bluuebunny/crossref_metadata_2025_split huggingface dataset:
The Use of Propofol for Sedation in the Emergency Department
Authors: Swanson Eric R. , Seaberg David C. , Mathias Susan 
Published: September 2008

ABSTRACTObjective: To evaluate the effectiveness of propofol and fentanyl when used by emergency physicians (EPs) for systemic sedation and analgesia in the ED.Methods: Over an eight‐month period, a convenience sample of consenting patients at an urban teaching hospital ED who required sedation for painful procedures were enrolled in a descriptive study of therapeutic propofol sedation. After receiving 2μ‐g/kg of fentanyl IV, the patients received a continuous infusion of propofol at 0. 21 mg/kg/min IV to the desired level of sedation. A maintenance infusion of 3–6 mg/kg/hr was administered during the remainder of the procedure. Sedation time, total procedure time, and recovery time were recorded and the presence of side effects was noted. The patients and the physicians rated their satisfaction with the technique on a 100–mm visual analog scale. The patients were contacted at 24 hours for follow‐up information.Results: Twenty patients (aged 19–62 years) received propofol infusion for procedures that included ten abscess incision and drainages, eight orthopedic reductions, one chest tube placement, and one wound exploration. The mean (±SD) total dose of propofol was 200 ± 160 mg. The mean time to onset of sedation was 6. 6 ± 3. 2 min, the mean procedure interval was 9. 6± 6. 3 min, and the mean interval until recovery was 6. 1 ± 4. 1 min. The median patient satisfaction score was 97 mm (range 40–100 mm); the median rating by physicians was 88 mm (range 4–100 mm). Side effects were noted in six patients: three had pain on injection, one had pain on injection and brief (<1 min) hypotension (systolic blood pressure = 80 mm Hg), and two had apnea (<30 sec). Seven patients had some recall of the procedure immediately afterwards, but only five had any recall at 24 hours. All 20 patients stated they would be willing to receive the same sedation again for a future procedure.Conclusion: Propofol appears to be an effective agent to provide systemic sedation and analgesia when used in conjunction with fentanyl for procedures in the ED. Given its rapidity of onset and elimination, it may become a useful agent to EPs for IV sedation in the ED.
The Emergency Department Electrocardiogram and Hospital Complications in Myocardial Infarction Patients
Authors: Zalenski Robert J. , Rydman Robert J. , Sloan Edward P. , Caceres Luis , Murphy Daniel G. , Cooke David 
Published: September 2008

ABSTRACTObjective: To determine whether acute myocardial infarction (AMI) patients who have negative ECGs on presentation have significantly lower complication rates than do those AMI patients who have positive ECGs on presentation.Methods: Retrospective, cohort analysis comparing rates of hospital complications (ventricular fibrillation or tachycardia, shock, atrial arrhythmia or bradyarrhythmia with systolic blood pressure 90 mm Hg, pulmonary edema) or interventions among patients with a final hospital diagnosis of AMI and an initially negative vs positive ECG. A negative ECG was normal or had nonspecific ST–segment and/or T–wave abnormalities (upright, flattened T waves; an isolated inverted T wave; ST depression <0.1 mV; tall T waves with J–point elevation) or minor nonischemic abnormalities. Sample size was adequate to detect a 30% between–group difference in complication rates [α = 0.05, 1 —‐ β (power) = 0.80].Results: The 27 negative–ECG AMI patients differed from the 38 control patients in (mean X SD) age [57 X 12 vs 66 X 12 years, p < 0.01] but not in gender or history of AMI. The negative– and positive–ECG groups had similar rates of hospital complications [30% (95% CI: 13–47%) vs 42% (95% CI: 26–58%), p = 0.44] and intensive procedures [19% (95% CI: 4–34%) vs 29% (95% CI: 15–43%), p = 0.50], respectively. The negative–ECG patients with hospital complications had ECG evolution precede the event in 83% (95% CI: 69–97%) of cases; persistently negative–ECG patients had no complication [(95% CI: 0–33%), p = 0.06].Conclusions: Negative– and positive–ECG AMI patients do not have moderate or large differences in the rates of in–hospital complications. Most negative–ECG patients who suffer complications evolve ECG changes prior to the event and such changes indicate the potential need for a higher level of care.
Association of Training Level and Short–term Cosmetic Appearance of Repaired Lacerations
Authors: Singer Adam J. , Hollander Judd E. , Valentine Sharon M. , Jr. Henry C. Thode , Henry Mark C. 
Published: September 2008

ABSTRACTObjective: To determine the association between emergency practitioner level of training and cosmetic appearance of primarily closed wounds as evaluated at the time of suture removal.Methods: A retrospective analysis of wound registry data was performed. At the time of wound closure, standard data were collected including details of patient demographics, wound characteristics, preparation, closure, and postoperative care, for consecutive patients sutured in the ED. Follow–up data were obtained at the time of the return visit using a previously described cosmetic scale. With the scale, all lacerations were assigned 0 or 1 point each for the presence or absence of six items: a step–off of borders; contour irregularities; margin separation; edge inversion; excessive distortion; and overall appearance. For analysis, the proportion of wounds with a score of 6 (optimal cosmetic appearance in all categories) was associated with practitioner level of training.Results: Five hundred fifty–two patients' wounds were evaluated. The percentages of various practitioners' achieving an optimal cosmetic score were: medical students (MSs), 50%; first–year residents (EMls), 54%; second–year residents (EM2s), 66%; third–year residents (EM3s), 68%; physician assistants (PAs), 70%; and attending physicians (APs), 66%. The senior practitioners (EM2s, EM3s, PAs, APs) were significantly more likely to obtain a maximal cosmetic score than were the junior practitioners (MSs, EMls) (68% vs 52%, p = 0.016).Conclusion: Significant improvement in short–term cosmetic results following wound repair is associated with a training level beyond PGY1. These data reinforce the need for careful patient selection and close supervision of wound repair by trainees, especially of wound repair by medical students and interns.
Emergency Physicians' Obligations to Managed Care Patients under COBRA
Authors: Wood Joseph Patrick 
Published: September 2008

ABSTRACTIn 1986 the federal government enacted a statute, the Consolidated Omnibus Budget Reconciliation Act (COBRA), intended to address the perceived problem of patients being denied essential emergency medical care, or being transferred in an unstable condition, because of the patient's lack of an adequate payer source. Compliance with COBRA has been a concern among hospitals and emergency physicians (EPs). Indeed, by the end of 1993, the federal government investigated δ1,500 allegations of COBRA violations. Since COBRA was enacted to address the problem of “economically motivated” transfers of indigent patients, many EPs are unaware of the potential for COBRA violations inherent in the accommodations currently being sought by some managed care organizations. This paper reviews hospitals' and physicians' obligations to managed care patients under COBRA.
Systemic Toxicity from Ocular Homatropine
Authors: Reilly Kevin M. , Chan Lisa , Mehta Nalin J. , Salluzzo Richard F. 
Published: September 2008

ABSTRACTToxidromes are well known to emergency physicians. An unclear or incomplete history and subtle findings on physical examination make the diagnosis of poisonings challenging. This article reports a patient who had an acute onset of visual hallucinations, pressured speech, and mania. Although she denied taking any medications, she was ultimately diagnosed as having anticholinergic toxicity. On further questioning of family members, it was discovered that she was being treated for anterior uveitis with 5% homatropine. This case illustrates the potential role of ocular medications in systemic toxicity. Patients often do not consider eyedrops to be medications, and their use may be overlooked in the medical history. It also is important to educate patients and medical staff in methods to minimize systemic toxicity when using ocular medication.
A Population‐based Study of Fatal and Nonfatal Firearm‐related Injuries
Authors: Coben Jeffrey H. , Dearwater Stephen R. , Forjuoh Samuel N. , Dixon Bruce W. 
Published: September 2008

ABSTRACTObjective: To determine population‐based firearm‐related morbidity and mortality for Allegheny County, PA (population = 1.3 million), for the year 1994.Methods: Fatalities were identified from a review of death certificates. To identify nonfatal cases, an active surveillance was conducted at all 24 acute care EDs in the county. The ED surveillance used 2 existing sources of case identification from each hospital to minimize undercount.Results: Firearms were the leading cause of injury death to county residents, accounting for 155 deaths. The crude mortality rate from firearms was 11.7/100,000. Black males aged 15–19 years were most at risk for a firearm fatality (293/100,000). There were 514 nonfatal firearm injuries, producing a case fatality rate of 23%. The highest age‐specific rate for nonfatal firearm‐related injuries treated in the county EDs was observed for black males aged 15–19 years (2,245/100,000), which is 58 times higher than the firearm‐related injury rate for the entire county population (38.7/100,000).Conclusion: Firearm‐related injury and death are a significant public health problem in Allegheny County. Although the crude mortality rate from firearms in the county is lower than the reported national rate, the observed rate for nonfatal injuries in the black youth of this community is the highest firearm injury incidence rate ever reported. Local surveillance of firearm‐related injuries, including nonfatal events, is needed to more accurately demonstrate the magnitude of this problem.
Work‐related Injuries in a Rural Emergency Department Population
Authors: Williams Janet M. , Higgins Doloris , Furbee Paul M. , Prescott John E. 
Published: September 2008

ABSTRACTObjective: To describe the spectrum of work‐related injury evaluated in a rural ED population. Methods: An ED‐based injury surveillance system (EDBISS) was used to collect injury data for all ED patients seen over a 1‐year period. A patient was classified as injured if his or her record contained an ED log injury code, an ICD‐9 N‐code between 800 and 995 in any diagnostic field, an E‐code, or an entry in the trauma registry. An injury was considered work‐related if the patient reported that the injury had occurred while at work.Results: Work‐related injuries accounted for 1,539/12,321 (12.5%) of all injuries. The mean age of patients injured on the job was 33.8 years (range, 16–77 years), compared with a mean age of 27.7 years for all the injured patients. Males accounted for 1,026/1,537 (67%) of the work‐related injury visits, compared with 57% of all the injury visits. The most common mechanisms of work‐related injuries were: overexertion (313; 20%); cut or pierced by sharp implements (248; 16%); falls (250; 16%); struck by object (202; 13%); and transportation‐related injuries (71; 5%). Sprains and strains were the most common type of injury sustained (415; 27%), followed by wounds to upper limbs (283; 18%), contusions (182; 12%), and fractures (151; 10%). Of the 1,539 patients presenting with occupational injuries, 178 (12%) presented to the ED via ambulance. Most (1,401; 91%) were treated and released from the ED, with the remainder (136; 9%) hospitalized. The mechanisms of injury that most commonly resulted in hospitalization included struck by an object (28; 21%), transportation (26; 19%), falls (27; 20%), crushing mechanism (13; 10%), and machinery (20; 15%). Of those requiring hospitalization, 132/136 (97)% were male, and the average length of stay was 4.4 days. Four of the hospitalized persons died of their work‐related injuries. Known medical charges incurred by patients injured at work were as high as $62,622. The average charge for those treated and released was $273; the average charge for those who required hospitalization was $10,910.Conclusions: Occupational injuries contribute significantly to the overall incidence of injuries seen in this ED and are responsible for significant medical charges each year.
Calcium, Magnesium, and Phosphorus: Emergency Department Testing Yield
Authors: Rose William D. , Martin Julia E. , Abraham F. Matthew , Jackson Rebecca L. , Williams Janet M. , Gunel Erdogan 
Published: September 2008

ABSTRACTObjectives: To investigate how often the ED ordering of stat serum calcium (Ca+2), magnesium (Mg+2), and phosphorus (PO4‐3) levels affected clinical treatment; to define the diagnoses of patients for whom Ca+2, Mg+2, and PO4‐3 measurements did affect clinical therapy; and to suggest guidelines for more appropriate ordering of these laboratory tests.Methods: A retrospective chart review was performed in an academic teaching hospital. All adult ED patients who had Ca+2, Mg+2, or PO4‐3 laboratory testing during the 9‐month study period were included and evaluated for potential clinical impact of an abnormal Ca+2, Mg+2, or PO4‐3 laboratory test.Results: 1,477 patients had Ca+2, Mg+2, or PO4‐3 measured while in the ED during the study period. Of these, 260 patients (17.6%) had a total of 312 abnormal Ca+2, Mg+2, or PO4‐3 values as defined by results exceeding ±15% of normal reference values. Of these, only 5 patients (0.3%) received treatment for abnormal values in the ED, while 75 patients (5.1%) were treated once admitted to the hospital. In this study, the only diagnostic groups to whom significant treatment was administered were diabetic patients (Ca+2 and PO4‐3); alcoholic patients (Mg+2); and renal failure patients (Ca+2, Mg+2, and PO4‐3).Conclusion: These results suggest that stat Ca+2, Mg+2, and PO4‐3 levels seldom affect clinical treatment in the ED. The frequency of ordering these tests may be reduced by obtaining Ca+2, Mg+2, or PO4‐3 measurements only for patients known to be at risk for such abnormalities, based on their existing or suspected diagnoses. The authors suggest obtaining these tests, when indicated, on a “non‐stat” basis, with the subsequent laboratory results becoming available in‐hospital, where treatment is more likely to occur.
Psychosocial Difficulties and Emergency Department Use
Authors: Pilossoph‐Gelb Susan , Mower William R. , Ajaelo Ikem , Yang Sherry C. 
Published: September 2008

ABSTRACTObjective: To determine whether psychosocial difficulties are more prevalent among ambulatory patients using the ED for nonemergent complaints as compared with ambulatory patients having emergent complaints.Methods: A survey of noncritical ED patients was performed using anonymous questionnaires addressing psychosocial difficulties: psychiatric illness, educational level, homelessness, alcohol and/or drug dependency (CAGE and DAST surveys), and depression (DSM‐III criteria). Three independent physicians ranked each patient's chief complaint as either emergent or appropriate for primary care. The majority ranking was used to determine whether the complaint was emergent. Groups with and without specific psychosocial difficulties were compared for their proportion of emergent vs primary care complaints.Results: Of 700 patients, 367 (52%) met criteria for ≥1 psychosocial difficulty [acute psychosis—36 (5%), illiteracy—139 (20%), homelessness—45 (6%), alcohol dependency—111 (16%), drug dependency—66 (9%), and depression—130 (19%)]. There were 379 (54%) ED visits considered emergent. Patient groups with vs without ≥ psychosocial difficulty had similar rates of emergent visits (58% vs 50%, p = 0.04). Emergent visit rates also were similar for subgroups with vs without specific psychosocial difficulties: psychosis (56% vs 54%, p = 1.00), illiteracy (58% vs 53%, p = 0.89), homelessness (62% vs 54%, p = 0.33), alcohol dependency (62% vs 53%, p = 0.08), drug dependency (59% vs 54%, p = 0.47), or depression (58% vs 53%, p = 0.42).Conclusion: Psychosocial difficulties are common among ED patients; however, emergent complaints are just as common in these patients as they are in those without psychosocial difficulties.
Emergency Department Evaluation of Geriatric Patients with Acute Cholecystitis
Authors: Parker L. Joseph , Vukov Larry F. , Wollan Peter C. 
Published: September 2008

ABSTRACTObjective: To estimate the frequency of abnormal clinical symptoms, laboratory tests, and diagnostic imaging studies in the ED assessment of elderly (≥65 yr) patients with acute cholecystitis, and to compare these factors in the young‐old (65–74 yr), middle‐old (75–84 yr), and old‐old (≥85 yr) population groups.Methods: A retrospective, cross‐sectional study was performed by review of ED records, hospital charts, and surgical operative reports of consecutive elderly ED patients determined at surgery to have acute cholecystitis. Records were reviewed between April 1990 and April 1995 at a large Midwestern tertiary care facility with 65,000 annual ED patient visits. Clinical signs and symptoms were compared in the young‐old, middle‐old, and old‐old population groups.Results: Of the 168 patients reviewed, 141 (84%) had either epigastric or right upper quadrant abdominal pain, and 8 (5%) had no pain whatsoever. Only 61 patients (36%) had back or flank pain radiation. Ninety‐six (57%) experienced nausea, 64 (38%) had emesis, and 13 (8%) had visible jaundice. Ninety‐four (56%) patients were afebrile and 69 (41%) had no increase of white blood cell count. Twenty‐two (13%) patients had no fever and all tests were normal. No statistical difference was noted in any symptom or laboratory factor for the 3 age groups, except jaundice was more common among the patients aged ≥85 years. Ultra‐sonography was diagnostic for 91%, and CT was beneficial for only 1 patient. Eight patients had normal results on their ultrasonographic and CT studies.Conclusion: Classic symptoms and abnormal blood test results are frequently not present in geriatric patients with acute cholecystitis. Increasing age does not appear to affect the clinical and test markers used by clinicians to diagnose this illness. A high degree of awareness is essential for correct diagnosis of acute cholecystitis in geriatric patients.
Assessing Bedside Cardiologic Examination Skills Using “Harvey,” a Cardiology Patient Simulator
Authors: Jones Jeffrey S. , Hunt Stephen J. , Carlson Scott A. , Seamon Jason P. 
Published: September 2008

ABSTRACTObjective: To assess the cardiovascular physical examination skills of emergency medicine (EM) housestaff and attending physicians.Methods: Prospective, cohort assessment of EM housestaff and faculty performance on 3 valvular abnormality simulations (mitral regurgitation, mitral stenosis, and aortic regurgitation) conducted on the cardiology patient simulator, “Harvey.” Participants examined each of the 3 study disease simulations and proposed a diagnosis (session I). They were then given a cardiac examination form and repeated the programmed simulations (session II). The examination form was used to prompt physicians to interpret 23 separate cardiac findings for each simulation in a multiple‐choice format.Results: Forty‐six EM housestaff (PGY1–3) and attending physicians were tested over a 2‐month study period. Physician responses did not differ significantly among the different levels of postgraduate training. The overall correct response rates for participants were 59% for aortic regurgitation, 48% for mitral regurgitation, and 17% for mitral stenosis. For aortic regurgitation, recognition of a widened pulse pressure and recognition of diastolic decrescendo murmur were associated with a correct diagnosis (p < 0.01). For mitral regurgitation, correct assessment of the contour of the holosystolic murmur predicted a correct diagnosis (p < 0.001). For mitral stenosis, proper characterization of the mitral area diastolic murmur predicted a correct diagnosis (p < 0.001).Conclusion: Housestaff and faculty had difficulty establishing a correct diagnosis for simulations of 3 common valvular heart diseases. However, accurate recognition of a few critical signs was associated with a correct diagnosis in each simulation. Training programs may need to focus attention on selected key components of the cardiovascular examination to facilitate teaching of physical diagnosis.
Comparison of Types of Research Articles Published in Emergency Medicine and Non‐Emergency Medicine Journals
Authors: Singer Adam J. , Homan Clark S. , Stark Mary Jo , Werblud Marc C. , Jr. Henry C. Thode , Hollander Judd E. 
Published: September 2008

ABSTRACTIntroduction: As the specialty of emergency medicine (EM) matures, its journals should be publishing research of a quality similar to that which appears in other premier journals.Objective: To compare the types of original research published in 4 EM vs 3 non‐EM journals.Methods: Retrospective review of all 1995 articles published in Academic Emergency Medicine, American Journal of Emergency Medicine, Annals of Emergency Medicine, Journal of Emergency Medicine, Annals of Internal Medicine, JAMA, and New England Journal of Medicine. Research articles were classified as longitudinal vs cross‐sectional, prospective vs retrospective, and interventional vs observational. Other characteristics noted were number of subjects, randomization, blinding, control, and power calculations. Journals were reviewed by 4 investigators who received specific training in research classification, adhering to previously reported criteria for retrospective reviews. Interobserver reliability was independently validated.Results: The authors reviewed 3,524 articles, of which 874 (24.8%) were original research. Compared with research reported in non‐EM journals, EM journals contained fewer longitudinal studies (40.5% vs 60.4%, p < 0.0001) and fewer prospective studies (70.8% vs 78.7%, p = 0.008). Fewer EM journals had studies that were blinded (13.7% vs 18.9%, p = 0.047) or controlled (36.3% vs 50.0%, p = 0.003). Studies reported in EM journals had fewer subjects (138 vs 300, p < 0.001). Research reports in EM journals were less likely to have been funded, even after adjustment for the differences in study designs (adjusted odds ratio 7.0, 95% CI 5.1–9.7).Conclusion: Significant differences in types of research published in EM and non‐EM journals were identified.