Patient preferences regarding pain medication in the ED.

Previous studies have reported inadequate pain control in the emergency department (ED). The primary purpose of this study was to determine the proportion of ED patients with acute fractures who actually wanted pain medication given in the ED. A convenience sample of 107 adults with acute long-bone fractures seen in a community hospital ED were surveyed on the pain level they had on ED presentation, the pain level desired at ED discharge, and their preferences for administration of analgesia in the ED. Eighty-eight percent of the patients wanted pain medication given in the ED and 77% actually received it. Sixty-nine percent were comfortable with a nurse administering pain medication before physician evaluation. Seventy percent wanted pain control without being sedated and 25% wanted complete pain relief even if sedation was necessary to achieve it. Sixty percent were either slightly concerned or not concerned about potential medication side effects.

Rectal methohexital sedation for computed tomography imaging of stable pediatric emergency department patients.

OBJECTIVE: Rapid onset of sleep, brief duration of action, and ease of administration are properties that make rectal methohexital (MXT) an attractive choice for sedating stable pediatric emergency department (ED) patients for computed tomography (CT) imaging. METHODOLOGY: One hundred stable patients between 3 and 60 months of age who presented to any of 3 participating EDs and required sedation to undergo CT scanning were given 25 mg/kg of rectal MXT approximately 15 minutes before their imaging. Vital signs and oxygen saturation were recorded at regular intervals. Data collected included indication for CT imaging, time to achieve sleep, time to reach discharge criteria, adequacy of sedation, adverse effects, and parental satisfaction. RESULTS: Ninety-five percent of the patients were adequately sedated with rectal MXT. It took an average of 8 minutes to achieve full sedation and the duration of action averaged 79.3 minutes. Ten percent had transient side effects, but all recovered completely. None required intubation. Parental satisfaction was 90%. CONCLUSION: Rectal MXT compares favorably to other methods of nonintravenous sedation for CT scanning of stable pediatric ED patients in terms of rapidity of onset and reliability but does cause a significant amount of transient respiratory depression. Its use requires careful monitoring of oxygen saturation and should be used only in a setting where physicians skilled in airway management are present. If these requirements are met, it may be a good choice for the relatively noninvasive sedation of pediatric ED patients undergoing painless but anxiety-provoking procedures.methohexital, pediatric procedure sedation, rectal administration, computerized tomography imaging.

Primary sequence and location of the idiotopes of V-88, a DNA-binding monoclonal autoantibody, determined by idiotope scanning with synthetic peptides on pins.

In this study, the primary sequence and location of the idiotopes of monoclonal antibody (mAb) V-88 have been examined. V-88 was derived from an adult (NZB x NZW)F1 mouse, has been partially defined previously with polyclonal anti-idiotype antisera, and is a member of the 16/6 idiotype (Id) family. From the inferred primary amino acid sequence of the antibody, sets of hexapeptides, overlapping by five residues, were synthesized on pins and used to scan the expression of epitopes (idiotopes) in the V regions of the light and heavy chains. A heterologous rabbit antiserum raised against the native antibody V-88, and absorbed to make it idiotype specific, was found to react with eight major epitopes distributed between the VH and VL regions. Half of these determinants mapped to the complementarity determining regions, with the others in framework sequences. Thus, the idiotype of antibody V-88 comprises, at least in part, continuous linear idiotopes in both hypervariable and framework areas. The process of absorbing the anti-idiotype antiserum on normal mouse immunoglobulin removed much of the background antibody activity against V region peptides, but left the activity against the dominant idiotopes. The sequence of a major idiotope, VATISG, in the FW2/CDR2 VH region is homologous to sequences of human antibodies that express the 16/6 idiotype, suggesting that Id.16/6 is at least in part defined by this region of the antibody. The same VH area is also homologous to sequences in bacterial and mammalian heat-shock proteins (hsp60-65). Thus there may be a functional link through idiotype connections, especially those involving Id.16/6, between anti-bacterial responses and production of autoantibodies, and some bacterial antigens may function indirectly as superantigens for B cells.

Handlebar hernia: diagnosis by abdominal computed tomography.

Traumatic "handlebar" hernia, produced by impaction of a bicycle handlebar on the abdominal wall, is a rare entity. Presented is the case of a 7-year-old boy who sustained such a hernia, which contained an incarcerated loop of small bowel. The use of abdominal computed tomography to confirm the diagnosis before operative reduction of the hernia appears to be a safe and efficacious adjunct to physical examination.

The role of an emergency department observation unit in the management of trauma patients.

During a 12-month period, 20,838 patients with acute traumatic injuries were seen in the Emergency Department (ED) of Denver General Hospital. Of these patients, 520 (2.5%) were admitted to the ED Observation Unit, a seven-bed acute care unit situated within the ED and sufficient data were available on 485 (93%) for inclusion into the study. Fifty-three (15.4%) of these observation unit patients required subsequent admission, 389 (80%) were discharged, and 16 (4%) left against medical advice. There were no observation unit deaths. These groups of patients were analyzed and compared with regard to severity of injury, length of stay, and discharge diagnosis. The observation unit is useful in the evaluation of blunt chest or abdominal trauma when work-up, including chest x-ray studies and peritoneal lavage, is initially negative and when drug or alcohol ingestion obscures the initial evaluation in the ED. An observation unit within the ED is cost-efficient and has proven very useful in the management of trauma victims.

Cyclobenzaprine overdosage.

The clinical findings in three patients who ingested 260-900 mg cyclobenzaprine (Flexeril) consisted of delayed onset and long duration of anticholinergic symptomatology. In two of these patients, symptoms responded to treatment with physostigmine. The third patient recovered without specific therapy. Despite its structural similarity to amitriptyline, cyclobenzaprine overdosage did not result in coma, seizures, or cardiac toxicity. The pharmacological properties of cyclobenzaprine may account for the observed toxicity.