bluuebunny/crossref_metadata_2025_split huggingface dataset:
Esophageal Countershock: Anthropometric Determinants of Impedance
Authors: McKeown Pascal P. , Croal Simon , Allen J. Desmond , Anderson John , Khan Mazhar M. , Adgey A. A. Jennifer 
Published: September 2008

ABSTRACTObjective: To examine the use of a novel esophageal electrode system for countershock of atrial and ventricular tachyarrhythmias, with particular regard to the measurement of transesophageal and transthoracic impedances and their association with anthropometric variables.Methods: Transesophageal cardioversion was attempted during 131 episodes of arrhythmia in 105 patients (including 109 episodes of atrial fibrillation). The esophageal system also was used in 29 patients undergoing electrophysiologic studies for investigation of ventricular tachyarrhythmias. Transesophageal and transthoracic impedances were estimated during passage of a high‐frequency, low‐amplitude current between the respective electrodes. Impedance estimates were associated with anthropometric measurements using linear regression (least‐squares method).Results: In the group of patients undergoing attempted transesophageal cardioversion, the mean estimated transesophageal impedance of 52.6 ± 11.7 Ω was significantly lower than the mean estimated transthoracic impedance of 63.1 ± 16.4 Ω(n = 104, p < 0.01). For all the patients, transesophageal impedance was associated with weight, body mass index, and chest circumference (all r 0.65, p < 0.01). Transthoracic impedance was associated with the same factors (all r 0.55, p < 0.01).Conclusion: This esophageal electrode system results in lower impedance values for countershock between the esophagus and the cutaneous cardiac apex in comparison with standard transthoracic cutaneous electrode placement. Both techniques are dependent on anthropometric factors.
Association of Out‐of‐hospital Criteria with Need for Hospital Admission
Authors: Burstein Jonathan L. , Hollander Judd E. , Henry Mark C. , Delagi Robert , Thode Henry C. 
Published: September 2008

ABSTRACTObjective: To validate high‐risk historical and physiologic out‐of‐hospital criteria as predictors of the need for hospitalization following ED evaluation.Methods: Consecutive patients entered into the Suffolk County advanced life support system were enrolled. Previously proposed historical and physiologic “high‐risk” criteria for hospitalization were prospectively collected. Criteria were associated with the need for hospital admission following ED evaluation.Results: 1,238 patients were enrolled; 391 were released from an ED after transport. Most patients (843/1,238; 68%) were admitted to a hospital; and four died in the ED. Factors associated with an increased likelihood of admission or death among the transported patients were: bradycardia (90% admitted, p < 0.02); hypotension (80%, p < 0.03); hypertension (89%, p < 0.03); and age > 55 years (81%, p < 0.0001). Unresponsiveness and other abnormal vital signs were not associated with admission on univariate analysis. Logistic regression analysis identified two other factors associated with admission or death: tachycardia (72%, admitted, p < 0.01) and head injury (78% admitted. p < 0.001).Conclusions: Abnormal pulse or blood pressure, head injury, and age > 55 years are associated with patients' requiring hospital admission after accessing the emergency medical services system. These criteria may aid the design of out‐of‐hospital refusal‐of‐care policies.
Ultrasonographic Examination by Emergency Physicians of Patients at Risk for Ectopic Pregnancy
Authors: Mateer James R. , Aiman E. James , Brown Michael H. , Olson David W. 
Published: September 2008

ABSTRACTObjective: To evaluate a diagnostic protocol that includes the early use of endovaginal sonography (EVS) by emergency physicians of patients at risk for ectopic pregnancy.Methods: During this prospective study. pregnant patients ≥ 18 years old and at risk for ectopic pregnancy were assessed. Emergency physicians who had completed a training program performed EVS on a convenience sample of eligible women. Clinical disposition was based on predetermined clinical, laboratory, and ultrasonographic criteria. The EVS examinations were reviewed on video by a gynecologist whose interpretation was correlated with the emergency physician EVS readings and with the final clinical diagnoses. Quantitative serum P‐human chorionic gonadotropin (βhCG) levels were determined for patients who had no definite intrauterine pregnancy (IUP) on EVS.Results: Of 157 patients studied during a 12‐month period. four were lost to follow‐up. Emergency physician ultrasonographic diagnoses included: definite IUP, 87/146 (59%): probable abnormal IUP. 17/148 (11%); definite ectopic pregnancy. 31148 (2%); and no definite IUP. 41/148 (28%). The gynecologist agreed with 93% of the initial interpretations. Twelve of 16 patients who had the final diagnosis of ectopic pregnancy were admitted from the ED with this diagnosis. The ultrasonographic diagnosis of the other four was no definite IUP. and no mass or free fluid. For the latter four patients, the presenting serum βhCG level was < 2,000 mlU/mL (First International Reference Preparation). They were diagnosed as having ectopic pregnancy after serial outpatient EVS and βhCG measurements.Conclusions: The application of EVS to emergency practice appears promising. Emergency physicians trained in its use and who apply this diagnostic tool in conjunction with a defined protocol can stratify the risk of patients who have the potential for ectopic pregnancy.
Continuous Noninvasive Determination of Pulsus Paradoxus: A Pilot Study
Authors: Steele Dale W. , Wright Robert O. , Lee Calvin M. , Jay Gregory D. 
Published: September 2008

ABSTRACTObjective: To evaluate two methods of continuous, noninvasive monitoring of pulsus paradoxus (PP).Methods: A single‐subject, nonblind assessment was conducted of the ability of noninvasive monitoring techniques to measure experimentally induced PP. Variable degrees of PP were induced in a healthy adult breathing through a oneway valve to which a series of external airway resistances were added. Intra‐arterial pressure (IAP), finger arterial blood pressure (FINAP), pulse oximeter pulse waveform, and chest wall motion were continuously recorded. For each resistance, PP was calculated from the IAP (PPIAP) and the FINAP (PPFINAP) recordings. PP was measured manually (PPmanual) in the opposite arm. The percentage pulse waveform decrease on inspiration (%PWDpleth) was derived from the oximeter pulse waveform. These measurements were compared with the PPIAP. Bias was assessed as the mean difference between PP measures.Results: PPFINAP, was highly correlated with PPIAP (r = 0.96; 95% CI 0.93 to 0.98; p < 0.0001). There was a weak correlation between PPmanual and PPIAP (r = 0.27; 95% CI ‐0.05 to 0.55; p = 0.0963). The %PWDpleth correlated with PPIAP (r = 0.59, 95% CI 0.32 to 0.78; p = 0.0002). Bias was ‐1.515 ± 5.6 mm Hg between PPIAP and PPFINAP; and ‐4.508 ± 23.4 mm Hg between PPIAP and PPmanual.Conclusion: An accurate and continuous PP can be measured noninvasively using a FINAP monitor. This method has much better agreement with IAP measurements than do manual measurements. The qualitative information provided by the oximeter pulse waveform is less accurate than that provided by the FINAP monitor, but is a potentially useful screening tool for detection of significant PP.
Evaluation of Capnography in Nonintubated Emergency Department Patients with Respiratory Distress
Authors: Plewa Michael C. , Sikora Steven , Engoren Milo , Tome Daniel , Thomas James , Deuster Anthony 
Published: September 2008

ABSTRACTObjective: To evaluate the ability of noninvasive capnographic measurement of end‐tidal CO2 tension (Petco2) to predict artenal CO2 tension (Paco2) in nonintubated ED patients with respiratory distressMethods: A prospective, nonblind study was performed in a level I trauma centerkommunity teaching hospital ED. Participants included all nonintubated adult patients with respiratory distress requiring measurement of arterial blood gases (ABGs): 29 patients were enrolled Petcoz was measured with a capnography monitor. using both baseline tidal volumes and forced expiratory volumes. The bias between Petco? values and simultaneous measurements of Paco2 by ABG was assessedResults: Petco, measured with forced expiration, and Pace? agreed well, with bias (i.e, average difference) = 044 ± 0.52 kPa (33 ± 3.9 torr). Petco2 measured with the tidal volume breath produced an unacceptably high bias of 0.82 ± 0.70 kPa (6.1 ± 5.2 torr). Levels of agreement between Paco2 and Petco2 were similar for smokers and nonsmokers and for men and women. The arterial‐end‐tidal CO2 tension (Pa‐etco2) difference was not related to Paco2 Pa‐etco2 correlated with age (r = 0.473; p = 0.01), and was significantly higher in patients with pulmonary disease (132 ± 0S6 kPa; 99 ± 42 torr) than it was in those without pulmonary disease (0.46 ± 055 kPa, 3.5 ± 4.1 torr, p < 0.001).Conclusions: Noninvasive Petcoz monitoring may adequately predict Paco2 in nonintubated ED patients with respiratory distress who, are able to produce a forced expiration. Petco2 is less accurate for Paco2 with tidal volume breathing and in patients with pulmonary disease
Observation of Emergency Medicine Residents at the Bedside: How Often Does It Happen?
Authors: Burdick William P. , Schoffstall John 
Published: September 2008

ABSTRACTObjective: To determine how often trainees in emergency medicine (EM) are observed while performing a history, a physical examination, or specific procedures.Methods: The 26 members of the National Consensus Group on Clinical Skills in Emergency Medicine affiliated with an EM residency program were asked to circulate a survey to their residents during February and March 1994. Twenty‐one programs participated. surveying a total of 514 residents. The residents were asked how many times they had been observed by an attending physician while they performed a history, a physical examination. endotracheal intubation. or central vein catheterization during training. The residents also were asked about observation of specific components of the physical examination. such as the heart. lung, and genitourinary systems.Results: Three hundred nineteen residents (62%) responded to the survey. Thirteen percent of the residents reported that they had never been observed taking a history during training. During their PGYI training, 19% of the residents reported that they had never been observed taking a history, 42% had been observed one to three times, 255% had been observed four to 12 times. and 13% had been observed >12 times. Six percent of the residents reported that they had never been observed doing a physical examination during training. During their PGYI training, 10% of the residents had never been observed performing a physical examination, 38% had been observed one to three times. 34% had been observed four to 12 times, and 18% had been observed >12 times.Conclusions: Many residents report that they are infrequently observed performing histories and physical examinations during their EM training. with a significant number of residents reporting that they were never observed performing basic bedside clinical skills. More direct observation with trained faculty observers may provide an opportunity for better evaluation and remediation of bedside clinical skills.
Effective Treatment for Acute Alkali Injury to the Esophagus Using Weak‐acid Neutralization Therapy: An Ex‐vivo Study
Authors: Honiun Clark S. , Mairra Subir R. , Lane Bernard P. , Thode Henry C. , Finkelshteyn Jonathan , Davidson Lev 
Published: September 2008

ABSTRACTObjective: 1) To evaluate whether neutralization therapy with weak acid is effective in reducing observed histopathologic esophageal tissue injury secondary to liquid alkali. 2) to quantify the temperature change of the neutralizing agent. and 3) to determine the effect of interval to therapy on injury severity.Methods: Harvested Sprague‐Dawley rat esophagi were catheterized and placed in an oxygenated saline bath (37°C) for 60 minutes and then fixed in 10% formalin. Nine groups (ti = 10) were perfused with 50% sodium hydroxide (NaOH). Six of the groups were treated hy neutralization with cooled orange juice (OJ) or cola that was maintained between 2°C and 4°C. This was performed at 0, 5. or 30 minutes after injury. In addition, two positive control groups were exposed to OJ or cola at time 0 and were not exposed to strong alkali. A third control group was exposed to strong alkali hut was not administered any subsequent treatment. The temperature of the neutralizing agent was recorded prior to instillation and after exiting the esophagus. Blinded pathologic scoring of 0 (no injury) to 3 (severe) was performed for six histopathologic categories: epithelial cell viability, cornified epithelial cell differentiation, granular cell differentiation. epithelial cell nuclei, muscle cells, and muscle cell nuclei. Comparisons were made among treatment times using the Kruskal‐Wallis test and linear trend analysis.Results: For each histopathologic category and each treatment mode, the Kruskal‐Wallis test showed significant differences between the groups (p < 0.003) over time. Trend analyses showed more severe injury with delayed ncutralization therapy (p < 0.05) for each treatment mode and histopathologic category.Conclusion: Early neutralization therapy with OJ or cola reduces acute esophageal alkali injury. Additional in‐vivo study is needed before neutralization therapy is adopted for clinical use.
Lack of a Hyperkalemic Response in Emergency Department Patients Receiving Succinylcholine
Authors: Zink Brian J. , Snyder Howard S. , Raccio‐Robak Nancy 
Published: September 2008

ABSTRACTObjective: To determine whether serum potassium (K) levels increase significantly following succinylcholine (SCh)‐assisted intubation in ED patients.Methods: A prospective. noncontrolled, consecutive case series design was used to evaluate the change in serum K levels in ED patients who received SCh for emergency intubation. The study was performed at an academic medical center staffed by board‐certified emergency physicians. The subjects were 100 consecutive prescreened ED patients with various diagnoses who received SCh for intubation. The eligible subjects had serum K levels determined prior to and 5 minutes after administration of a 1.0–1.5‐mg/kg IV dose of SCh. Serum K levels were measured by the ionselective electrode assay method.Results: The mean change in serum K levels was ‐0.04 mmol/L (95% CI ‐0.14 to 0.06). The maximum increase was 1.10 mmol/L. The serum K level rose in 46 cases, decreased in 46 cases, and was unchanged in eight cases. No instance of SCh‐induced cardiac arrest was identified.Conclusion: Changes in serum K levels following SCh administration in prescreened ED patients were minimal. A hyperkalemic response is uncommon in ED patients who undergo SCh‐assisted intubation.
Ethics of Emergency Department Triage: SAEM Position Statement
Authors:   SAEM Ethics Committee
Published: September 2008

ABSTRACTEmergency department overcrowding, the growth of managed care, and the high cost of emergency care are creating pressures to triage patients away from US. EDs. Paradoxically. this pressure to limit patient access to EDs has increased in spite of federal laws that restrict patient triage and transfer The latter regulations view EDs as the safety net for the US health care system. The SAEM Ethics Committee evaluated the ethical implications of policies that triage patients nut of the ED prior to complete evaluation and treatment. The committee used these implications to develop practical guidelines, which are reported.
Mock Drug Delivery to the Proximal Aorta during Cardiopulmonary Resuscitation: Central vs Peripheral Intravenous Infusion with Varying Flush Volumes
Authors: Gaddis Gary M. , Dolister Michael , Gaddis Monica L. 
Published: September 2008

ABSTRACTObjective: To compare mock drug deliveries to the proximal aorta during CPR after peripheral vs central IV administration when the mock drug is followed by different postinfusion flush volumes.Methods: Delivery of indocyanine green (ICG) dye to the proximal aorta of an instrumented 20‐kg canine cardiac arrest model was examined. The ICG administration (2.5 mg) preceded either a 2‐mL or a 10‐mL saline flush, for either a central or a peripheral IV route of dye administration. Five dogs each underwent three sets of the four possible route/flush‐volume combinations in a stratified randomized order. Real‐time dye‐absorbance‐vs‐time curves, as sampled from the proximal aorta, modeled central‐circulation drug delivery. Systolic and diastolic blood pressures (BPs) were monitored, and the absorbance‐vs‐time curve upstroke phases were used to estimate cardiac output during arrest.Results: Times (mean ± SD) to onset of dye appearance did not differ significantly between peripheral/10 mL (126 ± 35 sec) and central/10 mL (108 ± 35 sec), or between central/2 mL (123 ± 31 sec) and central/10 mL. Times to onset of dye appearance did differ between peripheral/2 mL (161 ± 70 sec) and central/10 mL [analysis of variance (ANOVA) p = 0.032]. Times to peak dye concentration did not differ significantly between peripheral/10 mL (230 ± 88 sec) and either central/10 mL (202 ± 88 sec) or central/2 mL (215 ± 83 sec), but differed between peripheral/2 mL (326 ± 134 sec) and every other route/flush‐volume combination (ANOVA p = 0.009). Peak dye concentrations and systolic/diastolic BPs (averaging 23/10 for all route/flush‐volume combinations) did not differ significantly between any route/flush‐volume combinations.Conclusion: An adequately sized post infusion crystalloid flush (0.5 mug) permits peripherally administered model drug to reach the central circulation as quickly and in equivalent concentration as centrally administered drug during CPR in a canine cardiac arrest model.
Standard and Higher Doses of Atropine in a Canine Model of Pulse less Electrical Activity
Authors: Behnke Daniel J. De , Swart Gary L. , Spreng David , Aufderheide Tom P. 
Published: September 2008

ABSTRACTObjective:To determine whether standard or increased doses of atropine improve the return of spontaneous circulation (ROSC) rate in a canine model of pulseless electrical activity (PEA).Methods:A prospective, controlled, blinded laboratory investigation was performed using an asphyxial canine cardiac arrest model. After the production of asphyxial PEA, 75 dogs remained in untreated PEA for 10 minutes and then were randomized to receive placebo (group 1) or one of four doses of atropine (group 2, 0.04 mg/kg; group 3, 0.1 mg/kg; group 4, 0.2 mg/kg; group 5, 0.4 mg/kg). All the animals received mechanical external CPR and epinephrine (0.02 mg/kg every 3 minutes) throughout resuscitation.Results:The ROSC rates were not significantly different between the groups (group 1, 73%; group 2, 67%; group 3. 40%; group 4, 47%; group 5, 27%; p = 0.06). The heart rates and hemodynamics during resuscitation were not significantly different between the groups.Conclusion:In this canine model of asphyxial PEA cardiac arrest, standard‐dose atropine did not improve ROSC rates, compared with placebo. Increasing doses of atropine tended to decrease ROSC rates, compared with placebo and standard‐dose atropine.
Applying the Trauma Triage Rule to Blunt Trauma Patients
Authors: Mechanic Andrew D. , Hedges Jeri's R. , Sparkman Kent , Jui Jon , Mullins Richard J. 
Published: September 2008

ABSTRACTObjective: To determine the accuracy of the Baxt Trauma Triage Rule (TTR: systolic blood pressure < 85 mm Hg; Glasgow Coma Scale‐motor score < 5; or penetrating trauma to head, neck, or trunk) for prediction of major trauma in an independent data set of blunt trauma patients.Methods: Retrospective evaluation of the TTR in a cohort of patients identified by Oregon Trauma System entry criteria. Accuracy for prediction of “major trauma” victims was measured using resource‐based definitions of major trauma. Participants included 626 adult, blunt trauma patients at a level‐I trauma center serving a metropolitan center of more than one million people.Results: Of 524 patients with sufficient registry data to apply the TTR, 95 (18%) and 63 (12%) patients met the criteria for major trauma suggested by Baxt et al. and Emerman et al., respectively. Using the Baxt definition of major trauma, the TTR had a sensitivity of 74% (95% CI: 0.65–0.83) and a specificity of 84% (95% CI: 0.81–0.88). There were 25 significant false‐negative results, including 12 patients requiring urgent laparoscopy and four patients requiring emergency airway procedures. Using the Emerman definition of major trauma, sensitivity improved modestly to 76% (95% CI: 0.65–0.87) and specificity decreased slightly to 80% (95% CI: 0.77–0.84).Conclusions: In this blunt trauma population, the Baxt TTR failed to identify a significant number of severely injured patients. Slight alterations in the definition of “major trauma” can significantly affect the performance characteristics of triage instruments.
Spontaneous Agonal Respiration in a Swine Model of Out‐of‐hospital Cardiac Arrest
Authors: Menegazzi James J. , Check Brian D. 
Published: September 2008

ABSTRACTObjective: To describe ventilator dynamics following the onset of ventricular fibrillation (VF) in an experimental swine model.Methods: Twelve female mixed‐breed domestic swine (mean mass 21.3 2 1.7 kg) were sedated with IM ketamine (10 mag) and xylazine (1 mgntg), anesthetized with α‐chloralose (40 mgkg loading dose, 10 mg/kg/hr rnaintenance infusion), incubated, and mechanically ventilated on room air. ECG, and aortic and pulmonary artery pressures were monitored continuously. VF was induced with a 3‐sec, 60‐Hz, 100‐mA Tran thoracic shock, and left untreated for 8 minutes. Respiratory rate, tidal volume, and minute ventilation were recorded until respiratory activity ceased.Results: All 12 animals (100%) had agonal respirations through the first 2 minutes of arrest. This decreased to 11 (92%) at minute 3, five (42%) at minute 4, and two (17%) at minute 7. Mean respiratory rates ranged from 6 to 11 breathdmin. Mean tidal volumes ranged from 502 to 852 mL. Mean minute ventilations ranged from 3.3 to 5.8 L.Conclusion: In this swine model, 11 of 12 (92%) continued to have spontaneous agonal respirations for the first 3 minutes of VF cardiac arrest. Many animals had supernormal tidal volumes, and near‐normal minute ventilations. These findings have potential implications for lay‐rescuer and first‐responder contributions to resuscitation of victims of out‐of‐hospital cardiac arrest.
Qualitative Research Methodologies in Emergency Medicine
Authors: Binder Louis S. , Chapman Dane M. 
Published: September 2008

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