Epidemiology of thoracolumbar spine injury in blunt trauma.

OBJECTIVE: To evaluate the prevalence, distribution, and demographics of thoracolumbar (TL) spine injuries following blunt trauma. METHODS: Prospective, cross-sectional study of a consecutive sample of all blunt trauma patients presenting initially to the emergency department (ED) of a Level 1 trauma center and undergoing thoracic and/or lumbar spine radiography from August 1997 to November 1998. The age, sex, and mechanism of injury of each patient as well as location and type of spine injury were recorded for those patients with vertebral fractures, dislocations, or subluxations. RESULTS: Two thousand four hundred four blunt trauma patients were enrolled. Vertebral injuries were identified in 152 individuals (6.3%, 95% CI = 5.4% to 7.4%). Two hundred sixty distinct anatomic levels of injury were identified in these 152 individuals. Of these 260 injuries, 42 (16.2%) occurred at L1, 38 (14.6%) at L2, 29 (11.1%) at L3, and 27 (10.4%) at T12, making these the most commonly injured vertebrae. Injuries were most common (34 patients) in those aged 30-39 years and were least common (12 patients) in those under 18 years. Compression fractures (52%) were the most common injury in the thoracic spine, while transverse process fractures (48%) were the most common injuries in the lumbar spine. CONCLUSIONS: The prevalence of TL injuries in ED blunt trauma patients undergoing TL radiographs is 6.3%. The most commonly injured area of the TL spine is the thoracolumbar junction.

Test performance of the individual NEXUS low-risk clinical screening criteria for cervical spine injury.

BACKGROUND: The National Emergency X-Radiography Utilization Study (NEXUS) recently validated the ability of a decision instrument to define a population with an extremely low risk of cervical spine injury (CSI) after blunt trauma. It is unclear whether each of the 5 individual criteria is necessary for the decision instrument to maintain its high sensitivity. METHODS: NEXUS was a prospective observational study at 21 emergency departments, which enrolled all patients with blunt trauma for whom cervical spine radiographs were ordered. In this substudy, we examined the NEXUS database to determine the contribution of each of the 5 individual low-risk clinical criteria to the overall sensitivity of the decision instrument. RESULTS: All but 8 of 818 patients with CSI, and all but 2 of 578 patients with significant CSI, were identified by using the decision instrument. A substantial number of patients with CSI (236/818 [29%]) and patients with significant CSI (175/578 [30%]) met only 1 of the 5 non--low-risk criteria, and each of the 5 criteria was the only indicator of non--low-risk status in at least 8 patients with CSI and at least 5 patients with significant CSI. CONCLUSION: Because each of the 5 low-risk criteria was the only marker of non--low-risk status in at least a few patients with significant CSI, modification of the overall NEXUS decision instrument by eliminating any one of the criteria would markedly reduce sensitivity and make the instrument unacceptable for clinical use.

Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement.

OBJECTIVE: Provide explicit expert-based consensus recommendations for the management of adults with primary and secondary spontaneous pneumothoraces in an emergency department and inpatient hospital setting. The use of opinion was made explicit by employing a structured questionnaire, appropriateness scores, and consensus scores with a Delphi technique. The guideline was designed to be relevant to physicians who make management decisions for the care of patients with pneumothorax. OPTIONS: Decisions for observation, chest tube placement, surgical interventions, and radiographic imaging. OUTCOMES: Effectiveness of pneumothorax resolution, duration of and patient tolerance of care, and pneumothorax recurrence. EVIDENCE: Literature review from 1967 to January 1999 and Delphi questionnaire submitted in three iterations to a multidisciplinary physician panel. VALUES: The guideline development group determined by consensus the relevant outcomes to be considered in developing the Delphi questionnaire. BENEFITS, HARMS, AND COSTS: The type and magnitude of benefits, harms, and costs expected for patients from guideline implementation. RECOMMENDATIONS: Management decisions vary between patients with primary or secondary pneumothoraces, with observation of small pneumothoraces being appropriate only for primary pneumothoraces. The level of consensus varies regarding the specific interventions indicated, but agreement exists for the general principles of care. VALIDATION: Recommendations were peer reviewed by physician experts and were reviewed by the American College of Chest Physicians (ACCP) Health and Science Policy Committee. IMPLEMENTATION: The guideline recommendations will be published in printed and electronic form with distribution of synopses for patients and health care providers. Contents of the guideline will be incorporated into continuing medical education programs. SPONSORS: The ACCP.

A comparison of succinylcholine and rocuronium for rapid-sequence intubation of emergency department patients.

OBJECTIVE: To compare rocuronium and succinylcholine for rapid-sequence intubation (RSI) in the emergency department (ED). METHODS: A one-year prospective cohort comparison study was performed using a data collection form completed at the time of intubation. Data collected included the reason for the neuromuscular-blocking agent (NMBA) chosen, the time to onset of paralysis, and any complications encountered. Three ten-point numerical descriptor scales recorded the degree of body movement, vocal cord movement, and the physician's overall satisfaction with the extent of paralysis. RESULTS: Succinylcholine was used in 382 patients and rocuronium was used in 138 (26% of all RSI) patients. The mean (+/- SD) times of onset of succinylcholine and rocuronium were 39 +/- 13 sec and 44 +/- 20 sec, respectively (p = 0.04). No patient desaturated and required assisted ventilations while waiting for paralysis to occur. Types of body movements were similar with the two agents, but less frequent with succinylcholine (median = 10, mean = 9.5 +/- 1.1) than rocuronium (median = 10, mean = 9.1 +/- 1. 5) (p = 0.01). Vocal cord movements were similar for succinylcholine (median = 10, mean = 9.2 +/- 1.6) and rocuronium (median = 9, mean = 9.0 +/- 1.6) (p = 0.15). The physician's overall satisfaction with the extent of paralysis was also higher for succinylcholine (median = 10, mean = 9.4 +/- 1.3) than rocuronium (median = 10, mean = 8.8 +/- 2.0) (p < 0.01). Only one complication, widening of the QRS complex secondary to succinylcholine use in a patient with unsuspected hyperkalemia, could be attributed to the choice of NMBA. CONCLUSIONS: Both succinylcholine and rocuronium produced fast and reliable paralysis for RSI. Although succinylcholine had a faster onset and provided more relaxation, the difference had no clinical significance. Approximately a fourth of ED RSI patients qualified for use of rocuronium using these high-risk criteria.

Bench to bedside: tumor necrosis factor-alpha: from inflammation to resuscitation.

Proinflammatory mediators such as tumor necrosis factor-alpha (TNF) have been implicated in the pathophysiology in a number of acute disease states. Tumor necrosis factor-alpha can contribute to cell death, apoptosis, and organ dysfunction. Tumor necrosis factor-alpha can be generated with sepsis or ischemia-reperfusion by activation of cell mitogen-activated protein kinases and nuclear factor kappa B, leading to TNF production. A number of strategies to modulate TNF have been recently explored, including factors directed toward mitogen-activated protein kinases, TNF transcription, anti-inflammatory ligands, heat shock proteins, and TNF-binding proteins. However, TNF may also play an important role in the adaptive response to injury and inflammation. Control of the deleterious effects of TNF and other proinflammatory cytokines represents a realistic goal for clinical emergency medicine. The purpose of this article is to provide a background of relevance to emergency medicine academicians on the production and regulation of TNF, the acute effects of TNF on pathophysiology, and the rationale for therapeutic interventions directed toward TNF and the clinical experience with these strategies.

Advanced Trauma Life Support (ATLS): necessary for emergency physicians?

A survey was conducted to determine differences in perspective towards Advanced Trauma Life Support (ATLS) between emergency medicine (EM) physicians and other specialties (OS), assess its value in the management of acute trauma, and identify areas in the course which could be revised or updated. The survey was devised and completed by physicians after ATLS. Of 26 course participants, there were 11 EM physicians (42%), four family practitioners (15%), four surgeons (15%), four internists (15%), two paediatricians (8%), and one anaesthesiologist (4%). Both groups found ATLS useful and relevant, and reported little deviation from their prior management of acute trauma. Unclear topics identified were airway, spine trauma, and burns/cold injury for EM, and head, abdominal, and paediatric trauma for OS. Significant differences were noted for the following: 91% EM vs. 13% OS felt ATLS could be shortened into a one-day course (p = 0.002), 64% EM vs. 7% OS thought the laboratory could be omitted (p = 0.003), and all (100%) EM vs. 60% OS believed the course could be taught by EM physicians as effectively as surgeons (p = 0.02). EM disagreed with OS over the proposed requirement that all EM physicians be required to take ATLS (2.0 +/- 0.2 vs. 3.5 +/- 0.4, p = 0.03). The EM group reported doing > 20 per year of airway, vascular, and thoracostomy procedures in their own practice, whereas OS did significantly fewer. ATLS may not be useful for EM practitioners actively involved in trauma care. Proposed changes from the EM perspective include shortening ATLS to one day, increased use of EM instructors, clarifying certain portions of the manual, and omitting the laboratory section or making it optional.

Rocuronium for rapid sequence intubation of emergency department patients.

Rocuronium is a recently synthesized non-depolarizing neuromuscular blocking agent (NMBA) that has been demonstrated to have a faster onset of action than any other non-depolarizing NMBA. Although widely studied in the operating room, there are no reports regarding its use for emergent tracheal intubation in the emergency department (ED). The purpose of this study was to evaluate the use of rocuronium for rapid sequence intubation (RSI) in ED patients. An intubation data collection form was completed prospectively for any patient receiving rocuronium for RSI in the ED from July 1-December 31, 1997. Two hundred eighty-eight patients were intubated in the ED over this six-month period, of whom 261 (91%) underwent RSI. Fifty-eight of the patients undergoing RSI received rocuronium for paralysis (22%). The most common reason reported for use of rocuronium was a concern regarding hyperkalemia (53%). The mean dose used was 1.0 +/- 0.2 mg/kg. The mean onset to paralysis was 45 +/- 15 s. Of the complications reported, none appeared to be related to rocuronium. Use of rocuronium in the ED setting appears useful.

Procedural competency in emergency medicine: the current range of resident experience.

OBJECTIVES: To evaluate the recorded range of procedures tracked by emergency medicine (EM) programs, and to determine whether differences in procedural experience occur in various types of residency or hospital settings. METHODS: The program directors of 112 approved EM programs were asked to send actual procedure logs. The requested information included the average total number of a given procedure per graduating resident, for all procedures that were tracked. Data were categorized by program format, hospital type, and ED volume. To assess the global procedural experience among programs, a set of 22 "index procedures" were identified; all procedures the EM residency review committee (RRC-EM) required to be tracked were included in this set. The means per graduating resident for each index procedure were added together to generate a "mean index procedure sum" (MIPS) per graduating resident for each residency program. These MIPSs for a residency were then compared by program format, hospital type, and ED volume. A similar analysis was performed for all resuscitations, and a "mean index resuscitation sum" (MIRS) per graduating resident was generated. RESULTS: An overall response rate of 82% was achieved; a number of programs had not graduated a residency class and were not included. Sixty-five of 85 eligible programs (76%) provided procedural data. The average number of a given procedure per graduating resident (95% CI in parentheses) for selected procedures is as follows: oral intubation 65 (46 to 85), intubation unspecified 75 (62 to 87), nasal intubation 6 (4 to 9), cricothyroidotomy 2 (1 to 2), subclavian catheter 23 (16 to 30), chest tubes 17 (14 to 20), intraosseous line 2 (1 to 3), thoracotomy 3 (2 to 5), and vaginal deliveries 17 (13 to 21). The only statistically significant differences in subgroup comparisons were in diagnostic peritoneal lavage, trauma resuscitations, and pediatric medical resuscitations when compared by postgraduate year format, and intubation-unspecified and cricothyroidotomy when compared by hospital type. There was no statistically significant difference when MIPSs were compared by format, hospital type, or ED volume. CONCLUSIONS: To the authors' knowledge, this is the first study of the range of EM resident procedure experience across the spectrum of EM residency types and settings. Overall, there are few statistically significant differences in procedure experience among different program formats. Similar experiences are recorded in a variety of different hospital types or ED volumes. However, some programs report very limited EM resident experience with selected critical procedures. There is a large variation in the types and numbers of procedures recorded by EM programs.

Comparison of 2 cricothyrotomy techniques: standard method versus rapid 4-step technique.

STUDY OBJECTIVE: To compare the success rate, complication rate and time required for the rapid 4-step technique versus the standard technique for cricothyrotomy. METHODS: We conducted a prospective, randomized crossover study. Twenty-seven emergency medicine interns, 1 junior medicine resident, and 4 senior medical students, without prior cricothyrotomy experience, were randomly divided into 2 groups. Group 1 was initially instructed in and then performed the standard technique; group 2 was initially instructed in and then performed the rapid 4-step technique. Each group was then instructed in and performed the alternate method. Cricothyrotomies were performed on preserved human cadavers. RESULTS: A surgical airway was established in 28 of 32 attempts with the use of the rapid 4-step technique (88%); the average time elapsed before tube placement was 43 seconds. Thirty of 32 attempts involving the standard technique (94%) were successful; the average time to tube placement was 134 seconds (95% confidence interval for a difference of 91 seconds, 63 to 119; P < .001). Complications were identified in 12 attempts involving the standard technique (38%; 1 considered major) and in 12 involving the rapid four-step technique (38%; 3 considered major). The incidence of major complications was 6% higher for the rapid 4-step technique (95% confidence interval, -9% to 21%). CONCLUSION: In a group of inexperienced subjects working on a preserved human cadaver model, the rapid 4-step technique for cricothyrotomy was performed in about one third the time required for performance of the standard technique. This finding was both clinically and statistically significant. Although the 2 techniques had similar success and complication rates, we noted a trend toward more severe complications in the rapid 4-step technique.

Airway management in the emergency department: a one-year study of 610 tracheal intubations.

STUDY OBJECTIVE: To describe the methods, success rates, and immediate complications of tracheal intubations performed in the emergency department of an urban teaching hospital. METHODS: This was an observational, consecutive series undertaken in an urban university hospital with an emergency medicine residency training program and an annual ED census of 60,000 patients. The study population included all patients for whom intubation was attempted in the ED during a 1-year period (July 1, 1995 through June 30, 1996). At the time of each intubation, the intubator filled out an intubation data collection form. If an intubation was performed in the ED but no form was filled out, the data were obtained from the medical record. RESULTS: A total of 610 patients required airway control in the ED; 569 (93%) were intubated by emergency medicine residents or attending physicians. Rapid-sequence intubation (RSI) was used in 515 (84%). A total of 603 patients (98.9%) were successfully intubated; 7 patients could not be intubated and underwent cricothyrotomy. In 33 patients, inadvertent placement into the esophagus occurred; all such situations were rapidly recognized and corrected. Eight (24%) of the 33 esophageal intubations resulted in a reported immediate complication. Overall, 49 patients (8.0%; 95% confidence interval [CI], 6% to 11%) experienced a total of 57 immediate complications (9.3%; 95% CI, 7% to 12%). Three patients sustained a cardiac arrest after intubation; two of these patients had agonal rhythms before intubation, and one probably had a succinylcholine-induced hyperkalemic cardiac arrest. CONCLUSION: At this institution, the majority of ED intubations were performed by emergency physicians and RSI was the most common method used. Emergency physicians intubated critically ill and injured ED patients with a very high success rate and a low rate of serious complications.

A national survey of board-certified emergency physicians: quality of care and practice structure issues.

The opinions and experiences of board-certified emergency physicians regarding employment structure and finances, professional society policies, and quality of patient care have never been formally studied. A survey questionnaire was sent to a random sample of 1,050 emergency physicians certified by the American Board of Emergency Medicine. The survey contained 29 multiple choice questions. Of the 1,050, 465 (44.3%) of the surveys were returned. Respondents averaged 13.5 years of emergency medicine practice, 83% were members of the American College of Emergency Physicians, and 44% were emergency medicine residency trained. Seventy-five percent felt they had been financially exploited by the emergency department contract holder and 49% considered leaving their employer because of unfair business practices. Fifteen percent have been terminated without due process/peer review, and 11% have been forced to leave a position, move, or pay compensation because of noncompete clauses. The majority reported encountering instances of substandard emergency medical care, most commonly in settings with multihospital contract company coverage. The majority also believe their specialty societies should address issues of employment structure and quality of patient care standards.

Severe rhabdomyolysis with renal failure after intranasal cocaine use.

A case of acute renal failure due to rhabdomyolysis in a patient who used cocaine on a daily basis is presented. In contrast to many prior reports of renal failure occurring with cocaine-associated rhabdomyolysis, our patient did not use intravenous cocaine and did not have any evidence of trauma, seizure, hypotension, hyperthermia, hyperactivity, or coma. His creatine phosphokinase peaked at 448,000 U/liter. He was treated initially with forced diuresis and i.v. furosemide, but he became oliguric, developed pulmonary edema, and required hemodialysis. He recovered fully after 3 weeks of dialysis. The literature is reviewed in an attempt to delineate a rational approach to evaluating cocaine users at risk for rhabdomyolysis.

Response to dopamine vs norepinephrine in tricyclic antidepressant-induced hypotension.

OBJECTIVE: To compare the efficacy of dopamine (DA) with that of norepinephrine (NE) in the treatment of refractory hypotension caused by tricyclic antidepressants (TCAs). METHODS: A retrospective analysis was used to compare blood pressure responses in concurrent case series of patients treated with vasopressors for TCA-associated hypotension. The patients were adults (aged > or = 16 years) treated at 2 urban teaching hospitals from 1983 to 1994. All patients were diagnosed as having TCA ingestion (positive serum toxicologic assay), were hypotensive [systolic blood pressures (SBPs) < or = 90 mm Hg], and required vasopressor therapy. The patients were grouped by initial vasopressor treatment (i.e., NE vs DA). RESULTS: There were 26 hypotensive adult patients who met study criteria. All 26 patients remained hypotensive after initial treatment of their TCA-associated hypotension with crystalloid infusion and alkalinization. The NE and DA groups were similar in age, sex, and proportion of patients with single and co-drug ingestion. The NE group, however, had a significantly lower average SBP at study entry (56 vs 74 mm Hg, p = 0.04). Nine of 15 (60%) patients responded to DA (5-10 micrograms/kg/min) and 11/11 (100%) patients responded to NE (5-53 micrograms/min). The difference in response rates was statistically significant (p = 0.02). Six patients in whom DA (max rate 10-50 micrograms/min/kg) failed to raise the SBP subsequently responded to NE (max rate 5-74 micrograms/ min) when this drug was later used. One patient receiving NE (12 micrograms/min) developed ventricular ectopy, successfully treated with lidocaine. There were no ischemic complications from either NE or DA. Patients who failed DA therapy tended to be older (39 vs 30 years, p = 0.08), to be more hypotensive at study entry (64 vs 81 mm Hg, p = 0.008), and to remain hypotensive even at higher doses of DA (24 vs 7 micrograms/min/kg, p = 0.002). CONCLUSION: While this was not a prospective randomized study, NE appears advantageous over DA as the first-line vasopressor agent for those patients who require vasopressor support in the setting of TCA-induced hypotension that is refractory to IV fluid and serum alkalinization.