Accuracy of an enzymatic assay device for serum ethanol measurement.

OBJECTIVE: To determine the accuracy of an enzymatic assay of serum to measure blood ethanol levels in the emergency department. METHODS: A blinded, prospective study of emergency department patients for whom a blood ethanol was ordered and performed. After skin prep with betadine, two blood samples were drawn into separate sodium fluoride-containing vacutainers. One sample was sent to the hospital laboratory for blood ethanol analysis. The other was centrifuged for 5 minutes and the serum was then assayed using the QED A350 Saliva Alcohol Test. Values were then compared by kappa statistic and Pearson's correlation. Sensitivity and specificity calculations were determined for the QED device to detect a blood ethanol > 100 mg/dL. RESULTS: Sixty-six patients were enrolled. The kappa value for QED compared to lab blood ethanol was 0.93. The Pearson's correlation coefficient was 0.94. The QED, in general, tended to overestimate blood ethanol slightly. The QED was 100% sensitive and 82% specific in detecting a blood ethanol > 100 mg/dL. CONCLUSIONS: Analysis of serum using a QED A350' is a sensitive and accurate index of low to moderate increases in blood ethanol appropriate to emergency department, but not legal, interpretation.

Effectiveness of mechanical versus manual chest compressions in out-of-hospital cardiac arrest resuscitation: a pilot study.

A prospective, randomized effectiveness trial was undertaken to compare mechanical versus manual chest compressions as measured by end-tidal CO2 (ETCO2) in out-of-hospital cardiac arrest patients receiving advanced cardiac life support (ACLS) resuscitation from a municipal third-service, emergency medical services (EMS) agency. The EMS agency responds to approximately 6,700 emergencies annually, 79 of which were cardiac arrests in 1994, the study year. Following endotracheal intubation, all cardiac arrest patients were placed on 100% oxygen via the ventilator circuit of the mechanical cardiopulmonary resuscitation (CPR) device. Patients were randomized to receive mechanical CPR (TCPR) or human/manual CPR (HCPR) based on an odd/even day basis, with TCPR being performed on odd days. ETCO2 readings were obtained 5 minutes after the initiation of either TCPR or HCPR and again at the initiation of patient transport to the hospital. All patients received standard ACLS pharmacotherapy during the monitoring interval with the exception of sodium bicarbonate. CPR was continued until the patient was delivered to the hospital emergency department. Age, call response interval, initial electrocardiogram (ECG) rhythm, scene time, ETCO2 measurements, and arrest outcome were identified for all patients. Twenty patients were entered into the study, with 10 in each treatment group. Three patients in the TCPR group were excluded. Measurements in the HCPR group revealed a decreasing ETCO2 during the resuscitation in 8 of 10 patients (80%) and an increasing ETCO2 in the remaining 2 patients. No decrease in ETCO2 was noted in the TCPR group, with 4 of 7 patients (57%) actually showing an increased reading and 3 of 7 patients (43%) showing a constant ETCO2 reading. The differences in the ETCO2 measurements between TCPR and HCPR groups were statistically significant. Both groups were similar with regards to call response intervals, patient ages, scene times, and initial ECG rhythms. One patient in the TCPR group was admitted to the hospital but later died, leaving no survivors in the study. TCPR appears to be superior to standard HCPR as measured by ETCO2 in maintaining cardiac output during ACLS resuscitation of out-of-hospital cardiac arrest patients.

Injuries distracting from intraabdominal injuries after blunt trauma.

While most conscious patients with severe intraabdominal injuries (IAI) will usually present with either abdominal pain or tenderness, there is a small group of awake and alert patients in whom the physical examination will be falsely negative because of the presence of associated extraabdominal ("distracting") injuries. We sought to define the types of extraabdominal injuries that could lead to a false negative physical examination for potentially severe IAI in adult victims of blunt trauma. This study was prospectively performed on consecutive blunt trauma patients over a 14-month period in our level I trauma center. Inclusion criteria were as follows: (1) Glasgow Coma Scale score of 15; (2) age 18 years or older; and (3) computed tomography (CT) of the abdomen or diagnostic peritoneal lavage (DPL) performed regardless of initial physical examination findings. Patients were questioned specifically about the presence of abdominal pain and the initial abdominal examination was documented in addition to other extraabdominal injuries. Abdominal injuries were considered to be present based upon either abdominal CT findings or a positive DPL. Patients with and without abdominal pain or tenderness were compared for the presence of IAI. A total of 350 patients were enrolled. There were 142 patients with neither abdominal pain nor tenderness (group 1) and 208 patients with either or both (group 2). Ten of the 142 patients (7.0%) in group 1 had IAI compared with 44 of the 208 patients (21.2%) in group 2 (P = .0003). Presence of pain and/or tenderness had a sensitivity of 82%, a specificity of 45%, a positive predictive value of 21%, and negative predictive value of 93%. All 10 patients in group 1, and 36 of the 44 group 2 patients, had associated extraabdominal injuries. Although the presence of abdominal pain or tenderness was associated with a significantly higher incidence of IAI, the lack of these findings did not preclude IAI.

Complication rates of tube thoracostomy.

This study compared the complication rates of tube thoracostomy performed in the emergency department (ED) versus the operating room (OR) and the inpatient ward (IW). A retrospective case series of all patients at an urban, university-based level 1 trauma center hospital who received tube thoracostomy for any indication between 1/1/93 and 12/31/93 was conducted. Complications were defined as empyema, unresolved pneumothorax (persistent air leak or residual pneumothorax), persistent effusion, or incorrect placement. The data for age and duration of tube placement were weighted for analysis of variance (ANOVA). A total of 352 tube thoracostomies was placed in 239 patients. Twenty-three patients had three or more chest tubes placed, 65 had two placed, and the remaining 181 had a single tube. Ninety-nine tubes were placed in the ED, 87 in the OR, and 166 on IW. The mean age of patients in the ED was 37 years, and differed significantly (P < .015) from those in the OR (48 years) and the IW (44 years). The duration of tube placement was similar for all groups (mean = 6.5 days). The overall complication rates related to tube insertion were: ED, 14.0%; OR, 9.2%; IW, 25.3%. Significance was achieved when comparing complication rates between the ED and IW, with less complications in the ED (P = .0436). When comparing complication rates between the ED and OR, there was no significant difference (P = .3643). A power calculation indicated too small of a sample size to truly determine an insignificant difference between complication rates between the ED and OR. Placement of emergent thoracostomy tubes in the ED does not result in an increased complication rate as compared to placement in the IW.

Attitude of emergency department patients toward HIV-infected health care workers.

A telephone survey of a random sample of adult emergency department (ED) patients was conducted at a university health science center. The purpose of the study was to determine the opinion of ED patients concerning the risk of human immunodeficiency virus (HIV) transmission and their willingness to be treated by HIV-infected physicians and nurses. Surveys from 107 ED patients were compiled and available for analysis. Ninety percent of the respondents were tolerant of an HIV-infected physician or nurse (HIV + HCW)performing noninvasive procedures. Fifty percent were tolerant of an HIV + HCW performing invasive procedures. Twenty-six percent of the patients said they would leave the department rather than be treated by an HIV + HCW. Patients older than 50 years were less tolerant (P = .004) and more likely to leave the ED (P = .001).

Variables that affect patient throughput times in an academic emergency department.

One of the most important parameters that influence patient satisfaction with emergency department care is their perception of throughput time. It is defined in our department as the time from patient arrival to time of discharge. Measurement of throughput time is one objective measure of efficiency that is feasible in most emergency departments. The purpose of this study is to analyze the impact of certain demographic and resource utilization factors on patient throughput times. Analysis of variants through multiple regression was used to determine associations between the average daily throughput time and factors commonly assumed to have significant influence on patient throughput time. Our data analysis found that patient throughput was significantly affected by the number of inpatient admissions from the emergency department, daily census in the main emergency department, pediatric volume, and the number of ambulance arrivals. Several factors that were commonly assumed to affect patient throughput time, such as nursing hours worked and day of the week, were not significant.

Spontaneous cervicothoracic epidural hematoma following prolonged valsalva secondary to trumpet playing.

Spontaneous spinal epidural hematoma is an uncommon clinical entity. Patients with this disease may present with devastating neurological deficits that can mimic other diseases. Emergency physicians should be familiar with this condition to assure appropriate therapy in a timely manner. A typical case of spontaneous spinal epidural hematoma is presented with review of appropriate differential diagnosis and management.

Topical tetracaine attenuates the pain of infiltration of buffered lidocaine.

OBJECTIVE: To determine whether topical tetracaine attenuates the pain of buffered lidocaine infiltration. METHODS: A prospective, randomized, double-blind trial was conducted involving adults with lacerations being repaired following local anesthesia. Two 0.5-mL injections of buffered lidocaine were given in a standardized manner. Injection 1 was given prior to application of topical study solution. Injection 2 was given on the opposite side of the laceration after topical application of a study solution that was 4 mL of either tetracaine or normal saline. Pain of each infiltration was measured using a visual analog pain scale. Pain score differences (injection 1 - injection 2) were compared for the 2 study solutions using a Wilcoxon 2-sample signed-rank test. RESULTS: Of 57 subjects studied, 29 received tetracaine and 28 received saline. The groups were similar in age, gender, wound length, wound location, and initial pain score. Pain scores decreased significantly in the tetracaine group as compared with the saline group. The median pain score difference for tetracaine was 12.0 mm, with an interquartile range (IQR) of 2 to 43 mm, as compared with 2 mm, with an IQR of - 17 to 21 mm for saline (p = 0.048). CONCLUSION: Topical tetracaine attenuates the pain of infiltration of buffered lidocaine.

Systemic toxicity from ocular homatropine.

Toxidromes are well known to emergency physicians. An unclear or incomplete history and subtle findings on physical examination make the diagnosis of poisonings challenging. This article reports a patient who had an acute onset of visual hallucinations, pressured speech, and mania. Although she denied taking any medications, she was ultimately diagnosed as having anticholinergic toxicity. On further questioning of family members, it was discovered that she was being treated for anterior uveitis with 5% homatropine. This case illustrates the potential role of ocular medications in systemic toxicity. Patients often do not consider eyedrops to be medications, and their use may be overlooked in the medical history. It also is important to educate patients and medical staff in methods to minimize systemic toxicity when using ocular medication.

Geriatric use of emergency medical services.

STUDY OBJECTIVE: To quantify use by geriatric patients of emergency medical services (EMS) compared with that by young adult patients. METHODS: We conducted a retrospective, consecutive case series over a 6-month period in a suburban, all-paramedic municipal EMS system serving 76,500 residents, of whom approximately 15% are 65 years of age or older and 33% are between 25 and 45 years old. Patient age, the sole entry criterion, was used to distinguish two groups: the young adult group, defined as patients 25 to 45 years old; and the geriatric group, defined as patients 65 years or older. RESULTS: Of the 2,712 patients whose cases were reviewed during the study period, 1,734 (65%) met the entry criterion. The geriatric group (n=1,043) accounted for 39% of the total call volume, compared with the young adult group (n=690), which accounted for 25% of total call volume. Patients in the young adult group were 7.3 times more likely to have been in a motor vehicle accident, whereas the GP group was 2.6 times more likely to have cardiorespiratory complaints, 1.8 times more likely to have fallen, and 1.7 times more likely to have minor medical problems requiring transportation and more frequently required advanced life support (ALS) care (54% versus 33%) (P<.001 for all comparisons). Scene times for geriatric patients were found to be longer than those for young adults (ALS, P<.001; basic life support [BLS], P<.05). However, costs billed to the patient were greater for young adults for all care rendered (BLS, P<.001; ALS, P<.05). CONCLUSION: Use by geriatric patients of EMS differed significantly from that by young adults. Geriatric patients used EMS more frequently and required more ALS care than did young adults. Although geriatric patients required longer scene times for EMS care, young adults incurred greater charges for service. These findings, although perhaps system specific, speak to the need for ongoing analysis of EMS health care delivery to better serve a population increasing in age.

The effects of warming and buffering on pain of infiltration of lidocaine.

OBJECTIVES: To investigate the effects of warming vs buffering, and warming with buffering, on the pain of lidocaine infiltration. METHODS: A randomized, double-blind clinical trial was conducted using volunteers aged 18 years or more and without an allergy to lidocaine. The study consisted of two parts, each comparing two solutions. The solutions for Part I were warm (38.9 degrees C; 102 degrees F) plain lidocaine and room-temperature buffered lidocaine. Warm buffered lidocaine and room-temperature buffered lidocaine were used for Part II. The subjects received two standardized 0.5-mL intradermal injections, one study solution in each forearm. Immediately after each injection, pain was assessed using a 100-mm visual analog pain scale. Pain scores were analyzed by the sign test, with significance defined as p < 0.05. RESULTS: Part I (n = 10): Nine subjects reported room-temperature buffered lidocaine to be less painful than warm plain lidocaine. Mean pain scores were 28 mm lower for room-temperature buffered lidocaine than they were for warm plain lidocaine (p < 0.01). Part II (n = 24): Eleven subjects found warm buffered lidocaine to be the least painful, 11 reported room-temperature buffered lidocaine to be the least painful, and two reported no difference. A mean pain score difference of 2.1 mm favoring warm buffered lidocaine was not statistically significant. Part II had a power of 80% to detect a 10-mm difference between the two solutions at alpha = 0.05. CONCLUSION: To reduce the pain of lidocane infiltration, buffering is more effective than warming. Warming does not enhance buffering.

Does topical lidocaine attenuate the pain of infiltration of buffered lidocaine?

OBJECTIVE: To determine whether topical lidocaine attenuates the pain of buffered lidocaine infiltration. METHODS: This was a prospective, randomized, double-blind, placebo-controlled trial conducted at a university-based ED. The subjects were adults who had lacerations being repaired using local anesthesia. Two 0.5-mL injections of buffered lidocaine were given in a standardized manner. The first was given prior to application of topical study solution. The second was given on the opposite side of the laceration after topical application of study solution, which was 5 mL of either 2% lidocaine or saline placebo. The pain of each infiltration was measured using a visual analog pain scale. Pain scores were calculated and compared using a Wilcoxon test with significance defined as p < or = 0.05. RESULTS: A total of 54 subjects participated; 29 received lidocaine topically and 25 received placebo. The groups were similar with respect to age, gender, wound length, wound location, and initial pain score. Pain scores decreased by 11.6 +/- 18.6 mm for lidocaine and 10.9 +/- 20.9 mm for placebo (p > 0.5). The study had the power to detect a 15-mm pain score difference (alpha = 0.05 and beta = 0.20) on a 100-mm scale. CONCLUSION: Topical 2% lidocaine does not attenuate the pain of infiltration of buffered lidocaine more than does topical normal saline. Investigation of other topical anesthetics with and without epinephrine in conjunction with buffered lidocaine is warranted.

Spontaneous clostridial myonecrosis with abdominal involvement in a nonimmunocompromised patient.

Spontaneous clostridial myonecrosis is a rare but aggressive disease usually associated with underlying immunosuppression or malignancy. We present a fatal case of clostridial myonecrosis arising in a patient with intact immune defenses.

The efficacy and safety of methohexital in the emergency department.

STUDY OBJECTIVE: To determine the efficacy and safety of methohexital sodium (MTX) in emergency department patients. DESIGN: A consecutive case series; all ED patients who received MTX from July 1989 through July 1990 were studied in a prospective manner. SETTING: A university hospital ED. PARTICIPANTS: All 102 adult and pediatric patients who received MTX. INTERVENTIONS: Emergency physicians trained in the use of MTX administered the drug. A study form was completed that provided data on dosage and response, indications for use, final diagnosis, hemodynamic and respiratory parameters, and an efficacy survey. RESULTS: Average cumulative dose of MTX was 1.6 +/- 1.3 mg/kg. The average duration of action per dose was 7.6 +/- 5.0 minutes. Leading indications for use were orthopedic procedures (54), endotracheal intubation (18), head computed tomography scan (ten), and wound care (eight). Hemodynamic changes were minimal; the average change in systolic blood pressure five minutes after MTX was -1.8 +/- 20 mm Hg. Average heart rate change was 3.0 +/- 20 beats. Percent respiratory depression was 17 +/- 24%. There was no correlation between MTX dose and the degree of respiratory depression. Narcotics and/or benzodiazepines were given with MTX in 92 cases, with no significant increase in respiratory depression. No major complications attributable to MTX were identified. CONCLUSION: MTX, when used by trained personnel who adhere to an established protocol, appears to be a safe and effective drug in selected ED patients.

Atypical presentation of pulmonary embolism.

Today we have discussed an interesting patient with an atypical presentation of pulmonary embolism. We have outlined a suggested algorithm to aid in the diagnosis and management of this disease. References 8 through 24 in the reference section are suggested readings that offer further insight into the diagnosis and management of this entity.

Clinical practice guidelines: promise or illusion?

The uncertainties about appropriateness and rates of use are unfolding against the backdrop of rising costs and an explosion in new biomedical and technological information. Achieving consensus in this environment is increasingly difficult as payers demand proof of effectiveness, consumers want access to the newest technology, and physicians struggle to assimilate new information. The net result is a drive toward practice standards or guidelines.