bluuebunny/crossref_metadata_2025_split huggingface dataset:
The Development of International Emergency Medicine: A Role for U.S. Emergency Physicians and Organizations
Authors: Kirsch Thomas D. , Holliman C. James , Hirshon Jon Mark , Doezema David 
Published: September 2008

ABSTRACTThere is a rapidly growing interest in emergency medicine (EM) and emergency out‐of‐hospital care throughout the world. In most countries, the specialty of EM is either nonexistent or in an early stage of development. Many countries have recognized the need for, and value of, establishing a quality emergency health care system and are striving to create the specialty. These systems do not have to be high tech and expense but can focus on providing appropriate emergency training to physicians and other health care workers. Rather than repeatedly “reinventing the wheel” with the start of each new emergency care system, the preexisting knowledge base of EM can be shared with these countries. Since the United States has an advanced emergency health care system and the longest history of recognizing EM as a distinct medical specialty, lessons learned in the United States may benefit other countries. In order to provide appropriate advice to countries in the early phase of emergency health care development, careful assessment of national resources, governmental structure, population demographics, culture, and health care needs is necessary. This paper lists specific recommendations for EM organizations and physicians seeking to assist the development of the specialty of EM internationally.
Evaluation of a Bedside Whole‐blood Rapid Troponin T Assay in the Emergency Department
Authors:   Rapid Evaluation by Assay of Cardiac Troponin T (REACTT) Investigators Study Group
Published: September 2008

ABSTRACTObjective: To evaluate the performance of a new bedside whole‐blood rapid assay for cardiac troponin T (cTnT) in patients presenting to the ED with symptoms consistent with acute coronary ischemia.Methods: A prospective, observational trial was performed in 8 participating medical centers. Serial blood samples were obtained on presentation to the ED and 3 and 6 hours later. The cTnT whole‐blood rapid assays were performed immediately at the site. Treating physicians and patients were blinded to the results of the rapid assays. Serum samples were analyzed at the core laboratory for serum cTnT, creatine kinase (CK)‐MB, and myoglobin. The sensitivity of the rapid assay for detecting acute myocardial infarction (AMI) was compared with the sensitivities of serum cTnT, CK‐MB, and myoglobin assays.Results: Of 721 patients, 102 were diagnosed as having AMI. The median elapsed time from symptom onset to ED arrival was 3 hours. The sensitivities of the rapid assay for detecting AMI were 19.6%, 59.0%, and 69.7% at 0, 3, and 6 hours, respectively. The sensitivities of the serum cTnT assay (p‐values for comparison with the rapid assay for cTnT) were 25.0% (p = 0.18), 69.6% (p = 0.04), and 79.8% (p = 0.02) at 0, 3, and 6 hours, respectively. The CK‐MB and myoglobin sensitivities were 21.9%, 64.5%, and 81.0%; and 43.8%, 77.4%, and 71.4%, respectively. There were 7 patients with AMI who had negative rapid assay readings and positive serum cTnT levels; 4 of these patients were enrolled at the same site. Twenty patients not diagnosed as having AMI had at least one positive rapid assay. Fourteen of these 20 patients had a diagnosis of clinically relevant cardiac disease.Conclusions: The sensitivity of this whole‐blood rapid cTnT assay for detecting AMI is comparable to that of current serum assays and offers the advantage of providing rapid bedside results. Discrepancies between serum and whole‐blood assays for cTnT noted in this study may indicate the need for further education for the test reader prior to patient use.
Detection of Electrolyte Abnormalities in Children Presenting to the Emergency Department: A Multicenter, Prospective Analysis
Authors: Rothrock Steven G. , Green Steven M. , McArthur C. L. , DelDuca Kevin ,   Detection of Electrolyte Abnormalities in Children Observational National Study (DEACONS) Investigators
Published: September 2008

ABSTRACTObjective: To prospectively derive high‐yield criteria for the detection of clinically significant electrolyte abnormalities (CSEAs) in children presenting to the ED.Methods: A prospective, multicenter, observational study was performed at the EDs of 2 urban teaching hospitals, a university medical center, and a children's hospital with a combined census of >275,000 patient visits/year (100,000 visits for children <13 years old). All children <13 years old who had electrolyte panels obtained were eligible for analysis. A data form containing potential predictor variables for a CSEA was completed by the clinician prior to receipt of electrolyte results. A CSEA was any abnormal electrolyte value that 1) stimulated constructive assessment of the patient's condition (monitoring, reevaluation of nonspurious laboratory values, or admission), 2) led to further diagnostic studies, 3) led to a new diagnosis, or 4) affected therapy, χ2 recursive partitioning was used to derive a decision rule for ordering electrolytes.Results: Of 715 eligible patient visits, 488 (68%) electrolyte panels contained a laboratory abnormality, with 182 (25%) CSEAs. A decision rule requiring 1 of 6 clinical criteria was 100% sensitive (95% CI 98–100%) and 24% specific (95% CI 21–28%) in detecting CSEAs with positive and negative predictive values of 31% (95% CI 28–34%) and 100% (95% CI 97–100%), respectively. If these criteria had been used to screen patients for whom electrolyte panels were ordered, 128 patients (18%) would not have had electrolyte panels obtained and no CSEAs would have been missed.Conclusion: A set of clinical criteria was derived that may be useful for limiting electrolyte panels ordering in children. This criterion set requires prospective validation in a separate patient population.
Case Management by Physician Assistants and Primary Care Physicians vs Emergency Physicians
Authors: Hirshberg Alan J. , Holliman C. James , Wuerz Richard C. , Chapman Dane M. 
Published: September 2008

ABSTRACTObjectives: To determine whether physician assistants' (PAs') and primary care physicians' (PCPs') case management for 5 common primary care medical problems is similar to that of emergency physicians (EPs).Methods: An anonymous survey was used to compare PAs, PCPs, and EPs regarding intended diagnostic and treatment options for hypothetical cases of asthma, pharyngitis, cystitis, back strain, and febrile child. Published national practice guidelines were used as a comparison criterion standard where available. The participants stated that they treated all of the patients and responded to all of the cases to be included in the survey. The responses of the PA and PCP groups were compared with those of the EP group, and financial charges for care by each group were analyzed.Results: The EPs tended to follow treatment guidelines closer than did other primary care specialists. The management of PCPs and PAs differed from that of EPs, as follows:Conclusion: The EPs more closely followed clinical guidelines than did the PAs and PCPs for these standardized clinical scenarios. Although the relationship of such theoretical practice to actual practice remains unknown, use of these clinical scenarios may identify intended practice patterns warranting attention.
Analysis of Alcohol Use Clusters among Subcritically Injured Emergency Department Patients
Authors: Minugh P. Allison , Nirenberg Ted D. , Clifford Patrick R. , Longabaugh Richard , Becker Bruce M. , Woolard Robert 
Published: September 2008

ABSTRACTObjectives: 1) To cluster patients according to self‐reported drinking patterns using cluster analysis; 2) to externally validate clustered groups on variables related to drinking but not used in the cluster analysis; and 3) to use the clustered patients' responses to alcohol consumption questions to develop a brief screening tool emergency physicians can use to identify patients in need of referral or intervention related to potentially hazardous alcohol consumption.Methods: A self‐report battery was administered to 95 subcritically injured patients. Patients also were saliva alcohol‐tested upon arrival to the ED. Using the patients' self‐reported quantity, frequency of alcohol consumption, and frequency of having ≥6 drinks on a drinking occasion, patients were categorized into 3 groups using cluster analysis. The 3 clusters were externally validated using injury‐related variables, alcohol‐related consequences, and the patients' reported readiness to change drinking. A screening tool was developed using cutoff values reported by the patients' answers to drinking pattern questions.Results: Fifty‐nine patients were alcohol‐negative, and 36 tested alcohol‐positive (i.e., >4 mmol/L [>20 mg/ dL]) or had elevated scores on an alcohol problem screening instrument. Three distinct drinking pattern clusters were found. Clusters were validated using discriminant function analysis and multivariate analyses of variance to confirm cluster classifications. Steady and high‐intensity drinkers reported more alcohol‐related negative consequences, and high‐intensity drinkers indicated they would consider changing their drinking. The screening tool correctly classified 97% of the patient sample into their respective clusters.Conclusions: Using the drinking pattern questions in the clustering procedure was effective for grouping injured patients into clusters that could be differentiated on other drinking‐related variables. The resulting screening tool can be used in the ED setting to screen patients for further assessment and intervention. The readiness‐to‐change results support the assertion that the injury event provides a “teachable moment” for subcritically injured patients whose injury may be related to their alcohol consumption.
Proper Depth of Placement of Nasotracheal Tubes in Adults Prior to Radiographic Confirmation
Authors: Reed David B. , Clinton Joseph E. 
Published: September 2008

ABSTRACTObjective: To determine the optimal initial depth of tube placement in nasotracheal intubation (NTI) of adult patients, measured at the naris, prior to obtaining a chest radiograph (CXR).Methods: Part 1: A prospective, observational study was performed to compare the initial depth of NTI, measured at the naris, with the observed height of the endotracheal tube (ETT) tip above the carina on the initial CXR. Optimal depths were predicted by gender. Part 2: Results from Part 1 were prospectively validated by measuring the frequency of adequate placement when ETTs were placed to this depth. ETT placement was considered adequate if the tip was at least 2 cm above the carina and below the larynx on the CXR.Results: Part 1: The mean depth measured at the naris was 27.5 ± 1.5 cm in women (n = 50) and 27.8 ± 1.0 cm in men (n = 74). The mean distance of the tip of the ETT to the carina was 3.9 ± 2.7 cm in women and 6.4 ± 2.2 cm in men. Initial tube position was adequate in 39 (78%) of the women and 72 (97%) of the men. It was determined that if a depth of 26 cm had been used in the women and 28 cm in the men, 45 (90%) of the women and 70 (95%) of the men would have had adequate tube placement, resulting in statistically significant improvement of placement in the women (p < 0.05; McNemar & chi2)‐ Part 2: These calculated depths (26 and 28 cm) were then prospectively applied in 26 women and 52 men. Twenty‐five (96%) of 26 women and 51 (98%) of 52 men had adequate placement, with a mean height above the carina of 4.5 ±1.4 cm in women and 5.6 ± 1.8 cm in men.Conclusion: Initial placement of NTI at 26 cm in women and 28 cm in men, measured at the naris, resulted in adequate initial placement for most adult patients.
Comparison of Routes of Flumazenil Administration to Reverse Midazolam‐induced Respiratory Depression in a Canine Model
Authors: Heniff Melanie S. , Moore Gregory P. , Trout Anne , Cordell William H. , Nelson David R. 
Published: September 2008

ABSTRACTObjective: To determine whether flumazenil, a drug used to reverse benzodiazepine‐induced respiratory depression and approved only for IV use, is effective by alternative routes.Methods: A randomized, controlled, nonblinded, crossover canine trial was performed to evaluate reversal of midazolam‐induced respiratory depression by flumazenil when administered by alternative routes. Mongrel dogs were sedated with thiopental 19 mg/kg IV, then tracheally intubated. With the dogs spontaneously breathing, tidal volume, end‐tidal CO2, and O2 saturation were observed until a stable baseline was achieved. Incremental doses of midazolam were administered until respiratory depression (30% decline in tidal volume, 10% decrease in O2 saturation, and 15% increase in end‐tidal CO2) occurred. Flumazenil was administered by a randomly selected route [0.2 mg followed 1 minute later by 0.3 mg IV, sublingual (SL) or intramuscular (IM); or 1 mg followed 1 minute later by 1.5 mg per rectum (PR)]. Time to return to baseline respiratory functions was recorded (“time to reversal”). Each of 10 dogs was studied using all 4 routes of flumazenil administration with a washout period of at least 7 days. An additional dog served as a control (no flumazenil).Results: The control time to reversal was 1,620 seconds. The IV route was significantly faster (mean 120 ± 24.5 sec) than the other 3 routes (p < 0.005). The SL route was the second fastest (mean 262 ± 94.5 sec), the IM route was the third fastest (mean 310 ± 133.7 sec), and the PR route was the slowest (mean 342 ± 84.4 sec). The SL, IM, and PR routes did not differ significantly from one another.Conclusions: Flumazenil administered by all 4 routes reversed midazolam‐induced respiratory depression in a dog model. For the selected dosages used, the IV route was significantly faster than all 3 other routes, and SL was the second fastest.
Incidence of Deep Venous Thrombosis Associated with Femoral Venous Catheterization
Authors: Mian Nabeela Z. , Bayly Robert , Schreck David M. , Besserman Eva B. , Richmond David 
Published: September 2008

ABSTRACTObjective: To determine in adult medical patients the incidence of deep venous thrombosis (DVT) resulting from femora] venous catheterization (FVC).Methods: A prospective, observational study was performed at a 420‐bed community teaching hospital. Hep‐arin‐coated 7‐Fr 20‐cm femoral venous catheters were inserted unilaterally into a femoral vein. Each contra‐lateral leg served as a control site. Age, gender, number of FVC days. DVT risk factors, administration of DVT prophylaxis, and DVT formation and site were tabulated for each patient. Venous duplex sonography was performed bilaterally on each patient within 7 days of femoral venous catheter removal.Results: Catheters were placed in 29 men and 13 women. Femoral DVT was identified by venous duplex sonography in 11 (26.2%) of the FVC legs and none (0%) in the control legs. Posterior tibial and popliteal DVT was identified in both the FVC and control legs of 1 patient. DVT formation at the site of FVC insertion was highly significant (p = 0.005). There were no statistically significant associations with age (p = 0.42), gender (p = 0.73), number of DVT risk factors (p = 0.17), number of FVC days (p = 0.89), or DVT prophylaxis (p — 099).Conclusion: Placement of femoral catheters for central venous access is associated with a significant incidence of femoral DVT as detected by venous duplex sonography criteria at the site of femoral venous catheter placement. Physicians must be aware of this risk when choosing this vascular access route for adult medical patients. Further studies to assess the relative risk for DVT and its clinical sequelae when using the femoral vs other central venous catheter routes are indicated.
Medically Unnecessary Pediatric Ambulance Transports: A Medical Taxi Service?
Authors: Camasso‐Richardson Karen , Wilde James A. , Petrack Emory M. 
Published: September 2008

ABSTRACTObjective: To characterize ambulance utilization in a pediatric population and pediatric emergency physicians' judgment of the medical need for ambulance transport.Methods: A convenience sample of ambulance transports were studied prospectively during a 5‐week period. Exclusion criteria included transfer from another medical facility, study physician not available, need for immediate resuscitation, or trauma team activation. A questionnaire completed by the physician assessed medical need for the ambulance based on chief complaint, general appearance, vital signs, and ambulance run sheet information. A separate questionnaire was administered to the parents regarding reasons for ambulance use and other available means of transportation. Caregivers were contacted by telephone 2–3 days later to determine the mode of transportation home and the clinical outcome.Results: Of 172 eligible patients, 92 (53%) were enrolled. Most (61%; 56/92) transports were considered medically unnecessary. Interestingly, 40% (37/92) of the subjects had no other means of transportation; 86% (32/37) of ambulance transports for this group were judged medically unnecessary. Overall, 86% (79/92) of families had not called their physician. There was no association between having spoken with the physician and medical need for an ambulance. Many (82%; 46/56) Medicaid transports were judged medically unnecessary. Overall, follow‐up was achieved for 91% (85/92) of the patients. No patient for whom transport was medically unnecessary had a repeat ED visit for the same complaint or required admission. Most patients (74%; 68/92) returned home without any assistance. Among the medically unnecessary transports, 52% (32/ 60) of the caregivers cited no other means of transportation, yet 34% (11/32) of these patients returned home by private car.Conclusions: Most pediatric ambulance transports in this sample, which excluded patients requiring immediate resuscitation or trauma team care, were judged to be medically unnecessary. Caregivers often use an ambulance as a convenience or as the only means of transportation. An alternate, less resource‐intensive transportation system may be more appropriate for this population.
Alkalinization Is Ineffective for Severe Hyperkalemia in Nonnephrectomized Dogs
Authors: Kaplan Justin L. , Braitman Leonard E. , Dalsey William C. , Montgomery Michael , Mangione Antoinette ,   Hyperkalemia Research Group
Published: September 2008

ABSTRACTObjective: To determine whether alkalinization with sodium bicarbonate (NaHCO3) in near‐lethal hyperkalemia either lowers potassium (K) rapidly or shortens duration of cardiac conduction disturbances. Methods: A controlled canine laboratory investigation of 3 treatments for severe hyperkalemia. Conditioned dogs (n = 8; 17–30 kg) received, in random order, 2 mmol/kg of each of 3 treatments (matched in sodium and water) in separate experiments ≥1 week apart: 1.05% NaHCO3 over 60 minutes (infusion therapy); 8.4% NaHCO3 over 5 minutes, then 14 mL/kg sterile water over 55 minutes (bolus therapy); 8.4% NaCl over 5 minutes, then 14 mL/kg sterile water over 55 minutes (saline therapy). Prior to administering one of the above therapies, the animals were anesthetized with 0.5–2.5% isoflurane and ventilated to maintain a normal Pco2. After 30 minutes of equilibration, 2 mmol/kg/hr (loading dose) of a 2‐mmol/mL KCl solution was given until idioventricular or relative junctional bradycardic dysrhythmias were sustained for 15 minutes. Then KCl was decreased to 1 mmol/kg/hr (maintenance dose) for 2 hours and 45 minutes. Treatment was begun after 45 minutes of maintenance KCl infusion.Results: The pretreatment K level (all studies) was 9.06 ± 0.82 mmol/L (mean ± SD). Although the mean K level decreased more after saline therapy than after bolus therapy at every time, differences were neither statistically significant nor clinically important during the first 30 minutes. The means of the differences in decreases (saline minus bolus) were small, 0.26 (95% CI, ‐0.48 to 1.00) at 15 minutes, 0.16 (95% CI, ‐0.67 to 0.98) at 30 minutes. Dysrhythmia duration was shorter with bolus therapy than for saline therapy in only 1 of 5 dogs (p = 0.38).Conclusions: Hypertonic saline bolus lowered plasma K as effectively as NaHCO3 bolus in this animal model within the first 30 minutes. Clinically meaningful decreases due to alkalinization alone within 30 minutes are unlikely.
Efficacy of Atropine Sulfate in Combination with Albuterol in the Treatment for Acute Asthma
Authors: Díaz José E. , Dubin Reva , Gaeta Theodore J. , Pelczar Peter , Bradley Keith 
Published: September 2008

ABSTRACTObjective: To determine the efficacy of combination therapy using atropine sulfate and albuterol in the treatment for an acute exacerbation of asthma.Methods: A prospective, randomized double‐blind, placebo‐controlled study was performed in the ED of a large, inner‐city, university‐affiliated teaching hospital. Participants were a convenience sample of patients presenting to the ED between September 1993 and March 1994 with acute exacerbations of their asthma. Patients judged to be in extremis were excluded. All patients received 3 nebulized treatments with 2.5 mg of albuterol at 0, 30, and 60 minutes. Patients were randomized into 1 of 3 groups with the following added to their nebulizer solutions: 1) saline placebo during all 3 treatments; 2) 2.0 mg atropine sulfate added to the first nebulizer and saline in the second and third; or 3) 2.0 mg atropine to the first and third treatments (with saline in the second). No other medication was administered during the study period. At 90 minutes, the patients were evaluated for admission or release from the ED according to predetermined criteria, and additional medications were given as necessary. Vital signs, peak expiratory flow rate (PEFR), degree of wheezing, level of distress, and side effects were measured before and after each nebulizer treatment. Results: Of the 153 patients eligible for the study, 126 completed the entire study protocol. There was no significant difference between the 3 groups on any parameter studied, including improvement of PEFR, vital signs, or level of distress. There was no difference in the admission rate between the 3 groups, nor was there a difference in the incidence of side effects among the groups.Conclusion: In this study population, combination therapy with atropine sulfate and albuterol offered no significant benefit over the use of albuterol alone in the treatment for acute exacerbation of asthma.
Mortality and Morbidity Associated with the Distribution of Monthly Welfare Payments
Authors: Verheul Glenn , Singer Sharon Manson , Christenson James M. 
Published: September 2008

ABSTRACTObjective: The impact of major social policy decisions on community health is rarely considered or analyzed. This article describes the association of major community and health resource use in relation to the distribution of monthly welfare payments.Methods: A descriptive, retrospective study was performed using existing accessible databases in the city of Vancouver, British Columbia (BC), and St. Paul's Hospital, a tertiary care, downtown institution. The mean numbers of admissions or responses per week and per day related to the monthly welfare check issue day in 1993 were collected from the following health agencies: the BC Ambulance Service, the Vancouver Fire Department, the BC Coroner's Office, the Vancouver Detox Center, the Vancouver City Police Jail for public drunkenness, and St. Paul's Hospital ED.Results: Comparison of weekly events for non‐payweeks vs the week starting on welfare payday (mean ± SD) are: St. Paul's ED, 949 ± 51 vs 993 ± 81 (p = 0.10); Detox Center observation admissions, 29 ± 5.6 vs 40 ± 7.3 (p < 0.001); Vancouver Fire Department medical responses, 453 ± 44 vs 527 ± 45 (p < 0.001); BC Ambulance Service responses, 3,338 ± 101 vs 3,634 ± 85 (p < 0.001); and coroner‐reported deaths, 8.8 ± 3.0 vs 13.6 ± 2.6 (p < 0.0001).Conclusions: As measured in multiple independent databases, there is a significant increase in morbidity and mortality in the week after the distribution of monthly welfare paychecks.