bluuebunny/crossref_metadata_2025_split huggingface dataset:
Theoretically Optimal Duty Cycles for Chest and Abdominal Compression during External Cardiopulmonary Resuscitation
Authors: Babbs Charles F. , Thelander Keir 
Published: September 2008

ABSTRACTObjective: To use an electronic model of human circulation to compare the hemodynamic effects of different durations of chest compression during external CPR, both with and without interposed abdominal compression (IAC).Methods: An electrical analog model of human circulation was studied on digital computer workstations using SPICE, a general‐purpose circuit simulation program. In the model the heart and blood vessels were represented as resistive‐capacitive networks, pressures as voltages, blood flow as electric current, blood inertia as inductance, and cardiac and venous valves as diodes. External pressurization of the heart and great vessels, as would occur in IAC‐CPR, was simulated by the alternate application of damped rectangular voltage pulses, first between intrathoracic vascular capacitances and ground, and then between intra‐abdominal vascular capacitances and ground. With this model compression frequencies of 60, 80, and 100 cycles/min and duty cycles ranging from 10% to 90%, both with and without IAC, were compared.Results: There was little difference in hemodynamics when the overall compression frequency was varied between 60 and 100 cycles/min, but the effects of duty cycle were substantial. During both standard CPR and IAC‐CPR, total flow and coronary flow were greatest at chest compression durations equal to 30% of cycle time. Interposed abdominal compression substantially improved simulated systemic blood flow and perfusion pressure at all duty cycles, compared with standard CPR without abdominal compression. Mean arterial pressure > 75 mm Hg and artificial cardiac output > 2.0 L/min could be generated by 30% duty cycle compression with IAC. Coronary perfusion in the model is clearly optimized at 30% chest compression (i.e., high‐impulse chest compression technique).Conclusion: Combined high‐impulse chest compressions and IACs maximize blood flow during CPR in the electrical analog model of human circulation.
Bi‐level Positive Airway Pressure Support System Use in Acute Congestive Heart Failure: Preliminary Case Series
Authors: Sacchetti Alfred D. , Harris Russell H. , Paston Carrie , Hernandez Zaida 
Published: September 2008

ABSTRACTObjective: To describe the use of a noninvasive bi‐level positive airway pressure (PAP) support system for ED patients with acute congestive heart failure (CHF).Methods: Retrospective case series analysis of ED patients presenting with acute CHF in imminent need of endotracheal intubation (ETI) managed with a bi‐level PAP system. The bi‐level PAP system was applied at the discretion of the treating emergency physician. Management of the bi‐level PAP system, including setting of inspiratory PAP (IPAP) and expiratory PAP (EPAP), weaning, adjunct pharmacologic therapy, and failure of bi‐level PAP support, was determined by the treating physician.Results: Only two (9%) of 22 patient presentations necessitated ETI. The mean duration of bi‐level PAP therapy was 7.9 hours. The mean maximum IPAP and EPAP settings were 10.8 and 5.8 cm H2O, respectively. Mean intensive care unit length of stay (LOS) was 2.4 days, with a median LOS of only 1 day. There were three deaths in the series; none were attributed to the bi‐level PAP system. No technical difficulty with the bi‐level PAP system was noted.Conclusion: Noninvasive pressure support ventilation with a bi‐level PAP support system may avert ETI in acute CHF patients. This device can be effectively used by ED personnel.
Padded vs Unpadded Spine Board for Cervical Spine Immobilization
Authors: Walton Ross , DeSalvo Jay F. , Ernst Amy A. , Shahane Aditi 
Published: September 2008

ABSTRACTObjectives: To determine whether padding the long spine board improves patient comfort, affects cervical spine (c‐spine) immobilization, or increases sacral transcutaneous O2 tension.Methods: A prospective randomized, controlled crossover study of healthy volunteers was conducted over a two‐week period. Participants included 30 volunteers with no previous history of c‐spine injury or disease. The subjects were randomized to either padded or unpadded long spine board immobilization with serial measurements of discomfort (using a visual analog scale) and transcutaneous tissue O2 tension obtained at zero and 30 minutes. Measurements of ability to flex, extend, rotate, and laterally bend the c‐spine were made using a goniometer. The subjects then returned a minimum of three days later to complete the opposite half of the study (padded vs unpadded boards).Results: Subject discomfort was significantly reduced in the padded group compared with the unpadded group (p = 0.024). There was no significant difference in flexion (p = 0.410), extension (p = 0.231), rotation (p = 0.891), or lateral bending (p = 0.230) for the two groups. There was no significant difference in the actual drop in sacral transcutaneous O2 tension from time zero to 30 minutes for the padded and the unpadded groups (mean drop = 14.8% ± 17.5% vs 12.2% ± 16.8%, respectively; p = 0.906).Conclusion: Adding closed‐cell foam padding to a long spine board significantly improves comfort without compromising c‐spine immobilization. Sacral tissue oxygenation does not appear affected by such padding for healthy volunteers.
Stiff‐man Syndrome: Case Report
Authors: Kuhn Walter F. , Light Peter J. , Kuhn Sharon C. 
Published: September 2008

ABSTRACTStiff‐man syndrome is a rare neurologic disorder characterized by progressive, fluctuating muscle rigidity with painful muscle contractions affecting predominantly the back and proximal extremities. In the ED, the diagnosis can be easily overlooked and misdiagnosed as acute or chronic low back pain and muscle spasm. This syndrome is often associated with diabetes, autoimmune diseases, and cancer. This report describes an illustrative case of a 39‐year‐old woman who presented to the ED with a two‐year history of right leg spasms and low back pain that had become so severe in the preceding two days that she was unable to ambulate. Clues to the patient's proper diagnosis coincide with the diagnostic criteria for stiff‐man syndrome: the presence of a slowly progressive stiffness of the axial muscles and proximal limb muscles, making ambulation difficult; hyperlordosis of the lumbar spine; episodic spasms precipitated by jarring or sudden movement; a normal intellectual, sensory, and motor examination when not in spasm; and a marked amelioration of symptoms with the IV administration of diazepam. High‐dose oral diazepam is the maintenance drug of choice.
The Use of a Break‐even Analysis: Financial Analysis of a Fast‐track Program
Authors: Saywell Robert M. , Cordell William H. , Nyhuis Allen W. , Giles Beverly K. , Culler Steven D. , Woods John R. , Chu David K. W. , McKinzie Jeffry P. , Rodman George H. 
Published: September 2008

ABSTRACTObjective: To calculate the financial break‐even point and illustrate how changes in third‐party reimbursement and eligibility could affect a program's fiscal standing.Methods: Demographic, clinical, and financial data were collected retrospectively for 446 patients treated in a fast‐track program during June 1993. The fast‐track program is located within the confines of the emergency medicine and trauma center at a 1,050‐bed tertiary care Midwestern teaching hospital and provides urgent treatment to minimally ill patients. A financial break‐even analysis was performed to determine the point where the program generated enough revenue to cover its total variable and fixed costs, both direct and indirect.Results: Given the relatively low average collection rate (62%) and high percentage of uninsured patients (31%), the analysis showed that the program's revenues covered its direct costs but not all of the indirect costs.Conclusions: Examining collection rates or payer class mix without examining both costs and revenues may lead to an erroneous conclusion about a program's fiscal viability. Sensitivity analysis also shows that relatively small changes in third‐party coverage or eligibility (income) requirements can have a large impact on the program's financial solvency and break‐even volumes.
Sensitivity of New‐generation Computed Tomography in Subarachnoid Hemorrhage
Authors: Sames Thomas A. , Storrow Alan B. , Finkelstein Jeff A. , Magoon Michael R. 
Published: September 2008

ABSTRACTObjective: To determine the sensitivity of the initial new‐generation CT (NGCT) scan interpretation for detection of acute nontraumatic subarachnoid hemorrhage (SAH) and to decide whether lumbar puncture (LP) should follow a “normal” NGCT scan.Methods: A retrospective chart review was performed of patients admitted between March 1988 and July 1994 with proven SAH. Exclusion criteria were age <2 years, diagnosis other than acute SAH, history of head trauma within 24 hours before symptom onset, NGCT scan not done before diagnosis, and records not available. Patients were placed into two groups: symptom duration <24 hours (group 1) and >24 hours (group 2) prior to CT scan. The resolution of each NGCT scanner was recorded. An NGCT sceinner was defined as a third‐generation scanner or more recent.Results: Of 349 SAH patients, 181 met inclusion criteria. The sensitivity of NGCT scans for SAH was 93.1% for the group 1 patients (n = 144) and 83.8% for the group 2 patients (n = 37). The overall sensitivity was 91.2%. All the patients who had SAH not detected by NGCT scans were diagnosed by LP. There was no significant relationship between NGCT scanner resolution and sensitivity for SAH.Conclusion: Initial interpretation of NGCT scans to detect SAH does not approach 100% sensitivity. A “normal” NGCT scan does not reliably exclude the need for LP in patients who have symptoms suggestive of SAH.
Out‐of‐hospital Rapid‐sequence Induction for Intubation of the Pediatric Patient
Authors: Sing Ronald F. , Reilly Patrick M. , Rotondo Michael F. , Lynch Michael J. , McCans James P. , Schwab C. William 
Published: September 2008

ABSTRACTObjective:To determine the effectiveness and morbidity of out‐of‐hospital rapid‐sequence induction (RSI) for endotracheal intubation (ETI) in the pediatric population.Methods: The medical records were retrospectively reviewed for a consecutive series of pediatric patients undergoing out‐of‐hospital RSI by flight paramedics from July 1990 through July 1994. Patient demographics, pharmacologic agents, ED arterial blood gas data, pulmonary complications, and RSI‐related complications were abstracted.Results: Forty patients (31 injured, 9 medical) with a mean age of 8.1 years (range 0.5–17 years) underwent out‐of‐hospital RSI. Indications for intubation included hyperventilation (n = 20), combativeness (n = 16), apnea (n = 5), and unknown (n = 5). Intubation mishaps occurred in 13 patients (33%); these included multiple attempts (n = 9), aspiration (n = 8), and esophageal intubation (n = 1). The success rate of ETI was 97.5% (one failed attempt). Hemodynamic side effects occurred in three patients (8%); all three had bradycardia, with one developing hypotension. Bradycardia was associated with failure to pretreat with atropine (p < 0.05). Sixteen pulmonary complications, seven pneumonia (18%) and nine atelectasis (22.5%), occurred in 13 patients within the first ten hospital days. Intubation mishaps were not associated with pulmonary complications. There were six deaths, none associated with RSI.Conclusions: 1) Rapid‐sequence induction is an effective method for obtaining airway control in the critically ill pediatric patient. 2) Intubation mishaps did not influence the rate of pulmonary complications. 3) Omission of atropine was associated with bradycardia during RSI in pediatric patients.
Ethanol Ingestion and Related Hypoglycemia in a Pediatric and Adolescent Emergency Department Population
Authors: Ernst Amy A. , Jones Kathleen , Nick Todd G. , Sanchez Julie 
Published: September 2008

ABSTRACTObjective:To estimate the frequency of associated hypoglycemia in an ethanol‐ingesting pediatric and adolescent population.Methods: The study was a retrospective review of nondiabetic pediatric and adolescent patients with measurable ethanol levels (i.e., >2 mmol/L) who had an ED serum glucose level determined.Results: Over the four‐and‐a‐half‐year study period, there were 254,234 pediatric visits. One hundred eleven had ethanol levels determined (0.044% of patients) due to suspected ingestion. Of these 111, 88 had glucose levels determined. The mean age of the 88 patients was 14 years, with a mean glucose level of 5.6 mmol/ L [101 mg/dL; interquartile range (IQR) 4.7‐6.3 mmol/L] and a mean ethanol level of 30 mmol/L (IQR 15–43 mmol/L). Glucose levels were < 67 mg/dL (hypoglycemia) in three of the 88 (3.4%) ethanol‐positive patients; all the hypoglycemic patients had significant behavioral changes.Conclusion: In this large retrospective series, the number of patients for whom the clinical suspicion of ethanol ingestion was confirmed was quite small. Hypoglycemia occurred in only 3.4% of these selected patients; all had altered behavior. Pediatric patients with presentations suggesting ethanol intoxication with altered behavior should be assessed for concurrent hypoglycemia.
Advance Directives in the Emergency Department: Too Few, Too Late
Authors: Ishihara Kristina K. , Wrenn Keith , Wright Seth W. , Socha Cawlynn M. , Cross Marya 
Published: September 2008

ABSTRACTObjective:To determine: 1) the number of patients arriving at the ED who had executed an advance directive (AD), 2) how many of the patients who had an AD brought the AD with them, and 3) whether those patients who did not have an AD had ever discussed ADs with their primary care providers (PCPs) or had ever heard of an AD.Methods: A cross‐sectional, observational survey of a convenience sample of high‐risk patients presenting to the ED of a university hospital was performed. Patients presenting to the ED for acute complaints who were elderly or had an underlying disease that suggested a risk of death in the near future were considered high risk.Results: Of the 238 patients surveyed, 90% had PCPs. However, only 22% had ADs. Of these, only 23% brought the AD to the ED. Of the patients who did not have ADs, 95% had never discussed ADs with their PCPs, and 42% did not know what an AD was. Blacks were less likely than whites to have ADs (p < 0.0002) or to know about them (p < 0.004).Conclusion: The majority of high‐risk patients presenting to this ED do not have ADs. Among those high‐risk patients who did have ADs, fewer than 25% brought the ADs with them. The development of ADs for high‐risk patients and the availability of ADs in the ED are woefully inadequate. Emergency physicians need to collaborate with PCPs to remedy these deficiencies.
Effects of Parental Presence during Children's Venipuncture
Authors: Wolfram R. Wayne , Turner Edwin D. 
Published: September 2008

ABSTRACTObjective:To determine whether parental presence during venipuncture (VP) altered self‐reported distress of the child, the parent, or the health professional (HP) performing VP.Methods: During nine consecutive months, 130 nonconsecutive 8–18‐year‐old children having VP in an urban pediatric ED were prospectively randomized into two groups of 65 patients each. Before VP, every child, parent, and HP completed a questionnaire developed to measure epidemiologic variables believed to influence distress during VP. The patients were randomized to have either a parent present or both parents absent during VP. The patients, the parents, and the HPs privately self‐reported their distress during VP on a visual analog scale (VAS). Statistical significance was determined by the Mann‐Whitney U (rank‐sum) test.Results: In the parent‐present group, distress scores were lower for the parent (p < 0.01) and for the child (p < 0.04) than they were in the parents‐absent group. The HP performing VP had no difference in distress scores with and without parental presence (p < 0.55).Conclusions: Parents and children having VP have less distress with parental presence. Health professional distress is not affected by parental presence.
Prospective Evaluation of Emergency Medicine Instruction for Rotating First–postgraduate–year Residents
Authors: Wyte Collate Ditz , Adams Stephen L. , Cabel Jennifer A. , Pearlman Kenneth , Yarnold Paul R. , Morkin Michael , Hott Kimberly A. , Mathews James J. 
Published: September 2008

ABSTRACTObjective:To determine whether either bedside teaching alone (group A) or bedside teaching with written course materials (group B) improved written examination scores, satisfaction with the rotation, or clinical grades of rotating PGY1 residents.Methods: A prospective, controlled educational trial was conducted. Sixty–five PGY1 residents from diverse specialties rotated in the ED for one month over a ten–month study period, and were included in the study. The PGY1 residents were assigned to group by month of rotation. All the PGY1 residents received unstructured bedside teaching by emergency medicine (EM) residents and faculty. In addition, group B received written course materials on day 1.Results: Mean posttest scores were higher than mean pretest scores for the interns considered as a whole (p < 0.0001), but mean pretest, posttest, and clinical grades were comparable across instructional groups. Mean satisfaction ratings were higher for group A than for group B (p < 0.015). The interns specializing in EM achieved higher mean test scores (p < 0.013) and clinical grades (p < 0.003) than did the interns specializing in another medical specialty.Conclusion: Both instructional methods were associated with improved written test performance. Written course materials did not augment bedside teaching in terms of test scores, clinical grades, or satisfaction. with the rotation. At a university–based, high–volume ED, bedside teaching offers educational benefit to rotating PGY1 residents that may not be augmented by written course materials.
Injury in West Virginia: A Statewide Survey
Authors: Williams Janet M. , Derk Susan J. , Furbee Paul M. 
Published: September 2008

ABSTRACTObjective: To determine an estimate of the period prevalence of medically attended injury in West Virginia via a statewide random telephone survey.Methods: A statewide random telephone survey, the West Virginia Social Indicator Survey (WVSIS), was modified to incorporate questions regarding the incidence and mechanisms of injury. The WVSIS is periodically conducted on a representative cross‐section of West Virginians to gather information about their social and economic conditions as well as to monitor change in the quality of their lives over time.Results: Of the 1,498 households interviewed, 412 (28%) reported having sustained injuries for which medical care had been obtained. This translates to a conservative estimate of 231,000 medically attended injuries within West Virginia in 1993. The average age of those injured was 35 years. Falls were the most frequently reported causes of injury, with motor vehicle crashes being the second most reported cause. Most injury victims (70%) were treated in an ED. Most respondents (67%) were able to suggest ways in which the injuries might have been avoided. Only 37% of the respondents with children 13 years of age reported ever having received injury prevention information from a physician. The most commonly reported physician advice concerned childhood poisoning (34%).Conclusions: Injury questions added to ongoing state health surveillance surveys provide valuable insight into population‐based injury rates and potential preventive measures.
Effect of Permissive Hypotension in Continuous Uncontrolled Intra‐abdominal Hemorrhage
Authors: Silbergleit Robert , Satz Wayne , McNarnara Robert M. , Lee David C. , Schoffstall John M. 
Published: September 2008

ABSTRACTObjective: To determine the effects of aggressive fluid administration vs permissive hypotension on survival, blood loss, and hemodynamics in a model of uncontrolled hemorrhage in which bleeding has been shown to be continuous.Methods: In this porcine model, 10 animals were bled through a flow‐monitored shunt placed between the femoral artery and the peritoneal cavity. The animals received either no fluid (n = 5) or 80 mug lactated Ringer's solution (n = 5) during a resuscitation phase between 10 and 20 minutes postinjury, followed by a 40‐minute evaluation phase. Arterial pressures, cardiac output (CO), and hemorrhage rate were measured, Survival and blood loss were calculated outcome measures.Results: The difference in survival between the animals left hypotensive (40%) and those receiving normotensive resuscitation (20%) was not significant (p = 0.49). In the animals receiving fluid resuscitation, mean arterial pressure (MAP) and CO increased during the resuscitative phase, but all the animals suffered the same pattern of hemodynamic deterioration in the evaluation phase. Rate of hemorrhage during the resuscitative phase was 20 ± 5 mL/min in the animals not receiving fluid and 56 ± 9 mL/min in the animals receiving fluids. Total blood loss was subsequently 20 mL/kg greater in the animals receiving fluids than in the animals without fluid resuscitation.Conclusions: In this model of continuous uncontrolled hemorrhage, the difference in survival between the animals left hypotensive and the animals receiving fluid resuscitation was not statistically significant. Increases in MAP and CO with fluid resuscitation were transient and were offset by larger volumes of blood loss. In contrast to the aortotomy model (where thrombosis is likely and hypotensive resuscitation has proven beneficial), this model suggests that in continuous bleeding, avoiding fluid resuscitation has a much smaller effect on outcome. Much of the benefit from hypotensive resuscitation may depend on having an injury that can stop bleeding.