Food-dependent exercise-induced anaphylaxis.

Food-dependent exercise-induced anaphylaxis (FDEIA) is a specific variant of exercise-induced anaphylaxis that requires both vigorous physical activity and the ingestion of specific foods within the preceding several hours. When patients present to the emergency department (ED) with allergic reactions, careful history regarding these 2 factors is required to establish the correct diagnosis. Correct diagnosis of FDEIA will allow patients to take control of their lifestyles and avert repeated events and ED visits. Two cases of FDEIA are presented, and the diagnosis, pathophysiology and therapy of food-dependent exercise-induced anaphylaxis are reviewed.

Implementation of the Ottawa Knee Rule for the use of radiography in acute knee injuries.

CONTEXT: The Ottawa Knee Rule is a previously validated clinical decision rule that was developed to allow physicians to be more selective and efficient in their use of plain radiography for patients with acute knee injuries. OBJECTIVE: To assess the impact on clinical practice of implementing the Ottawa Knee Rule. DESIGN: Controlled clinical trial with before-after and concurrent controls. SETTING: Emergency departments of 2 teaching and 2 community hospitals. PATIENTS: All 3907 consecutive eligible adults seen with acute knee injuries during two 12-month periods before and after the intervention. INTERVENTION: During the after period in the 2 intervention hospitals, the Ottawa Knee Rule was taught to all house staff and attending physicians who were encouraged to order knee radiography according to the rule. MAIN OUTCOME MEASURES: Referral for knee radiography, accuracy and reliability of the rule, mean time in emergency department, and mean charges. RESULTS: There was a relative reduction of 26.4% in the proportion of patients referred for knee radiography in the intervention group (77.6% vs 57.1 %; P<.001), but a relative reduction of only 1.3% in the control group (76.9% vs 75.9%; P=.60). These changes over time were significant when the intervention and control groups were compared (P<.001). The rule was found to have a sensitivity of 1.0 (95% confidence interval [CI], 0.94-1.0) for detecting 58 knee fractures. The K coefficient for interpretation of the rule was 0.91 (95% CI, 0.82-1.0). Compared with nonfracture patients who underwent radiography during the after-intervention period, those discharged without radiography spent less time in the emergency department (85.7 minutes vs 118.8 minutes) and incurred lower estimated total medical charges for physician visits and radiography (US $80 vs US $183). CONCLUSIONS: Implementation of the Ottawa Knee Rule led to a decrease in use of knee radiography without patient dissatisfaction or missed fractures and was associated with reduced waiting times and costs. Widespread use of the rule could lead to important health care savings without jeopardizing patient care.

Prospective validation of a decision rule for the use of radiography in acute knee injuries.

OBJECTIVE: To validate a previously derived decision rule for the use of radiography in patients with acute knee injury. DESIGN: Prospectively administered survey. SETTING: Emergency departments of two university hospitals serving adults. PATIENTS: Convenience sample of 1096 of 1251 eligible adults with acute knee injuries; 124 patients were examined by two physicians. MAIN OUTCOME MEASURES: Attending emergency physicians assessed each patient for standardized clinical variables and determined the need for radiography according to the decision rule. Patients who did not have radiography underwent a structured telephone interview at day 14 to determine the possibility of a fracture. The rule was assessed for ability to correctly identify the criterion standard, fracture of the knee. An attempt was made to refine the rule by means of univariate and recursive partitioning analyses. RESULTS: The decision rule had a sensitivity of 1.0 (95% confidence interval [CI], 0.94 to 1.0) for identifying 63 clinically important fractures. Physicians correctly interpreted the rule in 96% of cases, and the k value for interpretation was 0.77 (95% CI, 0.65 to 0.89). The potential relative reduction in use of radiography was estimated to be 28%. The probability of fracture, if the decision rule were "negative," is estimated to be 0% (95% CI, 0% to 0.4%). Attempts to refine the rule led to a model with improved specificity but with an unacceptable loss of sensitivity. CONCLUSION: Prospective validation has shown this decision rule to be 100% sensitive for identifying fractures of the knee, to be reliable and acceptable, and to have the potential to allow physicians to reduce the use of radiography in patients with acute knee injury.

Use of radiography in acute knee injuries: need for clinical decision rules.

OBJECTIVES: To study: 1) the efficiency of the current use of radiography in acute knee injuries, 2) the judgments and attitudes of experienced clinicians in their use of knee radiography, and 3) the potential for decision rules to improve efficiency. METHODS: This two-stage study of adults with acute knee injuries involved: 1) a retrospective review of all 1,967 patients seen over a 12-month period in the EDs of one community and two teaching hospital, and 2) a prospective survey of another 1,040 patients seen by attending emergency physicians. The prospective survey assessed each clinician's estimate of the probability of a knee or patella fracture; 120 patients were independently assessed by two physicians. RESULTS: Of the 1,967 patients seen in the first stage, 74.1% underwent radiography but only 5.2% were found to have fractures. Of the 1,727 knee and patella radiographic series ordered, 92.4% were negative for fracture. In the second stage, experienced physicians predicted the probability of fracture to be 0 or 0.1 for 75.6% of the patients. The kappa value for this response was 0.51 (95% CI 0.34 to 0.68). The physicians also indicated that they would have been comfortable or very comfortable in not ordering radiography for 55.5% of the patients. The area under the receiver operating characteristics curve for the physicians' prediction of fracture was 0.87 (95% CI 0.82 to 0.91), reflecting good discrimination between fracture and nonfracture cases. Likelihood ratios for the physicians' prediction ranged from 0.09 at the 0 level to 42.9 at the 0.9-1.0 level. CONCLUSIONS: Emergency physicians order radiography for most patients with acute knee injuries, even though they can accurately discriminate between fracture and nonfracture cases and expect most of the radiographs to be normal. These findings suggest great potential for more efficient use of knee radiography, possibly through the use of a clinical decision rule.

Derivation of a decision rule for the use of radiography in acute knee injuries.

STUDY OBJECTIVE: To derive a highly sensitive decision rule for the selective use of radiography in acute knee injuries. DESIGN: Prospectively administered survey. SETTING: Emergency departments of two university hospitals. PARTICIPANTS: Convenience sample of 1,047 adults with acute knee injuries. RESULTS: Attending emergency physicians assessed each patient for 23 standardized clinical findings, which were recorded on data collection forms. A total of 127 patients was examined independently by two physicians to determine interobserver agreement. The outcome measure was fracture of the knee. Any patients who did not have ED radiography underwent a structured telephone interview to determine the possibility of a missed fracture. Those variables found to be both reliable (highest kappa values) and strongly associated with a fracture (highest chi 2 values) were further analyzed by a recursive-partitioning multivariate technique. The derived decision rule included the following variables: (1) age 55 years or older, (2) tenderness at the head of the fibula, (3) isolated tenderness of the patella, (4) inability to flex to 90 degrees, and (5) inability to bear weight both immediately and in the ED (four steps). The presence of one or more of these findings would have identified the 68 fractures in the study population with a sensitivity of 1.0 (95% confidence interval [Cl], .95 to 1.0) and a specificity of .54 (95% Cl, .51 to .57). Application of the rule would have led to a 28.0% relative reduction in the use of radiography from 68.6% to 49.4% in the study population. CONCLUSION: A practical, highly sensitive, and reliable decision rule for the use of radiography in acute knee injuries has been derived. Clinical application should await prospective validation of the rule.

Prehospital care at a major international airport.

Medical emergencies at a major metropolitan airport have a significant impact on prehospital care capabilities for the rest of the community in which the airport is located. Stapleton International Airport in Denver, Colorado, is a facility that in 1985 had 14.4 million passengers and a static employee population of 12,000 to 15,000. In 1981, there were 1,182 ambulance trips to the airport, 40.4% of which did not result in the transport of a patient. The expense of sending an ambulance and fire engine out on such calls was great, and paramedics were out of service for approximately 300 hours on these nontransport cases. In order to improve prehospital services to the airport and the city, a paramedic has been stationed in the concourse at the airport 16 hours a day since 1982. The records for airport paramedic services for the 12 months ending September 1985 were reviewed. Paramedic services were requested for 1,952 patients. Of these, 696 (35.7%) were transported to hospital by ambulance; 115 (5.9%) went by private car; 284 (14.6%) refused any paramedic care or transport; and 857 (43.9%) were released, after base station contact, with instructions to seek definitive care at the final destination. Presenting complaints were classified into 55 categories and the frequencies and dispositions are described. The most common presentations resulting in transport were chest pain, 110 (5.6%); syncope, 60 (3.1%); psychiatric, 57 (2.9%); abdominal pain, 49 (2.5%); seizure, 36 (1.8%); fracture, 31 (1.6%); and cardiac arrest, 29 (1.5%).(ABSTRACT TRUNCATED AT 250 WORDS)

Toxic shock syndrome following diagnostic peritoneal lavage.

We report the case of a 15-year-old girl who developed high fever, syncope, abdominal pain, nausea and vomiting, myalgia, pharyngitis, and a desquamating rash eight days after a diagnostic peritoneal lavage. The diagnostic peritoneal lavage wound was erythematous and tender. Incision of the site yielded 10 mL of exudate that cultured Staphylococcus aureus. The patient was treated with a first-generation cephalosporin and recovered without sequelae. To our knowledge, this is the first reported case of toxic shock syndrome following diagnostic peritoneal lavage.

Prehospital advanced trauma life support for critical blunt trauma victims.

The ability of paramedics to deliver advanced trauma life support (ATLS) in an expedient fashion for victims of trauma has been strongly challenged. In this study, the records of 114 consecutive victims of blunt trauma who underwent laparotomy or thoracotomy were reviewed. Prehospital care was rendered by paramedics operating under strict protocols. The mean response time (minutes +/- SEM) to the scene was 5.6 +/- 0.27. On-scene time was 13.9 +/- 0.62. The time to return to the hospital was 8.0 +/- 0.4. On-scene time included assessing hazards at the scene, patient extrication, spine immobilization (n = 98), application of oxygen (n = 94), measurement of vital signs (n = 114), splinting of 59 limbs, and the following ATLS procedures: endotracheal intubation (n = 31), IV access (n = 106), ECG monitoring (n = 69), procurement of blood for tests including type and cross (n = 58), and application of a pneumatic antishock garment (PASG) (n = 31). On-scene times were analyzed according to the number of ATLS procedures performed: insertion of one IV line (n = 46), 14.8 +/- 1.03 minutes; two IV lines (n = 28), 13.4 +/- 0.92; one IV line plus intubation (n = 7), 14.0 +/- 2.94; two IV lines plus intubation (n = 9), 17.0 +/- 2.38; and two IV lines plus intubation plus PASG (n = 13), 12.4 +/- 1.36. Of the 161 IV attempts, 94% were completed successfully. Of 36 attempts at endotracheal intubation, 89% were successful.(ABSTRACT TRUNCATED AT 250 WORDS)

Peroneal retinaculum injury: an unusual cause of ankle pain.

A case of superior peroneal retinaculum injury is described. The patient's clinical presentation included tenderness at the peroneal groove and anterior subluxation of the peroneal tendons at the lateral malleolus. Radiographs of the ankle demonstrated an avulsion fracture from the lateral cortex of the lateral malleolus, pathognomonic for this injury. The patient wore a cast with the ankle in a neutral position for six weeks, following which she experienced repeated subluxation of the peroneal tendons. She subsequently required operative reconstruction of the retinaculum. Clinical findings and management of peroneal retinaculum injury are reviewed.

Lightning injuries.

The physical properties of lightning are given, including a description of the different observed lightning forms. The wide variety of effects of lightning on humans is reviewed. In the prehospital care of those struck by lightning, emphasis is upon immediate resuscitation of those who appear unresponsive. Recommendations for emergency department evaluation, treatment, and disposition are given. Guidelines to prevent humans from being struck by lightning are discussed.