The advanced pedi-bag program: a hospital-EMS partnership to implement prehospital training, equipment, and protocols.

OBJECTIVE: The Advanced Pedi-Bag Program is a partnership between a trauma center and a county-wide EMS agency (LCEMS) with three major goals: 1) train all LCEMS paramedics in the American Heart Association's Pediatric Advanced Life Support (PALS), 2) stock each Life Squad with a specific bag containing the equipment necessary to treat both basic and advanced pediatric emergencies, and 3) develop treatment protocols for pediatric patients. DESIGN: Descriptive study. SETTING: LCEMS serves a population of 450,000. Pediatric runs account for 800 to 1,200 LCEMS runs per year. RESULTS: The LCEMS Medical Director established and facilitated mandatory PALS training of 180 paramedics. A committee of emergency/pediatric/trauma professionals developed and distributed 40 bags with a comprehensive inventory of basic and advanced pediatric supplies and equipment to all LCEMS Life Squads upon completion of PALS training. Protocols were developed that integrate the use of the bag's contents. CONCLUSION: This partnership between a trauma center and an EMS agency resulted in improved training of county paramedics, Life Squads that have an Advanced Pedi-Bag with specific equipment and supplies to manage pediatric emergencies, and pediatric protocols that support the use of this equipment. Paramedics benefit from advanced training opportunities and patients benefit from improved prehospital care.

[Red cell Na+/H+ exchange and role of protein kinase C in its stimulation in diabetes mellitus, essential hypertension and nephropathy].

Na+/H+ exchange (NHE) was measured as maximal initial velocity of pH-dependent H+ efflux from red cells into an alkaline medium containing Na+ in patients with insulin-dependent or noninsulin-dependent diabetes, with and without hypertension and in normoglycemic, essential hypertensives and normal controls (50 subjects in each subgroup). Maximal velocities of NHE were found in microalbuminuric patients in all subgroups, and NHE correlated with the rate of micro-albuminuria (r = 0.61, p = 0.02). Daily insulin requirements were greater in those with elevated NHE (84 +/- 8 vs 42 +/- 4 U/day). There was no correlation between NHE and levels of plasma glucose, HbA1 and plasma aldosterone and lipid profile and PRA. NHE was correlated with plasma prolactin (r = 0.51, p = 0.02) and PTH r = 0.24, p = 0.05). In uremic patients, NHE was inversely correlated with creatinine clearance (r = -0.48, p = 0.03). Since calphostin C, a selective inhibitor of protein kinase C, lowered increased NHE in vitro, the protein kinase C-dependent pathway of the exchanger regulation was concluded to be responsible for NHE activation in diabetes mellitus and essential hypertension.

Pleural effusion as a presenting manifestation of giant cell arteritis.

Pulmonary involvement is rare in giant cell arteritis (GCA). Only a few cases have been reported, manifested by interstitial infiltration, pulmonary nodules, pulmonary artery vasculitis, and granuloma formation. Moreover, only 3 previous cases of pleural effusion associated with GCA have been described. Herein we report a 67-year-old woman with biopsy-proven temporal arteritis, presented with prolonged fever, weight loss, cough and pleural effusion. ELISA test for the presence of anti- proteinase-3 antibodies was negative. The importance of the anti-neutrophil cytoplasmic-antibodies (ANCA) examination in the differential diagnosis from other vasculitides with pulmonary involvement is discussed.

[Hypercalcemia following rhabdomyolysis-induced acute renal failure].

Hypercalcemia is an uncommon clinical feature during recovery from acute renal failure. Moderate hypercalcemia developed during recovery of kidney function in a 24-year-old man with acute renal failure following polytrauma-induced rhabdomyolysis (myoglobinuria). He presented with multiple hematomas of the back, chest, abdomen and upper and lower limbs. He was asymptomatic during the hypercalcemic phase, when Ca reached 13.2 mg and PTH levels (immunoradiometric assay) were low, 8.7 muug/ml (normal 10-65).

Pediatric emergency medicine fellowships: a survey revisited.

A survey of all known pediatric emergency medicine fellowship programs as of December 1990 was conducted in order to characterize and compare certain attributes of these programs with those that existed in 1988. The following attributes of the training programs were studied: number of programs, length of training, number of first-year positions, number of graduates, program participation in the National Resident Match Program, amount of clinical time required, elective rotations, didactic, research, administrative, and teaching experience, patient volumes, and attending staffing. Emergency department time varies between three and nine months each year. Forty-three (100%) of the programs require specific rotations and offer didactic medical education, and nearly all (97%) require research and offer training in administrative areas. Patient volumes vary between 15,000 and 90,000, with a median of 39,000. The data offered are meant to act as a guide to further development of new and existing programs.

Pediatric emergency medicine fellowships: a survey.

A survey of 24 existing pediatric emergency medicine fellowship programs as of December 1987 was conducted in order to characterize the following attributes of training in pediatric emergency medicine: amount of clinical time, required and elective rotations, didactic and research experience, patient volume, and staffing. Time spent in the emergency department varies between three and 10 months annually, with a mean of 34.5 hours per week. Twenty-two (92%) of the programs have required rotations. All responding programs require research and some degree of didactic education. Patient volume varies between 20,000 and 70,000, with a median of 41,000. The data offered should act as a reference for the further development of new and existing programs.

Emergency department management of the intoxicated adolescent.

It is widely recognized that many young people will have experiences with alcohol and with psychoactive recreational drugs before emerging from the adolescent years. It is estimated that before leaving ninth grade, one half of the total student population will have had experience with alcohol, and approximately one third with marijuana. Cocaine also is more available to adolescents. For these reasons, the emergency physician is more likely to see teenage patients for drug-related problems.

Pulmonary edema due to acute upper airway obstruction from aspirated foreign body.

A case of pulmonary edema following upper airway obstruction is presented along with a review of the literature. The causes of this entity are not well known, and opinions vary as to the mechanism of formation of this form of noncardiogenic pulmonary edema.

Expanded spectrum of organisms causing osteomyelitis after puncture wounds of the foot.

Although there is a general awareness developing about the role of Pseudomonas aeruginosa in producing osteomyelitis following puncture wounds of the foot, it is not generally appreciated that other organisms may gain access to the bones of the foot following penetrating injuries. This paper addresses two additional cases of osteomyelitis produced by organisms other than Pseudomonas, and characterized by the same indolent course. It is emphasized that puncture wound osteomyelitis generally requires surgical intervention, not only for proper diagnosis, but for evacuation of the infective process.

Pancreatitis in association with hypercalcemia in patients receiving total parenteral nutrition.

Six patients receiving total parenteral nutrition (TPN) developed hypercalcemia and acute pancreatitis. Four were long-term home TPN patients, and two were short-term hospital TPN patients. Causes of pancreatitis other than hypercalcemia were not found. The etiology of the hypercalcemia remained unclear and in particular was not due to calcium infusion or hyperparathyroidism. In 4 patients in whom it was measured, the plasma parathyroid hormone was normal (in 2) or nondetectable (in 2). Hypercalcemia and pancreatitis subsided with discontinuation of TPN. Thus, some patients receiving TPN develop hypercalcemia, and in some of these pancreatitis ensues.

Colonic varices. Three case reports and review of the literature.

Three cases of colonic varices are presented. An extensive review of the literature revealed 29 other cases, whose clinical summaries are included. The majority of patients had portal hypertension and almost always presented with hematochezia. The most fruitful diagnostic tests were sigmoidoscopy and SMA arteriogram. The best therapeutic regimen for the severe bleeder with colonic varices is portacaval shunt.