High-sensitivity electronic Stark spectrometer featuring a laser-driven light source.

We report developmental details of a high-sensitivity Stark absorption spectrometer featuring a laser-driven light source. The light source exhibits intensity fluctuations of ∼0.3% over timescales ranging from 1 min to 12 h, minimal drift (≤0.1%/h), and very little 1/f noise at frequencies greater than 200 Hz, which are comparable to or better than an arc-driven light source. Additional features of the spectrometer include balanced detection with multiplex sampling, which yielded lower noise in A, and constant wavelength or wavenumber (energy) spectral bandpass modes. We achieve noise amplitudes of ∼7 × 10-4 and ∼6 × 10-6 in measurements of single A and ΔA spectra (with 92 data points) taking ∼7 and ∼19 min, respectively.

Reassessment: neuroimaging in the emergency patient presenting with seizure (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.

OBJECTIVE: To reassess the value of neuroimaging of the emergency patient presenting with seizure as a screening procedure for providing information that will change acute management, and to reassess clinical and historical features associated with an abnormal neuroimaging study in these patients. METHODS: A broad-based panel with topic expertise evaluated the available evidence based on a structured literature review using a Medline search from 1966 until November 2004. RESULTS: The 15 articles meeting criteria were Class II or III evidence since interpretation was not masked to the patient's clinical presentation; most were series including 22 to 875 patients. There is evidence that for adults with first seizure, cranial CT will change acute management in 9 to 17% of patients. CT in the emergency department for children presenting with first seizure will change acute management in approximately 3 to 8%. There is no clear difference between rates of abnormal emergent CT for patients with chronic seizures vs first. Children <6 months presenting with seizures have clinically relevant abnormalities on CT scans 50% of the time. Persons with AIDS and first seizure have high rates of abnormalities, and CNS toxoplasmosis is frequently found. Abnormal neurologic examination, predisposing history, or focal seizure onset are probably predictive of an abnormal CT study in this context. CONCLUSIONS: Immediate noncontrast CT is possibly useful for emergency patients presenting with seizure to guide appropriate acute management especially where there is an abnormal neurologic examination, predisposing history, or focal seizure onset.

The quick confusion scale in the ED: comparison with the mini-mental state examination.

The Quick Confusion Scale (QCS) is a 6-item battery of questions focusing on orientation, memory, and concentration weighted to yield a top score of 15. Analysis of the QCS compared with the Mini-Mental State Examination (MMSE) is needed to determine if the QCS is a valid marker of cognitive mental status. The MMSE and the QCS were administered to a convenience sample of 205 patients presenting to the emergency department. Exclusions included head trauma, multisystem trauma, Glasgow Coma Scale less than 15, non-English speaking, education level less than 8 years, contact or droplet isolation, acute illness, or incomplete data for reasons such as restricted patient access. Mean scores were 24.8(SD = 4.7; range 2-30) on the MMSE and 11.89 (SD = 3.5; range 0-15) on the QCS. QCS scores were significantly correlated (r = .783) with MMSE scores. The QCS appears comparable with the MMSE and is quicker to administer.

Emergency department management of patients with seizures: a multicenter study.

OBJECTIVES: Patients with seizure disorders are common in the emergency department (ED), yet little is known regarding the management of these patients. This study was performed to define the frequency of patients with seizure disorders in the ED patient population and to determine possible seizure etiologies, characteristics of diagnostic activities, treatments, and dispositions. METHODS: Twelve EDs monitored all patients with a chief complaint related to seizure disorders presenting over 18.25 days (5% of the calendar year) in late 1997. Retrospective chart review was used to gather specific data regarding these consecutive cases. RESULTS: Of the 31,508 patients who presented to these 12 EDs during the study period, 368 (1.2%) had complaints related to seizures. Three hundred sixty-two charts were available for analysis and make up the study population. Two hundred fifty-seven (71%) utilized emergency medical services (EMS) for transport and care. Advanced care, including intravenous access, laboratory work, cardiac monitoring, or oxygen administration, was utilized in 304 (84%) patients. Antiepileptic drugs were given in 199 (55%) patients. Ethanol withdrawal or low antiepileptic drug levels were implicated as contributing factors in 177 (49%) of patients. New-onset seizures were thought to be present in 94 (26%) patients. Status epilepticus occurred in only 21 (6%) patients. Ninety-eight (27%) of all patients were admitted to the hospital. CONCLUSIONS: Patients with presenting complaints related to seizures are frequent in the ED population and make considerable demands on EMS and ED resources. Six percent of patients with seizure-related presentations were in status epilepticus and more than a fourth of all patients required hospitalization.

Concussive convulsions: emergency department assessment and management of a frequently misunderstood entity.

Immediate concussive convulsions are an unusual but dramatic sequela to head injuries. Previously believed to be an epileptic phenomenon, they are now thought to be a brief traumatic functional decerebration that results from loss of cortical inhibition. With concussive convulsions generally occurring within seconds of head impact and lasting up to several minutes, patients are initially in a tonic phase, followed by a clonic convulsion. A postictal phase is generally brief if it occurs at all with these episodes. Patients with isolated concussive convulsions have no evidence of structural brain injury as assessed with neuroimaging studies or physical examination. Neuropsychological testing often demonstrates transient cortical dysfunction consistent with the concussive episode. The long-term outcome for patients with isolated concussive convulsion is universally good, with no long-term neurologic sequelae and no increased incidence of early or late posttraumatic epilepsy. Emergency department management should focus on evaluation of the associated concussive injury. The concussive convulsion requires no specific therapy, and antiepileptic medication is not indicated.

The use of the mini-mental status examination in the ED evaluation of the elderly.

This study was done to examine the impact of the mini-mental status examination (MMSE) in the emergency department (ED) evaluation of the elderly patient. The study was a prospective study of the MMSE applied by the investigators with a comparison to the findings of the treating physician, in a university hospital ED with annual volume of 60,000. Participants were a convenience sample of patients older than 65 years of age without apparent mental status abnormality presenting to the ED. Seventy-four patients were entered in the study with 43 exclusions (23 with low educational level, 5 with Glasgow Coma Scale score of <15, and 15 other) leaving 31 cases for analysis. Of the 31 patients, 20 patients had an MMSE score of <24. The MMSE findings agreed with the treating physicians' assessments in 21 (67%) cases. Disagreement occurred in 10 (32%) cases in which the treating physician believed that both the patient's mental status and results of the investigator's MMSE were normal; these 10 cases all involved low MMSE scores as performed by the investigator. When informed of the abnormal MMSE, both the physician's estimate of the patient's mental status and the patient's ED course were altered in all cases. These results show that the MMSE is a valuable screening tool to assess the mental status of the elderly in the ED setting. Unexpected abnormality was noted in a significant minority of patients in this study, altering the patient's course in all instances. The MMSE should be considered in evaluation of all geriatric patients encountered in the ED.

Selective role of partial XI-VII anastomosis in facial reanimation.

OBJECTIVES: Review techniques available for transposition of an alternative motor neuron if end-to-end anastomosis or interposition nerve grafting cannot be accomplished when there has been a complete facial nerve loss. Describe the selective use of a partial spinal accessory-facial nerve anastomosis and highlight cases when this may be a useful alternative. Describe the modifications of decompression of the facial nerve for tension-free anastomosis and the use of the muscle pedicle for repair of cerebrospinal fluid leakage. STUDY DESIGN: Report of three cases and a review of the literature. METHODS: Charts were reviewed and indications for the procedure were analyzed. The degree of facial movement was recorded as well as the resolution of any cerebrospinal fluid leak. RESULTS: The results varied between Class III and Class IV on the House-Brackmann scale following initial complete paralysis. In the two cases in which spinal fluid leakage had occurred before surgery the leakage was resolved. No donor site morbidity was noted. CONCLUSIONS: The potential of low morbidity associated with the use of the sternocleidomastoid branch, along with the potential for delivering a vascularized muscle pedicle to the temporal bone region, makes selective use of this procedure a valuable addition to the multiple reconstruction options for the paralyzed face.

Comparison of peak expiratory flow rate with speaking time in ED patients presenting with acute exacerbation of asthma.

Thirty-six patients with a history of asthma who presented to an emergency department (ED) with an acute exacerbation were studied prospectively to determine if a correlation existed between peak expiratory flow rate (PEFR) and speaking time. Each patient listened to an instructional audiotape on the proper method of counting and then maximally inhaled and counted until it became necessary to take a second breath. This represented the patient's "speaking time" in seconds. A PEFR was then obtained using a hand-held peak flow meter. The speaking time and PEFR were measured before and after each nebulized albuterol treatment. A total of 169 pairs of pretreatment and posttreatment PEFR and speaking time measurements were obtained. Regression analysis of the PEFR and speaking time demonstrated the PEFR can be predicted by the speaking time with statistical significance (P < .0001). The regression analysis equation was: peak flow (L/min) = 114.8 +/- (17.6 x speaking time).

A multicenter study to improve emergency medicine residents' recognition of intracranial emergencies on computed tomography.

STUDY OBJECTIVE: Cranial computed tomography (CT) has assumed a critical role in the practice of emergency medicine for the evaluation of intracranial emergencies. Several recent studies have documented a deficiency in the emergency physician's ability to interpret these studies. The purpose of this study was to quantify the baseline ability of emergency medicine residents to interpret cranial CTs, and to test a novel method of cranial CT interpretation designed for the emergency physician in training. METHODS: A standardized pretest was administered to assess baseline ability to interpret CT scans. A standardized posttest was given 3 months after the course. Each test consisted of 12 CT scans with a short accompanying history. All scans were validated by 3 expert reviewers for difficulty and diagnosis. A 2-hour course based on the mnemonic "Blood Can Be Very Bad" was then administered. "Blood" reminds the examiner to search for blood, "Can" prompts the examiner to identify 4 key cisterns, "Be" denotes the need to examine the brain, "Very" prompts a review of the 4 ventricles, and finally "Bad" reminds the examiner to evaluate the bones of the cranium. RESULTS: Eighty-three residents at 5 institutions were initially examined. The mean percentage correct before the course was 60% (95% confidence interval [CI] 58%-64%) on the standardized pretest. At retesting 3 months after the course, the accuracy rate increased to 78% (n=61, 95% CI 75%-81%, P<.001 paired t test). CONCLUSION: Emergency medicine residents are deficient in their ability to interpret cranial CT scans. A novel educational course was demonstrated to significantly improve this ability.

New-onset sensory loss or alteration.

New-onset sensory loss often poses a problem for emergency physicians because of the vast array of potential causes for this condition and the imprecision patients display in explaining their condition. This article reviews potential causes of particular interest to the emergency physician and illustrates approaches to sensory alteration complaint with case studies.

Pseudotoxemia: new onset psychogenic seizure in third trimester pregnancy.

Eclampsia, or toxemia of pregnancy, is a disorder of pregnancy characterized by seizures associated with hypertension, edema, and proteinuria. Toxemia carries significant maternal and fetal morbidity and mortality. Psychogenic seizures are defined as events that clinically resemble epileptic seizures but are not accompanied by abnormal electrical activity of the cerebral cortex. We report the case of a third trimester pregnant patient who presented with new onset convulsive activity that was associated with peripheral edema, intermittent hypertension, and proteinuria. The initial impression of the treating physicians--emergency medicine, obstetrical, and neurology--was toxemia of pregnancy. After further review and the application of numerous procedures and therapies with potential risk, the diagnosis of psychogenic seizure was made.

Comparison of a colorimetric end-tidal CO2 detector and an esophageal aspiration device for verifying endotracheal tube placement in the prehospital setting: a six-month experience.

INTRODUCTION: Hand held, colorimetric, end-tidal CO2 detector devices are being used to verify correct endotracheal tube (ETT) placement. The accuracy of these devices has been questioned in situations of cardiac arrest. The use of the esophageal detector device (EDD) is an easy alternative for detection of ETT placement, and may be more accurate in situations of cardiac arrest. HYPOTHESIS: The use of the esophageal aspiration device in comparison with a colorimetric end-tidal CO2 detector is more accurate in detecting proper ETT placement and easier to use in the prehospital setting than is the colorimetric end-tidal CO2 detection device. METHODS: This was prospective alternating weeks, 6-month study in a prehospital setting. Participants included all patients older than 18 years who were intubated by the Portsmouth, Virginia Emergency Medical Services (EMS) personnel from 01 July 1993 through 31 December 1993. The aspiration device used, also known as an esophageal detector device (EDD), was a 60 ml, luer-lock syringe attached to a 15 mm ETT adapter. Its efficacy was compared with an already accepted method of ETT position detection, the colorimetric end-tidal CO2 detector. Each device was used on alternating weeks, and correct ETT placement was determined by the receiving emergency department physician using standard techniques. Chi-square analysis and Fisher's Exact test were used to compare parameters, time of device use, and ease of use. Sensitivity and specificity were calculated, and provider preference was assessed using a survey instrument administered following completion of the study. RESULTS: There were 49 patients who met the inclusion criteria, but six were excluded because of situational circumstances rendering use of the device a possible compromise of patient care. Twenty-five patients were in the EDD group, and 18 were in the end-tidal CO2 detector group. There was no statistically significant difference detected between groups for the gender ratio, underlying condition, CPR in progress, perceived difficulty of intubation, or percentage of nasotracheal intubation. The EDD was significantly easier to use (p < 0.005). There was no statistically significant difference in time required for use of end-tidal CO2 detector device versus the EDD. The sensitivity and specificity for correct tracheal placement using the EDD was 100%, and the sensitivity for correct tracheal placement using the end-tidal CO2 detector device was 78%. Use of the EDD was preferred over use of the end-tidal CO2 detector device by 75% of participating EMS providers. One case of nasotracheal intubation with an ETT placement above the cords raised the question of accuracy of this device in situations where direct visualization is not utilized. CONCLUSION: The EDD was accurate in all cases of orotracheal intubation, and was easier to use than was end-tidal CO2 detector device. It was preferred by 75% of participating EMS providers. In cases in which the ETT may be above the vocal cords, caution must be used with interpreting the results obtained by use of the EDD.

Hemiballismus as a presenting sign of hyperglycemia.

A 53-year-old man arrived at the emergency department after the onset of progressive hemiballismus. This movement disorder was the only manifestation of his hyperglycemic state. Prompt recognition of the association of unusual movement disorders with nonketotic hyperglycemia will allow for prompt treatment.

Case conference: complete heart block in a young man.

A previously healthy 32-year-old man presented to the ED in complete heart block. Ischemic, infectious, and inflammatory conditions were considered in the differential diagnosis. Management options for complete heart block, the etiology of heart block in young adults, and treatment guidelines are reviewed.

Dr. C. Miller Fisher's description of acute cerebellar hemorrhage.

The clinical picture of acute cerebellar hemorrhage and the necessity for rapid recognition and intervention were described by Dr. C. Miller Fisher over 25 years ago. Many of his observations and comments are relevant to current practice.

Judicial outcome for the intoxicated driver admitted to a regional trauma center.

OBJECTIVE: To examine the judicial outcomes for intoxicated drivers who were admitted to regional trauma centers as a result of motor vehicle collisions (MVCs). METHODS: A retrospective review of the trauma registry of a Level I trauma center was conducted for the period from January 1, 1989, through December 31, 1990. Inclusion criteria for entry into the study were 1) identification of the patient as the driver involved in an MVC, 2) a blood alcohol content (BAC) above 0.10 g/dL, and 3) survival until discharge from the hospital. A total 245 patients from the trauma registry met the inclusion criteria. The number of persons from the submitted list who were later convicted of driving under the influence of alcohol (DUI) was obtained from the Department of Motor Vehicles (DMV) of the Common- wealth of Virginia. RESULTS: Of the list submitted to the DMV, only nine individuals (3.7%; 95% confidence interval = 1.3--6.0%) were convicted of DUI during the MVCs that led to hospitalization during the study period. During the same time period, the statewide conviction rate for DUI-cited drivers was 85%. CONCLUSION: Admission to the trauma service at a Level I trauma center may provide a refuge from legal consequences for intoxicated drivers involved in MVCs.

Spinal epidural hematoma associated with cocaine abuse.

A 41-year-old man rapidly developed quadriparesis moments after injecting cocaine. Investigation discovered a cervical spinal epidural hematoma. This complication of cocaine abuse has not been previously reported.