American Journal of Emergency Medicine - Articles in Press

Ileal mesenteric cyst in a patient with immediate abdominal emergency: always consider appendicitis - Corrected Proof

2010-07-16

Mesenteric cysts are typically described as benign interabdominal lesions. Basically, mesenteric cysts are rare with an incidence rate of between one case per 27 000 to one case per 25 000. The etiology has not been clearly discovered yet. It can occasionally be asymptomatic or present with acute life-threatening manifestations such as acute abdominal emergency that occurs in 10% of cases. It can arise from any site on the gastrointestinal tract. When it manifests with right lower quadrant (RLQ) pain and tenderness, it is difficult to distinguish from appendicitis, especially when there are no definite diagnostic criteria. We reported the case of a 74-year-old man with RLQ pain and tenderness, nausea, anorexia, and leukocytosis. Considering Alvarado scores, he had a score of 6. Ultrasonography revealed hypoechoic cystic structure on RLQ with a size of 7.3 × 3.2 cm, with internal septi and also partial increased thickness of one intestinal loop. Ultrasonography of appendix showed thickening of appendiceal wall 4 mm in diameter. Because we suspected mesenteric cysts, but considering signs and symptoms and paraclinical data, we could not rule out appendicitis and decided to make a diagnostic laparatomy. On laparatomy, an ileal mesenteric mass was found and completely resected. The appendix was also resected. Although appendicitis cannot be ruled out, the appendectomy should be performed, even if the appendix does not have any inflammation grossly or when other pathologic problem was seen in abdominal cavity such as mesenteric cyst.

A comprehensive approach to achieving near 100% compliance with The Joint Commission Core Measures for pneumonia antibiotic timing - Corrected Proof

2010-07-16

Abstract: Background: Adherence to The Joint Commission (TJC) Core Measures benchmarks is required for hospital accreditation, and data are publicly reported as an indication of hospital quality. Published approaches to date for adhering to the pneumonia antibiotic timing (PN5c) Core Measure have shown moderate to limited success in reaching high levels of compliance.Objective: The objective of the study was to evaluate the effectiveness of a 3-phased intervention directed at improving compliance with TJC pneumonia antibiotic administration within the 6-hour requirement (PN5c) in an academic urban emergency department.Methods: A 3-phase interventional study with retrospective analysis of contemporaneous data collection during a 57-month period ending September 2009 was performed. Phase 0 was baseline, phase 1 was physician evaluation at triage, phase 2 was implementation of a specific pneumonia screening tool and pathway, and phase 3 was implementation of an emergency department electronic medical record system that facilitates removing subjects with “diagnostic uncertainty” from consideration. Main outcome measure was the proportion of patients receiving antibiotics within 6 hours among those meeting PN5c criteria. Mean times to antibiotics and percentage of compliance with PN5c were compared for each phase.Results: Percentage of compliance with PN5c increased from a baseline of 77% through each of the 3 phases: 85%, 91%, and 95%, respectively (Cochran-Armitage trend, P < .001). Mean time to antibiotic administration decreased from a baseline of 285 minutes with each successive intervention to 224, 189, and 169 minutes, respectively (linear regression, P < .001).Conclusion: Implementation of a structured intervention that includes early physician triage, a screening tool for immediate imaging and reporting, and electronic record–facilitated compliance review effectively improves TJC PN5c compliance to high levels.

Cardiac disease in pediatric patients presenting to a pediatric ED with chest pain - Corrected Proof

2010-07-14

Abstract: Background: Chest pain is a frequent chief complaint among the pediatric population. To date, limited data exist on the full spectrum of emergent cardiac disease among such patients; and existing data have been limited to relatively small cohorts.Objectives: The aims of the study were to investigate the emergent cardiac etiologies of chest pain in a large cohort of patients presenting to a tertiary care pediatric emergency department (PED) and to examine the use of resources (electrocardiogram, chest radiograph, echocardiogram, and laboratories) in those with and without cardiac-related chest pain.Methods: Patient visits to 2 tertiary care PEDs were evaluated over a 3 and half-year period. Records of patients less than 19 years of age with a chief complaint of chest pain and no history of cardiovascular disease were reviewed. Patients were categorized as having cardiac or noncardiac etiologies or history of cardiovascular disease at the time of discharge, based on PED attending's final diagnoses. Final diagnoses classified as emergent cardiac etiologies were determined a priori.Results: Four thousand four hundred thirty-six patients reported a chief complaint of chest pain during the study period. Three percent were excluded secondary to a history of heart disease. Only 24 (0.6%) of the remaining 4288 were determined to have chest pain of cardiac origin. Those with cardiac-related chest pain had a rate of admission of 50% compared to those without cardiac disease at 4% (P < .001). Nine patients had an arrhythmia, 6 had pericarditis, 4 had myocarditis, 3 had acute myocardial infarction, and 1 had pulmonary embolism and pneumopericardium. Ninety-two percent of the cardiac-related chest pain cohort received electrocardiograms compared to those without cardiac-related chest pain at 27% (P < .01). Only 1 (4%) of 24 subjects with cardiac-related chest pain had a prior emergency department visit within 72 hours suggesting a high detection rate upon initial presentation. The most common noncardiac etiologies for the chest pain were 56% musculoskeletal disorders; 12% related to wheezing, asthma, and cough; 8% infectious causes; 6% gastrointestinal; and 4% related to sickle cell anemia.Conclusion: Cardiac-related chest pain in pediatric patients is rare but potentially serious. Arrhythmia was the most common cardiac-related etiology among this cohort. Those with myocarditis and myocardial infarction were the most acutely ill. An electrocardiogram in addition to history and physical examination was most useful in detecting relatively uncommon but significant cardiac-related chest pain. Using a thorough physical examination and potentially an electrocardiogram evaluation by a pediatric emergency care physician has an excellent rate of detection of cardiac-related causes.

Transient vision loss in a patient with metformin-associated lactic acidosis - Corrected Proof

Allyson A. Kreshak, Richard F. Clark — 2010-07-14

Metformin-associated lactic acidosis (MALA) can occur when renal function is impaired and metformin accumulates in the body. Symptoms of MALA are varied and have rarely included vision loss. The objective of the study was to describe a case of MALA-associated vision loss. A 67-year-old woman presented to an emergency department (ED) with a complaint of acute vision loss. She was taking metformin for treatment of type 2 diabetes mellitus. In the ED, the patient had a temperature of 32.3°C (90.1°F), a heart rate of 55 beats per minute, a blood pressure of 117/94 mmHg, and respiratory rate of 34 breaths per minute, with a pulse oximeter reading of 98% on room air. On neurologic examination, she was awake and alert and was answering questions. She had no visual acuity, visual fields were not intact, her fundoscopic examination result was unremarkable, and her pupils were midsized and slow to react. Laboratory evaluation revealed a severe lactic acidosis (pH 6.65; lactate, 19.9 mmol/L). Creatinine concentration was 7.0 mg/dL (baseline creatinine, 1.3 mg/dL). Her metformin concentration was 28 μg/mL. Methanol and formic acid concentrations were negative. Result of her head computed tomographic scan was unremarkable. She underwent dialysis and had resolution of her metabolic acidosis with full return of her vision. This patient experienced transient vision loss associated with severe acidosis due to metformin. Treatment of the acidosis was effective in restoring vision in this patient.

Diagnostic imaging rates for head injury in the ED and states' medical malpractice tort reforms - Corrected Proof

2010-07-14

Abstract: Objective: Physicians' fears of being sued may lead to defensive medical practices, such as ordering nonindicated medical imaging. We investigated the association between states' medical malpractice tort reforms and neurologic imaging rates for patients seen in the emergency department with mild head trauma.Methods: We assessed neurologic imaging among a national sample of 8588 women residing in 10 US states evaluated in an emergency setting for head injury between January 1, 1992, and December 31, 2001. We assessed the odds of imaging as it varied by the enactment of medical liability reform laws.Results: The medical liability reform laws were significantly associated with the likelihood of imaging. States with laws that limited monetary damages (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.40-0.99), mandated periodic award payments (OR, 0.64; 95% CI, 0.43-0.97), or specified collateral source offset rules (OR, 0.62; 95% CI, 0.40-0.96) had an approximately 40% lower odds of imaging, whereas states that had laws that limited attorney's contingency fees had significantly higher odds of imaging (OR, 1.5; 95% CI, 0.99-2.4), compared to states without these laws. When we used a summation of the number of laws in place, the greater the number of laws, the lower the odds of imaging. In the multivariate analysis, after adjusting for individual and community factors, the total number of laws remained significantly associated with the odds of imaging, and the effect of the individual laws was attenuated, but not eliminated.Conclusion: The tort reforms we examined were associated with the propensity to obtain neurologic imaging. If these results are confirmed in larger studies, tort reform might mitigate defensive medical practices.

Patterns and correlates of drug-related ED visits: results from a national survey - Corrected Proof

2010-07-14

Abstract: Purpose: Drug treatment can be effective in community-based settings, but drug users tend to underuse these treatment options and instead seek services in emergency departments (EDs) and other acute care settings. The goals of this study were to describe prevalence and correlates of drug-related ED visits.Basic procedures: This study used data from the National Epidemiologic Survey on Alcohol and Related Conditions, which is a nationally representative survey of 43 093 US residents.Main findings: The overall prevalence of drug-related ED visits among lifetime drug users was 1.8%; for those with a lifetime drug use disorder, 3.7%. Persons with heroin dependence and inhalant dependence had the highest rates of ED visits, and marijuana dependence was associated with the lowest rates. Multivariate analyses revealed that being socially connected (ie, marital status) was a protective factor against ED visits, whereas psychopathology (ie, personality or mood disorders) was a risk factor.Conclusions: Significant variability exists for risk of ED use for different types of drugs. These findings can help inform where links between EDs with local treatment programs can be formed to provide preventive care and injury-prevention interventions to reduce the risk of subsequent ED visits.

The cardiac literature 2009 - Corrected Proof

Amal Mattu, Michael Bond, William J. Brady — 2010-07-14

Olasveengen TM, Sunde K, Brunborg C, et al. Intravenous drug administration during out-of-hospital cardiac arrest. JAMA 2009;302:2222-2229. Despite the widespread use of cardioactive medications, such as vasopressors and antiarrhythmics, in the resuscitation of cardiac arrest victims, there is actually very little evidence to support these therapies. On the contrary, a recent multicenter center study demonstrated that the use of intravenous medications that are advocated in standard advanced cardiac life support (ACLS) guidelines was ineffective at improving survival of patients with out-of-hospital cardiac arrest . Olasveengen and colleagues now add further support to the contention that the use of intravenous medications in victims of nontraumatic cardiac arrest is not associated with improvements in meaningful outcomes.

Are BNP plasma levels useful in heart failure diagnosis each time? A dyspneic patient with anasarca - Corrected Proof

2010-07-14

Decompensated heart failure (DHF) is one of the most common causes of hospital admission linked to alterations in the body fluid content due to hemodynamic, cardiorenal, and neurohormonal changes. An accurate diagnosis of DHF is a challenge because signs/symptoms are sometimes nonspecific given the frequency of comorbidities; thus, B-type natriuretic peptide (BNP) is associated with high probability of cardiogenic cause. However, the current methods to diagnose dyspnea due to DHF had to date many limitations; on the other hand, an early differentiation of cardiac cause from others may permit the institution of the appropriate treatment with improvement in clinical outcome. We describe a case of BNP pitfall in DHF diagnosis in a 58-year-old dyspneic man with history of rheumatic heart disease admitted with signs of severe fluid overload but normal BNP levels in the emergency department. The correct diagnosis and subsequent treatment were premised on medical history, clinical assessment, and body hydration estimation by bioelectrical impedance analysis. Our suspicion was confirmed by transthoracic echocardiography. This report teaches that DHF diagnosis based on BNP testing could place the patient at risk for misdiagnosis and that neurohormonal activation may fall in such cases and contributes to fluid accumulation. We discuss the probable causes of this pitfall and suggest the obvious need to optimize the in-hospital management of DHF, integrating medical history, physical examination, neurohormonal markers, and instrumental data comprising new attractive diagnostic methods such as bioelectrical impedance analysis. We also propose the need for researchers to investigate the issues concerning the gray zone of the pathophysiology of DHF and BNP physiology.

Bedside ultrasound identification of a duplicated inferior vena cava - Corrected Proof

Geoffrey E. Hayden, Carrie Klotz — 2010-07-14

A 47-year-old man presented to the emergency department with upper abdominal pain radiating to his back. Other than mild, reproducible abdominal pain, he had a normal physical examination. A bedside ultrasound examination of his aorta was performed and demonstrated a third vascular structure on axial (short-axis) imaging of the abdomen. Computed tomography of his abdomen and pelvis confirmed a duplicated inferior vena cava. This anomaly is discussed in terms of its relevance to the emergency sonographer, with a brief review of the literature on the subject.

Health literacy of adults presenting to an urban ED - Corrected Proof

Travis Olives, Roma Patel, Sagar Patel, Julie Hottinger, James R. Miner — 2010-07-14

Abstract: Objective: The aim of the study was to assess the prevalence of limited health literacy in an urban emergency department (ED) and its association with sociodemographic variables.Methods: This was a cross-sectional study of patients presenting to the ED of an urban county hospital. For 3 months, we screened a convenience sample of patients presenting to the ED. Participants completed a brief demographic survey and a validated assessment of health literacy, the Short Test of Functional Health Literacy in Adults (S-TOFHLA). Multinomial logistic regression model was used to analyze data.Results: Of the 15 930 patients presenting to the ED, 5601 met inclusion criteria. Of eligible patients, 65% (3639) agreed to complete demographic surveys and 26% (960) of them agreed to complete the S-TOFHLA. The most common exclusions were inability to contact the patient and age less than 18 years. Participating patients were younger than those who declined (mean age, 36.8 compared to 40.8 [t = 7.49; P < .001]). Sex and ethnicity were not significantly different across groups. Of all participants, 15.5% possessed limited health literacy. Inadequate health literacy was independently associated with increasing age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.05-1.10), non-English primary language (OR, 6.97; 95% CI, 2.76-17.6), male sex (OR, 1.82; 95% CI, 1.03-3.21), nonwhite ethnicity (OR, 2.66; 95% CI, 1.40-5.04), and years of education in the United States (OR, 0.63; 95% CI, 0.42-0.92). Marginal health literacy was associated with increasing age (OR, 1.03; 95% CI, 1.00-1.05); male sex (OR, 1.84; 95% CI, 1.04-3.24); ethnicity (OR, 2.08; 95% CI, 1.12-3.85); and a housing status of homelessness (OR, 9.66; 95% CI, 2.33-40.0), living with friends (OR, 4.59; 95% CI, 1.18-17.9), or renting (OR, 4.16; 95% CI, 1.21-14.3). Moderate to high correlation among housing variables was observed.Conclusions: Of patients enrolled in the study, 15.5% have limited health literacy. Age, male sex, non-English first language, nonwhite ethnicity, limited education, and unstable housing were associated with limited health literacy.

Acoustic cardiography S3 detection use in problematic subgroups and B-type natriuretic peptide “gray zone”: secondary results from the Heart failure and Audicor technology for Rapid Diagnosis and Initial Treatment Multinational Investigation - Corrected Proof

2010-07-14

Abstract: Background: Dyspneic emergency department (ED) patients present a diagnostic dilemma. The S3, although highly specific for acute heart failure (AHF) and predicting death and readmission, is often difficult to auscultate. The HEart failure and Audicor technology for Rapid Diagnosis and Initial Treatment (HEARD-IT) multinational trial evaluated the S3 via acoustic cardiography (Audicor). Our goal in this secondary analysis was to determine if the strength of the S3 can provide diagnostic/prognostic information in problematic heart failure subgroups.Methods: Dyspneic ED patients older than 40 years and not on dialysis were prospectively enrolled. A gold standard AHF diagnosis was determined by 2 cardiologists blinded to acoustic cardiography results. The S3 strength parameter was delineated on a scale of 0 to 10. This secondary analysis of subgroups from the HEARD-IT database used univariate/multivariate regression to determine the diagnostic/prognostic ability of the S3 strength.Results: In the 995 patients enrolled, S3 strength was a significant prognosticator in univariate analysis for adverse events but not in a multivariable model. In patients with “gray zone” B-type natriuretic peptide (BNP) levels (100-499 pg/mL), acoustic cardiography increased diagnostic accuracy of AHF from 47% to 69%. Acoustic cardiography improved S3 detection sensitivity in obese patients when compared to auscultation.Conclusion: The strength of the S3 gallop provides rapid results that assist with identification of AHF in selected populations. S3 detection complements the use of BNP in the gray zone, and its diagnostic/prognostic ability is largely unaffected by body mass index and renal function. S3 strength shows promise as a diagnostic and prognostic tool in problematic HF subgroups.

Evaluation of cerebral metabolism by 1H-magnetic resonance spectroscopy for 4°C saline-induced therapeutic hypothermia in pig model of cardiac arrest - Corrected Proof

Zhiyu Su, Chunsheng Li, Yi Han, Xi Yin, Min Guo — 2010-07-14

Abstract: Background: Previous studies have shown that therapeutic hypothermia could improve neurologic recovery when induced after cardiac arrest, but dynamic changes in cerebral metabolism have not been studied at low temperature. In this study, we aim to evaluate hypothermia-induced changes in pigs' cerebral metabolism by 1H-magnetic resonance spectroscopy (1H-MRS).Material and Methods: Ten anesthetized Landrace (25-30 kg) pigs were randomized into 2 groups and subjected to 4 minutes of ventricular fibrillation, followed by cardiopulmonary resuscitation. The hypothermic group was given an infusion of 30 mL/kg of 4°C normal saline (NS) at an infusion rate of 1.33 mL/kg per minute starting after restoration of spontaneous circulation (ROSC), then 10 mL/kg per hour for 4 hours. The control group received the same infusion of room temperature NS. Core temperature and hemodynamic variables were monitored at baseline and repeatedly for 240 minutes after ROSC. The 1H-MRS scans were obtained at baseline, 1 hour, and 3 hours after successful ROSC to observe the dynamic changes of cerebral metabolism at different temperatures.Results: The mean reduction of temperature was 1.5°C ± 0.4°C in the hypothermic group. There was no difference in hemodynamic variables between groups. 1H-MRS detected statistically significant (P < .01) changes in cerebral metabolism between the control and hypothermia groups (P < .01).Conclusions: Infusion of 4°C NS can effectively reduce cerebral metabolism after successful cardiopulmonary resuscitation and have a protective effect on the recovery of neurologic function. The 1H-MRS technology can be used as a powerful tool to evaluate interventions in the treatment of cardiopulmonary resuscitation.

Short-term functional decline of older adults admitted for suspected sepsis - Corrected Proof

2010-07-14

Abstract: Introduction: We investigated the degree of functional decline and loss of independence among older adults presenting to the emergency department (ED) with serious infection and to estimate 90-day case fatality.Methods: Consecutive patients 70 years or older (n = 50) presenting to the ED with potentially serious infection were identified using an automated case-identification algorithm. Fifty age- and sex-matched controls were recruited from a registry of community volunteers. Functional and residential statuses were ascertained at hospital admission, discharge, and 90 days. Details regarding patients' comorbidities, acute illness, and diagnostic evaluation were collected along with 90-day survival.Results: Older adults with suspected sepsis had substantial 90-day mortality (32.0%). Baseline functional impairment was more severe among cases than among control subjects, although activities of daily living and instrumental activities of daily living deficits did not predict outcome. Hospital admission was also not uniformly associated with deterioration in either activities of daily living or instrumental activities of daily living performance. Patients admitted from home were at no greater risk of functional decline than were those admitted from care facilities. No enrolled case enjoyed an increase in residential independence after discharge; of the 28 who were independent upon admission, 19 survived to 90 days, and 8 of the 19 required visiting assistance or were in a care facility.Conclusions: Older adults presenting to the ED with potentially serious infection have significant 90-day mortality. Although functional status does not consistently deteriorate in survivors, there seems to be considerable risk in the short-term for loss of residential independence.

Predictive factors of the duration of a first-attack acute urticaria in children - Corrected Proof

2010-07-14

Abstract: Purposes: This study's aim was to determine the predictive factors of the duration of first-attack acute urticaria in children.Basic Procedures: The sample included 1075 children admitted to the emergency department with first-attack acute urticaria. Variables comprising the clinical features and past histories of children with duration of disease of 3 days or less, 4 to 7 days, 8 to 14 days, and 15 days or more were compared to determine the predictors of duration of acute urticaria.Main Findings: Age, various etiologies, clinical presentations, coexistent pyrexia or angioedema, and personal histories of allergic diseases were significant factors (all P < .05). Among allergic diseases, atopic dermatitis was the most significant predictor of duration of acute urticaria, and those with multiple allergic diseases had longer durations of urticaria (both P < .05). Oral plus injection forms of antihistamine or steroid were related to shorter duration of disease (P < .05).Principal Conclusions: Etiologies and personal allergy history may be the most important predictors of the duration of a first attack of acute urticaria.

Effect of delay in presentation on rate of perforation in children with appendicitis - Corrected Proof

2010-07-14

Abstract: Introduction: Appendicitis is the most common emergency operation in children. The rate of perforation may be related to duration from symptom onset to treatment. A recent adult study suggests that the perforation risk is minimal in the first 36 hours and remains at 5% thereafter. We studied a pediatric population to assess symptom duration as a risk factor for perforation.Methods: We prospectively studied all children older than 3 years who underwent an appendectomy over a 22-month period.Results: Of 202 patients undergoing appendectomies, 197 had appendicitis. Median age was significantly lower in the perforated group, but temperature and leukocytosis were not. As expected, length of hospital stay was longer in the perforated group (4-13 vs 2-6 days). The incidence of perforation was 10% if symptoms were present for less than 18 hours. This incidence rose in a linear fashion to 44% by 36 hours. Prehospital delays were greater in patients with perforated appendicitis. However, in-hospital delay (from presentation to surgery) was less than 5 hours in the perforated group and 9 hours in the nonperforated group.Discussion: Appendiceal perforation in children is more common than in adults and correlates directly with duration of symptoms before surgery. Perforation is more common in younger children. Unlike in adults, the risk of perforation within 24 hours of onset is substantial (7.7%), and it increases in a linear fashion with duration of symptoms. In our experience, however, perforation correlates more with prehospital delay than with in-hospital delay.

Pneumomediastinum from acute inhalation of chlorine gas in 2 young patients - Corrected Proof

2010-07-14

Trichloroisocyanuric acid is a high-efficiency and-low toxicity fungicide and bleach. It is commonly used as disinfectant for industrial circulating water, swimming pools, restaurants, and other public places in China. When trichloroisocyanuric acid is put into water, chlorine gas is produced. Chlorine gas is a potent pulmonary irritant that causes acute damage in both the upper and lower respiratory tracts (J Toxicol Clin Toxicol. 1998;36(1-2):87-93). Pneumomediastinum is a rare complication in patients with acute chlorine gas poisoning. A small amount of gas can be asymptomatic, but a large amount of gas entering the mediastinum suddenly will lead to respiratory and circulatory disorder, mediastinal swing, or even cardiopulmonary arrest. Severe chlorine gas poisoning patients usually need mechanical ventilation; if the pneumomediastinum is not found on time, threat to life would be greatly increased. It requires a high index of suspicion for diagnosis and rapid treatment. The proper use of ventilator, timely and effective treatment of original disease, and multiple system organ support had significant impact on the prognosis. The pneumomediastinum case secondary to inhalation of chlorine gas that we report here should remind all emergency department physicians to maintain a high index of suspicion for this disease and seek immediate and proper intervention when treating patients with acute chlorine gas poisoning, once diagnosed, especially in younger patients.

Transmission of 12-lead electrocardiographic tracings by Emergency Medical Technician–Basics and Emergency Medical Technician–Intermediates: a feasibility study - Corrected Proof

Howard A. Werman, Robert Newland, Brad Cotton — 2010-05-05

Abstract: Introduction: Prehospital transmission of the electrocardiogram (ECG) in ST-elevation myocardial infarction patients has been shown to reduce door to treatment time and improve outcome. Acquisition of the ECG tracing is a paramedic skill, thus limiting the benefit of early ECG transmission to primarily urban areas. The purpose of this investigation was to determine whether prehospital ECGs could be transmitted by nonparamedic personnel.Methods: A prospective case series of consecutive patients with a chief complaint of chest pain was conducted. An ECG was transmitted on all eligible patients. Proper lead placement was verified, and the diagnostic quality of the ECG was assessed on emergency department arrival. Time on scene was recorded and compared with historical controls.Results: Ninety patients were enrolled in the study. An ECG was transmitted successfully in 89 (98.9%) of 90 patients. Accurate lead placement was noted in 89 (98.9%) of 90, and the ECG was of “diagnostic quality” in 85 (95.5%) of 89 patients. There was no increase in scene time during the study period.Conclusion: Prehospital transmission of diagnostic-quality ECG can be reliably performed by nonparamedic providers.

An uncommonly recognized cause of rhabdomyolysis after quetiapine intoxication - Corrected Proof

Julian Robert Mario Dickmann, Laura Maria Dickmann — 2010-05-05

Antipsychotics can cause acute rhabdomyolysis (RM) as part of a neuroleptic malignant syndrome or via a direct toxic effect on myocytes. Such a serious adverse effect has been rarely linked to quetiapine treatment. This report highlights a different pathophysiology of RM after quetiapine overdosing with suicidal intent. The 44-year-old patient had schizophrenia and took 9000 mg, 10 times his daily dosage. He became somnolent and later unconscious. After lying for 14 hours on a firm mattress probably motionless, he was difficult to arouse next morning and could hardly walk. In the emergency department (ED), brown urine and a creatinine kinase (CK) of 30 660 U/L were detected. Rhabdomyolysis was treated successfully with plasma expansion. A compartment syndrome led to bilateral peroneal paresis. A direct toxic effect of quetiapine on myocytes as claimed in the past is unlikely because, after reexposure to quetiapine 3 months later, CK remained normal. It is recommended that every patient who overdosed on quetiapine should be thoroughly assessed in ED including measurement of CK to detect RM due to long immobility early and avoid acute renal failure.

Pulmonary capillary leak syndrome after influenza A (H1N1) virus infection - Corrected Proof

2010-05-05

Pulmonary capillary leak syndrome after influenza A (H1N1) virus infection was not previously reported. We report 5 cases. The diagnosis of noncardiogenic pulmonary edema due to pulmonary capillary leak syndrome after influenza A (H1N1) virus infection was obtained by a medical committee of 6 physicians of our intensive care unit (intensive care unit physicians). Cases of 2009 H1N1 influenza were confirmed by testing nasal aspirates or combined nasal and throat swabs with the use of a real-time reverse-transcriptase polymerase chain reaction assay at Tunisian national laboratory. All 5 patients with a confirmed influenza A (H1N1) virus infection have respiratory distress. All patients have a respiratory distress with lung crackles on auscultation of one or both lungs and with alveolar pulmonary edema on the chest roentgenograms. The cardiogenic nature of pulmonary edema was ruled out in all cases by a transthoracic echocardiography showing normal systolic and diastolic functions. All patients were treated with oxygen ± noninvasive ventilation (NIV); oseltamivir and steroids in addition to empiric antibiotics were commenced. Bacterial cultures of blood, urine, and sputum and serologic reaction for atypical respiratory pathogens were negative in all cases. Evolution was marked by a good outcome in all patients. Infection by influenza A (H1N1) virus can leads to acute respiratory distress due to pulmonary capillary leak syndrome. Evolution is usually favorable under oxygen ± NIV; oseltamivir and steroids in addition to empiric antibiotics were commenced.

Trimethoprim-sulfamethoxazole–induced aseptic meningitis - Corrected Proof

Michael D. Repplinger, Peter M. Falk — 2010-05-05

Drug-induced aseptic meningitis is a known but rare adverse reaction to some medications including nonsteroidal antiinflammatory, antiepileptic, antimicrobial, and immune modulating medications. Of the antimicrobial medications causing aseptic meningitis, trimethoprim-sulfamethoxazole (TMP/SMX) is the most frequently cited cause in the literature. It has been reported to primarily affect women and patients with immune dysfunction. We report a case of a healthy 52-year-old man, the youngest adult male with TMP/SMX-induced aseptic meningitis reported in the United States. The patient presented with rapidly progressive neurologic decline requiring intensive care unit-level admission, followed by rapid recovery when TMP/SMX was withheld. Cerebrospinal fluid analysis was consistent with aseptic meningitis. Further testing for herpes simplex virus, HIV, cryptococcus, Lyme disease, blastomyces, histoplasma, lymphocytic choriomeningitis, coccidioides, enterovirus, syphilis, methicillin-resistant Staphylococcus aureus, and streptococcus were all negative. The patient made a full recovery. This report highlights the presentation and management of a rare reaction to TMP/SMX. In addition to a thorough evaluation for infectious meningitides, physicians should recall medications causing meningitis, including TMP/SMX.

The efficacy of obidoxime 72 hours after intoxication by organophosphates - Corrected Proof

Sergio Emilio Prieto-Miranda, Maciel Joe Esparza-Ceseña — 2010-05-05

Organophosphates include a large number of substances used for diverse purposes. Acute exposure by ingestion, inhalation, or contact with the skin or the eyes triggers off the toxicity of these substances. Organophosphates are potent inhibitors of cholinesterase, and the characteristic signs and symptoms of this intoxication are based on this inhibition. Their absorption is rapid; and they combine in an irreversible manner with erythrocyte acetylcholinesterase and butyrylcholinesterase, which are responsible for the hydrolysis of acetylcholine to choline and acetic acid. Obidoxime is the antidote to intoxication with organophosphates and should be administered, it is suggested, between 6 and 48 hours after acute intoxication. We report the use of obidoxime 72 hours after the intoxication with organophosphates.

A 2-year survey of treatment of acute atrial fibrillation in an ED - Corrected Proof

Michael M. Hirschl, Christian Wollmann, Sebastian Globits — 2010-05-03

Abstract: Objective: Pharmacologic cardioversion of atrial fibrillation (AF) is a reasonable mode of treatment if the arrhythmia is of recent onset. Results concerning the response rates of different drugs, respectively, in daily clinical practice and data with regard to the parameters associated with successful cardioversion are not very prevalent.Methods: Three-hundred seventy-six patients who were admitted to the emergency department with acute AF and a duration of shorter than 48 hours were enrolled into the AF registry.Results: The most effective drugs were flecainide and ibutilide (95% and 76%). Low response rates were observed with amiodarone (36%) and the individual use of digoxin or diltiazem (19% and 18%). Factors associated with a successful cardioversion were a lower blood pressure on admission (P = .002), a shorter time interval between the onset of AF and admission to the ED (P = .003), and adherence to treatment guidelines (P < .0001).Conclusion: The use of flecainide and ibutilide is associated with a much higher rate of cardioversion than other drugs we studied.

Cardiopulmonary resuscitation feedback improves the quality of chest compression provided by hospital health care professionals - Corrected Proof

2010-05-03

Abstract: Study Objective: High-quality chest compressions (CCs) are an important component of successful resuscitation. Suboptimal in-hospital CC are commonly reported. Skill degradation and fatigue have been implicated. We assessed the effect of a handheld feedback device on the measured and perceived quality of CC and rescuer physiologic response.Methods: This is a nonblinded randomized controlled study of nurses at an academic medical center. Participants performed CC on a mannequin either with or without a feedback device. Compression rate (CR) and compression depth (CD), heart rate, and oxygen saturation were documented. Perceived quality of CC, fatigue, and ease of use of the device were obtained.Results: Twelve nurses were in the feedback group (FG) and 13 were controls. Mean CD was significantly higher in the FG (1.99 ± 0.37 in vs 1.52 ± 0.36 in; P = .005) and mean CR significantly lower in the FG (127 ± 13.8 per min vs 101 ± 9.7 per min; P ≤ .0001). Using a CD of more than 1.5 in and a CR of 90 to 100 as a composite measure of high-quality CC, the FG performed significantly better (81.4% ± 22.0% vs 10.4% ± 21.9%; P < .0001). Perceived CD, CR, and fatigue did not differ between groups; however, participants overestimated depth and underestimated rate. The FG rated the design as user-friendly (85% + 26%) helpful in maintaining correct CR (83% + 26%).Conclusion: A handheld accelerometer-based audiovisual cardiopulmonary resuscitation (CPR) feedback device significantly improved the quality of CCs provided by experienced hospital nurses in a simulated setting, with no perceived or measured difference in fatigue between the 2 groups. The CPR feedback provides an effective means to monitor and improve CPR performance.

Lingual hematoma due to streptokinase in a patient with acute myocardial infarction - Corrected Proof

2010-05-03

Thrombolysis with streptokinase is routinely used for the treatment of acute myocardial infarction. Hematoma of the tongue, vocal cord, uvula, and pharyngeal hemorrhage after streptokinase treatment is a very rare condition. Herein, we describe a case of lingual hematoma after thrombolysis with streptokinase in a patient with acute myocardial infarction.

Usefulness of triggering receptor expressed on myeloid cells-1 in differentiating between typical and atypical community-acquired pneumonia - Corrected Proof

2010-05-03

Abstract: Objectives: The purpose of this study is to investigate the clinical use of inflammatory marker triggering receptor expressed on myeloid cells (TREM)-1 at admission for differentiating between typical and atypical bacterial community-acquired pneumonia (CAP).Methods: A prospective, noninterventional study of patients with CAP hospitalized through the emergency department was performed. Surface expression of TREM-1 was analyzed using flow cytometry on peripheral blood cells, and soluble TREM-1 (sTREM-1) concentration was determined in plasma.Results: Eighty-eight patients with clinical suspicion of CAP were eligible. The causative pathogen was identified in 39 patients (44.3%). After excluding 4 mixed pneumonia cases, 21 typical and 14 atypical bacterial infections were enrolled. Patients with typical bacterial CAP demonstrated increased TREM-1 surface expression on monocytes and neutrophils. Median plasma sTREM-1 levels at admission were 65.2 pg/mL (range, 17.6-138.1 pg/mL) in patients with typical CAP and 25.9 pg/mL (range, 11.5-54.8 pg/mL) in patients with atypical CAP (P < .001). Soluble TREM-1 had good discriminative value to differentiate typical from atypical pathogens with an area under the receiver operating characteristic curve of 0.87 (95% confidence interval, 0.75-0.98). At a cutoff level of 44.2 pg/mL, sTREM-1 yielded a sensitivity of 81%, a specificity of 79%, a positive likelihood ratio of 3.79, and a negative likelihood ratio of 0.24.Conclusions: In newly admitted patients with CAP, determination of the TREM-1 levels may provide useful additional diagnostic information on the bacterial etiology.

Traumatic cervical spinal epidural hematoma mimics brachial plexus injury - Corrected Proof

2010-05-03

Cervical spinal epidural hematoma is rare, and most cases are reported sporadically as caused by spontaneous bleeding. Traumatic cervical epidural spinal hematoma is extremely rare, and mimicking the symptoms of brachial plexus injury has never been reported. We describe a 32-year-old man who sustained a motorcycle accident and had multiple trauma with bilateral lung contusion and spleen laceration. He had left clavicle bone fracture and was diagnosed to have brachial plexus injury with the symptoms of weakness and paresthesia of left upper limb. Brachial plexus injury was suspected, and cervical spinal computer tomography was obtained to rule out the cervical spinal injury. He was admitted to the trauma intensive care unit for the polytrauma. Cervical spinal epidural hematoma was further confirmed after obtaining magnetic resonance imaging. He received surgical decompression to evacuate the hematoma due to persisting weakness and severe paresthesia. However, his symptoms did not have significant improvement after surgical decompression, and he received long-term rehabilitation thereafter. Herein, we present this rare injury with an unusual manifestation.

Incidence of desaturation during prehospital rapid sequence intubation in a physician-based helicopter emergency service - Corrected Proof

Anders Rostrup Nakstad, Hans-Julius Heimdal, Terje Strand, Mårten Sandberg — 2010-05-03

Abstract: Background: Hypoxemia may occur during rapid sequence intubation (RSI). This study establishes the incidence of this adverse event in patients intubated by physicians in a helicopter emergency service in Norway.Methods: This was a prospective, observational study of all RSIs performed by helicopter emergency service physicians during a 12-month period. Hypoxemia was defined as a decrease in Spo2 values to below 90% or a decrease of more than 10% if the initial Spo2 was less than 90%.Results: A total of 122 prehospital intubations were performed during the study period. Spo2 data were available for 101 (82.8%) patients. Hypoxemia was present in 11 (10.9%) patients.Conclusions: Prehospital, RSI-related hypoxemia rates in this study are lower than reported rates in similar studies and are comparable with in-hospital rates. Prehospital RSI may accordingly be considered a safe procedure when performed by experienced physicians with appropriate field training.

Incidence of tricyclic antidepressant-like complications after cyclobenzaprine overdose - Corrected Proof

Vikhyat S. Bebarta, Joseph Maddry, Douglas J. Borys, David L. Morgan — 2010-05-03

Abstract: Background: The cyclobenzaprine structure is similar to amitriptyline; however, tricyclic antidepressant (TCA)-like wide complex dysrhythmia has not been reported. Our objective was to determine the incidence of TCA-like effects in cyclobenzaprine overdoses as reported to 6 poison centers for 2 years. We compared the incidence of these effects to amitriptyline overdoses collected during the same period.Methods: We performed a retrospective review of 2 years of cases as reported to the Texas Poison Center Network. We identified sole ingestions of cyclobenzaprine and of amitriptyline. Cases had a recorded clinical outcome and clinical effect. A trained reviewer used a standard data collection sheet within a secured electronic database. One investigator audited a random sample of charts.Results: We identified 3974 cases of cyclobenzaprine calls. Of these, we collected 209 cases of acute overdoses without coingestions. There were no deaths. No cases of cyclobenzaprine ingestions were reported to have died or have a wide QRS or ventricular dysrhythmia. Seizures were reported in 2 cases; however, both were unrelated to cyclobenzaprine. Hypotension was reported in 1.4% (3/209) of cases, and a vasopressor was used in one case (0.5%). Patients with an amitriptyline overdose were more likely to have seizure, coma, tachycardia, a wide QRS or ventricular dysrhythmia, and have received sodium bicarbonate or be intubated.Conclusions: Cyclobenzaprine overdoses were not reported to cause widened QRS, ventricular dysrhythmias, or seizures, and hypotension was rarely reported. Tricyclic antidepressant-related effects occurred more often in our comparison group of amitriptyline overdoses.

Submassive pulmonary embolism in a middle-age man with trivial avulsion fracture - Corrected Proof

Tzu-Yao Hung, Tzong-Luen Wang, Ruei-Fang Wang, Tzu-Yao Hung — 2010-05-03

Our case demonstrates that pulmonary embolism can also occurred to a middle-aged adult man with minor trauma as simple avulsion fracture. A 33-year-old man presented to emergency sdepartment (ED) due to sudden onset of shortness of breath for 2 hours. The patient appeared pale and tachypneatic with right knee localized swelling without leg calf tenderness. There is no remarkable systemic disease based on his medical history. Tracing back his history, he got his right knee crushed on the ground through a traffic accident 11 days ago before this ED visit. He had visited ED at that time without casts or any other joint immobilization device and came back for the orthopedist follow-up where posterior-crucial-ligament avulsion fracture was diagnosed () and 10 mL bloody synovial fluid was tapped. He was therefore advised avoiding too much exercise and conservative treated with ice packing.

Successful management of penetrating cardiac injury under guidance of transesophageal echocardiogram - Corrected Proof

Hai Yu, Da Zhu, Peng Liang, Bin Liu — 2010-05-03

Penetrating cardiac injury is a rare medical emergency but with very high mortality. A quick and clear diagnosis and treatment strategy is of paramount importance in this emergency situation. Intraoperative transesophageal echocardiogram (TEE) is now considered to have an important role to play in this process. We then presented a case of a 42-year-old man who had 2 stab wounds and arrived in emergency department with altered consciousness, two 4-cm laceration over his left fourth intercostals space near the cardiac apex, and eighth intercostals space in posterior axillary line; blood pressure was maintained 74/40 mm Hg with infusion of vasoactive drug and colloid. Transthoracic echocardiogram image was difficult to obtain and only showed the mass cardiac tamponade with thrombus in the apical of the pericardium. However, under the guidance of the TEE, clarified internal heart and pericardium structure were visualized with no valvular structure, interventricular septum, ventricular wall, and great vessel damage. Only massive thrombus was noted at the posterior part of heart apex. This heart injury was then successfully treated through left thoracotomy without cardiopulmonary bypass. It further proved that TEE can play a pivotal role in evaluating the internal heart injury as well as selecting the surgical strategy in this critical situation.

Acute left-sided appendicitis with situs inversus totalis: a case report - Corrected Proof

2010-05-03

Appendicitis is the most common cause of surgery in acute abdominal pain with a ratio of approximately 7%. Situs inversus totalis is a rare condition in which orientation of all asymmetric organs is a mirror image of the normal one. A 24-year-old girl was referred into the emergency department with the acute left lower quadrant pain as chief complaint. Nausea and loss of appetite were also reported. Pain was persistent with no radiation. Left lower quadrant tenderness was obviously observed in physical examination. Throughout her routine chest x-ray, dextrocardia was discovered. Abdominal ultrasonography showed situs inversus totalis with inflamed appendix. Appendectomy was performed, and the patient was discharged after 5-day hospitalization with no complications anymore. Considering this, rare anomaly in acute abdomen in particular leads to early diagnosis and reduces complications such as perforation, abscess, and peritonitis as well as reduces hospitalization time.

Unusual metastatic localization of osteosarcoma in a teenager with ventricular tachycardia - Corrected Proof

2010-05-03

Most malignant tumors of the heart are metastatic. Metastatic cardiac tumors are usually associated with Wilms tumor, neuroblastoma, and non-Hodgkin lymphoma in children (Br J Radiol 71:336-339). Osteosarcoma rarely metastasizes to the heart. Twenty-four cases have been reported in the literature so far. The right side of the heart is more commonly involved than the left, and the pericardium and/or myocardium is more frequently involved than the endocardium (Br J Radiol 71:336-339). We report a rare case of osteogenic sarcoma of the right femur with left ventricular metastases presenting with ventricular tachycardia that has not been reported previously.

Upstream treatment of acute coronary syndrome in the ED - Corrected Proof

J. Douglas Kirk, Michael Kontos, Deborah B. Diercks — 2010-05-03

Abstract: Rapid risk stratification, selection of downstream management options, and institution of initial pharmacotherapy are essential to ensure that patients admitted to the emergency department with acute coronary syndromes receive optimal care. A broad range of antiplatelet and antithrombotic medications is available that permits tailoring of initial pharmacotherapy to each patient's risk status. In the urgent setting, thienopyridines (clopidogrel and prasugrel) carry limitations including response variability and increased risk for bleeding in patients requiring subsequent coronary artery bypass graft surgery. Glycoprotein IIb-IIIa receptor inhibitors, although they are highly effective in preventing ischemic events, must be used with care to reduce bleeding risk. Bivalirudin, a relatively new direct thrombin inhibitor, represents another upstream option but is costly and does not have approval for this indication. Simplified institutional management paradigms can streamline the process of selecting appropriate pharmacotherapy and aid in care delivery that will optimize patient outcomes.

Posterior comminuted scapular fracture induced by a low-voltage electric shock - Corrected Proof

Wen-Cheng Huang, Yu-Hui Chiu, Chorng-Kuang How, Jen-Dar Chen, Carlos Lam — 2010-05-03

Scapular fractures caused by electric shock usually occur when victims fall over or are hit by other objects. As the direct result of electric shock, it is uncommon. In this report, we present a 44-year-old man who complained of severe left shoulder pain after suffering from an electric shock at the workplace. Physical examination revealed tenderness over his left suprascapular area with restricted left shoulder movements. Radiographic studies demonstrated comminuted fracture of posterior left scapula. After conservative management with an arm sling and swathe immobilization for 3 months, he made an uneventful recovery. In comparison to currents between 240 and 440 V reported in most published cases of scapular fractures, this patient who suffered scapular fracture after a 110-V current might be the most vulnerable case ever diagnosed. Because domestic electricity supplied with 100- to 240-V output is used mostly, scapular fractures should be suspected in patients with shoulder pain without direct injuries.

Aortic dissection presenting as isolated lower extremity pain in a young man - Corrected Proof

Shih-Ming Huang, Frank Du, Chung-Yi Wang, Ming-Jong Bair, Kuang-Te Wang — 2010-05-03

Aortic dissection, demonstrated by symptomatic isolated ischemia of the lower extremities and renal artery infarction in the absence of abdominal symptoms, is rare and often misinterpreted. This diagnosis is often delayed or missed, frequently resulting in a fatal outcome. It should be considered in young patients with an atypical presentation of acute lower extremity ischemia. This case report describes a 38-year-old man who presented with a sudden onset of diaphoresis with severe nonradiating leg pain in the right lower limb. The patient underwent surgical repair aided by biologic glue, and both lower extremity and kidney functions were preserved.

Allergic angina can be determined by the early use of cardiac magnetic resonance imaging - Corrected Proof

2010-05-03

Kounis syndrome (KS) is the simultane appearance of acute coronary syndrome with circumstances accompanied with mast cell degranulation and is precipitated via inflammatory mediators released through the mast cell activation. Generally, in published cases with KS, ST elevations on electrocardiogram (ECG) and marked cardiac enzyme elevations including troponins were observed. Here, we introduce a case who represented with symptoms of allergic angina without any finding on ECG and troponin elevation. Cardiac magnetic resonance imaging, on the second day, showed tapering of myocardium, hypokinesis in cardiac apex and apicoposterior septum, and minimal pericardial effusion adjacent to apex. We suggest that cardiac damage can happen in patients without any ECG and cardiac enzyme abnormality in KS. For chosen patients without any history of acute coronary syndrome, ECG change, and troponin elevation, we offer early use of cardiac magnetic resonance imaging, which is noninvasive and needs hypoallergic gadolinium for contrast imaging to show cardiac damage indirectly.

Emergent precordial percussion revisited – pacing the heart in asystole - Corrected Proof

Peter P. Monteleone, Kostas Alibertis, William J. Brady — 2010-05-03

Abstract: Precordial percussion is a technique by which a manual force is applied repeatedly to the chest of a patient experiencing an unstable bradycardic or asystolic rhythm. The force is used not to defibrillate the myocardium as is the case with the “precordial thump” in pulseless ventricular tachycardia/ventricular fibrillation but rather to initiate a current through the myocardium in the form of an essentially mechanically paced beat. In this review, we discuss the physiology and utility of precordial percussion, or precordial thump, in the emergency setting as a very temporary bridge to more effective and permanent pacing techniques.

Acute life-threatening presentation of unknown lymphatic malformation - Corrected Proof

2010-05-03

Lymphatic malformations (LMs) are rare congenital vascular malformations. Lymphatic malformations include a wide variety of diseases, such as lymphangiomatosis, macro or microcystic lymphatic malformation, and lymphangiectasia. Lymphatic malformations are often first seen at birth, although intrauterine diagnosis is not uncommon. Depending on their size and location, they can be asymptomatic or threaten life by compression of vital structures. We report 2 children admitted to the emergency department with an acute life-threatening presentation of undiagnosed LM. They both required immediate cardiopulmonary resuscitation. Because acute presentations of LM are rare, proper diagnosis can be difficult. Emergency physicians must be aware that sudden enlargement of an unknown thoracic LM can result in airway compression, cardiac tamponade, or rapidly progressive pleural or pericardial effusion. Prompt diagnosis is essential to avoid further morbidity or mortality. The treatment of extensive forms is challenging, requiring a multidisciplinary approach. The prognosis can be poor.

Fatal hyperhemolytic delayed transfusion reaction in sickle cell disease: A case report and literature review - Corrected Proof

Amr El-Husseini, Alaa Sabry — 2010-05-03

Patients with sickle cell disease (SCD) may require repeated red blood cells (RBCs) transfusion, putting them at risk for minor blood group alloimmunization and the development of hyperhemolytic delayed transfusion reactions (HDTR). We recently cared for an adolescent with SCD who was admitted to the hospital with a severe HDTR. The patient had been discharged from the hospital five days previously, and had been transfused while hospitalized. The patient continued to hemolyse, despite the use of antigen compatible blood and end-up by disseminated intravascular coagulopathy (DIC), acute kidney injury (AKI) and he went on to develop cardiac arrest and could not be resuscitated. In addition to demonstrating the potential severity of HDTR we are focusing on potential side effects of transfusion therapy in SCD. Physicians caring for patients with SCD should be aware of the unique complications and transfusion requirements in this population. HDTR is a potentially life-threatening complication. It is of crucial that when a patient presents with symptoms of a painful episode with worsening anemia and has a history of recent transfusion, the clinician be alert to the possibility of a HDTR.

Aortic dissection presenting as left leg numbness and paralysis - Corrected Proof

David Barbic, Will Grad — 2010-05-03

We present the case of a 46-year-old man with a Stanford A aortic dissection presenting as left leg numbness and paralysis. There were few indications of dissection on history and physical examination, and the patient was initially seen by an orthopedist for an acute radiculopathy. A complaint of mild chest pain was elicited on repeated questioning and eventually led to the correct diagnosis. The patient underwent extensive stenting and revascularization intraoperatively and was eventually transferred from the intensive care unit to the ward. This case highlights the need for a high level of suspicion required to diagnose aortic dissection and the atypical and painless manner in which a small proportion of aortic dissections can present.

Suicide by Duragesic transdermal fentanyl patch toxicity - Corrected Proof

Frank LoVecchio, Lee Ramos — 2010-05-03

Duragesic (Ortho-McNeil-Janssen Pharmaceuticals, Inc., Raritan, NJ) is a transdermal system providing continuous systemic delivery of fentanyl, a potent opioid analgesic, used for managing moderate to severe chronic pain. We report a case of a 42-year-old woman who committed suicide via the application of multiple Duragesic patches.

Brief communication: cannabis-induced acute pancreatitis - Corrected Proof

Olivier Belze, Annick Legras, Stephan Ehrmann, Denis Garot, Dominique Perrotin — 2010-05-03

We present the case of a 17-year-old boy with no history of alcoholism or biliary lithiasis (the 2 most frequent causes of acute pancreatitis in France), experiencing a rare cause of acute pancreatitis–chronic cannabis use.

Accelerated management of patients with ST-segment elevation myocardial infarction in the ED - Corrected Proof

2010-05-03

Abstract: Purposes: The objective of this study was to evaluate improvement opportunities in the emergency department for timely ST-segment elevation myocardial infarction management and evaluated the new process flow.Basic Procedures: In a prospective study, we compared time from door to cath laboratory before and after implementation of a new ST-segment elevation myocardial infarction (STEMI) protocol. The new protocol included a blend of strategies to reduce door to cath laboratory time.Main Findings: We included 55 patients. After implementing a new STEMI protocol, we included 54 patients. Time to cath laboratory was 21 (interquartile range, 9-40) minutes before and 10 (interquartile range 5-25) minutes after initiation of the new protocol (P = .02). A door to cath laboratory time less than 15 minutes was reached in 36% of our patients in phase 1 and in 61% in phase 2 (odds ratio; 0.36, 95% confidence interval, 0.16-0.81; P = .01).Principal Conclusion: Simple changes in organizational strategies resulted in a significantly faster care for patients with acute uncomplicated STEMI.

Abdominal compressions do not achieve similar survival rates compared with chest compressions: an experimental study - Corrected Proof

2010-05-03

Abstract: Aim: The aim of this study is to investigate whether abdominal compression cardiopulmonary resuscitation (CPR) would result in similar survival rates and neurologic outcome than chest compression CPR in a swine model of cardiac arrest.Materials and methods: Forty Landrace/Large White piglets were randomized into 2 groups: group A (n = 20) was resuscitated using chest compression CPR, and group B (n = 20) was resuscitated with abdominal compression CPR. Ventricular fibrillation was induced with a pacemaker catheter, and animals were left untreated for 8 minutes. Abdominal and chest compressions were applied with a mechanical compressor. Defibrillation was then attempted.Results: Neuron-specific enolase and S-100 levels were significantly higher in group B. Ten animals survived for 24 hours in group A in contrast to only 3 animals in group B (P < .05). Neurologic alertness score was worse in group B compared with group A.Conclusion: Abdominal compression CPR does not improve survival and neurologic outcome in this swine model of cardiac arrest and CPR.

Serum troponin testing in patients with paroxysmal supraventricular tachycardia: outcome after ED care - Corrected Proof

David J. Carlberg, Sarah Tsuchitani, Kevin S. Barlotta, William J. Brady — 2010-05-03

Abstract: Paroxysmal supraventricular tachycardia (PSVT), a common dysrhythmia seen in the emergency department (ED), is usually managed without difficulty and with a favorable prognosis. Serum cardiac troponin I (cTnI) testing provides important risk stratification information in certain patients; its use in PSVT patients, however, has not been explored. A retrospective review of consecutive adult ED PSVT patients seen for 21 months was performed. Fifty-four PSVT patients were identified on the basis of International Classification of Disease, Ninth Edition codes and the ED patient log at a university hospital. Three patients were excluded for incorrect rhythm, leaving 51 who were included in data analysis. Thirty-eight patients had at least one serum cTnI value measured. Of those, 11 had a positive result, defined as serum cTnI of more than 0.02 ng/dL. Thirty-day outcomes for these patients were evaluated and showed one ED return, no PSVT recurrences, and no deaths at our regional hospital. In this sample, serum cTnI testing did not identify PSVT patients at risk for poor outcome. Further consideration of the use of this testing modality in the PSVT patient population is recommended.

Impact of positive end-expiratory pressure on cerebral injury patients with hypoxemia - Corrected Proof

Xiang-yu Zhang, Qi-xing Wang, Hai-rong Fan — 2010-05-03

Abstract: Background: Traumatic brain injury or intracranial hemorrhage patients with acute lung injury/acute respiratory distress syndrome need mechanical ventilation. The use of positive end-expiratory pressure (PEEP) in this situation remains controversial. This study explored the impact of PEEP on intracranial pressure (ICP), cerebral perfusion pressure (CPP), central venous pressure (CVP), and mean arterial pressure (MAP) in cerebral injury patients.Methods: Nine cerebral injury patients with lung injury who needed mechanical ventilation and met the criteria for ICP monitoring were included in this study. Intraventricular catheters were positioned in 1 of the bilateral ventricles and connected to pressure transducers. Invasive arterial pressure and CVP were monitored continuously. Pressure control ventilation was applied during this clinical trial in a stepwise recruitment maneuver (RM) with 3 cm H2O intermittent increments and decrements of PEEP.Results: A total of 28 RMs were completed in 9 patients. Mean values of MAP, CVP, ICP, and CPP 5 minutes after RMs showed no significant differences compared with baseline (P > 0.05). Correlation analysis of all the mean values of MAP, CVP, ICP, and CPP showed significant correlation between MAP and CPP, PEEP and CVP, PEEP and ICP, and PEEP and CPP with all P values less than 0.05.Conclusion: The impact of PEEP on blood pressure, ICP, and CPP varies greatly in cerebral injury patients. Mean arterial pressure and ICP monitoring is of benefit when using PEEP in cerebral injury patients with hypoxemia.

Abdominal pain in the ED: a 35 year retrospective - Corrected Proof

Ramin S. Hastings, Robert D. Powers — 2010-05-03

Abstract: Objective: Research published in 1972 and 1993 has detailed the demographics, diagnoses, and diagnostic test utilization of adult patients presenting with nontraumatic abdominal pain to the emergency department (ED) at the University of Virginia Hospital. This is an update of those studies, designed to examine the present state of diagnosis and management of abdominal pain, as well as to look at trends during the 35-year span of the investigations.Methods: One thousand consecutive adult patients presenting in the year 2007 with abdominal pain as their chief complaint were included in the analysis. Demographic data, discharge diagnosis, disposition, ED length of stay, charges, and diagnostic test utilization information were gathered and analyzed using electronic databases.Results: These patients represented 6.5% of the total ED census. Sixty-five percent were female, 24.7% hospitalized, and 21% diagnosed with undifferentiated abdominal pain. Relative to 1993, there were more patients receiving specific diagnoses, (79% versus 75%) and a higher rate of hospitalization (24.7% versus 18.3%). Use of diagnostic testing has markedly increased in frequency, most notably computed tomography and ultrasound, which have risen 6-fold. One of these imaging modalities is now used in 42% of patient encounters. Visit times were longer and patient charges higher. There were 2 cases of missed surgical disease in 2007 compared with 1 in 1993 and 8 in 1972.Conclusion: Over the past 35 years, ED management of atraumatic abdominal pain has become time, money, and resource intense. Widespread use of sophisticated imaging has had a small impact on diagnostic specificity but has not produced lower admission rates or fewer cases of missed surgical illness.

Tetanus Quick Stick as an applicable and cost-effective test in assessment of immunity status - Corrected Proof

2010-05-03

Abstract: Introduction: Tetanus vaccine and immunoglobulin administration are challenging decisions mostly because of the fact that the current protocol for immunization against tetanus is based on 2 variables: the vaccination status of the patient and the nature of wound and its exposure. To solve this problem, Tetanus Quick Stick (TQS; Nephrotek Laboratory, Rungis, France), an immunochromatographic dipstick test, was developed to determine the tetanus immunity of the patients. The aim of this present study was to investigate the sensitivity, specificity, and the positive and negative predictive values and cost-effectiveness of TQS in the emergency department (ED) setting.Methods: Blood samples were collected from 200 patients presenting to our ED. Information including demographic information, tetanus immunization status, wound description, and the preventive measures taken by the emergency physician were gathered by a preeducated nurse. Tetanus Quick Stick test and enzyme-linked immunosorbent assay were performed as the standard diagnostic test by an emergency physician and a laboratory technician, respectively; and results of the 2 techniques were compared.Result: Overall, tetanus vaccine was administered to 141(70.5%) patients and immunoglobulin to 105 (52.5%) patients. The analysis revealed 88.1% sensitivity and 97.6% specificity for the TQS test. The positive and negative predictive values of TQS test were 99.3% and 66.1%, respectively. Our analysis is also showed a significant decrease in cost when TQS was applied for patients with dirty, tetanus prone wounds or injuries and unknown or incomplete vaccination history (€ 9.48 versus € 12.1).Conclusion: This study revealed TQS test to be appropriate and cost-effective for ED use especially in evaluating patients who do not remember or cannot give their tetanus immunization history.

The role of emergency ultrasound for evaluating acute pyelonephritis in the ED - Corrected Proof

2010-05-03

Abstract: Background: Controversy remains over the imaging method of choice for evaluating acute pyelonephritis (APN) in the emergency department (ED).Objective: The aim of the study was to determine the efficacy of ultrasound in the diagnosis and management of patients presented to the ED with APN.Methods: This was a retrospective study of prospectively collected data. A cohort of ED patients diagnosed as APN were prospectively registered, and their medical records were then retrospectively reviewed for the presence of complications (admitted >14 days, admission to intensive care unit, or received invasive procedures), significant abnormalities (hydronephrosis, polycystic kidney diseases, renal abscess, emphysematous pyelonephritis), and mild abnormalities (cysts, stones, swelling).Results: The study included 243 patients. Most of the patients received one or more renal imaging studies (n = 206) and 39.5% of which were considered abnormal. The rates of significant abnormalities on different imaging methods were Kidney-ureter-bladder (KUB), 16.3%; emergency ultrasound (EUS), 39.6%; combination of KUB and EUS, 56.6%; and computed tomography, 58.8%. Factors contributed to complicated APN were elderly, male, a history of preexisting renal diseases, current use of catheters, previous renal calculi, and diabetes mellitus. Significant abnormalities can be identified by EUS in 61% of patients with complicated APN. In fact, the presence of significant sonographic abnormalities effectively diverted 34.3% of patients to receive surgical interventions (percutaneous nephrostomy, abscess aspiration, ureteroscopic stone manipulation, lithotripsy, or nephrectomy).Conclusion: Structural abnormalities are not uncommon in ED patients with APN. Early assessment of these patients with EUS is likely to have a great impact on their diagnosis and management.

Evaluation of 2 different instruments for exposing the chest in conjunction with a cardiac arrest - Corrected Proof

Solveig Aune, Thomas Karlsson, Johan Herlitz — 2010-05-03

Abstract: Background: Time between onset of cardiac arrest and start of treatment is of ultimate importance for outcome. The length of time it takes to expose the chest in out-of-hospital cardiac arrest (OHCA) is not known. We aimed to compare the time from onset of OHCA until the time at which the chest was exposed using a new device (S-CUT; ES Equipment, Gothenburg, Sweden) and a pair of scissors.Methods: In a manikin study, the 2 devices were compared in a simulated cardiac arrest where the initial step was exposure of the chest. The tests were performed using ambulance staff from 3 different ambulance organizations in Western Sweden. Six different types of clothing combinations were used. The primary choices of clothing for analyses were a knitted sweater and shirt (indoors) and a jacket with buttons, a shirt, and a college sweater (outdoors).Results: The mean difference from onset of OHCA until the chest was exposed when S-CUT was compared with a pair of scissors varied between 6 seconds (P = .006) and 63 seconds (P = .004; shorter with the S-CUT), depending on the type of clothing that was used. The mean differences for the clothing that was chosen for primary analyses were 23 and 63 seconds, respectively.Conclusion: We found that a new device (S-CUT) used for exposing the chest in OHCA was associated with a marked shortening of procedure time as compared with a pair of scissors.