot ascertain whether this is a frequent event or a rare one, the safety of MCO gatekeeping deserves further study.
Confidentiality and Privacy Breaches in a University Hospital Emergency Department
Authors: Mlinek Edward J. , Pierce Jessica 
Published: September 2008

ABSTRACTObjective: To determine the frequency of visual and auditory confidentiality and privacy breaches in a university ED.Methods: A prospective, observational study of medical personnel behavior was performed using participant and direct observation techniques. Observations were made in a university tertiary referral and trauma center emergency facility. Observers recorded auditory and visual confidentiality and privacy breaches in various patient care areas during 1‐hour periods. Information collected included patient name or room number, complaint/diagnosis, diagnostic tests, past medical history, and personal information. It was then determined whether a clear identification of the patient's name or face and/or an association to his or her clinical course could be made.Results: All members of the health care team committed confidentiality and privacy breaches. Frequency of breaches was dependent on room location and design. Breaches in the triage/waiting area occurred for >53% of the patients. Breaches near the physician/nursing station ranged from 3 to 24 per hour and 1.5 to 3.4 per patient hour. Other inappropriate comments also were noted. One hundred consecutive patients and family members were interviewed at ED release, with only 2/100 having noticed the status board, although neither could recall any specific details.Conclusion: Confidentiality and privacy breaches occur in a university ED by all members of the health care team. The ED architecture and floor plan affect patient confidentiality and privacy.
Effectiveness of an Organized Follow‐up System for Elder Patients Released from the Emergency Department
Authors: Jones Jeffrey S. , Young Michael S. , LaFleur Robert A. , Brown Michael D. 
Published: September 2008

ABSTRACTObjectives: To determine whether an effective telephone callback system can be successfully implemented in a busy ED and to quantify the benefits that can be obtained related to the follow‐up care of elder patients.Methods: This was a prospective, cohort study conducted at a community teaching hospital during a 6‐month period. Consecutive patients ≥60 years old and released from the ED were selected for telephone follow‐up. Calls were made by a research nurse within 72 hours after the patient's ED visit. Follow‐up information included current medical status, problems encountered during the ED visit, compliance, and impact of the illness on self‐care capabilities.Results: Seventy‐nine percent (831/1,048) of the patients selected for telephone follow‐up were successfully contacted. The calls lasted an average of 4 ± 2.5 minutes. Although 94% (778/831) of these patients had a regular physician, 14% failed to make their recommended follow‐up arrangements. Compliance was significantly improved when a follow‐up physician was contacted during the patient's ED visit. Approximately 96% of the patients were either satisfied or very satisfied with their ED care. However, 13% (109/831) had moderate deterioration in their ability to care for themselves. Of the patients contacted, 333 (40%) required further clarification of their home care instructions, 31 were advised to return to the ED for reevaluation, and 26 were referred to a medical social worker for psychosocial concerns.Conclusion: A telephone callback system is a feasible and effective method to improve follow‐up care of elder patients released from the ED.