The future of the certification system in emergency medicine.

The heart of the specialty of emergency medicine, like all specialties and subspecialties, is training. The excellence in medical care that has accrued to the American public has proceeded from the belief that a well-defined and accredited program of education will produce the highest probability that a physician providing care will be competent. There is now a joint opportunity in emergency medicine to build a certification and recertification system that meets the criteria to provide the highest quality care for the public and to offer an efficient and effective system for the members of the specialty.

Safety assessment of high-dose narcotic analgesia for emergency department procedures.

STUDY OBJECTIVE: To evaluate the safety of high-dose IV narcotics in patients requiring analgesia for painful emergency department procedures. DESIGN: Prospective multicenter clinical trial. SETTING: Five adult urban EDs. METHODS AND MEASUREMENTS: All patients received IV meperidine (1.5 to 3.0 mg/kg) titrated to analgesia followed by a painful procedure. Vital signs and alertness scale were recorded at regular intervals, and patients were observed for four hours. Adverse events were monitored and documented. Comparisons between baseline and postanalgesia intervals were made with a repeated measures ANOVA (Dunnett's test). RESULTS: Although statistically significant changes in vital signs and alertness scale occurred, they were not clinically significant. Opiate reversal with naloxone was not needed in any patient, and no significant respiratory or circulatory compromise occurred. CONCLUSION: This study of 72 patients demonstrates that high-dose narcotic analgesia is appropriate, well tolerated, and safe when used in selected patients before painful procedures in the ED. Narcotic antagonists and resuscitation equipment nonetheless should be available to maximize safety.

Respiratory rates in pediatric emergency patients.

Respiratory rates are routinely measured in pediatric emergency patients. The normal range has not been established, and commonly reported ranges seem lower than those encountered in clinical practice. This prospective study selected subjects from pediatric patients presenting for care to a suburban emergency department. All respiratory rates were measured for one full minute. Patients with complaints related to the cardiopulmonary system or with an elevated temperature were excluded. A total of 434 patients were entered into the study over a 3-month period of time. Ages ranged from 2 weeks to 18 years. Respiratory rates ranged from a high of 65 breaths/min in a 4-month-old to a low of 12 breaths/min in a 14-year-old. Respiratory rate was inversely related to age, and there was a broad range in every age group. Our study shows that a normal respiratory rate is inversely related to age and is higher than noted in previously published studies. The wide range of "normal" pediatric respiratory rates makes identification of "abnormal" more difficult.

Flatology.

Advances in flatology are often close-lipped but of note. Cultural constraints and scatologic implications at times impede meaningful research. Historical and contemporary perspectives on flatus range from the biblical and theatrical, to paleontologic and environmental concerns, to the omninauseant legal and psychiatric sequelae. The current state of flatal physiology, pathophysiology, and diagnosis of aberrancy are reviewed. Flatoanalysis, air-flow studies, and flatulograms are discussed, as well as various remedies.

Intussusception associated with Henoch-Schonlein purpura.

Henoch-Schonlein purpura is a clinical diagnosis, based on a presentation including rash, arthralgia/arthritis, and abdominal pain, often with renal complications. A rare complication is intussusception, presumably initiated by an edematous vasculitic leading point in the small bowel's mucosal surface. A case is described involving a 3-year-old male, with a brief review of the literature.

Economic impact of motor vehicle restraints in Kentucky: a trauma center's experience.

Motor vehicle seat belts save lives and decrease the cost of care. Victims involved in motor vehicular accidents requiring ED evaluation and in-patient care were evaluated for seat belt usage. In addition to outcome parameters, the economic impact was assessed. During the five month study period, 38 (14%) restrained drivers and 238 (86%) unrestrained drivers were entered. Unrestrained drivers were more likely to be killed or disabled. The average cost of medical care for unrestrained drivers ($18,165) was significantly higher than that for restrained drivers ($7,634) (p less than .02). Twenty-eight percent of the unrestrained drivers' bills were paid with public funds. Assuming mandatory seat belt legislation would alter usage patterns as demonstrated in other states, the Commonwealth of Kentucky could save not only lives but millions of tax dollars.

Infrared tympanic thermography in the emergency department.

The failure to diagnose hypothermic and hyperthermic states can have profound clinical implications. Thus, accurately determining body temperature is an integral component of the evaluation of all emergency department (ED) patients. Oral measurements are most commonly obtained but may not reflect core temperatures. Rectal temperatures are considered more reliable but may not reflect fluctuating core temperatures, and are dependent on site placement. The objective of this study was to determine the practicality and comparative accuracy of tympanic thermographic measurements in the ED. Oral, rectal and tympanic readings were compared in 411 patients. There were significant differences when comparing tympanic to oral (R2 = 0.599, P = 0.0001) and rectal to oral (R2 = 0.554, P = 0.0001) temperatures. In contrast, the correlation between tympanic and rectal measurements was R2 = 0.805, with no significant difference between the two, (P = 0.7077). No complications associated with the use of the tympanic probe were detected. Infrared tympanic thermography is an efficient and noninvasive technique for accurately measuring the temperature of ED patients.

Prehospital blind nasotracheal intubation by paramedics.

Blind nasotracheal intubation attempts by paramedics in the field were prospectively reviewed. In particular, we analyzed the frequency, success rate, complication rate, frequency of performance by each paramedic, indications, and patient outcome. Blind nasotracheal intubation was attempted in 324 patients and successful in 231. The average success rate for medical patients was 72.2% (195 of 270 attempts) and for trauma patients was 66.7% (36 of 54 attempts). This difference was not significant (P greater than .05). Even with 59.8% of the 82 participating paramedics attempting blind nasotracheal intubation less than four times over the 19-month study period, the average success rate was 71.3%. There was a significant increase in success when blind nasotracheal intubation was attempted more than three times during the study period (P less than .005). Major complications occurred in 0.9% (three) of the patients. The overall complication rate was 13% (42). The incidence of complications tended to decline with increasing paramedic frequency but did not reach statistical significance (P greater than .05). Blind nasotracheal intubation is a safe initial field airway approach in spontaneously breathing patients in whom there are no contraindications. Even with a low frequency of performance, success and complication rates are acceptable.

Duration of antagonistic effects of nalmefene and naloxone in opiate-induced sedation for emergency department procedures.

Naloxone is an effective opiate antagonist, but its short half-life limits its usefulness. For outpatient procedures, a longer acting opiate antagonist could eliminate two to four hours of nursing observation in patients postoperatively. A controlled, randomized, double-blind trial comparing the effects of nalmefene, naloxone, and placebo in reversing opiate-induced sedation was carried out to determine efficacy, duration of action, and adverse effects in patients undergoing outpatient procedures. Each patient received 1.5 to 3.0 mg/kg meperidine intravenously before the procedure. After the procedure, each patient received either nalmefene, 1.0 mg; naloxone, 1.0 mg; or saline, 1.0 mL intravenously. Vital signs and assessments for alertness were performed for four hours. Naloxone significantly reversed sedation for only 15 minutes, whereas nalmefene was significantly effective (P less than .05) for up to 210 minutes. Nalmefene was significantly more effective than naloxone in reversing sedation at 60, 90, and 120 minutes. Nalmefene is an effective agent for the reversal of opiate-induced sedation after outpatient procedures.

Respiratory rates in emergency department patients.

The respiratory rate is a sensitive and nonspecific indicator of respiratory dysfunction. Establishing a "normal" respiratory rate has mainly been arbitrary. This study evaluated "normal" respiratory rates in 110 emergency department patients. The mean respiratory rate was 20.1 (+/- 4.0). Women had a more rapid respiratory rate 20.9 (+/- 3.9) than men 19.4 (+/- 4.0) (p less than .04). Smokers had a higher respiratory rate 20.5 (+/- 4.0) than nonsmokers 19.3 (+/- 4.0), but this was not statistically significant (P = 0.124). It was also noted that the respiratory rate measured by the nurse was almost always different from that measured by the medical student (P less than 0.0001). Based on a review of the literature concerning what constitutes a "normal" respiratory rate, we conclude that the "normal" respiratory rate may be higher than that suggested in the medical literature.

Hypothermia outcome score: development and implications.

Multiple rewarming methods have been recommended for the treatment of hypothermia in the ED. Because the hypothermic patient population is heterogenous, a method for stratifying mortality risk when comparing therapies is desired. We used univariable and multivariable statistical analyses to identify variables which discriminated between patient death or survival in the 24 h after arrival in the ED. Prehospital cardiac arrest, a low or absent presenting BP, elevated BUN, and the need for either tracheal intubation or NG tube placement in the ED were found to be significant predictors of patient demise in a large database (n = 428). The likelihood ratio was used to develop and validate an empiric hypothermia outcome score that can be used in future hypothermia treatment studies to account for differences of patient presentation.

Emergency department violence in United States teaching hospitals.

Violence in the emergency department is a common concern. However, most aspects of this problem remain unstudied because no organization or government agency tracks such data and no regulatory or administrative guidelines adequately address its management. We surveyed 170 US teaching hospital ED medical directors with respect to violence and security issues and received responses from 127 (74.7%). Among other findings, 41 institutions report at least one verbal threat each day, and 23 report at least one threat with a weapon each month. Four-point physical restraint is used by 125 of the 127 facilities. Personnel in 32 of these facilities restrain at least one patient each day. Seventeen institutions report having significantly injured a patient during restraint in the last five years, resulting in one death. Twenty institutions report involvement with litigation with respect to restraint. Only 51 institutions provide ED nurses with formal training in recognition and management of aggression and violence, and only 79 institutions have security personnel present in the ED 24 hours a day. A sizable number of facilities receiving frequent threats and batteries are not among those with 24-hour-a-day security personnel. A preventative, risk-management approach that addresses environmental factors, training policies, restraint, security arrangements, and legal precedents is suggested.

Acute dystonic reaction due to diazepam.

Two cases of acute dystonic reactions associated with diazepam ingestion are reported. This report is a brief review of drug-induced extra-pyramidal syndromes, and a mechanism for diazepam-induced dystonic reactions is proposed. Intravenous diphenhydramine was successful in treating both patients.

Hyperthermic syndromes.

Heat stroke victims lack thermoregulatory control. Treatment includes immediate cooling, circulatory support and monitoring for secondary complications. Neuroleptic malignant syndrome is a complication of neuroleptic drug therapy; skeletal muscle hypertonicity helps distinguish this entity from heat stroke. Malignant hyperthermia should be considered in any patient who is under physiologic or anesthetic stress and develops hyperthermia plus skeletal muscle rigidity, tachypnea, hypoxia, tachycardia and hyperkalemia.

Airway management of aeromedically transported trauma patients.

The airway management of 176 consecutive traumatized patients aeromedically transported from the scene of injury was reviewed. In particular, the frequency of performance and time requirements for both blind nasotracheal intubation and cricothyrotomy were analyzed. Airway control was attempted in 70 (39.5%) patients and successful in 67 (95.7%). The average scene Glasgow Coma Scale (GCS) score of these 70 patients was 7.16 (SD = 3.94) and ranged from 3 to 15. For the remaining 106 patients the average GCS was 14.3 (SD = 1.36) and ranged from 6 to 15 (P less than .0005). The scene trauma score (TS) of the two groups was 10.2 (SD = 3.11) and 15.2 (SD = 1.38), respectively (P less than .0005). In the field, blind nasotracheal intubation by an emergency physician (n = 59) or paramedic (n = 3) was successful in 62 of 65 cases (95.1%). The complication rate for this procedure was 4.6%. Cricothyrotomy was performed in two patients. Only three orotracheal intubations were performed. The remaining three patients were nasotracheally intubated in the emergency department. Neuromuscular blockade was not used in either setting. Despite the difference in patient acuity, there was no statistically significant difference in scene or transport times between those patients emergently intubated and those who were not (P greater than .05).

Multicenter hypothermia survey.

A multicenter survey evaluated the clinical presentation, treatment, and outcome of accidental hypothermia. Data were collected from 13 emergency departments, with 401 of the 428 cases presenting during a two-year study period. Core temperatures ranged from 35 C to 15.6 C (mean, 30.57 C +/- 3.53) with 272 cases (63.6%) less than or equal to 32.2 C. There were no significant differences by age in presenting temperature, rewarming strategies, or mortality. The first hour rewarming rate was significantly (P less than .05) faster in the population less than or equal to 59 years (1.08 +/- 1.39 C/hr) than in those greater than or equal to 60 years (0.75 +/- 1.16 C/hr). Male core temperatures averaged 30.27 +/- 3.44 C versus female temperatures of 31.1 +/- 3.61 C. There were no clinically significant differences in male (N = 296) versus female (N = 132) profiles. High ethanol levels (315 to 800 mg%) did not affect outcome. Nine of 27 (33%) patients who received CPR initiated in the field survived, versus six of 14 (43%) with CPR begun in the ED. The profile of the CPR versus non-CPR population differed significantly (P less than .05) in location (outdoors), initial temperature (24.8 +/- 3.77 C vs 30.94 +/- 3.12 C), third-hour rewarming rate (2.28 +/- 1.53 C vs 1.17 +/- 1.18 C/hr), and numerous laboratory parameters. Tracheal intubation was performed without incident in 117 cases, of which 97 were less than or equal to 32.2 C. There were 73 fatalities (17.1%). Of these, 84.9% (N = 62) were less than or equal to 32.2 C. Predisposing conditions in this group included "serious" illness (30), systemic infection (28), trauma (15), immersion (ten), frostbite (seven), and overdose (two). The initial pulse, hemoglobin, and first-hour rewarming rate was lower in the deceased population, while the potassium, urea nitrogen, creatinine, and phosphorus were elevated. Excluding treatment combinations, outcome with exclusive use of a single rewarming strategy was passive external rewarming, 14 deaths below 32.2 C, 13 above; active external rewarming, six deaths below 32.2 C, two above; active core rewarming, 38 deaths below 32.2 C, none above. Refinements of the American Heart Association's CPR standards in hypothermia and a Hypothermia Survival Index are proposed.