J.Stephen Huff, Elana Farace, William J. Brady, John Kheir, Gregory Shawver
DOI: http://dx.doi.org/10.1053/ajem.2001.25769
Published in issue: October 2001
xThe Quick Confusion Scale (QCS) is a 6-item battery of questions focusing on orientation, memory, and concentration weighted to yield a top score of 15. Analysis of the QCS compared with the Mini-Mental State Examination (MMSE) is needed to determine if the QCS is a valid marker of cognitive mental status. The MMSE and the QCS were administered to a convenience sample of 205 patients presenting to the emergency department. Exclusions included head trauma, multisystem trauma, Glasgow Coma Scale less than 15, non-English speaking, education level less than 8 years, contact or droplet isolation, acute illness, or incomplete data for reasons such as restricted patient access.
Janelle A. Thomas, Michael W. Potter, Francis L. Counselman, Douglas G. Smith
DOI: http://dx.doi.org/10.1053/ajem.2001.24485
Published in issue: October 2001
xThis study seeks to determine patterns of emergency physician (EP) practice regarding steroid use in the management of acute asthma attacks in the emergency department (ED), and to compare practices of academic and private practice EPs. Two hundred eight questionnaires were mailed to academic and private practice EPs. The survey requested information regarding the preferred initial route (oral or intravenous) for steroid administration; the initial dose of steroid; the preferred steroid regimen for outpatient management; and whether or not inhaled steroids were routinely prescribed at the time of discharge.
Cynthia L. Leslie, Mary Cushman, Gregory S. McDonald, Wandana Joshi, Anne M. Maynard
DOI: http://dx.doi.org/10.1053/ajem.2001.27147
Published in issue: October 2001
xThe objective of the study was to evaluate the effectiveness of triage, treatment, and transfer interventions on multiple burn casualties managed in a high volume ED that does not have a verified in-hospital burn unit. The charts of 11 male patients injured in a 1999 foundry explosion and brought to Baystate Medical Center (BMC), a level I trauma center, were reviewed. All patients sustained deep partial and full thickness burns. The injury severity score (ISS) ranged from 9 to 75. Five patients had total body surface area (TBSA) burns of 10% to 50% and 6 patients had TBSA burns of 70% to 95%.
Daniel W. Spaite, Carol Conroy, Katherine J. Karriker, Marsha Seng, Norma Battaglia
DOI: http://dx.doi.org/10.1053/ajem.2001.27146
Published in issue: October 2001
xThis study evaluated the impact of a paramedic training program on emergency medical services (EMS) responses for children with special health care needs. EMS responses for children with a congenital or acquired condition or a chronic physical or mental illness, were reviewed. Responses, related to the child's special health care need, involving paramedics who had completed our training program were compared with responses with paramedics not participating in the training. There was significantly more advanced life support treatment for responses with paramedics completing the training program compared with other responses.
Wells A. Messersmith, David F.M. Brown, Michael J. Barry
DOI: http://dx.doi.org/10.1053/ajem.2001.27137
Published in issue: October 2001
xWe reviewed reports from 321 consecutive emergency department (ED) noncontrast, helical “renal stone” abdominal CT scans obtained at a single medical center between April 1996 to June 1997 for incidental findings. Incidental findings were common (45% of scans), and approximately half were rated of “moderate” or “serious” concern by 2 independent reviewers (kappa = 0.72). ED records indicated that only 21% of incidental findings were documented, and only 11 (18%) of cases with findings of “moderate/severe” concern had evidence of follow-up on hospital chart review.
Marjorie Funk, Janice B. Naum, Kerry A. Milner, Deborah Chyun
DOI: http://dx.doi.org/10.1053/ajem.2001.27135
Published in issue: October 2001
xThe aims of this prospective, observational study were to compare: (1) symptom presentation of coronary heart disease (CHD) between patients with and without diabetes and (2) symptom predictors of CHD in patients with and without diabetes. We directly observed 528 patients with symptoms suggestive of CHD as they presented to the ED of a 900-bed cardiac referral center in the northeastern United States. There were no significant differences in symptom presentation of CHD between patients with and without diabetes, although patients with diabetes were slightly more likely to present with shortness of breath (P =.056).
John L. Hick, Jeff D. Rodgerson, William G. Heegaard, Steven Sterner
DOI: http://dx.doi.org/10.1053/ajem.2001.27133
Published in issue: October 2001
xThe objective was to determine correlation between vital signs and hemoperitoneum in ruptured ectopic pregnancy. A retrospective chart review of ectopic pregnancies at our urban county hospital between 1990 and 1998 was conducted. Fifty-one cases met inclusion criteria. Mean minimum systolic blood pressure (SBP) 89mmHg (range 40-118), mean maximum heart rate (HR) 101 beats/min (range 62-156). Mean volume of hemoperitoneum 1,050 mL (range 400-2,000 mL). Correlation between vital signs and volume of hemoperitoneum was poor (R2 = 0.04 for HR, R2 = 0.1 for SBP).
Robert T. Gerhardt, Kevin M. King, Richard S. Wiegert
DOI: http://dx.doi.org/10.1053/ajem.2001.25780
Published in issue: October 2001
xThe objective was to determine whether an inhaled 50:50 mixture of nitrous oxide and oxygen (N2O/O2) provides significant pain and anxiety relief during intravenous cannulation in healthy adults. The study was conducted at the ED of a military teaching hospital. Participants included adult volunteers aged 18 to 50 years. Excluded were those with allergy to N2O, anemia, cardiac disease, pregnancy, asthma, or bone marrow disorder. A prospective, randomized, double-blind, placebo-controlled crossover design was used comparing a 50:50 mixture of N2O/O2 versus O2.
Larisa Nadukhovskaya, Robert Dart
DOI: http://dx.doi.org/10.1053/ajem.2001.24492
Published in issue: October 2001
xFetal death early in gestation is common. Patients in the first trimester of pregnancy with abdominal pain or vaginal bleeding often present to the emergency department for care. Over the past 20 years, the technology available to confirm or exclude the diagnosis of a nonviable pregnancy has improved dramatically. These improvements have altered the diagnostic approach to these patients and have lead to a change in the terminology used to categorize the pregnancy status. In addition, the therapeutic options available to manage patients with a confirmed nonviable pregnancy have expanded greatly.
Robin Cuddy, Guohua Li
DOI: http://dx.doi.org/10.1053/ajem.2001.27171
Published in issue: October 2001
xAsthma is among the most common ED diagnoses. Asthma exacerbations are generally treated by medications that cause bronchodilation and those that reduce airway inflammation. The effect of alcohol on asthma has been studied by investigators with mixed results. Some studies have reported that alcohol has a beneficial effect on asthma; others report worsening of symptoms. It has been suggested in some quarters that additives in alcoholic drinks cause bronchoconstriction and that pure ethanol has a salutary effect on asthma.
Amal Mattu, William J. Brady, Andrew D. Perron, David A. Robinson
DOI: http://dx.doi.org/10.1053/ajem.2001.25776
Published in issue: October 2001
xTall lead V1 (tall RV1), defined as an R/S ratio equal to or greater than 1, is not an infrequent occurrence in emergency department patients. This electrocardiographic finding exists as a normal variant in only 1% of patients. Physicians should therefore be familiar with the differential diagnosis for this important QRS configuration. The electrocardiographic entities which can present with this finding include right bundle branch block, left ventricular ectopy, right ventricular hypertrophy, acute right ventricular dilation (acute right heart strain), type a Wolff-Parkinson-White syndrome, posterior myocardial infarction, hypertrophic cardiomyopathy, progressive muscular dystrophy, dextrocardia, misplaced precordial leads, and normal variant.
Edward Ullman, William J. Brady, Andrew D. Perron, Theodore Chan, Amal Mattu
DOI: http://dx.doi.org/10.1053/ajem.2001.27172
Published in issue: October 2001
xThe electrocardiogram (ECG) may be entirely normal in the patient with pulmonary embolism (P/E); alternatively, any number of rhythm and/or morphologic abnormalities may be observed in such a patient. The abnormal ECG may deviate from the norm with alterations in rhythm, in conduction, in axis of the QRS complex, and in the morphology of the P wave, QRS complex, and ST segment/T wave. The electrocardiographic findings associated with PE are numerous, including arrhythmias (sinus tachycardia, atrial flutter, atrial fibrillation, atrial tachycardia, and atrial premature contractions), nonspecific ST segment/T wave changes, T wave inversions in the right precordial leads, rightward QRS complex axis shift and other axis changes, S1Q3 or S1Q3T3 pattern, right bundle branch block, and acute cor pulomnale.
Joji Inamasu, Yoshiki Nakamura, Ryoichi Saito, Kiyoshi Ichikizaki, Kim Shiei
DOI: http://dx.doi.org/10.1053/ajem.2001.27134
Published in issue: October 2001
x—Insertion of a central venous (CV) catheter is associated with various complications, although it is a routine procedure in the emergency department and intensive care unit. We report a case of cerebral air embolism during CV catheterization, a rare but potentially fatal complication. Emergency physicians should be familiar with the knowledge on its pathophysiology, presenting symptoms, diagnosis of choice, and treatment.
David Jerrard, Jeahan Hanna
DOI: http://dx.doi.org/10.1053/ajem.2001.27167
Published in issue: October 2001
x—A common complication of diabetes mellitus is ketoacidosis which results from the accumulation of acetoacetic and B-Hydroxybutyric acids. A less often seen and recognized metabolic alteration is diabetic ketoacidosis with alkalemia This disorder is a mixed acid-base disorder in which diabetic ketoacidosis exists alongside a state of metabolic alkalosis. Blood pH will be determined by which disorder predominates. Diuretic use, vomiting, alkali ingestion, and hypercortisolism have all been implicated as causes of this disorder.
Gamal Mostafa, Brent D. Matthews, B.Todd Heniford, Ronald F. Sing, Andrew D. Perron
DOI: http://dx.doi.org/10.1053/ajem.2001.27144
Published in issue: October 2001
x—Injury to the diaphragm is a challenging diagnostic problem with a myriad of potential clinical presentations. In the acute phase, these injuries are commonly missed. The resulting diaphragmatic hernias are notorious for delayed presentation and complicated clinical picture. This report describes a patient with a missed diaphragmatic injury caused by an isolated stab wound to the left lower chest. The patient represented 6 months after his original injury in hemorrhagic shock because of a splenic capsular laceration, caused by an incarcerated diaphragmatic hernia.
Thomas Mussack, Ernst Wiedemann, Ulrike Szeimies
DOI: http://dx.doi.org/10.1053/ajem.2001.27170
Published in issue: October 2001
x—Intraabdominal extraluminal air caused by perforated hollow viscus may appear in 10% to 15% of patients with blunt abdominal trauma mandating an emergency laparotomy.1 In many cases hollow viscus perforations are diagnosed secondarily by the signs of incipient peritonitis or increasing abdominal tenderness.2 The high morbidity and mortality of these injuries after blunt abdominal trauma justify an aggressive approach to diagnosis and surgical treatment.3,4 However, there are reported few patients with blunt abdominal trauma and free intraabdominal air in the absence of a bowel perforation.
Adolfo Napolez
DOI: http://dx.doi.org/10.1053/ajem.2001.25782
Published in issue: October 2001
x—Torsion of the testicles is typically found in the prepubertal age group. This case shows the rare finding of testicular torsion in a 24-day-old neonate. This diagnosis is rarely entertained in the emergency department in such a young age group because of the infrequency of its occurrence. Emergency physicians should be aware of this and its presentation in neonates, thereby allowing rapid intervention and preservation of the testicle.
Mark Newman, Paul Kolecki
DOI: http://dx.doi.org/10.1053/ajem.2001.25773
Published in issue: October 2001
x—Argyria, a generalized irreversible grayish discoloration of the skin caused by the chronic absorption of silver, has been associated for centuries with the therapeutic use of silver products. The following is a report of argyria associated with the chronic ingestion of a colloidal silver product touted as a natural alternative to antibiotics. The patient ingested the colloidal silver product in an attempt to treat Lyme disease.
William D. Rose, Frank Ciocci III
DOI: http://dx.doi.org/10.1053/ajem.2001.27145
Published in issue: October 2001
Anne-Michelle Ruha, Kevin Wallace, David A. Tanen, Pradipkumar Patel
DOI: http://dx.doi.org/10.1053/ajem.2001.25781
Published in issue: October 2001
x—A previously healthy 57-year-old woman ingested 4 to 8 ounces of Spectracide Grass and Weed killer concentrate, containing a dilute preparation of 2.3% diquat dibromide (1.26% diquat ion), in a suicide attempt. The ingestion was immediately followed by 3 episodes of nonbloody emesis. In the emergency department she complained only of mild throat irritation, denying abdominal pain or other symptoms. Heart rate was 114 beats/min, blood pressure 150/80 mmHg, respiratory rate 16 breaths/min and temperature 98.5°F.
Tipufaiz M. Saleem, Manoj Singh, Muhammad Murtaza, Anurag Singh, Moiz Kasubhai, Isaiarasi Gnanasekaran
DOI: http://dx.doi.org/10.1053/ajem.2001.25778
Published in issue: October 2001
x—Cocaine-related ED visits have doubled over the last decade.1 Renal infarction is a rare complication of cocaine abuse; only 4 such cases have been reported in literature.2 Common toxic effects of cocaine on vascular system manifest as myocardial ischemia or cerebrovascular accidents. Rare cases of upper extremity infarction,3 muscle and skin necrosis,4 aortic dissection,5 mesenteric artery thrombosis,6 and renal infarction2,7 have also been reported in association with cocaine abuse.
Manoj Singh, Mohammed Murtaza, Nina D'souza, Isaiarasi Gnanasekaran
DOI: http://dx.doi.org/10.1053/ajem.2001.25779
Published in issue: October 2001
x—Ethylene glycol is an organic solvent found in automobile antifreeze and a variety of other commercial products. Easy accessibility and sweet taste has made it a fairly common culprit in overdoses. Despite adequate therapeutic levels of ethanol, even as “pretreatment,” patient can develop severe acidosis with end-organ damage.1 Target organ cellular damage is seen in the kidney, brain, myocardium, pancreas, and blood vessels.2 Ischemic bowel necrosis has never been reported in association with ethylene glycol, although necrosis of bilateral putamen3 and focal hemorrhages in the gastric lining have been reported.
Daniel C. Smith, Timothy J. Mader, Howard A. Smithline
DOI: http://dx.doi.org/10.1053/ajem.2001.27152
Published in issue: October 2001
x—The “dissociative” anesthetic, ketamine, has been in wide use for more than 25 years. It induces a unique combination of sedative, amnesic, and analgesic effects without suppressing the reticular activating system. Laryngeal reflexes remain intact and cardiorespiratory function is not depressed.1,2 Use of ketamine by emergency physicians has typically been limited to brief painful procedures performed on children.3-5 It has a half-life of 7 to 11 minutes and duration of action of <1 hour after IV infusion.
Matthew T. Spencer, Bonny J. Baron
DOI: http://dx.doi.org/10.1053/ajem.2001.27149
Published in issue: October 2001
x—Between 60% and 90% of the general population suffers from a headache in any given year. As a direct result of their headaches, 9% to 15% of those afflicted miss days from work or school.1,2 Headache is the chief complaint of 1.3% to 2.5% of all patients presenting to the ED.3,4,5 Studies have shown that anywhere from 1% to 16% of these ED patients have serious pathology.6 It is necessary to quickly recognize and treat these patients to avoid morbidity. We present what appears to be a straightforward case of headache that concludes with the diagnosis of acute bacterial meningitis caused by the unlikely organism Stenotrophomonas maltophilia.
Marius A. Tijunelis, Paul Hanashiro, Kevin Kissane, Jerrold B. Leikin, John A. Timmons, Daniel O. Hryhorczuk
DOI: http://dx.doi.org/10.1053/ajem.2001.27168
Published in issue: October 2001
x—Chest pain is a common complaint evaluated at EDs throughout the United States every day, accounting for approximately 5 million visits annually. It is essential that emergency physicians evaluate these patients appropriately, to both reduce the risk of overlooking atypical presentations representing unstable angina and acute myocardial infarctions, as well as to deliver cost efficient care to the vast majority of these patients that do not have serious underlying heart disease. As recently as the late 1980s and early 1990s, organized emergency medicine recognized the need for the development of observation medicine to assist in these efforts.
DOI: http://dx.doi.org/10.1016/S0735-6757(01)70012-5
Published in issue: October 2001
xEDITOR J. Douglas White, MD, MPH, Medical College of Virginia/VCU, Richmond
