Emergency department evaluation of the chest pain patient.

The emergency physician must have a high degree of suspicion for myocardial ischemia in patients presenting with no obvious for their chest pain. The role of the emergency physician is to determine a relative risk for each patient and to order the appropriate studies to minimize the risk of missed myocardial infarction as well as to recognize acute ischemia or infarction and manage it aggressively. It is not possible to rule out myocardial ischemia or infarction subjectively. It is the opinion of these authors that some form of further testing should be performed on patients in all categories, except those determined to be at very low risk.

Acute coronary syndrome: pharmacotherapy.

Acute coronary syndrome (ACS) refers to the spectrum of cardiac disease, from unstable angina to ST-segment-elevation myocardial infarction. In the emergency medical services (EMS) setting, ACS may be more broadly thought to include patients with chest pain or other symptoms believed to have a cardiac origin who have evidence of ischemia or acute myocardial infarction on a 12-lead electrocardiogram, or symptomatic patients with a previous cardiac event or known cardiac disease. Pharmacologic management of these patients is based on the use of three primary classes of drugs: those that affect clotting, those that establish and maintain hemodynamic control, and those that relieve pain. Many of these agents have been evaluated in large clinical trials for in-hospital use, and a number of ongoing studies are assessing their efficacy in the prehospital setting. The appropriateness of prehospital use of specific agents within each class depends on proper patient selection, the necessity of immediate intervention, ease of use in the field, expertise of EMS personnel, and cost-effectiveness of therapy. This consensus group reviewed agents from all three classes (including aspirin, GPIIb/IIIa inhibitors, unfractionated and low-molecular-weight heparins, fibrinolytics, beta-adrenergic blockers, calcium antagonists, nitrates, and morphine) for their overall indication, applicability to the prehospital setting, and current prehospital use.

Selected controversies in cardiopulmonary resuscitation.

Cardiopulmonary resuscitation (CPR) is performed frequently by paramedics, emergency department personnel, and inpatient physicians. Unfortunately, after more than 40 years of practice and study, there are still many controversies and unresolved treatment issues. This article focuses on four current controversies in CPR: (1) the role of end-tidal CO2 (ETCO2) detection, (2) the use of bicarbonate, (3) whether epinephrine is the optimal alpha agonist, and (4) whether amiodarone should replace lidocaine as the initial antiarrhythmic of choice in the treatment of ventricular fibrillation.

Hypophosphatemia in the emergency department therapeutics.

Although hypophosphatemia is relatively uncommon, it may be seen in anywhere from 20% to 80% of patients who present to the ED with alcoholic emergencies, diabetic ketoacidosis (DKA), and sepsis. Severe hypophosphatemia, as defined by a serum level below 1.0 mg/dL, may cause acute respiratory failure, myocardial depression, or seizures. Because hypophosphatemia is not as often treated by ED physicians, becoming familiar with a single intravenous phosphate solution and specific guidelines for phosphate repletion are essential. One mL of the most commonly available phosphate solution (K2PO4) contains 4.4 meq of potassium and 3 mmol (93 mgs) of phosphate. Administering K2PO4 at a rate of 1 mL per hour is almost always a very safe and appropriate treatment for hypophosphatemia. This article provides guidelines for phosphate therapy in hypophosphatemic ED patients including those in DKA, those presenting with alcohol-related complaints including alcoholic ketoacidosis and patients with acute exacerbation of asthma and chronic obstructive pulmonary disease.

Self-reported cardiac risk factors in emergency department nurses and paramedics.

STUDY OBJECTIVE: Our objective was to assess the prevalence of cardiac risk factors in a sample of urban paramedics and emergency department (ED) nurses. METHODS: We asked 175 paramedics and ED nurses working at a busy, urban ED to complete a cardiovascular risk assessment. The survey asked subjects to report smoking history, diet, exercise habits, weight, stress levels, medication use, history of hypertension or cardiac disease, family history of cardiovascular disease (CVD), and cholesterol level (if known). RESULTS: 129 of 175 surveys were returned (74% return rate) by 85 paramedics and 44 nurses. The percentages of paramedics and nurses at high or very high risk for cardiac disease were 48% and 41%, respectively. Forty-one percent of female respondents and 46% of male respondents were at high or very high risk. Cigarette smoking was reported in 19% of the paramedics and 14% of the nurses. The percentages of paramedics and nurses who reported hypertension were 13% and 11%, respectively. High cholesterol was reported in 31% of paramedics and 16% of nurses. CONCLUSIONS: Forty-eight percent of paramedics and 41% of ED nurses at this center are at high or very high risk for cardiovascular disease, by self-report. Efforts should be made to better educate and intervene in this population of health-care providers in order to reduce their cardiac risk.

Management of difficult airways in the field.

Establishing an airway is a critical first step in emergency management of comatose patients and those who have suffered head trauma, cardiac arrest, or respiratory failure. The use of succinylcholine, a paralytic, to assist with intubation is a safe and effective way to help establish an airway under difficult circumstances, in the prehospital setting. It requires excellent intubation skills, a thorough knowledge of the indications and contraindications of its use, and similar knowledge of any other medications employed. Succinylcholine-assisted intubation should never be implemented without close physician monitoring. Therefore, under the auspices of strong medical control, it is an effective way to establish adequate oxygenation and to control ventilation in some of the most critical patients encountered in the field. Additionally, because physical examination alone is not dependable for ensuring proper endotracheal tube placement, an objective confirmatory device such as an end-tidal carbon dioxide detector should be used.

Anxiety levels in EMS providers: effects of violence and shifts schedules.

We tried to measure anxiety levels in emergency medical service (EMS) providers to determine the effects of (1) having had a violent encounter during a shift and (2) different shift schedules, conducting a prospective observational study over 3 months in an urban EMS system setting. A convenience sample of 23 EMTs and 40 EMT-Ps was observed. Anxiety levels were measured using the Spielberger State-Trait Anxiety Inventory. A total of 99 inventories were completed by 63 EMS providers. The mean state (32.6+/-8) and trait (31.7+/-7.1) scores were less than normative scores (35.7+/-10.4 and 34.9+/-9.2 respectively) for working adult males (P = .004 and .007, respectively). Paramedics had lower anxiety scores than basic EMTs (P = .015 and .039) and years of experience also decreased anxiety scores (P < .0001). There was no significant difference in state scores between those EMS providers who had encountered violence during the preceding 12 hours and those providers who had not. Comparisons of state scores of providers assessed at hour 12 of a 12 hour shift, hour 12 of a 24 hour shift, and hour 24 of a 24 hour shift failed to show any significant differences. Although the working environment of the EMS provider contains numerous stressors and uncertainties, this population of providers were no more anxious than the general working public. Advanced training and years of experience decreased anxiety. Violent encounters during a shift did not appear to affect anxiety levels. There was no difference in anxiety levels in providers who worked 12 and 24 hour shifts.

Alcohol on campus: alcohol-related emergencies in undergraduate college students.

OBJECTIVES: We reviewed demographic factors associated with alcohol-related disorders in undergraduates seen in the emergency department (ED) and determined the incidence of alcohol-related ED visits among undergraduates. METHODS: This prospective, observational study was done in a university-affiliated emergency department. Demographic variables and incidence of students with alcohol-related disorders were analyzed. RESULTS: Of the 616 students seen in the ED during 1 academic year, 101 (16%) had an alcohol-related disorder. White students and freshmen were overrepresented. There were equal numbers of male and female students. The overall annual incidence for an alcohol-related visit among undergraduates was 1.7% per academic year. The incidence for freshmen was 2.9%. Four students were admitted; one died of a severe head injury. CONCLUSIONS: We estimate that 1 of every 15 undergraduates at our college comes to our ED with an alcohol-related problem during their 4-year college career. Younger and nonminority students were more commonly seen; there was no difference by sex. Serious outcomes included one death. This study probably underestimates the true incidence of alcohol-related disorders among students on campus.

Prospective field study of violence in emergency medical services calls.

STUDY OBJECTIVE: To investigate the nature and frequency of violence encountered by EMS personnel. DESIGN: We conducted a prospective, observational case-series study of a city-county EMS system serving a population of 500,000. RESULTS: We analyzed 297 EMS runs over 737 hours of observation. The Overt Aggression Scale (OAS) was used to assess each violent episode. There were 239 (81%) nonviolent runs, 16 (5%) violent runs, and 42 (14%) violent runs that occurred after a violent episode had taken place (postviolent runs). This was a frequency of one violent episode for every four 12-hour shifts, or for every 19 runs. The violent behaviors included verbal aggression solely in 50% (n = 8), physical aggression solely in 13% (n = 2), and both verbal and physical aggression in 38% (n = 6). One episode involved an unsecured weapon. CONCLUSION: These data indicate that violent situations occur in 5% of calls in this EMS system. The fact that an additional 14% of calls are precipitated by the results of violence may influence perceptions by EMS personnel of danger and frequency of exposure to unstable situations. Exposure to violence is underreported in our EMS documentation.

Tenure track in emergency medicine.

STUDY OBJECTIVE: Tenure was designed to guarantee academic freedom through lifelong job security. Productive research, especially in the basic sciences, is the main criterion for tenure at most institutions; therefore faculty in more clinically focused specialties may experience more difficulty obtaining tenure. We examined the relationship between academic emergency medicine and tenure. METHODS: We used a questionnaire to survey the directors of all 108 approved US emergency medicine residency programs. The surveyed population was asked whether the program was affiliated with a medical school, the number of full-time faculty, and how many faculty members were tenured or on the tenure track. Follow-up mailings were sent to nonresponders. We also conducted a search of the Association of American Medical Colleges (AAMC) database to compare the number of emergency medicine faculty involved in the tenure process in other specialties. RESULTS: One hundred surveys (93%) were returned. At programs in which faculty were eligible for tenure, 9% (95% confidence interval [CI], 4% to 16%) were tenured and 27% (95% CI, 19% to 37%) were on the tenure track. Therefore only 36% of all EM faculty (95% CI, 27% to 46%) were tenured or on the tenure track. Among the 53 residency programs that offered tenure, 45% (95% CI, 32% to 60%) had no tenured faculty. At programs with academic department status, 74% of chairs were tenured, in contrast to only 32% of chiefs at institutions without academic department status (95% CI for difference of 42%, 14% to 71%). The AAMC survey revealed that about one-third as many emergency medicine faculty members were tenured compared with the other specialties. The proportion of faculty on the tenure track, however, was similar between the specialties. CONCLUSION: Most eligible emergency medicine faculty members are not tenured or on track to become tenured, and fewer emergency medicine faculty are tenured compared with the more traditional specialties. Emergency medicine may be vulnerable to being considered less academic unless its faculty members gain access to the tenure process.

Lidocaine in the treatment of status epilepticus.

Intravenous lidocaine has the potential to control seizures. This article reviews the available evidence related to lidocaine's efficacy and clarifies its potential role in the management of status epilepticus (SE). Although there are no large, double-blind, placebo-controlled studies of lidocaine's efficacy in SE, numerous case reports and case series support its use. Most of the reported cases involve patients who were refractory to multiple antiseizure medications. Additional support for lidocaine's efficacy in SE comes from the pediatric literature, where lidocaine has been very effective in controlling SE in neonates who have not responded to barbiturates. Initial lidocaine doses used to stop seizures have ranged from 1 to 3 mg/kg. Most reports recommend a maintenance infusion of lidocaine after initial termination of SE, and a continuous infusion is almost universally recommended for neonates. Toxicity from a 1.5-2.0 mg/kg dose of lidocaine for the control of SE is rare; the authors found only 1 case of a possible side effect at that dose. The article provides a 5-step approach to treating SE that includes lidocaine.

Attitudes toward the use of a metal detector in an urban emergency department.

STUDY OBJECTIVE: To determine the attitudes of patients, their family and friends, and ED staff toward a walk-through metal detector in the ED. METHODS: We conducted a survey of a convenience sample of ED patrons (patients and their friends and family) and staff at a university-affiliated Level I trauma center. RESULTS: We surveyed 176 patrons and 95 employees (35 nurses, 30 physicians, 16 security officers, and 14 staff members). Overall, 80% of the patrons and 85% of the employees said they liked the metal detector. Eighty-nine percent of the patrons and 73% of the employees said the metal detector made them feel safer. Only 12% of the patrons and 10% of the employees said the metal detector invaded their privacy or the privacy of others. Fewer than 1% of the patrons said they were less likely to return to our ED because of the metal detector, and 39% said it made them more likely to return. We detected no significant differences with regard to age, sex, or race. CONCLUSION: Most patrons and staff liked the metal detector and said it created a safer ED environment. Only a few disliked the presence of the metal detector or said it invaded their privacy. Institutions concerned about their employees' and patrons' perceptions of safety should consider installing metal detectors in their EDs.

Feedback to emergency medical services providers: the good, the bad, and the ignored.

HYPOTHESIS: To determine the type and frequency of immediate unsolicited feedback received by emergency medical service (EMS) providers from patients or their family members and emergency department (ED) personnel. METHODS: Prospective, observational study of 69 emergency medical services providers in an urban emergency medical service system and 12 metropolitan emergency departments. Feedback was rated by two medical student observers using a prospectively devised original scale. RESULTS: In 295 encounters with patients or family, feedback was rated as follows: 1) none in 224 (76%); 2) positive in 51 (17%); 3) negative in 19 (6%); and 4) mixed in one (< 1%). Feedback from 254 encounters with emergency department personnel was rated as: 1) none in 185 (73%); 2) positive in 46 (18%); 3) negative in 21 (8%); and 4) mixed in 2 (1%). Patients who had consumed alcohol were more likely to give negative feedback than were patients who had not consumed alcohol. Feedback from emergency department personnel occurred more often when the emergency medical service provider considered the patient to be critically ill. CONCLUSIONS: The two groups provided feedback to emergency medical service providers in approximately one quarter of the calls. When feedback was provided, it was positive more than twice as often as it was negative. Emergency physicians should give regular and constructive feedback to emergency medical services providers more often than currently is the case.

Sudden respiratory deterioration in the positive pressure ventilated patient: an organized approach to diagnosis and therapy.

A case of sudden deterioration in the respiratory status of a 28-year-old man being manually ventilated is presented. The patient's deterioration was presumed to be secondary to malfunction of the expiratory valve of the Ambu bag. The resulting high pressure generated in the system caused the patient to develop a bilateral pneumothorax, pneumomediastinum, and displacement of the endotracheal tube into the oropharynx. An organized approach to the diagnosis and treatment of the rapid deterioration in the respiratory status of a manually ventilated patient is presented.

Drinking on campus. Undergraduate intoxication requiring emergency care.

OBJECTIVES: To (1) determine the incidence of undergraduate graduate students with alcohol intoxication who presented to our emergency department (ED), (2) examine the demographic correlates of the students, and (3) look at associated injuries that were sustained by the students. DESIGN: Retrospective case series. SETTING: A tertiary care medical center that was located on the campus of a major university. PATIENTS: Undergraduate students with alcohol intoxication who presented to the ED. MAIN OUTCOME MEASURES: Demographic data and associated injuries of intoxicated students who presented to the ED during 2 academic years. RESULTS: Forty-four students presented with alcohol intoxication for a yearly incidence of 3.9 per 1000 students. Freshmen were overrepresented compared with students in other higher classes, with an incidence of 9.3 per 1000 per year (P < .001). Nine (20%) of the 44 students sustained an injury from a fall, and 1 required mechanical ventilation for treatment of apnea. CONCLUSIONS: Alcohol intoxication that requires emergency care is not uncommon among college students, and many students with alcohol intoxication present to the ED following a fall. Freshmen are particularly likely to present for care in an ED.