Proposing short-term observation units for the management of decompression illness.

Decompression illness (DCI) is a potentially life-threatening disease, often requiring hyperbaric oxygen therapy (HBO2) for symptom resolution. Once treated, current guidelines recommend an observation period of at least six hours for patients with neurological symptoms in case of relapse. Surveys have shown a symptom relapse rate as high as 38.5%, with half of those occurring in the first twenty-four hours. We propose that a short-term observation unit (OU) would be an ideal setting for these patients to be monitored. To evaluate this, we did a retrospective study of patients presenting with DCI at a major hyperbaric facility. One hundred and two consecutive patients were evaluated with DCI diagnosis and receiving HBO2. Forty-two (41.2%) patients had neurological sequelae; ten required more than one treatment for refractory symptoms or relapse. Thirty-eight of the forty-two patients received up to three treatments, which can be done within the time requirements of short-term observation. We conclude that OUs would provide a safe and efficient disposition for patients after receiving HBO2.

Comparison of an automated thrombolytic predictive instrument to both diagnostic software and an expert cardiologist for diagnosis of an ST elevation acute myocardial infarction.

Because the electrocardiograms (ECGs) of patients with symptoms suggesting an acute thrombotic coronary occlusion are typically read by physicians relatively inexperienced in this skill, it is important to develop automated decision support. A Thrombolytic Predictive Instrument (TPI) is now available along with the standard diagnostic software in a commercially available electrocardiograph. This study evaluates the performance of the predictive software in comparison to both an expert cardiologist and standard diagnostic software. True sensitivity and specificity cannot be determined because acute coronary angiography was not performed. The specificities determined by this study were excellent (98% and 99%), and the sensitivities were very good (72% and 78%). These results that the TPI will be only rarely applied to patients who do not indeed have an acute coronary thrombosis. However, the reasons for even this small number of presumably falsely TPI positive patients should be determined and analyzed. It is unlikely that alterations of the thresholds for TPI activation will significantly improve on this very good level of sensitivity, without prohibitively decreasing specificity.

Differences between chest pain observation service patients and admitted "rule-out myocardial infarction" patients.

OBJECTIVE: To compare and contrast the patient characteristics of ED patients at low risk for acute cardiac ischemia who were assigned to a chest pain observation service vs those admitted to a monitored inpatient bed for "rule-out acute myocardial infarction" (R/O MI). METHODS: This was a retrospective, cross-sectional comparison of adult patients considered at relatively low risk for cardiac ischemia and who were evaluated in 1 of 2 settings: a short-term observation service and an inpatient monitored bed. All patients had an ED final diagnosis of "chest pain," "R/O MI," or "unstable angina" during the 7-month study period. Demographic features and presenting clinical features were examined as a function of site of patient evaluation. RESULTS: Of 531 study patients, 265 (50%) were assigned to the observation service. Younger age (OR = 1.75, 95% CI 1.26, 2.44, for each decrement of 20 years), the complaint of "chest pain" (OR = 2.35, 95% CI 1.34, 4.12), and the absence of prior known coronary artery disease (OR = 1.64, 95% CI 1.13, 2.38) were the principal independent factors associated with assignment to a chest pain observation service bed. CONCLUSIONS: Patients evaluated in a chest pain observation service appear to have different clinical characteristics than other individuals admitted to a monitored inpatient bed for "R/O MI." Investigators should address differences in clinical characteristics when making outcome comparisons between these 2 patient groups.

Sickle cell vaso-occlusive pain crisis in adults: alternative strategies for management in the emergency department.

The gene for sickle cell disease is carried by 8% of the African-American population in the United States. The primary care physician is often called upon to recognize and treat one of the major sequelae of sickle cell disease--vaso-occlusive pain crisis. An injectable nonsteroidal anti-inflammatory drug has recently become available and may offer some improvement in outcome of vaso-occlusive pain crises. We present five case reports reviewing various current therapeutic options, including newer pharmacologic agents, and comment on alternatives to impatient management of pain crises. The use of the emergency department short-term observation unit as an alternative to hospitalization is discussed.

Emergency department analgesia without narcotics for adults with acute sickle cell pain crisis: case reports and review of crisis management.

Vaso-occlusive crises are one of the most debilitating features of sickle cell disease. There appears to be no standardization of care for adults with pain crisis, and some commonly utilized regimens, such as those employing intramuscular meperidine, are pharmacologically unsound. Parenteral narcotic use may be associated with respiratory compromise acutely and with dependence over the long term, but nonopioid preparations are often unsatisfactory in relieving pain. We have recently enjoyed success with a combination of a parenteral nonsteroidal anti-inflammatory medication and an oral tricyclic antidepressant. We report four representative cases and review the salient points of the management of pain crisis in adult patients in the emergency department.

Treatment of pyelonephritis in an observation unit.

STUDY OBJECTIVE: To determine the feasibility of managing patients with acute pyelonephritis as outpatients after initial treatment with IV antibiotics in an emergency department observation unit. DESIGN: Prospective and uncontrolled. SETTING: ED observation unit. TYPE OF PARTICIPANTS: Nonpregnant female patients 14 years old or older without immunocompromise or serious underlying disease and no evidence of septic shock. INTERVENTIONS: All patients received two IV doses of trimethoprim/sulfamethoxazole at a 12-hour dosing interval and promethazine and acetaminophen as needed for nausea and fever, respectively. Baseline laboratory data, urinalysis, and urine and blood cultures were obtained. MEASUREMENTS AND MAIN RESULTS: Patients were observed for signs of septic shock, nausea, vomiting, and the ability to tolerate an oral intake. At the end of the observation period, 43 of 44 patients were discharged on oral trimethoprim/sulfamethoxazole. One additional patient who was doing well clinically was recalled and admitted because of a positive blood culture. CONCLUSION: Patients with acute pyelonephritis, despite significant fever or nausea and vomiting, can be treated effectively as outpatients after a brief period of observation and IV antibiotics.

Assault rifles; definitions, evolutionary history and medical consequences.

In summary, the evolutionary history of assault rifles may be of interest to some medical practitioners. It is important to realize that the term "assault rifle" is incorrectly and overused in the lay press. As a rough generalization, the wounds from such weapons may fall in between those of handguns on one side and full-sized rifles on the other. The major caveat is that there can be major variations in the severity of any wound by any weapon and though it may be of some help in analyzing potential damage, knowledge of the inflicting weapon does not replace the need for good, well established principles of wound management.

Sialolithiasis: case studies and review.

Three cases of sialolithiasis are presented, each representative of acute and chronic presentations of this problem. The evaluation and treatment of salivary gland and duct stones are outlined. The primary axiom is, "Treat the gland, not the stone," and the essential aspects of emergency medical management are antibiotics, sialogogues, warm compresses, mechanical stimulation, and appropriate referral to an otolaryngologist.

Acute carbon monoxide poisoning: emergency management and hyperbaric oxygen therapy.

An ice storm in February 1989 resulted in numerous incidences of carbon monoxide poisoning in central Mississippi secondary to exposure to open fires in unventilated living spaces. Sixteen cases were treated during this period at the University of Mississippi Medical Center and 6 received Hyperbaric Oxygen therapy. These 6 cases and the mechanisms of CO poisoning are discussed and recommendations for emergency management are reviewed.

A comparison of paramedic versus basic emergency medical care of patients at high and low risk during acute myocardial infarction.

This prospective study compares the outcome of patients with acute myocardial infarction managed by mobile intensive care (paramedic phase) with that of similar patients managed by basic emergency medical care (control phase) in the same community before the introduction of paramedics. All paramedic-transported patients were managed according to a standard chest pain protocol with use of prophylactic lidocaine and, as needed, treatment for sinus bradycardia, hypotension and life-threatening ventricular arrhythmia. There were no specific interventions for supraventricular tachyarrhythmia or hypertension. All patients were treated under similar in-hospital protocols. Percent mortality in patients with hypotension, the highest risk subgroup in the control phase, was significantly lowered with paramedic-level care (69 versus 10%, p = 0.01). Patients with hypertension, a relatively low risk subgroup during the control phase (16% mortality), were also at lower risk during the paramedic phase (10% mortality). In fact, there was no mortality in either study phase for patients with an initial systolic blood pressure greater than 180 mm Hg. During the combined study phases, patients with normotension and tachycardia demonstrated a tendency toward higher percent mortality (33%) than either patients with normotension without tachycardia (10%) or those with hypertension and tachycardia (6%). Although the overall percent mortality was reduced by 24% (from 21 to 16%), this decrease was largely due to the improvement of patients with hypotension. Investigation into the feasibility of prehospital interventions for the high risk patient with acute myocardial infarction normotension and tachycardia appears warranted.

Profound muscle weakness and hypokalemia due to clay ingestion.

We have presented the case of a 43-year-old woman with severe myositis due to clay ingestion and hypokalemia. EMG studies revealed a pattern consistent with myositis, and muscle biopsy showed a nonspecific diffuse myositis. The clay was shown to act as a potassium binder. With potassium replacement and discontinuance of clay ingestion, the symptoms and signs abated and laboratory values returned to normal.

Basic emergency medical care of patients with acute myocardial infarction: initial prehospital characteristics and in-hospital complications.

This prospective study documents the natural history of the prehospital phase of 110 patients with acute myocardial infarction transported by a basic emergency medical system during a 22 month period. Ambulances in a mixed urban-rural county were staffed by basic emergency medical technicians certified in basic life support and the administration of intravenous fluids. Systolic blood pressure, pulse rate and cardiac rhythm were noted for all patients at the time of ambulance arrival and intermittently during transport. Analyses of patient data were performed to determine the relation between the occurrence of subsequent in-hospital urgent complications and death and 1) patient delay time, 2) initial pulse rate, 3) initial systolic blood pressure, and 4) initial cardiac rhythm. Twenty-three (21%) of the 110 patients died and 66 (60%) experienced at least one in-hospital urgent complication. When initial rhythm, pulse rate and blood pressure were considered, patients with hypotension had a higher mortality rate than did those who were either normotensive or hypertensive. The 10 patients with initial sinus bradycardia but no hypotension constituted a subgroup with zero mortality. These results identify high and low risk patient subgroups that may benefit from either providing or withholding interventions directed toward hemodynamic stabilization during the prehospital phase of acute myocardial infarction.

Prognostic significance of isolated sinus tachycardia during first three days of acute myocardial infarction.

Sinus tachycardia often accompanies other indicators of poor prognosis in acute myocardial infarction. This study was performed to evaluate the prognostic significance of early (Days 1 to 3) in-hospital sinus tachycardia (isolated sinus tachycardia) in the absence of other common indicators of poor prognosis. All patients consecutively admitted directly to the cardiac care unit during a six-year period were evaluated. Patients who had confirmed acute myocardial infarction and no urgent complications during Days 1 to 3 with isolated sinus tachycardia (99 patients) or without isolated sinus tachycardia (159 patients) were included in the study. Both groups were followed for subsequent in-hospital outcome and long-term survival. Univariable and multivariable analysis of historical and demographic characteristics showed no significant differences between the two groups. When clinical descriptors of the infarct were evaluated, the group with isolated sinus tachycardia had a significantly higher mean peak creatine kinase level (p = 0.0007), a larger proportion of anterior infarcts and multiple infarct sites (p less than 0.001) by electrocardiography, a higher incidence of peri-infarction pericarditis (p = 0.007), and a higher incidence of recurrent chest pain (p = 0.03). Twenty-five patients (25 percent) in the group with isolated sinus tachycardia had subsequent urgent complications during the hospitalization compared with 11 patients (7 percent) in the control group (p = 0.00005). In multivariable analysis, isolated sinus tachycardia was an independent predictor of subsequent urgent complications (p = 0.0009) and mortality (p = 0.05).

Out-of-hospital management of cardiac arrest by basic emergency medical technicians.

The outcome in 126 consecutive patients with nontraumatic out-of-hospital cardiac arrest was analyzed to determine the effectiveness of a standard ambulance system over 22 months. Therapy was limited to basic life support (that is, administration of oxygen by mask, i.v. fluids, closed-chest massage and artificial respiration) by emergency medical technicians in a community in which less than 1% of the population had been trained in cardiopulmonary resuscitation (CPR). Analyses of patient data were performed to determine the relations between survival to hospital admission or discharge and 6 variables; response time, prior CPR, initial rhythm, acute myocardial infarction, initial blood pressure and initial pulse. Of 126 patients, 28 (22%) survived to hospital admission and 11 (9%) to hospital discharge. Two patient subgroups had a higher discharge rate: those with an initial rhythm of ventricular tachycardia or fibrillation (7 of 50, 14%), and those with an initial blood pressure greater than or equal to 90 mm Hg and a pulse rate of greater than 50 beats/min (3 of 6, 50%). For patients in arrest before ambulance arrival, there was no difference in outcome between those who did or those who did not receive prior CPR. Results of this study can be used as a basis for evaluating and comparing interventions directed toward stabilization of patients during the prehospital phase of cardiac arrest.

Criteria for early discharge after acute myocardial infarction: validation in a community hospital.

All patients admitted to a community hospital coronary care unit during an 18-month-period were studied to validate previously reported criteria for early hospital discharge after myocardial infarction. Factors present during the first four hospital days, which predict subsequent complications requiring urgent medical attention, were classified as either urgent or prognostic. Patients whose initial four days were marked by either no complications (81 patients) or prognostic complications (51 patients) are described. Only one patient in the group of 81 patients had a subsequent urgent complication. Four of 55 patients had late urgent complications. Persistent sinus tachycardia occurred during the first four days in all four of these 55 patients. Early hospital discharge would be feasible in the group with neither urgent nor prognostic complications. Further study of persistent sinus tachycardia is required to improve its predictive ability.