Showing papers in "American Journal of Emergency Medicine in 1998"

Gender differences in reported symptoms for acute myocardial infarction: Impact on prehospital delay time interval

Abstract: A retrospective observational study using database registry of consecutive patients admitted to 16 King County hospital Coronary Care Units (CCU) was conducted to assess gender differences in symptom presentation for acute myocardial infarction (AMI) and investigate how symptom presentation relates to prehospital delay time interval from acute symptom onset to emergency department (ED) presentation. Between January 1991 and February 1993, 4,497 patients were admitted to the CCUs with diagnosed AMI. Accredited record technicians abstracted age, gender, race, transport method, symptom presentation (chest pain, sweating, nausea, shortness of breath, epigastric pain, and fainting), delay time interval between acute symptom onset and presentation to hospital ED, and discharge diagnosis from the patients' medical records. After adjusting for age and history of diabetes, no gender differences remained for frequencies of chest pain, fainting, or epigastric pain. Women reported more nausea and shortness of breath but less sweating than men as symptoms of AMI. Chest pain, sweating, and fainting were associated with decreasing delay time intervals. Age, gender, histories of AMI and diabetes, and transport choice were also significantly related to delay time interval. These results show that gender differences occur in AMI symptom experience. However, how symptoms relate to the gender gap in delay time interval is not clear. These findings suggest that health care professionals need to tailor information about possible symptoms of AMI to the patient's gender, age, and medical history.

Comparative study of methods of measuring acute pain intensity in an ED.

Abstract: The best one-dimensional method for routine self-assessment of acute pain intensity in a hospital emergency department is unknown. In this study, an 11-point numerical rating scale (NRS), a simple verbal rating scale describing five pain states (VRS), and a visual analogue scale (VAS) were presented successively on admission to 290 patients with acute pain (200 with and 90 without trauma). VAS and NRS were closely correlated for both traumatic (r = .795) and nontraumatic pain (r = .911). The VAS could not be used with 19.5% of patients with trauma and the VRS with 11% of patients without trauma, whereas the NRS could be used with 96% of all patients. The NRS proved more reliable for patients with trauma, giving equivalent results to those with the VAS for patients without trauma. These two scales showed better discriminant power for all patients. Thus, the NRS would appear to be the means for self-evaluation of acute pain intensity in an emergency department.

Frequent ED users: patterns of use over time.

Abstract: The objective of this study was to examine the pattern of emergency department (ED) use by frequent ED users over time. This study was a retrospective study of adults with more than 10 visits to a university hospital ED from 890 through 791. ED visits of this cohort to all hospitals in the metropolitan area were followed for 3 years. Records were reviewed for the etiology of each patient's ED visits. This cohort was comprised of 76 patients making 1,119 (1.9%) of the total 59,051 ED visits. Thirty-five of the 76 (46%) were frequent ED users in only the initial year. Thirteen of the 76 (17%) made more than 10 visits in all 4 years. The remainder had sporadic episodes of ED use. Thirty-five (46%) were evaluated at three or more EDs in years in which they were frequent users. Forty-two (55%) had a medical problem for the cause of the majority of their ED visits. Fifty-eight percent of patients making more than 10 visits in more than 1 year had psychiatric or substance abuse problems. The pattern of ED use in this cohort changed over time and was influenced by substance abuse and psychiatric problems. These data suggest that most patients do not remain frequent ED users over time.

Utility of monitoring capnography, pulse oximetry, and vital signs in the detection of airway mishaps : a hyperoxemic animal model

Abstract: This study was undertaken to determine the time interval for changes in end-tidal CO2, oxygen saturation (SaO2), heart rate (HR), and blood pressure (BP) in response to an acute airway obstruction or hypopharyngeal extubation in a hyperoxemic model. Complete and partial airway obstructions were simulated with complete and partial cross-clamping of an endotracheal (ET) tube in five anesthetized, nonparalyzed, mechanically ventilated Yorkshire minipigs with initial PAo2 of > 400 mm Hg. Placement of the ET tube into the hypopharynx was performed to simulate accidental extubation. Both sidestream (SS) and mainstream (MS) capnography were used. Continuous pulse oximetry monitored SaO2, femoral arterial catheter monitored systolic BP, and electrocardiograph monitored HR. The time intervals for the capnograph wave to flatten and for the monitor to display zero were recorded after each airway alteration. The time interval to a change in the initial HR of 10 beats/min, a change of initial systolic BP of 10 mm Hg, and a change of initial SaO2 of 5% were recorded. Experiments were carried out for 180 seconds, and 25 trials were performed. HR, systolic BP, and SaO2 did not change for the 180-second duration of the trials. Complete obstruction produced a flattening of the SS and MS waveform in 8 +/- 2 seconds and 6 +/- 2 seconds, respectively. The SS and MS monitors displayed zero in 19 +/- 1 seconds and 68 +/- 7 seconds, respectively. Partial obstruction did not produce flattening of the wave or a monitor displaying zero. Hypopharyngeal extubation produced a flattening of the SS and MS waveform in 7 +/- 1 seconds and 7 +/- 2 seconds, respectively. The SS and MS monitors displayed zero in 18 +/- 3 seconds and 76 +/- 16 seconds, respectively. Continuous end-tidal CO2 capnography detects acute airway obstruction and hypopharyngeal extubation more rapidly than does pulse oximetry or vital sign monitoring in a hyperoxemic porcine model.

Mild protective and resuscitative hypothermia for asphyxial cardiac arrest in rats

Abstract: It has been shown in dogs that mild hypothermia (34°C) during or immediately after ventricular fibrillation cardiac arrest can improve cerebral outcome. The effect of mild hypothermia on outcome after 8 minutes of asphyxiation (5 minutes' cardiac arrest) was studied for the first time in rats. Restoration of spontaneous circulation was with external cardiopulmonary resuscitation and observation to 72 hours. Three groups of 10 rats each were studied. At 72 hours postarrest, compared with the normothermic control group 1, final overall performance categories (OPC) and neurological deficit scores (NDS) were numerically better in the resuscitative (post-arrest) hypothermia group 2 and significantly better in the protective (pre-intra-arrest) hypothermia group 3 (P < .05). Total brain histopathological damage scores (HDS) were 17 ± 5 in group 1, 14 ± 6 in group 2 (NS), and 6 ± 2 in group 3 (P < .001 versus group 1). HDS correlated with OPC (r = .6, P < .05) and NDS (r = .7, P < .05). Mild hypothermia improved cerebral outcome after asphyxial cardiac arrest in rats, more when induced before than after arrest. The model's insult is within the therapeutic window, which makes it also suitable for screening other cerebral resuscitation potentials.

Rapid sequence induction for intubation by an aeromedical transport team : A critical analysis

Abstract: Airway control is the initial priority in the management of the injured patient. The purpose of this investigation was to evaluate the experience of an aeromedical transport team in the utilization of rapid sequence induction (RSI) for endotracheal intubation in the prehospital setting. Records of a consecutive series of injured patients undergoing RSI between June 1988 and July 1992 by a university-based aeromedical transport team were reviewed for demographics, intubation mishaps, and pulmonary complications. The relationship between intubation mishaps and pulmonary complications was analyzed. Eighty-four patients were studied with a mean age of 30.8 ± 15.3 years. The mean Revised Trauma Score was 11.3 ± 2.4, and the mean Injury Severity Score (ISS) was 19.6 ± 11.5. Intubation mishaps occurred in 15 patients (18%), and pulmonary complications developed in 22 (29%) of the 75 patients surviving longer than 24 hours. There was no relationship between intubation mishaps and pulmonary complications. Abbreviated Injury Scale (AIS) face score was significantly higher in patients with intubation mishaps, compared with patients without mishaps (1.1 ± 1.2 and 0.5 ± 0.9, respectively, P < .05, Wilcoxon rank-sum). ISS and AIS chest were higher in patients with pulmonary complications, compared with those without (25.7 ± 12.6 and 17.4 ± 10.3 and 2.2 ± 1.8 and 1.0 ± 1.5, ISS and AIS respectively; P < .05, Wilcoxon rank-sum). Eighty-one patients (96%) underwent successful RSI, 73 (87%) on the first attempt. Failure to intubate occurred in three patients (4%). Performed under strict protocol by appropriately trained aeromedical transport personnel, RSI is an effective means to facilitate endotracheal intubation in the injured patient requiring definitive airway control. Pulmonary complications were related to injury severity and not to intubation mishaps.

Intubation success rates improve for an air medical program after implementing the use of neuromuscular blocking agents

Abstract: To determine whether the success rate for endotracheal intubation improves after implementing the use of neuromuscular blocking (NMB) agents in an air medical program, this retrospective study analyzed all patients requiring endotracheal intubation at two air medical programs (nurse/paramedic crews) over a 5-year period. Air medical program A, the control group, had employed NMB agents throughout the entire study period. Air medical program B, which did not use NMB agents from July 1, 1989 through June 30, 1992, implemented their use starting July 1, 1992. For program A, the overall intubation success rate was 93.5% (202 successful intubations in 216 patients) and the successful intubations/total attempts ratio was 0.67 (202 of 301). For program B, the overall intubation success rate improved from 66.7% (46 successful intubations in 69 patients) before NMB agent use to 90.5% (57 in 63) after NMB agent use (P = .001). The successful intubations/total attempts ratio increased from 0.36 (51 of 141) prior to NMB agent use to 0.48 (63 of 132) after NMB agent use (P = NS). In comparing the 92 patients who did not receive NMB agents to the 40 patients who did, the intubation success rate increased from 69.6% (64 of 92) to 97.5% (39 of 40) (P < .001) and the successful intubation/total attempts ratio increased from 0.36 (73 of 202) to 0.58 (41 of 71) (P = .007). With the use of NMB agents, program B's overall intubation success rate increased significantly, matching the results of program A.

Fatal colchicine overdose: Report of a case and review of the literature

Abstract: Colchicine poisoning is an uncommon, but potentially life-threatening, toxicologic emergency. A case is reported of a 21-year-old woman who presented to the emergency department approximately 1 hour after ingesting 30 mg of colchicine in a suicide attempt. Her clinical course included gastrointestinal distress, metabolic acidosis, pancytopenia, hypotension, adult respiratory distress syndrome, rhabdomyolysis, and hypocalcemia. Despite aggressive medical management, the patient suffered a cardiac arrest and died 8 days after the ingestion. The clinical features of colchicine poisoning are highlighted and current therapeutic options are discussed.

Skill mastery in public CPR classes

Abstract: Effectiveness of CPR performance on a manikin was evaluated immediately after training in public CPR classes by trained independent observers using validated measures and procedures. An instrumented manikin was used to assess critical skills thought to be related to survival following out-of-hospital cardiac arrest (compressions and ventilations), applying standards of the American Heart Association. The 226 subjects were enrolled in CPR classes offered to the public by the American Red Cross and the American Heart Association. Fifty percent of subjects performed 2% or fewer compressions correctly (the most common error being insufficient depth), and 50% performed 10% or fewer of ventilations correctly (the most common error being insufficient volume). Sixty-five percent failed to achieve a compression rate of 80 to 100/min. Forty-five percent of subjects failed to open the airway prior to a breathing check, 50% failed to adequately assess breathing, and 53% did not perform an adequate pulse check. Nearly half of all subjects made at least four errors in assessment and sequencing of skills. According to published criteria, trainee performance of CPR is poor. Failure in critical skills may contribute to poor survival rate following out-of-hospital cardiac arrest. CPR training programs must be developed with attention to learner outcomes.

Pain reduction in lidocaine administration through buffering and warming

Abstract: This study compared the pain from intradermal infiltration of (1) plain lidocaine, (2) warmed lidocaine, (3) buffered lidocaine, and (4) warmed, buffered lidocaine. A randomized, double-blind, Latin Square design of 20 volunteers was used. Each volunteer was injected with a series of four test solutions on four separate occasions, for 16 total injections each. Each volunteer served as his or her own control. The mean pain scores for the four solutions were: 44.2 for plain lidocaine, 42.2 for warmed lidocaine, 36.7 for buffered lidocaine, and 29.2 for warmed, buffered lidocaine. Buffered lidocaine was statistically less painful than both plain lidocaine and warmed lidocaine. Warmed, buffered lidocaine was significantly less painful than all other solutions, including buffered lidocaine (P < .005). However, warmed lidocaine did not yield pain scores significantly different from plain lidocaine. In this experimental model, warmed lidocaine was not superior to plain lidocaine, but warmed, buffered lidocaine caused significantly less pain than plain lidocaine, buffered lidocaine, or warmed lidocaine. Thus, there may be benefit from heating the buffered lidocaine now in common clinical use.

Nonbattering presentations to the ED of women in physically abusive relationships

Abstract: To determine which diagnoses in the emergency department (ED), apart from battering injuries, were more common among women who were living in physically abusive relationships than among women who were not, a study was conducted in 10 hospital-based EDs in two cities serving inner city, urban, and suburban populations. A total of 9,057 women between the ages of 19 and 65 years presenting to the EDs were eligible for the study. Medical records were reviewed, and a written questionnaire was used. The questionnaire was completed by 4,501 (73% of those asked, 59% of those eligible, and 50% of those presenting). Two hundred sixty-six (5.9%) were currently in a physically abusive relationship but not in the ED for battering injuries, and 3,969 (88.2%) were not currently in a physically abusive relationship. An additional 266 (5.9%) were positive, probable, or suggestive for battering injuries and excluded from diagnosis comparisons. Women in physically abusive relationships were more likely to be diagnosed with urinary tract infections, neck pain, vaginitis, foot wound, suicide attempt, and finger fracture. However, these represented only 19.8% of diagnoses in this group. The use of this knowledge alone to predict the presence of intimate violence in individual patients in the ED will not identify the majority of women at risk. These results suggest the use of routine inquiry for abuse in all women.

Ultrasound-assisted internal jugular vein catheterization in the ED.

Abstract: A prospective, descriptive study is reported on the use and success of ultrasound-assisted internal jugular central vein catheterization (CVC) in the emergency department (ED). In patients not in cardiac arrest who had an indication for internal jugular CVC, lines were placed by trained ED staff using ultrasound. Data were collected prospectively on age, sex, body habitus, indication, vein visibility, number of punctures and needle passes, and success. There were 40 attempts at internal jugular CVC in 34 patients and ultrasound was used in 32 of the 40 (80%) attempts. Incidences of successful puncture and cannulation using ultrasound were 93.8% (30 of 32) and 81.3% (26 of 32), respectively, compared with 62.5% (5 of 8) and 62.5% (5 of 8) in the landmark group. In 8 patients with no visual or palpable landmarks, cannulation was successful in 100% (7 of 7) using ultrasound and in 0% (0 of 1) using landmark technique. Ultrasound-assisted internal jugular CVC is an easily learned technique that is useful in the ED. It may be especially helpful in patients in whom landmarks are not visible and not palpable.

Can melatonin improve adaptation to night shift

Abstract: This study was undertaken to determine whether melatonin (N-acetyl-5 methoxytryptamine) is effective in helping emergency medical services (EMS) personnel who work rotating night shifts reset their biological clocks and minimize circadian rhythm disruption. A double-blinded, randomized, crossover study was performed using 22 volunteers. Participants were working a span of consecutive night (2300 to 0700 hours) shifts and received either a melatonin capsule (6 mg) or placebo to be taken before each of the consecutive day sleeps. Each participant completed a total of 4 spans of consecutive night shifts (2 melatonin, 2 placebo). Collected data included daily sleep diaries, quantification of alcohol/caffeine consumed, and drug side effects. Assessment of sleep quality, posttreatment mood, and workload ratings were measured daily by 10-cm visual analog scale (VAS). Analysis of sleep diaries found no significant difference (P > .05) between the two treatments with respect to mean sleep latency, duration, and efficiency, and subjectively rated sleep quality. Similarly, no significant benefits were noted between the median VAS scores for daily posttreatment mood or workload ratings. Adverse effects were rare; one patient taking melatonin reported a prolonged sedative effect. Despite recent interest in melatonin for treatment of circadian-based sleep disorders, no clinical benefits were noted in EMS personnel working rotating night shifts.

Comparison of normal saline with tap water for wound irrigation.

Abstract: This study compared irrigation with tap water versus saline for removing bacteria from simple skin lacerations. The study was conducted in an animal model with a randomized, nonblinded crossover design using 10 500-g laboratory rats. Two full-thickness skin lacerations were made on each animal and inoculated with standardized concentrations of Staphylococcus aureus broth. Tissue specimens were removed before and after irrigation with 250 cc of either normal saline from a sterile syringe or water from a faucet. Bacterial counts were determined for each specimen and compared before and after irrigation. There was a mean reduction in bacterial counts of 81.6% with saline and 65.3% with tap water (P = .34). One tap water specimen had markedly aberrant bacterial counts compared with others. Excluding this specimen, the mean reduction for tap water was 80.2%. In this model, reduction in bacterial contamination of simple lacerations was not different comparing tap water with normal saline as an irrigant.

Injuries distracting from intraabdominal injuries after blunt trauma.

Abstract: While most conscious patients with severe intraabdominal injuries (IAI) will usually present with either abdominal pain or tenderness, there is a small group of awake and alert patients in whom the physical examination will be falsely negative because of the presence of associated extraabdominal ("distracting") injuries. We sought to define the types of extraabdominal injuries that could lead to a false negative physical examination for potentially severe IAI in adult victims of blunt trauma. This study was prospectively performed on consecutive blunt trauma patients over a 14-month period in our level I trauma center. Inclusion criteria were as follows: (1) Glasgow Coma Scale score of 15; (2) age 18 years or older; and (3) computed tomography (CT) of the abdomen or diagnostic peritoneal lavage (DPL) performed regardless of initial physical examination findings. Patients were questioned specifically about the presence of abdominal pain and the initial abdominal examination was documented in addition to other extraabdominal injuries. Abdominal injuries were considered to be present based upon either abdominal CT findings or a positive DPL. Patients with and without abdominal pain or tenderness were compared for the presence of IAI. A total of 350 patients were enrolled. There were 142 patients with neither abdominal pain nor tenderness (group I) and 208 patients with either or both (group 2). Ten of the 142 patients (7.0%) in group I had IAI compared with 44 of the 208 patients (21.2%) in group 2 ( P = .0003). Presence of pain and/or tenderness had a sensitivity of 82%, a specificity of 45%, a positive predictive value of 21%, and negative predictive value of 93%. All 10 patients in group 1, and 36 of the 44 group 2 patients, had associated extraabdominal injuries. Although the presence of abdominal pain or tenderness was associated with a significantly higher incidence of IAI, the lack of these findings did not preclude IAI.

Colposcopy in evaluation of the adult sexual assault victim.

Abstract: The purpose of this study was to determine if the colposcope improves detection of genital trauma in adult women who are victims of sexual assault compared with gross visual examination alone. A prospective, 1-month pilot study was conducted of 17 women patients who presented consecutively to Charity Hospital New Orleans during April 1994 requesting sexual assault examinations. Use of the colposcope allowed documentation of trauma in 9 of the 17 sexual assault victims (53%), compared with 1 of 17 (6%) by gross visualization alone (statistically significant: χ2 = 0.64, P = .0114). The colposcope improved detection of genital trauma in adult female sexual assault victims as compared with gross visual examination alone at a statistically significant level.

The motorcyclist: Easy rider or easy victim? An analysis of motorcycle accidents in Germany

Abstract: This report reviews the findings from 86 motorcycle accidents during a 1-year period at the Trauma Center "Bergmannsheil" in Bochum, Germany. A study of the case histories supplemented by telephone conversations yielded the following results: 90.7% of the patients were men, and the average age was 28.8 years; most of the accidents occurred in the 25- to 30-year-old age group (27.9%). Motorcycle accidents happened mostly during recreational rides on weekends in the summertime. Although there was a high rate of helmet use (98.8%), the head region was affected in 12 victims. Two patients died because of their severe head injuries (2.3%). Lower extremity injuries (46%), especially open tibia fractures (19.7%), were among the most common injuries sustained. Fractures of the distal radius constituted the largest portion of upper extremity injuries (18.8%). The average stay in our hospital was 35.4 days; 23.4% of the patients had to change jobs after the accident. Fifty percent of the crashes happened with motorcycles between 500 and 750 cc stroke volume. Although 34.5% possessed their driver's licenses for more than 8 years, they had not had much experience handling a motorbike. These results underline the fact that motorcycle accidents are sustained by young men in their working prime; as a result, these accidents pose a tremendous burden to individuals and society and every attempt should be made to offer highly qualified surgical and trauma care to minimize the damage to the motorbiker. A plea is made for more prevention measures like driver education, better road conditions, or legislative changes to prevent motorcycle crashes. The wearing of a helmet is strongly advocated.

Treatment of acute anticholinergic poisoning with physostigmine.

Abstract: Five cases of acute anticholinergic poisoning presenting to an inner-city emergency department (ED) are discussed. All five patients presented with classic signs and symptoms of anticholinergic toxicity, which included tachycardia, hot, dry and flushed skin, markedly dilated and fixed pupils, and pronounced delirium. The patients were violently agitated, and physical restraint was required. Initial treatment with benzodiazepines did not diminish their combative behavior. Treatment with intravenous physostigmine salicylate resulted in a decrease in agitation within 15 to 20 minutes of therapy. No untoward effects occurred as a result of treatment with physostigmine.

Computed tomography for blunt abdominal trauma in the ED: a prospective study.

Abstract: A study was undertaken to determine the criteria for ordering abdominal computed tomography (CT) in the emergency department (ED) for stable patients who sustained blunt trauma and to identify a patient population at high risk for having intra-abdominal injury (IAI) utilizing physical examination, decrease in hematocrit, and hematuria Patients in a university ED who had abdominal CT from April 1995 to October 1995 were evaluated prospectively Before the scan, the examining physician completed an entry form that included physical findings, hematocrit, hematuria, Glasgow Coma Scale score, intoxication, distracting injuries, reasons for obtaining the scan, and planned disposition Patients were followed until discharge A total of 196 patients were evaluated Abdominal tenderness was present in 120 patients Twenty-two patients had IAI Eight required surgical intervention, and all 8 had abdominal tenderness A total of 40 potential trauma admissions were averted by obtaining CT within the ED The combined abnormal abdomen examination and presence of hematuria had a sensitivity of 64%, specificity of 94%, positive predictive value of 56%, and negative predictive value of 95% Decrease of ≥5 in hematocrit was not statistically significant for detection of IAI CT had no false negatives in this cohort These results show that early CT scanning of stable patients who have sustained blunt trauma is an effective screen for IAI and may result in fewer total admissions, but has potential for overuse Patients with abdominal pain and hematuria should be scanned The benefit of a CT scan for patients without tenderness or with an isolated decrease in hematocrit is questionable

Critical care provided in an urban emergency department.

Abstract: The emergency department (ED) provides a substantial amount of critical care. The purpose of this study was to quantitate the critical care provided in an urban ED. The study was performed at a large urban hospital with an annual ED volume of 70,000 patients. All patients requiring critical care in the ED or hospital were prospectively observed between September 1 and November 30, 1993. Patients requiring recovery room care or neonatal intensive care were excluded. Data collected included age, disposition, length of stay, triage acuity assignment in the ED, primary diagnosis, and critical care procedures. During the study, 11,989 patients were examined in the ED with 500 (5%) requiring admission, 340 (3%) requiring a critical care intervention, and 96 (1%) being admitted to an intensive care unit (ICU). Ten percent of patients receiving critical care in the ED were admitted to the floor for lack of bed space. Triage assignment of emergent life-threatening or urgent potentially life-threatening condition predicted critical care need and waiting time to examination. The spectrum of critical care procedures performed in the ED and ICU were similar except for advanced life support intervention, which was more common in the ED (17 versus 3), and arterial line placement, which was more common in the ICU (14 versus 1). The spectrum of diagnoses reflected the age of patients with cardiovascular illnesses (33%), metabolic illnesses (18%), and trauma (16%) common in adults (age > or = 17) and infectious illnesses (46%) or metabolic illnesses (21%) more common in pediatric patients. Overall, 14% of adult critical care, 23% of pediatric critical care, and 15% of all critical care provided in the areas studied occurred in the ED. A significant proportion of critical care is provided in the ED, and triage acuity assignment reflects this need. A significant proportion of critically ill patients was admitted to the floor for lack of bed space, which highlights the financial constraints in urban hospitals such as the one studied.

The computed tomography appearance of recurrent and chronic appendicitis

Abstract: The objective of this study was to determine computed tomography (CT) appearance of recurrent and chronic appendicitis. In 100 consecutive appendiceal CT examinations of proven appendicitis, 18 patients met criteria for recurrent (multiple discrete episodes) or chronic (continuous symptoms >3 weeks, pathological findings) appendicitis. CT findings were reviewed. Ten patients had recurrent appendicitis, 3 had chronic appendicitis, 3 had both, and 2 had pathological chronic appendicitis. CT findings in 18 recurrent/chronic cases were identical to 82 acute appendicitis cases, including pericecal stranding (both 100%), dilated (>6 mm) appendix (88.9% versus 93.9%), apical thickening (66.7% versus 69.5%), adenopathy (66.7% versus 61.0%), appendolith(s) (50% versus 42.7%), arrowhead (27.8% versus 22.0%), abscess (11.1% versus 11.0%), phlegmon (11.1% versus 6.1%), and fluid (5.6% versus 19.5%). CT findings in recurrent and chronic appendicitis are the same as those in acute appendicitis. Appendiceal CT can be beneficial for evaluating patients with suspected recurrent or chronic appendicitis.

Emergency department diagnosis of abdominal disorders in the elderly

Abstract: To assess the accuracy of emergency department (ED) provisional diagnosis (ProDx) as compared with the hospital discharge diagnosis (HDDx) and the impact on hospital morbidity and mortality among nonelderly and elderly persons presenting with acute nontraumatic abdominal complaints, a retrospective review was conducted of 1,863 nonelderly (younger than 65 years) and 428 elderly (65 years or older) adults admitted to a university hospital from its ED. The sensitivity/ specificity of the ProDx was 82%/86% for patients younger than 65 versus 68%/76% for those 65 or older. When the ProDx and HDDx did not agree, the overall disease-related morbidity was 16% for patients younger than 65 versus 45% for those 65 or older (P < .02). There were no differences in mortality based on agreement of the ProDx and HDDx. Prospective studies to determine the factors that are most useful in the ED diagnosis of acute nontraumatic abdominal disorders in the elderly are needed to improve the accuracy of diagnosis and reduce the incidence of morbidity in this high-risk group.

Esophageal perforation: A complication of nasogastric tube placement

Abstract: Esophageal perforation is a well-established complication of nasogastric intubation. This complication is rare but can result in a fatal outcome with inappropriate management. 1,2 The most important factor is the time period between perforation and initiation of therapy. 3,4 The management of esophageal perforation with regard to surgical and nonsurgical approaches is not standardized. Successful management at present requires an individualized approach. 2 We describe a case of esophageal perforation secondary to nasogastric intubation. This case illustrates an example of delayed diagnosis with subsequent individualized management and a good outcome. A review of the current literature on the management of esophageal perforation is also presented.

Effects of risperidone in overdose.

Abstract: This study was a 13-month prospective, descriptive case series of risperidone overdose reported by telephone to a regional poison control center (PCC) serving Philadelphia, PA. Patients were seen in local Philadelphia-area emergency departments. The variables examined were medical history, therapeutic use of risperidone, time postingestion, reported coingestants, clinical findings, decontamination and treatment, electrocardiograph results, laboratory data, standard toxicologic screen results, and length of time in hospital. Thirty-one patients (29 adult/adolescent, 2 pediatric) with reported risperidone overdose were identified. Risperidone was the sole ingestant in 15 cases (1 mg to 180 mg). The major observed effects in this group included lethargy (7), spasm/dystonia (3), hypotension (2), tachycardia (6), and dysrhythmia (1). Sixteen cases involved coingestants, including benzodiazepines, selective serotonin reuptake inhibitors, ethanol, tricyclic antidepressants, lithium, anticonvulsants, diphenhydramine, ibuprofen, and anticholinergic agents. Major effects in these patients included lethargy (10), coma (1), seizure (1), tachycardia (7), bradycardia (1), hypotension (4), and a syndrome of muscle spasms, diaphoresis, and fever. Treatment provided for patients in this study included antiarrhythmics (1), diphenhydramine (2), anticonvulsant (1), vasopressor agent (1), endotracheal intubation/assisted ventilation (5), and supportive care. One patient who coingested imipramine died of medical complications. In the remaining patients, symptoms resolved with 24 hours in the majority, with all patients asymptomatic at 72 hours postingestion. These data show that risperidone toxicity manifests primarily as mild central nervous system effects and reversible neuromuscular and cardiovascular effects.

Traumatic internal carotid artery dissections caused by blunt softball injuries

Abstract: This report describes recently treated patients with carotid artery dissection caused by blunt softball injuries, as well as the results of a study of carotid artery trauma in a community. Data obtained through the medical records linkage system used for epidemiologic studies in Olmsted County, MN were used to identify all cases of traumatic internal carotid artery dissection diagnosed from 1987 through 1994. Four patients with traumatic internal carotid artery dissections were identified during the 8-year period under study. In two patients (50%) the carotid dissection was a result of the direct impact of a softball. A 39-year-old-man, who developed transient cerebral ischemic symptoms, and a 35-year-old woman, who developed a painful Horner's syndrome, were struck by a softball on the anterolateral aspect of the neck. Both patients had a low carotid bifurcation. These data suggest that internal carotid artery dissections may be underrecognized sequelae of direct softball injuries to the anterolateral neck. A low carotid bifurcation may be a risk factor for such injuries.

Effectiveness of mechanical versus manual chest compressions in out-of-hospital cardiac arrest resuscitation: a pilot study.

Abstract: A prospective, randomized effectiveness trial was undertaken to compare mechanical versus manual chest compressions as measured by end-tidal CO2 (ETCO2) in out-of-hospital cardiac arrest patients receiving advanced cardiac life support (ACLS) resuscitation from a municipal third-service, emergency medical services (EMS) agency. The EMS agency responds to approximately 6,700 emergencies annually, 79 of which were cardiac arrests in 1994, the study year. Following endotracheal intubation, all cardiac arrest patients were placed on 100% oxygen via the ventilator circuit of the mechanical cardiopulmonary resuscitation (CPR) device. Patients were randomized to receive mechanical CPR (TCPR) or human/manual CPR (HCPR) based on an odd/even day basis, with TCPR being performed on odd days. ETCO2 readings were obtained 5 minutes after the initiation of either TCPR or HCPR and again at the initiation of patient transport to the hospital. All patients received standard ACLS pharmacotherapy during the monitoring interval with the exception of sodium bicarbonate. CPR was continued until the patient was delivered to the hospital emergency department. Age, call response interval, initial electrocardiogram (ECG) rhythm, scene time, ETCO2 measurements, and arrest outcome were identified for all patients. Twenty patients were entered into the study, with 10 in each treatment group. Three patients in the TCPR group were excluded. Measurements in the HCPR group revealed a decreasing ETCO2 during the resuscitation in 8 of 10 patients (80%) and an increasing ETCO2 in the remaining 2 patients. No decrease in ETCO2 was noted in the TCPR group, with 4 of 7 patients (57%) actually showing an increased reading and 3 of 7 patients (43%) showing a constant ETCO2 reading. The differences in the ETCO2 measurements between TCPR and HCPR groups were statistically significant. Both groups were similar with regards to call response intervals, patient ages, scene times, and initial ECG rhythms. One patient in the TCPR group was admitted to the hospital but later died, leaving no survivors in the study. TCPR appears to be superior to standard HCPR as measured by ETCO2 in maintaining cardiac output during ACLS resuscitation of out-of-hospital cardiac arrest patients.

Retained glass foreign bodies in wounds: Predictive value of wound characteristics, patient perception, and wound exploration

Abstract: A convenience sample of 164 adult patients with 185 glass-caused wounds who presented to an emergency department (ED) and consented to a radiograph was prospectively studied. The purpose was to determine the characteristics of wounds at high risk for foreign body (FB) and the predictive value of patient FB sensation and probing wound exploration for FB retention. Retained glass was located in 28 (15%) wounds. Motor vehicle as a mechanism of injury (P=.003), head as a location (P=.035), and puncture as wound type (P=.002) were more likely to be associated with retained FBs (chi2 analysis). Patients with wounds with glass were more likely to have a positive perception of a foreign body (41%) than those with no glass (17%) (P=.005). The positive predictive value of patient perception was 31%; negative predictive value was 89%. In five cases, wound exploration was negative and subsequent radiograph was positive for FB. In one of these cases, a 4-mm glass FB was removed; in the other four, no FB was found. In conclusion, head wounds resulting from motor vehicle accidents or puncture wounds are more likely to harbor retained glass FBs. Patients with glass FB in wounds are more likely to have a positive perception of FB; however, a positive perception has a low predictive value of glass FB. In this series, a negative wound exploration made the presence of retained FB greater than 2 mm less likely but did not rule out the presence of retained glass.

Age-related differences in diagnoses within the elderly population

Abstract: The most common diagnoses of elderly patients in the emergency department (ED) were compared among three age subgroups: 65 to 74, 75 to 84, and 85 and older. The computerized billing records for patient visits to 10 northern New Jersey hospital EDs for the years 1985 to 1991 were retrospectively analyzed. The most frequently occurring ICD-9-CM codes for elderly patients were compared among the three age subgroups. Elderly persons comprised 174, 146 (14% of the total) patient visits. The 176,146 patient visits were assigned 259,440 ICD-9-CM codes. The most common ICD-9-CM codes for medical diagnoses included chest pain, cardiac dysrhythmias, congestive heart failure, syncope, abdominal pain, and dyspnea. Fractures, particularly of the lower limb and upper limb; contusions; open wounds, particularly of the head, neck, and trunk; and falls were among the most common trauma diagnoses. The proportions in the three age subgroups of each diagnosis were statistically significantly different, except for cardiac arrest and contusions of the trunk and of multiple sites. The diagnoses with clinically significant higher relative risks in older age subgroups were atrial fibrillation, congestive heart failure, syncope, hypovolemia/dehydration, gastrointestinal hemorrhage, dyspnea, pneumonia, pulmonary edema, cerebrovascular accident, septicemia, urinary tract infection, fractures, and open wounds of the head, neck, trunk, particularly the scalp, and falls. Clinically significant lower relative risks were found in older age subgroups for chest pain, acute myocardial infarction, hypertension, angina, chronic airway obstruction not elsewhere classified, epistaxis, contusions of the upper limb, and open wounds of the finger.

Waiver of informed consent: A survey of emergency medicine patients

Abstract: Changes to Federal regulations pertaining to waiver of informed consent for acute care research were debated by the research and regulatory communities for more than 2 years before being finalized in October of 1996. Input from the general public was limited. This survey investigated the opinions of emergency medicine patients concerning wavier of informed consent for acute care research. A convenience sample of 212 patients were approached at a tertiary care academic urban emergency department. Seventy-three percent approved of waiver of informed consent if the absolute risks were minimal (50% if the absolute risks were greater than minimal but the incremental risk were minimal). Educational status and certain aspects of the patient's current health status (but not age, race, or gender) significantly affected the results. While most emergency medicine patients would want to be enrolled in a study if they had a serious illness and were unable to give informed consent, a significant percentage of patients would not want to be enrolled regardless of the degree of risk or availability of a family member to speak on their behalf. Waiver of informed consent for emergency research is an ethical dilemma pitting individual rights against societal needs and physician parentalism. A better understanding of what patients consider appropriate may help in resolving this dilemma.