S A E M
Societyfor AcademicEmergency Medicine
1992Annual Meeting Program
May 26-29, 1992 Toronto. Ontario
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A diagram of meeting room locationsis publishedon the inside back cover.
INDEX Generallnformation....
....1-2
K e n n e d y l e c t u r. e. .. .
,,...,
ScheduleofEvents
...
E d u c a t i o naanl dS p e c i aSl e s s i o n.s. . . P a p eS r essions
.......3
.....: . ;.. ..
...........4-7 ....8-10
. .. ,; . . . . . too- in3
Abstracts Annual BusinessMeeting Agenda LeadershipAwardandHalJayneAcademicExcellenceAwards A w a r d sP r e s e n t a t i o n s . . .
.....96
Slate of Nominees Constitutionand Bylaws of the Societyfor AcademicEmergencyMedicino . . : . MembershipApplication..
. .100-104 ..105
Exhibitors T o r o n t oR e s t a u r a G n tu i d e
.....109-ll0
SAEM gratefully acknowledgesgenerous contibutions from Nellcor, Inc. and Syntex, Inc.
The following award sponsorwas inadvertentlyomitted from page l: WeatherbyHealth Care: Best Oral Methodology Presentation
GENERAL INFORMATION REGISTRATION AND INFORMATION All registrantsmust check in at the SAEM RegistrationDesk to pick up namebadgeswhich are required for admissioninto The RegistrationDeskwill be open all AnnualMeetingsessions. during the times listed below: FrontenacBallroom Foyer 12:00-7:00pm Monday Tuesday 7:00 am-12:00noon FrontenacBallroom Foyer l : 0 0 - 5 : 0 0p m Wednesday7:00 am-12:00noon FrontenacBallroom l : 0 0 - 5 : 0 0p m Thursday 7:00 am-12:00noon FrontenacBallroom 3 : 0 0 - 5 : 0 0p m 7:00 am-12:00noon FrontenacBallroom Foyer Friday l : 0 0 - 4 : 0 0p m
SAEM MEMBERSHIP applicationis includedin this programand adA membership ditionalcopiesare availableupon requestto the SAEM office at 900 West Ottawa, Lansing,Michigan 48915 or call (517) 485-5484.If you are alreadya member,give this application to a colleague.SAEM needsyour supportfor the growth and of academicEmergencyMedicine. development
CONTINUING EDUCATION The Universityof Minnesota,accreditedby the Accreditation Councilof ContinuingMedicalEducation,certifiesthatthis programmeetsthe criteriafor up to 34.5 credithoursin Category I towardthe PhysiciansRecognitionAward of the American MedicalAssociation.A verificationof CME creditswill be sent to eachregistrantimmediatelyfollowing the Annual Meeting.
FUTURE MEETINGS The 1993SAEM AnnualMeetingwill be heldon Tuesday,May l7 throughFriday, May 20 at the Hyatt RegencyHotel in San Francisco.Abstractsubmissionforms for this meetingwill be availablein the fall of 1992. The 1994SAEM AnnualMeetingwill be heldon Monday,May 9 throughThursday,May 12 at the WashingtonHilton and TowersHotel in Washington,DC.
AWARD SPONSORS of many of the SAEM SAEM is gratefulfor the sponsorship awards.Thesesponsorsare: Marion Merrell Dow: KennedyLecture SpectrumEmergencyCare, Inc.: Hal Jayne Academic ExcellenceAward EmergencyMedicine: Best Oral Basic ScienceAward MICROMEDEX, Inc.: Best Oral Clinical ScienceAward EmergencyMedicine.New.r;Best Poster Award PergamonPress:Best ResidentPosterAward & Critical Care: BestPediatricEmergency PediatricEmerg,ency and Critical Care Award RonaldReaganInstituteof EmergencyMedicine: BestMedical Award StudentPresentation Annals of EmergencyMedicine: Annals Best ResidentPaper Award EmergencyMedicine Residents'Association:Best Resident/ Fellow Oral Award
OPENING COCKTAIL RECEPTION SAEM is hostingan openingcocktail receptionon Tuesday,May 26from 6:30 until 8:00 pm in SalonsB and C of the Harbour Ballroom. All Annual Meeting registrantsare invited to attend. Hors d'oeurveswill be servedand a cashbar will be available.
EMRA RECEPTION EmergencyMedicine and EMRA will host a Receptionon Wednesday,May 27 from 6:00-7:30pm in Pier 4. The highlight of the reception will be the presentationof the 1992 Jean Hollister Award for Excellencein EMS and PrehospitalCare (sponsoredby CoastalEmergencyServices)and the Academic ExcellenceAward (sponsoredby EmCare)'Hors d'oeurveswill be servedand a cashbar will be available.All interestedEMRA membersandothersare invitedto attend.The Receptionis sponsored by EmergencyMedicine.
EXHIBITS Exhibits will be availablefor viewing on May 2l , and28 from 9:00-12:00noonand 1:30-5:00pm in the FrontenacBallroom. The postersessions,Innovationsin Medical Educationexhibits, coffee breaks,and the registrationdesk will also be locatedin the Exhibit hall. Pleasetake an opportunityto view the exhibits during the scheduledcoffee breaks and exhibit hours.
ACEP/EMF TEACHING FELLOWSHIP RECEPTION Interestedin learningmore aboutthe ACEP/EMF TeachingFellowship Program?Come join the faculty and alumni to share their thoughtsand experiencesregardingthis excellentfaculty developmentopportunity at a Wine and CheeseReceptionon May 28 at 4:00-6:00pm in Pier 7.
SAEM BOARD OF DIRECTORS MEETINGS The SAEM Board of Directors will meet on Monday, May 25 from 1:00-5:00pm in the RichmondRoom and Thursday,May 28 from 7:00-l0:00 pm in Pier 2 and3. All interestedmembers .and others are invited to attend this, and all meetingsof the Board of Directors.
ANNUAL BUSINESSMEETING The Societywill hold its Annual BusinessMeetingfrom 1:303:00 pm on Thursday,May 28 in the MetropolitanBallroom. At the meetingWilliam Barsan,MD, will introduceincoming presidentLouis Ling, MD. Agendaitemsfor the businessmeeting will includeelectionof officers,Boardand committeemembers presentationof awards;amendmentsto the Constitutionand Bylaws; officers' reports;and other itemsof businesspresented by the membership.All membersof the associationare urged to attend,however, only active membersare eligible to vote.
PLACEMENT SERVICE A bulletin board will be maintainednearthe RegistrationDesk for personswishing to post positionsand physiciansavailable listings.
MESSAGEBOARD A messageboard will be maintainedat the RegistrationDesk. can be left at the SAEM RegistrationDesk by Phonemessages calling the Westin Harbour CastleHotel at (416) 869-1600and requestingthe SAEM RegistrationDesk.
BANQUET
PROCEEDINGS Proceedingsof the Annual Meeting will not be preparedas a scientific publication.However,selectedpresentations' separate in the Annals printed be will papersand pertinent discussion of EmergencyMedicine, the official journal of the Societyfor Academic EmergencyMedicine. In addition, the abstractsof the Annual Meeting were publishedin the lr4ay, 1992issueof Annals of Emergency Medicine.
SPEAKERS'READY ROOM A speakers'ready room will be availablefor those who wish to check their slides in advanceof their presentation'Keys to the ready room will be availableat the RegistrationDesk.
HEALTH CLUB FACILITIES In addition to the fine facilities at the Westin Harbour Castle with the Mayfair LakeHotel, Dr. Daya hasmadearrangements facilities during the their of shore Athletic Club for the use SAEM conference.The club has twelve indoor tennis courts (clay{ype surface),fourteensquashcourts,a largeweightroom and offers fitnessclassesthrough-outthe day. It is locatedat 801 LakeshoreBoulevard East and is a 5-minute drive from the hotel. Meeting registrantsand their spouseswho wish to use the facility will have to pay the customary$10 guest fee' They should identify themselvesas belongingto SAEM at the front desk. Thosewho wish to play tenniswill have to pay additional court-time fees.
This year the Annual Banquetwill begin with a cocktail recep"Empress of Canada" on Lake Ontario tion cruiseaboardthe canbeginboardingat 5:30 from 5:45 until 6:45 pm. Participants at Pier 27 - a60-secondwalk from the WestinHotel. The boat will leavepromptly at 5:45 pm. After a relaxingcruise,participantswill return to the Westin Harbour CastleHotel and enjoy dinner in the MetropolitanBallroom. During dinner, the 1992 Imago ObscuraAward will be presentedafter a review of all possibleentries.(Paperpresentersshouldnot be alarmedif some "missing" after their presentations. Pastwinbf thei. slidesare "collect" entries.Slidesare nersof the Imago ObscuraAward returned by SAEM staff after the Annual Meeting.) This year there will be additionalentertainmentin the form of ' ' 'ridiculousresearchabstracts' winof the four the presentation will be ten minutes usual, As Niemann. Dr. by ners selected allowed for presentation,followed by up to five minutesof questions or comments. As always, a free ticket to the banquetis provided to active, associate,and internationalmembersof SAEM. Residentsand medicalstudents,becauseoftheir discountedregistrationrates, do not receivea free banquetticket. Tickets are $35 each,but only a limited numberof ticketsare available.Tickets mustbe purchasedby May 27. Dressis alwayscasual'but the cruise could be chilly.
MEETINGS may Listed below are the meetingsscheduledduring the Annual Meeting by organizationsand committees.Additional meetings invited are registrants and membership to the are open meetings havebeenscheduledafter th"epublicationof thii program. These to attend. S A E M A A M C L i a i s o nC o m m i t t e e , l 0 : 3 0 - 1 1 : 3 0a m Sunday, llay 24 Yonpe Room 3324 EMRA Boardof Directors, 2:00-6:00pm l l : 3 0 - 1 2 : 3p0m - SAEM TechnologyCommittee, Richmond Monday, May 25 - SAEM Geriatric EmergencyMedicine p m l : 3 0 3 : 3 0 Richmond l:00-5:00pm - SAEM Boardof Directors, Task Force, Richmond 7:00-10:00pm - AnnalsEditorialBoard,Dockside3 pm - SAEM Research Committee, Yonge 3:00-5:00 \ pm - ACEP Sectionon Toxicology, Richmond 5:00-6:00 Tuesday,l{'ay 26 pm - SAEM Membership Recruitment 5:30-6:30 7:00-8:00am - SAEM ProgramCommittee Committee, Yonge
l2:00-3:00pm l:30-5:00pm 3:00-5:00pm pm.3:30-5:30
5:00-6:00pm 5:00-6:00pm Wednesday, May 27 8:00-5:00 pm 7:00-8:00am 7:00-8:00am 8:00-9:00 am 8:00-9:30 am -
Councll,Pier 7 EMRA Representative CORD,SalonsB & C Thursday,May 28 Committee,Yonge ACEP Research am 7:00-8:00 SAEM Public Health & Education 9:00-12:00 noonCommittee,Richmond noon9:00-12:00 Service, Consulting Undergraduate pm 3:00-5:00 Yonge pm 3:30-5:00 MedACEP Sectionof Observation icine. Richmond 4:00-6:00pm AACEM, Pier 7 & 8 5:00-7:M pm SAEM ProgramCommittee SAEM Ethics Committee 7:fi)-10:00pm & BiotechPharmaceutical SAEM nology Liaison Committee, Richmond SAEM EducationCommitteeStrategic Friday' NIay 29 7:00-8:00am Planning Session,Yonge
SAEM ProgramCommittee SAEM International Committee, Yonge EMRA Board of Directors, Salon A SAEM EMS Committee, Yonge SAEM Task Force on EmergencY Medicine in Traditional Academic Centers,Richmond SAEM GovernmentalAffairs Committee, Room 3324 SAEM Education Committee Business Meeting, Yonge SAEM Board of Directors Meeting, Pier2&3 SAEM ProgramCommittee
KENNEDY LECTURE
..CANADIAN HEALTH CARE: WHAT AMERICANS MOST OFTEN ASK"
MARTIN BARKIN, MD, BSc (Med), MA' FRCS(C) Dr. Barkin is the ExecutiveVice Presidentof Deprenyl ResearchLimited, a Canadianpharmaceuticalcompany.In June l992,he will be appointedPresidentand a director of the company. He is also Professorof healthadministrationat the University of Toronto. Before that he was a Partner and National Practice Leader for Health Care and Social Servicesfor KPMG Peat Marwick Stevenson& Kellogg, Canada. Thesepositionsand his former positionsas Deputy Minister of Health for the Province of Ontario, Secretary for the Premier's Council on Health, and Chair of the Committeeof Deputy Ministerswith social responsibilitiesfrom 1987to 1991, have placedhim in one of the most unique positionsin health care in Canada. He has now experiencedthe Canadiansystem as its most seniorexecutive;as the Presidentand Chief Executiveof one of its largestteachinghospitals,SunnybrookHealth Services Centerin 1983-1987;as a Chief of Staffpresidingover400 tulltime and 250 part-timephysicians;as a Chairmanof the Board of one of its largestmultidisciplinaryclinics; as a Professorof Surgery; as a researcher;and as a clinical practicing doctor. Dr. Barkin has also servedas Vice-Chair of the Ontario Hospital Associationand Presidentof the Ontario Council of Teaching Hospitals Each of these positions brought out his abilities as a leader oforganizationsand their many relatedprocessessuchas strategic planning,financialplanningand comptrollership.He has succeededin implementing strategieseven in the most troubled times and under the most difficult circumstances.Every institution or organizationthat he has led has emergedas a leader in its field. Dr. Barkin has beena leader in strategicplanning and implementation in circumstancesthat embraced a single hospital, a group of hospitals and an entire health system. This required bringing togethercomplex and disparateorganizationsand interests to develop and accept a single vision, to work towards achieving that vision and to emerge more organized, more resolved and more effective than before. One of the most difficult roles for a chief executive is to lead the formation of an organization'svision, and then articulate and communicate that vision in order to oversee an effective strategicplanning processand its implementation. This was the role in which his experienceand performance was on the forefront in Canada.
His public presencealso required an extensiveinvolvement in public issuesmanagement,interviews with the media and backgroundbriefings to editorial boards. He has spokento provincial, national, and internationalhealthand healthcarebodies, to visiting foreign delegatesand political leaders,giving more than 150 major addressesin Canada,the US and Europeover the past three years. Few in the health care field are as fully informed on how best to interact synergisticallywith the Provincial Government. Fewer still can combinethis knowledgewith an extensiveknowledge of interprovincialaffairs, the public policy process,and every facet of provider-governmentrelations.He participated in, and in most casesled the formulation of all of the future directionsofthe provincein healthcare, includingthe revision of the Public HospitalsAct, the landmarkagreementwith the Ontario Medical Association,the IndependentHealth Facilities Act, a new capitaland operatingframework for hospitals'new Consentlegislation,evolving funding formulae, integrationof Health and Community Support Services,Long Term Care, alternatepaymentplansfor physicians,the changingrole of Health ScienceCentres,the new information systemsuses,the deliberations of the Premier's Council on Health, the Ontario Futures Framework and many others. He has a broad knowledgeand understandingof advanced information systemsand has overseenthe designand implementation of small and large systems,from physicianoffice systems to the role model systemat Sunnybrook,to the $100 million dollar systemsproject at the Ministry of Health. Dr. Barkin has aspiredto, and has succeededin a rangeof leadershippositions at every level of the Canadianhealth care system, and has achievedrecognition as a leader in, and an authority on, the Canadianand other health systems. The Socieryfor Academic Emergency Medicine is pleased to have Dr. Martin Barkin present this year's Kennedy Lecture. We are honored to receive his views and his vision. SAEM gratefully acknowledges Marion Merrell Dow, Inc.'s sponsorship of the Kennedy Lecture.
SCHEDULE OF EVENTS Sunday, N{|.ay24 2:00-6:00 pm
EMRA Board of Directors, Room 3324
Monday, ls|.ay25 8:00 am-5:00 pm
l:00-5:00pm pm 5:30-6:30 pm 7:00-10:00
CPC Regional Competitions-
Central Region, Sqlon A SouthernRegion, Salon B EasternRegion, Salon C Western Region, Pier 2 & 3 SAEM Board of Directors, Richmond Room CPC Reception,Pier 7 & I Annals of Emergency Medicine, Editorial Board, Dockside 3
Tuesday,May 26
8 " ' l - 8 : 1 5a m
Introductory statementsand announcements,L[etropolitan West & Centre Program Chairman: James T. Niemann, MD, Harbor-UCLA 8;00-12:00noon "Effective Teaching" Workshop,DocksideI Gerald Kelliher, MD, Associate Dean for Medical Education, Medical College of Pennsylvania Ajit Sachdeva, MD, Director of Surgical Education, Medical College of Pennsylvania 8 :l 5 - 1 0l ;5 a m Scientific Papers:Plenary Session(Abstracts001-008), Metro West & Centre Moderator: Michael Callaham, MD, University of Calfornia, San Francisco l 0 :l 5 -l 0 : 3 0a m Coffee Break, Frontenac Ballroom Foyer l0:30-12:00 noon Scientific Papers:Pediatrics-Trauma(Abstracts009-014), Metro West & Centre Moderator: Gary Fleisher, MD, Children's Hospital, Boston ScientificPapers:Shock/Trauma- Basic Sciences(Abstracts015-019),Metro East Moderator: John Marx. MD. Carolinas Medical Center "How to Talk to a Statistician."Pier 2 & 3 AlJred M. Pheley, PhD, Division of Clinical Epidemiology, Hennepin County Medical Center "Substance Abuse Panel," Pier 4 & 5 Louis Binder, MD, Texas Tech University Edgar Nace, MD, Timberlawn Psychiatic Hospital, Dallas Jack Peacock, MD, Texas Tech University David Sklar, MD, University of New Mexico l2:00-I :30pm ResearchDirectors Luncheon"Multicenter Trials in EmergencyMedicine: The Time Has Come," QueensQual W. Brian Gibler, MD, University of Cincinnati Ed Panacek, MD, University Hospitals, Cleveland Robert W. Scott, MD, Director, Drug Delivery Devices, Eli Lilly & Company pm l2:00-3:00 EMRA Representative Council, Pier 7 l : 3 0 - 3 : 0p0m Scientific Papers:Pediatrics/Respiratory(Abstracts020-025), Metro West & Centre Moderator: David Wagner, MD, Medical College of Pennsylvania ScientificPapers:Shock/TraumaClinical (Abstracts026-031),Metro East Moderator: Richard Burney, MD, University of Michigan "Scientific Misconductand Fraud," Pier 2 & 3 Drummond Rennie, MD, Institute for Health Policy Studies, University of Califurnia, San Francisco and Deputy Editor (West), JAMA l:30-5:00pm Council of EmergencyMedicine ResidencyDirectors, Salons B & C, Harbour Ballroom l : 3 0 - 5 : 3p0m REPEAT: "Effective Teaching" Workshop (limited to 20 participants),Dockside I 3 : 0 0 - 3 : 1p5m Coffee Break, Frontenac Ballroom Foyer 3 : 1 5 - 4 : 4p5m Scientific Papers:Clinical Practice Infection Control (Abstracts032-037), Metro West & Centre Modercrtor: Gabe Kelen, MD, Johns Hopkins Scientific Papers:PediatricsInfectious Disease(Abstracts038-041), Metro East Moderator: Gary Strange, MD, University of lllinois "Pitfalls in 3 :l 5 - 5 : 1 p 5m EMS Research,"Pier 2 & 3 Eric Davis, MD, University of Pittsburgh Daniel Spaite, MD, University of Arizona Steve Weiss, MD, L<tuisianaState Universiry/Charity Hospital 4:45-5:45 pm PediatricsResearchInterestGroup, Metro West Centre Shock/TraumaResearchInterest Group, Metro East pm 6:30-8:00 Opening Reception,Salons B & C, Harbour Bqllroom
Wednesday,l[I'ay 27 8:00-5:00 pm
Associationof Academic Chairs of EmergencyMedicine, Pier 7 & I
8:00-12:00 noon
EMRA/SAEM ResidentLeadershipForum, Chateauneuf Carey Chisholm, MD, Methodist Hospital of Indiana David Levy, MD, Allegheny General Hospital Robert McNamara, MD, Medical College of Pennsylvania James Scott, MD, George Washington University "Technology and EmergencyMedicine," Metro Centre Stateof the Art Session: David Burnett, MD, []niversity Health Consortium, Technology Advancement Center David Caspari, MD, University of Toronto Kenneth Iserson, MD, University of Arizona Dietrich Jehle, MD, Erie County Medical Center Steve Seifert, MD, Kino Community Hospital "Learning to Use StatisticalSoftware Workshop - Part I," Queens Quay Jrffiry Jones, MD, Butterworth Hospital Stephen Pitts, MD, Emory University
8:00-10:00 am
8:30-10:00 am
9:30-12:00 noon
Exhibits Open, Frontenac Ballroom
Coffee Break, Frontenac Ballroom "Learning to Use StatisticalSoftware Workshop - Part lI," 10:30-12:00noon Queens Quay (Abstracts042-047), Metro Centre l0:30-12:00 noon Scientific Papers:CPR/Ischemia/Reperfusion Moderator: Arthur B. Sanders, MD, University of Arizona
10:00-10:30am
l2:00-1:30 pm
l2:00-l:30 pm
l:30-3:00 pm
Scientific Papers:Injury Prevention(Abstracts060-065), Metro East Moderator: Arthur Kellermann, MD, University of Tennessee " ,4n" NIH Guidelinesfor the Diagnosisand Managementof Asthma:An EmergencyMedicineResponse, SalonA Moderator: Richard M. Nowak, MD, Henry Ford Hospital Christopher H. Fanta, MD, Harvard Medical School William H. Spivey, MD, Medical College of Pennsylvania Glenn Tokarski, MD, Henry Ford Hospital "The Art and Scienceof Grantsmanship- Part I," Pier 2 & 3 Robert A. Lowe, MD, University of Califurnia, San Francisco Susan Rubin, MPH, University of Calfornia, San Francisco "starting a ResearchProject:AspectsUniqueto Emergency EMRA/SAEM ResidentResearchForum and Lunch: M e d i c i n e , "P i e r 4 & 5 John Marx, MD, Carolinas Medical Center "Getting Your Foot in the Door of the Undergraduate Curriculum," Pier 9 EducatorsLuncheon: Undergraduate William Burdick, MD, Medical College of Pennsylvania Peter Viccellio, MD, State University of New York, Stony Brook Scientific Papers:Wound Care (Abstracts048-053), Metro Centre Moderator: Joseph Waeckerle, MD, Baptist Medical Center (Abstracts054-059), Metro East Scientific Papers:CPR/Ischemia/Reperfusion Moderator: Richard Nowak, MD, Henry Ford Hospital Scientific Papers:Infectious Disease(Abstracts066-07l), Salon A Moderator: David Talan, MD, Olive View/UCl'A "The Art and Scienceof Grantsmanship- Part II," Pier 2 & 3 Robert A. Lowe, MD, University of Califurnia, San Francisco Susan Rubin, MPH, Universiry of Califurnia, San Francisco REPEAT: "Learning to Use StatisticalSoftware Workshop - Part 1,"
Queens Quay
1:30-5:00pm
Exhibits Open, Frontenac Ballroom
3:00-3:30,pm
Coffee Break, Frontenac Ballroom
3:30-5:00 pm
Poster SessionI: Innovationsin Education Exhibits (Abstracts072-083) Topics in Academe (Abstracts084-098)
3:30-5:00 pm
Pediatrics(Abstracts099-104), Frontenac Ballroom "Learning to Use StatisticalSoftware Workshop REPEAT:
6:00-7:30 pm
EMRA Awards Reception,Pier 4
Part Il," Queens Quay
Thursday, May 28 8:fi)-9:30 am
scientific Papers:clinical Practice: Sexually Tran_smitted Disease(Abstracts 105-ll0), Metro centre Moderator: Diane Birnbaumer, MD, Harbor_UCLA Scientific Papers:cpR/Ischemia/Reperfusion(Abstracts 1r1-r16), Metro Eqst Moderator: William G. Barsan, MD, [Jniversity of Cinciniati
8:00-10;00 am
8 : 0 0 - 1 1 : 0a0m
Scientific Papers:Geriatric,Emergencycare (Abstracts rr7-r2l), saron B Moderator: Glenn C. Hamitton, UO, Wriglrt X"t, Unirrri$ "Comparing the Major Health Care Reform proposals,,, pier 2 & 3 David Himmelsr,ein,-MD, physicians for National nroltn frogrom Richard Kronick, !'t-!' lenayrryrr i7 co* unity Me:iciie,'university of califurnia, san Diego P. John Seward,^M!, Board of Truitees, American Medical Association Gary Young, MD, portland Viterans Administration "Learning to use slide-Making Software and Hardware', workshop, eueens euay Lester Kallus, M?:^*7r: University of New yortr, Snry nioot, (arkI!_______________ngdorf ,MD,MH?E,Uniieriityof Catifornia,"titii'' Peter Viccellio, MD, State (Jniversity iyNew york, SLnv'Brootc
9:00-12:00 noon EMRA Board of Directors, Sulon A 9:30-12:00 noon Exhibits Open, Frontenac Ballroom 9:30-9:45am
Coffee Break, Frontenac Ballroom
9:45-10:45 am
Scientific Papers: Toxicology (Abstracts 122_125), Metro Centre Moderator: Lewis Gotdfrank, MD, New yori'Universtj, Bi,rr* Scientific Papers: shock/Trauma/Head Injury (Abstracts 126-129),Metro East Moderator: Ronald Krome, MD, Wiliiam beaumont norpitii'
9:45-10:45 am l0:45-ll;00 am
Scientific Papers:clinical practice pain Management (Abstracts 130-r33), saron B Moderator: James R. Roberts, MD, Mercy Cathol)c MedfcifCenter "common clinical rrial DesignsThat Reducethe Required Samplesize,,, pier 2 & 3 Roger J. Lewis, MD, phD, Harbor-UCL,q Coffee Break, Frontenac Ballroom
I l:00-12:00 noon Kennedy Lecture: "canadian Health Care: what Americans Most often Ask,,, Metro centre Dr. Martin Barkin, Former Deputy Minister of Heatth, pror)ni,
of Ontario
l2:00-l:30 pm
Luncheon "The
l:30-5:00pm
Exhibits Open, FrontenacBallroom
l:30-3;00pm
SAEM Annual BusinessMeeting, Metro Centre REPEAT: "Learning to Use Slide-Making Software and Hardware,,workshop,
3:00-6:00 pm
Care of the Elderly in EmergencyDepartments,,,pier 7 ' Moderator: Arthur B. Sanders, MD, lJniversity oy *fzoro
3:00-3: l5 pm
Coffee Break, Frontenac Ballroom
3:l5-5:00pm
Poster SessionII: Toxicorogy/Environmental Emergencies(Abstracts 134-14l) CPR/Ischemia/Reperfusion (Abstracts 142_152) Clinical Practice (Absrracts 153_166),Frontenac Ballroom
4:00-6:00pm
ACEP/EMF Teaching Fellowship Reception,pier 7
5:00-6:00 pm
CPR/Ischemia/Reperfusion ResearchInterest Group, Metro Centre , Toxicology/EnvironmentalResearchInterest Group, Salon B Injury Control ResearchInterest Group, Metro Eqst
7:00-10:00 pm
SAEM Board of Direcrors, pier 2 & 3
eueens euay
Friday, May 29 8:00-9:30 am
Scientific Papers: Computer Methods in Emergency Medicine Research (Abstracts 167-112), Metro Centre Moderator: Robert Wears, MD, Universiry of Floridn, Jacksonville Scientific Papers: EMS/Prehospital Care (Abstracts 173-178), Metro $ast Moderator: Odelia Braun, MD, Universiry of Califurnia, San Francisco "ABEM Synopsis for Faculty," Frontenuc Ballroom Harvey Meislin, MD, President, ABEM Ben Munger, PhD, Executive Director, ABEM
am 9:30-10:00
Coffee Break, Frontenac Ballroom Foyer
am l0:00-11:30
Scientific Papers: Cardiac Emergencies (Abstracts I79-I83), Metro Centre Moderqtor: Jerris R. Hedges, MD, Oregon Health Sciences University Scientific Papers: Pulmonary Emergencies (Abstracts 184-189), Metro East Moderator: Charles Emerman, MD, MetroHealth Universiry Scientific Papers:EMS/PrehospitalCare (Abstracts 190-195),Frontenac Ballroom , MBA, Medical College of Pennsylvania "Design of Intern Orientation Programs," Pier 5 David Sklar, MD, University of New Mexico Bruce Thompson, MD, Henry Ford Hospital Peter Viccellio, MD, State University of New York, Stony Brook "Funding Sources for Emergency Medicine Research," Pier 4 W. Brian Gibler, MD, Universiry of Cincinnati John Marx, MD, Carolinas Medical Center William Spivey, MD, Medical College of Pennsylvania
1 l : 3 0 - 1 : 0p0m
Public Health Luncheon: "Learning From Each Other - A View From Both Sidesof the Border," Pier 7 & 8 Ronald Stewart, MD, Victoria General Hospital, Halifax, Nova Scotia
l:00-2:30pm
Scientific Papers: Radiology/Imaging (Abstracts 196-201), Metro Centre Moderator: Phil Henneman, MD, Harbor-UCLA Scientific Papers: EMS/Prehospital Care (Abstracts 202-207), Metro East Moderator: Daniel Spaite, MD, University of Arizona "Survey Research Methods," Frontenac Ballroom Arthur B. Sanders, MD, University of Arizona Theodore Witley, PhD, East Carolina University "Bedside Teaching," Pier 2 & 3 Marc Nelson, MD, Stanford University Hal Thomns, MD, Bowman Gray David Wagner, MD, Medical College of Pennsylvania
pm 2:30-3:00
Coffee Break, Frontenac Ballroom Foyer
pm 3:00-4:30
Poster SessionIII: Technology Assessment(Abstracts 208-212) Injury Prevention (Abstracts 213-218) Health Care Delivery (Abstracts 219-223) Clinical Practice (Abstracts 224-236) Toxicology (Abstracts 237-242), Frontenuc Ballroom Foyer
4:30-5:30pm
EMS/Prehospital Care ResearchInterest Group, Metro East Multicenter Clinical Trial Research Interest Group, Metro Eust
pm 5:45-10:30
Banquet
EDUCATIONAL AND SPECIAL SESSIONS TUESDAY,MAY 26 EFFECTIVE TBACHING WORKSHOP The workshop on improving teaching skills will be a four-hour sessiontaughtby Dr. GeraldJ. Kelliher and Dr. Ajit Sachdeva, of the Medical College of Pennsylvania.The workshop will focus on principlesof oral communication,and group process skills. At the conclusionof the program, participantswill be able to organize and deliver oral presentationsand a variety of instructionalsettings,use a variety of instructionalstrategies, identiff and use of his/her teachingsfyle more effectively, evaluate the effectivenessof instructional communication, analyze the communicative process in terms of weaknesses and strengths, identify and demonstrateverbal and non-verbal behavior of individualsand groupswhich may enhanceor inhibit achievementofgroup goals,and be able to facilitatediscussion among a group of studentsor colleaguesafter formulating both a discussionplan and a processplan. Participantsare askedto prepare a three-minutepresentationprior to this seminar.
investigator" and an industry perspective on the involvement of EmergencyMedicine in MCTs.
PITFALLS IN EMS RESEARCH The purposeof this sessionis to presentand analyzesomeof the frustrations and obstaclesencounteredby researchersworking in the prehospitalarena.We will target a rangeof problems, from consentissuesto data collection, focusing on points that are not encounteredin hospital-basedresearchprojects. Our approach during the first hour will be to present the issues,then to reach out to other establishedEMS researchersin the national community to see how they have dealt with theseproblems in their environment. The final outcome will be to create an "educated" brainstormingsession,inciting newcomersto EMS research and adding to the breadth of solutions used by establishedinvestigators.
HOW TO TALK TO A STATISTICIAN
SUBSTANCEABUSE PANEL This panel will review the scientific, legal and personalsides of substanceabusein the academicsetting.Recognitionof the problem, interventionsand long-term prognosis will be explored. The panel will look at substanceabusefrom a variety of perspectivesto assistthe participantsin developingan approachappropriateto their setting.Sinceemergencymedicine hasbeenidentifiedas a high risk specialtyfor substanceabuse, the panel will specifically addressan approachfor residency programs.Attendeeswill learnto recognizeearly and late signs of substanceabuse;becomefamiliar with various options for interveningwhen substanceabuseor alcohol abuseis suspected; becomefamiliar with treatmentapproaches,long-term monitoring and prognosis;learn about the prevalenceofsubstanceabuse and alcohol abusein residentsand health care providers; and will be encouragedto considerthe administrativemechanisms for supportof the individual with a substanceabuseproblem as well as the protection of patientsfrom possibleharm.
RESEARCHDIRECTORS' LUNCHEON
The ResearchDirectors' Luncheon is entitled "Multicenter Trials in EmergencyMedicine: The Time Has Come" and will featurea panelof speakerson the subjectof increasedinvolvement of EmergencyMedicine in industry sponsoredmulticenter trials (MCT). Topics to be coveredare researchopportunities in MCTs, rationalefor increasedinvolvementby EM investigators, terminology, the resourcesneeded to participate in MCTs, examplesof current trials, characteristicsof the "ideal
This presentation will emphasizewhat a statistician needsto know to serve as a consultanton a researchproject. Topics for discussioninclude the questionsyou will be askedby the statistician, the outcomeyou expectto measure,the statementof goals and objectives,hypothesisformation, and methodsof your project. In addition, this presentationwill describewhat a statistician can do for you in additionto the statisticsfor your project.
STATE.OF.THE-ART SESSION: TECHNOLOGY AND EMERGENCYMEDICINE
The "State-of-the-Art" sessionat this year's Annual Meeting will be on "Technology and EmergencyMedicine." Speakers will include: David Burnett, MD, Director of the University Health Consortium,TechnologyAdvancementCenter, a consortium of 55 university medical centers for the purpose of technologyassessment; Dietrich Jehle, MD, a member of the SAEM Technology Committeediscussingtechnologyassessment for the practicingEmergencyPhysician;David Caspari, MD, on the faculty of the University of Toronto, discussing the effects of a managedhealth care system on technology assessmentand utilization; and KennethIserson,MD, MPH, from the University of Arizona, Division of Bioethics, discussing ethicalissuesin technologydevelopment,assessment andutilization. Steven Seifert, MD, Chair of the SAEM Technology Committeewill moderatethe session,attemptto articulatea philosophyof "technology consciousness"and look aheadto the technologieswe will haveto assessand integrateinto the practice of Emergency Medicine in the future.
WEDNESDAY, I/IAY 27 LEARNING TO USE STATISTICAL SOFTWARE WORKSHOP The world of microcomputerstatisticshas changedmarkedly in the last few years. Performing statisticalanalyseson a PC is now routine, and the softwarepackagesnow availableequal or even exceed the sophistication and features of their mainframe brethren. This sessionwill review the top-ratedstatistical softwarepackagesnow availablefor the IBM PC and Macintosh. Each package has strengthsand weaknessesin the main areas
of interestto medicalresearchers:analyticfeatures,cost, data management, graphics, and written documentation. Because learning any statisticsprogram takes some investmentof time, we will also comparethe easeof use or "user friendliness" of each program. Dr. Pitts will also introducehis computeraided course in quantitative methods, designedexclusively for emergencyphysicians.A microcomputerworkshop will immediatelyfollow the discussion.The workshopwill allow participants to try out the latest statistical packageson IBM and Macintosh computers.
TIIE NIH GT]IDELINES FOR TIIE DIAGNOSIS ANb MANAGEMENT OF ASTHMA: AN EMERGENCY MEDICINI'ERESPONSE Increasesin the morbidity and mortality of asthmain the 1980's in the United Statesprompted the NIH to convene an expert panelof asthmaspecialiststo make recommendationsconcerning improved managementof the disease. The expert panel convened and developedguidelines for the diagnosisand management of asthma. These included the management of acute exacerbationsof asthmain adults while they were still at home and for their managementin the Emergency Department. Dr. Christopher Fanta will presentthe rationale for the NIH expert panels' recommendations.Emergencyphysicianswith expertise in the managementof acute asthmawill critically evaluate the algorithms/guidelinesfrom an EmergencyMedicine perspective. Audience participation into this discussion should make for a very lively debate.
THE ART AND SCIENCE OF GRANT WRITING Getting a research study funded is a process that involves a numberof important steps.One is being creative, recognizing important research questions and devising clever approaches to answeringthesequestions.Another is discovering what funding agencieslook for in researchgrant applicationsand tailoring applications to meet these requirements. This seminar is designedto sharpenyour skills in writing grant applications.We will focus on the criteria that grant reviewers use for evaluating the scientific merit of a proposaland on strategiesthat will maximize the probability of a grant being funded. Topics will include the evolutionofa researchquestion,selectionofan appropriate and efficient study design, choice of study subjects,samplesize planning, questionnairedesign, variable measurements,appropriate funding sources,and the review and funding of a research proposal. The material presentedin the afternoon will be a continuation of the morning session.
I]NDERGRADUATE EDUCATORSLI.]IICIIEON
This yearsUndergraduateEducatorsLuncheonis entitled, "Getting Your Foot in The Door of The UndergraduateCurriculum"
and will focus on ways emergencymedicineeducatorscan bring courses,electives,workshops, or other involvement into the medicalschoolcurriculum. The panelistswill describeexperiencesat their own institutions,sharingmethodsand ideasthat worked, as well as othersto avoid. By the end of the session, participantswill havea practicalunderstandingof the different methodsemergencymedicine faculty can use to become active participantsin the educationprogram at their medical school.
EMRA/SAEM RESIDENTLEADERSHIPFORTIM This sessionis opento all residentsbut is specificallydesigned for upcoming chief residentsand senior residentswho anticipate an activeleadershiprole during their last year oftraining. The forum will consistof three sections.The first sessionwill be taughtby Dr. Jim Scott who will discussthe topic of residents as teachersand will discussdevelopingteachingskills, teaching medicalstudentsand interns,teachingin the ED environment, and how to give feedback.The secondsessionspeakeris Dr. Carey Chisholm who will addressthe topic of Stressorsof Senior Residents.He will discussdeciding career pathways,the job search,and the increasedteaching/leadership role in residency programs.The final sessionis designedfor chief residents(and is opento all interestedresidents)and will consistof the following speakers:Dr. Carey Chisholm, Dr. David Levy, and Dr. Bob McNamara.They will discussthe role of the chief resident, building teamwork and morale among residents,conflict resolution skills, "making everyonehuppy," schedulinghints, and leading and motivating residents.
EIVIRA/SAEMRESIDENT RESEARCHFORUM: STARTING A RESEARCHPROJECT:ASPECTS UNIQUE TO EMERGENCY MEDICINE The speakerfor the EMRA/SAEM ResidentResearchForum will be Dr. John Marx, MD. The ability to conduct research is both helpedand hinderedby the natureof our specialty.This sessionwill addressaspectsof researchwhich are unique to emergencymedicineand avenuesto overcomethe obstaclesencounteredin design, funding, and implementation.
THURSDAY, MAY 28 COMPUTER SLIDE.MAKING WORKSHOP The courseis designedfor beginner and intermediatecomputer userswith little or no experiencein generating35mm slides. IBM compatiblecomputersand film recorderswill be used. The coursewill provide an introduction to effective slide-making, including amount, location and presentation of material. The registrantwill gain practical experienceusing the computer and slide-making software, with one computer and one tutor for every two students.Registrantsare encouragedto bring a text file of a samplelectureoutline to be usedto create5-10 slides and illustrate how the design and production process works. Slideswill be imagedand developedduring the workshop, and a synthesissessionwill take place late in the afternoonto review and critique the work of the class. It is hoped that registrants will leave the sessionbelieving that they can make excellent quality computer slidesto enhancetheir teaching. Comparisons of the different hardware and software will be provided, along with the cost of the various packages.
LUNCHEON: THE CARE OF THE ELDERLY IN EMERGENCY DEPARTMENTS The SAEM Geriatric EmergencyMedicine Task Force hasbeen working for the past l8 months assessingthe emergencyhealth care needsofelderly patients.The Task Force, chairedby Arthur Sanders,MD, will review the major findingsfrom their studies. Overall conclusionsand recommendationsin the areasof clinical service, academics (research and education), resources and social/personalissueswill be discussedin detail. Implementation of the recommendationsand future directions for researchand educationin geriatric emergencymedicinewill be a focus of discussion.All interestedindividualsare invited to attend.
CLINICAL TRIAL DESIGNSTHAT REDUCE THE REQUIRED SAMPLE SIZE Clinical trials are usually designedusing fixed predetermined samplesizeswith the assumptionthat the resultingdatawill be
analyzedonce at the conclusion ofthe trial. In a group sequential trial, on the other hand, the dataare analyzedmultiple times during the course of the trial, to determine if the data acquired up to that point have obtained statistical significance. Theseinterim dataanlysesoften allow the trial to be stoppedearlier than if a fixed samplesize and a singledataanalysishad beenused.
Two methodsfor performing theseinterim analyses,while controlling the risk of type I error, have come into common use. Methods for the designand analysisof clinical trials using group sequentialmethods will be explained and tables, which allow the use of these methods without any additional calculations, will be distributed.
FRIDAY, MAY 29 SYNOPSISFOR FACULTY: AMERICAN BOARD OF EMERGENCY MEDICINE
the delivery of both primary and specialtycare, and regionalization and rationing is more readily achieved in the Canadian system through central (ministry) planning. The influence of competition in the United Statesfor health care dollars is less evident in the Canadian system and not significant between health care institutions.The emphasison primary healthcare delivery is strong above the border, particularly through a network of family practitioners.The challengeon both sidesof the line will be to solvethe problem of escalatingcosts,while answering the question of rationing and the influence of new and unproven technology.
Harvey Meislin, MD, President,and BensonS. Munger, PhD, Executive Director of the American Board of EmergencyMedicine will outline the changesin Board policiesthat havetaken place during the past 12 months. Many of thesechangeshave direct applicationto programsand faculty. EmergencyMedicine program faculty and other interestedindividuals are urged to attend.The topics which will be addressedwill includecombined training programswith internalmedicineand pediatrics;credit for training in non-EmergencyMedicine programs; the intraining examination; the resident tracking system; and the developmentof additionalsubspecialties.Detailedmaterialswill be availableand time will be allocatedto respondto specific questionsabout theseand other related topics.
SURVEY RESEARCH METHODS Participantswill be introducedto survey researchmethodology. Although the focus will be on written questionnaires,surveys conductedby telephoneand interviews will be discussed,and many of the principles to be presentedwill be applicable to all three typesof surveys.The importanceof planning, including field testing, will be emphasized.Specific topics will include sample selection, writing questions, design and format, data storageand analysisconsiderations,and proceduresfor administration. Participantswill havean opporrunityto critique a questionnaire and to interact with the presentersand other participants.
DESIGN OF INTERN ORIENTATION PROGRAM Three ResidencyDirectorswill presenttheir program with emphasison why this is the approachthey've taken and why it works. They will describeunique aspectsof their orientation programs.Residentsfrom the programswill describetheir experiencesparticipatingin the programs. Handoutsdescribing the programswill be distributed,so the residencydirectorswill not describethe program in detail. Questionsare taken for 5 minutes.
BEDSIDE TEACHING After an introduction outlining the unique opportunity and responsibilitywe have for bedsideteachingin the Emergency Department,Dr. Nelson will presenta discussionon the theoretical underpinningsof bedsideteaching.Dr. Thomaswill presenta l0-15 minute discussionon practicaltechniquesto maximize learning. Dr. Wagner then will make a presentationon advancedbedsideteachingtechniques,focusing on videotaping and computer use in the Emergency Department. A period of questionsand interaction with the audiencewill complete the session.
PUBLIC HEALTH LUNCHEON
This year's sessionis entitled: "Learning From Each Other A View From Both Sidesof The Border. " Differenceson either side of the "longest undefendedborder" in the world are no more pronouncedthan in the healthcare systemsof the United Statesand Canada. There are some similarities - the USA deliverscarein the most expensivesystemin the world - ll.8% of its GNP, and Canadavia the most expensivesystemof those countrieswith national health systems.The fundamentaldifferencesderive from the history and social fabric ofthe two countries, exemplifiedin the original Canadianconstitutionalgoals "peace, of order, and good government," populationanddemographic differences,and the Canadianphilosophy, view and balanceof communaland individual rights. The relatively direct involvementof governmentin the Canadiansvsteminfluences
FUNDING MECHANISMS FOR RESEARCH IN EMERGENCY MEDICINE This coursewill review non-NIH grant sourcesincluding Emergency Medicine Foundation, pharmaceuticalcompanies,appliance manufacturers, and potential institutional support.
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PAPER SESSIONS TUESDAY, MAY 26 Scientific Papers: Pediatrics-Respiratory am) ScientificPapers:PlenarySession(8:15-10:15 (1:30-3:00pm) Measures Heart Rate as Objective Pressure and 001 Role of Blood of Pain Intensity in Emergency Department Patients, William A. Watson, PharmD, University of Missouri-Kansas City
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002 Routine Admission Electrocardiography In Emergency Department Patients, Allan Wolfson, MD, University of Pittsburgh
RespiratorySigns And SymptomsAs Markers For Pneumonia In Febrile Infants Less Than Two Months Of Age, Despina Demestihas, MD, Children's Hospital, Buffalo
021 RoutineChestRadiographyin the Evaluationof Febrile Infants Under 8 Weeks Old, Kate Delany, MS, Butterworth Hospital
003 SuccessfulConversionof UnstableSupraventricularTachycardia to Sinus Rhythm with Adenosine, Frantz R. Melio, MD, University of Southern California
022 Efficacy of Oral Prednisonein the EmergencyDepartmentTreat-
004 A Prospective Study of Low Risk Criteria for Cervical Spine Radiography in Blunt Trauma, William Mower, MD, University of Califurnia, lns Angeles
023 AerosolizedEpinephrine(AE) Use in the Treatmentof Croup,
ment of Acute Asthma in Children, Richard J. Scarfone, MD, University of Pittsburgh Nanette C. Kunkel, MD, Children's Hospital, Philadelphia
005 Infection Control for Health Care Workers Caring for Critically Injured Patients: A National Survey, William A. Berk, MD, Detroit Receiving Hospital
024 Duration of Clinical Responseto Racemic Epinephrine in
006 Failure of CDC Recommended Ambulatory Therapy In The Treatment Of PID, Kurt Popke, MD, University of Califurnia, Davis
025 A PediatricEmergencyDepartmentTrial of ContinuouslyVs.
Children with Croup, K. Wussow,MD, Case WesternReserve University IntermittentlyNebulizedAlbuterol, Dale Steel,MD, Children's Hospital, Philadelphia
007 ProsecutionOf Injured Alcohol-IntoxicatedDrivers For DWI, Jeffrey W. Runge, MD, Carolinas Medical Center
ScientificPapers:Shock/Trauma-Clinical (1:30-3:00pm)
008 Variability of PhysicianInterpretationof Advance Medical Directives, lVilliam Mower, MD, Universityof California, hts Angeles
026 RoutineChemistry Laboratory ScreeningTestsAre Not Indicated in the Initial Treatmentof the Trauma Patient,BartholomewJ. Tortella, MTS, MD, New Jersey Trauma Center
Scientific Papers: Pediatrics-Trauma (10:30-12:00 noon)
027 Admission Lactate: A Rapid Predictor of Survival Following Traumatic lnjury , StephenMenlove, MD, GeorgetownUniversity
009 A Clinical Trial Comparing N-2-Butyl-CyanoacrylateVersus SuturingFacial Lacerationsin Children, J.V. Quinn, MD, University of Onawa
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010 Cervical SpineImmobilization: Time for a Change,D.J. Treloar, MD, Henry Ford Hospital 01 I
Rapid ResuscitationMay Contribute To Hypothermia Despite Blood Warmer Use, Jack M. Bergstein, MD, Medical College of Wisconsin
029 Emergency Department Ultrasound in the Evaluation of Abdominal Trauma, Dietich Jehle, MD, Erie County Medical Center
Head Trauma: EnhancedPredictionof PositiveComputedTomographyby PediatricTrauma Score and Glasgow Coma Scale, StevenA. Kohler, MD, University of Florida
030 IntravenousAccessIn The Critically Ill TraumaPatient:A MultiCentered Prospective,RandomizedTrial Of SaphenousCutDown And PercutaneousFemoral Venous Access, Mark D. Westfall, DO, Northwestern Memorial Hospital
012 Utility of Routine Laboratory Testing in the Pediatric Trauma Patient, Daniel Isaacman, MD, University of Pittsburgh 013 RandomizedControlled Trial of RadiographOrdering for Extremity Trauma-bla Triagâ&#x201A;Ź Nurse, L. Ropp, MD, Henry Ford Hospital
0 3 1 Comparisonof
a Neural Network Versus Triss for Predicting Survival After Trauma, CharlesM. Shffiebarger, MD, Methodist Hospital of Indiana
014 Two-Thumb VersusTwo-Finger ChestCompressionDuring CPR in a Swine Infant Model of Cardiac Arrest, JamesJ. Menegaui, PhD, University of Pittsburgh
ScientificPapers:Clinical Practice- Infection Control (3:15-4:45pm)
Scientific Papers: Shock/Trauma-Basic Sciences (10:30-12:00noon)
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016 A Comparisonof the Responseof Controlled and Uncontrolled Models of Severe Hemorrhagic Shock to Aggressive Fluid Resuscitation,StevenC. Dronen, MD, University of Cincinnati
0 3 3 What is Leaky Can Be Risky: SequentialGlove Leak Detection
SplatterDuring Jet Irrigation Cleansingof a Wound Model: A Comparisonof Three InexpensiveIrrigation Devices,Edwin C. Pigman, MD, George Washington University Using Electroconductance,S. Ibarra, MD, Bunerworth Hospital
034 Loss of Glove Integrity During Common E.D. Procedures,Karen
015 Effect of AggressiveResuscitationon Coagulationin Uncontrolled Hemorrhagic Shock in Swine, ThomasH. Blackwell, MD, University of Cincinnati
035 Determinationof Procedure-and Condition-SpecificUniversal
017 A Trial of Multiple ResuscitationRegimensin SevereHemorrhagic Shock, Susan A. Stern, MD, University of Cincinnati
(barrier) PrecautionsRequirementsfor Optimal ED Provider Protection, Gabor D. Kelen, MD, Johns Hopkins University
018 RecombinantEndotoxin Neutralizing Protein from L. Polyphemus ReducesMortality from E. Coli SepsisinRatModel, Nathnn Kupperman, MD, Children's Hospital
036 SharpInstrumentDisposalPracticesDuring Resuscitationsin a
EMRS Best Paper: 019 Gut PermeabilityAfter Injury, R. John Corson, FRCS, University of Manchester, United Kingdom
037 DiminishingOccupationalExposureto CommunicableDiseases
N. Hansen, MD, Johns Hopkins University
University Emergency Department, James Campain, MD, George Washington University in an EMS System, Peter A. Curka, DO, Baylor College of Medicine
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scientiric Papers : tlili:rr
.,iourDisease r$ft
in Children, StevenG. Rothrock, MD, RiversideGeneralHospital
040 Utility of Serum Interleukin-6 for Diagnosisof InvasiveBacterial
038 IntramuscularAntibiotic Therapyfor Preventionof BacterialSequelaein Children with Occult Bacteremia,Gary R. Fleisher, MD, Children's Hospital
Disease in Children, R. Saladino, MD, Harvard University
04l SuprapubicBladder Aspiration vs Urethral Catheterizationin Ill Infants: Success,Efficiency, and ComplicationRates, Charles V. Pollack, Jr., MA, MD, University of Mississippi
039 Single-DoseIntramuscularCeftriaxonefor Acute Otitis Media
WEDNESDAY,M'AY 27 ScientificPapers:CPR/Ischemia/Reperfusion Scientific Papers: CPR/Ischemia/Reperfusion (10:30-12:00 noon) (1:30-3:00pm) 042 MagnesiumSulfate(Mg) Lowers Coronary PerfusionPressure
054 Effect of High Dose Epinephrineon Myocardial High Energy
(CPP) During Human CPR, Mark G. Goeuing, MD, Iililliam Beaumont Hospital
PhospatesDuring Ventricular Fibrillation and Closed-ChestCPR, James W. Hoekstra, MD, Ohio State University
043 Effect Of MagnesiumOn Cardiac ResuscitationOutcomeAfter
055 HemodynamicEffectsOf RepeatedDosesOf EpinephrineIn Pro-
Prolonged Arrest, CharlesB. Cairns, MD, Universityof Colorado
longedCardiac Arrest And CPR, David Persse,MD, HarborUCLA
044 StandardExternalCPR (SECPR)DecreasesMorphologic Brain Damagein Dogs, Comparedto no Intervention,Ann Radovsky, DVM, PhD, University of Pittsburgh
056 The Effect of High Dose Epinephrineon Hemodynamicsand Electrolytes in the PostResuscitationPeriod, StevenG. Crespo, MD, Medical College of Pennsylvania'
045 An ExperimentalAlgorithm VersusStandardACLS in A Swine
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Model Of Out-Of-Hospital Cardiac Arrest, JamesJ. Menegazz.i, PhD, Center for Emergency Medicine, Pittsburgh 046 Sodium Bicarbonatein Cardiac Arrest, Rade B. Vukmir, MD, University of Pittsburgh
High Dose EpinephrineResultsIn GreaterEarly Mortality Following ResuscitationFrom Prolonged Cardiac Arrest, Robert Berg, MD, University of Arizona
058 A Studyof High Dose Epinephrinein Human Cardiopulmonary Resuscitation, Ian G. Stiell, MD, University of Oxawa
047 Effect of Epinephrineand Sodium Bicarbonateduring CPR on Survival and NeurologicOutcomefollowing Asphyxia Induced Cardiac Arrest in Rats, Robert Neumar, University of Pittsburgh
059 A RandomizedClinicatTrial of High DoseEpinephrineandNorephinephinevs. StandardDose Epinephrinein PrehospitalCardiac Arrest, Michael Callaham, MD, University of California. San Francisco
Scientific Papers: Injury Prevention 060 QuantitationOf ImpactAttenuationOf DifferentPlaygroundSur-
ScientificPapers:InfectiousDisease(1:30-3:00pm)
facesWith A Traxial Accelerometer,RoseanneNaunheim,MD, St. ktuis University
066 Identification Of Serious Illness In Febrile Adults, E. John Gallagher, MD, Albert Einstein College of Medicine
0 6 1 FactsVersusValues:Why lrgislators Vote AgainstInjury Control Laws, StevenR. kmenstein, MD, MPH, University of Colorado
067 Reevaluationof Throat Culture for Diagnosisof Strep Pharyn-
062 Intoxicated Emergency Department Patients: A Five-Year
gitis: Is the Rapid Group A Antigen Test the New Gold Standard?, Michael J. Burns, MD, University of Califurnia, Imine
Follow-Up of Morbidity and Mortality, Paul Davidson, MD, University of Coktrado
068 Non-group A Beta-hemolyticStreptococcalPharyngitisin the ED:
063 An EmergencyDepartmentBasedIntentionalInjury Surveillance
Implicationsfor Rapid StrepScreening,Michael J. Burns, MD, University of Calfornia, Irvine
System, Edward Bernstein, MD, Boston City Hospital
064 Fatal Childhood Injury Patternsin an Urban Setting:The Case
069 Acute Pyelonephritisin the ED: How Effective is Outpatient
fbr Primary Prevention,Carol L. Weesner,MD, Medical College of Wisconsin
Management?, GH Lindbeck, MD, University of Virginia
070 Primary Varicella Infection in Adults, Jill M. Baren, MD, [Jniver-
065 Changesin SexualAssaultOver Time: A Prospective Comparison
sity of Califurnia, Los AngeLes
of 1974 and 1991, DJ Magid, MD, Denver General Hospital
0 7 1 Relationshipof Clinical Presentationto Time to Antibiotics for the EmergencyDepartmentManagementof Suspected Bacterial Meningitis, David A. Talan, MD, Olive View/UCL4
ScientificPapers:Wound Care (1:30-3:00pm) 048 Cefazolin And PovidoneIodine As Irrigants Of Contaminated
PosterSessionI Innovationsin EducationExhibits
Wounds, John M. Howell, MD, Georgetown lJniversity
049 QuantitativeBacterialCounts Following AggressiveTreatment vs. "Benign Neglect" In A RabbitPunctureWound Model, ,/. Dewey Cooper, MD, Methodist Hospiral of Indiana
072 A ProposedModel For A ResidentExperienceIn Mass Gathering Medicine: The United StatesAir Show, Robert A. Del,orenzo, MD, Wright State University
050 Predictorsof Infection in Uncomplicated,Traumatic Wounds, Richard L. Inmmers, MD, Valley Medical Center
073 IntegrationOf EmergencyMedicine And BasicScienceInstruc-
0 5 1 The Efficacy and Acceptability of Using a Jet Injector in Per-
tion In The First Year Of Medical School, William P. Burdick, MD, Medical College of Pennsylvania
forming Digital Blocks, GeorgeL. Ellis, MD, WesternPennsylvania Hospital
074 Developing A Four-Year Medical School Curriculum In Emergency Medicine, Connie Mitchell, MD, University of California, Davis
052 Buffered Versus Plain Lidocaine For Digital Nerve Blocks, Davld T. Ford, MD, Albany Medical Center
053 Time-Dependenceof the Pain Attenuation Associatedwith Buffered
075 StressIn ResidencyTraining: Developing A Program For In-
Lidocaine,JanetInch-Donahue, MD, AlleghenyGeneralHospital
tervention, ConnieMitchell, MD, Universityof Califurnia, Davis
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076 DatabasingLecturesand Seminarsin an EmergencyMedicine Residency, F. Wright Hartsell, MD, Wifford Hall USAF 077 "kt's Not Meet By Accident" - A Trauma PreventionProgram for Teens, Alison Lane-Reticker, MD, St. Francis Hospital
090 The Effect of Varying Levels of Attending Supervisionof Housestaff on EmergencyDepartmentPatientDispositionDecisions, Edward A. Panacek, MD, University Hospitals of Cleveland 091 Post Care Follow-up In Emergency Medicine Residencies, William H. Adams, MD, Geisinger Medical Center
078 A New EducationalProgramfor DeathTelling: Didactic, Video and StandardizedFamily Scenarios, Robert J. Schwartz, MD, MPH, Hartfurd Hospital
092 EmergencyMedicine Faculty Salaries:A Studyof Data Submitted to SAEM, Bruce M. Thompson, MD, Henry Ford Hospital
079 The Effectivenessofan InteractiveVideodisc Systemfor Instruction of Paramedicand Fourth-Year Medical Studentsin Cognitive and PsychomotorSkill Required for Advanced Airway Managemenq Walt A. Stoy, PhD, EMT-P, University of Pittsburgh
093 Information Needsand Resourcesin a TeachingHospitalEmergency Department,Audrey L. Carnvright, RN, MethodistHospilal of Indiana 094 Compliancewith EmergencyDepartmentPatientReferral: The Effect of ComputerizedDischargeInstructions, Rade B. Vukmir, MD, University of Pittsburgh
080 The Crush Injury CadaverLab: A New Method of Training Physiciansto Perform Fasciotomiesand Amputationson Survivors of a Catastrophic Earthquake, Carl H. Schultz, MD, University of Califurnia, Irvine 08 I
095 Associationof PatientEntry Rateswith EmergencyDepartment Record Documentation,David W. Munter, MD, Naval Hospital, Portsmouth
An Evaluationof ResearchTraining from a Large ResidencyProgram, Robert J. Rydman, PhD, Cook County Hospital
096 Urban Trauma: Diurnal Variationsin the Incidence,Severityand GeographicalDistribution of Various Mechanismsof Injury, Brian Zachariah, MD, Baylor College of Medicine
082 Can the Basic Preceptsof Trauma Managementbe Learned with Computer Assisted Instruction?, Rita K. Cydulka, MD, MetroHealth Medical Center 083 A NeedsAssessmentSurvey for a Death Notification Program, Loice A. Swisher, MD, Medical College of Pennsylvania
097 Incidenceand Type of HazardousObjects Found Among Patients and Visitors Screenedby Magnetometerin an Urban Emergency Center, Bruce M. Thompson, MD, Henry Ford Hospital
Topicsin Academe
098 PhysicianCompliancewith ACLS Guidelines,KennethJ. Welch, MD, East Carolina University
084 Impact of EmergencyMedicine ResidencyProgram on Rotators' EmergencyMedicine Education,Roben A. Schwab,MD, Ilniversity of Virginia
Pediatrics 099 Comparisonof IntramuscularMeperidineand Promethazine, with and without Chlorpromazine:A Prospective,DoubleBlind Trial, Daniel J. Dire, MD, Darnall Army Hospital
085 Does EmergencyMedicine Draw ResidentsDisproportionately Away From Other Specialties?,Allan B. Wolfson,MD, University of Pittsburgh
100 IntranasalMidazolamas a Sedativefor ChildrenDuring Laceration Repair, James H. Ellis, DO, Darnall Army Hospital
086 Evaluationof Criteria Used to SelectApplicantsfor Emergency Medicine Residencies,Richard E. Wolfe, MD, Denver General Hospital
101 Intraosseous Infusion:Successofa Standardized RegionalTraining Programfor PrehospitalALS Providers, ThomasE. Arulerson, MD, ChambersburgHospital
087 Influenceson Medical StudentsChoosingA Career in Emergency Medicine, Diana R. Williams, MD, University oJ'lllinois
102 Incidenceof SubclinicalMethemoglobinemia in Infantswith Diarrhea, Emily S. Pender, MD, University of Missi.s,sippi
088 CharacteristicsInfluencingCareerDecisionsOf AcademicAnd Non-AcademicEmergencyPhysicians,Arthur B. Sanders,MD, University of Arizona
103 The SuccessfulUse Of A Metal DetectorIn Locating Coins Ingested By Children, Simon P. Ros, MD, ktyoh University
089 The RelationshipOf EmergencyMedicineResidentsAnd Faculty With BiomedicalIndustry Representatives, SamuelM. Keim, MD, University of Arizona
104 The Efficacy of Parent Educationin the PediatricEmergency Department, S.E. Krug, MD, Case WestemResene University
THURSDAY, MAY 28 ScientificPapers:SexuallyTransmitted Disease I l0 DNA Probe to Detect SexuallyTransmittedDiseasein Female Sexual Assualt Victims, John R. McPherson, MD, Universin of (8:00-9:30am) Floridn
105 EmergencyPhysicianDiagnosis,Treatmentand Reportingof Sexually TransmittedDiseases:Their Effect on Transmissionand Conlrol, Thomns D. Kirsch, MD, MPH, Johns Hopkins
Scientific Papers: CPR/Ischemia/Reperfusion (8:00-9:30am) u t IsolatedAnimal Heart Cell Cultures:A Model For CardiacRe-
106 ComplianceWith OutpatientAntibiotics Among Women Treated In The EmergencyDepartmentFor Pelvic Inflammatory Disease, Daniel Brookoff, MD, University of Tennessee
suscitation, T.L. Vanden Hoek, MD, University of Cincinnati Preventionof Post-IschemicNeurologic Injury By Acetyl-LCarnitine, Roben E. Rosenthal, MD, George Washington IJniverstty l 1 3 Altered Patternsof Cerebral Correx Energy Metabolismand Normalizationby IntravenousAcetyl-L-CarnitineFollowing Cardiac Arrest in Dogs, CtaryFiskum, PhD,-George WashingtonUniversity CuprizoneIntoxicationResultsin Oxidative Stressand Demyelination, Hubert S. Mickel, MD, Ittboratory of ExperimentalNeuropathology
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107 The Incidence of Gonorrhea in Males Presentingto an Urban EmergencyDepartmentwith Visible PurulentUrethral Discharge, Dale S. Birenbaum, MD, ThomasJffirson University
108 Preventionof N. Gonorrhoeaein Victims of Sexual Assault: Clinical and Cost Effectiveness,DJ Magid, MD, Denver General Hospital
109 Clinical and Microscopic Diagnosesof Vaginal Yeast Infection: A ProspectiveStudy, Jean Abbott, MD, University of Colorado
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132 Ketorolac Versus Meperidine and Hydroxyzine in the Treatment of Acute Migraine Headache: A Prospective, Randomized, Double-Blindlr\al, Frank Dunaway, MD, St' Francis Medical Center 133 Comparison of Intravenous Metoclopramide, Ketorolac, and Morphine for the Acute Relief of Renal Colic, Beverly L' Timerding, MD, llake Forest University
Brain Nuclear ProteinsContaining Phosphotyrosinein Cardiac Arrest and Resuscitation,Brian J. O'Neil, MD, Wayne State University
Neutrophil ChemotacticFactor Generated I 16 Reperfusion-Induced in Canine Plasma, Donna L. Carden, MD, Ittuisiana Slate University
"' session Poster ;ffi;:11{13u1ilffiil,;lt
Scientific Papers: Geriatric Emergency Care (8:00-9:30am) I l7
The Use Of EmergencyDepartmentsBy Elderly Patients:ProiectionsFrom A Multi-Center Database'Gary R' Stange, MD, Ilniversity of ltlinois
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of MyocardialInfarctionWith Increasing ChangingPresentation Age, A. Knapp, MS, Buttenuorth Hospital
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Misdiagnosisof Acute Meningitis in Elderly Patients,Tod Wyn' MS, Butterworth HosPital
134 Respiratory Depression As A Mechanism Of Cocaine Induced Deith, Robert W. Derlet, MD, University of California, Davis 135 Failure Of Dihydropyridine ClassCalcium ChannelBlockers To Antagonize CocaineToxicity, Robert W' Derlet, MD, University of Califurnia, Davis 136 Effect of Delay of Treatment with Sodium PolystyreneSulfonate (SPS)on its Ability to Lower Serum Lithium (Li) Concentrations in Mice, JG Linakis, PhD, MD, Brown University 137 RepetitiveDosesofSodium PolystyreneSulfonate(SPS)Enhance the Elimination of Parenterally Administered Lithium (Li) and l,ower Serum Potassium(K) Concentrationsin Mice, JG Linnkis' PhD, MD, Brown UniversitY 138 The Efficacy of Magnesiumand Calcium for the Treatmentof Dermal Hydioflouric Acid Burns, Keith K. Burkhatt, MD, Roclcy Mountain Poison and Drug Center 139 Prevention of Neurological SequelaeFrom Carbon Monoxide by Hyperbaric Oxygen in Rats, C. Tomnszewski,MD, Carolinas Medical Center 140 Bee Stings in the Emergency Department: Clinical Featuresand the NeeJfor EmergencyMedical Care,John J' Kelly, DO' Medical College of PennslYvania l4l The Incidenceof Wound Infection Following Crotalid Envenomation, Richard F. Ctark, MD, (lniversity of Califurnia, SanDiego 238 Positive Toxicology ScreeningPredicts Improved Survival in Severely Injured Neuro-Trauma Patients, Scott W' Jolin, MD, Georgetown UniversitY 239 Do Overdose Patients Lie About What Drugs They Took?, Michael Yaron, MD, University of Colorado
120 Alveolar-ArterialOxygenGradientsin Elderly Patientswith SuspectedPulmonary Embolism, N. VanDeelen,MS, Butterworth Hospital l2l
EmergencyDepartmentPredictorsof Bacteremiain the Elderly' Christopher C. Rose,MD, Western Pennsylvania Hospital
ScientificPapers:Toxicology(9:45-10:45am) in a SwineModel of 122 AntidotalEfficacyof 3,4-Diaminopyridine Verapamil Toxicity, Michael C. Plewrt, MD, WesternPennsylvania Hospital 123 Extraordinary Medical Therapy For SevereVerapamil Overdose, Thomas G. Martin, MD, Montefiore University OverdoseWith 124 RecoveryFrom SevereTricyclic Antidepressant Hypertonic SalineIn A Swine Model, JamesL' McCabe, MD, IJniversity of Pittsburgh 125 ExperimentalAmitriptylinePoisoning:TreatmentOf SevereCardiovascularToxicity With CardiopulmonaryBypass'GregoryL' ktrkin, MD, West Virginia University
CPR/Ischemia/RePerfusion
Scientific Papers: Shock/Trauma/Head Injury (9:45-10:45am)
142 Asphyxial Cardiac Arrest Survival Model in Rats with Quantitative Brain HistopathologicalEvaluation, l-aurenceKatz, MD, University of Pittsburgh 143 Cardiac Arrest PatientsPresentingWith Asystole or EKG Complexes Without Pulses: Contribution of Resuscitation Efforts ioward Total Survivorship, Peter Curka, MD, Baylor College
126 The Effects of Ethanol on RespiratoryFunction in a Porcine Brain Injury Model, BrianJ. Zink, MD' Albany Fluid-Percussion Medical College 127 Admission Glasgow Coma Score Is A Poor Predictor Of The Need For Early Airway InterventionIn Trauma PatientsWith SubstanceAbuse, Sco// W. Jolin, MD, Georgetown University
of Medicine I44
128 BiochemicalMarkers of IntracranialInjury in Patientswith Simultaneous Minor Head Trauma and Ethanol Intoxication, M' Andrew lzvitt, DO, Highland General Hospital
Characterizationof Systemic Oxygen Transport PatternsAfter Human Cardiac Arrest: Implications for Survival, EmanuelP' Rivers, MD, Henry Ford HosPital
145 Invitro Effect Of Deferoxamine (DFO) and 21-Aminosteroid (21-AS) on Hyperbaric (HBO) Induced Lipid Peroxidationin Rat Brain, K. Mascotti, BS, University of Minnesota
129 High Yield Criteria for CT Scansin Head Trauma Patients,C' Madden, MD, UniversitY of Arizona
146 The Evaluation of Magnetic ResonanceSpectroscopy During CPR with a New NonferromagneticCPR Device, Kevin R' Ward, MD, UniversitY of Pittsburgh
ScientificPapers:Pain Management (9:45-10:45 am)
147 Fluorescent Histochemical Localization of Lipid Peroxidation During Brain Reperfusion, Blaine C. White, MD, WayneState UniversitY 148 Comparison of Standardand Deep EndotrachealEpinephrine in a Prolonged Swine Cardiac Arrest Model, Allan Doctor, MD, IJniversity of Pittsburgh 149 TransesophagealEchocardiography During Human CPR, Mark G. Goettins, MD, William Beaumont Hospital
131 A Randomized,Double-Blind, ComparativeStudy Of The Efficacy Of Ketorolac Tromethamine Versus Meperidine In The Treaiment Of SevereMigraine' Gregory hke lnrkin, MD, West Virginia Universiry 130 Most Linear Analog Pain Data Should Be Analyzed by Nonparametric Statistical Techniques, Gary M. Gaddis, MD, PhD' University of Missouri-Kansas CitY
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A
A
1 5 8 Achievementof VascularAccessUsins the IntraosseousRoute
150 l-Year Survival After Prehospital Cardiac Arrest: The Utstein Style Applied to a Suburban-RuralSystem,Lawrence Kass,MD, York'Hospital l5l
I
r UY in the Adult Tibia, DS Schafer, Univirsity of Texas
1 5 9 Comparison of Haloperidol and Lorazepam in Controlling the Acutely Violent Patient, John T. Mullen, MD, Valley Medical Center
High Atrial Natriuretic Factor Levels Are More Common In Humans During CPR And Blunt The PressorResponseTo HighDose Epinephrine, Norman A. Paradis, MD, Bellevue Hospital
160 Respiratory Drive During Induced Seizures:Comparison of the
152 Gastric Inflation In The Unintubated Patient: A Comparison Of Common Ventilating Devices, Ronnie S. Fuerst, MD, University of Florida
Effects of Diazepam and Lorazepam, ThomasE. Terndrup, MD, State University of New York, Syracuse
1 6 1 Hydromorphone Provides Analgesia Superior To Meperidine In Emergency Department Patients With Renal Colic, Neil B. Jasani, MD, Medical Center of Delaware
Clinical Practice r62
154 Acute Appendicitis in the Elderly: Clinical Featuresof Early and Delayed Diagnosis, Roben J. Munson, MD, Northeastern Ohio Universities
Ketorolac Tromethamine Versus Meperidine for Treatment of Acute Pain States,Kristi L. Koenig, MD, University of California, Irvine
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155 Perceptionsof EmergencyCare by the Elderly: Resultsof MultiCenter Focus Group Interviews, Sidney I. Lee, BA University of Califurnia, lns Angeles
Ketorolac for Sickle Cell Vaso-occlusiveCrisis Pain in the Emergency Department: Lack of a Narcotic Sparing Effect, Seth W. Wright, MD, Vanderbilt University
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156 The Impact of Emergency Departmentand Institutional Practices on the Timing of Initial Antibiotics in Patientswith Sepsis, Edward A. Panacek, MD University Hospitals of Cleveland
Atropine in the Treatmentof Biliary Tract Pain: A Double-Blind PlaceboControlled Trial, SteveG. Rothrock, MD, Inma Linda Universiry
1 6 5 Pelvic Inflammatory Disease:Do We Treat For Pain?, Stephanie
153 OrthostaticVital Signsin the Elderly, Rita Manfredi, MD, George Washington University
Abbuhl, MD, University of Pennsylvania
166 An AcceleratedDosing Regimen For IntravenousTitration of
157 A Predictive Model for the Diagnosis of PneumocystisCarinii Pneumoniain the EmergencyDepartment, Gregory Moran, MD, Olive View/UCLA
Fentanyl and Midazolam During Painful Emergency Department Procedures, Jane L. Kotecki, MD, Methodist Hospital of Indiana
FRIDAY, MAY 29 Scientific Papers: Computer Methods in 176 A Study of Ambulance Collisions in an Urban Environment, E. Saunders, MD, University of Califurnia, San FranEmergencyMedicineResearch l!r::*t (8:00-9:30am) 177 ProspectiveEvaluation Of The ACS Trauma Triage Criteria, Crawford Mechem, MD, Valley Medical Center
167 A Comparison Of Bayesian And Classical Group-Sequential Clinical Trial Designs,Roger J. Izwis, MD, PhD, Harbor-UCl,A
178 Comparisonof the Baxt Rule with Other Trauma Triage Rules, Charles L. Emerman. MD. MetroHealth Medical Center
168 Analysis of CSF Shear Forces on the Brain in Head Injury, SamuelR. Neff, MD, Cooper Hospital/University Medical Center 169 StressDistribution in Aneurysm Walls: FactorsAffecting Growth and Rupture, William Mower, MD, University of Califumia, lns Angeles
ScientificPapers:Cardiac Emergencies (10:00-11:30 am)
170 A Methodology for Determining Which Variables Drive the Diagnosis of an Artificial Neural Network Designed to Detect the Presenceof Acute Myocardial Infarction, William G. Baxt, MD, University of California, San Diego
179 Early Detection of Myocardial Infarction with Magnetic ResonanceImaging in a CanineModel, Mark G. Angelos,MD, Wright State University
17l
180 Early Evaluationof Oxygen ConsumptionFollowing Uncomplicated Acute Myocardial Infarction, Mohamed Y. Rady, MD, Henry Ford Hospital
The Use of an Artificial Neural Network for Modeling Physician Diagnosis of Myocardial Infarction, Robert C. Stone, BS, Texas College of Osteopathic Medicine
181 Not All CK-MB Immunoassaysare Created Equal, Gary P. Young, MD, Portland VeteransAffairs Medical Center
172 The Misdiagnosis of Acute Myocardial Infarction: Modeling a Cognitive Sciences-Based Explanation for Diagnostic Errors, Frank Papa, DO, PhD, Texas College of OsteopathicMedicine
182 ED CK-MB ElevationsPredictAdverseOutcomesIn ChestPain Patients, Gory P. Young, MD, Oregon Health SciencesUniversity
ScientificPapers:EMS Prehospital(8:00-9:30am)
183 MagnesiumReducesMortality and Morbidity Following Acute Myocardial Infarction: A Meta-Analysis,Michnel A. Gibbs, MD, University of Pittsburgh
173 Race, Age and InsuranceStatusAre Determinatesof Interhospital Helicopter Transport Time and Frequency, Brendan R. Furlong, BS, University of Pixsburgh
Scientific Papers: Pulmonary Emergencies (10:00-11:30am)
174 Time-to-Patient Interval: The Hidden Component of Response Time, Jack P. Campbetl, MD, University of Missoui-Kansas City 75 Prospective Validation of a New Model for Evaluating EMS : Systemsby In-Field Observation of Specific Time Intervals in Prehospital Care, Daniel W. Spaite, MD, University of Arizona
184 D-Dimer TestingAs A Rapid ScreenFor Deep VenousThrombosis Or PulmonaryEmbolism. StevenN. Connelly,MD, University of Arkansas
l5
185 Magnesium Bolus or Infusion Fails to Improve Spirometric Performance in Acute Asthma Exacerbations,Brian R. Tffiny, MD, Wayne State University
204 Improved Survival of Trauma Patients by Appropriate InterHospital Transfer, David P. Milzman, MD, GeorgetownUniversity
186 Influenceof Weatheron Asthma Adrnissions,Howard Blumstein, MD, Medical College of Pennsylvania
205 Safetyand Efficacy of PrehospitalBlind NasotrachealIntubation, Scoi Parazynski, MD, Denier General Hospital
187 Estrogen Alters The Responseof Bronchial Smooth Muscle, Emil M. Skobeloff, MD, Medical College of Pennsylvania
206 Safety Of Prehospital Nitroglycerin, Richard C. Wuerz, MD, Milton S. Hershey Medical Center
188 Correlations Between Respiratory Rate and Gas Exchange Abnormalities in Young Adults, William Mower, MD, UCLA
207 Evaluation of ST SegmentElevation Criteria for the Prehospital ElectrocardiographicDiagnosis of Acute Myocardial Infarction, kturie A. Otto, MD, Medical College of Wisconsin
189 Differences in Combined Treatment with Glycopyrrolate and Albuterol Between Asthma and COPD, Rita K. Cydulkn, MD, MetroHealth Medical Center
Poster SessionIII: TechnologyAssessment
Scientific Papers: EMS/PrehospitalCare (10:00-11:30 am)
208 The ComparativeSensitivity,{nd Specificity Of SerumAnd Random Urine B-hCG Determinations In The Emergency Department, Claudette Bibro, MD, Medical Center of Del'aware
190 Inter-Rater AgreementOf ParamedicRhythm Labeling: Implications For Uniform Reporting Of Data From Out-of-Hospital Cardiac Arrest, Ronnld G. Pinallo, MD, William Beaunnnt Hospitctl l9l
209 Immediate ENG In The DiagnosisOf The Dizzy Patient,Robert D. Herc, MD, University of Utah
Emergency Response Intervals Versus Collapse to CPR and Defibrillation Intervals : Monitoring EMS System Performance in Sudden Cardiac Death, Daniel Spaite, MD, University of Arizona
210 Evaluationof a Hand-Held PortableClinical, ChemistryAnalyzer in the EmergencyDeparrnent, John B. MeCabe, MD, StateUniversity of New York at Syracuse 2ll
192 PhysicianVersus Algorithm Interpretationof Electrocardiograms in the Prehospital Diagnosis of Acute Myocardial Infarction, ,Steve Hampton, PhD, Physio Control
Accuracy of Chemstrip bG ReagentStrips in the EmergencyDepartment, Phillip A. Scott, MD, University of Cincinnati
212 lnaccuracy of the Infrared Tympanic Thermometer in the Emergency Department, Michael Yaron, MD, MPH, University of Colorado
193 Agreement oflntrepretation of Prehospital Cardiac Rhythm by Paramedics,Emergency Medicine Physiciansand Cardiologists, Eric A. Davis, MD, University of Pittsburgh 194 Impact of First Responder Defibrillation in an Urban EMS System, Arthur L. Kellermnnn, MD, University of Tennessee
Injury Prevention
195 PrognosticSignificanceof Post-ShockCardiac Rhythm in Patients Defibrillated by Urban First Responders, Odelia Braun, MD, University of California, San Francisco
213 Motorcycle HelmetsAnd SpinalInjuries: DispellingThe Myth, Elizabeth M. Orsay, MD, University of lllinois 214 Motor Vehicle Deaths:A Rural Epidemic, RobertL. Muelleman, MD, University of Nebraska
ScientificPapers:Radiolory/Imaging(1:ffi-2:30pm)
215 Alcohol Intoxication in Victims of Subcritical lnjury , Roben H. Woolard, MD, Brown University
196 Ultrasonoghraphyin The Emergency Departmentby Emergency Physicians:A One Year Perspective,Dan Schl.ager,MD, Kaiser Foundation Hospital
216 lJrban Firearm Deaths: Are There Any Innocent Victims?, Michael D. McGonigal, MD, University of Pennsylvania
197 Cranial CT Is Not Cost-Effective In The Management Of The Oriented Head Trauma Patient, David Slobodkin, MD, Texas Tech University at El Paso
217 Fire FatalitiesAmong New Mexico Children, DouglasJ. Parker, University of New Mexico
198 Routine ScreeningAbdominal CT is Cost Effective in Head Injured Patients, Daniel Ness,MD, Medical College of Wisconsin
218 Weapons In The Emergency Department, Jonathan Wasserberger,MD, Martin lather King/Drew Medical Center
199 Prospective Evaluation of Radiologic Criteria for Head Injury Patients in a Community Emergency Department, Lloyd K. Richless,MD, Centerfor EmergencyMedicine of WestemPenn' sylvania
Health Care Delivery 219 Refusing Care To Emergency Department Patients: A Test of The Criteria, Robett A. Inwe, MD, MPH, University of Califurnia, San Francisco
200 Validation of Decision Rules for Radiography in Ankle Injuries, Ian G. Stiell, MD, University of Ottawa 201 Usefulness of High Yield Criteria to Limit Chest Radiographs in Acute Exacerbation of COPD, Charles L. Emerman, MD, MetroHealth Medical Center
220 Improvement In Patient SatisfactionFrom Orientation To Emergency Department Workings, Judith Brillman, MD, University of New Mexico
Scientific Papers: EMS/PrehospitalCare (1:00-2:30pm)
221 Effect of Emergency Department Information Materials on Patient Satisfaction, Scott J. Krishel, MD, UCLA
202 The Effect Of Prehospital Transport Tirne On The Mortality From Traumatic lnjury, Roland W. Peti, MD, Northwestern University
222 Simplifrcation of Emergency DepartmentDischargeInstructions Improves Patient Comprehension,B. Tilman Jolly, MD, George Washington University
203 The Impact of EmergencyMedical Serviceson Trauma Morbidity and Mortality, Kum S. Ham, PhD, PennsylvaniaDepartment of Health
223 Patient and Physician Perceptionsof Acuity in the Emergenc Department,DavidW. Munter, MD, Naval Hospital, Portsmou
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232 Prospective Evaluation Of Adverse Drug Interactions In The Emergency Department, Robert D. Herr, MD, University of Utah 233 The Efficacy of Phenytoin in the Prevention of Recurrent Alcohol Withdrawal Seizures,Gail D'Onofrio, MD, Boston City Hospital 234 Are Spinal Precautions Indicated in all SeizurePatients?, C.L. McArthur, III, MD, Riverside General Hospital 235 Ovarian Torsion: An EightYear Review, Jean Abbott, MD, University of Colorado 236 Death After Dischargefrom the EmergencyDepartment,Michnel P. Kefer, MD, Medical College of Wisconsin
224 Physicians'"Judgementin the Use of Ankle Radiography, 1an G. Stiell, MD, University of Atawa 225 The Role of Knee Radiographs in the Emergency Department: A Prospective Study, lC Saxena, MD, Brooke Army Medical Center 226 ReductionOf Anterior ShoulderDislocationsBy ScapularManipulation, Roben M. McNamara, MD, Medical College of Pennsylvania 227 ProspectiveEvaluation of the Scapular Manipulation Technique in the R.eductionof Anterior Shoulder Dislocations, Rashmi U. Kothari, MD, University of Cincinnati
Toxicology 237 Therapeutic Effects of Water Versus Milk Dilution for Acute Alkali Injury of the Esophagus,Clark S. Homnn, MD, State Ilniversity of New York, Stony Brook 240 The Effectivenessof Medical Toxicology Consultations from a Regional Poison Information Center, SandraM. Schneider,MD, Moitefiore University Hospital 241 Etiology Of Alcohol Withdrawal Seizures(AWS) And Their OccurrenceIn RelationTo DecreasedAvailability Of Alcohol, Mels K. Rathlev, MD, Boston City Hospital 242 Controlled-ReleaseFormulations Have Less PotentialFor Abuse Than Other Opioid Medications, Daniel Brookoff, MD, University of Tennessee
228 The Ring Sign: Is It A Reliable Indicator For Cerebrospinal Fluid?, William Fales, MD, Geisinger Medical Center 229 Critical Angle Of Incidence For Delayed Vessel Perforation By Central Venous Catheter: A Study Of In Vivo Data, Robert H. Blackshear, MD, University of Florida 230 Preventionof Hyperbaric AssociatedMiddle Ear Barotrauma, M. Brown, MD, Butterworth Hospital 231 Safety and Efficacy of Endotracheal Intubation by Emergency Medicine Physicians,Fred Harchelroad, MD, Alleghent General Hospital
EMRS BESTPAPERAWARD SAEM and the EmergencyMedicineResearchSociety(EMRS) of the UnitedKingdom work closely togetherand have establisheda tradition of sendingone of their paper award winners to the other organization's Annual Meeting.This year, SAEM is pleasedto welcomeDr. R. JohnCorsonwhose paper, "Gut PermeabilityAfter Injury," was selectedas the Best Paper last fall during the EMRS Annual Meeting. After graduatingmedicalschoolfrom the Universityof Glasgowin 1984,Dr. Corson undertookpostgraduatetraining in General Surgery at the University of Manchester.He then took a researchposition working in conjunctionwith the Departmentof Surgery and the North Western Injury ResearchCentre at the University of Manchester.Dr. Corson's researchinteresthas focused on the effect of peripheral tissue injury upon intestinalpermeability.
Dr. R. John Corson 6
Dr. Corsonwill presenthis paperto the Annual Meetingattendees on May 26 in the Shock/Trauma; Basic Sciencessessionwhich will be held from 10:30 am until 12:00 noon. SAEM will selectthe 1992BestResident/FellowOral Presentation Award winner who will attendthe EMRS Annual Meetins in the fall.
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Abstractsof the 22nd Annual Meetingof the Societyfor AcademicEmergencyMedicine
T'he follouing
242 qbstrrcts
of the Socicty for Academic
uill be presented Ewgercy
at the Annwl
Meditirc
Cando, Moy 26-29, 1992. Presenters'nomes
in Toronto,
ore printed
Meetiry Ontario,
in itolics;
uhere presenter is rct ind,boted, none uas specificd by the authors.
*Study done primarily by a resident or fellow. fStudy done primarily by a medical student.
* { Roleol BloodPressureand HeartBateas 0biectiveMeasuresof I Painlntensityin EmergencyDepartment Patients KTStradling, WA Watson, ML Heim,JA Salomone, llllUniversity of MissouriKansas City,School of Medicine, Truman Medical Center/Emergency Department. Kansas City,Missouri Study background:The sympatheticresponseto acutepain hae beensuggested as beingusefulin assessing the validity of a patient's statementofpain severity.Data supportingthis approachare availablcin poetoperativcpatientsrather than in thosetreatedin the emergency department. Objective: To determine whether systolic blood pressure (SBP) and heart rate (FIR) are related to pain intensity in ED patients and useful in assessingpatient pain intensity. Design: A prospective, noninterventional protocol undertaken as part of an ED acute pain clinical management assessment.The assessmentdid not influence physician treatment eelection. Setting: An urban teaching-hospital ED. Type ofparticipants: Two hundred forty-four adult ED patients who had SBP and HR determined at the time of pain intensity determination with a 100-mm visual-analog scale. Patiente were physiologically stable, not receiving cardioactive medications, and d i d n o t h a v e i n j u r i e s a s s o c i a t e dw i t h b l o o d l o s s o r c a r d i o v a s c u l a r i.rrjury. M e a s u r e m e n t sa n d r e s u l t s : S B P a n d H R w e r e d e t e r m i n e d b y auscultation and palpation, respectively. Linear regression analysie and visual inspection ofpresentation pain intensity versus SBP or HR demonstratedno correlation (rz < .005) and almost horizontal slopes (< .06). In 98 patients, both presentation and discharge values of pairr intensity, SBP, and HR were measured, Comparison of the change in pain intensity to change in SBP or IIR during ED care also demonstrated no correlation (r2 < .005) and almost horizontal slopes (< .04). Conclusion: These results demonstrat.e there is no relationehip between SBP or HR and pain intensity at patient ED presentation, which is further supported by the lack of relationship in the changes in theee parameters during ED rreatment. The ED clinician should not use HR or SBP in an attempt to validate patients' assesement of pain inten sity. Pairr is defined by the pa tient and cannot be c o r r o b o r a t e d b y e v i d e n c e o f s y m p a t h e t i c r e s p o n s ei n E D p a t i e n t s . at
Z Routin,Admission ECGin Emergency Department Patients JLGarland, ABWolfsonllniuersity 0fPittsburgh, Center forEmergency Medicine 0fWestern Pennsylvania, Pittsburgh Study objetive:
To determine
conld havc been avoided patients
18
admitted
if routine
performance
of an ECG
safely in a subset ofemergency
department
to a university
hospital.
Design: Retrospective chart review of a consecutive, unselmted cohort. Participants, setting, and interventions: All ED patients admitted to the medical eervice of a university teaching hospital during a three-month period. No interventions were performed. Methods: Acceptable indications for an admission ECG were considered to include a history or symptoms suggestiveof sigfficant heart disease; syncope; abnormalities of pulse, blood pressure, or serum potassiuml and suspected cardiotoxic drug overdose. Charts were reviewed to determine whether any of these indications were present, whether an admiseion ECG was performed, and whether an admission ECG reeulted in a change in patient management or outcome. An ECG wae classified as routine when performed in the absence of documentation of any of these indications. Results: There were 636 ED admissions to the medical service during the study period. Of the 631 patients whose charr could be located, 3M (617o) had at least one indication for an ECG and all excepl.one had an ECG performed. No indications for an admission ECG were identified in the remaining 247 patients; of these, 202 (82Vo)had an ECG performed and45 (I9Vo) did not. Among rhe 202 who had a routine admission ECG, the test resulted in a change in management in on-ly three (I.5o/o) (95Vo confidence intervals ICI], 0.3Vo Lo 4.3Vo) and affected patient outcome in none (95Vo Cl,0o/o L o 1 . 5 7 o ) .A m o n g t h e 4 5 w i t h o u t i n d i c a t i o n s w h o d i d n o r h a v e r o u tine admission ECG, none experienced an idcntifiable adversc consequence during hospitalization (95o/aCl,07a Lo 6.7o/o).Assuming a charge of$I05 per test, omission ofthe routine ECG in patients without indications would have resulted in savings of more than $20,000 in patient charges in this one hospital during the threemonth study period. Conclusion: The admission ECG could have been avoided in an identifiable subset of ED patients admitted to the medical service of our hospital with no adveree effect on patient outcome. This finding, ifcorroborated in other patient populations, suggesl.sthe potential for significant cost savings for the emergency health care s y s t e ma s a w h o l e . I
of adenosine; the remaining four required an additional l2-mg bolus. Chest pain and hypoteneion resolved within minutes of conversion to systolic blood pressure in all casee. There were no clinically significant adverse effects or recunence of PSVT during ED obeervation (mean, 1.8 hours). All patients responded to adenosine, and none required electrical cardioversion. Conclusion: In the unetable PSVT patient, adenosine appears to be a safe and effective alternative to current advanced cardiac life support-rtrommended immediate electrical cardioversion.
Criteria for Ceryical-Spine A Prospective Studyol Low-Risk 'l/l Badiography in BluntTraunra J Hoffman, WMower,J Luo.M Zucker/Department of Emergerry DSchriger, Medicine, UCIA Medical Center, LosAngeles Study hnothesis: Cervical-epine radiography can be omitted safely in multiple trauma victims who are awake, nonintoxicated, do not complain of midline neck pain, have no tendernese on palpaLion of the bony spine, and have no other severely painful inj0ries, Design: Prospective study using data questionnaires completed by the examining physician at the time of injury assessmentand before radiographic evaluation. Data items included mechanism of i n j u r y , l e v e l o f a l e r t n e s s ,e v i d e n c e o f i n t o x i c a t i o n , c o m p l a i n t o f midline nek pain, tenderneee on palpation of the bony epine, presc n c e o f o t h e r s e v c r e l yp a i n f u l i n j u r y , a n d p r e s e n c e o f f o c a l n e u r o logic deficits. S c t t i r r g :E m e r g e n c y d e p a r t m e n t o f a L e v e l I I I t r a u m a c e n t e r o f a university hospital. T y p e o f p a r t i c i p a n t s : C o n s e c u t i v eb l u r t t t r a u m a p a t i e n t s f o r whom cervical-spine films were ordered and data questionnaires were completed. Reeulte: During the 19 months it took to collect data forme on 1,000 patients, cervical-spine radiography wae performed on 11342 p a t i e n t s . A l o t a l o f 2 6 c a s e sh a d i n c o m p l e t e d a t a f o r m s a n d w e r e excluded from the study (none had fractures). Cervical-epine injuries were present in 27 of the 974 patients for whom data forms werc completed. At least one of the four characteristics of midline n e c k t e n d e r n e s s ,i n t o x i c a t i o n , a l t e r e d l e v e l o f a l e r t n e s s , o r o t h e r scvcrely painful injury was present in all 27 patiente with fracture (957o confidence intervals ICI], .9f2 to I). Ofthe 353 patients who had none of these four findings, none had a cervical-spine injury ( 9 5 o / oC l , . 0 0 t o . 0 0 7 ) . Conclusion: Cervical-spine radiography may not be necessary in blunt trauma patients who are awake, alert, nonintoxicated, do not complain of midline neck pain, have no tenderness to palpation of the bony spine, and have no other severely painful injuries. A policy to limit films in such patients would have reduced radiographic studies by more than one third in this series yet identified all patierrts with fractures.
Successful Conversion of Unstable Supraventricular Tachycardia
rf to SinusRhythm WithAdenosine FBMelio. WKMallon, ENewton/Los Angeles County andUniversity 0f Southern California Medical Center, Department of Emergency Medicine, LosAngeles Study purpose: To evaluate the efficacy of adenosine in the treatment of emergency department patients with unstable paroxysmal supraventricular tachycardia (PSVll). Design: A retrospective chart review. Setting: A university hospiral ED. Type of participants: Twelve adult patienrs with unstable PSVT (systolic blood pressure less than 90 mm Hg, chest pain, pulmonary edema, and/or altered mental etatus) who were treated with adenosineInterventions: Patients' preadenosine and postadenosine heart rate, symptoms, and blood pressure were recorded, as were complications and recurrence of PSYT. PSYT was diagnosed by surface ECG. Results: Twelve patients were identified: three men and nine women (mean age,4?.6 years). Nine paLients presented with hypotension (mean systolic blood pressure, 79 mm Hg), ten wirh chest pain, and six with both chest pain and hlpotension. There were no patients with altered mental status or pulmonary edema. Eight patients converted to sinus rhythm with a single 6-mg bolus
f I n f e c t i o n C o n t r o lf o r H e a l t h C a r e W o r k e r s C a r i n gf o r C r i t i c a l l y rf Iniured Patients: A National Survey KTodd, WA Berk/Deparlment of EmergencyMedicine,DetroitBeceiving
Hospital andUniversity Health Center; Department ofEmergency Medicine, Wayne State University, Michigan Detroit, Study objective: The prevention of lransmission of blood-borne p a t h o g e n st o h e a l t h c a r e w o r k e r s ( I I C W s ) i n v o l v e d i n r e s u s c i t a t i o n of critically injured patients presents special challenges- To promote discussion of a standard, we surveyed the currcnt. infection control practices of the 100 busiest US emergcncy departments. l)esign, setting, and participants: A telephone survey ofthe I00 busiestUSEDsbyl990annua|izedcensuswasperformed.>
t9
Interviews were obtained with either nursing or medical dirmtors, or with ED staffphyeiciane knowledgeable about ED infection prevention protocols. Questions concerned special equipment' protective clothing, and general strategies used to protect HCWs caring for critically injured patiente. Results: Surveys were completed for 82 EDs. Of these,56 (68Vo) either function as primary trauma care facilities for their locales or are designated l-cvel I trauma centers by the American College of Surgeons. Specific infection control protocols for trauma resuscitation had been promulgated by l8 (217o),wirh the remaining 65 (787o) wing the same universal precautions for care of severely injured patients as for other patients. There was a specific policy relating to invasive proceduree for 66 (80Vo). In l5 EDe (l87o),protocols were posted in resuscitation areas. Only 59 (727o) provided "sharps'o containers that were always convenient to the HCWs with material to discard. Gowning was rcquired by 43 (527a), whereae inrpermeable gowns with sleeveswere avai-lable n 63 (777o). Available eye protection included face masks (76, or 93o/o)' goggles (72 , or 88Vo\, or face shields (74, or 90o/o)- Spccially a dapted equipmerrt included self-eheathing IV catheters (21, or 267o) and needle/syringe combinations (16, or 20o/o).Formal ED-based infection control education programs for HCWs had been established by 26 (32Vo), whereas videotaping of patient care was used for infection conirol quality assuranceby six (7Vo). Conclusion: There is coneiderable variation irr infetion control practices in busy US EDs during resuscitation ofcritically injured patients. Modalities used include educat^ion,strategies for handling contaminated material, protective garb, and equipment specially adapted to minimize exposure. Establiehment of a standard requires further discueeion among health care professionals.
79Vo from group A and 2l%o from group B. Of these, 2l7o had' con' tinued symptoms upon dischar ge and' llTo had symptoms one week after discharge. No correlation could be made in outcome for vital signs, white blood cell count' age' LMP or antiliotic, or guideline group A or B. Conclusion, A signficant proportion of women receiving ambulatory treatment for PID fail therapy regardless of whether CDC guidelines are followed.
-, forDVUI Drivers Alcohol'lntoxicated ofIniured f Prosecution MedicalCenter,Charlotte,NorthCarollna JW Bunge,CLPulliam/Carolinas Study objective: To study a population of alcohol-intoxicated drivers injured in motor vehicle accidents to determine how frequently they are charged with driving while impaired (DWI) and of the group that wae charged vereue the group that "hu"""t".irti", was not. Design: Retrospective study of consecutive patients of a specific cause ofinjury identified by ICD-9 E code assigned on presentation to the emergencY dePartment. Setting: An ED in a Level I trauma center serving a population of I million. Type of participants: Consecutive drivers involved in motor vehicle arcidents who were treated in the ED during a lS-month period and had a blood alcohol level (BAC) of L}O mgVo ot greater' Age, gender, race, craeh locale, need for admiseion, BAC, Trauma Score status, and time and day of crash were obtained fTS1, ""o.o*i" from the hospital's mainframe data baee and trauma regietry' Data on charges frled, court outcome' and prior convictions for DWI or other moving violations were obtained from the district attorney's office. The groups charged and not charged with DVI were compared ueing12. Values of P < .05 were considered significant' Results: Of the 187 Patients in the study grouP' 53 (287o) were charged with DWI and'3l (I77o) were convicted' Mean BAC was 208 t 64.2 mgTo (r ange, I 00 to 43 I mgVo). Mean TS was l4'8 + 2'46 ( r a n g e , 4 r o f 6 ; . T * o o f 2 9 ( 6 . 9 V o )w i t h T S o f 1 2 o r l e s s , n i n e o f 3 2 (287a) w.rthTS of l3 to 15, and 42 of 126 (33%) with TS of 16 were charged (P = .01?). Eighteen ofLI2 (167o) with zero, 20 of36 (567o) with o.e, I I of 2I (527o) with two ? three of 12 (25Va) with three, and
Ambulatory Control'Becommended lor Oisease ol Centers f f, Failure I fl Therapy Disease of PelvicInllammatory in theTreatment Sacramento Davis, ofCalifornia, KPopke,R\N Derlet/University S t u d y h y p o t h e s i s ; T h e C e n t e r s f o r D i s e a s eC o n t r o l ( C D C ) c r i t e r i a for hospitalizing women diagnosed with pelvic inflammatory disease (PID) in the emergency department provide a high degree ofpredictability for identifying patiente who would fail ambulatory therapy. Design: Vomen diagnosed with PID in the ED and diecharged were identified within 48 houre of their ED visit and were contacted by telephone 48ao92 hours and one to two weeke after their ED visit. Charts of hospitalized patients also were reviewed. Patients were divided into two etudy groups: those for whom CDC guidelines were followed (group A) and those for whom CDC guidelines were not followed (group B). These two groups then were compared with regard to treatment failure. Setting: University hospital ED with 60,000 visits annually. T y p e o f p a r t i c i p a n t s : V o m e n d i a g n o s e da s h a v i n g P I D i n t h e E D during rhe period of August through December 199I Interventions: Contact ofpatients at home after hospital or ED discharge. Results: A total of80 women were given the diagnosis of PID in the ED: 66 were treated and discharged, and 14 were admitted to the hospital. Of the outpatient group' M (67Vo) were contacted for the first follow-up call, and 35 (537o) were contacted for the second call. In group Ar55Vo ofpatients failed outpatient therapy compared with 587o of patients in group B. There was no difference between groups A and B in incidence of GC- or Chlamyd'ia-positive cultures of DNA probes. Continued symptoms were reported in 86.47o of allprtients reported by thc first call and 487o of all patients c o n t a c t e d f o r t h e s e c o n d c a l l - H o s p i t a l i z e d p a t i e n t s c o n s i s t e do f
none of five with four or more prior DWI convictione were charged (P < .00I). There were no significant differences between groups for other parameters. Conclorion, Injured alcohol-impaired drivere treated in the ED are infrequently charged with DWI, charged with DWI lese frequently with increasing severity of injury, charged with DVI variably in association with the number ofprevious I)WI convictions, and charged independent of age, raceogender, economic status, time or day of crash, BAC, prior moving violations, or whether admitted or discharged from the ED' Variability ol Physician Interpretation ol Advance *Q O Medical Directives
UCIAMedical Medicine, 0fEmergency LBaraff/Department WMower, LosAngeles Center,
'fo determine if physician interpretalion of Study objective: advance diratives produces unilorm treatment decisions and if physicians are equally willing to withhold different therapies' Design: Physicians were presented with a patient scenario and an accompanying advance directive in each of three separate mailed surveys. Physicians were asked to review each scenario and indicate wherher they would initiate or withhold specific therapies based )
20
I
I
i
or cause a spinal cord injury. There are no data on cervical-spine flexion when children are immobilized in semirigid collars' Objective: To determine whether semirigid cervical-spine collars eliminate cervical-spine flexion in children on backboards' I)esign: Prospective clinical study conducted over nine months' Setting: An urban emergency department. Type ofparticipants: Twelve head-injured children less than ? years old undergoing cervical-spine radiographs. Exclusion criteria included cardiovascular instability or a positiYe cervical-spine
on their interpretation ofthe advanced directive. The specific therapies were CPR, intubation, hydration and IV therapy' surgery' dialysis, chemotherapy, invasive testing, transfusion therapy, antibiotics, laboratory testing, and pain medication or sedative. Setting and participants: Four hundred forty-four full-time faculty from the department of medicine of a university medical school. Results: Physicians fid not make unjform treatment decisions. With written advance directives alone, less than 907a of the physi cians would agree to initiate or withhold any individual therapy (range,57o to 907o). Physiciane were uniformly willing to withhold therapy only in a single instance involving CPR in a terminal cancer patient with a diretive prohibiting CPR, supported by prior patient-physician discuesion and reinforced by the proxy. Despite identical instructions in the directives, physicians were more likely to withhold CPR than pain medications (1007o ve l37o). Similar nonuniformity of interpretation existed for all therapies examined. Given directives supported by discussion and proxy, physicians withheld therapy n 83Vo of their choices; therapy was withheld in 53Vo of the choicee involving a written dirative alone (P < .05). Conclusion: Physicians do not make uniform treatment decisions when interpreting written dirmtives. Advance directivee coupled with physician-patient discuesions and a designated proxy furnish the most reliable medical directivee.
film. Informed consent was obtained. Interventions: Children were taped and secured to backboarde with semirigid cervical collars (STIFNECK@' California Medical Products). After the lateral cervical spine was cleared in the collar, the collar was removed, and an additional lateral film without collar was obtained. C2 through C6 lateral cobb angles were measured on both lateral films. Results: The cervical spine was flexed with and without the collar. Mean flexion was 5.8'with the collar and 6.3o without a collar (P > .05). Conclusion: Our study found that children less than 7 years old are placed into cervical-spine flexion when immobilized on backboards. Application of a semirigid cervical collar does not eliminate flexion. Further study is needed to develop and teet safer methods of cervical-spine immobfization baause Present equiPment is unable to position the cervical spine in extension correctly.
With >k(l A ClinicalTrial Comparing/U-2-Butyl-Cyanoacrylate in Children FacialLacerations if Suturing 1 { { H e a dT r a u m a :E n h a n c e dP r e d i c t i o no l P o s i t i v eC o m p u t e d | | Tomography by Pediatric Trauma Score and Glasgow Coma Scale Plastic Surgery Medicine, JV1uinn, A Drzewiecki, M LilDivision of Emergency , n i v e r s i toyf y e d i c i n eU S A K o h l e r , AH a r w o o d - N u s s / D i v i soi of nE m e r g e n cM Canada Ontario, University of Ottawa, Ottawa, andDepartment of Paediatrics, F l o r i d aH e a l t hS c i e n c eC e n t e r - J a c k s o n v i l l e Study objective:To comparethe useof the tissueadhesiveN-2Study objective: To determine if either the initial Glasgow Coma butyl-cyanoacrylate(HistoacrylBIue) with the useof suturesirt thc Scalc(GCS) or the Pediatric Trauma Score (PTS) would predict repair of pediatric facial lacerations. a c c u r a t e l y a b n o r m a l c o m p u t e d t o m o g r a p h y ( C T ) s c a n si n p e d i a t r i c head injuries in the trauma center. Design: A prospective observational study from April to Drcember 1991. Setting: A 450-bed urban teachirrg hospital with an ED volume of 1 0 0 , 0 0 0a n d t r a u m a c e n t e r v o l u m e o f 2 ' 4 0 0 v i s i t s p e r y e a r . Type ofparticipants; Children (2 to 12 years old) in the trauma center who received head CT (I{CT) to evaluate either loss ofcon-
Design: Prospective, randomized c[nical trial. Setting: Emergency departmerrt of a pediatric teaching hospital. 'Iype of participants: Eighty-one children presenting with clean facial lacerations less than 4 cm in Iength and 0.5 cm in width. Interventions: Patienie were allocated randomly to have their Iacerations repaired with sutures or Histoacryl. Reeults: The two groups were eimilar for demographic and clinical characteristics. Photographs taken at three months were rated by two plastic surgeons blinded to the method of closure. There was no difference between groupe for appearance scorea on a visualanalog scale (VAS) (68.4 mm for adhesive vs 68.3 mm for suture) or on a categorical scale (CAT). Measures of observer agreement produced Pearsoncorrelations of.72 and .84 on the VAS and kappa c o e f f i c i e n t so f . 4 6 a n d . 5 5 o n t h e C A T s c a l e . T h e t i s s u e a d h e s i v c w a s a s s e s s e da s l e s s p a i n f u l o n a V A S ( 2 4 . 7 m m v s 4 3 . 7 m m , P < . 0 0 3 ) and faster (7.9 vs 15.5 minutes, P < .001). Conclusion: The tissue adhesive is a faster and less painful method offacial laceration repair than the use of sutures and produces similar cosmetic results.
sciousnessor decreaeed level of consciousness. Interventions: None. R e s u l t s :T h e s t u d y g r o u p c o m p r i s e d 2 0 p a t i e n t s . F o u r t e e n p a t i e n t s ( 6 5 V o ) h a d a n o r m a l I I C T , w h e r e a s s e v e no f 2 0 ( 3 5 4 o ) h a d an abnormal HCT. Of thosewith an abnormal HCT' three of eeven ( 4 3 o / o ) h a da. n o r m a l G C S ( 1 5 ) b u t a n a b n o r m a l P T S ( l e s st h a n l l ) ' 'Ihe r e m a i r i n g f o u r p a t i e n t s ( 5 7 o / o ) h a da, n a b n o r m a l C C S , a n d threc of four had an abnormal PTS. The sensitivityof a GCS of less tharr 15 was 574o, the specificity was lo07a, and the confidence interval was t 36.?. PTS of less than ll had a sensitivity of 867o arrd a specificity of 464o. The presence ofeither an abnormal GCS oflees than l5 or an abnormal PTS oflees than ll in all seven patients predicted an abnormal HCT, with a sensitivity of l00Vo
a - r la.l t I l f C e r y i c a l - S p i n el m m o b i l i z a t i o n T : ime lor a Change n e d i a t r i cE m e r g e n cM y e d i c i n ea n d D J T r e l u r ,M V a n H o l s b e e c k / D i v i soi of P , e t r o i tM , ichigan D e p a r t m e notf R a d i o l o g yH, e n r yF o r dH o s p i t a lD Study background: From l0o to 20oof cervical-spine extension is preferred during the immobilization and transport of young headinjured children. Previous investigation has shown that immobilization of young children on backboards without cervical-spine collars forces the cervical spine into a flexed position that may exacerbate
and a specificityof 46Vo. Conclusion: Our study findings suggestthat in pediatric head trauma, a normal GCS doesnot preclude abnormal HCT. However, thc use ofboth GCS and PTS appears to be highly sensitive in predicting abnormal HCT.
2l
Laboratory Testins intrePediatric >tr1 2 i,Tifft :;:11' DJlsaacman, EJScarfone, SI Kost,LM Bernardo/Department of Pediatrics, University of Pittsburgh School of Medicine, Divisions of Ambulatory Careand Nursing, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania Study objtrtive: To aesess the prevalenceoflaboratory abnormalities(CBC, electrolytes,BUN, creatinine,glucose,SGOT, SGPT, amylase,lipase,urinalysis)and the sensitivityand specificity of the physical examination and screening laboratory tests for identifying intra-abdominal injury in moderarely injured pediatric pa tients. Design, participants, and setting: Phase l: Retrospective chart review of 288 consecutive Level II (moderately injured) trauma patients seen at a children's hospifal emergency department or pediatiic trauma center. All patients were received diretly from the scene, and data recorded included mechanism ofinjury, C l a s g o p vC o m a S c o r e , T r a u m a S c o r e , P e d i a t r i c T r a u m a S c o r e , systematically rmorded physical examination findings, laboratory results, and injuries detected durirrg hospitalization. Phase 2: 'l'o confirm the sensitivity of the examination and urinalysis found in phase I, the model was applied to 9l additional trauma patients i d e n t i f i e d b y I C D - 9 c o d e s a s h a v i n g a n i r r r r a - a b d o m i n a li n j u r y . Results:Phase l: SGO'[ and SCPT were obrainedirSgo/o of p a t i c n t s ; g l u c o s ew a s o b t a i n e d i n T l l o / o o f p a i e n t . s l a n d e a c h o f t h e rcmaining teets was obrained in nrore Lhan ll1%oof patients. 'lhc overall prevalence of laboratory abnormalities in phase I was 5.57o. Fourteen patients (4.8o/o) were identified who had a toral of l7 sigrrificant intra-abdominal injuries (five splenic, fivc renal, four hepatic, and three pancreatic). 'Ihe physical examination combined with urinalysis showing more than 20 RBCs/high-power field had a sensitivity of l0o7o, a specificiry of 66Vo, a positive predictive vaLte of 137o, and a negative predictive value of l00o/o for the d e t e t i o n o f i n t r a - a b d o m i n a l i n j u r y . ' f h e p r e s e n c eo f l a b o r a t o r y abnormalities suggestinginjury did not increase the sensitivity of the model and signficantly decreased both specificity and positive predictive value. Phase2: 'fhe physical examination and urinalysis identified an abnormalir.y in 89 of 9 I c a ses(97 .Bo/a)(95Vo aonfident:<: intervals, 94.87oLol007o). Each of the two "missed" paticnts had elevatione in pancrearic <rnzymesrequiing only supporrive ::*:"", Conclusion: In the moderately injured pediatric trauma patient, there is a low prevalence oflaboratory abnormalities, the physical examination combined with urinalysis is a highly sensitive screen for intra-abdominal injury, and in patients with a normal physical examination of the abdomen and a normal urinalysis, laboratory testing seldom identifies unsuspected intra-abdominal injuryR a n d o m i z e dC , o n t r o l l e dT r i a l o f R a d i o g r a p h0 r d e r i n g l o r { Q I rl Extremity Trauma by a Triage Nurse L f r o p p , I K l a s s e nT, S u t c l i f f eC , D u l b e r gS, R a m a nR , B l o u i nM , L i l H e n r yF o r d H o s p i t a lD, e t r o i t M , i c h i g a nC ; h i l d r e n 'H s o s p i t aol f E a s t e r nO n t a r i oU , niversity o f O t t a w a ,O t t a w a .0 n t a r i o ,C a n a o a 'fo Study objectives: determirre the effect on patienl. tirne in the emergency deparrment and radiograph utilization by instituting a triage nurse radiograph-ordering system. Design: A prospective, randomized clinical trial. Setting: University children's hospiral ED. Type of participants: Nine hundred seventy-four consecutive patients with extremity injuries divided into a nurse ordering group (486) and a physician ordering group (488).
22
Interventions: In the intervention group, the triage nurse ordered the radiograph, with the physician seeing the patient after any initial radiograph wae completed. The control group had the radiographa ordered and performed after seing the physician. Before the start of the study, the nuraea were trained in a protocol on ordering radiographs, using parameters, such as point tenderness, dcformity, aeyere swelling, severe ecchymosis, and pain with weight bearing. X2 lest was used for proportions, and an unpaired t test vras used to test significance in the times. Results: The nurse ordered radiographs inBl.97o of all patients, whereas the physicians ordered radiographs in 87 .lVo (P - .003). 'l'he proportion of clinically significant radiographs wae 40.87o in the nurse group and 42.5Vo n the physician group (P: .2I). The nurse group had 16 patienta (3.34o) with significant radiographs that were not ordered initially, compared with none in rhe physician group. Mean time in the ED was 3.65 I I.47 hours foi the physican group compared with 3.28 + 1.66 hours for the nurse group
( P< . 0 0 0 1 ) . Conclusion: Having triage nurses order the initial radiograph resulted in significant reductions in waiting time in the ED. In addition, insl.il.uting the triage nurse radiograph-ordering system did not rcsult in significantly more radiographs than when the emergency physicians ordered the initial radiograph. / l T w o - T h u m bV s T w o - F i n g e rC h e s tC o m p r e s s i o nO u r i n gC P Ri n a I rl Swine Infant Model ol Cardiac Arrest JJ Menegazzi. TEAuble, KA Nicklas,GM Hosack,L Back,J Goode/University o f P i t t s b u r g hD, i v i s i o no f E m e r g e n cM y e d i c i n eS , c h o ool f M e d i c i n eC , e n t e fro r E m e r g e n cMy e d i c i n eo f W e s t e r nP e n n s y l v a n iPai,t t s b u r g h Study objective: To test the hypotheais that two-thumb cheet compression generates higher arterial and coronary perfusion pressures (CPP) than the current American Heart Aseociationapproved [wo-finger method. Design: Randomized, crossover experimental trial. Setting and participanl.s: Animal laboratory experiment with scven swine of either sex and weighing 9.4 t 0.8 kg representing i r r f a n l s l e s st h a r r I y c a r o l d . I n t e r v c n l i o n s : A n i r n a l s w e r e s e d a t e dw i t h i n t r a m u s c u l a r ketamine/xylazine, intubated with a 6-0 Hi-Lo endotracheal tube, anesthetized with c-chloralose, and paralyzed with pancuronium. ECG *ae corrtinuously monitored. lcft femoral arterial and SwanGanz catheters were placed. Cardiac arrest was induced with an IV bolus ofpotassium chloride and verified by ECG and pressure tracings. Five American Heart Association-certified basic rescuers were assigned randomly to perform external chest compressiong for one minute by either the two-finger method that is currently ,recommended or by the two-thumb and thorax-squeze method. After all frve completed their first trial, rescuers crossed over to the othcr method for a second method of compressions. Ventilation wae perfornrcd with a bag-valve device, and no drugs were given during CPR. Aftcr thre complete cycles, the fourth through sixth cycles of compressions were recorded. Every compreesion wae analyzed for arterial systolic blood pressure (SBP), diastolic blood prccEure (DtsP), mean blood pressure (MAP), and coronary perfusion pressure (CPP). One thousand fifty compressions were analyzed with two-tailed Student's , te8t, with o set at .05 (Table). Results: Group means presented (*P < .001 differences). {
Melhod IW
SBP(mmHs)
DBP(nmHs)
MAP(m Hs)
Twolingen
41.6
18.5
26 1
CPP(rmHg) 12.2
Conclueion:
The two-thumb
ates significantly than the two-finger
higher
arterial
method
method
of chest compression
and coronary
in this infant
model
perfusion
gener-
Regults: Data were compared
pressures
ofcardiac
Student's
! test. Fisher's
using analysis of variance
exact test was used to compare
and the
mortality
(Table).
arreat.
Resuscitation on Coagulation k{ f EffectofAggressive in I rf Uncontrolled Hemorrhagic Shockin Swine THBlackwell, SAStern,SCDronen/Department 0f Emergency Medicine, University of Cincinnati Medical Center, 0hio Studyobjective:Previousstudiesof uncontrolledhemorrhagic
GonlrollcdHcmorrhagcModcl
UnconlrollcdllcmorrhagcModcl
GrouP1 {l{ = 8) GrouP2(l{=9}
GrouP3 11{=8} GrouP{ {t = 9)
No 100'
Fluidresuscitated (%) 1o[4orraliry Peritoneal hemrrhage (mL/kg) volume
Yes 01
Yes l8
No 88
/ 131 010 0101 ' P < 0 5g r c u1pv s2 ,t P < . 0 g 5 r c u2pv s4 ,1P <0 5g r o u3pv s4 .
shock have shown a marked increase in hemorrhage and mortality with aggressivecrystalloid resuscitation. This study attempted to evaluate whether impaired coagulation may be a factor responsible for this increase in hemorrhage volume. Design: Sixteen immature swine with 4-mm infrarenal aortic tears were bled to a pulse pressure of 5 mm Hg (estimated blood loss, 507o). Interventions and methods; Animals were chosen at random to receive either B0 ml/kg of normal saline at a rate of 4 mIJkg/min (eight) or 9.6 mUkg of hypertonic saline/dexrran at a rate of 0.48 mUkg/min (eight). Crystalloid infusion was followed by 30 mllkg of shedblood at a rate of 2 mlJk{mn I'Iemodynamic paramercrs, platelets, fibrinogen, and prothrombirr times were measured at basel-ineand throughout hemorrhage and resuscitation. 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 t h e S t u d e n t ' s I t e s t a n d a n : r l ysisof variance where appropriate. All animals showcd sigrrifi<:ant prolongations in prothrombin times and reductions in platelcls and fi-brinogenlevels. Compa rable co agulop a thies were dcmons trated betweengroups with the exception of a more pronounced thrombocytopenia in ihe hypertonic ea]ine/dextran-treated animals. Conclueion: Resuscitation of uncontrolled hemorrhagic shock with crystalloids causes sigrrificant alterations in coagulation parameters. Impaired coagulation may be a factor responsible for the poor outcome associated with aggressive fluid resuscitation of uncontrolled hemorrha ge.
Conclusion: Aggressive volume replacement causes a marked increase in blood loes from the site of a vascular injury. Controlled hemorrhage models ignore this important pathophysiologic event and consequently may not simulate accurately the response to ther apeutic interventions. Uncontrolled hemorrhage models may be preferable for the study of hemorrhagic shock resuscitation.
in Severe Regimens Xll-, A Trialof MultipleResuscitation I I Hemorrhagic Shock
University SAStern, SCDronen, XWang/Department of Emergency Medicine, ofCincinnati lVedical Center. 0hio
k { R A G o m p a r i s o no l t h e R e s p o n s eo l C o n t r o l l e da n d I l f U n c o n t r o l l e dM o d e l s o l S e v e r e H e m o r r h a g i cS h o c k t o
Aggressive FluidResuscitation SAStern, SCDronen, XWang/Departmenr 0fEmergency Medicine, University ofCincinnati Medical Center, 0hio Study objective: Although studies using traditional controlled hemorrhage models suggestaggressivefluid resuscitation may bc efficaciousin the management ofhemorrhagic shock, recent studies ofuncontrolled hemorrhage demonstrate an increased blood loss and mortality with rapid volume expansion. This study's purposc was to compare directly the responses ofcontrolled and uncontrolled models of severc hemorrhagic shock to aggressivefluid resuscitatton. Design and methods: Thirty-four immature swine (14.6 to 23.2kg) were instrumented and subjectcd to severc (40 to 46 mllkg) blood l o s s .G r o u p s I a n d 2 w e r e h e m o r r h a g e d i n a c o n t r o l l e d m a n n c r from a femoral artery catheter. Groups 3 arrd 4 were bled irr the s a m em a n n e r t o a m e a n a r t e r i a l p r e s s u r e o f 3 0 m n r H g , a t w h i c h time a 4-mm tear was created in the infrarenal aorta, pernritting uncontrolled hemorrhage. Resuscitation began when thc pulsc pressure reached 5 mm Hg. Intervention: Groups 2 and 4 were resuscitated with normal salineinfused at a rate of 6 ml-/kg/min, followed by shed blood ar a rate of 2 mUkg/mtn. Groups I and 3 served as controls and were not resuscitated- All animals were observed for 60 minutes or until death.
Study objective: Recenl.studies have shown improved survival b u t i n c r e a s c d a c i d o s i si n a n i m a l s i n t e n t i o n a l l y m a i n t a i n e d h y p o t e n sivc during cryst.alloid resuscitation of uncontrolled hemorrhagic shock. Early blood use may minimize hemodilution and prevent the a c i d o s i sa s s o c i a t e dw i t h h y p o t e n s i v e r e s u s c i t a t i o r r .T h e p u r p o s e o f this study was to compare early arrd delayedblood administration i r r a n i m a l s s u b j e c t c d [ o s e v c r e u n r : o n t r o U c dh e m o r r h a g i c s h o c k a n d r e s u s c i t a t e dt o m e a n a r t e r i a l p r e s s u r o s o f 4 0 r 6 0 , a n d 8 0 m m I I g . I)csign: Fifty-four immature swine with 4 mm infrarenal aortic tears were bled to a pu-lsepreasure of 5 mm I{g and then resuscitatr:d (estimated blood loss, 40 to 45 mlJkg). Interventions arrd methods: Groups l, 2, and 3 were resuecitated with shed blood at a rate of 3 ml-/kglmin followed by normal saline at a ral.c of 6 m[,,/kg/min. Groups 4, 5, and 6 rmcived the same flui d s i r r r e v e r s eo r d e r . F l u i d s w e r c i n f u s e d a s n e e d e d t o m a i n t a i n m c a n a r t c r i a l p r e s s u r e so f 4 0 , 6 0 , a n d B 0 m m I I g . A n i m a l s w c r e o b s r : r v c df o r 6 0 n r i n u t c s o r u n t i l d e a t . h . llesults: I)ata were compared using analysisof variance and I i ' i s h e r ' se x a c t .t e s t ( T a b l e ) .
1 2 3 4 5 5 BO MAP(mmHg) 40 60 80 40 60 Blood Elood NS NS NS lnrtiallntusion Slood Morraliry(yo) ll 11 11 22 t8' 33 Minimunr brmrbonale (mEq/t) 16171 20t5' 1/16t 814 I 1514 ll t4 " P< 5 grou5 p v s 1 . ? . 4 ,I5P,< 5 g r o u pI v s4 ; t P < 0 5g r o u 2 p v s5 ; t P < . 0 5g r o u 3 p w 6, P< .05group4 vs 5 Conclusion: parable
Mainten:rn<:c of rhe hypotensive state produces com-
reductions
irr mortality
regardless
of whether
blood
or
salinc is used as the irritial resuscitation agent. Early blood use, however, minimizcs thc acidosis associated with underresuscitation. Uypote nsivc resuscitation with early blood administration the ideal prcopcrativc hemorrhagic
ZJ
shock.
thcrapcutic
may be
regimcn in severe uncontrolled
*{
Endotoxin-Neutralizing ProteinFromLimulus Q Recombinant | 9 PolyphenusReducesMortalityFromEscherchra ColiSepsis in BatModel N Kuppernann, D Nelson. CTGarcia. BASaladino, CMThompson, BKHammer, N Wainwright, TJ Novitsky, GBFleisher, GRSiber/Children's Hospital, Harvard Medical School, Boston; Dana-Farber Cancer Institute. Boston; Associates of CapeCod,WoodsHole.Massachusetts Study objmtive: Endotoxinreleaseduring sepsiswith Gram-negative bacteria dren.
causes significant
Ve investigated
ing protein
(ENP)
whether
from
morbidity
and mortality
a recombinant
Linulus
polyphemus
mogenic Limulus amoebocyte lysate aseay before tourniquet application, immediately before their release, and after reperfusion. Hydration was maintained by sterile 0.97o eaLne (3 ml.kgt.5.-t;, body temperature was maintained at 37.5 Co and mean arterial pressure was recorded from a cannula placed in the caudal artery. Inteetinal transmucosal permeability to horseradish peroxidase (HRP) was assessedby electron microscopy after the intraluminal injection of HRP into the ieolated i-leoceal loop l5 minutes before death. Results: Mean arterial pressure increased during the period of ischemia from 105 + 5 to 136 + 4 mm HB, but upon removal of the tourniquets and reperfusion, it fell to and remained, at79 +7 mm Hg. In all animals examined after two hours of reperfusion, there was evidence ofincreased intestinal permeability, defined as the penetration of HRP beyond intercellular tight junctions. None of the lS-minute reperfusion group and only one of six animals in both the corrtrol and ischemia-alone group showed such a change. This increase in mucosal permeability in the two-hour reperfusion group was associated with a significant increase in systemic but not portal plasma endotoxin levels. Conclusion: BHLI and subEequent reperfusion are associated with changes in gut permeability and systemic endotoxemia. Preliminary results suggest thaI these changes are not due to circulating hJpovolemia and hypotension. If such changes are implicated in the development of MOF, lhen any therapeutic intervention wi]l havc to be given as soon after the injury as possible.
in chil-
endotoxin-neutralizreduces mortality
in a
rat model of sepsis. Design: Randomized,
placebo-controlled trial. rats (200 g) were implanted intraperitoneally with sterile gelatin capsules containing 2.5 to 7.5 x 107 Escherchia Methods:
coli 0l8ac
\Vistar
Kl
and sterile cecal conrents
to induce
E coli peritonitis
and bacteremia.
blood cultures (cfu/ml) were Quantitative obtained from a tail vein in one fourth of the animals in each group just before ENP and antibiotic adminierration (pre Rx). One hour after antibiotic therapy (post Rx), one fourth of the animals from each group
were killed
to obtain
blood for culture and levcls of 'I'he remainder of tht: animals wen: observed for 24 hours. Interventign: The rats received intramuscular gentanricin (5
endotoxir
(pg/ml)
and tumor
mglkg) or salirre one hour gentamicin-treated
after implarrtation
animals
minutes after implantation
necrosis facror.
of thc capsulc- 1.h<: were given IV saline or llNp 30 to 60 of thc capsule in a dose of 5, 25, or S0
mdkc. R e s u l t s : S u r v i v a l w a s0 7 a i n t h e u n t r e a t e d c o n t r o l a n i m a l s a n d 237o in the gentamicin-rreated animals. The addition of ENp signif_ icantly increased 24-hour survival in a dose-dependent fashion in g e n t a m i c i n - t r c a t c da n i m a l s ( T a b l e ) .
Xrn 4lf
El{PDose{mOfts)
25 pâ&#x201A;Ź-Bxbacterial l\4ean count Meanposl-Bx bacterial count post.Rx [.4ean endotoxin level Suryival at 24hou6 'P"
Bx I S I x I 0r 4 5 x tff g/40
123y.) 003vs0 ENP,'P<.001w 0 ENP
i.sxlOa 5xl0' 14x1ff t3/41 1321,,1
1x105 1x10s 3.3xly 23140. {58%)
1 . 4x l 0 s 1 xl Y 3 . 8x 1 0 4 2B/411 (68%)
C o n c l u s i o n : E N P m a y a c r s y n e r g i s t i c a l l yw i r h a n t i b i o t i c s i n r e d u c i n g m o r t a l i t y f r o m G r a m - n e g a t i v e s e p s i si n r a t s a n d m a y h a v e therapeutic potential in humans.
tI or, GutPermeabilityAfterInjury BJCorson, STO'Dwyer. E Kirknmn, CNMcCollum, BALittle/University Department of Surgery andNorthWestern Iniury Research Centre. Unlversitv of Manchester, United Kingdom Studybackground:The pathogenesis of multisystem organfailure (MOF) followinginjury is poorly undersrood,althoughrecenrevidence suggeststhat the gut may have a signficant role. In the present study, the effects of a model of soft-tissue d,amage(bilareral hindlimb ischemia IBHLI]) on gur pcrmeability have been invesr.i_ gated in male Visrar rats (2?0 to 3zlo g) anesthetized with pentobar_ bitone. Methods: Four groups were studied: three-hour tsHLI alone, thre-hour BHLI plus lS-minure reperfusion, three-hour BHLI plus two-hour reperfusion, and controls anesthetized for five hours. Systemic and portal endotoxin levels were measured using a chro-
24
Respiratory SignsandSymptoms asMarkers for Pneumonia in Febrile InlantsLessThan2 MonthsOld
D D e m e s t i h aA s ,E K o r n b e r g / C h i l d r eH n 'oss p i t aol f B u f f a l oS ; U N Ya t B u f f a l o S c h o ool f M e d i c i n eB . u f f a l oN . ewYork Study objective: To correlate chest radiography findings for pneumonia in febrile infants less than 2 monthe old with respiratory s i g n sa n d s y m p t o m s . Design: A retrospective study from April through October 1991. Setting: All patients were evaluated in a pediatric emergency department. 'fype of participants: A total of 169 infants presented with a tempcrature of 38 C or grealer or a history of fever within the previous 24 hours. All were evaluated for rcspiratory signs and symptoms. Interventions: Infants receiyed sepsis workups including cheet radiographs and were admitted to rhe hospital to receive IV antibiotics. Fourteen werc excluded because chest radiographs were not done. Measuremcnts: Of the 155 infanrs, 146 had negative chesr radiograpic findings including normal readings, hyperinflation, or bronchial thickening. The radiographs that were positive for focal irrliltrates wcre found in nine infants. Four infants with positive radiographs had at least one sign or symptom indicative of respiratory illncss, but five did not. Ninety-six of the 146 infants with negative chest radiographs had evidence of respiratory illness, and 50 did not. Diagnostic testing results were sensitivity of MTo, epecificiry of 660/o,positive predic tive v alue of 7 7a, and negative predictive value of 95o/o. Conclusion: This study suggeststhat the presence or absenceof respiratory signs and/or Eymptoms does not predict findings on chestradiographsinfebrileinfantslessthan2monthsold.>
uati onorFe briIeInra nts t 21rJiff"t"TilHl:?,Tttt intheEvat
charge) after two hours of therapyo based on clinical criteria. Of the 35 patients who would have ben admitted if therapy were restricted to two hours, ten of 17 (58.87o) in the OP group and three of 18 $6.7qo) in the control group were discharged within the next two hours (P = .012). No one sent home from the ED relapsed within 48 hours (100% follow-up). Conclusion: Our data indicate that the early use of OP in the ED decreasesthe need for hospitalizarion of children with moderate-tosevere acute asthma. This benefit was observed within four hours and occurred in patients receiving aggressive B-agonist therapy.
K Delnay, B Hill,J Jones,D McKee,G Hoffman/Emergency Medicine Residency Program, Butterworth Hospital, Michigan StateUniversity College of Human Medicine. Grand Bapids Studyhypothesis:Routine chestradiographsare not necessary in the evaluation of young febrile infants without respiratory signs. Design:Retrospectivecaseseriesduring an l8-month period. Setting:University-affiliatedcommuniryhospital. Participante:Two hundred sixty-sixconeecutive infants less than 8 weeke old who were evaluated in the emergency department during the study period and had a temperature greater than 38 C
!L.llA "
AJAerosolized Epinephrine Use in the Treatment ol Croup NC Kunkel,MD Baker/Division of GeneralPediatrics.EmergencyMedicine. C h i l d r e n 'H s o s p i t aol f P h i l a d e l p h i P a ,e n n s y l v a n i a Study objective: To define a subpopulation of patients reeiving aeroeolized epinephrine for croup who could be obeerved for two hours and then discharged home. D e s i g n : P r o s p e c t i v eo b s e r v a t i o n a l s t u d y . Setting: Urban pediatric emergency department. Type ofparticipants: Forty-nine patients, aged 3 months to 6 years, made 52 visits to the ED for croup. Thirty-eight met the clinical criteria for croup and had no history of previous airway manipulation; this was lhe convenience sample. l n t e r v e n t i o n a n d m e t h o d s : P a t i e n t s w e r e a s s i g n e dC r o u p S c o r e s (CS), received mist lherapy, and were scored again after 30 minutes. All patients who rmeived aerosolized epirrephrine were admitted and followed with eerial CS. Results: After two hours of observation, seven patients had CS ofless than 3, no O, requirement, and had receivedonly one aerosolized epinephrine administration in the ED. None of these patients rmeived subsequent aerosolized epinephrine. Thirteen patientE reeived aerosolized epinephrine with a mean initial CS of4.82 (range,0 to l7). Only two patients required eubeequent aerosolized epirrephrine after admission. The initial CS wae not predictive of the need for further aerosoLzed epinephrine. Conclusion: Children receiving aerosolized epinephrine treatment for croup can be discharged home after a two-hour period of observation if they clinically appear well to an experienced physician and have reccived only one aerosolized epinephrine treatment during the observationperiod.
( r 0 0 . 4F ) . Interventions: Records were reviewed for patienr demographics, clinical findings, laboratory and radiographic features, and hospital course. The radiographic interpretations were compared with the presence of respiratory sigrrs. Results: Two hundred seven infants (78Vo)had chest radiographs available for interpretation. Of these, 42 (z|qo) were identilied as abnormal. Thirty-three of 105 infants (3f70) wirh any respirarory signs had an abnormal chest radiograph. In comparison, nine of the 102 asymptomatic infants (97o)had, an abnormal chest radiograph. None of the nine had complicated hospital courses. The sensitivity ofrespiratory signs was 79Vo (95Va confidence intervals lCIl,glVo to 667o). The negative predictive value (likelihood of havirrg a negative chest radiograph if the infant had no respiratory signs) was 9lVo (95Vo CI,977o to 86Vo). Conclueion: These results suggestrestricting chest radiography to febrile infante with signs of reepiratory distress.
Ellicacyof OralPrednisone *tt in theEmergency Department G4 Treatment ol AcuteAsthma in Children BJScarfone, SFuchs, ALNager, SAShane/University 0fpittsburgh School of pennsylvania Medicine, Children's Hospital ofPittsburgh, Study objective: To determine the efficacy of oral prednisone (OP) in the emergency department treatment of children with moderate-to-severe acute asthma. Design: Prospective, randomized, double-blind, placebocontrolled study. Setting: The ED of a children'g hospital. Type ofparticipants: Sixty-nine children from I to l? years old with moderate-to-severe acute asthma who presented to the EI) during a l2-month period. Those who had received corticosteriods within 72 hours were excluded. Intervention and methode: Patients were examined and assigrred a pulmonary Index Score (IS) indicating the severity of illness. Those with an IS of9 or grearer were given either 2 mglkg Op or placebo at entry. All children then received an identical regimen of nebulized albuterol (2,5 mgldose). The first rhree treatmenrs were given every 30 minutes, and eubsequent treatments were 45 minutes apart. Children either were discharged as soon as they showed sufficient clinical improvement or were hospitalized if not adequately improved within four hours of entry. Resulte: At entry, the two groups were similar in age, sex, recenr B-agonist uae, wheezing duration, and asthma severity. The Op group had a significantly lower overall hospitalization rate: eight of 33 (24.2Eo) vs l7 of 36 (47 .27o) (P - .04). The difference in hospital_ izatior rates was eyen greater for patients more severely ill at entry (IS of fl or higher): five of 19 (26.3Va) in the Op group vs 12 of lS (80Vo)in the placebo group (P = .002). To simulate srandard ED practice, we assigned a "preliminary disposition" (admit vs dis-
ol Glinical Response to Racemic J<t A Duration Epinephrine in 4rl Ghildren Wth Crouo K Wussow, SEKrug, TYamashita/Department 0fPediatrics, Case Western Beserve University School ofMedicine. Bainbow Babies andChildrens Hospital, Cleveland, 0hio Study objective:
To better
deecribe the clinical
lized racemic epinephrine
(RE) in the treatment
determine [he occurrence phenomenon. "
of clinical
Design: Clinical,
prospective,
worsening
observational
effects of nebu-
of croup and to oorebound or the etudy over a one-
year period. Setting: Urban
university
Type of participants: l0 years with the clinical principle Croup
investigator
hospital.
Patients
betwen
the ages of 3 months
diagnosis of croup
in the emergency
Score (CS). Patients
were digible
were evaluated
department if the inirial
and
by the
using a Fogel
acore was greater than or equal to 4 (equal to stridor at reet and moderate retractions) after a normal saline (NS) nebulization. Patients who werecyanoticorwheezingorhadotherairwaypathologywere>
25
excluded. Patients were enrolled consecutively as identified. All 24 eligible patients participated. Interventions: Patients received nebulized 0.5 mL RE in 3 mL NS and were scored by the principle investigator at 0.5, one, two, three, and four houre after the RE. All children were admitted. Results: Twenty-three of the enrolled patients had a mean initial CS of 4.09 + 0.20 and were between the agesof 3 and 25 months. The results were evaluated in terms of mean change in the CS. The mean change in CS at 30 minutes was 1.68 t 1.49. This decreaeed at one hour to 0.91 + 1.00 and by two hours to 0.50 +0.80. The mean CS at four hours was 3.73 +O.62. One patient's post-treatment CS remained at I for four hours and failed to return to within 0.5 ofhis pretreatment CS of4, as was obgerved in the other 23 patients. Conclusion: Children with etridor at rest are likely to return to their baseline level of respiratory disrress after a single RE aerosol. The usual duration of RE's clinical effect in children with modera t e l y s e v e r ec r o u p i s o n e t o t w o h o u r s . R e b o u n d o r w o r s e n i n g s t r i dor was not found.
*t|fA 4rf
trauma patiente and to aeeeeswhether treatment in tbese patients was affeted. Design, setting and participants: A retrospective study of 1,005 consecutive patient8 admitted to a level I trauma center (July through December 1989) was undertaken. Patients without initial electrolytes drawn in the trauma area and those without follow-up chemistriee were excluded from further study, leaving 9I2 patients. Decision limits on clinically significant electrolyte abnormalities (CSEA) were formulated from a survey of traumatologists and current literature. Medical recorde of CSEA patients were reviewed to determine if patient management was affected. Interventions: None. Results: Seven hundred fifty-five patients (837o)had one or more electrolyte value outeide of the normal laboratory range. Only 54 (5.9%) exhibited CSEAs. The most frequent CSEA was low CO, (42Vo). Associated with CSEAs were increased Injury Secerity Scores, decreased Revised Trauma Scores and Glasgow Coma Scores (P < .0001), nonpenetrating trauma, age (more than 50 years), diuretic and steroid use, and history of diabetes, hypertension, or renal failure. Test results influenced therapy in less than l7o (six) ofpatients (six patients receiving potassium supplement). Conclusion: The annual cost ofperforming initial screening chemistry labs is $53,280. Laboratory results prompted treatment irr lcss than l7o of cases,and in no instance were unsuspcted severe laboratory abnormalities revealed. We recommend against the use of initial screening chemistry panels in trauma patients because they are costly and do not reveal unsuspected abnormalities.
Pediatric Emergency Department Trialof Continuously vs lntermittently Nebulized Albuterol
D Steele, MDBaker/Division of General Pediatrics, Emergency Medicine, Children's Hospital of Philadelphia, Pennsylvania Studyobjmtive:To comparethe efficacyof continuouslynebulized albuterol (CA) versusintermir.tentnebulization(IA) in the initial emergency department lherapy of asthma in children. Deeign: Prospective, alternate- day randomized, nonblinded study. Setting: Children'e hospital ED. Type ofparticipants: A convenierrce sample of?2 children 6 ro 18 years old with asthma exacerbations (FEV',less than60Vo predicred). Intervention: Patients received either CA at a dosage of 0.5 mgtkglhr (maximum, l5 mglhr) for one hour or IA at a dosage of 0.15 mglkg (maximum, 5 mg) at hourly intervals. Spiromerry was performed at 30-minute intervals up to 90 minutes after treatment. Results: Mean percent improvement from baeeline at 90 minures was60.3 t 56.2 in IA patients and 58.4 t 57.6 in CA parienrs. Improvement was not statistically significantly differenr betwcen groups (r rcst). A 38Va or greater dilfercnce in percent improvement between groups can be detected given o = .05 and B = .2. Conclusion: Continuous administration of albuterol during the first hour of therapy for asthma is both effective and safe, but it results in improvement in FEV, similar to standard intermittent nebulizationgiven at hourly iniervals.
Lactate: A RapidPredictor ol Survival Following ] Admission f Traumatic Iniury DPMilzman, S Menlove, BBBoulanger, KAMitchell. CEWiles,lll/Department of Emergency Medicine, Georgetown University Medical Washington, Center, DC;Departments of Critical CareandTraumatology, Baltimore, MIEMSS, Maryland
f fi BoutineChemistryLaboratoryScreeningTestsAre Not Indicated 4fl in the Initial Treatmentof the TraumaPatient N Tortella, BFl-avery, M Bekant/Section of Trauma Surgery, TheNewJersey Jrauma Center, Department of Surgery; Department of Trauma andEmergency Medical Services; NewJersey Medical School; University of Medicine and Dentistry of NewJersey Study objective:Routineinirial screeningchemistrylaboratory testsare usuallyobtainedupon admission in traumapatients.'l'he rationalefor obtainingthesestudiesvariesbut usuallyinvolvesthe desireto determineif unsuspectedabnormalitiesexist that may havea clinical impact on the patient's subsequenttreatment. Becauseof the growingpressureto contain health care costsand the desire to practice
the most cost-effective medicine consistent with care, a study was conducted to determine the frequency of abnormal electrolytes (sodium, potassium, chloride, COr, BUN, creatine, and glucose) found in routine chemistry scrrens in optimal
Study objctive: Serum lactate has been shown to reflect tissue hypoperfusion and to correlate with survival in shock slates. The goal of this study was to determine if the admission lactate level can be used as a rapid predictor of outcome in trauma. Design: Retrospective cohort observational study, Setting: Statewide Level I trauma center. Type of participants: Four thousand three hundred sixty-Eeven consecutive adult trauma patients directly admitted between November 1987 and June 1990 were included. Smoke inhalation victims were excluded. Interventions: Serum lactate was drawn before resuscitation. Additional data were obtained from the trauma registry. Results: The mean Injury Severity Score and Glasgow Coma Score for all patients were I4.0 and 13.8, respectively, and overall mortafity was 5.8Vo. Patients were divided into five groups baeed on lactate levels. Lactate was shown to correlate directlv with mortalitv (Table).
laclslr {mil/[)
ilo. of Paliotrls
<?.0 2 1- 4 . 0 41-8.0 8 . 1- r 2 . 0 > 121
1.51? 1,992 663 91 49
Modaliry(%)*
1% 3.3% 16.1% 38.5% 57.lyo
'P< .001. lnlergroup dilterencesi
patient
Lactate's association with morrality was independent of ageoInjury Severity Score, and Glasgow Coma Score (Mantel-Haenszel test, )
26
the ultrasound examination were documented and interpreted before any other diagnostic studies and a DPL or laparotomy was performed. The ultraeound examination coneiated of a single right inter/subcostal longitudinal view with the patient in the Trendelenburg position and performed by the emergency physician or eurgeon. A real-time sector scanner with a 3.5-MHz probe was uged. The presence of an anechoic (black) stripe between the liver and the right kidney (Morrison's pouch) was interpreted as a positive study, and the absence of this finding was interpreted as a negative etudy. A positive DPL was defined as l0 mL or more of gross blood or a cell count of 100,000 or more cells/mm3 in the returned lavage fluid, and a positive laparotomy was defined as 100 or more mL of
P < .001). Lactate predicte the variability of eurvival better than the combination of admiseion heart rate and blood pressure (* = .146 ve r2 = .020). Conclusion: Admiseion lactate is a rapidly available and independent indicator of survival in trauma. The use of biological markers such as lactate would improve trauma outcome scores that rely on physiologic parameters like admieeion vital signs.
28 liliiffifi:lt.l:'Mav
Gontribute toHvpodrermia Despite
JM Bergstein, MEBobertson, D Hodell, College of S Hargarten/Medical Wisconsin. Milwaukee Studyobjective:Becausethe routine useof"high-efficiency" blood warmers during trauma resuscitations has not eliminated hypothermia, this study was performed to determine whether patients could still be losing heat to cold infused fluids. Design: Laboratory teet of fluid temperatures under carefully controlled conditions. Interventions: We tested high-efficiency blood warmers' abilities to heat blood and saline under a variety ofconditions desigrredto replicate aggressiveresuecitation. We tested two coaxial countercurrent warmers (H250, H500) with power outputs of 600 and lB00 W, respectively, with two different iubing sets (D50, Dl00) as well as a plate-type warmer (Fenwal). Saline and expired red blood cells at 4 C were pressurized to 300 mm Hg and administered through l8-, lG, and l4-gaugeand 8.5F catheters. Runs were timed to detcrmine flow rates, and effluent temperat.urc was measured with a calibrated digital thermometer. Both cold and warm start-ups wcre teeted. Resulte: Temperature varied eubstantially during administration for all warmer/tubing configurations under eome conditions. The highest and lowest observed effluent temperatures, highest flow rate achieved, and plateau temperature at highest flow rate (ml-,/min) are shown (Table). Watme/Tubing: Highest temperature {C) [owesttemperature {C} (C) Plateau temperature Highestflow (mt/minl
H50Dlm
H50D50
37.8 18.0 35.7 318
35.9 21.5 34.6
intraperitoneal blood. Resulte: Thirty-five patientE met the inclusion criteria for the study. Ten patients (28.67o) in this population had either a positive DPL or poaitive laparotomy. The eensitivity, specificity' and accuracy of bedeidc sonography in identifying intraperitoneal hemorrhage were 807o , 96Vo, and 9l.4Vo, reepectively. The ultraeound study provided an anewer within one minute in most Patients. C o n c l u s i o n : V e c o n c l u d e t h a t b e d e i d ee o n o g r a p h yi s a s a f e , rapid, accurate screening technique for detection of h e m o p e r i t o n e u mi n t h e p a t i e n t w i t h a b d o m i n a l t r a u m a . *t
C o u n t yH o s p i t a lC, h i c a g o ^ S t u d yo b j e c t i v e : T o e v a l u a t e i n v a s i v c v c n o u s a c c e e 8i n t r a u m a p a t i e n t s , b y c o m p a r i n g s a p h e n o u sc u t d o w n ( S C D ) w i t h p e r c u tane ous femoral catheterization (PFL). This etudy compares two c o m m o n m e t h o d s o f i n v a s i v e v e n o u a a c c e a si n t r a u m a p a t i e n l . s , thereby testing the American College of Surgeons' advance trauma M e s u p p o r t r m o m m e n d a t i o n f o r v e n o u s a c c e g gi n t r a u m a r e s u s c i t a tron. Dcsign: Prospective,randomizcd, multicentered trial from S c p t e m b e r 1 9 9 0 t h r o u g h S e p t e n r b e rI 9 9 1 . Setting: Patients wcre cnrolled at three urban l,evel I university trauma cenl.crs. 'f ypc of participants: Seventy-eight critically ill trauma patients morc than I8 years old who were judged to have inadequateperiphe r a l v e n o u s a c c e s s ,h a d p a l p a b l e f e m o r a l p u l s e s , a n d h a d n o c o n -
H25ryD5O Fenwal/Standard'
35.6 24.0 32.8 r86
n I n t r a v e n o u sA c c e s s i n t h e C r i t i c a l l y l l l T r a u n r aP a t i e n t A M u l t i ' centered, Prospective, RandomizedTrial of Saphenous Cutdown r)ff a n d P e r c u t a n e o u sF e m o r a lV e n o u s A c c e s s Mrenm o r i a l . PriceM . L a m b e r tF. G H i m m e l m a n / N o r t h w e s t e M D W e s t f a l lK ; ook l e n t e r , 0 a kL a w n ,l l l i n o i sC H o s p i t a lC , h i c a g oC; h r i s tH o s p i t aal n d M e d i c a C
34.5 30.8 33.6 58
'Standard Fenwal tubing. available ina single size Of the teeted blood warmers, only the H500 warmer with the Dl00 tubing set provided consistent euthermic (> 35 C) fluid delivery at high flow rates (more than 300 ml/min) and only when the reservoir was first allowed to reach operating temperature. Other warmer/tubing configura tione canno t achieve this standard. Conclusion: High-efficiency blood warmers may decrease but not eliminate heat loss due to transfusion. Of the teeted warmers. the Level I H500/D100 is recommerrded for maior trauma resuscitatione.
traindications to either procedure were randomized. Interventions: Paticnts were randomized to one of two groups: SCD or PlrL. After successful cannulation of the vein, I L of crystalloid was infused by gravity. Three electronic time stamps were made: l) slart of the procedure, 2) completion of the procedureo and 3) completion of I L fluid infusion. Results are given (Table). ProcedursTime(min) Inlusim Time(min) ToialTim {min)
Department Ultrasound in theEvaluation ol f (l Emergency 4if Abdominal Trauma DJehle, J Guarino/Erie County Medical Center, SUNY at Buffalo, NewYork Study objective: To compare bedside sonographic detection of hemoperitoneum with diagrrostic peritoneal lavage (DPL)Aaparotomy in the patient with abdominal trauma. Methods: A retrospetive review of all trauma patients who underwent emergency department (bedside) sonography to rule out intraperitoneal hemorrhage at a kvel I trauma center in 1991. Patients were included in the study population only if the results of
PFL
Resulls
sco
No.of patients Mean Meandillerene P
36 -U 5.63 3.18 2.45 <.0001
scD
Pfl-
30 31 6.65 4.56 2.09 <.03
scD
Pfl,
30 3l 11.167.67 4.09 <.0002
Conclusion: The placement of a PFL in the critically ill trauma patient with a fcmoral pulse is efficient and effective compared with SCD. It allows for rapid venous accessand essential fluid administration- Ve therefore, support the use of PFL as an acceptable and potcntiallysuperioralternativetoSCDintraumapatients.>
27
on the floor, at the l0:30 and I:30 ooclock poeitions, I m from the base of the wound model stand. The study area was contained in a 3 x 3 x 2 m plastic eheet encloeure to Prevent air drafts. Intervention: Ten irrigations were performed with ANGIOT IRRIJET, ZERO-I, and ZERO-C. Each run ueed 200 mL of a methylene blue eolution delivered with a 50-mL eyringe by one-hand pre88ure. The methylene blue splatter on each of the gride wae counted by size (diameter, Iese than I mm, more than I mmr lese
Network Versus TRISSlor Predicting a Q { Comparison ol Neural rf I Survival AfterTrauma Hospitalof lndiana,lndianapolis; EM Cottington/Methodist CM Shufflebarger, ResearchInstitute,Pittsburgh,Pennsylvania Allegheny-Singer Study objective: To develop a neural network for the estimation of survival in trauma victims that is more powerful than TRISS, the existing standard. Design: Development of neural network using retroepaLive lrauma registry data. Prospective comparison of survival prediction by the neural network compared with TRISS. Setting: Two large urban lrvel I trauma centers in different states (Indiana and Pennsylvania). Type of participants: All patiente with a diagnosia of trauma who were admitted to or died in either center. Interventiong: A multilayered neural network was developed ueing data from I1608 congeutive trauma victims presenting to the Indiana trauma center during a one-year period. The neural rtetwork program used a conventional back error propagation, feed forward algorithm, and trained to an average internal error rate of .032. The neural network was tested prospectively on data from 4r316 consecutive victims trealed at the Pennsylvania trauma center over a two-year period. Prediction of survival by the neural network was compared with TRISS using the 12 test. Resulte: The overall survival in the test group was 9f .2%. TRISS misclaeeilied 333 patients and the neural network mieclassified 285 (P < .05). Neural network prediction of survival wae also superior when subgroups with epecific injuries were evaluated. Conclueion: Research and quality aEsurance in trauma care rely substantially on the ability to quantify and predict expected outcome. TRISS, a multiple regression model that is the current standard methodology, typically misclassifiee 6Va to l07o of trauma victims into "unexpected outcome" groups, necessitating quality asEurancecase review for a large number ofpatients. TRISS is also a poor discriminator between observed and expected group outcomeg and therefore is a weak model for trauma outcomc research, A neural network is a new paradigm for predicting outcome. The network, baeed on rmognition of injury and vital sign patterns using artificial intelligence computer systems, produces significantly fewer misclassifications. Networks are a powerful regearch tool that may limit unneceesary quality assurance case reviews.
*etr!, r)4
than 5 mm, and more than 5 mm)Reeults: The splatter counts ofeach location and each size category rvere compared by analysie of variance and the Newman-Keule procedure of multiple comparisons. There was significantly less splatter of the irrigator'e face and cheet with IRRIJET ' ZERO-I ' and ZERO-C (P = .0000083 to P - .00118). No facial eplatter occurred with ZERO-C. There was significantly l,esesplatter at 9:00 and 12:00 o'clock, at both heights, and on the floor with IRRIJET' ZERO-I, and ZERO-C (P = .0000f2f to .00'0184). Irss eignificant splatter difference was noted at 3:00 o'clock (P = '00547 to .146)' Conclusion: IRRIJET, ZERO-I' and ZERO-C are euperior to ANGIO in preventing splatter during this wound irrigation model' 'lhe correct use of Zerowet (ZERO-C) was particularly effective in preventing splatter of the irrigator's face. This etudy wae not an attempt to evaluate the wound cleansing effrcacy of either technique'
GloveLeakDetection X;tt Whatls LeakyCanBeRisky:Sequential r)r) UsingElectroconductance Program, Besidency Medicine BGreen/Emergency J Jones, Stbana, Medicine, ofHuman College University State Michigan Hospital, Butterworth Lubbock University, Texas Tech ofTechnology, Bapids: Department Grand Study background: The riek of contacting bloodborne diseasee such as AIDS and hepatitis has caused increased awarenese of the need for effective cross-infection control procedures in medical practice. Recent studies indicate static leak rateg frorn 25Vo Lo 387o in latex surgical gloves. 'fo test the integrity oflatex surgical gloves under inObjective:
of a WoundModel:A SplafterDuringJet lrrigadonCleansing Comparison of ThreeInexpensivelrrigationDevices
Program, George Residency ECPignan, BKarch, J Scott/Emergency Medicine Washington, Washington-Georgetown Universities, DC Study objective: Preesurized jet irrigation is commonly used to c l e a n s et r a u m a t i c w o u n d s b u t r e s u l t s i n s p l a t t e r o f b l o o d , w h i c h i s a biohazard. Thre inexpensive irrigation devices are compared to asseesthe degree of splatter produced: a 1.25-in.-long l8-gauge angiocath from Deeeret Medical, Inc (ANGIO), the Irrijet Irrigation System, with a 5-in. splash shield, from Ackrad Laboratories (IRRIJET), and the Zerowet Splashield (Redondo Beach, California) held directly against the wound (ZERO-C) or held I to 3 cm away from the wound, which is an incorrect technique (ZERO-I). Design: A standard laceration was created in pieces ofbeef. This wound model was placed I m off the floor. Paper grid sheets were placed on the irrigator's face and chest. Six grid shets were suspended at the 9:00, 12:00, and 3:00 o'clock positions, I m from the wound model, and I m and 1.5 m above the floor to simulatc exposure to nearby individuals. Two grid shets were placed flat
use conditions. Design: Time-based sequential analysis ofglove leaks usingelectroconductance. Glovee hands were immersed in a saline bath connected to a digital multimeter (DMM). Any current flow between the outside and inside of the glove was recorded. To eetimate the eeneitivity of the DMM, 20 control gloves were Punctured with a 30gauge needle and tested randomly throughout the investigation. Interventions: Three hundred new eurgical glovee (50 paire per manufacturer) were collected from predetermined sites within the hospital and teeted for integrity. Ninety gloves (15 pairs Per manufacturer) that passed initial testing were worn for one hour. During this time, fingers.were flexed and extended to mimic clinical activity. These gloves were tested for leaka ge every 15 minutes. Results: In controls, the DMM tested 10074 sensilive for holes equal to or larger than those caused by a 3O-gaugeneedle. The static leak rate in unused gloves was five per 300 (L.7Vo). Four of these leaks (807o) occurred in gloves packaged for nonsterile use. Further sequential testing over one hour detected one punctured glove
(r.rEo). Conclusion: In this model, sterile latex aurgical gloves met Food and Drug Administration etandards and provided adequate barrier protection.
28
l|lorueilion3 wilh BAFC(%l
*34|-.* ofGloveIntegrity DuringCommon EDProcedures
Hopkins Johns KNHansen,0M Kornicwcz, El-arson, GBGreen, G0Kelenflhe
ABGS Cent6l lire Chesttube ETtube Exam l[,,!iniection Woundinigation local aresthesia tP lV linesandblood Suture All
S c h o ool f M e d i c i n eD , i v i s i o no f E m e r g e n cM y e d i c i n ea, n d T h eJ o h n sH o p k i n s , aryland S c h o ool f N u r s i n gB , a l t i m o r eM Study hypothesis: Breaches in glove integrity occur during the performance of emergency department proceduree, subjating the health care worker (HCV) to possible risk of infectious di.sease through direct contect with patient body fluids. Setting: High-volume inner-city ED and Level I trauma center. Type of participants: HCWe performing procedures within the ED. Design: During the three monthe of Fall I99l, ED procedures were observed directly, and the sterile surgical gloves ueed by HCWs were collected,labeled, and subjected to an industry standard watertight leak teet. Data were prospectively collected. Rates ofglove lerikage were determined for each procedure. Associated variables (eg, length of glove wear, HCW type, glove type, and lot number) were assessed. Results: Two hundred ten procedures were observed. The overall leakage incidence for used glove pairs was 15 of 210 (7. l7o) versus none of 50 (07o) for unused glove pair controls (P < .05). OnIy two ofthe l5 gloves found to have leaks had visible holes. Factors associated with glove leakage included type ofprocedure performed (phlebotomy, 0 7o; lY ltnes, 6.57o ; | &D s, 7 .7 Vo; su turing, 9. \Vo ; centr al lines, 13.57o); duration of glove w ear (4.37o, 5.6Vo, l3Vo, and.307o for less than ten, ten to 20, 20 to 30, and more than 30 minutes, respectively) ; and difficulty of procedure (none, 4.67o ; medium, 7.17o; very difficult, 20Vo). Of an additional 59 pairs ueed for unspecfied procedures during reeuscitation, 20.37o Ieaked. Conclusion: Breach in glove integrity oocurs at a significant ratc duringperformance of common ED proceduree, subjtxting HCWs to the possible risk ofexposure to infectious disease through contact with patient fluids. Glove holee not visible on inspection can be permeable to water and therefore may allow passage of body fluids. Rates of loss of glove integrity vary with procedure performed and increase with length of wear and difficulty of procedure.
l{o. of horumtiona 145 128 23 55 281 53 158 226 40 953 196 2.684
F*o
ExoossdAroa toot Body
... ... 4.3 ... 14
2.1 10 30.4 7.3 6.4
0.6
2r.5 1.8
2.5 ... 0.4
2.2 2.6 4.4
Hrndr 44.8
3.1 Lt
s7.7 100.0 83.6 83.6
1.9 .. ... .. 1.0 0.6
86.7 52.7 90.0 51.9 95.4 64.5
Factors sigrrificantly related to B/BFC were heavy procedure-related bleeding(odds ratio IOR]' f .7)' bleding patient (OR, 8.4), eucc e s s f u l( O R , 2 . 8 ) , m o r e t h a n o n e a t t e m P t ( O R ' I - 6 ) ' H I V p o s i t i v e patient (OR, 0.4). Health care worker type, severity of illness,and a d v e r s ec o n d i t i o n s d i d n o t i n f l u e n c e B / B F C ( P > . 2 e a c h ) ' Conclusion: Glovcs are required for all ED procedures except possibly intramuscular injection. Impermeable gowns are required for the majority of ED proccdures. Face and eye protection can be applied to a select group of ED procedures. Derailed recommendatiorrs for specific procedures and conditions will be presented-
in a DuringResuscitations Practices Disposal *2 A SharpInstrument Department Emergency d fl University Emergency Washington-Georgetown RShesser, S Sanford/George J Canpain, Medicine/George of Emergency Program; Department Besidency Mediclne DC Washington, Center, Medical Washington University Study hypothesis:Needlesand other sharp objectsoften are in the emergencydepartdisposedimproperly during resuscitations mcnt. Design: Prospective,observational study of sharp instrument d i s p o s a lp r a c t i c e s d u r i n g m a j o r m e d i c a l a n d t r a u m a r e s u s c i t a t i o n s . S e t t i n g : A 5 2 , 0 0 0 - v i s i t - p e r - y e a ru n i v e r s i t y h o s p i i a l E D . 'fype ofparticipants: A convcnience eample of 27 critically ill
ol ProcedureandGondition-Specific Universal Qf Determination rfJ (Barrietl Precautions Requirementsfor Optimal EDProvider Protection GDKelen, DBush,KNHansen, CGanguli, NTang,A Chanmugam, S Beinecke, JMHirshon, GBGreen/The Johns Hopkins Universitv School ofMedicine, Baltimore, Maryland; NewYork University NewYork School ofMedlcine, Study objective: To determine body areas ofblood and body fluid contact (B/BFC) during performance ofemergency department proceduree under various conditions and thus determine optimal procedure-spefic barrier preca ulions. Design: Prospective, direct observational study conducted during nine consecutive weeke during Summer 1991. Using a stratified blocked design with double sampling of busy shifts ( I ,250 hours of observation), protected and unprotected ED provider B/BFC were n o t e d f o r a l l o b s e r v e dp a t i e n t i n t e r v e n t i o n s . Setting: Large, inner-city, university hospital. Participants: All ED health care workers, including attendings, t r a i n e e s ,a n d n u r s i n g s t a f f . Results: There were 24 different interventione performed an agregate of 2 1684times on 2,497 pa tients. Of these, 1,77 3 (64.67o) resulted in B/BFC to at least one area of the body (Table). More than 90Vo were blood contacts (Table).
patienl.s. l n t e r v e n t i o n s : D u r i n g a n e i g h t - w e e kp e r i o d ' t h e u s e a n d d i s p o s a l of all sharp instruments by different categoriee ofhealth care worke r s ( I I C W s ) w a s c a t a l o g u e db y a r e e e a r c h a e e i s t a n t .T h e H C W s i n the ED were not aware that sharp instrument disposal practicee werc being audited. Results:Of thc 89 sharp instruments used on the monitored patients, 37 (41.67o) were disposcd properly. Of the 52 incorrect d i s p o s a l s( 5 8 . 4 % ) , 1 6 ( 3 0 . 8 7 o )w e r e p l a c e d o n t h e s t r e t c h e r ' 1 2 (23.lVo) were thrown on the floor, ten (l9.2Vo) were placed on a s t a n d , s i x ( l 1 . 1 V o ) w e r e h a n d c d t o a n o t h e r I l C W , f o u r ( 7. 7 7 o ) w e r e p l a c e d o r r a c o u n t e r , t h r e e ( 5 - 8 7 o )w e r e s t u c k i n t h e m a t t r e s s , a n d one (l-97o) was reapped. The frequency of corrat disposal differed greatly among HCWs with nurscs correctly dispoeing of 14 of l7 sharps (82.37o); technologists, 19 of 52 (36.5Vo); emergency medicine residents, two of eight (25%o); and other trainees, lwo of 12 (l6%a). The proportion of correct sharp instrument disposals by nurseswas higher than for other I{CWe (123 - 14.88, P - .0019). Conclusion: Sharp objects represent a eerioue threat to HCW safety during major ED resuscitations. Educational ProgramE should target primarily traines and tahnological staff. Several potential noneducational intervenLions suggestedby the locations of the incorrect dispoeals will be discussed.
29
Diminishing0ccupationalExposureto Communicable Diseases Q] rJ f in an EMSSystem PACurka, SLAlmeida, PEPepe,BSZachariah/Departments of Medicine, Surgery, andPediatrics, Baylor College of Medicine; Cityof Houston Center for Resuscitation andEmergency Medical Services, Houston, Texas Study objective:Despiteconcernsover HIV exposures,studiesof emergency care providers have demonstrated continuing expoEures and noncompliance with communicable disease (CD) control procedures. This study was conducted to see if a comprehensive emergency medical eervices (EMS) CD education and control program would alter the rate and the risk of occupational expoeure to HIV and other CD infections. Design and setting: A proepective four-year study of all possible exposures to CD reported to the formal CD control program of a large fire department occurring between January l, 1988, and December31, 1991, using a set (mandatory) reporting procedure as well as state and Centers for Disease Control criteria for designaring signficant exposures. Type of participants: Approximately 2,<1100 EMS firefighters (firstresponders, emergency medical technicians, paramedics) reporting e x p o s u r e st o a n y C D d u r i n g t h e s t u d y p e r i o d . Intervention: A formal CD corrtrol program involving intensivc training in epidemiology, modes of infecLion, and use of univcrsal precautions conducted for the 2,400 firefighters by a dcsignatcd CI) coordinator during late 1989 (ycar 2). Results: Ileported exposures dcclirrcd 47Vo by year 4. Morr: important, by year 3, sigrificant (documenred) exposures droppcd by nearly 80o/o ('table\. Rsportod CDExposuros Signilicent Bloodor godyBluidExposuros 1988(yearl) 1989lyear2l 1990{year3) 1991iyear4)
684 6/0 457 361
54 35 12 l2
Conclusion:A formal CD control program for EMS personnel can lower substantiallythe incidenceof occupationalexposuresto HIV and other CD enrities. rlQ Intramuscular AntibioticTherapylor preventionol Bacterial rf ll Sequelae in Children With 0ccultBacteremia GfrFleisher, RPlatr,The0ccultBateremia StudyGroup/Children,s Hospital, Harvard Medical School, Boston Meningitis and other focal bacterial infecLions occur in l0Zo to 4A7o of febrtle young children with occult bacreremia (OCCBACT'). Previous studies of presumptive antibiotic therapy at the initial visit have shown limited efficacy in reducing the incidence of these sequelae. Thus, we performed a prospective, multicenter trial to compare ceftriaxone (CEF), an intramuecular antibiotic with a lone half-Me with amoxicillin (AMOX), sr.andard pO therapy for presumed OCCBACT. During a pcriod of 42 months, 6,?94 febrilc (temperaturc ofmore than 39 C) children from ten emergency d e p a r t m e n t s w e r e r a n d o m i z e d t o c i t h e r a s i n g l ed o s e o f C E F ( 5 0 mglkg) or AMOX (60 mg}<{d.ay fo. t*o daysi. one hundred ninerytwo patients (2.8%)had OCCBACT: 167had Streptxoccus pneu_ ynnile (PNEUMO), nine had Haemophilus influenzae (HIB), two had Neisserirr meningitidis, four had SahnonelJa (SALM), and r.en had other. These patients had a mean ageof 14.5t 2.4 months, a mean initial temperature of 40.0 t 0.6 C, and a mean initial VBC of 19,000 +8,060/mm3. A significanrly (P - .02 by rwo-tailed Fisher,s ilact test) greater prDportion of childrm treated with AMOX (five of90) than with CEF (none of 102) developed definite focal infec_ tions, including meningitis (two HIB, one pNEUMO), pneumonra
30
(one PNEUMO), and persistent bacteremia (one SALM). Three of 90 children with AMOX had bacteria isolated from the blood after 24 hours (two HIB and one SALM), and two had bacteria isolated from the cerebral spinal fluid (two HIB) versua none of 102 from the blood (P - . l0) and none from the cerebral apinal fluid of the patient with CEF. Ve conclude that CEF compared with AMOX in the febrile child with OCCBACT significantly reduces the incidence of subsequent focal bacterial infections and eradicates bacteria from the blood.
Gertriaxone forAcute otitis 39 ii:lil ,?tTll[x'*"rar SM Green,SGflothrock/Departments of EmergencyMedicine,Biverside G e n e r aH l o s p i t aal n d L o m aL i n d aU n i v e r s i tM y e d i c aC l e n t e rC ; alifornia E m e r g e n cPyh y s i c i a nM s e d i c aG l roup Study objective: To compare the efficacy of single-doseintramuscular ceftriaxone with ten daye of oral amoxicillin for the treatment of uncomplicated acute otitis media in children. Design: Prospective, ra ndomized, double-blind clinical trial. Setting: Emergency departments of a county hospital and a university medical center. 'I'ype of participants: Two hundred thirty-three children aged5 months to 5 years with signs and symptoms of uncomplicated acute otitis media and abnormal tympanography. Intervcntions: Subjects raeived either a single intramuscular dose of ceftriaxone (50 mgftg) plus placebo oral suspension for ten days or a placebo injection plus amoxicillin suspension (4'0 mgkg/d,ay divided three times per day) for ten days in a doubleblind fashion after sequential randomization. Statistics were twotailed and included 12 a nalysis a nd the Student's t test with a 57o level of significance, Measurements and main results: Demographics, clinical characteristics, and initial tympanography were similar for both groups. Trcatment was judged eucceeefulin I07 of ll? given amoxicillin ( 9 1 7 o ; 9 5 7 o c o n f i d e n c e i n t e r v a l l C l ) , 8 6 7 o t - o 9 7 7 o )a n d 1 0 5 o f I 1 6 g i v e n c e f t r i a x o n e ( 9 1 7 a ; 9 5 V a C l , 8 5 V o t " o 9 6 7 o )( P - . S 0 3 ) . R a r e eo f improvement, failure, relapse, and reinfection were similar for both groups, as were otoscopic and tympanographic evaluations at l 4 - a n d 6 0 - d a y f o l J o w - u pv i s i t s . Conclusion: A single intramuscular injection of ceftriaxone (50 mglkg) is as effective as ten days of oral amoxicillin in the treatment of uncomplicated acute otitis media in children.
forDiasnosis ofInvasive Bacteri 40 |li:JJ,tlililo',:Tn.'*in'6 B Saladino, M Erikson, N Levy,B Bachman, G Siber.G Fleisher/Harvard Medical School. Boston. Massachusetts Study objective:Interleukin-6(lI-6) is one of severalcytokines released in bacterial endotodn-induced sepsis. Serum IL6 levele were measured in children to determirre the utility of serum IL-6 levels in assessingchildrerr for bacteremia and eepsis. D e s i g n : P r o s p e c t i v ec o h o r t s t u d y . Setting: A children's hospital emergency department. 'Iype of participants: Study patients were 20 children with clinically suspccted sepsis or meningitis; control patients were 50 febrile children aged 3 to 36 months with negative blood cultures. Interventions: None. Results: Eleven of 20 patients (55Vo) with clinical signs of sepsis had bacteriologically documented infections: four with meningitis and two with bacteremia due to Neisserilt neningiti.dis, three with meningitis due Io Hoemophilus influeruu type b, and one each )
Design: Retrospective review of l?5 consecutive adults in cardiac arrest with aortic (Ao) and right atrial (RA) Pressure monitoring' Setting: Large urban emergency center' Patientsr All seven Patients (with a total of eight arrests) who received magnesium eulfate IV (2 to 5 g) during CPR'
with meningitis and bacteremia due to Streplrcoccus pneumoniae' The geometric mean IL6 level in the serum of these 6ulto." positive patients was 40? + 85 pg/ml; all three patients with levels greater than 300 pglml. developed septic shock, and one died. One ofnine culture-negative patients (ff7o) with clinical signs of sepeie had detectable eerum IL-6 (If pglml.); none of the 50 control Patients had a detectable IL6 level. The detection of IL-6 had a sensitivity of glvo (ten of I l) and a specificity of 987o (58 of 59) for invaeive
Interventions: None. Results: Mean duration of CPR before magnesium sulfate was 27.5 minutes (range 3 to 57 minutes). CPP before magnesium sulfate was stable for three miutes or more' Pressuree (mm Hg) were compared at the time of magnesium eulfate bolus and three minutee
bacterial dieease. Conclusion: High levels of IL6 occur in children with septic shock, and the presence ofIL-6 in serum is predictive for the ieolation ofbacteria from the blood and/or spinal fluid.
Iater (Table).
*/| ,l Suprapubic Bladder Aspiration Versus Urethral Gatheterization rl I in lll Infants: Success. Efliciency, and Complication Rates of Mississippi CVPollackJr, ESPender,ERSmith,JJ Donaldson/University M e d i c aC l e n t e rJ. a c k s o n Study objective: To compare success' complication rates, and efficiency of suprapubic bladder aspiration (SPA) with urethral
Ao compEsston Ao relaration RAcompression RArelaxation CPP
7 7 .+ 314.6 r2.9 33.41 t:12.6 72.5 25.1t7.4 8 . 3i 11 . 5
/llt
rlt)
P
.008 .001 .30 .26 .009
Ellect ol Magnesium on Cardiac Resuscitation Outcome After
Arrest Prolonged Sciences Health ofColorado JTNiemann/University DPersse, CBCairns, California; Torrance, Center, Medical Harbor-UCLA Colorado; Denver. Center. York New Center, Hospital Municipal Bronx S t u d y b a c k g r o u n d : M a g n e s i u m h a s p o t e n t c a r d i a c e f f e c t s ,i n p a r t due to direct alterations of cellular calcium fluxes' Altered cellular calcium homeostasis is thought to play a major role in ventricular dysfunction during ischemia and arrest' Purpose: To determine the effect of magnesium on outcome of prolonged ventricular fibrillation (VF), CPR' and high-dose (HDE). epinephrine D"tigot Canine model of cardiac arrest. All animals were subjected to electrically induced VF followed by ?.5 minutes of VF without
cPu. lnterventions: After 7.5 minutes of VF, only manual closed-chest CPR (S0 to 100 compressions/minute, one positive Pressure ventilation after every fifth compression) was performed for the nexi 20 minutes. After this 20-minute period, all animale received HDE, ( 0 . 2 m g l k g ) . C o u n t e r s h o c k sw e r e t h e n p e r f o r m e d , r e c o m m e n d e d ACLS drugs were given, and CPR was continued until regtoration o f a p o n t a n e o u sc i r c u l a t i o n ( R O S C ) o r f o r a n o t h e r 2 0 m i n u t e e ' Group I (five) received 5 g MgSOn IV before VF' Group 2 (five)
Iessefficient in that it requires physician participation and failure rates are higher. Reported successrates for SPA are around 907a, but these were derived from etudies of clinic Patients who were not as ill as this pediatric ED population. Our data suggestthat successful SPA ie primarily dependent on the volume of urine in the bladder; thus in the ill or febrile ED infant who may be dehydrated, the likelihood of euccessdecreaees.Although SPA is safe, UC is equally safeodoes not require a physician, and is a time-efficient meane of obtaining urine in this population. The authors recommend that ED
served as a control (no MgSOn). Methods: Aortic (Ao) and right atrial (RA) PressureEwere measured using micromanometer catheters. Coronary perfusion pressure (CPP: diasto[c Ao - RA pressure d-ifference) wae meaeured before and after HDE. ROSC afier 20 minutes was coneidered a
nursing and physician staffbecome comfortable with performing UC on infants.
l'.
Aftor Mg
86.5r 13.8 40.1 4 14.1 75.8116.4 26.9 + 8.0 1 3 .j51 3 . 4
s p o n t a n e o u sc i r c u l a t i o n .
volume recorded. Reeults: Thirty patiente underwent primary SPA. Successrate (2 mL or more of urine obtained) wae 377o. Mean t SD time per SPA attempt wae 23 + 6 seconde. Thirty patients underwent primary UC; the succeesrate was IOOVo, and,the mean required time was 84 + 33 geconds.After failed SPA, UC was I007o successfull draining volu m e ew e r e 0 . 2 5 t o 9 m L u r i n e ( m e a n l S D ' 2 . 8 + l ' 2 m L ) . N o i m m e diate problems were identified among any instrumented patients; later post-procedure complications (next-void hematuria after either procedure, other visceral injury after SPA) were abserrt. Conclusion: Both SPA and UC afford the emergency physician with low-risk accessto uncontaminated urine in ill infants. SPA is
r
Boloro Mg
Return of sporltaneous circulation occurred in three of eight arrests, all after high doses of epinephrine. Conclusion: Magrresium sulfate PromPtly lowers the CPP during CPR, probably due ro arterial dilation. Magnesium sulfate may ."dr." -yo"".dial blood flow and decrease chance of return of
catheterization (UC) in ill infants. Design: Prospective, convenience-randomized clinical study. Setting: A university hospital PED. Type ofparticipants: Infants less than 6 months old requiring an uncontaminated urine specimen in the evaluation of febrile illness, suspecied UTI, or sepsis. Infants with wet diapers were excluded' Interventions: Patients were randomized to undergo timed SPA (performed by a physician and a registered nurse) or UC (by two "bag" urinalysis registered nurses). All patients had a next-void performed for post-procedure hematuria. tf SPA was unsuccessful, UC was immediately performed and the bladder drained with urine
'-
Prs:surss
Pressure Perfusion SullateLowersCoronary dl t Magnesium rf4 During CPR Hunran ofPediatrics, GBMartin/Department EPRivers, NAParadis, Goening, l1/lG Medicine, ofEmergency Hospital. Royal 0ak;Department Beaumont $Villiam Michigan Detroit, Ford Hospital, Henry
s u c c c s s f u lo u t c o r n e . Results: In group I (maglresium)' five of five animals achieved = ROSC compared with none offive in group 2 (control) (P '008 by F i s h e r ' s e x a c t t e s t ) . T h e h e m o d y n a m i c r e s p o n s et o I I D E t r e p r e s e n t ed.as the change in CPP (mean + SD), was significantly higher in group I (23 I f0.2 mm Hg) than in o group 2 (f0 + 5'8 mm He) (P: .03 by unpaired t test)'
Study hypothesie: Magneeium sulfate lowers the coronary perfusion pressure (CPP) during CPR.
3l
Conclusion: Pretreatment with magnesium significantly improved outcome in this model of eevere normothermic myocardial ischemia. Magrreaium appears to affect outcome by preserving the hemodynamic response to HDE.
External GPRDecreases Morphologic BrainDamage in 1| /l Standard -l'l OogsCompared Wth NoIntervention A Badovsky, M Angelos. PSafar, HBeich/lnternation, Besuscitation Besearch pennsylvania Center, University ofPittsburgh, Study Objective: In a dog model of 2O-hour ventricular fibrillation cardiac arrest flFCA), standard exrernal CpR (SECpR) from VF at ten hours to YF at twenty hours signficantly improved clinical outcome. 'fhis report adds brain histopathologic confirmation to the efficacy of SECPR over no intervention for 20-hour VF. Design and Interventions: In dogs, normothermic VFCA of 20 hours was reversedwith briefcardiopulmonary bypass, IppV to 20 hours and intensive care to 96 hours. Group I (six) had no blood flow from zero to ten hours ofVF and then received SECpR from ten to twenty hours. Group 2 (seven) remained with no flow from zero unti-l twenty hours of VF. At 96 hours, the reanesthetized does were euthanized, and the brains were perfusion-fixed with 3Vo paraformaldehyde. Seven coronal sections representing l9 major anatomic areas were paraffin-embedded and stained with hema_ toxylin-eosin-phloxine. Each area, bilaterally, was scored blindly in four categories, from 0 (none) to 8 (most severe) for microscopic prevalence of shrunken, hypereosinophilic, angular ischcmic ncur o r r s , a n d s c o r e sw e r e s u m m e d f o r c a c h b r a i n . R e s u l t e :M e a n b r a i n n e u r o n a l d a r n a g cs c o r c f o r g r o u p I w a s 36 118 (range, ll to 62), as comparcd wirh 65 1g (range, 59 to Zl>) in group 2 (P = .01). Conclusion: Blind scoring of rhe prevalencc of microscopically ischemic cerebral neurons confirmed the abilitv of tcn-rninute SEPCR to mitigate neuronal death throughout the brain, cvcn afr.cr l0 minutes of no-flow VF. An Experimental Algorithm Versus Standard ACLS in a Swine Model of 0ut-ol-Hospital Cardiac Arrest J J M e n e g a z zE i . A D a v i s ,D M Y e a l y ,B L M o l n e r ,K A N i c k l a sG , M H o s a c kE, A H o n i n g f o r dM. M K l a i n / C e n t ef or r E m e r g e n cM y e d i c i n eD ; i v i s i o no f E m e r g e n c y M e d i c i n eS, c h o ool f M e d i c i n eU , n i v e r s i toyf p i t t s b u r g hM; o n t e f i o r eU n i v e r s i t y a ;i v i s i o no f E n r e r g e n c y H o s p i t a lU, n i v e r s i toy f P i t t s b u r g hp,e n n s y l v a n i D
/l 'lrl E
M e d r c i n eC, o l l e g eo f M e d i c i n eT, e x a sA & M U n i v e r s i t yC, o l l e q eS i a t i o nT . exas Study objctive: To comparc an cxpcrimcrrtol ulgorith1 l ) A . 1t o standard advanced car&ac Me supporr (ACLS) in a swine model of p r o l o n g e d ( e i g h t - m i n u t e )o u t - o f - h o s p i t a l c a r d i a c a r r e s t . Design: Randomized, controlled experimental trial. Setting and parricipants: Animal laboratory, using lg swine (mass,17.8 to 23.7 kg) of either sex. I n t e r v e n t i o n s : A n i m a l s w e r e s e d a t e d ,i n t u b a t e d , a n e s t h c t i z e d , and instrumented for monitoring of arterial and central venous preEsures and ECG. Ventricular fibrillarion (VF) was induced using a bipolar pacing catheter- Animals were randomized to lreatment with the EA or srandard ACLS after eight minutes of unrreated VF. T h c E A c o n s i s t e do f s t a r t i n g m e c h a n i c a .cl h e s t c o m p r e s s i o r r ,g i v i r r g high-dose epinephrine (0.20 mg&g),lidocaine (1.0 mglkg), b..tyti, ym (5.0 mglkg), and propranolol (0.5 to 1.0 mg) by pcripheral IV line, hyperventiliting (20 to 25 breaths/min), delaying counrershock (5 J/kg) 60 seconds after completion of drug delivery, and starring IV dripe ofepinephpine and lidocaine. Outcome variables unulyr"d i n c l u d e d a r t e r i a l a n d c e n t r a l v e n o u sp r e s s u r e , r e t u r n o f s p o n t a _ n e o u sc i r c u l a t i o n ( R O S C ) , a n d o n e - h o u r s u r v i v a l . D a r a w e r e a n a _
32
lyzed with Student'e I teet, Mann-\fhitney U test, and Fisher's exact te8t. with a set at .05. Reeults: Measured hemodynamic variables did not differ among groups during CPR. ROSC occurred in seven of nine in the EA group (777o) versus two of nine in the ACLS groap (227o) (P - .028). Four of nine of the EA animals (MVo) survived to one hour versus none of nine in the ACLS group (P :.041). Conclusion: In this swine model of out-of-hospital cardiac arrest, the EA produced statistically significant improvemenr in ROSC and one-hour survival when compared with ACLS. Although brief VF responds well to early countershock, the cascading physiological effects ofprolonged cardiac arrest minimize the effectiveness of ACIf . Multifaceted approaches, such ae thie EAn should be explored further. +" {rOt t S o U i u r B i c a r b o n a t ei n C a r d i a cA r r e s t
frBVuknir, NGBircher, A Radovsky. J Menegazzi, PSafar/lnternational Besuscitation Besearch Center, Department ofAnesthesiolosy/CCM, University ofPittsburgh, Pennsylvania Study objetive: The use of sodium bicarbonare (SB) in cardiac arrest has declined due to suggestedadverse effects. The effects of SB on outcome in canine ventricular fibrillation (VF) arreet of moderatc duration (five, ten, and l5 minutes) were examined. Design: Seventy-two dogs (10 to l? kg) were prepared with ketamine, halothane, N2O-02, and pancuronium. Electrically induced VF was maintained for five, ten, or l5 minutes. CPR and dcfilrillarion were followed by canine ACLS prorocol with epinephrine (0.1 ^glkd, atropine and lidocaine, and norepinephrine with restoration of circulation (IIOC). Inlcrvention: The SI] group received I mEq&g, and base deficit (llD) was corrected to less rhan 5 mEq/kg. Hemodynamic parametcrs and Neurologic Deficit Score (NDS, 0% Io 1007o)were derermirred at five minutes and 24 hours after CPR. Data analyeis used Mann-Whirney, RMANOVA, Fisher's exact, and Student.'E,-tests (Table). BBrults: 10 Minutos SB Conllol No.ol dogs ttOc Suruival NDS pll c0, ll0 [/AP cPP 'P<.05.
6 6 5 1/ . 8 ' 7.29 38.8 8 .t ' 11.5 61.7
6 6 5 4 2t 1.22 31.1 14.6 58.3 45.5
20 20' t9' 26.6 7.26 50.1' 5.5'
20 15 11 65.0 7.20 36.8 14.3
10 9
'
/l.9' 1. 2 7 43.4 7.3' 49.5' 35.6-
t0 3 1 98.7 7.11 37.9 16.3 28.5 15.3
The SB group demonstratcd improved (ten and 15 minutes ofVF) or equal (five minutes of VF) ROC and 24-hour survival, with leesened neurologic deficit (five, ten, and l5 minutes ofVF). The acidosis of arrest was decreased (five, ten, and l5 minutes ofVF) without alkalemia but with hypercarbia in the lO-minute group. Improved coronary (CPP) and systemic perfusion pressures (15 minutes) with decreased epinephrine requirement (ten and l5 minutes) werr: notedConclusion: The empiric administration of SB improves the suryivalandneurologicoutcomeaftercardiacarrestindogs.>
andSodium Bicarbonate Ouring GPR on :k/l ] EflectofEpinephrine It f Survival andNeurologic Outcome Following Asphyxia-lnduced Gardiac Anestin Rats BNeumar, N Bircher, KMSim,FXiao,KSZadach, PSafar/lnternational Resuscitation Besearch Center andAffiliated Residency lnEmergency Medicine, University ofPittsburgh, Pennsylvania
Each offour lacerations on each animal was irrigated with 180 mL of the following: l) cefazolin solution (l g mixed in 500 mL normal saline), 2) normal saline, 3) l7o (voUvoI) povidone-iodine solution in normal saline, and 4) no irrigation (control). Irrigation wae done at a standard distance using a 35-mL syringe and an l8-gauge needle. Each laceration was biopsied and quantitatively assayed two, seven, and 12 hours after irrigation. Data were converi.ed to log(10) values and analyzed using a repeated measures analysis of variance and a Tukey's post-test comparison. The study was designed to have etatistical power of.8 to detect a 2.log(I0) difference. Results: Povidone-iodine irrigation resulted in a 2.log(10) decrease (P < .01) in bacterial counts compared with control two hours after irrigation only. No other djfferencea were noted. The overall meane for all biopsies after irrigation were 4.9 + 0.9 for cefazolin;5.1 + 1.3, normal salinel 5.2 I 1.3, povidone-iodine;and 5.5 + l.l. control. Conclusion: In this guinea pig model, irrigations of lacerations contaminated with S aareu using povidone-iodine, normal saline, or cefazolin were no better than control in reducing bacterial counte over 12 hours.
Study hypothesis: Epinephrine and NaHCO, during CPR improve long-term survival and neurologic outcome after prolonged asphyxia-induced carfiac arreet. Design: Eighty male Sprague-Dawley rats (397 + 33 g) were srudied prospmtively in a randomized, placebo-controlled trial. Rats were anesthetized, instrumented, paralyzed, and mechanically ventilated. Each underwent ten minuteE ofasphyxia, resultingin 6.8 + 0.4 minutes of circulatory arrest; then, manual external CPR was performed. Successfully resuscitated ra[8 were monitored invasively and ventilated mechanically for one hour, Neurologic Deficit Score (NDS) was determined at ?2 hours. Interventions: Placebo (P) or 0.01,0.1, or 1.0 mglkg epinephrine (EPI) IV was given at the onset of CPR followed by placebo or 1.0 mEq/kg NaHCO. IV (Table). Reeulte:
48 fflffiXlr
Ouantitative Bacterial Counts Following Aggressive Treatment 'Benign vs N e g l e c t - i n a R a b b i tP u n c t u r eW o u n d M o d e l JD Cooper,CD Chisholm,GA Denys/Emergency Medicineand TraumaCenter a n d D e p a r t m e notf P a t h o l o gayn d L a b o r a t o rM y e d i c i n el,t / e t h o d l sH t o s p i t aol f I n d i a n al,n d i a n a p o l i s 'fo Study objecrive: compare the effect of aggreesivetherapy ( p u n c h b i o p s y a n d i r r i g a t i o n ) v e r s u 8n o t r e a t m e n t o n q u a n t i t a t i v e b a c t e r i a l c o u n l . si n c o n t a m i n a t e d p u n c t u r e w o u n d s . D e s i g n : A r a b b i t p u n c t u r e w o u n d m o d e l w a s d e v e l o p e d .N e w Zealand rabbits were anesthetized, and the dorsal midline was shaved with electric clippers. A l4-gauge bone marrow biospy needle was uscd to inflict a 2-cm-deep puncture wound 2 cm lateral to the spinous procees. Four wounds were inflicted sequentially on each side of the midline of each animal for a total of eight puncture wounds per arrimal. All wounds were injected with an infective inoculunr (0.25 mL of a 1.5 x 108/mLsolution) of phage-typed Staphylncoccu dureus. Each rabbit served as its own control, Interventions: In group A (five), the four wounds to the right of the midline received immediate aggressive therapy consisting of a 3-mm epidermal punch biopsy of the puncture tract and irrigation with 240 mL normal saline delivered by a high-pressure syringe system. The four wounds to the left of midline had no therapeutic interventions. Twenty-four hours after wounding, two 3-mm punch biopsies were obtained from each wound tract and analyzed for quantitative bacterial counts. In group B (five), therapeutic interventions were identical but delayed until 24 hours after wounding. Tissue samples from thie group were obtained 24 hours after treatment. The two treatment groups were compared using the paired ! test, Vilcoxon signed rank test, and ANOVA. Results: In group A, there was no difference (P> .10) between the colony-formirrg units (cfu) per gram of tissue in the 20 aggressively treated and 20 control wounde. AII group A wounds grew infective bacterial counts (more than l0s/g of tissue). In group B, all 40 wounds demonetrated clinical evidence ofinfection 24 hours after wounding. In this group, there was a signficant (P < .0005) der:reasein the cfu per gram of tissue in wounds after aggressive treatment compared with controls. Conclusion: In this animal model, aggressive therapy did not significantly decrease quantitative bacterial counts compared with "benigrr neglect" in puncture wounds treated immediately afier )
>k/l (l 'lrf
NaHC0,(mEc/kO) P P P P 1.0 1.0 1.0 l0 EPI P 0.01 0.1 {mg/kg) 1.0 P 0.01 0.1 1.0 No.ofrars l0 10 i0 t0 10 10 t0 10 C P P ( m m H g l1 S4Df )1 5 2 8 r 2 0 3 8 + 2 2 4 5 r 2 5 1 6 1 1 73 1 r 2 0 5 0 1 2 64 3l : 2 1 (%) 5 (50) 5 150) 8 (s0) B(80) 5 (50) s (s0) 9190) s (s0) 80sclNo.) 72.Hour (No.) (%) 2 (20) 3 {30i I (10) 0 (0) 3 (30) 5 (50) 4 (40) 0 (0) suruival 72-Hour N D S ( % i S D4)7 * 1 0 2 5 r 1 1 2 8 . 43j7 34t9 1719 perfusion CPP, pressure coronary during CPR; R0SC, relurn ofspontaneous crrculation; NDS, 0% (brain to 100% dead). {normal}, Conclusion: Similar [o its actions in human beings, EPI improved CPP (r - .26, P -.04 by Pearson's correlation) and ROSC (P = .02 by 12) over placebo. Compared wirh 0.01 mglkg EPI, 72-hour survival did not improve with 0.1 ^glkg g : .S by Fisher's e x a c t t e s t ) a n d d e c r e a s e dw i t h I . 0 ^ g l k g g = . 0 0 3 b y F i s h e r , s e x a c r tesi). However, NDS in 72-hour survivors corelated inversely with EPI dose(r = -.7O by Spearman's rank order). NaHCO, rherapy tended to improve 72-hour survival (P - .09 by Fisher's exact resr), but there was no detectable difference in NDS.
andPovidone-lodine astrrisants otGonraminared
JMHowell, T0Stair, AWHowell, DJMundt/Georgetown University Hospital, Washington, DC Study objective: Several eurgical studieg and one uncontroled study of outpatient wounds suggest that antimicrobial irrigation decreaseswound infection rate8. This study examines the effect of various irrigants on bacterial counts in contaminated lacerations in guinea pigs. Deaign: Controlled animal study. Intervention: Six male albino guinea pigs were anesthetized with intramuscular ketamine, buprenorphine, and inhaled methoxyflurane solution. At time zero, each pig received four lacerations inoculated with 0.4 mL of a penicillin-sensitive Staphylococcus aureus (ATCC 25923) suspension. The lacerations were parallel ro rhe spine at shndard depths and lengths. 'fhe inoculum was matched to a 0.5 McFarland standard at I x I08 cfu/ml. Twelve hours after inoculation, each wound was biopsied to ensure that each wound was contaminated and then either irrigated or left as a control. Quantitative bacteriology was performed using standard techniques.
33
wounding.
with controls. puncture
treated
counts in the aggressively
group compared
These data suggest that routine
aggressive therapy
after wounding
does not decrease
immediately
wounds
quantitative
decrease in quanti-
there was a significant
24 hours after wounding, tative bacterial
evidence ofinfection
with clinical
in wounds
However,
tract.
counte in the wound
bacterial
may benefit
cal evidence ofinfection
Wounds
of
with clini-
such therapy.
from
Ell F l l
TraumaticWounds Ufl Predictorcof Inlectionin Uncomplicated, Medicine, of Emergency M Seaman/Department BLLammers, DLHudson, San of California, University California; Center, Fresno, Valley Medical Program, Education ValleyMedical SanJoaquin Francisco: Fresno-Central Fresno. California Study objative: To identify and weighclinical factorsmostpredictive of subsequentinfectionin uncomplicated,trau matic, suturedwounds. Design:Prospectivecaseseriesduring a 39-monthperiod. Setting:
Emergerrcy
teaching hos-
county
of an urban
department
using visual analog scales to assessthe degree ofpain at the time of injection as well as one, thre, six, 12r and 24 hours later' Setting: Emergency department of an urban, teaching hoepital' Type ofparticipants: Twenty-four adult Patients with injuriee of the middle or distal phalanges ofthe fingers requiring digital block anesthesia before repair' Interventions; Patiente received figital blocko using a jet injector on one eide of the finger and a needle-syringe on the other side; pain was assessedar zero)one, thre, six, 12, and 24 houre using visual analog scales. Results: Differences in pain scores for the two proceduree (jet injector vs needle) were tested at each time period using nonparametric statistical procedures for paired of matched data (Wilcoxon)' At the rime of injection (time 0), the jet had a significantly lower pain score than the needle. At six and 12 hours, the lower pain score reported using the jet injector compared with the needle attained borderline significance. Comparisons made at the other time points were statistically nonsignificant at a - '05 (Table)'
pital. Participants:
Patients
Wounds
wounde were included. mouth wounds
presenting
to rhe ED with suturable
older than 24 hours; hand' foot, or
older than eight hours;
bites; missile or explosion
wounds contaminated
injuries; stabs or puncturesi
lrmeu Time1 Iime3 Time6 Tim 12 Time24
with debris that
could not be removed; wounds irrvolving l.endons, joints, or open fractures; and irrfected wounds were excluded. A total of l'216
lnterventions:
Residents
and emergency
protocol
and then estimated
using a five-point personnel
blinded
variablee,
the likelihood
to the initial
by the t teet and Pearson's and locationl
illnessesl and patient
assigned weights using neural equation was derived.
network
Melhodol Prsdiction Sensitivity
46% C||nical iudgment Neuml networkmethod 13%
NerveBlocks lor Digital PlainLidocaine CZ gufereaVersus Albany Medlcine, 0fEmergency Homer/Department DTFord,PJ JMBartfield, NewYork Albany, Avenue, NewScotland Hospital, Center Medical Study hypothesis: Buffered lidocaine (BL) is less painful to administer as a digital nerve block (DNB) than plain lidocaine (PL)' Design: Ran domized, double-blind, prospective clinical trial' Setting: University hospital emergency department' 'f ype of participants: Adults not allergic to lidocaine who
age. These factors were
analysis'
equation was a more accurate predictor physicians' clinical judgment
Ftt
12 statistic' contaminationl
and a decision
Using a tcst set, we determined
that this
of wound infectiorrs thart
(Tablc).
Specificity
Positivs Prediclivs Value
l{egativs Prodiclivo Valus
78% 13%
l5% 18%
95% 970i
P
.0001 2300{Ns) 5560{NS) .0660 {borderline} .0500 .0830
methods.
infectiorr
by medical
rate was 7 .37a. The most predictive
were wound age, depth' configuration, absence of medical
cvalu-
prediction.
infection
as determined
of subsequent
was followed
healing
5.5 15 1 2 2 1
anesthesia achieved using the jet injector was considered adequate in 23 of 24 patients. Conclusion: The jet injector can be used effectively in performing digital blocks and is less painful than standard needle-syringe
wounds according to a st.andardized
scale. Wound
Results: The overall
faculty
medicine
NssdleMsdian
z 1 1 0.5 0 0
'l'he
wounds were entered in the study; li1866 cases were lost to followup, and 142 cases were excluded for various protocol violations. ated and managed traumatic
Jot Msdian
required a DNB. Interventions: Srudy solutions were prePared by 9:I dilutione of Lalolidocaine with either sodium bicarbonate (buffered) or eodium chloride (plain). Subjects received DNBe by injection ofBL on one side'and FL on the other in a predetermined randomized order' Pain of infiltration was measured using a previously validated visual-analog pain scale. Scores were compared ueing a two-tailed I test and rank order nonparametric analysis. Multiple regression analysis was used to assessthe ptissible mitigating effects of order of infiliration, age, and sex. Standard l7o lidocaine was ueed if addi-
Conclusion: Using combinations of several clinical features, physicians could improve their ability to identify wounds at high risk for subsequent infection at the time of initial treatment. Additional measures could be taken in the management of these selected wounds [o lower infection rates.
tional anesthetic was required. Results: Thirty-one Patients were enrolled. Baeed on differences BL wat significantly less painful to in pain scores (pain""-painul), administer than PL (P < .001, t = 4.21)- No further differencee were found with regard to order of infiltration, age, and sex (all incre mental F < 1.00, NS). Supplemental anesthesia was required less often for BL (twice) than for PL (six times), although this difference
The Ellicacy and Acceptability of Usinga Jet Iniectorin f { J I P e r l o t m i n gO i g i t a l B l o c k s P e n n s y l v a nH i ao s p i t aal n d U n i v e r s i t0yf P i t t s b u r g h , 6l f//lsAilestern P i t t s b u r g hP,e n n s y l v a n i a Study hypothesis: Jet injection can be used effectively as a Iess painful way to perform digital blocks. Design: Prospective, nonblinded study comparing jet injectio n with needle-syringe injection oflidocaine in perfoming digital blocks
was not statistically significant. Conclusion: Because it causes less pain and is equally efficacious, BL is preferable to PL for DNB.
34
with Associated Attenuation *53I'#",LTi,x:::ff 'l thePain
Conclusion: HDE (0.20 mglkg) increases CPP and repletes PC during closed-chest CPR, thereby increasing myocardial energy stores.
GeneralHospital, J Loch-Donahue, B Jewart, S Donahue,D Hanlon/Allegheny Departmentof EmergencyMedicine;St FrancisMedicalCenter;The Eyeand EarInstitute,Universityof Pittsburgh,Pennsylvania Study objective: Anecdotal evidence suggeEtsthat the clinical benefit ofbuffering lidocaine with bicarbonate is time dependent, an area not addregsed in previous studies. We hypothesized that buffered lidocaine causeg less discomfort when used immediately
Hemodynamic Ellects of Repeated Doses of Epinephrine in !f Prolonged Cardiac Arrest and GPR lllf of ColoradoHealthSciencesCenter,Denver: CB Cairns,JTNiemann/Unlversity l e n t e rT, o r r a n c eC, a l i f o r n i a H a r b o r - U C LMAe d i c a C Study purpose: To hseessthe hemodynamic resPonse to repeated doses ofepinephrine (EPI) in an animal model ofcardiac arrest' Design: Randomized study in a canine model of cardiac arrest' All animals were subjected to electrically induced ventricular fibrillation (YF) followed by 7.5 minutes of VF without CPR. Interventions: A-fter ?.5 minutes of VF, manual closed-chest CPR (80 to 100 compressions/min, one positive Pressure ventilation after every fifth compression) was initiated. Countershocks were performed, reommended advanced cardiac Me support drugs were
after mixing. Design and type ofparticipants: A double-blind, randomized trial with l4 healthy volunteers was conducted following a singleblindo randomized trial of 34 similar subjects. Intervention: In each trial, buffered lidocaine (9O7oof 2Vo hdocaine with I : 100,000 epinephrine and l|o/a of 8. 47a sodium bicarbonate) was mixed one and 45 minutes before use. The right forearm ofeach subject was injected subcutaneously with 0.2 mL of one solution, and the left forearm was injeted immediately thereafter with 0.2 mL of the other eolution. On a scale of I to 7, subjects ranked the initial discomfort, total discomfort and length of discomfort for each solution. Data were analyzed with paired ! tests, with
given, and CPR was continued until restoration ofspontaneous circulation (ROSC) or for 20 minutes. Group I animals (14) were given EPI (0.04 mglkg), followed by the same dose when indicated' Group 2 (14) were given EPI (0.0S mg&g)' followed by repeated doses of 0.04 mglkgwhen indicated. Methods: Aorric (Ao) and right atrial (RA) Pressuree were meas u r e d w i t h m i c r o m a n o m e t e r c a t h e t e r sb e f o r e a n d a f t e r E P I , a n d CPR coronary perfusion prcssure (CPP) wae calculated (CPR diasto[c Ao-RA pressure difference). Survival was defined ae mainte-
P < .05 coneidered significant. Results: In both trials, mean scores in each area were higher for the 5-minute solutions. The mean difference in initial discomfort was I.2 in the single-blind trial (P < .05) and 1.5 in the double-blind trial (P < .05). The mean differences in total discomfort for the two t r i a l s w e r e I . 3 a n d 1 . 2 , r e e p e c t i v e l y( b o t h P < . 0 5 ) . L e n g t h o f d i s comfort was significant for the single-blind trial (0.9; P < .05). Conclusion: Buffered lidocaine causes less disconfort. when usod
nancc of ROSC for 30 minutes. llesults: l'hree of 14group I and nine of 14 group 2 animals surv i v e d ( P = . 0 1 4 ) . I ' l e m o d y r r a m i cd a t a e v a l u a b l e i n 2 5 a n i m a l s a r e summarized (Iablc). Values (mm llg) arc given mean * SD.
immediately after preparation.
l{0.ol EPI aCPPld EPI aCPPZndEPI aCPP3tdEPI Animls CPPBetors 7{ 1 ) 2lt11' 12t7 3 1.Suryived 2t4 2+.4 312 114 10 1 .D i e d 2 9t 4 ' 6r2 I 2, Survived ?t:4 71 9 8 r12 6f3 5 z,Died
onMyocardial High-Energy of HighDoseEpinephrine f /l Eflect CPR During Ventricular Fibrillation andClosed-Chest J'l Phosphates of JWHoekstra, RGrifflth, DLewis, RKelley, RJCody, CGBrown/Department University, Columbus Emergency Medicine, Division ofCardiology, 0hioState
Group
Study objective: The purpose of this study was to evaluate the effects of high-dose epinephrine (HDE) on myocardial high-energy phosphate (HEP) metabolism during resuscitation from cardiac arregl.. Design: Prospective, blinded, rronrandornized, controllcd study using a swine model ofcardiac arrest and resuscitation. Interventions: After anesthesia, intravascular pressure irrstrumentat-ion, and ten minules of ventricular fibrillatiorr arrest, closedchest CPR was begun. After three minutes of CPR, animals received either 0.02 mglkg epinephrine (standard dose ISD], eight animals) or 0.20 mgll<gepinephrirre (high dose [HD], nine animals) IV. At 3.5 minutes after epinephrine, the animals underwent thoracotomy and rapid-freezing transmural myocardial core biopsy for HEP analysis. HEP values were determined blindly with high-performance liquid chromatography (Table). Results: P SOE(0.(nmg/ks) HDE(0.mmsAs)
' P < 0 5b yp a i r e td- t e s t
cPP
rc'
ATP' ADP" ATP/ADP AC
13.014.8 0.410.8
9.814.7 5 . 4+ 2 . 1 2.1+ 1.4 0.68+0.12
23.715.5 6.2r4.4 1 ? . r1s . t
C o n c l u s i o n : ' f h e h e m o d y n a m i c r e s p o n s et o t h e f i r s t d o s e o f E P I determines if a critical CPP needed for ROSC or survival will o c c u r . I l e p e a t d o s e so f E P I d o n o t a P P e a r t o i m p r o v e C P P e n o u g h to affc'ct clinically meaningful measureE of outcome (ie, successful countershockand survival)-
and onHemodynamics Epinephrine ol High-Dose f f, TheEflect Period in thePost-Resuscitation llll Electrolytes Medical College Medicine, ofEmergency Spivey/Department SGCrespo,WH Philadelphia ofPennsylvania, Study objective: High-dose epinephrine has been advocated for use in cardiac arrestl however, concernshave been raised about immediate post-resuscit.ative cardiac and hemodynamic inslability. We hypothesize that exogenous epinephrine is metabolized rapidly and does not produce significant adverse cardiovascular or metabolic effmts during the immediate post-resuscitation period. Design, Prospective laboratory investigation with unblinded com-
001 0003 .30
parison of two doses of epinephrine. I n t e r v e n t i o n s : E l e v e n d o m e s t i cs w i n e ( 1 3 t o l 7 k g ) w e r e anesthctized with 30 mglkg ketamine and maintained with h a l o t h a n e a n e s t h e s i av i a e n d o t r a c h e a l t u b e . C a t h e t e r s w e r e p l a c e d v i a t h e f e m o r a l a r t e r i e s a n d v e i n s t o m e a s u r ea o r l i c p r e s s u r e , r i g h t a t r i a l p r e s s u r e , p u l m o n a r y a r t e r y P r e s s u r e ,c a r d i a c o u t p u t , a n d
4l 6.1113 99 2.110.9 .81 0 1 2* . 0 . 1 2 AUP. CPP. coronaryperfusionpresure{mmHg);K, phosphocreatrne; AIP. ademsinetriphosphate, 'ng/mg protein. admsire diphosphate; AC,aderrylate duqe.
for blood sampling. Lead II ECG was monitored continuouely. Ventricular fibrillation wae induced using a 60-Hz transthoracic
35
)
shock, and CPR was atarted five minutes later. Five animals received 0.f mg&g epinephrine IV, and six animals received O.2 mgkg epinephrine IV at minute l0 after arrest. Animale were defibrillared and resuecitated uaing standard protocol. Catecholamines, cardiac output, right atrial pressure, aortic pres_ sure, heart rate, ABGo, and electrolytes were measured at control and at zero, two, four, six, eight, tenr 20, 30, 60,90, and 120 minutes after return of spontaneous circulation (ROSC). Animals recovered and were observed for 24 hours. Data were onulyr"r), using a two-way ANOVA and_/ort test when appropriate. A value of P <.05 was considered significant. Results: The O.2-mg/kg dose group had a significantly grearer mean t SD peak epinephrine level rharr rhe 0.I-mglkg group (9,784t 3,043 vs 1,662 + 490 nglnL,respectively). Elevared epinephrine levels persisted until ten minutes after ROSC. Mean blood pressures tended ro be highcr after 0.2 mglkg epinephrine compared with 0.01 mglkg. ln rhe first minure afrer epirrephrirre adminietration, the 0.2 mglkg group had a higher heart. rate tharr the 0.I-mgi&g group (185 + 45 and I l0 1 l0 beats/min, respectively). The time from defibrillation to ROSC and time ro esrablish a stable sinus rhythm were not different berween groups (15 + 12 vs 25 + 32 seconds and 228 + 82 vs 2961412 scconds for the 0. I mglkg and O,2 mg/kg groups, reepetively). Both groups had sigrrificant r n c r e a s e si n p o t a s s i u m , m a g n e s i u m , a n d l a c t a t e a n d a d e c r e a s ei r r calcium that rcturned to or near baseline. .l'here was no differencc b e t w e e ng r o u p s w i t h r e e p e c t t o c a r d i a c o u t p u t , c o r o n a r y p c r f u s i o n pressure, or AIJCs. Conclusion: fligh-doseepinephrinr: did not produce sigrrificarrt. . d y s r h y t h m i a s o r c a r d i o v a s c u l a r i n s t a b i l i t y i n t h e p o s t - r c su s c i t at i o n period. In addition, there were no significantABCs, clectrolyte, or lactate abnormalities.
High-Dose Epinephrine Resultsin GreaterEarlyMortality f,] rf f FollowingResuscitation FromprolongedCardiacArrest B Berg,C 0tto,A Sanders, K Kern,B Helweg, M Milander, J Nelson, G Ewy/University of Arizona College of Medicine, Steele Memorial Children,s Besearch Center; University of Arizona HeartCenter, Tucson Study objective:High-doseepinephrine(HDE) has beenrccom_ m e n d e d f o r c a r d i a c a r r e s t b e c a u s eo f b e n e f i c i a l e f f c c t s o n m y o c a r _ dial perfusion pressure, myocardial blood flow, and ccrebral blood flow in animal models as well as uncontrolled reports in hunran b e i n g s . O u r o b j e c t i v e w a s t o d c t c r m i n c s u r v i v a l a n d r r c u r o l o g i co u t _ come after administration of HDE (0.2 nglkg) vcrsusstandard-dos<: epinephrine (SDE, 0.02 mg&g) during CI,ll. Design; A randomized, blinded, 24-hour study of liO pigs rccciv_ ing HDE or SDE during CPR. Intervention: Thirty pigs underwent electrical fibrillation for I5 minutes, followed by three minutes of CpR. HDE or SDE were ran_ domly administered after one minute of CpR, and the investigators were blinded to dose. Standard advancedlife support protocols, including defibrillation, were provided for ten minutes. pigs with r e t u r n o f s p o n t a n e o u sc i r c u l a t i o n ( R O S C ) w e r e p r o v i d e d w i t h t w o hours ofintensive care. ECG, arterial blood p.essu.e, and right atrial pressure were continuously recorded from time of fibrillation through intensive care unit period- Survival and neurologicoutc o m e w e r e d e t e r m i n e d o v e r t h e n e x L 2 4 h o u r s . C a t e g o r i c a lv a r i a b l e s w e r e a n a l y z e d b y y z a n d c o n l . i n u o u sv a r i a b l c s * e r e u r a l v r " d b n unpaired Student's , test. Reeults: Five minutes after defibrillation, five of 14 HDE pigs had heart rates of more than 2S0 yersusnone of 14 SDE pigs
36
(P < .02), and the diastolic blood pressure was 130 + l8 mm Hg, after HDE versus 94 + 24 after SDE (P < .0001) (Table). Etiollh.ii!Do$ l{o. BOSCtCUDotht 2+Hoursunivrl coodl{curoloeicOI.cm 0.02 mg/kg 15 t4 0.2mg/ks 15 t4 S z 'P= 03Wx2 Conclusion: HDE induced severe tachycardia and hyperteneion in some pigs. HDE resulted in more intensive care unit deaths. HDE did not improve 24-hour survival, and HDE did not improve neurologic outcome. Fl.t .lO n Study of High-Oose Epinephrine in Human CpR l G S t i e l l , P CH e b e r tB , N W e i t z m a nG , A W e l l s ,S R a m a nB, M S t a r k L , AJ H i g g i n s o nJ,A h u j a ,G D i c k i n s o n / U n i v e r s0ift y0 t t a w a ,O t t a w a O , ntario, Canada Study objmtive: To compare the effects of high-dose epinephrine (HDE) and standard-dose epinephrine (SDE) on survival rates of aduli patients treated in the hospital for cardiac arrest. Design: Randomized, double-blind, conrrolled trial. Setting: Wards, intensive care units, and emergency departments of two tertiary care hospitals served by emergency medical technician-defrbrillation level prehospital care. 'l'ype of participants: Six hundred fifty adult patients who suffered nontraumatic cardiac arrest either in-hospital or out-of-hospital and required epinephrine according to standard advanced cardiac life support (ACLS) guidelines. lntervcntion: Random allocation to reeive either HDE (7 mg) or SDE (l mg) every five minur,es as needed to a maximum of five d o s e s ,a c c o r d i n g t . os t a n d a r d A C L S p r o t o c o l s . Results: Demographic and clinical characteristice were eimilar for the two groups. Mean times to epinephrine administration were 14.9 minutes overall and 6.6 minutes for in-hospital arrests. Survival for at least one hour and to hospital discharge and the 957a confidence intervals (CI) of the difference between groupe w c r e a Bs h o w n ( T a b l e ) . Pationts
llo. Suruival %HDE
Ovcmll
650 Onehour 1'1.7 drsdarge 3.2 l n - h o s p r t a3l 1 5 O n e h o u r Z b . Z disdrarge 4.8
%SDE
p
ZZ.g 1? 4.9 .38 3j.0 .3t 7.1 .52
%Differsnce(g%Cl)
S . t( - 1 . 2 1101 . 5 1 1 . 6i _ l . s t o 4 . g ) b . B ( - 4 . 51160. l ) 2.3(_3.2 to7.9)
In addition, survival was not significantlybetter for HDE patients than for SDE patients in other subgroups, including out-of-hospital location, witnessed arrest, initial rhythm, or time to epinephrine administration. There were no differences between the survivors in the I{DE and SDE groups for median cerebral performance caregor y ( l v s l ) o r m e a n F o l s t e i n m e n t a l s t a t u s s c o r e e( 3 6 . 0 v e 3 6 . 8 ) . C o n c l u s i o n : H D E d o e s n o t i n c r e a s es u r v i v a l f o r a d u l t p a t i e n t c treated in-hospital for cardiac arrest.
ClinicalTrialol High-Dose Epinephrine and trO A Randomized JJ I'lorepinephrine VersusStandard-Dose Epinephrine in PrehospitalCardiacArrest M Callahan, CDMadsen, CWBarton, CESaunders, M Daley, J Pointer/Division of Emergency Medicine, University of California, San Francisco. SanFrancisco Department of Public Health Study hypothesis:fligh-dosecatecholamines do not improve survival in prehospital Type
adult cardiac
of participants:
arrest.
San Francisco prehospital cardiac victimsfromAugustl990throughDecemberl99lwhowerein>
arrest
ayEtole or blectromechanical dissociation on paramedic arrival or who failed early defibrillation by fire department firstresPonders. Intervention: Prospective, double-blind, randomized trial of standard-doee epinephrine (SDE, I mg), high-dose epinephrine (HDE, 15 mg), or high-dose norepinephrine (NE, lI mg), in place of SDE in all adult advanced cardiac life support prehospital cardiac arrest treatment algorithms. Methods and resulte: Data were analyzed by ANOVA, t teet, and contingency analysis. Nine hundred twenty-eight arrests occurred during the study period; 762 patiente were eligible and enrolled. Study groups were comparable in response time, rhythm, and other prognostic factors; 237o of patients were in ventricular fi-brillation on paramedic arrival. One hundred sixteen etudy patients were resuscitated in the lield (l1Vo\,lM were admitted to rhe hospital (l$Vo), and 13 were discharged (27o). "Iwo of the 13 survivors received SDE, and the remainder received high-dose catecholamines. Combined HDE plus NE discharge rate was I57o verets 8Vo for
the dry or frozen condition (P < .05). Vood chips had a lower force ofimpact than gravel but this only reached statistical significance only in the frozen gtate (Table). Inpactfsca (G)on5 ruilacesunderdiffcralt|anyirmmsdrlcondilions Wood Chips
Fieldresuscitation lnpatient admission fromED Hospital discharge, patients alladmitted Overall survival, all patients
% HDE
%tIE
%SDE
P
20 31
15 27
11 21
.02 .11
13 2
17 2
1
I .
4
Sand
158.3' 155.8'
Grar:
Md
I r5.9 165.4
Values: WhyLegislators VoteAgainstlniuryControl fi { FactsVersus lf I Laws M Orleans/Section of SRLowenstein, J Koziol-McLain, GStatterfleld, University ofColorado Health Sciences Emergency Medicine andTrauma, Center, Denver Srudy background: Prevention of motor vehicle-related injuriee d e p e n d so n m a n d a t o r y s a f e t yb e l t ( S B ) l a w s . Y e t , s t a t e l e g i s l a t o r s often oppose these laws. Objective: To identify factors (knowledge, experiences, attitudee and beliefs) associated wirh "yes" and "no" votes. Design: Prospective. A 62-item questionnaire was mailed to etate Iegislators. Participants: Ninety-seven incumbenI state legislators who voted
.63 3
The number of days ofcritical care (mean, 4.3; SD, 5.5) and hospitalization (mean, 4.4; SD,4.6) were not different betweendrugs (P - .94). Best Glasgow Coma Score during hospitalization did rrot differ betweendrugs (mean, 3.8; SD, 2.6; P :.6; B - .3?). Three fourths of survivors were intact neurologically. 'fhere were 48 survivors overall during the study period; 35 (73o/o)responded to early defibrillarion and did not receive the study drug. Seven survivors (l\Vo) were defibrillated but also required the study drug. Only six gurvivors (13%) did not receive first-responder early defibrillation. Conclusion: HDE and NE increaeed resuscitations in the field compared with SDE, but increaees in inpatient admissions and overall survival were not significant. HDE and NE did not lengthen inpatient stay. Moet hoepital diecharges were the result ofearly defibrillation by first-responders.
o n a 1 9 8 7S B l a w . 'l'o Statistical Methods: test for associations between attributeg and the legislators' recorded votes, odds ratios (OR) and,95Vo confrdence intervals (CI) wcre calculated. A stepwise logistic regression identified irrdependent predictors of "vol.e." Results: l-ifty-three of the legislators (557o) responded. Ilesponders and nonresponders were similar demographically. Vote was not associated with age, gender, young children in the family, perceived injury risk, rment traffic tickets, family or personal crash experience, or knowledge of risk reductions attributable to wearing SBe. Ninety-six percent of the legislators knew SBe reduce the risk of death, and 877o bebeved a SB law would save livee. The strongest prcdictors of a "yes" vote were impression that constituents favored the law (OIt, 3l-95Vo CI, 3.5 to 270) and belief that mandatory SB laws save lives (OIl, 20;954o CI, 2. I to 203). l,egislators who considered rest.rictions on individual freedoms an "extremely" criterion "no." werc 43 times more likely (7, 267) to vote In the logistic model, only extreme importance assigned to individual freedoms (B - -3.7;
of lmpactAttenuation ol Oifferent Playground f,fl Ouantitation ff ff Sur{aces WithA TriaxialAccelerometer BNaunheim, LMLewis,J Standeven, KNaunheim/St LouisUniversity Medrcal Center, Missouri
'fo Study objective: rank playground surfaces with respect to impact attenuation under various simulated environmental conditions. Design: An IS I00 impact recording sphere (Techmark, Inc.) was dropped from a height of @ in. onto five different playground eurfaces including grass, rubber mats, wood chips, sand, and gravel (all except lhe mats were 6 in. in deprh). Impact attenuation was measured (G forces) with the above surfaces in the dry, wet, and frozen state. The experimenter was blinded as to the results until ihe experiment was completed. Interventione: The sphere was dropped ten conseculive limes onto each surface. All surfaceg (except the mat) were tested in the wet and dry state. The wood chips, sand, and gravel also were tested in a wet frozen state. Results: Using ANOVA and Tukey's test to correct for multiple variables, wood chips significantly lowered impact forces compared with sand in the wet or dry condition or to grass or rubber mats in
I 19.4
166.9' Dry t 1 1? . 161.0 468.6' Wetfrozen 159.7' 126.1 180.7' 221.8' Dryfrozen 66.7' 'P< .05. Conclusion: Vood chipe appear to the single beat playground surface under a variety ofenvironmental conditione when asseseed by impact attenuation etudiee.
s D E( P = . 6 5 , 8- . 5 7 ) . Variabls
Gravsl
75.6' 62.6'
Wet
OR, .025, P = .002) and policy effectivenees(8 = +3.1; OR, 22; P - .01) predicted "vote." The model corratly predicted 907o of legislator's vo[es. 'fhe Conclusion: strongest predictors of voting behavior were concern for individual freedoms, perceived constituents' support, and attention paid to policy effectiveness. Those seeking to persuade legislators to vote for mandatory SB lawe muet pay attention to attitudes and values in addition to scientific facts.
Patients: A Five-Year FollowDepartment J<tr|Intoxicated Emergency andMonality 114 Upol Morbidity Medicine P Davidson, S Lowenstein, J Koziol-McLain/Section of Emergency andTrauma, Health Sciences Center, Denver University of Colorado Study
objective;
(ETOI{)-related emergency
To determine
morbidity
department
Design: Retrospective
37
the five-year
and mortality
patientscohort.
incidence
in a cohort
of alcohol
of intoxicated
Setting: Urban Level I university ED. Participants: One hundred fifty consecutive ED patients who presented intoxicated (blood alcohol, more than 100 mg%o)in June 1986 and 50 unintoxicated controls matched for age, sex, and ED arrival time and date. Interventions: We reviewed hospital ED and admission records from all state Level I trauma centers and three computerized statewide data bases (motor vehicles, vital statistics, alcohol and drug abuse). We determined the incidence of death, ED recidivism, drunk driving (DUI), admission to public detoxification (DETOX) units, and later problem drinking. 12 or Fisherns exact tests were used to compare proportions. Results: Five-year study results (Table).
were male; 227o were 15- to l9-year-old males, although this group made up only 3.5Vo of the city'B population. Among adults, the ratio of GSV to SW was I:1.9; among youths under 20, the ratio was l:0.8 (P < .001). Most ictime (717o) live in thre communities with the city's highest poverty and unemployment rate8. Data on precipitating circumstance and offender were missing or unknown in 377o of the casee. Conclusion: Tenage males were oyerrepresented among victims, and youths were more likely than adults to be injured by guns. ED etaff have used the data succeesfully to argue for funding for victim services and to target interventions on teenE in the three high-risk communitiee. The high caseload documented indicates that protocols and staff training are nmded to incorporate victim safety planning and education into the discharge process. ED surveillance appears to be feasible and useful in identifying risk groupe and tracking incidence trends. Methods are needed to improve information on precipitating circumstances of the injury.
EDBditia
o.rtii Populrtior St!dygroup{150) Control group150)
Totrl 7 (s%i 1( 2 % l NS
EI0H Brlltd 4 12.6%) 0t0%) NS
EI0HViobncry' n.llbd Suicidr DUI DEIoX WithOneor WidrOnror Whi Onror Widr0rr or MoreVititr MoroYisitr Morr Arr.$! MoroAdmits 39y" 12% 45% 78% 4% 4% 10% 22% < m1 10 003 ms
After ageadjustmcnt (direct method), rhe death rate in the study population was 3.5 times that of the statepopulation-at-largc.The five-year death rate among intoxicated middle-aged (40 to 69 years old) patients was especially Iryh (l9o/o). Sixty of the 150 study patients were interviewed by ETOIJ counselors after DUI arrcsl.s o r D E T O X a d m i s s i o n s .U s i n g M o r t i m e r - F i l k i n s s c o r o sa n d o t h e r criteria,977o were "problenr drinkers;" only 37o were oosocial drinkers." ln 1007a of interviewed patients, significant ETOI{related family, legal, or job problems existed. Conclusion: The reeults demonsl.rate the importance of a sirrgle alcohol-related ED visit as a risk factor for continued problem drinking, DUI, and premature death. Clinical rrials of ED-based E'I'OH treatment and referral are warranted.
Fatal Childhood Iniury Patterns in an Urban Sefting: The Gaselor *4;|| 't Primary Prevention ff C LW e e s n e rC, A p r a h a m i a nS,W H a r g a r t e n / M e d i cCaol l l e g eo f W i s c o n s i n ,
Milwaukee Begional Medical Complex, Milwaukee Study objetive: To describe fatal childhood injury patterns in an urban county. I)esign: Retrospective chart review of medical examiner fiIes, prchospital and hospital records, and police and fire department reports. Setting: Urban. Type ofparticipants: All children l5 years and under who eustained fatal injuries in l9B9 or 1990 (70). Intervention: None. Results: Housefires were the leading cause ofinjury death (347o), followed by firearms (I97o) and drowning (ll7o). Motor vehicleoccupant deaths occurred less frequently (74o). One third of deaths w e r e h o m i c i d e s ( 4 8 V o b y f i r e a r m s , a n d S U V ob y a s s a u l t ) .O n I y 2 T V o of victims survived to become inpatients (84Va dted within 72 hours). Twenty-four percent of deaths were pronounced at the scene, l27o were DOA (no emergency department reeuscitative efforts)o and377o were DOA-failed ED resuscitations. Mean scene time (16.5 +8.3 minutes), transport time (9.4 *4.6 minutes), and succeEsrates for prehospital peripheral IV [nee (727o)rintvbation (9lVo), and intraosseous Ene (867o) were not significantly different among those who were DOA, DOA-failed resuscitations, or eventual inpatients. Conclusion: Fatal childhood injury patterns in this urban setting differ from reported national injury patterns. This study found a higher percentage of deaths from housefires, gunshot wounds, and homicides and a lower percentage of moi.or vehicle-related deaths. Prevention Btrategiesned to address the injury patterns of a particular community. Only a small percentage of victims survived to receive inpatient care after sustaining their injuries, suggestingthat increased attention and resources be directed toward prevention of such injuries.
Department-Based Intentional Iniury A2 An Emergency llrf SurveillanceSystem EEernstein. C Barber, P Moyer. J Meunier-Sham, V Ozonoff, H Spivak, B Gonsalves/Boston CityHospital; Boston University; Boston Department 0f Health andHospitals; Massachusetts Department of Public Health; New England Medical Center, Boston Studyobjmtive:This studywasdesigned to providedata on nonfatalgunshotwounds(GSW)and srabwounds(SW) treatedin the e m e r g e n c yd e p a r t m e n t . V i o l e n t t r a u m a h a s b e e n r e p o r t e d t o h a v e a recurrence raLe of MVo and a five-year mortality raLe of 207o.'lhis study assessesthe feasibiJity of ongoing ED-based surveillance to identify risk groups and to provide data useful to prevention/interv e n L i o np r o g r a m s Design:Patients presenting to the ED with a GSW or SW were i n t e r v i e w e d b y p r o v i d e r s - V i c t i m d e m o g r a p h i c s ,i n j u r y circumstance, victim/offender relationship, place of occurrencc, m o d e o f a r r i v a l , a n d d i s p o s i t i o n w e r e r e c o r d e d . C o n f e r e n c e sa b o u t the srudy were held for physicians, nurses, and clerks. Compliance was monitored and frequent feedlack to staff was provided. Setting: An inner-city Level I trauma center with ?5,000 yearly visits. 'fhe Results: first-year sample (July l, 1990, through Junc 30, l99l) yielded 992 reports. Quarterly compliance tests showed an 8Uo/ocapttre rate. No reporting bias was detecred by age (P : .29) or sex (P - .82); bias did exist by treatment area and diagnosis (P < .001). Eighty-five percenr of the injuries were recorded as violently inflic ted, and,3Vo were self-inflic ted. Eighry-seven percenr
*65
:lilrffil
SerualAssault OverTime: AProspective Compadso
DJMagid.ABZiller,CAJenny,MBSoules, VSMarkovchick/Denver General Hospital, Denver, Colorado; TheChildren's Hospital, Denver, Colorado; University of Washington, Seattle Study objmtive:
To describe
assault (SA) over time.
38
and analyze changes in sexual
Design:Prospective study comparing all SA patients prcsenting l0 theemergency department from July through November in 1974 andin 1991. Setting:Urban ED that provides care for all SA victims in a wesr.erncity and county. Typeof participants: All female SA victims 14 years old or older whopresentedto the ED for evaluation. Prospective data were collectedon 102 victims in 1974 and 155 victims in 1991. Intervention: Victim, assailant, assault, and treatment characterirticswerecompared for the two iime periods. Continuous data wereanalyzedwith Student'8 , tests; categorical data were analyzed with1z teets. Reeulte:A 60.17o increaee in the incidence of ED SA prescnt-ation w a sn o t e di n f 9 9 I ( 3 3 . f o f 1 0 0 , 0 0 0 p e r s o n s ) c o m p a r e d w i t h 1 9 7 4 (20.6of 100,000). The proportion of assailants known to'their victimswashigher in l99I $A.zVo) than in 1974 (35.6qo) (P < .001). Theproportion of SA involving vaginal intcrcourse was lower in l 9 9 I ( 8 0 . 8 % )t h a n i n 1 9 7 4 ( 9 5 . 0 q o ) ( P < . 0 I ) . T h e p r o p o r t i o n s o f SAsinvolving oral and anal intercoursc were both higher ir I 99 I ; 0 r a l a s s a u l t sw e r c 3 I . 3 7 o i n l 9 9 l a n d 1 2 . 9 o k i n l 9 ? 4 ( P < . 0 1 ) , andanal assaults \|ere 17 .9Eo in 199 I and 4.0Vo in 1974' (f' < . 001 ). Ratesof genital trauma were comparable (1991, 17.37o; 1974, l?.07o),but rates of general body trauma were higher in l99l ( 1 9 9 1 , 6 3 . 2 V o ; 1 9 7 4 , 4 9 . 5 7 oP; - . 0 3 ) . l n I 9 9 I , 8 7 . 4 7 o o f p a L \ e n t s weregiven empiric antibiotics for sexually transmittcd diseases, whereas only 29.0Vo of patients rcceived antibiotics in 1974 ( P < . 0 0 I ) . P r e g n a n c y p r o p h y l a x i s i n v a g i n a l l y a s s a u l t c dp a t i c n t s ueingno birth control was given to 87 .27o of SA victims in l99l and 3 8 . 9 V o i n l 9 7 4 ( P< . 0 0 1 ) . T h e r e w e r e n o s i g n i f i c a r r td i f f e r e n c c s i n victimethnicity, use ofbirth control, or rate of Neisseria gonorrlroeceinfection, time from assault to examination, or assailant numberor ethnicity. Conclusion:This is the only atudy to comparc characteristics of SAin two time periods separated by more than five years. Durirrg t h e p a st w o d m a d e s , t h e p r o f r l e o f S A h a s c h a n g e d c o n s i d e r a b l y , warrantinga reassessmentof the evaluation and managemcnt of the SAvictim. |r'T
wise, logistic regression
model, only age (P <.0001)
(P < .002) were associated independently improve
their clinical
into ascending
utiJity,
ordinal
these two variables
catqlories.
at age50 years or older and VBC A simple multicategorical then was developed Conclusion:
and WBC count
with illness eeverity. To
Optimal
were partitioned
cutoffpoints ofillness
index for prediction
for these threshold
severity
values-
adults less than 50 years old with
Febrile
counts less than 15r000/mm3
occurred
count of 15r000/mm3 or more.
WBC
have a 1Vo incid.ence of serious illness.
In contrast,
those who are 50 years old or older with WBC counts of
15,000/mm3
or more hava a 367o incidencc
Patients
in this latter
it is concluded
category
of serious illness.
should be evaluated
carefully
before
rhat they are not seriouely ill.
of StrepPharyngitis: Diagnosis olThroatCulturefor Re-evaluadon f,] U f ls the RapidGroupA AntigenTestthe New GoldStandard? Medicine and of Emergency MJ Burns, M Pezzlo, D lverson/Division lrvine of California. University Department of Pathology, Study objectivc:
'fhroat
culture has a scnsitivity of 95/o or less
for detecting group A I3-hemolytic strcptococci (GAS). We evaluated the accura<:y of a rapid antigen test for deteclion for CAS in throat swabs and investigated the hyporhesis thar the antigen test may dctect paticnt.s with GAS pharyngitis who are not deteted by culturo. Design: Prospectiv<: casc scries of scvcn months' duration' Set.ting: Urriversity hospital cmergency departmcnt. 'I'ypc of parricipants: Convcniertcc sample of lli2 adults (age' l5 ycars or older) prcsenting ro rhc LID with complaint ofsore throat.. Fifty adults sccn for minor trauma scrved as controls. 'fwo throat swabs (Culturcttc II) were obtained Interventions: from each subjcct and control- Onc swab was streaked onro a5o/o shecp blood trypticase soy agar plate and incubated overnight at 35 C in 57a CO2. GAS was identified by f3-hemolysis and PYR reactions. An enzynte immunoassay for group A antigen (ICON Strep-A, Ilybritcch,
Irrc) was performcd
on the other swab. A clinical data and the Centor deci-
form was completed by thc trcating physician' sion rule for predicting
GAS pharyngitis
in adults was used to calcu-
Iatc a clirrical scorc (ranging from 0 to + 4) for each subject' Itcsult.s: GAS werc found on culturc in 42 subjects (23%).
00 tOentitication ol Seriouslllnessin FebrileAdults College of Medicine/Bronx fl Gallagher, F Brooks, PGennis/Albert Einstein l\,4unicipal Hospital, NewYork Studyobjective:To identify clinically usefulpredictors of serious illness in febrile adults. Design: Prospective,observationalcohort study-
with culture, the anligen test had a sensitivity and speciwil.h positive and negativeficity of93o/o and.95o/o, respcctivcly, prcdictive values of 857o and 987o, rcspectivr:ly- All t:ontrols were negativc orr both tcsts. Five of scven false-positive antigen tests
Setting:Municipal hospital emergency department. Participants: Six hundred thirty-nine patients l8 years old or olderwith rectal temperature of 37.7 C or greater met entry criteria. Serious i-Ilnesswas defined before the initiation of data collection as any one of the following: admission to intensive care unit, nredfor emergency surgery, intubatiorr, shock, bactcremia , or
pharyngitis.
Compared
(7 I 4o\ w ere foun d i n thc 457o of total s ubjects ha ving clinical scores (+3 or +4) indicative of the greatest likelihood of having GAS 'l'hesc
fildings support thc inference thar the antigen test may be at least as sensitivc as culture in detecting GAS pharyngitis and may detmt infections that are not detected by culture' Conclusion:
in theED: Pharyngitis Streptococcal A R-Hemolytic l!O Non-Group f or RapidstrepScreening Od tmptications 0f andDepartment Medlcine of Emergency M Pezzlo/Division MJ Burns, lrvine of California. University Pathology. (NGAS) streptococci Studyobjecrive,Non-groupA f3-hemolytic
death.Thirty-one patiente (4.97o) were lost to follow-up. lntervention: Thirry-five clinical and laboratory variables wcre obtainedby trained research assistants through direct intcracLion wilh patients, using a standardized data collection instrument with
arc known to cause rare food-borne outbreaks ofpharyngitis' 'l'here whether these organisms, which are not is a controversy detectcd by rapid group A antigen tests' are a cause ofendemic
a closed-questionformat. Results:Six variables were associated with serious illness in theunivariate analysis: age (P < .0000I), leukocyte (VBC) count ( P < . 0 0 8 ) , p u l s e ( P < . 0 0 9 ) ' e r y t h r o c y t e s e d i m e n t a t i o nr a t e ( P < . 0 2 ) , c a r d i o p u l m o n a r y d i s e a s e( P < . 0 2 ) , a n d c o m p o s i t e c o m o r bidity (P < .02). In the multivariable analysis, with a forward, step-
pharyngitis. pharyngitis
We investigared
whether
NGAS
are associated with
in adults with sore throat.
Design:Prospectivecaseseriesofsevenmonths'duration.>
39
Setting: University hospital emergency department. Type of pArticipante: Convenience aample of I82 adults (age, 15 years or older) preaenting to the ED with complaint of sore throat. Fifty adults seen for minor trauma served ag controle. Interventions: Two throat swabs (Culturetre II) were obtained from each subject and control. One swab was sl.reaked onlo a SVo sheep blood trypticaee soy agar plate and incubated overnight at 35 C in |Vo COr. Streptococci were identified by B-hemolysis PYR reactions and Meritec latex agglutination. An enzyme immunoassay for group A antigen (ICON Strep-A, Hybritah, Inc) was performed on the other swab. A clinical data form was completed by the treating physiciansn who wae blinded to the result of the antigen test. Reeults: NGAS were detected in 19 subjects (lDVo) (eix group B, five group C, one group F, eeven group G) but none of the controls (P - .018 by Z test). Group A Btreptococci (GAS) were found in 42 (23%) subjects but none of the controle. ICON Strep-A was negarive in all subjects with NGAS and all conrrols. When subjects with NGAS and GAS were compared for 14 clinical symptoms and sigrs, no clinically significant differences were detected. Conclueion: This investigation supports prior studies reporting that NGAS are associated with endenric pharyngitis in adults and that pharyngitis asgociated wirh NGAS cannot be distinguished clinically from that caused by GAS. Because rapid antigen tests do not detect NGAS, this had implications for the ED evaluation of patients with pharyngitis. A c u t e P y e l o n e p h r i t i si n t h e E D : H o w E f fe c t i v e l s 0 u t p a t i e n t *GO ff if Management? AG Pinson,JT Philbrick,GH Lindbeck,JB Schorling/Oivisions of Emergency M e d i c i n ea n d G e n e r aIln t e r n aM l e d i c i n eU , n i v e r s i toyf V i r g i n i aH e a l t h S c i e n c eC s e n t e rC , harlottesville Study objective: Optimal therapy for acure pyelonephritis (APN) remainscontroversial. Ve sought to determine the clinical outcome of adult nonpregnant femaleslrcatcd for APN in a university hospital emergency department. Design: The study was retrospecl.ive; eligible patienrs wcre identified by examining ED logs and ED patient records for a one-year period. Outcomes were determined using chart review and telephone or mailed questionnaires. Setting: The study took place in the ED ofa university teaching h o s p i t a l w i t h a n a n n u a l c e n s u so f 6 0 , 0 0 0 v i s i t s . Type ofparticipants: All nonpregnanr female patients agc l5 years or older were considered eligible for the study. APN was defined ae the presence of infected urine (? or more WBCs/highpower field or urine culture with l0a or mdre bacteria/ml) and fever (37.8 C or higher) withour another source. Interventions: Patient treatment regimens and disposil.ions were made by the ED attending physician and housestaff caring for the patient. Results: Eighty-three patienrs discharged from the ED and 26 hospitalized patients eatisfied study entrance criteria. Admitted patient8 were older (P - .002), more likely to be diabetic (P - .0001), and had higher temperatures (P - .005). Sixty-seven of rhe patienrs (81%) discharged from the ED were treated with a single parenteral dose of 80 to 120 mg gentamicin (59) or I to 2 g ceftriaxone (eight) before discharge on oral antibiotics. Follow-up was obtained in ?5 of the 83 outpatients (90Vo); seven (9Vo) were larer admitted for persistent symptoms of APN (six within one day of the initial visit). Only two other patietrte returned for persistent symptoms of APN. Both were treated again with parenteral therapy; neither was
40
admitted. The APN in the nine returningpatiente responded promptly to further therapy. Conclueion: Selected outpatients with APN can be treated gucceesfully with one dose of a parenteral antibiotic and discharged on oral therapy. However, becauee a significant minority fail to respond, we recommend a follow-up visit or telephone call for all patients within 24 hours.
*70 PrinnryVaricella Inlection in Adults JMBaren, PLHenneman, BSHockberger/Department of Emergency Torrance, California Harbor-UCIA Medical Center, Study objective: To evaluate clinical factors that affect ad decieions for adults with primary varicella (PV). Deaign: Retrospective chart review ofadult emergency department patientE. Setting: Urban county hospital. Type of participants: One hundred thirty-five consecutive patients (74 women and 6l men) with PV during 3l months and ll admissions for PV (no women and ll men) from the preceding 36 months. Statistical Results:
analysis:
Values are expressed
One hundred
thirty-five
patients
as mean t SD. (age,24
t 6 years)
seen for PV during a 3l-month period; 12 (97o) were admitted, and two died. Of the 125 patients discharged from the ED, 22 were nant, and three had mild pneumonitis; two women returned in labor and were admittedl were admitted
with
and all did well. Twenty-three
PV (including
the two initially
patients
discharged)
dur-
ing the 67-month study period: pneumonitis, l7 patiente (747o) of whom were pregnant); active labor, four (177o); andphary one (47o). Two men with pneumonitis (age, 26 years) died from res. piratory arrest; one had chronic renal failure, and the other had amyotrophic lateral sclerosis. Admitted patients with pneumonitis (14 men and thrre women, mean A-a gradienl, 45 + 33 mm Hg) presented with vital signs that were not different from thoee of discharged patients without pneumonitis. Conclusion: Contrary to previous recommendations, pregnant patients with uncomplicated varicella do not require admission, Patients with pneumonitis and any evidence of respiratory mise should be considered for admiseion, especially if they have significant comorbid disease.
Relationship ol ClinicalPresentation to Timeto Antiobiotics ]l f I fort'reEmergency Department Management of Suspected Bacterial Meningitis 0A Talan, J Zibulewsky/Olive View-UCl-A Department of Emergency Sylmar, California Study hypothesis: The nature and severity of the clinical preren. tation of bacterial meningitis greatly inlluence the time to initiation of antibiotics (ABT). Design: Retrospective review ofbacterial meningitis casesfrom l98l throueh 1990 for clinical and time factore. Setting: A 700-bed university hospital and a 1,000-bed c ty hoepital. Type of participants: One hundred twenty-two pariente with terial meningitis primarily evaluated in the emergency department who were from I month to 9l years old (mefian age, 18 months). Interventions: Association of clinical variables to time from ED registration to initial ABT was analyzed by ANOYA and Also analyzed
were predefined
presentations,
"claeeic"
(tempera-
tureofmorethan39Candstiffneck,bulgingfontanelle,or>
altered mentation) and o'eick" (two of the following: temperature of more than 40 C, altered mentation, low blood pressure, and tachycardia) and previously identified management variables, treatment site (ED vs ward), and management scenario (group l: ABT-lumbar puncture [LP], LP-ABT, or ABT-computed iomography ICT] scan-LP; group 2: CT scan-LP-ABT, LP-LP results-ABT, or CT scan-ABT-LP). Reeults: Study group ABT was 0.5 to 18 hours (geometric mean, 2.7 hours). Variablee associated with lese ABT were age of2 to l0 yeare (P - .02), vomiting (P - .0003), no headache (P - .001), Iow blood pressure (P = .03) altered mentation (P - .001), bulging fontanelle (P = .007), "sick" (P - .02), ED treatment eite (P < .0001), and group I managemeni ecenarioe (P < .000f). Geometric mean ABT was l.? hours Iess for ED versus ward treatment site and 1.8 hours less for group I versus group 2 management scenarios. Adjusting for treatment site and management scenario, thc following variables were associated independently with less AIIT (hours l e s s ,P v a l u e ) : v o m i t i n g ( 0 . 5 , . 0 6 ) , n o h e a d a c h e ( 0 . 8 , . 0 1 ) , l o w b l o o d pressure (1.0, .02), bulging fontanelle (0.9, .01), and o'sick" presentation (0.5, .06). Proportionately more parients less than 2 months old or without stiff neck, bulging fontanelle, vomiting, or altered mentation had ABT initiated on the ward; more patients with headache, normal mentation, or no vomiting were managed with group 2 scenarios (P < .05 by I2). Conclusion: Clinical presentation may have some influence on the rapidity ofABT initiation and choice of managemenI for bacterial meningitis. However, management practices such as the order of interventions and the site of initial treatment arc of much grcater importance in predicting the degre of Al3'll delay.
generate useful patient preparations
ing supervision;
and postevent
Conclusion: gathering
volumesq organized
meeting local or published
on-site attend-
debriefing.
A model experience
medicine
and dieaster
medical
standardsl
is proposed
and training
for emergency
program
on mass graduate
me&cine
education.
Integration of Emergency MedicineandBasicScience ]rl f rf Instructionin the FirctYearol Medical School WPBurdick, GJNilsen/Medical College of Pennsylvania, Philadephia Integratingclinical ekillsteachinginto the first two yearsofmedical school with baeic ecience education nent of the contribution graduale
education.
Ve present
the cases and objectives
their emergency
compo-
to under-
program
in which
between the gross anatomy
to emergency
medicine
school. In the l2-week
small groups begin work
faculty
a problem-based
are coordinal.ed
course and the introducdon first year ofmedical
can be an important medicine
ofemergency
course in the
curriculum,
students in
on a new casc at the start of rhe week with
medicine
facilitator.
Several days later,
within
the
context of the anatomy course, the students address lhe same case in a resource
session with a faculty
ment, during
which
brcn
anatomic
raised in the initial
the small group and the casc is
member
in the anatomy
issues pertinent
discussion,
depart-
to the case, which
are reviewed
or explained.
had In
the following week, the learning issues are reviewed, "closed." I'he objecrives for each case are writl.en to
meet the goals of both the gross anatomy medicinc course. Interviewirrg, primary
and the emergency fluid and airway manage-
mcnt, clinical reasoning, and some physical examination t.aught. in thc coursc.
While involvement
r:ducators has occurred
in thc fourth
of emergency
skille are
medicine
ycar, and to a lesser extent in
the third year, of medical school, thcre is litrlc use of emergency
Modelfora Resident Experience in MassGathering f.7t A Proposed f 4 Medicine: TheUnited States Air Show BADeLorenzo, MFBoyle, BGarrison/1flright StateUniversity, School of Medicine, Dayton, 0hio Study objective: The care oflarge gatherings ofpeople is an increasingly important role for emergency physicians, A formal experience in mass gathering medicine is a beneficial element of emergencymedicine graduate education. Design: Fducational model based on field experience and retrospectivechart review from l98l through 1991. S e t t i n g :T h e U S A i r S h o w i s a s u m m e r e v e n l t h a l a n r a c t c a n averageof223,000 spectators annually. Medical care is provided by physicians, nurses, and technicians operating within an organized s y s L e mo f c a r e . P o s t g r a d u a t e y e a r l r 2 , a r r d 3 r e s i d e n t p h y s i c i a n s evaluate and treat patients appropriately for their level of resporrsibiJity. Residents provide immediate medical conrrol and are intcgrated into the event disaster plan. On-site attending physician supervision ie available at all timee. Didactic inetruction and evenl oriental.ion are integrated into the curriculum. Residents participate in the planning stages of the event. '., Resulte: During the atudy period, 2,091 patients were sren. The most common presenting problems were heat illness (277a)rbhsters and scrapee (24Vo), hea dachea (22Vo), frac tu res and lacera l.ions (9Vo), and eye injuries (SVa). One hundred forty-eight (TVo) required transportation to the hospital. Approximately l6 residents p a r t i c i p a t ee a c h y e a r a n d t r e a t a n a v e r a g eo f l l . 8 p a t i e n t s d u r i r r g their four-hour shift. A resident training model for a mass gathering experienceis proposed to include didactic instruction on history, principles, and current iesues; participation in planning and organizing the eventl regularly scheduled eventsl adequate crowd size to
nrcdicinc
faculty
in thcir
first half of undergraduate
tion. Our high rcliance on intcrviewing clinical
practice
makes emergency
physicians
of theee ekills. The type of coordinated
demonstrated
in this program
in the expansion
undergraduate
in
thc logical leaders in
thc education interested
medical educa-
and physical examination
teaching effort
can bc used as a model by others
of emergency
medicineos role in the
cducal-ion of medical students.
a Four-Year Medical School Cuniculum in I rl /l Developing f Emergency Medicine C MitchelUlniversity ofCalifornia, Davis
'l'he p r o c c s so f d e v e l o p i n ga s t r o n g a c a d e m i c d e p a r t m e n t o f e m e r gency nrcdicine should include thc integration of the specialty and its particular body of science and clinical skille into all levele of the 'fhis medical school curricu-lum. exhibit will include one sample of the four-year curriculum currently in use at the University of California, Davis, an outlilre of steps for inrplementation, and a listirrg of educational resources. Content: l. Gaining access a - N e e d s a s s e s s m e not f t h e s t u d e n t b o d y b. Curiculum review c. Establishing dialogue with the Dean of Curricular Affairs d. Membership on the Curriculum Committee 2. Organzing within your own department a. Director of Undereraduate Education b. Budgetary
concerns
c. Polices and procedures d. Secretarial demands e- Faculty development
4l
3. Establishing a presence within the medical school a. Student advising and mentoring b. Student reeearch program c. The ttguest lecturer" approach d. The emergency medicine seminar, forum, or lecture series e. The emergency medicine student club f. Possible required courses, electives, and preceptorships in emergency medicine 4. Sample curricllum 5. Educational resourcec Stress in Residency Training: Developing a program for 7E f rf Intervention C Mitchellluniversityof California,Davis Stress has been identfied as an occupational hazard of residency training. This exhibit will include one sample curriculum currenrly in use at the University of California, Davis; key referencesl sample instruments for measuring stressI and guidelines to successful implementation of a stress intervention program. Content: l. Didactic presentations a. Literature review of stress in residency training b. Role of exercise and nutrition in stress reduction c. Techniques for time managemenl d. Physiologic parameters of st rese 2. Skille eessione a. Coping skills analysis b. Using trigger cues to change rcsponses to stress c . P o s i t i v e a s s e r t i v e n e s st r a i n i n g d. The relaxation response 3. Support and counseling a. Peer support b. Group support c. Maximizing available suppori systems d . S p o u s es u p p o r t e. Individual counseling 4. Assessingand measuring stress a. Baseline inquiry b. Review ofinetruments available for measuring stress ( a d v a n t a g e sa n d d i s a d v a n t a g e s )
IncorporatingLecturesand SeminarsIntoa DataBase ]f f Ll in an Emergency MedicineResidency
M Hartsel[\Nilford HallUSAF Medical Center, SanAntonio, Texas Study hypothesis: residency
is complex.
The didactic
process in an emergency
A data base of formal
didactic
medicine
experiences
enhances the ability to track, plan, and document resident training. Design: In a descriptive format, an innovative method used ro mcorporate into a data base the elesrents of 24 months of didactic curriculum
is suggested. A personal
ware, and the emergency
medicine
computer,
widely
core content
available
numerical
soft_
structure
are ueed. Setting: Academic, residency
military,
Reeulte: One thouaand were reorded, procedure tic program
two-hospital
emergency
medicine
with 42 residents. including
four
hundred
grand rounds,
labs, and special lecturesby each facility
thirty-two morning
didactic reports,
The contribution
was equal.
sessions
emergency to the didac,
The data base reporrs
facili, iated analysis of the forums used to present core conteni topics. .fhe data baae facilitated eimple report generation for multiple usc, including prospeti-ve and retrospective lecture plannrng, reports
Aa +L
for quality assurance and the residency review committee, and specially requested reports for individual staff and residente. Conclueion: Implementation of the didactic data baee reduced the neceesity to use multiple logs and ineffrcient tracking methods in a large emergency medicine residency. Although neither the clinical experience nor reading topics were incorporated, development of a comprehensive data base ie a desirable goal for future desigrr. -Let's llot Moet by Accident"-A Trauma Prevention 77 f I Prcgramlorfoens P Jessen,V Lane.4 Lane-Beticker. P Peta/SaintFrancisHospitaland Medical Center,Hartford,Connecticut "Iet's Not Met by Accident" is a trauma prevention program for teens. The students are brought to our Icvel I trauma center for a two-hour program that presents statistics about trauma, seat belts, and the relationship of alcohol to trauma. A man who eurviyed a drunk-driving crash but was responsible for the death of the other driver talks with the students. We show a 2O-minute lilm, "staying Alive," that shows the devastating effects of drunk driving on four teens and their families. Unlike many trauma prevention programe, "Let's Not Meet by Accident" capitalizes on the impact of the trauma center. In the family room and in the reeuscitation room, students begin to see the human cosl. of what may be momentary indiecrelions. The program starts with a preteet that measuree etudents' attitudes toward eeat-belt use and alcohol use and elicite problemg they may have encountered related to drunk driving. We conclude with a written evaluadon of the program. To date, 1,000 students have participated in the program. We are beginning research to attempt to measure changed attitudes and developing a companion trauma prevention program for urban teenagers that focuses on violence prevention. A N e w E d u c a t i o n a lP r o g r a mf o r D e a t hT e l l i n g : D i d a c t i c ,V i d e o , 7Q f ff and StandardizedFamily Scenarios BJ Schwartz/Hartford Hospital,Hartford,Connecticut Emergency physicians are in a unique situation to ease the pain of family members who must be notified of a sudden unexpected death of a loved one. Emergency physicians have an impact on the family's healing and bereavement through the way in which they are notified about death. An innovative educational program using mulriple media sources has been developed and is being tested to teach the emergency physician bereavement theory, the process of death telling, and the "skill" of death telling. There are three phases to the educational methodology of dearh relling. The firer is a didactic session that focuses on the griefprocess and bereavement, the needs offamily members (based on previous research at this institution), and the "ABCs" of death telling. The second phase uses a videotape to reinforce and demonstrate the process of death telling. The third phase allows the physician to actually practice the death telling skill using a standardized family member scenario consisting of actors who have predetermined responses to physician behavior and communication. The standardized family scenario ie either obeerved directly or videotaped so thar the physician doing the death telling can have immediate feedback and education to further modify hie or her style and behavior. An evaluation tool hae been developed and preteated that makes it possible to measure the effectivenessof the different educational methods and the learning accomplished by physicians.
computer and a Sony Hi8 camera. The video will be available to course graduates so that they periodically may review ihe material and increase their retention. The second component ie an interactive crush injury lab. The lab consists of an inetructor demonstration ofprocedures on human cadaver arms and lege followed by student performance of these procedurea under direcl supervision. Tahniques emphaeized are uee of the Stryker monitor, eingle skin incision fasciotomy, and guillotine amputation. Although the proceduree are relatively eimple, an emergency physician unfamiliar with these techniques may be uncomfortable performing them in the field. Preliminary results of a survey sent lo recent course graduates reveal they would be more likely to perform a fasciotomy or amputation after taking the course and the crueh lab. Through use of this hande-on crush injury lab, we are empowering emergency physicians to act under austere conditions to perform life- and limb-
of an InteractiveVideodiscSystemlor ]Q TheEffectiveness f if Instructionof Paramedicand Fourth-Year Medical Strdents in Cognitiveand Psychomotor Skills Requiredfor Advanced AinvayManagement WA Stoy, JL McCabe, TEPlatt,GSMargolis, MB Heller/University of Pittsburgh, Schoolof Medicine, Centerfor Emergency Medicine of Western Pennsylvania, Pittsburgh Study objective: Compare interactive videodisc (IVD) with traditional lecture-demonstration-practical (LDP) instruction in developingcognitiveachievementand psychomotorskills for advanced airway management. Design: Randomized, prospetive design with croee-over testing. Setting and type of participants: Ninety-one paramedic and medical etudente. Intervention: Students were randomized to M (34 paramedics, 14 medical students) or LDP inetruction (32 paramedics, I I medical students). The LDP group trained using a standard manikin. The IVD group ueed a sensorized and computerized manikin. Cognitive achievement was measured using written pretests, posl-tests, and retention tests. Psychomotor skiUs were measured using poet-tests and retention teets. Each group completed psychomotor teste on both LDP- and IVD-t1pe manikins in randomized cross-over fashion. Fisher'e exact test with an c error rate of.05 was used to analyze all tests reeults. Results: For cogrritive achievement, post-test scores for all students were higher (P : .03) for LDP than IVI) irrstruction, whereas retention acores were similar (P = .34). Within paramedir:-only e t u d e n t s ,L D P a n d I V D s c o r e sw e r e s i m i l a r f o r p o s t - t e s t s( I ' = . l l ) rnd retention tests (P = .45). Within medical-only students, pretcst ( P = . 0 2 ) , p o s t - t e s t ( P - . 0 2 ) , a n d r e t e n t i o n t e s t ( P < . 0 1 ) s c o r e sw e r e higher for LDP than for IVD. For psychomotor skills, more students passed post-teets (P < .05) and retention tests (P < .05) after IYD than after LDP instruction. This occurred regardless of whether IVD or LDP manikins were ueed. A similar pattern of results occurred within paramedic-only students. In conirast, posl.teet and retention test resulte were not different for LDP and IVD instruction within medical-only students. C o n c l u s i o n :F o r t e a c h i n g a d v a n c e d a i r w a y m a n a g e m e n t ,I V D instruction may improve psychomotor skills more than the traditional LDP method. In contrast, cognitive achievenrent may bc greater for LDP than for IVD inetruction. For some testsolhc effect ofinstruction technique on medical students and paramedic students may differ.
saving procedures on victims of a major earthquake. O { A n E v a l u a t i o no f R e s e a r c hT r a i n i n g F r o ma L a r g e O I R e s i d e n c yP r o g r a m of EmergencyMedicine,Cook RJ Tydman,BJ Zalenski,JK Fagan/Department i n E m e r g e n cM , n i v e r s i toy f y e d i c i n eU C o u n t yH o s p i t a lC, h i c a g oP; r o g r a m lllinoiC s o l l e g oe f M e d i c i n a e n dS c h o ool f P u b l i cH e a l t hC, h i c a g o Study objective: Multidimensional evaluation of a resident research training program with the objective of testing and diffueing multiple implementation BtrategieB. D e s i g n : C r o s s - s @ t i o n a l ,d e s c r i p t . i v ca n a l y s i s w i t h m u l t i g r o u p comparative postintervention impact evaluation. Sctting: University-affiliatcd emcrgcncy medicine residency prog r a m w i t h i n a I a r g e - v o l u m e ,i n n c r - c i t y h o s p i t a l . 'fype of participants: Eighteen first-year emergency medicine residents for cross-sectional analysis and 43 emergency medicine residents for multigroup postintervention impact evaluation. Interventions: Thirty-two-hour researchcurriculum baeed on pullished Society for Academic Emergency Medicine guidelinee for emergency physician fellowships delivered in four-hour Saturday morning classes. Results: Ilesident atlendance, pretest and post-test self-perceived k n o w l e d g e a s s e s s m e n t sp, o s t - t c a t o b j e c t i v e c o n t e n t r e t e n t i o n ' r e s i d e n t s a t i s f a c t i o n ,a n d p o s t c u r r i c u l u m r e s c a r c h p r o d u c t i v i t y w e r e a s s e s s c d I. l e s i d e n t a t t e n d a n c e a v e r a g e d 8 2 7 o ( S D , 1 3 . 3 7 o ) . C h a n g e scores on self-perceivcd knowledge revealed gains (P < .05) in etudy design, computerized literature searches, selrcting journals for publication, research planning and funding, and personal microcomputer fiteracy. Objective test scores average 72Vo (SD, llTo). Objective knowledge gains (from most to least) were critical literat u r e a n a l y s i s ,e p i d e m i o l o g y , e t h i c s a n d i n f o r m e d c o n s e n t , e t u d y design, computerized literature searches, and bioatatistics. Test itcms on the comprehensive exam had an .82 internal consistency. Resident satisfaction was highest for critical literature analysis, followed by journal se]ection for publications, ethics and informed c o n s e n l , s t u d y d e s i g n a n d b i o s t a t i s t i c s ,a n d c o m p u t e r i z e d l i t e r a t u r e s e a r c h e s .S e v e n t y - t w op e r c e n t ( t 3 o f 1 8 ) o f f i r s t - y e a r r e s i d e n t s complcted an original research proposal within four months following the training program versus residents who were not exposed in p r e v i o u sy e a r s ( 1 2 - 9 . 8 2 , d f - I , P < . 0 5 ) .
IniuryCadaver Lab:A NewMethodofTraining Qfl TheCrush lflf Physicians to Perform Fasciotomies andAmputations on Survivors ol a Gatastrophic Eartrquake KLKoenig, CHSchultz, RDiLorenzo/University 0fCalifornia, lrvine Medical Center,0range After a catastrophic earthquake, thousands ofpotential survivors will have treatable crush injuries. Austere conditions and lack of specialized training may render the emergency physician ineffective in treating these injuries in the field. To make it more likely that emergency physiciane will act to treat these victims and give appropriate care, we developed a hands-on crush injury lab as a new adjunct to our medical disaster response (MDR) training coursc. The educational methodology used is twofold. First, course participants view a video that demonstrates fasciotomies and amputations on both live patients and cadavers. The video diecusseeindications for fasciotomies and amputations and demonstrates analomy. A revised version of this video ie under development using a Macintosh
Conclueion: Residents werc satisfied with this level of training and made both subjective and objective gains in their skills and knowledge of research activities. llesearch productivity surpaseed that found in previous cohorts.
43
ol Traunra Management BelearnedWith Qf CantheBasicPrecepts lf 4 Gomputer-Assisted Instructi on? RKCydulka.CLEmerman/Department of EmergencyMedicine,[/etroHealth M e d i c aC l e n t e rC , a s eW e s t e r nR e s e r v eU n i v e r s i tSy c h o o ol f M e d i c i n e , C l e v e l a n d0.h i o Study hypothesis: Medical students can learn the basic preeptg of trauma management ueing computer-aesisted inetruction (CAI). Design: Prospective, randomized, controlled study. Type ofparticipante: Fourteen third- and fourth_year medical student volunteere. Interventions: Students were eligi_blefor participation after completing the required core junior surgery and emergency medicine rotation. Students who had already completed a four_wek trauma elective were excluded from participation. Upon entry into the study, all participants completed a S2-question written examination (preteet) covering the basic precepte of trauma. Seven students were randomized into the CAI group, and seven were randomized. into the control group. The CAI group used a computerized trauma sim_ ulation program until they had mastered the baeic concepts of the program. At least two weeks after enrollment, students were again given a S2-question trauma exam (post-test). R e s u l t s : T h e t t e s t a n a l y s i s r e v e a l e d t h a l s c o r e so n t h e p r e t e s t were eimilar for both the conrrol group (66 + l0% SD) ani rhe CAI qyup (67 !l27o SD). Posr-tesr scores in the CAI group were 4 !So/o SD higher than pretest, whereas post-test ."o... i. the control group were 2+AVo SD lower than pretest (p< .02). Conclusion:Medical studentscan learn the basic precepts of trauma using CAI, ae demonstrated by their improved performancc on a written trauma examination. CAI may significantly augmenl. emergency medicine trauma education ftir third- and fourth_year medical students.
8-3 A NeedsAssessment program Survey fora DeathNotilication lA Swisher,ll Nieman, GJNilsen, WHSpivey/Medical Colleoe of Pennsylvania, Philadelphia Study objective: Training in dcath notification is not a parl of th<: core curricu.lum in formal residency cducation. The objective of this study was to identily thoee areas of death norificarion that emergency physicians are not adequately trained for and to develop a training program to improve these skills. Design: Prospective survey of residents and faculty. Intervention: Forty-five residents and 2l attendings of an emergency medicine residency program were surveyed ae part of a neds assessmentfor a death notification educational program. The survey ueed a five-step Likert-type scale (l is low and 5 is high) to rank subjects according to perceived importance and the amount of stress each produced. The survey included questions on prehospital a n d - h o s p i t a lc a r e , o r g a n d o n a t i o r r , a u l o p s y , c a u s e o f d e a i h , . . r p o r , _ sibiJity of the family, social supporr, o.J ui.*irg the body. Physiciane also raied the frequerrcy with which ihey discussed rhe ubjects-with the family and the perceived d.g".. oii-porrance of these subjecrs ro the family. R e e u l t e :H o s p i t a l c a r e ( m e a n r e e p o n s eo n a l _ t o - 5 s c a l e r4 . S Z ) , cause of death (4.46), preparation for surveying the body (4.3?j, and prehospital care (4.I?) were most f".qr"rrtly discussed with the family. However, no aepect of dearh notification was done l00%o of the time by all physicians. Inquiry into social eervices (2.g6) and suggestion of a liaison (2.82) were performed less rhan S\Vo of the time despite the fact that these were perceived to be the fourth and f i f t h m o s t i m p o r t a n t s u b j e c r s f o r t h e f a m i l y . O r g a n d o n a t i on ( 2 . 7 7 )
44
and autopsy request (2.82) are required by law but were perceived to be unimportant to the family. A family response of anger (3.98) or hyeteria (3.79) to death notification produced the greateEt dq,ree of streseby physicians. Requests for organ donation, autopsy, and an unknown cause of death aleo produced high degreee of etrees. There were no differencee betwen the level of etress of anv level of residents and attendings Conclusion: This etudy indicatee rhat the information provided to families varies widely among physicians. Furthermore, the death notification process produces high degres of streee that may prevent adequate transfer ofinformation to families for decigion making. An educational program needs to be developed to train physiciane how to deal with the complex issuee that eurround death and notification of the family. This program should highlight mechaniems of dealing with familial grief responsee, approach to organ donation and autopey, and appropriate social eervicee resources.
MedicineResidencyProgramon Rotators' Q1l| lmpactol Emergency lf 'l Emergency MedicineEducation
BASchwab, TPKuhlmann, YHFaulDivision of Emergency Medicine, University ofVirginia School ofMedicine andCurry School ofEducation, Charlottesvill Virginia Study objective: To assegsthe perceived impact ofemergency medicine residency programs on other program directors'perception of emergency medicine as a dislinct service and educational entity. Design: Self-administered questionnaire. Type ofparticipants: Residency directors in medicine, surgery, pedia trics, and obstetrics/gynecology at sites containing emergency medicine residency progra ms. Results: Two hundred twenty-four of 372 questionnalee (60,IVo.\ were returned completed, with equal dietributions among all epecialties. Ninety-nine percenl. of respondents scheduled emergency medicine rotations and thought that guch rotatione were important for their residente'education. Respondents stated that the presence of the emergency medicine residency program has positively influenced their attitude toward emergency medicine as a apuialty (6l%o agre,26Vo neutral), improved their residents' training in emergerrcy medicine (477o agrer SlVo neutral), and improved emergency care at their instil.ution (65Vo agreer26To neutral). Fifty-seven percenr think emergency physicians should teach emergency medtcine(27Vo neutral), There were statistically sigzrificant associations between age of the emergency medicine program and perceived improvement in rotating residents'education and emergency care. Negative comments suggestthat directors feel their residents are ignored by emergency medicine faculty. Conclusion: Residency directors in other specialties have a generally positive view ofemergency medicine as a specialty and as an important component of their residents' education. The presence of an emergency medicine training program appears to have positively inlluenced their attitudes, improved their residentso education, and improved emergency care. Planners of emergency medicine training prog'ams should consider developing rotator-specific educational programE to ensure that rol.ator needs are met.
MedicineDraw ResidentsDisproportionately Qf, DoesEmergency lJrf Away From0ther Specialties? AB Wolfson/Uniuersity 0f Pittsburgh; Center for Emergency Medicine of WesternPennsylvania, Pittsburgh Study objective:To estimatethe degreeto which fourth-year medicalstudentsapplyingto an emergencymedicineresidencyare )
drawn inpo the field dieproportionately at the expense of certain other medical specialties. Design: Prospective nonrandomized cohort study. Subjects and setting: Convenience sample ofresidency candidates interviewed at an urban university-based emergency medicine program over a three-year period (1988-I991). Interventions and methode: All fourth-year medical student candidates were asked the following question by one interviewer: *Vhich field of medicine would you have gone into if the specialty of emergency medicine did not exiet?" The reepondente' first answer waa recorded, and reeults were tallied by recruiting year ; and applicant gender, For each year, the proportion of applicants I'answering affirmatively for each specialty was compared with pubrlished figures on the proportion ofstudente entering that specialty nationally. Proportions were also analyzed by candidate gender and tracked by year. Data on choice of speialty by all PGY-I housestaff nationally were derived from published sources. DaLa were analyzed by 1z and Fisher'e exact test. Results: Of a total of 225 candidares interviewed, 182 (of whom 76Vo were mate,247o female) responded to the quest.ion. Internal medicine was the specialty most commonly indicated, accounting for 4l7o of men and.32Voof women. Surgery (257o of males, l67a of females) and familypractice(177o of males, Il7o of females) were next in frequency. Together, theee three specialties accounted for 83Vo of male respondents and"59Vooffemale respondents. Proportions of respondents indicating each specialty varied insignificantly over the three years studied: internal medicine, lgVo; surgeons,23Vo;family practice L6Va.When compared with the proportion of non-emergency medicine interns entering these specialties during the same period, reepondents were more likely to have chosen surgery (P < .02) and family pracrice (P < .05), bur nor internal medicine (.8 power to detecr.a difference of llo/o).'lhe male:female ratio of respondents was essentially the same as the ratio for all emergency medicine reeidente. Female rcspondcnts were more likely to have chosen surgery than non-emergency medicine female residents nationally (P = .02); no significant differenceswere seen for internal medicine and family practice despite a .8 power to detect at least a 20Vo Mference. No differences were seen among men for these three specialities despite a ,8 power to detect at leaet a L27o difference. Conclusion: These results Buggestthat emergency medicine traineee may be drawn disproportionately from students who would otherwise choose to pursue surgery or family practice, but not internal medicine. Because there are clear limitations to the internal and external validitiee of this study, however, more definitive conclusions must await investigaiion of a more demonstrably representative sample of the population in queslion.
Type of participant8: Ethty-eight emergency medicine residents who gtaduated between 1980 and 1989. Interventions: Comparieon of NBMEI ecores and other selective criteria with subsequent performance in the emergency medicine training program. Performances of each resident were independently scored on a l-to-S ecale by four faculty membere who had eupervised all residente during the study period. The reviewere evaluated clinical judgment, interpersonal skills, rechnical skille, and fund of knowledge. Interrater agreement wae measured using weighted kappa (KW) etatietice. Correlation between mean performance score and NBMEI score wa8 meaeured using Peareon'e r. The sample size was eufficient to exclude a correlation coefficient as low as .2. A Vilcoxon two-sample test was ueed to compare performance of residents with negative or equivocal dean'e letters (25) versue those without negative comments in deannsletters (66). Results: NBMEI scores were obtained in 78 caees (mean, 530; S D , 8 0 . 8 ; r a n g e , 3 8 5 t o 7 4 5 ) . N B M E I s c o r e sd i d n o t c o r r e l a t e w i t h performance during residency (r = .03, P ' .80). Negative commenta in the dean's letlcr were associatedwith poor performance (P - .05). 'Ihere was no association between performance and any of the foll o w i n g : a g e ,N B M E p a r t 2 , o r i n t e r v i e w s c o r e s . Conclusion: Dean's letters are moderately predictive ofperformance during residency. flowever, NBMEI scoree do not predict performance and should not be used in ranking applicants for reeidency training in emergency medicine.
*
Q 1 l E v a l u a t i o no l C r i t e r i a U s e d t o S e l e c t A p p l i c a n t s l o r E m e r g e n c y fllf Medicine Residencies BE Wolfe,JM McGoldrick.JA Marx, S Lowenstein,V Markovchick/Denver
General Hospital, University ofColorado Health Sciences Center Study background: Surveye have ehown that National Board of Medical Examiner Part I (NBMEI) scores are commonly uaed in selecting applicants for residency training. Hypothesis: NBMEI scores do not predict performance during residency training. Design: Retrospective review. Setting: A single accredited emergency medicine residency established in 1977.
45
onMedical Students Choosins a Career in Emersency 87 fll,tjil:. DRWillians, GBStrange/University oflllinoisHospitals andClinics, Chicago Study objective; There is a need to increaee the number ofmedical students selecling a career in emergency medicine. Our null study hypothesis was that a medical student rotation in emergency medicine, number and specialty of the faculty in the emergency d e p a r t m e n t o f t h e a c a d e m i c m e d i c a l c c n t e r , a n d p r e s e n c eo f a n emergency medicine residency do not influence the likelihood of a medical student matching in emergency medicine. D e s i g n :A n S A E M s u r v e y o f a c a d e m i c m e d i c a l c e n t e r s w a s c o n ducted to determine availability of a rotation in emergency medicine and faculty staffing of the ED. Matched reeults were obtained from NIIMP, and residency information was obtained from ACGME. 'I'ype of participants: Survey response was obtained from94 of 126 academic medical centers. Results: The medical gchools from which no studente matched in emergency medicine (17) werc compared with the echoole from wlich AVo or more of the students matched in emergency medicine ( 1 7 ) i n 1 9 9 1 . C o m p a r i n g t h e s et w o g r o u p s , t h e r e w a s n o d i f f e r e n c e in the availabilily of a required (three of l7 vs three of l7) or elective rotation (16 of 17 vs l7 of l7), or in the total number offaculty ( 7 . 9 v s 8 . 2 ) o r e m e r g e n c ym e d i c i n e - b o a r d e df a c u l t y ( 3 . 3 v s 5 . 3 ) . Thcre was a significant difference between the two groupe regarding the presence of an emergency medicine residency at the medical school (only two of l7 schools with 07o of the students matching in emergency medicine vs ten of l7 echoole with AVo or more of the students matching in emergency medicine; P - .004by yz\. Conclusion: The presence of an emergency medicine residency at a medical school is correlated with a higher percentage of medical students matching in emergency medicine. It appeare that the most effective means ofincreasing recruitment of medical students to emergency medicine is by increasing the number of emergency medicine residencies based at medical schools.
InlluencingCareerDecisionsol Academicand QQ Characteristics lllf ltlonacademic EmergenclPhysicians AB Sanders, JV Fulginiti, DBWitzke, KABangs/University of Arizona College of Medicine. Tucson Study objetive: To determinecharacteristicsmotivatingphysiciane to choose a career in academic
and nonacademic
emergency
medicine. Design: A survey
of l,0l?
active members
Academic
Emergency
American
College of Emergency
Physicians
Questions fellowehip
were asked regarding
medical
training;
career decisionsl reeearch.
Medicine
the irnportance and perceived
Responses from
of the Society for
and of a random
sample of 2,000
membere wae done.
school, renidency,
of specific
factors
obstacles to emergency
academic
and clinical
and
in influencing medicine
physicians
were ueing 12 analyais for diecrete variables and the Student'8 t teet for continuous variablee. Results: Initial responseE were obtained from l,l0g physicians. Compared with nonacademic physiciane, academicians were significandy more likely to complete an emergency medicine residency (SBVovs33Vo, P <.01), do fellowship training, do required research compared
during
rraining,
puters,
and be influenced
Levelsol Attending Supervision of Qfl TheElfectofVarying Jlf Housestaff onEmergency Department PatientDisposition Decisions EAPanacek, WFButherford, NJ Jourlles/Department of Emergency Medicine, University Hospitals of Cleveland; Department of Medicine, Case Western Beserve University, Cleveland, 0hio Study background:The ideal quantity and degreeof direct attendingsupervisionof housestaffin the emergencydepartment are controversial,and its effecton actualpatient care is unknown. flypothesis:Constantand dirmt attendingsupervisionofhousestaffin the ED improvesthe rate of appropriatepatient dispoeition
have research
seminars available, work with comby role models and mentors. Compared nonacademic physiciane placed significantly
with academicians, more importance
on personal income, family obligations, and indebtedness waB not a significant differcnrial
leisure time- Personal
between the two groups.
Academic physicians dJvore significantly more time to administration than do nonacademiciarrs. Academicians report. that finding time to do research, rcsearch funding, and preesures to do clinical work arc thc major obstacles to research productivity. data on factors Conclusion:
influencing Expoeure
reeearch experience do research
These factors resident
are compared
need 12 hours per year (P < .01). Fifty percent ofreeidents and 747o of directors feel that biomedical company marketing techniques affect emergency physician prescribing practices. Seventy-five percent of reeidents feel that company representatives occasionally cross ethical boundaries by gifting to physicians. Sixty percent of residents responded that they accept gifts from biomedical companies because it is a good way to learn about new productel 667o aay they would accept expense-paid tripe to conferencee. A knowledge ofbirethical concepts correlated with hours ofbioethice training, a sensitivity to ethical concerns regarding gifting, and following currently recommended standards. Conclusion: There is a wide variation in resident and faculty attitudes regarding professional interactione with biomedical companies. Many practices violate acceptcd standards set by the AMA and ACGME. Residents need training regarding conllicte ofintereet and acceptable etandardr of practice in dealing with biomedical companies,
with similar
career choices.
to academice
through role modele and in career choice. protected time to funding are perceived as major obstacles
ie important
and research to productivity. Factors influencing career decisions can be used [o plan strategies to meet the future neede of academic ernergency medicine.
TheRelationship ol Emergency MedicineResidents andFaculty QQ lf rf to BiomedicalIndustryRepresentatives SMKein,ABSanders, DBWitzke,JV Fulginiti/Section of Emergency Medicine, University of Arizona. College of Medicine, Tucson Study objective:To determineresidentand facultv attitudesand practicesregardingprofessionalinteractionswith biomedicalcompanres. Design: A 3S-item questionnaire was adminietered to residents in conjunction with rhe l99l American Board of Emergency Medicine i n - s e r v i c ee x a m . I n f o r m a t i o n o n r h e e x t e n t o f t r a i n i . i g d u r i n g r e s i dency and knowledge of specific bioethical concepts was elicited, followed by specific queetions regarding interactions with biomedic a l c o m p a n i e s .A n i n d e x o f e t h i c a l k n o w l e d g e a n d s e n s i r i v i t yw a s compiled using combinations of questions. A 20-item companiorr survey was sent to residency directors assessingbiomedical gift_ giving practicea and support for educational activitiee in t.rainins programs. f,2 analyeis was uged for categorical variables and A N O V A o r S t u d e n t ' s t t e s t f o r c o n t i n u o - u sv a r i a b l e s . Results: The survey was distributed to 1,g45 residents with l,3BS (75%) responding. Eighty of 8I residency direcrors (99Vo) completed their survey. Thirty-five percent of residents reeived no training in bioethical issues during residency. Of those who do receive traini-ng, residents get eight hours of instrucrion per year but feel that they
decisions. Desigt: Prospective data colleclion for quality aseurancepurposes. Retrospective study analysrs. Setting: University hospital ED. All patients are aen primarily by houseetafffrom a number ofprimary departments, but thereis no emergency medicine residency program at this site. Participanrs: All ED adult admissions for the first six months of 1987, when attendings were present on only a part-time basis (12 hours a day) and ihe first six months of 1988 (full-rime attendi.gr). Methods: AII ED admissions who experienced a major change in their status within the initial 24 hours were analyzed further. The ED disposition decision was categorized as appropriate, questionable, or inappropriate based on ED and hospital policy criteria for floor and intensive care unit admissions. Review was performed by both a quality asaurance registered nurse and an emergency physician. The total cases and the percentagee in each category were compared for the two periods (Table). Results: Disposition0ocision Appropriate 0uestionable Inappropriate Total
Part-TimAttendings 6s(537o) 33{2s%) 2s122%) (r00%) 131
Full-TimeAnendinsr 83 (88%) 6 {6%) 6 (6%)' 9 5( 1 m % )
Conclusion: The full-time presence of attendings had a eignificant and substantial positive impact on the appropriateness of ED patient disposition decisions.
46
*91
Conclusion: A sizeable increase in faculty salaries has occurred since the last survey. Variablee such as hospital funding aource, emergency medicine residency training, ABEM certification, postresidency years, and demographic region were associated with salary differences. A more etandardized method of evaluating fringe benefits and work responeibilities must be establiehed in future survevs.
,o.,."r" Follow-up in Emergency Medicine Residencies pennsylvania WHAdans. BEKeller/Geisinger Medical Center, Danville, Postcare follow-up is recognized as an important part of emergency medicine residency training. Using a l2-question survey of all chief reeidente in ACGME-approved emergency medicine programs, the current mechanisms for follow-up were studied. The survey contained four questions regarding follow-up of admitted patients, three questions regardingpatiente who either were referred to consultants aE an outpatient or returned to the emergency department for further care, and five queetions designed to determine the importance of patient follow-up and methoda for its improvement. Ninety percent of all ACGME emergency medicine residency programs reeponded. Only 337o of thoae responding felt they currently received adequate feedback from admitting services. Twenty-one percent of the programe had a mechanism in place for emergency department physicians to automatically receive disch arge summaries. Eighty-six percent of the programs received reports from outpatient consultants lees than l\Va of the time. In a majority of the programs, residents were rarely informed of unscheduled returns of patients they had eeen for the same problem. More than 937o of the chief reeidente surveyed felt that feedback was important and that more feedback would improve both job satisfaction and resident education. We conclude that patient follow-up is an important part of the emergency medicine residency training pro_ cess. Specfic suggestionsfor improving this are presented.
92,rftTtr^l"y
+(|2 I ifrf
Medicine Facutty Sataries:A Study ofData submitted
BMhonpson, SKristal/Society forAcademic Emergency Medicine, Henry Ford Hospital, Detroit, Michigan Study objective: The last survey of emergency nredicine faculty salary was done by the Society of Teachers of Emergency Medicinc in 1983. Society for Academic Emergency Medicine commissioned a study of emergency medicine faculty salaries, benefits, and working conditions for the 1990 through I99l academic year. Survey forms were sent to all accredited programs as ofJuIy 1990. Responses were collected by SAEM and blinded from rhe investigators. Population: Sixry-three of 83 accredite d. progru^"\7g%o1 r e s p o n d e d .T h e d a t a o f t w o p r o g r a m s , a s s u b m i t t e d , w e r e u n u s a b l e . A total of 579 full-time facuhy positions were reported from a majority ofprograms in all Council of Residency Directors and American AesociaLion of Medical Colleges regions. Methods: Blinded program and individualized faculty data were entered in Fu,nM,rynn PRo, a flat-file data base program. Resulte: Total cash payment equals base salary plue incentive or bonus plus expected nonguaranteed payments (does not include fringe benefits) (T"blt)' tot"t cu.h p"yr",,r r$) Msan Standard Chalaclorislics ltledian Salary Doviation High Low Financial Sourcs Hospital Comunity(N=l4l) 142.000 146,403 f34.704 260,000 83,000 (N= 230) lJnvesity 109.500 r 14,825 r30.121 740,000 63,000 (N=2m) Municipal 106.570 rr3,90r 134,154 225,000 63.000 AAMCRegions Northeast j 33,r25 118.083 lN= 171) 260,000 65,000 SouthiN=ll0) 125,098 134,058 t99.000 63,000 Midwest 139,650 {N= 152} 160.521 740,000 76,000 West{N= 120) I 14.634 1i26,?94 232.W0 70.000 Emergorcy Madicino Beridsncy Trained Yes{N=407) 124,406 133,525 260,000 63.000 = No{N 165) 131,076 159.307 740.000 65.000
47
Information l{ecdsandResources in a Teoching Hospital Emergency 0epartment
AL Cartwright.WH Cordell,JP Hage/lndianaUniversityShool of Medicine. E m e r g e n cM y e d i c i n ea n dT r a u m aC e n t e r[,, 4 e t h o d i sHto s p i t aol f I n d i a n a , I n d i a n a p o l iD s ;e p a r t m e notf M e d i c a lB e s e a r c hM, e t h o d i s H t o s p i t aol f I n d i a n a , I n di an a o o l i s Study objective: In terms ofinformation availability, emergency physiciane often work "on fumes.n'They frequently make critical clinical deisions with little or no informaiion regarding either the patient or the multirude ofpresenting clinical problems. To evaluate information neds and resources in the emergency departrcnt, we asked the following five research questions. What questione are being asked by emergency medicine resident physicians? Are they being answered? Ifnot, why? If they are, what. information resources are being used? And do computer knowledge and owner, ship correlate with use of computerized knowledge reeources in the department? D e s i g n : P r o s p e c t i v e ;s u r v e y o b s e r v a t i o n a l m e t h o d . Sctting: ED of an 1,100-bed tertiary-care, cenrral city teaching hospital. Participants: Eighteen emergency medicine resident physicians ( p o s t g r a d u a t ey e a r s I t h r o u g h 3 ) . Interventions: Four-hour observation period of each resident physician with interviews before observation, after each patient contact, and at the end of the observationperiod. Results: Residents asked an average of 2.2 questions per patient. Of rhese, 610/oconcerned diagnostic and treatment etrate$eer24Vo were related to patient informationn and,lSVo were operational or nonmedical questions. Sixty-three percent of these questions were answered while the patienl. was still in the ED. Asking colleagues or staff physicians the answers to questions was the primary information resource (827o). Other information resources were drug handbooks (87o), texts or manuals (4Vo), palmtop pereonal computere (3olo),CD-ROM data bases (ZVo), and, other (27o). Physicians were observed to stand in line to consult a colleague rather than accese an available computerized information resource. There was a strong correlation between a high perceived computer knowledge level and the uee of compuierized resources (Spearman correlation coefficient; P< .04). Conclusion: These findings are similar to those of other survey observational studies of internal medicine and family practice physicians. Colleagues were the mosI frequently used resource in the clinical environment, and the simple availability of computerized knowledge reaources does not mean that they willbe used to any great extent. More attending needs to be devoted to the information needs of physicians, to understanding factors that affect their information-seeking strategies, and to integrating computerizedinformationresourcesintotheclinicalenvironment.>
WithEmergency Department PatientRelerral: The errors. The patient-entry rate was determined for each ETR )kO1|| Compliance if'l Ellectof Computerized Discharge Instructions (number of patients that hour divided by number of emergency BBVukmir, RKreman, 0ADeHart, GLEllis, M Plewa, J Menegazzi/Universityphysicians) and compared with the ETR discrepancy rate. Data ofPittsburgh Medical Center, Presbyterian University Hospital Anesthesiology/were analyzed by the use of Peareon'e correlation coefficient and CCM; Western Pennsylvania 0epartment ofEmergency Medicine Student'8 t te8t. Study objectives: To evaluate the effat of computerized discharge instructione on emergency department patient refenal recommendations. Deeign: Prospective deecriptive analysis and clinical trial. Setting: Emergency medicine residency-affiliated urban hoepital with 29,000 visits. Type of participante: One thousand ED patients referred to a siable outpatient network. Interventions: Mandatory referral wae provided in written or computerized format (Logicare Co, Eau Claire, Wisconsin) for each S00-patient group. Demographic data and compliance or appointmenl completion within 30 days were analyzed using f,2 with Yates' correction, Fisher's exact test, and odds ratio comparisons with P < .05 and 957o confidence intervals (CI) considered significant. Results: Patients encountered had a median age of36 years (age range,2 weeks to 9l years). They were predominately young adults (12 to 40 years old) (56.lVo), female (S9.lVo), and clinic parienr.s (5S.8qo) and had an eetabliehed (one year) hospital association (85.lEo) with nonurgent complaints (93.|Vo) mosr often diagnosed ae contusion or strain (27.4Vo), or they were referred to medical cLn\c (M.47o). Institution of computerized diecharge inetructions increaeed overall patient referral compliance from 26.2Vo to l6.2Vo ( P < . 0 0 0 1 ) w i t h a n o d d e r a t i o o f L . 5 9 ( 9 5 V oC I , 1 . 2 t o 2 . 1 ) . S u b s e r a n a l y s i sd e m o n s t r a t e d i n c r e a s e d c o m p l i a n c e i n p a t i e n t s w h o w e r e older than 4O years (32.47o t"o 6l.l7o), female (28.7Vo to 39.7Vo), had a private physician (36.4Vo ro 53.9Vo)ohad an esrabliehed hoepital relationship (26.IVo to 38.97o), had nonurgent complaints (26.5Vo to 36.2Va), were diagnosed with strain and contusion (l7 .0Va Io 36.87o), or were referred t o the obstetric./gynecologic c\nic (9.SVo to 19.4Vo) (P < .001). No preresr inrergroup differences were noted (P > .05) Conclusion: Computerized discharge instructions resulted in improved compliance with ED referral recommendations.
Reeults: A aignificantly poeitive correlation between ETR discrepancy rate and the patient-entry rate was found for each of the five etudied chief complaints as listed (Table). Chiol Gomplainl Composite Abdomimlpain fwer Chespain Asthm/COPD Laceration
llo. of P.lirnl. 980 187 Zffi ?ffi 193 2n
I
.520 .426 .517 .604 .551 .559
<.0001 < .000t <.0001 <.0001 <.0001 <.0ml
Conclusion: Increased ED patient-entry rates are associated with increased ED charting diecrepancies in hand-written charts,
DiumalVariations in theIncidence, Severity, and Qfi UrbanTrauma: rf lf Geographical Distribution ol Various Mechanisrrs ol Iniury PEPepe, PACurka, BSZachariah, MJWall,Jr,KLMattox, VF Ginger/Departments ofSurgery, Medicine, andPediatrics, Baylor College of Medicine; CityofHouston Emergency Medical Services, Texas
of PatientEntryRatesWithEmergency (lf Aasociation Oepartment J rf Record Documentation DWMunter, MDMozzetti, RAGilmore/Department 0fEmergency Medicine, Naval Hospital, Portsmouth, Virginia Study objetive: Determination of the relationship between patient-entry rates and emergency department record documentatron, Desigrr: Retroepective chart review ofa total of980 ED rmords in a 35-day period. Setting: Military referral cenl.er and teaching hospital ED. Type of participants: ED parienrs with a chief complaint of abdominal pain (187), fever (200), chesr pain (200), asthma/chronic o b a t n u c t i v ep u l m o n a r y d i s e a s e( C O P D ) ( 1 9 3 ) , a n d l a c e r a t i o n ( 2 0 0 ) . Interventions: Emergency treatment records (ETRs) of patients with one of the five above chief complaints were reviewed for documentation of I I predetermined complaint-specfic items obtained from the history, phyeical exam, or ED intervention/treatment. AII ETRs in thie insritution are hand-written. Each ETR was assigned a nurnber of discrepancies (poesible range, 0 to I l) based on the number of nondocumented iteme. ETRs from a 35-day period (total of 5,242 patient visits) were reviewed to obtain a total of 200 in each group. Twenty reviewed charte were later excluded due to clcrical
Study objective: No studies have ever clearly quantitated dirunal variatione in urban trauma. The purpose of this etudy was to delineate the relative occurrence and severity of varioug mechanieme of irjury, according to rhe time ofday, throughout each ofthe geog r a p h i c a l z o n e so f a l a r g e c i t y . Design and intervention: With a computerized emergency medical services (EMS) dispatch/patient record integrated data base, all patients transported with injuries were coded according to type, severity, age, and one of 156 geographical zone8, as well as time of day and day of the week. Setting: A single-provider EMS trauma center system in a large urban municipality. 'I1pe of participants: All 31,847 consecutive victims of injury occurring within the catchment area of the EMS who were transported to hospitals during calendar year 1990. Results: More than 507o of theinjuries, regardless of mechaniem, occurred between 3:00 pu and 12:00 midnight, whereas orly 77o occurred between 4:00 mt to 8:00 eM. However, 537o of eevere vauma, predominantly gunshot wounds and major motor vehicle accidents, occurred between 6:00 pu and 2:00 eM, peaking between 10:00 pu and 12:00 midnight. In terme ofgeographical patterns, however, diurnal variations were virtually identical in all areae of the city, except for the city center, where moet trauma tended to occur later in the evening. Conclusion: Throughout all sections of a large city, the frequency and severity of each of the various mechanisms of injury have a similar, quantifiable, and rela tively predictable diurnal variation. Such data can be used in trauma system planning, EMS systems status management strategies, and hospital personnel ataffing considerations.
andTypeof Hazardous 0bjectsFound Among Q] Incidence if f PotienbandVisitorsScreened byMagnetometer in anUrtan Emergency Center BMThompson, JCNunn, TLKramer/Henry Ford Hospital, Detroit, Michigan Study hypothesis: The incidence of guns, knives, and other hazardous objects attempted to be carried into our emergency department by patients and visitors creates a dangeroue eituation )
48
for all and warrants continuation of a comprehensive eecurity pro_ gram. 'lstiens Pop During the 48-month study period, fugpT6consecu_ . tive patiente and visitors entered the clinical area of an urban emergency center serving 82r00O to 84,000 patient visits per year. Methode: Prospective data were guthe..d on hazardous objects detected by a system of arch and handheld magnetometer screening of all patients, visitors, and their belongings thlt were attempted to be brought into the clinical arena of rh;ED. Data gathered includ_ ed whether patient or visitor, legality, and type ofhazardous object found. Resulte: The syetem """*.r.d BZ2.l persons per day. patients composed 60.367o and visitors composed 39.64Va of the population screened. Hazardoue objects, defined as any item that could be used to injure snother or was potentially harmful to the patient or staff, were found. on 3.0Vo of the perrons screened. A totul of 16,Zg9 oljects (5?l guna l3.A%of,9,550 knives !"_r_"^"do.o,s fS6.9Va), and 6,668 other hazardous objectsf}g.iVol) were removed from rhe workplace and patient care areas. Conclueion: Universal magnetometer screening of all patients and visitore.revealed a dangerous and contin uing i."i-d".,"" of pa tients and visitors attempting to bring hazardous o-bjects into the clinical area. The n:1d for magnetometer screcning of all patients and visi_ tors in our ED is warranted as part of a comprehensrve security system. Other EDs should consider seriously detecting and climinat_ inghazardous objects to reduce the risk ofinjury to patients, visitore, and ED personnel.
t98 Physician Compliance wirhAcLsGuidelines (J Welch,DM LECline, Cline, CKBrown/Department ofEmergency Medicine, East Carolina University School ofMedicine, Greenville, North Carolina Study objective: To determine the compliance with advanced cardiac life eupport (ACLS) guidelines among certified and non_ certified physicians. Deeign: Retrospective review of co'secutive cardrac arres[s during 1990, including assessmenr.of the resuscitation leaders, ACLS certification.
and participante: All nontraumatic hospital and prehospi_ ,Setting tal cardiac arrests for a rural university hospital. Interventione: None. Results: Two hundred seven arresl,s were studied, totaling 436 rhythms with a maximum of four rhythms per arrest. There were 207 initial rhythme, 122 eecond "hyth-., ?B third rhythms, and 34 fourth rhythms analyzed. Asystole (38. 37o), ventricular fibrilla tion (25.AVo),bra dycardia ( I l. 6), and ventric uiar tachycardia $ nd;i were the moet commonl.y encountered rhythms. There were ?g suc_ cessful resuecitations (J6.3Zo). A total of 2,03g interventions wcre recorded for all rhythms, with 1,320 complianr (64.g%a)with ACLS guidelinc compared with ZIB deviariorrs (ZS.Zrny..Ihere werc 326 indication devia tions (l6.OEo), l 29 sequence deriation. (g.g%o), 107 dlne. ns (5. TVo), 100 dosing Jeviations (4.9 o/o),and six, f l1leutio other (0.37o). Calcium and sodium bicarbonate *... ,r"d wirh sig_ nificantly higher noncompliance (p * .0001). Noncompliance was greatest with unetable ventricular tachycardia (61.7TVo of treat_ ments), varying degrees of atrioventric ular block (59.09Vo), unsfa_ ble eupra ventric ular tachyca r dia (57 . | 47o), prl. j"" ventric ula r tachycardia (52.OJVo), atable brajyca .ai" (iO.OOU.1, and stable supraventricular rachycardia (46.lSEo). ACLS_cert'ilied and nonACLS-certified physicians leading resuscitations were compared for mean number of deviatione per rJsuscitation attempt, and no
49
differences were found, Successful resuscitations (return of sponta_ neous circulation) were compared with nonsuccessful resuscitatione, and there was no difference in time-controlled deviation ecores between groups. No differences could be found between ACLS_certi_ fied and non-ACLS-certfied physicians for return of spontaneous circu_ lation and out-of-hospital eurvival rates. Conclusion: Despite biannual ACLS training of all reeidentg and intensive care unit nurses, noncompliance with ACLS guidelines toLaled 35.2Va of treatments. Ve found no correlation between ACLS certification and ACLS guideline compliance. QQ Comparison ol Inbamuscular Meperidine and promethazino rrr, Wth and Widrout Chlorpromazine:A prospective, D o u b l e - B l i n dT r i a l T El e r n d r u p C , M MaddenD , J D i r e , DG a v u l aR , M C a n t o r / D e p a r t m eonf t E m e r g e n cM y e d i c i n ea n d P e d i a t r i c sS,U N yH e a l t hS c i e n c eC e n t e ra t S y r a c u s e ; S e c t i o no f E m e r g e n cM y e d i c i n eD , e p a r t m e notf S u r g e r yU, n i v e r s i toy f 0 k l a h o m aH e a l t hS c i e n c e C s e n t e r0, k l a h o m aC i t y ;D e p a r t m e notf E m e r o e n c v M e d i c i n eD , a r n a lAl r m y H o s p i t a lF, o r tH o o d ,T e x a s Study objective: To compare thc safety and effectivenees ofintrameperidine (2 ^{kd and promerhazine (l mglkg) with Tl_:irl"" (MPC) or withour. (MP) ch,lorpromazine (l m/l<g) for sedarion and analgesia of children undergoing emergency deparrment proccduree. Design:Randomized, doublc-blind. S e t t i n g :A c o m m u n i t y a n d u n i v e r s i t y h o s p i t a l E D . Typ" of participants: Eighty-seven hemodynamically and neuro_ logically stable children less rhan 16 vears old. Interventions: Intramuscular ..d"tio. followed by the intended p r o c e d u r c . M e d i c a l o b s e r v e r s r a t e d s c d a t i o n a n d a n a l g e s i ao n E e p a _ r a t e 1 0 . 2 + m v i s u a l - a n a l o gs c a l e s .C o m p a r i s o n s w e r e m a d e u s i n g 1z a n a l y s i s , F i s h e r ' s c x a c t t e s t , o r i h e M a n n - W h i t n e y U t e e t w i t h c re e t at.05. llcsults: Children rmciving eit.her combination were not signifi_ r:antlydifferent with respectto age, sex, weight, chronic illness, and indications. Proceduresincluded laccration repair (46), fracture rcduction (25), and orhers (16). Onset of actiori was nearly idenrical (mean, 16 minutes), whereas the duration of action was significanrly longer after MPC (mean + SD, 63 + 5T minutes) compared with Mp (29.t3!, minutes) (P < .05). Paradoxical hyperactiviiy occurred o n l y a f t e r M P ( t h r e e o f 4 3 ) ( P = . 1 2 ) , w h e r e a Er r a n s i e n t O . d e s a t u ration occurred only after MPC (one of 44) (p - .49). No 6ther complications were obseryed. Overall, MpC wae significantly better (7.4 t2.l cnr) than MP (5.2 + 3.0 cm) (p - .0068). Farente believed sedation worked well n 90Vo of cases, whereas children were thought to have bad memories of the procedure in only 9Vo, with no significant differences between groupe. Conclusion: We suggestnot eliminaring chlorpromazine from the i n L r a m u s c u l a rc o m b i n a t i o n o f m e p e r i d i n e a n d p r o m e t h a z i n e for pcdiatric sedationduring ED procedures.
1 00 [::ffil1:i:ioram
asasedative rorchirdren Durins
DMYealy, JH Ellis,GD Hobbs, RMMoscati/Texas A&M University, Division of Medicine, College of Medicine, College Station, Texas; Scottand !19rOqncy WhiteMemorial Hospital, Temple, Texas, Darnall ArmyCommunity Hospital, FortHood.Texas Study objective: To evaluate the effectiveness and eafetv of intranaeal midazolam (INM) as a sedative for children during lacer_ ation repair.
Design and setting: Retroepective review of dictated charts from a tertiary-care urban teaching hospital emergency department during an eight-month period. Participants: Children aged12 to 72 monthe. Interventione: INM wae dripped into both nares, followed by Iocal anesthesia and wound repair. Each dose was choeen by the treating physiciane baeed on a r@ommended range of 0-2 to 0-5 m9lk9. Meaeuremenie: Dose (mglkg)r time until sleepy or cooperative, recovery, and diecharge were calculated. Sedation was considered adequate if no phyeical restraint was used, and a speific statement documeniing a clinical effect was recorded. Vomiting and signficant oxygen desaturation (defined before review as an O, saturation value oflees thanglVo or a drop of more than AVo on room air) were sought. Data are reported as the mean + I SD or frequency with eurrounding957o confidence limits (CL). Results: Forty children received INM, with only two cases excluded because ofinadequate records. Overall' 7l7o (957o CL, 547o t-o85Vo) achieved adequate sedation after 0.32 1 0.6 mglkg INM. However, sedation was adequate n 277o (957o CL,60/o to 60Vo) of children receiving 0.2 to 0.29 mglkg compared with 80olo (954o CL, 624o to 95Vo) and 1007o (95Vo Cb,797o to l00o/o) after 0 . 3 t o 0 . 3 9 a n d 0 . 4 t o 0 . 5 m g l k g , r e s p e c t i v e l y .S e d a t i o n o c c u r r e d within 12 t4 minutesr recovery at 4l + 9 minul,es, and dischargc at 56 + ll minutes. Mean Pretreatment and post-treatment O, saturation levels were 98 !I7o and.977o ! lVo , and the lowest value
Conclusion: A standardized training eesgion wae uaed succesefully to train prehospital providers in the procedure of IO infueion' IO infusion then wae implemented into their clinical practice with a satisfactory succest rate and few complications'
*
Witt in Inlants obinemia inicalMethemosl ol Subcl 102H1*::t Jackson Center, Medical ofMississippi JrlUniversity Pollack, ESPender,CV
Study hypotheaig: Infanta with diarrhea are at riek of developing methemoglobinemia and its complications' Deeign: Prospeciive clinical study. Setting: A university hospital pediatric emergency department' Type ofparticipants: Infants under 6 monthe old with a history of diarrhea of more than one day's duration and no vomiting' Interventione: A venous blood eample was obtained for rnethemoglobin (MHgb) aseay (normal, 0.47o Lo I'57o) and electro\tee' Treatment interventione were performed as indicated clinically' Patients with elevated MHgb levels later underwent hemoglobin
recorded was 93Vo. No vomiting was obeerved. Conclueion: INM ie a eafe and effective sedative for laceration repair under local aneetheeia. We obeerved doses between 0.3 ro 0'5 mglkg to be more effective than a dose of less than 0.3 mglkg.
electrophoresis to exclude congenital methemoglobinemia' Results: Thirty-five patients were studied' Mean (+ $p) age rvag 8 + 6.5 weeks, and mean duration of diarrhea wae 85 * 3l hours' Mean MHgb levele were 5.2 t3.67a (range,0'8Vo to 367o)' Twentyo.e i.fant-. (60%) had a MHgb level that exceeded the upper limit of normal; three were cyanotic. Patients with elevated MHgb levels also tended ro have elevated serum chloride levele' The magnitude of the methemoglobinemia varied invereely with age and directly with duration oi di".th""; clinical assessmentsof dehydration did not correlate with MHgb levels. Twenty patients (57%) required admission for rehydration. Twenty-four patienta (687o) received IV fluids, and 2l (&Ea) received oxygen. One patient (aget 4 weeks; d-iarrhea for I20 hours) required methylene blue and pediatric
Regional ofa Standardized Success lnlusion: Intraosseous 1n{ ALSProviders forPrehospital Program I U I Training DBEitel, RDrawbaugh, DBaker, KArthur, M Kleinman, TEAnderson, of Hospital Children's YorkHospital; Hospital; CSOgden/Chambersburg Pennsylvania Philadelphia,
intensive care unit admiesion for methemoglobinemia PIH$,364o)' All patients recovered from their illnesseel no patiente were identifred with congenital methemoglobinemia' Conclusion: Although methemoglobinemia usually reaulte from a toxic etiologyt infants lese rhan 6 months old with diarrhea are at risk for de*Iopitg methemoglobinemia even if they are not clinically dehydrated. Younger age and longer duration ofillnese correlate with the incidence of methemoglobinemia. Cyanosis often is not apparent in these Patients' but elevated serum chloride levels may serve as a marker for methemoglobinemia' Specific treatment may be indicated. In young infants with prolonged diarrhea, routine screening may be useful clinically in the early diagnosis of methe-
Study objative: To evaluate a standardized training progranr irt intraoeseous (IO) infusion for prehospital providers. Deeign: Prospective multicenter 24-month study. Setting: IO infusione were performed by prehospital providers from eight advanced life support (ALS) units serving 14 hospitals within nine countieg. Type ofparticipante: Field ALS providers (paramedics arrd registered nursea). Interventions: AII providere participated in a one-hour standardized training session and supervised hands-on simulation. Providers completed a data sheet on all IO infusions performed. Data sheets
moglobinemia.
Coins in Locating Useofa MetalDetector ^ ||l.l TheSuccesslul bychildren I UJ Ingested Center, Medical University Loyola ofPediatrics, Ceita/Department SPBos,F lllinois Maywood,
were collected and summarized. Results: One hundred thirty-four prehospital providers complcted the training session and were approved to perform the procedure. Fifteen patients requiring IO infusion were encountered during the study period. Thirteen (87o/o)had'lO infusion completed successfully. Clinical indications included ll patients in cardiac arrest, two trauma reauscitations, one seizure, and one toxic exposure. Patient ages ranged from I to 24 monthe. Seven patients were
Study objective: The purpose of this srudy was to examine the accuracy of a metal detector in locating coins swallowed by children. Design: Prospective, nonrandomized case series' Setting and participants: All children preaenting to the emergency department oia medical center after a coin ingestion were eligible for participation in the studYAfter an interview and physical examination, all Itt".t".tior,r, with a Super Scanner (Garrett Security were scanned patients -Sy",.-r, Inc, Texas) metal detector and underwent chest and
initially reeuecitated. Four eurvived to hoepital discharge' Procedural complicationa included one incidence oflocal fluid extravaeation and one IO infusion that became dislodged en route' There were no complications at time of discharge in the four survivors. All procedures were performed in less than two minutes.
uLdo-"r, .udiogr.piry.
50
Reeulte: Sixteen children, ranging in agee between 9 months and 6 yeare (mean age, 3 years), participated in rhe study. .fhe metal detector correctly identified the preeence or absence of coins in l5 patients, as confirmed by radiographic studies. Both examinations were negative in three patients, and swallowed coins were located eorrectly in 12 patients. The metal detector failed to locate a coin in the rectum of a patient who presented 26 hours after ingestion. Conclueion: We conclude that the metal detector evaluared by us ie highly accurate in locating swallowed coins.
*1
04lHrtflff?
t Parenr Education inrhepediatric Emergency
VAAlmeida, SFKrug, TSYamashita/Department ofpediatrics, Case Western Beserve University School ofMedicine. Rainbow Babies andChildrens Hospital, Cleveland. 0hio
.
.
Study hlpothesis: Parents will acquire and retain knowledge taught in the emergency department, Objective: To examine the effectiveness ofpatient education irr a pediatric ED (PED). Design: Prospective, randomized, comparative, experimental study conducted over a nine-month period. Setting: Urban university hospital pED.
Setting: Three EDs from a single metropolitan area represenl.ing pu-blic, private, and academic hospitals. Interventions: All charts wirh a diagrrosiE,treatment, or testing consistent with an STD were included. Culture resulte were confirmed with labs, and reported cases were confirmed with the state health department. Results: A total of 1,168 cases (male,49Vo; female, SlVo) were reviewed. Physicians at the teaching hospital were much less likely to diagnose correctly and treat properly STDs (seneitivity of diagn o s i s , 5 4 7 av s 9 6 4 o ; P < . 0 1 ) t h a n t h o s e a t t h e p r i v a t e h o s p i t a l . Overall, some significant differences were found between the sexes (Table). Malo (",6) Treatrnent fordrlamydiawilh GCtreatment Treated forGCwithoutculture Testedfor syphiliswith GCtreatrnent Gram-stain forGD Properdischarge instructrons
Emergency PhysicianDiagnosis,Treatment. and Reportingol I ntr I lf rf SexuallyTransmittedDiseases:TheirEflecton Transmission andControl TDKirsch, DABradt,RShesser, MRMoon,/Department of Emergency Medicine, TheJohnsHopkins Hospital, Baltimore, Marvland: Department of Emergency Medicine, George Washington University, Washington, DC; Department of Pediatrics, TheJohnsHopkins Hosoital Studyobjective:To evaluateemergencydepartmentphysicians' diagnosticskills, treatment,and public health repordn; oisexoully transmitteddiseases(STD) and their effecton transmissionand control of these diseasee. Design: A two-month retrospective chart review with follow_up of Iaboratory results and of reported cases.
5l
Femah(%) 76 70 26 2
P < .01 <.01 <.01 <.01 <.01
22 11 diagnostic and treatment practices also varied significantly betwecneach ED and were relatcd [o ED policy and management. Overall,less than 43o/oof probable Neisseriagonomhoeae (GC) c a s e sw e r c r e p o r t c d , w i t h s i g n i f i c a n t v a r i a t i o n a m o n g t h e h o s p i t a l e (57o/ovs 49o/ovs 8o/o,P < .01). C o n c l u s i o n : I n a p p r o p r i a t e d i a g n o s i sa n d t r e a t m e n t o f S T D s b y l i D p h y s i c i a n s c o n t r i b u t e t o t h e s p r e a d o f t h e s e d i s e a s e sa n d m a y crpose the physicians to liability. ED policy can directly affect correct diagnostic and treatment practices and reporting completeness. Males are more appropriately managed for STDs than females. The STD diagnostic sensitivity and specificity by emergency phyeicians at some hospitals are low. Despite legal requirements, few treated c a s e so f S ' f D s a r e r e p o r t e d . 'I'hese
Type ofparticipants: Parents ofchildren 0 to 16 years old prcsenting to the PED with a chiefcomplaint offever. patients requiring admieeion and familiee without a telephone were excluded. Interventione; Parents were aseigned randomly to one of three groups. Group A (GpA, 26) was the conrrol group. Group B (GpB,48) received a standardized teaching package (Tp) with both oral and prinred materials (pM). Group C (GpC, i5) received only PM. Effectiveness of the TP was evaluated by a pretest "rrd o po.i_ test at the beginning and end of the PED yieit and by telephone sur_ vey one to four days later and again two to four months later (GpA and GpB only). Reeults: Results were analyzed using ANOVA, paired r_tesr,12 and Fieher's exact teEt. Sociodemographic variables and test, pretest scores were similar for all groups. Using the changc from pretest to post-test score as a measurc of acquired knowlcdge, GpI| wa8 the only group to have a signfficant increase in score (13 total q u e s t i o n s lm e a n c h a n g e ei n s c o r e , G p A : 0 . 4 + l . l ; G p B : 2 . 0 + l . Z ; P < . 0 5 ; G p C : 0 . 5 + 1 . 2 ) . S e v e n t y - t h r e ep e r c e n t o f p a r e n t s e n r o l l e d completed the follow-up ar two to four monrhs. GpB had a persistent increasein poct-test score at this time (I.Z + l.B, p < .05), d.emon_ strating that the TP did result in long-r.erm retenrion of informa_ tion. In addition, gSVo of the parents in GpB found rhe Tp helpful. Conclusion: We found that parents were enthueiastic about our TP in the PED and that the combinarion of oral and prinred teach_ ing materials resulted in the acquisition and retention of krrowledge.
89 44 58 11
Witr 0utpatientAntibiotics AmongWomen { nA Compliance I lf ff Treatedin fre EmergencyDspartment lor PelvicInllammatory Disease 0 Brookoff/Uniuersity of Tennessee College of Medicine, Memphis
'I'o Study objecrive: assesscompliancc with a prescribed couree of d o x y c y c l i n e a m o n g i n n e r - c i t y w o m e n d i s c h a r g e dw i t h t h e d i a g n o s i s o f p e l v i c i n l l a m m a t o r y d i s e a s e( P I D ) . 'fwo Design: hundred sixty-five consecutive womcn with a presumptive diagrrosisof PID who responded to a telephone survey ten to l5 days after discharge from the emergency department were asked about their usc of doxycycline and its side effects. Setting: Inner-city municipal hospital ED. Type of participants: Vomen aged l8 to 45 yeare who were diagnosed with PID and discharged with a prescription for doxycycline (100 mg twice daiJy for ten days). Results: Eighty-two patienrE (317a) reported compliance with the cntirc ten-day course of medicarion, irrcludingeight (l0o/o)who reported epigastric discomfort due to the drug. Seventy-two patients (279o) reporled that they had not filled their prescriprion; cost (507o), inconvenience (28Vo), and resolution ofsymptoms (20Vo) were the most common reasons given. One hundred eleven patients (42Vo) took an incomplete course of medication (mean 4SD, 3.5 + 2 days). The most common reaaons given for discontinuing therapy were side effuts (367o), ineffectivenese in treating the pain (297a), and resolution of symptoms (227o). Conclusion: The majority ofinner-city patients treated for pID are not compliant with a full course of doxycycline. Alternate methode ofdispensing the medication or use ofan effective single-doee )
agentshouldbe consideredto increasecomplianceand decreasethe potentialfor long-termsequelaeof PID.
Sensitivity analysea show that the choice of strategy depends greatly on the probability of GC infetion but less so on the rate of return for follow-up culture. TREAT ALL is the strategy ofchoice when likelihood of GC infection (pre-exieting plue newly acquired) is more than 0.03 since compared with TEST, TREAT ALL prevente the most major complications, is cheaper, and incurs relatively few excese minor complications. TEST is the optimum Btratqly for probabilities of GC oflees than 0.01. For probabilitiee of GC = 0.01 - 0.03, the likelihood of return for follow-up culture
in MalesPresenting to an * { n7 TheIncidenceof Gonorrhea I lJ f Urtan Ernergency Department Witr VisiblePurulentUrethral 0ischarge EJasper, DSBirenbaum, AJ McDonald, M Miller,K Nekoranik, L Halleck, B Brown/Thomas Jefferson University Hospital, Philadelphia Study hypothesis:Past studiesin sexuallytransmitteddisease clinicshave ehownthat gonococcalurethritis can be diagnosedclinically with 967o spectficityand confirmed by Gram-stained urethral smearsand cultures.We hypothesizedthat malespresentingwith
influences choice of strategy. Conclusion: For most SA victims, TREAT ALL is the superior strategy.
visible purulent discharge have gonorrhea. Design: Prospective. Inclusion: One hundred six male patients presenting with visible purulent urethral discharge between May 1990 and June l99l to an urban university hospital. Exclusion: Recent use of antibiotics or presentationwith clear, w a t e r i n g , o r s c a n t d i s c h a r g eo r w i t h o u t d i s c h a r g e . Reeults, Patients with culture-positive urethral dischargc or Cram-stain revealing more than 4 WBCs/high-power field with claesic kidney-shaped Gram-n€gative intracellular or extracellular diplococci were presumed to have gonorrhea. Of 106 patients, l0l had positive Gram-stains in the ED, 9l specimens were culture posiLive, and 60 patients had positive Gram-etains in the microbiology lab- OnIy one patient was diagnosed by positive culture only. In no caEewas any patient negative by all three, yielding 1007o serrsitivity. Conclueion: Men presenting with visible purulent urethral discharge to an urban ED have a high likelihood of having gonorrhea present, making the need for further diagnostic evaluation nccess a r y o n l y f o r e p i d e m i o l o g i cp u r p o s e s . * {
nO
C l i n i c a l a n d M i c r o s c o p i c D i a g n o s e so f V a g i n a l Y e a s t { nO Infection: A Prospective Study I ffif , n i v e r s i toyf C o l o r a d o J / b b o t t l S e c t i o no f E m e r g e r nM y e d i c i n ea n dT r a u m aU H e a l t hS c i e n c eC s e n t e rD . enver Study hypothesis: History and physical and microscopic examin a l i o n s a r c u s e f u l i n d i a g r r o s i n gy e a s t v a g i n i t i s . Design: Prospective. Setting: Urban teaching hospital emergency department and walk-in clinic. Participants: Seventy-one consecutive women with complaints of v a g i n a l d i s c h a r g e ,i t c h i n g r o r p a i n . Interventions: An emergency physician or trained nurse practitioner who was blinded to culture resulte collected information about the chief complaint, performed a physical examination, and examined vaginal secretions using standardized methods. Yeast culture was obtained in all women. S t a t i s t i c a l m e t h o d s : A s s o c i a t i o n sa m o n g c l i n i c a l a n d l a b o r a t o r y parameters and yeast culture results were evaluated using sensitivity (Sens), specificity (Spec), positive- (PPV) and negative-predictive valucs(NPV), and percent accuracy. Results: Twenty-three patients Q2.A7o) had positive yeast cultures. Other diagnoses were bacterial vaginosis (4I7o), urinary tract infection (87o), trichomoniaais (7Vo), and chlamydia (34o).Theteat results are given (Table).
Prevention ol /Veissenb Gononhoeae in Victinrs ol Sexual
I lfO Assault Clinicaland Cosr-Effecriveness DJMagid, JM Douglas, JSSchwartz/Denver General Hospital, Denver, Colorado; Department of Public Health, Denver, Colorado; University of Pennsylvania. Philadelphia Study background:Neisseriagonorrhuoe (GC) and other sexu-
Prwl%) Scnsl%)spc{%} PPVI%)l{PV(%lAcerrcrl%)
ally transmitted dieeaeesare the most common comp.lications of sexual assau.lt(SA). Early treahrent with antibiotics prevents most sequelae of GC infections, but the appropriateness of empiric antibiotic treatment in adult SA victims remains undefined. S t u d y o b j e c t i v e : T o c o m p a r e t h e h e a l t h o u t c o m e a ,c o s t s , a n d cost-effectivenessof two alternate treatment strategies for the SA victim: treat all patients empirically with antibiorics (TREAT ALl,) versus treat only patienta who have a positive culture (TEST). Design: Decision analytic model. Clinical estimates were obtained from the literature, patient records, and expertsl costs were from Blue Cross/Blue Shield reimbursements. Baeeline clinical eetimates included rates ofpre-existing (0.06) and newly acquired (0.03) GC infections, rate of follow-up treatment after positive culture (0.90), and rate of return for follow-up culture (0.50). Reeults: Known ratec of major and minor antibiotic reactione and GC sequelae were us€d to calculate net major and minor complications. For a hypothetical cohort of 100,000 SA victime, the resulta are as followe (Teble). S'rr|ogy TREAT AI-I TEST
llrilr Cotr?lic.tioos lg) 9q)
llhor Con?licaliom
Avarago Cost(t)
6.182 ?.521
r5.08 38.28
'yeas1 Patientsuspe(ts aqain
llegativeaminewhifl tesl
18 63 33 34 73 58
Positive Gram'stain
t
Absenceol clueceils Salinepreparation
54 38 36 31
Itchysensatron Cheesydischarqe Perineal edemaor erylhema Absenceol walerydrscharge
KOH [.,]€thyleneb]!e
35 87 65 57 96 83 0
7
83 65 61 64
89 62 48 44 73 54 18 5A 38 43 48 55 lm 100 60 50 7 5 6 7 7 5 6 83 64
14 89 81 78 95 97 85 88 5 f
f 83
n i
71 61 70 70 56 64 89 66 n 1
2 77
Pregna ncy, oral contraceptives, diabetes, a ntibiolice, dysuria, pain, vaginal pH, and WBCs (> epithelial cells) did not predict culture results. In a stepwise multiple logistic regression, the significant (P < .05) independent predictors ofa poeitive yeest culture were patient suspicion of yeast infection, poeitive Gram-stain, and a b s e n c eo f w a t e r d i e c h a r g e . Concluaion: The Gram-stain provides the most accurate predictor of yeaet infetion. The other etandard clinical end laboratory criteria are relatively unreliable and just ar accurate ae a patient's seH-diagnoeis.
52
in Female Disease Transmitted )k{ { n DlrlAProbeto DetectSexually I I lf SexualAssaultVictims Health of Florida Medlcine, University of Emergency JBMcPhersonlDivision Center. Jacksonville Science
traclions, but the amplitudes decreased by 30Vo from prearrest levele "stunned myocardium'" Cells were (P < .0I), resembling clinically spontaneously contracting five days after this arrest, indicating viability. In contrast to one minuter cells died after {ive minutes of
Study objective: To evaluate the Gen-Probe PACE 2 DNA probe for detection of Chlonryd'ia trachomatis (CT) and Neisserilt gonorrhoeoe (NG) genital infections in female sexual assault victims. Design: A prospective clinical study comparing the performance of the Gen-Probe PACE 2 DNA probe with that of the standard chlamydia culture with McCoy cells in a shell vial procedure (Bartels) and the standard gonorrhea culture with Thayer-Lewis agar. The DNA probe for the direct detection of CT and NG is targeted againet ribosomal RNA. Three cervical awabs were obtained from ll5 coneecutively examined sexual assault viclims over a three-month period. One ewab was proceesed for probe analysie and the other two for CT and NG culture. Setting: Sexual assault treatment center (SATC) for Duval
arre8l. Conclusion: Contract amplitude and variability, vital end points of reeuscitation, can be monitored continuously in myocyteao and viability can be aseeeeeddays after sn arrest. Reeponseein thie study are similar to thoee of clinical events, including hypoxic arrest, reperfusion, and stunned myocardium. These results demonstrate that myocyte cultures have measurable featuree perti-
County, Florida. Type of participants: One hundred fifteen conseutive female sexual assault victims examined at the Duval County Sexual Assault Treatment Center within ?2 hours after vaginal penetration. Interventione: None. Results: Thirteen of I 15 patients (ll7o) were both probe and culture positive for CT. Fourteen patients (l2%o) were CT probe positive. Eight of ll5 patients (7Vo) were both probe and culture positive for NG. Eleven patienta (107o) were NG culture positive. With culture as a gold standardo the probe had a eeneitivity of I 0 0 V a a n d ,a s p e c i f i c i t y o f 9 9 V o f o r C T . F o r N G , t h e p r o b e w a s 6 2 T o
Study hypothesis: During cardiac arreEr (CA)' inhibition ofbrain energy metaboliem leads ro rapid depletion ofneuronal ATP' It hae been suggestedthat ATP deplction results in ionic integrity and, eventually, in cell death. For brain tiEeueto recover from prolonged ischemia, brain mitochondria (the site of more than SOVoof cerebral oxidative phoephorylation) must be rapidly re-energized during reperfueion, so that ATP can again be produced and ionic homeostasis can be reetored. Previous studies have demonstrated that thc naturally occurring subetance acetyl-L-carnitine, when adminietered exogenously' can increase mitochondrial metabolic rate and oxygr:rrutilizaLion, suggeetingpotential uee for thie drug in counteracting some of the effects of ischemia on the brain. This study teste
eensitive and I007o specific. Conclusion: The DNA probe shows high sensitivity and specificity for CT and high specficity for NG and merits consideration as cvid e n c ei n a c o u r t o f l a w .
*1
1 1 irjl::'.r#:T"l
cardiac cellcultures: AModelror Heart
in RZaklUniversity ofCincinnati TLVanden Hoek, LBBecker, MLGriem, cooperation withtheUniversity ofChicago Study objective: Cardiac reguscitation has been studied traditionally in clinical trials, animals, and organ preparations. Although animal heart cell cultures (ie, myocytes) are used to study ischemia, these syetemeare not uged exteneively for resuecitation reeearch. An easily manipulated cell culture environment allowe for well-controlled triale of multiple interventions during hypoxia. The purpose ofthis study wae to evaluate myocyte preparations ae a model for cardiac resuscitation. Desin: Contracting myocytes were placed in a closed chamber and vieualized on a microscope equipped for videorecording. Continuous chamber perfusion and electrical pacing of the cells allowed for control of metabolic supply and demand. Contractiort amplitude was measured and graphed by computer image process-
nent to the etudy of cardiac resuscitation. S ll it
Prevention of Postischemic Neurologic lniury by
I I 4lcetvt-t-Carnitine of GFiskum/Department I Tilles, BGamma, RWilliams, REBosenthal, Biology. andMolecular ofBiochemistry and0epartment Medicine Emergency DC Washington, Center, Medical University Washington George
the hypothesis that acetyl-L-carnitine may provide neuroprotection after resuscitation from prolonged experimental CA. Design: In a randomized, controlled trialn anesthetized female beagles underwent ten minutes of CA induced by electrical fibrillat i o n . R e t u r n o f s p o n t a n e o u sc i r c u l a t i o n ( R O S C ) w a s a c c o m p l i s h e d w i t h e p i n e p h r i n e , s o d i u m b i c a r b o n a t c , o p e n - c h e s tC P R , a n d d e f i - b rillation. A standard intensivc care protocol was followed in all animals for 24 hours after ROSC. Interventions: Twenty-five animals successfully resuecitated from ten minutes of CA received one of three drug regimene immediately after ROSC: l) acetyl-t -carnirine, 100 mglkg (eight); 2) carnitine' 67 mglkg,in acetate, 33 mglkg (seven); or 3) pH-adjuated drug vehicle only (ten). Animale received half the original dose of the appropriate drug at six, 12, and 1B hours after ROSC. Controlled ventilation was maintained for 20 hours. At hour 23, neurologic injury wae agsessedby two blinded examiners' using a standardized 100-point neurologic deficit scoring (NDS) system (NDS of 0' normal; NDS of 100,brain death). NDS was compared belween groupe using oneway ANOVA followed by appropriate post-hoc comparisons
( P< . 0 s ) . Results: The mean t SEM NDS for ten vehicle-trealed animals was 48.4 +5.4. Most animals in this group showed marked alterations in their levels of consciousnesel several appeared totally unaware of external stimuli. In contrast, animale receiving acetyl-L-carnitine showed significantly less neurologic injury (NDS' 22.3 t5.2\ rhan vehicle-treated controle (P < .004). Moet animale in thie group demonstrated only minimal impairment of their Ievele of
irgInterventions: To assegeeimilarities to an intact heartt myocytes were expoeed to nine incremental increases (0.3 to 4.8 mm) of calcium. Second, to simulate hypoxia, cells were depleted of ATP with 5.0 mm dinitrophenol (DNP), an uncoupler of oxidative phosphorylation, and laler reperfused with normal media to atl.empt resuscitation. Results: Vith increased calcium, contraction amplitude increased 375Vo in dose-response faehion (P < .001). With DNP' contractions ceased by 35 aeconds. After one minute of arrested contraction, normal media reperfusion restored simultaneous con-
consciousneseand appeared aware of externdl stimuli. Intereetingly, animale receiving carnitine and acetate after ROSC demonstrated neurologicinjury(NDS,4l.613.5)notsiglificantlyimproved>
53
a diet Deaig.n: Eighty weanling Swiss outbred male rnice were fed a fourby followed weeks, eight for Ctprnone 0.74o mixed with week recovery periodspecific Interventione, Animale in one group were perfused at Brain interv als w ith 47o phospha te-bufrered paraformaldehyde' paraffin-embedded blocks and etained eections *... p".po""ifrom using rabbit anti-bovine myelin baeic proi-*,r.o"yt*iemically in another grouP rYere etudied for protein Animals tein antibodiee. weeke of oxidation at zero and eight weeks of toxicity and four by reactwas determined oxidation protein brain Soluble Fecovery. and measurirg "olull" p.oteine with 2, 4-dinitro-phenylhydrazine ing hydrazone formation. Demyelination, similar in location to that seen in hyperhoolt", by oxic reperfuaion and electrolyte-induced myelinolyeiet mcurred extensive demyelination occurred by of toxicity, *h.""", fit" *..k. eight weeka. Early remyelination wae seen by four weeks of reovery' '01 by oneTiofold increase in protein oxidation (four animale, P < miled ANOVA) occurred at eight weke of toxicity, returning
from control but significantly worse (P < .02) than that of animals treated with similar concentrations of acetyl-Lcarnitine' Conclueion: Postischemic adminiatration of acetyl-L-carnitine (but not free carnitine) substantially improvee neurologic outcome after resuecitation from CA, presumably as a reeult of potentiation of recovery of cerebral energy metabolirm'
and Metabolism CortexEnergy ol Cerebral ^ i ]l AlteredPattems Following Ace$l-r'Gamitine I I J lorn"tizationbyIntravenous Arrestin Dogs Cardiac of School University Washington REBosenthal/Geroge Bogaert. G Fiskun,YE 0C Washington, Medicine, Study hypotheeie: The working hypothesis for this atudy was that cerebral iechemia results in inhibition of oxidative metabolism, which regults in a shift toward anaerobic metaboliem that continues for hours into the period of reperfuaion and can be ameliorated by of aeetyl-L+arnitirre' postieâ&#x201A;Źhemiâ&#x201A;Ź adminietr*tion Design: A canine model of cardiac arrest and resuscitation was used to induce complete, global cerebral ischemia and reperfusion' Fifty-two adult female beaglee were divided into groups that were subjected to control aneethesia (chloralose) with no cardiac arrest (CA), ten minutee of electrically induced CA' and CA followed by resuacitation and two or 24 hours of reperfusion (CA 2 or 24 Re)' At the end of the experimental period, a sample of the right frontal cortex waE removed, placed in liquid Nr, deproteinized, and
toward normal by four weeks of recovery' in Conclusion: Cuprizone intoxication ie the third animal model with in aeeociation occur to which oxidativ" ,t"""" is demonstrated myelin damage. Ve have proposed that white matter is uniquely toln..able to oxidative damage as a result ofits low levels ofprotective antioxidant enzymes.
in Phosphotyrosine Containing la tlE BrainNuclearProteins Besuscitation I I U CardiacArrestand ofEmergency JMSkjaerlund/Department White, BJ0'Neil,BC DJDeGracia, Michigan Detroit, University, State Wayne Medicine,
assayedfor levels of Iactate and pyruvate. Intervenlions: Reeuecitated animals were randomized into grouPg receiving either acetyl-l-carnitine (ALCAR) in sodium bicarbonate at 100 mglkg IV immediately after electrical defi-brillation and at 50 mglkgevery six houre, pH-adjusted bicarbonate alone ae the vehicle control, or concentrations of acelate plus carnitine in sodium bicarbonate equivalent to thoee present in the ALCAR group' Reeulte: The following lactate-to-pyruvate ratios were obtained
Study hypothesie: It is known that ineulin hag poetischemic neuroprotective effecte unrelated to glucoee levels; ineulin EuPPortg synthesis' acting through cell gurface-receptors with do r-rolipid tjrosine kinase activity, and selectively vulnerable i.r"""elltia. neurons hat. inc.eas.d insulin receptore that co-map with phosphotyrosine (Ty.tP]), which is concentrated in neuronal nuclei' tfr"r, lTyr[P]) may play an important role in regulating neuron ior enzymeE involved in lipid syntheeis' The hypothet"ur."tiptiit (in consi, of this study is that brain (Ty.tP]) levels are diminiehed during complete brain depletion) ATP junction known with -ischemia and that the electrophoretic pattern of these regulatory
for the experimental groups (Table). Control
r AICAn + Ac.tttc Plus Clrnitin.
1 3 .r62 . 4 l,lonatrested 291r44' of CA Tenminutes 55.9r20.9* 9 . 5f 1 . 1 31.315.5' CA2hrBe 32.7 t2.2' r2.5r3.0 49.8r22.8 CA24 br Re 'significantlygreaterthannonanested posrhoc wih appropriate contmls(P< 05)viaAN0VA mmparisons.
proteins is changed during reperfusion' Nuclei were imlated by centrifugation at lr000g after homogenizarion of the cortex in nonischemic rats (three), after ten minutee of cardiac arrest (three), and after 90 minutee of reperfueion (three). The nuclei were lysed (0. l7a Triton X-lqO-)f and eoluble protein concentration was determined (Inwry)' ELISAg with monoclonal anti-body against (Tyr[P]) were done on protein tPots on nitrocelluloae; specificity was confirmed by preabaorbance of (Ty.tP]) onto the antibody- Weatern blotg were performed after
Conclueion: Cerebral cortex lactate-to-pyruvate ratlos were abnormally elevated after ten minutes of CA and two hours of reperfusion. Postischemic administration ofALCAR but not acelate plus carnitine normalized this indicator of anaerobic versue aerobic energy metabolism, which may help explain the protective effect of ALCAR toward neurologic impairment in this model'
1 1 43:il11l":Tif
and stress dative inOxi onRe surts icati
of Experimental CN0liver/Laboratory HSMicket.PEStarke-Beed, andStroke, Disorders of Neurological Institute National Neuropathology, National Heart.Lung,andBloodlnstitute, National of Biochemistry, l-aboratory Maryland of Health,Bethesda, lnstitutes oxaldihydrazone)is Study objective:Cuprizone(bicyclohexanone known to produce revereible demyelination. Published studieehave shownan associationbetweenoxidativestreeeand myelin damagein hyperoxic reperfusion and dectrolyte-induced myelinolysis' This studyfocuseson the possibilitythat cuprizone-induceddemyelination is aseociated wiih
oxidative
SDS-PAGE with size standardsResulte: During a ten-minute arreBt' total nuclear (Ty'[P]) is reduced arleastsOVo but recovers by 90 minutes ofreperfuaion' During reperfusion, a major band at 120 kd ie completely lort, a are n"* bitd'"ppears at 40 kd, and bande between 12 and 55 kd enhsnced. Conclusion: (Tyr[P]) ie diminished in brain nuclear proteine during a ten-minute cardiac arrest, and there are prominent ehifts pattern of (Tyr[P]) proteins during rerperfuin thelbctrophoretic sion.
strese.
54
tl ll tr Reperlusion-lnduced Neutrophil Chemotactic Factor I I lJ Generated in Canine Plasma DL Carden,BJ Korthuis/Departments of Physiologyand EmergencyMedicine, LouisianaState University,Shreveport Background: Neutrophile (PMNe) contribute to reperfueion-. induced microvaecular dyefunction in canine ekeletal muecle. Although thie granulocyte-mediated injury ie dependent on the adherence of the PMNo to the microvascular endothelium, the factor or factors that promote this interaction between neutrophils and the endothelium during ischemia/reperfueion (I/R) remain unknown. Hypothesis: Because superoxide dismutaee (SOD) attenuates the microvasculsr dysfunction and neutrophil infiItration into poEtischemic ekeletal muscle, SOD produced during reperfusion may be involved in the generation of neutrophil chemotactic activity. Design: We exposed 20Vo (diilated with sterile ealine to gimulate interstitial fluid) or INVa canine plasma to a SoD-generaring system (500 ttM K SOD) in the presence and absence of SOD. Chemotactic activity was aseegeedby determination ofmyeloperoxidase (MPO) activity (a eensitive marker of tiesue neutrophil content) in ekin biopeiee taken two houre after intradermal injection of these plasma samplee. Resulte: Intradermal injection of SOD-treated 2OVoplasma induced a marked increase in tissue neutrophil content compared with eites injected with sterile saline or SOD-treated l00Vo plaama (MPO,69.4 +6.9,9.312.3, and 15.611.8 u/g, reepectively) that wae aboliahed by the preaence of SOD (MPO, I5.4 + 2.2 Dld. Decomplemented.2OVoplasma exposed to the SOD-generating sys*em produced very Iittle chemoracric activity (MPO, 20.4 t l.S u/g). rinally, intradermal injection ofplasma obtained after IiR induced r marked increaee in tigeue neutrophil conrent (MPO,4O.2 t2.9 u/g) that wae attenuated by decomplementing the plasma (MPO, I5.2 10.9 u/g) but accentuated by incubation with a canineepecific Cr. antibody (MPO, 103.4 +7.1 u/d. Conclueion: These reeults suggest that SOD plays a role in the generation ofpotent chemolactic activity during reperfusion by a proceEs that may involve Cr" activation. Jl ,l', I I f
The Use of Emergency Dopartments by Eldedy patients: Proiections From a Multicenter Data Base
Conclusion: With the rapid growth of the elderly population, it ie important that we aseeer the reaources needed for emergency care of the geriatric population,
wth ofMvocardiar Inrorction tl 1 I fiiil:ff;11'jntation A Knapp, J Jones, DMcNinch/Emergency Medicine Besidency Program, Butterworth Hospital, Michigan StateUniversity College Medicine, of Hunnn Grand Bapids Study objective: To determine the incidence ofpainless infarction in a series ofemergency department patients and evaluate the effects ofgender and increaeing age on presentation, Design: Retrospective, comparative cohort study (1989 through
leel). Setting: University-affiliated community hospital. Participants: Six hundred patients, I00 consecutive patiente within each age group (leee than 40, 40 to 54, 55 to &r 65 ro 74, ?5 to 84, and 85 or more yeare), admitted during the study period with a diecharge diagnoeis of acute myocardial infarction. Diagnosie was confirmed by World Health Organization criteria of ECGe and biochemical findinge. Interventione: Recorde were reviewed for patient demographice, presenting eigns and Eymptoms, and laboratory findings. Patients then were categorized according to presence or absence of chest p a i n , g e n d e r , a n d a g eg r o u p . R e s u l t s :M e a n + S D p a t i e n t a g e w a e 6 3 + 6 y e a r e ( r a n g e , 2 9 t o 9 6 years). A total of 78 patients (137a) experienced painless myocardial infarction. Nine percent of men and 25Vo of women preeented without cheet pain (P < .05). There algo was a positive correlation between the incidence of painless infarction and increasing age (P < .01). Older patiente had up to a 357o incidence ofpainlese infarction. Dyspnea, although the most frequently reported symptom in the absence of cheet pain, was equally common for all ages. Conclusion: Classic symptoms aseociated with acute myocardial infarction change significantly with increasing age. Emergency physicians must be prepared to screen for the diagrtosis in moet acutely ill elderly patients.
t1
GBStrange, EHChen, ABSanders/College 0fMedicine andSchool ofpublic Health, University oflllinois, Chicago; College ofMedicine, University of Arizona. Tucson
1 I Misdiagnosis ofAcuteMeningitis in ElderlyPatients TWyn, J Jones, W Cordell/Emergency Medicine Residency Program, Butterworth Hospital; Mlchigan State University College ofHunnn Medicine, Grand Rapids; Methodist Hospital, Indianapolis, Indiana
Study objective: To aegeesthe implicatione of meningitie in a more mature emergency department population, with epecial emphasis on promptness ofinitial antimicrobial therapy. Design: Retroapective case seriee over a five-year period. Setting: Four community hospitals, including inner-city and teaching institutions. Type ofparticipants: Sixty-five consecutive ED patients more than 64 years old who were admitted during the study period with a discharge diagtosis of acute meningitis. Interventione: Recorde were reviewed for patient demographice, clinical features, laboratory findings, and hospital course. Times and intervale related to diagnosis, laboratory testing, and therapiee were calculated. Results: Mean + SD patient age was 71.5 * 6 years; the oldest
Study objective: To aeeessemergency care use by the elderly. Design: A retroepective data baee review ofelderly emergency department patients, a comparison with nonelderly patiente, and an estimation ofthe nationwide use ofemergency services. Setting and participante: Seventy hospitals in 25 etates. Reeulte: Fifteen percent of the ED visits were made by patienrs over tlre age of 64 years. Thirty-two percent of elderly patienis were a dmitted (7 %oto ICU beds) compare d w ith 7 . 57o and l. lTo, r espectively, for the nonelderly. Thirty percenr of elderly patients used ambulances compared with 8Vo of the nonelderly. It is estimated that 13,693,400 elderly patients wâ&#x201A;Źre 6een in EDs in 1990, and more than 4 million of them were admitted. The elderly are 4.4 times more likely to use ambulancee, 5.6 times more likely to be edmitted, 5.5 timee more likely to be admitted to an ICU, and 6.1 timee more likely to have a comprehensive level of service. In the eample, the elderly comprieed,s6Vo ofpatients arriving by ambulance, 43Va of admissiona, and,$Vo of ICU admiseions.
patient was 89 years old. Predisposing conditions were present in 27 patients (42Va), and,concurrent infectione occurred in 12 patients (l9Vo). Change in mental status was the most frequent symptom (687o); fever wa8 present in only SlVo , and meningiemus )
55
was present in 35Vo. Twelve patients (l9%o) presented with focal neurologic deficits. Streptococcus pneurcnilte accounted for ihe majority (517o) of all isolates. Thirty-seven patients (S7Vo) were misdiagnosed initially; common misdiagnosesincluded cerebrovascular ischemia (217o) and sepsis (187o). The mean durarion between presentation and the administration of antibiotics was 10.6 hours. The mortality rate in this sample popularion was 3l7o (20 of 65). Conclusion: Long delays exist in the ED before initiation of antimicrobial therapy for acute menirrgitis in the elderly population, and in general, these delays appear to be avoidable.
Alveolar-Arterial 0xygenGradientsin ElderlyPatientsWith +' 1tn a LV Suspected Pulmonary Embolism program, N VanDeelen, J Jones,D Plowman/Emergency Medicine Residency Butterworth Hospital; Michigan StateUniversity College of Human Medicine, Grand Rapids, Michigan Study objetive: To determine the usefulnees of the alveolar-arterial (A-a) oxygen gradient for derecting pulmonary embolism (pE) in elderly patients presenting to thc emergency department. Design: Retrospective cohort analysis. Setting: University-affiliated community hospita,. 'fype of participants: One hundred fifty-five conseutive paticnts over the age of 65 years who underwent pulmonary angiography for t h c p r e s u m e d d i a g n o s i so f a c u t c l ) l i . N o n e h a d a p r i o r h i s t o r y o f cardiopulmonary disease. I n v e n t i o n s : A r t e r i a l b l o o d g a s s a m p l e sw e r e c h o s c n f o r c o m p a r a tivo analysis only if obtained whcn the PE was first suspccted clinically (before lung scans or angiograms) and the pal.ient was breathilrg room air. Predicted arterial Po, (Iraor) arrd A-a gradients were calculated for each age group. R e s u l t s :A t o t a l o f 1 5 5 p a t i e n t s m c t a l l s t u d y c r i l . e r i a l n r e a n t S I ) p a t i e n t a g e w a s 7 5 + 7 y e a r s . E i g h r y - o n e p a l i e n r s ( S 2 V o )h a d a n g i o graphically documentcd emboli. ln this cohort, rhe mean paO- was -gradi62.4 mm llg (range, 34.3 to 108.5 mm Flg), and the mean A-a ent was 45 mm IIg (range,4 to 84 mm Hg). In five patients, lhe A-a g r a d i e n t w a s n o r m a l f o r a g e . I I o w e v e r , i n c o r n p a r i s o r rt o t h c ? 4 , p a t i e n l . sw i t h r r o r m a l p u l m o n a r y a n g i o g r a m s , t h e r c w a s n o s i g n i f i cant difference in Pao, (mean,60.? mrr I{g) or lhe A-a gradicnt (mean,46mnr IIg). C o n c l u s i o r r :A n e l e v a t c d A - a g r a d i c r r t i s n o t a s < : n s i t i v ci r r d i c a t o r of l)E irr cldcrly patients. A norrn:rl A-a gradicrrrshould nol prcc l u d e f u r t h c r d i a g n o s t i cp r o c e d u r c s i f t h e r c i s a h i g h i n d e x o f s u s p i cion.
Setting: Urban teaching hospital. Participants: All patients over the age of 75 years were studied regardless of the chief complaint or origin (nursing home, domestic residence, other hospital). The average age wae 82 + 5 yeara, 66Vo were females, and the average temperature w ae 36.9 + 2 C. Methods: A computer-seleted multiple logistic regression analysis was performed, with a set at .05. Resulte: The model X2 was 12.63 (P < .002) with the regression accounting for 3.697o of the log likelihood. Nursing home origin (P < .003) and leukocytosis (P < .03) were the only signficant predictors ofbacteremia, although percent band forms (P < .08) and tachycardia (P < .09) approached significance. The relative risk for the model was 1.37. Of 7l positive blood cultures,42 (597o)were contaminants, and,29 (Al%a) had other pathogens, Escherichia coli being the mosl common (five of 29). Fifteen of the 29 (52Vo) were and 16 (557o) were from nursing homes or personal care i".Tt: Conclusion: Elderly patients (more than 75 years old) presenting from any nursing home milieu who have leukocytosis (WBCe, more than 15,000/mm3) have a relative risk of 1.37 ofbeing bacteremic, even if afebr:ile. The highest risk for bacteremia was seen in febrile patients from a nursing home or pereonal care home setting.
Eflicacy ol 3,4-Diaminopyridine in a SwineModelol 4 trt Antidotal I ZZVerapamil Toxicity MCPlewa, TGMartin, JJ Menegazzi, DCSeaberg. ABWolfsonlThe Western Pennsylvanla Hospital, Montefiore University Hospital, Division ofEmergency Mediclne, University ofPittsburgh Study hypoihesis: 3,4-Diaminopyridine (DAP) may reverse the hemodynamic cffects of severe verapamil toxicity. f)esign: A randomized, nonblinded, controlled animal model. Intervcntions; Eighteen chloralose-aneethetizedand instrumented swinc were poisoned with verapamil at l0 mglkglhr for five minutes arrd therr at 5 mglkglhr until eystolic blood pressure of 55 mm Hg. Hcart rate (HR), ECG, blood pressure,left ventricular contractility (dP/dT-",), and cardiac output (CO) were monitored. Nine animals re<:civedI mglk{min DAP until systolic blood pressure of 100, or an isovolumetric infusion of normal saline (NS). llcsults: Target hypotension and decreased dP/dT-", and CO wcrc reproduced in all casesand transient atrioventricular block w a s r e p r o d u c e d i n 2 2 o / ow i t h 1. 3 8 ! 0 . M m g l k g v e r a p a m i l . M A P , dP/dT-"*, HIl, and CO wcre significantly increased afrer 14 +6 nrglkg DAP (Table). Mortality was unchanged (22Toborhgroups).
a tFta
fimo (min)
I Z I errrgrncy Department Predictors 0f Bacteremia in the Elderly CCBose, JJ Menegazzi, J Green, MAAmin/Department of Emergency pittsburgh; Medicine, TheWestern Pennsylvania Hospital, Center for pittsburgh Emergency Medicine 0f Western Pennsylvania, Background:The optimal treatmentof sepsisin the r:ldcrly requiresthc timcly identificationof bacteremia.Prcvioussrudi<:s have shown leukocytosis,
age, and <:ornorbidity to be hclpful in this
rcgard. [Iypothesis: tion of clinical bacteremia
Ilegardless
of the presence offever,
and laboratory
variables
will predicr
Design: Over a two-year period (1990 rhrough l99l), a prospccLive analysis of the charts of 1,000 unselected elderly patients (morc 'Ihe than 75 years old) was performed. usual clinical examination studies were performed.
0
m
1!
MAP(mmlls) NS utl 4 1t 4 4 7t 1 5 62t24 64118 DAP 8918 A1t4 59129 116129. l2lll8 dPldT_b,{mmHg/sec) NS 1,5331449 489t2./8 50612991,114tl44 1,28611,171 DAP 1.367r33r 433r190 5631318 3,3ffit2,312-4,071t2,002C0 (mL/kg/min) NS 1 8 14 6 1 80r4r /t r75 115170 124t76 DAP 151161 95156 12rn 2c4rw221t82
DAP treatmcnt was complicated by muscle twitching, tachycardia of more than 180, and hypertension (diastolic blood pressure, more than I l0 mm IIg) each in MVo of cases. Conclusion: DAP rapidly reverses the hypotensive and negative furotropic effects of verapamil toxicity but is complicated by muscle twitching, tachycardia, and hyperteneion.
of
in elderly patients.
and laboratory
1
'P< 05byrnulliple mmparimns ANOVA andIulev'smelhod.
somc combinarhe finding
Bassline
Blood cultures were
obtained rn 327o.
56
a4ttt ' a t a ll,rf Extraordinary Medical Therapy lor Severe Verapamil Overdose T GM a r t i n J, J M e n e g a z zH i , M P e r e l J, P h i l l i p sM . M Klain/Montefiore U n i v e r s i tH y o s p i t a lC, e n t e rf o r E m e r g e n cM y e d i c i n eU . n i v e r s i toy f P i t t s b u r g h M e d i c aC l enter Study objective: Very large (unconventional) doses of antidotes were compared in severe verapamil poisoning refractory to cardiopulmonary bypass (CPB). Design: Nonblinded, placebo controlled. Interventions: After baseline measuremenls, 24 swine (weight l7 to 25 kg) were poisoned with verapamil (VER) f0 mglkg/min IV until the aortic tracingwae flat, YER was decreased to 5 mglkg/min, peripheral CPB was initiated, and an antidote was given every five minutes with subsequent doses doublcd urrtil systolic blood pressurc (SBP) wae more than 90 mm Hg, blood pressure dropped, or tht: maximum dose was given. Saline was given to keep ccnl.ral venous pressure at more than l0 mm Hg and pump flow at-morc than 100 ml/kg. Four groups of six each (salirre I SAL] , calcium ICAL] , epinephrine [EPI], and glf,cagon [GLU]) were tested. VEIi was a ssayed by high-performance liquid chroma tography. Results: The mean total doses given were CAL, 373 mg&g; EPI, 0.8 mgll<giand GLU, 2.3 mgn<g. Only with CAL was SBP more than 90 mm Hg (six of six) achieved during CPB and was weaning from CPB successful (four of six) P < .0O2 by X,2.Calcium levels fell lower with EPI and SAL during CPB and werc highest with CAL (P < .001, by MANOVA-Tukey). For all groupso thc mearr VEll peak was 3r3I2 n{mL before CPB, which decreascd by 38o/ot.o 21065 nglmL after five minutes of CPIJ. Aftcr 30 arrd (r0 minutcs of CPB, the mean VER valueswere 1,995 rnd 2,199 n1y'm[,d , cspitr: the S-mglkg/hr infusion. C o n c l u s i o n : W h e n c o m b i n e d w i t h C P l i , h i g h - d o s t :0 A l , t h r : r a p y w a s s u p e r i o r t o t h e o t h e r a n t i d o t e s . l l i g h d o s e so f I r [ ' l a n d C L U were no better than SAL when com-birredwith CPll. 'f he usual safe limits for CAL levels may not apply during CAL treatmenl of a CAL channel blocker overdose. A significant drop in VER levels occurred with CPB and was sustained despite continued VER infusion.
FromSevere TricyclicAntidepressant 0verdose X I t A Recovery I 4T WithHypeftonic Salinein a SwineModel JLMckbe,DJCobaugh, JJ Menegazzi, TEAuble/University ofPittsburgh Division ofEmergency Medicine; Center forEmergency Medicine ofWestern Pennsylvania; University ofPittsburgh Beglonal Toxicologrc lreatment Center S t u d y b a c k g r o u n d : T r i c y c l i c a n t i d e p r e s s a n l . sr e m a i r r a n r a j o r cause of morbidity and mortality from ovcrdosc, and there is no uniformly effective treatment for severe toxicity. Hypothesis: Hypertonic galine reverses hypotension and QIIS prolongation and improves survival in severe tricyclic antidcpreseant overdoee. 'fhis Design: was a randomized, controlled, experimental trial. 'Ien swine weighing 20 to 24kgwere anesthetized with ketamine and xylazine and maintained with cr-chloralose. ECG was rnonitored continuously, and a femoral artery was cannulated for conLinuous blood pressure monitoring and blood sampling. Nortriptylinc (N'I') was infused through a femoral vein until subjects reached scvcre toxicity, defined as systolic blood pressure (SPB) of 504/oof basclin<: and a QRS duration of 120 ms or greatcr. lnterventions: After reaching toxicity, subjecLs reccived eilher a l0-mf./kg bolus of normal saline or thc sanre volume of a 7.5o/o saLne/67odextran solution. All subjects were observed for 60 mirrutes or untif they died. Arterial blood gases and electrolytes were
measured at baseline and at tenr 30, and 60 minutes into toxicity. N T l e v e l sw e r e m e a s u r e d a t t o x i c i t y . C o n t i n u o u s v a r i a b l e s w e r e compared using two-way repeatcd nteasurea ANOVA and Scheffe's m u l t i p l e c o m p a r i s o n sw h e r e n m e s s a r y . S u r v i v a l w a s c o m p a r e d 'l'he experiment crerror rate using two-tailed Fisher's exact lest, wassetat .05. Results: There were no statistically signficant differences in measured variables between groups at baseline. All subjects reached toxicity within seven minutee of NT infusion. There wae no statistically significant dilference in NT levels between the control group (mean, 7,881 ngldl,) and the hypertonic saline group (meano ?,584 n{dL) (P - .59). Mean SBP at ten minutes after treatment was 45.5 mm I-Ig in the control group and I15.2 mm IIg in the hypertonic salinegroup. Mean QRS duration at ten minutes after treatment was 180 ms in the control group and 86 ms irr thc hypertonic saline 'fhesc group. findings were statistically significarrt (P < .05). All c o r r t - r oa l nimals died within 20 mirtutes,and four of five hypertonic s : r l i n ca n i m a l s s u r v i v e d t o 6 0 n r i r r u t c sw i t h a m e a n S l l P o f 1 2 6 . 0 n r r r rl l g a n d m e a n Q I I S d u r a t i o n o f 8 7 . 5 m s . T h i s w a s f o u n d t o b e s t a t i s r i c a l l ys i g n i f i c a n t ( P < r . 0 5 ) . Controls HypeilonicSaline S B Pa l 1 0m i n 0 B Sa t 1 0m i n Suruival 'P<.05.
180.0 0/5
11 5 . 2 ' 86.0' 415'
C o n c l u s . i o n :l n l h i s s w i n e m o d c l o f s c v c r c T C A t o x i c i t y , a s o l u t i o n o l 7 . S o / as a l i n c a n d 6 0 / od e x t r a n s i g n i f i c a n t l y r r : v c r s e dh y p o t e n s i o n a n d Q l l S p r o l o r r g a t i o na n d i m p r o v c d s u r v i v a l .
of Severe Treatment Amitriptyline Poisoning: Xll4'tr Experimental Bypass WithCardiopulmonary I L., Cardiovascular Toxicity WestVirginia 0fSurgery, GLLarkin, GMGraeber, M Holllngsed/Department Nilorgantown University Health Sciences Center, S t u d y o b j c c t . i v c :T o c o m p a r c c a r d i o p u l m o r r a r y b y p a s s ( C I ' l l ) with conventional thcrapy in thc trcatment ofscverc amitriptyline poisoning. l ) c s i g n: P r o s p e c t i v e , c o n t r o l l e d , l a b o r a t o r y i n v e s t i g a t i o n . S e t t ir r g :A n i n r a l l a b o r a t o r y . 'f 'lwcnty Yorksh.ircswine (72 + 8.3 kg). ypc of participants: lntcrvcntions: Profound cardiovascular toxicity was irrduced in all anesthetized a n i m a l sv i a a m i t r i p t y l i n c ( I ' C A ) i n f u s i o n a t 0 . 5 n g l k g l m i n . V e n t i l a t i o n w a s a d j u s t e d t o k c c p a r t < : r i a lp l l a t 7 . 5 0 1 0 . 0 5 a n d l ) c o , a t 3 5 m m I l g . l l o t h C I ) l l - a d v a r r c e d < ; a r d i a cl i f e support (ACf,S) (control) and CI)li groups receivcd'[CA infusion 'I'he control until the systolic blood pressurc fcll bclow l)0 mnr IIg. g r o u p w a s t h c n g i v e r r o p c n - c h e s tc a r d i a c m a s s a g ea n d s t a n d a r d (ACLS) pharmacologicintervcntions, including sodium bicarbona L o ,v a s o p r e s s o r s ,a n d f l u i d s , w h c r r i n d i c a t e d . ' f h e C P B g r o u p receivcd only fcmoral-fcmoral CPB for 90 to 120 minutes. llcsults: All 20 animals expcricnced cardiac conduction delays, d y s r h y r h m i a s , a n d p r o g r e s s i v c h y p o t e r r s i o nw i t h i n 3 0 m i n u t e s o f r<rciving IV amit.riptylinc at 0.5 mglk{mn. The ten swine receiving CP[] as treatrlent for cardiovascular toxicity were able to completely corrcct the dysrhythmias, cardiac conduction abnormalities, and hypotensionproduced by thr:ll'CA; howcver, only one of ten control a n i n r a l sc o u l d b c r c s u s c i t a t c d ( I ' < . 0 1) . N i n e o f t e n s w i n e t r e a t e d with Cl'l] wcrc casily wcaned off of bypasswithout any pharmacol o g i c i n l . e r v e n t i o n lh o w e v e r , o r r c r e q u i r c d r r o r e p i n c p h r i n e t o b e w c a n e d o f f C P I | . A l l l l r e s u s c i t a t c ds w i n c w e r c a b l e t o b e s a l v a g e d . C o n c l u s i o n : C P B m a y b e u s c f u l i n t h e t r e a t m e n t o f s e v c r ec a r d i o v a s c u l a r t o x i c . i t yf r o m T C A p o i s o n i n g .
5'1
tl Functionin a Porcine The Ellectsol Ethanolon Respiratory ttr | 411 Fluid-Percussion BrainIniuryModel of Emergency N Zink,PFeustel/Albany Medical College, Departments Medicine andSurgery, NewYork Studyhypothesis: In a previousstudy,we found that ethanol producedprolongedapneafollowingbrain injury. This irvestigaventilation(Vu) tion teststhe hypothesisthat ethanolsuppresses and hypercapnicrespiratory drive after brain injury and that
gender, GCS, TOX+, TOX-, and ISS, only ISS was found to be an independent predictor of early intubation (by Mantel-Haenszel test P < .05). Conclusion: Although altered mental status secondary to substance abuse may require early airway control in the trauma victim, the admission GCS is not a reliable predictor for early endotracheal intubation in the TOX+ trauma patient. The severity of injury appears to identify the need for advanced airway manage-
naloxone reverses this suppression-
ment.
swine (weight,
Design; Immature sia were subjected
to a 2.S-atm
device. Respiratory
15 kg) under
brain
anesthe-
With Iniuryin Patients Markersof Intracranial *rl ||O Biochemical Intoxication andEthanol MinorHeadTrauma I ZO Simultaneous San ofCalifornia, VLWilliams/University BSimon, MA Levitt, LStaffeld, Hospital Highland General Francisco,
with a fluid-percussion
injury
including
parameters,
halothane
tidal volume,
frequency
blood gases, were measured on 1007.o O, and on 60/o inspired CO, just before brain injury and at ten, 60, 120, and 180 Vu, and arterial minutes.
lleduced
respiratory
with an increase in Paco"r or by apnea at normal Pacor. Other measured parametcrs
before brain
glucosc, and ethanol.lcvels-
animals (group I) (six) received normal
Control
2 (eight) received
saline. Croup 90 minutes
and clcvatcd
included lCP, nrean artcrial
prcssure, heart rate, brain tempcraturc, Interventions:
Study objective: The similarity bctween the clinical sigrrsof acute ethanol inloxication and those of craniocerebral injury make it difficult to distinguish between the two for physicians practicing acuto trauma care medicine. Early recognition ofintracranial injury through biochemical markers would reduce morbidity and 'fhe present study evaluates mortality duc to delayed diagnosis. creatine kinase (CPK-BB) in and brain-type scrum catecholaminee patients who are ethanol intoxicated and have suffered minor head
in V,
as a dccreare
drive was defined
13.5g/kg ethanol
injury.
Croup
tube
by orogastric
3 (six) received ethanol
as
above, plus rraloxone (0.25 mglkg), 25 mirrutes after brairr injury. Results, injury,
Etharrol
levels averaged
and l?0 mgldl- two hourg after injury.
Hypercapnic
V"
was dccreased in sevcn of oight
response onc hour after injury
animals in group 2 and none of six anirnals in group increased Vn in four of the six animals without rcspiratory
trauma. f)esign: Prospcctive, case-control. Setting: Courrtyhospital. 'fype of participants: One hundrcd seven patients with eerum gthanol levels of B0 mgldl or more who have sustained minor head
at the time of brain
ll13 mg/dl
drivc. Mean arterial
3 atbaseline (just beforcinjury)
l. Naloxonc
alterirtg hypercapnit:
l - r au n ta . Intcrvcntions; Cranial computed axial tomography (CT). Results, P CTVYi$odlniurv CTWilh Iniury
prcssurc was lowcr in groups I artd ( i r i >+ 4 v s 7 0 l I l l r n r r l l g , P < . 0 1 - r ,
Studr:rrt's two-tai.lcd , tcst with Ilorrfcrrorri <:orrt:ctiorr). I(ll'was elcvated in group 3, compared with group I at. the thr<x>hour rrtark afterinjury (2414 vs ll +4 mm llg, I'<.05, Student's two-tailcd I test with Bonferroni Conclusion: injury
corrction).
Respiratory
control is disrupted
followirrg brairr
in animals receiving moderate doses of cthanol. Naloxorre
may increase V" in ethanol-treated
Xl
No ot palients CPK.IJB {ng/L) (pg/nt) Dopamine (pg/nti Epinephrine (pg/nt) Norepinephrine Totalcatedlolamines
animals.
brain-injurcd
Study objmtive:
The associatiorr bet.ween substance abusc arrd extcnsivcly.
stance abuse plays in the ned
However,
the role that sub-
for carly post-traumaLic endotracht:al
Design: Prospcctive
data from the trauma
patients (92.7o/o) had routine
Jr, KEMclntyre JA Guisto, ABSanders, Valente, DBWitzke, CMadden.JF Tucson Center, Health Sciences of Arizona JFSeeger/University Study objective:To develophigh-yieldpredictivecriteria for trauma patientsneedingheadcomputedtomography(CT) ecansin
registry wcre retro-
period.
Setting: Level I trauma center. 'f ype of participants: Of 6,181 adult blunt trauma
an emergency department. Dcsign: A prospective study was undertaken in two six-month p h a s e s .l n p h a s e l , p h y s i c i a r r so r d e r i n g h e a d C T s c a n sc o m p l e t e da form enumerating the history arrd physical exam' Variables studied , e c h a n i s mo f i n j u r y t i r r c l u d e d h i s t o r y o f l o s s o f c o n s c i o u s n e s sm G l a s g o wC o m a S c o r e ( G C S ) , a n d s i g r r so f d i r e c t c r a n i a l i n j u r y . llead CT scans werc classified as clinically signficant or insignific a n t , a n d c h a r a c l . c r i s t i c so f t h e t w o g r o u P s w e r c c o m p a r e d . I t e s t analyses for conl.inuous variables and X2 analyses for categorical
victims, 5,731
toxicology screening.
Resuf ts, Of 5,731 patients, 2|JA!) (A|o/a) had positive toxicology 'f screcns (IOX+). rauma patienl.s intubated within (r0 nrinutcs of 'l'OXadmission wcre more likely to b<:'l'OX+ (25.7o/o) vcrsus irr 'llhcr<: patients (15.8o/o) (P < .001). was no significant differcncc irr '['OX+ thc Clasgow Coma Score (GCS) bctwecn thesc Lwo groups. patients did have higher Injury than TOX-
Severity Score (lSS) valucs (15.6)
patients (13.5) (P < .01). Among the parameters
98 13.2 t1.Z 1 3 0 .r 9 . 1 1 6 7 I. 51 7 . 8 r76.8 t,089.6 +88.0 1.394
Scans inHead Tomographv *129fl:1il?:,1*1'Jia forcomputed
intubation (within 60 minul.es of admission) has nol. been evaluatcd. 'fhe goal of rhis study is to evaluate the need fel sarly airway irttcrvention in trauma patients with positive toxicology scrcens. spcctively exarnined for a four-year
NS .0144 .0299 NS NS
Conclusion: Serum dopamine and epinephrine are increased significantly in ethanol-intoxicated patients sustaining intracranial irrjury. Scrum norepinephrine did not demonstrate a significant 'I'hcsc biochemical markers may allow the physician to increasc. reaogrizc early patients rcquirirrg C'I scanning and neurosurgical intervontion. ln additional, determining the body's catecholamine rcsponse to cranioccrebral injury will help in understanding the physiologic changes that occur during traumatic neuronal injury.
Admission GlasgowComaScorels A PoorPredictorol the t', I t4 f Needfor EarlyAirwaylntervention in TraumaPatients With Substance Abuse SWJolin,M Domsky, DPMilzman, A Bodriguez, K [/itchell/Georgetown University Medical Center. of Emergency Medicine, Washington. Department DC;Departments Maryland of Critical CareandTrauma, MIEMSS, Baltimore, trauma has becn reported
I 1 61r 3 . 7 2 1 8 .f25 0 . 3 298.3154.2 8 1 7 .r21 3 5 . 5 7M.9 1 . 4 2r 1
variablcs were computcd
of agc,
58
Setting: University hospilal ED. Design: Prospective, controlled, randomized, double-blind trial' Type ofparticipcnts: ED Patients with isolated diagnoses of s e v e r e( c o m m o n o r c l a s s i c )m i g r a i n e . I n t e r v e n t i o n s : S u b j e c t sw e r e r a n d o m i z e d i n a l : l r a l i o t o r c e i v e a single IM injection ofeither 30 mg ketorolac tromethamine or 75
,setting: A l-evel I trauma center in a university hospital. Typebf participants: Patients with a traumatic mechanism of head injury on presentation to the ED. Intervention: High-yield criteria developed will be inrplemented in phase 2. Results: Of M8 phase-l patients, 660/owere ntale, and 48o/owerc involved in a motor vehicle accident. Eighteen percent ofpatients had positive scan results. These patients were significantly more likely to have suffered loee of consciousness and severe facial injury and to have been injured in an aseault or by an unknown mechanism. These patients also had a lower GCS (mean of 10.2 compared with 14.2 for patients with negative scans) (P <.01)' Conclusion: High-yield predictive criteria have been formulated for patients needing head CT scanning for trauma. These criterja are now being implemented to test validity in a clinical setting.
mg meperidine hydrochloride. Results: Of the 3l patients completing the trial, 15 received ketorolac and l6 received meperidine.'fhe demographic characteristics of the two groups were comparable. At one hourr ketorolac was signficantly less effective than meperidine in reducing headache pain (P = .02) and in improving clinical disability (P - '01) as measured on numerical and verbal analog scales, resPectively' The majority of the ketorolac grouP (537o) reporl'ed no improvemenl in disability during the observation period compared wirh l2'SVa of thc meperidine group (P - .001). Ketorolac also was less effective at r e d u c i n g n a u s e a ' p h o t o p h o b i a , a n d t . h cn c c d f o r r c s c u r :m e d i c a t i o n ( J ) < . 0 5 ) . S u s t a i n e d h e a d a c h r :r e l i r : f w a s e x p c r i c n c e d b y M V o o f t h e p a l i e n t s t r e a t e d w i t h m e p c r i d i n c a t l 2 - t . o2 4 - h o u r f o l l o w - u p c o m p a r e d w i t h l 3 o / oo f r h a p a t i e n t . st . r c a t c dw i t h k e t o r o l a c ( P : N S ) ' No significarrt side effects wcrt: observcd for either group. C o n c l u s i o n : I M k e t o r o l a c t r o m c t h a m i n e a s a s i n g l e a g e n t 'i s s a f e bur lcss effective than nropcridinc in t.hc El) treatment of acute
by { 2n MostLinearAnalogPainDataShouldBe Analyzed Statistical Techniques I rl fl ltlonparametric City of Missouri-Kansas GMGaddis, JA Salomone, WAWatson/University City Medicine, Kansas Department of Emergency School of Medicine, 'fhe Studybackground: l99l ACEP ResearchCataloglists14 plannedstudiesat 13 sitesunder "Pain management"or "Analgesia"headings.With increasingstudy of emergencydepartment pain management, continuous linear analog pain scales (I-APS) have become popular. LAPS validity has been confirrned 'I'he continuagainst traditional nominal and ordinal rating scales. ous nature of tAPS suggeststhat parametric techrriques could bc proper for LAPS data analysis. However, no publishcd LAPS dala '',listributions exist. Normal distribution is rcquired for parantcl.ric ,tatistical techniques. Objective: To deternrine whether LAI)S are rtorrrtally distributcd. llypothesis: LAPS data are not norrnally distributr:d. D e s i g n ,s e t l . i n g ,a n d p a r t i c i p a n t s : I ) r o s S r c c vt ir : t t o r t b l i t t d c dc v al u a tion of LAPS data from 908 consenting patienl-s with pain of less than four days' duration who prescnted to a public hospital Ul) b e t w e e nJ a n u a r y l , 1 9 9 1 , a n d M a y l , 1 9 9 1 . Interventions: Before and after the adminisl.ration of an analgesic of the physician's choice, I-APS scores were recorded on a l00-mnr scale marked only with'ono pain" to the right of the scale and "intolerable pain" to the left. Data distri-butions were compared
s e v c r em i g r a i n e .
in the and Hydroxyzine VersusMeperidine Xtl aC, Ketorolac A Prospective, of AcuteMigraineHeadache: I r)4 Treatment Trial Double-Blind Randomized, Center, Medical Francis J Aldag.B Frederick/St L Turner, F Dunaway, CDuarte, at Pe0ria of Medicine College of lllinois University S t u d y o b j c c t . i v c :1 ' o < : o m p a r cl h < :r : f f c c t i v < : r t c sosf l M k e t o r o l a c vcrsus IM mepcridinc and hydroxyzinl: irt [hr:troatment of acutc n ri g r a i n t : h c a d a < : h t : . I ) c s i g n : l ) r o s p c c l . i v c ,r a n d o m i z c d , d o u b l < : - b l i n dt r i a l ' S c t t . i n g :U r b a n c m c r g < : n c yd c p a r t m e n t w i t h a n n u a l c e n s u so f 42,000 patients. [)articipants: Forty-eight adulr migraincurs wcrc enrolled on 50 separatcvisits. Interventions: Patient.swcre randomly assigrreda single IM inject i o n o f e i t h e r k e t o r o l a < :( 6 0 n r g ) o r m e p r : r i d i n e ( 1 0 0 m g ) a n d h y d r o x t a : rm a d e ^ l z e r o , 3 0 , a n d 6 0 m i n y z i n e ( 5 0 m g ) . P a i n a s s e s s m c nw utcs usingboth visual analog and vcrbal dcscriptor scales. Rcsults:'fwenl.y-fivcpaticnts rcr:civcdkctorolac (group l), and 'l'here was no 2 5 r e c c i v c d m e p c r i d i r r ea n d h y d r o x y z i n c ( g r o u p 2 ) . b e t wrcn grouPs' s c o r c s d i l f c r e n c < :i n d c n r o g r a p h i c so r i n i t i a l p a i n A t 6 0 n r i r r u t e s ,l 5 p a t i c n t s ( 6 0 0 / o )f r o m g r o u p I v c r s u s l 4 p a t i e n t s (560/o)from group 2 reported a great dt:al of or complete relief 'fhc (P: .77). mcan pain relief scorcsa[ 60 minutes (3.35 vs 3'37) wcre not significantly differcnt. (P : -99). Nine patients (367a) from group I and seven patients (28o/o)from group 2 required additional 'fhe sample size could detmt a large effect size ana.lgesia(P : .76).
againet normality in l-SD increments by f,2. Resulte: Nine hundred eight patients had pain scores recordcd at leastonce.P < .05 indicates non-normality (Table). Group
llo. ol PredrugScorss
All lbuprcfen Ketorolac (li/ 0r P0) Narcotics
892 236 90 145
X2--
P
l{o. ol PostdrugSco.os ?(2"".,
24.32 < 001 15.81 <.01 3.77 NS 11.53 < .05
55i 182 67 12
P
5286 < 001 12.69 <.03 NS t.12 8.00 NS
Conclusion: LAPS pain data often arc not normally distributed. Nonparametric analysis is appropriate in these instances.'fhe data distribution should be validated as normal if slightly more powerful parametric techniques are used.
Double-Blind, Comparative Study ofthe Randomized, Xla||A in the I rl I Etlicacy ofKetorolac Tromethamine Versus Meperidine Treatment ol Severe Migraine Medicine Service, GLLarkin; JEPrescott/Department ofSurgery/Emergency WestVirginia University Health Science Center. Morgantown Study objective: tromethamine
To compare
and meperidine
the efficacy
of kr:torolac
in thc cmergency
deparlmcnt.
trcat-
ment of severe migraine.
59
of .80 with a statistical power of t)Io/o. Conclusion: Ketorolac is as effectivc as meperidine and hydroxyzine for the trcatment of acute migraine headache and should be considcredasana|ternativetonarcolicsintheED.>
Comparison ol lV Metoclopramide, Ketorolac, andMorphine { 22 I rlrJ fortheAcuteReliefof RenalColic BLfimerding, P Hite,S Gin-Shaw, W Bowen. K FaningtonAfiake Forest University Medical Center, Winston-Salem, NorthCarolina; Maricopa Medical Center, Phoenix, Arizona Study objective: Metoclopramide and nonsteroidal anti-inllammatory drugs have been touted as effective alternatiyes for renal colic pain. This study sought to compare the efficacies of IV metoclopramide, ketorolac, and morphine for the treatment of acute renal colic. Design: Ongoing prospective, randomized, double-blind clinical trial. Setting: Two teaching hospital emergency departments irr thc s o u t h w e s ta r r d s o u t h e a s tU n i t e d S t a t c s . Type ofparticipants: Patients bcrwcen thc ages of l8 and 70 presenting with acute renal colic necessitating immediatc pain relief. Final inclusion in the study also required a positive IV pyelogram, positive renal ultrasound, or hematuria. Interventions: Study participants received IV administration of either metoclopramide 0.5 mglkg, ketorolac 0.6 mglkg, or morphine 0.1 mglkg. Degree of pain wae evaluated by the patients via a visual a n a l o g s c a l ea t 1 5 , 3 0 , 6 0 , a n d 1 2 0 m i n u t e s a f t e r a d m i n i s t r a r i o n . Results: Twelve patients received metoclopramide, l5 received ketorolac, and l3 received morphin<:. Ketorolac rerrdcred thc fastcst. o n s e l o f p a i n r c l i e f a t l 5 m i n u r c s ( r , < . 0 S ) , l h c g r c a l e s t .d u r a r i o r r o f r c l i e f a t m o r c t h a n 1 5 0 m i n u t e s ( t , < . 0 3 ) , a n d r h e g r e a t c s td e g r c c o f relief at 60 minutes after administration (P < .05). Metoclopramidc and morphinc did not differ significantly in onser of pain rclief.'llhc most common side effects were drowsincss (metoclopra nide, So/o; ketorolac, 60lo; morphine , MVo) and persistent or de noao emt:srs (metocloprami d,e,|Va ; ketorolac, 6Vo; morphine r'.)lo/o.) Conclusion: Ve conclude that IV ketorolac is a safe, rapidly cffective means of relieving renal colic pain. In addition, the duration of relief from ketorolac is significantly greater than that from either metoclopramide or morphine. No dilferences were fourrd b e t w e e nm e t o c l o p r a m i d e a n d m o r p h i n c i n o n s e r o f a c t i o n , d u r a t i o r r of relief, or degrec of relief rcndered.
1 34
fi:ilrr"n
l07o seizuree (P< .002 compared with group l) and9OTa death. Group 5 received MK-801 followed by cocaine and then were mechanically ventilated after respiratory arrest. They had207o seizures (P < .002 compared with group I), and no animals in this group died (P < .002 compared with group I or 4). Group 6 received valproic acid (400 mglkg) followed by cocaine. This resulted in 2070 seizures (P <.002 compared with group I) andX)Vo death. Group 7 received valproic acid followed by cocaine and were then mehanically ventilated. They had 307o seizuree (P < .002 compared with group l), and all animals survived. Conclusion: Mechanical ventilation reducee cocaine lethality. Cocaine-induced death was prevented totaUy by combination of anticonvulsants and mechanical ventilation. In addition to seizures, reepiratory depression in itself is a mechaniam of death.
ClassCalciumBlockersto { 2 tr Failureol Dihydrophyridine I rfd AntagonizeGocaineToxicity BWDerlet, J Tseng, TEAlbertson/University of California, Davis Study hypothesis:Calciumchannelblockere(CCBs)antagonize cocaine toxicity. Design: Male Sprague-Dawley rats weighing between 200 and 300 g received vehicle or nifedipine (nifed) or nimodipine (nimo) intrapcritoneally (IP) or IV either before or after challenge with cocaine (75 mglkg) IP. All agents werc delivered in a volume of I ml/kg. 'l'cn animals were studicd in cach group and observed for behavior < : h a n g c ss, c i z u r e s , o r d e a t h . l n t e r v e n t i o n s : I n j e c t i o n o f C C B s i n t o c o c a i n e - i n t o x i c a t e dr a t s . Ilesults: Animals in the vehicle group (control) displayed stereorypic behavior after cocaine and developed seizures in 5.6 + 1.0 minutes and respiratory arresl. in 9.8 + L4 minutes. Behavior, seizures, and time to arrest in groups pretreated or post-treated with CCIIs were not statistically different compared with controls (Table). Group TrsEtmont 1 Tim (min)' Trostmont 2 % Soizulos 06Deslh
Depression asa Mechanism ofCocaine-tnduced
B W D e r l e t J. T s e n g T , EA l b e r t s o n / U n i v e r soi tfyC a l i f o r n i a Davrs S t u d y o b j c c t i v e : ' I o d e t e r m i n c i f r e s p i r a t o r y d c p r e s s i o ni s a r r i m p o r t a n t m c c h a n i s m o f c o c a i n e - i r r d u c e d d e a t h i n c o n s c i o u sr a t s . Design: Male Sprague-Dawley rats received intraperitoncal (lp) saline (vehicle), MK-801, or valproic acid and then wcre challerrgcd 30 minutes later with 70 mgll<gcocaine IP. Rats were randomized to spontaneous breathing or mechanical ventilation groups. Behavior, s e i z u r e s ,d e a t h , c o r t i c a l e l e c t r o e n c e p h a l o g r a m s ,a n d E C G s w e r e recorded. I n t e r v e n t i o n s: A n t i c o n v u l s a n t a d m i n i s t r a t i o n a n d / o r m e c h a n i c a l ventila tion. R e s u l t . s I: n g r o u p I , a n i m a l s r c c c i v e d s a l i n e f o l l o w ed b y c o < : a i n c 'fhe incidence rates of seizurc and dcath wcre 92Vo undBJok, respectively. Group 2 rmeived salirrc followed by co<:aincand then were mechanically ventilated after respiratory arrest- 'I'his group had l00vo seizures and 67Vo death. Group 3 also received salinc followed by cocaine but were mechanically ventilated immediately after the first seizures with the result of l00%o seizures and JTVo death, the latter being significantly (P < .025) reduced compared with group l. In group 4, the NMDA antagonistand anticonyulsant MK-801 (t mg&g) was given before cocaine challenge, resulting in
1 ? 3 4 5 6 I I I
Vehicle lP N i f e d0 . 5 l P Nimo0.5lP Vehicle lV N i f e d0 . 1l V Nimo0llV Cocaine lP Cocaine lP C o s i n el P
30 30 30 l0 10 10 3 il 3
C o m i n leP CocaineIP CominelP Cocaine lP Cocaine lP CominelP VehiclelV Nifcdc0 2 lV Nimo0.2lV
80 90 79 90 80 90
70 90 50 80 70 80
90 100 90
90 80 80
'I imebetween treatments 1and2.Above doses ofnimoandniledaregiveninmg/kg. Nostatistimllysignificant reduclion rndeath orsuureswasseen. Conclusion: The dihydrophyridine class CCBs nimo and nifed do not antagonize cocaine toxicity in this model.
| 2A Ellectof Delayof TreatmentWith SodiumPolystyrene I rJlJ Sulfonate(SPSIon its Ability to LowerSerumLithium Concentrations in Mice JGLinakis, KMHull,C Lee,PGLacouture, TJ Maher,WJ Lewander/Section of Emergency Medicine andDepartment of Pediatrics, BrownUniversity; Bhode lsland Hospital; Bhode lsland Poison Center. Providence; Massachusetts College of Pharmacy Study objative: In earlier studies,sodiumpolystyrenesulfonate (SPS)was shownto lower serumlithium (Li) concentrationewhen administeredorally immediatelyafter an orogastricinfusion of LiCl in mice.The presentstudy wasintendedto determinewhetherdelay in administrationof SPS attenuatesits ability to reduceserumLi concentra tions. Design: Placebo-controlled
animal
study.
into two main Intervention: The study involved 306 mice, divided lavage' g.orpr. All mice initially received LiCl (250 *dkg)-by.oral 5 g/kg (group of dose a in SPS received group one Eob*q,r"ttly, (controls)' SPS), and the other reeived water in an equal volume water or SPS receive to eubdivided werefurther Th.r. g"oop" after LiCl (time 0) or 15, 30, or 45 minutes after "i,t ". i*-"dl"tely five hours)LiCl (gastrointestinal transit times were approximately groupe were killed Subgi"o,rp. of mice from each of these treatment and serum "t oi", t*o, four, and eight hours after Li treatmentt was analyzed for Li concentrations' S) demonReeults: Statistical analyses (ANOVA and Scheffe's concentraLions strated that overall SPS reeulted in lower serum Li there was no at each of the times of death (P < '001)' I{owevero after a delay effect of treatment delay; that is, animals treated showednoincreaseintheirserumLiconcentrationscomparedwith of death' the thoee treated immediately. Furthermore, at each time and controls group sPS the betweerr concentratione difference in Li (ie' no inleraction ,n". "orr.t"trt regardless of the delay in treatment of the treatment group and delay factors)' of SPS did not Conclusion: Moderate delays in the administration animal an in concentrations Li serum Iower to impair its ability of Li *od.l, Thi. effect may have been the result of the interruption Whethcr elimination' of Li enhancement the or absorption by SPS of SPS remains -o." p.aorri"d delays will impede the effectiveness to be determined. R e o e t i t i v eD o s e so l S o d i u m P o l y s t y r e n eS u l l o n a t eE n h a n c e a 4a
Tahls 2.
Tlme Allsr Li Admnidration (h1)
2 1 ---5ti(mEqArSD) 7'13111 8 . 01 0 . 6 5 1?91949 Gr.rtl,ls/11"0 s 771043 6 88t0 sl 6 521046 ;fi; i'ilffii6 r21os4 7 4 e + o 2 e 7 1oio84 ;;;;;;iH;o 4 6610.63 6 15+ 15 6 2110 64 Li/siSt Grouo 'siqnificanllY overall NS/H,0 thangmup lower I i/Hr0overall 'sidnrficantly thangroup lower that repetitive doses of C"o.clusiont Statistical utuly'"t revealed ['r' SPS also lowSPS enhanced the elimination of IV administered those not treatin as well as Li with treated ered K levels in animals ed with Li.
of rreatnent |orthe 3g l:'jll'r1i1,11*?,'ff:llt;l*'"'''" andDrug Poison Mountain Rocky
'.I
KWKuligfihe MAKirk, if gwnift,JBrent, Sclences Health ofColorado Univeisity Hospital, General irn,tt Otnutt State Pennsylvania The Center' Medical Hershey S Cr.itt,if-rtMllton UniversitY -
of topical magnesium Si"ay objective: To determine the cfficacy acid (HF) burns' -and calcium treattnents for dermal hydrofluoric fur removed from the had rabbits Zealand New Fifreen il;;' was applied for three rheir backs. After anesthesia, 150 pI, :]67o|lF o r t e - m i n u t cr t l t s e ' a A f t c r s p i n e ' t h < : a l o n g s i t c s mittutcs to four block design' Each rabbit lreat.nrcntswere applicd i" u tui"lot'i't:d r e c c i v t : da l l L r e a t m c n t s ' gluconate' magnelntervenliorts: Iiquinrolar amoullts of calcium jelly and KI KY in aII corrtairrcd II Mylot'u .i.- glt.o.,ut., uti at one' four' and minutes 20 oppii.,t blindly at lour and "1.""'*.t.
and Lithium Administered ol Parenterally I J I tfti Elimination in Mice Concentrations Potassium LowerSerum and 24 hours. WJLewander/ TJMaher' PGLacouture, burn diameter (BD) and JA tirufit,KMHull,GBLockhart, Ilesults: IJlinded observers measured Brown Pediatrlcs' of andDepartment Medicine h o urs' rated burn sitee 4 8 t n d ' ofEmergency Section 2 4 , f o u r , a t surface area (BSA) (l' 2' 3' University;RhodelslandHospital;RhodelslandPoisonCenter'P rao" .vol,de e nacn e d ;s e v e r c ) , a n d r a n k e d b u r n : e v e r i t y * o , 1.nita, using Wilk's ofPharmacy ANOIA College measures Massachusetts repeated A il *lrl,i" each rabbir' Study objectivet Previous studies have shown that orogasl'rrc Li concen(PO) sodium polystyrene sulfonate (SPS) lowers saum Additionally' ofLiCI' dose a PO after adnrinistered i.u,io.. when of PO Li' multiple-dose SPS appeared to enhance the etimirrarion doses of PO multiple whether determine to d.sig.red Thi, ,tody wus K corlcerltraSPS enhance rhe elimination of IV Li and alter serurn
tions. Design: Placebo-controlled animal study' l-icl (I25 Inteiventions: l) Seventy-five mice wcre admirristcred (group C) mglkg) IV and divided into two groups: a control group after LiCl' and """eit.d PO water 20,40' 90, liO, und 2I0 minutes of group S received SPS (5 g/kgldose) at equal times- Subgroups lreatafier hours six and four, two' one' Iu"h'g"o,rp were ki-lled at mice (60) were ment, and aerum was analyzed for Li' 2) Additional IV admiristered was mglkg) (125 LiCt tr"d io. K determinatio..' to the to half the mice, and normal ealine (NS) IV was administercd then were remaining haU. Half of the mice in each of these groups NS or l'iCI giv.. Po'wate.20,40, 90 150, and 2I0 minutes afier the other hllf relciled SPS (5 g/kg/dosc) [groops NS/H,O and Li/HrO); of cach )"t "qrut time3 (groups NSISpS and LilSI'S)' Subgroups t r e a t m ent' and a f t e r h o u r s s i x a n d g.oop *""" kilJd uio.", two, 2)' J..o* *o. analyzed for K concentrations (Tables I and Tablsl (hr) TimeAftsr[i Admnidrarion 6 4 .2 Li(mEqAlSD) 1 0741040 1151029 l56t03B 1901025 G-tpC 0 2210 08 0 4210 07 0 96t0 16 16610.27 S Croup < 005 < 005 <.005 NS P
or
for BD test criteria did not detect a treatment effect difference in tre.atment was-no There '74)' (P if = .OAZIor BSA test "oti.g determined by a Cochran-Mantel-Ilaenszel 12 itr. (P : '43)' test l"reidman'3 by deiermined rank ip = rii oi b,r.t to dctect a 33o/oredluc' 'l'his study was designcd to havc 80olopowcr ;;l;
tion in llSA. (lonclusion: ln our rabbit modcl of dormal Ill'burns' scverrty was rlot influenced by was delermincd at the time of thr:burrt and or calcium' s u b s e q u e n tt r e a t m c n t w i t h m a g n e s i u n t ..|.l| tlal
G a r b o nM o n o x i d e P r e v e n t i o no l N e u r o l o g i c S e q u e l a eF r o m
0xYgenin Bats by HYPerbaric | JJ K Kullg/Department J Brent.N Bosenberg, Budy,J Wat]hen, I fimaszewst<'i,'I NorthCarolina; Charlotte' Center' Medical Carolinas Medlcinl, of ft.,gr*V Denver' Center' Mountainfoison Rocky Boulder; U.*tttnV of Colorado, Colorado Englewood' Center, Medical Swedish Coloradoj oxygen(HBO) Study objective:To study thc ability of hyperbaric CO poisoning' t o p r e v e n t t - h . . . , . o l o g i t s e q u e l a co f s c r i o u s CO sensitivity)' b"rigt, After left caiotid iigation (t'o incrcasc, CO (l '000 to 5'000 ppm) i n c r c o s i n g w i t h p o i s o n e d w e r c r a t s Wistar recovery in room air' untiJ syncope.'l'hiswas followed by l5-minute r a n d o mized to three treatw e r e r a t s C O p o i s o n e d Itt..u"ttiots: a b s o lute(ATA)' 2) 100% a t m 3 O , r n e n t s( n r n e p e r g r o u p ) : l ) 1 0 0 4 o poisoned' Three not were uiti*ult control illine l;""i.. o. O, t liA, platform in a a hidden to days later, rals were timed in swimming later' Brains then ) hours 24 performed retesting with water mazeo
61
were examined histologically (H and E) for hippocampal no damagel 4, no viable neurons) (Table). Results: Data represent mean I SD values. liilial Swims(socl
Control C0+3ATA0, C0+ I ATA0, C0+arr
damage (0,
141[|;Jff*iffi
BFClark. BSSelden, BFurbee/UCSD Medical Center, SanDiego, California; Department ofEmergency Medicine, Maricopa Medical, Phoenix. Arizona
Bstsstswims lsoc) Hippocampal Damagg
t4.s19.9 21.5 !12.7' 22.6 r r6.3' 2 6 .1 3 r4.7'
11 . 4+ 7 . 8 0+0 12.3!8.2 1 . 10 0 j 15.9' 19.6 3 . 3 IL z t r 9 . 7j 1 5 . 4 ' 3 . 3I t . 2 r 'P< . .05vs controlby AN0VAandDuman's;no differenceamong groupsbycolumn. fP< .05vs controlbyKruskal-Wallis andDunn's, no difference amongr groups. Conclusion:
al carotid
CO exposure
ligation
until
ofwound Inrection Following Grotarid
syncope in rats who had unilater-
caused performance
deficits in a water maze swim times) and hippocampal damage. I{BO (3 ATA 02) had no effect on initial swim times but prevented memory deficitslt 24-hour retest. Hisrologically, HllO prevenred CO hippocampal (increased
damage.
intheEmergency Oepartment: Glinical Features 1 'ltf An BeeStings I andtheNeedforEmergency Medical Care JJKelly. philadelphia BMMcNamara/The Medical College ofpennsylvania, Study objective: As summer turns Lo fall, bee stings become a very common emergency department complaint. 'I'he purposc of this study was to examine the spcctrum ofpatients prcsenting to [he I I D a f t e r h y n r e n o p t e r a e n v e n o m a t i o n a n d t o d e L a i l t . h e i r< : l i n i c a l f e a t u r e s a n d a s s e s st h e n e e d f o r h o s p i t a l - b a s e de m e r g r : r r c y< : a r c . Design: Retrospective chart revicw for tlre timc pcriod of August I through September 30, 1991. Paticnts were identified by cxarnirration ofthe ED daily log sheet, and their medical records werc sought for review. Setting: The EDs of an urban academic medical center and two community hospitals, one urban and one suburban. Participants: All patients presenting to the ED with a history of a recent bee sting were eligille. This was a consecutive samplc of 240 patiente. Of these, ten \tere excluded because the chart was unavail_ able or the patient left before examination by a physician. Thc 230 involved patients representcd l-5o/o of all patients evaluatcd in thc ED during this period. l n t e r v e n t i o n s ; P a t i e n t s w e r e c l a s s i f i e db y t h e a u t h o r s i n t o t h o s c r c q u i r i n g o n l y b a s i c m e d i c a l c a r < :a n d t h o s c i r r w h o m c v a l u a t i o n i n the ED was considcred appropriatr:. l l e s u l t s : O f t h e 2 3 0 i n c l u d e d p a r i c n t . s ,I 7 3 ( 7 5 . z o / a )p r e s c n r c d with purely local rcactions and wcr<:judgcd to rcquirc only basi<: medical care. Of the remaining 5? parienrs (24.BVa), the following were felt to be appropriate users of the ED: nine with symptoms and signs of a systemic reactionl ten with symptoms of a systemic reac_ tion, but no signs; eight with envenomations of,the tongue or airway; eight with a generalized cutaneous reactionl two with symp_ t o m s o f a g e n e r a l i z e dc u t a n e o u s r e a c t i o n , b u t n o s i g r r s ;a n d s i x w i r h a retained sLinger apparatus. I n a d d i t i o r r , t h e r e w e r e l 4 p a t i e n t s t r e a t e d a s i n f c c t e d s t i n g s ,b u t o n l y t h r e e o f t h e s eh a d o b j e c t i v e c v i d c n c e o f i n f c c t i o n b c y o n d w h a t m a y u s u a l l y b c s e e nw i t h a l o c a l r e a c t i o n t o h y m c n o p t e r a c n v e n o mation. Conclusion: fhe majority of palients presenting ro rhc IiD aftcr sustaining a bee sting will require on.ly basic medical care that carr be provided at home or in a less costly setting than the ED. Publi<: education during the months before o,bre sting season" may help reduce the cost of emergency health care.
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Study objective: Many sources advocate the empiric use of antfiiotics to prevent wound infection (VI) after crotalid (rattlesnake) envenomations. It has ben suggestedthat crotalide produce bacteriocidal enzymes within their venom that may inhibit the development of infetione after envenomation, We undertook a prospective study to observe the incidence of infections following crotalid envenomation to test our hypothesis that there would be no difference in the incidence of "WI" in patients receiving prophylactic antibiotics. Design: Prospective evaluation ofpatients with crotalid envenomations who presented to our ingtitution with follow-up by dirett examination or telephone consultation. A WI wag a clinical definition based on the presence of three or more of the following: fever, a positive wound culture, erythema, swellingo or purulence at the bite site. Setting: Urban hospital and poison control center in Phoenix, Alizona. 'Iype of parricipants: All paticnts presenting to our institution bctween Juno 1990 and O<:t.oberl99l wirh history and clinical evid t : n c eo f c r o t . a l i de n v e n o m a t i o n . I n t e r v e n l . i o n s :I l o u t i n e m a n a g e m e n to f c r o t a l i d e n v e n o m a t i o n , including thc use of antivenom, surgical debridement, and antfiiotics when indicated. Results: A total of54 patients were entered into the study. Patients were classified into mild, moderate, or severe envenomations. All bites occurred to the trunk or extremities. Twelve patiente received prophylactic antibiotics begun either before tranefer to our institution or after a surgical procedure. The compositions of mild, moderate, and severc envenomations were similar when comparing groups that did (AB) and did not (NAB) receive antibioiics. One paticnt developed clinical evidence of VI before initial discharge from the hospital (AB group). Follow-up was obtained on 4l patients sevclror morc days afler envenomation (32 NAB, nine AB). WI occurrcd in two additional patients in this group (one NAB and one AB). if'he incidcnce of WI in the Al| group was lwo of nine (22Vo). The incidence of WI in the NAI} group was not. increased at one of 32 (3%) (Fisher's exact test, P = .12). All parients developing VI had nrodcrate envenomations. Eighteen patients required a surgical procedure such as debridement after envenomation (eix were placed on prophylatic antibiotics after surgery), but none developed WI. Eleven patients received IV sreriods in the management of mild hypersensitivity reactions to antivenom, but none developed WI. 'I'wenty-six patients had some form of prehospital intervention consisting of the placement of a ligarure (15), elecrroshock to the bite site (one), cryolherapy (ice; six), or cur.ring and sucking of the bite sitc (four), but only one of thesc patients (cryotherapy) developed WI. Conclusion: Wc conclude that the incidencc ofinfection is not dccreased in patients who receive prophylactic antibiotics after crotalid envenomation, and, therefore, they are not indicated routinely.
Asphyxial Cardiac ArrestSurvival Xl ll Modelin RatsWith I 'lA 0uantitative BrainHistopathologic Eyaluation LKan,KM Sim,A Radovsky, RNeumar, UEbmeyer. PSafar/lnternational Resuscitation Research Center andAffiliated Residency in Emergency Medicine, University ofPittsburgh, Pennsylvania
Results: We evaluated 2"404 consecutive adult victimg of OHCA ofpresumed primary cardiac etiology. Although survival "rates" with asystole, PIYR, and claesic EMD were 1.67o , 4.77o , and 6.97o, respectiyely, 22.2Vo of the 193 surviving study patients (confidence interval, t5.9%) initially presented with one of these rhythms (14 asystole, l8 PM, ten EMD, and one other). Conclusion: Despite poor survival rates, resuscitation efforts in those with asystole, PIVR, and EMD contribute significantly to total cardiac arrest survivorship. Initial efforts ehould not be waived in these patient.s.
Study objective: To develop a reproducible animal outcome model that quantifies brain hietopathologic damage after asphyxial cardiac arrest (ACA) in rats. Design: Prospective controlled trial using 24 male SpragueDawley rats (weight,350 to 450 g) randomized into sham (S, surgery and no asphyxia;6) or asphyxia (A, surgery, asphyxia, and CPR; l8) groups. Interventions: S and A rate underwent anesthesia, intubation and controlled ventilation (IPPV), placement of aortic and IVC catheters, and paralysis with vecuronium. Group A wae asphyxiated by discontinuing IPPV, resulting in cardiac arrest within three minutes. After eight minutes of asphyxia, CPR was begun using IPPV, chest compressions, IV epinephrine, and NaHCOr. S and A animale were weaned from IPPV one hour after return of spontaneous circulation (ROSC). Animals were killed at one, r.hree, or seven days after the insult. Brains were perfusion-fixed with parafqrmaldehyde and examined by light microscopy. Ischemic neuronal changes (INC) were quantified by courrting the ischenric neurons divided by the total number of rreurons in the CAI region of the hippocampus. Results: Sixteen of I8 animals had IiOSC. Fourteen of 18 were extubated and survived lo fixation. Shanr rats had,\Vo INC at one, three, or seven days after ROSC. Group A had,\Vo INC at one day, 5 2 t l l V o I N C a t t h r e e d a y s oa n d $ t s q a I N C a t s e v e n d a y s . I n group A, INCe at three and seven days were significantly djfferenr compared with S (ANOVA and Tukey's test, P < .01). Conclusion: ACA of eight minutes consistently produces INCs in the hippocampus at three and seven days after ROSC. This ACA model is efficient and inexpensive, and it reliably quantirates INCs. The model shows promise as a tool for evaluating brain rceusciLation therapies.
n i Characterization of Systemic Oxygen Transport Patterns Aftel rlrl I Hunnn Cardiac Arrest: lmplications lor Survival EPRivers,MY Bady,GB Martin, H Smithline,TJ Appleton,BM Nowak/Henry F o r dH o s p i t a lD , e t r o i tM , ichigan Study objective: To characterize the O, transport patterns of patients resuecitated from cardiac arrest (CA) and their relationship to survival. Design: Ca se-controlled, consecutive series. Setring: Urban emergency departrnent. Participants: Adult patients presenting in CA who develop a r e t u r n o f s p o n t a n e o u sc i r c u l a t i o n ( I t O S C ) . I n t e r v e n t i o n s: ' f w e n t y - t h r e e c o n s e c u i l v e n o r m o t h e r m i c , n o n t r a u rrratic CA patients succcssfully resuscitatcd by advanced cardiac lile supporl. (ACLS) werc studied in the IiD over six hours. An aortic and fiberoptic mixed venous O, saturatiorr (Svor) pulmon ary arlery catheter was placed. Survivors livcd for 24 hours or longer. Mean arl.erial pressure (MAP), cardiac index, systemic O, delivery (Dor), systemic O, corrsumption (VOr), and O, extraction ratios (OER) were calculated using standard equations. The duration ofcardiac arrest (DCA) and epinephr:ine dosc required during ACLS are reportcd below. P values werc calculated using unpaired I tests. Results: The mean values (SD) over the six-hour period are shown. I
Survivors
Cardiac ArrestPatients Presenting WithAsystole or ECG I Aa | 'lr.l Complexes WithoutPulses: Contribution of Resuscitation Efforts TowardTotalSurvivorship PEPepe, BLLevine, REFromm, P4Curka,PS Clark/Department ofMedicine. Baylor College ofMedicine; CityofHouston Emergency Medical Services. Texas Study objective: The medical literature portrays poor prognoses for out-of-hospital cardiac arrect (OI{CA) patients presenting wirh asystole, idioventricular rhythms with pulselessness(PIVR), or electromechanical dissociation (EMD) with normal-appearing ECG complexes. With evolving recommendations to waive resuscil.aliorr in such patients, our purpose was to delermine the contribution of resuscitation efforts in casespresent-ing with asystole, PIVR, and EMD to overall survivorship fron OFICA. Desigrr, setting, and participanl.s: Excluding cases associated with trauma, drugs, or primary respiral.ory lllness, all OHCA cases occurring in a large municipality were analyzed prospectively for two years in terms of presenting rhythm, age, 6ex, wit_ne8sstatus, bystander CPR, and survival to hospital discharge. Interventions: Advanced cardiac life support was provided in all casesby a tiered emergency medical technician-paramedic emergency medical services response ByEtem.Frequency ofbystander CPR was237o.
Nonsurvivors
P
No. 10 13 N/AP{mm Hs) 103(6) 9?(8) 3l (L/min.mz) Cardiac index 2.8(0.3) 1.210.21 001 Svo,{7"i 66(1.9) 6912.7) 05 0oz(ml/min m2' 4M(58) 167(231 001 Vo,{ml/min mr} 128(l) 55{7) 001 0tn(%) 43{10) 5 1( 1 1 ) 07 (min) OCA 28{5) 36(6) 28 [pinephrine 11{4) 26(6) 05 {mg) Conclusion: Nonsurvivors exhibit defects in systemic O, utilization as characterizcd by an inability to increase their OER despite a lower Do, compared with survivors. lligher doses ofepinephrine re.ceivedduring ACLS in nonsurvivors may have a casual relationship in the low VO, obscrved. Failure to attain a Vo, of more than 90 m[-/min'm2 in the first six hours after ROSC caruies a 1007o mortality at 24 hours.
ol Deferoxamine and21-Aminosteroid on +tl Alln VitroEllect I I -lr, Hyperbaric-lnduced LipidPeroxidation in BatBrain KMascotti, M Biros, T Nida, PKim,BPauley/University of Minnesota Medical School, Minneapolis; Department ofEmergency Hennepin Medicine, County; Department ofNeurosurgery, Universlty ofl\,4innesota Srudy background: Despite its suspected benefits for certain clinical problems, hyperbaric oxygen ([IBO) therapy may causâ&#x201A;Ź oxygâ&#x201A;Źn toxicity by inducing membrane lipid peroxidation. Study objective: The purpose of this study was to investigate the c f f e c t i v e n e s so f D F O ( a n i r o n c h e l a t o r ) a n d 2 l - A S ( a n a n t i o x i d a n t ) ,
63
alone or in combination, on llBo-irrduced lipid peroxidation of rat brain homogenates. Design and interventions: Nine adult Sprague-Dawley rats were euthanized with halothane. The brains were removed immediately, and each cortex was homogenized separately. Aliquots of homogenized tissue from each cortex were treated with DFO (0.005 mm), 2l-AS (0.00001mm), both DFO and 2l-AS, or normal saline (NS). Treated samples from each cortex then were exposed to 90 minutes of IOOVaoxygen at 1.5 ATA or normobaric room air (NRA) for 90 minutes. Lipid peroxidation was determined by spectrophotometric a s s a yo f t h i o b a r b i t u r a t e ( T B a r s ) p r o d u c t s a n d c o m p a r e d a s a b s o r b a n c e a t 5 3 2 n m . m g w e l .w t t i s s u c . C o m p a r i s o n s w e r e m a d c using ANOVA and Scheffe's tesr, wirh significance ser ar P < .0S. Results: The results are summarized (Table). In HllO-exposed homogenates, mcasured TBars increased sigrifi ca ntly compared with NRA-exposed samples, and both DFO and 2l-AS treatment significantly reduced TBars compared with NS. Combined 2l-AS and DFO treatment did nor reduce'fBARs morc rhan DFO rrear ment alone.
Results: Unambiguoue reproducible spectra and pH. valuee were obtained. HEP changes were observed during arrest and CPR with Pi continuing to increase and shift. No MDPA shift was deteted, indicating no shift of resonance from CPR motion. Motion of the CPR device did not perturb the magnetic field. Conclusion: CPR during MRS is possible and allows for adequate reproducible signal acquisition without gating. This technique should allow MRS to become an extremely powerful tool to allow real-time evaluation of baeic cellular processes and effects of therapy on the brain during actual CPR. Fluorescent Histochemical Localization of Lipid Peroxidation 4 'I-, l I f D u r i n gB r a i n R e p e r f u s i o n BC White.JA Rafols,DJ DeGracia,JM Skjaerlund,GS Krause/Departments of Emergency Medicineand Anatomyand Cell Biology,Wayne State University S c h o ool f M e d i c i n eD , etroit Study objective: To histologically localize postischemic peroxidative brain injury. Design: Ve used fluorescence rnicroscopy to evaluate an in siru reaction of thiobarbituric acid (TBA) with brain peroxidation products. A perfusion fixative (507o aldehyde-free methanol rl0To acetic acid,2 mm EDTA,0.047o butylated hydroxytoluene, and 0.3757o TBA) was introduced through the left ventricle after a saline w a s h o u t l ) i r r n o n i s c h e m i cr a t s , 2 ) a f t e r t e n m i n u t e s o f c a r d i a c arrest, and 3) after 90 minutes and 4) six hours ofreperfueion. The hcads werc hcated at 80 C-for onc hour, the brains were removed, and sections (40 to 50 pm) were prcpared on chromalum subbed glass slidcs and coverslippcd using aquamount; adjacent sections worc Nissl stained. Perfusion-fixation wirh all reagents except TBA provided controls for evaluatiorr of in situ formation of the TBAmalondialdehyde (MD) adduct by difference spetroscopy after tissue extraction with methylethylketone and evaluation ofTBA dependence of microscopic fluorescence (fluoreecence excitation peak for the TBA-MDA adduct, 515 nm). Results: Difference spectra confirmed in sitz formation of the 'I'IIA-MDA adduct. Ffuorescence was not seen when TBA was omittcd from the perfusion frxativc. Nissl-stained sections revealed good l.issuefixation without post-mortcm artifacts. 'fhere is little fluoresccrrcc present in normals or brains aftcr ischemia only. However, aft.cr eithcr 90 or 24O minutcs of reperfusion, intense fluoreecenceie s<:enin thc soma (especially at thc base of the apical dendrite) of numerous pyramidal neurons in cortical layers 5 and 6 and the pyramidal layer of Ammon's horn in the hippocampus. The nuclei of these cells exhibit little fluorescence . Neither glia nor white mattcr exhibit similar fluorescence. Conclusion: Neuron cell bodies in the selectively vulnerable zones of the cortex and hippocampus are specific targets of peroxidation during postischemic reperfusion.
M6anAbsorbancoal 532nm {+ SDymgwot wt Troalmgrt(l{ = 9l
. HBO + H80 Df0 0 . 4 1( 90r 1 ) (0038) 0.227 2I.AS 0.12210.1131 0.364 {0057) DF0+21-AS 0 4 0( 0r 2 4 0 24r {0.038) NS ? 5t? l0 3491 l 29r(0.2bb) Conclusion: Although borh l)li'O and 2l-AS appcar to rcduc<: I I I J O - i n d u c c d l i p i d p e r o x i d a t i o n i r r r a r L r r a i r rh o m o g c n a t < : sD, I i ' O i s significantly more effectivc. 'I'hc <:ombination of 2 t-AS and DI,'O is no more effective than DFO treatnrcnI alonc.
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ofMagnetic Resonance Spectroscopy During llflThe Evaluation f T[l CPRWitha NewNonferromagnetic CpRDevice
KBWard. DSWilliams, EADavis, JJ Menegazzi, M Baldwin, C Ho/University pittsburgh of Pittsburgh Affiliated Besidency in Emergency Medicine; NMR Center forBiomedical Besearch, Carnegie MellonUniversity Studyobjective:Magneticresonancc spectroscopy (MIiS) allows noninvasive real-timemeasuretrrent of high-energy phospharcs (IIEP) and intracellularpH (pIl,). 'l'o dare,MllS has rrolbecnusr:d duringCPR low-flowstatesbe<:ausr: of thc inabilityro pcrforrnCpll ir the magneticfield. Ve evaluatcdMIIS during CPll pcrfornrr:d by a m i c r o p r o c c s s o r r e m o t e - c o n l . r o l l < :;dr r r c u n r a t i c a l l yd r i v c n r r o n f c r r o nragnetic CPII system. Design: Prospective technology assessrrcnl using a swine model of cardiac arrest (four swine; weight, 2l t2 kg). I n t e r v e n t i o n s : A f t e r a n e s t h e s i aa n d i n s t r u m e n t a t i o n , t h e s c a l p a t the apex of the head was removed. A spmially designed butterfly coil was placed at ihe apex to allow signalacquisition to be obtairred from areas of both sides of the frontal/parietal cortex. Animals werc placed supinc in a Bruker Biospm 4.7- f 40-cm horizontal-borc magnetwith the CPR device applied. 'l'hc coil was tuned [o 3rP al 8 l M H z . T h e m a g n e t w a s s h i m n r e d t o a c h i c v ep r o t o r r l i n e w i d t h o f l e s st h a n 5 0 H z . W i t h o u t g a t i n g , 3 l I , M I I S s i g n a l sw e r e a c c u n r u l a t c d e v e r y 2 . 5 m i n u t e s i n s e q u e n t i a l b l o c k s o f ? 2 s o a r r sa I r e p c t i t i o r r times of 2.0 minutes. An exterrralstarrdard of mcthylcnc diphosphonic acid (MDPA) was placed on the coil [o dcrect any shift of rcson a n c e s d u e t o C P R m o t i o n . A f t e r c a r d i a c a r r e s t a n d 8 . 0 r r r i n u t c so f no flow, 30 minutes of CPR werc performed (80 CIrM, 2-in depth, 50:50 duty cycle, pressure-cycled ventilation after each fifrh compression). pIL was calculated by nreasuring the inorganic phosphatc (Pi) peak relative to phosphocrearine (PCr) resonance signal shifr.
ofStandard andDeepEndotracheal Epinephrine Xt AQ Comparison I 'ttl in a Prolonged SwineCardiac ArrestModel A Doctor, JJ Menegazzi, EDavis/University ofPittsburgh, Center for Emergency Medicine ofWestern Pennsylva"nia
64
Study objative: Clinical experience with standard endotracheal dclivery (IiT) of epinephrine (EPI) has been suboptimal. The tracheobronchial tree and alveolar bed appcar to have different absorption ratesl preferent.ial alveolar delivery may enhance absorption. We hypothesized deep ET EPI would produce higher EPI lcvels and coronary perfusion pressures (CPP) compared with standard deliverv.
Design: Rqndomized, controlled, unblinded labora tory investigation. Intervention: After an eight-minute ventricular fibrillation arrest with no intervention, three attempted defiIrillations, and 90 seconds of mechanical CPR, l5 swine (weight, 16 to 24 kg) received 0.I4 mg&g EPI diluted to l0 mL in sterile water. After randomiza_ tion, EPI was given via either the external port of the ET tube (standard) or through a l&-gauge 60-cm catheter with six sideports inserted 45 cm beyond the external port of the ET tube ldeepj. ECG, right atrial, and aortic pressures were recorded. Arterial blood was drawn at baseline and at 3O-secondintervals after d.rug delivery. EPI levels meaeured by high-performance liquid chromatography and CPP were examined. Analyses were performed using repeated measures ANOVA, Tok.y', multiple comparisons, and Pearsonns correlation. Results: CPP correlated with EPI levels (r : .69) (p = .0000I). CPP (mm Hg) did not differ during NSR (deep, I09 * 6; srandard, 95 t 9) or CPR (dep, l? * 3; standard, l8 + ?), nor did EpI levels (ng/mL) during NSR (deep, 0.9 + 0.4; standard, l.S t 0.5) or CpIl (deep,89 * 52; etandard r62 +231. The most profound differences between techniques were found within 1.5 minutes after delivery. Data.are given below by time after drug delivery (Table). Tim (ninl
t.5 a 4.5 SdtPl 3 0 r1 7 8 3 6 4 1 1 1331 9 t 1 23f t' 2 x 1 Z3A4 4 ! 1 z2t t dt t9 1 3 t z l t 4 63 2 6 i t i 3 0 e e p E P t5 8 S6l 2 .7 4 4 61 9 .7 4 S5l 3 ' 7 1 8 j j 0 0 . 0 8 3 1 1 0 i , 6 5 8 j 1 4 4 05 , 50gt t0B10t 8 0 srdcPP 2113 26!4 23!4 23!7 25lB 21i5 1818 l2r8 DeepCPP 3 5 1 i 0 .4 1 1 t 1 4 4 1 8 . 4 0 1 7 ' 3 4 1 8 3 3 1 1 03 9 1 9 2 5 1 t 3 'P<.05 Conclusion: Deep instillation of ET EpI resultcd in significanrly higher EPI levels for three minutes and higher Cpp for two minutes after delivery. Correlation was found between EpI levels and Cpp. Clinical use of thie technique may result in a superior ET delivery system.
1 49 tr"rrrsophageal Echocardiography During Human cpR MGGoetting, NAl-Khaled, SSmith/Department ofpediatrics, William Beaumont Hospital, Royal Oak, Michigan; Department ofpediatrics, Henry Ford Hospital, Detroit. Mlchigan Study objective: To better define lhc rncchanisnr ofblood flow in CPR. Design: Prospective study. Setting: A large urban emergency center. Patients: Ten adults in arrest undergoing mechanical (Thumper) CPR. Interventions: Transesophageal echocardiography was begun 16.9 + 13.2 minutes after starrine CpR.
produces a hybrid of volume and pressure pump effects. Propoeed changes in CPR technique should take advantage of these observations.
*l
Survival AfterPrehospital Cardiac Arrest: trn 0ne-Year f rrU TheUtsteinStyleAppliedto a Suburban-Rural System I Kass, DREitel, N Sabulsky, CS0gden, DBHess/Department ofEmergency Medicine, York Hospital, York, Pennsylvania
Study objective: To evaluate the "Utetein style" (Ann Emerg llled l99l;20:861) of reporting immediate and one-year survival after prehospital cardiac arrest. Design: A retrospective review of all advanced life support (ALS) "trip sheets" and hospital records of paticnts with prehospital cardiac arrest between January 1988 and l)ecember 1989. Subsequent follow-up was performed to determine one-year survival. Setting: A suburban-rural setting with an area of I 0500square miles and estimated population of 410,000 served by a two-tier basic lifc support/AlS emergency medical services (EMS) system and cight hospitals. Type ofparticipants: All prehospital cardiac arrestsin whom r e s u s c i t a t i o nw a s a t t e m p t e d . Intervcntions: Data ext.raction from existing data base with telephone/letter follow-up to del.ermine one-year eurvival. Results:Sevenhundred lhirteen patients with cardiac arrests h a d a t t e m p t e d r e s u s c i t a t i o n sw i t h i n t h e 2 4 - m o n t h s t u d y p e r i o d . O f t h r : 6 0 1 p r e s u m e d t o b c o f c a r d i a c o l . i o l o g y ,l 9 Z ( l l . g E o ) h a d r e r u r n ofspontaneouscirculation, 3!, (5.\Eo) survived [o discharge,and 24 (4'.0o/oof total, or 690/oof eurvivors lo discharge) were alive at oneyear follow-up. 'I'hc Conclusion: Utstcin stylc is a useful algorithmic format for r e , p o r t i n gp r e h o s p i t a l c a r d i a c a r r e s I d a [ a i n a m a n n e r t h a t c o u l d allow dircctor comparison between EMS systems. Existing prehospital record-keeping practices (trip sheets) are easily adapted to this style of data collection, alrhough certain data for the remplate (such a s " r e s u s c i t a t i o n sn o t a t t e m p t e d " a n d " a l i v e a t o n e - y e a r " ) a r e m o r e difficult to ascertain. We report our own experience over a rwo-year period, including data that show lhaI the majority of patients with cardiac arrcst who survivc to hospital dischargeare still alive at one y c ar .
tltr ll HighAtrialNatriuretic FactorLevels AreMoreCommon in I rl I Human Beings During CPR andBluntthepressor Response to High-Dose Epinephrine NAParadis, J Wortsman, WBMalarkey, GBMartin,MGGoetting, EpBivers, M Feingold, BMNowak/Bellevue Hospital Medical Center, NewyorkUniversity Medical Center, NewYork; Henry Ford Hospital, Detroit, Michigan Study objective: Highcr rhan physiological doses ofepinephrine ( E P I ) a r e n e c d e d t o r a i s e p e r f u s i o n p r e s s u r e sd u r i n g C p R , b u t n o t a l l p a t i e n t s h a v c a n a d c q u a t e r e s p o n s e .E n d o g e n o u s a t r i a l n a t r i u r e t i c f a c t o r ( A N F ) c a u s e sa r t e r i a l v a s o r e l a x a t i o n a n d m a y a n t a g o r r i z eE P I d u r i n g C P I I . W e m e a s u r e d A N F a n d d e t e r m i n e d i t s r e l a t i o n s h i p t o t . h ep r e s s o r r e s p o n s c a f t c r h i g h - d o s e E p I d u r i n g standard CPII. l)esign: Prospcctivc study. Sctting: lJrban emt:rgcncy departnrcnt. 'l'ype of participanrs: Aduh paticnrs (14) in medicalcardiac arres[. A n a l y s i s : T w o - s i d e d t w o - s a m p l e! t c s t s w i t h F i s h e r ' s e x a c t t e e t f o r proportions. Intervention: Patients were separated into those with and thoae withoutdetectableserumANF:low-ANFandhigh.ANFgrouPs'>
Results: Chest compresrion uliuy, created a large concave defor_ mity of the heart focused at the tricuspid annulus m proximal right (RV). Cavirary volume decreases in descendirg o.d.. *".., ::loi"l. RV, right atrium,left atrium (LA), and left ventricle (LV). Most of the small volume change in the LV appeared to be due ro sepr.al displacernent. Neither the tricuspid nor mitral valvcs closed. 'I.he aortic valve opened in compression and closed in rclaxation. .l.hc compression phase seemed too brief for optimal chamber enrptyirrg in six patients, as cavitary emptying was still in progress at the onsel of relaxation. There was incomplete t A ."filli.e b"flre rhe eeond through fifth compressions. Conclusion: Neither the cardiac nor thoracic pump model explains blood flow with CPR. Rather, chest compre-ssionlikely
65
respectiyely. The aortic pressure responses to high-dose (O.2 mgkg) EPI were compared. The proportion with positive assays was compared with that of a control group in spontaneous circulation. Reeults: Eight patiente had low-ANF levels, and six had highANF levels. The mean level in the high-ANF group was l5l + B2 pglml-- The proportion with positive assays (six of 14) was greater than that in persons with spontaneoue circulation (three of 29) (P - .002). The maximal increases in the aortic relaxation phase pressures after EPI were 9 t 7 mm Hg in the low-ANF group and 0 + 5 mm Hg in the hth-ANF group (P - .03). The maximal increases in the aortic compreseion pressures after EPI were l7 + l3 mm Hg in the low-ANF group and 2 * l0 mm Hg in the high-ANF group ( P : . 0 3 ) . T h u s , a p r e s s o r r e s p o n s ca f t e r h i g h - d o s eE P I w a s observed in the low-ANF group but was absent in patients with high ANF. Conclusion, Cardiac arrest patients rmeiving CPR have highcr ANF levels than persons in spontaneous circulation. lligh ANF Ievels may antagonize the vasopressor effect of EPI on the arterial vasculature. Blocking this effect may improve outcomes in these p a l r e nt s .
*1
vitalsisnsintheElderly 53 orthostatic
University, Washington CWhiting/George CChudnofsky, BManfredi, Worcester Center, Medical 0f Massachusetts DC;Universl{ Washington, Study objective: To determine normal orthostatic heart rate (HR) and blood pressure (BP) changes in the community-dwelling elderly population. Design: Descriptive. Setting: Suburban adult day care and senior citizen centers. Type ofparticipants: Three hundred ninety-nine volunteers over the age of60 years. lnterventions: After the patients spent lhree minutes in a supine position, HR and BP were raorded using an automatic vital signs '.f monitor. hese measurements were repeated after the patients stood unassisted for one minute. Results: After standing,544o of subjects had a fall in systolic BP (mean, 14 mm Hg), whereas 46Vahad, a rise in systolic BP (meant lI mm Ilg). Similar variability was seen with diastolic BP. In contrast, standilrg increased llRing27o of all subjats (mean' l0). Of those individuals on ll-blockers,SSVohad, an increaee in HR (mean, l0). Of those individuals on B-blockers, SSVohad' an increase in HR ( m e a n , 5 ) c o m p a r e d w i t h 9 3 7 o o f s u b j e c t s( m e a n , 9 ) n o t t a k i n g B - b l o c k e r s( P : . 0 0 I ) . Conclusion: In the community-dwclling elderly population, there were no consisl.ent orthostatic changes in systolic or diastolic BP. ifhis suggeststhat BP may be of linritcd value in assessingvolume s t a l u s i n t h c c l d e r l y p o p u l a t i o n . F I l l , h o w e v e r , i n c r e a s e dm o d e s t l y 'fhc risc irr I-IR appears to be blunted in in thc majority of subject.s.
G a s t r i c I n l l a t i o n i n t h e U n i n t u b a t e dP a t i e n t A C o m p a r i s o no f a .rL C o m m o nV e n t i l a t i n g D e v i c e s B SF u e r s tM , J B a n n e rR , J M e l k e r / D e p a r t m e not fsS u r g e r ya n dA n e s t h e s i o l o g y , a o l l e g oe f M e d i c i n eG, a i n e s v i l l e U n i v e r s i ot yf F l o r i d C . ulttortary S t u d y o b j c c t i v e : C a s t r i c i n f l a t i o r r a r t d s u b s c q u c r t lp a s p i r a t i o n a r e w e l l k n o w n c o m p l i c a t i o r r so f m c c h a r t i c a lv c r t t . i l a t i o r t i n u n i n t u b a t e d s u b j m t s d u r i r r g c a r d i a < ia r r e c L . W c h y p o t h r : s i z ct h a r venlilation with a portable ventilator using approprial.cinspiratory paticnts taking B-blockers. ['urther studies are needed t i m e ( T , ) a n d i n s p i r a t o r y f l o w r a t e s e t t i n g s r e s u h s i n l e s sg a s t r i c to detcrminc if orthostatic changes in [IR outside this normal range irrflation tharr other devices commonly used during CPll, including will bc useful in diagnosing hypovolemia or hemorrhage in the self-inflating bag, pocket mask, and demand flow valve breathing cldcrly population. devices. and ofEarlv Features clinical inElderly: i r r v e s t i g a t i o n . Design:l)rospectivelaboratory *1 54 i:ij;,itffi1{;itis Interventions: A mechanicallung was attached via a pneumoMedicine of Emergency L Gerson/Departments BJ Munson,PB Fontanarosa, tachograph and simulated trachea to the head of a starrdard a n dC o m m u n i tH y e a l t hS c i e n c e sN, o r t h e a s t e r0nh i o U n i v e r s i t i eCso l l e g eo f R e s u s c i - A n n i cm o d e l . A s i m u l a t e d e s o p h a g u sw a s a t t a c h e d t o a y e d i c i n eA, k r o nC i t yH o s p i t a l M e d i c i n eD , e p a r t m e notf E m e r g e n cM w a t e r - c o l u m n p e a k e n d - e x p i r a t o r y p r e s s u r e v a l v e t o s i n r u l a t ct h e 'l'hc clinical presentation of acute appendicitis Study hypothesis: l o w c r e s o p h a g e a ls p h i n c t e r , w h i c h i n t u r n w a s a t t a c h e d t o a v o l u n t < : in the elderly differs between paticnts diagnosed early and thosein d i s p l a c e m e n ts p i r o m e t e r t h a t s c r v c d a s t h c s t o m a c h . L u n g c o m p l i 'l'wcnty w h o m t h e d i a g n o s i si s d e l a y e d . a n c e w a s s e t a t 0 . 0 5 f - , / c ml l r 0 t o s i n r u l a t c a c a r d i a t : a r r c s l . I)esign; lletrospective revrew. volunteer rcscuers (paramedicsor respiratory thcrapists) usedcach Setting: University-af6liatcd comnrunity teaching hospital with d e v i c e t o d e l i v c r a v o l u m e o f I L c v e r y f i v c s e c o n d sf o r a t o t a l o f 65,000 adult emergcncy departnrent visits per year, including Iive breaths while watching a flow-sensing spirometcr. I'he portablc approximately 12,000 visits by patients older than age 65v e n t i l a l o r w a s u s e d i n t w o s e p a r a t e t r i a l s w i t h ' l ' , p r e s e l e c t e da t o n e Type of participants: Ninety-five elderly Patients (mean age, 73.4 s e c o n d o r t w o s e c o n d s .T h e d e l i v c r e d v o l u m e w a s c o n t r o l l e d b y t h c years; range, 65 ro 99 years) with acute appendicitis confirmed by r c s c u e r sv i a t h c i n s p i r a t o r y f l o w r a t c c o n t r o l o n l h e v e n t i l a l o r . laparotomy and histologic findings over a ten-year period. All Tidal volume was measuredby the pneumotachograph. Gastric volpatients had appendectomies performed within 72 hours of ED ume was measuredby the spiromeler that served as the stomach. cvaluation. Patients with subacute or chronic appendicitis were Data were analyzed.using a two-factor ANOVA (Table). al|fi.t
Results: Vstrtilatol DW Pockst Vsfltilator Ssll-lnllalinOOFV Bag Highflow Lowtlow Mask {T11.0) (Tr2.0) D e l i v e r ve od l u m(em L ) 5 4 3r 1 4 8 ' 5 1 2I 1 4 4 ' / 6 9I 2 2 l
5 0 / t 1 5 6 ' 17 6 7i 1 6 5 ' 7 0 0t 1 9 7 '
G a s t r i c v o l u m e ( m8L1) 5 r 4 3 71 , 3 3 9 1 4 0 / r2 1I 5 0
300r2ll
851102
0l
groupandlowest{') andhighcsl(!}in gastric P< .05lowest(') andhighest vOlume {') in delivered gr0up.All dataaremean1 I SD volume Conclusion:
A portable
in less gastric inflation lating unintubated
ventilator
than other
patients.
set at an appropriate'I',
devices commonly
results
used for venti-
excludcd. I n t e r v e n t i o n s a n d m e a s u r c m e n t s :E D c h a r t s a n d h o s p i t a l r e c o r d s wcre reviewcd for prescntirrg clinical features, laboratory findings, and adnritting diagnoses. Patients correctly diaglrosed in the ED (carly diagnosis) were comparcd with patients whoee diagnosis bccame apparent after admission (delayed diagnosis). Statistical analysis included 72 and t tests' with significance set at P < .05Odds ratios (OR) with 95%oconfidence intervals (CI) were calculated. Results: Of the 95 patients, 62 (65Vo) were evaluated in the ED and admitted with corretly diagnosed acute appendicitis. Thirtythree patients (357o) were admitted with a diagnosis other than )
appendicitig. The most common initial misdiasnoses were bowel obstruction (nine patienrs, 27Va of d,elayedg.Jrp) and abdominal pain of uncertain etiology (eight patients ,24Vo). Sixty-four patients had perforated appendicitis, includirrg 39 patients (63Vo) with early diagnosis and 25 patients (76Vo) with delayed diagnosis. There were four deaths, one in the early group and three in the delayed group. Compared with patients with early diagnosis, those with delryed diagnosis were more likely to be older (?5.6 + 8.3 SD vs ?2.3 + S.4 SD; P - .M6), have generalized abdominal pain (OR, 4.91;9SVo Cl, 1.66 to 14.84; P = .002), lack right lower quadrant (RLQ) pain (OR, 6.7I;95Vo CI,2.B9 to 19.30; p - .0001), and lack RLe t..d.r.... (OR, 6.35; 95Vo C1,2.09 to l9.g5; p - .0004). There were no sisnificant differences between the groups with respect to duration oi symptoms, temperature, peritoneal signs, WBC count, WBC djffer_ ential, or abecessformation. Conclusion: In the study sample, absence of RLe pain or tender_ ness and presence ofgeneralized abdoninal pain were associated with a delayed diagrrosis of acute appcndicitis. Enrergency physi_ c i a n s e h o u l d b e c a r e f u l t o r u l e o u t a c u t _ ea p p < : n d i c i t i si r r c [ d c r l y p a t i e n t s w i t h a b d o m i n a l p a i n w h o d o n o l p r c s r : n f w i l h c l a s s i cs i g n s and symptoms.
Study background: Signficant delay in the adminietration of antiliotics (ABX) was found to be a cause of judgments against emergency physicians in recent malpractice casesinvolving patients with sepsis. Purpose: To quantitate the time until administration of the initial dose of ABX in ED patients admitted with the diagnosis of sepsis and to examine the effect of iniriating the AIIX orders in the ED v e r s u so n t h e i n p a t i e n t s e r v i c e . Design: Data were collected prospectively for a period of one year for quality assurance purposes. Setting: Single-institution large university hospital ED. Participants: All adult patients (67) admirred from the ED during a one-year period with a diagnosis of sepsis were reviewed. Eleven patients were dropped due to a change in diagnosie within l2 houre of admission. 'Ihre casescould not be reviewed due to an unavai.la b l c m e d i c a l r e c o r d , l e a v i n g 5 3 c a s e si n t h e s t u d y . Mct.hods: Measuremcnl.s wcrc lakcn frorn the time of triage to the d i a g n o s i so f s c p s i sa r r d t h e t i n r c o f d i a g ' n o s i st o t h c a c L u a l a d m i n i s l . r a t i o n o f A l l X . D a t a t h c n w c r < :g r o u p c d a n d a n a l y z e d a c c o r d i n g t o w h c l . h c r t . h ef i r s t d o s c o f A l i X w a s i n i r . i a l l yo r d e r r ; d i r r t h e E f ) o r a s a r ri n p a t . i e n t 'firnc Ilcsults: inrcrvals arc in hours + Sl) (and range).
| f,f,.fercentions of EmergencyCareby the Elderly:Resultsof I rf rf MulticenterFocusGrouptnterviews S/lee,U Baraff, E Bernstein. K Bradley, C Franken, LWGerson, SRHanneoan. KSKober, M Maotta, ABWolfson/UCLA School of Medicine Study objective:To determinethe elderlynsperceptionof emer_ gencycare and to identify sprcific problemsand solutions. Design:Focusgroup interviews. Settingand participants: Communityseniorcitizens"centersin BostonlLos Angeles;Pittsburgh;youngstown,Ohio; and Norwalk, Connecticut. Ambulatoryand articulateseniorcitizcnswho had
received emergency care in the past y(jar. M e a e u r e m e n t sa n d r e s u l t e : P a r t i c i p a n t s w e r c s a t i s f i c d w i t h L h c i r o,verail medical care. Long waits were a hardship for pal.ients and their families. The elderly are not familia. *ith ihe process of <:nrcr_ gency care. Many negative comments centered on thc process of communication of staff with patients. They werc frightened by thoir injury or illness, and their anxiety was not allayed unrjl they wcrc informed of the nature of their illness and what their treatmerrt and disposition were to be. Participants felt there should be patient advocates in the emergency department. The ED environment frequently made them uncomfortable. When not accompanied by family_or friends, participants reported diffic ulty a rran gin g lra rrs_ portation home if they were not admitted. And thcre was considcr_ able confusion caused by the billilg processConclusion: 'Ihe clderly would bcnefit. from prior or oonourronI education regarding emergency care. Staff "horld b,, more s(rnsrtiv(: to the anxiety feh by rhe elderly and should explail rhc rcasons f o r d e l a y si n c a r e a n d w h a t t o e x p e c t . p a t i e n t s s h o u l d b e informed of the nature and seriousness of their illness as soon as possible. Family and friends may be encouraged to stay with patients. The billing process needs to be clarified and simpiified.
Department andlnstitutional I trA Thelmpactol Emergency I rllJ Practices ontheTimingof InitialAntibiotics in patients Wth Sepsis EAParncek, NJJouriles, WPRutherford/Department of Emergency Medicine. University Hospitals ofCleveland; Department ofMedicine, Case Western Beserve University, Cleveland. Ohio
61
Tliagsto Diagnosis Diagnosis toABXTriago toAgX(totallims) Ul ABXorder 1.4j 0.5(0.6-2; / I n p a t i eA n tI J X o r d 0 r I 9 i 0 . 6 1 10 - 3 . 2 ) ' 'P< 05.
0.510.2(02,r.0) 1.9r06(09-3.6) 4 . 7 t 2 . 8 \ ? 2 . 1 2 . 1 16' . 4 r 2 . 4 ( 4 - 1 3 ) .
C o n c l u s i o n : I n i t i a t i o n o f A I l X o r d e r s i n t h e E f ) f o r s e p s i sr a t h e r than as an inpaticnl.results in a signficant and clinically substantial d e c r c a g ei n t h e t i n r c u n t i l i n i t . i a l A B X a d n r i n i s t r a t . i o n .T h c s e r e s u l t s s t r o n g l y s u p p o r t a c o n s i d c r a t . i o ni n t h e I i D o f i n i t i a l A l l X r h c r a p y for scpsis.
*{
pneumocystis Carinii tr7 A PredictiveModelfor the Diagnosesol I rl f Pneumonia in the Emergency Department G Moran,0A Talan/0live View-UCLA Department of Emerqencv Medicine. Sylmar, California
Study objccrive:'l'o devclop a prcdictivc model to help discriminall: Pneumocystis carinii pncumonia (lrClr) from other respiratory diagnoses for lil)-pn:scrrting paticnts. D e s i g n : R e t r o s p c c t i v ec o h o r t s t u d y o f E D c a s e sp r c s c n l i n g bctweenJanuary and August 1990. Setting: A 450-bed urban university-affiliated county hospital til). l ) a r t . i c i p a n t s :N i l r c t y - n i n c c o n s < : < : u t i vpca t i e n t s l 8 t o 5 0 y e a r s o l d w i t h r i s k f a c t o r s f o r o r k n o w n l l l V i n f e c r . i o na n d t h c E D d i a s n o s i s o f p r r < : u n r o n (i al ) ) . I n t c r v e n t i o n s : C l j n i c a l a r r d l a b o r a t . o r yd a t a w t : r e r c c o r d e d f r o m r h r : l , i l ) c h a r t , a r r d t h c f i n a l d i a g r r o s i sw a s b a s c d o n r h e h o s p i l a l o r f o l l o w - u p v i s i t d i a g ' n o s i s .V a r i a b l e s w c r e c o m p a r c d f o r p C p a n d n o n - l ) C P d i a g n o s c sb y l i s h c r ' s e x a c t a n d I t c s t s , a n d n o n n o r m a t i v e data were analyzet),with Wilcoxon's rank sum tcst. The independent. contribution of significant univariates was deternrined by multivariatc logistic regression. Based on the regression coefficients, a s c o r i n g s y s t e n lw a s d e v e l o p e d t o p r e d i c t P C P . D a t a a r e s u m m a rized as mean t SD. I l e s u l t s : P a r i e n t d i a g n o s e sw e r e P C P ( 3 S ) , b a c r e r i a l p ( Z l ) , n r y c o b a c t e r i a lP ( s i x ) , f u n g a l P ( o n e ) , u n s p c c i f i e d p ( t e n ) , a n d n o n - P d i a g n o s c s( 2 6 ) . P a r a m e t e r s a s s o c i a t e dw i t h d i a g r r o s l sw e r e h o m o s e x u a l i r y( P C P , 7 4 o / o ; n o r r - l ) C P , ! ) 7 o / opi : . 0 0 1 ) , n o c h e s t p a i n (74o/ovs52o/o,P:.03),thrush(497ovs|7qa,I,:.002)diffuse>
c h e s t X - r a y i n f i l t r a r e ( 8 3 V ov s 2 7 7 o , P < . 0 0 0 1 ) , A - a O , g r a d i e n t ( 6 2 + 83 vs 3? + 19 mm Hg, P - .003), and lactate dehydrogenase (LDH) (1,25O +974 vs 924 + 637 ru, P < .0001). Homosexuality, thrush, diffuse infiltrate, and LDII had consistent independent association wirh PCP. The following Additive scoring system optimized sensitivity and epecifrcity for the [iagnosis of PCP (ecore of I0 or more' 857o and 83Va, r eepecrively) : h om o sexuality, 4 ; diffuse infiltra te, 5; LDH (IU) < 349, 0; 350 to 999, 3; 1,000 ro2,699,6;>2,7o0,9Poeirive- and negative-predictive values were 737o and9l7o, respectively. Conclusion: PCP is an increasingly frequent diagnostic consideration for ED patients with respiratory symptoms. Application of this predictive model may help to discriminate PCP from other respiratory diagnoeeeand help Prevent unneessary additional dia gnostic iests, hospitalization, a n d./or treatmcnt.
1 58 fflfft'JlliLHlf
*1
59 nT,til'iiL:llTi:,t#
Iinsthe paminGo ntror dorandLoraze
of Emergency BDWells/Department RKKnopp, Fisher. JTMulten.AK ofPediatrics, Department California; Fresno, Center, Medlcal Valley Medicine, of School SanFrancisco, ofCallfornia, University Center; Medical Valley Program, Education Medical Valley SanJoaquin Central Fresno Medicine, Fresno Study objetive: To compare haloperidol and lorazepam in rapid tranquilization of acutely violent emergency department patiente' D""igrr Prospective, randomized, double-blind, controlled clinical study. Setting: Urban teaching hospital EDParricipants: Ninety-eight violent males between the agesof l6 and 5l years required four-point re8traints' Despite physical reetraints their continued agitation prevented adequate medical evaluation. Exclueion criteria included all femalee, patiente with identifiable agc ofless than 15 or more than 5l years, and unetable
therntraosseous using rAccess
.C t sC, K r a m e rN D S S c h a f e r , SG Ro u z e n n eC, Y o u m a n s - R i e n i eG s n d D e p a r t m e notf A n e s t h e s i o l o g y , S c h a f e r / D i v i s i o nf E m e r g e n cSye r v i c e a , alveston U n i v e r s i toyf T e x a sM e d i c a lB r a n c hG Study objective: The intraosseous (IO) route for establishing vascular accesshas wide accePtance in pediatric patients but rarely is used in adults. Successful establishment of adult venous acccss can be difficult and delay the delivery ofcrirically needed fluids and gucdrugs. In the present experiments, we evaluated the spccd and c e s sr a t e o f g a i n i n g v a s c u l a r a c c e s si n a d u l t c a d a v e r i c t i b i a s ' Design:Twenty-five 60- to 90-year-old donated cadavors embalmed and stored in phenolglycerine ethanol werc used' Jamshidi lS-gauge disposable lllinois sternal aspiration needlcs (Baxter) were used to attemPt placenrent into the trabecular bone of the medial malleolus or proximal tibia I to 3 cm below the tuberosity. Infusion of I0 and then 20 mL ofbarium and standard anterior-posterior x-rays were used [o measure the successor fai]urc ofgaining vascular access.Aspiration of marrow was attempted, 'frials and the precence of fatty yellow or red marrow was noted. were performed by an emergency physician, medical studcnts, and a research technician who had 30 nrilutes ofinstruction irl thc tech-
medical or surgical Patients. lnterventions: Patienrs reeived either 5 mg haloperidol or 2 mg lorazepam IM. Vital signs and Overt Aggression Scale Parameters *".. "rr"r."d every l5 minutes the firsthourt every 30 minutes the second hour, and then every hour for a total of six hours' Patiente continuing to met entrance criteria at 30 minutes received a second dose of the same study drug. If determinations at 60 and 90 minutes indicated the patient still met entrance crileria, the alternate study drug was adminietered as part of a modified cross-over design' Follow-up was obtained at 24 houre to identify side effects' llesolts, Ninety-eight patients wero studied over a l7-monthperiod' No behavioral differences were noted on the Overt Aggression Scale belween the two grouPs (P > .05) either before or after initial treatment. No d.ifferenceswere noted in physiologic Parameters between thc two groups either before or after initial treatment except that patients initially receiving haloperidol had eignificantly lower pulse rates from 45 nrinutes to four hours after the initial injection (P < .05). Five side effects were identified in the haloperidol group' and two side effets were identified in the lorazepam group' Conclusion: IM haloperidol arrd lorazepam are equally effective in control[ng violent patients in the ED to allow adequate medical
ruque. f l e s u l t s : T h c J a m s h i d i n e e d l c s w t : r c p l a c r : di n t o t h e b o n a i n 2 4 of 25 attempts; time for insertiort rangcd fronr four to 30 seconds' Aspiration was successful in22 of 24 attemPts with nrarrow bcing red in ten trials, yellow in eight trials, and indctcrminatc in four trials. Contrast media was succcssfully infused in2l of 24 attempl's' After a lO-ml infusion of barium, the contrast mediunr had clearly entered the large veins of the leg and thigh n 2l of 24 infusions; in three infusions, only the tibial intramedullary space was filled' 'Iwenty-milliliter infusions (six) usually fllled superiorly to the pelvic inlet regardless ofwhether infused from the proximal or
cvaluation.
or$e comparison 1 60 ff:ll'J:i3':iffil'J#J;,o,::'-,o,seizures: of Emergency BJPierluisi/Department B Culver, TETerndrup,WEFordyce, of Medicine, College at Syracuse; Center Science SUNYHealih Medicine. at Syracuse Center Science SUNYHealth
Study objetive: To compare the influence of diazepam and lorazepam on respiratory drive in a swine eeizure model' Design and setting: Nonblinded, controlled animal study' Type of participants: Twenty-seven, mixed-breed domestic ewine' lnterventions: A tracheostomy, arterial catheter, and epidural clectrodes werc inserted under kelamine maintenance anesthesia' After baseline recordings, seizurcs were induced with a pentylenetetrazol (YIZ\ bolus and 20-minutc infusion (5 to 6 mg&g/min)' After
distal tibia. Conclusion; Vascular accesswas achieved rapidly and effectively in adult cadavcric ribias. Our dara suggest that emcrgency delivcry of drugs can be achieved via eithcr the yellow or red marrow of thc 'fhe IO route should bc considered in both pediatric adult tibia. a n d a d u l t p a l i e n t s w h e n l r a d i t i o n a l I V a c c e s sd e l a y s e m c r g e n c y
assigned animals received diazepam terr mirrutes of VIZ,randomly (D; 0.5 nrglkg), lorazepam (L;0.2 mglkg), or 0'97o saline (C; controls) by rapid peripheral vein injection' Measurements and main results: Minute ventilation (V ), Paco"' and the pressure change in response to airway occlueion at end expiration (P0"1) were measured at standard intervals' After ten + minutes of untreated seizures, groups had comparable mean SD )
therapy.
68
I
i n c r e a s e si n V " ( D , 1 5 + 3 . 3 ; L , 7 . 3 t 3 . 8 ; C 1 7 . 7 + 4 . I [ - , / m i n )c o m pared withbaseline. Changes in V" and P0.I were reduced ro baseline values or below in groups D and L but not C, from two to 45 minutes after treatement (P < .05; repeated measures ANOVA). Onset of reductions in V" and P0.l occurred more rapidly in group D (0.5 minute) yersus group L (two minutes). No significant changes were observed in PaCo, after treatment. After use of anticonvulsants, the duration of seizures was reduced signficantly in L (l.l +2.9 minutes) and D (1.5 + 2.3) groups compared with group C
Design: A single-dose, prospective, double-blind, randomized study over a nine-month period. Serdng: A moderate-volume university hospitral ED. Type of participants: C onsecutive nonpregna nt adult patients (age, 18 to 75 years; weight, 100 ro 250 lb) without bleding disorders or other contraindicatione to nonsteroidal anti-inllammatoriee or narcotics, Interventions: Each subject was given an injection of study drug at baseline (60 mg KT vs 100 mg DM). Verbal and vieual ecaleswere used to monitor pain and sedation at hourly intervale while the patient remained in the ED. Vital signs, side effecte, and other interventions were recorded. Ilesults: Seventy-two patients (4O men and 32 women) were enrolled in the study (36 receivcd Kl'and 36 received DM). The mean age wae 37.8 years (rangeo 20 to 68 ycars). The average differencc in pain reliefbased on a four-point (l to 4) verbal scale was 1.44 for KT and 1.25 for DM (P = NS). The average difference in pain rcliefbased on a ten-point visual-analog scale was 3.47 for KT arrd 3.28 for DM (P = NS). Rescue analgesia was required for six of 36 patients receiving DM but only onc of 36 patienls receiving KT ( P = . 1 0 , F i s h e r ' s e x a c t ) . B a s e d o n a f o u r - p o i n t v e r b a l s c a l e( l t o 4 ) , l h e a v e r a g e s e d a t i v ee f f e c t o f D M w a s 2 . 3 3 a n d o f K T w a s 1 . 9 4 (P =.05,72).
; <.05). ( r 5 . 3+ 5 . 3 P Conclusion: Increases in respiratory drive occur during tonicclonic seizuree induced with PTZ. Amelioration of geizure activity with an injection of lorazepam or diazepam results in a reduclion in respiratory drive but not reepiratory failure.
Provides Analgesia Superior to Meperidine in l tr l Hydromorphone I lf I Emergency Departnent Patients WithRenalColic NBJasani, RE0'Connor, JKBouzoukis/Department of Emergency Medicine, TheMedical Center ofDelaware, Wilmington Study objective: To compare the efficacy ofequianalgesic doses of meperidine (MP) and hydromorphone (HM) in the rrearmenr of renal colic in the emergency department. Desin: A prospective, double-blind, randomized clinical trial conducted over six montheSetting: A tertiary referral center with 93,000 annual ED visits. Type ofparticipante: Patiente over the age of 18 presenting with renal colic were e.ligible. Pregnancy or allergy to MP or HM constituted exclusion. Informed consent was obtained from 75 consccutivc patients; 67 completed the study. Interventions: Patients received I mg IIM or 50 mg MP lVar [ = 0. Pain intensity was determined using a l0-cm visual-analog scale at t = 0, 15, 30, 60, and 120 minutes. A second dose of the study drug could be given between t - 15 and r = 120. Inadequar,e pain relief l5 or more minutes after the eecond dose of the study drug was treated with a "rescuet' analgesic. Reeults: Gender, "rescue" medication proportions, incidence of side effects, and the rate of IV pyelography and admissions werc analyzed by Xz test, whereag mean age and visual-analog scores were analyzed by ANOVA. Thirty-two parients received HM, and 3 5 r e c e i v e dM P . T h e i n i t i a l p a i n i n r e r r s i t y ( [ I M , 8 . 3 8 ; M P , 9 . 4 3 ) , age, sex distribution, and side effects of lhe two groups were corrparable. Pain relief was better (P < .005) with I-IM ar r = 15, 60, and 120 minutes. The HM group required oorescuc"analgesia lcss oftcn (317o vs 637o, P < .05), had fewer IV pyelograms (28o/ovs 1lo/a, P< .05), and had fewer hospital admissions (257o vs 467a, P = .08). Conclusion: Renal colic patients receiving HM achieve greater pain relief, require lees'orescuen'medication, undergo fewer IV pyelograms, and are diecharged more frequently than those receivingMP.
1 62 fifllfl:,tlg[,Jrrine
C o n c l u s i o r r :W h e r r u s e d t o t r c a t a c u t c p a i n s t a t e si n a m o d e r a t e volumc urriversiry hospital BD, Kif is a safe and effect.analgesic and has fcwcr sedative effects than I)M. ^ F]l
K e t o r o l a cf o r S i c k l e G e l l V a s o - o c c l u s i v eC r i s i s P a i n i n t h e
I OJ f rrtgrncy Department: Lackol a Narcotic-Sparing Elfect SW Wright, RLNorris, TR[/itchell/Vanderbilt Medical Center, University Nashville. Tennessee Study objective:'Io determincif a singledoscof IM ketorolac given on prescntationto the emergencydepartmenthas a clinically sigrrficantnarcotic-sparingeffectirr patientswith sicklecell vasoo c c l u s i v ec r i s i s p a i n . D e s i g n : A p r o s p c c t i v e , r a n d o m i z e d , s i n g l e - d o s e ,d o u b l e - b l i n d study. Setting: ED of a universil.y medical center and affiliated county hospital. 'fype of parlicipants: Twenty-four adult padcnts with sickle cell c r i s i s w h o r a t c d t . h e i rp a i n a s m o d c r a t e o r s c v c r c o n a c a t e g o r i c a l s c al c . Intcrvcntions: Patients werc randonrizcd to rcccivc cithcr 60 mg ketorolac lM or placebo on prcscntation to thc ED. Each subject also rcccived 50 mg meperidine IV and 12.5 mg promcthazine IV on p r e s e n t a t i o n .T h e p a i n w a s r a l c d o n b o t h a c a t e g o r i c a la n d a y i s u a l -
versus Meperidine lorTreatment ol
KLKoenig, RKozak. L Hodgson, KJordan/UC lrvine Medical Cenrer Study background: Historically, narcotics have been the standard treatment for acute pain in emergency department patrcllts. An effective rlronnarcotic analgesic would be beneficial in EI) patients to elimina[e the potential for drug-seeking behavior and to potentiate early, independent discha rge. Hypothesis: There is no dilference in pairr reliefor sedation following a single IM injection of ketorolac tromethamine (KT) or meperidine (DM) in ED patients.
69
arralog scalc every 30 minutes. Subjects were given a standardized dose of IV meperidine every 30 minutcs during the four-hour obeervation period based on the severity ofpain on the categorical scale. S t a t i s L i c a cl o m p a r i s o n s w e r e m a d e u s i n g t h c S t u d e n t ' s , - t e e t , M a n n Whitney U test, or Fisher's exact test as indicated. Pretrial analysis s h o w c d t h a t a s a m p l e s i z eo f 1 2 p a t i e n t s i n e a c h g r o u p w o u l d h a v e sufficierrt power to detect a 40o/o difference betwcen groups (twot a i l e dc r : . 0 5 , 8 : . 2 ) . llesults: Baselirre pain scores were similar irr both groups. The subjects in thc kctorolac group rcccivt:d an average of 231 + 92 mg mcpcridine, whereas the subjects in the placebo group received an average meperidine dosc of 250 + 85 mg (P = .61). Eleven of 12 patients (92%) ln the ketorolac group stated rhey would want the drug at a future ED visit, whereas sevcn of 12 (58Vo) in the placebo groupstatedtheywouldwan[thedrugagain(P=.08).>
and cervical motion tenderness, and adnexal or uterine tenderness' or higher' 2) at least one of the following: temperarure of 100'5 -C gonorrhea WBC of 101500or greater count' or positive culture for or chlamydia. to the ED R.eultsr Of the 255 patients with PID, 997o preaented of theee with the chief complain of pain. However, only 29Vo IAVo received patients received fain m.dication in the ED, and only ISTo wete " .,"""oti" medicaiion. Of the 136 discharged patienta' a narcotic teceived n; 27o medicatio pain given a prescription for an order written lr"di"utiot. Ofthe l19 admitted patients,T6Vo had (86Vo for pain medication for their initial period of hospitalization of those of the medicationa were narcotics)' Seventy-four Percent written for medication requested analgcsia' with PID Conclueion: Our study demonstratcs that ED patients discharged are who those that and pain for treatej ".e rot .outitely rarely receive a prescription for pain medication' A ProsPectr've neceesary to arr.se-ent ofpain on entering and leaving the ED is for the pain associated with und.ertreated are paticnts thaI prove 'ptl. are a number of disturbing psychosocial issues relating tt.". lack ofpain to PID that are potential explanations for the apparent these in management Patients'
Conclusion: The use ofIM ketorolac did not significantly reduce the requirements for narcotics during the four-hour ED treatment period.
ADoubrePain: Tract 1 64 ffil1'ffi1f.:J;:?i:liJlil':'iarv Loma Medicine, 0fEmergency EGorton/Departments Green, SGBothrock.SM California Hospital; General Blverslde Center; Medical University Linda Group Medical Physicians Emergency
Study rationale: Injection of atropine has long been advocated as a diagrrostic and therapeutic agent useful for relief of pain due to biliar:y tract disease.Ho*.ver, no prior clinical trials have evaluated atropine for this indication. This study was performed to compare the efficacy of IM atropine with placebo for the treatmcnt of acute pain due to biliary tract disease. Design: Prospective, randomizt:d, double-blind cross-over study' Setting: Emergency dePartmcnts of a university medical center and affiliated county hospital' Participants: Eighty-two Patients aged l8 to 60 years were enrolled over l5 months. Twenty-three were found to not have biliary tract disease, and four were lost to follow-upr leavirrg 55 p"ii.nts for analysis. Patients were excluded from enrollment if th.y had at least one of the following criteria: suspicion of bowel obstruction, pregnancyr myocardial ischemia,poorly controlled h y p e r t e n s i o n , u r i n a r y r e t e n t i o r l , m y a s t h e n i ag r a v i s r g l a u c o m a ,
ol Titration lor Intravenous Regimen Dosing ^ FE AnAccelerated rgency Eme Painlul During Midazolam and I OO ftnunyl Procedures Department WHCordett,EJSasin,JLKotecki.DSKlan,AWNyhuls/Eme of Department Indianapolis; ofIndiana, Hospital Methodist Center, andTrauma lndianapolis lndiana, of Hospltal Methodist Besearch. Medical
bleeding diathesis, or uee of cholirtergic mefications' Interventions: Subjects were randomized to reveivc cithcr 0'fr nrg (0.5 mL) IM atropine or (0.5 mL) normal salinc placebo' lf responsc to the initial injection was inadequate after 30 to 40 minules, patients received the alternate injection. Pain was asscssedby a visual-analog scale (0 to 100 mm) beforc the initial injecriorr and 30
'l'o determine the efficacy and safety of an accelStudy objective: titrating lV fentanyl and midazolam to for regimen .rot"d iosi.g during painful emergency department achieve "tol!"ri"-u*.,.sia studied these two agents using a smaller Ve previously p"u""do."r. loading doseand slower titration regimen'
to 40 minutes after each subsequent injection' Statistical analysis included 12 analysis and paired I test with significance at P < '05' Measurements and main reeults: Relief of pain was complcte aftcr rhe initial irrjection in four of 28 who received atropinc (l4o/o;95o/o confidence intervals lCl), 3Vo to 357o) and four of 27 who received safine ( l57o ; 95Vo Cl, 37o to 364o)- For all subjects with bilia ry tract disease who received both injmtions, atropine and placcbo resulted in similar pain relief (-ll vs -16 mm' P = '202)' Therc also was no difference in pain relief bctwecn atropirro and placebo for the subset of patients with biliary coli<:rr:ceivirrgboth injcct'ions ( - I 5 v s - l ? m m , P : . 6 5 S ) . T h i s s t u d y h a d g r e a t c r t h a n 8 0 o l op o w < : r to detect a 7.S-mm difference betweenatropinc and placcbo in all patients with biliary tract disease and a 12'S-mm dilfcrencr: in thost: with biliary colic. Conclusion: Atropine is no better than placebo ill l'hetreatment of pain due to biliary tract diseasc. tAs
PelvicInflamnntoryDisease:0o We Treatfor Pain? f b5 of University of Medicine, I Reyes, M Chansky/Department SAbbahl,FShofer, Wood Robert of Medicine, Department of Medicine; School Pennsylvania of Medicine School Johnson Studyobjective:The purposeof our studywasi'oreviewthc ntarta g e m e n to f p a i n i n p a t i e n t s w i t h p e l v i c i n f l a m m a t o r y d i s e a s e( [ ' l l ) ) ' Design: Retrospecrive chart review of emergency departrncnt patients diaglosed with PID over a one-year periodSetting: Two urban university hospitals located in separate cities' Type of participants: PID was the single discharge diagnosis for 744 patients. Of these' 255 patienrs (34%) fulfilled the criteria for a strict definition of PID: I) presence of lower abdominal tenderness,
I ) e s i g n t P r o s p e c t i v e , c a s es e r l e s ' teachS.ttii,gt ED of u. I,100-bed iertiary referral, central ciiy ing-Type hospital. ofparti"ipants: Patients lB lo 80 years old undergoing were eligible' Exclusion. criteria-included pregpai.ful p"o".dt.", ."."y, iur.li.re arterial oxygen saturation (Saor) ofleae than927oo rate of Iess systoiic blood pressure of less than 90 mm Hg, heart hypert i l a n 5 5 , i r r t o x i c a t i o n , m e n t a l e t a t u si m p a i r m e n t , a n d k n o w n m e d i c a t r o n s . scnsitivity to the mg midaInlervcnLions: Patients rs:eived an IV loading dose of 2 pgfen50 and midazolam mg of I Doses pg fentanyl. zolam and l00 o'conscioussedation" wae tarryl werc gi".rr1u""y three minules until on achieved. This was defined as slurred speech or no movement eigns pinching, shaking, or blood pressure cuffinflation' Vital including Sao, were -orrito"Ld. Patients were questioned immediproceately anJ ot"-hot. and at least 24 hours (by telephone) after they pain much how and remembered they what dr.." "o.""..ing trend had cxperiencedl Chu.g."'i. vital signs were evaluated with analysis models using ANOVA ter:hniques' age R.soltrt Nineteen patients were studied' The average patient average and female; were 14 and malc were was 35.3 yearsl five weight was ?8 kg. The types ofprocedures included nine(474o) incision and drainages, seven(377o) reductions offractures abs-cess were or dislocations, and three (167o) olher' The averag" doses the after hour one At pm fentanyl' 3.? mg midazolam and 184.2 13 ($Eo) remembered no pain during the procedure' p.o".l.l.., for irift"*. of 19 patients (79To) required supplemental nasal oxygen saturation8droppingbelow927o.Therewerenostatietically>
70
significant changes in heart rate, respirations, and systolic blood pressure. lhere was a preprocedure trend of decreasing diastolic blood pressure (-0.84 mm Hg/min; p = .0,l{|5) thar flartened our after procedures (P: .03?0). Conclueion: The combination of midazolam and fentanyl given by this protocol in the ED produced adequate analgesia-amnesia. Most patients, however, required supplemental oxygen for desaturation. Ve recommend that Sao2 and vital signs be monitored when these agents are administered and that supplemental oxygen, reversal agents, and resuscitation equipment be available immediately .
| 67 t' ff HH11"J.'llis
ianandcrassi cGroup-sequentiaI
RJLewis, DABerry/Department of Emergency Medicine, Harbor-UCtA Medical Center; Institute 0f Statistics andDecision Sciences, DukeUniversity For ethical and economic reasons, investigators often analyze clinical trial (CT) data after each of several lroups ofpatients are s_tudie_dSuch group-sequential CT designs (GSC1'Ds) usually allow the CT to be stopped eooner than if only a final data analysis were used. The purpose of a CT is to learn efficiently about alternative treatments to be able to reliably promote the more effective medical therapy. Ve consider this goal explicitly by assuming thar the "costno of a CT depends on the sample size and the risks of type I and type II errors. Classic GSCTDe (C-GSCTDs) do nor weish such c o s t sa n d i n s t e a d c o n s i d e r o n l y e r r o r r a l e s , e s p e c i a l l yt h a t o ] t y p c l . We used Bayesian decision theory to determine the GSCTD for which the expected cost is a minimurn, termed an optimal Baycsian GSCTD (OB-GSCTD). We consider C'l's for treatments of a diseasc outcomes, using Monte-Carlo simulation to compare OIi1|,!j:" GSCTDs with three-analysis C-GSCTDs of pocock and of O'Brien Fleming. The variables P.and. Prare the successrates for the con_ trol and test treatments, andD, "rrdA, u." the mean sample sizes *^1"" P" uld P ,= P Ao, iespectively. Ao is the djfference in "+ l, efficacy to be detecred (Table). Trial Ciassic ErorBates Erpoct€d Cosl r) Pocock .40 .g5b .0S4 70.3 39.2 65.9 0'Brien .40 .0S5 .061 b9.6 45.5 58.3 Bayesian .40 .038 .054 42.1 44.3 4Z.l Pocock ZD .051 .081 ZU4 t58.b 211j 0'8rien .20 .043 .092 238.6 181I 200.3 Eayesian .20 .051 000 152.0 1b6.7 118.9 A s e x p e c t e d ,t h e O B - G S C T D s h a v c l o w c r c o s t s t h a n l h c C _ GSCTDs. More surprisingly, they usually havc lower mean classit: sample sizes and often have lower classic error rates as well.
Fluid Shear Forces onrheBrain 1 68 f,TLt"il"r,t"ffrebrospinal S B N e i f S EB o s s / C o o p eHro s p i t a lU , n i v e r s i tM y edicalCenteC r.amden. N e wJ e r s e y The spatial distribution of cerebral injuries observed after accel_ eration is not completely explained by analytical biommhanical m o d e l s . S o m ef e a t u r e s o f h e a d i n j u r y , s u c h a s a c u t e s u b d u r a l hematoma (SHD), are not easily repl_icatedin animal models. We hlpothesized that a numeric simulation of head acceleration that included cergprospinal fluid (CSF) hydrodynamics would reveal stresseson the brain that could help cxplain observed patterns of injury. The models used for the hydrodynamic studies consist of a rigid ellipsoid of revolution separated by a layer of fluid from a slightly larger ellipsoidal shell. The ourer shell is separared from the i n n e r s h e l l b y d i s t a n c e so f 0 . I t o 0 . 5 c m . T h i s g a p c o n t a i n s s i m u l a t _ ed CSF with viscosity 0.01 poise and density oi l.O g/"*r. Impacrs
were simulated by the application of an (acceleration) field of a magnitude of l0 to 200g. Linear and rotational forces were conside r e d . T h e N a v i e r - S t o k e s a n d c o n t i n u i t y e q u a L i o n sw e r e u s e d t o describe CSF flow. Models were run on a deskt6p worketation and a massively parallel supercomputer, CSF velocitie8 greater than 100 cmlsec were shown to occur in rhe CSF in the subarachnoid space, corresponding to shear forcee on the order of 800 kPa (250 mm Hg). These force levels are known to cause local brain injury in human beings. Thus, the initial results of this numeric simulation may provide an explanation for acute SHD in human beings. This computational approach permits a detailed understanding of the forces that contribute to brain injury during impact.
*1
69 |::,?',rt; fflXl
inAneurysm warrs: Factors Arfectins
W Mower, L Baraff,J Sneyd/Department of EmergencyMedicine,UCLA MedicalCenter Study objecrive: To determine how stresseein the wall of an aneurysm change as a function of aneurysm diameter, wall thickrress,and material propertiee and to determine the relative import a n c e o f t h e s ef a c t o r s i n a n e u r y s m g r o w t h a n d r u p t u r e . Designt Aneurysms were modeled mathematically as axially symnlel.ric structures of revolution. Stress distributions were calculated for the aneurysm wall as changes wcre made to the geometric and m a t c r i a l p r o p e r t i e s o f t h e a r r e u r y s m . S t r c s s c sw e r e c a l c u l a t e d u s i n g a l i n i t c e l e m e n t a n a l y s i sp r o g r a m , S A pI v , ( : x c c u l . e do n a 1 . S - g i g a b y t e lIlM 3090 Model 600J supercompurer. I l e s u l t s : S t r c s s e sw e r e g r e a t e s to. n t h c i n n e r w a l . lo f a n e u r y s m s , near the region of maximum diameler, arrd dccreased nonlirrearly as lhe outer wall was approached. Circumferenlial stresseswere significanlly greater than longitudinal stresses. Doubling the diameter of a n a n e u r y s m p r o d u c e d a t w o f o l d i n c r e a s ei n m a x i m u m w a l l s t r e s s . I)ccreasing the wall thickness by one half also produced a twofold i n c r e a s c i n m a x i m a l s t r e s s .C h a n g i n g m a t e r i a l p r o p e r t i e s p r o d u c e d no change in wall stressl howevcr, since weaker materials fail at proportionally lowcr stresses, halving material strength would be equal to doubling wall stresses. Comparing streEsescalculated using finitc clenrent analysis with prcdictions fronr the theoretically inaccuratc law of Laplacercveals thc Laplacc relation significantly u n d e r c s l . i m a t e sm a x i m u m w a l l s t r e s s c s Conclusion: Proportional changcs in thc diametcr, wall thickness, or malerial strcngth have roughly cqual cffectson ancurysm growth and rupture. 'l'he law of Laplace is inadcquate in prcdicting or evalu a t i n g a n e u r y s m w a l l s t r e s s e s ,a n d m o r e s o p h i s t i c a t e dt o o l e s u c h a s finitc element analysis are necdcd for understanding this complex phenomenon.
Methology for Determining WhichVariablesDrivethe 1-rnA I f fl Diagnosis ol an ArtilicialNeuralNetworkDesigned to Detect the Presenceof Acute MyocardialInlarction WGBaxt/Uniuersity of California, SanDiegoMedical Center Artificial ncural networksarc a powerful rnethodfor the recognitiorrofcomplcxpatterns.Suchnetworkshavebecnshowncapable ofidentifyinglhe prcsenceof acutcnryocardialinfarction(MI) in pal.icnts presentingto the cmergcncydcpartmentsubstantially more accurately(sensitivity,97o/o;specrticity ,96Va)than the physician carirrgfor the samepatients(sensitivity,78%oispuificity,BsTo).
'I'he
objcct of the study was [o determinc which of the clinical variables used by the network have the greatesl. impacts on network output (daision). Because artificial neural networks are able to )
1l
appreciate relationships among clinical variables that human analysia ie unable to elucidate, these techniques may allow greater insights into the relationship among these inputs. Six hundred ninetyseven patients over 18 years of age presenting with anterior chest pain were used to train the network. A new methodology was developed to measure the etatistical impact of each of the 20 clinical variables used by the trained network. The methodology revealed that the network used the presence of ECG findings as major predictive sourcea, but also revealed that the presence of rales, left anterior location of pain, diaphanousness, response to trinitroglycerin, nausea and vomiting, syncope, maleness, and age over ?0 years were major positive determinants toward the diagnosis of MI. The presence of rales were found to have a more profound effect toward positively affecting the diagnosis of MI than mosr of the ECG findings. The network appears to use clinical variables that have been shown in the past to have high predictive power for MI but also uses some clinical variables that have not been previously shown to be highly predictive for MI. At leasr onc of rhe latter is given as rnu<:h w e i g h t a s m o s t o f t h e f o r m e r . T h i s m a y s u g g e s tt h a t t h e p r c s c n c e o f s u c b v a r i a b l c s a r e f a r m o r e i m p o r t a n t [ o t h e d i a g n o s i so f t h c p r c s ence of MI than previously recognizcd and represcnl.s thc first instance in which an artificial neural network has ben used to elucidate such a relationship.
.l-rt TheMisdiagnosis ol AcuteMyocardial Infarction: Modeling a I f 4 Cognitiye Sciences-Based Explanation for Diagnostic Erros FPapa, RRusnak, SMeyer/Texas College of0steopathic Medicine, Fort Worth; Hennepin County Medical Center, Minneap0lis, Minnesota Study background: Prototype theory suggeststhat clinicians use their knowledge base (KB) to construct a prototypical representetion for each dieeaeeknown to them. This prototype serves as a template or pattern against which the clinician attempts to match a new patient'e signs and symptoms (S/S). The prototype that best matches the patient's S/S provides the clinician with their clinical diagnosis. A clinician's diagnostic accuracy therefore appears to be directly related to the degree to which a given prototype correctly anticipates the various clinical manifestations ofa given disease. Objective: To determine if prototypes can be ueed to model and account for differences and commonalitiee among experte and novices in the misdiagnosis of myocardial infarction (MI) test caees. Participa nts : Twenty-six boa rded emergency medicine specialiste (experts) and 88 medical students (novices). Methodology: An artificial intelligence (AI)-derived tool acquired a KB from each subject consisting of the relative frequency of occurrence of 67 S/S associated with nine 'oacutecheet painnoetiologies: MI, angina, dissecting aorlic aneurysm, pericarditis, upper gastrointesti-nal disorders, pneumonia, penumothorax, musculoskeletal disorders (MS), and pulmonary embolus. The AI tool then transformed each subject's KB into a prototypical representation for each of these nine diseasee.Each subject's protot)?es were used by the AI tool to diagnose 20 documented and distinct MI test cases. Results: Hotelling's I teet revealed group differencesl novices wcrc morc likely to misdiagnose MI test cases as either angina (P < .002) or MS (P < .0lB) in origin. Pearson correlation revealed group similarities in that the less typical the MI case presentation (as judged by the subject's prototype), the more likely the caee would be misdiagroscd (P < .01). Conclusion: The superior diagnosric performance of experts appears to be due, in part, to expert KBs and prototypes that more effectively anticipate, and value, the S/S that differentiate MI from angina and MS presentations. However, the diagnostic errors of novices and experts are similar in that both groups are more likely to misdiagnose MI test cases as a function of the degree to which the case presentation (S/S) varies from the subject's proto- ' typical representation. AI tools and prototype theory are useful for modeling a cognitive sciences-basedexplanation for the misdiagnoses ofMI. Such an approach represcnts an important step in i m p r o v i n g t h e m e d i c a l e d u c a t i o n p r o c e s sa n d p a t i e n t c a r e , a n d possibly in building a scient.ific basis for defending clinicians in malpracticc litigation.
tlThe Useof an AilificialNeuralNetworklor Modeling +rl'r . a , I PhysicianDiagnosisolMyocardial Infarction RCStone, FJPapa/Emergency Division, Texas College of 0steopathic Medicine, FortWorth Increasingly,artificial neural nctworks(ANNs) are beingstudied for their usein diagnosinga variety ofpatient problems,includirrg acul.emyocardial infarction (AMl). Ilecenrly, ANNs achicved highcr diagnostic accuracies for AMI than did urraided physicians. 'fhe A-NlNs'diagnostic strength lies in irs abiJiry to dcrive previously unrecognized ru-les from the complex pattcrns inherent in diseas<: presentation. 'I'his study sought t.o determine if ANNs lrained with physician's conditional probabilities (CPs) could more closcly model the actual diagnostic accuracy of the physicians. 'I'wenty-four emergency medicine physicians completed Cp questionnaires regarding patients presenting to the ED with ,.chest pain." Thc dara received included probability estimates for 6? features in cach of nine chest pain differentials. Twenty-four networks were trained, each with an individual physician's CPs. 'fhe nerworks rhen were tested by presentation of the clinical data from l0l actual chest p a i n c a s e s .O f t h e l 0 l c a s e s ,2 0 h a d a c o n f i r m e d d i a g n o s i so f A l l l l . 'l'he average dia5'nosricaccuracy of thc physiciarderived Cp-trairrcd ANNs was 14.8 of 20 for AMIg and 65.l] of 8l for rron-AMls.'l'ht: a c c u r a c y o f t h e A N N s i s c o m p a r c d w i t h t h a r .p r b v i o u s l y r c p o r t c d f o r unaided physiciansis reported: scnsitivity of74.2 vs 77.0 and spr:<:ificity of80.6 versus81.0. Statistical analysisof the accuracy of thc ANNs revealed that the performance was statistically higher than random (yz = 1,M5, P < .001) and srarisrically less than ANNs trained with real cases for clinical use (X2 - 68, p < .001). These data appear to support the use of physician-derived Cp-trained ANNs for modeling physician accuracy in diagnosing AMI in the ED. The ANNs' ability to represent the data base used to train it may provide insight into how experts perform diagnosis. This would have application in both teaching diagnostic skills and resring diagnostic abilities.
Race, Age,andInsurance Status AreDeterminates ol Y,-ra ' | , g Interhospital HelicopterTransportTime andFrequency BfrFurlong, MBHeller, TEAuble/University ofPittsburgh School ofMedicine, Center forEmergency Medlcine 0fWestern Pennsylvania
12
Study objetive: This study hypothesized that within rural settings, l) the time bctween admission to and subsequent air medical transporl. from rural to urban hospitals is affected by patient age and insurance status (INS) and 2) the observed proportion of nonwhite transports may differ from thal expected on a population basis. Design: A retrospective revicw ofinterhospital air medical transports. Time before patient transport from rural hospitals (TIME) as a function ofpatient agc (pediarric vs adult) and INS (insured )
vs uninqured) were compared using thc Student's I test for unpaired samples. The binomial test was used to compare observed vs expected transport rates for nonwhites with a error raie set at .05. Setting, participants, and interventions: Three hundred fifteen patient transfers from hospitala within a two-county region in cen_ tral Pennsylvania to urban tertiary-care centers were analyzedAll recorde with sufficient demographic, TIME, and INS data were included. Absence of data wae the only exclusion. Results: TIME (mean + SD) was lorrger (p < .01) for adult than pediatric patients (2t66+ 1,301 vs 619 + 135 minutes) and longer (P<.01) for insured than for uninsured patients (2,580 +4,04i vs 6,10I I,301 minutee). The obeerved proportion ofnonwhitee trans_ ported was less than (P < .05) that expected baeed on the proporrion in the region (0.4lVo va 2.IVo). Conclueion: The time between admittance to and air me&cal transport from hospitals in the rural region studied to urban centers was longer for adults than for children and longer for insured than for uninsured patients. Furthermore, nonwhites were transported by air less frequently than expected.
is generated, resulting in misleading information about response time and its relationship to patienl. outcome.'
t 'rtr Prospective Validation ofa NewModelfor Evaluating EMS | , ., Systenrs byIn-Field 0bservation of Specific Timelnteryals in Prehospital Care p Hinsberg/Arizona DWSpaite, TDValenzuela, HWMeislin. EACriss, Emergency Medicine Besearch Center, University 0fArizona College of Medicine, Tucson
Study objecrive: Development and validation of a new emergency medical servicee (EMS) time-sequencc model for identifying system, patient, intervention, and problem-rclated dilTerencee in prehospital care intervals Lhat are useful for sysl.cmevaluation. I)esign, setting, and participants: Prospective analysis of 300 EMS runs among 20 advanced life support agencies throughout an entire state by direct, in-field observation. I n t e r v a l s : R e s p o n s e( R I , a l a r m t . oa r r i v a l I a r r ] o n - s c e n e ) ,p a t i e n t ( p t ) a c c e s s( P A I , a r r o n - s c e n et o a r r a t p t ) , i n i t i a l a s s e s s m e n(t I A I , arr at pt to first intervention), treatnrent (TREAT, firet intervent r o n t o m o v e p t ) , p t r e m o v a l ( P R I , m o v e p t t o l e a v i n g s c e n e ) ,t r a n s _ /17 Time-To-Parient Interval: TheHidden Component ol port (TRAN, leaving scene [o arr hospital), delivery (DI, arr hosA f f 'l Response Time pital to physician [MD]/rcgisrered nursc IttN] at bedside),and JPCampbell, MCGratton, JASalomone lll,WAWatson/University of recovery (IiEC, MD/RN at bcdside to in service). Missouri-Kansas City, School ofMedicine; Truman Medical Centei Emergency I t e s u l t s : M c a n t i m e s ( m i n ) w e r c l i l , 6 . t t ; P A I , 1 . 0 ; I A I , 8 . 3 ; 'f Department, Kansas City, Missouri IlfiAT, 4.4; PllI, 5.5; 'IiltAN, I l.7; Dl , 3.5; ttlic, 22.9. \^he Study backgrourrd: An accurately dcfincd responsctinreirrtcrval, l a r g c s t c o m p o n c n t o f o n - s c c r r ci n l . c r v a l ( O S l = l r A I + I A I + T I T E A T + as well as identilication of the variables that inlluence that inl.erval, l ' I l l ) w a s P I i I . T R E A T a c c o u r r r c df o r o n l y i ) | . 0 o / oo l O S I , w h e r e a s is critical to defining the relationship bctwecn prchospiral intervcna c c c s s i r r ga n d r e m o v i n g p t s t o o k n r : a r l y h a l f o f ( ) S l ( A S . 8 o / o ) . tions and patient outcome. O p e r a t i o n a l p r o b l e m s ( i e , c o m m u n i < : a t i o n se , quipment, uncooperaObjective: To measure the time interval from ambulance arrival t i v e p t ) i n c r e a s e d P R I ( 6 . 4 ,v s 4 . 5 , P - . 0 0 4 ) , I i E C ( 2 S . 4 v s 2 0 . 2 , on-scene to paramedics'arrival at the patient'e side (time_to-patient P - .03) and out-of-servicc inrerval (45.3 vs 24.7 , P = .0005). Rural interval), identify influencing variables, and determine their impact a g e n c i e sh a d l o n g c r R I ( 9 . 9 v s 6 . 4 , P = . 0 1 4 ) , T R A N ( 2 1 . 9 v s 1 0 . 3 , on the time-to-patient interval. P < .0005), and IIEC (29.8 vs 22.1, P: .049) rhan nonrural. Total Design: A prospective study of the time interyal from ambulancc O S I w a s l o n g e r i f a n I V w a s a n e n r p t e d a I s c e n e( 1 7 . 2 v s 1 2 . 2 , arrival at the gcene to paramedics'arrival aI the patientns side. I ' < . 0 0 0 1 ) . T h i s r e f l e c t e d i r r c r c a s ei n T I I E A T ( 9 . 2 v s 2 . 8 , p < . 0 0 0 1 ) Time interval data were collected by independeni third_party ridcrs w h i l c P A I a n d P R I r c r r r a i r r c du r r c h a r r g c d . (medical etudents and emergency medicine residents) over slx C o n c l u s i o n : A r r e w m o d e l i s r e p o r t c d a n d s t . u d i e dp r o s p c c t i v e l y months on life-threatening calls. potential barriers such as doors, t h a t i s u s e f u l a e a n e v a l u a t i v c r c s r : a r c ht o o l f o r E M S s y s t e m sa n d i s stairs, and elevalorsl bystander interfcrenccl and police secur.ing a p p [ i < : a b l et o m a n y s e t t i n g si n a d c n r o g r a p h i c a l l y d i v e r s e s t a t e . the ecene were recorded. a -la\ Setting: Public utility model urban emergency medical services I t b A Study ofAmbulance Collisions in anUrban system. Environment
CESaunders, DFloersch/University 0fCalifornia. SanFrancisco. School of Medicine; SanFrancisco Department ofPublic Health
Types of participants: Two hundred rhirty-two life_threatening ambulance calls were observed. Of these, 216 were entered into the study. Six were deleted because no patient was found, and ten were delered due to incomplete data. lnterventions: None. Results: Of the 216 runs measured, 122 had some barrier influ_ ence on the time-to-patient interval. .I.he data were skewed, and parametric analysis could not be used. Barriers significantly pro_ longed the time-to-patienr interval (p < .001, Kolnlgrov_smirnov test). The median time-to-patient interva.l was 2.29 -ir,rt", (interquartile range, l.0l to 4.82 minutcs) for runs with barricrs (122).This contrasted to a median timc-ro-patienl irrtcrval of0.g2 mrnutes(infrquartile range,0.3? to 1.96 minutes) for runs wirhour barriers (94).
Study objcctive: "Lights and sirens" ambulance rravel (LS) ie p r e s u m e d t o h a v e i n h e r e n t r i s k s a n d t h u s i s u s u a l l y r e e e r v e df o r critical patients. Efforts to improve emcrgency medicine eervices response through cxpanded LS operation must be weighed against r h e r i s k o f c r e a t i n g L S - a s s o c i a t e di n j u r y . W e s o u g h t t o r e s t t h e hlpothesis that LS increases the risk of collisiorr and injury by dctcrnrining thc incidcnce of ambulancc collisions and injuries for I-S vcrsusnon-LS travel in an urban cnvironmclrt. D c s i g n : R e t r o s p c c l . i v ca n a l y s i s o f a l l 9 l I a m b u l a n c e c o l l i s i o n s i n S a n l i r a n c i s c o o v e r a 2 7 - m o n t h p c r i o d u s i r r ga c c . i d e n ti n v e s t i g a t i o n r e p o r l . s ,d i s p a t c h d a t a , c l a i n r s , a n d a n r b u l a n c ef l e c t m i l e a g e d a t a . llcsults: One hundred thirty-fivc collisions occurred, the majority d u r i n g n o n - L S ( 7 7. 0 % ) . V e h i c l c s t ar u s a t c o l l i s i o n w a s e n r o u r e t o sccne (3O.4o/o),ar scene (9.60/o),en route to hospiral (2O.\Vo), at hospital (4.47o), and nonparienr-related (BS.SCo).Typee ofmove_ ment were fom ard (33. 37o), srari on ary (20.77o), backing ( I l. I Zo), turning (l5.sEo). Main causarive factors were: inattention (46.JVo\, )
The study shows that the time-to-patient interval -Conclusion, adds a variable amount of time to the overall "..io.." time inter_ val. In the urban setting, barriers further inc."ale this time. Bv not determining the time-to-patient interval, a false sense of timeline""
73
failure to yield. (l4.9%o), unsafe speed (13.47o), and unsafe backing Q0.A7o). The speed wa s less than 20 mph in 80.97o, a nd the damage was minor (less than $500) in 89.67o. A patienr was on board in 237o of collisions. The overall incidence of collisions was l3 per 10,000 miles and 5.2 per 101000dispatch events. The LS collision rate (4.3/10,000 dispatches and 6.8/I0,000 transports) did not differ sigrrificantly from the non-LS rate (2.5/10,000 dispatches and 2.9/101000 transports). However, the injury rate during LS was significantly higher (2.2/10,000 events) compared with non-LS (0. 14110,000events: P < .001 , by X2). Of 17 injuries rhat occurrcd, all were minor, and none occurred to the patient on board. C o n c l u s i o n : L S t r a v e l i s r e l a t i v e l y s a f ei n a n u r b a n e n v i r o n m e n t , with collieion rates comparable to those of non-LS. Although the risk of injury is greater with LS, the incidence is low, and mosr injuries are minor. 'a a-l-, t ,
I f f Prospective Evaluation olthe ACSTrauma TriageCriteria GWKallsen, BBHolroyd, C MechemlDepartment of Emergency Medicine, Valley Medical Center, Fresno, California; Fresno County Department 0f Health, Emergency Medical Services Division; Department of Familv andCommunitv Medicine. UCSF. School of Medicine Study objctive: Systems of trauma care rely on specific crit<:ria t o l . r i a g em a j o r t r a u m a p a t i e n t s [ o t r a u f i l a c e n t e r s . ' I h r : t r a u m a triage criteria of the Americarr Collcg<:of Surgcons (ACS) is th<: most widely uscd criteria. The purposc of our study was to dctcrmine the effectiveness of the ACS triage criteria to idcrrtify nrajor trauma patients. Design: The prospectively collected data included all elements of the ACS triage criteria on all trauma pal.ients who were evaluated by ambulance personnel and transported to the hospital or who suffered prehospital arrest during a l3-month consecutive period in our mixed urban/rural county of600,000 population and 6,000 sq. miles. T y p e o f p a r t i c i p a n t s : A I I p a t i e n [ s w h o h a d s u s t a i n e da t r a u n r a t i c injury and wcre cvaluated, treated, and,/or transportcd by cnrergcncy medical technician or paramedical pcrsonnel during thc study pcriod were included. Prehospital arrests were includcd only if thcy were evaluated and treated by paramedical pcrsonne,. Intervention: Patients were triaged according to local triagc critcria. Data were collected on patients at all destinarions. Results: There were 14,265 patients studied. Of these, therc wcre 214 deaths (l.\Vo),2,238 admitted survivors (lS.7Vo), and 543 p a t i e n t s ( 3 . 8 o l o )w i t h I n j u r y S e v e r i t y S c o r e ( I S S ) o f m c r e t h a r r 1 5 . A total of 4r2M patients mer ACS rriage criteria (srep I and/or step 2); t h c s ei r r c l u d e d I 9 3 d e a t h s ( 4 - 5 % ) , 1 , 3 ? 4 a d m i u c d s u r v i v o r s ( J 2 . 4 o / o ) , and 468 patients (lI.UCo) with tSS of more than lS. If step 3 of the ACS criteria ("consider taking to trauma center") was uscd, an additional 2,511 parients met ACS criteria, including 19 deaths ( 0 . B E o ) 1 3 3 7a d m i t t e d s u r v i v o r s ( 1 3 . 4 o / a ) ,a n d 2 5 p a t i c n r s ( 1 . 0 % ) with ISS of more than 15. The ACS crireria (cxcluding thc,,consider" category ofstep 3) identify major lrauma paticnts with ISS of more than 15 with a sensitivity of 0.8(rand a spccificity of 0.72. Conclusion: The ACS triage criLcria impcrfecrly identify major trauma patients. Further study is ncded to improve the sensitivity and specificity of trauma triage tools.
74
lTSGomparison of the Baxt Rute Wth 0ther Traunu Triage Rules CLEnerman.B Shade,J Kubinacanek/City of ClevelandEmergency Medical Services,Cleveland,Ohio;Departmentof EmergencyMedicine.MetroHealth M e d i c aC l e n t e rC ; a s eW e s t e r nR e s e r v eU n i v e r s l t yC, l e v e l a n dO, h i o Study objective: The Baxt Trauma Triage Rule (TTR) identifies adult major trauma as systolic blood pressure ofless than 85 mm Hg, motor component of Glasgow Coma Scale ofless than 5, or penetrating head or trunk injuries. The purpose of this study was to validate the TTR and compare it against the Prehospital Index (PHI), the CRAMS Scale, and the Triage-Revised Trauma Score (T-RTS). Design: Retrospective using previously accumulated data base. The scores were compared for mortality and, in a subset, mortality or cmergency operation. Setting: Adult trauma victims transported by Cleveland Emergency Medical Services System. Interventions: None. Results: Complete infornration was available for 11027adult trauma patien[s. All four rules predicted mortality with a sensitivity of 1.0. The specificity of the TTR (0.90) was eimilar to that of the PHI (0.88) and T-RTS (0.88) and betier than that of the CRAMS (0.83, P < .00I). The sensitivityof three of the rules, TTR (0.94), CIIAMS (0.94), and PllI (0.94), in prcdicting mortality or need for cmergency operation was similar, although the T-ltTS (0.85, I' - .07) was somewhat lowcr. 'fhc specificity values of the TTR (0.89), PHI (0.88), T-IiTS (0.88) were higher than that of the c I i A M S ( 0 . 8 0 ,P < . 0 1 ) . Conclusion: Wc conclude that the TTII is a valid instrument for identifying adult major trauma victims. It performs simi-larly to the PIII and is more specific than tbe CMMS scale.
of Myocardial Infarction Wth Magnetic { 7O EarlyDetection I f J Resonance lmaging in a Canine Model MGAngelos, A Katz-Stein, JELeasure, BBaton/Departments of Emergency Medicine, Wright State University, Dayton, 0hio;TheOhio State University, Columbus S t u d y h y p o t h e s i s :M a g n c t i c r c s o n a n c ei m a g i n g ( M I I I ) c a n d e t e t carly myocardial changes intiuo afLer coronary artery occlusion. Design: A prospective, controlled, canine study using a left anterior descending coronary artery (LAD) ligation model. Interventions: After thiopental general anesthesia, nine mongrel dogs underwent MRI using a 2.35-T magnet with a 40-cm bore before and four hours after ligation of the LAD. The mean image intensity ratio ofthc suspected infarct region to the normal myocardiun was dctermined in the four-hour postocclusion images and compared with the ratio from thc same anatomic region obtained at baseline. The area of nerotic and ischemic myocardium was delermined using fluorescein and triphenyl tetrazolium staining immediately after four-hour images. flcsults: Al] animals werc noted to have ntrrotic (rangerl.87o to 20.47o) and ischemic (range,9.2o/a to 36.60/o)myocardium with 'I'he histochemical staining. mean myocardium intensity ratio four hours after LAI) occlusion was signficantly higher than baseline (four hours, 2.41 + 1.72; baseline, 1.04 + 0.02; P = .021). Infarct size at four hours assessedby MRI showed a reasonable correlation with histochemical staining infarct size determinations (R - .63, P = .07). Conclusion: MRI can distinguish myocardial edema, aesociated with acute myocardial infarction, inuiuo, as early as four hours after LAD occlusion.
*{
Otl I Olf
Following EarlyEvaluationol OxygenConsumption Acute MyocardialInlarction Uncomplicated
of Emergency M Alexander/Department JDEdwards, EPRivers, MYRady, Department Michigan; Detroit, Ford Hospital, Henry Medicine andCardiology, ofSouth Hospital University andCardiology, Care Medicine ofIntensive England Manchester, Manchester, Study objective: Oxygen coneumption (Vor) has been ehown to be decreased after acute myocardial infarction (AMI) complicated by pump failure. This study evaluates early measurement of Vorafter an uncomplicated AMI (UAMI). Design: Prospective, nonrandomized case study. Setting: Emergency department of large urban hospital. Type of participants: Twenty-six normothermic patients presenting with UAMI. All patients had laboratory confirmation, including
predictive values. andnegative PPVandNFV,positive
The CK-MB monoclonal antibody immunoassay was significantly more sensitive (P < '0005 by McNemar's test) arrd had a significantly better PPV (P < .001 by 12) at both baseline and after thre houre' All three lests were significantly more sensitive after three houre compared with results at the time of ED presentation' C o n c l u s i o n : A C K - M B m o n o c l o n a l a n t i b o d y i m m u n o a s s a yp e r formed significantly better than a CK-MII immunoinhibition i r , r , r r n o . r u y a n d t . o t a lC K m e a s u r c m e n t si n E D p a t i e n t s w i t h c h e s t tliscomfort. Emergency physiciarrs necd to know which CK-MB i n r m u n o a s s a yt e c h n i q u c i s p c r f o r n r c d b y t h c i r c l i n i c a l l a b o r a t o r y '
ECG and enzymatic evidence of AMI. Interventions: Vo, was measured by direcr Fick method (Deletrac, Datex lnstruments) after admjnistration of nitroglycerin' 'Iwenty-four patients presented within six hours and two Results: patients within 24 hours after onset of symptoms. l-ifteen patients had anterior AMI and ll patients had inferior AMI (Table). Ageiymrs) Voz(mt/min m2) MAP {mmHs) HR
Mean(S0)
Bange
62112) 150(28) 95{15} 8 5( 1 4 )
36-84 s6-.226 70,r3i 60-117
Results: A total of 548 patients were enrolled, includtng44 (87o) MI patients. The tests performed as follows' Total CK-MB CK-MB Crsatine lmmuno' Monoclonal Kinase inhibition Antibody 0 Hour 3 Hour 0 Hour 3 Hour 0 Houl 3 Hour 33% 52% 35% 16% 81% 62% Sensilivity s3% 90% 95% 98% 95% 97% Specificity 33% 3l% 410t" 45"/" 64% M% PPV 94% 95% 94% 93% 99% 96% NPV
GK'MBElevationsPredictAdverse Department /l (l,Gt Emergency a OZ 0utcomesin ChestPainPatients JB Swanson/Portland TBGreen, WBGibler, GBHenkel, GPYoung, JF Hedges, University. Sciences Health Orgeon AffairsCenter; VeteraisMedical Chemistry Clinlcal Medrcrne, of Emergency Division Servcies; Emergency Department of Cincinnati, University Laboratory, Chemistry Cllnical Laboratory, Medicine of Emergency elevations Study hypothesis:Creatinekinast;(CK)-M13enzym<:
Of twenty-four patients, four had a Vo, of less rhan Ll0 nrllmin' m2 (normal range 120 to 140). These patients developed cardiogenic shock and two died within 24 hours ofadmission. Survivors had a significantly higher mean Vo2 of 155 ml/min.m2 (957o confidencc intervals, I05 to 205 ml-,/min.m2) than nonsurvivors' Conclusion: The rise in Vo, might bc related to the sympathoadrenal releaee of catecholamines after AMI. However, a subsequcnt reduction in Vo, after AMI may be an early reflection of dcterioration in systemic oxygen delivery below its critical value, indicating pump failure. Early measurement of Vo, may be of valuc :rs art
n o t c d w i t h i n t h r c e h o u r s o f c m e r g e n c y d c P a r t m e n t p r e s c n l a L i o na r e a s s o c i a t e dw i t h a d v e r s c c v e n t s i n h c m o d y n a m i c a l l y s t a b l e c h e s t p a i n p a t i e n t s h a v i n g n o n d i a g n o s t i cF I C ( l s . D c s i g n : 1 ' w o - y e a r , p r o s p e c l - i v cc o h o r t . s t u dy ' gospitals' S c t t i n g : ' I ' w o u n i v c r s i L y - a f f i l i a lr : d t e a < : h i r t h 'Iiypc o f p a r t i c i p a n t s : C o n s c n t . i n gh c m o d y r r a m i c a l l y s t a b l e E l ) c h c s i p a i n p a t i c n t . sm o r c t h a n 2 5 y e a r s o l d . F l x c l u s i o n si n c l u d e d t l c v a t i o n o f a t .l c a s t I m V i n t w o o r m o r e t . h o s cw i r h S ' l ' - s e g m e n e ECG lcads, chest wall traumar abnormal x-ray studies,and incom-
index of severity of AMI and its prognosis'
ArecreatedEqual lmmunoassays 1 81 NotAttGK-MB Veterans W Cimikoski/Portland C0'Connor. WBGlbler, GPYoung, TRGreen, University, Sclences Oregon Health Portland, 0regon; Medical Center, Affairs Portla nd Study h)?othesis: That two different creatine kinase (CK)-M[| immunoassays will perform similarly irr emergency department patients complairring of chest discomfort with rrondiagnostic ECGS. Design: Prospective sampling of serum cardiac enzyrnes. Setting: Universiry-af{iliated teaching hospital ED. Type ofparticipants: Patients less than i30 years old with chcst pain warranting an ECG. Excluded werc hcmodynamically unstablc patients and patients with ECG evidcncc for acutc MI. Measurements: Serum specimens wcre drawn on patients with chest discomfort at the time of ED prcsentation and at thc crtd of three houre (two specimens). The specimens were analyzed for total CK and CK-MB bv two different immunoassaYs (monoclonal anti-
p l e t c d a t a c o l l e c t . i o n( 4 4 9 ) . t r { e a s u r c m e n l . sl :) r e s c n t i n g a n d t h r m - h o u r C K - M B l e v e l s , p r e s c r r t . i n gE C G , a n d c l i n i c a l f o l l o w - u p a t 4 8 h o u r s , h o s p i t a l d i s c h a r g e , o , , d , " " " r d a y s i f n o t a d n r i t t e d o r i f d i s c h a r g e dw i t h i n o n e w e e k ' N { o n i t o r e d a d v e r s ee v e n t s i n c l u d e d m y o c a r d i a l i s c h e m i a , n e c e e e i t a t i n g a g i o p l a s r yo r c a r d i a c b y p a s s s u r g e r y , b r a d y c a r d i a r c q u i r i n g p u " i r i g , . - " . g . n c y c a r d i o v e r s i o n , c a r d i o g e n i c s h o c k ov e n l ' r i c u l a r f i b r i l l a t i o n , a n d d r : a l h ' X 2 a n a l y s i sw a s u s e d . llesults: Thcrc werc 38 patients with an elcvated ED CK-MB lcvcl. Ovcrall, <:ightof M9 patients (2o/o) dcmonsrrated an adverse c v r : n 1w i t h i n r h e f i r s r 4 8 h o u r s . A l l c i g h r p a t i e n t s r e q u i r c d e i t h c r 'l'hrr:e of thc cight patients (38Vo) arrgiopfasty or bypass surgcry. with early adversccven[s had an clcvalcd CK-MlJ lcvcl' Of 24 p a t i e n t s d e m o n s t r a t i n g c o m p l i c a t i o n s a f t a r 4 8 h o u r s , s e v e n( 2 9 7 o ) had an clevatcd ED CK-MI] Ievel. Whi.lea rclativcly insensitive marker, an elcvated CK-MI] levcl was associated with the occurr e n c e o f a n a d v e r s ee v e n t ( w i t h i n 4 { l h o u r s ' P < ' 0 2 5 ; a n y t i m e during hospitalization, P < .0005). Conclusion, An clevated CK-MB level within threc hours of ED w i t h a s u b s c q u e n ta d v e r s ee v e n t i n t h e presentationis associat.cd s t a b l e c h estpain patient with a nondiagnostic hemodyhamically E C G . N e v e r t h c l e s s ,t h e E D C K - M B i d e n t f i e s o n l y a n i n o r i t y o f 2
b o d y I H y b r f t e c h ] a n d i m m u n o i n h i b i t i o n 1S . . " a y " 1 ; .
75
otherwise markers
*rl
QQ I llrJ
low-risk
patients
for diagnosing
who develop
myocardial
Tlpe of participants: Patients presenting to the emergency department with symptoms of D\lT or PE of less than one week'e duration. Twenty-three consecutive patients met the inclusion criteria; one was not included because his medical record was unobtainable. Age range was 28 to 77 years. Interventione: Latex agglutination d-dimer aasay (STAGO) was obtained at time of presentation. Results were independent of diagnostic workups. After the conclusion of the study period, d-dimer data were compared with final diagnoses. Reaults were subjected to statistical and cost-benefit analyses. Results: D-dimer aseay was I007o seneitive for DYT and PE. Even in this emall patient population, two VQ scans, two pulmonary angiograms, and two venous Dopplers could have ben avoided, resulting in a savings of$4,836. Conclusion: D-dimer measurement shows significant promise as a screcning test for DVT and PE in the acute setting. Further study is
adverse events, and other
ischemia
in the ED are needed.
Magnesium Reduces MortalityandMorbidityFollowing Acute Myocardiallnfarction:A Meta-Analysis
MAGibbs, TEAuble, JJ Menegazzi/University ofPittsburgh, for Center Emergency Medicine ofWestern Pennsylvania Study background: Previous studies evaluating the role ofmagnesium in acute myocardial infarction (AMI) have shown mixed results. Hypothesis: Prophylactic magnesium therapy reduces mortality and morbidity (arrhythmias requiring treatment) in patients presenring with AMI. Design: A meta-analysis of etudies regarding prophylactic magrcsium therapy in AMI wae performed after a computerizcd literature search of the MEDLARS data base. Studies included werâ&#x201A;Ź prospective, randomized, double-blind, placebo-controlled trials. All patients presenting with acute chesI pain suggestiveof AMI were given magnesium therapy; only those with documented AMI were included in the analysis. Initial doses ranged from2.4 to l3 g of IV magaesium given within 24 hours of presentation. Therapy was continued for up to 72 hours, and patients were followed for up to s e v e nd a y s . I n t e r v e n t i o n s : A m e t a - a n a l y s i sw i t h t h e c e r r o r r a t e s e t a t . 0 5 . Ites uhs: Srudy(yâ&#x201A;Źa.) (1990) Shecter (1989) Ceremuryunski 1987) A b r a h a(m smirh(1986) Basmussen(i986) Ioral
Mg
necded in a larger, more diverse patient population.
*{
Study hypothesis: Magnesium sulfate administered IV improves objective nleasures of expiratory flow in patiente with asthmatic e x a c e r b at i o n s . Design: Randomized, double-blind, placebo-controlled clinical trial. Setting: Inncr-city emergency department. 'f ype of participants: Forty-cight asthmatic patients aged I8 to 60 ycars with initial peak cxpiratory flow rates (PEFR) oflees than 200 L/min who failed to doublc their initial PEFR afler two 2.S-mg aerosolized albuterol treatments, Patients were excluded for history of chronic obstructive pulmonary diseascocongestive heart failure, r c n a l d i s e a s c ,o r t e m p e r a t u r e o f m o r e t h a n l 0 l F . Interventions: Subjects were randomized to one of three groups: magrresium sulfate 2 g IV loading dose over 20 minutes and then 2 glhr over four hours (infusion); magnesium sulfate, 2 g over 20 minutes and then placebo infusion (bolus); or placebo loading dose and irrfusion (placebo). All subjmts received standardized amino-
Monality Coilrolt
0
s
0
s
1 12 2 3 4 11
49 4 46 89 52 260
I 3 1 t4 14 41
44 21 45 19 B0 268
Y
i 10 7 I / 21 58
l 34 tB 4l 85 l]5 213
Spirometric Bolusor Infusion Failstolmprove Qtr Magnesium I lfrl Performance in AcuteAsthma Exacerbations of Emergency Medicine, 8fl Tiffany, WABerk,KTodd,SRWhite/Department Wayne State University, Detroit, Michigan
Y i l 24 225 t5 5 16 30 14 /9 4/ 2t 11 9 1 7 0
D,death; S,suruived. yes(Y)orno(N) Arrhythmias requiring lreatment: Meta-analysis offive qualifying studies showe that prophylactic magnesium reduces mortality (P - .00006) and morbidity (P - .0000004) after AMI. The relative risk of death for magnesium v s p l a c e b o w a s 0 . 3 1 ( 9 5 7 o c o n f i d , e n c cl i m i r s [ C L j o f 0 . 1 6 t o 0 . 6 1 ) . The relative risk of arrhythmias requiring treatment for magnesiunr v s p l a c e b o w a s . 5 5 ( 9 5 7 o C L , o f 0 . 4 3 t o 0 . 7 0 ) . T h e s t u d i e sw e r e s i m i lar enough to be combined (f,2tcst: mortality, P = .50; nrorbidity,
P = .3s).
C o n c l u s i o n : M e t a - a n a l y s i si n d i c a t . c st h a t p r o p h y l a c t i c n r a g r r c s i u m therapy after AMI reduces the risk of morrality by 69Va and thc risk of morbidity by 457o.
Xrl Q ll D-0imerTestingas a RapidScreenlor DeepVenous I lf 't Thrombosisof PulmonaryEmbolism BEHarrell. SNConnelly/University 0f Arkansas for MedicalSciences, Little Rock, Arkansas; JLMcClellan Memorial VAMedical Center, LittleBock, Arkansas Studyobjtrtives:This studywasdesigned to determirre rhe use-
phylline arrd steroid therapy. Measurements: PEFIi and forced expiratory volume at one second (FEV') werc measured at 0 (start ofloading dose),20, 50,80, 140, 200, and 2(r0 minutes using a water-displacement spirometer. Changes from baselinc (t = 0) werc compared by one-way ANOVA for repeated measures (Table). Chango in PEt[ (Uminl SDl Grouo l{o. ol Palisds O min 200min Placebo 0 . 0 1 3 f 0 . 2 5 0 . 2 5 1 0 , 4 6- 1 . 5 f 3 0 4 0 1 6 6 21 t5 0.043 0.24 Bolus r0.25 r 0.39 7.3+32 47185 lnlu$on 12 0 . 0 0 1 1 0 . 1 10 . 1 9 r 0 . 2 8 1 9 i 1 9 4 4 + 1 5 Magrresium sulfate administration did not at any time point significantly improve FEV' (F : .036, P: .96) or PEFR (tr'= .51, P = .61). 'fhis study had the power to detect a PEFR difference of 2l L,/min and an FEV, difference of0.16 L betweengroups (B = .20, o, = .05, two-tailed significance). Conclusion: Use of IV magnesium sulfate in addition to etandard the rapy does not provide clinically meanin$ul improvement of objer:tivc meaaures of cxpiratory flow in patients with severe asthma
f u l n e s s o f a r a p i d d - d i m e r a s s a yi r r p a t i e n t s w i t h a n a c u t e p r c s e n t a t i o n s u g g e s t i v eo f d e e p v e n o u s t h r o m b o s i s ( D V T ) o r p u l m o n a r y e m b o l i s n r( P E ) . P r e v i o u s s t u d i e s o r r r h c u s e f u l n e s so f a d - d i m c r a s s a yt o s c r e e n f o r D V T a n d P E h a v e n o t c o n s i d e r c d t h e d u r a t i o n of symptoms before patient presentatioll. D e s i g n :T h c p r o s p e c t i v e s t u d y w a s c o n d u c t e d f r o n r N o v c m b c r 1 9 9 0t h r o u g h N o v e m b e r 1 9 9 1 . a Setting:A tertiary care veterans hospital-
ex acerba tio ns.
16
Tukey's post hoc teet. A P value of< .05 was significant- Change in tension for each group ie as follows (Table). MI m2 tc llc (t=e) (rl = 6) (it= 18) (1{= 15}
*1 ofweatheronAsthma Admissions 86 Influence College of HBlunstein, J Schoffstall, W Spivey, ESkobeloff/lhe Medical Pennsylvania. Philadelphia Study objective: Rapid changee in the weather have been postulated to exacerbate asthma and increase the frequency ofemergency department visite and admissione. The object of the study was to correlate the effect of different weather parameters or changes in these parameters on aethmatic admissions to the hospital. Design: Retrospective, computer-assisted chart review. Type of participants: All patients admitted to one of the 67 hospitals in the five-county Philadelphia area from July l, 1988, through June 13, 1990, with an ICD-9 code indicating asthma (493.x). Methods: Veather and pollution data were extracted from monthly reports of climactic conditions made by the Department of Agriculture Weather Service and from local newspapers. AII asthma admiesions over the two-year study period were analyzed using a multiple regression for a possible relationship with pollution, temperature, humidity, barometric pressure, wind speed, direction, and changes in these parameters from one day to the next. Analysis also was done of admieeione with one- and two-day lag periods. Results: There were 14.879 admieeions available for analysis. 'The strongest determinant of admissions rates was for.d toie time of year (P < .001). Fall months (Seprember through November) had the most admissions, and summer months (June through August) had the fewest. Sigrrificant correlations (P < .05) were found between admissions and mean daily temperature, low daily temperature, and humidity. Cold days with a large difference between high and low temperatures had a strong correlation with admissions (P < .00f). No correlation was fourrd with day-to-day changcs in thc weather, daily atmospheric pressureo wind speed or direction, or daily pollution index. No correlation was found between envlronmental conditions admigeions one or two days later. Conclusion: The time ofyear was the strongest predictor of admissions for asthma. However, a large variation in temperature during the cold months ofthe year is correlated with increased admissions for asthma. Thie raises the possibi,lity that patients could have medications or dosages altered based on weather forecasts to decrease the number of admissions for asthma.
Beth (0.5mM) Beth {2.0mM) Beth (7.0mM) EPI (t0r Ml EPI M) {10-2 MgC1, {50mM)
974t145
1.2161114
807r132
1.6531296 15160
2 9 2* 5 0
162r39
\ 2 7+ 4 3
105 127
104r33
r 3 1l 3
+11+17
- r 8r 1 6
0rt0
-1 14133
-25/']t14
-260t82
--480+147
-393153
-576166
340i82
-2,022t383
80120 -95157
The overall contractile response to Beih was Ml > (P <-001) FC > ( P = N S ) M C > ( P < . 0 0 1 ) M 2 . R e s p o n s et o E P I w a s M l > ( P < . 0 0 1 ) > F C > ( P = N S ) > M 2 > ( P * N S ) > M C . I l c l a x a t i o n r e s p o n s et o M g C l , w a sM l > ( P < . 0 0 1 ) > F C > ( P = N S ) > M 2 ( P = N S ) > M C . Conclusion: Treatment with estrogen alters the response of bronchial smooth muscle to Beth, EPI, and MgCl". Changes in estrogen levels may play a role in the frequency and eeverity of asthmain women.
*{
andGasExchange EetweenRespirations OO Gorrelations I OO Abnornnlitiesin YoungAdults , C t AM e d i c a l y e d i c i n eU e fnE t m e r g e n cM W M o w e r ,E C a r d e n a s / D e p a r t m o Center Study hypothesis: Young, healthy irrdividuals with acul.e p u l m o n a r y d i s e a s em a y e x h i b i t n o r m a l r e s p i r a t i o n s ( R R s ) d e s p i t e significant abnormalities of gas exchangc. D e s i g n :A n o n c o n c u r r c n t p r o s p c c t i v c c x a m i n a t i o n o f t h e c o r r e l a t i o n b c t w e e n I I R a n d a r t e r i a l b l o o d g a s m e a s u r c m e n t si n y o u n g adults with acute respiratory complaints. Age, sex, resPiratory ratet arterial oxygen tension (Pa02), arterial carbon-dioxide teneion (Pacor)r and calculated alveolar-arterial oxygen gradient (DA-aor) were collected for each patient. The Pearson product-moment coefficient of correlation was used to determine relatedness. The normal RR was determined in a cohort of matched controls. Setting: Emergency departments of a university medical center and affiliated county medical ccntcr, I ' y p e o f p a r t i c i p a n t s : T h e s t u d y g r o u p c o n s i s t e do f a l l 1 0 5 patients, aged l5 to 45 years, who underwent room-air blood gae analysis in thc EDs during a two-month study period. Patiente with a h i s t o r y o f c h r o n i c p u l m o n a r y d i s c a s c ,s u c h a s a s t h m a o r c h r o n i c obstructive pulmonary disease, were excluded. A group of 100 matched controle were selected from patients presenting with non-
*1
87 Esfrogen Alterc theResponse ofBronchial Smooth Muscle EMSkobeloff,\NH Spivey, of RMMcNamara/The Medical College
P e n n s y l v a n iDae, p a r t m e notf E m e r g e n cM y e d i c i n eP , hiladelphia Study objective: Astlma recently has been shown to !e more common in women than in men. The experimental hypotheeis of this study was that eetrogen alters the response ofbronchial smooth muscle to stimuli. Design: Prospective controlled laboratory investiga tion. Interventione: Male New Zealand. rabbits treated with B-OHestradiol either for two continuous weeks without a recovery period (M2) or continuously for one week wirh a one-week recovery period (MI). MaIe (MC) and female (FC) controls did not receive estrogen. Bronchial rings (3 mm) from each group were placed in a Langendorffapparatus and treated with bethanechol (Beth) (0.5, 2.0, or 7.0 mM) to induce contraction. This was followed by epinephrine (EPI) (I0-3 or l0-2 M) and MgCl, (50 mM) to induce relaxation. Results: Changes in muscle tension (mg tension) were reorded for each intervention, and data were analyzed with an ANOVA and
pulmonary complaints. Results: The mean RR in the study group was significantly higher than the control group (22 vs 18, P < .05). The correlation coefficientswere RR and DA-aor, .2?5; RIt and Pco", -.238; and RR and Por, -.189. RR was 397o sensitive in identifying patiente with pulmonary dysfunction and demonsl.rated a specficity of 777o. 'fhirty ofthe study patients having a DA-ao, greater than 20 had RRs within 2 SDs of the mean rate for the control group. Conclusion: RR correlates poorly with blood gas measurementg in young healthy adults. These patients can have marked abnormalitiesofgasexchangeandstiI|exhibitnormalRRs->
77
With Glycopyrrolate and { QO Ditlerencesin CombinedTreatrnent I lf rf AlbuterolBetweenAsthnraand Ghronic0bstructive PulmonaryDisease BKCydulka, CLEmerman/Department of Emergency Medicine, MetroHealth Medical Center, CaseWestern Beserve University. Cleveland, 0hio Study objective:Comparisonof combinationtreatmentwith aeroeolizedglycopyrrolateand albuterol againstalbuterol aloneirr acuteasthmaor chronic obetructivcpulmonary disease(COPD). Design:Prospective,randomized,blinded controlledsrudy. Setting:County-owned,urban cmcrgencydepartments. T;pe of participants: One hundrcd ninety patients with acute exacerbatiorr of asthma of COPD. Patients were excludcd for congestive heart failure, pneumonia, penumothorax, and contraindica_ tions to glycopyrrolate. Intervention: All patients received a total of three aerosol treatments. Patients were randomized to receive aerosolized 2 mg glycopyrrolate plus 2.5 mg albuterol (combination rherapy) vs albuterol alone (control) for the first aerosol. Both groups reccived aerosolized 2.5 mg albuterol alone for their next l.wo treal.ments. A s t h m a t i c p a t i e n t s a l s o r e c e i v e d6 0 m g s o l u m c d r o l I V p . Results: Student's l-test analysisrcvealcd that there was rro difference in pretreatment FEV, betwcn the control and the glycopyrrolate group. Patients with COPD reciving combination thcra_ p y h a d a g r c a t e r A F E V , ( p o s t - t r e a t n r t : n rF E V , - - p r e t r e a t m e n t F E V ) ( 5 4 E o )t h a n c o n t r o l p a t i c n r . s( 1 6 % o ,p < . 0 1 ) . A s r h m a r j c s receiving combination therapy had a lower A FEV, (S2Vo) than c o n t r o l p a t i c n l s ( 8 2 V o ,P < . 0 5 ) . Conclusion: The combination of glycopyrrolate and albuterol is beneficialin treating patients with acute exacerbation of COpD. but it is of no benefit compared with albuterol alone in treating patients with acute asthma.
*{
ol Paramedic Rhythm Labeling: On InterraterAgreement I rflf lmplications forUnilorm Beporting of DataFrom
0ut-of-Hospital CardiacArrest BGPirrallo, BASwor,BFMaio,JETintinalliANilliam Beaumont Hospital, Roval O a kM , ichigan Studyhypothcsis:Intcrratcr agrq)mentis prescntirr paranredi<:,s labelingof vcntricularfibrillation(VI,')and asystolicrhyrhms. Design:Prospective, cross-sectional study. 'f 1pe of participants: Onehundred five practicirrgpara nredics from
nonvolunter
agencies who are certified
in advanced
cardiat:
Me support. Methods:
Five static cardiac
arresr rhythm
strips,
classified
average peak amplitudc method, were randomized five ways and placed into five survey booklets. The paramedics were instructed to label each rhythm VF or asystole based on rhythm recogrrilion, not on treaLmcrrl plan. 'fhe overall kappa value for labcling r.hcfivc rhythms is _Results: .63, indicating a moderate dcgrec of interrater agr(rmcnL. [Iowevcr, as thc rhythm's amplitude decreases, lhe amount ofinler_ different
rater
agreement
proportion
also decreases markedly. I mm, agreement
Whcn
is no different
the amplitude than chance:
arrest caaes.Time of collapse, dispatch time, scene arrival time, rime of CPR, and time of first defibrillation were determined from computerized dispatching records, real-time cassette tape recordirgs of oscilloscope and audible events during the arrest, telephone interviews with bystanders, and hospital records. Setting: Southwesrern city (400,000 population; area 390 km2 with a two-ticred basic life support/advanced Me support [ALS] emergency medical services IEMS] system). Type ofparticipants: One hundred eighteen casesofwitnessed, out-of-hospital cardiac arrest with initial ventricular fiIrillation. Intervenl.ions: Standard American I-Ieart Association advanced cardiac life support protocols. llesults: Died No.ol 6ses Bystander CPB Age(yr) (rnin) Firstresponse A[Sresponse {min} Collapse ro CPR{min) Collapse to d c l i b r i l l a t i(omni n )
100 39(3s%) 66r13 4 . 21 1 . 6 5 . 11 1 . 9 5 . 21 3 . 5
Survivsd
18 14{7870) 66r13 3 . 7f 1 . 8 4 . 8t 2 . 3 r . 71 1 . 3
.01 .94 .34 .57 .00
12.2 Lt
1.8
9 . 51 5 . 1 7.4t7.4 .01 -Minimum dillerenm delectable wirh95probabiliry. Conclusion: Response intervals of emergency vehicles as recommcnded by tho Utstein sty.leare inadequate indirect measures of collapsc to intervenLion inl.crvals in prehospital sudden car.diac death arrd should not be used to characl.erize EMS system lerform a n c c i n t h c t r e a t m e n t o f o u t - o f - h o e p i t a lc a r d i a c a r r e s t .
t Ot Physician Versus Algorithm Interpretation ofElectrocardiogra I JLin thePrehospital Diagnosis ofAcuteMyocardial lnfarction TDValenzuela, DRHamptom, S Butman, T Lyster,LClark,T lseman, DASpaite HWMeislin, M 0lsulfka/Arizona Emergency Medicine Research Center, College ofMedicine, University ofArizona, Tucson Study objective: To compare the performance characteristics ofa computer ECG interpretation algorithm to a physician dual certified in emcrgency and internal medicine. Design: A l4-month case series of patients with nontraumatic chest pain- Paramedics obtained a l2-lead ECG from each before emcrgency depart.ment arrival. Patients' medical records were reviewed for final diagnosis. Performance characteristics ofan ECG ilrterpretation algorithnr were compared wirh those of a physician reading ofeach ECG. Setting: Southwestern city (400,000 population; area, 390 kmz) with a two-l.iered emergency response system. 1'ype of participanrs: Eligible were parients who call 9ll ro request assistancefor nontraumatic chest pain. Three hundred ninety patients met criterial ECGs were obtained on 234, Interventions: An ECG obtained by paramedics before ED ar r i v a l . Results: Performance characteristics for algorithm and physicians were as follows.
by
Cummins'
approximately
,l Response lntervalsVersssGollapseto GPRand Oa, Emergency I rf I DefibrillationIntervals:MonitoringEMSSystemPerlormance in SuddenCardiacDeath TDValenzuela, DWSpaite, HWMeislin,LLClark, ALWright,GAEwy/Arizon Emergency Medicine Besearch Center andSection of Cardiology, College of Medicine, University of Arizona, Tucson Study objective:To compareemergencyvehicleresponseintervalsto collapseto interventionsintervalsfor correlationwith eurvival after prehospital,witnessed,ventricular fibrilla tion. Design:Twenty-two-monthcaseseriesof prehospitalcar&ac
is the
ofparamedice
labeling the rhythm !T is .46 (9SVo confi_ .36 to .56). Only a flat line (0 mm) demonstrares complete interrater agreement with no paramedic labeling the rhythm VF. dence intervals,
Conclusion:
Interrater agreement of paramedic labeling of VF is dependent. An analysis ofVF rhythm data that does rror control for interrater agreement of rhythm labeling cannoI cnsurc uniform labeling of VF and reporting of cardiac arrest data. amplitude
78
Alqorilhm
Sensitivity Soecificitv False-positive Positive value oredictive predict;ve Negative value
.265 .996 .004 .900 .909
Design: Population-based, controlled clinicql trial with periodic
Plwsician
.50 .9M .032 .654 .934
cro880ver.
Setting: An urban EMS service. Type of participants: Victims of out-of-hospital cardiac arrest treated by one of4O engine companies of the Memphis Fire f)cpartment over a 3l-month period. Intervention: All 40 companiea were trained to use a semiautomatic defibrillator (AED) and initiate three-rescuer CPR until paramedic arrival. Half were randomized initially to use an AED (Heartstart 2000@,Laerdal Medical, Armonk' New York) to treat cardiac arrest; the other halfperformed CPR until paramedics arrived. Every ?5 days thereafter, group roles were reversed. All survivors were followed to hoapital discharge. Neurologic disabiliry
Physician and algorithm has identical accuracy (.908); however, the phyeician erroneously interpreted nine ECGs as diagnostic of AMI versua one by the computer. The physician corectly identified twice as many AMIs (17 vs nine) as the algorithm. Conclusion: Requiring computer algorithm confirmation of physician AMI diagnosis would improve sigrrificantly the safety of prehospital AMI diagnosis at the cost of eliminating from consideration for thrombolysis half of AMI patients diagrrosable by physician ECG interpretation. * { (|2
alsowas aeeessed. Results: Six hundred eixty-eight patients were treated by project c o m p a n i e s ,T h e a g e , s e x , a n d r a c e o f A E D a n d C P R p a t i e n t e w e r e conrparable. AED and CPll <:onrpanieshad similar rates of witnessed arrest (610/ove 56o/a),and bystarrder Cltll (lzo/a vs l47o). The percerrtof patients fourrd in ventricular fibrillation (W) (49% vs 50Vo) a l s o w a s s i n i l a r . E M S r e s p o n s e l . i m e sw c r c i d e n t i c a l i n b o t h g r o u p s , cxcept AED companies got a defribrillator to the gcene a mean of 2.4 minutes faslcr tharr did controls (I' - .0001). Despiresuccessful usc of the AED, overall rates of survival in the AED grouP were not s i g n i f i c a n d y b r : t t c r t h a n t h o s r :i n t h e C P R g r o u p .
Agreement of Interpretation ol Prehospital Cardiac Rhythm by
I rfrf Paramedics, Emergency Physicians, andCardiologiss EADavis. JJ Menegazzi, RVidichich, SMDunmire, BNRoth, JH Coben, ECurtis/Division of Emergency Medicine, University 0f Pittsburgh Studyobjective:The correct interpretation of cardiac rhythm (CR)is an important factor in determiningprehospitaltreatment; however,stu&esshowmisidentificationas high as 357oand inappropriatetieatment ashigh as 26Vo.We soughtto determinethe accuracyofinterpretationsofprehospital CR by pararnedicsand emergency physicianscomparedwith that of a cardiologist.
3113/'2l'10.8"t 1 VF/Wonly 291169117 zY.l WitneswdVF,&l 20198|.20.4Y.1 V[, ventricular tachys rdia. A l l6 s s
P
CPB
AED
Design: Retrospective, cross-sectional, consecutive case design. Setting: Urban advanced li]fe support emergency medical services system. Type ofparticipants: Five cons<rcutiveweeks of tripsheets werc used. All CRs, prehospital interpretations, and treatrlents wcrc rmorded. 'I'he lnterventions: monitor strips werc interprctcd by a cardiolog i s t a n d t h r e e b o a r d e d e m e r g e n c yp h y s i c i a n s . I ' h e s c w c r c c o m p a r c d and evaluated for agrement and in cases of disagrecmcnt if clinical treatment was affected. Results: Five hundred five ECGs were interpreted by the cardiologist, with 56 (ll7o) paramedic disagreements; 34 (6.77o) had an effect on treatment. For the three emergency medicine physicians, t h e r e w e r e 6 4 ( 1 3 7 o ) , 4 0 ( 8 7 o ) , a n d 5 7 ( l l 7 o ) d i s a g r e e m e n t s ,w i t h 2 8 (6% ), l5 (37o), and,24 (\Co) bein g significa n t clinic ally. Usin g the Mantel-Flaenszel test for > I control, X2 was 1.42 (P < .22), indicating significant agreement. The odds ratio of paramedic agreement with the cardiologist was MVo that of thc emergency physiciarr (Miettinens 957o confid.enceintervals,0.65 ro 1.00). Of rhe 34 clinically significant paramedic-misinterpreted rhythms, ten also wcre similarly misread by at least one emergency physiciarr. Thcrc were eight life-threatening paramedic misinterpretations, an d six involved ventricular tachycardia. Conclusion: There is significant agreerrent among paramedic, emergencyphysician, and cardiologist interpretations of prehospital CRs. The majority oflife-threatening errore involved ventricu lar tachycardia; proper quality assurance and continuing medical education measurcs should address rhig.
26132618.0v,) Ns ( 111 . 9 % ) N S 19/14 t 1 l t 4 | t 1 4 . 9 % lN S
Conclusion:I"irst-respondcrA [iDs may inrprove survival in s e l c c t c dc a s c s ,b u L t . h eo v e r a l l i n r p a < : to f t h i s i r r t e r v c n t i o n i n a n u r b a n p a r a m e d i < :s y s t c m w i t . h f a s t .r o s p o n s c t i n r c s i s s m a l l .
195i:t*t'l'j'#i[:ili;'.i;:.;i?,'j.i::H;J:I*'''
y edicine M C a l l a h a nW , C l a r k / D i v i s i oonf E m e r g e n cM , V a l e n t i n e , 0B r a u n D , n i v e r s i toyf C a l i f o r n i a , a n dt h e C e n t e rf o r P r e h o s p i t aRl e s e a r cahn dT r a i n i n gU S a nF r a n c i s c o Study hypothesis:Cardiac rhythm determined shortly after attcmpted dcfibrillation of ventricular fibrillation (VF) by urban f i r s [ - r c s p o n d e r s c an p r c d i c t p at i c n t o u t c o m e . Participants: Two hurrdred lifty-four San Francisco adult cardiao arrest victims found bctwer:n June 1989 and September 1990 to bc in VF on arrival of firc dcpartrrrent (li'l)) first-responders c q u i p p < : dw i t h s e m i a u t o m a t i c d c f i b r i l l a t o r s . I n t e r v e n t i o n : D e f i b r i . l l a r i o na c c o r d i n g t o a d v a n c e d c a r d i a c l i f e support and first-respondersprotocols. Methods and results: ECG data were rreorded digitally by solidstatc module and tapcl data were analyzcdby ANOVA' t-test' and X2. llhythm was analyzcd at one minutc (Tl) and four minutes (T4) after shock. Mean FD responsc time was 4.2 minutes and was not correlatc d w i t h p o s t s h o c kr h y t h m . A , t ' 1 1 , 3 3 7 o h a d n o t c o n v e r t e d , 7 7 o w e r e in asystole, and,604o were in other rhythms. AITA,567o had refi,brillatcd,24a were in asystole, and 42o/awere in other rhythms (133). NoConvsrsion
194$:l*'First-ResponderDe|ibri||ationinanUrbanEMSVariabls ALKellerman, 8BHackman, LCNail/University 0f Tennessee, Memphis Study objective: defibrillation
To evaluate
to an emergency
the impact medical
of adding firefighter
scrvices (EMS)
or Befib
VFamplitude.64mV Prcvious 6% T 1 .p r sa d m i r r e d I I, pts.di$harged 2cL 14,pts.admiiled 26y. 14,pts disharged 9% ?Bo/. Bystander CPfl
systenr
already served by paramedics.
19
Asystolo
other (EMo)
92 mV 53% 120/. 50% 50% 6%
1 . 0m V 250/" 13% 33% tB% 30%
P
000l 0001 03 55 1t l0
QRS duration at Tl was 0.12 ms in survivors vs 0. 14 in deaths (P - .f 7); at T4, it was 0.12 vs 0.14 (p = .04). eRS rate ar Tl was t h e s a m ef o r b o t h o u t c o m e e( m e a n . 3 ? ) , b u t a t T 4 , s u r v i v o r s had a rate of 98 vs 49 in deaths (P - .00f). presence of p waves was signifi c a n t a t b o t h t i m e s ( T l , 2 9 V ov s S V o ; T 4 , 4 7 V o v s l l % o , p = . 0 1 ) .p waves were associated with prior VF amplitude of 1.2 mV vs 0.95 at Tl (P : .006); at T4, there was no difference (1.2 vs l.l, T,hr^ll P - .34). Abnormalitiee of ST segments were not significant at either time. Normal T wavee were not associated with suruival at Tl, but all survivors had normal T waves ar T4 (p = .24\. Conclusion: Preceding VF amplitude is highly predicrive of subsequent postshock rhythm. At onc minute after shock, continued VF is an ominous rhythm, whereas asystole is more favorable. At four minutes, refribrillation is unfavorable; asystole is associated with much higher survival. eRS duration and rate at four minures a l s o a r e a s s o c i a t e dw i t h o u t c o m e . p w a v e s p r e d i c t s u r v i v a l at both times.
Study
objetive:
(CT) of the cranium
Coat-benefit in trauma
analysis of computed patients
with normal
neurologic
examinations.
Design: We retrospectively reviewed a computerized trauma registry to identify all rrauma patienrs with a Glasgow Coma S (GCS) of l5 who underwent central nervous system (CNS) CT ing 1986 through 1990. Sampling was used ro esrimare the of cranial CTs performed. Ve idenffied all patients undergoing CNS CT and either intracranial procedures or more than two d: in_intensive care without procedures as potentially having had ful positive" scans. We reviewed these patients'charts to detet if cranial CT had altered managemenr. Setting: Emergency department of a large Level I trauma Interventions: ED cranial CT in trauma patiente. Type of participanre: All 84? GCS-f S rrauma patients CNS CT during the study period of 1986 through 1990. Results: An estimated 662 trauma patients (957o confidence intcrvals [CI] 576 to ?48) prescnring wirh GCS of l5 underwenr cranial CT. No CT revealcd significant pathology in the absence clinical signs or sympl.oms. Thc estimatcd cost of screening crani CT jrr this study was fi256,6}9 (gSEa Cl,#207,g25 to $fOSpfS;. Conclusion: Cranial CT is not cost effective in the ED ment of neurologically inl.act trauma patients.
bvEmersencv ilffilH:l1lil:,j1;,'ff :[::l0epartment 1 -96 D S c h l a g e rG, l - a z z a r e s c h , hitten, DiW
A B ' s a n d e r s / K a i sF eo r u n d a t i oHn o s p i t a l , S a n t aR o s a C , alifornia Study objective: To study the use oflimited, focused ultrasound studies performed by emergency physicians and assessthe accuracy of their readings. Design; A one-year prosprctivc study was done using an emergcncy , department ullrasound with a 3.S-rI-Iz regular transducer and S.0 v a g i n a l t r a n s d u c e r . E m e r g e n c yp h y s i c i a n sw e r e t r a i n c d to do linritcd, f o c u s e d u l t r a s o u n d s i n a s e r i e s o f p r o c l . o r i r r gs e s s i o n s rn coopcral.ron with radiologists. Laser print ultrasourrd .ciords wcre collccted from all ED ultrasounds ovcr a onc-ycar pcriod and comparcd with formal ultrasounds in radiology and/or the paticrrt,s hospital re.co_rd.Sensitivity, specificity, an d positivc( ppV) an d riegariuc (NPV) predicrive values were calculared. Setting: A l0<1*bedcommunity hospiral with an El) volume of 25,000patients per year. l'ype of participants: Patients whom thc emergency physician fell needed ultrasound studies in the IjD. I n t e r v e r r t i o r r s :U l t r a s o u n d s t u d y i r r t h c E D . Ilesults: ED ultrasounds were performed on 16? patients by [4 ovcr a one-year period. For the 132 parienrs in which lhytfo,,l"-: formal follow-up was completed, lhc ovcrall diagnostic accuracy of DI) ultrasound yielded a sensitivity of0.95,.p.""ifi"i,y of0.9g, l)l)V o f 0 . 9 9 , a n d N P V o f 0 . 8 9 . E l c v e n < : a r < : g o r i ,.,,.f ,lt"orornd usc wcr<: r e p o r t e d . T h c t . h r c cs t u d i r : sn r o s t o f t c r r p c r f o r n r e d w c r < :f o r g a l l b l a d _ d e r d i s e a s e( 5 3 o l a ) ,i n t r a u r e r i n c p r c g n a n < : y( 2 g o / o ) , and abdominal a o r t i c a n e u r y s m s ( 7 V o ) .A c c u r a c y o f I i D g a l l b l a d J c r u l r . r a s o u r r df o r 65 patients demonstrateda sensitivityof b.g6, specificityof 0.()7, PPV of 0.9?, and NPY of 0.85. Therl were no f a l s e _ p o s i r i v eo sr false-negativesfor ED uitrasounds performed on 42 patients for intrauterine pregnancy or ll patients for abdominal aortic aneurysms. Conclueion: With appropriate training, emergency physicians can perform diagnostic ultrasound srudies with u hieh d.s.". of accuracy.
. g7 ntofthe 1 |';ljjljf il: I 1ffi:T:1'*Tin'reManaseme
TRHarringron, BFShamos, BKNelson/Texas Tech University !,5t9!o^af.in Health Sciences Center. Elpaso. Texas; Barrow Neurological Instrtute, Phoenix, Arizona; StJoseph's phoenix. Hospital andMedical Cenier, Arizona
Screening *1 OQ Routine Abdominal CTis Cost-Effective in I rffl Head-lniured Patients CAprahamian, DrVess, MKThorsen/Medical College ofWisconsin, Milwaukee Study background: Wt: previously rcported the role of c o m p u t . e dl o m o g r a p h y ( C ' f ) i n c v a l u a t i n g a b d o m i n a l t r a u m a a n d m o n i t o r i n g p a t i e n t s m a n a g c d n o n o p c r at i v c l y . Objectivc: To evaluate the rolc of scrcening abdominal CT in head-injured patients. Design: A retroepective review of all normoteneive head patients undergoing CT evaluation of the head and ecreeninq CT { s c a n so f t h e a b d o m e n d u r i n g l g B B t h r o u g h 1 9 g 9 . Setting; Univcrsity Level I trauma center-
Intervention: Abdominal Cl'. I l c s u l t s : A b n o r m a l h e a d C T w a s p r e s e n t i n 7 4 ( 4 9 V o \a n d w a s d i r t r t l y r c l a t c d t o t h c G l a s g o wC o n r a S c o r e ( G C S ) . T h e r a t e s f o r C C S o f 1 3 r o 1 5 , g L o 1 2 , a n d 8 o r L : s sw e r e i 6 % o , S 0 7 o , a n d g l % o , rcspectivcly. Screening abdominal C'l was positive in 38 patients; 22o/o,23o/o, and 2lo/o werc in rhe rhree GCS groups. Routine DpL would have rcsulted in opcration in 33, but ".lioiomy was nece in only thrcc p aLienLs(2Va). The estimated cost of routine DpL x 150 patients) and anesthesia/surgery ($S,228 multiplied b, !{ZOO 33 patients) would have cosr $2M,14?, while screening ubjominai CT ($1,124 multiplied by 150 parients) and surgery/anesthesia ($5,278 multiplied by three patienls) coet $lg3,gg4. Conclusion: Despite higher costs for CT scans than for DpL, I . itirrg surgery to those with an absolute need identfied by routine scanrs more cost ef ctive than routine use of DpL.
t OO ProspectiveEvaluationol RadiologicCriteriafor Head-lniury I rf rf Patientsin a Community EmergencyDepartment LKfrichless. K English, MBHeller, TEAuble/Center forEmergency Medicine of Western Pennsylvania, Pittsburgh; Allegheny ValleyHospital, Natrona Heights, Pennsylvania Study objective:Severalstrategiesfor radiographicevaluationof head-injurypatientshavebeen developed,all basedon rer.rospective analysis.We attemptedto prospectivelyevaluatethe previously publishedMasterset al's criteria defininglow-, medium-,and highyield patients. Designand setting:Prospectivestudy in a communityhospital emergency department. Type of participants: One thousand patients over 2 years of age presenting with historical or physical evidence of blunt head trauma were aeked to participate;967 conaented. Field-triaged par.ients were excluded. Interventions: Patients were categorized in the ED as low-, moderate-, and high-yield for intracranial injury on the basis of an initial history and physical exam. These categories guided inraging dccisions in accordance with the guidelines of Masters ct. al. paticnts were evaluated 12 weeks later by quest_ionrraireand lelcphonc t.o determine whether injuries were missed. Results: Of the 967 patients initially evaluared, gg6 werr: at low, 78 at moderate, and three at high risk ofintracranial injury. Of these patientso complete follow-up data were available for 895 (937a). Others were nonreeponders (?2) for whom a death certificate search is ongoing. Only one intracranial injury was diagnosed (high-risk group). Ofthe 895 patients, none had evidence ofmissed intracranial injury requiring intervention on follow-up, although ?l patients (7.9Vo) received follow-up medical care for head injury. It therefore can be inferred lhat0.37o or fewer of pa[ients initially diagnosed not to have intracranial injuries requiring intcrvention upon presentation to the ED with evidence of blunt bead t.rauma actually may have these injuries (95oloprobability based on binonrial test). Conclusion: In our population, the use of previously proposed low-, medium-, and high-yield criteria for radioloqic investigation of head injuries identfies parients with intracraniul Lir.y rcq"uiring intervention.
200 Validation of 0ecision Rutes forRadiography in AnkteIniuries lGSTiell, GGreenberg, BDMcKnight, I McDowell, BCNair, Jp Stewart/Emergency Department, Ottawa CivicHospital, 0ttawa. 0ntario. Canada Study objective: Clinical decision rulcs for rhe use of railiography in acute ankle injuries have been devcloped previously and refined on 1,782 patients. 'Ihis study prospcct.ively validatcd lhe rcfincd rules on a new set ofpatients. Design: Prospective, blinded survey. Setting: Emergency departments of aduh two university hospitals. Type ofparticipants: Four hundred fifty-three consecuLive,eligi_ ble adults with acute blunt ankle.trauma. Interventione: Emergency attending physicians assessedeach patient for six etandardized clinical variables and classified the need for radiography according to the decision rules but before actual radiography. Thirty-seven patients were examined separate_ ly by two physicians to determine interobserver aareement. Afl patients undement slandard radiography after as"sessment.
Measurements and results: All 50 malleofar region fractures were identified by the ankle radiograph series rule (sensitivity, I007a; specificity, 38.87o), and all 19 midfoot fractures were identified by the foot radiograph series rule (sensitivity, 1007o; specificity, 34.8Vo). Physicians were98.77o and99.(>Voaccurate in interpreting the ankle and foot rules, respatively, and demonstrated good interobserver agreâ&#x201A;Źment, based on kappa values ranging from 0.44 to 0.87 for the clinical lindings. Application of these decision rules would have reduced use of the ankle geries by 33.87o and the foot series by 30.07o. Conclusion: Prospective validation has shown theee decision rules to be 1007a sensitive for fractures, to be reliable, and to have the potential to allow physicians to reduce confidently by one third the number ofradiographs ordered in ankle-injured patients. Field trials will assessthe feasibility of implementing these rules into clinical practice.
Uselulness ol High-Yield Criteriato LimitChestRadiographs in tnl LV a AcuteExacerbation ol Chronic0bstructivePulmonaryDisease CLEmerman, BKCydulka/Department of Emergency Medicine, MetroHealth Medical Center, Case Western Beserve University, Cleveland, 0hio Studyobjectivc:'fherc is disagrccmr:rrt. aboutthc ncedfor chesl radiography in acute exaccrbation chronic obs[ructive pulmonary d i s c a s c( C O P I ) ) , a l t h o u g h h i g h - y i e l d c r i t e r i a h a v e b e e n d e v e l o p e d . 'l'he objective of this study was to l) acccgethe incidence of abnormal chcst radiographs and 2) test the validity of previously developed high-yield criteria. Design: Retrospective cha rt-rcview study. Settirrg: County-owned, urriversity-affiiated urban emergency dcpartment. 'l'ypc ofparticipants: ED pationts sccn bctwecn January 1988 a n d J u l y 1 9 9 1w i t h C O P D . I l c s u l t s : E i g h t h u n d r c d f o r t y - s c v c n p a l . i c n t sw < : r ci d c n t f f i e d o o f whonr medical rccords wcrr: availablc for 742. lladiographs were I r o l t a k c n i n S V o , l e a v i n g6 8 5 p a t i e n r s i n t h e s t u d y . O n c h u n d r e d n i n e ( l 6 o / a )h a d s i g n f i c a n t a b n o r m a l i r . i e s ,i n c l u d i n g 8 8 i n f i l t r a r e s , l w o l u n g m a s s e s ,o n e p n e u m o l h o r a x , a n d 2 0 w i t h p u l m o n a r y cdcma. Ilistory ofcongestivc heart failure, sputum production, or f c v c r w a s a s s o c i a t e dw i t h a b n o r m a l i t i c s , a s w e r e f i n d i n g s o f r a l e s , pedal cdcma, and jugular vcnous distcnsion.There wa8 no assocrat i o n w i t h W B C , t e m p e r a t u r c , c o r o n a r y a r t e r y d i s e a s e ,o r c h e s t pain. Previously establ.ishcdhigh-yicld criteria had a sensitivity of 0.76, specificityof0.4l, positive predictive value of0.20, negative p r e d i c t i v cv a l u c o f 0 . 9 0 , a n d a c c u r a c yo f 0 . 4 7 . Conclusion: Radiographic abnormalities are common findings in acutc COPD. Almost onc fourth of radiographic abnormalities arc not prcdictablc on the basis of prcviously developed hlgh-yield critcria. Iloutirrc chest radiography should bc consideredin p a l i e n t s w i t h a c u t e e x a c e r b a t i o n o f C O I ) D t o d i a g n o s ct r e a t a b l e , r a d i o g r a p h i c a l l y a p p a r e nL a b n o r m a l i t i e s .
TheEffectofPrehospital Transport TimeontheMortalityFrom tnt ZVLTraumatic Iniury RWPetri, J Lumpkin, A Dyer/Northwestern University Medical School Study objective: To tesl. the hypothesis that there exists a prehospital time threshold (PhTT), which, when exceeded, significantly i n c r e a s e st h e m o r t a l i t y o f t r a u m a p a t i e n t s t r a n s p o r t e d d i r e c t l y f r o m t h c s c e n eo f i n j u r y t o a t r a u m a c e n t e r r a t h e r t h a n t o t h e c l o s e s th o s pital. l)csign; Iletrospectiverevicw ofdat.a contained within the state t r a u m a r e g i s t r y , e n c o m p a s s i n gr h e p e r i o d f r o m 1 9 8 9 t h r o u g h 1 9 9 f . >
8l
Injury eeverity expressed as Injury Severity Score (ISS), scene time (ST), transport time (TrT), total prehospital time (TphT), and outcome were determined for each padent. patients were stratified into groups on the basis of ISS. Mean ST, TrT, and TphT were compared between ISS groups. After controlling for the effect of ISS, the rela_ tionehip between each of the times and outcome was evaluated. Type ofparticipants and serting: .fhere were 5,215 injured persons with ISS of l0 or more who wcrc cared for in a state l,evel I or II trauma center. Interventions: Standard trauma care. Reeults: Patient outcomee were related direcrly to ISS (p < .001 by Xz). Mean ST and TphT, but nor TrT, *.." .ig.,ifi"u.ily diff".ent between ISS groups (P < .001 by ANOVA). Lo-wer ISS was asso_ ciated with longer times. Mean ST, .frT, and TphT were significantly different between survivors and nonsurvivore (p < .O'Otly estimate ofpooled variance). Survival was associated with longer times. Each of the mean times remained significantly differeni between survivors and nonsurvivo.r, ."". oft.. controlling for ISS (P < .001 by rwo-way ANOVA. Conclusion;No PhTT, beyond which tinrepatienI rrarrsport to t h e c l o s e s th o s p i t a l s h o u l d h a v c d e < : r r : a s c n dr o r t a l i t y , w a s i d e n t i f i _ able as there was an inverse rclationship bctwccn .ilrh,l, u.d nrortality.
t;:Hfi vttr"ui"utservicesonTrauma ff H r r , W S Y o u n gJ, L M e n e g a z zpi ,M p a r i s / D i v i s i o n
2031nffi i'f I
o f E m e r g e n cM y edical {S S e r v i c e sP, _ e n n s y l v aD n ieap a r t m e notf H e a l t h p ; ittsburgh B e s e a r c lhn s t i t u t e ; Centerfor EmergencyMedicine,University0f pittsbur;h Study objective: To assessthe effectivenes. Jfp.ehospital care on trauma mortality. D e s i g n : D a t a a b s t r a c t e d r e t r o s p e c t i v e l yf r o m trauma patients, prehospital and hospital records ..l"ti""io patienl. mortality, enrer_ g e n c y m e d i c a l s e r v i c e s( E M S ) s y s t c n r s ,a n d p a t i e n t characteristics. S e t l i l g - . A l 2 - c o u n t y r e g i o n i r r l r c n r r s y l v a n i aw i t h a basc popula_ tron of 3. I million. Type of participants: The rccords of 7,055 irrpatienr.s containing prehospital care data from 44 hospitals, including fivc regional lrauma centers, were reviewed, Intervention; Stepwise mukiple logistic regressions were performed. Odds ratios based on the most.ii"i..t models were calculatedarP<.0S. Iiesults: Prehospital advanced life support (ALS) availability and .. dirct patient admission to trauma centers were the most irrlluencing factors on patienr mortality. The probability of patient survival is 2.S-fold grcater among the patienrs "o..d fo.iy ALS rho. thor" artended by basic life support services alone. The patients dircctly transported [o trauma centers arc ncarly 2 . S _ f o l dr n o r e l i k c l y t o survive tharr those transported [o llolltraunla (:cntcrs_ C o n c l u s i o n : I n t h e t r a u m a s y s t t : r ra r r r d d r : l i v r : r yp r o c e s s , a l l c n l . l o r l should be givcn ro rhe availabiiry of pr"ho"pirrl'Al-S s o r v i c c sa n d p a t i e n t l . r i a g ec o m p l i a n c e t o t r a u m a c c n t o r s in the EMS systcm.
to deliver care ae determined by the American College of Surgeons' (ACS) Committe on Trauma designation. The purpose of this etudy was to analyze the propriety of trauma patient transfers. Design; Retrospective review of a prospectively collected trauma regjsl.ry for the three-year period of l98g rhrough 1990. Setting: Statewide Level I trauma center with 3,200 annual admits. Type of participants: One lhousand six hundred sixty-three (23.17a) of the 7,183 adult trauma parient admiseione were inter_ hospital transferg and included for analysis. Results: The transfers were older, mme severely injured (ISS), had longer hospital stays (LOS), and required moie ICU and venti_ lator (VENT) days than diret admissions (Table). Transferred patients suffered no increased mortalily vs direcr admit e (g.SVova 8 . 3 C a )( P : . 8 1 ) , r e s p e c t i v e l y . to. of Patisnrs Agc(yr) Transler 0irect
1,663 5,522
35.9 32.7
p<.004 djflerences, {AllIntergroup )
ISS
tOS
tCU
VEilT
1 1. 1 14.7
15.7 10.3
8 .I 4.9
3.5 2.9
Conclusion: Transferred trauma patients had significantly increased age and ISS comparcd with directly admitted patients; b o t h o f l h e s ef a c t o r s a r e s u r v i v a l d e t e r m i n a n t s i n t r a u m a a n d are associatcd with higher mortality rates. flowever, transfers achieved similar survival rates as dirmtly admitted patients. Since transferred trauma victims require more resources and longer hos_ pital stays, we conclude that they benefit from current ACS triage protocols. These findings provide further proof of the u"efu-lneeJ of patient transfers to l.ertiary-care trauma centers.
*205
fffr:;#
Efficacy orprehospirat Btind Nasotracheal
S Parazynski, B Wolfe, J Roe,p Hudson,J Forster,p pons/Emergency Medical S e r v i c e sD, e n v e G r e n e r aHl o s p i t a lC , olorado S t u d y b a c k g r o u n d : D e s p i t c t h e s u c c c s so f b l i n d n a s o t r a c h e a l intubation (IINTI) in the emergency depart.ment, many prehospital systems do not perform BNTI in thc field. .I'he safety and efficacy of prehospital IJNTI havc nevcr been rigorously tested. llypothesis: BNTI is a safe and effective merhod ofprehospital airway management. I)esign: Phase I: A lhree-month retrospective study with field reporl. and inpatient chart review. phase II: A three_month
prospecLive evaluation of successrate and immediate complications. Settirrg; An urban 9ll system with Z0 paramedics and a run vol_ ume of 44,000/year. I'ype of participants: Two conseutive populations of 15? (phaee I) and 126 patienrs (phase Il) meering the protocol for BNTI. bne hundred fifty-seven field reports and l16 inpatient charts were obtaincd and reviewed (phasc I); 126 data forms and field reports wcrc reviewcd (phaseII). I n t e r v e n t i o n s : P h a s c I s u c c e s sr a t e a n d f r e q u e n c y o f c o m p l i c a _ esrablished by emergency medical rechnician-paramedic lo_rtl*:.. (EMT-P) field reports, ED records, and inparient charts. phaee II successrate and prevalence of immediate complications were deter_ O^!!!*tr.Bfi. Boutanger, FBLaFleche. A Rodriquez, BJ Nauta/Departments mjned by a detailed data collection sheet, completed immediately 0r Emergency Medicine after the procedure by the paramedic artendant; EMT-p andSurgery, Georgetown University Medical field Center, Washington, reports were also reviewed. The complications evaluated DC,Vancouver General Hospital; Departments ot Critical were Care andTraumatology, epistaxis/retropharyngeal trauma, aspiration, and cranial MIEMSS, Baltimore, Marvland vault Studyobjective:The widespreaduseofinrerhospital placement. transferof 'fhe trauma victins is based on the recciving Results: s u c c e s sr a t e s o f B N T I w e r e M . l T o ( p h a s eI ) a n d hospital,s improved abiliry 84.1o/o(phase II). V&en BNTI was unsuccessful, oral inrubation )
Pati ents bvAppropriate 204i1ffi::l,illi';1}:rraunn
82
was performed Euccessfully inl.SVo (phase I) and ll.l%o (phase II). Alrhough eliotaxis (31.77o) and emesis (4.O7o) are the only immediate complications, retrospective chart review shows only minimal long-term consequencee. Conclueion: BNTI is a eafe and effective means of prehospital airway management.
cases, 305 (7lCo) dtd,not meet STSEC. Forty of these 305 (137o)had a final hospital diagnosis of AMI. ECGs not meting STSEC had a sensitivity of 80Vo, speificity of 8l%a, and PPV of STVaforthe absence ofAMI. STSEC also was analyzed for iletection ofacute cardiac ischemia (ACI) defined as AMI or angina. The 123 ECGo meting STSEC had a sensitivity of 377o, specificity of 817o, and. PPY of TlVo for ACI. The 305 ECGs not meeting STSEC had a eensitivity of8l7a, specificity of 377o, and PPV of SIVo for the absence ofACI. Conclusion: STSEC by itself lacks thc sensitivity and epecificity necessary for reliable AMI diagnosis. Consideration of additional ECG characteristice is required to improve diagnostic accuracy,
206 Salety otPrehospitat l{itrogytcerin RCWuen, GSwope, GRoth, SAMeador, CJHolliman/University Hospital, The Milton S HersheyMedicalCenter,The Pennsylvania State University,Hershey Study objective: To de6ne vital sign and cardiac rhythm changes in prehospital patients given sublingual nitroglycerin (NTG). Design: A five-month prospective cohort study with NTG administration as the independent variable. Setting: Fiveindependent advanced Me support (ALS) services. Type ofparticipants: Study patients (SB 300) were those given NTG for cardiac ischemia or failure; excluded were those without repeat vital signs or those given additional medications. Comparison patiente (CP, 53) were those transported for similar symptoms but not given NTG. Intervention: N'fG was administered by protocol or on-lirre command. R e s u l t s :S P a n d C P p a t i e n t s w e r c s i r r r i l a r i n d e m o g r a p h i c s , i n i t i a l v i t a l s i g n s ,a n d c a r d i a c r h y t h m . F o u r S P p a l i e n r s ( l . B o / o ) h a r l adverse effectsl one became asystolic and apneic for two nilrrules, two experienced profound bradycardia with hypotension, and onc became hypotensive while tachycardic. All recovered. ThegSVo confidence intervals (CI) for adverse effects were \Ea ro J.AEa. Mean fall in systolic blood pressure for the other 296 Sp was 14mmHg(95Vo CI, 8 to 19 mm Hg); for Cp, it was 4 mm Hg (95Va Cl, -8 ro 16 mm Hg). Conclusion: NTG appears to be a relatively safe ALS drug; however, a small number ofpatients will experience serious adverse effects. Pretreatment patient characterisr.ics did not reliably predict. adveree effects.
TheComparative Sensitivity andSpecificity of Serumand *tnQ LIJ||J Random Urinef3-hCG Determinations in theEmergency
Evaluation Xtn', of STSegment Elevation Criteria lor the -V , Prehospital ECGDiagnosis ofAcuteMyocardial Inlarction U ?tto.TP Autderheide/Medical College ofWisconsin, Milwaukee Regional Medlcal Complex Study objective: To determine the sensitivity and specificity of the ECG ST segmenr elevation crireria (STSEC) of I mm or greater in two anatomically contiguous leads for the prehospital diagnosis or acute myocardial infarction (AMI),Design and setting: During a six-nront.h period, paramedicb acquired prehospital l2Jead ECGs on chest pain patients. Investigators blindly classified ECGs retrospectively as meering or not meeting STSEC. Hospital charts were reviewed for final cardiac diagnosis. Type of participants: Four hundred tn,cnty-eight stablc adulr prehospital chest pain patients in whom paramedics acquircd prc_ hospital I2-lead ECGs. Intervenlions: None. Results: Of the 428 cases, 123 (29o/o) met STSEC. Fifty-seven of these 123 (59Vo) had a final hospital diagnosis of AMI. The STSEC for AMI had a sensitivity of SgVo,specificity of 8OVo,and posirive predictive value (PPV) of 43Vo. False-posirive ECGs with STSEC frequently had one or more of the following ECG characreristics: left bundle branch block, right bundle bra-nch block, Ieft venrricular hypertrophy, or intraventricular conduction delay. Of rhe 42g
Departnent CBibro,BE 0'Connor, PJPegg, JK Bouzoukis/Departments of Emergency Medicine andClinical Pathology, TheMedical Center of Delaware, Wilmington Study objective:To determincwhcther the qualitativemeasuremerrtof the B-subunitof humanchorionicgonadotropin(Q B-hCG) using random urinc specimens is as reliablc as thc serum measuremcnt of Q Il-hCG ilr the cmergency dcpartment. D e s i g n :D u r i n g t h e e i x m o n t h s o f t h c s t u d y , a U E D p a t i e n t s o n whom a serum Q B-hCG was ordered submittcd a urine specimen f o r b U n d e d s i m u l t a n e o u sQ I J - h C G . Sctring: A tertiary-care rcfcrral centr:rwith an annual BD census of 93,000. I ' y p c o f p a r t i c i p a n t s : O n e h u n d r c d c i g h t y - s i x c o n s e c u ti v e patienl.s. Inlervention: I]oth specimens were analyzed using the Tandem Icon II I.ICG assay (Hybritech). Lower limits of detection (1007o s e n s i t i v i t y )a r e l 0 m I U h C G / m L f o r s e r u m a n d 2 0 m I U h C G / m L f o r urinc. Ilesults were reported as ncgativc, equivocal ifpositive but l e s st h a n 2 5 m I U h C G / m L , o r p o s i t - i v ei f m o r e t h a n 2 5 m I U h C G / m L . E q u i v o c a l t e s t sw e r c f o l l o w e d u p . llesults: Of the ltl6 total urinc and scrum dcterminations (urine: n c g a t i v e , 1 2 6 ; e q u i v o c a l , 0 ; p o s i t i v c , ( r 0 ; s c r u m : r r e g a t i v e ,1 2 7 ; c q u i v o c a l , 2 ; p o s i t i v e , 5 7 ) , 1 2 6 n e g a t i v ea n d 5 7 p o s i t i v e r e s u l t s w e r e c o n c o r d a n t . T h r e e p a t i e n t s w i t h p o s i t i v e u r i n e t e s t sh a d e q u i v o c a l (two) or negative (one) serum tests. lJoth urine-positive/serumequivocal patients werc pregnant, whcreas the urine-positive/ serum-negative patient was seerrthrce wecks after a miscarriage and was nol. pregnant (urine: sensitivity , l00o/o; spccficity, 99Vo; serum: scnsit ivity, 97 o/o; specrfrctty, 1007o). Conclusion:Serum and random urine Q B-hCG determinations are of comparable sensitivity and specificity in ED patients.
209'ff
inthe0iasnosis olthe li;,t,:flrrtronystasmosraphy
RDHerr,LAluord, LJohnson, DValenti, B Mabey/Unjversity of UtahMedical School, SaltLakeCity,Utah Studyobjcctive:Do resultsof elcctronysr.agmography (ENG) testi n g i m p r o v e t h c c m e r g e n c y p h y s i c i a n s ' d i a g n o s i so f d i z z i n e e s ? Design: Prospective, one year. Setting: One university and three community emergency departments. Participants: Ninety-three consecutive patients presenting with dizziness. I n t e r v e n t i o n s ; E D i m p r e s s i o n o f d i z z i n e s sw a s r e o r d e d . E N G was performed within one hour by trained personnel, who interpreteditaseither..centraI,,'..peripheral,''or..normal.''ENG>
83
reading was given to the emergency physician, who was invited to revire his impression (called ..ED impression after ENG review,'). Final diagnosis was based on the ED impression but modfied after contact with the patient's physician(s) arrd the patient at four weks after discharge. Accuracy of ENG was assessedby comparing ENG readingwith final etiology using12. ln additiorr,contribution of E N G t o E D d i a g r r o s i sw a s a s s e s s e db y c o m f a r i n g a c c u r a c y of the -ED ED irnpression after ENG review wirh th. i.ip.rrsion alone usingMcNamara's test (hit versusnonhir). ENG significanrly correlated with final eriology . _Results: ( y z _ - 7 0 . 7 9 , P < . 0 0 0 1 ) . E N G c o r r e c r l y d i a g n o s e dn i n e of ll parienrs with central dizziness, including o.. puti.it each with cerebellar tumor, cerebellar infarction, hypertension, and medication reac_ tion, all missed by ED evaluation. Of 23 patients with undetermined cause after ED evaluation, ENG correctly identified seven patients with peripheral and three with central dizziness. ED impression after ENG review was more accurate than ED inrpression alonr: (yz:6.t3, P< .05). Conclusion:A ten-minute abbrcviated ENG sigrrificantlv the emergency physician,s ability to diignose .Lirrin.r". yP..r:1 More widesprcad use of ENG could idenrify cliricilly unsuspccrcd *rrt.ss as well as the eriology of dizziness of underermincd :::[:,
zl0illlliil:;f
of Chemstrip bGo Reagent Strips in the Emergency lAccuracy C- | | Department PA Scott,LBWolf, MP Spadafora/Department of Emergency Medicine, U n i v e r s i toyf C i n c i n n a M t i e d i c a lC e n t e r0, h i o Study objective: Although used commonly, rhe reliabiJity of reagent strips to estimate serum glucose and guide administration of dcxtrose solutions in the emergency department has not been proyen. We determined the accuracy of Chemetrip bG@ reagent strips and tbeir ability to idenrily hlpoglycemic patients in the ED setting. Design: Prospective, nonrandomized, blinded clinical study of the visual estimation of serum glucose by ED personnel using Chemstrip bG@ reagent strips over a two-month period. Simul_ taneously drawn samples sent for laboratory glucose determination served as controls. Setting: University hospital ED with an urban par.ient popula_ . tion. 'I'ype of participants: Arry ED paticnt requiring a renal panel (with glucose determination) was cligible for inclusion. We obtained a convenience sample population of 169 adult patients with complet_ ed data forms. Four patients were cxcluded from etatistical analysis because their estimatcd glucose reached the limir of the reasent s tr i p s c a l c . Intervention: No study intervention was tested, although timing _ of a dministra tion of dextrose solutions, if given, was recorded. Results: The correlation coefficient (Spearman r) between reagenI strips and laboratory values was .92. Ninety percent ofthe rcagent strips were within +60 mgldl ofthe control value for the laboral.ory glucosereference range < 350 mgldl or less. Hypoglycemia was defirred as a glucose of 60 mgldl, or less. Reagent strips identificd l5 of 16 of rhese par.icnrs (scnsitiviry, 94Va) and.143 of 149 palien ts wi thou r hypoglycem i a ( spc<:ificity, 96Vo negativ epredictive ; value,99o/o).Tho one fals<rncgativcreagent strip reading ofb0 mgldlh a d a l a b o r a t o r y g l u o o s cv a l u c o f l J 9 m g l d l . Conclusion: Visually inrerpreted ChJmstrip bG@ reagent stripe p r o v i d e a n a c c e p t a b l ee s t i m a t i o n o f s e r u m g l u c o e ei n t h e E D . Rcagent strip values of more than 80 mgldL*er"not associated with any laboratory glucose resulte of 60 mgldl, or lese.
*tl
I
crinicar chemistry Anarvzer $T:fffJ;;l"o''
JB McCabe,J Woo, T Schug,D Chauncy,D Sipley,JB Henry/Departments 0f E m e r g e n cMy e d i c i n ea n d p a t h o l o g yS, U N yH e a l t hS c i e n c e ienter ar Syracuse Study hypothesis:A handheld portable clinical chemistry analyzer can be reliably and easily ueed by emergency departzrcnt. staff [o pcrform bedside rapid analysisof sodium, potar.ium, chlorid<:, g l u c o s e ,b l o o d u r e a n i t r o g e n ( I J t I N ) , a n d h c n r a t o c r i r wirh rcsuhs c o m p a r a b l c t o t h o s e o f s t a n d a r d c l i r r i c a lc h c m i s t r y nrcthods. Design:Durirrg a two-month pcriod, *hulc blo.d and scrunr sam_ ples were obtained from ED paticnts. Whole blood a n a l y s i so f s o d i _ u m , p o t , a s s i u m ,c h l o r i d e , g l u c o s e , l 3 [ J N , a n d h c m a l . o < : r i t was per_ formed ar rhe bedside using the portable clinical analyzer (piA) ( I - S T A T , K a n a t a , C a n a d a ) . S e r u m a n a l y s i sw a s performcd in clini_ cal pathology using standard clinical chemistry equipment (CX3, Beckman Instrumenl.slHI, Technicon). Sctting: University hoepital ED. Typ" ofparticipants: Four hurrdred sixty ED patienrs, rcprescnt_ . ing a convenience sample, vho werc undergoing lubo"ulu.y r.rtr,g during a two-month period. Results:Precision obtained with quality control n r a t c r i a l sw a s excellent for all anolytes, using rhc pCA coefficient of varial.ion at 95Vo confidencclevel of 2.SVo for sodium, 3.Solo for potassrum, 2.87o for chloride, l\Vo for glucosc, and,9.3o/o fo" BUN. Whol" blood resuhs correlated well with plasma values o n r e g r c s s i o na n a l ysis(R2 = .79 for sodium, .93 for potassium, .?0 for chloridc, .96 f o r g l u c o s e ,. 9 3 f o r B U N , a n d . 2 9 f o r h e m a t o c r i t ) . En staff was able to easily use the clinical analyzer withoui technical djfficuhy. Conclusions; The portable clinical analyzer demonstrates good when compared wirh a standard clinical chemisrry aualyzer. 1:"r.1"I The ability Lo analyze whole blood samples withirr minutes of collection and at the patient bedside along with its small samplesize r c q u i r e m e n t a n d e a s eo f o p e r a t i o n m a k e t h e p c A a varuabledevicc for ED use. The addition of the pCA ro rhe ED wi,ll makc STAI, a c c e s st o c l i n i c a l l y r e l e v a n t l a b o r a t o r y t c s t i n g m o r c rcadily avail_ a b l e t o a s s i s ti n u r g e n t c l i n i c a l d c c i s i o r , . , r k i i e .
84
Inaccuracy olthelnfrared Tympanic Thermometer inthe t/lt Z a L Emergency Department M Yaron, SLowenstein, J Koziol-McLain, J Murphy/Section of Emergency Medicine andTrauma, University ofColorado Health Sciences Centei, Denver Study background: Prcvious studics of the infrared tympanic thcrmometer (IT'f) havc showrr a high correlation with the rectal t h c r m o m e t e r ( R T ) , b u t a g r e c m c n t b e t w e e n t h e t w o d e v i c e sh a e never beerr tested. Objcctive: To assessrhe accuracy of the ITT compared with the
ItT.
l)esign: Prospective'I'wo-month Setting: study irr a university hospital emergency department. 'fype o f p a r t i c i p a n t s : C o n v e n i e n c es a m p l e o f 1 0 9 a d u l t E D pa trents. Interventions: Examinations were performed to assessthe pres_ encc of cerumen and otitis- Temperature measurements were performed using rhe First Temp 2000Ao rhermometer in both ears and thc IVAC 2000 rectally. S t a t i s t i c a lm e t h o d s : C o r r c l a t i o n b e r w e n t h e I T T a n d R T w a s dclermined using Pearson's r, whereas agreement was measured by the intraclass correlation coefficient (ICC).
I
Main results: Left and right ITT temperatures showed high correlation (r - .94, P: .000f) and agreement (ICC : .94); rherefore, only riht ITT results are reported. Both instruments recorded similar mean temperaturee, standard deviations, and ranges. The correlation between the ITT and RT (r: .6S) and the agrâ&#x201A;Źment between them (lCC : .6?) were only moderate. The mean r.emperature difference (AT - ITT-RT) betwen the two devices was 0.2I 10.66 C (range, -3.2 to l.l C). lnl$Vo of patients, AT ) + I C; rn67o LT > + 1.5 C, and,in2Vo AT > + 3.1 C. The seneitivity of the ITT in detecting a singificant fever (RT > 38.S C) wae only 547o. Cerumen in the auditory canal did not affect these results. Conclusions: The ITT often ie inaccurate in the ED setting compared with the RT. Despite a moderately high correlation between the ITT and RT, clinically significanr differencee (more than 1.0 C) occurred frequently. Agreement is a more important test than correlation when evaluating a new measuring inetrument, and these deviceedo not demonstrate high agreement.
prised urban counties (three); group II, counties with a town of more than 10,000(nine); group III, total county population ofmore t h a n 1 0 , 0 0 0( 1 9 ) ; g r o u p I V , t o t a l c o u n t y p o p u l a t i o n o f l e s s t h a n 10,000 (62). Age-adjusted death rates for heart disease, cancer, cerebrovaecular disease, pneumonia, and injury were tabulated, with injury deaths categorized as intentional (homicide, suicide) or unintentional (motor vehicle accident, fall, drowning, poisoning, farm machinery accident, choking, firearm, fire, burn.;. Interventions: None. Results: Age-adjusted death rates per 1001000population in group IV were lower than those for group I for heart diseaeeo 209 vs227.4; cancer, 135.9 ve 176.3; cerebrovasculardisease, 39.9 v s 44 -6; pneumonia, 19.6 v a 23. 4; a nd intentional inj ury d e a t h s , 1 3 . 3 i , s I 5 . 1 . H o w e v e r , a g e - a d j u s t e du n i n t e n t i o n a l i n j u r y death rates were54.24o higher in gfoup IV than in group I: 42.7 vs 27.7. Motor vehicle deaths were 93o/ohighcr (23.3 vs 12.l) a n d f a r m m a c h i n e r y d e a t h s w e r e 1 , 2 5 0 o / o h i g h e r( 2 . 7 v s . 0 . 2 ) . Conclusion: Age-adjusted unintentional injury deaths are higher in rural counties, even though death ratcs for the four other leading c a u s e so f d c a t h a n d i n t e n t i o n a l i n j u r y a r c l o w c r . A l t h o u g h f a r m machirrery deaths have thc highcst percentage dilference, motor vehicle deaths are the major contri-butor to the unintentional injury death ratc discrepancyin rural Nebraska.
tra
L I r , M o t o r c y c l e H e l m e t sa n d S p i n a l I n i u r i e s :0 i s p e l l i n g t h e M y t h E M ) r s a y ,B L M u e l l e m a nT, D P e t e r s o nS, W H a r g a r t e n / U n i v e r soi tf yl l l i n o i ia t C h i c a g oU; n i v e r s i toyf N e b r a s k al ;o w a M e t h o d i s M t e d i c a lC e n t e rM ; edical Collego ef Wlsconsin Study'objectives: To determine the incidence ofspinal injuries versue head injuries in patients with and without helmet use in motorcycle crashes. Design: Multicenter retrospeclive review. Setting: Twenty-eight hospitals throughout Nebraska, lowa, Illinois, and Wisconsin. T y p e o f p a r t i c i p a n t s : M o t o r c y c l e r : r a s h v i c L i m sp r c s c n t i n g l o a r r y of the participating hospitals during rinrc pcriods in | 988 through 1990. Interventions: None. Results: Among 1,153 patients etudied, Sl (4.4o/a)susraincd significant (Abbreviated Injury Scale, 2 or greater) spinal injuries, with cord involvement occurring in l5 of these cases (ll cervical, lwo thoracic, one lumbar, and one unknown). Of these 5l cases, 30 (58.8Vo) also suffered significant head injuries. The incidence of spinalinjury was not associated with helmet use, with S.lZo helmeted versus 4.2Vo nonhelmeted patients sustaining spinal injury ( o d d sr a t i o , 1 . 2 2 ; 9 5 7 o c o n f i d e n c e i n r e r v a l s ICI], .63 to l.9S). Thc number of subjects was sufficient to iderrtify wilhg}ok statisrical power lack ofhelmet use as a risk factor for spinal injury if the rrue odds ratio for that relationship were at least 2.S-fold. Of the patients studied, 254 (22Eo) had significant head injurics. 'l.he rarc of significant head injuries wae 26.9o/oamong those not helneted versus ll.37o among those with helmets (odds ratio, 2.92;9|o/o Cl, 1.93to 4.,{0). Conclusion: In contrast to a significant protective effect identified for head injuries, helmet use neither increased nor decreased the occurrence rate of spinal injuries in motorcycle crashes.
a|a?
Z-l 5 nfrof,olIntoxication in Victinrsof Subcritical Iniury flH Woolard, B Becker, T Niremberg, J Hoffman/Section of Emergency Medicine, BrownUniversity; Department 0f Emergency Medicine, Rhode lsland Hospital, Providence Studyobjectivc:'llo invesl.igat<: an approachto identifyingand rt:fcrringto counscling all irrtoxicatcd subcritir:ally injurcd patientg
2l4Motor vehicte oeaths: A Rurat Epidemic
BLMuellenan, RAWalker, EJMlinek/University of Nebraska Medical Center, 0maha Study objective: To determine the magnitudc of the discreparrcy in injury death rates betweenurban and rural counties and which types ofinjury deaths contribute most to this discrcpan<:y. Design: Nebraska death certificates from betwen 1985 and 1989 were reviewed with counties divided by population. Group I com-
85
p r c s c n t i n g t o t h c e m e r g e n c yd c p a r t . m c n t . D e s i g n : P r o s p e c t i v ec v a l u a L i o n o f s u b c r i t i c a l l y i n j u n : d p a l . i e n t s for alcohol intoxication with refcrral to counseling and review of demographic data. 'l'ypes of participants: Cases were patients with surgical subcritical injuries. Controls were subcritical medical patiente. Saliva alcohol testing (SAT) was performed whilc raking viral signs by the l.riage nurse. All other health care workers were blinded to the confidcntial results of SAT. Interventions: The ED socialworkcr contactcd 857o of SAT-positivc patients either in the ED or afterwards by tclcphone or letter. Dcmographic variable and physician and nurse chart documentation of intoxication were rcviewcd. 'lherc M e a s u r e m e n t sa n d m a i n r e s u l t s , w c r c 8 0 2 c a s e ea n d 4 3 3 c o n t r o l s ; 2 l 7 o o f c a s e sa n d I 0 o / o o f c o n t r o l s w e r e i n t o x i c a t e d . T h e r e werc greatcr intoxication ratcs among males (247o), victime of assault (457o), motor vehicle accidents (l|ok), and,industrial accid,cnts (l4o/o). Patients arrived at nighl (AIVo). There were fewer intoxication rates among women (lSrla). Only 97o were more than 5 5 y e a r s o l d , a n d v i c t i m s o f s p o r t s a c c i d e n t s c o m p o s e d9 7 o . B o t h physician and nurse documcntation of intoxication was present in lcssthan one half of SAT-positive patients. Less than 207o of p a t i e n t s c o n t a c t e d a c c e p t e dc o u n s e l i n g . Conclusion: SA'I is feasible in the Ef) and reveals sigrrficant levcls of intoxication. Nursc and physician documcntation are unrelia b l c . S A ' [ f o r i d e n t f i c a t i o r r o f i n t o x i c a t i o r r r e p r e s e n t sa p r o m i s i n g opportunity to contact and refer the problen drinker. Methods of counsr:ling and refcrral ned to be refined.
t2l6urban
*zlBweapons Anytnnocentvictims? AreThere Firearm Deaths:
Departnent intheEnrergency
G Ordog,M Kolodny,K Allen, E Hardin/King/DrewMedical J Wasserberger, C e n t e rL, o sA n g e l e s Study hypothesis: Homicides have been reported in the emergency departments of both middle-class community hospitals and teaching hospitals. Violence ie causing eignificant physical, emotional and economic hardships to ED personnel. Design: Retrospective review. Setting: Level I trauma center. "code trauma" patients PresentType of participants: All major ing from 1979 through 1987. Interventions: Weapons were removed and catalogued by armed security officere stationed in the ED for 24 houre per day' Results: Twenty-five percent of the victims of major trauma Presenting to our ED were armed with lethal weapons. A total of 41796 weapons were confiscal.ed from major trauma Patients during the nine-year study period. Five of the guns confiscated were automatic
i ae d l c a l l . W S c h w a b / U n i v e r s iot fyP e n n s y l v a nM J C o l e ,M D M c G o n i g a C C e n t e rP. h i l a d e l p h i a Study objective: Analyze the incidence ofhigh-risk activity (drug use and prior criminal activity) in victims offatal firearm violence. Designr Survey of medical examiner (ME) records of all firearm homicide victims in Philadelphia during 1990. Type of participants: Three hundred thirty-two victims were identfied; eight were excluded due to missing records. Drug use (ethanol, cocaine, other) and criminal record (number of chargee) were tabulated. Reaultg: Two hundred ninety-four of 324 recorde contained data on antemortem drug uae. One hundred three victime (s\Vo)had used ethanol and ll5 had used (397o) cocaine before death; 19 had used other druge (6Eo). Overall, 179 (6lVo) had used one or more intoxicants. Two hundred seventy-three of 324 records contained police data. One hundred eight-four vicims (677o) had criminal records rangingfrom one to 84 counts (mean, 7.6) and had beerl arrested an average of four limes. Drug and police data actually art: understated due to the presence of victims carrying drugs that had n o t b e e n i n g e s t e da n d d u e t o t h c o m i s s i o n o f c r i m i n a l r c c o r d d a l a i r t the ME reports of juveniles. C o n c l u s i o r t :O f 2 4 9 h o m i c i d e v i c l i m s w i t h b o t h d r u g a n d p o l i c e dala available, 209 (847o) had uscd intoxicants and/or comm-itted previous crimes. We conclude that the majority of our urban homicide victims previously have engaged'in some type of high-risk
weaPons, Conclusion: We have demonstrated thaI persons presenting to the liD carrying weaPonE are not uncommon and that both the magnitude and the severity of thc problcm are greater than hae been reported previously. Protection of patients and ED personnel must be ensured. Appropriately armed police must bc immediatly accessible to the ED.
ATest Patients: Department toEmersencv 21gf:;:';l,:?,T
KGrumbach, DKeane, GNorman, SKUlrich, DWashington, RALowe, forAIDS Center SanFrancisco, ofCalifornia, ABBindman/Unlversitv ofGeneral Division Medicine; ofEmergency Division Studies; Prevention Policy forHealth Institute Hospital; General SanFrancisco Medicine, Internal Studies
activity.
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children NewMexico FireFatalitiesAmong ofNew M Hauswald, REZumwalt/University DJParker, DPSklar, DTandberg,
Mexico School of Medicine, Albuquerque Study hypothesis:Children who live in mobile or substandard
Study objetive: Physicians at the [Jniversity of California, Davis, Medical Center (UCD) EI) havc published a set of criteria "nonemergent" defirring Patientsr whom they refuse to treat in their FII). If these criteria become accepted widely, they could alter eubstantially patients' accessto emergency medical care. This study attempted to determine whether the UCD criteria for refusing care
homes are at increased risk of dying in a firc compared with children who live in standard dwellings. Design: Retrospective analysis of the State Office of thc Mcdical Investigator master mortality file. Type of participants: All New Mexico children 0 to 14 years old who died from fire-related injuries between I98l and I991. Interventions: Caee recorde were reviewed and abstracted. Demographic and housing figures were obtained from US Census reports. Data were analyzed by X2 *ith correction for multiple comParis o n8. Ilesults: Fifty-seven fatalities in 44 fires were identified, giving a n a n n u a l a g e - a d j u s t e dm o r t a l i t y r a t e o f I . 4 d e a t h s / I 0 0 , 0 0 0 . T w o thirds of decedents were male, and three fourths werc 0 to 4 ycars old. Mobile homes, which comprisc only 160/oof dwellings, accounted f o r 3 0 V o( 1 3 ) o f t h e f i r e s a n d 2 6 7 o ( 1 5 ) o f t h e d c a t h s ( P : . 0 1 ) . Ilomes without plumbing (substandard), which comprise only 3.60/o of dwellings, accounted for l4o/o (six) of rhe fires and l47o (eight) of the deaths (P < .001). Eighty percent of decedents dicd at the scenel only lOVo reached a burn center. Lack of child supervision or misuse of flammables by adults occurred in more than one half of the
wcre predictive of patients not in need of emergency carel)esign: Historical cohort studY. Setting: A publ-ic, university-affiliated hospital whoee ED eervee abour 78,000patiente annuaIlY. Type ofparticipants: All patients seen in the ED during the week ofJ"ly 9 to July 16, 1990, who were older than l8 years; spoke English, Spanish, or Cantonese; were mentally coherent; and were not triaged for immediate care were eligible for the study. Of the ?29 eligible patients, 598 (82o/o)agrcd to participate, and complete data were available for 515 (717o). Interventions: The predictor variablc was whether the patient mct thc UCD crireria for refusing care' The outcome variables included whether the patient required hospitalization, we reasoned that if the UCD criteria led to refusing care to even a small fraction of the parients needed admission, the criteria probably would lead to refusing care to a larger group ofpatients requiring other emergency services. Two experienced ED nurses, who were blinded to the srudy hypothesis, reviewed each triage sheet to determine whether the case met the UCD criteria. This ED doee not refuse care to any patients, and follow-up data were available for all
deaths. Conclusion: Improved prehospital or burn unit care is unl-ikely to affect pediarric fire mortality rates significantly. Prevention offirc fatalities in children will require improvement of mobile home safety, housing conditione, and adult safetypractices-
patients studied.
86
satisfaction questionnaire to Patients immediately afier they rceived dir.h".ge instructions. No patient refuged to fill out the questionnaire' "rrd th" study continued until 100 patients in each g.otp hud completed the questionnaire' The 12 and Mann-Whitney
Results: When the nurses ecored the cases independently, they disagreed on whether the patient met the UCD criteria in 60 cases (127o), After discussion, the nurses achicved consensus on 501 cases (977o), of whom 5I (107o) were admitted from the ED and Il0 (227o) met the UCD criteria for refusing care. Four (87o) of the admitted patiente would have been denied care by the UCD criteria (sensitivity, 0.92;957o confidence iniervals, 0.8I to 0.97). Conclusion: Ambiguities in the UCD criteria make their clinical application difficult. The high hospitalization rate among Patientg who would have been refused care and who may have no alternative source ofprompt care suggestthat ihe UCD criteria create a dangerousbarrier to patients needing emergency medical care' *Otn
lmprovement in Patient Satislaction From Orientation to
Wo*i ngs Department lZV Emergency of Medicine, School of NewMexico M Hauswald/University HNall. J Brillnan, Albuquerque Medicine, of Emergency Department Study objective: Doee familiarization with the operation of tho emergency department improve patients'perception of their carc? Design: Single-blind, prospective, comparative study using a convenience sample. Setting: Urban, university/county ED with 42,000 annual visits and a meari visit time of 3.7 hours. Type ofparticipants: Low acuity patients or their guardians who could read educational materials in English and complete a paticrrt satisfaction survey. Low acuity was defincd by written triagc protocols. 'I'he control group (34) was registered, triagcd, Interventions: 'fhc cxpcrimental group (42) and cared for in the usual manner. at registration describing thc packets also received orientation triage syetemr potential areas of delay, estimated waiting time, and an ED patient flow diagram. All participants filled out a bricf patient satisfaction survey instrument upon discharge. 'fhe proportions of patients who Measurements and main results: rated their care as good or excellenl were compared using he binomial distribution. One-tailed tests and an c[ of.05 were used throughout. Eighty-six Percent of the experimental group rated their care as good or excellent, whereas only TlVo of the control group did so (P = .05). Conclusion: Low acuity patients who are oriented to the operation of the ED are more satisfied with their care than are those who are not oriented. This study suggeststhat increased efforts to educate low acuity patients about what to expect during their visit will
U tests were used to compare the two groups' Results: The two groups ofpatients did not differ significantly with respat to their total time in the ED, age' 8ex' and insurance status. Fatients who received the EDIM were significantly more satisfied with their overall level ofcare that was the control group (P < .0001). Other areas ofimproved pcrceptions by the patients tire skill and competence, and thc concern and caring of ir.lrd.d t h e d o c t o r ( P < . 0 1 3 9 a n d I . 0 0 5 4 , r e s p e c t i v e l y ) ,c h a n c e t h e y w o u l d use this ED again (P < .0001)' thc ability of thc ED etaff to decrease t h e p a t i e n t ' s a n x i e r y ( P < . 0 0 0 1 ) , a n d t h e e a s c a n d c o n v e n i e n c eo f El) care (P < .0013). Conclueion: ED IM have a significant effect on patiente'PercePtion of the quality of care and overall satisfaction'
Discharge Department of Emergency simplification *rterir PatientComprehension ZZrL|nstuctions lmproves Medical University Washington George SMSanford/The Scott, BTJolly,JL DC Washington, Center, Study hypothesis: Emergenr:y department patients have been shown to havc difficulty understanding written discharge instrucr i o n s . I m p r o v e m e n t s i n c o m p r e h e n s i o nc a n b e a c h i e v e d b y s i m p l i f y ing " Da.v. iagi .l a , blc materials. W c p r c v i o u s l y h a v c t c s t e d p a t i c n t u r t d t : r s t a n d i n go f s t ' a n d a r d d i s c h a r g ci n s t r u c t i o n s . l l a s c d o n l h o s c r c s u l t s ' w c e i m p l i f i e d t h e i n s t r u c t i o n s f o r t h i s s t u d y . l ) a t i e n t ' sw c r e g i v c n o n e o f t w o s e t eo f thc simplilied instructions. After rcading thc instructions, the patients were askcd fivc specific qucstions and then allowed to refer back to thc instructions for thc corrccl answers' Ilesults wcre compared with those for the morc dilficult original instructions' Sctring: An inner-city university hospital ED' 'Ihc s a m p l e p o p u l a t i o n c o n s i s t e do f a l l Typ* of purti.ipants: paticnts who prerented to thc ED during randomly selected study periods, met inclusion r:ritcria, and agrced to participate' Major exclusioncriteria were scvcrc illncss and inability l'o understand English. Eight hundred ninety-fivc patients were considcred, and 423 participated. Interventions: None. 'l'he s a m p l e ' s p o p u l a t i o n ( 4 2 i ) )w a s w c l l m a t c h e d t o t h e Ilesults: prcvious group (400) for scx, age,and cducation' The two tyPes of instructions were equally difficult. Among patients who noled a l 2 t h g r a d e c d u c a t i o n o r l c s s ( 1 5 5 ) , 7 l ' 6 4 o a n s w e r e da t l e a e t f o u r of five questions correctly using the simplified instructions aa compared with 58.7o/oof the same cducational group achieving similar "ucc"ss originally. Ofpatients educated beyond high school (284)' 90.8o/oanswered at least four of fivc questione correctly using simplifred instructionsl 83-ilo/oof thc same group had identical r e s u l t s o r i g i n a l l y . I n t h e l a r g e s l .a g c g r o u p ( a g e s l 8 t o 3 9 , 2 8 1 ) ' a t least four of fivc questions were answcred correctly by 86'57o of the s u b j c c t s c o m p a r c d w i r h 7 6 . 0 0 / oo r i g i n a l l y ' A t r e n d t o w a r d i m p r o v e - . r t * ^ , d e m o n s t r a t e d i n a l l d e m o g r a p h i r :g r o u p s w i t h s i m p l e r i n s t r u c t i o n s . M e a n s c o r e sf o r t h c o r i g i n a l a n d s i m p l i f i e d i n s t r u c tions (4.08 vs 4.36) were significantly different (I'< '0f)' Conclusion: Simplified written materials may help a group of patientswho do nol understand current standard materials' Health care providcrs should simplify written materials as much as pos- -
result in improved perception of care.
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221F1i::l!:T:ff,L.I
onMateriarson entInformati Departm
SJ Krishel.LJ Baraff/UCIASchoolof Medicine/LosAngeles Study hlpothesis: Patient satisfacdon with emergency department care is enhanced by emergency medicine information materials (EDIM) distributed to patients upon their arrival to the ED' Type ofparticipants and setting: A convenience sample of 200 randonly chosen ambulatory adult university ED patients who were alert, coherent, and English spcakirrg. Design and intervention: EDIMs werc distributed cvery othcr day for a period of three monthe to all ambulatory ED paticnts when they registered. The EDIM described how the ED functioncd and specifically addressed the time their evaluation should take and reasons why that time may be prolonged. Patients not receiving the EDIM served as the control group. A research assistant explained that the ED was doing a satisfaction survey and administered a
sillc io reach the greatest number of parients'
81
and Physician perceptions ol Acuity in tre Emergency ???,Patient LAg Department DW Munter/Emerg encyDepartment,NavaI Hospital, portsmouth,Virginia Study hypothesis: Emer-gencydepartment patients, perception of _ their acuity, even when offered detailed infor'mation, Jiff".. ,ignifi_ cantly from that of emergency physicians. Deeign: Prospective suryey. Setting: Community hospital wirh 60,000 census. Type ofparticipante: Thre rhousandconsecutive ED patients in a three-week period. Intervention: Patiente were given one of three survey forms to complete. In addition to demographic information, pal.rentswero asked to place themeelveeinto one of our acuity "uiegori... E""h f o r m ( d e s i g n a t e d1 , 2 , a n d 3 ) h a d " n i . c . " a " i n g . p . " L o ofinfor_ mation to help the patient make this determin;tiin, ranging from a simple safe waiting time model (l) to a detailed description of each category with explicit examples (3). The patient then was prosptr_ tively triaged by a physician *ho r."o.ded an acuity car.egory. : A total of 2,67 6 corrc tly completed fo"-, *""" collcctcd .^ ^R_esults (89.2-Vocomphance); lz testing was used ior analysis of data. Conditions in the three highesi acuity categorics *e.c "onride.ed t.o be appropriate for ED use. Overall, patient and physician acuity categorizations were sigrrificantly different for each'category regardless of the form used, with patients categorizing their condi_ tions higher than physicians, as notcd (Table). _ torml
Palrents ftrysicians
93.3% 49.6% < 0001
Acuity Judgsda$ Approprialgfor EDUss Form2 Form3 Totsl
93.0% 41.4ya < 0001
87.8% 42.1% < 0001
91.4y. 46 4ya <.0001
Conclusion: ED patients' perception of the acuity differs signifi_ cantly.from that of ED physicians, regardless of the information provided to rhe patients.
Judsmenr intheUse ofAnkte Badiography ??4,flrr"ians' lGStiell,l McDowell,
BCNalr, A n.ta,CCr.rrnler.s, ndMrirtgh,, J Ahuja/University ofOttawa, Ontario, Canada
Study objecrives: To study l) rhe ability ofcxperienced cmcrgcn_ cy physicians to distinguish between fracture ani nonfracturc cases among ankle injury patiente, 2) the physicians, attitudes toward their use.ofradiography in these pu,i"n,r, and 3) the potential for improved efficiency over the currcnt low_yield p"u.ti"" of ordering "u{ogl"p!, on virrually all ankle injury iatients. Design: Prospective survey. Emergencydepartments of two adult universily hospi_ . ,Setting: tals. of participants: Sevenhurrdred rhirty_l.wo adult ankle . .T).p" inj ury pa tients seen by one of 2 I emcrgency a ttending physicia ns. M e a s u r e m e n t sa n d m a i n r e s u l t s ; E x f , . r i . n " e d phy.i"iur. predict_ ed theprobabiJ,ityoffracture Lobe\vo or r\va ttsT.go/oofcases. The kappa level for interobserver agreement in ggloti"rt, ."". tlT::l.lrtt by two physicir.. *u, 0.SS (gSEo"o.fid.r"" i.r.._ q.rn ,"^o::r.):_The sensitivity for fracrure or the 0o/o proh_ :ll:!-ajl, a b r r f . t yl e v e l w a s 0 . 9 2 ( 9 S V oC I , 0 . 9 6 t o .Ihe 0.98). area under the receiver operating characteristic curve for physicians, predictcd s . 0 . 8 8 ( 9 5 v o C I , 0 . 8 4 t o 0 . 9 2j , r . f l e " t i r g good lltbib},v.*" dlscrrmulation between fracture and nonfracture cases. Likelihood *li:: predicted probabilities ranged from 0.0g for tltc}a/a level !. to l5I for the l\OVo level. The physicians also indicarcd thcy woulcl
88
be very comfortable or comfortable in not ordering any x_ray in 4 5 . 9 7 oo f c a e e e( k a p p a l e v e l , O . S 2 ; 9 S V oC I , 0 . 3 4 t ; 0 . 2 0 ) . Conclusion: Emergency physicians can discriminate accurately _ fracture from nonfracture casesand clearly expect most of the radiographs ordered for ankle injury patients io be normal. These findings suggest significant potential for more efficient use of radio_ graphy in ankle injury patienrs, possibly through guidelines.
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iosrap hsintheEme rse ncvDepartme nt 225[ ;,H: .11lJii,,1rld
ACSaxena, BLNorris, KFinstuen, DEMadison/Brooke ArmyMedical Center. SanAntonio, Texas; program USArmyBayror University Graduate hearth care Administration, FortSamHouston, Texas Study objective: The evaluation ofemergency department patientg with acute knee complaints frequently invol"eu oidering of radiographs. The purpose of this study was to define a subgroup of patients who are likely to have normal knee radiographs. Design: Between May lgBT and January 1990, dl6 consecutive patients over the age of l5 years wilh knee pain or injury ofless [han one week's duration werc entered into this proepective study. llased on a standardized history and physical examination, physicians noted any specific radiographic findings they expected. All patients received standard anteroposterior and laieral views ofthe involved knee. Setting: Level I with emergency medicine residency program. 'fype of participants: Patients were evaluated by attending emer_ gency physicians and housegtaff. Exclusion criteria were presence of a palpable mass, medical history suggestiveof an increaeed ri8k of fracture, impaired sensation, or inabi.lity to obtain accurate physical examination. Thirteen patients were omitted from the analysis. 'fhe Itesults; radiographs altered the management of the patient . irr 5l cascs (8.37o). Unsuspccted fractures were discovered in ten p a t i e n r . s( l . 6 E o ) . R a d i o g r a p h s w e r e n o r m a l i n 3 2 p a t i e n t s ( S . Z V o )i n w h o m f r a c t u r e s w e r e s u s p e c t e dc l i n i c a l . l y . C o n c l u s i o n s :' l ' h o v a s t m a j o r i t y o f k n e c r a d i o g r a p h s wcre nor_ mal. Using correlation analysis, w<:found that oi the 3l variablee studied, thc absence of immcdiatc swclling, ecchymosis, effusion, deformity, increased warmth, and abrasiJn4"""""tio.r, is eigrrifi_ cantJy predictive of normal radiographs (r > .143, p < .01). Further research using these criteria is necessary before firm recommenda_ tions can be made,
2261r'"11 ;: iil,:t
^' terior shouIder 0istocationsbyScapuIar
BCMcNannra/TheMedicalCollegeof pennsylvania, philadelphia Study objarive: Scapular manipulation (SM) has been reporred to be a rclatively simple and painless nrr:thod for cloeed reduction of a n t e r i o r s h o u l d e r d i s l o c a t i o n s ,b u t t h c r e h a s o n l y b e e n one case series published in the literature. This study examined the success rate, time requircd, technical ease, and rcported discornfort to the patient of SM for acute anterior shoulder dislocations. Design: Prospective case series over a l9_month period. -_ Emergency physicians were instructed in this technique in a classroom setting and requesred to initially attempt SM for the reduction of anterior shoulder dislocations. A data sheet was completed for eachpatient wirh attempred SM. Settirrg: The emergency departments of a university and a com_ munity hospitat.
*2281,T#tt
Type ofparticipants: A group of ED patients. Physician participants #ere considered experienced with SM if they had performed this technique at least two timeg previouslyInterventions: Physicians first attempted SM followed by any technique of their choosing aE necessary for successful reduction. Premedication was at the physician's discretion. Results: There were 54 patients with 6l dislocations enteredl 28 (467o) were recurrent dislocations. Physicians attempting SM included 19 residents and 12 attendirrgs in emergency medicine. Successrates according to level ofcxpcriencc with SM were as folIows:
. a n v i l l eP, e n n s y l v a n i a l e n t e rD ee r dicaC D J D u l a ,W F a l e s l G e i s i n gM Study hypothesis: A ring or halo sign is a sensitive and specific indicator of blood containing cerebrospinal fluid thar could be used in the clinical diagnosis of a cerebrospinal fluid leak in head trama. Design: One drop ofblood was placed simultaneously on filter paper with one drop of cerebrospinal fluid. In a similar fashion, one drop of blood and a drop of normal salinesolution, rhinorrhea werc fluid, or tap water also were tested for the appearancc of a ring orhalo sigl. Each sample was testedten times. At l5 minutes, thc speimens were evaluated for lhe presence of a ring or halo sigr
Trsating Physician SMSuccss: 0lherEDMothod E0frilurss Experienced {42) (19) Inexperienced Overall i6l)
36{86%) r2{63%) 48(79%)
Al / . 1 6 l32Y.l ! 0i 1 6 % )
forCerebrospinal lndicatgr Sisn:lslt a Reliable
and photographed. Results: In reviewing the various test combinations of cerebrospinal fluid, saline, tap water, and rhinorrhea with blood, we found that each sample produced an easily reogrrizable ring or halo signNo dctcctiblc differences in quality or size ofthe ring occurred with a n y o f t h e t e s t e d f l u i d s . [ J s eo f b r : d l i n e n s ' c o f f e e l i l t e r s , o r p a p e r t o w c l s a s s u b s t . i t . u t cfso r f i l t c r p a p c r d i d n o t a l t c r t h e d c v c l o p m e n t o f a r i - r r go r h a l o s i g n . l | l o o d a l o n e d i d r r o t c a u s e a r i n g o r h a l o s i g n . 'fhis s t u d y d e m o n s t r a t o st h a t a r i n g s i g n d o e s o c c u r Summary: when blood and spinal fluid arc placcd on filtcr paper. Thc sigr, h o w r : v e r ,i s n o t s p c c i f i c f o r c e r c b r o s p i n a l f l u i d , a n d q u a l i r a t i v e l y s i n r i l a r r i r r g s w i l l d r : v e l o pw i t h r h i n o r r h t : a f l u i d , n o r m a l s a l i r r e ,o r
2 {5%) 1(5%) 3 (57")
Of the 48 successful SM reductions ,31 (657o) were performed in less than one minute and,M (747o) were rated by the physician as very easy or easy to perform. Thirty-two (67Va) of those with successful SM received no premedication and rated their parn as nono, five; mild, 151 moderate, eight; and scvere, four. Patients who received premedication reported a sinrilar frcquency of modr:ratc or s e v e r ep a i n ( P > . 0 5 b y 1 2 a n a l y s i s ) . N o c o n r p l i c a t i o n sw e r e n o l . t : di r r this study. Conclusion: SM is a generally simple, rapid, reliablc tcchnique for the closed reduction of anterior shoulder dislocal.ions. Performance without premedication did not increase pcrceived patient discomfort.
l.ap wal.er.
G r i t i c a lA n g l e o l I n c i d e n c e f o r D e l a y e dV e s s e l P e r l o r a t i o nb y *iDtDn Central Venous Catheter: A Study ol ln Vivo Data ZZJ t t', Prospective B H B l a c k s h e aN r , G r a v e n s t e i n / D e p a r t m eonf tAsn e s t h e s i o l o gayn d Evaluation ol theScapular Manipulation ZZ I Technique intheReduction olAnterior Shoulder Dislocations N e u r o s u r g e rUy .n i v e r s i toyf F l o r l d aC o l l e g eo f M e d i c i n eG, a i n e s v i l l e 'llo detcrnrine thc in uioo critical anglc of inciStudy objcctivc: BUKothari, SCDronen/Department of Emergency Medicine, University of a s s o c i a t c d w i r h d c l a y e d p c r f o r a t i o n o f t h c v e s s e lw a l l o r h c a r t d c n r : r : Cinclnnatl Medical Center, 0hio Study hypothesisr Many techniques for the reduction of ant.erior s h o u l d e r d i s l o c a t i o n s( A S D ) h a v e b e e n d c s c r i b e d . [ I o w e v e r , l h c r c is little documentation of the speed, cfficacy, or safcty of thcse techniques. The scapular manipulation t.cchni<1ue(SMl') diffcrs fronr ail other methods of reducing ASD in that [hr:focus is on rcposil.ioning the glenoid rather than the humeral head. This study prosp<:ct.ivcly e v a l u a t e d t h e S M T f o r s u c c e s sr a t e , i r r c i d e n c co f c o m p l i c a t i o r r s , dosage of analgesics required, and time to reduotion. Design: Patierrts were prospectively entered ovcr a l7-month period. Reduction time, doses of analgesics used, and complications were recorded. Setting: Patients were recruited from a univereity-based ED. Type of participants: All patients prescrrting to the IiD with radiographic evidence of ASD were considered for irrclusion. Patients were excluded if the dislocatiorr occumcd rnorc than 24, hours earlier, if the humeral shaft was fractured, or if thcrc wcr<: c o n t r a i n d i c a t i o n s t o t h e u s e o f m i d a z o l a r r r o r f e n L a r r y l .l ' o r t y - c i g h t . of 52 eligible caseswere included. Results: SMT was successful in M of 48 cases(96Vo).'l'hc avcrage time to reduction was 6.05 minutes and no complications werc d e t e c t e d .A v e r a g e d o s e so f l . 8 3 m g m i d a z o l a m a n d 2 0 4 p g f e n t a n y l were required for reduction. Conclusion; We found the SMT to be effective in960/o of aases with an average reduction time of six minutes and no complicationsWe conclude that this technique is a safe, fast, and effective method for reduction of ASD.
b y a < : c n t r a lv c n o u s c a L h e t e r( C V C ) . Dcsign:f)claycd perforaLion was dcfint:d as perforation of the h c a r l . o r c c n t r a l v e i r t t h a t o c c u r r c d f r o n r l J Om i r l u l . e st o s c v c r a l d a y s a f t t : r i n i t i t a l C V O p . l a c c m c n t .W r : e v a l u a t . r : di l l ; < : h e s rt a d i o g r a p h s f r o n r b o t h p u b l i s h c d r c p r i n l . s a n d < : a s c sf r o m o u r i n s t i t u t i o n i n w h i c h r : at h c t c r - r r i l a t o d d c l ay t : d p c r f o r a t i o r r w a s d o c u m c n t c d . I n t c r v c n t i o n s : I r r c i d c n t .a n g l e sb e t w a : r r c a t h c t c r t i p a n d v e s s c l wall or heart werc mcasurcd in a standardized fashion with a goniometcr and recorded along with tinrc to pcrforation, approach used, pcrforation site, and treatment of thc complication. Ilesults: lncidcnt anglcs in all cascs rcvicwed wcre greater than 4 0 ' w i t h a m c a n i n c i d e r r ta n g l eo f 6 2 . 4 o ( r a n g e r 4 2 " t o 9 0 o )a n d a m o a n l . i m et o p e r f o r a L i o n o f l 9 l h o u r s ( r a n g c , 0 . 5 t o 1 , 8 4 8 h o u r s ) ( 1 ' a b l c ) . O f 3 5 d e l a y e d p e r f o r a l . i o n s ,t h e C V C w a s p l a c e d b y w a y o f a l c f t - s i d e d a p p r o a c h 7 4 o / oo l l h r : t i n r r :a n d a r i g h t - s i d e d a p p r o a c h f 6o/aof the timo. In 8Jo/aof thc <:ast:s,thc catheter tip entered the r i g h t c h e s t w i t h r e s u l t a n t h y d r o t h o r a x . I r t a l l < : a s c so f r e c o g n i z e d p e r f o r a t i o n , t h o r a c e n t e s i sw a s p r : r f o r r r t e d . C o n c l u s i o r r ; l ' h e d a t a p r e s e r r t c ds u p p o r t p r t : v i o u s i n u i t r o f i n d i n g s , w h i c h s u g g c s tt h a t i f t h e p o s t p l a t : e m e n ti n c i d e n t a n g l e r e l a t i v e t o t h c v e s s c lw a l l o f a s t r a i g h t - t i p p e d C V C i s g r e a t e r t h a n 4 O o ,t h e catheter should be repcsitioned. An irrcident angleof40o or less helps minimize the possibility of delayed perforation. Data from 3 5 i n u i u o c a s c so f d e l a y e d p e r f o r a t i o n o f a v e s s e lb y a C V C a r e p r e s e n t e d( T a b l e ) . Range Msan Angleof Incideneat perloralr on (hours) 1rne to perloration
89
62.4" 1C1
42' to 90" 0 . 5t o 1 . 8 4 8
*
230
MiddleEarBarotraunra of Hyperbaric-Associated Prevention
Program, Besidency Medicine S Carlson, J Jones,M Brown/Emergency Medicine. College of Human Hospital, Michigan StateUniversity Butterworth Michigan Grand Bapids,
oxygen saturation to 607o to 707o in four patiente secondary to del^ys duritg intubation. No patients undergoing oral endotracheal intubation sustained serious adverse effcts related to this proce durel however , six (l1%o) of those nasally intubated developed lifethreatening epistaxis when a coagulopathy occurred during their clinical course. Conclusion: Oral endotracheal intubation performed by emergency physicians is an effective and safe procedure- Care must be taken in patient selection if nasal intubation is performed because of the increase in serious late comPlications.
Study objective: To determine the efficacy of topical nasal decongestants in the prevention of middle ear equâ&#x201A;Źze in patients undergoing hyperbaric oxygen (HBO) therapy. Design: Proepective, parallel, double-blind, randomized trial. Setting: University-affiliated community hospital emergency department with HBO facilities. Type ofparticipants: Forty-two patients undergoing IIBO thcrapy; 2l subjets in each treatment arm. I n t e r v e n t i o n s: A f t e r r a n d o m i z a t i o t t , c o n s e n t i n gp a t i c n t s w c r c g i v e n t w o s p r a y s o f o x y m e t a z o l i n eh y d r o c h l o r i d c o r s t c r i l c w a t c r t e n t o 2 0 m i n u l . e sb e f o r e I { B O t h e r a p y - C o l l m t c d d a t a i n c l u d c d p a t i c n t d e m o g r a p h i c s ,e a r e x a n t i r t a l . i o r tbs c f o r c a r r d a f t t : r I l l l o 'l'hc o t o s o p i t :a p P e a r a l l c ( : trcatment, and subjectiveear conrplairlLs. of the tympanic membranc was gradcd according to lhc amourlt 'l'[iED scorcs ranging front of hemorrhage in the eardrum, with
inthe Druglnteractions 4rt!'rt Prospective ol Adverse Evaluation Department L, Z Emergency of Utah, LSlyler,Elorg,MSLinscott/Universlty Caravati, frDHen.EM City SaltLake Study objetive: To find thc incidcnce and risk factora of clinicall y r e l e v a n t a d v e r g ed r u g i n t e r a c t i o n s i n t h e e m e r g e n c yd e p a r t m e n t ' D c s i g n : P a t i c n t s ' d r u g r c g i m c n s w c r c c v a l u a t e d p r o s p e c t i v e l ya t t h c t i n r e o f t h e e m c r g e n c ye v a l u a t i o n . S e t t i n g : U n i v e r s i t y h o s p i t . a lE D ' 'l'ype of part.icipants: Convenience sample of 341 patients' Inlervcntions: Patients' medicationsupon arrival to the ED (oocurrent" medicines) and thosc initiated in the ED were entered i n t o l l a n s t e n ' s c o m p u t e r - b a s c dd r u g i n t e r a c t i o n p r o g r a m t o i d e n t i fy potential drug interactions (PDls). Ail PDIs were brought to the a t t c n t i o n o f t h r : E D a t . t . e r r d i n gw, h o s c s u b s e q u c n t a c t i o n e w e r e n o t c d . C l i n i c a [ [ y r c l e v a n t i n t . e r a r : t i o n s( C R I s ) w e r e d e t e r m i n e d b y a p h y s i c i a n p a n c l b a s c d o n t . h cl i D a t t c n d i n g s ' a c t i o n s , s e t c r i t e r i a , a n d a r e v i e w o f h o s p i t a l c h a r t . sa r r d f o u r - w c c k t c b p h o n e f o l l o w - u p
0 ( s y m p t o m s o n l y ) t o 5 ( g r o s sh e m o r r h a g e a r r d r u p t u r c ) . Results: The treatment groups were simi-lar with regard to agc, scx, and past mcdical history. Ear discomfort during IIBO therapy w a s p r e s e n t t n 5 7V o ( 1 2 o f 2 l ) o f t h o s t : r e c e i v i n g o x y m e t a z o l i r t e v e r s u s4 8 7 o ( L c n o f 2 l ) o f t h e c o n t r o l g r o u p ( f ) > . 5 ) . L i k < : w i s c ,b o t h g r o u p s h a d s i m i l a r T E E D s c o r c sa f l c r I I B O t h c r a p y ( I ' > . i r ) . N o a d v e r s ee f f i : c t sw c r e n o t e d . P o w c r a n a l y s i s d c t r t o n s l . r a t c ds a m p l l : size was la rge enough to rejmt a 2l>o/orisk rr:d uc[iott of ba rol-ra utrta i l p a t i e n t s t r c a t c d w i t h o x y m e t a z o l i r t c( o : . 0 5 , o n c - t a i l c d ) . C o n c l u s i o n : I h e r e s u l t s o f t h i s p i l o t s t u d y s u g g c s tt h a l l o p i o a l d e c o n g e s t a n l .m s a y n o t b e e f f e c t i v c i n p r c v e r r t i n g n r i d d l t :t : a r b a r o trauma during I{BO therapy. a n d E l l i c a c y o f E n d o t r a c h e a lI n t u b a t i o nb y E m e r g e n c y talSalety I Physicians Art l o s p i t a lP, i t t s b u r g h , F H a r c h e l r o aK d ,P o t t s ,J T r a p p / A l l e g h e nGye n e r aH P e n n s y l vnai a Study objective: To determine the cfficacy and safcty ofcndot r a c h e a l i n t u b a L i o n a s p e r f o r m e d b y c m c r g c n < : yp h y s r c t a n s . D e s i g n : A c o n s e c u t i v ec a s c s c r i e s o f a l l e m e r g e n c yd t l p a r t n r c r r l . p a t i e n t s r c q u i r i n g e n d o t r a c h e a l i n t u b a t i o n b y c r r t c r g c r r c yp h y s i < : i a r r s f r o m J a n u a r y l 9 9 I t h r o u g h D < x x : r n b t :1r9 9l . Setting: A [crliary-carc referral, urbarr Ijl). 'f c a l . i c r r t s( a d u l L a r r d ; p e o f p a r t i c i p a n t s : A l l I 7 I c o r t s < x : u t i vp pediatric) who rcquired endotracheal intubation by enr<:rgcn<:y m e d i c i n c p h y s i c i a n s f o r a i r w a y n r a n a g c m e l r t .[ ' ] x c l u d e dw c r < :a l l p a t i e n t s i n t u b a t e d b y s p e c i a l i s t . rst o t .t r a i r t e d i n c n l e r g e n c ym ed i c i n c . Interventions: Daily chart review and videotapc review of physicians performing endotracheal irrtubations, specifically noting nasal versusoral, use ofpharmacologic adjuncts, failed attcmpts b e f o r e s u c c e s s ,a n d i m m e d i a t e c o m p l i c a t i o n s . L a t e c o m p l i c a t i o n s
of paticnts with PDIs. 'l'hrcc hundrcd forty paticnts wcre cnrolled' The mean Itesults: wir.h173males and 167females' Onehundred y c a r s agowas 34.5 thirty-fivr: PI)Is werc idcntified in 6I patients. Twenty CRIe were i d c n t i f i e d i n l 5 p a t i e n t s . C l i n i c a l l y r e l e v a n t a d v e r e ed r u g i n t e r a c t i o n w a s s i g n i f i c a n t l y l e s sf r o m m e d i c a t i o n a d d e d b y t h e E D t h a n f r o m c u r r e n t n r e d i c a l . i o n( X 2 : 3 ' 9 5 , P = ' 0 4 7 ) ' C R I f r o m b o t h c u r rcnt and lll)-initiated mcdication was signilicantly associated with t a k i n g t h r e e o r m o r e m c d i c a t i o n su p o n E D a r r i v a l ( P - ' 0 1 6 ' P : .045, rcspcctivcly). C o n c l u s i o n : C l i n i c a l l y r c l e v a n l .a d v e r s c d r u g i n t e r a c t i o n w a s s i g nificantly less from medi<:atiorraddcd by the ED than from current mcdication.'l'hrcc or morc mcdicationsuPon arrival to the ED < : o u l db r : a p o t . t : n t i a sl r : r c c n i r t gt o o l f o r i d < : n t i f y i n gp a r i e n t s a t r i s k for intcractions from both currcnt and ED-initiated mcdications'
were noled by direct patient follow-up. R e s u l t s , O f l T l . p a t i e n t s e n d o t r a c h e a l l y i n t u b a t c d , 4 0 ( 2 3 o / a )w < : r < : p er f o r m e d n a s a l l y , a n d 1 3 l ( 7 7 o / o )w t : r < p: a s s e d o r a l l y . N o p a t i t : n t s r e q u i r e d e m e r g e n c yc r i c o t h y r o t o r n y o r l . r a c h c o s t o n r-y N a s a l i n t u b a tion was successful B57o of the tinrc (40 of 47), aftcr an avcragc of 2 . 2 a t t e m p t s . O r a l i n t u b a t i o n s w c r e s u c c e s s f u ll 0 0 a / oo f t h c t . i r n e ( l 3 l o f l 3 l ) , a f t e r a n a v e r a g eo f 1 . 2 a t t c r r p t s . I n i t i a l p l a c c m e n t i r t the right mainstrcam brochure occurred on 2I (127a)occasions. S e v e n t y - e i g h t( 6 0 7 o ) o r a l i n t u b a t i o n s w c r e f a c i l i t a t c d b y p h a r n r a c o l o g i c a d j u n c r s . I ) u l s e o x i m e t r y o b t a i n e d o n 9 6 p a t i e n t s ( 5 6 7 o )f o u n d
90
rtet?t The Efficacyol Phenytoinin the Preventionol Recunent ZJJ AlcoholWithdrawalSeizures EBernstein/ RWHossack, PMHarrison, SSFish, GD')nofrio, NKBathlev, CityH0spital B0ston Department, Emergency of IV phenytoin Study objectivc:To deternrinethe effectiveness (I'llT) in the prevcntion of recurrent alcoholwithdrawal seizures (AWS). trial comparDesign:A prospcctivc,randomized'double-blinded ing IV PIIT with nornralsaline(NS)placeboconductedfrom .lanuary1990throughDecemberI 991. Setting: Emergency
departmcnt
Participanl.s: One hundred
of an inner-cil.y
teaching hospital'
sevcnty-sevcn consecutive adults
more than 25 years old who prescntcd
with a witnessed generalized
seizure and dccreasing alcohol intake or alcohol withdrawal' Entry was based on history, Iaboratory l.csts, and past medical work-up' Paticnts with known potcntial physiologic or metabolic causes of )
I
Type of participants: All women admitted from 1984 to l99l with surgically proven OT. R e e u l t s :T h e 3 I w o m e n r a n g e d i n a g e f r o m 1 5 r o 7 7 y e a r s ( m e a n , 3l). Six were pregnant (two in each lrimester): three were postmenopaueal, and two were poethysterectomy. Fifieen (487o) had prior abdominal or pelvic surgery; ten had prior tubal ligation. Twenty-five patients presented to the ED, six to the obstetrics/ gynecology clinic (four with pain and two with an asymptomatic m a s s ) . P a i n c h a r a c t e r i s t i c sw e r e v a r i a b l c : O f 2 9 w o m e n w i t h p a i n a t p r e s e n t a t i o n , t h e o n s c t w a s s u d d c n i t o n l y 2 4 o / o ; 2 8 7 o h a dp a i n o f t w o o r m o r c d a y s ' d u r a t i o n . N i n e t c c n ( 6 6 0 / o )h a d p a i n r a d i a t i n g t o thc back or groin; in 19, it was'osharp" or stabbing. More than half (18) had vomiting. Only five (l7o/o)had signficant peritoncal findi n g s , a n d f i v e h a d l e u k o c y t o s i s( > 1 5 , 0 0 0 ) . F e v e r w a s r a r e ( o n e paticnt). Eleven patients (38o/a)had had similar pain before, and t c n h a d s e e na p h y s i c i a n p r e v i o u s l y f o r s i m i l a r s y m p t o m s . O T w a s c o n s i d c r e d i n t h e d . i f f e r e n t i a ld i a g n o s i si n o n l y l 6 o f p a t i e n t s ( 5 2 7 o ) a f t c r i n i t i a l a s s c s s n r c n t2; 2 p a t - i c n t sw c r c a d m i t t e d ( f o u r d i d n o t havc surgcry on that admission).An cnlarged ovary (at least 5 cm) was found in 26 oflJl paticnts at surgory. Surgcry occurred within 2 4 h o u r s o f i n i t i a l p r c s c n l . a t i o ni n o n l y t c n p a t i e n t s . I n t h e o t h e r 2 l p a t i c r r t s ,t h c m c a n t i m c t o s u r g e r y w a s f i v e d a y s ( r a n g c , t w o t o 2 t l d a y s ) . l n n i n t : , p r o g r c s s i v c p a i r r a n d p c l v i < :m a s s p r o m p t t : d s u r g c r y w i t h i n f o u r d a y s o f p r c s c n t a t . i o n .I n l i 3 , p a i n r c s o l v c d , d c c r c a s e d ,o r w a s i n t c r m i t t c n t , a l t h o u g h s i x h a d s u s t a i n c d i n f a r c tiorr al surgcry. In only two patierlts (surgcry at Lwoand ninc days) was dctorsion possible. 'l'hc Conclusion: d i a g n o s i so f t o r s i o r r i s o f t c n m i s s e d a n d o v a r i a r r s a l v a g ci s r a r e . I ) a i n i n O l ' o f t c n r e s o l v e so r i s i n t e r m i t t e n t r a t h e r t h a n s u d d e n , a c u t ( j ) o r s u s t . a i n c d ;o b j a : t . i v ef i n d i n g s o f t e n a r e m i n i -
seizure or who received benzodiazepines to treat withdrawal werr: excluded. One hundred patients completed the study. Interventions: Patients received PHT l5 mgkgor NS at equal volumes via IV pump. Patients were observed for six hours in lhc ED. Those with a second seizure were admitted. R e s u l t s :T w e l v e ( 2 4 E o ) n t h e N S g r o u p ( 5 0 ) a n d l l ( 2 2 7 o ) i n t h e PHT group (50) had recurrent AIVS. 1z analysis shows no signific a n t d i f f e r e n c e sb e t w e e n t h e t w o g r o u p s ( X r : . 0 5 , P > . 1 0 ) . P o w e r analysis shows that with the current sample size, thereis a99o/o chance ofdetecting a I00Vo reduction in seizurc ratc in the Pll'l'treated compared with the NS group and a 35o/achancc of dctccting a 507o reduction. Conclusion: PIIT has no significant benefit in the prcverrtion of reurrent AWS. Limitations include elimination of paLients who reeived benzodiazepines, recurrent seizures before treatmcnt, and previous seizure work-up may leave recent structural lesions undctected. /tttt
,r
t arl Lla AreSginal Precautions Indicated in All Seizure Patients? CLMcArthur, CTRooke/Biverside General Hospital, Biverside, California Study objective: Many patients are trancportcd to cmcrgcn<:y d e p a r t m e n t si n f u l l s p i n a l p r e c a u t i o n s a f t e r u n c o m p l i c a l c d s c i z u r c s . 'fhis increases the time to provide carc and cxpcnsc for thcs<: patients. A study was undertaken to detcrminc thc incidcncc of spinalinjuries as a direct result ofseizure activity. Litcratur<; review provided no definitive data on this topic. Design: A retrospective review of 5.5 ycars of El) outpaticnts and 10,5 years of in-patients. Setting: A university-affiIiated teaching hospital. Type of participants: AII patients ovcr 5 years of age with a diagn o s i so f s e i z u r e , a l o n e a n d i n c o m b i n a t i o n w i t h s p i n a l f r a c t u r e , s p i n a l d i s l o c a L i o n ,a n d / o r s p i n a l c o r d i n j u r y w i t h o u t s p i n a l b o n c injury, were reviewed. Exclusion critcria includcd febrilc scizurt:, trauma-induced seizure, and seizure with resultant nrajor Lraunra (motor vehicle accident, falls from grcat heights, ctc). I n t e r v e n t i o n : O u t p a t i e r r t c a s e sw c r c i d c n t i f i c d f r o n r t h c l i t ) l o g . l n - p a t i e n t s w e r e i d e n t i l i e d b y c o m p u t r : r s r : a r c h .A l l p a t i c n t t : h a r t s were abstractedby the samephysician. I l e s u l t s : T h e r e w e r e 7 9 8 E D o u t p a l . i c r r t s ,l , ( v 1 4 ,i n - p a t i c n l s w i t h p r i m a r y d i a g n o s i so f s e i z u r e , a n d 2 r 4 0 I i r r - p a t i c n t s w i t h a n a s s o c i a t e d d i a g n o s i so f e e i z u r e f o r a t o t a l o f 4 , 8 4 1 3c a s e sr e v i e w c d . O n l y o n r : ED outpatient was noted to have spinal injury, a 45-year-old marr w i t h c o m p r e s s i o nf r a c t u r e s o f T T a n d ' I l 0 o f u n c e r t a i n a g e w i t h o u t neurologic sequelae. Only one spinal injury was noted in thp inpatient group, a 55-year-old man with a compression fracture of I'9 of uncertain age also with neurologic se<1uelae. Conclusion: The incidence of spinal injuries is extremely low. The routine use of spinal precautions in uncomplicated scizurr: c a s e si s q u e s t i o n a b l e . C o s t c o n t a i n m e n L , r i s k m a n a g e n r e n t ,a n d quality improvemcnt informaLion also will be prescnted.
rnal.
.236 Department Fromthe Emergency DeathAfterDischarge of Wisconsin, MPKefer, SWHargarten, J Jentzen/Medical College Begional andPathology, Milwaukee Departments of Emergency Medione M e d i c aClo m p l e x of dcath(COl)) aftcr discharge Studyobje<:tivr:: I)ata on t:ausr:s fronr t.hc cmcrgcncy dcpart.ment havc not bcen prcviously rcportcd. 'l'hc purposc of t.his study is to dcterminc lht: numbcr and COf) of paticnt-s who wt:rc evaluatcd,
dischargcd,
and not admitted from the
lll) and how thesc rclatc to thc ED visit. l)esign: Retrospr:ctive chart revicw of medical examincr from.fuly
cases
l, 1990, through June 30, 1991.
Setting: Urban
county
scrved by 14 hospital
EDs with an estimated
394,000 annual visits. Type ofparticipanl.s:
Cases evaluatcd
and released from an ED
within eight days before death. lrtLcrvcntions: None. llesults: l-orty-two inclusion critcria
of Lhc 2r(165 mcdical exanriner cases met
(ages,9 months to 95 ycars). Complete ED data
arc availablc on 37. Death was classificd as cxpected or unexpected
/tlAF t alr 3-.t.t Ovarian Torsion: An Eight-Year Review J A b b o t t ,B C a r s o nW , D a v i l aE , A p a r i c i o / S e c t i oonf E m e r g e n cM y e d i c i n ea n d T r a u m aU . n i v e r s i toyf C o l o r a d o H e a l t hS c i e n c e C s e n t e rD , enver S t u d y o b j e c t i v e : T o d e s c r i - b et h e h i s t o r y a n d p h y s i c a l a n d l a b o r a tory findings in women with ovarian torsion (OT). D e s i g n: R e t r o s p e c t i v ec h a r t r e v i e w . Setting: Urban university teachirg hospital.
bascd on chnical status at timc of dischargc and as directly related or unrelated ccrti{icate.
to the ED visit based on the COD listed on the death Eleven deaths x'cre r:onsidered unexpmted
Of these, four (360/o)rcsultcd from complications 76 to 90 years), and three (27o/o) wcrc ruptured (two patients had two prior death).
The remaining
and related.
of injury
(ages,
aortic aneurysms
relatcd EI) visits within
seven days of
four COD were bowel infarction,
left ventric-
u|armyxoma'pu|nr<rrraryembo|us,artdpneumonia.>
91
Conclusion: Unexpected related dcath after dischargc from an ED is rare. Complications of injury composc the most common cause, followed by ruptured aortic aneurysm. Our results suggest the threshold for admitting elderly patients with injury should be Iow and that there is an important role for ultrasound in the llD.
this study was to determine if subslance abuse identifies improved survival in trauma patients with low admission GCS. Desigrr: Prospectively collated data were reviewed retrospetively for JuIy 1986 through June 1990. Setting: Statewide Level I trauma center. Type ofparticipants: Five hundred thirty-two consecutive, adult blunt trauma victims with an admissione GCS of 3 to 8. Routine toxicologic screening is performed on all admits, Interventions: None. Results: Two hundred cighty-two (52.94o) of these severely injured neurolrauma patients were positivc (TOX+;. The TOX+ patients were younger (29.6 ve 33.5 years, P < .006) with a lower mean Injury Severity Score (35.9 vs 38.2, P < .05) and eimilar mean GCS (5.1 vs 5.0) (P - NS) compared with the TOX- patients. There was no difference in degree of traumatic head injuries between the two groups as demonstrated by head compuled tomography scan ' results (P < .05). TOX+ patients had a significantly lower mortality (P .007). Regression rate (43.4o/a)than TOX- patients (56.5%) < analysis found TOX+ to be an independent predictor of survival (1' < .002). Conclusion, Toxicology screening for trauma victims is neceseary br:causesubstance abuse appears to falsely lower admiesion GCS detracting from its outcome predictiorr accuracy. Although s u b s t a n c ea b u s e p r e d i c t s i m p r o v e d s u r v i v a l a f t e r t r a u m a , n o p h y s i cal cvidence cxists to demonstral.c any irrjury differences between 'IOX+ and TOX- paticnts.
Therapeutic Elfectsol WaterVersusMilk Dilution forAcute ta', Lrt , Alkalilniuryol theEsophagus CSHoman, SRMaitra,BPLane,M Sable/Trauma Research Laboratory, Departments of Emergency Medicine, Surgery andPathology, SUNY at Stony 8rook, NewYork S t u d y b a c k g o u n d : A l k a l i i n g e s t i o n sc a u s c p r o g r e s s i v ea n d d e v a s tating injury to the esophagus via liquifaction narosis. However, therapeutic efficacy ofwater or milk dilution for alkali-induced 'I'his esophageal injury has not been determined. study uscd our previously reported controlled model of alkali-induced esophageal injury to evaluate the effectiveness of water and milk dilution. Hypothesis: E,arly dilution with water or milk is efficacious in d e c r e a s i n ge s o p h a g e a ld a m a g e f r o m a l k a [ e x p o s u r e . 'fhe Methods: e s o p h a g u sw a s h a r v c s t e d f r o r r r S p r a g u e - D a w l e y r a t s ( 7 5 ) , a n d c a c h e 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 e t c r . Specimenswere maintained in an oxygcn-perfused saline bath (37 C) during a 60-minute experimental period and then fixcd immcdiatcly i n l 0 7 o f o r m a l i n s o l u t i o n f o r h i s t o l o g i r :c x a m i n a t i o n . S i x e x p c r i n x : n t a l g r o u p s ( t c n e a c h ) w e r e p e r f u s c d w i L h l ) \ o / aN a O I I s o l u l i o n a t L i n r cz e r o . ' l ' r c a t m e n t w i t h w a t c r o r m i l k d i l u t i o r r w a s p c r f o r r n c d i n m e d i a t e l y a t z e r o m i n u t e s , f i v c n r i n u t e sa f t e r i n j u r y , a n d l j O n r i n u t e s a f t e r i n j u r y . B l i n d e d p a t h o l o g i < :c x a m i n a t i o n w a s p < : r f o r r r r c d u s i n g a s c o r e o f 0 ( n o i n j u r y ) , I ( m i n i m a l ) , 2 ( n r o d e r a t e ) ,o r 3 ( s c v c n : ) for six hoetolgic categories: epithelial viability (IiV), cornified epithelial cell differentiation (C E), gra nula r cell differen tia tion (GC), epithelial cell nuclei (EN), muscle cclls (MC), and musclc cell nuclei (MN) (Table). Porcsdags ol Esophageal IniurySatod 2 or More WAISI EV CE GC EN MC MII MiIK EV CE GC EN MC 0 N4rn40 50 ?0 10 10 40 0 Min 20 1 0 0 1 0 r 5 t\4rn 60 100 100 90 50 70 5 Min i0 i0 80 60 50 30Min 90 100 100 100 80 100 30ivin 90 1 0 0 1 0 0 r 0 0 r 0 0
ttttltl
Z J Do OverdosePatientsLie AboutWhat DrugsTheyTook? of Emergency M Yaron, S Lowenstein, J Koziol-McLain, M Weissberg/Section Denver University of Colorado Health Sciences Center, Medicine andTrauma, Srudyhypothesis:Overdosepatientsgiveinaccuratehistories about the drugs they ingest. Design: Prospective. Settirrg: Urban universiLy emergcncy department, l y p e o f p a r r i c i p a n t s : C o n v e n i e n c cs a m p l e o f 7 0 n o n c o m a t o s e o v e r d o s cp a t i e n t s . I n t e r v c n t i o n s : A n i n t e r v i e w e r b l i n d e d t o d r u g s c r e . e nr e s u - l t e asked each patient if they had ingr:stcd alcohol (ETOH), salicylate ( A S A ) , a c e t a m i n o p h e n( A C E T ) , a n t i d e p r e s s a n t ( T C A ) , s e d a t i v e "stret drugs" (STREET; amphetamine, hypnotic (SED), or cocaine, or opiate). A urine drug screen was obtained in all pa trents. Ilesults' Most patients were female (737o), white (7AVo), and young (mcan, 25.4 years; SD, 8.2 years). Most (80%) were fully cooperative, but 20Va were judged reluctant or difficult historianel 7J7o were alert, whereas 2'lVo were somnolent. Many had histories of depression (l6Vo) or alcoholism (187o), and.37Vahad previous 'liwenty-seven percent were actively suicidal at the time ovcrdoses. of the intcrview. Drug assayswere positive in 9l9b for drugs 'fhe (cxcluding nicotine arrd caffeine). response (yes or no) to each drug question was compared with the urine screen (positive or negative), and the sensitivity and ncgativc-predictive value (NPV) were calculated(Table).
MN 0 r 0 60 1)0
P o s i t i v e a n d r r e g a t i v ec o n t r o l g r o u p s s h o w e d c x p c c t c d o u t o o l n c s . A X2 analysis demonstrated significant diffcrcnces between troal.'frend ment groups. analysis showed a significant progression of injury for every category for both water and milk dilution. 'l'he injury scores for the milk-treated group at zero minutes werc lcss t h a n o r e q u a l t o t h e i n j u r y s c o r e sf o r t h e w a t e r - L r e a l . c dg r o u p a t zero minutes for all categories. However, these differenccs were nol. signficant. Conclusion: Early dilution therapy with watcr or milk rcduces a c u t e a l k a l i i n j u r y o f t h e e s o p h a g u sa n d s u p p o r t s u s e o f t h i s f o r m o f emergency treatment. P o s i t i v eT o x i c o l o g y S c r e e n i n gP r e d i c t s l m p r o v e d S u r v i v a li n *t2Q 3-.tat Severely Iniured Neurotrauma Patients D PM i l z m a nS , W J o l i n ,B B B o u l a n g e rM, D o m s k yA, B o d r i q u e zK, M i t c h e l l i G e o r g e t o wU n n i v e r s i tM y edicaC l e n t e rD , e p a r t m e notf E m e r g e n cM yedicine,
Washington, 0C;Departments ofCritical Care andTrauma, MIEMSS, Baltimore, Maryland Study
objective:
Toxicology
the assessment of trauma
screening is performed
patients
with
an altered
sensorium.
Glasgow Coma Score (GSC) is an accepted
reliable
reproducible
predictor.
assessment tool and outcome
routinely
ETOH % POSlhistory) 50 % POS{screen) 41 Sensilivily ol history 94 NPVof history 94
in
The
and
ASAS
ACET
TCA
SED
6 15 40 91
26 30 71 BB
16 14 60 93
23 23 31 79
The goal of Overall,
487o of the sample had positive
urine screns
SINEET o
20 ?l 83 for at least
one..serious''drug(ACET,ASA,orTCA);247oofthesepatients>
92
{
were undetected by history (eensitivity, 76Vo;NPY ,797o). There was no association between level of alertness, cooperation, or suicidal ideation and the accuracy of the history. Conclusion: The history is inaccurate in a high proportion of overdose patients, and harmful drugs are missed frequently' There is support for the teaching that overdose patients misstate their histories and that seleted laboratory screens aPPear lo be necessary.
Type of participants: One hundred thirty-sdven coneecutive patients with a diagnosis of AWS' Interventions: None' Results: Forty-five percent of patients had no underlying causes of seizures identified. Potential etiologies in addition to alcohol withdrawal (AW) were distributed as follows in the remaining 557o of patients (Table). Eiology
rt nnThe Ellectiveness Froma Consultations of MedicalToxicology Poison Inlormation &AV Regional University Hospital; SMSchneider, BSDean, EPKrenzelok/Montefi0re Pittsburgh Poison Center, Pennsylvania
Trauma tpilepst ClA lesions inlracmnial Nontraumatic 0thertoxic/metabolic
Study objective: Medical toxicologists (MD) provide consultatiort to regional poison information centers (PICs) and diretly to the treating physician. The impact of these consultations on treatment to toxic patients has not been etudied. Design: Retrospective review of all poison caseswith major outcomes (intensive care unit admission, coma, or hemodynamic instabfity) and unusual toxins, where MD conultation was offered to or requested by a treating physician. Consecutive cases for one year were analyzed. Setting: Records were used from a PIC that serves physicians p r a c t i c i n g i n h o s p i t a l si n c l u d i n g r u r a l , u r b a n , c o m m u n i t y , a n d u r t i v e r s i t y h o s p i t a l s . A l l o f t h e M D c o n s u l t a n t . sw c r c f r o r n a u n i v c r s i t y
76 16 6 A 3
Of 133 patients with availablc data,66 (49.6Eo) seized on either Sunday or Mondayo whereas 67 (5l.aTo) seized on the remaining five days of the wek (X2 = 28.88, P < .001). C o n c l u s i o n :A W S o c c u r r c d w i t h g r c a t e r f r e q u e n c y o n o r t h e d a y after closurc of liquor stores, supporting the theory that such s e i z u r e sa r e c a u s e d b y d e c r e a s e di n t a k e o f a l c o h o l . P o t e n t i a l c a u s e e of scizures in addition to AW were found in 557o of patients. Gl ilJl
Controlled-Release Formulations Have Less Potential lor
0pioidMedications Other AAu""Than 1*Z Memphis ofMedicine, College ofTennesse D Brookoffllniuersity S t u d y h y p o t h e s i s r C o n t r o l l e d - r c l e a s co p i o i d s , w i t h t h e i r l o n g t i m e t o o n s e t o f a c t i o n a n d I o w p t : a k l c v c l s , h a v c l t : s gp o t c n t i a l f o r a b u e e a n d i l . l c g a lr e s a l c t h a n t h e s h o r t - a c t i n g o p i o i d m c d i c a t i o n s t h a t a r e u s u a l [ y p r e s c r i b e d i n t h e e m c r g c r l c yd c p a r l . m c n t ' Sctting: llDs and prison unit of two urban hospitals and a free-
teaching hospital. Iype of participarrts: AII charts ort pal-itnl.s *'ith nrajor o u t c o m e / u n i q u et o x i n w e r e e x a m i n e d ; 9 3 h a d a r r r e d i c a lt o x i c o l o g y consultation offered/requested. Intervention: Specialists in poison (SPI) suggesta medical consultation once a major outcome was identified and documented. Follow-up with the health care providers assessedthe degree to which the advice was followed. Patient demographics, toxin ingest.ed, level of the consultation (SPI-MD/IID-MD), advice givetr, adherence to advice, patient outcome, and patient disposition wcrc nored. 12 was used for statistical analysis. Result: Medical consultation was refused in M.6o/a of cases if o f f e r e d b y a S P I a n d o n l y 5 . 5 V a o f c a s e si f t h e M D c o n s u l t a n Ls p o k < : to the treating physician. There werc 93 cascs and l3ll medical consultations don+587o for treatment of toxin-relatcd problems,2So/o for antidoteso and,ZLVafor toxin e[nrinal.ion. ln 46ok of thc cascs,
s t a n d i n gd r u g t r e a t m c n t u n i t . 'lype o f p a r r i c i p a n t s : O n e h u n d r e d t h i r t y a d u l t P a t i e n t ew h o reportcd self-injecting, buying, or selling narcotics illegally within lhc past six months. Dcsign:Participants wcrc survcyed about thc use and streetPrice o f t : o n r m o n l yp r c s c r i b e d o p i o i d d r u g s , n o n s c h e d u l e d p r e s c r i p t i o n d r u g s u s e d i n a s s o c i a t i o nw i t h n a r < : o [ i t : sa, n d a l i s t o f p r e s c r i p t i o n d r u g s t . h a th a v c n o k n o w n a s s o c i a t . i o nw i t h n a r c o t i c s a b u s c . R c s u l t s : A I I r < : s p o n d e n t sw c r c f a n r i l i a r w i t h c o m m o n l y p r e s c r i b e d o p i a t c s a n d a s s o c i a t e dd r u g s a n d l r a v c s L r c c l p r i c c s [ h a t w e r e c o n s l s tcnt with valucspreviously reportcd in thc litcrature. Eighty-five porcent werc r:ither familiar with or had used slow-released morp h i n e p r c p a r a t i o n s a n d r e p o r t e d t . h a tt h c s e h a d a l o w e r s t r e e t P r i c e t h a n a d j u n c t d r u g ( e g ' D i l a u d i d 5 m g a v e r a g e d$ 4 7 ; P e r c o c e t , $ 1 5 ; clonidinc 0.2 mg, $8; and MS-Contin 30 mg, $3 when prices were g i v c n ) . S i x t y p e r c c n t r c p o r t c d t h a I s l o w - r e l e a s e dm o r p h i n e p r e p a 'Ihc control drugs were not reported to ralions had no strcet value.
there was a recommendation to change the current therapy. This was followed fully in ABVoand partially in 8o/oof the cases. Thcre was a greater likelihood to follow medical consultation advice (63.04a vs 42.57o) if the contact was MD-MD rather than SPI-MD. Conclusion: PICs and their MD are purveyors ofinformationt which is not mandated but available at the discretionary use of those physicians who use the PIC. Medical consultatron was morc likely to occur and the advice followed il contact occurred MD-Ml). The medical toxicology physician musI assume a more proaclivc role in consultations within a PIC.
have any street value. C o n c l u s i o n , S l o w - r e l c a s em o r p h i n e p r c p a r a t i o n s h a v e s u b s t a n r i a l l y l e s ss t r c e t v a l u c t h a r r o t h e r c o m m o n l y p r e s c r i b e d o p i o i d m e d i cations. In situationswherc thcrt: is conccrn about potential abuse o r i l l c g a l d i v c r s i o n o f p r c s c r i b c d o p i o i d s , c m e r g e n c yp h y s i c i a n s s h o u l d c o n s i d c r p r c s c r i b i n g s l o w - r e l c a s c dp r c p a r a t i o n s . !
ofAlcohol Seizures andTheir Witttdrawal Xn i{ Etiology olAlcohol 4t | 0ccunence in Relation to Decreased Availability NKBathlev, TShieh,M CityHospital Callum/Boston Study objectives: To determine thc frcqucncy *'ith which paticnts with alcohol withdrawal seizures (AWS) have potential underlying causesof seizures and to test the hypothesis that AWS occur with greater frequency on or immediately after Sundays, when liquor stores are closed in Massachusetts. Design: Retrospective chart review during a five-month period. Setring: Inner-city, university-based teaching hospital.
93
ANNUAL BUSINESSMEETING AGENDA l. Elections, Louis Ling, MD, Chairman, Nominating Committee The slate of nomineesis listed below and biographicalinformation President-Elect - (one l-year position) Louis Binder, MD
on each candidateis publishedon pages97-99.
Research Committee Chairman-Elect _ position) Michelle Biros, MD Ed Panacek,MD
Board of Directors - (two 2-year positions) Bob Jorden, MD Gabe Kelen, MD Marcus Martin, MD John Marx, MD Gary Strange, MD Program Committee Chairman-Elect - (one 3-year position) Art Kellermann,MD Art Sanders,MD Education Committee Chairman-Elect _ (one 3_year position) Bill Burdick, MD Hal Thomas,MD
one 3_year
NominatingCommitteeMember- (one2_yearposition) Phil Henneman, MD SalVicario,MD
Constitution and Bylaws Committee Member _ (one 3-year position) Bob McNamara, MD Brian Zink, MD
2' Amendments to the constitution and Bylaws, Marcus Martin, MD, Chairman, constitution and Bylaws committee Amendment I would alter the processfor approval of membership applicationsand is locatedon page 101 in the Bylaws under Article I - Membership' Amendment 2 *ouid ult". the process 16r approval of membershipapplicatons and is iocatedon page 104 in the Bylaws under Article vI - Standingcommiitees. Amend-ment3 wourd alteithe languageof one of the objectives and is locatedon page 100 in the constitution-underArticte II objectives. 3. Awards Presentations, JamesNiemann, MD and Bilt Barsan, MD 4. Secretary-Treasurer's Report, Bitt Spivey,MD, Secretary_Treasurer A. Membershipat April 28, 1992:2,146 A c t i v e M e m b e r s :1 , 1 3 2 A s s o c i a t eM e m b e r s : 2 l l R e s i d e nM t embers:5g2 InternationalMembers: 70 Emeritus Members: 15 Honorary Members: ll B. FinanceReport - year Ending December31, lggl
M e d i c a lS t u d e n t sg: 9 pendins: 36
Revenues Expenses Dues. ...$271,125 Salaries,wages,Taxes. ...$139,507 A n n u a lM e e t i n g .$106,371 A n n u a lM e e r i n g . . . .$103,021 PhysioControlFe|lowship..'.$62,500GeriatricGrant'' E M F c o n t r i b u r i o n.s .....$ll;469 Telephone and posrage $$,547 Inreresr ....925,g69 OtheiRdministration. $ 40,6j3* G e r i a t r i cG r a n t . . .$4s,r54 AAMC .$13,906** S a l eo f M a i l i n g L i s t
andnewsrett6r ads
.$16,200
ft:;t[,:Jt;:tfl::.1:" . . . .sli;3?i
other' . ..$9,241 EMRA newsletter andJobcararog.....$20,091 Edinburgh Symposium . '.$to,orl C o n s u l t i nSge r v i c e ......$47,330 TorAL -;ffiY:il.tj::il:f""t'
EMFContrlbutions. ..$12,300 physiocontrorFellowship ..$62,500 otherorganizations/meerings..... ..$21,612*** C o n s u l t i nSge r v i c e ...$36,624
..$62s,96r TorAL .....$s63,776 photocopving, printing'officerentandinsurance, accounting, bankcharges, presidenr,s discretionary
x*includes councilof Academicsocieties dues,AAMC representative -: expenses, staffexpenses to attendAAMC AnnualMeeting, and SAEM sponsored posterar rhe AAMC AnnualVl"ti"j. *x*includesEMRA' ACEP ScientificAssembly,AMA, AAMI, AACEM, coRD, longrangeplanning session, andcommittee expenses. 5. President'sAddress:Bill Barsan,MD 6. Introduction of New president:Louis Ling, MD 7. New Business 8. Adjournment 94
LEADERSHIP AWARD
HAL JAYNE ACADEMIC EXCELLENCE AWARD
This year'srecipientof the SAEM LeadershipAward, RichardC. k,ry, MD, MPH has a long and distinguished history of contributionsto the developmentof academicemergencymedicine.After receivinghis MD from the University of Louisville and an MPH from Harvard University in 1973, Dr. Levy came to the University of Cincinnati and joined a newly established residency p r o g r a m i n l 9 1 4 . I n l 9 l l , Dr. Levy RichardC. Levy,MD took over as director of the Division of EmergencyMedicineat the University of Cincinnati. Under his directionover the lastfifteenyears,the Division hasevolved into the Departmentof EmergencyMedicine and has gone from a two-yearresidencywith twelve residentsto a four-year residency with thirty-two residents. In addition to spearheadingthe academicdevelopmentof emergencymedicineon his home court, Dr. Levy hasbeenactive nationallyin promotingemergencymedicine.Dr. Levy was one of the early membersand reviewers for the LREC, the predecessor for the modern day RRC. Currently, he servesas a site sur.veyorfor the RRC. He has a long and distinguished history of serviceto UAEM and SAEM. Dr. Levy servedas a memberof the executivecouncil for UAEM for eight years includingservingas presidentof UAEM in 1984-85.Dr. Levy was also one of the founding membersfor the Associationof AcademicChairmenof EmergencyMedicineand servedas the presidentlast year. Dr. Levy also has a long involvementwith AAMC and has servedas a delegateto AAMC on the CAS for the pastfive years. Dr. Levy has also beenactive with ABEM and has served as an examiner for the past nine years. In additionto providing leadershipin all ofthese professional organizations,Dr. Levy hasprovided leadershipin his academic worksas well. He hasservedasthe associate editor for theJournal of EmergencyMedicine sinceits founding in 1983and has actedas an editorial consultantfor a number of other distinguishedmedicaljournals. He hasbeenan authoron over thirty articlesas well as serving as editor on two medical texts. Probably more important than this impressive catalog of achievements which can be recordedon paperis the leadership and vision which Dr. Levy has provided to the field of emergencymedicine.He was one of the first leadersin emergency medicineto recognizethe importanceof researchto academic developmentin our new field. While presidentof UAEM, Dr. Levy stressedacademicexcellenceand tried to find ways to improve emergencymedicine'svisibility in the nationalresearch arena.Dr. Levy brought membersfrom NIH to UAEM in an effort to establishour presencewith that institution.Even more importantly,Dr. Levy has inspiredand directedcountlesspast residentsand members of UAEM, STEM, and SAEM to developsuccessfulacademiccareers.Each year, about halfof the graduating residents from his residency program enter careersin academicemergencymedicine. SAEM is proud to bestowthis year's leadershipaward upon RichardC. Levy, MD, MPH, for his outstandingcontributions to academicemergencymedicine. His leadershipand vision serveas models for all of us in our developingspecialty. William Barsan, MD University of Cincinnati
Dr. Kelen graduatedfrom the University of Toronto Medical Schoolin 1979. After a rotating internshipat St. Michael's Hospitalin Toronto, he did two years of an Internal Medicine Residency, then entered the Emergency Medicine ResidencyProgram at Johns Hopkins University. Upon completionof his residencyin 1984, he joined the EmergencyMedicine faculty at JohnsHopkins Hospital where Gabor D. Kelen, MD he hasservedfor the pasteight years. Dr. Kelen's researchhas had profound influenceon the practiceof emergencymedicine,and the practiceof medicine.He hascontributeduniquedatato our understandingof ttre epidemiologyof AIDS. His work on healthcare worker safetywas instrumentalin convincingpractitionersof the importanceof infectioncontrol precautions,particularlyUniversal hecautions. Dr. Kelen's studiesproved the needfor UniversalPrecautions,advancedearlier by the Centersfor DiseaseConffol. More recentlyhis work has encompassed more detaileddata regarding emergencyhealth servicesutilization in patientswith AIDS. Dr. Kelen'scontributions encompass the teachingof clinical emergencymedicine,as well as researchtechniques.Dr. Kelen has lectured in the emergencymedicine course for first-year medicalstudentsat JohnsHopkinssince 1984.He lecturesin the first year ethicscourse,and is involvedin the clinical teaching of second-yearstudents,the clinical and didactic teaching of third-yearstudentsand the fourth-yearemergencymedicine elective. He designeda nine-weekprogram that teachesthe fundamentalsof researchincluding researchdesign,database programs,computerdataanalysisand datadisplay.Dr. Kelen developeda curriculato teachresearchthrougha post-graduate researchfellowship program. Implementedin 1986, this researchfellowshipis now considereda model in emergencymedicine and has consistentlyreceived funding from EMF. Dr. Kelen restructuredthe EmergencyMedicine Residency Program and developeda five-year program. The fourth year is a researchyear and the fifth year is the AssistantChief of Service.More recently,Dr. Kelen has assumedthe Acting Director position for the Departmentof EmergencyMedicine at Johns Hopkins Hospital, and is negotiatingto make Emergency Medicine a full departmentat the medical school. Dr. Kelen is on the editorial board of the AmericanJournal of EmergencyMedicine and a consulting reviewer for JAMA andAnnals of Internal Medicine. CDC researchersrecognized Dr. Kelen'suniqueexpertiseand consultedhim on the design of a multicenter study for which they issuedan RFP. Dr. Kelen's enthusiasmhasinspiredmany young physicians to pursueacademiccareers.Possessingunquestionedintegrity, tirelessdedication,andacademicbrilliance,Dr. Kelenserves as a role model for future leaders. Through his research, teaching,administrativeand clinicalcareresponsibilities, he has significantly contributedto the respectability,statureand acceptanceof emergencymedicine in academia.It is for these accomplishments that Dr. Kelen is extraordinarilydeservingof the Hal JayneAcademicExcellenceAward. His receiptof this award with his American and Canadiancolleasuesin attendance is truly befitting this most oursrandingindiriidual. Charles Brown, MD Ohio State University
95
.
AWARD PRESENTATIONS
The Academic Leadershipand the Hal Jayne Academic ExcellenceAwards will be presentedduring the Annual Business Meeting on May 28. The following awards will also be awardedduring the Annual BusinessMeeting: 1992 Physio Control EMS Fellowship Ted Delbridge, MD Institution: University of Pittsburgh This $50,000 fellowship is sponsoredby Physio Control.
1991 ANNUAL MEETING
Best Oral Methodology Presentation "Patients Who kave the EmergencyDepartmentWithout Medical Evaluation:Severityof Illnessand Need for Acute Care," Carl Stevens,MD, Harbor-UCLA
Emeritus Membership Christine E. Haycock, MD GeorgeJohnson,Jr., MD
Best Innovations in Medical Education Presentation ''lmplementation of a ResearchDesignand StatisticsCurriculum for EmergencyMedicine," JamesJ. Menegazzi,PhD, University of Pittsburgh
Ohio/Midwestern Regional Emergency Medicine Research Symposium Best Paper Award ' 'Effect of Aggressive Resuscitationon Coagulationin Uncontrolled HemorrhagicShockin Swine," ThomasBlackwell, MD, University of Cincinnati
Best Oral Resident/Fellow Presentation "Role of Magnesiumas a Calcium Antagonistin RabbitBronchial SmoothMuscle," Emil Skobeloff,MD, Medical College of Pennsylvania
1992 SAEM/EMF Innovations in Medical Education Awards "A Comparison of Clinical and EducationalExperiencesof EmergencyMedicine Residentson Rotationin Three Major Specialties," A. Roy Magnusson,MD, Oregon Health Sciences University "Implementation of a ResearchDesignand StatisticsCurriculum for EmergencyMedicine," JamesJ. Menegazzi, PhD, University of Pittsburgh "Development of Family ResponseScenariosto Teach Residentsthe Processof DeathTelling, " RobertJ. Schwartz,MD, MPH, Hartford Hospital "Evaluation and Enhancementof InterpersonalSkills of Emergency Physicians," StevenRosenzweig,MD, ThomasJefferson University "Decision Analysisin EmergencyMedicine," Bern Shen,MD, University of Pittsburgh
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Best Resident Poster "Clinical Presentationand Treatmentof Black Widow Spider I I Envenomations: A Reviewof 163Cases," RichardClark, MD, , I Good SamaritanRegional Medical Center
{ Best Pediatric Acute Care and Trauma Presentation "Strategies for Diagnosis and Treatmentof Febrile Infants: Clinical and Cost-Effectiveness,"Tracy Lieu, MD, Children's Hospital of Boston Best Medical Student Presentation "Effect of IV Glucoseon Survival and Neurologic Outcome After CardiacArrest," MelissaNielsen, University of Cincinnati
1992 SAEM/EMF Medical Student Awards Applicant: Mark Banks Preceptor: JamesE. Olson, PhD Institution: Wright State University School of Medicine "Blood-Brain Project: Barrier Permeability During the Developmentof Brain Edema"
Selected to be Presented At the AAMC Annual Meeting "Academic Emergency Medicine in US Medical Schools," Alexander Trott, MD, University of Cincinnati "Factors InfluencingCareerChoicesin AcademicEmergency Medicine," Arthur Sanders,MD, University of Arizona
Applicant: Edward A. Bartkus Preceptors:Eustacia(Jo) Su, MD and Jerris R. Hedges,MD Institution: Oregon Health SciencesUniversity "Liver Function Project: Test in the Diagnosisof Biliary Colic" Applicant: Preceptor: Institution: Project:
AWARDS
Best Oral Basic Science Presentation "Phospholipid Deterioration and Free Fatty Acid Releasein CerebralCortex Following CardiacArrest and Resuscitation," Robert Rosenthal,MD, George WashingtonUniversity
Pedro Guevara SusanS. Fish, PharmD, MPH EmergencyDepartmentat Boston City Hospital "Health and SociodemographicFactors that Influence the Use of the Emergency Department at Boston City Hospital by the Hispanic Patient"
Best Oral Clinical Science Presentation "Increased Rural Motor Vehicle CrashMortality: Role of Crash Severityand Medical Resources,"RonaldMaio, DO, University of Michigan
Applicant: Alan Manheimer, BA Preceptor: SandraSchneider,MD Institution: Center for Emergency Medicine of Western Pennsylvania "A Project: Comparisonof the Bioavailabilitiesof Oral Ethanol and intravenousEthanol"
Best Scientific Poster "Milwaukee Prehospital ChestPain Project - PhaseI: Feasibility and Accuracy of PrehospitalThrombolytic Candidate Selection," Thomas Aufderheide, MD, Medical Colleee of Wisconsin
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SLATE OF NOMINEES PRESIDENT-ELECT
University. He graduatedfrom the University of Toronto in l9l9. He completedhis residencyin EmergencyMedicine at t h e J o h n sH o p k i n sU n i v e r s i t y .
Louis Bindero MD, graduated from the University of Minnesota Medical School in 1980 and completed an EmergencyMedicine residency in 1983from Truman Medical Center,KansasCity. Dr. Binderhas beena memberof SAEM since1982 and since 1990hasbeena memberof the Board of Directors. He is the Chairmanof the UndergraduateEducationConsultingService,and served as Chairman of the Constitution and Louis Binder. MD BylawsCommittee(1990-91),Chairman of the Undergraduate Curriculum Committee(1988-1990) which developedthe "Model Curriculum in EmergencyMedicine for Undergraduatesand RotatingResidents," and was a member of the NominatingCommittee.Dr. Binder was a moderatorat the 1989and l99l AnnualMeetings.Since1987he hasalsobeen an Oral Examiner for ABEM and a reviewer for Annals and AJEM. Dr. Binder is an AssociateProfessorin the Department of EmergencyMedicine and AssistantDean for Medical Education at Texas Tech University Health SciencesCenter.
Marcus L. Martin, MD, is an associate professor of Emergency Medicine, Vice Chairman of the Emergency Departmentand Residency Program Director at the Medical College of Pennsylvania, AlleghenyCampus(AlleghenyGeneral Hospital).Dr. Martin hasbeen a memberof SAEM since1984.He is the Chairmanof the Constitution and Bylaws Committee,servesas a Marcus Martin. MD consultantwith the ResidencyConsultationCommittee,and is a member of the CORD Executive Committee. Dr. Martin was the winner of the 1984STEM Silver TongueOrator Award, and participatedin the 1988STEM Debate.He hasbeena reviewer/ consultantfor Annals since 1985and is an Oral Examinerfor ABEM. Dr. Martin graduatedin 1976 from EasternVirginia Medical School, worked with the Public Health and Indian HealthServicesfor two yearsand completedresidencytraining in EmergencyMedicineat the Universityof Cincinnatiin 1981. John A. Marx, MD, is Chairman, Departmentof EmergencyMedicine at CarolinasMedicalCenter.He attendedStanfordMedical Schooland trained in the Denver Affiliated Residencyin EmergencyMedicine from 1978to 1980. Dr. Marx has beena memberof SAEM since1982 and has been a moderator at the 1988-1992 Annual Meetings. He servedon the ACEP ResearchComI mittee. He is an associateeditor of John Marx. MD Rosen, EmergencyMedicine: Conceptsin Clinical Practiceand is the SectionEditor for Original Contributionsfor the Journal of EmergencyMedicine. He cofounded CaseStudiesin EmergencyMedicine andEmergindex. He has been a guest editorial reviewer for JAMA and AJEM. Dr. Marx was the 1991recipientof the Hal JayneAcademic ExcellenceAward. Gary R. Strange, MD, is an Associate Professor and Director of EmergencyMedicineat the University of Illinois, Chicago.He graduated from the University of Kentucky in 1914 and completed his Emergency Medicine residencyat the University of SouthernCalifornia in 1979. Dr. Strangehas beena memberof SAEM since1982and is currently the Chairmanof the EduGary R. Strange,MD cation Committee,a memberof the Program Committeeand a member of the Task Force on EmergencyMedicine in TraditionalAcademicMedicalCenters.In 1984, 1987,and 1988Dr. Strange was also a representativeto the AAMC-CAS. He is a member of the Editorial Board of Pediatric Emergency Care and Annals. He is also a guestEditor for pediatricsfor AJEM and an Examiner for ABEM.
BOARD OF DIRECTORS Robert C. Jorden, MD, is Chairman, Deparfrnentof EmergencyMedicine at MaricopaMedical Centerand a Clinical Professorin the Sectionof EmergencyMedicine at the University of Arizona Schoolof Medicine. He is a memberof the ResidencyAid Committee, a member of the Residency ConsultingServiceand servedon the Task Force on Revisionsof the Core Content (1989-90). He has coordinated the National CPC CompetiBob Jorden. MD tions for the past two vears. He was a memberof the STEM Program PlanningCommittee(1983-85) and a memberof the UAEM Constitutionand Bylaws Committee (1983-84).Dr. Jordenhasbeena memberof SAEM since1982. He is a reviewer for JEM and an AssistantSectionEditor of CaseConferencefor Annals. Dr. Jordengraduatedfrom Ohio StateUniversityin 1973,did threeyearsof a surgicalresidency (1973-16)at New York University, and completedan Emergency Medicine residencyin 1980 from Denver General. Gabor D. Kelen, MD, is a former presidentof STEM and served on rhe STEM/UAEM amalgamation task force. He also served on the SAEM Board of Directors from 1988-89. He moderated several STEM/UAEM paneldiscussions and was among the featuredpresenters in the SAEM State-of-the-ArtSession in 1989. Dr. Kelen has beena memberof SAEM since 1984and is the chair of the AIDS Task Force. Gabor Kelen. MD He is on the Editorial Board of the American Journalof EmergencyMedicine and is a consulting reviewer for Annals of Emergency Medicine. Dr. Kelen is an associateprofessorof EmergencyMedicine at JohnsHopkins
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PROGRAM COMMITTEE CHAIRMAN-ELECT Arthur L. Kellermann. MD. MPH, graduatedfrom Emory University Schoolof Medicinein 1980, completedhis residencyin 1983,and completed his masters of public health in 1985 at the University of Washington followed by a General Internal Medicine Fellowship (1983-85)at the Universityof Washington. He has been a member of SAEM since 1987and is currentlya Arthur Kellerman,MD member of the Program Committee (1990-92), Nominating Commirtee (19D1-92)and Public Health Commitrffi (l990iE2). Dr. Kellermann was the recipient of the JamesMackenzieAward at the 19g7 Annual Meeting. He is a reviewer for NEJM, Annals, AJEM andJAMA. He is an Associateprofessorin the Departmentof InternalMedicineand Chief, Division of EmergencyMedicine, at the University of Tennesseeand the Regional Center at Memphis.
Hal Thomas, MD, has been a member of SAEM since 1988 and since 1991has beena memberof the Educational Meetings Subcommittee, since 1988 a member of the Education Committee, and since 1989 the Chairman of the Innovations in Medical EducationSubcommittee. Dr. Thomas is an Examiner for ABEM and the AssociateEditor of Emergindex. After graduating from the University of Miami School Hal Thomas. MD of Medicine in 1976, Dr. Thomas completedan Internal Medicine residencyat Denver General Hospital in 1980 and an EmergencyMedicine Fellowship at Ohio StateUniversityin 1989.Dr. Thomasis an AssistantFro_ fessorin the Departmentof EmergencyMedicine at Bowman Gray School of Medicine.
RESEARCHCOMMITTEE CIIAIRMAN-ELECT Michelle Biros, MS, MD, has beena memberof SAEM since 1982 and a memberof the ResearchCommittee since 1989. She is Chair of the Research Subcommittee to develop the ResearchProgram at the 1992Annual Meeting.Dr. Biroshas been an abstract reviewer 1987-90 and was a moderator at the 1988, 1990 and 1991 Annual Meetinss. She was the recipient of the Bist Basic SciencePaperAward in 1985 Michelle Biros. and the Best Oral Basic SciencepresentationAward in 1990and is a reviewer for Annals. Dr. Biros graduatedfrom the University of Minnesota inl9g2, completed an EmergencyMedicine residencyfrom the UniversityoiCin_ cinnati in 1986and completeda ResearchFellowshipirom the Universityof Cincinnatiin 1985.Sheis a SeniorAssociatephy_ sician in the Departmentof EmergencyMedicine at Hennepin County Medical Center.
Arthur B. Sanders. MD. is a Professorof EmergencyMedicine at the University of Arizona Health SciencesCenter. Since 1990, Dr. Sandershas been the Chairman of the Geriatric EmergencyMedicine Task Force, Chairmanof the Resident SurveyTask Force and a member of the Ethics Committee. Since l99l he has been a member of the Publications Task Force and the Arthur B. Sanders.MD Task Forceon EmergencyMedicine in Traditional Academic Medical Centers.Dr. Sandershas servedas presidentofSAEM (19g9_ 90), a member of the program Committee (19g5-gg), and a Boardof Directorsmember(1986-91).He servedon the STEM Board (1986-88)and rhe UAEM Board (1986-g9)and chaired the STEM UndergraduateCurriculum promotion Committee (1983-85).He is a reviewer for Annals, AJEM, andJAMA and hasbeena member of SAEM since 1980. After graduationfrom Cornell Medical Schoolin 19j3, Dr. Sanderscompletedan In_ ternalMedicineResidencyin 1916at the Universityof Arizona Health SciencesCenter
Edward A. Panacek, MD. in May will assumethe positionof AssistantProfessorof Medicine, Division of Emergency Medicine and Medical Toxicology, and Director of the Emergency Medicine Residency Program at the University of California, Davis. Dr. Panacekwas an AssistantProfessorof Medicine at Case Western Reserve Universitv and Research Director and Actins Director of the Departmentof Emerl Edward Panacek. MD gency Medicine at the University Hospitalsof Cleveland.Dr. panacekhasbeena memberof the ResearchCommitteesince 1990 is Chairmanof the Research Subcommitteeon Multicenter Clinical Trials. He has been a memberof SAEM since1986.Dr. panacekgraduatedfrom the University of SouthAlabamamedicalschoolin l9gl, completed an Internal Medicine residencyin 1984and an EmergencyMed_ icine and Medical Toxicology Fellowship in 19g6, botlhfrom the University of California, Davis.
EDUCATIONCOMMITTF,ECHAIRMAN-ELECT William P. Burdick. MD. is an Associate Professorof Emergency Medicine at the Medical Colleeeof PennsylvaniaS . ince 1986 Dr. Burdick has been a member of the EducationCommittee,since 1989a member of the Undergraduate Education Consulting Service, and since 1990Chairmanof the Annual Meeting Subcommittee of the Education Committee. He is the William Burdick, MD AssociateEditor of the Yearbook of EmergencyMedicine. Dr. Burdick graduatedfrom Cornell University in l9j9 and completedan Internal Medicine residencyat Boston City Hospital in 19g2.
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NOMINATING COMMITTEE MEMbER Philip L. Henneman, MD, is an AssistantProfessorof Medicine at UCLA. Dr. Hennemanhas been a moderator at the Annual Meetinss since 1988 and receivedthe 1988 Best Oral MethodologyAward. Dr. Hennemanhas been a member of SAEM since 1986. He is a member of the ResearchCommittee and was s rmember rrrrrru!r a u r the of r r r s Membership lvltrllluglsillp aIl(l and 4t ;\ public EducarionCommitee ffi./\ lteSO_ 91). He hasalso servedas Chairman PhilipHenneman, MD of the Task Force on Subspecializationin EmergencyMedicine(1990-91).Dr. Hennemanis a con_ sultantforAnnals andJEMS andis also an examinerfor ABEM. In 1980he graduatedfrom Harvard Medical School,completed anInternalMedicineResidencyin 1982at Mount Auburn Hos_ pitalin Cambridge,and in 1984compleredhis EmergencyMed_ icineResidencyat Denver GeneralHospital. Sal Vicario, MD, has been a member of SAEM since 1980, is a reviewer for AJEM, and is a consulting Editor for Emergindex. Dr. Vicario graduatedfrom Mount Sinai School of Medicine in 1976, completed an Internal Medicine Residency in 1978from SUNY at Stony Brook and an EmergencyMedicin! Residencyin 1980from the University of Louisville.
CONSTITUTION AI\rI) BYLAWS COMMITTEE MEMBER Robert McNamara, MD, is an AssistantProfessor in the Department of Emergency Medicine and AssociateResidencyDirector at the Medical College of Pennsylvania. Dr. McNamara graduatedfrom JeffersonMedical Collegein 1982and completedan EmergencyMedicine residencyat the Medical Collegeof Pennsylvania in 1985.Sincel9i0 he has beena memberof the Geriatric Emergency Medicine Task Force, Robert McNamara. MD 1989a memberof the ResidencyAid Committee,and is currentlya memberof the ResidentInservice Survey Task Force. He servedas a moderatorat the l9g9 An_ nual Meeting and has been a memberof SAEM since 19g2.
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Brian J. Zink, MD
Sal Vicario, MD
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Brian J. Zink, MD. is an Assistant Professor of Emergency Medicine and ResearchDirector at Albany Medical Center. Dr. Zink hasbeena memberof SAEM since 1986 and is a memberof the ResearchCommittee.He will also be coordinatingthe ResearchConsulting Service. Dr. Zink graduated from the University of Rochester medicalschoolin 1984and in 1988 completedan EmergencyMedicine residencyat the Universityof Cincinnati.
CONSTITUTION OF THE SOCIETY FOR ACADBMIC EMERGENCY MEDICINE ARTICLE I - NAME The name of this organizationshall be, ,,The Societyfor AcademicEmergencyMedicine," hereinafterref-erredto as, "The " Association.
ARTICLE II _ OBJECTIVES Section1: The objectiveof this Associationis to improvethe emergency,urgent,or criticalcareof the acutelyill or injured patientby promoting,research, by educatinghealthcare pro_ fessionals andthe public,by fosteiingrelatioishipswith organ_ izationswith a similarpurpose,and by supportingthe spelial_ ized o.rmultidisciplinecare of suchpitienis thro"ughre.search andeducation.The Associationwill functionas a scientifrcand educational organization as definedin Section501(c)(3) ofthe InternalRevenueCode, as amended. Seclion2: The Associationshall pursueits purposeby: l) sponsoringfbrun.rsfor the presentationof peer-reviiwedscientific andeducationalinvestigations,2)sponioringand convening educatio-nal programsfor healthcare professio-nals and the la! public, 3) promotingacademicdevelopmentand education of rtsmembership through.specialized programs,4) servingas lz an.academic capacity to further developand proiote t'hemosi ap_ propiate meesuresfo1 careof the acutelyill or injured pa_ the tient, 5) developingIiaison with other organization.s with a slmllarpurpose,and6) publishingresearch andeducational data in thescientificandeducational literatureandothermediaavail_ a b l et o t h c l a y p u b l i c . SetrionJ; A. This corporationis organizedexclusivcly fbr educational and scientific.purposes,irrctuaing,for such pur_ poses,thc makingof distributionsto organizations thatqrotify as exemptorganizations underSection501(c)(3) of the Inter_ nal RevenueCodeof 1954(or the corresponding provisionof any future United StatesInternalRevenueLaw). B. No part of the net earningsof the corporationshall inure to thebenefitof, or be distributable to its members,Directors, or_orherprivatepersons,exceptthat the corporation 9fl::rr shallbe authorizedand empoweredto p;y reasonable .o_p"nsationfbr serviccsrenderedand to makbpayments and distribu_ tronsin furtheranceof the purposesset forth in paragraph A No subsranrial parr of the activitiesof the corfioration l,.r::a snallbe thecarryingon of propaganda, or otherwiseattempting to influencelegislation,and the corporationshall not participate in, or intervenein (includingthe publishingor distribution of statements) any political.campaign on behalfof any candidate for publicoffice.Notwithstandin-g any otherprovisionof these articles,the corporationshallnoi.a..y on uny other activities not permittedto be carriedon (a) by u io.po.uiion exemptfrom FederalInconretax under Section501 G) (3) of the Internal Revenue Codeof 1954(or corresponding piovisionof any future UnitedStatesRevenueLaw) or (U;Uy i.orporation, contribu_ tionsto which are deductibleunder SecriontZO(.) (2) of the InternalRevenueCodeof 1954(or the correspondingpiovision of any future United StatesInternal RevenueLaw;.
ARTICLE III - MEMBERSHIP
Section 2: Qualifications. (l) Candidates for active membershipshall be (a) individualswith an advanceddegree (MD, PhD, DO, PharmD,DSc, or equivalent)who holda ried_ ical schoolor university faculty appointmentand who actively participatein acute,emergency,or critical care in an administratrve, teaching, or researchcapacity, or (b) individualswith similardegreesin activemilitary service(U.S. or abroad) who actively participatein acute,emergency,or critical carein an administrative,teaching,or researchcapacity.Individualswho otherwisemeetqualificationsfor activemembershipasdefined abovebut who do not hold a universityfacultyappointment may petitionthe Membershipcommitte" for conside.ation for active membershipstatus,if desired.(2) Candidates for associate membershipshallbe healthprofessionals, educators,government 0fficials,membersof lay or civic groups,or membJrsof thepublic at large who may have an interestor desire to participate in pursuing the purposesand objectivesof the Asiociation.(3) Candidates for emeritusmembershipshallbe (a) activemembers who seeksuch statusand who havegiven l5 continuous years of active service to the Associationand have attainedthe age of 65 yearsor (b) other active memberswho underspecial ci"r_ cumstancesare invited for such emeritus statusby ihe Mem_ bershipcommittee. (4) candidatesfor resident/fellowmembership must be resident(s)or fellows in residencytrainingpro_ gram(s)who havean interestin emergencymedlcine.(sliandidatesfor honorarymembershipshall be individualswhohave made outstandingresearchor educationalcontributionsto the purposeand objectivesof the Association.(6) Candidates for internationalmembershipshallbe individualswho reside outside the U.S. and who meet qualificationsfor activeor associate membershipas describedabove.Suchcandidates may applyfor active, associate,or other membershipin the Association. Section3: Member Rights and privileges. All membersmay have the privilege of the floor and of sJrving on the commit_ teesof the Association.All membersof the-Association may serve on the Board of Directors or as a committeeChairper_ son. Only active membersshall have voting riehtsand shall serveas officers of the Association. Section4: The Associationshallnot discriminate,with respect to its membership,on the basis of race, sex, creed, relision o r n a t i o n aol r i s i n .
ARTICLE IV - OFFICERS Section,/rThe officersof this organizationshallbe thepresi_ dent, Vice-President (president-Ele-t), and Secretary_Treasurer. Section2: Board,of Directors shall serve as the governing body of the Association.The Board of Directors shall consi$ of the above officers, the program CommitteeChairman, the immediatepastpresident,and five Councilmen_at_Laree. Both activeand associatemembersmay serveon the BoardoiDirrr_ tors, but only active membersmay be officers of the Associa_ tion. Section3: The ExecutiveCommitteeshall consistof the presi_ dent, President-Elect,past-presidentand Secretary_-freasurer.
ARTICLE V - COMMITTEES
Sec.tionl: Classffications.There shall be seven classesof membership: active,associate, emeritus,resident/fellow, hon_ orary, and internationalactiveand international associate.
The standingcommitteesof the Associationshallbe: (l) Nom_ . inating Committee,(2) MembershipCommittee, (3) program
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Section 4; Adoption of a bylaw amendment shall be by a majority vote of the active members present and voting at any annual or specialmeeting.
Committee, (4) Constitutionand Bylaws Committee, (5) Education Committee, (6) ResearchCommittee, (7) Liaison Committee to the Association of American Medical Colleges, (8) Governmental Affairs Committee, and (9) Committee on International Affairs. Additional committees may be created by the Board of Directors and ad hoc committeesmay be created by the Presidentto aid in the Association'sefforts to achieve and further its goals.
ARTICLE VIII _ ADOPTION OF THE AMENDMENTS TO THE CONSTITUTION Section 1; The constitution may be adopted or amendedat any annual or specialmeeting of the membership.
ARTICLE VI - ANNUAL MEETING
Section2.' Proposedamendmentsto the constitution shall be by threememsubmittedin writing to the Secretary/Treasurer bers at least60 days prior to the meetingat which they are to be considered.The Secretary/Treasurershall mail the proposed amendmentsto the membershipat least 30 days prior to that meeting.
Section1; There shall be an annualmeetingof the Association. This meetingshallconsistof an educationaland scientific program and a businesssession. Section2: The Board of Directors, by majority vote, may call, upon 30 daysnotice, a specialmeetingof the membership or standingcommitteeto conductany businessthat the Board of Directors shall place before the membershipor standing committee.
Section3; The Board of Directors may, by resolution,propose amendmentsto the constitution;providedthe proposedamendments are mailed to the membershipat least 30 days prior to the meeting at which they are to be considered.
Section3; The Board of Directors may call and conduct any specialmeetingby mail. For purposesof notice, the meeting date shall be a date set for the return of mail ballots and it shall be calledthe voting date. Adoption ofany proposal,resolution or amendmentby mail ballot shall be achieved by affirmative vote of a majority of voting active membersunlessotherwise providedby anotherprovision of this constitution.Only those mail ballots receivedat the businessoffice of the Association within 30 days subsequentto the voting date shall be counted.
Section4; Adoption of a constitutionamendmentshall be by a majority vote of the activememberspresentand voting at any annualor specialmeeting.
ARTICLE IX - DISSOLUTION Upon the dissolutionof the corporation,the Board of Directorsshall, after paying or making provision for the payment of all of the liabilities of the corporation,disposeof all of the assetsofthe corporationexclusivelyfor the purposesofthe corporation in such manner, or to such organizationsorganized and operatedexclusivelyfor charitable,educational,religious or scientificpurposesas shall at the time qualify as an exempt organizationor organizationsunder Section501(c) (3) of the Internal RevenueCode of 1954 (or the correspondingprovision of any future United StatesInternal RevenueLaw), as the Board of Directorsshalldetermine.Any suchassetsnot so disposedof shallbe disposedby a Court of CompetentJurisdiction in the Council in which the principal office of the corporation is then locatedexclusivelyfor suchpurposesor to suchorganization or organizations,as said court shall determine,which are organizedand operatedexclusively for such purposes.
ARTICLB VII - BYLAWS Section/; Bylaws may be adoptedor amendedat any annual or specialmeeting of the membership. Section2.' Proposedamendmentsto the bylaws shall be submitted in writing to the Secretary/Treasurerby three members at least 60 days prior to the meeting at which they are to be considered.The Secretary/Treasurershall mail the proposed amendmentsto the membership at least 30 days prior to that meeting. Section3; The Board of Directors may, by resolution,proposeamendmentsto the bylaws; provided the proposedamendments are mailed to the membership at least 30 days prior to the meeting at which they are to be considered.
BYLAWS OF THE SOCIETY FOR ACADEMIC EMERGENCY MEDICINE ARTICLE I _ MEMBERSHIP
electionto one of the membershipcategories,eflective immediately. Section 2: Dues. Annual dues for active, associate,resident/fellow, and internationalmemberswill be establishedby the Board of Directors. Honorary and emeritusmemberswill not pay dues. Membershipin the Associationmay be terminated for nonpaymentof dues. Section3: Rightsand privileges. All membershave the privitege of the floor at businessrneetingsof the Associationand may serve as a committee member, committee chair, or Member-at-Large of the Board of Directors. Only active members may vote and serve as officers. Any member may submit agendaitems for considerationby the Board of Directors.
Section1: Application Process.Membershipapplicationforms the Execmay be obtained from @ utive Director of the Association. The Applicant must return the completed application forms and supporting letters to the ExecutiveDirector. Reard of Direetors Uersnipar*a+time' The qualifications of applicants for membership willbe reviewedby the@ Executive Director and Sec@ of applicants by the Beard Approval retary/Treasurer. Executive Director and Secretam/Treasurer shall constitute
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ARTICLE II BOARD OF DIRBCTORS Sectionl: Members.The Board of Directors shall consistof the President,Vice-President(president-Elect),the Secretary/ Treasurer,the Immediatepast president,the proeram Chair. and five Members-at-Large. Section2: Election of Officers. (a) The Vice_presidentshall be electedfor a term of one year with automaticsuccessionfrom Vice-Presidentto Presidentthe followin gyear. During this two year period, the electedmember will serveas an officer of the Association. Following terms of Vice-president (president_ Elect) and President,this member will automaticallyassume the position of Immediate past president. Election as Vice_ PresidentshallconferBoardof Directorsmembershipfor a min_ imum of threeyears.Nomineesfor this office will^beselected by th_eNominating Committee,and must have agreedto stand for electionprior to formal nominationfor electionat the busi_ nesssessionof the annualmeeting.Alternativenominationswill be acceptedfrom the floor. Such nomineesmust also asreeto standfor election.Electionshallbe by majorityvoteof thJactive memberspresentand voting at the businesssessionof the annual meeting.The Vice-Presidentmay also be electedor appointed as Chair of other standingor ad hoc committees,with the ex_ ceptionof the Program Committee,and shall be an ex_officio memberof all standingcommittees.(b) The Secretary/Treasurer shall be electedto a three year term. An active member may serveonly one term as Secretary/Treasurer. Nomineesfor this office shallbe selectedby the NominatingCommitteeand must haveagreedto standfor electionprior to their formal nomination for electionat the businesssessionof the annualmeetins.Alter_ native nominationsmay be offered from the floor. Suih nom_ ineesmust also agree to stand for election. Election shall be by majority vote of the active memberspresentand voting at the businesssessionof the annual meeting. The Secretiry/ Treasurermay also be electedor appointedas the Chair of stand_ ing or ad hoc committees,with thebxceptionof the Nominating Committee_and Program Committee, and may serve as a member of all committees. Se.ction Election of Members-at-lnrge. Members_at_Large . ,3: shall be electedto two-year terms, the terms being staggerei. Members-at-Largemay only be elected for two consecutive terms. Nomineesfor the aboveoffices shall be selectedby the NominatingCommitteeand must haveagreedto standfor elec_ tion prior to their formal nominationfor electionat the business sessionof the annualmeeting.Alternativenominationsmay be offered from the floor. Suchnomineesmust also agreeto siand for election. Election shall be by majority vote of the active memberspresentand voting at the businesssessionof the an_ nual meeting. Members-at-Largemay also be electedas Chairs of standins committees,with the exceptionsof the Nominatine and prol gram Committees,appointedas Chairs of ad hoc cJmmittees, or serveas a member of standingor ad hoc committees,with the exceptionof the Nominating Committee. Section 4: Election of program Committee Chair. The pro_ gram Committee Chair shall be electedto a three_yearterm, with the first year of the term servedas Chair-Elect.Nominees must have agreed to stand for election prior to their formal nomination for election at the businessJessionof the annual meeting. Alternative nominationswill be acceptedfrom the floor. Suchnomineesmust also agreeto standforilection. Election shall be by majority vote of the active memberspresent
and voting at the businesssessionof the annualmeetine. The Program Committee Chair shall not be eligible for other Jlected positionswithin the Association,but may serveas an appointed member of other standingor ad hoc committees. Section5: Termsof Office. Terms of office will beein at the conclusionof the annualbusinessmeeting.The presiJentshall appointeligible Associationmembersto fill vacanciesand unex_ pired terms on the Board of Directors and standingand ad hoc committeesuntil the next scheduledelection, Section 6: Meetings of the Board of Directors. Meetinss of the Boardof Directorswill be convenedat leasttwice durine-theterm of the Presidentof the Association.Additional meeting-smay be convenedat the President'sdiscretionor by petition of six mem-bers of the Boardof Directors.A final noticeoftime and placeof such meetings shall be sent to all members of the Bbard bv the Secretary/Treasurerat least 7 days before the meetine. Six members of the Board of Directors will constirut. u qu-o*rn. Membersof the Association,regardlessof membershipcategory, may submit agendaitems. Such items must be submittedwithin 30 days of the meetingdate. Meetingsof the Board of Directors are open to all membersof the Associationand to the public. Closed meetingsof ilre Association'sofficers and ExecutiveDirec_ tor may be convenedby order of the president. 7: Duties of the president. The president shall pre_ .Section side over both the educationalprogram and business,eriion of the annualmeetingof the Association,and the meetinssof the Board of Directors. It shall be the duty of the preside-nt to seethat the rules of order and decorumare properly enforced in all deliberationsof the Association,to sign the approved minutesof each meeting,and to executeall documentswhich may be requiredfor the Association,unlessthe Boardof Direc_ tors shall have-expressly authorizedsomeother personto per_ form suchexecution.The presidentshall serveai Chair ofthe Board of Directors and shall serveas an ex-officio memberof all committees.The Presidentshall appoint membersto fill vacanciesand unexpiredterms on the Board of Directors and standing and ad hoc Committees until the next scheduled election. Section 8: Duties of the Vice-president (president-Elecil. The vice-Presidentshallpresidein the absenceof the president.The Vice-Presidentshall serveas Chairmanof the Nominatins Com_ mittee 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 keepa true and correct record of the proceedingsof the annual businessmeetingand meetingsof the Board of birectors, shall preserve documentsbelonging to the Association and issue notice of the annualbusinessmeetingand meetingsof the Board of Directors 60 days prior to such meetingr. ih" Secretary/ Treasurershall keepan accountof the Associationwith its mem_ bers and maintaina current registerof memberswith datesof their election to membershipand preferred mailing address,the latter to be circulatedannuallyto the membershipriithin 30 days ofthe annualbusinessmeeting. The SecretaryiTreasurer shill be re^sponsiblefor reporting unfinished businessrequiring ac_ tion from previous meetingsof the membershipoi goaid of Directors and will be responsiblefor the agendaof the annual businessmeetingand meetingsof the Board of Directors. The Secretary/Treasurer shall collect the dues of the Association, make disbursementsof expenses,and maintain the financial ac_ counts and records of the Association. The financial record will be presentedto the membershipat
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meeting,biannuallyto the Board of Direcbusiness at suchtimes as requestedby the Presidentof the ion.The financialrecordsof the Associationshall be annuallvbv two other membersof the Board of Direcntedbv the President,or a certified accountantor consultantretained by the Board of Directors of the ion. l0: Duties of Board of the Directors, Members-cttshall assumewhatever duties are Members-at-Large I by the Officers of the Associationor by Articles tn of the Association. Il: Dutiesof Program CommitteeChnir' Actingunder icesof the Presidentand Board of Directors of the Asso!on,theProgramCommitteeChair shall be responsiblefor annualresearchand educationmeeting, as well Association's fihersymposiaor meetingssponsoredor co-sponsoredby to meetits purpose.The dutiesof the Program Association Chair shall include but not be limited to: (1) selecof committeemembers,(2) selectionof meetingsites,(3) of ad hoc committeemembersspecificallyselected isnation ieviewof materialsto be presentedat the annual meeting otherAssociationmeetings,(4) peer-review and selection to be presentedat meetingsor forums sponsoredor ored by the Association, (5) publication of call-fornotices,and (6) schedulingactivities at the Associa's annual meeting or other meetings sponsoredor cofrom the Prooredby the Association.Recommendations CommitteeChair must be approvedby the Board of Direcby majority vote. 12: Duties oJ'thePast President.The PastPresident Section I assumewhateverdutiesare assignedby the Presidentor articlesin the Bylaws of the Association. SectionI 3 : Absenteeism/terminationof ffice ' Absencescan or excusedonly by the President.Two unexcused approved from scheduledBoard of Directors meetings,annual ierrces meeting, or specialmeetingsof the Board of Direcduring any term as a member of the Board of Directors conititute a resignation. Such resignation shall be tive two weeks after notification by the President.Any ber of the Board of Directors may voluntarily resign and suchresisnationwill become effective immediately. Section 14: Special meetings of the Board of Directors' unscheduledmeetingsof the Board of Directorsor the Special, Officersof the Associationmay be convenedby the President, or by any six membersof the Board of Directors. Upon petition-bylbO or more activemembersof the Association,stating thereason(s)for calling a specialmeetingof the Directors or Officers, the Secretary/Treasurershall call such a meeting within30 daysof receivingthe petitionto be convenedat a time andplace designatedby the President. Section I5: Duties of the ExecutiveCommittee;The Executive Committeeshall conductthe businessof the Board of Directors and act in lieu of the Board on routine issues.All actions by the Executive Committee are subjectto review and approval by the full Board of Directors at their next meeting.
for vote by active membersshall includebut not be limited to: (2) amend(l) a financialreport from the Secretary/Treasurer, (3) Association' the of Bylaws and ments to the Constitution and Directors, of Board the of members officers, of election the Chairs and membersof standingcommitteesof the Association, (4) reportsof committeeactivities,(5) transactionof other businesswhich may come before the membership' and (6) a ''Stateof the Association"addressby the President.Wheredictatedby the Constitutionand Bylaws, the Associationshall be governedby a majority vote of active membersin attendance it the annualbusinessmeeting. The Presidentof the Association shallpresideover the meetingand the Secretary/Treasurer will circuiate agendaitems to the membership30 days before the annualbusinessmeeting.The Chairsof the Constitutionand Bylaws Committeeand Nominating Committeewill presideover the respectivepartsofthe annualmeeting.The annualbusiness meeting shall be held at a time and place determinedby the Board of Directors of the Associationapproximatelyone year in advanceof the convocation. Section2; Betweenannualbusinessmeetings,within the polby the Association'smembershipand the Coniciesestablished stitutionand Bylaws, the Associationshall be governedby the Board of Directors. Actions of the Board of Directors shall be determinedby a majority vote of thoseof its memberspresent at its meeting, six membersconstitutinga quorum' Seaion 3: Annunl scientificand educationalassembly'The Association shall sponsoran annualscientificand educationalmeeting or assemblyto meetits purposeand objectives.This meetingwill includebut not be limited to: (1) presentationof original research in the sciencesand e.ducationalmethodology, (2) educational/ researchforums, (3) specialprogramsfor tlrc membershipas determined by the purposeand objectivesof the Association,and (4) meetingi of the standingand ad hoc committeesof the Association. The researchandeducationalprogramsof the annualmeeting shall be open to the public and the general membershipof the Associationin good standing.All meetingsof standingand ad hoc committeesare open to the public and membersof the Association in good standing.Programsfor the annualmeeting shall be u.rang.d by the ProgramCommitteeand approvedby the Board of Diiectors of the Association.A final noticeof the time, place, and program of the annualassemblyshall be sentto all members of the Associationby the Secretary/Treasurerat least 30 days before the meeting. Section4: Specialmeetingssponsoredor cosponsoredby the Association.The Associationmay sponsoror cosponsorother scientific or educationalmeetingsof interestto the membership to meet its purposeand objectives.Such meetingsshall be convenedby the President,BoardofDirectors, and Program Committee Chair and publicized 30 days in advanceby the Secretary/Treasurer.
ARTICLE IV _ FINANCES Section,l:The annualmembershipduesfor all membersshall be determinedby the Board of Directors. The annualmembership will be payablewithin 30 daysof requestby the Secretary/ Treasurer.The Board of Directors may establishprocedures and policies regardingnon-paymentof duesand assessments'
ARTICLE III _ MEETINGS Sectionl: Annual businessmeeting.An annualbusinessmeeting of the membershipof the Association shall be convenedannually and in conjunctionwith the annualscientificand educationai meetingof the Association.A majority of the activeand voting membersin good standingand in attendanceshall constitutea quorum. Businessitems presentedas informationalor
Section2: The Board of Directorsshall adoptsuchmembership schedulesas is necessaryto encourageparticipationby the interestedpublic.
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ARTICLE V PARLIAMENTARY AUTHORITY
bership, with the first year of the term servedas Chair-Elect, and six other membersappointedby the committeeChairfor staggeredtwo-year terms. The committeeChair and appointees may be membersof the Board of Directorsor otherAssociation committees.The Chair shall createad hoc educationsubcommitteeswith the approvalof the Board of Directors.TheCommitteeshall fostereducationin emergencymedicalcareandassumedutiesand tasksas determinedby the Boardof Directon
Rule of order. Any questionof order or procedurenot specifically delineatedor provided for by thesebylaws and subsequentamendmentsshallbe determinedby parliamentaryusage as containedin Robert Rules of Order (Revised).
ARTICLE VI - STANDING COMMITTEES
Section 6: Research Committee. The ResearchCommittee shall consist of a Chair, electedto a three-yearterm by the membership,with the first year of the term servedas ChauElect, and six other membersappointedby the committee Chair for staggeredtwo-year terms. The committeeChair andappointeesmay be membersof the Board of Directorsor other Associationcommittees.The chair shall createad hocresearch subcommittees with the approvalof the Boardof Directors. The Committeeshall fosterresearchin emergencymedicalcareand assumedutiesand tasksas determinedby the Boardof Directon.
Sectionl: NominatingCommittee.The NominatingCommitteeshallconsistof the Vice-President, as Chair, the pastpresident, a member of the Board of Directors electedfor a oneyear term by the board, and three electedmemberswho may not be membersof the Boardof Directors.The lattershallserve staggered two-yearterms.It shallbe the taskof this committee to selecta slateof officersto fill the naturallyoccuringvacancieson the Boardof Directorsandelectedpositionson the standing committeesof the Associationnot otherwisedesignatedand providedfor by thesebylaws.The NominatingCommitteewill seekthe candidatesapproval for formal nominationand shall placetheir namesin nominationbefbrethe membershipfor election at the businesssessionof the annual meeting The NominatingCommitteewill alsoprovideslatesfbr any awards off'eredby the Board of Directors..
Section 7: Liaison Committeeto the Associationof American Medical Colleges (AAMC) The Committeeshall consistofa Chair, appointedto a five-yearterm by the Boardof Directors, and threemembersappointedby the committeeChair for $aggered three-year terms. The official emergency medicine delegatesto the AAMC will be membersof this committee. The committeeChair and appointeesmay be membersof theBoard of Directorsor other committeesof the Association.Onlycur. rent or past membersof the committeewill be nominated by the NominatingCommitteefor electionto Chair.The Committee shall developprogramsfor the Associationto be presentedat the annualmeetingof the AAMC and assumeother dutiesand tasksof similarpurposeasdeterminedby the Boardof Directon,
Sec'tion2: MembershipCommittee.The Board of Direcbrs shallconstitutethe MembershipCommittee.The membership committeehas the responsibilityfor establishingthe qualifications for each membership classificadon. {+sha}l bet$eseetetary/Treasurer'sduty to review the qualifieationsand reeomApplicants reviewedby the @ Executive Director and Secretary/Treasurer not meeting the qualificationsfor election to a requestedclassification of membershipshall require presentation/o and approval by the majority of the MembershipCommittee, before membershipin that classiftcation can be granted.
Section8: GovernmentalAfrbirs Committee.The Committee shall consist of a Chair, electedto a three-yearterm by the membership,with the first year of the term servedas ChairElect, and three membersappointedby the committeeChair fbr staggeredthree-yearterms. The committeeChair andappointeesmay be membersof the Board of Directorsor other committeesof the Association.Only current or pastmembers of the committeewill be norninatedby the NominatingCommitteefbr electionto Chair. The Committeeshallassume duties and tasksas determinedby the Boardof Directorsto fosterfederal and statesupportof researchand educationin emergency medicalcare.
Sedion 3: Program Committee.The Program Committeeshall be composedof a Chair, electedby the membershipfor a threeyearterm, with the first yearof theterm servedas Chair-Elect; two membersappointedby the Presidentto staggeredthree-year terms:and two membersappointedby the committeeChair to staggered three-yearterms. The ResearchCommitteechair and the EducationCommitteechair will be membersof the Program Committee.Noneof the appointedmembersof the committee can be membersof the Board of Directors.The dutiesof the committeeshallbe to arrange,in conformitywith instructions from the Board of Directors, the program for all meetingsand s e l e c t h e f o r m a lp a r t i c i p a n t s .
Section 9: Committeeon International Affairs. The Committee shall consistof a Chair, electedto a three-yeartermbythe membership,with the first year of the term servedas ChairElect, and three membersappointedby the committeeChair for staggeredthree year terms. The committeeChair andappointeesmay be membersof the Board of Directorsor other committeesof the Association. The committee shallassume dutiesand tasksas determinedby the Board of Directorst0 fostel internationalrecognitionofeducation and researchin emergency medicalcare.
Section4: Constitutionand Bylaws Committee.The Constitution and Bylaws Committeeshall consistof a Chair and two other members,electedfor staggeredthree-yearterms so that the memberwith the leastremainingtenureshall serveas Chair during their final year on the Committee.This Committeeshall studythe potentialmerits, adverseconsequences and legal implicationsof all proposedconstitutionalamendments or changes in the bylaws and report their findings and recommendations to the Presidentand Boardof Directorsprior to the time of fbrmal considerationof the proposedchangesby the membership. The membersof the Committee may themselvessuggestappropriateconstitutionalamendmentsand bylawschangesto the Presidentand Board of Directorsupon study of problemsarising out of the existingconstitutionand bylaws. Section5: EducationCommittee.The EducationCommittee shallconsistof a chair, electedto a three-yearterm by the mem-
ARTICLE VII - DISSOLUTION OF THE ASSOCIATION Section,l:Dissolutionof this Associationcanonly beinitiated by a majority vote of all membersof the Board of Directors and must be approvedby two-thirds of the active membership presentand voting at any annual or specialmeeting. Section2; Dissolutionshall be achievedin compliancewith A r t i c l eI X o f r h e c o n s t i t u t i o n .
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SAEMMEMBERSHIP APPLICATION Pleasecompleteand send, with the appropriatedues and initiationpayment,to: Society for Academic EmergencyMedicine . 900 West Ottawa . Lansing, Michigan 48915 . (512) 4g5-54g4 (sl7) 48s-0801FAX
Name
Title: DO MD PhD Other
Home Address
Business Address Preferred MailingAddress(pleasecircle): Home Business Telephone:
Home (__)
Birthdate
Sex: M
Business(_)
Institution FacultyAppointment
Positions currently heldin Emergency Medicine: 1. 2. 3. Department Chairman Check the appropriate membership category:
-Active
-Associate
-Resident/
Fellow -tnternational
Active -lnternational
Associate
Active membership is open to individuals(a)with an advanceddegree,hold a medicalschoolor universityfacultyappointmentand activelyparticipate in acute, emergency,or criticalcare in an administrative,teaching or researchcapacity;(b) with similardegreesin active militaryserviceor (c) who otherwisemeet qualifications but who do not hold a facultyappointmentand who petitionthe MembershipCommittee.Annualdues are $195 olus a $15 initiationfee payablewhen the applicationis submitted.The applicationmust be accompanied by a curriculumvitaeand a letterverifyingthe faculty appointment.Membershipbenefitsinclude a subscriptionto Annalsof EmergencyMedicine,the officialSAEM journal; a subscriptionto the SAEMnewsletter; a reducedSAEMAnnualMeetingregistration and freebanquetticket;and reducedregistration feesto otherSAEMeducationalmeetings. Associate membership is open to health professionals,educators,governmentofficials,membersof lay or civic groups,or membersof the public at largewho havean interestin EmergencyMedicine.Annualduesare $175plusa $15 initiationfee payablewhen the applicationis submitted.The applicationmust be accompaniedby a curriculumvitae.Membershipbenefitsincludea subscriptionlo Annalsof EmergencyMedicine,the officialSAEM journal; a subscriptionto the SAEM newsletter;a reducedSAEM Annual Meetingregistrationand free banquetticket; and reduced registrationfees to other SAEM educationalmeetings. Resident/Fellowmembershipis open to all residentsand fellowsinterestedin EmergencyMedicine.Annualdues are $50 plus a $15 initiationfee payablewhen the applicationis submitted.The applicationmust be accompaniedby a letterfrom the directorverifyingthat the applicantis a resident or fellowand the anticipatedgraduationdate. Membershipbenefitsincludea subscriptionto Annalsof EmergencyMedicine,the officialSAEMjournal; a subscriptionto the SAEM newsletter;a tree SAEM Annual Meetingregistration;and reducedregistrationfees to other SAEM educationalmeetings. MedicalStudent membershipis opento all medicalstudentsinterestedin EmergencyMedicine.Annualduesare $50 (includesAnrals subscription) or $35 (excludesAnnalssubscription), plus a $15 initiationfee payablewhen the applicationis submitted.The applicationmust be accompanied by a letterverifyingthat the applicantis a medicalstudent.Membershipbenefitsincludea subscriptionlo Annalsof EmergencyMedicine(if applicable), a subscriptionto the SAEM newsletter,free registrationto the SAEMAnnualMeeting,and reducedregistrationfeesto otherSAEMeducationalmeetings.
i
International active and international associate membership is open to individualswho meet the criteriafor SAEM activeor associatemembershio but do not residein the UnitedStates.Annualdues are $95 plus a $15 (U.S.funds)initiationfee, payablewhen the applicationis submitted.The applicationmustbe accompaniedby a curriculumvitaeand a letterverityingthe facultyappointment, if appropriate. Membershipbenefitsincludea subscription to Annalsof EmergencyMedicine,lhe officialSAEMjournal;a subscriptionto the SAEM newsletter;a reducedSAEM Annual Meetingregistrationand free banquetticket; and reduced registrationfees to other SAEM educationalmeetings.
I
My signaturecertifiesthatthe information containedin thisapplication is correctand is an indicationof my desireto become a SAEM member.
;
Signatureof applicant
I I I
t
May 1992
Dare This form can be photocopiedif additionalcopies are needed.
EXHIBITORS ALK Laboratories,Inc. 132 ResearchDrive Milford, CT 06460
(203) 877-4782
ALK Laboratorieswill be presentingeducational materialson insectstinganaphylaxisand uenomfiil;;;;;py. Represen_ tativeswill be availableto provide you *itf,-.tinical support and other educationalmaterial.
Annuls of Emergenc.yMedicine PO Box 6l99tl
(2r4)ss0-09il
Dalfas, TX 75261-99ll Annalsof Emergency Medicine,co_sponsored by theAmerican Collegeof Emeigency physicians;,,iffi;;"ry fbr Academic Emergency trleaicineis *,! rp".i"ttv;l r""din"jir,;,*l andscien_ tific journal.
Clinical Resource Systems, Inc. (sr2)4s2-726r 3701 North Lamar Austin, TX 78705 Emstat,from Clinical ResourceSystems, is a comprehensive emergencydepartmentinformationsystem, includingmodules for real-timetrackins. triage, orderr, .;;j;; and charting. Emstatusesan oraclJrelatiJnaldatabase *ti.i t", extensive dataqueryand retrievalcapabilities. frnrtut-i, ,u"cessfullyin_ stalled in several academii emergency O.purtrn"ntr.
CompuGraphics 1323East El parque Drive Tempe, AZ SS28i
(602)73r-4727
laser,poinrer($2O0vatue). CompuGraphics wiil Y::"lllt very thi ng n::d^"{ prepare stunni ng Iecture pre_ :.1:lt,.ut:," 19 sentatlons.The Montase_FM Film Recorder allowsyou to pro_ duce professionalcol6r lecture ,lid"r7;;;;;;s using pC or Maclntosh.Also seelaserpointersuna .orniut", frardware/soft_ ware demonstrations.Specialconference Oir.ornt, offered.
EmergencyMedical Abstracts (800) 702 ContinentalDrive Harleysville,pA 1943g Em.ergency MedicalAbstracts reviewsthecontents of over500 majorjournalsmonthryandlistsuil urti.r", g"imane to emer_ gencymedicine andprovides abstracts on foity keyarticles. In addition,subscribers receivea SO_minule ;iiio.la uuaio"urr"tte on specific-u"r,r.ur.ropicsand :,:jg :,i1. T_indeprhcssay a program offering AAFP andACEp CME-credits -serr-srucry EMA is providedin printejanO.".p"t".i^d u".sions.
PT.qn"y MedicineResidents'Asscciation(214)SS0_09f1 P.O. Box 6t99tl Dallas, TX 75261-9gtl TheEmergency MedicineResidents, Association (EMRA)rep_ resents over2,000emergency medicineresidents andmedical rv vr6q.taqrrv'D
s iurvurvct.t nvolvedrn in emergencv "r".s";;t
medici pol_ medicine :,111"1r^ l:, :lganizarion itics, practice, andresearch. TheBoarJof-oi.J.to., exDresse presses
residenr concerns to ACtrp,SAEM,n"riA"""Vii#;ffi;:
mitteeandABEM. EMRA l*A"., *ili iJ"""ifuul" to answer questions.
H.vbritechIncorporated (619)4ss-6700 P.O. Box 269006 San Diego, CA 92196-9006 Hybritechis a research-based companythatdevelops,manufac_ tures,andmarketsdiagnostic urruy,Uur.Jon nionoclonal anti_ 111^r".!!_ol9gy.TheFybrite"t "^t iUit*iff f.utu.. theICON@ QSR@CKMB readeriystem,ICON@HCC,IcON@ Strep B, andConciseimmunoassays.
i-STAT Corporation 3034 CollegeRoad East Princeton, NJ 08540
(609) 243-9300
The i-STATTMportable Clinical
DanielStern and Associates The Medical CenterEast, Suite240 2ll North Whitfield Street Pittsburgh,PA 15206
(4r2) 363-9700
DanielSternand Associates providesplacement/recruitment ser_ vices, billing^consulting and medicaliuff A"u"iopment/analysis natronwide.Our emergencymedicine division has successfully servedhospitals/physicians andphysiciangroup, for morethan z I years' Pleasestop by our booti #12 to"revLw our services and availableopporiuniti"r.
DuPontPharmaceuticals 2655North SheridanWay #lg0 Mississauga,Ontario L5K 2pS
(416)8ss-4380
Analyzer i vitroanarysis"f ri"rr,**r,i'r'jTijjo"ol?,t*'"""l1l,i"tl to deliver quantita-
tive resultsfor a panelof restsin upp.o?i*;;;90,*"#;:'J,
a single,smatlsample {1n_g1gr,.OS "Ll. fi," n.J,single_use carl tridge available,
the i_STAT'" e+,'contains"r"nro., for the determinationof: Sodium 1N4, fotassiu_ fral, an,o.ide (Cl), Glucose (Glu), Urea nitrogen (BUN), Hematocrit (Hct) and calculatedHemogtobin (Htb).
Knoll PharmaceuticalsCanada 100 Allstateparkwav Suite 600 Markham, Ontario L3R 6H3 CANADA
(416)47s-7070
Cardiovascular:For acutemanagement of emegencysupraven_ tricular arrhythmiasthe world'sh.rt .ut.iuro "iannel blocking agent,Isoptinl.V.@ (verapamil).For tong t".- preventionof seriousarrhythmiasRvthmol@ (propuf"n8n"j, is wiAely used in Canadaand internationally because ofit, ll=iou.uble efficacy and safety profile.
CANADA Information is availableon.acutemanagement of the patientwith alteredmental status- diagnostic,"a ,f,"."p."tic challenges to the emergencymedicine-physician unJ pi.L"oic sraff.
106
Kurzweil Apptied Intelligence,Inc. 411 Waverley Oaks Road Waltham. MA 02154
(617)893-slsr
impactspatient care. We designand manufactureelectrocardiographs,ST monitor, stresssystems,Holter analysissystemsand recordersas well as data managementsystems.
VoiceEM is a voice-activatedemergencymedicinepatientcharting systemusedby EmergencyMedicine physiciansto instantly createlegible reports,completewith ICD-9 and CPT-4 codes. The systemhasbeendesignedto meetthe new RBRVS standards and gives you total flexability to create each individual report. The system is speakerindependent.
Laerdal Medical Corporation One Labriola Court Armonk. NY 10504
Nellcor, Inc. 25495Whitesell Street Hayward, CA 94545
(9r4\ 273-9404
Heartstartautomateddefibrillators and early defibrillation training systems.
Lasergraphics,Inc. 20 Ada Irvine. CA 92718
(7r4\ 727-2000
Emergencymedicineequipmentrelating to oxygen resuscitation, including demand valves, regulators and automatic ventilators. Productsalso include rescueand ffauma./bumproductssuchas antishocktrousers,Miller full-body splint/litter, trauma/burnsheets.
Marquette Electronics 8200 West Tower Avenue Milwaukee.WI53223
(414)362-3000
Marquettemanufacturesa full-line of prehospitalECC products, including: Defibrillators,l2-lead ECG devices,and datamanagementsystems.
MICROMEDEX' Inc. 600 Grant Street Denver. CO 80203
(303)831-1400
The ComputerizedClinical Information System(CCN) contains information on drug therapy, emergencymedicine, toxicology, dosing programs, and patient instructions.The systemsare used by physicians,pharmacists,nurses,and allied health professionals.CCIS is availableon CD-ROM for use with personal computerc on computer apes for mainframes,and on microfiche.
Mortara Instrument 7865 North 86th Street Milwaukee.Wl53224
(617\ 320-3164
A new rapid test for serum Myoglobin is now availablethat can aid in the detectionor exclusionof an acutemyocardialinfarction and in thrombolytic therapy. The l5-minute test procedureis not availablein unique self-containedtest cartridges on the table top OPUS Immunoassaysystem from Polaroid Behring Diagnostics.
The LasergraphicsPersonalLRF is a digital film recorder that representsa true breakthroughprofessionalquality, razor-sharp 4,000line color slidesquickly for under $6,000. The Personal LFR sports a permanentlymounted 35mm cameraback, the SmartBack.Permanentmounting economicallyprovides exceptional optical alignment, which in turn contributesto the exceptional imagequality of the PersonalLFR. The PersonalLFR, like other Lasergraphicsproducts,is compatiblewith virtually any computerplatform and even works without a color monitor.
Life Support Products, Inc. P.O. Box 19569 Irvine. CA 92713
Nellcor Incorporatedmanufacturesand marketshigh-performance, electronic,medicalmonitoring instruments,disposableand reuseablesensors,and accessoriesfor patient safetyand management throughoutthe hospital,in emergencytransportand in the home. Nellcor's arterial blood oxygenand respiratorygasmonitors provide continuous,real-time, noninvasivemonitoringof oxygen saturationand end-tidal carbon dioxide levels.
P.B. Diagnostics 151 UniversityAvenue Westwood.Massachusetts02090
(7r4)727-26sr
(s10)293-413s
(206\ 867-4569 Physio Control 11811Willows Road NE Redmond, WA 98052 LIFEPAK@ l0 Defibrillator/monitor/pacemaker; LIFEPAK@9P Defibrillator/monitor/pacemaker; LIFEPAK@300 AutomaticExternolDefibrillator; DefibrillationSystem;AmbuShockAdvisorySystem;Hands-free Man VIP-DruInteractivedefibrillatorandCPRTrainingSystem.
(416) 829-2030 SmithKline Beecham Pharma Inc. 2030 Bristol Circle Oakville. Ontario CANADA L6IJ 5V2 SmithKlineBeechamPharmaInc. is one of the most researchintensivecompaniesin the industry, committedto innovative programsto bring a steadystreamof quality prescriptiondrugs to patients.Eachyear the companyinvestsnearly $700 million to pursuedrugs in various therapeuticareas:anti-infectives,gastrointestinal,cardiovascular,mental health, inflammationand tissue repair, diabetesand vaccines.
Spacelabs,Inc. 15220NE 40th Street Redmond,WA 98052
(206) 882-3700
Automated defibrillators, information managementsystemsfor medicalcontrol and automatedportableblood pressuremonitors.
(414)3s4-1600
Synergon
(3r4) 469-s324
P.O. Box 419052 St. Louis, MO 63141 Synergon specializes in emergency departrnent staffingandmanagement for high-volume,academic andpediatricemergency care.
Mortara Insffumentis dedicatedto providing the most innovative and advancedtechnolosv for the medical communitv that trulv
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SyntexInc. 21fi) Syntex Court Mississauga,Ontario CANADA LsN 3X4
(416)821-4000
of a program to provide other innovative wound closure products, the company introduceda full-line of advancedsutures in April, 1991.
Productsdisplayedare: Toradol - (Ketorolac)- an oral and parental,non-narcoticanalgesicfor the managementof acute pain in the emergencydepartmentand/or the operatingroom. Ticlid - (Ticlopidine HCL) - a significanttherapeuticbreakthrough in the preventivetreatmentof initial or recurrentnoncardiogenicstrokes,proven effectivein both men and women.
U.S. SurgicalCorporation 150 Glover Avenue Norwalk. CT 06856
WeatherbyHealth Care 25 Van Zant Street Norwalk, CT 06855
(203) 866-1144
Physiciansearchfirm specializingin the recruitmentof emergency medicine physicianson a national basis.
(203\84s-4422 (317) 631-1745 Wilderness Medical Society P.O. Box 2463 Indianapolis, IN 46206 The WildernessMedical Society'sgoal is to provide a professional and scientific forum for wilderness-relatedmedical interestsand to encourageboth basic scienceand clinical research that will result in the developmentof the scientificbasisfor the health of the individual in the wildernesssettins.
United StatesSurgicalCorporation(USSC) is the world leader in salesofsurgical staplingand laparoscopicproducts.The use of surgical staplingoffers greater speed,precisionand safety over the manualsuturingmethod,facilitatinghealingand shorthospitalstay. Laparoscopicproductsallow eningpost-operative surgeryto be performedthroughminute incisions,dramatically reducing hospital stay, pain, recuperationand costs. As part
Meeting attendeesare urged to qttendthe exhibitson May 27 snd May 28. Also, be sure to visit the Innovations in Medical Educution exhibits (abstracts072-083) which will be locqtedin the exhibit hall during the postersessionon May 27. Many of them will also exhibit on May 28. 108
TORONTO'S RESTAURANTS RecommendedRestaurants-
*Recommended -
price listed represents:dinner for 2, with a bottle of the House wine where applicable,all taxes and 157a gratu:'ty
food/atmosphere/value/all round experience
A La Mode The Avocado Club Bistro 999 French Teula Italian SplendidoItalian Centro
$7s-8s $ 1 0 0 -120 $90-100 $ 1 0 0 -120 $ 1 0 0 -120
165 John St. 990 Bay St. 35 Elm St. 88 Harbord 2472 Yonge St.
598-4656 92t-9990 597-0020 929-1788 483-22rr
83 BloorSt. W. 129PeterSt. 253 VictoriaSt. 1276YongeSt. 595 MarkhamSt.
960-0306 345-9345 364-7511 967-9463 536-3211
133 John St. 100 Cumberland 81 Bloor St. E. 97 Harbord 361 QueenSt. W. l7 BaldwinSt. 328 QueenSt. W.
595-8201 964-2222 5 15-7560 920-2r86 s93-0934 581- 1676 596-6406
418 SpadinaAve. 412 SpadinaAve. 371 SpadinaAve. 5 Baldwin St. 358 SpadinaAve. 339 SpadinaAve. 122 St. Patrick St.
598-1325 593-983 I 977-4079 971-3173 593-9524 596-1685 s9 3- 9819
30 Baldwin St. 349 QueenSt. W. 35 Baldwin St. 134 Avenue Rd.
917-1287 598-3490 596-0218 928-952r
* { < * { < { < * { â&#x201A;Ź * { < { <
American Bemelmans SanteFe *Senator's Tipplers SouthernAccent
$60-80 $70-80 $90-100 $85 $80-100 { < * * * * * { < * { . { <
Cafe *Amsterdam Bellair Cafe Maccheroni(Italian) Poretta's (Italian) Raclette La Soiree Le Select
$ss-70 $70-8s $40-s0 $65-8s $7s-90 $6s-7s $80-100 * { < * { < * * * * * *
Chinese. . . highly recommendedin Toronto Chong Star House $45 *Hunan Palace $30-40 Kom Jug Yuen $30-40 Kowloon $45 *Lee Garden $40-50 SangHo $30-40 xYong Lok $50-70 * { < { < * * * * * { < { <
French *La Bodega Le Bistingo Le Petit Gaston Arlequin
$85 $80-100 $e0 $80-90
109
Indian Babur Raja Sahib The Moghul
$50-70 $45-s5 $ss-70 *
International Movenpick Sanssouci Tapestry's *Truffles Scaramouche
*
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<
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279 DundasSt. W. 254 AdelaideSt. W. 33 Elm St.
599-1720 593-4156 597-0522
165York 955 Bay St. 108Chestnut St. 21 AvenueRd. 1 Benvenuto Pl.
366-5234 924-922r 977-5000 961-8011
193 Carlton St. 101 Yorkville Ave. 157 King St. E. 45 Elm St.
96t-4147 929-9rtl 366-4040 597-0155
205 RichmondSt. W. 55 AdelaideSt. E. 154 CumberlandSt.
977-9519 362-1373 964 8665
300 CollegeSt. 582 Yonge St.
922-1636 960- 1010
18 Elm St. I Baldwin St. 111 GerrardSt. E. 112 DundasSt. W.
917-6748 s85-9052 599-9099 599-8308
440 Danforth Ave. 33 Yonge St.
469-9595 947-1r59
129 Yorkville Ave. 330 DundasSt. W.
926-9545 591-0071
26 Alexander St. 463 Church St.
924-8697 922-9594
709 QueenSt. E.
463-6906
*
$100 $I 30- 1s0 $110 $ 125-180 $160
940-04rr
* * * * * * * * * t
Italian *Barolo Bellini Biagio Old Angelo's
$ 11 0 - 1 3 0 $90-r00
$es $70-90 * * { < * t * * l t { < *
Japanese Masa Nami *Shogun
$7s-90 $90-100 $80-90 { < { r { < * * * * s * { < *
Latin Don Quijote Segovia
$7s-90 $70 * { < * * { < { < * { < * x
Asian *BangkokGardens Sri Malaysia Young Thailand Chieng Mai
$100 $40 $s0-60 $s0-60 * { < * * { < * * * * *
Greek xPappasGrill Penelope
$60 $70-9s * * { < { < * * * * * *
Seafood La Pecherie The Mermaid
$100 $85-100 * { < * * * * * * { < *
Steaks xCarman'sClub GeorgeBigliardi's
$12s $110 * * { < 8 * * * { < * *
Caribbean The Real Jerk
$s0 110
WINNERSOF THE BEST RIDICULOUSABSTRACTS After careful review of thirteen submittedabstracts,the following abstractswere selectedas the winners and will be presentedat the Annual Awards Banqueton May 29: "Two Beers, Doing Nothing and Minding One's Own Business:The Most DangerousActivities Possible," SteveSeifert, MD * { < * * * { <
"The Cheez-DoodleTest in Acute Abdominal Pain," Bob McNamara, MD * * { < * * { <
"The Effects of Dude Incarceration on EmergencyDepartment Visits in an Urban Environment," Bill Barsan. MD
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Visit the Synergonbooth and register to win a three-volumeset:
EMERGENCY MEDICINE Conceptsand Clinical Practice (Third Edition) SeniorEditor. PeterRosen.MD
*Drawing on Thursday,May 28 at 4:30 p.m. at the Synergoncomplimentary Wine and CheeseTable PosterSessionII
Synergon specializss in academic, pediatric and high-volrrme emergency care staffing, management and recruiting.
SYNERGoN, 999 Executive Parkway St. Louis, Missouri 63141 lAWm-79e