bluuebunny/crossref_metadata_2025_split huggingface dataset:
Treatment of Out‐of‐hospital Supraventricular Tachycardia: Adenosine vs Verapamil
Authors: Jr. William J. Brady , DeBehnke Daniel J. , Wickman Lauri L. , Lindbeck George 
Published: September 2008

ABSTRACTObjective: To compare the use of adenosine and the use of verapamil as out‐of‐hospital therapy for supraventricular tachycardia (SVT).Methods: A period of prospective adenosine use (March 1993 to February 1994) was compared with a historical control period of verapamil use (March 1990 to February 1991) for SVT. Data were obtained for SVT patients treated in a metropolitan, fire‐department‐based paramedic system serving a population of approximately 1 million persons. Standard drug protocols were used and patient outcomes (i.e., conversion rates, complications, and recurrences) were monitored.Results: During the adenosine treatment period, 105 patients had SVT; 87 (83%) received adenosine, of whom 60(69%) converted to a sinus rhythm (SR). Vagal maneuvers (VM) resulted in restoration of SR in 8 patients (7.6%). Some patients received adenosine for non‐SVT rhythms: 7 sinus tachycardia, 18 atrial fibrillation, 7 wide‐complex tachycardia (WCT), and 2 ventricular tachycardia; no non‐SVT rhythm converted to SR and none of these patients experienced an adverse effect. Twenty‐five patients were hemodynamically unstable (systolic blood pressure < 90 mm Hg), with 20 receiving drug and 13 converting to SR; 8 patients required electrical cardioversion. Four patients experienced adverse effects related to adenosine (chest pain, dyspnea, prolonged bradycardia, and ventricular tachycardia). In the verapamil period, 106 patients had SVT; 52 (49%) received verapamil (p < 0.001, compared with the adenosine period), of whom 43 (88%) converted to SR (p = 0.11). Two patients received verapamil for WCT; neither converted to SR and both experienced cardiovascular collapse. VM resulted in restoration of SR in 12 patients (11.0%) (p = 0.52). Sixteen patients were hemodynamically unstable, with 5 receiving drug (p = 0.005) and 5 converting to SR; 9 patients required electrical cardioversion (p = 0.48). Four patients experienced adverse effects related to verapamil (hypotension, ventricular tachycardia, ventricular fibrillation). Recurrence of SVT was noted in 2 adenosine patients and 2 verapamil patients in the out‐of‐hospital setting and in 23 adenosine patients and 15 verapamil patients after ED arrival, necessitating additional therapy (p = 0.48 and 0.88, for recurrence rates and types of additional merapies, respectively). Hospital diagnoses, outcomes, and ED dispositions were similar for the 2 groups.Conclusion: Adenosine and verapamil were equally successful in converting out‐of‐hospital SVT in patients with similar etiologies responsible for the SVT. Recurrence of SVT occurred at similar rates for the 2 medications. Rhythm misidentification remains a common issue in out‐of‐hospital cardiac care in this emergency medical services system.
Directional‐tip Endotracheal Tubes for Blind Nasotracheal Intubation
Authors: Hooker Edmond A. , Hagan Stuart , Coleman Royce , Heine Michael F. , Greenwood Patrick 
Published: September 2008

ABSTRACTObjectives: To compare initial success rates of blind nasotracheal intubation using directional‐tip endotracheal tubes vs standard endotracheal tubes.Methods: A prospective trial comparing directional‐tip and standard endotracheal tubes during initial attempts at blind nasotracheal intubation (BNTI) at a university hospital ED. Using an alternating schedule, the directional‐tip or standard tube was used for the first attempt at BNTI. An attempt was defined as beginning when the tube was placed through the nose into the posterior pharynx and ending when the patient was intubated or the tube was removed from the nares. After the intubation, the physician graded the difficulty of the technique (i.e., easy/routine, intermediate, difficult, or unable to intubate nasally).Results: There were 49 patients entered over 5 months. Patient presentations for the intubations were trauma (45.8%), overdose (33.3%), respiratory/cardiac event (12.5%), seizure (2.1%), and other (6.3%). Intubation was successful on the first attempt in 18 of 21 patients (86%; 95% CI, 64% to 97%) for the directional‐tip tube vs 16 of 28 patients (57%; 95% CI, 37% to 76%) for the standard tube (p = 0.03). The groups did not differ in age, sex, clinical presentation, or perceived difficulty of intubation. Only 1 patient could not be intubated nasally and was subsequently intubated orally.Conclusion: The use of directional‐tip tubes may improve the success rate of the first attempt at BNTI.
Emergency Medicine Expeditions to the Developing World: The Loma Linda University Experience in Papua New Guinea
Authors: Clem Kathleen J. , Green Steven M. 
Published: September 2008

ABSTRACTEmergency physicians (EPs) are increasingly participating in international medicine in regions that are chronically medically underserved. In August 1994, a ten‐member emergency medicine team from the Loma Linda University School of Medicine staffed a 70‐bed bush hospital in the primitive highlands of Papua New Guinea, providing both outpatient and inpatient medical care. Typhoid fever, malaria, polio, and numerous other infectious diseases were encountered. Rampant local tribal warfare resulted in regular penetrating injuries from arrows, spears, and machetes. The expedition was judged highly successful, in that 1) substantial medical service was provided to tribespeople accustomed to minimal care, 2) education was provided to local health care providers, and 3) team participants became adept at managing medical conditions uncommon in industrialized societies, and gained valuable ethical and utilitarian perspectives regarding health care delivery in underserved areas. In this article the objectives, organization, and experiences of the team members are described. This information may encourage other EPs to participate in medical expeditions to the developing world, and to provide general principles to assist in their organization and implementation.
Out‐of‐hospital Treatment of Opioid Overdoses in an Urban Setting
Authors: Sporer Karl A. , Firestone Jennifer , Isaacs S. Marshal 
Published: September 2008

ABSTRACT Objectives: To investigate clinical outcomes in a cohort of opioid overdose patients treated in an out‐of‐hospital urban setting noted for a high prevalence of IV opioid use. Methods: A retrospective review was performed of presumed opioid overdoses that were managed in 1993 by the emergency medical services (EMS) system in a single‐tiered, urban advanced life support (ALS) EMS system. Specifically. all patients administered naloxone by the county paramedics were reviewed. Those patients with at least 3 of 5 objective criteria of an opioid overdose [respiratory rate <6/min, pinpoint pupils, evidence of IV drug use, Glasgow Coma Scale (GCS) score <12, or cyanosis] were included. A response to naloxone was defined as improvement to a GCS 14 and a respiratory rate 10/min within 5 minutes of naloxone administration. ED dispositions of opioid‐overdose patients brought to the county hospital were reviewed. All medical examiner's cases deemed to be opioid‐overdose‐related deaths by postmortem toxicologic levels also were reviewed. Results: There were 726 patients identified with presumed opioid overdoses. Most patients (609/726, 85.4%) had an initial pulse and blood pressure (BP). Most (94%) of this group responded to naloxone and all were transported. Of the remainder, 101 (14%) had obvious signs of death and 16 (2.2%) were in cardiopulmonary arrest without obvious signs of death. Of the patients in full arrest, 2 had return of spontaneous circulation but neither survived. Of the 609 patients who had initial BPs, 487 (80%) received naloxone IM (plus bag‐valve‐mask ventilation) and 122 (20%) received the drug IV. Responses to naloxone were similar; 94% IM vs 90% IV. Of 443 patients transported to the county hospital, 12 (2.7%) were admitted. The admitted patients had noncardiogenic pulmonary edema (n = 4). pneumonia (n = 2), other infections (n = 2), persistent respiratory depression (n = 2). and persistent alteration in mental status (n = 2). The patients with pulmonary edema were clinically obvious upon ED arrival. Hypotension was never noted and bradycardia was seen in only 2% of our presumed‐opioid:overdose population. Conclusions: The majority of the opioid‐overdose patients who had initial BPs responded readily to naloxone, with few patients requiring admission. Noncardiogenic pulmonary edema was uncommon and when present, hypoxia was evident upon arrival to the ED. Naloxone administered IM in conjunction with bag‐valve‐mask ventilation was effective in this patient population. The opioid‐overdose patients in cardiopulmonary arrest did not survive.
Criteria‐based Expert System for Cardiac Ischemia Evaluation in the Emergency Department
Authors: Hirshberg Alan J. 
Published: September 2008

ABSTRACT Objective: To develop and evaluate a cardiac ischemia computer expert system using a criteria‐based expert shell for assessment of chest pain patients in a community hospital ED setting. Methods: A retrospective, comparison study of the expert system against the clinical judgment of board‐certified emergency physicians (EPs) was performed in 1 community hospital ED. All chest pain patients had either a cardiac catheterization, Persantine stress testing, or both within 1 month of ED presentation. A final diagnosis of acute myocardial infarction or unstable angina by a consultant cardiologist represented the criterion standard for cardiac ischemia. Results: Of the 59 patients meeting study criteria, 28 (47%) had cardiac ischemia. The expert system had equal sensitivity (100%) and was more than twice as specific (39% vs 16%) in diagnosing ischemic cardiac disease as were the board‐certified EPs (p < 0.001; McNemar's chi‐square with Yates' correction). Conclusions: The criteria‐based system built around a system of findings ordered by Bayes' rule has potential to augment the ability of the EP to accurately diagnose ischemic heart disease.
Hypoglycemia Manifested by Sinus Bradycardia: A Report of Three Cases
Authors: Pollock Gary , Brady William J. , Hargarten Steve , DeSilvey Dennis , Carter C. Tom 
Published: September 2008

ABSTRACTThree cases are reported of hypoglycemia manifested by profound sinus bradycardia and fatigue, which responded to IV dextrose with prompt normalization of the cardiac rhythm. The cases involved 3 different patients and disease processes: a young female who had anorexia nervosa and profound malnutrition; an elderly, nondiabetic male who subsequently experienced a transient ischemic attack; and a patient who had diabetes mellitus managed with chronic, subcutaneous insulin administration. It is vitally important that the emergency physician recognize unusual clinical manifestations of hypoglycemia and fully evaluate such scenarios when hypoglycemia may occur. Untreated, hypoglycemia may result in significant chronic morbidity, and rarely, in death. Bradyarrhythmias–particularly sinus bradycardia–should be added to the list of potential clinical manifestations of hypoglycemia.
Informed Consent for Medical Research: Common Discrepancies and Readability
Authors: White Lynn J. , Jones Jeffrey S. , Felton Christopher W , Pool Linda C. 
Published: September 2008

ABSTRACTObjective: To identify common discrepancies and average reading grade levels for informed consent forms (ICFs) us submitted to institutional review boards (IRBs) by medical researchers.Methods: A retrospective evaluation of ICFs as submitted to IRBs of 3 university‐affiliated hospitals during a I‐year period. ICF content was evaluated using a checklist of 23 requirements specified in the federal regulations governing human research. Documents then were computer‐analyzed to determine the readability scores using 2 common indexes of comprehension. A discrepancy was defined as any instance in which an ICF did not address an applicable requirement in the Code of Federal Regulations.Results: Eighty‐two ICFs representing 16 medical specialties were evaluated; 8 (10%) were from emergency medicine. Eighteen ICFs (22%) were conspicuously incomplete, lacking 29 federal requirements. The mean number of discrepancies was 4.7 (95% CI, 3.9–5.5) Common omissions included: a statement about who is doing the research, number of subjects in the study, circumstances when a subject's participation may be terminated, disclosure of alternative procedures, and notice to subjects regarding new findings. The mean Flesch grade level required to read all ICFs was 13.8 (95% CI, 13.5–14.2), implying that the majority of the U.S. adult population would be unable to comprehend these forms.Conclusion: Designing a consent form to meet all of the federal requirements while maintaining a level of reading comprehension suitable for the general population is a difficult task for investigators.
The Complete Blood Count and Reticulocyte Count–Are They Necessary in the Evaluation of Acute Vasoocclusive Sickle‐cell Crisis?
Authors: Lopez Bernard L. , Griswold. Sharon K. , Navek Anke , Urbanski Linda 
Published: September 2008

ABSTRACTObjective: To assess the usefulness of the complete blood count (CBC) and the reticulocyte count in the evaluation of adult patients with acute vasoocclusive sickle‐cell crisis (SCC) presenting to the ED.Methods: A 2‐part study was performed. Part 1 was a retrospective chart review of patients with a sole ED diagnosis of acute SCC. Part 2 was a prospective evaluation of consecutive patients presenting in SCC. In both parts of the study, patients with coexisting acute disease were excluded. The remaining patients were divided into 2 groups: admitted and released. The mean values for white blood cell (WBC) count, hemoglobin (Hb) level, and reticulocyte count were compared. In Part 2. the change (Δ) from the patient's baseline in WBC count, Hb level, and reticulocyte count also was determined. Data were analyzed by 2‐tailed Student's t‐test.Results: Part 1: There was no difference between the admitted (n = 33) and the released (n = 86) groups in mean WBC count (p = 0.10), Hb level (p = 0.25), or reticulocyte count (p = 0.08). Part 2: There was no difference between the admitted (n = 44) and the released (n = 160) groups in mean Hb level (p = 0.88). reticulocyte count (p = 0.47). AHb level (p = 0.88). and Areticulocyte count (p = 0.76). There was a difference in mean WBC counts (15.8 ± 4.9 × 109/L admitted vs 12.8 ± 4.9 × 109/L released, p = 0.003) and ΔWBC counts (5.1 ± 4.6 × 109/L admitted vs 1.8 ± 4.6 × 109/L released, p < 0.002).Conclusion: Determination of the Hb level and the reticulocyte count do not appear useful in the evaluation of acute SCC in the ED. Admission decisions appear associated with elevations in the WBC count. Further study is required to determine the true value of the WBC count in such decisions.
Comparison of Hyperbaric Oxygen and Dapsone Therapy for Loxosceles Envenomation
Authors: Hobbs Gregory D. , Anderson Alena R. , Greene Thomas J. , Yealy Donald M. 
Published: September 2008

ABSTRACTObjective: To determine whether hyperbaric O2 (HBO), dapsone, or HBO plus dapsone affects lesion size in a swine model of Loxosceles envenomation.Methods: In a randomized controlled animal laboratory experiment, 32 piglets were assigned to 1 of 4 equal groups. Each piglet received 15 μL of purified venom intradermally on day zero. Group 1 received no treatment; group 2 received HBO at 2 atm for 2 hours on days 1–3; group 3 received 50 mg of dapsone orally on days 1–3; and group 4 received dapsone 50 mg orally and HBO at 2 atm for 2 hours on days 1–3. On days 1–7, 14, and 21, an investigator blinded to the treatment groups measured necrosis and induration. Mean necrosis and induration rates were compared using analysis of variance for repeated measures.Results: Comparing groups on any day, no significant difference was noted in necrosis, induration, reduction in necrosis from day 1, or rate of change in lesion size from days 1–7. A difference was seen in the reduction of induration between all 3 treatment groups and the control group on days 7 and 14 only. The sample size permitted a power of 0.8 to detect a 12‐mm mean change in lesion size.Conclusion: Compared with the control, neither dapsone, HBO, nor the combination of dapsone and HBO reduced necrosis from Loxosceles envenomation on days 3–21. An increase was seen in the rate of reduction in induration between all 3 treatment groups and the control group on days 7–21. However, the magnitude of this effect was clinically insignificant. In this animal model, treatment with either dapsone or HBO or a combination offers little clinical benefit in Loxosceles envenomation.
Amrinone as an Antidote in Experimental Veraparnil Overdose
Authors: Koury Shaheed I. , Stone C. Keith , Thomas Stephen H. 
Published: September 2008

ABSTRACTObjective: To evaluate the effect of amrinone as a treatment for the hemodynamic effects of verapamil overdose in a canine model.Methods: This nonblind interventional study was performed in an established canine model of verapamil toxicity, without concurrent control animals. Pentobarbital‐anesthetized and instrumented dogs (n = 8) were maintained and observed for 60 minutes or until death. The animals were overdosed with verapamil, 15 mg/kg IV, over 30 minutes. Hemodynamic parameters, including cardiac index (CI), heart rate (HR), and mean arterial pressure (MAP), were monitored. Completion of the verapamil infusion represented the defined point of toxicity; at that point, all the animals received an amrinone bolus of 2 mgkg IV over 2 minutes followed by an amrinone drip at 10 μg/kg/min. The hemodynamic values at the defined point of toxicity were compared with those obtained postinitiation of the amrinone infusion.Conclusion: Amrinone appears to reverse the depressed cardiac index associated with verapamil overdose in a canine model while having no significant effect on the hypotension or bradycardia.
The Rate of Clinically Significant Plain Radiograph Misinterpretation by Faculty in an Emergency Medicine Residency Program
Authors: Nitowski Leonard A. , O'Connor Robert E. , Reese Charles L. 
Published: September 2008

ABSTRACTObjective: To estimate the rate of clinically significant discrepancies between radiograph interpretations by attending radiologists and emergency medicine (EM) faculty in 2 academic EDs, using a unique scoring system.Methods: A retrospective comparison of radiographic agreement between EM and radiology faculty members was performed. All plain films initially interpreted by EM faculty or by EM residents with immediate rein‐terpretation by EM faculty were subsequently reviewed by attending radiologists. All discrepancies between these readings were reported to the ED on the following day for review by an EM faculty member (usually different from the initial EM faculty reader) who determined the need for treatment or follow‐up changes. A secondary chart review by a quality assurance faculty member determined whether radiographic findings not noted on the x‐ray log were present on the ED record. All discrepancies from February to June 1994 were reviewed. A severity score was assigned based on the following criteria. Q‐0: There was no change in treatment or follow‐up; or the initial interpretation by EM faculty was validated by repeat or additional views. Q‐1: Discrepancy is minor. Q‐2: Discrepancy is significant, with potential for injury or bad outcome. 4–3: Discrepancy is significant, with actual injury or bad outcome.Results: Of 14,046 radiographic studies eligible for enrollment, there were 134 discrepancies (0.95%). Only 28 cases (0.2%) were found to be clinically significant. Of these, 25 were scored Q‐1, 3 were scored Q‐2, and 0 were scored 4–3. These clinically significant discrepancy rates were highest for the finger, skull, elbow, hand, and lumbar spine.Conclusion: Emergency medicine faculty provide highly accurate rates of plain radiograph interpretation, particularly when adjusted for clinical significance and actual impact on patient care.
Emergency Medicine Resident Interpretation of Pediatric Radiographs
Authors: Brunswick J. Eric , Ilkhanipour Kaveh , Fuchs Susan , Seaberg David 
Published: September 2008

ABSTRACTObjective: To examine the concordance of pediatric radiograph interpretation between emergency medicine residents (EMRs) and radiologists.Methods: A prospective, observational study was performed in a university pediatric ED with an annual census of 60,000 visits. Radiographs ordered by EMRs from December 1993 through October 1994 were initially interpreted solely by the EMR, with subsequent unmasked final review by attending radiology staff. Misinterpreted radiographs were placed into 3 categories. The groupings included overreads, underreads with no change in treatment, and underreads that required a change in treatment.Results: A total of 415 radiographs were interpreted by PGY1–3 residents. Overall concordance was found for 371 radiographs (89.4%). There were 44 misinterpretations (10.6%), with 24 (5.78%) overreads, 13 (3.13%) underreads, and 7 (1.69%) underreads that required follow‐up interventions. Misinterpretations were similar for the different levels of training:The 5 most frequently ordered radiographs were chest (28%), ankle (7%), foot (6%), wrist (5%), and hand (5%). The most frequently misinterpreted radiographs were sinus, foot, shoulder, facial, and hand.Conclusion: 89.4% of all the radiographs interpreted by PGY1–3 residents were read correctly. Only 1.69% of the misinterpreted radiographs led to a change in management. Level of training did not significantly correlate with radiograph misinterpretation rates.
Structure and Practice of Institutional Review Boards in the United States
Authors: Jones Jeffrey S. , White Lynn J. , Pool Linda C. , Dougherty James M. 
Published: September 2008

ABSTRACTObjective: The institutional review board (IRB) is a critical element in the protection of patients' and subjects' rights with regard to their participation in research protocols. The purpose of this study was to describe the structure and current practices of IRBs in the United States.Methods: A self‐administered questionnaire was mailed to the IRB chair of each U.S. hospital with a capacity of at least 400 beds (n = 907). The survey contained 21 questions outlining committee size and structure, review of research proposals, and policies concerning scientific misconduct. Chairs also were asked what advice they would offer a young investigator preparing a proposal for submission.Results: A total of 488 surveys (54%) were returned; 447 of the responding institutions had an IRB committee. Committees had an average of 14 members, representing 27 medical specialties. Orthopedics had the least IRB representation (10% of committees), followed by emergency medicine (12%) and ophthalmology (15%). The majority of research proposals go through 5 specific steps once submitted for review. Common reasons for proposal rejection were improperly designed consent form (54%), poor study design (44%), unacceptable risk to subjects (34%), ethical or legal reasons (24%). and scientific merit (14%). When a research proposal is rejected, 86% of the responding IRBs assist the investigator in making appropriate revisions. Although a number of IRBs (17%) have dealt with scientific misconduct allegations, only 58% have a written policy regarding research integrity.Conclusion: Despite variations in committee structure and representation, IRBs have similar procedures for governing research. Investigators should be familiar with these procedures and are encouraged to discuss their proposal with an IRB representative prior to formal review.