American Journal of Emergency Medicine

Impact of procalcitonin on the management of children aged 1 to 36 months presenting with fever without source: A randomized controlled trial

2009-11-23

Abstract: Objective: The aim of the study was to evaluate the impact of procalcitonin (PCT) measurement on antibiotic use in children with fever without source.Method: Children aged 1 to 36 months presenting to a pediatric emergency department (ED) with fever and no identified source of infection were eligible to be included in a randomized controlled trial. Patients were randomly assigned to 1 of 2 groups as follows: PCT+ (result revealed to the attending physician) and PCT− (result not revealed). Patients from both groups also had complete blood count, blood culture, urine analysis, and culture performed. Chest radiography or lumbar puncture could be performed if required.Results: Of the 384 children enrolled and equally randomized into the PCT+ and PCT− groups, 62 (16%) were diagnosed with a serious bacterial infection (urinary tract infection, pneumonia, occult bacteremia, or bacterial meningitis) by primary ED investigation. Ten were also found to be neutropenic (<500 × 106/L). Of the remaining undiagnosed patients, 14 (9%) of 158 received antibiotics in the PCT+ group vs 16 (10%) of 154 in the PCT− group (Δ −2%; 95% confidence interval [CI], −8 to 5). A strategy to treat all patients with PCT of 0.5 ng/mL or greater with prophylactic antibiotic in this group of patients would have resulted in an increase in antibiotic use by 24% (95% CI, 15-33).Conclusion: Semiquantitative PCT measurement had no impact on antibiotic use in children aged 1 to 36 months who presented with fever without source. However, a strategy to use prophylactic antibiotics in all patients with abnormal PCT results would have resulted in an increase use of antibiotics.

Effectiveness of mouth-to-mouth ventilation after video self-instruction training in laypersons

2010-02-08

Abstract: Background: Mouth-to-mouth ventilation is a skill taught in cardiopulmonary resuscitation (CPR) training for laypersons. However, its effectiveness is questioned. Our aim was to determine the effectiveness of mouth-to-mouth ventilation training using a self-instruction CPR training video for laypersons.Methods: Video-self-instruction CPR training was conducted with CPR Anytime (American Heart Association [AHA] & Laerdal Corporation) for laypersons who had not received CPR training during the recent 5 years. Immediately before, immediately after, and 8 weeks after the CPR training, an AHA basic life support instructor carried out a skill performance test using a standardized checklist. Also, 8 weeks after the training, a skill test concerning chest compression and mouth-to-mouth ventilation was conducted using a trained reporter.Results: Cardiopulmonary resuscitation training of 84 laypersons was conducted. The mean performance score (from 0 to 2) for mouth-to-mouth ventilation was 0.24 right before the training, 1.58 right after the training, and 0.95 eight weeks after the training. The mean performance scores for chest compression were 0.13, 1.79, and 1.40, right before, right after, and 8 weeks after the CPR training, respectively. The rates of successful mouth-to-mouth ventilation and compression were 11.9%, and 39.1%, respectively.Conclusions: The effectiveness and short-term retention rate of mouth-to-mouth ventilation after video self-instruction CPR training in laypersons was significantly lower than for chest compressions.

Impact of renal dysfunction on acute coronary syndrome evaluation in observation unit patients

Alexander T. Limkakeng, Abhinav Chandra — 2009-11-30

Abstract: Objectives: The impact of renal disease on risk stratification of patients at low risk for potential acute coronary syndrome has not been well defined. The objective of this study was to document the prevalence of renal dysfunction and assess the association between renal impairment and abnormal cardiac evaluation in observation unit (OU) patients.Methods: Retrospective cohort study at an academic medical center OU. Data were abstracted using predetermined definitions of data outcomes by trained abstractors. Patients had symptoms consistent with acute coronary syndrome and did not have obvious evidence of acute MI or ischemia on electrocardiogram, unstable vital signs, abnormal cardiac markers, serious arrhythmias, or uncontrollable chest pain. Observation patients received serial cardiac markers and electrocardiograms, with the majority receiving stress testing at treating physician discretion. Patients were stratified by glomerular filtration rates (GFR) at cut-off points of less than 60 and less than 90 mL/min per 1.73 m2. Odds ratios were calculated for stress test findings of inducible ischemia or hospital admission.Results: Five hundred and twenty-nine out of 545 patients had complete data and were enrolled. Sixty-nine (13%) patients had a GFR of less than 60 and 300 (56%) patients had a GFR of less than 90. An abnormal cardiac evaluation was found in 64 (12%) patients, of whom 31 (49%) had some renal impairment. The odds ratio of an abnormal cardiac evaluation with a GFR of less than 90 is 1.65 (95% confidence interval, 0.95-2.88) and 1.65 (95% confidence interval, 0.83-3.28) for GFR less than 60.Conclusions: Renal dysfunction is common in OU patients. In these patients, renal dysfunction did not confer higher risk for abnormal cardiac evaluation.

Circadian, day-of-week, and age patterns of the occurrence of acute coronary syndrome in Beijing's emergency medical services system

2010-03-26

Abstract: Background: Previous in-hospital studies suggest that there are significant circadian rhythms associated with the incidence of acute coronary syndromes (ACSs). No study to date has examined the presentation of ACS in the prehospital setting. Our goal was to examine circadian, day-of-week, and age patterns of occurrence in ACS in a large, urban emergency medical services (EMS) system.Methods: We retrospectively reviewed the electronic prehospital medical records from the Beijing's EMS system spanning August 1, 2005, to July 31, 2007. Data were analyzed by hour of the day and day of the week. χ2 tests were performed to compare the difference.Results: Seven thousand thirty-two cases of ACS were identified by the EMS system physicians during the 2-year study period, including 536 cases of acute myocardial infarction. A significant variation of circadian distribution of ACS was observed in both 24-hour (P < .001) and 2-hour (P < .001) interval time course. Two peaks were observed in the morning from 0800 to 1000 and approaching midnight from 2200 to 2400. Increases of 50% and 60.8% in the morning and evening peaks were found, respectively, when compared with the early morning baseline (nadir). No significant difference was found among the accumulated cases in 2 years on each day in a week (P = .203).Conclusions: Our study shows that, in the Beijing metropolitan area, the presentation of ACS has significant circadian rhythm characterized by 2 peaks within 24 hours, the morning peak is 0800 to 1000, and the late evening peak is 2200 to 2400. No significant weekly rhythm was observed in the present study.

Rapid treatment reduces hospitalization for pediatric patients with odontogenic-based cellulitis

2010-04-05

Abstract: Purpose: The study aimed to assess characteristics of facial cellulitis admissions and their relationship to cost of hospitalization (COH) and length of stay (LOS) in children ages 0 to 20 years at an urban hospital and to compare outcomes of rapid management to published and national statistics for LOS and COH.Methods: A retrospective review of 376 charts of facial cellulitis admissions between 2000 and 2006 revealed 63 of confirmed odontogenic cases from which cellulitis characteristics, COH, and LOS were gleaned. Variables were correlated to LOS and COH. Data on LOS and cost of admission were compared to published studies and 506 entries from the 2006 Kids' Inpatient Database (KID).Results: Of 63 charts included, children included were 8.3 years (SD, ±3.8 years) and equal in sex distribution. Treatment rendered and site of infection had no significant relationship to COH. Overall mean hospital LOS was 2.08 days and significantly less as compared to 3.97 days for published studies and 3.4 days for KID (P < .0001). The mean overall hospital COH was $4166 and significantly less compared to $3223 in the literature and $8998.43 for KID.Conclusion: In the management of pediatric facial cellulitis of odontogenic origin, rapid treatment had a significant positive impact on length of stay and total cost of treatment compared to published studies and nationally reflective data.

Probability of survival, early critical care process, and resource use in trauma patients

2010-02-08

Abstract: Background: Trauma Injury Severity Score is a frequently used prediction model for mortality. However, few studies have assessed the probability of survival (Ps) and early resource use after trauma. We studied the impact of Ps on early critical care or costs to test its applicability to efficient trauma care.Methods: The relationship between Ps in 8207 trauma patients and patients' demographics, organ injured, comorbidities, use of critical care, and total charges during the initial 48 hours was analyzed using multiple regression analyses.Results: Significant differences were observed among study variables across different Ps. A large variability in total charges was observed and explained by critical care, which Ps was significantly associated with.Conclusions: Trauma Injury Severity Score offers a tool for estimating resource use and might improve monitoring of early trauma care quality. Measuring the combined effect of Trauma Injury Severity Score and injured organs would refine the methodology for evaluating the trauma care system.

The effect of an observation unit on the rate of ED admission and discharge for pyelonephritis

Jon W. Schrock, Svetlana Reznikova, Suki Weller — 2009-07-16

Abstract: Objectives: We sought to determine if the opening of an adult emergency department (ED) observation unit (OU) would impact the rate of hospital admission and ED discharges for pyelonephritis.Methods: A retrospective cohort study was performed with all adult patients from October 2003 through December 2006 in the ED meeting inclusion criteria for pyelonephritis. Clinical, demographic, and laboratory data were recorded. Primary outcomes were rates of admission, ED discharge, and return ED visits before and after the opening of our OU. We compared admission, discharge, and readmission rates using the χ2 test.Results: Nine hundred thirty charts were reviewed with 633 included for analysis. Urine cultures were performed on 420 subjects with 71% being positive. The percentage of patients admitted to a hospital inpatient unit from the ED decreased from 36% to 26% (relative risk [RR], 0.73; P = .01) after opening the OU. The percentage of patients discharged home from the ED decreased from 65% to 51% (RR, 0.76; P < .001). Among OU patients, 29% were admitted to the hospital for further inpatient care. Emergency department recidivism was unchanged by opening the OU (RR, 0.86; P = .68).Conclusions: The creation of an OU appears to influence admission decisions of ED physicians. We found that the creation of an OU significantly reduced hospital admissions for pyelonephritis but also significantly reduced ED discharges to home for pyelonephritis at our institution.

Evaluation of a modified early goal-directed therapy protocol

Colleen A. Crowe, Chintan D. Mistry, Kathleen Rzechula, Christine E. Kulstad — 2010-02-08

Abstract: Objectives: The study aimed to determine mortality in septic patients 2 years after introduction of a modified early goal-directed therapy (EGDT) protocol and to measure compliance with the protocol.Design: This was an observational study of prospectively identified patients treated with EGDT in our emergency department (ED) from May 2007 through May 2008 and compared with retrospectively obtained data on patients treated before protocol implementation, from May 2004 to May 2005.Setting: This study was conducted at a large tertiary-care suburban community hospital with more than 85 000 ED visits annually and 700 inpatient beds.Patients: Patients with severe sepsis or septic shock were included in the study.Interventions: A modified EGDT protocol was implemented.Measurements and Main Results: A total of 216 patients were treated with our EGDT protocol, with 32.9% mortality (95% confidence interval [CI], 26.6%-39.2%); 183 patients (84.7%) had septic shock, with a mortality of 34.4% (95% CI, 28%-41%). Our control group of 205 patients had a 27.3% mortality (95% CI, 21.2%-33.5%), of which 123 had septic shock with a mortality of 43.1% (95% CI, 34%-52%). Early goal-directed therapy protocol compliance was as follows: 99% received adequate intravenous fluids, 99% had a central line, 98% had antibiotics in the first 6 hours, 28% had central oxygen saturation measured, 3.7% received dobutamine, and 19% were transfused blood.Conclusions: Although we found a trend toward decreased mortality in patients with septic shock treated with EGDT, with an absolute difference of 8.7%, this difference was not statistically significant. Compliance with individual elements of the protocol was variable.

ED triage of patients with acute myocardial infarction: predictors of low acuity triage

Clare L. Atzema, Peter C. Austin, Jack V. Tu, Michael J. Schull — 2010-03-26

Abstract: Objective: Virtually all emergency department (ED) patients receive an ED triage assessment that determines their priority to be seen by a physician. Previous research found that half of patients who are having an acute myocardial infarction (AMI) are given a low priority triage score, which is associated with delays in electrocardiogram (ECG) acquisition and reperfusion therapy. We sought to determine some of the reasons why ED triage is failing in these patients.Methods: We conducted a retrospective cohort analysis of a population-based cohort of AMI patients admitted to 102 acute care hospitals in Ontario, Canada, from July 2000 to March 2001. We examined 10 potential patient- and hospital-level predictors of low acuity triage: age, sex, number of comorbidities, arrival mode, socioeconomic status, time of day, day of week, ED AMI volume, hospital type, and department use of triage ECGs.Results: Mean age of the 3088 patients was 67.5 (SD, 14.0), and 65% were men. In adjusted quantile regression analyses, low acuity triage was independently associated with ED AMI volume (odds ratio [OR], 0.44 at very high volume centers), arrival mode (OR, 0.60 for ambulance arrival), sex (OR, 0.80 for males), age (OR, 1.1 per 10 years of age), and a low number of comorbidities (OR, 0.92 for every cardiac co-morbidity).Conclusions: Low acuity ED triage of AMI patients may be predicted by several patient- and hospital-level characteristics. Focusing future interventions on these factors may improve ED triage and, subsequently, time to initial ECG and reperfusion, in this patient group.

Relationship between abnormal pupillary reactivity and the outcome of a psychotropic drug overdose

Youichi Yanagawa, Masaki Miyazaki, Toshihisa Sakamoto — 2010-03-26

Abstract: Objective: The association between abnormal pupil reactivity (abnormal) and the outcome among patients with psychotropic drug overdose (OD) was retrospectively investigated.Methods: The study included patients that had experienced an OD between January and December 2007. The subjects were divided into 2 groups, namely, abnormal and normal groups.Results: There were 12 subjects in the abnormal and 74 subjects in the normal group. Glasgow Coma Scale in the abnormal was significantly smaller that that in the normal group. An average quantity of ingested tranquilizer per subject in the abnormal was significantly larger that those in the normal group. However, the duration of admission and survival rates between the two groups were not significantly different.Conclusion: The patients that experienced an OD, who demonstrated abnormal pupil reactivity, tended to have ingested larger amounts of drugs while also demonstrating severe unconsciousness. However, the patients with abnormal pupil reactivity had a favorable outcome.

Postural hypotension as the initial presentation of fulminant right ventricular myocarditis

Cheng-Hsuan Ho, Ya-Chieh Wu, Yen-Yue Lin, Chin-Wang Hsu, Shih-Hung Tsai — 2009-07-16

Abstract: Myocarditis can be totally asymptomatic or can manifest with chest pain syndromes, ranging from mild persistent chest pain of acute myopericarditis to severe symptoms that mimic acute myocardial infarction. About 60% of patients may have antecedent arthralgias, malaise, fevers, sweats, or chills consistent with viral infections 1 to 2 weeks before onset. Here, we report a postpartum young woman who developed postural hypotension as the first manifestation of fulminant myocarditis with initially acute “cold and dry” right-sided heart failure and cardiogenic shock. Common causes of postural hypotension include volume depletion, medications, diabetes, alcohol, infection, and varicose veins as well as dysautonomic syndromes. Fulminant myocarditis can cause cardiogenic shock. Myocardial inflammation more frequently affects localized areas of the left ventricle free wall, rarely right ventricle (RV). However, predominant RV involvement with acute right-sided heart failure and low cardiac output syndrome can be easily overlooked due to lack of typical heart failure signs. On reviewing medical literatures, we had found no report regarding the RV involvement with acute right-sided heart failure as the initial presentation of fulminant myocarditis.

Concordance between capnography and capnia in adults admitted for acute dyspnea in an ED

2010-03-26

Abstract: Background: End-tidal carbon dioxide pressure (etCO2) is widely used in anaesthesia and critical care in intubated patients. The aim of our preliminary study was to evaluate the feasibility of a simple device to predict capnia in spontaneously breathing patients in an emergency department (ED).Patients and methods: This study was a prospective, nonblind study performed in our teaching hospital ED. We included nonintubated patients with dyspnea (≥18 years) requiring measurement of arterial blood gases, as ordered by the emergency physician in charge. There were no exclusion criteria. End-tidal CO2 was measured by an easy-to-use device connected to a microstream capnometer, which gave a continuous measurement and graphical display of the etCO2 level of a patient's exhaled breath.Results: A total of 43 patients (48 measurements) were included, and the majority had pneumonia (n = 12), acute cardiac failure (n = 8), asthma (n = 7), or chronic obstructive pulmonary disease exacerbation (n = 6). Using simple linear regression, the correlation between etCO2 and Paco2 was good (R = 0.82). However, 18 measurements (38%) had a difference between etCO2 and Paco2 of 10 mm Hg or more. The mean difference between the Paco2 and etCO2 levels was 8 mm Hg. Using the Bland and Altman matrix, the limits of agreement were −10 to +26 mm Hg.Conclusion: In our preliminary study, etCO2 using a microstream method does not seem to accurately predict Paco2 in patients presenting to an ED for acute dyspnea.

Monday preference in onset of takotsubo cardiomyopathy

2010-02-26

Abstract: Objective: Acute cardiovascular events show definite temporal patterns of occurrence. Takotsubo cardiomyopathy (TTC) has been recently shown to exhibit a seasonal (summer) and circadian (morning) temporal distribution. The aim of this study, based on the database of a multicenter Italian network, was to investigate the possible existence of a weekly pattern of onset of TTC.Methods: The study included all cases of TTC admitted to the coronary care unit of 8 referral cardiac centers in Italy (five in Southern Italy and three in Northern Italy, respectively), belonging to the Takotsubo Italian Network (January 2002-December 2008). Day of admission was categorized into seven 1-day intervals according by week, and chronobiological analysis was performed by partial Fourier series.Results: The database included 112 patients with TTC (92.9% females). The weekly distribution identified the highest number of cases on Monday and the lowest on Saturday. Chronobiologic analysis yielded a rhythmic pattern with a significant peak on Monday (P = .036).Conclusions: This study confirms a Monday preference for TTC occurrence on Monday, similar to that reported for acute myocardial infarction. Stress of starting weekly day life activities, could play a triggering role.

Phloroglucinol as an adjuvant analgesic to treat renal colic

2010-05-03

Abstract: Purpose: We tested whether the addition of phloroglucinol to piroxicam could improve pain relief in patients with acute renal colic visiting the emergency department.Materials and Methods: Patients with a diagnosis of acute renal colic were prospectively randomized to receive intravenous phloroglucinol (200 mg) or placebo combined with intramuscular piroxicam (20 mg). We monitored the visual analogic scale (VAS), heart rate, arterial blood pressure, need for rescue therapy, and adverse events at different time points for 1 hour. We recorded admission requirement and new visit at 72 hours for renal colic. The primary end point was to assess pain relief at 1 hour, defined as a decrease of 50% or more as compared with the initial VAS. The secondary objectives were to compare the 2 groups for VAS at any time points, the need for rescue therapy, and the occurrence of adverse events.Results: Of the 309 eligible patients, 253 entered the study. A total of 126 patients received phloroglucinol and 127 patients received placebo. Pain relief at 1 hour was obtained in 89 patients (71%) receiving phloroglucinol and 89 patients (70%) receiving placebo (P = .89). There were no differences in VAS between the 2 groups at any time points. Rescue therapy was required in 37 patients (29%) receiving phloroglucinol and 38 patients (30%) receiving placebo (P = .51). Number of adverse events was similar with phloroglucinol and placebo: 20 (16%) and 16 (13%), respectively (P = .44).Conclusions: There was no evidence that the addition of phloroglucinol improved the efficiency of piroxicam to relieve pain in acute renal colic.

Are 2 smaller intravenous catheters as good as 1 larger intravenous catheter?

2010-03-26

Abstract: Objective: Using Poiseuille's law and standardized gauge sizes, an 18-gauge (g) intravenous catheter (IV) should be 2.5 times faster than a 20-g IV, but this is not borne out by observation, in vitro testing, and manufacturer's data. Our objective was to determine if the infusion rate of a single 18-g IV was equivalent to the infusion rate of two 20-g IVs.Methods: This was a prospective study in healthy adult volunteers. Subjects simultaneously received 500 mL of normal saline via an 18-g IV in one arm and 500 mL of normal saline via two 20-g IVs in the other arm. We measured the rates of fluid administration. Paired Student's t test was used for comparison of the 2 arms of the study. We estimated that 18 trials were needed in sample size analysis.Results: Eighteen trials were completed. The mean infusion rate for a single 18-g 500-mL IV administration was 35.6 mL/min (95% confidence interval [CI], 30.3-40.8), with manufacturer's rating being 105 mL/min. The mean infusion rate for two 20-g IVs was 41.3 mL/min (95% CI, 36.1-46.4), with manufacturer's rating being 120 mL/min. The rate of infusion via two 20-g IVs were statistically significantly faster than the single 18-g IV, with a mean difference in flow rate of 5.7 mL/min (95% CI, 1.3-10; P = .026).Conclusion: In healthy volunteers, administration of intravenous fluids through two 20-g IVs is faster than a single 18-g IV, although both approaches are markedly slower than the manufacturer's estimates.

Spectrum of corrosive esophageal injury after intentional paraquat ingestion

2010-02-26

Abstract: Introduction: This is an observational study that examines the clinical features, the degrees of esophageal injury, physiological markers, and clinical outcomes after paraquat ingestion and seeks to determine what association, if any, may exist between these findings.Methods: The study included 16 of 1410 paraquat subjects who underwent endoscopies at Chang Gung Memorial Hospital between 1980 and 2007.Results: Corrosive esophageal injuries were classified as grade 1 in 8, 2a in 5, and 2b in 3 patients. No patients had grade 0, 3a, or 3b esophageal injuries. After paraquat ingestion, systemic toxicity occurred, with rapid development of hypoxia, hepatitis, and renal failure in many cases. Hypoxia occurred in 1 (12.5%), 5 (100%), and 3 (100%) patients with grades 1, 2a, and 2b esophageal injury, respectively. There were more hypoxic patients with grades 2a and 2b than those with grade 1 esophageal injury (P < .05). The nadir Pao2 was lower in patients with grades 2a and 2b than those with grade 1 esophageal injury (P < .05). However, there were no significant differences in terms of acute hepatitis, peak serum alanine aminotransferase, acute renal failure, and peak serum creatinine between the 3 groups (P > .05). Kaplan-Meier analysis did not find any difference in survival between the groups (P > .05).Conclusion: Paraquat, a mild caustic agent, produces only grades 1, 2a, and 2b esophageal injury. Our findings showed a potential relationship between the degree of hypoxia, mortality, and degree of esophageal injury, although such a low number of study subjects limits the conclusions that can be made by this study.

An initial analysis: working hours and delay in seeking care during acute coronary events

2010-03-29

Abstract: Background: The purpose of the study was to examine the association between working hours, job strain, and duration of prehospital delay in seeking care by employed patients with acute coronary syndrome (ACS) in the United States and Japan.Design and Subjects: In this cross-sectional study, a total of 234 consecutive patients (Americans, n = 148; mean age, 50.7 [SD ± 7.1] years and 73.6% male, and Japanese, n = 86; mean age, 56.3 [SD ± 11.0] years and 93.0% male) admitted with ACS who worked more than 20 h/wk were recruited. A structured interview was conducted while patients were hospitalized to assess prehospital delay time, ambulance use, number of working hours per week, and job strain.Results: In the US sample, the median delay time was 4.4 hours, whereas in the Japanese sample, the median delay time was 8.3 hours. Average working hours per week in the US and Japanese samples were 49.7 (SD ± 13.2) hours and 55.1 (SD ± 19.5) hours, respectively. In multivariate analysis, the interaction between working hours and nationality on log-transformed delay time was significant (P = .001) after controlling for potential confounding factors. Among the Japanese sample, for every 1-hour increase in working hours per week, prehospital delay increased by approximately 4% (95% confidence interval [CI]; 1.0%-7% [P = .003]). However, among the US sample, no association was found (−2.0%; 95% CI, −4.0% to 0%; P = .08).Conclusions: These findings support the need for worksite educational programs, particularly in Japan, that encourage a rapid response to acute cardiac symptoms.

Airway scope vs Macintosh laryngoscope during chest compressions on a fresh cadaver model

Junho Cho, Hyun Soo Chung, Sung Pil Chung, Young-Min Kim, Young Soon Cho — 2010-03-11

Abstract: Purposes: This study compared the Airway scope (AWS) to the Macintosh laryngoscope (ML) during chest compressions on a fresh cadaver.Methods: This was a prospective crossover study. The participants who had experiences with AWS were excluded. The participants intubated with randomly assigned AWS or ML on a fresh cadaver during chest compressions. Primary outcome were as follows: time to intubation, ease of intubation (rated by using the visual analog scale [VAS]), and intubation success rate.Results: Twenty-five were enrolled. Median time of intubation was similar between the AWS and ML (AWS, 18.5 seconds vs ML, 18.3 seconds; P = .112). The median VAS of AWS and ML were 3.0 and 2.0, respectively (P = .023). There was no failure of intubation. However, participants replied that the AWS was more difficult to use than the ML.Conclusion: Considering the lack of experience with the AWS, AWS could be an alternative intubation device during chest compressions after practices with AWS.

An unusual case of bilateral anterior shoulder and mandible dislocations

2010-04-05

Unilateral anterior shoulder dislocation is the most common major joint dislocation seen by emergency physicians. Bilateral glenohumeral dislocations are rarely seen and almost always posterior after seizure or electrical shock. We present an unusual case of bilateral anterior dislocation of shoulder that had anterior dislocation of temporomandibular joint simultaneously. These problems occurred after a course of generalized tonic-clonic seizure. The coincidence of these dislocations is the first case published in the literature.

Isolated traumatic pancreatic rupture

Ming-Tse Tsai, Jen-Tang Sun, Kuang-Chau Tsai, Wan-Ching Lien — 2010-03-26

Traumatic pancreatic rupture is associated with high morbidity and mortality. The diagnosis is difficult and usually accompanied with other injuries. We reported a 17-year-old adolescent boy who experienced this disease alone. The diagnosis was first suspected in ultrasonography and then confirmed by computed tomography. Endoscopic retrograde pancreatography showed his pancreatic duct was patent. He made an uneventful recovery after 10 days of hospitalization. Ultrasonography is well known for detecting the presence of hemoperitoneum in blunt abdominal trauma. Furthermore, it can be applied to the assessment of patients with posttraumatic abdominal pain. It provides a real-time, noninvasive, and inexpensive means for screening this kind of patients.

Femoral neck fracture in association with low-energy pelvic ring fractures in an elderly patient

Samuel B. Adams, Stephanie W. Mayer, Mark G. Hamming, Robert D. Zura — 2010-03-26

Concomitant fractures of the pelvic ring and proximal femur in the setting of low-energy trauma are rare but not mutually exclusive. An 82-year-old woman, without prior hip pain, presented to our institution after a fall from standing height. Ipsilateral pubic rami and sacral ala fractures were diagnosed with plain radiographs and computed tomography scanning, respectively, and corroborated by physical examination. No further imaging was performed in the emergency department. However, with adequate in-house pain control, the patient's complaints and physical examination were also indicative of a hip fracture. A subsequent magnetic resonance imaging study revealed a nondisplaced ipsilateral intertrochanteric femur fracture. Previously, it has been reported that occult fractures of the hip and pelvic ring appear to be mutually exclusive. Moreover, if acute fractures of the pubic ramus are identified, it has been recommended that no further investigation is warranted to rule out fracture of the hip. This case report demonstrates that low-energy pelvic ring and hip fractures can occur together. Sound clinical acumen is imperative and must supercede literature reports when providing patient care.

Tight control of effectiveness of cardiac massage with invasive blood pressure monitoring during cardiopulmonary resuscitation

2010-03-26

The continuity of chest compression is the main challenge in prehospital cardiopulmonary resuscitation in the field as well as during transport. Invasive blood pressure monitoring with visible pulse waves by means of an arterial line set prehospitally allows for tight control of the effectiveness of chest compressions as well as of the impact of the administered epinephrine and also captures beginning fatigue of the rescuers. In this case, maintaining uninterrupted circulation through manual as well as mechanical chest compressions continued until the successful percutaneous coronary intervention saved the patients life without neurologic damage.

Mega aorta syndrome: a case of thoracic and abdominal aortic aneurysm

William C. Wu, Christopher A. Mitchell, Derek Linklater — 2010-03-26

An 83-year-old woman presented to the emergency department (ED) via emergency medical services with the chief complaint of “strokelike symptoms.” Physical examination revealed altered mental status, tachycardia, hypotension, and a large nonpulsatile periumbilical mass. Bedside ultrasound revealed a 9-cm abdominal aortic aneurysm with absent central flow. Computed tomography scan demonstrated diffuse thoracic and abdominal aortic dilation with rupture into the mediastinum along with left hemothorax. Repeat beside ultrasound demonstrated abdominal aortic aneurysm rupture not seen on the computed tomography scan. Despite aggressive resuscitation, the patient developed bradycardia, which devolved into pulseless electric activity cardiac arrest. She was unable to be resuscitated. The patient's diffuse aneurysmal dilation places her into the small category of patients with a disease entity known as mega aorta syndrome (MAS). Mega aorta syndrome is defined as aneurysmal dilation of the aorta to greater than 6 cm in diameter. Although not in our case, most cases of MAS are symptomatic before catastrophic presentation. The disease progression for these patients is slow and occurs over years. When this disease is recognized early, a surgery known as the elephant trunk procedure can be performed. This operation replaces the entire aorta in multiple stages. This gives the emergency physician a critical role in the diagnosis and outcome of these patients because they may come through the ED for an unrelated complaint early in the disease process. This case report illustrates an advanced case of MAS.

Benign persistent T-wave inversion mimicking ischemia after left bundle-branch block—cardiac memory

Richard Byrne, Lisa Filippone — 2010-03-26

The electrocardiographic presence of deep T-wave inversions in a patient presenting with chest pain is highly concerning for cardiac ischemia. There are certain situations, however, when this finding may represent a benign phenomenon. In this report, we illustrate a case of non–ischemia-related T-wave inversion after resolution of a rate-related left bundle-branch block pattern—a case of cardiac memory. This poorly understood process occurs when the heart resumes a sinus rhythm after a period of abnormal depolarization, typically a bundle-branch block or ventricular pacing. The precordial leads in these patients will demonstrate alarmingly deep, symmetrical T-wave inversions. As our case demonstrates, however, this finding is an expected consequence of the antecedent aberrant conduction pattern and has no correlation with the presence of ongoing myocardial ischemia.

Echinococcosis presenting as acute abdominal pain

Jean Lee Nelson, Frank LoVecchio — 2010-03-26

We present the case of a 71-year-old man with hydatid disease who travels frequently to and from the United States and Mexico. He presented to the emergency department (ED) with a chief complaint of acute abdominal pain accompanied by neurological and urinary symptoms. A large cystic mass was found in the abdomen, as well as multiple metastases secondary to prostate cancer. Limited availability of history and lack of compliance in the past led to the unusual presentation of this patient. Challenges to diagnosis are discussed.

Is threshold for treatment of methemoglobinemia the same for all? A case report and literature review

Amr El-Husseini, Nick Azarov — 2010-03-29

Acquired methemoglobinemia (MetHb) is a rare complication of exposure to toxic chemicals or drugs, most commonly topical anesthetic agents. This condition occurs when the rate of methemoglobin production exceeds the rate of methemoglobin reduction. Topical anesthetics have been reported to cause MetHb, but this adverse event is extremely rare and is not usually listed as one of the possible complications of transesophageal echocardiography (TEE). However, the number of published case reports of TEE-associated MetHb has recently increased . Benzocaine (ethyl aminobenzoate) is a topical anesthetic widely used for oropharyngeal anesthesia before TEE. Health care providers who are not familiar with the association of TEE and benzocaine-induced MetHb may not recognize the idiosyncratic and often nonspecific characteristics of this condition. Recognition is critical, as clinically important symptoms may occur at relatively low MetHb levels. If left untreated, MetHb can lead to cardiopulmonary compromise, severe neurologic impairment, and even death. The current report documents a case of TEE-associated MetHb from a high-volume (3000 cases per year including 300-350 TEEs per year) echo laboratory. Our patient was symptomatic and severely distressed, despite a MetHb level of only 10.8%. This case report emphasizes the importance of early recognition and treatment of MetHb, as it represents a medical emergency and can be severely symptomatic, especially in young children and the elderly, even with low MetHb levels.

Guillain-Barré syndrome presenting as mimicking croup

Shao-Hsuan Hsia, Jainn-Jim Lin, Chang-Teng Wu, I-Anne Huang, Kuang-Lin Lin — 2010-03-26

Stridor is a commonly encountered presenting symptom of upper airway obstruction in the pediatric population. Although infection etiologies such as croup, retropharyngeal abscess, and epiglottitis predominate in the pediatric population, other less common etiologies must also be considered in the differential diagnosis. We report a case of 3-year-2-month-old girl who exhibited the following symptoms: progressive hoarseness, backing cough, and dyspnea. Initial clinical symptoms were mimicking croup. After admission, she developed progressive muscle weakness and areflexia. Flexible laryngoscopy showed bilateral vocal cord paralysis. Finally, she was diagnosed with Guillain-Barré syndrome (GBS). We emphasized that the early recognition of atypical presentations of GBS warrants further evaluation and appropriate management.

Bundle branch block old and new in myocardial infarction

Oscar M.P. Jolobe — 2010-03-26

When left bundle branch block (LBBB) is associated with accute myocardial infarction (AMI) as many as 39.2% to 46.9% of patients may have old LBBB, as opposed to new-onset LBBB. In a typical presentations of AMI, however, the prevalence of old LBBB relative to new-onset LBBB is known, and may well be higher, given the association of old LBBB and 3-vessel coronary heart disease even in the absence of AMI.

Noninvasive positive pressure ventilation in procedural sedation

Jason Remick, Alfred Sacchetti, Gust Bages, Kristen Delagol — 2010-03-26

Maintenance of spontaneous effective ventilations can present unique challenges to emergency physicians directing procedural sedation in patients with underlying anatomic or physiologic upper airway pathology. In a morbidly obese patient requiring electrical cradioversion, use of bilevel positive airway pressure facilitated deep sedation while averting any adverse respiratory complications. Noninvasive pressure support ventilation may present another emergency department adjunct for difficult procedural sedation cases.

Rescue a drowning patient by prolonged extracorporeal membrane oxygenation support for 117 days

Chih-Hsien Wang, Chun-Chih Chou, Wen-Je Ko, Yung-Chie Lee — 2010-04-05

Drowning is one of the most common causes of accidental events. Here we report a drowning patient who experienced acute respiratory distress syndrome after hospitalization. Although the compliance of lung was as poor less as 5 mL/cm H2O, this patient was eventually rescued and recovered by extraprolonged extracorporeal membrane oxygenation support for 117 days.

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2010-07-01

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2010-07-01

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2010-07-01

American Journal of Emergency Medicine

Impact of procalcitonin on the management of children aged 1 to 36 months presenting with fever without source: A randomized controlled trial

Effectiveness of mouth-to-mouth ventilation after video self-instruction training in laypersons

Impact of renal dysfunction on acute coronary syndrome evaluation in observation unit patients

Circadian, day-of-week, and age patterns of the occurrence of acute coronary syndrome in Beijing's emergency medical services system

Rapid treatment reduces hospitalization for pediatric patients with odontogenic-based cellulitis

Probability of survival, early critical care process, and resource use in trauma patients

The effect of an observation unit on the rate of ED admission and discharge for pyelonephritis

Evaluation of a modified early goal-directed therapy protocol

ED triage of patients with acute myocardial infarction: predictors of low acuity triage

Relationship between abnormal pupillary reactivity and the outcome of a psychotropic drug overdose

Postural hypotension as the initial presentation of fulminant right ventricular myocarditis

Concordance between capnography and capnia in adults admitted for acute dyspnea in an ED

Monday preference in onset of takotsubo cardiomyopathy

Phloroglucinol as an adjuvant analgesic to treat renal colic

Are 2 smaller intravenous catheters as good as 1 larger intravenous catheter?

Spectrum of corrosive esophageal injury after intentional paraquat ingestion

An initial analysis: working hours and delay in seeking care during acute coronary events

Airway scope vs Macintosh laryngoscope during chest compressions on a fresh cadaver model

An unusual case of bilateral anterior shoulder and mandible dislocations

Isolated traumatic pancreatic rupture

Femoral neck fracture in association with low-energy pelvic ring fractures in an elderly patient

Tight control of effectiveness of cardiac massage with invasive blood pressure monitoring during cardiopulmonary resuscitation

Mega aorta syndrome: a case of thoracic and abdominal aortic aneurysm

Benign persistent T-wave inversion mimicking ischemia after left bundle-branch block—cardiac memory

Echinococcosis presenting as acute abdominal pain

Is threshold for treatment of methemoglobinemia the same for all? A case report and literature review

Guillain-Barré syndrome presenting as mimicking croup

Bundle branch block old and new in myocardial infarction

Noninvasive positive pressure ventilation in procedural sedation

Rescue a drowning patient by prolonged extracorporeal membrane oxygenation support for 117 days

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