SAEM 1991 Annual Meeting Program

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Societyfor AcademicEmergency Medicine

I99L Annual Meeting Program

NIay 12-15,l99l Washington,DC

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INDEX G e n e r aI ln f o r m a t i o n

.......1-2

K e n n e d yL e c t u r e

......3

LeadershipAward and Hal Jayne Academic ExcellenceAwards . . . .

. . .4-5

A w a r dP s resentations....

..........6

S c h e d uol e f Events

.......i-10

..:...

P a p eS r essions..

Educationaland SpecialSessions

..ll-16 . 17-18

Abstracts

. .19-68

Exhibitors

. .69-i0

AnnuaB l u s i n e sM s e e t i n gA g e n d a

.........j

Slateof Nominees

.72-i4

Constitutionand Bylaws of the Societyfor AcademicEmergencyMedicine

.75-79

V a d eM e c u m. . . .

.80-82

MembershipApplication

A diagramof meetinglocationsis publishedon the insideback cover.

SAEM gratefully acknowledgesa generous contibution from Genentech,Inc., which has been used to assistin funding the Annual Meeting.

at.

GENERAL INFORMATION REGISTRATION All registrantsmust check in at the SAEM RegistrationDesk and pick up namebadgeswhich are requiredfor admissioninto all Annual Meeting sessions.

OPENING COCKTAIL

RECEPTION

SAEM is hostingan openingcocktailreceptionon Sunday,May A room ofthe l2 from 6:30 until 8:00 pm in the Independence to attend.Hors are invited registrants Meeting All Annual Hyatt. d'oeurveswill be servedand a cashbar will be available.

BANQUET The historicCar Barn, built in 1760,is the site of this year's Annual MeetingBanquetwhich will be held on the eveningof Wednesday,May 15. The site, locatedat the foot of the Key Bridge in Georgetown, was first used as an old tobacco warehouse,was later converted.to the original Union Station, and, after severalface lifts, becamethe Car Barn, providing administrativesupportto D.C. Transit, owner and operatorof the District's ground and trolley transportationsystemduring t h e 1 9 5 0 ' sa n d 1 9 6 0 ' s .

In the last three years the Car Barn has been renovatedwith

COMMITTEE

a specialfourth floor eventscenter,which sitsatop the original three story structure. Trolley tracks can still be seenas they lead onto the Car Barn's parking garage.Much of the original architecture and fixtures remain intact and will soon enjoy designationas a historical national landmark. The Penthouse West and Rose Garden Penthouseinclude large picture windows which offer an uncompromisedview.

As always, the Banquetwill include transportation,dinner, and drinks, however, this year Richard Bray and his Orchestrawill enliven dinner! After dinner, the Annual Imago ObscuraAward Presentationwill be held. Sincethe Banquetwill be held in Georgetown, information sheetswill be availableafter the Banquetfor "hot spots" thoseparticipantswho wish to visit someof ttrearea's and extend the evening into the wee hours of the morning!

A free ticket to the Banquet is available to every active associationor international member of the Society, but must have been requested on the Annual Meeting registration form. Resident and medical student members of SAEM do not receive a free banquet ticket. Tickets are $35, but only a limited number will be available for purchase on-site, dress is casual. Buseswill begin loading at 5:15 and will begin leaving for the Car Barn promptly at 5:30. Buses will return between 10:00 and 11:00 pm

MEETINGS

Listed below are the comitteeswhich are scheduledto meetduring the Annual Meeting. Additional committeemeetingsmay havebeenscheduledafter the publicationof this program. Thesecommitteemeetingsare open to the membershipand meeting participantsare invited to attend.

Sunday, May 12 l0:15-11:00am l1:00-12:00noon ll:00-12:00 pm l2:00-1:00 pm l2:00-1:30pm l:30-3:30 pm 4:00-5:00 pm -

SAEM SAEM SAEM SAEM SAEM SAEM SAEM

BurnhamRoom Annual Meeting EducationalSessionsSubcommittee, on BiomedicalPolicies,LatrobeRoom Ethics Subcommittee ResidencyConsultingCommittee,BurnhamRoom BurnhamRoom ResidencyConsultingCurriculumSubcommittee, EthicsCommittee,LatrobeRoom EducationCommittee,BurnhamRoom Faculty DevelopmentSubcommittee,Burnham Room

Monday, May 13 7:00-8:00am 8:00-9:00 am 9:00-10:00am l0:00-12:00noon 12:00-l:30 pm l:30-2:30 pm 2:30-3:30pm Tuesday, May 14 3:00-4:00 pm 4:00-6:00 pm -

SAEM PublicationsTask Force, Grand Cafe SAEM EMS EducationSubcommittee,Renwick Room SAEM TechnologyCommittee,Renwick Room SAEM ResearchCommittee,Renwick Room SAEM GovernmentFunding for ResearchSubcommittee,Renwick Room SAEM ObservationMedicineCommittee,Renwick Room ACEP ObservationMedicineSection,Renwick Room SAEM EMS ResearchSubcommittee,Latrobe Room SAEM GovernmentalAffairs Committee, Latrobe Room

Wednesday, May 15 ACEP AcademicAffairs Committee,ConstitutionD 9:00-10:30am SAEM Subcommitteeon Public Health and Prevention,ConstitutionD 2:00-4:00 pm 3:00-4:30 pm SAEM EMS as a SubspecialtyTask Force, ConstitutionC

CONTINUING EDUCATION

SPEAKERS'READY ROOM

The AnnualMeetinghasrequested35 hoursof CategoryI credit from the American College of EmergencyPhysicians.

A speakers'ready room will be availablefor those who wish to check their slidesin advanceof their presentation.Keys to the ready room will be availableat the RegistrationDesk.

ANNUAL BUSINESS MEETING The Associationwill hold its Annual BusinessMeeting from 1:30-3:00pm on Tuesday,May 14. At the meetingJerris R. Hedges,MD, will introduce incoming presidentWilliam G. Barsan,MD. The agenda,slateof nominees,and Constitution and Bylaws are publishedin this program. All membersof the Societyare urged to attend,however,only activemembersare eligible to vote. Awards will also be presentedduring the Annual BusinessMeeting, includingthe Leadershipand Academic ExcellenceAwards.

EXHIBITS Exhibitswill be availablefor viewingon May l3 and l4 from Ballroom.

9:00-12:00noonand l:00-5:00pm in theConstitution Poster SessionA, Innovationexhibits, Computer Software displays,coffeebreaks,and the registrationdesk will also be are urgedto visit the locatedin the Exhibit Hall. Registrants exhibitsduring the scheduledcoffee breaks.

LUNCHEON SESSIONS at the AnThis year thereare many specialluncheonsessions nual Meeting. The cost of lunch ticketsis $30 each ($15 for the ResidentResearchForum), howcver,theatreseatingwill also be availablefor registrantswho do not wish ttl purchase a lunch ticket.

PLACEMENT SERVICE Desk A bulletinboardwill be maintainednearthe Registration for personswishingto post positionsand physiciansavailable listings.

MESSAGE I}OARD Desk.

A message boardwill be maintainedat the Registration Phonemessagescan be left at the SAEM RegistrationDesk by calling the Hyatt Hotel at (202) 582-1234and requestingthe SAEM RegistrationDesk.

AWARD SPONSORS SAEM is grateful for the sponsorshipof many of the SAEM awards.Thesesponsorsare: Marion Merrell Dow: Kennedy Lecture SpectrumEmergencyCare, Inc.: Hal JayneAcademicExcellenceAward EmergencyMedicine: Best Oral Basic ScienceAward MICROMEDEX, Inc.: Best Oral Clinical ScienceAward EmergencyMedicine News; Best Poster Award PergamonPress: Best ResidentPoster Award Pediatric Traumaand Acute Care: Best PediatricTraumaand Acute Care Award GeorgeWashingtonUniversity:BestMedicalStudentPresentation Award Annals oJ'EmergencyMedicine: Annals Best ResidentPaper Award

EMRA RECEPTION EmergencyMedicineand EMRA will hosta Receptionon Tuesday, May l4 fiom 6:00-7:00pm. The highlightof the recepof the 199I JeanHollisterAward tion will be the presentation by and PrehospitalCare (sponsored firr Excellencein EMS the Academic Exellence and CoastalEmergencyServices)

by EmCare).Hors d'oeurveswill be served Award (sponsored will be available.All interestedEMRA members bar and a cash and othersare invitedto attend.The Receptionis sponsored

by EmergencyMedicine.

BOARD OF DIRECTORS MEETING The SAEM Boardof Directorswill convenea meetingon Tuesday, May 14from 7:00-10:00pm. Thismeetingwill bechaired

by Bill Barsan,MD, who beginshis termas theSAEM presidentat theAnnualBusinessMeetingon May 14.All interested membersand othersare invited to attendthis, andall meetings of the Board of Directors.

PROCEEDINGS Proceedingsof the Annual Meeting will not be preparedas a scienseparatepublication.However, selectedpresentations, printed Anpertinent will in the papers discussion be and tific journal of Society official the Emergency Medicine, the nals of for Academic EmergencyMedicine. In addition, the abstracts of the Annual Meetingwere publishedin the April 1991issue of Annals of Emergency Medicine.

POSTER PHOTO SERVICE WeatherbyHealth Care is pleasedto announceits photoservice for poster presentations.Presentersinterestedin having a free photo take of their postershouldstopby the Weatherby Health Care exhibit to schedulean appointment.

rKENNEDYLECTURE

Robert G. Petersdorf. MD President Association of American Medical Colleges "The Place of Emergency Medicine in the Academic Community" Dr. Petersdorfis one of the best known physiciansin the world. His contributionsto academicmedicinehavebeenlegion.

His trainingand academicaffiliationshavebeenwith manyof the major educationalinstitutionsin this country. Following his medicalschooltraining at Yale University in 1952, he first trained at the Grace-New Haven Community Hospital. He becamethe Senior AssistantResidentin Internal Medicine at the PeterBent BrighamHospitalin 1954prior to beginninga ResearchFellowshipin InternalMedicine(InfectiousDiseases) at the JohnsHopkins llospital. Following his fellowship,he returnedas Chief Residentin InternalMedicinefor the University Serviceat Grace-NewHaven CommunityHospital.

R

Dr. Petersdorfhas servedas a medical schoolfaculty member for Yale University,JohnsHopkinsUniversity,the Universityof Washington,HarvardUniversity,the Universityof Californiaat San Diego, and (currently) GeorgetownUniversity. Of special note, he served as Chairman of the Department of Internal Medicine at the University of Washingtonfrom 1964-1979during which time he developedone of the strongestnational programs in his specialty.Many of his former faculty have become departmentalchairsand nationalfigures at other institutions.Dr. Petersdorfbecamehesident of the Brigham and Women's Hospital in Boston in 1979. This teaching hospital administrative role precededhis appointmentas Vice Chancellorfor Health Sciences and Dean of the Schoolof Medicine at the University of California at SanDiego from 198l-1986.At SanDiego he expandedupon his national educationalfocus and proposednew approachesto medical education and academic organization. Dr. Petersdorf subsequentlywas enlistedto serveas Presidentof the American Associationof Medical Collegesin 1986.

Dr. Petersdorfhas also servedon the Board of Governors of the American Board of Internal Medicine (Chair, 1976-1911), as Presidentof the American Collegeof Physicians,as Chairman of the Council of Academic Societiesfor the American

Associationof Medical Colleges,as Presidentof the Association of American Physicians,and in many other administrative postsfor theseand other organizations.Dr. Petersdorf'scontributionsto medicinehaveextendedbeyondhis administrative accomplishments.He has published over 400 articles and chaptersrelatedto bacterialinfections,the pathogenesis of infections, epidemiology, the organizationof academichealth centers,public policy, physicianmanpowerand other topics.

He hasbeenEditor-in-Chiefof I1arrison's Principlesof Internal Medicine and has servedon the editorial board of a large numberof medicaljournals. For theseextensivecontributions to academicmedicine,Dr. PetersdorfhasreceivedI I honorary degreesand l8 additional honors and awards.

At this time as we clinicians, educators,and researchersin academicemergencymedicine move toward integrationinto organized academia, the guidance of the President of the American Associationof Medical Collegesin extremelypertinent. The science,practice, and administrationof emergency careare beingpursuedin complextimes.Academicemergency physiciansmust provide care for an increasingnumber of indigentpatientswith complicatedhealthcare needswhich commonly are not being met elsewhere,either in the private setting or in the confinesof the teachinghospital.There is an increasedemphasison ambulatorypracticeand diagnosticsin the emergencydepartmentwhich placesincreasedemphasison the educationaland clinical role of the emergencyphysicianin the academicsetting.Dr. Petersdorfwill speakto how emergency medicine can contribute to academe and advance as a new academicspecialty.

The Society for Academic EmergencyMedicine is pleased to haveDr. Robert Petersdorfpresentthis yearsKennedyLecture. We are honored to receive his views and his vision.

SAEM gratefully acknowledgeMarion Merrell Dow, Inc.'s sponsorship of the Kennedy Lecture.

ACADEMTCLEADERSHIP AWARD Glenn Hamilton's Professional career has been marked bY disting u i s h e ds e r v i c ea n d i n n o v a t i v ceo n tributions to academic emergency medicine.After graduatingfrom the University of Michigan Medical School with distinction in 1973, Glenn completeda residencYin Internal Medicine at the University of Michigan. He then went on to do a residencyin EmergencyMedicineat Denver General Hospital and was GlennC. Hamilton, MD selectedthe outstanding seniorresident in 1979 in that Program.

Following completionof his training, Glenn embarkedon a careerin academicsas an assistantprofessorat the University of Cincinnati.In 1981,he becameChair of the Departmentof EmergencyMedicine at Wright State University in Dayton.

Glenn has contributedto many organizationsin emergencymedicine.,He was presidentof the Societyof Teachersof Emergency Medicine (STEM) in 1984-85and servedon the Board of Directors 1982-86.His influenceon STEM was widespread.He believed very stronglyin the needfor specificfacultydevelopmentactivities.

He nurturedfaculty developmentactivitiesat the annualmeeting and through many publications.He emphasizedthe need for incorporating sound educationalprinciples into the teaching of level. emergencymedicineat both the graduateand undergraduate curriculum of a defined importance the taught were Young faculty with objectivesand evaluationcriteria. He developeda library for faculty going into academicemergencymedicine.He chairedthe EducationalMethodologyGrant Review processwhich, through SAEM and EMF, provides funding for innovative projects in teaching.For the American College of EmergencyPhysicians, Glenn was Chair of the Gradmte/Undergraduateand AcademicAffairs Committees.In that capacity,he led the revisionof the Core ContentKnowledgeBaseand Skills List for residentsin emergency medicine.Glenn was on the Board of Directorsof the University Associationfor EmergencyMedicine and was very instrumental in the amalgamationcommitteewhich resultedin the merger of STEM and UAEM into the Societyfor AcademicEmergencyMedicine. He wrote about the needfor restructuringacademicorganiza' tions in emergencymedicineand was a major contributorto the as they are presentlystructured.He presentlyserves organizations of the Associationof AcademicChairs in as Secretary-Treasurer EmergencyMedicine(AACEM) and hasbeena major contributor to the developmentof that organization.

One of Dr. Hamilton's major contributions to academic emergencymedicinewas his recognitionof the importanceof Associationof American Medical Colleges(AAMC) and the Councilof AcademicSocieties(CAS) to emergencymedicine.

In 1984, Glenn became the representativeof emergency medicineto the AAMC and CAS. He worked hard, brought his innovativeideasand energiesto that position, and quickly becamea very respectedmemberof the CAS. Emergencymedicinehasa strongvoicein organizedacademicmedicinethrough the leadershipand efforts of Glenn Hamilton. For his work, he was namedto the AdministrativeBoard of the CAS and is now completing his fourth year on the policy-making CAS Board. ThroughGlenn'sleadershipand activities'emergency medicinehas developeda strong presenceat the AAMC. The (continued on next page)

HAL JAYNE ACADEMIC EXCELLENCE AWARD In tracking the career of John Marx is it easyto understandwhYhe was namedthis year's reciPientof the Hal JayneAcademicExcellence Award. After graduatingfrom the StanfordUniversityMedicalSchool, Johncompletedhis internshipin internalmedicineat the Universityof Massachusetts.He then enteredthe DenverGeneralHospitalEmergency Medicine ResidencyProgramunder ': i: Peter Rosen, where he served as John A. Marx, MD chief resident.Upon completionof his residency, John joined the himselfover theenDenverfacultywherehe hasdistinguished s u i n gl l y e a r s .

He has beenan integralpart of the Denver program having servedin severalcapacitiesincluding:researchcoordinator,both advisorand more internand studentcoordinator,faculty-student recently the assistantdirector of the department.Effective in Johnwill becomethe chairmanof the Department September, of EmergencyMedicineat the CarolinasMedical Center in Charlotte.North Carolina. contributionsto the advanceJohn has made immeasurable In his own areasof Medicine.

Emergency mentof researchin interest,abdominaltraumaand alcoholrelatedillnesses,he has publishedextensivelyand is recognizedwithin the collegeas an authority,particularlyin the areaof diagnosticperitoneal lavage.Perhapsevenmore significantis the influenceJohn has exertedas researchcoordinator.As such,he is the driving force thathasresultedin a steadyoutputoforiginal work by the resident staff in Denver.That work has not only beenpublished, thus adding to the body of knowledgethat is emergency at our nationalmeetings, medicine,but hasalsobeenpresented and sharingof ideasamong providinga stimulusfor discussions other institutions.The fact that John has chairedthe Colorado Committeesince1984,hasbeena memberof ACEP Research review boardof his institutionsince 1982, the investigational Committee,and hasservedas a memberof ACEP's Research has beenthe recipientof an extraordinarynumberof grants' asa researcher. of his capabilities all provideacknowledgment as Other scholarlypursuitsincludean extensiveexperience an editor. He has servedin this role for Emergindexand Case Stutliesin EmergencyMedicine, and has beena guesteditor for JAMA, Chest andthe AmericanJournal cf EmergencyMedicine.

He is also the ResearchSection Editor for the Journal of Emergency Medicine. John has authored numerous book chaptersand is one of the editors for the upcomingeditionof Rosen's EmergencyMedicine Textbook.

As a teacherJohn is no lessaccomplished.Whetherhe is giving a routine studentlectureor a presentationat the Scientific Assembly,he brings the sameenergyand effort to the podium.

His thorough preparation,extensiveknowledgeand senseof John informativeandentertaining. humor makehis presentations has been an invited speakerat multiple regionalconferences, has servedas a visiting professorat severalprogramsacross the country and has been a speakerat the ACEP Scientific (continuedon next puge)

Academic Leadership Award

Qoncluded)

Hal Jayne Academic Award

(concluded)

SAEM and the AACEM Boards meet regularly at the fall AAMC meeting. The SAEM AAMC Liaison Committee, chairedby Dr. Hamilton, coordinatesAAMC activities from all the emergencymedicineorganizationsincludingACEP, CORD, AACEM, and ABEM. Emergencymedicinesponsors at the Inand severalpresentations seminars,plenarysessions, novationsin MedicalEducationsession.Theseactivitieshave as immenselyhelpedemergencymedicineto gain acceptance an academicspecialtyin medicalschoolsthroughoutthe country.

Assemblyevery year since 1982.He hasalso moderatedpaper sessionsat the SAEM Annual Meetings.

On a more individualbasis,at the bedsideJohnis an outstanding teacher.His clinical acumencombinedwith his knowledge make for a thoroughdiscussionof differentialdiagnosiswhich is both exactingand informativefor his residents.The fact that he has been named the outstandingclincial teacher,3 of the last 4 years,by the graduatingresidentclass,further atteststo his teachingabilities.

Glenn'scareerhasbeenmarkedby severalawardsanddistinctions.In 1986,he wasthe recipientof the AcademicExcellence Award from STEM. Glenn was the first recipientof the EMRA TeachingExcellenceAward in 1985.Also prominentlylisted in his curriculumvitaeis the 1982STEM SilverTongucOrator Award and the 1983UAEM Imago ObscuraAward.

Despiteall ofthe accoladesthat havebeenlisted,perhapsthe mostcompellingreasonwhy Dr. Marx deservesthis awardis the mannerin which he combineshis talentswith a charismatic personalitythat translatesinto an ideal role model for academic emergencyphysicians.Residentsquickly appreciatethe extra high cffort thathe putsforth to maintainan uncompromisingly standardfor clinicalandacademicexcellence.The fact thatJohn can accomplishthis and still maintaina warm and friendly relationshipwith his residentsmakeshim all the more successful.

Dr. Harr.rilton hascontinuedto apply his innovativeideasttl academics. He has recently edited a textbook, Emergency' Merlicine:An Approachto Clinical ProblemSolving,which atand decisionpointsfor temptsto capturethe thinking processes miiking clinical decisions.He is developinginteractivevideo disk teachingaids and has receivedlarge grant supportfrom the NationalAeronauticsand SpaceAdministrationfbr research proJects. by his peersat Wright Dr. Hanriltonis very highly respected StateUnivcrsity.As Chair of the Departmentof Emergency Medicinehe hasbuilt the programinto oneof the bestgraduate teachingprogramsin the country.In 1986, and undergraduate Award fbr outhe was awardedthe Wright StatePresidential standingachievementin research,service,and teaching.In chairof theSchoolof Medicine'sDean's 1987,he wasappointed SelectionCommittee.In 1989,he was the invitedcommencement speakerat the graduationcercmoniesfor the medical schoolclass.

A good exampleof John'sacademiccharacteris the way in which he hashandledthe studentcoordinatorpositionover the past ll years.He has takena mundanejob and by investing his time and efTortturnedit into a very positivepersonalized experiencefbr eachstudent.The impactthis hashad on these future physiciansand how they view emergencymedicineis immeasurable.How many of them have chosenemergency medicineas their specialtyas a resultof this experienceis difficult to know, but certainlymany have.

To sum up, John Marx exemplifieswhat an academic speakfor emergencyphysicianshouldhe; his accomplishments themselveswhile his dedicationand personalityresultin emulation by students,residqntsand peersalike.

Rtberr Jorden, MD

Dr. Hamilton is a true leader in academicemergency as a scholarandacademic rnedicine.His energyandenthusiasm leader have motivated many academiciansin emergcncy have medicine.Dr. Hamilton's ideas and accomplishments helpedshapethe practiceof academicemergencymedicine.

Arthur B. Sanders,MD

EMRS BEST PAPBR AWARD

Paul Martin, MD

SAEM and the EmergencyMedicineResearchSociety(EMRS) of the United Kingdom work closely togetherand haveestablished a traditionof sendingoneof their paperawardwinnersto the otherorganiza"A Study tion's Annual Meeting.This year, SAEM is pleasedto welcomeDr. Paul Martin whosepaper, to Determinethe MaximumTolerableDeadSpacefor the Designof ProtectiveSmokehoods,"was selected as the EMRS BestPaperlastfall during the EMRS/SAEM CombinedMeetingin Edinburgh.After graduating trainingin Emergency from the Universityof ManchesterMedicalSchool,Dr. Martin undertookpostgraduate Invernessand Aberdeen.His work Medicine,Anaesthesiology, and CriticalCareMedicinein Manchester, on dead spaceis part of a project undertakenas a researchfellow in Applied Physiologyat the University Medicine.He has now returnedto clinical of Aberdeen'sDepartmentof Environmentaland Occupational and IntensiveCare. Dr. Martin will dutiesin AberdeenRoyal Infirmary's Departmentsof Anaesthetics presenthis paperto the SAEM membershipon Tuesday,May 14as thefinal paperin the RespiratoryEmergencies sessionwhich will be held from 9:30 to 10:45am.

Award winner who will attendthe EMRS SAEM will selecta 1991BestResident/FellowOral Presentation Annual Meeting in Chesteron October 11-12, 1991.

AWARD PRESENTATIONS The Academic Leadershipand the Hal Jayne Academic ExcellenceAwards will be presentedduring the Annual BusinessMeeting on May 14. The following awards will also be awarded during the Annual BusinessMeeting: 199L Physio Control EMS Fellowship

1990 Annual Meeting Paper Award Winners

Ronald Pirrallo, MD Institution: William BeaumontHospital This $50,000 fellowship is sponsoredby Physio Control.

Best Oral Basic Science Presentation "Effects of Chemical Interventionsof FunctionalRecovery Following Closed Head Trauma," Michelle Biros, MD, HennepinCounty Medical Center

1991 SAEM/EMF Medical Student Research Grants Recipient:Kenneth Buccino Preceptor:RebeccaSmith-Coggins,MD Institution: Stanford University Project: Rotating Shiftwork Schedules:Effects on Sleep, Performance, Mood and Quality of Life of Emergency Department Attending Physicians.

Recipient: Robert Gerhardt Preceptors:Richard Furlong, MD, and Kathleen Schrank, MD Institution: University of Miami Project: Evaluationof the Efficacy of IntravenousAdenosinefor the Terminationof ParoxysmalSupraventricularTachycardia(PSVT) in the PrehospitalEnvironment Recipient:Jose R. Santana Preceptor:Ricardo Martinez, MD Institution: Stanford University Project: Injury Patternsand Modifiers in Frontal and Lateral Motor Vehicle Collisions (MVC); RelationshipBetween Point of Sale and of Consumptionof Alcohol and MVC; Accuracyof EmergencyPhysician Data Collection Recipient: Daniel Warner Preceptor:Thomas Terndrup, MD Institution: State University of New York, Syracuse Project: Initial Infant Ventilation and Oxygenationby Basic Emerency Medical Technicians 199f SAEM/EMF Educational Methodology Grants "The Use of Videotapeto Teach ResidentsAbout Death Telling in " Casesof SuddenUnexpectedDeath, RobertJ. Schwartz,MD, Hartford Hospital "Proposals for A Computer Aided Course in QuantitativeMethods for Emergency Medicine Residents," Stephen Pitts, MD, Emory University "A Core Curriculum Model for Instructionof EmergencyMedicine Residentsin Ultrasound," Michael B. Heller, MD, Universityof Pittsburgh "Can the Basic Preceptsof Trauma ManagementBe Learned with Computer Assisted Instruction," Rita Cydulka, MD, MetroHealth Medical Center "Use InteractiveProgramsto EnhanceMedical of Computer-Assisted StudentEducationDuring a RequiredEmerencyMedicine Rotation," Dan Mayer, MD, Albany Medical College "Factors Influencing Career Choices in Academic Emergency Medicine," Arthur B. Sanders,MD, University of Arizona

Best Oral Clinical Science Presentation "Injury SeverityAmong Helmetedand Non-HelmetedBicyclistsInvolvedin Collisionswith Motor Vehicles," DanielSpaite,MD, University of Arizona Best Scientific Poster "Use of HypertonicSaline/DextranVersus LaceratedRinger'sSolution as a ResuscitationFluid Following UncontrolledAortic Hemorrhagein Anesthetized Swine," William Bickell, MD, LettermanArmy Institute Best Oral Methodology Presentation "The Useof An Artificial NeuralNetwork for Decision-MakingUnder Uncertainty: The Diagnosisof Myocardial Infarction," William G. Baxt, MD, Universityof California,San Diego Best Oral Resident/Fellow Presentation "The Effect of pH on the Changein Coronary PerfusionPressureAfter EpinephrineDuring CPR in Humans," Norman Paradis,MD, Henry Ford Hospital Best Resident Poster "Recurrent HypoglycemiaAfter D50 Administration," JudithJ. Dennis.MD. Mt. Sinai Medical Center Best Pediatric Acute Care and Trauma Presentation "Validity of a DisposableEnd-Tidal CO2 Detector in Verifying En' dotrachealTube Positionin InfantsandChildren," ManandaS. Bhende,

MD, University of Pittsburgh BestResidentPaper "Comparison of StandardExternal CPR, Open-ChestCPR, andCardiopulmonaryBypassin a CanineMyocardialInfarct Model," Dani J. DeBehnke,MD, Wright State University Selected to be Presented At the AAMC Annual Meeting "Faculty Attrition Among Three Specialties," Harold Thomas, MD, Wake Forest University "Academic EmergencyMedicine: A National Profile With and EmergencyMedicine ResidencyPrograms," StevenM. Chernow, University of Colorado

SCHEDULE OF EVENTS SATURDAY, MAY 11 8:00am-5:00pm

CPC Competition Western Region, ConstitutionC Eastern Region, ConstitutionD Central Region, ConstitutionE

pm 12:00noon-7:00

SAEM Registration, outsideConstitutionBallroom

l:00-4:00pm

Annals Editorial Board Meeting, BurnhamRoom

SUNDAY, MAY 12 8:00-10:30 am

EMRA Board of Directors Meeting, LatobeRoom

a5 m 8:15-10:1

A Scientific Papers:Plenary Session,Independence Moderator: Michael Callaham, MD, University of Califurnia, San Francisco

1 0 : 1 5 - 1 0 :a 3m 0

Coffee Break

10:30-12:00 noon

A Scientific Papers:Prehospital/EMS,Independence Moderator: Daniel Spaite, MD, University of Arizona

10:30-12:p 3m 0

"SelectedTopics in

Rooms the StatisticalDesign and Analysis of ResearchStudies," Fatagut/Iafayette

Roger lzwis, MD, PhD, Harbor-UCl,A, and Robert Wears, MD, Univbrsity of Florida, Jacksonville

1 2 : 0 0 - 1 : 3p0m

UndergraduateEducatorsLuncheon: "Problem-BasedLearning in UndergraduateEducation" (preRooms registration required), Wilson/Cabinjohn /Arlington/Roosevelt Harold Paul, MD, Director, Alternative Curriculum, Rush Medical Center

pm l:30-3:00

A Scientific Papers: Trauma, Independence Moderator: John Marx, MD, Denver General Hospital

l:30-5:00pm

"Improving

F, G Your Skills as a Lecturer" (limited to 50 participants),Independence

Barbara F. Sharf, PhD, Department of Medical Education, University of lllinois

1 : 3 0 - 5 : 3p0m

Grant Writing Workshop, "Proposals to Private Foundationsand GovernmentAgencies" (limited to 50 participants), Independence H, I Liane Reif-Lehrer, PhD, President, Tech-Write Consultants/Erimon Associates

3 : 0 0 - 3 : 1p5m

Coffee Break

3 : 1 5 - 5 : 0p0m

Scientific Papers:Infectious Disease,Independence A Moderator: David Talan. MD. Olive View/UCLA

3 : 1 5 - 5 : 3p0m

"Improving Your Skills as a Lecturer" continues Grant Writing Workshop continues

pm 6:30-8:00

Opening Reception, Independence A

MONDAY. MAY 13 7:00 am-5:00pm Registration, ConstitutionBallroom 9:00 am-5:00pm Exhibits Open, ConstitutionBallroom 8:00-10:00 am

"Federal State-of-the-Art Session, Support for Research in Treatment and Prevention of Medical and Traumatic Emergencies," Independence A Elinor llalker, Agencyfor Health Care Policy and Research;RemyArnoff, Division of Organ Transplantation; John Chew,Departmentof Transportation; David Heppel,Maternaland Child HealthBoard; and BonnieSingal,MD, WrightStateUniversity

10:00-10:30 am

Coffee Break. ConstitutionBallroom

10:30-12:00 noon Scientific Papers: CPR, Independence A Moderator:JamesT. Niemann,MD, Harbor/UCl-A Scientific Papers: Public Health/Health Care Delivery, Independence B, C, D, E Moderator:EdwardBernstein,MD, BostonCiry Hospital "Resident Selection" Panel, Independence H, I RichardAghababian,MD; MarcusMartin, MD; Ken Iserson,MD; Dan Tandberg,MD and David Sklar, MD.

l2:00-l:30pm

Luncheon Debate: "Emergency Department Observation Beds Improve Patient Care" (preregistration

required),

Arlington/Cabinjohn Rooms

I'es Zun, MD; Jerrold Leikin, MD; ktuis Graff, MD; Michael Weinstock, MD; Brian Gibler, MD; James Mathews, MD; and Georges Benjamin, MD

Luncheon: "Geriatric Emergency Care" (pre-registration required), witson/Roosevelt Rooms Art Sanders,MD; Bonita Singal,MD; RobertMcNamara,MD; Gary Strange,MD; Jeff Jones,MD; and larry Baraff, MD. EMRA/SAEM Resident Research Forum and Lunch, "Opportunities and Pitfalls in Academic and Community Research" (pre-registration required), Fanagut/l,afayetteRooms William Spivey,MD, Medical Collegeof Pennsylvania

1:30-3:00 pm

Scientific Papers: Clinical Practice, Independence A Moderator:E. JacksonAllison, MD, East Carolina University Scientific Papers: Radiology/Imaging, Independence B, C, D, E Moderator:Philip Henneman,MD, Harbor/UCl,A "Ethical Issues in Emergency Medicine Research" Panel, Independence G, H, I Michael Callaham,MD; Jerris Hedges,MD; KennethIserson,MD; JamesScon,MD; and Mark Smith,MD "Primer

l:30-5:00pm

of Research Methods for Emergency Medicine," Independence F RaywinHuang, PhD, Detoit ReceivingHospital "The Use of Standardized Patients: A 'Hands-On' Approach" (limited to 50 participants), Kalaroma/McPhersonRooms Paula Stillman,MD, CurriculumDean, Universityof Massachusetts

pm 3:00-3:30

Coffee Break, ConstitutionBallroom

pm 3:30-5:00

Scientific Papers: Environmental Emergencies, Independence A Moderator:Paul Auerbach,MD, Vanderbib[Jniversity Scientific Papers: Pediatrics, Independence B, C, D, E Moderator:lnuis Binder, MD, TexasTechUniversiv "Primer of Research Methods" continues "IJse of Standardized Patients ." continues

6:00-9:00pm

Council of Emergency Medicine Residency Directors Meeting, witson/Cabinjohn/Arlington/Roosevelt Rooms

TUESDAY, MAY 14 7:00 am-5:00pm Registration, ConstitutionBallroom 9:00 am-5:00pm Exhibits Open, ConstitutionBallroom 8:00-9:00am

"The Place of Emergency Medicine in the Academic Community" Kennedy Lecture: RobertPetersdorf,MD, President,Associationof AmericanMedical Colleges

am 9:00-9:30

Coffee Break, ConstitutionBallroom

am 9:30-10:45

A Scientific Papers: Respiratory Emergencies, Independence Hospital MD, Henry Ford Nowak, Moderator:Richard B, C, D, E Scientific Papers: Ischemia/Reperfusion, Independence Moderator:MichelleBiros, MD, HennepinCountyMedical Center

" Rooms Bulffinch/Renwick noon "Preparing for an RRC Site Visit, 9:30-12:00 GlennaCase,PhD, ExecutiveSecretary,RRC-EMand I'ttuis Ling, MD, Chairman,RRC-EM 'Hands-On' Approach" repeat (limited to 50 participants), "The Use of Standardized Patients: A Burnham/IntrobeRooms

noon AssoCiationof Academic Chairs Annual Meeting, 10:00-12:00

"should

the NIH Have a Study Sectionon Emergency

"

Arlington/CabinjohnRooms Medicine, ThomasMalone,MD, BiomedicalResearch,AAMC

1 0 : 4 5 - 1 1 :a 0m 0

Coffee Break" ConstitutionBallroom

A 1 1 : 0 0 - 1 2 :n 0o 0 o n Scientific Papers: Geriatric Emergency Care, Independence Moderator:Arthur Sanders,MD, Universityof Arizona B, C, D, E Scientific Papers: Cardiology, Independence Moderator:Mark Smith,MD, GeorgeWashingtonUniversity "Preparing for an RRC Site Visit" continues "Use ." continues of Standardized Patients

l 2 : 0 0 - 1 : 3p0m

"Interacting With Your Institutional Review Board: Advice from ExResearch Directors Luncheon, F, G perts" (pre-registration required), Independence Paul Goebel,Centerfor Drug Evaluationand Research,Foodand Drug Administration;CharlesMacKay,Officeof Medical of Health;andJffiey Runge,MD, InstitutiornlReviewBoard,Carolinas NationalInstitutes ExtramuralResearch, Center

pm l:30-3:00

SAEM Annual Business Meeting: Elections and Awards Presentations,

l:30-5:00pm

H, I EMRA/SAEM Chief Residents Program, Independence Neal Whitman,MPA, EdD, Universityof Utah

3 : 0 0 - 3 : 1p5m

Break

3 : 1 5 - 5 : 0p0m

Ballroom Poster Session A and Innovations in Emergency Medicine Education Exhibits, Constitution

6:00-7:00pm

Rooms EMRAI Emergency Medicine Reception, Wilson/Cabinjohn/Arlington/Rooseveh

pm 7:00-10:00

BoardRoom SAEM Board of Directors Meeting, Washington

WEDNESDAY,MAY 15 8:00am-3:00pm

Registration

8:00-9:30 am

Scientific Papers:Pediatrics,Independence A Moderator: Gary Fleisher, MD, Children's Hospital, Boston Scientific

Papers: Toxicology, IndependanceB, C, D, E Moderator: Edward P. Krenzelok, Pharm. D, Pittsburgh Poison Center

"Providing

Feedbackfor Learnersin the EmergencyDepartment" (limited to 50 participants), Conference Theatre Jack Ende, MD, Associate Professor of Medicine, IJniversity of Pennsylvanta

"Physician

Wellness: Adapting to the EmergencyPhysicianLifestyle to 50 participants),Independence H, I

Part I" (limited

Marty Klein, PhD, Founder and Clinical Director, The Grear Plains Sleep Physiology Center

9:30-10:0a 0m

Coffee Break

l 0 : 0 0 - ll : 3 0 a m

Scientific Papers:Injury Prevention,Independence A Moderator: Arthur Kellermann, MD, University of Tennessee

Scientific Papers:Ischemia/Reperfusion, Independence B, C, D, E Moderator: Blaine Wite, MD, Wayne State University

"Physician

Wellness: Adapting to the EmergencyPhysicianLifestyle - Part II" (limited to 50 participants),Independence H, I "Providing Feedbackfor Learnersin the EmergencyDepartment" repeat(limited to 50 participants), Conference Theatre I l : 0 0 a m - l : 0 0p m

EMRA RepresentativeCouncil Meeting/Luncheon,

I l : 3 0 a m - l : 0 0p m

Luncheon: "The PotentialRole of EmergencyMedicine in Injury control" (preregistrationrequired), Consritution C, D Mark Rosenberg, MD, Director, Division of Injury, Centerfor Environmental Health and Injury CDC

Luncheon: "Subspecializationin EmergencyMedicine" (pre-registrationrequired),1n- .i dependenceF. G Roger Barkin, MD; odelia Braun, MD; Philip Henneman, MD; Bruce Janiak, MD; Marty smilkstein.

MD; and Douglas Rund, MD

1:00-3:00 pm

Scientific

Papers: Shock, IndependenceA Moderator: StevenDronen, MD, lJniversity of Cincinnati

Scientific

Papers: Clinical Practice, IndependenceB, C, D, E Moderator: J. Douglas Wite, MD, Georgetown University "Tenure and Academic Freedom" Panel, IndependenceH. I Janet Bickell, Senior Staff Associate, Association of American Medical Colleges; Neal Flomenbaum, Associate Professor of Clinical Medicine, State University of New York at Brooklyn; Jordan Kurland, PhD, Associate General Secretary, American Association of lJniversity Professors; Jeanne Walther, Director of Faculty Affairs and Affiliations, Georgetown University; and Arthur Sanders, MD, of Emergency Medicine, University of Arizona

3 : 0 0 - 3 : 1p5m

Coffee Break

3 : 1 5 - 5 : 0p0m

Poster SessionB, Constitution A, B "Synopsis for Faculty: American Board of EmergencyMedicine," Independence F, G Bruce Janiak, MD, ABEM President; and Benson Munger, phD, ABEM Executive Director

Busesleaveat 5:30 pm

SAEM

Annual

Banquet,

Car Barn in Georgetown

10

PAPER SESSIONS MAY 12 ScientificPapers:PlenarySession(8:15-10:15am)

1 3 .Effect on Mortality and Length of Stay of Prehospital Medica-

l. IncreasedHealth Care CostsAssociatedwith EmergencyDepartment Overcrowding, Paul Krochmnl, MD, Hospital of Saint Raphael

1 4 . Comparison of Aeromedical Crew Performance by Severity Scor-

tions, Richard C. Wuerz, MD, Pennsylvania State University ing and Outcome, Richard E. Burney, MD, University of Michigan

z . Homelessness and EmergencyMedical Services:A Studyof Clinical, Economic, and Systems Operations Factors, Charles E. Saunders, MD, University of Califurnia, San Francisco

ScientificPapers:Trauma (L:30-3:00pm)

PatientsWho Leave the Emergency Department, Without Medical Evaluation: Severity of Illness and Need for Acute Care, Carl D. Stevens.MD, Harbor-UCLA

21. Magnetic ResonanceImagining in Minor Headlnjury, David Doezem.a,MD, University of New Mexico

4 . Cost Implications of DelayedAccessto Care in PatientsAdmitted

22. lntracranid, HemorrhageFollowing Minor Head Trauma, M. Andrew Levitt, DO, Highland General Hospital

J.

Through the EmergencyDepartment,GreggA. Pane, MD, MPA, University of Califurnia, Inine

23. Cervical Spine Movement During Airway Management: Cinefluoroscopic Appraisal in Human Cadavers, Mark Hauswald, MD, University of New Mexico

5 . IntravenousAdenosinein the PrehospitalTreatmentof Supraventricular Tachycardia, James L. McCabe, MD, University of Pitrsburgh

24. Emergency Department Echocardiography Improves Outcome of PenetratingCardiac lnjvy, David Plummer, MD, Hennepin County Medical Center

An Evaluationof the Use of Prophylactic, Antibiotics in the Management of Oral Lacerations, Ronald S. Benenson, MD, York Hospital

25. Monitored Bed Admission to Rule Out Myocardial Contusion May Be Unnecessary,Edson G. Brock, MD, Orlando Regional Medical Center

7 . The Efficacy of Non-InvasiveIn-Hospitaland OutpatientManagementof Febrile Infants: A Four-Year Experience,M. Douglas Baker, MD, Children's Hospital of Phil"adelphia

26. A ProspectiveStudy of Complications AssociatedWith the Use of Abdominal CT Scanning in Trauma Patients, James Vayda, MD, University of Arizona

PossibleConfounding Effect of Minute Ventilation on ETC02 in Cardiac Arrest, Christopher W. Barton, MD, University of Califurnia, San Francisco

Scientific noon)

ScientilicPapers:InfectiousDisease(3:15-5:ffipm)

Prehospital/EMs(10:30-12:00

27 . E,mpiricAntibiotic Treatmentof Acute Infectious Dianhea, M.L. Neighbor, MD, University of Califurnia, San Francisco 28. Interleukin-6 Determination in Emergency Department Patients as a Predictor of Bacteremia and Infectious Disease Severity, Harry Moscovitz, MD, University of Pennsylvania

9 . Non Transport of PrehospitalPatients:Is Stronger Medical Control Needed?, W. John Tzhner, Jr, MD, Medical College of Pennsylvania

29. A ProspectiveEvaluation of Topical Antibiotics for Uncomplicated.SoftTissueLacerations.Daniel J. Dire, MD, Darnall Armv Community Hospital

Computer-Aided EMS Priority Dispatch: Ability of A Computerized Triage Systemto Safely SpareParamedicsFrom Responses Not Requiring Advanced Life Support, Peter A. Curka, DO, Baylor College of Medicine

30. Respiratory Compromise in Adult Measles Patients, Philip L. Henneman. MD. Harbor-UCl,A

The Effect of EMT-Defibrillation on Time to TherapeuticInterventions During Cardiac Arrest, James W. Hoekstra, MD, Ohio State University

31. Prevalenceof PositiveAsymptomaticSyphilis Titers (HATTS) During Pelvic Exams in the Inner City Emergency Department, Patrick M. O'Brien, MD, UMDNJ/Roben Wood Johnson

Predictionof Outcomeof Ventricular Fibrillation Waveform and Need for Prompt ALS Responsein PatientsDefibrillated by First Responders,Odelia Braun, MD, University of Califurnia, San Francisco

32. Antibiotic Delays in the BacteremicPatient:An Analysisof Emergency Department Healttr Care Delivery, Maj Eisinger, MD, Universiry of Pennsylvania

MAY 13 Scientific JJ.

)+-

CPR (10:30-12:00 noon)

From Cardiac Arrest, G. ScottMeyer, MD, Henry Ford Hospital Adrenal Insufficiency During and After Human Cardiac Arrest, Carol H. Schuhz, MD, Henry Ford Hospital

Correlationof End-Tidal CO2 to CerebralPerfusionDurins CPR. lnwrence M. Lewis, MD, St. lnuis University

3 7 . Correlation of Blood PressureWith Mortality and Neurologic

Mixed Venous Oxygen SaturationMonitoring as an Indicator of Return of SpontaneousCirculation During Human CPR, Emanuel P. Rivers, MD, Henry Ford Hospital

Recoveryin ComatosePost ResuscitationPatients,William H. Spivey, MD, Medical College of Pennsylvania Effect of tV Glucoseon Suwival ard Neurologic OutcomeFollowing Cardiac Anest, Melissa M. Nielsen, BS, University of Cincirvrati

3 5 . Circulatins Tumor Necrosis Factor in Humans After Resuscitation ll

ScientificPapers:Public Health/HealthCare Delivery (10:30-12:00 noon)

5 3 . Comparisonof PhysicianJudgmentand DecisionAids for Ordering Chest Radiographsfor Pneumonia,Charles L. Emerman, MD, Case Western Universiry

39. Emergency Department-Based Home Care, Daniel Brookoff, MD, PhD, University of Pennsylvania

<A

40. HospitalAdmissionsof Children From the EmergencyDepartment: Are DecisionsRegardingChildren on Public Assistance Different? Marina B. Molinari, Case WesternReserveUniversity

A Studyto Developa Clinical Decision Rule for the Use of Radiography in Acute Ankle Injuries, Ian G. Stiell, MD, University of Ottawa

5 5 . RetrospectiveEvaluationof the Role of X-Rays in the Diagnosis and Managementof GlenohumeralDislocations,Gary M. Gaddis, MD, PhD, University of Missouri-Kansas City

41. The Relationshipof Day Versus Night Sleepto PhysicianPerformance and Mood, Rebecca Smith-Coggins, MD, Stanford University

ScientificPapers:EnvironmentalEmergencies (3:30-5:00pm)

42. EducationalIntervention IncreasesDocumentationof Requestfor Organ and TissueDonationand RecoveryFrom the Emergency Department, Richard R. Riker, MD, Maine Medical Center

56. High-Flow PeritonealLavage in an Animal Model of Extreme Hypothermia, Scon C. Westenberg,MD, Methodist Hospitalof Indiema

43. Misdiagnosisof Acute Appendicitis in EmergencyDeparment Patients: An Analysis of Common Errors Discovered After Litigation, Robert A. Rusnak, MD, Hennepin County Medical Center

57. Transcutaneous Pacing in a Hypothermic DogModel, Donald Lombino, MD, Nonheastern Ohio Universities

44. Hospital EmergencyDepartmentComplaint Frequency:Variation by PatientMedian HouseholdIncome, Blaine J. Dennis, MD, William Beaumont Hospital

58. Dapsoneor Electric Shock Therapy of Brown RecluseSpider Envenomation, StevenM. Barrett, MD, University of Oklahoma 59. The Effect of ConstrictionBandson Rattlesnake Venom Absomtion: A PharmacokineticStudy,JeffereyL. Burgess,MD, IJnivusity of Arizona

ScientificPapers:ClinicalPractice(1:30-3:00pm) 45. A Comparisonof Three AntiemeticsUsed in the Treatmentof Motion Sickness,ThomasA. DiGiovanna, MD, Johns Hopkins University

60. Evaluationand Treatmentof Local Reactionsfrom Hymenoptera

46. The Efficacy of Metoclopramidein the Treatmentof Migraine Headache,George L. Ellis, MD, Universiryof pittsburgh

6 1 .EmergencyPhysicianReferralfor Venom Immunotherapy of Pa-

Stings: A Preliminary Study, Brett D. Bender, MD, Akron City Hospital tientswith Hymenoptera Stings:A DecisionAnalysis,LouisG. Graff, MD, University of Connecticur

47. Effectivenessand Safety of IntravenousNalmefenefor Emergency DepartmentPatientswith SuspectedNarcotic Overdose, Justin Kaplan, MD, Temple University

ScientificPapers:Pediatrics(3:00-5:00pm)

48. Comparisonof Intermittentand ContinuouslyNebulizedAlbuterol for Treatmentof Asthma in an Urban Emerqencv Center.Gail Rudnitsky. MD, Medicat College of pennsflvan'ia

15. PediatricBacterialMeningitis:Is PreliminaryAntibioticTherapy Associatedwith an Altered, Clinical Presentation'J, StevenG, Rothrock, MD, Inma Linda University

49. Usefulnessof Empiric ChestRadiographyand UrinalysisTesting in Adults with Acute SickleCell PainCrises,CharlesV. pollack, Jr, MD, University of Mississippi

16. Screeningfor CocaineIntoxicationin ChildrenWith Unexpected Seizuresin the EmergencyDepartment,Richard D. Marble, MD, Case WesternReserve University

50. High-Yield Criteria Have PredictiveValue for Hypomagnesemia in EmergencyDepartmentPatients,David S. Groopman,MD, Universiry of Virginia

17. High Prevalence of LaboratoryAbnormalitiesin ChildrenWith Clinical Dehydration, Mananda S. Bhende, MD, Chitdren's Hospital of Pirrsburgh 18. AerosolizedMagnesiumSulfateas Acute Therapyfor pediatric Asthmp, Mark C. Clark, MD, Orlando Regional Medical Center

ScientfficPapers:Radiologr'/Imaging(1:30-3:ffi pm) 51. Quality Assurancein Triage Nurse RadiographOrdering, C.t.

McArthur, III, MD, Riverside General Hospital

19. The Inaccuracyof Infrared Tympanic MembraneTemperatures in Young Children, Michael Donato, DO, Universityof South Carolina

52. Correlation of Neurological Examination and Magnetic Resonance Imaging in Acute Cervical SpinalColumn lnjury, M. Andrew Levitt, DO, Highland General Hospital

20. PediatricOut-of-HospitalCardiopulmonaryArrest: prognosticatorsof Ultimate Outcome,John H. Simmons,DO, BrookeArmy Medical Center.

MAY 14 ScientificPapers:RespiratoryEmergencies (9:30-10:45 am)

64.Impactof EmergencyDepartmentObservationUnit on Asthma Admissions, Judith C. Brillman, MD, University of New Mexico

62. The Role of Magnesiumas a CalciumAntagonistin RabbitBronchial Smooth Muscle, Emil Skobeloff, MD, Medicat Coltege of Pennsylvania

65' PotassiumLowering Effects of Beta-agonists in Asthma/COpD Patients, John Manning, MD, Inuisiana State university

63. The Efficacy of MagnesiumSulfate in the Initial Treatmentof SevereAsthma, Brian A. Nester, DO, Albert EinsteinMedical Center

190. A Study to Determinethe Maximum TolerableDead Spacefor the Design of Protective Smokehoods,Paul D. Martin, MD, Aberdeen Royal Infirmary, Scotland

I2

t

c%-7q ScientificPapers:Ischemia/Reperfusion (9:30-10:45 am) 66. Reductionof InfarctSizeDuring MyocardialIschemiaandReperfusionby Lazaroid,A Novel 2l-Aminosteriod,M. ArulrewLevitt, DO, University of California, San Francisco 67. Enhancement and Preservation of MitochondrialFunctionDuring ProlongedCardiac Arrest and CPR, Charles B. Cairns, MD, Harbor-UCI-4 68. Brain MitochondrialDNA After CardiacArrest and Resuscitation, Blaine C. Iilhite, MD, lYayne State Univt'rsiry 69. Initial Studiesof ProteinSynthesis

by PurifiedRibosomes Afier CardiacArrest and Resuscitation,Brian J. O'Neil, MD, Wavne State University 70. Synaptosome and PolysomeProteinPeroxidalionin the PostIschernicBrain, Gary S. Kruuse, MD, WayneState Universitt,

Scientific Papers: Geriatric Emergency Care (11:00-12:00noon) 71. Clinical Patternof FatalFalls,JeffrcyHutunontl, MD, UMDNJRobert Wood Johnson '1.

72. UsingParamedics to IdentifyArRisk Elderly,Dunicl Schelble, MD, NortheasternOhio Univarsitias 73. Predictionof Resistent UTI's in the GeriatricPooulation. ./a.rorr D. Eiband, MD, Mt. Sinui, Clevelarul 74. Diagnosisand Treatmentof PulmonaryErrbolism in the Elclerly, D. Plowmut, MD, Mi<hican Statc Universitl'

ScientificPapers:Cardiology (11:00-12:00noon) 75. Do SerialEmergencyDepartmentECG's ProvicleUselulInlbrmationin ChestPainPatients'J, Gury Young,MD, OrcgonHutlth Scien<'esUniversitl 76. How Well Do EmergencyPhysiciansInterpretElectrocardiograms'/, Mit'hael J. Zappa, MD, University ofFlorida, Ja<'ksottville 77. The Use of an Artificial Neural Network For the Diagnosisol' MyocardialInt'arction:Phase| - ProspcctiveValidation,Williun G. Bcrt, MD, University ol'Calilornia, San Dicgo (CK-MB) and MyoglobinAssays 78. SerialCreatinePhosphokinase in the EmergencyDepartmentEvaluationof PatientsWith Possible Myocardial Infarction, Murk Hostetler, MD, Saint Frunt'is Medical Center

PosterSessionA (3:15-5:00pm) Topics in Academe 79. Academic Emergency Medicine in U.S. Medical Schools.

Alexander Trott, MD, University of Cincinnutr

/t {/

l

21 {

T

84. Impact of an EmergencyMedicine ResidencyProgram on the Quality of Care in an Urban CommunityHospitalEmergency Department, Robert M. McNamara, MD, Medical College of Pennsylvonia Public Health/Health Care Delivery 8-5.The EmergencyDepartmentCare of the SpanishSpeakingPatient; K. Rosen,MD, George WashingtonUniversity in the 86. The Use of a Bilingual Medical History Questionnaire EmergencyRoom, Isanr Nasr, MD, Universitv-of Illirutis 87. Ability to UnderstandWritten DischargeInstructionsas a Ref'lection.of.the Levcl of Literacy Anrong EmergencyDepartnrentPatients, B. Tilmun Jolll', MD, Gertrge WashingtonUniversitt' Patients on HumanResource Utiliza88. The Effecto1-HIVInf'ected tion in the EmergencyDepartnrent: A Time-and-Motion Study, Gar.,-B. Green, MD, Johns Htpkins Universitt' 89. PositivcEffectof an EducationalInterventionon Complianccwith UniversalPrecautionsin a PcdiatricEmcrgencyDepartment, Lconurtl R. Friedlantl, MD, St. Christopher'.sHospiral fbr Child ren 90. The Eff icacy o1'anACLS Training Programon Resuscitation Frour,CardiacArrest in a Rural ConrrrunityHospital,knald T. Gt'novu, MD, Univarsitt'ol Ari:.ortu Clinical Practice 91. MilwaukeePrehospital ChestPainPro.lect PhascI: Feasibility ThronrbolyticCandidate and Accuracyo1'Prehospital Selection.

Tom P. Au.filarhcidc,MD, Madicul Colla,gcoJ Wiston.sirt 92. Thc El'l'ecto1'anE,nrergency DepartmentInitiatedTrcatnrentProtocolon the Timing ol'ThrombolyticTherapyin MyocardialInfarctions. Edwurd A. Punacek, MD, Univcr.sitl Hospitul.ttf' Clcvclantl 93. Bradycardic Responses BedsidcManeuvers to VagallyMcdiatecl in Healthy Volunleers, Williun A. Bark, MD, Wut'ncStotaUrtiversily 94. EarlyWoundTcnsilcStrengthEnhanccr.ncnt With PluronicF-68, Puul Puustiun, MD, Mt'dical Collcgc ol Ca,,rgitt 95. Thc ShorthandVertical MattrcssStitch: Evaluationol a New SutureTechnique, S. Par'ft, MD, Michigun Stuta Uniy,cr.sitt' 96. Efltct of Body Localeand Additionol'Epincphrine on thc Duralion of Action of a Local AncstheticAgcnt, Kclr Todd,PA C, W(t.\ n(' Stut( Un i vcrsit t' 97. Reliabilityol'theGlasgowCorla Scaleandthe Neurobehavioral AssessnrentScale, Janas J. Manega:.2.i , PhD, Universitt' ol Pittsburph 98. Delaysin Presentation in PatientsWith Acute Stroke:Factors Affecting Early Hospital Arrival. Williatn G. Borsun, MD, Uttivt'rtit.t t,J Cintinntti

80. FactorsInfluencingCareer Choicesin AcademicEmergency Medicine, Arthur B. Sanders,MD, Universityof Ariz.onu

99. EmergencyUse of Electroencephalography with a 2-Channel EEG Monitor in Comatose Patients, Sitlnat' Starkmun, MD, UCLA

8l . DirectedGroup InteractionCasePresentationModulesto Tcach Principlesand Practicesin EmergencyMedicineto Second-Year Medical Students,John S. Rose, St. ktuis Univer,tiry

100. Saf'etyof the Lumbar Puncturein PatientsWith Hemophilia, Robert Silverman,MD, kmg Islund Jewish Medical Center

82. EmergencyMedicineResidentPatientManagement:Implications for ClcrserAttendingSupervision,Alfred Sacchetti,MD, Thomas Jefferson University

134. Effectsof Dichloroacetate on PyruvateDehydrogenase Activity in Ischemic Rat Brain, Melissa M. Nielsen, BS, Universityol Cincinnati

83. Impact of an EmergencyResidencyon the Cost of PatientCare in an Urban Community Hospital Emergency DeparImenf.,John J. Kelly, DO, Medical College oJ Pennsylvanta

189. The Use of the PulseOximeter Wave Display to Determine Systolic Blood Pressurein the EmergencyDepartmenl,Daniel Carlin, MD, Morristown Memorial Hospital.

106. An EducationalFellowship in EmergencyMedicine, Gwendolyn J. Nilsen, MD, Medical College of Pennsylvania

Innovationsin BmergencyMedicine Exhibits (3:15-5:00pm)

l0?. A Logbook - PreceptorSystemfor the Educationof Emergency Me.diiine Residents,hob ert M. McNamara, MD, Medical College of Pennsylvania

101. A Community Experiencefor EmergencyMedicine Residents' David P. Sklar, MD, University of New Mexico 102. Guiding Novice StudentInterviews with StandarizedPatients: A Facrilty Development, Program, William P' Burdick, MD' Medical College of PennsYlvania

108. A Model of a ResidencyResearchDesign and StatisticsCurriculum, James J. Menegaui, MD, University of Pittsburgh

103. DisasterMedical Direction - A Medical EarthquakeResponse Curriculum, Carl H. Schultz,MD, Universityof Califomia, Inine 104. Intem Perceptionsof the Teaching and Practiceof EmergencyMedDrill-Mellum, MD, Hennepin County Medical Center icine, buii

'AcademicStimulation 109. ComputerizedLiterature Searchin the ED: and Effects on Patient Care, Kristi L. Koenig, MD, University of California, Inine

ACLS Instruction:A Reportof One Year's Ex105. Problem-Based periencein the Community Setting,RobertF. Polglnse,JD, EMTP. Mercer UniversitY

110. ComputerizedDatabasefor EmergencyMedicine ResidentCases and irocedures, Mark I. lnngdorf, MD, MHPE, Universiryof Califurnia, Inine

MAY 15 124. Real and ReportedIncidenceof Cocaine Use Among Victimsof Major Triuma, Daniel Brookoff, MD, PhD, IJniversityo!

Pennsylvania 125. Motor Vehicle Crashesand Seatbelts:A Study of Emergency Physician Proceduresand Charges,StephenW' Hargarten, MD' MPH, Medical College of Wisconsin 126 Motorcycle Injuries and Costs: Effect of a Re-EnactedComprehensiveHelmet Use Law, Roben L. Muelleman,MD, University of Nebraska 127. Alcohol and Injuries in the EmergencyDepartment:Patients, Placesand Problems, StephenW. Hargarten, MD, MPH, Medical College of Wisconsin 128. Men, Women and Murder: Gender Specific Differencesin Rates of Fatal Violence and Victimization, Arthur L' Kellermnnn,MD' MPH, UniversitY of Tennessee

ScientificPapers:Pediatrics(8:00-9:30am) I I I . AcetaminophenOverdosein Children: A Comparisonof Ipecac Versus Aciivated CharcoalVersus No GastrointestinalDecontamination, Mark A. Kirk, MD, Rocky Mountain Poison Center as an Indicator of Injury Severity in I 12. CreatininePhosphokinase Pediatric Patients,J. M. Burg, MD, Children's Hospital, Boston I13. Hematuriain InjuredChildren:Is EmergentRadiographicEvaluation Mandatory?, Robert L- Sweeney, DO, UMDNJ/Robert Wood Johnson I 14. Strategiesfor Diagnosis(Dx) and Treatment(Rx) of Febrile Infants (FD: Clinical and Cost-Effectiveness,Mark N. Baskin, MD, Children's Hospital, Boston I15. Metal Detectors- An Alternative Approach to the Evaluation of Coin Ingestionsin Children?, Simon P. Ros, MD, lnyola University 116. Relationshipof Poison Center Contact and Injury in Children 2 to 6 Years of Age, lnrry J. Baraff, MD, UCLA

Scientific Papers: Ischemia/Reperfusion (10:00-11:30 am)

ScientificPapers:Toxicology(8:00-9:30am)

129. The Role of Complementin PostischemicReperfusionInjury, Donna L. Carden, MD, lttuisiana State University 130. Motor Function and Activity Levels: Reliable Predictorsof Anterior Horn Motor Neuron Survival in a Rabbit Model of Spinal Cord Ischemia, Ruth V. W. Dimlich, PhD, Universiryol Cincinnati

I17. The Effect of Body Position on Drug Absorption in a Human Overdose Model, Brad S. Selden, MD, Good Samaritan Regional Medical Center 118. ActivatedCharcoalSurfaceArea and Its Role in Multiple Dose Charcoal Therapy, Kaveh llkanipour, MD, University of Pittsburgh

l3l.

I19. The Anion Gap is Not Sensitivein the Diagnosisof Toxic Metabolic Acidosis, Jffiey Brent, MD, PhD, RoclcyMountain Poison Center

Traumatic Spinal Cord Neuronal Injury In Vitro Is Attenuated by the N-Meihyl-D-Aspartate ReceptorAntagonist Dextrorphan, Raymond F. Regan, MD, Stanford University

132. Phospholipid Deterioration and Free Fatty Acid Releasein CereLral Cortex Following Cardiac Arrest and Resuscitation, Robert E. Rosenthal, MD, George Washington University

120. TransplacentalTransport of N-Acetylcysteinein an Ovine Model, Brad S. Selden,MD, Good Samaritan Regional Medical Center

133. Dichloroacetateand Hyperbaric OxygenationTreatmentof Po$Traumatic Cerebral Edema in Rats, Michelle Biros, MS, MD, Hennepin CountY Medical Center

l2 I . Effective Treatmentof Acute Alkali Injury of the Esophaguswith Early SalineLavage, Ctark S. Homan, MD, SUNYat StonyBrook 122. Treatmentof Experimentally Induced OleanderToxicity in a CanineModel Using Digoxin-SpecificFab Fragments, Kevin J ' Morrissey, MD, University of Mississippi

ScientificPapers:Shock(1:00-3:00pm) 135. HemodynamicEffects of Cimetidine in AnaphylacticShockin a Canine Model, Timothy M. O'Toole, MD, NortheasternOhio Universities 136. A PotentialMechanismfor the DeleteriousInteraction Haemorrhage and Injury, M.Y' Rady, FRCS, University Manchester

ScientificPapers:Iniury kevention (10:fi111:30am) 123. IncreasedRural Motor Vehicle Crash Mortality (MVCM): The Role of Crash Severity and Medical Resources,Ronald F' Maio, DO, MS, University of Michigan

14

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! (! (.' i t

137. Effect of EndotoxinNeutralizingProtein(ENP) on Gram Negative Sepsisin a Rabbit Model, CarmenT. Garcia, MD, Children's Hospital, Boston 138. The Effect of Blood Pressureon HemorrhageVolume and Survival in a Near-FatalUncontrolledHemorrhageModel, Szsan A. Stern, MD, University of Cincinnati 139. Rapidity, Reliability and Safetyof Vascular Accessby IntraosseousInfusion Into Human Sterna,R. Guerrero, MD, University of Califurnia, Davis 140. Comparisonof Intraosseouswith IntravenousInfusionsof Hypertonic Saline Dextran in Swine, M.A. Dubick, PhD, Letterman Army Institute of Research 141. Resuscitationof Hypovolemia Using IntraosseousInfusionsof a Small Volume of 25% NaCll24% Dextran-7O.D.E. Runvon, BS, Lbtterman Army Institute 142. Resuscitationof Canine HemorrhagicHypotensionWith Large Volume IsotonicCrystalloid Does Not IncreaseVenousAdmixture or Lung Water, William H. Bickell, MD, St. Francis Hospital, Tulsa

ScientificPapers:ClinicalPractice(1:00-3:00pm) 143. Is Admission Following Intravenous Narcotic Overdose Necessary?,David A. Smith, MD, Texas Tech University 144. MethotrimeprazineVersus Meperidine and Dimenhydrinatein the Treatment of SevereMigraine: A RandomizedControlled Trial, Ian G. Stiell, MD, University of Ottawa 145. A Double-BlindPlaceboControlledEfficacy Studyoflntranasal Butorphanoland IntramuscularMeperidine in the Acute Treatment,of Migraine and Severe Headache,James Scott, MD, Georg,e Washington University 146. Prevalenceof Folate Deficiency in EmergencyDepartmentPatientsWith Alcohol-RelatedIllnessor Injury, RobertA. Schwab, MD', University of Virginia I 47. ProspectiveStudyof Early HemorrhageGrowth in PatientsWith SpontaneousIntracerebralHemorrhage(ICH), Rashmikant U. Kothari, MD, University of Cincinnati 148. Light ReflectionRheographyas a Non InvasiveScreeningTest for Deep Venous Thrombosis, Thomas P. Kuhlmann, MD, University of Virginitt

V

t?K

u'7-

1 5 5 OutpatientManagementof Febrile Infants (FI) 28 to 89 Days of Age with IntramuscularCeftriaxone(CTX), Marc N. Baskin, MD, Children's Hospital, Boston Trauma 156. Pre-ExistingIllnessand the Trauma Patient,David P. Milzman, MD, Maryland Institute for Emergency Medical Services 157. The Effect of Ethanol on Brain Injury in a Porcine FluidPercussionHead Injury Model, Brian J. Zink, MD, Albany Medical Center 158. Motorcycle Fatalitiesin New Mexico - TheAssociationof HelmetUseWith Alcohol Intoxication,DonnaNelson,MD, University oJ New Mexico 159. RapidSequenceIntubationofHead Trauma Patients:Prevention with Pancuroniumvs. Mini-Dose Succinylchoof Fasciculations line, Krisri L. Koenig, MD, University of California, Irvine 160. SteeringWheelDamageas a Predictorof Injury in Mobr Vehicle Trauma, Elizabeth Orsay, MD, University of lllinois Between9l I Accessand Per Capita l6l . Analysisof the Association Trauma DeathRatesin North Carolina, TamaraPatselt,University of North Carolina at Chapel Hill Trauma:Society'sBurdenand the TraumaCenter 162. Penetrating Bad Debt, Harvey W. Meislin, MD, Universitl-oJ Arizona 163. The Roleof MandatoryLaparotomyin PatientsWith a Positive PeritonealTap, Edward P. Sknn, MD, University-oJ'lllinois EMS/Prehospital Care 164. Prevalenceof EthicalContlicts in the PrehospitalSetting,Jarne^r G. Adams, MD, Univcrsity ofPirtsburgh 165. Eff'ectof StandingOrderson ParamedicSceneTime fbr Trauma Patients, Matthew C. Gratton, MD, UniversitVoJ MissouriKansas City 166. ParamedicPhysicalExam Skills as Comparedto a Disposable End-TidalCOr Monitor fbr Confirmationof EndotrachealTube Placement,RussellU. Braun, MD, Maricopa Mediul Center TraumaTriage 167. Comparisonof EMT Judgmentand Prehospital Instruments,CharlesL. Emennan, MD, Case WesternUniversity 168. The Releaseof Patientsby ALS to BLS - Is It Saf'e'I,Bernard L. ktpez, MD, Thoma.sJefrerson University

149. Droperidol vs Haloperidol for Chemical Restraintof Agitated and Combative Patients,Harold Thomas,Jr, MD, Bowman Grav School of Medicine

169. ResourceUtilizationand Impactof Using Fire Apparatusfor a Fully-IntegratedEMS First-ResponderProgram,Paul E. Pepe, MD, Baylor College oJ Medicine

150. A Comparisonof IntravenousFenoldopamVersusSodiumNitroprusside in the Managementof Hypertensive Urgenciesand Emergenbies,lnla M. Dunbar, MD, PhD, Irtuisiana State Universtty

170. PrehospitalNitrous Oxide: Oxygen Analgesia:A Nine-Year Multicenter Evaluation, Donald M. Yealy, MD, Universityof Pittsburg.h

PosterSessionB (3:15-5:00pm)

l7l. Tidal Volume, IntrapleuralPressure,and GastricVolumeWith Bag-Valve-MaskVersusOxygenPoweredDemandYalve,James J. Menegazzi, PhD, University of Pittsburgh

Pediatrics

Toxicology/Environmental Injury

151. The Spectrumand Frequencyof PediatricIllness Presentingto a GeneralCommunity Hospital EmergencyDepartment,Douglas S. Nelson, MD, Children's Hospital, Boston

172. Is UnexplainedBronchospasmAssociatedWith the Use of Cocaine?, Edward A. Panacek, MD, Case llestern Resente Universtty

152. Chloral HydrateSedationin Children, RoyM. Kulick, MD, University of Michigan

173. CocaineToxicity: Unaffectedby Naloxone and Potentiatedby Morphine, ksbert W. Derlet, MD, Universiryof Califumia, Davis

153. The Ill Child with a VP Shunt:Infection,Obstruction,or Normal Function?, ConstanceM. McAneney, MD, Children's Hospital of PhiladeLphia

174. A One-YearEvaluationof CalciumChannelBlockerOverdose: Toxicologyand Treatment,Henry A. Spiller, RN,MS, Delaware Valley Regional Poison Control Center

154. Evaluationof the Use of Vecuronium for Emergency Department EndotrachealIntubation in Pediatric Trauma Victims.

Francisco A. Medina, MD, Miami Children's Hospital

175. RapidQuantitativeDeterminationof Blood AlcoholConcentration in the Emergency Department Using an Electro-Chemical Method, Paul M. Wat, MD, New York University/Bellevue

WidowSpider Ent'|6. Clinical Presentationand Treatment of Black F' Ctark' MD' Richard Cases' 163 of A Reuiew ;;il;;;;;, Good Samnritan Regional Medical Center Against Oral Snake Antibacterial Activity of Crotalid Venoms

t'77. il;;;;'i;ilbri'ircur

DavidA' Tatan'MD' otive Bacteria,

View/UCI'A

CPR by theInWhenAdministered of Epinephrine 178.Pharmacokinetics William H' Routes' Endot'ucheal unl Intraosseoul travenous Spivey,MD, Medical Collegeof Pennsylvania Administration 179.AorticArchVersusCentralVenousEpinephrine ''JamesE' Manning'MD' Resuscitation' ;;;i"g Cardiopulmonary (lniversitYof North Carolina on Survivalin a Caninel5-Minute 180.Effectof SodiumBicarbonate B' Vukmir' MD' Universityof Rade Cardiacerr.rt tuoJeiPittsburgh For ResusctBypass Cardiopulmonary of Emergency 181.Feasibility ^"- A Preliminarv Arrest caidiac CPR-Resiitant ;.ii;; From of Pittsburgh il.pon, SamuelA. ii'herman' MD' Universiry

of Rats' John

Arrest Survival 182. The Effect of CP21 on Post-Cardiac '"" state universitv wavne DvM, s';;";rtud:MD,PhD,

Dissociation-Using' 183. ResuscitationFrom Electromechanical Epinephrine'DanieI nypassanAHi g-h-Dose.

Cardiopulmonary J. DeEehnke,MD, WrightStarcUniversity PulseOximetrY

or.Misused?' Rita K' 184.

-" PrehospitalPulse Oximetry:-Useful Universitv Resewe Westem MD, Case iiiitit, Care' SusanM' 185.

---' The Value of PulseOximetry in Prehospital Pittsburgh of irn*irr, MD, University e InjuryandCosts'Robert BasedStudyo!-rr{o1or1V9,f 186. A Population ttosptmt HartJord MPH' J. Sihwartz,MD' on the Utilizationof 187. The Impact of BedsidePulseOximetry Department' Emergency the in Measurements Gas Arteriat'glood 'i'iii singrr, MD, UniversityHospitalsof Cleveland InEndotracheal PulseOximetryDuringEmergency 188. Continuous ^--' Wisconsin of College Medical tulution, JamesR. Mateei, MD'

EDUCATIONALAND SPECIAL SESSIONS SELECTED TOPICS IN THE STATISTICAL DESIGN AND ANALYSIS OF RESEARCH STUDIES This sessionwill cover a range of statisticalconceptsand methodsuseful in the analysisof both clinical and benchresearch data. Topics will include classicalhypothesistesting, the P value,type I and type II errors, methodsfor samplesizecalculation, indicationsfor the use of non-parametrictests,the use of multiple statisticaltests,linear regressionmethods,multivariate regression,and logisticregression.The sessionwill focuson the more advancedof thesetopics, yet sufficientdetail will be into practice. given for thosewho wish to put thesetechniques A detailedhandoutwith explanations,examples,tables,and referenceswill be supplied.

ETHICAL ISSUES IN EMERGENCY MEDICINE RESEARCH by symposiumfaculty will adA seriesof shortpresentations dressthe following topics: ethical dilemmasin the day to day emergencydepartmentpractice of clinical research,teaching the principles of ethical researchto our residentsand junior faculty, role and responsibilityof SAEM and of emergencymedicine journals to promote ethical research,and obtaining informed consentfrom patientswho are having life-threatening illness.The symposiumpanelwill then discuss,in a structured format, someof the lively and toughethicalissuesin emergency medicineresearch.This will be followed by questionsand comments from symposiumattendees.

PANEL ON SELECTION OF RESIDENTS A facultypanelwill discussselectionof residentswith particular emphasison selectioncriteria, data accumulationand display,applicantconcernsand minority recruitment.The purpose of the panel is to assistall programsand applicantsin minimizingthe time, expenseand effort of the selectionproc c s sw h i l e i n s u r i n gf a i r n e s s .

PHYSICIAN WELLNESS: ADAPTING TO THE EMERGENCY PHYSICIAN LIFESTYLE Dr. Klein will discussthe basicprinciplesof sleepphysiology and their applicationto shiftwork and changingsleeppatterns.

He will addressspecific manipulationsin schedules,diet and the sleepenvironmentin order to improve the senseof wellbeing and generaloverall healthof shift workers. Specificapplicationsto emergencyphysicianschedulingwill be addressed in a questionand answersession.Novel schedulingtechniques will be discussed.

SYNOPSIS FOR FACULTY: AMERICAN BOARD OF EMERGENCY MEDICINE andBensonS. Munger,PhD, BruceD. Janiak,MD, President ExecutiveDirector, of the American Board of Emergency Medicinewill outlinethe changesin Board policiesthat have takenplaceduring the past l2 months.Many of thesechanges have direct applicationto programsand faculty. Emergency Medicineprogramfacultyand other interestedindividualsare will include urgedto attend.The topicswhichwill be addressed combined training programs with internal medicine and Medicinepropediatrics;creditfor trainingin non-Enrergency grams;the in-trainingexamination;the residenttrackingsystem; Detailed and the developmentof additionalsubspecialties. materialswill be availableandtime will be allocatedto respond to specificquestionsabout theseand other relatedtopics.

IMPROVE YOUR SKILLS AS A LECTURER This program is gearedfor emergencymedicinephysicians who lectureto small and large groupsat professionalmeetings will discusscriteriafor planning Participants or in classrooms. and delivering an effective presentation,be provided with for improving lectures,and evaluatea videotapedlecstrategies ture to assessits strengthsand ways to improve it. Participants will be activelyengagedin small and large group discussions throughoutthe program.This programwill not be a lecture, it will prove to be fun and informative.

PROVIDING FEEDBACK FOR LEARNERS IN THE EMERGENCY ROOM Feedbackis one of the critical determinantsof clinical teaching.Yet learnersreportconsistentlythat they receivef'eedbacksporadically,or not at all. In this workshopthe participants will explorethe problemsthat underlieprovidingeffectivefeedback in an emergencyroom setting,and developguidelinesfor providing feedbackmore effectively. Feedbackthat is enmeshed within the fabric of clinical instruction,as well as feedbackthat comesat the end of a one-monthrotation will be considered.

Techniques usedin this workshopwill includeanalysisof a case, brief lectures,and review of videotapes,with time allottedfor group participation.

TENURE AND ACADEMIC FREEDOM What doesthe conceptof tenuremean'?Why did it arisein the universitysystem.Tenurein one medicalschoolmay have vastlydifferentimplicationsthantenurein anotherschool.Some scholarsarguethat tenureis an outdatedconcept.What protection doesit give the faculty?What are the economicimplicaIs academicfreedoman issue tions of tenureto universities? in the medicalschoolsof the 1990s? Thesequestionsandothers will be discussed.JanetBickel will give data from a recent surveyof medicalschooldeansand facultyaffairsadministrators on the statusof promotionand tenureat U.S. medicalschools.

JeanneWalther will discusshow medicalschooladministrators try to implement policies that are both fair to faculty and economicallysoundfor universities.Neal Flomenbaum,MD, will review potentialabusesof academicfieedom and tenure in medicalschools.JordanKurland, PhD, will describeprosuchas AAUP tectionsfor facultyandthe work of organizations to protect faculty interests.

THE USE OF STANDARDIZED PATIENTS: A..HANDSON'' APPROACH This workshop will demonstratethe use of standarizeclpaof clinical skills. Standardtients for teachingand assessment ized patientsare non-physicianstrainedto portray a patientencounter in a realistic and consistent fashion. During this workshop,the participantswill have an opportunityto interact with two different standardizedpatientsand discussstrategies as to how this techniquemight be incorporatedinto their own programs.

RESEARCH DIRECTORS LUNCHBON This year's ResearchDirectorsLuncheonwill includea panel discussionwhere participants will be able to interact with representativesfrom the FDA, the NIH and established emergencymedicine researchers.Clinical investigatorswho t t

wish to facilitate researchproposal approval by their institution's IRB should plan to attend. SAEM memberswho wish to inquire about the issue of deferred consent are encouraged to bring specific questions.

UNDERGRADUATE EDUCATORS LUNCHEON Problem-basedlearning will be the focus of this year's EducatorsLuncheon.Harold Paul, MD, DirecUndergraduate tor of the Alternate Curriculum at Rush Medical School, has been invited to speak about the application of this method to undergraduateemergencymedicineeducation.Dr. Paul initiated a problem-basedcurriculum at Rush in 1983, and will share his views on adapting the techniqueto learning emergency medicinethroughoutthe four yearsof medicalschool,but with particularemphasison the fourth year. The sessionwill involve active participationso that sharedconcernsand problemscan be discussedand solved by the group.

PRIMER OF RESEARCH METHODS FOR EMERGENCY MEDICINE This sessionis targetedtowardsemergencymedicineresidents and will be directed towards what participantsneed to know to perform good research.Subjectsto be discussedinclude, 1) basicconceptsof research,2) hypothesisformulation/testing, 3) sampling methods, 4) research/experimental designs, 5) statisticalanalyticalmethods,6) uses/misuses of statistics,and 7) theory formulation.

HOW TO WRITE A GOOD GRANT APPLICATION: PROPOSALS TO PRIVATE FOUNDATIONS AND GOVERNMENT AGENCIES The workshopleader,Dr. Liane Reif-Lehrer, has servedas a memberof a National Institutesof Health Study Sectionand is the author of Writing a SuccessfulGrant Application (Jones and BarlettPublishers,Boston;2ded.,282pp,1989). Shehas also publisheda numberof articlesaboutgrantsmanship in The Scientistand elsewhere.

Dr. Reif-Lehreris a scientist,lecturer,veteranwriter of grant proposals,and the authorofover 50 publications.Shereceived a B.S. degreefrom BarnardCollege,ColumbiaUniversityand a PhD in chemistry from the University of California at Berkeley.Dr. Reif-Lehrer was an AssociateProfessorat Harvard Medical Schooland a SeniorScientistat the Eye Research Institute and Retina Foundationfor many years. She is now presidentof Tech-WriteConsultants/Erimon Associates,a consulting firm for proposal writing and related subjects.

In the workshop, Dr. Reif-Lehrer will discussmany aspects of writing a good grant proposal for both private foundations and federalagencies.Shewill discussthe review process,with specialemphasison writing for the reviewer - that is providing the information the reviewer needs to know. She will also discusshow to deal with the different parts of an application, especiallythe researchplan. Dr. Reif-Lehrer will detail how to plan, outline, draft, revise and track the proposaland will also teachsomegeneralstrategiesfor good expositorywriting.

EMRA/SAEM

RESIDENT RESEARCH FORUM

This sessionwill discusscommon mistakesmade by young physicians who leave residency and pursue researchinterests in either a community or academicsetting. As a rule, physicians are not trained in researchmethodology and have litte or no experienceconductingclinical trials. Consequently,most physiciansare not ready to start a researchinvestigationwithout spendingseveralyears with an experiencedinvestigator. Finding the right mentor, securing protected time and focusingon specificareasofinterest are essentialin order to avoid making errors commonly seen in research.Other areasthat will be discussedincludethe needto interactwith the emergencydepartment staff, funding of clinical protocols and limitations of community and academicresearch.

GERIATRIC

EMERGENCY MEDICINE

LUNCHEON

During the Geriatric Emergency Medicine Luncheon membersof the SAEM Geriatric EmergencyMedicine Task Force will discuss the preliminary results of the Geriatric Emergency Medicine Study which was funded by the Hartford Foundation. Annual Meeting participants are invited to attend and give their opinions, suggestions,and criticismsbeforethe final report is prepared.Topics to be reportedupon are: aftitudes of elderly patientswho have visited the emergencydepartment, attitudes of emergency physicians regarding the care of the elderly in the emergencydepartment,a multi-centereddatabase on the use of emergencydepartmentsby the elderly, attitudes of emergencymedicineresidentstoward geriatric emergency medicine,and discussiongroupswith elderly at multiplesites, PREPARING FOR AN RRC SITE VISIT This workshopis intendedto meetthe needsof existingprogram directors and individuals interested in beginningan emergencymedicineresidency.The workshop will briefly cover the organization of the ACGME and the RRC for Emergency Medicine, but will focus on preparing for an RRC site visit.

Extendedtime for questionsand answerswill be provided.

AnnualMeetingAbstracts SAEM Presenters'names are printed in italics; where presenteris not indicated, none was specified by the authors. .Study done primarily b y a resident or fellow. tStudy done primarily b y a medical student.

IncreasedHealthCareCosts Associated With EmergencyDepartment Overcrowding Medicine, Hospital ol ofEmergency PKrochmal, T Riley/Department a I

Conclusion: Homelessness substantially affects EMS, in tcrms of both cost and the use of scarce ambulance resources.

A l c o h o l a n d d r u g u s e a n d a s s a u l t - r e l a t e dt r a u m a o c c u r f r e q u e n t ly in this group.

S a i n t R a p h a e l ,N e w H a v e n , C o n n e c t i c u t Study hypothesis: The ovcrcrowding ol emergency dcpartments wrth inpatients rcsults in an increasedavcragc total rnpatient length o{ stay; thercforc, overcrowded hospitals have i n c r e a s c dc o s t s p c r p a t i e n t .

Design: All admissions to our institution for 1988, i989, and the first six months of 1990 were reviewcd. Analyscs were pcrformed for the five rnedicai diagnosis-related groups with the highest volumes of admissions via the ED and furthcr dtvided based on whether the paticnts wcre transfcrrcd to an inpaticnt unit in less than onc, two, or three days. Wc also rcvicwccl all c a t c g o r i e so n t h e b a s i s o f M c d i c a r c o r n o n - M e d i c a r e s t a t u s .

Intervention: This was a retrospcctive data analysis of tw<t and one-half years of hospital averagc length of stay and ED length of stay.

Results: Total number of patients adrnittcd for l98tt, 19U9, and the first half of 1990 were 8,314, 8,514, and 4,547, rcspcctivcly, and the average lengths of stay were 10.U4, i1.93, and 11.76 days, rcspectively. Comparablc data for paticnts transferred after lcss than one day or a{ter morc thap onc day wcrc 6 , 7 6 5 , 5 , 8 1 3 , a n d 3 , 3 2 2 p a t i c n t s a n d 1 0 . 6 3 , 11 . 4 4 , a n d I 1 . 3 0 days, respectively,or I,549,2,7O1, and 1,225 patients and11.77, 12.95, and 13.03 days, respectivcly.

Conclusion: Inoaticnts who rcmain in thc ED aftcr admission have a gteatc. average length of stay than those who arc promptly transferred to inpaticnt units. Thc increased averagc length of stay means an increased cost pcr paticnt; thc ovcrall cffect for a 490-bed hospital is more than $2 million pcr ycar.

Homelessnessand Emergency MedicalServices: A Study Of Clinical, Economic,& SystemsOperationsFactors SanFrancisco, S Wong/University of California, CESaunders, S c h o ool f M e d i c i n eD; e p a r t m eonft P u b l i cH e a l t hC, i t ya n dC o u n t y of SanFrancisco.

Study purposeand methods: To study cmergencymcdical services(EMS)systemsusedby thc homelcssin San Francisco, we audited prehospital medical records,billing data, and computerizeddispatch data to characterizethis group clinically and identify patternsof use.All EMS patientcontactsfor onc month were studied (total number ol records,3,332; total number of homeless,329). Using ambuiance use data, we analyzedthe impact on responsetimes with computcr simulation and constructed financial models to determine the cost of these servrces.

Results:In 1990,the homelessconstitutedO.6%oI the city's populationyet used9.87%of 9l I EMS services.Mean ageof the homelesswas 38 years;males constituted 86.4% of the study population;and alcohol was involved in 67.6% of cases.The most common clinical problemswere trauma |,35.7%,mostly assaultl,altered consciousness,21.6y"1,and seizureslIl.7%).

For the nonhomelesspopulation, these problems were encount e r e d 2 6 . 5 7 " , 7 . 1 % ,a n d 5 . 2 % o I t h e t r m e , r e s p e c t i v e l y .

Advanced life support iALS) care was provided in 50.5% of cases,with 15.0% requiring "lights and sirens" transport; only 3.3% deteriorateden route. The most common ALS procedures performedwere IV line placement137.1%),naloxoneadministratior ll9-2o/"),and 50% dextroseadministration(1a.0%|.Had these servicesnot been required,EMS system responsetimes would have been 0.67 minutes faster for critical calls and 3.0 minutes faster for noncritical calls. The total annual cost o{ EMS to the homelesswas $1.38million.

PatientsWho Leavethe Emergency DepartmentWithoutMedicalEvaluation: Severityof lllnessand Needfor Acute Care C D S t e v e n s ,D W B a k e r ,R H B r o o k / D e p a r t m e not f E m e r g e n c y , C L A S c h o o lo f M e d i c i n e ,H a r b o r - U C L AM e d i c a lC e n t e r ,T o r r a n c e U M e d i c i n e ,R o b e r tW o o d J o h n s o n C l i n i c a lS c h o l a r sP r o g r a m ,U C L A S c h o o lo l M e d i c i n e ,D e p a r t m e not l M e d i c i n e ,C a l i f o r n i a Study hypothesis: C)vcrciowding has led to an increasc in thc nurnbcr of paticnts who scck carc in our emcrgcncy dcpartment anclthcn lcavc without bcing sccn by a physician. Paticnts who lcavc without bcing sccn havc lcss urgcnt medical problcms than thosc who wait until they arc trcatcd.

D c s i g n : P o p u l a t i o n - h a s c d ,c a s c - c o n t r o l s t u d y . D u r i n g a t w o wcek period, consccutivc arnbulatory adults who conscntcd and cornplctcd a health status qucstionnaire werc enrolled. The study group compriscd all paticnts who lcft thc ED bcfore bcing callcd to sec a physician. Thc control group compriscd a 20"/" random samplc of ambulatory patients who complcted the entry qucstionnairc and wcre trcated in thc ED. Both groups wcrc intervicwcd by telcphone onc wcek later. Four indcpcndent mcasurcs of illncss scvcrity werc uscd: l) sclf-rcported hcalth status; 2) triagc nursc urgcncy rating, a thrcc-point scalc used routincly by our triagc nurscs; 3) physician acuity score, a fourpoint scale uscd by thc authors based on cxplicit, complaintbascd criteria and triagc data; and 4) hospital admission rate.

Setting: Urban public hospital with an annual ED ccnsus of I 10,000.

Participants: of 2,031 eligible patients, 1,190 completed the c l u c s t i o n n a i r e ; l f l ( r p a t i c n t s 1 9 . 2 % )l e f t w i t h o u t b e i n g s e e n , a n d 2l l controls wcrc sclectcd. Telcphone follow-up was obtained on l4(r paticnts who lcft without being scen (78%land l72controls (fi2'1,).

Results: No differences werc dctected between patients who l e f t a n d c o n t r o l s b y a n y o f t h c f o ^ u ri l l n e s s - s e v e r i t y m e a s u r e s { P >.05 by two-sidcd t tests and X/). Forty-six percent of those who left and 4O"/" of controls received the highest physician acuity scores, indicating the need for prompt care in the ED. Elcvcn pcrcent of the group who left and 9% of controls were admitted to a hospital within seven days.

Conclusion: Patients who left our ED without treatment wcrc as ill as those who waited to be seen. Nearly half of them needed immediate medical evaluation, and many required hospitalization. ED overcrowding at public hospitals jeopardizes a c c e s st o h e a l t h c a r e f o r s e r i o u s l y i l l a m b u l a t o r y p a t i e n t s .

Cost lmplicationsOf DelayedAccess to Carein PatienlsAdmittedThroughthe EmergencyDepartment Medicine, KASalness/Division ofEmergency GA Pane,MCFarner,

t4

Universityo f C a l i l o r n ilar v i n e .

Study hypothesis:Admitted emergencydepartment patients who initially delay seekingcare have higher hospital charges and longer lengths of stay than do patients who do not delay.

Design: Prospectivestudy of ED admissionsduring a fiveweek period.

Setting: University oi California lrvine Medical Center, an urban 493-bed/noncounty, Level I teaching hospital that treats 38,000emergencypatients annually.

Partrcipants:A total of 263 nontrauma, nonobstretics,admit-

ted ED paticntswere eligiblefor the study. Of thcse, 198 were able to be intervicwed.The final study group,for whom comp l e t e h o s p i t a l f i n a n c i a l d a t a w e r e a v a i l a b l c ,c o m p r i s e d1 7 1 pailents.

Interventions: Patients were given a questionnaire to elicit d a t a c o n c e r n i n g a c c e s sa n d d e l a y s i n c a r c . A f t c r d i s c h a r g c , h o s pital financial data were examincd.

Results: Public aid or self-pay insurance status was signific a n t l y a s s o c i a t e dw i t h d e l a y i n s e e k i n g c a r e ( P < . 0 5 ) a n d c o n d i tion worscning lP < .02).Hispanics wcrc significantly morc likcly than Caucasians to bc of public aid or sclf-pay status {P < .001). Dclay was srgnificantly associatedwith longer lcngths of s t a y ( P < . 0 3 ) a n d h i g h e r ^ h o s p i t a lc h a r g c s ( 1 ' < . 0 3 ) . S t a t i s t i c a l analysis was donc with Xz and Mann-Whitncy U test.

Conclusion: Admittcd ED paticnts who initially dclay secking carc had significantly longer lengths of stay and higher hosp i i a l c h a r g e st h a n p a t i e n t s w h o d i d n o t d c l a y . T h e s e d a t a s h o u l d be useful to health policymakcrs in formulating strategics that emphasizc early treatment and prcvention.

*5

IntravenousAdenosinein the Prehospital Treatmentof Supraventricular Tachycardia

of University PMParis/The G Adhar, JJ Menegazzi, JL McCabe, c ye d i c i nTeh; eC e n t e r fi l i a t eR d e s i d e nicnyE m e r g e nM P i t t s b u rA gh TheMercy Pennsylvania; Medicine of Western forEmergency e ,n i v e r s i t y c ye d i c i nU H o s p i toafl P i t t s b u r gDhi ;v i s i oonl E m e r g e nM gh c h o oolf M e d i c i naen; dt h eC i t yo f P i t t s b u r g h o l P i t t s b u rS Department of PublicSafety : o c v a l u a t ct h c c f f i c a c ya n d f c a s i b i l i t yo f S t u d yo b j c c t i v e T tachyadcnosincadministrationin thc ficld for supravcntricular cardia{SVT).

Dcsign:Prospcctivccascscriesduringa ninc-nlonthpcriod.

Sctting:An urban cmergcncymcdical scrviccssystem with an annualcall volumc of (10,000.

P a r t i c i p a n t sT:w c n t y - f i v cc o n s c c u t i v ca d u l t s m o r e t h a n l 8 ycarsold who prcscntcdto pararncdicswith a rcgular,narrowcomplcx tachycardiaof morc than 150 and no visiblc P wavcs on thc monitor.All 25 paticntsrcccivcdadcnosinc.

I n t e r v c n t i o n sC : o n s u l t a t i o nw i t h a n c m c r g c n c yc o m t n a n d physicianwas obtaincdbcforcthc administrationof mcdication.

Six milligramsof adenosinewas administercdby rapidIV bolus through an antccubitalvcin. If thcrc was no effect within two minutcs,a I2-mg dosewas givcn.If this was not effcctivcwithin two minutcs, a second l2-mg dosc was given. If thcre still was no cffect, thc command physicianwas notified, and stanHcart ratc, dard trcatmcnt for SVT commcnced.Measurcments: b l o o d p r e s s u r c ,r e s p i r a t i o n s ,a n d s y m p t o m s w e r c r e c o r d c d bcforcand after the administrationof adenosine.Electrocardiog r a p h i ct r a c i n g sw e r c o b t a i n e db c f o r e ,d u r i n g , a n d a f t c r t h c adrninistrationof adenosinc.

Results:Nincteen of 25 paticntshad documentedSVT. Two p a t i c n t sw e r c i n r a p i d a t r i a l f i b r i l l a t i o n , t w o w e r e i n s i n u s and two were in ventriculartachycardia.Of the l9 tachycardia, p a t i e n t s i n S V T , 1 7 l 9 1 % l c o n v e r t e dt o s i n u s r h y t h m a f t e r adenosine.Eleven (65%) required(r mg and the remaining six (45%)requireda l2-mg bolus. Of the two patientswho did not convert,one was receivingtheophylline,and the other received only two 6-mg doses.The two patientswith rapidatrial fibrillarhythms initially, and the diagtion had fairly regular-appeanng nosis was confirmed as the ventricular responseslowed after adenosineadministration.The two patients with sinus tachycardia included one patient in status epilepticusand one patient in septic shock who had no responseto adenosine;P waves appearedonly on subsequentECGs at the receivinghospital.

B o t h p a t i e n t s w h o w e r e i n v e n t r i c u l a r t a c h y c a r d i ah a d n o changein rate, rhythm, or blood pressureafter the three dosesof adenosine.Mean systolic blood pressuresbeforeadenosinewere l12 mm Hg for SVT, 96 mm Hg for atrial fibrillation, 125 mm Hg for sinus tachycardia,and 88 mm Hg for ventricular tachycardia.No patients had a decreasein blood pressureafter adenosine administration, and of five patients in SVT who had systolic blood pressuresof less than 90 mm Hg, all had significant hemodynamic improvements after conversionto sinus rhythm.

All patients who converted to sinus rhythm had transient atrioventricular block with ventricular or junctional escapebeats.

Three patients had pauses,the longestbeing 3.6 seconds,but

none had adversehemodynamic sequelae.One patient {5'l") had a recurrenceof SVT en route to the hospital.

Conclusion: In this small seiles,adenosineproved to be effi' cacious (90% conversion)in the prehospital treatment of SVT and was administeredsafely by paramedicswith direct medical command.

An Evaluationof the Use of Prophylactic Antibioticsin the Managementof Oral Lacerations GL Goding,DW Weaver,PF Mitchell,DR Eitel,DR RSBenenszn, Medicineand Dental of Emergency Hess,CS 0gden/Department Center,YorkHospital,York,Pennsylvania Study objective:To determine the ef{ectivenessof prophylactic antibiotics in the preventionof infectionsassociatedwith oral lacerations.

Design: A prospectivetrial comparing the use of prophylactic antibiotics with placebo in a randomized,double-blinded fashion. Mcta-analysiswas performedby pooling this data with those collccted in a prior study of a similar designlAnn Emerg Med 1989t18:847-8521.

Setting:Emergencydcpartment and outpatient dental center of a community teachinghospital. Participants:Patientspre' scnting within six hours of iniury to the ED with intraoral and t h r o u g h - a n d - t h r o u g hl i p l a c e r a t i o n sw h o g r a n t e d w r i t t e n informedconsent.

Interventions: Patients received penicillin or placebofor two days after wound repair. Penicillin-allergic Patients were treated with erythromycin oi placebo. Presenceof infection was determined.by patient wound instruction follow-up on day of repair and clinical evaluation at seven days.

Rcsults:Onc hundred scvcn patients were included in the c o m b i n c d s t u d i c s .O v c r a l i i n f e c t i o n r a t e s w e r e 1 9 % i n t h e placebogroup and 8% in the treatment group. Odds of infection wcrc 3.38-foldgrcaterin the placebogroup by logistic regression analysis(I' < .05).

Conclusion:Oral prophylacticantibiotic therapyreducesthe r i s k o f i n f c c t i o n a s s o c i a t e dw i t h i n t r a o r a l a n d t h r o u g h ' a n d through lip laccrations.A five-daycourseof oral penicillin or crythromycinis rccommendcdfor theselacerations

The Efficacyof NoninvasiveIn-Hospital and OutpatientManagementof Febrile Infants:A Four-YearExperience of GeneralPediatrics, MD Baker,LM Bell,JB Avner/Divisions Hospital Children's Diseases, Medicine,and Infectious Emergency o f P h i l a d e l p h iPae, n n s y l v a n i a Background:Since 1987, we have prospectively studied the of noninvasive in-hospital and outsafety and cost-effectiveness patient managementof well-appearingfebrile infants.

Population: Four hundred twenty-five infants 29 to 56 days old with rectal temperaturesof more than 38.2 C presentingto the Children's Hospital of Philadelphiawere enrolled.

Methods: After a complete history, physical examination, and sepis workup, each child was assignedto one of three groups. The hospital control group comprisedchildren with either laboratoryor clinical parameterssuggestiveof serious infection. The remaining 175 well-appearinginfants with normal laboratoryparameterswere randomly selectedfor either inhospital observationwithout treatment llH.O,92l, or outpatient observationwithout treatment (OPO, 83) but with repeatphysi' cal examination ^t24 and48 hours.

R e s u l t s : S e r i o u si l l n e s s o c c u r r e d i n l l 6 o f 4 2 5 i n f a n t s 127.3%i.One hundred fifteen of 116 children with a seriousillness were identified by our admission criteria (sensitivity, 99.1%o;conftdenceintervals, 95.3"/oand 100%).Negative predict i v e v a l u e w a s 9 9 . 4 7 "{ 9 5 % c o n f i d e n c ei n t e r v a l s , 9 7 . O Y t"o I00o/o). Averagemedical chargeswere $5,653 controls, $2,947 (IHo), and $716(OPol. Conclusion: Our data indicate that using strict selectioncri' teria, it is possibleto safely and cost-effectivelymanagefebrile one-to two-month-old infants without initial antibiotic treatment in either the in-hospital or the outpatient settinS.

PossibleConfoundingEffectof Manute Ventilationon ETco2in CardiacArrest

C W B a r t o n ,M L C a l l a h a m / D i v i s i oonf E m e r g e n c yM e d i c i n e ,S c h o o l o l M e d i c i n e ,U n i v e r s i t yo l C a l i f o r n i aS, a n F r a n c i s c o Study hypothcsis: Changcs in minutc vcntilation, tidal volume, and rcspirations do not affect mcasurcments of end-tidal c a r b o n d i o x i d c ( E T c o 2 ) c o n c c n t r a t i o n s i n p u l s c l e s sv i c t i m s o f cardiacarrcst and do not nccd to bc controllcd.

P o p r . r l a t i o n : P r o s p c c t i v c c a s c s c r i e s o f 2 0 a d u l t v i c t i l - t . t so f nontraumatic cardiac arrest trcated in an emergcncy dcpartmcnt of a univcrsity tcaching hospital from 1989 through 1990 with s i n r u l t a n c o u sm c a s u r c m e n t s o f E T c o ' 1 a n d m i n u t e v c n t i l a t i o n h c l rr r c r h r ' r t t u r n o f s p (I n l a n c o u \ c rr c u i l t r " n ' Methods: A calrbratcd capnomctcr scnsor was conncctcd to an cndotrachcal tubc in paticnts vcntlletcd by cxpcricnccd clir"rr' cians with bag valve according to advanccd cardiac lifc support g u i d c l i n c s a n d r c c c i v i n g c h c s t c o m p r e s s i t l n sw i t h a p r ' r grammablc thumpcr. ETco2 rcadrngswcrc paircd with simr-rltan c o u s m e a s u r c m c n t s o f m i n u t c v c n t i l a t i o n a t s t a n d a r dv c n t i l a tory ratcs and during delibcratchypcrvcntilation Corrclations bctwecn ETcor and minutc vcntilation wcrc analyzcd r-rsing srrlplc rcgrcssion.

R c s u l t s :T w c n t y p a t i c n t s ( 1 3 r r c n a n d s c v c n w o r . r - r c nw)i t h a m c r n : l g e o f 7 4 . 3 y c a r s w c r c c n r o l l c c li n t o t h c s t u d y E l g h t y - n i n c p a i r c t l m e a s u r e n t c n t s o f E T c o l a n d t r i t t t t t e v e n t i l a t i o n _w c r c o b t a r n c c li n t h c s t t r d y g r o u p . I n c r c a s c s i n I l l i n u t e v c n t i l i r t i o n w ! ^ r c a s s o c i a t e cw l i t h a r c c l u c t i o n i r . rE T c o r w i t h a n r v r t l u e < l f 3 ( r . t n c a n l n c r c a s c i n n r i t t t t t c v e n t i l a t i o n f r o t n ( r ' . 5t t r { 1 '= . 0 0 0 1 i 1A l9 L/rrrn was associatcd with a I.ncandccrcasc in ETcol frotlr " . i t o i . { n r t l H A r 1 '. 0 5 t (;roup

N

All prtrcnts [.Mt) V irlr Asystolc

i]9 .11 ll{ )7

R Value R Squarr:d .19 5l .56 .)4

. 15 ..1.6 II .06

Equation

P

v - . ( r 7 X + 2 . 0 . 1 1 . ( X X I) .0(X)7 ) =-.9X + 1.1..2 y = 1 . 0 4 X+ 2 ( r . l .016 + .2211 v- .9(rX 1.0.4

(]rnclusions: Chan{cs itr Irtilrlttcvcntilatioll havc atl cffcct o n E T c o l c o n c c n t r a t i o l l si n p t r l s c l c s sv i c t i t l s t l f c a r c l i a cl t r r c s t .

A l t h o u g l i t h e c o r r c l a t i o n r c p o r t c i l i n t h i s s t r " r d yi s w c r r k , s t l c h r r . t c i i e c t c a n w c a k e t r t h c p r c v t t t t t s l y d c t l l t t n s t r a t c da b i l i t y o f E T c o r t o n r c d i c t o t t t c o t l e i n c a r t l i ; t c a r r c s t . F t l t L l r c s t l - l d l c s( r f E T c o r " d u i i n g r e s u s c i t a t i o n l t t t l s t c o n t r o l f o r c l r : t t . l g c si l l l l l i n u t e v c n t i l a t i o n , l n d c l i n r c t a n s s h o l t l r - tl n t t n i t o r v c t l t i l : t t i t r t lt t ) s t i l l l tllrrdizcresults.

*9

Nontransportof PrehospitalPatients:ls StrongerMedicalControlNeeded?

, C i o n n i / T hM e e d i c aCl o l l e g e W JZ e h n e rJ,r ,S J D a v i d s o nJ ,J K e l l yD o l P e r t n s y l v a nPrhat.l a d e l p h i a S t u d y o b j c c t i v e : T h e 1 1 ( ) n t r a l l s p t lor tl p a t i e l l t s i n c t r l c r g c n c y nrctlrcalscrvices (EMSI systctrtsis lratrgllt with nlcdtcal arld l c g a l c o m p l i c a t r o n s , b l t t v c r y f c w s t u t l t c s h i t v c a i l c l r c s s c dt h i s s u b j e c t . ( ) u r s y s t e t l p e r n r i t t e c lp a r a u r c c l i ct l i s c r c t i o n t n d e t c r ' rnining the nccd for pattcnt trtnsport. As part ttf rcttrgatlization, w c s t r . r d i e dt h c n o n t r a n s p t t r t o f p a t i c t r t s i l l o L l r s y s t e l l l t ( r ( l | t t r l ) ) r n ( 't h c f i u r c c n t i l l i ({ ) l i l l i l P l r r ) l r i J t ( I l 0 l l l r i l l t s F ( r r t .5l l l d f d c t o r s r c l a t r n et o t h c m .

D e s r g n : A r c t r o s p c c t i v c c h a r t r c v i c w o n 1 0 0 ' 2 ,o f a l l a d v a n c c d l i f c s r - r p p o r tp a r a r . n c d t cr u n s r c s u l t i n g i n n o n t r a n s p o r t o f p a t i c n t s i n t h c P h i l a d c l p h i aE M S s y s t c m b c t w c c n f u l y l , l 9 t t 9 , a n d D c c c m b c r 3 1 , 1 9 U 9 ,w a s c o n d u c t c d .

Setting: An urban, rrunrcipal firc dcpartmcnt-clpcratcdEMS s y s t e m s e r v i n g 1 . 5 r n i l l i o n p e o p l c w i t h 1 0 2 , 0 0 0 d i s p a t c h e si n I989.

Particioants:1.730 runs wcre rcviewcd. Paticnts who wcrc deadon ariiual werc cxcludcd.

I n t c r v e n t i o n s :N o n e .

Results:Data collcctcd on each run included docutnent;rtion, chicf complaint, patient disposition, whcthcr against mcdical advice form was signcd, and whether nontransport was approp r i a t c . O f a l l n o n t r a n s p o r t s , 5 4 2 ( 3 1o l , Jw e r c c o n s i d e r c d i n a p p r o priate. A potcntially serious chief complaint not recognizcd by paramedics was cited 78.8"/"of the time as the reason for inappropriate nontransport. There was a significantly grcater {P < .05) percentagc of inappropriate nontransport decisions from without on-linc medical control {537 of 1,636) compared with on-line medical control lfive of 94).

Conclusions: The system had a high level of inappropriate nontransport of patients. Bccause EMS systems must exercise

strong medical control over the nontransport of patients, we altcred our system to require on-line medical command for paticnts for whom paramedics thought transport was not necessary.

EMSPriorityDispatch: Computer-Aided TriageSystem Abilityof a Computerized to SafelySpareParamedicsFrom ResponsesNot RequiringAdvancedLife SuPPort of RCSherrard/Departments VFGinger, PEPepe, PACurka,

10

, n d P e d i a t r i c sB, a y l o rC o l l e g eo f M e d i c i n e ;C i t y M e d i c i n e ,S u r g e r y a o l H o u s t o nF i r e D e p a r t m e n tE, M S a n d C e n t r a lC o m m a n dD i v i s i o n s ' H o u s t o n ,T e x a s Study objcctivc: To test thc ability of a computcrized priorit y d i s p a t c h s y s t c m t o s a f e l y e x c l u d e t h c n c e d f o r a c i v a n c e dl i f c A:L S J . s u -pbpcosr it g( n Rctrospcctivc stucly of 35,075 cmcrgcncy medical scrviccs {EMS) incident rccords gcncratcd during the sccond qlrartcr of 1990 {April through func) to scc how often lonc dispatchcs of basic lifc support units staffcd with basic cmergcncy i r - r c d i c a lt c c h n i c i a n s s u b s c c l u c n t l y r c c l u i r c d o r i n v o l v e d A L S carc.

Sctting: Onc ccntralized municipal EMS (including all disp a t c h , { i r s t - r c s p o n c l c r ,a n d t r a n s p o r t u n i t s ] i n a l a r g e u r b a n c c n tcr.

Intcrvcntion: A fcw rlucstions that hclp dispatchers idcntify ( o r c x c l u d c ) s i g n s o r s y t t t p t o l t t s i n c l i c a t r n gt h c n c c d f o r A L S R c s u l t s : A L S u n i t s w c r e s p a r c c lf r o t n i n i t i a l d i s p a t c h i n 1 4 , 1 ( X )o f a l l E M S i n c i d c n t s l 4 O . 2 " l ) , t h t t s i n c r c i r s i n g t h e i r a v a i l ability and usc for morc scrious calls. Only l.tl'l" of thcsc cascs ( 2 5 4 ) s L r b s c q L r c n t l ryc c l u i r c d o r i n v o l v c d A L S p r o c c c l u r c s ;m o s t o f thcsc rcccivcclonly an IV linc without volumc infusion, drugs, or any othcr ALS thcrapy. On furtl-rcr rcvicw, thc irnmcdiatc prcscnce of a paramcdic would havc bccn consiclcrcdthcorctically atlvantagcous (cg, posttralllnatic arrcst, hypoglyccrnia) in lcss than a dozcn of thc 14,100 cascs.Evcn so, it still appcarcd ur"rlikely tl-ratthc bricf dclay in providing ALS carc madc any disccrnrblc diffcrcncc in olltcornc for any of tllosc paticnts ( l o n c l r r s i o n : A c o r n p u t c r - z r i d c dd i s p a t c h t r t a g c a l g o r i t h n - rc a n s a f c l y i d c n t i i y n - r a n yE M S . i n c i d c n t s r c q r " r i r i n go n l y b a s i c l i f c support carc. Although pararncdic arrival may bc dclaycd in an "ALS cascs," ncgativc cffccts trn cxiicrncly surall nurnbcr of p a t i c n t o L r t c o l r r ca r c n c g l i g i b l c . I n s t c a d , n l a n y o p c r a t i o n a l a n d mctlical carc bcncfits arc providcd by such a systclll.

a a I I

on Time The Effectof EMT-Defibrillation to TherapeuticlnterventionsDuring CardiacArrest

r ighJ W H l e k s t r a ,J B a n k s ,D M a r t i n ,C G B r o w n ,t h e M u l t i c e n t e H S t u d yG r o u p / D e p a r t m e no tf E m e r g e n c yM e d i c i n e , D o s eE p i n e p h r i n e , o l u m b u s ,0 h i o ; t h e e m e r g e n c ym e d i c a l 0 h i o S t a t eU n i v e r s i t yC s e r v i c e ss y s t e m so f C o l u m b u s , 0 h i o ,K i n g C o u n t y ,W a s h i n g t o n , , nd , i s c o n s i n ,R i c h m o n d ,V i r g i n i a a H o u s t o n ,T e x a s ,M i l w a u k e eW S y r a c u s e ,N e w Y o r k Study objcctivcs:To dcfinc and comparc timc intcrvals to C P R i n i t i a l c o u n t c r s h o c k , I V a c c c s s ,i n t u b a t i o n , a n d d r u g t h c r a py in cmcrgcncy rnedical tcchnician {EMT)/paramedic vcrsus EMT de{ibrillation/paramcdic systems.

Dcsign: Prospcctively collected data from a l5-month multicentcr study. Outcomes were compared by thc use of Student's t tcst with thc Bonferroni correction.

Sctting: Thrcc EMT and threc EMT-defibrillation urban cmergency medical services systems. Participants: 1,574 patients with primary cardiac arrest.

Interventions: Patients eligible for the study recervedclosedc h c s t C P R , i n i t i a l c o u n t e r s h o c k , i n t u b a t i o n , I V a c c e s s ,a n d a d v a n c e dc a r d i a cl i f e s u n p o r t d r u g t h c r a p y .

Results: P EMT = Defibrillation EMT Time Interval (min t SD) 5 . 2! 5 . 2 . 8 5 5 . 3t 4 . 3 C o l l a p s ct o C P R 1 3 . 0t 5 . 0 . 0 0 0 1 1 0 . 7i 5 . 9 C o l l a i ' s ct o i n r t i a l c o u n t e r s h o c k 9 . 9t 6 . 0 0 0 0 1 1 3 . 2t 5 . 3 C o l l a - o steo o a r a m e d i ca r r i v a l 0001 7.2t5.I 4.7!3.7 P a r a n i e d i c a r r i vt o al V a c c e s s 4 . 7t 4 . 7 69t 5 8 .0001 P a r a m e d i c a r r i v at ol i n t u b a t i o n 8 . 31 4 . 8 . 0 0 7 P a r a m e d i ac r r i v a lt o d r u ga d m i n i s t r a t i o n7 . 2t 4 . 5 Conclusions: EMT-defibrillation systems provide shorter

times to countershockthan EMT systems.By delegatinginitial countershocksto EMTs, this allows significantly shorter times to IV access,intubation, and drug therapy for patients in cardiac arrest.

12

Predictionof Outcomeof Ventricular FibrillationWaveformand Needfor Prompt ALS Responsein Patients

Defibrillated by Urban First-Responders 0 Braun,M Callaham, W Valentine, D Clark,C Condie/Division of Emergency Medicineand Centerfor Prehospital Researcn ano Training,University of Calilornia, SanFrancisco Study hypothesis:Certain characteristics of ventricularfibr i l l a t i o n ( V F ) t r e a t c d b y u r b a n f i r s t - r e s p o n d e r cs a n p r e d i c t response to defibrillationand ultimate patientoutcomc.

Participants:Adult cardiacarrest victims between fune 1989 and Scptember1990 who were found to be in VF on arrival of thc San FranciscoFire Department first-respondersequippcd with semiautomaticdefibrillators.

Intervention: Defibrillation accordingto advancedcardiac life support and first-responderprotocols.

Methods:Electrocardiographic data were digitally recorded by a solid-statemodule with an jntcrnal clock and analyzedby analysisof variance,t test,and X2.

Results:Mean responsctimc was 4.2 minutes. One hundrcd eighty-eightpatientswith 312 episodesof VF had 205 convcrsions. First refibrillationoccurreda meant SD of 5.3 + minutcs after firc departmcntarrival. Ninety-nine patients i53%l had stablcconversioniSC) of VF,39 {21%) were admittcd as inpatients,and 13 17'/.)werc discharged alive. Fifty-ninepcrcentof SCsoccurredon thc first convcrsion,28o/"on the second,9% on thc third, and 47" on the fourth.

Initial VF First Reiib (N = 188) (N = 7z) Min to Convert . u t 5 . 7 1 . . t3 L 4 Coarse ( >8 m V ) % olYF 4l 37 %,SC 55 l a + A Min to rcfib .3.5r ^3 Med (2-8mv) '2,of VF 55 +f, %SC i4 33 Min to rcfib 1 . 61 l 2 , 1! 2 Fine ( <2 m V ) %ofVF 3 4 7. SC 3.3 0 Min to rcfib I t I 1.2!.7 All valucs are mcan * SD

SecondRefib Third Refib (N = 34) (N= ll) . 7! . 4 .61.3

LA

20 z.i!3

7l 50 L . / - L

6 0 . 8t . 4

55 75 t . 7! . 6

+) 33 l!.7 0 0

Initial VF amphtudc predictcdstableconversion(p = .0001J, timc to refibrillation(P = .0t), and ultimate outcome (p =.02).

Mean t SD amplitudc was 12.5t 5.5 mV for those discharged alive; died in the hospital,8.5 t 4 mV; died in the emergency dcpartment,9.2 t 5.3 mV; and died in the field, 7.2 t 4.6 mV. Initial VF of l0 mV or more predictcdhospitaldischargewith a sensitivityof 777" anda specificityof 68%.

Conclusion: Sixty-six percent of patients successfullydefibrillated by first-respondersrefibrillate within three minutes.

Prompt advancedlife support is important becauserefibrillation occurs within six minutes of fire department arrival. and each successivcrefibrillationis much less likely to convertto a stable_rhythm. Initial VF amplitude predicts outcome, including stability of conversion,return of pulse in the field, admissionto hospital,and overall survival.

*{

Effect of PrehospitalMedicationson e Mortality and Length of Stay r, _!

RCWuerz, SAMeador/The MiltonS Hershey Medical Center, Pennsylvania State University, Hershey

. _Studyhypothesis:We studied patients with congestiveheart failure to assessthe effect of prehospitalmedicatiorion hospitalmeasuredoutcomesof mortality and length of stay.

Design: This was a retrospectivecase series.patients were separatedinto those treatedby nitroglycerin, furosemide,and/or morphine {l7l} and those not treated (154}and analyzedby chi-

square,t test, and logistic regression.

Setting: A rural and suburban emergencymedical services system servinga population of 140,000with three paramedic unlts.

Participants: In 1987 through 1988,5, 509 paramedictransports occurred.The receiving hospital diagnoseswere available Ior 5,427 of transports 198.5%).Of these 5,427, 325 consecutive casesof congestiveheart failure were identified and studied.

Interventions:Oxygen was given to 321 patients by protocol.

Other medications were given only by order of on-line medical commanders.

Results:Treated and not-treatedgroups were comparablein age/sex, rhythm, cardiacmedication, responsetimes, and transport times.Treatmentwas associated with reductionin mortality 15.9%vs 16.2o/oi oddsratio of survival,3.08t 95% confidence intervals,i.43 and 6.65fand length of stay in survivors{7.2 vs 9.9 daysi95% confidenceintervals-.15 and 5.47 days).Adjustment for systolic blood pressureresulted in odds ratio for survival with treatmentof 2.12 195%confidcnceintervals,O.94and.

4.82).Samplesize was insufficientto comment on the relative merit of spccifictreatmentregimcns.

Conclusions:Prehospitaluse of nitroglycerin,furosemidc, and/or morphincappearsto improve outcomesin paticntswith congestivcheart failure. Further study is indicatedto explore spccificdrug therapyand patientsclcctionfor trcatment.

14

Comparisonof AeromedicalCrew Performanceby SeverityScoring and Outcome

REBurney, L Passini, D Hubert, R Maio/Section of Emergency Services, University of Michigan, AnnArbor B a c k g r o u n d :O n e o f t h c c o n t i n u i n g c o n t r o v e r s i c si n acromcdicaltransportregardscrcw composition.Since1987,we havc uscd both physician/nurse{P/N) and nursc/nursc{N/N) crcwsto stafftwo idcnticallycquippcdhclicoptcrambulanccs.

Study purpose:To comparethc scvcrity of illncss or injury with outcomcof patientstransportcdby P/N and N/N crews.

Dcsign:Rctrospectivc cohort.

Mcthods: Data were obtaincd from thc air ambulanceand mcdical rccordsof all aeromcdicaltransfersbctwccn Scotcmber l , 1 9 8 7 , a n d A u g u s t3 1 , 1 9 U 8P. a t i e n t sl c s st h a n l ( r y e a i so l d o r transfcrrcdto other hospitalswerc cxcludcd.Scverityof illness o r i n j u r y w a s m c a s u r c db y R c v i s e dT r a u m a S c o r c { R T S ) , A P A C H E - I I , a n d T h e r a p e u t i cI n t c r v c n t i o n S c o r i n gS y s t e m { T I S S ) o; u t c o m e m e a s u r e sw e r e m o r t a l i t y a n d i n t e n s i v ec a r e unit and hospital lengthsof stay. Patientswere categorizedas cardiac,trauma, or other. Origin of transfer(scene,emergency department,or hospital)and transfcrtimes were includedin the analysis.

R e s u l t s :S i x h u n d r e d s e v e n t y - t w op a t i e n t t r a n s f e r sw e r e studied; 430 P/N and 242 NiN. No dlffercnces were found between these groups with regard to sex, RTS, APACHE-II, or TISS,although P/N patients were younger {45.7vs 50.9 years,p = .001),included more cardiac {40% vs 36%l and trauma (38% vs 30%| patients lP = .002),and were more likely to have been transferred from an ED (68% vs 5 I % ) or the scenell% vs 2%l lp =,0_01).Mortality, intensivecareunit length of stay,and hospital length of stay of P/N and N/N patients were not different, nor was time spent at scene or hospital. Subgroupanalysis did not alter theseresults.

Conclusions:No obiectivedifferencesin outcome of patients were found betweenP/N and N/N teams.Although s-ail diffetenceswere found in the types of flights taken by p/N and N/N teams/there was no differencein obiective measuresof severity between these two teams.We find no obiective evidenceto prefer one crew composition over the other.

15

PediatrlcBacterialMeningitis:ls PreliminaryAntibioticTherapy AssociatedWith an Altered Clinical Presentation?

SGRothrock, SMGreen, J Wren,D Letai,L Daniel-Underwood, E Pillar/Department of Emergency Medicine, LomaLindaUniversity Medical Center; LomaLindaUniversity School of Medicine; Department of Emergency Medicine, Riverside General Hospital, LomaLinda.

California

Study hypothesis: Clinical features of children treated with antibiotics before the detection of bacterial meningrtis differ from those of children who received no antibiotics.

D e s i g n : R e t r o s p e c t i v ec a s es c r i e s .

Setting: University medical ccnter.

Participants: Two hundred sixty-fivc children 24 months old or younger who had bacterial mcningitis and had becn dischargedduring a l2-year period wcrc cnrollcd. The study group comprised 85 children prctrcatcd with antibiotics, and the control group comprised 180 childrcn who reccivcd no antibiotic therapy before diagnosis.

Interventions: Nonc.

Methods: The emcrgcncy dcpartmcnt charts and hospital rccords wcre revicwcd for prcscnting fcaturcs. Using Xz analysis and Student's t tcst, fcatures wcrc cornparcd bctwcen groups.

Rcsults: Tcmpe raturc of morc than 38.3 C and an altcrcd rncntal status wcre morc comnlon in untrcatccl paticllts. Prctrcatcd chilclrcn had more frctlucnt vomiting, cars, nosc, and throat infcctions and physician vrsits in thc wcck bcforc thc c l e t c c t i o no f m c n i n g i t i s ( P < . 0 5 f o r a l l c o m p a r i s o n s ) .T h c r c w c r c no diffcrcnccs in mcan agc, scx, incitlencc of uppcr rcspirat'lry syn.lptoms, scizurcs, nuchal rigiclity, Kcrnig's and Brudzinski's signs,focal ncurologic signs, mortality ratc ancl lcngth of hospitalizatior.r.

C o n c l u s i o n : C l i n i c a l { c a t t t r c s o f c l - r i l c l r e twt h o h a v e t a l < c n antibiotrcs bcforc thc dctection of u.tcuinqitis cliffcr fronl thosc o f c h i l c l r c n w h o h a v c t r o t u n c l er g o n c a n t i b i ( ) t l c t h c r a p y . I ) h y s i crans should bc aware of thcsc differcnccs whcn cvalltattt.tg y o u n g c h i l d r c n o n a n t i b i o t i c s f o r t l i c p o s s i b i l i t yo f t t t e n i n g i t i s .

16

Screeningfor CocaineIntoxicationin Seizuresin ChildrenWith Unexplained the EmergencyDepartment.

of Pediatrics, SEKrug,RD Marble,DL Lubitz,TJ Long/Department n e s e r vUe n i v e r s i tSyc h o ool f M e d i c i n eR, a i n b o w C a s eW e s t e r R l, levelan0 dh , io B a b i eas n dC h i l d r e nH s o s p i t aC S t u c l yh y p o t h c s r s(:l h i l d r c r rp r c s c n t r r r fgo r c t t t c r g c n c yc a r c w r t h i t r . tu n c x p l a i n e d c o t . t v t t l s i t l nl t t a y r c p r c s c t l t : t p o p t - t l i t t i t t na t r i s l <f o r c o c a i n c i n t o x i c a t i o n .

P o p u l a t i o n : C h i l d r e n 0 t o l ( r y c a r s o l t l p r es el t t t l l t t ( t r l l t u r b a n ,u n i v c r s i t y h o s p i t a l p c d i a t r i c c r l c r g c r t c y t l e p a r t t r t c n t ( P E I ) )w i t h a h i s t o r y o f u r r ex p l a i n c d c t t n v t t l s i t t t .wr i t h i n t h c p r ecedingl2 hours.

M e t h o d s : A s p a r t o f t h c i r I r E [ ) c v a l t r a t i o n ,a l l c n r o l l c d c h i l ' drcn had blood ancl urit.tc s:unplcs collcctccl for toxicology s c r c c n i n g . T h c p r c s c n c c o f t h c c o c : t - 1 n ct n c t a b o l i t c b c n z o y l c c g o n i n c w a i . d c t c r r n i n c d v i a t h c E M I T @ u r i n e a s s a y .C h i l d r c n w i t h a known history of cpilcpsy or prior scizures;an idcntifiablc traumatic, rnetabolic, or infcctious prccipitant; or a prescntation c o n s i s t c n t w i t h a s i m p l c f c b r i l c s e i z r . r r ca t t h c t i n l c o f t h c i r P E D cvaluation werc excludcd. AII PED visits for thc pcriod of thc study wcrc retrospcctivcly rcvicwed to clctcrtninc complctcncss of paticnt enrollmcnt.

R c s u l t s : D u r i n g a o n c - y c a r p c r i o d , ( r ( rc h i l c l r c n w c r c e n r o l l c d , represcnting [i0ol,of all potcntial cnrollccs. Thirty of thcsc c n r o l l c d p a t i e n t s w c r c t h c n c x c l u d e d b a s c d o n s u b s c c l u e n ti d c n tification of a causc of thcir scizurc, including trauma {fivc), m c t a b o l i c o r e l e c t r o l y t c d i s o r d c r s ( s i x ) , i n f c c t i o n s { s e v c n ) ,p r i o r e p i l c p s y { f o u r ) , a n d s i m p l e f e b r i l c c o n v u l s i o n ( ei g h t ) . N o n c o f thesc children had a positivc toxicology scrccn. Of the remaining 3(r patients, four {l l'l.) had a positivc urine toxicology screcn for cocaine. Subsequcnt history confirmcd cither intcntional (patients 14 and l5 years old) or accidental ingcstion (patients l4 and 32 months old) in thc four children.

C o n c l u s i o n : S t u d y r c s u l t s s u g g e s tt h a t c h i l d r e n p r e s c n t ) n g t o an urban PED with an unexplained convulsion reprcscnt a group at risk for cocaine intoxication and warrant consideration for toxicology screening.

a a a I

High Prevalenceof Laboratory in ChildrenWith Clinical Abnormalities Dehydration

0f HW Davis,RB Karasic, SM Fuchs/Department MS Bhende, of Pittsburgh Schoolol Medicine;Emergency Pediatrics, University P,e n n s y l v a n i a .

Cth, i l d r e n H ' so s p i t aol f P i t t s b u r g h Departmen

Studv obiective: To determine the usefulness of laboratory studies and the prevalence of abnormalities in children with clinical dehydration.

Design, participants and setting: Prospective study of 135 children {age range,2 to 180 months, mean age,39.9 months) who receivcd IV rehydration for vomiting and/or diarrhea in a c h i l d r c n ' . h o s p i t a l c m c r g e n c yd e p a r t t n e n t .

Intervention: Before IV rehvdration, detailed histories and physical examinations were obtained by investigators, and routrnc laboratory studies {including serum electrolytes, BUN, gluc o s c , a n d b l o o d g a s )w e r e p e r f o r m e d .

Rcsults: Onc or more clinically significant abnormal values (sodium, 130 or lcss; potassium, less than 3.0r BUN, more than 20; glucosc, less than 60; pH, less than 7.3; HCO3 or CO2, less than 15) were prcscnt rn 47.4% of the study population. The frcclucncies of specific abnormalities were electrolytes, 5.1%; BUN, 19.2%, pH, HCO3, or CO2, 30.3%; and glucose,15.5% Childrcn with-abnormal-values wlre significantly younger than thosc with normal studies (29.6vs 49.2 months, P : .003 by Student's t test). Those with hypoglycemia were even younger { m c a n a g e , 1 9 . 9 m o n t h s ; P - . 0 1 b y S t u d e n t ' st t e s t ) . A b n o r m a l i t i c s w c r e s i g n i f i c a n t l y a s s o c i a t c dw i t h l e n g t h o f i l l n e s s ( P = . 0 3 ) , v o l u m c o f d i a r r h e a ( P = . 0 5 1 ,h i s t o r y o f w l e i g h t l o s s ( P = . 0 0 0 1 ) , ancl abnormal skin turgor (P = .003),iry Xz analysis. In gencral, labor:rtory abnormalitics were not accurately predicted by staff physicians.

Conclusion: Thcre is a high prevalcnce of clinically signifioant laboratory abnormalitics in young children undergoing IV rchydration in thc El). Obtaining screcning laboratory studics s h o r - r l db c s t r o n g l y c o n s i d c r c d i n s u c h p a t i c n t s .

-l Q I l,

AerosolizedMagnesiumSulfateas Acute Therapyfor PediatricAsthma

M C C l a r k ,G D W r i g h t J, L F a l k ,L M a l o n e ,J P R o b e l l i / D e p a r t m eonft l e d i c a lC e n t e r ;D e p a r t m e n t E m e r g e n c yM e d i c i n e ,0 r l a n d o R e g i o n a M o f S t a t i s t i c sU, n i v e r s l t yo f C e n t r a lF l o r i d a ,0 r l a n d o Study objcctivc: Magnesium sulfatc is a bronchodilator whcn administcrccl intravcnously, but ncbulizcd magnesium sulfatc has not bccn tcstcd during acutc cxaccrbations of asthma. Wc tcstcd the cffcct of ncbulizcd magncsium sulfatc alonc and as a dilucnt to albutcrol. l)csign: Doublc-blindcd, placcbo-controllcd, randornizcd, prospcctivc study.

S e t t i n g : C o n r n - r u r " r i t y - b a s ctc la c h i n g h o s p i t a l .

Participants: Twcnty-two children 5 to 1ll years old with acutc bronchospasrn,Clinical Asthma Scorc lCAS) of lcss than 4, and a history of rcvcrsiblc bronchospasm.

Intcrvcntions: Ncbulized magnesium sulfatc {3.t3 mg/kg/dosc; maximum dosc 200 mg) or normal saline (NS) as thc initial trcatmcnt followed by thc addition of albuterol (0.03 mL/kg/dosc; maximurn dose, 1.0 mL) to cither diluent at 30minutc trcatmcnt rntcrvals.

Rcsults: Data includc pretrcatment and posttreatment values for FEV1, MMEF, PEFR, pulse-oxygen saturation, vital signs, and CAS, Statistical analysis was pcrformed by Wilcoxon ranksulrl tcst. l)ata are orcscnted as mean * SD. PostTx 2

Post Tx 3

Mg NS

1 0 4t 2 1 ll9r19

1 0 6t 1 2 tz4!19

1 0 7r I 0 ' 1 2 41 1 5

ll01 16' t32 I l8

MC NS

2 . 4r O . t t 2 . 4! 0 . 6

2 . 5x O . 7 2 . 21 0 . 5

1 . 1t l . l 1 . 3t 0 . 7

Mg NS

1 . 4 8l l . l 2 Z . t O+ t . 2

I . 6t 1 . 5 ' 0 . 8r 0 . 8 I . 0 1t 0 . 3 9'

PreTx

cAS

'

PostTx I

L 3 ( r 1 1 . 1 3 L l8 I 0.(r4 2 . 0 5 1 rL 4 1 . 5 4r 0 . 8

3.1812.0

1) < .05 between groups.

Groups were comparable before treatment in demographics and othcr parameters. Patients receiving NS and albuterol were more tachycardic and had lower CAS and higher PEFR values after treatment than patients receiving magnesium sulfate and albuterol.

Conclusion: Nebulized magnesium sulfate appears to blunt the bronchodilatory and chronotropic effects of aerosolized albuterol. There was no demonstrable bronchodilator effect from the use of nebulized magnesium sulfate alone.

.1g

Inaccuracyof InfraredTympanic MembraneTemperaturesin Young Children

M Donato,TPMcHugh/Department of EmergencyMedicine, R i c h l a nM d e m o r i aHl o s p i t a l / U SSCc h o ool f M e d i c i n eC, o l u m b i a , S o u t hC a r o l i n a Study hypothesis: The tympanic membrane temperature iTMT) obtained by an in{rared radiation sensing thermometer should be the same in both ears when obtained at a nearlv simultaneoustime.

Design:Prospective,unblinded study.

S e t t i n g :A n u r b a n t e a c h i n g h o s p i t a l w i t h a n e m e r g e n c y departmentcensusof approximately60,000visits per year.

Participants:A conveniencesampleof l0l children who presentedto the ED during a one-month period.The children's ages rangedfrom 8 daysto 7 yearsimean+ SD age,1.59t 1.65years).

I n t e r v e n t i o n s :A f t e r o b t a i n i n g p a r e n t a l p e r m i s s i o n , w e obtained temperaturesin rapid successionfrom the children's rectum and ears using an electronic thermistor device (IVAC II Temp Pluss, IVAC Corp, San Diego, California) and an infrared radiation-sensingdevice (First Temp@,Intelligent Medical Systems Inc, Carlsbad,California). The infrared thermometer operating in the rectal mode was.usedto obtain one TMT measurem e n t f r o m e a c h e a r . T h e p r e s e n c eo f o t i t i s m e d i a o r a n y obstruction secondaryto cerumen within the externai auditory canal was then noted. The mean temDeraturefor the rieht and left earsand the differencebetweenthe two carswas caliulatcd and comparedwith the rectal temperaturein each child. Statistical comparisonswere madeusing Student'st test, acccptinga significancelevel of P < . 05.

R e s u l t s :N o s i g n i f i c a n t d i f f e r e n c e sw e r e d e t e c t e di n t h c mean infrared temperaturemeasurementsin each ear lP = .75).

The presenceof otitis media in either or both earsdid not affcct the TMT measurementlP : .40|,nor did the presenceof marked or total blockageof the external auditory canal by cerumen (P = .(r0and P = .40,respectively).

Although the mean *SD temperature differencein both ears was only 0.04 t 1.23 C, therc was a surprisingly wide range (- 5.3 to + 4C). The absolute difference in TMT showed a discrepancyrate between the two ears as follows1 : 8%> , l C , 9 y o , > - 2 C , 5 T o , > 3 C , 4>%4 C , a n d1 % , > 5 C. A fever,definedas a rectal temperatureof > 38 C or higher, was presentin 53 patients but would not have been detcctcdby one or both TMT measurements in 2l patients(40%).

Conclusion:TMTs in children do not appearto lre affectcd by the presenceof otitis media or obstructivecerumen.However, the absolutedifferenceof 2 C or more observedin 9"k of children suggeststhat infrared temperature measurementsare not reliable as a screeningtest.

Xqrll Z|t

PediatricOut-of-Hospital Cardiopulmonary Arrest

JH Simmons,WC Dalsey/Joint MilitaryMedicalCommand(JMMC) E m e r g e n cMye d i c i n e R e s i d e n cPyr o g r a mW ; i l l o r dH a l lU S A F MedicalCenter,Lackland AFB,Texas;BrookeArmyMedicalCenter, Ft SamHouston,Texas

of ED deathswas 6.61, and of ED resuscitations,5.78. This differencewas statistically significant with a P value of .015 by the analysis of variance using the /-test. The predominant rhythm Forty-six of the patients were managedby was asystole169o/ol. paramedics.Seven had prehospital endotrachealintubation, 33 were ventilated by bag-valve-mask,and three by bag-valvetrach. Two patients had inadvertent esophagealintubation, one w a s m a n a g e dw i t h a n E G T A . C o n c l u s i o n s : T h e p e d i a t r i c patients who presentedto the ED in CPA had a uniformly poor outcome in this series.Although a statistically significant higher pH is demonstratedin ED resuscitationsand survivors, it is not clinically significant as there were no survivors without severeneurological impairment. The absenceof a perfusing rhythm carries an equally grave prognosisdespite the fact that some of these patients were resuscitatedin the ED. Endotracheal intubation was not shown to be superior to bag-valvemask in that it was used infrequently and all patients in the study had a poor outcome. With few exceptions,once the pediatric patient presentsto the ED in cardiopulmonaryarrest,there is little we can do to improve the ultimate outcomâ&#x201A;Ź.

21

MagneticResonancelmagingin Minor Head Injury

D Doezema, MC Espinosa, JN King,WW Orrison,D T a n d b e r g / U n i v e rosfi N t ye wM e x i c oS, c h o ool l M e d i c i n eD, i v i s i o n o i E m e r g e n cMye d i c i n eA, l b u q u e r q u e Study obfective:To investigate the role of cranial mdgnetic resonanceimaging (MRI| in evaluatingpatients dischargedfrom the emergencydepartmentafter minor head infuries.

Design:A prospective,double-blindedcohort study.

Setting:UniversityhospitalED. Participants:Fifty-eight patients with minor head injuries who were dischargedfrom the ED with written head injury instructions. Patientsadmitted to the hospital were excluded.

Intervcntions:Ultra-low-field cranial MRI scanswere performed on patients within 24 hours of discharge.Scanswere readblindly by two radiologists.

Results:Fisher'sexact test was used to comparesymptoms in paticnts with abnormaland normal MRI scans.There were no significantdifferencesin symptoms betweenpatients with abnormalscansand thosewith normal scans(P > .10).The proportion of abnormalMRI scanswas analyzedusing the binomial d i s t r i b u t i o n .S i x o f t h e 5 8 p a t i e n t s{ 1 0 . 3 7 . )h a d t r a u m a t i c i n t r a c r a n i a la b n o r m a l i t i e s{ p r o p o r t i o n 0 , . 1 0 3 ,S D , 0 . O 4 i9 5 % confidenceintervals,0.04 and 0.21).Three patientshad cortical contusions,and three had small subduralhematomas.Two of the six patientswith abnormalMRI scans,both with small subdural hematomas,had normal computed tomographyscans.

Conclusions:Ten percent of patients dischargedfrom the ED after minor head injury had abnormal ultra-low-field cranial MRI scans.Additional researchis neededto establishthe clinical importanceof this unexpectedobservation.

22

IntracranialHemorrhageAfter Minor Head Trauma

MG Mikhail,MA Levitt,TA Christopher, M Sutton,D Nathan/Highland GeneralHospital,University of California, San Francisco; ThomasJefferson University Hospital,0akland

Obiectives: To examine the long-term survival of pediatric patients presentingto the ED with cardiopulmonaryarrest and determinei{ the initial arterial pH, cardiacrhythm, or prehospital management of the airway was prognostic of the ultimate outcome.

Design:Retrospectivereview of hospital and ED records.

Setting:Three urban Level I emergencymedical servicescenters.

P a r t i c i p a n t s :I n c l u d e d w e r e p a t i e n t s l e s s t h a n l 8 y e a r s undergoingCPR on arrival to the ED. Excludedwere victims of trauma and those resuscitatedprior to arrival in the ED. Drownings were not excluded.fifty-five consecurivepatients were studied. There were 26 infants, 21 children I to 5 yearsold, and eight were 5 to l8 yearsold.

Interventions:None.

Results:Thirty-eight 169"/"1 were pronounceddeadin the ED. Seventeen13l%) were resuscitatedin the ED. Thirteen l247ol died in the pediatric ICU and four patients were subsequently dischargedwith severe neurological impairment. No patients were dischargedneurologically intact or with minimal impairment. Forty-onepatients had ABGs documented.The mean pH

Study hypothesis:There is increasingevidencein the medical literature that intracranial infury exists in patients with minor head trauma who present awake and alert. This study was to determine if clinical patameters exist that will predici the presenceof intracranial hemorrhagein patients with minor headtrauma.

D e s i g n : C r o s s - s e c t i o n a l f, o u r - w e e k f o l l o w - u p p e r i o d i f patient was not hospitalizedto determine clinical outcome.

Setting:University hospital.

Participants: Eighty-five patients presenting with Glascow Coma Scoreof l3 or more.

Intervention: Cranial computed axial tomography(CAT) and neurosurgery.

Results: Multiple historical and physical examination variables were entered into a stepwise logistic regressionmodel to determine if any would have a significant predictive value of intracranial injury. Of the 85 patients, 35 had CAT scansof the head, of which eight demonstrated intracranial hemorrhage. No

24

study patients, except the one who had surgical intervention, demonstrated clinical deterioration. Stepwise logistic regression found that age of 40 years or more {P = .05; odds ratio,6 4i 95"h confidenceintervals, 1.0 and 38.8) and complaint of headache(P = .039; odds ratioi 8.167i 95% confidence intervals, 1 074 to 62.091were significantly predictive of intracranial injury.

Conclusion: Intracranial injury appears to have an incidence of 9.4% in patients with minor head trauma. In minor head trauma, age of 40 years or more and complaint of headache are a s s o c i a t e dw i t h a h i g h r i s k o f i n t r a c r a n i a l i n i u r y . P a t i e n t s w i t h intracranial injury after minor hcad trauma appcar to do well with nonopcrative management.

23

MovementDuringAirway Cervical-Spine Appraisal Cinefluoroscopic Management: in HumanCadavers

M H a u s w a l d ,D P S k l a r , D T a n d b e r g ,J F G a r c i a / U n i v e r s i t y0 f N e w M e x i c o ,S c h o o lo f M e d i c i n e ,D i v i s i o no f E m e r g e n c yM e d i c i n e , Albuoueroue Background: Emcrgency airway management is challenging in trauma patients with possible cervical-spinc injurics. We perf o r m e d c i g h t a i r w a y m a n e u v e r s i n f r e s h h u m a n c a d a v e r sd u r i n g c i n ef l u o r o s c o p y t o b et t e r d c f i n e o p t i m a l m a n a g e m c n t .

Methods: Eight victims of traumatic cardiac arrest each "mask" procedures undcrwcnt four groups of procedures: including bag-valvc-mask anl thc mask from an csophagcal "oral" procedurcs including curved and obttrrator airway, "guidcd oral" proccstraight laryngoscopc blade intubations, durcs consisting of intubation with a lightcd stylct and fibcrop"nasal" procedures including blind and tic bronchoscope, and bronchoscopic nasotrachcal intubations. Cincfluoroscopic mcas u r c m r : n t o f m a x i m u m c e r v i c a l d i s p l a c c n - r c n td u r i n g c a c h p r o c c durc was made with sublccts in the supinc position with the ncck sccurcd by a hard collar, backboard, and tapc. All proccdures wcrc completcd within 40 minutcs of death.

Rcsults: Thc mcan maximum cervical-spincdisplaccrncnt w a s 2 . 9 3 m t n f o r p r t t c c d u r e si n t h e r n a s k g r o u p , I 5 l m r n f o r r u r a l ,l . ( r 5 m m f o r g u i d e d o r a l , a n d I . 2 0 m r n f o r t h c n a s a l . T h c use of a facc rnask causcd morc ccrvical-spine dispIacclncnt than thc othcr procedurcs studicd {analysis of variancc, F = 9 . 2 1 ) 8P , = .00004).

C o n c l u s i o n : V c n t i l a t o r y m e t h o d s r . r s i n ga m a s k m o v c t h c intact ccrvical spine significantly morc that any comrnonly uscd mcthod of cndotracheal intubation. Physicians shor-rld choose thc intuhation tcchniquc with which thcy have the grcatcstcxpcrience and skill.

24

EmergencyDepartment lmprovesOutcomeof Echocardiography

Penetrating Cardiac lniurY of E Ruiz/Department D Blake, R Assinger, D Brunette, D Ptummer, y e d i c aCle n t e r , e ,e n n e pCi no u n tM E m e r g e nMc ey d i c i nH M r n n e a p oM l i si n, n e s o t a

Conclusion: Since the introduction of immediate ED twodimensional echocardiography, the time to diagnosis of PCI has decreased, and both the survival rate and neurologic outcome of survivors have improved.

.

25

out tonure ffi::':'l;,:'Ti"tf#ssion Unnecessary

E G B r o c k , R K e r r ,J L F a l k / D e p a r t m e not l E m e r g e n c yM e d i c i n e , , l o r i d a ;D i v i s i o no l l e d i c a lC e n t e r ,O r l a n d o F O r l a n d oR e g i o n a M E m e r g e n c yM e d i c i n e , D e p a r t m e n to f S u r g e r y ,U n i v e r s i t yo f F l o r i d a , C o l l e g eo { M e d i c i n e Study hypothesis: Fear of delayed complications of myocardial coniusion, including malignant dysrhythmia and pump failure, resulting in the admissron of large numbers o{ patients with blunt chest trauma and suspected myocardial contusion to monitored critical care bcds despite the absence of cardiac comp r o m i s c a t p r e s e n t a t i o nm a y b e u n w a r r a n t e d .

Design: Retrospectivechart review.

Sctting: A Level I teaching hospital trauma center.

Participants: All patients more than 16 years old with blunt chest trauma during a four-rnonth interval.

Interventions: Iniury Severity Scores and Trauma Scores werc recorded, ECGs were reviewed, and clinical status was monitored to hospital discharge.

Results: C)f431 trauma patients, l3I 124%l with a mean age o f 3 7 1 1 . 5 y e a r s w e r e m o n i t o r e d m o r e t h a n 2 4 h o u r s 1 4 . 4! 0 . 5 days). Motor vehicle accident was the mechanism in 92% of paiietrts. ECGs were normal in 61 patients (46%), of whom ihrce dicd as a result of serious head iniury. Abnormal ECGs wcre present in (r5 patients {50%), of whom eight died and four cxncrienced serious cardiac events. These 15 patients (ll deaths, two cardiac arrests,and two with heart block CHB) had critical clcctrocardiographicatrnormalitics or injuries on admission, which was reflectcd in higher Injury Severity Scores(43 + l . ( r v s 1 7 . 4 t I . 1 l a n d l o w c r T r a u m a S c o r c s( 9 . 8 + 1 . 1 v s 1 4 . 0 + 2.(r)than thc rcrnaining paticnts (P < .05). No paticnt without critical clectrocardiographic abnormalitics (CHB, vcntricular tachycardia, ventricular fibrillation, or clectromechanical dissociation) or critical injury on admission devcloped sequelae of myocardial contusion requiring cithcr inotropic or antiarrhythmic therapy during their hospital stay.

Conclusion: Wc conclude that patients with blunt chest trauma who do not display serious dysrhythmia, other serious clcctrocardiographic abnormality, or signs of pump failure in the cmergency department are at low risk for developing late cardiac sequclae. A prospcctivc study dcsigned to re-evaluate currcnt admission policies for thesc patients is in progress

.26

A ProspectiveStudy of Complications AssociatedWith the Useof Abdominal ComputedTomographyScanningin TraumaPatients

J V a y d a ,W D R a p p a p o r t ,R C D a r t / S e c t i o no l E m e r g e n c yM e d i c i n e a n d D e p a r t m e n to f S u r g e r y ,U n i v e r s i t yo l A r i z o n a H e a l t hS c i e n c e s CenterT , ucson

Study objcctivc: To determinc thc effcct of immccliate twodimcnsional cchocardiography on thc timc to diagnosis,salvage ratc, and neurologic outcome of patients with penctrating cardiacinjury {PCIl. f ) c s i g n : A t e n - y c a rr c t r o s F c c t i v cr c v l c w .

Sctting: Regional trauma ccnter serving a population basc of 1 . 2 5r n i l l i o n w i t h 8 5 , 0 0 0 v i s i t s p e r y c a r .

Participants: All paticnts presenting to the emergency departmcnt with PCI. Measuremcnts and results: The rccords of 49 patients with PCI were rcvicwed. Of these, 28 rcccived immediatc twodimensional cchocardiography in the ED (group 1), and 21 did not (group 2). The probability of survival was determincd using TRISS methodology. Diffcrcnces between groups werc determined using the two-sample t test. The overall probability of survival was 33.2"k, and the actual survival rate was 81.6%.

T h e p r o b a b i l i t y o f s u r v i v a l w a s 3 4 . 2 Y oa n d 3 1 . 8 % f o r g r o u p s I and 2, respectively. The actual survival rate was 100% in group t and 57.1% in group 2. The averagetime to diagnosis and disposition {or surgical intervention was 15.5 + I1.4 minutes for g r o u p I a n d 4 2 . 4 ! 2 1 . 7 m i n u t e s f o r g r o u p 2 ( P < . 0 0 1 ) .T h e a v e r age Glascow Outcome Score was 5.0 for group I and 4.158 for group2lP=.0071.

Study objective: To perform the first prospective assessment of complications of abdominal computcd tornography (AbCT) in the trauma paticnt.

Design: Complications occurring in trauma patients during adminisiration of contrast media or AbCT were prospectively collected on 96 consecutive patients during a six-month period.

All patients were accompanicd by a rcsident and a nurse. A complication was defined as an unanticipated event during CT that harmed or had the potential to harm the patient.

Setting: A 300-bed trauma center in a midsize city.

Results: The study population was 69.8% male with a mean age of 27.1 years, mean Injury Sevcrity Score of 12.0 x 3.2, and mean Clasgow Coma Score of 13.4 t 2.1. No complication occurred in 51 patients (53%1. Potential complications occurred 56 times in 45 patients (47%): In CT Suite or En Route

During Oral Contrast Loss of C'spine control Intratracheal NC tube Vomiting

25

3 3 l0

Reaction to IV contrast Need to intubate/reintubate Loss of C-spine control

I 2' 4

I0 paralvsis requirins Asitation

t, l;3:iiilf:::::TlT'

9 instabilitY HemodYnamic develdeficit) neurologic shock, (eg, aspiration, No sequelae ooed.and no patient'siourse *at altered' "'";;;;i;;;ileu-cr t."""ing in the trauma patient is safe it .lot"lv obierved and potential complica*h;;;;;;,i;ti p;;;ptly treated.' However, the potential for serious ;i;;;; sequelaeexists.

ara G I

of Acute EmpiricAntibioticTreatment InfectiousDiarrhea

of GWModin,MASande/University it Cohen, t tt Urionoor.

San Hospital' General SanFrancisco 6lrii.ii-ri.,5." Francisco, California Francisco, reportedthat in 134adultspreWe.previously Background: General sentinq to the emergency depa'tment at San Francisco

ciprofloxacin proved more efiec"""iJai"i't'.i, ;i;;i?"i;ii trimethoprim/sulfameihoxazole(TMP/SX) or placebo ;i;;'.h;r treati" L"a.li"* t,ools'free'of pathogenson the fourth day of ment. It wis unclear, however, whether antibiotic treatment be iden^f,.i"a iit. clinical outcome or whether patients.could from ,iii.a-"i iit. time of presentation who would benefit treatment. antibiotic empiric '^"i,r.,n"atir*o clinical outcomeswere measured:Total Diarwhich is a composite measurement of th;i'iii;;;t-rndex, of vomiting, temperature,^andnumber pain, nausea, abdominal "time to and l8)' to 0 of possibleicore a ti;"ts {wittr ;;l;;;J as time irom initiation of therapv to passageof *.ri;; ;;;t.ed stool. unformed esu lts: the - - Rlast P a t i e n t sw i t h m o d e r a t e - t o - s e v e ri lel n e s s ( T o t a i oi"tr-nJ Iifn.ss Index, 7 or higher) who had fecal leukocytes of diarp Gb, p . .oLl"t bloodi6a, . .0051had shor.tened.courses il.r-*tt.n't..ated with antibiotics(ciprofloxacinor TMP/SX)' fecal There was a strong correlationbetwein the presenceof pathogen,(eg' recognized a of culture with f"rl"1v,.t or blooi (P r-fti*Jfl, ."f-onella, campylobacter,yersinia,a.eromonas) -' *iih " -od.tate-to-severe illness and fccal .0'0ili.'P;ri;;; as meaUf""i i+-si"t leukocytes(41)were clinically.improved iliness index when treatedwith tr"r.a'Uv ift.-Jirt*."t ciorofloxacinbut not TMP/SX or placebo{P < 0O5)'-Interestrng, .od.t"i.-to-severe illnesswho did not have i;:;;;i;;;;tth of their il!ifi.tl*t,.. {e9)ot blood {331had earlier resolutions Ji"iift." *(." treated with rrutn/sx than those treated with ciprofloxacin '-'Eon.i"tlon:or placebo(P < .051.

Adult patients presentingwith moderate-toillnesi benefit from empiric antibiotic treatdir.rh.al s.u.r.

-."t, .ip-floxacin is superiorto fMn/SX when fecal leukowhen .ui"t'"nd blood are,pres.ni,b.tt TMP/SX may be of value fecal leukocytesand blood are absent'

.28

in Emergency Determination lnterleukin-6 of Predictor a as Patients Department Disease andInfectious Babteremia

SeveritY D Hoover'L H Mignoti,P Cobb,A Behrman'F Shofer., H Moscovitz, ol Universtty Pediatrics' and Medicine of Xiioai"r,lOtpurtmdnts Schoolof Medicine,Philadelphia Pennsvlvania B".kero.lnd, Sepsisis a major causeof morbidity and mortali," "-o?* pati.nis admitted through the emergencydepartih; nonspecificnature of methods applicableto acute ;;;. of infection in the ED prevents efficient therapv ;;;g;;t; and dispositionof thesepatients.

S t u d v o b i e c t i v e :T o d e t e r m i n e i f p l a s m a l e v e l s o f i n t e r l.rki; a; a cytokine mediator of sepsisand immune activation' with diseaseseverity in patients with-bacterial infec;;;;;it; a i-"". p.o"t"tion and setting: All patients admitted from bacteremia suspected for ED hospiial university "tf"n iri*.-, weie eligiblefor inclusion.Patientson antibtottcs,lmmunosuppressiveagents,or nonsteroidalanti-inflammatory drugs before patients with known neoplasmsor AIDS were la-itrioti""a excluded.

-"-il.ti*", Before antibiotic therapy, plasma was collected for a.,.t-iitiion of interleukin-6by enzyme-linkedimmunoadsorEach patient was foll'owedprospectivelythrough his b;;lttt"y.

II or her admission to assessclinical course (eg, APACHE

scores,bloodandothercultures,.lengthofhospitalstayrand of the interorrt.o-.) by investigators blinded to the results Fisher's leukin-6 assay.Data were analyzedby a two-tailed exact test.

Intewention: None.

57 n"rtrt,r' Thirty-one women and ten men {averageage' Plasma intervears; age range,'19 to 95 years) were enrolled' in l2 patients (mean, 8 37 ng/ml; i;i.;:e-*;;ietectable Tenbl these l2 patients{83%).had ng/ml-). i" 6I.lI i""-.,'OS+ .utiut.t [blood and other) compared-with]5 ;;i il;;;ti"t (52ol.w 1 i t h u n d e t e c t a b l ei n t e r l e u k l n - ol e v e l s ' t f 2 9 p a t i e n t s'tig"iii".", differencesin tvpe of pathogen culil;";;;;;o of six patients with interleukin-6 Five grorrpt. two the in tured cultures on i.".1. "f more th"an2.0 ng/ml- had positive blood ;;.pared withlix of 35 patient-s-withinterleukin-6 ;;;;t;;; discharsedbefore ; eimr lp < .001).All pafie.nts.(251 i.;;i;;at.0 than 2'0 ng/ml less of rtra'i"terleulin-('levels i'i Jrv ir;;i;f than 2 0 tn addition, patients with interleukin-6 levels of more Plasma ;;/"tL h;J'ti*nificantlv longerhospitalstavs{P < 001) .l."ri.a ii threebf the four patients who died ;fl;;];i.i;;";"' duringtheir hosPitalization' -Elevated plasnrainterleukin-6on admissionis Conclusion: with bacteremiaand severityof illness associated

A ProspectiveEvaluationof Topical Antibioticsfor UncomplicatedSoft'Tissue Lacerations of JLKarrlDepartment JJLorette, DADwyer, DJDire,M Coppola, pr0gram' Residency Medicine Emergency Medicine, Emergency Texas FortHood' Hospital, ArmyCommunity barna"t

ltat ZJ

infection rates Studv obiective: To determinc differences in treated with are lacerations that t.p,it.d ,-;;;;t;;;'tpltltt.d,

sulfate' ,"pi.""r !r.i,t"'cin zinc 1dnc, roo nalientg!.11omvcin patients)' bacitracinzinc, anclpoiymyxin B sulfate {NEO' I l0 108 .ifu"i tuffrai"zine {SiL, 99 patients);or petrolatum iPTR' patients). placeboDesign: Prospectlve,randomized,double-blinded' controlled -"-S.iiing,studY. Community hospitalemergencymedicineresidency program. n'"illJ.iprn,s: Four hundred twenty-six patients seenwithin who did not have puncture wounds' allergies 12 h;;;t;ai;yury ,rt.d, ot historv of immunocompromising disor;; ;i';;;;;; ders; wh"owere not presently taking antibiotics' chemotherapy' past seven oi ti.toiJt, who had not taken antibiotics within the history' by pregnant not were who and davs, *'r"i.tu"n,lons: Lidocain"el% or bupivacaine0 5% without was .pi".p-tttl". ,na high-pressureirrigation with normal saline a.nd u ' t . a ' fo t a l l p a t i i n i s w i t h s c r u b b l n g , - d e b r i d e m e n t ' nylon oolvslactinSQ sutures,if necessarySimple,.interrupted i,sed for cutaneousclosure Unlabeledvials were ;;;;;;;-;;t. to inspect' *iu.n ,o each patient with standardizedinstructions ii.t", ""a *ar'esstheir woundsthreetimes a daY'Wounds,were analyzed cvaluatedfor clinical iniectionat follow-up Data were analysisof varianceand Xz testswith d set at 05 wlih "^;iil6;Gong the groups,there were no significant,differsex; wound location, type, lengtn' anc age; patient in ences iniurv to ED treatment; scrubbedor /to;;;,h, ;i;; ;irpt"i used; ;;[;i.i.J -outd^r, amount oi itiig"t't or anesthetic agent with ttrnU.. "t SQ and cutaneouss"tuJtt used;and compliance the topical agents given. The BAC group had six infections I2 t{91lroup;"five infections {4'5olo);SIL-grolqt = i;.;i"l,'NiD il""t iii.rz"f , ,nO prn group;ten infectionsll7 '6%l {P 0034}' lower Conclusion:seC aid NIEOgto'pt had significantly groups' PTR or SIL than rates infection

30

inAdurt fi'::3i'S"#,!;gn'o'i"e of CB Cairns/Department

DM Birnbaumer, Pi Henneman, MedicalCenter'Torrance' Medicine,Harbor-UCLA Emergency Calilornia Study obiective:The United Statesis experiencinga measles .piJ.-i.. Tile purposeof this study wes to review our experi.'n.. *itft aduit pitients admitted to Harbor-UCLA Medical 1990' d.",.t *irtt -."ri.. betweenOctober 1989and October Design: Retrospectivechart review of all patients admitted

26

F

Participants and setting: All patients with culture-proven bacteremia seen in the emergency department of a large, urban university hospital.

Design: A review was performed of charts of all bacteremic ED patiJnts seen in 1989. Clinical features frequently associated with sepsis, including fever, leukocytosis, and hypotension, were noled. Significant coexisting conditions that increase risk of infection {eg immunosuppression, diabetes, or indwelling catheters) were identified. Physician seniority or tlpe of specialty training and presence or absence of subspecialty consultation, were also noted. For each patient, the throughput time {defined as time between triage and disposition) as well as time elapsing betwecn trlage and evaluation by a physician, and time of triage to initiation of antlbiotics were calculated. Separate analyses were then performed on the above variables of patients seen as long as three months subsequent to the dissemination, via an organized quality assurance (QA) program, of findings to ED practitioncrs regarding variables affecting timeliness. Data were analyzed by Student's t test.

Intcrvention: Presentation of results regarding timeliness variablcs in a QA format to ED practitioncrs.

Results: Charts of patients seen before (prc-QA, 421 and after (post-QA, eightI intervention wcre reviewed. In the pre-QA group, throughput time was 6.6 hours, time to evaluation - 1 .-ean 1 hours, and time to antibiotics was 4.5 hours. Neither was clinical fcaturcs of paticnt prescntation nor physician variables affcctcd timc to antibiotics. The presence of coexisting conditions was thc only factor significantly associated with timelincss of antibiotic thcrapy (P = .05).After thc intervcntion, mean throughput timc and timc to antibiotics were reduccd to 3.5 and 2.3 hours, rcspcctivcly, and mcan timc to evaluation was 0.7 hours. Although a change in time to cvaluation was not significant, throughput and antibiotics times were significantly shortc r ( P < . 0 0 4 1 .C o n c l u s i o n : S i g n i f i c a n t d e l a y s e x i s t i n t h e i n i t i a tion of antibiotic thcrapy in the ED. Surprisingly, level and type of physician training, subspecialty consultation and common clinical fcaturcs of sepsis (cg, fcvcr, leukocytosis, hypotension) do not significantly affcct thcsc delays. Prescnce of significant cocxisting conditions associated with increased risk of sepsis and hcightcned physician awarcness of antibiotic timeliness are thc only factors that significantly rcducc delays in antibiotic initiation. Dissemination of thesc rcsults through a QA mechanism has rcsulted in a 50% reduction in antibiotic delays.

through the emergencydepartment and dischargedfrom the hospital with the diagnosisof measles.

Setting:Urban county hospital in southern California.

P a r t i c i p a n t s :T w e n t y - s i x c o n s e c u t i v ea d u l t p a t i e n t s ( 1 2 women and 14 men; mean age,26.3 +l- 4.6years;agerange,lZ to 36 vearsl with measles.

Statistical analysis: Values are expres^sedas mean t S D , a n d comparisons are by two-tailed t test, Xz or Fisher's exact test where appropriate. Significance is defined as P < .05.

Results: Patients presented with complaints of fever (100%), c o u g h ( 1 0 0 % ) , a n d s h o r t n e s s o f b r e a t h 1 7 7 % )a s w e l l a s v o m i t i n g i73%), sore throat l73o/o), eye irritation 162o/o),diatthea 158%1, r h i n o r r h e a ( 5 8 % 1 , h e a d a c h e { 3 1 % ) , a n d p h o t o p h o b i a 1 2 7 % ) .T h e mean duration of symptoms was 5.6 + 2.5 days; 467o reportcd a reccnt exposurc to measles. Initial vital signs revealed rcspirations of 22+ 6; temPerature,3B.9 t 0.8 C, and pulse, l13 t 16.

Physical examination rcvcaled clear lungs in {85%}, as well as a diffuse rash {100%), which sometimes involved thc palms in ( 3 5 % ) , c o n j u n c t i v i t i s i B B % ) , p h a r y n g i t i s 1 7 3 % ) ,K o p l i k ' s s p o t s l 6 L ) % ) ,a n d a b d o r n i n a l t e n d e r n c s s ( 3 5 % ) . O n l y f o u r p a t i e n t s {15%} had an abnormal chest radiograph in the ED, yct all paticnts had an incrcased P lA-a) o2 gradient (41 t10 mm Hg; range,23 to 65 mrn Hg). Arterial blood gascs on room air revealed a Pao2 <tf 70 + 9 mm Hg and a Paco} oI 32 ! 4 mrn Hg Patients born in thc United Statcs i16) dif{crcd from those born outside o{ thc United Statcs (ten} only in their initial sodiurn v a l u c s { 1 3 2 t 3 v s 1 3 8 t . 5m m o l / L , r c s p e c t i v c l y ; P = . 0 1 1 .

C o n c l u s i o n : C l c a r l u n g s a n d n o r m a l c h c s t r a d i o g r a p h sd o n o t cxcludc significant respiratory compromise in adult paticnts with measlcs; arterial blood gases should be considcrcd, cspecialty if patrcnts arc tachypneic or complain of shortncss of brcath.

31

Prevalenceof PositiveAsymptomatic SyphilisTiters(HATTS)DuringPelvic Examinationin the lnner-CityEmergency Department

P M ] ' B r i e n , C S u g d e n / D i v i s i o no f T r a u m a a n d E m e r g e n c yM e d i c a l S e r v i c e sU M D N J ; R o b e r tW o o d J o h n s o n M e d i c a lS c h o o la t t ye d i c a lC e n t e r CamdenC ; o o p e rH o s p i t a l / U n i v e r s i M Study objcctivc: Thc national incidcnce of primary and sccondary syphilis for 1989 was 0.01U%. Wc sought to dctcrminc the prevalenceo{ untreatcd, asymptomatlc syphilis in a sr-rspcctcd high- risk population.

Dcsign: A prospcctivc, cross-scctional survcy conductcd b e t w c c n J r , r l y1 , 1 9 9 0 , a n d O c t o b e r l , 1 9 9 0 .

Setting: Inner-city university clncrgcncy dcpartmcnt.

Participants: Consccutivc wolncn (306) rcquiring pclvic cxamination cxcluding prior exposure to or symptoms of syphilis.

Intervention: Patients' scra that wcre RPR-positive werc tested for positivc asymptomatic syphilis titers and rccalled for treatmcnt, as recluircd by Centcrs for Discase Control guide-

33

Correlationof End-TidalCO2to Cerebral PerfusionDuringCPR

J B Chandel,M Kurtz,J Stothert, LM Lewis,J Standeven, Surgery MedicineDivision,Experimental Fortney/Emergency of Texas,Galveston of Surgery,University Department Institute, a correlaStudvobiectivc:Severalstudieshavedemonstrated tion bctwecn end-tidalCOr (ETcor)and cardiacoutput and/or return of spontaneouscircllationlin cardiopulmonaryarrest' However, there are no correlationsbetween ETco2 and cerebral p e r f u s i o n d u r i n g C P R . W e c o m p a r e dE T c o 2 w i t h i n t e r n a l carotid artery flow rates and radioactivemicrosphereperfusion measurements IMCS)in the arrestedpig model.

Design: Ten l2-kg piglets were anesthetized,intubated, and instrumented. A transonic flow probe was placedon both internal carotid arteriesfor continuousflow readouts.The animal was fibrillated, and CPR was started. Continuous ETco2 measurementswere obtained and comparedwith simultaneousflow readoutsas well as with the microsphereperfusiondata.

Results: There were 14 comparisonsbetween ETco2 and microspheresand 36 comparisoni between ETco2 and carotid flow measures(below).Correlationsamong ETco2,carotid flow, and microsphereperfusion were determined using Pearson's method. The validity of correlation was determinedusing both straight and Bonferroni'sadiustedprobabilities.The correlation between ETco2 and left internal carotid flow (L IC) was .80 (P < .01; Bonferroni,P = .O2),but the correlation to total carotid flow ( I C ) w a s o n l y . 5 8 { P < . 0 5 i B o n f e r r o n iP , =.3}.Correlation between ETco2 and microsphereswas .69 (P < .05; Bonferroni,P = .09t.

Iines.

Rcsults: Mean patient age was 28 years.Twcnty-one paticnts were HATTS-positive, resultrng in a prevalence of 6.9%. Six of t h e 2 l w o m c n 1 2 8 . 6 % )w e r e p r e g n a n t , a n d e i g h t ( 3 8 % ) h a d c o n current sexually transmitted diseases.

Conclusion: The prevalence of untreated asymptomatic syphilis in inner-city paticnts seeking emerSency care for peivic-related problems is considerably higher than thc national mean. There{ore, routine RPR screens should be done on all inner-city women presenting to thc ED for pelvic-related comp l a i n t s . B e c a u s em a n y o f t h e s e p a t i e n t s h a v e l i t t l e p r e n a t a l c a r e before dehvery, the increase in congenital syphilis may be related to these findinss.

32

AntibioticDelaysin the Bacteremic Patient:An Analysisof Emergency DepartmentHealthCare Delivery ofMedicine, D Brookoff/Department M Eisinger,F Shofer.

of P e n n s v l v a nSi ac h o ool f M e d i c i n eP, h i l a d e l o h i a University Study objectives: To identify the variables that affect timeliness of antibiotic therapy in the bacteremic patient and to study changes in physician behavror that result from dissemination of information regarding these variabies.

ET CO2 L IC Flow

27

Baseline {11}

CPR I

37.6 I0.4

22.1 1.9

{r1}

CPR 2 (8)

Recovery (8)

23.5 L9

36.4 20.8

t4.9 25.3

R IC Flow lL

ttow

MCS {Brain) MCS {Cortex)

{4) 120.2 87.1

2.3 4.2

{s)

37.5 31.5

1.5 3.4

{01 0 o

7.6 28.4

Results: No. of Patients

{s}

Survivaltime

82.1 64.6

1 <4 hours No'

TNF detected ( m a x i m u ml e v e l )

2

6

3

6-27 hours

>20 days

Yes Yes ( 4 6 8 . 5p g / m L l l2s3 pslmLl 24 hours 6 hours

Conclusion: ETcoj correlatesto c e r c b r a l p e r f u s i o n a s d e t e r mined by two indepentrentmethods i n a n a r r e s t e d s w i n e m o d e l CPR. undergoingclosed-chest

Time TNF first detected

34

Conclusion: TNF is releasedafter ROSC from cardiacarrest patient, but not until at least six hours and TNF presenceat six hours was associatedwith 100% mortality secondaryto MOSF. No long-term survivor demonstratedeither the early presenceof TNF or a level of more than 26OpglmL. TNF may play a role in the ischemia/reper{usioniniury and MOSF commonly seenafter ROSC from cardiacarrest.

MixedVenousOxygenSaturation Monitoringas an lndicatorof Returnof SpontaneousCirculationDuringHuman

CPR TJAppleton, CH H Smithline, J Petriangela, GBMartin, EPRivers, of Emergency RMNowak/Department MGGoetting, Schultz, t ,i c h i g a n y o r dH o s p i t aDl ,e t r o iM M e d i c i nH ee , n rF Background: Continuous mixed venous oxygen saturation {SvO2) is used as a.monitot of hemodynamic status during s p o n t a n e o u sc l r c u l a i l o n .

Study objective: To determrne thc ability of SVO2 to prcdict a return of spontaneouscirculation (ROSC) during CPR. Design: Six-month, prospective/nonrandomized casc sertes.

S c t t i n g :U r b a n c m e r g c n c yd c p a r t m c n t .

Participants: Seventy-three consccutive paticnts with a mcan agc of 63 1 14 ycars, who prescntcd in medical cardiac a r r c s t . F o r t y - t h r e e c p i s o d e so f R O S C w e r e m o n i t o r e d .

Intervcntions: Central aortic and double-lumcn right atrial cathcters were insertcd. A fiberoptic SVO? cathctcr was placcd in the right atrium. All paticnts rcceived-advanccdcardiac lifc s L r p p o r t .H i g h - d o s c e p i n c p h r i n c w a s g i v c n a t t h c c l i n i c i a n ' s d i s crction. ROSC was defined as a svstolic blood rrrcssurc of (r0 rnm Hg or morc for at least fivc minutes.

R e s u l t s :T a b l c g i v c s r n c a n S V O 2 + i S D p e r c c n t a g c s f t r r ROSC and no-ROSC groups.

lnitial Mern' Mrxirlum'

ROSC

No ROSC

26!14 42! t5 6 f Jt 1 4

2 4! l I 29 t 1.3 4lt14

' l ) i l i r e dl - t c s tr e v c a l c ds i c n i f i c a n d t i f f e r e n c ebsc t w e e nt h e R O S Ca n d n r r R ( ) S Cg r o u p s( 1 )< . 0 0 Il .

Conclusion: Paticnts with ROSC havc significantly highcr m c a n a n d m a x i m a l S V O 2 v a l u c s . A m a x i m u m S V O 2 o f 6 0 < ' l 'o r rnrrrc had a positive predictive valuc of 90"1, for ROSI. A rnaxir n r - r mS V C ) 2 o f I e s s t h a n 3 0 o 1 ,h a d a n c g a t i v c p r c d i c t i v c v a l u c o f l0O'X' for ROSC. SVO, can bc casily measurcd and is a reliablc prcdictur of ROSC and monitor of thcrapcutic rcsponsc during CPR.

.35

CirculatingTumor NecrosisFactorin HumansAfter ResuscitationFrom CardiacArrest

J EPRivers,H Schultz, G Meyer,MA Basha,L Kunkel,RM Strieter, l , e p a r t m eonft E m e r g e n c y P o p o v i c hJ ,r l H e n r F y o r dH o s p i t a D M e d i c i n ae n dD i v i s i o no l P u l m o n a rayn dC r i t i c aCl a r eM e d i c i n e , H e n r yF o r dH e a l t hS c i e n c eCs e n t e rD, e t r o i tD; i v i s i o no f P u l m o n a r y y ,n i v e r s i toyf a n dC r i t i c aCl a r eM e d i c i n eD, e p a r t m eonft P a t h o l o g U M e d i c aSl c h o o lA, n nA r b o r M , ichigan Michigan Background:Tumor necrosisfactor (TNF) is a biologically active polypeptidehormone and a primary mediattrrin sepsis and multiorgan system failure lMOSF) as wcll as in jury. ischcmia/reperfusron S t u d v o b i e c t i v eT: o d c t e r m i n ei f T N F i s r c l c a s c di n t h c i s c h e m i a / r e p e r f u s i oinn j u r y o f c a r d r a ca r r e s t w i t h r e t u r n o f spontaneous circulation(ROSC).

Design:Four-monthprospectivecasesericswith repctitivc sampllng.

Sctting:Urban cmcrgencydepartmcnt.

Participants:Twenty-oneadults resuscitatedfrom normothcrmic, nontraumaticcardiacarrest.Exclusioncritcria includcd currentinfection,renalfailure,and malignancy.

I n t e r v e n t i o n sS : e r u mc o l l e c t e do n E D a r r i v a l , R O S C ,a n d o n e , t w o , t h r e e ,f o u r , s i x , 1 2 , a n d 2 4 h o u r s a f t e r R O S C a n d with an enzymeimmunoassay. assayed

'TNF level < l0 pg/ml

Not detected

considered undetectable.

Arter and fi1fr:;'Jl;;,X'ixffit",""rins GB EGGoad,HA Smithline, CH Schultz,EPRivers,S Feldkamp,

.36

, Nowak/Henry M a r t i nD , C L e a c hM , G G o e t t i n gM, G h e o r g h i a dReM Medicine,Detroit, of Emergency FordHospital,Departmenl Michigan Background:Cortisol and catecholaminesact synergistically to augmentvasculartone and myocardialcontractility.

S t u d y o b j e c t i v e :T o s t u d y t h e h y p o t h a l a m i c - p i t u i t a r y adrcnalaxis in cardiacarrcst (CA) and with return of spontancouscirculationlROSCl. Dcsign:Five-monthprospectiveseries.

Sctting:Urban emergencydepartment.

Participants:One hundred nine consccutiveadult cardiac arrcstpatients(meanage,64 X 16 years),who were not receiving stcrolds.

Intcrvcntions:Cortisol and adrenocortisolicotropin {ACTH} lcvcls wcrc drawn on prcsentation.ROSC patientshad cortisol lcvcls drawn hourly for six hours. An ACTH level was drawn and a cosyntropinstimulation test (CST)was performedat six and 24 hours.

Rcsults:Mean initial cortisol level was 28 ! 28 gg/dl. Fiftyfivc patientshad levelsof lessthan 20 ttgldL.Of the 3l ROSC paticnts,30 had an initial cortisol level of more than l0 pg/dl.

Cortisol lcvelsincreasedby l3 t 17 ltgldL from one to six hours (1)<.001, paired t tests).There was no further increaseat 24 hours (P = .2tl).No paticnt rcspondedto CST at six or 24 hours.

Mcan ACTH lcvclswerc at or abovenormal.

Conclusions:Fifty-onepcrccnt of patientsstudiedhad cortisol lcvels bclow 20 pg/dl, which is consideredadrenalinsuffi' ciency in noncardiacarrcstpatientsunder stress.Ninety-seven pcrccnt of ROSC paticnts had cortisol levels above 10 gg/dl.

Failurcto rcspondto the CST indicatesa primary adrenaldisordcr that cxhibits incompletcrccoveryduring the first 24 hours aftcr ROSC.Adrenalinsufficiencymay haveimportanthemodyduring resuscitationfrom cardiacarrest. namic consequcnces The rolc of cxogenouscortisol administration during cardiac further study. arrestand aftcr ROSCdeserves

37

Correlationof Blood PressureWith Mortalityand NeurologicRecoveryin Patients ComatosePostresuscitation

P Safar,K SuttonTyrell,JM Schoffstaff, WHSpivey,NS Abramson, f R e s e a r cD h ,e p a r t m eonft B R C Tl l S t u d yG r o u p / D i v i s i o n of Pennsylvania, E m e r g e n cMye d i c i n eM, e d i c aCl o l l e g e e s e a r cChe n t e rU, n i v e r s i toyf P h i l a d e l p h iRae; s u s c i t a t iR on P i t t s b u r gP h ,e n n s y l v a n i a Studyobjective:To correlatereperfusionsystolicblood pressureduring the first hour after cardiacarrestwith mortality and neurologic recovery.The hypothesiswas that patlents who are hypotensiveafter cardiacarrest have a higher mortality and a lower neurologicrecoveryrate than patientswith normotensive reperfusion.

Design:Retrospectivestudy using data from the Brain Resuscitation Clinical Trial II study. Setting:Multicenter hospital e m e r g e n c yd e p a r t m e n t s c, r i t i c a l c a r e u n i t s , a n d p r e h o s p i t a l emergencymedicalservices.

Participants:Patients who remained comatoseafter successful resuscitationfrom cardiacarrest and did not have a terminal

Department-BasedH ome

illness, intracranial bleed, drug overdose, or hypothermia.

Interventions: Patients received protocol-defined standard postresuscitation therapy. Patients received either lidoflazine or placebo in a randomized, double-blind fashion within 30 minutes of resuscitation. Patients are reported as a single group.

Hemodynamic, neurologic, and overall pcrforqrance data were collected for six months after resuscitation. XL used for analysis.

Results: Five hundred sixtecn paticnts werc cnrolled. At 30 minutes after resuscitation, 4il4 had sufficicnt data for analysis.

Mortality rates for systolic blood pressure of less than 90 mm Hg or more at 30 and 60 minutcs after rcsuscitation are as follows.

N

24 Hours

7 Days

(r lllonths

39

ol the University of M Minnitti,S McNichol/Hospital D Brookoff, P e n n s y l v a nainadS k i l l e dN u r s i n gl n c ,P h i l a d e l p h i a

Good Neurologic Recovery

30 min BP < 90 mm Hg 290mrnHg

66 4llt

60 rnin BP < 90 rrrrnHg 290mmHg

3 Kr"l'l 50 20 (40.0'Z') ,\7 174'v,') 4lt (9rr'X,) 4 3 0 7 l ( 1 6 5 ' 2 , )2 0 s 1 4 7 . 6 " 1 ' ) , 1 4 5 ( 8 0lzl 0' x( ,2l 5 . ( r " 1 , )

: a 8( 4 2 . 4 % ) 4 2 $ 3 . 6 " 1 , 5 9 ( u 9 . 4 ' Z , l l 2 ( l l i . 2 ' l . 1 7 0 1 1 6 . 7 " 1 '2) O 2 { 4 8 . . 1 ' 2. 1 , ). 1178 0 . 6 ' l ' 11 0 21 2 4 . 4 " 1 ' l

P a t i c n t s w h o r c c c i v c d p r c s s o r s 1 2 6 7 Jh a d a h i g h e r m o r t a l i t y r a t c ( t t u . 4 % lt h a n t h o s c w h o d i d n o t ( 2 0 1 , o r 7 f l . l % , )( P < . 0 0 5 . ) Good neurologic rccovery occurrcd in 5l paticnts (19.(r%)whtr r c c e i v e d p r c s s o r s v e r s u s ( r 2 o f t h e g r o u p ( 3 5 ' 2 , )n o t r e c e i v i n g p r c s s o r s( , P< . 0 0 1 ) .

Conclusron: Dcspitc aggrcssivc thcrapy, outcolrc is poor ir.t comatosc survivors of cardiac arrcst with systolic blood prcssurc o f l c s s t h a n 9 0 n i r l H g d r - r r i n gt h c f i r s t ( r 0 n r i n u t c s a f t c r r c s t r s c i t at i o r l .

138

M M N l e l s e n ,W G B a r s a n ,R V W D i m l i c h / D e p a r t m e n ot f E m e r g e n c y M e d i c i n eU, n i v e r s i toy f C i n c i n n a tCi o l l e g eo f M e d i c i n e , 0 h i o

2 5 4!

207 !

2 3 5t 1 7 4I

27' 44' 33' .18'

HospitalAdmissionsof ChildrenFromthe EmergencyDepartment:Are Decisions RegardingChildrenon PublicAssistance Different?

S E K r u g , M B M o l i n a r i , T S Y a m a s h i t a / D e p a r t m e notf P e d i a t r i c s , C a s e W e s t e r nR e s e r v eU n i v e r s i t yS c h o o l o f M e d i c i n e , R a i n b o w , l e v e l a n d0, h i o B a b i e sa n d C h i l d r e n sH o s p i t a l C

Study hypothesis: Elcvatcd serum glucosc has bcctr associated with poor neurologicoutcorre aftcr brain ischcmia. Wc hypothcsizc that paticnts rcsuscitatcd from cardiac arrcst who rcccivc [V dcxtrosc solutions (lVD] havc worse neurologic outc o m c st h a n t h o s c r c c c i v i n g s a l i n c .

D c s i g n : R c t r o s p c c t i v c a n a l y s i s o f c < t n s c c t t t i v ep i t t i e n t s admitted to thc intcnsive carc unit aftcr resuscitation from c;lrd i a c a r r e s t b c t w c c n A p r i l 1 9 t 3 9a n c l f r . r n c 1 9 9 0 . D a t a w c r c i l n a l y z c d u s i n g a n a l y s i s o f v a r i a n c c , D u n c a n ' s r n r " r l t i p l c - r a n gt ce s t , a n d K r u s k a l - W a l l i st es t s .

R c s u l t s : S i x t y - s c v c n p a t i c n t s w c r e r c s u s c i t a t c d f r o n . rc a r c l t a c arrcst and admittcd to thc intcnsivc carc unit. Twenty-one wcre cxcludcd for inadequatc data (19) or bccausc thcy rcccivcd Dq6 (two). Twenty-two paticnts survivcd to hospital clischargc.

L e n g t h o f c a r d i a c a r r c s t w a s i n v c r s c l y r c l a t e d t o s r . r r v i v a l { 1 )= . 0 0 0 6 ) .T h i r t y p a t i c n t s r e c c i v c d I V D , a n d l ( r r c c c i v c d s a l i n c .

Patients who reccivcd IVD and survivcd 24 hours had sicnificantly higher admission glucosc levcls than those rccciving s a l i n e( P < . 0 5 ) . T h e r c w a s n o s i g n i f i c a n t d i f f c r c n c c i n a g c , lcngth of cardiac arrcst, 24-hour glucose Ievcls, or survival bctwccn IVD and salinc groups. Neurologic outcomc (aftcr car' diac arrcst neurokrgic function/bcfore cardiac arrcst ncurologic functionI was significantly better in paticnts rcceiving salinc {P < . 0 5 ) . T h i s w a s a l s o t r u c f o r n o n d i a b e t i cp a t i c n t s ( P < . 0 1 5 )

A l l p a t r e n t sI V D All paticnts S NondiabeticIVI) NondiabeticS 'P. . 0 5 ;t P = . 0 1 5

S t u d y o b j e c t i v e : T o a s s e s sn e e d f o r h o m e n u r s i n g s e r v i c e s among patients being discharged from the emergency department and the effectiveness of stationing a home'care nurse coordinator in the ED. Dcsign: Srx hundred fifty consccutrve adult patients were surveyed about past use of home-care services. Specially orrentc d c m e r g e n c y n u r s e s a s s e s s e dt h e s e p a t i e n t s w i t h r e s p e c t t o need for home-care services, including skilled nursing, home rehabilitativc scrvices, and medical equipment. Standard Medicarc and Mcdicaid rcimbursement guidelines wcre used as criter i a f o r a p p r o p r i a t c n c s so f r e f e r r a l . A f t e r t h e s u r v e y w a s c o m p l c t cd, an ED-bascd home-care group was established with a fulltimc dedicatcd nurse coordinator, specially ortented emcrgency physicians, and rapidly dcploycd serviccs.The outcomes of Datients rcfcrrcd from thc ED to hornc care for a nine-month pcriod wcre comparcd with casecontrols.

Sctting: Urban tcaching hospital ED. P a r t i c i p a n t s : A d u l t E D p a t l e n t s o n d i s c h a r g ch o m e .

R c s u l t s : S c v e n p e r c c n t o f p a t i e n t s b c r n g d i s c h a r g c dw e r e e l i gible for and in need of home-carc scrviccs that thcy were not rccciving. Four hundred fifty patients wcrc referred to hotne carc, comparcd with ten in thc previous ycar. Compared with casc controls, rcferred paticnts had 60% fcwer admissions and 40"1, fewcr hospital days during the ycar for which thcy werc followcd. Thcy also rcquired 30% fcwcr ED visits.

Crlnclusion: Home-care rcfcrral can bc a uscful and costc f f e r t i v c c ( ) n r p ( ) n e not f e t n c r g t n c y s e r v i c e s .

140

Effectof lV Glucoseon Survivaland NeurologicOutcomeAfter Cardiac Arrest

Admitting Glucose

E1.ln"n"tDepartment'BasedHome

Study hypothcsis: Children on public assistancc arc lnorc likcly than othcr payor classchrldrcn to bc aclmittcd for hospital care for nonmcdical reasons.

Population: Childrcn 0 to 17 ycars old admittcd from an urban, univcrsity hospital emcrgcncy dcpartment.

Mcthods: A prospectivc questionnairc survcy was complcted by thc admitting physician for cvcry child admittcd from thc cmcrgcncy dcpartment. The qucstionnairc rccordcd dcmographic tlata, insurancc status, primary carc provider, adrnittir-rg diagr . r o s c sa, n d r c a s o n f o r a d m i s s i o n . T h e r c a s o n f o r a d m i s s i o n w a s notcd as bcing strictly medical or nonmedical (rncdical but c o r - r l dh a v c i r c c n { o l l o w e d a t h o m c , o r p u r e l y s o c i a l ) . I n t h e c a s c of nonrncdical admissions, thc admitting physician was asked what rcsources, if availablc, might havc prcvcnted thc admis^ s i o n . G r o u p c l i f f c r e n c e sw c r e a n a l y z c d b y Y a t c s ' c o r r c c t c d X z analysls.

Rcsults: During the first two months of study, thcrc wcrc (r/0 admissions and (r70 surveys completcd. Of thc adrnittcd children, 50.3% werc Medicaid insured, 36.lol' wcrc commerciallv insured. and 5.5% had no insurance. Of Medicaid admiss i o n s , 9 . 5 % w e r e f o r n o n m e d i c a l r e a s o n s ,c o m p a r c d w i t h 1 . 9 % of noninsured and2.B% of commercially insured children. Childrcn admitted for nonmedical rcasons were youngcr (3.3 vs (r.0 y c a r s , P < . 0 0 ( r ) , m o r e I i k c l y t o h a v e M e d i c a i d c o v e r a g e{ P < .001),and lcss likely to have a prrmary care physician (P <.03) t h a n t h o s e a d m i t t e d s o l e l y f o r m e d i c a l c a u s e s .F o r t h e c h i l d r e n admittcd for nonmedical reasons, the most freclucnt rcsponses regarding the necessary resources to prevent the adrnission involved either guaranteed transportation to ensure follow-up care (58%) or the availability of homc-care nursing (47%).

Conclusion: These preliminary data demonstrate a significant difference in the incidence of nonmedical admissions for c h i l d r e n o n p u b l i c a s s i s t a n c e .T h e a b s e n c e o f a n i d e n t i f i e d p r i mary care provider, guaranteed transportation for follow-up caret or home-care nursing may contribute to these admissions.

Further study should heip to better define this problem and identify potential solutions.

Neurologic 0utcome

s l ' / "( 1 r 0 1 ' f]9% )til)' 46"/,,! IIr

r00.r,t

Conclusion: Patients who receivc IVD during and after cardiac arrest have higher serum glucosc levcis and worsc ncurologic outcomes than patients receiving saline. Further evaluation of IV solutions used during cardiac arrest is indicated to clarify the rclationship between IV glucose administration and n e u r o l o g i co u t c o m e a f t e r r e s u s c i t a t i o n f r o m c a r d i a c a r r e s t .

29

41

Relationshipof Day Versus Night Sleepto PhysicianPerformanceand Mood

^4, r+1)

0f S Hurd,K Buccino/Department MRRosekind, R Snith-Coggins, California Stanford, Stanlord University, Services, Emergency

Medical Center, County JS Fastow/Hennepin J Borer, RARusnak. i t yc h o oolf M i n n e a p o lM i si ,n n e s o Jt ao;h n sH o p k i nUsn i v e r s S Maryland Baltimore, Medicine,

Study obiectives: To examine the effect of shift work on physicians' sleep, cognitive and motor skill performancesand

Background:Missed appendicitisis the secondleading cause of litigation againstemergencyphysicians.

Methods: ihe emergencydepartrnentevaluation of 65 cases of missed appendicitisthat resultedin litigation were compared with 56 conCurtentcontrol casesto test the nq.!l hypothesisand analyzedusing the Mann-Whitney U test, Xz test or Fisher's .*""i t.rt and stepwisediscriminate analysis;a P value of less than .05 was consideredsignificant.

Results:Comparedwith controls, missed caseshad a longer duration of symploms; complainedless frequently of abdominal pain, right lower-quadrantpain, or nauseaand vomiting; complained more frequently of right upper-quadrantor epigastric pain; less frequenlly had physical examination findings of tenderness,rebound, or guarding; had fewer rectal examinations per{ormed;had white blood cell counts of lessthan 10,000;were more frequently treated with narcotic pain medication;wâ&#x201A;Źrâ&#x201A;Ź frequently diagnosedas having gastroenteritis;had more operations and moie operativecomplications;and more often had gangrenousor perforatedappendicitis.Two patients died The iverage total settlement amount was $20,429.In the only jury trial, ihe defendantphysician was found innocent. There was no differencein the number of yearsof experienceor the board certification status of physiciansbetween missed and correctly cases. diagnosed -Conclusion: Correctly diagnosingacute appendicitisis still a challengefor both novice and expert clinicians Quality assurance recommendationsbasedon discriminate analysis are presented.

Design: University hospital and homes of the attending physicians.

Participants:Six volunteer attendingemergencyphysicians.

Intervintions: EEG, EOG, and EMG recordings were obtained for two 24-hour periods comparing day work/night sleepwith night work/day sleep.Three performancetests were administered five times during these 24-hour periods with hourly subiective mood ratings obtained while subiects were awake.The performancetests included a triage test to measure cogrritivefunction, mannequin intubation to assessmotor skill, and a performancevigilance task for reactiontime.

Relults: The physicians spent significantly less time in bed {P =.01) and had significantlyless sleeplP = .O2lwhen sleeo occurredduring the day. The reducedsleeptime was associated particularly with lessrapid eye movement sleep(REM)lP = .O21, in the secondhalf of the sleep period. Physiciansworking day shifts rated themselvessignificantly less sleepyiP < .01),more h a p p y( P < . 0 1 ) , a n d a b l e t o t h i n k m o r e c l e a r l y{ P < . 0 1 ) t h a n when they worked night shifts. Physiciansworking night shifts were slower at intubating a mannequin (P = .O4land more likely to commit an error as their shift progressed(P = .041.Physicians in both conditions were more likely to err during a simulated triagetest toward the end of their shifts {P = .02).

Conclusion:Physiciansworking the night shift and sleeping during the day had significantly less time in bed, less total sleep time, and less REM sleep,and they showed deteriorationin both psychomotor and cognitive performances.,Theywere significantly more tired, less happy, and less clear thinking while working during the night comparedwith the day shift.

.42

44

EducationalInterventionIncreases Documentationof Requestfor Organ and Tissue Donationand RecoveryFrom the ED

Study obiective:To assessthe effect of an educationalintervention on the rate of donation request and recovery from patients dying in the emergencydepartment.

Design:A prospective,blinded, six-month chart review comparing physiciansexposedto the educationalintervention {EDP) with those who did not receivethe intervention {CON) and to a retrospectivereview of charts for the l4 months precedingthe intervention {RCR}.

Setting:A 600-bedteachinghospital that has renal and bone marrow transplant programsand approximately 45,000 ED visits annually.

Interventions: Two didactic sessionsreviewing recognition and care of potential donors, required-requestlegislation, and the servicesavailablefrom our transplantprogramwere presented four weeks apart. After a one-month grace period, the prospectivechart review began.

Results: EDP 4 76Y" 65% 32V" 487o 50V"

CON IJ

4O"/"' 7"/.# 7'/.

8%' O%

HospitalED ComPlaintFrequency: Variationby PatientMedianHousehold Income

Beaumont M StraitAVilliam LRSchwartz, BJDennis, DTOverton, StateUniversity Michigan Oak,Michigan; Hospital, Royal Hospital, WilliamBeaumont Studies; forMedical Center Kalamazoo i tfyM i c h i g aMn e d i c aSlc h o o l n ;n i v e r s o T r o yM , i c h i g aU department emergency Studieshavedetermined Background: in specificsettingsandhavesugpatientComplaint{requencies

Maine; MedicalCenter,Portland, RRRiker,BW White/Maine of Vermont University

N 3 Donation mention Family discussion Consentobtained Comea recovery Valve recovery

in of AcuteAppendicitis Misdiagnosis Patients:An Department Emergency Analysisof CommonErrorsDiscovered AfterLitigation

gestedtheir use as comparativequality assurancemeasures.

However, complaint frequenciesr.i'ayvary among different populations. If so, indiscriminate use may incorrectly imply underlying differencesin the quality of care and service.

Purpose:To determine whether ED complaint frequency varies with patient median household income, as measuredby patient zip code.

M e t h o d s : A l l c o m p l a i n t s r e c e i v e di n o n e E D f r o m 1 9 8 5 through 1989 were reviewed.Median household income of the residencezip code of the person registeringthe complaint was obtainedfrom availabledemographicdata.Patientswere categorized into the following seven zip code-determinedmedian household income categories:less than $25,000,$25,000to $30,000,$30,000to $35,000,$3s,000 to $40,000,$40,000to $45,000,$45,000to $50,000,and more than $50,000.Zip code data for the entire ED patient population during the same time oeriod were obtained.Exclusionswere l) casesin which zip codes could not be determined or zip code income data could not be obtained, 2) complaints from physicians rather than patients, and 3) data from zip codes remote from the hospital. bistributional analysis^wasperformed_toconfirm adequate group size.Armitage's X2 test for trend of proportionswas used to comparecomplaint frequenciesin different income groups.

Results:During the study period, 285,331patients were seen in the ED. Of the 285,331patients,7,164 werc patients from remote zip codes, and 957 patients gave incomplete zip code information or were from zip codes without available income d a t a . T h u s , 2 7 7 , 2 1 Ov i s i t s w e r e a n a l y z e d .O f t h e 2 7 7 , 2 1 0 patients, 793 complaints were received.Seventy-eightwere from physicians, and 40 had incornplete zip code information or were from zio codes without available income data. Thus, 575

RCR I JJ

167o+ 27o+ O.67"+ Oo/o+ 2o/o+

' P < .05,#P< .01;+ P < .001;RCRor CON vs EDP. The EDP rate of donation mention decreasedduring the six months from 100% to 43"/"lP = .0041.

Conclusion: An educational intervention can increase documentation of donation request with an accompanyingincrease in donation and recovery of tissue. Repeatedinterventions may be necessaryto maintain the increased rates of documentation and recovery.

30

complaints were analyzed. Complaint frequencles ranged from 1.65 to 3.14/1,000 visits. Statistical analysis revealed that higher-income patients were more likely than lower-income patients to complain (P = .00000581.

Conclusion: In this setting, ED patients residing in highermedian-income zip codes are more likely to register complarnts than those from lower-income zip codes. Complaint frequencies from hospitals with different demographics may not be comparable or reflect underlying differencesin quality.

Af,^ rlr,

A Comparisonof ThreeAntiemeticsUsed in the Treatmentof MotionSickness

T A D i G i o v a n n a ,G B G r e e n ,K T S i v e r t s o n ,G D K e l e n / D e p a r t m e not I EmergencM y e d i c i n e ,T h e J o h n s H o p k i n sU n i v e r s i t yS c h o o lo f MedicineB , a l t i m o r eM , aryland Study objective: To cvaluate the use of prochlorperazine, oromethazine. and trimethobenzamide in thc trcattnent of icvcre motion sickncss after failed nonparcnteral thcrapy. l)esign: Prospective, randomized, doublc-blind, controllcd trial.

Setting: Four-wcek duration for each of two cruise ships, each with seven-day itincraries in thc Caribbcan. Ship A has a c a p a c i t y f o r 8 0 0 p a s s c n g c r sa n d 3 1 0 c r c w ; s h i p B h a s a c a p a c i t y f o r 2 , 2 O Op a s s c n g e r sa n d 9 3 5 c r c w .

Particrpants: All patients presenting to thc ship's hospital with motion sickness, actively vomiting, and failcd nonparcntcral thcrapy.

Methods: Paticnts wcrc givcn IM injcctions of l0 mg prochlorpcrazinc,50 mg promcthazinc, or 200 mg trirncthobenzamidc. Groups werc comparablc for prognostic indicators. Follow-up occurrcd in 24 hours. Scdation was rankcd from I to 4.

Rcsults: Thcre wcre U4 fcmales and 20 malcs (agcrangc frorn l 4 t o U l ) e d r s ; m c a n a g c , 4 1 . 0 y c a r s ) . A l l h a d v o r n i t c d f r o t . t to n e t o s e v en t i m c s . F o r t y - t w o l 4 O % ) c o m p l a i n c d o f v c r t i g o .

Nausea

Vertigo

Sedation'

Drug

Vomiting

Prochlorperrzinc Pnrrnethazine Trimcthobcnzamitlt

2el)'x,) 291.1"1,)8 (l.tu'z,) 2.4r.t 3 7{ 3 , / , , ) 3 7( 3 ' U , ) r s ( 2 0 ' U , ) 1 e 7 3 0 { r 0 ' 2 , )3 0 { 2 3 ' l , , l1s { r i O ' z , l 1 . 2 . 1

P < . 0 5f o r a l l c o r r p a r i s t : nasc r o s sg r o u p s . ' M c a n r a n k s c o r e( h i s h e ri n d i c a t e sm t t r es c d a t i o n l .

Conclusion: Prochlorpcrazinc and promcthazinc wcre supcrior to trimcthobenzamidc for thc trcatmcnt of motion sickncss.

Promcthazinc was superior to thc othcrs for thc trcatrncnt of vcrtigo. Prochlorpcrazinc was thc most scdating, and trimcthobcnzamidc was thc lcast. Wc recommcnd promcthazincas ovcrall best for scvcrc motion sickncss.

46

in the Efficacyof Metoclopramide Treatmentof MigraineHeadache

G LE l l i sJ,D e l a n e y A v e sPt e rnnn s y l v aHn oi as p i t aPl i, t t s b u r g h , d e s i d e nicnyE m e r g e n c y U n i v e r soi tl P y i t t s b u rA gh f ifl i a t eR M e d i c i nPei ,t t s b u r g h Background:Other invcstigators havc suggcstcd that metoclopramide(M) is effective in trcating migraine headachcs{HA) b _ yr e l i e v i n g g a s t r i c s t a s i s a n d a l l o w i n g a b s o r p t i o n o f a n o t h e r t n e r a p e u t l ca g e n t .

Study purpose: By evaluating the cfficacy of M alonc and in combination with ibuprofen {l} versus placcbos (P),this study is d e s i g n e dt o b o t h e v a l u a t e t h e c f f i c a c y o { M a n d c l u c i d a t e i t s m e c h a n i s mo f a c t i o n .

D e s i g n :T h e s t u d y w a s c o n d u c t e d o v e r a t w o - y e a r p e r i o d a n d was a randomi.zedd , ouble-blind, placebo-controlledstudy.

S e t t i n g :P e r f o r m e d i n a n u r b a n , t e a c h i n g h o s p i t a l .

P a r t i c i p a n t s :P a t i e n t s e n r o l l e d w e r e m o r e t h a n l U y e a r s o l d with recurring HA and having one or more of the following h e a d a c h ec h a r a c t e r i s t i c s : u n i l a t e r a l , p r e c e d e d b y n e u r o l o g i c symptoms, significant nausea and vomiting, or mood changes and photophobia.

Intervention: Ten milligrams of M or cqual volume of normal saline IV and 600 mg of I or idcntical-appearing placcbo weregiven orally at time 0. Patients rated their pain and nausea at times 0, 30 minutes, and 60 minutes, using a visual analog scale.

Results: The differences in parn and nausea scores for the M + P group versus the other three groups were tested using non-

parametric statistical procedures (Mann-Whitney test) and the P values are shown below (Table). Nausea scores for the P + P group were not analyzed due to excessive baseline variance from the other clinical groups. As can be seen {Table), the M + P group showed significantly lower median pain scores than the P + I and P + P groups. The M + P group also showed a statistical trend in the direction of lower median nausea scores compared with the P + I group. A11 comparisons of the M + P and M + I groups were not statistically significant.

60 minutes Pain N a u s ea

liI+P vs ill+I

NS NS

ill+P vs P+I

.0301 .0660

llI+P vs P+P .0041

C o n c l u s i o n : M i s e f f i c a c i o u si n t h e t r e a t m e n t o f H A a n d t h i s is a direct action not dependent on the addition of another agcnt.

47

Effectivenessand Safetyof lV Nalmefene for ED PatientsWith SuspectedNarcotic Overdoses

tf J K a p l a n ,J M a r x / E m e r g e n c yM e d i c i n e S e c t i o n ,D e p a r t m e n o , hiladelphia, M e d i c i n e ,T e m p l eU n i v e r s i t yH e a l t hS c i e n c e sC e n t e r P P e n n s y l v a n l aE ; m e r g e n c yM e d i c a l S e r v i c e s ,D e n v e rG e n e r a l H o s p i t a l ;U n i v e r s i t yo f C o l o r a d oH e a l t hS c i e n c e s Study objective: To evaluate efficacy and safety o{ nalmefcnc, an invcstigatronal narcotic antagonist that has potential aclvantaccsovet naloxone because o{ its five-to-six-hour halflifc, in crnergency dcpartment patients with possible narcotic ovcrdose.

P a r t i c i p a n t s : M u l t i - i n s t i t u t i o n a l , p r o s p e c t i v e , p h a s e - I l ,o p e n labcl study. Con-rplete data are availabie for 53 cases from two t c a c h i r - r gh o s p i t a l s . M e n 1 8 y e a r s o l d o r o l d e r w h o w o u l d o t h e r wisc rcccivc naloxone were eligible.

Mcthods: Over four hours, one to ten boluses imedian, l)of 0.5 or l.O mg IV nalmcfcne were given as often as every two rninLltcs bascd on clinical need. Respirations, blood pressure, pulsc, pupil sizc, and Overall Clinical Response (OCR) were r u r o n i t o r c c l .O C R ( n o c h a n g e , l ; p a r t i a l r e s p o n s e , 2 , c o m p l e t e rosponsc, 3), first asscssed at two minutes, was analyzedby Wilcoxon rank-sum tcst.

Rcsults: Fiftccn of 25 (0.5 mg) and nine o{ 28 (i.0 mg} cases wcrc opiatc-positivc. Elevcn of I5 (0.5 mg) and six of 9 (1.0 mg) o p i a t c - p o s i t i v c c a s c s h a d a r a p i d c o m p l e t e r e s p o n s e .C o i n c i d e n t car:scsof dcpressed sensorium were identified in the other scvcn opiatc-positive cases. No difference in initial OCR was s c c n b c t w c c n 0 . 5 a n d 1 . 0 m g o p i a t e - p o s i t i v e c a s e s( P = . 5 9 ) . N o clctcrioration rcquiring rcpeat nalmefene occurred in opiate-positive cascs, cvcn if methadone {four), codeine (two), or pentazocinc {onc) was found. No scrious adverse events were judged r el a t c c l t o n a l m c f c n e .

Conclusion: Nalmefene is cffective in the reversal of opiate ovcrdosc and safe in the management of patients with altered scnsorium.

48

Comparisonof Intermittentand ContinuouslyNebulizedAlbuterolfor Treatmentof Asthmain a UrbanED

J Mazur,J WH Spivey,RS Eberlein, G Rudnitsky, of Department Collegeof Pennsylvania, Schoffstall/Medical o f R e s e a r cP h ,h i l a d e l p h i a E m e r g e n cMye d i c i n eD, i v i s i o n Study objective:To comparecontrnuousnebulization(CN) w i t h s t a n d a r di n t e r m i t t e n t n e b u l i z a t i o n( l N l o f a l b u t e r o li n t r c a t m e n t o f p a t i e n t sw i t h a c u t e a s t h m ai n t h e e m e r g e n c y deoartmcnt.

D e s i g n : R a n d o m i z e db l o c k d e s i g ni n g r o u p so f t e n w i t h opcn-labeldrug administration.

Setting:Urban hospitalED. Participants:Patrentsl7 yearsold or older with peak flow ( P E F R )o f l e s s 2 0 0 L / m i n a f t e r 2 . 5 m g a l b u t e r o l t r e a t m e n t .

Exclusions included patients with temperatureof 38.3 C or more, pulmonary infection, heart failure, and pregnancy.

Interventions:Patientsreceived125 mg IV solumedrol.IN patients receivednebulized2.5 mg albuterol 30, 60, 90, and 120 minutes after the initial treatment. CN patientsreceivedl0 mg albuterol in 70 mL normal saline solution deliveredvia continuous nebulizer during 90 minutes. PEFRand vital signswere

I scor?s recordedevery30 mrnutes'Asthma 1e1:^:1lt:l:f,tr:":; ol analysis using

"r,"ly"ed lff fiTf ]i'iz6i,ii,,i[r*or,"'*ei. mean t SEM' a s mean-r,SEM l ] ] - ^ , 1 - - - ^ - , 1 v 2 t o r ^ e r e --'i"-*tt" r e o o r t e d as reported

for an addi41% oftotal test use' Other admissions.'*:"X::g on patients dischargeddirect*"r.-oid.t.d lg% and 40% tional was t{ p"tie"it lacked HYC' Low magnesium i"l'il".*ii,?i;2"

:l?i.Tl ;1'/i"

g: g'iik"*rltnl:'1# ?"J11i"":fi: ili:miTii ;::'.li".Ji:n::l:

ffi:IJ';;"":;;i:;;; *ji:l rr'"'" "''':^:Ti'i"-rtt" aft';i;'--1.1s:jr"lfrti

use of HYC Prospective in onlv oneof 140ED pattents' i,r"#o""iii "ri;i."| i"t"-ttttion

fz. ;;;;; tancearru^ iT'1?#:""1

Results: Fifty-two patrel

enrolled: 3l in the cN t.-^^-.,^-t2A+j !7 werct34

il'q[1i PEFRrralues -,"ff'":'i;oT?h;in ;'ffi;' -^^s var"tivelv'Val respectively' and IN groups, *{41':in" i,tn+ Q L/min" t;; for the6N ffi tN;;lN

to 303I ri""a iso i 1o'i".'.11-'.;)^T:,15 uesincreased

ri,l,r'i ..* r:l(P :;:3j#rl'"s ;,'.,ill *:'rl;Tl]; < oll "i1'-T:: fir*;'; :1.'*ll,j.::* between betweengrouPD sroups. 1'*: 1o w s r t ' *IUJ ; s r o n heart n e a r t rrates a f , c swere sion ,

*'1iit; in the 101 t 5

#ri#*:r"."i'd::"1;ru.x'#?Tfi ""t:'"1ii:"J"f

li; !l:,ry:';;.'il"3J*::*1i;T',!llifr

iii *n'&'t$d;*"rTi::','x':::t'$""*:'np*; j;lr;[r':;ffi]:J*iil""#iT]i1i"'iis j6;,: {ortheIN cN gtonf'"d

r in N t h e cCN i n the t 3 9l + i " t t d or ht;';;tt IN group; at 120 minutet, - L ^ ^ r * i . . i ^ n / . r i e . h a r q er a t e

*:",';"s

f;:1tt:t-";';;;;iiii''"i-'p-"a

with t4izt

iiXi'."a"",1"" i" -'gt'"tit'tm

group,(P.<.05). 'd-11,'^'"t:^:i:i CN methodof B-agonist I rrc Lr.i'"i;;;;.fr'ut ;oncrusrolr:rhe t?'iir";YJ;, did not offera ciin i r e dl e s sn u r s i n ga n d P n Y S ^ : - . : - - -cN N

i::iif :l-f'?#il"fi ;ff;p;';;i'ili;;tfu admitted.

49

receivine ;#;;;i1 rir 1 PatLe111 ""i'v'^idr" '"d werelesslikelv to be

testing without morbidity'

gJdr :,;:ill::,,,,,. r?: ?1^,,,,,1:siil{fi,[ Calilornia

i"on' #iifl;li'#*L{i1tgi'#".}H:j{trtll ffi'il',ffi3J"T$'H!ii1"T3o'lu'f tlT

lcute Siclile Cell Pain crisis Medicine' o1Emergency iCr-oinToivision Jr,RCJoroen, CVPottack Jackson Center' Medical rtlisilssippi Urirttlitv'.j u s e f u l n e sosf r o u t i n e S t u d yo b i e c t i v eT: o d e t e r m i n et h e occuit detecting-clinicallv and ";;i;;;l-;t chestradiographs rn department emergency infectionin adultsptttt"iin! to-the (SCPC)', crisis pain cell "i"t. ti.ti.

-3"^*i',t' D esign: Prospectivecllnlcal stuqy' "*i";'J"1:*;T1,1? ;, .*'rL known sickIe p'eiented to the ED with acute non-

*t'o h.;;;i;it;;prtitv traumaticPainful comPlaints' underwent all pli::tt Interventions: on "tiu'i in the ED' (cxR)' routrne url"nJ t*ttt"t chest radiographv ""#;;;;;;i;,

t t"?top.t t "o t t pat i ent s I", i o.,: A mbu Iat orv rtt ,n:.dv1,1T:"1 i l.t*:

i*ttt*lt:::? nonp."tt'^ti"! withacute Xff#H'T: !ll.tnrrt.nrswithcompromisedneurovascu ItJ:i.'r"rti".XXJ,ifi

ilxi111*i* d"'.'rl*ffi :: :":;-: t*,.1;,xi,{;. "%i:il; ilit"il"n''l.liiiff t$-:{":i:ttl,'u,rmf ;'*ift n "?"dJ".'avfo'* t'' "-,$ Design:A Prospectl\ or denv the hYPothests' "' identifie.dtl"ii"t M;ih"Jr;'\ihen eligible patients are

in count(cBC-RC) #i;:ii.ru;i;r"d. Csc-;ith reticulocvie ttsts A standardquesaddition to any otner "ti"i"tiiy

inaicated

::Tf;:

;;?.i.a ;,d;.;;';;;; J he or she feels are nccessa :T* 1'11;:1itg-ifr.'t^ai"graphs

#,:$*:"''"',:','mil;ily;T,q*1;ti

;i;;;;"r";1::*i'g.i'"Tl,tr,""tffmt,,ll'"::;il,61 *fii:*fl":,:{ix;fi'i:i:"dits *lllq**rtfu urinarYtract (UTI) intt studies with AII CXRs*.r. ,n,.rpr.i"a ""a **p."a were ol.rtaincd -previouson all t"tt'-ites ijiint bv staff radiologists' pain,and/ormorcthan5 ,iri.r" *irt ""iEi"g ,Vlpior*, flank a colonvcount or at u't' o" f'eld il;ffi";; fi'Cthitf 6;;; positive' considered was 100,000 least of ED presentations Results:s.u."ty-o"JltiJtiiJ **tt 134 osf d i a g n o s i s i x m o n t h a P e r r o o ' , A o v e r S C P Cw e r es t u d i e d

JlEilffi:::; ::*.**:ru':nfiffi:l';ii:5qq::n -of

have been detected without UTI *"r. made; six ;;;le;;t emPiric UA screentng' C o n c l u s i o n : M o r e t h a n S 0 % o l d i a g n o s physical e d i n f e c texaminaionsinthis hiJtory' serieswere no, .*pt"ftd based.on

tttKiit:ti"

with '271 date,263patientshavebeenenrolled'

*ai"g,^phe.ii:;y:1#lijn*;:m}:"j,?,i:.(.,l1 Predtc ty, and Positive t'rl,-t.t ,i. summirized (Table)' SPecilicitY PPv SensitivitY N Fingers Hano Wrist Forearm blbow Knee Ankle Foot

37 +t 28

.86 .85 .71

97 96 98

80 76 83

1; i; ;a

.83 .87 loo

'e7 1.oo oo

ss l oo e6

A

.87

.eB

8e

aa

iHi6i*:ft'e';:,t'.-::':::l'1;'i?il'xTl3;:iJ""'::i#il infection' of crisis-related ;il;il'd;Aosis

.e6

.ee

es

NPv .97 .98 .98 .99 .99 t.00 .99 98

99 84 included presently not The humerus, tibia, and toes are areas

Total

27r

ar"'iiiiiii.oliil.';;;;;;'

lilhT:''flfJffJtil:liEfiiT'J;,J"'u" 50 Eilop,41,A"tbry:',lr'l'Ji;::.:'5ffi :?:Biu.il?,ti,l?;

'87

98

rherewas.no patternor trendbv

influencedthe resultspreanv one triage nurse tn'i-'duttstlythe above

h':.1T.1:::o il;,;;. a;;".i'rio'' No p'ioi "uav p'"itnt study indicate:

H of Virginia University

tl'-.:1.1n:11-:::,Y:1tiffi To determi"".

Studyobiective: : .'" p t j : i:i1: " d' L;;;;" ; ,hr;';i;s; 1:l"l, (TXci,' :and :1-" evaluate HYC "riteria ) :Xt ;'ii;il;;is;-;i"iJ'"linlcal their predictive values' patients on whom serum Design:Retrospectrvereview of ED drawn' were levels magnesium ----'S.tting' UniversityhospitalED' presentrng on; hu;dred forty adult patients e"i,ffi"",.' duringa one-month.Period'

values

:lil":l hvpothesisin a generatt6' fnt practrces triage nurse radiographordering ;i'{;'; ;ll ;;;;;il *ith"the gold standardused have good-to-excellentt&it'f"tio" forearm'with PPV of 0 55' However, two areas'* ;i;;t*t: The El physician ordered o'if sensitivity-"i with wrist, and rhis area

i#.-;"i:,

seriesin t!:.:'ldt

,ili""':;"T;";18 f;,""'-'.*,,".:'-*rtll.r\n.J;:*['::fi radlograpns' extremity order iccurately can

52 :;J'fii:$;:,iJ UJfi i"iJq'=ilill'tT" AcuteCirvicalSpinalColuml,lniury

ilf.?"H..i#il'iri.'p"h"*e :f :h,:::-'ll:l:?l*1: f'ili'",""""i1-^r""9:tT'::lY*T":. *."1:"JJ."'il;'Ji,;fi or aminoglvcoJi*"irc, theophvlline' H:,'#';ilt;ili",'"J ttut*Tli,r.r, comprised admissions for cardiac ordering Protocol

;;;;;;-i;';-ioi'"'-

General Highland of CafifoiniaSin Francisco, MA Levitt/UniTersity CaliJornia Oakland, HosDital,

Studvobiective:To evaluatethe finding of spinal cord contusion, edema,and transectionon magnetic resonancein,aging (MRi) with the level, completeness,and type of cord injury foundon neuroiogicexamination.

Design:RetrosPective.

Setting:Level I trauma and regionalspinal cord center.

Forty-eightpatients with cervical spinal colPartrci"pants: umn iniury.

Interventions:MRI, neurologic examination to determine l e v e l o f i n j u r y a n d g r a d i n ga s c o m p l e t e ( C S C I ) ,i n c o m p l e - t e IISCI),central cord (CCl, or Brown-sequardIBS)as definedby the American Spinal Injury Association.

Results:Seventy-oneiniuries were identifredby MRI including l9 spinal cord iniuries. Neurologic gradingresulted in CSCI (ten),tSCt (271,CC lsix),and BS (two).Findingsof cord pathology on MRI were CC of 0% and BS of 50%. Seventypercentof CSCIand 75% of ICSI showedcord pathologyon MRI {P = .016).

Fifty percentof patients with and 36% of patients without fracturesor disc herniationshad cord pathologyon MRI {P = .028).

Injuries that were penetrating demonstratedcord pathoiogy 100%of the time and blunt iniurv 427. of the time.

Conclusion:Completenessof spinal cord injury on neurologic examinationwas found to have a significant associationwith t h e p r e s e n c eo r a b s e n c eo f c o r d p a t h o l o g y o n M R I . T h o s e patiantswith CC syndrome lacked MRI finding'" The radiographicpresenceof fracture and disc herniation did demonstrate with cord iniury on MRI. The neurologa significantassociation ic level of cord injury found on MRI correlatedwell with the l e v e l o f i n j u r y o n n e u r o l o g i ce x a m i n a t i o n .P e n e t r a t i n gc o r d iniuries uniformly demonstratecord injury on MRI, whereas blunt iniuriesdo lessthan half the time.

53

Design:Prospectivesurvey over a five-month pUriod.

Setting:Two university hospital emergencydepartments.

Participants:Sevenhundred fiity consecutiveadults presenting with blunt ankle infuries.

Interventions:Thirty-two standardizedclinical findings were prospectivelyassessed and recordedon data sheetsby emergency ' siaffphysiciansbeforeradiography.

Meaiurements:Those variablesfound to be most reliable for interobserveragreementby the k coefficient and most strongly associatedwith significant fracturesby univariate analysiswere then analyzedby logistic regressionand recursive partitioning techniquesto developa decisionrule.

Results:All 103 significant fractures{ound in the 919 ankle or foot radiographserieswere identified among peoplewho were 55 vearsold or blder, had locaiizedbone tendernessof the posterioi edgeor tip of either malleolus, the baseof the fifth metatarial, or the naviculz(; or werâ&#x201A;Ź unable to bear weight at any time after the injury. This rule was 100% sensitiveand 36.47. spectlicfor detectingfractures,so it would allow a reduction o{ i2.3% of radiographsordered.Conclusion:This decision rule will now be validated and may permit clinicians to confidently reducethe number of radiographsorderedin ankle iniury Datrents.

.55

Dislocations

of Emergency WAWatson/Department GMGaddis, JCJordan, M e d i c i nU en , i v e r soi tlyM i s s o u r i - K a nCsiat ysS c h o oolf M e d i c i n e , , i s s o u rSi ;c h o oolf Cle n t eKr ,a n s aCsi t yM T r u m aM n edica P h a r m a cUyn, i v e r soi ttyM i s s o u r i - K a nCsiat ys shoulderradiographs Obtainingprereduction Background: or glenohumeral dislocation (PRSXR|for a1lcasesof probable subluxation(GHD/Sldelaysexpedientreductionandpredispos-

Comparisonof PhysicianJudgmentand DecisionAids for OrderingChest Radiographsfor Pneumonia

D Effron,F NV Dawson,T Speroll,C Sicialiano, CLEmerman, t sm e r g e n cMye d i c i n e , R a s h a uZ d ,S h a w E , L B e l l o n / D e p a r t m eonf E t he d i c aCl e n t e rC, a s e Medicine a ,n dR a d i o l o g yM, e t r o H e a lM 0hio Cleveland, Western Reserve University,

es the patient to complications from delayedreduction, but it permits the prereducti,ondiagnosisof any significant associated irr.tut. {SAi): Hill-Sachs{HS)and Bankart{B)fractures,which may be noted on prereductionor postreductionradiographs,are not SAF,and do not alter prereductionmanagement.

Study hypothesis:Pati-entswith recurrent GHD/S are unlikelv to have SAF and mav safelvhave PRSXRomitted.

Dcsign, setting, and participants:Retrospective36-month chart review of patientswith new (50)or recurrent(57,29 individuals) GHD/S, identified through a computerizeddata base maintaincdat our institution.

1'3.5%) patients with recurrentCHD/S Results:Two of 57 and five of 50 (10%) patients with new GHD/S had SAF (P = N S ) ; s i x p a t i e n t sw i t h n e w a n d 1 7 p a t i e n t sw i t h r e c u r r e n t GHD/S trad an HS or B 1P < .05). Forty-five of 57 recurrent G H D / S p a t i e n t s s t a t e d a c h i e f c o m p l a i n t c o n s i s t e n tw i t h "minor" u n c o m p l i c a t e dG H D / S , w h e r e a s 2 3 o f 5 7 s t a t e da mechanism of iniury. No one in these subgroupshad an SAF. Neither mechanismof injury nor chief complaintwas adequately predictive of SAF among new patients with GHD/S. Obtaining nRSXn addedapproximately 90 minutes and $58 ior radiographic chargesper patient.

-- -Conclusion: A chief complaint consistentwith an uncomplicated recurrentGHDiS or a history of a minor mechanismof injury associatedwith a clinically diagnosedrecurrent GHD/S had a negativepredictive value for SAF of 100%. PRSXRsmay be safely omitted in these subgroups,permitting cost and time savings.A confirmatory prospectivestudy is warranted.

High-yieldcriteriahavc beendcvelopedto limit Background: c h e s tr a d i o g r a p h isn p a t i e n t sw i t h s y m p t o m s o f r e s p i r a t o r y infection.

Study oblective:To compareclinical iudgment with previouslypublisheddecisionards.

Study population:Adult patients in the emergencydepartment and clinics were included if they presentedwith cough andeitherfever,sputum production,or hemoptysis.

Methods:Physiciansindicatedwhether patients requireda to demonstratepneumonia.AII patientsunderchestradiograph includingpatientsfor whom the physiwent chestradiography, cian would not have orderedradiographs.Physicianjudgment was comparedwith decisionaids developedby Diehr, Singal, Heckerling,and Gennis. Using a cutoff point that maximized accuracy,sensitivity,specificity,and overall accuracyof each aid werecomparedwith physicianjudgment.Results:Two hundredninety patientswere studied,of whom 7% had pneumonia.

T h e s e n s i t i v i t yo f p h y s i c i a nj u d g m e n tw a s 0 . 8 6 , s p e c i f i c i t y , 0.5t1; and accuracy,0.50.Specificityof the Gennis (0.76),Diehr { 0 . 6 7 )a, n d H e c k e r l i n g{ 0 . ( r 7 r) u l e s w e r e g r e a t e rt h a n t h a t o f p h y s i c i a nj u d g r n e n t .T h e a c c u r a c yo f t h e G e n n i s ( 0 . 7 6 )a n d Heckerling{0.68)rules were greaterthan physicianjudgment.

N o n e o f t h e r u l e s h a d a s e n s i t i v i t y g r e a t e rt h a n t h a t o f t h e physicians.

C o n c l u s i o n :T h e d e c i s i o na i d s o f C e n n i s a n d H e c k e r l i n g weredemonstratedto have greaterspecificity and accuracythan p h y s i c i a nj u d g m e n t .T h e s e d e c i s i o na i d s m a y h a v e a r o l e i n patientsfor chestradiography. selecting

54

Evaluationof the Roleof Retrospective Radiographsin the Diagnosisand of Glenohumeral Management

anAnimar il,3i;i11ffi:llJiij,:il:?;in Inc, Hospital 0f Indiana JHJones/Methodist SCWestenberg,

.56

I n di a n a p o l i s

A Studyto Developand Assessa Clinical DecisionRulefor the Use of Radiography in Acute Ankle Injuries

Study obiective: Peritoneallavagecore rewarming, a readily available treatment for hypothermia, has historically achieved rewarming rates of 0.5 to 4.5 C/hr with a maximal reported lavageflow rate of 175 ml/kgihr in dogs.Our objective was to achievemore rapid core rewatming with peritoneallavageusing a high-flow fluid warmer.

Design: Animal study with historical controls. Hound dogs l2Oto 25 kg) were anesthetizedwith thiopental and isoflurane.

of RC Nair/Division RD McKniOht, lG Stiell, G Greenberg, and ol Epidemiology Emergency Medicineand Department of 0ttawa,0ntario,Canada Medicine,University Community Study obiective:To developa decision rule for the use of radiographs in ankle iniuries.

JJ

Pancuronium was administered to prevent shivering, and the ao*. *"t. shavedto facilitate cooling. The dogswere-suspended i"?u^, o{ ice water and cooled to za C as measuredby a right atrial probe.Vital signs,central venou pressure/peak inspiratory arterial lactate, pr.r.*. {PIP),electiolytes, arterial blood gase.s, and core temperaturewete monitored. Baseline,-postcooling, ,nJ ootti"t.*ention values were comparedwith the use of single and pairedt tests.

'--i"i.iu."tions: The dogs were removed from the vat and A.i.a. e" 8.5 F influx cathJter was percutaneouslyplacedin the r"p*i"i atdominal midline. A 28 F efflux tube {a chest tube *ianoed in sterile gauze to prevent omental blockage)was olace'din the in{erior abdominal midline by minilaparotomy lechnique. Sterile dialysate was infused through a Bard Infuser iTo rias.s to 40.I C with a circulatingvolume of 12 L Efflux was sterilely returned for rewarming and reinfr,rsion'Lavagewas discontinuedwhen core temperaturereachedl0 C above the cooling nadir.

Results:Ten dogs were studied. An averagerewarmlng rate of 7.35 C/hr and r*n ru.ttg. lavageflow rate of 1 33 Likg/hr were obtained.These rat.s rv.re significantly different comp a r e d w i t h h i s t o r i c c o n t r o l s ( a . 5 C / h r l P - 0 0 1 4 1. a n d 1 7 5 i"Ut g/ttt [P < .0001],respectively).No significant changein pr.ss.-rie,peak inspiratory pressure,arterial lac-."n"art.ii^l i;;., "; blood gas valuei occurredduring rewarming' No dog of arrhythmiasor died before.termination .f."if "pJ-"tiinant data collectionlTwo incidencesof hemodynamically-insignificant hemoperitoneumwere nbted. Conclusion: High flow pcri ion.ri fru"s. using a fluid warmer is an effective,readily available n-rethoi of aciive core rewarming in a dog model of severe hypothermia.

*EZ -.,

I

Pacingin a Hypothermic Transcutaneous Model Dog

J Dougherty/Akron GeneralMedical D Lombino,R Dix-onR Rusnak, ol Cso l l e g e C e n t eirn a l f i l i a t i owni t hN o r t h e a s t eOr nh i oU n i v e r s i t i e M e d i c i nA e ,k r o n , 0 h i o externalcardiacpacinghas Studv obiective:Transcutancous b c c o m e ' a ne f f e c t i v ea d i u n c ti n t h e t r e a t m e n to f s y m p t o m a t i c t r . r a v " t t t t v t t t m i a s ;h o w e v e r , i t h a s n o t b e e n e v a l u a t e d i n iruolitt"t-ir. This study evaluatedthe safety and efficacy-of ,1"ln..u,ro.ot,s external'cardiacpacing in a hypothermic dog model.

Design:A prospective,controlled study using,2Omongrel dogs.T;1 dogs*ere in the exper-imentalgroup, and the remainintuing"ten *erei:sed as controls. All dogs-were ane-sthetized, b a i . d , a " d m e c h a n i c a l l yv e n t i l a t e d .S w a n - G a n zc a t h e t e r , femoral arterial line, and esophagealand rectal temperature probeswere placed in each animil. Cardiac rhythm and core iemperatureswere continuously monitored All dogs were surtranface-cooledto 27 C core temperatureand then underwqnt @ Quick-Pace noninscutaneouspacing using , i;iiv.i-c"",t"l umiu. pr..-rker"(expeiimenial group) or sham pacing (control group).'serialhemodynamicmeasurementswere obtained,and itt. dogt *.r. e*t.tn.lly rewarmed to their baselineprecooling t.*p.i"tr.rr.r. Results:We demonstratedan averageincreasein \n the experimental group of dogs, ."rd'ir. output of 36.4o/o which were externally paced,comparedwith a 7'2% average increasein the nonpacedgtoup (P . 01 by X/.f, \o dog had signifi"rn, hemodynamic deterioration,potentially lethal arrhythmias, cardiac,o"y^, abnormalities,or histologic evidenceof cardiaciniurv. Time to rewarming occutred twice as fast in the groupof dogs. experimental{paced) Conclusion: We conclude that transcutaneousexternal cardiac pacing is safe,effective and easy to use in.a hypothermic dog modelltt may representa useful adignct in the treatment of severehypothermiawith bradycardiain human beings'

Dapsoneor Electric Shock Therapyof E O Br6wn RecluseSpiderEnvenomation {lO ofOklahoma DEFisher/Unlversity M Romine-Jenkins, SMBarrett, City Center,Oklahoma HealthSciences Study hypothesis: Different therapeutic modalities have beenproposei for brown reclusespiderenvenomation,but there have been few controlled evaluationsof these therapies We tested the null hypothesrsthat no outcome di{{erencesexist

the treatmentSroups.

-"'6."r*n, among we condu'cteda randomized,prospective,placebostudy with the guineapig model Hartexperimental conitotlEd, ley guinea pigs were randomized into treatment groups: Dapr J " E i l " i o l r i s P h a r m a c e u t i c a l , P r i n c e . t o n ,N e w f e r s e y ) , i^r:^!iii""t stun gun, Guardian stun gun, placebo,and no treatment.

Interventions:Brown recluse spider skin lesions were induced with intradermal iniections of 30 pg spider venom and i.."t.d beeinning I6 hours after inoculation Shock regimens consisted6f foui.rott shocksof one-secondduration on anesihetized animals.OraI Dapsonetreatment 1va90,7 mg/kg.BID foi three days. Lesion arei was measureddaily for four days' A n i m a l s w e r e k i l l e d a t 7 2 h o u r s , a n d t i s s u e s a m p l e sw e r e obtainedfor histologic examination.

Results:Data were analyzedby the statistic.alprogram SAS (SASInstitute,Cary, North Carolina)using analysisof variance ior repeatedmeasuresand Duncan's test for muitiple gompaiD^prot. therapv group demonstratedsignificantlv i;;;;:ih; less induration (P < .05) thln ihat shown by the Guardian stun grln or control groups 72 hours after envenomation There were !i." lnJi"^iio.ti that the area of necrosis was decreasedwith Drp.on. therapy, although there was no.statistical significance 1p ' .OSt.We beiieve thaistatistical significancemay have been !.hl.u"d if more study animals had been used and the wounds ["J t..t "lt.rved {or more than 72 hours The electric shock regimen deliveredby the Guardian stun gun did not show a staiis"tical dlfferencefrom the control group (P ' 05) The shock deliu.redby the Parali/azerstun gun delayed.woundhealing.as inal.rt.a by thc area of induration compared.with that of the study group (P < .05).Conclusion:Dapsone.therapyappears-to b. ;o;. efiectivethan either electric shock or no therap-yfor iliu*n ,."lut. spidercnvenomationin the guineapig model

Effectof ConstrictionBandson *E(| RattlesnakeVenomAbsorption:A rra, PharmacokineticStudy Medicine ofEmergency M Mayersohn/Section RCDart, JL Burgess, of[/edicine, College Sciences, ofPharmaceutical andDe-partment Center, Information andDrug Poison Arizona ofArizona; University Tucson Studyobjective:To determinewhether the use of a constriction bank aitcrs systemic absorptionof rattlesnakevenom in pils and whether a constriction bank increaseslocal swelling' Design: Using a random, crossoverdesign,five pigs were s t u d i e d " w i t ha n d w i t h o u t c o n s t r i c t i o nb a n d i n g l o d i n e - 1 2 5 l a b e l e dW e s t e r n D i a m o n d b a c k( C r o t a l u sa t r o x ) v e n o m w a s injected subcutaneouslyinto one foreleg. The opposite.legw.as ,.r.d ri* days later. The constrictionband was applieda.tthe ii-. of injectionand removedfour hours later' Plasmaradioacwere seriallymeasured' tivitv and leg circumference Rcsults:[atios o{ cuffcddatato noncuffeddata Maximum AUc cmax t l'/2 cmax 0'4 hours 4'96hours 0'4 hours Circumference Mean SD

r.02 0.747' 0 . 3 7 0 .I s 0

L020 0.420

0.(168.

0.118

0 985 0.0L2

'P < .05 by pairedt test;t l,/2iseliminationhalf-li{e;p"ox i' maximum plasma concentrati6;;and AUC is area under concentration-aimecurve. A sharp increase in venom absorption after constriction band removal was not observed' Conclusion: The use of a constriction band was effectivein reducing venom absorptionbefore four hours (reducedCtalx and AUL values in the cuffed group). However, after constriction band removal, maximum levels were the same Venom swelling, and time to. maximum swelling were elimination, leg -B.cause ionstriction band use delayedvenom not affected. absorptionwithout increasingswelling, it promisesto be a use' ful first-aid measure.

.60

Evaluationand Treatmentof Local

stinss:A Fffllil:il'ffit'"no'tera Akron, 0hio CityHospital, J R6ss/Akron M Mackan,

BDBender, to To designan animalmodelandprocedure Studyobiective:

34

simulate hymenoptera stings, to pictorially record the natural history of the sting local reaction and to evaluate the efficacy of topical treatments on the sting local reaction.

Population: Ten adult New Zealand rabbits.

Design: Hymenoptera stings were produced by injecting 50 pg of commercial Apis mellifera venom in 5 pL using a IO-pL, beveled, gas chromatography syringe inserted into the dermis to a depth of 2 mm. Each rabbit received two simulated "stings" on its depilated back. In this prospective, randomized, blinded study, one of eight topical agents (calamine B% and diphenhydramine HCl l% [CDPH], heat, ice, isopropyl alcohol 70%, ammonium hydroxide INH4OH], 0.5% hydrocortisone, meat tenderizer [papain] or baking soda Isodium bicarbonate]) was applied to one sting site. The othcr sitc was le{t untreated {control).

Measurements: Each sting site was photographed and measured twicc at the following intervals: baseline; ten minutesi one, two, srx, 12,24, 36, 48, and 72 hours; and five, ten and 15 days after the strng. Mcasurcments included the diameter of erythema and diameter of induration.

Results: The simulated sting was reproduced consistently.

CDPH decreased the size and severity of the local reaction by more than 75"/".lce, heat, and isopropyl alcohol had no effect.

Meat tenderizer, baking soda, NHaOH, and hydrocortisonc prod u c e d a d v e r s ee f f c c t s .

Conclusion: A rabbit rnodel and a proccdure using commercial A meliifcra venom provide a reproducible simulation of hymcnoptera sting local reaction. Of various topical agcnts, only CDPH was effective in rcducrng the local sting ruactlon.

61

EmergencyPhysicianReferralfor Venom lmmunotherapyof PatientsWith HymenopteraStings:A DecisionAnalysis

L G G r a f f / N e wB r i t a i n G e n e r a lH o s p i t a l ,U n i v e r s i t yo l C o n n e c t i c u t H e a l t hC e n t e r .N e w B r i t a i n S t r - r d yh y p o t h e s i s : A d u l t p a t i c n t s t r c a t c d f o r s y s t e m i c a n a phylaxis rcsulting frorr a hymcnoptera sting will havc fcwcr future anaphylactic events if they are referrcd for vcnom immunotherapy (\,IT).

Dcsign: Dccision analysis using results of 56 publishcd studi c s o n t h e c f f i c a c y o f V I T . T h r c e d i f { c r c r - r tr a t e s o f r c - s t i n g w c r e c o n s i d c r c d :2 7 " p c r y c a r { l o w , p a t i c n t s w i t h o u t s i g n i f i c a n t o u t door exposurc), IOY" per year {moderatci patients with signific a n t o l r t d o o r c x p o s u r e ) ,a n d 5 0 % p e r y c a r ( h i g h , b c c k c c p c r s ) .

R c s u l t s :T h e r i s k p c r y c a r o f a s y s t c m i c a n a p h y l a c t r c c v c n t l s lowcr for paticnts rcfcrrcd for VIT than for patients not rcfcrrcd for VIT:1ow rate of re-sting (0.05% vs 0.96%1, moderatc ratc of r e - s t i n g{ 0 . 2 5 % v s 4 . 8 % ) , o r h i g h r a t e o f r e - s t i n g 1 1 . 2 6 %v s 2 4 % 1 .

The risk of an anaphylactic event from VIT itself is minimal (0.17%pcr year, no reported deaths).The bencfit of rcfcrral for VIT is less than the above ideal because of patient noncompliance (8% of patients drop out of VIT during induction and 23% drop out of VIT during maintenance). Including patient noncompliancc in the analysis, the risk per ycar of a systemic anaphylactic event is still lower for patients referred for VIT than for patients not referred for VIT: low rate of re-sting {0.3(r% vs 0 . 9 6 % ) ,m o d e r a t e r a t c o f a r e - s t i n g { 1 . ( r % v s 4 . 8 % ) , a n d h i g h r a t e of a re-sting 18.0% vs 24%l Conclusion: Patients who have an anaohvlactic event after a hymenoptera sting have a lower risk oi fr-rture anaphylactic events if they are referred by the physician for evaluation for VIT.

i

.62

Roleof Magnesiumas a Calcium Antagonistin RabbitBronchialSmooth Muscle

EMSkobeloff, WH Spivey,R LevrnlDivision of Research, Department 0f Emergency Medicine,TheMedlcalCollegeol P e n n s y l v a nPi a h ,i l a d e l p h iDae; p a r t m eonft U r o l o g yH, o s p i t aol f t h e U n i v e r s lot fyP e n n s y l v a nP i ah, i l a d e l p h i a Studyobjective:To demonstratemagnesrum'srole as a calcium antagonistin bronchial smooth muscle.

Design:Prospective,controlled laboratoryinvestigation.

Subjects:New Zealand rabbits weighing2.4 kg anesthetized with ketamineand xylozine(44and 12 mg) and killed with pentobarbital(50mg).

Interventions:Three-millimeter bronchial rings that were placed in aeratedTyrode's buffer under I g passivestretch in a Langendorffapparatus.Bronchial rings were treated with antagonists and agonistsof extracellularand intracellular calcium in the presenceand absenceof magnesium.Eifects were recorded, and data were analyzedusing two-way analysis of variance for overall effect and Student's t test for comparisonof specific effectsamong groups.Values are reportedas mean +SEM. Results:Atropine {0.1 mM) decreasedresting tension by 89 t 47 mg and limited the normal contractile responsâ&#x201A;Źto bethanechol (5 mM) to an increasein tensionof 6 t 10 mg. CaCl2 (5, l0 and 30 mM) causedincreasesof 168 ! 43,94 + 19, and +Ox tZ m g , r e s p e c t i v e l y I. n t h e p r e s e n c eo f a t r o p i n e ( 0 . 1 m M ) a n d MgCl2 (50 mM), contractile responsesto CaCi2 (5,10 and 30 y .P Z l 0 . l m M ) w e r e- 3 ! 9 , - 2 3 t 5 a n d - 9 ! 6 m g , r e s p e c t i v e l C mM) {a calmodulin inhibitor) and MgCl2 (50 mM) decreased r e s t i n gt e n s i o nb y 3 4 0 t 4 2 m g , a n d l i m i t e d t h e r e s p o n s er o bethanecolto lB + 10 mg. CaCl2 {5, lQ, and 30 mM) increased tensionby 140 + 74, 80 x 28, and 85 t 29 mg, respectively(P < .05.)

Conclusion: Magnesium does not appearto significantly inhibit calcium ion flux at receptoroperatorchannelsor memb r a n eb o u n d c a l c i u m c h a n n e l s .C a l m o d u l i n i s a s i g n i f i c a n t intracellularsitc of magnesiuminhibition of excitationcontraction coupling in bronchial smooth muscle.

.63

Efficacyof MagnesiumSulfatein the lnitialTreatmentof SevereAsthma

BA NesterV , S c a l i / A l b e rEt i n s t e i nM e d i c a lC e n t e r ,P h i l a d e l p h i a ; Philadelphia C o l l e g eo f 0 s t e o p a t h i cM e d i c i n e ,P h i l a d e l p h i a Background: Bascd on its known smooth muscle relaxation propcrties, magncsium sulfatc (MgSO4) has anecdotally been u s c d w i t h s o m e s u c c e s si n t h e t r e a t m e n t o f a s t h m a .

Study objcctivc: To cxamine the bronchodilatory effect of MgSOa compared with that of placebo as an adjunct to initial standard therapy for sevcrc asthma.

Dcsign: Ongoing, doublc-blinded, randomized study.

Mcthods: Study admission criteria includcd asthmatics 18 to 55 ycars old with a pcak flow of less than 100 L/min. All patients with cardiac or renal disease,chronic obstructive pulmonary discasc, pregnancyi or pneumonia were excluded. In addition to standard doscs of inhaled albuterol, IV methylprednrsolonc, and theophylline, 13 patients initially received I.2 g IV MgSOa and l4 rcccivcd IV normal saline solution {given over l5 rninutcs). Patient response was documented by peak flow ancl Borg Dyspnea Scalc measurements at 20- to 60-minutc intervals to a maximum disposition time of 240 minutes.

Rcsults: Although the MgSO4 group showed a greater rate of pcak flow improvement than the placebo group during the first 2 0 - t o ( r 0 - m i n u t e p e r i o d a n d a g r e a t e r a v e r a g ed i s p o s i t i o n p e a k flow in the (r0-to 24O-minute period, no statistical difference or corrclation was notcd. Similar results were found for static peak flow and Borg Dyspnea Scale measurements as well as admission rates.

Conclusion: MgSOa {1.2 g dosc)provided no added benefit in the acute-phase treatment of severe asthma. It may prove to yicld dclaycd improvement in peak flow measurements, but further study is warranted.

64

lmpactof EmergencyDepartment ObservationUnit on AsthmaAdmissions

JC Brillman,D Tandberg/Department of Family,Community and E m e r g e n cMye d i c i n eU, n i v e r s i toyl N e wM e x i c oA, l b u q u e r q u e Study hypothesis:The use of an observationunit in the emergencydepartment results in cost savingsby lowering the hospital admissionrate for ED patients with asthma Design:A retrospective,comparativecohort study.

Setting:An urban, university-aifiliatedcounty hospital.

Participants:All asthmatic patients in the ED between fanu a r y 1 , 1 9 8 9 ,a n d O c t o b e r 7 , 1 9 9 0 , w e r e i n c l u d e d .G r o u p I patients (834)were seen before the observationunit opened; group 2 patients {390)were treatedafter the unit opened.

Interventions: Patients in group 2 meeting standardcriteria were admitted to the observationunit. The binomial distribution with Yates' correction was used to analyzeproportionsof admitted patients, and t tests were used to evaluatedifferences

'" "itt',rt,r,

sion .t'lt t :?1 cj:,i^l^l :",i : ' ^ " "spital " t ' - l . t i ' admis , " ' " ho K E s u r r J ' The T h i s d i { { e r e n c ew a s i " t p tttlu"ly 3 l 6 a 0 % . a n d patients were , ^ - .. ^ r ^ . - ^ + - q o l ^, l i f f e r e n c e i n

= -.ti +1,+"ooy61:: d::T::. :'/:'di:fT'::",,'l ili " g'rii.", (n" j'""lli Fo''admittednatients o{ :';;]:i."

;;;' *r'

sqt.

1:,1

cardiac arrest and Design: Animal model {ten) of prolonged CPR. conventional fibrillation' Interventions: After / 5 minutes of ventricufar 20 minutes' for conventional CPR was rnitiated and continued was administered, and electrical de{ibrrllatron ;;;;;oi ;";;; biopsy speclmens ventricular lelt Endocardial "'"i?i,.*pr.J. Abrtic and right were obtained using a "o"ut"iio""t biotome catheters' micromanometer with atrial Dressure,*"r. -a"*'ed vari h " ;;Jv ;" mic p ressures' and m^etabolic tis,":,iJ'; ##;;

qavs ur rrurPr' ilil':'ii:#t;r[iii.""""i-"-'p-i-"''v'l:;:*;:l;:;:;3L1 not iignificantlv difierent h o s p i t a l t z a t; ; - ; ; ; ; total cost of

^ -s. thh, -m a rai t i c u n i t r{ ^o-r a C o n c l u s i o n :T h e u s e o i - " ' o b " t u " t i o n hospiof rate the in decrease in , 1""-th^n-57o i'",i.t""t"."f,i ial admissions.

of B Potassium-LoweringE-ff-ects *,AE -OC Patients Agonistsin Asthma/COPD Universrty' State AAErnst/Louisiana -uilirg, D M;Gill, "otpiti.t-ni New0rleans Medicrne' ofEmergency of.nebulizedB-agonists Study obiective:To study the effects asthma or chronic with patients (xli iir "" t;;;-;;,;srium disease(colo) . iirti-"iit.'p"lmonary Design:Prospective,nonblinded study' ;",",i;,;' Rural, university-affiiiated ho-spital'.' patientswho Particioants:rn.tusion Jttttiia includedstablc coPD "Itia"' with a historv t-rfasthma t-rr *.;J'i;;".^;;-.ra with-a comPlaint of Jtp'*-tni "-.,iJ"tv ;;;;tifi.n.

37,to l5 whcezing or snortness3i f t6'ttt There-were .Patients period who mct thts 30-day a during p..,tt*d *hu il^;;?ld criteria. for the study' -a baseIntervcntions: If a patient was suitable was followed by two This ,.,i"'-*^t-drawn electrolyt" line

--g albuteJ treatments

i. 6 ?Fnroxl*,tt,rj9-it"; -i""..' "r1:l:!" l;;'1;;;. ;hi,?v :ll:::::'."'::: LT:.11''' paticnt the *'*"--'ltiit"t"d J a r b s r u;r r rili ;;a;;;;,nd :#';ffi

;;;""ii;'

P Results: All P "-iqi,'ir" a t i e n t s e x^'-"""

,r^;:;",j:i,.1i.r

Y.i:"T::'::?::: in scrum K* ' d"t'"ttt

. *.^ TL;. a"t""c, was0 5 mEq'This

;^t statisticailvsignificant{P.< 00011 i:h;;; "" rccomN.b"ro"a"g agonistthe.rapvin currentlv 6;;;i;;;, on scrum K+ in any ,r"n-J.Jaut"t may have " tigiiflt'nt effeit patientwith asthmaor COPD'

Reductionof InfarctSizeDuring irruo""tAi"r lschemia and Reperfusionby tizarolo: A Novel21-Aminosteroid San ofCqlifornia' MA Levitt,nr-silutit,CLwolfe/Universitv

66

l . a k l a n dU' a l l l 0 r n l a d e n e r aHl o s p r t aO F r a n c i s cHoi g; h l a n G

i dt h a t H y p o t h es i s : L a z a r o i d( u - 7 4 5 0 0 A )a' 2 i - a m i n o s t c r osignif idcmonstratod previouslv t'as i"h;biitGi; ;"-*iJrtio"i in animal modcls of viabilitv 'i""'oia "' #i';;;;;:;";-.ii..i' teststhe hypothischemicneurologlc,nr".y'iti" presentstudy .r'h"nJt' mvocardial salvageafter ischcmia ;ri; ,h;; l;;;;"i; 'and " - I ;rcperfusion. ,;;;;;i;"t, Using an establishcd mvocard,ial were treatedwith cither ischemia/reperfusioniniury"model, rats to 45 ( and t I) Lizatord iitus i.ttrcnsublected 3l;'' ;"'iiil'ii by 120 minfollowed oc"lusion aiiery coronary minutes of left utes of reflow. had similar R e s u l t s :R a t s r e c e i v i n g v e h i c l c t x L a z a r o i d phthalocvnanineblue dve bv a"it'tLi""J ff ir"i;;i.;;k;;r P = 75i meant SEM)' r"r^"irg f+o.s-tz.+y' "t';8 0 ! 3'0%, was markcdly reduced 't'ittittg'. iiC ov Infarct size, measureo *ith "ot'trolt when expre-sstd1t^.t in Lazaroid .r,, "o-p"td 4 6"ki ue,ii""l"' mass (1 6 t 0'077o,vsrr'3 ! ;t;;;;;;;-.i1eft 'p= percenta as otz. infarct mass/leitventricularmassx 100)or P=

lr. "i',ti'.','.t#:i;+

areas {34 t r'4%vs 16'0! 4v"'

;;i;{L;',.*Jil",::.::*.lf linl,y;:'"eT:::*,:'J:J,'lJ :?,f L*iJ"iu" function.was": t-tt^t-:d and 7.5 minutes ot ventrl(

vals duringCpn. rvutocnoidii"T c ox1"l""ttod" chamber'and cvto'chrome ;#;;;:"tlai"ik Mitochon-

dase activity *^, -.,,rlrJ'pttttophoto*etrically using glutamate/malateas Aiirf ."-pf6. I activity *as "ttttttd was assessedusing succomplex.Il and substrate, ;;;;iil;;" analvsis or variance and i"'ria'a ;".i;; ;i;";;: s*;,*;i asmean t SD' pr.e9e11e$ ir"" ,"if.J prrted t test' Values are Mitochondrial data "l^t-"to"d {table) ,'" Rcsults:Findings a,..pr.s.ntedinn-anogramsof-oxygen'perminuteperinternastateJ' tional unit of cytochromec oxidasedurlng 3

0 min Mitochondrial Complcx I Mitochondrial Comple x II

7.5

1 r q

l2'5

27,5

Ii.O4' 301.07"'261 06 23! 0(r'20! 05 22t.O2 .22r,.O6.3

.381 12

l)iastollc Ao RA {rrm Hg)

' 33t09 1 4 1 . 1 3. 3 6 1 . 1 3. 3 9 i . 1 1 3 7 1 1 1 3 7 1 1 2

0

0

17!6

l7_4

l4i4

1413

C c l n c l u s i o n : C o m p l c x l f u n c t i o n i s s e l e c mitochontiveiyaugmented mvo"a"lr"l hvpoperfusion; d"i;';;;i;;;.J;i;[;i hypoperfusion; prblonged during tlrial function ,, -",.,t"'n6J in mvocardialadenosine decreases ffi'tt;i;;;l;"';-o*t"a

iHlJ'Jlti:i[*fl'" mru tl*"**:*

creasedsub duerode

i"il:,1H"#liJSHUArtercardia 68 GSKrause'.Ll DJVanDerLaan' dV w-ntt,nc-iiibrruwan, and.Molecular Medicine er.ttiiil.lotp.iittnti,itEmergency Michisan Detroit' Bi;6ffi;d;.titi, wuvntsdteuniversitv'

lD N A S t u d v o b i e c t i v e :T o e x a m i n e b r a i n . m i t o c h o n d r i aduring or strands bases to d"mage t"ol't^ai.ri--"diated r-ijirXr ischcmiaand rePerfusion' groupscomprisingsix in Design:Dogs were divided into four c a r d i a c ^ a r r e's 3t \ 2 0 c a c h g r o u p : t 1 n o r m a r s ,Z l 2 0 m i n u t e by internal massage *ith'resuscitation ar,"st cardiac minute hour reperfusion' The 4J eight ;#;;";;;;i#tfuti"",-ttta the nuclear parictal cortex was used ior DNA iiolation both purilied on a 1 0i l'5 M ^iJp"tl"t"r.aimitochondria ffi;;; or mtnNA is circulai and lacks excisional t;;;;sl.ef;t"dte,,t in nicked circles is t"ptt"oiling oi iott repair; recombinational mobilitv All

:,Xi;"il;;il

bi; ;h*g' l"'i'"t'"pri"retic

brain DNAs *.r.

.t".t'olhoresed on agarosegels; mtDNA

{wiih a ph::!1"; i",'i.,,*.i" la.r,iiil"a b;^;;-;;i;ttidizaion probe)and quantrtated mtON,A alg Z.O'-kb ,"r-iZ aCip_fabeled g ^"." rraiogt"oht li vi tro radical darnage fi r".i"]-tJtt ;Xnt? [t

Nu,,*',.'-* :i*if"*jim:*ilixxii:"*$:":l?il['#f ttt l'"a"at or piperidine {0'q M' pH' l0'7s) ;;#;^;;d;;;ciease nucleotideshaving and exonuclease[r lprplgxo3)'whii:h excise bases' radical-damaged pMFe'reduced super.

Results:In vitro radical damagewith I. supercoiled tot'l'-IDNA; of o0'Ul-'iJilZiro. coiled mtDNA to 18% and endo3 after 27"/o to mtDNA was further reduced accompaniedthe loss of after pip-exo3.tn.,.""d nl"ktd circles ptoa"ct-plecursor relationship' supercoiledmtDNA *iln'

n: *:*;ilr*imm*nffiil Jl'l":;l'?Fii;Fl'": +i-i"t,.. i;#;i;;fl;

followed by two o{ left coronaiy ^tt"y oc.clusion. ischemia' reversible of model animal in thls

67

='?,:X1""?H,:'l ""i:fl ?liJ'[i"Jl?r'i'oJ'?'o'ong"o h::n'."lll"*;'*tintt'lti#ll: ii;l"','"x'ffi CPR and CardiacArrest coiled mtDNA

SchoololJVledicine' CB Cairns,LSfriima,JT Niemann/UCLA MedicalCenter' Harbor-UCLA Medicine, Emergency of Deoartment California Toirance, of cardiac arrest Studv obiective: To determine the effects ,"a ip( on mitochondrial oxidative function'

-- '367\ or after before lanalysis of variance P

""t'"ll;,li,f ,';l;r;n',,iil,'"'i'0"-,*.dduring2'-minut cardiacarrestor eight-hourreperfusron'

36

69

InitialStudiesof ProteinSynthesis

by Purified Ribosomes After CardiacArrest and Resuscitation

DJ DeGracia, BJ O'Neil, GSKrause, BCWhite/Department ol Emergency Medicine, Wayne StateUniversity School of Medicine, Detroit, Michigan prolongeddepressionof protein . S.tudyobjective: synthesis has been observedafter brain ischlmia despite'uninlured nucle_ ar and mitochondrial DNA and intac_ttranscription. Therefore, w e s t u d i e dt h e t r a n s l a t i o na b i l i t y o f b r a i n r i b o s o m e st n v i t r o after cardiacarrestand resuscrtatlon. large,dogswere anesthetized,instrumented, ^-Pt_:]ry ano equalyly:t],{ olvldedrnto four groups:l) nonischemiccontrols,2i 2O-minutecardiacarrest withoui resuscitation,3J 20_minute cardiacarrestwith resuscitationand two hourreperfuslon and, 4 ) g r o u , p3 w i t h e i g h t - h o u rr e p e r f u s i o n p. o l y s o m e sf r o m the cereDralcortex were isolatedby magnesiumprecipitation and n,uri{icd,dissociated,.and_reasiociai.a.fnf.rJ."ger RNA was oDtarnedby phenol:chloroform extractionsof crude polysomes Protein translation cofactors.were obtained Ay iiit"rritiit t o 6 6 o k) a m m o n i u m s u l f a t e p r e c i p i t a i i o n f r o m lzlu brain homogenate.The translation ..r.iion inctuJ"a HfpES buffer p.n Z .Cl,KCL, 10 mM M-g,adenosinctriphosphate,guanosine ,'"ltj RNA, crcatjnc [inrri, .r.rirnc phos_ l;:i'fh"*hrlgr pnate,spermrdrne,DTT, amino acids with carbon_14-leucinc, 5 g g m e s s e n g eR r NA, and l0 gg protein l 9 , 9 l q I t btJlank -qr"mes, coractors. rcactionsdid not include nbosomcs.ih. ,.r.in 0. I N NaOH after one, two, and fow houi., ::"11ir_:,gpped ano rne protetnproductswere precipitated,washed,and count_

':.;rT ."f i r;:l)il :':* ffili,"%,T, 1:T * : i il *ribosomes/hr) ::,1 *oJ'? je wereasfollows: gruupi, r i 92,i-up 2, 13.5 t

ls y'and group4, rio t ts. Grcuplwasiignifi_

]:r:ilgyfjl rllrl]rted+lanalysisof varianccF = 4.9(t,l, = .OOS1 iu_:1l-tly parcdwlth thc other groups.

Conclusion:We confirmcd suppressionof in vitro protein synthesisat two hours of,rcpcrfusion", pr.uiuurty ,.iort.a.

However,we found that riboiomc, .o-pl.t.iy ,".over transla_ tional.competencewithin eight hours ,i ,.p.i.turtn.

Th; t;;_ protein'iynthesis of tf,riiuff,i*, global brain f9191dgunnression rscnemta ls rot causeby irreversibledamageto ribosomes.Fur_ tler r.es,egchrs necessaryto elucidate the mechanism of tran_ srentlnhtbltlon of translation.

7n l^ V

Synaptosome protein andpotysome Peroxidation in the post_lschemic Brain

GSKrause, D.JDeGracia, JM Skjaertund, eJb;Nr-iliDlpurrment of rmergency Medicine, Wayne StateUniversity, Detroit, Michigan Studyobjective: We examined brainribosomcs andsynapto_ peroxidatron duringrepcrfusion, prgl.il whcnpciox:."T:f:l

roauonot Ilplclsbut not DNA is known to occur. , Design:Dogs were anesthetized,instrumented,and <tivided into four groups of six each: l) nonischemic controls, Z1 ZO_ minutecardiacarrest,3) 20-minutecr.dlac "rresi *ith two_irour repertusron, and 4) eight_hourreperfusion.polysomesfrom thc c e r e D r acl o r t e x w e r e i s o l a t e d b y m a g n e s i u mp r e c i p i t a t i o n .

Synaptosomes were isolatedfrom the ioranu.l.ii,"pernatant usinga sedimentation-flotationsucrosestep_gradient. protcin concentrationswere determined by the Brad"ford assay.Caroroducts of protein peioxidation, weie assayedby l;1tl-r::ry method. positive contrors were pre_ :l:^:tt1:iiph:."ylhydrazine pir:o py reacrrngisolatedpolysomesand synaptosomes ln ylllo wrtl^tl:,.lelton reagcntat IFe2*]bctweeng00 nM and 400 pM. c o n t r o le x p e r i m e n t sc,a r b o n y gl r o u p s( n m o i c a r _ .ogly]i ^ - 1 f l u , , tprotern) 'ln werc tripled in reactionscontainingonly g00 pg nM Fe2+.Data from the experimentalgroupsar. as iotto*., Polysomes

Group I 4.2!0.6

Synaptosomes

6 . 4 ! 2 . 4 5 . 01 2 . 9

Group 2 4.2!0.4

Group 3 5 . 1I l l

Group 4 5 . 4r l . . s

NS

7.9t3.6 2.(t!t.4.

.04

P

. Conclusion:There is no significant accumulation of carbonylcontentin either the poly"some_ ;; ed proteins;there is a significant ,"au.iio";.d;;;;e_assocrat_ oi.r.U"onyl content

37

rn tne synaptosomeproteins at eight hours of reperfusionthat is accon]paniedby a reductionin yield ldata not ,horvn).We l_ol nave not found evidencethat the free radical reactionsof reper_ fusion lipid peroxidationpropagateinto other cellular macro_ molecules.

71

Ctinicatpatrernof FaralFails

J Hammond, GAGomez, M Castro, K Buechter/UMDNJ_Robert WoodJohnson Medical NewBrunswick, New.tersey; 9.!qqt, I n d i a nUan i v e r sS i t cy h o ool f M e d i c i nIen,d i a n a p oIlni sd i a n i ; University of Miami/Jackson Memorial Medicai Center, Miami, Florida L ;S US c h o oolf M e d i c i nS eh , r e v e p oLrot ,u i s i a n a Fallsa_re the -second leadingcauseof injury. Background: relateddeathsin the United_States, ,,_r.prr#.1 only Uy -oi6. vehicleaccidents.

Fall_mortality is disproportionrt.ty'nigh ; the clderlyiovera^ge makeup Izii oi-thepopuf?fion !s.l,..wfro

h u t a c c o u n r l o r 7 4 o / oo f f a l l d e a t h s . .^^Design: A retrospective review of all fall-related deaths in 1 9 8 9i n o u r c o u n r y { p o p u l a t i o nI . g m i l l i o n ) .

M e t h o d s : W c f o u n d 9 4 c a s e s ,c x c l u s i v c o f s u i c i d c s .

Mcan patrent.age ]va9 Z0 years. Of the 94 falls,55% of fatal falls i n t h e .h o m e , 1 2 7 o o c c u r r e d i n a h e a l t h c a r e s e t t i n g , a n d :::ytr"9 81% originated from a bed, a chair, or ground lcvel.

Assoiiated factors,included.aprior tall l27"kl, rt.ut ot iu" tiZ\.l, and maLignancy (18.%). Thirty-two percent of patients waited more than 24 hours before. see.king medical attention. Mean survival from tne documented lall to death was 26 days. A head injury was thc of i".f1%, only l(r% dietl as a cornplication of a hip ;r .r1a-cl t: u . re.*ilf Ut the 44 head iniury_relatcd deaths for which a Clas_ g o w C o m a S c o r c w a s k n o w n , 3 6 n k h a < la s c o r c of 13 or more.

Study findings with relcvancc to prevention crr rreatment

of .dea.ths irom g",""a_f"".i fr"igir"r, il:1y9. the.preponderance. of fata]falls rclatcd'tosrairsor hcights 11 1%) ind 1[c.naucitr more than 10 ft.

T w o t h i r d s o f d e a t h s w e r c d u c t o h e a c li n j u r y , rathcr,tha.nthc popular notion of ostconorosis-rclatctl tractures. unc thrrd.ot patients dying from falls did not apprcciate thc scverity of injury and had a delaycd prescntation^to the cmcr_ gency dcpartmcnt, and thc.Glasgow Cbma Score was not prcdic_ tive in one third of fall-related head injury dcaths, indicating a necd for incrcascd clinical suspicion of hcad injury in the cldcrly.

Using paramedicsto tdentify 7, a 3 At-RiskEtderty L Gerson, J Wilson, DTSchelbl\/Northeastern OhioUntverstties College ofMedicine, Akron CityHospital, Alroneeneraf Medical Center, Akron, Ohio To evaluatcparamedics,ability to identify . Study_objective: t h e e l d e r l ya t r i s k a n d l i n k t h e m w i t h , p p i o i i i a t e s e r v i c e s , Emergencymedicalseryices(EMS)pcrsonn.l^.nrc.and can cvaluatepatients/living environments.

Thrs prospectivg nonrandomized,open_trialstudy .was .^^O"1fI conducredin Akron, Ohio, from August I, 19g9,through April 30, I990. Regardlessof thc rcasonfo"rthe call, t;.;;;Ji?; assessed all EMS users(r0 yearsold and older io, -.al.rt, rn.n_ social,or environm.ental problems.icreenrngtdenti1,1] ,h::Th, rtc.u t9/ patrentswho were.referred for follow-upevaluationby traincdgeriatricassessors of the-area.g.n.y on ,iing. hls an advanced . . Setring:Akron, Ohio, {populationiqO,0OOl life support EMS systcm t11i ,rp.rrt., ,tir-"rdh;h. fire dd;; ment, which includes 130 filefighterpaiamedics ^nrl tZ response vehicles.

Participants:Of the 6,000pati_ents who were potentialstudy candidates,197 werc referredior follow_up.urluitlo.,.

Th. g;;iatric assessors were able to complete.rr.i.-.nt, on i24 of the people{63%)initially identified.'

Interventionsl The program was useful for 94 oI the identi_ .. t t e op a t r e n t s{ 4 8 % 1I.t w a s o f e q u a lb e n e f i rr o p a t i e n t s who had social,physical,or mcntal probiemsand slighti; lcss bcneficial ror rnosewrth envlronmentaloroblems.

Results:The assessors coniirmetl paramedic-identified problems in l2l casesfor a positivepretliciive,ri". oflsz.

Lonclusron: We concludethat paramedicscan serveas case _ for at-risk elderly and thai .ff..irr"linf.rge to seruice !1drr9 agencrescan occur.

information for myocardial infarction in chest pain patients with initial nondiagnosticECCs. Design:Prospective,observationalstudy.

Setting:University hospital and university-af{iliatedveteran's affairsmedical center emergencydepartments.

Participants:One hundred fifty patients 30 yearsold or older with chesi pain warranting an ECG and consentingto observation {or thrie hours in the EO. Exclusionswere hemodynamic or rhythm instability and ST elevations of I mm or more in two or more electrically contiguous leads.Interventions:ECCs were obtained at presentation and at three hours Significant ECG changes{ECC a) were categorizedas either 0.5 mm or greatcrST segmentelevation or depression,Q wave developi't.nt, ot T wlve inversion in two or more contiguous leads.

Blinded ECG review was performedby two of the authors.Creatine kinase-MB(CK-MB)levels were obtainedat baselineand hourly for three hours (positivelevel, 8 ng/ml or more).Outcome was obtained by record review and basedon independent CK-MB measurements.

Results:Twenty-five patients lI7%lhad an ECG-D,and 19 study patientsll2%) had a myocardialinfarction.One patient met criteria for thrombolytic therapy at three hours. Ten of the myocardial infarction patients 1'52%)had an ECG-E comparqd with lS of non-myocardialinfarction patients {1' < .0001by Xz) Daticntswith ECG-Dand CK-MB elevations,eight of ten (80%l irad a rnyocardial infarction. Of patients with neither, four of 118 {3%i had a myocardialinfarction. Only two of l5 ECG-d Datientswithout a CK-MB elevationhad a myocardialinfarciion. Sensitivitiesand specialtiesof ECG-d versusCK-MB {or myocardialinfarction were 53% vcrsus 687o and 89% versus 97%, respcctively.Thrce-hour CK-MB elevationswere more accuratcihan three-hourECG-8 in prcdicting myocardialinfarction (/) < .03by McNemar'stest).

Conclusion: Serial ECG-Din three hours correlatedwith rnyocardialinfarction, but wcre infrcquent and less accurate than scrialthrcc-hourCK-MB clcvations.

Predictionof ResistantUrinaryTract Infectionsin the GeriatricPopulation Center, Medical Sinai PLerner/Mount JD Eiband, MKAllen,

Y3

0hio Cleveland, Study objective: Prediction of urinary tract in{ections caused by multiple-drug-resistant, Gram-negative bacteria in the geriatric population.

Disign: Retrospective study of patients admitted from- fanuary through December 1988 with a primary dragnosrsof urinary tract infection.

Setting: A 465-bed,university-a{filiated community teaching hosoital. i'articipants: One hundred two of 189 patients admitted with urinary tiact infectrons and initial cultures or tnore than 1 0 0 . 0 0 0C F U / m L .

Interventions: None Results: Gram-negativc bacilli caused 7L)'k of urinary tract infections. Multiple-drug resistance was present in 32%; resistance was to amprcillin l3O%), celazolin {18%), and gcntamicin ll3%1. Predictive factors were determined using large-samplesize comparison of population means or ratios. Predictive facto.s 'rer. hclspital admission within two months (I' < .001), nursing home iesidence (P < .01),and diabetes rncllitus (P < .05).

Nonpredictive factors (P > 0.2) were age, sex, dehydration, urologic abnormality, and renal insufficiency.

Conclusion: Significant Gram-negative rcsistancc to amplcillin and gentamicin is seen rn the geriatric population. Predictive factors for resistanceare rcccnt hospital admission, nursing h o m e r e s i d e n c e ,a n d d i a b c t e s m e l l i t u s . I n i t i a l a n t i b i o t i c t h e r a p y should bc adjusted to re{lect the higher risk in thc gcriatric group.

+a ' f +A

Diagnosisand Treatmentof Pulmonary Embolismin the Elderly

y d i c i n ae n dM e d i c i n e , M o t t / E m e r g e nMc e D P l o w m a nJ,S J o n e s M n tate l, ichigaS t ho s p i t a M R e s i d e n cPyr o g r a m sB,u t t e r w o rH o f H u m a nM e d i c i n eG, r a n dR a p i d s U n i v e r s i tCyo l l e g e Studv obicctive:To detcrminethc valuc of clinical findings and quantify physicianpracticcsin thc care of cldcrly paticnts with acutepulmonaryembolism. analysisof rncdicalrccordsfrom l9B8 Design: Retritspcctivc through 1990.

S c i t i n g :U n i v c r s i t y - a f f i l i a t c cd o m m u n i t y h o s p i t a lw i t h annualemcrgcncvdcpartmcntccnsusof ('ii,000.

Participants:Scventy-eightconscctttivcpaticnts morc than 64 yearcold admitted during thc study pcriod with a dischargc diagnosisof pulmonary embolism. Diagntlsiswas dctcrmined usion y la8%) or high-probabilityvcntilati<-rn-pcrf by irteriograph l u n gs c a n s( 5 2 % ) . interventions:Recordswere rcviewedfor historical,physical cxamination,laboratory,and radiologicfcaturcsfor all paticnts on prescntationto the ED. Times and intervalsrelatcdto diaSnosis,laboratorytesting,and therapieswcre calculated.

Results:Mcan + SD patient agewas 74.8 ! 6.1 years.Dyspnea was thc most frequentsymptom (81%),and most patients them to had threeor more well-definedconditions,prcdisposing pulmonaryembolism.Only 31% had pleuritic chest pain, l9% had leg pain or swelling, and 12% had hemoptysis.Common p h y s i c a [f i n d i n g s w e r e n o n s p e c i f i ca n d i n c l u d e d t a c h y p n c a [85%),pulmonaryrates 163%1,and tachycardia{41%).Twcntyfour percentof the patients (19 of 78) were initially misdiag,tosedin the ED. Only five patientswere treatedwith heparinat the time of the initial clinical suspicionof thromboembolism beforediagnostictesting.In the remaining cases,there was a 3 . 8 4 - h o u rd e l a y b e t w e e nd i a g n o s t i ct e s t i n g a n d i n i t i a t i o n o f heparintherapy{range,0.2 to six hours).

Conclusion:Lack of classicsignsand symptomsand concern in elderlypatientshaveled to aboutthe risks of anticoagulation practicesthat delay ef{ectivetherapy.

*16

Physicians HowWellDo Emergency lnterpretECGs?

, L i / D i v i s i oonf E m e r g e n cMye d i c i n e , MJ Zappa, M S m i t h S e e n t e r - J a c k s ol lnev i Universio t yf F l o r i d aH. e a l t hS c i e n c C Study hypothesis:The discrepancyratc between emergency p h y s i c i a n s la n d c a r d i o l o g i s t si' n t c r p r e t a t i o n so l e m e r g e n c y dcpartmcntECGsis low.

P o p u l a t i o n :1 , 2 9 7c o n s e c u t i v eE C G s p e r f o r m e do n E D paticnis during a four-month pcriod in a busy urban teaching hospital.

M c t h o d s : A s p a r t o f o u r E D q u a l i t y a s s u r a n c ep r o g r a m , cmergcncyrncdicrnercsidentECG interpretationsare compared with-ihosc of the attcndingcardiologistwithin 24 hoursof the tracing.The cmergcncymcdicine attendingthen reviewsthese two interpretations.If a discrepancyis found and the emergency meclicineattcnding determinesthat reevaluationis indicated basedon the clinical presentation/thc patient is calledbackto the ED. Comparisonswere made on 1,124of 1,297ECGsthat had both intcipretations recorded.The ECGs were evaiuatedfor discrepancicsin ratc; rhythm; conductioh; Q, ST, or T wave abnormalitics;and overall interpretation. A1l patients with discrepanciesrn their ECG interpretations were then followed-up throughthe hospital'sdatasystemand telephonecontact.

R e s u l t s :O n e h u n d r e df o r t y - s e v e no f t h e E D E C C s ( 1 3 % ) revealeda discrepancy.However, in light of the clinical presen(0.8%)resultedin patient tation, only nine ECG discrepancies reevaluations.No adverseoutcomes were identified in these nine patients.The discrepancyratc was less for PGY4s{10%) than for PGY2s(16%)(P < .05).The two most common discrepancies noted were failure to identify nonspecific ST or T wave changes141%)andfailure to identify Q waves (24%l Conciusion:The discrepancyrate between emergencyphysicians' and cardiologists'interpretationsof ECGs in our study w a s l 3 % . H o w e v e r , w e o b s e r v e dn o r e s u l t a n t s h o r t - t e r m adverseoutcomes in these patients (two-month minimum follow-up).

-rF Do SerialED ECGsProvldeUseful Informationin ChestPainPatients?

I C W TRGreen, RJSwanson, GPYoung, GHenkel, JRHedges,

77

Allairs Veterans Portland University; HealthSciences Gibler/oregon ol Cincinnati MedicalCenter;University S t u d y h y p o t h e s i s :S e r i a lE C G s p r o v i d e u s e f u l d i a g n o s t i c

38

The Use of An Artificial NeuralNetwork for the Diagnosisof MyocardialInfarction: Phasel- ProspectiveValidation

of Medicine, University of Emergency WGBaxtlDepartment

C a l i f o r n iS a ,a nD i e g oM e d i c aCl e n t e r

dial infarction.

Background:Artificial neural networks (ANNs) have become a powerful new computer-basedmathematical paradigm for c o m p l e xp a t t e r n r e c o g n i t i o n .I n v i e w o f t h i s , a n A N N w a s developedfor clinical application to identify the presenceof acute myocardial infarction {AMI) in patients presentingto the emergencydepartment with anterror chest pain. When the network was retrospectively tested on a group of patients with a high likelihood of having sufferedAMIs, it had a sensitivity of 92o/oand a specrficity of 96%. This was substantially better than the performancereported for either physicians (sensitivity of 88% and specificityof 72%) or any machrne-based approach (sen_sitivity of 88% or specificity oI 76%). Bccausethe initial study was retrospective,a prospectivevalidation of the network was undertaken.

Participants:The first phaseof this process,the testing of 310 adult patientswho presentedto thc ED with antcriorchest pain, is reportedhere.

Methods:The network was testedbv presentationof clinical admissiondata.The physiciancaringforiach patientrn the ED w a s a l s o a s k e d t o m a k e a d e t e r m r n a t i o na s t o w h e t h e r t h e patient had sustainedan AMI. All patients were followed-up to confirm final diagnosis.

Results:Of the 310 patients eniisted in thc study, 3l sustained AMIs, 43 were diagnoscdas having crcscendoangrna,34 patientswere diagnosedwith simplc angina,and202wcrc diagnosedwith noncardiacetiologies.Physicianand nctwork performancesaresummarized{Table).

Infarction Cotrect Incorrect Physician Network

24 29

Noninfarction Correct Incotrect

7

726

2

26r

53 ltt

The sensitivity and spccificity of the physicianswerc 77ok and UI%, respcctivcly,and that thosc o{ the ANN were ()4,'h and94"/o, respcctively.Statisticalanalysiswas accornplishcd by us^ing a 2 x 2 contingcncytable to calcuiatca Yates,corrccted Xz. This analysisrevealedthat the differencein scnsitivity had P v a l u co f . 1 4 9a n d t h c d i f f c r e n c ci n s p e c i f i c i t vh a d a p v a l u co f lessthan .001.In addition,the likelihood ratio X2 of the differcncein sensitivitieshad a P value of.0(r5. Becauscof thc low i n c i d c n c eo f A M I i n t h e s t u d y g r o u p , a l a r g c r s t u d y w i l l b c rcquiredto demonstratestatisticalsignificanccof thc diffcrencc in sensitivities.

If this is achieved,a largemulticenterstudy will b e n e c e s s a r yt o d e m o n s t r a t et h c r e l i a b i l i t y o f t h c A N N i n prospectivc dccision-bascd pracrice.

Conclusion:Thesc initial data appearto supportthc carlier observation that an ANN may be able to substantiallyimprove the diagnosticaccuracyof physiciansin the diagnosisof AMI in p a t i e n t sp r e s e n t i n gt o t h e E D w i t h a n t e r i o rc h c s t r r a i n .T h i s t e c h n o l o g yc o u l d b c e x t e n d e dt o o t h c r d i s e a s cs t a t c sa n d becomean adjunctto clinical diagnosis.

*79

SerialCreatinePhosphokinase(CK-MB) and MyoglobinAssays in the ED Evaluationof PatientsWith Possible MyocardialInfarction MHzstetler, L Walling-Braastad, RWolford/Emergency Medicine

The results are as follows: Specificity ppv

Sensitivity

NPV

TOCK-MB

46%

99%

94%

86%

TOMC

43%

94%

67./,

85%

T6+3CK-MB

92%

967"

87%

98%

T6*3MC

84v"

89%

69%

95v"

Conclusion: Serial CK-MB and MG measurements are both sensrtrve and specific in detectrng patients with acute myocardial infarction, although CK-MB is more so than MG. A single determination of either type is not sensitive in detectrng acute myocardial infarction patients.

AcademicEmergencyMedicinei n U S

79 fi:iffsgimersencvl A Trotf Blackwell/Universitv

0 f C i n c i n n aCtoi l l e g eo f M e d i c i n e ,

Cincinnati,0hio Study hypothesis:Despite the fact that emergencydepartment patient visits have exceeded80 million per year for ten ycars,medicalschool-associated medicalcenterslag behindthe clinical demandsfor the developmentand support of training programsfor emergencyphysicians.

D e f i n i t i o n : A n a c a d e m i cu n i t i n e m e r g e n c ym e d i c i n e i s definedas a clinical/educational/research unit with duties and rcsponsibiliticscomparableto those of other traditional academic units of a medicalschool.

D c s i g n : A n i n v e s t i g a t o r ' b l i n d e ds u r v c y i n s t r u m e n t w a s dcsignedto dclincatcthe acadcmicstatusand positionof emergcncymedicineacademicunits in medicalschool-based medical centcrs.Infonnation was catheredon the administrativcstatus of thc acadcmicunit, availability of promotion and tcnure to cmorgencymcdicine faculty, cstimatedacademicproductivity, and fulfillmcnt of ovcrall mission.For schoolswithout academic units, an asscssmont of supportand futurc plansfor the estabIishmcntof acadcmicunits was solicited.

Participants:Scnior dcansof all 1990AMMC-rcgisteredUS rncdicalschools( I 231.

Rcsults:Nincty-four of 123 survcy instrumentsl7(t%l were complctcd:56 oI 94 {(r0ol,) rcportcdhaving an academicunit of cmcrgcncymcdicinc (16 full dcpartmcnts,five divisionsof thc dean'sofficc,and 35 divisionsor sectionsof other departments), five of 5(r (9%) reportcd being more academicallyproductive c o m p a r c dw i t h o t h e r s i m i l a r d e p a r t m e n t s2, 6 o l 5 6 1 4 6 % l |'45%) rcportedbeing academicallycquivalent,25 of 56 reported bcing lcss academicallyproductive,36 of 56 164%)acadenic units wcre assessed as beingin their appropriateadministrative position,ten of 5(r {18%}rcportedthat they should be elevated abovethcir currcnt position,and ten of 56 (18%)reportedthat thcy wcrc not mcetlng current mission expectations.

Forty-one of 56 173%lreportedtcnurc and promotionavailability.Of medical schoolswithout academicunits, sevenof 38 (18%)haveformal commitments for establishingan academicunit of emerg c n c y m c d i c i n c ,f o u r o f 3 8 ( 1 0 % )h a v e a c t i v ep l a n s , l 7 o f 3 8 146'/.Jhave administrative/facultysupport,and only ten of 38 havc no supportfor academicemergencymedicineat any 126"/") level.

Conclusions:With only 6O% oI medical school-associated medicalcentershavingacademicunits of emergencyrnedicine, with a total of 1(r full dcpartments,these centersare neither close to capacitynor meeting current demandsfor training of e m e r g e n c yp h y s i c i a n s .A l t h o u g h p r o m o t i o n a n d t e n u r e a r e offeredto most emergencymedicine faculty, 45% oI emergency mcdicine academicunits were consideredto have lower academic productivitythan comparableacademicunits. This finding points to a possiblehindranceto developmentand growth of academicprograms.It is noteworthy, however, that only ten of 94 110.5%lreportno supportwhatsoeverfor academicemergency meorclne.

R e s i d e n c yS, a i n t F r a n c i sM e d i c a lC e n t e r ,P e o r r a l, l l i n o i s Study hypothesis: Serial serum myoglobin (MGl and creatinc phosphokinase (CK-MB) measLrrements will identify acurc myocardial infarction (AMI) in emergency department parients.

Setting and population: All admitted patients with chcst pain who were 35 years old or older and presentcd to a largc community teaching hospital ED. Design: Six-month prospective study.

Interventions: None.

Methods: Venous specimens werc obtarned on ED prcscntat i o n ( T 6 )a n d t h r e e h o u r s l a t e r i T 1 ) a n d s t o r e da r - 7 0 C u n r i l t h e t i m e o i a n a l y s i s . C K - M B , w a s d c r er m i n e d u s i n s t h e T a n d c r n Icon QSR assay (Hybritechl and MG by standard radioimmunc a s s a y .S t a n d a r d E D a n d i n - h o s p i t a l c a r e a n d c l i n i c a l j u d g m c n t were not altered. Hospital charts were audited to determine inpatient evaluation, complications, and dischargc diagnosis.

Sensitivity,specificity, and positive and negative predictive valu e s ( P P Va n d N P V ) w e r e c a l c u l a t e d .

R e s u l t s : O f t h e 1 6 0 p a t i e n t s , 3 7 , . 2 3 % lh a d a n a c u t e m y o c a r -

an lrt

FactorsInfluencing CareerChoicesin Academic Emergency Medicine

AB Sanders, JV Fulginiti,DB Witzke/University 0t Arizona,College o f M e d i c i n eT,u c s o n Studyobjective:To assessthe attitudesof residentsin emergency medicine regardinga careerin academics.

Design:A I5-item questionnairewas administeredto resi-

39

examlnadents in conjunction with the yearly A.BEM inservice information as well as factors influencing 6;;;;taphic ;;. ivere elicrted. Respondents were classified by c.a"re.t-;;;;i intentonAcateerinemergencymedicine-.-Athree-wayanalysis *", ured to adlress group differences. for eight spe;i';;;;; was used .ifi. fr.,orc impacting on career"deciiion xz analysis variables to address questlons lnvolving relationships among r c s p o n s e s ' c a t e S o r i c a l o r d i c h o t o m o u s with residents' w-ith Results: The survey w'as distributed to 1,654 differLzzC is"t"l completing the questionnaire Signiiicant in,.n, lilannei a cateer in academic medicine' ;; ;.;i ;;;; in did not deiire a career in academicsJ were found ;;;;;,h;;, in c a r e c r a T h t ' r s e . p l a n n i n g f a c t o r s m o t i v a t i n g . r . n o f t h e ei g h t to teach, locaacatlcmics weie motivated primarily by_a desrre f o r o t h e r i n t - e r e s t s ,o r a d e s i r e t o m a k e a c o n t r L ii"tt-ii".-,r-. m e d i c ine. Those not planning a carccr In cmcrgency t o bution frcc timc,for mcdicine wcre motrvated primarily by location, t h a n E U T oo t other interests, and financial compensation Morc me.dicine {elt they ihur. nu, going into academic "-"tgtnty in residency compa,rcd ."pos"d to """tit ,J.qiir,.iy *"* (P < 0l) with (r5%'of those i.,t"nt o.t a carcer in academics a n"r"tt.ft in medical school, residency, and.authorship-of for residents research paper were srgnificantly more.prevalent

(P < 0lJ rwentv-sixpercentof ;;l;i;;;;';;";i.'-'"ra.-i.' wereless modelsfor rescarch rolc their that ;"t"1;;1;"t;"ndcd

of rcsidcntsintc'ndto takc felSeventeenpcrccnt than adequate. for fcllowshipswerc i"*.fttp iiritlng. The moit popu.lar.ficlds. pediatrics i"-i."ftgv (257")cmergency'mcdicalserviccs{21%)' ( 9 % ) . (' "1' c5 ;' ;/ ;" i1a; ;,ni ;d; r, e s e a r c h -it'f t t t u t t . o f t h i s s u r v c vi n d i c a t c a t t i t u d e s a m o n g r e s i d e n t st o w a r d a c a r e e ri n a c a d e m l ce l n c r g c n c y -"Jiiit.. i..,ors such as motivation, rolc modcls' and cxpoplan stratcgicsto mcet .ui. ,o ,"t."t.h may help acadcmicians the iuture needsof academicemergcncyrnccllclne'

rg1

DirectedGrouPInteractionGase PresentationModulesto TeachPrinciples and Practicesin EmergencyMedicineto

Second-Year Medical Students n tL o u i s Mnecdyi c i nDei v i s i o S J S R o s eL ,ML e w i s / E m e r g e , issourt u n i v e r s iSi yc h o oolf M e d i c i nSet,L o u i sM S t u c l yo b j c c t i v e :W e c o m p a r c ctlh e u s c f u l n e s so f d i r e c t e d in tcaching *ruuo-iri,.rr.,ion {DGI) with narrativeinstruction sccond-ycar irirJrti.. ,"J ptr.tl..i in emcrgcncymedicinc to students. medical "'';;;;;.;;ii.tg t.t,t participants:AII second-vcarmedical stud"nti'^i our iniiitution werc cligiblc to participateStudents One with prior emergencymedical L'xpcrienccwere cxcluded format nunat.a four studenrswerc randomizcdto cithcr a DCI narrative format. The students were c-quallvdivid;;;;i;;;;i divided betwecnthe two groups.DGI participantswcre further discussion' and completion foimodulc groups .J intn ts s erc , l l p a r t i c i p a - n tw I n t e r v e n t i o n :B e f o r er a n d o m i z a t i o n a obicctivcs;. *,u.n , 0..,..t that cvaluarcdspccificcascm-odulc then randomizcdThc DGI modulcsc.nsistcdof :;;;;",t'*;;; chcst pain' and ;;;;;;;;. irtt"t.a level of consciousncss, and a discussionbooklct that introduced ;h;;";;a;teath) to principlesand practicesin tmcrgcncymedicine' ;i ;.;;;;t presenThe DGI participantsdirectedquestionswithrn the casc questions directed group; each in dir.r].."d ,".r. tri-n ,tttt case *.i. a..ls""a to have students problem.solve within the the discussionmaierial The narrative group read ;;f;;.;;;Atil ra-."ii.rl "t",?rial without the directedquestionsor opportunity After completionof the material,all participants for discussion. r e c e i v e da p o s t - t e s ta s w e l l a s a s a t i s f a c t i o nq u e s t l o n n a r r e ' *hrch t.r.lrrd.d a 7-point rating scalc (7, outstanding;4' indiffercnt; and I, wasteof time). and results: Measurements Narrative DGI (s2l (52) Mean pretest score i % I

satisfying Conclusion:DGI is an equallyeffectiveand more e m ergency I n a n d p r i n c i p l e s method o{ learning -practtces medical stud-entscomparedwith indi;;;i;t;.G;;..o,t6lvear vidual narrative instruction

82

Attending SuPervision Camden' Center' Medical n-UliiijlOuriadybfLourdes A Sacchetti, j;;;;t; ittrgtncv MedibineResidencv, Jellerson Thomas i'ieivi University necTo determinethe extentof supervision Studyobiective: in practicing residents medicine {EMRs) for emergency essary dePartment. emergency the "---S;;ti#,,t ED tertiarv-carâ&#x201A;Ź universitv-affiliated, az,obo-ulsit, duringstudyhours p"o"ii i"t, itt Eo patientspresenting duringa four-monthPeriod. in the

study wasconductedof changes Design:A prospectrve of Eb patients seeninitially by second-yearEMRs -rn"e.;,..t, medicine atten.ding(EMAs)' uv .-.'g."cv -;;;;;;;;;;;itv -were V f " i f t o a . , S e c o n d - y e a rE M R s r o t a t i n g i n t h e E D them-durby patients evaLuated all of list a ..orri."J-. -"intain of ,h.it ED shi{t All patients seen bv the EMR .;;; il;; io- ^-tp..tl.a EMA, who also interviewed and ;;;';"t;;"d by examinedthose patlents.Initial patient care.was desigrred modification Attending h'tvtR the bv modified ;h;';;;ia;"; and resident's *"'r^t*"iO.a bv the EMn in a coded fashion on the .fteet. Modifications of the residentsproposedcare "",i.tif"* m folLo*t, maior was consideredas changethat ;;;;';;is"t;;J in patient disposition' detection of "lt.ration ;.;;;..1 in an pathology,or marked revislon of intended treatur*io..,.a resulted in a rlcsscrmodification of *'.'*trn'i.*'Jr"g.'irtr, X/ analysiswas used to -''''nagt-t"t oaticnt tnanagement;and no change in the of tvpes ;h;;u-t.t'rno :;;;;;. ,changes firsthalf of the study with thoseot the secondnalt' '^'"il;;;l;' itur h.r.tdredeight patient encounterswere includmaior modifications c,l in the study. Sixteenpatienti (a%)-h-ad ano 'z5dlor-/or modittcatlons' minor I34 of thcir carc, i33%lhad Jrtg.. Tirere was no significant di{ferencein the numh;;;" Jf modificationsin iatient care for thosc treatedin ir.iri."". .o-p"t.d with thosc in the latter studv ;;; ;;ri;;.iJi--""it't c o n c l u s i o n : i M h e u t l u " t i o n i s r e q u i r e df o r a l l ;;;;h;. *.tt .".-ingly routine patients m-anagedby second;;il;;; include direct patient interi.rr irttnt This evalu"aiionshould to resiiri"w, arr,lexaminationsby the EMA and not be limited cosignatures' prcscntations record ED or dcnt

lmpactof an EmergencyResidencyon thd Cost of PatientCarein an Urban CommunitYHosPitalED The Medicine' ol Emergency RMMcNamara , JJ KetlylDipartment

83

i ah, i l a d e l p h t a e f P e n n s y l v a nP M e d i c aCl o l l e g o ge.nerally Background:Teachingprogramsin medicine are has not issue this patient care; of theioit "*p."i.f,o increase ,tudied in emergencymedicine, the newest specialty' b.in "--i;;;G;;;d settin!: Iniulv- 1989,an emersencvmedicine resla..,.v ^l.r't-.d care'in ,tt .ttb,n community hospital emergenreview of fanuaryand Febru.u-J.orr,-..t,, and a retrospective .on,rr., group)charts and |anuary and Febru;iy-ii;tir.ci"J gto,,pI charts was-insti tuted' -'' ,ii, i 9so ir.iid.n.y ptogt"-" *of t"ttt orderedfrom six discharge M;ih;;;,-ih.'ttlq"in.v a marker of cost' The discharge as used was diasnosiscategories testsfor arri."..t .ita'l.J ".. .t follows, listed with the marker disotd.t-csc, serum chemistries, anticonvul.r."rt,]i l.J"t.

ETOH' rr"i f.".1.,-"t,erial biood gases,calcium, magnesium' asthma 2) tomographv; com-puted hea"d ""a ;;;i";i;;t;...!.'', serum chemistries,theophylline.level' ir*. Ls ,Z so years)-CgC, .^ai"gt"brt, 3J lumbar strain (agel5 to 50 vears)-lum;rii ;; t;Ji";"ptt,' +J cervical strain iaEe-l5 to 50 vears)with ;;; ;i;; -.;-;;i"i'",jh i.r. accident-cervi&l-spineradiosraph;5) il;iil and "ttriu".*it'it {age5 to 50 years)-CBC,serum chemistries' 6) vira[ upper respiratoryinfection (agel5 to ir'r"i..'"ii"*,"and io "."*j-csc, r.tr.tn chemiitries, and chest-radiograph' "" ordered most frequentlv bv the residencv h;i,;-iile-test disorderwere calcium l2l"/' vs.2'6%' P < 051 *-;;l;;;.;;ie vs o"/o,P < 05)' rests orderedmost {te:;;;;;;;;t;i-dtn

(r7tl2rt

6 71 8 r

)r,.

Mean post test score {7oI

9t!5'

Mean satislaction score

6 . 9! O . 2 '

ooot

EmergencyMedicineResidentPatient Manalemdnt:lmplicationsfor Closer

/P<.ool 8 9t 1 3 ' 4 . 8t 0 4 '

'P<.05.

40

quently by the contract group for lumbar strain were lumbar spineradiograph(87% vs 2I7o, P < .001);for cervicalstrain,cervical spine radiographl79ok vs 44%, P < .001); and for pharyngitis; throat culture(5(r%vs 9%, P < .0O1.).

Conclusion:Using the frequencyof testsorderedin six commonly treated dischargediagnosiscategoriesas a marker for costs,the introductionof an emergencymedicineresidencyinto an urbancommunity hospitaidid not increasecosts.

84

lmpactof an EmergencyMedicine ResidencyProgramon the Qualityof Carein an UrbanCommunityHospitalED

Medicine,The RM McNamara, JJ Kelly/Department ol Emergency M e d i c aCl o l l e g eo l P e n n s y l v a nP i ah, i l a d e l p h i a Background: In fuly 1989,an accreditedemcrgcncymcdicinc r e s i d e n c yp r o g r a m a s s u m c dt h c o p c r a t i o n o f a 2 t 3 , 0 0 0 - v i s i t urban community hospital emergcncydcpartmcnt prcviously staffedby a group of ninc physicianscmploycd by a rcgional contract8roup.

D e s i g n :A r e t r o s p c c t i v cc o m p a r i s o ns t u d y u n d c r t a k c nb y reviewingeveryED cncounterfor fivc prescntingcornplaintsfor and 1990{rcsidcncy).

Januaryand Fcbruary1989(prcrcsidcncy) Mcthods: Frcqucncyof physician documcntation of itcr.ns r e f l e c t i n gt h c q u a l i t y o f c a r e w a s n o t e d a n d s u b j e c t c dt o X z analysis.

R e s u l t s :P a r t i a lr e p r e s e n t a t i vrec s u l t sf r o m t h r c c o f t h c s c presenting complaintsareas follows: Preresidency Residency Lowerabdominalpain, f e m a l ea g â&#x201A;Ź1 5 t o 4 0 P e l v i ce x a r n i n a t i r n P r e g n a n ctyc s t o b t a i n c c l Nontraumaticchest pain, age30 or greater Q u a l i t yo f t h e c h c s tp a i n A s s o c i a t escyl r n p t o m s Cardiacrisk factors

{107) t { 3l T t t ' U , l tl8 (82'Z,l ( I 25)

le4l 9 4{ 1 0 0 ' 2 , ) / ) < . 0 0 1 92 198' X,) /) < .001 l s 4)

57 146"/,,1 75$)'h,l 67 154"1,) (n= 126)

4l \76'k,l 1 5I ( 9 4 ' 2), 4.1(tl0'2,)

P u p i le x a r n i n a t i r n 59 147"1'1 B a s i cn e u n r k r g i ce x a r n 57 145'h,l C e r v i c asl p i n ca s s e s s r n c n t 7 0 ( 5 5 ' 7 , )

1 3 41 9 7 ' l ' l 1 1 6l 8 4 " l , l 1 3 4P 7 ' h ' l

Headtrauma

x2

/, < .00I 1' < .(X)I /) < .01

(n= l3ttl 1'< .001 /) < .001 1 )< . 0 0 1

Similar results were secn for extrcmity laccrations rcgarding n e u r o v a s c u l a r ,t e n d o n , a n d f o r e i g n b o d y a s s c s s m c n t a n d f o r atraumatic headachc rcgarding mcningcal signs, ncurokrgic, and f u n d o s c o p i cc x a m i n a t i o n .

C o n c l u s i o n : A s a s s e s s e db y d o c r . r r n c n t a t i o n o f t h c m c d i c a l r e c o r d ,a n d e m e r g e n c y m c d i c i n e r c s i d c n c y p r o g r a m s i g n i f i c a n t l y improved the quality of care in this urban community hospital ED.

-85

experience as were their English-speaking counterparts. Our telephone survey of ED patients, however, showed that IZ"k of Spanish-speakingpatients were not satisfied with their ED encounter (vs 0% of controlsJ. The major complaint was that their primary problem was not appreciated by the physician and t h u s n o t a d e q u a t e l y a d d r e s s e d .T w e n t y - e i g h t p e r c e n t o f S p a n ish-speaking patients did not understand, at least in part, their diagnosis or instruction. There was no differcncc in follow-up compliancc between thc study group and controls despite the fact that only 23% of Spanish-speaking patients had discharge instructions in Spanish.

Conclusion: Emergency physicians should bc aware that the prcsence of a translator does not necessarily ensure adequate patient understanding and satisfaction and the most commonly perceived problem is a failurc to fully appreciatethc presenting compralnt.

.86

l N a s r , B H o u m e s ,M C o r d e r o ,C G r e e n e / D e p a r t m eonft E m e r g e n c y M e d i c i n e ,C o o k C o u n t yH o s p i t a l ;U n i v e r s i t yo f l l l i n o i sC o l l e g eo f M e d i c i n e ,C h i c a g o Study purposc: To dcmonstratc that a complete and rapid clinical history can bc obtaincd by using a self-administcred, bilingual qucstionnairc rndcpcndent of a translator.

Design: A post-tcst, cxperimental dcsign was used to evaluatc thc timc spent in obtaining the clinical history and information completeness for thc two study groups. A scalc for complctcncss of clinical data was developedand used.

P a r t i c i p a n t s : A l l p a t i e n t s w c r e n < l n - E n g l i s h - s p c a k i n gH i s p a n ic womcn, who prcsentccl with obstetric/gynecologic cor-np l a i n t s t o t h c em c r g c n c y d c p a r t m c n t .

Mcthods: Fifty-fivc paticnts complctcd the bilingual form, which through the usc of carbon papcr, automatically convcrts thc routinc obstctric/gynccologic history responscs from Spanish to English. Thc history was obtained frorn thc 55 patrcnts rn r h c c ( ) n r r ( ) gl r r r u pv i a a S p a n i s h ' i n t c r p r c t c r .

Rcsults:Avcragc complction time was significantly less {l4.3tl minutcs, 1)<.0001 )for thc cxpcrimcntal group (X,5.(r7 minutcs; SD = l.u9) than for controls (X = l4.5U minutes; SD = 4.19). AlthoLrgh thc rcsults cvaluating thc completcness of the qucstionnairc wcre not statistically significant, scven of the c i g h t c r i t c r i a ( u 7 . 5 ' X , )r c v i c w c d w c r c s c e n i n t h c E D c h a r t s o f paticnts who complcted thc qucstionnairc as often or morc frcqucntly than thosc using an rntcrprctcr.

Conclusion: Using a bilingual qucstionnaire to obtain a clinical history rcsults in morc rapid paticnt evaluation without affccting thc quality of information obtaincd,

.87

ofthespanish-speakins F3,3ll"

Hisrorv Hl'ff"?Xll"'ifl#Tfa'

Abilityto UnderstandWrittenDischarge Instructionsas a Reflectionof the Level of LiteracyAmong ED Patients

K Rosen, S San{ord, J Scott/Department of Emergency Medicine, G e o r gW e a s h i n g t oUnn i v e r s i tMy e d i c aCl e n t e rW , a s h r n g t oD n ,C

BT Jolly,JL Scott,S Sanford/Department ol Emergency Medicine, G e o r gW e a s h i n g t oUnn i v e r s i tMy e d i c aCl e n t e rG, e o r g e t o w n / G e o r g e W a s h i n g t oUnn i v e r s i tEym e r g e n cMye d i c i n R e e s i d e n cPyr o g r a m , W a s h i n g t oD n ,C

S t u d y p u r p o s e :T o i d e n t r f y t h e p e r c e n t a g eo f c m e r g c n c y departmentpatientswho are exclusivclySpanishspeaking,the availabilityand levei of trarning of interpreters,and the perceivedeffectof the languagedifferenceon the careof patients.

Population:Part I was a nationwide survey of 258 EDs, and part 2 was a telephonesurvey of 43 Hispanic patients and 33 English-speaking controls seenin this ED. Methods:The nationwide survey consistedof a written questionnaireto determine the percentageof Hispanic patients seen, the availability of Spanish-speaking translatorsand their level of m e d i c a lt r a i n i n g , a n d t h e p h y s i c i a n ' sp e r c e p t i o no f w a i t i n g timesand the overallsatisfactionof Spanish-speakrng patients.

The teiephone survey asked patients about translator use and u n d e r s t a n d i n gw , aiting times, compliancewith discharge instructions,and overall satisfactionwith their care.Results: The ED survey demonstratedthat, in general,as the pâ&#x201A;Źrcentage of Spanish-speakingpatients increased,translators were more availableand more likely to be medically trained. However, in EDswith 40Toto 60% Hispanic patients, only 41"/oalways have and 14% rarely have a translator within the department.Most EDs felt that Hispanic patients were as satisfied with their ED

S t u d y p u r p o s e :T o d e t e r m i n et h e a b i l i t y o f e m e r g e n c y dcpartmentpatients to understandwritten dischargeinstructions.

Population:Four hundredadults who presentedto an innercity university hospital ED on randomly selecteddays during the studyperiodand met inclusioncriteria.

Methods:Selectedpatientswere given one of two standard sets of written dischargeinstructions. After readingthe instructions, the patients were asked five specific questions and then were allowed to refer back to the instructions for the correct answers.

Results:Sevenhundred eighty-four patients were considered, and 400 patients(51%)wereentered.Of the 384 not entered,84 "didn't feel like it" or were "too tired," 13 l2L9%) {3.4%}did n o t h a v e t h e i r g l a s s e s ,f i v e ( L 3 % ) c o u l d n o t r e a d , a n d t h e remainder173.4%lmet exclusion criteria. Basedon overall scoring, the two sheetswere equally difficult. Males and females had virtually identical levels of success.Among patientswho noted a l2th gradeeducationor less,45 137.2%lwere able to answer five of the five questions correctly/ whereas20 124.8%l

A 1

+l

answered no more than two of fivc correctly. Of paticnts cduc a t e d b e y o n d h i g h s c h o o l , 1 2 6 1 6 7 . 7 % l a n s w er c d f i v c o f f i v c questions correctly, whercas l1 {5.9%) answcrcd no morc than two of five correctly. Youngcr paticnts pcrforrncd bcttcr than older patients. Of patients IU to 39 ycars old, 190 \76.0%l answcred at least four of five questions corrcctly. Thc samc succ e s s w a s a c h i e v e d b y 8 1 1 7 1 . 7 ' 1 , o) f t h o s c 4 0 t o 5 9 y c a r s o l d a n d by 23 {63.8%)of those more than 59 ycars old. Thrcc tlucstior-rs wcrc notably difficult, producing 587u, 67"k, and 247, corrcct answcrs. Answcrs to these qucstions were containcd within c i t h c r a r e a so f d i f f i c u l t s e n t e n c c c o n s t r u c t i o n o r l o n g p a r a g r a p h s containing large amounts of information.

Conclusion: A significant proportion of ED paticnts havc a demonstrableinability to undcrstand writtcn instructions, rcflecting thcir potcntial for inclusion alnong thc functionally illitcratc of socicty. Hcalthcarc providcrs shoulcl strrvc to sinrplify writtcn matcrials and dcvclop ncw mcthods for instructir.rg thosc for whom writtcn matcrialshavc no rrcaning.

tQQ 'lrl,

Effectof H|V-lnfected Patientson Human ResourceUtilization in the ED:A Timeand-MotionStudy

.90

G D K e l e n ,G B G r e e n ,P P r o n o v o s tJ, R W h i t e ,L V e r n a c c h i oC , Chan, Y G u i s l a i n / T hJeo h n sH o p k i n sU n i v e r s i tSy c h o o lo l M e d i c i n e , B a l t i m o r eM , aryland S t r . r d yo b i c c t i v c : T o d c t c r n - r i n c r f s y u r p t o m a t i c H I V - i n l c c t c c l p a t i c n t s L r s er r o r c h u r n : r n r c s o t r r c c s w l t h i n : u r i t . r r r c rc l t y u l l r r g c r . r c yd c p a r t m c n t t h a n n o n - H I V - i n f ec t c c lp a t i c n t s . [)esign: Prospcctivc,tirnc-ancl-motion stlrrly of hcalthc;rrc w o r k c r / p a t i c r . t ti n t c r a c t i o r . r s . _S c t t i n g : I n n c r - c i t y , t c r t i a r y - c a r e ,t c : r c h i r r gh o s p i t a l a n d A I I ) S r c l c r r a lc c n t c r .

P a r t i c i p a n t s :A l l l < n o w n s y n t p t o l l i l t i c H I V - i n f e c t c d p i l t i c n t s ( g r o u p l ) a n d n o n - H I V - i r r f c c t c da c u i t y - n t a t c h e r lc o n t r o l s ( g r o t r l t 2 ) s e c n i n t h c E l ) c l u r i n ga s i x - w c c l <p e r i o t l r l u r i n g s r . r m r n c rI 9 9 0 : r n d r r l l E l ) h c a l t h c a r cw o r k c r s i n v o l v c d i n t l t c i r c a r c .

Inttrvt nttrrn>:Nonc R c s u l t s :T h c r e w c r c . 3 , ( r 5 ,i3n t c r a c t i o n s ( i n c l u d i n g l . i 2 l {p r o c c d u r c s l o b s c r v c df o r 1 4 2 p a t i en t s { 7 1 p c r g r o r - r p M ). carrtintc itr tltc E [ ) f o r g f t r u p I p a t i c n t s w a s , 3 ( r 9 l l l i n t - l t c sc O n r p : r r c cwl i t h . ] 0 8 m i n u t e s f o r g r o u p 2 { / ' < . 0 5 ) .M c a n t i r l c o f l 0 ( r . 4 n t i l t u t c s p c r p a t i c n t w a s s p c n t b y h e a l t h c a r c w r t r l < res o n t l i r c c t t n t c r : l c t i o n s w i t h g r o r - r pI p a t i e n t s c o n t p : r r c cw l i t h f . t 0 . 7n t i l l u t c s f o r t h o s c i n g r o u p 2 ( / ' < . 0 5 ) . T o t a l t i r l e r c t p r i r e t lf o r p n r c e t l u r c sw a s . 1 , 4 7 4 n u n u t c s f o r p l t i c n t s i n g r o u p I c o r n p a r c t lw i t h 1 , 7 7 7 n r i n u t c s f o r g r o u p 2 . G r o r " r p I p a t r c r r t s r e c l t r i r c t lm o r c p r o c c t l r l r c s p c r p a t i c n t { m c a n , 7 . 1 v s 4 . 5 m i n r - r t e s /; , < . 0 . 5 ) l n t l t r r , ' r c r i r n e | r r p r o c c t h r r c( ( r . 9v s 5 . 5 n t i n u t c s ; 1 , < . 0 5 ) . T h i s r c l a t i o n s h i p h c l d w h c n c o n t r o l l c t l f o r a c r - r i t yA . m o r . r ga r l m i t t c c lp e t i c n t s / t h o s c i n g r o u p I s p c n t s i g n i f i c a n t l y l c s s t r m c i r . rt h c E D c l i n i c r r l a r c a { , 3 5 2 v s 5 . 3 0m i n t r t c s ; / ) < . 0 5 ) .

C o n c l u s i o n : P a t i c n t s w i t h s y n - r p t o l r a r i cH I V i n f c c t i o n rcquirc a grcatcr cxpcnditurc of ED hcalthcarc workcr tirrc c o m p a r c d w i t h a c u i t y - m a t c h c d c o n t r o l s . P r c s c r r c co f c l c s i g n a t c c l hospital bcds for HIV-infcctcd paticnts may aceounr firr thc shortcr ED timcs for HIV infcctcd paticnts rccluiringaclmission.

*cDll |CDY

od, thcy worc gloves 65 of 70 times {93%J1P < .001, RR, 3.6; confidcncc intcrvals ICI] 2.3 to 5.8). Regrstcrcdnurses were observcd for an additional three wecks, and their continucd c o m p l i a n c c w a s 5 0 o f 5 6 1 ' 8 9 % l jt h i s w a s n o t s t a t i s t i c a l l y d l f f e r cnt comparcd with one to four wccks after intcrvention (93%) {P = 0.5' RR, 0.9, CI, 0.ti to 1.1). Bcfore intervcntion, physicians w o r c g l o v c s 9 o f 5 l t i n - r c s ( 1 8 % ) c o n - r p a r e dw i t h 5 5 o f 5 9 t i m c s (93%,)during a four-weck pcriod after intervcntion (P < .001, RR, 5 . 3 ; C I , 2 . 9 t o 9 . ( r ) . T l - r ec n t i r c c o h o r t ' s s u c c c s s r a t e o n t h e f i r s t attcmpt at vascular acccsswhrlc wcaring gloves was 141 ol 192 t i m c s ( 7 3 ' 2 , )c o m p a r c d w i t h 6 3 o f 9 5 \ 6 6 % l w i t h o u t g l o v c s ( P = 0 . 2 7 ; R R , 1 . 1 ;C I , 0 . 9 t o 1 . 3 ) . P h y s i c i a n sw o r c a f a c c v i s o r n o n c o f 2 l t i n - r c sb c f o r c i n t c r v c n t i o n a n d f i v e o f l 4 t i m c s a f t e r i n t e r v en t i o n { 1 '< . 0 0 1l .

Conclusion: Intcnsivc cducational intcrvcntion dramatically i r . n p r o v c sc o r . n p l i a n c c w i t h u n i v e r s a l p r c c a u t i o n s b y r c g r s t e r e d n u r s c s a n t l p h y s i c r a n s i n t h e E D ; t h i s i r n p r o v em c n t d i d n o t cxtingLlish among rcgistcrcd nurscs cluring scven weel<s after intervcntion, glovc usc did not intcrfcrc with thc proficient pcrf o m r a n c c o f v a s c u l a r a c c c s sp r o c c d u r c s ; a n d l o n g e r - t e r m f o l l o w l u p c l a t aa r c b c i n g c o l l c c t c c l t o b e t t c r p l a n f o r c o n t i n u i n g c d u c a tion.

Efficacyof an ACLSTrainingProgramon ResuscitationFrom CardiacArrestin a RuralCommunityHospital

R f G e n o v aA,B S a n d e r sM, B u r r e s sM, M i l a n d e rK, K e r n G , E w y / U n i v e r soi tf yA r i z o n a H e a l t hS c i e n c eCs e n t e rT, u c s o nS; a f f o r d H o s p i t aS l , a f f o r dA, r i z o n a Study hypotl'rcsis: An advanccdcardiaclifc support{ACLS) trlrinrng.prograr.r.t, in a rural hospitalwill irnprovcrcsuscitatiun s u c c c s sI r o l l c a r o l : l c : l r r c s t .

I)csign: A rctrOspcctivccasc rcvicw Of all paticnts in carcliac arrcst drlring a l.J-rronth pcriocl bcforc and aftcr thc institr.rtion o f t h c l - r o s p i t a l ' sf i r s t A C L S t r a i n i n g p r o g r a m . C a t c g u r r c a l v a r i a b l c s b c f o r c a n c l a f t c r t _ l r cA C L S c o u r s c w c r c c o m p a r c d u s i n g t h c F r s h c r ' sc x a c t a n c l X 2 t c s t s w h i l c c o n t i n u o u s v a r i a b l c s w c r c c o r . n p a r c du s i n g t h c S t u d c n t ' s I t c s t .

S e t t r n g :A 9 9 - b c dr u r a l c o n r m u n i t y h o s p i t a l . l)articipantsA : l l p a t i c n t s i n c a r d i a ca r r c s t d u r i n g a l 3 - m o n t h p er i o t l s b c f o r c a n c l a f t c r t h c A C L S t r a i n i n g .

I n t c r v c n t i o n : A C L S - p r o v i d c rt r a i n i n g .

R c s u l t s : ( ) v c r a l l , t w o o f 2 9 p : t t i c n t s 1 7 " l , li n t h c p r c - A C L S p c r i o r l w c r c s u c c c s s fr . r l l yr c s u s c i t a t c d c o m p a r c c l w i t h s c v r : n o f 3 5 p a t i c r . r t s{ 2 0 ' 2 , )i n t h c p o s t - A C L S p c r i o c l ( 1 , = 0 . l 2 ) . P a t i c n t s i n v c n t r i c u l a r f i b r i l l a t i o r - ro r t a c h y c a r c l i ai n t h c p o s t - A C L S p c r i o d h r r d s i g n i f i c a n t i r r p r o v c r . n en t i n r c s u s c i t a t i o n s u c c c s s c o m p a r c d w i t h p a t i c n t s i n v e n t r i c r . r l a rf i b r i l l a t i o n o r t a c h y c a r d i a i n t h c p r c - A C L S p c r i o d ( s i x o f l 5 v s n o n c o f n i n c , 1 ) < . 0 5 ) .O u t - o f - h o s p r t a l c a r c l i a ca r r c s t r c s l l s c i t a t i o n w a s s i g r - r i f i c a n t l ym o r c s u c c c s s ftrl in thc post-ACLS pcriod corlparcd with thc prc-ACLS pcriod {fivc of .30vs nonc 25, 1, < .05). Comparisons of agc, scx, transp o r t t i m c , t o t a l r c s u s c i t a t i o n t i m c , w i t n c s s c c lo r u n w i t n e s s c d arrcst/ prcscnting rhythm, ancl prcscncc of othcr discascswcrc not significantly diffcrcnt for paticnts with cardiac arrcst in thc prc'ACLS pcriod comparcd with thosc in the post-ACLS pcriod.

Conclusion: Thc institution of an ACLS-providcr training p r o g r a m i n a r u r a l c o m m u n i t y h o s p i t a l w a s a s s o c i a t c dw i t h s i g n i f i c a n t i m p r o v c r n c n t i n r e s u s c i t a t i c l nf o r p a t i c n t s w i t h v c n t r i c ular fibrillation or tachycardia and out-of-hospital arrcst.

PositiveEffectof an Educational Interventionon ComplianceWith UniversalPrecautionsin a PediatricED

L R F r i e d l a n d ,M J o f f e ,J F W i l e y l l l D i v i s i o n o l E m e r g e n c yM e d i c i n e , S e c t i o no l G e n e r a P l e d i a t r i c sS, t C h r i s t o p h e r ' H s o s p i t a lf o r C h i l d r e n , P h il a d e l p hi a , P e n n s y l v a n i a

91

S t u d y o b j e c t i v e: T o p r o s p c c t i v e l y s t u d y c o m p l i a n c e w i t h universal precautions by registcred nurses and resrdents in our pcdiatric emcrgency department and then investigatc the effect o f a n i n t e n s i v e e d u c a t i o n a l i n t c r v e n t i o n { l e c t u r e s ,w r i t t e n m a t c r i a l s , p o s t e r s ) t h a t s t r e s s e dt h e n e e d f o r u n i v e r s a l p r e c a u t i o n s i n thc ED. Design: The cohort was observcd without their knowledge in a time-series study design.

Methods: We monitored glove use during venipuncture and IV line placement and face visor use during wound irrigation in preintervention and postintervention phases.

Results: Before interventlon/ registered nurses wore gloves l3 of 5l times (25%); during a four-week postintervention peri-

MilwaukeePrehospitalChestPain Project-Phase l: Feasibilityand Accuracy of PrehospitalThrombolyticCandidate Selection

TPAufderheide, M Keelan, Jr, GEHendley,NA Robinson, T H a s t i n g sR, L e w i nH , H e w e sA, D a n i e lD, E n g l eB, G i m b e lK, B o r t i n , D C l a r d yG , Schuchard D,S c h m i d tT, B a l w aP, H o l z h a u e r / M e d i c a l College o l W i s c o n s i nM, i l w a u k eRee g i o n aMl e d i c aCl e n t e r , M ilwaukee Study objective:To prospectivelydeterminefeasibilityand accuracyof prchospitalthrombolytic therapy candidateselection by basestation emergencyphysicians.

Design and setting: During a six-month period, paramedics acquiredand transmitted prehospital l2-lead ECGs and then a p p l i e d a t h r o m b o l y t i c t h e r a p y c o n t r a i n d r c a t i o nc h e c k l i s t .

42

I

I

92

Effectof an ED InitiatedTreatment Protocolon the Timingof Thrombolytic Therapyfor MyocardialInfarction

E A P a n a c e k ,N J J o u r i l e s W F R u t h e rof r d / D e p a r t m e n o t f Emergency M e d i c i n e ,U n i v e r s i t yH o s p i t a l so f C l e v e l a n dC , a s eW e s t e r nR e s e r v e U n i v e r s i t yC, l e v e l a n d0, h i o

t I

cally inhibit sinoatrial and atrioventricular node function have been studicd cxtensively, but few data are available on their relative potcncy. We compared their effects by performing them scqucntially on a group of healthy volunteers.

Partrcipants: Twenty volunteers with no history suggestive o f c a r d i o v a s c u l a r o r o p h t h a l m o l o g i c d i s e a s e .M e a n a g e w a s 4 3 . 0 + 1 3 . ( ry e a r s { a g c r a n g e , 2 5 t o 6 8 y e a r s ) , a n d t h e r e w e r e 1 8 m e n ano two womcn.

D c s i g n : C o l d f a c c i m m e r s i o n { c o 1 d )a n d V a l s a l v a m a n e u v e r wcrc pcrformcd twicc to maximum endurance {M) and to the subjcctivc point of first discomfort (D); warm face immersion lwarrn) and thc Mucller mancuver were executed to ntaximum c n d u r a n c c o n l y . R i g h t a n d l e f t c a r o t i d m a s s a g e( R C a r , L C a r ) a n d lcft, right, and bilatcral eycball compression (REC, LEC, BECI wcrc cach pcrforrncd for l5 seconds.Changc in heart rate was takcn as basclinc minus thc rate over thc slowest three consecutivc QRS cyclcs clicitcd by each maneuver. Heart rate responses wcrc analyzcd by Fisher's Icast significant differencc multiplecomparison procedurc. Significancewas taken as P < .05.

Rcsults: Maximum pulsc decrements from bascline and95"k confidcncc intcrvals in beats per minutc wcre cold M, 15.5 {12.3 t o 1 l t . 5 ) ;C o l d D , 1 0 .I { 6 . 7 t o 1 3 . 1 ) ;V a l s a l v a M , 9 . 2 ( 6 . 3 t o 1 2 . 4 ] t , V a l s a l v a D , U . 3 { 5 . 0 t o 1 1 . 3 ) ;R C a r , 7 . 3 1 4 . 3t o 1 0 . 3 } ;L C a r , 5 . 2 ( 2 . 3 t o l i . 4 ) ,R E C ( r . 0 1 3 . l t o 9 . 2 ) , L E C , 6 . 6 ( 3 . 6 t o 9 . 5 ) ; B E C , 6 . 0 ( 3 . 1 t o 9 . 2 ) ;w a r r . n ,7 . 0 { 3 . 2 t o 9 . 8 ) ;a n d M u c l l e r , 1 . ( r { - 1 . 3 t o 4 , 9 ) . B r a d y c a r d i aw a s s i g n i f i c a n t l y g r c a t e r f o r c o l d facc imrrcrsion pcrforrned t<l maximum cndurance than for all o t h c r m a n c l r v c r s { 1 )< . 0 5 t o < . 0 0 1 ) . N o c h a n g c si n P R i n t e r v a l o c c u r r c c li n t h c a b s c n c c o f a c h a n g c i n r h y t h m .

C o n c l u s i o r - r :I n h c a l t h y s u b j c c t s , t h c d i v i n g r e f l e x i s t h c m o s t 1 - x r t c no t f t h c v a g a l l y n ' r c d i a t e dr c f l e x e s u s c d i n c l i n i c a l p r a c t i c e .

Cold facc immcrsion may provc cffcctivc at the bedside when o t h c r m a n c u v c r s f a i l t o a d c c l u a t c l ya u g m c n t v a g a l t o n e .

Emergency physicians interpreted prchospital ECGs and prospcctively sclected thrombolytic therapy candidatcs. A safcty committee of cardiologistsreviewed prchospital ECGs, checklists, and hospital records to indcpendcntly dctcrmine accuracy.

Participants: Six hundred-cighty stable adult prchosprtal paticnts with a chief complaint of nontraumatic chest pain wcrc initially cvaluated. Two hundrcd forty-one cascs wcrc excluded duc to I ) failcd ECG transmission \149L 2l transport to nonparticipating facilities l72l; and 3) unavailablc medical rccords (20).

Thc final study population compriscd 439 paticnts.

Intcrventions: No prchospital thrombolytic therapy was aclministcrcdin this study R c s u l t s : O f 4 3 9 c a s c s ,9 l l 2 l % l h a d t h c f i n a l d i a g n o s i s o f m y o c a r d i a l i n f a r c t i o n , 3 8 o f 9 l 1 4 2 % ' )h a c l d i a g n o s t i c p r c h o s p i t a l ECGs, and l2 of 38 (32%) wcrc sclcctcd by crncrgcncyphysic i a n s a s t h r o m b o l y t i c t h c r a p y c a n c l i c l a t c s .S c v c n t y p c r c c n t o f m y o c a r d i a l i n f a r c t i o n c a s e sh a d c h e c k l i s t c x c l u s i o n s f o r t h r o r n bolytic thcrapy. Prchospital cvaluation incrcased sccnc tilne by 3 . I r . n i n u t c s .T h c m c d i a n t i m c f r o m c h c s t p a i n o n s c t t o p a r a r n c d r c a r r i v a l i n n - r y o c a r d i a li n f a r c t i o n p a t l c t l t s w a s ( r 0 m i n u t c s . T h c c s t i m a t c d a v er a g c t i t n c s a v c d i f p r c h o s p i t a l t h r o r n bolytic thcrapy had bccn availablcwas 101 I Ul minutcs. Thc S : r f c t y C o m n - r i t t c e c o n c l u d c d t h a t a c c c p t a b l c a c c L l r : l c yo 1 c r r c r g c n c y p h y s i c i a n p r c h o s p i t a lE C G i n t c r p r c t a t i o n ,c h c c k l i s t , a n d casesclcction was achicvecl.

Conclusion: Emcrgcncy physicians can accuratcly idcntify p r c h o s p i t a lt h r o m b o l y t i c t h c r a p y c a n d i d a t c s .

Background:Substantial tlclays in thc initiation of thrornb o l y t i c t h c r a p y ( T T ) f o r a c u t c m y o c a r u l i a l i n f a r c t i o r . r( A M I ) h a v c b c c n r c c o g n i z c c la s a c o n c c r n a n d a r e c o l r s i c l c r c t lt o b c t . t . r u l t i f a c torial in natLlrc.

S t r - r d yh y p o t h e s i s : l m p l c r n c n t a t i o n o f a n c n r c r g e n c y c l c p a r t ment-drivcnprotocol for thc initiation of TT in AMI can signific a n t l y d c c r c a s ct r c a t m c n t d c l a y s .

Dcsign: I)ata wcrc collcctctl prospcctivcly for cluality assurr n c c p L l r p o s c s .S t u d y a n a l y s i s w a s r c t r c s p c c t i v c , c o r n p a r i n g t h c g r o r , r p sr c c c i v i n g T T b c f o r c a n d a f t c r c x i s t c n c c o f a n E D A M I protocol.

S c t t i n g :A t c r t i a r y - c a r cu n i v c r s i t y h o s p i t a l .

P a r t i c i p a n t s : A l l E D p a t i c n t s { 5 ( r )r e c c i v i n g T T f o r A M I d u r ing a four-ycar pcriod (l9tt7 through 1990)wcrc rcvicwcd. Scvcn cascswcrc cxcludcd duc to dclays in TT that wcrc outsidc tlrc clinrcian's control, lcaving 49 for analysis.

Intcrvcntions: None for study purposcs.

Methods: The ED AMI protocol addresscd rcgistcrcd nursc and physician practices, stocking of TT agcnts in thc ED itsclf, and a treatmcnt decision for TT madc by cmergency physicians.

Results: There were 35 eligiblc patients in thc postprotocol group and 14 in thc preprotocol group. Intcrvals {mean + SD), given in minutes, for timcs from ED arrival to TT wcre 3U 1 1l in the postprotocol group and 93 + 38 in the prcprotocol group (P . .05). In the postprotocol group, no patient (range 15 to (r5 minutes) approachedthe averagc timr' to TT scen in the preprotocol group. Although improvement in timc to obtaining an ECG was also seen with use of the AMI orotocol. it was not statistically significant and accounted for-only i8% of the total improvement seen in the time to TT. Conclusion: Implementation of an ED-directed AMI protocol significantly shortened the time to admrnrstration of TT in p a t i e n t s w i t h A M I . T h e d e c r e a s ei n t i m e w a s s u b s t a n t i a l .

93

.94 ElllLY:$:i,''iil,?iB':l'""J,3' PWPaustian, AHChuang, RR Jt BDFitzpatrick, JC McPherson Stu r g e r( yE m e r g e n c y R u n n eJrC , M c P h e r s lol ln/ D e p a r t moefn a ;SA r m y , M e d i c i nSee c t i o nM) ,e d i c aClo l l e goefG e o r g iAa u, g u s tU y ,tG o r d o n G,e o r g iD a ;e p a r t m e on f Ct l i n i c a l D e n t aAlc t i v i tF r yM e d i c aCle n t eFr ,tG o r d o n InvestigatE i oins ,e n h o wAer m

l l a c l c g r o u n c lE : vcn though crroncous, thc gcneral public's pcrccption of thc prin-rarycarc providcd by the cmergency physician is to clcan and rcpair wounds. Thcrcforc, wound healing should bc an irnportant conccrn of thosc working in an emerg c n c y c l c p a r t r n c n t .M c t h o d s o f c l c a n s i n g a n d s u t u r i n g a n d a p p l i cation and/or adrninistration of various agcnts to improve healing arc numcrous, but fcw havc changed wound care.

Study objcctivc: To cvaluatc thc use of IV adrninistered P l u r o n i c F - 6 t 3( F - 6 8 )a s a n a g c n t t h a t s i g n i f r c a n t l y i n c r e a s e se a r l y w o u n d h e a l i n g t c n s i l c s t r e n g t h . F - ( r 8h a s b e e n u s e d t o c l e a n c o n taminatcd wounds with final removal from the wound surface w i t h a w a s h o f s t e r i l c s a l i n e.

Methods: Full-thickness skin incisions (8 cm in length) were madc in both flanks of shaved anesthetized adult male rats {olIowcd irnmcdiatcly by suturing the wound with 4-0 silk sutures placcd 0.5 cm apart. No cxternal care was provided. Immediately after suturing, an isotonic solutron of I0ok F-68 {in diluted saline) was given IV {dose8 ml/kg body wt). Doses were repeated IP every cight hours until sacrifice under anesthesia at 24, 48, or 96 hours. The incision was cut into 2-cm-wide strips and the tensile strength measured with a Kayeness,Inc Tensile Tester, Model D-509(r. Groups of animais, administered saline, served as controls.

Results: At 24 and 48 hours after surgery, there was a slight decrease in the wound strength of the F-68 group (24 hours: 196 + 45 g control vs I27 + 50 g F-68; 48 hours: 176 r 40 g control vs 132x40 g F-68). This may reflect the antifibrin activity reported for F-68. At 96 hours, however, there was a significant increase ,354 in wound strength in F-68-treated animals t I49 g F-68 vs 2O3t27 g control, P < 001), an almost doubling of the wound strength. This may be due to our earlier iindings of a stimulation of fibroblast growth in tissue culture by F-68.

Conclusion: For wound repairs, in at least a selected population (ie, athletesl in whom an early increase in wound strength is desirable, the administration of F-68 IV may be justified.

BradycardicResponsesto Vagally MediatedBedsideManeuversin Healthy Volunteers

WABerk,MJ Shea,BJ Crevey/Department Medicine, ol Emergency WayneStateUniversity,, Detriot,Michigan;Departmenl ol Internal M e d i c i n eD, i v i s i o no l C a r d i o l o g U y ,n i v e r s i t0y{ M i c h i g a n Study objective:The vagally mediated reflexesused to clini-

43

Stitch: VerticalMattress Shorthand of a NewSutureTechnique Evaluation

*.lE :tO

Medicine G Drew/Emergency M Gartner, lS Jones, S pactr, StateUniversity Michlgan Hospital' Butterworth n.tiOtn.VProgram, d apids e ,r a n R n e d i c i nG C o l l e goef H u m aM is Study hypothesis: The shorthand vertical mattrcss suture of , ,,"* t,.r,nia techniquc that provide.s the ,same amount w o u n t l c v e r s i o n i n l c s s t i m c a s t h c c l a s s l cm e t n o o D e s i g n : R a n d o m i z e d ,p r o s p c c t i v cc l i n i c a l . t r i a l ' Sctting: University-affiliated community hospital' Participants: Thirty patients who presented to the emergcnclocv department with traumatic laccrations requiring primary r , 1 r " .h o u " a t i n v o l v i n g t h e h a n d s , f c e t , o r f a c e w c r e c x c l u d c d ' Interventions: Patients meeting inclusion critcria wcrc randomly allocated to have either shorthand or classic vertical mat,ra., ,u,rlrar. Wound information was collected on data shects r of a r - r di . t c l u d e d p h y s i c i a n l e v c l o f t r a i n i n g , r e p a i r t i m c , n u m b e k n o t s p l a c e d , a n d d e g r e eo f w o u n d e d g c e v c r s i o n f o r e a c h s u t u r c tcchnique. Subjects were thcn asked to return to thc ED in . " r a t , " t e n d a y s f o r w o u n d a s s c s s m e n ta n d s u t u r e r c m o v a l ' Rcsults: We evaluated 36 lacerations to thc scalp, trunk, and cxtrcmitics. Shorthand vertical fiiattrcss suturcs wcrc usccl ln 20 wounds {56%), and classic mattrcss suturcs wcre used in l(r t + + 7 ul . f h " ' s h o r t h a n d s t i t c h p r < - r v i d e dt h c s a m e a m o u n t o f wound cversion in half the time as the classic tcchnicluc No infcctious complications, dclaycd wound healing, or costnctic

PM EADavis,AN Sucov,LC Mancione, JJ Menegazzi, Medicine,Schoolof Medicine, o{ Emergency Paris/Diriision Medicineol Western Centerfor Emergency ol Pittsburg6, University P e n n s y l v a nP i ai t, t s b u r g h Objectivc:To determrnethc reliabilityof thc GlasgowComa Scale{CCS)and the NeurobehavioralAssessmentScalc(NASI when used by paramedicsand emergencyphysicians'Design: p-.o..tiu., nonrandomizedtrial in a classroomsetting,with subjectsblindcdto all others'scoring. f iliated cmcrgencyphysii,articipants:Ninctecn university-af cians and 4l profcssionalparamedicsfrom an urban EMS sysvoluntarilY tem particiPatcd Intcrventions:Participantswerc shown a seriesof four videoa paticnt/ rcporting assesscs tapcdsccnesin which a paramedic .Ih. f i . t t t h r e c s c e n e sr e p r c s e n t e d ,firJ "ff of his findingi. sevcre,moderate,and mild alterationin levcl of conscrousness ifOCt. ntl of thc vital sigr.rsand findings in thc fourth sccne of intra-rater wcre identicalto the first, allowing determinatior-r of iach scenc,subiectsassigncd i.ii"frlii,v. At thc cotr.rpletion both a iCS and a NAS scorc.Thc kappastatisticwas uscd to d"t.r,nin" inter-ratcrrcliability, and thc rcliability coefficicnt was uscdto dctcrmincintra-raterrcliability' Rcsults:

c r: c s c e n . n ' - r' co,br l.ct .m t ust iw un Thc shorthand vertical mattress stitch dcscribed here is an cfficicnt, alternative mcthod for laccration rcpair without compromising wound eversion or cosmctic rcsults'

Effectof Body Localeand Additionof Epinephrine6n the Durationof Actionof a Local AnestheticAgent Medicine' ofEmergency RHuang/Department Berk, K Todd,WA Department Center; Health andUniversity Hospital Receiving Detroit Michigan Detroit, University, State Wayne Medicine, ofEmergency

nG :tfl

Study objcctivc: Littlc inforrnation cxists rclating lxrdy Iocalc to thc duration of action of local ancsthctics, thcrcforc, *" tcst",l thc duration of action of a krcal ancsthctic with ancl without epinephrine at differcnt body localcs Participanti: Twenty hcalthy voluntccrs agcd27 to 4ti ycars '{ m c a n ,3 2 . 0 y c a r s ) .

Dcsign: In thc first of two expcrimcnts (L), 20 subjccts had I mL of buffered I% lidocainc iniccted intraderrnally on thc forohcad, hand, forcarm, and cal{. In thc second cxpcritncnt (LE),ten subjccts wcrc injectcd at thc samc sitcd with l% lidocainc containing cpinephiinc (concentration,-l:100,000) Subjccts rankcd , n . . , f i " t l t t o p i n p r i c k f r o m 0 ( c o m p l e t e Jt o 2 0 ( n o n c ) o n a g r a p h ic chart with'tcsiing done every i-S {f-) or 30 (LE) minutcs and continued until no anesthetic effect was prcsent Duration of effectivc (A) and o{ any (B) ancsthesi? were, respcctively, timc ,rt'ttil ..oi. more than 5 and more than 19 Mean duration of anesthesiawas compared by analysis of variance (betwecn body a r e a s )a n d p a i r e d t w o - t a i l e d t t e s t ( L v s L E ) .

Significancewas taken as P < .05. + SEM) is RJsults: Duration of anesthesia in hours (mean tabuiated below:

L

Face A B 0.7!0.I I.6rb.2

LE

3 . 0 1 0 . 64 . 2 1 0 . 1 t Anesthesia

Arm Hand , A B A B \.4l]O.ZZ'LO.Z l.2t0l 25102 eztoo g'ttor' 6 . 8 1 0 68 1 t 0 6

was significantly

briefer

KaPPa

Ml) EMT,I'

Sevcrc scvere

5.(r 5..1

0,11.1'

Il{5 I l1.'1

06tt'

Ml) EMT I'

Moclerrtu Mtxlerrrc

Il.ll lo7

0..14'

107 I2'l

016

Mt) EMT,I'

Mild Mil(l

11.9 1 , 1N

0.i15

55

0..15'

. s i g n i f i c a nat t 1 )< . 0 0 0 1 .

I n t r a - r l t . , r c l i a b i l i t y( r 1 . 2 )f o r t h c G C S w a s 0 ( r 3 ( / r < 0 l ) a n d w a s0 . ( r (1. 1.) . 0 1 )[ t r rt h c N A S Cirnclusions:Both scalcsshow statisticallysignificantrcliability (ic, significantagrccment)bctwccn cmcrl;cncyphysicians '"na'Efrnr ijs. Thcv ais,rhavc a significantlcvcl of intra-ratcr r c li a b iI i t y .

i e d i c aCl e n t e rU; n i v e r s i t0y1 M a r l e r / U n i v e r soi{t C y i n o n n a tM l n i v e r s i tMy e d i c aCl e n t e rN, a t i o n a l V i i o i n i aM e d i c aCl e n t e rC; o r n e lU l n s t r t u t eosf H e a l t hN, I N D S B a c k g r o u n dN : c w s t r o k c t h c r a p i c sa r c f o c u s i n g - o t cr a r l v n a t i c n t i d e n t i f i c a t i r l na n d e a r l y i n t c r v c n t i o n l t h a s b c c n s u g l " r i r i , t t " , o n l y a s m a l l p c r c e n t a gocf s t r o k cp a t i c n t sa r c c l i g i i , l " f u i n t " r u . n t l ( ) n atlr c a t l n c n th c c a u s cd e l a y si n p r c s c n t a t i o n dre cxccsslvc.

Study hypothcsis:

Paticnts

who

contact

911 arrive at thc

hospital'cariicrthan thbsc who do not, there is no differencein .r'tlv ritlurt attributablcto sexor racctmore-than30% o{ stroke or,l.nrt arrivc at the hospital within four hours of onset;and i,"ii"",t with hemorrhagiistroke arrive soonerthan thosc with ischcmicstroke.

Design:Data were gatheredprospectivelyon all patientsprer.tt,r"f"*i,tti" 24 houis of onset of stroke symptoms to one of i f t . p j r , i . i p t t i n g h o s p i t a l s f r o m b e t w e e n M a r c h 1 9 U 7a n d December i990. b^ta were gatheredas Bart of a multicenter study or tPA in early strokeireatment.Xz and two-tailedt test were usedfor statisticalanalysis.

Results:A total of 1,810patients were studied Adequate time data were availableon 1,169patients,of whom 48o/owere female and 52"h male. Although 47% of all patients were transported by life squad, 60% of all patients.arriving within four 'hours by life squad'Patients of ty-pto- onset were transported. .o"t""ti"i life squadfirst were more tikely to presentwithin i4 hours tha"nthose arriving by other means (P < '005)' There was no sisnificant differencein sex or race in patients presentlng *ithi"tt {o.r. hours of onset. Patients with hemorrhageon initial co.rrput.d tomography did not present sooner than those witho n i i " r n o t t h r { , t Z l S v s 2 9 0 m i n u t e s ) .O v e r a l l , 6 l ' / " o f a l l or,i*.t arrived'within four hours of symptom onset, and 55% lrtiu.d within three hours o{ symptom onset' The time from

B 24!O2

for all

other body localesby both indexes of duration (A and B) {PP.< .001 to < .051.An.sth.tia with epinephrinelasted significantly Ionger than with lidocaine alone in all body localesand for both indexesof duration{P = .0001to .001).

Conclusion: The duration of action of local anesthesiais considerablyshorter for the face than for other body areas' Epinephrinesigniiicantly increasesthe duration of action of lidocainein all bodv locales.

97

NAS

Delaysin Presentationin PatientsWith Acut-eStroke:FactorsAffectingEarly HosPitalArrival JA JPBroderick, Jr,DELevy, ECHaley TGBrdtt, WGBarsan,

99109 Il'3l0il

for the face than

Kappa

LOC Dcpression

98

Leg A |2!ol

GCS

Raters

Reliabilityof the GlasgowComaScale and the NeurobehavioralAssessment Scale 44

(3%) had mild deficiency.There were no seriouscomplications ieoorted as a result of the lumbar puncture. The number of red blbod cells in the cerebralspinal fluid rangedfrom none to 1,295 (median,2). Becausethe rate of serious complicat-ionswas 0%, we used the "rule of three," (3/n) to calculatethe maxrmum The projectedrisk of a serious potentialrisk from the procedure. complication occurring would be as 1ow as 0% but no more than 5.8% (threeof 52;t5% confidencelevel).Conclusion:With adequatcfactor replacement/a lumbar puncture can be done safclyin paticntswith hemophilia.

onset to hospital arrival was shortest if the first medical contact was with the life squad, and significantly longer if the hospital (P < .0001}was the first {P < .0001}or the personalphysician contact.

Conclusion: The maiority of patients wrth strokc (55%) prcsent withrn three hours of symptom onsct. Those who ctlntact a life squad first arrive at the hospital earlicr than thosc transportcd by other means. Prehospital carc should bc a iocus arca tn inteivcntional stroke studies bccause the majority of paticnts arriving early are transported by life squad.

99

rorEmersencv 1 01 fi"T$,["f;:t]'5J,f3''"""" Schoolof Medicine, Mexico

EmergencyUse of EEGWith a TwoChannelEEGMonitorin Comatose Patients

ol New DP SklarlUniversity A lb u o u e r a u e

S S t a r k n a n l D e p a r t m e n tos { M e d i c i n e a n d E m e r g e n c yM e d i c i n e a n d N e u r o l o g yU , C L A S c h o o lo f M e d i c i n e S t u d y h y p o t h c s i s : E m c r g c n c y d c p a r t m c n t a s s c s s t t t c n to f hrain function ts currently bascd solcly on thc physical cxamination, which can bc inaccurate and is difficult in intubatcd, paralyzcd paticnts. Emergcncy two-channcl-clcctrocnccphalography (EEG) is useful in thc managcmcnt of coln:ltosc patiL'nts

Background: We have incorporated a six-month community cxpericnce into thc second year of an emergency medicine resid c n c y . D i d a c t i c s e s s i o n st h a t c o v e r c l i n i c a l e p i d e m i o l o g y , m e d i cal-lcgal-ethical issues, economic and cross-cultural topics, and intcrpersonal skills providc somc background for understanding thc physician's role in thc community as well as present corc matcrial for an emcrgency medical residency in an appropriatc

in thc ED. D e s i g n : P r o s p c c t i v ec v a l u a t i o n o f p a t i c n t s p r e s c n t i l l g l n colna.

Sctting: UnivcrsitY hosPital ED. Population: A convcnicncc sarnplc of 1[l paticnts presumcd by houscstaff to bc in coma who wcrc sccn b y t h c i n v c s t i g a t o r during a two-month pcriod.

Intcrvcntion: A portablc compact two-channcl EEC unit was uscd. Fivc necdlc clcctrodcs were applicd to frontoparictal ancl ground scalp sites. Raw EEC tracings wcrc displaycd on a lronrior, and compresscd spectral array data wcre printcd. C)nly gross abnorrnalitici of frequcncy and arnplitudc wcrc sought.

Rcsults: For all paticnts, data wcre availablc withir-rIivc n-rinutcs of initiating EEG hookup. Thc EEG had a rnajor irnpact ()rr thc carc of thrcc patients. Onc paticnt with acutc hcad trautna was found to bc in elcctrical status cpilcpticus, which was conf i n n c d b y s u b s e q u c n t f o r m a l 1 ( r - c h a n n c lE E C . A n o t h c r p a t i c n t , who had bccn piralyzcd and cndotrachcally intubatcd for thc managcmcnt of-suspcctcd status cpilcpticus, was founcl to havc a normal, awakc, alcrt, and nclnpostictal tracing. Thc diagnosis w a s c o r r c c t c d t o p s c u d o s c i z u r c s ,a n d t h c p a t i c n t w a s d i s c h a r g c d from the ED. A tlird paticnt, who had alrcady bccn admittcd trr thc intcnsivc carc unit for rigidity and unrcsponsivcncss, was found to havc a normal tracing. With additional stimulation, it bccamc clcar that thc paticnt was not in coma. Hc was sttbscq-u c n t l y t r a n s f e r r c d t o t h c p s y c h i a t r y s c r v i c c .

Conclusion: This first rcport of thc cmcrgcncy usc of a twoc h a n n c l E E G m o n i t o r s u g g e s t st h a t t h i s t c c h n o l o g y r n a y o f f c r a simplc way of improving the ED rnanagcmcnt of comatosc

contcxt.

Study obicctive: It is hoped that residents will bccorne intercstcd in'the prevention of cmergencies through the usc of comrnunity rcsourccs.

Rciults: Proiccts of residcnts thus far includc epidcmiology of unintcntional gunshot injury in children; hcalth care of the homclcss; sports injuries of hlgh school athletcs, poisonous plant ingestion in children; use of motorcycle helmets in motorcvclc riJcrs, school clinics and education about drugs, scx, and violcncc for high school and junior high school studentst drownings; Nativc-Amcrican injury epidemiology; and a rninirccord for chronically ill or disablcd childrcn.

Conclusion: Initial asscssmcntof thc cxpcricncc by rcsidcnts has bccn positivc.

a flq, I VZ

Medical Medicine, 0f Emergency D Cohen/Department WPBurdick.

Pihai,l a d e l p h i a C o l l e goef P e n n s y l v a n patientsare individualstraincd to Background:Standardizcd dcpict thc history, and frcqucntlythe physicalfindings,consistcnt with a particulardiseasc.

Study oblcctivc:To use group interviewswith standardizcd patients in our freshman undergraduateemergencymcdicinc courscto tcachintervjewingskills.

Mcthods:A vidcotapeto demonstrateappropriateand lnappropriatefaculty preceptingwas developedto enhancefaculty skills in guiding novice students through a group interview.

With thc use of volunteer second-yearstudents and one of our standardizedpatients,a twenty-minute videotapewas edited form two one-hourgroup interviews. The tape demonstrates the goalsof the group interview-to teach studentsto ask useful op.iing questio;s, to allow the patient to tell the whole story of their piesent illness, to ask helplul follow-up-questions,to elicit the important parametersof symptoms,and to becomeempat h e t i c l i s t e n e r s . T h e t a p e a l s o d e m o n s t r a t e st w o c o m m o n errors among faculty preceptors-the use o{ the sessionas a lecture and the use of the sessionto teach differential diagnosis.

The videotapesessionis followed-up by a reiteration of the goalsand an opportunity for questions.

Results:O6iervers from the Of{ice of Medical Educationand the standardizedpatients both note significant improvement in faculty adherenceto the statedgoalsof the sessions.

Conclusion: Faculty development programs that teach new e d u c a t i o n a l m e t h o d o l o g i e sc a n b e e f f i c i e n t l y c a r r i e d o u t t h r o u g h t h e u s e o f v i d e b t a p e dm o d e l s ' T h e s t a n d a r d i z e d patients technique is one method emelgency-medicineeducaio., .m sue to maximize effectivenessin undergraduatemedical education.

patients.

{ nn I lrl,

With GuidingNoviceStudentInterviews A Faculty Patients: Standardized Program DeveloPment

in Patients Safetyof the LumbarPuncture WithHemophilia

R Lipton,M N Sanders,M Hilgartner, S Bernstein, B Sitverman.

C a h i l l - B o r d aKsJ, a c k s o nT, K w i a t k o w s k i / D i v i s ioof nEsm e r g e n c y Ptr o g r a mL,o n gl s l a n dJ e w i s h M e d i c i naen dH e m o p h i l iTar e a t m e n Cte n t e rN, Y M e d i c aCl e n t e rN, e wY o r k ;H e m o p h i l iTar e a t m e n n alilornia H o s p i t a l - C o r nMe el l d i c aCl e n t e rN, Y ;S o u t h e rC l ,a s a d e n a H e m o p h i lC i ae n t e rH, u n t i n g t oHno s p i t a P safety of lumbar puncthe determine To objective: Study turesin hemophiliapatientspretreatedwith factor.

Design:Retrospectiveanalysisof medical recordsbetween 1980to 1990.

Setting:Three hospitals,each serving as a regional hemoohiliacenter.

Paiticipants:Thirty-three patients with hemophilia A or B who receivedone or more lumbar punctures.

Intervention: All patients receivedreplacementof deficient factorbeforethe lumbar puncture. Seriouspost-lumbarpuncture complications were defined as motor or sensory deficits, incontinence,or documentedintraspinal hemorrhage.

Results:Thirty-three different patients with hemophilia A or B receiveda total of 52 lumbar punctures during the study period. Thirty oi 33 patients (91%l had severebaselinefactor deficiency, two o{ 33 {6%) had moderate deficiency,and one of 33

[",?;tJll,",f""' 10331,?ln"l?.IiH:3131'ff 45

CH Schultz,RA DiLorenzo, KL Koenig,R Bade,RW Kingston,C ja lrvineMedicalCenter; Salinas,KA Salness/University of Californ 0rangeCountyEmergency MedicalServices, California Background: To date, no disaster medical trainrng program . has adequatelyaddressedthe provision of immedrate, on-scene advancedlife support to victims isolatedin a comDartmentalized disaster,such as a massiveearthquake.

Study purpose:Becauseoutside hcip may not arrive Ior 24 to 72 hours,.and most preventabledeathi occur within 4g hours, we have developeda medical training program that targetsearly physician intervention.

Methods: Emergencyphysicians are trained and equippedto . initiate advancedresuscitationindependentof outjide-assis_ tance immediatelyafter an earthquakc.The coursecurriculum includes triage instruction, field inesthesiaand analgesia,air_ way rntervention,managementof crush injuries and amputa_ tions,and integrationinto the incident commandsysrem.

Results:After course instruction, thc physician is further trained with_a computer-interactivedisastci program with both teachingand testingmodes.Eachphysicianis thin certifiedas a disastermcdical director. These directorsarc provided with offi_ cial identification, an advanced_ medical baikpack containing suppliessufficientfor six critical victims, and authorizationto accesslarger storesof equipment in nearby fire stations.This dlsastermedicaltraining programwas developedin cooperation w l t n s t a t ea n d l o c a l g o v e r n m e n t sc, o u n t y c m e r g c n c ym e d i c a l servicesand fire services,and the emcrgencyphyiicrancommu_ nity.

1nA f lr't

lnternPerceptions of theTeaching and Practice of Emergency Medicine

RF Polglase, DC Parish,RL Buckley,RWSmith/Mercer Universitv Schoolof Medicine;MedicalCenterof CentralGeorgia, Macon, Georgia B a c k g r o u n d :T h e a p p l i c a t i o no f p r o b l e m - b a s e dl e a r n i n g methods to the advancedcardiaclife support {ACLS}courseha! beenpreviously_reported.

The first cours. wa, taught to medical studentsimmediately beforetheir clinical rotations.

Study obiective: We conducted a series of problem_based ACLS coursesin the community using local ACLS instructors to determine the feasibility of offering the problem-basedcourse outside of the medical school settins.

Design: Four courses*ere conducted over one yedr; two coursesare in progress.Local ACLS instructors were trained in problem-based methods.Studentswho took the courseshad lit_ tle or no prior ACLS training. All studentswere given the ACLS pretest at the start of the course.Courseswere tiught according to ACLS standards.

S e t t i n g :V a r i o u sh o s p i t a l si,n c l u d i n gt e a c h i n gc, o m m u n r t y , ano small rural.

Interventions:None.

Results:Forty-sixstudentswere enrolled.Mean pretcstscore was 4(;. Forty-fourstudentswere tested,and 39 pissed {90%).

Mean written examinationscorewas 82.

Conclusion:The problem-based method is an effectivealternativc to a traditionaltwo-dayACLS course,especiallyfor those with little experiencein resuscitations.

ACLS instructorscan be orientcd to basic problem-basedmethods in a short period of timc, allowingthe courseto be presentedin the communrty.

-1

MHBiros,L Drill-MillumlDepartment of Ehergency Medicine, H e n n e pCi no u n tM y e d i c aCl e n t eM r , i n n e a p o lM i si ,n n e s o t a Studyobiectives: To determine effcctsof specificinterven_

tions on perceptionsand attitudesof non-emeigencymcdicinc the practice/ specialty,teaching of cmergency il::1:ir::*"'Oing _ P a r t i c i p a n t s :N o n - e m e r g c n c yr n e d i c i n c i n t c r n s r o t a t i o n throughthe emergencydepartmcntof a largeteachinghospital.

M c t h o d s :T w o c l a s s e so f n o n - c m c r g c n c m y e d i c i n ci n t c r n s wcrc_survcyed aftcr complction of thcir intcrnshipin l9ft.){691 a n d .1 9 9 0 { 7 5 ) , w h i c h i n c l u d e d a m o n t h - l o n g " - . r g " . , . y m e d i c i n e r o t a t i o n . A f t e r a n a l y s i so f r e s u l t s f i o m t q g s ( e u

r e s ppoonnsseess/ ,5 5 . 5%%J)/ ,e m e rrggecnnccyy m ec d i cciinncc s t a {f f[ w ec r c i n f o r m e d o l intern background, attitudes, pcrceived areas of eme c r g e n c yv

medicineexpertiseand weaknesi,perceptionsof teachingin thc ED, and issuesconcerningthe ED worli environment. ihe fO orientation was revised,the schedulestandardized,exposurero emâ&#x201A;Źrgencymedical servicesprovided, procedurelaboratories and.conferencesincorporatedwithin the schedulc,and certain work environmental concernswere addressed.After one year,s experiencewith these changes,the survey was repeated. Frequency of responsewas calculated and compared tetween the two classesbeforeand after interventions.

Results: In 1990, 26 responses(38%) were returned. Forty_ sevenpercent had never worked in an ED before. Compared with 1989, 1990interns had a better understandingof theii role in the ED.(76% completely understoodvs 65%) ,.,i ED expecta_ tion-qof .their per{ormance189%vs 66%). They viewed the ED staff as tetter educators 1780o/o rated staff good to excellent vs 37%l who treatedthe interns professionallylS4% vs 13%) and 1-!!owedmore frequent participation in management decisions 177%vs 537"|. Their expectationsfor learning in the ED were unchangedfrom 1989but more frequently met 19e%vs 77%1.

Conclusion:M.any physicians,first exposureto emergency meolclne occursduring their internship;their experiencemay l n t l u e n c e t u t u r e i n t e r a c t i o n s a n d p e r c e p t i o n so f t h e f i e l d .

Awareness of rotating interns, backgrounds,perceptions, and expectationsmay be useful in changing our educational approachand behavior toward these phyiiciins, thus creatrnga more meaningful experienceand a more favorableimpression*of our specialty.

Problem-BasedACLS Instruction:A 1105 Report of One Year's Experiencein the CommunitySetting 46

06

inEmergency filoSl,lrT,,"narFelowship

GJ Nilsen,L Neiman/Department 0f Emergency Medicine,Medical College o f P e n n s y l v a nP i ah, i l a d e l p h i a

Backg_round: The Medical College of pennsylvaniaEduca_ tional Fellowshipin EmergencyMedicine has becn designedt<; re.spondto a need for effective teaching in emergency-.'.li.ln..

The dcpartmentof emergencymcdicinc and oifice'of mcdical e d u c a t i o nt o g e t h e rh a v e c r e a t c da n o p p o r t u n i t yf o r a y c a r o f study and practiceof a wide varietyof educationalconceptsand skills.

Mcthods:.Fellowship activitiescan include lecturing,direct_ ing problem,based lcarninggroups,evaluatinglcarners'andgrving fccdback,dcsigningcurriculi, and writing'proposals. practi_ cal applicationof skills occursthroughthe emergencymedicinc depanment.There arc opportunittejto teach emergencymedi_ c.altechnlctans,paramedics, nurses,undergraduate medicalstu_ dents of all lcvels, emergencymedicine residents,and off-service residentsrotating in the emergencydepartmeni.

Results:As a result of the_fellowship,bur departmentnow has a radiology-curriculum for the ..riden.y, a proposalfor developm_ent of a teaching model for giving'information to bereavedfamily members,and a nationally ba"sedneedsassess_ ment m e n t ftor or e emergency me medicine faculty development.Depart. ments interestedin advancingemergencymedicine,spositionin ln the academicmedical community is well as their own educational developmentcan be well servedby the introduction of an educationaif ellowshio.

Conclusion: Our _experienceshows that a single fellowship canr eenhance n h a n c e iindividual ndividual ffaculty acultv d evelonm".t rthroughout h r n r r o h n r r t tthe hp development levelopment throu department as well as strengthen the department'seducational position within the institution.

107 tResidents ix??,::-;'#ff 8"dfi:ffLfJ'n" RM McNamaralDepartment of EmergencyMedicine,The Medical College o f P e n n s y l v a nP i ah, i l a d e l p h i a . Background:The specialrequirementsfor residencytraining in emergencymedicine indicate that formal testing of residenti must occur that should include both wdtten and oral examinations. A feedbackmechanism should exist for the residentduring the process of achieving the goals and obiectives of the curriculum.

Study obiective: Given the diversity of clinical rotations in an emergencymedicine residencyprogram and the varied duty hours, a highly structured testing program is difficult to imple-

Methods: The residency computcr, located in the physicians' c h a r t i n g r o o m i n t h e E D , h a s a c c e s st o M e l v y l t h r o u g h a s t a n dard 2,400 baud modem. Emergency medicine residents have been inserviced on the data base so literature searchescan be pcrformcd in five to ten minutes by reviewing a brief set of instructions.

Results: Emergency medicine residentsand faculty as wcll as rcsidents from other specialties currently perform two to fivc s c a r c h e sp e r d a y . E m e r g e n c y m e d i c i n e r e s i d e n t s a r e e n c o u r a g c d to search the literature on one patlent per shift. Residcnts writc a brief treatment plan before and a{tcr thc scarch so wc can a s s c s st h c i m p a c t o n p a t i a n t c a r c . T h i s i s t h e o n l y 2 4 - h o u r a c c e s st o c u r r e n t l i t e r a t u r e a t o u r m c d i c a l c c n t c r .

Conclusion: This service helps emcrgcncy mcdicinc garn academic respect among residents and faculty frorn othcr scrvrccs. Wc havc immediatc acccssto the latest rnfclrmation and c a n s t i m u l a t e r e s e a r c hr n t e r e s t a m o n s o u r r c s i d c n t s .

ment.

Mcthods: An cducational testing and fecdback program was developcd for an accrcditcd cmergency medicine residency program. The cornerstones of this program arc a rcsidcnt logbook and a faculty-rcsidcnt preceptor system. Thc logbook consists of multiplc oral cxaminations to be completcd by each rcsidcnt in thc presence of a faculty mcmbcr, who thcn provides csscntlal fccdback. Thcsc cxaminations ari dividcd into thc major subjcct areasof thc corc contcnt of emergcncy mcdicinc and covcr toprcs of significant importancc or arcas that arc not frcqucntly cncountcrcd in the clinical arcna. Although any faculty mcnrbcr can conduct a particular oral cxamination, it is thc prcccptor's rcsponsibility to ensurc thc timcly complction of thc rccluircd matcnal.

Results: In addition to achicving thc rccluircrncntfor oral cxamination and fccdback, thc logbook can be structurcd to d o c L r r n c n tp r o f i c i c n c y i n s k i 1 1 s ,r c c o r d i n g o f p r o c c d u r r s , r u s u s c l tation involvcmcnt, and paticnt follow-up. Tl-rclogbook will bc p r c s e n t c d i r . ri t s c n t i r c t y a s r e p r o c l u c t i o n , w h i c h i s b c y o n d t h c c o n f i n e so f a n a b s t r a c t .

I

nA r lrt

{

I

n I l,

ComputerizedDataBasefor Emergency MedicineResidentCasesand Procedures

M l L a n g d o r f ,C S S o b e l , K A S a l n e s s / D i v i s i o no 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 a l i f o r n i al,r v i n e

A Modelof a ResidencyResearchDesign and StatisticsCurriculum

J J M e n e g a z z rA , B W o l f s o n , D M Y e a l y / A f f i l i a t e dR e s i d e n c yr n E m e r g e n c yM 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 hS c h o o lo f M e d i c i n e , D r v i s i o no f E m e r g e n c yM 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 hS c h o o lo f M e di ci n e S t u c l y p u r p o s c : l l c c a u s c u n c l c r g r a d u a t cn t c c l i c a l c c l u c a t i o n a l k r w s l i t t l c t i n r c f o r f o r m a l s t r , r c l yo f s t a t i s t i c s a n t l c x p c r i r . n c n t a l dcsign, wc havc clcvclopcd a curriculum fur our elncrgency mcdicinc rcsidcncy. Thc goals of thc coursc arc to dcvclop tl-rc a b i l i t y t o c r i t i c a l l y a n a l y z c r r . r c d i c al li t e r a t u r c , c l c v c l o pt h e a b i l i ty to dcsign cxpcrimcnts, clcvclop thc ability to choosc ancl usc t h c a p p r o p r i a t c s t a t i s t i c a l t c s t f o r a g i v c n s c t o f c l a t a ,a n c l c l e m y s tify statistics.

M c t h o d s : W c b c g a n b y a n a l y z i n g a r a n d o m i z c c l s a r t r p l co f 2 5 0 m a n u s c r i p t s f r o m t h r c c p r o r . r r i n c n tr c f c r c e d c t r c r g c n c y m c d i c i n c j o u r n a l s . T h i s a l l o w c d L r st o f o c u s t h c c u r r i c u l u r . n u r . r t h o s c s t a t i s t i c a l t c s t s a n d c x p c r i m c n t a l c l c s i g n st h : t r a r c n r o s t c o n t r n o n l y u s c c li n c r n c r g c n c y m c c l i c i n c I i t c r a t L l r c .

R c s r . r l t sT: h c c u r r i c u l u r n i s D r c s c n t c c li n t c n o n c - h o r . r rl c c t u r c s ( o n c p e r l n o n t h ) o v c r t c n c i r n s e c r r t i v cr t r o n t h s a r c n t c r g c n c y m c d i c i n c g r a n d r o u n c l s .I t c o n s i s t s o f t h c f o l l o w i n g t o p i c s : i n t r o c l u c t i o n t o b i o s t a t i s t i c s ;p o w c r a n d c o n f i d c n c c , t h r c a t s t o v a l i d i t y ; l - r a s i cc x p c r i m c n t a l d c s i g n s ; c h o o s i n g a s t a t i s t i c a l t c s t , c o n t i n g c n c y t a b l c s ; S t u d c n t ' s t t c s t ; a n a l y s i s 0 f v a r i a n c c ,a n a l y sis of covariancc, and multiplc comparisons; corrclation and r c g r c s s i o n ;a n d n o n p a r a m c t r i c s t a t i s t i c s . W c u s c d a P C - d r i v c n s l i d e - r r r a k i n gp a c k a g c t o d e v e l o p a 3 5 - m m s l i d c s c r i e s , c o n s i s t ing of more than 350 slides, from which thc coursc is taught.

For cach of the lecturcs pcrtaining to a spccific statistical tcst, a computer and a PC-contpatiblc softwarc packagc arc uscd to dcmonstratc the casc with which commonly uscd statistical testscan bc applicd to analyze spccific data scts.

C o n c l u s i o n : T h e p r o g r a m i s n o w i n i t s s c c o n c ly c a r . T h i s type of curriculum could be casily adaptcd and uscd by othcr residcncies.

I nO r lra,

f

Computerized Literature Searchin the ED:Academic Stimulation andEffectson PatientCare

Background: We devclopcd a data cntry and report program f u r c m c r g c n c y m c d i c i n e r e s i d c n t s u s i n g F o x b a s c + s o ft w a r c , which tracks procedurcs and paticnt diagnoscs.Ahnost half of thc diagnoscs containcd in the corc content for cmcrgcncy rncdicinc prr:sent too rarely to ensurc casc managemcnt cxpericncc for cach rcsidcnt. Similarly, rcsidcnts pcrform variablc numbcrs and typcs of emcrgcncy mcdicinc procedures.

Study purposc: It is uscful to monitor the activitics of caclr rcsidcnt to conccntratc tcaching modalitics on uncommon proccdurcs and diagnoscs.

Mcthods: Rcsidcnts cnter cach casc into thc data basc on a complltcr locatcd in thc cmcrgency departmcnt. Infonration incluclcspaticnt namc, agc, hospital numbcr, date, and as many a s c i g h t d i a g n o s i s c o d e s f r o m t h e I C D 9 - C M . T h e p r o g r a r . nc a n acccss thc code numbers of 1,200 potential dcscriptors for U50 E D d i a g n o s e sw i t h a f e w k c y s t r o k e s . T h c r e s i d e n t s a l s o e n t c r a s many as cight proccdurc codes {from a list of 75) along with paticnt disposition and whcthcr thc casc was a resuscltatlon.

Thc avcragctimc to entcr cach paticnt is 30 to 45 seconds.

Rcsults: Rcports include number of patients and diagnoscs sccn by cach rcsidcnt, numl')cr and percent of paticnts admittccl and rcsuscitatcd, and numbcr of cach procedurc performecl by cach rcsidcnt. Thc program can gencratc a list of patients witlr any givcn diagnosisor procedurc for retrospcctive study.

Conclusion: The system identifies deficiencics in individual or aggrcgatcclinical cxpcrience. We plan to develop a banl< of casc simulations to supplement real-life casemanagement.

*.1 -l -l r r r

Acetaminophen Overdosein Children:A Comparisonof lpecacVersusActivated CharcoalVersusNo Gastrointestinal Decontamination

MA Kirk,J Peterson, K Kulig,S Lowenstein, BH Rumack/Rocky Mountain P o i s o nC e n t e rE; m e r g e n cMye d i c i n R e e s e a r cChe n t e r , University of ColoradoHealthServiceCenter;DenverGenerar H o s p i t aD l , e n v e rC, o l o r a d o Study objective:To compareearly gastrointestinaldccontamination with ipecacat home versusactivatedcharcoal{AC) in the emergencydepartment versus no gastrointestinaldecont a m i n a t i o n a f t e r a c u t e a c e t a m i n o p h e n( A P A P )i n g e s t i o n si n children.

Design and setting: For nine months, patients wete collected in a prospective,nonrandomizedmanner. The study population was derivedfrom consecutivecasesreferredto a regionaipoison center.

Particrpants:Children 6 years old or younger were eligible if they had a history of ingesting approximately 150 mg/kg or more of APAP and had a postingestionAPAP level obtained at four hours and 30 minutes. One hundred fifty-six patients were entered,but 33 were subsequentlyexcluded{rom data analysis becausethe treatment protocol was not followed.

Intervention: Groups were assignedbasedon availability of treatment: administration of ipecac at home within one hour

Ml Langdorf, KLKoenig, KASalness, M Suleiman/Division of E m e r g e nMceyd i c i nU e ,n i v e r soi tfyC a l i l o r n li rav, i n e

Background: Bccause emergency medicine evolvcs rapidly, information from an emergency department textbook library may be outdated. The University o{ California library system offersa Medline-type search service, called Melvyl, free to University of California faculty, residents,and students. It currently contains 1.57 million citations from journals indexed by the National Library of Medicine from |anuary 1986 through the present. We are developing an emergency medicine journal library adjacent to the computer to supplement the abstracts contained in the data base.

Study hypothesis: The ability to easily search the medical literature through a computerized data base can improve panenr care and stimulate academic discussion and inouirv.

47

postingestion (group l), AC in ED within two hours postingrstion {group 2), or no gastrointestinal clccontamination {group 3) if ncither ipccac nor AC was availablc wrthin two hours, Results: Mean four-hour APAP levcls wcrc analyzedby oncw a y a n a l y s i s o f v a r i a n c e a n d D u n c a r l ' s m u l t i p l c r a n ' g ct e s t . T w o children, both in group 3, had toxic lcvcls based on thc ApAp nomogram and were trcatcd with N-acetylcystcinc.

Group t 2 l 'P.

6 3 2

N 2 6 5

Mean (tSD) EstimatedAmount Ingested(mg/kg)

Mcan (iSD) Tinrr To Trcat (min)

2 2 t i l l 5 . l l l 4 71 0 9 6 ) 16r t7t5r)01 2 0 51 5 9 ( 1 , 1 , 1 . . 1 1 J 4 1 r . l 1 , i l t l 0 l 2 0 l 1 9 2 1 4 6{ 1 4 7 - . l , l a ) l No trcrrnrrnl

Mean {1SDJApAp Level(1.rg/nrl) ll 1 lt l07.llNsl)' 2 01 t 9 t 0 6 a ) 1 . , 1 91 . 1 9{ 0 l 5 9 l

.05 whcn cach comparcd to group.l (contnrll.

Conclusion: For childrcn 6 years olcl or youngcr with a history of toxic APAP ingcstion, ipecac givcn within onc hour or AC g i v c n w i t h i n t w o h o u r s r c s u l t c d i n s i g r - r i f i c a n t l yl o w c r A p A p l c v c l s c o m p a r c d w i t h u n t r e a r e t lc o n r r o l s .

a a t a a3

Creatinine Phosphokinase as an Indicatorof IniurySeverityin pediatric Patients

J M B u r g , D L u n d , G R F l e i s h e r / D i v i s i oonf E m e r g e n c yM e d i c i n ea n d D e p a r t m e not f S u r g e r y ,C h i l d r e n ' sH o s p i t a l ,B o s t o n ;D e p a r t m e not f P e d i a t r i c sH, a r v a r dU n i v e r s i t yS c h o o lo f M e d i c i n e ,B o s t o n Study objcctivc: Crcatininc phosphokinase (CpK) is an c n z y m e t h a t i s r c l c a s e d b y i n s u l t t o s k c l c t a l r . n u s c l c ;p r c l r r . r . r i nary studies indicatc that it may bc a uscful marke r foi scrior-rs i n j u r y r n a d u l t s . D a t a r c g a r c l i n gt h c C p K v a l u c f o l l o w i n g t r a L u n a in childrcn arc limitcd, and major injurics in this polrulation may be subtlc. Thc purposc of this invcstigation is triclctcrminc whethcr an clcvatcd CPK prcdicts thc scvcrity of iujury following trauma in childrcn.

Dcsign: Prospcctivc analysis of CpK valucs in rriluutil p a t i c n t s d u r i n g a f i v e - m o n t l - rp c r i o c l .

Sctting: An urban cmcrgcncy dcpartmcnt.

P a r t i c i p a n t s : O n c h u n d r c d f o r t y - f u r . r rc h i l d r c n w e r c c v a l n r t c d f o r t r a u m a a n d h a d b l o o d w r r r l <t l r a w n i n t h u E t ) b e t w e c n l u l v a n d N o v e r n b c r 1 9 9 0 . S i x t y - n i r . r cc h i l c l r c n { 4 8 , 2 , )h a d C t , K d c t c i minations.

I n t c r v e n t i o n s : E D s t a f f w c r c c n c o l l r a q c d t o r . n c a s u r ct o t a l CPK lcvcls in cligible paticnts. Log shccts ancl rncdical rccords w c r e r c v i c w c d t o d c t c r r n i n c p a t i c n t p o p L l l a t i o n , t . n c c h a n i s r . no f i n j u r y , I n j u r y S c v c r i t y S c o r c { l S S ) ,l a b o r a t o r y r c s u l t s , a n c l s t r b s c _ t l u c n t d i a g n o s r sa n d d i s p o s i t i o n , R c s u l t s : S e v c n t y - c i g h t p c r c c n t o f p a t i c n t s : r n a l y z c c lw c r c m a l e . M c a n t S D a g c w a s [ J . ( r+ 5 . 5 y c a r s . N i n c t y , t h r c u p c r e u n r of injuries werc duc to blunt traulna; thc rnost c,,,.t-,,-r..,.,,.r incchan i s m s w c r e f a l l s ( 3 0 % ) , m o t o r v c h i c l e a c c i d c n t s( 2 1 , 2 , )a, n d b i c y c l c r n j u . r i c s{ 1 7 7 . ) , F i f t y s i x p c r c c n t w c r c a c L n i t t c d t o t h c h o s p i tal, and onc child died. CPK analysis dcmonstrated a urcan of 152 ! 172 pm/ml. Mean ISS was (r 1 (r. ISS corrclatcd si,:nific a n t l y w i t h _ C P K ( P c a r s o nc o r r c l a t i o n c o c f f i c i c n t , r = 3 6 , 1 , = . 0 1 ) but not with hematocrit, WBC, amylasc, SGOT, or SGpT. When children sustaining blunt trauma from motor vchiclc accidcnts w e r e a n a l y z e d s e p a r a t e l y ,t h e c o r r e l a t i o n c o c f f i c i c n t w a s . 5 1 ( p = . 0 1 ) .C P K v a l u e s w e r c d i v i d c d i n t o t h r e c g r o u p s : l ) 0 t o 5 0 g m . / m l ( t w i c e . t h e u p p e r l i m i t o f n o r m a l ) , 2 ) 5 l t o . 5 0 0p m / m l ; and 3) more than 500 gm/rnL. Using the Kruskal-Wailis oncway analysis o{ variance, mean ISS in group.l (t5 t U), diffcrcd s i g n i f i c a n t l y ( P = . 0 5 ) f r o m t h a t o f g r o u p I ( 5 j 5 ) o r Z 1 6! ( t ) .

Conclusion: Our data demonstrate that thc total CpK lcvcl foilowing_ trauma correlates significantly with thc sevcnty ot injury. This enzyme proved to be more predictive of injury severity than other commonly obtained laboratory tests. A CpK elevated to more than tenfold normal followine trauma in children warrants investigation Ior occult lesions in the abscnce of apparent injuries.

in Injured Chitdren: ts a a Q, Hematuria r r l, Emergency Radiographic Evaluation Mandatorv?

RLSweeney, EJDoolin, SERoss/Department of pedjatrrcs ano Divisions of Pediatric Surgery andTrauma andEmergency Medical Services, Department ol Surgery, UMDNJ/Robert Wobdlonnson

M e d i c a lS c h o o l ,C a m d e n ,N e w J e r s e y ;C o o p e rH o s p i t a l /U n i v e r s i t y M e d i c a lC e n t e r ,C a m d e n ,N e w J e r s e y Study objectivc: To cxaminc hcmaturia as an indicator ol u r i n a r y t r a c t i n j L l r i e si n p e d i a t r i c t r a u m a v i c t i m s , Dcsign: Retrospcctive revicw of trauma registry and medical recoros.

Sctting: Regional trauma ccntcr serving 2.3 million people.

Participants:Children lcss than l6 ycars old who were injured in road crashcs and trcatcd bctween August l, 1986, and Octobcr31, 1990.

Methods: In jurcd paticnts less than I (r years old wcre s c r e e n e df o r d o c u m e n t a t i o n o f u r i n a l y s i s r c s u l t s a n d t h e n rcvjcwcd to idcntrfy thosewith unnary tract rniurit.s.

R c s u l t s : C r i t c r r a w c r c l n c t b y 2 9 2 p a t i c n t s ( p e d e s t r i a n so r bicyclists struck by motor vehiclcs, I 54; alrtomobile occupants, l 2 l ; a n d m o t o r c y c l i s t s , l 7 ) . M c a n a g c w a s [ 3 . 4y c a r s ; T r a u m a Scorc was 12.4, anclInjury Scvcrity Scorc was 13.9. Hcmaturia was found in 172 l< 5 RBCs/high powcrcd field Ihpf],59 patients; 5 to l5 RBCs/hpf, 50 paticnts; 16 to 49 RBCs/hpf, 2l p a t i c n t s , a n d > 5 0 R B C s / h p f , . 3 ( rp a t i c n t s . C o m p u t c d t o m o g r a phy, IV pyclography, and cystography wcrc used in evaluation. l n j u r i c s w c r c i c l c n t i f i c c li n t c n : f i v c r c n a l c o n t u s i o n s / t h r c c r e n a l f r a c t u r c s ,a n d t w o b l a d d c r i n j u r i c s . O n l y p a t i c n t s w i t h b l a d d c r i n j u r i c s r c c l u i r c d s u r g i c l l i r ' r r c r v e n t i ( ' nO . nc rcnal fracture was a s s o c i a t c cwl i t h l c s s t h a n 5 0 R B C s / h n f .

C o n c l u s i o n : I n t h c a l r s c n c ur r f s h , r c l <r ) r s i l n s o f a b d o n - r i n a l i n j u r y , m i c n r s c o p i c h c r . n a t u r i af o l k r w i n g m a j o r b l u n t t r a u m a i n a c h i l d d o c s u o t r c q u i r c e n r c r g c u c yr a d r o g r a p h i ee v a l u a t i o n .

*.1 -l I I I T

Strategies for Diagnosis andTreatment of Febrile Infants: Clinical andCost Effectiveness

T t i e u , M N B a s k l n ,G R F l e r s h e r / C h i l d r e n ' H s o s o i t a l ,h a r v a r o M e d i c a lS c h o o l ,B o s t o n Ilackground: Managcnrcnr of febnlc infants .j nronths old or yollngcr rcntains controvcrsial bccausc Of the risk Of undiac_ n o s c c ls c r i o u s b a c t c r i a l i n f c c t i o n s ( S B I )v c r s u s c o n r p l r c a t r , r n sr i f I V a r r t i b i o t i c sa n d h o s p t t a i i z a t i o n .

S t u d y h y p o t h c s i s :O u t p a t i c n t t r c : l r n t c n t w i t h I M c c f t r i a x o n c woulcl proviclc thc optin-ral :rpproach. Dcsign: Wc conductcd a c l i n i c a l a n d c o s t - c f f c c t i v ca n a l y s i s t r s i n g a c ( ) n . r p u t t :mr o d c l ( c o n s t r u c t c c l w i t h S M L t r c e @ o f p o s s i h ) e ( r u t c ( ) n r c sa n d a d v c r s c c f f c c t s . S i x s t r a t c g i c s w c r c c v a l L l a t c d :l ) n o d i a g n o s i s a n d n o t r c a t n l c l t t r 2 ) l r . r n t b a rp u n c t u r c ( L I r ) w i t h c c r c b r a l s p i n a l f l u i d , l . r l o o c la, n d u r i n c c u l t u r c s , W B C s , a n c l r - r n n a l y s i s ,p l u . s I V a n t i b i o t i c s f o r a l l f c b r i l c r n f a n t s ;3 ) L p a n d I M c c f t r l a x o n cf o r a l l f c L r r i l ci n f a n t s w i t h n o r m a l L I r s ; 4 1 b l o o d a n d u r i n c c u l t u r c s w i t h W B C s a n c l r . r r i n a l y s i s ,5 ) W I I C s a n d r . r r i n a l y s i s ;a n d ( r ) j u d g n r c n t . I n s t r a t c g i c s 4 , 5 , a n d ( r , f c b r i l c i n f a n t s j u c l g c da t h i g h r i s k hacl trcatrrrcnt with IV antibiotics; low-rrsl<fcbrilc infanis wcre O b s c r v c cal s o u t p a t i c n t s w i t h o u t a n t i b i o t i c s .

Sctting: Urban cmcrgency dcpartrtrcnt.

ParticrpantsF : ivc hundrcd thrcc fcbrilc infants and data estimatcs frotr thc litcrature .

Intcrvcntions: IM ceftriaxone and IV antrbiotics werc tested rn thc computcr modcl along with various diagnostic approachcs. . Rcsults: For a hypothetical cohort of 100,000febrilc infants, t h e r t ' s u l t sa r c a s f o l l o w s :

Strategy

No.of No.Antiobiotic Cost/ Deaths No. (%) of Complsi Average Death or Maior Sequelae Sequelae Cost/ or Sequelae prevented pt previnted SequalaePrevented

LP + IV antibiotic 244 LP + IM ceftriaxon 248 Bltxrdu , rinccultures398 wBC & UA 4(r8 692 fu d g m e n t No Dx, No Rx 991

747l75l 7 4 3l 7 5 l 594{(rO) s23{s8l 2 9 9( 3 0 1 0 l 0)

34 23 14 t6 30 NA

2038 528 846 841 823 247

272,600 71,000 t42,500 160,800 275,300 NA

Sensitivity analyses show the choice of strategy depends g r e a t l y o n t h e e f f e c t i v e n e s so f I M c e f t r i a x o n e b u t l e s s s o o n e s t i mates of complications.

Conclusion: Strategies that combine Lp and IM or IV antibiotics for all febrile infants prevent the most complications; Lp and IM ceftriaxone have equal clinical and superior cost eifectiveness compared with LP and IV antibiotici; and strategies

Background: Many factors influence rate of gastric emptying and thercfore the rate of drug absorption in the orally poisoned paticnt. Limitcd studies have evaluated the effect of body position on thc rate of gastric emptying of radiographically marked foods and contrast media alonc, but effects on drug absorptron have not been previously studied.

Study hypothesis: Body position has an effect on the rate of drug absorption in oral overdose. Design: A partially blinded, w i t h i n - s u b j e c t s ( c r o s s o v e r )d e s i g n .

Participants: Six male and six iemale healthy, adult volunteer subjects with no concurrent drug or medicatron use affecting gastrointestinal function. All subiects completed the study.

Interventions: Five body positions commonly used in prehospital and emergency departmcnt settings were examined: left Iateral decubitus (LLD), right lateral decubitus (RLD), supinc, pronc, and sitting. All werc performed by all subjects in random order with a three-day washout phase between trials. To simulatc an acute overdose,fasted subjects ingestcd 80 mg/kg acctaminophen as I (r0-mg pediatric tablets. They then remained in the body position for that trral for two hours.

Acetarninophen levels wcre obtained at l5-minute intervals, and a two-hour area under thc curve IAUCI was calculatcd for each subject trial to represent total drug absorption. Invcstigators were blinded to all results until all trials were completed.

R e s u l t s : G r o u p m c a n d r u g a b s o r p t i o n a s r e p r e s e n t e db y t w o hour AUC was calculated for each body position. AUC for LLD ( ( r , 0 0 ( r1 2 , 6 1 4 ) w a s l o w e s t b u t d i d n o t s i g n i f i c a n t l y d i f f e r f r o m s u p i n c ( 6 , ( 1 4 9t 2 , 7 6 1 J . B o t h w e r e s i g n i f i c a n t l y l c s s t h a n p r o n e 1 7 , 4 3 2) : l , t t 0 9 ) ,R t D ( U , 9 5 0t 1 , 4 0 5 ) ,a n d s i t t i n g ( 8 , 6 0 8 t 1 , 7 2 5 ) positions (1' < .05, onc-way analysis of variance and follow-up paircd t tcsts).

Conclusion: Initial drug absorption as dctcrmined by twohour AUC is lowcst in paticnts in thc LLD position. Although thc differcncc frot-n thc supinc position did not reach significancc, both LLD and supinc wcre significantly lowcr than three othcr common paticnt llody positions tested. Becausc the LLD p o s i t i o n h a s o t h c r a c l v a n t a g e s( e g , p r c v e n t i o n o f a s p i r a t i o n ) i n addition to mrnimizing drug absorption,we recommcnd that orally poisoncd paticnts bc placed in the LLD position for initial prehospital and ED lnanagcmcnt.

using WBCs and urinalysisor judgmentdo not surpassLP and antiblotios,evenwhen test sensitrvityis high.

*-l .l f, t I r,

Metal Detectors- An Alternative Approachto the Evaluationof Coin Ingestionsin Children?

S P R o x . F C e t t a / D e p a r t m e n tos f P e d i a t r i c sa n d I n t e r n a lM e d i c i n e ; L o y o l aU n i v e r s i t yM e d i c a lC e n t e r ,l l l i n o i s Background: Foreign body ingestions constitute a common problem in pediatric emergency mcdrcine. Recent data indicatc that despite current recommendations, most childrcn who ingest coins do not undergo radiologic evaluation.

Study purpose: To determine the accuracy of a metal dctcctor in localizing corns in a model simulating coin ingestions in children.

Methods: The distance betwccn the anterior chest wall ( A C W ) a n d t h e e s o p h a g u sw a s m e a s u r c d o n 1 7 c h e s t c o m p u t e d tomograms obtained on children betwcen 3 months and 6 ycars old. Subsequently, a diamctcr cqual to the mean ACW to lowcr esophageal sphincter measurement was markcd across thc investigator's forearm. A sccond investigator thcn attcmpted tcr detect the prcsqnce of the coin through the forearm by using a Super Scanncru {Garrett Sccurity Systems,Inc, Tcxas) mctal detector. The study was conducted in a blindcd manner and consisted of 50 attempts equally divided among pcnnics, nickcls, dimes, quartcrs, and controls (no coins).

Results: Thc accuracy of thc mctal detcctor in idcntifying t h c p r e s c n c eo r a b s e n c co f c o i n s r n o u r m o d c l w a s 1 0 0 % .

Conclusion: The mctal dctector we evaluatcd is highly accurate in idcntifying coins through human tissucs and should become a valuable and practical tool in evaluations of childrcn after coin ingestions.

{

I

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A I tl,

Relationshipof PoisonCenter Contactand Injuryin Children2 to 6 YearsOld

M, J B a y e r / U C LSAc h o ool f M e d i c i n eL,o s L J B a r a f J{ ,J G u t e r m a n Angeles Studyhypothcsis:Childrcn 2 to (r ycarsold frorn houscholds in a child in that call a poison center for a possiblepoisonir-rg thrs agegroupareat incrcascdrisk of injury.

S t u d y p o p u l a t i o n :O n c h u n d r e d t w c n t y - n i n c h o u s e h o l d s identified by the regionalpoison ccntcr (PC) and l3(r control householdslnon-PC).

Methods: We conductcda telcphonc survcy of houscholds with childrcn 2 to (r ycarsold to dctermincthc ratc of iniury in t h e s ec h i l d r e ni n 1 9 8 9 .I n j u r y w a s d e f i n c da s a n y i n i u r y t h a t resultedin medicalcare.We investigatedtwo groupsof housch o l d s :t h o s e i d e n t i f i c db y a r e g i o n a lP C a s h a v i n g r c c l u e s t c d i n f o r m a t i o nr e g a r d i n gt r e a t m en t o f a p o s s i b l cp o i s o n i n gi n a child 2 to 6 ycars of age in 19U9,and houscholdsthat did not contact the PC. The control group was matchcd by area codc and the first three digits of the seven-digittelephonenumbcr.

The last four digitswere choscnby randomdigit dialing.

Results:Children 2 to 6 years old in these householdsin 1989numbered 190 in the 129 PC householdsand 209 in the 136 non-PChouseholds.There were 45 injuriesamong the 190 childrenin the PC group,includingtwo fractures,16 lacerations requiringsuturing, and 27 other injuries, and 31 such injuries among 209 children in the non-PC group, including six fractures,nine lacerationsrequiringsuturing,and I6 other iniuries.

The annual rate of injuries per child 2 to 6 was significantly greater in the PC group 123.7%)than in the non-PC group 114.8%l(P < .025),oddsratio, 1.6,95% confidenceintervals,1.1 to 2.4).One child from the PC group and three from the non-PC group were hospitaiized.There were no deathsin either group.

Conclusion:Children in householdsthat contact a PC are at increasedrisk of injury. PCs should consider expandingpoison prevention programsto include injury prevention for householdswith childrenwith poisonexposure.

*l I

{

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*{

Effect of Body Position on Drug Absorptionin a HumanOverdoseModel

of MedicalToxicology, MV Vance, B Selden,RFClark/Department Arizona RegionalMedicalCenter,Phoenix, GoodSamaritan

49

{ I

O ActivatedCharcoalSurfaceAreaand lts I CD Role in Multiple-Dose charcoalTherapy

h oison Center, K l l k h a n i p o u r ,D M Y e a l y , E P K r e n z e l o k / P i t t s b u r g P ; n i v e r s i t yo f P i t t s b u r g h - Ai fl if a t e d C h i l d r e n ' sH o s p i t a lo f P i t t s b u r g hU R e s i d e n c yi n E m e r g e n c yM e d i c i n e Study hypothcsis: Incrcasing the surface arca (SA) of activatcd charcoal (AC) will cnhancc theophyllinc elimination in multiplc-dosc AC thcrapy Population: Fivc hcalthy, nonsmoking, nonmcdicated, voluntccr mcn ltl to 25 ycars old.

Mcthods: A prospcctive,randomizcd, crossovcr study was conducted with cach subjcct scrving as their own control. Subjects fastcd ovcrnight bcforc receiving 8 mg/kg IV aminophyllinc IV at thc bcginning of a control phasc and two study phases.No AC was administered in the control phase. Two experimental phases compared USP XXI AC {950 mz/g) and Norit A Supra (2,000 mz/g). In each phase, 50 g of the AC in an extemporaneously prepared aqueous slurry was orally administered after the conclusion of the aminophylline infusion. Subsequent 50-g doses of the AC preparations were administered at four and eight hours after the initial dose of AC. Serial blood samples for theophylline levels were obtained at 0.5, 1.0, 1.5, 2.O,3.0, 4.0, 6.0,8.0, 10.0, and 12.0 hours after the completion of the aminophylline infusion. For each of the three data sets, the area under the absorption curve (AUC) was calculated to infinity using the trapezoidal rule. Data were analyzed using repeated measuresi analysis of variance, and Tukey's tests. The alpha error was set at .05. The research design had a pretrial power of 0.8 to detect a 25o/o or greater dif{erence between the groups.

Results: The AUC {pg x hr/ml) for each of the two experimental groups was significantly reduced (P < .05) compared with the control qf theophylline alone (control,223 ! I l3; AC surface area, 95O mLlg = ll2 ! 52i AC surface area, 2,000 mLlg = lll 157). There was no srgnificant difference between the two experimental groups.

Conclusion: Multiple-dose AC administcrcd cvcry four hours significantly enhancesthe climination of theophvllinc.

Increasingthc surface area of thc AC by a factor of l0O% has no cffect on cnhancing thcophyllinc climrnation comparcd with conventional USP XXI AC.

-l I (| I f -,

Anion Gap is Not Sensitivein the Diagnosisof Toxic MetabolicAcidosis

J B r e n t ,R W a n g , M F o l e y ,K K u l i g / R o c k yM o u n t a i np o i s o n C e n t e r , D e n v e rG e n e r a H l ospitaiD , e n v e r ,C o l o r a d o S t u d y o b j e c t i v e : T o a s s e s st h c s e n s i t i v i t y o f a n c l c v a t c d a n i o n g a p i n d i a g n o s i n g a t o x r n - i n d u c c d n r t i t a b o l i ca c i d o s i s

{TrMA).

Design: Two-phasc study consisting of a pilot rctrospectivc s t u d y f o l l o w e d b y a p r < r s p c c t i v ed a t a c o i j c c t i o n p h a s c .

Sctting: A certificd rcgional poison control icntcr that man_ a g e sa p p r o x i m a t c l y 9 0 , 0 0 0 c a s e sp e r y e a r .

P a r t i c i p a n t s :N i n c t c c n a n d Z i p a t i c n t s w r r c i n c l u c l c di n t h c rctrospectivc and prospcctivc phascs of thc stucly, rcspcctivcly. r n c t u s l o n c n t c n i l w c r c s c r u r n . t o t a l _ C O 2( T C O 2 ) o f < l 9 r n m o l / L and a documentccl toxic lcvcl of the t6xin inv'olvctl t"g,,rfi.y_ late, g l y c o l , r n r . t h a n o l ,i r o n , o r t h u t r p h y l l i n " j ' * i t h i n .ethylenc f o u r h o u r s o f t h c c l c c t r t r l y t c c l e t c r r n i n a t i o n .E x c i u s i o n c r i t e r i a werc thc prcscncc of diabetic or alcoholic kctoacidosis, scpsis, h y p c r v c n t i l a t i o n ^ s y n d r o m c s ,v c n t i l a t o r - i n d u c c c l . . r l i i r r i u r y a l k a k r s i s , r c , n a 1f a i l u r c , s c i z u r e s , o r h y p o t c n s i o n {systolic blooi p r c s s u r eo f 1 0 0 m r n H g i n a d u l t s o r l c s i t h a n t h c i l i t h p c r c c n t i l ; ior pediatric paticnts) within four hours of thc clcctrolytc dctcr_ minatron. A normal :rniong4p (N;r* _ lCl- * Teoll) w:is dcfincd a s t h c n o r r n a l r a n g c f o r r h u l : i b ( ) r a t { ) r y, l t , i n i t h r i l c t c r n i i n : r r i t f w h i c h w a s r c p o r t c c li n . J 4c l c t c r r r r i n a t i i r n s .

I n t c r v c n t i o n s :N o n c .

R es u l t s : M e a n a n i o n g a p i n 5 l t d c t c r t l i n a t i o n s r n 4 4 c o n s c c u _ t i v c p a t i c n t s w i t h a d c r n o n s t r a t c dT I M A w a s l Z . 3 n t n t o l / L .

Of t h c s c , t c n ( 1 1 3 . 9 , 2 , ) w c r<c l , l r n r n o l / L ; 2 l l 3 r ) . ( t , 1 ,<) , l 5 n r r i o l / L ; 1 5 .1 2 7 . 3 ' y . ) ,l 5 t o 2 0 m m o l / L ; 1 7 1 3 0 . t ) , 1 ,>1 2 0 m m o l / L I n c a s c s whcrc-a n.rrnal lni,n gap c.uld bc dctcrminccl f.r that lab.r:rt.ry, only l6 61 .34wcrc abovc thc uppcr limit of norntal.

This g r v c s . a s c n s i t i v r t y o f 4 7 , , 1 ,f o r a n c l c v a t e c l a n i o n g a p as a prcdict o r o f a d i a g n o s r so f a T I M A .

C o n c l u s i o n : T h c u s c o f t h c a n r o r .gr a p i s i n s c n s i t i v c f o r d c t c r _ m i n i n g w h c t h c r a n a c i d o s i si s c a u s c c bi y a t o x i n . T h c l a c l < of an clevatcd anion gap clocsnot prccludc tic possibility of a toxic c t i o l o g y f o r a p c r s i s t c n t u n c i p l a i n c d n - r c t a i r o l i ca c i i l o s i s ; a l r i w Tco2 alonc should prompt thc cvaluatiun of toxic causcs.

Xa tll _l +V B^l

TransptacentatTransport of M Acetylcysteine in an OvineModel

S:l!:, SCCurry,RFClark/Departrrnt oi MrOicur Toxicotogy, Lj00d S a m a r i tR a ne g l o nM a le d i c aCte n t epr h o ejnx ,A r i l o n a

Background: Acetaminophcn ingcstion is thc most frcqucnt intcntional ovcrdosc in prcgnancy. Dcspitc matcrnal trcatincnt w r r h t h c a n t r d o t e N - a c c t y l c y s t e i n c( N A C ) , f e t a l d c a t h with mas_ sive hepatic necrosis may still occur. It hr. .r.u., becn shown w h c t h e r N A C c r o s s e st h c p l a c e n t a t o y i e l d f e t a l l e v e l s "qual tl t h o s e a s s o c i a t e dw i t h h c p a t o p r o t e c t i v e c f f e c t s i n h u m a n bcings.

Srudy obiective: To cvaluate this in a widely accepted largc a n i m a l m o d e l f o r m a t e r n a l - f e t a l r e s e a r c h .T h c s h c c p h r . a higi_ p e r f u s i o n ,v e n o u s c q u i l r b r a t i o n ,c o t y l e d o n o u . p l a c c n t a and feto_ p t a c e n t a lc r r c u l a t i o n t h a t c l o s c l y r e s e m h l c t h o s e o f thc human being. _ Design: A nonblinded, experimental study four domestic sheep at near-term gestation. After induction of steady_state general anesthesia and placement of maternal arterial and v e n o u s c a t h e t e r s , t h e f e t a l _h e a d w a s s u r g i c a l l y d c l i v c r e d , and a ' neck vern was cannulared ior blood ,r-ping.

Interventions: NAC (150 mg/kg IV| *rr"r,l-ini.t.red to the ewe over l5 minutes. Maternal and fetal blood samples were obtained at the end of NAC infusion and at 30_minute intervals for four hours. Serum NAC levels ,e.e deter-rneJ by gr. .hio_ m a t o g r a p h y / m a s s s p e c t r o s c o p y( d e t e c t i o n l i m i t , 5 Fg/mL).

Maternal peak NAC levels were 619,6b1, 1,157, and ^ -R^esults: ),512 ltglmL, respectively,within 30 minutes of infusion lapproxlmarrng therapeutic levels and kinetics after similar qoses rn_human beings).However, NAC was not detectable in serum of two fetal animals and only minimally detectable in

two. othcr animals (isolatedpeak levels, 7 and 25 pg/ml). None of thc fetal animals attained serial NAC levels'iiiat .q"rt.a thosc assocratcd with therapcutic dosing or hepatoprotective effccts in human beings. Our study had a powcr of .94 to detect thc attainmcnt of serial therapeutic NAC concentrattons in 50% c>f ctal animals, but we were unable to do so. Conclusion: We conclude that transplacental transport of NAC is clinically insignificant in a mammalian modcl resembling the human b e r n g . T h c s e f i n d i n g s s u g g e s tt h a t t h e f c t a l l i v e r i s n o t p r o t e c t e d from acctamrnophcn toxicity by maternal NAC therapy.

"j," 121 "=li?'J't: Jfi :il:llii i'"11i 3lTf,li' Lavaqe

SRMairia, BpLane, ERGeller/School ofMedicine, QSHoryan,

S U N Y S t o n yB r o o k ,S t o n y B r o o k ,N e w y o r k

Background: Controversy pcrsists rcgarding the appropriate t r c a t m c n t o f a c u t c a l k a l i i n j u r y t o t h c c s o p h a g u s .C o n t i o l l e d studics rclating trcatmcnt of allcali injury td orli.o-. are lacking. Thc currcnt study cstablishcs a controllcd model of alkali c - s o p h a g c a il n j u r y a n d c x a m i n e s t h e c f f i c a c y o f s a l i n c d i l u t i o n rncrapy. . S t u d y h y p o t l . r c s i s :E a r l y s . a l i n el.a v a g e t h e r a p y c f f e c t i v e l 'y r c d u c c s .e s o p h a g c a li n j u r y r c s u l t i n g f r o r n a c u t e , l k r l i . * p o r r . . .

M-c^thods :.Thc csophagr werc harvcstccl f rom Sprague_Dawley . a c h c n d w a s c a n n u l a t e d w i t h a 2 0 _ g a u g ec a t h c t . r , r a t s ( . 5 2 )E and spccirncns wcrc maintaincd in an oxygcn_perfuied saline bath (37 C).during a (r0-minutc cxpcrimcntil period and then fixcd irrrnediatcly in l0%, forrnalin solution for histologic ."r-in^t i o r - r .T h r c c c x p e r i m c n t a l g r o u p s ( A , B , a n d C ) w c r e p e r f u s e d with 50'2, NrOH srrlution at tlmc 0. Trcatmcnt *ith s"iin" per_ f(r\i('n wJs perfornte(lrrnrtrediltc)y in gr0up A, fivc mrnutcs a f t c r i n j u r y i n g r o u p B , a n d . l 0 n r i n r . r t c sa f t e r ' i n j u r y r n g r o u p C. P a t h o l o g i c c x a r n i n a t i o n w a s p c r f o r m ed l n a b l i n d c d ' - f a s h i o n using a scalc of 0 to 3 (0, no injury; l, rninimal; 2, moderatc;3, scvcrc) for scvcn histologic.critcria: cpithelial viabillty (EV), c x t c n t o f i n j u r y { E I ) ,c o r n r f i c d c p i t h c l i a l c c l l d i f f c r c n t i a t i o n iCfi, granular ccll diffcrcntiation (GCl, cpithclial ccll nuclei I'fNi, r . r . r r . r s cclccl l s { M C l , a n d n t u s c l c c c l l n u c l c i l M N l .

R c s u lt s : Prrccntageof Esophageal Infury with Rating of 2 or Greater Group EV EI CE CC EN MC

MN

A (l,r) Ir(l.rl ct{l.l)

3l 77 100

s4 92 t(n

69 100 l0o

69 92 100

.18 85 100

23 92 t00

15 s4 r00

Thc control dcmonstratcd O-lcvcl scorcs.A X2 analy.groLrp srs shuwctl a signifrcant diffcrcncc among trcatment groups.

Trc.nd analysis rcvcalcd.a significant progiession ,rf ,"1irry io1 c a c h c a t c g o r y _ i ng r o u p s A , B , a n d C . D i s c r i m i n a n t , r r a l y i i s i n d i _ catcs that MC was thc most useful category with which to dis_ tinguish among groups.

Conclusion: Early saline lavage therapy rcduces acute alkali . . injury of thc csophagus.

This study supports_ thc use of saline lavage thcrapy in the acutc trcatment of alkali ingestion.

.122 li::liHl i:l=, Jil,",x?"s:x' iIJ?frff :l UsingDigoxin-specificFab Fragments KJMorriss_ey RsHilme,Fa Carltoi, A Ma;ko;CWa-ierer, R

RockholdS.Whitney/Bay MedicalCenter,panamaCity,Florida; U n t v e r s iM t ye d i c aCl e n t e rU, n i v e r s i o t yf M i s s i s s i p pJi a , cKSOn Digoxin-spccific Fab fragments can rapidly f'Vquthcsis: ,S!ydf and ettecrtvelyreverseoleandertoxicity in the caninemodej.

- Participants:Six mongreldogs(weight,I0.5 to lZ kg; mean 2.3 kg).

E a c h . d o gw. a s a n e s t h e t i z e dw i t h t h i a m y l a l 3 5 |te1f,o{s: mg/kg IV, intubated endotracheally,and ventilated on room arr.

Abdominal aortic, femoral.venous,left ventricular, -Jp"i_ monary arterial lines as well as ECG leads were placed. iach dog was administeredIV oleanderextractlequivaGr.i" +O-g dried oleanderleaf per kg dog weightl over iive mrnutes.ECG and_hemodynamicevidence_ of _cardiacglycosidetoxicity was confirmed. At ten minutes half the dogi ieceived digoxiir_spe_ cific Fab fragments l0 mg/kg IV push. investigationswere ter-

minated at 60 minutes.

Results: A1l animals developedsigns of oleander toxicity. All anrmals in the treatment group returned to sinus rhythm within 40 minutes after Fab infusion (average, 37 minutes); none in the control group ever returned to sinus rhythm. Animals in the treatment group had better hcmodynamic recovery (by aortic mean pressure and left ventricuiar systolic pressure mcasurcments) than the control group.

Conclusions: l) Oleander poisoning in this canine model produces ECG changes typical of cardiac glycoside toxicity; 2) significant hemodynamic changes following oleander poisoning i n c l u d e a d e c r c a s ei n c a r d i a c o u t p u t a n d a n i n i t i a l i n c r c a s c b u t eventual decrease in systemic blood pressurc; and 3) digoxinspecific Fab fragments effectively reverse dysrhythmias while restoring hemodynamic function in thrs caninc model of oleander toxicity.

I

al4, I ZO

Participants: Five hundred twenty consecutive paticnts prtsenting with an Injury Severity Scoreof more than I6.

Mcthods: Testing of urine for cocaine metabolites was pcrformed with EMIT DAU procedures and thin-laycr chromatography.

Results: Thirty-eight pcrcent of ail patients prcscnting with major trauma were positive for cocaine; this included 57% of al| victrms of violent assault and 30% oI patients less than 40 ycars old who were injured in motor vehicle accidents. None of thesc patients was reported to DAWN despitc compliance with the nctwork's guidelines.

Conclusion: The DAWN system is not designed to detect drug-rclated trauma. The relationship between cocainc usc and major traurna-especially its possiblc role in motor vehiclc accidcnts-rs being obscured by an ineffective national rcporting system.

a qE a L!

IncreasedRuralMotor VehicleCrash Mortality:Roleof CrashSeverityand MedicalResources

R F M a i o , P E G r e e n ,M B e c k e r ,R E B u r n e y ,C C o m p t o n / S e c t i o no f E m e r g e n c yS e r v i c e s ,D e p a r t m e n to f S u r g e r y ;D e p a r t m e n to f B i o s t a t i s t i c sS,c h o o l o f P u b l i c H e a l t h ;U n i v e r s i t yo f l \ / l i c h i g a n T r a n s p o r t a t i o nR e s e a r c hI n s t i t u t e ,A n n A r b o r

S W H a r g a r t e n ,T K a r l s o n / M e d i c a lC o l l e g e o f W r s c o n s i n ,M i l w a u k e e RegionaM l e d i c a lC o m p l e x Study objective: To study the emergcncy physician charges and practice patterns of patients involved in motor vehiclc crashes(MVCs), comparing seat belt use (SU) with nonscat belt usc {NSUl. Dcsign: Rctrospcctivc examination of 2,225 emcrgcncy dcpartmcnt rccords of MVC patients from four communrty EDs anclonc Lcvcl I trauma ccntcr ED during a five-month pcriod.

Intcrvcntions: Nonc.

Rcsults: Reportcd SU obtaincd from thc ED record inTO'% ol t h c r c c o r d s ( 1 , 5 4 t 3 )o: n l y 6 4 . 5 7 ' o f t h c r c c o r d s f r o m c o m m u n i t y E D s h a d a r c c o r d o f S U c o m r r a r c d w i t h t ] 1 . 7 % ,o f t h c E D r c c o r d s frorn thc traurna ccntcr ED l1'<.0011. Comparcd with the SU group, thc NSU group had a grcatcr mcan number of physician p r o c c d u r c sp c r f o r m c d ( 1 . 4 v s 1 . 2 , 1 ) < . 0 0 1 ) a n d m o r c f a c c a n t l s k t r l l r a d i o g r a p h s o r d c r c d 1 , 1 1 . 9 %v,s 6 . l l % , 1 , < . 0 1 ) . T h c S U group had more ccrvical-spinc radiographs ordercd than thc N S U g r o u p ( 7 1 . 5 v s 6 5 . 7 , P < . 0 5 ) . P h y s i c i a n c h a r g e sf o r N S U paticnts were highcr than for the SU group (P < .001),averaging $22.00 rnorc pcr patient.

Conclusion: Emcrgcncy physician practice patterns rcflcct thc scvcrity and distribution of injury associated with SU and N S U . R c d r " r c c dp h y s i c i a n c h a r g c s f o r b c l t e d M V C p a t i e n t s c o n tributc to hcalth care costs savings. Emcrgency physicians nccd to bc cncouraged to consistcntly obtain and record whether an individual was wcaring a seat bclt during MVC.

Background: Drivers involvcd in rural Michigan motor vchic l e c r a s h e s{ M V C s ) a r e 1 . 9 - f o l d m o r c l i k e l y t o d i c t h a n a r e t h c i r nonrural counterparts.

Study objectivc: To explorc thc relationshrps among agc, crash severity and mcdical resourcc density, and probability of survival in rural and nonrural Michiean MVCs. Dcsign: Retrospectivc casc-control study using logistic regression.

Methods: The l9U7 Michigan Accidcnt Census was uscd to obtain data regarding all drivcr MVC nonsurvivors {733) and a random samplc (2,483of 650,000)of survivors. A logistrc regression modcl was developcd using survival as thc dcpcndcnt varia b l e ; c r a s h c h a r a c t e r l s t i c s /a g e / s c x , a n d r u r a l o r n o n r u r a l c o u n t y were indcpendent variablcs. Mcdical resource dcnsity variablcs (emcrgcncy medical technicians, ambulances, surgcons, cmcrgency physicians, hospital bcds, and opcrating rooms pcr squarc mile) and level of carc varrablcs (basic or advanced lifc support, emergency department category) werc thcn introduccd, and t h e i r e f f e c t s ,w e r e a n a l y z e d .

Results: Significant {best fitting) variablcs wcrc vchiclc d e f o r m i t y ( c o e f f i c i e n t , 3 . 9 3 2 ) , s e a t b c l t u s c 1 3 . 4 3 7 ) ,v c h i c l c t o w e d f r o m s c e n c ( 3 . ( r ( r )a, g c o f m o r c t h a n 5 0 y c a r s ( 1 . 4 9 ) ,d c f o r m i t y / s e a t b e l t i n t e r a c t i o n ( 1 . 2 3 ) ,r u r a l c o u n t y ( 0 . 4 I ) , a n d a g e o f 2 6 t o 5 0 y e a r s ( 0 . 4 1 ) .P v a l u c s f o r t h c s c c o e f f i c i c n t s r a n g e c lf r o m .0001to .002. Controlling for crash charactcristics and agc, rural drivers were 1.5-fold more likcly to dic than wcrc nonrural d r r v e r s . W h c n m e d i c a l r e s o u r c e v a r i a b l e s w c r c i n c l u d c d i r - rt h c model, they wcre highly corrclated among thcmselves and with rural or urban status, but they did not improvc thc fit. Low values of medical resources were associated with rural areas, and h i g h v a l u e s w e r e a s s o c r a t e dw i t h u r b a n a r e a s , r e s u l t i n g i n r n u l ticolinearity. Medical variables werc thus interchangcablc with rurai/urban rn the modci and essentially defined thc rural/urban situation.

C o n c l u s i o n : T h i s m o d e l s u g g e s t st h a t a g e a n d c r a s h s e v c r i t y make a contribution to cxcess rural mortaLty but that diffcrencesin medical care avaiiability may makc a larger contribution to this problem.

n qtA a a-

MotorVehicleCrashesandSeatBelts:A Studyof Emergency Physician Procedures andCharges

" 126 H::;:""[f li$';?:,iJ,i i":ffi#:ii::'

Law RLMuelleman, EJMlinek, PECollicott/University ol Nebraska M e d i c aCle n t e0r .m a h aN. e b r a s k a

Study obiectivcs:To document the effect of a reenactedcomprchensive hclrnet use law (CHUL) on rates of motorcycle crashes, fatalities, severe head iniuries, and acute medical charges.

D c s i g n : R e t r o s p e c t i v e b e f o r e - a n d - a f t e ra n a l y s i s .

Setting: Two urban counties representing 4O"/" oI Nebraska's population. All I I hospitals in the study region participated.

Participants: Six hundred seventy-one patients reported injured to the Department of Roads in the period from one year before through one year after the reenactment on fanuary l, I989. Two hundred eight-six of these patients who were transported by a study ambuiance service to any of the study hospitals were investigated for specific injuries and costs.

Results: Crash rates per I0,000 registered motorcyclists in Nebraska decreased 22o/", with the CHUL having a significant (P < .05) effect. In the study region, the rates per 10,000 registrations of reported injured decreased 28%, ambulance transports decreased 37"/", severe head injuries decreased 54o/", and fatalit i e s d e c r e a s e d3 8 % . T h e r a t e o { s e v e r e h e a d i n j u r i e s p e r 1 , 0 0 0 reported injured decreased 35% lP > .05, power o{ 33%}. The number of all specific types of severe head iniuries decreased.

Acute medical charges decreased 38% 19324,0001,and 48% of the acute medical charges were unpaid or paid by government

RealandReported Incidence of CocaineUseAmongVictimsof Maior Trauma

D B r o o k o f f ,E C a m p b e l l ,L S h a w / E m e r g e n c yS e r v i c e s ,H o s p i t a l o f t h eU n i v e r s i t 0 y f P e n n s y l v a n i aP, h i l a d e l p h i a Study objective: To determine whether victims of major trauma who tested positive for cocaine were reported to the National Institute of Drug Abuse's Drug Abuse Warning Network (DAWN).

Design: Review of emergency department records, toxicologic screening results and DAWN reports for the first six months of 1990.

Setting: ED of an urban Level I trauma center.

51

mal strategies for their prevention and control.

funds.

C o n c l u s i o n : T h e r e e n a c t m e n t o l a L H U L r c s u l t c Ol n l e w c r c r a s h e s , f a t a l i t r e s , a n d s e v e r c h e a d i n y u r i c sa s w e l l a s r c d u c c d acute medical charges.

1127

i[:*';#l?iT,'fiY

Patients' theED:

, K a r l s o n ,G 0 l d h a m / M e d i c a l C o l l e g e o l W i s c o n s i n , S W H a r g a r t e nT l e d i c a lC o m p l e x M i l w a u k e eR e g i o n a M Background: Alcohol is an important risk factor for injuries treated rn thc cmergency department, but littlc is known about the circumstances of thesc events and the rolc of ED intervcntrons.

Study objective: To study the epidemiology of alcohol purchaseand consumption before an alcohol-relatcd injury event.

Design; Prospectivc survey of 259 patients who were acutcly iniured {within six hours) and tested positivc for alcohol in an ED. Each patient was askcd where thcy had purchased and consumed alcohol bcfore the iniury evcnt.

Intcrvcntions: None.

Rcsults: Thc patients wcrc primarily young (mean age, 31 years) and malc (tl3'/.).Bcforc thc iniury cvcnt,32% of thc patients had consumcd alcohol at homc, 287" at a tavern,22Y" it an acquaintancc's homc, and 16% at a public place other than a t"u"rn, Motor vehiclc crash victims werc more likely to havc consumcd alcohol at homc or at an acquaintancc's homc {(r4%) bcforc the injury evcnt than werc assault participants (50%)(1'= N S ) . M o r c t h a n o n c f o u r t h { 2 U % } o { t h e m o t o r v e h i c l e c r a s hv i c tims consumcd alcohol at tavcrns or at other public placcs b c f < r r ct h c i r i n j u r y c v c n t c o r n p a r c d t o 4 9 " k t t f t h e a s s a u l t p a r t i c i p a n t s{ 1 ' = N S ) .

C o n c l u s i o n : S t r a t c g i e st o d c c r e a s cd r i n k i n g a n d d r i v i n g r n u s t bc dircctcd at thc homc environmcnt in addition to tavcrns.

Policics affccting taverns and other public placcs need furthcr study to rcduce thc large numbcr of assaults taking placc in this cnvironmcnt. Emergcncy physicians must play an active rolc in affccting alcohol paticnt education and alcohol policy dcvclopm c n t t o d c c r c a s ct h c t o l l o f a l c o h o l - r c l a t c d i n i u r i c s .

Men,Womenand Murder:Gender' Specific Differencesin Ratesof Fatal Violenceand Victimization Memphis; ofTennessee, ALKellermann, JAMercy/University {

Roleof Complementin Postischemic tO a ZJ ReperfusionInjury Medical Center, State University RJKorthuis/Louisiana DLCarden, Shreveporl andBiophysics, ofPhysiology Department

*{

It(| I GIO

e o n t r o lA, t l a n t aG, e o r g i a C e n t e rfso r D i s e a sC objective: To study the potential differcncesthat disStudy t i n g u i s h h o m i c i d e si n v o l v i n g w o m e n a s v i c t i m s o r o f f c n d c r s f r o m r h o s ci n v o l v i n gm c n .

Methods:We analyzedFederalBureauof InvestigationUniform Crimc Reports data on homicides that occurred in thc United Statesbctwecn 1976and 1987.Only casesthat involved victims aged15 yearsor older were included.Personskilled by police werc cxcluded.A total of 215,273homicideswere studied: 77% involvcd male victims, and 23o/"involved femalevictlms.

Results:Although the overall risk of homicide for women was substantrallylower than that of men (RR,0.271,the risk of being killed by a spouseor intimate acquaintancewas higher { R R , 1 . 2 3 ) .I n c o n t r a s tt o m e n , t h e k i l l i n g o f a w o m a n b y a strangerwas rare (RR,O.18).More than twice as many women were shot and killed by their husbandor intimate acquaintance than were murdered by strangersusing guns, knives, or any other method. Although women comprisemore than half the US population,they committed only 14.7% of the homicides noted during this interval. In contrastto men, who killed acquaintances,strangers,or victims of undetermined relationship in 80% of cases,women killed their spouse,an intimate acquaintance,or family member in 60% of cases.When men killed with a gun, they most often shot a strangeror nonfamily acquaintance.When women killed with a gun, the victim was fivefold more likely to be their spouse,an intimate acquaintance or a member of their family than a strangeror person of undeterminedrelationship.

Conclusion: Recentpromotion of small handgunsfor women as an effective means of self-defensemay be counterproductive.

Greater recognition of gender-specificdifferencesin the nature and rate of violence and victimization is neededto identify opti-

52

Background:Postischemicreperfusioniniury is an important oroblem in which restoration of blood flow to ischemic tissue doesnot alleviate cellular dysfunction.A largebody of evidence indicates that polymorphonuclear leukocytes contribute to reocrfusion-inducedmicrovasculardysfunction and that this neutrophil-mediatediniury is dependenton neutrophil adherence to vascularendothelium. However, the factorsthat initiate neutrophil/endothelial ce11 interactions elicited by ischemia/reperfusion(l/R) are poorly understood.It has been suggcstedthat leukotriene 84 iLTB4) or the complemen-tcomnonint CSa mav induce neuirophil adherenceto endothelium tissueby inducand microvascuiardysfunctionin pcistischemic ing an upregulation of the CD1 l/CDl8 adherencecomplex on thc surfaceof granulocytes.

Study objective: To determine the role of LTB4 and C5" in thc genesisof postischemicmicrovasculardysfunction.

Methods:The efficacyof LTB4 UM) and C5a as chemoattractants for canineneutrophilswas iestedby intiadermalinjection ( 1 0 0 U L ) .N e u t r o p h i l i n f i l t r a t i o n i n t o i n j e c t i o n s i t e s w a s by dctermination of myeloperoxidase{MPO} activity in assessed skin biopsicsobtainedfour hours after iniection of C5a or LTB4.

In addition, changesin vascularpermeabilityinduced by I/R, I/R plus the lipoxygenaseinhibitor, diethylcarbamazine{DEC, in the iso40 mg/100mL blood)or C5a infusion were assessed latcd liood-perfusedgracilis muscle by measurementof the solvent drag reflection coefficient (Ei for total plasma proteins.

Data werc analyzedby comparisonof meansby using a one-way analysisof variance.

Results:Both L.IIB4and C5. induced marked tissue neutrophil infiltration conipared t'iih control sites (MPO, 23'29 !

0.t3p/g wct wt, 21.2t 3.5 F/g wet wt, and 5.8 r.0.7 ltlg wet wt/ with a significant In addition,IiR was associated respectively). incrcasein mtcrovascularpermeability(D = 0.61 + 0.02) comnaredwith control musclesld = 0.86I 0.03)that was not attenuatcd by pretreatmentwith DEC iE = 0.63 + 0.01).C5, infusion to rcsultedin an increasein microvascularpermeability"Similar that secnafterI/R (a = 0.59t 0.09).

Conclusion:The resultsof this study suggestthat C5a but not LTBa may contribute to postischemicvasculardysfunction.

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Motor Neuron Survival in a Rabbit Model of Spinal Cord lschemia KN Hall,DT Wilcox,AM Ezrin,MS RVWDimlich,WG Barsan, Medicine, andAnatomyand Cell o{ Emergency N/iller/Departments t i e d i c aCl e n t e rC, i n c i n n a t0i ,h i o ; B i o l o g yU, n i v e r s i toyl C i n c i n n aM SterlinD g r u g ,I n c ,R e n s s e l a eNre, wY o r k Background:Monomethoxypolyethyleneglycol-superoxide dismutaseiPEC-SOD)has been reported.tohave a beneficial effect on neurologic function after spinal cord ischemia when given beforereperfusion Study hypothesis:Motor function and activity levels used to evaluaterabbits in that study will correlatewith the percentage of surviving motor neurons.

Subiects:Eighteen New Zealand White male rabbits {2.8 to 3.3 kg) with a damagedspinal cord resulting ftom26 minutes of ischemia induced by clamping the aorta distal to the left renal iltery.

Intervention: Beforeischemia, rabbits were randomly assignedto one of three groups: group I {six} received placebo treatment, group 2 {sixf received 10,000units/kg MEG-SOD immediately b-fore reperfusion, and group 3 {six) received 10,000units/kg IV PEG-SOD20 minutes after reperfusion' Design: After neurologic testing on day 7 after ischemia, anestheiizedrabbits were perfusion-fixedwith l0% neutral buffered formalin. From each treatment group, spinal cords in three rabbits that were paralyzed and three that were not paralyzed were selectedfor microscopic analysis.The percentageof normal anterior horn motor neurons was determined for one

scction from cach of five spinal cord lcvcls for each rabbit.

Means for each motor function and activity group werc compared using Kruskal-Wallis, Dunn's, and curve-fitting statistics.

R e s u l t s : R a b b i t s t h a t w c r c p a r a l y z c , Jl n i n e ) a n d i n a c t i v e {cight) exhibited more cxtcnsive antcrior horn motor neuron necrosis, inflammation, and granulation tissue formation than nonparalyzcd (nine) and spontaneously active rabbits (ten).

There wcrc significant differences bctween thc pcrcentagc o{ n o r m a l m o t o r n e L l r o n sa t e a c h m o t o r o r a c t i v i t y l c v c l ( P . . 0 0 0 2 to.0l)as wcll as a hrgh corlelationbctween motor function (Rz = 1.00)or activity lcvcls (Rz =.98) and thc mcan perccntagc of u n a f fc C t e d m o t o r n C u r o n s .

Conclusion: These results verifrcd thc use of motor function and activity levcls as reliablc indicators of motor ncuron viabrlity in this modcl and suggest that thc grcater activity in pEGSOD-trcated rabirits is dircctly rclatcd to improvcd ncuronal function in these animals.

*a

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TraumaticSpinalCord NeuronalIniury,n Vitrols Attenuatedbythe lV-Methyt-DAspartateReceptorAntagonist Dextrorphan

R F R e g a n ,D W C h o i / D e p a r t m e n o t 1 N e u r o l o g y ,S t a n fo r d U n i v e r s i t y , S t a n f o r dC . alifornia S t u d y h y p o t h e s i s : S c c o n c l a r yi n j u r y p r o c c s s c s a f t c r s p i n a l cord trauma arc mediatcd in part by cxcessivc activation ;f Nmcthyl-D-aspartate {NMDAI icc.pti,rs dLlc ro rclrasc of cxcitatory arnino acids from inlurcd ncurons.

Design: Spinal cord cell culturcs wcrc prcparcd fron-r fctal Swiss-Wcbstcr micc at l3 days' gcstation. Mature culturcs (14 to 20 days in vitroJ werc subjectcd to tcaring of thc culturc m o n o l a y c r w i t h a s t y l c t . I n ; u r y w a s a s s c s s c d2 4 h o u r s l a t c r b y m e a s u r c m c n t o f l a c t a t c d c h y c l r o g c n a s ci n t h c c u l t r - r r cn r c t l i a a n d by ccll counts.

Intcrventions: Thc ncuroprotcctivc cfficacy of 1hc noncor.r.rp c t i t i v c N M D A r c c c l t t o r a n t a g o n i s t c l c x t r o r p h a n ,p r c s c n t d u r i n g a n d a f t c r i n j u r y , w a s c l r . r a n t i t a t i v c l ya s s c s s ed .

R c s u l t s : W i t h i n m i n u t c s o f i n j u r y , n c u r o n s a c l j a c c n tt o t h c tear clcvclopcd acutc swclling that bccomcs morc markccl antl w i d e s p r c a do v c r t c n t o l 5 m i n u t c s . A m a i o r i t y o f t h c s c c c l l s d c g c n c r a t co v c r t h c f o l l o w i n g 2 4 h o u r s . D c x t r u r p h a n c f f c c t i v c l y rcduccd both acutc ncuronal swclling and latc dcgcncration, in conccntration-dcpcndcnt fashion bctwccn I and 100 UM {1C50 near l0 pM). At 100 pM, ncuronal death was rcducctl by rrrore t h a n U 0 u l ,c o m p a r c d w i t h c o n t r o l u n t r c a t c d c u l t u r c s ( 1 , < . 0 1 , two-tailcd t tcst with Bonfcrroni corrcctionl.

C o r - r c l u s i o n :A m c c h a n i c a l i n s u l t t o s p i n a l c o r c l n c u r o n s a n c l g l i a i n c u l t u r c r c s u l t s i n i n j u r y L r fn c L r r ( ) n d s i s t a n t f r o r . nt h c s i t c o f t r a u m a . T h i s p u r c t r a l r m a t i c i n j u r y i s r c d r . r c c db y t h c N M D A rcccptor antagonist dcxtrorphan irnd hcncc rnay be in part clr-rc to cxccssivcactivation of ncuronal NMDA rcccptors.

a Qq a gZ

PhospholipidDeteriorationand FreeFatty Acid Releasein CerebralCortex FollowingCardiacArrestand Resuscitation

R ER o s e n t h a lG , F i s k u m / D e p a r t m e n t so f E m e r g e n c yM e d i c i n e a n d B i o c h e m i s t r yT,h e G e o r g eW a s h i n g t o nU n i v e r s i t yM e d i c a lC e n t e r , W a s h i n g t o nD, C B a c k g r o u n d : R a p i d r e l e a s e o f b r a i n f r e e f a t t y a c i d s ( F F A s )h a s been demonstrated in deveral different modcls of cerebral ischcmia and is implicated in the cellular pathophysiology assoc i a t e dw i t h p o s t i s c h e m i c n e u r o n a l d a m a g e .

S _ t u d yh y p o t h e s i s : B r a i n F F A r e l e a s e o c c u r s n o t o n l y d u r i n g cerebral ischemia but also during reperfusion, thus exacerbating i s c h e m i a - i n d u c e db r a i n d a m a g e .

Design: In a nonrandomized, controlled trial, anesthetized f e m a l e b e a g l e su n d e r w e n t t e n - m i n u t e c a r d i a c a r r e s t i n d u c e d b y electrical epicardial fibrillation. Restoration of spontaneous crrc u l a t r o n i R O S C ) w a s a c c o m p l i s h e d u s i n g e p i n e-p h r i n e , s o d i u m bicarbonate, open-chest CPR, and defibrillation.

Interventions: Ten animals underwent cardiac arrest; four dogs were not resuscitated at the end of ten minutes of ventricular fibriilation. Six animals were resuscitated; three received intensive care for two hours and an additional three animals were maintained for 24 hours. Four dogs served as nonischemic

controls. At the end o{ the appropriatc period, a cranioromy was performed, and a samplc of right frontal cortex was removed.

FFA and phospholipid contents wcre determincd using thinlaycr and gas chromatography; results from experimcntal groups wcre comparcd with controls using two-sample t test {P < .5) .

N e u r o l o g i c i n j u r y w a s a s s c s s c di n 2 4 - h o u r s u r v i v o r s u s i n g a 1 O 0 - p o i n tn c u r o l o g i c d e f i c i t s c o r c ( N D S ) .

Results: Brain cortical FFA content was rncreascd sienifi cantly not only during ischernia but also at two hours, of ROSC, approaching significancc at 24 hours. Conversely, brain cortical phospholipid conccntration was significantly decreasedduring i s c h e m i a a s w c l l a s a t 2 4 h o u r s . I n c r e a s e si n F F A o c c u r r c d p r e dominantly as a result of relcase of saturated FFA {cg, at two hours, thc conccntration of saturated FFA was I13.3 t 2l $SlS c o m p a r c d w i t h 2 t 3t 1 6 p g / g u n s a t u r a t c d ) ( 1 ,< . 0 3 ) , Group

FFA (Fg/g)

Phospholipids(mg/g)

Control

9 5 . 51 1 3 . 4

27.6t2.6

l0 min ischemia

l 7 3 . l . t1 1 . 1 . 2 (P = .0051

t 7 . Ir 1 . 0 ( P- . 0 0 9 1

2 hr ROSC

1 4 1. 3 1 5 . l l lP= .04)

1 9 . 7r 1 . 3 { P= . 0 ( r )

24 hr ROSC

2 5 1i u 6 . 6 { P= . O e l

1 6 . 2r L I J {/' = .02)

NDS

35 r (r

Conclusion: Brain cortical FFA conccntration incrcascd sign i f i c a n t l y d u r i n g t c n m i n L l t c s o f c a r c l i a ca r r c s t a n d f , r r a p r o longccl pcriocl during ROSC. Thc incrcascs in FFA appcar to occur as conscclucncc of rclcasc of phospholipid fatty acyl g r o u p s . T h c p r c d o m i n a n c c o f s a t u r a t c d F F A r c l c a s c d s u g g c s t sa m c c h a n i s r . r -sr c p a r a t e f r o m o r i n a d d r t i o n t o a c t i v a t i o n o f p h o s pholipasc A2. Phospholipid brcakdown with rcsultant FFA r c l c a s c r . n a yc o n t r i b u t c t o n c u r o l o g i c i n j u r y a f t c r c a r d i a c a r r c s t .

Dichloroacetate and Hyperbaric 1133 Oxygenation Treatmentof Posttraumatic CerebralEdemain Rats M Biros, J ZinklDepartment of Emergency Medicine, Hennepin C o u n tM y e d i c aCl e n t eM r ,i n n e a p o M l i si n , nesota

Study hypothcsis: Curnbincd thcrapy with dichloroacctatc ( D C A ) t o r c d u c c t i s s r - r cl a c t i c a c r d o s i s a n c l h y p c r b a r i c o x y g c n {HI}O) to incrcasc tissuc oxygcn is r.nurccffcctivc at rcclucing p o s t t r a L l n t a t i c c c r c b r a l c t l c r . n ai n r a t s s u b i c c t c d t o h c a d t r a L l m a than cithcr thcrapyalonc.

D c s i g r - ra n d p a r t i c i p a n t s : L a b o r a t o r y s t u d y u s i n g f c d , a d u l t , rnalc Spraguc-Dawlcy rats.

Mcthods: Brain dcformation injury was produccd in prcparcd r a t s u s i n g a f l u i d p c r c u s s i o n c l c v i c cd c l r v c r i n g a n i n r p a c t f o r c c o f 2 ATA. Four cxpcrimcntal groups (six to ninc pcr group pcr tinrc) rcccivccl l DCA (25 rng/kg IV) l5 rninutcs aftcr trauma, f o l l o w c d b y t H B O { ( r 0r n i n u t c s a t 1 . 5 A T A ) a t 3 0 m i n u t c s a f t c r trauma. Untrcatcd trauma controls (six) rcccivcd ccluivolumc n o r m a l s a l i n c ( N S ) . N o n t r a u m a s h a m - o p c r a t i v cc o n t r o l s ( f o u r ) rcprescntcd normal brain. 1n vitro brain tissuc harvcstint was donc at two or four hours after trauma. Spccific gravitics (SpC) o f c o r t c x f r o m t h c t r a u m a s i t e ( s l ) , i m m c d i a t c l y a d j a c c n tt h c s i t c ( s 2 ) ,a n d a t a c o n t r e c o u p s i t e { s 3 ) w c r c d e t e r m i n c d o n p r e c a l ibratcd organic gradicnt columns. Comparisons of SpG lmong g r o u p s w e r c d o n c u s i n g a n a l y s i s o f v a r i a n c e a n d t t e s t ( 1 )< . 0 S ) .

Group Tratr+NS

Spc sl (SD) 2hr 4 hr

Spc s 2 (SD) Zhr 4 hr

1.039 1.041 1.039 L040 1.002) 1.0021 {.002) (.0o2) Trarr+DCA |.042 L044 |.O42 I.043 1 . 0 0 2 1 '( . 0 0 1 1 ' # ( . 0 0 2 ) . #1 . 0 0 2 ) ' # Trau+HBC) 1.037 1.037 1.041 1.041 1 . 0 0 2 1 1 . 0 0 3 ) { . 0 0 3 1 ' #( . 0 o 3 ) , # Trau+HBO+ | .042 | .O42 L043 1.044 (.003)'# {.0021'# (.001).#1.001)'# DCA

Spcs3 (SD) 2hr 4 hr \.O44 lO14 1 . 0 0 1 ) . #I . o 0 l ) . # t.O44 LO44 ( . 0 o t ) . #( . 0 0 1 ) ' # t.043 1.043 1 . 0 0 2 ) , #( . 0 0 1 ) . # 1.043 |.O44 ( . 0 0 2 ) . #( . 0 0 1 ) ' f

'Significantly differcnt from traumatized untrcated controls ltrau+NSl; #Same as n o n t r a u m a c o n t r o l s 1 1 . 0 4 4t . O 0 l )

Conclusion: In this animal model, DCA reduced posttraumatic cerebral edema by two hours and normalized by four hours. Although HBO did not appear to be effective at the site

o f t r a u m a { s 1 ) ,i t r c d u c e d w a t e r c o n t e n t o f a d j a c e n t t r a u m a t i z e d tissue (sj), where marginally viable trssuc is probably found.

Comparc? with either treatment alone, combined thcrapy may hastcn the normalization of water content of injured brain to levcls equal to nontraumatized tissue. Furthcr studics are necdcd to dclineate mechanism and sitc of action of thesc potentiallv bcncficial thcrapies.

of Dichloroacetateon Pyruvate tl 34 Effects Activityin lschemicRat Dehydrogenase Brain M M N i e l s e n ,R V W D i m l i c h / D e p a r t m e n 0t f E m e r g e n c yM e d i c i n e ,a n d i e d i c a lC e n t e r , A n a t o m ya n d C e l l B i o l o g y ,U n i v e r s i t yo l C i n c i n n a t M Cincinnati,0hio Background: Postischcmic treatmcnt with dichloroacetatc I D C A ) i n d u c c s a m o r c r a p i d d e c r c a s ei n b r a i n l a c t a t c d u r i n g r c n c r fu s i o n a f t c r i s c h c mi a .

Study hypothesis: DCA mcdiates this cffcct by stimulating t h c e n z y m c c o m p l e x p y r u v a t e d e h y d r o g c n a s e( P D H C ) .

Intcrventions: In a random manner, 42 adult malc Wistar rats wcrc assignedto sham or real ischemic groups and trcated with DCA (250 mg/kg IP four times over two hours or 25 mg/l<g IV bolusl or carricr as a ctlntrol.

Design: Ischemia was induced in ancsthctizcd rats by bilatcral carotid ligation and blccding to a moan arterial blood pressurc of 40 mm Hg. Rats wcre killcd immcdiately or after 30 minutes of rcpcrfusion by freczing the brain in sittt. Samplcs of cercbral c o r t e x w c r c a n a l y z c , Jf o r P D H C a c t i v i t y b y a r a d i o a s s a y u s i n g carbon-15-pyruvate and for lactate hy fluoromctry. Paramctric data wcrc analyzcd by analysis of variancc and Duncan's rnultiplc-rangctcstr nonparamctric data wcrc analyzcd by KruskalWallis.

Rcsults: DCA at thc highcr dosc stirnulatcd PDHC in rats.

Althoueh trcatmcnt with the lowcr dosc of DCA significantly d c c r c a s c db r a i n l a c t a t c , i t p r o d u c c d n o s i g n i f i c a n t s t i m u l a t i o n o f PDHC activity during rcpcrfusion following ischcmia.

Length ol Ischemia

PDHC Activity

Lactate C0ncentration

0 r n i n( 5 )

2 . 3 1 t. r 0 . 9

. 1 . 4I 0 . 2

l5 min{4)

4 . s ir] I . 7 r 0.3 2.2r.i

1 9 . 9! 2 . 5 2 , 1 . !6 7 . 1

I . 4 5t 0 . 3

1 5 . 01 I . r J '

L . 5 3t 0 . 2

7 . 9! t . 7 '

. 3 0m i n { 6 ) . 3 0r n i n + 3 0 m i n repcr{usion,no TX ((r) 30 min + 30 min rcpcrfusion,DCA TX {61 ' 1'=.01 lDuncan's)

Conclusion: These data indicate that although DCA is effectivc in reducing brain lactate, the mechanism of action does not involve DCA's known ability to stimulate PDHC.

*{

2E I rrr,

HemodynamicEffectsof Cimetidinein AnaphylacticShock in a CanineModel

Medicine, TM0'Toole, PBFontanarosa/Department 0f Emergency Aultman Northeastern OhioUniversities College ol Medicine, H o s p i t aCl a , nton 0 ,h i o A ; k r o nC i t yH o s p i t aAl k, r o n0,h i o Study objective: To evaluate the hemodynamic effects of IV cimetidine in the treatment of anaphylactic shock (AS).

Model: Fourteen anesthetized dogs subjected to AS using horse serum presensitization and IV challenge injection.

Interventions: Dogs were randomly assigned to receive cimetidine i30 mg/kg IV) or placebo (controls) administered ten minutes after IV challenge infection and induction of AS Methods: Heart rate, arterial pressure, pulmonary artery pressures, and cardiac output were measured at baseline, just after challenge iniection, and at five-minute intervals up to 60 minutes during the AS phase. Values calculated using a microcomputer included mean arterial pressure, percent change in mean arterial pressure, cardiac index, percent change in cardiac index, peripheral vascular resistance, and percent change in peripheral vascular resistance: (% change = Imax - min] during AS/baseline). Cimetidine-treated dogs were compared with controls using analyses of variance and independent t tests. Criteria for rejection of the null hypothesis was set at 0.05. Values are expressed as mean f SEM.

Results: All animals demonstrateddramatic decreasesin mean arterial pressure,cardiacindex, and peripheralvascular resistanceimmediately after IV challengeinjection. Cimetidine producedno significant (P > .05) effect on percent changein mean arterial pressure(cimetidine, 30.6 x 6.9 mm Hg; controls, 37.3t 7.8 mm Hg),cardiacindex {cimetidine,73.0! 7.9 mm Hg; controls,90.8 t 23.8 mm Hg), or peripheralvascularresistance (cimetidine,(r1.6t 10.6mm Hg; controls,50.6I 12.0mm Hg).

Conclusion:IV cimetidine admrnistrationfor treatment o{ anaphylacticshock fails to produce significant improvement in hemodynamicparameters,

.136 i":,:,'ff:f:1n:i:ltT $n"""

Hemorrhage and Iniury Iniury Western RALittle/North DWYates, E Kirkman, MYRady, UK Manchester, ol Manchester, University Research Centre, Morbidityand mortalityfollowinghemorrhage Background:

arc increased markedly by concomitant tissue injury and noci' ception.

Study objectivc: To investigate the mechanism of this interaction.

Methods: We examtned the effects of nociccptive afferent activity and injury on thc blood loss required to produce a given changc in oxygcn transport and cardiac function. Three groups o f l a r g e W h i t e p i g s 1 1 6t o 2 7 k g ) w c r e a n e s t h e t i z e d w i t h ketamine (20 mg/kg IM) followed by isoflurane i1% to 5%) in N jO and Or {FIOr, 0.5) and subjected to hemorrhage at a r^te oI -rl g" of their estimated blood volume per minute 1 1 0 . 7m 5 t.ks whilc recording changes in oxygen transport and cardiac function-cardiac index (CI) and shock index (SI; heart rate/systolic blood pressurc, inversely related to cardiac performance before (c) and at thc end of hemorrhage (EH). Hemorrhagc was given alonc in group l, whilc it was supcrimposed on bilatcral electrical stimulation of thc brachial ncrves (BNS) to activate nociceptivc afferent fibcrs or pcnetrating injury using a captivc bolt pistol to thc muscle of both hind limbs {lnj), rcspectively, in groups 2 and 3 (onset of BNS and Inj 75 minutes before blood loss).

Rcsults: Group III GroupIl GroupI (18) {20) {21) C E H C E H C E H 29.0{1.4)'+ 35.7(0.61'+0 0 40.0(0.0) 0 1 . 3{{4l ) 6 4( 3 ) ' 1 3 01 4 ) 6 7l 4 l ' 1 3 91 4 ) ( r i ll 3 ) ' 1 . 4{ 0 . r 13 . 21 0 . 2 ) '1 . 4( 0 . 1 ). 3 . {00 . 1 1 '1 . 6l 0 . l ) 3 . s( 0 . 1 1 ' ' . l l ( 0 . 1l li .)0 { 0 . 5 12' 0 . 5 1 0 .150) 9 1 0 0 ) ' 2 0 . 2 1 0 .l701. s ( 0 . 6 )l e 6 . 7( 0 . , 1 16 . 9( 0 . 2 ) 6 . 2\ 0 . 2 1 7. ol o . z l 7 . s1 0 . 3 )6 9 1 0. 3 ) Valuesare mean t SEM. 'P < .05 versusrespectiveC; +P < .05 versus g r o u pI { a n a l y s ios f v a r i a n c e ) .

Conclusron: It can be seen that smaller blood losses are required to produce an equivalent depression of oxygen delivery and cardiac function when the hemorrhage is superimposed on nocrceptive afferent activity or injury. This may in part explain the deleterious interaction between blood loss and iniury and illustrates that even a modest blood loss may be of significance in the presence of injury.

I l l x x lk r s sl ' ) 1 , 1 ( - -{l r n l / m i n . k s ) sr Dorlml/kg) v c r 2{ m l / k s l

Xa lDa I r) t

Effectof EndotoxinNeutralizingProtein (ENP)on Gram-Negative Sepsisin a

Rabbit Model B Hammer,GR Fleisher, GR C Thompson, RASaladino, CT Garcia, d e d l c aSl c h o o lB, o s t o n l , a r v a rM S i b e r / C h i l d r eH n 'oss p i t aH Background:Gram-negative sepsis is associatedwith high morbidity and mortality. Many of the pathophysiologiceffects of Gram-negativeshock are felt to be mediated by endotoxin.

Endotoxin neutralizing protein (ENP) is a basic protein that binds a variety of endotoxinsand inhibits their ability to gelate Limulus lysate.

Study hypothesis:To determine the role of ENP in the treatment of septic shock,we evaluatedits efficacyin protectingrabb i t s a i t e r I V c h a l l e n g ew i t h a n L D g g ( I 0 0 p g / k g ) d o s e o f Escherichiacolr lipopolysaccharide(LPS|.

Design: New Zealand White rabbits were anesthetized,and femoral venous and IV arterial lines were placed.The animals were divided into four groups: lf controls (LPSalonel,2l 2.5 mg/kg ENP five minutes before LPS, 3| 5 mg/kg ENP 30 minutes before LPS, and 4) 5 mg/kg ENP 30 minutes after LPS.

P h y s i o l o g i c a l m e a s u r e m e n t s , a r t e r i a l b l o o d g a s e s ,a n d e n d o t o x l n lcvcls were obtained hourly in all groups.

Participants: New Zcaland White rabbits.

Intcrvention: ENP administered bcfore or aftcr challcngc with LPS. Results: Mean artcrial pressurc, respirations, urinc output, b r c a r b o n a t e ,p H , P C O 2 , p e r c c n t s u r v i v a l , a n d m c a n s u r v i v a l timc wcre all significantly improved {P <.05) relativc to thc c o n t r o l s r n g r o u p s p r c t r c a t c d w i t h E N P . A n i r - r - r a l st r e a t c d w i t h ENP after administration of LPS showcd improvcmcnt in meln bicarbonatc and pH. All ENP-trcatccl groups had lowcr geornctric mcan LPS conccntrations {mcasurcd at two hours by Limul u s l y s a t c a s s a y )r c l a t i v c t o t h c L l n t r c a t c d g r o u p .

Survival

(LPS)

"t 24 h o u r s M e a n( m i n ) E U / m L

.13I l:s:'J,'J; l:X:31'l",XlH3l""'J"" lnfusionInto HumanSterna

R G u e r r e r o ,D J E l i o t , H A P a t e r s o n ,L H a l v o r s e n ,B K B a y , J M t yf , C K r a m e r / U n l v e r s i0 H e n d e r s o nR , A G u n t h e r ,F W B l a i s d e l lG C a l i l o r n i a ,D a v i s E a s t B a y P r o g r a m ,O a k l a n d ;U n i v e r s i t yo f C a l i fo r n i a ,D a v i s ;U n i v e r s i t yo f T e x a sM e d i c a lB r a n c h ,G a l v e s t o n Background: Adcquate prchospital resuscrtation is iimited by documcntcd difficulties in achieving meaningful volume infusion and delay and failure rate in establishing venous cannulation. Hypcrtonic salinc dextran {HSD) in small volume effectively rcsuscitatcs hypovolcmia when infused intraosseously or lntravcnously.

Study objcctive: To evaiuate a new intraosseous infusion dcvicc for its rcliability, rapidity, and safety as an alternative mcans oI vascular acccss.

Dcsign: Sixty-cight infusions werc made into the manubrium or stcrnal body in 47 adult cadavers. The devicc incorpor a t c s a l s - g a u g c s h a f t w i t h a t h r c a d e d t i p t h a t e n g a g e st h c a n t e rior cortical bone but spins freely as the tip completely enters thc rnarrow spacc. This feature and a short shaft length are dcsigncd to prevent puncture of vttal rntrathoracic structures.

Infusions of 200 mL of either India ink (14 trials) or contrast n - r c d i a{ H y p a c l u e( r 0 % ) w e r c a d m i n i s t c r e d o v e r t w o t o f o u r m i n tutcsto dcfinc dircct or radiographic visualization of infusate rn t h e i n t c r r r a lt h t ' r r r c i cv c i n s .

R c s u l t s : M c a n i n s c r t i o n t i m c w a s 1 2 . 5 ! 5 . 7 s e c o n d s ,a n d a c c c s sw a s a c h i c v c d r n 9 3 % o f t r i a l s { 6 3 o f 6 8 ) . I n f u s a t e w a s o b s c r v c c li n t h c p u l r n o n a r y v e i n s w i t h a s l i t t l e a s l 5 m L . P r c s surcs of 9 to 20 psi dclivcrcd 200 rnl in two to four minutes.

Cunclusion: Thcsc data suggcst that rapid, reliablc, and safc v e n o L l s: r c c c s sc a n b c a c h i e v c d b y i n f u s i n g d i r e c t l y i n t o t h c r e d rr:lrrow of aclult stcrna using thc intraosseous infusion device.

This routc ancl tcchniclttc rnay facilitate prehospital delivery of fluid ancldrugs.

(HC03) mEq/mL

LPSrlonc control 1,101

.t,t

755

7.3

2.5mg/kg ENI' 5 ntirt prc LI)S{2t)l

lls'

I,332'

.1.1'

1,1.10'

5 m g / l < gE N I ' . 1 0 t r i n prc L|S 120)

90'

1,.150'

.1.0'

16.50'

5 m g / k g E N I ) . 1 0m i n post LI'S {201

50

2.4'

10.(X)'

947

incrcased hemorrhage volume and markedly higher mortality

7.68

' / ' < . 0 5 ,t r c r t c ( vl s c o n t r l ) 1 .

C o n c l u s i o n : W c c o n c l t r d c t h a t E N P i n t p r < t v c st h c o t l t c o l l l c ironr (lram-ncgativc cntlotoxic shock and has thcrapeutic poten tial in childrcn.

.1

oJ,rvivat 3 I il;'##J:"'[''ffiT:ffi ina Near-FatalUncontrolledHemorrhage Model

S A S l e r n ,S C D r o n e n ,P B i r r e r ,X W a n g ,T K o w a l e n k o / D e p a r t m eonl t i o l l e g eo l M e d i c i n e E m e r g e n c yM 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 C C n c i n n a t iO, h i o B l c k g r o u n t l : A g g r c s s r v cs a l i n c i n f l t s i o u i s c t t u l t l t l l r l y l l c i v o c a t e c lf o r r e s t o r a t i o n o f b l o o d p r c s s L r r ei n h c r t t o r r h a g i c s h o c k .

Reccnt stutltcs using nonfatal tlncontrollcd hctlorrhagc t.tlodcls s L l g l l c s t h a t a g g r c s s r v cs a l i n c r c s u s c i t l t i o n i l l c r c a s c s t . n o r t a l i t y .

Thc l.rostulatcdr.ncchanism is an incrcasc in het.norrhagcvolLllncthat accompanics rcstoration of nortnal prcssllrc. Thc rclat r < l n s h i pb c t w c e n b l o o d p r c s s u r c a u d s t r r v t v a l h a s n t t t b c c n s t l t c l i c d i n a p o t c n t i a l l y f a t l l r n o d el o f t t n c o t t t r o l l c t l h c l t t o r r h a g c .

S rt r r l y l r y p t t t h c s t s :l ) r r r g r c s . i v ri l t c r c ; t . c r i t r t t t t t t t t i l r t u r t i l l p r es s r r r c{ M A P ) d u r i n g r es u s c i t a t i o n a r c a s s t t c i a ttel w i t h i n c r c a s ing hcrnorrhagcvolunrc antl tlortality. l)csign: A swinc rnodcl of potcntially lcthal uncontrollctl herrorrhagic shock was uscd to cotrparc thc cffects of rcsltscitat i o n t o M A P s o f 4 0 , ( r 0 ,a n c ll l 0 n r r t t H g .

Intcrvcntion: Twcnty-scvcn {ully instrumcntccl imlt.liltLlrc s w i n c ( 1 5 t o 2 0 k g ) , c a c h w i t h a s u r g i c a l s t c c l a o r t o t o t . t . t yw r r e i n p l a c c , w c r c b l c d c o n t i r - r u o u s l yf r o m a f c r n o r a l a r t e r y c a t h c t c r t o a MAP of 30 mm Hg. At that point, the aortotorly wire was pullcd, producing a 4-mm aortic tcar antl uncontrollccl intrapcritoncal hemorrhagc. Whcn the anirnal's pulsc prcssurc rcachcd 5 mm Hg, thc fcrnoral artery hcmorrhagc was discontinucd.

Salincinfusion was bcgun at (r mL/kg/min and continucd as nccdcdto maintain thc following dcsircd cncl points: gr()up I (nine) to a MAP of 40 mm Hg, group 2 (nine) to a MAP of (r0 mm Hg, and group 3 {nincJ to a MAP of 80 mm Hg. Aftcr 30 minutcs or a total salinc infusion of l0 ml-/kg, thc rcsuscitation fluid was changcd to shed blood infused at 2 mL/kg/min as n e e d e dt o m a i n t a i n t h e d e s i r c d M A P o r t o a m a x i m u m v o l u m c of 24 mL/kg. Animals were obscrved for (r0 minutes or until d e a t h ,w h i c h e v c r c a m e f i r s t . R e s u l t s : D a t a w e r e c o m p a r e d u s i n g a n a l y s i so f v a r i a n c e a n d F i s h e r ' s e x a c t t e s t . D i f f c r e n c e s i n m o r tality and intraperitoneal hemorrhage volumes were statistically significant when comparing groups 1 and 3 and groups 2 and 3. Mortality rates were ),1%,22%, and 7B"k and intraperitoncal h e m o r r h a g ev o l u m e s w e r e 1 2 . 5 7 , 2 0 . 4 8 , a n d 4 5 . 9 5 m l / k g f o r groups1, 2, and3, respectively. Comparcd with group l, group 2 had significantly greater cardiac outputs and less acidosis throughout resuscitation.

Conclusion: We conclude that up to a point, increases in MAP result in improved cardiac output, tissue perfusion, and survival. Attempts to restore normotension, however, result in

a All I tl,

WithlV of Intraosseous Comparison SalineDextranin Infusions of Hypertonic Swine

Army MA Dubick,DERunyon,CB 0lifford,GC Kramer/Letterman C,a l i f o r n i a ; h ,r e s i d i o l S a nF r a n c i s c o I n s t i t u toef R e s e a r cP U n i v e r s i toyf T e x a sM e d i c aBl r a n c hG, a l v e s t o n Srnall volumc hypertonic saline dextran {HSD) llackgr<lr-rnd: can effcctivclyrcsuscitatchypovolcmia.

Study purposc:With rcnewed intcrest in intraosseous(lO) thc prcscnt study examincd if IO infusion providcd rnfr.rsion, vascularcntry of HSD as cfficicntlyas IV infusion.

Dcsigr-r: Twclve ancsthctizedpigs were preparedwith vascular cathctcrsof major vessels.Histologicsectionsof sternums and lungswcrc preparedaftereuthanasia.

Intcrvcntions:Six pigs were given a 4 mLlkg IO infusion of 7.5"1,NaCll6'1, dextran 70 over two to six minutes; each pig was paircd with anotherthat had beengiven HSD IV over the samc time course.Initial plasma volume was measuredwith dyc dilution, while expansionwas calculated{rom the dilution of plasma protein. Rapid arterial blood sampling was used to cvaluatevascularentry of NaCl and dextranwith monitoring continued for two hours after infusion.

Results:Maximum blood levels of sodrum and dextran were achievedduring infusion, while complete vascular entry of the total doseof both sodium and dextran was complete within one minute after infusion rn all experiments.Cardiovascularfunction was indistinguishablebetweenIO and IV infusions, with an increasein cardiacoutput ol I to 2 L/min peaking at two to five minutes after infusion. Plasmavolume expansionat one minute after IO infusion was ll.9 16.2 ml/kg versus10.4t 5.2 by IV. Histologic examination showed minimum pathology to the sternum and no significant pulmonary complications.

Conclusion: IO vascular delivery of HSD is as rapid and effectively as IV infusion and a viable alternative in emergency scenariosin which vascularaccessis difficult.

of HypovolemiaUslng 1141Resuscitation lntraosseousInfusionsof a SmallVolume 55

of 25/o NaCl l 24"/" Dext ra n -70 MADubick, GC CEWade, CBCliflord, SPBruttig, DERunyon, Presidio of San ArmyInstitute of Research, Kramer/Letterman G,a l v e s t o n s e d i c aBlr a n c h i t'yT f e x aM F r a n c i s cCoa, l i f o r nU i an; i v e r s o Background: Prehospital fluid resuscitation is limited by difficulty in field delivery of large fluid volumes and time dclays a s s o c i a t e dw i t h g a i n i n g v a s c u l a r a c c c s s .

S t u d y o b j e c t i v e : W e a d d r e s s e dt h e s e l i m i t a t i o n s b y e v a l u a t ing a highly efficient volume expander, a near saturated saltdextran solutron (SSD),administered by a new infuston devicc t h a t g a i n s v a s c u l a r a c c e s sv i a i n t r a o s s e o u s ( I O ) i n f u s i o n i n t o t h c sternal bone marrow.

Design: We anesthetized 14 immature swine (35 to 55 kg), performed a splenectomy, placcd Doppler flow probcs, and cannulated major vessels{or cardiovascularmonitoring. Aftcr a steady-statebaseline, all animals wcre hcmorrhagcd to 45 mm Hg for one hour.

Interventions: Half of the hernorrhagcd anin-rals (blcd volu m e , 1 ( r . 9t 1 . 9 m l / k g ) w e r e t r e a t c d w i t h a 1 2 - t o 3 0 - m i n u t c I O infusion pressurizeddelivery (1- to 2-atrn) of normal salinc iNS) {seven animals) until cardiac output was rcstorcd to bascline.

No further rnfusion was givcn, but anirnals werc followcd for two hours. A second paired group (scvcn animals) was trcatcd with SSD, 25'k NaCIlZ47o dcxtran 70, grvcn IO over idcntical time pcrrods.

Results: Both rcgimens were ablc to rcstorc cardiac output to b a s e l i n e b u t o n l y 1 . 3 t 0 . 1 m l / k g o f S S D w a s r ec l u i r ed c o m p a r c d with 31.(rt 6.3 ml/kg for NS. No delctcrious cffccts of IO infusion of SSD wcrc observed dcspite mean scrum sodium reaching 158 to I65 mEcl/L. Cardiac output was bcttcr sustaincd aftcr two hours with SSD than with NS (4.9 + 0.2 vs 3.8 t 0.3 L/rnin).

SSD also maintained portal vcin blood flow better than NS (530 + 10 vs 370 t l0 ml/min), but fernoral artcry blood flow was better maintaincd with NS (98 t 26 vs (r[i1 2(r rnL/min), Conclusions: Intraosscous SSD can cffcctivcly trcat hypovolemia and may allow ficld trcatmcnt whcn logistic considcrations makc conventional resuscitation impractical.

a Aq, I AL

a '!'.f i i I

VersusMeperidine Methotrimeprazine in the Treatmentof and Dimenhydrinate SevereMigraine:A Randomized ControlledTrial

l G S t i e l l ,D G D u t o u r , D M o h e r , M Y e n , W J B e i l b y , N A S m i t h / D e p a r t m e n tosf E m e r g e n c yM e d i c i n ea n d R e s e a r c ha n d t h e P h a r m a c yD e p a r t m e n to f o t t a w a , o t t a w a , 0 n t a r i o , C a n a d a Study objcctivc: To comparc thc cffcctivcncss of IM admrnistration of rncthotrimcprazinc, a non-narcotic, nonaddicting phcnothiazinc dcrivativc, with that of a combination of mcpcridrnc and dimcnhydrinatc in the trcatmcnt of scvcrc migratnc.

Dcsign: Doublc-blind, randomizcd, controllcd trial.

Sctting: Univcrsity hospital cmcrgcncy dcparttncnt.

P a r t i c i p a n t s :C o n s c c u t i v c , c l i g i b l c a d u l t p a t i c n t s w i t h mlgralnc.

Intcrvcntions: Random allocation to rcccivc IM inicctions of cithcr 37.5 mg mcthotrimcprazinc or 75 rng rnepcridinc comb i n c d w i t h 5 0 m g d i r n c n h y d r i n a t c ,R c s u l t s :T h e 3 7 p a t i c n t s i n cach group who cornplctcd thc study wcre similar for all dcmographic and clinical characteristics. There werc no statistical diffcrenccs for pain intcnsity onc hour after treatmcnt, change in pain intensity, or pain relief as measured on a visual analog s c a l e , n e c d f o r a d d i t i o n a l a n a l g e s i a ,p e r s i s t e n c e o f n a u s e a o r vomiting, adverse effects, or follow-up status, except for prolongcd drowsiness in the group receiving methotrrmeprazine, Conclusion: Methotrimeprazine is an effective, nonaddicting, IM alternativc to narcotics for the management of severe mlgralne.

Resuscitation of CanineHemorrhagic Hypotension WithLargeVolumelsotonic Venous DoesNotIncrease Crystalloid Admixture or LungWater

PC Valko,PEDowns,SS Hull WHBickell,MR Jenkins,SM Barrett, s o s p i t aTl ,u l s a , J r l D e p a r t m eonl tE m e r g e n cMye d i c i n eS, t F r a n c i H of Emergency 0 k l a h o m a0;U H S CD e p a r t m e not IsS u r g e r yS, e c t i o n , dB i o p h y s i c 0 s ,k l a h o m a M e d i c i n eA,n e s t h e s i o l o gPyh,y s i o l o gay n C i t y ,0 k l a h o m a Studyhypothesrs: After hcmorrhagichypotension,rcinfusion of the shedblood with threefoldthat volumc of lactatedringcrs (LRI will significantlyincreaselung water and vcnous admixsystemicartcrialPO2. ture and hencedecrease Model:Eighteenanesthetized dogssubiecledto fixed volumc hemorrhage.

Methods:After a 40-ml/kg blood withdrawal through a femoral artery catheter, the dogs were randomized to the control group (nine),which receiveda reinfusion of the shed blood, or the LR treatmentgroup(nine),which receivedan IV mixture of the shed blood plus 120 ml/kg of LR. Results:After fluid resuscitation,pulmonary artery wedge pressure(PWP),cardiac output (CO),and mean arterialpressure{MAP) were signrficantly increasedin the LR group comparedwith control animals ( P W P 1, 8 . 7+ 1 . 1v s 1 3 . 4 ! 2 . 9m m H g ; C O , 8 . 1 4t 1 . 0 8v s 4 . 5 9I 0.47 Llmin; MAP, i35 + 6 vs I21 + 9 mm Hg; P . .05 each).

However, venous admixture, systemic arterial PO2, and lung water were similar betweengroups.

Conclusion:In this fixed volume hemorrhagemodel, hemodiluting the reinfusedblood with threefold the volume of LR does not significantly affect lung water, venous admixture, or systemic arterial PO2.

a iQ f -f,

emergency department require observation for a period of 12 to 24 hours bccause of the dangers of recurrent narcotic-induced rcspiratory depression and the delayed onset of pulmonary edema.

Study hypothesis: This is incorrect, and after reversal of an IV narcotic ovcrdose with naloxone, most patients who arc awakc and alert without signs of pulmonary complications can be safely discharged from thc ED after a short (two- to fourhour) observation period.

Mcthods: We revicwed the hospital and emergency medical services IEMS) records of 124 visits involving IV and illicit (eg, heroin) overdose for a five-month period. Of thesc, there werc five deaths in the ED, l2 hospital admrssions, and 107 patients w h o w c r e d i s c h a r s e d .W c a l s o r e v r e w e d t h e d c a t h c e r t l f i c a t e s o f ll5 persons having succumbed to a narcotic overdose during a 45-month penod and comparcd them with our hospital rccords.

Rcsults: Seventy-cight percent of paticnts transportcd by EMS for treatment of hcroin overdosc wcrc transported to our hospital; rlnly 22"k wcrc transported to one of the six othcr hospitals in our city. Neither dclaycd onset of pulmonary cdcma n o r r c c u r r e n c c o f r c s p i r a t o r y d e p r e s s i o nw a s o b s e r v c d .

Conclusion: Ovcrdose is a signrficant cause of morbiclity and rnortality resulting from thc abusc of IV narcotics. Admission a r - r dp r o l o n g e d o b s e r v a t i o n a r c n o t n e c e s s a r y { o r p a t i c n t s w h o arc awakc, alcrt, and lacking cvidcncc of pulmonary complications aftcr an IV narcotic overdosc.

Placebo-Controlled A Double-Blind, EfficacyStudy of IntranasalButorphanol Meperidine in the and Intramuscular AcuteTreatmentof Migraineand Severe Headache RShesser, RRosenthal, J Smith, KGhezzi, J J Scott,M Smith, Y Haywood, Petterson, M Hunt, C Feied, S Sanlord/George Washington, DC Washington University, a rf AE r r,

Study objective:To assessthe effectivenessand safety of transnasalbutorphanol for the treatment of migraine headache pain.

Participants:Seventy-sixpatients with headachessevere enough to require narcotic analgesics.Patientswith a history of trauma or a suspicionof seriousintracranial pathologywere not included.

Design and intervention: A randomized,prospective,doubleblind placebo,controlied study. Patients were randomized and receivedincremental dosesto a total of 3 mg transnasalbutorphanol, 75 mg IM meperidine,or placeboadministeredin a double-blind fashion. Using a visual analog scale and a descriptive

ls AdmissionFollowinglV Narcotic OverdoseNecessary?

DA Smith,L Leake,JR Loflin/Texas TechUniversity HealthSclences of Emergency Medicine,El Paso,Texas Center,Department B a c k g r o u n d :M o s t t e x t b o o k s a n d a u t h o r i t i e s s t a t e t h a t patients with an apparent narcotic overdosepresenting to the

56

five-point Likert scale, patients and a blinded observer assessed the initial pain response to medication, side effects, and global rmpression of the efficacy of each medication. If adequate pain relief was not achieved within 30 minutes, the patients were rescued with one of several other narcotic analgesrcs.

Results: Twenty-six patients received transnasal butorphanol, 24 received IM meperidine, and 26 received placebo.

Patients' overall global impressions were, on the Likert scalc, 3.12 for transnasal butorphanol, 3.21 |or IM meperidinc, and 2.23 for placebo. Both of these differences for butorphanol and meperidine were statlstically signi{icant at the P < .05 level.

The observers' global impressions were 2.92 for butorphanol, 3.21 for meperidine, and 2.31 for placebo. One hundrcd percent of patients receiving transnasal butorphanol reported at least one side effect versus 92% oI patients receiving mepcridine and 69% receiving placebo. The most common sidc cffccts were dizziness (butorphanol, 54%; mcpcridine, 371'; and placebo, l9%), drowsiness (butorphanol, 69'k; meperidine, 62"h; and p l a c c b o , 3 l % ) , a n d a d r s a g r e e a b l ct a s t e ( b u t o r p h a n o l , ( 7 3 ' / " ; meperidine, l2'k ; and placebo, 27 %).

Conclusion: We conclude that transnasal butorohanol is an c f f e c t r v e a n d s a f e m e t h o d o f r c l i e v i n g p a r n i n t h i em e r g c n c y department. Its efficacy is comparable to that of IM meperidinc, and differcnt from meperrdine, its only major sidc effect is rclated to the taste of the medication after transnasal adrninistration.

Participants: All patients more than 18 years old presenting to l2 community and university- based hospitals within three hours of ICH onset were included. Patients with isolated subarachnoid hemorrhage and trauma were excluded. Informed consent was obtained.

Methods: A CT was obtained at ED admission zero hour and at one and 24 hours. Blood pressure and GCS were recorded by emergency rnedical services and at one, three, six, 12, and 24 hours. Use of intubation and antihypertensive medication were recorded. CTs wcrc compared visually {or signs of ICH growth at one hour (ICH S). Data were analyzed using two-tailed Studcnt's I tcst and Xz tests.

Results: Fifty patients were entered during a 22-month pcriod. Thirteen patients (26%) showed ICH growth at one hour.

ICH-C paticnts had significantly lowcr one- and 24-hour GCS and srgnificantly higher rnortality.

GCS I hr CCS24 hr Mortality

ICH Growth

No ICH Growth

l l . 8r 4 . 5 7 . 3t 4 . 7 62"/"

I Z . t! 2 . 6 I 0 . zr 3 . 9 23%

P

.005 .oz .0s

Thcrc was no signrficant diffcrcnce in systolic or diastolic blood pressurc bctwccn patients wrth anci without ICH growth at any timc interval. Thirty pcrccnt of patients rcquired intubatron within 24 hours of ED arrival, and 63"/uof all patients rccluiring intubation wcre intubated within thc first threc hours.

Twcnty-six percent of paticnts required antihypertcnsive medrcation within onc hour of prcscntatton, and 55% within thrcc hours.

Conclusion: Early hcmorrhagc growth occurs in morc than 25"1' of all patients with ICH and is associatcd with a significantly lowcr GCS at onc hour. Morbidity at 24 hours (as a s s c s s e db y t h c 2 4 - h o u r G C S ) a n d t h r c c - w c c k m o r t a l i t y w c r c significantly greater in ICH with early hcrnorrhagc growth. The majority of paticnts rccluiring intubation and blood prcssurc r - n a n a g c m c n tn e c d e d i n t c r v c n t i o n w i t h i n t h e f i r s t t h r c e h o u r s o f prcscntation.

146i:il"1liJ;,;*?'L:':1""ffi :iii"Tll,il"!"o",.

Injury R A S c h w a b ,R D P o w e r s / D i v i s i o no f E m e r g e n c yM e d i c i n e , U n i v e r s i t y o f V i r g i n i aH e a l t hS c i e n c e sC e n t e r ,C h a r l o t t e s v i l l e V,i r g i n i a Study hypothesis: Thc prcvalencc of folatc dcficicncy in alcohol-abusing emergcncy departrncnt paticnts docs not diffcr 'Ihc from that of the general ED paticnt population. practicc of administering empiric folatc therapy to ED patiollts with alcoh o l - r e l a t c di l l n c s s o r i n j u r y i s u n n c c e s s a r y .

D e s i g n : P r o s p e c t i v e ,n o n c o n s c c u t i v e c a s u s c r i c s w i t h r a n domizcd controls.

Setting: University hospital ED. Participants: Patients prescnting with alcohol-rclatcd illncss or injury with alcohol as a cofactor and rcquiring vcnipuncturc wcre eligiblc. Exclusion criteria includcd prior entry into study, documented folate administration withir-rprior four months, and no venipuncture rcquircd. Intcrventions: RBC folatc and CBC were mcasurcd in all paticnts. Dietary and alcohol histor i c sw e r c c l i c i t c d f r o m a l l p a t i e n t s .

Results: Nincty-five paticnts wcrc cnrollcd in thc study; two wcre cxcludcd from analysis for insufficicnt data, ancl onc was cxcluded for prior folatc administration. Two of 43 study p a t i c n t s 1 4 . 6 ' l , l a n d o n e o f 4 9 c o n t r o l s ( 2 . 0 u 1 ,w ) c r c f o r - r n dt o b c folate dcficicnt {NS, P > .5 X2,95"/" confidcncc intcrvals, -4.ti,2, to 10%).

Conclusions: Thc prevalcnce of folatc dcficicncy in ED patients with alcohol-related illncss or injury is lcss than 10% and does not differ {rom that of the general ED paticnt population. Empiric folatc therapy is not indicatcd in this group of patients,

a AZ I T t

Prospective Studyof EarlyHemorrhage Growthin Patients WithSpontaneous Intracerebral Hemorrhage

R U K o t h a r i ,W G B a r s a n ,T G B r o t t ,J P B r o d e r i c k / D e p a r t m e n tosf E m e r g e n cM y e d i c i n ea n d N e u r o l o g y 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 eo f M e d i c i n e ,C i n c i n n a t i 0, h i o B a c k g r o u n d :I n t r a c e r e b r a l h e m o r r h a g e { l C H ) i s a d e v a s t a t i n g d i s e a s ew i t h a 5 0 % m o r t a l i t y r a t e . L i t t l e i s k n o w n a b o u t t h c growth or early clinical course in ICH. Study hypothesis: As many as 33% of patients prcscnting within three hours of ICH onset will show hemorrhage growth by computed tomography (CT), patients with ICH growth will have lower Glasgow Coma Scores(GCSI at 24 hours and highcr three-weekmortality, initial HTN and GCS will correlate with ICH growth, and the majority of ICH paticnts requiring intubation and antihypertensive medicatron will require them within the first three hours after oresentation.

a -fAQ. I l,

LightReflection Rheography as a Noninvasive Screening Testfor Deep VenousThrombosis

T P K u h l m a n n , C L S i s t r o m / D e p a r t m e n t so l M e d i c i n e a n d R a d i o l o g y , D i v i s i o no f E m e r g e n c yM e d i c i n e ,U n i v e r s i t yo f V i r g i n i aS c h o o lo f M e d i c i n eC . h a r l o t t e s v i lV l ei ,r g i n i a Study hypothcsis: Light rcflcction rheography{LRR) is an cxccllcnt screcning tcst for the cvaluation of suspcctcd lowercxtrcmity dccp vcnous thrombosis. LRR is easy to pcrform; a normal tcst will prccludc the nced for furthcr testing.

Participants: Forty-cight adult univcrsity hospital cntcrgcncy dcpartment paticnts with a clinical suspicion for lowcr-cxtremity dccp venous thrombosis who wcrc having venography and/or ultrasound (US) as a dcfinitive diagnostic tcst.

Methods: Wc prospectivcly perforrned LRR on 4[J consecutivc ED patients, from May through Deccmber 1990, who were schcduled to have cmergcncy US and/or VC to evaluate for possiblc acute deep vcnous thrombosis. LRR was performcd immcdiatcly beforc US and/or VG on patients who could sit and perform active repctitive ankle/foot dorsiflexion. The spccificity, sensitivity, and confidence levels were determined for LRR in relation to US and/or VG (LRR-Io-US/VG).

Rcsults: Forty-eight patients had LRR: 48 had US, tcn had US and VG, and thrce had VG alone. In those cascs in which both US and VG were performed, US results agrced with VC results in all except onâ&#x201A;Ź casâ&#x201A;Ź; the one abnormal US with a normal VC was due to technical difficulty during the US. LRR, per g r a p h a p p e a r a n c e ,w a s n o r m a l i n 2 8 a n d a b n o r m a l i n 2 0 . L R R and US/VG were normal in 28; LRR was abnormal and US/VG was normal in nine; LRR was normal and US/VG was abnormal in none; and LRR was abnormal and US/VG was abnormal in 1l . N e g a t i v e p r e d i c t i v e v a l u e w a s 1 0 0 % ( 9 5 " / . c o n f i d e n c e i n t e r vals [CI] 88% to 100%], sensitivity was 100% (95% CI, 83% to 100%), specificity was 76% (95% CI, 59% to 88%), and positive predictive value, 55% 195%CI 32"/"to 77%1.

Conclusion: LRR is an excellent screeningtool for the evaluation of lower-extremity deep venous thrombosis. A normal LRR effectively excludes the diagnosisof deep venous thrombosis. An abnormal LRR mandates clinical correlation and oossible further testins.

Conclusion: This study suggeststhat fenoldopam is a safe, effectivedrug for use in the managementof hypertensiveurgencies or emergenciesthat may have advantagesover SNP, particularly with regardto cardiac stressrelated to increasein heart rate.

DroperidolVersusHaloperidolfor ChemicalRestraintof Agitatedand CombativePatients ESchwartz/Department ofEmergency Jr,RPetrilli, H Thomas a AO I +-,

M e d i c i n e ,B o w m a nG r a yS c h o o lo f M e d i c i n e ,W i n s t o n - S a l e mN, o r t h C a r o iln a

.151

Study objective: To compare two related pharmacologic agentsfor chemical restraint of agitatcd and combative patients.

Desrgn and setting: A randomized, double-blind, prospective study of adult patients rcquiring physical restraint presenting to a university hospital emergcncy department during a ninemonth period.

Participants: Fifty-eight violent or agitated adult patients, who in the opinion of the attending physician would benefit from chemical rcstraint to protect the patient or staff and expedite evaluation. Patients known to be allereic to either of the study drugs were excluded as wcrc patients given other psychotropic medications.

Intervention: Twenty-six participants wcre grven 5 mg haloperidol: 21 IM and fivc IV. Thirty- two patients wcrc givcn 5 mg droperidol: 25 IM and seven IV. Thc routc of administration was at the discretion of the physician.

Results: All patients werc ratcd on a five-point combativeness scale at fivc, ten, 15, 30, and (r0 minutes after thc study drug was given. Vital signs were also recordcd at thcsc timcs.

Results were analyzed by a Mann-Whitncy t-l test. IM dropcridol dccreascdcombativeness significantly morc than IM h a l o p c r i d o l a t t c n ( P = . 0 0 6 ) , l 5 l P - . 0 1 2 1 ,a n d 3 0 ( P = . 0 5 4 ) m i n u t e s . T h e r c w c r e n o s i g n i f i c a n t d i f f c r e n c e s a t f i v e ( 1 )= . 4 3 ) o r ( r 0 {P = .98) minutcs. There were no significant diffcrcnces in vital signs. One patient who received haloperidol had an acutc dystonic rcaction 24 hours after receiving the drug.

Conclusion: In equal doses {5 mg}, IM dropcridol rcsults in morc rapid control of agitated patients than halopcridol, without any increascin untoward effects.

. RF l e i s h e r / D e p a r t mo ef M n te d i c i n e DS Nelson,K W a l s hG (Emergency l ,o s t o n M e d i c i n eC ) ,h i l d r e n H ' so s p i t aB

A Comparisonof lV FenoldopamVersus SodiumNitroprussidein the Management of HypertensiveUrgenciesand Emergencies LMDunbar, A Shayesteh, TWDyer/Department of Medicine, Section {

Spectrumand Frequencyof Pediatric lllnessPresentingto a General CommunityHospitalED

En r rrl,

o f E m e r g e n c yM e d i c i n e ,L o u i s i a n aS t a t eU n i v e r s i t yM e dj c a l C e n t e r ; C h a r i t yH o s p i t a lo f N e w 0 r l e a n s ,N e w 0 r l e a n s ,L o u i s i a n a

Study objective: Knowledge of the pediatric illnesses seen in a general emergency department influences the decision to add pediatric emergency physicians to the staff. Our study provides a detailed description of the pediatric population served by one generalED. Design: A retrospective review of the general ED log entry of all patients less than l9 years old seen during four one-week periods in 1990. Patient age, chief complaint, diagnosis, arrival t i m c , s c a s o n ,a n d d i s p o s i t i o n w e r e e x a m i n e d .

Setting: Framingham Union Hospital in Framingham, Massachusetts. Its general ED has 48,000 ED visits annually and pediatric staffing from I 1:00AM to I 1:00 PM daily.

Participants: Eight hundred seventy-eight pediatric patlents were seen during thc study (23% of total); complete information was obtained on U74of these patients.

Interventions: None.

Results: The mean patient age was 7.9 ! 6.ZZ fears; Ilo/o were less than I ycar old, and 35% were 12 years old or older.

Injury, fcver, and rcspiratory distress were the three most comrnon chicf complaints, accounting ior 4lo/o, l1% and 7"/" oI vrsits. Thc frcclucncy of injury rose with age, from 5% for those lcss than 4 months old to 57% for those more than 13 years old.

Thc threc most frequent diagnoses were minor trauma/ otitis rncdia, and viral upper respiratory infection, present in 42%, 9'h, and u% of cases.Minor trauma comprised sprains (37%), l a c c r a t i o n s 1 2 7 " / o lf,r a c t u r e s { 1 5 % } , a n d m i l d h e a d t r a u m a 1 1 1 % ) .

Scizurcs, asthma, and abdominal pain had the greatest admission ratcs 129f,,,14%, and l4%li the overall rate was 3.8%.

Paticnts lcss than I year o1d were admitte^d more frequently than those morc than I year old (P < .05 Xz|. Admission rates varied significantly with time of arrival, irom 3.3% during dqy/cvening shifts to 8.6% from midnight to 8:00 AM lP < .05

x"l.

Conclusion: We conclude that the large number of children seenin the gencralED and the variety and severityof illnesses support thc role of pediatric emergencyphysiciansin the general ED. Training for thesephysiciansshouldemphasizethe managementof trauma becauseof its frequencyamong pediatric patlcnts.

Study hypothesis: Fcnoldopam is a ncw agcnt with dopamine-l receptor agonist activity that promises to be an cffective agent for the managemcnt of hypcrtcnsivc urgcncics and emcrgcncies.

Dcsign: This is a prospectivc, open-labcl study in patients with severe hypertension (diastolic blood pressureof morc than 120 mm HgI randomizcd to receive either IV fcnoldoparn or sodium nitroprusside (SNP).

S e t t i n g : T h e e m c r g e n c y d c p a r t m c n t < - raf l a r g c i n n c r - c i t y h o s pital with subsequent admission for two days for follow-up and c o n t r o l < - rbf l o o d p r e s s u r eo n o r a l m e d i c a t i o n .

Participants: Thirty-two patients l1(r in each group) betwcen 2l and U0 years who met blood pressurc and conscnt rcquircments and had none of the exclusions. Thirty patients completcd thc study with one treatment failure in each group. Groups w e r e e q u a l i n a g e ,g e n d e r , a n d b a s e l i n e b l o o d p r c s s u r e .

Intervention: Blood pressurewas titrated to a diastolic valuc of 95 to ll0 mm Hg or a reduction of 40 mm Hg if initial pressure exceeded 150 mm Hg. After six hours, the infusion was d e c r e a s e do v e r t w o h o u r s a n d o r a l m e d i c a t i o n w a s s t a r t e d .

Rcsults: Both antihypertensive agents successfully controlled the blood pressure in I5 of I6 patrents with no significant difference in rapidity of blood pressurecontrol or final press u r e s .T h e g r o u p t r e a t e d w i t h S N P s h o w e d a s i g n i f i c a n t i n c r e a s e in heart rate compared with the fenoldopam-treated group {P < .002). Multiple regression analysis of the data confirmed this finding. Electrocardiographic evidence of myocardial ischemia m a n i f e s t e d a s n e w o r i n c r e a s e dS T s e g m e n t d e p r e s s i o no r i n v e r sion of T waves was seen in six of the SNP-treated oatients and two of the fenoldopam-treated patients. In all but iwo patients (one in each group), these changes were associated with marked increases in heart rate. There were no maior adverse events in either group.

rate sedati on 1 52 i"1"il,?l llr"t

RMKulick,ESPomeranz, EGuz/Department of Pediatrics, Pediatric A m b u l a t oCr a y r eS e r v i c eUsn, i v e r soi tfyM i c h i g aA nn , nA r b o r Study objective:To describethe patternof use,efficacy,and complicationsof chloral hydrate(CH) in a pedratricemergency department.

Design: Descriptive,retrospectivechart review coveringa 20-monthperiod. pediatricED. Setting:University-based Participants:One hundredfifty-sevencasesof CH Administration {150 patients)were idcntifiedby a controlledsubstance log. Ten caseswere excludedbecauseeither CH use could not b e c o n f i r m e do r a n o t h e r s e d a t i v ew a s u s e d b e f o r eC H . T h e remaining147casesformedthe final studygroup.

Results:Mean patient agewas 28.4 months (range,I month to l4 years),and 67.4Y"presentedwith acute neurologicprobpotential ventriculems including closed-headrn):ury127.9%1, Ioperitonealshunt malfunction (21.8%),and seizures117.7%1. respiraChronic medicalproblemsincludedneurologic127.9%), tory |,3.4%), and cardiac(0.7%lproblems.When recorded,presedepressed dation mental status was judgedas normal 179.4%1, 110.3'/'),or agrtated(10.3%).Sedationwas used for nonpainful proceduresincluding computed tomography scan177.67"),dtrasound (2.0%),magneticresonanceimaging ll.4%1,EEG ll.4%1,

58

and bone scan (1.4%).Painful proceduresaccountedfor only 13.6%.The mean initial CH dose was 54.8 mg/kg {SD, 16.4 mg/kg; range, 14.5 to 102.3mg/kg).The maximum initial total dosewas 1,800mg, given orally or rectally. Supplementalsedation was required in 15.7"/o.Overall, procedureswere successfully completed in 98.6% (139 of lal). Imaging studies were of goodquality in 98.3% {ll8 of 120).There were no major respiratory or cardiovascularcomplications. Minor complications included prolonged sedation ll.4%l and agitation lO.7T"l.

Conclusion: CH appearsto be a safe and effective sedative over a wide dosagerange for a broad spectrum of pediatric patients in the ED. It is particularly useful for inducing sleepin children undergoing nonpainful imaging studies requiring prolongedmotionlessperiods.

decreasedtheir preintubation heart rate approximately30% during intubation. One patient had a branchial aspiration detected during intubation, two died in the ED, and one in the hospital, none due to causesattributable to the RSI. VEC appearsto be a safeparalytic agent and gives appropriateintubating conditions for RSI techniquein pediatric trauma victims.

The lllchild with a VP Shunt: lnfection.Obstruction.or Normal Function?

Pediatrics, MDBaker/Division ol General CMMcAneney,

Study hypothesis:Selectedfebrile infants 28 to 89 days old may be managedas outpatientsusing IM ceftriaxone.

Design: Thirty-nine-month prospectivecohort study with seven-dayfollow-up.

Setting:Urban emergencydepartment.

Participants:Five hundred three infants 28 to 89 days old with fever of 38C or more who were nontoxic, had no sourceon physical examination, peripheralWBCs oi less than 2O x 1091L, cerebralspinal fluid WBCs of less than l0 x 106/L, negative urine WBC esterase,and caretakeravailableby telephone.Four hundred ninety-four{98%) had a follow-up evaluationand IM ceftriaxoneat 24 hours.

Intervention: A{ter obtaining blood, cerebralspinal fluid, and urine cultures, the febrile infants received50 mg/kg IM ceftriaxone. Febrile infants went home, returned for IM ceftriaxone24 hours later, and had telephonefollow-up on days 2 and 7.

Results:Twenty-ninefebrileinfants{5.%)had seriousbacte,?4.2%) did not. rial infectionsidentifiedduring follow-upi474 The infants with seriousbacterial infections had higher temperpercentband forms atures(39.0+ 0.6 vs 38.7 t 0.6 C, P = .O21, 17.I ! 6.2% vs 4.2 + 4.9o/",P= .003),and absoluteband counts ( 0 . 7 8i . 7 3 v s 0 . 4 4 + 0 . 5 8 x l } g l L , P = . 0 0 3 |t h a n t h c i n f a n t s without seriousbacterialinfections.OI the 29 febrile infants with bacterialfoci, nine (1.87')had bacteremia{two caseseach group B Streptococcusand Escherichiacolil one caseeach,Naoplastic meningitis, Salmonella sp, Streptoccuspneumctniae, Staphylococcusaureus,and Haemophilusinfluenzae type B.l One infant had a urinary tract infection with E coli bacteremia.

Nine had simple urinary tract infections.Ten had bacterial gastroenteritiswithout bacteremia(eightwith Salmonella,and one eachwith YersiniaandCampylobacterl.Twofebrileinfantshad pertussis.At follow-up, seven of the nine bacteremicinfants w e r e a f e b r i l e ;a l l h a d s t e r i l e c u l t u r e s a n d w e r e g i v e n i f u l l c o u r s eo f a n t i b i o t i c t h e r a p y .T h e i n f a n t w i t h S a u r e u s b a c teremia had osteomyelitisdiagnosedone week after initial visit, w a s h o s p i t a l i z e d ,a n d w a s s u c c e s s f u l l yt r e a t e d .O f t h e t e n febrile infants with bacterialgastroenteritiswithout bacteremia, nine were followed at home and one was hospitalizeddue to b l o o d y d i a r r h e aw i t h o u t d e h y d r a t i o no r t o x i c i t y . T h e e i g h t febrile infants with urinary tract infections were well with sterile culturesat follow-up.The two febrile infants with pertussis were admitted six to 15 days after study entry due to severe spells of coughing.Of the remaining 474 febrile infants without a bacterialsource,453 ,95.6'/")were managedas outpatientsand w e r c w e l l a t s e v e n - d a yf o l l o w - u p . T w e n t y - o n e 1 4 . 4 % lw e r e admitted to the hospitalfive hours to ten daysafter study enrollment and had uncomplicated less-than-72-houradmissions.

Conclusion: For nontoxic febrile infants 28 to 89 days old, who after a full evaluation for sepsisdo not have a bacterial sourceidentified by physical examination or screeningIaboratory tests,outpatient managementwith IM ceftriaxoneand adherence to a strict follow-up protocol is a safealternative to hospital admission.

,r{ E2 f rrr,

Hospitalof Philadelphia, Emergency Medicine,TheChildren's Philadelphia, Pennsylvania Study obiective:To identify factors that can help to separate VP shunt-relateddiseasefrom nonshunt-relateddiseasein children.

Methods:We retrospectivelyreviewedthe medical recordsof 167 visits of acutely ill children VP shunts. Final diagnosesin thesepatients included mechanicalshunt dysfunction (MSD) { s h u n t o b s t r u c t i o n , 8 3 p a t i e n t s ; s h u n t d i s c o n n e c t i o n ,t e n patients,and shunt malfunction, eight patients),brain tumor {BT}(sevenpatients),shunt infection (SIl(15 patients),and nonshunt disease(NSD) i44 patientsl.

Results:SI patients were more often febrile by report and had observedshunt site erythema or had more irritability than other patients with or without VP shunt-relateddisease.BT patients more often reported dizzinessand exhibited focal neurologic f i n d i n g s .B T a n d M S D p a t i e n t s w e r e m o r e l i k e l y t o r e p o r t headacheand to be afebrile or have no obvious sourcc of infection on examination. Otherwise, MSD patients were not distinguishablefrom other groups.NSD patients were more likely to havehad observedseizures.

Conclusion: Although there were historical and physical findings that more often occurredin difierent diagnosticgroups of shunt patients, neither the presencenor absenceof any individual historical or physical finding specificallydistinguished shunt-relatedfrom nonshunt-relateddisease.

a E i I rt'!

for Evaluation of the Useof Vecuronium Endotracheal Emergency Department in Pediatric TraumaVictims lntubation

Hospital,Miami, FAMedina/Emergency MiamiChildren's Services, Florida Prospectiveinformation was obtained during 24 consecutive months on the safety, difficulties, and observationsof all the pediatric trauma patients requiring the use of vecuronium bromide (VEC)for a rapid sequenceintubation (RSI)technique in a pediatricemergencydepartment.Twenty-thrce patients were enrolledinto the study; mean agewas 76 months, and the maleto-femaleratio was l8:5. The mechanismof trauma was motor vehicle accident-pedestrian,l2; motor vehicle accident-passenger,five; head trauma, five; and gunshot, one. PediatricTrauma Scorewas 10 or more, six;4-9,11; and lessthan 4, six. Glascow ComaScorewas ll-15, seven;7-10,eight;and 3-6, seven. Indicationsfor intubation were head trauma with abnormal neurologic examination, l7; abnormal respiratorystatus, five; and hypovolemicshock, one. Mean time for intubation after anival to the ED was 25 minutes. Fourteenunsuccessfulfirst attempts without medication were made. The route of intubation was oral with cervical-spineimmobilization. Mean doseof VEC was 0.15mg/kg. Mean time of intubation iafter VEC was given) was I76 seconds. Successfulintubation was assessed by visualizing the tube going through the vocal cords,chest breath sounds,and pulse oximetry. Successrate on first laryngoscopywas l5 patients,second,seven;and third or more/ one. No patient sufferedupperor lower airway trauma and all were kept with pulse oximetry above 95% during the procedureand between a t t e m D t s .S e c o n d a r ve f f e c t s i n c l u d e d t h r e e o a t i e n t s w h o

OutpatientManagementof Febrile Infants 28 to 89 Days of Age With lM Ceftriaxone 0fEmergency EJO'Rourke/Divisions MNBaskin, GRFleisher, Boston; Hospital, Disease, Children's Medicine andInfectious School ofMedicine, Harvard University Deoartment ofPediatrics, Boston {

EE, f rrr,

.1

56

l:?iJli

,"nrrrness andtherrauma

DPMilzman, BRBoulanger, CASoderstrom, CMMagnant/Maryland Maryland; Medical Baltimore, lnstitute forEmergency Services, Hospital, University, University Georgetown Georgetown W a s h i n g t oDnC, of the effect Background: Thereis an increasingawareness

chronic medical conditions have on trauma patient outcome.

Prior studies have relied on discharge diagnoses to identify preexisting illness (PEI).

Study objective: In retrospective review, PEI on admission were deiined using speci{ic historical, physical, and laboratory criteria to more accurately determine the occurrence and the effect on outcome that chronic medical iliness may have.

Participants: AII 7,798 adult trauma patients presenting to our Level I trauma center between July 1986 and fune 1990.

Results: Sixteen percent of patients had one or more PEI was 11,246). Hypertension accounted lor 48"/" o{ the PEIs and found in 7:f% 1597)of all patients, followed by pulmonary disease 3.77o 1286), cardiac disease 2.9'/" 1233J,and diabetes 2.5% (198). Trauma patients with PEI had a significantly higher fatality .rt. - g.Z% compared with 3.2% (P < .00) for patients without PEI. The two groups were well matched with no difference demonstrated for mean Injury Severity Score or Glasgow Coma S c o r e- 1 5 . 7 a n d 1 3 . 9 f o r p a t i e n t s w i t h P E I v e r s u s l 5 ' 6 a n d 1 3 . 8 with no PEI, respectively (P = .98); 41.6% of those with PEI were more than 55 years old; and 71.9% without PEI were less than 35 years old. The fatality rates remarned significantly elevated for'all age groups with PEI compared with matchcd ages withOUtPEI. Conclusion: There is a significant effect of PEI on the outcome of trauma patlents. These findings suggest that changes to existing prehospital triage criteria and modifications to traum a o u t c o m e p r e d i c t i o n s c o r e sa r e n e e d e d .

a Ra f r, t

Effectof EthanolonBrainIniuryin a HeadIniury PorcineFluid-Percussion

Model andSurgery, Medicine of Emergency BJZink,P Feustel/Department e ,l b a n yN,e wY o r k A l b a nM y e d i c aCl o l l e g A Study obicctive: To investigatc thc effects o{ cthanol intoxication on brain injury in a porcinc fluid-percussion model' Dcsign: Immaturc swine, unclcr halothane ancsthcsia, had a measured hcad iniury delivcrcd with a fluid-percussion dcvice Paramcters followed for threc hours. After head iniury includcd mean arterial blood prcssure (MAP), ICP, artcrial blood gascs, and serum lactatc. Radioactivc microsphcres wcre injected via a left ventricular cathetcr for ccrebral blood flow dctermination.

After formalin pcrfusion and brain removal, thc degrcc of subarachnoid hemorrhage was graded.

I n t e r v en t i o n s : T h c e x p e r i m e n t a l g r o u p ( f i v e ) r e c e i v c d 3 . 5 g/kg ethanol via gastric tube. Control animals (fivc) reccivcd n o r m a l s a l i n e.

Results: The avcrage cthanol level at (r0 minutes aftcr head injury was 221 mg,Y". Results, using thc two-tailed t tcst, arc s u m m a r r z c d l T a h l c l ; S D s a r e g i v c n i n p a r en t h c s c s .

Parameter H c a di n j u r y { a t m ) MAP at I50 rnin (mm Hgl P o s t - i n j u r ya p n e a( m i n ) I C P a t 6 0 m i n { r n mH g ) I3asilarhcmorrhagescore

t

P

Control

Ethanol

2.5(0.rrl 90 {tt) 0 . s( 0 . 4 7 1 1 4( n ) I.(r11.ll

NS 0.(r 2 . i t( 0 . 7 ) 5..1(r < 002 s9 {9) < .01 1 2 . 2{ s . 3 ) 4 . 9 s NS 0.s zr \27\ l0 2.u{0.s) L.l9

C o n c l u s i o n : E t h a n o l i n t < - r x i c a t i o n i, n t h i s h e a d i n j u r y m o d e l , leads to increased postinjury apnea, decrcased blood pressure, and possibly increiscd brain injury. Ccrcbral blood flow data arc penolng.

.1 5I T''"ix5L:i,ili":'ff S"iliffi ii#:t Alcohol Intoxication ol New BJSkipper/University PJMcFeeley, DPSklar, D Nelson,

c ye d i c i n e , e ,i v i s i oonl E m e r g e nM M e x i cS o c h o oolf M e d i c i nD A l b u q u e r qN u e ,wM e x i c o

Studv obicctive: To determinc the relationship among alcohol use, helmet use, and cthnicity in people killed on motorcycles.

Design: Retrospective review of all motorcyclc fatalttics in New Mexico from 1984 though 1988.

Interventions: Review of all autopsies, medical investigator reports, traffic fatality reports, and toxicologic studies on fatally iniured motorcyclists.

Results: Nine of the helmeted drivers {18%} were legally

intoxicated comparedwith 67 (51% ) of the nonhelmeteddrivers lxz,15.7, P < .0001),37o/ooI white non-Hispanics,.l2%of Hiqpanics,and 0% of Native-Americanswere wearing helmets (X2, lg.g3i P < .0002).The head and neck region was the most severelyiniured body region rn 42 oI the nonhelmetedcases i84%Jand in eight of the helmetedcases{50%} (Fisher'sexact test.P < .02). tonclusion: There is an associationbetween nonuse of helmets and alcohol intoxication in fataliy iniured motorcyclists in New Mexico. Strategiesfor preventing motorcycle fatalities should addressalcohol abuseand ethnicity in coniunction with helmet use.

*o .1 5 I LrJ*$:t:?::,!

H:3ff:nolf With PancuroniumVersus Fasciculations Mini-DoseSuccinYlcholine

lrvineMedicalCenter,Highland of Californla KL Koenig/lJn:ersity H o s p i t aO l, akland Background:Fasciculationsduring-rapidscquenccintubation may leadto increasec {RSII ' intracranialpressureand emesis with aspiration.Standard RSI requiresa nondepolarizingblocking agent in addition to succinvlcholine,which is cumbersomein an cmergcncy Study hypothesis:Prevention of fasciculationsduring RSI of head trauma patients (HTPJcan be accomplishedas e{fectively and safcly with minidose succinylcholineas with a defasciculating dose of pancuronium, before the full paralytic dose of succinylcholine. besign: A prospecttve,randomized,double-blindstudy.

Setting:A busy {70,000patientsper year)inner-city county traumacenter.

Participants:SequentialHTPs prescntingto the emergency to sucdepartmentrequiringRSI who had no contraindications cinylcholineor pancuronium. intcrventioni: Each HTP requiring RSI who met the inclusion criteria rcceivedstandardRSI maneuvcrsand lidocaine(l mg/kg IVJ Patients were randomizedto receive either minidose (0.1mg/kgl or pancuronium(0.03mg/kg)IV one suCcinylcholine m i n u t e b e f o r et h e f u l l p a r a l y t i cd o s eo f s u c c i n y l c h o l i n e( 1 . 5 mg/kg) IV. Fasciculationswere recordedusing a gradedvisual scilc. Results:of a total of 32 patients,five of l4 (36%)in group A and four ol 18 122%lin group B experiencedfasciculations.

No statisticallv significant differencewas detectedbetween the two groupsuti.g 12 analysis.Completerelaxationof the cords was found in all except two patients {one in each group),and only one drug-relatedcomplication was detected. bonclusions:Pretreatmentwith minidose succinylcholine causesno greaterincidence of fasciculationsthan pancuronium in RSI o{ HTps in an ED setting. Thus, succinylcholine may bc uscd as the sole paralytic agentin RSI of HTPs

SteeringWheelDamageas a Predictorof Iniury in MotorVehicle Trauma at oflllinois University ol Medicine, T Erickson/College E0rsay, {

Cn I t l,

C hi c a g o Background: For patients involved in motor vehicle crashes, knowlcdge of resultant vehicle damage may present an indication of injuries sustained.

Studv obiective: To evaluate the correlation of steering wheel damagewith injuries.

Dcsign and participants: A retrospective review of the medical rccoids of all drivers involved in motor vehicle crashes and aclmitted to a Chicago-area Level I trauma center between )uly 1989 and Iulv 1990 were reviewed for crash cntetia, presence of steering wheel damage, restraint use, length of hospital stay, and iniurv data.

Methods: Patients were separated into two groups based on steering wheel damage documentation and compared with respect to the remaining variables.

Results: Of the 236 patients investigated, the maiority (1,64) were male. There were no intergroup differences with regard to age, ethanol level, speed, tlme, or location istreet vs highway) of ciash. However, fewer patients in the steering wheel damage group used safety restriints. There were no significant differ-

encesbetween groups with respect to mean Iniury Severity Score(9.3 + ll.2 vs lO.2 + 16.81,highest AbbreviatedIniury Scale{AIS)in any body region (2.1t l.l vs Z.I t 1.41}, or.ir.rt AIS (1.2+ I .3 vs 0.9 t l.2l for patientssusrainingsteeringwheel damagecomparedto those without steeringwheel damalge.The correlation coefficientsbetween steering wheel damaigeand chest,abdominal,and head injuries were nonsigniflcant (_.t23,_ .084,and .048, respectively).The number of days sDentin a monitored unit or in the hospital did not differ among the groups.

Conclusion:The presenceof steeringwheel damageis a poor predictor.ofseverity of injury, anatoriical site of iniury,'and length of hospital stay.

tained 155 gunshot wounds and 182 stabbings. Thirty-nine wome-n(mean age,32 years)sustained23 gunshot wounds and l6 stabbings.

Total Charge

Penetrating Trauma:Society,s Burden andthe TraumaCenter'sBadDebt

HWMeislin,D Spaite,T Valenzuela, L Criss,K Mclntyre/Arizona Emergency MedicineResearch Center,TraumaCentei_ University MedicalCenter,University of ArizonaHealthSciences Center, I ucson Studyobjective:To study the financial burden of pcnerranng trauma on Level I trauma center and society,stri-rrpport.d reimbursers.

During the period from fuly lggg through September . ^P..i.gl' 1 9 9 0 ,a l l c o _ n s e c u t i vpea t i e n t s a d m i t t e d w i t h a " p e n e t r a t r n g injury to a Level I regional trauma center were studied witf, r e s p e c t o , t o t a l c h a r g e so f a c u t e _ h o s p i t a l i z a t i o(ni n c l u d i n g pnyslcranchargesf,payor mix, reimbursement,and Infury Sever_ ity Score{lSS).Data were obtained from the uauma regiitry and retrospectivechart review.

Setting:Level I university trauma center servinga midsize metropolitanarea.

Participants:Three hundred forty-six consecutivelyadmitted penetratingtrauma patients.

Results:Three hundred seven men (mean age,3l years)sus_

Mean Charges per ISS Range, 17-24 25-34 35-44 45_54

>55

$2889 20,254 36,5tO t2,53t5 44,84g 36,079

Cun shots

9lt7l

20,550 35,645 t2,374 91,331 3(t,O79

6524

l9,8ZZ 39,392 12,537821,608

Payor Mix

2,973,483 t6,7O4

Total Charge

0

"/" Toaal

o/.

Charge

Reimb

GSW _ % Total

Stab_ % Total

44% 80% 26,1, 80% 24% 16"1,

2(t,% 4y" rc%, 6% t./" 47%

ZZ% ly" Oy" 0"1, ,),,/" 26,%

Mcdicaid $2,244,45t 49V,, ,15 Medicare 191,{t53 County 489,037 I I% Strtc 256,4OO 5,'/" Fcdcral 193,100 4V" Total Covt Payors $3,:174,841 73%

Ratesin North Carolina

1At I rv-

l.16

Stab Wounds 1,630,528 tO,7Z7 '.24-hour deathscxcluded.

of the AssociationBetween911 tl 61 Analysis Access and Per CapitaTrauma Death J Messick,R Ruiledge,C Baker,A Meyer/Department of I Patsey, Surgery, University of NorthCarolinaat Chapelilill . Background:Decreasingthe responsetimes for inlury should decrease the morbidity and mortalily of trauma. . S t u d y o b j e c t i v e : T h i s s t u d y a n a l y z e dt h e a s s o c i a t i o n between.county9l I accessand per capiia county trauma death ratesto determine if 9l 1 accessis assoiiatedwith decreasedper capitatraumadeathrates.

Methods: Data on all trauma deaths from l9g6 through 1988were obtained from the North Carolina medical .*r-in_ er's data base.Counties were divided into those that had 9li accessduring the entire study period{15),those that never had 911 access(621,and those that installed9ll during l9g7 (ten).

Countiesobtaining 911 accessin 1986 or Iggg were excluded lr3l.

The per capita trauma death rate in countiesthat . _Results: had 9ll accessthroughoutthe study was 5.9 t l.l per 10,000 populationversus6.9 + I.9 per 10,000population in countics t h a t n e v e rh a d 9 l l a c c e s s( p . . 0 1 ) . C o m p a r e dw i t h c o u n t i e s having9.1I ac.cess, counties without 9l l wire more rural, werc lesslikely-to have a trauma center, and were less likely to have advancedlife supportcertification(p < .08 for all). Controlling tor_theseother factors, multivariate analysisdemonstratedthai 9ll.accesshad no significantindependentassociationwith per c a p i t ac o u n t y t r a u m a d e a t h r a t e s .I n t h e t e n c o u n t i e s t h a t implemented9l I accessin 1982,no significantchangeoccurred in per capitacounty trauma deathratei after implementationof 9ll.

Conclusion:Althor.rghcountics with 911 acccsshad lowcr traumadeath_rates-by t test, multivariate analysisshowcclno signrficantindependentassociationof 9l I accesiand pcr capita countytrauma deathrates.In the ten countiesthat implemcnt_ ed 911 accessin 1987,no significantchangesin trauma dcath ratesoccurred after implementation. alth-oush other factors may explainthcsefintlings,this study demonsiratesno srgnific a n t r n d . e p e r d e ni m t p a c t o f 9 l I a c c e s so n p e r c a p i t a c o u n t y traumadeathrates.

Mean Charge

All Patients $4,604,011$13,306

Data will be presented geriatric patients.

on suicide,

homicidc,

pediatnc,

and

Conclusion: The costs of penetrating trauma arc immense, increase with severity until the ISS exceeds 45, are borne pri_

pa.riJf.by tax basc-supported reimbursers,and are a sourceof haddcbt for traumaccnters.

1 R? I lrl,

TheRoteof Mandatory Laparotomy in Patients Witha positiveperitoneaiTap '

EPSloan, VHGelman, S Shabowski, JA Barrett/Cook Countv Hospital Trauma Unit,Program in Emergency Medicine and Departme n t 0 fS u r g e rU y ,n i v e r s o i tfyl l l i n o i s b o l l eogfeM e d i c i n e , Chicago Study,hypothcsis: A_positive peritoneal tap may not always mandate laparotomy following abdominal trauma.

Study participants: C)ne hundred conscclltivc patients who reccived a laparotomy from 1985 to l9g9 because of a positive tap {defined as thc withdrawal of any amount of blood fiom thc necdle or lavagecatheterj.

M e t h o d s : R c t r o s p e _ c t i v cr e v i c w o f p a t i c n t d c m o g r a p h i c s , p e r i t o n e a _tla p d a t a , a n d - o p e r a t i v c d a t a p i o v i d c d . r r . , . i i . i drtr, 95% confidence intcrvals (CI) arc provided.

Results: _Eighty-nine percenr of patients wcre male, with a mean age of 3l years. The trauma mechanism was 50% blunt 50.% penetrating. All of the penetrating trauma panents 3n{ had cither an injury requiring rcpaii or more tf,at 100 mL of frce pcritoncal blood or operative blood loss. A negative laparotomy, o . n cj n w h i c h n o i n j u r y w a s o b s e r v e d , w a s p e r T o r m c d i n t h r e e o i t h c b l u n t t r a u _ m ap. a t i L ' n t s 1 6 % ; C I , 0 % t r . t 2 0 % 1 . A n a d d i t i o n a l trvc parlents had unncccssary laparotomics (10%, CI, 0% to 24%). Three of thcsc fivc paticnts had pclvic hcmatomas; two had nonrcpaired livcr laccrations with lcss than 100 mL oi free pcritoncal.blood or operativc blood lcss. Overall, unneccssary laparotomies werc performcd on eight blunt trauma patients { l ( r 9 . , 9 1 , 0 7 o . t o J 0 o z o ) .O n l y o n c o f t h c s e e i g h t p a t r c n t s , w h o hacla pelvle fracturc and secondary pelvic hematoma, reccived laparotomy due to unstable vital signi.

Conclusion: While a positivc tap mandates operative inter_ ventlon ln penetratlng trauma, stabie blunt trauma patients with a positive tap may benefit from subsequent peiitoneal lavage or computed tomography, thus reducing the number of u n n e c e s s a r yl a p a r o t o m i e s .

*a

Prevalence of EthicalConfticts in the AA r lr't Prehospital Setting JGAdams.

L Siminoff, h Arnold, ABWolfson/Universitv ot Pittsburgh Affiliated Residency in Emergency Medicinei Center tor Medical Ethics, University of pittsburgfrschool of Medicrne, Pittsburgh, Pennsylvania

. Background: Ethical issues arise in many medical settings, but no empiric studies have investigated the type and {requen"cf of ethical dilemmas encountered inlhe prehospital arena. _Study obiective: To assess the prevalence and range of ethi_ cal conflicts that confront prehospiial care providers.

De;ign: Prospective convenience sample during the period , trom October 1989, to fanuary 1990.

Setting: An urban advanced life support emergency medical

servicethat transportsapproximately3,000 patients per month' Methods: Six hundred seven paramedicresponseswere analyzed by a single observer. Identification and classification of eihical'conflic-ts were carried out in coniunction with physicians experiencedin medical ethics and epidemiology. An ethical confiict was identified when a paramedic faceda dilemma "ought to be done" and the paramedic'svalues conabout what flicted or potentially conflicted with the patient's.

Resulis: Ethical conflicts arose in 14.4"/ool paramedic responses(88 of 607 casesf. Forty-for+rqercent of the conflicts inv'olvedinformed consent.Requestsfor limitation of resuscitation accounted for an additional l4%. Other situations that oresentedethical conflicts involved the roles and responsibili iies of paramedics{ll%), resourceallocation{10%f, dangerous patienti {87.f, coniidenliality (8%), truth-telling (3.4%),and t r a i n i n g( l . l % ) .

Contiusion: Prehospital care providers are frequently con{ronted with important ethical issues.These data demonstrate the rangeof ethical conflicts encounteredin one particular-prehospital setting and point to areas where emergency medical , . . u i " . r s y s t e m s m i g h t d e v e l o p g i r i d e l i n e st o h e l p d i r e c t paramedics'actionsin-the field. This information may-alsobe useful in developing an ethics curriculum {or paramedicsand emergency physicians. The applicability of these findings to otherlmerg'enly medical servicessystemsremains to be determined.

-1

period are presented:42 medical (35 cardiac and seven respiratory) '' and eight traumatic arrests.

IntervEntions:Seventyintubation attempts were requiredfor successfulintubation of 50 patients.

Results: In 9Oo/oof casei (a5 of 50) paramedicsauscultated breath sounds in the chest, whereas auscultation of breath ror'rndr itt both the chest and gastric regions occurred in l0% of successfulintubations (five of 50). In contrast, monitor color chansesoccurred in 86"/oof successfulintubations (43 of 501' fufoniiot color changesdid not occur in 14"/oof cases{sevenof including one of two casesof tension pneumothorax' 50), 'Conclusi6n: There was no significant statistical difference U.t*..n paramedicphysical exairination skills and the use of the end-tidal COc moniior. Fourteenpercentof the monitors did not changewith"successful intubation' This finding reinforces oreviousitudies that have shown that low-flow statesmay be a [i*iring factor for colorimetric confirmation of endotracheal placement.

a Ca I l, t

and of EMTJudgment Comparison TraumaTriagelnstruments Prehospital

of Emergency CL Emerman,B Shade,'JKubincanek/Department o1Surgery, MedicalCenter,Department Medicine,MetroHealth Cityof Cleveland Cleveland; University, CaseWesternReserve 0hio Cleveland, MedicalServices, Emergency of prehospital perability the Study obiective: To compare sonnel to predict mortality or need for emergency-surgerywith determinaiionsusing the'iriage-RevisedTrauma Score(T-RTS), PrehospitalIndex iPHI), and CRAMS Scale' Population: tiauma patients transported by. the Cleveland .*"tg.t "y medical services(EMS)system' All victims were included regardlessof apparentseverity or mechanism. tvtethodi Patient iniormation was collectedprospectivelyby the emergency medicine technicians {EMTs). The EMTs predicted thi likelihood of mortality and rated the severity of iniuries.Outcome was verified by review of the coroner's recordsand hospital trauma logs. EMT iudgment was compared with triage instruments by c-omparing ROC curves ior area under the curve {AUC}.

Results:There were 1,153patients with complete data (aver^ge age,32.1 years).There wis no difference in prediction of tiortitity among the PHI {AUC, 0.99),-T-RTS{AUC, 0'9911, CRAMS je'UC, O.SS),and EMT probability estimates (AUC, of need foiemergency surgery or death 0.981.EMT .ttl-rt.J (AUb, 0.94) performed as well as the PHI {AUC, 0.96) and bnarurs {AUa, 0.95) estimates,but the T-RTS (AUC, 0.90} per' formed significantly worse.

Conclirsion: Prehospital personnel perform as well as the PHI and CRAMS scale in predicting mortality and need for emergencysurgery. These results suggestthat it .is not neces,"ry iot EMS Jystems to use triage instruments in their decisions on transportto trauma centers'

Paramedic 6 5 Sff:?H5['J+?"?f:FJ,:

of RA Bethke,MC Gratton,WA Watson,GM Gaddis/Department ot MissouriMedicine,Schoolof Medicine,University Emergency Ambulance KansasCityTrumanMedicalCenter;Metropolitan SchooloJPharmacy, Practice' Trust;Divisionof Pharmacy Services City of Missouri-Kansas University Study obiective: To determine if a protocol changethat allowed-paramedicsto perform certain Proceduresbefore base station cbntact (standingorders)would decreasescene time in trauma patlents.

Design: Retrospectiverevlew.

Setting: A single-tiered, all advanced life support, public utility model emergencymedical seryicessys,tem.

Participants:All physiologicallyrlnstabletrauma patients transoortedto a Level I trauma center by ambulance.

Results: One hundred ninety seven patients met the inclusion criteria,8T before and ll0 after the initiation of standing orders.Mean scene times were similar for the control group 115.3t 8.4 minutesl and the standingordersgroup (I5.1 t 7 6 minutes) (P =.18). The power of the study to detect a twominute differencein scene time was 0.92. Scenetime was not influenced by mechanism of injury, and the number of procedures performed on patients were similar between the two groups. ionclusion: Standing orders did not decreasescene time in physiologically unstable trauma patients. Further study is necIrj"ry tJd.hneate which factors are important in determining whetirer standing orders or on-line medical contact should be used.

"166

1 68

3:[?""

bvALSto BLS'lsrt ofPatients

Medicine' of Emergency L Scaccia/Division G Steckler, BL Lopez, Philadelphia Hospital, University Jefferson Thomas in a life support(ALS)personnel Advanced Studyhypothesis:

ParamedicPhysicalExaminationSkills ComparedWith a DisposableEnd-Tidal COe Monitorfor Confirmationof Tube Placement EndTotracheal

two-tiered .*"tg.ttcy medical services{EMS)system can safely releasepatients to a basic life support (BLSfcrew.

'Design: A retrospectivereview of prehospitaland emergency departmint charts from |uly through October 1990.

Setting:A 200-bed,rural community hospital.

Particlpants:One hundred sixty-sevenpatients evaluated-by prehospitalALS personneland treated in the ED. Patientsrefusing treatment or transportedto another hospital were excluded' Interventions:All minor illness patients were releasedby the base physician to BLS. The ED chart was evaluatedfor any interveniion given within the first l5 minutes of being seenby the physician-that could have been givel by e!9 personnel' All maior illness interventions occurredprehospitally;all minor illness occurred in the ED. Interventions between maior and minor illness patients were compared.

Results: Numberof Interventionsn 5 l 0 Iflness

Medicine, of Emergency RIJBraun,RDLonderee/Department Memorial Scottsdale Arizona; Phoenix, Medical Center, Maricooa Arizona Hospital, Scottsdale, Studyobjective:To compareparamedicphysicalexamination skiils with an end-tidalCOr colorimetricmonitorfor confirmation of endotrachealplacem-ent.

Design: A l2-month piospective study of paramedicprehospital intubation skills. Endotrachealtube placement was determlned bv auscultation of ventilated breath sounds over the chest and gastric area. If breath sounds were auscultated over the chest,t'iremonitor was usedand expiratory color was noted.

Setting: A multicenter, two-tiered emergency medical services system in two urban areas.

Pariicipants: Fifty casesoccurring during a seven-month

62

Farr

utes, subjectivepain assessmentusing a 0 (no pain) to 4 {severe pain) verbal scale,and side effects.

Results:A total of 2,180 patients receivedthe N2O mixture P < .001by Fisher'sexact test.) {agerange, 8 to 98 }ears; rnâ&#x201A;Ź4n age,33 yearsf' Orthopedic and Of the minor illness patients with intervention, two had trauma {82%f, nontraumatic torso pain (10%),and so-ft-tissue monitors placed with normal sinus rhythm, and an IV line was for the majority of indications. Complete burns i4%laccounted 'was olaced in one with a normal examination and vital signs. There pain relief obtainedin 12%, marked relief (changeof,3 units were no adverse outcomes in the minor illness patients. or to a post-treatmentscore of l) in 21"/o,and partial relief, Conclusion: In a two-tiered EMS system, it appears that ALS (change-ofat least I unit) in 58% oI patients. No relief was patients can safely release patients to BLS personnel. A prospecobtained rn9"/oof subfectstreated. Sideeffectsoccurredrn26o/o tive study is needed. of patients treatment, all minor (dizziness,-nausea,mild sedation, or excitementf. N2O was discontinued\n 7"/ooI subiects.

ResourceUtilizationand lmpactof Using No clinically significant-consistenteffectson heart rate or blood { GO Dressurewere noted.

I Ir-, Fire Apparatusfor a Fully IntegratedEMS Nro/50% O, mixtures proConclusion:Inhalationof 50ozo Program First-Responder RLClayton/Departments vides analgesiafor most patients in ihe prehospitalsetting-and PEPepe, JEKelly,MVlvy,CMMatsumoto, i s s a f e i n u r b a n , s u b u r b a n , a n d r u r a l l o c a t i o n s s e r v e db y 0fMedicine; College Baylor andPediatrics, Surgery, ofMedicine, advancedlife support emergencymedical servicesunits.

M a i o r{ I 2 l ) Minor (46)

34 43

44 3

2 0

7

9

0

3

0

4 0

FireDepartment CityofHouston

Background:Routine use of fire department{FD) trucks as first-responder(FR)units for emergencymedical services(EMS) incidents is often opposeddue to perceivedconcern over excessive wear and fuel Costt as well as compromisedavailability for other emergencies.

Studv oEiective:To assessthe actual cost and operational impact of using FD apparatusfor a fully integratedEMS FR program.

Design and intervention: 14,comparisonof annual FD expenditures11986vs 1990)for FR activities {includingall costs for personnel,maintenance, fuel, training, and supplies) after the i987 to 1989 implementation of a formal FR training and dispatch program that routinely sends a FD FR to-almost all seribr. ""ilr (comparedwith the previous system of sporadicambulancerequestsfor assistance).

Setting:A large, urban FD EMS program with 108 fire apparatus.

Results: Amplified by a concomitafi 41o/oincreasein total EMS calls during the comparisonperiod, the use of FD FR units increasedsixfold from ll% of 99,000EMS incidents (1986)to 43okof 140,000(1990).However, even by liberal calculations, the gross,unadiustedimpact was still only a 3 97o increasetn the entire operating budget and a meager0.3% increasein the total FD annual budget (an amount equal to the cost of operating one ambulancein the concurrent s0-ambulancefleetI Also, on-the average,the total time spent on EMS calls was only 3,7" of an FR crew's activities (30 to 6O minl24 hr). Meanwhile, responsetimes, survival rates,and letters and polls of puirlic satisfactionall clearly improved during the comparisonperiod.

Conclusron:A highly active and successfulfire apparatusFR programcan be implementedwithout significantcompromisc to budgetor other fire operations.

aal|| I t l,

NitrousOxide:Oxygen Prehospital Multicenter A Nine'Year Analgesia: Evaluation

RM Kaplan,GR JJ Menegazzi, PM Paris,RD Steward, DM Yeaty, D,i v i s i o no f E m e r g e n cMye d i c i n e ; Y o u n g / U n i v e r soilt P y ittsburgh Medicineol WesternPennsylvania; for Emergency Center of PublicSafety,Cityof Pittsburgh Department Study hypothesis:Inhalation of a 50"h N2O/50% 02 mixture providessafeanalgesiain the field.

Design:A multicenter, prospective,open-label,uncontrolled trial.

Setting:Urban, suburban,and rural advancedlife support systems.

Participants:Patients 8 years old or older with acute pain treatedover a nine-yearperiod. Those with a history of chronic obstructivelung disease,drug or alcohol intoxication, dyspnea, cyanosish , y p o t e n s i o n , s u s p e c t e dp n e u m o t h o r a x o r b o w e l s ere o b s t r u c t i o n ,a n d a n y i m p a i r m e n t o f c o n s c i o u s n e s w exclude.

Interventions:After an initial assessmentthe NiO mixture was administeredusing a single tank attached to a demandvalve deviceand a mask or mouthpiece. Patientswere instructed on the proper technique and were continuously observedby the field oroviders. Variables recordedincluded indicatron for use,history of lung or heart disease,vital signs every ten min-

a ai I I

I

TidalVolume,lntrapleuralPressure,and Gastric Volume With Bag-Valve-Mask Versus Oxygen'PoweredDemandValve

HJ Winslow/Dfvisionof EmergencyMedicine,School JJ Menegazzi, Centerfor Pittsburgh; of Pittsburgh, of Medicine,University Pittsburgh Medicine0f WesternPennsylvania, Emergency Study hypothesis:Tidal volume, intrapleural pressure(lPP), and gasiric-volume do not differ when the bag-valve-maskand the oxygen-powereddemandvalve (OPDV)are used in both normal and decreasedlung compliance.

D e s i g n : P r o s p e c t i v e r, a n d o m i z e d ,i n v i t r o e x p e r i m e n t a l model, with subiectsblinded to volume Sauges.

P a r t i c i p a n t s :T h i r t y e m e r g e n c ym e d i c a l t e c h n i c i a n s The paramedic(EMT-Ps)and EMTs volunteeredas subjects-.

L m f - p s { t e n }h a d a m e a n a g e o f 3 1 . 5 y e a r s( S D , 5 . 4 )a n d 1 1 . 8 yearsof experience{SD,4.11.The EMTs (20)were in paramedic iraining and had a mean ageof 22.7years{SD,3.6}and 3.7 years of experience(SD,2.4).

Interventions:Each subiect randomly performedfour oneminute trials ventilating a mechanicaltest lung through a mannikin head ^t a rate of 20 breaths/min.Each subjectused the bag-value-maskand OPDV to ventilate the lung during normal (O.bSI-/cm) and decreased(0.02 L/cm) co.mpliance.Tidal volumes and IPPs were recordedfor every breath from the test lung. The gastric volume was recordedfor each trial using a flowmeter placedbelow a simulated esophagealsphincter (20 peak end-expiratorypressurevalve).Data were anacm HcO -using inalysis of varianceand Tukey's repeated-measures lyzed test.with alpha setat .05.

Device Compliance

BVM

OPDV Notmal

M e a nI S D ) 8 8 7( 1 9 8 1 8 4 0i l 6 8 ) TV lml) 9 . 71 2 . 2 1 9 . 4{ 1 . 5 } r P P{ c m H -. r o l 0 . 0 .( 0 . 0 ) 1 . 3l l . 3 ) GV (L) ' S i g n i f i c a n tP < . 0 0 1

BVIVT OPDV Decreased M e a n{ S D 7 7 8( 1 0 4 ) 8 0 2( 1 0 2 ) 1 8 . 8{ 2 2 1 1 8 . 51 2( r l 3 . 7{ 1 . 8 } l . l ' { 1 . 2 )

Conclusion: In this model, tidal volume and IPPs did not differ between the two devices. When compliance was normal, no subject delivered any gastric volume with the OPDV, whereas the bag-valve-mask averaged 1.3 L. With decreased compliance, the Op;DV again delivered significantly less gastric volume than the bag-valve-mask (l.l vs 3.7, respectively)' These findings need corroboration in an in vivo model.

Bronchospasm ls Unexplained aAq, I f G AssociatedWiththe Useof Cocaine?

0f NJ Jouriles,A Singer,WF Rutherford/Department EA Panacek, Case of Cleveland; Hospitals Medicine,University Emergency 0hio Schoolof Medicine,Cleveland, University, WesternReserve in emergency Study hypothesis:Unexplained bronchospasm patients may be associatedwith the use of cocaine Design: Prospective,cohort study over l4 months with blinded laboratoryanalyses.

Setting:Singleinstitution, Iargeuniversity referralhospital.

Participants:Adults who presentedto the emergencydepartment with a new onset of bronchospasmor after a symptom-

free interval of at least five yearsfrom a prior episodeof wheezing were considered.A conveniencesample of 22 patients was eniolled into the study group. Another group of 22 patients with different complaints brt orr whom urine samples were already available s.rved "s the controls Control patients were closely matchedfor time of ED presentation,age,and gender.

Interventions: Patients with unexplained bronchospasm were questionedregardingthe use of cocarne,and a urine toxicologii screenwas performed.Analyseswere performed on the con;ols from already availableurine; no control patient underwent an additional requestfor a urine sample' Urine toxicologic analysiswas performed^usingan EMIT method {SYVA).Data were reviewedusing a Xz analYsis.

R e s u l t s :M e a n i g e a n d g e n d e rw e r e s i m i l a r i n t h e b r o n chospasm 1'26r 8 yelrs and 59% women) and control 124+ 8 yeari a.rd 59% womenJ groups. The frequency of cigarette imokins was also similar in the bronchospasml42o/")and control (35%) groups. Urine was positive for cocaine in 36'47o (eighi of 22fof the bronchospasmgroup but only 13.6%lthree of 221of the controls (P < .051.Of the seven patients in the bronchospasmgroup who tested positive, six admitted to inhalational use and-one-reported only nasal use of cocaine.In addition, four of the sevenpatients noted black sputum Conclusion:In this ED population,the use of cocaineshows a s i g n i f i c a n ta s s o c i a t i o nw i t h o t h e r w i s eu n e x p l a i n e db r o n c h o J p a s m .T h e s e d a t a s u p p o r t c o n s i d e r a t i o no f t o x i c o l o g i c s.r...ti.tg and appropriatequestioning in patients with new or unexplainedwheezing.

CocaineToxicity:Unaffectedby Naloxone 1aq, I t g and Potentiatedby MorPhine of TEAlbertson/Unlversity CCTseng, RSTharratt, RWDerlet, Davis,SchooloJ[/edlcine,Sacramento California Study hypothesis:Acute cocaine toxicity is -modulatedby the opiate antagonistnaloxoneand potentiatedby the agonist morphine.

Design: Male Sprague-Dawleyrats were pretreatedin-traperitoneallywith normal saline{NS},25 mglkg morphinesulfate,or 2 mg/kg naloxone l5 minutes beforechallenge-bycocaine.Each Dretieatmentwas then testedat three dosesof cocaine{35, 50, ind 75 mg/kg IP). Each of the nine drug combinationswere tested on ten animals.Animals were observedfor behavior,seizure, and death.

Interventions:Saturationof opiate receptorsbeforechailenge with cocaine.

Results:Animals pretreatedwith NS and then challenged with cocaine{35, 50, and 75 mg/kg} had 0%, 40%, and 100% incidencesof seizures,respectively.Pretreatmentwith morohine increasedthe incidencesof seizuresto 30% and 80% at 3 5 a n d 5 0 m g / k g , r e s p e c t i v e l y( P < . 0 i ) . P r e t r e a t m e n tw i t h naloxonedid not significantly alter the incidenceof seizures comoaredwith NS controls.The incidenceof death in animals pret;eatedwith NS and then cocainei35, 50, and 75-mg/kg).was O"t, lOU, and 7oo/o,respectively.Pretreatmentwith morphine respectively and90"/"', increasedthe ratesof deathto 107o,6O7o, ani{P < .05 at 50 mg/kg).The death ratesin naloxone-treated mals were 0%, 20'/", and 607",respectivelyand were not significantly different from the NS group.Times to death were significantly decreasedin the animals pretreatedwith morphine comparedwith the NS groups.In the 75 mg/kg cocainegroup, death occurredin I5.0 t 1.2 minutes for NS versus7.1 t 0.8 minutes for the morphinegroup(P < .011.

C o n c l u s i o n : C o c a i n et o x i c i t y i s p o t e n t i a t c db y m o r p h i n e and unalteredby naloxone.

Participants:One hundred thirty-nine patients who ingested a CCB and were evaluatedin a hospital; 26 casesinvolving coingestantswere excluded.

Iiterventions: Calcium, dopamine, atropine, isoproterenol, pacemakers, and glucagon.

Results: Total Hypotension SA DePression AV Block Dysrhythmia 2 9l s 7 % ) 28 l55o/ol 15 l29o/o) 27 153"/"1 1 6\ s 7 % l 4lI4o/"1 9132%1 to IO 1r29%l 13 138%) lzev"l rs l44v.l

Verapamil 51 N i f e d i p i n e2 8 Diltia2em 34

There is no statistically significant differencein the frequency of cardiovasculartoxicity among the threeCCBs, exceptthat airioventricular block occurs more commonly with verapamil overdoseslxZ, P..025|. Calcium was used in 23 patientsand was helpfui in seven of I I patients with sinoatrial node depression, Id of 18 with atrioventricularblock, and 16 of 20 with hypotension. Dopamine was used in ten hypotensive patients and all experienceda positive effect-Atropine was useful in two of seven patients with sinoatrial depression-andfailed in one patient with third-degree atrioventricular block. Pacets were used successfully in two patients. Isoproterenol increasedthe heart rate rn two patients with sinoatrial depressionbut had no effect in one patient with atrioventricular block. Glucagon increasedthe 6iood pressurebut had no effect on heart rate in one Datient. ionclusion: Overdose with any CCB can lead to hypotension, dysrhythmias, and sinoatrial and atrioventricular nodal depression;however, atrioventricular block is more common wiih verapamil ingestions.Calcium is useful for improving conduction and raising blood pressure.Dopamine is also useful for eievating blood pressure.Isoproterenoland pacing-can be used to comb"atbradycardia, wheieas atropine is helpful in only a small subsetof patients.

.1 7 5 gtrilllill,'il3H3j;i,lilif i'fl#'.o

Using an Electrochemical Method of Emergency LRGoldfrank/Department PM Wax,RSHoffman, Bellevue Schoolof Medicine; NewYorkUniversity Services, NewYork Center, Hospital To determinewhethera rapidelectrochemiStudvobiective: UK) canreliablyquantitatebloodalcohol cal meter(Medisense, concentration {BAC).

Design: A prospective study comparingthe iVledisensemeter criterion standaid was undertaken during a thr data with the^TDk ten-weekperiod.

Setting: The adult emergency department of a large innercity municipal hospital.

P a r t i c i p a n t s : T h r e e h u n d r e d e i g h t y - t h r e ec o n s e c u t i v e Datientswiih altered mental status or suspectedalcohol intoxi' tation were enrolledinto the study. Fifteenpatientswere excludedfor lack of simultaneousTDX data.

Interventions: Each patient underwent routine phlebotomy at which time blood sampleswere obtained for meter and TDX BAC determinations.

Results: Two hundred nineteen patients (60%) had BAC detectableby both meter and TDX; meter results rangedfrom 7 to 296 mgldL with a mean of 168 mg/dl, and TDX results ranged frJm 2 to 508 mg/dl with a mean of 213 mg/dl. The BAe measuredby meter correlated strongly with the TDX determination (Pearson'scorrelation coefficient lrl = .94, P < In the ll9 patients (327.)with no detectableBAC .00000001).

In bv TDX, meter determinations were all less than 15 mg/dl. "high," the remaining 30 patients in whom the meter read meaning too high io quantitate, the simultaneous TDX BAC were always more than 300 mg/dl.

Conclusion: The Medisensealcohol meter, which uses a newly developed rapid electrochemical technique, provides a reliablemethod for determining BAC in the ED in 50 seconds.

a ^| A One-YearEvaluationof Calcium I I J+ ChannelBlockerOverdoses:Toxicityand Treatment Valley DBorys/Delaware M Winter, EARamoska, HASpiller, I

University RegionalPoisonControlCenter;ThomasJefferson PoisonCenter TexasSlatePoisonCenter;Hennepin Hospital,

*{

Studv obiective:To examine the cardiovasculartoxicity of the calcium channel blockers {CCBI and the efficacy of various treatments.

Design:One-yearprospectivelycollectedcaseseries.

Setting:Three regionalpoison control centers.

7G I t L

Glinical Presentationand Treatmentof A BlackWidowSpiderEnvenomations:

Review of 163 Cases Regional Samaritan MVVance/Good RFCtark, S Wethern-Kestner, Phoenix, Arizona Center, Medical casesof black We reviewed172consecutive Studvobiective:

64

widow spider lLatrodectus hesperus ILH]] envenomation to describe the clinical presentation and evaluate the efficacy of treatment. Design: Retrospective chart review.

Setting: An urban toxicology referral center.

Participants: Al1 patients discharged between fanuary 1980 and June 1990 with a diagnosis of LH envenomation were reviewed. Inclusion crrteria were either positive LH identification or a visible envenomation site ("target lesion").

Interventions: Depending on clinical presentation, patients were categorized as grade I (local muscle pain), grade 2 (generalized muscle pain), or grade 3 (diffuse muscle pain plus systemic manifestations such as hypertension). The efficacy and side efiects of treatment alternatives (including Latrodectus-specific antivcnin [AVl, parenteral narcotics, sedative hypnotics, calcium gluconate [CG], muscle relaxants, and other analgesics) were evaluated.

Results: One hundred sixty-three patrents met the inclusron crrterta (547" grade 3, 37% grade 2, and 9% grade I ). The most common sites of envenomation were the upper (28%) and lower (48%) extremities. The most common presenting complaint was g e n e r a l i z e da b d o m i n a l , b a c k , a n d l e g p a i n ( 5 3 % ) . O n e h u n d r e d cightccn patients initially prcscnted to our institution, and 45 128%) were trans{ers. Pain relief of grade 2 and 3 envenomations was achieved most effectively with either AV alone or a combination of IV narcotics and muscle relaxants. Fifty-seven (36%) patients received AV with complete resolution of symptoms in a mcan time of 3I minutes lSD, +26.7 minutesl. One patient died with severe bronchospasm after AV administration. Of the ll8 patients seen initially at our institution, the mean total duration of symptoms was nine hours {SD, +22.7 hours) in the AV group, versus 22 hours (SD, +24.9 hours JP < .05 Student's t t e s t ] )i n p a t i e n t s n o t r e c e i v i n g A V . F i f t y - t w o p e r c e n t o f p a t i e n t s not receiving AV required hospitalization (mean, 1.46 daysl, whereas only 12"/o(P < .05 Student's t test) of patients who r e c e i v e dA V w e r e a d m i t t e d ( m e a n , L l 4 d a y s ) . C G w a s n o t e f f e c t i v e i n p r o v i d i n g s y m p t o m a t i c r e l i e f i n t h i s s e r i e s ,w i t h 9 6 % o f grade2 and 3 envenomations treated with CG requiring the addition of IV narcotics or other analgesics for symptomatic relief. Fifty-five percent of those receiving IV morphine and70o/" of those receiving both IV morphine and benzodiazepines obtainedsymptomatic relief without additional medication.

Conclusion: One hundred sixty-three envenomations by LH were reviewed and graded according to severity, with treatment modalities evaluated. Although CG has usually been considered the first line treatment of severe envenomations bv LH, we found it ineffective for pain reiief compared with AV or a combination of IV narcotics and benzodiazepines. The use of AV sig.nificantly shortened the duration of symptoms in severeenvenomations.

AntibacterialActivityof CrotalidVenoms AgainstOral SnakeFloraand Other ClinicalBacteria DATalan, DMCitron, PFroman, EJC GDOverturf , BSinger, Goldstein/0live View/UCLA Department ofEmergency Medicine, aaA a I I

S y l m a rC , alifornia

I I

Study hypothesis: The crotalid oral cavity and fangs are heaviiy colonized with potentially pathogenic bacteria. However, bacterial infection is a rare complication of crotalid bites and envenomation. We hypothesized that this phenomenon may be due to bactericidal activity of crotalid venom.

Methods: Minimal inhibitory and bactericidal Concentrations (MIC/MBC| of three crotalid venoms lC viridus helLeri, C atrox, and C horridus horridusl were determined against aerobic and anaerobic reference and oral crotalid bacteria by microdilution method.

Results: All anaerobic isolates lC perfrigens, C sordellii, C carnis, Eubacterium sp, Lactobacillus ijnsenii, B fragilis, and B thetaiotaomicrom) were resistant to 20,480 ltglmL ll0% strength native venom). Variable activity {range, 5-2O,480 pg/ml) was observed for aerobic strains. Venom had the greatest activity (ie, MIC < 80 pg/mll against S aureus, P aeruginosa, A faecalis, Citrobacter sp, Proteus sp, and Providenicia sp. There was variable activity against S epidermidis, S faecalis, E coli, Entercbacter sp, S marcescens, and K pneumoniae. generally equal to or within one dilution of MIC . MBCs were values.

Conclusion: Crotalid venoms are broadly active against aerobic Gram-negative and Gram-positive bacteria. This activity may play a role in the low incidence of infection associated with envenomation iniuries. Venom activity does not follow any known pattern of antimicrobial activity. Further studies are needed to determine the active components and mechanism of venom antimicrobial action.

of EpinephrineWhen Pharmacokinetics AO I t (D Administeredby the lV, lO, and EndotrachealRoutes 0fEmergency SGCrespo/Department WHSpivey, JMSchoffstall,

l

of M e d i c i n e / D i v i s ioof nR e s e a r cTh h, eM e d i c aCl o l l e g e P e n n s y l v a nP i ah, i l a d e l p h i a Study objective:To correlatethe effect of epinephrineon b l o o d p r e s s u r ea n d c h a r a c t e r i z et h e p h a r m a c o k i n e t i c so f e p i n e p h r i n ea d m i n i s t e r e db y t h e I V , I O , a n d e n d o t r a c h e a l routes. laboratoryinvestigation.

Design:Prospective with 30 Subiects:Forty-fourswine (10 to 15 kg) anesthetized mg/kg ketamine and 75 mg/kg chloralose.

Intervention: Animals were insttumented for blood pressure and ECG monitoring. Ventricular fibrillation was induced, and CPR was initiated after five minutes of arrest using a Michigan InstrumentsThumper.

Methods: Blood sampleswere drawn every two minutes and the plasma was frozen for Iater measurementof epinephrine using high-performanceliquid chromography.CPR was continued for 25 minutes. Epinephrine0.i mg/kg was administeredat ten and 20 minutes alter arrest by IV (superiorvena cava, six), IO (six),or endotracheal{six} routes. This was repeatedfor 0.01 mg/kg epinephrine in the same number of animals. Eight animals did not receiveepinephrineand servedas controls. Linear regressionwas performedfor the model: mean arterial blood pressure= coristallt + A Log (E) + B ramp with ramp = simple ramped linear variable. Plasma half-life of exogenous epinephrine was calculated.

Results: Coefficient P Log (E)

(mm Hg)

Ramp

IV

58

-3.58

8,6

<.0001

3.7

T V20.r (min) 3.6

ro

-l L9

-2.40

13.7

< .001

2.7

1.8

ET

t6

).67

5.6

< .001

T l'20.01

Conclusion: Each route of epinephrine administration has a characteristic slope and t I l1 ior epinephrine. The rates of distribution and elimination are-affected by other variables such as tissue hypoxia and acidosis.

l

ral I t :t

AorticArchVersusCentralVenous DuringCPR Epinephrine Administration

RA Mueller, JE Manning,CA MurphyJr, DN BatsonJr, SG Perretta, Medical EANorfleet/Department of Surgery,Divisionof Emergency University ol North Services, and Department of Anesthesiology C a r o l i naat C h a o eHl i l lS c h 0 ool f M e d i c i n e Study hypothesis:Epinephrine (E) given via the aortic arch {Ao} during CPR may yield higher diastolic Ao pressure(dAoP), higher coronary perfusion pressure(CPP),and earlier return of spontaneouscirculation (ROSC)than central venous (CV) E. Methods: Eight anesthetizeddogs {26 to 3l kg) had AoP, right atrial pressure(RAP),and 9.0F superior vena cava and Ao cathetersplacedusing fluoroscopy.After ten minutes of ventricular fibrillation IVF) and three DC shocks in the next one minute, manual CPR at I}Olcpm was begun. Dogs were randomized to receive I mg E/50 mL 0.9% NaCl every five minutes via the Ao or CV route with the first E given at 60 seconds of CPR. After E doses,one minute of CPR precededdefibrillation. Data included CPP (dAoP - RAP),VF amplitude {averageoI five maximal deflections/ten seconds)at VF onset (VF-O),ten minutes (VF I0), and one minute after the first E {VF-E);and time from first E dose to ROSC with a systolic AoP {sAoPfol more than 60 and 100 mm Hg. Data (mean+ SD) were analyzed

by Student'st test.

Results:CPP did not changeduring the one minute of CPR before E in either group. CPP rose rapidly during one minutâ&#x201A;Ź

after Ao E but not CV E. VF-E amplitude was greaterwith Ao E ROSC was achievedin less time with Ao E than CV E. AOE CVE CPP (mm Hg) with CPR 50 secpre-E l0 secpre-E l0 secpost-E 30 secpost-E 50 secpost-E

l0r2 2 0! 9

ll l6 13!7 3 01 l 2 ' 5 0r l 6 ' 6l t 35.

VF amplitude (mm) VF.O VF-IO VF.E

1 4x 2 ztr 7!2

I38r8 311 l4x4'

lst E to ROSC(min) sAoP > 60 mm Hg sAoP > 100 mm Hg 'P<.05,AoEvsCvE.

9l: I l0l: I 9 1 1

8 . 41 4 . 0 10.8r70

. 1 _ )r z , J .t.() r z,J

Conclusion: Ao E provides faster and greater increasein CPP, earlier VF amplitude recovery,and earlier ROSC than CV E during cardiacresuscitatton.

"180

Effect of Sodium Bicarbonateon Survival CardiacArrest in a Canine1S-Minute Model

RB Vukmir,NG Bircher,P Safar,A Abraham/lnternational Medicine, CenterirndDrvisionol Emergency Research Resuscitation Pennsylvania ol Pittsburgh, University Studv obiective: The use of sodium bicarbonate{SB)in cardiac arrest has recently been discouragedwithout basis in outc o m e e v a l u a t i o n .A l 5 - m i n u t e v e n t r i c u l a r f i b r i l l a t i o n ( V F ) model was used to examine the effectsof SB on survival and neurologicoutcome.

Design: Prospective,randomized clinical triai of SB in cardiac arrest.

Setting:Canine intensive careunit with 24-hour monitoring.

P a r t i c i p a n t sS: i x t e e nn o r m o t h e r m i cc o o n h o u n d s( 1 1 . 4t o drameterof lessthan 1.2.

17.6kg) with anteroposterior Intirvention: The dogs were induced with kctamine and halothaneand maintained with 50% N2O/50% 02. Electrically induced VF lno {lowl of 15 mrnutes was treated with canine advancedcardiac life support protocol using Thumper CPR, epinephrine,atropine, lidocaine,and norepinephrine.The SB gioup received I mEq/kg empirically, and the base deficit coriected to less than 5 mEq/L, whereasthe control group received no SB with the initiation of CPR. Neurologic Deficit Score {NDS) from 0% {normal)to 100% (cerebraldeathlwas assessed at 24 hours. Data were analyzedby Fisher'sexact and Students's t tests.

Results:Comparedwith control group, the SB group demonstratedsignificantimprovement in restorationof spontaneous circulation {ROSC),one-hoursurvival, neurologicdeficit, and level of acidemia measuredas arterial pH (pHa)and basedeficit (BD) (-P < .02).The trends toward increased24 hour survival 1625% vs 12.5%llP = .059)systemic/coronaryperfusionpressures(MAP and CPP),PCO2 and C(a-v)02 differencedid not it this samples-ize. reachstatisticalsignificance Controls SB 218' 718 ROSC li8' 618 Suru I hour l/8 s/8 Suru24 hour NDS % pHa BD (mEq/L) MAP {mm Hg} CPP {mm Hg}

/o

7.29 -l).

I

45.0 30.9

98 7.09' -16.9' 30.6 T 7, I

Conclusion:The administration of SB may improve outcome in a prolongedcanine cardiacarrestmodel.

Pennsylvania of Pittsburgh, Center,University Research carof ciosed-chest feasibility the To test Studv obiective: diopulmonarybypassiCPB) in the emergencydepartmentfor prehospital cardiacarrestvictims. ' Pariicipants:Eight patients have been entered.Eligibility crit e r i a i n c l u d e d 1 ) w i t n e s s e d ,n o n t r a u m a t i c c a r d i a ca r r e s t ,2 ) life support.iCPRpulselessin the ED despiteCPR-advanced Afs), a) age of 15 to 60 years,4)CPR duration of lessthan 30 minutes, 5) duration of no flow iarrest without CPR) for less than six minutes,and 6) no evidenceof strokeor headtrauma.

Methods: The CPB system {Sarns),which included a centrifugal pump, hollow-frber membrane oxygenator,and heat exchanger,wis primed (crystalloid)while surgeonsplaced l7F to 20F cannulaevia a femoral cutdown.

Results:Only one patientdid not have immediateCPR.Vessel cannulationrequired20.3 t 11.5 minutes lrange,12 to 47 minutesl.Total CPR time (includingcannulationtime) was 53 + 7.5 minutes lrange,44 to (r5 minutes).CPB was continuedfor woman with mitral 1.5to 30 hours.iwo patients(a 29-year-old valve prolapseanda 7}-year-oldwoman with h-ypothermialcore t"rrrp"iatrl.., 24C]) werc weancd from CPB after l5 and three h o u i s , r e s p e c t i v e l ya, n d s u r v i v e dn e u r o l o g i c a l l yi n t a c t . T h e other six patients experiencedno neurologrcor cardracrecovery In two piticnts (oni with a diltiazem overdoscand one with IHSS).CPB was discontinuedafter 30 and 16 hours,respcctively. In four patients,CPB was discontinuedin the ED after 1.5to thrce hours.Three had cnd-stageheart disease{two congcnital The famand one ischemic)and were not transplantcandidates. ily of the fourth requestedCPB termination.Conclusion:CPB for prchospitalcardiac arrest is feasible.Appropriatc p-atient selcition ".td mor" rapidcannulationtechniquesneedto be further explored.

1 82

Slii:l :i;lton

iacArrest Post-card

Medicine, of Emergency GSKrause/Department JM Skiaerlund, Michigan Detroit, Wayne StateUniversity, B a c k g r o u n d I: r o n - m e d i a t e dp e r o x i d a t i o nr c a c t i o n sa r e rcsoonsiFlefor at least a portion of the brain iniury seenafter . . r d i t . a r r e s ta n d r e s u s c i t a t i o nl.- E t h y l - 2 - m e t h y l - 3 - h y d r o x y pyrid-4-one(CP2l)is a small (MW, 153)iron chelatorthat partitions into hydrophobicsolventsand inhibits in vitro DNA damageby oxygenradicals. toxicity Studypurpose:We studiedCP21 for dose-dependent and its effecf on survival and neurologic outcome after CPR in rats.

Design: Acute toxicity was determinedby giving CP2l at 300, l0d; or 40 mg/kg IV over l5 minutes to three groupsof five male Wistar rats. A ten-minute cardiac arrest was producedby p e r i p h e r a lI V i n i e c t i o n o f 0 . 8 m E q / k g K C I i n 3 4 r a t s a n e s ihetized with ketamine, xylazrne,and isoflurane. CPR resuscitated 3l rats, which were then given sodium bicarbonate(5 mEq/kg over two minutes) and observedfor survivai and neurologic outcome for 72 hours. perfusion,aniIntervention:After resumptionof spontaneous mals were randomizedbv coin toss to receiveeither saline(l5l or 40 mg/kg IV CP2i, over six minutes (16) Results:CP21(300mg/kg)was lethal to 6O%of normal rats.

The 1O0-mg/kgdosedid not kill normal rats but was associated -90% mortality in a pilot resuscitationstudy. At 72 hours, with ten of 15 control rats survived,.and ll of 16 CPzl 40 mg/kgtreated rats survived lP = .9, Xzl. At 72 hours, eight in each group were neurologicallyimpaired iP = '851,and five rats in seizures. eachgroupexperienced Conclusion: CP2l did not improve either survival or neurologic outcome in this model of cardiacarrest and resuscitation.

We concludethat this drug is not useful in ameliorating postresuscitationencephalopathy.

"181 5:ffi :lxh'i,l#i"""J""J=,",

CD{D ResuscitationFrom Electromechanical f OO DissociationUsingCardiopulmonary Bypassand High-DoseEPinePhrine State University JELeasureAVright MGAngelos, DJDeBehnke,

*{

ResuscitationFrom CPR-Resistant CardiacArrest - A PreliminaryReport K RKormos, GMarrone, PSafar,NSAbramson, SATisherman, olSurgery, P Paris/Departments Stein, A Peitzman, Resuscitati0n International Anesthesiology/CCM, andMedicine,

S c h o ool f M e d i c i n eD, a y t o n0, h i o Background:Cardiopulmonary bypass (CPB)and high-dose epinephrine(HDE) have shown improved outcomes in ventricu-

lar fibrillation animal models but have not been studied in elec_ tromechanicaldissociationiEMDl. Study hypothesis: CpB and HDE do not improve Derfusion pressures, resuscitationrates,or regional myocaidialbiood flow " iRMBF)in a canine model of EMD. Design: Twenty-four mongrel dogs receivedEMD cardiac arrestusing a postcountershockmodel.

Intervention: Animals were randomized to receive CpB, HDE (0 2. mC/kC),or standard-doseepinephrine (SDE) (0.02 mg/kg) after 15 minutes of arrest. Blood fiow was measured using nonradioactivecolored microspheres.Group data were comparedusing analysisof variancewith a Tukey pbst hoc test.

Resuscitationrateswere comparedusing Fisher,sexact test.

Results:Eight of eight CpB and three of sevenHDE animals, comparedwith three of eight SDE animals were resuscitated(p =_:0:26l,: One dog was resuscitatedwith the use of mechanical CP\ "lo.r: Coronary perfusion.pressure(Corpp) was signifi_ cantly hrgher rn the CPB group than in the HDE or SDE group iCPq 76^t-45-.m Hg; HDE,t4 + 13 mm Hg; SDE,3 t 14"mm Hg P < .002)-After epinephrine,cardiacoutirt *r, signifrcant_ lyfower in^the HDE group than in the CpB 1Cnn,:,:ti ):1,216 mL/min, 73"/"oI baseline;HDE, 55 I t 6(10mL/min and ll% of baselrneJ. RMBF was higher after CpB and HDii comparedwith S L J t b u t d i d n o t r e a c h s _ t a t i s t r c as li g n t f i c a n c e { C p B , ( _ 9t g I mlimini 100g_and92% of baseline;HDr, St t 120ml/min/100 g and lO9% of baseline;SDE, 8 1 1.2 mL'lminll}0 g and t26/" ot b a s e l i n eP' : N S ) . . C o n c l u s i o n : C P B p r o d u c e dh i g h e r C o r p p a n d i m p r o v e d lmmedrateresuscitationrates from EMD cardiac,rr.ri co__ paredwith HDE and SDE. There was a trend toward higher RMBFin the CPB and HDE groupsthan in the SDE group.

184

purse oximetry: usefuror [,]:|3:!T",

J LK Cydulka,B Shade,CL Emerman,H Gershman, Kubincanek/Department of Emergency Medicine,MetroHealth MedicalCenter,Cleveland; Depaitmeht of Surgery,Cise Western Reserve University, Clevela-nd; the Cityol Ctev;ta;;;;d Emergency MedicalServices Bureau,Cleveland, Ohio . Study objective:To evaluate the ability of emergencymedi_ cal technicians{ElvIT-Asand EMT-ps) ,o "r. puti. orii-.,ry measurementsin determining patient oxygenrequirements.

Design:Prospective caseseries. , _ S e t t i n g : C l e v e l a n d e m e r g e n c ym e d i c a l s e r v i c e ss y s t c m

icEMs).

Participants:Five hundred thirty-two consecutive CEMS patients,no exclusions.

Intgrventions:EMTs.performedpulse oximetry on prehospi_ -_, tat patlentswho were breathingroom air {RA SpO2}.Oxygen therapyguidedby the patient,s iiitial Ra Spot;;, reviewedto oetermlnerts appropriateness.

Results:Data were analyzedusing the X2 test and correla_ tion analysis..Eleven percentof patients(59)had an initial RA 5pU2ot lessthan 917o.EMT-ps increasedoxygensupplementa_ tion on all desaturatedpatients, whereasEMT-is failid to make appropriateincreasesin FIo2 in 2O% ltwo) < .0001).Sixty_one {p percentof patients (325) h-adan initial ie SpO, oI 97'"h or more.EMT-Ps withheld supplementaloxygen ih.irpy in oniy 77o,ofpatients(lJ) already-well.saturatedjandEMT-As with_ ne-lo^supplemental oxygenin only 6% of thesepatients (nine). {1, = NS).

Conclusion:EMT-ps were more likely to appropriatelybase oxygentherapy on oximetry measurementsthan wire EMT-As. Bothgroups failed to decreasesupplementaloxygen in patients with high saturationson room air-.We ,..o--.n? on_linemed_ ical.control or explicit protocols for EMS ,y.i.*. contemplat_ lng rne use ot tleld oximetry.

1 85

H:.:

" putseoximetry in prehospttal

SMDunmire, PMParis,JJ Menegazzi, SATisherman/Division of Emergency Medicine andInternational Resuscitation nerrrrcn pittsburgh; Center, University of TheCenter ior fmerge;cyMedicine pittsburgh, 0fWestern pennsylvania Pennsylvania, Studyobiectives: To evaluate.the accuracy of the prehospital assessment and treatmentof hypoxemiaand to i.t.rrnin.

whether pulse oximetry is a valuable prehospital tool in detect_ ing unrecognized hypoxemia.

Design and setting: prospective, consecutive sample ol patrents presenting between August i990 and October tqqO in a n u r b a n e m e r g e n c y m e d i c a l s e r v i c e ss y s t e m .

Interventions.: patients more than l g years old who .All requrreo advancedltfe support were included in the study. Once the patient had been evalulted, paramedics estimated th. a.gr.. of hypoxemia according to a predetermined scale and initiited 02 at a flow rate based on their clinical judgment. After five minutes of 02 therapy, _pulseoximetry was initiated. Any sub_ sequent increase in 02 flow rate or other therapeutic interven_ tlon armed at rmproving oxygenation was documented.

R e s u l t s : O f t h e 2 . 8 5p a t i e n t s e n t e r e d i n t o t h r s s t u d y , 5 4 {I9%) were significantly hypoxemic {02 saturation, less than'90"/"j a.tter initial 02 therapy After deiermining the 02 saturation l5aU2) by pulse oximetry, the 02 flow ratcs were increased in 3 . 1 p a t i e n t s , a . s i g n i f i c a n t f i n d i n - g1 l < . 0 0 1 o n c s a m p l e c x a c t Drnomral testl assuming,a l0% chancc that the paramedic might have increasedthe flow rates without knowing tt. SrO2.

02 flow rate resulted in an increase-in SaO2 o"f jl:*r:.^,tn 11" more than 5%.in 3O patients and more than l0% in l6 patie-nts.

A signrficant level of agreement betwcen the parameiics and t l r e p u t s e . o x l m e t e _ ri n p a t i e n t s w i t h n o o r s e v e r e r e s p i r a t o r y dis_ tress is illustrated (Table). Their judgment was lcss accurate tn patients with mild-to-moderate respiratory distress.It is important to notc, however, that e-ight of the 33 patients (25%) with an o f l e s s t h a n _t i 5 % ( d e f i n e d a s s c v " i c h y p o x c m i a ) w e r e .SaO2 csttmated to havc no hypoxemia.

Estimated Hypoxemia N o n e { S a O e >9 . 5 % )

Mild {saoteo-es) Mod (SaO285-90) Severe (SaO2 < tl5J

Kappa

P Value

.339 .078 .t46 .464

<.0000000I .090 .003s209 <.00000001

Conclusion: Paramedics frequently underestrmate ancl undertreat hypoxcmia in t-he prehospital care setting. pulse oxrmetry is a valuable prehospital tool in detectlng patlents with unrecognizcd hypoxcmia.

1 86

studyofMotorcycre f;,H:'fj'B:-"tased

Vt brariOocl,G Lapidus,L Banco,LM Jacobs/Harfford lrl Schwar,!2.

H o s p i t aC l , o n n e c t i cC u th i l d h o o ldn j u r yp r e v e n i i oCn e n r ear n o Department 0f Emergency Medicine,Hartford, Connecttcut

S t u d y - o b j e c t i v eT:o p r o v i d ea p o p u l a t i o n _ b a s e i ndj u r y a n d c o s lp r o f i l cf o r m o t o r c y c l ei n i u r yo i c u r r i n gr n C o n n c c t r c u t .

D e s i g n :P o p u l a t i o n - b a s erdc t r _ o s p e i t i vec p i d e m i o l o g i c 'gZ) review. All Connccticut.deathcertificates(19H5 and hoipi tal discharges{FYlgUZ89) were rcviewed.ICD_9-CM E cod^es were.usedto identify cases.Dischargcdata from hospitalswith E-coderatesof more than 707" were-usedto estlmatestatewide hospitalizationratesand costs.

Intervention:Calculation.ofdeath and hospitalizationrates; developmentof injury profile; comparisonoihospital charges ano rermbursement Results:Connectrcutdeathcertificatesidentiiied Il2 motor_ cycle injuries as the externalcauseof death resuitingin 4,954 yggg of potential life lost and an annual death,rt."of 1.2'p., 100,000persons.Death rates were highest among persons20 to Z! ycarsof age{4.3).The deathrrte "-ong malei was z.f tim., t h e l e m a l e sr a t e { 2 . 3v s 0 . 1 } ( p < . 0 5 } .T h e r ew e r e a n e s t i m a t e d 2,361 dischargesfrom Connecticut hospitals resulting fiom motorcycle iniuries. The annual hospitalization rate was 24.7 per 100,000persons.Hospitalization iates were highest among persons/2O to 24 years of agel92.Zl. Male hospitalization rate; wer,e46.9, ll times the female.rate l4.Zl (p . :051.Head, neck, and spinal injuries accoun-tedfor one ihird, and ;t;;it; iniuries nearly one half of all infuries. Head, chest, and abdomi_ nal iniuries were associatedwith fatality ip . .OS).e total of 23,994 hospital days, including 2,994 intensive care days, were used at a cost exceeding $24.4 million dollars. Three percent {$691,000)of the total iesulted fto- .;;;;;;.y a.p"'rt-.ni charges.Sixty percentof caseshad commerciai i-nsurance;29% hact no i1^s9r1199.Using Connecticut,s DRG_basedall-payor system/ 42y" lgl0.3 millionf was not reimbursed to the hoJji_ tals.

Conclusion:This population-basedstudy revealsthat motorcvcle-iniuriessignificanily contribute to Connecticut's mortality, morbidity, aid health'carecosts.Hospitals caring for.motorcvcle iniuriei are at significant financitl risk due to the high"f uninsurei and the inadequatereimbursement of "1"""-"" ijnh--t"r.a svstems.This methodology,using readily available data sources,can be reproducedby emergencyphysiciansinterestedin studying the impact of motorcycle iniuries in their own siates. such'daia arc ciucial in advocating re-enactment of motorcvclehelmet laws.

*1O-a t O t

lmpactof BedsidePulseOximetryon the Utilizationof Arterial Blood Gas

Measurements in the ED EAPanecek/Emergency WFRutherford, NJJouriles, A Singer, CaseWestern of Cleveland; Hospitals University Depar'iment, 0hio Cleveland' ol Medicine, School University Reserve of bedsidepulse The readyavailability.

Studyhypothesis: bloodgas(ABG) arterial use of the (pO) reduce witt oximetry tests in the emergencydepartment.

Desisn: Retrospectiveanalysis of the total number of ABC t.r,. oriet.d each'month for tfie ll-month period beforeinstallation of ten bedside monitoring units that included PO (fune iSA8.o April 1989)and during an lI-month periodafter instalIation (|anuaryto November 1990). hospital.. -Setting:A universitytertiary-care l"tti.ip..ttt' All ABG tests'orderedfiom the ED during the aboveperiods.

Intirventions: No interventions specificto this study' Results: Analysis was performed.on the monthly ABG use fot lir. "bou. periods(l I months each),calculating the monthly mean, SD, atti Sru. Total ABGs orderedfor the pre-Po period iit i,ezd, with a monthly mean of t sD 42o t 48.22.Total for the post-Pb period was 5,592,with a monthly mean of t SD 508 t ed.rZ. Thi differenceis statistically significant (P < 001)' e""fvtis of possibleconfoundingvariablesdid not reveal anothfor the increase(eg,an increasein.patient er probable-cause .rurnb.tr, change in patient acuity or diseasedistribution, .ft"ti. it staff, & changein ED policy) separatefrom the use of PO. Conclusion:Availabilitv of bedsidePO does not lead to a in ABG use but rather to a significant increasein ABG j;:*^.

PulseOximetryDuring { CDCDContinuous Intubation I CDCDEmergency Endotracheal

Collegeof JR Mateer,HA StuevJn,TP Aulderheide/Medical W i s c o n s i nM, i l w a u k eCeo u n t yM e d i c aCl o m p l e x Study objective: To determine whether continuous-pulse oximetry improves the recognition and managementof hypoxemia during emergencyendotrachealintubation' Setting and participants: All patients requiring emergency intubatio-nfor whom data collection would not compromise patient care were entered into the study. Two hundred eleven intubation attempts were analyzedin 113 consecutiveadult depariment/trauma center patients qualifying for .-..".t"u ;;;;y .;,.y. Siventy-eight patients were excludeddue to insufficient data collection.

Design and interventions: This prospectiveserial l4-month study in"cluded57 patients with continuous oximetry data.coli.",.d blittdlu, foll,owed by 56 patients with oximetry values to the clinician. oDen ' Methods: AII sampleswere obtainedfrom a finger site at a 5secondsampling rattand stored in computer mâ&#x201A;Źmory' Patients the nasotrachealor orotracheal route' The *it. i"t"lrt.d"via Iength o{ eachintubation attempt was recorded,and the number of hypoxemic episodeswere evaluated' anJlength n,.t,iltt' ftre Utlna vs open Sroups were comparable with resDectto total Or saturation daia analyzed,percent of nasal vs lef,gth of intubation attempts, and percent of oi"il".t.-p,t, patients experiencinga hypoxemic episode(p: {!, {2). Hyggx; [-i. o"""o.a durin"gan'intubation attempt in 30 of Ill blind vs l5 of 100 open attempts {P < .05, X2). In addition, the length of severehypoxemia (Or-saturation less than 85%) duringintub"tiott *'"t'iigttificantly"greater 185t 45 vs 40 t 35 secondsfor blind [22] vs open [seven]attempts (P < .05, t test)'

Conclusion:Continuous pulse oximetry reducesthe frequency and duration of hypoxemia associatedwith emergencyintubation attempts.

.1I 9,'i3:J"ll: ?l :r3['#iY:J"t"[' IJLT"?ii the ED of.Emergency R Cody/Department D Carlin,M Althoff'E Rancatore, NewJersey MorristownMemorialHospital,Morristown, trrteOicine,

Study objective:To evaluatethe pulse-oximeterwave display -.ihod of determining systolic blood pressure' ,. "-D;;i;r, -" Systolic blood-pressurewas measuredby five different methods on 100 random patients presentrngto our community - hospital ED. Methods, At three- minute intervals, each patient had systolic blood pressuremeasuredby Korotkoif sounds,palpation, Doppler, ani pulse oximeter waveform termination and return

tpdfui'.na pownl. Powr andPowRweremeasuredbv

of the pulse bl..tul.u the disappearanceand reappearanc.e disifay while inflating and deflating a blood o*i*.,.i*rue cuff, respeitively. Systolic blood pressurebv Doppler ;;;;;t. was taken as thegold standard The age range of participants -n"t"ttt, 5 months to 160years;patients in shockwere excluded' was Systolic blood pressureby Doppler.rangedirom-84 to 254 mm Fig. The correlition coefficients(r) between POWT ""0 pOWn vJrsus Doppler were 0.98 and O'9,7,-respectively; *fr.i.rt r for both arterial palpation and Korotkoff soundsverr"r-ooppt.t was only 0.92. Nine patients had inaudible blood oi.r*t'.i by Korotkoif sounds. Al[nine were successfullymea' ;;;;e ;tD;ppier, palpation, PowT, and.PoWR We also noted and PoWR was fast and repro-ducible' . in"t a"i.t-it'ting'lbltr Conclusion: We conclude that determining POWT and POwi provides two accurate ways of determining-systolic ilood pi.tt.tt.. We also found this method to be valuable in patien;swith inaudible Korotkoff sounds'

glil""lil? "' lf,xH3il" 1I 0 +"?:liJ,:H:f

Protective Smokehoods and of Environmental PD Martin,JASRoss,SJ Watt/Departments Care, and Intensive MedicineandAnaesthetics Occupational Scotland Aberdeen, RoyalInfirmary, Aberdeen After the Manchesterair disasterof 1985and other incidents since, in which individuals died after smoke inhalation that incapacitated thEm, preventing an effective escape,attentron has 6een directedat the developmentof an apparatusto protect "erirriltt; i"ttalation of smoke and its toxic constituents' The C"ivil Auiation Authority (CAA) has determinedthe designspeciJi""iiotts and the conditions in which any apparatuswould be required to be worn and specific levels of inspired oxygen/ car' LLii Oi"*iO. and carbon monoxide, and exerciselevels and time Proposeddesignsof smoke hoods include a filter for the ;;;t;;. i.t"ourt of'toxins and irritants and the conversion of carbon -o""*ia. ,o carbon dioxide. There is no fresh gas supply and a dead spacewith respiratoryimplications is necessary' At I ,esult, the ambient gasesinipired are made further hypoxic and huo.t.rtbi.. this siudy has iought to define the maximum tol.irUt. O""a spacefor a wide varlety of individuals (children to ;i;;;iyi .nA,riittg the cAA-determined scenario' we have used a commercially"availablecomputer program that simulates cardiot".pit"toty physiology to define individuals and their i.rpo"i. to ttre iee conditions with dead spa-cesof varying volftt. program was first scrutinized to determine its basis "-'o itt the ."iettilfiJ literature. Then it was validated against data iiorn h.rtttty volunteers who were exposedto.the CAA conditions in a laboratory. AIter this, modelling of 8-year-olds,30vear-olds,and 65-year-oldsundergoing the experiment with a iril.,v oi addeddead spaces(57o, 15"/o,25.Y",and 50% of their vital capacities) was peiformed. finally, the respiratory performance under these c-onditions was interpreted and recommen' dations for the maximum allowable dead spacemade' We outit". o"t methods, results, and recommendations in detail as original research into an aspec-tof preventive emergency -eti"itte and introduce an example of use of a computer model that allows experiments with ethical and logistic implications to be attempted on individuals.

EXHIBITORS Annalsof EmergencyMedicine ll25 ExecutiveCircle Irving, TX 75038

(214)ss0-091r

Annalsof EmergencyMedicine, sponsoredjointly by the American Collegeof EmergencyPhysiciansand the Societyfor AcademicEmergency Medicine,reportsthe latestin emergencymedicineresearch,clinical studies.and issues.

DanielStern and Associates Suite240, The Medical Center East 2ll N. Whitfield Street Pittsburgh,PA 15206

J.B. Lippincott Company 227 East WashingtonSquare Philadelphia,PA 19105

Lippincott will display a variety of books of interest. Featuredwill be Harwood-Nuss: The Clinical Practice of EmergencyMedicine. your visit to examine this and other outstandingpublications will be most welcome.

Kurzweil Applied Intelligence 411 Waverly Oaks Road Waltham, MA 02154

(4r2\ 363-9700

With over 2l yearsof dedicatedEmergencyMedicine service,Daniel Stern and Associates provide nationwide placement/recruitment assistance, fee-for-serviceand medical staff development/analysis.Opportunitiesare available nationally for academic, staff and ad-

(2rs\ n8-4',00

(6rD893-s15r

Kurzweil VoiceEM allows the Emergency Medicine physician to generate legible reports simply by speaking - without handwriting or transcription. Words or phrasesappear o.nthe computer screenas they are spoken, and ICD-9 and CPT-4 codes can be automatically generated. Typed reports can be printed immediately by voice. The systemhas a functionally unlimited vocabulary.

ministrativephysicians.Pleasestop by our booth to review our servicesand new computer searchoptions.

DeyLaboratories,Inc. 2751Napa Valley Corporate Drive Napa,CA 94558

Laerdal Medical Corporation One Labriola Court Armonk, NY f0504 (707) 224-3200

Deylaboratories, Inc. specializesin unique packagingof solutionsfor thehealthcareindustry and recently has launchedDEy-WASH@ Skin WoundCleaner.DEY-WASH@ containsSodiumCtrlorideSolution0.9% l-ina pressurizedcan delivering a streamof approximately 19 gauge at 9 psi.This ensuresefficient removalof bacteriaand debris from wounds.

(9r4\ 273-9404

Heartstartautomateddefibrillatorsand early defib. training systems

Medical Marketing ResearchAssociates 132 ResearchDrive Milford. CT 06460

Q03\877-47n

Mdica.l MarketingResearch Associates is conducting physiciansurveyson Emergency neparurrcnt rumagement of patients wilh insectstinganaphylaxis.

I

Medicine Residents'Association ,Dmergency P.O.Box6199ll Dallas,TX 75261-99t1

(2r4)ss0-091r

EmergencyMedicineResidents'Association(EMRA) represents 1.The over2,000 emergencymedicine residentsand medical studentsto organizations involved in emergencymedicine politics, pratice, and The Board ofDirectors expressesresidentconcernsto ACEp, M, ResidencyReviewCommitteeand ABEM. EMRA leaderswilt availableto answer questions.

"'Fujisawa PharmaceuticalCompany 3 ParkwayNorth Center Deerfield.IL 60015

(708)317-0600

Adenocard(Adenosine)- IV antiarrhythmicused for the treatment ofparoxysmalsupraventriculartachycardia.Onset of action approximatelyl-2 minutes, half-life under l0 seconds.

(619)4s5-6700

Incorporated is a research based company that develops, res,and marketsdiagnosticassaysbasedon monoclonalantechnology.The Hybritech exhibit will featurethe ICON eSR readersystem.

(303)mr-6s62

Clinical information systemsfor healthcareprofessionals;evaluated, referencedsourceof information on toxicology (clinical and industrial). drug therapyand EmergencyMedicine; also availableare patientinstructions,dosingprograms,and martindale:the extrapharmacopeia.

Delivery on CD-ROM for use with personalcomputers,compurertapes for mainframes,and microfiche.

Mosby-Yearbook, Inc. 3028 Drawbridge Road Mechanicsville. VA 23111

(804')746-A32

Medical publications.

Nellcor Inc 25495 Whitesell Street Hayward, CA 94545

Hybritech Incorporated

.O. Box 269006 Diego,CA 92196-9006

MICROMEDEX, Inc. 600 Grant Street, 6th Floor Denver, CO 80203-3527

(41s)887-58s8

Nellcor producesmedicalelectronicmonitoring and measurementinstruments,principally for use in direct-careenvironments.Nellcor,s arterial blood oxyen and respiratory gas monitors provide continuous, real-time, noninvasivemonitoring ofoxygen saturationand end+idal carbon dioxide levels. Nellcor also producesa variety of disposable and reusable sensors and airway adaptors for patient use.

Ohmeda 1315W. Century Drive Louisville, CO 80027

(9t4\ 273-9404

Ohmeda offers emergency care physicians patient monitors that revolutionize the ability to detect and treat oxygenation and ventilation problems in both ttre ED and the field. Wittr Ohmeda'sfrrll rangeof pulse oximeters, CO2 monitorsand probes,physicianscan assesspatientoxygenationimmediately and monitor therapeutic intervention continuously and noninvasively, without the guessworkof visual assessment.

Physio Control 11811Willows Road NE Redmond,WA 98052

(206\ 867-4569

Life Net STM, ST Monitor, ShockAdvisory Adapter, Lifepak@ 300, Automatic Advisory Defibrillator, Lifepak 10, Defibrillator/Monitor/ Pacer, Lifepak 9P, Defibrillator/Monitor/Pacer, Ambu VIPD Interactive Training SystemrM,Code SummaryrMCritical Event Record, Hand Free Defibrillation.

Synergon P.O. Box 27352 St. Louis. MO 63141

(3r4) 878-2268

Synergon specializesin emergency department staff and management for Academic, Pediatric and high-volume emergencycare.

Video Sonics 2004 LakesideLane Birmingham, AL 3524/.

(41$ 663-9107

The Wilderness Medical Society provides a professional and scientific forum for wilderness-relatedmedical interestsand encouragesboth basicand clinical researchwhich will result in the developmentof the scientific basis for the health ofthe individual in the wildernesssetting.

Zerowet P.O. Box 7000-16 RedondoBeach, CL90277

(213)378-2150

What's the differencebetweena wound inigation and a wet T-shirt contest?The Zerowet Splashshield.Come seethis revolutionarynew product which will rcdefine your conceptof protectionduring wound irrigation'

CoordinatedHealth Services 255 BusinessCenter Drive Horsham. PA 19044

(800)247-8060

Foundedin 1978, CoordinatedHealth Services(CHS) has achieved a reputationfor delivering consistentlyhigh quality emergencymedical care. We offer physiciansa variety of avenuesfor professionalgrowth and career advancementincluding the active support of the development and implementationof emergencymedicine residencyprograms.

(205)988-s639

Video Sonics is a multi-media firm specializingin the customized preparation of educational materials related to diagnostic ultrasonography.Current projects of interest to emergencyphysicians include an introductory educationalvideo and an interactive computer graphics/animationprogram assessingbasic ultrasonographyskills.

W.B. Saunders Company 911 Schindler Drive Silver Spring, MD 20903 Current publicationsin EmergencyMedicine: New editions of Roberts: Clinical Procedures in Emergency Medicine; Hamilton: Emergency Medicine; Barsan: Emergency Drug Therapy,' Redman: Emergency Radiology and the Amertcan Journal of Emergency Medicine.

Weatherby Health Care 25 Van Zant Street Norwalk. CT 06855

WildernessMedical Society P.O. Box 397 140BuenaVista Avenue Point ReyesStation, CA 94956

(800)36s-8900

Weatherby Health Care is a prominent physician placement firm with over 400 practiceopportunitiesnationwide.Pleasestop by booth #17 to explore these opportunities and pick up your free gift.

Clinical ResourceSystems,Inc. 1111W. 6th Street Suite C230 Austin. TX 78703

(.512\478-1792

EMSTAT - A comprehensivecomputer'systemfor the management of the ED includes patient tracking, point-of-careorder entry and clinical charting, algorithm triage, printing of prescriptions and dischargeinstructions, and generatinglogs and other reports including research-orientedreporting.

California Medical Products, Inc. 1901Obispo Avenue Long Beach, CA 90804

(213)49+7r7r

California Medical Products,Inc., is highlighting three innovativeproducts. Come view the new StifneckrMcervical collar with many new features, and the exciting new manually-powered suction unit, V-VACTM - the lightweight, compact, economical suction unit that's there when you need it. Also, experience the HeadBedrM CID disposablecervical immobilization device.

-

ANNUAL BUSINESSMEETING AGENDA l. Elections, William Barsan, MD, Chairman, Nominating Committee information on each candidateare included in this program The slateof nomineesis listed below and photos and biographical (one 3-year International Committee Chairman President-Etect- (one 1-yearposition) position) Louis Ling, MD DouglasA. Rund, MD Secretary/Treasurer - (one 3-year position) Louis S. Binder, MD William H. SPiveY,MD

Nominating Committee Members Larry J. Baraff, MD Edward Bernstein,MD David M. Cline, MD Connie Greene, MD

Board of Directors - (three 2-year positions) StevenDronen, MD Lewis R. Goldfrank, MD Gary Krause, MD V. Gail RaY, MD David P. Sklar, MD Gary R. Strange,MD Governmental Affairs Committee Chairman 3-yearposition) Robert A. Lowe, MD

(one

- (two 2-year positions)

Constitution and Bylaws Committee Member 3-yearposition) Carey D. Chisholm,MD M. Andrew Levitt, DO SuzanneM. ShePherd,MD

(one

Chairman, constitution and Bylaws committee 2. Amendment to the constitution and Bylaws, Lttuis Binder, MD, that individualselectedto chair standingcommitteeswould Theproposedamendmentto the constitution and Bylaws would require of the committeebeforea two year term as chairman' beelectedone year in advanceand during ttratfear rould serveas chair-elect are included in this program with the new languagepublished The proposedamendmentand the entirJ constitution and Bylaws in boldface.

MD 3. Awards Presentations,JamesNiemann, MD and Jeris Hedges' 4. Secretary-Treasurer's Report, I'ouis Ling, MD, Secretary-Treasurer A.Membershipat APril 20, l99l: 1,915 AssociateMembers:247 Active Members: 1,036 EmeritusMembers: l3 InternationalMembers: 64

3l' 1990 Report- YearEndingDecember B.Finance Revenues ' "$242"166 Dues ' ' '$95'231 AnnualMeeting '$22,972 (Edinburgh) Symposium $8'995 .

EMF contributions " "$27 'ol4 Interest "$45'155 Grant' Geriatric List Mailing of Sale ' " '$8'045 ads.. andnewsletter ""'$l'825 other' andJob Catalog.. ' ' '$10'701 EMRA newsletter

ResidentMembers: 435 Honorary Members: I I

Medical Student:82 Pending:27

Expenses Taxes Wages, rr 46vrr rg), Salaries, JAt4l A n n u a lM e e t i n s r q^vr

(Edinburgh) Symposium t-eteptroneand Postage Other ldministration AAMC Annals Subscriptions Newsletterpublication

EMF ' 7th World Congress Other organizations

.$t22,970 ""'$91'915

q39'191 $26'056 . $35'147* '$14'449** ' .$6,650 $16,461

' '$9'o9o . . .$5'000 . '$12,709x**

" " '$371'216 TOTAL ..$462,104 TOTAL discretionary president's charges, bank accounting, *includes printing,officerentandinsurance, photocopying, officesupplies, fund,depreciation. to attendAAMC AnnualMeeting, staffexpenses expenses, x*includes dues,AAMC representative Societies Councilof Academic posterat the AAMC AnnualMeeting' andSAEM sponsored Force' and AACEM' {.r6tincludes EMRA, ACEP ScientificAssembly,AMA, AAMI, EMRS, CoreContentTask Address:Jerris R. Hedges,MD 5. President's 6. Introductionof New President:William G. Barsan,MD 7. NewBusiness 8. Adjournment 7l

J

SLATE OF NOMINEES Disaster Medicine Symposium in Beijing in 1990. Since 1990 he has been a member of the Annals of Emergency Medicine Editorial Board and since 1989 a member of Journal of Emergency Medicine Editorial Board. Dr. Spivey graduatedfrom East Carolina University Medical School in 1981 and completed his residency in 1984 and a Research Fellowship in 1985, both from the Medical College of Pennsylvania'

PRESIDENT.ELECT Louis Ling, MD is the Associate Medical Director for Academic Affairs, and Senior Associate Physician in the Department of Emergency Medicine, Hennepin County Medical Center. Dr. Ling was electedto the SAEM Board of Directors in 1988forthe three year secretaryltreasurer position. Since 1989 he has also been the editor of the SAEM newsletter,Academic Emergency Medicine. From 1983-1987he was a member of the STEM Curriculum Promotion Louis Ling, MD Committee, serving as the Committee's chairmanfrom 1987- 1988. Dr. Ling hasbeena memberof SAEM since 1983. After graduating from the University of Minnesota in 1980, Dr. Ling completed a flexible internship in 1981 at Hennepin County Medical Center, after which he completed his Emergency Medicine residency in 1983 at the University of Chicago. Dr. Ling has been a member of the RRC-EM since 1987 and was recently elected as the

BOARD OF DIRECTORS Steven Dronen, MD, comPleted an Emergency Medicine residency in 1980 at Henry Ford Hospital after graduating from the University of Ill-inois Medical Schoolin 1977. Dr. Dronen developed theResidencyConsultingServicein198990 and chairs the Residency Aid Committee. He is also a member of the ResearchCommittee. He was a memberof the ad hoc Journal Task Force in 19841985 and was chair of the ad hoc Mem1986-87.Heserved bershipCommitteein StevenDronen,MD on the UA/EM Journal Task Force in 1984 and is a member of the Council of Residency Directors Board of Directors. He has been a member of SAEM since 1982 and has beena moderatorat the Annual Meeting since 1984' Dr. Dronen is anAssociate Professorof Emergency Medicine at the University of Cincinnati.

Chairman-elect.

SECRBTARY/TREASURER Louis S. Binder, MD is an Associate Professor and Director of Education in the Department of Emergency Medicine at Texas Tech University. He is also the Assistant Dean for Graduate Medical Education and Student Affairs. He is cuffently a member of the SAEM Board of Directors (elected-1990),chairman of the UndergraduateEducationConsulting Service,chairmanof the Constitution and Bylaws Committee, and a member of the Nominating Committee. He also served Louis S. Binder, MD as chairman of the UndergraduateCurriculum Committeefrom 1988-1990.Dr. Binder also servesas the Associate Editor for Education for the SAEM newsletter, Academic EmergencyMedicine. He hasbeen a member of SAEM since 1982. He served on the STEM Goals and Objectives Committee, the Public Relations Committee, and the Membership Committee. Dr. Binder graduatedfrom the University of Minnesota Medical School in 1980, and completed an Emergency Medicine residency in 1983 at Truman Medical Center. Since 1987, he has been a reviewer for Annals of Emergency Medicine and AJEM.

Lewis R. Goldfrank. MD

Lewis R. Goldfrank, MD, is an Associate Professor of Clinical Medicine at New York University School of Medicine and Director of EmergencyServices at Bellevue Hospital Center and New York University Medical Center. He is also the Medical Director at the New York City Poison Control Center. Dr. Goldfrank graduatedfrom University of Brussels, Belgium Medical School in 19'70and completed his residencyin Internal Medicine at Montefiore Hospital and Medical Center in 1973. Dr.

Goldfrank was appointed to the Board of Directors in 1990 to fill an unexpired term. He has been a member of SAEM since 1974. He has been an Annual Meeting abstract reviewer since 1986 and was a moderator at the 1988 and 1990 Annual Meetings. Dr. Goldfrank is a member of the Editorial Board of Clinical Toxicology and Medical Toxicology andwillbe the Chairman of the AmericanBoardof Medical

William H. Spivey, MD, is chief, division of Research;Associate Director of the emergency Center; Fellowship Director, and AssociateProfessorof Emergency Medicine at the Medical College of Pennsylvania. He has been a member of the SAEM Program Committee since 1987 and is currently the chair of the Research Committee. He was also the chairman of the Constitution and Bylaws Committeein 1989andhasbeena member of SAEM since 1985. Dr. Spivey actedas William H. Spivey, MD moderator of the SAEM program at the "InformedConsentforBiomedi1990AAMC AnnualMeetingentitled, cal Researchin Acute Care Medicine." Dr. Spivey was also a SAEM representativeto the 6th World Congresson Emergency and Disaster Medicine in Hong Kong in 1990and to the l st International Emergency

Toxicology until1992.

Gary Krause,MD

72

Gary Krause, MD, is an AssistantProfessor and the AssociateResearchdirector in the Department of EmergencY Medicine at Wayne State University School of Medicine. He hasbeena member of SAEM since 1981 and was a member of the Program Committee from 1988-1990. Dr. Krause is currentlya member of the ResearchCommittee and was a moderatorat the 1987, 1988and 1989 Annual Meetings. Dr. Krauseis a reviewer for Annals of EmergencyMedi"Controversiesin Recine and edits the

suscitation" section for Resuscitation. Dr. Krause graduated from WayneStateUniversity School of Medicine in 1981 and completeda residencyin emergencymedicine at Wayne State University in 1984.

V. Gail Ray, MD, is an Associate Prof'essorand ResidencyDirector at the East Carolina University. Shegraduatedfrom the University of Arkansas Medical School in 1977and completedher Emergency Medicine residency at Truman Medical Center, University of Missouri at KansasCity in 1980. Dr. Ray is currently the Chairman of the Membership Recruitment and Public Education Committee and a member of the Residency Consulting Service Committee.

V. Gail Rav. MD Shewas alsoa memberof the Education Committee from 1986-1989and a memberof the ResidencyDirectors Committee from 1987-1989.Dr. Ray is a guestreviewerfor Annals of Emergency Medicine and hasbeena memberof SAEM since 198I .

David P. Sklar, MD, graduated from Stanford University Medical School in 1976, completed an Internal Medicine residencyin 1978 at the University of New Mexico, and an EmergencyMedicineFellowshipin 1980at theUniversity ofCalifornia, SanFrancisco.Dr. Sklar is the Chairman of the PublicationsTask Force and a memberof the Ethics Committee. As a member of the Education Committee he is a member of the Methodology Grant Subcommitteeand the David P. Sklar, MD FacultyDevelopmentSubcommittee.He alsoparticipated in the SAEM presentationat the 1989AAMC Annual Meeting entitled,"Innovationsin EmergencyMedicineEducation."Dr. SklarisanAssociateProf'essor in the Division of EmergencyMedicine; Residency DirectorandAssociateDirectorin theDivision of Emergency Medicine at the University of New Mexico Schoolof Medicine. He is areviewer for Annals of EmereencvMedicine and hasbeena member ofSAEMsince 1986.

Gary R. Strange, MD, is an Associate Professor and Director of Emergency Medicine at the University of Illinois, Chicago. He graduatedfrom the University of Kentucky in 1974 and completed his EmergencyMedicine residencyat the University of SouthernCaliforniain 1979.

Dr. Strangehasbeena memberof SAEM since 1983andis currentlythe Chairman of theEducationCommittee.

From 19821986 Dr. Strange was the Chairman of the Educational Resources Committee and was the editor of the Educational Resources Compendium.,In 1984,1987,and 1988Dr. Strangewasalso theRepresentative to the AAMC-CAS. He is a member of the Editorial BoardofPediatric EmergencyCare and a guestEditor for pediatricsfor AJEM.

GOVERNMENTAL AFFAIRS COMMITTEE CHAIRMAN Robert A. Lowe, MD, has been a member of SAEM since 1985. He was appointed the Chairman of the Governmental Affairs Committee to complete an unexpired term. He is also a member of the Research Committee. He was a member of the STEM Public Education Committeefrom 1987-1989and was an ad hoc abstractreviewer for the I 988 and 1989Annual Meetings.Dr. Lowe graduated from the University of California, Davis Medical Schoolin I 977, completed Robert A. Lowe,MD an Internal Medicine residency from the Universityof Michiganin 1980,anEmergencyMedicineresidencyfrom the University of Cincinnatiin 1984,and will completehis Mastersin Public Health program from University of California, Berkeley, School of Public Health, in 1991. Dr. Lowe is an AssistantProfessorin the Division of Emergency Medicine at the University of California, San Francisco.

INTERNATIONAL COMMITTEE CHAIRMAN Douglas A. Rund, MD, is a professorand chairmanof theDepartmentof Emergency Medicine at the Ohio State University.

Dr. Rund was the Program Chairman of the UA/EM-IRIEM 1985ResearchSymposium. He wasalsothe UA/EM delegate to the Board of Directors of the Emergency Medicine Foundationfrom 19871990 and has been a delegate to the American Board of EmergencyMedicine since1988. Dr. Rund hasbeena member of theInternationalCommitteesince 1987 and a memberof SAEM since 1977. He is a reviewer for JAMA and Annals of EmelgencyMedicine. He is a 1971 graduateof StanfordUniversity Medical School and completed an Internal Medicine residencyin 1973 and a GeneralSurgeryresidencyin 1974. ln 1976Dr. Rund completed a fellowshipSurgeryresidencyrn 1974. In l976Dr. Rund completeda fellowship as a Robert Wood JohnsonFoundation Clinical Scholar. In 1987he completeda posFdoctoralscholarfellowship at the University of Edinburghin the Departmentof Community Medicrne.

NOMINATING COMMITTEE MEMBERS

Larry J. Baraff, MD

Larry J. Baraff, MD, is a professor of Pediatricsand Emergency Medicine and associate director at the University of California, Los Angeles Emergency Medicine Center. He graduated from Georgetown University Medical School in 1910 and completedhis residencyin pediatrics at Georgetown University Hospital in 19'73. He then completed an infectious diseasesfellowship in 1976 at USC Medical Center. Dr. Baraff is currently a member of the SAEM Geriatric EmergencyMedicine TaskForce and is a

member of the Annals of EmergencyMedicine Editorial Board. He has been a member of SAEM since 1982.

CONSTITUTIONAND BYLAWS COMMITTEE MEMBER Carey D. Chisholm, MD, has been a member of SAEM since 1985 and is a member of the EMS Committee and the ResidencyAid Consulting ServiceCommittee. He was also the co-editor for the SAEM Emergency Medicine Residency Cataloguefor the past two years and has been a grant reviewer for the PhysioControl EMS Fellowship. He graduatedfrom the Medical College of Virginia Medical School in 1980. He completed a Transitional Internship in CareyD. Chisholm,MD 1981 and an Emergency Medicine residency in 1983,both from Madigan Army Medical Center. Since 19g9, he has been a reviewer for Annals of Emergency Medicine. Dr. Chisholm is a Clinical Associate Professorof Emergency Medicine at the Indiana University School of Medicine and is alsothe Director of the Emergency Medicine Residency Program at Methodist Hospital of Indiana,Inc.

Edward Bernstein, MD, is an Associate Professor of Emergency Medicine and Public Health at Boston University Medical School and an attending at Boston City Hospital. He is the chairman of the Public Health and Prevention Subcommittee of the Membership andPublic Education Committee. He also organized the Roundtable Luncheon on public Health and Health Policy Issuesat the 1990 SAEM Annual Meeting and will Edward Bernstein, MD organizea similar luncheon for the I 99 I SAEM Annual Meeting. Dr. Bernsteinis currently a member of the Geriatric Task Force. From l9g7_g9 he was the STEM Chairperson of the public Education Committee. He com_ pleted his internship in 1970 at the University of California, San Franciscoaftergraduatingfrom StanfordUniversity School ofMedicine in 1969. He was Board Certifiedin Family practicein 1975and Board Certified in EmergencyMedicine in 1983. Dr. Bernsteinhas been a memberof SAEM since 1987.

M. Andrew Levitt, DO, is an Assistant Professor of Medicine and Director of Researchin the Division of Emergency Medicine at the University of California, San Francisco. Dr. Levitt has been a member of SAEM since 1984. He has also been a member of the ResidentResearchin EmergencyMedicine Commi! tee and the Committee on Animal ResearchinEmergencyMedicine. Dr. Levitt graduatedfrom the University of Osteopathic Medicine and Health Sciencesin M. Andrew Levitt, DO DesMoines in 1980,completeda surgery residency in 1982 at Albert Einstein and completed an emergency medicineresidencyin 1984 at the University of Arizona.

David M. Cline, MD, graduated from Wayne State University Medical School in 1982 and completed an emergency medicine residencyin 1985 at the University of Illinois. Dr. Cline is currently a member of the SAEM ResearchCommittee and is the chairmanof the Resident ResearchCurriculum Subcommittee.He was the coordinator for the Research Director'sLuncheonatthe 1989and 1990 SAEM Annual Meetingsandwill beagain for the 1991Annual Meeting. Dr. Cline David M. Cline, MD hasbeenamemberofSAEM since1985.

Dr. Cline is an assistantprofessorof EmergencyMedicine, and Medical Director, Division of Research,Departmentof EmergencyMedicine, at East Carolina University.

Suzanne M. Shepherd, MD, graduated from Georgetown University School of Medicine in 1980 and completed her EmergencyMedicine Residencyin 1983 at the Georgetown/GeorgeWashington University. She has been a member of SAEM since 1984 and was a memberof the STEM Educational ResourcesCommittee, the Goals and Objectives Committee, and was SubcommitteeChair of the UndergraduateCurriculum Commif tee. She is currently a member of the SuzanneM. Shepherd,MD SAEM Education Committee and the UndergraduateEducational Consulting Services. Since 1990 she has also been a member of the Membership and public Education Commif tee. Dr. Shepherdhasbeenboth a reviewer for the American Journalof Emergency Medicine, and an oral board examiner for the American Board of EmergencyMedicine since 1989. Dr. Shepherdis an associate professorof EmergencyMedicine and Vice-chair for Clinical Affairs at East Carolina University.

Connie Greene, MD. hasbeena member of SAEM since 1981 and from 19861987wasamemberofthe STEMFaculty Development Committee. Dr. Greeneis currently a member of the SAEM Ethics Committee. Since 1983shehasalsobeen an examiner for the American Board of Emergency Medicine. After graduating from Rush Medical Collegein 1978,Dr. Greenecompleted a pediatric internship at Michael ReeseHospital in 1979 andan emergency medicine residency at the Connie Greene, MD University of Chicagoin 1981.Dr. Greene is currently a clinical associateprofessor in the Department of Emer_ gency Medicine at the University of Illinois, Abraham Lincoln Medical College. t+

CONSTITUTION OF THE SOCIETY FOR ACADEMIC EMERGENCY MEDICINE ARTICLE I _ NAME "The

The name of this organization shall be, Society for Academic Emergency Medicine," hereinafter referred to as, "The Association."

ARTICLE II _ OBJBCTIVES Section1; The objective of this Association is to improve the emergency,urgent, or critical care ofthe acutelyill or injured patientby promoting research, by educating health care professionalsand the public, by fostering relationshipswith organizationswith a similar purpose, and by supporting the specialized or multidiscipline care of such patients through research andeducation.The Association will function as a scientific and educational organizationas definedin Section501(c) (3) ofthe InternalRevenue Code, as amended.

Section2: The Associationshall pursue its purposeby: l) sponsoringforums for the presentationof peer-reviewedscientific and educationalinvestigations,2) convening and sponsoringeducationalprograms for health care professionalsand the laypublic, 3) promoting academicdevelopmentand education of its membershipthrough specializedprograms,4) servingas anacademic,university-based,and/or teachinghospitalrepresentativefor the care of the acutely ill or injured patient, 5) developing liaison with other organizationswith a similar purpose,and 6) publishing researchand educationaldata in the scientificand educational literature and other media available to the lay public.

Section3: A. This corporationis organizedexclusivelyfor educational and scientific pulposes, including, for such purposes, the making of distributionsto organizationsthat qualify asexemptorganizationsunder Section501(c) (3) of the InternalRevenueCode of 1954 (or the correspondingprovision of anyfuture United States Internal Revenue Law).

B. No part of the net earningsof the corporationshall inure tothebenefitof, or be distributableto its members.Directors.

Officersor other private persons,exceptthat the corporation shallbe authorizedand empoweredto pay reasonablecompensationfor servicesrenderedand to make paymentsand distributionsin furtherance of the purposes set forth in paragraph A hereof.No substantialpart of the activities of the corporation shallbe the carrying on of propaganda,or otherwise attempting to influencelegislation, and the corporation shall not participate in, or intervene in (including the publishing or distribution of 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 exempt from FederalIncome tax under Section 501 (c) (3) of the Internal Revenue Codeof 1954(or correspondingprovision ofany future UnitedStateRevenueLaw) or (b) by a corporation, contributionsto which are deductible under Section 170(c) (2) of the InternalRevenueCode of 1954(or the correspondingprovision of any future United State Internal Revenue Law).

ARTICLE III _ MEMBERSHIP SectionI: Classifications. There shall be seven classesof membership: active, associate,emeritus, resident/fellow, honorary,and international active and international associate.

Section 2: Qualifications. (l) Candidates for active membership shall be individuals with an advanceddegree (MD, PhD, DO, PharmD, DSc, or equivalent) who hold a medical school or university faculty appointmentand who actively participate in acute, emergency, or critical care in an administrative, teaching, or research capacity, (b) individuals with similar degreesin active military service (U.S. or abroad) who actively participate in acute, emergency, or critical care in an administrative, teaching, or research capacity. (c) Individuals who otherwisemeet qualificationsfor active membership as defined above but who do not hold a university faculty appointmentmay petition the Membership Committee for consideration for active membership status, if desired. (2) Candidatesfor associatemembershipshall be health professionals, educators,governmentoffrcials, membersof lay or civic groups, or members of the public at large who may have an interest or desire to participate in pursuing the purposesand objectives of the Association. (3) Candidatesfor emeritus membership shall be (a) active memberswho seeksuchstatusand who havegiven 15 continuousyearsofactive serviceto the Associationand have attainedthe ageof 65 years O) other active memberswho under special circumstancesare invited for such emeritus statusby the Membership Committee. (4) Candidatesfor resident/fellow membershipmust be resident(s)or fellows in residency training program(s) who have an interest in emergency medicine.

(5) Candidatesfor honorary membership shall be individuals who have made outstanding research or educational contributions to the purpose and objectives of the Association. (6) Candidatesfor internationalmembershipshall be individuals who resideoutsidethe U.S. and who meet qualifications for active or associatemembership as described above. Such candidatesmay apply for active, associate,or other membership in the Association.

Section3: Member Rightsand Privileges. All membersmay have the privilege of the floor and of serving on the committeesof the Association.All membersof the Associationmay serve on the Board of Directors or as a committee Chairperson. Only active members shall have voting rights and shall serve as officers 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: Board of Directors shall serve as the governing body of the asociation. The Board of Directors shall consist of the above officers, the Program Committee Chairman, the immediatepastpresident,and f,rveCouncilmen-at-Iarge. Both active and associatemembers may serve on the Board of Directors, but only active members may be officers of the Association.

Section3; The Executive Committee shall consist of the president, President-elect,past-Presidentand Secretary-Treasurer.

ARTICLE V _ COMMITTEES The standing committees of the Association shall be: (1) Nominating Committee, (2) Membership Committee, (3) program

Cornmittee' (5) EducaCommittee, (4) Constitution and BylaJvs (6) Researchcommittee' (7) I iaison committi-e;;;ti";, Medical Colleges' (8) tee to the Association of American (9) Committee on Inand Committee, Affairs ;;";--;td by Additional committees may be created ;;;;Aff"irs. created be may the Board of Directors u"J uA hoc committees efforts to achieve Un tft" pt"tiAent to aid in the Association's und futth"t its goals.

ARTICLE VI - ANNUAL MEETING Sectionl;ThereshallbeanannualmeetingoftheAssocia'i'hit meeting shall consist of an educationaland scientific dt. program and a businesssession' Section2:TheBoardofDirectors'bymajorityvotg'ntfY of the membership ""li tp"t gOAaysnotice, a specialmeeting that the Board business any "otiao"t io or standing committee or standing oi iii""io"tt shall place before the membership committee.

-of.call and conduct any Section3: The Board of Directors may the meeting ,p""iuf meeting Uy -ul' fot purposes ,notice' and it shall ballots mail of ieturn the date shall be a date set ior resolution proposal' any of Adoption date' ili ."ff"A rft" "oting-mail affirmative by ballot shall be achieved by "t "*l"a*""t active members unless otherwise voting of *".ioriiy "i" """ only those p;;;id"J uy unoti,er.provisfon of this constitution' Association the of office Uusiness ttte af mail ballots recelveo date shall be counted' within 30 days suusequenilo tft" voting

be by a Section4; Adoptionof a bylaw amendment,shall at any voting and present trt. u"tiuemembers *;;tny;;;"-oi annualor sPecialmeetlng'

ARTICLE VIII - ADOPTION OF THE AMENDMENTS TO THE CONSTITUTION adopted or amendedat Section 1: The constitution may be membership' the or special meeting of ^"y ;;;"i the constitution shall be Section2; Proposedamendmentsto by three mem,uf-itt"A in wriiing to the Secretary/Treasurer they are to which at meeting the to prior 60 day; ;;;i"* shall mail the proposed be considered. The Secretary/Treasurer 30 days prior to that amendmentsto the membeiship at least meeting.

Section3:TheBoardofDirectorsmay,byresolution,proposâ&#x201A;Ź the proposedamendamendmentstottre conJiution; provided 30 days prior to least at membeiship -"ni" ur" mailed to the at which they are to be considered' ;il;;G amendmentshall be by Section4; Adoption of a constitution voting at any vote of the active memberspresentand " ;;j;tit annual or sPecial meeting'

ARTICLE IX - DISSOLUTION Boardof DirUpon the dissolutionof the corporation'the thepayment for provision ectoisshall,afterpayingor making of all of the dispose "otpoiation' liabilitiesoi trt" ;';ii;ith; ofthe corcorporationexclusivelyfor thepurposes ;;;;lth" organized porationin suchmanner,,orto such,organizations religious educational' exclusivelyfor charitable' ffi-ofer;il exempt an as time the at Wali! or scientificpurposesasshall 501(c)(3) of the Section under "i"".i""ti"t^or'organizaiions provior rqs+(orthecorresponding ff;;Til;;;-ffi; asthe Law) ' Revenue ri"" ;i ";t futureUnitedStatesInternal disso not assets such Any determine. ii""rJJ6ir"ctors shall Jurisdiction Competent of Court a by disposJ ;"ll be ;J;f the corporation i""ii" L-"t*it in which the principaloffice of to suchorganior purp.os?.s exclusivelyfor such i;;;;ilfu which determine' court-ihall said ut organization,, ;;;oi purposes' for such ut" otgunir""Oand operatedexclusively

ARTICLE VII - BYLAWS amendedat any annual Sectionl; Bylaws may be adoptedor or special meeting of the membership' bylaws shall be subSection2; Proposedamendmentsto the to the Secretary/Treasurerby three members tri,tJ-i"'*tiiing are to be dayJprior to the meeting at wiich.they "iil".t60 proposed the mail shall considered. The Secretary/Treasurei amendmentstothemembershipatleast30dayspriortothat meeting. by resolution' proSectionS; The Board of Directors may' o*.u*"notnentstothebylaws;providedtheproposedamendpriorto

at least30 davs i" it'" membeiship ffi;;;;;ii"J considered' be to are they iii. .""titg at which

BYLAWS OF THE SOCIETY FOR ACADEMIC EMERGENCY MEDICINE active' associate' resiSection 2: Dues. Annual dues for by and international members will be established a*llf"tto*, will members the Board of Directors' Honorary and.emeritus vt"-u".tttip in the Association may be terminated il il;; for nonPaYmentof dues'

ARTICLE I - MEMBERSHIP

application forms Section 1: Application Process'Membership Ex-

throughthe rr"" u" "ulin-Jarro* theSecretary/Treasurer mustreturn

"".i,1"" Directorof theAssociation.TheApplicant letters.to the ,fr" ""-pi"i"a applicationforms and suppbrting monthprior one afleast B*"ri,ii" niredtor of the Association for be to order in to Board of Directorsmeeting "considered for applicants. of ThJqualifications time' il"rnU"ttftip at that Committee -"t U"ttftip will be reviewedby the vtembership Approval of ap"i "*ft -.i ing of the Board of Directors' electionto one constitute shall "ii""ti, Ut tft"tooncil Board immediately' effective .ut.gories, ;ffi;hb"rrttip

have the privSection3: Rightsand privilege's' All members and the floir at businessireetings of the Association t6;;i or chair' committee may serve as a committee member' 'il;d; memactive only Directors' of the Board of ;-;rge submit o:no**" ut officers' Any member mav ;;;;y;; of Directors' Board the by consideration for un"nau items

't6

ARTICLE II _ BOARD OF DIRECTORS SectionI: Members. The Board of Directors shall consist of the President,Vice-President (President-Elect),the Secretary/ Treasurer,the Immediate Past President, the Program Chair, and five Members-at-Large.

Section2: Election of Officers. (a) The Vice-President shall be electedfor a term of one year with automaticsuccessionfrom Vice-Presidentto Presidentthe following year. During this two yearperiod, the electedmember will serve as an officer of the Association.Following terms of Vice-President(President-elect) andPresident,this member will automatically assumethe position of Immediate Past President. Election as Vice-President shallconfer Board of Directors membership for a minimum of threeyears. Nominees for this office will be selectedby the NominatingCommittee, and must have agreedto standfor electionprior to formal nomination for election at the businesssessionof the annualmeeting.Alternativenominationswill be acceptedfrom the floor. Such nomineesmust also agree to stand for election. Election shall be by majority vote of the active memberspresentand voting at the businesssessionof the annualmeeting.The Vice-Presidentmay also be electedor appointedas Chair of other standing or ad hoc committees, with theexceptionof the Program Committee, and shall be an exofficio member of all standing committees. (b) The Secretary/Treasurershall be elected to a three year term. An activemembermay serveonly one term as Secretary/Treasurer.

Nomineesfor this office shall be selectedby the Nominating Committeeand must have agreed to stand for election prior to theirformal nominationfor electionat the businesssessionof theannual meeting. Alternative nominations may be offered fromthe floor. Suchnomineesmust also agreeto standfor election.Election shall be by majority vote of the active members present and voting at the businesssessionof the annualmeeting.The Secretary/Treasurermay also be electedor appointed astheChair of standingor ad hoc committees, with the exception of the Nominating Committee and Program Committee, andmay serve as a member of all committees.

Section3 : Election of Members-at-lnr ge. Members-at-Large shallbe electedto two year terms, the terms being staggered.

Members-at-Large may only be electedfor two consecutive terms.Nomineesfor the above offices shall be selectedby the NominatingCommittee and must have agreedto standfor electionprior to their formal nomination for election at the business session of the annualmeeting.Alternativenominationsmay be offeredfrom the floor. Such nomineesmust also agreeto stand for election. Election shall be by majority vote of the active memberspresentand voting at the businesssessionof the annualmeeting.

Members-at-Largemay also be elected as Chairs of standing committees,with the exceptions of the Nominating and ProgramCommittees,appointedas Chairs of ad hoc committees, or seryeas a member of standing or ad hoc committees, with the exceptionof the Nominating Committee.

Section4: Election of Program Committee Chair. The ProgramCommittee Chair shall be elected to a three year term, wilh thefirct year of the term semed as Chair-Elect Nominees musthave agreed to stand for election prior to their formal nominationfor election at the businesssessionof the annual meeting.Alternative nominations will be accepted from the floor. Suchnomineesmust 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. The Program Comminee Chair shall not be eligible for other elected positionswithin the Association,but may serveas an appointed member of other standing or ad hoc committees.

Section5: Termsof Office. Terms of office will begin at the conclusion of the annualbusinessmeeting. The Presidentshall appointeligible Associationmembersto fill vacanciesand unexpired terms on the Board of Directors and standingand ad hoc committees until the next scheduledelection.

Section 6: Meetings of the Board of Direaors. Meetings of the Board of Directors will be convenedat leasttwice during the term of the President of the Association. Additional meetings may be convenedat the President'sdiscretionor by petition of six members of the Board of Directors. A final notice of time and place of such meetings shall be sent to all members of the Board by the Secretary/Treasurer at least 7 days before the meeting. Six members of the Board of Directors will constitute a quomm.

Members of the Association, regardlessof membershipcategory, may submit agendaitems. Such items must be submitted within 30 days of the meeting date. Meetings of the Board of Directors are open to all members of the Association and to the public.

Closedmeetingsof the Association'sofficers and ExecutiveDirector may be convened by order of the President.

Section 7: Duties of the President. The President shall preside over both the educational program and businesssession of the annual meeting of the Association, and the meetingsof the Board of Directors. It shall be the duty of the Presidentto see that the rules of order and decorum are properly enforced in all deliberations of the Association, to sign the approved minutes of each meeting, and to executeall documentswhich may be required for the Association, unlessthe Board of Directors shall have expressly authorized some other person to perform suchexecution.The Presidentshall serveas Chair ofthe Board of Directors and shall serve as an ex-officio member of all committees. The President shall appoint members to fill vacanciesand unexpired terms on the Board of Directors and standing and ad hoc Committees until the next scheduled election.

Section 8: Duties of the Vice-President (President-Elect). The Vice-Presidentshall presidein the absenceof the President.The Vice-Presidentshall serveas Chairmanof the Nominating Committee and ex-officio member of all committees.

Section 9: Duties of the Secretary/Treasurer.It shall be the duty of the Secretary/Treasurerto presidein the absenceof both the Presidentand Vice-President.The Secretary/Treasurershall keep a true and correct record ofthe proceedingsofthe annual businessmeetingand meetingsof the Board of Directors, shall preserve documentsbelonging to the Association and issue notice of the annualbusinessmeetingand meetingsof the Board of Directors 60 days prior to such meetings. The Secretary/ Treasurer shall keep an account of the Association with its members and maintain a current register of members with datesof their election to membershipand preferred mailing address,the latter to be circulated annually to the membership within 30 days of the annual businessmeeting. The Secretary/Treasurershall be responsiblefor reporting unfinished businessrequiring action from previous meetings of the membership or Board of Directors and will be responsiblefor the agendaof the annual businessmeeting and meetingsof the Board of Directors. The Secretary/Treasurershall collect the dues of the Association, make disbursementsof expenses,and maintain the financial accounts and records of the Association.

The hnancial record will be presentedto the membershipat

r for vote by active members shall include but not be limited to: (1) a financial report from the Secretary/Treasurer,(2) amendments to the Constitution and Bylaws of the Association, (3) election of officers, members of the Board of Directors, and the Chairs and membersof standingcommitteesof the Association, (4) reports of committeeactivities, (5) transactionof other businesswhich may come before the membership, and (6) a "State of the Association" addressby the President.Where dictated by the Constitution and Bylaws, the Association shall be governed by a majority vote of active members in attendance at the annual.businessmeeting. The Presidentof the Association shall preside over the meeting and the Secretary/Treasurer will circularc agendaitems to the membership 30 days before the annualbusinessmeeting. The Chairs of the Constitutionand Bylaws Committee and Nominating Committee will preside over the respectivoparts of the annual meeting. The annualbusiness meeting shall be held at a time and place determined by the Board of Directors of the Association approximately one year in advance of the convocation.

the annual businessmeeting, biannually to the Board of Directors, and at such times as requestedby the President of the Association. The financial records of the Association shall be reviewed annually by two other members of the Board of Directors appointed by the President, or a certified accountant or finanpial 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 11: Duties of Program CommitteeChair. Acnngtnder the auspicesof the President and Board of Directors of the Association, the Program Committee Chair shall be responsiblefor the Association's annual researchand education meeting, as well as other symposia or meetings sponsoredor co-sponsoredby the Association to meet its purpose. The duties of the Program Committee Chair shall include but not be limited to: (l) selection of committee members, (2) selectionof meeting sites, (3) designationof ad hoc committee members specifically selected for review of materials to be presentedat the annual meeting or other Association meetings, (4) peer-review and selection of papers to be presentedat meetings or forums sponsoredor co-sponsoredby the Association, (5) publication of call-forabstract notices, and (6) scheduling activities at the Association's annual meeting or other meetings sponsored or cosponsoredby the Association. Recommendationsfrom the Program Committee Chair must be approved by the Board of Directors by majority vote.

Section2: Betweenannualbusinessmeetings,within the policies establishedby the Association's membershipand the Constitution and'Bylaws, the Association shall be governed by the Board of Directors. Actions of the Board of Directors shall be determinedby a majority vote of those of its memberspresent at its meeting, six members constituting a quorum.

Section3: ,4nnualsciertific and educationalassembly.The Asso. ciation shall sponsoran annual scientific and educationalmeeting or assemblyto meet its purpose and objectives. This meeting will include but not be limited to: (1) presentationof original research in the scienoesand educational methodology, Q) educational/ researchforums, (3) specialprogramsfor the membershipas determined by the purpose and objectives of the Association, and (4) meetings of the standing and ad hoc committees of the Association. The researchand educationalprogams of the annualmeeting shall be opeR to the public and the general membership of the Association in good standing.All meetingsof standingand ad hoc committees are open to the public and members of the Association in good standing. Programs for the annual meeting shall 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 members of ttre Association by the Secretary/Treasurer at least 30 days before the meeting.

Section 12: Duties of the Past President. The,PastPresident shall assumewhatever duties are assignedby the President or by articles in the Bylaws of the Association.

Section I3: Absenteeism/terminationof ffice. Absencescan be approvedor excusedonly by the President. Two unexcused absencesfrom scheduledBoard ofDirectors meetings, annual businessmeeting, or special meetings of the Board of Directors during any term as a member of the Board of Directors shall constitute a resignation. Such resignation shall be effective two weeks after notification by the President. Any member of the Board of Directors may voluntarily resign and such resignation will become effective immediately.

Section 14: Special meetings of the Board of Directors.

Special, unscheduledmeetingsof the Board of Directors or the Officers of the Association may be convenedby the President, or by any six members of the Board of Directors. Upon petition by 100 or more active membersof the Association, stating the reason(s)for calling a special meeting of the Directors or Officers, the Secretary/Treasurer shall call such a meeting within 30 days of receiving the petition to be convened at a time and place designatedby the President.

Section4: Specialmeetingssponsoredor cosponsoredby the Association. The Association may sponsoror cosponsorother scientific or educational meetings of interest to the membership to meet its purpose and objectives. Such meetings shall be convenedby the President,Board ofDirectors, and Program Committee Chair and publicized 30 days in advance by the Secretarv/Treasurer.

SectionI5: Duties of the ExecutiveCommittee.'TheExecutive Committee shall conduct the businessof the Board of Directors and act in lieu of the Board on routine issues. All actions by the Executive Committee are subject to review and approval by the full Board of Directors at their next meeting.

ARTICLE IV _ FINAI\CES Section 1; The annual membership dues for all members shall be determinedby the Board of Directors. The annual member. ship will be payablewithin 30 days of requestby the Secretary/ Treasurer. The Board of Directors may establish procedures and policies regarding non-payment of dues and assessments.

ARTICLE III _ MEETINGS Section I: Annual businessmceting. An annual businessmeeting of the membership of the Association shall be convened annually and in conjunction with the annual scientific and educational meeting of the Association. A majority of the active and voting members in good standing and in attendanceshall constitute a quorum. Businessitems presentedas informational or

Section2: The Board of Directors shall adopt such membership schedulesas is necessaryto encourageparticipation by the interested public.

78

ARTICLE V _ PARLIAMENTARY AUTHORITY Rule of order. Any question of order or procedure not specifically delineatedor provided for by thesebylaws and subsequent amendmentsshall be determinedby parliamentary usage as contained in Robert Rules of Order (Revised).

ARTICLE VI _ STAI\DING COMMITTEES Sectionl: Nominating Committee.The Nominating Committee shall consistofthe Vice-President, as Chair, the past president, a memberof the Board of Directors electedfor a one year term by the board, and three elected members who may not be membersof the Board of Directors. The latter shall serve staggeredtwo year terms. It shall be the task of this committee to selecta slateofofficers to fill the naturally occuring vacancieson the Board of Directors and electedpositions on the standingcommitteesof the Association not otherwisedesignatedand providedfor by thesebylaws. The Nominating Committee will seekthe candidatesapproval for formal nomination and shall placettreir namesin nomination before the membership for election at the business session of the annual meeting The NominatingCommittee will also provide slatesfor any awards offeredby the Board of Directors.,.

Section2: Membership Committee. The Board of Directors shallconstitute the Membership Committee. It shall be the Secretary/Treasurer'sduty to review the qualifications and recommendations of each applicant, for presentation and approvalby the majority of the Membership Committee.

Section3: Program Committee. The Program Comrnittee shall becomposedof a Chair, electedby the membershipfor a three yearterm, with the firct year of the term semed as Chair-Elect; twomembersappointed by the President to staggeredthree year terms:and two members appointed by the committee Chair to staggered three year terms. The ResearchCommittee chair and theEducationCommittee chair will be members of the Program Committee.None of the appointed members of the committee canbe members of the Board of Directors. The duties of the committeeshall be to arrange, in conformity with instructions fromthe Board of Directors, the program for all meetingsand selectthe formal participants.

Section4: Constintion and Byl.awsCommittee. The Constitution and Bylaws Committee shall consist of a Chair and two othermembers, elected for staggeredthree year terms so that thememberwith the least remaining tenure shall serveas Chair duringtheir final year on the Committee. This Committee shall studythe potential merits, adverseconsequencesand legal implicationsof all proposed constitutional amendmentsor changes in the bylaws and report their findings and recommendations to thePresidentand Board of Directors prior to the time of formalconsiderationof the proposedchangesby the membership.

The membersof the Committee may themselves suggestappropriateconstitutionalamendmentsand bylaws changesto the Presidentand Board of Directors upon study of problems arising out of the existing constitution and bylaws. t

I t

r I

h

Section 5: EducationCommittee.The Education Committee consistof a chair, elected to a three year term by the

ip, with thefirst year of the term semedas Chair-

|EW, and.six other members appoirrtedbl ttre cornmiteeCtrau 6r sraggeredtwo year terms. The committee Chair and appintees may be members of the Board of Directors or

other Association committees. The Chair shall create ad hoc education subcommitteeswith the approval of the Board ofDirectors. The Committee shall foster educationin emergency medical care and assumeduties and tasks as 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, with the Jirst year of the term semed as ChairElect, and six other members appointed by the committee Chair for staggeredtwo year terms. The committee Chair and appointees may be members of the Board of Directors or other Association committees.The chair shall createad hoc research subcommitteeswith the approval of the Board of Directors. The Committee shall foster researchin emergencymedical care and assumeduties and tasks as determinedby the Board of Directors.

Section 7: Liaison Committeeto the Association of American Medical Colleges (AAMC). The Committee shall consist of a Chair, appointedto a five year term by the Board of Directors, and three membersappointedby the committee Chair for staggered three year terms. The official emergency medicine delegatesto the AAMC will be membersof this committee.The committee Chair 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 Committee for election to Chair. The Committee shall develop programs for the Association to be presentedat the annual meeting of the AAMC and assumeother duties and tasks of similar purpose as determined by the Board of Directors.

Section8: GovernmentalAffairs Committee.The Committee shall consist of a Chair, elected to a three year term by the membership, with the Jirst year of the term served as ChairElect, and three members appointed by the committee Chair for staggeredthree year terms. The committee Chair and appointees may be members of the Board of Directors or other committeesof the Association.Only current or past members of the committee will be nominated by the Nominating Committee for electionto Chair. The Committeeshall assumeduties and tasksas determinedby the Board of Directors to foster federal and state support of researchand education in emergency medical care.

Section 9: Committeeon International Affairs. The Committee shall consist of a Chair, electedto a three year term by the membership, with the Jirst year of the term semed as ChairElect, and three members appointed by the committee Chair for staggeredthree year terms. The committee Chair and appointees may be members of the Board of Directors or other committees of the Association. The committee shall assume duties and tasksas determined by the Board of Directors to foster internationalrecognitionofeducation and researchin emergency medical care.

ARTICLE VII _ DISSOLUTION OF THE ASSOCIATION

' sdcndnririis'sottitrijnot ftiis eisocrducin canontyubiriitidteo by a majoriryvote of all membersof the Boardof Directors andmustbe approvedby two-thirdsof the activemembership p(esent and voting at any annuat o. speci.( rrreetitrg.

SectionZ; Dissolution shall be achieved in compliance with Article IX of the constitution.

VADE MECUM BEST ORAL BASIC SCIENCE 1990- Michelle Biros, MD, MS, Hennepin County Medical Center, "Effects of Chemical Interventions of Functional Recovery Following Closed Head Trauma"

1985- HarlanA. Stueven,MD, MedicalCol"Bystander/ lege of Wisconsin, Ten Years ExFirst ResponderCPR: perience in a ParamedicSystem"

1989- Ray E. Keller, MD, GeisingerMedical "Contribution of SorbitalComCenter, bined with Activated Charcoal in Prevention of Salicylate Absorption"

BEST ORAL METHODOLOGY

re88- DouglasSinclair,MD,

Victoria General "The Evaluationof Suspected Hospital, Renal Colic: UltrasoundScanvs. Excretory Urography"

1990- William G. Baxt,MD, Universityof California,SanDiego,"The Useof

1989- RobertNeumar,Ohio StateUniversity, "High Energy PhosphateMetabolism During VentricularFibrillation"

an Artificial Neural Network for Decision-MakingUnderUncertainty; 198'l- Robert L. Muelleman, MD, Truman "Blood PressureEfMedical Center.

The Diagnosisof MyocardialInfarc-

MD, University 1988- SandraM. Schneider, "Amanita Phalloides of Pittsburgh, Poisoning:Mechanismof Cimetidine Protection"

tiontt

1987- Eric Davis, MD, Ohio StateUniver"The sity, Comparative Effects of MethoxamineversusEpinephrineon RegionalCerebralBlood Flow During CPR'' 1986- Peter A. Maningas,MD, Letterman "Use of Army Instituteof Research.

7.5 % NaCll6 % Dexrran70 for Treatmentof SevereHemorrhasicShockin Swine" 1 9 8 5 - M i c h e l l eH . B i r o s ,M D , M S , U n i v e r "Post InsultTreatsity of Cincinnati, Cerebral ment of Ischemia-lnduced Lactic Acidosis in the Rat"

BEST ORAL CLINICAL SCIENCE 1990- Daniel Spaite, MD, University of Arizona, "Injury Severity Among Helmeted and Non-Helmeted Bicylists Involved in Collisions with Motor Vehicles" 1989- Kathleen Hargarten, MD, Medical "Prehospital College of Wisconsin, Prophylactic Lidocaine Does Not Favorably Affect the Outcomeof Patientswith ChestPain" 1988- William G. Baxt, MD, Universityof California,SanDiego, "The Inability of PrehospitalTrauma PredictionRules to Classify Trauma Patients Accu' rately' 1987- RanjanThakur, MD, Medical College "A Randomized of Wisconsin, Study of EpinephrineversusMethoxaminein PrehospitalVentricular Fibrillation" 1986- Stuart A. Malafa, MD, Butterworth Hospital, Grand Rapids, "Prehospital Index: A Multicenter Trial" and JosephF. Waeckerle,MD, Baptist Medical Center,KansasCity, "A ProspectiveStudy Identifying the Efficacy of ClinicalFindingsand Sensitivityof Radiographic Findings in Carpal Navicular Fractures"

1989- MichaelSmith,MD, HighlandGeneral Hospital, "Comparison of Different Definitions of Critical Trauma Patients" 1988- Phillip L. Henneman,MD, Harbor"AttendingCoveragein AcaUCLA, demicEmergencyMedicine:A National SurveY"

BEST SCIENTIFIC POSTER 1990- William Bickell, MD, Letterman Army Institute, "Use of Hypertonic Saline/Dextran Versus Lacerated Ringer's Solution as a Resuscitation Fluid Following Uncontrolled Aortic Hemorrhage in AnesthetizedSwine 1989- StevenG. Crespo,MD, MedicalCol"Comparisonof legeof Pennsylvania, Intravenousand IntraosseousAdministration of Epinephrinein a Cardiac Arrest Model"

t,? le88- DavidL. Schriger.

uS!.1.

"Defining Normal Capillary Refill: Variationwith Age, Sex, and Temperature"

fects of Thyrotropin-Releasing Hormone and Epinephrine in Anaplylactic " Shock. l 9 g 6 _ Steven Chernow, MD, University of "Use of the Emergency Arizona, Hypertensive Department for Screening" 1985- William C. Dalsey,MD, and ScottA. Syverud,MD, Universityof Cincinnati, "Transcutaneousand TransvenousCardiac Pacing For Early Bradyasytolic Cardiac Arrest" 1984* Gerard B. Martin, MD, Henry Ford "Insulin and GlucoseLevels Hospital, During CPR in the Canine Model" l9g3_ Jeffrey A. Sharff, MD, Oregon Health "Eflect of Time on SciencesUniversity, RegionalOrgan PerfusionDuring Two Methods of Cardiopulmonary Resuscitation"

BEST RESIDENT POSTER l99l-

Judith J. Dennis, Mt. Sinai Medical Center, "Recurrent Hypoglycemia After D50 Administration"

1987- Ruth Dimlich, PhD, Universityof Cin"Effects of SodiumDichlorocinnati, acetateon ATP and Phosphocreatinein IshchemicRat Brain"

l9g9_ Marc Smith, MD, Harbor-UCLA, "PharmacologicInterventionsin Acute

1986- Mark Howard, DO, Henry Ford Hospital, "Improvementin CoronaryPerfusion PressuresAfter Open ChestCardiac Massage in Humans: A PreliminaryReport"

1988- KatherineM. Hurlbut, MD, Universi"Reliability of Clinical ty of Arizona, Presentationfor Predicting Significant Viper Envenomation"

BEST METHODOLOGY POSTER 1988- Frank J. Papa,DO, Texas Collegeof "A ComputerOstcopathicMedicine, AssistedI-eamingTool Designedto ImproveClinical ProblemSolvingSkills"

BEST RESIDENT PAPER 1990- Daniel J. DeBehnke, MD, Wright State University, "Comparison of Standard External CPR, Open-Chest CPR, and Cardiopulmonary Bypass in a Canine Myocardial Infarct Model"

80

CocaineToxicity"

1987-Gert-PaulWalter, MD,

MichiganState "Emergency Intraosseous University, Infusions in Children: A Practical Method of Teaching Prehospital Personnel"

BEST PEDIATRIC TRAUMA AND ACUTE CARE 1990- Mananda S. Bhende, MD, University of Pittsburgh, "Validity of a Disposable End-Tidal CO2 Detector in Verifying Endotracheal Tube Position in Infants and Children"

1989- J. G. Linakis, MD, Children'sHospital, "Role of Activated Charcoal and Sodium PolystyreneSulfanate(Kayexalate) in Gastric Decontamination for Lithium Intoxication: An Animal Model" 1988- Peter Atjian, MD, Valley Medical "Endotracheal Intubation of Center, PediatricPatientsby Paramedics"

BESTEDUCATIONAL PRESENTATIONS Selectedto represent Emergency Medicine at the AAMC Annual Meeting 1990- StevenM. Chernow, MD, University of Colorado, "Academic Emergency Medicine: A National Profile With and Without Emergency Medicine Residency Programs" Harold A. Thomas, Jr., MD, Wake Forest University, "Faculty Attrition Among Three Specialties" 1989- RobertA. Delorenzo, Albany Medical "Analyzing Clinical Case College, Distributionsto Improve an Emergency Clerkship" RobertF. Polglase,Mercer Universi"Problem-Based ACLS Instruction: ty, A Model Approachfor Undergraduate EmergencyMedical Education"

BEST PAPBR 1984- Charles G. Brown, MD, Ohio State "Injuries Associatedwith University, t h e P e r c u t a n e o u sP l a c e m e n t o f Transthoracic Pacemakers" 1983- Charles F. Babbs, MD, Purdue "Improved CardiacOutput University, During CardiopulmonaryResuscitation with InterposedAbdominal Compres' sions' 1982- Carl D. Winegar, MD, Wayne State "Early Amelioration of University, Brain Damage in Dogs After Fifteen Minutes of Cardiac Arrest" 1981- Blaine C. White, MD, Wayne State "Correction of Canine University, Cerebral Cortical Blood Flow and PostArrest Using VascularResistance Flunarazine,A Calcium Antagonist" 1980- Blaine C. White, MD, Wayne State "Mitochondrial 0, Use University, and ATP Synthesis:Kinetic Effectsof Ca'* and HPO. Modulatedby Glucocorticoids" 1979- Albert E. Cram, MD, Universityof "The Effect of PneumaticAntiIowa, Shock Trousers on Intercranial Pressurein the Canine Model" 1977- LawrenceB. Dunlap, MD, Josephine General Hospital, Grants Pass, "PercutaneousTranstracheal Oregon, Ventilation During Cardiopulmonary Resuscitation"

1988- FrankJ. Papa,DO, TexasCollegeof "A ComputerOsteopathicMedicine, Assisted Tool Designed to Improve Clinical ProblemSolvingSkills" " MD. Vanderbilt CharlesE. Saunders.

"Videotape Review of University, Analysis CardiacArrest Resuscitation: of Elementsof ResuscitationTeam Performance"

BEST PRESENTATION

1987- David Plummer,MD, HennepinCoun"Emergency ty Medical Center, DepartmentCritical Care Registry"

1982- StephenR. Boster,MD, Universityof Louisville, "Translaryngeal Absorbtion of Lidocaine"

1984- Paul M. Paris, MD, University of Pittsburgh, "The PrehospitalUse of TranscutaneousCardiac Pacing" 1983- SandraH. Ralston,MD, PurdueUni"Intrapulmonary Epinephrine versity, During Prolonged Cardiopulmonary ImprovedRegionalBlood Resuscitation: Flow and Resuscitationin Dogs"

l98l-

BESTRBSIDENT/FELLOW ORAL PRESENTATION 1990- Norman Paradis,MD, Henry Ford Hospital, "The Effect of pH on the ' Change in Coronary Perfusion PressureAfter EpinephrineDuring CPR in Humans" CharleneB. Irvin, MD, University of Cincinnati,"Effect of Hypertonicvs.

Normotonic Resuscitation on Intracranial Pressure After Combined HeadInjury and HemorrhagicShock"

RobertW. Strauss,MD, Universityof "Expanded Role of the Chicago, Barium Enema in the Acute Abdomen"

1980- JacekB. Franaszek,MD. and Harold A. Jayne,MD, Universityof Illinois, "Medical Preparations for an Outdoor Papal Mass"

KENNEDY LECTURBRS 1973-Fraser N. Gurd, MD 1974-Oscar P. Hampton,Jr., MD 1975-Curtis P. Artz, MD 1976-John G. Wiegenstein,MD

81

797'7-PeterSafar,MD 1978-SenatorAlan M. Cranston 1979-AlexanderJ. Walt. MD 1980-EugeneL. Nagel,MD 1981-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-GailV. Anderson,MD 1989-D. Kay Clawson,MD 199O-ArthurL. Caplan,PhD 1991-Robert G. Petersdorf.MD

HONORARY MEMBERS 1973-RobertH. Kennedy,MDt FraserN. Gurd, MD C. BarberMueller,MD MD 1974-Iohn G. Wiegenstein, AlexanderJ. Walt, MD P. Hampton,MDt 1975-Oscar N. H. McNally,MDt CurtisP. Artz, MDt 1976-AnitaM. Dorr, RNt EugeneL. Nagel,MD 1977-PeterSafar,MD Jr., MD 1978-EbenAlexander, 1979-DavidR. Boyd,MD, CM 198l-R AdamsCowley,MD 1982-CarlJelenko,III, MD 1990-RonaldBellamy,MD MD D. Kay Clawson,

HAL JAYNE ACADEMIC EXCELLENCE AWARD 1985-James T. Niemann. MD 1986-Glenn C. Hamilton, MD 1987-CharlesG. Brown, MD 1988-Jerris R. Hedges,MD 1989-Richard F. Edlich, MD, PhD 1990-Lewis Goldfrank, MD 1991-John A. Marx, MD

ACADEMIC LEADERSHIP AWARD 1989-Ronald L. Krome, MD 1990-Peter Rosen, MD David K. Wagner, MD 1991-Glenn C. Hamilton

SILVER TONGUE ORATOR DEBATE AWARD 1979-Ann L. Harwood-Nuss,MD 1980-Peter Rosen, MD l98l-Jerome L. Hoffman, MD 1982-Glenn C. Hamilton, MD l983-Frederick B. Epstein, MD 1984-Marcus L. Martin, MD 1985-Paul M. Paris, MD 1986-Daniel Danzl, MD 1987-Nicholas Benson, MD 1988-Daniel Danzl, MD

T-

PAST PRESIDENTS SAEM 1988-1989-James T. Niemann,MD 1989-1990-Arthur B. Sanders, MD 1990-1991-JerrisR. Hedges,MD

1976-1977-David K. Wagner, MD 1977-1978-CarlJelenko,III, MD 1978-1979-RonaldL. Krome, MD 1979-1980-Kenneth L. Mattox, MD 1980-1981-W. KendallMcNabney,MD l98l-1982-Joseph F. Waeckerle,MD

UA/EM 1970-197 l-Charles Frey, MD l97l-1972-AlanR. Dimick,MD 1972-1973-RobertB. Rutherford,MD 1973-1974-James R. Mackenzie,MD 1974-1975-George Johnson,Jr., MD

STEM

1975-1976-Leslie E. Rudolf, MD

1982-1983-BarryW. Wolcott, MD 1983-1984-JackB. Peacock,MD 1984-1985-RichardC. Levy, MD 1985-1986-StevenJ. Davidson,MD 1986-1987-RichardM. Nowak, MD 1987-1988-ErnestRuiz, MD

l9'15-1976-Frobert H. Dailey,MD -Peter Rosen,MD 1976-1977 1977-1978-C.C. Roussi,MDf 1978-1979-G.RichardBraen,MD 1979-1980-Harvey W. Meislin,MD 1980-1981-Frank J. Baker,II, MD 1981-1982-John R. Lumpkin,MD 1982-1983-Harold A. Jayne,MDf 1983-1984-Kenneth V. Iserson,MD 1984-1985-Glenn C. Hamilton,MD 1985-1986-Daniel MD Schelble, 1986-1987-Thomas O. Stair,MD 1987-1988-Mary Ann Cooper,MD D. Kelen.MD 1988-1989-Gabor

IMAGO OBSCURA AWARD

MACKENZIE AWARD

1976-NormanE. McSwain.Jr.. MD 1977-SungRock Lee, MD 1978-G. PatrickLilja, MD 1979-Stephen Karas,MD 1980-JackGoldberg,MD 198l-Robert Knopp,MD 1982-BlaineC. White.MD 1983-Richard C. Levy,MD 1984-GlennC. Hamilton,MD 1985-JerrisR. Hedges, MD 1986-DavidDuBois,MD 1987-NormanAbramson.MD 1988-Charles G. Brown,MD 1989-MichaelCallaham,MD 1990-Keith T. Sivertson.MD

1976-JamesR. Mackenzie,MD 1971-Cyril 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-CharlesF. Babbs,MD 1985-Blaine C. White, MD 1986-JamesT. Niemann,MD 1987-Arthur Kellermann,MD 1988-Richard E. Burney, MD 1989-Robert McNamara, MD

PAST ANNUAL MEETINGS November 18, 1970 Denver,Colorado

M a y 1 5 - 1 81, 9 7 7 KansasCity, Missouri

M a y 1 4 - 1 5l,9 7 l Ann Arbor, Michigan

May l8-20, 1978 SanFrancisco,California

May 12-13,1972 Washington, D.C.

May 24-26, 1979 Orlando,Florida

May 23-25,1973 Hamilton,Ontario

April 20-23,1980 Tucson, Arizona

May 28-Junel, 1974 Dallas,Texas

A p r i l 1 3 - 1 51, 9 8 1 SanAntonio,Texas

May 20-24, 1975 Vancouver,BritishColumbia

A p r i l 1 5 - 1 71, 9 8 2 SaltLakeCity, Utah

May 2l-24, 1990 Minneapolis, Minesota

M a y l 1 - 1 5 ,1 9 7 6 Philadelphia, Pennsylvania

June1-4, 1983 Boston,Massachusetts

May 12-15,I99l Washington, DC

May 22-25,1984 Louisville,Kentucky May 2l-24, 1985 Kansas City, Missouri M a y 1 3 - 1 51, 9 8 6 Portland,Oregon May 19-21,1987 Philadelphia, Pennsylvania

82

May 24-26, 1988 Cincinnati,Ohio May 22-25,1989 SanDiego,California

I SAEMMEMBERSHIP APPLICATION Pleasecomplete and send, with the appropriate dues and

$15 initiationpayment,to: society for Academic EmergencyMediciner 900 west ottawa r Lansing, Michigan 4gg15 . (517)485-5484 (sl7) 48s-0801FAX Name Title:MD DO phD Other HomeAddress

Business Address PreferredMailing Address(pleasecircle): Home Business Telephone:

Birthdate

Sex: M

Home (.-)

Institution FacultyAppointment Positionscurrenflyheld in EmergencyMedicine: 1. z.

DepartmentChairman Checkthe appropriate category: olt#ff:'o

-Active

-Associate

-Resident/Fellow

-Medicat

student -tnrernationat

Active -tnternational

Activemembership is open to individuals(a) withan advanceddegree,horda medicalschooror university facultyappointmentand activeryparticipate Inacute'emergency'or criticalcare in an administrative, teachingor researchcapacity;(b) with similardegreesin activemilitaryservrceor (c) who otherwise meet qualifications but who do not holdafaculty appointment and who petitionthe Membershipcommittee.Annualdues a$15initiationfee payablewhen the application are 9195 plus is submitted. ine apptication must ne accompaniedby a curricurumvitaeand a retterverifying facultyappointment' Membershipbenefits the includea subscriptionto'A,nnals of EmergencyMedicine,the officialsAEM journal; a subscription sAEMnewsletter;a reducedsAEM Annualrrrr"eting-r"gistr"tion to the and freebanquetticket;and ieducedregistration feesto othersAEM educationat meetings.

Associatemembership is open to health professionals, educators,governmentoffi-ciars, members of ray or civic groups,or membersof the pubric atlargewho have an interestin Emergency Medicine'Annualduesaie $175plusa $15 initiation payabte fee when the applicationis submitted.The application must be accompaniedby a curritulumvitae.Membership benefitsin.tro" u subscriptionlo Annalsof EmergencyMedicine,the officialsAEM newsletter; a reduced

il[i^il;iif-i"j'jJ:T

:Xn::f,Ir4

sAEMAnnuar Haeetins registration andrreebanquet ricket; andreduced resisrration rees

Resident/Fellow membershipis open to all residentsand lellowsinterested in EmergencyMedicine.Annuardues are $s0 plus a g15 payable initiationfee when the applicationis submittedrhe application mustbe accompanied by a letterfrom the directorverifyingthat the applicanris a resident or fellowand the anticipatedgraduationdate Membershipbenefitsincludea subscriptionto Annarsof EmergencyMedicine,theofficiarsAEM journar; a subscription to the sAEM newsletter; a freesAEM AnnualMeetingregistration; and reducedregistration iu". to oth". 5AEM educationat meetings" MedicalStudentmembershipis opento all medicalstudentsinterested in Emeigency Medicine.Annualduesare $50 (includes or $35(excludesAnnalssubscription), Annalssubscription) plus a $15 initiationt"" p"v"oi" *h"r"'ii" uppri.utionis submitted.The application a letterverifyingthat the applicantis a medical must be accompaniedby student.Membershipbenefitsincrudea subscriptionto Annatsof Emergencymedicine(ifappricabre), a subscription to the sAEM newsletter,free registrationto the sAEM AnnualMeeting,and reducedregistrationfeesto othersAEM educationarmeetings. lnternationalactive and international associate membership is open to individualswho meet the criteriafor sAEM activeor associatemembership but do not residein the Unitedstates Annual dues are $95 plus u sr s tu.s. trnor) initiationfee, payable plication whenthe application is submitted.The apmustbe accompanied by a curriculum"it;;;; letteiverifyingtr," ru"rltv uppointment, if appropriate.

Membership lo Annalsof EmergencyMedicine'lhe official benefitsincludea subscription sAEM jorrn"t; u subscriptionto tne sne v newsletterj a iree sAEM AnnualMeetingregistrationand banquetticket;and reducedregistration fees to other bnEM educationur,.n""iing..-

Mysignature certifiesthatthe information containedin thisapplication is correctand is an indication of my desireto become a SAEMmember.

Signatureof applicant

Date

January1991 83 I

This form can be photocopiedif additionalcopiesare

needed.

Visit the Synergonbooth # 3 and registerto win a two-volumeset:

EMERGENCYMEDICINE Conceptsand Clinical practice SeniorEditor, PeterRosen.M.D.

* Drawing on Tuesday, May 14 at 4:30p.m. at the Synergoncomplimentary Wine and CheeseTable PosterSessionA Synergon specializesin academic,pediatric and high_volume emergency care staffing, management and recruiting.

SYNERGoN. 999 ExecutiveParkway St. [.ouis, Missouri 63141 r-8n-m_7964