American Journal of Emergency Medicine - Articles in Press

ED overcrowding is associated with an increased frequency of medication errors - Corrected Proof

2010-02-08

Abstract: Objectives: Despite the growing problems of emergency department (ED) crowding, the potential impact on the frequency of medication errors occurring in the ED is uncertain. Using a metric to measure ED crowding in real time (the Emergency Department Work Index, or EDWIN, score), we sought to prospectively measure the correlation between the degree of crowding and the frequency of medication errors occurring in our ED as detected by our ED pharmacists.Methods: We performed a prospective, observational study in a large, community hospital ED of all patients whose medication orders were evaluated by our ED pharmacists for a 3-month period. Our ED pharmacists review the orders of all patients in the ED critical care section and the Chest Pain unit, and all admitted patients boarding in the ED. We measured the Spearman correlation between average daily EDWIN score and number of medication errors detected and determined the score's predictive performance with receiver operating characteristic (ROC) curves.Results: A total of 283 medication errors were identified by the ED pharmacists over the study period. Errors included giving medications at incorrect doses, frequencies, durations, or routes and giving contraindicated medications. Error frequency showed a positive correlation with daily average EDWIN score (Spearman's ρ = 0.33; P = .001). The area under the ROC curve was 0.67 (95% confidence interval, 0.56-0.78) with failure defined as greater than 1 medication error per day.Conclusions: We identified an increased frequency of medication errors in our ED with increased crowding as measured with a real-time modified EDWIN score.

Electrocardiographic manifestations of cardiac infectious-inflammatory disorders - Corrected Proof

2010-02-08

Abstract: Inflammatory disorders of the heart, although uncommon in the general population, often present initially to the emergency department. Symptoms and clinical manifestations are shared with other more common cardiopulmonary diseases, particularly acute coronary syndrome and congestive heart failure, making prompt diagnosis challenging. This review will highlight some of the clinical and electrocardiographic features that will help early diagnosis and differentiation of inflammatory cardiac disorders from other more common conditions.

Factors associated with sustained return of spontaneous circulation in children after out-of-hospital cardiac arrest of noncardiac origin - Corrected Proof

2010-02-08

Abstract: Purpose: The study aimed to determine the factors predictive of sustained return of spontaneous circulation (ROSC) in children with out-of-hospital cardiac arrest (OHCA) of noncardiac origin.Methods: Eighty children were included in this retrospective study. The variables that lead to sustained ROSC and those that do not lead to sustained ROSC were analyzed. Survival analyses, including chance of achieving sustained ROSC and sum duration of ROSC, were conducted according to the duration of in-hospital cardiopulmonary resuscitation (CPR).Results: Etiologies of noncardiac OHCA differed significantly across different age groups (P < .001). Only 8.8% of children had initial arrest rhythms that were shockable. Predictors of sustained ROSC included the initial cardiac rhythm (P = .002), a shorter period between collapse and the first chest compression (P = .002), a shorter in-hospital CPR duration (P = .004), and prehospital CPR (P = .007). In children where ROSC was initially sustained, those with in-hospital CPR of more than 20 minutes, ROSC was sustained for less time (P < .001).Conclusions: Few children with noncardiac OHCA present with shockable cardiac rhythms. Furthermore, long-term ROSC is difficult to maintain in children who receive in-hospital CPR for more than 20 minutes.

Electrocardiographic differential diagnosis of narrow QRS complex tachycardia: an ED-oriented algorithmic approach - Corrected Proof

Matthew P. Borloz, Dustin G. Mark, Jesse M. Pines, William J. Brady — 2010-02-08

Abstract: The differentiation of narrow complex tachycardias is a common diagnostic conundrum encountered by emergency physicians. Although a number of published algorithms are available to assist the clinician in evaluating features of the 12-lead electrocardiogram (ECG), many of these are too cumbersome, requiring multiple decisions and introducing treatment suggestions within the diagnostic framework. To optimize the diagnosis of the narrow complex tachycardia, we propose 3 separate algorithms tailored to address varying levels of available clinical information. The static algorithm depends only on the 12-lead ECG without the benefit of historical data or diagnostic interventions. The comparative algorithm requires a baseline ECG to which the presenting ECG is compared. The dynamic algorithm encourages the clinician to take advantage of diagnostic maneuvers to further elucidate the tachycardia mechanism. Each of these algorithms requires the clinician to answer either “yes” or “no” for each criterion and does not include treatment recommendations.

Aspirin administration in ED patients who presented with undifferentiated chest pain: age, race, and sex effects - Corrected Proof

Kevin M. Takakuwa, Frances S. Shofer, Judd E. Hollander — 2010-02-08

Abstract: Study Objectives: The study aimed to determine whether aspirin therapy was differentially administered according to race, sex, or age in patients with undifferentiated chest pain who presented to an urban academic emergency department.Methods: This was a prospective observational cohort study of patients older than 24 years who presented with chest pain between July 1999 and March 2002. Patients were grouped according to 30-day final diagnosis: acute myocardial infarction AMI, unstable angina USA, and non–acute coronary syndrome (ACS) chest pain. Data were analyzed using Fisher exact test and relative risk regression using the Gaussian estimating equation.Results: There were 4478 patient visits, of which 4470 (99.8%) had complete information. Mean age was 52.2 ± 15.8 years. Blacks were 70.1% (n = 3135), whites 26.3% (n = 1175), and other 3.6% (n = 159). Women comprised 59.0% (n = 2639) of the patients. Aspirin therapy differed by race, sex, age, and final diagnosis. Patients who received aspirin were more likely to be white (60% vs 54%, P = .0009) or have an ACS diagnosis (82% vs 50%, P < .0001). By final diagnosis, there were no race, sex, or age differences for AMI or USA (P > .05). There were significant sex and age differences for non-ACS chest pain patients: men (53% vs 48% women, P = .0009) and older patients (>55 years, 60% vs 44% younger, P < .0001) had higher aspirin therapy due to administration to the patients with non-ACS chest pain.Conclusion: For patients with undifferentiated chest pain, overall race, sex, and age differences were explained by higher rates of aspirin administered to older men with non-ACS chest pain.

Derivation and reliability of an instrument to estimate medical benefit of emergency treatment - Corrected Proof

Jason S. Haukoos, Mallory D. Witt, Roger J. Lewis — 2010-02-08

Abstract: Objectives: For many patients, it is difficult to define the benefit derived from a visit to the emergency department (ED). No criterion standard exists that defines benefit from emergency treatment compared to routine outpatient care, and our limited ability to estimate benefit from emergency treatment has significant implications for emergency care-related health services research. The objectives of this study were to develop a decision algorithm to be used in estimating benefit of emergency treatment (EBET) and to assess its reliability when applied to patients making unscheduled ED visits.Methods: The EBET instrument defines benefit as a 3-level outcome, namely, significant, possible, or unlikely, and its content validity was assessed through expert review. The instrument was independently applied by multiple investigators to 3 different ED patient cohorts. A consensus-based process was used to determine the final EBET for each patient visit. Weighted κs and their 95% confidence intervals were calculated to assess the reliability of the EBET Instrument applied individually, and the Spearman-Brown formula was used to assess the overall reliability of the EBET instrument when applied using multiple raters and a standardized consensus process.Results: A total of 875 visits (300 from a general ED population, 300 from a homeless ED population, and 275 from an HIV-infected ED population) were scored using the EBET instrument. The consensus process included independently scoring groups ranging from approximately 50 to 100 patient visits, determining the level of agreement, discussing the discordant results among the investigators, and assigning a final EBET category to each visit. This process was repeated sequentially until all visits within each cohort were scored. The overall weighted κs ranged from 0.66 to 0.76, and the Spearman-Brown correlation ranged from 0.83 to 0.87.Conclusions: The EBET instrument demonstrated good to excellent reliability when applied independently by raters to both unselected and selected ED patients. Its reliability, however, was excellent to outstanding when multiple raters applied it using a consensus process. The EBET instrument may serve as a useful tool for defining benefit from emergency treatment.

Triage pain scales cannot predict analgesia provision to pediatric patients with long-bone fracture - Corrected Proof

Yi-Ming Weng, Yu-Che Chang, Yu-Jr Lin — 2010-02-08

Abstract: Purpose: This study evaluated the effects of pain assessment at triage on analgesia provision to pediatric patients with closed long-bone fractures in the emergency department (ED).Methods: This was a retrospective cohort study conducted at a university-affiliated teaching hospital. Children who presented to the ED of a teaching hospital with the main diagnosis of a closed fracture of the extremities in 2007 constituted the study cohort. We reviewed the charts and collected the following variables regarding the subjects' ED visits: patient demographics, pain scale reassessment, category of fracture, associated injuries, time from triage to the first administration pain medication, and the route and type of analgesic. The data were divided on the basis of triage in accordance with pain assessment or other triage modifiers.Results: In our study, 211 (54.7%) patients enrolled received analgesia. Oral acetaminophen was the most commonly prescribed medication (131 patients, 62.1%), whereas opioids were used in only 24 (11.4%) patients. The average time taken to deliver analgesia to children arriving in our ED was 70 minutes. The logistic regression analysis indicated that enrolled patients triaged based on the pain assessed at triage was not associated with the subsequent provision of analgesia. Analgesia provision was not associated with patients with moderate or severe pain assessed at triage as compared to patients with mild pain.Conclusion: The pain management of pediatric patients with closed long-bone fractures in the ED was inadequate and delayed. Moreover, the pain assessment at triage did not predict analgesia provision to these patients.

Initial serum glucose level and white blood cell predict ventricular arrhythmia after first acute myocardial infarction - Corrected Proof

Jiann-Hwa Chen, Chiu-Liang Tseng, Shin-Han Tsai, Wen-Ta Chiu — 2010-02-08

Abstract: Objective: The aims of this study are to analyze the factors that predispose the occurrence of ventricular arrhythmia (VA) in young patients with a first acute myocardial infarction (AMI) in the emergency department (ED) and to establish predictive implications.Methods: This is a 10-year retrospective cohort study. Patients who were older than 18 years and younger than 45 years with a first attack of AMI were recruited from the ED of 3 university teaching hospitals from January 1, 1998, to December 31, 2007.Results: Five hundred young patients (472 men and 28 women) who met the inclusion criteria were enrolled. Within these patients, the incidence of life-threatening VA with first attack of AMI was 8% (n = 40). They were categorized into 2 groups: VA attack (n = 40) and non-VA attack (n = 460). In univariable analyses, acute anterolateral ST-segment elevation myocardial infarction (65% vs 47.8%; P = .04), elevate white blood cell (WBC) count (16.4 ± 3.4 vs 11.5 ± 3.1 × 103/mm3; P < .01), and initial serum glucose level (202.6 ± 90.9 vs 151.9 ± 64.7 mg/dL; P < .01) were significantly increased in the VA group. Multiple logistic regression model identified WBC count and initial serum glucose level as the significant independent variables in the prediction of VA attack for young patients with first attack of AMI. The receiver operating characteristic area for WBC count and serum glucose level in predicting the risk of VA occurring after AMI was 0.869 and 0.756, respectively.Conclusion: Initial serum glucose level and WBC may be used as valuable predictors for VA attack in young patients with first AMI.

Platelet aspirin resistance in ED patients with suspected acute coronary syndrome - Corrected Proof

Jonathan Glauser, Charles L. Emerman, Deepak L. Bhatt, W. Frank Peacock — 2010-02-08

Abstract: Background: Platelet aspirin resistance is reported to be as high as 45%. The prevalence of emergency department (ED) platelet aspirin resistance in suspected acute coronary syndrome (ACS) is not described. Our purpose was to determine the prevalence of platelet aspirin resistance.Methods: We determined platelet aspirin resistance in a convenience sample of ED suspected ACS patients. Eligible patients had longer than 10 minutes of chest pain or an ischemic equivalent. Two hours after receiving 325 mg of aspirin, blood was assessed for platelet function (Accumetrics, San Diego, CA). Definitions are as follows: aspirin resistance, at least 550 aspirin reaction units; positive troponin T, greater than 0.1 ng/mL; significant coronary lesion, at least 70% stenosis. The composite end point was prospectively defined as a 30-day revisit, positive cardiac catheterization, or hospital length of stay (LOS) longer than 3 days.Results: Of 200 patients, 50.5% were male, 50.0% were black, troponin T was positive in 7.5%, cardiac catheterization was done in 10.5%, and 33.3% had a significant stenosis. Final diagnoses were noncardiac in 83.4%, stable angina in 8.0%, and unstable angina in 8.5%. Overall, 6.5% were resistant to aspirin; and high-risk patients trended to more aspirin resistance than non–high-risk patients (23.1% [3] vs 9.1% [17]; P value 95% confidence interval [CI], −0.0929 to 0.373). One-month follow-up found ED revisits in 12.5% of aspirin-resistant vs 4.9% of non–aspirin-resistant patients (95% CI, −0.114 to 0.182) and rehospitalization in 12.5% of resistant patients vs 4.3% of nonresistant patients (P value 95% CI, −0.108 to 0.187). Although LOS was similar at index admission, if rehospitalized, LOS was 6.5 for aspirin-resistant patients vs 3.2 days in nonresistant patients (P < .0001).Conclusion: This first report of platelet aspirin resistance in patients presenting to the ED with suggested ACS finds that it is present in 6.5% of patients.

Prospective comparison of emergency physician–performed venous ultrasound and CT venography for deep venous thrombosis - Corrected Proof

Stephen A. Shiver, Matthew Lyon, Michael Blaivas, Srikar Adhikari — 2010-02-08

Abstract: Background: Venous thromboembolic disease is a major cause of mortality and morbidity.Objectives: The aim of this study is to compare emergency physician–performed ultrasound (EPPU) of the lower extremities with CT venography (CTV) in emergency department (ED) patients undergoing workup for pulmonary embolism (PE).Methods: This was a prospective study performed at a busy academic ED. Adult patients (>18) undergoing workup for PE were eligible for the study; enrollment was based on a convenience sample, during hours worked by the investigators. Study patients underwent EPPU of the lower extremities followed by CT angiogram (CTA) of the chest and CTV of the lower extremities. Sensitivity and specificity of the ultrasound examination were calculated using CTV as the gold standard.Results: A total of 61 patients were enrolled. Of 61 patients, 50 (82%; 95% confidence interval [CI], 72%-91%) had negative workups; 11 (18%; 95% CI, 8%-27%) were noted to have PE on CTA; 6 (10%; 95% CI, 2%-17%) were noted to have lower extremity deep venous thrombosis (DVT) on both EPPU and CTV evaluation; whereas 1 patient was found to have an external iliac DVT on CTV, which was not noted on EPPU. All patients with DVT (by either EPPU or CTV) were found to have PE on CTA. Sensitivity and specificity of EPPU when compared to CTV in the diagnosis of DVT was 86% (95% CI, 42%-99%) and 100% (95% CI, 91%-100%), respectively.Conclusions: Emergency physician–performed ultrasound produces results consistent with CTV in the diagnosis of femoropopliteal DVT. More proximal clots are not evaluated with EPPU and thus may result in a false negative.

Efficacy of tramadol vs meperidine in vasoocclusive sickle cell crisis - Corrected Proof

Belkan Uzun, Zeynep Kekec, Emel Gurkan — 2010-02-08

Abstract: Despite progress in management, patients with sickle cell disease who are experiencing acute painful episode are often incompletely treated. We compared meperidine and tramadol with respect to their effects on the hemodynamics and pain relief in patients with sickle cell disease who were admitted to the emergency department with painful crisis. A total of 68 patients with sickle cell disease were randomly assigned to receive either tramadol 1.5 mg/kg (n = 34) or meperidine 1 mg/kg (n = 34). Hemodynamic parameters were recorded at regular intervals after analgesic infusions. Pain intensity and relief were documented by visual analog and pain relief scale, respectively. Sedation level was defined according to Ramsay sedation scale. Both meperidine and tramadol administration resulted in a significant reduction in systolic and diastolic blood pressure after 2 hours (P < .05). Efficacy in pain relief between the analgesics was more rapid and better in the meperidine group, although the degree of relief were significantly improved compared to baseline levels in both groups (P < .05). Sedation was more commonly seen in the meperidine arm. None of the patients had experienced neurotoxicity. In summary, both agents had proven safe and effective for emergent use in patients with sickle cell disease. Avoiding meperidine injections as recommended with previous guidelines needs to be carefully reconsidered especially when low doses are mentioned.

Risk of venous thromboembolism in patients with borderline quantitative D-dimer levels - Corrected Proof

Taku Taira, Breena R. Taira, Matt Carmen, Jasmine Chohan, Adam J. Singer — 2010-02-08

Abstract: Objective: The lower threshold for D-dimer in evaluating patients with low clinical risk of venous thromboembolism (VTE) ranges from 200 to 500 ng/mL. We compared the rates of VTE in patients based on D-dimer values. We hypothesized that the rate of VTE in low-risk patients with D-dimer levels less than 500 would be less than 1%.Methods: Study Design: This was a retrospective chart review: Setting: The study was performed in a academic, suburban emergency department (ED). Subjects: Emergency department patients with suspected VTE and D-dimer obtained were included in the study. D-dimer assay: The D-dimer assay is a quantitative instrumentation latex suspension of plasma specimens. Outcomes: Presence of VTE within 30 days of ED visit. Data Analysis: Assuming a 0% event rate in patients with D-dimer levels between 200 and 500 ng/mL, a sample of 450 patients would result in a 95% confidence interval upper limit of 0.6%.Results: There were 1270 ED patients with suspected VTE in which D-dimer levels were performed between October 2005 and October 2006. Patient mean age was 47.8 ± 19.3 years; 63.2% were female, 78.2% were white. Of all D-dimer levels, 497 (39.1%) were less than 200 ng/mL, 479 (37.7%) were between 200 and 500 μg/mL, and 294 (23.1%) were greater than 500 ng/mL. There were no VTE events diagnosed in any of the patients with D-dimer levels less than 200 ng/mL. Four patients with D-dimer levels between 200 and 500 μg/mL had a pulmonary embolism on computed tomography angiography. Of these 4 patients, 3 had moderate clinical risk based on Well's criteria and one had a false-positive computed tomography. There were no cases of VTE in the remaining 475 patients (0%; 95% confidence interval 0%-0.6%).Conclusion: The rate of confirmed VTE in low-risk patients with D-dimer levels between 200 and 500 ng/mL is very low. Low-risk patients with suspected VTE with D-dimer levels less than 500 ng/mL might not require additional testing.

Intravenous tissue plasminogen activator and stroke in the elderly - Corrected Proof

W.T. Longstreth, Ronit Katz, David L. Tirschwell, Mary Cushman, Bruce M. Psaty — 2010-02-08

Abstract: Objective: Since publication in 1995 of the National Institute of Neurological Disorders and Stroke (NINDS) trial of intravenous tissue plasminogen activator (IV tPA) for acute ischemic stroke, the benefit and frequency of use of IV tPA in the elderly have remained uncertain.Methods: We obtained data from the NINDS trial to summarize outcomes for randomized subjects older than 80 years. We used data from the Cardiovascular Health Study, a cohort study of 5888 elderly participants from 4 US communities followed longitudinally for stroke since 1989 to estimate the use of and hospital outcome after IV tPA in older adults following publication of the trial in 1995.Results: In the NINDS trial, 44 subjects older than 80 years were randomized, and their 3-month functional outcomes were not significantly improved with IV tPA. Of 25 randomized to IV tPA, 4 experienced symptomatic intracranial hemorrhages within 36 hours of treatment. Compared with younger patients, older patients were 2.87 times more likely to experience a symptomatic intracranial hemorrhage within 36 hours of IV tPA (95% confidence interval, 1.04-7.93). Of 227 Cardiovascular Health Study participants hospitalized for ischemic stroke between 1995 and 2002, seven, whose mean age was 84 years, were treated with IV tPA (3.1%; 95% confidence interval 1.2-6.2). Two had symptomatic intracranial hemorrhages, 3 failed to improve, and 2 of the 7 had good outcomes.Conclusions: These data highlight the need to clarify the risk-benefit profile of IV tPA in ischemic stroke victims who are older than 80 years.

Iatrogenic water intoxication after pelvic ultrasonography imaging - Corrected Proof

Meltem Akkaş Camkurt, Figen Coşkun, Nalan Metin Aksu, Erhan Akpınar, Didem Ay — 2010-02-08

Ultrasound (US) is a simple, easily accessible, and noninvasive method. Thus, it is commonly used. The bladder should be sufficiently filled to acquire pelvic images by US. This report describes water poisoning in 3 patients with no hepatic, cardiac, or renal disease. Both patients had a history of excessive fluid intake.

Radiopacity of ingested transdermal medicinal patches: a simulated human model - Corrected Proof

Adam K. Rowden, Christopher P. Holstege, Marcia L. Buck, David L. Eldridge — 2010-02-08

Numerous transdermal medicinal patches are currently available on the pharmaceutical market. Patients who ingest transdermal medicinal patches, either accidentally or intentionally, typically present to emergency departments (EDs) . Such cases are not benign and may develop adverse outcomes . For example, over a 2-year period, a network of 15 regional poison centers received 453 reports of intentional fentanyl patch abuse. One hundred fifty-seven of those cases involved the actual ingestion of the patch . Ingestion of other types of transdermal medicinal patches have also been reported with some cases resulting in delayed and prolonged adverse clinical outcomes .

Survival in out-of-hospital cardiac arrest before and after use of advanced postresuscitation care: A survey focusing on incidence, patient characteristics, survival, and estimated cerebral function after postresuscitation care - Corrected Proof

2010-02-08

Abstract: Background: Knowledge of the epidemiology of postresuscitation care is insufficient. We describe the epidemiology of postresuscitation care in a community from a 26-year perspective, focusing on incidence, patient characteristics, survival, and estimated cerebral function in relation to intensified postresuscitation care and initial arrhythmia.Methods: The study included patients with out-of-hospital cardiac arrest (OHCA) who were brought alive to a hospital ward in Göteborg, Sweden, between 1980 and 2006. Two periods (1980-2002 and 2003-2006) were compared.Results: In all, 1603 patients were included. For age, sex, and history, no significant differences between the 2 periods were seen. There was a significant multiple increase in bystander cardiopulmonary resuscitation, the use of coronary angiography, coronary revascularization, and therapeutic hypothermia. The number of patients found in ventricular fibrillation (VF) decreased (P = .011).For all patients, 1-year survival did not change significantly (27% vs 32%; P = .14). Among patients found in VF, an increase in 1-year survival was found (37% vs 57%; P < .0001), whereas no significant change was seen in nonshockable rhythm (10% vs 7%; P = .38). Survivors to discharge displaying low cerebral function (ie, cerebral performance categories score ≥3) decreased from 28% to 6% (P = .0006) among all patients.Conclusion: After the introduction of a more intensified postresuscitation care, there was no overall improvement in survival but signs of an improved cerebral function among survivors. There was a marked increase in survival among patients found in a shockable rhythm but not among those found in a nonshockable rhythm.

Ultrasound guidance for central venous catheter placement: results from the Central Line Emergency Access Registry Database - Corrected Proof

2010-02-08

Abstract: Background: Ultrasound guidance of central venous catheter (CVC) insertion improves success rates and reduces complications and is recommended by several professional and regulatory organizations.Methods: This is a prospective observational study using data extracted from the Central Line Emergency Access Registry database, a multicenter online registry of CVC insertions from medical centers throughout the United States. We compared success rates with ultrasound and with the anatomic-landmark technique.Results: A total of 1250 CVC placement attempts by emergency medicine residents during the study period were selected from the Central Line Emergency Access Registry database. Because a few attempts (n = 28) were made to place lines in either the left or right supraclavicular locations, data on these attempts were eliminated from the analysis. A total of 1222 CVC attempts from 5 institutions were analyzed. Successful placement on the first attempt occurred in 1161 (86%) cases and varied according to anatomic location. Ultrasound guidance was used in 478 (41%) of the initial attempts. The remainder of placements were presumably placed using the anatomic-landmark technique based on visible surface and palpatory subcutaneous structures. Overall successful placement rate did not vary according to the use of ultrasound guidance, nor did it vary at different anatomic sites. However, ultrasound was found to be significant for reducing the total number of punctures per attempt (P < .02, t = 2.30).Conclusions: Our study did not observe improved success with the use of ultrasound for CVC cannulation on the first attempt, but we did observe a reduced number of total punctures per attempt.

Physiologic effects of prolonged conducted electrical weapon discharge in ethanol-intoxicated adults - Corrected Proof

Ronald Moscati, Jeffrey D. Ho, Donald M. Dawes, James R. Miner — 2010-02-08

Abstract: Objectives: This study examines the physiologic effects of prolonged conducted electrical weapon (CEW) exposure on alcohol-intoxicated adult subjects.Methods: Adult volunteers were recruited at a TASER International training conference. All subjects ingested mixed drinks until clinical intoxication or until a minimum breath alcohol level of 0.08 mg/dL was achieved. Blood samples for venous pH, Pco2, bicarbonate, and lactate were measured in all subjects at baseline, immediately after alcohol ingestion, immediately after exposure to a 15-second TASER X26 discharge (Taser International Inc, Scottsdale, AZ), and 24 hours post-alcohol ingestion. Laboratory values were compared at sampling times using repeated-measure analysis of variance. A focused analysis comparing time points within groups was then performed using paired t tests.Results: Twenty-two subjects were enrolled into the study. There was a decrease in pH and bicarbonate and an increase in lactate after alcohol ingestion. There was a further increase in lactate and drop in pH after CEW exposure. No subject experienced a significant adverse event. All values had returned to baseline levels at 24 hours except lactate, which demonstrated a small but clinically insignificant increase.Conclusions: Prolonged continuous CEW exposure in the setting of acute alcohol intoxication has no clinically significant effect on subjects in terms of markers of metabolic acidosis. The acidosis seen is consistent with what occurs with ethanol intoxication or moderate exertion.

Topical antacid therapy for capsaicin-induced dermal pain: a poison center telephone-directed study - Corrected Proof

2010-02-08

Abstract: Purpose: The study aimed to assess the effects of topical antacids for treatment of capsaicin-induced dermal pain after exposure to capsaicin containing hot peppers, personal protection sprays, or topical creams.Procedures: Participants of the study were California Poison Control System (CPCS) hotline callers 12 years or older with dermal pain from exposure to capsaicin-containing products or plants. Participants were instructed to apply a topical antacid and assessed for perceived pain (using a 0-10 scale) pre- and posttreatment. A positive response was defined as a sustained reduction of pain 33% or more within 30 minutes or achieving a pain score of 0 to 1.Main findings: Of 93 eligible patients, 64 applied antacids and had outcome data available. Patients contacted the CPCS a median of 1 hour postexposure with a median initial pain score of 7.5/10. Thirty-six (56%) were exposed to unrefined (natural) peppers and 28 (44%) to refined capsaicin (eg, capsaicin-containing cream). Before calling the CPCS, 57 (89%) attempted at least one treatment. Forty-five (70%) reported positive response to antacid treatment as a 33% reduction in pain in 30 minutes (n = 17), a reduction in pain to a score of 0 to 1 (n = 3), or both (n = 25). A 33% reduction in pain within 30 minutes was associated with exposure to refined capsaicin (odds ratio, 3.37; 95% confidence interval, 0.98-11.66). Concomitant refined capsaicin exposure and early treatment (<1 hour of symptoms) was associated with even greater odds of response (odds ratio, 5.4; 95% confidence interval, 1.4-21.2).Conclusion: Topical application of antacids for capsaicin-induced pain is effective, particularly in early treatment of exposure to refined capsaicin.

Accurate prediction of the needle depth required for successful lumbar puncture - Corrected Proof

Sze Yee Chong, Lee Ai Chong, Hany Ariffin — 2010-02-08

Abstract: Introduction: The aim of this study is to formulate an accurate estimate of the spinal needle depth for a successful lumbar puncture in pediatric patients.Methods: This is a prospective study of pediatric oncology patients who had lumbar punctures in the course of their treatment. The distance from skin entry point to the tip of the spinal needle was measured after lumbar punctures were performed. The relationship between the depth of needle insertion with weight, height, body surface area, body mass index, intervertebral space used, ethnicity, and sex of patient were studied. Predictive statistical models were used for the formulation of the ideal lumbar puncture needle depth.Results: Two hundred seventy-nine patients who had nontraumatic lumbar punctures were studied. The patient characteristics were as follows: age, 0.5 to 15 years; weight, 7 to 63 kg; and height, 70 to 162 cm. Analysis using multiple regression tests with stepwise approach showed a strong relationship between the lumbar puncture needle depth and weight/height ratio. By using a predictive regression model, ideal depth of needle insertion (cm) = 10 [weight(kg)/height(cm)] + 1, with a regression coefficient r = 0.77.Conclusion: This formula is accurate and practical with less complex calculations. However, further validation in a prospective study will be needed.

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

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.

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

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.

Verification of airway management during cardiac arrest: a manikin-based observational study - Corrected Proof

2010-02-08

Abstract: Introduction: The study aimed to clarify the difficulties concerning insertion of advanced airway devices during cardiac arrest.Method: In an observational study using manikins, we examined the airway management techniques of 19 teams at the Osaka Senri medical rally. For ex-post verification, we recorded chest compression and ventilation using the Resusci® Anne Advanced Skill Trainer (Laerdal, Norway) and recorded actions of the teams using a video camera.Results: Only a small proportion of teams did not adopt advanced airway management (4 teams, 21.1%). Thirteen teams selected tracheal intubation. None showed chest compression interruptions during intubation manipulation, and the median duration of chest compression interruption during confirmation of postintubation was 6.4 seconds. The median duration of ventilation interruption during intubation was 45.5 seconds. When teams were evaluated for the duration of direct laryngoscopy, that is, so-called duration of intubation, the median duration was 19 seconds, which constituted a large underestimate compared with the duration of ventilation interruption. This represents an underestimation of about 27 seconds. We considered the issues to be identified for shortening the duration of ventilation interruption.Conclusion: From this study, it is clear that the strategy of Guideline 2005 that was designed to minimize chest compression interruption has permeated deeply. The recommendation that the duration of intubation manipulation should not exceed 30 seconds has had various interpretations, but it is important to focus on the duration of ventilation interruption.

Diagnostic nuclear medicine in the ED - Corrected Proof

2010-02-08

Abstract: Although the decision to use nuclear medicine (NM) modalities in the acute care setting is limited by several factors, there are instances in which the use of NM techniques can provide elegant and efficient solutions to otherwise expensive and resource consuming situations. Herein, we describe the indications and NM techniques used for the evaluation of low-risk patients with chest pain, suspected pulmonary embolus, acute cholecystitis, gastrointestinal bleeding, acute scrotum, and the radiographically occult fracture.

Evaluation of a modified early goal-directed therapy protocol - Corrected Proof

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.

Usefulness of emergency ultrasound in nontraumatic cardiac arrest - Corrected Proof

Giovanni Volpicelli — 2010-02-08

Abstract: Treatment of nontraumatic cardiac arrest in the hospital setting depends on the recognition of heart rhythm and differential diagnosis of the underlying condition while maintaining a constant oxygenated blood flow by ventilation and chest compression. Diagnostic process relies only on patient's history, physical findings, and active electrocardiography. Ultrasound is not currently scheduled in the resuscitation guidelines. Nevertheless, the use of real-time ultrasonography during resuscitation has the potential to improve diagnostic accuracy and allows the physician a greater confidence in deciding aggressive life-saving therapeutic procedures. This article reviews the current opinions and literature about the use of emergency ultrasound during resuscitation of nontraumatic cardiac arrest. Cardiac and lung ultrasound have a great potential in identifying the reversible mechanical causes of pulseless electrical activity or asystole. Brief examination of the heart can even detect a real cardiac standstill regardless of electrical activity displayed on the monitor, which is a crucial prognostic indicator. Moreover, ultrasound can be useful to verify and monitor the tracheal tube placement. Limitation to the use of ultrasound is the need to minimize the no-flow intervals during mechanical cardiopulmonary resuscitation. However, real-time ultrasound can be successfully applied during brief pausing of chest compression and first pulse-check. Finally, lung sonographic examination targeted to the detection of signs of pulmonary congestion has the potential to allow hemodynamic noninvasive monitoring before and after mechanical cardiopulmonary maneuvers.

Agreement on sedation-related events between a procedural sedation registry and computerized medical records - Corrected Proof

Kyle Shaver, Steven Weiss, Darren Braude — 2010-01-25

Abstract: Objectives: Little is known about the accuracy of the medical record to document sedation-related events (SREs). Our hypotheses were that, when compared to a reference database (RD), a procedural sedation quality assurance registry (PSQAR) and medical records were accurate documentation of SREs.Methods: All cases in our PSQAR over 13 months were examined. Those with SREs were entered into the RD. We reviewed the computerized medical record (CMR; both physician documentation and nursing documentation) to determine the presence of procedural sedation notes and documentation of SRE.Results: A total of 203 sedation cases were entered into the PSQAR. The RD consisted of 74 SREs during 60 cases. The PSQAR included 61 (82%) of 74 events (95% confidence interval [CI], 72%-90%), whereas the CMR included 44 (60%) of 74 events (95% CI, 47%-71%). Physician documentation completely matched the RD in 12 (20%) 60 cases (95% CI, 11-32) and nursing documentation completely matched the RD in 24 (40%) of 60 cases (95% CI, 28-53). Physician and nursing documentation were complete and agreed with each other in only 4 (9%) of 60 cases (95% CI, 2-16; κ = 0.13).Conclusion: When compared to the RD, the accuracy of the PSQAR was very good. However, the accuracy of the CMR, including both nursing and physician documentation, was poor and there was poor agreement between them. This has implications for chart review–based research and quality improvement.

Injury patterns related to ultralight aircraft crashes - Corrected Proof

2010-01-25

Abstract: Purpose: Flying ultralight aircraft is a popular and growing form of recreation. However, there is considerable risk involved in this activity. This study was undertaken to catalogue the injury patterns, surgical procedures, and complications of patients involved in ultralight crashes in southwest Michigan.Basic procedures: The trauma registry at Bronson Methodist Hospital was used to retrospectively identify all ultralight crashes between 1983 and 2006. All patients who survived to the hospital were included in the study.Main findings: Seventeen patients were identified, all males with a mean age of 48.5 years. Mean injury severity score was 23, with all patients sustaining multiple injuries. Mortality was 17%. Lower extremity fractures were most common, followed by head/neck/facial injuries. Orthopedic extremity procedures were most commonly performed.Principal conclusions: Ultralight crashes result in complex high-energy injury patterns. These patients are likely to require the resources of designated trauma centers. Increased oversight may help prevent ultralight-related injuries.

What is the optimal dose of epinephrine during cardiopulmonary resuscitation in a rat model? - Corrected Proof

Meng-Hua Chen, Jun-Yu Lu, Lu Xie, Jun-Hui Zheng, Feng-Qing Song — 2010-01-25

Abstract: Objective: Because different species may require different doses of drug to produce the same physiologic response, we were provoked to evaluate the dose-response of epinephrine during cardiopulmonary resuscitation (CPR) and identify what is the optimal dose of epinephrine in a rat cardiac arrest model.Methods: Rat cardiac arrest was induced via asphyxia, and then the effects of different doses of epinephrine (0.04, 0.2, and 0.4 mg/kg IV, respectively) and saline on the outcome of CPR were compared (n = 10/each group). The primary outcome measure was restoration of spontaneous circulation (ROSC), and the secondary was the change of spontaneous respiration and hemodynamics after ROSC.Results: Rates of ROSC were 9 of 10, 8 of 10, 7 of 10, and 1 of 10 in the low-dose, medium-dose, and high-dose epinephrine groups and saline group, respectively. The rates of withdrawal from the ventilator within 60 minutes in the low-dose (7 of 9) and medium-dose epinephrine groups (7 of 8) were higher than in the high-dose epinephrine group (1 of 7, P < .05). Mean arterial pressures were comparable, but the heart rate in the high-dose epinephrine group was the lowest among epinephrine groups after ROSC. These differences in part of time points reached statistical significance (P < .05).Conclusion: Different doses of epinephrine produced the similar rate of ROSC, but high-dose epinephrine inhibited the recovery of spontaneous ventilation and caused relative bradycardia after CPR in an asphyxial rat model. Therefore, low and medium doses of epinephrine were more optimal for CPR in a rat asphyxial cardiac arrest model.

Patient population and factors determining length of stay in adult ED of Medical Center of Hacettepe University - Corrected Proof

Didem Ay, Meltem Akkas, Bulent Sivri — 2010-01-25

Abstract: This study is designed to analyze retrospectively patients who present to adult emergency department (ED) from January 1, 2002, to February 28, 2002. Age, sex, presentation time to ED, length of stay in emergency service, consultations, the number of patients who need to be hospitalized and also the number of hospitalized patients, diagnosis categories, and discharge instructions are analyzed. It is found that patients in most admissions are at 21 to 25 years of age. At night, the number of visits is decreased. Hospitalizations could be done to only about half of patients who in fact should be hospitalized. There is a correlation between the length of stay of patients in emergency service and the number of consultations per patient. There is also a correlation between patient complexity and length of stay in emergency service. The ED overcrowding rises with increased visits and patients staying in ED who should be hospitalized.

Effects of high-urgency ambulance transportation on pro-B-type natriuretic peptide levels in patients with heart failure - Corrected Proof

2009-11-30

Abstract: Objectives: We hypothesized that pro-B-type natriuretic peptide (proBNP) levels in venous blood increase in patients with acute out-of-hospital heart failure because of stress during emergency ambulance transportation, and furthermore, we wanted to show if there is an effect of increasing proBNP levels on hemodynamic parameters.Methods: Venous proBNP levels, visual analog scale (VAS) for pain and anxiety before and after transportation, heart rate, blood pressure, and transcutaneous Spo2 were measured every 3 minutes in 32 patients with defined clinical signs of heart failure.Results: ProBNP levels increased significantly (P < .01) during transportation (278.13 ± 113.20 vs 984.67 ± 627.33 pg/mL), whereas heart rate and mean blood pressure remained almost stable. There was no significant change in VAS for pain and anxiety (3.79 ± 3.70 and 2.89 ± 3.01 vs 2.13 ± 3.30 and 1.57 ± 2.78).Conclusion: A rapid increase in proBNP levels was shown in patients with acute out-of-hospital heart failure during emergency ambulance transportation but no significant changes in hemodynamic parameters.

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

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.

Prescription use and survival among nonagenarians presenting to the ED - Corrected Proof

Rebecca L. Rao, Raquel M. Schears — 2009-11-23

Abstract: To characterize prescription medication use and survival effect among nonagenarians with an emergency department (ED) visit, we performed a retrospective chart review for all nonagenarians presenting to the ED in 2002. Data were collected on medication number and category and on survival after discharge. At admission, patients were taking no medications (3.2%), 1 to 4 medications (35%), 5 to 9 medications (51.9%), or at least 10 medications (9.9%); the median number increased by 2 at discharge (P < .001). Among 565 patients dismissed, 6-month survival was 77.8% and 1-year survival was 65.6%. Patients discharged with prescriptions for opioids or other analgesics were more likely to die within 12 months than those discharged without these medications. Patients taking aspirin had a 40% lower mortality compared with those not taking aspirin (P = .004). Patients discharged with medication in other categories had no excess mortality.

Validity of serum tau protein levels in pediatric patients with minor head trauma - Corrected Proof

Ahmet Guzel, Serap Karasalihoglu, Hakan Aylanç, Osman Temizöz, Tufan Hiçdönmez — 2009-11-23

Abstract: Background: The aim of this study was to investigate the relationship between intracranial injury and serum tau protein levels in pediatric patients with minor head trauma (MHT).Methods: We included 60 pediatric patients with MHT (Glasgow Coma Scale [GCS], 14-15) and 28 control patients. The patients were divided into 3 groups as follows: those without (group 1) and with (group 2) intracranial lesions shown on cranial computed tomography (CCT) and the control group (group 3).Results: The mean serum tau protein level was 96.06 ± 70.36 pg/mL in group 1, whereas it was 112.04 ± 52.66 pg/mL in group 2, with no statistically significant difference between the groups (p = .160). The mean serum tau protein levels between the study groups (group 1 and group 2) and control (38.52 ± 29.01) were statistically significant (P < .001 and P < .001, respectively). The GCS score and pathologic condition in CCT were only influential variables on tau protein levels.Conclusions: We found that serum tau protein increased after MHT but did not distinguish between those with and those without intracranial lesions demonstrable on CCT.

Prognostic factors for primary septicemia and wound infection caused by Vibrio vulnificus - Corrected Proof

2009-11-23

Abstract: Objectives: The purpose of this study was to explore the predictive factors for mortality in primary septicemia or wound infections caused by Vibrio vulnificus.Methods: A retrospective review of 90 patients 18 years and older who were hospitalized due to V vulnificus infection between January 2000 and December 2006 was performed. Clinical characteristics, laboratory studies, treatments, and outcomes retrieved from medical records were analyzed. Multiple logistic regression and receiver operating characteristic curve analyses were performed.Results: Of 90 patients identified as V vulnificus infections, 39 had primary septicemia and 51 had wound infection. The mean age was 63.0 ± 11.9 years. The mean Acute Physiology and Chronic Health Evaluation (APACHE II) and Mortality in Emergency Department Sepsis (MEDS) scores on admission were 11.1 ± 4.9 and 5.5 ± 3.8, respectively. Fifteen patients died, yielding an in-hospital mortality rate of 17%. Multivariate analysis revealed that higher APACHE II (odds ratio, 1.5; 95% confidence interval [CI], 1.2-1.8; P< .0001) and MEDS (odds ratio, 1.3; 95% CI, 1.1-1.6; P = .0201) scores on admission were significantly associated with mortality. The area under the receiver operating characteristic curves values for APACHE II and MEDS in predicting in-hospital mortality were 0.928 (95% CI, 0.854-0.972) and 0.830 (95% CI, 0.736-0.901), respectively.Conclusions: The APACHE II and MEDS scores on admission are significant prognostic indicators in primary septicemia or wound infections caused by V vulnificus. A further prospective study to strengthen this point is required.

San Francisco Syncope Rule, Osservatorio Epidemiologico sulla Sincope nel Lazio risk score, and clinical judgment in the assessment of short-term outcome of syncope - Corrected Proof

2009-11-23

Abstract: Objective: The study aimed to compare the efficacy of the Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) risk score, San Francisco Syncope Rule, and clinical judgment in assessing the short-term prognosis of syncope.Methods: We studied 488 patients consecutively seen for syncope at the emergency department of 2 general hospitals between January and July 2004. Sensitivity, specificity, predictive values, and likelihood ratios for short-term (within 10 days) severe outcomes were computed for each decision rule and clinical judgment. Severe outcomes comprised death, major therapeutic procedures, and early readmission to hospital.Results: Clinical judgment had a sensitivity of 77%, a specificity of 69%, and would have admitted less patients (34%, P < .05 vs decision rules). The OESIL risk score was characterized by a sensitivity of 88% and a specificity of 60% (admission 43%). San Francisco Syncope Rule sensitivity was 81% and specificity was 63% (admission 40%). According to both clinical rules, no discharged patient would have died. With combined OESIL risk score and clinical judgment, the probability of adverse events was 0.7% for patients with both low risk scores, whereas that for both high risk scores was roughly 16%.Conclusion: Because of a relatively low sensitivity, both risk scores were partially lacking in recognizing patients with short-term high-risk syncope. However, the application of the decision rules would have identified all patients who subsequently died, and OESIL risk score and clinical judgment combined seem to improve the decision-making process concerning the identification of high-risk patients who deserve admission.

The diagnostic role of capnography in pulmonary embolism - Corrected Proof

2009-11-23

Abstract: The aim of this study was to evaluate the diagnostic contribution of alveolar dead space fraction (AVDSf) measured using capnography in patients admitted with suspected pulmonary embolism (PE). A total of 58 patients who were admitted to our hospital with suspected PE between October 2006 and January 2008 were included in this study. All patients were assessed using the Wells clinical score, capnography, computed tomographic pulmonary angiography, D-dimer measurement, lower-extremity venous Doppler ultrasonography, and V/Q scintigraphy. Forty patients (69%) had PE based on computed tomographic pulmonary angiography findings. The AVDSf value with the highest sensitivity and specificity, which was at the same time statistically significant, was 0.09. This value was consistent with the AVDSf value obtained using receiver operating characteristic analysis. In our study, the sensitivity of capnography was 70%, with a specificity of 61.1%, positive predictive value of 80%, and negative predictive value of 47.8%. The use of AVDSf in combination with any of the several scoring systems that evaluate clinical likelihood of PE and D-dimer levels resulted in higher sensitivity and specificity rates for the diagnosis of PE.

Pigtail catheter for the management of pneumothorax in mechanically ventilated patients - Corrected Proof

2009-11-23

Abstract: Purpose: There has been a paucity of data regarding the efficacy and safety of small-bore chest tubes (pigtail catheter) for the management of pneumothorax in mechanically ventilated patients.Methods: We conducted a retrospective review of mechanically ventilated patients who underwent pigtail catheter drainage as their initial therapy for pneumothorax in the emergency department and intensive care unit from January 2004 through January 2007 in a university hospital.Results: Among the 62 enrolled patients, there were 41 men (66%) and 21 women (34%), with a mean age of 63.8 ± 20.3 years. A total of 70 episodes of pneumothoraces occurred in the intensive care unit, and 48 episodes of pneumothoraces (68.6%) were successfully treated with pigtail catheters. The average duration of pigtail drainage was 5.9 days (1–27 days). No major complications occurred through use of this procedure, except for pleural infections (n = 3, 4.2%) and clogged tube (n = 1, 1.4%). Comparing the variables between the success and failure of pigtail treatment, the failure group had a significantly higher proportion of Fio2 >60% requirement (45.5% vs. 14.6%, P = .005) and higher positive end-expiratory pressure levels (8.7 ± 3.0 vs. 6.2± 2.3 mm Hg, P = .001) at the time of pneumothorax onset than the success group. Further comparing the efficacy of pigtail drainage between barotraumas and iatrogenic pneumothorax, pigtail catheters for management of iatrogenic pneumothorax had a significantly higher success rate than barotraumas (87.5% vs. 43.3%, P < .0001).Conclusion: Pigtail catheter drainage is relatively effective in treating iatrogenic but less promising for barotraumatic pneumothoraces.

Serial hematocrit testing does not identify major injuries in trauma patients in an observation unit - Corrected Proof

Troy Madsen, Matthew Dawson, Joseph Bledsoe, Philip Bossart — 2009-11-23

Abstract: Background: Routine serial hematocrit measurements are a component of the trauma evaluation for patients without serious injury identified on initial evaluation. We sought to determine whether serial hematocrit testing was useful in detecting significant intra-abdominal injuries in trauma patients in our observation unit.Methods: We performed a retrospective chart review of all trauma patients placed in our observation unit over a 14-month period. Patients had received trauma surgery evaluation before placement in the observation unit and routinely received serial hematocrit testing (≥2 hematocrit levels) while in the observation unit. We compared trauma patients with a hematocrit drop of 5 points or more to those without a significant hematocrit drop.Results: Three hundred sixty-five trauma patients were placed in the observation unit, and 310 patients (85%) had at least 2 hematocrits drawn during their stay. Of these patients, 20.6% had a hematocrit drop of 5 or more. Of patients with the hematocrit change, 18.8% were admitted to an inpatient unit from the observation unit compared to 9.3% of patients without a significant hematocrit change (P = .034). In one of these patients who had a computed tomography scan before observation admission, which demonstrated free fluid, the hematocrit drop assisted in diagnosing significant intra-abdominal injury.Conclusion: Although serial hematocrit testing may be useful in specific situations, routine use of serial hematocrit testing in trauma patients at a level I trauma center's observation unit did not significantly aid in the detection of occult injury.

Quality of emergency care provided by physician assistants and nurse practitioners in acute asthma - Corrected Proof

Chu-Lin Tsai, Ashley F. Sullivan, Adit A. Ginde, Carlos A. Camargo — 2009-11-23

Abstract: Objective: The aim of this study was to evaluate the quality of care provided by physician assistants or nurse practitioners (ie, midlevel providers [MLPs]) in acute asthma, as compared with that provided by physicians.Methods: We performed a secondary analysis of the asthma component of the National Emergency Department Safety Study. We identified emergency department (ED) visits for acute asthma in 63 urban EDs in 23 US states between 2003 and 2006. Quality of care was evaluated based on 12 guideline-recommended process-of-care measures, a composite guideline concordance score, and 2 outcome-of-care measures (admission and ED length of stay).Results: Of the 4029 patients included in this analysis, 3622 (90%) were seen by physicians only, 319 (8%) by MLPs supervised by physicians, and 88 (2%) by MLPs not supervised by physicians. After adjustment for patient mix, unsupervised MLPs were less likely to administer inhaled β-agonists within 15 minutes of ED arrival (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.1-0.7), less likely to prescribe systemic corticosteroids in the ED (OR, 0.4; 95% CI, 0.2-0.9), and were more likely to prescribe inappropriate antibiotics at discharge (OR, 2.1; 95% CI, 1.1-4.1), as compared with physicians. Overall, their composite guideline concordance score was lower than that of physicians (−6 points; 95% CI, −9 to −3 points). Supervised MLPs provided similar quality of care to that of physicians.Conclusions: The MLPs were involved in 10% of ED patients with acute asthma and provided independent care for 2% of these patients. Compared with care provided by physicians or by supervised MLPs, there are opportunities for improvement in unsupervised MLP care.

Prehospital intervention probability score: a novel method for determining necessity of emergency medical service units - Corrected Proof

2009-11-23

Abstract: Objective: This article models use of emergency medical services (EMS) within a defined geographical area. Our goal was to develop an original quantitative method to delineate the need for EMS units within a geographical population.Methods: Use of the EMS system within 11 municipalities was analyzed in 2007. The geospatial distributions of interventions during this year were examined, as well as the population dynamics of the region. A statistical model to determine the probability of an individual within the call area requiring an intervention was proposed using weighted population statistics and the application of an intervention probability.Results: The observed interventional probability increased exponentially with age, notably after the age of 75. Areas with higher proportions of elderly residents had substantially higher rates of intervention and EMS use. Municipality H had the largest age-group of 20 to 24 years with an intervention probability of 0.34% (95% confidence interval [CI], 0.24-0.44), their more than 85-year age-group also had the largest intervention probability of 19.54% (95% CI, 15.60-23.48).Conclusions: Contrary to current practice patterns of placing paramedic units in regions of greatest population density, we established a formula based on population vs intervention probability. We found the actual numbers of interventions performed are not dependent solely on population size but also are affected by the age of the population being served. This is particularly relevant to growing elderly communities. This determination will aid in the disbursement of limited prehospital resources in regions by improving availability of EMS personnel.

Reliability of anion gap calculated from data obtained using a blood gas analyzer: is the probability of error predictable? - Corrected Proof

Norio Otani, Sachiko Ohde, Toshiaki Mochizuki, Shinichi Ishimatsu — 2009-11-23

Abstract: Background: Anion gap (AG) is a useful index for assessing the clinical condition of critically ill patients especially in intoxication. Recently, AG can be obtained easily using a blood gas analyzer (BGA); however, its reliability requires validation.Methods: We enrolled patients who simultaneously underwent blood gas analysis and blood test in the central hospital laboratory and patients who visited the emergency department of our hospital from January 1, 2004, to December 31, 2007.The deviation of AG calculated using the BGA and that calculated by the central hospital laboratory were extracted. From the data obtained using the BGA, the independent risk factor causing a significant error in AG was statistically analyzed.Results: A total of 2922 patients were enrolled, of which 339 were defined as the significant error group. Male sex, abnormal Hco3−, abnormal lactate, abnormal K, abnormal Cl, and abnormal Na were the independent risk factors producing the significant error. The results indicate that regardless of whether the original electrolyte data of the patients are abnormal, when the electrolyte measurement results obtained using the BGA are abnormal, the calculated AG might show a significant error. In addition, the fact that lactate was determined as a risk factor indicates that AG might be more useful in patients who have intoxication than in those under an unstable state in terms of vital signs.Conclusion: When risk factors are present, the medical condition of a patient should be reevaluated by comparing results without heavily relying on the AG obtained by a BGA.

Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration - Corrected Proof

Loren Yamamoto, Joan Kanemori — 2009-11-23

Abstract: Background: Compared to fixed-dose single-vial drug administration in adults, pediatric drug dosing and administration requires a series of calculations, all of which are potentially error prone. The purpose of this study is to compare error rates and task completion times for common pediatric medication scenarios using computer program assistance vs conventional methods.Methods: Two versions of a 4-part paper-based test were developed. Each part consisted of a set of medication administration and/or dosing tasks. Emergency department and pediatric intensive care unit nurse volunteers completed these tasks using both methods (sequence assigned to start with a conventional or a computer-assisted approach). Completion times, errors, and the reason for the error were recorded.Results: Thirty-eight nurses completed the study. Summing the completion of all 4 parts, the mean conventional total time was 1243 seconds vs the mean computer program total time of 879 seconds (P < .001). The conventional manual method had a mean of 1.8 errors vs the computer program with a mean of 0.7 errors (P < .001). Of the 97 total errors, 36 were due to misreading the drug concentration on the label, 34 were due to calculation errors, and 8 were due to misplaced decimals. Of the 36 label interpretation errors, 18 (50%) occurred with digoxin or insulin.Conclusions: Computerized assistance reduced errors and the time required for drug administration calculations. A pattern of errors emerged, noting that reading/interpreting certain drug labels were more error prone. Optimizing the layout of drug labels could reduce the error rate for error-prone labels.

Improving Crotalidae polyvalent immune Fab reconstitution times - Corrected Proof

Asia N. Quan, Dan Quan, Steven C. Curry — 2009-11-23

Abstract: Background: Crotalidae polyvalent immune Fab (CroFab) is used to treat rattlesnake envenomations in the United States. Time to infusion may be a critical factor in the treatment of these bites. Per manufacturer's instructions, 10 mL of sterile water for injection (SWI) and hand swirling are recommended for reconstitution. We wondered whether completely filling vials with 25 mL of SWI would result in shorter reconstitution times than using 10-mL volumes and how hand mixing compared to mechanical agitation of vials or leaving vials undisturbed.Methods: Six sets of 5 vials were filled with either 10 mL or 25 mL. Three mixing techniques were used as follows: undisturbed; agitation with a mechanical agitator; and continuous hand rolling and inverting of vials. Dissolution was determined by observation and time to complete dissolution for each vial. Nonparametric 2-tailed P values were calculated.Results: Filling vials completely with 25 mL resulted in quicker dissolution than using 10-mL volumes, regardless of mixing method (2-tailed P = .024). Mixing by hand was shorter than other methods (P < .001). Reconstitution with 25 mL and hand mixing resulted in the shortest dissolution times (median, 1.1 minutes; range, 0.9-1.3 minutes). This appeared clinically important because dissolution times using 10 mL and mechanical rocking of vials (median, 26.4 minutes) or leaving vials undisturbed (median, 33.6 minutes) was several-fold longer.Conclusion: Hand mixing after filling vials completely with 25 mL results in shorter dissolution times than using 10 mL or other methods of mixing and is recommended, especially when preparing initial doses of CroFab.

Which stroke symptoms prompt a 911 call? A population-based study - Corrected Proof

2009-11-23

Abstract: Introduction: Many studies show that a major barrier to short-term treatment of stroke is patient or bystander delay in responding to stroke symptoms. Most studies have found that less than half of stroke/transient ischemic attack (TIA) events result in a 911 call. We sought to determine which symptoms prompt the public to call 911.Methods: A population of 1.3 million within a 5-county region was screened for TIA and all strokes in 1999 using all local hospital International Classification of Diseases, Ninth Edition, codes for stroke (430-436) during 1999. Documented stroke symptoms were abstracted from the medical record. Symptoms were grouped as weakness, numbness, speech/language, confusion/decreased level of consciousness, headache, visual changes, and dizziness/vertigo/coordination. Cases included in this analysis had their strokes at home or work and presented to an emergency department. Logistic regression assessed which symptoms predicted a 911 call, adjusting for age, race, sex, prior stroke, baseline disability, overall stroke severity, home vs work, and stroke subtype.Results: Two thousand nine hundred seventy-five stroke/TIA patients met inclusion criteria, of whom 40% used emergency medical services. After adjustment, symptoms that increased odds of a 911 call were weakness, confusion/decreased level of consciousness, speech/language, and dizziness/coordination/vertigo. Numbness was less likely to result in a 911 call as were visual changes. The presence of headache was not associated with the decision to call 911.Discussion: The public appears to respond differently based on the type of stroke symptom, independent of overall severity. Public awareness messages regarding stroke warning signs should be designed with this in mind.

Can urine dipstick predict an elevated serum creatinine? - Corrected Proof

2009-11-23

Abstract: Objective: Chart review studies have suggested that point-of-care urine dipstick testing may accurately predict an elevation in serum creatinine (Cr). We aimed to prospectively evaluate the test characteristics of proteinuria/hematuria in predicting elevated serum Cr.Methods: A prospective, observational study was conducted between March 2007 and June 2008 at 2 affiliated, urban hospitals with an annual emergency department census of 150 000. Patients undergoing laboratory urinalysis, point-of-care urine dipstick, and a serum chemistry panel were enrolled. Trained research assistants collected data on consecutive patients 18 hours per day using preformatted data forms and entry into an anonymized Access (Microsoft, Seattle, Wash) database. Demographic baseline variables including age, sex, chief complaint, vital signs, and source of sample (catheter vs “clean catch”) were also collected. An elevated Cr level was defined as greater than 1.3 based on the laboratory reference range. Standard statistical methods were used to calculate diagnostic test operating characteristics of proteinuria or hematuria as a predictor of elevated serum Cr.Results: Five thousand four hundred sixteen subjects were enrolled with 28.3% male and a mean age of 50.2 years. Elevated serum Cr greater than 1.3 mg/dL was found in 13.9% (755/5416) of subjects. The sensitivity of either proteinuria or hematuria for elevated Cr was 82.5% (95% confidence interval [CI], 80%-85%) and specificity was 34.4% (95% CI, 33%-36%). Positive predictive value was 16.9% (95% CI, 16%-18%) and negative predictive value was 92.4% (95% CI, 91-94%). The likelihood ratio for a positive test was 1.3 (95% CI, 1.1-1.5), and the likelihood ratio for a negative test was 0.5 (95% CI, 0.3-0.8).Conclusions: Although negative predictive value was high, the presence of proteinuria/hematuria was only moderately predictive of elevated serum Cr level.

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

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.

A bedside ultrasound sign of cardiac disease: the left atrium-to-aorta diastolic diameter ratio - Corrected Proof

2009-10-26

Abstract: Purpose: This study evaluated a simple ultrasound method to detect left atrial (LA) enlargement by comparing the diameters of the LA and aortic root.Procedures: The LA and aortic diameters, the LA volume index (LAVI), and significant echo findings were analyzed in 101 consecutive echocardiograms. Mean LAVI and the prevalence of an abnormal echo were compared between groups in which the ratio of the LA diameter to aortic diameter in diastole was >1 vs ≤1.Findings: Left atrial-to-aortic diameter ratio increased with LAVI (r = 0.64, P < .001). Left atrial-to-aortic diameter ratio >1 vs ≤1 was noted in 45% vs 55% of patients and had a mean (±SD) LAVI = 39 ± 12 vs 27 ± 7 mL/m2 (P < .001) and a 78% vs 43% prevalence of an abnormal echo (P < .001).Conclusion: The left atrium-to-aorta diastolic diameter ratio can detect LA enlargement and may be useful as a quick bedside technique to screen for cardiac disease.

Comparison of ultrarapid and rapid intravenous hydration in pediatric patients with dehydration - Corrected Proof

Alan L. Nager, Vincent J. Wang — 2009-10-26

Abstract: Objective: The purpose of this study is to test the efficacy of ultrarapidly infused vs rapidly infused intravenous (IV) hydration in pediatric patients with acute gastroenteritis and moderate dehydration.Methods: Patients 3 to 36 months, with vomiting and/or diarrhea and moderate dehydration, were eligible. Subjects were randomly assigned “ultra” (50 mL/kg normal saline for 1 hour) vs “standard” (50 mL/kg normal saline for 3 hours) after failing an oral fluid challenge. Subjects were weighed and had serum electrolyte testing, and urine was obtained before/after IV hydration. Input/output and vital signs were tabulated hourly during the study. Subjects were discharged after fulfilling specified criteria. A follow-up questionnaire was completed 24 hours after discharge. Comparison data included success and timing of rehydration, number of patients who returned and/or were admitted, output during the rehydration period, laboratory differences, and serious complications.Results: Eighty-eight of 92 subjects completed the study: 45 ultra and 43 standard. Four patients failed treatment (1 ultra and 3 standard), were hospitalized, and excluded from the study. Groups were similar regarding sex, days of symptoms, episodes of vomiting/diarrhea before treatment, capillary refill time, tears, and vital signs and laboratory results. No subject had evidence of serious complications. Ninety-one percent of subjects completed the follow-up questionnaire. Seven ultra and 6 standard subjects returned. Six ultra subjects received oral fluid, one received IV fluid, and all were discharged. Five standard subjects received oral fluid, one received IV fluid, and all were discharged.Conclusion: Based on this pilot study, ultrarapid hydration for 1 hour preliminarily appears to be an efficacious alternative to standard rapid hydration for 3 hours and improves emergency department throughput time.

Microneedle pretreatment improves efficacy of cutaneous topical anesthesia - Corrected Proof

2009-10-26

Abstract: Methods to facilitate topical anesthesia for venipuncture are characterized by substantial limitations. This randomized double-blind study was undertaken to assess whether use of a quickly and painlessly applied microneedle system (functional microarray, FMA) to create punctures in the stratum corneum facilitates topical anesthesia in healthy adults. In 25 volunteers receiving topical dyclonine, FMA was applied to one forearm and a sham device in the other, followed by assessment of pain levels associated with application of a standardized stimulus at 5-minute intervals over an hour. Analysis of the primary end point, time required to achieve a significant degree of pain reduction (13 mm on a 100-mm scale), revealed that FMA significantly sped time to pain reduction (log-rank P = .007). Functional microarray also resulted in a greater degree of pain reduction (Kruskal-Wallis P < .0001). Functional microarray application had no adverse effects, and the device shows promise for facilitation of topical anesthesia.