SAEM (UAEM) 1984 Annual Meeting Program

UniversityAssociationfor EmergencyMedicine

1984Annual MeetingProgram and MembershipDirectory

May 22-25, 1984 Louisville, Kentucky

INDEX Generallnformation VadeMecum Kennedylecture AnnualMeetingOverview ScheduleofEvents Abstracts Constitutionof theUniversityAssociationfor EmergencyMedicine Bylawsof the UniversityAssociationfor EmergencyMedicine MembershipDirectory(alphabeticalorder) MembershipDirectory(stateorder)

.... I ....2 ....... 3 ..... 4 5 .....,. 9 . . . . . .3i . . . . .39 .........41 .........52

GENERAL INFORMATION

REGISTRATION AND INFORMATION

UA/EM.STEM COCKTAIL RECEPTION

The Registration and Information desk will be open in the lower level of the Commonwealth Convention Center during the times listed below.

STEM and UA/EM are sponsoring a cocktail reception on Tuesday, May 22 from 5:30 pm until 7:00 pm. The reception will be held in the exhibit hall. There is no charge for the reception. Hors d'oeuvres will be served and a cash bar will be available. All registrants and exhibitors are invited to attend.

ll:00 am to 5:00pm 8:00am to 5:00pm 8:00am to 12:00pm 8:00am to 4:30pm A message board will be maintainedat the RegistrationDesk.

Tuesday,May 22 May 23 Wednesday, Thursday,May 24 Friday, May 25

CONTINUING MEDICAL EDUCATION The Medical College of Pennsylvania designatesthis continuing medical education activity for l8 credit hours in Category I of the Physician's Recognition Award of the American Medical Association. ACEP Category I credit has been applied for.

AFTERNOON AT THE RACES On Thursday,May 24, the Annual Meetingwill adjournat 12:00 noon to allow the registrantsto go to ChurchillDownsfor lunch and an afternoonat the horseraces.Buseswill leavethe Hyatt at approximately12:30pm and will return around4:00pm. Tickets for this eventwill be availableat the registrationdeskfor $7.00 apiece.Lunch is not includedin the ticket price' A limitedsandwich menuis availableon a cashbasisfrom the SkyeTerraceand a cashbar is also available.The ticket price includesthe costof transportationand admissionto the fourth floor of the SkyeTerraceClubhousewhich is glassenclosedand overlooksthe track.

Participantswill havea bird's eyeview of the races!Bettingis, of course,legaland bettingwindowsare closeat hand! Ticketscan be purchasedat the RegistrationDesk.

EXHIBITS The exhibits will be available for viewing on May 22 from 3:00-4:30pm and during the cocktail reception from 5:30-7:00pm On May 23 the exhibits will be open from 8:00-11:00 am and 3:00-4:30pm. Please take an opportunity to view these exhibits durins the scheduled coffee breaks.

PROCEEDINGS Proceedingsof the Annual Meeting will not be prepared as a separatepublication. However, selectedpresentations, scientific papersand pertinent discussionswill be printed in the Annals of Emergency Medicine, the journal of the American College of Emergency Physicians and the University Association for Emergency Medicine. In addition, the abstracts from the 1984 Annual Meeting will be published in the May 1984issueof -4rnals of Emergency Medicine.

TOUR OF HUMANA HOSPITAL A tour of the Universityof LouisvilleHumanaHospitalemergency departmentand staff flight helicopterprogramis availableto The onehour tour will be heldon Thursall interestedregistrants. day, May 24 at 12:30pm and is sponsoredby the Universityof Louisvilleemergencymedicineresidencyprogram.Buseswill be availableto transport the tour participantsto the Humana Hospitaland then on to ChurchillDownsfor lunchand the afternoon at the races.A sign-upsheetfor the tour will be availableat the registrationdesk.Thereis no chargefor this tour.

UAIEM ANNUAL BUSINESSMEETING Meetingat 5:00pm The Associationwill hold its Annual Business on Thursday,May 24. At the meeting,Jack B. Peacock,M.D' will introducethe incomingpresident,Richard C. Levy, M'D. meetingwill includethe electionof Agendaitemsfor the business officers, proposed changesin the constitution and bylaws, reports,and other items of businesspresentedby the membership. All membersof the Associationare urgedto attend.

PLACEMENT SERVICE A bulletin board will be maintained near the Registration Desk for persons wishing to post positions and physicians available listings.

UA/EM.STEM METHODOLOGY SESSION the methodologypaperswith the UA/EM is proud to co-sponsor Societyof Teachersof EmergencyMedicineon Tuesday,May 22 from l:00-5:00pm. The exhibitswill be open during the coffee breakfrom 3:00-3:30pm. of All registrants Thereis no registrationfeefor the joint session. eitherthe STEM or UA/EM AnnualMeeting,or both, areinvited to attendthe methodologypaperssession.

BANQUET The UAIEM banquet will be held aboard the Belle of Louisville' an authentic riverboat, on Thursday, May 24 from 6:30-10:30pm This year's banquet will include the cruise on the Ohio River aboard the Belle, an open bar and dinner and the presentation of the Imago Obscura and James Mackenzie awards' The dinner menu will include traditional Kentucky fare: burgoo (a hearty soup), bibb lettuce salad, barbeque (chicken, beef and pork ribs)' all the "fixins" and Derby Pie for dessert.Transportation from the Hyatt to the Belle of Louisville and back again will be provided. Tickets are $35. Active and associatemembers of the Association are entitled to one free ticket but must inform the UA/EM staff at the Registration Desk if they will be using their free ticket so that a proper count of those attending the banquet can be obtained. Tickets for the banquet can be purchasedat the UA/EM reeistration desk.

VADE MECUM 1983-1984 EXECUTM COUNCIL Jack B. Peacock. MD President Richard C. Levy, MD Vice-President Steven J. Davidson, MD Secretary/Treasurer

MACKENZIE AWARD 1976-JamesR. Mackenzie,MD 1977-Cyril T. M. Cameron,MD 1978-JohnH. Hughes,MD 1979-JosephF. Waeckerle,MD 1980-KennethL. Mattox, MD l98l-Barry W. Wolcott,MD 1982-Hubert T. Gurley,MD 1983-RonaldL. Krome.MD

Barry W. Wolcott, MD Immediate Past President Joseph F. Waeckerle, MD Past President W. Kendall McNabney, MD Past President Robert Knopp, MD Councilman-at-Large Richard Nowak, MD Councilman-at-Large Mary Ann Cooper, MD Councilman-at-Large

1984ANNUAL MEETING PROGRAM COMMITTEE Judith E. Tintinalli, MD, Chairman William Barsan,MD Mary Ann Cooper,MD Robert Knopp, MD Jack B. Peacock,MD

BEST PAPER 1977-LawrenceB. Dunlap, MD 1979-AlbertE. Cram. MD 198o-BlaineC. White, MD 1981-BlaineC. White, MD 1982-Carl Winegar,MD 1983-CharlesF. Babbs,MD

BEST PRESENTATION 1980-Jack B. Franaszek.MD and Harold A. Jayne,MD l98l-Robert W. Strauss,MD 1982-StephenR. Boster,MD 1983-SandraH. Ralston.PhD

1978-1979-Ronald L. Krome,MD 1979-198O-Kenneth L. Mattox,MD 1980-1981-W.KendallMcNabney,MD l98l-1982-JosephF. Waeckerle, MD 1982-1983-Barry W. Wolcott,MD 1983-1984-Jack B. Peacock,MD

PAST ANNUAL MEETINGS KENNEDY LECTURERS 1973-FraserN. Gurd, MD 1974-OscarP. Hampton,Jr., MD 1975-CurtisP. Artz, MD MD 1976-John G. Wiegenstein, 197'7-Peter Safar. MD 1978-SenatorAlan M. Cranston I979-Alexander J. Walt, MD 1980-EugeneL. Nagel,MD 1981-C. ThomasThompson,MD 1982-R Adams Cowley,MD 1983-RonaldL. Krome,MD 1984-David K. Wagner,MD

lst Annual Meeting M a y 1 4 - 1 5 ,1 9 7 1 Ann Arbor, Michigan 2nd Annual Meeting May 12-13,1972 Washington, D.C. 3rd Annual Meeting May 23-25, 1973 Hamilton, Ontario 4th Annual Meeting M a y 2 8 - J u n el , 1 9 7 4 Dallas, Texas 5th Annual Meeting May 2O-24,1975 Vancouver, British Columbia

HONORARY MEMBERS 1973-RobertH. Kennedy,MDt FraserN. Gurd. MD C. BarberMueller,MD MD 1974-JohnG. Wiegenstein, AlexanderWalt. MD 1975-OscarP. Hampton,MDt N. H. McNally,MDt CurtisP. Artz, MDt 1976-Anita M. Dorr, RNt EugeneL. Nagel,MDt 19'17-PeterSafer,MD 1978-EbenAlexander,Jr., MD 1979-DavidR. Boyd, MD, CM l98l-R AdamsCowley,MD 1982-Carl Jelenko.III. MD

6th Annual Meeting M a y l 1 - 1 5 ,1 9 7 6 Philadelphia, Pennsylvania 7th Annual Meeting May l5-18, 1977 Kansas City, Missouri 8th Annual Meeting May l8-20, 1978 San Francisco,California 9th Annual Meeting May 24-26,1979 Orlando, Florida lOth Annual Meeting April20-23, 1980 Tucson, Arizona llth Annual Meeting April l3-15, l98l San Antonio, Texas

IMAGO OBSCURA A.WARD

PAST PRESIDENTS

1976-NormanE. McSwain,Jr., MD 1977-SungRock Lee,MD 1978-G. Patrick Lilja, MD 1979-StephenKaras,MD 1980-Jack Goldberg,MD l98l-Robert Knopp, MD 1982-BlaineC. White, MD 1983-Richard C. Levy, MD

1970-197 l-Charles Frey, MD l97l-1972-Alan R. Dimick, MD B. Rutherford.MD 1972-1973-F.obert R. Mackenzie.MD 1973-1974-James 1974-197s-George Johnson,Jr., MD E. Rudolf, MD 1975-1976-Leslie 1976-1977-DavidK. Wagner,MD 1977-1978-Carl Jelenko.III. MD

l2th Annual Meeting April l5-17, 1982 Salt Lake City, Utah l3th Annual Meeting June l-4, 1983 Boston, Massachusetts l4th Annual Meeting May 22-25, 1984 Louisville, Kentucky

KENNEDYLECTURE

1 , t \

The 1984 Kennedy Lecture will be presented by David K. Wagner, M.D., who is the chairman of the Department of Emergency Medicine and the Director of the Emergency Medicine Residency Program at the Medical College of Pennsylvaniain Philadelphia. Dr. Wagner is a nationally recognizedleader in Emergency Medicine and has served as president of the University Association for Emergency Medicine and the American Board of Emergency Medicine. He is also chairman of the American Board of Emergency Medicine Test Development Committee and is a member of the American Board of Medical Specialties.He is a member of the American College of Emergency Physi cians and the Society of Teachersof Emergency Medicine.

In 1983 Dr. Wagner receivedthe James D. Mills Outstanding Contribution to EmergencyMedicine Award from the American College of Emergency Physicians in recognition of dedicatedand exemplary contributions of time, intellect and talent that have furthered the goals and principles of the College.

The dominant theme of Dr. Wagner's careerin Emergency Medicine has been the education of nearly a generation of

students and residentswhich has included the development of one of the first Emergency Medicine residency programs; co-editing the first major text book of Emergency "Principles and Practice of Emergency Medicine, Medicine" and being the founding editor of the Yearbook of Emergency Medicine.

Dr. Wagner's contributions to education have been recognized by the prestigious awards he has received. In 1983 Dr. Wagner was elected to Alpha Omega Alpha in recognition of his contributions to the education of medical students and residents at the Medical College of Pennsylvania. He was presented with the Golden Apple Award in 1979 and received the Lindbeck Distinguished Teaching Award from the Women's Medical College of Pennsylvania.

Dr. Wagner's Kennedy Lecture presentation at the Annual Meeting in Louisville representsa further exposition of his foresight in Emergency Medicine education' The Universi ty Association for Emergency Medicine is proud to welcome Dr. Wagner to the 1984 Annual Meeting'

ANNUAL MEETING OVERVIEW

Tuesday,May 22,l9E4 ll:00- 5:00 pm Registration l:00- 3:00pm UA,zEM_STEM Methodologypapers I 3:00- 3:30 pm Coffee n..ut _ E*tii'Uiir-6;:"

3:30- 5:00pm UAlEM_srEM r\t;il;"I;; papers rr 5:30- 7:00pm UA,UEM_:qTEM Co.i.l"tiili..ption,

Exhibit Hall 7:00-10:00 pm A nnars E mergency MedicineEditorial _of Board Meeting, Seneca-IriquoisRoom

Wednesday,May 29, lgg4 8:00- 8:30am 8:30-10:00 am _ 10:0O-10:30am 10:30-12:00pm 12:00- l:00 pm l:00- 3:00pm 3:00- 3:30pm 3:30- 5:00pm 5:00- 7:00pm 7:00- I 0:00 pm

Coffee and Registration Scientificp"pei, i-'--" Coffee nreati _ ExhibitsOpen Scientificpapers ,.The First five tvtinutes:CpR Around the World" ScientificpapersIII Coffee sreaf _ iit itit, oo.n Scientificpapers EMRA Discussion,Derbt Room UA/EM p..uti* coun'.ii'ri"..ring, Churchill Room

Thursday,l.{;ay24,l9E4 8:00- 8:30am 8:30-10;00 am _ 10:00-10:45am 10:45-11:00am 1l:00-12:00 pm l?,29- l:30 pm l?r19- 4:00 pm 5:00- 6:00 pm

Coffee and Registration ScientificfapJrs V-'--" CoffeeBreali Awards presentation ---KennedyLecturi Tour of Humananospitat Aftern-o_on at the Races,Churchill Downs UA/EM Annual nrrirJrr-#.tine

6:30- I 0:30pm UA/EM sanqct-:'EJii"' iil ouisv itte

Friday, May 25,l9E4 8:00- 8:30am Coffee and Registation 8:30-10:00 am Scientific papers VI 10:00-10:30 am Coffee Break 10:30-11:30 am Scientific papers VII l1:30-12:00pm PresidentialAddress l:00- 2:30pm *Clinical Researchin Emergency

Medicine: Does _GoodScienceConfliciwitil c;;.#;_ tient Care?"

2:30- 3:00pm Coffee Break 3:00- 4:15pm Scientific papers VIII

University Association for EmergencyMedicine FourteenthAnnual Meeting Scheduleof Events May 22-25, 1984 Tuesday, is[day 22, 1984 1:00-3:00pm

UAIEM-STEM Methodology Papers I, Convention Center.

Room 117

Moderator: RebeccaA.H. Anwar, PhD l. "Methodology Reporting in Three Acute Care Journals: Replication, Reliability, and Validity" Charles G. Brown, MD, and G.D. Kelen, M.D. Ohio State University and Johns Hopkins Hospital 2. "Survey of Undergraduate Medical Education in the United States:Part I" Arthur B. Sanders, MD, University of Arizona 3. "An Emergency Medicine 'Clinical ReasoningProcess' Worksheet" Frant J. PoPa, DO, Texas College of Osteopathic Medicine 4. "Expansion of Emergency Medicine's Responsibilitiesfor Preclinical Education of Medical Students" William p.

Burdick, MD, Medical College of Pennsylvanio 5. "A Student Emergency Medicine Clerkship Which Utilizes New Information Technologies" Robert Shesser, MD, George Washington (/niversity 6. "A Course in Anatomy for the Emergency Medicine Residency" Glenn C. Hamilton, MD, Wright State University

7. "STEM EducationalResources Compendium" Gary R. Strange, MD, University of lllinois, Ulive_yitt o{ Chicago, Akron General Hospital, Wright Stote University, Denyer Generol Hospital, North Memorial Medicalcenter, universityHospital of Jacksonville, Mount Carmel Meriy Hospital

8. "Preparation and Utilization of the Site Survey Book" Gloria Kuhn, DO, Mount Carmel Mercy Hospitol 3:00-3:30pm

Coffee Break, Exhibit Hall, Convention Center

3:30-5:00pm

UA/EM-STEM Methodology Papers II, Convention Center.

Room 117

Moderator: Scott Freeman, MD 9. "Computer Aided Teaching in the Emergency Department" Sandra M. Schneider, MD, University of Pittsburgh 10. "On-Line Medical Information in a Clinical Site, How Useful?" Steven J. Davidson, MD, Medical College of Pennsylvania

ll. "Diagnosis of Complex Acid-Base Disorders: Physician Performance vs the Microcomputer" David M. Schreck, MS, MD, Columbia Uniyersity Affiliated Hospitols 12. "Application of Microcomputers in the Emergency Department to Aid in Patient Management and Documentation of the Critically lll" Scott J. Januzik, MD, Butterworth Hospital 13. "Reducing Diagnostic Testing in the Emergency Department Through Cost Containment Education" Stephen Karas, Jr, MD, Tri City Emergency Medical Group, Denver General Hospital, Our Lady of the Loke Medical Center, San Francisco General Hospital, Spectrum Emergency Care, Worcester Memorial Hospital, Valley Medical Center, Hermann Hospital 14. "Teaching Emergency Departments: Profiles from a Survey" Thomas P. Kuhlmann, MD, University of Virginia

5:30-7:00pm

UA/EM-STEM Cocktail Reception, Exhibit Hall, Convention Center

7:fi)-10:fi) pm

Annals of Emergency Medicine Editorial Board Meeting, Seneca - Iriquois Room, Hyatt

Wednesday,

May 23, 1984

E:00_g:30am

Coffee and Registration, Exhibit Hay, Convention Center

8:30-L0:00am

scientific PapersI, Convention Center, Room 117

Moderator: Robert Knopp, MD 15. "Effect of Cardiac Arrest (CA) Time on the Cortical Cerebral Blood Flow (CBF) Generated by Subsequent Standard External Cardiopulmonary Resuscitation (SECPR) in Rabbits" S. Kwon Lee, BS, University of Pittsburgh and Prebyterian-University Hospital 16. "Cerebral Blood Flow (CBF) and Common Carotid Artery Blood Flow (CCABF) During Open-Chest Cardiopulmonary Resuscitation (OCCPR) in Dogs" Karl Stojduhar, BS, University of Pittsburgh and PresbyterianUniversity Hospitol 17. "Effect of Diltiazem on Total Brain Calcium Content Following Ischemia and Reperfusion in a Rat Circulatory Arrest Model" Lawrence de Garavilla, MS, Purdue University

18. "A Small-Animal Model of Cerebral Ischemia: Verapamil Improves Neurological Outcome" David C. Hodorn, MD, Pennsylvania State University 19. "Prolonged Cardiac Arrest and Resuscitation in Dogs II: Brain Mitochondrial Function after CPR Versus Interposed Abdominal Compression CPR" Blaine C. White, MD, Michigan State University 20. Cerebral Acidosis and Treatment Assessed by 3lP NMR" David C. Hadorn, MD, Pennsylvania State University 10:fi)-10:30 am

Coffee Break, Exhibit Hall, Convention Center

10:30-12:fi) noon Scientific Papers II Track A-Convention Center, Room t17 Moderator: Glenn C. Hamilton, MD 2l. "Lack of Effectiveness of Calcium Chloride in Refractory Asystole" Harlan A. Stueven, MD, Medical ColIege of Wisconsin 22. "The Effectiveness of Calcium Chloride in Refractory Electromechanical Dissociation (EMD)" Harlan A. Stueven, MD, Medical College of Wisconsin 23. "Preliminary Resultsof a Study of Immediate Countershock Treatment of Asystole in the Pre-Hospital Setting" R. Christopher Brooks, MD, Medicol College of Wisconsin 24. "lmmediate Emergency Department External Cardiac Pacing for Prehospital Brady asystolic Arrest" Jason M. White, MD, Henry Ford Hospital 25. "The Prehospital Use of Transcutan eous Cardiac Pacing" Paul M. Paris, MD, University of Pittsburgh 26. "Injuries Associated with the Percutaneous Placement of Transthoracic Pacemakers" Charles G. Brown, MD, Ohio State University, Johns Hopkins Hospital and Georgetown University Hospital Track B-Convention Center, Rooms 105 and 106 Moderator: Jack B. Peacock. MD 27. "Evafuation of Triage Performance During a Disaster Simulation Utilizing Four Techniques: Real Time Video Recording, Time Flow Tracking Cards, a Portable Microcomputer, and Field Observers" Andrew I. Bern, MD, Wright State University 28. "Financial Implications of Disaster Preparedness:A Cost Analysis of an Area-wide Community Based Mass Casualty,/Disaster Incident" Andrew I. Bern, MD lVright State University

29. "ComputerAssistedDecisionAnalysis During the Preand DataManagement hospitalPhaseof a SimulatedDisaster Exercise" Andrew L Bern, MD, Wright State University 30. "Designand Utilizationof a 'Moulage InstructionalVictim Card' in Simulated Disaster Exercises" Jon R. Krohmer, MD, Wright State University 31. "DisasterMedicalDirection:A Plan" R. H. Bade, MD, Emergency Medical Services Agency and University of Colifornio, Irvine 32. "Hearing Loss in EMS Firefighters" Paul E. Pepe, MD, Boylor College of Medicine 12:00-1:00pm Panel, Convention Center. Rooms 105 and 106 "The First Five Minutes:CPR Around the World" ll/ayne Longmore, MD, moderator A paneldiscussioninvolvingexpertsfocusing on variouscardiopulmonaryresuscitation techniquesusedby healthpractitioners in other countries. l:fi)-3:fi) pm

ScientificPapersIII

Track A-Convention Center, Room 117 Moderator:LynnetteDoan, MD 33. "Insulin and Glucose Levels During CPR in the Canine Model" John F. O'Brien, MD, Henry Ford Hospital 34. "Histamine Blockersin the Treatment of Shock Hyperglycemiain the Rat" Ruth V.W. Dimlich, PhD, University of Cincinnati 35. "A Comparison of Central Venous and Mixed VenousOxygenSaturation During OpenChestCPR in the Canine Model" GerardB. Martin, MD, Henry Ford Hospital 36. "A Comparison of Central Venous and Arterial pH and pC02 During Open Chest CPR in the Canine Model" GerardB. Martin, MD, Henry Ford Hospital 37. "Fluid Loading with Whole Blood VersusRinger'sSolutionDuring CPR in Dogs:Effect on OxygenUptakeand R e g i o n a l B l o o d F l o w " W .D .

Voorhees,III, PhD, Purdue University 38. "Comparison of Cardiorespiratory, Biochemical and Transcutaneous ParametersDuring Graded Hemorrhage" Peter A. Maningas, MD, Madigan Army Medical Center 39. "Effect of Hyperoxia on Transcutaneous Oxygen MeasurementsDuring Graded Hemorrhage" Peter A. Maningas, MD, Modigan Arm Medicql Center 100."Iced GastricLavagefor Treatmentof Heatstroke: Efficacy in a Canine Model" Scott Syverud,MD, University of Cincinnati Trrck B-Cozvention Center.Rooms 105and IM Moderator: StevenJ. Davidson, MD 41. "Medical Reliability of Pre-Hospital

AdvancedCardiacLife Support" ,/ack B. Peacock, MD, TexasTech University 42. "The Effect of Telemetryon Urban Prehospital Cardiac Care" C. Gene Cayten, MD, New York Medical College, Drexel University, Jefferson University Hospital, Hospital University of Pennsylvanio, Hahnemann University 43. "The Evaluation of Paramedics' Clinical Performance and Competence:The Stateof the Art" M. Haim Erder, PhD, Philadelphia Health MonagementCorporation and Medical ia Collegeof Pennsylvan M. "A Proposed Data Base for the Evaluation of ALS Care" M. Haim Erder, PhD, Philadelphia Health ManagementCorporation 45. "A PrehospitalParamedicExperience with Poisoning" Kathleen M. Horgarten, MD, Medical College of Wisconsin 46. "PrehospitalFactorsInfluencingMortality of Ruptured Abdominal Aortic Aneurysm" Philip F. Troiano, III, MD, Medicol College of Wisconsin 4 T ." R e s u s c i t a t i o n a n d T r a n s f e r o f Trauma Patients:A ProspectiveReEvaluation" Daniel F. Danzl, MD, University of Louisville 48. "TherapeuticInterventionScoringasa Measure of Need for Helicopter EmergencyMedicalServices"Kenneth J. Rhee,MD, University of Michigan 3:fi)-3:30pm

Coffee Break, Exhibit HaA, Convention Center

ScientificPapersIV 3:30-5:fi)pm Track A-Convention Center,Room 117 Moderator: Bruce M. Thompson,MD 49. "Use of NaloxoneDuring CardiacArrestand CPR: A PotentialAdjunct for EMD" Robert J. Post-Countershock Rothstein, MD, Harbor-UCLA Medical Center 50. "Dose-RelatedResponseof Centrally AdministeredEpinephrineon Changes in Aortic Diastolic PressuresDuring Closed Chest Massage in Dogs" Joseph W. Kosnik, MD, WaYneState University 51. "Effect of Epinephrineand Calcium Chloride on Left VentricularPressure and Carotid Flow During Cardiopulmonary Resuscitation" Moses S.S. Chow, PharmD, UniversitY of Connecticut 52. "Ionized CalciumDuring CPR in the Canine Model" Randall Best, MD, Henry Ford Hospital 53. "The Influence of VeraPamil on Dopamine'sAbility to Augment Cardiac Output" lames T. Sturm, MD, St. Paul-RamseyMedical Center 54. "A RandomizedComparisonStudyof Bretylium Tosylateand Lidocaine in of Patientsfrom Out-ofResuscitation Hospital VentricularFibrillation in a

ParamedicSystem" David W. Olson, MD, Medical College of Wisconsin TrackB-Convention Center.Rooms 105and 1M Moderator: W. Kendall McNabney, MD 55. "Intravenous Streptokinase"Gabriel Mayer, MD, Florida Heart Institute 56. "Beta Blockersand the Sympathetic Nervous Systemin Coronary Occlusion Induced in Cats" William H. Spivey, MD, Medical College of Pennsylvanio in Evaluationof Syncope 57. ' 'Prospective PatientsPresentingto the Emergency Department" StephenL. Adams,MD, Northwestern University and Loyolo UniversityMedical Center 58. "Use of Clonidine in the Emergency Departmentfor Rapid Control of Uncontrolled Hypertension" Kenneth Doroski, DO, Philadelphia Collegeof OsteopathicMedicine 59. "Single Dose CeftriaxoneTreatment of Urinary Tract Infections" lack M. Rosenberg,BA, University of Cincinnati 60. "Lymphadenitis:Natural Historyand Aspiration" to Percutaneous Response Gary Fleisher, MD, Children's Hospital of Philadelphia 5:00-7:00pm

EMRA Discussion Session,DerbYRoom, Hyatt

7:00-10:00pm

UAIEM Executive Council Meeting,Churchill Room, Hyatt

Thursday, Nluy 24, l9E4 Coffee and Registration, Convention Centa FoYu am ScientificPapersY E:30-10:00 Track A-Convention Center,Room117 Moderator: G. Patrick Lilia, MD 61. "The HemodynamicEffects of Rate During Open Chest Resuscitation" Robert L. Bartlett, MD, Richland Memorial Hospital Cardiac 62. "Comparison of Open-Chest Massage Techniquesin Dogs" I/, Marc Barnett, MD, UniverstiY of Pittsburgh 63. "A Comparative StudY of Three ClosedChest Forms of Resuscitation: Compression, Open Chest Manual Compression,and Direct Mechanical Ventricular Assistance" Robert L' Bartlett, MD, Richland Memorial Hospital 64. "Prolonged Cardiac Arrest and Resuscitationin Dogs I: CardiacResuscitabilityand Net PerfusionPresAbsureswith CPR VersusInterposed dominal Compression CPR" Oliver Hayes, MD, Michigon State Universitl 65. "CardiopulmonaryBypass(CPB)for after ProlongedCardiac Resuscitation Arrest (CA) in Dogs" Peter Safar, MD, UniversitY of Pittsburgh and P resby terion-UniversityH ospital E:fi)-8:30am

66."CardiovascularResuscitabilityof Dogs After Up to 90 Minutes Cold Water Drowning Using Cardiopulmonary Bypass (CPB)" Samuel Tisherman, BS, University of Pittsburgh ond Presbyterian-University Hospital TrackB-Convention Center,Rooms105and 1M Moderator:Robert Rothstein, MD 67. "Serum ElectrolyteAbnormalitiesin EmergencyDepartmentPatientswith Seizures" Robert D. Powers, MD, Universityof Virginia 68. "EmergencyPhenytoin Loading by ConstantIntravenouslnfusion" Bryan Carducci, MD, University of Cincinnati 69. "Serum Amylase IsoenzymeAlterationsin AcuteAbdominalConditions" Erik E. Swensson,MD, Medical Collegeof Virginiaand Universityof Tennessee 70. "An Evaluation of Carboxyhemoglobin Spot Tests" Edward J. Otten, MD, Universityof Cincinnati 71. "HepatitisB Prevalence in Emergency Physicians"Kenneth V. Iserson,MD, Universityof Arilona 72. "ConcomitantUseof ActivatedCharcoal and N-Acetylcysteine"FrancisP. Renzi, MD, PennsylvanioState University 73. "Influenceof theNutritionalStateand Immunity to Prognosisof the Severe Trauma Patients" Kazuhiro Yasuda, Nippon MedicolSchool, Tokyo, Japan

Friday, May 25, 1984 E:fi)-E:3Oam

Coffee and Registration Convention Center Foyer

8:3G10:fi) am Scientific Papers YI Track A-Convention Center, Room 117 Moderator: Williom Barsan, MD 74. "Antishock Trousers: A Comparison of Inflation Techniques and Determination of Optimal Inflation Pressure" Barbara Hanke, MD, Valley Medical Center 75. "The Effect of the Trendelenburg Position and MAST on Blood Volume Distribution" Herbert G. Bivins, MD, Valley Medical Center 76. "Control of Intra-Abdominal Hemmorrhage and Shock: A Comparison of Fluid Resuscitation,MAS-Trousers, and Balloon Aortic Occlusion" Ronald B. Low, MD, University of Oklohomo 77. "Pneumatic Trousers in Refractory Prehospital Cardiopulmonary Arrest" Brian D. Mahoney, MD, Hennepin County Medical Center and Wausa Hospital Center 78. "Effect of Military Antishock Trousers on Cardiac and Respiratory Function Following Acute Myocardial Infarction" Jeffrey A. Sharff, MD, Oregon Health Sciences University 79. "The Effect of MAST on the Trauma Score: A Prospective Analysis" William H. Bickell, MD, Brooke Army Medical Center and Baylor College of Medicine

Track B-Convention Cmter, Rooms 105 and 106 Moderator: Ronald D. Stewart, MD 80. "Efficacy of the Post-Traumatic Cross 10:45-11:ffi am Awards Presentation Table Lateral View of the Cervical 19E3Best Paper-Charles F. Babbs, Spine" William H. Blahd, Jr., MD, MD, "lmproved CardiacOutput DurUniversity of Arizona ing Cardiopulmonary Resuscitation 81. "Emergency Evaluation of Cervical with InterposedAbdominalCompresSpine Injuries: CT vs Plain Radiot sionst graphs" Sharon Mace, MD, Mount Sinai Medical Center 19E3 Best Presentation-SandraH. 82. "Computerzied Tomography in the Ralston, PhD, "Intrapulmonary Emergency Department" Steven A. EpinephrineDuring Prolonged CarMeador, MD, Wayne State University diopulmonaryResuscitation: Improv"Usefulness of Abdominal Flat Plate edRegionalBloodFlow andResuscita- 83.

Radiographs in Suspected Ureteral tion in Dogs"' Calculi Patients" Kurt F. Zangerle, 11:fiI'12:fi)noon KennedyLecture MD, University of Arizona David K. Vl/agner, MD, "Gradtale 84. "Accuracy of the Plain Abdominal Educationfor Emergency Medicine:A Roentgenogram in the Diagnosis of Choiceof Horsesand Yaks or Mules Ureteral Calculi" Craig S. Roth, MD, andZotstt Mayo Clinic pm 12:30-1:30 Tour of Humana 85. Correlation of Historical and Physical Hospital Findings with Fractures in the Knee" 12:3{H:fi)pm Lunch and an afterR. Jerry Salomone, MD, Medical Colnoon at the Races lege of Pennsylvonia

10:fi110:,6am

Coffee Break ConventionCenter Foyer

Churchill Downs 5:fi)-6:fi)pm

6:30-10:30pm

10:fi110:30 am

UA/EM Annual BusinessMeeting Convention Center,Room 117

Coffee Break, Convention Center Foyer

10:30-11:30am

Scientific Papers YII

UA/EM Banqtet Belle of Louisville

Track A-Convmtion Canter, Room 117 Moderator: Donno Carden. MD

86. "Ventilation During Cardiopulmonary Resuscitation:Two-Rescuer Standards Reappraised" Richard J. Melker, MD, University of Florida 87. "A Standardized Comparison of the EOA and Endotracheal Tube in Cardiac Arrest" Yvonne Hommargren, MD, Hennepin County Medical Center 88. "Guided Orotracheal Intubation Using a Lighted Stylet" Timothy Vollmer, MD, University of Pittsburgh and Western Pennsylvania Hospital 89. "Influence of Mask Design on BagMask Ventilation" Ronald D. Stewort.

MD, University of Pittsburgh and Center for Emergency Medicine of Western Pennsylvonia TrackB-Convmtion Cmter, Rooms 105 and 1M Moderator: Kenneth V. Iserson, MD 90. "Coin Ingestion: Does Every Child Need an X-Ray" Dee Hodge, III, MD, Children's Hospital of Philadelphia "A Comparison of the Effectiveness 91. of Different Cervical Immobilization Collars" John B. McCabe, MD, Wright State University and Miami Volley Hospital 92. "Intraosseous Administration of Sodium Bicarbonate: An Effective Means of pH Normalization in the Canine Model" Bruce M. Thompson, MD, Medical College of Wisconsin 93. "Effects of High Pressure and Large Bore Tubing on IV Flow Rates" James R. Mateer, MD, Medical College of Wisconsin 11:30-12:00pm PresidentialAddress Jack B. Peacock, MD, Convention Center, Room 117 12:00-1:00pm

Lunch Break

1:00-2:30 pm Panel Discussion "Clinical Researchin EmergencyMedicine: Does Good ScienceConflict with Good Patient Care?"

Norman S. Abramson, MD, Panel Moderator Associate Director, Clinical Affairs of the Resuscitation ResearchCenter, University of Pittsburgh Assistant Professor. Critical Care Medicine Michael Bracken, PhD Associate Professor, Epidemiology, Yale University Principal Investigator, National Acute Spinal Cord Study Alan MeiseL fD Professor of Law, [Jniversity of Pittsburgh Schools of Law and Medicine Of Counsel, Berkman Ruslander Pohl Lieber and Engel, Pittsburgh Formerly Assistant Director for Legal Studies President's Commission on Medical Ethics

2:30-3:fi)pm 3:fi)-4:15pm

Coffee Break, Convention Center Foyer ScientificPaPersVIII

Track A-Convention Center,Room 117 Moderator: Kenneth L. Mottox, MD 94. "Registration of Cardiopulmonary Cerebral Resuscitation(CPCR) May Allow Calculation of Prognostic Indices" Herman H. DeLooz, MD, PhD, Academish Ziekenhuis SintRafael, Belgium 95. "Difficulty and Delay in Intravascular Access in Pediatric Arrests" Valerie Rossetti,MD, Medicol College of Wisconsin of ClosedHead Injury in 96. "Assessment Traumatic Spinal Cord Injvy" EIIiot L Roth, MD, NorthwesternUniversity

and Rehabilitation Institute oI Chicago 97. "Pediatric Head Injury: The Critical Role of the EmergencYPhYsician" Thom A. Mayer, MD, Georgetown Universityond Primary Children'sMedical Center 98. "A Methodology for Comparing Trauma Patient Populations" Howard R. Champion, MD, llashington Hospitol Center TrwkB-Convention Center,Rooms105and 1M Moderator: Richard M. Nowak, MD 99. "Automatic Gastric Lavage and a Comparisonof Tap Water vs 0.990 Normal Saline Solution Irrigant" Joseph P. Rudolph, MD, McKeesPort Hospital

40. "A HemodynamicModel for Anaphylactic Shock" William G. Barsan,MD, University of Cincinnati l0l. "Microwave Ovens: A Safe New Method For Warming CrYstalloids" David L. Werwath, MD, Eostern Virginia Medical School and Norfolk GeneralHospital l02. "Diagnosis of Intraperitoneal Extravasation of Urine via Peritoneal Lavage" Mork J. Rubin, MD, Univer' sity of Arizona l03."Outcomes of EmergencyThoracotomy in theUrban CommunitYHosPir al: Cardiac Rhythm as a New Prog n o s t i c I n d i c a t o r ?" M a r k W , Brautigon, MD, Michigon State University and Mount Carmel MercY Hospital

Abstracts of the 14th Annual Meeting of the University Association for Emergency Medicine [Editor's note: The t'ollowing 103 abstracts will be presented at the Annual Meeting of the University Association f or Emergency Medicine in Louisville, May 22-25, 1984. Presenters'names are pfinted in italics; wherc presenter is not indicated, none was specified by the authorc.l

Methodology Session cine, Critical Care Medicine, and lournal of Trauma. Eleven critcrra previously reported {or evaluation of clinical trials in the medical literaturc were used. Thesc were: l) eligibility criteria,2l admissiolr before allocatron, 3) randorn allocation, 4) rncthod of randomization, 5) patrents' blindncss to treatment, 6) blind asscssmcnt of outcomc, 7) treatment complcations, 8) loss o{ fo1low-up, 9) statistical methods, 10) statistical analysrs, and 1l) powcr. All prospectivc, interventional, controlled trials appearing ir-rthe journals from fanuary 1980 to fune l9B3 wcrc identified. A total o{ 45 trials werc {ound. Each study was then indepcndently read by 2 rcvicwcrs to determinc whether each of thc criteria was clcarly rcportcd, not clearly rcported, or not applicable. Disagrccmcnts wcrc resolved by a third reader (adjudicator). Results are reportcd as thc mcan proportior-l of items clearly reportcd * standard deviation'. Annals of Emergency Medicine {n : 16), 0.40 + .181 lournal ol Trattma (n : l8), 0.4I + .24i and Critical Care M e d i c i n e ( n - 1 1 ) ,0 . 3 6 + . 1 8 . A o n e - w a y a n a l y s i s o f v a r i a n c c Iound no statistically significant difference bctween journals witlr rcspcct to thesc proportions lP : .761. This study rcveals tl-rat thesc journals do not report enough information pertaining to bias-rcducing tcchniqucs and statistical methodology to adecluatcly analyzc the validity of an invcstigation.

Acute Reporting in Three Methodology a A I ll Replication and Reliability Care Journals: CG Brown, MD; GD Kelen, MD; MJ lvose( MD; ML M o e s c h b e r g e r ,P h D ; D A R u n d , M D , F A C E P / D i v i s i o n o f E m e r g e n c y M e d i c i n e a n d D e p a r t m e n t o f P r e v e n t i v eM e d i c i n e , O h i o S t a t e U n i v e r s i t y ,C o l u m b u s ; D e p a r t m e n t o f E m e r g e n c y M e d i c i n e ,J o h n s H o p k i n s H o s p i t a l , B a l t i m o r e An important mcasure of the quality of research in any scientific disciplinc is reliability. Reliability is the ability to rcplicate an experiment and its rcsults. As the sciencc of cmergency and acute care medicinc dcvclops, rt becomcs imperative for rcsearchers ir-r these fields to rcport accurately and completely thc methodology of their invcstigations so that other investigators can critically examine, replicatc, or cxpand on tirc results of an investigation. The purposc of this study was to compare thc completencss o{ mcthodology reporting in thrcc acutc carc journais, Annals of Emergency Medicine, Critical Carc Medicine, and lournal of Trauma. Thirty-cight critcria necessary for thc replication ol a clinical trial were idcntificd and groupcd into 10 categorics: 1) cxpcrimcntal dcsign, 2) recruitmcnt and exclusion of subjects, 3) selection of study samplc, 4) subject allocatron, 5) therapeutic regimcn, 6) blindncss, 7) outcomc critcria, B) analysis of confounders, 9) withdrawal of subjccts, and l0) statistical analysis. All prospective, interventional, controlled trials appearing in the journals from January 1980 to |une 1983 wcrc rdentified. A total of 45 tnals were found. Each trial was thcn indcpendently read by 2 reviewers to determine whethcr each of thc 38 criteria was clearly reported, not clearly rcported, or not apphcable. Disagreements were resolved by a third rcader (adjudicatorl. Resuits are reported as the mean proportion of items clearly rcported * standard deviation: Annals of Emergency Medicine (n : 16), 0.39 + .10; Iotnnal of Trauma (n : IB),0.33 + .14; and Critical Care Medicine (n - 1l), 0.32 l: .08. A one-way analysis of variance {ound no statistically significant difference between iournals with respect to these proportions ltt - .25).The results of this study indicate that prospective, interventional, controlled trials are not being reported in these journals with sufficient information on methods to allow replication of thc investigation. One solution to this problem would be to encourage journal editors to develop and publish standards for methodology reporting.

Survey of Undergraduate Medical Education in the United States AB Sanders, MD, FACEP;E Criss, RN; D Witzke, PhD; MA Levitt, DO / Section ol Emergency Medicine and Office of Medical E d u c a t i o n , U n i v e r s i t yo f A r i z o n a H e a l t h S c i e n c e s C e n t e r , T u c s o n A survcy was donc to determine the status of undergraduate education in emergency medicine in thc United States. Questionnaires werc sent to the academic deans of 126 medical and 15 osteopathic schools. Two mailings and a tclephone follow-up resulted in a 96% response rate (135/l4t). Of those responding, 15% have a required and 90% have an elective fourth-year rotatlon rn ernergency medicine. An average of 164 h are spent in the required rotation. In the third-year curriculum 12% of those schools responding have a requircd emergency medicine rotation, and 24'/" o{fer an elective. In the combincd third and fourth year 35 respondents required clinical rotations through emergency medicine. Of the respondents 22"/o reported that emergency medicine is taught rn the second year o{ medical school. Twentytwo schools reported required time, with an average of 15.6 h.

Seven schools offer electives in emergency medicine in the second year, with an average of 33.4 h. Emcrgency medicine is taught during the first-year curriculum in 38% of the schools.

Thirty-six schools reported required {irst-year time in emergency medicine, with an average of lB.4 h. Nineteen schools reported first-year elective time in emergency medicine, with a mean of 27.4 h. CPR is offered during medical school in 96% oI the schools responding. Students are required to take CPR in 860/" ol the schools, but only 53% require certi{ication for graduation.

ACLS is o{fered in 73% oI the medical schools; students are requrred to take ACLS in 39% oI the schools, and 23% require certification Ior graduation. AILS is taught rn 17% oI the schoois; it is required in 7% oI the schools, and less than 7'/o require certification {or graduation. A residency in emergency medicine was

Methodology Reporting in Three Acute f I I Gare Journals: Validity GD Kelen,MD, CG Brown,MD; MJ Moser,MD; J Ashton,MS; DA Rund,lVD,FACEP/ Department of EmergencyMedicine, JohnsHopkinsHospital,Baltimore; Divisionof Emergency Medicineand Department Medicine,Ohio State of Preventive University, Columbus A study is valld if its results accuratelyreflect the true situation. Validity in medical researchdependsin part on the elimination or reduction of various biases. A clear reporting of how biaseswere handled, as well as the statistical method used to analyzedata, is essential to the critical reader trying to evaluatc the merits of an investigation.The purposeof this study was to compare how frequently certain items relating to validity were reportedin three acute careiournals,Annals of EmergencyMedi{

9

UAEIVABSTRACTS 1 4 T HA N N U A LM E E T I N G

reported by 30% of the medical schools. An academic department in emergency medicine was present in 18% of schools responding. Eighty-nine percent of respondents felt that undergraduate education in emergency medicine is appropriate, while 1l% Iek it is not. This survey provides some data on the basic status of emergency medicine education in the medical school curricula of the United States.

An Emergency Medicine .IGlinical Reasoning Process" Worksheet FJ Papa,DO / Divisionof EmergencyMedicine,TexasCollegeof Osteopathic Medicine,FortWorth Emergencymedicine is a major clinical learning experiencefor the maiority o{ medical students throughout the country. While it is di{{icult to estimate the educationalimpact of an emergency medicine clinical rotation on these students, acute cardiai and trauma casesprovide the students with opportunities to learn to deal with high-impact medical problems under the guidance oI well-defined,structured protocols and concise medical content.

Howeve4 these kinds of acute care situations constitute the minority of case presentationsin most emergencymedicine facilities. While there is wide acceptanceand reinforcement of standardprotocols (advancedcardiic life support/ advancedtrauma life supportl for these few presentations,there seems to be little agreement on physician/student protocols or evaluation techniquesfor the majority of EM cases.How, then, is the emergencyphysician to evaluateand treat the maiority of patients and then teach the students to do the same?Clinicai mehical education has traditionally used the SOAP approach(Subjectiveiinding, Objective findings, Assessment,Plan) as a guideline for the "clinical reasoningprocess" utilized in patient care. The actual chart of the emergencypatient/ howevel,doesnot encouragethe clinician and student to share a clinical reasoningptocesJ.Th. author presentsa simple "clinical reasoning,,stu-dent/clinician worksheet especially designedto reveal the reasoningapproach for the_majorityof EM cases.The potential value of an e-ergency medicine student-orientedclinical evaluation worksheei for student education is presentedfor discussionand input.

Expansion of Emergency Medicine's Responsibilities for Preclinical Education of Medical Students

processes for further development as clinicians. Departments o{ emergency medicine should be willing to accept this incremental responsibility for the introduction of the medical student to the clinical and laboratory assessment of patients.

A Student Emergency Medicine Glerkship That Utilizes l{ew Information Technologies R Shesse4MD; M Smith,MD; P Kline,MD; J Reich,MD; T Turbiak,MD; R Rosenthal, MD / GeorgeWashington University MedicalCenter,WashingtonDC The effectiveteachingof clinical emergencymedicine to medical students requires efficiency in the managementof both student and faculty time. The didactic process can be enhanced through the use of new technology that permits a busy clinical faculty to presenta standardizedcourseto a large number of rotating students. Presentedis a course outline that utilizes the following elementsto structure and augment clinical time in the emergencydepartment: 1) The use of videotapeto presenta 25-h series of faculty-producedlectures covering a,,core" emergency medicine curriculum. Production cost for the taped lectureswas $1,013in a university audiovisual department.VHS format playback equipment is readily available,easy to use, and relatively inexpensive.2J Use of a stand-alonemicrocomputer to {acilitate staggeredschedulingof clinical time. This permits 143 students per year to have a lO-shift, 2-week clinical rotation through an emergencydepartmentwith 43,000patient visits per year.3) The use ot a microcomputer test generationprogram that permits a secretary to formulate, administer, and grade a different final exam each rotation. The program permits variable numbers and types of multiple-choice or true-falsequestions to be askedon a given examination. 4J Computer-assistedrecordkeepingfor faculty evaluation o{ a student's clinical performance.Once established, this program can be administerbdwith fewer than 5 faculty hours per month assistedby a25% FTE clerical coordinator.

This coursedesigngivesthe student a highly structuredemergency medicine experience,rich in both clinical and didactic components, with efficient use of faculty lecture, clinical, and administrative time.

A Gourse in Anatomy for the Emergency Medicine Resideney GC Hamilton,MD I Departmentof EmergencyMedicine,Wright StateUniversity Schoolof Medicine,Dayton,OH understanding of human anatomy is a critical component _The of the practice of medicine. A specialtywith the breadthof emergency medicine is best approachedwith a sound basisin anatomy and pathophysiologywhich leadsto a betrer understandingof the differential diagnosis.It was the author's opinion that a specialty with the surgical emphasis{ound in emergencymedicine should have a correlating emphasis in the anatomical sciences.Subsequent testing of PGY-2residentsdemonstrateda fair-to-poorunderstanding of anatomy when gauged by a standard fieshman anatomy exam tailored to clinical circumstances.Reportedis a 2yr experience in giving a one-week, 40-h prosected anatomy course that includes didactic presentationsby the anatomydepartment and clinical correlationby the departmentsof emergen. cy medicine and surgery. The impact of this course on clinical practice, problems in its preparation,and outcome of a shared experiencewith residentsfrom generalsurgeryare discussed.

The course is thought to be a successful addition to the trainins of emergencymedicine specialists.Future directionsfor this typi of course ate discussed.

WP Burdick, MD; SJ Davidson, MD / Divislon of Emergency M e d i c i n e , T h e M e d i c a l C o l l e g e o f P e n n s y l v a n i a ,p h i l a d e l p h i a Many medical schools have required emergency medicine courses for freshmen medical students, usually through participation in BLS or EMT activities. For several years students at our institution have participated in a required emergency medical technician-ambulance grade (EMT-A) course. While retaining much of the material presented in that original EMTA course, the course has now been expanded to serve as the medical stul dents'introduction to clinical medicine. This expansion resulted from the belief that emergency medrcine provides initial patient contact in the presence of a faculty uniquely suited to introduce the broad domain of clinical medicine to the medical student.

Emergency physicians, more than any other specialists, must possessthe ability to obtain an incisive history promptly/ perform an accurate physical examination, and arrive at an assessment with limited laboratory and radiologic data. The goals of our revised course are: 1) to introduce the essential tools o{ clinical medicine - history taking and physical examination; 2) to teach students to provide basic on-site first aid; 3l to demonstrate clinical_applications o{ physiological concepts through lectures on shock, respiratory distress, drowning, and drug oveidose; 4) to teach motor skills in airway management and intravenous access; and 5) to cultivate an appreciation for the sociologic aspects of emergency medicine. Initial access to the clinical educatibn of medical students provides the opportunity to direct their e{{orts in a prioritized fashion, and thus help to organize their thought

STEM Educational Resources Compendium GR Strange,MD; R Strauss,MD; J Dougherty,MD, FACEp; G Hamjlton,MD; R Jorden,MD; S Dannewitz, MD; L Doan,MD;

t0

G Kuhn, DO / STEIVEducational Resources Committee In the spring oI 1982, the Educational Resources Committee of the Society of Teachers of Emergency Mcdicrne (STEMJ was formed with the express purpose of collecting from emergency medicir-reresidcncy programs a wrde variety of materials of use in the cducation of EM residents. It was our intcnt to collect, review collate, and make available to EM educators a selection o{ materiais that would prove use{ul rn the organization and managemcnt of a rcsidency program. The culmination of this effort has rcsulted in the publication of the STEM Educational Resources Compendium, which is of{cred for the first timc at the 1984 annual meeting. The Compendium is divided into 14 broad scctions, cach with a spccific editor. Each cditor, an authority in the field of emergency medicine, has o{fered general rntroductory commcnts and included a selection of the most useful and reoresentativc material submitted from our nationwide solicrtation o{ residency directors. In some cascs so many exccllcnt examples were submitted for a given topic that representativc samples were chosen and the other examplcs were filed {or usc in future editr.ons. An extensivc section on curricuium developmcnt (including core curricula, general goals and objectivcs, specific rotations, and didactic curriculum outhncs) forms the {irst scction. This is followed by cliscussions of faculty dcvclopment; fellowships; rcsident application, seieotion, and orientation; rcsidcnt and program cvaluations; reprint frling systcmsi quality dssutxDCC;ED refercncc libraries; ancl rcscarch activities. We providc a discussion of the usc ol oral case simulations in rcsidcnt cducation, and 1(r case outlinos arc included. Thc final section is an cxtenslvc Drcscnraticln of surgical skills laboratorics, with 5 cxamples. This cornpilation will bc of Lrsc to any teachcr in the ficld of cmcrgency medicir"rewho is currcntly involved in thc dcvclopmcnt cll ongoing management of an emergcncy rncdicinc rcsiclcncy.

most popular simulations were those with finite endings - ie, life or death. Paticnt simulations provided students exposure to syndromes that are uncommon in our emcrgency departmcnt.

Bascd on our use pattern/ we recommend that a system be availablc over extcnded hours o{ thc day. Our greatest usc was in the early morning and late evening hours. New material should be added {requently because this resulted in an increase in use o{ al1 programs.

On"Line Medical Information in a Glinical n I lY Site: How Useful?

SJ Davidson, MD, RAHAnwar,PhD/ Divisionof Emergency Medicine, TheMedicalCollege of Pennsylvania, Philadelphia {

Bctwcen May and September 1983 a sophisticated microcomputcr data base {ull-text searching system was operational in our cmergency dcpartment (ED) adjacent to thc preexisting ED "mini-library," a collection of approximately 30 texts maintaincd and updated for rcfcrcnce and teaching purposes. The computer systcm providcd the full tcxt and illustrations of 24 texts.

Illustrations were providcd on a video disk system linkcd to and controlled by the local microcomputer. There was a concordance of only 2 volumcs between the paper and electronic collections but an overlap of approximately 5O% in topic arcas. Of 32 potential system uscrs (faculty or rcsrdcnts in emcrgency medicineJ, ll actual uscrs 134%) werc identified by author #2 by a telephonc or pcrsonal intcrview that consisted of structured questions covering thc followir-rg arcas: 1) user background,2) user intcrcst,3) user instruction, and 4) user problems/suggestions. Rcsults were tabulated and frccluencics arc rcported. Four uscrs had previous cxpcricncc but only onc currently owncd a home computer. Eight rcqucstcd Mcdlinc scarchcs through the clinical librarian program but only onc rcportcd running his own Medlinc search.

Scvcn wcrc ir-rfrcqucnt and 4 werc frequent users. Seven rated thcmsclvcs as havlng high tolerance and interest. Uscrs werc instructcd by author #I ("key user"), by the system provider's represcntativc, or by self-instruction. Eight wcre pleased with the pl-rysical location of thc systcm in the clinical settlng, while 3 would have prefcrrcd to have it located in a quietcr office area away from tl-re rmmcdiate clinical cnvironment. The results suggest that rnany morc potcntial wers 123/241 than actual users (11/34Jdcveloped, pcrhaps because of rotations away from the ED or low tolerancc/intcrest for computer systems. "Key user" instruction was associated with a higher degrec of tolerancc and satisfaction. Rcspondents suggcsted that {urthcr refinemcnt of system spccd and content is necessary rf this system is to provide cffcctivc augmcntation to irnmediate clinical decision making.

On-line, fu11-tcxt data base systcms are rn thcir infancy and are not yet supplantrng an ED re{erencc coliection.

Preparation and Utilization of the Site Survey Book G Kuhn, DO / Department of Emergency lvedicine, Mount Carmei Mercy Hospita, Detroit Dcscribcd is a tool, thc Sitc Survcy Book, that can bc usecl to rapidly and logically prepare {or a sitc survey. It contains a framcwork tl-rat covcrs all thc spccial rcquircments considcrcd by the Rcsidcncy Rcview Committcc. This framework can bc easily modified to the indivrdual nccds of each program while still adhcring to the guidclines set forth by the Rcsidcncy Revrew Committce of thc Accreditation Council for Graduatc Mcdical Education. It is dcsigncd to be updatcd periodically so that rt accluatcly reflccts what is occurring in thc program. Thc Site Survey Book can be used as a mastcr guide whcn planning any changes in thc curriculum or when planning a lecturc scrics. It is also an icleal method o{ rapidly acquainting residency candidates with the structure of the training prograrn durrng the rntcrvrew proccss.

1a I I

Gomputer.Aided Teaching in the Emergency Department

Diagnosis of Gomplex Acid.Base Disorders: Physician Performance Versus the Microcomputer

S M S c h n e i d e r ,M D / D e p a r t m e n t o f M e d i c i n e , U n i v e r s i t yo f P i t t s b u r g ha n d l v l o n t e f i o r eH o s p i t a l , P i t t s b u r g h

D M S c h r e c k , M D ; D Z a c h a r i a s , M D ; C F V G r u n a u , l V D , F A C E P/ C o l u m b i a U n i v e r s i t yA f f i l i a t e d H o s p i t a l s R e s i d e n c y i n E m e r g e n c y M e d i c i n e a n d l \ , 4 o r r i s t o wM n e m o r i a l H o s p i t a l , M o r r i s t o w n ,N J

To augment the norrnal teaciring of emergency medicine to internal medrcine housestaff, a {lcxible, uscr-friendly computeraided learning system was developed that allowed the emergency medicine faculty to provide a wide variety o{ instructional material within a set framework. The following systems were devcloped from the same so{tware package: 1Jquestior-r and answer, 2J lecture format, and 3) patient simulations. The software allowcd {or student input, analysis of input, and appropriate branching based on input- Use patterns were monitored and analyzed. Thmost popular lormat was patient simulatrons. Thc software allowed the student to obtain a history and physical examrnarron, order and receive laboratory data, and treat the patient. The student could move between any of these categories freely, treating life-threatening conditions prior to completing the history. The

Patlents with oftcn complex acid-base disturbances frequently prescnt to thc ernergency department, where the often hectic environment can preclude the appropriate quantitative analysis required by these disorders, especially when mixed disturbances are present. A computer program incorporating generally accepted acid-base and electrolytc formulae was developed for use on the Applc II+ or IBM-PC microcomputer. Each o{ a series of 35 acid-base disturbances incorporatrng single, double, and triple disordcrs was identified corrcctly by thc computer in lcss than a minute. Problem sets based on the same 35 disturbances were prescnted to 21 physicians at various levels of training in the following specialties: emergency medicine, internal medicine, pediatrics, surgcry, and family practrce. Although the physicians were given unlimited time and the formulae necessary to reach a diag-

u

UAEMABSTRACTS 14THANNUALIVEETING

nosis, they were asked to per{orm their analysesin the same fashion that they used in the emergency department. Although times varied widely, no physician spent more than 5 minutes on any problem.The physicians'correct responserates were 86%,49%, ind 17% for single, double, and triple disorders respectively.The primary disordei correct responserate was 89Yofior double disorders and 94% for triple disorders. The primary and secondarydisorder correct responserate was 57.8% Ior triple disorders.The data suggestthat the computer may be beneficial by rapidly assessingcomplex acid-basedisorders.

a

el

Application

of Miclocomputels

in the

Emergency Department to Aid in Patient Management and Documentation of the Gritically lll Program and MedicineResidency SJ Januzik,MD i Emergency Grand Hospital, Butterworth Medicine, of Emergency Department Ml Rapids, to assist A programusinga personalcomputerwasdeveloped I Z

the physician accuratelyin both patient managementand timing and recording of events during cardiac arrest or trauma. Documentation of events uses the computer's internal clock to initialize procedures,drugs,vital signs,and rhythm documentation.

Speedis acquiredwith various menus that allow the operatorto oLtain time, dosage,and route of administration with a minimal number of key strokes.The number o{ eventsrecordedis limited only by the dimension parametersset by the programmerand the memoiy capability of the computer. There is no limitation to the duration of the record. New ideas are incorporatedinto the program continually. Special features of the program include a time clock and an arrest duration clock with warning reminders to indicate need for repetitive drugs or vital signs. Calculation functions built into the program include drip mixture rates,pediatric dosagesbased on age, Glasgow Coma Scale,and calculation of anion gap and A-A gradients. TWo printouts are generatedby the program. The first is a simultaneous record of drugs and times of administration {or quick review while arrest is in progress.The secondis a final printout that lists basic information including name/ age/sex, dite, and duration of the arrest. History is listed for both pre- and post-hospitalphases.A complete patient event su^mary, listing ill the eventsin a chronologicalsequencealong with the time of the event, is then printed. To facilitate billing and morbidity and mortality review,summariesof defibrillations, medications, procedures,and laboratory or x-ray results are given.

The physicians involved in the arrest and patient outcome are included.

a lt f r,

on all diagnostic tests ordered in its ED, reporting the 100 highest-total-c-osttests, determined by test charge multiplied by frequency ordered. A panel o{ 8 emergency physicians, nurses, and administratorsselectedl7 test categoriesto be targetedfor reduction through education. Criteria {or selection were the following: 1) high tolal cost, 2) probable excessiveuse, 3f availability of lowei-cost altematives, and 4) amenability to reduction through education. Educational obiectives and materials were developed to facilitate independentimplementation of cost containmenteducation at each hospital from May to fuly 1983.Following this educational period, a test covering the educational material was given to the ED staff at the participating hospitals and at 3 conirol hospitals. The mean scoreswere 88'1% for project participants a{ier education and 7I.6% for the control- group with no iducation. During |une through August 1983, data on the 100 highest-total-costtests orderedwere reportedagain by-eachhospitat. fo analyze the effects of education, each hospital's averaâ‚Źe patient cost [total chargesdivided by total patients during the baselineperiod)was comparedto the averagepatient cost for the post-educationperiod. fune 1982prices were used for all months of the study. Average patient costs were computed for both the targeted teits and lne tOOhighest-total-cost tests' Results for each hospital were reported and analyzed separately,including information on diagnostic cateSoriesof patients, post-education test results,rates of patient admissionfrom the ED, and staffing variations. Analysis bf 7 hospitals showed a mean reduction ol 2I.4% in averagepatient cost for the targetâ‚Źdtests, with a range of 3.5% to 32.7%.(Funded by the WK Kellogg Foundation)

a ,i I rl

Teaching Emergency Departments: Profiles from a Survey

TP Kuhlmann,MD; FW Schoonover;RH Hodge, Jr' MD; of DL Kaiser,DPH / EmergencyMedicalServices,University of VirginiaHospitalsand the Schoolof Medicine,University Virginia,Charlottesville A survey oI 324 teaching hospital emergency departments (EDsl was conducted to obtain information about staffing patterns, teaching,and patient care activities. A total of 168institutions nrovided data for a responser. .teof 52%oi37% were univer"other." sity-based; 4OYo,private; t3%, city-county; and l0o/o, to census according analyzed Each of these 4 hospital types was (averageyearly patient visits). Data on a wide variety of variables *ere stndied,'including demographics,staffing patterns, house' stal|I iauity I patient interrelationships, administrative organiza' tion, standards for professional fee generation, faculty hours per weet, salaries,and other variables.Analysis of the data allowed construction of profiles by hospital type/census.When the most common censutcategories{25,000to 45,000)were comparedfor university-based EDs and private hospital EDs, the following was noted: faculty to housestaffratio from 4 PM to 8 nlur,0'36 vs0'76, respectively;direct patient careby faculty on a 1:l basis,27'8% vs 54.8%, supervisionof patient caredeliveredby housestaffon a casepresentalion basis without f aculty-to-pati errt contact, 49.3o/o vs 4.6o/oiresearchac' vs 34.0%; unsupervisedpatient cate,4.Oo/o tivity, 50% vs 27o/oifaculty hours per week, 42'8 vs 44'3i presenceof medical directorwhose primary responsibilityis ED, 90% vs 94T"i departmental pressure to generate income, 55% vs 12%i and university/private faculty salary ratio, 0.85. This type oi profile analysis daia can be used by medical directors and administrators as a source of comparative data between similar and dissimilar institutions, enabling assessmentof current operations and standardsof the ED.

Reducing Diagnostic Testing in the Emergency Department Through Cost Gontainment Education

S Karas,Jr, MD, FACEP;SV Cantrill,MD; R Davidge,FACHA; P Harding,RN, MS; R Heroux,MHA, PhD;G Josephson,MD, FACEP;RK Knopp,MD, FACEP;P McCall,RN, MSN;M Wiseman' MA / Cost ContainmentProjectTask Force TWenty-twohospitals in 8 states participated in a 2-year cost containment program aimed at reducing the total costs of diagnostic tests orderedin the emergencydepartment (ED).Eight of the 22 EDs were emergency medicine residency training sites, and 3 additional departmentshad other residents on rotations.

From fune to August l9B2 each hospital collected baselinedata

t2

General Sessions valucs wcrc several times higher than during external CPR measurcd by us and others in other models. CCABF values during OCCPR were disproportionately low compared to CBF, which suggests a shi{t of {low from face to brain. During external CPR, data suggest a shi{t of flow from brain to face. OCCPR should be taught again and used if possible when external CPR is not promptly effective.

Effect of Gardiac Arrest Time on the Gortical Gerebral Blood Flow Generated

by Subsequent Standard External CPR in Rabbits M MD;P Safar, MD;SWStezoski; SKLee;P Vaagenes, of / Resuscitation Research Centerand Department Scanlon of Pittsburgh Anesthesiology/Critical University CareMedicine, Pittsburgh Hospital, andPresbyterian-University {

E l a,

Blood sludging and clotting during stasis in cardiac arrest might hamper reperfusion with standard external CPR (SECPR), particularly after long cardiac arrcst (CA) times without CPR. Rabbits were Iightly anesthetized {or preparation. After tracheal intubation and insertion of monitoring sensors/ a parietal burr hole was madc, and a platinum H2-sensitive electrodt- was insertcd 2 mm into the cercbral cortex by micromanipulator. Cortical cerebral blood flow ICBF) bv cortical H2 desaturation was recordcd, and scmr-log plots of clearance curves were obtained.

CO2 sensrtivity under normotension was establishcd {n5). Motion artifacts were controlled. In 2l CA experiments, under IPP! 2 or 3 control CBF valucs were obtained. Ancsthesia was discontinued. A{ter saturation for 15 min with l0% Hz/50% N2O/40% 02, the heart was stopped with KCl. CA was permittcd to persist for l, 3, 5, 7, or 9 min in randomized sequencc. At the end of CA, SECPR was started with IPPV/FiO2: 1, and stcrnal corrpressions with 2 fingcrs (80-100/min), trying to optimrze arterial prcssurc.

H2 desaturation curves were obtaincd during SECPR. Prearrest cortical CBF remained consistent with * l0% (23-40 mL/IO0g/ min). AIter arrcst, during SECPR, H2 washout curves showed cortical CBF values above viability limit (above 20% of normal) only alter 1 mln arrest time (AT), with CBF 12% to 3l% of control.

Wher-rAI was increased to 3 min, CBF during SECPR was only 9% of control; aftcr 5 min Nl, 6ok i and after 7 and 9 min AJ CBF was 0. MAP during SECPR was 42 + 17 after 1 min Al and 15 :t 2 altu 7 min AI Aftcr 15 min of SECPR, opcn-chcst CPR (OCCPR) raised MAP but not CBE Thc longer thc CA time without CPR, the worse the CBF generated by subsequent SECPR. SECPR should be started as rapidly as possible, and must bc improved for use after prolonged (unwitnesscd) cardiac arrest.

12 a f

Effect of Diltiazem on Brain Galcium Content Following lschemia and

Reperfusion in a Rat Girculatory Arrest Model L d e G a r a v i l l a ,M S , C F B a b b s , M D , P h D ; J L B o r o w i t z ,P h D / Biomedical Engineering Center and Department of Pharmacology and Toxicology, Purdue University, West Lafayette, lN Calcium entry into damaged neurons during reper{usion has been hvoothesized as a ma'ior cause of Dost-resuscitation brain d a m a g e . -D u r i n g r e p e r { u s i o n , p l a s m a c a l c i u m , w h i c h i s m a i n tained by homcostatic mechanisms, provides a virtually unlimited sourcc o{ calciurn to enter damaged brain cells. We measured total brain calcium content following ischemia and rcper{usion in the presence of varying doses of diltiazem (a calcium cntrv blockerl in a cardiac arrest model in the rat to seek cvidcncc for calcium intoxication and its prevcntion by calcium cntry blockcrs. In 50 rats we induced cardiac arrest and ischemia with intracardiac KCI for a mean duration of 1I.B min, resuscitated thc animals with CPR and iet ventilation, and monitored a palpablc apcx bcat for 60 min. Brain calcium was determined by perfusir-rg thc cerebral vasculature with t0 mL of a Ca-free solution, rcrnoving thc brarn, digesting it in hot nitric acid, and measuring thc calcium in the residue using atomic absorption spectroscopy. Following ischernia and 60 min of reperfusion, brain calcrurn morc than doubled from a pre-arrest control value of 30 p.g/g-dry weight o{ brain to 69 p"g/g. Wet/dry weight ratios were not di{{erent from pre-arrcst control, ruling out significant extraccllular eden.ra.Diltiazem (5, 60, 600 pglkg IV in 10-20 min) adrninrstered withir-r 5 min of cardiac resuscitation abolished the increase rn brain calcium seen after 50 min of reperfusion. These studies indrcate that calcium accumulates intracellularly in the brain following ischemia and reperfusion, and that diltiazem at relatively low and clinically realistic doses, given in the reperfusion phase, can completely abolish the increase in brain calcium.

Cerebral Blood Flow and Common Garotid Artery Blood Flow During Open.

Ghest GPR in Dogs K Stajduhar; R Steinberg; M Sotosky; P Safar,IVD;W Stezoski / Resuscitation Research Centerand Department of Anesthesiology/Critical CareMedicine, University of Pittsburgh andPresbyterian-University Hospital, Pittsburgh { A I l,

a CD A Small.Animal Model of Gerebral I C, lschemia: Verapamil lmproves Neurological Outcome DC Hadorn, MD / Emergency lvedicine Division, MiltonS Hershey MedicalCenter, Hershey ThePennsylvania StateUniversity,

Cerebral blood flow (CBF) of at least 2O% of normal (needed for brain viability) cannot be counted on with external CPR. We used H2 clearance for CBF determinations, with a platinum needle electrode in the sagittal sinus. Common carotid artery blood {low lCCABF) was measured by electromagnetic flowmeter. Global CBF and gray matter CBF were measured under normal conditions during spontaneous circulation in 5 dogs under normocarbia f 77 mL/100 g/min), hypercarbia ll4|ok o{ normal), and hypocatbia l4I% of normal). Six dogs were prepared under light anesthesia, the chest was opened, heparin was given, saturation with H2 was achieved, and cardiac arrest was induced with KCl. One minute after pulselessness, CBF was determined during H2 washout while performing open-chest CPR (OCCPR). Resaturation with H2 was obtained and the second CBF measurement was made at 25 to 60 min. During OCCPR, while CBF was 427" to 105% of control, CCABF was only 9% to 36% of control. After 5 min and 7 min arrest time without CPR, gray CBF produced by OCCPR was 45"/o ar.d 17% of control, respectively. In all 6 dogs near-normal EEG activity was maintained throughout OCCPR of I h. OCCPR produces CBF values above viability limits, even after I h of OCCPR and an additional 5 min without CPR. CBF

We descrrbe our adaptation ol an established small-animal model of transient cerebral ischemia (TCI), which is widely used to study stroke. Seventeen fed male Wistar rats were anesthetized with pentobarbital and halothane. The vertebral arteries were clectrocoagulated in the alar foramina of the first cervical vertebrae and permanently occluded. The carotid arteries were isoIated and a poiyethylene vascular clasp was placed Ioosely around each vessel. Catheters {illed with heparinized saline were placed in a juguiar vcin and in the abdominal aorta and were routed subcutaneously, emerging and secured dorsally adjacent to the midthoracic spine. After recovering for 24 h, subjects were normal by behavioral and EEG criteria. The awake rats were then hand-held and the carotid clasps were tightened, effecting 4-vessel occlusion. Following 30 min of ischemia, the carotid clasps were removed, permitting reestablishment of cerebral blood flow At this time 5 mL o{ normal saline (S) with or without I mg/kg verapamil (V) was administered by infusion pump over 20 min through the iugular vein. Subiects were evaluated at 24 and 48 h

t3

UAEMABSTRACTS 1 4 T HA N N U A LM E E T I N G

gradrng post-ischemiaand were ratcd on a behavioral de{icit death Thev 5""r., -rlfi, ;aximum oiio points rndicatingbrain occlusion with isoelectric EEGs following il:;;;;;;;;; and 7 of 17 died from resprratoryarrest arteries, oi th" "".otid 4 iit. "t"'luttg animals'.6 received v and .l;.-g ;;;;.'oi ischh alter 24 within dicd reccivcd S. TWo V-treat"J ,"i-'ti 4 control animals emia. The remainder weie-alive ^t 24 h' A11 immobile and lying ar..dwere i'+h, I riai (q 7 above had scorcs survivanimals V-treated 4 The explore' ""rUf. i"-"r,, clrink, or

163 * 3 2 nM o'l*:"/jlsf';jl'i; chonclrialinjury (Stat-e-4,

-" s#git s<}ii s zoi s,,,p'i :1"I J,i;"?,t"1 J;;'.;n',",}'ffi ltocnonurlar iniury ol m

protetn; KLK' S t a t e J , 7 O . 4 | 1 8 . 4n M O 2 / m i n / m $

r e s u l t c di n s c v c r e - t ^ y 5 ' ^ ^ _ + 3') 25'+ protein;^S^tate,3' iaJ,.^*t; 7.s .. t.o nMio2lmin/mg g'a 4 7 + 9 Sigma SOD' and l 7; rf"Cn, proteln; nM Or/mir-r/mg minim al mitochonir'.t!,*"itt'1'tot'strate ili ;';;;;;;i'ir. there is a signi{itlrial injury ciuring 15 -t" itt'li"rni',- although damage sboir' : o'it Further brain mitochondriai ;il; il;i" cven though CPR' IAC by ,,'"*""ttb"ttd anct CPR, occurs during brain perfusion. ifr"l"aa., frrJ teen'shown previously to.augment brain t"lg.t, the'hvpothesis that-loss of SoD bv iil;;;i; mav allow exacerbatedinjurv bv a"?i"g i'"r'.-i ;'i;;;i;;;i; oxrdative raclicalspccicsduring repertusron'

*[,i;$;:'T$it'**;1"'"1;i':lllxl'*#':::::x?ii"': 'L'y#i{::i:i':l#;llixtx?.:?ffi ',}i"i""il?1f,"'l}'l'0"'iJi Gerebral J"'a' A114 v-treated animals scored ,.-o,ia'ro,'i.,iirln :;;l;;; ate, drank' and.rcspondedapproexplored, i t1'n,td i;rt;it;;:li of TCI describedo{fcrs numerous model Thc tii-"rl. ;;;;;il;

hindbrain iio*-t. Jolirh"d n, .'"ttr"iy reciuceclduring.ischcmia' cases'marnpJ"tin" is relatrvely spared- pcrmitting' ii11::t pcripl-rcralvascularretcnancc of rcspiratron,cardiacoutput, and (rhc rclativclv intcrval' ischemic ;;il.,h; ;;;;;;;; we observedmight have.bce'rc **ll;l:t i;;il;;";;1itv substratclcv,;;;i.ing irom th" fe'l stot", with elcvated ;;;,;;; associatcdwith in, i,-,r"rnbi" -etabolism' )-variablcs. ;i; ;;;il;1" eliminatcd' whercas i"rur"i ",iu" and intcnsivc carc are tl-rus (eg' hypoxia' acidosis) arrest *ittt-""iJio" conditions associatcd pn."d ti"glv ti' in combinaiion 1n a controlled :;;;;';-il;t is that rcgional manncr. An additional adlvantagcin using rats. bc dctermincd accucan iii'top"ihologv "r.t,l tio* uiouJ ;;;il ancsr " i . i t * i , f t w c l l - c s t a b l i s h c t cl c h n i q u c sC o n c c r n sa b o u t isclcrnia bccrusc trbviated' arc function li':-i: .ii;, ;; ;.'J; is irnposctlon awakc animals'

20

Acidosis and Treatment aisesseo bY srP Nuclear Magnetic

Resonance S Hershey MD I EmergencyMedrcineDivrsion'M,ilton -Center, DC Hadorn, Hershey University' State Pennsylvania The fVeOicaf arrest apThe ccrebral aciclosisthat dcvclops durirrg cardiac ncurological periistent o{ d"v"1oprrltnt. i" ir.to, ^^f."y p."t."," i* retroi,.irrrv followins rcsuscrtation.Scveralanimal trials and have indicated that undcr conditions ;1';i;,il ;i;li"' :;i;,i; glucose),relil<elv to oroducc cercbral aciclosis(clevatcdserum ischemia is srgnrtttransicnt following lunction ..*iv',,iitt,"n the wl''r. i iit'o siudies clcarlv demonstrate i;;;i;;i. ;ili; conof aciclosison cercbral tissuc, dircct evidcnce i."i"'"ii"i, ,il J"t"t-,"" ,,r t"tJt't acidosisto in vjvo anoxic-ischcilffi; i, trct i"g. S,'dittm bicarbonate'an agent commonlv ;;'i;; actually produce utilizcd in thc trcatmcnt of cardiacarrcst' may acidosis This occursbecausecarbondiox;;';;;irt;;;ercbral aitt"r""J i" bicarbonatc-solutronand rcleased il."(co;ii;-b.iii ,"r",i.". co2 rapidly crosscsthc blood ncutralizatlon in thc acicl Alteinative agcnts'including .,Jotti" i.rin fr^tii"t to form -ilir'ir"ir"i may bc supcrior.to brcarbonate in this critiVersus GPR After trgAM), Function Mitochondrial generCO2 is'lrcithcr dissolvcd in Tiis solution nor CPR ;;i"t;;;",' iilerposea Abdominal Gompre-ssion as an organic Furthermore' reaction' ncuiralizatiln DVM; "i,f-r" "a"i D Johns'MD; AT-Evans' BC White,uo, iu Hildebrandt; relatrvelyintact' Huang' n-rolcculc,Tiis may crossthc blood brair-rbarrier MD; RJ Indrieri,DVM;T Hoetrner'L Fox; R L A;;.;; "*tr"-"ly polat bit,'bottatc.ion crossesextremely ;il;;;;;-lh P h D / S e c t i o n o t E m e r g e n c y M e d i c i n e , D e p a r t m e n t o t P h y s i o | o g y , rf at all. Rccently it bttu-" to detect and meaDevelopment' .i,*fv, Poj:tbl", irP "nJ Oit'i!-ot MedicalEducationResearchand Magnetic ResoNuclcar usi'g vivo in acidosis Medicine' il-t,."f ,.,if Vetertnary other) tissue C"ll"g;;l iuman Medicine,and College-of "J stimulation Magnctic . ot "l"."-iNrunf -!t111.(:t Hli"f-liiunState University,East Lansing;Dep^artment elcctromagnetic emit atoms-to phosphorous Ml causcsthe contalncd M;oi"ln", s,ttet*orth Hospital'Grand Rapids' il:;#;"; in this frequencyare """igy "f a charactcristi"it"qt"tt"y Shifts 25 kg wcrc and bgtYt:l,20 wcighing dogs Sixicen mongrel chcmical cnvironments of theseatoms' spcci{ic the bv ti,rai,'""a 'rrt"irglt<s) tollowcd by-halothane anesthctizeclwith ketaminc"iz "diof'equencv surfacecoil rhese 6;;'p*i'i ;;i;;"];il; "niirals were.intubatcdand a "tvg""t *i,tt with each-spectralpeak assignspcctra, iii::;A;;"i. tittf,t'"t. i"a"g.rt..t i,tti (cv) rinJl^uas inserted rhe scalp was rcflccted compounds Studies indicate that :;;r;;i;;;;; ilili;''p";i;;i;;ph"';;' Thc deLJphlit" ft"ft'*"t Jtttt"d in the parietal skull t"a', is--the NMR spcctra so ootained permit non-invasive'-real-time follows: l) and h.avedevelopcd w9 *"i" aiiia.a i"1o + '*p"'i-ental groups as 'ndpu' ;;i;i; ""tig'ti's ;:;;;;,-t";;il*"u'a (cstablishedby CV non-ischemiccontrol; f;tS -it-t t"'diac arrest bit"ompati6lt tadiofrcquency surface .""""..f"ffv i-pl"nt"Ju the {irst o{ a-seriesof adult ""ir'. u'"ii ;;'il"i" ;;;ff;;,li adequate.NMRsignal-tostudies pilot arrest plus 30 min C -onk"y,'-i" .,""*o-;6 and 4) 15 mtn coil placedexternalto the with ;;;htd" ltO pg/kg) IV at the initiation ,of-CPR; Lr.^oli^i"",1 not could ratio noise compression sessionthe subexperimentil ;;i;;;;;;; it"!'ao mi" i"t"'po'ed abdominal the skull. At the beginiittg-oi""ft epineph-rine(20' pg/ parahaiothanc' and oxide nitrous Cpn Uic- Cpni r"d NnFicot if eults] and wiih ;-. *";;;"il;6J IAC-CPR'At the end of cachproccdure and ventilated A {emoral artery intubated, Pavulon, Gl-iv ", the initiation of *i,ft iv"La immediately cooled monitoring and a 4- to 5-g sample * an""f""i" *as 'emot'ed' ancl vcin *"r" "rnr..,,,t"J ior'arterial pressure mitocho"d1l1-Tl: The respectively' drug,in{usion' tto 0 C, ,rrd proc"ssea {oi itoi"tion o{ ""4 [i""a g"t determinations, warming a in wrapped chamber mitochondriawerestudied{orquantitative^oxygenconsumptlon Nlfn subiect was placed ln ttte substrate during State 4 {resting) and by a mass spec;j;;-;i;;;;i.7-a^t' blankct. Eni-expiratory PCO2, as measured superoxide Mitochondrial through constant kcpt State 3 (Aop-strmulaiJdil"tpii"tro"' was g", "tt"iy""r, ;r;;;;;t ilt"1?t1:lt'i1 Respiratoryconartenal ait-"i^1" lsOD) was determinedquantitativelyrate. Paired, simultaneou,s-measurements ot t"rpi*ati glStuti 4) were calculated' Non-is*:t".T1-1' energetics pH and trol ratios {RCR : Soit l,tii'""llular rd ;.r"t ;"J ;1;; "H + Ozl nM 2 10 be 14 7 there"ft"-* a*" showedSt^i" + ittpit"tion to control period and at appropriateintervals i"-ift.'i"i,i"t t 5.5tpnM O2lmin/mg by itttt"'"ttnrrs infusion of i"dt'""d min/mg protein; state a 'etpitniion, 115-'7 ""ido,ii-*at "l,"r.ivti.;r. units/mg ve-ntilatingthe.a.ni s.e I 3-.t;;d soD, 10'1.+ l'e sisma ;;;;.";'ncn, 0.;i.{H'ctgr;ded tissuc hypoxia (imposedby changein pH stabilizedfolprotein. Fllteen -r.,.,tes of ischemia resulted in littie cerebral When U'oth mal with s%Jo% ori-oi State 3 resprrahypoxia.,acidosis.wascorrectedwith 5i"i"-+ fi+.s * tz.g ttm O2lmin/mg protein),or and/or infusion acid lowing RCR the however' ,io"-tfei.S 't 6S.t ntvt O"tt"i"|y'qy.i"teinJ; ;; ili'' rt'i' chronic preparationis the bi;;;.";;. ;;;;'"#;; 34 t l 5 sigma units/ long-term repeatedmeasurements' was reducedto 5.0 + b.i#J ioo T"il to-6 permits and f.i"d, iitt,-"ii,. mitorr"tt.-i" !i"t--PR ptodu"ed some additional ;;;t;,el;.'

#tr fiT.t'J:il 19 l'"""t]:,::.3fl

i"i"* ""-ncr,05-E^,iF [l.r,l:";Z,a] i: iLl?,SiHA':f:

l4

lFla Lack of Effectiveness of Galcium 1l Chloride in Refractory Asystole HA Stueven,MD; B Thompson,MD; C Aprahamian,MD; DJ Tonsfe dt, MD: J Darin.MD / Instituteof Traumaand EmergencyMedicine,MedicalCollegeof Wisconsin,Milwaukee The effectivenesso{ calcium chloride in asystolehas beenchallenged.Retrospectrvestudies have not supportedits use. A prospective,randomized,double-b1indstudy comparing calcium chlorideand saline was carried out in the prchospital paramedic setting.From October 1982to October 1983,a total of 73 patients who had receivcd epinephrine, bicarbonate, and atropine and were in refractory asystolewere included in the study. Patients with traumatic or pediatric arrestswere excluded.The successful resuscrtationrate was 3139in the calcium group versus I/34 in the sahncgroup {P < .37).A success{ulresuscitationwas defined as the conveyanceof a patient with a pulse and a rhythm to an emergencydcpartment. Groups were analyzedfor sex, age, and wrtncssedarrests.There was no statistlcally significant differenccbetweenthe groups.No patient who was success{ullyresuscitatedin the ficld was dischargedfrom the hospital alive. It is concludedthat calcium chloride is not of value in resusclrarlns refractoryasystoiern the prehospitalcardiac arrcst sctting.

22

Effectiveness of Calcium Ghloride in Refractory Electromechanical Dissociation

The effcctiveness of calcium in EMD has bccn challcngcd. Retrospective studies have been contradictory. To answer the question a prospective, randomized, double-blind study comparrng calcium chloride and saline in re{ractory EMD was carried out in the prehospital paramedic setting from October l9B2 to October 1983. Only patients who had received epinephrine and bicarbonate and wcre refractory were entered into the study. All trauma and pediatric arrests were excluded. Seventy-ninc patients presented in refractory EMD. Nine of 40 who received calcium were successfully rcsuscitated (SR) in the field, while 2 of 3L) who received saline were successfully resuscitated (P < .05). A successful resuscrtatron was de{ined as the conveyance of a patient with a pulsc and a rhythm to an emergency department. Patients were analyzed for age, sex, and witnessing o{ arrest. There was no statistical difference in demographic data. When thc entrre group of EMD patients was broken down rnto subgroups based on width of QRS, it was noted that patients with a QRS wrdth less than 0.12 did not respond to calcium, whercas the SR in the group with widened QRS was 9/31 versus l/28 lP < .01). Only one patient who was successfully resuscitated was discharged from the hospital alive. Calcium has been shown to be effectivc in cardiac resuscitatron of patients in refractory EMD. There may be a subset of patients with widened QRS complexes who will bencfit to a greater extent from the use o{ calcium chloride.

Preliminary Results of a Study of lmmediate Gountershock Treatment of Asystole in the Prehospital Setting

C, E -J

RC Brooks, MD; C Aprahamian, l\4D; JR Mateer, MD; RS P i o n k o w s k iM , D; BM Thompson, IVD / Section of Trauma and EmergencyMedicine, Medical College of Wisconsin, Milwaukee Protocols for prehospital resuscitation of the cardiac arrest patient usually call for a "quick-look" interpretation of a single lead rhythm strip and standardized ACLS resuscitation measures. under these conditions, ventricular {ibrillation could masquerade as asystole. Presented are preliminary results of a prehospital study of adult cardiac arrest seen in a county-wide, single-base, medically controlled urban paramedic system in which "quick-look" internretation of asvstole was treated with immediate

Cl A 37]

lmmediate Emergency Department External Gardiae Pacing for Prehospital

Bradyasystolic Arrest J M W h i t e , M D , R I V N o w a k , M D , F A C E P ;G B M a r t i n , M D ; D L C a r d e n , M D ; R M B e s t , M D ; M C T o m l a n o v i c h ,M D , F A C E P/ Department of Emergency Medicine, Henry Ford Hospital, Detroit Patients presenting to the emergcncy dcpartment (ED) with bradyasystolic cardiopulmonary arrest have a mortality rate approaching 100%. This study was undertaken to determine the utility of immediatc external cardiac pacing (ECP) in such paticnts. TWcnty paticnts were entered into the study and were trcatcd according to currcnt ACLS guidelines, with the exception that ECP was rmmediately initiated using the Heart-Aid device in thc manual mode. Electrical capture was attained in 2120 paticnts (10%), although none developed a pulse or blood pressure.

Sinus rhythm and an adequate blood pressure developed rn 4/20 patients (20%) without evidence of electrical capture. A11 4 ol thcsc patients died within 48 h without evidence of neurologic rccovery. In the remaining patients ECP was noted to increase the ratc of pulsclcss idiovcntricular rhythm (PIVR). In the most extrcmc case, the rate of PIVR increased from 20 complexes per minutc to 60 complexes per minute without evidence of electrical capturc. Patients presenting to the ED with bradyasystolic cardiopulmonary arrest do not appear to have an improved outcome with immediate ECP using the Heart-Aid device. ECP may bc ineffective because these cases represent a deterioration of viable rhythms into non-salvageable rhythms. Insufficient current dehvery (I50 ma for 20 ms), as supported by the rarity of electrical capture, is another possible explanation for the lack of succcssful pacing. It is possible that external electrical stimulation of the heart, in the absence o{ electrical capture, may make the myocardium more responsive to other pharmacologrc interventions or may primarily improve myocardial {unction. This theory warrants {urther investigation. The Heart-Aid device is easy to operate and may prove more beneficial if applied promptly in the prehospital setting. Further studies are indicated to address this oossibilitv.

H A S t u e v e n ,M D , B T h o m p s o n , M D ; A J A n d e r s o n , M S ; C A p r a h a m i a n , M D ; D J T o n s f e l d t ,I V D ; J D a r i n , l t / D / I n s t i t u t eo f T r a u m aa n d E m e r g e n c y M e d i c i n e , M e d i c a l C o l l e g e o f W i s c o n s i n , Milwaukee

23

tershock at 200 Ws. Following onc or 2 countershocks, all patients recerved standard ACLS protocols for asystole. From April I, 1983, to December 3I, 1983, 119 patients were entered into a study and were compared to system controls of asystolic patients seen and treated in 1982. The endpoint for evaluation was successful resuscitation (SR),which is defined as arrival to a hospital with a rhythm and palpable pulse. Saves, defined as discharge from the hospital, were not evaluated. Eleven patients 19.2%l showed an rmmediate rhythm change related to the initial countershock. Another l0 patients iB.4%) converted to a rhythm after additional ACLS protocols for asystoie. Six of the original 1l and all o{ the 10 late conversions entered the hospital with a rhythm and pu1se, for an SR rute oI 13.4"/" which is almost identical to the l9B2 system results for asystole of 12.5%. While our preliminary data do not show an increase in the SR rate, we note with interest that ll patients responded immediately and that 6 155%J sustained their rhythm until they reached the hospital. Our data support the need {or an ongoing evaluation of this problem.

Prehospital Use of Transcutaneous Gardiac Pacing

P M P a r i s , M D ; R D S t e w a r t , M D ; R K a p l a n , M S , R W h j p k e y ,M D / D e p a r t m e n t s o f M e d i c i n e a n d A n e s t h e s i o l o g y / C C M ,U n i v e r s i t yo f P i t t s b u r g h ,a n d T h e C e n t e r f o r E m e r g e n c y M e d i c i n e , P i t t s b u r g h The use of external transcutaneous cardiac pacing for the treatment of bradyarrhythmias was first introduced by Zoll rn 1952.

The technique was largely abandoned because o{ muscle contraction and pain, as well as the development of transvenous pacing.

Recent advances in the technology of transcutaneous pacing have made this technique more acceptable. To test the efficacy of transcutaneous pacing in prehospital cardiac arrest, we applied

coun-

l5

UAEMABSTRACTS 14THANNUALMEETING

the Paceaid{Cardiac ResuscitatorCorporationl in Datients with asystole,pulselessidioventricularrhyihm (pfVR),and complete heart block (CHB) with hemodynamic compromise. paceniaker units were c-arriedby EMS physicians and specially trained personnel in a busy urban mobile intensive care unit service. The pac-emakerwas applied as soon as possible in casesof asystole and PIVR, but was used in CHB only after drug therapy was unsuccessful. Patients were followed to determine hosplial course and outcome. Seventy-threepatients were included in the study.

Of these, 35 were asystolic, 35 had PIVR, and 3 were in CHB. Electrical capture was achievedin 63"/o(ZZlB5lof asvstolic oatients,55% {19135) of thosewith PIVR,and 100%(J/Jl of thosein C_HB.Mechanical capture (developmentof a palpablepulse)was effectedin 18% (6/35)of the asystolicgroup and tB% (O7aSf of ttre PIVR group. None of the patients with CHB demonstrated any mechanical effect of the pacing. There were no long-term suivivors. The averagetime-to-sceneo{ paramedicunits fiom receipt of dispatch was 6.75 min. The averagedelay from receipt-of-call to application, o{ the pacemaker was 19.3 min. Our data strongly suggestthat delayeduse of transcutaneouspacing does not improve the dismal survival rates of patients with bradyasystolic arrest. Further studies should be directed toward investigating survival rates in patients paced immedi ately after the onset o]

qrQ -V

Iniuries Associated with Percutaneous Placement of Transthoracic pacemakers

CG Brown,MD; GM Hutchins,MD; HT Gurley,MD; JD White,MD; EJ MacKenzie,PhD / Divrsionof EmergencyMedicine,The Ohio StateUniversity, Columbus;PathologyDepartment, Divisionof EmergencyMedicine,and The HealthServicesResearchand Development Center,The Johns HopkinsHospital,Baltimore; and Departmentof EmergencyMedicine,GeorgetownUniversity Hospital,Washington, DC Injuries associated with the percutaneousplacement o{ trans, thoracic pacemakersare poorly documented. We prospectivelv sought_todetermineany injuries associated with malplacemeni.

Six different approacheswere employed in each of 20 adult patients.examinedat autopsy.Three parasternalapproachesutilized the fifth intercostal space{SICS).One pacing wire was inserted immediately to the left of the sternum along the parasternalline (SICS-PS), one pacing wire was inserted 4.0 im to the left o{ the midsternal line (5ICS-4),and the third wire was inserted 6.0 cm from the midsternal line (5ICS-6).All parasternalneedle insertions were directed medially, dorsally, and cephalad toward the right secondcostochondraliunction at an angleof 30" to the skin.

Three suhxiphoid approacheswere insertedlhrough the left xyphocostalnotch at an angle of 30'to the skin. One pacing wiie was directed toward the right shoulder {SXRS),one-towaid the sternal notch (SXSNI,and one toward the left shoulder {SXLSI. Iniuries puncture Ltver

S|CS-PS 5 l C S - 45ICS-6SXRSSXSN SXLS 0

0

0

5

5

4

Lung puncture

0

2

4

0

0

0

Inferiorvena cava puncture

0

0

Right atrial puncture

0

0

Pulmonaryartery puncture

3

4

I Z

Intelnel mrunnnruyi vessel puncture

0

2

Right coronary artery lac.

0

0

Left anteriordesc. coronaryartery lac.

o

2

0

l6

Injuries,were assessedby autopsy,postmortem coronary angiography and stereoscopicradiography.The SICS-PSapproach reiulied in fewer iniuries when compared to all other appioiches (p < .01).

Becauseprevious work has demonstrated that the parasternal approach is more accurate than the subxiphoid approach for tranithoracic pacemakerinsertion, the 5ICS-PSrepresenrsan aDp r o a c h t h a t c o m b i n e s r e a s o n a b l ea c c u r a c y w i t h t h e l e a i t likelihood for injury in the placement of percutaneous transrnoracrcpacrngwlres.

27

Evaluation of Triage Performance During a Disaster Simulation Utilizing Four Techniques

Al Bern,MD; JR Krohmer,MD / Departmentof Emergency Medicine/School of Medicine,WrightStateUniversity and Good SamaritanHospital,Dayton,OH The educationalobjectivesof any test or exerciseare to ascertain what is_currently known and provide guidance for teaching what is not known. Four different techniques to measure the oerl formancelevels of prehospitalcareprovide's were utilized du;ing a simulation exercise.They were: 1) a real-time video recordine of the exerciseby mobile camerasand a stationary camerain i fire department tower; 2) time-flow tracking cards-forlogging15 informational items from the victims (nime, addresrl-ot-otr. number which could be correlatedwith a master listins of victim numbers, time of moulage, placement in the field, lime first seen/ time carried to the triage station, time placed in the ambulance, travel time to the receiving hospital ind the hospital,s name/ time of hospital arrival, time of first treatment, time of final treatment, time of release,time of departure,and time returned to the starting location); 3) a portable microcomputer{RadioShack TRS-80Model 100)- ro assistin decisionmakine and data management;and 4) the traditional technique of field observationby iudges.Discussedare the benefits and iimitations of each technique in assisting physicians, educators,and EMS personnel in evaluating triage performance by prehospital providers during a simulation exerclse.

28

Financial lmplications of Disaster Preparedness: A Cost Analysis of an Area.Wide Gommunity.Based Mass Gasualty/Disaster Incident

Al Bern,MD, E Galloway; JR Krohmer,MD; SR Gamm,MD; RM Roth,DO / Departmentof EmergencyMedicine/School of Medicine,WrightStateUniversity and Good SamaritanHospital, Dayton,OH The |oint Commission on Accreditation of Hospitals (ICAH) requires each accreditedhospital to have two extarnal disaster exercisesper year iStandardIII, Functional Sa{etyand Sanitation).

This standard has existed since at least 1970, with the developmental criteria identified as early as 1964(,,Checklistfor Hospital Disaster Planning," Bulletin G217, AHA, 1964).ln the pre-DRG era, the,cost of planning and implementing those disasier plans was embedded in the operational costs of the institution. It is uncertain how these costs will be reflected and reimbursed in the future. A prospective and retrospective analysis was conductedto determine the estimated costs of planning and implementing an area-wide mass casualty/disaster incident. On September20, 1983,l7 hospitalsin a multi-county areaparticipatidin a combined civilian and military (CMCHS) eiercise. O{ those participating, 11 received moulaged victims and 13 ful{illed the rew$eqtFs$t{frq}gt(lt\tcsraM.c\\s.ffi (city and township units), 4 high school buses, one bus {rom the city transportation system (RTA),one bus from an outlying county, one military bus, and 20 vehicles from the American Red Cross Disaster ServicesDivision evacuated312 moulaged victims, classified as Red, Yellow, or Green, to area hospitals. A temporary morgue was set up on site. Cost estimates were determined from documents which listed the direct and indirect costs

I

of participating for each organization (15). Cost di{ferentials bctwecn the,participating and the coordinating/resource hospitals were noted. The cost per victrm {or the reJource hospitai was approximatcly $325.91, while those for participating irospitals tnat recelved moulaged victims averaged $200. personnel and ad_ m i n i s t r a t i v e s u p p o r r t o d e v c l o p a n d i m p l e m e n t t h e e x c r c i s ea c _ counted for an additional $g9.44 pcr victim. Also discussed is the "Diamond Thcory o{ Revenue Reduction,, which was created bc_

ffH:fj

a hospital'sresponseto a rcal masscasualtydisaster

Gomputer.Assisted Decision Analysis and Data Management During the prehospital Phase of a Simulated Disaster Exercise Al Bern,MD,R McOlintock, EMT-p / Department of Emergency Medicine, Schoolof Medicine, WrightStateUniversity and Good Samaritan Hospitai; Cityof DaytonFireDepartment, bayton,OH a cs itdeer ntth e p r i m a r yr e s p o n s i _ . J . n. u g r Tn r a s s . c a s u a l t y / d i si n ,Dlllty

number o{ victims must be mouiaged. During an area-wide disastcr excrcise Mouiage Instructronal Victim Cards, physician and mcdical assistant coachcs, and an assembly iine approach were used to successfully moulagc 312 victims in less than 3/z h. The key paramcters identified on the cards are the followrng: an inju_ rylseverity classi{rcation (Red, yellow, Green, Black); a victim diagnosis (including vital signs and a detailed identification of a1l injuries); a situational overview describing the cause and circumstances of each iniury; a task-oriented moulage instructron section; an identification space {or the victim,s nimc and diaenostic number; the nurnber of simiiar injuries in thc group; and"placemcnt instructions on a predetermined sectional grid map.

DO -J

oI tne lnrtral respondcrs is to assess the numbcr and sever, rty oi victims at thc scene. Their second responsibility is to determrnc thc resourccs available for trcating and cvacuating thc victims to dcfinitivc carc. Limited knowledge of thc untque rc_ sources of thc definitive care hospitals and liiritcd transpoitation make it di{ficult for rescue personnel to effcctivcly cvacuate the scr'ne A scries of computer programs {or a Radio Shack TRS_SO Modcl 100 Portable Computer werc developcd to assrst in the complcx ilccision making and data managcmcnt tasks of the pro_ vlders. Ih(.se programs wcre evaluated during a simulatcd mass casualty/disaster exercise involving 312 mou'iagc<l victims. The oqe,rat,orof this por.tabie microcomputcr intcractcd dynamically wlth the system and receivcd information about squad status (un_ available, en route to scenc/ crcw_bcing used on sccne, waitrng for patients, or en route to hospital); and hospital status (name of hospital, maximum number of patients it can rcccivc, total numbers of patients_already received, and number of paticnts in cach category of Red, Yellov,l Green, or Black). Thc squacl status and nospltal status were automatically updated whcn thc operaror en_ tered that a new victim had been pliced in an ambulancc with a destination hospital. A beep alcrted the operator if th" .c""l"i"l hospltal had already received its maximum number of patients.

Each victim record contained a victim identi{ication number, a M,ETJAG number, a tnage color designation, a destination hospi_ tal/ the squad and ambulance transporting, and the time logged o.nto the systcm. Discussed are thc benefits and limitationi of the Model 100 Portable Computer during a disastei excrcisc.

30

Design and Utilization of a Moulage lnstructional Victim Gard in Simu]ated Disaster Exercises

JR Krohmer, MD; Al Bern, MD / Department of Emergency M e d i c i n e ,S c h o o l o f M e d i c i n e , W r i g h t S t a t e U n i v e r s i t / a n d G o o d S a m a r i t a nH o s p i t a l , D a y t o n , O H "The Role o{ the Emergency physician in Mass Casualty/Disas_ ter Management," an ACEp position paper, was published in the November 1976 issue oI Annals of Em&gency \v/ledicjne.In that paper the College states, ,,Th_eem.rg"icy physician, through trarnrnâ&#x201A;Ź/ pracice, and day-to-day involvemeirt with large nuir_ bers ot undillerentiated patients, 1ras developed a responsibility and untque role in mass casualty/disaster management . . .,,Mosi emergency physicians will not be called on {requently to utilize the_ski11s needed for a mass casualty disaster; however, those skiils must be maintained. Educatois have demonstratecl that two,effectivetechnrques{or mainraining and acquiring thcse s k r l l s a r e p a r t i c i p a t i o n i n s i m u l a t i o n c x e r c i s e sa n d - r o l c p l a y i n g .

Moulage is a technique whereby an uninjured individu;l is "made up" to apperr injured or sick in some predefined way. The current practice.of completing the instruction and moulage pro_ cess tor each individual be{ore the next person enters the p"roiess can cause long delays and technical problems when a large

Disaster Medicat Direction: A plan ?{ ryI RH Bade, MD; M Eisner,MD; B O,Rourke/ EmergencyMedical ServicesAgency Countyof Orange,SantaAna; Em"rgency Department,University of California, lrvineMedicalCenter.

Orange.CA Tiaditional medical curricula do not preparephystcransto con_ trol ficld medical care of .multiplc viciims. Many communities havc.disasterplans that relcgateirrtical medical decisionmaking and ficld stabrlization of victims to nonphysicians.Our plan foi disastermcdical directior-rborrows Irom proven successfulmeth_ ods that employ traincd, cxpcriencedpiysicians to direct and providc carc at thc scenc of a multiple-caiualty incidcnt. These physicians arc drawn from the existing pool of specialistsin re_ suscitation and stabilization,allowing a relativelybrief sessionof fornal traininS Qa h). A curriculuri outline and standardized ccluipment list are prescnted,as is thc generalMedevacI and II o{ prioritized stabilization and &acuation of mass casu_ :fi::-

32

Hearing Loss in EMS Firefighters

P ^ EP e p e , M D ; J J e r g e r , P h D ; R M i l l e r ,M D ; S J e r g e r , M S / City of Houston Emergency Medical Services, Fir6 and Health Departments; Departments of Medicine and Otorhinolaryngology and CommunicativeSciences, Baylor College of Medicine, llouston.

Fircfightcrs arc typically exposcd to relatively high lcvels of noisc when per{orrning thcir job. When emergency iredrcal scr_ vices are rncludcd as a function o{ a fire dcpirtment, noise ex_ posure (particularly siren noisc) increases su6stantiallv Our our_ posc was to determinc the prevalencc of hearrng loss among EMS firefighters and to assess.the relationship beti,een hearing loss and duration- of job-relatcd noise exposure. We tested the hJaring of 192 malc fircfighters from the Houston Fire Department, two_ thirds of whom had been regularly assigned to EMS (ambuiance) duty. This service responds to approxitately 90,000 EMS calls per year. Each{irefighter,(average age 3l +-7, range 2l_59) was screcned fur.other possible sources, past and p..r.it, oI hearing loss and rcceivcd a physical examinatron of the ears. Audiometrii testing was conducted using 2 criteria for hearing loss: l) the cri_ tcrion of the American Academy o{ Otolaryngjogy (Caa6), in

tonehearingthreshhoid y^!"! t!: al/crlseof_pure tii,ei, [Hii1 nt a1di,000 Hz e""eeds25 decibetshearinglevel :93,,-l,,000,.2,p0Q

{dBHL);.and 2) a high-frequency criterion (Csp) in which thi average of the HTt at 3,00O, 4,000, and 6,000 Hi'exceeds 25 dBHL, a frtqucncy region in which the cffects of noise exposure first ap_ pear..In these fire{ighters thc prevalence of significant hearing loss rn at least onc ear was 5% using the Cnno and was 32"/o u s i n g r h e C s p _ T h e d e g r e e o t h e a r i n g -l o s s w a s ' r c l a t e d r o b o r h lengrlr oi _employmcnt and chronological age, but not to other sources nolg_gxgosure The prevalence Estimates of hearing 9f l o s s r n r h e s e .E M S f i r e f i g h t e r s e x c e e d t h e e x p e c t a t i o n f o r n o n l noise-exposed men of this young age group. Consideration should be given to job-related noise exposure in an EMS system and, when appropriate, preventive -ersr.rr., should be iniiiated.

l7

I

UAEIVABSTRACTS 1 4 T HA N N U A LM E E T I N G

41 1, rlrt

Insulin and Glucose Levels During GPR in the Ganine Model

GB Martin,MD; JF O'Brien,MD, R Best,MD; J Goldman,MD, MD' FACEP/ PhD: RM Nowak.MD, FACEP;MC Tomlanovich, Departmentof EmergencyMedicine,HenryFord Hospital,Detroit Cardiopulmonary arest and resuscitationproducesa tremendous physiological stress with resultant biochemical derangements. Previous research has shown that infusion of glucose, insulin, and potassium improves myocardial function during ischemia. The purpose of this investigation was to determine insulin and gluCoselevels during cardiopulmonaryarrest in the canine model. Baseline insulin and glucose levels were obtained {rom an ascendingaortic arch catheter in 6 adult mongrel dogs.

Ventriculariibrillation was induced by an electrical stimulus and ventilation was terminated. After 5 min o{ {ibrillation, CPR was initiated using external, mechanical CPR and a continuous epinephrine in{uJion at 5 pglkg/min. Serum insulin and glucoselevels were repeated15 min a{ter beginning CPR. Mean serum glucose15 min after initiation of resuscitation(305 * 114mg/dl) was signi{icantly increasedfrom prearrestlevels {124 + 29 mg/ dL. P <.011. Mean serum insulin 15 min after initiation of resuscitation {11.3* 3.3 pU/mL) was significantly decreasedcomp a r e d t o p r e a r r e s tl e v e l s ( 1 6 . 2 t 6 . 0 p r , U / m l ,P < . 0 5 ) . E p i nephrine, because of its cr-sympatheticactivity/ suppresses insulin releasefrom the pancreasand inhibits the net effect of insulin at the insulin receptor.During ischemia,the myocardium becomesprimarily dependenton glucose as a source of energy.

Inappropriatelylow insulin levels during CPR may adverselyaffecl-an-alreadycompromisedmyocardial glucosemetabolism' Further investigationis neededto determinethe utility of insulin infusion during CPR.

4t A rrrf

Histamine Blockers in the Treatment of Shock Hyperglycemia in the Rat

RVWDimlich,PhD / Divisionof EmergencyMedicine,University of CincinnatiMedicalCenter,Cincinnati Long-term survival in a variety of anoxic-ischemicstates has been shown to be inverselv related to shock-inducedhyperglycemia. Vasoactivemediators including histamine have been implicated in the etiology oi hyperglycemia in shock, and histamine blockers in{luence survival in shock. This study was designed to determine if endogenoushistamine a{iects blood slucose levels and if histamine-l lH-ll and histamine-2 {H-2) 6lockers alter this responseand thus play a role in survival o{ these states. Thirty-three non-{astedmale Sprague-Dawleyrats that had been anesthetizedwith IP iniections of urethane were iniected {I! femoral) with histamine (10 mg/kg) 5 min after pretreatment with Ringer's solution (control), diphenhydramine (l mg/kg) (H-1 blocker),metiamide (l mg/kg) (H-2 blocker),or,a combination of these blockers. Mean arterial pressure(carotid), blood glucose,and hepatic glycogen were measured'Within 30 min hiitamine evokeda significant increasein blood glucoseand decreasein hepatic glycogen.As expected,blood pressurewas reduced significantly in rats treated with histamine. Rats treated with the H-2 blocker metiamide did not show a hypotensiveresponseto histamine but did developan increasein blood glucose.

These data suggestthat the hypotension itself was not causing the hyperglycemic event. Use of the H-l blocker diphenhvdramine induced a depressedglycemic state. Previousstudies have demonstratedthat H-l blockers plomote survival in shock' Because hyperglycemia is incompatible with long-term survival, H-l {nor H-2) blockers appearto be beneficial to survival by virtue of their antiglycemic property.The results of this study suggest the control of glycemia as one mechanism by which histamine blockers Dromote survival in shock.

GB Martin,MD: DL Carden,MD; RM Nowak,MD, FACEP; MD, FACEP/ Departmentof Emergency MC Tomlanovich, Medicine,HenryFord Hospital,Detroit Mixed venousoxygen saturation (svO2)is a valuableparameter used in monitoring critically ill patients,for it servesas an index of the adequacy of the oxygen delivery system. Mixed venous oxygen saturation, as reflected by the easily obtainable central venous oxygen saturation (cvo2),may prove useful during resuscitation as an indicator of both the adequacyof varying CPR regi mens and the efficacy of pharmacologic interuentions. The purpose of this study was to investigate the reiationship between svO2 and cvO2 and their clinical usefulnessduring CPR. SwanGanZ and central venous catheters were placed in 20 mongrel doss. Ventricular {ibrillation was then induced and, after varying predetermineddowntimes {rom 5 min to 60 min, thoracotomy was performed and open chest bimanual cardiac massagewas startad.Mixed venousand central venousblood gaseswere drawn every 5 min during a 30-min period of CPR. The correlation between svO2 and cvO2 was 0.8719(P < .001)pdor to arrest/but deterioratedat all times during CPR with a rangefrom 0.1589iP : .5421to0.5781lP : .O24).The correlationsbetweenchangesin svO2 and cvO2 during CPR were not consistently significant, with a ranee of r values from 0.0582 (P = .831)to 0.6539 {P = .004).Although statistically significant at times/ the correlation between svO2 and cvO2 during CPR is not consistently high enoush to etrabl" the routine substitution of cvO2 for svO2 in assesir.rgthe oxygen delivery system.

of Central Venous and Arterial pH and PGO" During Open Ghest 36 Gomparison GPR in the Ganine Model GB Martin.MD: DL Carden,MD; RM Nowak,MD, FACEP; MD, FACEP/ Departmentof Emergency MC Tomlanovich, Medicine,HenryFord Hospital,Detroit The reliability of central venous gasesas a substitute for arterial blood gasesin assessingacid basestatus has not beenadequately investigated under conditions of CPR. Arterial blood gar.s "re difficult to obtain during CPR in human beings,and the possibility of their being venousis {requently raised.Centralvenous cathetersare quickiy and easily placed during resuscitation and may representa reliable sourcefor repeatedblood gas measurements during CPR. Femoral arterial and central venous catheterswere placedin 24 mongrel dogsand ventricular fibrilla' tion was electrically induced.After varying predetermineddowntimes from 5 to 50 min, open chest CPR was begun and arterial and central venous blood gaseswere simultaneouslydrawn every 5 min during a 30-min period. Arterial pH (pHa)was consistently higher than central venous pH {pHcv} by an averageof 0.048 units. A significant correlation existed between the pHa and pHcv at all times during CPR, with overall r : .9771{P < .00011. the difference between central venous PCO2 (PcvCO2Jand ar' terial PCO2 (PaCO2)was 5.17 mm Hg prior to cardiacarrest,but increased300% to a mean o{ 15.51mm Hg during CPR. Correction of pHcv using conventionalmethods to accountfor this respiratory component decreasedthe correlation between pHa and pHcv to r : .6905. The ability of pHcv to substitute {or pHa showeda sensitivity oI 10O%when pHa oI 7.2 wasusedasa criterion for treatment. In this model, pHcv is a sensitiveindicatorof pHa, and may be used to guide bicarbonate therapy.The increased DcvCOzduring CPR probably results {rom the marked tissuelactic acid oroduction and subsequentshift of the bicarbonatebuf{er into free carbon dioxide.

37

of Central Venous and Mixed Venous Oxygen Saturation During Open 35 Comparison Ghest GPR in the Ganine Model

Fluid Loading with Whole Blood Ver$us Ringer's Solution During GPR in Dogs: Effect on Oxygen Uptake and Regional Blood Flow

WD Voorhees,lll, PhD; C Kougias;PMW Schmitz;SH Ralston, West Center,PurdueUniversity, PhD / BiomedicalEngineering Lafayette,lN

18

PvO2 and PCWP are the most sensitive indicators of intravascular volume changes during graded hemorrhage in the animal model.

We examrned the effect of moderate {luid loading during clectrically induced ventricular fibrillation (VF) and CPR in 18 dogs (12 26 kg). Oxygen uptake was measured with a modified recording spiromctcr. Blood flows were measured with tracer mrcrospheris (15 + 0.9p dia) at 5, 13, and 20 min a{ter the initiation of VF and CPR. After 10 min of CPR, 9 dogs receivcd a rapid in{usion (11 ml/kg IV) of whole blood and 9 dogs received Rrngcr's.

Differcnces between thc blood- and the Ringer's-treated groups were not signi{icant for any of the measurcd variablcs. Howcver, some ef{ccts of fluid loading were signi{icant. Aftcr fluid loading, cardiac output (CO) increased 34% lat 13 min) and then decrcased (at 20 min) to 84o/oof the control (5 min) valuc. Despite the increasein CQ le{t ventricular (LV) periusior-r lcll to 74'1, of control after fluid loading, while brain flow dccreascd to 65o1,of control.

At 20 min (10 min aiter fluid loading), CO anci brain flow returned to near control value, while LV flow remained low. Oxygen uptake was not significantly a{fectcd by fluid loading with cithcr whole blood or Rrnger's.

LV Time CO (min) (mL/min/kg) (mL/min/g)

Brain (mL/mln/g)

39

PA Maningas, MD; KE Friedl, PhD; SC Dronen, MD / Departments o f E m e r g e n c y M e d i c i n e a n d C l i n i c a l l n v e s t i g a t i o n ,M a d i g a n A r m y Medica Center, Tacoma, WA Rccent intcrest has developed about the clinical application of transcutancous oxygen monitoring in thc traumatized patient.

While orior studies l-ravcdemonstrated a reduction in transcutancous vaiues during hemorrhagic shock, the effcct of hyperoxia on transcutar-reous valucs during hemorrhage has not bcen str-rdicd. Tl-ris study was undcrtaken to evaluate the influence o{ oxygcn t1]erapy on transcutancous mcasurefiIcnts during graded hcmorrl-rage. Fifteet't mongrel dogs wcre bled and reinfused 40% of tl-rcir calculatcd intravascular volume over 90 min (35 cclkg).

Or-rcgroup (n - 9) was blcd whilc spontaneously breathing room air. Tlrc sccond group (r'r : 6) undcrwent identicai hemorrhage, but was maintaincd or-ran FiO2 of 40% durir-rg thc eutirc experimcnt. Thcro was r-ro significant diffcrcnce bctween thc 2 groups ir-rrcgard to cardiac indcx, mixcd venous oxygcn tension and scrun'r lactzrtcs prror to hcmorrhage, aftcr hernorrhage, and aftcr rcinfusion of shctl blood. Thc PaO2 and P1.O2 of anlmals maintaincd on ar-rFiO2 of 40(2, wcre highcr than thosc on room alr ln c z r c ho f t h c 3 p c r i o d s { 1 ' < . 0 1 ) . T h c P , . O 2 o f t h c o x y g e n - t r c a t e d grolrp, though lighcr, foliowcd closcly thc changcs that occurrcd ii-r th" .u,rt-t-t:rir anirlals lr : .76). Thcrc was no signi{lcant diffcrcncc bctwccn groups ir-r thc pcrccntagc change in P,.O2 attcr hcmorrh:rgc or rcinfusion. Thc transcutancous oxygt'n index (P,.O2/PaO2) was significantiy lower in thc oxygcn-trcatcd group p . i i , r i o h c m o r r h a g c a n d a f t c r r c i n f u s i o n 1 P < . 0 0 1 ) .W c c o n c l u d c that transcutancous oxygcn valucs are elevatcd as a conscquencc o{ l-rypcroxia. Thcsc valucs rcmain significantly higher, though follow closclv thc trcnd of thosc lcvels obtaincd at room air during gradcd hcmorrhagc. Thus thc use of oxygen as adiunctivc thcrapy for thc traumatrzcd paticnt may alter thc intcrpretation of tl-rc initiai transcutaneous oxygen rreasurcment, howcver, it docs r.rot prccludc tl-rc use of this device as a trcnd monitor during hcmorrhagc.

Uptake (mL/mln/kg)

0 . 6 5 + 0 0 6 0 . 7 5* 0 . 0 8 4 . 1 8+ 0 2 9 5 6 5 . 8+ 5 . 0 13 B B . 4t 8 . 6 - 0 . 4 8 t 0 . 0 8 0 . 4 9 t 0 0 6 . 4 2 9 + 0 . 2 7 20 5 5 . 1+ 5 . 0 - 0 5 1 + 0 . 0 8 0 . 7 3 : t 0 . 1 0 4 4 6 + 0 . 3 2 .lndicatessrgnlficant fromcontrol(5 min)value(o<0 01) difference Thc changcs in organ pcr{usion can bc cxplainccl in p:rrt by thc concurrcnt changcs in blood prcsslrrcs (BP). Prcvious stlrdics havc shown that tl-relevcl of ccntral :rrtcrial diastolic prcsslrrc (CADP) and thc ccntral artcnovcnous diastolic prcssurc diffcrcncc (CAVDP) corrclatc witl-r vital organ perfusion. h'r this stucly, ccntral venous diastolic BP incrcascd significantly (9.2 to 13.9 rnm Hg) aftcr fluid 1oad. Howcvcr, CADP did not risc proportionatcly (31.9 to 33.9 rnrn Hg) ancl thc CAVDP actuaily dccrcascd. Althougl-r fluid loading during CPR improvcs CO, flow to thc hcart and brain dccrcascs. Furthcr, thcrc is no inctcasc in oxygcn consumpt i o n , i n d i c a t i r - r gt h a t f l u i d l o a d i n g c l o c s n o t i m p r o v c m c t a b o l i c statlls.

38

Effect of Hyperoxia on Transcutaneous Oxygen Measurements During Graded Hemorrhage

Gomparison of Cardiorespiratory' Biochemical, and Transcutaneous Parameters During Graded Hemorrhage

Model for Anaphylactic A Hemodynamic A ll -1, Shock W G B a r s a n , M D , J B H e d g e s , M D , F A C E P ;S S y v e r u d , M D ; W C D a l s e y , M D / D i v i s i o n o f E m e r g e n c y M e d i c i n e , U n i v e r s i t yo f C i n c i n n a t iM e d i c a l C e n t e r ,C i n c i n n a t i The treatment of cardiovascular collapse in anaphylactic shock is largely cmpiric and not wcll understood. A simple animal model was developed to evaluatc the hemodynamic altcrations in anaphylaxis. This modcl provides a method for investigating ncw treitmcrrt modalitics. Six adult New Zealand whitc rabbits of both sexes wcre studicd. All animals weighcd 3.8 to 5.3 kg. Sensitization was accomplished with a 2-cc subcutaneous dose ol irorsc serum followed in 2 days with a 2-cc intravenous dosc. At lcast 14 days elapsed a{ter the intravenous dose before a 1.0-cc challcnge dosc of horse scrum was givcn. On the day of the challcngc dose, a fcmoral artcrial cathetcr, arterial tcmperature probe, and right atrial cathcter were placed under mcthoxyflurane anesthesia vra nosecone. The temperature probe was posrtioned in the aortic arch. The methoxy{lurane was discontinued and the only sedation givcn during thc shocl< phase was intravenous diazepam (0.1-0.5 mg/kg). At least 30 min after thc methoxy{lurane was drscontinued, the chailenge dose of horse serum was given through the right atrial cathetcr. Before and durrng the shock phase, cardrac rhythm, arterial pressure, and intravascular temperature were continuously monitored. Cardiac outputs {CO) were performed by a thermal dilution tcchnique using 0.8 cc of room temperature saline injectate through the right atrlal catheter. Tem-

PA Maningas,MD; SC Dronen, MD; KE Fried , PhD / Departments o f E m e r g e n c y M e d i c i n e a n d C l i n i c a l I n v e s t i g a t i o n ,M a d i g a n A r m y Medical Centet Tacoma, WA Numerous parametcrs have becn suggested to aid in thc diagnosis, management, and prognosis of paticnts in hcmorrhagic shock. Among these are central venous pressure (CVP), pulmonary capiliary wcdge pressure (PCWP), mixed venous oxygen tension (PvO2), serum lactate, basc deficit, and transcutaneous oxygen tension (P."O2). This study was undertal<en to compare thc sensitrvrty of these parameters in detecting graded hcmorrhage.

Nine dogs were bled 4O"/" oI their calculated intravascular volume over 30 min (35 cclkg). Therc were 5 sampling periods (H1H5) at 6-min intcrvals corresponding to an 87o reduction in intravascular volume during each period. A fall in PvO2 and PCWP preceded a significant change in all other parameters. This occurred after thc initial withdrawal period (P < .001 and P < .005, respectively). This was followed by a reduction in CVP and an increase in serum lactate alter HZ lP <.001 and P < .01, respectively). P,"O2 fell after H3 (P < .051 and base dcficit increascd a{ter H4 (P < .005). Four dogs maintained mean arterial pressures greater than 70 mm Hg after hemorrhagc. Six dogs had abnormally elevated base deficits during the control period desprte normal lactate levels. TWo dogs had normal lactate levels after hemorrhage.There was a poor correlation between CVP and PCWP ( r = .411,and only a fair correlation between base deficit and serum lactate (r - .52). We conclude that of the parameters measured,

l9

UAEMABSTRACTS 1 4 T HA N N U A LM E E T I N G

Derature de{lection o{ the aortic probe was recorded and cardiac *rt calculated. Three control CO were determined' After ;;i;;, eivine the challengedose,CO was measuredat 3, 5, 10,15,25,35, Zs. ,f,a 60 min. A"ll 6 animals showeda signi{icant (P < '01) faII in CO, cardiac index {Cl), and blood pressure(nn) within 3 min "ft"t ld-mlttering the challengedose.The fali.in.cardiac index was 50% o, gr"rt.i in all animils. No animais died as a resuit of shock. All aiimals showedspontaneousrecoveryto baselineval""r "t CO, CI, and BP by 50 min. By avoiding anesthesia,which can depressthe cardiovascularsystem,the baselinevalues of CQ Ci, ,;a BP are essentially unchanged{rom unanesthetizedlabbits. This model is reproducibleand relatively inexpensive,yet ^ifotdr good hemodynamic parameterswith which one can evaiuate new tTeatmentPlocedures.

Medical Reliability of Prehospital a I Advanced Gardiac Life SuPPort JB Peacock,MD; M Wainscott,MD; V Blackwell,RN / Department ol Surgery,Divisionof Traumaand EmergencyMedicine,Texas Schoolof Medicine,El Paso,TX Tech University Recordsof 210 consecutivepatients receivingprehospitalACLS for dvsrhvthmias associatedwith clinical cardiac arrest were re," determine the following: 1) accuracy of diagnosis-of ;;;a pi..."ti.tg rhythm by both the paramedic in the field and the iledical Jo"tiol physician at the telemetry base station, and 2) *h"th"t treatme;t ienderedwas appropriate.Physiciansinvolved were residents or faculty members in emergencymedicine previously certified in ACLS (AHA), and both physicians and para-"Ji". had received speciiic instruction in iocal EMS protocol' ihe initial rhythm wis misinterpreted by,the paramedic in 34 patients 116%)and by the medical control physician in 18 paiients {q%). In 14 patients (7%) both paramedic and physici:ns ,nisint.tpt.t.d the initial rhythm. Tieatment errovsoccurred in failure qip"ti."tt 144%).A total of 18 .t.ott (13%)resultedfrom (5%), from failure to to istablish an intravenous line; l0 errors ,29%)wete medication securea controlled aiway; and 60 errors eiiot.. rhe latter resultei from failure to adhere to established protocol (sequenceerrors, use of nonprotocol drugs)and Jrom .ttott. We conclude that errori in management-of preil.i"* hospiLl cardiac arrest victims in our EMS system result most often from errots in specific therapy rather than from {ailure to identify the precipitating dysrhythmia. Careful, ongoing joint review oi prehospital advinced cardiac care by both medical control physlcians'and paramedicsmay reduce the magnitude of the problem. ^ It

on Urban Prehospital Effect of Telemetry A t)t'f i Gardiac Gare CG Cayten,MD, MPH;J Oler,PhD; K Walker,RN; J Murphy,PhD; for Traumaand MD; R Staroscik,MD / Instrtute J Morganroth, EmergincyCare,New YorkMedicalCollege,Valhalla;Drexel Departmentof Surgery,Jefferson Philadelphia; University, EmergencyServices UniversityHospital,Philadelphia; of Pennsylvania, Department,Hospitalof the University of Medlcineand Pharmacology' Departments Philadelphia; phia lnstitute,Philadel LikoffCardiovascular HahnemannUniversity, A 3-year controlled trial o{ the use of telemetry in the prehospital care of cardiacpatients was conductedin a major metrop"ii',"" area. Five o{ the tO paramedic squadsin the city- used ielemetry, while the other 5 squadsdid not. The e{fect of telemetry on the following was studied: 1) paramedics'.retentionot arrhvthmia recognition skills; 2) paramedics'abilities to identily ii{.-tht.atettln"garrhythmias irrthe field; 3) accuracy-ofparame<lics'interpr"etationsof ECGs as comparedto that of basestatron physicians; 4) the difficulty in interpreting an ECG; 5) ^-o"'"t'ot time spent by paramedicsin the fieid; 6) rates oI survival ol ventricular fibrillation (VF) patients; and 7J attitudes of the paramedics. Telemetry did not a{{ect th.e abilities of paramedics to read ECGs in either test or field situations' Using

matched ECGs, readingsby base station physicians were more : 76) No accuratethan were thoie by paramedicslP : '002, n base strips and {ield between found signi{icant dif{erence was with reg"td to degreeof di{ficulty in interpreting the arrhythmias (P : .85, n : 115).Paramedicswho used telemetry spent more time in tire field with their patients than did-paramedicswithout telemetry (P : .015).We found no statistically significant e{{ect of telemetry on rate of survival of VF patients.Ninety-six percent of the paramedics{n : 50) who used,telemetry tho-ughtthat it did noihelp them to savelives. They thought that telemetry was -ost helpi"l in treating patients with ]reart block' Technical ptobt"t"t *ittt telemetr/equipment precludedits extensivefield use. The effects of these pioblems on the study results are discussed.{Fundedby the Nitional Center for Health ServicesResearch,i'ublic Health Services,Grant #1 R18-HS03555' Grant supportedin part by the City of PhiladetphiaDepartment o{ Public ifealth, Dlvision o{ EmergencyMedical Services)

43

Evaluation of Paramedics' Glinical Performance and Gompetence: The State of the Art

MH Erder,PhO,B Cheney,MA; SJ Davidson,MD; L Pethick,MD; HealthManagementCorporation; DG Faris,MD / Philadelphia Divisionof EmergencyMedicine,The MedicalCollegeof Departmentof EmergencyHealthServices Pennsylvania; Departmentof PublicHealth,Philadelpha Philadelphia The ability to evaluatesystematicallythe clinical performance "nd "o-p.t".rce of individual paramedics is.an important and ,r."".trty part of EMS management.While this evaluation is a continuing task for system minagers and-EMS medical directors decisions,it is usually done on an ad-hocbasis' makine pe"rsonnel A cons"istentand comprehensivedata basecould assistmanagers and evaluation of paramedicpersonnel ln addi i" -""r*"-."t tion, anaiysisof the data could help direct paramedicmonitoring and'training programsby identifying proll-en-rareas'It could also be used to 6u"l,rlt. specificprotocols and help isoiate the contri bution of prehospitalcare to patient outcome..Despiteits potential use{ulnesst; EMS system operations and to the quality of care,there is little researchand developmentactivity in the area oi oaramedic evaluation.Included in the discussionare the following, l) A survey of the state o{ the art of paramedicevaluation in 10 maior cities whose paramedicservicesare proas obs-erved vided by city fire departments.The results of the surveyarepresentedand the mosiadvanced and innovative aspectsof the evai' ,rriion .ytt.-s are discussed; 2-)A proposal for a conceptual for the evaluation of parimedic performance The tr"-.*oit data system required to implement this paramedicevaluationts presentedand iis possibleusesare discussed.

A Proposed Data Base for Evaluation of A A Itrl ALS Gare MCP; MH Erder,PhD, R Cheney,MA; M Woll,MS; J Silberner, HealthManageD Appleby,PA-C;DG Faris,MD / Philadelphia and Departmentof EmergencyHealthServices' ment'Corporation Departmentof PubllcHealth'Philadelphia Philadelphia Medical evaluation oi the impact of advancedlife supporton practical problems' Datient 'oui.o-. care poses dilficult conceptual and variablesof prehospitalALS .are are hard to defineand -.r..rr.. In addition tLe elfiiacy ol prehospitaiALS caredepends to a large extent on the performanceof EMS system components such aJdispatching,parimedics, and medical-command'Thus to identify how the ."ytl"-'t performancecould-be.improved,it is necessaryto evaluate the performanceof each ot Its parts s.eparately. The evaluation of prehospital care requiresa comp(ehensive data system that includes,in addition to-the informationtraditionally iecordedon the ambulance{orm, data generatedduring on-line medical command and data that will account fol the quality of paramedic performance. Relatively lit-tle ef{ort has b...r -u.tt"d in the diveiopment and use of such data, which

20

will account for the performance o{ prehospital system components. The Philadelp[ia EMS system has developed a data base and data collection instruments that are particularly useful for evaluating the effectiveness of prehospital ALS,care. In addition to the daia collected on the ambulance form, data are collected {rom the base station hospitals providing on-line medtcal command and from a medical-review process in which all cases for which ALS care was given or indicated are reviewed by the system's medical staf{. The data collected are used to create two major data bases, one for evaluation of patient care and one for paramedic evaluation. These two data bases setve as a basis {or evaluation of all system activities. Because the two data bases are linked they can be used {or creation o{ additional data sets, which can be used to evaluate such changes in system policies as medical protocols, medical ecluipment, or patient routing policies Prescnied is the prehospitai ALS data 6ase and thc data collection .Ih. dria sets constructed, their structure, ar-rdtheir instluments. for variety o{ administrative, planning, and evaluation tasks use a

as to agc, prior diagnosis of AAA, associated cardiovascular disease, di raiio.t of symptoms {presence of abdominal and back pain, syncope), prehospital and emergency department systolic Llood pressure (BP] measurements, application of antishock trousers (MAST suit), fluid resuscitation, and paramedic transport times. The overall mortality of patients undergoing emergency ancurysmorrhaphy was 64.7%. As shown below, BP < 60 torr in the field or in the emcrgency department was found to be a critical determinant o{ mortality.

Systolic BloodPressure(torr) <60 >60

(No. Dead/TotalPts) EmergencyDepartment

Prehospital 10/10 7t15 P <.01

11t12 11t22 P <.05

All patients with an initial systolic BP < 60 torr died despite paramedic Iluid resuscitation laveraging 1,000 cc), MAST suit appiication (9/10 paticnts), and prchospital transport times less than +5 -it-r. Prehoipital and emergency department fluid resuscitation rcsulted in BB%, of patients reaching thc operating room with a BP ) (r0 torr. Preoperative cardiovascular resuscitation has an impact on the numbcr of patients reaching the operating room for clcfinitivc treatment. Improvement in patient survival rcquircs prompt operative intervention based on patient sympt,r-ntology and clinical signs, mrnimizing prehospital and cmergcncy dcpartlucnt resuscitation time, and avoidance o{ ancillary diagnostic proccdures.

are demonstrated.

with 1|.tr^ A Prehospital Paramedic Experience

Poisonlng -V K M H a r g a r t e n , M D ; I ' A S t u e v e n , M D ; J D a r i n , M D / I n s t i t u t eo f T r a u m aa n d E m e r g e n c y M e d i c i n e , M e d i c a l C o l l e g e o f W i s c o n s i n , and Section of Emergency Medicine, Mount Sinai Medical Center, lvlilwaukee The managemcnt of prehospital cardiac arrest patlcn-ts and trauma patients has bccn revicwed cxtensively. To datc, there is limited literature reviewing prehospital care of suspectcd poisoned patients. Wc revicwed all patients who prescnted to a regional paramcdic systcm and were transported to-a regional mediial center from fanuary to December l9B2 with a dragnosis of suspected poisoning or overdosc. Of thesc 126 paticnts, with a tn.i.r rg. of eO yr ind a range of I to 76 yr, 47.67" were rnale. A total of 66.4o1,oI patients had an altcrcd levcl of consciousncss, and 27.2u1,wcre "omatos". Of those with documented pupil examinations, 17.7o/uwerc dilated and 14.2"k werc constricted. Four patients presented in cardiorespiratory arrest. Of the remainder, 48.4u/" *rre hypertensive, 8.8% were hypotensive, 49.67" were tachycardic, and 37.3% wcre tachypneic. Advanced care givcn included initiation of IVs in 53% and endotracheal intubation in werc intubated. Medicall.g%. OI the comatose patients 40T" 1.20.7%l and D.6 (5.6%) Of tions administered included Narcan the comatose patients, only 599% received IV Narcan and 13.3% received D.6. A total oI 20.3% of patients improved subiectivcly prior to arrival in an emelgency department. There was a significant improvement (P < .01) in patients receiving Narcan versus no medications. Of the 126 patients, 1.6% died. Of the patients reviewed above, a significant number (? < .00011who were candidates for Narcan, D5e, and intubation did not receive this intervention. This review o{ a paramedic system's experience with poisoning suggests that a potential for morbidity and mortality ixists. Cparimedic system has a potential impact in the initial -rn"gemint of these patients, and that roie must be emphasized more srrongry.

.^ a a] I

Resuscitation and Transfer of Trauma Patients: A Prospective Reevaluation

48

Therapeutic Intervention Scoring As a Measure of Need for HelicoPter Emergency Medical Services

DF Danzl, MD; Sl Ackerman, IVD; C Anderson; DM Thomas, MD; LM Flint, MD / Departments of Emergency lVedicine and Surgery, U n i v e r s i t yo f L o u i s v i l l eS c h o o l o f M e d i c i n e , L o u i s v i l l e Aggressive, adcquate resuscitation and technique per{ormance on tiaurna patients decreases morbidity and mortality. An earlier prospcctivt study of 100 consecutive patients- transferred to our Iron-" ccnter in 1980 from 18 emergency departments documcnted noncompliance with accepted standards of the American Collegc o{ Emerycncy Physicians and the American College of Surgc"onsCommittee on T?auma in more than 70% of cases. We now report a prospective study of 100 consecutive patients transportedio our Category I trauma center in 1983. In all cases, iniiial treatment was by a physician in an emergency dcpartmcnt' Thc stuily group includes patients from 23 hospitals, 5 more than ln the previoui study. Prior notification of trans{er was received in 93 patients, in contrast to 43 in the earlier study' Thirty-nine *"r" i.ontpottcd by helicopter versus none previously. Noncompliance with accepted standards for patients with multisystem (66), CNS (60), chest (32), or orthopedic (37J trauma averaged 27'1,. Factors potentially responsible for- the improvement iiclude the following: a marked increase in the number of residency-trarned {19) and career emergency physicians practicing in the ieierring hospitals, availability o{ rotorcralt aeromedical transport by trainid personnel, and implementation of regional teachlng programs.

u,| lF Prehospital Factors Influencing Mortality of Ruptured Abdominal Aortic Aneurysm +9 MD; MD;BMThompson, tll,MD;C Aprahamian, PFTroiano, of MD/ Section MD;DF Bandyk, MD;JF Tucker, JRMateer, of Vascular andSection Medicine andEmergency Trauma lvlilwaukee of Wisconsin; lVedical College Surgery,

KJ Rhee,MD; RE Burney,MD; JR Mackenzie'MD; J Conley,RN; RN; J Flora,PhD / Sectionof Emergency K LaGreca-Reibling, of Michigan,Ann Services,Departmentof Surgery,University Arbor An objective measureis neededto evaluateand comparehelicopter emergency medical service {HEMS) systems utilization "ttb to snppott the need {or this expensiveand limited resoutce'

Despite improved emergency transport systems, the mortality associated with ruptured abdominal aortic aneurysm {AAA} remains high due to delays in patient presentation- and diagnosis and the magnitude o{ preoperative blood loss. The prehospital and emergency department management of 34 consecutive patients with ruptured abdominal aortic aneurysm was reviewed to determine factors influencing mortality. Patients were analyzed

2l

UAEM ABSTRACTS 14THANNUALIVEETING

produced a perfusing rhythm in 4 o{ 5 animals' In contrast coun["rsho"k resulted in Pfvrb in 4 of 5 animals that initidlly received EPI. N was then given and 4 of 4 developed a perfusing rhythm' We concluded thal naloxone has no hemodynamic ef{ect during CPR and does not facilitate defibrillation, and that naloxone may be of benefit in the management of EMD following countershock'

We have used the Therapeutic Intervention Severity Score {TISS} of utilization of an HEMS system to measurethe appropriateness during 5 .o.rt."ltiiu"honths of serviceto assessits value for this or,rrooi". The TISS measuresintensity of care during a 24-h perrira 6asedon the use of 57 medical and surgical interventions as.igtr"d u"lr.,"t ranging from I (example: urinary cathetea)1o 4 (ex; ariole: controllef, ventilation). The TISS was recorded on 114 Dat;entsduring the 24 h beginningat the time HEMS transport was requested.These flights were also classifiedas necessaryor given the in'iormation available, at two times: at the """.".it"tv, time HEMS J"r" *r. initiated, and when the diagnosis was well establishedand the outcome was clear' Classificationwas made Uv iloth a flight physician and a flight nurse, with,out knowledge oi ,t " iris, 6tt tit" i"tit of the {ollowing criteria: did the speedof ir^.rrport, th" pr"r"rr". of a skilled flight team, or the helicopter's abiliw to orr"t"o-. hostile environmental conditions (potentiallvi ensure patient survival or improve outcome?Seventy-two of the l14 fligirts 163%)werethought to be medically necessary/ both at the tiine AEMS *rt requesiedand at the time of hospital discharge,with a mean TISS of 28 (ANOVA 0'0000J'Nineteen the informalil;t"l ti.i thought to be medically necessaryusing iion available at"ilight time, but not after the in{ormation available at dischargewis examined.The mean TISS was 12 TWentytiti, tZOV.ldiinot appearto require helicopter transport and had a mean TISS of 9. We-concludethat the TISS accuratelyreflects the need for HEMS transport/ and may be a useful parameterfor the comparativeevaluation of HEMS systemsoperatrons'

49

50

Use of Naloxone During Cardiac Arrest and CPR: A Potential Adiunct for Post' Gountershock Electromechanical

Dissociation

MD; Jf Niemann,MD; CJ Rennie,lll, MD; WO RJ Rothstein, PhD / Departmentof Emergency Suddath,MD: JP Rosborough, MedicalCenter'Torrance,CA; and Medicine,Harbor-UOLA BaylorCollegeof Medicine,Houston Departmentof Physiology, Naloxone increasesarterial pressurein hemorrhagicand s-eptic shock. To determine whethei naloxone (N) has salutory e{fect-s d"ii"g ""tdl"" arrest and CPR, 10 canineswere anesthetizedwith meth6xyflurane and were studied during 20 min of VF and CPR, and duiing a 30 min post-countershock period' Central aortic (EDP) ieol a"d r"ight atrial (RA) systolic (qrst) and end-diastolic Dressures;d electromagnetic cardiac output (CO) were meaiured. Ao and RA samplei were analyzed during a control period and at S-min intervals during CPR for POz, PCO2, and pH Durwas used to pertorm ing VB a piston-cylinderdevice (Thumper@) ,lislllposterior siernal depressionsand positive pressureventilatio"r (fbOy"02) at standardratesand ratios. After 15 min of CPR, animals were-iandomized and given either N (5 mg/kg) or,epineohrine (EPII ll ms). Defibdll;tion was attempted 5 min later 2, 4, 8, 12,and 16 |/kg until VF using I J/kg "nd thei, if necessary, was iermiriated or maximum energy dose was reached' If VF persisted or ii countershockresulted in asystoleor electromechanical dissociation(EMD), the alternate drug (N or EPI) was given' M."trrt.d pressures/CQ and blood gaseswere not significantly different during the'control period or at 5, 10, and 15 min of VF and CPR betwin animals thit receivedN or EPI prior to the first countershock(unpairedStudent t test).Whel comparedto hemovalues ,neasured at 15 min, N had no significant effect ay""-i. o.r pr"rrrrr., or CO measured5 min a{ter administration (pairedt + tesil as follows: svst Ao was 75 + 20 mm Hg vs 74 29; AoEDB 22 t: 11 vs 19 + 11; slst RA, 70 + 25 vs 78 t 29j coronary i 16 perfusionpressure[Ao-RA],16 t:,7 vs,12 j7t ^!9 Cq 56 values 20-min aifected EPI-signi{icantly vs 59 ,t 34.

-t/-i.t *h..r "o-prt"d to those at 15 min (P < .05, paired t test) as fol+ lows: syst Ao *"t 110 + 26 mm Hg vs 69 :' 17; AoEDI 50- 19 vs 21 i 5; syst RA, 116 :! 19 vs 95 + 16; coronart perfusion pressure,+g t Zg vs 16 * ll; and CQ 46 + 46.mL/minvs77 !

42. No animal that receivedN prior to countershockwas defibrillrted d.spite maximal ".r.rgy do.", following EPI/ countershock

Dose-Related Response of Centrally Administered Epinephrine on Ghanges in Aortic Diastolic Pressures During Glosed' Ghest Massage in Dogs

JW Kosnik,MD; RE Jackson,MD; S Keats,MD; RM Tworek; SB Freeman,MD / Sectionof EmergencyMedicine,Department and Schoolof JMedicine; of Surgery,WayneStateUniversity Deparimentof EmergencyMedicine,DetroitFeceivingHospltal' Detroit Current recommendationsof the American Heart Association are that 0.5 to I mg (7.5 to 15 pg/kg in a 70-kg man) of epinephrine (EPIJbe giv"enIV every 5 min during cardiac arrest' The opiimal dose of Epl fo. augmenting aortic diastolic pressure lAodBP)is not known. The eflect of various dosesof central bolus ilpi o" tft. AodBP during closed-chestmassage{CCM) was studl.a. f*"",y-one large d"ogsweighing 17 to 33 kg were divided eouallv into 5 qroups,anJsthetiied with ZS mg/kg lV pentobarbitat, ind intubited and placedon a volume ventilator' The thora.i" "or,, and right atrium were catheterized. Ventricular {ibrillaiiott *^t inducelclby means of a low-voltage, 50-Hz current to the iigt-t, u""rti"t. by means of a transvenouspacemakerwire and cJssationof artilicial respirations.Complete cardiopulmonary.arlest was maintained for 3 min. Side-to-sideCCM was then initi ated at 60 compressionsper min with interposed ventilations after each 5th compressionwith a Tiavenol HR 50/90 p,neumatic resuscitator.After i min of CCM, EPI at a doseof 0 pg/kg, 15 p'gl kg, 75 pg/kg, or 150 pgikg was iniected into the central venous tlne. fhJaodBP was then monitored for 15 min.

2 min Post-EPlPre-EPl 3 1. 9 + 2 3 . 8 - 5 . 1 t 3 . 7

C o n t r o(l N : 5 ) 1 5 p g / k g( N = 5 ) 2 5 . 0 t

22

9.7

7 5 p g / k g( N = 6 ) 2 1. 8 + 5 . 6

9.2 t 4.0 65 * 32

10 min 5 mrn PosfEPl. Post-EPl-9.8 :L 8 6 -121 + 12 -44 * 36 43 t 31

62*27 1 5 0 p g / k g ( N : 25 3) . 6 t 9 . 5 7 3 + 1 9 .signiticancebetweengroups at P < .05, ANOVA.

-7 5 + 43 -23 + 32 32+ 24

In the controls the AodBP decreasedover time' Changesin AodBPpeakedat 2 min after iniection in all groupsreceivingEPI, and the drop in pressureover time noted in the control groupwas oreventedsienificantlv bv increasingthe dose of EPI' The lS-pg group did no"tdiffer from the controls at 5 and 10 min-post EPI' o{ these results on CPR researchare discussed' ?tr" i-oii"rr-ns

Effect

Ea

C

I

of Epinephline

and Galcium

Ghloride on Left Ventricular Pressure and Garotid Flow During CPR

MSS Chow, PharmD; A Fieldman, MD; J Kluger, MD / Drug I n f o r m a t i o nC e n t e r , H a r t f o r d H o s p i t a l , H a r t f o r d , C T ; a n d S c h o o lo f P h a r m a c y , U n i v e r s i t yo f C o n n e c t i c u t , S t o r r s The effects of I mg IV epinephrine (EPI) and 5 cc 10% calcium chloride (administered 10 min apart) on left ventricular pressure t and carotid flow were investigated in 5 dogs (mean weight- 17 1.2 kg) undergoing conventional CPR {ollowing induced venarrest. CPR was performed by a pneumatic tricular fibritlation device set to compress the chest 60 times and inflate the lung (with 100% 02) l2limes a minute. Le{t ventricular {LV) pressures measured through a pigtail catheter and carotwere continuoisly id flow through a cannulating flow probe. Two minutes following

'1

I EPI, LV systolic prcssure increased 9 + (r rnm Hg (mean lncreasc 18oL,P <.05) over thc baselir-revalue. No significant ch:rnges it-t LV systolic pressurc at other times or in LV mid-diastolic pressures wcrc noted. Carotid blood {low was reduccd significantly {or 4 mrn {rncan reductron ranâ&#x201A;Źie, 43"/o to 53'lo). Followir-rg calcium chlorrde, ncither LV prcssures nor carotid flow werc changed signi{icantiy. The rcsults of thrs study show that clurrng CPR EPI produces transient elcvation of LV systolic prcssure and signi{icant reduction of carotrcl {1ow, wirercas calcium chloridc produces no significant effcct on LV pressure or caroticl flow when aclministerecl l0 min after EPI.

creased cardiac index 52.4 mL/kg/min ovcr baselinc. The dopaminc was stoppcd and thc animals were allowed to return to bascline. Doparline, 10 pg/kg/min, was administered again after pretrcatment with 0.15 mg/kg of verapamil, and increased cardiac over thc second baseline contlol. The rerr-rdex47.9 ml/kc/min sults wcre not statistically differcnt usrng the Studcnt t test for paircd data (1' > .05). In addition verapamil prctrcatment did not signi{icantly altcr dopaminc's effect on the other measured and derivecl hcmodynamic parametcrs evaluatcd in this study. It is concludcd that verapamil does not affect dopaminc's ability to alrgmcnt cardiac output in the dosagcs tested.

During GPR in the lonized Galcium !.4, Model Ganine J B B e s t ,M D ; G B M a r t i n ,M D ; D L C a r d e n , M D , R M N o w a k , M D ; C F o r e b a c k ,P h D ; M C T o m l a n o v i c h ,I V D / D e p a r t m e n t o f E m e r g e n c yM e d i c i n e a n d D i v i s i o n o f C l i n i c a l C h e m i s t r y ,H e n r y Ford Hospital,Detroit Thc usc of c:rlcium during CPR is currcntly controvcrsial.

Somc invcstigators claim that calciurn can bc bencfici:rl in ccrtain cascs, whilc othcrs sllggcst that it shoulcl ncvcr bc uscd. Dcspitc this controvcrsy/ dartaarc lacking in rcgard to scrul'n calcium lcvcls cluring CPR both bcforc and :rftcr calcium :rcl-ninistr:rtiot-t.

Thc purposc of this invcstigation was to clctcrminc ionizccl cal c i u n - rl c v c l s d u r i n g C P R . F o l l o w i n g p l a c c m c u t o f a s c c t l d i t l g a o r t i c cathctcrs in l5 adult mongrcl dogs, vcntricular fibrillation was inclnccclclcctrically. A{tcr 5 min witl'ror.rt thcrapy, mcchanical cx. n i m a l s r c c c i v c d c i t h c r s t a n d a r c lC P R t c r n a l C P R w a s i r . t s t i t t t t c c lA ( S - C P R ,n - t i ) o r s i m u l t a n c o t t s c o t - n p r c s s i o n l n t l v c u t i l a t i o t t C P R { S C V - C P R .n - 7 l f o r 3 0 m i r - r . I o n i z c d c : r l c i u m l c v c l s w c r c obtaincd prior to fibrillation ancl subscqucntly cvery 5 t-t-tincluring CPR. Mcar-rionizccl c:rlcium lcvcls cluring CPR (1.27 + 0.06 mmolc/L) clid not cliffcr srgnificantly from prc arrcst levcls (1.27 + 0 . 0 7 m m o l c / L ) a t a n y p o i n t c l u r i n g C P R . T h i s w : 1 st r u c w h c n all dogs wcrc an:rlyzcd togctl-rcr ll) - 12931anclwhct.t thc auimals r c c c i v i n g S - C P R ( 1 ) - . 4 4 6 5 1a r . r dS C V - C P R l 1 ' = . 6 4 7 0 ) w c r c ^ n z r resultccl Iyzcd by groups. Dcfibrillatior-r attcmptcd in all anir-r'ra1s i n c l c c t r c m c c h a n i c a l c l i s s o c i a t i o n( E M D ) i n t h r c c . N o n c o f t h c s c c l o g sw a s h y p o c a l c e n ' r i c c i t h c r p r i o r t o r c s l l s c i t i l t i o r l 0 r t l u r i n g CPR, and nonc dcvclopcd an cffcctivc rhytht.u witl'r thc acln-rini s t r a t i o r . ro l c a l c i u m . A l l a r r r m a l s r c c c i v t n g c a l c i u m d c v c l o p c d markcclly cicvated ionizccl calcium levcls. Hypoc:rlcctlia :rpparcntly docs r-rotoccllr during CPR. The bcneficial effcct of calciutr-t in rcportccl cascs cannot bc cxplaincd by corrcctiot.t of hypocalccmia. Furthcr studies arc nccclcd to dcfinc tl-rc rolc, if ar-ry,of calciun-radrninistraticrn in CPR.

54

A Randornized Comparison StudY ol Bretylium Tosylate and Lidocaine in Resuscitation of Patients from Out.of' Hospital Ventricular Fibrillation in a

System Paramedic D W O l s o n , M D ; B M T h o m p s o n ,M D ; J C D a r i n , M D ; M H M i l b r a t h , E I V T - P/ S e c t i o n o f T r a u m a a n d E m e r g e n c y M e d i c i n e , M e d i c a l College of Wisconsin; and Department of Emergency Medicine, S t M i c h a e l H o s p i t a , l V iw a u k e e A prospectivc, randorlizcd study using brctylium tosylatc (B) or lidoc:rinc (L) as thc first-linc anti-arrhythmic ior paticnts in vcntricul:rr {rbrillation was conductcd using thc Mrlwaukcc CoLUlty l)ar:rmcdic Systcn-r.If thc patlcnt failcd thc initial Arncric : r r . rH c a r t A s s o c i a t i o n p r o t o c o l , B ( 1 0 - 3 0 m g / k g t o t a l ) o r L ( 2 - 3 rng/kg total) w:rs givcn xs thc first anti-arrhythmic. If thc paticnt failccl to convcrt, thc alternatc ar-rtiarrhythn-ric (B or L) was givcn.

L ' r t l - r eL g r o r . r p , 3 9 o f 4 [ 3 p a t i c n t s ( { 3 1 ' 2 , ) o b t a i n c do r g a n i z c d c l c c trical rhytl'rn'r and 27 of 48 156"1')cttnvcrtcd to a rhythm with a pulsc. Tl'rc rcsuscitation ratc, or admission wlth a pulsc to an cmcrgcncy dcpartmcnt, was 1l o{ 48 (23'/") and thc savc ratc was 5 o f 4 1 3 1 1 0 . 4 ' l ' ) .h . r t h c B g r o u p , 3 2 o f 4 3 ( 7 4 % ' ) o b t a i n c d a n o r g a u i z c c lc l c c t r i c a l r 1 ' r 1 ' 1 1 - tl-5, o f 4 3 ( 3 5 ' 2 , ) w c r c c o n v c r t c d , l 0 o f 43 123"1'lwcrc rcsuscitated, and 2 oI 43 (5%,) wcrc savcd. L conv c r t c d p a t i c n t s s r g r - r i f i c a n t l yb c t t c r t h a n d r d B ( P < . 0 5 ) .O f t h c 2 4 paticnt; l<nown to bc on digitalis llrcparatiolls prior ttr arrtst, 5 of 1 2 l 4 l ' l ' l i n t h e L g r o l r p w c r c r c s u s c i t a t c c lv c r s u s 2 o f l 2 ( 1 6 ' l , Ji n tl"rc l3 grou1.r.l)ata wcrc also analyzcd for witncsscd arrcst outcomc and for patict.tts givcn nrultiplc antiarrhythmic drug thcra-

pv.

E E --

Intravenous Streptokinase

J J

G Mayer,MD,WE Story,MD; JF Seco, MD, FACC; MA Nocero, Jr, M D , F A C C ; D J S h a s k e y / T r a u m a - E m e r g e n c ya n d C a r d i o l o g y D e p a r t m e n t s , F l o r i d a H o s p i t a l ; F l o r i d a H e a r t I n s t i t u t e ;a n d U n i v e r s i t yo f C e n t r a F l o r i d a , O r a n d o Fibrinolytic thcrapy has shown a great dcal of promise for those paticnts who present vcry carly tn the stagcs of acute myocardial infarctior-r (Ml). W fibrilrolytic therapy, zl rcccnt area of research, has a grcat dcal o{ applicability ir-r the emcrgcncy medical ficld.

We report our cxpcriencc with 30 patients treatcd by thts methoci. Thirty consecutivc paticnts rn t1-reearly stagcs of acute evolving MI were assigncd consecutively to rcceive high-dosc IV streptokinasc, 1.5 million units during a 30-min pcrrod. Paticrnts prcscnted to thc trcating hospital at a mean trme of 1.5 h and trcatmcnt commcnccd at a mean timc o{ 3.04 h aftcr onset of symlrtoms. Using standard clinical criteria, 90% ln : 27J oI the paticnts reperfused initially; however, 3 rcoccluded within the {irst 48 l-r and thcir clinical symptoms of MI rcappeared. By clinical obscrvation 80% (n - 241 oI the patients reperfused and myocardial salvage was observed. A11 3 patients {100%) who had reoccluded clinically were also found to be occluded on angiography. The rerlaining 24 patlents who had clinical reperfusion and one additional paticnt had patency o{ thc affected artery, yielding zrreperfusron ratc of 83% (n - 251 as judged by angiography.

Clinical and angiographic methods yielded similar results for the judgment of reperfusron (80% versus 83%, with no significant

Influence of Verapamil on Dopamine's Ea Ability to Augment Gardiac Output arr, St PaulMedicine, of Emergency JTSturm, MD/ Department Ramsey Medical St Paul,MN Center, Calcium channel blockers arc used for thc treatmcnt of angina pectoris, cardiac arrhythmias, and hypertensron. Sporadic reports of hypotensivc rcactions to calcium channcl blockers havc indicatcd that thcse reactions arc not revcrscd readily by catecholamrne adrninistration. Thrs study was conducted to rnvestigate systematically the pharmacological interactions of calcium channel blockers and catccholamir-res. This study tcsts the hypothcsis that vcrapamrl pretreatmcnt does not alter the ability of dopamrne to augment cardiac output. Twelve mongrel dogs wcighing 15 to 25 kg were anesthctized with pcntobarbital and placed on a Harvard respirator. A Swan-Canz thermodilution cardiac output catheter was placcd in the pulmonary artcry by femoral vein cutdown. Right atrial, pulmonary artery, pulmonary capillary wedge, and central aortic pressures were mcasured directly. Cardiac output was measurcd drrectly by the thermodrlution technique. Derived variables included cardiac index, systemic and pulmonary vascular resistances, and right and left ventricular stroke work indiccs. Dopaminc, l0 pg/kg/min, in-

23

UAEMABSTRACTS 14THANNUALIVEETING

difference, P : NS). The resuits of our study tend to con{irm the efficacy oi IV ttreptokinase as a valuable management tool for early MI.

56

Beta Blockers and the SYmPathetic Nervous System in Goronary Occlusion lnduced in Cats

WH Spivey,MD; CM Lathers,PhD / Divisionof Emergency MedicalCollegeof Medicineand Departmentof Pharmacology, PhiladelPhia Pennsylvania, Clinical studies have shown that chronic treatment with timolol decreasesthe incidence of rein{arction and mortality and limits the size of in{arction when given IV during the acute phase o{ an infarction and {ollowed by chronic oral dosing' It has been Dostulatedthat beta blockers work not only by a direct mecha,ri.* o.r the heart, but by altering neural dischargeto the heart and depressingthe sympathetic overactivity seen in 35Y" oI patients immedLtely aitei an infarction. This study examined the effect of timoloi on sympathetic cardiacneural discharge (SCND),blood pressure(nn1,h"art r-ate(ftf.), and rhythmdur,rng acute coronary'occlusion (CO) produced by ligation of the left anterior descendingartery iLADI in o-chloralose-anesthetized cats. Cats were divided into chronic pretreatment (timolol 5 mg/ kg PO bid for I or 2 wk), acute pretreatment (timolol 5 mg/kg IV 15 min before CO), and post-Co (timolol 5 mg/kg IV 5 min post COJ groups. these datf were compared to .previouswork with -eioitolol (5 mg/kg IV 15 min before CO) and with controls' Cats'pretreatedr.ilth timotol for I or 2 wk exhibited a decreased gR and BP prior to CO. Mean times to arrhythmia for 1- and 2wk cats were 0.8 * 0.5 {P > .05)and 9.5 t 8.0 (P < .05)and to death,34.4 t 31.3(P< .05)and 128.0+ 66'9 lP <.05) min, respectively,when comparedwith no drug prior to CO' Timolol pioduced minimal chinges in SCND. In cats pretreatedacutely, ih. *.^.r times to arrhythmia for metoprolol and timolol were 4 . 1 + 1 . 6a n d 5 . 8 + 2 . 6 a n dt o d e a t h , 3 . 7+ 0 . 8 a n d 6 7 . 7 t 4 9 ' 5 min (P < .05 vs no drug), respectively.-Metoprolol decreased SCND to 72 + 6,5 min post infusion, and to 94 t 7 implsec,-o/o control in the minute pribr to CO. Comparablevaluesfor timolol were 105 + 20 and 115 i 17. Two-min, post-Co SCND was 103 + 13 (metoprotol)and 129 + 27 (timolol). SCND was not altered prior to or post CO in the chronic and acute,pretreatmentgroups br after CO in the group treatedwith timolol or saline 5 min post CO. Metoprolol, h6wever,demonstrateda uniform depressionof that there may be SCND pribr to, but not post, CO. This sugges-ts effect o{ the beta blockersand a differince in ihe neurodepressant that some may be more protective against the detrimental sympathetic componentof infarction.

E, -, I

hypoglycemic{1.S%), and psvchogenic(0'6%)' Signi{icant 12.4%1, to the syncope,-urinary incontinence, and paltlioiartv iir"-! pitations all were relativefu uncommon and not speci{ic for any irt.eoty. Two of I02 ECGs revealedabnormalitiescompatible *itfitft6 presumedetiology of the syncopalepisode Serumbicarbonate was decreasedi;'69% of our seizure patients' Other serum electrolytes were not diagnostically useful' Of 134 complete blood counts {CBCs),no cise o{ occult bleeding was discovered.Foliow-up was available in 89% of patients (mean, 6'2 months). The hisiory and physical examination alone made the diagnosisin 9l% of ihose patients who could be.qalegorizedin a rp"ii{i. etiology.We conclude the DWP is a useful historical feature. Routine CBCs and electroiytedeterminationsappearunwarranted. The serum bicarbonate level may suggesta seizure disorder in selectedpatients with unwitnessed,unexplained loss of consciousness.

EmergencY

of Glonidine in the Department for RaPid Gontrol of 58 Use Uncontrolled l{YPertension

OO; JW Becher,Jr' DO / Department DO; SJ Parrillo, K Doroskt, Collegeof Osteopathic of EmergencyMedicrne,Philadelphia Medicineand OsteopathicMedicalCenterof Philadelphia' Philadelphia in a retrospectivetevrew The efficacyof clonidine was assessed o{ patients seenin an urban emergencydepartment(ED)during a o.ri-y.rt period. This study was restricted-to.thosepatients treat' ed in the ED for dangeiously elevated blood pressurewith clonidine, and in somJ casesalso with furosemide,and subsequently discharged "on home. Fifty-sevenpatients met these criteria' each patient included age, sex, initial blood 6at^ collected p*rrrrr", final blood pressure/drug dose,time until onset of aciion, chiei complaint, and history of treated or untreatedhyper' tension. The averageblood pressure reduction was 36 mm Hg systolic and 2l mm Hg diastolic in an averagetime of 87 min, .,rittg ,tt averageof 0.t78 mg clonidine-. More than half the patienii concomiiantly received furosemide, and its use appearedto have an additive efiect in lowering blood pressure'All patients were dischargedsafely home from the ED to be {ollowed as outpatients by a-private physician or clinic. After an exhaustivereview of the liierature-this appearsto be the largeststudy to date of the outpatient use of clonidine in the ED for rapid blood-pres' sure titration. The use o{ clonidine in this milieu is both safeand effectivein the rapid control of markedly elevatedblood pressure in otherwise aysmptomatic individuals.

E(| Il-,

Prospective Evaluation of Syncope in Patients Presenting to the Emergency Department

GJ Martin,MD; SL Adams,MD; HG Martin,MD; J Mathews,MD; D Zull, MD; PJ Scanlon,MD / Departmentof Medicine'Section of EmergencyMedicine,and Sectionof GeneralMedicine, Chicago;and Departmentof Medicine' University, Northweltern' MedicalCenter, LoyolaUniversrty Sectionof Cardiology, Maywood,lL We analyzeddata collectedprospectivelyfrom 170 consecutive patients presenttngwith syncope.Histories were obtainedusing a checklisi to elicit"prodromal iymptoms, estimated duration of warning period (DWP),and other details of the history and,physical examination that otherwise o{ten are recordedincompletely' were cateAII pertinent laboratory data were recorded.Patients -Typicalvasogoriied by presumed etiology using strict crite4a. iagal syncopewas seenin 37.1"k,with a mean DWP of 2'5 min' Ca"rdiac"^.ir., ,"pr.r.nted 4.lo/" of patients and-had a signi{icantly shorter DWP {P < .05),with 5 o{ 7 patients having < 3 sec *"r.ri.rg. The remaining categorieswere as foljows: unknown (37.6%1,first seizure (8.8%), orthostatic 17.6%1,micturition

24

Single'Dose Geltriaxone Treatment of Urinary Tract Infections

RC Levy,MD; JF Cicmanec,PhD;JR Hedges' JM Rosenberg; of MD / Divisionsof EmergencyMedicineand Urology,University CincinnatiMedicalCenter,Cincinnati Single-doseantibiotic therapy -o{ for uncomplicated urinary tract greater patient compliance and in{ectfons holds the promise convenience.We preient the results o{ a single intramuscular doseoI a long-acting,third generationcephalosporin,ceftriaxone, compared tJ a standard 5lday regimen of trimethoprim-suIfameihoxazole(TMSI.A total of 53 patients were enteredinto the study basedon initial clinical and laboratoryfindings. After ran' domization, 26 patients were assignedto the TMS group and 27 were assignedto the ceitriaxone group. Of the patients who completed thE study, t3 of the TMS group and.20 of the ceftriaxone group had positive cultures at the time oi initial presentation' fuo-.t entered into the study were recultured, and were considered cured if the bacterial growth was eliminated and clinical symptoms abated.The study groups were found to have no statisticai difference in symptoms of dysuria, hematuria, frequency, flank pain, and nociuria using multinomial chi-square analysis with cbrrection {or continuity icr : .05).The physical parameters of age,blood pressure,pulse,-andtemperaturewere similar in the

2 groupsusing the 2-tailed Student t test (o : .05).Cornparable types of infecting organisms were cultured as revealed by multinomial chi-square analysis with correction for continuity {a : .05).When comparingthe 2 regimens,the ceftriaxonegloup cure rate ll8/20 : 90%) was not significantly different from that of the TMS-treatedcontrol group {13/13 : 100%1,using the 2tailed Student t test icr = .051.Type II error at the 50% level equals.13.

An lfll,

They initially were given l0 min of CCC at 60/min, followed by l0 min of OCMC at 60 and then 10 min of OCMC at 90. CCC produced a cardiac index {CI) of 886 (20% o{ pre-arrestvalue 1feV]1,wittr a mean arterial pressule(MAP) of 25 mm Hg 122%of PAV).OCMC at 60 produceda CI of 1,698139%of PAV)with a MAP of 53 mm Hg 147"/"of PAVJ(P < .01 and .0005,respectively, when comparedto CCC). OCMC at 90 increasedthe CI to 2,018 146%of PAVI and the MAP to 67 mm He 159%of PAV).These increasesin CI and MAP with OCMC at 90 were both significant (P < .05) when compared to OCMC at 60. Calculation of the stroke index (SI)during OCMC at 60 and 90 revealeda decrease from 28 to 22 ml/compression. Increasingthe compressionrate during OCMC does decreasethe SI (P < .05).Howevel, the net effect of an increase in rate is an inctease in MAP and CI. Blood flows and pressurescan be improved substantially by using OCMC. Use of compressionrates faster than 60/min will produce additional hemodynamic improvements.

Lymphadenitis: Natural History and Response to Percutaneous Aspiration

MD, FACEP;J Grosflam;S Selbst,MD; S Ludwig,MD G Fleisher, Hospitalof Philadelphia' The Children's Department, / Emergency Philadelphia Children {requently seek treatment in the emergency department IED) for enlargedlymph nodes, often the result of a bacterial in{ection. While the etiologic agents of lymphadenitis in childhoodhave been defined clearly optimal treatment remains uncertain. We studied lymphadenitis in children seen in an ED to determinethe course of patients with fluctuant and nonfluctuant infections and to assessthe roles oi antibiotics/ percutaneous needleaspiration{PNA), and surgical drainageas forms of therapy.During a 9-month period, all children who were diagnosed.as havinglocilized lymph node enlargement were contacted and followed by the investigators, who reviewed daily computer listings Irom the ED by diagnosis.The protocol called for administration o{ antistaphylococcalantibiotics to every patient with lymphadenitis, and for PNA o{ fluctuant lesions; surgical drainage was reservedfor treatment failures. Forty-two children were diagnosed as having enlarged nodes, due in 32 cases to bacterial Iymphadenitis.Thirty of the 32 l9a%l were followed until their lesions resolved;at diagnosis, 26 had nonfluctuant and 4 had fluctuant infections.These 30 patients rangedin age from 3 mo to 17 yri children with fluctuant nodes were younger iP < .05, t testl.Subsequentlyfluctuance developedin 4 oI 26 lymph nodes that initially were firm to palpation. All 8 children with fluctuant lesionsresolvedtheir infections following PNA and antibi otic therapy,and 25 of 26 with initially nonfluctuant in{ections were cured with antibiotic therapy alone or accompaniedby PNA (4 cases)when fluctuance developed.Staphylococcusaurcus, the only pathogenisolated,was recoveredfrom 5 infected nodes.We recommendantistaphylococcalantibiotics plus PNA for the treatment of lymphadenitis whenever abscessformation is detected clinically. Surgical drainage or excision should be reserved for persistentinfections.

e{ 19 I

Hemodynamic Effects of Rate During Open-Ghest Resuscitation

RL Bartlett,MD; NJ Stewart,MD; Jl Raymond,MD; GL Anstadt, DVM;SD Martin,EMT/ Departmentof EmergencyMedicine, Richland MemorialHospital,Columbia,SC ProlongedCPR using closed-chestcompression(CCC) is associated with poor survival rates and neurological outcomes. The magnitude and distribution of blood flow to vital organs during CCC are inadequateafter 5 to l0 min. There is a growing body of evidenceto support the use o{ open-chestmanual compression of the heart (OCMC) for potentially salvageablepatients who do not respondto standardACLS. Del Guercio and others have reported severalpatients who, after failing CCC, were resuscitated successfuilyusing OCMC. Although OCMC was first demonstrated to be an e{{ective method of resuscitation in 1898, few studies haveaddressed the technical aspectsof its use. Con{usion still existsregardingthe appropriate rate of compression. With little experimentalsupport/ it has been assumed generally that a nte of compression o{ 60 or less will producethe best results. Obiections to the use of faster rates cite the need {or an adequateventricular filling time between compressions. This study was designedto evaluate the hemodynamic ef{ects of compression rate during OCMC. Ventricular fibrillation was induced in 5 dogs.

25

Gel 3rZ

Gomparison of Open.ChestGardiac Massage Techniques in Dogs

63

Gomparative Study of Glosed.Ghest Compression, Open-Chest Manual Compressionr and Direct Mechanical Ventricular Assistance

WM Barnett.MD: JK Alifinoff,MD; PM Paris,MD; RD Stewart,MD; P Safat MD / AffiliatedResidencyin EmergencyMedicine, ResearchCenter,and Departmentof Resuscitation of Pittsburgh; Care Medicine,University Anesthesiology/Critical and Centerfor EmergencyMedicine,Pittsburgh Manual compression o{ the heart during open-chest cardiac massage(OCPR)has been shown to be superior to closed-chest compr6ssion.This study sought to determine,in a canine model, the optimal hand position {or manual compressionof the heart.

Twelve dogs were anesthetized with ketamine and orally intubated, and anesthesia was maintained with nitrous oxide, halothane, and pancuronium. Cannulae were placed to monitor diastolic (DBP)and systolic {SBP)blood pressures,intracranial pressule (ICP),and common carotid blood flow (CCBF).Control values were obtained under light general anesthesiaand ventricular {ibrillation was then induced. External CPR {ECPR}was per{ormed with a mechanical compressor before opening the chest and pericardium through the left fifth interspace.A ran' domized sequenceof 3 hand positions was used for OCPR, as follows: TbchniqueA - One-handedtechnique with thumb on left ventricle, fingers over the right ventricle, and apex in palm; Technique B - TWo-handedtechnique with right ventricle cuppedin left hand and fingers of right hand over left ventricle; and Technique C - One-handed technique with fingers of right hand over left ventricle and heart against sternum. Each was done at a rate of 60 compressionsper minute with the operator blind to results during performance.All 3 techniquesproduced significantly greater (P < .05) DBP and CCBF when compared with ECPR.All 3 also producedsignificantly lower (P < .05)ICP when comparedwith ECPR. DBq SBB CCBI and cerebralperfusion pressureswere similar for techniquesB and C and aII were significantly greaterlP < .05)than those achievedwith technique A. These data suggest that techniques B and C may produce greatercardiac and cerebralblood flow during OCPR'

RL Bartlett,MD; NJ Stewart,MD; Jl Raymond,MD; GL Anstadt, DVM;SD Martin,EMT/ Departmentof EmergencyMedicine, RichlandMemorialHospital,Columbia,SC Current cardiac arrest studies indicate that closed-chestcompressioniCCC) does not provide adequatecoronaryand cerebral oerfusionfor more than 5 to l0 min. Ditchey demonstratedcoronary blood flow to be less than lo/o o[ pre'atrest values during CCC. Cerebralperfusion studies suggestthat CCC cannot reliably supply a coitical blood flow at more than I0% of normal values after the first 10 min of resuscitation. A case control study

UAEMABSTRACTS 1 4 T HA N N U A LM E E T I N G

min of resuscitaDressure recordings were taken at 5, 10, and 20

w a s d e s i g n e d t o e v a l u a t e 3 d i f f e r e n t m e t h o d s o f c i r c(OCMC)' u l a t o r y s u p -i#fti;;;;;3l*" ^,10 min resuscitationtime All animals port,-ri"""a"ta CCC, open-chestmanual compression at 3 ws/kg after 6 min resuscitation' once ;;;;;;.tthocked a -""hanical u"rrtti""l"t assistance(DMVA)' DMVA is i"a"ait*i defibrillated There were no srguntil thereafter 2 min il;;;; glass assistor r"*fi"J .t open-chestcirculatory support.using a CPR and IAC-CPR in net between detected ;li;;;;a'lf;;nces and ex"""^iirl,"rirt'"ver the heart and'alteinately,compresses perfusion pressures,IlqYlgd number of Jl"ttoti" "nd systolic ;;;; The pi"tide systole and'diastole ! '9t,' "ria'r?i" t."ltt"f.t-L ; a.fibritlate-(Cpn, z.s t 1e' IAc-cP-R' 3's ;i';;h compresston 5)' time to lurriion, rate of compression,and force ol assistor IAC-CIR, (CPR, 6; resuscitated animals of ;il; it'" main drive svstem Ventricular fibrilla+ 7'l min; IAC CPR' 20'7 : ;;';;;;;;;ri.Juv ,*ni"n.ou. perfusion{CPR,17'9 of *d;""a n rs Oogs.rllev iniiiallv were given l0 min il;;"; grt.t'"r,.' I0 min resuscitation{cPR: pH' 7'51 bila ;:;il;;;; were period they i:6-c ".i"* a Thumper"'."At the end of this H99.;-18 4 I 6 0; and t-.it,;bor, 21:rf t 6.si to2r 318i- 7^9, Group I re+ 82' Jii"a.a i"?"-g grorrpsfor continued resuscitation' t.48, 27.0 P-4o2, t .10, l.as rnc-ipn, in, lo2, 180 not does tttltt oioclvtc at 60/min followed bv 10 min at 90/min' ;;i;;;10 IAC-cPR that indicate data iic-o.-,-zz.T" s.i1.rttese "ppu"a for similar periods at rates of 60 and 90' ;"iiil;;;,h"" alter a 15-mincardiacarrest' i--pto'u.""taiac resuscitability design lrr diotp II, DMVA preceded OCMC' The experimental group the same as in Group I The data from this ;;;;#;it" OCMC or were used to determine whether t[e order in which ^pplied had anv signi{icant ef{ects Group III cor;i;VA ;t 40 min' he ,i"""a ," ,"""iu" CCC ar OOlmin {or an additional of GroupsI Gardiac Arrest in Dogs Analvsis min 50 was groups 3 all for il;i;';;t;;i;e of application MD; P Vaagenes,MD; P Safar,MD;.W Stezoski/ order in the R Cantadore, d'ifference "o tig"iti.i"t ;illl-;i']*.j (CI) 780 Center and DepartmentoI of Research index cardiac a Resuscitation produced and DMVA. cCC ;fbaMa of Pittsburgh ;;;;ih*i;l"gy/Critical Care Medicine'University with " ttt",tt arterial pressurâ&#x201A;Ź(MAP) of 26 mm &%;i;";;al) Hospital,Pittsburgh open-chest of forms Presbyterian-University b.oth and cc-C, to co-p"t.a i{'b%^;;il;rri. circulaoCMC at 60/ With standardCPR {SCPR),restorationof spontaneous r.!r'it.i,",i"" pt"J"..a nigtt"t valuesfor all indices ;ry-rrot'U. ,"ttieved after long cardiacarrest{CA} a cr or f,o6s ls2% or normal) with a MAP of 50 .i;^(Rolc) ;;;;;;;i";d perfunormal).'DMVA at the same rate.produceda CI ii-"J. c"taioprri-onrty bypass{CPB)permlts control o{ ffi il;'Ait;;f tlood composlHC temperature, 72 mm o{ t657: MAP oxygenition, a flow, with normal) of ;;;;t"-.*t"; J i,t{O lTook :t 111r: but to tion, and administration"of drugs that may benefit the brain mal). These represent significant increases.wh-encompareo was.performed Changing A study MAPf for < 0005 .y.tJand CI 1cvs1' i""i"tt irt. ""iJi"""t""rrt ilcrurC ", 60 (P < .005 f"or g0lmin produced the greatest *hether CPB can reversenormothermic CA * a.r.t-i"" ;i;; Iiom standard ccc to DMVA at by fibrillation (vr) better than can SCPR' diastolic pregsyg increased ;;;til."tr ;i ;iru* hemodynamic t-prou"*"ttt: the at 90' ouve' : with SCPR; Group-II ,it = 9l' with 340% (n resuscitated by was cr, ""a 9) f 250%; bv Crollp 380%, MAP statisticallv be and Group Ill-ll = /ll not could priming cI and blood index, with {CPB-B), "t"1. *i,t'Cpb ;;;;ii; ;;#., studv This priming vaiues pte-arrest lDextran 4ullactateo with CPB with plasma substitute il*-."t.-.on"o11eil ii"*;;itit; suppolt ni.*.t;t 1:Il lCPb Pl. Preparationwis with light halothane-N2O' indicaies that DMVA is capableof long-term circulatory and bv scnRwith drugs ibac';"; achieved Ai,;;"o;il;F; during ventricular fibrillation' for 2 h continued was groups CPB CPB in the "o"",.ttfto"i.; and tlhen ROSC was accomplished A pe' *'i,ft""r-."""iershock, with one pump and priming volumeoi Jiatric bubble-oxygenator, "t6[, *ittt'" flow of eb to loo ml/kg/min' cardiac ijod;il;; output (CO) was measured (by thermodilution), andarterioResuscitability and Net Perfusion o, differenceand o2 utiiization coellicient (Ca-vo2).were ;;;;;.

Sacrifice was at 4 h SCPR achieved RoSC within 5 ;;ilil;,i.

Pressures with CPR Versus IAC'CPR RJ DVM; Evans' AT MD; White BC MD; of ir, 9 dogs (5 countershocks); all 7 zurvived 4 h but with Otn"nt, -in 7 O Hayes,,tZO;..J Departments / Hoehner T Fox; L CpB was feasible for 2 h and was followed MD; Aronson, ayttfty,hriias.

LD r.u"t. fnori&i, ovH,f ;' Lansing [y nOS6 with one countershockt there were no dysrhythmias ot itu'r.gun.V Medrcine,lnghamand SparrowHospital Hospital' olst ROSC. There were no dif{erences in return times for spon-Vf ; b"pittt.nt of EmergencyMedrcineButterworth Collese Medicine' pupillarv light reflexes, or !!G activitv' Co Emergencv of Section and Ml; i;;;;;;;";h;.'g, ciltJli"pioi Michigan Medicine' Veterinary of "bttttoi at 1 to 4 h post Rosc in the SCPR College 507."'oi and ; ;;;;;;r;J ; Hr;;'Medicine post East Lansing ""J Cps-s groups. In the CPB-P gtoup, -o was rormalized State UniversitY, both as the result of were kg coefficient"was'worse, 25 and l"iOr"",ilization d,qr weighing dogs Sixteen mongrel -be119e.n.f'O min halothane fi"tit.Jif"tio" {hematocrit, 15%}.ROSC is {easiblealter 20 anesthetized*iih k..r--itt. iz -glkg) IV followed by the CVS stabilizes however, CPB, CbR; lntuDatecl or were CPB using animals.

CA {VFl ll"k to 2"/o mixture with oxygen)' The and facllitates Rosc as comparedto SCPR'CPB ;tl;;;!;;t;"t (CV) lin'e was insertedbv right.venisection' ;;; ;;;;"f;;nous anc venous further for emergency resuscitation after procenttal .*pfot"a Both .fr.r1f[ f" catheterized was artery femoral The left attransducers pressure CA. longed to connected arterial catheters were standardir"fr"a to an EFM-BR8 fast photorecorder, which was each experiment' All animals were ECG-monitored' i""a l.i"* -c"tai* KCI of Dogs Resuscitability t^ G Gardiovascular "..t, was induced by CV iniection of 0'5 mEq/kg arrest' of cardiac min 15After drawn' |DlD After UP to 9O Minutes Cold Water were "ft.i pr"-"rt.tt ABGs CPR and 8 animals were resusclt;ted with manual front-to-back Drowning Using Cardiopulmglary Byp1s.-s MD; PSafar'MD;J Lewis' W ClSugherty; 8animaiswelelesuScttatedwithintelposedabdominalcompresChabal; Tisherman;C S prpto of.

Reseirchbenterand Departments ri"" iiedf cpn. ntt animals were secured in a V-trough / Resuscitatlon W Stezoski cuff was of University and Medicine' Medicine vent'motion. For IAC-CPR a folded blood pressure Care nn".iG..rogv/Critical Pittsburgh mid-abdomen and compressedmanuallv to 100 mm Hospital, Presbyterian-University arid ;i;;;t;;;h; iittsnurgn Chest compression after cold ij* or"r.u.. between chest compres-sions' Anecdotal human case reports include recoveries at 80/min in both groups,and-100% 02 ;;i"tr*.d ;;:J;;; at restoratlon oI sponAttempts min' 40 to up o{ drowning water by manual bag ventilation ev-ery'sixth chest comdrowning by *".-d.liu.t.a taneous circulation (ROSC) in cases of cold water IV) and epithe heart' o*rio,l. All animals *.r. giu." NaHCO3 (3 mEq/kg restart and rewarm to fail o{ten standard external CPR resus;;;;;;; iiii **7r.g rvt via ihe cv line at the beginning^of designed to determine the longest peri was study i.^*"fl,y ifrlr pg/kg/ .iirtion, and naa a continuous epinephrineinfusion {J ""tbi"" arresiu"der hvpothermiafrom which ;J;i;;hy;t "tti{icial per{usion' Simultaneous arterial and CV ;i;l ;;;t

"",YBffi [:.

6 5 fi3:t';'i,t.lli:1ft

"" 3ililT"t'Ji:Ul$ 6 4 *""f#,i:,

26

A loading dose o{ phenytoin is often needed on an emergency basis {or seizure therapy. This study evaluates the efficacy of constant intravenous (IV) phenytoin in{usion as an alternative to the usual mode of manual IV push. Thirty-eight emergency department patients were evaluated prospectively lor complications of continuous in{usion phenytoin loading. A total dose of l8 mg/kg was administered as a solution of 500 mg phenytoin in 50 mL normal saline using a constant infusion pump. The initial delivery rate was 40 mg/min. The cardiac rhythm was monitored by telemetry, and rhythm strips and vital signs were obtained every l5 min during in{usion. Therapeutic phenytoin blood levels lgreater than l0 pglml) were achieved in 37 patients by this method. Infusron was discontinued in one patient because of IV site irritation shortly a{ter initiation o{ the infusion. Phenytoin levels in the toxic range were seen immediately post infusion in 22 patients and in the 4-h post-infusion samples of 16 patients.

Thirteen of 18 levels drawn 12 to 24 h after infusion were therapeutic. Phenytoin levels greater than 20 pg/ml were tolerated without significant change in rhythm, QRS interval, or QT interval. A small decrease in systolic and mean arterral pressure was noted during the infusion. Complications included burning at the IV infusron site in 4 patients, the discomfort was relieved in 3 cases by reducing the rate of in{usion to 20 mg/min. Seizures occurred in two patients during the in{usion, requiring the additional use of diazepam or phenobarbital. It is concluded that administration of a loading phenytoin dose by constant IV infusion is an cffective means for achieving therapeutic levels in a briel period o{ timc.

ROSC is possible. Seventeen dogs were lightly anesthetized for preparation. After the dogs breathed aiq, the tracheal tube was clamped (simulating laryngospasm) and the dogs were immersed in ice water {or 20 to 120 min. Cardiac arrest occurred at 6 to ll min. ECG complexes continued. At the end of submersion, the dogs were removed from the water and CPB was started using venoarterial pumping via oxygenator primed with 400 mL Dextran, 40 mL Ringer's, and heparin. Initial CPB flow o{ 10 ml/kg/ min was increased as venous return allowed, to achieve normotension. The heat exchanger was kept 10 C above rectal tem't perature iT). ROSC was attempted with rectal ^t 32 C, using epinephrine, NaHCO3, and countershocks as needed. Life support was continued for 2 h (n : B) or 24 h i" : 9). At start of CPB, rectal T was 34 C a{ter 20 min and 1l C afuer 90 min of submersion, while cerebral T was 26 C after 20 min and 7 C after 120 min submersion. Followine CPB of 0.5 to 3 h to achieve rectal T of 32 C, ROSC was succeisful a{ter up to 90 min of submersion. Limiting {actor for ROSC a{ter 90 and 120 min submersion was clottrng in large vessels. One survivor after 90 min submersion recovered spontaneous breathing and EEG activity, and so did others with shorter submersion times. CPB decreased hematocrit to 16% to25%. There was capillary leakage. A supplementary study in rats with asphyxial arrest showed large vessel clottins at 20 min of normothermic arrest and at 40 min of hypothermic arrest. CPB is capable of ROSC after up to 90 min of cold water submersion. Crude signs of early cerebral recovcry appear promising. CPB for outcome studies is indicated.

67

Serum Electrolyte Abnormalities in Emergency Department Patients with Seizures

aa 9-t

RD Powers,MD I EmergencyMedical Services,Universityof VirginiaMedicalCenter,Charlottesvilie It is common practice to check serum electrolyte levels as part of the evaluationof patients with seizures.To determinewhether this was useful in an emergencydepartment IED), recordswere reviewedto identify patients presentingto a university hospital ED with seizures.In a 6-month period, 110adult patients made 124visits to the ED {or evaluation and treatment of a recent seizure. Analyzing each visit as a separatepatient encounter,the following data were obtained: 109 (BB%)had serum electrolytes and renal function parametersmeasured.Ninety-four 176%)had serum Ca measured,and 90 173%l had serum Mg measured.

Seven(6.4%)had Na < 136,615.5'kl > 145.SerumK: 19 (15.3%) were( 3.5, 5 14.0%)wele > 5.0. Serum Cl: B 17.3%lwere < 96, < 24, 5 l4.O%)> 3.0.

22 \20%l > 106.SerumHCO3: 42 ,.33.8%) R e n a lf u n c t i o n :B U N : 3 3 ( 3 0 . 3 % )< 1 0 , 5 1 4 . 6 % l> 2 6 i C r : 4 1 3 . 7 %<J 0 . 7 , 6 1 5 . 6 % l> 1 . 5 .S e r u mg l u c o s e3: ( 2 . 7 % )< 6 5 , 2 2 > 150.SerumCa: 5 (5.3%) < 8.5,2 l2.l%) > 10.5.Serum 120.2%l Mg: 30 {33%)< 1.8,I (1.1%)> 2.8. Mg levelsof ( 1.5 occurred more frequentlyin alcoholicsll2/371 than in nonalcoholics(l/531 (P = .00006).OnIy 3 (2.4%) of the seizuresin the entire series wereattributedto electrolytedisturbances(2 hypoglycemia,I dialysis-reiated).

Abnormalitiesin serum electrolytesoccur with variable{requenciesin ED patients with seizures.The most common electrolytedisturbancesin this serieswere low serum levels of magnesiumand bicarbonate.Abnormalities oi other electrolytes were relatively uncommon and rarely provided helpful diagnosticor therapeutic information. When a history of aicoholism,renal failure, or diabetesis presentin an ED patient with seizures, measurementof serum electrolytesis indicated.In most other situations, routine determination o{ serum electrolytes, magnesium,and calcium provides little useful information.

Emergency Phenytoin Loading by Alt lr19 Gonstant Intlavenous Infusion B Carducci,MD; JR Hedges,MD, FACEP;J Beal,RN; RC Levy, MD,FACEP; M Martin,lvlD/ Divisionof EmergencyMedicine, University of Cincinnati, Cincinnati;Departmentof Emergency Medicine, AlleghenyGeneralHospital,Pittsburgh

Serum Amylase lsoenzyme Alterations in Acute Abdominal Gonditions

EE Swensson, MD; Kl Maull, MD; ME King, PhD / Center for Trauma and Emergency Medicine and Department of Pathology, Medical College of Virginia,Richmond; Department of Surgery, U n i v e r s i t yo f T e n n e s s e e M e m o r i a l R e s e a r c h C e n t e r a n d H o s p i t a l , Knoxville In the initial evaluation o{ patients with abdominal pain, elevation of serum amylase is often considered an objective marker for pancreatic disease. Recent studies have shown that the serum amylase is composed of two major isoenzymes and several less active fractions. Normally the serum amylase consists oI 60% nonpancreatic isoenzyme {salivary or S-type} and 407" pancreatlc isoenzyme (P-type). To determine the accuracy o{ the serum amylasc in identifying a pancreatic source, amylase isoenzymes were determined prospectively in 65 patients initially evaluated in the cmergcncy department with a complaint oi abdominal pain and associated hyperamylasemia. Isoenzyme patterns were dcmonstrated by standard chromatographic techniques, and results o{ the isoenzyme patterns were correlated with initial and final diagnoses. Standard clinrcal parameters were employed to determine diagnoscs when operative {indings were not available.

Patients were divided into two diagnostic groups based on adrnission diagnosis. Group I consisted of 42 patients with acute pancreatitis. P-type isoenzymes were normal or elevated in 30 patients in Group I 170%) and S-type isoenzymes were elevated in 12. Group II consisted of 23 patients with abdominal pain attributed to causes other than Dancreatitis. There were no eievations of P-type isoenzyme in this group. However, S-type isoenzyme was elevated in all 23 patients. It is concluded that serum amylase is a useful but nonspecific indicator of significant rntra-abdominal disease. Amylase isoenzymes enhance the diagnostic specificity of the serum amylase when the P-type isoenzyme is elevated. Elevations o{ S-type isoenzyme suggest, but are not conclusive for, diagnoses other than pancreatitis.

7 O $"tYi::?:ion

of Garbox'hemosrobin

EJ Otten,MD; JM Rosenberg; JT Tasset,PhD/ Divisionof EmergencyMedicine,University of Cincinnati, Cincinnati A number of spot tests for carboxyhemoglobinare describedin )1

UAEIVABSTRACTS 1 4 T HA N N U A LM E E T I N G

to occur. The intent of this study was to investigate this theo4, recognizing that the ability to concomitantly use both agents in acetaminophen overdose would enhance therapeutic management. Ten healthy male volunteers were selected for the study.

The subjectsrefrained from the use o{ all medications for one week prior to the trial, and liver function studies and a general physical examination were performed.Each subiectwas fastedfor 6 h prior to and for 6 h after each phase o{ the study began.In the first, or control, phase of the study each subiect was given an oral dose of 140 mg/kg of NAC and venous blood sampleswere obtained initially and at 30 min, I h, 2 h, 4 h, 6 h, and 12 h aftet NAC ingestion. In the second phase, alter a 7-day washout period, eachsubiectreceivedan oral doseof 60 g of activatedcharcoal {ollowed by the same 140 mg/kg o{ NAC orally as before. Venous blood sampleswere again obtained at the same time intervals.

NAC serum levels were measured using high-pressure liquid chromatography and levels were compared with and without the concomitant administration of charcoal. Each subiect servedas his own control. Resultswere subjectedto the paired one-sidedt test. Resultsshowedthat in both phasesof the study there were measurable NAC levels throughout the first 6 h {ollowing ingestion, with peak levels consistently achievedat I to 2 h. When NAC was taken with charcoai, there was a statistically signifi cant lP < .0051mean reduction o{ peak NAC levels of 26.3% {rom controls. Differencesin levels were less marked at all other time intervals, and there was no measurabledelay in peakswith charcoal.These results tend to support the current practice of withholding activated charcoal when administering oral NAC. Howeve4 it remains to be determined whether this degreeof reduction in levels affects the clinical efficacy of NAC therapy becauseoptimal dosing regimensof NAC are not known. In addi tion, we propose that it is reasonableto administer activated charcoal and adjust the NAC dose basedon our results.

the emergency medicine literature. Four of these tests were evaluated for specificity, sensitivity, easeof performance, accuracy,reproducibility, precision, easeof interpretation, and expense'Second- and third-year emergency medicine residents were given samples of blood and were asked to perform each of 4 spot tests on the samples. They were told that the samples might or might not contain carboxyhemoglobin. The reagents and instructions were available,but no technical assistancewas given. The residents were asked to record the results of the tests and answer a questionnaire. Test results were analyzed by linear regressionand for within-run precision. The evaluatorsfelt that the tests were inexpensive, required a minimum of technical expertise/ and were easy to perform and interpret. None of the evaluators had any prior experiencewith carboxyhemoglobinspot tâ&#x201A;Źsts. It was found that the available spot tests for carboxyhemoglobin, found in the literature, are unable to accurately determine clinically significant levels of carboxyhemoglobin.

Zl I I

Hepatitis B Prevalence in Emergency Physicians

KV lserson,MD, FACEP;E Criss,RN / Sectionof Emergency of ArizonaSchoolof Medicine,Tucson Medicine,University The seriousnessof hepatitis B (HBV) as an occupationalhazard to health care workers is well documented. The prevalenceof serologicmarkers for this diseasein the generalUS population is approximately3o/oto sok.In medical and dental workers it is significantly higher: 16% in general dentists, 23o/oin anesthesiologists, 28% in surgeons/ and 30% in emergency department nurses. A study done under the auspicesof the American College of Emergency Physicians (ACEPI focused on the prevalenceof HBV markers in emergencyphysicians.Attendees at the ACEP Scientific Assembly, October 24-27, 1983, in Atlanta, Georgia, were given an opportunity to participate in an HBV serosurvey' Of the 1,252emergencyphysiciansand emergencymedicine residents who attended, 316 |25%) participated. Physiciansalready vaccinatedagainsthepatitis B were excludedfrom participation.

Of the participants,99 {31%}were emergencydepartment teaching faculty, 184 i58%) were community emergencyphysicians, and 33 111%)were emergencymedicine residents.The maiority were in the 30 to 39 age group and 167 (\a%l had 6 or more years in emergency medicine. A total of 297 physicians indicated no prior diagnosisof hepatitis. Of those physicians,258 186.9%)had no serologicmarkers for HB! 20 16.8%lhad surfaceantibody (anti-HBs),3(1%)hadcore antibody(anti'HBc),15 (5%)had both anti-HBs and anti-HBc, and I (0.3%) had hepatitis B antigen (HBsAg).Nineteen physiciansindicated a prior diagnosisof some type of hepatitis. Of these, l0 i53%lhad HBV serologicmarkers.

The overall prevalenceof serologic markers for HBV in emergency physiciansin this study, with or without a prior diagnosisof hepatitis, is 15.5%. These results indicate that HBV markers in emergency physicians are 5 times more prevalent than in the general population, and that HBV should be considered an occupational hazard to physiciansin emergencymedicine.

,1, t ll

Influence of Nutritional State and lmmunity on Prognosis of Severe Trauma Patients

MD; K Mashiko,MD; K Yasuda,MD; H Hemmi,MD; Y Yamamoto, T Otuka,MD / Departmentof Emergencyand CriticalCare Medicine,Nippon MedicalSchool,Tokyo Injury due to wounds, burns, or other trauma is o{ten complicated by microbial infections, including pneumonia and sepsis.

Numerous investigators have documented that trauma suppressesnormal host deiensemechanisms.Although prognosisof the trauma patient is influenced primarily by the extent of infury other {actors (ie, age,treatment, nutritional state,and immunity) are also related. We examined transferrin, albumin, total lymphocyte count, percentageof T cell, skin tests of delayedhypersensitivity, and phagocytoticindex (lipid emulsion test) on 28 consecutive Datients who were admitted to our department. The patients were divided into two groups.Group I comprised16noncomplicated patients with a mean iniury severity score (ISS)of 24.7. Group II comprised 12 patients with infection complications (concludingin death) with a mean ISS of 13.3.The mean age in Group I was 34.6 y1, and in Group II itwas 44.6 yr. Older patients have more complications.We estimatedthe extent of iniury by the ISS. Group I datum was significantly higher than that of Group II, and thus we conclude that this score is not useful when we speculate the prognosis of those patients. Other data were higher in Group I than in Group II, leading us to conclude that these laboratory examinations are useful. Nutritional state and immunity have considerable influence on the prognosisoI trauma patrents.

-t C) Goncomitant Use of Activated Gharcoal I I ana N-Acetylcysteine FP Renzi, MD; JW Donovan, MD; L Morgan, MD, PhD; TG Martin / Emergency Medicine Division,Milton S Hershey Medical Center, P e n n s y l v a n i aS t a t e U n i v e r s i t yC o l t e g e o f M e d i c i n e , H e r s h e y ; D e p a r t m e n t o f P h a r m a c o l o g y ,L o u i s i a n a S t a t e U n i v e r s i t y M e d i c a l Centet New Orleans Activated charcoai is a safe, effective, inexpensive adjunct in the management of most toxic ingestions due to its ability to adsorb a wide variety of drugs and chemicals. Acetaminophen, readily adsorbed by activated charcoal and commonly taken in overdose, also has a speci{ic antidote available, the sulfhydryl (NACf. However, the standard mancompound N-acetylcysteine agement of acetaminophen overdose does not recommend the of these two useful agents beconcomitant oral adrninistration cause adsorption and inactivation of NAC by charcoal is thought

74

Antishock Trousers: A Gomparison of Inflation Techniques and Detelmination of Optimal lnflation Pressure

HG Bivins,MD; B Hanke, MD; R Knopp, MD; PAL dos Santos, MD / Departmentof EmergencyMedicine,ValleyMedicalCenter, Fresno.CA

28

t I

The current standard o{ practice is to inflate antishock trousers {MAST suit) sequentially (legs followed by abdomen). No data exl rst to verify this method as being superior to simultaneous infla_ tion. Additionally no data demonstiate the optimal pr"rrr,,.. of lnlatrorr. Ihe_purpose of our study was to determine the optimal m,e.thodo{ inflating.the MAST suit and the optimal prcs.,.,re of r,:t_t3-\rn"as reilected by the perccntage of the total blood volume ilttvJ dlsplaced to rhe central circulatron. Ten healthy men were studied. Each subject,s TBV was determinccl and the blood vol_ umc distribution was calculatcd by injecting autologous red blood cells tagged with Tcchnetium 99 ^ ar'd s'.,irs.qu.it -hol. body_scanning with a radionucleotide gamma scanrring camera.

The MAST suit was inflated to pr..r,rr"., of 40 mm Hg and 100 HS srmultancously. and sequertiaily. After "o.t i"ftatio", Tchanges in the blood volume distribution werc determined.

The suit was then inflated simuitaneously to pressures oI 20, a0, 60, and 100 .mT HS and changes in volume of distributron were de_ termined after each maneuver. With simultancous inflation 4.5% and 6.6% of the TBV was displaced to thc cential circulation at 40^and 100 mm Hg, rcspectively. Sequential in{lation resultcd in J.6%, and 4.7"/" oI thc TBV being displaced centrally ar pressurcs of 40 and 100 mm Hg, rcspcctiiely.'simultaneor'r, inflrtior, *rs uscrl to dcrermlne the optimal inflation pressure. Inflation of the surt to prcssures oI 20, 40, 6O, and 100 mm Hg results in displace_ mcnt o{ 4.J%, 4.g,1,, and 6.61u o{ thc'fBV centrally. Our ,45%, rl,,tr.ul.,that a.greater perccntage of the TBV is displaced l1:l ccnrrally wrth slmultancous inflation of the suit than with sequ^ential,inflation, and rhat.high inflation pressurc (100 mm Hg) orspraccdmorc blood centrally.than.dicl_low prcssure (20 mm Hgl. However, thc differcnce in thc blood volume displaced, regardless or inflation pressure, is small and unlikcly io t rr,. "rly :l:::ld clmrcal rmpact. Both thc mcthod of inflation and thc pressurc of inflation should bc dctermined by thc clinical setting and clinical responsc to inflation of the MAST suit.

P Downs; SM Barrett,MD / Emergency Medicine and Trauma C e n t e r a n d D e p a r t m e n t o f A n e s t h e s i o i o g y ,U n i v e r s i t yo f O k l a h o m a College of Medicine, Oklahoma City

a tr !-f!ect of the Trendelenburg position and I I MAST on Blood Volume Distribution MD,.R,f1opo, MD;pALdosSantos, MD/ Department 1,G_Plyirt oI tmergency Medjcine,

ValleyMedical Center, Fresno, iA Thc Tiendelcnburg.position is commonly uscd to trcat the hy_ potcnsivc paticnt, although data that qrro.rfitrt" changcs in blood volulrc ln thrs positron alc scarce. Thc purposc of our study was to determinc the effcct of the Tiendel*U,irg position on bloocl volume distribution and the cffect of antishJci< trousers (MAST att8lentlng blood volume displacement in subjects :y]jl ll pllceo ln thr lrendelcnburg position. Ten hcalthy men werc stud_ i9d fo1il. blood volume (T-BV) was determincd l.,a tl. clistributron ot btood volume was calculated using Technetium 99 m tagged red blood cells and total body scann"ing wilh a ,adionu_ cleotide gamma scanning camera. Each subjec"t was scanncci in tnc suprne position and then placed in 15. of Tiendelcnburg ancl rescanncd to determine the change in disttibution of blooj vol_ the tw_opositions. The MAST suit was appliccl and lT..b:,r.:l rnllated to 4.Umm Hg and 100 mm Hg, and changes in-distributlon ot ttlood volume were again determined. At 15; of Tiendelcn_ burg, 1.1% of the TBV waslisplaced to the centrai circulation.

With inflation of the suit to.4d mm Hg and 100 mm Hg in thc Tiendelenburg position, an additional 2.6% and, B.6i/" oI thc TBV was drsplaced to the ccntral circulation. Our data indicate that placing patients in the Tiendelenburg position J*t"., a small amount of blood to the central circulaltron. Inflation of the MAST suit to 40.TT Hg and 100 mm Hg in subjectsplaced in Tren_ o € . l c n b u r gd r s p l a c c dn o m u r e b l o o d c e n t r l l l y t h a n did inflation of tne surt ln the supine position.

Gontlot of Intra-Abdominal Hemorrhage 7A f rY and Shock: A Gomparison of Fluid Besuscitation, Antishock Trousers, and Aortic Balloon Occlusion RBLow,MD,C Schmidt, MD;RJWilder, MD;W Massion, MD,

29

Control of _hemorrhage and hemodynamic stabilizatron are the principal goals of management of hemorrhagic shock.

Thls study cxamines.the c{ficacyo[ four rreatm.nt rnddrliti.s in obtainins thcse goals: intravenous fluid replacement {IV), fluids used conl comitantly with military antishock trousers 1lneSf1, fluid used concomitantly wrth intra-aortic balloon occlusion at the level of the diaphragm.(balloonJ, and a combination of fluids, MAST suit lnlatron/ and balloon occlusion {MAST plus balloon). Twentycight mongrcl dogs were anesthetized, intubatecl, vcntilated, a;d nad artcrlal/ venous and abdominal pressure monrtoring catheters placed. Following laparotomy, the ipleen was severely lacerated by blunt rrauma. The abdomcn was then tightly closed and the exp,eriment was begun. Measurcments continu;d until the dog orcd or ulttl thc experiment was tcrminatcd after 4 h.

For all trcatment conditions hematocrit dropped during the coursc of "ot thc experiment; balloon occlusion was'e{fectivc ,to*i"! ini, . .00011,but MAST had no statistically significant e"ffect.

9top tl After 60 min thc mcan hematocrits wcre rV iz,'laeST lg; balloon, 25; and MAST plus balloon, 27. Average rrte, of blood loss l c c / n l r n J _ c t u n n €t h r . e x p e r i m c n t w e r e I ! 1 9 . 6 , M A S T 7 . 0 9 ; b a l _ loon, 1.73; and MAST pius balloon, 1.55. Animals with balloons b^lcdIrrorc slowly thal did animals in the other two groups {p < .0001J. MAST werc also cf{ective at slowing ttre Ute"caing 1Z < .05). Mcan survival time for IV dogs was l32"min, and for'MAST dogs it was 161 min. This differcnce is not statistically signifi_ cant. Of the balloon and MAST_plus balloon dogs, all ";""pi ";; s u r v i v c r . lt h c c r r t i r c 4 h ; t h i s d i { { C r c n c eb c t w c c n " b a l l o o . , r n d non_ dogs is signific.ant lp : .002). Mean arterial pressure P_r,tl,:qr, {rvrAl.J dcchncd durlng thc coursc of the experiment and the balloon was cffectivc at slowing this decline (p< .0001), none of the othcr.comparisons was staiistically signilicant. Sixty minutes into thc_cxpcrimcnt MAps in torr wcrc iil SZ, naeSl Ai, balloon, 113;.and MAST plus balloon, 124. Although thc MAST fit corrcctly. around thc dog,s abdomcn, inflating ti. trorlr"r. to I00 torr raisccl intra-abdominal pressure to a m6an of 40 torr. This re_ "r dogs suggcsts that intra_aortic balloon occlusion may :^:.ri:l D c ( ) I D c n c l t l l n t h c m a n a g , c r n c not f p a t i c n t s w i t h m a s s i v c intra_ hcmorrhagc arid shock. We plan to study the effrcacy 1fll-l"ll o r iltc tulloon rn human trauma victims.

Pne_umaticTrousers in Refractory 77 CardiopulmonaryArrest IB D M.la h o nPrehospital ey,

MD, MJ Mjrick, MD / Departmenti ol Emergency Medicine, Hennepin County Medical Center, Minneapolis, and Wausau Hospital Center,Wausau. Wl Persons refractory to carly application of ACLS have a dismal prognosis. Ncw modalities are needed for this almost univcrsally letl-ral condition. We have evaluated prreumatic lrousers in the trcatm€nr of refractory prehospital cirdiopuimonary arrest. To aate zy4 patrents have been entercd into this controlled, prospec_ tive, randomrzed study..All patients were more than 20 years old anu ln cardrac arrest of apparent cardiac etiology.

To be cntcred ,lt study all paticnts had ro bc rc{ractory"io therapies'in_ 1?l: cllloed 1n our paramedic standing orders. If at the end of these standins orders the paticnt remained in arrest, t. l".. entered lnro.tne study and pneumatic trousers wcre applied or not ac_ c o r L t r n gt o a r a n d o m i z e d l i s t . T h e r e s u s c i t a t i o n and discharge rates for thc control group.were 22"/" and,6To, respectively.

Wiih pne-umatrc trousers/ resuscitation increased to 27% and discharge to.€%. Thc control group in ventricular fibrillation (VF) had"a l,/70 resuscrtation ratc and.a 9To discharge rate.

The pneumatlc trouscrs group with VF had a 26% resusCitation rate ind, a l0% rare. In pulseless rdioventricular rhythm (pIVR), the :1.-:11],C. controt group had a 9"k resuscitation rate and 0% discharge rate.

For PIVR thc pneumatic trousers group had a B0% resuscitation 4% discharge rate. Theloniroi group in asystole (AS) 1,,^,,. nao a:igj t/Yo resuscitation rate and a 0% discharge rate.

The pneu_

UAEMABSTRACTS 14THANNUALIVEETING

group demhospital intravenouscrystalloid infused The MAST no signi{icani improvement over the c-ontrol group in ."ri*,.a t S {MAST: l0'6 '- 5 9' t h e o r e s c n t i n ge m e r g e n c yd e p a r t m e n T widelv .;;,;;i 9.ii ;'o.e 1.r"h.t.'p..iiminarv data contradictthe patients in all is indicated suit MAST thc premise that ....p,.a hypotensive states'Irom this investigation' ,"rtiioti,i"""matic that further study is necessary-to determine *"-"6""f"a" whether the prehospital use of the MAST suit benetlts certaln mor,rrLgro,rp,ani to evaluate the overall effects of MAST on bidity and mortalitY.

rate and a matic trousers group in AS had a 24% resuscitation ta?e. The difference in resuscitation rate with pneu6%;i.;lt;tg" of these matic trousers was not statistically significant in any and disr e s u s c i t a t i o n e n h a n c e d s o m e w h a t T h e s e "at.gories. *ittt ttt" pneumatic tlousers make it only-an adiunct ;h;G;;;,;t to be considered in patients presenting with, bradyasystolic rhythms who are refractory to standard rnltlal tneraples'

78

Effect of Antishock Trousers on Cardiac and Respiratory Function Following Acute

Inlarction MYocardial MD / Departmentof JA Shaff,Mb; K Dittrich,MD; GA Pantley, Et"tg"n"y Medicine,St VrncentHospitaland Medi,calCentel ;;J d;p;ltt"nts of EmergencyMedicineand Cardiology'oregon Portland HealthSciencesUniversity, The effects of in{latron ol antishock trousers (MAST) on carand respiratory gas exchan-gewere studied di;-h;;y;amics iolforlll"g """,e myocardialinfarction {AMI) 1n l2.dogs'The AMI *m p.oi"".a by mercury embolization of the circumfiex coronarv arterv.In 7 dogsMAST were inflated to 90 mm Hg at 25 min post AMI/.while 1n-5 ;;;i AMiIC'"up Ii and deflated at 75 min i"st tG-.ip II) MAST were not inflated ln Group I when MAST 3l *"?" i"ttrt"a post-AMI cardiacoutput (Co) fell (3 6 L/min to : niJ, and systemicvascuiarresistance(svR) increased i-lil;-t -A:i/i' * z,O7z'dy sec cm-s)but {ell significantly when MAST [ei" d"{lat"d 12,973to 2,343 dy-sec-c--6,P < '05)' Mean arterial prcso*"t. |MAP),hcart rate {HR),pulmonaryartery diastolic i;;;{PADPi ,nJt.i, u.",ti.ular'work {LVw) did not changc'Ad"?,"iirlpH fcll (7.38 to 7.3r, P < 02J Po2 decreased iii-i'rri" i' . .oor), and ihe alveolar-arterial 02 gradient (A-a l;;";;i4, grrdi-i,t"r""t"d (I2.4'to g1.4,P <.0i). The MAP a HR product ' , < 0001) l i r " i " i i " r t . a - . i g t l f i . u n , t y i t + . . ] t o t t o 1 68 . . < . t 0 3 P *ith infl^tiott o"fMAST'In Group II (control)following AMI' p (6 7 to 4 5 Itep d""t"ot.d (128to 104mm Ug, < '02),LVW fell in C.Q change tto significant wai there < and .02) P ii-l-Zi"-. iiln, r]4,'peoP artcrial pH, Po2, or A-a-gradient Additionally to ;h" i\4AP x HR product-decreasidsignificantly (197 x 103 15.1x 103,P < .0001).Following AMI, MAST inflation appearsto sustain MAP only by increasing SVR without improvement rn (an esCO. Infl"tio.t of MeSf elevated-theMAP x HR product gratl-r,io" of MVOz) and adverselya{fccted th-e-!Oz and A-a rlient. Thus ,tt. oT MAST to incrcasc MAP following AMI may havc delctcriouseffcctson ischemicmyocardium'

rrtl I J

Effect of Antishock Trousers on the Score: A Prospective Analysis l"rna

1!tf|

CDt

Efficacy

of the Post'Traumatic

Cross

Table Lateral view of the Gervical Spine

MD / JC BJCIIANd, MD, FACEP; Jr, MD; KV /SCTSON, W-HBLhd'Emergency Medicineand Departmentof Radiology' Sectronof ArizonaHealthSciencesCenter,Tucson disA retrospectivestudy o{ 128randomizedpatients with the "ft"tn"'airi"otis of cervical spine {racture,dislocation' or subluxto "tt"blith the accuracv o{ the-post;;i;;-;;;;dcrtaken view radiographof the cervical spine lateral ir""-"ai" "rors table physiiCrivf Radiographswere read by the {aculty emergency dirgttotit differedfrom the patient's final radilliii ;;ti,h;.. radiof*i. ai"*"osis, the"radiograph was reevaluated by the olo"gist,,r1hor. The accuracy in diagnosing post-traumatlc tptt" ,t "ot-alities on CTLV ilone was 74'21" lor the ;;;"";l physician and 79.7% for the radiologist' Thirtv per;;"i;;;.; cas.; undiagnosedby the emcrgencvphysician were sub;;;l;i trcated ai unstabie iniuries' Thirty-five percent of C1' s"qr-,cr-ttlv on 1;:;;i ;i c", ond 42'4% ol c6' abnormalitie.swere missed The bitn Uy boiil ttt" emergencyphysician.andthe radiologist' found -o., tt"iot"t radiologictlg.tt'oi abnormality on CTLV were th9 of anv of nonalignment fractuie logt ;;;;;b;;;" \4d.4%1, vertebril bodv size 1,27'3%l'soft ^"J "t"o'-al ;;";r'A;.1%i groupsThree patients' oI ilss.,e swelling was found in only 4J% #"plir"""- *""e identrfied who were at increasedrisk becauseof frli.-,t"grtiu" CTLVs: lJ patients with significant arthritic manii".trtiol.r, on their CTLV; 2) patients with poor technical quality iraiogrrpt., and 3) patients oider than 35 years Although several tt"alLt (ie, CJ laminographv)have been advocated ;;t#r;;-hi; ," the CTLV in evaluatio-nof tht tt^"-' patient with ^.lJiii"i,. "".fJrt cervical spine radiographs,no single type o{ subsequent was clearly t"pittiot in demonstratinglesions'.This ;;;i;ril" seiies .lca.ly iliustratei that a normal CTLV alone is unreliable to ,r-rJpot""ti"tty dangerousif used as a screeningexamination Ji"giot" post-trauniatic abnormalities of the cervical spine'

WU Ai"futt,MD; PE Pepe,MD; DJ Applebaum;CH Wyatt;WR Oedo;KL Mano,MD / Departmentof Emergencyand Ambulatory Medicine,BrookeArmy MedicalCenter,FortSam Houston; and Departments.

Ciiy of HoustonEmergencyMedicalS^ervices; of (4edicineand EmeigencySurgicalServices'BaylorCollegeol Medicine,Houston Despitc the extensiveuse o{ the antishock trouserssuit (MAST To ,,-,*i-iiotp.",ive studies delineating its ef{icacy are lacking (TS), a-prospecscore trauma the on MAST of ef{ect the "urt""t" ilve, controlled investigation was corrducted Criteria for entry included those patientJ sustaining blunt or penetrating injuries *iih ^ ty.toll" Llood pressure{BP)o{ -< 90 mm H.g 4il patients to a singletraumaIacility underthe directionot *.r. ,rr,-rrpor,ed a singlephysician and receivedidentical prehospitalmanagement with the exception that the MAST suit was apby pitr-.ii"., pit.la ""a fully inflated prior io intravenous-catheterplacement tn aiternatedays.From November l, 1983,to |anuary 31,1984'68 oatients 185%with penetratinginjuries)were enteredinto the (n : ii"av. ift. i"itial pre'hospital BP and TS of the MAST group t aOtJ"a the contro'lgtor.p(tt : 32) were 55 :t.31,mm Hg/9'9 4.4 and 59 ! 32 t"m Ug I 9.2 + 4.9, respectivelyThere was no significant di{ferencebeiween the MAST and control groups in preth-eresponse,scene,and transport times or in the volume of

fflil"'?f'#" 8 1 if"?i::lS+'":1'fJBil,"'l

The Mt SinaiMedical S Mace,MD-l EmergencyDepartment, Center.Cleveland Twenty-two casesof acute spinal cord injury were seenln the .-"tg.tt"y department of Mt Sinai Medical Center during a 14petlod. Two patients with cervical spine fractures diag-ottl "ot.J "it plain x-ray films did not have computerizedtomograpity lCfl sca.tsa.td were managed as outpatients' The remaining lo'pi,i."a" *"re hospitalized.iht"e of these patients had a centraf cord syndrome with normal cervical spine plain films, and CT scans.There was a disparity between the plain film and the CT r."., in more than half o{ the remaining patients 19/17'ot 53%1.In 4/17 patients 124%)the plain x-ray film was read as nor-nf iv , radioiogistwhrle the CT scanshoweda fracture' In 8/17 p"ti"*. t+/y.t tfre cervical-spinefilm was read as a fracture,disiocation,'or soft tissue widening between the cervical spine vertebiae, but the CT scan done a'fter admission was normal' The plain x ray film suggesteda {racture or dislocation that was coniirmed by'the CT scanin only 5/17 patients (29%l'The use oI CT body scansis a rapid, accuratemethod for delineatingacute cervical spine iniury.^Plainx-ray films are-frequentlyinadequatein d"li"nit ""rrri"ri spine trauma. Indeed, significant iniury that

30

nose and manage patients suspected o{ having ureteral calculi.

The accuracy of the PAR for detecting ureterolithiasis in emergency department (ED) patients is not known. This study was designed to determine the sensitivity, speci{icity, and predictive value of the PAR for diagnosing ureteral calculi in an ED' Records of 206 adult patients 1747 men,59 women) who underwent emergency excretory urography were reviewed as part of an ED evaluation for suspected ureteral calculi. A PAR was taken shortly before the excretory urogram (EXU) was performed on all patients.

Each PAR was separated from the corresponding EXU and both were reviewed for radiographic evidence of ureterolithiasis. The results o{ the PAR and EXU interpretations were compared.

There were 92 true-positive PARS (45%1, 19 false positives (9%), 56 false negatives 127%1, and 39 true negatives (tl%), yleldlng a sensitivity oI 62% and a speci{icity of 67%.In those patients with the highest clinical probability of having a ureteral calcuius, the PAR had a positive predictive value of 86% and a negative predictive value of 22"/'. Based on these data, we recommend the following guidelines for accurate and cost-e{{ective radiographic evaluation of ED patients with suspected ureteral calculi: l) a PAR should be obtained initially on all patients; 2) when there is no evidence of a ureteral calculus on the PAR, an EXU should be obtained as soon as possible; and 3) when there is radiographic cvidence of a ureteral calculus on the PAR and the patient has clinical features highly consistent with ureterolithiasrs, an emergency EXU is not necessary.

cannot be seen on plain x-ray film may be present. CT scan is superior to plain radiography in diagnosing spinal iniriries, and eliminates the large number ll2/I7, or 7l%l of false-positive (a7%l afi false-negative(24%Jresults obtained when relying solely on piain roentgenograms.

O 4t 9Z

Computerized Tomography in the Emergency Department

SA Meador, MD; RA Walker, MD / Section of Emergency M e d i c i n e , D e p a r t m e n t o f S u r g e r y , W a y n e S t a t e U n i v e r s i t yS c h o o l oJ Medicine, Detroit A retrospective study was made of 2O7 c;^anial computed tomography (CT) scans executed within 24 h of presentation to the emergency department iED). Of all patients who entered the ED, one in 74 was scanned. Overall 32% of the scans showed acute intracranial lesions. The most frequent findings were iucencies, intracerebral hemorrhage, subdural hematoma, epidural hematoma, intracranial {oreign body, intraventricular hematoma, and subarachnoid hemorrhage. The CT scans provided valuable diagnostic assistance, altering many provisional diagnoses. The time to obtain the CT was shortened significantly when the initial examinrng physician ordered the scan without waiting for evaluation by the consultant.

83

4

Usefulness of Abdominal Flat Plate Radiographs in Suspected Ureteral Galculi Patients

CD E Gorrelation of Historical and Physical Findings with Fractules in Knee Iniufies CrIl of MD/ Division MD;R McDowell, MD;RJ Salomone, WH Spivey, of Pennsylvania, TheMedicalCollege Medicine, Emergency Philadelphia

KF Zangerle,MD; KV lserson,MD, FACEP;JC Bjelland,MD / Sectionof EmergencyMedicineand Departmentof Radiology, ArizonaHealthSciencesCenter,Tucson The evaluatronof suspectedureteral colic patients usually includesan abdominalflat piate radiograph.Between80% and90% of such stonesare said to be visible on plain radiographsdue to their calcium content; however,these radiographsdo not enable the readerto localizeradiopacluebodiesto the ureterswith confidence.The purposeof this study was to determine the usefulness of abdominalflat plate films in correctiy identifying ureteral calculi. One hundred seventeenscout {ilms {rom patients who underwent IVP studies were examined by an emergencyphysician and a radiologist.The films were presentedwithout history in a random,blind manner to the readers,who were askedto identify and localizea1lcalculi and assigna confidencevalue to the reading. There were 50 scout films from patients whose IVPs demonstratedradiopaquestoneswith ureteral obstruction (38 patients with a total of 40 stones)or obstruction without visible stones (12patients).The radiologist correctly identified 23 of the radiopaquestones(confidence: likely or better),ialsely predicted14 stones(confidence- Iikely or better),and {ailed to identify any stone in 9 of these films. The emergency physician correctly identified14 of thesestones,Ialsely predicted6 stones,and failed to identi{y any stonesin 12 o{ these films. There were 67 scout films from negativeIVPs. The radiologist identi{ied 42 of these films as having a possiblestone and stated that 16 of these films were likely to have a ureteral stone. The emergencyphysician statedthat 44 of these{ilms had a possibility of a stone,and 23 ol thesefilms were likely to have a ureteral stone. Whether read by the radiologistor the emergencyphysician, abdominal flat plate radiographsare poor predictorsof ureteral calculi and do not add significantinformation in suspectedureteral colic patients.

84

To determine the clinical indications for radiographic examination of the traumatized knee, a prospective study was conducted of 250 patients presenting to a residency-based emergency department and aifiliated hospitals. The patients included in the study were those with trauma to one knee within 72 h of presentation to the emergency department. Patients with muitiple iniuries from trauma were excluded. Historical data included mechanism of iniury ability to ambulate, ability to bear weight on the affected knee, and time course of pain and swelling. Physical data included appearance of the knee; presence of contusion, effusion, or abrasion; stability oi the ioint; and results of McMurray's test.

Computer-assisted single and multifactional analysis of the data was performed to determine those factors that had the highest statistical correlation with a fracture. Historical data that strongly correlated with a fracture inciuded the inability to ambulate (P < .002) and the inability to bear weight on the iniured knee (P < .001). The mechanism o{ iniury (ie, direct trauma, twisting the knee, etc) was not useful in predicting a fracture. A difference in the gross appearance of the iniured knee when compared to the normal knee was the most significant factor o{ the physical examination in predicting a fracture (P < .002). A gross difference was observed in all fractures. Tenderness (P < .003) and decreased range of active flexion of the knee lP < .OZ) also correlated strongly with {ractures. Effusion, ecchymosis, and ligamentous laxity were not helpful in predicting fractures. No historrcal data or positive physical findings were {ound to be 100% predictive of a fracture; however, several {actors were strongly rndicative of a fracture. The inability to bear weight or ambulate, a dilference in the gross appearance of the knee, tenderness, and a decrease in the active range o{ flexion had high correlations with fractures.

The presence of these historicai and physical findings is a strong indication that radiographic examination may be beneficial.

Accuracy of the Plain Abdominal Roentgenogram in the Diagnosis of Ureteral Galculi

(t1Q Ventilation During GPR: Two-Rescuer |frll Standards Reappraised of Anesthesioiogy, RRT/ Departments RJ Melker,MD; MJ Banner, of Medicine, College Pediatrics, and Surgery, University of Florida Gainesville

CS Roth,MD; fH Berquist,MD; BA Bowyer,MD / Departmentsol InternalMedicineand Radiologyand Divisionsof Emergency Mayo Clinic, Rochester, MedicalServicesand Gastroenterology, MN A plain abdominal radiograph (PAR)is commonly used to diag

3l

UAEIVABSTRACTS 1 4 T HA N N U A LM E E T I N G

(V1) During two-rescuerCPR, ventilatig" *ilh^l tidal volume is interposed (T1) 5 sec 0 o{ time insprraiory an and mL o{ 800 allway cvery Iifth chest compression;this pattern may-.rncrease if the airot..{"i.lpr*t.nough to precipitategastricinsufflation ir* ii ""oi.r.ctcd."To tett this hypothcsisand to study an alterair""1*. -.',noa of ventilation, we developedan.unprotected aY to proximal connected was pneumotachograph A wav model. a ,Jipio. a.rd on. Iimb was connectedto a test lung and one to drain w"te, "ol.,mn pressurevalve by using a 30-cm long Penrose an .iophag,rs.The column was fillcd to 15 cm H2O' If io -l-i. pr* .*...d.a tS cm"Hrg V1 could partially enter the esophagus' t-r,ng"o-plia.tce (C1)was set at 0.1,0 04, or O'02-L-lcmH2O and In"ii-l,i"y t"iittrn . nl.2 cm H2O/L/sec; TI was 0,'5 or I sec' rplrrii,tv iv't and expiratory{v.) flo*t, Paw.and lung inflation ,irl"-riitit inirtrtr,ii,n volumeswerc recordcdCestric insuf[iaoccur with a C1 of 0.1 L/cm H2o and a T1 of-1 sec; ii."fiJnot C1 or a T1 of 0.5 sec or both decrcaseslung-inflation ;;;;;"g ,nJ i.r"r."rt.i gastrii insufflation (FigureJ'With ventilation by substantialV1 enters the stomach when Cpn ,.lo--"idations, the airway is unprotected,especiallywith decreasedC1 A T1 of 1.0 reducesthis;ffect but doesnot prevent it' For lay CPR, ven iiLtio" should be done with a longer T1 and, thus, a slower V1' which requires a pause a{ter every filth chest compression'For .-"rg"n"y personnel,cricoid pressureshould.be used to prevent srstri" inrrrfflation. Finally o*yg.tt-po*"ted breathing -devices ?rrri a"i*.i higtt v1 should be'riodi{ied or not used when the airway is unprotected.

Comparison of the EOA and G)-, Standardized Tube in Gardiac Arrest Endotracheal I O Y Huiru,g,"r, MD; JE Clinton,MD; E Fuiz, MD / Departmentof EmergencyMedicine,HennepinCountyMedicalCenter' Minneapolis Previous comparisons of esophagealobturator airway (EOAJ aJcndotrach"ri 1E11ventilation havc suf{eredfrom lack of standardizationof important variables.Variablesstandardizedin this ri"Jy i""l"a"d "rirrrrrrr"" of arterial sampling by using cutdown in pulsclcsspaticnts,timing o{ bloodgassamplrngin relation.to ""i"ir".r..ri intubation,anI mcthod of vcntilationusedwith thc two airways. An oxygen-poweredbreathing device was used for ventilation becauseincreasedvolume requirements of the EOA an inherent bias if bag-valvedeviceswere used' -igfit-i"t-a"ce patients suf{eringprehospital.cardiacarrest had an Tw"cnty-seven ABG drawn a mean 7.3 min after arrival in the emergencydepartmcnt while being ventilated with the EOA' ET intubation was performedimmedlatety,and anotherblood gaswas drawn a mean Z-8 -i.t following intubation. All patients without pulse were ,"-pt"a through in arterial line placedby.cutdown' Patientswho a""i"p.a " p",rlt. during the resuscitation were sampled per"..t^r..trrrly. i'ulselessp"ii.tttt (n : 15)had mean EOA gasesof pH, 7.38; PCOy,25i ".td POr, 29l Their mean ET gaseswere pH' i'.iiz' iior, z6', and Po2, 2t1. Patients with a-p-er{usingrhvthm PCO1,25i,and PO2, i"-: iZl h-admean EOA gasesoI plH,7'i?'; 446. Their mean ET g^tes*er. pH, 7'35; PCO1,24i and PO2-,40I' p"it.J i test analysis"ofthe blobd gas data revealsno significant clif{erencebetween EOA and ET ventilation with 100% oxygen ui, ," o"vg""-powered breathing device' We conclude that the EOA, when"usei with an oxygen-poweredbreathing device.,is an effeciive means of airway manlagement,with ventilation achieved equal to that of an endotrachealtube.

cD CD Guided

(rlotracheal

lntubation

Using

a

mands specialskills of the emergencyphysician This challenge ir oriii"irf"tfv difficult in those patients in whom cervical spine A techniquebl light-guidedorotrachealintuiniliv i. suspected. il;;;";-h;;-lieen describedin the IiGraturc and was perlormed rlnJ"r p.oto"ol by residentphysiciansin a busy urban mobile insyst;m. The method utilizes a flexible lighted stvlet ;;;l;;;;;; FL) to provide a iri""i f,"-, ioncept Corporation, Clearwater, of the soft !""a" to "oirect plaie-ent through transillumination iirr""t "i ,tt. neck. Rapid intubition was achievedin 79 ol 22 paticnts (86%).Lacerationof the {renulum o{ the tongue, a comilication'seen in one patient during initial operatingroom train;; "ccur in'thc {ield study' other trauma to the soft il;,-;il of-this ,itlu.t *rt seenin on.lyone othcr patient The advantages -",n"a, including rapidity of intubatio:', ability to intubate thc head or neck, and the apparently *ltfr."i'manipulaiion-of few complications,are particularly attractive to emergencypersonnel.A detaileddescriptionof the method is given, suggestlons ior modl{icatlon of the d-eviceare offered,and {urther studies are proposed. of Mask

ltal

Influence

CDl|

Ventilation

Design on Bag'Mask

nb Stewart,MD; R Kaplan,MS; F Thompson;B Pennock,PhD / Care Olpartmeniso'fMedicineand Anesthesiology/Critical of PittsburghSchoolof Medicine;and Office l,liiili"", University of Research,Centerfor EmergencyMedicineof Western Plllsburgh Pennsyrvania.

Rcccnt rcsearch and clinical experiencewould suggest th.at most cmergency careprcrvidersfind it difficult to ventilate adequatcly wiiit bag-maslidcvrccs'Much of the probiem appearsto masl<seaion J*i"t .-"n.t thc difficulty in maintaininga pro-per ih. nrti.ttt t face. A newly introduced facc'mask dcsign consists "balloon" through which a Guedel airway is atof aiow-p..ssure ir"f-r.a ,ia extendedproximally ihrough the-mask to allow the a ",ir"fr*""a of a veniilation bag. This balloon, resembling undcrsurfacc,sealsthe nares and mouth when iJlyi;i; il;the the airway o*6t"J againstthc facc. Vcntilationis achievcdvia i"t-ti.tt ""i""a. through the nask to iust abovethe epiglottis our r,"ay *"t J"tlg.red t'o evaluatetidal volumes deiiveredand mask paicak'with thislnnovative mask design,and to compare.these *ith thote achieved with standard bag-maskventila;;;"i";; volunteers with varied experience in bag-mask aion. fttltt.." vcntilation wcre chosen to vcntilate a specially adaptedventilaLaerdal Corporation) The group tion mannil<in (Resuscianne, 2 EMT:As, 4 EMT:Ps,and 4 emer"u.rtnined3 nurse-anesthetists, gency mcdicine residents.The tracheaof the mannil<inwas coni..,.d to a test Iung that allowed for varied compliancesettings (0.10.01).Peakpressuregeneratedby squeezingthe bag was mea,.,i.d ,t'th. ventilation iort (outletJof ihe bag' A constantrate of 12 ventilations per min was carried out by each volunteer for 2 min. Tidal volu-meswere calculatedby noting the amount of air ,ia""iv t"",.d into the test lung. Mask leak was estimatedby r"titr.ai"g this volume from the volume extractedfrom a reser"oi.fr"g fe"edinginto a Laerdalbag-maskdevice'Volunteersventilated tfre test Iung using three irasks in rand-omsequence:,the a Laerdal mask (old Gilvf*n" mask (F.espir6nicsCorporation), inflatable black with mask Robertshiw typei, and a transparent "iellvfish" mask ;i;.'Tti. ,;..^g" iidrl volume deliveredby the was consistentiy ttigtt.t than either o{ the others' Averagemask l.ak -us considerably lower at both compliances (Thble) We conclude that, pending clinical studies, this mask design appears pto-itl"g'in solvirig the problem of mask leak and inadequate ventilation.

CrCD Lighted stvlet

Tnollmer,MD; RD Stewirt,MD; PM Paris,MD; D Ellis,MD; PE of Medicineand Anesthesiology/ Berkebile,MD / Departments of PittsburghSchoolof CriticalCare Medicine,University and Department Medicine;The Centerfor Emergencyl\4edicine; Hospital,Pittsburgh WesternPennsylvania of Anesthesiology, The managementof the airway in acutely iniured patients de-

AverageTV (cc) Averagemask leak (cc)

32

"JellYf ish" 0.01 0.1 506 832 BO

208

Laerdal 0.01 0.1 409 615 358

455

Robertshaw 0.1 0.1 445 757 196

331

90

Every f;:ro,:flT.i""b"oes Ghird

D Hodge,lll, MD; F Tecklenburg, MD; G Fleisher, MD / EmergencyDepartment, CnitOrenS Hospitalof ph'iladetphia; and Department pennsylvania of Pediatrics, University of Schoolof M e d i c i n eP, h i l a d e l p h i a We studied 76 children who presentedto the emergency depart_ ment (ED) with a complaini of coin ingestio., io d"i.r_i.r. roentgenogramsare necessaryin all sltuations/ and :l:a,h:l wnlch, symptoms or signs are predictive of esophageal coins. X_ r a y t l t m s w e r e c o n s i d e r e dp o s i t i v e i f t h e c o i n was in the esophagusor aiway, and negative if the coin was subdiaphrasor nor seen.X-rayfilms were positivein 24 oi rheie l}2"hl :lalrc / b p a t r e n t so,t w h o m l l ( 1 4 % l . h ando s y m p t o m sF. i f t y _ t w o {(rg%) ol the 76 patients had subdiaphrrg-rtii ioi.ig" fZar6" tqz,'s,iy"li, f:1",'gr bodies {t0, t3y.J.sein or, ,o.nt'g"r,ogrrplry. irlo p^i :,r^:: u e n r s n a d n e g a t r v el i l m s w i t h s y m p t o m s ,a n d i h e r e were no .oli:,i". airway..Four.teen (18%l of the chiljren required re_ moval ot !f. the coin. The following symptoms and signswere noted 16.(zi%), vomitin'g, 6 lB%); and 1:.]:$::!-i,,chokrng/coughing, 5 {/%). Signsnoted in the ED included iocalization, 8 l{:li"q1i, ll-1t""1i"9, 4 l5%,)rand.chest pain, 4 (5%). Multiple regres_ lit^f performed. Variables correlating with positlve is:rron :lnlyrsls ryas rrm. ln order_ot signiticanceincludedlocaiization,choking at in_ in the ED, vomiting,and chestprin. ng" iid ,rot ,g_.,tli:l, 9rgoli"g the analysis.Those requiringremovalhad tlie follow_ Inlrugn..9. symptornsor signs:localization,drooling at inges_ llC-.tC^ltll..*, uon, cnoktng rn the ED, and vomiting ar ingestion.

Sy_pt*o_ type is prcdictive of x-ray iindings and iray be""predictivc of'nccd ror rcmovat.Ihirteen of 13patientswith symptorns had positive x-ray film^s, io.il of eS wiih io symptoms lchi 39_compared p -.001) Atthough the chi square i, iig"iti.r"i, :Hif ; i0 366, tne trndrng.ot csophagealforeign body rn 17% of patients with no symptomsleadsus to the recommendationthat alt patients need an x-ray film of chest and abdomenlf coin lngestion is suspected.

I

Gomparison (|{ of the Effectiveness of V I Different Gervical lmmobilization Gollars JB Mccabe,MD; DJ Nolan/ Departmentof fmergency Medicine, 'Vailey Universiry^Schoot of Medicine:and Miami Yl'^Sll ?.:t: nospttat Btosciences center,Dayton.oH Immobilization oi the cervical spine is a key element in the .1r9,o1,,htmultiple.trauma_patieni.

Although many dcuiccsare availaDle tor cervtcalimmobilization,data supportingthe clear superiorityof one immobilization device are siarce. f"h. p"rpor. was to compare, by radiographic mJa-surement,the :l,li-l: :l*r4 aDlnryor cervrcalcollars to immobilize the cervical spine. The following coilars were compared: Jolst Stifnecklji Zi--", C"tCollar (z), D_ep"uy i,t itra.tpt t" -Jii^, 1t1,and Fer1fT1ja lervical no-washrngton L,xtricationCollar (E).These representj distinct designconcepts,incervicalcollars.'Sevenm.rr#"r. ,t"ai.d.

With eachcollarin.place,radiographs of the ceruicalipin. *.r. tok.r, wltn maxrmallateralbending,_flexion, and exteniion.The degree of spinal immobilization was*'determi;;J L; ;;;;ement ol the the upper and lowe.rcervical ,t,* l" all J posi_ :,1*_t: F*.:. uons.ln eachsubjectand for eachdirectionof motion, the collars were ranked {rom one to fou4,with one being the collar providint theâ&#x201A;Źreatest degreeof rank scores _immobilization. Th.'";;;rg. ror lexron were as follows: L l.Z9) Z, Z.S7,E 3.07i andE,3.O7. r.:ot. for the fobst Stifneck "ottr, *".'ri"tiriiJrffy di{ferent I!1 other scores(p < .01).For extension,there was no statis_ l-T ll9 trcatortterence betweenthe scores.for the 4 collarsll,2.7giZ, ).5 j . o r l a t e r a lb e n d i n g t, h e Z i - . 1 i ' c o l l a r h a d l 2 ; a n d E , 3 . 1 4 )F a rank score.statisticallydifferent from the score {or the philaoerpnraand txtricarion collars (t 2.14.iZ, I.7Ij p, 3.0j ]p and E, 3.14).We-concludethat the :_.05).

IrUr, 3.i'frr"ll'trlmobilization oevrceoters a drstinct advantageover the other 3 collars in that it providessignificantly more_protectionagainst Ilexion of the cervicalspine.It doesthis without sa_crificiigit. a.gr.. of pro_ tectron against extension and lateral bending provi"iled by'the other 3 collars.

33

lntraosseous Administration of Sodium Eicarbonatel An Effective Means of pH Normalization in the Ganine Modet BM Thompson, MD,V Rossetti, MD;J Miller, MD;Jn Mateer, MD; C Aprahamian, MD;JC Darin,MD/ Section of iraumaanO Emergency Medicine, MedicalCollege of Wisconiin, Mitwaukee The,inabiiityto rapidlyestablishintravenous (IV)access in OD v -

cntlcallv rll or arrestedchildrenis not an infrequentoccurrence/ even when surgical cutdown -is begun immediately. Ailh;"gi drugs ca-nbe given endotrachealiy,such kll TllI as.

1:r$.itatron orugs blcarbonate,crystalloids and blood remain unavailable to the child without an IV Historically, prioilo the advent of modern IV.therapy,intraosseousinfusion 1iOIl "ia the tibial mar_ r o w i n p c d i a t r i cp a . t i e n t sw a s u s e ds u c c e s s l u l l yt o administer sucn suDstances as blood,crystalloids,glucose,epinephrine,and antibrotics..The techniqueis easilyp"it"o.-.a "# noiablefor its speed,retrahthty,and very low complication rate. No systematic study of sodium bicarbonateadmiiistration fr", U.""'r.poil"a.

This study was conductedto determine whethei sodium bicarbonate could be-given effectively through the intrar_rsseous route.

S-elcnmongrel dogs were anesthetizel and mechanicaily venti_ rareo at a constant rate..An indwelling afte:.ralcontinuous pH mo.nilgr (Lifespanl00r! Biochem)was pliced i., th" i"-or"i ,itJry and_pH was stabilized.Both IV and irrtraoss.ous-infusions were cstabiished,the latter with a common lg_gaugesfinal needle in cither the sternal or femoral marlow. Sodiu? f,lcaibonate t mrq/ kg was administeredIV and_pH..frr"g. *"r-ol.erved against time. After normalization of pA, the sarie dog recelvedan iienti_ cal doseof sodium bicarbonaievia the intraos"seous-route, and pH changcwas againobserved,and results_w.r;;;;i.J Although;te injection time requircd to adrninisterthe neededsodium biZarbol nate doseaveragedli sec longer for intraosseous 1CSsecl than for sec), rhr time_to peak pH *", "oi significantly ::j,t:-:]",i: Ji4 orilcrcnt {ApH max : 33 sec IV and 85 sec IOIj. From-a baselinl pH,o{ 7.4,_th.e rncan ApH for IV infusion *r"'iO.iS in 33 sec. tul, n].e.pApH was + 0.t2 in J5 sec. After 30 sec,the i-.-ll:ytiC largest averagcditterencein pH curves in the l0 min following j]l-.,-t{:-.1." was only o.02 ,rrritr, "*."pr ioi,t .1."..rr.d injec_ non .tlme requircd. No clinically significant di{ferences were noted bctween the 2 routes. The rapidlty ".r.l.ff..iiu".ress of so_ dium bicarbonateadministered via tfr" i"trrorrlous route rs clinically equivalentto that given by the intravenlu, ro,.rtein the canine model. Tibial intraosseousadministration should be con_ sideredin children in shock arrest.

"'oLarse'Bore 93 +lffiF."i il,lT,fiT:il: JR Mateer,MD, BM Thompson-

Jr/D; J Tucker,MD; C Aprahamian, MD; JC Darin,MD / Sectionof TraumaunOtr"ig"n"y Medicine, MedicalCollegeof Wisconsin,Milwaukee An in vitro study.was conducted to determine the maximum ., flow rares that can be obtained with commercially available IV ca(hcterswhen in{usionpressure,na fV ruii"g size are modilicd. rrow rateswerecalculatedlor the Arrow,,,8.5 French introducer sheath (Arrow International, Inc, Reading,paf-""i the nrgylg;; Medicut " l4-.and l6-gaugecatheters tShi.*ooJ rrl.dical Indus_ b_tLoulsJby averagingthe time for I00 mL in 3 consecutive :tl.:, rrrars.r,achmean flow rate was statisticaliy analyzed by calculat_ ing the 95% confidence interval. Standard ,"ti.fg __ fO1 and two sizes of experime.ntallarge bore tubfiE% t3.i mm and 6.4 mm ID) were tested with tap water and dilited packed cells 45Y",1 ar 600 mm Hg,.300 "r- Hs;;; flow. f,.1r1::lt l ne maxrmum ilow rate obtained for tap water sravity was J,l5'g mll min at 600,mmHg throughthe (r.4mm ID tuLin; and g.5 French cathetcr.Thc rate for diluted packedcells,.,oder" ih.re conditions was 3,000 mllmin. The incriase in flow .ra., b.i*..r, grrur,y i:.q,300 TT Hg pressureis.significant tp < Gl""A provides a Izly" to 2007oincreasefor all Jatheter/tubing.oLbr.rrtiorrs t..,_ g!. Whgn the pressureis increasedfrom 300'mm-ig to oo0 mm Hg, a significant increase(p < .0S)i" fto* irte"-J 28% to 5Sy"

UAEIVABSTRACTS 14THANNUALIVEETING

attempts at in children in shock or arrest states Simultaneous

occuls{orallcombinationstested.Large-bore'tubingism o s t e t .central venous ".""., ",tJ surgical cutdown should be made' catheters'For until a reliabie aci""-,i.r. *tt." used in coniunctron witli large-bore "fong *ith percutaneous-periphiral attempts' 2 '-'i"ig" catheter,a change in tubing {rom standard {3 in this study-have resuriir" s.l irench outlined Problems "rtrbtished. ""r.'i. inIo1 resulted in^a^.signi{ic-ant which is curU.t. tA.+ -t rn- fof old t."httiqrr. of interosseous in{usion' i."LJ,ft" regardlessof as an initial hospital .t""r. fb = n51 i., no* ,"i"t of more than 2007o children's our "iifrr"a-,t il;;; ;;;s;;^"J pressure. we conclude that large-bore IV tubing and i;i;;i"; access' intravascular of technique when infusion -"y ptou" to be a valuable adiunct iiisil:pt"tJ"* t"iid^fl.,id infusion is indicated'

Registration of Gardiopulmonary Gerebral Reiuscitation May Allow Galculation of Prognostic Indices

"i"''" 9 6 +,""="?'"T:T;li':"":: -il,:ilr]

Bleiberg'PhD / ii-o*nori MD; EJ Roth,MD;J Morris,PhD;-J Medicineand Psychiatry' of Rehabilitation Oepartments MedicalSchool'and The Rehabilitation N;Iil;"t1;;; Universitv MD; HH DeLooz,Ub, pnO; H Verbruggen,RN; A Meulemans' Chicago Chicago, lnstituteof Universrty min "{ 19:t-:{ n f,,lrf|r",Mb; P Lewi,Eng / EmergencyDepartment' Mild hcad injuries resulting in as little as 20 Group ;";;ii"l sinl-nataet- GisthuisbeJg,Leuven;Res.earch a m n e s l al r r ^ l p o s t t r a u m a t l c o f h l 2 o r and c o r r s c i o u s n c s{ Ls O C ) attentlon' ". ipcn "i'tn" eltgiun Societyof britical Care Medicine; Beerse' hru. b..n associatedwith deficits in concentratron/ JanssenPharmaceutica' intoi.ation Sciencebepartment, ottt.t""tion of the medical records of spinal;;i";";;err,r"t Institute of Belgium ""ia-i"-tt..i fsCtl ^a-irtiotts to the Rehabilitation a multiWithin the BelgianSociety of Critical Care Medicine' i""idence of LoC and PTA is undertr'" tr'ri ;;#;;;;"t to study and we systecentcr tcsearchgrorrpo., CP'CRwas founded-inI9B2 t-.ooit'"a an"d''underobservedTo test our observations' in this i-"t"t" Cpcn i.ta io opti-i'e EMS and public education -"ai"al recordsof 101trauma-relatedSCI t""rl*.Jitt.

-i,Jrfft of Northform suitable foi computerized analvsis A il""ri.oi"'" ;;;;;;. "i-lr,La to the McGaw Medical center il;;; ""a-rppt"a at the Universitv of Leuven to 300 and rehabilitation we evalu;;il;;;i;; "" i;'^*" i;';;;J;i;;;;"t period' casesol iii",,l,toty arrest during a l4-month ;;;r.;ut; incidence of LoC and PTA in SCI pa;*.1 ,h";i;;tili"pott.a of circulatory setting'' and v;;i;bl;t included age and pre-a"est status,.type tients in the emergency^atp"tt-""t/critical care interventtons' ""Ji"tpltr,oty arresi site of attest, timing o{ CPR the level and nature of iniurv and neuwith ""-;;;;l;t;-e;d o{ performed state o{ and eflect o' p'..,pil,and swallowing,cluality ii a"v. o{ l0l patient files.reviewed' BTY, werc ;;il;i;;"'il; immediate dpn "itot,t, quality ind timing of drug tlierapy' and ^ii'zzrt {or pre'' Level of injurv did not influ;';:;;if;;;6c post CPR were docuPatients susand long-term CPR result. The"first 24 h """" *ft"ift.t such an assessmentwas performe^d events.anddruâ&#x201A;Ź therapv The wounds (n : 1.8)wete assessed il."i#f"i oiit-p^tf'"fo*cal to-l""tttot SCi."condary ;;;;iil Coma Scale'and depth of coma was ,."orJ"a'*ittt the Glasgow far less oftcn for LOC tli; were all other etiologies 9:Tilttl of 88 136%Jadfunctionaloutcome2weekspostCPRwas-measuredaccordingto iSilZ, u".t"t 92Y,,).OI those patients assessed,.39' p"tfot"iance scale The patients were divid101 Fortv-two.or PrA' (li%) admitted il;l;;;;;.;Jio"d zz ziit #;;;i;oc'^"'i 2|9 paeil into three outcome categories:Group I (CPR failures), or both according to emergen^cy PTA, LOC, .departt"ti^i""d 38 patientsll2'5%)i ,*",trlzaZ'lr Group II (shori-termsurvrvals), care documentation Oi theie, only 12 129%)tnder' -""i7.ti,i""f or iit 1lo,tg'-t..- survivals),43 patients ll4'5%')'rne y1i ;;Jei";p cvaluation with either skull roentgenography ", i,rrtt *"lri patient groups lnassessed is Although scan' "Ui"" tt nt difierel significantly among the brain -L,OC it-p"i".L iomographic PTA is largely clude<ltype o{ circulatory arrest,type of respiratory*ltl'^lltl-"rt routinely in the patient *t,^i"ittg traumati' scl' anq clrculatory^zrrest between intervals closedhead iniutimâ&#x201A;Ź of arlest/ circulatory as 'it ittdit'tor iis,sensitivity icspite ig*r"a state oi and population appears the di{ferent CPR modalities, total duration of CPR' ,'v.Netrrologi" workup of such patients in this qualrty ol "ffe"t of CPR on pupils and swallowing activity' and incomplete' or ignored to be largely a discrimiexternal cardiac iompressions'For these variables providing of purpose the with out carried is o.t"lyris ,rrtlrr. calculation of a prognostic index for determining f";;" ;;;; Head lnjury: The Gritical Role ^,-t Pediatric chanceso{ immediate and long-term survlval PhYsician of the EmergencY I Y and fi UiV",,-MD; ML Walker,-MO/ bepartmentsof ,Pediatrics Medicine' of School University.

Georgetown N/ltJicine ft"ts;iy North Wuthingtoir DC; Departmeritof EmergencyMedic-ine' of FL; a.nd.Departments Lauderdale, Ft District, Aro*uti'ffotpital "N;; JC Centet Medical ren's V nottut,, MD, BM Thompson,MD; C AprahamianJVD; i ld Ch Primarv iutti".'

P"d ;nd ;.;|.g;;iDarin,MD; JR Mateer,MD / Sectionof Traumaand tmergency Salt Lake CitY w"Oi"lnu,MedicalCollegeof Wisconsin,Milwaukee and morNeurologic iniury is a significant.sourceof morbidity (ED)in shock outinfluencing Children presentingto an emergencydepartment the-factors clarify To patiettts. pJa*tric ,"iiiy to the nonor in cardiorespiratorya,,est pttsettt many problems patie,tis *ith '"u"tt head-iniury' we.studied p.a-tri" l" ""-1, the in access .r'" mosi difficult is viscular defined as ilo"g ;;d;;;;i;;. ioo """.i,"",ive p;tients with severehead injury vascularaccess small infant. Even rn pediatric centers,however' (GCS) < B' The {ollowing data were s"o'e Scale ai;.;;;-a;; oculocephai, ,r.i,h". assurednoi necessarilyrapid' A 3-yr retrospective *ti"?t"a' age,GCS score,presenceof mass lesions' was carpressiutly o{ lntravascularaccessin 66 pediatric ED arrests lic re{lexesfOCnt), pupillary size and reactivit} intracranial (BP< 80 + twice the r i e d o u t a t a c h i l d r e n , s h o s p i t a l . E D . r e c o r d s - w e r e e x a m i n e d , a n r*. d hypotension ipOr-'ZO), UCpl,f.vpo*lJ access of multiple times {rom onset of arrest to achievementol intravascular .g. i., y.^rri'hyp.rcapriin{PCb;; 35 torrl' presence of resusscore'out*"i. *^fv""a and correlatedto patient 1q9-?"-g:ut"o-e Scale^{M,lss) Severitv Iniurv n'l,jalii.i ;r";r;;,-;r; was never ciiation. Ir-t-or. thar. 6o/oo{ patients l4l66l, IU access by the GlasgowOutcome Scaleat a mlnlmum come was assessed minutes' ""fr.ued. An additional 24% li6/66) requiredI0 or more r..o.'.'! Of the 200 patients in the'study' following 6 months of in code into the C",J.*". were placed at an averageof -Z+ mitt r'.rJ 4"'v {IHI) and rr4 ls7%) had head isolatei hra sL'iai%l time was patients ii;t" .,t iases1zttee1.For IVs begun in the rD,,average tra,'m" {HI - MT)' o,n-tllll 26"/"or ;;,i; ac;l;;;"itipl. hyper i"..ess{ully resuscitatid patients-had.intravascular hvpoxia' 29"k, 7:a --. and ICP; inteased 79ok, Iesionsi i;J;;* , not resuscrcess establishedsignificantly sooner than did those mortality was 2I'5"/o' Severityot hypotension.'Overall or carbia, prolonged under 2 vr had significantlv pupils) a-fild; OCR' GCS' ;ft'(P-<^G). lesions' -*ru'tu, iudieedby p,",""tt of mass diffiii-.r',o IV placement iP < '05)' This study highlights,the i" p"tients with IHI, although increased il;#;';;;;""'i.!a access vascular accompany often that delays culty and signi{icant

6A Y+

Lilli3""'"u'"' I 5 l*':::'Y'TiJ",;',?:

34

ICP was more common in patients with HI -l- MT However, death was nearly 3 times more common in patients with HI + MT (10.5% versus 30%). In the IHI group, 2 ot9 deaths 122%l were associated with hypoxia, hypercarbia, or hypotension; all but 4 patients IBB%) in the HI + MT group had hypoxia, hypercarbia, or hypotension. Among all patients, those with hypoxia, hypercarbia, or hypotension had a 62% mortality. The following data correlated signiiicantly with outcome (P < .01): GCS, increased IC! MISS score, and presence of hypoxia, hypercarbia, or hypotension. These data indicate that overall mortality from severe head injury in pediatric patients is good 121.5%1.However, the maioritv of deaths were associated either with extremeiy severe initial injury or with increased intracranial pressure/ severe multiple trauma, or presence o{ hypoxia, hypercarbia, or hypotension. Thus, while the primary impact injury dictates outcome for some pediatric patients, many patients die of the secondary iniury. In this sense, the emergency physician may be more critical to patient salvage than is the neurosurgeon.

(|(t .rL

Methodologylor Comparing Trauma Populations

HR Champion, FRCS, FACS; C Frey, FACS; WJ Sacco, PhD / TraumaService,Washington Hospital Center, Washington, DC A major goal of emergency medicine research is devclopment and implementation o{ objective methods with which to cvaluate system effectiveness. The absence of such methods has made it dilficult to assess accurately the effectiveness of efforts to improve emergency cxet particularly for the trauma patient population, for to do so requires comparrsons between differing patient populations and between institutions and regions. The authors have developed and implemented a methodology that allows for comparison of trauma patient populations while controlling for case mix. The methodology is based on the Tiauma Score, a physiologic measure of iniury severity, the Injury Severity Score, an anatomrcal measure of injury severity, and age. The methodology is being applied in the Major Tiauma Outcome Study. A total of 99 hospitals have committed to pool outcome and severity data on trauma patients. The methodology of the study is described, together with a preliminary analysis oI 6,332 patients entered into the study from |anuary through |uly 1983. Results chart a national normative outcome for trauma patients between the ages o{ 15 and 54. Participating institutions are able to compare the outcome o{ their trauma patients to the national average on a confidential basis. Further applications of the methodology in evaluatrng system and treatment strategies is discussed.

99

Automatic Gastric Lavage and a Comparison of Tap Water Versus O.9olo Normal Saline Solution lrrigant

patients treated with ice solutions had rapid lowering of their body temperature to 35 C. Conservative use of ice in the solution resolved this problem. One patient with hyperthermia was treated with iced water lavage. The core temperature decreased from 4l.I C to 38.3 C in 30 min. In the second part of the study, 32 adult patients requiring gastric lavage were randomly selected for lavage with Autovage using 0.9% saline solution or tap water.

Measurements prelavage and postlavage were made o{ blood hemoglobin, hematocrit, urea nitrogen, and electrolyte concentrations. Overall there was no signi{icant change in any parameter in either treatment group. Gastric lavage is an important technique {or the treatment of toxin ingestion, upper GI hemorrhage, hyperthermia, and hypothermia. An effective automated method of lavage is available. With this method either 0.9% saline solution or tap water may be utilized for adults.

31", i?i'.'!T,lil3i[ :="ilX'""' 1OO lf""i,$ilil

S Syverud, MD; W Barker,MD; JT Amsterdam, DMD, MD; D G o l t r a , M D ; J C A r m a o ; J H e d g e s , l V D , F A C E P/ D i v i s i o n o f E m e r g e n c y M e d i c i n e , U n i v e r s i t yo f C i n c i n n a t i M e d i c a l C e n t e r , Cincinnati Standard external cooling techniques for treatment o{ heatstroke can be cumbersome and slow when treating a hemodynamically unstable or seizing patient. This study was undertaken to evaluate a central cooling technique, gastric lavage with iced tap water, for speed of cooling and ef{icacy o{ treatment in an anesthetized canine heatstroke model. Eleven mongrel dogs were anesthetized, shaved, and externally heated until core temperature reached 43.0 C. Control animals (" : 6) were passively cooled in room air Tieatment animals (n : 5l were cooled with the addition of gastric lavage via a large-bore orogastric tube. Lavage was performed at a r^te of 200 cclmin for 30 to 40 min using an automated lavage device (Autovage). Temperatures were monitored via thermocouples in the brain, pulmonary arteryt rectum, and subcutaneous tissue of the chest wall. Samples for serum electrolytes were drawn prior to heating, at the end of hcating, and 30, 60, and 120 min and 12 h alter heating. Central cooling rates achieved in the lavage group were 5 to 6 times faster than in the control group, and are comparable with those reported rn the literature for external cooling techniques. Rectal cooling rates were 0.036 C/min/mz (SD : 0.008) in the control group versus 0.216 Clmtn/rnz (SD : 0.034) in the lavage group (P < .05). No signi{icant complications (eg, disturbance in serum electrolytes, aspiration, gastrointestinal bleeding) were induced by tap water lavage. Gastric lavage with iced tap water appears to be an effective alternative or adjunctive cooling technique for heatstroke.

Microwave (lvens: A Safe New Method ft{ f l, f for Warming Crystalloids MD;JR DL Werwath, MD; CtNSchwab,MD;WL Robinett, Medicine and Multiple MD/ Department of Emergency Scholten, Norfolk Virginia MedicalSchool, Trauma Eastern Service, Warmcrystalloidparenteralfluids are essentialfor resuscita{

JP Rudolph, MD I Department of Emergency Services, M c K e e s p o r tH o s p i t a l ,M c K e e s p o r t , P A

+

Gastric lavage is a Irequently used emergency treatment for upper gastrointestinal (GI) hemorrhage, toxin ingestion, drug overdose, hyperthermia, hypothermia, and other emergency cases requiring repetitive gastric irrigation. An automatic method of gastric lavage {Autovage) was studied, and the use of tap water versus 0.9% saline solution as irrigant was compared. Autovage uses a fixed timed cycle to alternate irrigant reservoir fluid by gravity feed into the stomach via an oral or nasogastric tube and Iow suction (60 mm Hg to 80 mm Hg) to remove gastric contents.

Reservoir fluid flow rate is controlled by reservoir height adjustment to provide 4 mL/kg/cycle. Conducting tubing, reservoir, and drainage cannister are disposable. In the first part of the study, 60 patients ranging from 18 mo to 94 yr were treated using Autovage. There were no complications. The drug ingestion population was, as expected, younger than the GI hemorrhage population. Time for total lavage was linear, with total time ranging from 30 min for a 6-L lavage to 120 min Ior a 2O-L lavage. All patients had a complete return of irrigant + 100 mL. The first

tion of the hypothermic, hypovolemic patient. Emergency departments currently utilize various types of fluid warmers. A survey of 25 regional hospitals revealed that 92% of the respondents had access to a {luid warme4 while only 36% had a warmer in the emergency department 24 h a day. Sixty-eight percent had microwave access in or near the emergency department, while 8% had warmed fluids in microwave ovens for patient use. This study was undertaken to develop a method and protocol for warming crystalloid utilizing microwave radiation. Experimental trials were conducted to establish a method for warming liters of normai saline and lactated Ringer's in a 650-W microwave oven. Liter bags made of polyvinyl chloride PL146 plastic were chosen because of previously demonstrated safe use in microwaves.

Starting temperatures were obtained pdor to heating. Bags were

35

UAEMABSTRACTS 1 4 T HA N N U A LI V E E T I N G

warmed on high power for 60-, 75-,9O-, 120-,135-, and 150-sec intervals. Heating was interrupted alter 60 sec for bag turning and vigorous agitation. The fluid was agitated at the end of the heating time. Temperatures were obtained simultaneously after heating with 3 thermometers with a fold technique. Inner fluid temperatures were obtained with an anesthesia probe thermometer. thermometer measurement technique and reliability was dem' onstrated on 3 separate thermometers, with outside and inner fluid temperatures being virtually equal. Experimental trials show that a single liter o{ lactated Ringer's or normal saline with an average starting temperature of 70 F microwaved for 120 sec by the described technique raises the temperature approximately 3l F with a 95% confidence limit of 0.7 E Heating for 135 sec raises the temperature 36 F + 0.7 I from a starting temperature of 69 E The results indicate that a temperature-plemeasured bag of normal saline or lactated Rinser's can be accuratelv and safelv warmed utilizing microwave radiation and applied for use in the hospital.

10231ff1":'#il,i1Tr;il'j"i,:"' Peritoneal Lavage MJ Rubin, MD; WH Blahd, MD; TH Stanisic,MD; HW Meislin, MD / S e c t i o n s o f E m e r g e n c y M e d i c i n e a n d U r o l o g y ,A r i z o n a H e a l t h Sciences Center,Tucson The diagnosis of intraperitoneal extravasation of urine in the multiple trauma patient is o{ten deiayed, resulting in increased morbidity and mortality. To determine whether intraperitoneal extravasation of urine can be detected by peritoneal iavage, an animal study was designed to investigate whether urea nitrogen and creatinine levels in the urine, serum, and lavage fluid would be predictive of urinary extravasation. Seventeen adult mongrel dogs, weighing 2I to 30 kg, were divided into 2 groups. Group I, 6 dogs, served as controls, and had peritoneal lavage (15 mL normal saline/kg) performed using the open technique {direct visualization of the peritoneum). Blood, urine, and lavage urea nitrogen and creatinine, and lavage red cell count were measured. Croup II, ll dogs, had varying amounts of urine (5 mL to 330 mL) instilled into the peritoneal cavity. Group IIa, 9 dogs, had urine instilled under direct visualization through a peritoneal lavage catheter. As bladder dome ruDture is the most common cause of intraperitoneal urine extravaiation, Group IIb, 2 dogs, had bladder dome ruptures performed. The bladders were ruptured via cystoscopy using the resectoscope. Cystograms were performed in the bladder-ruptured dogs to confirm intraperitoneal extravasation of bladder contents. In these animals urine was instilled back into the bladder following bladder rupture. Diagnostic peritoneal lavage was performed 30 to 45 min after the instillation of urine in Group II animals. Results demonstrate urea nitrogen and creatinine can be measured in peritoneal lavage fluid when extravasation of urine is in amounts o{ 15 mL or more, and are not measurable in amounts of 5 mL or less. Four of the iroup II dogs had hemoperitoneum (red ce1l count > 80,000). Measurements of lavage urea nitrogen and creatinine were not a{{ected by the presence of blood in the peritoneum. Detection of peritoneal lavage urea nitrogen and creatinine was significantly diiierent (P < .051 between the Group I (control) and Group II (urinary extravasation) animals by analysis of variance. Results indicate that when

36

Iavage urea nitrogen and creatinine exceed serum levels, with or without hemoperitoneum, intraperitoneal extravasation of urine should be strongly suspected. Routine measurement of serum and lavage urea nitrogen and creatinine is use{ul in the early diagnosis o{ intraperitoneal extravasation of urine in trauma patients.

{ nr| f rVg

Emergency Thoracotomy in the Urban Gommunity l{ospital: Gardiac Rhythm as a New Prognosticator?

MW Brautigan, MD, G fieV, DO / Department of Emergency Medicine, Mount Carmel Mercy Hospital, Detroit Several authors have reviewed their experience with emergency thoracotomy in the university hospital setting. We, in an urban community hospital, are seeing increasing numbers of patients who require emergency thoracotomy. In an initial study we compared our experience with that recorded in the university hospital setting by reviewing the charts of 47 patients who underwent emergency thoracotomy in our institution during 19Bl and 1982.

In our series, 39 thoractomies (83%) were done for penetrating trauma, of which 29 162%l were for gunshot wounds and 10 (21% ] were for stab wounds. Eight patients i17%) underwent thoracotomy for blunt trauma. A total of 13 patients 127.6%) survived and were drscharged {rom the hospitai. O{ the 13, 8 (17% oI the totai} had no neurological deficit. Our outcome dat^ xe comparable to those o{ univeriity centers in which similar reviews wire undertaken. We think that emergency thoracotomy can and should be done in the community hospital setting as a lifesaving procedure.

The decision to pcrform emergency thoracotomy is based on data available in the early assessment o{ the patient. Prognostic {actors include the prchospital evaluation, presenting vital signs, initial neurologic eriamination, type and location oI iDjury, and response to initial therapy. The presenting cardiac rhythm has not been used as a prognostic indicator in patients undergoing emergency thoracotomy. In a second study we performed a retrospective analysis of all patients undergoing emergency thoracotomy from |anuary 7, l99l, through December 3I, 1982. A total of 47 thoracotomies were performed during the 2-year period. Seventeen patients survived beyond the operating room and were admitted to intensive care. Of these. 13 Datients survived hosnitalization and were dischargedhomi. tight patients were neurologically intact. AII 17 survivors presented with sinus rhythms, either sinus tachycardia il6) or normal sinus rhythm il).

Five of these 17 patients presented with no blood pressure, and 2 of the 5 were apneic and had fixed and dilated pupils. Thirty patients failed to survive beyond the operating room. Twenty-four nonsurvivors presented with bradyasystolic rhythms, including sinus bradycardia {4), agonal ventricular rhythms (5}, ventricular fibrillation (5), and asystole (10). Six nonsurvivors presented with sinus rhythms, either sinus tachycardia l4l or normal sinus rhythm (2). Four of these patients (2 from each group) suffered severe blunt trauma. The 2 remaining patients died of massive hemorrhage in the operating room. Both patients had gunshot wounds to the aorta. We have found that the presentins cardiac rhythm is the most accurare prognostic indicaior in patients undergoing emergency thoracotomy. Any patient suffering a penetrating iniury who presents in a bradyasystolic rhythm, regardless of vital signs, cannot be expected to survive beyond the operating room. The patients should not undergo emergency thoracotomy.

CONSTITUTION OF THE UNIYERSITY ASSOCIATION FOR EMERGENCY MEDICINE ARTICLE III - MEMBERSHIP

ARTICLE I _ NAME

be, "The University The name of this organization shall " hereinafterreferredto as, Medicine, Emergency for Association "The Association."

ARTICLE II _ OBJECTIVES

I

Section1.'The objectiveof this Association shall be improvern*t in the quality of medicalcare of the acutely ill and injured by operatingas a scientificand educationalorganizationas defineOin Section501(c)(3) of the InternalRevenueCode,as amended.

2.'TheAssociationshallpursueits objectiveby surveySection ing medicaland scientificarticlesboth publishedand unpublishedl and selectingarticlesof note. The Associationshall make available,at cost,to the public copiesof the selectedarticlesupon request.ihe Associationshallselectmedicaland scientificarticles of note and educatethe physicianand the public by presenting those articlesat discussiongroups' forums, panels, lectures' seminarsand other similar programs' The Association may chooseto sponsorfor publication selectedmedical and scientific articlesof note by treatise,thesis,trade publication or other mediaform in order to makethat information, including patents' formulas, medical apparatus and medical system designs' availableto the public at large on a nondiscriminatorybasis' The Associationmay conduct and/ot sponsorpublic interest,scientific researchin the field of emergencyrnedicinein order to improve the quality of emergencymedical treatment and care' The Issociation shalipublishiis researchdata by treatise,thesis,trade publicationor other media form, in order to make that informaiion, includingpatents,formulas, medicalapparatusand medical system designs, available to the public .at -large on a nondiscriminatorybasis.The Association shall inform and educate i-tt.puUfi., as well as the medicalprofessional,in the resultsof its researchby conductingdiscussiongroups' forums, panels, lectures. seminarsand other similar programs.

Section3: A. This corporation is organized exclusivelyfor educationaland scientificpurposes'including, for suchpurposes' the making of distributionsto organizationsthat qualify as eximpt orginizationsunder Section 501(c) (3) of the Internal of 1954(or the correspondingprovision of any Revenue-Code future United StatesInternal RevenueLaw)' B. No part of the net earningsof the corporationshallinure to the benefitof, or be distributableto its members,Directors'Officersor other private persons'exceptthat the corporation shall be authorizedind empoweredto pay reasonablecompensation for servicesrenderedand to make paymentsand distributions in furtheranceof the purposesset forth in paragraphA hereof' No substantialpart of the activitiesof the corporation shall be the carryingon of propaganda,or otherwiseattemptingto influence i.girfutiln, und ttt. iorporation shall not.participate in, or inteivenein (includingthe publishingor distribution of statements) any potiticatcampaignon behalf of any candidatefor public office.'Notwithstandinganyotherprovisionofthesearticles'the corporationshall noi carry on any other activitiesnot permitted to be carriedon (a) by a corporationexemptfrom FederalIncome taxunderSection501(c)(3) of the InternalRevenueCodeof 1954 provisionof any future United StatesRevenue (or corresponding iaw; or (t) Uv a iorporation, contributionsto which are deducti bleundei S..iion l7-0(c)(2) of the Internal RevenueCode of 1954 provisionof any future united StatesInter(or the corresponding nal RevenueLaw).

Section l: Classifications.There shall be five sevenclassesof membership:active, associate'emeritus,resident,honorary' and internationol active, ond internationalassociate' Section2: Qualifications.(l) Candidatesfor activemembership shallbe(a)physiciansof-universityoruniversity-affiliated ftorpit"ft *fto ftot,Omedicalschoolfaculty appointmentsand who are continuing to participate actively in the field of emergency medicine cari and serviies, have a demonstratedinterest in emergencymedicine, whether in an administrative,teaching'or .iiri.""f capacity (b) other medical educatorswho under special circumstancesare invited for such active statusby the Memberrttip C".-ittee. (2) Candidatesfor associatemembershipshallbe uni pttvti.iu", medical professional, educator,.government-ofii.iutl ..mu.r of a lay oi civic group or any memberof the public puruitu.g., who may havean interestor desireto participatein (3) CanAssociation' the of objectives and putpot.t rulne"ti. didalesfoi emeritusmembershipshall be (a) activememberswho seeksuch statusand who have given 10 yearsof activeserviceto the Associationand haveattainedthe ageof 60 years(b) otheracwho under special circumstancesare invited for ii". -.-u.tt (4) Cansuctr emeritus status by the Membership Committee' a residency in resident a be must membership resident for didates (5) i.uining program who havean interestin emergencymedicine' are who individuals be shall membership ior honorary candid-Jes outstandingmedicalor lay contributors in the field of emergency Ineaicut,.r-ni..t. (6) Candidatesfor internationolactivemember'ii-U iiat be indiv'idualswho meet the qualificationsfor active -ii*iirtinip in uA/EM ond who reside outside of the united silatis. fzi Condidatesfor international ussociotemembership inan il individuats who meet the qualifications for associate, -iiiintnip in IJA/EM and who reside outside of the United States.

Section3.' Onty active membersshall have voting rights'

37

Section4..TheAssociationshallnotdiscriminate,withrespect to it, .t-b.tship, on the basisof race,sex,creed,religionor national origin.

ARTICLB IV _ OFFICERS Section 1.' The officers of this organizationshall be the Presiand Secretary-Treasurer' dent. Vice-President, Council shall serveas the Board of Executive The 2: Section Directorsof the Association.The Executivecouncil shallconsist of the aboveofficers, the Program CommitteeChairman,the last ttrr.e pietiO.ttts, and threeCouncilmen-at-Large'Both activeand membersmay serveon the ExecutiveCouncil,but only associate activemembersmay be officersof the Council'

ARTICLE V _ COMMITTEES The standingcommitteesof the Associationshallbe: Membership CommittJe, Nominating Committee' Program Committee' Constitution and BylawsCommittee,EducationCommittee,and n"Oiting Committee. Additional committeesmay be createdby itr. B*.Jutiu. Council and ad hoc committeesmay be created-by itt. Ft.siaent to aid in the Associationefforts to achieveand further its goals.

ARTICLE VI _ ANNUAL MEETING Section1.'Thereshallbe an annualmeetingof the Association' profttit -..ti"g shall consist of an educationaland scientific session' gramand a business Section2:TheExecutiveCouncil,bymajorityvote'maycall' or stanupon 30 daysnotice,a specialmeetingof the membership CounExecutive the that business anv to conduct ;i;;;;ittee committee' standing or .l-t"tt"iipi"". before the membership any Section3.' The ExecutiveCouncil may call and conduct date meeting the notice' purposes.of For tpJ.i"f -."titg Uy mail. be callrtuiit"u aut.-r.ifo, the returnof mail ballotsand it shall prior days 30 least at be sent shall ballots "Jit. uoti"g date.Mail or resolution proposal' any of Adoption date. voting the to of vote affirmative by be achieved stratt biymail Ualtot "..n0-.nt providedby otherwise unless members active voting of ;;j;t"y -of this constitution' onlv those mail ballots ;;;;it;;t;"ision office of the Associationwithin 30 days business the i"..i".a'at to the voting date shallbe counted' subsequent

ARTICLE VIII _ ADOPTION OF THE AMENDMbNTS TO THE CONSTITUTION

at any Section1.'Theconstitutionmay be adoptedor amended membership' the of annual or specialmeeting shallbe Section2.' Proposedamendmentsto the constitution members three Secretary/Treasurer-by ru[tnitt"O in writing to the to be conui t.urt 60 days prior to the meetingat which they are amendproposed the mail sliall ,iO.r.i. in" Seiretary-Treasurer t" the memberihip at least 30 days prior to that meeting' ;;;; propose Section3.'The ExecutiveCorrncilmay, by resolution' amendmentstotheconstitution;providedtheproposedamend. prior to the ";. mailedto the membershipat least30 days ;;;; meetingat which they are to be considered' be by a Section4.'Adoptionof a constitutionamendmentshall at anyanmajtritv voteof the activememberspresentand voting nual or specialmeeting.

ARTICLE IX _ DISSOLUTION

ARTICLE VII _ BYLAWS

Council Upon the dissolutionof the corporation,the Executive paymentof all of for the ptouision making paying or after shali, of the assets the liabilitiei of the corporation,disposeof all of the in corporation the of purposes the for exclusivelv ;;;;;i;; organized organizations or ,u.t.unn.t, or to suchorganization religiousor "rd "p.."t.,i exclusivelyfoi charjtable,educational' an exempt qualify as time the at scientific purposesas shall (3) of the In501(c) Section under organizations 6r ".g""it"tfi" provision.of ier"nalRevenueCode of 1954(or the corresponding Executive as the Law)' Revenue Internal States United iut"r.

S e c t i o n S . ' T h e E x e c u t i v e C o u n c i l m a y , b y r e s o l u t i o n ' p r o p o s eurv of shall disposed so. not assets such Any amendments Councilshalldetermine. to the bylaws;providedthe proposed u**O-."tt in the County Jurisdiction meeting Competent prior the of to Court a days by 30 least Jitp.t"O at U. ui. *uif.O to the membership located' i" *tti.it the principal office of the corporationis then at which theYare to be considered' organizationor organizasuch to or purposes such foi exclusively a maSection4.' Adoption of a bylaw amendmentshallbe by tions,assaidCourtshalldetermine,whichareorganizedand presentand votingat any annual membirs u.tiu. tt. of "ot. .i".iiy operatedexclusivelyfor suchpurposes' or specialmeeting.

or Section1; Bylawsmay be adoptedor amendedat any annual specialmeetingof the membership' to the bylawsshallbe submitamendments Section2.'Proposed by, three membersat teJ in writing to the Secretary/Treasurer are to be conwhich,they at meeting prior the to days least60 amendproposed the mail shall ;il;;J. The Secretary-Treasurer ^."t'tothemembershipatleast30dayspriortothatmeeting.

38

BYLAWS OF THE UNIVERSITY ASSOCIATION FOR EMERGENCY MEDICINE ARTICLE I - MEMBERSHIP Section1.' Application and Election to MembershipApplication forms rnuyU. obtainedfrom the Secretary/Treasurerof the Association.The Applicant must return the completedapplication forms and supportingletters to the Secretary/Treasurerof theAssociationat ieast one month prior to an ExecutiveCouncil meetingin order to be consideredfor membershipat that time' The q-ualificationsand recommendationsof candidates for membirshipwill be reviewedby the MembershipCommittee at eachmeetingof the Executive Council. Approval of the candidatesby the Council shall constitute election to the membership,effectiveimmediatelY' 2.' All membersshall pay dues' Only activemembers Section serveas officers.Associatemembersmay not vote and vote may but may serveon the ExecutiveCouncil.

ARTICLE II - OFFICERS

I

Sectionl: Election of Officers. The President and Viceshallbe electedfor oneyear' with automaticsuccession President and to President'The Secretary/Treasurer, from Vice-President shalleachbe electedto threeyearterms,thâ&#x201A;Ź Councilmen-at-Large for the latter. Nomineesfor the aboveofstaggered termsbeing -be ficesshall selectedby the Nominating Committee and must haveagreedto standfor electionprior to their formal nomination sessionof the annualmeeting'Alterfor eleitionat the business native nominationsfrom the floor shall be solicited' Such mustalsoagreeto standfor election.Electionshallbe nominees by majorityvoteof the activememberspresentand voting at the of the annualmeeting. session business Section2: Duties of the President.The Presidentshall preside of the ansession programand business overboththeeducational the Exof meetings the and nual meetingof the Association, ecutiveCouncil.It shallbe the duty of the Presidentto seethat the rules of order and decorum are properly enforcedin all of the Association,and to sign the approvedprodeliberations ceedingsof each meeting.The Presidentshall appoint active and unexpiredterms on the Executive membirsto fill vacancies hoc Committees.The Presidentshall ad and standing Counciland serveas ex-officiomemberof all standingcommittees' In the absenceor illness Section3: Dutiesof the Vice-Presidenf. of the President,the Vice-Presidentshall preside.The Viceshallserveas Chairmanof the NominatingCommittee President and ex-officiomemberof all standingcommittees.

It shall be the duSection4: Dutiesof the Secretary/Treasurer. of both the to presidein the absence ty of theSecretary/Treasurer recordof correct and a true keep to Vice-President, and President of the meeting,to preserveall books,papersand theproceedings artiilesbelongingto the Association,to keep an accountof the with its members,to keepa registerof the members Association with the datesof their admission,and current professionaladthe latter to be circulated annually to the membership dresses, within a month prior to the annual meeting.He shall report unpreviousmeetingsrequiringaction,and atfinishedbusinesJfrom as the Associationmay direct' He business other to such tend shall also superviseand conduct all the correspondenceof the He shallcollectthe duesof the Association, make Association. of expenses,maintain the financial accountsand disbursements recordsof the Associationand presentthe financial accountsand recordsof the Associationfor reviewby the Auditing Committee within 24 hours prior to the businesssessionof each annual meeting,at whictr time he shall presentan annual report of the financialcondition of the Association to the membership' He as he may incur in the proshallbe reimbursedfor suchexpenses perexecutionof his duties.He shallserveasex-officio memberof all standingcommittees.

ARTICLE III _ MEETING Section 1.' The Association shall be governedby the actions taken by a majority vote of the active memberspresent and by its uoii.tg. b.t*..tt meetings,within the policies.established mem6ership,the Associationshall be governedby the Executive Council. Riiions of the ExecutiveCouncil shallbe determinedby u .ujotity vote of thoseof its memberspresentat its meeting'five membersconstitutinga quorum.

Section2.' The annual meetingand any additional meetingsof the Association shall be held at times and placesfixed by the of actionby the Association,by its Rssociation,or in the absence for the annual meetingshall be arPrograms Council.

Executive rangedby the Program Committeeand approvedby the Presi Oeni. n final notice of the time, place and program of each meeting shall be sent to all membersof the Associationby the at least 30 days before the meeting,but the Secreta"ryZtreasurer place for the next two annualmeetingsshallortentativetime and of eachannual ainarifybe announcedduring the businesssesgign chosenby the be shall meetings ...tini. The site of the annual Executivecounciltwo yearsin advance.

The educationalprogramof the annualmeetingshallbe opened to the public.

ARTICLE IV _ FINANCES Section1.'The annualmembershipduesfor all membersshall be determinedby the ExecutiveCouncil' The annualmembership *lff be payuLl. within 30 days of request by the The ExecutiveCouncil may establishproSecretary,/i'reasurer' policies regarding non-payment of dues and cedures and assessments.

Section2.'The ExecutiveCouncilshalladopt suchmembership to encourageparticipationby the inschedulesas is necessary terestedPublic.

ARTICLE V _ PARLIAMENTARY AUTHORITY Rule of order. Any question of order or procedure-not and subsespecificaliydelineatedor providedfor by these.bylaws quent amendmentsshall be determinedby parliamentaryusageas containedin Robert Rulesof Order (Revised)'

ARTICLE VI _ STANDING COMMITTEES Section1.'The NominatingCommitteeshallconsistof theViceand President,as Chairman,the two most recentpastpresidents, two electedmemberswho may not be membersof the Executive two year terms'It shall Council. The latter shallservestaggered be the task of this committeeto selecta slateof officers to fill the naturally occuring vacancieson the Executive Council and the standini committies not otherwisedesignatedand provided for permission and havingobtainedeachcandidate's by these-bylaws, to do so, pt".. itt.it namesin nominationbeforethe membership for electionat the businesssessionof the annualmeeting' Section2.'TheExecutiveCouncilshallconstitutethe Memberduty to reship Committee.It shallbe the Secretary/Treasurer's view the qualifications and recommendationsof eachapplicant' toi p..setttatlon and approvalby the majority of the Membership Committee.

Section 3.' The Program Committee shall be composedof a Chairman, electedfor three years, and @ three membersaPpoiited by the President to staggeredthree year terms. None of 'the appointed membersof the committeecan be membersof the Execilive Council. Its duties shall be to arrange,in conformity

39

suggest appropriate constitutional amendments and bylaws changesto the Presidentand Executive Council upon study of problemsarising out of the existingconstitution and bylaws.

with instructionsfrom the ExecutiveCouncil, the program for+hefffiialmeeti"g all meetingsand selectjts/he formal participants.

Section 6.' The Education Committee shall consist of a chairman, electedfor threeyears,and@ staggereedthree year terms se that the memberswith the leastremaining tenure shall serveas €hairman during his final year en +he-e€mmi++ecrthree other membersappointed by the President to staggered three year terms. Neither the Chairman, nor appointed members,can be membersof the ExecutiveCouncil. The Committee shall foster continuing education in emergency medicine.

rvhe live in er near the eity in whieh the meetingis held and whe ef the leeal previsienste assnrethe sueeess will makeall neeessary -annu+fs€€+in& Section 4.' The Auditing Committee shall consist of two membersappointed by the President to audit the financial accountsand recordsof the Associationat the time of the annual meeting.

Section5.' The Constitution and Bylaws Committeeshall consist of a Chairman and two other members,electedfor staggered three year terms so that the member with the least remaining tenure shall serveas Chairman during his final year on the Committee.This Committeeshallstudy the potentialmerits,adverse consequences and legal implicationsof all proposedconstitutional amendmentsor changesin the bylawsand report their findto the Presidentand ExecutiveCouningsand recommendations cil prior to the time of formal considerationof the proposed changesby the membership.In addition, they may themselves

ARTICLE VII - DISSOLUTION OF THE ASSOCIATION Section1.'Dissolutionof this Associationcan only be initiated by a majority vote of all membersof the ExecutiveCouncil and must be approvedby two-thirdsof the activemembershippresent and voting at any annual or specialmeeting.

Section2.'Dissolutionshallbe achievedin compliancewith Article IX of the constitution.

40

Plan to attend the 1985 UAIEM Annual Meeting!

N,day 2l-24, 1985 RadissonMuehlebachHotel KansasCity, Missouri Abstractsshouldbe mailedto the UA/EM office at: 900 West Ottawa, Lansing, Michigan48915.For additionalinformationwrite to the UA/EM office or call (517) 485-5484.

The 1986Annual Meetingwill be held May l3-16 at the Portland Hilton Hotel, Portland, Oregon.