Showing papers in "Journal of The American College of Emergency Physicians in 1979"

Tricyclic antidepressant overdose.

Abstract: First introduced in the early 1960s, tricyclic antidepressants (TCAs) have been seen increasingly in overdoses, accounting for 10% to 20% of all cases. 1-5 This is not surprising, for amitriptyline was the 29th most frequently prescribed drug in the United States in 1974. 8 Since suicide-prone depressed patients and young children being treated for nocturnal enuresis1,2, ~ are the most common recipients of these drugs, overdoses probably will continue. These overdoses have a multiplicity of toxic effects, the most alarming of which are cardiac, 1 and a high mortality. The purpose of this article is to review current knowledge on TCA overdose and toxicity, with particular emphasis on pharmacology as the foundation of rational therapy.

Blood levels following intravenous and endotracheal epinephrine administration

Abstract: The blood levels of epinephrine and its metabolites which were obtained when the drug was given by both the intravenous (IV) and endotracheal (ET) routes were compared. Anesthetized dogs were subjected to radioactive epinephrine in doses of 0.005, 0.03, 0.06, and 0.09 mg/kg administered both intravenously and endotracheally. Blood levels were obtained at 0.25, 0.75, 1.5, 3, 5, 10 and 30 minutes following injection and analyzed by thin layer chromatography. The maximum measured concentration following IV injection was observed at 15 seconds. Epinephrine was rapidly metabolized with 20% of the original concentration detected at 5 minutes following IV injection. When the drug was given by the ET route, the maximum measured concentration was similarly observed at 15 seconds. Following ET installation, initial blood concentrations are sustained over a much longer period of time and 80% of the initial concentration was detected at 5 minutes. Maximum concentrations are approximately one-tenth of those achieved with an equal IV dosage. It is concluded that endotracheally and intravenously administered epinephrine rapidly reach maximum blood levels although there are differences in kinetics between the two routes.

Epidemiologic and Clinical Aspects of Animal Bite Injuries

Abstract: During 1975, 332 animal bite injuries accounted for 1.2% of all surgical problems treated at the UCLA Hospital Emergency Department. Data on 307 bite injuries were available and analyzed for environmental, animal, human, interaction, and clinical factors. More than half of the dog bites and almost three fourths of the cat bites-scratches happened at or near the victims' homes. Dog bites were almost twice as common among men, while cat bites-scratches were twice as common among women. Of the incidents in which ownership information was available, 85% of dog bites and 80% of cat bites-scratches were from an animal belonging to the victim, his family or friends, or another known person. Forty-three percent of dog bites, and 52% of cat bites-scratches were provoked, that is, happened while the victim was interacting with the animal. Of bites of the head and/or neck, 38% injured the upper lip; 17% of dog bites injured the eye or adjacent tissues; 48% were in children less than ten-years-old. One fifth of cat bites-scratches involved the head and/or neck, 60% of these injured orbital or periorbital tissues. Over 2% of patients were hospitalized. Five percent of dog bite victims and 29% of cat bite-scratch victims returned with complications, mostly cellulitis or lymphangitis. Pasteurella multocida was the most common pathogen cultured, as evidenced by the 50% and 80% culture-positive rates for dog and cat bite-scratches respectively in this series.

Prognostic factors in pediatric cases of drowning and near-drowning

Abstract: Ninety-three cases of drowning or near-drowning in the pediatric age group between 1972 and 1976 were reviewed. A scoring system for prognostic factors was developed using one point for each of five unfavorable factors involved in the drowning or near-drowning of each patient. The prognostic factors were 1) age less than three years; 2) maximum submersion time estimated longer than five minutes; 3) resuscitation not attempted for at least ten minutes after rescue; 4) patient in coma on admission to hospital, and 5) arterial blood pH of ≤ 7.10. This scoring system significantly predicted the eventual outcome of patients who had experienced the postsubmersion syndrome. Patients with scores of ≤ 2 had a 90% chance of full recovery; those with scores of ≥ 3 had only a 5% probability of survival. The early institution of resuscitative efforts was the single most important factor influencing survival.

Esophageal perforation secondary to alkaline battery ingestion

Abstract: A 16-month-old infant ingested an alkaline battery, 22 mm × 5 mm, which became entrapped in her esophagus. She was brought to the emergency department with a four-day history of vomiting. After tube thoracostomy, the battery was removed by esophagoscopy. However, she experienced cardiac arrest in the intensive care unit. Post mortem examination revealed exsanguination by perforation of the posterior aspect of the aortic arch as the cause of death. Microscopic examination showed liquefaction necrosis through the mucosa and submucosa of the esophagus into the upper mediastinum and right pleural space. The possible role of the alkaline center of the battery causing perforation is presented.

Asystole and its treatment: the possible role of the parasympathetic nervous system in cardiac arrest.

Abstract: Parasympathetic tone may be high during ventricular asystole because of reflex vagal stimulation from a number of sources Eight patients in cardiac arrest were treated with cardiopulmonary resuscitation All eight patients had ventricular asystole as the initial rhythm or as the result of defibrillation Six patients failed to respond to 5 cc to 20 cc of 1:10,000 epinephrine intravenously (IV) In all eight cases a regular rhythm (sinus in seven, idioventricular in one) appeared within 30 seconds of administration of the last dose of atropine (1 mg to 2 mg IV) Five patients (625%) lived 12 hours, three (375%) were discharged from the hospital These results suggest that atropine may be of value in the treatment of ventricular asystole

Spirometric evaluation of acute bronchial asthma

Abstract: Spirograms were obtained before and after emergency therapy in 85 episodes of acute bronchial asthma in 82 patients. The clinical status of all patients after emergency treatment was reevaluated 48 hours later. Patients could be divided into three groups: I) admissions; II) patients discharged but with later respiratory problems; and III) patients who were discharged and did well. The mean pre- and posttreatment one second forced expiratory volume (FEV 1.0 ) was significantly different among all three groups. FEV 1.0 ≦ 0.6 liter before treatment, or an FEV 1.0 ≦ 1.6 liter after emergency treatment, was associated with an unfavorable course. Eighty-eight percent of Group I patients (admissions) had either an initial FEV 1.0 ≦ 0.6 liter, or a posttreatment FEV 1.0 ≦ 1.6 liter. Among all patients whose initial FEV 1.0 was ≦ 0.6 liter, 80% were either admitted or had subsequent respiratory problems; 75% of all patients whose posttreatment FEV 1.0 was ≦ 1.6 liter were either admitted or developed subsequent respiratory problems. Moreover, 90% of patients who had both a pretreatment FEV 1.0 ≦ 0.6 liter and a posttreatment FEV 1.0 ≦ 1.6 liter were admitted or had subsequent significant airway obstruction. We conclude that spirometry can identify asthmatic patients who require admission or who will have significant airway obstruction within 48 hours after discharge from the emergency department.

External rotation method of shoulder dislocation reduction

Abstract: We used the external rotation method for reducing anterior shoulder dislocations on 85 consecutive patients seen in our emergency department during a one-year period. In relatively inexperienced hands, the external rotation method was successful on first attempt in 80% of cases. There were no complications attributable to the technique itself. We feel that it is a successful, easy, and atraumatic method of achieving reduction in both first occurrence and recurrent anterior shoulder dislocations.

What is an emergency? Depends on whom you ask.

Abstract: Since many patients enter the medical care system via the emergency department, the primary care aspect of emergency medicine is receiving attention. Less frequently analyzed is the attitude of emergency department staff to this primary care function. Listening to staff members, one is struck by the universality of the comment, '~Most of these people don't belong here; they are not emergencies." Like old war buddies trading stories, everyone from billing clerks to department chairmen relate a litany of abuses they have observed. Most involve patients with multiple visits for the same chronic complaint, patients requesting evaluation of ~trivial" complaints, and patients seen as bringing on their own illnesses through drug or alcohol abuse, smoking, failure to observe basic safety precautions, or failure to comply with prescribed treatment. Families, police, paramedics, and a variety of social agencies also involve the emergency department in the care of patients with chronic medical problems or even nonmedical social problems. Many emergency department personnel react to such patients with hostility either overt or covert. Predictably, this hostility can alter performance, causing emergency department personnel to be inconsiderate, unhelpful and/or incompassionate. This hostility affects the way they practice medicine and can foster errors of judgment detrimental to the patient. Even if it does not alter the care provided, this hostility can alter the manner in which it is provided, thereby changing the entire process of care. Whether perceived by the patient as overt hostility, or simply as unusual patterns of care, this attitude affects patient behavior, usually producing anger directed at the emergency department: Complaints to ombudsmen, hospital trustees, elected officials, and the media soon follow. The staff often spends longer answering these complaints than they would have spent properly caring for the patient initially. Thus, staff hostility, either overt or covert, is counterproductive. I feel the effects of such staff-patient-society hostility to bethe largest single emergency department cause of iatrogenic disease, patient complaints, and political difficulties. Similarly, the hostility house officers feel toward these patients is a major impediment to their education in the emergency department.

Endotracheal epinephrine in cardiorespiratory collapse

Abstract: The endotracheal route for the administration of epinephrine has been studied extensively in dogs There has been little in the medical literature to document the successful use of this technique in humans The successful use of endotracheally administered epinephrine in two patients with cardiorespiratory collapse is reported Specific points concerning endotracheal drugs are discussed and a set of guidelines for clinical use is offered

Follow-up of 514 consecutive patients with cardiopulmonary arrest outside the hospital

Abstract: During the years 1974 to 1976, 514 patients with prehospital cardiopulmonary arrest were brought to the Hennepin County Medical Center (HCMC) Emergency Department. Of these, 344 patients (67%) were either dead on arrival or died in the emergency department despite efforts at resuscitation. The remaining 170 patients were admitted to the coronary care unit. Eighty-seven patients (51%) died in the coronary care unit, primarily from uncontrolled rhythm disturbances and/or cardiogenic shock. The remaining 83 patients (16% of the total group, 49% of those admitted to the hospital) were discharged alive from HCMC. In this group, 49 patients of the 83 long-term survivors were ambulatory with full mental function when discharged. The remaining 34 patients were transferred to chronic care facilities for medical treatment of on-going problems. Of the 49 ambulatory patients, satisfactory data for follow-up was obtained on 47. Their mortality rate was 15% in the first year and 50% in the second, primarily from sudden death syndrome.

Endotracheal epinephrine in a canine anaphylactic shock model

Abstract: This study was undertaken to determine if epinephrine administered endotracheally is as effective in treating anaphylactic shock as is intravenously administered epinephrine. An animal model of anaphylactic shock was produced in anesthetized dogs by the intravenous administration of histamine phosphate. Both the endotracheal and intravenous routes of epinephrine administration resulted in efficient and effective reversal of histamine-induced hypotension. At the doses employed, the intravenous administration of epinephrine resulted in the production of significantly (p

Intravenous glucagon in the management of esophageal food obstruction.

Abstract: The use of intravenous glucagon in patients with obstructing esophageal food impaction of at least 24-hours duration has recently been described. Two cases of acute esophageal obstruction were relieved within ten minutes by intravenous infusion of 1 mg of glucagon. Esophagram performed both before and after glucagon administration confirmed the original obstruction and the passage of the food bolus. Therapy for bolus obstruction of the esophagus has classically included proteolytic enzyme digestion, as well as esophagoscopy with manual extraction. Each entails risk of esophageal perforation and mediastinitis. Also, the dose of proteolytic enzymes, such as papain, may take several hours to administer while endoscopic examination is generally not feasible as an outpatient emergency procedure. Intravenous glucagon can dissolve food other than meat and has the further advantage of safety in the patient in which anticholinergics, another occasionally employed therapy, are contraindicated. A protocol for management of these patients is included.

Epidemiology of cardiac arrest and resuscitation in a suburban community

Abstract: A surveillance system identified all out-of-hospital victims of cardiac arrests who received emergency aid in King County, Washington, as well as the etiologic condition and cardiac rhythm causing each arrest. During an 18-month period, 649 cardiac arrests occurred (annual incidence 7.2/10,000). Primary heart disease was the cause in 81%. Ventricular fibrillation was the associated rhythm in 57% of cardiac arrests. Based upon the incidence of cardiac arrest in the community and the likelihood of resuscitation under optimal conditions, we estimate the maximum incidence of lives saved to be 2.0/10,000 annually.

An injury severity scale for comprehensive management of central nervous system trauma

Abstract: The Glasgow Coma Scale (GCS) is used in central Virginia by emergency medical technicians (EMTs), emergency department personnel and neurosurgical staff to evaluate patients with central nervous system (CNS) trauma. In a series of 406 patients admitted to the neurosurgical services at the University of Virginia Hospital between October 1977 and February 1978, a GCS score was recorded by the neurosurgeon, nurse, and EMT. All 250 data points, including clinical diagnosis and incidence of associated injuries were entered into our information system analysis. The scale can be easily mastered by all members of the emergency medical team giving reproducible results. It also appears to be a valid predictor of the ultimate outcomes of head injury. The GCS has substantial clinical value in the management of the neurotrauma patient. It is presently being employed in all phases of the emergency medical system to monitor the progression of the neurologic injury. Ultimately, this injury severity scoring system will be used to standardize patient populations in well controlled clinical studies in which different treatment parameters will be assessed.

Transient ST elevation associated with tension pneumothorax.

Abstract: In a 52-year-old man, a spontaneous right tension pneumothorax was associatedwith transient bradycardia, hypotension and electrocardiogram (ECG) changes consisting of precordial ST elevation suggestive of acute myocardial injury. Immediately after chest tube placement, the ECG reverted to near normal. Serial cardiac enzymes and isoenzymes showed no evidence of myocardial infarction. To our knowledge, this is the first reported case of this association. The ECG changes may be related to the hypotensive state induced by the tension pneumothorax with resulting decreased coronary artery blood flow and myocardial ischemia that resolved without infarction.

Comparative evaluation of the effect of a high yield criteria list upon skull radiography

Abstract: Based on results of studies using high yield criteria to determine the need for skull radiography, the Utilization Review Committee of the University Hospital (UH), University of Washington, Seattle implemented a policy encouraging use of the criteria in ordering skull radiology. The Bureau of Radiologic Health of the FDA supported a project comparing skull radiology use patterns at UH, with the high yield criteria policy, and Harborview Medical Center (HMC), without a policy. Results showed an increase of around 60% at HMC since the 1972–73 academic year. At UH, there was a decrease of 40% since the 1972–73 academic year. At HMC a medical record review showed only 51 positive reports that significantly contributed to patient care, about the same rate observed in 1967. At the UH, only nine positive reports significantly contributed to patient care, with 62% compliance with the high yield criteria. A current demonstration project under the auspices of the Washington State Professional Standards Review Organization and Bureau of Radiologic Health involves implementing the high yield criteria list at both HMC and UH. After three months, out of 6,003 patient visits, skull radiography was deemed necessary in 518 cases. Of this total 181 had high yield criteria checked. There were 37 positive reports out of these and 23 examinations that made a documented significant contribution to patient care. In the group without high yield criteria, 434 cases, there were 22 positive reports but no significant contribution to patient care documented after four weeks.

Phenazopyridine hydrochloride toxicity: a cause of drug-induced methemoglobinemia.

Abstract: Phenazopyridine hydrochloride, an azo dye, has been used as a genitourinary antiseptic and analgesic since the late 1920s. Despite its widespread use, alone and in combination (Table 1), there have been few reports of toxicity. Only two cases have been reported in which phenazopyridine was ingested with suicidal intent.I, 2 Seven cases of acute accidental ingestion 3-9 and nine cases of chronic overdose, often in patients with renal impairment, have also been reported. 7,1°-15 Of the seven acute accidental ingestions, five were in chilclren three years of age or less (Table 2). In addition, a phenazopyridine-induced hypersensitivity hepatitis has been noted in four other patients, l~-~s No deaths directly attributable to phenazopyridine toxicity have occurred, although Alano and Webster 7 described an elderly patient who died from pulmonary embolism while being treated for accidental phenazopyridine overdose.

Pneumomediastinum following the Heimlich maneuver

Abstract: The Heimlich maneuver appears to be a widely accepted technique advocated as a means of clearing an obstructed airway. Reports of complications have been few. We report a case of pneumomediastinum that occurred following the generation of increased pulmonary pressures during performance of the Heimlich maneuver.

The observation-holding area; a prospective study.

Abstract: Although emergency department observation-holding units have been shown to be effective in limiting hospitalizations and improving the accuracy of disposition, the possibility of adverse outcome following discharge from such units has not been addressed. To establish the safety of the unit, a five-month prospective study of all patients admitted to this area was carried out and included long-term follow-up. There were 442 patients admitted. Of these, 78% were discharged improved. Complications in the unit were minimal and there were no deaths. Long-term follow-up revealed four deaths (1%) and four patients (1%) who had complicated hospitalizations. Diagnosis, age, patient condition, and time of admission to the unit were predictive of the need for inpatient hospitalization. We conclude that the observation-holding unit, with appropriate supervision, represents a safe alternative disposition for selected emergency patients.

Emergency management of acute phencyclidine intoxication

Abstract: Phencyclidine (PCP) is a potent sympathomimetic and hallucinogenic dissociative anesthetic agent. As an abused street drug, it is most often smoked, thus allowing the user to titrate the dose. The clinical signs of PCP intoxication can be viewed in three dose-related stages, but waxing and waning of signs through the three stages is not uncommon. Treatment protocols for each stage address drug therapy and both clinical and psychological supportive measures.

Acute chlorine gas exposure.

Abstract: The heavy use of chlorine gas in industry and water purification poses the constant threat of mass gas exposure. In a recent experience with a chlorine gas disaster involving over 100 patients, 64, including six subsequently requiring admission, were treated in the main emergency unit facility. The remainder were triaged to a safe area away from the emergency unit with instructions for symptomatic treatment. Injuries were limited to four organ systems: pulmonary, gastrointestinal, ophthalmic, and cutaneous. Current treatment methods are compared with those in the literature and a protocol for management provided.

Self-administered nitrous oxide: an adjunct analgesic.

Abstract: In a pilot study of 26 patients, a mixture of 50% nitrous oxide and 50% oxygen (N 2 O-O 2 ) appeared to be an effective and safe analgesic for the incision and drainage of closed-space infections. The analgesic effect of N 2 O-O 2 , as measured by a Mean Analgesic Index, is augmented by both amnesic and dissociative effects, ie, patients remembered experiencing significantly less pain than they complained of during the procedure (p 2 O-O 2 and made uniformly favorable comparative statements concerning the analgesic effect of the gas.

Treatment of drug-induced dystonic reactions

Abstract: Thirty-two cases of drug-induced dystonic reaction were treated by the author with diphenhydramine or benztropine mesylate, intramuscularly or intravenously, in a prospective, nonrandomized fashion. Recovery time with the two drugs was compared. Benztropine mesylate lessened recovery time in this case series. An epidemiological study of drug-induced dystonic reactions found that most of the patients were drug abusers. The commonest offensive agent in this case series was haloperidol. The most common dystonic reactions seen were buccolingual and torticollic.

Ketamine dissociative anesthesia — Emergency department use in children

Abstract: An on-going study to determine the efficacy and safety of ketamine dissociative anesthesia in the emergency department for children less than 10 years of age is presented. Preliminary results of the first 30 cases indicate that this technique may be safe and convenient if used within the appropriate protocol.

CPK-MB isoenzyme determinations in blunt chest trauma

Abstract: To identify the most sensitive screening test for cardiac contusions, a series of 35 patients with blunt chest trauma was evaluated with serial electrocardiograms (ECGs), creatine phosphokinase isoenzymes, and serum enzymes (serum glutamic-oxaloacetic transaminase, lactic dehydrogenase, and creatine phosphokinase). Twenty of the 35 patients had diagnoses of cardiac contusions by ECG. Three with contusions developed complications. Although isoenzyme elevation was present in most patients sustaining blunt chest trauma, no complications of the injury were seen in patients with elevated enzymes and normal ECGs. The ease of obtaining ECGs and their reliability in identifying patients who will have complications make it the best screening procedure for the diagnosis of cardiac contusions.

Metabolic acidosis with pneumatic trousers in hypovolemic dogs

Abstract: To evaluate the possibility of anaerobic metabolism occurring beneath pneumatic trousers because of the decreased circulation, 20 mongrel dogs were evaluated for central and femoral vein levels of lactic acid, potassium and central pH changes when the trouser pressure was both above and below systolic arterial pressure. The results indicate that if the systolic pressure is less than trouser pressure, there is a significant increase in both potassium and lactic acid levels. There was a drop in the central pH accompanying these metabolic changes. When the pneumatic trouser pressure was less than systolic arterial pressure, changes in anaerobic metabolism were present but not nearly as great. This change was much closer to that in the central circulation and may result from other factors. Based on these results, trouser inflation pressure should not exceed that required to achieve adequate arterial pressure. Deflation should be started as soon as possible and be gradual.