The American journal of emergency medicine

Published by WB Saunders
Print ISSN: 0735-6757
Toxicities and medical outcomes associated with nefazodone poisoning were characterized using national poisoning data from the American Association of Poison Control Centers and through prospective collection of additional data elements. Nefazodone exposures involving concomitant agents were excluded. There were 1,338 human exposures included in the final data analysis. Seventy-five percent of exposures were acute and 20% involved children < 13 years. Twenty-five percent of patients remained asymptomatic. There were no deaths. No dose response relationship was evident in the 45 cases where estimated doses were available. The most common manifestations were drowsiness (17.3% of all patients), nausea (9.7%), and dizziness (9.5%). The most common serious clinical effect was hypotension (1.6%). The median onset time for symptoms was 1.75 hours. Manifestations resolved within 8 to 24 hours. Most patients were treated with only gastrointestinal decontamination. No patients required intubation, mechanical ventilation, or vasopressors. Nefazodone appears to be of low toxicity during poisonings.
Emergency physicians attending to pediatric patients in acute care settings use electrocardiograms (ECGs) for a variety of reasons, including syncope, chest pain, ingestion, suspected dysrhythmias, and as part of the initial evaluation of suspected congenital heart disease. Thus, it is important for emergency and acute care providers to be familiar with the normal pediatric ECG in addition to common ECG abnormalities seen in the pediatric population. The purpose of this 3-part review will be to review (1) age-related changes in the pediatric ECG, (2) common arrhythmias encountered in the pediatric population, and (3) ECG indicators of structural and congenital heart disease in the pediatric population.
Carbon monoxide (CO) toxicity may cause persistent injuries in tissues sensitive to hypoxia. Neuropsychiatric sequelae may be observed in about 67% of cases after severe CO exposure. The aims of this study were to demonstrate the usefulness of S-100beta and neuron-specific enolase (NSE) in CO intoxications, show the degree of neurological response, and determine the indications for hyperbaric oxygen treatment (HBOT) as biochemical markers. The S-100beta and NSE levels of the sera of 30 patients were studied upon admittance and at the third and sixth hours. S-100beta levels were found to be high in all 3 analyses. There was no significant change in NSE levels. When the S-100beta levels were compared with Glasgow Coma Scale levels, a strong negative correlation was found for all hours (r = -0.7, -0.8; P = .00). The correlation between S-100beta and carboxyhemoglobin levels at the initial hour was found to be statistically significant (r = 0.4; P = .01). The S-100beta levels in patients receiving HBOT showed a considerable decrease compared with those in patients not receiving the treatment. The same decrease was valid for NSE, although it was insignificant. S-100beta may be useful in evaluating intoxications as an early biochemical marker in CO intoxications, as well as in the differential diagnosis due to other causes, and in determining HBOT indications.
Ketamine is widely used as a procedural sedation agent in pediatrics, where its safety and efficacy are supported by numerous studies. Emergency physicians use ketamine infrequently in adults, as it is believed to have a more significant side effect profile in this population. However, adult data on ketamine use in the emergency medicine literature are sparse. Our objective was to determine ketamine's adverse effect profile in adults when used for procedural sedation. We performed a literature review based on adverse effect research methodology recommendations. PubMed, EMBASE, TOXNET, and a variety of specialized databases were queried without regard to publication date or language. Experts were contacted to locate additional data. Inclusion criteria included adult study; ketamine used to facilitate the performance of painful procedures; dose of at least 1 mg/kg intravenous or at least 2 mg/kg intramuscular; original data and adverse events reported; spontaneously breathing patient, and no continuous cotherapies. Studies that met inclusion criteria were abstracted onto structured forms and their results qualitatively summarized. Of the 5512 unique citations that were evaluated, 87 met criteria for inclusion. Most studies were performed in the 1970s and published in the anesthesia literature. Contexts, end points, and methodological quality varied widely across studies. Ketamine reliably produces conditions that facilitate the performance of painful procedures. Pharyngeal reflexes are generally preserved and cardiovascular tone stimulated, including a rise in blood pressure and myocardial oxygen demand. Laryngospasm and airway obstruction are reported, and though ketamine is a respiratory stimulant, a brief period of apnea around the time of injection is common. Reports of significant cardiorespiratory adverse events are rare, despite ketamine's frequent use in austere, poorly monitored settings. Dysphoric emergence phenomena occur in 10% to 20% of cases; sedating medications are effective in preventing and managing these reactions. When ketamine is used for procedural sedation in adults, emergence phenomena occur in 10% to 20% of patients. Although providers must be prepared to recognize and manage airway obstruction, cardiorespiratory adverse events are rare and typically do not affect outcomes.
Little is known about the proficiency of prehospital personnel when performing cricothyrotomies. The authors compared two techniques for establishing an airway through the cricothyroid membrane used by paramedic students. One technique used a prepackaged kit that consisted of a dilator that is passed percutaneously through a breakaway needle. This percutaneous device (PD) was compared with a standard surgical approach (SA) using a scalpel and endotracheal tube. Data was collected on a total of 44 paramedic students who were allowed to attempt each of the procedures. No significant difference in the success rate on the first attempt was found between the two procedures (86% for the SA and 73% for the PD; P = .186). The surgical approach was significantly faster (46 +/- 17 seconds v 103 +/- 62 seconds; P < .01). It was also judged to be significantly easier to perform when evaluated on a linear analog scale (SA, 2.6 +/- 2.0 v PD, 5.1 +/- 2.8; P < .001). Because some procedures were performed on cadavers whose cricothyroid membranes had already been violated, the procedures performed on intact membranes only were also analyzed. Similar, statistically significant differences for insertion time and ease of insertion were again found. Prehospital personnel can be trained to perform cricothyrotomies with a reasonable degree of proficiency. A traditional surgical approach, however, may be faster and less difficult to perform than a comparable procedure using a commercially available percutaneous device.
The purpose of this study was to examine the emergency department (ED) management of hypothermic cardiac arrest and its outcome. The medical records of all patients with hypothermic cardiac arrest treated in the ED from January 1, 1988 to January 31, 1999 were retrospectively reviewed. Data collected included initial body temperature, serum potassium, methods of rewarming, return of perfusing rhythm, and morbidity and mortality. Data were analyzed by descriptive methods. Eleven patients were treated in the ED resuscitation room for hypothermic cardiac arrest. Six patients were found in cardiac arrest in the field, one patient arrested during transport, and four patients arrested after ED arrival. The average initial temperature was 79.1 degrees F (range 69.0 degrees F to 86.7 degrees F). Seven patients received an ED thoracotomy with internal cardiac massage and warm mediastinal irrigation. Four patients had airway management in the ED and then direct transport to the operating room for cardiac bypass rewarming. Three of the seven patients who received an ED thoracotomy subsequently went to intraoperative cardiac bypass rewarming. Five of the seven (71.4%) patients who received an ED thoracotomy survived, versus none of the four patients (0%) who went directly to intraoperative cardiac bypass. A direct comparison of immediate ED thoracotomy versus intraoperative cardiac bypass without ED thoracotomy is cautiously made as this was an unmatched and nonrandomized study. Three of the surviving patients underwent intraoperative cardiac bypass rewarming after receiving an ED thoracotomy. In two of these patients a perfusing rhythm had been established after thoracotomy in the ED and before transport to the operating room for cardiac bypass. Only one of seven (14.3%) patients who arrested prehospital survived versus four of four (100%) who arrested in the ED. ED thoracotomy with internal cardiac massage and mediastinal irrigation rewarming is effective in the management of hypothermic cardiac arrest.
Drowning is one of the most common causes of accidental events. Here we report a drowning patient who experienced acute respiratory distress syndrome after hospitalization. Although the compliance of lung was as poor less as 5 mL/cm H2O, this patient was eventually rescued and recovered by extraprolonged extracorporeal membrane oxygenation support for 117 days.
The quality of cardiopulmonary resuscitation (CPR) is a very important prognostic factor for cardiac arrest. Chest compression is thought to be one of the most important aspects of high-quality CPR. Recent studies have prompted that there may be an interaction between chest compression rate and other factors related to the quality of chest compression. We aimed to investigate the effect of different compression rates on chest compression depth, recoil, and rescuers' fatigue point during CPR. Participants performed 2 minutes of chest compression-only CPR after the guiding sounds, at 3 rates (100, 120, and 140 compressions/min) in random sequence. A repeated-measures analysis of variance was used to compare the average chest compression depth and other factors related to the quality of chest compression among the groups. As the chest compression rate increases through all the 3 rates, the fractions of chest compressions with complete release and the fractions of chest compressions with sufficient depth were deteriorated at the rate of 140 compressions/min (P < .05), although the average compression depth was above the recommended 2010 guideline depth of 5 cm(P > .05). Of note, the fatigue point at 140 compressions/min happened significantly (P < .05) sooner. Our study supported the concern of some that there may be a risk of increasing recommended chest compression rate without providing an upper limit. An appropriate choice may be 120 compressions/min. Copyright © 2015 Elsevier Inc. All rights reserved.
This study examined consecutive patients with unexplained fever (UF) presenting to the ED to define their characteristics and to compare distinctive parameters between admitted and discharged patients. During a 3-month period, all adult patients presenting to the ED with UF were prospectively followed for 1 month. Of 139 patients with UF, 58 patients (42%) were admitted to the hospital, whereas 81 patients (58%) were discharged. Whereas most of the discharged patients had self-limited febrile disease and eventually recovered, the admitted patients had more unresolved fever, serious infections, or systemic diseases and a 5% mortality rate. The admitted patients were older, had more comorbidity, higher leukocyte count, and anemia, but not a higher degree of fever. Older age, comorbidity, leukocytosis, and anemia, but not higher degree of fever, should direct the decision toward admission of a patient with UF.
The aim of the study was to evaluate the risk of Friday the 13th on hospital admission rates and emergency department (ED) visits. This was a retrospective chart review of all ED visits on Friday the 13th from November 13, 2002, to December 13, 2009, from 6 hospital-based EDs. Thirteen unlikely conditions were evaluated as well as total ED volumes. As a control, the Friday before and after and the month before and after were used. χ(2) Analysis and Wilcoxon rank sum tests were used for each variable, as appropriate. A total of 49 094 patient encounters were evaluated. Average ED visits for Friday the 13th were not increased compared with the Friday before and after and the month before. However, compared with the month after, there were fewer ED visits on Friday the 13th (150.1 vs 134.7, P = .011). Of the 13 categories evaluated, only penetrating trauma was noted to have an increase risk associated with Friday the 13th (odds ratio, 1.65; 95% confidence interval, 1.04-2.61). No other category was noted to have an increase risk on Friday the 13th compared with the control dates. Although the fear of Friday the 13th may exist, there is no worry that an increase in volume occurs on Friday the 13th compared with the other days studies. Of 13 different conditions evaluated, only penetrating traumas were seen more often on Friday the 13th. For those providers who work in the ED, working on Friday the 13th should not be any different than any other day.
Acute spontaneous coronary artery dissection is a rare and catastrophic event that is not completely understood. It typically involves a medial tear in the vessel followed by hematoma formation (J Am Coll Cardiol. 2012 Mar 20;59(12):1073-9). This process occurs in women more than men and has a high mortality rate. Although most common in the peripartum and postpartum periods, typical atherosclerosis risk factors such as hypertension and smoking are loosely associated. Discussed is a case of a 14-year-old girl who presented from her school track meet with chest pain and altered mental status. She was hypotensive, tachypneic, and hypoxic upon presentation. During rapid sequence intubation and resuscitation efforts, the patient had severe pulmonary edema and underwent cardiac arrest. Cardiopulmonary resuscitation was initiated, and after return of spontaneous circulation, she was taken to the cardiac catheterization laboratory where she was found to have an acute left main coronary artery dissection.
This study evaluates the effect of early administration of an empirical (1 mEq/kg) sodium bicarbonate dose on survival from prehospital cardiac arrest within brief (<5 minutes), moderate (5-15 minutes), and prolonged (>15 minutes) down time. Prospective randomized, double-blinded clinical intervention trial that enrolled 874 prehospital cardiopulmonary arrest patients managed by prehospital, suburban, and rural regional emergency medical services. Over a 4-year period, the randomized experimental group received an empirical dose of bicarbonate (1 mEq/kg) after standard advanced cardiac life support interventions. Outcome was measured as survival to emergency department, as this was a prehospital study. The overall survival rate was 13.9% (110/792) for prehospital arrest patients. There was no difference in the amount of sodium bicarbonate administered to nonsurvivors (0.859 +/- 0.284 mEq/kg) and survivors (0.8683 +/- 0.284 mEq/kg) (P = .199). Overall, there was no difference in survival in those who received bicarbonate (7.4% [58/420]), compared with those who received placebo (6.7% [52/372]) (P = .88; risk ratio, 1.0236; 0.142-0.1387). There was, however, a trend toward improved outcome with bicarbonate in prolonged (>15 minute) arrest with a 2-fold increase in survival (32.8% vs 15.4%; P = .007). The empirical early administration of sodium bicarbonate (1 mEq/kg) has no effect on the overall outcome in prehospital cardiac arrest. However, a trend toward improvement in prolonged (>15 minutes) arrest outcome was noted.
Objective: Therapeutic hypothermia is now regarded as the only effective treatment of global ischemic injury after cardiac arrest. Numerous studies of the neuroprotective effects of 17β-estradiol have yielded conflicting results depending on administration route and dose. Herein, we investigated the neuroprotective effect of postischemic 17β-estradiol administration combined with therapeutic hypothermia. Methods: Twenty-one rats were randomly divided into 4 groups: control (group I), therapeutic hypothermia (group II), 17β-estradiol treatment (group III), and therapeutic hypothermia combined with 17β-estradiol treatment (group IV). One rat was assigned to a sham operation group. With the exception of the sham-operated rat, all animals underwent transient global cerebral ischemia for 20 minutes by the 4-vessel occlusion method. Hypothermia was maintained at 33°C for 2 hours in groups II and IV, and 17β-estradiol (10 μg/kg) was intraperitoneally administered to rats in groups III and IV. Neurologic deficit scores and hippocampal cornu ammonis 1 neuronal injury were assessed 72 hours postischemia. Results: The neurologic deficit score was not significantly different among the groups. The percentage of normal neurons in the hippocampal cornu ammonis 1 was 7.32% ± 0.88% in group I, 53.65% ± 2.52% in group II, 51.6% ± 3.44% in group III, and 79.79% ± 1.6% in group IV. The neuroprotective effect in the combined treatment group was markedly greater than in the single treatment groups, which suggests that hypothermia and 17β-estradiol work synergistically to exert neuroprotection. Conclusion: Postischemic administration of low-dose 17β-estradiol appears to be neuroprotective after transient global ischemia, and its effect is potentiated by therapeutic hypothermia.
Spontaneous spinal epidural hematoma is a rare cause of spinal cord compression. Symptoms typically include a sudden onset of back pain followed by neurologic deterioration including weakness, numbness, and incontinence. We report the case of a 17-year-old adolescent boy who presented to the emergency department with acute onset of back pain that woke him from sleep, progressing to paralysis and anesthesia of lower extremities, accompanied by priapism. Magnetic resonance imaging (MRI) demonstrated an epidural hematoma of the thoracic spine with spinal cord compression. The patient was taken to the operating room for decompression laminectomy where they discovered a thrombosed dural arteriovenous fistula. Postoperative angiography shows no residual lesions. Emergency physicians see many patients with back pain and should be clinically suspicious of spontaneous spinal epidural hematomas to reduce morbidity and mortality.
An analysis was undertaken of 8,470 visits to a pediatric emergency department (ED) over a three-month period during 1975-76. The ED was busiest in the evening and on weekends. Visits were overwhelmingly for acute conditions, which varied seasonally. Very young children accounted for a large proportion of visits (22.3% less than 1 year old, 47.0% less than 3 years old). The proportion of very young children increased as the hour of day got later. Overall, 7.3% of visits resulted in admission to the hospital, and 10% of children less than 1 year old were admitted. Admission rates were significantly higher on the day and night shifts than in the evenings, and rates were higher on weekdays than on weekends. Visits were mainly by children living in areas near the hospital, and children from the most distant areas were significantly more likely to be admitted than those from the nearest areas. The authors conclude that the documented ED usage patterns reflect the conditions of the children seen (age, medical problems, and severity of illness) and diminished availability of other services on weekends and evening. This indicates reasonable utilization of medical services and suggests the need for non-ED sources of care at times of peak ED use. These ED usage patterns in the 1970s are similar to those described in the 1960s, and together with the earlier data they provide a basis for comparison of utilization patterns during the current period of rapidly changing health-service reimbursement schemes.
As emergency medicine comes of age, it is interesting to examine the scientific nature of the specialty as reflected in the literature. Representative volumes of three emergency medicine journals were reviewed for number and type of article, institutional origin, article length, and number of authors. For Annals of Emergency Medicine, (AEM) volumes for 1975, 1980, and 1985 were studied. For The American Journal of Emergency Medicine (AJEM) and The Journal of Emergency Medicine (JEM), articles from the first 12 months of publication (1983 to 1984) and the complete 1986 issue were examined. Analysis of the scientific sections of the journals discloses some interesting trends. While the average article length has remained about the same (four to six pages), the average number of authors per article has steadily risen. The percentage of articles listing an academic origin has remained steady in AEM and JEM, but has risen in AJEM. Multicenter collaborations and basic science articles are appearing with significantly increased frequency. A noteworthy trend is the rise in multiple authorship of articles. There have been significant p less than 10(-4] increases in the number of multiple-authored (more than three authors) articles in AEM and JEM. As reflected by the literature, scientific progress in EM is maintaining a rapid pace. However, there are increasing numbers of papers with multiple authors. Listing of multiple authors on papers has prompted criticism of the literature in other medical specialties. If this trend continues, there may be a risk of compromising the integrity of the published research.
This study reviewed 549 malpractice claims filed against emergency physicians in Massachusetts from 1975 through 1993, with a total of $39,168,891 of indemnity and expense spent on the 549 closed claims. High-risk diagnostic categories (chest pain, abdominal pain, wounds, fractures, pediatric fever/meningitis, epiglottitis, central nervous system bleeding, and abdominal aortic aneurysm) accounted for 63.75% of all closed claims and 64.23% of the total indemnity and expense spent on closed claims. Missed myocardial infarction (chest pain) claims accounted for 25.47% of the total cost of closed claims but only 10.38% of closed claims. The number of claims for missed myocardial infarction increased in the post-1988 closed claim group compared to the pre-1988 group; fractures and wounds were significantly less frequent in the post-1988 group. The frequency of high-risk claims decreased in the post-1988 group, largely because of the decline in fracture and wound claims. The category of missed myocardial infarction had a larger percentage of claims closed with indemnity payment than without indemnity payment. This parameter may serve as a marker for the overall seriousness of claims associated with a particular allegation, unlike the average cost per claim, which may be skewed by a few large awards.
In 1983, the American Association of Poison Control Centers (AAPCC) piloted a project to collect epidemiological data on poison exposures reported to poison centers nationwide.1 In 1984 the Data Collection System was available to all interested AAPCC member poison centers and was established as an ongoing National Database. The following data represent the annual report for 1984 for this National Data Collection System.
In 1983, the American Association of Poison Control Centers (AAPCC) piloted a project to collect epidemiological data on poison exposures reported to poison centers nationwide.1 Sixteen participating poison centers reported 251,012 human poison exposures during that year. Forty-seven centers participated in the National Data Collection System in 1984, reporting 730,224 human poison exposures.2 The data presented herein reflect 900,513 human poison exposures reported in 1985 to 56 participating poison centers.
Top-cited authors
Toby Litovitz
  • National Capital Poison Center
Wendy Klein-Schwartz
  • University of Maryland, Baltimore
Jessica Youniss
  • George Washington University
George Rodgers
  • University of Louisville
Brit Long
  • Brooke Army Medical Center