American Journal of Emergency Medicine - Articles in Press

A rare entity in ED: posterior reversible encephalopathy syndrome - Corrected Proof

Mehmet Fatih Yetkin, Omer Salt, Polat Durukan, Fusun Ferda Erdogan, Seda Ozkan — 2012-05-04

Posterior reversible encephalopathy syndrome is a cliniconeuroradiologic entity with typical symptoms and symmetric high-signal intensity lesions in the bilateral parietooccipital lobes on T2-weighted or fluid-attenuated inversion recovery magnetic resonance imaging. In this presentation, we report a case of posterior reversible encephalopathy syndrome who was admitted to our emergency department because of seizure and deterioration of consciousness. The aim of this presentation is to alert the emergency physicians about one of the hypertensive emergencies with neurologic symptoms associated with hypertension.

Efficacy of high-flow oxygen therapy in all types of headache: a prospective, randomized, placebo-controlled trial - Corrected Proof

2012-05-04

Abstract: Objective: We aimed to assess the efficacy of oxygen inhalation therapy in emergency department (ED) patients presenting with all types of headache.Method: We performed a prospective, randomized, double-blinded, placebo-controlled trial of patients presenting to the ED with a chief complaint of headache. The patients were randomized to receive either 100% oxygen via nonrebreather mask at 15 L/min or the placebo treatment of room air via nonrebreather mask for 15 minutes in total. We recorded pain scores at 0, 15, 30, and 60 minutes using the visual analog scale. At 30 minutes, the patients were assessed for the need for analgesic medication. Patient headache type was classified by the treating emergency physician using standardized diagnostic criteria.Results: A total of 204 patients agreed to participate in the study and were randomized to the oxygen (102 patients) and placebo (102 patients) groups. Patient headache types included tension (47%), migraine (27%), undifferentiated (25%), and cluster (1%). Patients who received oxygen therapy reported significant improvement in visual analog scale scores at all points when compared with placebo: 22 mm vs 11 mm at 15 minutes (P < .001), 29 mm vs 13 mm at 30 minutes (P < .001), and 55 mm vs 45 mm at 60 minutes (P < .001). When questioned at 30 minutes, 72% of patients in the oxygen group and 86% of patients in the placebo group requested analgesic medication (P = .005).Conclusion: In addition to its role in the treatment of cluster headache, high-flow oxygen therapy may provide an effective treatment of all types of headaches in the ED setting.

Therapeutic hypothermia and effects on coagulopathy - Corrected Proof

Narat Srivali, Saeed Ahmed, Wisit Cheungpasitporn, Daych Chongnarungsin — 2012-05-04

We thank Camp-Rogers et al for their excellent case study “Therapeutic hypothermia after profound accidental hypothermia and cardiac arrest.” This was a very interesting case report as usual for the American Journal of Emergency Medicine. The successful therapeutic hypothermia after cardiac arrest in humans was first described in the late 1950s . This therapy has subsequently been recommended by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation and the American Heart Association as one of the mainstay treatment after cardiac arrest . Screening for coagulopathy before initiating the hypothermic protocols is vital and should have been addressed in the case study. Hypothermia may cause significantly impaired homeostatic and coagulation pathways from the fact that the kinetics of enzyme activity are temperature dependent . Coagulopathy is one of the relative contraindication for therapeutic hypothermia. Blood tests for prothrombin time/partial thromboplastin time, fibrinogen, and d-dimer should be considered at admission and every 6 hours during hypothermia treatment period.

Susceptibility-weighted imaging in patient with consciousness disturbance after traffic accident - Corrected Proof

Ling-Chun Huang, Meng-Ni Wu, Chun-Hung Chen, Poyin Huang — 2012-05-04

Both diffuse axonal injury (DAI) and fat embolism syndrome could be the cause of altered consciousness in patients who suffered from traffic accident. In some situations, distinguishing DAI from fat embolism syndrome may be difficult because routine brain imaging could not detect the lesions. Susceptibility weighted imaging is sensitive to detect petechial hemorrhages in cerebral fat embolism and DAI. The areas most vulnerable to DAI are the cerebral gray-white matter junction, splenium of the corpus callosum, and dorsolateral brainstem. However, cerebral and cerebellar white matter and splenium of corpus callosum are the areas most vulnerable to cerebral fat embolism. In additional to history, clinical manifestation, and prognosis, evaluating the distribution of hypointense lesions in susceptibility-weighted imaging could be useful to differentiate these 2 conditions.

The influence of hemorrhagic shock on ventilation through needle cricothyroidotomy in pigs - Corrected Proof

2012-03-30

Abstract: Background: The aim of this study was to examine the effects of controlled hemorrhage and shock on oxygenation and ventilation using needle cricothyroidotomy and jet ventilation in an animal model.Methods: Twenty-four male pigs were randomly allocated into 4 groups: SHOCK (animals in hemorrhagic shock only), CRICH (animals that underwent needle cricothyroidotomy only), SHOCK+CRICH (animals in hemorrhagic shock + needle cricothyroidotomy), and SHAM (anesthetized animals submitted to surgical preparation only). All animals were surgically prepared and were observed for a period of 40 minutes (T0 − T40). Hemodynamic and blood gas variables were compared using analysis of variance and Bonferroni post hoc testing at a level of significance of 95%.Results: CRICH and SHOCK+CRICH developed respiratory acidosis, with a progressive decrease of arterial pH after T20, and they presented a significant increase of PaCO2 levels after T10, when compared with SHAM and SHOCK (P < .001). When SHOCK+CRICH was compared with CRICH, it presented a larger increase of PaCO2 after T10 (P = .036) and an even more significant increase after T20 (P = .009).Conclusion: Hemorrhagic shock anticipated and intensified the retention of carbon dioxide and respiratory acidosis during manual jet ventilation through needle cricothyroidotomy in comparison with animals with jet ventilation but without shock. The results found in this work should be considered in future protocols for the assistance of victims of trauma in prehospital settings.

In-hospital cardiac arrest characteristics and outcome after defibrillator implementation and education: from 1 single hospital in Sweden - Corrected Proof

Marie-Louise Södersved Källestedt, Anders Berglund, Mats Enlund, Johan Herlitz — 2012-03-30

Abstract: Background: Survival after in-hospital cardiac arrest (CA) has been reported to be surprisingly low without any major improvement during the last decade.Aims: The aim of this study is to evaluate the clinical impact (delay to defibrillation and survival after CA) of an intervention within 1 single hospital (Västerås, Sweden), including (1) a systematic education of all health care professionals in cardiopulmonary resuscitation and (2) the implementation of 18 automated external defibrillators.Methods: Information was retrieved from the Swedish National Register of Cardiopulmonary Resuscitation. The differences between the 2 calendar periods were evaluated by χ2 and Fisher exact tests. Logistic regression was used to control for potential confounders.Results: In total, there were 73 in-hospital CAs before (12 months) and 133 after (18 months) the intervention. The overall delay to defibrillation was not reduced after the intervention, and the proportion of survivors to hospital discharge was 26% before and 32% after the intervention (P =.51). Cerebral function, however, was improved after the intervention (as judged by the cerebral performance categories score; P < .001). Thus, the proportion of survivors among all CA patients discharged with a cerebral performance scale score of 1 or 2 (good or acceptable cerebral function) increased from 20% to 32%.Conclusion: An intervention within 1 single hospital (systematic training of all health care professionals in cardiopulmonary resuscitation and implementation of automated external defibrillators) did not reduce treatment delay or increase overall survival. Our results, however, suggest indirect signs of an improved cerebral function among survivors.

Risk scores prognostic implementation in patients with chest pain and nondiagnostic electrocardiograms - Corrected Proof

2012-03-30

Abstract: Background: Several risk scores are available for prognostic purpose in patients presenting with chest pain.Aim: The aim of this study was to compare Grace, Pursuit, Thrombolysis in Myocardial Infarction (TIMI), Goldman, Sanchis, and Florence Prediction Rule (FPR) to exercise electrocardiogram (ECG), decision making, and outcome in the emergency setting.Methods: Patients with nondiagnostic ECGs and normal troponins and without history of coronary disease underwent exercise ECG. Patients with positive testing underwent coronary angiography; otherwise, they were discharged.End point was the composite of coronary stenosis at angiography or cardiovascular death, myocardial infarction, angina, and revascularization at 12-month follow-up.Results: Of 508 patients considered, 320 had no history of coronary disease: 29 were unable to perform exercise testing, and finally, 291 were enrolled. Areas under the receiver operating characteristic curves for Grace, Pursuit, TIMI, Goldman, Sanchis, and FPR were 0.59, 0.68, 0.69, 0.543, 0.66, and 0.74, respectively (P < .05 FPR vs Goldman and Grace). In patients with negative exercise ECG and overall low risk score, only the FPR effectively succeeded in recognizing those who achieved the end point; in patients with high risk score, the additional presence of carotid stenosis and recurrent angina predicted the end point (odds ratio, 12 and 5, respectively). Overall, logistic regression analysis including exercise ECG, coronary risk factors, and risk scores showed that exercise ECG was an independent predictor of coronary events (P < .001).Conclusions: The FPR effectively succeeds in ruling out coronary events in patients categorized with overall low risk score. Exercise ECG, nonetheless being an independent predictor of coronary events could be considered questionable in this subset of patients.

An electrocardiogram technician improves in-hospital first medical contact-to-electrocardiogram times: a cluster randomized controlled interventional trial - Corrected Proof

2012-03-30

Abstract: Background: In the case of chest pain, the current guidelines require electrocardiogram (ECG) recording and patient assessment within 10 minutes upon arrival in the emergency department.Methods: We investigated the effect of an ECG technician (ECG-T) on in-hospital first medical contact-to-ECG times (iFMC-to-ECG) investigated in a cluster randomized, controlled trial. Allocation of intervention was concealed. Staff satisfaction and feasibility was defined as a secondary outcome. Delays between ECG and the availability of an emergency physician and the assessment of ECG were additionally evaluated.Results: A total of 163 (44 clusters) and 191 (47 clusters) patients were allocated to control and intervention, respectively. Twenty-seven (17%) of 163 patients in the control group vs 110 (58%) of 191 patients in the intervention group received ECG registration within 10 minutes (risk ratio, 3.40 [2.24-5.15]; P < .001). The iFMC-to-ECG time was 23 (95% confidence interval [CI], 20-27) minutes for the control group vs 9 (95% CI, 8-11) minutes for the intervention group (P < .001). Nursing staff judged the feasibility of intervention with a median of 1 (interquartile range [IQR], 1-1 (on a scale of 1 [best] to 5 [worst]), perceived workload alleviation with a median of 1 (IQR, 1-1), and improvement of quality of care with a median of 1 (IQR, 1-2). The ECG-to-EP time was 78 (95% CI, 64-92) seconds, and diagnosis was made within 17 (95% CI, 16-18) seconds.Conclusions: Delays of iFMC-to-ECG can be effectively addressed by implementation of an ECG-T. The service of an ECG-T is feasible and improves staff satisfaction. Both ECG-to-EP time and ECG assessment constitute no relevant delay.

A randomized controlled trial of adding intravenous pantoprazole to conventional treatment for the immediate relief of dyspeptic pain - Corrected Proof

2012-03-30

Abstract: Introduction: Acute, severe dyspeptic pain is a common condition in the emergency department. Despite the traditional “GI cocktail” (GI indicates gastrointestinal), an intravenous (IV) proton pump inhibitor (PPI), a novel acid-lowering drug, has recently been used to treat this condition. The aim of this study was to evaluate the immediate effect of IV pantoprazole in addition to the conventional GI cocktail in the relief of severe dyspeptic pain.Methods: This double-blind, randomized, controlled study was conducted in the emergency department of an urban tertiary-care hospital from January 2011 to October 2011. Selected patients with severe dyspeptic pain were randomized to treatment with a placebo, antacid, and antispasmodic (conventional group) or IV pantoprazole, antacid, and antispasmodic (pantoprazole group). The self-reported 100-mm visual analog scale score, adverse effects, and overall satisfaction were evaluated in 15-minute intervals for 60 minutes.Results: Eighty-seven eligible cases were enrolled in the study. Forty-four and 43 patients were randomized in the conventional group and pantoprazole group, respectively. There was no difference in the mean 60-minute visual analog scale scores between the treatment groups. The rate of “responders,” additional drug use, adverse effects, and patient satisfaction were similar between the groups.Conclusion: Intravenous PPI provides no additional benefit over the conventional GI cocktail in the relief of acute, severe dyspeptic pain. Because of its neutral effect and higher cost, the use of IV PPI to treat such conditions should be discouraged in general clinical practice.

The use of i-gel extraglottic airway in a trauma patient - Corrected Proof

2012-03-30

Endotracheal intubation (ETI) is currently the “gold standard” for airway management in a prehospital setting, but this is a complex technique requiring practice and experience. Alternative procedures are essential for emergency physicians, to reduce unfavorable effects of multiple failed intubation attempts . The i-gel disposable airway (Intersurgical Ltd, Workingham, UK) is proposed as a new supraglottic airway device made of a medical grade thermoplastic elastomer (). Its unique design does not need an inflatable cuff because the thermoplastic elastomer provides the seal . The i-gel is gaining a reputation for ease of insertion and for its use in many clinical situations . Initial studies have demonstrated that the i-gel can be placed more quickly than conventional laryngeal mask airways, which might play a role in prehospital settings .

Sonographic evaluation of a paralyzed hemidiaphragm from ultrasound-guided interscalene brachial plexus nerve block - Corrected Proof

Daniel Mantuani, Arun Nagdev — 2012-03-30

The ultrasound-guided interscalene brachial plexus is becoming increasingly popular for anesthesia in the management of upper-extremity injuries by emergency physicians. Traditional high-volume injections of local anesthesia will also affect the phrenic nerve, leading to temporary paralysis of the ipsilateral hemidiaphragm. With direct ultrasound guidance, more precise needle placement allows for lower-volume injections that reduce inadvertent spread of local anesthetic to the phrenic nerve without decreasing the efficacy of onset of time and quality of the block. However, the risk of incidental paralysis of the hemidiaphragm is still not eliminated with low-volume intraplexus injections. This case highlights this common complication of interscalene brachial plexus nerve blocks and demonstrates how emergency physicians can easily use B-mode and M-mode ultrasound to evaluate the paralysis of the hemidiaphragm.

Heart-type fatty acid–binding protein as a prognostic factor in patients with severe sepsis and septic shock - Corrected Proof

2012-03-30

Abstracts: Objective: This study was performed to evaluate whether heart-type fatty acid–binding protein (H-FABP) could predict 28-day mortality in patients with severe sepsis and septic shock.Methods: We performed a prospective observational study and included consecutive patients with severe sepsis and septic shock. Patients' demographic data, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and the blood test results including H-FABP concentrations were compared between the 28-day survivors and nonsurvivors. The association between the concentration of H-FABP and survival was analyzed with multivariate logistic regression and Cox proportional hazards regression analyses. The prognostic performance of H-FABP was compared with those of the APACHE II score and albumin using the area under the receiver operating characteristic curve.Results: Of the 99 patients, 38 (38%) died. The mortality rate increased with increasing H-FABP concentration. In multivariate logistic regression analyses, H-FABP greater than 40 ng/mL was an independent predictor of mortality compared with H-FABP less than 7 ng/mL (odds ratios, 9.23; 95% confidence interval, 1.29-65.86). By Cox proportional hazards analysis, H-FABP greater than 40 ng/mL was associated with a 5.57-fold increased risk for death during the 28-day follow-up period (hazard ratio, 5.57; 95% confidence interval, 1.20-25.80). The area under the receiver operating characteristic curve of H-FABP was 0.739 (95% confidence interval, 0.640-0.839), which was comparable with those of the APACHE II score and albumin.Conclusion: The H-FABP was an independent prognostic factor and could be a useful biomarker for 28-day mortality in patients with severe sepsis and septic shock.

Superior vena cava syndrome masquerading as an allergic reaction - Corrected Proof

Jamie S. Johnson, Joseph G. Kotora, Brett F. Bechtel — 2012-03-30

Patients are often referred to the emergency department for further evaluation, yet the astute physician will maintain a broad differential to avoid anchoring on prior diagnoses. In this case, a 56-year-old man was referred to our emergency department from the radiology suite secondary to concerns for an “allergic reaction” to prior magnetic resonance imaging contrast. Upon presentation, he was noted to have facial swelling with ruddy appearance and vascular congestion extending to the midchest region; no airway compromise or dyspnea was noted. He had a smoking history and recent diagnosis of brain mass, which, combined with his current appearance, was concerning for superior vena cava syndrome. A chest x-ray that demonstrated right mediastinal mass was ordered, and a computed tomographic scan confirmed compression of the superior vena cava. A brief discussion on the history, etiologies, presentation, and evaluation of superior vena cava syndrome is discussed.

Unilateral paralysis associated with profound hypokalemia - Corrected Proof

Wen-Fang Chiang, Fu-Chiang Yeh, Shih-Hua Lin — 2012-03-30

Unilateral paralysis is rarely reported to be primary presentation of severe hypokalemia. We describe a 24-year-old woman who presented to the emergency department with sudden onset of right-sided weakness. Neurologic examination revealed diminished muscle strength and tendon reflexes over the right limbs. Computed tomography of the brain showed no organic brain lesion. However, laboratory data showed hypokalemia (K+ 2.0 mmol/L) with metabolic acidosis (HCO3− 19 mmol/L). She needed a total of 260 mmol K+ to achieve complete recovery of muscle strength at a serum K+ level of 3.2 mmol/L and was proved to have distal renal tubular acidosis. Severe hypokalemia must be kept in mind as a cause of acute unilateral paralysis without organic lesions to avoid unnecessary examination and potentially life-threatening complications.

Age variability in pediatric injuries from falls - Corrected Proof

Purnima Unni, Matthew Ryan Locklair, Stephen E. Morrow, Cristina Estrada — 2012-03-19

Abstract: Objective: The objective of this study is to examine the nature and circumstances surrounding pediatric fall-related injuries for specific age groups and their implications for age-appropriate injury prevention efforts.Methods: This is a retrospective analysis of data (October 2006 to April 2009) from the trauma registry of a level 1 pediatric trauma center. Inclusion criteria are patients admitted because of fall-related injury younger than 15 years (n = 675). Injury mechanism specifics were obtained from medical records.Results: Falls were the leading cause of admissions and accounted for 37% of all cases during this period. Most pediatric fall-related injuries (73%) occurred between 1 and 9 years of age. Although infants accounted for only 8% of fall injuries, a greater proportion of these children were more severely injured. The mean Injury Severity Score for infants was significantly greater than the overall average (P < .001). Causes of fall injuries vary by age and have been discussed.Conclusions: The high incidence of pediatric fall injuries warrants dedicated injury prevention education. Injury prevention efforts need to be age appropriate in terms of focus, target audience, and setting. Recommendations for injury prevention are discussed.

Potential synergy between advanced primary stroke centers and level I or II trauma centers in the United States - Corrected Proof

2012-03-19

Abstract: Objective: The objective of this study is to determine the number of primary stroke centers (PSCs) that exist concurrently (synergic relationship) with designated higher level trauma centers (level I or level II trauma centers) and associated characteristics.Methods: We identified all PSCs certified by the Joint Commission or local state authorities in 2010. Concurrently, all the higher level trauma centers (designated level I or level II) were identified using data collected from the trauma information exchange program. Additional data was collected from the Accreditation Council for Graduate Medical Education and the American hospital directory.Results: A total of 788 existing designated PSCs were identified in 2010; coexisting PSC-trauma centers were found in 252 centers (32%) with PSCs coexisting with level I trauma centers in 138 hospitals (17.5%). The remaining 536 PSCs (68%) are based in hospitals without trauma centers. There was a higher proportion of residency training programs including neurology, neurosurgery, and general surgery in coexisting PSC-trauma centers (P < .001). In a proof-of-concept analysis in 1 state, PSCs with level I trauma facilities were found to have the highest rates of thrombolytic administration as compared with PSCs with level II trauma centers and PSCs without trauma facilities (12.8% vs 3.8% vs 4.9%)(P < .0001). Primary stroke centers with level I trauma facilities were also more likely to follow the drip-and-ship paradigm (5.7% vs 1.8% vs 0.9%) (P < .0001).Conclusions: Despite evidence of higher capability among institutions with coexisting PSC-trauma centers, two thirds of PSCs are in hospitals without advanced trauma systems. These findings have implications for establishing stroke systems in the United States.

Delayed presentation of hypovolemic shock after a simple pubic ramus fracture: a case report and literature review - Corrected Proof

Wai-Ming Kong, Cheuk-Kwan Sun, I-Ting Tsai — 2012-03-19

Although trauma-induced simple pubic ramus fracture is common in the emergency department (ED), it can result in life-threatening hemorrhagic shock. We describe a 58-year-old woman with closed minimally displaced simple pubic ramus fracture. Hemodynamic instability became apparent 2 hours later. She was successfully treated with transarterial embolization and discharged uneventfully 10 days later. Literature review showed involvement of the superior pubic ramus in all reported cases probably because of hemorrhage from “corona mortis” with delay in shock presentation mostly within 6 hours, suggesting at least an equivalent observation period for these patients, particularly those at high risk for hemorrhage.

Analysis of the appropriate age and weight for pediatric patient sedation for magnetic resonance imaging - Corrected Proof

2012-03-19

Abstract: Sedatives with a long duration are required for pediatric magnetic resonance imaging (MRI) in the emergency department. The success rate of chloral hydrate for pediatric sedation is 80% to 100% according to some studies. However, the success rate varies by age, weight, and underlying disease. To identify factors affecting the success rate, we compared the chloral hydrate sedation success rate and adverse event rate by age, weight, and underlying disease. Compared with patients in the failure group, patients in the successful group were younger (23.8 vs 36.9 months, P < .01) and weighed less (11.4 vs 14.4 kg, P < .01). No differences in neurological problems, reasons for MRI, or adverse events were observed between the 2 groups. Patients 18 months old had a success rate greater than 95%, but the success rate decreased in children older than 18 months. The adverse event rate was about 10% in patients 18 months old and increased to 20% in patients older than 36 months. Patients 24 months of age who had a neurological problem (seizure disorder or developmental delay) had a success rate greater than 95%, but the adverse event rate increased after 24 months of age. Chloral hydrate sedation was appropriate for pediatric MRI in patients younger than 18 months. Although we observed no fatal adverse events, it is necessary to monitor patients until full recovery from sedation.

External laryngeal manipulation does not improve the intubation success rate by novice intubators in a manikin study - Corrected Proof

Nir Samuel, Karyn Winkler, Shuny Peled, Baruch Krauss, Itai Shavit — 2012-03-19

Abstract: Background: External laryngeal manipulation (ELM) is a technique used in cases of poor glottic view in direct laryngoscopy. Studies investigating ELM in the pediatric population are lacking. The objective of this study was to examine if use of ELM by inexperienced intubators improves the success rate of pediatric intubation.Methods: We conducted a randomized, controlled, manikin study comparing intubation using ELM (study subjects) with standard intubation (controls). Study participants were paramedic students. Each participant performed 1 intubation attempt on 3 different pediatric airway manikins, independently. If an optimal Cormack-Lehane glottic view (CLGV) of more than 2 has been obtained, study subjects were previously instructed to perform the intubation using ELM; controls were instructed to continue with standard intubation. Outcome measures were single-attempt intubation success rate, preintubation CLGV, and duration of intubation.Results: The study group included 13 subjects who performed 39 intubations. In 19 intubations, CLGV of more than 2 had been obtained; and ELM was used. The control group included 14 subjects who performed 42 intubations. In 20 intubations, CLGV of more than 2 was obtained. Median CLGV score improved from 3.5 before ELM to 2 when ELM was used. However, no difference was found between the groups in intubation success rate (10/19 vs 14/20, P = .43); and the duration of intubation was significantly shorter in controls (25.8 vs 37.8 seconds, P < .007).Conclusions: In this pediatric manikin study, ELM performed by novice intubators improved laryngeal view, but lengthened the duration of intubation and did not improve intubation success rate.

The influence of physician seniority on disparities of admit/discharge decision making for ED patients - Corrected Proof

Kuan-Han Wu, I-Chuan Chen, Chao-Jui Li, Wen-Cheng Li, Wen-Huei Lee — 2012-03-19

Abstract: Objectives: Differences in disposition between emergency physicians (EPs) have been studied in select patient populations but not in general emergency department (ED) patients. After determining whether a difference existed in admit/discharge decision making of EPs for general ED patients, we focus our study in examining the influence of EP seniority on the decision to discharge ED patients.Methods: In a 1-year retrospective study, we included a convenience sample of all 18 953 adult nontraumatic ED patients. We reviewed the admit/discharge dispositions at each shift made by 16 EPs. EPs were categorized by seniority to determine whether seniority influenced disposition. Three groups had 5, 4, and 7 EPs each, with >10 years, 5 to 9 years, and <5 years of working experience, respectively.Results: Patient demographics, triage level, and number of patients per shift did not differ statistically between EPs and each group. The number of discharged patients per shift differed statistically between EPs (P < .001) and each group. The most senior EPs had the lowest discharge rates compared with EPs in intermediate and junior groups. They had lower discharge rates for patients at triage levels 1, 2, and 3 as well as for all patients. However, no difference in unscheduled ED revisit rates was found.Conclusions: EPs vary in their admit/discharge decision making for general ED patients. More importantly, the most senior EPs were found to have the lowest discharge rates compared with their junior colleagues.

Intraabdominal focal fat infarction in a 75-year-old woman presenting as acute abdomen - Corrected Proof

2012-03-19

Epiploic appendagitis is a rare, self-limiting inflammation of the epiploic appendices or omental appendices. It presents as abdominal pain often misdiagnosed as appendicitis, cholecystitis, or diverticulitis. Epiploic appendagitis can be treated conservatively with anti-inflammatory and pain medications. It is important to diagnose this etiology of abdominal pain in order to avoid long-term hospital stay and other medical expenses including surgery. In this case report we present a rare case of epiploic appendagitis that presents in a 75 year old female patient.

Effect of intravenous fat emulsion therapy on glyphosate-surfactant–induced cardiovascular collapse - Corrected Proof

YeonHo You, Won Jun Jung, Mi Jin Lee — 2012-03-19

Intravenous fat emulsion (IFE) therapy is an adjunct therapy administered to hemodynamically compromised patients with glyphosate-surfactant intoxication when they respond poorly to conventional therapies such as fluid resuscitation or vasopressors . However, the use of IFE as an adjunct therapy in collapsed patients with glyphosate intoxication has not been reported previously. Here, we describe the case of a patient with glyphosate-surfactant–induced cardiovascular collapse who responded to IFE.

Impact of metformin use on the prognostic value of lactate in sepsis - Corrected Proof

2012-03-19

Abstract: Objective: The objective of this study is to determine if metformin use affects the prevalence and prognostic value of hyperlactatemia to predict mortality in septic adult emergency department (ED) patients.Methods: This is a single-center retrospective cohort study. Emergency department providers identified study subjects; data were collected from the medical record.Patients: Adult ED patients with suspected infection and 2 or more systemic inflammatory response syndrome criteria were included. The outcome was 28-day mortality. The primary risk variable was serum lactate (<2.0, 2.0-3.9, ≥4.0 mmol/L) categorized by metformin use; covariates: demographics, Predisposition, Infection, Response, Organ Dysfunction score and metformin use contraindications.Setting: The study was conducted at an urban teaching hospital; February 1, 2007 to October 31, 2008.Results: A total of 1947 ED patients were enrolled; 192 (10%) were taking metformin; 305 (16%) died within 28 days. Metformin users had higher median lactate levels than nonusers (2.2 mmol/L [interquartile range, 1.6-3.2] vs 1.9 mmol/L [interquartile range, 1.3-2.8]) and a higher, although nonsignificant, prevalence of hyperlactatemia (lactate ≥4.0 mmol/L) (17% vs 13%) (P = .17). In multivariate analysis (reference group nonmetformin users, lactate <2.0 mmol/L), hyperlactatemia was associated with an increased adjusted 28-day mortality risk among nonmetformin users (odds ratio [OR], 3.18; P < .01) but not among metformin users (OR, 0.54; P = .33). In addition, nonmetformin users had a higher adjusted mortality risk than metformin users (OR, 2.49; P < .01). These differences remained significant when only diabetic patients were analyzed.Conclusions: In this study of adult ED patients with suspected sepsis, metformin users had slightly higher median lactate levels and prevalence of hyperlactatemia. However, hyperlactatemia did not predict an increased mortality risk in patients taking metformin.

Factors associated with shock in anaphylaxis - Corrected Proof

Hyun Jun Park, Sun Hyu Kim — 2012-03-19

Abstract: Background: The aim of this study was to investigate the clinical characteristics of anaphylactic shock and the factors associated with anaphylactic shock in anaphylaxis.Methods: Data were retrospectively collected from patients with anaphylaxis for 10 years. Study subjects were searched with broad disease codes including anaphyla-, adverse, angioedema, allergy, insect bite, bee, and hypersensitivity to prevent omission. All the 294 study subjects were divided into shock and nonshock groups.Results: The mean age of the subjects was 43 years old, and males comprised 162 patients (55%). There were 119 patients (41%) in the shock group and 175 patients in the nonshock group. Age was older in the shock group than in the nonshock group; however, there was no difference in sex between 2 groups. Frequent causes of anaphylaxis were drugs in the shock group and food in the nonshock group. Nonsteroidal anti-inflammatory drugs and radiocontrast media were the most common cause of drug-induced anaphylaxis in the nonshock group and shock group, respectively. Cardiovascular symptoms were the most frequent symptoms in the shock group. Factors associated with the shock in cases with anaphylaxis were old age, emergency department (ED) arrival by emergency medical services use, radiocontrast material, symptoms with cyanosis, syncope, and dizziness.Conclusion: Elderly anaphylactic patients with symptoms of cyanosis, syncope, and dizziness were at increased risk for the development of shock. Physicians in the ED have to be alert to the possibility of progression to shock in patients with anaphylaxis, and early recognition of anaphylactic shock is critical for adequate treatment.

Optimal headrest height for the best laryngoscopic view: by anatomical measurements - Corrected Proof

2012-03-19

Abstract: Background: We hypothesized that the oro-pharyngolaryngeal axes, occipito-atlanto-axial extension (OAA) angle and intubation distance would be influenced by the height of headrests.Methods: Twenty patients were enrolled. The Macintosh 3 blade was used for direct laryngoscopy without a headrest or with the headrest of 6 or 12 cm high in randomized order, whereas a lateral radiograph of the neck was taken when the best laryngoscopic view was obtained. The following measurements were made: (1) the axis of the mouth (MA), the pharyngeal axis (PA), the laryngeal axis (LA), and the line of vision (LV). The various angles between these axes were defined: α angle between MA and PA, β angle between PA and LA, and δ angle between LV and LA. (2) Intubation distance, (3) mentovertebral distance, and (4) OAA angle.Results: Compared with 12-cm and no headrest, the δ angle decreased significantly with 6-cm headrest (19.4°/29.2°/29.2° in 6-cm/12-cm/no headrest, respectively; P < .001), and the intubation distance increased significantly (46.2/37.3/38.7 mm in 6-cm/12-cm/no headrest, respectively; P < .001). Mentovertebral distance was smallest (107.0/106.7/98.5 mm; P < .05) at 12-cm headrest. Occipito-atlanto-axial extension angle was largest significantly (40.7°/35.2°/34.5°; P < .05) at 6-cm headrest.Conclusion: We conclude that compared with no or 12-cm headrest, 6-cm headrest could facilitate more alignment of these axes, increase the OAA angle, and enlarge the intubation distance.

Twitter use during emergency medicine conferences - Corrected Proof

2012-03-19

The Internet has become ubiquitous in all of our lives and medical education. With the advent of Web 2.0 and social media, there has been a push for new media to have value and purpose. It has been postulated that social media has value as a tool for medical education . However, most publications focus on guidelines or reports of unprofessionalism .

Takotsubo cardiomyopathy associated with hypoglycemia: inverted takotsubo contractile pattern - Corrected Proof

Shungo Katoh, Yoichi Yamada, Rikiya Shinohe, Kenji Aoki, Masahiko Abe — 2012-03-19

Classic takotsubo cardiomyopathy (TCM) is characterized by transient dysfunction of the apical portion of the left ventricle with hyperkinesis of the other parts of the heart wall. Recently, wall motion abnormalities in parts other than in the apical portion of the heart have been reported. Inverted TCM is one form of these anomalies. In this form, the basal segments rather than the apical part of the heart are akinetic/dyskinetic, and the apex is hyperdynamic. Emotional or physical stress is known to trigger TCM, leading some authors to call TCM stress-induced cardiomyopathy (SC). Hypoglycemia is regarded as one of the physical stresses that cause TCM/SC. We present a case of inverted TCM/SC with hypoglycemia. In this case, a 60-year-old woman was brought to our hospital with loss of consciousness caused by hypoglycemia. Initially, the echocardiography revealed an inverted takotsubo contractile pattern. The patient was stabilized with continuous intravenous fluids and a glucose injection, whereas the echocardiography on day 4 showed an almost normal contractile pattern. Among the case reports regarding hypoglycemia as a preceding stressor of TCM/SC, a case of inverted TCM/SC with hypoglycemia is rare. Hypoglycemia is a relatively common case in emergency department; however wall motion abnormalities are not usually expected in hypoglycemic patients. Thus, undiagnosed self-limited TCM/SC cases are possible among hypoglycemic patients. TCM/SC is reported to be a cause of torsade de pointes, which can be fatal. This might warrant an echocardiogram for hypoglycemic patients so as not to overlook TCM/SC in the emergency department.

Short- and long-term cardiac events in patients with chest pain with or without known existing coronary disease presenting normal electrocardiogram - Corrected Proof

2012-03-19

Abstract: Aim: The aim of this study is to evaluate incidence of adverse cardiac events in patients with chest pain with or without known existing coronary disease presenting normal electrocardiogram (ECG) and initial troponin.Methods: Prospective, nonrandomized study enrolled low-risk patients with normal ECG and troponin on admission who underwent observation and/or stress testing by unstandardized clinical judgment. Patients who experienced recurrent angina or positive ECGs or positive troponins during observation or patients with positive stress testing were admitted; otherwise, they were discharged.End Point: The end points are cardiac events at short- and long-term follow-up including cardiovascular death, myocardial infarction, unstable angina, and revascularization.Results: Of 5656 patients considered, 1732 with ischemic ECG were initially admitted and, therefore, excluded from the analysis; 2860 with pleuritic chest pain and normal ECG were discharged; 1064 with visceral chest pain and normal ECG were enrolled. Patients with known coronary disease (45%) were older and likely presented known vascular disease. Patients with known vascular disease, older age, female sex, diabetes mellitus, and lower chest pain score were likely managed with observation. In patients with known coronary disease as compared with patients without, overall cardiac events account for 35% vs 14%, respectively (P < .001), as follows: in-hospital, 23% vs 10%, (P < .001); 1 month, 4% vs 2% (P = .133); and 9.9 ± 4.9 months, 8% vs 2%, respectively (P < .001).Conclusions: One-third of patients with chest pain with known coronary disease, negative ECG, and biomarkers were subsequently found to have adverse cardiac events. The value of this research for an emergency medicine audience could be extended to all clinicians and general practitioners beyond cardiologists.

A hitch in hiccups - Corrected Proof

2012-03-19

We have read the article by Davenport et al with great interest. This article is a salient reminder for the emergency physicians (EP) to consider cardiac etiology in the high-risk patients whenever the symptoms are apparently only gastrointestinal and to give additional weightage for hiccup. Recent literature suggests that diabetes is closely linked to heart disease, and it is a risk factor for acute myocardial infarction (MI) an equivalent to known coronary artery disease. Chowta and colleagues had observed atypical symptoms such as epigastric pain or abdominal distress in 50% of patients with inferior-wall MI presented to them. Also, painless infarction was demonstrated in those patients with inferior-wall MI . The hiccups were seen much more often in patients with inferior MI compared with infarctions of other territory. It may be explained by the anatomical fact that the vagal fibers of cardiac plexus are within the inferoposterior myocardium and the phrenic nerve, which provide motor fibers to the diaphragm and sensory branches to the pleura and pericardium. The irritation from the infarct area or ischemia may result in stimulation of these fibers and cause hiccups. In view of that, treating physicians shall consider extension of infarction to inferior wall if a patient with an otherwise stable MI develops hiccup. Missed MI remains one of the greatest sources of litigation against EP. Med America mutual malpractice cases suggest that EP must maintain high index of suspicion for acute coronary syndrome and always recognize the possibility of an atypical presentation.

Comparison of ultrasonographic methods as a marker of blood loss - Corrected Proof

2012-03-19

Hypovolemia evaluation with bedside ultrasonography has been studied previously . Difficulties as large body size, excessive bowel gasses, or large amount of intrathoracic air have been leaded emergency physicians (EPs) to investigate different types of ultrasonographic location to asses the hypovolemia by bedside ultrasonography (BUS). Previously, we have shown that right ventricular outflow tract fractional shortening (RVOTFS) can be alternative method for noninvasive measurement of low central venous pressure . This study compared RVOTFS and inferior vena cava collapse index (IVCCI) before and after blood donation of the volunteers in prospective, cross-sectional, cohort fashion.

Utilization of coronary computed tomography angiography for exclusion of coronary artery disease in ED patients with low- to intermediate-risk chest pain: a 1-year experience - Corrected Proof

2012-03-19

Abstract: Objective: We describe our preliminary experience with coronary computed tomography angiography (CCTA) in emergency department (ED) patients with low- to intermediate-risk chest pain.Methods: A convenience cohort of patients with low- to intermediate-risk acute chest pain presenting to a suburban ED in 2009 were prospectively enrolled if the attending physician ordered a CCTA for possible coronary artery disease. Demographic and clinician data were entered into structured data collection sheets required before any imaging. The results of CCTA were classified as normal, nonobstructive (1%-50% stenosis), and obstructive (>50% stenosis). Outcomes included hospital admission and death within a 6-month follow-up period.Results: In 2009, 507 patients with ED chest pain had a CCTA while in the ED. The median (interquartile range) age was 54 (47-62) years; 51.5% were female. Thrombolysis in myocardial infarction risk scores were 0 (42.6%), 1 (42.2%), 2 (11.8%), 3 (2.4%), and 4 (1.0%). The results of CCTA were normal (n = 363), nonobstructive (n = 123), and obstructive (n = 21). Admission rates by CCTA results were obstructive (90.5%), nonobstructive (4.9%), and normal (3.0%). None of the patients with normal or nonobstructive CCTA died within the 6-month follow-up period (0%; 95% confidence interval, 0-0.9%).Conclusions: Many ED patients with low- to intermediate-risk chest pain have a normal or nonobstructive CCTA and may be safely discharged from the ED without any associated mortality within the following 6 months.

What do you think about the best time for surgical intervention in patients with massive pulmonary embolism? - Corrected Proof

Khalil Zarrabi, Hamed Ghoddusi Johari, Azimeh Azimifar — 2012-03-19

We read with great interest the article by Close and Cherkas “Successful treatment of presumed massive pulmonary embolism during cardiac arrest,” which describes about the first documented case of successful use of reteplase for presumed massive pulmonary embolism during cardiac arrest in the United States. It is very interesting that the patient had such a dramatic response to reteplase. However, the fact that made us write this article is that we have performed and published a large study from 2004 until 2010 on 30 patients with massive and submassive pulmonary embolism in which retrograde pulmonary embolectomy was used as a main treatment modality . In this method, the patients with lack of response to thrombolytic therapy and those who are critically ill or have contraindications for thrombolytic therapy are given a surgical option.

To-Go medications for decreasing ED return visits - Corrected Proof

2012-03-19

Abstract: Objectives: The primary objective was to determine if providing patients with a complete course of antibiotics for select conditions would decrease the rate of return to the emergency department (ED) within 7 days of the initial visit.Methods: In an urban, academic medical center, we compared patients who received medications at discharge (To-Go medications) with patients who received standard care (a prescription at discharge). Emergency department patients were included if they were older than 18 years; had a discharge diagnosis International Classification of Diseases, Ninth Revision, code for urinary tract infection, pyelonephritis, cellulitis, or dental infection; and presented initially between January and December 2010. Candidates had limited health insurance or were discharged when nearby pharmacies were closed. Return visits were included if the condition was related to the initial diagnosis. Wound checks and scheduled revisits were excluded. Medications dispensed were penicillin, clindamycin, sulfamethoxazole-trimethoprim, and nitrofurantoin.Results: A total of 4257 individuals were seen in initial ED visits for the included conditions. Comparing the 243 individuals given medications with the 4014 who were not given medications, the To-Go medications group was less likely to return than the comparison group (2.5% vs 5.9%; P = .026). The cellulitis subgroup also showed a significant reduction in return visits (1.6% vs 6.9%; P = .024). Three hundred eighteen courses of medication were given to the 243 individuals for a total cost of $1123.Conclusions: For a 1-year expense of $1123, we demonstrated a 50% reduction in ED return visits for patients who were given a free, complete course of antibiotics at discharge for select conditions.

Lack of efficacy of phenytoin in children presenting with febrile status epilepticus - Corrected Proof

2012-03-02

Abstract: Background: Fever is the most common precipitant of status epilepticus in children. Animal models suggest that only γ-aminobutyric acidic drugs are effective in the treatment of febrile seizures, but there is limited clinical evidence to support this.Objective: The aim of this study was to determine the efficacy of phenytoin, a sodium channel blocker, in the treatment of febrile status epilepticus in children.Methods: This study is a retrospective chart review of 56 children (62 episodes) who presented to our emergency department with febrile status epilepticus and received phenytoin. The clinical parameters were evaluated by reviewing the charts. The efficacy of phenytoin was classified into 3 categories: positive, negative, and nonevaluable response.Results: The primary outcome was to evaluate the efficacy rate of phenytoin; there were 9 (14.5%) of 62 episodes with a positive response, 25 (40.3%) with a negative response, and 28 (45.2%) with a nonevaluable response because phenytoin was given simultaneously with a γ-aminobutyric acidic (GABAergic) drug (P < .001). The secondary outcome was to measure the mean seizure duration for each treatment category, which were 52.8, 109.9, and 52.6 minutes, respectively (P < .01).Conclusion: Phenytoin is rarely effective in controlling febrile status epilepticus. Children exposed to phenytoin have more prolonged febrile seizures, increasing the risk of brain injury.

The upper hand on compartment syndrome - Corrected Proof

2012-03-02

Metacarpal fractures are common injuries, accounting for approximately 30% to 40% of all hand fractures and with a lifetime incidence of 2.5%. Traditionally regarded as an innocuous injury, metacarpal fractures tend to be associated with successful outcomes after closed reduction and immobilization.

ED crowding and the use of nontraditional beds - Corrected Proof

2012-03-02

Abstract: Background and Objectives: In an effort to compensate for crowding, many emergency departments (EDs) evaluate and treat patients in nontraditional settings such as gurneys in hallways and conference rooms. The impact of this practice on ED evaluation time is unknown.Research Design and Subjects: A historical cohort of adult ED visits to an academic hospital between August 1, 2009 and August 1, 2010, was used to evaluate the relationship between ED bed assignment (traditional, hallway, or conference room bed) and mean ED evaluation time, defined as the time spent in an ED bed before admission or discharge. Chief complaints were categorized into the 5 most frequent categories: abdominal/genitourinary, joint/muscle, general (fever, malaise), head/neck, and other. Multiple linear regression and marginal prediction were used to calculate the mean ED evaluation times for each bed type, overall, and by chief complaint category.Results: During the study period, 15 073 patient visits met the inclusion criteria. After adjustment for patient and ED factors, assignments to hallway and conference room beds were associated with increases in a mean ED evaluation time of 13.3 minutes (95% confidence interval, 13.2-13.3) and 10.9 minutes (95% confidence interval, 10.8-10.9), respectively, compared with the traditional bed ED evaluation time. This varied by chief complaint category.Conclusions: Use of nontraditional beds is associated with increases in mean ED evaluation time; however, these increases are small and may be further minimized by restricting the use of nontraditional beds to patients with specific chief complaints. Nontraditional beds may have a role in improving ED throughput during times of crowding.

Development and validation of the excess mortality ratio–based Emergency Severity Index - Corrected Proof

Ki Jeong Hong, Sang Do Shin, Young Sun Ro, Kyoung Jun Song, Adam J. Singer — 2012-03-02

Abstract: Purpose: The purpose of this study is to develop and validate the excess mortality ratio–based Emergency Severity Index (EMR-ESI) that feasibly and objectively assesses the severity of emergency department (ED) patients based on their chief complaints.Methods: We used data from the National Emergency Department Information System of Korea from January 2006 to December 2009. We obtained information on mortality and the corresponding chief complaints exhibited by patients presenting to all EDs. The EMR-ESI was computed from the ratio of sex-age standardized hospital mortality for each chief complaint and the sex-age standardized mortality of the entire population of Korea. We tested the discriminatory power of the EMR-ESI on the prediction of hospital outcomes using the area under the receiver operating characteristic curve (AUC) from a multivariate logistic regression model. This model was adjusted for clinical parameters, and the goodness of fit was estimated using the Hosmer-Lemeshow logistic model.Results: Included in the study were 4 713 462 patients who presented 7557 chief complaint codes from 2006 to 2008. The EMR-ESI had a range of 0 to 6389.45 (mean ± SD, 1.11 ± 4.67; median, 0.70). The adjusted odds ratio of the EMR-ESI (unit, 1.0) for hospital mortality was 1.11 (95% confidence interval, 1.11-1.12). The AUCs for predicting hospital mortality, ED mortality, admission mortality, and admission were 0.95, 0.98, 0.90, and 0.74, respectively. There were 3 422 865 patients from 2009 who were included for external validation, and the AUCs for predicting mortality in the hospital, the ED, the inpatient ward, and for predicting admission were 0.95, 0.99, 0.90, and 0.75, respectively.Conclusion: The EMR-ESI was notably useful in predicting hospital mortality and the admission of emergency patients.

Two questions for Kounis syndrome: can we use magnetic resonance imaging in the diagnosis and does ST elevation correlates with troponin levels? - Corrected Proof

2012-03-02

Kounis syndrome (KS) is an acute coronary vasospasm after exposure to an allergen due to mast cell degranulation and existing mediators. Various drugs, conditions, and environmental exposures can cause KS. We presented 2 cases, 1 of whom had taken an antiflu drug (containing paracetamol, pseudoephedrine, and dextromethorphan). His electrocardiogram (ECG) showed inferior ST elevations (2 mm) with normal cardiac biomarkers. His cardiac magnetic resonance imaging showed hypokinesis and myocardial hibernation on apical septum and on the left ventricle. The second patient took a pill of naproxen sodium. The ECG showed 1-mm ST elevation in leads DII, V5, and V6. His troponin was markedly elevated. These cases showed that there seems to be no correlation with ECG and troponin levels in KS. In addition, for patients in whom KS type 1 is expected without troponin elevation, noninvasive cardiac magnetic resonance imaging study seems to be appropriate for the diagnosis of KS.

Seminal vesicle cysts causing pelvic pain: importance of computed tomography - Corrected Proof

Matthew T. Heller, Matthew Hartman, Benjamin McGreevy — 2012-03-02

A seminal vesicle cyst is a rare etiology of pelvic pain. However, its rarity may result in oversight or misinterpretation if the radiologist or emergency physician is unfamiliar with this entity. Seminal vesicle cysts may cause pelvic pain because of mass effect, infection, internal hemorrhage, or urinary and bladder obstruction. Because seminal vesicle cysts rarely result in physical examination findings or laboratory abnormalities, pelvic computed tomography plays a pivotal role in their diagnosis and in evaluating patients with pelvic pain. Recognition of the imaging findings of seminal vesicle cysts is necessary to allow prompt, accurate diagnosis. Therefore, emergency physicians and radiologists interpreting examinations from the emergency department should be familiar with these imaging findings because seminal vesicle cysts may be the etiology of pelvic pain and the patient may benefit from urologic consultation and cyst aspiration or resection. The purposes of this article are to provide examples of pelvic pain caused by seminal vesicle cysts, illustrate the key imaging findings on computed tomography, and briefly review the literature.

Neurologic complaints in young children in the ED: when is cranial computed tomography helpful? - Corrected Proof

Tarannum M. Lateef, Rebecca Kriss, Karen Carpenter, Karin B. Nelson — 2012-03-02

Abstract: Main Objective: The objective of this study is to describe the use of emergent head computed tomography (CT) in young children and ask in which circumstances scans contributed to immediate management.Methods: We reviewed electronic records of children, aged 1 month through 6 years, who received a head CT at a large suburban emergency department between February 2008 and February 2009. Age, sex, chief complaint, history, physical examination, indication for and results of head CT, red flags in history or physical examination, final disposition, and number of head CT scans performed to date were recorded. Abnormalities on CT scans were classified as significant or incidental, and subsequent interventions were documented.Results: Emergent head CTs were performed on 394 children. The most common indications were trauma, 65%; seizure, 11%; and headache, 6%. Computed tomographic abnormalities were found in 40% (154 children): 32 significant findings,104 incidental findings, and 22 preexisting abnormalities. Four children with significant findings required immediate intervention. They all had red flags in both history and physical examination, and 3 of 4 children had known preexisting pathology; 1 child had nonaccidental trauma. Only 1 child had a significantly abnormal CT with no identifiable red flags; this child was admitted for observation and was discharged within 24 hours. Approximately a third of children had no readily identifiable red flag for the CT scans that they received. Of note, 20% of the young children had received more than 1 head CT scan to date, and 6% had between 6 and 20 scans.Conclusions: Every child in this sample who required emergency intervention had red flags on history and physical examination. The 35% of CT scans performed in young children without red flags did not contribute usefully to their acute management.

Inequalities in the early treatment of women and men with acute chest pain? - Corrected Proof

2012-03-02

Abstract: Purpose: The aim of this study was to identify sex differences in the early chain of care for patients with chest pain.Design: This is a retrospective study performed at 3 centers including all patients admitted to the emergency department because of chest pain, during a 3-month period in 2008, in the municipality of Göteborg. Chest pain or discomfort in the chest was the only inclusion criterion. There were no exclusion criteria.Data Sources: Data were retrospectively collected from ambulance and medical records and electrocardiogram (ECG), echocardiography, and laboratory databases.Main Findings: A total of 2588 visits (1248 women and 1340 men) made by 2393 patients were included.When adjusting for baseline variables, female sex was significantly associated with a prolonged delay time (defined as above median) between (a) admission to hospital and admission to a hospital ward (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.25-2.03), (b) first physical contact and first dose of aspirin (OR, 2.22; 95% CI, 1.30-3.82), and (c) admission to hospital and coronary angiography (OR, 2.50; 95% CI, 1.29-5.13).Delay time to the first ECG recording did not differ significantly between women and men.Principal Conclusions: Among patients hospitalized due to chest pain, when adjusting for differences at baseline, female sex was associated with a prolonged delay time until admission to a hospital ward, to administration of aspirin, and to performing a coronary angiography. There was no difference in delay to the first ECG recording.

The validity of 9 physical tests for full-thickness rotator cuff tears after primary anterior shoulder dislocation in ED patients - Corrected Proof

Chi Kit Yuen, Ka Leung Mok, Pui Gay Kan — 2012-03-02

Abstract: Purpose: This study was undertaken to validate the diagnostic values of 9 different physical tests in emergency department patients with primary anterior shoulder dislocation (PASD) to select the best screening test for full-thickness rotator cuff tear (FTRCT) after PASD.Methods: A prospective analysis of 49 consecutive patients with x-ray-confirmed PASD was performed. All patients were followed at an average of 6.9 days (ranged from 4 to 10 days) in the emergency department. On the day of follow-up, 9 physical tests (namely, Jobe test, external rotation lag sign test, infraspinatus muscle strength test, dropping test, drop test, liftoff test, internal rotation lag sign test, belly-press test, and belly-off test) followed by shoulder ultrasound scan were performed to detect FTRCT.Results: The prevalence of FTRCT after PASD is 37% (95% confidence interval [CI], 24%-52%). Fourteen percent of the patients with PASD were complicated with isolated supraspinatus tendon tear, whereas 22% were complicated with supraspinatus tendon tear combined with subscapularis and/or infraspinatus tendon tear. Jobe test has the highest sensitivity among the 9 physical tests being evaluated. The sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratio for positive test, and likelihood ratio for negative test of Jobe test as a screening test for FTRCT after PASD are 89% (95% CI, 64%-98%), 55% (95% CI, 36%-72%), 53% (95% CI, 35%-71%), 89% (95% CI, 65%-98%), 1.97 (95% CI, 1.29-2.99), and 0.20 (95% CI, 0.05-0.79), respectively.Conclusions: The prevalence of FTRCT after PASD is 37% (95% CI, 24%-52%). Jobe test has the highest sensitivity (89% CI, 64%-98%) among the tests.

National representation in the emergency medicine literature: a bibliometric analysis of highly cited journals - Corrected Proof

Qiang Li, Yuan Jiang, Mao Zhang — 2012-03-02

Abstract: Objective: In recent years, significant growth has been seen in the field of emergency medicine. However, the national productivity to the field of emergency medicine remains unknown. This study aimed to reveal the national contributions in the field of emergency medicine.Methods: Articles published in 13 highly cited journals in emergency medicine in 2006 to 2010 were retrieved from PubMed and Science Citation Index. The number of total articles, the per-capita numbers, impact factors (IFs), and citations were tabulated to assess the contribution of different countries.Results: A total number of 9775 articles were published in the 13 journals from 2006 to 2010 worldwide. West Europe, North America, and East Asia were the most productive regions. High-income countries published 87.9% of the total articles. United States published the most number of articles in 2006 to 2010 (4523/9775, or 46.3%), followed by United Kingdom, Australia, China, and Canada. Besides, United States also had the highest total IFs (8729.73) and total citations (22 117). When normalized to population size, Australia had the highest number of articles per million persons (26.00). Germany had the highest mean IF (2.27) and mean citations (6.87).Conclusions: United States is the most productive country in the field of emergency medicine.

Bedside ultrasound of acute adrenal hemorrhage - Corrected Proof

Marie Knorr, David Evans — 2012-03-02

Most complications from traumatic isolated adrenal hemorrhage are thought to be minor and do not require specific treatment. However, there are often additional intra-abdominal organ injuries, such as liver and ipsilateral kidney, associated with adrenal injury. It is, therefore, important to identify these injuries as early as possible, preferably on initial assessment. We describe a case of a 43-year-old man who presented to the emergency department after sustaining blunt force trauma to the flank during a soccer match and was subsequently diagnosed with acute adrenal injury by use of bedside ultrasonography.

High-velocity gunshot to the head presenting as initial minor head injury: things are not what they seem - Corrected Proof

Luis A. Robles — 2012-03-02

Tangential gunshots to the head are a special type of injury in which the bullet or bullet fragments do not penetrate the inner table of the skull. Most of patients experiencing this kind of injuries usually have a benign clinical presentation. We describe the case of a 22-year-old soldier who had a tangential gunshot to the head caused by a high-velocity projectile. Initially, the patient was neurologically intact, progressing to profound coma in the next 2 hours. The characteristics of the wound and initial neurologic condition led to first contact physicians to treat this injury as a case of mild head trauma. This case shows us that gunshots to the head caused by high-velocity missiles must be treated aggressively like a severe head injury, even when the initial neurologic examination is normal.

Status epilepticus after myelography with iohexol (Omnipaque) - Corrected Proof

Hossein Alimohammadi, Ali Abdalvand, Saeed Safari, Alireza Mazinanian — 2012-03-02

Myelography has been of great use as a diagnostic modality, especially when other modalities were not conclusive. However, considering the invasive nature of myelography, it should receive the attention of medical personnel for them to be aware of its possible complications, especially when newer agents are applied as the contrast media. Myelography could lead to some common adverse effects and complications, but in this case report, we will present one of the most serious and uncommon complications accompanied with myelography using Omnipaque, a nonionic second-generation contrast agent. These complications include lower-extremity myoclonic spasms, tonic seizure leading to status epilepticus, rhabdomyolysis, disseminated intravascular coagulation and anaphylactic shock. Having the knowledge of possible complications and available solutions, particularly fatal ones, could prepare medical staff beforehand for primary and secondary preventions.

Therapy-resistant ventricular tachycardia caused by amiodarone-induced thyrotoxicosis: a case report of electrical storm - Corrected Proof

Halil Ibrahim Erdogan, Enes Elvin Gul, Hasan Gok, Kjell C. Nikus — 2012-03-02

Electrical storm is a challenging diagnosis for the clinician and requires detailed evaluation of the patient. Amiodarone is frequently used for the cessation of ventricular tachycardia attacks. Within antiarrhythmic effects of amiodarone, there are some harmful effects of the recent drug. Thyroid gland toxicity is one of the most important adverse effects of amiodarone and is called amiodarone-induced thyrotoxicosis. Thyrotoxicosis may alter arrhythmia and lead to frequent ventricular tachycardia attacks. Herein, we report a case of electrical storm caused by amiodarone-induced thyrotoxicosis.

A case of esophageal rupture diagnosed with bedside ultrasound - Corrected Proof

Charlotte Derr, Jessica Maloney Drake — 2012-03-02

A 69-year-old man presented to the emergency department with hematemesis, hypotension, tachycardia, and hypothermia. The emergency physician performed a bedside ultrasound of the chest, heart, and abdomen. The heart was unable to be visualized in the parasternal, apical, or subxiphoid windows, and free fluid and particulate matter were visualized in the chest and abdomen. The inability to visualize the heart in the normal cardiac windows suggested a diagnosis of pneumopericardium. Based upon the patient's presenting symptoms and ultrasound findings, an esophageal perforation was suspected.

Simultaneous left anterior descending and right coronary stent thrombosis after aspirin withdrawal - Corrected Proof

2012-03-02

ST-segment elevation myocardial infarction is usually caused by plaque rupture and subsequent thrombosis of a single culprit vessel. In rare occasions, simultaneous thrombosis of 2 coronary arteries occurs, which is usually associated with a worse prognosis. Although surgery provokes hemodynamic stress, leading in some instances to myocardial ischemia due to supply/demand mismatch, other factors may also contribute to postoperative myocardial infarction. We present a case of postoperative simultaneous left anterior descending and right coronary stent thrombosis that followed cessation of long-term aspirin therapy in a patient with stable coronary artery disease. This case raises concerns with drug-eluting stents due to the higher potential for late stent thrombosis related to delayed endothelialization of the stent struts. Physicians should be very cautious when deciding to withdraw antiplatelet therapy preoperatively to avoid rebound coronary thrombosis.

Increased γ-glutamyl transferase levels predict early mortality in patients with acute pulmonary embolism - Corrected Proof

2012-03-02

Abstract: Background: Increased γ-glutamyl transferase (GGT) level is associated with increased oxidative stress, all-cause mortality, the development of cardiovascular disease, and metabolic syndrome. However, its role in acute pulmonary embolism (PE) is unknown. In this study, we aimed to investigate the relationship between GGT and early mortality in patients with acute PE.Methods: A total of 127 consecutive patients with confirmed PE were evaluated. The optimal cutoff value of GGT to predict early mortality was measured as more than 55 IU/L with 94.4% sensitivity and 66.1% specificity. Patients with acute PE were categorized prospectively as having no increased (group I) or increased (group II) GGT based on a cutoff value.Results: Of these 127 patients, 18 patients (14.2%) died during follow-up. Among these 18 patients, 1 (1.4%) patient was in group I, and 17 (30.9%) patients were in group II (P < .001). γ-Glutamyl transferase level on admission, presence of shock, heart rate, oxygen saturation, right ventricular dilatation/hypokinesia, main pulmonary artery involvement, troponin I, alanine aminotransferase, alkaline phosphatase, and creatinine levels were found to have prognostic significance in univariate analysis. In the multivariate Cox proportional hazards model, GGT level on admission (hazard ratio [HR], 1.015; P = .017), presence of shock (HR, 15.124; P = .005), age (HR, 1.107; P = .010), and heart rate (HR, 1.101; P = .032) remained associated with an increased risk of acute PE-related early mortality after the adjustment of other potential confounders.Conclusions: We have shown that a high GGT level is associated with worse hemodynamic parameters, and it seems that GGT helps risk stratification in patients with acute PE.