Motor vehicle safety: current concepts and challenges for emergency physicians.

Motor vehicle travel is the primary means of transportation in the United States, providing freedom in travel and enterprise for many people. Motor vehicle crashes are the leading cause of death for the young and contribute to a high degree of morbidity and mortality for all ages. Motor vehicle crashes produce an enormous burden for society in terms of suffering, disability, death, and costs. Motor vehicle crash injury prevention is developing as a focused discipline to implement proven interventions involving technology and behavior known to prevent or reduce the severity of motor vehicle crash injury. Emergency physicians have an important role in advocating motor vehicle safety and injury prevention, both in the emergency department and within the community.

Emergency medicine and the development of the Food and Drug Administration's final rule on informed consent and waiver of informed consent in emergency research circumstances.

This article reviews the federal regulations for emergency and acute resuscitation research in effect prior to October 1996, the historical issues that contributed to the development of these regulations, the controversies that arose surrounding the application of these regulations to emergency research circumstances, and the methods by which the regulations were changed. The new regulations introduced by the U.S. Food and Drug Administration (FDA) also are reviewed.

EMT defibrillation does not increase survival from sudden cardiac death in a two-tiered urban-suburban EMS system.

OBJECTIVE: The use of automatic external defibrillators (AEDs) by EMS initial responders is widely advocated. Evidence supporting the use of AEDs is based largely on the experience of one metropolitan area, with effect on survival in many systems not yet proved. We conducted this study to determine whether the addition of AEDs to an EMS system with a response time of 4 minutes for first-responder emergency medical technicians (FREMTs) and 10 minutes for paramedics would affect survival from cardiac arrest. METHODS: This prospective, controlled, crossover study (AED versus no AED) of consecutive cardiac arrests managed by 24 FREMT fire companies took place from 1992 to 1995 in Charlotte, North Carolina, a city of 455,000. Patients were stratified using the Utstein criteria. The primary endpoint was survival to hospital discharge among patients with bystander-witnessed arrests of cardiac origin. RESULTS: Of the 627 patients, 243 were bystander-witnessed arrests of cardiac origin. Survival to hospital discharge was accomplished in 5 of 110 patients (4.6%; 95% confidence interval [CI] 0.6% to 8.4%) with AED compared with 7 of 133 (5.3%, 95% CI 1.5% to 9.1%) without AED (P = .8). Both groups were comparable with regard to age, gender, history of myocardial infarction, congestive heart failure or diabetes, arrest at home, bystander CPR, and whether or not ventricular fibrillation (VF) was the initial rhythm. For arrests of any cause, witnessed by bystanders or EMS personnel, with an initial rhythm of VF or ventricular tachycardia (VT), 5 of 77 (6.5%, 95% CI 1.0% to 12.0%) with AED survived compared with 8 of 105 patients (7.6%, 95% CI 2.5% to 12.7%) without AED (P = .8). Statistically significant differences were noted in race and EMS response times between the two groups, which did not affect survival. CONCLUSION: Addition of AEDs to this EMS system did not improve survival from sudden cardiac death. The data do not support routinely equipping initial responders with AEDs as an isolated enhancement, and raise further doubt about such expenditures in similar EMS systems without first optimizing bystander CPR and EMS dispatching.

The urban epidemiology of recurrent injury: beyond age, race, and gender stereotypes.

OBJECTIVES: To profile all patients presenting to an urban ED with any injury, and to determine whether the rate of subsequent injury treated in the ED varied by demographic and E-code (external mechanism of injury) category. The hypothesis that young black males were disproportionately at risk for re-injury was addressed. METHODS: A cohort of consecutive patients presenting to an urban ED with any injury between January 1, 1991, and November 31, 1992, were followed prospectively for 1 year from their index visit dates. Any repeat ED visits due to injury were sought. The mean number of injury visits per year (the total number of ED injury visits for each patient divided by 1 year) was computed for the overall population and by race, age, gender, and E-code. RESULTS: The sample consisted of 34,378 patients who made 44,813 visits to the ED for injury. Of these patients, 22% had a repeat injury in 1 year, with a cohort mean of 1.30 injury visits per year. This mean did not vary appreciably by race (black 1.33, white 1.27), age (1-17 yr, 1.21; 18-24 yr, 1.32; 25-64 yr, 1.34; > 65 yr, 1.23), gender (males 1.33, females 1.27), or E-code category. Having a prior injury visit in the preceding year was the best predictor of future injury (mean repeat visit rate = 2.08). CONCLUSIONS: When examining patients presenting with any injury to an urban ED, the mean numbers of injury visits are remarkably similar across demographic and E-code categories. Although there are factors that place patients at risk for recurrent injury, those factors are not demographic-all patients presenting to an ED with injury should be considered at risk for re-injury.

Effects of pegorgotein on neurologic outcome of patients with severe head injury. A multicenter, randomized controlled trial.

OBJECTIVE: To evaluate outcome of patients with severe closed head injury treated with pegorgotein, a scavenger of oxygen-derived free radicals. DESIGN: Randomized, parallel, placebo-controlled, third-party-blind, multicenter trial, with a blinded, multicenter follow-up protocol. SETTING: Twenty-nine centers in the United States. PATIENTS: A total of 463 patients with severe closed head injury and a Glasgow Coma Scale score of 8 or less after resuscitation and stabilization. INTERVENTIONS: Patients received a single intravenous dose of placebo, 10 000 U/kg of pegorgotein, or 20 000 U/kg of pegorgotein within 8 hours after injury. OUTCOME MEASURES: The primary endpoint was the Glasgow Outcome Scale (GOS) score at 3 months after brain injury with GOS data trichotomized into good, fair, or poor outcome. Secondary efficacy endpoints included the Disability Rating Scale (DRS) and mortality. A secondary analysis was performed using GOS scores dichotomized into favorable and unfavorable outcomes. In a follow-up protocol at 6 months, GOS and DRS scores were again determined. RESULTS: Of 463 patients randomized, 162 received placebo; 149, pegorgotein 10 000 U/kg; and 152, pegorgotein 20 000 U/kg. Treatment groups were comparable with respect to demographic characteristics, mechanism of injury, and time to treatment. Pegorgotein was well tolerated at both dose levels. At month 3, the trichotomized analysis found no significant statistical difference in neurologic outcome between the pegorgotein and the placebo groups. Although differences were not statistically significant, there were more favorable outcomes and no increase in the number of deaths or vegetative states among the patients given pegorgotein, more subjects had good or favorable outcomes with the 10 000-U/kg dose than with the 20 000-U/kg dose or placebo, and less disability was observed with the 10 000-U/kg dose than with either the 20 000-U/kg dose or placebo. No differences in mortality rate or cause of death were found between the 10 000-U/kg and placebo groups at either month 3 or month 6. The only statistically significant difference between the groups was a decreased incidence of adult respiratory distress syndrome in the 10 000-U/kg group as compared with the placebo group (P<.015). CONCLUSIONS: In this clinical trial of 463 patients with severe head injury, no statistically significant difference in neurologic outcome or mortality was observed between patients treated with pegorgotein and those receiving placebo.

Emergency treatment of status epilepticus.

Status epilepticus occurs in more than 50,000 people in the United States each year and should be considered a neurologic emergency. A variety of drugs are used to treat status epilepticus, including i.v. benzodiazepines, phenytoin, and barbiturates. They are all short of being ideal, primarily because of difficulties with administration or associated toxicity. Fosphenytoin, a prodrug and phosphate ester of phenytoin, was developed to overcome the drawbacks associated with i.v. phenytoin. With its efficacy, safety, and ease of administration, fosphenytoin is a valuable option for the treatment of status epilepticus.

Enforcement of drunken driving laws in cases involving injured intoxicated drivers.

STUDY OBJECTIVE: To determine the frequency of driving while impaired (DWI) charges among alcohol-intoxicated drivers injured in motor vehicle crashes (MVCs) and any differences in the group of those charged compared with those not charged. METHODS: We performed a retrospective analysis of linked data from medical and judicial sources. Our setting was an urban emergency department of a trauma center serving a population of 1 million. We studied consecutive drivers injured in MVCs over a period of 15 months who had measured serum ethanol (BAC) levels of 100 mg/dL or higher. BAC, Trauma Score (TS), demographics, and crash data were linked to court records of charges, outcome, and prior convictions. The group of individuals who were charged with DWI were compared with those who were not charged. RESULTS: One hundred eighty-seven patients were studied; 53 (28%) were charged with DWI, and 32 (17% of total) were convicted. Two (7%) of 29 patients with severe injuries, 9 (28%) of 32 with moderate injuries, and 42 (33%) of 126 with nonsevere injuries were charged (P = .004). Eighteen (16%) of 112 patients with no prior convictions were charged; 20 (56%) of 36 patients with one, 11 (52%) of 21 with two, 3 (25%) of 12 with three, and 0 of 5 with four or more prior DWI convictions were charged (P < .001). There were no significant differences in BAC, demographics, or other measures between the two groups. CONCLUSION: Alcohol-impaired drivers who require ED treatment for injuries sustained in an MVC are infrequently charged with DWI. The likelihood of a DWI charge diminishes with increasing severity of injury. Repeat offenders are charged more often, but the frequency of charges does not increase with increasing number of prior DWI convictions.

Informed consent in emergency research. Consensus statement from the Coalition Conference of Acute Resuscitation and Critical Care Researchers.

OBJECTIVE: A coalition conference of acute resuscitation researchers was held to discuss the feasibility of applying current federal research regulations regarding informed consent to the emergency setting. This article presents consensus recommendations for regulatory changes for consent in emergency research. PARTICIPANTS: Representatives from the Society for Academic Emergency Medicine and the American Heart Association identified several professional organizations as stakeholders in this issue, including research, clinical, bioethics, legal, and patient advocacy groups. The Office for Protection From Research Risks (OPRR), the Food And Drug Administration (FDA), and staff from specific legislative offices were also invited to observe. Forty-three participants attended, including representatives from 12 professional organizations, five medical institutions, and the FDA and OPRR. This was a closed meeting. Participants were self-funded or sponsored by their professional organizations. EVIDENCE: Before the meeting, a draft of a position statement was developed by the conference organizers based on the current literature and discussions with experts in the field. This draft, copies of the current federal research regulations, and supporting articles were distributed before the conference. CONSENSUS PROCESS: Participants rotated through moderated discussion sessions to comment on subsections of the draft. Following discussion, a working draft was developed and distributed to each participant and represented organizational board for final review. All comments were considered in the final version of the document. CONCLUSIONS: We believe there are circumstances when it is not feasible to obtain prospective or proxy consent for enrollment into an emergency research protocol. In these circumstances, patients are vulnerable, not only to research risks, but also to being denied potentially beneficial therapy when there is no known effective treatment for their life-threatening condition. We offer recommendations that should be met when the critical nature of the illness or injury or the need to apply an investigational therapy rapidly precludes prospective consent for participation in emergency research.

Streptococcal pharyngitis: a review of pathophysiology, diagnosis, and management.

Pharyngitis is an illness frequently treated by emergency physicians and primary care practitioners. It is the subject of much controversy regarding optimal treatment in the acute care setting. This review discusses pertinent aspects of the pathophysiology, clinical features, diagnosis, and treatment based on available literature. This review is also meant to serve as a bibliographic resource for some of the controversies of this complex topic.