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ABSTRACT: The objective of this study was to assess the utilization of local anesthetics by emergency physicians (EP) and pediatric physicians (PP) who performed a lumbar puncture (LP) in pediatric patients from birth to 24 months of age.
We conducted a prospective study of children that received an LP at a university tertiary referring hospital. A convenience sample included children from birth to 24 months that received an LP for suspected meningitis in the ED or pediatric units during a one-year period. Physicians performing the LP were blinded to the objectives of the study. Data was collected using a standardized procedure form developed for this study.
Three hundred nine LPs were performed during the study period. Excluded patients consisted of 29 subjects who underwent moderate procedural sedation and 57 subjects that had incomplete procedural data forms. From our sample population of 223 subjects, 146 subjects received a local anesthetic prior to the LP. One hundred twenty six subjects received 1% lidocaine, 20 subjects received EMLA cream (with one subject that received both 1% lidocaine and EMLA), while 77 received no pre-procedural local anesthetic. The use of local anesthetics differed greatly with the age of the patient. Pre-procedural local anesthetics were administered in 65 of 120 subjects less than 12 months of age and in 81 of 82 patients 12 to 24 months of age. Interestingly, the neonatal subject population did not receive any procedural anesthetic by EP or PP. PP and EP differed in the type of local anesthetic utilized prior to performing a LP. EP exclusively used 1% lidocaine while PP preferentially administered EMLA. A subset analysis demonstrated that only PP utilized moderate sedation (Midazolam and Fentanyl) in 41/309 (13%) of the study population.
This is the first study to demonstrate that EPs and PPs differ in their preference in the use of local anesthetics prior to LP and that procedural anesthetic is not universal within this pediatric age group and that utilization of a local anesthetic varies by patient age, with younger children less likely to receive a local anesthetic.
Local anesthetic; Lumbar puncture; Emergency physician; Pediatric physician.
Journal of Clinical Medicine Research 07/2011; 3(4):164-7.
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ABSTRACT: Dizziness is a common presenting complaint to the emergency department (ED), and emergency physicians (EPs) consider these presentations a priority for decision support. Assessing for nystagmus and defining its features are important steps for any acute dizziness decision algorithm. The authors sought to describe nystagmus documentation in routine ED care to determine if nystagmus assessments might be an important target in decision support efforts.
Medical records from ED visits for dizziness were captured as part of a surveillance study embedded within an ongoing population-based cohort study. Visits with documentation of a nystagmus assessment were reviewed and coded for presence or absence of nystagmus, ability to draw a meaningful inference from the description, and coherence with the final EP diagnosis when a peripheral vestibular diagnosis was made.
Of 1,091 visits for dizziness, 887 (81.3%) documented a nystagmus assessment. Nystagmus was present in 185 of 887 (20.9%) visits. When nystagmus was present, no further characteristics were recorded in 48 of the 185 visits (26%). The documentation of nystagmus (including all descriptors recorded) enabled a meaningful inference about the localization or cause in only 10 of the 185 (5.4%) visits. The nystagmus description conflicted with the EP diagnosis in 113 (80.7%) of the 140 visits that received a peripheral vestibular diagnosis.
Nystagmus assessments are frequently documented in acute dizziness presentations, but details do not generally enable a meaningful inference. Recorded descriptions usually conflict with the diagnosis when a peripheral vestibular diagnosis is rendered. Nystagmus assessments might be an important target in developing decision support for dizziness presentations.
Academic Emergency Medicine 06/2011; 18(6):619-26. · 1.86 Impact Factor
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ABSTRACT: Evaluate the impact of adding emergency medicine residents to a medium-size urban hospital by comparing emergency department (ED) admission rate, total census, length of stay (LOS), and proportion of patients who left without being seen (LWBS).
Using the student t-test, the study compared commonly used ED metrics for a mid-sized urban hospital (annual census 43,000) for the four-month period prior to (March-June 2006) and after (March-June 2007) residents began providing 24-hour coverage at the institution.
There was no significant difference in the number of patients seen (NPS) in the two time periods, 14,471 and 14,699 patients respectively (p=0.507). Analysis of the NPS and LWBS was not statistically significant. The percentage of patients who LWBS decreased with the presence of residents (6.5% to 5.8%, p=0.531), and the overall ED LOS was similar (210 min vs. 219 min, p=0.56). Admission rate data demonstrated that residents had a similar admission rate (17.5% vs. 18%, p =0.332).
ED flow depends on a number of variables with complex interactions. When comparing two similar time periods in consecutive years, the presence of resident physicians in the ED had no effect on the number of patients seen, patient LOS in the ED, or LWBS, thus supporting the conclusion that residents did not adversely affect the patient flow within the ED.
The western journal of emergency medicine 09/2010; 11(4):333-5.
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ABSTRACT: Spinal epidural abscess is a rare debilitating disease that if left untreated may result in serious morbidity and mortality. Most cases involve the level of 3 or 4 vertebrae, but in very rare cases may affect the whole spine. The most common pathogen found in spinal abscesses is Staphylococcus aureus, which involves approximately two thirds of cases. The recent introduction of methicillin-resistant strains of S aureus has left physicians with the challenging task of identifying and treating this serious condition.We present the only case reported of a methicillin-resistant S aureus holospinal epidural abscess with subsequent neurological follow-up over a 1-year period.
The American journal of emergency medicine 06/2009; 27(4):514.e7-9. · 1.54 Impact Factor
