Determinants of survival in sudden cardiac arrest manifesting with pulseless electrical activity.

OBJECTIVE: The proportion of sudden cardiac arrests (SCA) manifesting with pulseless electrical activity (PEA) has increased significantly, and the survival rate remains lower than ventricular fibrillation (VF). However, a subgroup of PEA-SCA cases does survive and may yield key predictors of improved outcomes when compared to non-survivors. We aimed to identify key predictors of survival from PEA-SCA. METHODS: Our study sample is drawn from two ongoing community-based, prospective studies of out-of-hospital SCA: Oregon SUDS from the Portland, OR metro area (Pop. approx. 1 million; 2002-2017) and Ventura PRESTO from Ventura County, CA (Pop. approx. 850,000, 2015-2021). For the present sub-study, we included SCA cases with PEA as the presenting rhythm where emergency medical services (EMS) personnel attempted resuscitation. RESULTS: We identified 1,704 PEA-SCA cases, of which 173 (10.2%) were survivors and 1,531 (89.8%) non-survivors. Patients whose PEA-SCA occurred in a healthcare unit (16.9%) or public location (18.1%) had higher survival than those whose PEA-SCA occurred at home (9.3%) or in a care facility (5.7%). Young age, witness status, PEA-SCA location and pre-existing COPD/asthma were independent predictors of survival. Among witnessed cases the survival rate was 10% even if EMS response time was >10 minutes. CONCLUSIONS: Key determinants for survival from PEA-SCA were young age, witnessed status, public location and pre-existing COPD/asthma. Survival outcomes in witnessed PEA cases were better than expected, even with delayed EMS response.

Simultaneous densitometric determination of anthelmintic drug albendazole and its metabolite albendazole sulfoxide by HPTLC in human plasma and pharmaceutical formulations.

A new, simple, accurate and precise high-performance thin-layer chromatographic method has been developed and validated for simultaneous determination of an anthelmintic drug, albendazole, and its active metabolite albendazole, sulfoxide. Planar chromatographic separation was performed on aluminum-backed layer of silica gel 60G F254 using a mixture of toluene-acetonitrile-glacial acetic acid (7.0:2.9:0.1, v/v/v) as the mobile phase. For quantitation, the separated spots were scanned densitometrically at 225 nm. The retention factors (Rf ) obtained under the established conditions were 0.76 ± 0.01 and 0.50 ± 0.01 and the regression plots were linear (r2 ≥ 0.9997) in the concentration ranges 50-350 and 100-700 ng/band for albendazole and albendazole sulfoxide, respectively. The method was validated for linearity, specificity, accuracy (recovery) and precision, repeatability, stability and robustness. The limit of detection and limit of quantitation found were 9.84 and 29.81 ng/band for albendazole and 21.60 and 65.45 ng/band for albendazole sulfoxide, respectively. For plasma samples, solid-phase extraction of analytes yielded mean extraction recoveries of 87.59 and 87.13% for albendazole and albendazole sulfoxide, respectively. The method was successfully applied for the analysis of albendazole in pharmaceutical formulations with accuracy ≥99.32%.

Management of isolated sagittal synostosis in the absence of scaphocephaly: a series of eight cases.

BACKGROUND: The diagnosis of isolated sagittal synostosis is usually made at birth, with a boat-shaped deformity of the skull (scaphocephaly). The Oxford Craniofacial Unit has successfully managed eight cases of isolated sagittal synostosis without scaphocephaly. To the authors' knowledge, there have been no reports of this in the literature. METHODS: The Oxford Craniofacial Unit database (set up in 2004) was searched. This identified 193 cases of isolated sagittal synostosis, eight of which did not have a scaphocephalic head shape (i.e., a cephalic index <76). RESULTS: Patients with isolated sagittal synostosis in the absence of scaphocephaly represent 4.1 percent of all isolated sagittal synostosis patients in the authors' database. Intracranial pressure was measured in six of the eight cases and found to be high in four of these (67 percent). CONCLUSIONS: It is unclear why the secondary features of sagittal synostosis did not develop in these cases. Possible explanations include fusion of the suture late after the majority of skull growth has taken place and a patent metopic suture allowing growth to occur anteriorly; other sutures appeared patent radiologically but may not have been functioning normally. Although difficult to recognize, patients with isolated sagittal synostosis in the absence of scaphocephaly are important to identify because they are at high risk of developing raised intracranial pressure. A new management algorithm for treatment of these cases is described that has been used successfully in the Oxford Craniofacial Unit.

Applying the trauma triage rule to blunt trauma patients.

OBJECTIVE: To determine the accuracy of the Baxt Trauma Triage Rule (TTR: systolic blood pressure < 85 mm Hg; Glasgow Coma Scale-motor score < 5; or penetrating trauma to head, neck, or trunk) for prediction of major trauma in an independent data set of blunt trauma patients. METHODS: Retrospective evaluation of the TTR in a cohort of patients identified by Oregon Trauma System entry criteria. Accuracy for prediction of "major trauma" victims was measured using resource-based definitions of major trauma. Participants included 626 adult, blunt trauma patients at a level-I trauma center serving a metropolitan center of more than one million people. RESULTS: Of 524 patients with sufficient registry data to apply the TTR, 95 (18%) and 63 (12%) patients met the criteria for major trauma suggested by Baxt et al. and Emerman et al., respectively. Using the Baxt definition of major trauma, the TTR had a sensitivity of 74% (95% CI: 0.65-0.83) and a specificity of 84% (95% CI: 0.81-0.88). There were 25 significant false-negative results, including 12 patients requiring urgent laparotomy and four patients requiring emergency airway procedures. Using the Emerman definition of major trauma, sensitivity improved modestly to 76% (95% CI: 0.65-0.87) and specificity decreased slightly to 80% (95% CI: 0.77-0.84). CONCLUSIONS: In this blunt trauma population, the Baxt TTR failed to identify a significant number of severely injured patients. Slight alterations in the definition of "major trauma" can significantly affect the performance characteristics of triage instruments.

HIV seroprevalence in emergency department patients: Portland, Oregon, 1988-1991.

OBJECTIVES: In Portland, OR: 1) to determine the changes in HIV seroprevalence for ED patients from 1988 to 1991, 2) to define the characteristics of the HIV-positive ED patient, 3) to determine the hepatitis B seroprevalence of HIV-seropositive ED patients, and 4) to demonstrate the feasibility of an ED population-based surveillance investigation. METHODS: A prospective, multiyear observational, cross-sectional, multicenter, population-based seroprevalence study was performed using seven urban hospital EDs. Serologic testing for HIV and hepatitis B was performed on excess blood obtained from ED patients. Four sampling periods were used at each hospital at 14-month intervals starting June 1988 and ending December 1991. The blood specimens were obtained concurrently at all the participating hospitals. RESULTS: Of 1,681 patients, 17 (1.0%) were HIV-positive. The HIV seroprevalence rate was relatively stable over time: 0.5% (2/444) in 1988, 1.7% (7/396) in 1989, 1% (3/296) in 1990, and 0.9% (5/545) in 1991. Most (94%) HIV patients were men, 100% were white, 81% were > or = 30 years old. Most (59%) of the HIV-positive patients also were positive for hepatitis B core antibody. Many (76%) of the HIV-positive patients were known to be positive by the emergency health care worker. CONCLUSION: HIV seroprevalence among the ED patients in Portland, OR, was generally stable from 1988 to 1991. Many HIV-positive patients also were hepatitis B-positive, thus representing a double occupational infectious disease risk to ED personnel. A significant minority (24%) of the HIV-positive patients were not known to be HIV-positive by the ED personnel. Universal precautions and hepatitis B immunization are paramount for reducing the risk of infectious disease due to exposure to body fluids.

A public health approach to emergency medicine: preparing for the twenty-first century.

This paper focuses on the implications of an inadequate public health/preventive health care system for emergency medicine (EM), the role that EM providers can play in remedying critical health problems, and the benefits gained from a public health approach to EM. A broad definition of public health is adopted, suggesting shared goals of public health and EM. Critical problems posed for EM include alcohol, tobacco, and other drug abuse; injury; violence; sexually transmitted diseases and human immunodeficiency virus (HIV) infection occupational and environmental exposures; and the unmet health needs of minorities and women. A blueprint for future merging of public health issues with EM is presented that includes the application of public health principles to 1) clinical practice; 2) public education, community involvement, and public policy advocacy; 3) development of medical school and residency public health/prevention curricula and teaching methods; and 4) research opportunities and surveillance. Finally, recommendations are proposed that require restructuring the present health care system to provide resources, incentives, and organizational changes that promote an integration of public health and preventive services in the practice of EM.

ExacTech blood glucose meter clinical trial.

INTRODUCTION: Current prehospital protocols for the management of patients with altered mental status include the empiric administration of hypertonic glucose, naloxone, and thiamine. The injudicious use of 50% dextrose (D50W) may result in hyperosmolarity, a worsening of hypokalemia, and unwarranted additional health-care costs for the patient. The administration of D50W also may worsen the neurological outcome of patients with local or generalized ischemia. OBJECTIVE: To evaluate the ExacTech blood glucose meter's ability to estimate blood glucose levels accurately and rapidly. METHODS: Emergency medical technicians (EMTs) from selected advanced life support (ALS) units in the Portland, Ore., metropolitan area participated in a prospective clinical trial of the ExacTech blood glucose meter. A convenience sample was drawn from emergency medical services (EMS) patients with suspected diabetic emergencies, altered mental status, and other neurological deficits. Venous blood samples were drawn from these populations at the same time as the ExacTech readings were obtained. The venous blood was submitted to the receiving hospitals for laboratory analysis of blood glucose levels, and a comparison was made between the results of the two methods. RESULTS: A total of 80 matched sets of data were obtained from 1 April 1990 through 6 May 1991. The hospital blood glucose values ranged from 8 to 1233 mg/dl. Sixteen (20%) of the patients were hypoglycemic (&.lt.60 mg/dl) and 23 (28.8%) were hyperglycemic ( greater than 180 mg/dl). The ExacTech device sensitivity and specificity for hypoglycemia using venous samples were 94.6% and 89.2%, respectively. For hyperglycemia, these same parameters were 87.5% and 97.1%. Pearson's r over the range of the instrument (40-450 mg/dl) was 0.8656 (p less than .001). If the prehospital "definition" of hypoglycemia (for threshold-to-treat) is raised to 65 mg/dl, the device has 100% sensitivity in the sample population. CONCLUSION: The device functioned accurately and consistently in the prehospital environment over a wide range of temperatures, and in the hands of many different individuals.

Job satisfaction of paramedics: the effects of gender and type of agency of employment.

STUDY OBJECTIVES: To document specific factors important in paramedic job satisfaction and job performance. DESIGN AND TYPE OF PARTICIPANTS: A cohort analysis sampled 63 male public-agency paramedics and 131 private-agency paramedics (90 male, 41 female). METHODS: Three scales from the Michigan Organizational Assessment Questionnaire measured total job satisfaction. A four-item scale assessed attitudes toward paramedic job performance. RESULTS: Fire paramedics reported highest levels of overall satisfaction, followed by male and female private-agency paramedics. Fire paramedics reported higher levels of intrinsic job satisfaction (eg, opportunity to learn new things) than private-agency paramedics. Differences in extrinsic job satisfaction (eg, pay, benefits) were even greater between fire paramedics and private-agency paramedics. Fire paramedics reported higher satisfaction than female private-agency paramedics with the social rewards of work (eg, the way they are treated by their coworkers). These findings were not explained by age, race, education level, and years on the job. Analysis of the attitudes toward paramedic job performance scale suggested that male paramedics are more likely to believe that female paramedics are not as capable of performing certain job functions. CONCLUSION: Type of agency and gender affect job satisfaction. Male public-agency paramedics are most satisfied, and female private-agency paramedics are least satisfied with their jobs.

Occupational infectious disease exposures in EMS personnel.

Reports of occupationally transmitted hepatitis B virus (HBV) and human immunodeficiency virus (HIV) prompted the Portland Bureau of Fire Rescue and Emergency Services (PFB) to institute a comprehensive program for handling and tracking on-the-job infectious disease exposures. Data were collected for a 2-year period beginning January 1, 1988, and ending December 31, 1989, utilizing verbal and written exposure reports, prehospital care reports, and PFB statistical information. Two hundred and fifty-six (256) exposures were categorized. The overall incidence of reported exposure was 4.4/1,000 emergency medical service (EMS) calls. Of these exposures, 14 (5.5%) were needle sticks, 15 (5.9%) were eye splashes, 8 (3.1%) were mucous membrane exposures, 38 (14.8%) were exposure to nonintact skin, 120 (46.9%) were exposures to intact skin, and 61 (23.8%) involved respiratory exposure only. The incidence of exposure of nonintact skin or mucous membranes to blood or body fluids and needle sticks was 1.3/1,000 EMS calls. Forty-eight individuals (64% of those incurring needle sticks, or exposure of non-intact skin or mucous membranes to blood or body fluids) were treated and followed for signs of infection. Of this group, 11 individuals (26%) previously vaccinated against hepatitis B demonstrated inadequate HBsAb titers at the time of exposure. Requests for HIV and HBV information on source patients were made for needle sticks or exposure of nonintact skin or mucous membranes to blood or high-risk body fluids. Information on the source patient's HIV status was obtained for 57% of these requests.(ABSTRACT TRUNCATED AT 250 WORDS)

Multicenter HIV and hepatitis B seroprevalence study.

Prior single institutional investigations have found unrecognized HIV seroprevalence in emergency department (ED) patients to range from 0.38% to 4%. A prospective, anonymous study of HIV and hepatitis B (HB) seroprevalence was performed on excess serum of all ED patients over two 48-hour periods in May and August, 1988, from 7 hospitals in the Portland metropolitan area. Demographics were known for 338/444 (76%) of patients. Forty-six percent were male, 85% white, with a median age group of 30-39 years. Ambulance transport, trauma, external blood, presentations requiring ED procedure(s), and acuity resulting in ICU admission were present on 21%, 7%, 10%, 34%, and 14% of patients, respectively. Two of 444 (.45%) patients were HIV +, one previously undiagnosed. Fifty-five of the 444 (12%) and 3 of 444 (0.6%) samples were positive for HBcAB and HBsAG respectively. Risk factor assessment was possible on 180/444 (40%) patients. HBcAB seroprevalence correlated with race (P less than 0.01), IV drug use (P less than 0.0001), and hospital location, (P less than 0.006) but were sensitive in detecting only 14%, 18%, and 38%, respectively, of HBcAB+ patients. HBcAB was not associated with the following factors: sex, area of residence, presence of blood externally, trauma, acuity of illness, ED procedures, or mode of transport. This data strongly support the use of universal body fluid precautions. Hepatitis B poses a significant and distinct risk to all emergency care providers. HB vaccination should be strongly advocated for all ED health care workers (HCWs). Emergency medicine multicenter studies are both desirable and feasible.

Multicenter hypothermia survey.

A multicenter survey evaluated the clinical presentation, treatment, and outcome of accidental hypothermia. Data were collected from 13 emergency departments, with 401 of the 428 cases presenting during a two-year study period. Core temperatures ranged from 35 C to 15.6 C (mean, 30.57 C +/- 3.53) with 272 cases (63.6%) less than or equal to 32.2 C. There were no significant differences by age in presenting temperature, rewarming strategies, or mortality. The first hour rewarming rate was significantly (P less than .05) faster in the population less than or equal to 59 years (1.08 +/- 1.39 C/hr) than in those greater than or equal to 60 years (0.75 +/- 1.16 C/hr). Male core temperatures averaged 30.27 +/- 3.44 C versus female temperatures of 31.1 +/- 3.61 C. There were no clinically significant differences in male (N = 296) versus female (N = 132) profiles. High ethanol levels (315 to 800 mg%) did not affect outcome. Nine of 27 (33%) patients who received CPR initiated in the field survived, versus six of 14 (43%) with CPR begun in the ED. The profile of the CPR versus non-CPR population differed significantly (P less than .05) in location (outdoors), initial temperature (24.8 +/- 3.77 C vs 30.94 +/- 3.12 C), third-hour rewarming rate (2.28 +/- 1.53 C vs 1.17 +/- 1.18 C/hr), and numerous laboratory parameters. Tracheal intubation was performed without incident in 117 cases, of which 97 were less than or equal to 32.2 C. There were 73 fatalities (17.1%). Of these, 84.9% (N = 62) were less than or equal to 32.2 C. Predisposing conditions in this group included "serious" illness (30), systemic infection (28), trauma (15), immersion (ten), frostbite (seven), and overdose (two). The initial pulse, hemoglobin, and first-hour rewarming rate was lower in the deceased population, while the potassium, urea nitrogen, creatinine, and phosphorus were elevated. Excluding treatment combinations, outcome with exclusive use of a single rewarming strategy was passive external rewarming, 14 deaths below 32.2 C, 13 above; active external rewarming, six deaths below 32.2 C, two above; active core rewarming, 38 deaths below 32.2 C, none above. Refinements of the American Heart Association's CPR standards in hypothermia and a Hypothermia Survival Index are proposed.

Community-acquired methicillin-resistant Staphylococcus aureus endocarditis in the Detroit Medical Center.

Between June 1980 and September 1981 we evaluated 24 cases of endocarditis from methicillin-resistant Staphylococcus aureus. All of the cases occurred in drug addicts and all were community-acquired. The patients ranged in age from 21 to 59 years and represented an older population than that generally reported for bacterial endocarditis in addicts. Men and women were equally represented (one man presented twice). This unusually high proportion of women may reflect a difference in the rate and location of carriage of methicillin-resistant S. aureus compared with that of methicillin-sensitive staphylococci. Three patients died, one of whom had signed out of the hospital on the 14th day and returned moribund 27 days later. Vancomycin treatment for 28 days was adequate therapy for most patients.