Showing papers in "American Journal of Emergency Medicine in 2005"

2004 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System

Abstract: Toxic Exposure Surveillance System (TESS) data are compiled by the American Association of Poison Control Centers (AAPCC) in cooperation with the majority of US poison centers. These data are used to identify hazards early, focus prevention education, guide clinical research, and direct training. TESS data have prompted product reformulations, repackaging, recalls, and bans; are used to support regulatory actions; and form the basis of postmarketing surveillance of newly released drugs and products. From its inception in 1983, TESS has grown dramatically, with increases in the number of participating poison centers, population served by those centers, and reported human exposures (Table 1). 1-15 The cumulative AAPCC database now contains 24.8 million human poison exposure cases. This report includes 2,241,082 human exposure cases reported by 65 participating poison centers during 1998, an increase of 2.2% compared with 1997 poisoning reports.

Sonographic measurement of the inferior vena cava as a marker of blood loss

Abstract: Detecting and monitoring blood loss in trauma patients can often be challenging when an obvious source of hemorrhage is not readily seen. Objective: To provide a noninvasive measurement of circulating blood volume and of drop therein by measuring the change in the inferior vena cava diameter (IVCd) in relationship to blood loss. Methods: This was a prospective observational study on blood donors at a donation center. The IVCd, both during inspiration (IVCi) and during expiration (IVCe), was measured in volunteers both before and after blood donation of 450 mL. All actual blood donors aged 18 years and older were eligible for enrollment. Persons who were younger than 18 years, who declined to participate in the study, or who did not meet blood center criteria for blood donation were excluded. All examinations were performed in the supine position with the ultrasound transducer placed in a subxyphoid location. Sagittal sections of the IVC behind the liver were imaged and the maximal diameter of the IVCe and the minimal diameter of the IVCi were measured. Statistical analysis included test for normality, paired t test, and correlation analysis. Results: A total of 31 volunteers (18 male) with a mean age of 49.5 years (range, 18-73) were studied. The mean IVCe before blood donation was 17.4 mm (95% CI, 15.2-19.7 mm) and after blood donation was 11.9 mm (95% CI, 10.3-13.6 mm). The mean IVCi before blood donation was 13.3 mm (95% CI, 11.3-15.3 mm), but after blood donation was 8.13 mm (95% CI, 6.7-9.6 mm). The difference between IVCe before and after blood donation (dIVCe) was 5.5 mm (95% CI, 4.3-6.3 mm) yielding a P b .0001. The difference between IVCi before and after donation (dIVCi) was 5.16 mm (95% CI, 4.2-5.9 mm) yielding a P b .0001. The dIVCe and the dIVCi were closely correlated (r = 0.83). Similarly, the pre-IVCe correlated well to the post-IVCe (r = 0.74) and the pre-IVCi correlated well to the post-IVCi (r = 0.75). Conclusions: Our data indicates that the measurement of the IVC diameter is a reliable indicator of blood loss, even in small amounts of 450 mL. On average, there was about a 5-mm decrease in both the IVCe and IVCi after donation of 450 mL of blood. The measurement of the IVCe may be an important addition to the ultrasonographic evaluation of trauma and other potentially volume-depleted patients.

Shock index in diagnosing early acute hypovolemia.

Abstract: Objective The aim of this study was to determine the hemodynamic response and calculated shock index (SI = heart rate [HR]/systolic blood pressure [SBP]) in early acute blood loss Methods This was a prospective observational study that enrolled healthy blood donors Patients were excluded if not eligible for blood donation Baseline vital signs were obtained, 450 mL of blood was removed over 20 minutes, and vital signs were repeated immediately postdonation while lying and after 1 and 5 minutes of standing Difference was tested using a paired t test with P Results Forty-six patients were enrolled; means for each time interval are shown below with 95% confidence intervals Conclusions A significant elevation in mean SI was observed in healthy volunteers after standing for 1 and 5 minutes Although significant changes in HR and SBP were observed, these indices were still within "normal" limits The SI may be more useful in early hemorrhage than either the HR or SBP alone

Does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients

Abstract: This study evaluated the ability of cardiac sonography performed by emergency physicians to predict resuscitation outcomes of cardiac arrest patients. A convenience sample of cardiac arrest patients prospectively underwent bedside cardiac sonography at 4 emergency medicine residency-affiliated EDs as part of the Sonography Outcomes Assessment Program. Cardiac arrest patients in pulseless electrical activity (PEA) and asystole underwent transthoracic cardiac ultrasound B-mode examinations during their resuscitations to assess for the presence or absence of cardiac kinetic activity. Several end points were analyzed as potential predictors of resuscitations: presenting cardiac rhythms, the presence of sonographically detected cardiac activity, prehospital resuscitation time intervals, and ED resuscitation time intervals. Of 70 enrolled subjects, 36 were in asystole and 34 in PEA. Patients presenting without evidence of cardiac kinetic activity did not have return of spontaneous circulation (ROSC) regardless of their cardiac rhythm, asystole, or PEA. Of the 34 subjects presenting with PEA, 11 had sonographic evidence of cardiac kinetic activity, 8 had ROSC with subsequent admission to the hospital, and 1 had survived to hospital discharge with scores of 1 on the Glasgow-Pittsburgh Cerebral Performance scale and 1 in the Overall Performance category. The presence of sonographically identified cardiac kinetic motion was associated with ROSC. Time interval durations of cardiac resuscitative efforts in the prehospital environment and in the ED were not accurate predictors of ROSC for this cohort. Cardiac kinetic activity, or lack thereof, identified by transthoracic B-mode ultrasound may aid physicians' decision making regarding the care of cardiac arrest patients with PEA or asystole.

Relationship between the National ED Overcrowding Scale and the number of patients who leave without being seen in an academic ED

Abstract: Objective: We hypothesize that the number of patients who leave without being seen is correlated with the simple-to-use National Emergency Department Overcrowding Scale (NEDOCS). Methods: Results of a 6-item ED overcrowding scale (NEDOCS) were collected prospectively over a 17-day study period. The following additional data were extracted from records for each 2-hour study period: (1) number of registered patients, (2) number of ambulances that arrived, and (3) number of patients signed in that hour who eventually left without being seen. Spearman correlation coefficients were computed for the leaving without being seen (LWBS) rate with the NEDOCS score at the time of patient presentation and 2, 4, and 6 hours later. Results: The study period represents two hundred fourteen 2-hour periods. The LWBS rate was determined for 100% of the times; NEDOCS scores were determined for a sampling of 62% of the times spread equally over all hours of the day and days of the week. Correlation between the NEDOCS score and LWBS was 0.665. Conclusion: The NEDOCS score is well correlated with LWBS.

The minimum clinically significant difference in patient-assigned numeric scores for pain

Abstract: Objective To determine the minimum clinically significant difference (MCSD) in patient-assigned, 11-point numeric rating scale (NRS-11) scores for pain and to determine if the MCSD varied with demographic characteristics. Methods Eligible emergency department patients presenting with pain were asked to rate their pain on the NRS-11 every 20 minutes. Subjects compared pain intensity by choosing from the following verbal descriptor responses: “a lot more,” “a little more,” “about the same,” “a little less,” or “a lot less” pain. The MCSD was defined as the difference between scores rated “a little more” or “a little less” severe. Results Three hundred fifty-four subjects were enrolled. The MCSD was 1.39 ± 1.05 (95% confidence interval, 1.27-1.51). No statistically significant difference based on sex or pain etiology was noted. Conclusions Findings suggest that a change of 1.39 ± 1.05 (95% confidence interval, 1.27-1.51) on the NRS-11 is clinically significant when measuring pain.

Ultrasound-assisted paracentesis performed by emergency physicians vs the traditional technique: a prospective, randomized study.

Abstract: Study objective: To determine if emergency center ultrasound (ECUS) can be of value to emergency physicians in the evaluation of possible ascites and accompanying decisions to perform emergent paracentesis. Methods: During a 7-month period, patients suspected of having ascites and potentially requiring paracentesis were prospectively entered into a randomized study in an urban public hospital emergency center (N140000 annual visits). Patients were randomized to receive paracentesis using the traditional or the bedside ECUS-assisted technique. Indications for paracentesis included known liver disease and obvious ascites as well as suspected ascites or suspected subacute bacterial peritonitis. Participating physicians had received a minimum of 1 hour of formal didactic ultrasound training that included gallbladder, renal, vascular, and bladder studies as well as the focused abdominal sonography for trauma examination for trauma and the detection of ascites. A portable Terason 2000 laptop ultrasound machine with a 5-MHz probe was used to scan the patients. Data collected included the patients’ characteristics, estimation of ascitic fluid volume, number of attempts made to obtain fluid, speed of paracentesis, and the operator’s overall evaluation of the ECUS-assisted technique, if used. Results: Of 100 enrolled patients, 56 received the ECUS-assisted technique. Of 42 patients with ascites, 40 (95%) were successfully aspirated and 14 (25%) did not receive paracentesis because no ascites or insignificant amount of ascites was visualized. One patient was noted to have a large cystic mass in the left lower quadrant and another patient had a ventral hernia. Of the 44 patients randomized to the traditional technique, 27 (61%) were successfully aspirated. In 17 (39%) of these patients, fluid could not be obtained using traditional methods. Of these 17 failed attempts by traditional methods, 15 patients received ECUS in a bbreakQ from the study protocol. Ascitic fluid was obtained in 13 of these 15 patients; of the 2 remaining patients, 1 did not have enough fluid to be sampled and the other had no fluid visualized.

Use of an emergency department by nonurgent patients

Abstract: Objectives: The objectives of this study are (1) to determine whether patients seeking emergency department (ED) nonurgent care have primary care providers (PCP) or know of other care sources and (2) to determine the reasons why they choose to use the ED Methods: A cross-sectional survey in a university ED was administered to self-referred nonurgent patients for 6 weeks Use of a PCP, knowledge and attempts to seek other care, past use of the ED, urgency self-report, time of visit, and reasons for choosing an ED were recorded Results: Of the 563 approached subjects, 314 were eligible and 279 agreed to participate One hundred fifty-seven (56%) had PCPs For 183 (66%) subjects, the ED was the only place they knew to go for their present problem, and 75 (27%) reported that they depended on the ED for all medical care Of those patients with a PCP, 73 (47%) rated the ED better for unscheduled care Eighty-one (52%) subjects thought their PCP would be more efficient and 66 (42%) thought their PCP would be cheaper Conclusions: Although most ED nonurgent patients were not dependent upon the ED, the majority was unaware of other places to go for their current health problem Even those patients with a PCP sought care in the ED because the ED was believed to provide better care despite its perceived increase in both waiting time and cost

A randomized, double-blind study comparing morphine with fentanyl in prehospital analgesia.

Abstract: Study Objective The aim of this study was to compare, by a randomized double-blind method, morphine (M) and fentanyl (F) in a prehospital setting. Methods Consecutive patients with severe, acute pain defined as a visual analog scale score (VASS) of 60/100 or higher were included. The M group received an initial intravenous M injection of 0.1 mg/kg then of 3 mg every 5 minutes. The F group received an initial intravenous F injection of 1 μ g/kg then of 30 μ g every 5 minutes. The goal of analgesia was a VASS of 30/100 or lower. The end point was the VASS measured 30 minutes after initial administration (VAS [T30]). Results There were 26 patients included in the M group and 28 in the F group. Initial VASS(T0) and VASS(T30), mean (95% CI), were 83 (78-88) and 40 (28-52) in the M group and 77 (72-82) and 35 (27-43) in the F group ( P = NS). Sixty-two percent of patients in the M group described analgesia as excellent or good vs 76% of those in the F group who did ( P = NS). There were no differences in the incidence of side effects in the 2 groups. Conclusion This study demonstrates that M and F were comparable in treating severe, acute pain in a prehospital setting during the first 30 minutes in spontaneous breathing patients.

Predictive value of C-reactive protein at different cutoff levels in acute appendicitis

Abstract: Determining the different cutoff values of C-reactive protein (CRP) on the basis of how long the patient's symptoms were present can be used to early predict acute appendicitis. We analyzed retrospectively from 2001 to 2004 the hospital records of 568 patients who underwent appendectomies for suspected appendicitis. Receiver operating characteristic analysis has shown that CRP measurement can increase the diagnostic accuracy in acute appendicitis. The cutoff values of CRP concentration taken as the first, second, and third days after onset of symptoms that distinguish acute appendicitis from other acute abdominal diseases were 1.5, 4.0, and 10.5 mg/dL, respectively; the values that distinguish perforated appendicitis from other acute abdominal diseases were 3.3 mg/dL (first day), 8.5 mg/dL (second day), and 12.0 mg/dL (third day). The different cutoff values of CRP concentration may serve as a useful predictive parameter in the early diagnosis of acute appendicitis on the first 3 days after the onset of symptoms.

Factors predictive of acute renal failure and need for hemodialysis among ED patients with rhabdomyolysis.

Abstract: Objective: We assessed the primary causes of rhabdomyolysis, the factors associated with the development of acute renal failure (ARF), and the need for hemodialysis (HD) among a series of patients presenting to an urban emergency department with rhabdomyolysis. Methods: A chart review between January 1992 and December 1995 was conducted of patients aged 18 years or older with a diagnosis of rhabdomyolysis and an initial serum creatine phosphokinase greater than 1000 U/L. Patients were excluded if they had evidence of myocardial ischemia, cerebrovascular insufficiency, or the development of rhabdomyolysis after hospitalization. Demographic information, presumed causative factors, past medical history, medication usage, and laboratory data were collected. Results: Ninety-seven patients (93 men, 4 women) were enrolled, with a mean age of 35.7 years. The most common causes of rhabdomyolysis were cocaine (30), exercise (29), and immobilization (18). Seventeen of 97 (17.5%) patients developed ARF; 8 patients (8.25%) needed HD. Several clinical and laboratory factors were statistically associated with development of ARF and need for HD. The only variable that was predictive of both ARF and need for HD in separate multivariate regression models was the initial creatinine (Cr). Initial blood urea nitrogen also was predictive of the need for HD. No patient developed ARF with an initial Cr less than 1.7 mg/dL. Conclusion: Acute renal failure and need for HD are common complications of rhabdomyolysis. Except for initial serum Cr and blood urea nitrogen, clinical and laboratory factors were not reliable predictors for

Noise in the ED

Abstract: Background The impact of noise pollution on both the patient and the care provider has been extensively studied in the neonatal intensive care unit and in other critical care units. Noise pollution makes errors more probable and is one of the risk factors for provider burnout and negative outcomes for patients. The Environmental Protection Agency (EPA) recommends that the acceptable noise level in a hospital should not exceed 40 dB. Objectives The purpose of this study was to record and analyze noise in a large urban level I emergency department (ED) and compare to the EPA guidelines. Methods A 3-channel dosimeter Quest Q300 (Quest Technologies, Oconomowoc, WI) was placed as a stand-alone unit on the wall of the resuscitation booth in the ED. Sound was sampled 16 times per second for 12 hours and was recorded as peaks and averages for each minute. The dosimeter was then placed in the pocket of a medical student with a small 8-mm shoulder-mount type 2 microphone. The medical student followed an emergency medicine resident throughout an 8-hour shift in the main resuscitation area while monitoring and logging sound fluctuations in the environment. Sound pressure levels were logged in real time and subsequently correlated to the recorded peaks. Sound was sampled 16 times per second and recorded peaks and averages for each minute. Results In the initial part of the study, the time-weighted average was 43 dB. The average sound levels peaked approximately 25 times over 12 hours. Individually measured peak levels of 94 to 117 dB occurred every minute. In the second part of the study, the time-weighted average was 52.9 dB. Conclusions When compared to EPA accepted noise levels for hospital (40 dB), the ED under study had excessive noise on a regular basis. There are easily identifiable sources of noise pollution in the ED. By identifying and modifying sources of noise, stress in the ED may be decreased.

Real-time paramedic compared with blinded physician identification of ST-segment elevation myocardial infarction: results of an observational study.

Abstract: The aim of the study were to determine if paramedics can accurately identify ST-segment elevation myocardial infarction (STEMI) on prehospital 12-lead (PHTL) electrocardiogram and to compare paramedic with blinded physician identification of STEMI. Paramedics identified definite STEMI, or possible acute myocardial infarction but not definite, and nondiagnostic. Two blinded readers (cardiologist and emergency physician) independently categorized each PHTL. A third reviewer assigned final diagnoses and determined whether the PHTL met STEMI criteria. One hundred sixty-six PHTL were acquired over an 8-month period. Fifteen were excluded from analysis. Sixty-two percent of the patients (94/151) were male, mean age was 61.1 years (±14.8 SD, range 20-92 years), and 81% had chest pain. Twenty-five patients (16.6%; 95% confidence interval [CI], 11%-23.5%) had confirmed STEMI and 16 (10.6%) had confirmed non-STEMI acute myocardial infarction. Paramedic sensitivity was 0.80 (95% CI, 0.64-0.96); specificity was 0.97 (95% CI, 0.94-1.00) with positive likelihood ratio of 25.2 and negative likelihood ratio of 0.21. Overall accuracy was similar for paramedic and physician reviewers (0.94, 0.93, 0.95). Highly trained paramedics in an urban emergency medical services system can identify patients with STEMI as accurately as blinded physician reviewers.

Use of gum elastic bougie for prehospital difficult intubation.

Abstract: The objective of this study was to assess effectiveness of gum elastic bougie (GEB) in case of difficult intubation occurring in the prehospital settings. After manikin training to GEB handling, physicians were recommended to use GEB as first alternative technique in case of difficult intubation. Intubating conditions and details of patients requiring GEB-assisted laryngoscopy were recorded over 30 months. Among the 1442 extrahospital intubations performed, 41 patients (3%) required GEB. Gum elastic bougie allowed successful intubation in 33 cases (78%) and 8 patients sustained a second alternative technique. One patient was never intubated, another 1 required rescue cricothyroidotomy. Twenty-four (60%) GEB patients had associated factors for difficult intubation such as reduced or limited cervical spine mobility, morbid obesity, cervicofacial trauma, and ears, nose, and throat neoplasia. The success rate of GEB was 75% and 94%, respectively, depending on whether associated factors for difficult intubation are present or not. No adverse events associated to GEB use were noted.

Emergency management of agitation in schizophrenia

Abstract: Schizophrenia is a common psychiatric condition, affecting approximately 1% of the population. Acute emergent presentations often include hallucinations, delusions, thought, and speech disorders. Agitation is common among emergency patients with schizophrenia. Decisional capacity should be assessed in all patients. Reversible causes of agitation should be ruled out, including infection, metabolic disorders, endocrine disorders, trauma, pain, noncompliance, toxicological disorders, and structural brain abnormalities. Agitation may be managed acutely using a combination of pharmacological agents and nonpharmacological interventions. Effective pharmacological agents include several classes of antipsychotic agents and benzodiazepines. Potential life-threatening complications of pharmacological therapy should be anticipated, which may include neuroleptic malignant syndrome (NMS), prolonged QT syndrome, and respiratory depression. Nonpharmacological interventions may include a quiet environment, physical restraints, and behavioral interventions. Disposition decisions should be made based on the etiology of agitation, effective management, decisional capacity, and presence of suicidal or homicidal intentions. Many patients who have required nonpharmacological or pharmacological management of agitation require inpatient psychiatric treatment, either voluntarily or involuntarily. Psychiatric consultation should be sought for patients with schizophrenia and uncertain disposition determinations, or those requiring other complex management decisions.

The San Francisco Syncope Rule vs physician judgment and decision making.

Abstract: Objective To compare a clinical decision rule (San Francisco Syncope Rule [SFSR]) and physician decision making when predicting serious outcomes in patients with syncope. Methods In a prospective cohort study, physicians evaluated patients presenting with syncope and predicted the chance (0%-100%) of the patient developing a predefined serious outcome. They were then observed to determine their decision to admit the patient. All patients were followed up to determine whether they had a serious outcome within 7 days of their emergency department visit. Analyses included sensitivity and specificity to predict serious outcomes for low-risk patients and comparison of areas under the receiver operating characteristic curve for the decision rule, physician judgment, and admission decisions. Results During the study period, there were 684 visits for syncope with 79 visits resulting in serious outcomes. The area under the receiver operating characteristic curve was 0.92 (95% confidence interval [CI], 0.88-0.95) for the SFSR compared with physician judgment 0.89 (95% CI, 0.85-0.93) and physician decision making 0.83 (95% CI, 0.81-0.87). Physicians admitted 28% of patients in a low-risk group, with a median length of stay of 1 day (interquartile range, 1-2.5 days). The SFSR had the potential to absolutely decrease admissions by 10% in this low-risk group and still predict all serious outcomes. Conclusions Physician judgment is good when predicting which patients with syncope will develop serious outcomes, but contrary to their judgment, physicians still admit a large number of low-risk patients. The SFSR performs better than current physician performance and has great potential to aid physician decision making.

Evaluation of the Paediatric Canadian Triage and Acuity Scale in a pediatric ED.

Abstract: The aim of this study was to compare the performance of the Paediatric Canadian Triage and Acuity Scale (Paed CTAS) to a previous triage tool with respect to the percentage of admissions, the diagnostic and therapeutic interventions, and the mean pediatric risk of admission (PRISA) score in a pediatric tertiary center emergency department. Data were prospectively collected for 4 months before the Paed CTAS introduction (PRE group) and for 4 months after its implementation (Paed CTAS group). Both groups were similar in chief complaints, distribution of triage levels, and mean PRISA score. In the Paed CTAS group, more patients were triaged in the higher acuity levels (53% vs 36%, P P P = .001). The ability to predict requirements for interventions such as blood culture and intravenous fluid bolus was similar for both triage tools.

Derivation of a clinical guideline for the assessment of nonspecific abdominal pain: the Guideline for Abdominal Pain in the ED Setting (GAPEDS) Phase 1 Study.

Abstract: Objective: The purpose of this study was to identify a clinical guideline for the evaluation of nonspecific abdominal pain (NSAP) using history, physical examination, laboratory analysis, acute abdominal series (AAS) radiographs, and nonenhanced helical computed tomography (NHCT) clinical predictor variables (CPVs). Setting: The setting of this study was at an urban emergency department (ED) with 70000 yearly visits. Methods: This is an institutional review board–approved, prospective, observational study. The primary outcome variable was urgent intervention (UI), defined as a diagnosis requiring surgical or medical treatment to prevent death or major morbidity. Subjects underwent prompted history, physical, laboratory studies, AAS, and NHCT and were followed up to 6 months for ultimate diagnosis and outcome. CPVs were subjected to classification and regression tree analysis. Results: One hundred sixty-five subjects were analyzed. Thirteen percent of subjects required UI within 24 hours of presentation; an additional 34% underwent elective interventions that mitigated morbidity or mortality. Four guideline models were generated. Model 1 consisted of history and physical, with a sensitivity of 25%, a specificity of 92%, a positive likelihood ratio of 3.17, and a negative likelihood ratio of 0.81. Model 2 consisted of model 1 with laboratory, with a sensitivity of 39%, a specificity of 88%, a positive likelihood ratio of 3.25, and a negative likelihood ratio of 0.69. Model 3 consisted of model 2 with AAS, with a sensitivity of 56%, a specificity of 81%, a positive likelihood ratio of 2.94, and a negative likelihood ratio of 0.54. Model 4 comprised all inputs, including NHCT, with a

The prehospital 12-lead electrocardiogram’s effect on time to initiation of reperfusion Therapy: a systematic review and meta-analysis of existing literature.

Abstract: The prehospital electrocardiogram (ECG) is becoming the standard of care of suspected cardiac chest pain. We evaluated the evidence regarding the prehospital ECG and sought to quantify the reduction in time to reperfusion therapy attributable to the prehospital ECG. We conducted a systematic review and analyzed studies that were conducted in emergency medical systems relevant to providers in the United States. The papers were limited to studies that reported original data that compared prehospital ECG to no prehospital ECG groups. Four studies containing 99 patients met the inclusion criteria. A meta-analysis of these studies revealed a difference of 24.7 (95% confidence interval, 16.7-32.7) minutes. Providers now have a quantified value of the prehospital ECG based on the best published evidence. In addition, this search showed a relatively low quality and quantity of research on the prehospital ECG.

Correlation of arterial PCO2 and PETCO2 in prehospital controlled ventilation.

Abstract: Introduction This study was carried out to estimate the relationship between arterial Pco 2 (Paco 2 ) and end-tidal carbon dioxide (Petco 2 ) during prehospital controlled ventilation and also to evaluate variation of the gradient between Pco 2 and Petco 2 during prehospital transport. Methods Measurements of Petco 2 from capnography values and Paco 2 from arterial blood gases were registered at the beginning ( T 0 ) and at the end ( T end ) of out-of-hospital management. For all patients requiring invasive ventilation, the gradient between Pco 2 and Petco 2 was calculated for T 0 and T end , the Paco 2 − Petco 2 variation between T end and T 0 was also calculated. Results One hundred patients were included in this study (mean age, 58.4 ± 16.4 years; 57 were male). There was no variation of the mean gradient (ΔPaco 2 − Petco 2 ) during transport (8.64 ± 13.5 mm Hg at T 0 and 7.26 ± 12.94 mm Hg at T end ). Thirty-six percent of patients (n = 36) had a gradient above +10 mm Hg, and for 6% of patients (n = 4) the gradient was lower than −10 mm Hg. The Paco 2 − Petco 2 gradient was not significantly different according to the pathology, but was significantly higher in hypercapnic patients compared with hypocapnic or normocapnic patients. In patients with severe head injury, the capnia was normalized in 80% of patients at the end of the transport according to the last blood gas result. In this subgroup the ΔPaco 2 − Petco 2 ( T end − T 0 ) gradient was stable between T 0 and T end except in 20% of the patients for whom the ΔPaco 2 − Petco 2 was lower than −10 mm Hg. Fifty-four percent of critical care physicians had modified the respiratory setting after the first arterial blood gas results. Conclusions The Paco 2 cannot be estimated by the Petco 2 in the prehospital setting. There is wide variation in the gradient between Pco 2 and Petco 2 depending on patient condition, and over time, the relationship does not remain constant and thus cannot be useful in prehospital ventilation management.

Screening for extermity arterial injury with the arterial pressure index

Abstract: Certain extremity injuries presenting to the ED or Trauma Unit warrant increased suspicion for underlying arterial trauma. Such injuries include knee dislocations, displaced medial tibial plateau fractures and other displaced bicondylar fractures around the knee, open or segmental distal femoral shaft fractures, floating joints, gunshot wounds in proximity to neurovascular structures, or mangled extremities. Once the diagnosis of arterial trauma is made, a multi-disciplinary approach is warranted. The diagnostic strategies for vascular injury have undergone an evolution over the past 2 decades. One and a half percent to 4.6% of patients hospitalized with blunt extremity trauma have associated vascular compromise [Bunt TJ, Malone JM, Moody M, et al. Am J Surg 1990;160(2):226-8; Reid JD, Weigelt JA, Thal ER, et al. Arch Surg 1988;123(8):942-6; Applebaum R, Yellin AE, Weaver FA, et al. Am J Surg 1990;160(2):221-4; discussion 224-5; Dennis JW, Frykberg ER, Veldenz HC, et al. J Trauma 1998;44(2):243-52; discussion 242-3]. An efficient and effective evidence-based approach to diagnosing vascular injury is necessary, as the difficulty in diagnosis, the multiplicity of diagnostic strategies, the limited time frame in which to initiate appropriate treatment, the limb threatening complications of a missed diagnosis, and the increased awareness of health care expenditures make this entity an intimidating diagnostic challenge [Johansen K, Lynch K, Paun M, et al. J Trauma 1991;31(4):515-9; discussion 519-22; Lynch K, Johansen K. Ann Surg 1991;214(6):737-41; Walker ML, Poindexter Jr JM, Stovall I. Surg Gynecol Obstet 1990;170(2):97-105; Kendall RW, Taylor DC, Salvian AJ, et al. J Trauma 1993;35(6):875-8]. The purpose of this article is to present an evidence-based algorithm for patients who present with either arterial injury or a high-risk of arterial injury. A diagnostic algorithm will be presented, and the rationale for diagnostic interventions will be discussed in the context of current medical literature.

Optic nerve sheath diameter does not change with patient position

Abstract: Objectives Optic nerve sheath diameter (ONSD) has been proposed as a marker for increased intracranial pressure Trendelenburg's position is often used in hypotensive patients and reverse Trendelenburg's position (30° head up) is often used in head injury patients We asked if there would be any change in OSND in healthy human adults between the supine, Trendelenburg's, and reverse Trendelenburg's positions Methods Prospective case-control blinded study using consenting healthy adults Three separate investigators measured the ONSD in each eye of 10 separate volunteers in the supine, Trendelenburg's, and reverse Trendelenburg's positions with 30° angulation from the horizontal Data were analyzed using the paired t test Results In the supine position, the mean ONSD was 46 ± 071 (SD) mm in the right eye and 45 ± 056 (SD) mm in the left eye In Trendelenburg's position, the mean ONSD was 44 ± 072 (SD) mm in the right eye and 47 ± 053 (SD) mm in the left eye In reverse Trendelenburg's position, the mean ONSD was 44 ± 049 (SD) mm in the right eye and 48 ± 076 (SD) mm in the left eye There was no significant difference in OSND between positions for either eye by analysis of variance Interobserver agreement was ±1 mm in at least 90% of the subjects regardless of position Conclusion Optic nerve sheath diameter measurement by ultrasound does not significantly change with Trendelenburg's or reverse Trendelenburg's position in comparison with the supine position in healthy individuals

The use of abdominal computed tomography in older ED patients with acute abdominal pain.

Abstract: The objectives of this study were to determine the prevalence of use of abdominal computed tomography (CT) in older ED patients with acute nontraumatic abdominal pain, describe the most common diagnostic CT findings, and determine the proportion of diagnostic CT results. This was a prospective, observational, multicenter study of 337 patients 60 years or older. History was obtained prospectively; charts were reviewed for radiographic findings, dispositions, diagnoses, and clinical course, and patients were followed up at 2 weeks for additional information. The prevalence of use of abdominal CT was 37%. The most common diagnostic findings were diverticulitis (18%), bowel obstruction (18%), nephrolithiasis (10%), and gallbladder disease (10%). Eight percent of patients had findings suggestive of neoplasm. Overall, 57% of CT results were diagnostic (95% confidence interval [CI], 49%-66%), 75% (95% CI, 63%-84%) for patients requiring acute medical or surgical intervention, and 85% (95% CI, 62%-97%) for patients requiring acute surgical intervention. CT use is highly prevalent in older ED patients with acute abdominal pain. CT results are often diagnostic, especially for patients with emergent conditions.

Propofol for deep procedural sedation in the ED

Abstract: We sought to evaluate the use of propofol (2,6-diisopropylphenol) for ED procedural sedation, particularly when administered in a routine fashion for a variety of indications. Methods: This was a prospective observational study conducted in an urban teaching ED. Propofol was administered by handheld syringe and combined with fentanyl. Measurements included propofol and fentanyl dose, serial vital signs, pulse oximetry, adverse events, and patient and physician satisfaction. Results: One hundred thirty-six subjects (18 to 69 years) were enrolled. Procedures included 82 (60.3%) abscess incision and drainages and 47 (34.6%) orthopedic reductions. Adverse events occurred in 14 cases (10.3%; 95% confidence interval 5.2% to 15.4%), including hypotension in 5, hypoxemia in 7, and apnea in 5. One patient required intubation. Both patient and physician satisfaction were excellent. Conclusions: ED procedural sedation with propofol was effective and well accepted by patients and physicians. However, it produced a significant incidence of hypotension, hypoxemia, and apnea.

The prevalence of false-positive cardiac troponin I in ED patients with rhabdomyolysis

Abstract: Objective Cardiac troponin I (cTnI) is considered the most specific marker of cardiac muscle injury. We encountered several patients with rhabdomyolysis and elevated cTnI, although they did not otherwise have evidence of cardiac injury. We determined the prevalence of false-positive cTnI in emergency department (ED) patients with rhabdomyolysis. Methods We conducted a retrospective cohort study of ED patients admitted with a diagnosis of rhabdomyolysis. Patients were included in the study if they had a serum creatine kinase (CK) of 1000 U/L or greater and at least one serum cTnI determination. Patients with positive cTnI were considered true positives if they had either electrocardiography (EKG) or echocardiography abnormalities; false positives if both the EKG and the echocardiography were considered normal; or indeterminate if they did not have both an EKG and an echocardiogram. The primary outcome of the study was the prevalence of false-positive cTnI. Secondary outcomes included risk stratification by cocaine use, myoglobinuria, and renal failure and correlation of peak CK and troponin levels. Results One hundred nine patients were included in the final analysis; 55 (50%) patients had a positive cTnI. Of the 55 patients with positive cTnI, 32 (58%) were true positives, 18 (33%) were false positives, and 5 (9%) were indeterminate. The prevalence of false-positive cTnI was 17% (18/109, 95% confidence interval 0.10-0.25). There was no association between false-positive cTnI and cocaine use, renal failure, or myoglobinuria. There was poor correlation between peak CK and peak cTnI levels (r = −.08, 95% confidence interval −0.34 to 0.19). Conclusion The prevalence of false-positive cTnI in ED patients with rhabdomyolysis is 17%.

Purple urine bag syndrome

Abstract: The purple urine bag syndrome (PUBS) is a rare condition associated with chronic urinary catheterization. It is characterized by the purple discoloration of the urine, collecting bag, and tubing. A number of factors are involved, but not always present, in its development including female sex, urinary tract infection, constipation, indicanuria, and alkaline urine. Despite multiple theories that involve the complex tryptophan metabolism to the tubing dye, the cause remains elusive. The syndrome resolves usually after treatment of urinary tract infection or changing of the collecting bag. We present a case of a patient with purple urine bag syndrome and a pertinent literature review.

Can ruptured appendicitis be detected preoperatively in the ED

Abstract: Purpose: The purpose of this study is to determine which clinical symptoms/signs and computed tomography (CT) signs can help in distinguishing ruptured from simple appendicitis. Materials and Methods: The medical records and CT findings of 202 consecutive patients with surgically proven acute appendicitis were retrospectively reviewed and compared between 2 groups with and without appendiceal rupture. Results: Longer duration of symptoms (P b .001), peritoneal sign (P = .004), and higher C-reactive protein (P b.001) are significant clinical factors for predicting appendiceal rupture in acute appendicitis. Abscess, extraluminal air, wall defect, peritoneal enhancement, extraluminal appendolith, phlegmon, localized fluid, fascial thickening, ascites, stool impaction, and 4 patterns of bowel wall thickening (P b .001 to P = .047) are significant CTsigns for predicting appendiceal rupture. The appendiceal diameter is larger in patients with ruptured appendicitis than in those with simple appendicitis (13.2 F 3.2 vs 11.3 F 2.4 mm, P b.001). The appendolith size is larger in patients with ruptured appendicitis than in those with simple appendicitis (7.1 F 4.4 vs 5.1 F 2.8 mm, P = .018). Conclusion: Besides some clinical findings, CT scan can accurately determine appendiceal rupture in acute appendicitis and can further demonstrate the presence of local inflammatory mass, facilitating

Pediatric prescription pick-up rates after ED visits.

Abstract: Objective To determine the compliance rate in filling outpatient medication prescriptions written upon discharge from the emergency department (ED). Methods Emergency department records of children during a 3-month period were examined along with pharmacy claim data obtained in cooperation with the largest insurance carrier in the community (private and Medicaid). Pharmacy claim data were used to validate the prescription pick-up date. Results Overall, 65% of high-urgency prescriptions were filled. The prescription pick-up rate in the 0-to 3-year age group (75%) was significantly higher than in the rest of the cohort (55%) ( P P = .03). Conclusion This study demonstrates that filling a prescription after discharge from an ED represents a substantial barrier to medication compliance.