American Journal of Emergency Medicine - Articles in Press

Response to comment on dental pain as risk factor for accidental acetaminophen overdose: a case-control study - Corrected Proof

Kennon Heard, Jody Vogel — 2012-01-24

We thank the author for the interest in our article. The main inclusion criterion was a discharge diagnosis of acetaminophen poisoning (based on the structured International Classification of Diseases, Ninth Revision, search), so all patients were diagnosed by the treating physician (not the researcher) as acetaminophen poisoning. In most cases, the diagnosis was based on a history of excessive use, but in some cases, the clinician may have diagnosed acetaminophen toxicity in patients who reported therapeutic dosing but had laboratory findings suggestive of acetaminophen poisoning (such as transaminase elevation or supratherapeutic serum acetaminophen concentrations).

EZ-IO in the ED: an observational, prospective study comparing flow rates with proximal and distal tibia intraosseous access in adults - Corrected Proof

Boon Kiat Kenneth Tan, Stephanie Chong, Zhi Xiong Koh, Marcus Eng Hock Ong — 2012-01-13

Abstract: Introduction: Intraosseous (IO) access is an important alternative to conventional intravenous access when intravenous access is difficult.Methods: A nonrandomized, prospective, observational study comparing flow rates with distal and proximal tibia IO access in adults using the EZ-IO–powered drill device. The proximal tibia was the first site of insertion, and a second IO was inserted in the distal tibia if clinically indicated. Intravenous saline infusion was started for all patients, initially without, then with a pressure bag device applied.Results: From September 19, 2008 to November 3, 2010, 22 patients were recruited, with 20 proximal tibial and 22 distal tibia insertions. Two patients had only distal tibia IO insertions. Five distal tibia and 3 proximal tibia insertions had no flow when initiating normal saline infusion without pressure. Upon comparing the mean flow rates without pressure bag, it is significantly faster in the proximal tibia, 4.96 mL/min, compared with distal tibia, 2.07 ml/min, difference of 2.89 ml/min (95% CI 1.20-4.58). Flow rates with pressure bags also revealed a similar result. Flow rates in the proximal tibia were significantly faster, 7.70 ml/min to that of distal tibia, 3.80 ml/min, difference of 3.89 ml/min (95% CI 1.68-6.10). In both proximal and distal tibia groups, the flow rates are also significantly faster with pressure bags compared with without.Conclusion: Flow rates are significantly faster in the proximal tibia compared with the distal tibia. In addition, flow rates with pressure bags are significantly faster than without pressure bags in both groups.

5-Hydroxyindoleacetic acid in appendicitis: the importance of test selection - Corrected Proof

Mohammad Vasei — 2012-01-13

I read the article published in the journal, written by Jangjoo et al, discussing the validity of urinary 5-hydroxyindoleacetic acid (5-HIAA) in the diagnosis for acute appendicitis (AA). The authors showed approximately 44% sensitivity and 81% specificity .

Bedside ultrasound evaluation of tendon injuries - Corrected Proof

2012-01-13

Abstract: Objective: The primary purpose of this study was to investigate the overall accuracy of bedside extremity tendon ultrasound performed by emergency physicians in the emergency department. We also sought to investigate whether or not bedside tendon ultrasonography can be used to expedite the diagnosis and discharge planning in patients with suspected tendon injuries.Methods: This was a prospective study conducted at 2 academic level 1 trauma centers. Thirty-four patients were enrolled and underwent a comprehensive physical examination of the injured extremity, followed by a bedside ultrasound evaluation to look for tendon disruption. Results of the tendon ultrasound were compared against the findings seen during wound exploration in the emergency department, wound exploration in the operating room, or results from an extremity magnetic resonance imaging (MRI).Results: There were 6 finger injuries, 11 hand injuries, 6 arm injuries, 6 forearm injuries, and 5 lower extremity injuries. Of the 34 total patients, 4 patients had partial tendon injuries, 9 suffered from 100% tendon laceration or rupture, and 21 had no tendon injury noted on exploration or MRI. Bedside ultrasound had a sensitivity, specificity, and accuracy of 100%, 95%, and 97%, respectively. Physical examination had a sensitivity, specificity, and accuracy of 100%, 76%, and 85%, respectively. Average time to bedside ultrasound was 46.3 minutes compared with 138.6 minutes for wound irrigation and exploration, MRI, or surgery consultation.Conclusion: Bedside ultrasound is more sensitive and specific than physical examination for detecting tendon lacerations, and takes less time to perform than traditional wound exploration techniques or MRI.

The use of a 4-step algorithm in the electrocardiographic diagnosis of ST-segment elevation myocardial infarction by novice interpreters - Corrected Proof

Stephanie M. Hartman, Andrew J. Barros, William J. Brady — 2012-01-13

Abstract: The electrocardiographic (ECG) diagnosis of ST-segment elevation myocardial infarction (STEMI) represents a challenge to all health care providers, particularly so for the novice ECG interpreter. We have developed—and present in this article—a 4-step algorithm that will detect STEMI in most instances in the prehospital and other nonemergency department (ED) settings. The algorithm should be used in adult patients with chest pain or equivalent presentation who are suspected of STEMI. It inquires as to the presence of ST-segment elevation as well as the presence of STEMI confounding/mimicking patterns; the algorithm also makes use of reciprocal ST-segment depression as an adjunct in the ECG diagnosis of STEMI. If STEMI is detected by this algorithm, then management decisions can be made based upon this ECG diagnosis. If STEMI is not detected using this algorithm, then we can only note that STEMI is not “ruled in”; importantly, STEMI is not “ruled out.” In fact, more expert interpretation of the ECG will be possible once the patient (and/or the ECG) arrive in the ED where ECG review can be made with the more complex interpretation used by expert physician interpreters.

ED ultrasound diagnosis of a type B aortic dissection using the suprasternal view - Corrected Proof

Hans Rosenberg, Khaled Al-Rajhi — 2012-01-13

Aortic dissection is one of the most challenging diagnoses in emergency medicine because of its variable presentations and high mortality. With the increasing use of ultrasound in the emergency department (ED), the diagnosis of aortic dissection has become possible with bedside ultrasound. Our case report discusses a 51-year-old man who presented to the ED with abrupt onset epigastric pain. Limited abdominal ultrasound performed by the emergency physician showed an aortic intimal flap fluttering on transverse and longitudinal views. Limited echocardiogram showed a flap extending to the aortic arch seen on a suprasternal view. The flap was no longer visible at the aortic root, which also had a normal diameter. At this time, the diagnosis of a type B aortic dissection was made, and blood pressure management commenced. This case report is the first to highlight the use of the suprasternal view as part of beside echocardiogram to diagnose aortic dissection in the ED.

Evaluating the risk of venous thromboembolism in medical patients: which criteria? - Corrected Proof

2012-01-13

To evaluate the physician's perception of risk of venous thromboembolism and the use of pharmacological prophylaxis in nonsurgical patients, we performed a cross-sectional study by collecting data of 875 patients, hospitalized in 23 internal medicine and 10 emergency medicine units of 21 different institutions of Lazio, Italy. The physicians of the participating units were requested to provide information, filling in a data form, which included for each patient, the items considered by the Chopard and Kucher score systems as well as by the recommendations of the ACCP08; in addition, also the single bed rest criterion was considered . Seven hundred forty-two forms (84.8%) contained all the requested information and were included in our analysis. The percentage of patients considered at risk by the 4 methods was markedly different. The Kucher and Chopard score systems, respectively, considered 12% and 55% of our patients at increased risk; intermediate values were found using the ACCP08 criteria (16%) and immobilization (29%). The different percentage and distribution of patients considered at risk by the different systems are well displayed in the Venn diagram (), which shows that the Chopard score comprises all subjects meeting the ACCP08 and Kucher criteria and part of those immobilized.

Circadian variation of acute myocardial infarction in young people - Corrected Proof

2012-01-13

Abstract: Aims: The aim was to investigate the circadian and weekly variation in Chinese young patients with acute myocardial infarction (AMI).Methods: This was a 10-year retrospective cohort study. We studied patients (>18 to <45 years of age) with a first attack of AMI from the emergency departments of 3 university teaching hospitals in Taiwan from January 1, 2001, to December 31, 2010. We analyzed patients in the standard circadian fashion using 6-hour intervals (00:01-06:00, 06:01-12:00, 12:01-18:00, and 18:01-24:00). We also did an analysis by day of week.Results: The database had 505 patients with AMI with complete data. The percentage of total AMIs that occurred in the 6-hour intervals were as follows: 00:01 to 06:00, 30.9%; 06:01 to 12:00, 23.4%; 12:01 to 18:00, 25.9%; and 18:01 to 24:00, 19.8%. The percentage of AMIs between 00:01 and 06:00 was significant higher compared with that in the other three 6-hour intervals (df = 3, χ2 = 91.7, P < .001). However, there was no significant weekly variation for these patients in the present study.Conclusions: There was a significant circadian variation with a peak from 00:01 to 06:00 in Chinese young patients with AMI. However, there was no significant weekly variation in these patients. The circadian periodicity may create new possibilities for disease prevention and medication prescription.

Is inadequate human immunodeficiency virus care associated with increased ED and hospital utilization? A prospective study in human immunodeficiency virus–positive ED patients - Corrected Proof

2012-01-13

Abstract: Background: There is a lack of data on the effect(s) of suboptimal human immunodeficiency virus (HIV) care on subsequent health care utilization among emergency department (ED) patients with HIV. Findings on their ED and inpatient care utilization patterns will provide information on service provision for those who have suboptimal access to HIV-related care.Methods: A pilot prospective study was conducted on HIV-positive patients in an ED. At enrollment, participants were interviewed regarding health care utilization. Participants were followed up for 1 year, during which time data on ED visits and hospitalizations were obtained from their patient records. Inadequate HIV care (IHC) was defined according to Infectious Diseases Society of America recommendations as less than 3 scheduled clinic visits for HIV care in the year before enrollment. Cox regression models were used to evaluate whether IHC was associated with increased hazard of health care utilization.Results: Of 107 subjects, 36% were found to have IHC. Inadequate HIV care did not predict more frequent ED visits but was significantly associated with fewer hospitalizations (adjusted incidence rate ratio, 0.61 [95% CI: 0.43-0.86]). Inadequate HIV care did not significantly increase the hazard for earlier ED visit or hospitalization. However, further stratification analysis found that IHC increased the hazard of hospitalization for subjects without comorbid diseases (adjusted hazard ratio, 2.50 [95% CI: 1.10-5.68]).Conclusions: In our setting, IHC does not appear to be associated with earlier or more frequent ED visits but may lead to earlier hospitalization, particularly among those without other chronic diseases.

A rare neurobrucellosis case developing unilateral oculomotor nerve paralysis - Corrected Proof

Sedat Işıkay, Kutluhan Yılmaz, Akgün Ölmez — 2012-01-13

Brucellosis is a zoonotic infectious disease that is common around the world. Its clinical course demonstrates great diversity as it can affect all organs and systems. However, the central nervous system is rarely affected in the pediatric population. Neurobrucellosis is most frequently observed with meningitis and has numerous complications, including meningocephalitis, myelitis, cranial nerve paralyses, radiculopathy, and neuropathy. Neurobrucellosis affects the second, third, sixth, seventh, and eighth cranial nerves. Involvement of the oculomotor nerves is a very rare complication in neurobrucellosis although several adult cases have been reported. In this article, we present the case of a 9-year-old girl who developed unilateral nerve paralysis as a secondary complication of neurobrucellosis and recovered without sequel after treatment. This case is notable because it is a very rare, the first within the pediatric population.

Comment on “Dental pain as a risk factor for accidental acetaminophen overdose: a case-control study” - Corrected Proof

Hossein Sanaei-Zadeh — 2012-01-13

I read with interest the study conducted by Vogel et al recently published in your journal. They performed a case-control study at 2 urban hospitals and found that the patients with dental pain were at increased risk for accidental overdose with acetaminophen compared with the patients who took acetaminophen for other reasons. Their cases were retrospectively selected by chart review from those patients whose principle diagnostic code (International Classification of Diseases, Ninth and Tenth Revisions) had been confirmed as acetaminophen overdose within an 18-month period. They enrolled either the patients who—to treat a medical condition—had reported taking an excessive dose of acetaminophen or those who had reported the usage of therapeutic doses of acetaminophen, while they had laboratory evidence of its toxicity into their case group. Their controls were prospectively selected (within a 2-month period) from those who reported the use of any products containing acetaminophen for the treatment of a medical symptom within the 72-hour period preceding their emergency department (ED) visit. I think there are 3 major concerns about the methodology of this study. First, what did the authors mean by “laboratory evidence of acetaminophen toxicity”? Second, it is not clear how long the cases had used acetaminophen before presenting to the ED. Third, it is not clear why the authors have not checked the laboratory evidence of acetaminophen toxicity in the control group. In addition, they categorized the reason for acetaminophen use as dental or nondental pain. Although the authors have determined that a total of 25% of the dental pain cases had a peak alanine aminotransferase more than 1000 IU/L, they have not mentioned such measures in the controls. Furthermore, in the “Results,” they have declared that a total of 201 controls have been evaluated, whereas, when adding the number of controls in Table 1, they are only 195. In my opinion, other than the limitations mentioned by the authors themselves, the aforementioned points make this study too weak to withdraw statistically significant conclusions. For instance, they have shown that the median of alanine aminotransferase in the dental pain cases had been less than that of the nondental pain cases (26 vs 231 IU/L). Then, is it possible to conclude that the patient who overdoses on acetaminophen for dental pain is less likely to develop acetaminophen toxicity in comparison with the patient who uses it for some other medical condition?

Dignitary medicine: adapting prehospital, preventive, tactical and travel medicine to new populations - Corrected Proof

2012-01-09

Abstract: Dignitary Protection Medicine (DPM) is a new area of medical expertise that incorporates elements of virtually all medical and surgical specialties, drawing heavily from travel, tactical and expedition medicine. The fundamentals of DPM stem from the experiences of White House, State Department and other physicians who have traveled extensively with dignitaries. Furthermore, increased international travel of business executives and political dignitaries has mandated a need for proficiency in this realm. We sought to define the requisite knowledge base and skill sets that form the foundation of this new area of specialization.

Role of inferior vena cava diameter in assessment of volume status: a meta-analysis - Corrected Proof

Agarwal Dipti, Zachary Soucy, Alok Surana, Subhash Chandra — 2012-01-05

Abstract: Background and Objective: Hypovolemic shock is an important cause of death in the emergency department (ED). We sought to conduct a meta-analysis to quantify existing evidence on sonographic measurement of inferior vena cava (IVC) diameter in assessing of volume status adult ED patients.Methods: A search of 5 major databases of biomedical publication, EMBASE, Ovid Medline, evidence-based medicine (EBM) Reviews, Scopus, and Web of Knowledge, was performed in first week of March 2011. Studies meeting the following criteria were included: (1) prospectively conducted, (2) measured IVC diameter using ultrasonography, (3) inpatients under spontaneous ventilation, and (4) reported IVC diameter measurement with volume status or shock. Article search, study quality assessment, and data extraction were done independently and in duplicate. Mean difference in IVC diameter was calculated using RevMan version 5.5 (Cochrane collaboration).Results: A total of 5 studies qualified for study eligibility from 4 different countries, 3 being case-control and 2 before-and-after design, studying 86 cases and 189 controls. Maximal IVC diameter was significantly lower in hypovolemic status compared with euvolemic status; mean difference (95% confidence interval) was 6.3 mL (6.0-6.5 mL). None of the studies blinded interpreters for volume status of participants.Conclusion: Moderate level of evidence suggests that the IVC diameter is consistently low in hypovolemic status when compared with euvolemic. Further blinded studies are needed before it could be used in the ED with confidence.

A simple method of maintaining chilled saline in the prehospital setting - Corrected Proof

Derek L. Isenberg, Michael J. Pasirstein — 2012-01-04

Abstract: Objective: Mild therapeutic hypothermia has been shown to improve neurologic outcomes after sudden cardiac arrest. Therapeutic hypothermia should be started as soon as return of spontaneous circulation occurs. However, saline is difficult to keep chilled in the prehospital environment. We sought to determine whether a cooler and ice packs could keep saline cold under prehospital conditions.Methods: In phase 1 of the experiment, two 1000-mL bags of prechilled 0.9% normal saline were placed in a cooler with 3 ice packs. An additional bag of 1000-mL 0.9% normal saline remained outside the cooler as a control. Over 9 consecutive days, we measured the ambient air temperature and the temperature of each bag of saline every 4 hours. In phase 2 of the experiment, the cooler was kept sealed, and the temperature of the saline was measured after 24 hours.Results: The mean temperatures over 24 hours ranged as follows: ambient temperature, 24°C to 27.2°C; bottom bag, 0.6°C to 3.5°C; top bag, 1.4°C to 5.7°C; and control bag, 9.8°C to 26.8°C. A t test was used to compare the chilled saline against the control bag. Statistical significance (P < .05) was achieved at all times. In phase 2 of the experiment, after 24 hours, 100% of the bottom bags and 93% of the top bags were less than 6°C.Conclusions: Our data demonstrate that saline can be kept chilled in ambulances for 24 hours using ice packs and coolers. The estimated cost is less than $50.00 per ambulance. Using coolers and ice packs is an inexpensive way for emergency medical service agencies to initiate prehospital hypothermia.

Small-bore catheter versus chest tube drainage for pneumothorax - Corrected Proof

2012-01-04

Abstract: Study Objective: The aim of the study was to compare the effectiveness of drainage via a single-lumen (5F catheter) central venous catheter (CVC) to a conventional (14-20F catheter) chest tube (CT) for the management of pneumothoraces, including primary spontaneous pneumothorax (PSP), secondary spontaneous pneumothorax (SSP), and traumatic and iatrogenic pneumothoraces.Patients: All consecutive patients admitted to the intermediate intensive care unit of a university hospital for pneumothorax were retrospectively screened over an 8-year period. Patients were preferentially treated using CT from 2003 to 2007 and using CVC from 2008 to 2010. Drainage failure was defined as the need for a second drainage procedure or for surgery.Results: Of 212 patients included, 117 (55%) had PSP, 28 (13%) had SSP associated with chronic obstructive pulmonary disease, 19 (9%) had traumatic pneumothorax, and 48 (23%) had iatrogenic pneumothorax. The failure rate was 23% in PSP, 36% in SSP, 16% in traumatic pneumothorax, and only 2% in iatrogenic pneumothorax. After adjustment, iatrogenic pneumothorax was the only factor that had an influence on drainage failure. The failure rate was similar between the 112 patients treated using CVC and the 100 patients treated using CT (18% vs 21%, P = .60). However, the durations of drainage (3.3 ± 1.9 vs 4.6 ± 2.6 days, P < .01) and of hospital stay were significantly shorter in patients treated using CVC as compared with CT.Conclusion: Our findings suggest that drainage via a catheter or via a CT is similarly effective in the management of pneumothorax. We recommend considering drainage via a small-bore catheter as a first-line treatment in patients with pneumothorax, whatever its cause.

Intra-abdominal hypertension: a potent silent killer of cardiac arrest survivors - Corrected Proof

Athanasios Chalkias, Theodoros Xanthos — 2011-12-29

Cardiac arrest is a daunting emergency and a leading cause of death worldwide. Despite the progress in cardiopulmonary resuscitation (CPR) as well as in the diagnosis and treatment of postcardiac arrest syndrome, survival rates remain disappointing low. Restoration of spontaneous circulation is just the first step toward complete recovery, and many patients will require multiple organ support during the postresuscitation period. Characteristically, of those patients admitted to intensive care units, only 25% to 56% will survive to hospital discharge .

Effects of antithrombin and gabexate mesilate on disseminated intravascular coagulation: a preliminary study - Corrected Proof

Tomoki Nishiyama, Yumiko Kohno, Keiko Koishi — 2011-12-28

Abstract: Purpose: We hypothesized that antithrombin is more effective for disseminated intravascular coagulation (DIC) than is gabexate mesilate, which is a protease inhibitor, suggested from the previous studies. Initially, we compared the effects of antithrombin and gabexate mesilate for treating infection-related DIC.Methods: Sixteen adult patients with a diagnosis of DIC with infection who were assessed with an acute DIC score 4 or higher at the admission to the intensive care unit were divided into antithrombin-treated and gabexate mesilate–treated groups. White blood cell counts, C-reactive protein, platelet counts, antithrombin, fibrin and fibrinogen degradation product, d-dimer, fibrinogen, thrombin antithrombin complex, plasmin plasminogen complex, prothrombin time, and activated partial thrombin time were measured on the day of admission and on days 1, 3, 5, and 7 thereafter. Mortality over 28 days was also compared.Results: Platelet counts and antithrombin were significantly higher in the antithrombin group on day 7 and on days 5 and 7, respectively. Antithrombin increased to the normal level on day 1 in the antithrombin group but on day 7 in the gabexate mesilate group. C-reactive protein, fibrinogen degradation product, d-dimer, thrombin antithrombin complex, plasmin plasminogen complex, and prothrombin time were lower in the antithrombin group; but the differences were not significant. The 28-day mortality was 2 of 8 in the antithrombin group and 3 of 8 in the gabexate mesilate group, but they were not significantly different.Conclusions: Antithrombin may be a more effective treatment for coagulation and fibrinolysis disorders than gabexate mesilate in infection-related DIC, but there was no difference in 28-day mortality.

Optic nerve ultrasound for the detection of elevated intracranial pressure in the hypertensive patient - Corrected Proof

2011-12-28

Abstract: Purpose: We sought to determine whether dilation of the optic nerve sheath diameter (ONSD), as detected at the bedside by emergency ultrasound (US), could reliably correlate with patient blood pressure and whether there was a blood pressure cutoff point where you would start to see abnormal dilation in the ONSD.Methods: This was a single-blinded, prospective, observational trial from September 2010 to April 2011. One hundred fifty patients presenting to the emergency department were enrolled. There were 3 arms to the study with 50 patients in each arm: (1) ONSD in normotensive/asymptomatic patients; (2) ONSD in hypertensive/asymptomatic patients; and (3) ONSD in hypertensive/symptomatic patients. Ocular US was conducted on all subjects.Results: Neither the number of symptoms nor the type of symptom present in the hypertensive/symptomatic group was able to significantly predict the average ONSD before treatment (P = .818 and .288, respectively). There was a significant correlation between both systolic blood pressure (SBP) and diastolic blood pressure (DBP) with the ONSD in all hypertensive patients. The best SBP and DBP cutoff point for abnormal ONSD was 166/82 mm Hg. Decrease in ONSD observed after blood pressure treatment was not statistically significant (P = .073).Conclusions: In conclusion, our study shows that practitioners can use bedside ocular US and a blood pressure cutoff point to help predict whether patients require more aggressive management of their symptomatic hypertension. Knowing the SBP and DBP readings that lead to increased ONSD and increased intracranial pressure can help guide management and treatment decisions at the bedside.

ED identification of patients with severe sepsis/septic shock decreases mortality in a community hospital - Corrected Proof

2011-12-28

Abstract: Study objectives: Our objective was to quantify the mortality difference between patients with severe sepsis/septic shock (SS/SS) identified in the emergency department (EDI) vs those not identified in the emergency department (NEDI) within our community hospital.Methods: We conducted a retrospective review of all patients with SS/SS from July 2007 to January 2010 who were admitted to the intensive care unit within our community hospital. Our primary outcome measure was the difference in mortality rates of patients with SS/SS between the EDI and NEDI cohorts. Our secondary outcome measures included the final disposition, the length of stay, and direct cost (DC) for both groups. The data were analyzed using a 2 × 2 contingency table and the Fisher exact test for significance to compare the mortality rates between groups. Lengths of stay and DC between both groups were reported as medians, and significance was calculated using the Mann-Whitney U test.Results: A total of 267 patients with SS/SS were identified during the 31-month study period. Of these patients, 155 were EDI patients with a mortality rate of 27.7%, and 112 were NEDI patients with a mortality rate of 41.1%. This represents an absolute difference in mortality rates of 13.4% between the 2 groups (P = .0257). The median length of stay between both groups was 7 days for the EDI group and 12.5 days for the NEDI group, translating to median DCs of $9861.01 vs $16 031.07.Conclusions: Emergency department identification of patients with SS/SS in the community hospital significantly improves mortality.

Continuous chest compressions improve survival and neurologic outcome in a swine model of prolonged ventricular fibrillation - Corrected Proof

2011-12-28

Abstract: Introduction: Evidence suggests that any interruptions, including those of rescue breaths, during cardiopulmonary resuscitation (CPR) have significant, detrimental effects on survival. The 2010 International Liaison Committee on Resuscitation guidelines strongly emphasized on the importance of minimizing interruptions during chest compressions. However, those guidelines also stress the need for ventilations in the case of prolonged cardiac arrest (CA), and it is not at present clear at which point of CA the necessity of providing ventilations overcomes the hemodynamic compromise caused by chest compressions' interruption.Methods: Ventricular fibrillation was electrically induced in 20 piglets (19 ± 2 kg) and left untreated for 8 minutes. Animals were randomized to receive 2 minutes of either chest compression-only CPR (group CC) or standard 30:2 compressions/ventilations CPR (group S) before defibrillation. Resuscitated animals were monitored under anesthesia for 4 hours and then were awakened and placed in a maintenance facility for 24 hours.Results: There was no significant difference among groups for both return of spontaneous circulation and 1-hour survival. There was a significant difference in 24-hour survival (group CC, 7/10 vs group S, 2/10; P = .025). Blood lactate levels were significantly lower in group CC compared with group S in both 1 (P = .019) and 4 hours (P = .034) after return of spontaneous circulation. Furthermore, group CC animals exhibited significantly higher mean Neurologic Alertness Score (58 ± 42.4 vs 8 ± 16.9) (P < .05).Conclusion: In this swine CA model, where defibrillation was first attempted at 10 minutes of untreated ventricular fibrillation, uninterrupted chest compressions resulted in significantly higher survival rates and higher 24-hour neurologic scores, compared with standard 30:2 CPR.

Blood ammonia is a predictive biomarker of neurologic outcome in cardiac arrest patients treated with therapeutic hypothermia - Corrected Proof

2011-12-28

Abstract: Purpose: The aim of this study was to investigate the value of commonly examined laboratory measurements, including ammonia and lactate, in predicting neurologic outcome of out-of-hospital cardiac arrest (OHCA) patients treated with therapeutic hypothermia (TH).Methods: This was a retrospective cohort study of patients with a return of spontaneous circulation after OHCA who were treated with TH between February 2007 and July 2010. We measured typical blood measurements on arrival at the emergency department. The subjects were classified into 2 groups: the good neurologic outcome group (Cerebral Performance Category [CPC] 1-2 at 1 month) and the poor neurologic outcome group (Cerebral Performance Category 3-5). We compared blood biomarker levels and basal characteristics between the 2 groups. Logistic regression analyses were performed to determine independent biomarkers that predict poor neurologic outcome.Results: A total of 117 patients were included. Between the 2 groups, significantly different levels of blood measurements included hemoglobin level, pH, Pao2, Paco2, base excess, albumin, glucose, potassium, chloride, bilirubin, phosphorous, and ammonia. In multivariate analyses, blood ammonia level (>96 mg/dL; odds ratio [OR], 7.240; 95% confidence interval [CI], 1.718-30.512), noncardiac causes (OR, 46.215; 95% CI, 9.670-220.873), and time interval from collapse to return of spontaneous circulation (>33 min; OR, 5.943; 95% CI, 1.543-22.886) were significantly related to poor neurologic outcome.Conclusion: Among the blood measurements on emergency department arrival, blood ammonia (>96 mg/dL) was the only independent predictive biomarker of poor neurologic outcome. Thus, higher blood ammonia level was associated with poor neurologic outcome in OHCA patients treated with TH.

Prospective evaluation of an ED observation unit protocol for trauma activation patients - Corrected Proof

2011-12-28

Abstract: Background: The University of Utah emergency department (ED) observation unit (EDOU) cares for over 2500 patients each year, with a significant portion of these patients being trauma activation patients. We evaluated the safety and efficacy of our EDOU trauma protocol and described patient characteristics and outcomes of trauma patients managed in an EDOU.Methods: We performed a prospective observational study of all trauma patients admitted to the EDOU over a 1-year period. Patient disposition, interventions, and adverse events during observation were recorded. Thirty-day follow-up was performed by telephone and chart review to evaluate for missed injuries, repeat hospitalizations, or repeat traumatic events.Results: A total of 259 trauma patients were admitted to the EDOU during the study period and were contacted at least 30 days after discharge. There were no deaths, intubations, or other adverse events. At 30-day follow-up, there was 1 missed injury, which did not result in an adverse outcome. Ten patients were reevaluated in the ED or required hospitalization for events occurring after their initial EDOU stay but related to their initial trauma evaluation. The inpatient admission rate from the EDOU was 10.4%, and 3.1% of patients reported another traumatic event during the 30-day follow-up period.Conclusions: There were no adverse outcomes in trauma patients admitted to the EDOU, and our inpatient admission rate was within the generally accepted admission rate for patients in observation status. The EDOU appears to be a safe alternative to inpatient admission for the evaluation of minimally injured trauma activation patients.

An example of extreme cardiology: chest pain on the high seas and helicoptered medical evacuations: The French Navy experience - Corrected Proof

2011-12-28

Abstract: Medicalized high sea rescue is very different from prehospital medical evacuation. It requires specifically trained medical teams because the difficulties are marine, aerial, and medically related. The French Navy provides medical evacuations by helicopter on the Atlantic coast, up to 320 km offshore and under all weather conditions. The epidemiology of acute chest pain in the high seas has been poorly described. Therefore, in this retrospective study, we aimed to assess the prevalence and constraints found in the management of these emergencies.From January 1, 2000, to April 30, 2009, 286 medical evacuations by helicopter were performed, 132 of which were due to traumatological emergencies, and 154 to medical emergencies. Acute chest pain, with 36 missions, was the leading cause of medical evacuation. All evacuated patients were men who were either professional sailors or ferry passengers. The median age was 48 years (range, 26-79). The most common prehospital diagnosis was coronary chest pain in 23 patients (64%), including 11 patients with acute coronary syndrome with ST-segment elevation. Thirty-two patients were airlifted by helicopter. All patients benefited from monitoring, electrocardiogram, peripheral venous catheter, and medical management as soon as the technical conditions allowed it.

Blood-fluid level on computed tomography head: a sign of warfarin-associated intraparenchymal hemorrhage - Corrected Proof

Manoj K. Mittal, David B. Burkholder, Eelco F. Wijdicks — 2011-12-28

“Blood/fluid level” represents interface between the plasma and sedimented blood and is defined radiologically as presence of area of low computed tomography (CT) attenuation above and high CT attenuation below a discrete line of separation in an area of intraparenchymal hemorrhage. It is a rare finding seen in association with large clot volume of intraparenchymal hemorrhage. We present a case of warfarin-related intraparenchymal hemorrhage presenting with a classic sign of “blood/fluid level” on CT head with small clot volume.

Early embolic events complicating intravenous thrombolysis for acute ischemic stroke - Corrected Proof

Ping Song Chou, Chien Hung Lin, Hai Lun Chao, A Ching Chao — 2011-12-28

Intravenous recombinant tissue plasminogen activator (IV rt-PA) is the only established thrombolytic therapy for acute ischemic stroke. However, secondary embolism after IV rt-PA for acute ischemic stroke is recognized as an uncommon complication, and the pathophysiology is unclear. We describe a 72-year-old man with acute infarction in the territory of left anterior cerebral artery who developed new infarction in the territory of right middle cerebral artery and acute peripheral arterial occlusion after IV rt-PA therapy. It suggested a central embolic source. Because the patient has paroxysmal atrial fibrillation (Af), the possible embolic sources may come from fragmentation of pre-existing intra-atrial clot. Although Af and the presence of cardiac thrombus are not contraindication for IV rt-PA in acute ischemic stroke, our case and review suggested that the administration of IV rt-PA to patients with known Af and intracardiac thrombus could represent a particular risk situation and should be carefully evaluated.

Prospective study of computed tomography in patients with suspected acute appendicitis and low Alvarado score - Corrected Proof

2011-12-28

Abstract: Background: Computed tomography (CT) has been used in diagnosing acute appendicitis since late 1990s. Appropriate use of CT has not been studied prospectively in patients with suspected acute appendicitis and relative low Alvarado score.Methods: Sixty participants with suspected acute appendicitis and an Alvarado score of 4 to 7 points were enrolled for analysis. Clinical and laboratory differences were compared between patients with histologically proven acute appendicitis (AA group) and patients without evidence of acute appendicitis (non-AA group) in the first part of the analysis. In the second part of the analysis, participants were divided into 2 groups: leukocytosis (LK group) and nonleukocytosis (non-LK group).Results: In the first phase of the analysis, there were statistically significant differences in white blood cell count (13.5 K vs 10.9 K per μL), neutrophilia (81.5% vs 73.5%), and hospital stay (4.9 vs 3.5 days) between the 2 groups. Disease spectrum between LK and non-LK groups was obtained in second part of analysis.Conclusion: Computed tomography scan is necessary for patients with relatively low Alvarado score when leukocytosis is noted. In female patients without leukocytosis, further large-scale prospective studies are necessary to change the current diagnostic strategy.

Cerebrospinal fluid biochemistry reflects effects of therapeutic hypothermia after cardiac arrest in a porcine model - Corrected Proof

Rong Hua, Chunsheng Li, Ping Gong, Ziren Tang, Xue Mei, Hong Zhao — 2011-12-28

Abstract: Background: Mild induced hypothermia (MIH) is recommended to treat neurologic injury after cardiac arrest (CA). However, clinical trials to assess MIH benefit after CA have been largely inconclusive. We investigated the subsequent changes in cerebrospinal fluid (CSF) biochemistry after MIH (33°C-34°C for 12 hours) and evaluated the importance of ongoing fever control.Methods: Thirty-two male Wuzhishan inbred mini pigs (n = 16/group) underwent ventricular fibrillation followed by cardiopulmonary resuscitation and were randomized into 2 groups: hypothermic and control. Upon resumption of spontaneous circulation (ROSC) from CA, the hypothermic group was treated with MIH by endovascular cooling. The control group received no temperature intervention. Core temperatures were continually monitored. At various points throughout the procedure, CSF samples were obtained to measure glutamate, lactate, and pyruvate levels.Results: The core temperature of the hypothermic group was found to have increased postrewarming and reached levels comparable with those of the control group at ROSC 72 hours. In both groups, glutamate increased significantly after ROSC, but the glutamate levels in the hypothermic group were lower than those in the control group, except at ROSC 1 hour. The lactate-pyruvate ratio increased in the control group at ROSC 1 hour and was significantly lower in the hypothermic group (P < .05).Conclusions: Mild induced hypothermia mitigated and delayed the CA-induced increase of CSF glutamate. Therefore, our results suggest that clinically inducing hypothermia as soon as possible after CA, or prolonging the time of MIH in combination with controlling ongoing fever, may enhance hypothermic protective effects.

Lung ultrasound associated to capnography to verify correct endotracheal tube positioning in prehospital - Corrected Proof

2011-12-28

Endotracheal intubation is the “gold standard” of the control of airway patency but is associated with nonnegligible morbidity rates. A rapid detection of esophageal intubation is essential. Capnography is considered the reference technique for correct endotracheal tube (ETT) positioning confirmation. However, capnography can provide false-positive and false-negative results in some situations. Recently, the ultrasound assessment has been studied for confirming ETT placement. Despite of few trials, the ultrasound procedure may enhance physician confidence and decision making in airway management. We report the case of a 52-year-old female patient presenting cardiorespiratory failure. During cardiopulmonary resuscitation, there was a sudden absence of end-tidal CO2 capnographic detection. Correct tube positioning could not be ascertained by auscultation because the environment had become extremely noisy. However, TM-mode (Time Motion - mode) lung ultrasound revealed bilateral pleural sliding during insufflation with the self-filling balloon, thus confirming correct ETT positioning.

Amiodarone-induced T-U fusion - Corrected Proof

Hesham R. Omar — 2011-12-28

Amiodarone is a widely used antiarrythmic drug for various atrial and ventricular arrhythmias. It has the potential to cause prolongation of the QT interval, which, in turn, can increases the incidence of torsade de pointes. Amiodarone is also one of the causes of prominent U waves. The presented case exemplifies the phenomenon of amiodarone-induced T-U fusion and QT prolongation. Other causes of QT prolongation as electrolyte abnormalities or administration of other drugs that prolong the QT interval were excluded. Awareness of this phenomenon and method of calculation of QT interval in this scenario is of utmost importance.

Emergent cricothyroidotomies for trauma: training considerations - Corrected Proof

2011-12-28

Abstract: Background: Emergent cricothyroidotomy remains an uncommon, but life-saving, core procedural training requirement for emergency medicine (EM) physician training. We hypothesized that although most cricothyroidotomies for trauma occur in the emergency department (ED), they are usually performed by surgeons.Methods: We conducted a retrospective analysis of all emergent cricothyroidotomies for trauma presentations performed at 2 large level I trauma centers over 10 years. Operators and assistants for all procedures were identified, as well as mechanism of injury and patient demographics were examined.Results: Fifty-four cricothyroidotomies were analyzed. Patients had a mean age of 50 years, 80% were male, and 90% presented as a result of blunt trauma. The most common primary operator was a surgeon (n = 47, 87%), followed by an emergency medical services (EMS) provider (n = 6, 11%) and an EM physician (n = 1, 2%). In all cases, except those performed by EMS, the operator or assistant was an attending surgeon. All EMS procedures resulted in serious complications compared with in-hospital procedures (P < .0001).Conclusions: (1) Prehospital cricothyroidotomy results in serious complications. (2) Despite the ubiquitous presence of EM physicians in the ED, all cricothyroidotomies were performed by a surgeon, which may present opportunities for training improvement.

A before- and after-intervention trial for reducing unexpected events during the intrahospital transport of emergency patients - Corrected Proof

2011-12-28

Abstract: Background: This study was aimed to explore the effect of intervention in safe intrahospital transport on the incidence of unexpected events (UEs) occurring during the transport of emergency patients.Methods: This study was performed in an urban tertiary teaching hospital emergency department (ED) from May 17 to October 30, 2010. Patients older than 15 years who were transported to general wards; intensive care units; and magnetic resonance imaging, intervention, or operation rooms were enrolled. Demographics and data on all UEs related to the devices, clinical situations, and tubes or lines were measured by registered nurses at pre- and postintervention period. The intervention was that acting nurses were required to use a designed transport checklists before the patients were transported. Primary outcomes were the rate of all and serious UEs during the pre- and postintervention periods. Serious UEs were defined as any worsening of a patient's clinical status. Statistical values were measured with 95% confidence intervals (CIs) and compared using Student t tests or χ2 tests.Results: In total, there were 680 transports before interventions and 605 transports after interventions. Overall, UEs decreased significantly from a value of 36.8% (95% CI, 33.1-40.5) in the preintervention period to a value of 22.1% (95% CI, 18.9-25.7) in the postintervention period (P = .001). Serious UEs in clinical status also decreased significantly from 9.1% (95% CI, 7.1-11.5) in the preintervention period to a value of 5.2% (95% CI, 3.6-7.4) in the postintervention period (P = .005).Conclusion: A significant reduction in the rate of total and serious UEs during intrahospital transport from the ED was found through using transport checklists.

Subcutaneous emphysema: an immediate call for chest computed tomographic scan or ultrasonography - Corrected Proof

Hesham R. Omar — 2011-12-28

I have read the interesting article by Amrein et al in a recent issue of the journal regarding posttraumatic occult pneumothorax, which is now increasingly recognized due to the widespread availability of computed tomographic (CT) scans and the advent of the extended focused assessment with sonography for trauma (eFAST) in most centers. The case not only exemplified the phenomenon of occult pneumothorax but also the predictability of occult pneumothorax. The presence of subcutaneous emphysema in the neck or thoracic wall whether clinically or on chest x-ray should be an immediate trigger for obtaining a chest CT scan or ultrasonography to rule out pneumothorax for 3 reasons.

Prospective evaluation of the treatment of pain in the ED using computerized physician order entry - Corrected Proof

2011-12-28

Abstract: Background: Treatment of pain in the emergency department (ED) is a significant area of focus, as previous studies have noted generally inadequate treatment of pain in ED patients. Previous studies have not evaluated the impact of computerized physician order entry (CPOE) on the treatment of pain in the ED. We sought to evaluate treatment of pain before and after implementation of CPOE in an academic ED.Methods: We prospectively enrolled a convenience sample of patients presenting to the ED with a pain-related complaint in 4-month periods before and after CPOE implementation. We compared numbers who received pain medications, time from registration to administration of pain medication, and repeat dosing of pain medication.Results: Six hundred forty-six ED patients participated in the pre-CPOE period, whereas 592 patients participated post-CPOE. Similar numbers of patients received pain medications in the pre-CPOE and post-CPOE periods (55% vs 59%; P = .139), whereas those in the post-CPOE period were more likely to receive a repeat dose of pain medications (10.5% vs 17.6%; P < .001).Conclusion: The use of CPOE in the ED may offer modest benefits in the treatment of patients with pain-related complaints.

Neurogenic stunned myocardium as a manifestation of encephalitis involving cerebellar tonsils - Corrected Proof

Wen-Sou Lin, Yueh-Feng Sung — 2011-12-28

Neurogenic stunned myocardium is defined as a myocardial injury or dysfunction after neurological insults. It is most commonly reported in patients with subarachnoid hemorrhage, and the presenting symptoms may mimic an acute myocardial infarction or myocarditis. In severe cases, cardiogenic shock and acute pulmonary edema may occur and lead to a devastating event. Therefore, it requires prompt recognition and proper intervention. We herein report the case of a 25-year-old woman who presented to our hospital with the symptoms of acute pulmonary edema, shock, and consciousness disturbance. The diagnosis of encephalitis of cerebellar tonsils complicated with acute hydrocephalus and neurogenic stunned myocardium was made. Detailed neurologic examinations, neuroimaging studies, and characteristic echocardiographic changes expedite the correct diagnosis and treatment.

Hospital-level variation in the percentage of admissions originating in the emergency department - Corrected Proof

James Studnicki, Elena A. Platonova, John W. Fisher — 2011-12-28

Abstract: Purpose: Well over half of all US hospital patients are now admitted directly through the emergency department (ED) rather than scheduled through the admissions department by a referring member of the medical staff. This study sought to understand hospital-level variation in the percentage of admissions originating in the ED.Basic Procedures: This was a retrospective, cross-sectional analysis of 5 748 375 ED visits and 2 265 478 inpatient discharge occurring in 192 short-term acute Florida hospitals in calendar year 2005.Main Findings: Hospitals with increasing percentages of patients admitted through the ED are smaller in scale with fewer admissions, beds, and smaller medical staffs but admit a higher percentage of their ED visits to the hospital. Patients in these hospitals are increasingly Hispanic, older, Medicare insured, and likely to represent a preventable ambulatory sensitive condition.Conclusions: The increasing rate of admissions from the ED department is a national trend, but there is substantial variation at the hospital level. In Florida, measures of hospital scale and an older population with some limitations in access to, or the quality of, primary care are the factors influencing hospital-level variation. Factors implicated in increased ED use such as ED visit acuity, lack of insurance, and race are not important contributory variables. The process of admission and, particularly, the role of the organized medical staff in this process are evolving, and the consequences of these changes require further research.

Impact of inappropriate empirical antibiotic therapy on outcome of bacteremic adults visiting the ED - Corrected Proof

2011-12-28

Abstract: Objectives: To investigate the clinical impact of inappropriate empirical antibiotics on patient outcome and determine the risk factors for mortality in bacteremic adults who visited the emergency department (ED).Methods: Bacteremic adults visiting the ED from January 2007 to June 2008 were identified retrospectively. Demographic characteristics, clinical conditions, bacteremic pathogens, antimicrobial agents, and outcomes were determined from chart records.Results: The total of 454 eligible bacteremic adults were included in the analysis; excluded from the study were another 261 patients with contaminated blood cultures and 64 patients with ED stays of less than 24 hours. Among the included individuals, the mean age was 64.6 years, with a small predominance of males (230 patients, 50.7%). Of a total 494 bacteremic isolates, Escherichia coli (206, 41.7%) and Klebsiella species (81, 16.4%) were the most frequently encountered microorganisms. A lower 28-day mortality rate was demonstrated in bacteremic patients treated with appropriate antibiotics than that in those with inappropriate antibiotics or that in those with no antibiotic therapy, as judged by Kaplan-Meier survival curves (P = .01). Moreover, the differences among these three groups achieved higher significance (P = .002) in critically ill patients (Pittsburgh bacteremia scores of ≥4 points). In multivariate analyses, inappropriate antibiotic therapy in the ED was associated independently with mortality at 28 days (odds ratio, 2.26; 95% confidence interval, 1.01-5.13; P = .04).Conclusions: For bacteremic adults visiting the ED, their outcomes were favorable following appropriate antibiotics, compared to treatment with inappropriate antibiotics or no antibiotics.

Assessing prognosis of sepsis in the ED: do we have a magic ball? - Corrected Proof

Ilse M. Espina, Joseph Varon — 2011-12-28

Severe sepsis and septic shock remain the leading causes of in-hospital mortality . These clinical conditions are the second leading causes of death in noncoronary intensive care units and among the top 10 causes of death in the United States . It has been estimated that every year in the United States, 750 000 patients are hospitalized with a diagnosis of sepsis, and approximately 200 000 of these cases will be fatal . In addition to human loss, the economic drain of these conditions places them among the major health issues in this country with an estimated annual costs of $16 billion .

An electrocardiographic sign of tumor invasion of the myocardium - Corrected Proof

2011-12-26

Lung cancer is one of the most common neoplasms associated with cardiac metastasis, and the pericardium is often affected. However, isolated myocardial involvement in these patients is very uncommon. Most tumor invasions into the heart are nonspecific and clinically silent. Myocardial metastasis rarely mimics an acute myocardial infarction. We report a case of a 59-year-old man with a metastatic lung cancer into the myocardium mimicking an acute myocardial infarction.

Spontaneous splenic hemorrhage after initiation of dabigatran (Pradaxa) for atrial fibrillation - Corrected Proof

Charles Haviland Moore, Jonathan Snashall, Keith Boniface, James Scott — 2011-12-26

Dabigatran etexilate (Pradaxa; Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT) is an oral anticoagulant that produces a reliable, dose-dependent anticoagulant effect without the need for routine laboratory monitoring. Dabigatran is a direct thrombin inhibitor, acting like other members in its class (bivalirudin, argatroban) to impede the clotting process through selective and reversible binding with both free and clot-bound thrombin. Dabigatran anticoagulates rapidly: plasma levels peak 2 hours after absorption, with a half-life that ranges between 12 and 17 hours. Dabigatran was approved by the Food and Drug Administration in October 2010 after it compared favorably with warfarin in a large clinical trial studying its efficacy in stroke prevention in atrial fibrillation. Currently, there is no laboratory test on the market by which a physician can quantify the anticoagulation effect of dabigatran, nor is there any antidote to reverse a life-threatening bleed should it occur. We present a case of a patient with splenic hemorrhagic soon after initiation of dabigatran.

Adenosine-induced severe bronchospasm in a patient without pulmonary disease - Corrected Proof

2011-12-16

Adenosine is widely used for the treatment of supraventricular tachycardias for its efficacy and excellent safety, but it has been reported to precipitate severe bronchospasm in patients with pulmonary disease. The drug is therefore contraindicated in asthmatic subjects and should be used with caution in patients with chronic obstructive pulmonary disease. Nevertheless, true bronchospasm is rare and should be distinguished from the much more common occurrence of dyspnea, only as a symptom and without respiratory compromise, which is benign and transient.

A case of cardiac arrest with ST elevation induced by contrast medium - Corrected Proof

2011-12-16

A 62-year-old man with local recurrence of pancreatic cancer underwent his 17th infusion of contrast medium. He had no history of allergy and had not experienced any side effects from the contrast medium during any of the previous examinations. During infusion, he complained of nausea, followed by a loss of consciousness. He was injected intramuscularly with 0.3 mg adrenalin; however, he temporally went into cardiopulmonary arrest. He was therefore injected with 100 mg hydrocortisone and the continuous infusion of dopamine for shock. His electrocardiogram revealed ST elevation. An urgent cardiac echo evaluation revealed hyperkinetic wall motion. As his blood pressure increased after the initiation of the treatment, the ST elevation started to normalize. After transportation to an intensive care unit, the patient did not show chest pain, ST elevation on cardiograms, or any increase in the levels of cardiac markers. Based on his clinical course, the cause of the patient's ST elevation was considered to be coronary vasospasm. Kounis syndrome is the concurrence of acute coronary syndromes with conditions associated with mast cell activation, including allergic or hypersensitivity and anaphylactic or anaphylactoid insults. In cases of coronary vasospasm with shock due to contrast medium, supportive therapy using catecholamine, which has coronary vasodilator activity, and a steroid might be effective to treat the coronary vasospasm. Attention should therefore be paid to the patient's complaints, the findings of real-time cardiosonography, electrocardiograms, and the levels of cardiac markers to ensure a correct diagnosis and to achieve a good treatment outcome.

What is the significance of a previous molar pregnancy? - Corrected Proof

Nancy Lutwak, Curt Dill — 2011-12-14

Emergency department (ED) physicians frequently evaluate women with first trimester vaginal bleeding. Etiologies include spontaneous abortion, ectopic pregnancy, and, rarely, gestational trophoblastic disease. The clinical assessment may be difficult, but the use of transvaginal sonograms and serum quantitative β human chorionic gonadotropin levels is helpful. Pregnant women previously treated for gestational trophoblastic disease may present to EDs with vaginal bleeding. We describe gestational trophoblastic disease and its treatment and discuss the evaluation of a patient with previous history of molar pregnancy presenting to the ED with abdominal pain and vaginal bleeding during a subsequent pregnancy. Gestational trophoblastic disease is uncommon, but ED physicians should be familiar with its possible presentations, treatment, and the implications for future pregnancies in patients with this type of unusual tumor.

Myelopathy and polyneuropathy caused by nitrous oxide toxicity: a case report - Corrected Proof

2011-12-14

Abstract: A 19-year-old man presented with a 1-month history of progressive 4-limb numbness and gait imbalance. Physical examination revealed mild general muscular weakness, areflexia, and wide-based, ataxic, steppage gait. Sensory tests showed diminished superficial sensation below the level of the cervical-thoracic junction and a glove-and-stocking pattern of sensory loss at the 4 extremities. An initial magnetic resonance imaging examination of the cervical spine revealed an increased bilateral signal from the posterior and anterior columns on T2-weighted images. Nerve conduction velocity and electromyographic tests revealed polyneuropathy. On further inquiry, the patient admitted to chronic recreational use of nitrous oxide. The final diagnosis was nitrous oxide–induced neurotoxicity. The patient was treated for 5 days with injections of 1000 μg/day vitamin B12, followed by an additional 2-month treatment at a dose of 1000 μg/week. The numbness resolved after the first week, but there remained a mild sensory ataxic gait. The patient recovered fully after 2 months of treatment and nitrous oxide abstinence. We recommend an investigation of the patient's history of nitrous oxide exposure in cases where an individual presents to the emergency department or outpatient department with acute numbness characterized by megaloblastic red blood cells and symmetric neurologic deficits.

Serum sodium abnormalities during nonexertional heatstroke: incidence and prognostic values - Corrected Proof

2011-12-14

Abstract: Background: Although heatstroke is often associated with dehydration, the clinical significance of serum sodium abnormalities in patients with heat-related illness during heat wave has been poorly documented.Method: We evaluated 1263 patients (age, 82 ± 15 years; body temperature, 40.1°C + 1.2°C) admitted to emergency departments during the August 2003 heat wave in Paris, having a core temperature greater than 38.5°C and measurement of serum sodium concentrations. Patients were classified according to our previously described risk score of death.Results: Hyponatremia (<135 mmol/L) was reported in 409 (32%) and hypernatremia (>145 mmol/L) in 220 patients (17%). One-year survival was significantly decreased in patients with hypernatremia (45%; P = .004) but not in those with hyponatremia (58%; P = .86) as compared with patients with serum sodium concentration in the reference range (57%). Using Cox regression, only hypernatremia was an independent prognostic factor (hazard ratio, 1.35; 95% confidence interval, 1.09-1.36) when risk score was taken into account. Using logistic regression, 2 variables were independently associated with hyponatremia (heatstroke severity score and blood urea nitrogen–creatinine ratio <100). Conversely, 5 variables were independently associated with hypernatremia (living in an institution, dementia, serum creatinine >120 μmol/L, a blood urea nitrogen–creatinine ratio >100, and absence of long-term diuretic intake).Conclusions: Serum sodium abnormalities are frequently observed in patients with a nonexertional heatstroke during heat wave; however, only hypernatremia should be considered as an independent risk factor of death. Rapid measurement of serum sodium concentration is mandatory to appropriately guide electrolyte resuscitation.

The impact of overcrowding on the bacterial contamination of blood cultures in the ED - Corrected Proof

2011-12-14

Abstract: Objectives: This study aims to determine the risk factors associated with the bacterial contamination of blood cultures among adults visiting the emergency department (ED).Methods: Clinical variables and medical records of adults with bacterial growth of blood cultures in the ED as well as the degree of ED crowding, between August 2007 and July 2008, were prospectively collected.Results: Of the 11 491 adults who underwent blood culture sampling, the medical records of 558 (4.86%) eligible patients with bacterial growth in their blood cultures were analyzed. Most patients (366, or 3.19%) had true bacteremia, whereas 192 (1.67%) were regarded as contaminated. In multivariate analyses, ED overcrowding (scoring was based on a National Emergency Department Overcrowding Study [NEDOCS] score ≥100 points) was independently associated with blood culture contamination (odds ratio [OR], 1.58; P = .04). In contrast, other medical comorbidities, such as liver cirrhosis (OR, 0.31; P = .02), thrombocytopenia (<100 000/mm3; OR, 0.28; P = .002), or high serum levels of C-reactive protein (>100 mg/L; OR, 0.24; P < .001), were negatively associated with blood culture contamination. On further analysis of the 5 crowding categories as stratified by NEDOCS scores, which included not busy and busy (0-60 points), extremely busy but not overcrowded (60-100), overcrowded (100-140), severely overcrowded (140-180), and dangerously overcrowded (180-200), there was a strong correlation between blood culture contamination rates and the degrees of ED crowding (γ = 0.99, P < .001).Conclusions: Emergency department overcrowding may have an adverse impact on the quality of clinical care, including increasing the risk of blood culture contamination.

Underdosing of common antibiotics for obese patients in the ED - Corrected Proof

Jada L. Roe, Joseph M. Fuentes, Michael E. Mullins — 2011-12-14

Abstract: Background: Obesity is a growing problem in the United States. Obesity alters the pharmacokinetic profiles of various drugs. Although there are guidelines for dose adjustments for many of the antibiotics commonly used in the emergency department (ED), they are seldom used.Methods: This is an institutional review board–approved retrospective study at an American Society of Metabolic and Bariatric Surgery Center of Excellence and a level I trauma center with annual ED volumes of more than 80 000 visits. Data were retrospectively collected from ED pharmacy records during a 3-month period in 2008. Any first dose of cefepime, cefazolin, or ciprofloxacin administered in our ED to a patient recorded as both more than 100 kg and with a body mass index greater than 40 kg/m2 was compared with our hospital guidelines and found to either adhere or not adhere to those guidelines.Results: There were 1910 orders found to meet the study criteria: 775 orders for cefepime, 625 orders for cefazolin, and 510 orders for ciprofloxacin. Adherence rates for first dose of cefepime, cefazolin, and ciprofloxacin administered, respectively, were 8.0%, 3.0%, and 1.2%.Conclusion: Emergency physicians frequently underdose cefepime, cefazolin, and ciprofloxacin in obese patients. Underdosing antimicrobials presents risk of treatment failure and may promote antimicrobial resistance. Education is necessary to improve early antibiotic administration to obese patients.

Ketamine sedation is not associated with clinically meaningful elevation of intraocular pressure - Corrected Proof

2011-12-14

Abstract: Background: Ketamine is widely used for procedural sedation, but there is limited knowledge on whether ketamine use is associated with elevated intraocular pressure (IOP).Objective: The aim of this study was to examine whether there are clinically important elevations of IOP associated with ketamine use during pediatric procedural sedation.Methods: We prospectively enrolled children without ocular abnormalities undergoing procedural sedation that included ketamine for nonperiorbital injuries. We measured IOP for each eye before and at 1, 3, 5, 15, and 30 minutes after initial intravenous ketamine administration. We performed Bland-Altman plots to determine if IOP measurements in both eyes were in agreement. Linear regression was used to model the mean IOP of both eyes as a function of time, dose, and age, with a robust sandwich estimator to account for repeated measures.Results: Among 25 participants, median (interquartile range) age was 11 (9-12) years, and 18 (72%) were male. Median ketamine dose was 1.88 mg/kg (interquartile range, 1.43-2.03 mg/kg; range 0.96-4 mg/kg). Bland-Altman plots demonstrated a mean difference of IOP between eyes near zero at all time points. The largest predicted difference from baseline IOP occurred at 15 minutes, with an estimated change of 1.09 mm Hg (95% confidence interval, −0.37 to 2.55). The association between ketamine dose and mean IOP was not statistically significant or clinically meaningful (P = .90; estimated slope, 0.119 [95% confidence interval, −1.71 to 1.95]). There were no clinically meaningful levels of increased measured average IOP reached at any time point.Conclusions: At dosages of 4 mg/kg or less, there are not clinically meaningful associations of ketamine with elevation of IOP.

2010: the emergency medical services literature in review - Corrected Proof

Benjamin J. Lawner, Jose Victor Nable, William J. Brady — 2011-12-14

Propofol for sedation can shorten the duration of ED stay in joints reduction - Corrected Proof

Yi-Kung Lee, Chien-Chih Chen, Hsin-Yi Lin, Chen-Yang Hsu, Yung-Cheng Su — 2011-12-14

Abstract: Background: For joints reduction, adequate sedation is often required. Propofol has increasingly been used for sedation in the emergency department (ED) in recent years. The benefits of propofol are the rapid onset of action and the short recovery time. However, whether these characteristics can shorten the duration of ED stay is not been proved.Objective: Our study retrospectively compared patients receiving propofol for sedation during joints reduction with those who received sedatives other than propofol. The primary objective was to compare the duration of ED stay between the 2 groups. The secondary outcomes were rate of adverse events and the success of the procedure.Methods: Patients were included if they had a dislocated joint requiring management in the ED. The following covariates were recorded on a standard form for each patient: age, sex, indication for procedural sedation, sedative used, pain medications used, physician levels, duration of ED stay, failed reduction, and adverse events. We further matched each patient in the propofol group to the patient in the nonpropofol group using a standard propensity score greedy-matching algorithm. The primary and secondary outcomes were compared accordingly.Results: A total of 241 patients met our inclusion criteria and were enrolled for further analysis. In the propensity score assignment, 56 patients (28 in each group) were further selected. The duration of ED stay in the propofol group is significantly shorter compared with the nonpropofol group (127 vs 192 minutes, P = .0019). The successful reduction rate is higher in the propofol group (96.4% vs 64.3%, P = .002). The complication rate is similar in both groups (3.6% vs 0%, P = .313).Conclusion: Propofol is a safe sedative with few complications and higher successful rates when applied in the joints reduction. It can also shorten the duration of ED stay.

Emergency department visits: we are not prepared - Corrected Proof

Charles P. Davis — 2011-12-14

Abstract: Emergency department (ED) staff comments frequently about how patients are poorly prepared to answer important medical questions. To determine if the impression that patients were or were not prepared, a total of 309 patients were all asked a series of important medical questions and were graded as positive (or prepared) if they answered the question completely or negative (unprepared) if they partially answered, did not answer, or changed their answer during the ED stay. The patient population was older (mean age, 60 years) and was seen at 1 specialty hospital. Results indicated that many people were not prepared with information about their allergies, medications, medical and surgical histories, and some, even their physician's names. Patients were least prepared to know about an advance directive (79%) or to know their complete medical history (70%). Results indicated that most patients (99%) were not prepared to answer at least 1 or more important medical questions. The discussion considers why patients and others are not prepared for an ED visit and provides examples of ways to help people better prepare for such a visit.