Adjuvant N-(2-mercaptopropionyl)-glycine in blood cardioplegia does not improve myocardial protection in ischemically damaged hearts.

Oxyradicals potentially limit the myocardial protection provided by blood cardioplegia in ischemically damaged hearts. We tested the hypothesis that the addition to blood cardioplegic solution of a new oxyradical scavenger--N-(2-mercaptopropionyl)-glycine--would result in improved left ventricular performance and oxygen consumption compared to that resulting from the use of blood cardioplegia alone. Gauges and transducer-tipped catheters for left ventricular minor axis ultrasonic dimension were placed in 17 open-chest dogs, and instantaneous left ventricular pressure-diameter data were acquired by computer. The aorta was crossclamped for 30 minutes during total vented bypass to induce ischemic injury. The heart was reoxygenated and protected by multidose, hypothermic blood cardioplegic solution alone (n = 9) or enhanced with 0.0132 mmol N-(2-mercaptopropionyl)-glycine (n = 8) for 1 hour of cardioplegia-induced arrest. Preischemic and postischemic left ventricular performance was measured by slope changes in end-systolic pressure-diameter relations induced by gradual afterload reduction during right heart bypass. When blood cardioplegia alone was used, postischemic left ventricular systolic performance was depressed by 73.2% +/- 10.0% (166.8 +/- 56.1 mm Hg/mm versus 25.1 +/- 7.0 mm Hg/mm). N-(2-mercaptopropionyl)-glycine did not significantly attenuate this functional depression (62.7% +/- 9.0%, 146.6 +/- 67.6 mm Hg/mm versus 33.6 +/- 11.9 mm Hg/mm). The postischemic end-diastolic pressure-diameter relation was shifted to the right, whereas chamber stiffness was increased comparably, with or without N-(2-mercaptopropionyl)-glycine. Postischemic oxygen consumption in the beating working state, calculated from left ventricular blood flow (measured by microspheres) and arterial-coronary sinus oxygen extraction, averaged 7.8 +/- 0.9 ml O2/100 gm/min with blood cardioplegia alone and 7.5 +/- 1.0 ml O2/100 gm/min with N-(2-mercaptopropionyl)-glycine, and was unchanged from paired preischemic values in both groups. We conclude (1) that N-(2-mercaptopropionyl)-glycine added to blood cardioplegic solution in the dose and delivery regimen tested did not improve ventricular systolic and diastolic performance compared with blood cardioplegia alone and (2) that postischemic oxygen consumption may not parallel the extent of left ventricular functional recovery.

A retrospective review of air bag deaths.

OBJECTIVE: To describe occupant and crash characteristics in the first 27 publicly released investigations of air-bag-related fatalities. METHODS: A retrospective review of the first 27 released crash investigations of air-bag-induced fatalities was conducted. Data were obtained by the National Highway Traffic Safety Administration. RESULTS: Three separate groups of occupants are described: adult drivers, school-aged children riding in the right front passenger seat, and infants installed into rear-facing infant car seats placed into the right front passenger seat. Female drivers were significantly likely to be short-statured. Male drivers tended to be slumped over the wheel. Eleven children (100%) were improperly restrained and thrown forward by preimpact braking. Adults tended to have serious chest injuries, while children tended to have CNS or neck injuries. All three infants had fatal CNS injuries. The average deltaV (change in the vehicle's velocity at the moment of impact) was 12 mph and the average bumper crash was 8.8 inches. CONCLUSIONS: Air bags can cause fatal injury to car occupants in low- or moderate-speed crashes. Data suggest that proximity to the air bag at the time of deployment is the critical risk factor for fatal injury.

Color Doppler ultrasonography by emergency physicians for the diagnosis of acute deep venous thrombosis.

OBJECTIVES: To assess the feasibility of emergency physicians' (EPs') performing color-flow Doppler ultrasonographic vascular studies in the ED to diagnose deep venous thrombosis (DVT), after a modest training program. METHODS: A retrospective observational review was performed of the performance of color-flow Doppler ultrasonographic vascular studies by EPs. Prior to the study period, venous Doppler studies were not available at off-hours. Two attending EPs were trained by the hospital's vascular laboratory by observing studies and then performing 25-30 studies successfully. They were then available to examine all patients presenting to the ED at off-hours who were suspected of having DVT. Patients were admitted or released from the ED based on the examination results. All patients were to have formal vascular laboratory studies the next day. The study was performed at a university hospital ED and evaluated all patients who underwent off-hour examinations from January 1993 to February 1994. The examiners were aware of the clinical scenario. RESULTS: Of 23 eligible patients, 15 completed the protocol with a follow-up next-day study. Based on the follow-up study, the ED examination was 100% sensitive (7 true positives) and 75% specific (6 true negatives). The 2 false-positive studies were for patients with old DVT. The 8 patients without follow-up studies were not included in the analysis, although 4 of these patients had negative studies and unremarkable clinical outcomes. CONCLUSIONS: These preliminary findings suggest that Doppler ultrasonographic studies of the lower extremity veins by EPs can be used to make admission decisions when formal studies are not available. Confirmatory studies should be performed. EPs may overread acute thrombosis in the setting of old venous disease. Issues of cost and logistics remain to be resolved.

Pediatric ophthalmology.

A wide variety of pediatric ophthalmologic diseases may present to the emergency physician. It is important for emergency physicians to know which diseases can be treated and which require urgent ophthalmologic intervention. Any asymmetry in a patient's ophthalmologic examination must be referred to a specialist for continuing care and definitive treatment. When identified early, strabismus, esotropia, or exotropia can be treated with significant benefit to the child's vision in the future. Abnormalities in size, shape, or color of the anterior portions of the eye are easily detected with inspection and may be indications of more serious illnesses such as conjunctivitis, glaucoma, cataracts, or tumors. These entities can be recognized by their distinguishing characteristics, and treatment can be initiated. Chlamydial and herpetic conjunctivitis, orbital cellulitis, posterior uveitis, and glaucoma are a few of the more urgent problems that may present to the emergency physician and should not be missed. A good history and careful examination will prevent the devastating effects of these diseases.

Accidental hypothermia.

Hypothermia continues to be a major public health problem and a challenge to health care providers. The very young, the very old, and the poor are at greatest risk. Life-threatening physiologic changes make rapid rewarming mandatory. Numerous rewarming methods have been described in the literature; the decision to use any of the methods available depends on the degree of hypothermia present, the condition of the patient, and the rewarming rate possible with the method chosen. Cardiopulmonary bypass, if available, is the optimal method for rewarming the severely hypothermic patient.

Vascular ultrasonography.

Although vascular ultrasonography has been established as an essential diagnostic tool in many clinical settings, its role in the emergency department patient population is uncertain. Preliminary reports of emergency physician--directed ultrasonography are promising. Further studies are needed to establish its reliability and suitability in the emergency department setting.

Emphysematous cholecystitis in an elderly woman: case report and review of the literature.

Cholecystitis, a frequent diagnosis in emergency departments, has been discussed extensively in the medical literature. We report a case of emphysematous cholecystitis, an unusual form of this disease process, including the classic radiographic findings. We also offer a review of the literature, emphasizing the proposed pathophysiology and the life-threatening nature of this surgical condition. Early recognition and surgical consultation are vital in these patients.

Loiasis: a case of an unusual ocular foreign body.

Loiasis is a parasitic illness that is endemic in parts of Central and West Africa. In the United States, infection with Loa loa is seen in natives from that region of Africa and in those who have traveled to the area, often in the distant past. There can be significant differences in clinical manifestations between the two groups. We present a case of loiasis in an African native as well as a discussion of Loa loa infection in natives and non-natives and current treatment strategies.

Rhabdomyolysis secondary to keyboard overuse: occupational hazard of the computer age.

A 33-year-old man presented with rhabdomyolysis with bilateral forearm pain and a profoundly elevated creatine phosphokinase. The cause of his illness appears to be computer keyboard overuse soon after a viral illness. This is the first case report directly linking rhabdomyolysis with keyboard overuse.

Simplification of emergency department discharge instructions improves patient comprehension.

STUDY OBJECTIVE: Emergency department patients have been shown to have difficulty understanding written discharge instructions. We attempted to determine whether improvements in comprehension can be achieved by simplification of available materials. DESIGN: We have previously tested patient understanding of standard discharge instructions. For this study, we simplified the standard instructions. Patients were given one of two simplified instruction sets. After reading the instructions, each patient was asked to answer five specific written questions about them. Results were compared with those from the original study. SETTING: ED of a large inner-city university hospital. PARTICIPANTS: Four hundred twenty-three adult ED patients who presented on randomly selected days. RESULTS: The current and original groups were well matched for demographic variables. Each subject's responses were analyzed for overall success and for success with individual questions. The mean score for the current group was significantly improved over that of the original group. A trend toward improvement was demonstrated in all demographic groups with use of the simplified instructions. CONCLUSION: Simplified written materials may help patients who do not understand current standard materials. Health care providers should simplify written materials to make them understandable to the greatest number of patients.

A case presentation of Sweet's syndrome and discussion of life-threatening dermatoses.

Sweet first described acute febrile neutrophilic dermatosis in 1964. Since then, more than 425 cases of this typically benign, steroid-responsive disease have been recorded. Although often associated with myelodysplasic syndromes or hematologic malignancies, Sweet's syndrome has also been related to pregnancy, autoimmune disorders, and many drug therapies. Although it is not typically an acutely life-threatening illness, there is a potential for significant pulmonary involvement and respiratory compromise. Additionally, emergency physicians should be aware of this unusual disease and its frequent association with systemic illnesses. We report the first case of Sweet's syndrome in the emergency medicine literature and present a review and discussion of several common life-threatening dermatoses.

Functional illiteracy among emergency department patients: a preliminary study.

STUDY OBJECTIVES: To determine the ability of emergency department patients to understand common written discharge instructions and the level of reading difficulty of standard discharge instructions. DESIGN: The study was performed in two parts. In part 1, subjects were asked to read one set of standard written discharge instructions. Then, with the instructions to refer to, subjects were asked to answer five questions about the instructions. A subject's level of success was correlated with age, sex, and highest level of education. In part 2, 47 sets of standard written discharge instructions from six different EDs were computer analyzed using five commonly used readability formulas. Results were reported as grade levels. SETTING: The ED of a large inner-city university hospital. TYPE OF PARTICIPANTS: The subjects for part 1 were 400 adult ED patients who presented on randomly selected days. MEASUREMENTS AND MAIN RESULTS: Part 1: A significant proportion of patients failed to answer correctly at least four of five questions. Patients educated beyond high school demonstrated higher levels of success than did those with less education. A trend was noted for younger subjects to perform better than older subjects. The answers to the three most frequently missed questions were contained within areas of difficult sentence structure or long paragraphs containing large amounts of information. Part 2: The average grade level required to understand instruction sheets ranged from 6.0 to 13.4. More difficult instruction sheets tended to contain numerous multi-syllabic words, long sentences, and difficult sentence structure. CONCLUSION: A significant proportion of ED patients have a demonstrable inability to understand common written instructions. ED instruction sheets are written at a level of difficulty that is out of the readable range for many patients. Health care providers should strive to simplify written materials and to develop new methods for instructing those for whom current written materials have no meaning.

Evaluation of the Ottawa clinical decision rules for the use of radiography in acute ankle and midfoot injuries in the emergency department: an independent site assessment.

STUDY OBJECTIVE: Decision rules for the use of radiography in acute ankle and midfoot injuries have been developed. Radiographs are indicated if there is tenderness at the posterior edge or tip of either malleolus or at the navicular or base of the fifth metatarsal or there is inability to both weight bear immediately after the injury and ambulate four steps in the emergency department. This study assessed the efficacy of these rules with health care providers who had not been involved in their development. DESIGN: Prospective patient survey by emergency department attending physicians and triage nurses. SETTING: EDs of a university hospital and a community hospital with a combined annual volume of 100,000. PARTICIPANTS: One hundred ten patients older than 16 years who presented with acute blunt ankle and midfoot trauma during the 3 months of summer 1993. RESULTS: Fourteen fractures were diagnosed. When used by ED attending physicians, the decision rules had a sensitivity of 1.0 and specificity of 0.19 in detecting all midfoot and ankle fractures. When used by triage nurses, the sensitivity was 0.9 and specificity was 0.1. The negative predictive values of the decision rules were 1.0 for ED attending physicians and 0.88 for triage nurses. ED attending physicians and triage nurses agreed in 90% of cases regarding the overall decision to obtain radiographs. However, there was only a 47% agreement on all components of the clinical decision rules, with kappa values ranging from 0.60 to 0.76. The accuracies of the predictive rules were similar as applied by the ED attending physicians and the triage nurses (chi 2, P = .23). Application of the Ottawa predictive rules by ED attending physicians would have resulted in a 19% reduction in use of midfoot and ankle radiographs. CONCLUSION: Use of the Ottawa and midfoot clinical decision rules by ED attending physicians of institutions not familiar with the rules' development resulted in 100% sensitivity for all fractures and would have allowed these physicians to safely reduce the number of radiographs ordered by 19%.