Color Doppler ultrasonography by emergency physicians for the diagnosis of acute deep venous thrombosis.

OBJECTIVES: To assess the feasibility of emergency physicians' (EPs') performing color-flow Doppler ultrasonographic vascular studies in the ED to diagnose deep venous thrombosis (DVT), after a modest training program. METHODS: A retrospective observational review was performed of the performance of color-flow Doppler ultrasonographic vascular studies by EPs. Prior to the study period, venous Doppler studies were not available at off-hours. Two attending EPs were trained by the hospital's vascular laboratory by observing studies and then performing 25-30 studies successfully. They were then available to examine all patients presenting to the ED at off-hours who were suspected of having DVT. Patients were admitted or released from the ED based on the examination results. All patients were to have formal vascular laboratory studies the next day. The study was performed at a university hospital ED and evaluated all patients who underwent off-hour examinations from January 1993 to February 1994. The examiners were aware of the clinical scenario. RESULTS: Of 23 eligible patients, 15 completed the protocol with a follow-up next-day study. Based on the follow-up study, the ED examination was 100% sensitive (7 true positives) and 75% specific (6 true negatives). The 2 false-positive studies were for patients with old DVT. The 8 patients without follow-up studies were not included in the analysis, although 4 of these patients had negative studies and unremarkable clinical outcomes. CONCLUSIONS: These preliminary findings suggest that Doppler ultrasonographic studies of the lower extremity veins by EPs can be used to make admission decisions when formal studies are not available. Confirmatory studies should be performed. EPs may overread acute thrombosis in the setting of old venous disease. Issues of cost and logistics remain to be resolved.

Evaluation of the Ottawa clinical decision rules for the use of radiography in acute ankle and midfoot injuries in the emergency department: an independent site assessment.

STUDY OBJECTIVE: Decision rules for the use of radiography in acute ankle and midfoot injuries have been developed. Radiographs are indicated if there is tenderness at the posterior edge or tip of either malleolus or at the navicular or base of the fifth metatarsal or there is inability to both weight bear immediately after the injury and ambulate four steps in the emergency department. This study assessed the efficacy of these rules with health care providers who had not been involved in their development. DESIGN: Prospective patient survey by emergency department attending physicians and triage nurses. SETTING: EDs of a university hospital and a community hospital with a combined annual volume of 100,000. PARTICIPANTS: One hundred ten patients older than 16 years who presented with acute blunt ankle and midfoot trauma during the 3 months of summer 1993. RESULTS: Fourteen fractures were diagnosed. When used by ED attending physicians, the decision rules had a sensitivity of 1.0 and specificity of 0.19 in detecting all midfoot and ankle fractures. When used by triage nurses, the sensitivity was 0.9 and specificity was 0.1. The negative predictive values of the decision rules were 1.0 for ED attending physicians and 0.88 for triage nurses. ED attending physicians and triage nurses agreed in 90% of cases regarding the overall decision to obtain radiographs. However, there was only a 47% agreement on all components of the clinical decision rules, with kappa values ranging from 0.60 to 0.76. The accuracies of the predictive rules were similar as applied by the ED attending physicians and the triage nurses (chi 2, P = .23). Application of the Ottawa predictive rules by ED attending physicians would have resulted in a 19% reduction in use of midfoot and ankle radiographs. CONCLUSION: Use of the Ottawa and midfoot clinical decision rules by ED attending physicians of institutions not familiar with the rules' development resulted in 100% sensitivity for all fractures and would have allowed these physicians to safely reduce the number of radiographs ordered by 19%.

Splatter during jet irrigation cleansing of a wound model: a comparison of three inexpensive devices.

STUDY OBJECTIVE: Pressurized jet irrigation is commonly used to cleanse traumatic wounds but results in splatter of blood, a biohazard. Three inexpensive irrigation devices were compared to assess the degree of splatter produced: a 1.25-in. 18-gauge angiocath, an Irrijet Irrigation System with a 12.7-cm splash shield, and a Zerowet Splashield held directly against the wound (Zerowet-C) and held 4 to 10 cm from the wound, an incorrect technique (Zerowet-I). DESIGN: A standard laceration was created in pieces of beef. This wound model was placed 1 m from the floor. Paper grid sheets were placed on the irrigator's face and chest. Six grid sheets were suspended at the 9:00, 12:00, and 3:00 positions 1 m from the wound model and 1 and 1.5 m from the floor to simulate exposure to nearby individuals. Two grid sheets were placed flat on the floor, at the 10:30 and 1:30 positions, 1 m from the base of the wound model stand. The study area was contained in a 3 x 2 x 2 m plastic sheet enclosure to prevent air drafts. INTERVENTION: Ten irrigations were performed with the angiocath, Irrijet, Zerowet-I, and Zerowet-C. Each run used 200 mL methylene blue solution delivered with a 50-mL syringe by one-hand pressure. The methylene blue splatter on each of the grids was counted by size (diameter, less than 1 mm, more than 1 mm and less than 5 mm, more than 5 mm and less than 10 mm, and more than 10 mm). RESULTS: There was significantly less splatter onto the irrigator's face and chest with Irrijet, Zerowet-I, and Zerowet-C. No facial splatter occurred with Zerowet-C. There was significantly less splatter at the 9:00 and 12:00 positions at both heights, and on the floor with Irrijet, Zerowet-I, and Zerowet-C. Less significant splatter difference was noted at the 3:00 position. CONCLUSION: Irrijet, Zerowet-I, and Zerowet-C were superior to the angiocath in preventing splatter during this wound model irrigation. The correct use of Zerowet (Zerowet-C) was particularly effective in preventing splatter onto the irrigator's face.

Angioedema in the emergency department: the impact of angiotensin-converting enzyme inhibitors.

Angiotensin-converting enzyme (ACE) inhibitors have been reported to cause angioedema. The purpose of this study was to establish what proportion of patients who present to the emergency department (ED) with angioedema were concomitantly taking any of the ACE inhibitors and to show how this group differed in presentation and response to treatment from the larger population of patients with non-ACE inhibitor-related angioedema. An 8-year retrospective chart review of all patients with the diagnosis of angioedema observed from January 1, 1984 to December 31, 1991 was undertaken in the ED of an urban teaching hospital. Forty-nine patients ranging from 12 to 88 years of age with symptoms and physical examination that was consistent with the diagnosis of angioedema were entered onto the study. Twelve cases of ACE inhibitor-related angioedema were identified, all occurring in the last 4 years of the review, and when compared with the non-ACE inhibitor-related group were older (mean age, 63.3 vs 43.0 years), had less of an allergic history (0% vs 49%; P = .013), but demonstrated the same severity of symptoms and response to medical therapy. No case required an artificial or surgical airway. ACE inhibitor related angioedema is becoming a common type of angioedema observed in this ED. These patients are older and free of other allergic disease and respond well to traditional therapy.

Cervical anterior spinal artery syndrome associated with cardiopulmonary arrest.

Nontraumatic spinal cord ischemia is uncommon, especially when the cervical cord is involved. We present an elderly man who sustained acute occlusion of the anterior spinal artery at a high cervical level. This was followed by a respiratory arrest due to the paralysis of the diaphragm and chest wall muscles. A review of the vascular supply to the cord and of nontraumatic ischemic myelopathy is provided.

Military nordic skiing injury profiles with two different types of NATO ski bindings.

Two different types of NATO ski bindings were compared during military-nordic ski training of a Marine Corps infantry battalion of 534 men, who sustained 26 injuries (3.75 injuries per 1,000 skier days). Twelve injuries occurred with the 224 subjects using the NATO 100 bindings. Fourteen injuries occurred with the 310 subjects using the NATO 120 bindings. A total of 133 days were lost from training in the NATO 100 cohort and 121 days from training in the NATO 120 cohort, a statistically significant difference. It is concluded that the NATO 120 binding is safer.

Skiing injuries during initial military nordic ski training of a U.S. Marine Corps Battalion Landing Team.

During 4 weeks of military nordic ski training with 638 men, 45 skiing injuries occurred with 359 days lost from training (5.63 injuries per 1,000 skier days). Knee injuries represented 38% of total injuries, with 58% of these being medial collateral ligament sprains. Knee injuries represented a greater fraction of total injuries in the novice skier cohort than in the experienced skier cohort. All injured subjects except one responded favorably to conservative therapy available at the training facility. Despite the special rigors of military nordic skiing, the incidence and anatomic distribution of injuries is similar to that reported with civilian skiing.

Acute mountain sickness at intermediate altitude: military mountainous training.

A US Marine Corps Battalion Landing Team (BLT) of 638 men was deployed on a winter training exercise to an altitude of 2,065 to 2,620 m. Nine marines (1.4%) presented to the medical officers with incapacitating symptoms consistent with acute mountains sickness. Seven were treated with acetazolamide and experienced relief of their symptoms within 24 hours. The incidence of nonspecific complaints associated with acute mountain sickness at altitude was found to be significantly greater than the incidence at sea level of those same complaints in the same BLT performing a similar winter training exercise (0.16%). Blacks who had been raised in low-altitude regions were the most commonly afflicted. Prophylaxis with acetazolamide for subsequent altitude exposure can be recommended for those individuals identified as susceptible. Acute mountain sickness is not uncommon at intermediate altitudes.

Chronic beta-blocker therapy complicating the presentation of cardiac tamponade of malignancy.

A case report is related of an elderly patient with metastatic carcinoma who presented to the emergency department with mental status change and ultimately proved to have cardiac tamponade. All of the classic cardiovascular signs of this condition were obscured by chronic beta-blocker therapy and concurrent hypovolemia. A discussion of pertinent pathophysiology and review of the literature is included.