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ABSTRACT: To identify risk factors for exertional heat-related illnesses and to determine if patients who are afflicted with the human immunodeficiency virus or have acquired immunodeficiency syndrome have an increased risk of exertional heat-related illness.
Descriptive, retrospective, matched case-control study.
Mobile community of 2,650 participants in the California AIDS Ride 3.
Participants included 117 patients presenting for medical care with heat-related illnesses and 234 age-, gender-, and registration site-matched control subjects who did not develop a heat-related illness.
Retrospective, matched case-control study utilizing univariate and multivariate conditional logistic regression to determine if human immunodeficiency virus seropositivity, the number of chronic medical illnesses, or the number of current medications known to affect heat dissipation increased the risk of exertional heat-related illnesses.
The multivariate model revealed that patients with a greater number of chronic medical illnesses were at a significantly increased risk of a heat-related illness (odds ratio = 1.6, 95% CI = 1.2-2.1). The number of current medications (odds ratio = 1.1, 95% CI = 0.8-1.5) and human immunodeficiency virus seropositivity (odds ratio = 0.7, 95% CI = 0.2-3.1) were not significant predictors of risk for exertional heat-related illness.
Those riders suffering from a greater number of chronic medical illnesses were at a greater risk for developing an exertional heat-related illness. Human immunodeficiency virus seropositivity alone was not associated with increased risk of exertional heat-related illness.
Wilderness and Environmental Medicine 02/2001; 12(2):81-5. · 0.94 Impact Factor
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ABSTRACT: To provide a descriptive analysis of emergency department (ED) presentations and management of orthotopic liver transplant (OLT) patients.
A retrospective chart review was performed of OLT patients presenting to the University of California at Los Angeles (UCLA) ED during 1995. The sole inclusion criterion was receiving an OLT within three years prior to the ED visit. Data describing chief complaint(s), history of present illness, physical findings, laboratory results, imaging studies, and final diagnoses were collected.
One hundred forty-three patients accounted for a total of 290 ED visits. The patients had a mean age of 37 years (range 3 months to 74 years) and presented at mean post-OLT duration of 9 months (range 2 weeks to 34 months). There were 660 presenting complaints, of which abdominal (39%), fever (17%), respiratory (13%), and neurologic (11%) symptoms were the most common. There were 478 final diagnoses, of which abdominal (27%), infectious (24%), and metabolic (11%) disorders were the most common. Eighty-four percent of ED visits resulted in extensive diagnostic testing and 69% resulted in hospitalization.
Serious illnesses with nonspecific presentations were frequently encountered in this study population. These factors resulted in a majority of the patients' undergoing extensive diagnostic evaluations and being hospitalized.
Academic Emergency Medicine 09/2000; 7(8):898-905. · 1.86 Impact Factor
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ABSTRACT: Each year hundreds of thousands of children receive care in emergency departments after head injury. Minor head injuries account for a majority of these injuries. The prevalence, morbidity, and costs associated with pediatric minor head injuries make it an important topic. We review the management of pediatric minor head injury, emphasizing current areas of controversy, including criteria for neuroimaging, indications for hospitalization, the role of anticonvulsant therapy, and the long-term neurobehavioral sequelae of pediatric minor head injury.
American Journal of Emergency Medicine 02/2000; 18(1):96-101. · 1.98 Impact Factor
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ABSTRACT: Improved survival rates and more centers performing liver transplantation have resulted in increasing numbers of liver transplant recipients presenting to emergency departments. This article familiarizes emergency physicians with orthotopic liver transplantation and complications that cause liver transplant recipients to visit EDs.
Annals of Emergency Medicine 05/1998; 31(4):507-17. · 4.13 Impact Factor
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Western Journal of Medicine 03/1998; 168(3):183.
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ABSTRACT: Providing medical care at special events is a growing area of concern of emergency physicians. Little information has been published on events in which participants outnumber spectators. We describe such an event at which the medical encounters far outnumbered any previously published report.
The California AIDS Ride 3 bicycle ride took place June 1-8, 1996, and covered 547 miles of highway between San Francisco and Los Angeles. One hundred five volunteer staff members provided medical care. Extensive patient encounters were recorded on a one-page form; all other encounters were recorded as hash marks by the provider. Two physicians reviewed the medical records and categorized each encounter.
Of the 25,379 patient encounters recorded over the 8 days of the event, 509 were triaged as greater severity (requiring an examination by a physician); 31% of these involved heat-related illnesses. Fifty-five patients required transport to local emergency departments by the local EMS systems; 7 of these patients required hospital admission.
The California AIDS Ride 3 required more medical personnel and resulted in more patient encounters than any similar event previously described. We describe the medical care team and patient encounters to facilitate planning for medical care at future class 3 events.
Annals of Emergency Medicine 03/1998; 31(2):219-23. · 4.13 Impact Factor
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ABSTRACT: The use of adenosine as a therapeutic and diagnostic tool in wide-complex tachycardia is suggested in the current Advanced Cardiac Life Support (ACLS) guidelines. The ACLS guidelines are now 4 years old, and new information on the safety and efficiency of adenosine in wide-complex tachycardia is available. We review the ACLS recommendations in light of the current available literature. In general, the ACLS recommendations remain reasonable with some important caveats.
Annals of Emergency Medicine 02/1997; 29(1):172-4. · 4.13 Impact Factor
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ABSTRACT: To determine the extent of interobserver agreement in the ECG diagnosis of ventricular tachycardia (VT) by using a four-step algorithm and three observers.
Simulated emergency department setting from records of an urban university teaching hospital. All ECGs taken in the ED during a 2-year period that showed a QRS duration of more than 120 msec and a heart rate faster than 110 beats per minute were reviewed. ECGs were categorized as demonstrating sinus rhythm (SR), irregular broad-complex tachycardia (I-BCT), or regular broad-complex tachycardia (BCT). Copies of the BCT ECGs and short clinical histories were given to each of three emergency physicians, who used a published, four-step algorithm (the Brugada algorithm) to categorize the BCT ECGs as indicating VT, indicating supraventricular tachycardia with aberrancy (SVT-A), or indeterminate. Interobserver agreement was assessed with the K-statistic.
The records contained 178 ECGs, 88 of which were SR, 63 I-BCT, and 27 BCT. The 27 BCT ECGs were selected for review. The emergency physicians disagreed with each other 22% of the time in differentiating VT from SVT-A (K = .58).
Application of the algorithm to actual clinical practice in the ED would probably result in the misdiagnosis of a substantial minority of patients having BCT, with potentially serious adverse consequences.
Annals of Emergency Medicine 02/1996; 27(1):35-8. · 4.13 Impact Factor
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Western Journal of Medicine 02/1996; 164(1):63.
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ABSTRACT: Passenger restraints reduce fatalities and serious injuries. Restraint systems alter the distribution of injuries seen in accident victims, and they cause a number of injuries. The distribution of injuries is dependent on the type of restraint. Automatic motorized shoulder belts are being used without the accompanying manual lap belt. This greatly reduces the effectiveness of the system and is equal to the two-point shoulder belt of the 1960s. Airbag injuries include abrasions to the face, neck, and chest; minor burns to the upper extremities; and chemical keratitis. Airbags have been shown to reduce injuries overall, especially when used in conjunction with a lap and shoulder belt. Elderly patients incur more rib and sternal fractures due to seat belts than do younger patients. Nevertheless, restraint systems are effective at reducing serious internal injuries in this population. Children who are too large for child safety seats but too small for adult seat belts are at increased risk for injury. Improvement in restraint systems for children in this age range is recommended. All pregnant women should be encouraged to wear seat belts because they reduce maternal injuries, and there is no evidence that they increase the risk of fetal loss. In view of the injury reduction associated with passenger restraint systems, emergency physicians should emphasize to their patients the importance of wearing seat belts.
Annals of Emergency Medicine 08/1994; 24(1):77-84. · 4.13 Impact Factor
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ABSTRACT: The objective of this study was to characterize the effect of intravenous hypertonic sodium bicarbonate (NaHCO3) administration in patients with moderate-to-severe cyclic antidepressant (CA) overdose. We reviewed charts of all 91 patients given the diagnosis of CA overdose in the University of California Los Angeles (UCLA) Emergency Medicine Center (EMC), who either died in the EMC or were admitted to the medical intensive care unit (MICU), and who received NaHCO3 in the EMC between 1980 and 1988. Twenty-four other patients with the same EMC diagnosis were admitted to the MICU during this period but did not receive NaHCO3. The response of blood pressure, electrocardiographic parameters, and mental status to serum alkalinization with NaHCO3 were evaluated. Major morbidity and mortality were recorded for all patients. Hypotension was corrected within 1 hour in 20 of 21 (96%) patients, QRS prolongation corrected in 39 of 49 (80%), and mental status improved in 40 of 85 (47%). There was one death, in a patient who was moribund on arrival to the EMC. No complications were attributable to the administration of NaHCO3. NaHCO3 seems to improve hypotension and normalize QRS duration rapidly in most patients treated, and improve mental status changes in almost one half. Serum alkalinization with NaHCO3, in conjunction with appropriate supportive care, seems to limit major morbidity and mortality effectively in patients with serious CA overdose.
American Journal of Emergency Medicine 08/1993; 11(4):336-41. · 1.98 Impact Factor
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ABSTRACT: Neither response to hypertonic glucose (D50W) nor presence of hypoglycemia can be reliably predicted by "typical" clinical findings (tachycardia, diaphoresis, and/or an available history of diabetes mellitus) in prehospital patients with altered mental status (AMS).
Three hundred forty consecutive patients who received D50W for prehospital AMS as ordered by a university hospital paramedic base.
Review of prehospital records and tape recordings for all subjects to determine presence or absence of tachycardia, diaphoresis, and/or available history of diabetes mellitus at the time of field presentation, as well as response to D50W; final diagnosis was determined from emergency department charts in the 301 patients for whom they were available.
Twenty-five patients (7.4%) had a complete response to D50W: 20 had hypoglycemia, diagnosis for one patient was unknown, and four had other causes of AMS. Three patients with an ED diagnosis of hypoglycemia had partial or equivocal responses to D50W, and five had no response. Complete responders were more likely than other patients to have diaphoresis (40% vs 13%, P less than .001) and available history of diabetes (52% vs 12.1%, P less than .001) but not tachycardia (36% vs 35.2%, P = NS). Nine complete responders, including five with hypoglycemia, had none of the three clinical signs.
Although patients with hypoglycemia who respond to D50W are diaphoretic and have an available history of diabetes more often than other patients with prehospital AMS, 25% of complete responders who are hypoglycemic would not receive D50W if it were used only in patients with "typical" clinical findings. Selective use of D50W for AMS is desirable because very few patients respond, but it is only feasible with concomitant field use of a rapid test of serum glucose.
Annals of Emergency Medicine 02/1992; 21(1):20-4. · 4.13 Impact Factor
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ABSTRACT: Flumazenil is a recently discovered pharmacologic antagonist of the CNS effects of benzodiazepines. It acts by binding CNS benzodiazepine receptors and competitively blocking benzodiazepine activation of inhibitory GABAergic synapses. Animal studies and some human studies appear to demonstrate that flumazenil has weak intrinsic agonist activity; on the other hand, studies are inconclusive in demonstrating any inverse agonist effects of this agent. Evidence available suggests that flumazenil is well tolerated in human beings over a broad range of doses when given either orally or parenterally and does not produce serious adverse effects. In the setting of isolated benzodiazepine overdose, flumazenil is capable of completely reversing coma within one to two minutes, with this effect lasting between one and five hours. Repeat doses can be given safely to reverse recurrent effects of longer-acting benzodiazepines. Flumazenil is undergoing further evaluation by the Food and Drug Administration; should this drug receive approval, it is likely to be used in emergency departments as well as in a variety of other clinical settings. First, it could be used to effect rapid reversal of benzodiazepine-induced sedation that has been administered to facilitate medical, orthopedic, and surgical procedures, particularly in the event of inadvertent respiratory depression. Second, flumazenil might have a therapeutic role in the management of patients who have taken benzodiazepine overdoses. Although most of these patients can be managed successfully with supportive therapy alone, it is possible that the use of flumazenil may obviate the need for intubation and respiratory support in such patients and eliminate the possible adverse effects of even short-term endotracheal intubation. Finally, flumazenil could have both diagnostic and therapeutic value in patients with acute alterations of mental status of unknown etiology, particularly when possible drug overdose is a consideration. Because flumazenil appears to be specific in its antagonism of benzodiazepine-induced respiratory and CNS depression, it could be used empirically to confirm or exclude a role of benzodiazepines in the generation of mental status changes in the setting of overdose or coma of unknown origin. This in turn might obviate the need for further expensive (eg, computed tomography) and sometimes invasive (eg, lumbar puncture) diagnostic modalities. This might be particularly useful because there is nothing about benzodiazepine-induced coma that clearly distinguishes it from other causes of coma; thus, there are no signs or symptoms that may reasonably allow benzodiazepine overdose to be confirmed or eliminated on clinical grounds. Further studies will continue to define the ultimate use of this new agent.
Annals of Emergency Medicine 03/1991; 20(2):181-8. · 4.13 Impact Factor
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ABSTRACT: Patients with disorders of sodium and water metabolism are seen frequently in Emergency Departments, but in most cases these disorders do not require treatment. Severe hypo- and hypernatremia are relatively uncommon but can result in severe neurologic sequelae or death. Appropriate therapy, based on an understanding of the physiology involved, can reduce the morbidity and mortality associated with these disorders. A systematic approach to the assessment and management of patients with hypo- and hypernatremia is presented.
Emergency Medicine Clinics of North America 12/1989; 7(4):749-69. · 0.86 Impact Factor
