bluuebunny/crossref_metadata_2025_split huggingface dataset:
A Case–based Emergency Medicine Curriculum for Senior Medical Students
Authors: DeBehnke Daniel , Shepherd Dennis , Ma O. John 
Published: September 2008

ABSTRACTObjective: To determine the effects of a case–based, core content–oriented emergency medicine (EM) curriculum on the basic EM knowledge of senior medical students.Methods: All senior medical students rotating through the Milwaukee County EM elective during the 1992–1993 academic year were assigned specific chapter readings from a case–oriented EM textbook. A course curriculum consisting of goals and objectives for each chapter and two to three representative cases for the discussion topic also was distributed to each student. Interspersed with the cases was a series of questions directed at pathophysiology, diagnosis, management, and disposition. The EM faculty and residents conducted case discussions three times per week. AH students completing the rotation were given a pretest at the beginning and a final examination at the end of the rotation. In addition, the students rated the textbook, coursebook, and lecture series at the end of the rotation using a five–point Likert scale.Results: Seventy–five students rotated through the elective. The students showed a significant improvement in their EM knowledge base as judged by improvement in final examination scores compared with pretest scores (pretest score 62.2 ± 7.1%; final examination score 76.2 ± 6.3%; p < 0.0001). The mean change in scores was 14.8%, with a range of –1.6% to 34%. The students also rated the textbook, coursebook, and lecture series as effective, as shown by high median scores on a Likert scale.Conclusions: A case–based EM curriculum coupled with ED clinical experience improves basic EM diagnostic and management knowledge of senior medical students.
Screening and Empiric Treatment for Syphilis in an Inner‐city Emergency Department
Authors: Ernst Amy A. , Farley Thomas A. , Martin David H. 
Published: September 2008

ABSTRACTObjective: To examine targeted screening and empiric treatment for syphilis in an urban ED.Methods: Screening of emergency patients during previously arranged shifts from July 1991 through January 1992 in a university‐affiliated, inner‐city ED. Emergency patients who perceived that they had high‐risk factors for syphilis (i.e., cocaine or heroin use or sexual contact with a user of these substances) were compared with emergency patients denying high risk. All presumed high‐risk patients and alternate patients in the group who denied high risk (control group) were screened in the ED with the rapid plasma reagin (RPR) test. Empiric antibiotic treatment was initiated if the patient was RPR‐positive and gave no previous history of syphilis. In addition, serum was submitted to the state laboratory for VDRL and microhemagglutination‐Treponema pallidum (MHA‐TP) testing. Blinded serologic testing for HIV antibody was performed later on frozen serum.Results: Of 806 patients presenting to the ED, 276 (34%) admitted to high‐risk behavior. Of 373 patients tested by RPR in the ED (216 high‐risk and 157 control patients), no significant difference was found between the high‐risk and the control patients in untreated syphilis [8 (4%) vs 4 (3%)] or positive MHA‐TP [47 (22%) vs 25 (16%)]. In the high‐risk group, the women were more likely than the men to be MHA‐TP‐positive (OR = 2.58, 95% CI 1.12–7.98, p = 0.04). Among the women, the MHA‐TP was more often positive for the high‐risk than for the control patients (34% vs 15%, OR = 2.27, 95% CI 1.12–4.67, p = 0.023). For the high‐risk group, seven (3%) new cases of syphilis were managed empirically. vs three (2%) new cases for the control group. HIV antibodies were detected in 16 of 212 (8%) high‐risk patients and five of 155 (3%) control subjects (p = 0.13).Conclusion: This inner‐city ED population has a high frequency of positive syphilis and HIV serologies, regardless of acknowledged drug use risk factors. Therefore, in areas reporting high syphilis infection rates, consideration should be given to offering screening for syphilis to all emergency patients, along with establishment of adequate counseling and follow‐up.
Time to Equilibration of Oxygen Saturation Using Pulse Oximetry
Authors: Gruber Peter , Kwiatkowski Thomas , Silverrnan Robert , Flaster Edith , Auerbach Charles 
Published: September 2008

ABSTRACTObjective: To determine the time it takes for O2, saturation measured by pulse oximetry to equilibrate after a change is made in supplemental O2, administered by nasal cannula in patients with cardiac and pulmonary disease.Methods: A prospective, observational study of a convenience sample of 51 patients treated in a university‐affiliated ED with nasal cannula O2. Patients were placed on and/or subsequently taken off O2 via nasal cannula set at 2 or 4L/min based on clinical indications. Oxygen saturation was measured at l‐minute intervals over a 30‐minute period using finger‐probe pulse oximetry. Of the 51 patients in the study, 43 were monitored while O2, treatment was initiated and 18 were monitored when it was discontinued.Results: Most (95%) of the patients placed on O2, attained equilibration of O2, saturation within 3.5 minutes. Most (95%) of the patients taken off supplemental O2, attained equilibration of O2, saturation within 4.5 minutes.Conclusion: The interval to equilibration of O2, saturation in patients receiving O2 by nasal cannula is considerably shorter than the 20–30 minutes generally suggested. Adequacy of O2, supplementation should be assessable much sooner than was previously taught.
Effect of Continuous Quality Improvement Methods on Reducing Triage to Thrombolytic Interval for Acute Myocardial Infarction
Authors: Krall Scott P. , IV Charles L. Reese , Donahue Lorraine 
Published: September 2008

ABSTRACTObjectives: To assess the timeliness of thrombolytic therapy in the ED for selected patients with acute myocardial infarction (AMI) following continuous quality improvement (CQI) interventions.Methods: A retrospective, historical comparison study was performed of triage‐to‐thrombolytic time intervals for AMI patients using chart review for data collection. Patients treated after implementation of the CQI process vs a historical control group were compared. The patients with AMI who had received thrombolytics during the one‐year period prior to the CQI interventions and who had documentation of time intervals served as the control group. The patients treated during a four‐month period, beginning about one and a half years following introduction of the CQI interventions, served as the intervention group. Interventions included: a triage protocol, CQI review, and staff feedback.Results: The mean triage‐to‐thrombolytic interval was longer for the control group (72 ± 25 vs 40.0 ± 22 min; p < 0.0001). The mean triage‐to‐ECG interval also was longer for the control group (16.5 ± 8.9 vs 8.5 ± 7.5 min; p < 0.0001). Most (79%) of the study group received thrombolytic therapy within 60 minutes, and 39% within 30 minutes, whereas 39% of the control group received thrombolytic therapy within 60 minutes, and 3% within 30 minutes.Conclusion: The implementation of CQI techniques, including 100% chart review, intensive systems analysis, and staff feedback, had a positive effect on the timeliness of thrombolytic therapy for the ED patients who had AMI. As a result, most (79%) of the patients received therapy within the 60‐minute time window recommended currently by the American Heart Association.
Physical Diagnosis Skills of Physicians in Training: A Focused Assessment
Authors: Mangione Salvatore , Burdick William P. , Peitzman Steven J. 
Published: September 2008

ABSTRACTObjective: To assess the proficiency of emergency medicine (EM) trainees in the recognition of physical findings pertinent to the care of the critically ill patient.Methods: Fourteen medical students, 63 internal medicine (IM) residents, and 47 EM residents from three university‐affiliated programs in Philadelphia were tested. Proficiency in physical diagnosis was assessed by a multimedia questionnaire targeting findings useful in emergencies or related to diseases frequently encountered in the ED. Attitudes toward diagnosis not based on technology, teaching practices of physical examination during EM training, and self‐motivated learning of physical diagnosis also were assessed for all the EM trainees.Results: With the exception of ophthalmology, the EM trainees were never significantly better than the senior students or the IM residents. They were less proficient than the IM residents in cardiology, and not significantly different from the IM residents in all other areas. For no organ system tested, however, did they achieve less than a 42.9% error rate (range: 42.9–72.3%, median = 54.8%). There was no significant improvement in proficiency over the three years of customary EM training. The EM residents who had received supervised teaching in physical diagnosis during training achieved a significantly higher cumulative score. The EM residents attributed great clinical importance to physical diagnosis and wished for more time devoted to its teaching.Conclusions: These data confirm the recently reported deficiencies of physical diagnosis skills among physicians in training. The results are particularly disturbing because they relate to EM trainees and concern skills useful in the ED. Physical diagnosis should gain more attention in both medical schools and residency programs.
Delayed Subluxation of an Occult Traumatic Odontoid Fracture in an Elderly Patient
Authors: Higgins George L. 
Published: September 2008

ABSTRACTThe issue of whether a traumatic but occult cervical spine fracture can exist has generated significant debate in emergency medicine. The profound clinical and legal implications of missing an unstable cervical spine injury are well known to the emergency care provider. An elderly patient who satisfies all of the rigorous criteria for this type of injury is discussed. The patient experienced delayed subluxation of her acute odontoid fracture during a flexion/extension examination completed in the ED, with resultant development of cervical discomfort. Elderly victims of trauma with an appropriate mechanism of injury should be suspected of subtle or occult neck injuries.
Emergency Management of Blunt Testicular Trauma
Authors: Mulhall John P. , Gabram Sheryl G. A. , Jacobs Lenworth M. 
Published: September 2008

ABSTRACTObjective: Severe blunt testicular trauma is an infrequently reported consequence of injury, yet it is associated with significant sequelae. This case series evaluates the characteristics of patients with severe blunt testicular trauma, assesses the role of ultrasonography in their management, and offers an evaluation algorithm for use by both emergency and urology personnel.Methods: A retrospective review was conducted of ten patients who had severe blunt testicular injuries referred for urologic evaluation over a seven‐year period at a level 1 trauma center. Attention was focused on ultrasonographic results, operative findings, and testicular salvage rates.Results: With the exception of two motorcycle crash victims, patients presented in a delayed fashion (mean 3.5 days; range 1–5 days). Most (6/10) patients had true testicular rupture, all were explored urgently, and there was a 100% testicular salvage rate. Of the eight patients who had preoperative ultrasonographic examination, two were reported to show testicular rupture, but on exploration only one in fact had a tunica albuginea tear. Six patients had ultrasonographic examinations that revealed nonspecific abnormalities but failed to show testicular rupture; three had testicular rupture.Conclusions: Ultrasonography cannot be relied on to accurately diagnose rupture of the testis in high‐risk patients. However, testicular rupture is universally associated with an abnormal ultrasonography scan, albeit commonly yielding nonspecific findings. A high level of suspicion is mandatory with high‐energy transfer mechanisms. Since a significant delay in presentation is not unusual, early exploration is warranted in the setting of high risk and provides an excellent chance of testicular salvage. Injuries associated with normal testicular ultrasonography may be managed conservatively.
Terbutaline vs Albuterol for Out‐of‐hospital Respiratory Distress: Randomized, Double‐blind Trial
Authors: Zehner William J. , Scott Jay M. , Iannolo Patsy M. , Ungaro Alan , Terndrup Thomas E. 
Published: September 2008

ABSTRACTObjective: To determine the efficacy and safety of single doses of subcutaneous terbutaline (terb) or nebulized albuterol (alb) during out‐of‐hospital treatment for respiratory distress from asthma or chronic obstructive pulmonary disease.Methods: Patients aged >18 years who had respiratory distress were enrolled in a double‐placebo, double‐blind, randomized trial. Paramedics measured respiratory severity using an empiric score [respiratory rate, wheezing, speech, and peak expiratory flow rate (PEFR)], and the patients rated their own respiratory distress using a visual analog scale (VAS). The patients received 02 plus alb (2.5 mg) and saline injection (n = 40) or terb (0.25 mg) and saline aerosol (n = 43).Results: The groups were similar with respect to age, gender, initial empiric scores (median score 9 for both groups), PEFRs (89 ± 84 L/min, mean ± SD, for alb vs 97 ± 84 L/min for terb), and respiratory distress VAS scores. Both groups showed significant improvement in their respiratory distress VAS scores by the time of ED arrival. The alb group had a greater improvement in respiratory distress VAS score than did the terb group (p < 0.05). Empiric scores, PEFR scores, and hospital admission frequencies were not significantly different. No complication was observed.Conclusion: The out‐of‐hospital administration of either aerosolized alb or subcutaneous terb reduced respiratory severity. Albuterol provided greater subjective improvement in respiratory distress.
Prospective Assessment of Presenting Serum Markers for Cardiac Risk Stratification
Authors: Hedges Jerris R. , Swanson J. Robert , Heeter Carol , Sherer Margaret 
Published: September 2008

ABSTRACTObjective:To quantify the association of initial ED serum cardiac markers with the risk for life‐threatening events (LEs) or need for lifesaving interventions (Lis) or administration of IV nitroglycerin.Methods: A prospective, observational study was performed using a cohort of hemodynamically stable, hospitalized patients (age > 25 years) presenting with nontraumatic chest discomfort. Patients with ST‐segment elevation on their initial ECGs were excluded. Presenting serum samples were assayed for serum myoglobin and creatine kinase‐MB isomer (CK‐MB) using the Opus and Stratus systems. Target cases were defined as patients having LEs (e.g., cardiogenic shock, ventricular fibrillation, cardiac arrest), requiring Lis (e.g., intubation, cardioversion, pacing, reperfusion therapy), or needing IV nitroglycerin within 48 hours. Manufacturer's thresholds defined abnormal marker levels. Abnormal ECGs were defined using the Brush criteria.Results: Of the 178 eligible patients, 44 (25%) were target cases. Most (55%) target cases had blood drawn for assays within four hours of chest discomfort onset. The relative risk and sensitivity of the serum markers and the ECG for target cases follow:Of the seven patients with an LE/LI, six had blood drawn four hours or less after symptom onset; two LE/LI patients had abnormal myoglobin levels' no LE/LI patient had an abnormal CK‐MB level.Conclusions: Isolated serum myoglobin and CK‐MB levels obtained at patient ED presentation were not strongly associated with the 48‐hour risk for LEs, Lis, or the use of IV nitroglycerin. Future studies of risk stratification should address the merits of serial serum marker measurements that extend up to 12 hours beyond patient symptom onset.
Emergency Department Do‐not‐attempt‐resuscitation Orders: Next‐of‐kin Response to the Emergency Physician
Authors: Balentine Jerry , Gaeta Theodore , Rao Narasinga , Brandon Bernadette 
Published: September 2008

ABSTRACTObjective:To evaluate the response by families of incompetent, chronically debilitated, and/or terminally ill patients who were contacted for do‐not‐attempt‐resuscitation (DNAR) status by an emergency physician (EP).Methods: A prospective observational study was performed to assess next‐of‐kin willingness to support DNAR status for incompetent, chronically debilitated, and/or terminally ill patients. The families also were contacted by telephone follow‐up 48–72 hours after the ED visit. Upon follow‐up evaluation, the families were surveyed regarding prior DNAR instructions and their perceptions of the establishment of DNAR status in the ED. The study was conducted in an urban teaching hospital with an emergency medicine residency training program.Results: Of the 71 patient families contacted, 60 (85%) of the patients had DNAR orders written in the ED. The families of these 60 patients had no negative response regarding contact by ED personnel. Of theII (15%) patients whose families wished no DNAR order, only two families had negative responses to being contacted by the EP. In both cases the families had previously given detailed instructions to the chronic care facility.Conclusion: The EP can play an important role in assisting the decision making process of families of incompetent, chronically debilitated, and/or terminally ill patients regarding institution of DNAR orders in the ED. Improved communication regarding existing DNAR orders with chronic care facilities might minimize the rare complaints received from families with preestablished DNAR orders.
Subcutaneous Lidocaine Does Not Affect the Success Rate of Intravenous Access in Children Less than 24 Months of Age
Authors: Sacchetti Alfred D. , Carraccio Carol 
Published: September 2008

ABSTRACTObjective: To determine whether subcutaneous lidocaine (SQL), when used to decrease the pain of IV catheter insertion, adversely affects IV access in children <24 months of age.Methods: A historically controlled comparison of IV access successes with and without SQL in children <2 years of age was performed in a 30,000‐annual‐visit community hospital ED. On‐site data collected at the time of IV placement included: patient age, weight, hydration status, number of attempts, and location of attempts. All patients had IV attempts made by the same emergency physician.Results: A total of 110 children, mean age 9.6 ± 6.9 months, were included in the study analysis. Of the 110, 70 had an IV catheter placed with no pretreatment, while 40 had SQL pretreatment. The average number of attempts for all patients was 1.36 ± 0.73, with 83 (75%) performed successfully in 1 attempt and 101 (91%) within 2 attempts. The mean numbers of attempts were similar for the control and SQL groups: 1.34 vs 1.40, respectively (p = 0.68), as were the proportions successful in 1 attempt (77% vs 73%; p = 0.58) and within 2 attempts (91% vs 90%; p = 0.84).Conclusion: SQL use prior to an IV attempt in children 2 years of age does not impact vascular access. A secondary finding was that vascular access with and without SQL in infants and small children generally can be accomplished in 1 attempt.
Comparison of Staples vs Suturing for Securing Central Venous Catheters
Authors: Hightowel David , March Juan , Ausband Steve , Brown Lawrence H. 
Published: September 2008

ABSTRACTObjective: To determine whether skin staples can be used to secure central venous catheters as effectively as does suturing.Methods: A prospective, randomized trial of techniques to secure a central venous catheter was performed in a medical school human anatomy laboratory using human cadavers. Central lines were secured to the upper left thorax using either standard suture material (000 silk) or skin staples (5.7 mm ± 3.8 mm). Once secured, an upward force was applied to the hub of the catheter perpendicular to the skin. The amount of force needed to break the catheter hub free of the skin was measured in kg. A total of 10 measurements were made for each of 3 methods for securing the catheters (2 sutures, 2 staples, 4 staples). In addition, the site of catheter breakage was recorded.Results: Those catheter hubs secured by 2 sutures required a mean force of 3.1 ± 0.5 kg to cause breakage, and the break always occurred at the suture. Those hubs secured by 2 staples gave way at 3.0 ± 0.3 kg (p = NS), while those secured with 4 staples gave way at 4.5 2 ±.4 kg (p < 0.05). Although 1 hub did break, in all other stapled cases, the break occurred at the staple.Conclusions: Based on this cadaver model, use of staples appears to be as effective as suturing for securing central venous catheters. Further studies of safety and time for placement are needed.
Glucagon and Phenylephrine Combination vs Glucagon Alone in Experimental Verapamil Overdose
Authors: Stone C. Keith , Thomas Stephen H. , Koury Shaheed I. , Low Ronald B. 
Published: September 2008

ABSTRACTObjective: To evaluate glucagon and phenylephrine in combination as a treatment for the hemodynamic effects of verapamil overdose.Methods: Pentobarbital–anesthetized and instrumented dogs were overdosed using a previously developed verapamil overdose model (15 mg/kg IV over 30 minutes). The animals were maintained and observed for 90 minutes or until death. Cardiac output (CO), heart rate (HR), and mean arterial pressure (MAP) were monitored. Following the 30–minute verapamil infusion (toxicity), the control animals received no treatment; the glucagon animals received a 5–mg glucagon bolus and a drip of 5 mg/90 minutes; and the glucagon/ phenylephrine animals received the same glucagon therapy plus a phenylephrine drip titrated to 180 (μg/ min over 15 minutes. The groups were compared using analysis of variance: the experimental variables were group and time; the response variables were changes from toxicity for the hemodynamic parameters. Post–hoc comparisons were done with a set at 0. 05.Results: A significant change in CO was seen in the glucagon group (Δ = 2. 6 L/min) and the glucagon/ phenylephrine group (Δ = 1. 9 L/min) compared with the control group (Δ = 0. 8 L/min). The change in CO was significantly larger for the glucagon animals compared with the glucagon/phenylephrine animals. The change in MAP for the glucagon/phenylephrine group (Δ = 24 mm Hg) was significant compared with the control group (Δ = 14 mm Hg). The MAP change for the glucagon group (Δ = 19 mm Hg) was not significantly different from that of either the control or the glucagon/phenylephrine group. The change in glucagon HR (Δ = 6 beats/min) was significant compared with the control group (Δ = –4 beats/min) and the glucagon/phenylephrine group (Δ = –4 beats/min).Conclusion: The glucagon/phenylephrine therapy improved MAP compared with the control, but reduced CO and HR compared with glucagon alone. Glucagon/phenylephrine therapy is not as effective as glucagon alone in reversing the hemodynamic effects of experimental verapamil overdose.