Adaptation of Predictive Models to PDA Hand-Held Devices.

Prediction models using multiple logistic regression are appearing with increasing frequency in the medical literature. Problems associated with these models include the complexity of computations when applied in their pure form, and lack of availability at the bedside. Personal digital assistant (PDA) hand-held devices equipped with spreadsheet software offer the clinician a readily available and easily applied means of applying predictive models at the bedside. The purposes of this article are to briefly review regression as a means of creating predictive models and to describe a method of choosing and adapting logistic regression models to emergency department (ED) clinical practice.

Leukocytosis as a predictor of severe injury in blunt trauma.

OBJECTIVE: The objective of this study was to determine if the white blood cell count can predict severity of injury in blunt trauma victims. METHODS: This was a retrospective study comparing two groups of blunt trauma victims by severity of injury, one with significant injury and one without significant injury, and comparing their initial WBC in the emergency department (ED). We also examined if WBC correlates with degree of injury using Injury Severity Score (ISS) in both groups combined. Further, we examined the WBC as a predictor of serious injury. RESULTS: Our study showed a difference in mean WBC between the two groups that was statistically significant (p<0.001). A positive relationship between ISS and WBC was found, although the association was weak (correlation coefficient = 0.369). While the WBC had moderate discriminatory capability for serious injury, it could not, in isolation, reliably rule in or out serious injury. Nevertheless, this study supports using WBC on presentation to the ED as an adjunct for making disposition decisions. CONCLUSION: A significant elevation in WBC in a blunt trauma patient, even with minimal initial signs of severe injury, should heighten suspicion for occult injury.

Rapid oral loading of carbamazepine in the emergency department.

STUDY OBJECTIVE: This study evaluates the safety and efficacy of rapid oral loading of carbamazepine in the emergency department (ED). METHODS: Adult patients receiving maintenance carbamazepine who presented with negligible levels received an oral load of carbamazepine suspension, with a dose of 8 mg/kg. RESULTS: Forty-two oral loads among 36 patients were studied. Mean subject age was 36 years; 61% of the sample were male patients. The actual load administered ranged from 7.9 to 8.6 mg/kg. The mean 3-hour carbamazepine level (therapeutic 4 to 12 microg/mL) was 6.5 microg/mL (SD 2.0 microg/mL). Three patients had subtherapeutic levels after loading (successful loading rate 93%). Adverse effects occurred in 58% of patients, most commonly drowsiness (26%) and nausea (23%). Other adverse effects included dizziness, nystagmus, abdominal pain, vomiting, ataxia, and double vision. Two patients were treated for vomiting. All other adverse effects were mild and self-limited. CONCLUSION: Rapid oral loading of carbamazepine in the ED in this cohort, although effective, was associated with a high rate of adverse effects. Given a sample size of 36, 95% confidence intervals suggest that the rate of serious adverse effects may be as high as 9.7% and that the rate of successful loading may be as low as 76.9%.

Fatal pulmonary embolism in a 10-year old with nephrotic syndrome.

We present a case report of a 10-year-old male with nephrotic syndrome who presented with a complaint of shortness of breath. The patient had been recently hospitalized for an exacerbation of nephrotic syndrome and had received steroid and diuretic therapy. Initial vital signs showed tachycardia and mild tachypnea. After being observed for more than four hours without deterioration he was discharged home for close follow up. The patient returned 4 hours later with worsening symptoms and went into cardiac arrest in the ED. Autopsy revealed bilateral large pulmonary emboli. Pulmonary embolism is a known complication of nephrotic syndrome. Hyperviscosity occurs due to a variety of mechanisms. Nearly all reported incidents are associated with the use of steroids and diuretics. It is essential to maintain a heightened suspicion of pulmonary embolism (PE) when children with nephrotic syndrome present with pulmonary complaints, particularly when they have been treated with steroids and diuretics.