SAEM (UAEM) 1988 Annual Meeting Program by Society for Academic Emergency Medicine

University Associationfor EmergencyMedicine

1988Annual Meeting Program and MembershipDirectory

May 22-24, 1988 Omni Netherland Plaza Hotel Cincinnati, Ohio

|--

Call for Abstracts University Association for Emergency Medicine 1989Annual Meeting May 23-25,San Diego, California The l9th Annual Meeting of the University Associationfor EmergencyMedicine will be held May 23-25, 1989at the San Diego Marriott Hotel and Marina in San Diego, California. ProgramChairman,JerrisR. Hedges,MD, is now acceptingabstractsfor review for oral and posterpresentationat the 1989Annual Meeting. Becauseof the large numberof abstractsubmissions,the Annual Meeting ProgramCommitteehasdevelopeda two-pageabstractform to be usedfor all abstractsubmissions.A copy of theabstractform is publishedin this program. Abstractforms will be mailed to the UA/EM membership, will be publishedin the Decemberissueof Annals of EmergencyMedicine, and will be sent upon request to the UA/EM office. Abstractsnot submittedon the official abstractform will be returnedto the author for resubmission. The deadline for the submission of abstracts for the 1989 Annual Meeting is January 25, 1989. All abstracts must be submitted on the official abstract form and must be postmarked no later than January 25. Mail eight copies of the abstractform to: UA/EM 18th Annual Meeting 900 West Ottawa Lansing,Michigan 48915. Call (517) 485-5484if you have any questionsor would like to requestan abstractform. Abstractssubmittedor the resultantmanuscriptsmust not appearin a refereedjournal prior to publication of the meetingabstractsin the April 1989 issueof Annals of EmergencyMedicine, and must not have been presentedpreviously at a national meeting. Annalsof EmergencyMedicineis the official journal of the University Associationfor EmergencyMedicine. UA/EM stronglyrecommendsthat authorssubmit their manuscriptsto Annals. Annals will notiff authors of a decisionregardingpublication within 90 days of receipt. Cashawardswill be given for the bestabstractsin the following categories:Clinical Oral (Human Subjects), BasicScienceOral, MethodologyOral, GeneralPoster,Methodology,ResidentPoster,and Oral or Poster Presentation in PediatricAcute Care and Trauma. An award will be given by Annals of EmergencyMedicine for the Best ResidentPaper published in Annals. All award winners will be announcedat the 20th Annual Meetingwhich will be held May 22-24, 1990 in Minneapolis, Minnesota.

All abstractsmust be submittedon an official abstractform. Pleaseread the Call for Abstractscarefullv for details and instructions. :

PLEASE POST

INDEX General Information Kennedy Lecture Annual Meeting Overview

5-9

Schedule of Events.

10-11

Posters

12-66

Abstracts

67-69

Exhibitors

Annual BusinessMeetingAgenda Constitution of the University Association for Emergency Medicine ''''' Bylaws of the University Association for Emergency Medicine Existing and Proposed Organization Structure "

7r-73 73-76 77 78-79

Simplified Constitution and Bylaws

80-83

CincinnatiDining Guide .

UA/EM LeadershiP

85-86

Vade Mecum

87-105

MembershipDirectory (alphabeticalorder)' MembershipDirectory (stateorder) Membership ApPlication

AbstractForm . 1988Call for Abstracts

inside back cover

Future Annual Meetings 1989Annual Meeting May 23 - 25 San Diego, California

1989Annual Meeting May 22 - 24 Minneapolis, Minnesota

l99t Annual Meeting Washington,D.C.

GBNERAL INFORMATION REGISTRATION AND INFORMATION All registrants must check in at the UA/EM Registration Desk to pick up name badges which are required for admission into the Annual Meeting sessions.The Registration Desk will be open during the times listed below:

Tuesday,May 24 Wednesday,May 25 Thursday,May 26

9:00 am to 5:00 pm 7:00 am to 5:00 pm 7:00 am to 4:00 pm

POSTERS The UA/EM Annual Meeting includes both oral and poster presentations. This year there are 84 posters which have been assignedto three poster sessions;a different sessioneach day. Posters will be set-up each morning from 9:fi) - 12:00 and will be dismantled each aftemoon/evening after the poster session. There will be no oral presentations during the poster sessions and presenters will be available during their scheduled sessionto discusstheir poster with meeting attendees.However, the posters will be available for viewing throughout the Annual Meeting. The poster sessionsare scheduled as follows:

Tuesday,May 24 Wednesday,May 25 Thursday,May 26

4:30- 5:30pm 2:30- 3:30pm 2:30- 3:30pm

MESSAGE BOARD A message boardwill be maintainedat the RegistrationDesk.Phone messages canbe left at the UA/EM RegistrationDeskby callingthe Omni NetherlandPlazaHoteldirectly at (513)421-9l0oandrequesting the UA/EM RegistrationDesk.

CONTII\UING EDUCATION The University of Cincinnati,accreditedby the AccreditationCouncil for Continuing Medical Education,certifies that this program meets the criteria for 19 hoursof CategoryI towardthe PhysiciansRecognition Award of theAmericanMedicalAssociation.The Amual Meeting has also beenapprovedfor 19 hoursof CategoryI credit from the AmericanCollegeof EmergencyPhysicians.

UA/EM.STEM COCKTAIL RECEPTION STEM and UA/EM are sponsoring a cocktail reception on Tuesday, May 24 from 5:30 pm until 7:00 pm in the Hall of Mirrors. There is no charge for the reception. Hors d'oeurves will be served and a cash bar will be available. All registrants and exhibitors are invited to attend.

EXHIBITS

Exhibitswill be availablefor viewing on May 24 from 1:00 - 5:00 pm andon May 25 from 8:00- 11:00am and 1:00- 4:00 pm. The exhibits will be locatedin the Pavilion Room along with the poster presentations Desk:All coffeebreaksonMay 24 andthe Registration andMay 25 will be held in the exhibit hall. Pleasetake an opportunity to view the exhibits during the scheduledcoffee breaks and review the exhibitorlisting includedin this program.

INJURY RESEARCH PANEL A special panel on Injury Researchwill be held on Wednesday, May 25 from 5:00 - 6:00 pm in the Continental Room and will be moderated by Steven M. Barrett, MD. This panel will focus on what CDC funding is available and how to get it. A representative from the Centers for Disease Control will participate and discuss the areas of research that the CDC is interestedin funding. Other panel participants will discuss how they received Injury Research funding and give recommendations to the audience. Panel participants include C. Gene Cayten, MD, Howard Champion, MD, Arthur Kellerman, MD, Gabor Kelen, MD, and James Monroe, Grants Manager, Center for Environmental Health and Injury Control.

EMERGENCY MEDICINE RBSEARCH FELLOWS DINNER AND PROGRAM

UA/EM and STEM arejointly sponsoringthe EmergencyMedicine '24,fromT:3O ResearchFellowsDinnerandProgramon Tuesday,May "The pm. program Fellow Graduates The of will be, to 9:30 topic the

- What Next?" Panelistsinclude Dr. Louis Kettel, the Vice President for Academic Affairs at the AAMC; Larry Baraff, MD; Glenn Hamilton, MD; Jerris Hedges, MD; and Peter Rosen, MD. Complimentary tickets are available for Emergency Medicine fellows and their directors, however, pre-registration is required. Others wishing to attend the dinner can purchase tickets for $25 each. All tickets must be purchased by 2:00 pm on May 24.

RESEARCH DIRECTORS' LUNCI{EON UA/EM and STEM are sponsoringa luncheon for ResearchDirectors in Emergency Medicine on Tuesday, May A from 12:00 noon to I :00 pm. Those interestedin conducting researchin Emergency Medicine are welcome to attend. This will be an opporruniff for those who coordinate researchprograms in organized Emergency Medicine to meet and share "Research During Resiideas. The lunchtime roundtable topic will be, dency: A Requirement for All or an Opportunity for those Interested?" During the meeting, Donald C. Arthur, MD, will presentresultsfrom a recent national survey of researchactivities in Emergency Medicine ResidencyPrograms. Tickets are $25 eachand seatingis limited to 50 persons. No tickets will be sold at the Registration Desk.

VOLLEYBALL TOURNAMENT Dr. Edward Lukawski and Dr. Scott Syverud have made arrangements for a Volleyball Tournament to be held on Tuesday, May 24 from 5:30 - 7:30 pm and on Wednesday,May 25 from 5:00 - 7:00 pm. This tournament is sponsored by Boehringer Ingelheim and will be held at Moore's Nautilus near the Netherland Plaza Hotel. Pre-registration is required since a limited number of teams will be accepted.Annual Meeting attendeescan sign up individually or as teams, with a minimum of 6 persons per team. There is no fee for participation and participants will receive a T-shirt.

ANNUAL BUSINESS MEETING The UA/EM Annual Business Meeting will be held on Wednesday, May 25 directly following Dr. Ernest Ruiz's Presidental Address. Agenda items for the businessmeeting will include the election of officers, Council and Committee members; amendmentsto the Constitution and Bylaws; officers' reports; and other items ofbusiness presented by the membership. Also, Ernest Ruiz, MD, will introduce incoming president JamesNiemann, MD. All members of the Association are urged to attend. Only active membersof UA/EM are eligible to vote. The Annual Business Meeting agenda,the Constitution and Bylaws amendments,and the Slate of Nominees are included in this program.

SPECIAL INTERNATIONAL PRESENTATION Richard Nowak, MD, chair of the International Committee, is pleased to announcethat David W. Yates, MD, will addressthe membership during the annual businessmeeting on May 25. Dr. Yates, representing the Emergency Medicine ResearchSociety, will discussthe development of academic emergency medicine in the United Kingdom. Dr. Yates is a senior lecturer in Surgery at the University of Manchester, an honorary consultant in Accident and Emergency Medicine, and a member of the scientific staff at the North Western Injury Research Centre at the University of Manchester. AII Annual Meeting registrants are encouragedto attend this special presentation.

ANNUAL BANQUET A free ticket to the Annual Meeting banquet on the evening of Thursday, May 26, is available to every active, associate,or intemational UA/EM member, however, members must pre-register for their ticket by indicating on the registration form that they will be attending the banquet. Additional tickets can be purchased for $40 each. Pre-registration is required. The 1988 Banquet will begin by transporting the Annual Meeting attendeesvia bus to the riverboat, Becky Thatcher. Dress is casual. Buseswill begin shuttling attendeesto the riverboat at approximately 5:15. A cocktail reception will be held aboard the riverboat as the cruise begins on the Ohio River. A bluegrassband will provide

entertainment.The destination of the cruise is Coney Island where a grilled shrimp and tenderloin kabobs and lemon chicken buffet dinner awaits. During dinner the annual presentationof the Imago Obscura and JamesMacKenzie awards will be held. Last years's winners will provide the entertainmentas they review this year's entries and make the presentationsfor 1988. The awards are real, but the presentations are tongue-in-cheek. The Annual Meeting Banquet is a tradition you shouldn't miss.

PROCEEDINGS Proceedingsof the Annual Meeting will not be prepared as a separate publication. However, selectedpresentations, scientific papers and pertinent discussion will be printed inthe Anrnls of Emergency Medicine, the journal of the American College of Emergency physicians and the University Association for Emergency Medicine. In addition, the abstracts from the 1988 Annual Meeting have been published in the April 1988 issue of Annals of Emergency Medicine.

1989ANI\UAL MEETING CALL FOR ABSTRACTS 1989 Annual Meeting will be held May 23-25 in San Diego. The Call for Abstracts is published in this program. Becausethere are changes in this year's abstract submission process, please read the Call for Abstracts carefully and post it in you institution. The dealine for submission of abstractsfor the 1989 Annual Meeting is January 25. 1989.

day, May 25 from 7:00 pm to 9:00 pm. This meeting will be moderated by Bruce M. Thompson, MD, and will include a general discussion followed by roundtable discussions.

IN.HOSPITAL CPR STUDY GROUP A meeting of the In-Hospitat CPR Study Group will be held Wednesday, May 25 from 6:00 to 7:00 pm. The meeting will be moderated by Richard Nowak, MD, and will be an interesting forum in which to exchangeinformation and discussprojects, problems and solutions on the topic of in-hospital CPR.

KENNEDY LECTT]RE

The 16th Kennedy Lecture, "The Evolution, Current Statusand Future for Emergency Medicine," will be presentedby Gail V. Anderson, MD, on Wednesday,May 25, at ll:45 am. Dr. Anderson is the president of the American Board of Emergency Medicine and the Professor and Chairman of the Deparftnent of Emergency Medicine at the University of Southern California.

EMRA RECEPTION EMRA will hosta Reception on Wednesday, May 25 from 6:00- 7: pm. The highlight of the reception will be the presentationof the

UA/EM MEMBERSHIP A membership application is included in this program and additional copies are available upon request to the UA/EM office at 900 West Ottawa, Lansing, Michigan 48915 or call (517) 485-5484.If you are not a member, please consider joining UA/EM. If you are already a member, give this application to a colleague. UA/EM needsyour support for the growth and development of academic Emergency Medicini.

METHODOLOGY SESSION UA/EM is pleasedto cosponsorthe methodologypaperswith the Society of Teachers of Emergency Medicine on Tuesday, May 24 from 3:00 - 4:30 pm. This sessionis comprisedof six paperson education/administration. In addition there are severalmethodology posters, which along with other posters, will be availabte for viewing onMay 24. There is no registration fee to attend thisjoint session.Ail regisirants of the UA/EM or STEM Annual Meeting are invited to atiend the methodology paper sessions.

JeanHollisterAward for Excellencein EMS andPrehospital Care StephenW. Borron, MD. Hors d'oeurves will be served and a bar will be available. All interested EMRA members and others invited to attend. The Reception is sponsored by Emergency

EMRA BOARD OF DIRECTORS MEETING RicardoSanchez,MD, MPH, Presidentof the EmergencyMt Residents'Association,hasannounced thatthe EMRA Boardof torswill meetfrom 8:00amto 12:30pm on Tuesday,May 24. AlIi terested Emergency Medicine residents and others are invited to

EMRA.UA/EM RESIDENT RESEARCH The SecondAnnuat EMRA-UA/EM

Resident Research Forum will

held on Wednesday,May 25. Speakerswill includeJohn MD, State Universtiy of New York; Blaine White, MD, Wayne

University;and William Spivey,MD, MedicalCollegeof vania.

PLACEMENT SERVICE

Dr. McCabewill discussgeneralaspects of designinga research

A bulletin board will be maintainednear the RegistrationDesk for persons wishing to post positions and physicians available listings.

and then focus on clinical research desisns and his discussion will

SPEAKERS' READY ROOM A speakers'ready room will be available for presenterswho wish to check their slides and run through their material in advance of their presentation.Keys to the ready room will be available at the UA/EM Registration Desk.

vide insighton how differentclinical studydesignsanswer typesof questions.Dr. White will give an overviewof laboratory search design including insights on animal studies, biochemical

andtechnologyin thelaboratory.Dr. Spiveywill provideinsights how to get involved in research at the resident level and how to sue a research career. The ResearchForum will provide an excellent opportunity for

to gain new perspectiveson reseuch designand havequestions swered by authoritative experts who are at the forefront of

UA/EM EXECUTIVE COUNCIL MEETING The UA/EM Executive Council will convene a meeting on Friday, May 27 starting at 9:00 am. This meeting will be chaired by Jamls Niemann, MD, who begins his term as the UA/EM president at the Annual BusinessMeeting on May ?5. All interestedmembers and others are invited to attend this, and all, meetings ofthe Executive Council.

ACADEMIC PROGRAM DIRECTORS' MEETING

All interested residency directors and others are invited to attend the Academic Program Directors' Meeting which will be held on Wednes-

medicineresearch.All EMRA membersandothersareinvitedto TheResident Research Forumis beingcoordinated by JimManning,

EMRA FORUM EMRA will present a forum and open debatefor the discussionof i strrrounding attending coverage in residency programs. Di will include JosephClinton, MD, Hennepin County Medical

andJ. DouglasWhite, MD, GeorgetownUniversity.Atl EMRA bers and others are invited to attend and participate. This forum i coordinated by Ricardo Sanchez, MD, MPH.

KENNEDYLECTT]RE

Gail V. Anderson, MD Professorand Chairman Department of EmergencyMedicine University of Southern California

Gail V. Anderson, MD, is the 16th Annual Kennedy Lecturer at the University Association for Emergency Medicine Annual Meeting, and his lecture is entitled, "The Evolution, Cur" rent Status,and Future for Emergency Medicine. Dr. Anderson will highlight the developmentof Emergency Medicine as a specialty, the current efforts to achieveprimary board status, and the requirements for the future acceptanceby academic medicine as a full and complete discipline. Dr. Anderson graduated from Columbia Union College in Washington, DC, in 1949, and graduated from Loma Linda University School of Medicine in 1953. He did his internship at Washington Sanitariumand Hospital in Washington, DC and completedhis residency in Obstetrics and Gynecology at General Hospital and Georgetown University Hospital in 1957. After completing his training in Washington DC, Dr. Anderson moved back to California where he becamethe Director of Obstetrics and Gynecology at Los Angeles County - USC Medical Center and an instructor of Obstetricsand Gynecology at Loma Linda University and the University of Southern California. By 1968, Dr. Anderson was Professorof Obstetrics and Gynecology at the USU School of Medicine, a position he still holds. However, in 1971, Dr. Anderson becamethe professor and chairman of the first academic Department of Emergency Medicine in the United Statesat Los Angeles County - University of Southern California and the director of the Emergency

Department at this sameinstitution. He continues to hold both of these positions. ln 1976 Dr. Anderson became a founding member of the American Board of Emergency Medicine. He has beena member of the American Board of Emergency Medicine continuously since 1976and hasbeenan examinersince 1980. His involvement in the Board has been enormous. He has served as the Chairman of the Credentials Committee from 1976 to 1987, in 1985-1986,president-electin 1986-1987, Secretary/Treasurer and is currently the President of the Board. He is a fellow of the American College of Obstetriciansand Gynecologists and a fellow of the American College of Surgeons.He is a long-time memberof UA/EM, ACEP, STEM, the American Trauma Society, and the American Foundation of Clinical Research,as well as numerous university committees and local organizations. He was an examiner for the American Board of Obstetrics and Gynecology from 1961-1972. Dr. Anderson was also the program chairman for the Emergency '85 held in Hawaii Medicine '74 throughEmergencyMedicine each spring. His many research activities, publications, legislative testimonys, and grants run the gamut of Emergency Medicine and Obstetrics and Gynecology. In addition, Dr. Anderson completed a fellowship in Health Policy Analysis in 1986-1987. The University Associationfor EmergencyMedicine is proud to welcome Dr. Anderson, and is honored to have him speak at our 1988 Annual Meeting as the Kennedy Lecturer.

ANNUAL MEETING OVERVIEW Tuesday,May 24 8:009:009:009:00 -

12:30pm 5:00pm 12:00noon 12:00noon 11:00 12:00noon 12:00- 1:00pm 1:00- 2:30pm 3:00- 4:30pm

4:305:306:307:30-

5:30pm 7:00pm 8:00pm 9:30pm

EMRA Board of Directors meeting, Room 652 UA/EM Registration,Pavilion Room Poster SessionA Set-Up, Pavilion Room Annals of EmergencyMedicineEditoral Board Meeting' Room 658 American Journal of EmergencyMedicine, Editorial Board Meeting' Room 752 UA/EM-STEM ResearchDirectors Luncheon, Salon M Scientific Papers: Traurna, Hall of Minors Scientific Papers: Administration Track A, Hall of Mirrors CPR Track B, ContinentalRoon Poster SessionA, Pavilion Room UA/EM-STEM Cocktail Reception, Hall of Minors EMRA Forum: Faculty Supervision,SalansD and E UA/EM-STEM Fellows Dinner and Program, SalansF and G

Wednesday,May 25 7:00- 5:00pm 9:00 - 12:00noon 8:00- 9:30am 10:00- 1l:00am

UA/EM Registration,Pavilion Roont Poster SessionB Set-Up, Pavilion Room Scientific Papers: Diagnostics, HaIl of Minors Scientific Papers: DiagnosticsTrack A, Hall of Minors PediatricsTrack B, ContinentalRoom UA/EM Awards Presentation,Hall of Mirrors 1 l : 0 0 l 1 : 1 5a m l1:00- 12:00noon Kennedy Lecture, Hall of Mirrors Scientific Papers: CNS/CPR Track A, Hall of Mirron l : 0 0 - 2 : 1 5p m SelectedTopics Track B, ContinentalRoom Poster SessionB, Pavilion Room 2:30- 3:30pm 3:30- 4:00pm UA/EM President'sAddress,Hall of Minors 4:00- 5:00pm UA/EM Annual BusinessMeeting, HaU of Mirrors 5:00- 6:00pm UA/EM Panel Discussion:Injury Research,ContinentalRoom 5:00 7:00pm Volleyball Tournarnent,Moore's Nautilus In-Hospital CPR Study Group Meeting, SalonsD and E 6:00- 7:00pm EMRA-ErrergencyMedicineReception, Sal.onsF and G 6:00- 7:00pm 7:00 9:00pm AcademicProgram Directors Meeting, SalonsB and C 7:30- 9:00pm EMRA-UA/EM ResidentResearchForum. SalonsD and E

Thursday, May 27 7:00- 4:00pm 9:00- 12:00noon 8:00- 9:45am 10:15- 12:00noon 1:00- 2:15pm 2:30- 3:30pm 3:30- 4:45pm 5:00- 11:00pm

UA/EM Registration, Foyer Poster SessionC Set-Up, CapriceRoom Scientific Papers: Toxicology,Pavilion Room Scientific Papers: Cardiopulmonary Track A, Pavilion Room Trauma Track B, Continental Room Scientific Papers:EMS/Airway Track A, Pavilion Room C-Spine/CNSTrack B, ContinentalRoom Poster SessionC, CapriceRoom Scientific Papers: CPR Track A, Pavilion Room EMS Track B. ContinentalRoom UA/EM Banquet,

Friday, i[flday27 9:00 am - 1:00pm

UA/EM Executive Council meeting, Salon M 4

SCHEDULEOF EVENTS Tuesday, May 24, 1988 8:fi) - 12:30 pm EMRA Board of Directors Meeting, Room 652 9:fi) - 5:fi) pm Registration, Pavilion Room 9:ffi - 12:fi) noon Poster SessionA Set-Up, Pavilion Room 9:fi) - 12:fi) noninAnnals of EmergencyMedicineEditorial Board Meeting, Room 658 9:fi) - 12:ffi noon STEM Educational Forum ll:fi) - 12:fi) noon AmericanJoumal of EmergencyMedicineEditorial Board Meeting, Room 752 A Requirementfor All or an Oppottunityfor thoseInterested?, 12:fi) - l:fi) pm ResearchDirectorst Luncheon, "ResearchDuring Resi.dency: by DonaldC. Arthur, MD, who will discussthe resultsof a recentnationalsurveyof research SalonM This meetingwill includea presentation activitiesin EmergeniyMedicineResidencyPrograms.A1l researchdirectorsand othersare invited to attendthis luncheon.The cost is $25 for eachticket and seatingin limited to 50 persons.

ORAL PRESENTATIONS l:fi) - 2:30 pm Trauma l, Hall of Minors Moderator: John A. Marx, MD, Denver General Hospital Studyof the Effectof SafetyBeltsin Motor Vehil. Prospective cle Accidents, Elizabeth Mueller Orsay, MD, University of Illinois 2. DetectingAcuteComplicationAfter TraumainPregnarrcy,Mark Pearlman, MD, William BeaumontHospital 3. AeromedicalTransportof Patientswith PostTraumaticCardiac Arrest, ,SerftWright, MD, Universityof Cincinnati 4. The Effectsof the PneumaticAnti-ShockGarment(PASG)on Arterial pH andCentralVenousLactatelrvels Using a Baboon HemorrhagicShockModel, BrendaA. Goweslq,MD, Brooke Army Medical Center 5. Skin Testing:Implicationsin the Managementof Pit Viper Envenomation, Daniel W. Spaite,MD, Universityof Arizona of Hemor6. IV Fluid Therapyin the PrehospitalManagement rhagicShock:ImprovedOutcomewith HypertonicSalinel6% MD, Univer' Dextran70Rin a SwineModel, Carl Chudnofslcy, sity of Cincinnati

2:30 - 3:fi) pm Coffee Break, Exhibits Open, PostersOpen, Pavilion Room

3:fi) - 4:30 pm Track A - Administration, Hall of Minorc Moderator: David T. Overton, MD, William Beaumont Hospital 7. The Management of Stress and Prevention of Burnout in Emergency Physicians, Kathleen L. Keller, PhD, RN, CS, Califumia State University, Long Beach "Burn-Out" in Graduates of a Residency Pro8. The Status of gram in Emergency Medicine, Janet Slnpter, MD, Wight State University 9. Retrospective Review of Prehospital Care Lawsuit Claims in a Latge Metropolitan EMS System, Richard Goldberg, MD, University of Illinois 10. Attending Coverage in Academic Emergency Medicine: A National Survey, Philip L. Henneman, MD, Harbor-UCI'A 11. Emergency DepartmentRevisits, Kimberly Keith, MD, William Beaumont Hospital 12. RepeatEmergency Department Visits: Red Flag or Red Herring?, Edward A. Michelson, MD, University of Pittsburgh

3:fi) - 4:30 pm Track B - CPR l, ContinentalRoom Moderator: Gerard B. Maftin, MD, Henry Ford Hospital 13. Predictionof DowntimeDuring VentricularFibrillation, Charles G. Brown, MD, Ohio State University t4. The Role of Bicarbonateand Fluid Loading in Improving Resuscitation from CardiacArrestwith High FrequencyCPR, Anhur B. Sanders,MD, Universityof Artzona t 5 . DynamicChangesin ExpiredEnd-TidalCarbonDioxideas a PrognosticGuide During CPR in Dogs, Karl B. Kern, MD, Universityof Arizona from Car1 6 . Successfrrl hediction by Capnometryof Resuscitation diac Arrest, ChristopherW. Banon, MD, Universityof Califurnia. SanFrancisco t 7 . SimultaneousAortic, JungularBulb, andRight Atrial Pressures During StandardExternalCPR(SE-CPR),NormanA. Paradis, MD, Henry Ford Hospinl 1 8 . Cerebral Blood Flow During CPR - A Comparisonof VersusEpinephrine,Linda Robinson,MD, Ohio Norepinephrine State University

4:30 - 5:30 pm Poster Session A, pavilion Room 5:30 - 7:fi) pm UA/EM-STEM Cocktail Reception, HaIl of Minors 5:30 - 7:30 prn Volleyball Tournament, Moore's Nautilus The volleyball rournamenl.is by B-oehringerIngelheimandis opento all Annual Meetingregistrants.Becausespaceis :391t"^t-"d limited, attendees mustsign-upthroughthe UA/EM office by May l. 6:30 - 8:fi) pm EMRA meeting, "Issues on Faculty Supervisionin Residencyhograms,,, SalonsD and E Moderator: RicardoL. Sanchez,MD, JohnsHopkinsUniversity Panelists:JosephE. Clinton, MD, HennepinCountyMedicalClnter J. DouglasWhite, MD, GeorgetownUniversity 7:30 - 9:30 pm EmergencyMedicine ResearchFellowsDinner and hogram, ,,The Fellow Graduales- what Nert?,,, SalonsF anil G Moderator: shermanM. podolsky,MD, Albert EinsteinMedicalcenter Panelists: Louis J' Kettel, MD, Associatevice Presidentfor AcademicAffairs, Associationof AmericanMedicalcolleges PeterRosen,MD, DenverGeneralHospital GlennC. Hamilton, MD, Wright StateiJniversity Larry J. Baraff, MD, Universityof California,Los Angeles JerrisR. Hedges,MD, Universityof Cincinnati

Wednesday,May 25, 19gg 7:fi) - 8:fi) am Registration - Coffee and Breakfast Rolls, pavilion Room 9:fi) - l2:fi) noon Poster SessionB Set-Up, pavilion Room 8:fi) - 9:30 am Diagnosticsl, HaIl of Minors Moderator: Robert A. I-owe, MD, iailey Medicat Center 19. AccuracyoflnterpretationsofED-Radiographs: The Effectof ConfidenceLevels, Franklin E. Mayhui, iuID, Oniversityof Illinois 20. NoninvasiveMonitoringof Intra-AMominalFluid Accumulation UsingTransaMominalElectricalBioimpedanc e, WilliamBanon, BS, Vanderbilt(Jniversity 21. EmergencyDepartmentUseof DopplerUltrasonographyin the 'Llniver_ Diagnosisof DeepVein Thrombosii,foaa ZaUt, MD, sity of lllinois 22. RapidDetectionof AcuteMyocardialInfarctionUsingMagnetic ParticleBoundAntibodyto CPK-MB, W. Brian CiUter,Un, Vanderbilt University 23. Effrcacyof the LeukocyteEsteraseTest in the Detectionof CerebrospinalFluid Leukocytosis,Jan DeLozier,MD, Vander_ bilt University 24. TheEvaluationof Suspected RenalColic: UltrasoundScanvs. ExcretoryUrography,Doughs Sincl.air,MD, VictoriaGeneral Hospital, Halifax, Nova Scotia

9:30 - 10:fi) am Coffee Break, Exhibits Open, pavilion Room l0:fi) - ll:fi) am Track A - DiagnosticslI, pavilion Room Moderator: PhW L. Henneman, MD, Haibor-(JCLA 25. Lack of Value of Head CT Scanningin Alert, Awake, Neurologically-IntactVictims of Bluni Trauma, Barry i. larbrough, MD, Vanderbilt IJniversity 26. DoesConjunctivalOxygenTensionpreiict CerebralBloodFlow in NormalHumansDuring EucapniaandHypocapnia?,llilliam F. Rutherford,MD, Case WestemResemi University 27. Developmentof a HypothermiaOutcomeScore,ianiel F. Danzl, MD, Universityof Inuisville 28. Prospective Validationof ClinicalCriteriafor the Orderingof Serum Electrolytes, Henry Arst, MD, Valley Meiical Center,Fresno

l0:fi) - ll:fi) arn Track B - pediatrics, Continental Roon Moderator: Gary R. Fleisher, MD, Boston Childrens 29. OutpatientManagement of FebrileInfants2g-90Davsof with Intramuscular Ceftriaxone, Marc N. Basiin. , Children's Hospital, Boston Transtracheal Catheter Ventilation (TTCV) in a Small Model, Gary C. Fifield, MD, MpH, Hennepin County Center 3 1 . Diazepam and the Need for Intubation in the pediatric Setting, Richard A. Orr, MD, University of pittsburgh 32. Intramuscular Demerol, Phenergan and Thorazine: Anal, 30.

pediatricEmergencyD !Js9andComplicationsin 486 Patients,ThonwsE. Terndrup,MD, StateUniiersttyof

ll:fi)

- 11:15 am Awards Presentations, Hall of Minors 1987 Best Oral Basic Science Abstract Presentation The Comparative Effects of Methoxamine versus Epinephrine on Regional Cerebral Blood Flow During CPR, Eric Davis, MD, Ohio State University The Best Oral Basic Science Abstract PresentationAward is sponsoredby Emergency Medicine. 1987 Best Oral Clinical Science Abstract Presentation A Randomized Study of Epinephrine versus Methoxamine in Prehospital Ventricular Fibrillation, Ranjan Thakur, MD, Medical College of Wisconsin The Best Oral Clinical Science Abstract PresentationAward is sponsoredby MICROMEDEX, Inc. 1987 Best General Poster Abstract Presentation Effects of Sodium Dichloroacetateon ATP and Phosphocreatinein Ischemic Rat Brain, Ruth V.W. Dimlich, PhD, University of Cincinnati The Best General Poster Abstract PresentationAward is sponsoredby Emergency Medicine and Ambulatory Care News. 1987 Best Resident Poster Abstract Presentation Emergency IntraosseousInfusions in Children: A Practical Method of Teaching Prehospital Personnel, Gert-Paul Walter, MD, Michigan State University The Best Resident Poster Abstract PresentationAward is sponsoredby Pergamon Press. 1987 Best Resident Paper Blood PressureEffects of Thyrotropin-Releasing Hormone and Epinephrine in Anaphylactic Shock, Robert L. Muelleman, MD, Truman Medical Center The Best Resident Paper Award is sponsoredby Annals of Emergency Medicine.

1l:15 - l2:fi) noon Kennedy Lecture, Hall of Mirrors Gail V. Anderson, MD, President,American Board of EmergencyMedicine, Professorand Chairman, Departmentof EmergencyMedicine, University of Southern California "The Evolution, Current Statusand Future for EmergencyMedicine" The Kennedy Lecture is sponsoredby Marion Laboratories l2:fi) - l:fi) pm Lunch Break

l:fi) - 2:15 pm Track A - CNS/CPR ll, Pavilion Room Moderator: Michelle H. Biros, MD, Hennepin County Medical Center 33. A Model of Cytotoxic Cerebral Edema, James E. Olson, MD, Wright State University 34. Neutrophil Depletion Fails to Improve Neurologic Outcome Following Ten Minute Cardiac Arrest in Canine Model, Richnrd E. Burney, MD, University of Michigan 3 5 . Effect of CO, and Non CO2 Generating Buffers on Cerebral Acidosis During ReperfusionAfter CardiacArrest: A 3l-P NMR Study, "/act M. Rosenberg, MD, Henry Ford Hospital 36. Brain DNA During Cardiac Arrest and Reperfusion: Initial Studies, Blaine C. White, MD, Wayne State University ) t . High Energy PhosphateMetabolism After Graded Cardiac Arrest and Reperfusion: Correlation with Clinical Outcome, Gerard B. Martin, MD, Henry Ford Hospital

l:fi) - 2:15 pm Track B - Selected Topics, Continental Room Moderator: Daniel F. Danzl, University of Louisville 38. Forensic Aspects of Emergency Care, Richard H. Carmona, MD, University of Arizona 39. Deferred Consent: Use in ResuscitationResearch,Norman S. Abramson, MD, University of Pittsburgh 40. Natural History of Undifferentiated Abdominal Pain, Thomns W. Lukens, MD, Case Western Reserve University 41 . A Comparison of Butorphanol, Dihydroergotamine and Meperidine in the Treatmentof Vascular Headache,Ltuis Ling, MD, Hennepin County Medical Center 42. Comparative Efficacy of Chlorpromazine and Meperidine/ Dimenhydrinate in Migraine Headache, Peter L. Iane, MD, University of Toronto

2:15 - 2:30 pm Coffee Break, Exhibits Open, Posters Open, Pavilion Room 2:30 - 3:30 pm Poster Session B, Pavilion Room 3:30 - 4:fi) pm President's address, Hall of Minors Ernest Ruiz, MD, Hennepin County Medical Center 4:fi) - 5:fi) pm Annual Business Meeting, Hall of Minors (refer to agenda in this program) Special Presentation: David Yates, MD, Emergency Medicine Research Society, "The Development of Academic Emergency Medicine in the United Kingdom" Elections, Constitution and Bylaw amendrnents, officer and committee reports 5:fi) - 6:fi) pm Panel, "Injury Research", Continental Room Moderator: Steven M. Barrett, MD, University of Oklahoma James Monroe, Grants Manager, Center for Environmental Health and Injury Control, Centers for Disease Control Panelists: C. Gene Cayten, MD, MPH, New York Medical College Howard R. Champion, MD, Uniformed Services University of the Health Sciences Arthur L. Kellermann, MD, University of Tennessee Gabor D. Kelen, MD, John Hopkins University

5:fi) - 7:fi) pm Volleyball Tournament The Volleyball Tournament is sponsored by Boehringer Ingelheim and is open to all Annual Meeting registrants. Because space is limited, attendees must sign-up through the UA/EM office by May 1. 6:fi) - 7:fi) pm In-Hospital CPR Group Meeting Moderator: Richard M. Nowak, MD, Henry Ford Hospital, Detroit. 6:fi) - 7:fi) pm EMRA-Emergency Medicine Reception and Jean Hollister Award presentation, The Jean Hollister Award for Excellence in EMS and Prehospital Care will be presentedto StephenW. Borron, MD, University of Cincinnati. 7:fi) - 9:fi) pm Academic Program Directors Meeting Moderator: Bruce Thompson, MD, Henry Ford Hospital, Detroit This meeting is open to all residency directors and interested individuals and will include a general discussion followed by roundtable discussions. 7:15 - 9:fi) pm EMRA-UA/EM Resident Research Forum, Salons D and E Moderator: James Manning, MD, Harbor-UCLA Speakers: John McCabe, MD, State University of New York William Spivey, MD, Medical College of Pennsylvania Blain White, MD, Wayne State University

Thursday, May 26, 1988 7:fi) - 8:fi) am Registration - Coffee and Breakfast Rolls, Foyer 9:fi) - l2:fi) noon Poster Session C Set-Up, Caprice Rooms 8:fi) - 9:45 am Toxicology, Pavilion Room Moderator: Edward P. Krenzelok, PharmD, University of Pittsburgh 43. Effects of Calcium Channel Blocker Overdose-Induced Toxicity on Systemic Hemodynamics and Cardiac Output Distribution in the Conscious Dog, Wlliam H. Spivey, MD, Medical College of Pennsylvania 44. Use of IPECAC Increases Emergency Department Stays and PatientComplication Rates, Garrett E. Foulke, MD, University of Califurnia, Davis 45 . Prospective Evaluation of Gastric Emptying in the Self-Poisoned Patient, Kevin S. Mertgian, MD, University of Cincinnati 46. Amanita Phalloides Poisoning: Mechanism of Cimetidine Protection, Sandra M. Schneider, MD, University of Pittsburgh 47. Experimental Carbon Monoxide-Mediated Brain Lipid Peroxidation and the Effects of Oxygen Therapy, StephenR. Thom, MD, PhD, University of Pennsylvania 48. Plasma Catecholamines in Cyclic Antidepressant Overdose, Kevin S. Merigian, MD, University of Cincinnati 49. The Terminal 40 ms Frontal Plane QRS Axis as a Marker for Tricyclic Antidepressant Overdose, Timothy R. Wolfe, MD, University of Utah 9:45 - 10:15 pm Coffee Break, Foyer 10:15 - l2:(X) noon Track A - Cardiopulmonary, Pavilion Room Moderator: Harlan A. Stueven, MD, Medical College of Wisconsin 50. InconsistentHistories: A Patient or Physician Problem?, Roben M. McNannm, MD, Medical College of Pennsylvania 51. Myocardial Infarction in the Emergency Departrnent Patient with a Normal EKG: Complications and Interventions, Robert J. fulenski, MD, Cook County Hospital 52. Delay BetweenOnset of Chest Pain and SeekingMedical Care: The Effectof Public Education, MaryT. Ho, MD, MPH, University of llashington 53. Adverse Reactions During and Immediately After T-PA Infusion, Linnick J. William, MD, William Beaumont Hospital 54. Reperfusion Arrhythmia: Myth or Reality, Daniel G. Walsh, MD, University of Michigan 55. Lack of Effect of Methylprednisolone in the Emergency Department Treatrnent of Acute Exacerbationsof COPD, Charles L. Emerman, MD, Case Western Reserve University 56. Intravenous Magnesium Sulfate for the Treatment of Asthma in the Emergency Departrnent, William H. Spivey, MD, Medical College of Pennsylvania

10:15 - 12:(X)noon Track B - Trauma ll, ContincntalRoom Moderator: Nchard E. Bumey, MD, UniversiS of Michigan 57. Inigating Solutionsfor SuturedLacerations,,4nthonyP. DO, Darnall Army CommunityHospital 58. Fat EmbolismFollowing Intraosseous Infusion,Miclnel Plewa, MD, Universityof Pittsburgh 59.

Promising Novel Life Supporting First Aid Measuresfor Hemorrhagic Shock, Screenedin Awake Rat Model, David pen, MD, University of Pit*burgh

60. The Inability of PrehospitalTraumaPredictionRulesto Trauma Patients Accurately, William G. Baxt, MD, of Califurnia, San Diego 61. SubstantialIncreasein UnsuspectedHIV Infection in

Ill EmergencyPatientsand UnrecognizedHIV GeneralEmergencyPatients:Failureof RiskFactor Practices to Indicate Need for Barrier Precautions, Kelen, MD, Johns Hopkins University 62. , Human Immunodeficiency Virus (HIV) Seropositivity

MidwesternCommunityTraumaPopulation , MiclwelG. MD, Universityof lllinois, Peoria 63. Effect of HyperbaricOxygenTherapyon Western back Rattlesnake (Crotalus atrox) Envenomation in the Model, Michael R. Stolpe, DO, Brooke Army Medical

l2:fi) - l:fi) pm Lunch Break l:fi) pm - 2:15 pm Track A - EMS/Airway, Pavilion Room Moderator: Scofr Syverud,MD, Univercity of Cincinnati 64. EMS Call History Within a LargeUrbanSystem:Geographical Patternsof BasicandAdvancedLife SupportDemandsandthe Implicationsfor ProgramPlanning,Paul E. Pepe,MD, Baylor Collegeof Medicine JacquesLarochelle,MD, 65. EMT-D: The WisconsinExperience, Medical Collegeof Wisconsin Arrest,RobertW. 66. ALS WitnessPrehospitalCardiopulmonary Wolfurd, MD, Universityof Pittsburgh IntubationUsing a FlexibleLightedStylet, Vin67. Nasotracheal cent P. Verdile, MD, Universityof Pittsburgh TrachealCombitubeDuring Car68. Evaluationof Esophageal Iufidraclflmss,MD, hivenity of Www diqinnnary Resuscihtion,

2zl5 - 2230pm Coffee Break, Foyer 2:30 - 3:30 pm Poster Session C, Caprice Rooms 3:30 - 4:30 pm Track A - CPR lll, Pavilion Room Moderator: Gary S. Krause, MD, Ylayne State University 74. High FrequencyJetVentilationfor CardiopulmonaryResuscitation, Robert L. Izvine, Baylor Collegeof Medicine with BloodPressureDur75. Correlationof PlasmaCatecholamines ing Cardiac Anest, John M. Schoffstall,MD, Medical College of Pennsylvania 76. Myocardial HemodynamicsUsing Direct MechanicalVenfor CPR,Mark P. Anstadt,MD, OhioState tricularAssistance University 77. ReversibilityLimit of NormothermicVentricularFibrillation CardiacArrest Time in Dogs: 15Minutesfor Brain, 20 Minutes for Heart, Fritz Sten, MD, University of Pittsburgh

l:fi) - 2:15 pm Track B - C-Spine/CNS, Continental Room Moderator: J. Doughs Wile, MD, Georgetown University 69. Measurement of Cervical Spine Mobility in a Traction, Alignment, Cervical Immobilization, and Transport (TACIT) Device, Ahimsa Sumchai, MD, Stanford University 70. Comparison of Five-View and Three-View Cervical Spine Series in the Evaluation of Patientswith Cervical Trauma, JanrcsPiche, MD, Valley Medical Center, Fresno 71. Missed Cervical Spine Fracture, Steven A. Santanello, DO, Grant Medical Center, Columbus 72. Neuropsychological Evaluation of Cortical Function in the Mildly Head Injured Patient in the Emergency Department, Bruce Becker, MD, Rhode hland Hospital 73. Presentation of Patients with Acute Stroke, lYilliam G. Barsan, MD, University of Cincinmti

3:30 - 4:45 pm Track B - EMS, ContinentalRoom Moderator: C. GeneCayten,MD, MPH, New YorkMedical College 78. Data Collection by Paramedicsfor PrehospitalResearch, Miclwel D. Heller, MD, Universityof Pittsburgh 79. Necessityfor ObjectiveEvaluationof EMS SystemPerformance, Odelia Braun, MD, Universityof Califumia 80. Pre-HospitalCareby EMT's and EMT-Is in a Rural Setting: of ServiceJustifieA?,PaulJ. Donovan,DO, Is theAdvancement Heritage Hospital, Tarboro in VariousFormsof High 81. ClinicalandPhysiologyParameters Angle RescueTechniques,William D. Ramsey,MD, NortheastemOhio University 82. OccultHypoxiaDuring AeromedicalTransport:Directionby PulseOximetry,J.D. Melton, MD, Universityof Pittsburgh

5:fi) - ll:fi) pm Annual Banquet The 1988 Banquet will begin by transporting Annual Meeting attendeesvia bus to the riverboat, BeclcyThatcher. A cocktail reception will be held aboardthe riverboat as the cruise begins on the Ohio River. A bluegrass band will provide entertainment. The destination of the cruise is Coney Island where a grilled shrimp and tenderloin kabobs and lemon chicken buffet dinner awaits. During dinner the annual presentationof the Imago Obscuraand JamesMackenzie awards will be held. Last year's winners will provide the entertainmentas tley review this year's entries and make the presentation'sfor 1988. The awards are real, but the presentationsare tongue-in-cheek.The return cruise will include coffee, dessert,and relaxation. Pleasemake sure your plans include the Annual Banquet. As always, active, associate,and international members receive one free banquet ticket and pre-registration is required. Additional tickets can be purchased for M0. Dress is casual. The Annual Meeting Banquet is a tradition you shouldn't miss.

Friday, May 27, 1988 9:fi) - l:fi) pm UA/EM ExecutiveCouncil Meeting, SalonM All membersand interestedguestsare encouraged to attendthis, and all, meetingsof the ExecutiveCouncil.

POSTER PRESENTATIONS Poster SessionL - May 24 Effect of a Mandatory Emergency Medicine Lecture Curriculum on the Data Base of Junior Medical Students, Louis Binder, MD, Texas Tech University

84. A Computer-Assisted Irarning Tool Designed to Improve Clinical Problem Solving Skills, Franft"/. Papa, DO, Tems College of Osteopathic Medicine

8 5 . Emergency Department Evaluations Utilizing Results-Oriented

1 0 3 . Reliability of Patient History in Determining the Possibility of Pregnancy, Alfred University

Sacchetti, MD,

Thomas lffirson

104. Decision Rules and Clinical Prediction of Pneumonia. Bonita M. Singal, MD, University of Cincinnati

1 0 5 . Clinical and Cost Effectiveness of Serum Amylase in Acutely Ill Adults, l. Douglas White, MD, Georgetown University

106. The Usefulness of Serum Electrolytes in the Evaluation and Treatrnent of Acute Adult Gastroenteritis, Jomthan S, Olshakcr, MD, Naval Hospital, San Diego

Performance Standards (ROPS), Judith E. Tintinalli, MD, William Beaumont Hospital

86. ResearchPrograms in Emergency Medicine Residerrcies,Dorwld

107. Performance and Utility of the Vision Systemfor SerumTheophylline and Chemistries in the Emergency Department, Robert M. McNamara, MD, Medical College of Pennsylvania

C. Anhur, MD, Naval Hospital, San Diego

8 7 . Literary Discussion Group in an Emergency Medicine Residency Program, Arthur B. Sanders, MD, University of Arizona

8 8 . Emergency Department Patient and Visitor Awareness of the Specialtyof EmergencyMedicine, Walter C. Robey, MD, Morristown Memorial Hospital

89. Modeling Emergency Department Operations Using Advanced Computer Simulation Systems,CharlesE. Saunders,MD, Vanderbilt University

90. Formula for Emergency Physician Staffing, Louis G. Graff, MD, University of Connecticut

Poster SessionB - May 25 108. Endotracheal Intubation of Pediatric Patients by Paramedics, Peter Aijian, MD, Valley Medical Center, Fresno

109. Prehospital Blind NasotrachealIntubation by Pararndics, Daniel J. O'Brien, MD, Uniyersity of Inuisville

1 1 0 . Prehospital Cricothyroidotomy: Indications, Complications, and Outcome, Maralee Joseph, MD, University of Arizona

1 1 1 .Accuracy of Transcutaneous, Transconjunctional and Pulse Oximetry During Air and Ground Transportation, Sr.ran Dunmire, MD, University of Pittsburgh

9 1 . Emergency Departnent Violence in United StatesTeaching Hospitals, Frank W. Lavoie, MD, University of lnuisville

92. Disarming the Department: Weapon Screening and Improved

93.

Security to Create a Safer Emergency Deparfinent, Bruce M. Thompson, MD, Henry Ford Hospital "Bounces" An Analysis of Short Term Return Visits to an Urban Emergency Deparftnent, John M. Pierce, MD, University of Tennessee

94. Reanalysisof SurveillanceData Regarding Health Care Worker Risk of Nosocomial Acquisition of the Human Immunodeficiency Virus (HIV), Gabor D. Kelen, MD, Johns Hopkins University 95,

Using PLSI, an Artificial Intelligence Clustering Algorithm, for Medical Research, Rick Pionkowski, MD, University of lllinois, Urbana-Champaign

96. Objective Assessmentof Megacode Performance: The Results of Increasing Structure on Interobserver Reliability, Charles E. Saunders, MD, Vanderbilt University

9 7 . Videotape Review of Cardiac Arrest Resuscitations:Analysis of Elements of Resuscitation Team Performance. Charles E. Saunders, MD, Vanderbilt University

t 1 2 . Evaluationof A PulseOximeterin the PrehospitalSetting, ThomasJ. McGuire, EMT-P, BerkeleyFire Departnent 1 1 3 A Prospective Prehospital Trial of NitrousOxideUsein Urban and Suburban/Rural Systems:A Studyof Efficacyand Effects,Paul M. Parts, MD, Universityof Pittsburgh

r14. EMS Field TraumaTriageCriteriain an UrbanTraumaSyshm, Edward P. Sloan, MD, Universitvof Illinois I 1 5 . Defining Normal Capillary Refill: Variation with Age, Sex, Temperature, David L. Schriger, MD, UCUI

116. The Role of the Physician in a Helicopter Emergency Service, Roben J. Schwartz, MD, MPH, Hartford

t l 7 . PediatricCritical CareTransport:Is a PhysicianAlways on the Team?,Karin McCloskey,MD, Uniuersityof I 1 8 . RapidAcutePhysiologyScoringin Critical CareTransport tems, KennethJ. Rhee,MD, Universityof Califumia, l 1 9 . Geriatric Injury, Prehospital Epidemiology, Mechanisms Patterns, Daniel W. Spaite, MD, University of Arizona

t20. A ConstantForce Spring Device for Traction and Transport the Cervical Spine Injured AdlIt, Ahimsa Sumchai, MD, ford University

9 8 . Informed Consent for Pre-Hospital Administration of Tissue Plasminogen Activator (t-PA): Implications for Research in Emergency Settings, Pamel.a Grim, MD, University of Chicago

99. A New Model for Providing EmergencyMedical Care in Large Stadiums, Daniel W. Spaite, MD, University of Arizona

100. Value of Serum and Urine Creatine in the Emergency Department Diagnosis of Acute Myocardial Infarction, W. Buylaert, MD, State University Hospttal, Ghent, Belgium

1 0 1 . Hyperacute T-Wave Criteria Using Computer ECG Analysis, Mark S. Collins, MD, Northeastern Ohio University

ro2.

The Use of the Emergency Department for Routine Pap Smear Examinations in a High Risk Patient Population, Marc M. Izvine, MD, Texas Tech University

l2l.

CervicalSpineFracturesSustained by Childrenin Car SusanFuchs, MD, Universityof Pittsburgh 122. CervicalInjury in HeadTrauma,JerroWLeikin,MD, of lllinois 123. Cervical Spine Injury and Radiography in Alert "H Patients, Roben M. McNamara, MD, Medical College Pennsylvania lZ4.

A Fatal Hemorrhagic Shock Model in Immature Swine, F. VanLigten, MD, University of Cinciwati

125. Hemodynamic and Respiratory Effects of Hormone (TRH) in Anaphylactic Shock, Roben L. MD, Truman Medical Center, Kansas Citv

- tBl x cf*-

ttf J, _.C-= 147. Cerebral Oxygen Estraction During CPR in Children, Mark Goetting, MD, Henry Ford Hospital

126. Lipid Peroxidation in Liver Before and During Resuscitafion from Hemorrhagic Shock, Richard C. Dart, MD, University of Arizona

148. The Effect of an Alpha-2 Adrenergic Agonist (UK-14, 304) on Myocardial Blood Flow During CPR, JamesJenkins, MD, Ohio State University

121. Early vs. Late Fluid Resuscitation: Lack of Effect in Porcine Hemorrhagic Shock, Steven C. Dronen, MD, University of Cincinrwti

149. The Median Frequency of Ventricular Fibrillation: A Useful Guide to Therapeutic Interventions During CPR, Roger Dzwonczyk, PE Ohio State University

128. Blood Antibodies and UncrossmatchedType O Blood, Randy Smejlul, MD, Roben Wood Johnson Medical School

150. Effect of Sodium Dichloracetate Dose on Lactate in the Brains of Ischemic Fed Rats, Beverly L. Timerding, MD, University of Cincinnati

129. Evaluation of Blood Warming Devices Ushg the Apparent Thermal Clearance, l,ouis Flancbaum, MD, UMDNJ 130. Microwave Warming of Blood: Preliminary Report on a New Method, Douglas Gentile, MD, Vanderbilt University 13l.

151. Delayed Recovery of Brain pH During Reperfusion After Graded Cardiac Arrest, Richard M. Nowak, MD, Henry Ford Hospital

Accidental Hypothermia: An Analysis of Treatment Protocols, Jonathan M. Saxe, MD, llayne State University

152. Densitometric Analysis of Cytochrome Oxides Activity in the Brains of Ischemic Rats Treated with Sodium Dichloroacetate, Ruth V. W. Dimlich, PhD, University of Cincinnati

132. The Use of a PercutaneousCatheter in the Treatment of Spontaneous and Iatrogenic Pneumothoraces, Kimberly M. Pilard, MD, Eastern Virginia

153. Metabolic Effects of Hypertonic Sodium Bicarbonate Administration in Severe, Fixed Respiratory Acidosis in a Canine Model, David Il. Plummer, MD, Hennepin County Medical Center

133. Radiologic Evaluation of Soft Tissue Foreign Bodies, Marc Pollack, MD, York Hospital 134. Computed Tomography Versus "Poor Man's" Intravenous Pyelogram (lYP), Marc Shapiro, MD, St. ktuis University

154. High Ventilation Rate and Arterial and Mixed Venous Blood GassesDuring CPR, Don M. Benson, DO, Wayne State University

135. Selective Use of Pelvic X-rays in Multiple Trauma, Roben B. Rowland, Jr., MD, Geisinger Medical Center

I 55 . Reliability of Clinical Presentationfor Predicting Significant Pit Viper Envenomation, Katherine M. Hurlbut, MD, University of Arizona

136. Clinical Fracture of the Carpal Navicular-A Myth?, Mahendra P. Mehta, MD, Mount Carmel Mercy Hospital, Detroit

156. A ProspectiveHuman Crossover Study on Single vs. Multiple Dose Charcoal in Salicylate Ingestion, James Dougherty, MD, Northeastern Ohio University

137. The Clinical Use of the Patellar-Pubic PercussionSign in Hip Trauma, StephenL. Adams, MD, Northwestem University 138. The Frequencyof Cardiac Injuries in PatientsWith SternalFractures, James T. Sturm, MD, St. Paul-RamseyMedical Center

157. Toxicokinetics ofParaquat Through the Heart-Lung Block: Six Cases of Acute Human Poisoning, Christopher Keyes, MD, UCLA

139. Efficacy ofRoutine Toxicologic ScreeningofTrauma Patients, Michael A. Cruz, MD, University of lllinois

158. Liquid Automatic Dishwashing Detergents:A Profile of Toxicity, Edward P. Krenzelok, PharmD, University of Pittsburgh 159. Limitations of EmergencyFiberoptic ScopeIntubation, Edward J. Mlinek, Jr, MD, Hennepin County Medical Center 160. The Emergency Treatment of Acute Hypoglycemia: Effect on Serum Potassium in Insulin Dependent Diabetics, Joseph G. Kaczor, MD, Wayne State University

Poster SessionC - May 26 140. KeroseneHeater Injuries in Children, RoyM. Kulick, MD, Universiry of Pennsylvania

161. An Evaluation of Endotracheal Glucagon for Treatment of Hypoglycemia, Stephen C. Rector, MD, West Virginia University

141. Stopping the Heartbeat of America: Pediatric Trauma 1988, Robert lnvery, BA, MICP, New Jersey State Trauma Center

162. A ProspectiveDouble-Blind Study of Metoclopramide Hydrocholoride for the Control of Migraine in the Emergency Department, David S. McClellan, MD, Naval Hospital, San Diego

142. ReducedStaffing of a Pediatric Trauma Center at Night, James Lindsay, Children's Hospital, San Diego

163. Elevated Toxoplasma IgG Antibody in Patients Tested for Infectious Mononucleosis in an Urban Emergency Department, Michael Sayre, MD, Allegheny General Hospital

143. Suitability of the External Auditory Canal for Body Temperature Measurement in Emergency Department Patients, Robert D. Powers, MD, University of Virginia

l&. 144. A Comparison of Tympanic and Rectal Temperatures in the Emergency Department, Lynne Ward, MD, University of Pittsburgh

Atmosphere and Asthma: Why Pulmonary Patients Presentto Emergency Departrnent in Waves, Roruld B. ktw, MD, University of Chicago

165. Do Antibodies Modulate Severity of Myocardial Dysfunction in Toxic Shock Syndrome?, Edward A. Panacek, MD, Case Western Reserve University

145. Comparison of Axillary, Tympanic Membrane, and Rectal Temperaturesin Young Children, David Treloar, MD, Henry Ford Hospital

166. Comparative Acute Blood Pressure Reduction of Intravenous Fenoldopam Mesylate vs. Sodium Nitroprusside in Patients with Severe Hypertension, Mark A. Munger, PharmD, Case Western Reserve University

146. Comparison oflntraosseous, Intratracheal and Central Venous Administration of Lidocaine in Pigs, Krts Bickman, MD, St. Vincent Medical Center/The Toledo Hospital

Abstracts of the 18th Annual Meeting of the University Association for Emergency Medicine *Sfudy done primarily

by a resident. Editors note: The following 1.67 abstracts will be presented at the Annual Meeting of the [Jniversity Association t'or Eme.rgency Medicine in Cincinnati, Miy 24-26. Prcsenterc'names are pfinted in italics; where presenter is not indicated, none was specified by the authors.

Oral Presentations a I

Prospective Study of the Effect of Salety gelts in Motor Vehicle Accidents

E Orsay,T Turnbull,M Dunne,J Barrett,P Langenberg, of lllinoisAffiliatedHospitalsEmergency CP Orsay/ Unrversity of lllinoisDepartmentof Surgery, MedicineResidency;University Cook CountyHospital;Universityof lllinois,Schoolof Public Health,Chicago,lllinois I n f u r r e s s u s t a i n e da s a r e s u l t o f m o t o r v e h i c l e s a c c i d e n t s {MVA's) represent a maior challenge to our health care system and enormous socretalburden.It is currently the leadingcauseof death in personsaged I to 38. Few studies evaluatethe effect of safety beits (SB)on trauma resulting from MVA's in the United States.We undertook the following study to assessthe effect of SB on the extent and type of injuries sustainedin MVA's. A total of 1,364patients were prospectivelyevaluatedover the courseof 6 rnonthi at 4 Chicago area hospitals. Patientswere evaluatedin the emergencydepariment for SB usageand mechanism of injury. A researChteam member later reviewed the charts and assigned abbreviatediniury scale codes describing the specific injury and iniury severity scores (ISS).Fifty-eight percent of patients were weati.rg SB whereas42To were not. SB wearershad a 60% reduction in severity of iniury, as reflectedby a mean ISS of l'8 t .07 ( + [(standarderror of mean) vs 4.51 .31 in non-SBwearers{P .001) {two-tailed t test)]. Regardlessof the mechanism of iniury (front end, broadside,or rear end collisions),SB wearersfared significantly better than their unrestrainedcounterparts.Significant differenceswere also noted in the patients of injuries sustainedin MVA's between SB and non-SBwearers. With SB

No SB

P value

Head & Face

30.1%

67 27.

< 0.001

Spine:

61.6%

49%

Thorax:

11.8/"

20 6"/.

< 0.001

0.6%

31%

< 0001

Iniuries

Abdomen:

analysis. physical, and pelvic examination, and Kleihauer-Betk_e Fatients were hydrated and observedin the obstetrical unit for a minimum of four hours. Uterine contractionswere monitored with both tocodynamometerand continuous doppler.Sixty-two women, from 21.5 to 42 weeks gestation,were evaluated.Forty (65%| were in motor vehicle accidents,including three rollovers; direct blowsto the 17 128%)had {allen;and IB (29%)experienced abdomen,either alone or with a fall or motor vehicle accident. Forty-{ivewomen {73%}demonstratedtrunk, abdominalor uteror bruising;or uterine irritability on initial exam' inc tenderness ination.In 6l (98%),the pelvic examinationwas normal and cons i s t e n t w i t h g e s t a t i o n a la g e .T h r e e ( 5 % ) r e q u i r e de m e r g e n c y cesareansectron upon entry to the emergencydepartment.All three had placentalabruption and one infant was deadon presentation. Twenty'nine 147%)experiencedcomplications during monitoring; 2 (3%) developedpreterm labor; 3(5%) developed term laborl 3 (5%l had fetal heart tone irregularities;2l (34%) developeduterine contractions that resolved spontaneously. analysiswere availableon 53 (85%l Resultso{ Kleihauer-Betke p a t i e n t s ,a n d r e v e a l e df e t o m a t e r n a ih e m o r r h a g ei n 2 4 1 4 5 ' k l ianging irom 5 to 100.8cc's. We advocatethe use of obstetrical monitoring for a minimum of four hours, in order to detect com' plications1n patients beyond the 20th week of gestation,who have exoerienceddirect or indirect abdominal trauma.

{<6 rt

of SW Wright,SC Dronen,TJ Combs, D Storer/ Department ol Cincinnati EmergencyMedicine,University Patients experiencingcardiac arrest secondaryto trauma comprise 8-15%of air ambulancesceneflights in reportedseries'Al' ihough it is undeterminedwhich patients are optimal candidates for helicopter transport, it has been stated that transportmay not be indicaied for patients known to have a very dismal prognosis. The current study examines the role o{ aggressivephysicianintervention at the accident scenein conjunction with rapidair evacuationto a trauma center in reducing the mortality following post traumatic cardiacarrest. This was a retrospectivestudy evaluatingthe flight, hospital and autopsy recordsof.patients treated by a Univirsity basedair ambulancesystem from Deer 1987. During the 34-month study period cember I984-Septemb there were 526 tiauma sceneflights. Sixty-sevenof thesepatients 112.7%)experiencedcardiac arrest prior to arrival o{ the flight t"rtn. th"^tu.rage distance to the scene was l4.l flight miles' Fifty-eight patients 187%lwerc victims of blunt trauma, nine papatlents tients (13%) sustainedpenetratingtrauma. Forty-seven *.r. tir.,rported to the base hospital; twenty were pronounced dead at the scene after resuscitation attempts were made Proand ceduresperformed by the flight team included-peripheral central line placement,blood idministration, endotrachealintubation, cricolhyrotomyi needle and tube thoracostomy,and-peri' cardiocentesis.Six patients (9%) developeda pulse and blood Dressureat the scene and were admitted to the hospital;none iurvived to hospital discharge Review of autopsy data166of,67 patientsl revealid that the majority of patients.had headand/or ihoracoabdominaliniuries that were incompatiblewith life The We total charge for the 47 transportedpatients was $114,08.9 conclude tlat physician intervention at the sceneand rapidaeromedical transport is not iikely to improve mortality following traumatic .^rdir. arrest.If it can be deierminedprior to dispatch of the air ambulanceteam that the patient has suf{eredtraumatic

< 0 001

UpperExtremity

14.5%

23.6%

< 0.001

Lower Extremlty:

18.7v"

32 3%

< 0001

Spinal iniuries were the only group in which SB wears sustained more frequent injuries than non-SB wearers' However, the vast maiority of these 174%Jwerecervical strain - an uncomfortable, but minor injury. These results clearly demonstratcthe benefit of SB in reducing the severity of iniury. Furthermore,SB reducethe frequency of head,{acial, thoracic, abdominal and extemity injuries sustained in MVA's. *rl

Detecting

Acute

Gomplications

Aeromedical Transport of Patients With Post Traumatic Gardiac Arrest

Aftel

Trauma in Pregnancy

of Obstetricsand / Departments M Peailman,J Tintinalli and EmergencyMedicine,WilliamBeaumont Gynecology, Hospital,RoyalOak, Michigan From April 1986 through October 1987,women 20 weeks ol gestationor greaterwho experiencedacute trauma, were prospectively evaluited in the emergencydepartment and obstetrical unit. Tiauma was defined as indirect (falls or motor vehicle acctdents),or direct {blow to the abdomen).Patientswith isolated extremity iniuries were excluded. Data gatheredincluded history,

cardiac arrest, alternate methods of transportation should be considered.

The Effects of the Pneumatic Anti.Shock Garment (PASGI on Arterial PH and Gentral Venous Lactate Levels Using a Baboon l{emorrhagic Shock Model

BA Gowesky,CD Chisholm,DY Guiffre,JR Cooper/ Departmentof EmergencyMedicine,BrookeArmy Medical Facility Center,Ft Sam Houston,Texas;ClinicalInvestigatron AAMRL/VS, WrightPatterson AFB, Ohio The signi{icanceof metabolic acidosisin the setting of hemorrhagic shock with pneumatic antishock garment (PASG)utilization remains unclear.The only controlled studies to date examining the significanceof the contribution by the PASC to metabolic acidosisin the setting of hemorrhagehave been in the canine model which correlates variably with the human. This study examines the effects of the PASG on lactate levels and arterial pH using a primate model. Ten healthy male adult baboons lPapio anubis) servedas their own controls in this hemorrhagic shock model. Each baboonwas sedatedusing ketamine {3 cc IM) and pentobarbital (up to a total oI 25 mg/kg/IV) titrated during the experiment to maintain an appropriatelevel of anesthesia. The baboons were intubated and allowed to spontaneously breatheroom air throughout the experiment.A right cephalic central venous catheter and femoral arterial catheterwere inserted, and a baselineblood sample obtained for central venous lactate levels, electrolytes, hematocrit, and arterial and venous blood gases.Hemorrhagic shock was then induced through rapid withdrawal of 20% total blood volume {14 cclkg) over l0 minutes.During PhaseI, all three compartmentsof a PASGiPediatric MAST@,David Clark Company) were rapidly inflated and blood samplesfor the aforementionedtests serially obtained at 0, 5, 15, 30, 45, 50 and 70 minutes. After 70 minutes of inflation, the PASG was rapidly deflated over 30 seconds;blood sampling was repeated5 minutes post deflation. All animals were then autotransfusedthe entire withdrawn blood volume. Five weeks later the same baboonswere utilized in PhaseII during which the study was reproducedwithout the use of a PASG.The data were analyzedusing repetitive paired t tests with each baboonserving as his own control, as well as the analysisof covariance.During the PASG inflation the hypovolemic baboons had a significant elevationof central venous lactate levels (P < .051.No significant changesin pH and pCO2 were found, although there was a trend towardshypoxia during the PASG in{lation stage(PhaseIJ.Hypocalcemia developedduring both Phase I and IL Recovery time, measuredby a return to grossly normal activity and resumption of feeding,was markedly prolongedafter PhaseI as comparedto PhaseII. We conclude that utilization of the PASG in the hypovolemic baboon model results in significant increasesin central venouslactate as comparedto hypovolemic baboonswithout the PASG inflation. This elevation in lactate may stem from increasedproduction causedby additional hypoperfusionof tissues beneaththe inflated PASG or by decreasedhepatic clearancedue to diminished portal circulation secondaryto increasedintra-abdominal pressures.

Xq J

ary l, 1986,through November 1987.Sixty-nine 178.a%lpatients receivedantivenin {AV).Seventy-five(85.2%)ST were negative a n d 1 3 ( 1 4 . 8 % fp o s i t i v e .S i x t y - f o u ro f t h e 7 5 { 8 5 . 3 % )p a t i e n t s with negativeST receivedAV while 5 of 13 (38.5%)with positive ST receivedAV Among all patients receiving AV (69),23 133.3."/"1 sufferedan acute reaction.Ten of 23 143.5%)acute reactionswere severeihypotensionand/or respiratorydistress)while 13 156.5%) were considerednot li{e-threatening[rash oniy il0) or rash and fever i3)1.Among the 64 patients with negative ST who received AV 18 (28.1%)had acute reactionswhile all 5 patients (100%| with positive ST who receivedA! sufferedacute reactions(P < .02.5,chi-square|.Six ST:negativepatients and 4 ST:positivepatients had severereactions.Among thc l8 patientswith negative ST who had acute reactions, 8 subsequentlyreceived more AV Only one had an acute reaction during the secondAV administration although it was severe.One patient with a positive ST who had an acute AV reaction (rash)was subsequentlytreated again with AV This patient suffereda second,more severereaction with generalizedrash, wheezing and respiratory distress.Symptoms of serum sicknessoccurredin 4 of 5 {80%lof the patients with positive ST who received AV and in 2l of the 64 132.8%) who had negative ST and received AV Serum sickness also occurred in 3 of 18 116.7%lpatients receiving ST but not AV 12 negativâ&#x201A;Ź,I positivef.Severalfindings were significant: I 1 patients that receivedST and demonstrateda negativeresult were not treated with AV These patients should not have receivedan ST; acute AV reactionsoccurred with a higher frequency in patients with positive ST than those with negative oflâ&#x201A;Źs; rnost patients with negative ST who had acute AV reactionswere subsequently treated successfullywith AV Patients with positive ST who received AV had a high incidence of severereactions and serum sickness.Re-administrationof AV in an ST:positivepatient resulted in a second,more severereaction.

lV Fluid Therapy in the Prehospital Management of Hemorrhagic Shock: lmproved Outcome With Hypertonic Saline/6olo Dextran 70@in a Swine Model

CR Chudnofsky, SC Dronen, SA Syverud, BJ Zink, JR Hedges / Department of Emergency Medrcine, University of Cincinnati Recent studies suggest that IV fluid therapy is of limited benefit in the prehospital management of hemorrhagic shock. Studies failing to demonstrate efficacy have typically evaluated standard isotonic fluid therapy. Unlike conventional IV therapy, infusion of small quantities of hypertonic saline (HTS) has been shown to markedly improve hemodynamic performance. The smaller quantrties of HTS infusate potentially permit rapid in-transit administration of a therapeutically significant dose for volume expansion. HTS has not been studred in a model that closely simulates the temporal chain of events in pre-hosprtal care. The current: study uses a reproducible lightly anesthetized model of porcine continuous hemorrhage to evaluate HTS's ability to treat hemorrhagic shock rn the pre-hospital setting. Twenty-six immat u r e s w i n e ( 1 5 - 2 0 k g )w e r e b l e d a t a r a t e o f 1 . 2 5 m l l k g / m i n . A n i mals in the normal saline (NS) group {n: l4) received fluid resusbeginning 20 minutes after initration of citation at lml/kg/min hemorrhage; those in the HTS group (n: l2) received 7.5% HTS in 6% Dextran 70,. The 20-minute period simulated time {or ambuiance request and dispatch, travel to the scene, patient evaluation and intravenous cannulation. Infusions were continued for 22.5 minutes simulating time for patient treatment, loading and transport to the hospital. At T:42.5 both groups received saline and at T: 45 the fluid was changed to saline/shed at 3ml/kg/min blood in equal proportions at the same rate. Both groups had hemorrhage controlled 25 minutes after simulated hospital arrrval. Mean arterial pressure, central venous pressure/ cardiac output, hematocrit, arterral blood gases and serum lactates were measured at lS-minute intervals throughout the study. Cardiac

Skin Testing! lmplications in the Management of Pit Viper Envenomation

DW Spaite,RC Dart,K Hurlbut,JT McNally/ Sectionof of Arizona; EmergencyMedicine,Collegeof Medicine,University ArizonaPoisonand Drug Information Center,Tucson Recordsfrom 88 victims of pit viper envenomation who received skin testing iST) with horse serum were reviewed.Information was gathered from the Western Snake Envenomation Database.The databaseincludes the porsoncenter records,hospitalization recordsand follow-up questionnairesof casescontacting the Arizona Poison and Drug Information Center from fanu-

index, systemic vascularresistanceand oxygendelivery were calculated at the same intervals. Death was determinedby the presence of apnea and a mean arterial pressure.less than 20' Data were analyzedusing analysisof variancewith one repeatedmeasure. Following treitme.ti, cardiac index, mean arterial pressure, and oxygen delivery were significantly higlrer in the HTS group; vascular resistance and serum lactates were siSnifirvt,"#i "r"tiy to*.t There were no deaths in the HTS group vs 6 -deaths sigtii't"l i" the NS group. This differencewas also statistically nificant. No comlhcations o{ HTS therapy were noted' We conclude that HTS may provide significant advantagesover standard iroto.ri. fluid therapy in the pre-hospitalmanagementof hemorrhaeic shock.

The Management of Stress and Prevention of Bulnout in Emelgency Physicians KL Keller,WJ Koenig/ CaliforniaState University;Memorial MedicalCenterof Long Beach,Long Beach' California Purpose: The purpose of this study was to: l) determine .orrra.. of stress and satisfaction in the practice of Emergency Medicine 2) measureburnout levels of participating practrtloners and 3) identify coping methods used by-these.physiciansto man"g. .it".t. prccedurit A cross-sectionalstudy was done with a in si'mple of 104 physiciansemployed-ineme.rgency.departments 24 orivate, publlc and univeisity-affiliated teaching hospitals in the'greaterios Angeles area.Instruments used were: Emergency Phyiicians Questionnaire (EPQ),Maslach Burnout Inventory were ana{Mbll, and Bell Coping Methods Scale {BCMS).Data iur.d' nsine statisti;al iorrelations and chi-squaretests' Selected in findings:data revealedthat the three greatestsourcesof stress .-".sEn.y medicine are: l) patient load, 2l interaction with paii.nrJ rnd families, and 3) lack of administrative support' The iht." gt.rt.t, sourcesof satisfactioninclude: l) proficient use of skills,"2) variety and excitement, and 3) being a member of an effective t""-. Si*ty percent of the physiciansreportedmedium to high emotional exhaustion and 78"/omedium to high depersonalization,while 84% reported medium to high levels of personal achievement.Findings from this study also indicate that ohvsicianswho report higlilevels of job satisfactionand personal use a balancednumber of short and long term r..o*plith-.nt cooins methods in dealingwith stress.Recommendationsfot further iudy: Furtherstudiesshouldbe undertakento facilitatein Jepth analysis ol the characteristicsof those emergency.physicians who report low levels of emotional exhaustion and deper' sonalization as well as high levels of personal achievement' ihese studies should look not only at characteristicsof the individual physiciansbut those of the organizationin which they fu""tio" and the relationship between the two' A longitudinal st"dy *hich followed a sampieof emergencyphysiciansfrom the time of their internship tliLroughtheir careers would be even more helpful in identifying factors which lead to the successful practice of emergencYmedicine.

the 59 graduatesof our IntegratedResidencyin EmergencyMedicine. T-hesegraduatesrepresentedpractice experienceranglng from one to Eight years.The results were analyzedfor response and trends thaimay have extendedapplication to graduatesfrom emersencv medicine residencies.Our findings demonstrate: tl Th"atemergencymedicine residencytrained physiciansmay "burn-out" at the rate popularly perceived' ,ror be experiincing 2) There are consisient environmental elements thet contribute to "burn-out" in our specialty.3) That the problem exists to sufficient degreethat coniinued researchinto origins and prevention is warranted.

Retrospective Review of Prehospital Gare Lawsuit Glaims in a Large Metropolitan EMS System

J Zautcke'M Kling,R Goldberg, R Lee, M Koenigsberg, of lllinoisEmergencyMedicine F Nagorka,S Ward/ University Counsel, lllinoisMasonicMedicalCenter;Corporation Resid"ency, C h i c a g o l, l l i n o i s Previousstudies looking at the incidenceof lawsuits generated in the prehospital setting are limited. A re.trospectiveleview ot all claims brought against a large metropolitan EMS system re' lated to p"tr-"di"/p"tient encountersduring the eleven-yearperiod, 1976-1986,wai undertakenfor the purposeof reviewingand describingthe incidence and types of -malpracticeclaims' Cases were extiacted from the city law offices using computer case searchesas well as manual review of the files During this,period, irtrs ""iit responded to approximately two million calls and transoortedoue, orre million^ patientst 6I claims were produced yielding a rate of one lawsuit per 29,710 paramedic/patt-elte.n' 6ount.ir and one lawsuit per Ii,70O patient transports'While the total number of runs "ttd tt".ttpotis have not changed signifi' this time, the data indicates a trend of increasing cantly during "against the prehospital care provider (23% of cases clalms filed 777oof caies from I98l-85)' Approximately 1976-80"versus from il-o o.i..", o] claims alleged improper medical treatment while 30 il;;;"; of claims allegEdnegligencerelatedto dispatch'other less commonly cited causesof action included transport to rmoroper facilitv,'refusalof transport by patient, and iniury dlring i."irpor,. The data indicate a relatively higher rate of claims iif.a io. paramedic/patientencountersoccurring from midnight 24 to other times of day iparamedicswork l" goo "* .o-p"t.i ,,34"/"1 hours shifts in this E,MSsystem).To date, 2I of the 61 ""ta" ttau" been settled with nominal out of court settlements'

a al I l|

Attending Coverage in Academic Emergency lledicine: A llational SurveY

PL Henneman,RS Hockberger/ Departmentof Emergency MedicalCenter,Torrance,Cali{ornia Medrcine,Harbor-UCLA emergencymedicine residencyproaccredlted all We surveyed gr"-.-(Epfi,p) in the United StatJsduring 1986(N:66) on the itt.t" oi attending coveragein academicemergencymedicine Re,pott..t were reciived from + t t residentsand 287 faculty from 56 The Status of "Burn'Out" in Gladuates p?ogt"-t, this accountedlot 42lo of the residentsand 56% of the ir"fiiiv ftb- the responding programs. Information was obtained of a Resideney Plogram in Emergency per' ty t.l.ptto"" about non-respondlngprograms Seventy-three lledicine coverattending 24-hour had States lrr'ledicine, United in the Emergency f,mnp of of ""ttt / Department GC Hamilton,J Shapter "g.i" fSSe, l4o/ohadIT to23 hours,and 14%had'12to 16hours Schoolof Medicine'Dayton'Ohio WrightStateUniversity o?attending coverageat their primary training hospital'The inci' "Burnout" is a term often applied as one of the significant hazdence of 24"-hourc6ueragewai dependent on the type of institu" accepseeming Despite medicine. ards of practicein emergency tion: militarv 100%, community 95o/",university 73%, andcrty/ there specialty, tance ofthis concernas a negativeattribute of the "burn-out" cowty 47lo (P = .004). Programs with 24-hour coveragewere status in a consistentmanare few studies that assess less likely to require researchof their faculty for academicpro' ner, and over the longitudinal course of a residency graduates versus "burn-out" motion t'han programs without 24-hour coverage{407.o aspects three involving as defined career.This study = .Ofi U,it the number of hours spe'll each week by fac' i ii;t , de-personalization, of iob-inducedstiain: emotional exhaustion, ulty'doing researchwas not significantly different betweenpro' and a lowered senseof accomplishment.A validatedpsychologi*itt 24-hour coverageand those without' Whetheran iir-t ."i ittr*.,-..tt {Maslach Burnout Inventory} was completed by

EMRP had 24-ho.urcoverageor not, was not related to academic criteria for long term {aculty employment, faculty's salary dependenceon patient billing, the number o{ faculty, academicdepartmental status or departmentalaffiliation. Residentsfrom programs with 24-hour coveragereported that their faculty were physically present in the ED from 7 AM to midnight a greater percentageof the shift than residents{rom programswithout 24hour coveragereportedabout their faculty (comparisonof distrrbutions, P < .0001).Residentsfrom all programs would have preferredthat their faculty were physically present in the ED a greaterpercentageof all shifts than they were (comparisonof distributions, P < .0001),but wanted them to be physically present less during the midnight to 7 AM shift than the 7 AM to midnight shift (comparisonof distributions, P < .0001).Residents from programs without 24-hov coveragewould have ideally liked their {aculty to be physically present {rom midnight to 7 AM a smaller percentageof the shift than residentsfrom programs with 24-hour coveragewould have preferredof their faculty {comparisonof distributions, P < .0001).Residentsfrom programs with 24-hour coveragereported that their faculty spent a greaterpercentageof their shift doing primary patient care than residents from programs without 24-hov coveragereported about their faculty (35% versus I7%, respectively,P < .0001),as well as, a smaller percentageo{ their shilt educating residents P <.0001).Residentsfrom ail pro{21%versus30%, respectively, gramswould have preferredthat their faculty spent a greaterpercentageof their shi{t educating residents than they were 142% vercus24ok,respectively,P < .0001),as well as,a smaller percentageof their shift doing research/administrationll4o/" versus23o/", respectively,P < .0001).Residentsfrom programs with 24-hour coveragewould have preferredthat their faculty spent a smaller percentageof their shift doing primary patient care than they werc l23ohversus35%, respectively,P < .0001).Ninety-five percent of faculty andTI% of residents{P < .0001)thought that the quality of patient care was better or significantly better when faculty were physically presentin the ED. Sixty percent of residents and6l% of iaculty did not think that 24-hov attending coverage in academicemergencymedicine should be mandated;4O% and 39%, respectivelythought that it should be. This survey suggests that the majority of residentsand faculty in emergencymedicine in the United States would prefer that Z{-hour coveragenot be mandated by the ResidencyReview.Committee for Emergency Medicine. Further study is needed,howeveqto determine the effect of faculty presenceon the quality of patient care in an academic emergencydepartment.

*iI

propereducation;and 35 136.5%lwere due to patient non-compliance. Of the related visits, 192 147.2%)returned within 24 hours; 134 132.9%lbetween24 and 48 hours; and 8l {19.9%}between 48 and 72 hours. Of the avoidable visrts, 85% returned within 48 hours, as did 92'/" of those with medical management deficiencies.The data suggeststhat monitoring 48-hour revisits, rather than 72, is a useful and efficient tool for detectingmedical managementdeficienciesand other quality assuranceproblems, including proper patient education and appropriateness of follow up. The majority of the avoidablereturn visits representederrors or omissions of the medical staff which could be corrected by case review and education.

a a, | 3

Repeat ED Visits: Red Flag or Red Herring?

Hospital, EA Michelson,SM Schneider,R Clare/ Montefiore University o{ Pittsburgh Patientsreturning for unscheduledED visits have beenreferred to as "red'flags",posinga high medicolegalrisk. These encounters are often approacheddifferently than initial patient visits. We reviewedour recordsto assessif return visits really are "redflags" (RFs)or "red herrings"(RHs).Recordsof all patientspresenting to our adult med/surghospital ED during a six-month period were retrospectivelyreviewed to identify patients also seen in the precedingthirty days. Patient demographicswere recordcdfor thc initial and subsequentvisits along with a coded rcasonfor thc rcturn. Patientswith new unrelatedproblems,with schcdulcdvisits and thosc called back due to discoverederrors wcre then cxcluded.RFs were defined as patients who requireda significantchangein therapy(such as admission)on the return visit. In comparison,RHs' return visit resultedin no changein therapyor new intervention.Among 9,588patient-visitsduring the study period, there were 84(r repeatvisits by 661 patients. Thc study group of 475 visits includcda largcnumbcr 142.5'l'lof RFs,75'2,of whom rcquircdadmission.Thc RFswcrc oldcr,mcan agcof 57.7 + 1.4yrs vs 4(r.8 * 1.3yrs for RHs {1,< 0.0001).Thc intcrval bctwccn visits was similar for thc RF and RH groupsat t1.85* 0.(rand ll.5 + 0.5 days,rcspcctivcly. Lookingat thc cause of the return visit, 37.8Yuinvolved patient or physician failure (PF)and 62.20/"were unforseeable failures to improve (UF),including worsening of condition and recurrenceof symptoms. PFs wereyoungerthan UFs; mean agc44.8 + I.6 vs 55.5 + 1.3yrs (P < . 0 0 0 1 l a n dr e t u r n e ds o o n e r5 . 6 * 0 . 5 d a y sv s 1 0 . 4+ 0 . 5 ( P < 0.0001).Return visrts invoiving physicianfailurc occurredat a m e a n o f 3 . 2 + 0 . 4 d a y s , 7 4 7 oo f p a t i e n t s w c r e R F s . P a t t e n t failures returned latcr at 6.9 + O.7 days and only a 7.6"L were RFs.Thcrefore, a high percentageof ED return patient visrts are "red-flags"and descrvcheightenedscrutiny.Older patientsare at particularlyincreasedrisk. Physicianerror is likely to precipitate who the earlicstreturn visit. Thesepatientsareindccd"red-flags" posea high medicolegalrisk.

Emergency Department Revisits

K Kenh,J Bocka,M Kobernick,R Krome,M Ross/ Department of EmergencyMedicine,WilliamBeaumontHospital,RoyalOak, Michigan The charts of patients returning within 72 hours to our Emergency Department were reviewed to determine if monitoring revisits is a use{ul quality assuranceindicator. Patrentvisits for the months of fune and December,1987,werc selectedto eliminate a potential seasonaldi{ference.Of the I3,26I visits during these two months, 455 /3.4%) were revisits within 72 hours. Charts were availableon 444 patients, of which 407 19I.7%)represented casesin which the return visit and the initial visit were clearly related. Charts were reviewed for deficiencies in the foliowing areas:(1) medical managementi (2) appropriateprescribedfollow up; {3} patient education; and/or (4) patient compliance.Suspected medical management problems were discussedby the 3 senior authors and a consensusdecision was made. Return visits were consideredavoidable if a deficiency was noted in at least one of the areaslisted above.There were 4O7relatedreturn visits, 96 123.6%lof which were avoidable.O{ these avoidablevisits, 38 had medical management deficiencies; 14 114.6%)had 139.6'/.1 inappropriateprescribedfollow up; 20 ,20.8%)had not beengiven

Prediction of Downtime During Ventricular Fibrillation

CG Brown, F Dzwonczyk, H Werman, R Hamlin / Division ot E m e r g e n c y M e d i c i n e a n d D e p a r t m e n t o f A n e s t h e s i o l o g y ,O h i o S t a t e U n i v e r s i t yC o l e g e o f M e d r c r n e , D e p a r t m e n t o i V e t e r i n a r y P h y s i o l o g y a n d P h a r m a c o l o g y , O h i o S t a t e U n i v e r s i t yC o l l e g e o f V e t e r i n a r yM e d i c i n e , C o l u m b u s , O h i o As the duration of time between the onset of ventricular f i b r i l l a t i o n ( V F ) a n d t h e a p p l i c a t i o n o f d e f l b r i l l a t i o n i n c r e a s e s ,t h e rate of successful defibrillation {SDl decreases.In one animal study, SD was accomplished in 70% of the animals defibrillated within one minute of the onset of VF. The rate of SD decreased to less than lO% by l0 minutes of VF We recently have shown that the rate of SD could be increased to greater than 6O% after l0 minutes of VF when pharmacologicai therapy rs instituted prior to defibrillation. Thus an accurate prediction o{ the duration of

time between the onset of VF and the initiation of definitive therapy {downtimef could be critical in selecting the most appropriate therapeutic intervention. The purpose of this study was to determine whether changes in the frequency or amplitude of the VF electrocardiogram (ECG) sigrral during cardiac arrest could be used to estimate downtime (DTl. A standard lead II ECG was attached to l l swine, which were then placed into VF. The VF ECG was recorded continuously on an FM tape recorder for l0 minutes. The VF ECG signal was digitized by sampling at %28second intervals. Each 4 seconds of digitized data was transformed into the frequency domain utilizing a fast Fourier transform. The power spectrum was determined by squaring the amplitude at each frequency. The median frequency (FMl, that frequency which bisects the power spectrum, and the total power (PT) in each 4 secondsof data was determined. FM was then olotted versus DT for each animal. The plot of FM versus Di was then mathematically modelled. Therefore an observed DT (DTo) versus predicted DT (DTD)could be plotted with a 95% confidence interval. The results showed that PT increased from an initial value of 216.8 nW + 332.2,to a peak of 301.9 nW + 705.4 at I minute of VF. and then decreased to a minimum of 50.0 nW + 82.8 at 4 minutes. FM decreasedfrom an initial value of 13.50Hz (t 1.68)at the induction of Vl to 8.6 Hz + O.87at 1.22 minutes + 0.19, then increasedto a peak 13.7Hz + 1.79at 3.55 minutes + 0.57, and then decreasedagain to 7.23H2 + 0.95 at 9.7 minutes. The coefficient of variation for FM was less than 147o. Displayed below is a chart of DTo vs. DTo + 95o/oconfidence interval {CIl. ObservedDowntlme (mlns)

PEdlcted Downtlme(mlns) r 95o/o Cl

2.0

1.85 I

t.tc

4.0

3.86 t

1.28

6.0

5,87 t

1. 4 1

8.0

7.87 t

r.53

PT of the ECG signal during VF revealed a large interanimal variability. On the other hand, FM revealed a small coeflicient of variation. FM may more accurately predict downtime, and thus may further guide initial therapy for patients in VF.

The Role of Bicarbonate and Fluid Loading in lmproving Resuscitation From Gardiac Ar;est With High Frequency GPR

AB Sanders,KB Kern, P Perrault,J Nelson,S Fonken, G Ewy / Sectionof EmergencyMedicine,Departmentof Surgery, Sectionof Cardiology,Departmentol InternalMedicine,University of ArizonaHealth SciencesCenter,Tucson The optimal rate of cardiac compressionfor resuscitation of patients in cardiac arrest is unknown. Recent studies have demonstrated improved hemodynamics and resuscitability in a canine model of cardiacarrest when compressionrates of 120/minute are comparedto 60/minute. The resuscitationprotocolsusing high frequency CPR empirically include aggressivetreatment with bicarbonate to normalize arterial blood gasesand initial fluid loading to a mean right atrial pressureof 6-8 mm Hg. A study was done to determine the role of bicarbonateand fluid loading in conjunction with high frequencyCPR for resuscitation from cardiacarrest. Thirty mongrel dogs were anesthetizedwith morphine and halothane, endotracheally intubated and instrumented with high fidelity micromonometer-tippedcatheters to measureaortic and right atrial pressures.The anrmals were alter' natively assignedto three groups. Group A underwent high frequency compressionat l2o/minute, aggressivebicarbonatetreament to normalize arterial blood gasesand initial fluid loading to

a mean right atrial pressure of 6-8 mm Hg. Group B underwent high frequency compressions at 12O/minute without bicarbonate and fluid loading. Group C underwent standard CPR at 80/minute with bicarbonate and fluid loading. Ventricular fibrillation was induced using rapid ventricular pacing. CPR was begun immediately and continued for 30 minutes. The animals were ventilated with a tidal volume of 15 cclKg at a rate of l2lmin. Following 30 minutes of CPR, the animal was defibrillated with up to three 300 foule shocks. Seven of ten dogs in Group A (high frequency CPR with bicarbonateand fluidsf resuscitated,six survived 24 hours and were neurologically normal. None of the animals in Group B {high frequency CPR without bicarbonateor fluids) were resuscitated or survived. Three of the ten dogs in Group C {standardCPR with bicarbonateand fluidsf resuscitated and survived 24 hours neurologically intact. A significant differencein outcome was determined by chi squareanalysis{P < .01).Groups A and B (high impulse CPR)had significantly higher myocardialperfusionpressures122+7,19+7 vs 13+4 at 15 min| when compared to Group C {standard CPR). Croup B was significantly more acidotic (7.19vs 7.40,7.41 at 25 min) on arterial blood gas analysis than Groups A or C. Data from this experiment supports previous literature that high frequency CPR improvesmyocardial perfusionpressures,resuscitationand 24-hour survival in a canine model of cardiac arrest compared to standard CPR. However, aggressivetreatment of acidosis and/or fluid loading is necessaryto achievesuccessfulresuscitation.Further studies investigatingrapid compressionrates and the role of aggressivebicarbonate treatment and/or fluid Ioading are warranteo.

Dynamic Ghanges in Expired End. Tidal Gadon Dioxide a3 a Ptognostic Guide During GPR in Dogs

KB Kern, AB Sanders,WD Voorhees,CF Babbs, WA Tacker, GA Ewy / Sectionof Cardiology,Departmentof InternalMedicine,Sectionof EmergencyMedicine,Departmentof Surgery, Universityof Arizona College of Medicine;VA Medical Center, Center, Tucson,Arizona;HillenbrandBiomedicalEngineering Departmentof VeterinaryPhysiologyand Pharmacology,Purdue University,West Lalayette,Indiana Expiredend-tidal pCO2 monitoring is a non-invasivetechnique blood flow in cardiacarrest victims. for inferring CPR-generated Such end-tidal pCO2 measurementsmade during resuscitation have correlatedwith cardiacoutput and coronaryperfusionpres' sure,especiallywhen wide rangesof blood flow are included.The utility of such measurementsduring routine closed-chestCPR for predicting resuscitationoutcome remain uncertain. We stud' ied expiredend-tidal pCO2 and coronary perfusionpressurein l5 mongrel dogs undergoingclosed-chestCPR. Anesthesiawasac' complished with morphine (2 mg/kg IV) and halothane (0.5-I.0%).The animals were then orally intubated and instrumented for pressuremonitoring of the ascendingaorta and right atrium. Following appropriate warm-up and calibration/ a cap' nometer sensor was attached to the external end of the endo' tracheal tube. Ventricular fibrillation (VF) was electrically in' duced and allowed to continue for three minutes without treatment. External chest compressionsat 60/min with 50% duty cycles were then begun utilizing a mechanicalThumpero. Ventilation was provided at l2lmin by the Thumpero incorporat' ed ventilator. Advancedcardiaclife support (ACLSI,includingde' fibrillation, was provided after 17 minutes of VF. No sodiumbi' was carbonatewas usedduring the study.Successfulresuscitation defined as a self-sustainedarterial pressureof at least 60/40ilter ACLS and defibrillation. In six successfullvresuscitatedani the mean expiredend-tidal pCO2 was significantlyhigherthanin nine non-resuscitatedanimals onlv after l4 minutes ol CPR 16,2+ 1.2mm Hg vs 3.4 * 0.8 mm Hg; P < .05).No di in expired end-tidal pCO2 values were found at two, eight,ot minules of CPR. A significant decline in end-tidal pCOzler

during the courseof CPR was seenin the non-resuscitatedgroup {6.3 + 0.8 to 3.4 + 0.8 mm Hg; P <.05), while the successfully resuscitatedgroup had constant pCO2 levels throughout the CPR period{6.8 + 1.1 to 6.2 + 1.2mm Hg).Changesin expircdpCO2 levels during CPR appearto be a useful non-invasrveguide during resuscitationefforts. A decline in expired end-tidal pCO2 levels during CPR portends a poor outcome.

Successful Prediction by Gapnometry of Resuscitation From Cardiac Arlest

CW Barton,ML Callaham/ Divisionof EmergencyMedicine, of Departmentof Medicine,The MedicaiCenterat the University San Francisco California, An important problem in the managementof cardiac arrest is the lack of readily available prognostic factors that identify the patient likely to be successfullyresuscitated.Many previou-sly itudied predictive parametersare invasive and require time, skill and equipment that is generallyimpractical for the clinician. The first and-only practical predictive measureto date has been measurement of eipired pCO2. Animal studies found a good correlation ol expircd pCO2-with outcome, but one small human study did not. We conducted a study of human subjectspresenting in cardiacarrest, to determine whether the expired pCO2 was predictive of successfulresuscitation.From April 1986 through December 1988 all adult patients presentingto the EmergencyDeDartment at UCSF in cardiac arrest not due to trauma were iligibl. for the study. Prehospitalbasic and AdvancedCardiac Life Support was providcd to all patients accordingto American H c a r t A s s o c i a t i o n g u i d e l i n e s .O n a r r i v a l i n t h e e m e r g e n c y department patients were intubated orotracheally (if not already iniubatedl ind CPR was instituted with the programmable Thumper'i, delivering 60 compressionsper minute with a 50% compressioncycle. A Hewlett PackardModel 47210A capnometer was kept on standby and calibrated24 hours a day in the department. As soon as the airway was secured,the capnometer was connectedto the endotrachealtube and continuous end tidal pCO2 recordingswere obtained using a continuous-stripchart Ieiordcr. A resusiitation study record was completed and included the capnometer values at regular intervals during the resuscita' tion and whenever clinically significant events occurred,arterial blood gas values, drug therapy,length of resuscitation,and cardiac rhythm. End tidal CO2 is reported in mm Hg. Patientswere gto.-tpedinto those with return of a palpablepulse (+pulse) dulring the resuscitation and those who never developeda palpable pulsc(-pulsc). Thc first mcasuredcnd tidal pCO2was comparcd bctwccnthe two groupsusing thc unpairedtwo-tailcdt tcst. Surs ere v i v a l w a s n o t c x a m i n c d i n t h i s s t u d y .F i f t y - f i v c ' p a t i e n t w studied.Forty-onepatientsneverdcvclopeda palpablcpulseduring thcir resuscitationand had a mean expircdpCO2 at presentation to thc ED of 5.24 (95%,confidcnccintcrvalsoI 4.O5to 6.42). Fourteenpaticnts dcvclopcda palpablcpulse at some point in thcir resuicitationwith a mean initial pCOz of 19.1I (95% confidcncc intcrvals of l0.t't8to 27.341,a ncarly thrccfold difference comparcdto patientsncvcr achicvinga palpablepulse,that was significantat P < .0001.Previousrcportshavc indicatedthat expircd pCOz corrclatcswith coronarypcrfusionpressureand repcrfusingrhythm in both animalsand iu-ption of a spontaneous that the initial mcasuredpCO2 is sighumans.Our observations nificantly highcr in paticnts recovcring a per{using rhythm during resuscitationthan those who never recovera pulse is the first time that outcome has been predicted by a readily available parameter.It may be that expired pCO2 servedto identi{y those in whom standardclosed chest CPR producedadequatecoronary perfusionpressure,and who were thus most likely to be resuscitated.On the other hand, these may be patients with blood pressure or pulse that is completely undetectableby other routine methods.The initial expired pCO2 in our study servedas a reliable marker of patients most likely to respond to resuscitation, regardlessof other prognosticfactorssuch as a long down time or

apparentirreversiblecardiacarrest not responsiveto initial ACLS eiforts. This is clinically important since it may serveas a pr-edictive indicator of patients likely to respondto resuscitationettorts and therebyguide our allocation of resourcesduring resuscitation of the nontrauma cardiac arrest victim.

Simultaneous Aonicr Jugular Bulb' and Right Atrial Pressures During Standard External CPR (SE.CPRI

NA Paradis,JM Rosenberg,GB Martin,M Goetting'EP Rivers, of EmergencyMedicine J Chabot,RM Nowak/ Departments HenryFord Hospital,Detroit,Michigan and Pediatrics, Although there have been numerous studies on the mechanisms of blood flow during CPR in animal models, human data are limited. Patients (n= 16) brought to the EmergencyDepartment in cardiopulmonaryarrest receivedstandardACLS therapy, with SE-CPRprovided in l5/16 by pneumatic compressiondevice. Concurrently,aortic {Ao),jugular venous bulb (}B}and right atrial catheters IRA) were placed, and simultaneous pressure "Down measurementsrecorded.Averageage was 67 + 15 yeats. time" averagedl8 min in witnessedarrests.Catheter placement required approximately 15 min. Paper tracjngs were digitized using an optical/magnetic scannerwhich allowed measurement of inlerval averages.Compression/relaxationphase averagesare reported,along with standardpeak compressionand end relaxation pressures,A11values are averages,in mm Hg, of five cycles.

Compression Relaxation

Peak Compresslon

End Relaxation

4 9 . 0+ 1 7

2 3 . 9+ 1 0

63.0 + 22

2 2 , 6! 1 0

2 1 . 3a 1 1

1 4 . 2+ I

2 6 . 8! 1 2

1 3 . 0+ 9

3 9 . 6+ 1 4

1 5 . 4* 6

5 4 . 6+ 1 9

1 4 . 9+ 7

Compression Relaxation Ao-JB. JB-RA-

27.7+17 -182 ! 13

Early Relaxation

97*10 - 1 . 2i 6 . 8

1 0 . 0r I

8.5* 10 9.5 + 14 Ao-RA -Compression/Reiaxation differencesignificantat P < 0005

The Ao-fB gradientsrepresentthe maximum potential for perfusion acrosslhe brain, and indicate that this is significantly greater during compression.fB'RA is the gradient between the cranial gravenous drainage and the central circulation. The negative "valvdient during cdmpressiondemonstratesfunctional venous ing". The small negativevalue for relaxation is a result of averag' in! pressuresthroughout the phase'The gradient is positive (P < .OdOt)during early relaxation, indicating the potential for blood flow during this time. Individual Ao-RA gradientsduring comcardiac pression *ire gteater than 20 in 3 patients s-uggesting less compression.Among most patients it averagedconsiderablythroughout the cycie. The data do not support the animal observation of greatert/diastolic"gradients The Ao-fB, JB-RA,and AoRA gradiJnts during compressionare generally consistent with the Tthoracic pump" model of perfusion. The Ao-RA gradielt during reiaxation indicates the inability of SE-CPRto provide adequ-atemyocardial per{usion in the rnaiority of patients a{ter prolongedarrest.

* a O l9

Cerebral Blood Flow During CPR A Gomparison of NorePinePhrine Versus EPinePhrine

J Jenkins,K Bowman,J Schlaifer' CG Brown,L Robinson, H Werman,J Ashton,R Hamlin/ Divisionof EmergencyMedicine,

Departmentof Preventive Medicine,Ohio StateUniversitv Colleoe physiologyand of Medicine;Departmentof Veterinary PharmacologyOhio StateUniversity CollegeoiVeterinary M e d i c i n eC, o l u m b u sO , hio Alpha adrenergic agonist drugs improve cerebral blood flow {CBF,)during CPR, in part, by reversing carotid artery collapse and.b.yincreasingperipheral vascular rdsista.rce,thereiy shunting blood from extracerebralto intracerebralstructures.Adrenergic drugs with beta agonist properties {beta-2),cause peripheral vasodilation,and thus may be less beneficial in tiris s_etting. -The purpose of this study was to compare epinephrine {E),,an-alphaI,2i beta 1,2 agonist,versusnorepinephrine1Nf1,an alpha I,2; beta-l agonist,on CBF during CpR.-Twentyswine each weighing greater than 15 kg were instrumented for resional CBF measurâ&#x201A;Źmentsusing tracer microspheres.RegionalCBF was measured-duringnormal sinus rhythm (NSR).Animals were then placed into ventricular fibrillation iVF). Following l0 minutes of VF, the animals received closed-chestCpR using a mechanical thumper Regional_CBFwas measuredduring Cp"R..Following 3 minutes of CPR, the animals were allocated to receive eithei f, 0.20mg/kg (N = 51,NE 0.08 mglkg (N = s),NE 0.12mg/kg {N = 5), or NF 0.16 mg/kg (N = 5). Regional blood flows were again measuredfollowing drug administration. CBF,sfollowing d'rug admlnlstratronwere comparedusing an analysisof covariance IANCOVA) adfustingfor baselinedifferencesdurine CpR. A Newman-Ke_uls multiple comparisonwas used to follow-up significant iP < .05) differences.Statistical significancewas coniiddred at p < .05._Theregional CBF's following drug administratron are expressed.il.mllmin/100g; resultsmarked with an (,)are significantly different than NE : 0.08: E .20

NE .08

NE .12

NE .16

L . C o r t e x 1 1 . 1+ 5 . 3

4.9 + 3.8

2 3 . 4+ 2 4 . 9 '

R. Cortex 10.3 * 4.7

3.7 + 3.0

1 2 . 2* 1 . 6 ' ' 1 3 . 5+ 1.4

2 3 . 7+ 2 4 . 5

.14

Cereb e l l u m 2 6 . 0 + 1 0 . 3 1 O . 7+ 9 . 2

35.1 + 80

50.5+ 39.9

Midbrain 21.9 + 15.7

9.8 + 6.3

35.1 + 4.6-

48.9+ 34.1.

.02

2 7 . 2 + 1 1 . 7 1 4 . 2+ g . g

30.8 + 3.4.

Pons

P value

50.9+ 24.1-

l,4edulla 58.7 + 23.7. 22.4 * 16.4 6 7 . 9 + 1 3 . 1 ' 7 1 . 4+ 3 5 . 4 .

Cervical Cord 50.4 + 18.0- 25.9 + 19.4 66.2 + 10.4. 79.4 + 25.4-

1!| f V

Noninvasive Monitoring of lntla. Abdominal Fluid Accumulation Using Transabdominal Electrical

Bioimpedance C E S a u n d e r s , W B a r t o n / V a n d e r b i l t U n i v e r s i t yS c h o o l o f Medicine, Nashville,Tennessee

CBF levels above 15 ml/min/100 g are the minimal flow required to maintain a normal electroencephalogram. This study suggests that following a prolonged cardiai arreit, Iarge doses of Nf improve blood flow above this level during CpR. Alpha adrenergic agonis_tsthat lack beta-2 agonist properties therefore may prove more beneficial than E in this settins.

gency physicians. A desired outcome of this study was identification o{ a subset of ED-radiographs which do not require mandatory review by radiologists. A total of 1,872 consecutive EDradiographs were entered into this prospective 2-month study: 1 2 8 1 6 . 8 % ) s k u l l , 2 5 7 1 1 3 . 7 % ) s p i n e , 5 4 2 1 2 9 . 0 . / . 1c h e s t , I i l |.44.6%) extremity radiographs. Based i5.9%) abdomen, and 834 on a predetermined menu of operationally defined confidence levels, each interpretation was assigned a numerical confidence val. : mildly confident,3 : moderately ue: .l .: nonconfident, 2 confident, and 4 : very confident. Chi-square was used to tesi significance for nominal variables, and a Fisher Exact was calculated when necessary. Overall, the concordance rate was 94.6o/o and the mean confidence level was 3.6 (SD = 0.6). Confidence level varied (P < .001) by type of radiograph. Collectively, concordance varied (P < .001) by confidence livel: concordanc. rates were 97.Suk, 91.6%, 73.3%, and 83.3% for interpretations that were rated as very confident, moderately confideni, mildly confident, and noncon{ident respectively. Very confident interpretations were significantly (P < .00I) less frequent when acute Iindings were noted (57.6%J than when the radiograph was read as normal 17I.3y.l. When interpretations were grouped by type ol radiograph, concordance varied by confidence level only for ihest and extremity films {P < .05).The training level lresident vs at. tending physician) of emergency physicians in this study affected c o n f i d e n c e { P < . 0 0 1 ) b u t n o t c o n c o r d a n c e( P > . 0 S 1 . H o w e v e r , o v e r a l l c o n c o r d a n c e r a t e s w e r e s i g n i f i c a n t l y l p < . 0 0 1 1i n c r e a s e d at each training level when very confident interpretations were compared to those of lesser confidence. No subset of radiographs was found in which the emergency physician was arways correcr in rela_tion to being very confident. There were 102 radiographs with discordant interpretations; 30 of these were rated ai very confident. Even when the emergency physician was very confi dent that the radiograph was correctly interpreted, the discordance rate varied from LZT" Ior spine radiographs to 8.6% for s k u l l f i l m s . T i e a t m e n t w a s p o t e n t i a l l y a l t e r e d i n 3 8 1 2 . 7 % )p a . tients (2.0% of all radiographs) as a result of interpretive correc. tions by radiologists. In summary, interpretive agreement tends to increase as a function of interpretive confidence, but these f i n d i n g s s u p p o r t m a n d a t o r y r e p o r t i n g o f a l l E D - r a d i o g r a p h sb y r a dioloeists.

Accuracy of Interpretations of ED. Radiographs: the Effect of Gonfidence

Levels FE Mayhue,DD Rust,JC Aldag, AM Jenkins,JC Ruthman/ EmergencyMedicineResidencyProgram,and Departmentof Preventive Medicine,Universitv of lllinoisColleqeof Medicineat Peoria/ St. FrancisMedicalCenier peoria,lilinoii Responsibilityfor interpretation of radiographstaken in the emergencydepartment is sharedbetween emergencyphysicians and radiologists. Interpretations by emergency physicians are usually in agreementwith those by radiologists.The purposeof this study was to assessthe relationship between the rate of interpretiveagreementand the degreeof interpretive confidence held by emergencyphysicians. This relationship was ignored in previousstudiesthat examinedthe interpretive accuracyof emer-

Monitoring intra-abdominal fluid accumulation is of potential benefit in blunt abdominal tranma, increasing ascites, and ,,thirdspace" fluid sequestration. Current methods of detection are either invasive, expensive, or impractical in emergencies, and no method provides real-time monitoring. We studied transab. dominal electrical bioimpedance (TAEB) as a means for noninvasive, real-time monitoring of intra-abdominal fluid accumulation in an experimental setting in both dogs and in humans. On 5 adult mongrel dogs, weighing 17-24 kg each, surface electrodes were systematically placed rn locations along both horizontal and vertical axes of the abdomen. TAEB was measured before and after the addition of serial I00-ml aliquots of saline infused into a peritoneal lavage catheter, up to a maximum of 1,600 mL. Electrodes were placed in similar locations on 5 adult human volunteers about to undergo routine peritoneal dialysis. TAEB was measured before and after the addition to measured amounts of d i a l y s a t e i n f u s i o n { 2 , 0 0 0 m L t o t a l ) . T h e r e s u l t a n t c h a n g e si n TAEB were compared against volume of infusate by linear regres. sion analysis. In all cases, a linear decline in TAEB was observed wrth increasing amounts of infusate, with mean values as foll o w s : h o r i z o n t a l a x i s , d o g s , - 0 . 4 9 o h m s / 1 0 0 m L ( r = 0 . 9 8 ) ;v e r . tical axis, dogs, -0.19 ohms/100 mL {r : 0.99f; horizontal axis,

humans, -0.17 ohms/100mL (r : 0.82| and vertical axis, humans, -0.09 ohms/100 mL (r : 0.54].We conclude that TAEB is a sensitive and noninvasive means of detecting intra-abdominal fiuid accumulation. More studv is necessarvto determine its value in clinical settings.

Cr a i I

raoid identification of AMI within 4-6 hours after the onset of chest pain to maximize myocardial salvage.Appropriate disposition of oatients with AMI to intensive caresettinsswould also be facilitaied through early diagnosis.In this study,a rapid assayfor CPK-MB using anti-CPK-MBbound to magnetic particles is evaluated. One hundred and five patients were evaluated with 28 found to have had AMI by hospital dischargediagnosisusing standardcriteria. Patients greater than thirty years old of either sex, with chest pain not causedby trauma or radiographicfindings, were included in this study.Serum sampleswere obtainedat 0 hours (presentationto the emergencydepartment),3 hours and 6 hours. Serum myoglobin (Myo| levels were determined by radioimmunoassay(NMS Pharmaceuticals,Inc, Newport Beach, California) and the creatine phosphokinaseMB isoenzyme{CPKMB) level was measuredusing a standardradioimmunometric assay (I). A rapid CPK-MB assay(IIl using magnetic particle-bound antibody (InternationalImmunoassayLaboratories,Inc, Santa Clara, California) was also used. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the three serum marker assaysare given in the table below as a percentage(%):

Emergency Department Use of Doppler Ultrasonography in the Diagnosis of Deep Vein Thrombosis

TL Turnbull,T Zalut,J Dymowski/ University of lllinoisAffiliated Chicago HospitalsEmergencyMedicineResidency, Patients presentingwith signs and symptoms suggestiveof deep venous thrombosis (DVT) are a frequently encountered problem in the emergencydepartment. However,a typical clinical presentation of DVT is confirmed less than half the time. Noninvasive evaluation for DVT may not be readily available, while the acceptedgold standard,contrast venography,is invasive and may result in morbidity. Bedsideevaluationwith a hand-held Doppler stethoscope(HHDSI has been suggestedas an accurate screeningtest. We undertook a prospectivestudy to comparethe accuracy of HHDS to that of contrast venography over a 30month period at two residency affiliated hospitals. A11patients presentingwith the complaint of nontraumatic leg pain, swelling or tendernesswere eligible for the study. An evaluation of the deepvenous system was performed using a HHDS by an attending or resident emergencyphysician who had been taught a standardizedtechnique. The examiner was then asked to rate the Doppler exam as normal, abnormal or equivocal prior to obtaining a venogram. Excluded weie patients who underwent other confirmatory testing or were treated clinically by their private physician. A total of 68 patients had 70 venograms.Results are summarized:

Sens,

Abnormal Doppler

Normal

Equivocal

(r) CPK-MB

(lr) cPK-rvB

[/]ye

3 HOURS PPV Spec.

NPV

100

(r) CPK-MB

cPK-r/B(il)

r90

Sens.

Spec.

PPV

NPV

Mye

100

(r) OPK-MB

100

(il) CPK-MB

100

6 HOURS

J I

I J

In 56 patients who had an equivocally normal or abnormal Doppler study, 46 had venograms confirming the Doppler results, yielding a sensitivity of 88%, specificity oI79To, positive predictive value oI 65%, and a negative predictive value of 94%.If the equivocal Doppler results were included with the abnormal group,the calculated sensitivity is 89%, specificity 60%. Of the two patients with normal Doppler studies and abnormal venograms/ one was found to have an isolated calf vein thrombosis, while the other had a suboptimal venogramwith incomplete filling of the deep venous system. Our results suggestthat an unequivocally normal bedsideHHDS exam is reliable in ruling out the diasnosis of DVT Patients with an equivocal or abnormal exam s[ou]d undergo further testing.

NPV

Mye

Sens.

Venography Negative Positlve

O HOURS PPV Spec.

Myoglobin allowed early,sensitiveidentification of AMI with subsequentverification using the highly specific CPK-MB radiometric assay.The rapid CPK-MB assayshould decreasetotal test time to approximately one and a half hours compared to three hours for the standardassay,allowing rapid confirmation of AMI for myocardial salvagetherapy.

Efficacy of the Leukocyte Esterase Test in the Detection of Cerebrospinal

Fluid Leukocytosis Schoolof J DeLozier,P Auerbach/ VanderbiltUniversity Medicine,Nashville,Tennessee The leukocyte esterase(LE)test, availablein dipstick form, has beenshown to correlatewell with the presenceof pyuria, proving to be a rapid and simple screenfor diagnosingurinary tract in{ections. The test strip detectsthe presenceof an enzyme,leukocyte esterase,present only in human neutrophil granulocytes,which catalyzesthe hydrolysis of a substrate,the carboxylic acid ester o{ indoxyl, to a free indoxyl. The free indoxyl, in turn, reacts with a diazonium salt to produce the purple pigment changein the dipstick. The present study was undertaken to assessthe efficacy of the LE test in the detection o{ cerebrospinal fluid (CSF)Ieukocytosis and to evaluate the role of the LE test as a

Rapid Detection of Acute Myocardial Infaretion Using Magnetic Particle Bound Antibody to CPK-MB

WB Gibler,l-W Chen, M Zimmermann,M Sperling,SB Dubit, RE Erb i Sectionof SurgicalSciences,VanderbiltUniversity Departmentof RadiolSchoolof Medicine,Nashville,Tennessee; of CincinnatiSchoolof Medicine,Cincinnati,Ohio ogy,University Early identification of acute myocardial infarction (AMIf in chest pain patients with non-diagnostic electrocardiogramsremains a maior concern in emergency medicine. Advances in therapeutic intervention such as thrombolytic therapy and percutaneous transluminal angioplasty demonstrate the need for

quick screen for meningitis. A total of 942 CSF samples were collected from 800 patienrs, 499 men, and 443 women. The LE test was performed on each specimen and compared in a double blinded fashion with routine cell count determrnations and cultures. The clinical courses of all patients with Dositive cultures were revjewed to assessthe significance of the culture isolates. Statistical analysis of the above data revealed a sensitivity of 84.4% with a specificrty of 98.1% in the detection of bacterial meningitis. We propose the LE test as an adjunct to the CSF cell count and chemistry determination, culture, and c l i n i c a l a s s e s s m e n t .T h e L E t e s t m a y b e u s e d a s a s c r e e n i n g t e s t to enable the physician or technician to spend valuable time further examining CSF specimens with a higher likelihood of pathology.

*CrA 3-

The Evaluation of Suspected Renal Colic: Ultrasound Scan Versus Excretory Urography

D Sinclair, L Greenspan,S Wilson,A Toi/ Departmentof EmergencyMedicine,VictoriaGeneralHospital,Halifax,Nova Scotia;Depa(mentsof EmergencyMedicineand Radiology, TorontoGeneralHospital,Toronto,Ontario Patientscommonly presentto the emergencydepartment with a suspecteddiagnosis of renal colic. A prospectivestudy of 98 patients prescnting to the emergencydepartment with acute flank and/or abdominalpain was conductedto determinethe diagnostic accuracy of ultrasound scan (USS)vs excretory urography iEU) for the diagnosisof urinary tract calculi. All patients underwent standardizedUSS and EU as independentprocedures. Two different staff radiologistsreported the USS and EU were blinded to the results of the other diagnostictest and ultimate clinical outcome.All patientsdischargedhome from the Emergcncy Department were followed in the hospital Urology Clinic. The diagnosisof urinary calculus was made only by identification of calculus at sgrgeryor by reportedpassageof a stone by the patient.Of 85 patientsavailablefor followup study (56 males,29 fcmales,mean age 40.5, age range 18-771,calculi were identified in 69 (8I % f. Ultrasoundidentifiedcalculi in 44 cases{sensitivity 640/o,specilicity 100%1.Excretory urographyidentified calculi in 44 cases(identicalsensitivityand specificity).When the presence of obstructive hydronephrosisonly was utilized to diagnoserenal c a l c u l i , U S S i d e n t i f i e d 5 9 c a s e s( s e n s i t i v i t y8 5 % , s p e c i f i c i t y 100%) and EU identified 60 cases{sensitivity 90%, specificity 99%).When the resultsof both diagnosticmodalitieswere combined, calculi were identified in 59 patients {sensitivity,85%, specificity,100%) and hydronephrosiswas seen in 66 patients {sensrtivity,95%, specificity,93%).This study supportsthe use of USSin the initial evaluation of suspectedrenal colic and suggests that the combined use with EU in selectedcasesmav imorove diagnostic accuracy.

Lack of Value of Head GT Scanning in Alert, Awake, Neurologically Intact Victims of Blunt Trauma

B E Y a r b r o u g h ,J S p i l l e l , C E S a u n d e r s / V a n d e r b i l t U n i v e r s i t y S c h o o l o l l v e d i c i n e , N a s h v i l l e ,T e n n e s s e e The indications for head computerized tomographic (CT) scanning in blunt trauma victims who are alert, awake, and neurologically intact are unclear. High-risk criteria have been developed for skull radiography but have not been applied to head CT scanning. In an attempt to assess the need for head CT scanning in this group of patients, we retrospectively reviewed the records of l6l consecutive awake, alert, neurologically intact victims of blunt trauma who underwent emergent head CT scanning at our institution during a 3O-month period. All had either sustained a primary head injury or were victims of multiple blunt trauma in whom a suspicion of head injury existed. TWenty-nine patients had trauma-related intracranial abnormalities; all of these were

minor {small subarachnoidhemorrhage,small subdural hematoma, minor contusion, edemaIand did not affect management. Twenty-one skull fractures were diagnosedand 7 of these had minor CT abnormalities.Eleven patients had depressedskull fractures and l0 of these were taken to the operating room for elevation and debridement. All patients recovereduneventfully and no additional neurosurgicalprocedureswere required.When previously reported risk-stratification criteria for skull radiography were applied,3 of 7 high-risk patients 143%1,23of 144 moderaterisk patients116%1, and3 of l0 low-risk patienrs(30%)had minor intracranial CT abnormalities. One low-risk patient sustained a linear skull fracture with a small amount of subarachnoidhemorrhage;he was observedovernight and discharged uneventfully the next day.The only patients requiring a neurosurgical operation were those with depressedskull fractures, which could have been diagnosedby routine skull radiography. Application of risk-stratification criteria developedfor skull radiographywas not helpful. Basedon our data, we conclude that in awake, alert, neurologically-intactvictims of blunt trauma, the incidenceof seriousintracranial iniury is low, and head CT scanning is unnecessary. Prospectivestudiesinvolving largernumbers of patients are neededto determine if head CT scanningis neces. sary in this group of patients.

Does Gonjunctival Oxygen Tension Predict Cerebral Blood Flow in ilormal Humans During Eucapnia and l{ypocapnia?

WF Rutherford,EA Panacek,J Green, E Bednarczvk.M Munoer, G Lersure,F Miraidi,CJ Fisher/ Departments of Emergency Medicineand NuclearMedicine,UniversityHospitalsof Cleveland,Case WesternReserveUniversity,Cleveland,Ohio Cerebral blood flow {CBF)measuremenrin patients currently requires massive scanning devices and cannot be performed acutely at the bedside.Confunctival oxygenationis achieved through perfusion by branchesof the internal carotid artery,and may thereforereflect global cerebralperfusion.Conjunctival oxy. gen tension (Pc1O2)can be measuredby a non-invasive,silverplatinum electrodesuitable for bedsideuse. Using this device,we have previously shown that hyperventilation producesa decrease in both the PcfO2and the PcjO2lPaO2ratio, which we interpreted to be secondaryto decreasedcerebral perfusion. In the present study, CBF was measureddirectly via positron emission tomography using oxygen-15labeled water, along with simultaneous measurementof PaO2,PaCO2,pH, and PciO2.All studieswere performed at baseline and after at least 5 minutes of hyperventilation. Baseline Subiect CBF PciO" PaO, PaCO, pH 1

55.9 55

118

4 2 . 4 47

58.2

1 1 1 42 7

623

63 54

Hyperventllation CBF PcjO, PaO, PaCO, pll

36.9 7.40

25 8

357

7 40

20.1

7.39

2 4 . 1 65

162

15.2 7.74

122

38.5 7.39

4 3 . 3 54

148

20.7 7.59

102

36.0

42 1

143

19.4 7.60

7.38

148

19.2 7.60

25.8 7,53

CBF fell in all subiects,ranging from 30 to 59% from baseline, compatiblewith cerebralvasoconstrictionassociatedwith hypocapnia. Regressionanalysisbetween CBF and PaCO2producedan r : .732,which is consistentwith previous studies.PciO2alone indicated the trend in CBF in 4 of 5 subiects.Regressionanalysis between CBF and the PciO2/PaO2ratio achievedan r : .737,indicating that PcjO2 is influenced by both CBF and PaO2.This study demonstrates that the changes in PciO2 and the PcjO2/ PaO2ratio correlate well with the reduction in CBF.We believe

this non-invasivemonitor is a useful adfunct in predicting CBF in eucapnicand hypocapnic states.The role of PciO2measurement in non-hypocapnicstates of globally-reducedCBF,such as postcardiacarrest cerebralvasospasm/requires further investigation.

Development of a Hypothermia Outcome Score

Study DF Danzl,JR Hedges,RS Pozos,Hypothermia of Group/ Departmentof EmergencyMedicine,University Kentucky;Departmentof Physiology, Louisville, Louisville, Departmentof Emergency University of Minnesota-Duluth; of CincinnatiCollegeof Medicine Medicine,University Multiple rewarming methods have been recommendedfor the treatment of hypothermia in the emergencydepartment.Because the hypothermic patient population is heterogenous,a method of stratifying mortality risk when comparingtherapiesis needed.To developan empiric Hypothermia Outcome Score(HOS),we analyzed historical, physiological,and supportive measuresthat were prospectivelyrecordedon a standardizeddata collection instrument Ior 428 hypothermic patient visits (presenting core temperatureof < 35 degreesC). Univariate and multivariate statistical analyseswere used to identify variableswhich discrimi' nated betweenpatient death or survival in the 24 hours following ED presentation.Prehospitalcardiac arrest, a low or absent presenting blood pressure,elevatedBUN, and the need for either endotrachealor nasogastricintubation in the ED were found to be statistically significant independentpredictorso{ patient demise. The data basewas randomlv divided and a likelihood ratio analysis was used with the abovevariablesto developand validate an empiric HOS. Subsequentanalysis of treatment modalities used on these patients showed no statistically significant effect of treatment modality on 24-hour survival when HOS was controlled. There was a trend for increasedsurvival with heated humidified oxygen via mask (P : .l5l and peritoneal dialysis (P : .181.and there was a trend for deueased survival with active external rewarming {P : .25).Prospectiveevaluation of these treatment modalities using strati{ication of patient severity via the HOS should be pursued.

Prospective Validation of Glinical Griteria for the Ordering of Serum Electrolytes

H Arst, RA Lowe,BK Ellis/ ValleyMedicalCenter,Departmentof of California, San Francisco, EmergencyMedicine,University Departmentof Familyand CommunityMedicine,Fresno,California Serum electrolytesare among the most commonly orderedlaboratory studies in emergency departments, but their value has beenquestioned.A previous study of ED patients on whom electrolytes were ordered found that only l5.6oh had abnormalities which led to a changein patient management.In that study a set of 10 clinical criteria {CC) were developed,which detected98.8% of the clinically significant electrolyte abnormalities(CSEAs). The present study was an attempt to validate the CC prospectively, in a different clinical setting. This project was conducted in the ED of Valley Medical Center, in lresno, California, a county hospital with an annual ED census exceeding 65,000. Nine hundred and eighty-five patients on whom the emergency physicianorderedserum electrolyteswere evaluated.For eachpatient, the ordering physician completed a questionnaireindicating whether the patient met any o{ the CC expectedto be predictive of CSEAs (poor oral intake, vomiting, chronic hypertension, taking diuretic, recent seizure, muscle weakness, age > 65, alcoholism, abnormal mental status, or recent history of electrolyte abnormality).For every patient with electrolytesoutside the laboratory normal range, the chart was reviewed to ascertain whether the abnormality affected patient management, representing a CSEA.Sensitivity speci{icity,and predictive values of the CC for

detecting CSEAs were calculated. Seven hundred and thirty-three l7a%) of patients had one or more electrolytes outside of the laboratory normal range, but only I42 (la%)had CSEAs. Physicians were unable to predict accurately lab abnormalities or CSEAs. On the other hand, the CC predicted I34 of the CSEAs {sensitivity " f a l s e n e g a t i v e / / c a s e sw e r e r e v i e w e d , t h e e l e c 94%). When the 8 trolyte abnormalities did not affect patient outcome in any of these cases. Although the specificity o{ the criteria set was low (28%), implementation of the criteria in patients on whom the physician was considering ordering electrolytes would have avoided unnecessary testing in 244 patients (25%). Eighty-six percent of electrolyte testing did not lead to a change in patient management. Use of a set of clinical criteria couid substantially d e c r e a s ee l e c t r o l y t e o r d e r i n g w i t h o u t c o m p r o m i s i n g p a t i e n t c a r e .

Outpatient Management of Febrile Infants 28-90 Days of Age With lntramuscular Ceftriaxone

EJ O'Rourke/ Divisionof Emergency MN Baskin,GR Fleisher, Medicineand InfectiousDiseases,The ChildrensHospital, Boston,Massachusetts A bacterialfocus is demonstratedin 3-8% o{ non-toxicfebrile infants l-3 months oid despitea benign clinical examination. Tiaditional managementincludes admission and parenteralantibiotics pending bacterialculture results.We conducteda prospective study ol IM ceftriaxone for outpatient management of infants 28-90days old, with fever >38'C, and no sourceon physical exam or screeninglaboratory tests. After biood, CSF and urine were obtained for culture, if the peripheral WBC was <20,000 CSF WBC <10, and urine dipstick WBC esterasenegative,patients received50 mg/kg IM ceftriaxoneand were sent home. A second dose was administered 24 hours later and patients were followed by telephone. Further antibiotics were given only if a bacterial focus was identified. Over 8 months, 100 patients were enrolled. Eight patients {8%) had a bacterial focus identified {Group l) and 92 didJ:Iot (Group 2). There were no significant d i f f e r e n c e sb e t w e e nt h e t w o g r o u p s i n a g e { 8 . 6 + 2 . 7 w e e k s (Group l),7.7 + 2.2 weeks{Group2f, temperature(39.1 + 0.7 C, 3 8 . 8 t 0 . 5 C ) , Y a l eO b s e r v a t i o nS c a l e{ 7 . 4 * 3 . 5 , 6 . 7 + 2 . 1 1 , WBC x 19e (11.2 ! 3.4, IO.4 * 4.0),or % polymorphonuclear cells (37 + 15, 36 t l5l. Of 8 infants with bacterialfoci, 3 had bacteremia(one caseeachS pneumoniae, Croup B Streptococcus, and N menigitidis). All were afebrile and had sterile blood cultures obtained when recalled. Five infants had bacterial gastroenteritis without bacteremia (4 Salmonella, I Yersinia).Four were followed at home and one required hospitalization due to increasingbloody diarrheawithout evidenceof dehydrationor toxicity. Of 92 patients with a bacterial focus, 88 were managed as outpatients and all were well at follow-up. Foul infants were admitted to the hospital I-10 days after study entry due to either parental exhaustion,otitls media, a contamrnatedurine specimen, or a transient periorbital erythema of undetermined etiology. All were well at foliow-up. We conclude that for nontoxic febrile infants 28 to 90 days old, who after a full sepsis work-up do not have an identifiable bacterial sourceby physical exam or screening lab tests, IM ceftriaxone for two days with telephone follow-up at home may be an alternative to hospital admission.Our successfulexperiencesuggeststhis protocol warrants {urther study.

Transtracheal Catheter Ventilataon (TTCVI in a Small Animal Model

GC Fifield,T lvorton, E RuizI Departmentsof Emergency HennepinCountyMedicalCenter; Medicineand Pediatrics, of Minnesota,lVinneapolis Departmentof Pediatrics,University TTCV ii suggestedas a technique for emergencyventilation in children when endotrachealintubation is not possible.However,

there are no published recommendationsregardingthe safe and effective emergency application of the technique in infants and children. This study was performed to evaluati four methods of TTCV in animals of infant and child size. The animal models were.rabbits (n:5) weighing 4.6-5.3 kg and mongrel dogs (n = Z) weighing 8.6-12.3kg. The methods employed included:-l i wali 02 {-/50 pounds per square inch [psi]] with a pressurecontrol valve and on/off valve in-line; 2) the standardbxygen powered manually triggeredbreathing device with a pressuielimit of 40 mm Hg; 3) an 800 cc self inflating bag-valvedevice; and 4l intermittent ventilation with liter flow oxygen ar l5 L/min. Each of these was attached to a catheter placedlhrough the cricothyroid membrane.Arterial blood gaseswere monitored at {requentintervals.(-/every 5 min.) during each trial. Our findings irom these studies can be summarizedas follows: i. Severebar6trauma(tension pneumothorax,air in carotid sheaths,subcutaneousemphysema)occurredin animals weighing up to 5.3 kg when ventilated with 40 psi through a l6-gaugecatheier or 50 pii through an lggauge catlteter. 2. The manually triggered oxygen -to powered breathing device and bag-valvedevice wdre unable effectively ventilate the canine subjects through a l4-gaugecatheter.3. Eitective ventilation (pCO2<45, pO2>150) could be accomplished in.any-size subiect animal through an l8-gauge cathetei using either 30 psi wall oxygen or liter flow oxygen at 15 L/min. Venl tilation !y these techniqueswas continued for as long as 60 minutes with excellenr blood gasesand without ill-efficts. These studies can be used to begin to establish rational guidelines for the application of TTCV in emergencysituations.

.il{ Diazepam and the Need for Intubation I I in the Pediatric Prehospitat Setting RAOrr,RJDimand, S Venkataraman, VAKarr,KJKenneov I

Departments of Anesthesia, CriticalCare Medicineand pediatrics, Children's Hospitalof Pittsburgh,University of Pittsburgh Apnea and respiratorydepressionare well known side effectsof diazepamlDzl, yet Dz is often recommendgdas the initial treatment of status epilepticus.To test the hypothesisthat the use of Dz to treat prolonged seizures (Sz) contributes to the need for intubation in the pediatric prehospital setting, we reviewed all patients (n=98) transportedfrom other emergencydepartments (ED) by our transport team for Sz from Oct. i985 to Sept. 1986. Age, weight, prior history of Sz, length of Sz prior to medical therapy,time to control Sz, anticonvulsant doses,and need for intubation were determined. We excluded patients ln=441 who were not having active Sz upon arrival at the referring ED, and those whose Sz began after intubation for other reasons. Therapy

lntubated

Dz only

Dz + Pb and/or Ph Pb and/or Ph lst drug Dz 1st drug not Dz Dz

Intramuscular Demerol, Phenergan & Thorazine: Analysis of Use and Gomplieations in 486 Pediatric Emergency Department Patients

TE Terndrup,RM Cantor,CM Madden/ Departmentsof Critical Careand EmergencyMedicine,and Pediatrics, SUNYHealth Science Center at Syracuse,New York The intramuscular administration of a mixture of meperidine, promethazineand chlorpromazine(Demerol@, Phenergan@, Thor. azineo; DPT) is recommendedfor short-painful proceduresand diagnostic testing performed on pediatric patients. However,no systematicevaluationof the emergencydepartmentutilization of DPT has appearedin the literature. We reviewedthe medical records of all patients < 16 years old receiving DPT during the 24month period endingDecember 1987.An examination of datarel. ative to age,sex, weight, presentingproblem, chronic illness,ini tial mental status,indication, total ED time, dosage,specialty consultation, efficacy and complications was undertaken. The characteristicsof 486 consecutivepatients receiving DPT were: 60"/" male, 4OYofiemale; age 2.7 + 0.5 years {mean * standard d e v i a t i o n ) ;w e i g h t 1 4 . 5 + I . 5 k g ; E D t i m e 3 . 3 * 1 . 2 5h o u r s ; m e p e r i d i n e L 9 + 0 . 2 m g / k g ; p r o m e t h a z i n e0 . 9 + . l m g / k g ; chlorpromazine0.9 + 0.1 mg/kg. Maximum dosageof DPT was 50/25/25 mg respectively.Wound repair {68%),fracture reduction {11%}, ioint aspirationor burn debridement(5.8%), CT scansedation 14.37o), incision and drainageof abscess(2.5%) and foreign body extraction 12.3'/')accountedfor the mafority of indications. Specialtyconsultantsordered79% oI DPT's. Lacerationsmost commonly involved the face 165"/.1 or digits (20%).Mean lacera. tion length was 2.7 + 0.8 cm, only 8% exceeded6 cm in length, Efficacywas 98.3%,sinceonly 1.7%lN:81 requiredrepeatsidation for diagnostic testing or completion of a procedure.Comparedto other pediatricED patientsiage4.0 + 0.8 yearsand ED time with an x-ray 2.9 + l.l hours),patientsreceivingDpT hada significantly lower mean age and greater ED time {P < .0011. Of 30 patientswith potentialcomplications,only 2 patients(0.4%) experiencedsignificant side effects (both had respiratorydepression requiring baggingand naxolone).An abnormal initial mental status exam or an underlying neurologicalabnormality weresig" nificantly associated with complications(Fisher,s exacttest;p I 0.001J.Patients requiring repeat sedation receiveda lower mean initial meperidinedosage(1.5 + 0.5 mg/kgf than other patients receiving DPT {P < .05).DPT appearsto be a safe and effective sedativefor selectedpediatric ED patients. Dosageguidelinesof 2/l/1 lin mg/kg respectivelyfor DPT) should be followed to im. prove efficacy.Complicationsare increasedin patients with acute or underlying neurologic abnormalities.

Not lntubated

2 5

24 7

27 NoDz 4 .P < .001 b y c h i - s q u a r ea n a l y s i s Pb : Phenobarbital,Ph = Phenytoin.

.92

A Model of Cytotoxic

Gerebral Edema

JE Olson,LD Mishler/ Departmentof EmergencyMedicine, WrightStateUniversity Schoolof Medicine,Dayton,Ohio Brain edema is a common complication of a variety of condi. tions seen in the emergencyroom. Current treatment Ior brain. edema which relies on the osmotic removal of water from the brain tissue doesnot treat the underlying causeof the condition., Methods used to model brain edema in animals oroducea mixture of vasogenicand cytotoxic edema,and thus, complicatein. vestigationsinto the mechanisms of the production and resolu-'

7 to

tion of brain swelling. To address this problem, we ha developed and characterized a model of cytotoxic brain edema the rat. Under pentobarbital anesthesia, experimental anim (N:32) received an IP iniection of distilled water equivalent 5"/o or l5o/o of their body weight (W-5% animals or W-15% mals, respectively). Control animals {N:9} received no water jection. These animals were sacrificed l5 or 60 min after

Length of_Szprior.to therapy time to control Sz, dosesof drugs per kg did not differ in intubated vs. nonintubated patients or between those who receivedDz and those who did not. Intubation was more prevalent in older children {p < .05), and those with Dz as first or subsequenttherapy.These data support the hypothesis that Dz contributes to the need for intubation in patients treated for seizuresin the pediatric prehospital setting.

water injection by rapidly fueezingthe brain with liquid nitr, in situ. A coronal section was made in the mid-parietalarea

bilateral triplicate sampleswere dissectedfrom cortical gray and white matter for determination of the regional specificgravity.In another series of experiments, hypertonic NaCl (10% solution) was injected l5 or 60 min after the water injection in an amount calculatedto normalize the osmolarity of the previously injected water. Serial blood samples were drawn for measurement of serum osmolality and Na+ and K+ concentratrons.The specific gravity o{ gray,but not white matter was significantly decreased in water-injectedrats comparedwith controls lFlq35l':5.76, P < .01]. The change in gray matter specific gravity was greater in W-15%animalscomparedwith W-5% animals.In W-5% animals, the serum osmolaiity and Na+ concentration was decreasedby 5.7o/"and 7.5o/oafter 15 min and by 4.6% and 6.7% after 60 min, respectively.The W-15% animals had similar decreasesin the serum osmolarity and Na+ concentration at 15 min, but by 60 min these values had fallen by Il.3o/" and 19.(r%,respectively. Injection of hypertonic NaCl reversedthese changesin blood chemistry within 10 min. Serum K+concentrationswere elevated at each time point for all experimentalgroups,possiblydue to hemolysis. These data suggestthat, in this animal model, the brain edema is predominateiy in gray matter, a characteristicof cytotoxic edema.Pilot studiesusing magnetic resonancetechniques have supportedthis conclusion.By re-establishingnormal blood osmolarity following the production o{ cytotoxic edema, we anticipate that this model will be useful for studying the mechanismswhich resolve this state of brain edema.

Neutrophil Depletion Fails to lmprove Neurologic Outcome Following Ten. Minute Gardiac Arest in Ganine

Model RJ Schott,JE Natale,SW Ressler,RE Burney,LG D'Alecy/ of Michigan, Departments of Surgeryand Physiology, University Ann Arbor Neutrophil activation that results from ischemia-reperfusion eventsmay causeor augment tissue iniury. Neutrophil depletion has been used experimentally to determine the contribution of neutrophils to specific organ injury, and has been shown to reduceinfarct size after temporary coronary artery occlusion.Neutrophils accumulate in brain during early reperfusion following ischemia,and neutropeniahas been shown experimentally to protect brain function in early reperfusion.The purpose of this study was to assessthe possible protective effect of antiseruminducedneutropeniaon neurologic function in a cdnine model of cardiacarrest-inducedcentral nervous system ischemia.Antiserum to canine neutrophils was preparedby rmmunizing sheep with a nearly pure canine neutrophil preparationin Freund'sadjuvant. This serum producesprofound neutropeniawithin l5 minutes of intravenousinjection in the dog. Circulating neutrophils were depletedusing this antiserum in nine experimental animals prior to a ten-minute cardiac arrest. Neurologic deficit scoresmiasuring ischemic neurologic damagein these animals were comparedwith those of eight control animals that received vehicle only and four others that received non-immune sheep sengm,all prior to identical 10 minute cardiac arrest. Canines receivingrmmune serum averaged90% depletion of neutrophils immediately following resuscitation 1722 + 4O9 neutrophils/ mm3 vs 6,971 + I132/rnrn3 prior to immune serum), and averaged8l% depletion over the first three hours, and 68% depletion over 12 hours following resuscitation.Neurologic deficit scores assessed at one/ two, six, twelve and twenty-four hours post-arrest did not vary between experimental and control Sroups,nor did overall survival differ between neutrophil-depletedand control dogs. We conclude that prior depletion of circulating neutrophils doesnot protect against CNS injury in the 24 hours folIowing resuscitationfrom 10 minute cardiac arrest.

Effect of CO2 and Non GO, Generating Buffers on Cerebral Acidosis During Reperfusion After Cardiac Arrest: A 31-P NMR Study

JM Rosenberg,NA Paradis,RM Nwak,D Walton,TJ Appleton, of EmergencyMedicineand Neurology, GB Martin/ Departments N M R S e c t i o nH , ichigan , e n r yF o r dH o s p i t a lD, e t r o i tM Therc is controversy regardingthe use of alkalinizrng agents during reperfusionaftcr cardiacarrest. The potential deleterious effectsof sodium bicarbonateIBICARBIadmrnistration,including paradoxicalcerebralacidosis,have led to a searchfor alternative agents.Tiomethamine(TRIS)is a non-CO2generatingbufferthat has been proposedfor use during CPR. The purpose of this experiment was to comparethe ability of TRIS and BICARB to correct cerebralpH during reperlusionafter a l2-minute cardiacarrest. Adult mongrel dogs were instrumented and placed in the magnetsystem. borc of a BrukerBiospec1.89T superconducting Vcntricular fibrillation was induced and after tweive minutes, cardiopulmonary bypass(CPB)was initiatcd and maintainedfor 2 hours wrth minimum flows of 80 cclkg/min. BICARB {n=5) or TRIS (n=5) werc administeredto corrcctarterialpH as rapidlyas p o s s i b l c .3 l - P N M R s p e c t r aw e r e o b t a i n c d a t b a s e l i n ea n d throughout ischcmia and reperfusion.Intracellular brain pH {pH B) was determincdusing the inorganicphosphaterelativeto the phosphocreatine resonanccsignalshift. Prolileanalysisindicates a differcncebetwccngroups(2 < .02)relatedto an initial delayin pH B correction in thc TRIS group. By 48 minutes of reperfusion brain pH did not dif{cr between the groups.Moreover,there was no evidcncc of a paradoxicalcerebralacidosisin the BICARB group.Although TRIS correctsblood pH as quickly as BICARB,it is lesseffcctivein correctingpH B. Absenceof paradoxicalacidosis may be causcdby efficientelimination of CO2 by cardiopulmonary bypass.Further experimentsin models closely approximatine low flow statcsare being done. PHB control 1 2 m i n u t e sC P B

BICARB

TRIS

7OZ * .O3

7 . 1 1+ . 0 5

61l *

6.08 t

2 4 m i n u t e sC P B

6 . 6 3i = . 1 8

613 + .33

3 6 m i n u t e sC P B

6.82 * .08

6 . 7 3* . 1 6

4 8 m n u t e sC P B

6.96 * .03

6.89 * .09

6 0 m i n u t e sC P B

698 *

6.97 .t 07

710* 14

7 . 13 * . 0 5

1 2 0 m i n u t e sc P B

Brain DNA During Gardiac Arrest and Repeilusion: lnitial Studies

BC White, Ll Grossman, GS Krause, lK Todd, BJ O'Neil / From the Section oJ Emergency Medicine and the Department of M o l e c u l a r B i o l o g y a n d G e n e t i c s , W a y n e S t a t e U n i v e r s i t yS c h o o l o f M e d i c i n e , D e t r o i t ,M i c h i g a n DNA from brain cortex was examined in four experimental groups of three dogs each: non-ischemic controls (NIC); twentyminute cardiac arrest {20-I), twenty-minute cardiac arrest and 2 hours reperfusion (20-l + 2 hr R); and twenty-minute cardiac arrest and 8 hours reperfusion (20-l + 8 hr R). DNA was isolated by the method of Ciccarelli modified to include mannitol and DETAPAC in the isolation solution. The concentration of the rsolated DNA was determined by assay of deoxyribose. Pulse {ield gel electrophoresis shows that the NIC DNA size ranges between 60 and I50 kb, with no fragments evident below 60 kb. Klenow Polymerase I was used to label 3'-OH terminals with 32P-dCTP To ensure quantitative labeling, reaction conditions were stan-

dardized on 3'-OH recessed,blunt, and protruding ends generated in the synthetic plasmid pBS {Bluescribe)by restriction en' donucleases.'Onepgbf each experimentalbrain DNA,sample was labeled{1 unit klenow 37", 20 min.} and the mean valuesare exoressedin fmoles of dCTP incorporated/pgof DNA: Nlc 69.9

20-l 354.3

20-l a 2hrR 146.8

20-lt thrR 99.0

Each labeled DNA was also subiected to electrophoresison a 0.25% agarosegel. Ethidium bromide staining of the gel-showeda uni{ormlluorescence band present in the NIC, 20-I, and 2O'I + 2 hi n r"-pl.s in the 60+ kb size range, howevet considerable diminution in the fluorescenceof the 60 + kb band in 20{ + 8 hr R sampleswas noted. Autoradiographyof.all samplesrevealeda denselylabeledband presentat the 60+ kb size except in the 20I + 8'hr R sample. Here the incorporated label-is seen nearly exclusively in poiydispersedDNA fragments in the 5-25 kb size range.These fragmenis were not seen in the other samples'We "ott?lnd. that thire are 3'OH terminals being formed primarily by nicking during ischemia and that there is at least some repair during referfusidn. However, during reperfusion,.brain DNA is beine"frasmented so that the incoiporated label is principally in the 5 to 25 kb rangeby 8 hours' Based ,".rr"to be"polydispersed o.r " g.rrorrri"'sizi ol 2 x IOe base-pairs,our.data indicate that about- 100,000 small double-strandedDNA fragments pe-rcell have been producedafter 8 hours of reperfusion'This reperfusion phenomenamay account for the failure of protein synthesis in ihe selectivelv vulnerable brain areas.

l{igh Energy Phosphate Metabolism After Graded Gardiac Arrest and Reperfusion: Correlation With Clinical Outcome

GB Martin, RM Nowak,D Walton,TJ Appleton' N Paradis, KMA Welch/ J Rosenberg,M Smith,MC Tomlanovich, of EmergencyMedicineand Neurology- NMR Departments Facility, HenryFord Hospital,Detroit,Michigan Recoveryof cerebral energy metabolism has been used as an indicator of central nervouJsystem viability after ischemic insults. The need for brain sampling previously precluded direct correlation with clinical outcome. 31-P nuclear magnetic resonance (NMR) spectroscopyallows noninvasive measurement ot cerebtil energy-state/thus enabling survival experiments' This study investigates the relationship between,high energy phosphate metabolism and clinical outcome in dogs subiectedto 8 inin (n=S1,12 min (n=5), and 16 min (n=5) of cardiacarrestand reperfusion using cardiopulmonary bypass (CPB).Animals were initrumented and placed in the bore of a Bruker Biospec l'89 Teslasuperconductingmagnet system.A 4 cm coppersur{acecoil was positioned on thi exposedskull and ventricular fibrillation *as ih.tr induced. At tho end of the ischemic episode CPB was initiated and continued for two hours. The animals remained in the magnet {or an additional seven hours o{ critical care' 31-P N M R i e c t r a w e r e o b t a i n e d a t b a s e l i n ea n d c o n t i n u o u s l y throughbut ischemia and reperfusion' Repeat spectroscopywas performed at 36 and 144 hours post'ischemia in surviving animals. Neurologic deficit scoring was performed at 12 and 24 hours post-insilt and then daily in survivors. Profile analysis showed the groups to follow the same trends over time {P > '05) a"a to Ue equal acrosstime points (P > .051.There was a rapid and significant depletion of phosphocreatine (P9r) and p-adenosinJtriphosphate 1n-RTe1,ai well as of the PCI/B-ATP ratio by the end oi alllschemic intervals (P < .0001).PCr and B-AIP returned to baseline within 60 minutes of reperfusion with a significant overshoot of PCI/B-ATP ratio which persisted throughout energy phosphateswere maintained during Cpg tp < .005).High "post-ischemic monitoring without secondary the nine hours of

deterioration. Although neurologic outcome was different be' tween groups, there were no di{ferences from baseline between high enirgyphosphates -energyat 36 or 144 hours post-ischemia.Assessstate using 3 I -P NMR spectroscopydoes mEnt of cirebral indicator of neurologicoutcome' Re' sensitive be a not appearto trrttr oi hlgh energy phosphatesmay be a necessarybut not sufficient condition for cerebralrecovery after ischemia.

Forensic Aspects of Emergenct/ Care

RH Carmona,K Prince/ TraumaServices'TucsonMedical Center Introduction: Emergency and trauma physicians frequently evaluate and treat paiients who may be victims of crimes or themselvescriminali. These physiciansusually have little or no training in forensic medicine and, therefore,necessaryevidence is freqriently overlooked,lost, inadvertently discardedor its ad' missibility denied becauseof improper handling. Materials & Methods: We reviewed 100 consecutiveTiauma Serviceconsults and/or admissionsto ascertainif the caseshad forensic medical implications, and if so, was all of the potential evidencehandled oropetly.Each casewas also evaluatedblindly (relativeto forensic 'meit"ine), by criteria developed by a forensic pathologist and phvsician atiorney as to adequacy of documentation, history, phvsical exam, labi obtainedand preservationof evidenceif indi caied. Results:Eighty-threewere blunt force infuries and l7 were the result of pen-etratinginiuries. All 100 cases had potential lcriminal and/br civill foiensic medical implications' There was inadequateor improper documentation in 73 of the casesand ap' propriate labs noi orderedin I2 of the cases'Sixty-five casesin' volved the potential for criminal chargesand, therefore,gathering and/or protection of evidencewas of importance. In 40 of these ."r., .uid.tt". was either not properly secured,improperly docu' mented or inadvertently discarded.Conclusions: l) Tiauma and .-.rg"rr"y physicians frequently encountâ&#x201A;Źr patients where civil and/o-rcriminal actions may be anticipatedand evidenceis neces' sary.2) Emergencyand trauma physicianshave the responsibility when "nd li"biUty io ..tttt. that necessaryevidenceis-preserved possible.3) Educationalprogramsshould be developedand incor' oorated into residency and fellowships so the physicians are ,ware of the potential forensic medical aspectsof each case'

atl rtY

Deferred Gonsent: Use in Resuscitation Research

NS Abramson,P Safar,the Brain ResuscitationClinicalTrialll Study Group / ResuscitationResearchCenter,Universityof and 20 hospitalsin sevencountrres Pittsburgh, Deferred consent, a new approachto the requirement for in' formed consent in clinical rLiearch was used in a multicenter ir"ao-ir"d clinical trial of brain resuscitation.TWentyhospitals i" r.u." countries collaborated in this double blinded, placebocontrolled study of post-resuscitation administration of an ex' perimental calcium entry blocker (Lidoflazine)to comatosecar' hi"" "rr"rt survivors.Study protocols,including the deferredcon' sent mechanism/ were approved by each participating hospital's Institutional Review Board. Hospital investigators were treet0 use either the traditional prospecfine consent or the new deferred consent mechanism. Wiah the latter, the patient's family was contactedto consentto continued participation in the studya/rer ih. fi..t dose of experimental drug or placebo was administered' Study patients had to be in coma at the time of randomization ana ili first dose of experimental drug or placebo had to be initi ated within 30 minutes of restorationof spontaneouscirculation' These methodologic constraints usually precluded the use of pro' spective consent. A total of 558 patients were enteredinto the siudy: 343 from the U.S. and 215 from Europe.The deferredcon' sent mechanism was used for all but 27 patients' Written reports on the familv's reaction to the consent piocedures were obtained

in 228 cases:169 American and 59 European.Verbalreports were obtained on the remainder.The vast maiority of families were pleasedthat their relative was part-icipatingin the study Being oart of an NIH funded international study createdfeelings of re,rr.r."t.. that every thing possiblewas being done.With one exception, no family memberi expressedfeelingsof angeror hos.tility that their relaiive was enteredinto this study or that the first One woman doseof drug was given without their prior co-nse-n!. husband regrettedpa"rticipalionin the study becauseshe felt her "merciful" dielopei p.ttitt..rt vegetative state instead of a death as a result of the experimental drug. The main concerns expressedwere about the iaiety of the experimentaldrug and whether the drug or placebowas given. Few families understood the concepts oi ot the need for randomization, blinding or placebotreated controls. Refusalto participate lurther came only ?rom families who felt that the patient was terminally ill and shouldbe allowedto die peacefully(n= ll). In 8 casesthe patient died before consent coul-dbe obtained and in 7 casesno family confirm the impracmcmbcrscould be locatcd.Our cxperiences ticality of attempting to obtain traditional prospectiveconsent in resuscitationreseirch. Deferred consent was found to be a reasonablesolution to the inherent conflict between the requirement for informed consent and the methodologicalcon' slraints of clinical resuscitation research.

Natural History of Undifferentiated Abdominal Pain

TW Lukens,CL Emerman,D Effron,ME May / Departmentof GeneralHospital, EmergencyMedicine,ClevelandMetropolitan Cleveland,Ohio Case WesternReserveUniversity, Abdominal pain is a common complaint of personsseenin the emergencydepartment. Frequently the cause is unknown, even after extensiveevaluation a.td the patients are dischargedwith a diagnosisof undiflerentiatedabdominal-pain (UDAP). Little is knJwn about the short term morbidity of these patients. Therefore, we conducted a study to investigate the natural history of patients with UDAP dischargedfrom our emerâ&#x201A;Źencydepartment in 1987.All non-pregnantpalie.tts 18 years oldor older,without trauma, were includid. Patients were contacted at 2'3 days (lst .ont".i1 after dischargeand then again at 2-3 weeks {2nd co!tact)' A total of 402 patients were identified which correspondedto 0.86% of all EDvisits for 1987.Follow-up was obtainedfrom 302 which includesthosewith a partial response(5.2%l'The 175.1%I iemale to male ratio was 2.9-1, with an averageage of 36'5 years for males (range l9-85) and 33.8 years for females (range l8-90)' The ageand s& distribution of the 100 patients not contactedfor folloli-uo was the same as those contacted.At t'he first contact, 25.9'/" of the patients were pain fuee, 4l.5Yo had less pain, 85 had.the s"me ^moutti of pain, and 4.3o/"had pain' At the 128.2%) 88.9% of patientswere either pain free (60.3%)or second'contact better (28.6%)while 9%-of the patientshad the same degreeof pain and 2.1'/" had increasedpain. AIso, on second contact 5'4"/o ieported that their pain had Sotten worse than reported pre' viouslv or if gone at ihe first contact/ had returned.A total of six oatienis retuined to the ED within 2-3 days and an additional 22 went either to the clinic, or to a private medical doctor for further evaluation.Within three weeks, 55 patients had sought further care for the pain, with again, six returning to the ED' The total duration of ibdominal prin *rs variable. Of those stating that the pain was gone,3.7ok-hadtotal relief within two hours of their EDvisit, 246/owithin one day, and 85% within one week' Most patients (68%) reported taking medication {or the pain when first contacted.Lesi than hal{ however147.9"/"1weretaking any medication at three weeks {or the pain' Twelve patients l+.5%l were admitted during follow-up, nine were {or abdominal compiaints.The diagnosisfor those hospitalizedconsistedof gall bladderdisease{3), ihronic pancreatitis {2),pelvic inflammatory disease(I l, reflux esophogitis{1),ovarian cyst with hematoma (I },

and one with undifferentiatedabdominal pain' This study demonstratesthat undifferentiatedabdominal pain is a common ED diasnosis and a great maiority of these patients have a benrgn .ho"r, ,.t.tt .ou.t'.. while 60% have total relief of pain at 2-3 weeks after their ED evaluation fully 4Oo/.continued to havepain and will need a more specific diagnosisfor effective treatment'

A Gomparison of ButorPhanol' Dihydroergotamine and ltlepetidine in the Treatment of Vascular Headache

E Fuiz, M Ettinger/ M Belgrade,L Ling, M Schleevogt, of Neurologyand EmergencyMedicine,Hennepin Depar-tments CountyMedicalCenter,Minneapolis The standardtreatment for the acute managementof vascular headachehas remained parenteral narcotics. Becausethe suspicion of drug seeking is very high, there is e preferenceto use other medic;tions. Butorphanol(Stadolo)is a narcotic agonistan' tagonist with analgesiabut less euphoric effects' Dihydroergotamine iDHE a5) is in ergot alkaloid which may act directly on the urr".ri^t,rra to abort migraine attacks. These two medications hydroxyzine (Viwere compared to mepeiidine (Demerol@)-and trial' All patients with severe taril'.) in a prospective-randomized headacheand a normal neurologic examination were given a vascular scorewith one point eachfor aura, nauseaor vomiting, unilateral nature, throb6ing, photo or phonophobia,visual changes, periodic pattern, child[ood onset, history of motion sickness, i"-ily hii,oty, dietary triggers,relation to menses,and associated signs. Sixty cine patients with a score greate-r-than3 were randomlzed to receive 75 mg meperidine with 50 mg hydroxyzine (group 1), 2 mg butorphanol (gioup 2f o110 mg metaclopramide of groupsw-ereifr-.gti";i with"l mg DHE-45 (group3). The three vascular score (6'8,.6'6, age Bal 29, 30 res-pectlvely) .o-prtrfl. of drug seeking,(l'6, I.7,l'5]ton a scaleof 1-4' 6.5)and suscp"icion Patients were asked to eatimate their pain on a scale of 0-100 before and after treatment. Group I had a pretreatmentpain scoreof 82.4 and posttreatmentscoreof 45.9 fot an improvement 2 had a pretreatmentpain of 84'6 and of 36.5 144.3%1.'Group po.tit"rr-.ttt fain oiaO for an improvement of 54'6 164'5%l' 'Group 3 had a pretreatment pain of 83.3 and posttreatment-pain Butorphanol and of 58.8 170.6%1. of Z+.S *ith "tt i-ptou"-.nt DHE were both more effective than meperidine in the acute tr"rt-.rrt of vascular headaches'Side effects will be addressed'

Comparative

EfficacY

Ghlorpromazine and Meperidine/ Dimenhydrinate in ltligraine Headache

PL Lane,BA Mclellan,CJ Baggoley/ Departmentof Emergency Services,SunnybrookMedicalCentre;Departmentof Surgery, of Toronto,Ontario,Canada University headache, Approximately 2O% of people sufler-from.migraine "fixed" miand'a significant subpopulaiion of them develop graines,iefractory to oral medications. Of this-group, many be' Iome habitual narcotic users.A previously published caseseries usins intravenous (IVJ chlorpromazine ICPZI suggestedefficacy, so a"randomizeddouble'blind controlled trial was undertaken' againstIV meperidine{M} and diThe study comparedMPZ menhydrinate {b}. Entry criteria were emergencydepartmentpatients l8-60 years of age with a clinical diagnosisof common or classical migraine heidache. After informed consent was obtained, an IV.-of normal saline was established,and a bolus of 5 ml/kg administered.Patientswere randomizedinto two groups' CpZ X"a M/D, Bolus dosesof 5 mL of either D (25 mg) or saline were given, followed by .04 ml/kg oJ either M (0.4mg/kg) o1 QPZ {0.I mg/kg). Up to 2 repeat dosesof the secondsolution ICPZor M1 *.i" gl*'en-asneeded,at ls'minute intervals; if responsewas inadequaie at 45 minutes the code was broken, and the other at medication given. Blood pressureand responsewere assessed

by both visul5 minute intervals for one hour. Pain was assessed pari ""J u..b"l analoguescalesevery l5 minutes' A total of 49 tients were entered,25 CPZ and 24 M/D. Both groupswere comage, sex, type of migraine, duration of "ri"Ut. i., t.t-t'of i.ra""tt", prior medicaiions, number of doses.required, and adverse effects.No significant hypotensiveor dystonrc reactlons were encountered.Two of twenty-five rn CPZ groupsvs Il/24 \n lut g-np experiencedinadequate -both relief and.required other medithe visual and verbal analogue cation ip, .0t1. Ch"ttg.t in scaleswere significantly better in the CPZ group' IV CPZ appears to offer better relief than IV M/D to emergencydepartment patients with acute migraine headache.

Effects of Galcium Channel Blocker Overdose.lnduced ToxicitY on Systemic l{emodynamics and Cardiac Output Distribution in the Gonscious

Dog LM Gambone,FC Clayton,SP Sit / WH Spivey,JM Sc-hoffstall, Depaitmentof EmergencyMedicine,The MedicalCollegeof The JanssenResearchFoundation, Philadelphia; Pennsylvania, SpringHouse,PennsYlvanta The toxic effects of nifedipine, diltiazem, and verapamil overdoseon systemic hemodynamicsand blood flows to the coronary (C|, superior mesenteric(SM),renal iR), and iliac {l} arterieswere Lulf""i.a in six chronically instrumented consciousdogs Under sterile conditions, miniaturized pressuretransducerswere 1mpir"i"a in the left ventricle (LV),electromagneticflow probes ;;;;rd the acsendingaorta, catheters in the thoracic aorta and Ooppt.t ultrasonic fiow probes around the. C, .SM, R, and I arterici. Experimentswere performed2-3 weeksafter surgery'Infusion of nifedipine at a cumulative dose of 4.43 mgikg IV. (N-:^4) ou.t on. houidecreasedtotal peripheralresistance(TPR)by 517' from 0.092 mm Hg/ml/min and mean arterial pressurc (MAPJ in LV from I07 to 52 mm-Hg. This was accompaniedby decreases rrriofi" pressureand iP/dt-max of 50 and 80%, respectively At = ,ii.q"i-u"toaepressor dose [14 43 mg/kg/hour.l,d.iltiazem {N 4) bradycargrade AV block, high TPR, in decrease ".u..d " smaller dia, and decreasedcoronary output (CO) by..37ok'CBF increasecl 87o *here"s SM,'R, a;d I blood flow fell' Infusion of ;;'";it u!t*"*if {N:4} at the samedoseover one hour increasedTPR rfi*-fi iu, causedAV block, decreasedHR and CQ and had similar .li-..,.'o" regional blood flow distribution. In the consciousdog, calcium chainel blocker overdosehad a disparateeffect on systemic hemodynamics.Nifedipine induced reflex increaseti" TR which maintained CQ thus, the hypotension.wascausedby rn;;;;; p;;i;h.tal vasodilation.ln conirast, the direct action of dilil"".tti and verapamil on AV conduction preventedreflex tachycardia and the hypotension was causedmarnly by a decreasein CO. This indicaiei that dif{erent therapeutic interventions may b" ,r.""rr"ry for the managementof an bverdoseol each subclass of calcrum channel blockers.

Use of lpecac Increases EmelgencY Depailment Stays and Patient

GomPlication Rates

GE Foulke,TE Alberison,RW Derleti Divisionof Emergency Departmentof InternalMedicine' Toxicology, MedicineiClinical Davis'MedicalCenter,Sacramento of California, University We performed a prospective,randomized trial comparing the cli"icai effectivenessof syrup of ipecacand activated charcoalto activated charcoal alone for the treatment ot acute toxlc rngesAn oral o,rerdosedor poisonedpatients presâ&#x201A;Źnting-to the il;: i4--onth period ending i2l87 *tre eligible for the iD ;";-g; rt"av.',q*'rf." adult patients with a gag refler who did not have o-rioi uomitins and did not receive ipecacat home or in the am[trt'*.. wereiandomized by hospital unit numbers to 2 different of ipecac (30 mL, reito"pt. One group {IC} receivedoral syrup

(l oeatedin 30 min. if no response)followed by activatedcharcoal ;/[;t ih. othe, grorlp{C) receivedonly the acttvatedcharcoal' "prii."" *iitt possible ingestion of caustics, hydrocarbons,and *.ie excludeJ. TWo hundred patients were entered ri-.tr"i". ;;6-ih; study.The IC (N=93) and C 1N=107) groupsdid not hospitalized' Jiir.t-rt*"tri.intly in demographicdata,percentage ;e;itied to the"lc'U, length bf lcu stav,or hospital ;;;;;,;;; !i.v. rc-t.plii."ts had significantly longer ED stays(6'8t 0 2 hours' SEM) when c"omparedto C patients {6 2 .t 0'3 hours,P M;;r a .OSUV Student's t test). The reported times reflected time to medical discharge{rom the ED and did not include time spent psychiitric disposition.Chart review suggestedthat the ;;;*;g ,JJi,i"i"i tl-e spent by the IC patients was the result of awaitine the cessation^ofvomiting beforeattempting to give activated "fr?-""f . rc patients had a iomplication rite ot.5'4% compared io , t"," ol O.Sy"for the C group (P < 05 by chi-square)Complications included four patients witnessedto have asplratlon pneuwith emesisand the subsequentdevelopmentof aspiration monitis in three in the IC group There were no wltnessedasplrations and no episodesof pneumonitis in the C group'-Nopatients ai..fr.ri.a from the ED ieturned for re-evaluationof symptomsi of the initial drug overdose'We feel this study.adds .o-oii3.ti""t i"i,-fi.i ttg.iiicant evidencesupporting the abandonmentof rouli;. ;r. oi tyr,..pof ipecacin thi rn tieatment of the acutemild to moderatelypoisonedPatient. ,l

l+C

Prospective

Evaluation

of Gastric

Empiving in the Self'Poisoned Patient

A Pesce,RC Stuebing,JR Roberts' KS Merigian,JR H-edges, of CincinnatiCollegeof Medicine / University MC RasnXin The role of gastric emptying in the managementof acutelypoi' poisonedpatientJ is controveisia-i.While gastric emptying-of all s o n e d p a t i e n t s i s c o m m o n l y p r a c t i c e d , s o . m ea u t h o r s h a v e suesestedselectivemanagementwithout gastricemptying To aspro' seffthe safety and efficacyof one nonemptying protocol, we ,,..rdi.d the efiect of gastric emptving upon clinical ;;;;;i;.iu o'utcome'in acutely self-poisonedpatients Patients ingesting heavv metals, acetaminopiren,lithium MAO-inhibitors, digoxin' ethylene glycol, or substancesknown to be nontoxic -.t(""ot, patients(N=4761 *.t" .l<.fta"a'fromihe study.Other overdose. *.r. tr."t.d using an even-oddday protocol basedon perfor' premance on a ten-questioncognitive function examlnatlonand determined presentingvital sign parameters'Patientswere con' ria.t.d ".y*ptomatiJi{ they answeredeight of ten questionnaire it.-, .oti..tiy and had normal vital signs Symptomaticpatients ,.u# o. iess of the questionnaireitems correctly and/ ,".*"*a o i m a n i f e s t e da b n o r m a l v i t a l s i g n s A s y m p t o m a t i c p a t i e n t s emptyrng0t {N:234) did not receive gastric emptying' Gastric pa' symptomatrcpatientswaJperformedby using ipecacin alert ii."it tN : 43i and gastriclivage {N : 56) in obtundedpatientson .-ptyi.tg days.Activated charcoal therapy followed gastricemptvinq. Symptomatrc patients on nonempiying days were treated nJl,ii".,iu",.a charcoal'A nasogastrictube was passedand stom' ,.h "orr,"n,. aspirated{withoui lavage)prior to-the administra' = tion of activatedcharcoalin obtundedpatients {N 99)' Outcome measureswere comparedusing a two-tailed t testi P < 0 05' Cas" tri. .-ptyittg (GEi) proceduies did not significantly alter the clinical-outcome as measuredby mean length of stay in the Er) "; 4.1 hours for'non-GEG),mean time intubated f--cic fiil; vs I0.5 hrs for non-GEG)and-meanlengthol for GEG trc iiz.s intensivecareunit (19'7hrs for GEG vs 16'5 -.dical !i"u i".t* il;; f"; "o"-Crct Ior symptomatic patients Analysis of the patient group-showedno delayedpatient deteriora' "ry-pto-tti. pro' tio". b"t datatdo not-support the use of gastric emptying self-Poisonings. in all cedures

Amanita Phalloides Poisoning: Mechanism of Gimetidlne Protection Hospital, / Monteliore EA Michelson SM Schneider GJ Vanscoy,

46 26

University of Pittsburgh The death rate from Amanita phalloides has been reportedbetween 15% and 6OT",with no known effective therapy.We previously reported hepato-protection in mice pretreated with cimetidine (C). We have now further investigated the involved mechanism. Cimetidine may offer protection either by decreasing hepatic blood flow or interfering with the Par6 metabolism. Ranitidine (R) at equipotent H2 blocking doses only decreases hepatic blood flow. Therefore, by comparing treatment with C and R we can begin to understandthe hepatic protective mechanism. Swiss female mice were divided into 5 groups of 9 mice each and treated in the following manner: Group A f S received alpha amanitin {A) 0.6 mg/kg, i.p. (LDe5 dose)followed in four hours by saline I cc i.p. Group A + C receivedA 0.6 mg/kg followed in {our hours by C 120 mg/kg i.p. Group A -r R receivedA 0.6 mg/kg followed by R 30 mg/kg at four hours {equipotent dose).Control mice receivedeither C 120 mg/kg or R 30 mg/kg and saline I cc i.p. The mice were then given free accessto food and water and their suruival logged.The study was repeatedwith 5 groups of l0 mice. At 48 hrs these animals were anesthetized and phlebotomized by direct cardiac stick. The animals were then sacrificed, livers harvested, and the blood analyzedfor LDH, AP SGOT SGPT An increasein survival was observedin the A + C group (P : 0.005)vs the A + R andA + S groups,which experiencednearly identical survivals.Resultsof some liver tests are shown below. TWo animals in the A + R group failed to survive the 48 hour period thereby potentially lowering the mean hepatic enzyme elevation for the group. There was a significant reduction in enzyme levels in the mice treatedwith C compared to the other groups. Liver histology paralleledthese results. Group A + S

SGOT 15,442+ 3,540

End ot CO Exposure

Assay

Control

protein) 4233(O.D./mg

1 . 0 0* 0 1 9

100 * 0.09

1 . 0 0t 0 . 3 2

MDA(pM/mgprotein)

1 . 0 0+ 0 . 2 1

1 . 0 0* 0 . 1 0

0 . 8 6t 0 1 0

Assay 4 2 3 3( O . D . / m gp r o t e i n )

3ata 02

CQ then

CO + 45" air

Co + 45" air

1 5 h alr

+45" lala Oz

+45" 3ata 02

-2.18r 0.35

-1.99I 0.16

1 . 0 9* 0 . 3 6

.1 77 + 0.19 -1.74+ 021 1 02 t 0.38 I V D A( p l v / m g p r o t e i n ) - S l g n f i c a n t l iyn c r e a s e d( P < . 0 5 , o n e - w a ya n a l y s i so f v a r l a n c et o l l o w e db y ) .o d i f f e r e n c ies i d e n t i i n d i v i d u acl o m p a r i s o nus s i n gB o n f e r r o naid j u s t m e n tN f i e d a m o n gt h e s t a r r e dg r o u p s .

These data may provide an explanationfor a number of currently poorly understood clinical observationsregardingCO poisoning and its treatment.

SGPT 19,274+ 4,501

A + C (p)

5 , 6 8 2* 2 , 1 6 0( p = 0 . 0 0 2 ) 5 , 9 1 6+ 1 , 9 1 2( p = 0 . 0 0 0 5 )

A + R (p)

7,600+ 2,167(p=0.02)

AC, rlc,

Plasma Gatecholamines in Gyclic Antidepressant OYeldose

KS Meri$an,JB Hedges,LA Kaplan,A Pesce,RC Stuebing, of CincinnatiCollegeof JR Roberts,MC Rashkin/ University Medicine Cyclic antidepressantoverdose(CAO) is a maior causeof morbidity and mortality in self-poisonedpatients.The maior causeof death with CAO is cardiotoxicity.CAO cardiotoxicity is believed in part to be due to increasedadrenergicactivity from blockadeof presynapticcatecholamineuptake. We sought to verify the presence of increasedplasmacatecholamineleveiswith symptomatic CAO and determine the correlation of plasma catecholamineievels with QRS width (asa marker for cardiotoxicity).Plasmacatecholamine levels were determined in 4l symptomatic overdose patients meeting predefinedcriteria for either vital sign abnormalities, mentai status change,or electrocardiographicchanges. Venousblood was obtained following an approvedprotocol in 15 patients subsequentlyshown to have a CAO and 26 control overdosepatients. Specimenswere centrifugedwithin 30 minutes of phlebotomy and frozen for subsequentanalysis by High Performance Liquid Chromatography.For the presenting blood draw, the mean plasma norepinephrinelevel was 2,800 pg/ml in the CAO group versus 810 pglml for controls (P < .003).Similarly, the mean initial plasma epinephrinelevel was 460 pg/ml for the CAO group versus I45 pg/ml for controls lP < .O2).Mean systolic and diastolic blood pressuresdid not differ between the groups. Using a Iinear multivariate regressionanalysis,QRS width correlated with the presence of cyclic antidepressant,plasma norepinephrineand epinephrinelevels,and heart rate (P < .0001, R:0.83). Elevatedcatecholaminelevels normalized 4-6 hours after the presentingblood draw in the CAO group in concert with the known period of greatestlife threat. Our finding of elevated catecholaminelevels and QRS widening without a commensurate blood pressureresponsein the CAO patient group suggests desensitizationof adrenergicreceptors.Further study is neededto elucidate the pathophysiologic role of elevated catecholamine levels in CAO and resultant therapeutic implications.

9 , 2 9 0+ 2 , 9 7 5( p = 0 , 0 1 )

We conclude that C offers significant improvement in survival and reduction of hepatic iniury, even when given four hours postexposureto alpha amanitin. Further,we suggestthis is due to inhibition of the Pa5esystem rather than a decreasein hepatic blood flow.

mm Hg dropped to 65 + 20), so brief that in isolation it caused no apparent insult. Lipid peroxidation occurred only after the rats were returned to CO-free air, and there was no drrect correlation with carboxyhemoglobin (COHgbl Ieve1. Lipid peroxidatron could be prevented by 3 atmospheres absolute, but not ambient pressure 02 treatment. There was no evrdence of mitochondrial cytochrome oxidase inhibition in the CO-exposed animals. The data arc compared as relative units with the controls equal to 1.00 t SD as follows:

Experimental Garbon Monoxide Mediated Brain Lipid Peroxldation and the Effects of Oxygen'Therapy

SR Ihom / Institutetor Environmental Medicine,University of Pennsylvania, Philadelphia Poisoning by carbon monoxide may cause death or a variety of neurologicsequelae.Approximately half of all fatal poisoningsin the United Sta.tesare due to CO. In spite of extensive studies, questions remain regarding the biochemical mechanism of CO poisoning,as well as appropriatetreatment. The clinical and animal data suggestthat the pathogenesesof CO poisoning extends beyond the inhibition of hemoglobin function. Clinical experience indicates that hyperbaric 02 may be effective in reducing both CO morbidity and mortality to an extent greater than ambient pressure02 treatment. Experimentswere carried out using rats to assesswhether CO exposuremay causebrain lipid peroxidation. Rats were exposedto 1,000ppm CO for 3 hours. Using two methods, measurement of confugated diene (A63) and malonaldehyde{MDA), brain lipid peroxidation could be documented following exposure to CO at a concentration sufficient to cause unconsciousness(CO briefly increased to 3,000 ppm during the 3 hour exposure interval). Unconsciousness was associatedwith a l0 to 15 secondperiod of hypotension (mean B.P 123 t l9 ISD]

The Terminal 4O ms Frontal Plane QRS Axis as a ilarker for TricYclic

Antidepressant (rverdose

TR Wolfe,EM Caravati,DE Rollins/ Divisionol Emergency of Utah Schoolof Medicine;The Medicine,University IntermountainRegionalPoisonControlCenter,Salt Lake City' Utah Tiicyclic antidepressant(TCA) poisoning has been reported to causea right axis deviation of 130 to 270 degreesin the terminal 40 millisecond frontal plane QRS axis (T40 axis) of the ECG' This finding had a negativepredictive value of 100% which suggeststhat iis absenceshould be a reliable indicator that an overdosedpatient is not toxic from TCA's. Our study wasdesignedto evaluaie the correlation between the T40 axis and plasma TCA concentration and whether the T40 axis could distinguish TCA toxic patients from nontoxic patients taking TCA's therapeutically. Hospital recordsof all patients admitted for TCA overdose between fanuary 1985 and December 1987 were reviewed.Patients who had ingestedmultiple medicationswere excluded.All patients had clinical manifestattons oi TCA toxicity and.blood ioxicology screenspositive for TCA {group l, n=241. In addition, 16 of 24 patients had quantitative TCA plasma concentrations measured.Eleven asymptomatic patients taking TCA's therapeutically and with documentedTCA plasma levels were also itudred (group2, n=ll). All patrentsin groups I and 2 had an ECG performld within 2 hours ol the documentedTCA level.

Age*

TCA conc* (ng/mL)

T40 axis*

13% 557.

Group 1

33 t 11

1 , 0 6 3t 6 5 0

190 + 74

Group2

42 * 22

207 ! 128

115 + 93

0.10 P value tMean t standard deviation

0.001

T40 axis<130

questionnaireswere later reviewedfol discrepanciesand eachwas riviewed individually in a blinded fashion for an overall impression of the probability of cardiacdisease.Fifty-two patients were enteredand-themaiority were black (857.1and female (50%) with Seven(l3ol"} a meanage + S.D.of 5.05 + 12.8years{range25-771. had an eventualcon{irmeddiagnosisof cardiacdisease.The mean time + S.D. betweeninterviews was 65.3 :t 64 minutes but 38% were carried out within an interval of 30 minutes or less. The frequencyof conflicting responsesior the various questionsis listed below: Pain description

25%

Pain ocation

21"

Worsewith arm movement

Pleuritic

207.

Associated diaphoresis

15"/"

Radiation

25'/.

Associated nausea

15"/"

Painlength

171"

Relaxationto exertlon

1S%

%g C h o i c e :s h a r p / d u l l / b u r n i n g / a c h8i n

of cardiacdiseasewas the The overall impressionof the probability 1'54%1, paired as no probability/low same between interviews n 28 probability rn 5 {l0% ),low/moderateprobabilityn 15lLgy.),and modirate,4righprobabiliry n 3 16%1.One patient had the separaternterviews ranked as low and high probability ln those with proven cardiac disease,4 oI 7 157'/.1had a diJferentoverall impression.Despite the use of a standardizedquestionnarre,this group of patients often gave conllicting and confusrnganswersto separatetntervtewers.Furtherresearchfoi different patient populationsand presentingcomplaints mav be warranted.

0017

Results demonstratedthat the mean T40 axis was significantly higher in the toxic patients (group l) and that thirteen percent.of them did not demonstratea T40 axis between 130 and 27O de' grees.A poor correlation was found between plasma TCA concentration and T40 axis deviation in either group alone or combined (R<0.311.We conclude that the T40 axis became more rightward as clinical manifestationsof TCA toxicity appearedbut it did not correlate well with TCA plasma concentration The absenceof a T40 axis greaterthan 130degreesdid not exclude all TCA overdosepatients in our study population.

207.

Worsewith body 13% twist

AssociatedSOB 10'l"

Myocardial Infarction in the Emergency Department Patient With a l{ormal EKG: GomPlications and lnterventions

D Murphy,D Cooke/ RJ Zatenski,EP Sloan,S Saldivar-Zalenski, Departmentof EmergencyMedicine,Cook CountyHospital' of lllinois Chicago;LutheranGeneralHospital,University EmergencyMedicrneResidencyAffiliate,ParkRidge,lllinois; ChicagoMedicalSchool Myocardialinfarction{MI) that presentswith-an initially-nor" mal ED EKG representsa high medicolegalrisk becauseof the potential for misdiagnosisand inadvertent discharge.It alsoiden' iifies a subsetol Mfpatients contendedto be at low risk for subsequentcomplicationsaccordingto severalrecent studies.No rtrrdi.r, however,have documentedthe outcome of a seriesof MI patients that had an initially normal ED EKG. This study was undertaken to answer the question: does an initially normal ED EKG herald an uncomplicaled hospital course Ior patients with MI? Retrospectivelyreviewedwere 868 proven acute MI patients admitted from the ED during a 25 month period. In this MI group,30 (4%)patientsmet the entry criteria (normalED EKC, Ep ja-it diagnosisRiO MI or R/O unstable angina)'This group had a mean ageof 55 yearsi77o/owere male, 93% white, and l0% had a previous MI. Liie-threateningcomplicatlons (LTCsi(death, vfib, viach, bradycardiawrth hypotension,pulmonary e{emL 91 2nd or 3rd degreeheart block) in the ED occurred in2 of 30 l7%l patients. ED pharmacologicinterventions (IV vasodilators,pres' were requiredin 5 (17%) sors or therapeuticanti-dysrhythmics) of thesepatients. In-hospital EKG evolution which reflectednew ischemia or infarction oicurred in ZO167%lpatients. In-hospital LTCs occurred rn 8 127'k)of these MI patients,including-one death. In-hospital mechanicalinterventions (SGcatheter,balloon pump, pacemaker,intubation or defib/cardiovert)were required 1n 8 127%lpatients.In-hospitalpharmacologicinterventionswere

lnconsistent Histories: A Patient or Physician Problem?

RM McNamara, WJ Zehner, RS Fuerst / Department of Emergency M e d i c i n e , M e d i c a l C o l l e g e o f P e n n s y l v a n i a ,P h i l a d e l p h i a Obtaining an accurate history is critical to the proper care of a patient. The importance of this is heightened in the emergency iituation where-diagnosis and treatment must often be rendered with no or limited ancillary studies. It was observed that the history elicited from a patient often varied from one qhysician to the next. Conflicting historical information recorded on patient charts has been cited as a problem in malpractice defense. To examine whether this was i real phenomenon, a standardized auestionnaire was constructed with a series of questrons pertttr"trt to the diagnosis of acute chest pain. Subjects entered had to be alert, fully communicative and clinically stable emergency department patients with a presenting complaint of chest pain. Those intoxrcateC or who had received a narcotic analgesic were excluded. TWo separate interviewels questioned the patient at least ten minuteJ apart. It was required that each question be asked exactly as worded on the form. The 13 questions were slmple and direct with nine requiring a yes/no answer. The paired

required in 13 (43%). Overall, 16 153%)patients had a complicated coursewhiie being treated for an MI that presentedwith a normal ED EKG. EKG evolutionwas seenin 13 {81%)of these16 patients. We conclude that MI patients who present with a normal ED EKG are at significant risk of complication. The majority ol these complicated patients will, however,have evolving EKGs that should serve as a warning for subsequentproblems and the needfor transfer to the coronary care unit. Emergencyphysicians who admit patients with histories strongly suggestiveof MI should, even in the presenceof a negative ED EKG, be aware of the risk of in-hospital complication and the need for follow-up EKGs.

E 1, 3rt

Adverse Reactions During and lmmediately After t.PA Infusion

EA -r-

Reperfusion Arrhythmia: Myth or Reality

of Emergency R Ramos/ Departments W Linnick,JE Tintinalli, WilliamBeaumontHospital,RoyalOak, Medicineand Cardiology, Michigan The purpose of this study was to describethe type and incidence of adversereactionsduring and up to four hours after peripheral intravenousrnfusion of tissue plasminogenactivator (t-PA) in patrents with acute myocardial infarction {AMI). Medical recordsof patients receivingt-PA infusion as part of the TIMIII protocol {Thrombolysis in Myocardial Infarction, phase II, National Heart, Lung, and Blood Institutel, from April I986 to December 1987, were retrospectivelyreviewed.Patientswere eligible for entry into the study if they fulfilled criteria which included the following: I I age less than 76 years;2) no contraindications to thrombolytic therapy;3) ischemic chest pain lasting at least 30 minutes, with onset no more than four hours prior to therapy; 4) electrocardiographiccriteria of acute ischemia. The treatment regimen consistedof a standarddoseof t-PA infusedas a bolus and intravenousinfusion; and bolus and intravenousinfus i o n o f l i d o c a i n ea n d h e p a r i n .I n t r a v e n o u sn i t r o g l y c e r i nw a s given to 24 ll97.l, and 29 123%)patients were randomizedto receive intravenousmetoprolol. Medical recordsof 124 patients were reviewed.TWenty-threepatients llgu/") were female,and 101 in 181%lwere male. AMI locationwas anterioror anteriol-lateral inferior in 66 153'kl,and laterai in a P%). Complica54 144'/.1, t i o n s a s s o c i a t e dw i t h t - P A i n f u s i o n i n c l u d e d r e p e r f u s i o na r rhythmias, bleeding, hypotension, and allergy.The commonest idioventricular in 66 l13ohl;accelerated arrhythmiaswere PVC's 1'38%\ and ventricular tachycardia(VT) in rhythm (AIVR| in 47 28 1p3%).Bleedingdevelopedin I0 {8%),and was life-threatening in 3 l2%1.Hypotensionoccurredin a p%), and symptomsof allergy in 3 l2%). The administration of t-PA in the emergencydepar-tmentfor AMI will be necessary,and frequency of use will increaseas drug availability improves. Our study of I24 patients clearly indicatei that the incidence of complications during and rmmedrately after t-PA infusion is clinically significant. There were 245 problems in 124 patients, including a variety of arrythmias ind life-threateningbleeding.The risk-benefit ratlo and constant monitoring must be promust be carefully assessed, vided, when t-PA is administeredin the emergencydepartment.

Delay Between Onset of Chest Pain and Seeking Medical Gare: The Effect of Public Education

MS Eisenberg/ Centerfor MT Ho, P Litwin,S Schaeffer, Evaluation of EmergencyMedicalServices,King County County EmergencyMedicalServicesDivision,Seattle-King Department Departmentof PublicHealth,Seattle,Washington; Seattle of Medicine,University of Washington, Tieatment of acute myocardial infarction (AMI) with thrombolytic therapy {TT) has been shown to improve patient survival and myocardial function. However, the effectivenessof TT is strongly related to how early it can be administeredafter the onset of acute symptoms of AMI. Despite efforts to provide TT rapidly by moving the site of administration from the cath lab to the ED and to the prehospitalarena,a substantialportion of AMI patients still delay seekingcare by severalhours. In Seattle,up to 50% of AMI patients delay over 4 hours and oniy 33"/ooI patients use the EMS system. A surveillancesystem of patients admitted to King County, Washingtonhospitals for AMI was instituted in October, 1985. Patient demographics/symptoms, delay times, method of transport and dischargediagnosiswere recorded.In addition, 46o/oof patients were interviewed by phone to determine whether patients had recently heard any new information on period),an AMI. After 4.5 months of data collection (pre-message intense 2 month long public education campaignwas instituted via newsprint, radio and TV Data collection continued for anperiod).The number of patients other 4.5 months (post-message admitted for possibleAMI were 1,479in the pre-messageperiod and 1,438 in the post-messageperiod. The pre and post groups were evaluatedfor comparability on severalfactors. There were no significant differencesin age,sex, presenceof chest pain, history of angina or MI, or mortality. The two groups were significantly different in the proportion dischargedwith a diagnosisof AMIl29% in the pre period and 24T" in the post period, P < .01). There was a significant increasein the proportion of peoplehaving heard new information on AMI in the post-messageperiod (53% in the pre and77o/" in the post periods,P < .0001).When Iimited only to patients hearing one of the key elements of the message{signs and symptoms of AMI, importance of time, calling 9ll or new therapy available)from one of the correct media (radio,TV or newspaper)this differenceremainedsignificant {P < .0001).The campaign did not significantly increase the proportion of patients using the EMS system 143% pre vs 46% post message). Likewise, there was no significant di{ferencein the dispetribution of patients seekingcare in the pre and post-message riods: 35% vs 36Yo delayed less than 2 hours, 2Oo/"vs 22o/odeIayed,2-4 hours and 45o/ovs 43lo delayed 4 hours or more. Median delay time was 2.8 hours in the pre and 2.1 hours in the post period. The distribution of delay times and utilization o{ EMS remainednon-significant after stratifying by dischargediagnosis. We conclude that a relatively short and intense public campaigndirected at AMI patients may increaseAMI knowledge and awareness.Such a campaign, however, did not significantly alter patient behaviorin shorteningdelay times or increasingutilization of the EMS system.

RE Burney,PA Kearney,DG Walsh,LR Kaplan/ Divisionof Ann Arbor of lMichigan, EmergencyServices,University Emergencytransfer of patients with acute myocardial infarction (AMI) for thrombolytic therapy or angioplastyis carried out with increasingfrequency.Early reports have deemedsuch transfers to be safe,but have suggestedthat there may be an increased incidence of arrhythmia, particularly ventricular tachycardia, which is associatedwith reperfusionof a previouslyoccludedcoronary vesselduring thrombolytic therapy.To provide a more definitive answer to this question,we reviewedthe incidenceo{ arrhythmia in the last 500 patients with AMI transferredto our center within 48 hours of the onset of chest pain. Methods. Hospital and transfer recordsfor all patients with acute myocardial infarction transferredby our critical care transferservicebetween fanuary 1, 1985 and November 30, 1987were reviewed.The occurrenceof five types of arrhythmia, ventricular fibrillation {VF), ventricular tachycardia(VT), premature ventricular contractions {PVC},bradycardia,and atrioventricularblock, was noted both before and during transfer.Time from onset,type of AMI, treatment with thrombolytic agents, and discharge status were also recorded. Resu/ts.500 patients with AMI less than 48 hours old were transferredduring the period of study. 225 patients received thrombolytic therapy; 270 did not (5 unknown). Type of AMI was known for 471 patients; 192 were anterior, 203 were inferior, 76

nificant differencein the relapserate. We concludethat the early use of steroidsrn the EmergencyDepartment treatment of acute COPD does not improve lung function or lower the hospitalizatlon rate.

lateral. TWo patients died during transfer. Overali survival was 9l%. The incidence of arrhythmia is shown in the Iollowing table: VF

PVC Bradycardia Block Total

P R I O RT O T R A N S P O R T Thrombolysis(n=225)

6.2% 5.8"/" 12.9./.

N o T h r o m b o l y s i(sn = 2 7 0 ] | 6 . 7 % 8 . 9 % 1 1 . 9 " / "

6.77"

3.1% 35%

6.3%

3.0v" 37%

0.4%

0.97" 12L

2.2%

1 1% 127.

WH Spivey,RM McNamara,EA Skobeloff/ Departmentof EmergencyMedrcine,The MedicalCollegeot Pennsylvania, Philadelphia A previous study (Okayamaet al, JAMA 1987i257:1O76-1078l demonstrateda beneficiale{fect in reversingacute bronchospasm in ten patrentsusing intravenousMgSOa.Previousstudiesduring the 1940'salso demonstrateda beneficial effect with MgSOa, however,none of these studies were blinded or compared to a placebo.This study used a randomized,double blinded, placebo control design to compare MgSOa with a saline placebofor the treatment of moderateto severeasthmaticswho failed to respond to conventional beta-agonists.Initial peak expiratory flow rates (PEFR's)were obtained in patients who entered the Emergency Department with an acute exacerbationo{ asthma.They then received two metaproteranolor albuterol nebulized treatments45 minutes apart and solumedrol 125 mg IV Fifteen minutes after the secondnebulized treatment, PEFR'swere repeated.If the PEFRdid not double, the patient was enteredinto the study after signing consent. Patients were randomized to receive either MgSOa1.2gms/50cc salineIV (n: 13)or salineplacebo50 cc IV (n= l3) over 20 minutes. PEFR,heart rate, blood pressure,respiratory rate, reflexesand mental status were evaluatedat 0, 5, 10, 15, 20, 30, and 45 minute intervals. Serum magnesium and theophylline levels were obtainedprior to therapy.The initial mean + SD PEFR and values during and after therapy for the two groups are as follows:

D U R I N GT R A N S P O R T T h r o m b o l y s i(sn : 2 2 5 ) 0.9% 0.9y" 8.9% N o T h r o m b o l y s i(sn = 2 7 0 ) 0 A % 1 . 8 7 . 6 . 7 %

Conclusion. The incidence of arrhythmia in patients receiving thrombolytic therapy was virtually identical to that in other patients with AMI. We concludethat "reperfusionarrhythmia" during thrombolytic therapy is a myth.

Lack of Effect of Methylprednisolone in the Emergency Department Treatment of Acute Exacerbations of coPD

CL Emerman,AF Connors,TW Lukens, M May, D Effron/ ClevelandMetropolitan GeneralHospital,Case WesternReserve Cleveland,Ohio University, The use of steroids in the management of acute asthma has been establishedby severalrecent studies. However, the use of steroids in the treatment of COPD is more controversial.The purposeof this study was to evaluatethe effect of the early use of steroidsin the managementof patients with acute exacerbations of COPD. We conducteda randomized,double-blind,placebocontrolled trial involving 75 patients with acute COPD. The patients were at least 50 yearsof agewith acute respiratorydistress and without evidenceof acute CHI pneumonia, or other conditions mandating hospital admission.The diagnosisof COPD was verified by baselinespirometry during a period of clinical stability with a FEVI < 75% predictedor an FFVI/FVC ratio < 70To. None of the patients had an increasein FEVI > 30% in response to inhaled isoproterenol.Prior to initiation of therapy,blood was drawn for CBC, theophylline level, and arterial blood gases.Initial spirometry was obtained and therapy initiated with hourly administration of neubulized isoetharine,continuous oxygen by cannula,and intravenousaminophylline. Patientsreceivedeither methylprednisolone 100 mg intravenously or an equivalent volume of saline in a randomized,blinded fashion. Spirometry was repeatedafter the third and fifth aerosol treatments. After five aerosol treatments the patients were either admitted or dischargedfrom the EmergencyDepartment. Patientswho were dischargedwere followed-upwithin 48 hours with re-evaluationand repeat spirometry. TS patients completed the study with an aver' age age oI 64.5 + 8.7 (S.D.l years.96"/oof the patients had a history of cigaretteuse while 97% of the patients had chronic bronchitis. There were 34 patients in the control group and 42 patients in the steroid treatedgroup. There was no differencebetween the groups in age,medications use, cigaretteuse, or duration of illness. The initial theophylline level, white blood count, arterial blood gases,and baselinepulmonary function tests were similar between the two groups. The initial FEVI was 24o/oprc' dicted in the control group and 28% predicted in the steriod group (N.S.).The patients were treated for an average4,4 + 0.8 hours in the control group and 4.5 + 0.8 hours in the steroid group (N.S.).Post treatment, the FEVr was 33% predictedin the control group and 36% predicted in the steroid group (N.S.)The control group had a 44Yo improvement in FEVI while the steroid group had a 33% improvement in FEV1 with treatment {N.S.). The hospitalization rate in the control group was 26o/" with a 33% hospitalization rate in the steroid group. There was no sig-

lntravenous Magnesium Sulfate for the Treatment of Asthma in the Emergency Department

lnitial

MgSOo

156* 54

208 :t 51

222 * 59

239 t 69

Placebo

133 + 33

191i 57

190 + 58

1 9 1t 6 1

MgSOo

254 + 76

263 + 78

257 + 82

265 t 81

Placebo

188 * 60

186 + 67

1 9 1+ 6 7

1 8 91 7 0

An analysis of variance revealeda significant difference{P < 0.05) between the MgSOa and placebo groups for PEFR.There was no significant difference for heart rate, respiratoty ratet or blood pressure.There was no signi{icant di{ferencefor theo p h y l l i n e l e v e l s 6 . 7 + 4 . 9 , 9 . 7 + 6 . 7 o r m a g n e s i u ml e v e l s 1.9 * 0.2, I.9 t 0.2 for the magnesiumor placebogroups,respectively. This study ihdicates that MgSO4 may be a useful adjunct in the emergencytreatment of moderateto severebronchospasm that does not respondto conventional beta-agonisttherapy.

E -

lrdgating Solutions for Sutured Lacerations

AP Welsh,DJ Dire/ Departmentof EmergencyMedicine, EmergencyMedicineResidencyProgram,DarnallArmy CommunityHospital,FortHood,Texas The oblective of this study was to provide definitive, prospective data as to which of the more commonly used wound irri' gants is the most efficacious in terms of promoting wound healing, and reducing the risk of wound infection. Five hundred and thirty-one patients were randomizedinto 3 groupswho were irrigated with 3 different solutions. AII patients had their wounds

irrigated in a standard fashion using a 20 cc syringe with a 20 gaugeI.V catheter.Patients in Croup I were irrigated using norsolution;Group 3, Plumal saline;Group 2, l% povodine-iodinc They were closedwith intcrruptedsimronic-F68(Shur-Ciens''). ple sutures using the appropriatesize nylon suture. Vicryl was used for those wounds requiring subcutaneoussutures. Croup I (n= 189)patientshad a mean ageof 13.4years{rangel-71) and a mean time of injury to wound irrigation oI 2.32 hours. There w e r e 1 0 6 1 5 6 . 1 % )p a t i e n t s w i t h h e a d a n d n e c k w o u n d s , 2 7 1 1 4 . 3 %w ) ith upper extremity wounds,2 ll.l%) with trunk wounds, and 46 124.3'lo)with lower extretnity wounds. The type 3 11.6%)avulsions,and I of woundswere 185 197.8%)lacerations, 1 0 . 5 % )b i t e w o u n d . S e v e n t e e n9 . 0 % l o I t h e w o u n d s w c r c scrubbedprior to closure.Seventeen19.O%lof the patients receiveda 7 day courseof oral antibiotics.Group 2 {n:184) patients had a mean ageo{ t(r.5years{rangel-71}and a mean timc of injury to wound irrigation oI 2.22 hours. There were lI7 163.6%lpatients with head and neck wounds, and 36 119.6%l with truck wounds, and with upper extremity wounds, 1 10.5"1,) 25 113.6%lwith lower extremity wounds. The type of wounds were 168 191.3%llacerations,12 (6.5%)avulsions,3 (1.6%)bite wounds,and I i0.5%) crush injury. Thirty-seven{20.0%)of the wounds were scrubbedprior to closure. Eight {a.3%}patients receiveda 7 day courseof oral antibiotics,Croup 3 (n=158) patients had a mean ageof 16.9years(range1-78)and a mean time of injury to wound irrigation of 2.0 hours. There were 108 paticnts with head and neck wounds, and 34 121.5'/.) 168.4'/") with upper extremity wounds, 14 l9.9%l with lower extremity no patients with trunk wounds. The type of wounds wounds,and 1 90.5%) lacerations,9 15.7%lavuisions,I 10.6%lbite were 143 wounds, and 4 12.5'/.1crush injuries. TWenty-five115.8%)of the wounds were scrubbedprior to closure. Twelve l7.6%l of the patients receiveda 7 day courseof oral antibiotics. The number of woundinfectionslor Groups 1,2, and3, were 13 16.9%1,814.3'/"), and 9 \5.6%),respectively.These iniection rates were not statistically significant(P : .05).The authorsconcludethat there is not a significant differencein inlection rates in wounds irrigated with either saline, I% povodine-iodine,or Pluronrc-F68.

Fat Embolism Following Intraosseous Infusion

J McPherson,E Klein,JS MC Plewa,RM Kaplan,D LaOovey, of PittsburghAffiliatedResidencyin Stapczynski / University EmergencyMedicine;The Centerfor EmergencyMedicineoJ WesternPennsylvania, Pittsburgh Intraosseousinfusion has been describedas a safe alternative method of venous accessfor drug and {luid administration during pediatricresuscrtation.Fat embolization has previouslybeen documented following both experimental intraosseousinfusion and clinical intraosseousphlebography.The significanceof this fat embolization,however,or the incidenceof true fat embolism syndrome is unknown. We conducted a prospective,controlled animal study monitoring clinrcal signs of fat embolism syndrome,as well as sensitive markers for subclinical fat embolism {arterial blood gas determinations and staining of peripheralblood for fat macroglobules),in adult animals, following hemorrhage and using pressurizedintraosseousinfusions to maximize the likelihood of fat embolism syndrome.TWelveanesthetizedadult dogs (18.5-24.5 kg) were randomly divided into three groups;four controls receiving intravenousfluids, and two groups of four receivins intraosseousinfusion at either a low rate {LR} of 250 cc at 6 ccTmin,or a high rate (HR) of 1,000cc at 30 cclmin. Intraosseous infusions were performed through a commercially available 16 gaugeintraosseousneedle iCook Critical Care, Bloomington, Indiana)placed in the anterior tibial plateau.The animals were then observedfor 36 hours and blood samplesobtained from an indwellingarterial catheterat l2 hour intervals were analyzedfor hemoglobincontent, staining for fat macroglobulesand arterial bloodeasdeterminatrons.Followins a 20% blood volume hemor-

rhage, the dogs received similar infusions, with the HR and the LR dogs receiving intraosseous infusion into the contralateral tibia. The dogs were again observed for 36 hours prior to pathologic study o{ the lungs. During the observation periods no abnormalities in behavior, respirations or pulse were noted. No petechiae were found in the coniunctivae, mucosae/ or on gross inspection o{ the lungs. Blinded histologic examination of the lungs rcvcaled the presence of fat globules and bone marrow cells in the small vessels of multiple lung sections rn all four of the HR group, in three of the four of the LR group, but in none of the control animals. Despite the presence of intravascular fat globules, the characteristic pathologic changes of interstitial edema, leukocyte aggregation or perivascular hemorrhage seen in true fat embolism syndrome were absent. There were no statistically significant differcnces noted between control and experimental groups in partial pressure of oxygen, alveolar-arterial oxygen gradient, or hemoglobin content. No blood samples from any group demonstrated positive staining for fat macroglobules. This study confirms the presence of fat embolization following prcssurized intraosseous infusion without evidence of clinically significant, or even subclinical fat embolism syndrome, and suggests this procedure may be safely used for bolus administration of medications as well as fluid resuscttatton.

Promising Novel Life-Supporting First Aid Measures for Severe Hemorrhagic Shock, Screened in Awake Rat Model

D Cippen. P Safar.L Porter.C Snyder/ International ResearchCenter,Departmentol Anesthesiology Resuscitation and and CriticalCare Medrcine,Presbyterian-University of Pittsburgh St FrancisHospitals,University Massivehemorrhagein the field is the leadingcauseof death from trauma. Bystanderscan control external hemorrhagc.They could alsoadministernovel first aid measuresthat might support a pulse longer,to increasethe chance of survival until arrival of fluid resuscitation.This study examined 4 potential first aid measuresin our rat model of volume-controiled sevcrc hemorrhagic shock (HS).Male Sprague-Dawleyrats of about 450 g were lightly anesthetizedIor cannulation o{ the femoral artery and suoerior vena cava and insertion of leads for ECC. Catheters and ieadswere tunnelled to the back of the neck to allow unimpaired m o v e m e n t a f t e r a w a k e n i n g .T h e a w a k e r a t s w e r e b l e d 3 . 2 5 mL/100 g over 20 min. Without fluid resuscitation,survival time ionset o{ cardiacarrestl and survival rate over 3 h and 24 h were recorded.Four groups of 20 rats each were studied: 1) Controls, no treatment. 2J 100'/, 02 inhalation. 3) Externalcooling to rectal T of 30"C.3) Enemawith Ringer'ssolution 5 mL/100 g. 5) Acoustic and external arousal stimuli. During hemorrhage,MAP declined to 20-30 mm Hg, then in the maiority of rats rose to 50-75 mm Hg transiently for variable periods (attemptedself-resuscitation), and subsequentlyshowed a variable responseto death or survivall. Survival Rates: G r o u pl , c o n t r o l s G r o u pl l , o x y g e n

5 5 % a l i v ea t 9 0 m i n , 3 5 % a t 3 n , 2 7 % a l 2 4 n B5%- alive at 90 min, 75%' aI 3 h, 73%' aI 24 h

G r o u pl l l , h y p o t h e r m i .a. . 6 i % a l i v ea t 9 0 m i n , 6 5 % - a t 3 h , 6 0 % . . a t 2 4 h G r o u pl V ,s a l i n ee n e m a . 7 0 % . a l i v ea t 9 0 m i n , 5 0 % . a t 3 h , 4 0 % a l 2 4 n G r o u pV , a r o u s asl t i m u l .i 5 0 % a l i v ea t 9 0 m i n , 1 5 % a t 3 h , 1 5 " ka l 2 4 n -P - 051.-P = .06, cornparedwith controlgroup I

Of those that died within 3 h, mean survival time was for control group I, 64 min ln, l3l2o)i 02 group II, 64 min ln, 5/2OJihypothermia group III, 22 min ln, 7/2oli enemagroup I! 89 min (n, 10/20); and stimuli group ! 80 min ln, 17/201.Conclusions: In severe hypovolemic shock, O2 inhalation increasedsurvrval duration and survival rate at 3 and 24 h by self-resuscitation(without IV

found 92 {4.0%)patients to haveunrecognizedHIV infection. The agerangeof these patients was l6-75 years.Black-malesbetween ZS-Sf Ead the highest seroprevalence 19'O%1.OI the 276 patients with identified risk factors, 13.0% were seropositive.Of the 70 patients in whom risk factors were suspectedbut not confirmed, i.gyo wete seropositive.Of the 102 patients in whom all risk factors were denied,none were found to be seropositive.Risk factors were not found in another 281 patients but not all factors were {or could be} ruled out, and 2.lo/o were seroposttive.Among the remaining 1,546 patients in whom risk factors were not suspected or could not be assessed(but the true status of all factors iemained unknown), 3.1% were seropositive.There were 291 patients who presentedwith altered level of consciousnessprecluding assessmentprior to patient intelvention and 5.8% were seiopositive.Seropositrvepatients were found in all categorieso{ presintation. Patients with penetrating trauma had a seroprev' alenceof 13.6%.This was the only clinical presentationfound to denote a higher risk of unrecognized infection independent of other prediclors(P : .02].Unprotectedexposureto patients'body fluidsbccurred in 84% of casesand 4.3% of thesewere not recoSnized to be infectious specimens.We conclude that risk assessment practicesin this emergencysetting is inadequateto reliably identiiy patients with HIV infection. This study supports.the .o.r""pi ihat "universal precautions"be consistently applied by all health care workers whether or not HIV infection is known or suspected,and regardlessof presentation or knowledge of risk {actor status.

fluid therapy).Moderate cooling prolongedsurvival time with a trend towaid'increased24 h survival rate. Rectal fluid increased survival time, but not survival rate. Arousal stimuli had a-positive e{fect on suwival time, but a negativeeffect on 3 h and 24 h survival rate. Three of the four measurestested were effectivein improving the chance of longer survival during severe HS' Large "ni-"I stlndi.s are suggestedbefore clinical trials. (Supportedby the AS Laerdal Foundation.)

The Inability of Prehospital Trauma Predictive Rules to Classify Trauma

Patients AccuratelY

WG Baxt,CC Berry,MD Epperson,V Scalzitti/ UCSD Medical Center,San Diego Clinical decision rules are used extensivelyby most regionalized trauma systemsto identify which patients should be treat-d by tt"rr-, "attt.tt. Becauseoi reportedinaccuraciesof some of the rules and the known global difficulty with the transportability of prediction rules, foui such currently-utilized rules, the Tlalria S"ore, the CRAMS Scale,the RevisedTiauma Score,and the PrehospitalIndex, were tested on a cohort oI 2,434 iniured patients, of which 34 percent had an Iniury Severity Score (ISSJ greaterthan 14.Rules were tested by constructinghistogramsand ieceiver operatorcharacteristic{ROC)curves.All rules accurately predicteddeath with a minimum sensitivity-andsqecificity of 85 oercent. Howeve! none of the rules were able to identify surviving patients accurately who were later de{ined as having-sustaittid maior iniuries. In this instance,no rule was able to achieve a sensitivity of at least 70 percent while achieving-aspecificity of 70 percent. In view of the possibility that the rules were either inaiequately derived or not subiectedto a, sufficiently rigorous validaiion process, two new prediction rules r,rrerealso derived from half oi the patient cohort and tested on the remaining half' The first rule was derived by forward logistic regression analysis while the secondrule was derived by the tree-structuredclassification method of Brieman, et al. (BriemanL, Friedman f, Olshen R, Stone C (eds):Classification and RegressionTlees' Belmont, California: Wadsworth International, 1984.)Both rules were tested in the same manner as the existing rules. Neither lule was able to achieve a sensitivity of greater than 65 percent while simultaneously achieving a specificity of 35 percent' It is concluded that ihe poot pelformance of all rules is due to the inability of the data coltected in the prehospital setting- to be utilized accurately to define severity of iniury. In view of these results, the utility of existing prehospitaltrauma predictive rules must be questioned.

1!! { A f l| I

'li,u"o"""o Jl,,f 6 1 B iTilli::'i,Lili.l"ff# EmergencY Patients

Unrecognized HIV Infection in General Emergency Patients: Failure of Risk Factor Assessment Practices to lndicate Need lor Barriel Precautions

JL Baker' GD Keten,S Fritz,B Qaqish, R Brookmeyer, RM Cuddy, TK Goessel,DJ Floccare'KT Sivertson,S Altman' TC Quinn'/Divisionoi EmergencyMedicine,The Johns Hopkins University;Departmentof Biostatistics,The Johns Hopkins Schooloi Hygieneand PublicHealth,Baltimore, University NationalInstitute Maryland;Laboratoryof lmmunoregulation, of Ailergy and InfectiousDiseases,Bethesda,Maryland ln order to determine whether current risk assessmentpractices in an emergency setting identifies which patients have clinically inapparent human immunodeficiency virus (HIV) infection, the seri-of 2,275 consecutive unselected adult emergency Datients without known AIDS or ARC were anonymously anaiyzed for the presence of HIV antibodies by ELISA and Western Iilot. Data were related to demographics,risk {actors, clinical presentation and health provider exposure.Risk factor assessment practices of the treating team were noted in a blinded fashion' We

S Fritz,GD Kelen,JL Baker,RM Cuddy' DJ Floccare, TC Quinn/ Divisionof TK Goessel,S Altman,KT Sivertson, Baltimore, EmergencyMedicine,The Johns HopkinsUniversity, NationalInstituteof Maryland;Laboratoryol lmmunoregulation, Allergyand InfectiousDiseases,Bethesda,Maryland rate for the One year ago we reported a 37o seroprevale-nce human'immunodeficiency virus (HIV) in critically ill emergency patients. All the seropositivepatients were then confined to a tr"tro* age range and to a trauma presentation,particularly penetrating trauma. It was our concern that following that report, e-.rg."tr.y health care providers restricted their use o{ barrier precairtionsto patients with similar presentations.In order to deiermine if such practice was appropriate in an era of rapidly spreadinginfection, the seraof 145 consecutiveadult critically ill oi inl,rt.i patients was anonymously analyzed for the presenceof HIV antibodiesby ELISA and WesternBIot during a six-weekperiod exactly one year after the previous study.We found 8'3% {12 o{ 145} of iuch patients to be seropositive.This is a significant increasefrom one year previous (P < .05).In the earlier study all seropositivepatienis wer. co.tcenttatedin a narrow age rangeof 25 t;34 yeais. In the current seriesthe patient ages,ranged.from ig to sg years.Critical patients between the agesof 25-44hada oI 145%. Most oi the seropositivepatients-pre' seropreuaience sentld with trauma. However, unlike the previous year, 3 of the 12 125%ldid not. Patients presenting with penetrating--trauma had'a seroprevalenceof 13.6%, similar to a year ago' All.ol,the seropositivepatients had inapparentdiseaseand none had a his' iory of HIv in{ection. Risk factor status was unknown at time of presentationsand in 5 of the I2 seropositivepatients/no risk fac' iot *"t ever identified during the emergencyvisit Exposurcto patients' blood and body fluids was considerable.We conclude ih"t th"re has been a substantial increasein the risk of HIV exposure from critical emergencypatients at least.in this area'Po' iential exposurefrom patients with inapparentdiseaseis no long' er confined to a narrow age range or trauma presentatlonAppropriate barrier precautions should be taken with all critical patients regardlessof age or presentation.

*62

Human lmmunodeficiency Virus (HlVl Seropositivity in a Midwestern Gommunity Trauma PoPulation

MG Zeman,FE Mayhue/ SaintFrancisMedicalCenterResidency of lllinoisCollegeof Medicine, in EmergencyMedicine,University Peoria Healthcareworkers have grave concernsabout the risk o{ caring for acutely injured patients infected with human immunode{iciencyvirus (HIV}.To assessHIV prevalencein our trauma patient population, we prospectivelytested serum samplesfrom 262 consecutivetrauma patients {or HIV antibody.Our institution servesas the RegionalTiauma Center for a l7 county rural area of north-central Illinois. Sera{rom all patients admitted to the trauma service between Iuly I and December 31, 1987 was collected in identically marked vacutainersalong with the routine "trauma lab profile". These tubes were then stored and anaIyzed in batch fashion to ensurepatient anonymity. The patients rangedin age from 5 years to 91 years, with a mean age of.32 yearsiSD : 16 years)and a median ageof 28 years.Seventypercent of the patients were male, 9oo/owerc whrte, 44o/" were privately insured, and 95% resided within 50 miles of Peoria.The mechanismof trauma was blunt in 83% and penetratingin 17%. The mean trauma score(scaleof 1-l6Jwas 15 {SD : 2.6}.Seventy percent of the patients had active external bleeding,and all underwent invasive procedures.Each patrent was in close contact with l0 to 20 prehospitaland hospital-basedpersonnelduring the acuteohaseof resuscitation.There were two positive resultswith initial enzyme-linkedimmunoassay(ELISA)iesting, but only one subsequentpositive result on repeatHIV-ELISAand confirmatory WesternBIot analysis.This representsan initial seropositiverate olO.76'k and a true incidenceof 0.38% in our patient population. We conclude there is a low incidence of unsuspectedHIV infection in iniured patients presentingto our Tiauma Center.Precautions are warrantedin the care of trauma patients due to the high likelihood of contamination by blood or body fluids. Further studies are necessaryto define the prevalenceof HIV in other populations.

*63

Effect of Hyperbalic Oxygen Therapy on Western Diamondback Rattlesnake (Crotafus ahox) Envenomation in the

Rabbit Model MR Stolpe,RL Norris,CD Chisholm,MF Hartshorne, of Emergency C Okerberg,J Posh,WJ Ehleri Departments Medicineand NuclearMedicine,BrookeArmy MedicalCenter; lnstitute of SurgicalResearch,FortSam Houston;Clinical LacklandAir ForceBase,Texas Facility, lnvestigation Controversyexists whether polyvalent antivenin therapy alone decreases myonecrosisin severerattlesnake (Crotalidae)envenomation.Intermittent hyperbaricoxygen (HBO) therapy has been shown to reduce the amount of skeletal muscle necrosisin a compartment syndrome animal model. To study whether intermittent exposure to HBO augmented antivenin therapy by decreasingmuscle necrosis,twenty-nine medium sized {1.8 to 2.7 kg) female New Zealand white rabbits were envenomatedwith a sublethal dose (2mglkgl of Crotalus dtrox venom by an intramuscular iniection into the anterior thigh compartment of the right hind leg. An equal volume o{ normal saline was iniected into the anterior thigh compartment of the left hind leg. The animals were divided into three treatment groups. The first group {10rabbits}receivedone vial o{ antivenin intravenously.The second group (10 rabbits) received one vial of antivenin intravenouslyplus three HBO treatments.The three HBO treatments consistedof 90 minute dives in 98%"oxygenat 2.4 atmospheres - at two hours, eight hours, and twenty-four hours post envenomation.The third group (9 rabbits)receivedno treatment' Forty-eighthours after envenomation, all rabbits were injected intravenouslywith 500 microcuries of Tc99 stannous pyrophos-

o hate. Three hours later the rabbits were euthanized with an -overdose of sodium pentobarbital and were scanned with a standard samma counter. The vastus lateralis and rectus femoris of both hind legs were harvested, weighed, and stored separately for histologic examination. The lungs were also harvcsted for histologic examination for possible oxygen toxicity. Thc ratios of Tcee pyrophosphate uptake and muscle weight were derived bctween thc control lcft and envenomated right muscles for all three treatment groups. There was no statistically significant difference {ANOVA, P .05) between any of the groups in terms of the parameters measured imuscle weight and Tcee pyrophosphate uptakeJ. Histologic examination confirmed this lack of difference betwccn the groups, with all three demonstrating severe muscle necrosis. Therc was no evidence of oxygen toxicity by histologic examination of the lungs. We conclude that muscle necrosis secondary to Crotalus dflox envenomation is not significantly altered either by polyvalent (Crotalidae)antivcnin alone or in combination with intermittent HBO treatmcnts in thc rabbit modcl.

EMS Gall History Within a Large Urban System: Geographical Patterns of Basic and Advanced Life SuPPort Demands and the lmplications lor

Program Planning PE Pepe,CM Matsumoto,RR Bass/ Departmentof Medicine, BaylorCollegeo1Medicine;The City of HoustonFireDepartment EmergencyMedicalServicesDivision,Houston,Texas Many emergencymedical service(EMS)systemsmaintain internal statistics for both the total number of annual EMS resDonsesas well as the number of calls that require basic (BLS) vcrsusadvancedlife support(ALS)services.However,there exist very few publisheddata that detail such EMS systemcall histotherc arc virtually no publishedstudiesin the ries. Specifically, medicalliteraturethat identify and detail the relativedemandfor BLS and ALS throughout the various geographicalregions of a largeurban center.The purposcof this study was to demonstrate the use of a computerizeddatabasewhich integratesboth a computer aideddispatch(CAD) systemand a patient evaluationrecbrd as a data collection tool in evaluating the need for BLS and ALS servicesin the various geographicalareasof a large urban municipality. The study was conducted in a city with a nighttime population of approximatelytwo million which is servedby a singli emergencymedical service.The city was arbitrarily digridseachmeasuring4.5 by 3 miles. vided into 156 geographical In addition to identifyingcall volumes,the demandfor BLS and ALS scrvices were determined for each of those 156 individual patient reports.The geographicalzoncsusing computer-tabulatedi"rrrlts de-onstrated that, Ior a twelve month study period,there were a total of 100,841separateEMS unit responseswhich resultedin 46,400patienttransports.Of these,31,36(rreceivedBLS transport while another I5,034 also requrredALS procedures(ie, IV access,intubation, countershock,drug adrninistration,etc). Analysis of the I56 individual zones demonstratedthat a disproportionatelylargenumber o{ responsesoccurredrn the central potiio.r of the city wlth the two central-mostgrids accountingfor approximately twenty percent of the total responseswhile the suirounding twelve grids accountedfor anotherfifty percent.Call voiume conlinued to diminish more and more toward the periphery of the city. However,in striking contrast,the relative demand foi erS versus BLS transport servicesremained at a remarkably uniform ratio of I:2, regardlessof geographicallocation. In addition, the need for ALS serviceswas always shown to be a relativeiy fixed percentageof the total number of responsesfor each o{ the 156 individual zones.Therefore,the absolute demand for ALS serviceswas directly proportional to the overall cali volume for that zone of the city. Thus, the implications for EMS program planning are that provision of timely ALS and BLS servicescan be predicted not only by logistical obstaclessuch as distance,but also by the absolute call volume for individual zones within an

and servicecledetailed EMS call histori-es EMS system. Suc.h. which computerized,database " u"t'a"LJiy mands can be readlly tool' collection a"tt utilizes a cAD system ";d;ti,e;dttti

*65

The incidence of recovery of utes after arrival oi paramedics' t""tt 50% in clglg-y:t' VFT oulses following ,t'u""'iio" flvniryo r4'/"tztr4l'

EMT-D:The Wisconsin ExPerience

DFark' M Milbrath'G Hendley' J Larochelle, ilt-*. KM Hargarten/ Medical T Aufderheide'J Mateer,C ipt"f'"ti""' Collegeof Wisconsin,Milwaukee arrest.hasbeen improved Survival from prehospii"t ""tAi"" medrc11^Schnicians-dewith earlv defibdllation ;;;;;;"t pievious reports on survival iibrillators (EMT-Ds).tn '"'i'"1 "tXt' e" rUr-!-y,i]ot proiect was o"t'iu^'itttt' n"u" rate by EMT:D '"liluri.n1i tff ""tiuttt"t't in vario.s prehospital i""a"it""i".'itt par"'vices through-outthe state settings.Sixty-tour "-o"l""tt smll] cit111 tilv rro* -TIt-9t' ticipated in communrtr"t't'"ii"g

rii;i;iiLl l'; ,\ 36% t4tu),BHB isrrs),

ili;!;;* ,.:oye,:d *,f##,i :"'r;illJ:tll!1iryt:

:''T,:iJ"ii"t'iil,'.11:liiig',:i*';;1.';:;p onrvpattents vival to discharge trom tI

""i rwi'pyn r0%lr/r^01 iiiiii"tttilt'r:islr+i, tor"rutttt"to. l]-t'tt" iitta' t"*ived

f rom ul ly rdischarge successf cardiopulmop"t"^tait-*]::^t-t:f9 the hospital. I., "o""r""o"' ottt" soon after the initial evaluanary arrestsare common a"d group "" -o" ","TT-"^:, in this tnarJViT tion. Rhythms otner

H1*h}."Y;i'1""tr*,Il;:i*Tl':,il1:'r'tsurvive ^-.

Nasotracheallntub-ation-Using

F,!0,",,,".[lff :""-#$:'1?l $'8.:l:l'f?:-"#"'!,'rfao'an' xt.;r:hl#L':fi$ru":lt',1,"a'.1'i!1f :r'^';nali;rui{t:,,ffi odic refresher training *;";il;;

:'.ii*i:iy,n# HtlPfr

o."t'1 *"1 collected locally

t*tl"r;ui tr*';ilr'i4 iTi e*:il*ir**ru il';l'iF] inclu!1!,1'1 Y:* thoughtto have. pr,*"ri'.tiai"t-ttt"tt',{q vedlt";: survi 6'4olo ) p"ii6"tt { the study.Thirtv-six ::tf i;t:

i' Pittsburgh +i:ffJ':iJ"t5'l%3Effi

Thetechniqueofnasotrachealintubation(NTI)currentlyem.

lq''JH.'fi "'*n :l"rii.H##llilTT["]','ff '?;n;'n* i:T:+""*i{il; l*':"sm6tili?H-'iffi :#,'HiTlff nx!t,l=l*,;i:Fi'":"' !

*ilrft['il'##,l+rlpf ;*i'il'::"tx ;ll1'l fiil%q ::',*,:d::rk; iii"ill'.,ii";'rv._f:*',i);"1;['ru*::*ru,.';ffi nid :ll;*llj u.broade

tricular {ibrillation tvr'i *ttft

art l-lok survival.raie' Although

fot d.rign of a flexible lighted stylet orotrachealintubatron....t'li. technique pot"o'r"y''t"t"^ittt-itttsillumination NTI offers th.

t*'.i';

Tffifiif i :::*'i;lt*:l *i.lgl '"'i';f, :11.":,if r"ffi H'i:i'.T,,",:,llru,t+{if jt'-3tri'HJi::tJl;ulln:."""tlli'ts':'i$:i:i':: ,,::j:+fjxr, [it* "a;;; e'z'^z6''i'i""i.'. "1 "l?J;'ll;:l: Ht:lii':'.!',*::'i:lii?jttl;',:t'Jr,:li"d;:",,w

of -,v rhvthm initiar an iziiiv"Ir"a *::|rmr'-r"'rgdT'J#:,

il ;

1 -1o1';1'""il18

prlor to r'rvrr' r.ipectiuely (P = 002)' For arrests time was_greater than eight ,arpo.,ra itr. were no survivors *nan

Iiff{iq',ihr*,'n*+il*

";11*: t'rJfiiiil I mlf ll*" :'JTii*"'* rH,' * ;t,l!I;i:P'xi :{i":rft rui#" *# iil.":#:i fi,itJ,"t'"H[ii'tr1.'Hn1:1:it!:,!!tiiil""o?lo:#i .'i"*::';l'T114"pp;ii'r'"'indu s:f*;{lt;"11ff i..d

arrest To ti;;J ""d-EMi?'wi1ressin'cof with shorterresponse be directedto decreasrng should H;i*,i";;,-.iiu.J;f't;;;;;f;;t' time' resPonse ALS Witnessed PrehosPital

{<^arr

fot all intubation

technique.The intulation''*t"

performedby.a PGY III emer'

*l'}t'T;*dt::'"':Ci:;: 1 [+tH::[Ti:{.:,; g.:+[iHtr#i""'"'.*:!t"il':fJ':{Til. #f

Emersenry ;*[t''JJLlJli'i#::' nesiJency,n Center{or EmergencY n*ru

were permitted' with a 60 sec' tion. Three attempts ^'-i*"UJtioit an{^tle,n.,11entwas reoxyge' was ond time limit for t"tt''t*pt' ittd.oir^the"l'tut^e-placement nated betweett "tt"-ittFailureto tntu' auscultatto^n chtst b-y '""itpi after each assessed

Pittsburgn ir, *""tior,

ment with direct visui

caroioPulmonary !ry9st / Affiliated

tt|o

nrrltr<apraf,''-nij-5f"*"1 1v 911is RWWotford,

;;;;;i;.,,t,""'"'p"'i":*n;af trtrtl",'l'::1;l.Z*fi *i ;;;;,;;J"l{r:iil:i#i::',::.;lll'.?f il]';,*"l,beingattendei:fu"ruk1*:d:trJ31..j:1i',.t ;.-il'i1li,[]1 cardiopulmonaryarrest to evaluatethe outcome of

r::'';it"ll:ytl3iii\t".'T,*ilii;ij;i:l ;i,tii:'.1T,iryj'!!",:1'*[i'iili-tn{:l*:,".'*':;*; i".,";::-o-",', ii'iira.,,a *pti:**.; ]['.''*'ff Jlil,hil Jili:;:i41; ffi:,T3":1i.?'1"'#1y,Jttif, "',T I lLtii, and eLSgroup * o ; t ; o i'!;;19-'1e"1:*ifi::* ;; o ix;i""i* li:iil' lf,,lt"ll t L :l::-': -th :'"'l'" l,','.',','iL'i;3it11il'1,g Jlll: block{lIB]-",111 iiii'tJs.z.1-11,$l,rJTr_l{;lfu.;',',f rcrr.ii inf,biadvcardia/heart Each

prtGtttt under 18 Yearso

Ug;i',:.',i:-"!.:ri:

mechanicaldissociation-{PIVR/EMD)' ventricular/electrical 1999 A-!^1 guidelines' patient was treated """tt";;;;;tht

medr ii"vL' indicated,in,emergencY lil;1.i':,lti'J""l.J;tt traumawno it""i t"ti neck ot maxillofacial

"ill;.; J tili1r h+ llifi ?:'J'$'[1-fiiil#$:::i, :":i;h:;;Tlr'tg*Xi;,ii",1'HB.i""^:,iffi in'xi ::f#"5?i'*^iil;Tfi:"'*ltf :iifl Tii:ni:l :::x'.txff"ff ff cine for patients *itn

Nrltl;r^e1ded' our data sug' orotracheal t"be pr""t'it-"-i'tft""fa with the transilluminatton gest a trend clf i*p'o"tJ-'tuccess method.

:lm; ffnq;:it :,"iiiJ;{;'! Ti';ltii+i [.,.f1;'* 7l !

+ l0'5 minan averageof 16 74mm Hg' Arest-occured

*68

B'"HTi:ffx'Ji1"iir,', E:?[?ltil

or chest. The difference between the accelerationsdetected by these sensorsis proportional to the rate of change of displacement acrossthe subiect'sneck. A 50 lb-rangecable tension sensor indicatestraction force. Measurementsare plotted using a fixed PC-AT computer with internal analog-to-digitalconversion boards connected to sensorsby cables. Supine volunteers were placed in the TACIT device, then log-rolled 90" to the left and right, then rarsedto a sitting position during a 120 secondrun. Raw data were stored on disk, then scaledand integratedto yield velocity and relative displacement,which were plotted with compensation for gravity. Results- Preliminary tests using a single head-mounted3-axis accelerometershowed that installation of the TACIT generated< 0.05 g peaks on any axis. Log-rollingtypically produced peak compressiveaccelerationsof 0.07 g, representing 3.4 cm movement {an indeterminate proportion occurring in the neck). Log-rolling caused permanent change in traction force from 8.3 lb to 5.9 Ib. Two srtting/reclinrngcycles resulted in decreaseof traction from 6.5 lb distraction to 0.3 lb compression(ascribedto resting of the lower edgeof the boardon the floor), which reboundedto Il.0 lbs upon reclining after the first cycle and 9.0 lbs after the second.In all subjects traction force was accelerationsensitiveand subiect to some variation with intentional head motion. Conclusions- We conclude that the TACIT device is a non-invasivealbeit displacementsensitive method for effective cervical immobilization applicableto interhospital, prehospitaland transport needs.The developeris attempting to reduce internal friction in the traction mechanism, which is responsiblefor variation in reclining traction force after log-rolling or bearrngthe addedweight of the head in the sitting position. Accelerationof the head,body and patient support, and variations in traction force can be digitally recordedand integratedto yield the relative velocity and displacementof the neck.

Resuscitation M Frass.R Frenzer, O Traindl.F Rauscha,C Leithner/ 2nd Departmentof InternalMedicine,University of Vienna Prompt intubation and effectiveventilation are the maior goals in acutely traumatized patients during successfulcardiopulmonary resuscitation {CPR).While endotracheal intubation is the preferredmethod, its global and universal use is limited, since it needsa skilled endoscopist,adequateaccessto the patient'shead, and appropriate instruments. The esophagealobturator airway was constructedas an alternative to endotrachealairway in prehospital CPR. The disadvantagesof the esophagealobturator airway are complete airway obstruction after inadvertent tracheal insertion and significant dif{iculties obtaining adequatemask fit. Furthermore, one hand is needed to hold the mask. In consequence,we devised the esophagealtracheal combitube {ETC} to The ETC (SheridanCatheter Corp., obviate these disadvantages. Argyle, NY) is a twin-lumen tube, one lumen is designedas a conventionaltracheal lumen with a distal open end; the other is designedas an esophagealobturator lumen with a distal closed end and perforationsat the site of the pharynx. The two lumens are separatedby a partition wall. A special pharyngeal balloon servesto seal mouth and nose. The ETC is inserted blindly, ventilation is possible independentof esophagealor tracheal placement. Previous studies during routine surgery showed a higher mean arterial oxygen tension during ETC-ventilation when comparedto endotrachealairway.In this study patients with cardiac arrestwere intubated with either endotrachealairway {n : 201or with the ETC (n : 23) in randomized order during CPR at the generalward or intensive care unit. Ventilation with the respirator started5 + 3 min after intubation. Blood gaslevels evaluated 20 min after start of mechanical ventilation showed adequate ventilation with the ETC when comparedto endotrachealairway * Gomparison of Five-View and Three. (PaO2136 + 19 mm Hg with the ETC, and 125 + 10 mm Hg View Gervical Spine Series in the with endotrachealairway).Long term survival was comparablein Evaluation of Patients With Gervical both groups 126%in the ETC-group, and25o/" in the endotracheal Trauma airway-group). Resultssuggestthat the ETC might serveas a valB Freemeyer, J Piche,R Knopp,J Williams/ ValleyMedical uablealternativeto the endotrachealairway,especiallyin the preCenter,Fresno,California hospital setting whenever endotrachealintubation is not immeRadrographicevaluation of patients with cervical spine trauma diately possible. usually consists of three views: cross-tablelateral, anterior-posterior, and open-mouth. Recently,a five-view trauma series has Measurement ol Gervical Spine been advocated.The addition of supine-obliqueviews (SOV)is Traction, Alignment, Mobility in a purported to detect specific iniuries that might otherwise go unGervical lmmobilization & Transpoil detected:unilateral locked facets,posterior lamina fractures,and (T.A.C.l.T.lDevice real subluxations.No data has been published demonstrating AP Sumchai,EE Sabelman,M Eliastam,C Hargis/ Departmentof that the routine use of the five-view seriesis superior to the Surgery/Emergency Medicine,Divisionof EmergencyServices, three-view series (TVS).The purpose of this study was to deterStanfordUniversity Schoolof Medicine,Stanford,California; mine if SOV detected any radiographicabnormalities that were Rehabilitation Researchand Development CenterVeterans not demonstratedon the TVS using thin-section tomography as Administration MedicalCenter.PaloAlto, California the "gold standard."All patients who presentedto the emergency department over a two-year period with suspectedcervical spine Purpose- The TACIT device under development by Minto trauma were included in this prospectivestudy if they met the Laboratories,Redding,California, consistsof a short spine board {ollowing criteria: fracture or subluxation demonstratedon plain (extensiblein length) with width-adjustablefoam-paddedshells film radiographs,suspicious radiographic findings or inadefor applyingtraction via conformanceto the occiput, zygomaand quately visuahzed anatom), neurologic deficit, and severeneck Irontotemporalregions.Tiaction is generatedby a stack of acetal pain. All patients enteredin the study had thin-section tomograBellevillespringswithin the upper backboardwith output via a phy of the cervical spine. The TVS and SOV were read by two cableand pulleys to a sliding head restraint carriage.Forceis adjustableto 30 lbs. Tiaction force is dependenton patient position; radiologistsand one emergencyphysician separately,and in the caseswhere there was disagreementthe majority (2/3Jconsensus hence,patients are restrainedto the backboardby a iacket with was taken as the final impression.The tomographicresults were shoulderand leg straps.Previousstatic goniometric studies deminterpreted by a single radiologist. Of 58 patients between the onstraterestriction of range of motion comparabie to that agesof 14 and 73 who had tomography there were 34 patients achievedin the halo/vest (l-5" flexion-extension,l-2'lateral flexwith fractures, including two who had unilateral locked facets ion and l-5'rotation). The obfectivesof this investigationwere to and one who had an atlanto-occipitaldislocation. The TVS was test cervical immobilization in the TACIT unit under dynamic abnormal or suspiciousfor fractures in 3l of 34 and the SOV in conditionsand to explore the utility of accelerometryas a reonly 15 of 34. In the three fracturesthat were missed on TVS, an searchtool. Methods - Measurement of accelerations of the odontoid, C-7 Iateral mass and C-5 body compressionfracture, head,body and backboard are made using miniature (0.5 inch the SOV were also negative.There were no injuries detectedon cube)3-axis 5 g accelerometers.A single sensoron the forehead the SOV that were missed on the TVS readings.Of 34 fractures, can be used or two strapped on the head and a third on the back

there were 13 that fit into the categoiy of iniuries best detected on SO! 12 with posterior lamina or facet fractures,including one with a unilateral locked {acet and another with a locked facet associatedwith a C-6 lateral mass fracture. All 13 were read as positive or su:ricious on TVS, whereas,four of these had negative SOV readings.Our data doesnot support the routine ordering of SOV in the setting of acute cervical spine trauma. As with other special views, such as pillar and modified odontoid, SOV may be a useful adiunct to the emergencyphysician but do not appearto be indicated in the routine initial trauma serres.

lrlissed Gervical Spine Fracture

SA Santanello,A Gabriel,RE Falcone/ Sectionof Trauma, Departmentof Surgery,Grant MedicalCenter,Columbus,Ohio The indications for and the accuracy of cervical spine roentgenogramsin blunt trauma remains controversial.We undertook this study to identily patients at risk for diagnosticpitfalls. TWo thousandfour hundred thirty-three patients were admitted to the trauma service from fanuary l, 1983, to August l, 1987. Sixtythree patients (3%) sustainedcervical spine fracture comprising our study population. Patientsunderwent standardtrauma room radiographsper protocol (crossfire lateral, anterior-posterior,and open mouth odontoid viewsf. Their charts and x-lays were reviewed in retrospect.There were 45 males and I8 femalesaveraging 32 years of age. Mechanisms of iniury included: 49 motor vehicle accidents,I motorcycle accident, 5 motor vehicle-pedestrian accidents,4 falls, 2 diving accidents and 2 miscellaneous injuries; Tiauma Score (TSf on arrival averaged12 (range l-16). Fifty-six of 63 patients (88%f were diagnosedwith cervical fracture by protocol. Thirty-one patients with a normal level of consciousness(LOCf had symptoms and findings consistentwith injury. TWenty-fivepatients with an altered LOC had x-ray findings which were diagnostic of fracture. Sevenpatients (12%) were diagnosedafter admission in the face of normal trauma room cervical spine films. There were 5 males and I female averaging38 years of age, with an averageTS of 14 (range9-16). Missed Fractures Delayof Dx LOC Diagnostic Tesl 12 days altered f lexion/extension

Fracture Odontoid Odontoid C2 pedicle

23 days 5 days

altered flexion/extension altered

C - s p i n et o m o g r a m

CO posteriorelements 3 days C5 posteriorelements 24 hours

altered

C-spine CAT-scan

normal

C-spine CAT-scan

C6-7 subiuxation

24 hours

normal

C-spine CAT-scan

C6-7 subluxation

24 hours

normal

C-spine CAT-scan

Presentation ol Patients With Acute Stroke

WG Barsan, TG Brott, C Olinger, EC Haley, D Levy, JR Marler / Departments of Emergency Medicine and Neurology, U n i v e r s i t yo f C i n c i n n a t i C o l l e g e o f M e d i c i n e ; D e p a r t m e n t o f N e u r o l o g y , U n i v e r s i t yo f V i r g i n i a S c h o o l o f M e d i c i n e , C h a r l o t t e s v i l l e ;D e p a r t m e n t o f N e u r o l o g y , C o r n e l l U n i v e r s i t yS c h o o l of Medicine, lthaca, New York' NINCDS, Bethesda, Maryland Time has been an underemphasized factor in previous trials of therapy for acute stroke. Although experimental data would sug' gest that brain tissue cannot survive after sustaining several hours of ischemic insult, most stroke studies have evaiuated treatment starting at least 6-12 hours after the onset of symp' toms. There has been little data on the initial presentation of stroke patients concerning pertinent time factors which would be essential to consider in trials of early treatment modalities. We have collected and analyzed data prospectively on 360 patients who presented within 24 hours of the onset of signs and symptoms of stroke to three geographically separate medical centers as part of a trial on the effects of rt-PA treatment of acute stroke. The mean age of patients presenting with stroke was 59 {32-93} and the sex was evenly split between males {51%} and females 149"/").ln only 64"/" of cases was the patient himself first awareof the signs of stroke. The stroke was recognized by another layman i n 2 6 % , a n d b y m e d i c a l p e r s o n n e l i n l 0 % . S e v e n t y - e i g h tp e r c e n t of strokes occurred in the home. Only 37% of patients were transported by the prehospital care system and 39"/" had their first medical contact after arrival at the hospital. Of the 360 patients presenting with signs and symptoms of acute stroke, 59% ultimately were proven to have an ischemic stroke. Although

Three patients with a normal LOC had persistent neck symptoms and were diagnosedwithin 24 hours of admission.Four patients with decreasedLOC developedsymptoms as LOC improved and were diagnosedwith neck fracture an averageof 10.5 daysfollowing admission.No patient sufferedneurologicdamage as a result of diagnostic delay.In this series all patients with a normal LOC had symptoms referableto cervical spine fracture. Those patients with an alteredLOC developedsymptoms as their LOC improved. Patients with normal standardcervical spine roentgenogramsand symptoms, have bony iniury until proven otherwise by more sophisticatedtesting. Patientswith an altered LOC should be consideredfor additional radiographicevaluation regardlessof symptoms.

and Neuropsychology of the RhodelslandHospital;Brown University, Providence, Rhodelsland Mild head injuries (MHI) with or without brief loss of consciousness{<l minute) account ior 72-9O%of all head inluries. Patientswith MHI are generally dischargedfrom the ED with a "Head Sheet" and minimal instructions for follow-up. Research suggests,however,that up to one-half ol these patients never return to their pre-morbid level of function. The etiology of this persistent morbidity has not yet been elucidated due in part to methodologicproblems in existing researchincluding lack of: standardizedmethods sensitiveenough to assessMHI efficiently in the clinical setting, attention to pre-morbid medical history among participants,prospectivedata to investigateoutcome,and appropriatecontrols. We attempted to addresstheseissuesby performing a double-blinded,prospectivestudy in which we administered the High Sensitivity Screen(HSCl, a neuropsychological screeninginstrument, to a group of 40 patients presentingto the ED with minor trauma as identified by the ED physician who relied on standardcriteria. The sample included 20 experimental subjects with MHI and 20 age and sex matched controls with trauma but without MHI. Patientswith prior head infuries, CNS damage,substanceabuse,psychiatric histories or "whiplash" injuries without head trauma were excluded.Informed consentwas obtained.but subiectswere not told the basis for their selection or the researchhypothesis.Chi-squareanalysisdemonstratedsignificant separationof experimentaland control subjectsdetermined by the presenceor absenceof abnormal cognitive findings on the HSC iP < .01).ExperimentalsubjectsIrequently displayed deficits in memory, language,attention, concentrationTplanning, and self-regulation.One month telephonefollow-up of the MHI patients revealedno persistent symptoms, a result perhapsexplained by our conservativecriteria for MHI. We conclude that: previously undetectablecortical dysfunction following MHI can be demonstratedin the acute care setting with the HCS, the neurobehavroralfindings associatedwith MHI are compatible with diifuse brain injury, and these MHI patients denied morbidity or inhibition of daily function at one month telephone interview. The long-term significanceof these findings remains to be exolored.

Neuropsychological Evaluation ol Cortical Function in the llildly llead lnjured Patient in the Emergency Department

B Becker,L Tobin,D Faust/ Departmentsof EmergencyMedicine

only lI% of patients had clinically suspectedhemorrhageon evaiuation, 19% had blood present on the initial head CT Only 24% of patients presentedto the hospital within 90 minutes of the onsei of symptoms and over 2O% of patients presentedlonger than eight hours after the onset of symptoms. Only 17 patients were able to meet the entry criteria and receivedrt-PA within 90 minutes of the onset of acute stroke. These data would suggest that laymen need better education concerning the signs-and symptorns of acute stroke and that the need to seek immediate medical care needs to be emphasized. for Jet Ventilation High.Frequency 2 A GardiopulmonaryResuscitation la] RL Levine,M KIain,W Stezoski,A Sladen,P Safari Department of Medicine,BaylorCollegeof Medicine,Houston,Texas; Hospital,Departmentof Anesthesiology/CCM' Montefiore of Pittsburgh ResearchCenter,University Resuscitation High frequency iet ventilation (HFfV) can be used for ventilation during cardiopulmonary resuscitation iCPR).t The- optimal frequencylf), and inspiratory to expiratory (I:E) ratio have not been determined. Using dogs (n:5), as their own control, ventricular fibrillation {VFl was electricallv induced. Five minute control periods (C) of standardCPR (SCPR)performedwith a thumper, and positive pressureventilation (PPV),were alternated with 5 minutes of HFJV'CPR(|J.The thumper was adiusted to deliver 60 chest compressionsper minute with a 5:l comprâ&#x201A;Źssion:ventilationratio. Systolic blood pressurewas maintained between 50-75 mm Hg throughout the study. During HFIV periods, the HFIV was substituted for PP! while compressionscontinued without change.HFIV periods were randomly assignedto frequencies(f) ofZ0, 100, 150, 200. The I:E ratio was maintained at 30:70for all jet f. Both groupswere ventilated with 100% oxygen. Arterial and venous blood gaseswere obtained I and 5 minutes after each change.Results: SCPR was comparedwith HFIV-CPR over time for thi entire group and for each f (|I-4). Using analysis of variance,a significant decreaseof PaO2was noted from the C1|1period to othet C and I periods. The decreasein PO2 from C1f1io C2f2was significantat the P <.04 level; the C1|vto C3f3 or Cafachangewas significant at P < .004. The only significant dilferencebetween C and I was noted between C2 and 12P < .04 {seegraph).pH and PaCOzdid not changesignificantly throughout the-study.Conclusions:HFIV did as well as conventional ventilation during CPR, reflectedby measurementof pH, PaCO2, and PaO2.PaO2falls rapidly during thd initial phaseof CPR and this may be confusedwith a pulmonary embolus insteadof being appreciatedfor the effect of time on oxygenation.Despite the small number of observationsin this study, it was apparentthat varyingf did not effect the PaO2.Further HF)V studiesneed to be done to examine the effects of varied I:E ratio on the ability to oxygenateduring CPR. If found to be e{fective,HF|V may become

a useful adiunct for CPR.

/ R Kirkpatrick S Davidheiser, WH Spivey,JM Schoffstall, Depaitmentof EmergencyMedicine,The MedicalCollegeof PhiladelPhia Pennsylvania, While it is universally recommendedthat catecholaminesbe given during CPR, dosageand rate of administration remain coniroversial.We undertook to measurethe levels of endogenous norepinephrine(NE) and epinephrine(E)and exogenously.admrnistered E during cardiacarrest and correlatethem with biood pressure.Six young swine, mean weight I3.3 kg, were anestheiized with ketamine and alpha-chloraloseand ventiiated with room air. The right fcmoral artery, right carotid artery a-ndright internal jugular vein were cannulatedfor blood sampling and blood pressirremcasurement.Ventricularfibrillation was induced with 5b volts of 60 hz current deliveredto the riSht ventricle by venous pacemaker.Blood pressureand lead-II ECG were continuously monitored. Blood samples{or E and NE were drawn prearrest,and everv two minutes thereafter.At five minutes externai c a r d i a c c o m p r e s s i o n sw e r e i n i t i a t e d w i t h a m e c h a n i c a lr e suscitator and the animal was ventilated with 100% oxygen ln half the swine, .01 mg/kg E was given at l0 and 20 minutes-postarrest.Blood samplesweie assayedfor E and NE using a Seckman high pressureliquid chromatograph.Mean .+ SD catecholamine levels(nglml) and MAP (mm Hg) are as follows: Controls Time (minutes) Baseline

1 I V I NV S 5 N / I N lllvNCONTROL E 5 M I NC O N T F O L N 1 [/lN JET ! 5 lvlN JET *:P<0.04 **=p<0004

C2 J2

C3 J3

E MAP

108+23 56+2

NE E N/AP

EPinePhrineat 10 and 20 min 0 . 3 : t 0 . 3 5 4 . 3 * 1 0 1 8 . 8* 2 4 1 5 7 1 t 7 4 . 2 3 9 2 ! 5 7 9 3 5 7) . 2 7 4 3 7 2 ! 3 0 1 . 5+ 2 0 5 9 5 r : 2 4 2 8 0* 6 1 16*8 56:!12 107+13 34+10 65*24

39+20

23*13

13*4

Myocardial HemodYnamics Using Direct Mechanical Ventricular Assistance for GPR

CG Brown,MP Anstadt,J Jenkins,GL Anstadt,HA Werman, J Ashton,RL Hamlin/ Divisionof EmergencyMedicine, Medicine,and Departmentof Surgery' Departmentof Preventive Collegeof Medicine;Departmentof Ohlo StateUniversity Ohio StateUnrversrty Physiologyand Pharmacology, Veterinary Collegeof VeierinaiyMedicine,Columbus;and Departmentof Schoolof Medicine,Dayton,Ohio Surgery,WrightStateUniversity Direct mechanical ventricular assistanceiDMVA) is a method

150

674]!832 106*743 3 17 * 3 0 5 5 3 6 + 1 6 7

A two-way ANOVA for E (control vs E at l0 and 20 minute,sf demonstrateda significant difference{P < .05) over time for the two groups. NE and MAP were also signi{icantly different over timel E Levelsincreasedwith the initial resuscitationbut returned to low levels within four minutes, and remained low in the control group. ExogenousE produced a dramatic but short Iived I2-4 minutes) increasein E levels. This study demonstrates a low level of endogenouscatecholaminesduring resuscitation that may need to be supplementedwith exogenousE.

L S JET) P O 2( C O N T R O V

0 4 * . 2 7 2 4 6 * 9 0 1 3 . 3I 1 4 5 1 . 5+ 1 . 0 1 3 4+ 1 7 1 7 3 * 6 . 9

450

300

Gorrelation of Plasma Gatecholamines With Blood Pressure During Gardiac Arrest

C4 J4

i' I

of biventricular circulatory support which employs a pneumatic device for applying both systolic and diastolic forces directly to the ventricular myocardium. This study investigatedthe effects of DMVA on myocardial hemodynamics when applied following a prolonged cardiopulmonary arrest. Seven swine weighing 28.3 + 2.5 kgs were instrumented for regional myocardial blood flow (MBF)measurementsusing tracer microspheres.Ventricular fibrillation {VFl was then induced. After l0 minutes of VF, CPR was initiated. Following 3 minutes of CPR, DMVA was applied through a median sternotomy.Defibrillation was attempted after 2.5 minutes of DMVA. If unsuccessful,DMVA was instituted for another l5 minutes and a subsequentdefibrillation attempt made. Microsphereswere injected while simultaneous coronary sinus and arterial blood sampleswere obtained during: ll CPR, 2) the initial 2.5 minutes of DMVA {DMVAI), and 3f the subsequent 15 minutes of DMVA in those animals not initially defibrillated (DMVA2).Arterial oxygen content (C"O2),coronary sinus oxygen content (C""Oz), myocardial oxygen delivery/consumption {MD02/MVO2}, extraction ratio (ERl,and endocardial/epicar' dial blood flow ratio (endo/epi) were determined during CPR, DMVAI and DMVA2. Results were compared during CPR be' tween success{ullyand unsuccessfullydefibrillatedanimals using a paired Student's t test. The above parameterswere compared between CPR and DMVAI, and DMVAI and DMVA2, using a 95% confidenceinterval. Significancewas consideredat P < .05. There was no significant differencein C"O2, C""O2,MB!, MDOz, MVO2, ER or endo/epi lP > 0.2) between successfullyand unsuccessfully defibrillated animals during CPR. Three of the seven animals were successfullydefibrillated during DMVAI. Following the additional 15 minutes of DMVA, only one other animal was defibrillated. The hemodynamic data are displayedbelow:

C"O, (ccOr/100 mL) C."O2 (cco2/100 mL) M B F ( m l / m i n / 1 0 0g ) MDO2(cco2/min/100g) lVlVOz(cco2/min/1 00 g) ER enoo/epl

CPR (n = 7) DMVAI (n = 7) DMVA2(n = 4) 1 7 . 8* 1 . 8 1 6 . 2+ 3 . 3 1 9 . 0* 2 . 8 1 2 . 6+ 3 . 3 1.0+ 0.4 6.6 + 3.3 3.3 + 5.4 8 3 . 0 * 5 6 . 6 1 1 6 . 6+ 1 5 4 . 3 7.1 + 2.0 1 5 . 5+ 1 0 . 2 0.6 + 0.8 0.5 * 0.7 9 3 . 7+ 3 , 4 0.5 + 0.3

9.8 a 6.2 6 5 . 9t 1 5 . 1 0.9 + 0.1

2.0 + 0.4 29.8 * 12.6 0.7 + O.4

There was a significant improvement in C""O2, MBB MDO2, MVO2, ER and endo/epi ratio {P < .05),following the initial application of the DMVA device (DMVAlf comparedto CPR. Only MVO2 and ER improved significantly (P < .05),following the additional l5 minutes of DMVA {DMVA2l. These data support the concept that physical diastolic augmentation may enhancemyocardial hemodynamics when DMVA is applied during cardiac arrest.

Reversibility Limit of Normothermic Ventricular Fibrillation Gardiac Arrest Time in Dogs: 15 ltlin for Brain' 2O Min lor Heart

H Reich,F Sterz,P Safar,Y Leonov,M Angelos, SW Stezoski, H Alexanderi InternationalResuscitationResearchCenter, Care Medicine Departmentof Anesthesiology/Critical Hospital,Universityof Pittsburgh Presbyterian-University Inuoduction. Using an establisheddog model of prolongedventricular {ibrillation lVFl cardiac arrest lCAl, closed-chestcardiopulmonary bypass (CPB)for reperfusionand stabilization of the circulation, and long-term life support, we investigated the reversibility of various long periodsof CA (i.e.,total circulator! arrest; clinical deathl. Methods. Ten dogs each were insulted with a VFCA of l5 min, 20 min, or 30 min {no flow). Resuscitationwas with CPB without CPR. Reperfusionwith CPB included heparinization, hemodilution, and brief hypertension {ollowed by con-

trolled normotension. Defibrillation at 2-3 min was {ollowed by standardizedCPB for assistedcirculation over 4h. IPPV and convariableswas {or 20 h, and introl of cardiovascular-pulmonary tensive care to 96 h. Outcome was measuredby overall perform a n c e c a t e g o r i e s{ O P C ) :O P C # l = n o r m a l ; # 2 : m o d e r a t e disability; #3: severedisability; #4: coma-vegetativestates; and #5:brain death-death.Neurologic deficit scoreswere also determined. Results.After VFCA of I5 min, 20 min, or 30 min, all dogs could be successfullydefibrillated.Aiter VFCA of l5 min, all I0 dogssurvived to 96 h; 3 achievedOPC #1, 3 OPC #2, and 4 OPC #3. Good outcome IOPC #t or #21 was achieved more often than after VFCA 20 min {P < 0.01}.Aiter VFCA of 20 min, 7 of l0 dogsachieved96 h survival {3 had earlier cardiovascular death),but all 7 survivors remained with significant neurologic impairment {OPC #3-4l. ln the survivors,the heart developed diffuse multi{ocal hemorrhagicnecroses,but cardiacoutput normalized by 20 h. After VFCA of 30 min, 5 of l0 dogscould be defibrillatedduring CPB and achievedtransient hemodynamic stability that allowed them to be successfullyweanedfrom CPB; the other 5 dogsremainedCPB dependentwith tefractory VF at 4 h. All hearts after VFCA of 30 min developeddiffuse hemorrhagic necrosesand all dogsdied from cardiacfailure (onesurvivedto 40 hl. Conclusion With advancedtechnology(CPBIand intensive care life support, the time limit of normothermic CA from which complete recoveryof heart and brain function is possible,seems to be about I5 min in previously healthy dogs. Although longterm survival with stable cardiopulmonaryfunction can be obtained after VFCA of 20 min, meaningful recoveryof cerebral function cannot be achievedeven after CPB and use of an advancedlife support protocol. Additional etiology-specificcombination treatments will be have to be developed.These can be deliveredunder more controlled conditions usins cPB as an investigativetool.

for by Paramedics Data Gollection ,O Research Prehospital J I MB Heller,JB Melton,RM Kaplan,PM Parisi Divisionol The Centerfor of Pittsburgh; EmergencyMedicine,University Pittsburgh EmergencyMedicineof WesternPennsylvanta, Although the need for increasedresearchin prehospitalcareis widely acknowledged,few studies directly addressthe ability of field personnel to conduct objective creditableprospectiveevaluations. We used severaldifferent methods of training in an attempt to familiarize all paramedicsin an urban EMS systemin the use of an automatic pulmonary function testing (PFT)device to obiectively quantitate the degreeo{ airway obstruction and responseto nebulized therapy.Training consistedof five methods: ll videotapeinstruction broadcastfive times per day for four months over a universally available public service channel (700 viewings); 2f direct individual and small-group instruction per{ormed by a medical command physician and a researcherat the time paycheckswere distributed; 3) a specially preparedl6-page booklet on the field treatment of bronchospasm,the meaningof PFT's,and the protocol use of the device,distributed to all medic units; 4l a medical bulletin from the Medical Director to all personnel mandating use of the instrument and emphasizingits im' portance in documenting efficacy of therapy; and 5) contempoianeous individual instruction performed in person or via radio by the on-line physician.PFT data (FVC,FEV PeakFlow,and FEF) were drgitally displayedand reported to the command physician who was responsiblefor all record keeping.Analysis of datafrom I l0 consecutivepatients revealedthat of 440 possibledatapoints only 214 readingswere actually collected. Ninety-two of these 214 143%lwere not even theoretically possibleand just eight patients {77o)had three or more readingsthat were conceivablyvalid, although repeatedtesting of the instruments con{irmedtheir proper function. Possiblereasonsfor the observedresults were investigatedby means of a questionnaireand included: l) un-

familiarity with the basic concept of pulmonary function testing, 2) the belief that such data was not directiy beneficial to patient care; and 3) personneldissatisfactionrelated to a recent paramedic strike. We conclude that: ll there are severedifficulties in obtaining accurateresearchdata from paramedicsparticularly when the acquisition o{ a new skill is required; 2} prehospital studies should be designedso that the accuracyof paramedicderived data can be confirmed' and 3) even multi-faceted trainins programsmay be inadequateif the issueof paramedicmotivatio; is not exolicitlv addressed.

low-amolitude {and less treatablel VF. Most EMS systems do not publish cardiac arrest data, or other objective measures of performance. If they did, we believe many would have comparably poor r e s u l t s . I n a n a g e o f i n c r e a s i n g l y d e t a i l e d q u a l i t y a s s u r a n c ei n a l l other arenas of health care, this information vacuum is not acc e p t a b l e . W e c o n c l u d e : 1 Ja n e x p e n s i v e a n d e l a b o r a t e E M S s y s t e m with all the resourcesnecessaryfor good results is no assurance that satisfactory cardiac arrest survrval rates are being achieved; 2) population-based cardiac arrest statistics add a valuable analytic tool for comparing results bctween systems and have allowed us to identify responsetime, field treatment, incidence of bystander CPR and other specific problems in our system; and 3) all EMS systems should regularly monitor and report their cardiac arrest survival data to identify specific system problems and ensure that citizens receive the quality of care and likelihood of survival which the scientific literature leads them to expect and for which they are already paying.

Necessity for Objective Evaluation of EMS System Performance

D Clark/ Division O Braun,J Turns,R McCallion,J Fazackerly, Researchand of EmergencyMedicine,Centerfor Prehospital Training,University San Francisco;EMS,City and of California, Researchand Countyof San Francisco;Centerfor Prehospital Training,San Francisco Objective evaluation of EMS system performanceis essential to provide a scientific basis for allocating limited resources.Virtually the only published system performancestatistic is the cardiac arrest survival rate. Most EMS systems do not examine or report this statistic due to limitations of personnel or data acquisition or the belief that it is not necessaryii the mafor components of prehospitaladvancedlife support are in place.If the data are obtained, it is difficult to compare results between systems due to the many variables involved,.including dif{erent cardiac arrest criteria and cohort groups râ&#x201A;Źported by different authors, which may or may not representsimilar patients.We presentthe cardiacarrest data ol a "typical urban" EMS system costing $6.5 million a year and seemingly possessingall the maior resources neededfor good results, compare our data to other published reports by use of a previously unreported population-basedstatistic, and suggestthe necessityof regular cardiacarrest data analysis in all systems to identify and interpret system problems.We conducteda prospectivestudy o{ all adult, non-traumatic cardiac arrestpatients in San FranciscobetweenAugust 1985and August 1986.Datacollectedincluded age/sex, presenceof first responder unit, BLSresponsetime, ALS responsetime, witnessedarrest,bystanderCPR, IV type o{ airway, level o{ staffing, initial rhythm and ultimate survival, defined as survival to hospital discharge. Therewere 1,298resuscitationcalls.In70l 154'klALS was initiated and the patient transported.63 l8'/.1 patients had arrestsof non-cardiacetiology, the remaining 638 cardiac arrest patients comprisedthe study population. The ALS responsetime mean was 6.7 minutes + 4.43 minutes and the BLS responsetime was 4.1 minutes {SDl. 31.7% of patients were found in venticular fibrillation lVFl, 37.4% in asystole,and the remaining 30.9% \n other rhythms. The survival of patients in ventricular fibrillation was9.5o/",and of all arrestswas 4.5o/". l0.7yo of patients received bystanderCPR, 70% receivedIYs,49% receivedET intubation, 17% EOAs and34Tobag-valve-mask.These results are inferior to those reported in other major urban systems.To further analyze the data and correct {or possibledifferencesin patient definttions and cohort groups,we examined three additional statistics after determiningthat the agedistribution ol our population was comnarableto other cities. Our incidence of cardiac arrest was population/year,comparedto Pittsburg at 88, MilbeltOO,OOO waukeeat 75 and Seattleat 106,suggestingthat the patient populations and those being declareddead on sceneare the same. Pat i e n t s p r e s e n t i n gi n V F w e r e 2 6 . 5 / l 0 0 , O O O / y e ianr o u r s t u d y comparedto 46 for Pittsburgh, 54 for Seattle, and 50 for King County suggestingthat VF is unusually uncommon in our system. VF patients had a survival rate of 9.syo in our system, comparedto 27o/ofor Seattle, 3ll" for Kings County 15% for Pittsburg, and 25o/" for Milwaukee. This statistic demonstratesthat resDonsetime alone does not account for the poor results and thai some additional system problem must be sought.This problem may be suboptimal field care or perhapsa higher incidenceo{

Pre.Hospital Gare by EMTs and EMT-lsin a Rural Setting: ls the Advancement of Service Justified?

P J D o n o v a n , D M C l i n e , T W W h i t l e y ,C F o s t e r , M O u t l a w / Department of Emergency Medicine, Heritage Hospital,Tarboro, North Carolina; East Carolina School of Medicine, Department of E m e r g e n c y M e d i c i n e , G r e e n v i l l e ,N o r t h C a r o l i n a Thc advancement of rescue squads from basic emergency medical technicians IEMTs) to intermediate emergency medical technicians {EMT:ls} requires a tremcndous expenditure of time and effort not only by the squad members but also by the physicians and other personnel training these individuals. The additional physical assessment skills and the application of manual skills llVs, blood drawing, and EOA placement) are the basis for advancemcnt to thc EMT-I lcvcl. Thc iustification for advancement to this lcvcl is to cxpand the treatment ability of the EMT in order to increasethe quality and quantity of patient care rendered in thc pre-hospital setting. A retrospective study was done to asscss the difference in cffectivencss of pre-hospital care rendered by EMTs and EMT:ls in a rural sctting. All patients transported to thc cmergency department lED) betwcen |anuary 1982 and Decembcr l9ti6 by the area rescue squads with a chief complaint of c a r d i o p u l m o n a r y a r r e s t ( C A ) , s h o r t n e s s o f b r e a t h ( S O B ) ,p o s s i b l e s e i z u r c ( P S )o r c h c s t p a i n ( C P ) h a d t h e i r c h a r t s r e v i e w e d . A t o t a l of 480 charts were revrewed. 372 oI thcse charts were complete and represent our study group. Of 372, 262 (70%) were transported by EMTs and i10 (30%)by EMT:ls. Presenting chicf comp l a i n t s w e r e a s { o l l o w s : 1 ) C A 2 5 6 . 7 % ) , 2 1 C P t 2 5 { 3 3 . 6 % ) , 3 )P S 9 8 1 2 6 . 3 " 1 ' 1a,n d 4 ) S O B 1 2 3 1 3 3 . 1 % 1 F . ield IVs were attemptcd in 66 of I 10 patients transportcd by EMT:ls, and were successfulin 47 l7l%1. Blood drawing was attempted in (r3 of thesc. ll0 pat i c n t s a n d w a s s u c c e s s { u li n a 6 1 7 3 % ) . 3 0 6 p a t i e n t s h a d I V s s t a r t ed in thc ED. Scenc times for EMTs and EMT:ls not attempting an IV was comparable at (r.l and 6.9 minutcs, respectively. In contrast, thc averagc sccnc times of EMT:ls attempting an IV was 19.6 minutcs. This di{ferencewas statistically significant P < .001, by chi-square analysis. EOAs wcre attempted in 3 of 8 cardiac arrcst victims transported by EMT:ls and I was successful ,.33%1. 129 of 372 patients reccived IV medication within l0 minutcs o{ arrival in the ED. 10 of these paticnts had their IV successfully initiated in the {ield. 282 oI 372 paticnts were admitted ( o f w h i c h 4 t 3 d i e d p r i o r t o d i s c h a r g e ) .F o u r t e c n d i e d i n t h e E D a n d 76 were discharged from the ED. Based on this study, the following conclusions can be reached: l) Initiation of limited ALS procedures significantly prolonged scene time and this may be inappropriate since it delays transport of the patient to a definitive care {acility; 2) A success{ulIV in the field did not increase the likelihood of medication grven within 10 minutes of arrivai in the ED; and 3) Prospective studies are needed to elucidate probiems in skill training and maintenance of EMT:ls in the rural setting.

'"','"Ti ?il,:fi,ft#{iff:'J.'},:.}'"*5"",1,o";;,$l,}i:#ffi andphysio!9gy^11,i:T.-:.::.i" crinicar i'::l i|i,9;*'l3lno*::'"#ffiIiffiii;..";:i,rl,rl3

-Bi

epe d'Issu iii,l$.;l:J"nf'fi[fl';?i:T=":=J;""' :rm;u:iixase

I5fl:U3fli:.:ffi ns::l, H"3 i,*:,. *-:tf'1:; d th""o,'""p." :tti*ll+';iUf ",1'"".TJl'JX'iffi;o;tr; utiltzed of patients are taught and

poster Presentations

3 8 *.:'ffi i1i;'pJry::h*iidi,;ffi i}g:rtli*t}ri,#il[i,{i* +tffi t;o::li::'.1,F,'.,1-ri*$rT:,^rr;,fi;;j.,:l'"T il'i"'i'"i'a;a * sJl,in, $:rr.J"*iir'r",^l,ri*lii:"" l:::0",

,t;;;;ni;s

**Xg*U Hu+iiff##:lniirrr::;ffi $ftfr:'5$=Rt"*;[1]'frTi e'"','q:l:I,TriJ'."jl,L"itii'ir''t tt'. corecon' to .'"I"i1:^:l-'j*T,"i';;1r::l i; time ror teaching. humanvolunteers bien: ';;;;'siave ,*o' l'Ti*' ll ll ',i"..'.T[i,i}T"',11'u'i,i; "iJiir.,"* i..,, t:'=r*lli"'..i.;*x;***,1;.;f,i;l*":,11":',',t 'ha' do..,**,.tion ;* or ;il',.**i jrff;il';# y"# + to :::i +!-.,,i1]!:,'"";;;;i;;u [:i.#'ii*i:i *Lf;;;; iii,or. ffii;;;?;

i'*;:"J"9:":t:*"'x ,;*fl,J,...:l'lx*':tinm*t*rct='J'*fifr'J"'# t"':iJl.{Ftffii'lljl['..;:.*

*'l*l'l*el':;,g*,**'.*1f f$;;*1i,-*,-:ltl*r;1",u,

ru:il'.".",'affifi';..'=L,i"*',=:t:,'.,ffif,Hi-":#tr ",'':",:{':.Tt'j":::{iii:',",ffi ;?ry"ffii?t{l'};i1:'.ffFl;i t""J,1*.r".':lfJffi;#;#J;1bt*-1!,:l'}i.', l'"n:t;:::;""1iil'*iril::-:f'I

ir*:x:'::''n#ilti+::jjil:.ll1tiJf iif-l'r**+i*:::fltl:,jtjf"'i1"""ryr;'""ffirf

:ltU*1fr,iit*ih:{n-:'ru'l1;ru|itlil :?t"T;j$,1:,i'"::r'"1:','.',',ff:?t.t$'*f:i"A;i",*,'C t'n':.":1,"9,1':tt""i*,';t";*l u",,i."ii..r'.iqu., ;;",'s;il;i' ;* :{:1ry"::,t','#i,}X?11ff1ilT:l!'i}j' rwoipeciric *:tTi1E:'-11'trqtiili'.'Jtrr:il:l#: :ilTt,lL:T::,:Hl'TJi:n:,:l#JI**ii*l*:liiril'rd* isrecommen.eo assemblv il;;il6{"B"r ;::h""q;;.;;provi,,g", tttt ct-.tl'^jili;::i'i. sinceall prematureterminations

fi;-

ot.t'"::":;il;i,i;i,;;d;s"controls. iiculum {consisting

rhere

;rnT;.T:ru U$1;p fi*ifi:J."1"rff*5|ijf, !$;

.82 i'.?:Till':s:ixliilrsi;1is"o'""' "ii'"':"''!r ;-ii$it'"i$-:i!:ti*i:i:l:l'l*:$l o,iiJi'v

an ao 'ne :*i*:+]#,,yi1i'5uf"t1g*iir,_:l**1*Ji,l Melton,MB Hell -x_[1ff1;K,"r,:yrJr?l,tr. ""ip,t,.6,,br JD ArririaiEd :{ffl;,fi',#:1":,fin,**;t;,,t#*t "'**'":':::l:"":.Sensor. i';:il$'i-.i,[t: n:l*Ut;"_.liJL"Hl$*?ne; t'rEmersencv cen'er pittsbursh'u'^r"**;; Sensor- F:i!frT:'i"r::,r''* {Oxvshuttles useoI pulseoxime-trv' the :"";;;;

'Ut'jt we investigated '*n'{t;'it 'n1n:o} il3i{ntll{s'i:+",4p-"':*}*u'il+:}fi"f i" inicrinicar-evalutffi1,il'ff,r1.i:l ^n.ii.,i'iJ"lil,ai,ii'i, |"i.,n*ir ?"*'::T::titiktxnl,ljill'.1iru;ii;i;r

ti*r,.T*1qj$ii'?"iili!"Ji:i::.,'ly?lJ.H[tix'J",1'.H [:'*:*,ll 0n".:.*'$,"'.n:*i:Tffil5i:i:: in'r:: :yr::'"' currrcu" ::ii+'* *ir*Ltr'"r";1,:"ffi'.;dl* 13stril;1,"liffii third vear the inio ;tf.*mvlr"i"i'v*1 tv thepu]se ;:;.;;.d';i"e is alsoi'*"'p6'"i'a der"tur".tiliiiot.d " inr,rn.., l"jTi:il.J:itr..-r,

that acute airway interventron oximeter *"' tit""ii"il"ait"tiott remaining patients recerveo eleven "i-1ttt was indicated' N"*

lum'

e:",gf,:'*i",:#i*i:} ffiii,*ttil':.;:.M :*:t :*:r il$ilffl$fr**':l*, ',T:'iiil*q,t'"J"''tilH,{,:}}ifi,,'i'i.6{. 3",Hi:,r"ff.ftfll#ff:;;Jl 150 helicopter patients

(3%) had eprsooe

l?,l;'.','.",';j,'H:i:k.'}i.,iy416;[:li',$':;,sl'.:Ti ::ffi;,lt*i*']{'i,:.ffi:,.*:X,,.,."i, 'fffk '6ruins p.ti.,o ;;;,;;;"";'*"9lr1.t;';;i.,.r"p rerine and *",1;f*"f*:X3..'"1ifi n'.'.'..tionsarerequtrt """ o"x:111i"."h;;;-;;,;;,-oo In ii"*,;"a a..,.".""j.,r.iiudes. #:;i*n:i:lt

DC Arthur, DS Tek / Department of Emergency Medicine, Naval Hospital, San Diego To understand how emergency medicrne residcncies approach resident research, and to identify factors associated with successful block research rotations, we surveyed all U.S. residcncy program directors. Thc data received from the replying 61 oI 67 residencies in opcration for more than a year arc summarized. These data show that (r0% require residcnts to write a publishablc paper, 22o/o requirc an original rescarch paper, and 18% havc no authorship requircment. 70% havc a desigr-ratedrcsearch coordinator who dedicates l7'1, oI his or her timc to the task, 40% have a researchadvisor who spends 7% of his or her timc, and a small portion have both positions. Only 50% havc represcntatron on thcir facility's rescarch committcc. Most residencieshave access to animal rescarch facilities, computer time, and a bios t a t i s t i c i a n , o n l y a t h i r d h a v c a c c e s st o a n e d i t o r i a l o { f i c e . F u n d ing sourccs for research, affiliation, staffing, faculty authorship, and other gencral characteristics of programs are prescnted. (r7ol, of all residcncies havc a research block. Differcnces in general characteristicsbctwccn programs which do and do not offcr block r c s e a r c h r o t a t i o n s a r c d i s c u s s e d .T w o t h i r d s o f r e s e a r c hb l o c k s a r e clcctive and onc third are rcquircd. Most arc during thc PGY3 y c a r , a r c 4 w c c k s l o n g , a n d d o r - r o tr c q u i r e c o n c u r r c n t c l i n i c a l shifts. Most are supcrviscd by a dcsignated rcsearch coordinator. Residcnts pcrforming rcsearch mce t with their preccptor at variablc intervals and arc evaluatcd by the quality of the final rcs e a r c h , t h c i r o b s c r v c d c o n ' I p c t c n c y ,o r b o t h . T h c s u c c e s s o f r c scarch rotations was evaluatcd by six critcria, as wcll as thc rcsidency dircctors'and residcnts own pcrccptions of thc succcss and uscfulness of the rotation: half of thc rcsidcncy directors said that thc rcsearch blocks havc improved thc ratc of projcct succ c s s , t h c s p c c d o f s t a r t - u p a n d c o n - r p l c t i o no f p r o j c c t s , t h c n u n - r b e r of residcnt articlcs appcaring in peer-rcvicwed iournals, and the f r c q u e n c y o f n a t i c l n a l m c e t i n g p r c s c n t a t i o n s . 2 6 ' k ' < > Id i r e c t o r s said that having thc rescarch block resulted in a higher proportion of prospcctive studies, and 15'lu in a grcatcr proportion of aninal or bench studics. Spccific features of programs which have "succcssful" rcscarch block rotations arc comparcd to those w h i c h w c r e l e s s s u c c e s s f u lb y a b o v e m e n t i o n e d c r i t c r i a , w i t h p a r ticular attcntion to instanccs whcrc controllablc factors such as curricula, teaching methods, and rcscarch inccntivcs werc associatcd with succcss.A comparison between clcctivc and requircd rcscarch rotations is discussed.Rcasons for incrcasing enphasis o n c l i n i c a l a n d l a b c J r a t o r yr c s c a r c h i n e m c r g c n c y m c d i c i n c a r e prescntcd as wcll as a dcscription of our vcry active program as a model.

skills. Imparting the content and supporting the problem solving skills necessary for sound clinical performance with patients pre'Acute Chest Pain" is appropriately a primary educasenting with tional responsibility of Emergency Medicine clinical faculty. Students are likely to receive a sufficient didactic presentation dealing with acute chest pain as a formal component of their Emergency Medicine core content. However, the author has evidence which suggests that students taking an Emergency Medicine rotation may not experience a sufficient number and variety of acute chest pain presentations in order to significantly improve or refine their chest pain problem solving skills. The authors have investigated the potential of an interactive, computerbased patient case data bank and problem solving learning tool as a means of supplementing the clinicai problem solving experiences of medrcal students. The case data bank was programmed to provide students with a large number and variety of acute 'Acute Chest Pain" chest oain cases. Over a lS-month period, problem solving skills for 8B consecutive students rotating through a mandatory one month Emergency Medicine rotation were assessed.Approximately half of the students were given access to the computer-based chest pain case data bank and probIem solving learning tool. At the conclusion of their EM clinical rotation the chest pain problem solving skills demonstrated by students working with the computer-based learning tool were sign i f i c a n t l y h i g h e r t h a n t h e c o n t r o l g r o u p ( t t e s t , o n e - w a y ,N : 8 8 , P < .018).For a variety of reasons students may not experience a sufficient number and variety of acute chest pain case presentations for improving their problem solving ski11s (e.g., preferential "at risk chest pain patients" by clinical faculty, attendance to Emergency Medicine residents, and house officers, overall volume of chest pain presentations, etc). Expioration and implementation of computer-based problem solving sessions may prove to be a valuable clinical learning adiunct for high impact patient problems when either the number or variety of a student's clinical encounters appears to be insufficient.

Emergency Department Evaluations Utilizing Results-Oriented Pedormance Standards (ROPSI

J E T i n t i n a l l/i D e p a r t m e n t o f E m e r g e n c y M e d i c i n e , W i l l i a m Beaumont Hospital, Foyal Oak, Michigan Tiaditional methods of resident evaluation consist of ratings on a numerical scale of traits such as knowledge, iudgment, and interpersonal skills. Such terms are imprecise and do not provide objective criterta for performance evaluation. Results-Oriented Performance Standards (ROPS) used for employee evaluation in industry were modified for use in an emergency medicine residency. This well-proven methodology utilizes objective standards in rating (i.e., sees three patients/hour; less than onc patient c o m p l a i n t / y e a r , c h a r t s i e g i b l e ) i n s t e a d o f t r a i t s ( i . e . ,i n i t i a t i v e , i n tegrity, dependability). Separate expectations and evaluation criteria were determined by using performance objectives for 1) students and rotating house officers i and 2) EM residents at each level of training. In addition, EM residents were required to complete a quarterly report documenting academic, community, and administrative actlvities. Traditional trait evaluation criterta were continued for EM residents on non-EM rotations. Evaluation forms using a mrxture of methodologies were completed on PGII and III EM residents by the emergency nurse managers. All EM resrdent evaluatrons were summarized on a cumulatrve form. At the end of six months, EM residents preferred the ROPS. They felt the evaluations were straightforward, listed teasonable performance objectives, and clearly identified areas of weakness. The program director was easily able to track resident weaknesses and strengths, and could clearly communicate measures for improvement to the resident.

*86

EmersencY f,'::?:,l'ii::flJSl::"T 41

Literary Discussion GrouP in an Emergency Medicine ResidencY

Program AB Sanders / Section of Emergency Medicine, Department of S u r g e r y , U n i v e r s i t yo f A r i z o n a H e a l t h S c i e n c e s C e n t e r , T u c s o n Tiaining programs in emergency medicinc should provide opportunitics for residcnts to: {a) acquire didactic information and proccdural skills necessary to practtcc cmergency medicine, (bI d c v e l o p l i f e - l o n g l c a r n i n g a n d p r o b l e m s o l v i n g s k i l l s , a n d .( c ) d e velop irutnanistic qualities such as compassion, empathy and honesty that enable them to work with human beings in times of crisis and need. Medical schools and post graduate programs tend to focus on the didactic information and procedural skiils becausc they are most easily taught and evaluated. The CPEP report has influenced many programs to focus on teaching and testing problem solving skills. However, few training programs attempt to actively teach humanistic disciplines such as literature or ethics. We have developed a Literary Discussion Seminar Group for residents and faculty in emergency medicine with the following objectives: l. To expose residents and faculty- to works of literature and illustrate how literature impacts on their lives. 2. To promote an interchange of ideas and opinions among residents and multi-disciplined faculty in a non-medical environ-

ment. 3. To allow residentsand faculty to communicate feelings, doubts, and stressesabout residencytiaining and/or the sp.ciafty of emergencymedicine. 4. To use ih. lit.rriy works as the basi's for discussionsof ethical issuesand values ielevant to the practice of emergencymedicine. The literature is selectedUy "" ilrt.i_ disciplinary group of faculty from the EmergencyMedicine, En!_ lish, and Humanities Departments.Bi-moniirly Z-St o", .u."i"'g sessionsare held at the home of a faculty member.Excerptsfrori the selectedbook, play, etc. are distributed to the residints and taculty 3 4. weeks prior to each session.Examplesof the works used and drscussionare as follows: l.,,The Doctor Stories,,by William Carlos Williams, MD. Selected short stories such as "Old Doc Rivers" leads to the discussionof substanceabusein a seeminglycomperentfamily physician.2. ,,Theplague,,byAlberl Camus provokes discussion of our responsibilitiei and risks as emergencyphysicians in the treatment-andexposureto patients with AIDS. 3. "Equus,,by peter Schaferwas uied to discussthe concept o{ "normalcy,, and subtle ways in which residencypro_ grams enforce their own-conceptsof normalcy. 4. ,An Enemy of the People".by Henrik Ibsen leads to a discussion of tryin! to maintain values in an environment where economic factors iake precedenceover medical fudgment.The Literary DiscussionSem_ inar Croup has been well acceptedby the residints and faculty in emergency,medicine. Those attending these sessionsfind tirey are exposedto new literature and relate their readingsto ethical questionsregardingtheir careerand training program-.Long term ronow-up rs necessaryto determine if this exposureto literature dunng,a training program establisheslife_longpatternsand influences humanlstlc behavior.

Qa 919

Emergency Depailment patient and Visitor Awareness of the Specialty of Emergency Medicine

V,/CRobey,LA Johnson,TH Metz, LE McDonald/ Departmentof EmergencyMedicine,MorristownMemorialHospital,Morristown, New Jersey To determine_publicawarenessof the specialty of emergency medicine and the emergencyphysician, we disiributed a"brief questionnaireto ambulatory patients and visitors on their admis_ :i?i,tq jlr: :mer_C9l9ydepartment.Morristown Memorial Hospital {MMH) is,a 541-bedcommunity hospital serving a suburban population oI.over.50O,000, with 40,00b ED patient visits per year.The ED is staffed by full-time emergencyphysicians,mbst 'the of whom are EM residency trained diploiratei bf American Board of EmergencyMedicine and whb are faculty of the Emer_ gencyMedicine Residencyprogram.euestions regardingage,sex, place_ofresidence,and any previous MMH ED vlsits were asked as well as specificinquiries LoncerningEmergencyMedicine, the emergencyphysician, and emergencycare.A question on the re_ spolder's estimated ability to idminister first aid was also in_ cluded. Responderscould answeryes, no or don,t know. Sixty-six percent of individuals respondedand a total of lg0 comoieted questionnaireswere examined. The mean age of the responders was 36.7 years and 95To were New fersey residents.For 6g% of the participanrsthis was not the first visit to the MMH ED. The maiority 173%.1 of.respondershad a private physician. Fifty_five percent thought that EM was a recognizedspecialty.Sixty_nine percent believed that ED physicians ieceived-speciaitraining in emergency care and 84% thought there should indeed be siuch training. Forty-two percent answered that emergency depart_ ments.arestaffed_byphysicianswho practicefull-time emergency medrcine when 737" thought that EDs should be staffed by physicians wtro practice full-time emergency medicine. ninally,'57./. oI responders felt they could administer {irst-aid in a home emer_ gency.Age and sex were non predictors for all answers. We conclude from this data that a significant percentageof the general population is unaware of the existenc. of .-ergJrr"y medicine as a recognized medical specialty, but believes tliat ED physicians receive some type of training in emergency care. The overall pat_

tern of response supports specialized training and the presence of physicians who practice.full-time emergen-y medicine. In this consumer oriented health care system of increasing patient so_ phistication, it appears that there exists a demand ioi ,.riJ.*y trained, emergency medicine specialists, and that emphasis shoutcl be placed upon promoting public awateness of EM as a rormal speclalty.

Modeling Emergency Department Operations Using livanied Gomputer Simulation Systems CE Saunders,PK Makens,L LeBlanc/ VanderbiltUnrversitv Schoolof Medicine;VanderbiltUniversity, Owen GraduateSchool of Management, Nashville, Tennessee We developeda computer simulation model o{ emergencyde_ partment operationsusing advancedsimulation softwire. This model usesmultiple levelsof_preemptivepatient priority; assigns each patient to an individual nurse and physician; incorpora"tes all standardtests, procedures,and consultaiions; and allows pal trent serviceprocessesto proceedsimultaneously,sequentiaily, and/or repetitively.Selectedinput data,including'the"umbe, oi physicians,nurses,treatment beds,and the bloodlest turnaround time_werethen varied systematicallyto determine their simulat_ ed effect on patient throughput time, selectedqueue sizes,and rates of resourceutilization. The model was able to demonstrate a re.lationshipwith each. Patient throughput time varied directly with the severity of illness and the blood test turnaround time. Patient thro rghput time, physician utilization, and the time un_ til seeing_aphysician varied inversely with the number of physi_ cians on duty. A similar pattern was demonstratedfor nursesiaffing. The treatment bed queue and bed utilization varied inversely wlth the number of treatment beds.The simulation can be ani mateclon a computer monitor, showing simulated patients,specimens, and staff members moving throughout the i,o. Computer simulation.is a potentially useful tool wfiich ca., help prediit the results of changesin the ED system without actually alteringit, and may have implications for planning, optimizrng resources, and improving the efficiency and quality of care. Q(| |fr.t

(|n gV

Formula for Emergency physician Staffing

LG Graff MJ Radford/ New BritainGeneralHospital,University ol ConnecticutHealthCenter,New Britain,Conneciicut F,stimatesof emergencyphysician needstraditionally havere_ , lied on calculations based on the number of patients caredfor (volume formula). We have found this model-doesnot predict manpowerneedsin the modern EmergencyDepartment. The severity of patients/illness has increasedasEmergencyDepartment payment denials have encouragedless acutely ill patients to be treatedin walk-in centers.Patientsremain in ihe EmergencyDepartment longer,as prospectivepayment restrictions oi hoipital admissions have encouragedobservationand acute lsometrmes intensive)care to occur in the EmergencyDepartment rather than in the hospital. We have developid an altirnative formula { " L M S " ) t o e s t i m a t e e m e r g e n c yp h y s i c i a n n e e d s b a s e do n Length of stay in the EmergencyDepartment, Intensity of service, Volume of patients, Efficiency of physicians, and Service type {routlne emergency,critical care, cardiopulmonary arrest, observationJ. We used nine yearsof EmergencyDepartmentstaffing experience-atour hospital to comparJthe-predictivepowerof the two formulae. The LIVES formuli fit better with actualneeds by chi-squareanalysis (X2 : 0.39) than rhe volume formula lX2 : 5.75).By linear regressionanalysisthe LIVES formula showed a positive correlation with actual needs (regressioncoefficient 0.58) while the volume formula showed a nlgative correlation with actual.needs.(regressioncoefficient -0.4I). The LIVESformula had a high degreeof associationwith actual needs{correlation coefficient 0.841rhar was staristically significant [p value

departments. Reports of crtizenry armed for thcir own protection, weapons found on paticnts within emergency dcpartments, and incidents of nurscs and physicrans being attacked by hostile, intoxicated, or psychiatric patients have creatcd prcconceived fears in rcsidcnt and nursing recruits. The widespread concern over this issue is undcrscored by the 1987 AMA's resolution calling for incrcased hospital security measures. To combat these fears and to crcatc a sccure work cnvironment the l)epartmcnts of Security and Emcrgcncy Medrcinc at Hcnry Ford Hospital undcrtook a two-ycar project to crcate a safer work cnvironment. A comprchcnsivc approach was takcn includrng: wcap('n screening o f p a t i c r - r t sa n d v i s i t o r s , i n c r e a s e d s c c u r i t y p r e s c n c c , f a c r l i t y changcs, improved TV monitoring, and ongoing inscrvices of sec u r i t y r e l a t c d p o l i c i c s a n d p r o c e d u r c s .T h e c e n t e r p i e c c o f t h i s c x tensive security program is a pcrmancntly installed fcrrous detccting magnomctcr arch supplcrncntcd by hand hcld units. Signagc at thc departmcnt cntrances notify all paticnts and visi t o r s t h a t s c r c c n i n g w i l l b e p c r f o r m c d a r - r dl o c k e r s a r c p r o v i d c d for paticnts and visitors to chcck thcir belongings. Thc arch is locatcd at thc cntrancc to thc clinical triagc arca of thc emergcnc y d c p a r t m c r - r t ,w h c r e p c r s o n a l s c a r c h c s a r e c o n d u c t c d a n d h a z a r c l o u si t c m s a r c c o n f i s c a t c d i f d c t c c t c d . T h c f i r s t s i x m o n t h s o f thc scrcenir-rg opcration yicldcd 33 handguns, 1,324knivcs, 97 macc typc sprays, and many othcr haz:rrduus itcn.rs. C)nly twtr complaints havc bccn rcccivcd by Security and Adrninistrltiort, a r - r dn o l c g a l c h a l l c n g c s h a v e b c c r - tl o c l g c d s o f a r . A f t c r s i x m o n t h s of opcration a sllrvcy w:rs circulated to all mcmbcrs of thc I)cp a r t m c n t s o f E r - n c r g e n c yM c d i c i n c a n d S c c u r i t y s t a f f . R c s u l t s t n d i c a t c s t r o n g s u p p o r t f o r t h c i m p r t l v e c ls c c u r i t y m c a s u r c s , a n d signrficant incrcascd fcclings of safcty in thc workplacc. Implcmcntation of a comprchcnsivc sccurity progranl has climinatcd a significant numbcr of prcvrously undctcctcd wcapons frtrm thc chnic arca, is wcll acccptcd by thc staff, and has substantially i n - r p r o v c dt h c i r s c n s c o f s c c u r i t y . T h c d a t a g c n c r a t c d b y t h i s s t u d y rcenforccs thc nccd for improvcd hospital sccurity mcasurcs.

0.0044 by Student's t test), while the volume formula had a low degree of association with actual needs (correlation coefficient 0.41Jthat was not statistically significant (P value 0.27 by Student's t test). The volume formula explains only 17% of the variability in emergency physrcian needs (83% of the variability is due to other {actors), while the LIVES formula explains 7l"k oI the variability in emergency physician nceds. Changes ln servlces provided by the modern Emergency Department require a multifactorial analysis such as the LIVES formula to determlne manpower needs.

Emergency Department Violence in a a United States Teaching Hospitals =t I RL Berg/ Department of Emergency FWLavoie, GL Carter, L ,o u i s v i l l e , M e d i c i nU e ,n i v e r s iot fyL o u i s v i lSl ec h o ool l M e d i c i n e Kentucky Violence in the emergcncy department is a comprehensive concern. Howcver, most aspects of this problcm remain unstudied since no organizatron or government agency tracks such data, and no regulatory or administrative guidelines adequately addrcss its management. We surveyed, by mail, the emergency dcpartmcnt medical directors of all residcncy programs in emcrgcncy mcdicinc and ali members of the Council o{ Teaching Hospitals whosc annual ED volume is 40,000 patient visits or greater. Topics related cxclusrvely to violence and security issues. Rcsponscs wcre o b t a i n c d f r o r n 1 2 7 1 7 4 . 7 % ) .T h c f r e q u e n c y o f t h r c a t s t o s t a f f i n each ED was estimatcd. Forty-one institutions (32'ln) report at least one verbal threat pcr day; 23 118%Jrcport at lcast onc thrcat to staff with a weapon pcr month; 72 157%lat least one threat to staff with a weapon in the last Iivc years. TWo hostage incidcnts at knife-point werc rcported to have occurred in thc last five ycars. Fifty-five 143'h) reportcd at least one physical attack on medical staff per month; 102 (80.3%) report staff injury due to violcncc in thc ED rn thc last fivc years. Nine (7%)dcscribc acts o{ ED violcnce in the iast five years resulting in death. Only 79 of thc 127 162%l state that their security pcrsonnel arc prescnt in the ED 24 hours a day. Varying arrangements with rcspect to uniforms, arms, and powcr of arrcst arc utilized. Of thc 23 institutions wrth thrcats with wcapons > one/month, cight (35'l.) do not employ 24 hour ED sccurity; of 55 with physical attack > one/month, 16 129%l do not; and of nine with violcnt ED dcath, fivc (55%) do not. Ninety-eight facilities 177%) use chcmical rc,q98.4%l utrhze four-pornt straint; 78 l6l%)usc seclusron;and I25 restraint. Frequency of usc of force to control violencc was cstim a t e d . T h i r t y - t w o ( 2 5 % , )u t r l i z e r e s t r a i n t > o n c / d a y . S e v e n t c c n (13%) rcportcd significantly injuring a paticnt during restraint in the last five years, including onc strangulation and dcath. Fi{tyeight (46"1,)confrscate at least one weapon/month. Onc prollram c o n f i s c a t c s3 0 0 w e a p o n s / m o n t h u s i n g a m e t a l d e t e c t o r . O n l y 5 1 (40%) providc ED nurses wrth {ormal training in recogtlition and management of violent patients. Twenty (I6% ) state involvcmcnt cight (6%) for failurc to with litigation over violent patients restrain/detain,six (5%)for injury during restrarnt, and l3 {10%) for restraint, not resulting in injury. Theoretical classification of the prevention of violcnce rs classi{ied as primary, secondary, and tertiary. "Milieu" factors, administrative and training policics, restraint, security arrangements, and legal precedents are addrcsscd in view of results. Risk management guidelines are suggested.

"Bounces" - An Analysis of ShortTerm Return Visits to an Urban Emergency Department University of / Department of Medicine, AL Kelermann JM Pierce,

T^^^^^^^^

Disarming the Department: Weapon Screening and lmproved Security to Greate a Safer Emergency Department Environment

/ BM Thompson,J Nunn,T Kramer,I Timmins,M Tomlanovich Departments of EmergencyMedicineand Security,HenryFord Hospital,Detroit,Michigan Safetyof the hospitai workplace is an important issue when recruitingresidentand nursing staff to busy inner city emergency

[ t^-^hi-

Short-tcrm rcturn visits to thc cmcrgcncy dcpartment arc gencrally considcrcd to rcprcscnt failurcs of cmcrgcncy mcdical care, b u t t l - r i sc o m l l o n o c c u r r c n c c h a s n c v c r b c c n s t u d i c d i n d c t a i l . W e s y s t c m a t i c a l l y i d c n t i f i c d , t h r o u g h o u r E D c o m p u t c r d a t a b a s c ,a l l paticnts rcturnrng to thc ED of tl-rcRcgional Mcdical Ccntcr at Mcmphrs, a publicly subsidized hospital, within two days of inrtial registration. Cascswerc rcvicwcd to idcntrfy primary and seco n d a r y f a c t o r ( s ) a s s o c i : r t c dw i t h r c t u r n v i s i t s . D u r i n g t h c m o n t h of )uly 1987, our ED rcgistcrcd a total of 5,731 patrcnts, of whom 1 8 5 { 3 . 2 % , )r c t u r n e d w i t l - r i n t w o d a y s o f i n i t i a l r c g i s t r a t i o n . R c c o r d s w e r c l o c a t c d f o r r c v i c w t n 1 7 0 l L ) 2 % ' )o f t h e s c c a s c s . P a t t e n t ccntered {actors wcrc rcsponstblc for a majority of rcpcat visits, lncluding lcaving wrthout bcing sccn or lcaving against medical a d v i c c d u r i n g f i r s t v i s i t ( 3 4 c a s c s ;2 0 % ) h a b i t u a l u t i l i z a t r o n o f t h c E D f o r n o n u r g c n t p r o b l e m s ( 2 2 c a s c s ; 1 3 ' l o )n o n c o m p l i a n c e w t t h p r e s c r i b c d m c d i c a t l o r r s ( 1 0 c a s c s ;6 % l a n d a v a r i c t y o f p s y c h i a t r i c a n d / o r s u b s t a n c e a b u s e d i s o r d c r s { 2 9 c a s e s , l 7 ' Z ' 1 .I l l n e s s - r e l a t c d factors, particularly evolutron of disease under closc outpatient observation, prompted return in 27 cases (16%). An additional twelve patients rcturned with new problems unrelatcd to their initial prcsentation. Contrary to our expectations,physician-centered factors were the primary reason for return in only 25 cases (I5%). In l5 cases(6%), misdiagnosis and/or misinterpretation of diagnostic tests occurred, treatment was inappropriate in an additional three cases and hospitalization was indicated during the frrst visit in two. Also, three patients were told to return to the ED for reevaiuation within two days. Problems wrth our public health care system prompted return in only seven cases {4"/ol.A

searchcrs might use to analyze vast amounts of data, with the purposc of rctrospectively idcntifying factors or groups of factors ihai would nccd to bc furthcr investigated in a well-controlled prospective study. The cnd result being that a clustering alg o r i t h m n - r a yi d e n t i f y t h c s c { a c t o r s w h e r e a s , b e c a u s e o f t h e c o m binatorial complcxity, manual manipulation of thc data may not h a v c b c c n a b l c t o . T h e a d v a n t a g e sa n d l i m i t a t i o n s o f s t a t i s t i c a l a n a l y s i s u s i n g P L S I a r c d i s c u s s c d .T w o e x a m p l e s o f P L S I a p p l i e d to thc data of cardtacarrest paticnts are given. AII data was taken from thc actual records of a sophisticated two-tiered paramedic svstcm. Howcver, in thc first exan-rplc, the data was rcgrouped specifically to show how noisy data would be handled by PLSI. Noisy data is that which is not 100% certain. For all patients,36 a t t r i b u t e s ( i n c l u d i n g a â&#x201A;Ź i e ,s e x , w i t n e s s i n p i o f a r r c s t , m c d i c a t i o n s , cardiac history, rcsponse time, length of rcsuscitation, ctc.) werc recordcd and includcd in thc data. In the first cxamplc, two groups of 25 patients were analyzed. In the first group, thc rcsuscitated paticnts, 72% ha,l profcssional or bystander CPR. In the second,72"L had no CPR. If 100'/" of thc rcsuscitatcd paticnts had CPR and 0'lu of thc non-rcsuscitatcd patients had CPR, therc would be no ncisc, with respcct to CPR. It would be clear that CPR was a discriminating factor in classification of thc two groups. But with thc noisc intrilduccd, mimicking a rcal sccnario, FLSi successfully idcnti{icd that having CPR performcd was a d i f f c r e n t i a t i n g d c s c r i p t o r b c t w e c n t h c t w o c l a s s e s .I n t h e s c c o n d examplc, 515 paticnts, that had previously bccn subjectedto manual analysis and thc results published, wcrc dividcd into savcd and not savcd groups and analyzcd by PLSI. In its dcscript i o n o { t h e t w o c l a s s c s ,P L S I i n c l u d c d c v e r y { a c t o r t h a t h a s p r c " v i o u s l y b c e n r c p o r t c d b y m a n y d i { f e r c n t a u t h o r s . I t a p p c a r st h a t PLSI docs a good iob at classifying largc amounts of vcry complcx data and would bc hclpful to mcdical rcsearchcrs.

total of 3l returning patients ll8.2"l') required emergency hospitalization, including l0 discharged due to physician errors. Systematic review of short-term repeat ED visits may identify target populations and/or problems amenable to program-intcrventions While physician errors account for a minortty oi repeat vlslts, regular case review should prove a valuable addition to a comprchensive ED-based program of quality assurance.

Reanalysis of Surveillance Data Regarding Health Care Worker Risk of Nosocomial Acquisition of the l{uman lmmunodeficiency Virus (HlVl

G D K e l e n/ D i v i s i o n o ' f E m e r g e n c y M e d i c i n e , T h e J o h n s H o p k r n s U n i v e r s i t y ,B a l t i m o r e , M a r y l a n d The risk of acquiring the human immunodcficiency virus {HIV) following a known parenteral exposure is on the order of 0.5 to 1.0%. This figure has been arrived at by pooling the data from a seriesof health care worker {HCW) surveillancc studics. The cpidemiologic methods by which HIV infection in a HCW is attributed io a nosocomial source is quite conservative. Closer examination and re-analysis of the data from 5 major often cited surveillance studies show that the inferencc of low risk o{ infection post exposure is not yet fully substantiated, as cpidemiologic risk issessment methods may be biased toward undercstimating risk. These 5 studies combined, report on 2,241 HCWs with varying degrees of exposure to HIV from infected patients or material Only one of them is a proven seroconvertcr' Howcver, thcre is insu{ficient in{ormation available to calculatc truc scroconvcrsion rates. At least 509 subiects with known exposures were not tested. A further 828 enrolled subiects, many with known cxposures less than 6 months prior to the first serum analysis did not have follow-up sera tested leaving a large pool of potential seroconverters. lThe exact number cannot be ascertaincd from t h e d a t a a v a i l a b l e . )A l s o t h e r e a r e 2 7 s e r o p o s i t i v c H C W s w h o d i d not have presera available to prove or disprove scroconverslon. Five of thim did not belong to established risk groups, but bccause non-occupational sources could not be definitivcly ruled out thev are not currently considered as proven nosocomial transmissions. Infection control precautions takcn by HCWs have been shown to be poor even when dealing with known infccted patients. The conservative accounting of risk may inadvertently lull HCWs into a sense o{ complacency and thus thcy may not appreciate the need to adhere to unrversal precautions despite admonitions to the contrary. While strict accounting is approprtate for epidemrological documentation, it may be better to attribute HIV lnfection in HCWs to nosocomial transmission until proven otherwise rather than the other way around. At the vcry least, discussions o{ risks based on data from surveillance studies should be qualified by acknowledging their limitations and the possible influence their shortcomings may have on intcrpretation of risk.

Objective Assessment of Megacode Performance: The Results of Increasing Structure on Interobserver Reliability

C E S a u n d e r s ,W B a r t o n , R V o g e l p o h l , L W o o l d r i d g e , B Y a r b r o u g h/ V a n d e r b i l t U n i v e r s i t yS c h o o l o f M e d i c i n e , N a s h v i l l e , Tennessee T h e " M E G A C O D E , " a m o c k c a r d i a c - a r r c s ts c c n a r i o d c s i g n c dt o t c a c h a n d d e m o n s t r a t c A d v a n c c d C a r d i a c L i f e S u p p o r t ( A C L S )r c suscitation skills, is widcly uscd, and is thc basis for ACLS ccrtification. Studcnt pcrformancc in thc MEGACODE is subiectively cvaluatcd. Morc obiectivc methods of evaluation havc not b e c r - rt c s t e d f o r i n t e r o b s e r v e r r c l i a b i l i t y . W e t c s t e d f o u r d i f f c r e n t mcthods of assessmcnt for intcrobscrver rcliability, with each mcthod having incrcasing amounts of structure and obiectivity. Twelvc ACLS students wcre testcd using a single standardized MEGACODE sccnario script, in which programmed resuscitation tcam assistants gave a uniform, proscribcd degree of assistance. Each studcnt wai simultaneously graded by four pairs of graders, with each pair using a differcnt method of assessmcnt Thc com"pass/ Donents of each method werc as follows: l) a subjective w hich p e s t a n d a r d rformance i a i l " a s s i g n m c n t ; 2 ) a c h ec k l i s t yielded a numerical score;3) thc chccklist standard plus a writrecord; and 4l the checklist standard plus a scripted i.n.u..rt response guide. Score corrclation between gradcrs was highest.by - . l h o d 3 { t : . A l , P = . 0 0 1 4 ) .S i g n i f i c a n t s c o r e c o r r e l a t i o n s b e tween graders could not be demonstrated with methods 2 or 4lr : . 4 9 , - P = . 1 3 ; r : . 2 5 , P = . 4 3 , r e s p e c t i v e l y ) .M e t h o d 4 p r o v e d technically difficult to use, resulted in a significantly lower mean score. Method I, the method commonly used in ACLS courses, showed no srgnificant agreement between gradels. We conclude that the use of an objective method of evaluating MECACODE performance scoring can result in improved correlation between bbserver's scores. we recommend that a standardized method be employed for grading MECACODE student's performance.

Using PLS1 ' an Artilicial lntelligence Glustering Algorithm' for Medical Fesearch

R P i o n k o w s k i ,L R e n d e l l / M e r c y H o s p i t a l E m e r g e n c y D e p a r l m e n t , U r b a n a , l l l i n o i s ; D e p a r t m e n t o f C o m p u t e r S c i e n c e , U n i v e r s i t yo l l l l i n o i sa t U r b a n a - C h a m p a i g n This paper evaluates the potentral for using artificial intelligence in-the area o{ medical research. Specifically, the Probabilistic Learning Systems (PLSI) clustering algorithm was investigated. What clustering algorithms realiy do is classification - generating a description of the ciasses within the data that are given. A primary reason for using PLSI-is that it accomand noise within the data by having the inmodateslncertaintv ductive criterion incorporate both probability and error. The thrust of the paper is to suggest a tool, PLSI, that medical re-

Videotape Review of Gardiac Arrest Resuscitations: Analysis of Elements of Resuscitation Team Performance

tarled consent {orm from one of the investigators. The study will be discussed again in more detail. If he then declines ro parnclpate the drug and/or study protocol will be discontrnued at that time. With this method of obtainins informed consent the IRC felt the rights of the patient would be sufficiently safcguarded and has approved the study. This approach may help guide others developrngsimilar ambulance studies, but both public debate and w e l l - d c f i n c d r e s e a r c h w i l l b e n e c e s s a r yt o d e l i n e a t e t h c b e s t p o s sible approach to protect patlent rights.

CE Saunders, PK Makens, CA Barton, HR Hutson / School of Medicine, Owen Graduate School ol Management, Vanderbilt U n i v e r s i t y ,N a s h v i l l e , T e n n e s s e e Measuring the performance of a medical team resusclraung a cardiac arrest victim is di{ficutt due to the highly varied composition of the team, the diversity of cardiac arrest scenarios, a lack of defined performance criteria, and the absence of a reliable method of observation. Outcome measurements arc coarse and impracticai. Using a videotape review of resuscitations of cardiac arrest victims in the Emergency Department, we performed a descriptive study to analyze the elements of team performance. Each resuscitation was reviewed by a panel who rated B elements of team performance on a scalc of l-5: l) leadership, 2J tcam organization,3) adherence to ACLS protocols, 4) team-member interaction, 5) knowledge, 6l data observation, 7) therapeutic timeliness, 8) procedure skill. TWenty-three cardiac arrest resuscitations were videotaped and analyzed. Scores for leadership, knowledge, adherence to ACLS protocols, and team organization were highly associated with scores of many of the elements iSpearman correlation coefficients > 0.5J,suggesting a relationship between these and other elements o{ performance. Scores for leadership, adherence to ACLS protocols, procedurc skill, and therapeutic timeliness were significantly lower than scores of other elements (Friedman two-way analysis of variance; P < .002) impiying poorer performance in these areas. Team leaders from teams with high leadership scores tended to be characterized as aggressive,confident, and authoritarian, while those with low scores were passive, quiet, and disorganized. We conclude that videotape review of cardiac resuscitations is a feasibic means of observing resuscitation team performance. Leadership knowledge, adherence to ACLS protocols, and organization are associated with other elements of Derformance. Unlike knowledge and ACLS protocols, current methods of teaching cardiac arrest resuscitation faii to address leadership skills

A New Model for Providing Emergency Medical Gare in Large Stadiums

D W S p a i t e , H W M e i s l i n , T V a l e n z u e l a ,E C r i s s , R S m i t h / S e c t i o n o f E m e r g e n c y M e d i c i n e , C o l l e g e o f M e d i c i n e , U n i v e r s i t yo l Arizona. Tucson To dctcrmine the proper priorities for thc provision of health carc in large stadiums, we evaluatcd the medical incident pattcrns occurring during a four year perrod in a major college facility and combincd this with previously rcportcd information from other large stadiums. Medical incidents wcrc found to be an uncommon occurrence (1.20 to 5.23 per i0,000 fans) with true medical emergencies berng evcn morc unusual (0.09 to 0.31 per i 0 , 0 0 0 f a n s ) .T h e c a r d i a c a r r e s t r a t e w a s l o w ( 0 . 0 1 t o 0 . 0 4 e v e n t s p c r 1 0 , 0 0 0 f a n s ) . H o w e v e r , t h e r a t e s o f s u c c e s s f u lr e s u s c i t a t i o n i n three studies wcrc 85% or greater. In our own stadium, all four vrctims of cardiac arrest wcrc succcssfully resuscitated in thc ficld and arrived at the emcrgency dcpartment with good vital signs and normal neurologic status. Each sustained an episodeof ventricular fibrillation and was defibrillated by stadium ALS personnel within seven minutes of collapse. All prcvious studies (4) werc descriptive in naturc and failed to providc spccrfic recommendations for medical aid system configuration or for response t i m e s t o m c d i c a l e m e r g c n c i e s .B a s e d u p o n t h c s c f i n d i n g s , w e p r o posc the following model: I. ALS carc availablc within 5 minutcs t o a l l p c r s o n s i n t h e s t a d i u m w h c n i t i s a t f u l l c a p a c i t y .2 . A l a r g e network of CPR traincd persons throughout thc stadium (proba b l y u s h e r s ) ,w h o c a n i d e n t i f y p a t i e n t s i n c a r d i a c a r r e s t a n d i n i t i atc CPR immediately. 3. Communication capabilitics between all sections of the stadium to initiate immediatc dispatch of ALS personnel.4. On-linc medical control cither by radio with an ALS base hospital or from a physician present at thr: scenc..The physician, prcferably trained in emergency mcdicinc and/or critical care, should bc familiar with the out-of-hosprtal management of cardiac arrest. 5. Emcrgency transport vehicles easily acccssible and immediately available for transport to the nearcst appropriate f a c i l i t y . 6 . S u r v e i l l a n c e o f p a r k i n g a r e a sj u s t p r i o r t o a n d i m m e d i ately following games. This will provide early ALS care to victims of cardiac arrcst in a srtuation where the regular EMS systern will have difficulty rcspondrng due to traffic congestion in t h e a r e a . 7 . F i r s t a i d a v a i l a b l e i n a n e a s i l y a c c e s s i b l e ,w e l l - p u b licized area for minor medical problems. Previous investigations havc not enphasized short responsetime to cardiac arrest in stadiums despite the fact that salvage rates are very high when early ACLS care rs provided. Wc believc that the use of this modei in large stadiums throughout the United States could savc as many as 100 lives durine each football season.

Informed Consent for Pre.Hospital Administration of Tissue Plasminogen Activator (t.PAl: lmplications for Research in Emergency Settings

P Grim, P Grivas, T Feldman, S Hakim, R Childers / Sections of E m e r g e n c y M e d i c i n e a n d C a r d i o l o g y , U n i v e r s i t yo l C h i c a g o We recently developed a system to accurately diagnose myocardial infarction {AMI) in the pre-hospital setting. This would allow hospital-based physicians to order administration of thrombolytic therapy in ambulances. However, the developmcnt of a protocol for pre-hospital administration of t-PA and rts review by the Institutional Review Committee (IRCI has raised important ethical issues about appropriate ways to obtain rnformed consent. Previous ambulance drug trials have focused on patrents unable to give informed consent in any way iie, cardiac arrest). Consent to participate was frequently deferred by investigators and obtained from relatives after the fact. This study will involve alert, presumably competent patients who should be able to give informed consent. It is not clear, however, whether consent obtained from an acutely ill patient in an ambulance by a paramedic can be truly in{ormed. Given these issues we have designed our protocol to allow both, l) quick initiation of thrombolytic therapy in the ambulance, and 2) protection of patient rights. We use a 2-phase approach to obtaining informed consent. During the first phase patients will be requested to enroll in the study by specially trained paramedics who would read aloud a short consent form the patient would sign. Patients will be guided in their decision to give or withhold consent by a prepared list of answers to expected questions and by radio communrcation with the telemetry physician. During the second phase after arrival at the hospital, the patient receives a second, more de-

.100

Value of Serum and Urine Greatine in the Emergency Department Diagnosis of Acute Myocardial lnfarction

O Vanhaute,W Buylaert,M De Buyzere,I De Scheerdet J Delanghe,M Baert/ Departmentof EmergencyMedicine, Cardiologyand ClinicalChemistry, Hospital, StateUniversity G h e n t ,B e l g i u m Creatine,a constituent of both cardiacand skeletal muscle can nowadaysrapidly be determrnedin serum and urine, and has aiready been suggestedas an early marker of acute myocardial in-

patients admitted to farction {AMI). We studied its value in I33 department becauseof retrosternal pain sugiir. .-.ig.""y urine and sestiveof AMl. Creatrnewas determined in serum and and/or serum in concentration the *r'.n p.*i". i',X';;,i,id;;;J irg/L. In 83 patients a final diagnosjso{ AMI was ;;;;;;;-;10 ii lr'" i,'te'isi"e care unit' In this AMI sroup' the -;. ;;;;";iiy (i.e., I mm ST:elevationor -decalationin the iCC"*".'potitive -decalation in the andilor'2 mm ST:elevationor Itlnarra-tlrat arrd CKMB values CK (637'i; the leads)in 52 patients oi.""iaaf '*'"t" CKMB > l0%) in 5 l.**. ri.'e., 'and cK irso ull, 376c with serum creatine was positive in 25 pattents A'Z"f "rJi"-f .o"ta be obtained in the emergencvdepart ifii:i ;;;!r*pt.t j AMI patie.tts,urine creatinewaselevatedin both' 1".r,'i" ""iv 8l had a normal serum creatine' In the remaining "".-"i*ft"rn the intensrve lilr p"ti""tt the first urine samplewa.sobtained f ; 6 hours aiter admission when these first :;;ffi;;ii; were taken into account, creatine was considered ;;.-;;;;l"t non-AMI "".i"". iri Ze% of these AMI patients ln the 50 other pectoris was retained' In angina oi Ji"g"otit i-"i ;;;i;;;t,;" of -tzonl,""',a-ission was sussestivefor AMI in l0 ;."86b i;i;;;l" CK/ of elevation an showid them of none lit.t""pr,i*" urine) in 7 CKMB and creatine was ialsely positivâ&#x201A;Ź (serum.and/or

ili";"tJli;t;i.

;.Lv u.*""

to the '"set of painandadmission

not significantly emergencydepartment ln non--AMIpati;nts was incidence o{ di{ferent from AMI grorrp.Attfto"gh a rathtt high group the incidence of creatine positlvlty o""r,,J'it' the noin-AMI deoositive creatlne,n an. ."t"pt.s obtained-inthe emergency in is significantlv higher than group {ieles) ;;;;;,'t;;h;-,r'Mt results the angina pectorrs gto.,p 17lS0,P< 05)' These :1q9,"-t: of the emergencydepartment,creatlne iirrtl"'tfr" ciinical seiting -patients more pain is retrosternal with for AMI in "tl -rtt., sp-ecificthan more and CKMB, than ,p."lf* r*.ili*-U"ii.r. were able to pass icE. o"t data also suggestthat if patients the sendepartment' emergency the ;fi" admission-io ;; sitivity of creatine might even Increase'

-1

using 3ll,fffJ"E,J;'in,9::teria J dougherty/ Akron GeneralMedical Cente(

ol J Carter, C-ottins,

Ul Cbllegeof Medicine'Akron Ohio Universities Northeastern described HvDeracuteT:waves tHATWs) have been-previously seen m',jfi .-pfii"de, primary Twave abnormalities,sometimes Desptte infarction myocardial transmural of phasei ."tiv i" iit" presenceand "tta ""i-"i ttudies addressing.the ;;;t;;itJ;rn held, reliable significanceof HefWr, ifr.i" ,,iff-.-*lr no wiiely

1 02

=fflfl"Ti:P smear H"%T""i,'f' Examinations in a High'Risk

Patient Population Tovar/ Divisionot AF Gaidner'-RT DS Coffman, MM Levine, TexasTech Surgery' ol Department Medrcine, it.L"n.v Texas Paso' El Medicine' ot Univeisrtv'school

ls not Routine Papsmear screeningduring pelvic examinations are many reasons There practice' department r,""a"iJ"-.'tgency trequent assumpi"i-"* p"ti"ttiing'this examination; the most ln ,hrt th"epatient will have it performed elsewhere ;;;'f,efi gvnecolh;spltat, "o-ptiance to follow up with the ;;;^;;iy referral approximates "*u "il"ii aft.i .me'ge"iy department the incidence ol determine to *t' :3t .'ii'; ;;;i'";-;"''t;av population patient non-compliant irtit i" rig"rri"r",}?nJ"gv is useful Sigand to determine rt emergencyroom intervention a Papsmear class II or higher' nificant pathology was co"nsidered ^o;;;;-,';--oriih period, we performed 33,routine Pap smears were those over l8 during pelvic examinations'Patientsincluded vaginal bleeding'-andwhose last Pap ""tiut ;;;;""i;;;;ilho,,t Those-patlents smear was at least one year prior to-examination' malignancy or surgery gynecologic p,"uio"t of *i,ft-"'rtlt,oty Pap smear results were excluded.fft" pttltntS'with ab'normal lo the gvnecologvclinic The were contacted""d d";;;i;;;r"tita stated ihat they had averagepatient age was32 Sevenpatients unsure when patients.were seven and smear, Pap a had never of The average.length petfotm^ea. previous "*r-rr",io]i-*"s their one unhad p"p 3'3 smear'was vears.we rrtt ;ffi'.;;;;;t" one Class III Pap smear satisfactoryspecrmen,one Class II, and of significant pathologv was 6'25% in ilffi;;;:'+#;;ft;; iontlol ii our hospital o{ our patient popt,tr,tott1-o-p"t'ta to the clinics' We strongly feel our at ptii6i-"a 2.7% olall Pap smears the emer8encydepartin that routine I'ap smear'examinations and will be cost-effectivewhere ment are medically ";t;;;**, medicalfollow uP is inadequate'

103

of Patient HistorY in -Oetermining ReliabilitY the PossibilitY of

PregnancY AD Sacchetti,M Nepp I O91L301 ol Lourdes EA Ramoska' MethodislHosprtal MeOicatCenierEmergencyDepartment; Emergency University Jellerson Thomas Department, it"roun.v Philadelphta Program H,f"Jdin. Residency B c c a u s e o { t h e i m p l i c a t i o n s o f f a i l u r e . t o i d e n(EPsl t i { y - correctly pregnantpa. it is imperative that emergencyphysicians tierus a using "d'"tification the emergencydeth.i';;;;;; P"9i4ry ;8e';;;;ioi recognizethesepatrents*htn ttt"eypieient.to Realm ECC Packard Hew.lett a on prot'"the early stages' in computer paiticularly designed Dartment.Physicalexamination, 13,393adrrlt electrocardiogramsto making this diagnosis'foTjtt"Til: analysis system, we scr"eened i" inr.","î' i.-;;;;;i;";i; "-ptitudes greater than accepted ti,L.. tt",ri.tg r*,"" iil;iify ,.tu-o" p",i."t history or laboratory-determinatir ri-t leads; >i'omv precordial leads)'utiliz;;#dr-(;-o.s-v "i-p"iitnt'ttittoties in dctermining the ;"t*t:-;;'i.iiruli"v with Patients ielected ing this criteria 513 a;;lt tCGs were we evaluatedthe correlationbetween p"*l[l"v 'speciflc "f pr"gr,r,tiy (eg' bundle-branch blocks' other known "",rr., oiiîtC*ût' and the presence"t questions historrcal n }iStitil:#it::i u."t., PVC', ""tttti"ular.hvp,ertrophv' hvper;;;-;;";t;"p. ;".;;- ;;b""ii ;a h,r-att chorioni c gonadotropi { sexual activity, complaint, cf,ief k a l e m i a , a n e m r a , a c u t e C N S e v e n t s , r e c e n t - o n s e t h y p e r t e n s i o ndata } of age,_ consrsteJ collected Patients with tall ampli.i'; ti"dv t"-pit or birth contror' and tvpl aiJi;; il'"'.itri ;;'; ;il;i;i;;J;';;;ir'hi"o'v' then *""i o" to develop clinicallv veri{iable ;;;; i;;;;;;ho group The HATW theas were-iabelled myocardial infarction tall T:wave group for each of the hisiiATw ;t;"p (N:21) represented4'1"/oof the 33 |3z%\pregnanciesSl"tiitlt'f significancetwo tailed t patients not previouslyexcluded'who Stud-ent's a t"-"i"iig Tli.r. using sisj. ittt'mined *"' iN: torical parame,.,, Early Repolarizamenstrual last the questio;"was did not meet HAIW "liiE i", were Iabelled as. test. A positiv. r..po"'Jlo-tt" Variants {N : 58l Since Early.Repolarization only single stastically significant aniio.t-V"ti*,t (ERVS), the was time?" period on as HATWs' "r. fr.qrr..ttly a sourceof {aisepositive identification and difwe utilized this group i's ' "o"itot to study similarities periodwasnot betweJn Hetws and ERVs Both.grouos underwent i;;;.; this questron*"t" pttl"""i If ihe last menstrual wouldhave amplitude' I )"Twive a""ivtit-ia""tiiying:, pregnancies of morphology 316'5"/") computer o"ty and ""rvi" ii-. t,r, .t6trn1.i missed if in addition to a atrs^;;ph"a" ratioiil f-pointposition; ;ilil;;;;"fi been missed No p,.gtt"tt"its would be or concave shape-(convex' and slope, amplitude 5t s'it"i-.", n o r m a l o n t i m e r ^ , t m " " ' t . , t p e r i o d t h e . p a t i e n t n o t e dbecause s h e w aof s morphology paramHowever' straight).We comparedthese computer ECG also practictng .o-. ioirn"o? Ulith to"ttot discriminatidentify to this ERVgroups and characteristics three the'HATW 'tt rt""i"g ",.i-.'U.i*.." the small number "t ;;;;;; inq characteristics.

Tll Kjril:ti**:*xl;l;:*:*;:;:lu:.;:JilJ:,n'f ji':"3*:f 'il;"J? :x:*;rh*i;:t";'il;',:,';"t',:T:

hisnurnbcr was not statistlcally significant This study,suggests of prcg,,,rr."i a.,, are unreliablc iir dciermining thc p.ssibility nancy and supports thc libcral usc of labor:rtory dctcrminations of prcgnancy in thc ED.

104

3:"ii:r,:f:'ff"41"".l?i"'

B M S i n g a l ,J F H e d g e s , K L R a d a c k / D e p a r t m e n t o f E m e r g e n c y M e d i c i n L a n d D e p a r t m e n to f I n t e r n a lM e d c i n e , U n i v e r s i t yo f Cincinnatt for Dccision rulcs dcrivcd from analysis of clinical variablcs guide tl-rc t f - t e r ip i " J i . t i , , n o f o u t c o m c h a v c b c e n r c c o m m c n d c d t o rccotllor.l".ing of tcsts. Tcst ordcring dccrsion .ru.lc'sgcncrally Thc , - r " r " r -,r'd, o t t c s t i n g p a t i c n t s w i t h . a l o w p r o b a b i l i t y o f d i s c i r s c p r < r s p c c t i v c ' l yc o l l c c t e d o " i o , , * , , f t l - t l si i u d y w a s t o d c t c r m i n c i f p r . , l i . , u t t o { r a d i o g r i p h i c p n c u m o n i a - i n a . d u l ta n d p c d l a t r i c c m c r p,iii"..t .u.,l.t inlpti,u" upon thc.physicians' prctcst probai"tC cmcrLility cstimatc of pncumonia as a guidc for ordcrrng stat scncv departtucnt {ED) chcst films. A prospcctivc obscrvational ;;';-'.,,".luctc<l in a communitv hospital ED Expcricnccd ;;;;; whiclt . n t " i g . n . y p h y s i c i a n s c , , m p l c t c , J: l t w o p : l r t q u es t i r r r t t r r i r e c l i c i t ed . f i t i i . , , t d e t l f r rr n r t h " h i t t " t y r r n J p h y s i c i r lc x a m i t l a t i o t r discasc ancl thc physicians' probability- cstimatcs.of various vari""il,i"r rif.irl-tl" to thc chcst, bcforc chcst film rcvicw Thc subicctcd ,t i". t..t- thc history and physical cxamination wcrc (logistic rct u i - i u a . i a t c ( c h i - s q u a r c a r i , r l y s r s )a n d n r u l t t v a r i a . t c (n:255)' fcvcr' l n < t h r o u g h o u t ) O s a n a l y s i s 1li ei"rriort) -:rdults ;;;;i;l"t, and cough wcrc found io bc prcdictrvc of radi.graphic r (as dciineti by an indcpendcnt clding by a board ccr"n*-"iti, Thc p."t"n." of-crackles was thc only indcpcnil.d;;d.,tl;st). of'racli.graphic p'cumo'ia i'r children lcss tl-ra. lii a.rip.ai.,,ii ilcciv c z r r s " { n= 7 8 l . W c . n t r - t p o r " . lt h c p c r f o r r n a r - r c co f m u l t i v a r i a t c i l i . t f , , i a . l L r l t sa n d c h i k l r e n w i t h t h c p h y s i c r a n s ' p r o b a b i l i t y l;; prcdictivc .rii"-rnt. t-ty t-t-tclnsof RC)C curvc analysis ar-rdncgativc pl-rysiciat-t u"i". o""fi.i.. Thc arca undcr thc RoC curvc for thc + 041 vcrsus '729 )' 042 pi"tcst pt,rbabtlity cstirnatc was 750 - NS) Ncgattvc ior thc'logistic rcgrcssion rnodcl in adults (1) pl'ry.sician nredictivc'valu". *".. 96'1, Ior both thc I'nodcl and a <10'2, in adults Thc ncgativc prcdictive o f c s t i m : r t c i t y iriuir"t'ttf valuc for'pncumonia in childrcn was 78'Z' for thc rcllrcsslon <10'Z'' n - r , r d " la t - t , L 8 0 ' X f, o r a p h y s r c i a n ' s p r o b a h i l i t y . ( ' s t i n l a t c o f W c f c r r r n <t.hl a t t h c d c c i s i . i n r u l e p a i a m c t c r s t r d d l r t t l c t o s c a s o n c d clinicians' ovcrall imprcssions. Wc applicd othcr publishc.d.dccrfor thc ord'cring of chcst lilms to our data ancl found ;i;;i.. thc.rccu t l n . . " p t r t t V l o w n c g a t i v c p r c d i c t r v c v r l u e s ( . 7 4 - i { B ' )Zf' o r iules. rhise who sc.k to hmit thc ordering of chcst "--.tli.a of thtsc i i l . , - r su i n d e c i s i o n r u l c s m u s t b c a w a r c o f t l - r cl i m i t a t r o n s a c c o u n t ablc for h e l d b c a n d a c c c p t t o w i l l i n g b c a n d ,".f-r"iq"". somc prcccntagc o{ rnisscd diagnoses'

.105

tcst obtaining irtr abntlrnlal rcsult that had a clcarly bcncficial i l - n p a c t o n c l r n r c a l c a r e w o u l d c o s t $ 5 , 1 J 2 0i n u n n c c e s s a r y t c s t s prcS " . , r r a ^ r ' t t y l " . e d c t e r t l i n a t i o t l s t l o t . t t t tr c l i a b l y o r . a c c u r a t c l y clict tliseasctrr scverity of illncss i[r acutcly rll adults, cspccially ,,i .liffut" .r l.wcr e5d.'rt'ral c.l.tlplaitrts our rcsults ;;r-;; tlr i n t l i c a t e t l " r a tt h c u s e t t f s c r t t n l a t l l y l a s c : 1 s : r r o u t i n e r r d t n i s s i o n t h u i n c v e n d t s c a s e , P r c s , c llcu a t r d t l t n i t r a l s c r i t l u s i t t r t e s t ,ara"t.t,r'tg . i a b d u ' r i i n a l t r i r u l ' l l , c r t r . r r . r .btc i u s t i f i c d . E v c t t i l t c a s c s i . v r l l v i n g " i l ' r t t - t , , ti n g e s t l o l t a n c l u p p er a b d o r . r - r i n asly n r p t t r m s - l w h c r c c l c v a ' ) rovcd ttr bc of lrttlc valuc irl frcqucntiy I.totcclp iulri, *.t."tt,,st n l i l t l : l g c n l c n t alld tllsposltlou. c l l a g t . t t l s i s , the Datict.lt's

106

The Usefulness of Serum Electrolytes in the Evaluation and Treatment of Acute Adult Gastroenteritis

y e dc t n e ' , M a s o n/ D e p a r t m e notf E m e r g e n c M J S O l s h a k eJr D NavalHosprta, San Dlego,Ca ifornia A c r . r t eg i t s t r o i t l t c s t i l l a l d i s o r t l c r s l l r c i l l l l o l l l l t h c l l l o s t c o n l l . l l o n p r 0 b l c r T r sc r . r c o u n t c r c db y t l . r c c l t r c r g e r l c y p h y s i t : i a n . I ) i a r r h c a dcpartI r l , , n a " . . , , . , , . , , s f . r a l r . r . r . . s5t ' X , . f v i s i t s t o c l l t e r g c l t c y . , r - r c , ' t t sI.n t h i s c o L l l l t r y t l i a r r h c l t l . t r t c l t t l t si s r a r e l y l i f c t h r c a t c n of days i ; ; ; ; I * , i t i r r . . , , n , l , r i r l y t " t h e u t r r l r r r ) ' r t r . c r r l d ,I t rcsa u s c , . r k . C l i n i c a l ex p er i u . c e g r t i r et l t t r t h r s i r t s t i t t t t i . ' a n d li,.i fr,,n-w scrunl frot.n discttssiotrswith ctlllcagltcs itl others stllll{cst that of itrdic l ec t r t r l y t c s a r c c o l . l . t t . l t o n loyr d c r c d . i t l t h c c v a l r r r r t i o r l v i d r . r r r lw s i t l " r g a s t r o c n t c r i t i s E l c c t r o l y t c p a r l e l s ,w l - r i l ci n c x p c n ranl(lng sivc per test, arc a trlaior cotltributrrr ttl hospital costs' one study trii*li rut",ng all laboratory arld radiograpltic tcsts in , , . , , , t 1 . , .Y. .c t w 1 r c ' l . t r k c t l a t . t l a 6 r t l a d s c o p e t h e y rrnd twclfth 1,.n rei.t"fv yi.fl clirlicirlly sigrlificrrntdatit Wc retrr)\leetrvL'ly dcpartv i c w c t l t h c c h a r t s o f a l l l r i l t l t : n t ss r e n i l r , , u r . : l r c r g c n c y tlf m c l l t i l l i r r e c c l l t s l x , . t . t , , , t t l tp t r t o t l w t t l l ' t J r t c l t l r g e d i a g n o ' s i s or tlvcr 60 was I t t t l f t h c l g c t t t l r l c r A n y t l l l c r i t i s g a r , r , , " n t e ,r..,,. Elec. i * . l r . i . . l f r r r t l rt h c s t u d y 2 x I I r r t i u n t c h ; t r t s w t r c r c v i c w c d ; " t . o r d c r c t l o n 2 0 7 o f t l r e 5 up r t i u n t s t ) f t h c s c ' 2 4 \ l l " l ' ) ;;,;;i;; ( l ' Z ') t r a d h . i t ' " l " . t r , , l y t c i t b t r o r u r a l i t rse l l r - r to r l l y 2 p a t i c n t s ds v a l u c s c l r n i c a l l y s i g n i f i c a n t c l e c t r o l y t c i t b t l r r u r a l i t i e s ,d t : f i r . r c a thcsc pathat affelctcilpllticllt treatlllcrlt trr disposrtiorl Onc of ti.lnt, *"r ,r .i9-ycar-old fcnlalc witli dtabctcs and hypcrtcnsion was'J'l' w h t t w a s o n H C T Z , L o p r c s s o r ' ,a r l d l ) i a b c r l c s c ' H c r K ' T h c t l t h c r w a s a 2 g - y e a r - t l l d w h i t c w ( ) l l l l , l l l i n h c r f i r s t t' r i n r c s t c r t t f p r e g n . t t r c yw i t h : r 2 w e c k h i s t o r y o f l - r y p c r c t . t . l c s iHsc r K w a s 2 l i ' ( i Z , Z ,) n " A o r . r' r c s c r t a t i o ' . o r t h o s t r r t i c v i t a l s i g r . r ii;;;ii.,.',. 5 (10'U') l f - t " i r S " t ,c l c f i i c t t : r s a p u l s e i t r t l g r s L r t f 3 { J . t ' t l s t a n d i n g a b n o r n ] a l i t i u s . Z c r r r w e r u el i n i e e l l y s i g n i f i c a n t . I I nri.i i.i,r,,tyr. C ) n c p a t r c n - th l d c l c c t r o l y t c a h r - r o r i . r u " t . r i t i s ' z ,fi w c r c a c l m r t t c d . i r - r a l i t i c st h a t w c r c n o t t h c r c a s o t l f o r t h e p a t i c n t ' s a d m i s s i o n Wc con2 . r , , h " d c l i n i c a l l y s i g n i f i c a n tc l c c t r o l y t c r b n o r m l l i t i c s ordcring of cludc that thcrc is no iustificatittn for thc rolltillc "t".,t,,lytcs on tl.rc adr-rltf atient with acutc gastrocn:.:;Xltt

Clinical and Cost Effectiveness of Serum AmYlase in AcutelY lll Adults

1 07

J D W h i t e , K G h e z z i , D P e t r u s k a ,A S l o t k o f f/ D e p a r t m e n t o t Emergency Medicine, Georgetown Un versity; Department oT f m e r ! e n c y M e d i c i n e , G e o r g e W a s h i n g t o n U n i v e r s i t y ,W a s h r n g t o n ' DC hacl Threc hundrcd and twenty-one adult cmcrgcncy patients serum amylase determinatitlns performcd ovcr two consecutivc months at two tertrary care urbin teachir-rg h<-rspitals'Abnorn-ral paticrrts' levels were noted rn 15.5% of patients \2O% of trauma wcrc 15.3"/" oI non-trauma patients, P : '28)' Most clevatlons were obtained results o{ abnormal maiority vast the and modest, upi" or,i"nat with acute alcohol ingestion and prcsenting with complaints. Less tiian 1% of scrum amylase deter".irUa"-i"rt managcminations changed the treating physician'sdiagnosis' case was ment was significantly altered in only 1 case, and rn no 25 pet ih.r. r.ry iripact on disposition. Based on a cost of $18

i"JHt?:fffTi,t'$l'-.''n" TheoPhYlline and Chemistries in

the Emergency DePartment ot E Skobeoff/ Department WH Spivey, RM McNamara, E m e r g e n cMye d i cn e ,T h eM e d i c aCl o l l e goef P e n n s y l v a n r a ' Ph tadelohra dcThc ability to rapidly pcrform blood tests in thc emergency o".arr-l"t-,rshoulddecrcascpatientturn-overtimeandimprove.paof an i...tt.ur" by allowing calliur intervention in thc event The r a n g e t h e r a p c u t i c t h e o u t s i d e l e v c l d r " u g a u , u"ltt" ,tr""t-rf analyzer Abbott Vision System is a desk-top clinical chemistryand rethat uscs two-ciimcnsional centrifugation to mix samplc i" a disposable acrylic test pack The resultant mixture nl""t results are ,r"nd"rgoa, spectrophotometric analysis and the

inara.rge, rheutilityof.thissvstem printed r'0"1':i:nl:n?ff: 1 09 *"t studied for serum theophylline levels ili"Tio vis.ion (Vl results istry panel of glucose,Biii.i-;"J.r"riini.,.. t'toi"ioty il-1-u'y irtt^i]i"-rtttpittl "'f those to compar.d were ,"J ".'. Ir toi calculation of pearson."rr.f.ii"" coef{iclents1"."t Iows:

Levers Mean Rare uTn''b"v'" Rare v Success V success '-

il:,:l'"",?lflitf.1iHffl:acheal

DJ O'Brien,DF Danzl,EA Hooker,LM Danrel, rt'r-cboruniuniversity of LouisvilleSchool of Medicine by paramedics ut-a nasotrachealintubation (BNTI) attempts reviewed' In particular' *t'T:: r u r e v v L r v pttp"tt*ely L r r c rfitfa"*tit ri" r r tnt vrvvrv---.--l complication

rate'

fre-

'T"1 .".;;*.Nil;*I3+lT;:l,l-f"1Jo'ifl%'r1';1i,1;","J':ff

^':-^ ::ljfr H5:*;".*rlrt';*:r*'i# J;ix'i::T:ti?'#: '+i:?.1""1'

i:['GT,T;: ,?i;il:,';:; :;,:il:::3: $:m:i:ia*-,"';lilJ:t"*l ,'oo,;z :T",1|l,z"z'^2" 177* 137ms/dL16e+ 141ms/dlOee 258t26s(s6%\ \rv /o I

lJul\

BUN

lcot aor

creat

(98%) 283/288

1.6 * 1.4 mg/dL 13 * 1.3 mg/dL0978

+ 5 2 minThe mean time :r SD to obtain a V result was 13.2

"' ,i*lq:::l tt mimrtes 3'6 minutes t24+t.3 andr2'4 and theophylline fortheophylline utes for utes T"Uti;Ti'i::

"g"irifit

in iuccessll:" increase

llTt"Y'*tliTj:^11"i: (P < '005) Maior comtl,r.r tirt.. lim.s d,r.itrgthe study oeriod ilut' t"t" *"'lii;i-6:qzl

The itt"itlttt"t of complicationstended

BNTI is a safeinitial field airwav i::iJi:i:i:llu:tx:::w$1,3)1f:'lJ;L:tti.'i:i\xJ;; ll.i".iritr".al-signiflca*nic. are

inwhom.there patients u,91thing forthe ,pp.o,.f,in",!1.i"?'.""'rv iie"l T|"ff3t:'fr:;i?,$il:l"TiTu"o(t.':T"*inutes

;:';1 ll,ll":nl*:xlr:"d;,t"Tlll"";':":":';1"'J'? *itrft#niii5*kTffi[Tj:i*'-J:ffii'::1ffi:'# ffi;?;, ment62!oof the time ror theophyiline and.26"/o;;';# pn^"'' ii;i of the pa the chemistry pr.t"r. noith"ift"tittvrrln" had more rapid admission or dischargcdeciii."it'*""n'f;ve minutes ln no sionswith a mean trme savingi So o{ 109 I 50

paticnts with ..a,,r.'ip'p"."rtt p"tttur'iry suited to trauma tial cervical spine injury'

*1 "1fii:51;11,g$T!il:ii*::Tlt IO ix'.'JJ::i;l$i#i;J?'r6";.7;T:Tj:"$'-,""$'.',t"Ltilt i"ilt automated,,"q"itittg only thc addition o{ a two-drop ;il; andmachincload'br finger-sticksampleof blood toihe iest pack ttooa, ;itttciw}rot" ""n",ffir!i;1.pr*J;; ,t. of virtue ing. By "walk then can op-crator The "Sta *"y-f" plasma serum/ or .tgt:ll ittit jaway,,and later retneve ii.'ptir,.a^i.r,iltr. paticnt f.r.it. p"r""tial for impiovci patientcareand decreased

ED "'""'"iii-'inthe

Outcome Medicine' M Joseph'DW Spaite/ seclionof Emergency center' sciences Health Arizona center' U.r"r.i),'v"oical Tucson prchosp1t?J^,p,tltonntl Lri.",rryroidotomy (c) is pcrformcd bv thc ticld hasnot i" '''r"v r'rc^sof thc'country.Howcvcr,its usc.in

tfuf'xi.T",;*jjljl,:i'"j"[T"'":l1l;:i"J::": n:? we-rc20 such t"'"r i it'"ito C;;;ia";i"g a 2 vcarperiodrhcrc

'.,:t*jir;r:ilt*t"*lrl*1,,!{,r:1,"1 o'Pe-dia'lc . l Og F:f,::n"ffiiit*rir:

orEmersencv p-a:,En'n rea r ^t"+.::[iTn f:E:I,"T,"# lutr*tl$$LH+lil]":'":'Lfi,t],r"',#t.ii;

Medicine,ValleYMedica

ffi*ilili.i "*.",**W"ii:i:i,5i:[{,!ji$i"S:{l#'u.419 nfilfiT',:".',iit;;i;l'"'"*ffi ;,-.'* iiil,T;;;;;'.q'.ryi/1;pr1";U:h::y*y*;i-i flg:m;"#j:|:'#:lJffiTil"$ *: ;U:,'J f:L""t#i pediintubatiolr *;;;;;tin {requently prehospital*Jo,ir.rr"rl i*i".Ji"-""a.paramcdic *h"r* rrr.rt, atric cardioresprratory ,.'J Lo-pti""trachealintubation was present,2) the success.r"t. with the procedurein the field, ,"a el ""tJ()te: tions associated

incisron in the ED Twclve c ( protocol)lndicationsfor C were rr". o'iai."i'..ntrol (allowcribv bi {ailed {7) and suspectedC-spineinlu' -ttti;;i;;'i;;il;i'(8i 4 5 motor vehiclc accidents' included In"lftl"isms ry iri'l"it'v

i.'"r'''a.,a--:l*:*:tj',: p.iilir,.'b "J'J,-J;';h'.;.", rheretrospecti,",,"av

lji"lff;.i::::'J:5 A::i,',ffi;'Tilf'li: rt'' 6"v't" $:q:ii':*ii"i?JffixJ',ffi';*'":"':-u' lliuj#JiJ[i';';,"'-ff'::1".:l:i',",'.xl'ff3'l"l'fi:,:""1T io,pi'^"i"'i'i*j'r*;:6;wi: uv "",iri,.a death certificates, and

l'*:ri:rum**j*i*iiti{j";,:,'i,i{fr1Tn:,H

;;ltrlifi'1,**i'*rilt**y;lffiit'"r-ihi'# Fhi'.",'$rjilf'ilt*[i,i'lti:tl1 ,.,"",^*a .",;i"f #tui'JiJ,UUi+llli,.;111ruH::llr vr:1;"Tl:'":"*i:'i1'dtfiiiTlii;:+:J patients died {85%) (ll' EDi 3' *"V oUttl"ttion lil Seven-teen 2 sustainedserioushead g, ",r*'iuo's, 3 A;;"g,th. rcu). on, state one patient vegetative chronic irrl,rrt. rnd'r.maine"clin.a

and a minor comphca ET intubationattempted than one year,only.i* oitO 137.s%)had p;,,i.*" oi,t.'ls and only three of six (50%)'were successfur. "i'it."ii"tpiirr, who were successfullyintubated before arrival

##i+fi n*f'i* Hr*r*'li*+,ur,l"',q*nfi*i*[iti:+*,:#+E -rihen.compared *itt'.,tt'"'zl"i;;;;1"" Ft','."Tflli;iimli;;W1f,il:li:ii:'""iiii,11'"1"t'"'' testf exact Fisher 08e, occurred

pi"uabry80 ri,r,itiiii ii,.lci ;il,;;;;;;iir,g. L,?;i, to an was-hanged ri.ta i"'ini ;1ll"T:fl,:"1T:ii**it*-.,mxiii.ili;f,li,l..';ffii[l i"i?-prr..a *rr.irTi6:-* to paramedics differfrom adultrates.Further,,rav'r, i.q.,ir.d the overallcompricationratewas -evaluate exist. why thesedifferences

--'i"u.

l" irt. rn. th.tr,

31%. No hemorrhagic cornplications were notcd. On-scene time ( O S T ) w a s k n o w n f o r 5 c a s e s( 3 1 % ) o f a t t e m p t c d C . O n e w a s 1 9 min due to prolonged extrication. Avcragc OST of thc remaining 4 c a s e sw a s 7 . 5 m i n ( S D : 3 . 8 ) . T o o u r k n o w l e d g c , t h i s i s t h e f i r s t investigation of prehospital C. We fourrd a high succcss rate { 8 8 % ) a n d a l o w s e r i o u s c o m p l i c a t i o n r a t c ( 1 3 ' 1 , ) .O u r f i n d i n g s support further investigation of thrs proccdurc in thc ficld as it m a y p r o v i d c i m p r o v r ' , lo u t c o m c r n c c r t a i n s ( t l n g s .

Accuracy of Transcutaneous, Transconiunctional and Pulse Oximetry During Air and Ground Transport With Induced Hypoxia and l{yperoxia e ,M K a p l a nM, B H e l l e/rU n l v e r s o i t ty J G a l d u nS, D u n m r r F Medicine; The Pittsburgh Afliliated Residency in Emergency Medicine Pennsylvan a, Centerior Emergency of Western rgh Pittsbu a A I I I I

The role of noninvasive oximctry during air and ground transport is as yet incompletely dcfincd. Thc existencc of thrcc distinct tcchnologics, pulse oximctry (POX), transcutancous (TC), and transconjunctival (TCf) and thc markcting of numcrous drff e r e n t d e v r c e s h a s l e d t o u n c e r t a i n t y . I n a d c l i t i o n , t h e c l i r - r i c a la p plicability of thcsc tcchniqucs during the rigors of critical carc t r a n s p o r t h a s b c c n i n c o m p l e t c l y a d d r c s s c d .W c c v a l u a t c d t h c a c curacy and reliability of fivc pulsc oximctcrs, a TC rnonitor and a TC| monitor. Each of l0 hcalthy voluntccrs brcathcd roont air ( R A ) , n a s a l o x y g e n a t 4 l i t c r s ( 4 L N C ) a n d l 0 ' 2 , o x y g c n ( 1 0 ' 2 , 0 2 )i n thc ED, a moving ambulancc, and a hclicopter at 3,000 fcet. A r a d i a l a r t c r i a l l i n e w a s i n s c r t c d t o o b t a i n b l o o d s a n - r p l c sf o r a n a l y sis and for monitoring thc blood pressurc and hcart ratc. Each pcrson served as his or hcr own control whilc bcing monitorcd with each of the dcviccs in thc thrcc cnvironmcnts. Our results indicate that pulsc oximctry accuratcly rcflcctcd thc saturations o b s e r v e dw i t h R A , 4 L N C , a n d 1 0 ' 2 , 0 2 i n c a c h o f t h c t h r c c e n v i r o n m e n t s ( T h b l c ) .C r c a t c r s t a n d a r d d c v i a t i o n s w c r c o b s c r v c d among the pulsc oximcters under hypoxic conditions with thc oxygcn saturation approaching 70%. No statistical diffcrcncc was noticcd betwecn the mean artcrial hcmoelobin saturation and thc m e a n p u l s e o x i m e t e r s a t u r a t i o n ( P > . 0 5 ) .T h c m o t i o n o f t h c h c l i copter or ambulance did not appcar to affcct thc rcadings of ar-ry of the deviccs throughout thc coursc of thc stucly. TC rcquircd a calibration procedurc prior to cach usc and thc values recordcd were not often consistent with thc artcrial blood gas data. Thc TCf also rcquircd a calibration procedure prior to usc and prcdictable trends were not observed with cach of thc trials. Our data s u g g e s tt h a t p u l s c o x i m e t r y p r o v i d e s a r a p i d a n d a c c u r a t c a s s c s s ment of oxygcn saturatior-r in both thc ambulance and helicopter undcr conditions of normoxia, hypoxia and hypcroxia. Thc calibration procedures and data variability obscrvcd with TC and T C | w a r r a n t a d d i t i o n a l t c s t i n g t o d e t e r m r n c t h c i r e f f e c t i v c n e s sr n the ED, ambulance or helicopter.

Location RA Ambulance

Arterial Hemoglobin Saturation (%) 96.3%+ .6

Mean Pulse Oximeter Saturation (%) 9 7 . 2 %* 1 . 8

4LNCAmbulance

979/ +

98.7'k * 1.4

10./.O" Ambulance

81 2Y. + 7.9

8 3 . 6 %* 8 . 0

RA Helicopter (3,000Feet)

9 4 . 8 %! 1 . 3

9 5 . 5 " / "* 2 1

4LNCHelicopter (3,000 Feet)

9 7 . 5 y o+

98.2%+ 1.6

1 0 % 0 2H e l i c o p t e r ( 3 , 0 0 0F e e t )

7 5 . 7 " k* 7 . 8

769%* 78

112

Evaluation of a Pulse Oximeter in the Prehospital Setting

113

A Prospective Prehospital Trial of Nitrous Oxide use in Urban and Suburban/Rural Systems: A Study of Efficacy and Side Effects

T J M c G u i r e , J E P o i n t e r/ B e r k e l e y F r r e D e p a r t m e n t , B e r k e l e y , C a l i f o r n i aD , e p a r t m e n to f E m e r g e n c y M e d i c i n e , H i g h l a n d G e n e r a H o s o i t a l .O a k l a n d , C a l i f o r n t a l ) a r a n r c c l i c sf i c l d t c s t e d a p o r t a b l c , b a t t c r y p o w e r e d p u l s e o x imctcr (PO) to dctcrminc its applicability and uscfulncss as an adjunct to prchospital care. Thc PO was attached to (r2 consecutivc paticnts who mct krcal critcria for mandatory advanccd l i f c s u p p o r t b a s c l " r o s p i t a lc o n t a c t . A r t c r i a l h e m o g l o b r r - rs a t u r a t l o r . l ( S a O 2 )l c v c l s a n d c h a n g c s o v c r t i m c w c r e d o c u n t c n t c d b y t h c l rinter and prchospital carc rcports prcparcd by parP O ' s i r - r t c g r ap anrcdrcs. Thc PO pcrformcd rcliably ir-r(r0 paticnts 196.7%l by p r o v i d r n g c o n t i n u o u s S a O z l c v c l s . F i f t c c n p a t i e n t s { 2 4 . 2 ' 2 , )h a d s a t l l r a t i o n sb c l o w 9 l ' 1 , a n d t h c P O d c t c c t c d t w o ( 3 . 2 ' 2 , ) o t h c r w i s e u n d c t c c t c d s a t u r a t i o l . l sb c l o w i l 0 ' X , . I n c a c l - rc a s c , f i c l d i n t c r v c n tion inrprovcd saturation. l)ulsc oximctry quantifics SaO2 changescorrclatcd with many prchospital intcrvcntions: medications, suctioning, prccariousgurncy transport, oxygcn therapy a n c l v c n t i l a t o r y : l s s i s t a n c e .P O p c r f o r n r s r e l i a b l y i n t h c f i c l d a n d c a r r b e r n v a l u a b l c a s a n a d i u t . t c tt o 1 l a t i c n t c a r c . F u r t h c r p r c h o s p i t a l o x i r n c t c r s t u d i c s a r c n e c d c d t o c v a l u a t c s p c c r f r cf i c l d t r c a t m c n t s a n c l t e c h n i c l u c s ,t o a s s c s s t h c o x i n r e t c r ' s c f f c c t o n n-rorbidityand mortality, antl to :rnalyzc thc dcterurination of scvcrc hyproxcmia in thc ficld.

P M P a r i s ,R M K a p l a n J L R y a n , R J l V a h a , F D S t e w a r ti T h e U n i v e r st y o f P i t t s b u r g hA f f i la t e d R e s i d e n c yi n E m e r g e n c y Medicine The Center for Emergency l\led cine of Western P e n n s yv a n i a , P i t t s b u r g h F r o r l 1 9 8 5 t o 1 9 u 7 , 4 . 3 9 p a t i c n t s w c r e t r c a t e c li n t l . r eC r t y o f I ) r t t s b u r g h E M S S y s t er - n w i t h a 5 0 : 5 0 m i x t l r r c o f t r i t r o u s o x i d e a r r c lo x y g c n f o r p a i n r c l i c f a n d s t u t l i c t l w i t h a p r o s p e c t i v c d a t a s h c c t . F r o r . r .(r) c t o b c r l g l l ( r t h r o u g l - rI ) c c c u b c r 1 9 8 7 , 7 6 a d d i t i o r l l l paticllts wcrc trcatcd by l2 contigtrous suburban/rtrral EMS syst c n r s u s i r . r gt h c s a n r c d a t a s h c c t . F o r e a c h p : r t i c l t t , s e v c r r t y o f p a i n w a s r a t c c lo n a s c a l c o f 0 - 4 . V i t a l s i g r t s w c r c r c c o r d c d i n l t r a l l y a n d a g a r i na t 5 m i r . r - r t c s ,l 0 n r i n u t c s , r u t c lu p t l n a r r i v a l t t r t h c E m c r g c n cy Dcpartmcnt. Thc pirrilmcdic and paticnt indcpcndently gradcd t h c l r - ' v c lo { p a t n a t c ; r c h o f t h c s c f o u r p c r i o d s , a n d a l l s r c l cc f f c c t s wcrc also rccordcd. Contraindications to thc usc of nitrous oxidc i r - r c l u d c d :h c a c l i r - r j u r i c s ,s u s p c c t c d p n c u t l o t h o r a x , s c v c r c c h r o n i c l u n g d i s c a s c , a b d o n - r i n a lp a i n w i t h d i s t c t . t t i t t n , i n t o x i c a t i o n , a n d d c c o m p r c s s i o n s i c k n c s s . T h c I n d i c a t i o r - r sf o r u s c i n c l u t l c d m u s c r - r l o s k c l c t a lp a i n ( 4 3 . 3 ' X , ) ,f r a c t u r c / d i s l o c a t i o n ( 2 4 . 5 ' 2 , ) ,a b c l o m i l r a l p a i n 1 1 2 . 6 " 1 , Jf l,a n k p a i n ( 5 . 4 ' % ) ,c h c s t p a i n { 5 . 0 ' 2 , ) ,b u r n s ( . 1 . 5 ' 2 , l)a, c c r a t t o n / a v u l s i o n{ 1 . ( r ' 2 , )s, i c k l c c c l l c r i s i s ( 0 . | t ' 1 , )p, c n , m p u t a t i o n { 0 . a 9 { , ) ,a n d c t r a t i n g / p r o i c c t i l c { 0 . ( r ' 1 , ) ,c r u s h ( 0 . ( r ' 2 , ) a . f t h c 5 1 5 p a t i c n t s c v a l u a t c d , 3 5 9 ( 7 0 ' 2 , )o f t h e p a o t h c r ( 1 . 7 ' 2 , )O ticnts rcportcd somc dcgrcc of pain rclicf. Frfty-rrinc paticnts ( I 1 . 5 ' 2 ), a c l " r i c v c dt o t a l r c l i c f o f t h c i r p a i n . S i d e c f f c c t s o c c u r r e d i n 1 1 4 p a t i c n t s \ 2 2 " 1 ' 1 ,b u t t h c y w c r c a l l m i n o r c o n s i s t r n g o f d i z z i n c s s o r l i g h t h c a d c d n e s s ( 1 0 . 3 ' l . ) , d r o w s i n c s s ( 6 . ( r % ) ,n a u s e a o r , n d p a r c s t h e s i a s{ 0 . 8 % ) . N o v o r n i t i n g ( 2 . 5 % , ) ,c x c i t c r n c r - r t( 1 . ( r ' l o ) a srgnificant hcn-rodynamic change occurred in any paticnt. There w e r c n o e p i s o d e so f v o m i t i n g w i t h a s p i r a t i o n o r o t h e r s c r i o u s u n toward cffects. There wcrc no statistically-significant differences (P > .05) in efficacy of srdc effects of urban use versus rural/suburban use. This study providcs further support to previous studi e s , s h o w i n g t h a t n i t r o u s o x i d e p r o v i d e s a n a l g e s i ai n a m a j o r i t y o f paticnts and that it can be used sa{cly by paramcdics in the urban and suburban/rural prehospital care setting.

114

EMS Field Trauma Triage Griteria in an Urban Trauma System

cant categories (P < 0.0001),with the children and adult males having a mean of i.0 sec and an ULoN of 2.0 secs, the adult f e m a l e s h a v i n g a m c a n o f 1 . 4 s c c s a n d a n U L o N o f 2 . 8 s e c s ,a n d the elderly populatron having a mean CR of 1.9 secs and an ULoN of 4.2 secs.In the temperature experiment pre-rmmersron timcs werc significantly shorter (t = 1.6 sec, SD 0.9) than those a f t e r i m m c r s i o n ( i : 3 . 0 s e c s ,S D 1 . 5 ) ( P < 0 . 0 0 0 1 ) .

EP Sloan, M Koenigsberg, J Nolan, S Ward, P Hicke,, J B a r r e t t/ D i v i s i o n o f T r a u m a S u r g e r y , C o o k C o u n t y H o s p i t a l ; D e p a r t m e n t o f S u r g e r y , U n i v e r s i t yo f l l l i n o i s C o l l e g e o f M e d i c i n e ; l l l i n o i s M a s o n i c M e d i c a l C e n t e r , U n i v e r s i t yo f l l l i n o i s E m e r g e n c y Medicine Fesidency Afliliate;Department of Emergency Medicine, Cook County Hospital, Chicago Tiauma systems serve to maximize the immediate care of scverely injured patients. Field triage criteria identify high risk t r a u m a p a t i e n t s , s o t h a t l i m i t e d t r a u m a c e n t e r r e s o u r c e sa r e c o r rectly utilized. The Chicago EMS triage criteria idcntify three levcl I trauma patient groups: l) li{c-threatenrng injurics: penetrating or blunt torso trauma with a systolic BP < 100, penetrating neck injury, and traumatic arrest) 2) limb-threatening injuries: amputation or injury with loss of neurovascular function; and 3) patients with a field trauma score {TS) < 12. This study examined how severely rnjured patients met thc cstablished critcria for level I bypass in our urban trallma systcm. Telemetry run sheets trom two trauma centers were retrospectrvely exami n e d . D u r i n g t h e M a y - A u g u s t 1 9 8 7 s t u d y p c r i o d , 1 , 3 1 3 1 2 0 % )o I the 6,466 telemetry calls were trauma-related. Of thcse trauma patients, 180 (14%lclearly met level I trauma triage criteria. Lifethrcats made up 67'/" of the level I patient group. In this lifcthreat group, 29u/o were traumatic arrest patients; (r3% of these arrests wcrc rclated to penetrating trauma. Pcnctrating chest or abdominal trauma accounted for 46"k of the life-thrcat grolrp. Overall, pcnctrating trauma accounted ior 67Y" of the life-thrcat cases.Limb-threats were 12% of the level I trauma group. Thc most commonly met limb-threat criteria was loss of distal pulsc following limb injury. Those with a ficld TS < l2 wcrc 38%, of the lcvel I group. Thc Glascow Coma Scale (GCS) was 3 or 4 in 601" of thcse low TS patients. A CCS of < 7 was prescnt in 84(2, of the low TS paticnts. An additional 36 l3%) of thc trauma patients werc bypasscd to a levcl I trauma ccntcr based on paramcdic rcqucst. Pcdiatric bypass occurred in 50 l4"l'l of the 1,313 trauma cascs. From this data wc concludc the following: I ) the high mortality of the life-threat group is duc to a largc numbcr of traumatic arrcsts; 2) the mayority of lifc-threatcning injuries in an urban system aro rclated to penctrating traumai 3) a low TS is most oftcn thc rcsult of severe hcad-injury, such that a morc dircct use of the GCS in trauma triage may bc justificd; and 4) despitc thc presence of cstablished critcria, paramcdic judgmcnt is still neccssaryfor proper trauma tnage. Thcsc data may assist health carc officials in thc determination of urban trauma svstem oolicv

115

Age (Years) Cap Retill (SECS) Range Mean SD Mean SD ULoN 47 Zwk 12yrs 3 3 3.2 1.0 0 6 C H I L D B E Nl \ i l a l e s 22 18 F e m a l e s 5 3 1 m o- . - 1 2 y r s 2 7 2 9 0 . 9 0 5 Total I00 2wk 12 yts 3.0 3.0 0.9 0 5 20 ADULT: l\lales 27 20 47 y(s 31B 7.8 1 0 04 1.8 49 yrs 3?.O 7.O 1.4 0.7 2.8 Females 7 7 2 0 1 0 4 2 0 4 9 y r s 7 2 1 3 Total 320 0.7 26 N

42 63 ELDERLY l!4ales 95yrs 776 83 2.0 11 Females 5 8 6 2 BTyrs 723 6.2 1.8 12 1 0 06 2 . , 9 5 v r s 7 4 6 7 . 6 1 . 9 1 2 Total

42 42 42

Wc concludc that CR is agc and tcmpcraturc depcndcnt. For adult f c m a l c s a n d t h e c l d e r l y t h e u p p e r l i m i t o f n o r m a l e x c e e d s2 s e c onds, ranging as high as 4.2 scconds. Furthermore, CR rs tempcraturc dcpendent. llascd on thcse findings, the normal range o( CR must bc rcviscd to rcflcct its variation with age. Even if this is donc, thc variation of CR with skin tcmperaturc raisesserious qucstions rcgarding its rcliability in thc prchospital care setting.

116

The Role of the Physician in a Helicopter Emergency Medical Service

RJ Schwartz, LM Jacobs, M Lee / Hartford Hospital, LIFE STAR, U n i v e r s i t yo f C o n n e c t i c u t S c h o o l o f M e d i c i n e , H a r t f o r d A two-part survcy idcntifying thc contributing role of thc physician as acromcdical crcw in a hclicopter cmergency mcdical systcms (HEMSI was accomplishcd. A qucstionnairc was complctcd by thc flight nursc aftcr cach mission from June 1985 through Octobcr l9tt(r (n : 4fi3) to cvaluatc thc ncccssarycontribution madc by thc physician in mcdical judgment or interagenc y r c l a t i o n s . I n t u b a t i o n s u c c c s sr a t c s w c r c u t i l i z c d a s a p r o x y f o r physician ncccssity for tcchnical skills. Thc physician would intubatc a patient only after thc flight nursc had attcmpted and failcd. Thc rcsults rcvealcd a physician's judgmcnt and nontcchnical prcsencc was neccssary on 23"/" of flights lll3l472l: 76'% wcre interhosprtal flights and 24ul' were sccne flights. The flight nursc successfully intubatcd 64/91 170%)of patients. The physician was succcssful an additional 2l/26 l8l%l for an overall successratc of 85/9(r {89%) for intubations. Thus, the physician was ncccssary and utilized in 27ol' of flights where patients requircd intubation 26/96. Of thc l1 misscd intubations, 7 were scene trauma and 4 were intcrhospital (l cardiac, 2 trauma and I pediatric). From Novcmbcr 1987 until February 1988, the physician was part of thc HEMS crew only if requcsted by the flight nurse or referring physician and for pediatric flights. On the flights without physicians, their presence was felt to have been ncccssary 5% of the time (4/88):3 for physicians'technical skills and I for intcragency relatrons. The nurses intubation success r a t e w a s 7 5 7 , ' 1 1 2 / 1 6 \ .T h c r c w a s n o s t a t i s t i c a l d i f f e r e n c e i n n u r s c s ' s u c c c s s r a t e s ( P : . 7 O 4 )o r b e t w e e n o v e r a l l s u c c e s sr a t e s ( P - . 1 4 1 ) .T h e p h y s i c i a n s ' t e c h n i c a l s k i l l s i n i n t u b a t i o n w e r e most necessary on scene trauma and on 27"/u of flights requiring an intubation attempt (5'1, of all flights). The role of physicians' medical judgment and other contributions are difficult to measure. It was prcdictcd to bc necessary 5% oI the time when the physician was abscnt and observed to be necessary 23% of the flights when they were present. This is likely to be an underestimation of thc truc contribution of the phvsician.

Defining Normal Gapillary Refill: Variation With Age, Sex, and Temperature

D L S c h r i g e r , L J B a r a { f/ U C L A D i v i s i o n o f E m e r g e n c y M e d i c i n e Capillary refill iCR) has been advocated as an indicator of perf u s i o n s t a t u s ( s h o c k Ji n s e r i o u s l y i l l p a t i e n t s . T h e T i a u m a S c o r e , and texts on shock and trauma define the upper limit o{ normal (ULoN) as 2 seconds. There is no published evidence that supports this value. To investigate the validity of this 2 second ULoN and to examine the variation of CR with ase and temperature, we measured CR in healthy children (l mo-i2 yrs), adult (20-49 yrs), and elderly 162-95 yrsl volunteers. CR was measured to the nearcst 0. I second using the pulse of the distal phalanx of the middle and index fineers. These two measurements w e r e a v e r a g e d .M e a s u r e m e n t s * " i . d o n e w i t h t h e v o l u n t e e r s i t ting with the hand at heart level, in an ambrent temperature of 18-21'C. The endpoint was thc complcte return of normal color. In addition, 20 adults {10 maie/10 fcmalc} wcre mcasurcd before and after a I minute immersion in 14'C (57'F) water. Age (range, mean,.SD), sex distribution, and CR data (mean, SD, ULoN [x + 2 SDI) are shown below. CR times fell into 3 statistically signifi-

117

Pediatric Gritical Care Transport: ls a Physician Always l{eeded on the Team?

K A M c C l o s k e y , W D K i n g / U n i v e r s i t yo f A l a b a m a S c h o o l o t M e d i c i n e ,T h e C h i l d r e n ' sH o s p i t a lo l A l a b a m a , B i r m i n g h a m A study is in progress at Thc Children's Hospital of Alabama to dctermine if it is always neccssary to scnd a physician on pcdiatric critical care transports. Currently the team always includes a pediatrician or pediatric resident, a pediatric emergcncy departmcnt nurse, and a pediatric respiratory therapist. Results of 3 parametcrs evaluated arc reported. Procedurcs performcd during transport were divided into thosc which arc done only by physicians in our instrtution and those which are also pcrformcd by nurses or RT's. Physician procedures wcre performed in 9"/. oI transports. Medications glven during transport were divided into three categoncs. Category I included drugs used only in our intensive carc unit and thercfore with a physician present. Category 2 drugs wcre usually given in thc ICU but occasionally adminrstercd on the floor with close physician involvement. Catcgory 3 includcd drugs routinely given on the floor with rare physician involvcrncnt. Catcgory I drugs were required on lt)To of transports. Category 2 was the highcst level uscd on l5%, of the transports, and category 3 drugs alonc wcrc used on 20%. No medications wcrc adrninistcrcd on 46"k of transports. At the completion o[ cach trip the transport physician was askcd if he fclt the transport would have been succcssful without an MD along but with an cxperienccd pediatric cmergency room nurse and rcspiratory "ycs" in 46'l' oI tl-rcrapist (RT). The answer to that question was "no" in 43'% and "unsure" in lB%. In9l'l' of the cascs(n- 1(r(r); transports no proccdures wcrc performed which rcquircd an MD. I n 6 ( r % ,n o m c d i c a t i o n s w e r e u s c d w l - r i c h r c c l u i r c d p h y s i c i a n p r c s cncc. In at lcast 43% the physician felt his cxpcrtisc was not rccluircd for the transport's success. Thcsc data suggcst that it may not always bc nccessaryto send a physician as part of thc critical care transDort tcam.

118

Rapid Acute PhysiologY Scoring in Critical Care Transport Systems

KJ Rhee, WG Baxt, JR Mackenzie, FE Burney,RJ O'Malley' D S c h w a b e , D L S t o r e r ,R W e b e r , N H W i l l i t s/ U n i v e r s i t yo f , a n D i e g o ; U n i v e r s i t yo f C a l i f o r n i a ,D a v i s ; U n i v e r s i t y o f C a L i f o r n i a S M i c h i g a n ; C r e i g h t o n U n i v e r s i t y ;U n i v e r s i t yo f C i n c i n n a t i ; D u k e Unrversrty This multi-institutional, coopcrative study was undertaken to validate the Rapid Acute Physiology Score (RAPSI as a predictor o{ survival in ciitical carc transport systems. Since RAPS is derived from and meant to be used in complemcnt with the Acute Physiology and Chronrc Hcalth Evaluation Score (APACHE II), its predictrvi power was first measured and then compared to that of ApecHp u. RAPS is based on the clinical parameters of pulse, blood pressure, resprratory rate, and Glasgow Coma Scale. Six helicopter programs collected RAPS and APACHE-II on all their transported patients over the age of l0 years. There were 1,927 patrents transported (514 scene, (r33 emergency department, 778 hospital inpatient); 339 patients eventually died. RAPS, using initial clinical values a{ter transport, was available on 1,926 pa' tients; APACHE-II was available on 1,794 patients. Logrstic regression usrng RAPS and APACHE-II demonstrated signijicant predictive power for survival (P < .01 for all F values listed below,

patients and may therefore be a useful complement to APACHEII scoring.

1 19

D W S p a i t e ,T V a e n z u e l a , E C r i s s H W M e s i n / S e c t i o n o f E m e r g e n c y M e d i c l n e ,C o l e g e o f M e d i c i n e , U n i v e r s i t yo f A r i z o n a , Tucson L i t t l c i s k n o w n a b o u t t h c p r c l " r o s p i t a la s p c c t s o f i n l u r y i n t h e cldcrly. Wc evaluatcd all injurics among patients age 70 and oldcr for wLich 9lI EMS dispatch was rcqucsted durirrg a l2-rnonth period in a r.ncclium sizcd mctropolitan arca Fire l)cpartmcnt E M S p " r r , , t - t n " l c o n - r p l c t ea f i r s t - c a r c f o r m f o r c a c h p a t i e n t . T h i s d a t a i i c h c c k e d f o r a c c u r : r c y a n d c n t c r c d i n t o a d a t z r b a s cW e r c trievcd data on all cldcrly paticnts for which an injury t-ncchan i s m { l M ) w a s r c c o r c l c dd u r i n g a o n e y e a r p e r i o d ( a t o t a l o f 1 , 1 5 4 ) . S c v c n h u n d r c d f i f t y - o n c ( ( r 5 . 1 ' X , )w c r e w o m c n a n d 4 0 3 1 3 4 . 9 ' / o l w c r c m c n w i t h ( r 1 . 3{ 5 i l . l ' X , ) b c i n ga g c 7 0 - 7 9 , 4 5 3 ( . 3 9 . . } ' X , ) a g c 8 0 - U 9 , a n d l l l J ( 7 . ( ; ' 2 , )a g c 9 0 - 9 | t . I M s w c r c : f a l l s , 7 0 l 1 6 07 " / . ) ; m o t o r v c h i c l c a c c i d e n t s ( M V A ) , 2 4 l J ( 2 1 . 5 ) ;f l i g h t , 2 8 ( 2 . 4 ) ;a c c i d c n t a l p o i s o n i n g , , 2 7\ 2 . 3 ) ;c h o k i n g , 2 4 l 2 . l l ) s c l f - i n f l i c t c d i n i u r y / p o i s r r n i n g ,2 0 l l . 7 ) ) a s s a u l t , U ( 0 . 7 ) ; b i c y c l c 2 { 0 . 2 ) ; a c c i d c n t a l i r o w r r i n g , 2 ( 0 . 2 ) ; m i s c , 9 4 1 8 . 2 ) .F i v c h u n d r c d f i f t y - t h r c c o f t h e f a l l s { 7 8 . 9 ' Zl, o c c u r r e d o n l c v c l a r c a s w i t h 2 l . l ' 2 , b c i n g f r o m s t a i r s , l a d d c r s , o r f r o r - t -ot n c l c v c l t o a n o t h c r ' S p c c i f i c M V A l M s w c r c v c h r c l c v s v c h i c l c 1 1 7 8 ,7 1 . 8 " 1 , 1p, c d e s t r i a n s t r u c k ( 2 0 , { 1 . 1 ) , c o l l i s i o n w i t h o b j c c t 1 4 1 . 6 | 1m, o t o r c y c l c ( 1 , 0 . 4 ) , a n d m i s c . { 4 5 , I U . 1 l . P c r s o r r si n t h c i r 9 0 s h a d a l o w c r f r c c l u c n c y ( F ) o f M V A s ( 3 ) t h a n y o u n g c r p a t i c n t s \ 2 4 5 J l P < 0 0 5 ) , c h i - s q u a r c ) .A t o t a l o f 1 , 2 2 l i n j u r i c s o c c u r r c d a m o n g l , l I 2 p a t i c n t s w i t h 4 2 ( 3 . ( r u l ,s)u s t r r i n i n g n o i n j u r y . I n j u r i c s i n c l u d c d : h c a d / f a c c 3 0 9 ( 2 . 5 . 1 ' X ' )u; p p e r c * t r " . r . r i t y 2 l l l l 7 . 2 l ) h i p l 7 U ( 1 4 . 5 ) ;l o w c r c x t r e m i t y 1 6 9 ( 1 3 8 ) ; b a c k 1 2 0 { 9 . 8 ) ; c h c s t / a b d o m c n ( r l { . 50 ) ; i n g e s t i o n / i n h a l a t i o n 3 9 25 {3.2); suspcctcd vcrtcbral fxr. 3l (2.5); multiplc n-rinor injury ( 2 . 0 ) ;c o n t u s s i o n 2 2 ( 1 . t 3 )p; c l v i s 2 l ( 1 . 7 ) ;c h o k i n g l 9 ( 1 . ( r )s; c r i o u s n c u i o i n j u r y l 0 ( 0 . t i ) ,n . r i s c . 8( 0 . 7 ) ;d r o w n i n g 3 ( 0 . 2 ) ;m u l t i p l e m a j o r i n j u r y t ( 0 . 1 ) .T h c F o f s c r i o u s n c u r o i n j u r i c s w a s h i g - h c r . f o r I M s o t h c r t h a n f a l l s o r M V A s { P < . 0 0 5 ) .H i p ( / ' < . 0 0 1 ) a n d p c l v i c lP < 0.0051iniurics had a highcr F in falls than in othcr IMs, whcrcas back injurics occurrcd most frcqucntly in MVAs (P'< .001).Ccrtain agc groups had a higher F of givcn inluries: 70s suspccted crrbon monoxide poisoning {CMP) (1)< 005J; ttOs hip (1' < .005),chest or abdomen (P < .05). Scvcnty-one fa-llvict i m s ( 1 0 .l ' 2 , ) h a d s u s p c c t c dm c d i c a l c a u s e so f t h c i r f a l l i n c l u d i n g s y n c o p c { 3 1 ) ,c h c s t p i i n o r r c s p i r a t o r y d i s t r c s s ( 1 5 ) ,s t r o k c / T l A { 8 ) , CMP l7), GI bleed (3), hypoglyccmia (3), misc. (4). Tcn paticnts 1 0 . 9 ' l " ) w c r e i n c a r d i a c a r r e s t . T h c c a u s c si n c l u d c d s u i c i d c ( 3 , f i r e a r m / k n i f e / h a n g r r - r g ) ,a c c i d e n t a l d r o w n i n g ( 2 ) , s u d d c n d e a t h p r e c i p i t a t i n g a f r a V a { 1 ) , c h o k i n g o n f o o d ( 1 ) , a s s a u l t ( . 1) , M V A ( 1 ) ,f a l l (1j.The iO reported sclf-inflicted injuries includcd drug ingestion ( B ) ,f i r e a r m { 4 ) , k n i f e ( 4 ) , d r o w n i n g ( l ) , j u m p f r o m h c i g h t ( 1 ) , C M P 70s,4 it), hangrng (l). Fourtccn of these patient-swere in their their BOi, and 2 their 90s. To our knowlcdge, this is the first report of the prchospital injury patterns and mechanisms among eldcrly victims of trauma.

120

DF - r.781).

APACHE-1I BAPS

lnitial Values F=577.70 F=42856

E;,H:t.?,'JHlfi:J;::i$'3'." Patterns

A Gonstant Force SPring Device for Traction and TransPort of the Gervical Spine Iniured Adult

/ EE Sabelman,AP Sumchai,CB Wilmot,lV Eliastam Center,Veterans RehabiitationResearchand Development MedicalCenter,PaloAlto, Ca ifornia;Department Administration Schoolof StanfordUniversity N/edicine, of Surgery/Emergency SantaClaraValleyMedicalCenter Medicine,Stanford,California; o nn i t ,S a nJ o s e ,C a l l f o r n i a S p i n a lB e h a b i l i t a t i U Purpose:Stabletransporto{ the cervicalspine iniured adult is o{ gencralconcern due to an establishedtrend toward early trans-

24 hours WorstValues-1st F : 6 6 1s 9 F: 4 7 2 . 3 6

RAPS is a valid predictor of survival. It is not as powerful as APACHE-II, but it can be consistently collected on transported

fer to specialized spinal injury units. There is a recognrzed potential for exacerbation of iniury during ground and air transport. A multiple constant {orce spring (CFS} backboard traction apparatus has undergone field trials. It is the third prototype in the evolutron of a device designed to generate quantifiable constant force traction independent of patient position on the backboard. It is compatible with patient maintenance devices, inter and intrahospital transport equipment, computcrized tomography {CT) and magnetic resonance scanners/ conventional radiography and hyperbaric oxygen chambers. Methods: The principle components o{ the CFS backboard traction apparatus is illustrated using computer-aided dcsign {CADJ methods. Traction is generated from a housing at the head o{ the backboard which contains 9 cable output modules rated at 2.6 pounds force {lbf) cach. A maximum traction force of 24 lbI can thus bc generated using onc unit. A second unit can be inserted into thc housins to double the traction force generated.Cables exit the housing and arc tcrm i n a t e d b y g r i p r i n g s w h i c h i n s e r t i n t o k e y h o l e - s h a p e ds l o t s i n a summing bar. An S-hook connects the summing bar to the halo or tongs. Tiaction forces are transmitted to the spine via a halo or skull -alipers; Cardner Wells tongs are most iommonly used. The radiotransparent, carbon-fiber composite backboard is 75-7u inches in length, depending on helicopicr dimcnsions. Usage rcports are completed following each transport. Results: Laboratory tests have verified that traction force remains constant within + .5 lbf for any cable extension. In 59 helicopter transports no documented deterioration in motor neurologic function occurred. Flight crews reported no problems with movcmcnt of thc paticnt o n t h e b a c k b o a r d i n t o a n d o u t o f t h e h e l i c o -pdt curr i a nn gd no enisodcs of respiratory compromise or rcgurgitation rigid icrvicucranial restraint. There were no failures of the CFS traction unit in use; shouid a failure occut the modular nature of force output would permit continued traction. Thc CSF devicc has bcen routinely used {: 180 patients) for in-hospital transport to and from the CT scanner. Conclusions: A four-year expcriencc with thc use of a CFS backboard traction apparatus supports a conclusion t h a t t h i s d e v i c e r e p r e s e n t sa t e c h n i c a l l y a d v a n c e d ,s a l e m e t h o d o f generating acceleration-independent constant force traction.

121

estimates ranged from l5-45 mph, and weather conditions were c i t e d a s a f a c t o r l e a d i n g t o o n l y o n e o f t h e c r a s h e s .I n t r u s i o n w a s not the causc of injury in any case. Thus no unifying cause of these scvcre and unusual iniuries were identified. Although the overall incidence of cervical spine fractures in young children is very low, this series of patients scrves to: l) raise questions regarding the effect of current CSS dcsign on cervical spine stability during motor vchiclc crashcs, 2) make emergency department physicians aware of thc potcntial dangers of improperly uscd child safcty seats, and 3) convincc CSS and automobile manufacturcrs that changes in design and clcarer installation instructions to discourage misuse arc nccded.

.122

Gervical lnjury in Head Trauma

G L N e i f e l d , J G K e e n e , G H e v e s y ,J L e i k i n , A P r o u s t , R T h i s t e d / U n i v e r s i t yo f C h i c a g o H o s p i t a l sa n d C l i n i c s ,S t F r a n c i s H o s p i t a l M e d i c a l C e n t e r ,P e o r i a ,l l i n o i s , U n i v e r s i t yo f l l l i n o i sH o s p i t a l , C h i c a g o ; L u t h e r a nG e n e r a l H o s p i t a l ,P a r k R r d g e , l l l i n o r s Critcria for cxcluding cervical spine injury in patients who havc sustaincd blunt hcad or ncck trauma werc prospcctivcly studied at four hospitals in thc Chicago arca. Thc authors att c m p t c d t o d c f i n c a s u b s c t o f t h c s c a d u l t p a t i e n t s w h o , b a s c do n clinical critcria, could reliably be cxcludcd from ccrvical spine r a d i o g r a p h y ,a v o i d i n g u n n c c c s s a r y r a d i a t i o n a n d s a v i n g c o n s i d e r ablc time and moncy in thcir cvaluation. Patients fcll into four groups: Croup l) patients who wcrc awakc, alcrt, and had no complaint of ncck pain and no ncck tendcrncss on cxam; Group 2) paticnts who wcre awakc, alcrt, but had complaint tif ncck pain or tcndcrness on cxam latcrally ovcr the trapezius muscle only; Croup 3) patients who wcre awakc, alcrt, but had complaint of central neck pain or tcndcrncss on exam ovcr the ccrvical spincs or ccntcr of thc neck; and Group 4) patients who wcrc not fully awakc or alcrt, clinically intoxicatcd, had other painful or distracting injurics, or had focal ncurologic findings. Paticnts in Croup 4 had significantly more fractures l2ll408) when com. aticnts with ccntral neck pain p a r c d t o a l l o t h c r p a t i c n t s ( 7 / 4 7 8 | rP or tcndcrncss {Croup 3) had significantly more fractures l7/2371 than patients without pain or tenderness or with thcse findings l i m i t e d t o t h c t r a p c z i u s a r e a 1 0 / 2 3 6 ){ S e c T h b l e ) . I t i s c l e a r t h a t patients who havc an altercd mchtal status, an abnormal exam/ a distracting injury, or pain/tcndcrncss over the cervical spines m u s t h a v c c e r v i c a l s p i n e r a d i o g r a p h s .I n a p a t i e n t w h o i s a w a k e , a l er t , h a s a n o r m a l e x a m , i s u n d i s t r a c t c d b y a n o t h e r p a i n f u l i n j u ry, and has no pain or tenderness in the neck, or these findings limited to the trapezius arca, there is lcss than a l% chanceof a ccrvical spine fracture with a 90% confidence limit. Our data strongly suggcst we can modify our use of cervical spine radiographs in paticnts sustaining blunt head trauma without subjecting patients to undue risk

Cervical Spine Fractures Sustained by Ghildren in Gar Seats

S F u c h s , M B a r t h e l , A F l a n n e r y , K C h r i s t o f f e l/ D e p a r t m e n t o f P e d i a t r i c s , U n i v e r s i t yo f P i t t s b u r g h S c h o o l o f M e d i c r n e , Emergency Department, Childrens Hospital of Pittsburgh; D e p a r t m e n t s o f N e u r o s u r g e r y a n d P e d i a t r i c s ,N o r t h w e s t e r n U n i v e r s i t yS c h o o l o f M e d i c i n e ; C h i l d r e n ' sM e m o r i a l H o s p i t a l , Chicago The number of young chiidren who die annually in motor vehrcle crashes has decreased as more children are restrained in child safety seats {CSS}. However, improper use ol CSS are as high as 75% and most CSS provide inadequate protection when used incorrectly. Therefore, CSS must now be considered as factors in the type of injuries sustained by children who survive crashes. Information on children rnjured in this manner will help clarify the biomechanics of these injuries and therr consequences. We report 5 children (3M, 2F) under 2 years of age who sustained cervical spine fractures while in a CSS during a 20 month period. One infant died (Dl, 2 of the 4 who survived were left quadriplegic (Q), and 2 had no neurologic sequelae after spine stabiiization (N). Iniuries included one atlanto-occipital dislocation (D), 3 type II odontoid fractures (l Q, 2-N), and one C2-3 fuactve/ disiocation lQ). Data collected to clarify factors contributing to the injury were: type of motor vehicle, speed, impact direction, weather, make and model of CSS, position and orrentation of child in CSS and method of restraining both, position of all other car occupants, their method of restrarnt and injuries. CSS use was improper in 3 cases (l-N, 2-Q: no use of harness strap, unrestrained CSS, and front-facing infant seat), and proper in 2 cases (l-N, l-D: howevet, the speed of one crash (D), was above CSS crash standardsl. Five different CSS models were involved. Speed

Table Group 1 G r o u p 2 No Fraclure F r a c t u r eo r Dislocation Totals

123

96 0 (0%) 96

145 0 (0%)

r45

Group3 230

Group4 387

Totals 858

7 (2 957") 21 (5 17") 28 (3 16"/") 237

408

886

Cervical Spine Injury and Radiography an Alert "High-lndex"

Patients RM McNamara,E Heine,B Esposito/ Department of Emergency FrankfordHospital, Medicine,MedicalCollegeof Pennsylvania; Philadelphia Cervical radiographyhas been recommendedfor all "high-in-

dex" patients regardless of physical examination or the patient's symptomatology. A retrospective l4-month review was conducted of the trauma registry of an urban community hospital that serves as a Level II trauma center. Records of admitted patients were examined for high-risk mechanisms of injury including motor vehicle accidents, falls from heights (> 3 feet or > 5 steps), auto/pedestrian injuries, motorcycle/bikrng injurres, and diving or tackling injuries. Also sought out were high-risk iniuries rncluding head trauma with loss of consciousness, skull or facial fracture. Only patients having a mechanism and/or injury listed above who were alert on presentation {GCS > 13l were included in this study. Of 75I admissions reviewed,40l met the cntry criteria. O{ these, 511.2%) had a proven cervicai spine fracture or ligament disruption, and all were among the IOB 127%l patients who prcscnted with neck pain and/or tenderness. None of the 5 had significant ncurologic rnvolvement. The 108 symptomatic patients (S)werc compared to the 261 asymptomatic patients (AS); that is, those having documented absence of neck pain and tenderness (n - 178) or documented absence of one of these findings (n : 83) upon presentation. Statistical analysis was conducted using a two-sided, unpaired r tcst and chi-square tcst, when appropriate. The two groups were similar in age, sex, and race. There was no significant intergroup difference in the number of falls from heights (S : 13 [12%1, AS : 35 113.4%]1, head injuries with LOC (S : 36 [33%], AS : 62 IZ4%| or facial f r a c t u r e s ( S = 6 [ 5 % 1 , A S - 1 8 1 6 . 9 % ] ) ,b u t t h e S g r o u p w e r e morc likcly to have been in aMVAlT4% vs 56"/", P < .002), while the AS group were morc likely infured on a motorcycle/bike (13'lu vs 4.6%, P < .05). The AS group, surprisingly, was more severely injured as evidcnced by a longer length of stay + S.D. 17.2t 7d vs 4.6 * 4d, P <.001), a higher mean ISS ,t S.D. l L ) . 8* 7 . 2 v s 6 . 9 + 6 . 3 , P < . 0 0 1 ) , a n d a h i g h e r p e r c e n t a g eo f I S S abovc 9 143% vs 19%, P < 0.0011. If only the symptomatic patients and those intoxicated (BAC > 100 mg/dl) without documcnted symptoms ln : 6a) or having neurologic srgns of cord iniury (n = 2J underwent cervrcal radiography, 174 studies would have bcen required in these 401 patrents. The actual number of radiographs that would have been eliminated in this group would have been I16. TWo patients who presented without documented ncck pain or tenderness were found to have central cord syndrome. Neither had a proven cervical spine fracture or ligament disruption, and their presentations were not "occult" as obvious "high-index" neurologic signs were present. In this population of patients, cervical spine injury was infrequent. The alert, asymptomatic, non-intoxicated patient may not need cervical radiography despite a high-risk mechanism of injury and/or highrisk iniurv

124

A Fatal Hemorrhagic Shock Model in lmmature Swine

SA Syverud, SC Dronen, CR Chudnofsky,PF Van Ligten I D e p a r t m e n t o f E m e r g e n c y M e d i c i n e , U n i v e r s i t yo f C i n c i n n a t i We studied the effect of bleed rate on survival time and hemodynamics in a lightly anesthetized swine model of acute hemorrhagic shock. Fasted immature female swine {12-16 kg) were sedated with IM ketamine, endotracheally intubated, anesthetized with halothane 10.75%) nitrous oxide, and oxygen, and then prepared for experimentation by placement o{ femoral arterral and venous catheters, and splenectomy. After instrumentation, halothane was discontinued and sedation was maintained with nitrous oxide and intravenous lorazeparn. Thirty minutes later, the animals were bled continuously at 1.0 ccikglmin in : 8, Group I) or 7.25 cclkg/min (n = 8, Group II) by a roller pump connected to the femoral arterial catheter. Hemodynamic parameters were recorded every l5 minutes until death occurred. Mean survival trme was 50.2 + 3.0 minutes in Group I and 39.8 * 3.2 m i n u t e s i n g r o u p I I ( P < . 0 0 1 ) . T h e r e w a s a s t e p w i s e d e c r e a s ei n blood pressure and cardrac index consistent with progressive hemorrhasic shock.

Baseline S y s t o l i cB P ( m m H g ) 1 4 4( 2 1 ) Group| 1 4 2( 2 2 ) Groupll

15 min

30 min

45 min

1 O 2\ 2 O ) 10 3 ( 3 4 )

6 4 ( 13 ) 56 (12)

46(15)

C a r d i a cl n d e x ( L / m i n / m z ) 19(06)07(05) 30(08) 3 B ( 11 ) 11(03)' 26(05) 4 2 ( 1. o ) .P n = 8 r n e a c h g r o u p m e a n ( s t a n d a r dd e v a t i o n ) < 0 1 ( f t e s t ) Groupl Groupll

This model results in rcoroducible survival times with small standard deviations. Although the animals are lightly anesthetized and the expcriments are performed acutely, the hemodynamic rcsponses and survival times observed arc similar to those reported in previous studies of chronically instrumcnted, unanesthctized swine. This modcl may be more practical than unanesthctizcd, chronically instrumented swinc modcls for cvaluatins the effects of various intcrvention on survival time and hcmuJynamics in acutc hcmorrhagic shock.

125

Hemodynamic and Respiratory Effects of Thyrotropin-Beleasing Hormone (TRHI in Anaphylactic Shock

RL Muelleman, lvl Gatz, B Herndon, JA Salomone lll, GA Salzman / Department of Emergency Medicine, Truman Medtcal Center. Kansas C tv. Mrssourr T h y r o t r o p i n - r e l c a s i n g h o r m o n e { T R H ) h a s b e c r - rs h o w n t o i n creasc mcan arterial pressure (MAP) during anaphylactic shock. Thc hcmodynamic mcchanism of action and thc cffcct on thc respiratory systcm of TRH during anaphylactic shock is not known. A rabbit modcl of anaphylaxis was uscd to dctcrminc thc effect of TRH, cpincphrinc (EPI)and normal salinc (NS) on various cardiovascular and respiratory paramctcrs during anaphylactic shock. Anaphylactic shock was induccd by antigcn challcngc i n 3 l s e n s i t i z c d a n i m a l s . A | t e r a 2 5 " / u d c c r c a s ei n M A P t h c y w c r c randomly trcatcd with TRH (2 mg/kg), EPI (.005 mg/kg) or NS {10 cclkg). Blood was drawn at baseline and at thc cnd of thc cxpcriment for laboratory analysis. Cardiac and respiratory parameters wcrc monitorcd continuously and mcasured at baselinc, onset of shock lT = Ol and at time rntcrvals for 30 minutcs. Animals wcic trcated with repcated doses during the first fiftccn minutcs as nceded to maintain MAP above shock level. Fivc of ten TRH, fivc of eleven EPI, and six of tcn NS treated animals survived. The TRH treated group recluired fcwer doscs than the othcr groups and resultcd in incrcased heart rate (HR), MAq pcripheral vascular resistance (PVRI),respiratory rate {RR),minute vcntilation, a n d l u n g c o m p l i a n c c a s w e l l a s a d e c r c a s e ds t r o k e v o l u m c i n d e x (SVI)compared to the NS treatcd group. EPI treatment resulted in i n c r e a s e d m i n u t e v e n t i l a t i o n a n d d e c r e a s e dp u l m o n a r y r e s i s t a n c c compared to NS treatment. The EPI group also had a higher post survival epinephrinc level than the othcr groups. No difference in right atrial pressure, cardiac index, acid-basc status, pOZ, A-a gradient, lung weight, lactatc, or norepinephrine levels was found. Thesc results indicate that the effects of TRH during anaphylaxis on the cardiovascularsystem are to increaseHR, MAB and PVRI with a decreased SVI, and on the respiratory system to incrcasc R R a n d m i n u t e v e n t i l a t i o n w i t h a d e c r e a s ei n l u n g c o m p l i a n c e .

126

Lipid Peroxidation in Liver Before and During Resuscitation From Hemorrhagic Shock

lG Sipes,M Chvapil/ Section RC Dart, RL Misiorowski, of FmergencyMedicine,Departmentof Surgery,College oJ Arizona;Departmentof of Medicine,University University Collegeof Pharmacy, Pharmacology/Toxicology, of Arizona,Tucson Lipid peroxidationhas been demonstratedin severaltissues

upon reperfusionof ischemic tissue.In this study,a hemorrhagic shock model was developedto investigatethe production o{ lipid peroxidationin liver during hemorrhagicshock and during resuscitation. A two hout shock period induced by fixed volume exsanguination of male 300-400 g Sprague-Dawley,rats through a femoral catheter was utilized. Two experimental groups were studied. The shock only group was sacrificedafter two hours ol shock and liver homogenateassayedfor thiobarbituric acid reactive substances{TBARS).A shock * resuscitationgroup was similarly assayedafter two hours of shock and 30 minutes of whole blood resuscitationfrom shock. One sham ooeratedand one experimental animal were simultaneously tested.At sacrificeeach animal was perfusedvia the abdominal aorta with 150 mL of normal saline containing 0.01% BHT and 2.0YoEDTA. Liver and kidney biopsies(300 mg) were taken, homogenizedin 0.05% phosphatebuffer containing 0.01% BHT and 25% BH\ and tested,for TBARS using a modification of Suematsu'smethod. Results were: TBABS(nmol)/ TBARS(nmol)/ g wet tissue welght g proteln Group Control/Experlmental Control/Experlmental S h o c kO n l y 0 . 7 9 6+ 0 , 1 1 8 0 . 7 7 5+ 0 . 1 0 3 Shock+ Resuscitatlon 1.304+ 0.201-t 1.149+ 0.085-r Analysis by paired t test demonstratesthat the shock only group is significantly lower than sham treated animals and that the resuscitatedgroup is significantly higher than its control {-). In addition, analysisby two-tailed t test showedthat TBARS were increasedduring resuscitation compared to the shock period { + ). The decreasein TBARS during ischemia appearsto be a new observation.These results suggestthat, as in other pathological conditions where ischemia is followed by resuscitation,lipid peroxidation may be involved as a pathophysiologicalmechanism. This model and analytical technique may be useful to further investigateresuscitationfrom hemorrhagic shock.

.127

Early Versus Late Fluid Fesuscitation: Lack of Elfect in Porcine l{emorrhagic Shock

SC Dronen,CR Chudnofsky,SA Syverud,JR Hedges, BJ Zink / Departmentof EmergencyMedicine,University of Cincinnati The benefit of intravenous fluid therapy in the pre-hospital managementof hemorrhagic shock is unproven.Clinical studies addressingthis issue have yielded conflicting results and animal studies are lacking. This study used a reproduciblelightly anesthetized model of porcine continuous hemorrhageto evaluatethe utility of pre-hospital IV fluid therapy. Incorporated into the model were time delays associatedwith ambulancerequest and dispatch,patient evaluation,treatment, and transport to the hospital in the averageurban pre-hospital care system. Tieatment occurred concurrently with hemorrhage.Twenty-eightimmature swine (I 5-20 kg) were bled at a late of.1.25 ml/kg/min. Animals in the pre-hospitalIV group {n = l4) receivedfluid resuscitation at I ml/kg/min beginning 20 minutes after initiation of hemorrhage;those in the inhospital IV group (n : la) receivedfluid at a rate of 3 mllkg/min beginning 35 minutes after hemorrhage. Both groups receivedblood and saline at 3 ml/kg/min 45 minutes after hemorrhage began and both groups had hemorrhage controlled 25 minutes after simulated hospital arrival. Mean arterial pressure,cardiac output/ central venous pressure/hematocrit, arterial blood gasesand serum lactate were measuredat baseline and every l5 minutes thereafter.Systemic vascular resistance,cardiac index, and oxygen delivery were calculated at the same intervals. Survival was 57o/oin both groups and there were no statistically significant differencesseen in measuredhe-

modynamic or biochemical parameters. We conclude that early administration of intravenous fluid has no effect on hemodynamics or survival in a porcine hemorrhagic shock model simulating an urban pre-hospital care system.

128

i'"""":*T:'i,:l'ff ilf" . B,ood

129

Evaluation of Blood Warming Devices Using the Apparent Thermal Glearance

R Smejkal,D Unkle,R Snyder,M Lessig,SE Ross/ UMDNJ/ RobertWood JohnsonMedicalSchoolat Camden,Cooper Hospital/ University MedicalCenter,Camden,New Jersey The immediate transfusion of uncrossmatchedtype O blood {ITOB) in the initial resuscitationof the trauma victim remains controversial.In order to examine difficulties in crossmatching blood for further transfusions,we undertook a 23 month study of patients receivingITOB in a Level I Tiauma Center.Data regard. ing iniury severity,clinical course and blood use were collected prospectively.Of 1,691patients admitted in this period, 135 patients receivedITOB. This group of patients had a mean ISS of 34.7i mean age of 41.5; mean Tiauma Score of 9.3; and mean GCS of 9. Forty-eightpatientsexpired{36 percentf,l8 prior to definitive therapy,and 1I intraoperatively,ll7 patients 179percentl sustainedblunt trauma and 76 156percent)patients underwent emergent operation.467 units of ITOB, 200 units of typespecificblood, and a total of 2,008 units of blood were transfused in this group.No patient had a major transfusionreaction.Three patients had white cell allergic reactions/but upon evaluation had a negativeantibody screen.Six patients had blood antibodies presentat admission,and three patients developedsuch antibodiesduring their hospitalization.We conclude that ITOB may be used safely in initial resuscitationof the exsanguinatingpatient, but antibodiesto blood antigens,which can complicate later crossmatching,may developas a result of such trans{usion.

L Flancbaum,SZ Trooskin,H Pedersen/ Departmentof Surgery, UMDNJ-Robert WoodJohnsonMedicalSchool,New Brunswick. New Jersey;Departmentof ChemicalEngineering, Rutgers University,Piscataway,New Jersey Hypothermia (T < 35"C) associatedwith massivetransfusions is a serrousclinical problem. Maintainance of normothermia in this setting is essentialand requiresrapid and efficient blood warming devices.The optimal design of such units should include a low priming volume, large heat transfer area, low pressure drop,the ability to operateat high flow rates(> 250 ml/min) and be capable of warming blood from 4'C to 32'C, or higher, without untoward effects.We have previously formulated a the. oretical model {or blood warmers and desciibeda measureof the intrinsic efficiency of these devices,the apparent thermal clearance, Ya.1, that is easily determinedexperimentallyfrom the relation V r , " r : - F I o 9 " [ T 6 - T )/ ( T b - T " ) l where F is the flow rate of transfusate,and T5, To and T are the bath, inlet, and outlet fluid temperatures,respectively.V1,.1is the flow rate at which the blood temDeraturerises to 637" oI its limiting value. Thereby,a value of V1 "1of at least 400 ml/min is neededfor the blood warming device to be suitable as part of a rapid infusion system. We tested four different types of commercially availableblood warmers and determinedthe apparentthermal clearanceusing saline and packedred blood cells (PRBCf. The resulting data are summarized in the table below.

Design

Flow Range (mumin) Priming vol (mL) Saline PRBC

V.,.' (mumin) Saline PRBC

with tcmpcratures ranging to a low of 22" C. A subset of this large paticnt grollp was retrospcctively studicd, and we were able to raise thc core tenlpcrature in this group of 20 patients an average of 8.8'C/hour, whilc a similarly matched group of patients trcated with convcntional rcwarming (blankcts, warmcd IV fluids, ctc.) avcragcdonly 1.5" C/hour. Thc incidence of frostbite injury in thcsc two groups was signrficantly different; with no paticrlts trcatcd 'with rapid rewarnting sustaining frostbitc while f o u r p a t i c n t s i n t h c c o n v c n t i o r - r a l l yt r c a t c d g r o u p s u s t a i n c d f r o s t bitc injury, onc who rcquircd a Symcs arnputation. The immersion prutocol requircs only CVP and EKG t.nonitoring and fretlucnt artcrial blood gas dctcrminations, thus allowing it to be s a f c l y c a r r i c c lo u t i n t h e s t n a l l c s t o f h o s p r t a l s o r i n t h c e m c r g c n c y dcpartment wl-rilc awaitrng patient transfcr or prcparation for by"aftcr drtrp," pass. Tl-ris protocol has not produccd any cases of "lrrctic acid load" of rapid rcwarming is hanand thc hypothcsized d l c d s a { c l y w i t h s u p p l c n r c n t a l s t t d i u t r . rb r c a r b o n a t c . W i t h o t h e r treatmcnt pftrtoctrls {Or hypothcrmil dcruonstrating mortalitics r a n g i n g f r o t . t r4 5 ' X , t o 1 0 0 ' X , ,t h i s p r o t o c o l o f r a p i d r c w a r m i n g t h r u imrnersion has provcrt safc irr 4li patietlts ovcr a scvcn year perttld arrd nrcrits additional cotrsidcratiotrs.

Tubing Material

S i n ge C o i l m r n e r s l oH n eater

50-250

10-50

184

PVC

S i n ge C h a n n e l Dry Wal Heater

30,300

5-50

256

275

PVC

l v l uI c h a n n e l Counter CurrenH t eat E x c h a n gre

125

50-120010-1000 831

341

Auminum

S n ge C h a n n e Counter CurrenH t eat Exchanger

50 1800 50-1000 1356

058

Alumnum

Thcsc data indicatc that only thc single channel coulltcrcurrcnt unit is cfiicicnt cnough to meet thcse rcquircmcnts. Thus, the apparent thcrmal clcarancc pr0vidcs a useful and rigorous ncans I o r c o m p a r i n g a n d e v a l u a t i n g b l o < - r dw a r m i n g d e v i c e s .

130

Microwave Warming of Blood: Preliminary Report on a New Method

.132

D G e n t t l e , P A u e r b a c h , G S t a h l m a n , C W a l l a s , P T a n l e y/ , ennessee V a n d e r b l l tU n i v e r s i t yS c h o o l o f M e d i c i n e , N a s h v i l l e T Rapicl transfusion of rcfrigcratccl blood produccs a significant d n d p o t c n t i a l l y c l a n g e r o r - tfsa l l i n b o d y t c m p c r a t u r c . H y p o t h c r m i a can bc prcvcntcd, and morbidity antl n-rortality lcsscncd, if cold bloocl is warmcd prirtr to massivc transfusion. Convcntional inlinc bkrod warmiug dcviccs arc safc, but limit infusion ratcs, hindcring thc rcsuscitation of paticnts with hypovolcmic shock. Microw:lvc blood warmcrs offcr thc potcntial for fast, cfficicnt warming of blood units prior to tr:lnsfusion, but havc not bccn a r c c c p t c db c c a u s c o f p r o b l c m s w i t h l o c a l o v e r h c a t i n g a t t h c s u r facc of thc blood bag, with rcsultant hcmolysis. Wc used a commcrcial micnrwave ovcn to hcat blood units suspcndcdin a watcr bath. llccause microwavcs pcnctratc poorly into watcr, thc surfacc of thc blood unit is insulatcd from exccssivemicrowavc t-ttc r g y .B o t h w h o l c b l o o d a n d p a c k c d r e d c c l l u n i t s w c r e s u c c c s s f u l ly hcatcd to 32C without exceeding surface tcmpcratLlrcs at which hcrnolysis occurs. Samples obtaincd immcdiatcly beforc and aftcr hcating showcd no significant increase in frcc hemog l o b i n , s o d i u n - r ,p o t a s s i u m , o r l a c t a t c d e h y d r o g c n a s c . W a r m i n g timcs ranged bctwccn fivc and cight minutes, depending on the f i r - r a lt c m p e r a t u r c o b t a i n c d a n d t h c s i z e o f t h e b l o o d u n i t . W i t h modification, this tcchnique may provrde a practical and safe mcthod for microwave warming o{ rcfrigeratcd blood.

The Use of a Percutaneous Gatheter in the Treatment of Spontaneous and latrogenic Pneumothoraces

KM Piland, JH Piland, FM Yeiser RA Houseknecht/ Eastern V i r g i n i aG r a d u a t e S c h o o o f M e d c n e o f t h e N l e d i c a lC o l l e g e o f H a m p t o n R o a d s N o r f ok , V i r g t n r a H i s t o r i c i r l l y , p t t eu n t o t h t t r : r x h a s b c c r r t r c a t c d w i t h s u c t i o n t u b c thorlrcostorly.A retrospcctivc chart rcvicw w:ts undcrtakcn at t w o c o m n r u r r i t y h o s p i t a l s t o c o l t l p a r c t h c s u c c e s sr a t e i l n d c o m p l i c a t i o n s o f a 9 F r c n c h s i t n p l c p c r c u t a t r c o u sc r t h c t c r { C o o k , I n c ) w i t h t h r r t o i t h c l r t r g er , s t l n d a r d t h o r r c o s t o t l l y t u b c ( c l r c s t t u b c ) F i f t y - s c v c n c a s e s ( 4 0 p e r c L r t a n e o L l sc i t t l l c t e r s , l 7 c h e s t t u b c s ) t r f cithcr spontatrcousor tatrogctric noll-traurrirtic pttcuurotltoraces wcrc rcvicwcrl. l)cmographrc variahlcs,sizc trf pncumothorax, c t l o l o g y o f p n c u t . t - t t t t h o r a xd, u r a t i t t u o f l r o s p i t a l i z a t i r l t l , i n p a t i c n t v e r s u s o u t p a t i c l l t t r e : l t n l c l l t , d u r a t i o n o f c a t h c t c r p l a c c n - r c n t ,p c r c c n t r c s o l L l t i o n ,t r c c d f o r f u r t h c r t r e a t m c n t , a n d c o m p l i c a t i o n s w e r c a n a l y z c d . T h c c l u r a t i o n t t f c ] r c s t t u b e p l a c c m c n t a v c r a g e d4 . 7 tlays, whcrcas, thc duration of pcrcutancotts c:lthctcr placcment a v c r a g c t l3 . t l d a y s . S u c c c s s w a s d c t c r m i n c d b y n i n c t y p c r c c n t o r grcatcr rcsolution of thc pncumothrtrax without furthcr trcatm c n t r e c l u i r c d . E i g h t y - n i r - r cp c r c en t o f p a t i c n t s w i t l - r t h c c h c s t tubc and nincty pcrccnt of paticnt:; with the pcrcutaneous cathctcr showcd a succcssful outcome; tlrercforc, the typc of cathctcr usccldid not correlatc with cithcr a succcssful or unsucccssful outcomc {r - 0. 12, 1t .: .37).All pirticnts with chcst tubcs wcrc hospitalizctl whcrcas two subgroups of pcrcutancous cathctcr paticnts wcrc trcatcd as outpaticnts. Thc first group, c o m p r i s c d f i f t c c n p c r c c n t 1 6 / 4 0 1o f t h c p c r c u t a n c o u s c a t h e t c r s , h a d s p o n t a r - r c o u sp t . r c u m o t h o r a c c s , a n d w c r c t r c a t e d t o t a l l y a s o l l t p a t i c n t s a f t c r E m c r g c n c y i ) c p a r t m c n t i n s er t i o n o f t h u p c r c l l t a n c o u s c a t h e t c r . T h e s c c o n d g r o u p , c o n - r p r i s e df i v c p e r c e n t (2/a0) of thc pcrcutancous cathctcrs, had spontaneous pneumothoraccs, irnd wcrc trcatcd as outpatients irfter an inltial pcriod of inpaticnt stabrlization of twcnty-four to scvcnty-two hours. Younger paticnts lgcd twcnty to forty ycars tcndcd to bc treatcd : r s o l r t p a t i c n t s . T h c r c w c r c n o c o m p l i c a t i o n s a s s o c i a t c dw i t h t h e u s c o f t h c c h c s t t u b c a n d t c n p c r c c n t ( a / a O )h a d m i n o r c o m p l i c a t i o n s w i t h t l ' r c p c r c u t a n c o u s c a t h c t c r i r - r c l u d i n g :c a t h c t e r o c c l u sion, kinking, or falling out. Only onc paticnt with complications rcquircd further treatment. No signilicancc was found with chisquarc and odds rirtros Owing to thc size of thc study group. Results show that thc pcrcutaneous cathctcr was as succcssful as t l - r ec h e s t t u b c i n t r c a t i n g s p o n t a n e o u s a n d i a t r o g c n i c p n e u m o t h o r a c c s w i t h t h c a d d c c la d v a n t a g c o f o u t p a t i c n t t r e a t m c n t i n sclcctcdpaticnts.

ql Accidental Hypothermia: An f r, f Analysis of Treatment Protocols / Division of Plastic and JM Saxe,AA Smith,MC Robson WayneState Department of Surgery, Surgery, Reconstructive of TexasMedicalBranch, Detroit, MichiganUnrversity University, Texas Galveston. S e v e r ea c c i d e n t a l h y p o t h e r m i a , d c s p i t e a n i n c r c a s i n g u n d c r stancling of its pathophysiology, continucs to be a significant causc of traumatic death during the wintcr months. Cardiopulmonary bypass (CPBI has bcen uscd succcssfully in a small nurnber of cascsto rcsuscitate patrcnts from scvcrc hypothcrmia. C P t s ,h o w c v c r , r e q u i r e s s p c c i a l i z e d p e r s o n n c l a n d c q u i p m c n t l i m iting its widespread application. Additionally, iatrogcnic complications of CPB appear increased in this patient population prone to both arrhythmias and sepsis.Rapid cxternal rcwarming thru immersion, the acocptcd treatment for frostbitc, has becn successfully used by us in 48 patlents ovcr a scven ycar pcriod

a 1r4, f rrr,

Radiologic Evaluation of Soft Tissue Foreign Bodies

M Pollack,LJ Guzzardi,NK Sabulsky,DJ Schnapf,JA Robinson, DR Eitel,M Keeny/ YorkHospital,YorklmagingCenter,York, Pennsylvania Evaluation of the patient with a soft tissue iniury and possible foreign body is often difficult {rom both a diagnosticand management standpoint.Sincea negativephysical examination doesnot exclude a foreign body,radiologic examination is a logical adjunct. There is considerabledebate regardingthe best way to demonstratea soft tissue foreign body radiographically.Our study used freshly preparedpigs feet to evaluateboth the presenceand type of foreign body,using a variety of radiologic modalities. Foreign bodiesof wood, plastic, and glasswere implanted in pigs feet and then studied with plain-film radiography,ultrasonography, xerography,computerizedtomography,and magneticresonance imaging (MRI).The radiographswere read by an observerwho did not know the type or location ol the foreign body. We demonstratedthat: l) glasswas readilyvisualizedby plain-film radiography, but wood and plastic were not, 2) xerographyand ultrasound were not useful in detecting wood or plastic foreign bodies, 3) computerizedtomography was not consistently useful in detecting any foreign body,and 4) MRI could readily detect the presence of soft tissue {oreign bodies of all types, although this technique could not easily distinguish between the types. Our results suggest that MRI is the most useful technique to evaluatethe presenceof soft tissueforeign bodiesthat are not detectedby physical examination and are not seen on plain-film radtography.

134

become more sophistigated,many emergencydepartmentshave developed"routine" laboratory and radiographicstudies that are performed on all trauma victims. The pelvic x-ray is one study that has been advocatedas "routine". We attempted to delineate clinical criteria that could facilitate more selective use of this test. First, using a retrospectivechart analysis,five high yield clinical criteria were developed.These were: l) changein mental status prohibiting adequatehistory/physical exam 2) patient complaining of hip, pelvis or buttock pain 3) pain elicited by palpation of the pelvis 4) clinically obvious fernur fracture and/or dislocation 5) acute abdomen.Over a three-month period, 63 multiply traumatized patients presenting to the emergencydepartment of a rural, tertiary care center were evaluatedprospectively for the presenceof these criteria. Pelvic x-rays were then obtained on all patients and the variableswere evaluated,both independentlyand as a group,for their associationwith a pelvic fracture. A total of I I patients were found to have sustaineda pelvic fracture. TWo variables,a complaint ol hip/pelvis/buttock pain and the presenceof pain upon palpation of the pelvis were, predictably,independentlyassociatedwith an increasedincidence of pelvic fractures. None of the other variablesdemonstrateda significant correlation with a pelvic fracture. Thken as a group however,the absenceof all six variableswas found to be a highly sensitive predictor for the absenceo{ fracure. We conclude that there exists a subsetof multiple trauma victims who, if they do not demonstrateany of the clinical criteria used in this study, may be safely managedwithout pelvic radiography.

Gomputed Tomography Ve?sus ttPoot Mants" Inttavenous Pyelogram (lVPl

MountCarmelMercy Hospital,Detroit,Michigan The purpose of this prospective study was to determine the ellicacyof clinical and radiographicexamination in the diagnosis of caroal navicular fracture. We also evaluatedthe usefulnessof 25 degreepronation and supination views in patients whose initial four view radiographsdid not reveal a fracture. All patients who sustaineda fall on the outstretchedhand and had pain and swelling around the wrist were evaluatedclinically and radiographically.The clinical tests applied were anatomical snuffbox ienderness and the presence or absence of swelling over the snuffbox. All patients had standardfour view radiographsof the wrist rnitially. If a fracture was not detectedon the lour view ra' 'lrffSmThf", 25 4gg1t3 rvirtrwtt'rrc"t 'cht Ttrctnatrctnuri-r swpmratircnr tained.e,ll patient files and radiographswere reviewedtwo weeks later, when repeat radiographswere done. One hundred fifteen patients who fell on an outstretchedhand were evaluatedand 90 -had injuries in the immediate vicinity of the carpalnavicularand were entered in the study. Fifty-four patients had navicular fracture diagnosedon standardfour view radiographs.Thirty'six pa' tients who had negativefour view radiographshad the additional two views performed.Eleven were found to have fracture of the carpal navi-ular. No patient in the study demonstrateda fracture at two weeks if he had negative initial radiographs.Anatomic snuffbox tendernesshad a sensitivity of 1007oand the postive predictivevalue was 91.5%. Swelling over the anatomic snuffbox ichieved a sensitivity of 73.5"/oand a positive predictivevalueol 87%. Specificity of six view radiographywas 100%. From this study, ii appears that clinical signs are very useful in the diagnosis of navicular fracture. Additionally, pronation and supination views should always be a part of the radiologicevaluationof suspectedcarpal navicular iniuries.

MJ Shapiro,AS Hurwitz,RF Beckman,C Tirre/ St LouisUniversity MedicalCenter Computed tomography (CT) is becoming increasinglymore utilized in the evaluation of multiply injured patients/ especially those sustaining blunt trauma. However,some skepticism in evaluation of the genitourinary tract remains. In order to compare CT scanningand a modified intravenouspyelogram(IVP),a prospective,consecutivestudy of 41 patients was carried out in those patients admitted to the Tiauma Servicewho had sustained sulficient blunt trauma to warrant CT scan. As a basis of com"Poor Man's" IVP was per{ormed.This consistsof obBarison,,a taining an abdominal film immediately after contrast infected CT scan, having clamped the indwelling Foley catheter.The Foley is ailowed to drain and another abdominal film is obtained to provide a post-voidradiograph.The primary indications for CT scanning were hematuria in 89o/"of the patients. The other pa'37%1,shock (32%),pelvic fracture tients had abdominal pain 120%),abdominalecchymosis(10%)and flank ecchymosis(7%). N i n e t y - f o u r p e r c e n t l g a % l h a d e v i d e n c eo f m i c r o s c o p i c hematuria. The CT scan revealedlesions in 56% of the patients. Two patients had pertinent renal iniuries in addition to the many other pertinent findings, such as pelvic fractures,pneumothorax, splenic and hepatic iniuries. The IVI on the other hand, failed to reveal any lesions in any of the 4l patients. In fact, 667" oI the "Poor Man's" IVPs were unsatisfactoryin quality. Thus, the "Poor Man's" IVP is not necessarywhen a CT scan is used with contrast material as part of the overall evaluation of the blunt trauma patient. In fact, the cost of the two abdominal portable radiographsis $126.

135

ca'pal $lliffii,'1"f',;ril;n" IMP Mehta, 36 MW Brautigan / Departmentof EmergencyMedicine,

Selective Use of PelYic X.RaYs in Multiple Trauma

137

RB RowlandJr, RA Schwab, NR Wilkins,W Snover/ Department o{ EmergencyMedicine,GeisingerMedicalCenter,Danville' Pennsylvania As the management of the multiply traumatized patient has

The Glinical Use of the Patellar' Pubic Percussion Sign in HiP Trauma

UniversityMedicalSchool,Chicago SL Adams/ Northwestern Hip trauma constitutes a large proportion of orthopediciniu-

ries seen in the emergency department. Evaluation of hip injurres includes the physical examination and often a radiographic series. We evaluated the utilization of the patellar-pubic percussion t e s t ( P P P )t o a s s e s si t s r e l i a b i l i t y w h e n u s e d i n c o n i u n c t i o n w i t h the physical examination and radiographic examination. Fiftyone paticnts were prospectively evaluated by the PPP test. To per{orm thc test, the bell of the stethoscopeis placed over the symphisis pubis as the patient lies supine with the legs extended. Then each of the patella are percussed. In the normal exam with no disruption of bony conduction, both sides should produce an equal crisp sound. In the cvcnt of fracture or dislocation with disruption of bony conduction, the a{fected side should be duller in pitch and intensity. In those parients who had radiographic abnormalitres, 17/23 (73.9%) had an abnormal PPP sign (by at least one ol two raters). In those patients without radiographic abnormalitics (eg, contusions), only one (l/28) had an abnormal PPP sign. Of those paticnts with radiographic evidence of complete disruption crf thc bony pathway, 17/19 1'89.4%h l ad an abnormal PPP sign (1' < .01). Overall reliability of the PPP sign based on t w o o b s c r v c r s w a s 8 7 . 5 % ( P < . 0 0 0 1 ) .I n t h o s e p a t i e n t s w i t h f r a c turcs, intcr-ratcr rcliability was 84.2o/" lP < .02). In the series, the P P P t e s t r c s u l t e d t n a 3 . 6 0 / of a l s e p o s i t i v c c r r o r , a n d r e s u l t c d i n a 22.8% falsc ncgative error. Although the prcsence of a normal PPP sign docs not negatc the need for radiographic studics, the presence of an abnormal sign should suggcst the need for appropriate radiographic studres. We conclude that the PPP sign is a helpful adjunct to thc physical examination of hip injurics.

r38

In order to detcrmine the clinical value of toxicologic (tox) screening in acutely traumatized patients, a retrospective chart rcview of 1,364 paticnts admitted from July, 1986 through fune, 1987 with traumatic iniurics was done. St Francis Medical Center in Peoria is thc Rcsional Tiauma Ccnter for 17 counties in rural North-Central Illinois. Four hundrcd thirtv-one Daticnts had 749 t o x i c o l o g i c s c r c c n s p e r f o r n r c d : 4 0 ( r s c r u m s c r c L l n s( S S ) a n d 3 4 3 urine scrccns (US). Tox scrccns wcre donc by thin laycr chromatography and all positivc rcsults confirmed by radroimm u n o a s s a y .E t h a n o l a n d c a n n a b i n o i d s w c r e n o t p a r t o f t h e s t a n ) ale and d a r d t o x s c r c e n . T h e s c r e c n e dp o p u l a t i o n w a s 7 0 " 1 ' ( . 3 0 1 m 30% {130) fcmalc with an avcrageage of 3(r + l7 years. Mecha' / u nism of in;ury was 9l b h . r n t\ 7 9 ' / " M V A , I I % f a l l s , I 0 % a l t c r c a tions) and 9(% pcnctrating. Four hurrdrcd forty-ninc {60'l.) tox s c r c e n s w c r c n c g a t i v c . O f t h c . 1 0 0p o s i t i v c t o x s c r e c n s , 1 9 6 $ 5 % ) werc positivc only for nicotine and/or caffcinc and 104 (35%) wcrc positivc for substanccs othcr than nicotine and/or caffeinc ( S O T N C ) : l t J S S a n d l . i ( rU S . S c v c n t y - r w o p c r c e n t ( 7 5 l 1 0 4 ) o f t o x s c r c c r - r sp o s i t i v c f o r S O T N C r c v c a l e c l o n l y o v c r - t h c - c o u n t e r o r prcscribcd mcdications. Of all tox screcns positivc for SOTNC, l4% \15/104)showed narcotics, l0%, l5/104) dcmonstratcd cocainc, amphctamincs, or thcir rnctabolitcs, and an additional 5'lu (5/104) probable drug adultcrants. Thcrc was no diflcrcncc in l c n g t h o f s t a y o r p r c s c n c e o f a s s o c i a t c di n j u r i e s b c t w c u n p a t i e n t s with ncgativc or positivc (SOTNC) tox scrccns. Of thc 749 tox s c r c c n s p c r f o r m c d d u r i n g t h c p c r i o d r c v i c w ed , < 1 ' l ' o f t h c s c r u m s t u d i c s a n d < 5 ' % o f t h c u r i n c s t u d i c s r c v c a l c d s u s t a n c c so f p o t e n tial abusc. Thc cost of cach tox scrccn was $104; thus, thc 749 s t u d i c s c o s t $ 7 7 , 8 9 6 o r $ 2 , 5 9 ( rf o r c a c h s i g n i f i c a n t l c s u l t . I n c o n clusion, routinc tox scrccning of trauma paticnts is expcnsivc and ol low yicld. Our rcsults sugllcstthat toxicokrgic scrcening in thc t r : l u n 1 : rp a t i c n t s h o u l d b c s c l c c t i v e r a t h c r t h a n r o u t i n c . T h c c r i t c ria to sclcct traumi paticnts who migl-rtbcncfit from tox scrccni r - r ga r e s t i l l t o b c d c v c l o p c d .

The Frequency of Cardiac Injuries in Patients With Sternal Fractures

JT Sturm, MG Luxenberg, JF Perry Jr / Departments of E m e r g e n c y M e d i c i n e a n d S u r g e r y , S t P a u l - R a m s e yN / e d i c a l Center,St Paul, Minnesota Thc suggestion has bccn madc that cardiac injuries occur with incrcascd frccluency in paticnts with sternal fracturcs, but this assertion has nevcr becn subjccted to statistical scrutiny in a largc group of paticnts with blunt chest trauma. We retrospcctively rcvicwed 1,045 blunt chest trauma patlents treated between 1977 and 1986 to determine whether cardiac inluries occurrccl morc frequently in those patients with sternal fractures comparcd to paticnts without sternal fractures. There were 37 stcrnal fractures among the 1,045 patients with blunt chest trauma. Thc paticnts rangcd in age from 5 to 8I years, with a mean a g e o f 4 1 . 9 y c a r s . T h c c a u s e so f i n j u r y w e r e a u t o m o b i l e a c c i d e n t s ( 2 2 p a t i c n t s ) , f a l l s { 5 v i c t i m s ) , c r u s h i n i u r i e s ( 3 p e r s o n s ) ,m o t o r c y cles (2 patients), pedestrian accidents (2 victims), and other causes (3 pcrsons). The mean Iniury Severity Score for the sternal fracture paticnts was 17.02. Cardiac iniuries were lacerations, ruptures/ and contusions. Cardiac lacerations and ruptures were diagnosed at opcration or autopsy and cardiac contusions were diagnosed principally by elevation of the CPK-MB band. The Fisher exact text was uscd to determine statistlcal sisnificance. There were 29 of 1,008 patients without sternal fracture who suffered cardiac injuries (2.8%),and 8 of 37 patients with sternal fracture w h o h a d c a r d r a c i n j u r i e s l 2 1 . 6 u L ) ;t h i s d i f f e r e n c e w a s s i g n i f r c a n t , P = .000021.Cardiac contusions occurred in 2l of L024 oatients without sternal fractures {2.I%) and in 7 of 37 natients with stern a l f r a c t u r e s 1 ' 1 8 . 9 % )tj h i s d i f f e r e n c e w a s h i g h l y s i g n i f i c a n t , P = .00002L The incidence of cardiac lacerations and ruotures was not increased tn the group with sternal fractures. Wi conclude that the incidencc of total cardiac injuries and cardiac contusions is significantly increased in patients who suffer sternal fractures.

I I

140

Kerosene Heater Injuries in Ghildren

R Kulick, F Henretig,S Selbst D Bake| Emergency Department, C h i l d r e n ' sH o s p i t a lo f P h i l a d e l p h r aD ; e p a r t m e n to f P e d i a t r i c s , U n i v e r s i t yo f P e n n s yv a n a , P h l l a d e l p ha

Efficacy of Routine Toxicologic 20 f 9-t Screening of Trauma Patients MA Cruz,A Aldag,RWWolford / Emergency Medicine Residency, St Francis MedicalCenter; TheUniversity of lllinois College ol Medicine at Peoria {

Rising cncrgy costs havc lcd many consumcrs tt, purch:rsc m o r c e f f i c i c r - r t ,b u t p o t c r - r t i a l l yl - r a z a r d o u sh c a t i n g x p p l i a n c c s s u c h as kcroscnc hcatcrs (KHs).Tb study thc cpidcrniology of KH in;r.rrics, a qucstionnairc was administcred to thc familics of childrcn prcscnting to thc cmcrgcncy dcpartmcnt (ED) with a KH injury b et w e c n l 2 l l / 8 6 a n d 4 / 1 / 8 7 . A f o l l o w - u p c a l l w a s m a d e I m o n t h latcr. A control group (childrcn owning a KH but prescnting to thc ED for an unrelatcd problcrn) was also intcrvicwcd. Wc idcntificd 3l childrcn with KH injurics. In;urics includcd burns (84'X,), and one patlcnt cach with CO poisoning sccondary to a housc f i r e , a k c r o s e n c i n g c s t i o n a n d a l a c c r a t i r n . 8 7 " 1 ,w c r e < 5 y r s o l d , and 55% wcrc malcs. Thcrc was a history of previous injury in 35%. KHs werc used primarily for supplcmcntal heat. Only 20"1, discusscd safcty with thc salcsman at the timc o{ purchasc. Dang c r o u s p r a c t i c c s i n c l u d e d r e f u c l i n g i n t h c s a m c r o o m { 5 5 ' 2 ,) , s t o r i n g k e r o s c n c r n s i d c t h c h o u s c ( 8 3 % , ) ,h c a t i n g w a t e r ( l 3 o l , ) , a n d n o t a l l o w i n g a d eq u a t e v e n t i l a t i o n ( 5 3 % ) . I n j u r i e s i r - r v o l v e db o t h r o u n d (convcctivc) heaters (63%) and square (radiant) kerosene heatcrs ^the injury occurred at home in 57%. Thc KH was most 127%| o f t e n l o c a t c d i n t h c l i v i n g r o o m 1 6 7 % ) ,i n t h e c c n t e r o f t h e r o o m 1 6 5 % 1 ,a n d o n t h e f l o o r ( 9 6 % ) . T h e r e w a s a d u l t s u p e r v i s i o n a t t h e t i m c o f t h c i n i u r v i n 8 ( r % o f c a s e s .C o n t a c t b u r n s a c c o u n t e d f o r 73% oI injurics. Burns werc partial-thickness in 96% and involved thc hands in 62"1,.With the exception o{ a major scald burn and a kerosene rngestion, patlents were managcd in thc e m c r g e n c y d e p a r t m e n t a n d d i s c h a r g c d 1 9 6 %) . O t h c r t h a n o n e child with significant scarring resulting in a limitcd rangc of mot i o n r n o n e a r m , t h e r c w c r c n o m a j o r s e q u e l a cd i r e c t l y r e l a t e d K H injurics among those children available for {ollow-up. The control

group was significantly older (44% > 5 yrs),but did not otherwise differ significantly from the iniury group. KHs are potentially hazardous,particularly for youngerchildren. Preventiveefforts should be directed towardsconsumereducation,physical barriers to preventcontact with hot surfaces,and improvementsin design aimed at reducing conduction of heat to exposedsurfaces.

141

Stopping the l{eartbeat Pediatric Trauma 1988

100

LIJ F

stL

of America:

R Lavery,BJ Tortella,CC Griffin/ Departmentof Emergency MedicalServices,Divisionof TraumaSurgery,New JerseyState TraumaCenterUniversityHospital,Newark It is said that the soul of a society is its wise and experienced, while society's lifeforce and heart are its youth. Tiauma is the leading killer of this lifeforce; each child,s death decreasesthe potential of future generations.This report suggestsa startling trend that firearms, once the province of adults, have made an ominous foray into the pediatric ranks. We studied pediatric trauma by reviewingall 1986ALS run forms {14,215responses wirh 7,806 work-ups) for ages0-18, surveying mechanisms of iniury, on-scenetime and IV successrate. Resultswere comDaredto an adult ALS trauma survey done earlier. Our responsearea is Northeast, urban and primarily inner-city. There were 809 pediatric calls {5ol. of all responses},575 l7l} medical and 234 l29l trauma. ll5 (491of the trauma responses requiredALS, accounting Ior 27"/" of all pediatric ALS vs trauma making up l0% of ALS in the adult group.Males outnumberedfemales3:1. tv On-scenetlme succesg 7o GSW SW Assaull MVA MVA/PPenetratlngBlunt rab Adult 10 zt o 18 I 1 0 . 2 1 1 56 1 94 Pediatric 42 1 8 10 14 1 02 9 14.26 89

The attending trauma team leader is routinely in the hospital between 7 am and l0 pm. Data are corrlpleteon 30 of the 42 patients arriving after l0 pm. When the patient arrived after l0 pm, advancenotification still allowed the trauma physician to arrive beforethe patient 66y. l2O/3Olof the time. He arrived an average of 9.1 minutes after the patient in the l0 remaining casesof which none hdd a trauma score less than 14. Prior to his arrival resuscitationis directed by the PICU fellow and emergencyphysician. In our system the infrequency of pediatric trauma after 10 pm along with a communication system that ensuresearlynotification of the trauma team led to.a successfulreduction oi the hours of in-housecoverageby the trauma physician at night. This has resulted in a savingsof over $200,000a year to the hospital.

143

Pediatrictrauma in our series is a male diseaseand makes uo a Breaterportion of ALS responsethan adults. Our typical injuied child is male, agedl4-18 and a gunshot victim. While other series have reported motor vehicle related trauma and falls to be the bulk of their pediatric trauma, our data shows violence, especially firearms, to be the chief causeof seriousinjuries. Prevention efforts (infant car seats,window guards,etc,) have been successful in decreasingsome aspectsof trauma; firearms continue to proliferate.We testify that "coming of age in urban America,, exposeschildren to violence and gunshot iniuries at an ever younger age. Preventionof child abuse,educationagainstviolence and gun control must be addressedif we are at all to significantly decreasemorbidity and mortality from pediatric trauma. It is unfortunate that while we have the technologic and legal means to control firearm misuse, we lack the political will to accomplish it. The medical and social-politicalcommunities must move to halt this grim trend which seemsaimed at stopping the heartbeat of America's future: our young.

1 42

RD Powers,JK Hoover/ EmergencyMedical Services,University of VirginiaMedicalCenter,Charlottesville Measurementof body temperatureis a standardpart of the initial patient assessmentin the EmergencyDepartment.Factors such as respiratoryrate and cigarettesmoking interfere with the proper oral measurementof body tempâ&#x201A;Źraturâ&#x201A;Ź;considerationof patient comfort and dignity, and physical constraints such as MAST trousers may limit the suitability of rectal temperature measurement in the emergency setting. Since tympanic membrane temperature approximates the hypothalamic core tem. perature/this study was designedto assesswhether measurement of the temperatureof the exernalauditory canal {EAC)would provide a convenient and accurateassessmentof body temperature in EmergencyDepartment patients. Adult patients in a teaching hospital ED had their oral temperaturemeasuredwith a standard electronic thermometer {DIATEK Model 600).Immediately thereafter, the thermometer was zeroed and equipped with a new probe cover.The probe was then introduced one to two cm. into the EAC, and the temperaturerecorded.No patients reportedany discomfort, and there were no adverseeffects of the procedure. Oral and EAC temperaturesfrom 102 patients were plbtted on a scattergram to determine the relationship between the values. There was a good correlation betweenoral and EAC temperatures,with an R value oL758 lP = l0-s). The following re. gressionequation relating oral and EAC temperaturewas derived: oral temperature = 12.8 + 0.67 (EAC temperature).All patients with oral fevers(> 38.0" C) had EAC temperatures> 36.5'C.The one hypothermic patient {oral temp. 35.8"C) had an EAC temperature of 34.9"C. This study demonstratesthat EAC temperaturecorrelatesreliably with oral cavity temperature,and that the two can be interconvertedin a given patient by use of a simple formula. EAC temperature measurement using a standard electronic thermometer is rapid, convenient,safeand reliable. Consideration should be given to using the EAC for screening

o'1,3n?"0'""' f,:1H:%:1fl1""',

JN Lindsay,A Rodarte,BM Peterson,FP Lynch i Children's Hospitaland HealthCenter,San Diego,California Staffing hours by in-house physicians of a regional pediatric trauma center were reducedby examining the infrequencyof pediatric trauma after l0 pm. The center servesa population of 2.1 million and receivesall children under l5 years whose iniurv is seriousbasedupon anatomic factors,mechanism of injury, or Champion trauma score less than 13. Over 3 years, only 3To of the patients arrived between l0 pm and 7 am. The 142/1,266lr distribution of arrival times shown below is similar to that found in a previous study.l

Suitability of the External Auditory Ganal for Body Temperature Measurement in Emergency Department Patients

temperature measurements when the oral cavity is unavailable for use. Patients with EAC temperatures in excess of 36.5.C or less than 35.0'C may have ciini-ally srgnificant temperature derangements/ and should have their core tcmperature measured bv a more conventional method

744

tively largc probe diameter (8 mm) compared to an infant ear speculum (4 mm). Thermistor probe and Tmt thermomerer were compared wcekly to glass thcrmomcter using an oil bath heated to 38.0 C {corrclation (r) - 0.89) patrcnts wcie grouped according t o a g c a n d R t . F c v e rw a s d c f i n e d a s R t > . 1 8 . 0 , A t > - . 1 2 . 3 o , rTmi > .lll.0. At and Tmt werc compared to Rt by regrcssionanalysis. Scnsitivrty, spccificity of At and Tmt to predrct fever (Rt > 3g.0 C) was calculatcd.

l":'il::il'i?:;;"'l'.1r,::f"

the Emergency Department pittsourgn | . W a r d , R M K a p l a n , P M P a r i s/ T h e U n i v e r i i t y o f A f f i l i a t e dR e s i d e n c y i n E m e r g e n c y M e d i c i n e ; T h e C e n r e r r o r E m e r g e n c y M e d i c i n e o f W e s t e r n p e n n s y l v a n i a ,p h i l a d e l p h i a

Group

_ Rectal temperatures are more rcliable than oral remperarures, but_are resisted by many patients and staff. A rapid .,oni.,vasiuc and accurate method for measuring temperaturclsin thc ED is desirable.A potential site for t"mp"rat.ri" mcasurcment is the tympanic membrane. The tympanic membranc obtains its blood s _ u p p l yf r o m c a p i l l a r i e s o f t h e p o n t i n c a n d b a s r l a r a r t e r l c s . T o date, no studies have been conducted in the ED to cvaluate thc value of rympanic membrane temperature measurcmcnts. We conducted a prospective study comparing the tympanlc mem_ brane temperatures of the First femp' 1fi1 thermomctcr (lntel_ ligent Medical Systems, Carlsbad,^CA) with thc rectal tcm_ peratures of the IVAC (San Diego, CA). Thc FT measures temperatures within several seconds, while thc IVAC requircs about 30 seconds for a rectal tcmpcraturc. Thc FT ,"poit"dlu m e a s u r e st e m p e r a t u r e s f r o m 1 5 . 5 C - 4 3 . 3 C ,w h i l e t h c t c m p e r a t u r e range of the IVAC extends kom 82.2C-4Z.lC. Onc hundicd fiftv patients werc entered into the study. Inclusion criteria includei p a t i e n t s w h o w o u l d n o r m a l l y r e c l u i r ea r e c t a l t c m p c r a t u r c , n a m c _ ly those with rcspiratory distreis, acutc abdomGal pain, facial injuries, or trauma. Each member of the ED nursing siaff was in_ serviced on the use of the FT and all mcmbers oi'thc staff had routinely used the IVAC thermometer. All tympanic and rcctal temperature measurements were independently rccordcd on a data sheet. Of the 150 patients, thc correlation bciwccn tympanic ano rectal temperature measurements was 0.94. The IVAC idcnti_ fied i6 patients with temperatures below 35C. TWelveof these l(r patients had FT temperatures below 35; the remaining {our pa_ tients had temperatures that ranged from 35.0-35.(;. In iwo o{ ihe 16 cases, the IVAC appeared to reach the limit of its accuracv at 32.2C, while the FT recorded temperatures of 3I.0C and 31.4C. Forty-one patients had rectal temperatures above 3gC. Thirty_five of these patients had FT temperatures above 3BC, while the re_ maining_6-patients had temperatures rangrng from 32.6C_3g.0C. Thirty.of the 35 patients had FT and IVAC tJmperatures that did not differ_by more than 0.5C. We conclude that the FT provides a rapid and reliable method for measuring temperatures of hypothermic, normothermic, and hyperthermic ED patients. FT measurements may be helpful when initialty screening temperarures on all patients entering the ED.

| 45

al 223 081 Age (months) .:? 26 077 218 128 080 18-36 69 0.85 Rt (C) .,380 136 A12 38-395 67 065 >395 20 a24 Sensitivity S p e ci i c t y Postive predctive N e g a t r v ep r e d l c t i v e

Height of fever in infants and young children has been positively correlated with the incidence oflnvasive bacterial dis_ tympanic membrane thermometer (First_ 15j:_4".infrared TEMPo) that is purported to measure infrared output from the tympanic membrane is now available. It is noninvasive, quick, and.easyto.use. We compared axillary (At), rectal {Rt), and'tympanic membrane (Tmt) temps in children ln:ZZ4) i3 years of age. All temps were performed on presentation to the emergency department. Patency of the external audrtory canal and the"o.es_ ence o{ otitis media were noted. Rt and At were obtained via thermistor probe. Tmt was obtained via probe insertion into the externai auditory canal. Insertion was limited to l-2 mm by rela-

P <005

Rt vs At n r 224 075

P <0.05

P .:0 05 P <005 P <005

26 129 69

083 074 0.81

P <0.05 P <0.05 P <005

t J l

003 058 022

P .:0 05 ns

N S

P .:0 05 n s. 54% 100% 1007" 80%

67 20

N S

43% 99% 96% 7B%

C _ u r r c l a t i o r r( r ) w a s h i g h f u r a l l a n d a g c g r o u p s t r a t a , b u t l o w f o r a f c b r i l c a n d h i g h t c m p g r o u p s . O v e r a l l h i g 6 r s c e n - r st o b c t h c r c s u l t o f h i g h r i n t l " r cl u w f c v c r g r ( ) u p . R c s u l t s w c r c s i m i l a r r c g a r d l c s so f o t i t i s m c d i a o r c a r p a t c n c y . S c n s i t i v i t y w a s k r w c r t h a n e x p c c t c d f o r T m t , T l - r i sn r a y l r c t h e r c s u ] t , r f p n , [ g c o n f i g u r a t i o n and inability of Tmt probc to be fully inscrtcd into cxtcrnal auc l i t o r y c a n a l .A t s c n s i t i v i t y i s a l s o I o w A t a n d T m t ( F i r s t T E M p , . l t l c t c r m i n i r t i o r . r ss h o u l d b c v i c w c d w i t h c a u t i < > ni n t h i s s e t t r n c a n d popuhtior.r.

rvmpanic fiHts?:f:l*'.T:':i:Y,

Temperatures in young Ghildren D T r e l o a r ,B M u m a / D e p a r t m e n t o f p e d i a t r i c s , H e n r v F o r d H o s p i t a l ,D e t r o i t .l V i c h r g a n

Rt vs Tmt n r

14G

i"i[iil:i'*i:lT8"";,",:?i?,,o,,

Administration of Lidocaine in pigs K Brickman, P Rega, M Guinness / The Emergency Medicine Resrdencyof St Vincent Medical Center / The Toledo Hosoital. Toledo, Ohro

Vascular acccss for fluid and drug administration in pcdiatric cmcrgencics reprcscnts a major obstacle in successful resuscitation in children. The intraosscous and intratrachcal routes have bccn shown to be thc only cf{ectivc mcthods for emcrgency drug acccss when venous accessrs unobtainable. This study was del signcd to compare the efficacy of these altcrnativc forms of vasc u l a r a c c e s si n a n a r r e s t m o d e l . L i d o c a i n e a t 2 r n g / k g w a s a d m i n istered to thirty-three pigs in cither tibial intraosscous {N= 11). intratracheal (N= l0), or central venous {N: I2} routes, fifteen minutes after inducing cardiac arrest. Closcd cardiopulmonarv rcsuscitation was initiated at thc time of hdocaine rnfusion. Central vcnous drug samples wcre collccted at onc/ thrce/ six, ten, and twcnty minutc timc intervals post infusion for measurement of scrum lidocaine levcls. Our rcsults show significantly higher lidocainc levels through the intravenous and inlraosseous routes compared to intratracheal administration at one, three, srx and ten minutc intervals (P < .05). No statistically significant differences werc found between intraosseous and intravenous lidocainc levcls at any time interval. placement of an intraosseous cannula can be performed quickly and quite easily. This access route can also be used for fluid administration which is not avarlablc through thc intratrachcal route. Using the results of this animal study, we suggestthe possibility thai the intraosseous infusion of lidocaine in pediatric resuscitation, may be a more effective vascular acccss route than intratracheal infusion when venous access is unavailable or would cause an unacceptable delay.

and MDO2 (ccO2/min/I00gms),C"O2 and C".O2 (ccOz/100mL), ER and endo/epi are displayedbelow:

Cerebral Arteriovenous OxYgen Extraction During GPR in Children

147

MG Goetting,G Preston/ Departmentof Pedratrics,Divisionof PediatricCrrticalCare Medicine,HenryFord Hospital,Detroit, Michigan Outcome of CPR in children is poor,with most not survivlng hospitalization and most of the suivivors left neurologicallydisabled.While animal models demonstratethe inadequacyof cerebral blood {low (CBF)during CPR, human studiesare lacking We receiveddata on 87 consecutivecritically-ill children during a l9month period who had jugular venous bulb cathetersplaced for m o n i t o ; i n g o f a r t e r i o i u g u l a rd i f f e r e n c e s - o fo x y g e n c o n t e n t inloO") to"assessadequaiy of CBF.Eligibility criteria for this study i-ncluded:{l)no d-irecibrain iniury (21AJDO, < 7'0 within 30 minutes prior to CPR, (31arterial oxygencontent > 10 mL/dL; {41AIDO" p-erformed5-10 minutes into CPR. Four patients met th.se c.it-eiia.Standardtherapyaccordingto ACLS guidelineswas administered.All patients were in asystole and none survived' Blood oxygen satJration was measuredon the IL 282 Co-Oximeter. Pad2 was determined by the RadiometerABL 3 Oxygen content wal calculated in a standard fashion. The AfDO2 was increasedin all patients, demonstratinghypoperfusionof the brain during CPR. AJDO2 representsthe ratio of .cerebralmetabolic rate oi o"yg"n {CMROT}to cerebral blood flow {CBF}-Bel-6 hours earlier, -"tr. .u.ty patiiit had a previous-cardiac.arrest it is likely'tirat the CMRO2 was abnormally Iow beforethe studi.d "tr.ti and that cerebralvascular resistancewas reduced' Patlent 1

Age 2wk

Diagnosis

MAP

NSR

c"o, c".o, lv'1BF

33,! 2.9 ' 11 2 . 8+ 1 3 . 0 1337* 28.6

|\/DO2

163+ 3.5

N,4VO2

123!23

endo/epi

1.5.!02 74.7 * 18.2

ADP

Sepsis

10.2

29mo

Near drowning

47 rno

Asphyxia

15Yr

Asthma

1 34

1 . 1t 0 9 7.3 * 5.9 29 * 3.7 0 . 4 : t0 6 0 . 21 0 1 04*03 91 6 1: 4 7

CPR + UK,14,304 P'value .02 1 5 . 3I 1 . 6 10 1 . 7+ 1 0 9 . 0r 8 9 9.0 :! 13.8 1.5* 2.4 05 + 04 0.4 * 0.3 892 * 60

17 25 .25 06 .84 36

No significant improvement in ADB MBF, MDO2 or ER-was The lack of imnotedTollowingthe administrationof UK-14,304' orou.-.n, in IOp and MBF may be secondaryto a centrallyacti"n ou.ilrun"otic alpha-2agonisteffect becauseof disruptionof thi'blood-brain bariier lollowing a prolongedcardiacarrest,or becauseof saturation of peripheralreceptors This study suggests that UK-14,304does noi improve myocardialhemodynamicsat thesedosesduring CPR following a l0 minute arrest'

1 49

These data imply that during standard CPR, CBF is greatly reducedin children, possiblywell below levelsnecessaryto support neuronal life.

148

CPR '1 19:t36

T h e r ew e r en o s u c c e s s l udl e f i b n l l a t l o n s

AJOO2 8.1

12.3+2.5

The Effect of an AlPha'2 Adrenergic Agonist (UK'|4,3O41on Myocardial Blood Flow During CPR

CG Brown,J Jenkins,C Smith,H Werman,J Ashton' R Hamlin/ Divisionof EmergencyMedicine,Departmentof Collegeof Medicine; Medicine,Ohio StateUniversity Preventive Departmentof VeterinaryPhysiologyand Pharm?l:ology,Ohio Medicine,Columbus StateUniversityCollegeof Veterinary Severalrecent studies have suggestedthat adrenergicdrugs propertiesrncrease with peripheralpost-synapticalpha-2.agonist aortic dia:toli. it.t.ni. iADP), and thus in the setting-of CPR, may improve myocardial blood flow {MBF).This preliminary stuiy investigatei the effect of UK-14,304,a post synapticalpha-2 adrenergicaginist on AD! MB! myocardialoxygen delivery/utilization"{lrl5O 2/Mvoz), endocardial/epicardialblood flow ratio (endo/epi),"oto-ttrty sinus oxygen content {C".Oz) and extraction ratlo (Eni'during CPR. Five swine were instrumented for MBF measurementsising tracer microspheres.Catheterswere also olaced to measure arterial oxygen content {C.O2) and C""O2, MDO2/MVO2, endo/epi,-ER, C.O2 and C".O2 were eOB fufSF, 'during normaf sinus rhythm (NSR), and during CPR measured following a te.r-mittnte cardiorespiratoryarrest' Following this, received 2.O m9/kg of UK-14,304 through a right .r"tr ,"i-"t arial line. ADB MBF, MDO;/MVO2, endo/epi,-ER, C,O2 and C"rO, *.t" again determined.-De{ibrillationwas then attempted' d d.i.r*1""*r"hether UK-14,304improved ADB MBF and MDO2 over MVO2, comparedto CPR alone,resultswere comparedusrng a paired Strrdent'tt test. Statistical significancewas consideredat ,n! r, = .05 level. ADP (mm Hg), MBF (ml/min/100 gms),MVO2

Ius"tur ff,fff,':l'Tfifl[iil? to Therapeutic Interuentions Guide During GPR

J Jenkins'H Werman/ Divisionof CG Brown,R Dzwonczyk, Ohio E..rg"n.y Medicineand Departmentof Anesthesiology, Collegeof Medicine,Columbus StateUniversity The oxygen requirementsof the fibrillating myocardiumare CPR following-a prolongedarrest'This is .ro, -., b'y"closed'-chest confirmei by extraction ratios (ER) of greater than 95% While ihe addition of certain pharmacologicalagents,including nor' eoineohrine{NE),has shownpromisein this settingby improving mvocardialoxvgendelivery(MDOz)over myocardialoxygenuti-' ii;.,i;; IMVCi;, and thui an improvem-entin ER/ no reliabie h"t been found-that allows for this metabolic ;l;;i;;l-;r*-.i.t The purpose of this study was to determine if the ,r..t.-.nt. ir.o.r.n.u of the ventricular fibrillation (VF) signal during CPR "o,lfa i.iu. as a clinical guide to the metabolic state of the fibrillating myocardium. TWelveswine were attached to a stanaard tead"U E'CC and were instrumented for MDO2 and MVO2 The ECG signal was recordedcontinuouslyon an -.rrr.rr.-.ntr. VF was i"nducedand allowed to persistfor l0 recorder. taoe FM minutts, following which CPR was begun A{ter 3 minutes ol cpn, ,ti. animali were allocated to receive a dose of nor.pt".pnt-. (NE), .04-.02mg/kg 3l/l.minutes after drug admin' irt.ation, defibriliation was attempted' Following the experiment, ,z'28.second intervals' ;"il;dd tG;ri was digitized bv simpling at the frequencydo' into transfoimed i-r.i"r + r.."o"as of daL was -"in .ttit"tga fast Fourier transform. The median frequencyIFM) io, ea"h 4"secondsof data was determined,and a mean FM was ."t""ftt.a {or the VF signal during CPR prior to and after NE "J-lnirtrrtio.t. MVoz, il''too, and ER were determinedduring Cpn, ""a following NE administration.The FM and ER following NE administration was normalized for diflerencesduring CPR' The normalizedFM following drug administration was compareo resuccessfully,.tntJit^t.d (SR)and unsuccessfully ;;,*";; r"..ir",.J (Un) animals using a Wilcoxon rank-sum test' The normalized'changesin FM anl ER that occurred due to NE administration we-recalculated. A regressionanalysiswas p-e-rioi-.a U.,*".n thesechangesand the doseof NE' The meanFM igrl and ER in UR and SR animals during CPR and followingNE icPR + NEI are shown below:

CPR U R( n = 2 ) S B( n : 1 0 )

FM 76 * 05 79 * 1.7

CPR + N E EB

947* 43 9 3 . 7* 4 1

FM 61 * 0.7 107 + 2.8

ER 9 6 5* 1 3 76.4 * 13.9

Thcrc was a significant improvcment in FM (P - .03) over that s e e n d u r i n g C P R i n S R v e r s u s U R a n i m a l s . T h e r e g r e s s i o na n a l y sis showed that ER decrcased(P - .005) and FM increased {P : . 0 3 9 1w i t h i n c r e a s i n g d o s e s o f N E . I n t e r v e n t i o n s t h a t i m p r o v e MDO2 ovcr MVO2, and thus improve ER, may be reflected by an increase in the FM. Thc FM may serve as a clinical guide to therapeutic interventions during CPR.

150

Effect of Sodium Dichloroacetate Dose on Lactate in the Brains of

Fed Rats lschemic R V W D i m l r c h , B L T i m e r d i n g ,J K a p l a n , R C a m m e n g a / Departments of Emergency Medicine and Anatomy and Cell B i o l o g y ,C o l l e g e o f M e d i c i n e , U n i v e r s i t yo f C i n c i n n a t i ,C i n c i n n a t i , Ohio, Department of Emergency Medicine, Temple University, P h i l a d e l p h i aP , ennsylvania F o l l o w i n g i s c h e m i a , b r a i n l a c t a t e i n e x c e s so f l 8 p m o l / g l i m i t s ncuronal survival. In most but not all ischcmic fed rats treated prcviously with sodium dichloroacctate {DCA} {25 mg/kg), cortical lactatcs wcrc bclow this dangcrous level. Since DCA doses abovc 25 mg/kg arc morc cffcctive in reducing scrum lactate, the gual of this study was to dctcrminc the dose effcct of DCA on ischcmia induccd brain lactatc elevation in the fcd rat. A total of 4lJ adult malc Wistar rats wcrc studicd. Rats were assigned to ei t h c r a n i s c h c m i c o r c o n t r o l g r o u p f o r e a c h o f ( r d o s e s o f D C A { 0 , 25, 50, 100, 200 and 300 mg/kg). Ischcmia was induced by bilateral carotid ligation and bleeding to a pressureof 50 torr. After 30 min of ischcmia, reperfusion was initiated and contrnued for 30 min. Rats wcrc sacrificed by ln sif u freezing of the brain and metabolites wcre measured in bilateral samoles from the cerebral cortcx, hippi>campus, and cerebcllum by itandard enzyme fluorometric methods. When compared to controi, lactate was higher in thc cortex (P < .0006, ANOVA) and hippocampus (P < .001, ANOVA), but not in the cercbcllum ol ischemic rats. These res u l t s i r g r e cw i t h b l o o d f l o w a n d m o r p h o l o g i c a l d a t a t h a t s h o w n o cffcct of forebrain ischemia on the ccrebellum. Although lactate was not significantly lower in hippocampus when compared to cortex (ANOVA), it was less than l8 pmol/g suggesting that the hippocampus is less likely to exhibit irreversible ischemic effects.Aftcr treatment with 25 mg/kg DCA, mean cortical lactate (t SEMJ was 12.75 pmol/g lt:2.16). Bilateral sampling revealed a heterogeneous response to DCA treatment. 100% of the rats trcated with 25 mg/kg had cortical lactates in at least onc hemisphere that werc lcss than 1B prmol/g. Fewer rats responded to the lrigher doscs (i.e., 50 mg/kg,75% râ&#x201A;ŹSponsâ&#x201A;Ź; 100 mg/kg, 40% j 20O mg/kg, 6O"Li and 300 mg/kg, 50% J. Since doses of DCA above 25 mg/kg arc hypcrosmolar, the decrease in the number of rats responding to higher doses may reflect an adverse reaction of the vasculature to drug hyperosmolanty. Resultant hypoperfusion could reduce exposure of the tissue to DCA, prolong anaerobic metabolism, and decrease the cf{ectiveness of DCA. This study showed that postischemic treatment wrth a low nonhyperosmolar dose o{ DCA results in cortical lactate ievels that are below the dangerous threshold in the greatest number of rats. Although higher doses of DCA may lower lactates to a greater degrec, they may interfere with optimum reperfusion of the injured tissue. Subsequent investigations using hyperosmolar doses of DCA need to address this concern.

151

Delayed Recovery of Brain pH During Reperfusion After Graded Gardiac Arrest

G B M a r t i n , L A G o g u e n , R M N o w a k , D W a l t o n ,J R o s e n b e r g , N P a r a d i s , M C T o m l a n o v i c h ,K M A W e l c h / D e p a r t m e n t s o f E m e r g e n c y M e d i c i n e a n d N e u r o l o g y - N M R F a c i l i t y ,H e n r y F o r d Hospital, Detroit, Michigan Acidosis has been implicated as an important factor in the pathophysioiogy of cerebral ischemic injury. Current treatment regimens are directed at re-establishment and maintenance of normal systemrc arterial pH (pHa). Little information is available concerning the relatronship between pHa and brain pH {pHb} after ischemia and reflow. The purpose of the expenment was to define this relationship after cardiac arrest and reperfusion using cardiopulmonary bypass (CPB). After instrumentation and placement in the borc of a Bruker Biospec 1.89 Tesla superconducting magnet systcm, mongrel dogs were subiected to graded cardiac arrest 18 min:n=5; l2 min:n:5, 16 min:n:5) and reperfusion using CPB. 3l-P nuclear magnetic resonancespectra were obtained at baseline and then continuously throughout ischemia and reperfusion. Brain pH was determined by measuring the inorganic phosphate relative to phosphocreatine resonance signal shift. Sodium bicarbonate was given in amounts to correct pHa as rapidly as possible. The results are depicted in the table below. Brain pH decreased significantly by the end of ischemia in all groups. The pHb nadir did not differ between groups iP > .05). Thc mcan pHa-pHb gradients were significantly increased from basclinc at 30 min of repcrfusion in all groups indicating a lag in correction of ccrebral acidosis post-ischemla. Thus correction of pHa docs not indicate normalization of pHb in this model utilizing optimal reperfusion. The low llow states during and post-resuscitation with CPR might be expected to show even slower resolution of brain acidosis despite correction of pHa. Further studies are nceded to assess the effect of therapies directed at more raoid normalization of brain DH after cardiac arrest.

DHa pHb t2' 16'

oHa oHb pHa oHb

End-lschemia 30 Min CPB Baseline 7.39 :t .04 7.34 + .03 7 . 0 1+ . 0 1 6 3 0 r . 0 9 - 6 . 7 3+ . 1 4 7.36 + 06 7.35+ .03 7 . 0 2! . O 4 6 1 9 : t . 0 8 6 . 7 0+ 1 5 7.42 + .04 7.31 + .02 7 03 + .02 6 28 * 106.60+ .17-

60 Min CPB 7.35 + 03 6 . 9 7+ 0 3 7.39+ .03 6 . 9 8+ . 0 7 7 39 + .05 7 . 0 1+ . 0 4 '

P < 05 comparedto baseine

152

Densitometric Analysis of Gytochrome Oxidase Activity in the Brains of lschemic Rats Treated With Sodium Dichloroacetate

RVW Dimlich, MJ Showers, MT Shipley / Departments of E m e r g e n c y M e d i c i n e a n d A n a t o m y a n d C e l l B i o l o g y ,C o l l e g e o f M e d i c i n e , U n i v e r s i t yo f C i n c i n n a t i Markedly elevated brain lactate as observed in fed animals a{ter incomplete cerebral ischemia contributes to irreversrble changes in brain cell function. Excessive lactate results in a low intracellular pH that interferes with cellular mitochondrial respiratory activlty. Cytochrome oxidase (CO) is a mitochondrial respiratory marker enzyme and the histochemical densitometry of CO correlates highly with its biochemical activity. Since postischemic brain lactates in {ed rats given sodium dichloroacetate (DCA} i25 mg/kg) are less than in untreated rats, the goal of this study was to determine the effect of DCA on cerebral CO staining of rschemic rats. Of 16 male Wistar rats, 6 were sham-operated controls receiving either 25 mg/kg DCA (n:3) or an equal volume of carrier (n:3| immediately after sham-ischemia; 10 rats were subjected to bilateral carotid ligation and hypotension {or 30 min and treated with either 25 mg/kg DCA (n:5) or carrier (n:5). After 30 min ol reperfusion, brains were {ixed by rntracardiac perfusion and orocessed for the histochemical localization of CO.

Sectionswere incubatedand densitometric values evaluatedwith their controls. Multiple regressionanalyseswere used to identily and adjust for differencesbetween sraining that occurredwith individual runs. Data were analyzedusing ANOVA, Duncan's multiple range test, and Kruskal-Wallis statistical techniques. Four hemispheresin ischemic rats i2 untreated and 2 DCA-treated) were poorly fixed and not analyzed.In control rats hippocampus stainedless than cortex {P < .01,Duncan's}indicating that CO activity is greater in the cortex of these rats. Cortex and hippocampus in ischemic rats were stained less than in the controls (P < .01,Duncan's).This reaction to ischemia was of the samemagnitude in both regions {Kruskal-Wallis)suggestingthat CO enzyme activity is equally vulnerable in these areasof the brain with this insult. Both control and ischemic rats treated with DCA exhibited no significant difference in staining from their respectiveuntreated controls. There{ore,treatment with DCA had no effect on the staining, i.e., activity of CQ in theseareasof the brain. Since insulficient time for the effect of treatment to be detectedmight not have elapsed,future studies should examine tissue from rats following a longer period of survival. Although this study failed to show an effect of DCA on CO staining during the early recovery period from ischemia, identification of infarcted regions and areasto be sampled in future ultrastructural analysisof the responseto ischemia was achieved.These results also support the use of the CO technique for (l) mapping CO activity in the brain, (21analyzingthe effectsof ischemia on this activity, and (3) characterizingperfusion deficits with an ischemic insult that is not always uniform in its laterality and distribution.

153

nitude and duration of paradoxicCSF acidosisis dependentupon the dose of HSB. These paradoxicCSF changesare minimal and transient in comparison to the changes in arterial pH. Hypokalemia and severehypernatremiadid not develop.

.1 5 4

DM Benson,DL Schossow DR Deavers,RW Schwab/ Sectionof EmergencyMedicine,WayneStateUniversity Schoolof Medicine, Detroit,Michigan;Departmentof Physiologyand Pharmacology, University of OsteopathicMedicineand HealthSciences,Des Moines,lowa We evaluatedthe effect of increasedventilation rate on arterial and mixed venous blood gasesduring experimentalCPR in dogs. Ten dogswere anesthetizedwith pentobarbital(20 mg/kg IV) and intubated. Catheterswere placedin the right atrium, right ventricle, and thoracic aorta and used for pressuremonitoring and obtaining samplesfor blood gas determinations.Ventricularfibrillation was induced electrically.After five minutes of cardiacarrest, closed chest compressionswere begun (60/min). Ventilation was providedvia a manually triggeredvolume ventilator at a tidal volume of l5 ml/kg. Group I (n=5) were ventilated l2 times a minute (180 mllkg/min), and group II (n=5) dogswere ventilated30 times a minute (450 ml/kg/min). Arterial and mixed venous blood gaseswere obtained beforefibrillation, immediately before the initiation of CPR, and then at 5-minute intervals during 30 minutes of CPR. Coronary perfusion pressure(CPP| was calculated from the differencebetween diastolic aortic and right atrial pressures.Data was analyzedby ANOVA of repeatmeasures.Arterial pH was significantly higher and arterial PCO2 was significantly lower than controls at all times with high ventilation CPR (HVCPR).However,mixed venouspH and PCO2were not significantly different between the two groups,nor was CPP improved by HVCPR. Since it is believedthat mixed venouspH and PCO2 are a more accuratereflection of tissue conditions, these results suggestthat HVCPR does not improve tissue acidosisduring resuscitation.

Metabolic Effects of Hypertonic Sodium Bicarbonate Administration in Severe, Fixed Respiratory

Acidosis in a Ganine Model DW Plummer,DD Brunette,R Presner/ Departmentof Emergency Medicine,HennepinCountyMedicalCenter,Minneapolis, Minnesota The efficacy and safety of rapid hypertonic sodium bicarbonate (HSB)administration for severerespiratoryacidosishas not been adequatelystudied. The purpose of this study was to determine the acute metabolic effectsof raoid intravenousHSB administration in severefixed respiratoryaiidosis. Eight adult anesthetized mongrel dogs were monitored by intra-arterial catheter, central venous cathete{,electrocardiogram,rectal temperatureprobe and cisterna magna catheter.All animals underwent controlled hypoventilation and a steady-staterespiratory acidosis was maintainedat a mean arterial pHoI 6.94,and a mean CSFpH of 7.00. Animals were then divided into two groups.Group I and Group II receiveda rapid infusion of 2 mEq/kg and 8 mEq/kg sodium bicarbonate(8.4% solution) respectively.Arterial and cerebralspinal fluid gasanalysiswere obtainedimmediately pre-infusionand a t I , 3 , 5 , 1 0 , 1 5 , 2 O , 2 5 a n d 3 0 m i n u t e s p o s t - i n f u s i o nS. e r u m sodium, potassium, chloride, COz, blood urea nitrogen and glucose were obtained immediately pre-infusion and at l, 3 and 30 minutes post-infusion.The changein arterial pH for Group I was significant for all times post-infusionup to 25 minutes, with a peak change of 0.21. Group II arterial pH was significantly changedat all times up to 15 minutes post-infusion,with a peak changeof 0.10. Peak changesin arterial pH occurredat one minute. The change in CSF pH for Group I was significant at all times post-infusion up to five minutes, with a peak change o{ 0.09 at five minutes. Group II CSF pH was significantly changed at five minutes post-infusion only, with a changeof 0.07. Serum sodium peaked at one minute post-infusion with a mean peak value of 166 mEq/L and 161 mEq/L for Groups I and II respectively. Serum potassium tended to decreaseover time, although no animal becamehypokalemic. There was no differencein PO2 values.Rapid administration of HSB significantly and immediately alters arterial pH in severefixed respiratoryacidosis.The mag-

High Ventilation Rate and Artedal and Maxed Venous Blood Gases During GPR

.155

Reliability of Glinical Presentation for Predicting Signilicant Pit Vipel Envenomation

KM Hurlbut,RC Dart, D Spaite,J McNally/ Sectionof Emergency Medicine,University of ArizonaHealthServicesCenter;Arizona Poisonand Drug lnformation Cente( Tucson Recently,the usefulnessof initial clinical evaluationin predicting the courseof crotalid envenomationhas beendebated.In this study, 13l consecutivecasesof crotalid snakebiteregisteredwith the WesternSnake EnvenomationDatabasewere reviewed.This databasecontains the poison center records,hospitalizationrecords, and follow-up questionnairesof casescontacting the Arizona Poison and Drug Information Center from |anuary l, 1986 through November 1987.This report concerns45 patients with benign presentationsconsistingof minimal (lessthan 5 cm) or no s w e l l i n g , a n d w i t h o u t r e p o r t e d s y s t e m i c o r l o c a l s i g n so f envenomation(nausea,vomiting, perioral parasthesias, abnormal Ievel of consciousness, ecchymosis,bleb formation/ or more than minimal pain by patient/sevaluationf.Twenty-four(53%| of these patients subsequentlydevelopeda signi{icant envenomation (moderateto severeswelling, elevatedprothrombin time, or thrombocytopenia).The use o{ vital signswas testedas additional evidenceof envenomation.Of the 45 patients with unremarkable signs and symptoms on presentation,31 had no reportedabnormality in initial vital signs {heartrate, blood pressureand respiratory rate).Seventeenlsa%l of these went on to developevidence of significant envenomation.Fourteen patients had at least one abnormality of vital signs on presentationand 7 {50%) of these developedsignificant envenomation,including one death.Finally

trme required to develop signs of envenomation was evaluated. Of the 24 patients with unremarkable presentations who eventually developed srgnificant envenomations, ll l4(t%l worsened within 4 hours, 5 (21%) worsened in 4-8 hours, 6 (25%) worsened later than 8 hours aftcr envenomation, and was unreported in 3 patients. Four patients (17%) returned for medical evaluation after having been discharged from the facility where they were initially evaluated. In two o{ these the diagnosis of snakebite was entertained, but reiected. One of thesc two Datienrs returned in cardiac arrest 4 hours after discharge. We conclude that an unremarkable physical and laboratory exr- at prcsentation docs not reliably indicate an insignificant envenomation. Sirnilarly, the early clinical course does not necessarily indicatc a benisn outc o m e . I t i s r e c o m m e n d c d t h a t p h y s i c i a n so b s c r v e p a t i r ' n r sw i t h x history of snakebite more than 8 hours.

-l56

the lungs, beginnrng six to eight hours after admission. This patrent presented with the shortest delay from the time of ingestion i4 hrs). One of the patients underwcnt early hemodialysis {HD) during which RA > PA concentrations. Within 2 hours of cessation of HD, however, this relationship was revcrsed, with toxin bcing conccntratcd into thc lungs until thc pattent,s death. Scrum CPK valucs werc not suggestivc of myocardial involvemcnt in PQT fluxes. We concludc that thc previously described "slow" uptakc of PQT by lung tissue is actually an early occurr i n g _p r o c e s s , r a r c l y e n c o u n t e r e d b y t h e t i m c p a t i e n t s p r e s c n t t o m e d i c a l f a c i l i t i c s . T h e c c l l u l a r b u r d e n o f P Q T r - r - r al yc a d t o t i s s u e death and a subscquent efflux of toxrn into the circulation. SwanCanz catheterization is a potentially useful modality to cvaluate thc effect of toxins on the hcart-lune block.

158

A Prospective Human Grossover Study on Single Versus Multiple Dose Gharcoal in Salicylate Ingestion

D Y e a k e l ,C S t e m p l e , J D o u g h e r t y / A k r o n G e n e r a i M e d i c a l C e n t e r ,N o r t h e a s t e r nO h i o U n i v e r s i t y C o l l e g e o f M e d i c i n e , A k r o n Enteral activated charcoal in a multiplc dose (,,pulse,,charcoalI i s u s e d i n t h e t r c a t m e n t o f m a n y t y p e s o f d r u g o v e r d o s c s .I t s s u periority over single dose charcoal has not bccn established for many routine ingestions. Salicylatc is a common component of many lngcstions. In spite of its frequcncy in drug ingcstions, its elimination has not been studied with respect io single versus multiple dose charcoal treatment. We conducted a prospcctive, crossover clinical trial to compare thc elimination ratcs of salicylate in six healthy adult male volunteers trcatcd with sinsle and multiple charcoal doses. All subjects ingestcd crushed ispirin i650 mg) with water every four hours for three days, in order to obtain a steady state of concentration of the drug. During phase I all subyects ingested 80 gm of activated charcoal on day four. Group A members then ingested an additional 40 gm of charcoal at hours 2, 4, 6, and I0. Group B mcmbers rccciveJ only the single dose. All subjects had serum salicylate lcvels drawn at hours O, 2t 4, 6, 8, 10, 12, 16, 20, and 24 on thc fourth day. After a washout period of one week, all subiects again were brought to a state of steady concentration. All subiects were ,,crossed-over,,to the opposite group. Croup B subiects received the multiple doses of charcoal while Group A received the single dose on day four. Serum salicylate levels were drawn again on the fourth day at the previously described intervals. Analysis of variance revealed a significant decrease in the bioavailabiiity of salicylate between the two models lP =. 0302} in an ,Area undcr the curve,/ vs time model of elimination kinetrcs. Our results indicate that multiDle dose or "pulse" charcoal dosing appears to cnhance the eliminatron of ingestcd salicylate in healthy volunteers taking therapeutic doses of thc drug when compared to the standard, single dose charcoal modei.

EZ f J t

Toxicokinetics of Paraquat Through the Heart.Lung Block: Six Cases of

b'J['[#,'"1TI:"fi:T1il,1?,,

E P K r e n z e l o k / P i t t s b u r g h P o i s o n C e n t e r , C h r l d r e n ' sh o s p r r a of Pittsburgh,Schools of Medicrne and Pharmacy, Divisionof E m e r g e n c y M e d i c i n e , U n i v e r s i t yo f P i t t s b u r g h T h c r e c e n t i n t r o d u c t i o n o f l i q u i d a u t o m a t i c d i s h w a s l - r i n gc l e tergents ILADD) has resultcd in numerous calls to poisun information ccnters and subscclucntly a large nur-nbcrof rcfcrrals to cmcrgcncy dcpartmcnts. As witl-r thcir traditional granular cour.rt c r p a r t s , L A D D ' s c o n t a i n a l k a l i r - r cb u i l d c r s w h i c h c o n t r i b u t c t o t h c p H o f t h c s c p r o d u c t s ( 1 0 . 5 - 1 1 . 5 )E. x p o s u r c t o g r a n u l a r a u t o matic dishwashing dctcrgcnts has bccn associatcd with crustrc injury similar to thc pathology produccd by other alkalinc corrosivcs. Do LADD's producc sirnrlar toxicityl Thcrc is no publishcd information which profilcs thc toxic ntanifcsrations associatcd with cxposurc to LADD's. Tir dctcrminc thc toxicity of LADD's, all LADD cxposurcs rcportcd to a Rcgional poison Inlormation Ccntcr ovcr a twclvc month pcriod wcrc collcctcd. Onc hundrcd and sixty-ninc human cxposurc cascswcrc rcvicwccl. pcdiatric paticnts accountcd |ot 73"/" of thc cxposurcs. Scvcr.rty-five pcrccnt were ingestions, 13% wcrc dcrmal cxposurcs, ancl 12,2, wcrc ocular. Scvcnty-cight of thc paticnts wcrc cxposcd to full strcngth product and 22'k contactcd dilutc pftrduct 0r product which_had alrcady becn through thc dishwashing cyclc. Nincty p o i n t f i v c p c r c e n t o f t h c p a t i c n t s w l - r oi n g c s t e d a L A D D r c n a i n c c l asymptomatic, 8.7"1'hacl minor symptoms, and Only onc pirticnt i 0 . t 3 % ) s u f f e r e dm o d c r a t c t o x i c i t y . I n c o n t r a s t , 9 0 o 1 ,o I a l l p a t i c n t s who had an ocular cxposure dcvclopcd minor or modcritc toxicrty (70o1,vs 20"1'1.Sixty-cight pcrccnt of dermal cxposurcs wcrc asymptomatic and thosc with symptoms wcrc thc rcsult of inappropriate use. Ovcrall, 78% rcmaincd asymptomatic, ltj,Z, devclopcd minor toxicity anrJ 4ol, dcvclopcd modcratc toxrcity. Sn-rall o r a l a n d d e r m a l c x p o s u r e su s u a l l y d o n o t r c s u l t i n t o x i c i t y a n d d o not necessitatc refcrral to an cmergency department. Ocular cxposures are associated with a high incidencc of at lcast minor toxicity and requrre emergency departmcnt evaluatton.

-I

lil::3liT".:Hlil3""f."il"

EJ MlinekJr JE Clinton,E RuizI Departmentof Emergency M e d i c i n eH , e n n e p i nC o u n t vM e d i c a C l e n t e rM . inneaoolis.

Acute Human Poisoning FJ Baud, C Keyes, P Houze, C Bismuth, JM Sherrmann, A Jaeger / UCLA School of Medicine; Cllnique et Laboratoire d e T o x i c o l o g i e ,H o s p i t a l F e r n a n d W i d a l , P a r i s , F r a n c e

lvlinnesota Fiberoptic-aidcd endotracheal intubation has been shown to be effective in difiicult intubations secondary to various anatomic abnormalities and traumatic conditions. It can also be used to secure an airway after conventional methods fail. A retrospective review over a 2)/t year period revcaled 29 patients who had fiberoptic-aided endotracheal intubation: 25 involvine mcdical conditions and 4 in trauma patients. Indications in thi medical s u b g r o u p i n c l u d e d f a i l e d n a s o t r a c h e a l i n t u b a t i o n l B / 2 5 1 a, n a t o m i c c a u s e s i n c l u d i n g k y p h o s i s a n d a n t e r i o r l a r y n x { ( r / 2 5 ) ,a n d a s method of choice lll/25}. Indications in the trauma group with s u s p e c t e dc e r v i c a l s p i n e i n j u r y i n c l u d e d f a i l e d n a s o t r a c h e a l i n t u -

We describe the kinetics o{ pulmonary artery (pA) and radial artery {RA) concentrations of paraquat (PeT') rn six cases of ultimately fatal intoxication requiring Swan-Ganz catheterization. PQT concentrations were serially determined by radioimmun o a s s a y .F o u r o f t h e s i x c a s e s m a n i f e s t e d R A c o n c e n t r a t i o n s c o n sistently_higher than the corresponding pA values, suggesting an efflux of toxin from the lung, whereas in one patient the dif{erence was not significant. The remaining patient had initial pA ) RA concentrattons which teversed, ie, to an efflux of peT from

bation (l/4) and method of choice {3/a).In the medical subgroup, 2l out of 25 patients were successfullyfiberoptically intubated. All trauma patients 14/4)werc successfullyintubated. Limitations involving this technique are varied. Twelve of the 2I successful intubations had times recordedfor completion with a mean time of 1.25 minutes. TWo of the 4 {ailed attempts had recorded times oi 7 and 12 minutes. The mean time of the 4 t r a u m a c a s e sw a s 3 . 3 3 m i n u t e s . T h e p r e s e n c eo f s e c r e t i o n s , blood, or vomitus was the cause in 3 of the 4 iailed intubations. In the 4th failure, the patient kept swallowing the scope.Of these 4 patients, 3 eventually required orotrachealintubation and I a cricothyroidotomy.In 3 of the 2l successfulmedical intubations the scopefunctioned as an expensivelighted stylet visualized transcutaneouslyover the anterior larynx alter the vocal cords could not be directly visualized.Fiscalrestraintsmay also limit its use. At our institution, the financial commitment has been approximately$17,000over the last 9 years.This includesa rec e n t $ 3 , 5 0 0e x p e n d i t u r ef o r a F u j i n o n P e d i a t r i c3 - m m s c o p e which replaceda nonfunctioning fiberoptic scopepurchased2 years earlier for $3,000.Immediate airway control is often diffiintubation and shouldbe endotracheal cult with fiberoptic-aided used in selectedpatients only. The associatedcost of the expensive fragileequipmentmay requirethat specificindicationsexist for its use in the emergencydepartment.

The Emergency Treatment ol Acute Hypoglycemia: Effect on Serum Potassium in Insulin Dependent Diabetics

JG Kaczor,ML Zwanget BF Bock / SectionoJ Emergency of Medicine,DetrortReceivingHospital,WayneStateUniversity M e d i c i n eD , e t r o i tM , ichigan Acute hypoglycemiamust be suspectedin all patientspresenting to the emergencydepartment with coma or depressedlevel of When hypoglycemiais detectedstandardemer' consciousness. gency treatment includes rapid infusion of a hypertonic giucose infusion as a bolus. This therapy although often rapidly effective in reversingthe acute symptoms of hypoglycemia may be predicted to, as an undesirable side effect, also acutely lower the serum potassium in patients who present with acute insulin induced hypoglycemia.During insulin induced hypoglycemia two seDaratemechanrsmsact to lower serum potassium. An insulin mldiated intracellular influx of potassium ions from stimulation of membrane-bound ATPase and a counter-regulatory catecholamine decreasemediated by beta-adrenergicreceptors.The standard therapy of acute hyperkalemia takes advantageof the intimate relationshipbetweenglucose,insulin, and the serum potassium. Hypertonic glucose along with regular insulin is infused to acutely iower the serum potassium.This prospective clinical control study was done to determine if the hypothesized acute lowering of the serum potassium is occurring during the emergencytreatment of acute hypoglycemia.Patientspresenting to the EmergencyDepartment with coma or deplessedlevel of consciousnessand suspectedacute hypoglycemiawere treated with bolus infusion of 100 milliliters of 50 percent dextroseand then placed on a constant dextroseinfusion. Thiamine and narcan were also administered.An analysisof the serum glucoseand potassium was performedon samplesof blood taken beforetreatment and at one hour after treatment. An experimental group of twenty hypoglycemic insulin dependentdiabetics and a control group of twenty normoglycemic non-diabeticswere studied. The mean changern serum potassium for the experimentalgroup was a decreaseof -0.5 mEq/L and the mean changeseenin the control group was an increase of +0.1 mEq/L. Analysis using the Studint'st test showeda statistically significant {P < .001)lowering of the serum potassium in the experimentalgroup. Although the predictedacute lowering of the serum potassium was shown to occur as a result of the emergencytreatment of hypoglycemic crisis, no clinical significancewas shown.

161

An Evaluation of Endotracheal Glucagon for Treatment of Hypoglycemia

SC Rectol K Beamer,JC Michael/ EmergencyService, Morgantown Departmentof Surgery,WestVirginiaUniversity, Endotracheal(ET) administration is an acceptedmethod for emergencydelivery of severaldrugs. Some of these drugs, however,recently have been shown to be poorly absorbedor harmful when given by this route. Polypeptidedrugs have not been previously evaluatedfor endotrachealadministration.One such drug is glucagon,a standardsecond-lineagent for treatment of hypoglycemia or coma of unknown etiology when vascular accessis not immediately available.The hypertonicity of 50% dextrose limits its use to the intravenousroute. Inability to initiate an IV line quickly is a common plight, especiallyin the field. The traditional intramuscular (IM) and subcutaneousmethods of administration of glucagonhave theoretical disadvantagesin the presence of circulatory compromise.Therefore,endotrachealdelivery of glucagonis an attractive alternative.Hypoglycemiawas ind u c e d i n f i v e a n e s t h e t i z e dd o g s w i t h a n i n s u l i n i n f u s i o n . Glucagonwas then administeredby either the ET or IM method. After a minimum 7-day recoveryperiod, each dog was given the samedoseof glucagonby the other delivery route. Arterial blood gaseswere sampled to assessfor any obvious early pulmonary toxicity. After IM glucagonadministration all dogs showedIarge rises in serum glucagonand glucoselevelswithin 4 to 6 minutes. After ET glucagon,serum glucagon levels did not increaseto a similar extent and only one dog showed a glucose responseof over 20 mg/dl. Arterial blood gasesdid not vary betweengroups' We concludethat intrarnuscularglucagoninducesa Iargeglucose resDonsemore consistentlv than does endotrachealadministration in hypoglycemic dogs {p < .025).The evident lack of pulmonary absorption of glucagonis unexplained.This study demonstrates that the endotrachealdelivery route is unsatisfactory for this member of the previously untested polypeptideclass of drugs.

.162

A Prospective Double.Blind StudY of Metoclopramide Hydrochlodde for the Gontrol of Migraine in the

Emergency DePailment DS McClellan,DS Tek,JS Olshaker,CL Allen/ NavalHospital, San Diego Migraine is a very common problem seen in any emergency deoartment. A review of the literature has shown a remarkable laik of efiective, low morbidity treatments for migraine in this setting. Metoclopramidehydrochlorideis well acceptedas an adjunctive therapy for mrgraine, and a few reports were found attesting to its use as a single therapy.In our department,we have found it to be very effectivein combination with meclofenamate and have seen no morbidity associatedwith its use. The rapid onset of relief (10 to 30 minutes) led to the premise that the injected metoclopramidewas the effective agent. It is postulated that it is acting centrally,either via dopamine antagonismor di' rect smooth muscle action. It was thought this effect was in addition to the relief of gastric stasisand improved absorptionof the analgesic.This study is of a random, double-blindprospectivedesign and will consist of one hundred patients evenly divided into subjects{metoclopramide)and controls (normal saline}'Preliminary data analysiso{ the first forty-two patients has yielded twenty subjectsand twenty-two controls. Thus Iar, the experimental gioup has 65"/" and the control group 13.67oeffective relief of iymptoms within the one hour time limit of the study design'Jt is of interest to note, nine of the controls were subsequently given metoclopramideas a sole agent for "tescue,"and 87.5% of ihose patients reportedrelie{ of symptoms. It is anticipatedthat the effective relief percentagein the experimental group will climb as more patients are addedto the study.We concludethat

metoclopramide hydrochloride rs an effective therapy for migraine either as a sole agent, or when it is used in combinatron. It allows patients to rapidly leave the department with effectrve relief and without side ef{ects.

163

secutive days. We compared rates of admission to the emergency departments with weather, pollen, mold, and pollutron measurements. Third degree polynomial regression anaiysis was carried out to discover how much of the variation on number of ED visits could be explained by these factors. Twenty percent of the variability in adult l> 2l yr) admissions and 38% of the variability in pediatric admissions could bc predicted from measurements of tcmpcrature and humidity. Sixty percent of the variation rn overall ED visits can be explained by changesin weather and airbornc pollutants. Arrborne pollens and molds were relativcly unimportant predictors o{ ED admission. These findings can bc used to prcdict with some reliability how many patients will prcsent to the emergency department with pulmonary complaints on a given day. The data suggests that allergic mechanisms are relatively unimportant causes of an emergency department vrsit for lower tract respiratory illness. These results can be uscd to better understand the relationship of weathe4 pollution and airborne allergens to respiratory disease.

Elevated Toxoplasma lgc Antibody in Patients Tested for Infectious Mononucleosis in an Urban

Emergency Department M Sayre, D Jehle / Allegheny General Hospital/ Medical College o f P e n n s y l v a n i a ,P i t t s b u r g h Complaints of chronic fatiguc, lymphadcnopathy, sore throat, and low grade fever are very common in the cmergency department. Epstein-Barrvirus, cytomcgalovirus and toxoplasma gondii all cause such illncsscs. Toxoplasma antibody tcsting is rarcly performed in most cmcrgcncy departmcnts, as a rcsult toxoplasIgG IFA m o s i s i s i n f r e q u e n t l y d i a g n o s e d .W e o b t a i n c d t < . r x o p l a s m a titcrs on emergency dcpartment paticnts who had mononucleosis tcsting pcrformcd, to detcrminc thc frequcncy of toxoplasmosis in this population. Most patients had completc blood counts pcrformcd as wcll. A Mono-Spot was first completcd. Positivc rcsults wcrc confirmcd by a differential heterophil antibody tcst, with a positivc hcterophil defined as agglutination of shecp rcd blood cclls at a dilution of at lcast l:56. A toxoplasmosis titer = l:1024 w a s c o n s i d c r c d p o s i t i v e . M o r e t h a n 1 0 ' 1 ,a t y p i c a l l y m p h o c y t e s o n thc differcntial white ccll count was considercd clcvatcd. Thcre wcrc 273 mono tcsts ordered and fourtccn paticnts wcrc cxcludcd from analysis bccausc they didn't fulfill study critcria. Thcrc werc 259 paticnts includcd in thc study, Il (4.2'/")had a positivc m o n o t c s t , a n d 1 4 ( 5 . 4 % , )h a d a p o s i t i v c t o x o p l a s m a t i t c r . O n c paticnt had both a positive toxoplasma tltcr and an equivocal hete r o p h i l . T h c r c w c r c I 8 2 1 7 0 " / " JC B C ' s p c r f o r m c d i n t h e s t u d y group.TWclvc patients had morc than l0%, atypical lymphocytes. O f t h c s e 5 l - r a da p o s i t i v e m o n o t c s t , I h a d a n c q u i v o c a l m o n o tcst, I initially negativc mono tcst was positivc I weck latcr, and t had a positive toxoplasma titcr. In thc dctection of toxoplasmosis, toxoplasma IgG titcrs > l:1O24 have been shown to be a scnsitivc means of dctccting infcction in thc first six months. Howcvct the IgC titer can rcmain > l:1024 for morc than I ycar. Further tcsting with IgM antibody titcrs is nccdcd to cstablish a positivc diagnosis whcn dcfinitivc diagnosis is ncccssary. Wc found morc patients with clcvatcd toxoplasma IgC titers than with positivc hctcrophil antibody titers in an cmcrgcncy departmcnt population tcsted for mononuclcosis ovcr a two-year period. We conclude that toxoplasmosis may be as common as mononucleosis in patients prescnting to the emergency departmcnt.

164

165

Do Antibodies Modulate Severity of Myocardial Dysfunction in Toxic Shock Syndrome?

EA Panacek,CJ FisherJl JH Peirce,R Gunther,M Bergdoll/ Departmentof EmergencyMedicine,Case Western ReserveUniversity, Cleveland,Ohio; Food ResearchInstitute, U n i v e r s t yo f W i s c o n s i nM, a d i s o n Previouslywe rcportedseveremyocardialdysfunction in paticnts with toxic shock syndrome(TSS)and demonstratedmyocardial dysfunction in an animal model of TSS. .93% of TSS paticntshavc no antibody(AB) to toxic shock syndrometoxin-l (TSSTI).Using thc shcepchronic lung lymph fistula model,we studicd thc rolc of TSST:l AB on myocardial function and lung fluid balancc.Followinga stabicbaseline,10 prg/kgof TSST:1was infuscd ovcr 10 min in 5 AB ncgativeIAB-|and 5 AB positive and lung lymph flow (Q1)are sum{AB+ ) shccp.Hcmodynamics marized(mcan * SEM, . P < 0.05).

AB AB+ AB_ SVI (mL/b/1,12) A B + AB_ MAP (mmHg) AB+ AB Ppa CO (L/min)

Atmosphere and Asthma: Why Pulmonary Patients Present to Emergency Departments in Waves

(mm Hg)

AB+

( m L / 3 0m i n ) A B +

Baseline 6.1+ 0.4 58 + 0.3

4.7 + 60' 46 * 05

4H 43 * 06. 5.5+ 1.0

36+3.

27x4-

5 5 * 2

28+4.

27+4.

8 3 * 7 9 1* 6

76:t6 7 7 + 1 0

69*673 * 11.

1 2 + 1

z c a J

24+2.

1 4 * 2 2 . 0+ 0 1 1 . 61 0 . 1

27*4-

22+4.

71*2.3 7 . 0* 0 9 "

6.9*15. 4.9:!11

We {ound the presence of TSST:1 antibody to have a srgnificant protectivc ef{ect on myocardial functron and Qs. No protective cffcct on pulmonary hypertension or systemrc hypotension was oDserveo.

R B L o w , D E P a r k e r ,R Y N e l s o n / S e c t t o n o f E m e r g e n c y M e d i c i n e , U n i v e r s i t yo f C h i c a g o , D e p a r t m e n t s o J B i o s t a t i s t i c sa n d E p i d e m i o l o g y ,a n d E n v i r o n m e n t a lH e a l t h , U n i v e r s i t yo f O k l a h o m a College of Public Health, Norman Experienced emergency personnel recognize that patients with "flood" emergency departments obstructive lung diseases seem to on some days, whereas fcw require emergency treatment on other days. Some of the {actors which cxacerbate asthma such as weather and air pollution could significantly impact on a large number of asthma patients. While many of these factors and their influence on respiratory disease have been studied individually, no one has yet studied the combined and possibly synergistic effects of these factors on the need for emergency department treatmcnt for respiratory illness. We studied 5,559 admissions for lower respiratory symptoms to adult and pediatric emergency departments of a teaching hospital over 529 con-

166

Gomparative Acute Blood Pressure Reduction of lntravenous Fenoldopam Mesylate Versus Sodium Nitroprusside in Patients With Severe Hypertension

MA Munger,WB White,EA Panacek,EM Bednarczyk, AR Nara,JA Green/ Case WesternReserve WF Rutherford. Schoolof Medicine,Cleveland,Ohio; Hypertension University of Connecticut, Unit,Departmentof Medicine,University Farminqton

We cvaluated the acute blood pressure (Bp) reduction efficacy of intravenous fcnoldopam mesylate (F), a dopamine-l agonist, vs s o d i u m n i t r o p r u s s i d e ( N ) i n l 7 p a t i e n t s w i t h s e v e r eh y p e r t e n s i o n (DBP>120 mm Hg). Patients were excluded on the basis of DBP>170 mm Hg, pheochromocytoma, clinically significant liver or renal dysfunction or uncontrolled arrhythmiai. Initial rates of F and N infusions were 0. I p/kg/min and 0.5 p./kg/min rcspcctively. Following open-label, randomization to F or N,-titration to dcsired BP (DBP 95-110 mm Hg) was followed by a constant.infusion i> I hr) (maintenance) and detitration phase (2 hr). Population dcmographics were: age, F-48 + l(r y vs. N-51 + 16 y , g e n d c r ,F - 7 m a l e s , 2 f e m a l e s v s . N - 8 m a l e s ; r a c e F - 3 C a u c a s i a n , 6-Negroid vs. N-4-Caucasian, 4-Negroid. Diagnosis of hypertension was: esscntial/ F-3 vs. N-2; renovascular,F-4 vs. N-5: noncompliance, F-2 vs. N-1. Infusion dosc rangcimean) at maximal effcct was: F; 0.1-0.(r p/kg/min (mean 0.3 p/kg/min) and N; 0 . 5 2 - 4 . , 5p i k g l m i n { m c a n 1 . 4 p / k g / m i n ) . A d v e r s c e v e n t s : F ; f l u s h i n g - S , h y p o t c n s i o n ( p r o t o c o l s p e c i f i e d D B P < 9 5 m m H g J - 2 ,n a u s e a - 1 ,n o n - s p e c i f i c T : w a v e a b n o r m a l i t y - 1 , a n d N ; f l u s h i n g - 2 , n a u s e a -l . T h e f o l l o w i n g i s a h e m o d y n a m i c s u m m a r y f o r t h e F a n d N sutscts at basclinc, maximal cffect, end of maintenance infusion, I hour dctitration, 2 hours dctitration, and I hour Dost-infusion.

*Study done primarily by a resident.

Drug (N)

Baseline

191 + 21 127+ 6 76+17 N ( 8 )S B P / 210 + 29 DBP 127+5 HR 7 4 + 1 0 -P<.05Fvs.N F(s) sBP/ DBP HR

Drug (N) F ( e )s B P / DBP HR N ( B )S B P / DBP HR 'P<.05FvsN.

1-Detitration 158 + 24 1 0 1* 1 1 78*14 160+ 31 104*4 78+11

Maximum Effect toJ =

102+4 83 + l8 162 + 22 103+5 8 3 t g

2-Detitration roc = 1O4 +

tJ 7'

72+13 1 7 1+ 3 3 1 1 4+ 1 0 7 4 + 1 1

MaintenanceEnd 151 + 24 94+98 1 + 1 6 163+ 31 1 0 6+ 1 2 84+13

Post-lnfusion 179 + 25 1 1 7+ 1 0 7 1 + 1 2 185 + 30 1 1 8+ 1 0 75+10

We conclude that F is equivalent to the standard intravenous antihypertensive(NJ in acute BP reduction in severelyhypertensive Datients.

EXHIBITORS Abbott Laboratories D-2TM AP6C Abbott Park, IL 60064 (3rz) 937-r4M

Damon Corporation 115 Fourth Avenue Needham Heights, MA 02149 (617) ,t49-0800

ADx Drug Detection System. Fully automatedinstrument system effectivefor screening urine samples for abused drugs. Runs samples in either batch, panel or combination modes, making it ideal for onsite screening.

ScanMateII is a portable real-time sector scannerultrasound system " weighing approximately five pounds. The hand-held scanneroffers high resolution, diagnostic quality images, rechargeablebattery operation and documentation for patients frles. The system has applications in ED, CCU, surgery/recovery areas and radiology departments.

Aden Medical Products 5801 Safety Drive NE Belmont,MI 49306 (616) 784-6200 AdenMedical Productswill display their completeline of eye and face protectionfor the healthcare field. AmericanBoard of Emergency Medicine 200 Woodland Pass. Suite D EastLansing, MI 48823 (s17) 332-4800

Emergency Medicine Educational Enterprises, Inc. 5970 Rumpke Road Cincinnati. OH 45245 613\ 752-6382

Annalsof Emergency Medicine P . O .B o x 6 1 9 9 l l Dallas,TX 75261-9911 (214)550-0911

Emergency Medicine Residents' Association P.O. Box 6199ll Dallas, TX 75261-9911 (214) 550-0911

Arrow International , Inc. P.O. Box 6306 Hill and George Avenues Reading,PA 19610 ( 2 1 5 )3 7 8 - 0 1 3 1

This booth will disseminateinformation about EMRA and the benefits of membership. Also, a bulletin board will be available for posting job opportunities.

Calgon-VestalLaboratories P.O. Box 147 St. Louis, MO 63166 (314)862-2000 Laboratorieswill featureShor-Clen, skin wound cleanse, Calgon-Vestal and Epi-Lock, wound dressing. Also for the high risk emergency department, healthcare personnel handwashing and handrinsing products. California Medical Products, Inc. 1901Obispo Avenue Long Beach, CA 90804 (213\ 494-'1t'|| CaliforniaMedical Products' STIFNECKTM extrication collar comes in four adult sizes, as well as two models designed specifically for pediatricpatients. The collar is fully radiolucent and has been shown to provide safe and effective immobilization of the cervical spine in the neutral position in a series of radiographic studies.

Dupont Pharmaceutical 6837 Windwood Drive Cincinnati, OH 45241 (513\ 779-2544

Cook Critical Care P.O.Box 489 Bloomington,IN 47402 (t12\ 339-2235 Cook Critical Care, a division of Cook, Inc., will be featuring pneumothorax sets,Thal-Quick chesttube set and trays, and disposable intraosseousinfusion needles. CME 135Hill Road Wexford, PA 15090

Atz\ 935-6586

Encylopaedia Britannica, USA 310 South Michigan Avenue Chicago, IL 60604

(.3r2\347-7346 The new Encyclopaedia Britannica, Great Books of the Western World and Compton's Encyclopaedia: Plus a complete line of educational accessories, Ethox Corporation 251 SenecaStreet Buffalo, NY 14204 (716) 842-40N For your diverse gastric lavage needs, Ethox provides a wide selection of closed lavage systems, lavage tubes and mini-lavage sets, all are prepackagedand ready for use. Genentech 7388 Fireplace West Chester, OH 45069 613\ 777-6346 The exhibit will provide information regarding the use of activase(rtPA) in AMI. International Medical Corps 10880 Wilshire Boulevard, Suite 2008 Los Angeles, CA 900.24 (213) 474-3927 The International Medical Corps has been ongoing since 1984. We have established42 clinics inside of Afghanistan treating a volume of 35,000-50,000patientsper month. Our American Physicianstrain the Afghans students to become advanced surgical medics.

J.B. LippincottCompany 903 DeaconCircle Columbus.OH 43214

(614) 4sr-zMs Medical books.

Kurzwell Applied Intelligence, Inc. 4ll Waverley Oaks Road Waltham, MA 02154 (617) 893-5151 VoiceEM allows the Emergency Medicine physician to dictate his pa_ tient records directly to a computer through voice recognition. Typed, legible reports can be immediatley printed with a simple voice com_ mand, ready for signature.

Laerdal Medical Corporation P.O. Box 190 Armonk, NY 10504

MBB HelicopterCorporation 900 Airport Road P.O. Box 2149 West Chester,PA 19380 (2r5\ 43t-4r50 MBB HelicopterCorporation,the leaderin EMS helicopters,will displayphotosandgraphicsoftheir BO 105andBK I 17twin turbine helicopters.MBB Helicoptersareselected by morehospitalsthanany other twin enginehelicoptersin their class. MeadJohnsonPharmaceutical Division Bristol Myers USPNG Evansville,lN 47721 (8r2) 429-7343 we cordially invite you to visit our exhibit to meetour representatives who welcomethe opportunityto discussproductsandservicesof in_ terestto you. Featuredwill be: Duricef.

Heartstart 2000 Semi-Automatic Defibrillator, Airway Management Trainer Heartsim 2000 cardiac care simulator, skillmeter Resusci Anne CPR.

MICROMEDEX,Inc. 660 Bannock,Suite350 Denver,CO 802044506 (303) 623-8600

Level I Technologies,Inc. 29 Aldrin Raod Plymouth, MA 02360

Clinical, Industrial and EnvironmentalToxicology, Occupational Medicine,international druginformation,anddisease/trauma clinical informationsystemsfor theentirehospitalmedicalstaff.Theseinformationsystemsareavailableone:CD-ROM for usewith personalcomputers,computertapesfor usewith IBM pC'S andDEX VAX Mainframesand mocrofiche.

The Level I Fluid Warmer System will warm cold blood to normother_ mic temperaturesat rate to 500 ml/min, saline at 1000 ml/min. saline. The Level is easy to use. First time users can save the system set_up, primed and warming fluids in less than 30 seconds.

Life Support Products, Inc. One Mauchly Irvine, CA 92718 (714)272-2000 ext. 333 Life SupportProductswill display products relatedto oxygen resuscita_ tion and transport as well as trauma management.New equipment in_ cludesthe AutoVent Ventilators, a DisposableBag Mask Resuscitator, and new Peep Valve and some new imobilization products.

Mar-Med-Co l73l Michigan NE Grand Rapids, MI 49503

(616)4s4-3000 The exhibit is or "TOURNI-COT", which is an exhanguinatingdigit tourniquet. It is an elasomeric .O' ring that is rolled over a digit, ex_ hanguinatingthe digit as it occludes the vesselsofthe digit. It is very simple to use, and it applies a reliable pressure.

Marion Laboratories, Inc. 9300 Ward Parkway KansasCity, MO &ll4 (816) 966-4000 We are proud to be in attendanceagain this year, and hope you will stop by and let our representativesanswer your questions about any of our products. Featured will be SIBVADEN Cream fl% silver sulfadiazine).

Miles, Inc. Pharmaceutical Division 400 MorganLane WestHaven,CT 06516 937-2000 Miles, Inc. Pharmaceutical Division, is pleasedto invite you to their exhibitfeaturingcIPRo (ciprofloxacin),thelatestinnovationin antiinfectivetherapy

PennhurstMedical Suite114 ScottPlazaTwo Philadelphia; PA 19113 (215)521-5100 Respironics,Inc. 530 SecoRoad Monroeville,PA 15146 (4r2) 373-8rr4 Respironics,Inc. will be featuringthe new Bag Easy disposaable resuscitation bag for emergencyuse. Sheridan Catheter Corporation Route 40 Argyle, NY 12809 (518) 638-6101 Sheridan Catheter will feature the Sonatemp UC/ECGrM. This uni_ que esophageal stethoscope with temperature monitoring and ECG capability provides the anesthesiologieswith the ultimate in patient

Also deatured are Sheridan Airway Mei,nagementProducts Sher-I-BRONCHTM FlexibendrM and SonatemprM series of

monitoring products. Medical Systems, Inc. ood Avenue South

.NJ 08830

WeatherbyHealthCare Division of EmergencyMedicine 25 Van Zant Street Norwalk, CT 06855 Q03) 866-1144 EmergencyMeficine practiceopportunities

9t-4754 and compatible trauma systemof x-ray, monitoring, gas anesthesialights and patientstretcher from one manufacturer throughput and efficiency.

of Teachersof EmergencyMedicine . Box6199ll

:trx75261-9911 550:0921 liiaderswill be availableto answerquestionsaboutmemberDisplay items will include the Educational Resourses Goals and Objectives Project Report, and EM Core

otr 43221 {59-e330

C.V. Mosby Company 11830WestlineIndustrialDrive St. Louis,MO 83146 (800) 3254177 -: Medicalbooks.

'':

ZMI Corporation 325 VassarStreet Cambridge,MA 02139 (800)348-9011 ZMI will demonstratethe Zoll NTP@ Non-Invasive Temporary Pacemaker,a new generationCardiacPacemakerthat combinessafety, speedof application,andeaseof usewith clinically provenâ&#x201A;Źffectivenes$and documentedDatienttolerance.

ANNUAL BUSINESSMEETING AGBNDA 1. AmalgamationReport - Ernest Ruiz. MD 2. Secretary/TreasurerReport - Mary Ann Cooper, MD A.Membershipat April 27, l98g: 1,157 Active: 630 (54%\

Resident:230 (20%)

Emerirus:Il (l%)

Associate: 218 (19%) International: 58 (5%) B. FinanceReport- Year EndingDecember3L, lggT Revenues Dues Annual Meeting Symposium EMRA Interest Mailing List Sale TOTAL

l4g,7g5 32,945 39,105 26,150* 10,179 1,140

W3o3

Hononry: (l%) Expenses Salariesand Wages Annual Meeting Symposium EMRA Postageand Telephone Other Administration Committeesand Representatives TOTAL

57,552 33,959 lg,g07 15,537 1g,gg0 1g,g75xx 17,193xx*

i1!?,80?

* EMRA newsletterand 19g7and 19ggJob Cataloss x* office rentandinsurance,newsletterprinting, g"n"tufttinting, accoulting,bankcharges,depreciation,andcomputerexpenses. x*x Annalssubscriptions,AAMC' IRIEM, AMA CommissiJnon EMS, Committee;,and council expenses. 3. Amendmentsto Constitution and Bylaws _ JamesNiemann, MD, TheconstitutionandBylawsis publishedon pages7l-76. Theoriginalwording is shownin regulartype,with thesuggested changes publishedin italics'Thewordingwhichis crossedout wouldbereilaced with thewordingin italics,if theamendm"nlur" approved. 4' David Yates, MD, "The Developmentof AcademicEmergency Medicine in the United Kingdom" 5. Elections A. PresidentElect (oneposition- becomespresidentMay l9g9) B. Council-at-Large (four positions- two year rerms) C. NominatingCommitteeMembers(two positions_ two year terms) D. Constitutionand ByrawscommitteeMember(oneposition- threeyear term) E' Programcommitteechair (oneposition- threeyear term to begin May 1990) F. ResearchCommitteeChair (oneposition_ threeyear term) G. GovernmentalAffairs committeechair (oneposition- threeyear term) H. committeeon InternationalAffairs (oneposition- threeyear term) 6. Introduction of New president, JamesNiemann, MD - Ernest Ruiz. MD 7. New Business 8. Adjournment

CONSTITUTION OF THE UNIVERSITY ASSOCIATION FOR EMERGENCY MEDICINE ARTICLE I _ NAME "The

The nameof this organizationshall be, University Associationfor EmergencyMedicine," hereinafterreferred to as, "The Association."

ARTICLE II _ OBJECTIVES Section1: The objective of this AssociationsHl-beirnptoveifl-

jure+@-by-operating. is to improve the emergency, urgent, or critical care of the acutely ill or injured patient by promoting research,by educatinghealth careprofessiorutlsand thepublic, byfosteringrelationshipswith organizationswith a similar purpose,and by supporting the specializedor multidiscipline care ofsuchpatients through researchand education. The Association will function as a scientific and educationalorganization asdefinedin Section501(c) (3) of the Internal RevenueCode, as amended. Section 2: The Association shall pursue its obfeetive$y surveyi

RevenueCode of 1954(or the correspondingprovision of any future United StatesInternal RevenueLaw). B. No part of the net earnings of the corporation shall inure to the benefitof, or be distributableto its members,Directors, Officers or other private persons, except that the corporation shall be authorizedand empoweredto pay reasonablecompensationfor servicesrenderedand to make paymentsand distributions in furtherance of the purposes set forth in paragraph A hereof. No substantialpart of the activities of the corporation shall be the carrying on of propaganda,or otherwiseattempting to influencelegislation, and the corporation shall not participate in, or intervenein (including the publishingor distributionof statements)any political campaign on behalf of any candidate for public office. Notwithstanding any other provision of these articles, the corporation shall not carry on any other activities not permitted to be carried on (a) by a corporation exemptfrom Federal Income tax under Section501 (c) (3) of the Internal RevenueCode of 1954(or correspondingprovision ofany future United State RevenueLaw) or (b) by a corporation, contributions to which are deductibleunder Section 170(c) (2) of the Internal RevenueCode of 1954 (or the correspondingprovision of any future United StateInternal RevenueLaw).

ARTICLE III _ MEMBERSHIP

tasis

ia-,

Section 1: Classifications. There shall be seven classesof membership:active, associate,emeritus,residentl fellow, honorary, and international active and international associate.

ine

Section 2: Qualifications. (l) membershipshall be (a)

Candidates for active

ie-tneine

ie in

purposeby: I ) sponsoringforums for the presentation of peerreviewedscientific and educational investigations, 2) convening and sponsoring educationalprograms for health care professionalsand the lay public, 3) promoting academic developmentand educationof its membershipthrough specializedprograms, 4) serving as an academic, university-based, and/or teachinghospital representativefor the care of the acutely ill or injured patient, 5) developing liaison with other organizations with a similar purpose, and 6) publishing research and educationaldata in the scientific and educationalliterature and other media available to the lay public. Section3: A. This corporationis organizedexclusivelyfor and scientific purposes,including, for such pureducational poses,the making of distributionsto organizationsthat qualify asexemptorganizationsunderSection501(c)(3) ofthe Internal

individuals with an advanced @ degree (MD, PhD, DO, PhnrmD, DSc, or equivalent)who holl a medical school or universityfaculty appointmentand who actively participate in acute, emergency,or critical care in an administrative, teaching, or research capacity, (b) individwk with similar degreesin active military service (U.5. or abroad) who actively participate in acute, emergency,or critical care in an administrative, teaching, or researchcapacity. (c) Individuals who otherwise meet qualifications for active membership as definedabovebut who do not hold a universityfaculQ appointment may petition the Membership Committeefor consideration for active membershipstatus, if desired. (2) Candidatesfor associatemembershipshall be@ ie health Professiorutls, educators,governmentfficials, membersof lay or civic groups' or membersof the public at large who may have an interest or desire to participate in pursuing the purposesand objectives of the Association.(3) Candidatesfor emeritusmembershipshall be (a) active memberswho seeksuch statusand who havegiven l0 continuousyearsofactive serviceto the Associationand have attainedthe ageof 60 years (b) other active memberswho under

special circumstancesare invited for such emeritus statusby the Membership Committee. (4) Candidatesfor residentlfellow membership must be resident(s)or fellows in residency training program(s)who have an interestin emergencymedicine. (5) Candidatesfor honorary membershipshall be individuals who have made outstanding research @iees; or educational contributions to the purpose and objectives of the Association (6) Candidatesfor internationalaeti.vsmembership shall be individuals who rneetthequalifieatiotrfuivc

iate Stateran+€anada-.-reside outside the U.S. and who meet qualifications for active or associatemembershipas describedabove. Such candidntes may apply for active, associate, or other membership in the Association. Section 3: Member Rights and Privileges. All members may have the privilege of the floor and of serving on the committeesof the Association. All membersof the Association mny serve on the Board of Directors or as a committee Chairperson. Only active membersshall have voting rights and shall serve as fficers of the Association. Section4.' The Associationshall not discriminate,with respect to its membership,on the basis of race, sex, creed, religion or national origin.

ARTICLE IV _ OFFICERS Section1; The officers of this organizationshall be the president, Vice-President,and Secretary-Treasurer. Section 2; Theffi Board of Directors shall serve as thsffiireetors governing body of the Association. TheMMMMMMMMuneii-Boardof Direcrors shall consist of the aboveofficers, the Program CommitteeChairman, the last1rtt+i mmedi ate p ast presidentq and fow-fi ve Councilmenat-Large. Both active and associatemembers may serve on the Exeettive€ounet} Board of Directors, btronly active members may be officers of the €orneil- Association.

ARTICLE V - COMMITTEES The standingcommitteesof the Associationshall be: Membership Committee, Nominating Committee, program Committee, Constitutionand Bylaws Committee, EducationCommittee,and Auditing Committee. (l) Nominating Committee, (2) Membership Committee, (3) Program Committee, (4) Constitution and Bylaws Committee, (5) Education Committee, (6) Research Committee, (7) Liaison Committee to the Association of American Medical Colleges, (8) GovernmentalAffairs Commiitee, and (9) Commineeon International Affairs. Additional committees may be createdby the Exeeutive€onner} Board of Directors and ad hoc committees may be created by the president to aid in the Association'sefforts to achieveand further its soals.

ARTICLE VI - ANNUAL MEETING Section,l; There shall be an annualmeetingof the Association. This meetingshall consistof an educationaland scientific programand a businesssession. Section 2: The*xeeutive€onneiF Board of Directors,by majority vote, may call, upon 30 days noticej a specialmeeting

of the membershipor standing committee to conduct any businessthat the*xeerrtive€ouneifBoard of Direoors shall place before the membershipor standingcommittee. Section 3; The{neeutive-€ouncit Board of Directors may call and conduct any special meeting by mail. For pu.por", of notice, the meeting date shall be a date set for the return of mail ballots and it shall be called the voting date. Adoption of any proposal, resolution or amendment by mail ballot shall be achieved by affirmative vote of a majority of voting active membersunlessotherwiseprovided by anotherprovision of this constitution. Only those mail ballots received at the business office of the Associationwithin 30 days subsequentto the voting date shall be counted.

ARTICLE VII - BYLAWS Section1.'Bylaws may be adoptedor amendedat any annual or special meeting of the membership. Section2.' Proposedamendmentsto the bylaws shall be submitted in writing to the Secretary/Treasurerby three members at least 60 days prior to the meeting at which they are to be considered. The Secretary/Treasurershall mail the proposed amendmentsto the membership at least 30 days prior to that meeting. Section 3; The Exesutive-€ounei+ Board of Directors may, by resolution,proposeamendmentsto the byliws; providedthe proposedamendmentsare mailed to the membershipat least 30 days prior to the meetingat which they are to be considered. Section4; Adoption of a bylaw amendmentshall be by a majority vote of the active memberspresentand voting at any annual or special meeting.

ARTICLE VIII - ADOPTION OF THE AMENDMENTS TO THE CONSTITUTION Section 1; The constitution may be adopted or amendedat any annual or specialmeeting of the membership. Section2.' Proposedamendmentsto the constitution shall be submittedin writing to the Secretary/Treasurer by threemembers at least60 days prior to the meetingat which they are to be considered.The Secretary/Treasurershall mail the proposed amendmentsto the membershipat least 30 days prior to that meeting. Section 3r The ffi Board of Directors may. by resolution,proposeamendmentsto the constitution;provided the proposedamendmentsare mailed to the membershipat least 30 days prior to the meetingat which they are to be considered. Section4.'Adoption of a constitutionamendmentshallbe by a majority vote of the active memberspresentand voting at any annual or specialmeeting.

ARTICLE IX _ DISSOLUTION Upon the dissolution of the corporation, the Exee*ive.eouneit Board of Direclors shall, after paying or making provision for the paymentof all of the liabilities of the corporation,dispose of all of the assetsof the corporationexclusivelyfor the purposesof the corporation in such manner, or to such organization or organizationsorganizedand operatedexclusivelyfor charitable,educational,religiousor scientificpurposesasshall at the time qualify as an exemptorganizationor organizations under Section501(c) (3) ofrhe InrernalRevenueCodeof 1954 (or the correspondingprovisionof any future UnitedStatesInternal RevenueLaw), as theffiuncil Board of Direc-

f r r torsshalldetermine.Any such assetsnot so disposedof shall bedisposedby a Court of CompetentJurisdictionin the County in which the principal office of the corporationis then located,

exclusively for such purposes or to such organization or organizations,as saidcourt shalldetermine,which are organized and operatedexclusively for such purposes.

BYLAWS OF THE UNIVERSITY ASSOCIATION FOR EMERGENCY MEDICINE ARTICLE I -

MEMBERSHIP

Secti on I : App Ii cat i on Pr ocess. +pplieation-an+gHion-te Iae,mbershpMembershipapplicationforms may be obtained from the Secretary/Treasurerthrough the Executive Director of the Association.The Applicant must return the completed application forms and supporting letters to the Director of the Association at @+reasurerExecutive Board of Direcleastone month prior to an Efteeuffi tor.rmeetingin order to be consideredfor membershipat that time.The quali fi cationsan*reeommend*ions of eand#atesapplicantsior membershipwill be reviewedby the by the MembershipCommitteeat eachmeetingof the{xeeutiveMBoard of Directors.Approval of the candidaterapplicants by the Councll Board shall constituteelection to themembership one of the membership categories,effective immediately. Section2: Dues. Annual duesfor active, asxtciate, resident/fellow, and international memberswill be establishedby the Board of Directors. Honorary and emeritus members will not pay dues. Membership in the Associationmay be terminatedfor nonpayment of dues. Section3: Rightsand privileges.All membershavetheprivile14e of the floor at businessmeetings of the Association and nwyserveas a utmmitteemember,committeechair, or Memberat-ktrge of the Board of Directors. Only active membersmny voteantl serveas officers. Any membermay submit agendn items Jbr <vnsiderationby the Board of Directors.

ARTICLE II OFfIEER$ BOARD OF DIRECTORS

mti pri

ive-terffisT i ion inessses-

ive

meeths. SedionI : Members.TheBoardof Directorsshall consistof the President, Vice-President (President-Elect), the Secretary/Treasurer, the Immediate Past President, the Program Chair, and five Members-at-Inrge. Section2: Election of Officers. (a) The Vice-Presidentshall beelectedfor a term of one year with automaticsuccession from

Vice-Presidentto Presidentthefollowing year. During this two year period, the electedmember will serve as an fficer of the Association. Following terms of Vice-Presifunt (President-elect) and President, this memberwill automatically assumetheposition of Immediate Past President. Election as Vice-President shall confer Board of Directors membershipfor a minimum of threeyears. Nomineesfor this ffice will be seleaedby the Nominating Committee, shall be a current or past member of the Board of Directors, and must have agreed to standfor election prior to formal nominationfor election at the businesssessior? of the annual meeting. Alternative nomination of equally quali' fied Associationmemberswill be acceptedfrom thefloor. Such nomineesmust also agree to standfor election. Election shall be by majoriryt vote of the active memberspresent and voting at the businesssessionof the annual meeting. The Vice-President may also be elected or appointed as Chair of other standing or ad hoc committees,with the exceptionof the Program Committee,and shall be an ex-fficio memberof all standingcommittees. (b) TheSecretary/Treasurershall be electedto a threeyear term. An active member may serve only one term as Secretary/Treasurer. Nomineesfor this ffice shall be selectedby the Nominating Committeeand must have agreed to standfor election prior to their formal nominationfor electionat the business sessionof the annual meeting. Ahernative nominationsmay be offeredfrom thefloor. Suchnomineesmustalso agreeto stand for election. Election shall be by majoriry vote of the active members present and voting at the businesssessionof the annual meeting. The Secretary/Treasurer may also be elected or appointed as the Chair of standing or ad hoc committees,with the exception of the Nominating Committee and Program Committee, and may serve as a member of all committees. Section3 : Election of Members-atlnrge. Members-at-Large shall be elected to trvo year terms, the terms being staggered. Members-at-Inrge mny only be elected for two consecutive terms. Nomineesfor the above ffices shall be selectedby the Nominating Committeeand must have agreed to standfor election prior to theirformal nominationfor electionat the business sessionof the annual meeting. Alternative nominationsmay be offeredfrom theJloor. Such nomineesmust also agree to stand for election. Election shall be by majority vote of the active members present and voting at the businesssessionof the annual meeting. Members-at-l.arge may also be elected as Chairs of standing committees, with the exceptionsof the Nomirutting and Program Committees, appointed as Chnirs of ad hoc committees,or serve as a memberof standing or ad hoc committees,with the exception of the Nominating Committee. Section 4: Election of Program Committee Chair. The Program Committee Chair shall be elected to a three year term. Nomineesfor this ffice shall be current Program Committee members,and must have agreed to standfor election prior to their formnl nominationfor election at the businesssessionof the anruul meeting.Alternativenomirwtionswill not be accepted

from the Jloor. Election shall be by majority vote of the active memberspresent and voting at the businesssessionof the annual meeting. TheProgram CommitteeChair shall not be eligible for other electedpositions within the Association, but mny serve as an appointed member of other standing or ad hoc committees. Section 5: Terms of Office. Terms of ffice will begin at the conclusionofthe annual businessmeeting. The President shall appoint eligible Association membersto fill vacanciesand unexpired terms on the Board of Directors and standing and ad hoc committeesuntil the next scheduled election. Section 6: Meetings of the Board of Directors. Meetings of the Board of Directors will be convenedat least twice during the term of the President of the Association. Additional meetings mny be convenedat the President's discretion or by petition of six membersof the Board of Directors. A final notice of time and place of such meetingsshall be sent to all membersof the Association by the Secretary/Treasurerat least 60 days before the meeting. Sixmembersof the Board of Directors will constitute a quorum. Membersof the Ass,ociation,regardlessof membership category, may submit agenda items. Such items must be submitted within 30 days of the meeting date. Meetings of the Board of Directors are open to all membersof the Association and to the public. Closed meetings of the Association's fficers and Executive Director may be convenedby order of the President. Section?7: Duties of the President. The Presidentshall preside over both the educationalprogram and businesssession of the annualmeetingof the Association,and the meetingsof the*xeetrtiveâ&#x201A;Źouneil Board of Directors.It shall be the duty ofthe Presidentto seethat the rules oforder and decorumare properly enforcedin all deliberationsof the Association,{nd to sign the approved minutesof each meeting, and to executeall documents which may be requiredfor the Association, unlessthe Board of Directors shall have expresslyauthorized some other person to perform such execution. The President shall serve as Chair of the Board of Directors and shall serveas an ex-fficio member of all committees.The President shall appointa#members to fill vacanciesand unexpired terms on the :Mundl Board of Directoru and standing and ad hoc Committees until the next scheduledelection. ine eommittees. Section3 8 : Duties of the Vice-President (President-Elect). trt shat@ The Vice-Presidentshall presidein the absence of the President.The Vice-Presidentshall serve as Chairman of the Nominating Committee and ex-officio member of all rtanding committees. Section49: Duties of the Secretary/Treasurer.It shall be the duty of the Secretary/Treasurerto presidein the absenceof both the President and Vice-President. to The Secretary/Treasurer shall keep a true and correct record of the proceedingsof the annual businessmeeting and meetings of the Board of Directors, ts- shall preserve@ documents belongingto the Association,@ia-

ffibard issue notice of the annual businessmeetingand meetingsof the Board of Directors 60 daysprior to such meetings. The Secretary/Treasurershall keep an account ofthe Association with its membersand maintain a current register of members with dates of their election to membershipand preferred mailing address, the latter to be circulated annually to the membershipwithin 30 days of the annu.albusinessmeeting. The Secretary/Treasurershall be responsiblefor reporting unfinished businessrequiing actionfrom previous meetingsof the membership or Board of Directors and will be responsiblefor the agenda of the annual businessmeeting and meetings of the Board of Directors. The Secretary/Treasurershall collect the duesof the Association,make disbursementsof expenses,and maintainthe financial accountsand records of the Association.-and=present iew iiation to the membership:IIe sha'l be reirrbursedfor suehexpenses Zfte financial record will be presented to the membership at the annual businessmeeting, biannually to the Board of Directors, and at such times as requestedby the President of the Association. Thefinancial records ofthe Association shall be reviewed annually by two other members of the Board of Directors appointed by the President, or a certified accountant orfinancial consultant retained by the Board of Directors of the Association. Section l0: Duties of Board of the Directors, Members-atLarge. Members-at-Large shall assume whatever duties are assignedby the Officers of the Association or by Articles in the Bylaws of the Association. Section I I: Duties of Program Committee Chair. Acting under the auspicesofthe Presidentand Board ofDirectors ofthe Association, the Program CommitteeChair shall be responsiblefor the Association's annual research and education meeting, as well as other symposiaor meetingssponsoredor co-sponsored by the Association to meet its purpose. The duties of the Program CommitteeChair shall include but not be limited to: (l) selectionof committeemembers, (2) selection of meeting sites, (3) designation of ad hoc committee members specifically selectedfor review of materials to be presented at the annual meeting or other Association meetings, (4) peer-review and selectionof papers to be presentedat meetingsor forums sponsored or co-sponsoredby the Association, (5) publication of callfor-abstract notices,and (6) schedulingactivitiesat the Association's annual meeting or other meetings sponsored or cosponsoredby the Association. Recommendations from the Program Committee Chair must be approved by the Board of Directors by majority vote. Section 12: Duties of the Past President. The Past President shall assumewhatever duties are assignedby the Presidentor by articles in the Bylaws of the Association. Section I3: Absenteeism/terminationof ffice. Absencescan be approved or excusedonly by the President. Two unexcused absencesfrom scheduledBoard of Directors meetings,annwtl businessmeeting, or special meetings of the Board of Directors during any terrn as a member of the Board of Directors shall constitute a resignation. Such resignation shall be ffictive two weeksafter notification by the President. Any member

ofthe Board of Directors may voluntarily resign and such resignationwill become effective immediately. Section 14: Special meetings of the Board of Directors. Special,unscheduledmeetingsof the Board of Directors or the Officersof the Association may be convenedby the President, or by any sixmembersof the Board of Directors. Uponpetition by 100or more active membersof the Association, stating the reason(s)forcalling a special meetingof the Directors or Officers,the Secretary/Treasurershall call such a meeting within 30 daysof receiving the petition to be convenedctt a time and pLacedesignatedby the President.

ARTICLE III - MEETINGS Seerioil/: The Assoe+ati@ions

of the Asroeiationshall be l'el*at-times and plaeesfixed by

lr esident: me*tngsnaU@Treasurcf-af nualmeeting:The siteof the annualmeeting.shallbe ehosen fuueationaf opefted@lie. SedionI : Annual businessmeeting.An annual businessmeetingoJthe membershipof the Associationshall be convenedannuallyand in utnjunction with the annual scientfficand educatktnalmeetingrf the Associcttion.One hundredand fifiy (150) a('tiveand wiling membersin good standing and in attendance shallumstitute a quorum. Businessitems presented as informationalor Jbr wsteby active membersshall include but not belimitedto: (l ) afnancial reportfrom the Secretary/Treasurer, (2)amendmentsto the Constitution and Bylaws of the Associatkn, (3) eleuion of fficers, membersof the Board of Directors, and the Chairs and members of standing committeesof theAssocitttion, (4) reports of committeeactivities, (5) tansu('tionof other businesswhich may come before the membership,untl (6) a "state of the Association" adiress by the president.Wheredictated by the Constitutionand Bylaws, the Associationshall be governedby a majority vote of active members in attendanceat the annuctlbusinessmeetinR.The President of the As.sttciation shall preside over the meetingand the Secritan/Treasurer will c.irculateagenda items to the membership 30 da.rts before the annual businessmeeting. The Chairs of thLe Constitutionctnd Bylaws committee and Nominating Committeewill preside over the respectiveparts of the annual meeting. Theannualbusinessmeetingshall be held at a time and place determined b,r-the Board of Directors of the Associationapproximateb one year in advance of the convocation. Section2: Betweenannual businessmeetings, within the policiesestablishedby the Association'smembershipand the Constitutionand Bylaws, the Association shall be poverned by the

Board of Directors. Actions of the Board of Directors shall be determined by a mnjoriry vorc of those of its memberspresent at its meeting, six members constituting a quorum. Section 3: Annual scientific and educational assembly. The Association shall sponsoran annual scientific and educational meeting or assemblyto meet its purpose and objectives. This meeting will include but not be limited to: (l) presentation of original researchin the sciencesand educationalmethodology, (2) educational/researchforums, (3) special programs for the membershipas determinedby thepurpose and objectivesof the Association, and (4) meetingsof the standing and ad hoc committees of the Association. The research and educationalprograms of the annual meeting shall be open to the public and the general membershipof the Association in good standing. All meetingsof standing and ad hoc committeesare open to the public and membersof the Association in good standing. programsfor the annual meetingshall be arranged by the Program Committee and approved by the Board of Directors of the Association. A final notice of the time, place, and program of the annual assemblyshall be sent to all membersof the Association by the Secretary/Treasurer at least 30 days before the meeting. Section4: Specialmeetingssponsoredor cosponsoredby the Association. The Association may sponsor or cosponsorother scientific or educationalmeetingsof interest to the membership to meet its purpose and objectives. Suchmeetingsshall be convenedby the President, Board ofDirectors, and Program Committee Chair and publicized 30 days in advance by the Secretary/Treasurer.

ARTICLE IV - FINANCES Section1.' The annualmembershipduesfor all membersshall be determined by the +xeeutivq€ounei{- Board of Directors. The annualmembershipwill be payablewithin 30 days of requestby the Secretary/Treasurer.The*xeeutitrc-ffi Board of Directors may establish procedures and policies regarding non-paymentof dues and assessments. Section 2: The Erceutive=€ouneil Board of Direclors shall adoptsuchmembershipschedulesas is necessaryto encourage participationby the interestedpublic.

ARTICLE V _ PARLIAMENTARY AUTHORITY Rule of order. Any question of order or procedure not specifically delineatedor provided for by thesebylaws and subsequentamendmentsshallbe determinedby parliamentaryusage as containedin Robert Rules of Order (Revised).

ARTICLE VI _ STANDING COMMITTEES SectionI: Nomirnting Committee. The Nominating Committee shall consist of the Vice-President,as Chairman, theiwemssf reeentpast presidents,a mcmber of the Board of Directors elected for a one year term by the board, and three elected members who may not be members of the Exeeutive-€ouneil Board of Directors. The latter shall serve staggeredtwo year terms. It shall be the task of this committeeto selecta slateof officers tofi|lthenaturallyoccuringvacanciesontheMun.. & Board of Directors andelectedpositions on the standingcommittees of the Association not otherwise designatedand provided for by thesebylaws.

Nominating Committeewill seekthe can@The didates approval for formal nomination and shall place their namesin nomination before the membership for election at the businesssessionof the annual meeting The Nominating Committee will also provide slatesfor any awards offered by the Board of Directors.. Section 2 : M embership Committee. The {xeeutive€ounei} Board of Directors shall constitute the Membership Committee. It shall be the Secretary/Treasurer'sduty to review the qualifications and recommendations of each applicant, for presentationand approvalby the majority of the Membership Committee. Section3: Program Committee. The Program Committee shall be composedof a Chairmart elected by the membership for a three years/erm, an*two membersappointedby the President to staggeredthree year terms, and two membersappointed by the committeeChair to staggeredthree year terms. The Research Committee chair and the Education Committee chair will be members of the Program Committee. None of the appointed members of the committee can be members of the -Exesutivs ffiBoard of Directors.Wfhe dutiesof the committeeshall be to arrange, in conformity with instructions from theExeeutir'e .&aeciJ.Board of Directors, the program for all meetings and selectthe formal participants.

ing; Section4: Constitutionand Bylaws Committee.The Constitution and Bylaws Committee shall consistof a Chairma*and two other members,electedfor staggeredthree year terms so that the member with the leastremaining tenureshall serveas Chairman-during-hirtheir frnal year on the Committee. This Committee shall study the potential merits, adverseconsequences and legal implicationsof all proposedconstitutionalamendments or changesin the bylaws and report their findings and recommendationsto the President andffi Board of Directors prior to the time of formal considerationof the proposed changes by the membership.*---ad&tton,--+lrcy- The membersof the Committeemay themselvessuggestappropriate constitutionalamendmentsand bylaws changesto the President and-Exeerrtivqffi Board of Directors upon study of problems arising out of the existing constitutionand bylaws. Section5: Education Committee. The Education Committee shall consist of a chairma6 elected{sr-to a three years-term by the membership, andthresslr other members appointed by the President to committee Chair for staggered tl4neetwo year terms. ffi icinc- The committee Chair and appointeesmay be membersof the Board of Directors or other Association committees. The Chair shall create ad hoc educationsubcommitteeswith the approval of the Board of Directors. The Committeeshallfoster education in emergenry medical care and assumeduties and tasksas determinedby the Board of Directors.

Section 6: Research Committee. The Research Committee shall consist of a Chair, elected to a three year term by the membership,and six other membersappointed by the committee Chair for staggered two year terms. The committee Chair and appointeesnuy be membersof the Board of Directors or other Association committees. The chair shall create ad hoc research subcommitteeswith the approval of the Board of Directors. The Committeeshall foster research in emergencymedical care and assumeduties and tasks as determined by the Board of Directors. Section 7: Liaison Committeeto the Association of American Medical Colleges (AAMC). The Committee shall consist of a Chair, appointed to a five year term by the Board of Directors, and three membersappointed by the committeeChair for staggered three year terms. The fficial emergency medicine delegatesto the AAMC will be membersof this committee. The committeeChair and appointeesmay be membersof the Board of Directors or other committeesof the Association. Only current or past members of the committee will be nominated by the Nominating Committeefor election to Chair. The Commit tee shall developprograms for the Association to be presented at the annual meeting of the AAMC and assumeother duties and taslcsof similar purpose as determined by the Board of Directors. Section 8: GovernmentalAffairs Committee. The Committee shall consist of a Chair, elected to a three year term by the membership, and three membersappointed by the committee Chair for staggeredthree year terms. The committeeChair and appointeesmay be membersof the Board of Directors or other committeesof the Association. Only current or past members of the committee will be nominated by the Nominating Committeefor election to Chair. The Committeeshall assumeduties and tasl<sas determined by the Board of Directors to foster federal and state support ofresearch and education in emergency medical care. Section 9: Committeeon International Affairs. The Committee shall consist ofa Chair, electedto a three year term by the membership, and three membersappointed by the committee Chair for staggeredthree year terms. The committeeChair and appointeesmay be membersof the Board of Directors or ether committees of the Association. The committee shall assume duties and tasksas determined by the Board of Directors tofoster internatiornl recognition of education and research in emergency medical care.

ARTICLE VII _ DISSOLUTION OF THE ASSOCIATION Section1.' Dissolutionof this Associationcan only be initiated by a majority vote of all members of the €*eeu+ive-€euneiF Board of Directors and must be approved by two-thirds of the active membershippresent and voting at any annual or special meeting. Section2; Dissolution shall be achieved in compliancewith Article IX of the constitution.

EXISTINCUA/EMSTRUCTURE

ACADEMIC AFFAIRS TASK FORCE C O N S T I T U T I OA NN D BYLAWSCOMMITTEE COVERNMENTAL AFFAIRSCOMMITTEE EDUCATION COMMITTEE

CONSENSUS COMMITTEE ACADEMIC DEPARTMENTS

TECHNOLOGY COMMITTEE

COMMITTEON INTERNATIONAL AFFAIRS

FELLOWSHIP COMMITTEE

THERAPEUTICS COMMITTEE

PROPOSED STRUCTURE

N O M I N A T I N GA N D AWARDSCOMMITTEE

ACADEMIC AFFAIRS TASK FORCE

C O N S T I T U T I OA NN D BYLAWSCOMMITTEE COVERNMENTAL AFFAIRS COMMITTEE EDUCATION COMMITTEE

AD HOC ADMINISTRATION AND CLINICALSERVICES COMMITTEES

AD HOC RESEARCH SUBCOMMITTEES

COMMITTEON INTERNATIONAL AFFAIRS

SIMPTIFIED UA/EMCONSTITUTION

ARTICLE IV - OFFICERS president,vice-president,secretary-treasu rer

ARTICLEI-NAMEUA/EM ART|CTE || _ OB|ECTTVES The objective of this associationis to improve the ulgent, or criticalcare of the acuteiyill or in_ :m9lgen9y, ,ured pattentby.promoting research,by educatihghealth careprofessionals and the public,by fosiering,"tationsf,ip, with.organizations with a.simila.pJrporu, "frd by .rpp;;_ ing the specializedor multidiscipiinecareof ,r.h pdti"nt, through researchand education. The associationshall pursue its purpose by: 1) sponso-ring forums for the presentationof peer_reviewed scientificand educational'investigations, 2) convening and"sponsoringeducationalprogramsfor heatthcare professionals and the lay public, 3) promotingacademicdevelopmentand educationof its membershipthrough specidlizedprograms, 4) servingas an academic,university_based, and/orteaching hospitalrepresentative for the iare of ihe acutelyill o? injured patient, 5) developingliaisonswith otherorganizations with a similar purpose,and 6) publishingresearchand educationaldata in the media and available to the lay public.

governingbody: Boardof Directors.Membersof the Board of Directorsare the officers,programcommitteect air, immeaiaie past president,and 5 membersat large

ARTICTEV _ COMMITTEES standingcommittees 1) Membership 2) Nominating 3) Program 4) Constitutionand Bylaws 5) Research 6) Liaisonto the AAMC 7) CovernmentalAffairs B) International additionalcommitteesmay be createdby the Boardof Direc_ tors;president;and chairsof the educationand researchcom_ mittees may create ad hoc education and research subcommitteeswith the approvalof the Boardof Directors.

ARTICTE VI - ANNUAL MEETINC ARTICTEVII - BYLAWS 30 days notice, majority vote

ARTICLE III - ME MB E R S H IP Sevenclassesof membership: 1) Active a) advanceddegree(MD, phD, DO, pharmD,DSc,or equivalent). medicalschoolor universityfacultyappointment. participates in acute,emergency/oi.ciiticatcarein an administrative,teaching,oi researchcapacity. b) individualswith similar degreesand practicein activemilitary service(US or abroad). c) individuals with similar degrees and practice without universityfacultyap-pointment may peti_ tion for activemembershiil. 2) Associate healthprofessionals, educators,governmentoffi_ cials,membersof layor civicgro"ups,or members of the public at large. 3) Emeritus ten continuousyearsof service,60 yearsold. 4) Resident/Fellow in.residency or fellowshiptrainingwith an interest In emergencymedicine 5) Honorary outstandingcontributions. 6) International all membersmay havethe privilegeof the floor al membersmay serveon the Boardof Directorsor as Chair or memberof any committee only active membeis may vote or serve as officer

ARTICLE VIII - ADOPTIONOF THE AMENDMENTS TO THECONSTITUTION 30 days notice, majority vote

ARTICTE IX - DISSOLUTION

SIMPLIFIED UA/EMBYTAWS ARTICTE I - MEMBERSHIP reviewedby MembershipCommitteethen to Boardof Direc_ tors for consideration,dues set by Boardof Directors

ARTICTEII - BOARDOF DIRECTORS all memberselectedby majorityvote at the annualmeeting nominationsfrom the floor acceptedfor all positionsif specifieJ requirementsare met vice-presidentbecomespresidentthen becomesimmediate past president - three years total vice-presidentmust be current or past memberof Boardof Directors vice-president servesas chair of the nominatingcommittee presidentand vice-presidentare ex-officiomembersof all committees secretary/treasurer electedfor three yearterm, onlv one term

[ - five members-at-large elected to staggeredtwo year terms two consecutive terms only programcommitteechair electedfor three year term mustbe current programcommitteemember not eligiblefor other electedoffice president appointsmembersto fill vacanciesand unexpired termsof the Boardof Directorsand all committeesuntil next scheduled election m e e t i n gasr e o p e n t o a l l m e m b e r sa n d t h e p u b l i c closedmeetingsof the officersand the executivedirectorcan be convenedby the president financialrecordkept by the secretary/treasurer and reviewed annuallyby two other membersof the Boardof Directorsper the oresident absences approvedonly by the president two unexcusedabsencesconstituteresignation

A R T I CT III E _ ME E T IN GS 1 5 0m e m b e r sc o n s t i t u t e sa q u o r u m a t t h e a n n u a lb u s i n e s s meetrng 1 ) f i n a n c i arl e p o r t 2) amendments 3) elections 4) reportsof committeeactivities 5 ) o t h e rb u s i n e s s 6) "stateof the association",addressby president a n n u asl c i e n t i f i a c n d e d u c a t i o n aal s s e m b l y 1) originalresearch/methodology 2) forums 3) specialprograms 4) committeemeetings

AR T I CL E IV _ F IN A N C E S ARTICTE V _ PARLIAMENTARY AUTHORITY Robert'sRulesof Order (Revised)

ARTICLE VI * STANDINGCOMMITTEES

i :

1) Nominating Committee chairis vice-president p a s tp r e s i d e n ti s m e m b e r immediate onememberof the Boardof Directorselectedby the Board for one year threememberselectedfor staggeredtwo year terms who may not be membersof the Boardof Directors charge:.nominate membersfor office and recipientsfor awaros

2) Constitutionand BylawsCommittee chair and two memberselectedfor staggeredthree year terms such that the most senior member becomesthe chair 3) ProgramCommittee chair electedfor three year term automaticallya member of the Boardof Directors two membersappointedby the president two membersappointedby the chair Committeechair EducationCommitteechairand Research are members membersservestaggeredthree year terms none of the appointed memberscan be membersof the Boardof Directors 4) EducationCommittee chair electedfor three year term two year six membersappointedby the chairfor staggered terms with the chaircan createad hoc educationsubcommittees approvalof the Boardof Directors charge:foster educationin emergencymedicine 5) ResearchCommittee chair electedfor three year term two year six membersappointedby the chairfor staggered terms chair can createad hoc researchsubcommitteeswith the approvalof the Boardof Directors charge:foster researchin emergencymedicine 6) LiaisonCommitteeto the AAMC chair appointedto five year term by Boardof Directors five membersappointedby the chair for staggeredthree year terms official emergencymedicinedelegatesto the AAMC are membersof the committee charge:develop programsfor presentationto the AAMC 7) CovernmentalAffairsCommittee chair electedfor three year term three three membersappointedby the chair for staggered year terms charge:foster federal and state support of researchand e d u c a t i o ni n e m e r g e n c ym e d i c i n e B) Committeeon InternationalAffairs chair electedfor three year term three membersappointedby the chair for staggeredthree Vearterms charge:foster internationalrecognitionof educationand researchin emergencymedicine

VII ARTICLE DISSOTUTION OF THEASSOCIATION By vote of 213of activemembershippresent

DINING IN CINCINNATI This guide has been prepared by the faculty and residents of the University of Cincinnati to help you choose the best food and drink in town. Most of the restaurantsare walking distanceor a short cab ride from the Omni Netherland Plaza Hotel. The number on the map will locate the restaurantsin the downtown area for you. Best bets are hard to pick. (It dependson your mood, the type of food, and your wallet.) Cincinnati has many fine restaurants.For excellent food and formal dining within walking distance of the Omni Netherland consider the Maisonette, Orchids, the Palace, Pigall's, or Delmonico's. Alpha 2M W. McMillan Phone: 381-6559 Price: inexpensive Type: vegetarian Dress: casual Distance: short drive One of the best vegetarian/naturalfood restaurantsin Cincinnati. Great for breakfast (try the Belgian waffles). Attached bar. Arnold's Bar and Grill 210 East 8th Phone: 421-6234 Price: inexpensive (cash required, no cards) Type: Italian, unusual American, vegetarian Dress: casual Distance: long walk/short drive An English style pub with good inexpensive food, live music (usually classicjazz), an outdoor courtyard area. Open late. A good place to go for food, beer, and a long conversation.

Bacchus 1401Elm Phone: 421-8314 Price: moderate Type: continental Dress: can dress up or down Distance: walking Unusual sauces made with fresh herbs and spices. Fresh seafood, fish and pasta specials.

Dress: coat & tie Distance: long walk (10 blocks) or short drive Beautiful evening view of the city and the riverfront. Excellent veal and seafood. Nice wine list. Service good to superb. Reservations recommended.

Champs Ilyatt Ilotel, 151 .N. 5th Srreet Phone: 579-1234 Price: moderately expensive Type: steak and seafood Dress: probably formal, at least presentable Distance: short walk Typical quality of Hyatt restaurants.Adjoining bar may allow a view of local professional athletes. Basic steak and seafood nicely prepared in quiet atmosphere. Relatively small dining area, best to make reservations.

Chi Chi's 3 locations Phone:851-3333 Price: moderate Type: Mexican Dress: casual Distance: long drive Excellent Mexican cuisine, authenticatmosphere,large drinks.

Coach and Four 214 Scott Street, Covington, KY Phone: 431-6700

Blue Gibbon l23l TennesseeAvenue Phone: &l-4lOO Price: inexpensive to moderate Type: Chinese Dress: casual Distance: 25-30 minute drive

Price: moderately expensive Type: American Dress: dressy Distance: short drive Excellent food and wine, not as stuffy as the Maisonette.

A must for Chinese food lovers, the Blue Gibbon has a varied menu ofdeliciously prepared food. The restaurant's casual atmosphere, good service, and large portions makes it a very pleasant dining experience.

Cocots 322 Greenup, Covington, KY Phone: 491-1369

The Celestial 1071 Celestial Phone: 241-4455 Price: moderate to expensive (entrees $12-$20) Type: continental

Price: moderate Type : eclectic-continental Dress: casual Distance: short drive Interesting and well prepared meals which include fish specials' beef and chicken dishes. Live jazz on Friday and Saturday nights. Pleasant, friendly atmosphere.

I.FDeeFeliceCafe' 529 Main Street, Covington, KY Phone:261-2365 Price: moderate Type: Cajun Dress:informal Distance:10 minute drive A neatplacewith relaxed informal afinosphere, good cajun food, and classicjazz band. A touch of the deep South well worth the trip. Highly recommended.

Delmonicots FountainSquare Plaza Phone:241-3663 Price:expensive Type: continental Dress:formal Distance:walking Restaurantoverlooks Fountain Squarewith nice view of lights at night. Good service and very good food.

The Diner on Sycamore 1201Sycamore Phone:721-1212 Price: moderate Type: American Dress:come as you are Distance:short drive Enjoylunch, dinner or a late night snackin this unique renovated,authentic1950's stainlesssteeldiner. A modern decor (borderingon new wave) and a young interesting staff make thisa "fun" place to be. The menu offers somethingfor everyone:soups,salads,burgers, chicken, pastaand full scaledinnerswhich are usually imaginativeand delicious.

El Coyote 7404 State Road Phone:232-5757 Price:inexpensive-moderate (entrees$6-$14) Type: Tex-Mex Dress:casual Distance:20 minute drive For this misplaced Texan, El Coyote offers the closest thing to Mexican food that Cincinnati has to offer. The fajitas are tender,and the margaritas are smooth. Ask for a " Vz and Vz." Serviceis excellent.

Excelsior 317 Buttermilk Pike, Ft. Mitchell Phone:331-3000 Price: moderate-expensive Type: continental Dress:jacket/tie, reservations required, major credit cards Distance:8 miles

Outstanding contemporary continental cuisine in a dramatic yet elegant setting. Many specialties prepared at tableside. Reasonablewine list. The Excelsior, with its running fountains and pools, has become a "must" on the Cincinnati restaurant scene. F&NSteakHouse Highway 8, Interstate 417 to Route 8 Phone:261-6766 Price: $5.95-$26.00 Type: basic American steakhouse Dress: casual Distance: medium length drive This restaurantis noted for its steak and beef dishes. Lobster and chicken are served as well. This restaurantresides along the Ohio River just eastof Cincinnati. The decor is wood floors and rough hewn beamswith heavy wooden furniture. The ceilings are low and the ambience is warm and friendly. Ferdinand's 4400 Glenway Phone: 251-4800 Price: inexpensive Type: Mexican Dress: casual Distance: short drive Authentic Tex-Mex cuisine, family style meals. Gourmet Terrace Hilton Hotel, 15 W. 6th Street Phone: 381-4000 Price: expensive Type: French Dress: dressy, reservations required Distance: walking This elegantrestaurantis perchedatopone ofthe tallestbuildings in downtown. The view is nice and the food is usually outstanding. For a real treat, call aheadand ask for their walnut soup or BananasFoster. Grand Finale Sharon Road and Congress Avenue, Glendale, OH Phone:771-5925 Price: moderate Type: crepes, steak, seafood Dress: casual Distance: long drive 30 minutes Deliciously prepared steak, seafood, and chicken served with your choice of stuffed crepes. Wonderful homemade soups, breads and desserts. Heritage Restaurant 7664 Wooster Pike, I mile east of Mariemont Phone: 561-9300 Price: $8.00-S18.00 Type: basic American

Dress: sport coat with or without tie Distance: long drive This is an excellent place to enjoy an evening meal. The setting is of a large, turn-of-the-century country house that has been refurbished and well maintained. The ambience is cozy and warm. Food selectionsinclude Prime Rib, Filet Mignon, New York Strip, Grilled Chicken, and a variety of pastas.They have an excellent blackened red fish. House of Hunan 34 W. 7th Street Phone: 721-3600 Price: inexpensive-moderate Type: Chinese Dress: casual Distance:walking Somepeoplecan't go anywherewithout a good doseof Chinese food. This restaurantfrlls the bill as well as your stomach, offering a wide selectionof Chinese dishes in clean and pleasant surroundings.

Montgomery Inn Ribs King 9440 Montgomery Road Phone:791-3482 Price: moderate Type: barbeque Dress: casual Distance: long drive Best ribs in town. Bob Hope even hasthem flown in for special occasions. Very crowded but worth the wait.

Orchids Omni Netherland Phone:421-1772 Price: expensive Type American Dress: formal Distance: in Netherland Restaurantin the Palm Court Room. Beautiful art deco refurbishing. Piano music during dining.

La Normandie Grill ll8 E. 8th Street Phone: 721-2761

Palm Court Fifth & Race Streets Phone: 421-9100

Price: moderate Type: steaks, chops, and seafood from the grill Dress: sport coat recommendedbut not required Distance:walking An English pub-type atmosphereprevails in this more casual restaurant situated downstairs from the Maisonette. Crunch through the peanutshellson the bar floor and listen to live entertainment while you wait for your table (no reservations). The steaksand prime rib are excellent and the Maisonette wine list is availableon request.

Price: inexpensive-moderate Type: Dress: casual Distance: Omni Netherland Plaza

Maisonette ll4 E. 6th Street Phone:721-2260 Price: expensive Type: classic French Dress: dressy Distance: walking Long consideredthe best of Cincinnati dining. This Five Star restauranthasthe ambienceand culinary skills necessarytojustify its international reputation. Would suggestmaking reservations at least two weeks in advance. Mike Fink foot of the Greenup, Covington, KY Phone:261-4212 Price: moderate Type: seafood/steaks Dress: formal Distance: short drive Situatedin a refurbished riverboat moored on the Kentucky bank of the Ohio River overlooking the Cincinnati skyline. Good raw bar, great view. Call aheadfor reservationsand ask for a table by the windows.

A cafe in the most elegantof surroundings. The menu includes excellent light entres, pasta, and seafoodselectionsas well as an extensivedesserttray. The CreuvenetList and the selection of cognacs and ports is among the best in the city.

Palace Cincinnatian Hotel, 601 Vine Street Phone: 381-3000 Price: very expensive Type: French/American/seafood Dress: formal Distance; short walk Cincinnati's newest, and nearly most expensive, posh dining spot. Elegant decor in a newly renovated hotel. Unusual specialties,great desserts,and quiet aunosphere.More cosy than the stufff Maisonette with equal culinary benefits. Reservations suggested,plan to spendtwo hours in relaxed gustatory delight.

Saigon Dragon 7715 Reading Road Phone: Price: Inexpensive Type: Vietnamese-Chinese Dress: casual Distance: short drive (15-20 minutes) Atmosphere is very lacking but the food isn't. Good selection of Vietnameseand Chinesefood. Owners formerly ran several restaurantsin Saigon.

[ Scotti's 919 Vine Street Phone:721-9484 Price: inexpensive-moderate Type: Italian Dress:casual, reservations required, cash only Distance: 1.2 miles (better take a taxi) This venerablefamily run restaurantis the Gold Standardfor Italiancuisine in the Cincinnati Area. The decor is simple and comfortable.The menu is extensive featuring both Northern and Southern Italian specialties. The food is outstanding with homemadesauces,pasta and fresh bread, excellent veal and beef. The Italian food lover's Maisonette. Sebastian's 5209 Glenway Phone:471-2100 Price: inexpensive Type: Greek Dress:casual Distance:short drive AuthenticGreek cuisine, voted the best Gyros in Cincinnati. GreatBaclava. Sovereign QueensTower - Price Hill Phone: 471-2250 Price: moderate Type: American Dress:semi-formal Distance:short drive Make reservationsfor early evening and watch the city light up. Beautifulview of city and river. Lamb is a specialty;other itemsare superb. Wah Mee 120W. 5th Street Phone:579-0544 Price:cheap Type: Chinese Dress:casual Distance:walking Largevaried selectionofhot tasty food that is reasonablypriced. Combinationplates are the best buy. Can serve many patrons quickly in unhurried manner without crowding. Windows on the Water at the Waterfront 14 PeteRose Pier, Covington, KY P h o n e5: 8 1 - 1 4 1 4 I

Price: moderate-expensive Type:fresh seafood,Wisconsinveal, Indianaduck, Cantonese and Szechuandishes Dress:coat & tie Distance:short drive A two-story floating restaurant/night club docked east of the ClayWade Bailey Bridge (I-75). The food is excellentand there is a romantic view of the Ohio River and city of Cincinnati. Thereis a luxuriously decoratedladies restroom with a makeup artist, plush lounge with courtesy telephones,and a ladies VIP bar with Chippendale male bartender.

LTJNCH RESTAURANTS Camp Washington Chili Hopple and Colerain Avenues Phone: 541-0061 Price: dirt cheap Type: chili Dress: combat Distance: short drive The original Cincinnati chili parlor, with a varied clientele, great chili, and in a neighborhood time forgot. Lytle Food Shoppe 330 E. 4th Phone:241-6114 Price: cheap Type: sandwiches Dress: casual Distance: walking Spend your lunch hour by the Ohio River at Yeatman's Cove or at Lytle Park by the Taft Museum with a carryout from the Lytle Food Shoppe.Superbsandwiches(e.g., roastbeef;, soups, chips and pickles, beveragesavailableas are other grocery store items. Pig in the Poke 435 Elm Phone:381-6465 Price: inexpensive Type: barbeque ribs Dress: casual Distance: walking Cafeteriastyle serviceand limited seating.Sacrificeatmosphere of Montgomery Inn for cheaper ribs of the same quality. Separateeatingarea if one wishesto patronizebar on premises. Rookwood Pottery Restaurant 1077 Celestial.Mount Adams Phone:721-5456 Price: inexpensive Type: American, deluxe burgers Dress: casual Distance: short drive Inexpensivefood and nice atmosphereat this restaurantsituated atop Mount Adams overlooking the downtown skyline. The restaurantoccupiesthe historic rookwood pottery factory with some tables inside the massive kilns. Skyline Chili 30 W. 5th, 643 Vine, 6th & Walnut, etc. Phone: 381-1915, 241-2020, 381-4244 Price: dirt cheap Type: original Cincinnati chili Dress: Who cares? Distance: walking A must for Cincinnati tourists. Try a 3-way, S-way, Coney, orjust a bowl ofplain chili, but ask for extra cheeseand hold the beans.An experienceyou will sharewith your friends back home.

UA/EM LEADERSHIP

Jerris Hedges, MD Program Comminee Chair

Ernest Ruiz. MD President

EXECUTIVE COI.]NICIL Ernest Ruiz. MD. President JamesNiemann MD, President-Elect Mary Ann Cooper, MD, Secretary/Treasurer Richard Nowak , MD, Immediate Past President StevenDavidson, MD, Past President William Barsan, MD, Councilman Harvey Meislin, MD, Councilman Arthur Sanders,MD, Councilman Blaine White, MD, Councilman Jerris Hedges, MD, Program Chair Committee

COMMITTEES Constitution and Bylaws JamesNiemann, MD, Chair Donna Seger, MD William Spivey, MD Program Jerris Hedges, MD, Chair Paul Auerbach, MD Michael Callaham, MD G. Patrick Lilja, MD Judith Tintdinalli, MD Program Committee guest reviewers Arthur Sander, MD Basic Science-MichelleBiros, MD Gary Krause, MD Peter Maningas, MD Gerard Martin, MD William Spivey, MD EMS-Richard Burney, MD Paul Paris, MD Methodology-Carl Ferraro, MD Glenn Hamilton, MD Robert Lowe, MD Pediatrics-Dee Hodge, MD Gary Fleisher, MD Toxicology-Lewis Goldfrank, MD Edward Krenzelok. MD

Nominating JamesNiemann. MD. Chair Dan Danzl, MD StevenDavidson, MD G. Patrick Lilja, MD Richard Nowak, MD K. Douglas White, MD

Martin Keller, MD Rod Little, MD Michael Moles. MD Greg Powell, MD Bruce Rowat, MD Douglas Rund, MD David Yates, MD

Education ShermanPodolsky, MD, Chair Paul Adler, MD Kathleen Hubbell, MD V. Gail Ray, MD

Technology James Woodburn, MD, Chair Charles Babbs, MD Stephen Cantrill, MD Scott Janusik, MD Stephen Karas, MD David Plummer, MD Mark Smith, MD

AD HOC COMMITTEES Academic Departments of Emergency Medicine E. JacksonAllison, Jr., MD, Chair Gail Anderson, MD Louis Binder, MD Glenn Hamilton, MD Ben Honigman, MD Richard Levy, MD Harvey Meislin, MD William Robinson, MD John Schriver, MD David Wagner, MD John Wiegenstein, MD Consensus Conference SheldonJacobson,MD, Chair Louis Binder. MD Fellowship Charles Brown, MD, Chair Sherman Podolsky, MD Governmental Affairs Steven Barrett. MD. Chair Richard Levy, MD David Wagner, MD J. Douglas White, MD International Affairs Richard Nowak, MD, Chair Herman Delooz. MD Gordian Fulde, MD

Therapeutic Studies William Barsan. MD. Chair Michele Biros. MD Charles Brown, MD Richard Cummins, MD William Spivey, MD 1988 UA/EM-IRIEM Research Symposium William Barsan, MD, Chair

REPRESENTATIVES Association of American Medical Colleges, Council of Academic Societies Michael Callaham, MD, delegate Thomas Stair, MD, delegate Steve Dronen, MD, alternate Richard Levy, MD, alternate American Board of Emergency Medicine V. Gail Ray, MD Steve Davidson, MD Judith Tintindli, MD David Wagner, MD AMA Commission on EMS Paul Pepe, MD, delegate G. Patrick Lilja, MD, alternate Emergency Medicine Foundation Douglas Rund, MD

VADE MECT]M BESTBASIC SCIBNCEPRESENTATION 1985-Michelle H. Biros, MD, MS, Universityof Cincinnati, "post Insult Treatment of Ischemia-Induced Cerebral Lactic Acidosis in the Rat"

BEST RESIDENT PAPER

1986-Peter A. Maningas, MD, Letterman Army Institute of Research, "Use of 7.5 % NaCl/6 % Dextran 70 for Treatment of Severe HemorrhagicShock in Swine"

1983-Jeffrey A. Sharff, MD, Oregon Health SciencesUniversity, "Effect of Time on Regional Organ Perfusion During Two Methods of Cardiopulmonary Resuscitation"

1987-Eric Davis, MD, Ohio SrateUniversity, "The ComparativeEffects of Methoxamine versus Epinephrine on RegionalCerebral Blood Flow Durins CPR"

1984-Gerard B. Martin, MD, Henry Ford Hospital, "Insulin and GlucoseLevels During CPR in the Canine Model"

BESTCLINICAL SCIENCEPRESENTATION 1985-Harlan A. Stueven.MD. Medical Collegeof Wisconsin, "Bystander/ First ResponderCPR: Ten Years Experience in a Paramedic System" 1986-Stuart A. Malafa. MD. Butterworth Hospital, Grand Rapids, "Prehospital Index: A Multicenter Trial" and JosephF. Waeckerle, MD, BaptistMedical Center, Kansas City, "A ProspectiveStudy Identiffing the Efficacy of Clinical Findings and Sensitivity of Radiographic Findings in Carpal Navicular Fractures"

1987-RanjanThakur, MD, Medical College of Wisconsin, "A Randomized Study of Epinephrineversus Methoxamine in Prehospital Ventricular Fibrillation"

1987-Ruth Dimlich, PhD, Universiryof Cincinnati, "Effects of Sodium Dichloroacetateon ATP and Phosphocreatine in Ishchemic Rat Brain"

BESTSCIENTIFIC POSTER 1986-MarkHoward,DO, Henry Ford Hospital,"Improvementin Coronary PerfusionPressures After Open ChestCardiacMassage in Humans: A PreliminaryReport"

1985-William C. Dalsey,MD, and Scott A. Syverud, MD, University of Cincinnati, "Transcutaneousand Transvenous Cardiac Pacing For Early Bradyasytolic Cardiac Arrest" 1986- StevenChernow, MD, University of Arizona, "Use of the Emergency Department for Hypertensive Screening" 1987-Robert L. Muelleman, MD, Truman Medical Center, "Blood Pressure Effects of ThyrotropinReleasing Hormone and Epinephrine in Anaplylactic Shock."

BEST RESIDENT POSTER 1987- Gert-PaulWalter, MD, Michigan StateUniversity, "Emergency IntraosseousInfusionsin Children: A Practical Method of TeachingPrehospital Personnel"

BEST PAPER l97J-Lawrence B. Dunlap, MD, JosephineGeneralHospital, Grants Pass, Oregon, "Percutaneous Transtracheal Ventilation During Cardiopulmonary Resuscitation" 1979-Albert E. Cram, MD, University of lowa, "The Effect of Pneumatic Anti-Shock Trouserson Intercranial Pressurein the CanineModel"

1980-Blaine C. White, MD, Wayne State University, "Mitochondrial 0, Use and ATP Synthesis:Kinetic Effects of Ca'+ and HpO" Modulated by Glucocorticoids" 1981-Blaine C. White, MD, Wayne State University, "Correction of Canine Cerebral Cortical Blood Flow and VascularResistancePost Arrest Using Flunarazine, A Calcium Antagonist" 1982-Carl D. Winegar, MD, Wayne StateUniversity, "Early Amelioration of Brain Damage in Dogs After Fifteen Minutes of Caidiac Arrest" 1983-Charles F. Babbs, MD, Purdue University, "Improved Cardiac Output During Cardiopulmonary Resuscitationwith InterposedAbdominal Compressions" 1984-Charles G. Brown, MD, Ohio State University, "Injuries Associated with the PercutaneousPlacement of TransthoracicPacemakers"

BEST PRBSENTATION 1980-Jacek B. Franaszek. MD. and Harold A. Jayne,MD, University of Illinois, "Medical Preparations for an Outdoor Papal Mass" 1981-Robert W. Strauss,MD, University of Chicago, "Expanded Role of the Barium Enema in the Acute Abdomen" 1982-Stephen R. Boster,MD, University of Louisville, "TranslaryngealAbsorbtion of Lidocaine" 1983-Sandra H. Ralston. MD. Purdue University, "Intrapulmonary Epinephrine During Prolonged Cardiopulmonary Resuscitation: Improved Regional Blood Flow and Resuscitationin Dogs" 1984-Paul M. Paris, MD, University of Pittsburgh, "The Prehospital Use of TranscutaneousCardiac Pacins"

IMAGO OBSCIJRA AWARI)

MACKENZIE AWARI)

1976-Norman E. McSwain, Jr.. MD 1977-Sung Rock Lee, MD 1978-G. Patrick Lilja, MD 1979-Stephen Karas, MD 1980-Jack Goldberg, MD l98l-Robert Knopp, MD 1982-Blaine C. White, MD 1983-Richard C. Levy, MD 1984-Glenn C. Hamilton. MD 1985-Jerris R. Hedges, MD 1986-David DuBois. MD 1987-Norman Abramson. MD

1976-James R. Mackenzie. MD 1977-Cyrll T. M. Cameron, MDf 1978-John H. Hughes, MD 1979-Joseph F. Waeckerle, MD 1980-Kenneth L. Mattox. MD 198l-Barry W. Wolcott, MD 1982-Hubert T. Gurley, MD 1983-Ronald L. Krome, MD 1984-Charles F. Babbs, MD 1985-Blaine C. White, MD 1986-James T. Niemann, MD 1987-Arthur Kellermann, MD

PAST PRESIDENTS

KENNEDY LECTT]RERS

HONORARY MEMBERS

l97O-197 l-Charles Frey, MD l97l-1972-Alan R. Dimick. MD 1972-1973-RobertB. Rutherford.MD 1973-1974-James R. Mackenzie,MD 1974-1975-George Johnson,Jr., MD 1975-1976-LeslieE. Rudolf, MD 1976-1977-DavidK. Wagner,MD 1977-1978-CarlJelenko,III, MD 1978-1979-Ronald L. Krome,MD 1979-1980-Kenneth L. Matrox,MD 1980-1981-W.KendallMcNabney,MD 1981-1982-Joseph F. Waeckerle,MD 1982-1983-BarryW. Wolcotr,MD 1983-1984-Jack B. Peacock.MD 1984-1985-Richard C. Levy, MD 1985-1986-Steven J. Davidson.MD 1986-1987-Richard M. Nowak,MD 1987-1988-Ernest Ruiz.MD

1973-FraserN. Gurd, MD 1974-OscarP. Hampton,Jr., MD 1975-CurtisP. Artz, MD 1976-John G. Wiegenstein,MD 1977-Peter Safar,MD 1978-SenatorAlan M. Cranston t979-Alexander J. Walt, MD 1980-EugeneL. Nagel,MD l98l-C. ThomasThompson,MD 1982-R AdamsCowley,MD 1983-RonaldL. Krome.MD 1984-DavidK. Wagner,MD 1985-RichardF. Edlich,MD, phD 1986-HenryD. Mclntosh,MD 1987-RobertD. Sparks,MD 1988-Gail V. Anderson,MD

1973-RobertH. Kennedy,MDf FraserN. Gurd, MD C. BarberMueller, MD 1974-John G. Wiegenstein,MD AlexanderJ. Walt, MD 1975-OscarP. Hampton,MDt N. H. McNally, MDf Curtis P. Artz, MDf 1976-Anita M. Dorr, RNf EugeneL. Nagel,MD 1977-Peter Safar,MD 1978-EbenAlexander,Jr., MD 1979-DavidR. Boyd, MD, CM 198l-R AdamsCowley,MD 1982-Carl Jelenko,III, MD

ANIIUAL MEBTING PROGRAM CHAIRMEN l97l-1973-Leslie E. Rudolf, MD 1974-197s-Peter Canizaro.MD 1976-1978-KennethL. Mattox. MD 1979-1980-Joseph F. Waeckerle,MD 1981-1983-Richard F. Edlich,MD, PhD 1984-1986-Judith E. Tintinalli,MD 1987-1989-Jerris R. Hedges,MD

PAST ANI\UAL MEBTINGS Charter Meeting November 18, 1970 Denver, Colorado

7th Annual Meeting May 15-18, 1977 KansasCity, Missouri

lst Annual Meeting May 14-15, l97l Ann Arbor, Michigan

8th Annual Meeting May 18-20, 1978 San Francisco. California

2nd Annual Meeting May 12-13, 1972 Washington,D.C.

9th Annual Meeting May 24-26, 1979 Orlando. Florida

3rd Annual Meeting May 23-25, 1973 Hamilton, Ontario

10th Annual Meeting April20-23, l98O Tucson, Arizona

4th Annual Meeting May 28-June l, 1974 Dallas, Texas

llth Annual Meeting April 13-15, 1981 San Antonio, Texas

5th Annual Meeting May 20-24, 1975 Vancouver, British Columbia

12th Annual Meeting April 15-17, 1982 Salt Lake City, Utah

6th Annual Meeting May 1l-15, 1976 Philadelphia, Pennsylvania

13th Annual Meeting June 1-4, 1983 Boston. Massachusetts

14th Annual Meeting May 22-25, 1984 Louisville, Kentucky l5th Annual Meeting May 2l-24, 1985 Kansas City, Missouri 16th Annual Meeting M a y 1 3 - 1 5 ,1 9 8 6 Portland, Oregon 17th Annual Meeting May 19-21, 1987 Philadelphia,Pennsylvania 18th Annual Meeting May 24-26, 1988 Cincinnati. Ohio

University Associationfor EmergencyMedicine 9fi) West Ottawa Lansing, Michigan 48915 (51n 485-5484 FAX number: (517) 485-0801