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UniversityAssociationfor Emergency Medicine

1985Annual Meetingprogram and MembershipDirectory

May 2l-24,19Es RadissonMuehlebach Hotel KansasCity, Missouri

1986Annual Meeting Call for Abstracts Programchairman,Ju9tl! E..Tintinalli,M:?., is nowaccepting abstractsfor reviewfor presenration at the 1986Annuar Meetingwhich'will ue treta N,6t1'3:ffi; portland, oregon. The deadlinefor submissionof abstractsis Februaryl, r986. Abstractsmust be postmarkedno laterthan FebruaryI to be consideredfoi-presentation. Mail five copiesof the abstractto: 1986UA/EM Annual Meetine 900 West Ottawa Lansing,Michigan4g915 Call the UAIEM office at (517) 4gi_54g4for further details. Abstractssubmittedshouldnot ha-vebeenpreviouslypublished asa manuscript,nor presented at a nationalmeeting'cash awarrlsof $1,000'ia-ch will-b'l gi".r i* tite Bestclinical paper (Human subjects)and the Best.Basic pap.t. itte nestsaiic Sci.*.'rup., S-cience is sponsoredby UA7EM and the BestClinical Paper.(HumanSubjects)is sponsor.A Uv-ftArcnOMEDEX,Inc. AII award winnerswill be announcedat the tqsi Rnnuai 'Pliilaitelphia. Meetin! *rri.-rr will be held May 20-23in

INDEX I 2 3 ..'.... 4 5 6 12 . . . . ' ' 43 . , . . ,45 ' '., '....47 .... ' '...58 ' .61&63 i n s i d e backcover ..

Generallnformation VadeMecum UA/EM Leadership Kennedylecture Annual MeetingOverview ofEvents Schedule Abstracts Constitutionof the UniversityAssociationfor EmergencyMedicine Bylawsof the UniversityAssociationfor EmergencyMedicine MembershipDirectory(alphabeticalorder) MembershipDirectory(stateorder) Application Membership lg86CallforAbstracts.....


GENERAL INFORMATION REGISTRATION AND INFORMATION All registrantsmust check in at the UAIEM Registration Desk to pick up name badgeswhich are required for a"dmissioninto the Annual Meetingsessions. The RegisirationDesk will be open dur_ ing the times listed below; Tuesday, May 2l 12:00noon to 5:00 pm Wednesday, May 22 7:30 am to 5:00 pm Thursday, May 23 8 : 0 0a m t o l l : 3 0 p m Friday, May 24 8:00 am to 4:30 pm A messageboard will be maintained at the Registration Desk. Phone messagescan be left at the UAIEM Regis=tration D.r[;t calling the RadissonMuehlebachHotel directly-at(gl6) 471_l4OO and requesringthe UA/EM RegistrationDesk.

CONTINUING MEDICAL EDUCATION The Universityof Missouri at KansasCity designates this continu_ ing medicaleducationacrivity for l9 credit hoirs in Caregory I of the Physician's Recognition Award of the American Medicar Association.The Annual Meeting has also been approved fbr l9 credit hours of CategoryI by the American Collegeof Ern..g.n.y Physicians.

PLACEMENT SERVICB A bulletin board wilr be maintained near the Regisrrarion Desk for. persons wishing to post positions and physicians available llsnngs.

PROCEEDINGS Proceedingsof the Annual Meeting will not be preparecl as a separatepublication. However, selectedpresent.ationj, scientific papersand pertinent discussionswill be printed in the'Annal.soj Emergency Medicine, the journal of the American College oi Emergency Physicians and the University Association for EmergencyMedicine. In addition, the abstractsfrom the l9g4 Annual Meeting will be publishedin the May l9g5 issue of Annals of Emergency Medicine.


UAIEM is proud to cosponsorthe methodology papers with the Societyof Teachersof EmergencyMedicine on"iu.sauy, May 2l from l:30-5:15pm in the Grand and Colonial Ballrooms. A cof_ fee break will be hetd from 3:00-3:30pm in rhe Imperial Ballroom and the exhibitswill be open during ihis time. There is no registration fee to attend these joint sessions.All registrantsof either the UA/EM or STEM Annual Meetings are invited to attend the methodology paper sessions.

UAIEM.STEM COCKTAIL RECEPTION STEM and UA/EM are sponsoringa cocktail receptionon Tues_ day, May 2l from 5;30 pm until 7:00 pm. The receptionwill be held in the Terrace Room. There is no charge for the reception. Hors d'oeuvreswill be servedand a cashbar-will be available. All registrantsand exhibitorsare invited to attend.

UAIEM - STEM EMERGENCY MEDICINE RESEARCH FELLOWS DINNER AND PROGRAM The University Association for Emergency Medicine and the Society of Teachersof EmergencyMedicine are jointly sponsor_ ing the Emergency Medicine ResearchFellows Dinn.. and pro_ gram o-nTuesday, May 21. The dinner will be held in the Lido Room from 7:00-8:00pm and is being.providedto past and present Emergency Medicine fellows and their directors. others wishing to attend the dinner can purchaseticketsat the UA,zEM Registration Desk on Tuesday, May 2l for $20 each. During the dinner there will be five to ten minute presentations on the organization and activity of various fellowship programs.

The EmergencyMedicine ResearchFellowsprogram will be held from 8:00-9:30pm in the Trianon D Room. The program will consistof a panel moderatedby Shermanpodolsky, M.O., anA including Judith Tintinalli, M.D., discussingCertification of Fellowships, James Niemann, M.D., discusiing Funding for Fellowships,Glenn Hamilton, M.D., discussingLength andllon_ tent of Fellowships,and Larry Baraff, M.D., dlscussingResearch or clinical Fellowships.Ail interestedparticipanrsof the UA/EM and STEM Annual Meetingsare invited to aitend. There is no fee to attend this program.

IN.HOSPITAL CPR STUDY GROUP MEETING On Wednesday, May )) from 5:00-7:00 pm all interested participants of the UA,zEM and STEM Annual Meetings are invited the In-Hospital CpR Study Group Meeting which will lo 3rl.l9 be held in Room 5. The Study Croup will be discussingcode blue evaluation forms, code blue response,no_codepolicies, brain death policies, computer tracking, and quality assurance. In_ terestedparticipantsare asked to bring the forms used in their hospital. There is no fee to attend this meeting.

SOCIAL OUTING On Thursday, May 23 the UA,/EM Annual Meeting will acljourn at l:00 pm to allow the registrantsto enjoy,orne of Kunsas City. At 2:00 pm buses will leave the Radisson Muehlebach for the Nelson-Atkins Museum of Art and the Country Club plaza. Ticketsare availableat the uA,/EM RegistrationDesk for onry gl each startingon May 21. The buseswill return to the Nelson Art Callery at approximately 4:30 and will make a srop at the Country CluL pla; to pick up and drop off participants.The buseswiil then depart at arouni 5:00 pm to return to the RadissonMuehlebach.Registrants may wish to stay at the Plaza in_tothe eveningfor additio-nalshopping and dinner. Taxis are availablefor those wishing a longer visit.'

BANQUET A free ticket to this year's Annual Banquet on Friday, May 24 is available to every active, associateor international mem6er of UAIEM attendingthe Annual Meeting. This year'sbanquet takes place at rhe renovated, historical Folly iheatre, which is a minute's walk from the RadissonMuehlbach.The evening,s festi_ vities begin with a hosted bar located on-stage. visit withfriends and sip pre-dinner cocktails as you listen to ihe Kansas City jazz soundsof the Elder Statesman.A traditional KansasCity baibe_ que follows and then the show really begins as the annual Imago obscura and JamesMackenzie a*aids aie presented.The awar'ds are real, but the presentationsare tongue_in_cheek at best.Expect a hilarious ending to a fun-filled evening. Tickets can be purchasefor g35 eachat the UA,zEM Registration Desk located in the Imperial Ballroom of the RadissonMuehlebach Hotel starting on May 21.

EXHIBITS The exhibits wilt be available for viewing on May 2l from 3:00-4:30pm, in the Imperial Ballroom. On tvtay22 the exhibits will be open from 8:00-l l:00 am and 3:00_4:30 pm. pleasetake an opportunity to view these exhibits during the scheduled coffee breaks.

UAIEM ANNUAL BUSINESSMEETING The Association will hold its Annual Business Meeting from l2:15-l:00 pm on Thursday May 23 in the Grand Ballroom. At the meeting, Richard C. Levy, M.D., will introduce incoming president Steven J. Davidson, M.D. Agenda rtems fbr the businessmeeting will incrude the erectionoi officers and councir and committee members, officers' reports, and other items of business presented by the membersliip. All members of the Association are urged to attend.



1983-JeffreY A. Sharff, MD' Oregon ]9ll_,LawrenceB. Dunlap,MD, Josephine ff.utttt University,Portland GeneralHospital,GrantsPass,Oregon "Effect of Time on RegionalOrgan" Percutaneous Transt rachealVentiof Pirfrtioi During Two Methods lation During Cardiopulmonary Ret ion " Caidiopulmonary Resuscita suscitation" f S8+-GerardB. Martin, MD, HenrYFord of l97g-elbert E' Cram, MD, University HosPital,Detroit Iowa, Iowa CitY "Iniutin and GlucoseLevelsDuring llrni nffrrt of PneumaticAnti-Shock in the CanineModel" CPR Trousers on Interacranial Pressure in the CanineModel" 1980-BlaineC. White, MD, WayneState IMAGO OBSCURAAWARD UniversitY,Detroit "Mitochondrial O2Use and ATP 1 9 7 6 - N o r m a n E . M c S w a i n ,J r ' ' M D 1977-Sung Rock Lee,MD Kinetic EfJectsof Caz+ Svnthesis: 1978-C. PatrickLilja, MD ina HPoiModulated bY Glucocorri1 9 7 9 - S t e P h e nK a r a s ,M D coids" 1 9 8 0 - J a c k G o l d b e r g ,M D State 1981-BlaineC. White, MD, Wayne l98l-Robert KnoPP'MD Detroit UniversitY, "Correctionof CanineCerebralCor' 1 9 8 2 - B l a i n eC . W h i t e , M D 1 9 8 3 - R i c h a r d C . L e v Y ,M D ResisVascular and Flow tical Blood 1984-Glenn C. Hamilton, MD tance PostArrest UsingFlunarazine' A CalciumAntagonist" 1982-Carl Winegar, MD, WaYne State MACKENZIE AWARD UniversitY,Detroit MD "EarlyAmeliorationof BrainDamage^ 1976-JamesR. Mackenzie, MD Cameron, of M. T' Minutes 1917-CYril Fifteen ii Ooet After MD Hughes, H. 1978-John CardiacArrest" MD F. Waeckerle, 1979-JosePh 1983-CharlesF. Babbs, MD' Purdue MD Mattox, L. 1980-Kenneth UniversitY "lmProved Cardiac OutPut 1981-BarrYW. Wolcott,MD lurlnS MD C a r d i o P u l m o n a r YR e s u s c t t a t t o n 1982-HubertT. CurleY, MD Krome, L. Com1983-Ronald Abdominal with literPosed MD Babbs, F. 1984-Charles Pressions" 1984-'CharlesG. Brown, MD, Ohio State UniversitY KENNEDY LECTURERS "Injuries Associatedwith the PercuTransthoracic 1973-FraserN. Gurd, MD tanbousPlacementof l9?4-Oscar P. HamPton,Jr', MD Pacemakers" 1975-CurtisP. Artz, MD MD 1976-JohnG. Wiegenstein, MD Safar, 1977-Peter 1978-senatorAlan M' Cranston 1979-AlexanderJ' Walt, MD 1980-EugeneL. Nagel,MD PRESENTATION BEST 1981-C. thomas ThomPson,MD and^ 1980-Jacek B' Franaszek, MD' 1982-R AdamsCowleY,MD Harold A' JaYne,MD, UniversitYof 1983-RonaldL. Krome,MD Illinois, Chicago 1984-DavidK. Wagner,MD "Medical PreParations for an Out i b s s - n i . h u t d F . E d l i c h 'M D ' P h D Mass" door PaPal 1981-Robert W. Sttuutt, MD, University of Chicago "ExPanded Rotl of the Barium Enema in the Acute Abdomen" 1982-stephen R. Boster, MD, University of Louisville "TranslarYngeal Absorbtion oJ Lidocaine" 1983-Sandra H. Ralston, MD'


UniversitY "IntrapulmonaryEpinephrineDunng Proloiged Cardiopulmonary Resu-. scitatiin: ImprovedRegionalBlood in Dogs" Flow and Resuscitation of t984-Paul M. Paris, MD, University Pittsburgh "The PrehosPital Use of TranscutaneousCordiacPacing"

HONORARY MEMBERS MDt 1973-RobertH. KennedY, FraserN. Gurd, MD C. BarberMueller,MD MD 1974-JohnG. Wiegenstein' AlexanderWalt, MD 1975-OscarP. HamPton,MDf N. H. McNallY'MDt CurtisP. Artz, MDt 1976-AnitaM. Dorr, RNf EugeneL. Nagel,MD l9't7-Peter Safer, MD 1978-EbenAlexander,Jr', MD 1979-DavidR. BoYd'MD, CM 1981-R AdamsCowley,MD 1982-Carl Jelenko,III, MD

PAST PRESIDENTS | -Charles FreY, MD lg7O-lg'7 R. Dimick, MD lg'71-1g72-Prlan lglz-tsll-R.obert B. Rutherford,MD lgn-tgl+-lumes R. Mackenzie,MD Tslq, i-9ls-ceorge Johnson,Jr', MD E. Rudolf' MD l9'75-19'76-Leslie 19'76-19'.'7-DavidK. Wagner, MD 1977-1978-CarlJelenko,III' MD L' Krome,MD 1978-1979-Ronald iszs-tsso-fenneth L. Mattox, MD MD isso-tsst-w. KendallMcNabneY, MD igat-tgsz-losePh F. Waeckerle, W. Wolcott,MD 1982-1983-BarrY B. Peacock,MD 1983-1984-Jack C. LevY'MD 1984-1985-Richard

PAST ANNUAL MEETINGS lst Annual Meeting MaY l4-15'l97l Ann Arbor, Michigan 2nd Annual Meeting MaY 12-11, 1972 W a s h i n g t o n ,D . C ' 3rd Annual Meeting MaY 23-25, 1973 Hamilton, Ontarto 4th Annual Meeting MaY 28-June l, 19"14 Dallas, Texas 5th Annual Meeting MaY 20-24, 1915 V a n c o u v e r ,B r i t i s hC o l u m b i a 6th Annual Meeting MaYll-15, 1976 P h i l a d e l P h i aP, e n n s Y l v a n i a 7th Annual Meeting M a Y l 5 - 1 8 ,1 9 7 7 K a n s a sC i t Y , M i s s o u r t 8th Annual Meeting MaY l8-20, 1978 San Francisco,California 9th Annual Meeting MaY 24-26,1979 Orlando, Florida lOth Annual Meeting A p r i l 2 0 - 2 3 '1 9 8 0 Tucson, Arlzona llth Annual Meeting APril l3-15'l98l San Antonio, Texas l2th Annual Meeting A P r i l l 5 - 1 7 ,1 9 8 2 Salt Lake CitY, Utah l3th Annual Meeting J u n el - 4 , 1 9 8 3 Boston, Massachusetts l4th Annual Meeting MaY 22-25' 1984 Louisville, KentuckY 15th Annual Meeting M a Y 2 1 - 2 4 '1 9 8 5 K a n s a sC i t Y ' M i s s o u r i


,&, Richard Levy, MD President

EXECUTIVE COUNCIL RichardLevy, MD, President StevenDavidson,MD, President-Elect RichardNowak, MD, Secretary/Treasurer JackPeacock,MD, Pastpresident Barry Wolcott, MD, Pastpresident JosephWaeckerle,MD, Past president Mary Ann Cooper,MD, Councilman RobertKnopp, MD, Councilman ErnestRuiz, MD, Councilman Judith Tintinalli, MD, ProgramChairman ScottSyverud,MD, EMRA Representative

COMMITTEES Constitution and Bylaws Charles Aprahamian, MD, Chairman Robert Jorden. MD Patricia Sanner, MD Education T h o m a sS t a i r , M D , C h a i r m a n JamesNiemann. MD ShermanPodolsky, MD JamesRoberts,MD Nominating StevenDavidson, MD, Chairman Richard Burney, MD Lynnette Doan. MD Jack Peacock, MD Barry Wolcott, MD Program Judith Tinrinalli, MD. Chairman William Barsan, MD Michael Callaham, MD Arthur Sanders.MD

Judith Tintinalli. MD Program Chairman

AD HOC COMMITTEES Industrial/GovernmentalRelationships Ernest Ruiz, MD, Chairman CharlesF. Babbs, MD Daniel Danzl, MD Richard F. Edlich, MD Harvey Meislin, MD John G. Wiegenstein,MD International Affairs Bruce Rowat, MD, Chairman Herman Delooz, MD SheldonJacobson,MD Wayne Longmore, MD KennethMattox, MD Yasuhiro Yamamoto, MD Long RangePlanning StevenDavidson.MD. Chairman Jerris Hedges,MD Benjamin Honigman, MD Richard Nowak, MD Journal Task Force DouglasRund, MD, Charrman StevenDronen, MD G. Patrick Lilja, MD W. Kendall McNabney, MD Paul Paris, MD Robert J. Rothstein,MD 1985UAIEM-IRIEM ResearchSymposium Blaine White. MD Jerris Hedges, MD Richard Levy, MD Richard Nowak, MD J. Douglas White, MD

1986UA/EM-IRIEM Research Symposium Planning DouglasRund,MD, Chairman Gary Fiskum,PhD JerrisHedges,MD RonaldKrome, MD RichardNowak. MD

REPRESENTATIVES American Board of Emergency Medicine Gail Anderson, MD W. Kendall McNabney, MD J u d i t h T i n t i n a l l i ,M D David Wagner, MD ABEM Intraining Examination Committee V. Gail Ray, MD JosephZeccardi, MD AMA Commission on EmergencyMedical Services Paul Pepe, MD, delegate Jack Peacock.MD. alternate ACEP ResearchCommittee Peter Maningas, MD Annals of Emergency Medicine Michael Callaham, MD, associateeditor AAMC Council of Academic Societies Michael Callaham, MD, delegate Thomas Stair, MD, delegate Steven Davidson, alternate Richard Levy, MD, alternate Emergency Medicine Foundation Barry Wolcott, MD


by RichardF' Edlich' The KennedyLecturewill be presented o f t h e U n i v e r s i t yo f p f r O . m e m b e r a i s E d l i c h D r . frlb, of Vliginiu faculty where he is a DistinguishedProfessor Director and Engineering plaitic Surgery and Biomedical of the Burn-Center.He servedas the Director of Emergenfrom 1974 c y M e d i c a l s e r v i c e sa t t h e U n i v e r s i t yo f V i r g i n i a y o u a s the past i o f S A Z .D r . E d l i c h i s k n o w n t o m a n y o f H o w ever' his A s s o c i a t i o n ' Frogrurn Chairman of this His career care' wound of area in the is natiinal acclaim and PlasMedicine Emergency of fields the iiut-in,.t*ouen r i c S u r g e r yg i v i n g h i m a m o s t u n u s u a lp e r s p e c t i v e ' of He currentlyserveson the editorialboardsof theJournol ConCurrent Care Quarterly' P^iigenry'Medicine, Trsumq Jourtiptt'in irou*o Care, Journal of Surgical Research' in Advsnces and Rehubilitation, and Care nit o7 Burn auMedicine. He has published extensively' i.rignnry publications itroring over 250 articles and books' These care' major wound minor as diverse as deal w]th subjects

it is burn reconstruction,and nurseeducation'However' managment tissue of soft his contributionsin the area whichhaveaddedmosttothefieldofEmergencyMedicine. pracThe careof minor woundsis rarelystudiedbut often ti..a.p..Edlichhastakenadisciplinedapproachtothis addedto, and revised,much of the tradi*bi;;;;;has iionat tttinting about the careof soft tissueinjuries' titled Dr. Edlich's Kennedy lecture at Kansas City is Personal A ;i;"G;t Repair: of wound Infection and yet anotherof p-r' Edlich'scontriOdyssd" It represents of EmergencyMedicine'TheUnithe discipline Urtitnt tt Medicineis proud to Emergency for nttociation ".rtity at *"i.o-. Dr. Edlich, and is honoredto havehim speak our 1985Annual Meeting. grateThe UniversityAssociationfor EmergencyMedicine Kennedv 1985 the of sponsorship the iliiy;;kr;;iedges LecturebY Marion Laboratories'

ANNUAL MEETING OVERVIEW Tuesday,May 21, 198s 9:30am - 12:00noon 12:00noon - 5:00pm l : 3 0 - 3 : 0 0p m 3 : 0 0- 3 : 3 0p m 3 : 3 0- 5 : 1 5p m 5:30- 7:00pm 7:00- 8:00pm 8 : 0 0- 9 ; 3 0p m

Annals of EmergencyMedicine Editorial Board Meeting, Trianon A UAIEM Registration,Imperial Ballroom UAIEM-STEM MethodologypapersI, GrandBallroom Coffee Break,ImperialBallroom_ ExhibitsOpen UAIEM-STEM MethodologypapersII, Grandand Colonial Bollroom UA/EM-STEM CocktailReception,TerraceRoom uAlEM-srEM EmergencyMedicineResearch FellowsDinner, Lido Room uAlEM-srEM EmergencyMedicineResearch Fellowsprogram, TrianonD

Wednesday,May 22, lgts 7:30- 8:20am 8:20- 8:30am 8 : 3 0- 1 0 : 3 0a m 1 0 : 3 0- l l : 0 0 a m l l : 0 0 - l l : 1 5a m 1 l ; 1 5- 1 2 : 0 0n o o n l:00 - 3:00pm 3 : 0 0- 3 : 3 0p m 3 : 3 0- 5 : 0 0p m 5:00- 7:00pm 5:00- 7:00pm 7:00- 10:00pm

UAIEM Registration,Imperial Ballroom _ Exhibits Open WelcomingRemarks- Judith E. Tintinalli, MD, GrandBallroom UAIEM ScientificpapersI, GrandBallroom Coffee Break, Imperial Ballroom _ Exhibits Open 1984Annual MeetingAwardspresentationsGrandBallroom , Kennedl'Lecture- RichardF. Edlich, MD, phD, GrandBallroom UAIEM Scientificpapers II, Grand and Colonial Ballrooms Coffee Break, Imperial Ballroom - Exhibits Open UAIEM ScientificpapersIII, Grandand ColonialBallrooms In-HospitalCpR StudyGroup Meeting, Room 5 EMRA Annual Business Meeting,TrianonA UAIEM ExecutiveCouncilMeeting,MuehlebachA

Thursday,May 23, 1985 8:00- 8:30am 8 : 3 0- l 0 : 1 5a m l 0 : 1 5- 1 0 : 3 0a m - ll:30am 10:30 1 l : 3 0- 1 2 : 1 p 5m - l : 0 0p m 12:15 2:00 pm 3:00- 5:00pm 6:00- 7:00pm

UAIEM Registration, outside of Coloniat Ballroom UAIEM Scientific papers IV, Grand and Cotonial Ballrooms Coffee Break, outside of Cotonial Ballroom UAIEM Scientific papers y, Grand and Colonial Ballrooms Presidentiaf Address - Richard C. Levy, MD, Grand Ballroom UAIEM Annual BusinessMeeting, Grand Ballroom Buses leave for Art Gallery and Shopping Mall EMRA Executive Committee Meeting, Muehlebach A EMRA Reception, Lido Room

Friday, May 24, 1985 8:00- 8:30am 8:30- 10:00am l 0 : 0 0- 1 0 : 1 5a m - 1 l : 4 5a m 10:15 l l : 4 5 - l : 3 0p m l : 3 0 - 2 : 3 0p m 2:30- 2:45pm 2:45- 4:30pm 6 : 0 0- l l : 0 0 p m

UAIEM Registration,outsideof Colonial Ballroom UAIEM Scientificpapersyl, GrandBallroom Coffee Break, outsideof Cotoniat Ballroom UAIEM ScientificpapersyIl, Grand and ColonialBallrooms NationalAssociationof EMS physiciansMeeting,GrandBallroom UAIEM Scientificpapers yIlI, Grand and Colonial Ballrooms Coffee Break, outsideof Colonial Ballroom UAIEM Scientificpapers IX, Grand and Colonial Ballrooms UAIEM Annual AwardsBanquet,Folly Theatre

UniversityAssociationfor EmergencyMedicine Fifteenth Annual Meeting Scheduleof Events May 2l-24, 1985

Tuesday,May 21.,1985 9:30- 12:00 noon Annals of EmergencyMedicine Editorial Board Meeting Trianon A 12:00- 5:00 pm Registration Imperial Ballroom 1:30- 3:00pm MethodologyPapersI GrandBallroom Moderator:Harvey Meislin, MD A Core Content Surveyof UndergraduateEducation in EmergencyMedicine,Arthur Sanders,MD, University of Arizona 2. An Analysisof the NationalBoardExamwith Regardto Questionsin EmergencyMedicine,Arthur Sanders,MD, STEM UndergradmteCurriculumPromotionsCommittee MedicineKnowledgeBaseof SeniorMedi3. Emergency cal Students,Doniel Goodenberger,MD, Georgetown UniversityHospital


Design of a Resident In-Field Experience for an Emergency Medicine Residency Curriculum, Ronald Stewart, MD, University of Pittsburgh


Emergency Medicine and Surgery Resident Interaction on the Trauma Team - A Difference of Opinion, Scoll Slagel, MD, Geisinger Medical Center


Research Seminar Series for Emergency Medicine Residentsand Faculty, Ruth Dimlich, PhD, University of Cincinnati


3:00- 3:30 pm Coffee Break Imperial Ballroom 3:30- 5:15pm MethodologyPaPersII

3:30- 5:15pm MethodologyPaPersII

Track A Grand Ballroom

Track B Colonial Ballroom

Moderator:J. Ward Donovan,MD

Moderator:Barry Wolcott, MD

7. Decision Making and ConfidenceLevel Testing in Graduate Medical Education, Paul Adler, DO, ThomasJefferson UniversityHospital 8. PediatricCurriculum for EmergencyMedicineTraining Program, Susan Asch, MD, PhD, Children's Hospital Medicol Center of Akron 9. Emergency Pediatric Tracheotomies: A Useable Technique and Model for Instruction, James McLaughlin, MD, University of Arizona 10. ComputerSimulationof CPR: ComputerAnalysisof a SimpleElectricalModel of the Circulation, Steven Meador, MD, Milton S. Hershey Medical Center I l. Application of Microcomputersin the Emergency Department:Our Experiencewith a Computerized Logbook, Scott Januzik, MD, Butterworth Hospital 12. ComputerAssistedInstruction in Trauma, R' David Evans,MD, GeisingerMedical Center 13. A Comparisonof a VideotapeInstructionalProgram with a Traditional LectureSeriesfor MedicalStudent EmergencyMedicine Teaching,PrudenceKline, MD, GeorgeWashingtonUniversitY.

14. EmergencyDepartmentDaily Chart Reviewfor Quality Assurance:A One Year ProspectiveStudy in an Emergency Medicine Residency Progrdm, Fred Harchelroad, MD, Allegheny GeneralHospital. of an OrganizedEmergencyDepart15. The Effectiveness ment Follow-Up System,Robert Shesser,MD, George ll'ashington University 16. The Effect of a TreatmentProtocol on the Efficiency of Care by Houseofficersto the Adult with Acute Asthma, Sandra Schneider,MD, University of Pitts' burgh. in the Medical Office, 17. Managementof Emergencies Michael Kobernick, MD, William BeaumontHospital. 18. The Beta Error and Sample Size Determinationin Clinical Trials in Emergency Medicine, Charles Brown, MD, Ohio State University and Johns Hopkins University 19. A SimpleMethod for Establishingthe Safetyof High Yield Criteria, Robert Vl/eors, MD, University Hospital of Jacksonville

5:30 - 7:00 pm UA/EM - STEM Cocktail Reception TerraceRoom 7:00 - 8:00 pm UA/EM-STEM EmergencyMedicine ResearchFellows Dinner Lido Room g:00 - 9:30 pm UA/EM-STEM EmergencyMedicine ResearchFellows Program Trianon D This program will focus on current researchand the evolution of fellowships in EmergencyMedicine. All registrantsof the UA/EM and STEM Annual Meetingsare invited to participate.There is no registrationfee to attend this program'


Wednesday,May 22, lggs 7:30 - 8:20 am Registration(coffee and Rots) Imperiar Barrroom 8:20 - 8:30 am welcoming RemarksJudith E. Tintinalli, MD, IggsAnnual Meeting program chuirman Grand Ballroom 8:30- 10:30am ScientificpapersI CardiopulmonaryResuscitationGrand Ballroom Moderator:JosephClinton, MD 20. Comparison of Endotracheal and Intravenous EpinephrineDosageDuring CpR in Dogs, Sandra Ralston, RN, phD, purdue (Jniversity 21. Effect of peripheral Versus Central Injection of Epinephrineon Changesin Aortic Diastolicpressure During ClosedChestMassagein Dogs, Syndi Keats, MD, Wayne Stste (Jniversity and Deiroit Receiving Hospitol 22. A Comparisonof Epinephrineand phenylephrine for Resuscitation and NeurologicOutcomeof CardiacAr_ rest in Animals, Judith C. Brittman, MD, (Jniversity of Arizono 23. The Value of Epinephrinein Prehospital CpR, "/. Stephan Stapczynski, MD, University of California Los Angeles 24. Lactic Acidosis During ClosedChest CpR in Dogs, Donns Carden, MD, Henry Ford Hospital 25. TransconjunctivalOxygenMonitoring as predictor a of Cardiac and Neurological Outc-omeFollowing Resuscitation,Dietrich Jehte,MD, Attegheny Generil Hospital 26. Hemoconcentration During CardiacArrest and CpR, Dietrich Jehle, MD, Allegheny General Hospitot 12:00- 1:00pm Lunch Break l:00 - 3:00 pm ScientificpapersII Track A - cardiopurmonaryResuscitation GrandBailroom Moderator:BlaineC. White, MD 28. Aortic and Right Atrial pressuresDuring Standard and SimultaneousVentilationand Compression CpR in Humans, GerardMartin, MD, Henry Ford Hospitat 29. Interposed Abdominalcompression-ipR:Its Effects on Parametersof Coronaryperfusionin Human Sub_ jects, Mark Howard, DO, Sl. Vincent Medical Center/ The Toledo Hospital 30. CardiopulmonaryResuscitationby High pressure In_ termediateFrequencyVentillationwith Chestand Ab_ dominal Wall Binding, Charles Saunders, MD, University of Colorado Heatth SciencesCenter 31. VenaCavato RetinalArtery CirculationTime During MechanicalStandard and Modified CpR in Dogi Don Benson, BS, University of OsteopathicMedicine snd Health Sciences 32. Comparisonof CpR-InducedTrauma Among Three Methods of Manual, External Cardiopulmonary Resuscitationin an Animal Model, Karl Kern, h[D, University of Arizono and purdue (Jniversitv

27. PostcountershockAsystole and pulseless Bradyar_ rhythmias: Responseto CpR, AdrenergicAgonists, and Glucagon, A Non_AdrenergicStimulator oi Adenyl Cyclase, Kevin Haynes, MD, University of Calrfornia Los Angeles 10:30- 11:00am Coffee BreakImperial Ballroom 1l:00 - 1l:15 am Awards presentationGrqndBallroom UAIEM-MICROMEDEX l9g4 Annual Meeting Best PaperAward Injuries Associatedwith the percutaneousplacement of Transthoracicpacemakers,Charles G. Brown, MD, Ohio State University UAIEM 1984Annual MeetingBestpresentation Award The PrehospitalUse of Transcutaneous Cardiacpac_ ing, Paul M. paris, MD, University of pittsburgh Annals 1984Annual MeetingBestResidentpaper Award Insulin and GlucoseLevelsduring CpR in the Canine Model Gerard B. Martin, MD, Henry Ford Hospitat 11:15- 12:00noon KennedyLectureGrandBallroom Biology of Wound Infection and Repair: A personal Odyssey,Richard F. Edtich, MD, phD, bistinguishedpro_ fessor of Plastic Surgery and Biomedical Engineering, universityof virginia sponsoredby Marion Laboratories 1:00- 3:00 pm ScientificpapersII Track B - Cardiology Cotoniat Ballroom Moderator:William Barsan,MD 35. MyocardialTissueIron Delocalization and Evidence for Lipid peroxidationAfter Two Hours of Ischemia, StevenHolt, MD, Butterworth Hospital and Michigan State University 36. NonlinearTransformationof the Resting Electrocar_ diogramin the Diagnosisof CoronaryArtery Disease, David Schreck, MD, MS, Columbia University Af_ filiated Ilospitals 37. Improved DiagnosticAccuracyand Acute Manage_ ment of perplexingTachyarrhythmias with a pill Elic_ lrode for Esophageal Electrocardiography,Mites Shaw, MD, University of California LlosAngetes 38. RightHeartCatheterization in theEmergency Depart_ ment, Peter DiChiara, MD, (Iniversity of South Alabamq 39. Post ThrombolyticCourse in patients with Acute Myocardial Infarction Treated with Intravenous Streptokinaseand Acute Myocardial Infarction and

Track A (cont.)

Track B (cont.)

33. Open ChestCardiacMassagefor Victims of Medical Cardiac Arrest, Edward Geehr, MD, San Francisco GeneralHospital 34. EmergencyBypassSystem:Analysis of Gas Transfer, JamesAmsterdsm, DMD, MD, Universityof Cincinnati

Peripheral Streptokinase, Gabriel Mayer, MD, Universityof Centrol Florida and TransvenousCardiacPacingfor 40. Transcutaneous Early BradyasystolicCardiac Arrest, Jerris Hedges, MD, University of Cincinnati 41. The Use of TranscutaneousCardiac Pacing in the EmergencyDepartmentfor the Treatmentof Pre-Hospital BradyasystolicCardiopulmonaryArrest, Robert O'Connor, MD, Wilmington Medical Center 42. Radiologic Assessmentof Tranvenous Pacemaker flacement During CardiopulmonaryResuscitation, Scott Syverud, MD, University of Cincinnati and Lackland Air Force Base

3:00 - 3:30 pm Coffee B,reak Imperial Ballroom 3:30- 5:00 pm ScientificPaPersIII Track A-Airway Grand Ballroom Moderator:CharlesBrown, MD 43. Ventricular Fibrillation During OrotrachealIntubation in HypothermicDogs, JamesGillen, MD, Geisinger Medical Center ,14.High FrequencyJet Ventilation Cooling in a Canine Hyperthermia Model, William Barker, MD, Fairfax Hospital and University of Cincinnati Lumen Airway: An Assessment 45. Pharyngeo-Tracheal of Airway Control in the Setting of Upper Airway Hemorrhage, Robert Bartlett, MD, Richland Memorial Hospital 46. SuccessRates of OrotrachealIntubation by TransilluminationTechniqueUsinga LightedStylet,David Ellis, MD, UniversitYof Pittsburgh 47. The Radiographic Diagnosis of Upper Airway Obstruction in Maxillofacial Trauma, John Teichgroeber,MD, University of Texasut Houston 48. NeuromuscularBlockadefor Critical Patientsin the EmergencyDepartment,David Roberts, MD, Hennepin County Medical Center 5:00- 7:00 pm EMRA Annual BusinessMeeting,TrianonA

3:30 - 5:00 pm ScientificPapersIII Track B-Anaphylaxisand Pediatric Coloniul Ballroom Moderator:LynnetteDoan, MD 49. The Effect of Verapamilon AcuteAnaphylacticShock in Guinea Pigs, llilliam Jacobs, MD, Butterworth Hospital and Michigan State University 50. HemodynamicEffects on Naloxonein Anaphylactic Shock, William Barsan,MD, Universityof Cincinnati 51. Central and Peripheral Catheter FIow Rates in "Pediatric" Dogs,Dee Hodge, III, MD, Universityof Pennsylvania 52. Efficacy of Current Recommendationsfor Bicarbonate Therapy in a Pediatric Animal Model for CardiopulmonaryResuscitation,GraceCapulo, MD, University of PennsYlvanio 53. Diagnosisof Group A StrepPharyngitisin The Emergency Departmentin Ten Minutes, David DuBois, MD, Texas Tech University 54. Developinga ClinicalModel to PredictC-SpineInjury in Child Trauma Victims, David Jaffe, MD, North' westernUniversityand Children's Memorial Hospitol

5:00- 7:00 pm In-hospitalCPR Study Group Meeting, Room 5 7:00- 10:00pm UA/EM ExecutiveCouncil Meeting,MuehlebachA

Thursday,May 23, 1985 8:00- 8:30 pm Registration(Coffeeand Rolls) outsideof ColonialBallroom 8:30' 10:15am ScientificPapersIV E:30- 10:15am ScientificPapersIV Track A-Toxicology and Environment Grand Ballroom Moderator: Ronald Krome, MD 55. Caustic Ingestions- An In-Vitro Study of the Effects of Buffer, Neutralization and Dilution' Kimball Maull, MD, UniversitY of Tennessee 56. The Comparative Effectiveness of Cathartics Used With Activated Charcoal, Ray Keller, AB, University of Pittsburgh

Track B-Central Nervous System Resuscitation Colonial Ballroom Moderator: Robert Rothstein, MD 61. The Effect of High Dose Epinephrine on Regional Brain Blood Flow During Cardiopulmonary Resuscitation in a Porcine Model, Charles Brown, MD, Ohio Stote Universily

Thursday,May 23, 1985(Continued) Track A (cont.) 57. Propanolol Toxicity and the Use of Intravenous Glucagonin the Dog Model, Lorraine Hartnett, MD, lTayne Longmore, MD and Mary Ann Howlond, Pharm D, New york City poison Control, Bellevue and New York University 58. Phenytoin:Does it ReverseTricyclic_Antidepressant Induced Cardiac Conduction Abnormalities?, Ray Mayron, MD, Hennepin County Medical Center 59. High-DoseNaloxoneReversalof Acute Ajcohol In_ toxication, Robert Norton, MD, Oregon Health Sciences(Iniversity 60. Rapid Assay of SerumTheophyllineLevels,Thomas Reinecke,MD, University of Florida ond (Jniversitv HospitaI of Jacksonvil te

10:15 - 10:30 am Coffee Break outside of Colonial Bullroom 10:30 - 11:30 am Scientific papers V Track A-Toxicology and Environ ment Grand Ballroom Moderator: Joseph Zeccardi, MD 68. Drug Overdose patients Requiring Intensive Care Ad_ mission in the Greater portland Metropolitan Area: An Analysis, Mary Jones, MD and Jon Jui, MD, Oregon Health Sciences Universitv 69. Treatment of polonium poisoning with Dimercapto Chelating Agents, Richard Dart, MD, (Jniversity of Arizonq 70. A Retrospective Review of Black Widow Spider En_ venomation, Hershel Moss, MD, Texqs Tech (Jniversity 71. A Nine Year Evaluation of Emergency Department Personnel Exposure to Ionizing Radiation. Richard Grazer, MD, University of Ariaona

Track B (cont.) 62. Post Insult Treatment of Ischemia_InducedCerebral Lactic Acidosis in the Rat, Michette Biros, MS, MD, University of Cincinnati 63. Cerebral Resuscitation after Cardiac Arrest usins Hetastarch Hemodilution, Hyperbaric Oxygenationl Magnesium Ion, and Free Radical Scauenge.s, Douglas Brunette, MD, Hennepin County Ueaicail Center and University of Minnesoto 64. The Effect of Naloxone on Cerebral Blood Flow post_ Arrest, Mork Zwanger, MD, Detroit Receiving Hospital, Wayne State University and Wiiliam Beaimont Hospital 65. Effect of Nifedipine on the Recovery of Cerebral High Energy Phosphates after Cardiac Arrest and Resuscitation in the Rat, Herbert Garrison, ^Bt University of North Carolina 66. Brain Iron Delocalizationand Malondialdehydepro_ duction Following Cardiac Arrest, Jsmes Komara, D.O, Mt. Carmel Mercy Hospitat and Michigan State University 67. Brain Iron Delocalizationduring Various Methods of Artificial Perfusion, Kathleen Joyce, MD, Sinai Hos_ pital of Detroit and Michigan State Llniversity

10:30 - l1:30 am Scientific papers V Track B-Central Nervous System Resuscitation Colonial Ballroom Moderator: Robert Knopp, MD 72. Cardiac Arrest ancl Resuscilation: [Jrain lron Delocalizationduring Reperlusion,Gar-yKrau_se, MD. M ic'higan St a te tJn i ver.sit v 73. Effect of Desferoxamineon Late Deaths Followins Cardiopulmonary Resuscitationin Rats, SushitaKoi palo, MB, MS, purdue University 74. Effects of Carbon Dioxide, Lidoflazine and Deferox_ amine Administered after Cardiorespiratory Arrest and Cardiopulmonary Resuscitationin Rats, Steohen Badylak, DVM, phD, purdue (Iniversity 75. Protective Head Cooling during Cardiac Arrest in Dogs, .Eric Brader, MD, Attegheny Generol Hospital and Resuscitqtion Reseurch Center

11:30 - 12:15 noon presidential Address, Richard C. Levy, MD, University of Cincinnati, Grand Ballroom 12215- 1:00pm UAIEM Annual Business Meeting Grand Bsllroom

1:00- 5:00pm Social Event 3:fi) - 5:00pm EMRA ExecutiveCommitteeMeeting MuehlebachA 6:00- 7:00pm EMRA ReceptionLido Room

Friday, May 24, 1985 8:00 - 8:30 am Registration(Coffee and Rolls) outsideof Colonial Ballroom 8:30 - 10:00am ScientificPapersVI Prehospital Grand Ballroom 79. Enhancing Survival After Cardiac Arrest - The Effect of Initial Rhythm and A New Strategy in Emergency Care, W. Douglas Vl/eaver, MD, University of Washington

Moderator: StevenDavidson, MD 76. Factors in Sudden Cardiac Death Decision Making, Charles Aprahamion, MD, Medical College of Wisconsin TT.Bystander/FirstResponderCardiopulmonaryResuscitation: Ten Years Experience in a Paramedic System, Harlsn Stueven, MD, Medical College of Wisconsin 78. Professional Bystander Cardiopulmonary Resuscitation in Prehospital Coarse Ventricular Fibrillation, Robert Kowolski, MD, William Beaumont Hospitol snd Medical College of Wisconsin

g0. Prophylactic Lidocaine in the Prehospital Patient with Chest Pain of Suspected Cardiac Origin, Ksthleen Hargorten, MD, Medical College of Wisconsin 81. Prehospital Use of Isoproterenol for Complete Heart Block, E. H. Kustenson, MD, Medicul College of Wisconsin

10:00 - 10:15 am Coffee Break outside of Colonial Ballroom l0:15 - 11:45 Scientific Papers VII

10:15- 11:45ScientificPapersVII

Track A - Prehospital Grund Ballroom

Track B-Medicine Colonial Ballroom

Moderator: Robert Kowalski. MD

Moderator:Donna Carden.MD

8 2 . P r e h o s p i t a lU s e o f H a n d H e l c l A e r o s o l N e b u l i z e r :A Preliminary Trial, Angel Lscovich,MD, St. Francis Hospital oJ Santa Barharq 83. Aminophylline in PrehospitalCare, Pqul F-reitas,MD, Highland General Hospital 8 4 . L i q u i d C r y s t a l T h e r m o m e t r y i n t h e P r e h o s p i t a lE n vironment, SlanJ'ord Lee, MD, Ariz,ona Health SciencesCenler 8 5 . E v a l u a t i o n o f F i e l d P e r f o r m a n c eo f P a r a m e d i c sb y B a s e P h y s i c i a n sa n d F i e l d S u p e r v i s o r sS , / e y eD a v i d .son, MD, Medical College oJ' Pennsylvania and Rose Cheney, MA, Philadelphia Health Management Corporution 8 6 . S o u r c e so f O c c u p a t i o n a lS a t i s f a c t i o na n d S t r e s sf o r E,mergencyMedical Technicians, Theodore Whitley, PhD, East Carolina University 8 7 . V i r a l H e p a t i t i s R i s k i n U r b a n E M S P e r s o n n e l ,P a u l Pepe, MD, tsaylor College of Medicine

8 8 . A Comparison of the Supraclavicular Approach and the Infraclavicular Approach for Subclavian Catheterization, Steven Sterner, MD, Hennepin County Medical Center 8 9 . SubclavianCatheterizationin the EmergencyDepartment: Comparison of Guidewire and Non-Guide Wire Techniques, C. Blake Schug, MD, Valley Medical Center 90. A Comparison of Intraosseous, Central and Peripheral Routes of Administration of Sodium Bicarbonate during Cardiopulmonary Resuscitationin Pigs, William Spivey, MD, Medical College of Pennsylvanio 91. Alternate Therapy for Traumatic Pneumothora in "Pocket Shooters", Kimberlydawn Wisdom, MD, Henry Ford Hospital 92. The Hemodynamic Responseto Rapid Military AntiShock Trouser Deflation, William Bickell, MD, Brooke Army Medical Center 93. Lack of Efficacy of Naloxone in a Fixed Volume Hemorrhage Model, Steven Dronen, MD, University of Cincinnati and Letterman Army Institute of Resesrch

11:45- l:30 pm NationalAssociation of EMS Physicians Meeting Grund Bullroom 1:30 2:30pm ScientificPapersVIII 1:30- 2:30pm ScientificPapersVIII Track A - PrehospitalGrand Ballroom

Track B - Medicine Colonial Ballroom

Moderator:William Robinson.MD

Moderator:RichardNowak. MD

94. Empiric Development of a Prehospital Approach to

9 8 . Effect of Technique of Administration on the Endotracheal Absorption of Lidocaine, Sharon Moce, MD, Sinai Medical Center

Multiple Victims, Bruce Haynes, MD, University of California Los Angeles

9 5 . Evaluation of Major Trauma Care in a SevenCounty

9 9 . Arterial Blood Gases Before, During and After Nitrous Oxide: Oxygen Administration, Marc Gorayeb, MD, University of Pittsburgh

Northern California EMS Region, R. Myles Riner, MD, Alpine, Mother Lode, San Joaquin EMS Agency


Friday, }'day 24, 1985(Continued) Track A (cont.)

Track B (cont.)

96. SpecialEvent Medical Care: The l9g4 Los Angeles Summer Olympics Experience, William Baker, MD, Universityof California Los Anseles 97. A MicrocomputerBasedAnticipitory AmbulanceDe_ ployment Strategyin a Large Urban EMS System, JosephRyan, MD, University of Missouri

l00.Methemoblobin Levels Following Sub_Lingual NitroglycerinAdministrationin Human Volunteers. Paul Paris, MD, University of pittsburg l0l. SerumConcentrations of Meperidinein patientswith SickleCell Disease,Stephanie Abbuhl, MD, Universi_ ty of Pennsylvania

2:30 - 2:45 pm Coffee Break outside of Cotoniat Ballroom 2:45- 4:30pm ScientificpapersIX Track A - PrehospitalGrand Ballroom

2245- 4:30 pm ScientificpapersIX Track B-Medicine Coloniul Baltroom

Moderator:Jack Peacock,MD 102.The Utilization of ComputerSimulationto Enhance Mass Casualty Incident ResponseSkills, Rodger Kelley, MD, QuintessentialMoss Casuolty Consultant Services 103.Dispositionof patients Referredfrom Freestanding EmergencyCentersto a Hospital EmergencyDepart_ ment, Louis Ling, MD, Hennepin County Medical Center l(X. Is the Flight physician Needed for Helicopter Emergency Medical Services?, Kenneth Rhee, MD, University of Michigan

105.Transconjunctival OxygenMonitoring as a predictor of Hypoxemiaduring HelicopterTransport,Charles Shufflebarger, MD, Altegheny General Hospital 106.Rural Aeromedical Interhospital Transports of CategoryI Motor Vehicle RelatedTrauma: Causes for Delaysand Recommendations,ThomasAnder_ son, MD, GeisingerMedical Center 107.PrehospitalIndex: A ScoringSystemfor Field Triage of Trauma Victims, John Koehler, MD, Butterworth Hospital and Michigan State University 108.Trauma Score Simplified, Donald kamens, MD, University of Florida 6:00- 1l:00 pm UAIEM AwardsBanquetFoily Theatre

Moderator:W. KendallMcNabney,MD 109.The Efficacy of a ,,Standard" SeizureWork_Up in the Emergency Department, Robin Eisner, MD, University of lllinois ond Mercy Hospital and Medical Center ll0. The Efficacy of Home Observationfor Victims of Mild Closed Head Injury, CharlesSounders,MD, Universityof Colorado lll. High Yield Criteria for EmergencyCT Scans,Myron Mills, MD, University Hospital of Jocksonville ll2. Sutured Wounds in an Urban EmergencyDepart_ ment, Mark Smith, MD, GeorgeWashingtonUniversity l13. A Trial of Povidone-Iodine in the preventionof In_ fectionin SuturedLacerations,Al Gravett,MD, Hen_ nepin County Medical Center

Abstracts of the isth Annual Meeting of the_

ffiivei;itv n"JoliJtion for EmergencyMedicine Association fot will be Oresen\gf-althe Annual Meeting of the Univercity presenteris not [Editor's note: The fol]owing 1-L3absttacts where in italics; appear names TSSSPresentets' EmergencyMedicine in Kansas.Citv Miss,ourt,,ittii 6t Zq, indicZted, none was specifiedby the authorc'l

MethodologY Session a I

Gore Gontent Survey of Undergraduate Education in EmergencY Medicine

Medtcine of Emergency / Section nE Suna"ts,E Criss,D Witzke Center' HealthSciences Arizona unOOtti""of MedicalEducatron, Tucson

variedfrom a low of 3 5"/" Ior the quescategories subsoecialtv HLr,r't,to a high oI 25'9%for questionsin Suri."Ti.'n"iri. medi.i .o.,".t it'potses to the em-ergencv ;;;. +il. ff.*rs" in 1983and67'r% in r97e' The items werc 7]g.3o/" :i;; ";il "".otdittg to the STEM Core C.ontent Knowl,ft" "f"t.iii"d *.t. was noted' on the 1979 il]ttt-cl"tia.trnt""variabilitv ;;; medical exam. no questlons were asked pertaining to emergency

The Socicty o{ Teachersof EmergencyM5{1cr-1erecently develunderophthalop"J r-Cot.'Content KnowledgeEaseand Skills List for "a;;.ts""v '"", env'ronmental' ;ffiiG, til;i;l;; l4l 4 items onlv exam' 1983 In the s i a d u a t ec d u c a t i o nr n e m c r g e n c ym e d i c i n c A s u r v c yo f emergeicies' 6r behavior ;;i;;i;; detcrques24 contrast' In ateas' Content Coie lii.n",i'ri.-r.a osteopathicm"edicalschoolswas done to these from *.t"?ti"a core content toplcs were being-taught ;#;;"t. asked pertaining to the Core Content area of trauma *"t. tio". than 80 in the "ur.icrrlum. Responseswere obtained {rom more q""t,iors iro- toxiiologic emeryencies'Some Core Con,"Jx 5 r"fr""fr itti."gh 2 maiiings and a random telephone follow-up' varied from exam tolxam For example' there were ;;;;;; l1 tht topic or skill but whether exam' to as 1979 asked the in specificall! emergencies ;ardiovascular d;;"t,i.;;.tl ;;;;,i;;;.; reias offcred,rf it was a requiredor electivepart o{ the curriculum' in the t983 exam. ThJmean percentageof correct ;;;;;i;;; to devoted hours of number total the offered,and iirln""iii'i. {rom a low of 53'3% on the topic o{ nervous svs;;d ;;;;; 69 ;i;; i;;i". D"ta i., thi, ,"port represent the analvsis from or 85.4% on urogenital diseases'The data , r"gt' ;#;;;;;;;. "d"-ottttrate of .-"rg..t.y medical services{cg,prehospital that questions Jrom the Core ;;h.;l;. il;tpl", ;;;;i-il;;"lysis the "ri", prrr-"aics) are taugh"tin'57 1% of the schools responding' of emergencymedicine are being tested in Part II of Content r-rriculum Some There is, however,considerablevariability t", f"fv 29.4"/"haveit as1 requiredpart of the c n.-JE"*"-. Nr,lt""f schoolsThcsc and in subinoics *.r. offercdin the vast maiority of mcdical 194'2%1, muscui., ihe lte-s being tested both from year to year and ve-rylittle received nervous system that areai topic i"fiua"a ,t""ma 194.O%), several categorics soecialtv (80'37'l' identilied' been have ioskeletal lg}.l%) emergencies.Topics in l-o,*lgglosv cxam aitcntion nn Jith.t (86.l% ), a*ndophthalmologic (81'5%) emergencies """ii""-"","1 required a were they but wcre taught in most medical schools, o artofth"ecurriculuminaminority{toxicology,4697o;envtron"-."*f, Base of Knowledge Medicine Emergency Topics in the skills list 1, +ir ^7"f opbth"l*ology, 45"5Y"1' varied These Studqots Medical ichools' medical of Senior 8z.i;t rt ol ti."r" *.t" i*gft, n'" MA Rolnick/ Departmentof Medicine' DM Goodenberger, irom airway management,which is taught in all medical schools taught UniveisitvSchool of Mediclne,and Departmentof c;"ts;i*; tut required \n57:l%, to llnsr suit application,which is ir"t"g"n"V Medicine,GeorgetownUniversityHospital' i" OS.f7" and rcquired tn 28'6% of medical schools'This survey medicine emergency of DC status the on Washington, data batic "t.tia"t *m" core content toprcs in the undergraduatecurriculum' Guidelines for the student curriculum in emergencymedlcrne ,t. i"tt'.i inclusive and general rhe problem of d;';;,h;y n]anningastudentcurriculumiscompoundedbyanignoranceof to Analysis of the National Board ih;;;;r?*" student'sfund of knowledgein areasof importance itt.t. is a geneial belief among traditional gxaliination with Regard to Questions in ;";;;?;;Jr"'".. that studentsIearn about the careof emergen;;:;i-;;.;i"lists lledicine EmergencY *i,hi" the purview^of their specialties f"ll / Undergraduate witzke D ;;;lfi;;t"l AB Sanders,wP-BurdiCk,TO Stair, specialty services obviously this would of respective #nii. o., the Committee,Societyof Teachers CrrriculumPromotions true, so that we might concentrate our i{ know, to useful be Medicine tmergency .ff.tit ^ppioptiately. In order to assessour students' knowledge The obiectivesof this study were 1) to determine the,percentsenior base,a pretest was constructedand administeredto each on age of qucstionsthat directly pertain to emergencymedlclne rotaemergency required school,s of our day first the ,i"a"",'o" if,. NJ""t.t Board Exam;'2i to determine the successfulrcquestionsabout emergenconsistedof open_ended test ir,. il"r. 3) and medicine; to emergency ,po.rr. t",. of the items tp..ifi"urology' .u .rr" problems from pediatrics, surgery and trauma' to d"t.r-i.rc if there is any differcnce in the number of items disease,toxicologv.'ob-gvn' infectious .rtalotogv, ;"1;; ;;h.;"1 penod' With medicine overa 4-yer,time pertarnrngto emerg,ency internal .medicine' and orthopedics' 3 ;i';;il;;;y; t"ff '."-t6!v, irr.-...p*1rii.n oi th.'National Board of Medical Examiners' stulents have been tested thus far' repre^i*"iftitJ. h,rnJr.d-twenty b.r. Promotions Curriculum {rom the Undergraduate of ttt. academic year in this' .*il"g 1979 Committee o{ STEM reviewediach item on the 1983 and Twenty-five percent of students' all with striking. are ift"l".s"i,t document Nr,i""^f Board Exam, Part II. The committee used the recognizedan inferior wall myocarme"dicine, of *..r.s ii "il""ti entitled "Core Content for UndergraduateEducation.inEmergenThe percentage iliproved to 467" with an addi aiJl.ttrr.tio.t. pertalnrng drrectly items selecting cv Medicine" as the basis for pâ‚Źlcent-cortional cardiology or iritical care rotation' Nineteen medicine. Each item wai then classi{iedaccording ;; ;;;;;;;;y and morphine oxygen/ diuretic, loop of -ini-rr" listed rectlv Conio th. t irtio"al Board subspecialtycategoryand the Core ol prrl-ottrry "d"-", a statistic essentially un;H;;;; ror tent KnowledgeBaseList. The percentageol correct responses pieviously mentioned rotations' Six percent' all the bv chansed by recorded was also medicine eachitem pertaining to .*.rg..t.y of pediatrics,could give the correct doseoI weeks 8 least with"at diexam 198'3 the on items o{"the b9z era11,\4.7ok .",.g"ir.r'o" e o i n e p h r i n e f o r a 3 S -Ibasthmaticchild.Fitty-onepercentrecogsubby at looked rectiy pertained to emergencymedicine' When tachycardia,and 68% recognizedventricular "i".a'"""iii""far of items pertaintngto emerthe percentage rp..i"[ty categories, of iiUrlit",io.t. twenty eight percent, all with ai least 4 weeks uari.,l f.o- l.3dzoin ob-Gvn to 27'2"/" of the ;!;;; ;J;t;; hemorrhag,eas a cause of severe t"U"ti"tttt"id fitr"a "."i"i.gv, -fr""a^.f,? its o{ 8% 13 had Exam Board i,.rn( n i"tg"ry. The 1979National *i* onset during intercourse' All students had at least q,...stlo.rspJrt"it to emergency medicine' Once again' the


surggl),but only 30,%cou.ld list use of lidocaine with l1,Y::1..d eprnephrineon fingers.qelrtals, and so forth as contraindica_ would be i potential mistake i" ;;;;; l'^.^Ll-I, thrt ,trd.nt,

posrtron varied widely,

';ily.*i**j iflt![:H1i,:t'L.:q:*,iliTTi'.".'"",f

"", k"'-

i' ag'"i"' ., r'., speciartv 3."t;:::'l;:l ;1:.:ff ;*::: t-' pranning ;,;#; ;:dJiJ:ti[.Jljjl;?jfil' oi;; i;

trauma caprainsS0% of ,l..,ri_:, *a ,t-*

general surgery staf{


with a gener_ o.,,oip.iiil ; ::fl?"','r'i':il''t" Ii,l"-'i-" wiir'ir" "*l"p'i ff p"oi"d ,h..Jt ;f,; ;;;.;i :li;:?;,"."T Tii,?:i?ft u,..*.,. InTIT:?""p.d";;id;,.,po.,a..,i,hJ;;ilt',1!""Zi1

l_esiSn_ofa Resident In.Field Experience

reenev uec:ciie i"-JiilliEli' lffi :,:ff parrs, MB

only 54"/o included

j;ffi ;#ililffiI ;'il"ij:,t;::'#T:l,lJ;Tfffi i::*'1"'#:1


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Besearch Seminar Series_for Emergency -' r' re rr!

anc racurt

I^"ti",I:^ l"-"11g"1" ?Iy,!:!,:1,}:p,:1".,i*nJ;;-",:ib:o-#;il,iy", Biorosv,

The.specialtyof .*11i,.n medicine has been described specrattyin breadth. wiih 11 as a a',,core,.,ifr"il, ,p*ltc to the disciplrne, This core represent: the emergency Tr: *",,i1;";"dii'

Univers*v or

biffi#;f tilii"?: :?,fi:ilffil"3l#S"i"

{o'-"i curriculaiave iiJ'i' li1'1,l,".Ti'J]|;:o expert'Severar

B e c a u s er e s e a r c h i s p l cy medicine, , ,.-inrr'^Tg

U"ai""grrms havede_ formalmechanism b;tg;e

a more important

role in emergen-

"^ar..,iiyL,il;L':J,,T.ffi .X:L!il:l..rr.l,::,:,',['J,:.*,,, lI:?emercenr-J,:hT{^,1",:*,i,1i'l"J:fl i1.,";:,".t":*',: tne lmportance the what, where, how of in_fieldexperience,

;;;H:",,ride_alongs,,, whrclr tor the most Dart and sporadic.We developeda comprehens^ive curriculum, ;;;" busy {50,000 catrs/yearlurban EMS system for .*p.?i"n... Residents receivea formal didactic.urrt"ulumresident j;i;;;;#;,.",,on week pri_ or to the pGy-l year and-partrcipate as observerson mobilc intensrve care units, but ther jo .,bt "r.u-. ii.lJ J, ,"aio respon_ srDrrrtres until their secondyear.Thi. f;;r";j;;; i1 a,nexpandeduersio.,imrnediately prior ," ,h.,;ET-T;:f:i;l clrrdedin this didactic portion are slmulatJ caljs, skill srations, ancla_required written bxamination. n;;;;;;;."""rve at least 2 monthsof formal in_field experience.dur-irg;;,:."rd and third vearandareregularlv r.l:0.:l:o i"ir*ra',3.piril o' nigr,t, weekendsthroughoui their "nd training. whire ;;;;;rron residents orrect field calls via norrable,"d;o, ;;;i., l-r""*t,y physician monitorins all calls 24'hours , d"t il;ril;;,r."ii'irouia.d responsevehicle that is with , owned,""a "p.rri.iJrin. emergency medrcrneresidency.k is a 4_wheet_ari".-r.ili[ provided with

whv "f science and 1_!program ,;;;;;;;iic The goals of this were to Jirr"_irrrt. in{orma_


of research technlaue!, i.,"tuJing :,i:"11y"9i".8 ;;"rimentat desrgn and dr;;;t;;?; "nd clinical research.Attainment of ,t;1.s*t. _", d"e,Jtil; demonsrrate tfie clinical relevanceof basic science,o iir" .ur..n, and future of.emergencyme{r-ci1e rr,. ,"_i""r. *l'ri ,.r,.aul.a ,, lii.:l::


;i ;;i'-- ffi ,,'a*.'.ruI

:'::1.. ,'." il';:','.?lr,tffi preseminar. qi.,tro,,,,"i,l'i{l[JT:.j ;#ff::::i,il:$::::"t topicsfor theseseminarsas well as-t-hl

i".i"?rJrl"" needsand 'r p a u"' ;iiil'. ..."ii. "; ;; i;;: l'ffi:T:L f 1" Tili,"itfrp:; 11

,'r"Jff ;tq#J..,..:",*#ruiry*:b#i ji:l:#,Jr

est and needfor information Research.inter.rt.*Jr. greatest rn I{re ?r_easof experimentz

Needror i"r",il;;;;';;,' |.i","Tqfil{ f i,;nL:::*. !,.1;,::l penmental design, and $?'T::s *l;:: lii':;l'lll cor j seminarq.,",tii,,.,"i,.-,".TJ,:jTi,l;'f;loii:':'Jnff ri,", jlll " p_: i - # T,i"'" r,, yumpers t'li i;TiHr:'.""XT,.,1; rnythmras, ll :1. postseminarsurvey will be presented. ;i:li.; from bridgesand or buld:;;;; -"di;;i';;;;;:;t

Requirea ie.

or whenever requested by the field ,i1p b,"r,fg ;il;j,;f"j months leO responses werenoted,with a detaiied ;;l;;,"i"g kept in ll5 rnstances. seventy_six "ldii: "...rr, *"r.-lii.ri;.a. Tianscu_ raneous pacingwasplacedin, 14,pati;"ir,'jrrir.riii,ltubations curred.rn oc_ 26 cases, which included5 digi;"1;';;;;racheal, 'gn tedstylet pracemen and2 ts.,as r;i".jlu,rr,,, r,,.rr,"l lugular,and saphenous l; f #;;i, I! ]^1e,1


Decision ilaking

and Gonfidence

Level !!, .,_,. restins in_Gradiai;-u"lii Jii'oucation

's:[:y,r*gi j"*t;,m:[i"j-" #.;1:i|3;:1ff :i.ff Mostexperience *trh

. t""i"* ,"ji.1,., ,rrr, ,t... H.ff3::1.,i.::y..r1T.'J.1'?* 1[11rormar.,i,eih;;1i:,xTf r s c o n s i d e r a b l ev a r i a t i o n _ldy.llrg"rr rn rndrvidual performance that

orrermaior advantages,o reasonsof exposure to cri.ll 11r,..g.rr.y lurriculum for

does not

correlate with test scorer

jLjIffi i, g.::,.,11';d,;iil,"#J,i.,.,1:',T:l'":::il:[.;:i:U,rr. :.t:"rridd;;;;;;"";il:j;,llL1',f,::l#::1":X,i? Lontldence level testins to paramedic continuing educition ifrr""if, , feedback. j:Hiff 11*:rlii=!1s,hH1i"I",fr .-.,g",,"f _.di;i;;;;::'i:ff E_meren_cy i,.i..,t':l;:1.,,:1,;...,,.1..1: Medicine_

and Surgery Resident hter?_ction on lhe lrauma Team: lEqrr pjfference "t opiilii"q ca cr^^^,A,

oxrenozrelewski, GG Martyak,S ;l^:,oeyl,^.r.r Erotman/ Departmentof E Medicine, Geisinger




wrrtten examination testi qr: es tion,tr,"y*... ; i.#r; "fl [ :":*?:ffjf :, iH ;::l J;,,j their answer. The correl;

jsl:,j:11. l:.1-.:_l::!i*a'.rxii,il'T;,'.:i1?'.,,,.",LIn1f

.rrverndrceswere developed..fhe correcr answer times confiden.. weiihtJ ,.ir..iri.fir.d as the r.u.-[ ir,""J;;;lt;y index is ar_ nved at by the incorrect a hish conride"i' Ie.,'l pl'.'s the correci ;*;;;;;i:::1:1'1:

prosrams are :1!i cineEM) residencv mur tispeci"ii/;;# il "":::,: or.po,itil.i;:.:,,,'#i:ilfi 1T, #fi lT ?f"t::1.' :,li:kl ii": ,rne ;:.i ,#:.n:i: *:i: Hry:::i". oent at such centers, we rnvestigatorsfeel that it is ttnt survevs to the essential ,".T*l?ff#i:;f,H:t"

"pprou"d r-M ;;'rd;J;

directors of all

t" l. "lf!t"

64 distinguish Detweenstudents who are-overc""ria."i -"r"?.r.lnfident. b;ik,3etzzi"l-iii'iil,;.lffiH?1,i1"d,11,'"o,lt,T#:i*l nypothesizedthat certainty.o, It is un..r,"ir,1y ."r,.j[r,., cantly to the clinical behavror ot physicians.


Pediatric Gurriculum

for Emergency

Medicine Training Program at fwe igunJ lJ^/-;-'J l Departmi nt 9t ! T :,19:: I X:.?,i:':"" services' orEmersencv/rt?:T1

ilrfi dililfituibiuitioi,

Ohio HospitalMedicalCenterof Akron'Akron' Cr.riiOr.u"t programsreresidenc.y medicine emergency Revicwso{ current

':i p"'";i;'i"";;;;t;:j':'-.i#:i'+:'.'ff liliitlJ"lT:ffi rience of emergency Pe and e-mergencvpe-

medicine oi "tttgtt'cv J:;;c.h.,.' ;;;;i.; cura"tig;a'""a'pito-t tested an integrated #;;;;;.-ioi.tttv medicine emergencv a 3-vearwithin a;.ig;.d to ope'ate ;i;;; educaresidency.This integratei-p"ai"tti" :Y;1""llT-:9enti{ies and propediatric,e-:lq:l"itt in trarniln-g tor obiectrves tional with coordia specificpl"n to' -"'"ting these obiectives intensive vides "r;ffi;;., and d"emonstrations' s, i^u.i,t"iit ;'"1e these rrtt io-ttitat also dem-onstrateshow irt""r""i'."""rr. on the particular capitalize to filGlv 'rtiliz'i ^;T ;;i';t';;;f. medical residencies and their l"dtuia"'r "t"iJt"cv ;,r-.;;,ht tralnees

Emergency Pediatric Tracheotomiesl A Usable Technique and Model for Instruction Mediclne' / Seclionof Emergency KV lserson JH McLaughtin, Tucson Center, Xri.on"HJalthSciences

for emergency pedratrlc We have dcveloped a reliable technique Because ."oa"t {or PracticinS the ^Procedure' ;;J', ,.;;.*;;; demanded.of emergency rarely it u"t"t' surgrcai such emergency ft1't1t tht oppottttttity to become nhvsicians or pediatriciant,-ft*

crico;l'rh rhi; dt"-"ti" life-savingmaneuver' i;;ii;i;; 't" '.""tt size"ofthe cricothvroid i,;;;l"dJ;v ii';;;;;; tra,t'"t( "ntiatt", and the conventional spacein intants.ano and operexperience "o"tiderable ,.q'-tit* cheotomytcchnrque found in equipment ative equipment' our, *Jh"tq;; uses basic tube lt may be anv ED: svrlnge,"""ott, t"'ipii, ^nd tndotrachial edema or forfrom obttttt"tiott ^ii*iv ;ffi"'"".,," ;i;i;

.'g"u'ai.',t,cialoi.larvngeal,,li,:ti'ffi #H:".UTfr :'r:it1? lith'possible Ytt"4 ll',.,"r,. thesmallanapooriyl"ri'tedt'a t"'it',| enterthe li"*, rreelvor whenair bub6les m*m'rli:: the needle is sta-

syringe, indicating entrance into the lumen' ; made lateral to and against'the ;ubUing i";i;i; ;ii;;?-';; is rt""ar" to open the.stoma' the needle uil;iit.-["ir" ;ffi; "i'aot""heal tube is inserted' ti*a,ta'ptai"'i" ;;;;;J;;d"" l'000-I'500 g to We have found the ".t.'tli"tittd kitten weighing technique' this reheaisjnB and tt""tting tot il;';.;ilG"a.t 6'0 mm' which'is This size cat has " *"t-tt""i-Ji'meter of 5'5


"r " "r'iiJu.'J'r t vearof.ageAdultcatsin the Teaching sessions

child' 4,000 g range srmulate well the older

concerned with vascular system. Most have been

;;"#i; il;;i.t

} u"Jh'*

the hemo-

witha beating l"q": T:::T].t the circulation to slmu-

work using a simple electrical model of resuscitation (CPR) late the hemodynamic, oi^""iaiop"fmonary of the heart consists circuit ir* U"i'"'",i[iltit.J. rrtit hard-wiied presa resistive-capacitivenetwork' -.a.r.i" ild il;;";;;.r.



" ""'""-t' bioodinertiaasinduc-

Such a.model is use{ul for tance, and vascular',"'utt "t aioles and techniquesof methods examining the physiotogy";i;;;t lrru.stig"tion, a generalpurposecircpR administration. In tli,-ilicE' vtitlott 2G ! wa.sused to anacuit simulatio.t ptog,"-, witlr. minor modif icamodels' i;;: ;ffi;'lt ;;b'l*h;tCPR

*xA*" *l;*l:;:tt"l+il'inffff:#iii nnr'-1" ot parameter model modification and a wide range of increased accuracv "dua"t"g"s tt'' oit.,' fi"-;;;; ;i;;, are for rapid evalua"ppli""iiottt f"t"* and low cost. Suggesteo tion o{ new CPR concePts'

1I lllj[::i:l3:lTiH$t'=:r5':*1"*nn Logbook a GomPuterized Medicine'Butterworth SJ JanuztklDepartmentoiEt"'g"i"y Hospital,Grand RaPids,Michigan ED maintarn a conThc ICAH rcgulationsstipulate that every Tvpicallv' logbooks seen p^tit"tt tit ,r.j';;fi ;; ;iioru'or''oi' -^l"t"ined by the ED cierical i,r.,dT'ittt"-tl"oti i""tit,*"i" th^t"ttttittlcallr 1 slow and staff.The retrieval oi r"gi-L-a"t' it with the fatigue of the commensurate"'''o' ,o prone tcdious task 'Jepartment must be records ;;;;Jit'i scarcher.In addition, physician lequests' satis{y to able to retrieve patrent in{ormation term.recordkceping Furlong and a""if,., l[-r*r"".'li"rl-eo is highlv dependenton thermore,the effectiven"Js;-;fih. logb"ook has logbook computerized rt."a*riting -A i'ril'ii-iiiri,'y "iii'" an utilizing microcompu.ters persoial d";;;i;;.J fo, ,""'o" #; tl9ttt", Each-patient record economical database;;H;;;

identifvi* i""r"Jfi.'!basic ;;;;"" ;i l7 {iclds, ittt*:fflrrf; anddispos

involved' phvsicians ;ilil;*s;"G contarnrng iog-nf'p^ti"",t seenis a computer-genet'l:9 l-lt:to"t

rry4timesthe""18";,if il*;:', ffi1,i'iil:'i":Lt;,t ;l: ne-a handwritten log sYsten to obtain :;;;';;;;


would be too time consuming

P;;"*,f 9Ti"rr*mlt*l,l'"i',ill,,[?:;'f]:':?J:::l; listings of admrssrons, log"::.Titr[:lgi ;ffi;.;J

pt'vr,"i"' o'ti"nt lisis The

o*x*:$3:.T'f T"ol"anemersencv ilr';*X::""'i:i"x"r1'."1:lff allows our program t" *rffi:":;,:l:tT1: residency, and -"ai"i". listings Researchdata cz ;il;;;;;;;"dt.giaph '"a eflort usually requiredby amouni""T'?i-" tne a fraction ot searchingor sortrng capable.of is Jatabase The ;;;;i;.,h.ds. assurancepurposes' qualitv Ior useful t""ki"g it ;;;';.;;it;iJ, -*"o"T,lllrrtl:l:Hti The advantageof an eas'v-to-usedatabase ""v pt'vil"i"n or staff member tr ;#fi;;l;t on hospital computer pertion on a 24_hbasiswlihorrt depending sonnel.

r#::T{if"'i,Tl;illitmru*ri::*:;,J;"*'JT"'"::ii had sessions an adequatealrwav.rhe iltii"ip-^t"tl" tttt te1"f11s ;; ;;i;i.;;al


tracheotomies and- varied experience

pl"ii"" *iir' this model greatlv enhanced ;;,t^;;i.;;;i",.-v. using this model can enExperience trti[' iittii i."itiJ"""l"i confident with this becomt to able emergen.y p,"tttiiottri and to perform suctracheotomy p"Ji"ttit emergency for method alrway conservatrve when ..rt]"irv i. the"criticil-situations managementwill not suttice'

a tl


Gomputer Simulation

Computer'Assistedtnstruction in Trauma 12 RDEvans,SBrotman/Departmentofsurgery,GersingerMedica| Center, Danville. PennsYlvania I n a n e f f o r t t o i m p r o v e e d u c a t i o n i n t r a u m a , a c o m p u t e r rteaching' ntel. self education and acttve program *"' a*t*f opJ for m a n agement as patient The program conslsts of caies presented

of GPR: Computer

ai"ii"rc "t a Simple Electrical Model

of the Girculation M-edicine Emergency of of Medicine' SA Meadir/ Department lrtoi"t answersare providedand a series ThePennsylvania "iiiri.-?.'t*"rirpi" MedicalCen[er, incorrect and ihecorrect Oiriri"."in. ViironS Uersney both i"i"t*lit"-r."pJit "s^Jio discuss HersheY differentoutcomes StateUniversitY, "ftt'i""" piog.ambranchingis usedto provide Therehavebeennumerousattemptstomodelthecardio.



ln certaln cases.A case book containrng radiographs, gram-stalns, and other visual aids is useo,wrth the_program. This system also has thc capability of record keeping.for ,;rtin!;;;;"res. lt pro_ vidcs a simptc, cost-effectivc ;;',h6l ;; ;;;;i;?r";l"rtructional programs for self-education.

daily chart review for quality as.surancepurposes as described is effective in reducing pl

care errors in a setting orr."q.,..,-t-."'J,:'!l1ii1:1il:1tXJ#:::,

Emersencv ""J3i:',:j "fShesser, 5 Sli::il#ff":Lil | 3 i'#ffiTilf :1,"jff,?Hffrnstructional R M Smith.S Garson.S AOJrc iO"p-"r'tment of EmergencyMedjcine.The George Series foriledical Studeni Wr.f,i"gt#Uriversity Medicine Teaching



Center,Washington, DC Hospitalsand their r

g3:". ilj"n::Tt:% fi,"ryfrF 1i:i:iff:#eil*,JiTi

j'j ],r,Xr"','.""'JJrr^11,:l:y l.p;;;;g;+;'J:!;,T;"r,.ff

washingtonUniversity[/edicaiCe;ei Viurhi""qtn, oC

and improve the qualit.

struction with that of a iraditionaf f..iur",-glo"ps of students receivcdinstruction ir



tempermits", "l"lto'j,ji.ii r".',T::"Jlrf # :ru Ip sys ji":ff "iffil'1,*:;'l;;:X,Jf ffi:":i ft?:iilfl11.?:,t:.:1,,,fi :$:r'":it,ffJ,.ff ,H:1l:*ai*;rj::tt',.'*ii j*TTf.nli:"# o.i ].r,: pcrceptionor tr,. io-u,rli. w.' *"'""_,y assigned lli. ilJ'x3:?:';i::Jl'ilt*ffi!:il:..#Hx:;natf thc patientsdischargedhome_fromthe iO'witf, the dias-

of acute infection r. u.y r..,".. ir,;il,i."f;,,:*;?LrxiTffild inanothertop.",";i"il;;;"i1fi::#H:..,,r.,T1ifi ii?i::n:X;:l;

n'utitpt. "t'or..'."*r.i-rro.,administered rc li"l t a,3,0J| e" q;;;; ;;; ;b#uriJ,ii#tiil mate,iaI t^ught ffi :: ; ::''* : /;,,,1 9:5_0


"p tetept-rone-call 2_3 daysri*;;i;';;ut.


in jlf,?J*; yji:;*:l'yr.Tlil:T:ILA';T,y".iil:'ff 1,.i";*j

il::.ri.:1*:'ffi ';i5;;r,'llffi wffi r* i+j1!,ihL?Ji:'i;,fi::1"iy*t":H:l;",

tivcan.cducati.;;i ;; ;i X",'il',::il:** H*: l;: l; : n.**. cy mcdicine course.

rus and,clarified the-aftercarer"a r.f"rr?i-i.r.,.,r",ro.r, received

i:F!xii,::L'"',1*{:Hti,il'rui:*tiTiJ.: tj.;"T,1::

ceivc a follow-up call. A nursJwas "Uf.j to i.""f, r 45 of the 297 patients assignedto the study grg"p, ;"i_c'"'i ,u..rg. of l.6g + .9(r calls per patient tha

14 Prospective ','il:r.ii'ii{}lji#i,:; Fff:trffI &r,?,'JT::1,?11'":3;1.,"", ;:h:n,,,,.*i:*trfi sJyai ii a; i;;;sency

Medicine Resi_deniy pi"gr;;ML Martin,Fp Harchetro,aO, Rt/ Krehen f<iruVliruy / Divisionof Emergency Medicine, Altegheny c"r"r"l l"rpi,l, pittsburgh

prospcctive study utilizing a daily patient chart revlew of ll c..-l a t e g o r i e so f p h y s i c i a n

a;"i *"i ; it:;;;f " "P:il:!,".1"11x ljJl"l rJ;#i rHl J1 rhe

:::'l':1i:?fft:x?nfl"'poses r"i"i6Ji-i'sidnonAcl

iit#im$li,kL*l*T lTtr":; ;p1r"* il# 3:i

ventionsweremadein 54 cises. tajz"t,l".i"aj.r! i p"ti.r,t, *ho were instructedto return to. the ED. qr"rtioirr"rr.s werereby 82 of t45 l4e%)in tt " ,t"ay gffii"d'bi l:.:S "i 262(3s%l



group. The aver.agescore in all 6 patient satisfac_


'#ij''ttp*ii*'iv'i"rj"'""p'ti',,t.'p.,1 ::fft""':,":iiil:i.';ff

il,ffi:':f | 6 ^EI,"":ff .j'8:lTt,il;::"#,:1,:1", t*;{$# $!*iiti'iin#rT'i*zi:#: ,

!!Gs; radioi.;;;;' l#"*,ory data,diagnosis; d;H*T,::l:

6 v'i"ii"';x'.i; ;h;; t,'i' tr,HX, ffip"X:Tl : :::1 v" qr' -; Xl'l| mcnt pcy"'iJ';Aqiii:::?Jff:i:;',:i.T,'l ,, #.,. i}i,lffifi


s and recervedorientation to patient

care and chart

the Adutt with Acut6 astfrma-SMSchneider / Medjcat S"-ri#,'ffintetioreHospitat; il.rS"."y D.epartmenr of Medicrne, univJrsity oi Fiii.orig;,"iin*rot pittsburoh Medrcine,

prJsent frequently to our adult ^^Asthmatics ED. we became "rp..r, concerned about the length of ,i'"r" ".trr.riJJ., in our de_ partT:lt as well as frequent return visits arrd a f,igh admission rate. we attempted to iorrect tn, .ii""tiJ" ii "r."rrrrg "r, ,g-

liiiFiliiTffiX'.'Jiii:ft',:Ji.T,;":,il*:-_fr:iUlt J*

pa.trent discharge and was,approximately " +-horrr_"_ary responsi_ otlrtv ol 2 emergency-m:9,r:il.

".rttri.d, ,.gi.iJ..a .rur.. prr.,t_ yljh attending physician supervisioi. Feedback l:":lr: on errors rn_.arr categorieswas given,to the physician(rl ,.iiirrllt". N"""r_ sary corrections were made as soon ", porribl...ri pothesisthat the quality

j?,i,i"l1lj"lo'iIiij:tf *'#*i:;.}Hj ll:Ti:::,1*.';,*.; t*ifi,T:-,'':j,:l'^p.''"" t'g' or"''o"-to'ali the rirst

jk*.;;*ttil i{1,'".,.=TilT;t!{t'*:!."iii';**,*,i

nephrine{withheldif ageless tt"" gsl,-ir*i#rirr", and Al_ buterol.Thesewerereoea"ted .u.t aii#ffi1;;;ephrine lim_ J total doses). lf ,-ft,.,,"y go -_"i."p1""r"_a,n" patient l::,1 j9to rcspond, tarled

a loadingdoseof aminophyllinewasgiven over period, and.a.maintenance iniusion was begun. Beta1^3^?-,T-t-"".. agonrstswere continued throughout tti. ti-.. i"il]rre to respond ov.1.rrty l-hour.period while on maintenanceinfusion led to ad_ mrssron. Steroidswere initiated. o"fy o" ,a_itt"i patients. The patient's responsewas measured 1.,i, ,"nl*,lr.ii ly tr,. lorr.._ otticer as 1v9ll ap objectively by ,p,;il;J;."ET.'h'p"rr"r,, *", ,o be assessed in this manner.lgy ao _i";',.;-;d.;."r" was de_ an im.provementof 20."/o i" ,f,.i, eiVI.'Xnp"ti.r,t Itl.* Ir *r, " candrdate for dischareewhen^the f.Vi,.r"frJ Z'Oi otpredicted or 70"/oof normal baieline. A rebound ;i;;; A;*ed as a re_

ff#?f;I'iXr ,..o,,a-o.,tr,;ldfu';;f nil::ff T,.J#%:ifi H'+i:,*il; j, rot. ,ie",i.r""iryrowerthan yr:found l;'Ti,,t. r"l:"8'._in :'J"#,',*'Jl:;:1: l.:::=*:'":'ol"*'n"i'1i'i,iJ'l"l:il':'T;'ff rreated as.relatrve constant rn.iipi...],J.

r"-.ur.rr.J i,."a.r".Jo_r, ofdecreasing,".", 1,1-"i1'..1 ;;,Tfij llXil"I over the l2-month period. We .or.t.rJ.Jl-roir" thJ study that a


t u l n v i s i t t o t h e E D w i t h i n T d a y s . T h e t l e a t m e n t p r o twas o c oand lwas t" fanuary 1982' Treatment of the patient i"irla"".a pGYl and PGY2 housestaff' AlU. Jit""'t"a by the "?"""""a-," housestaf{'strict direct the to si,es'ed *", ;;;;il;h.;"io*l retof i,, ,..r. *r, ,tot possible' Charts were reviewed r"p;;;iti;" protocol' Rerosoectivelv to assesstne impact of the treatment sulis ,re shown in the table'

Year 198.1 1982 1983 1984 (6 mos)

No. Seen 146 121 147 60

% Admitted 36.3 36.4 25 8200

Stay in ED Discharqed Admitted 4.3 * 2.8fi 3.2 * 24nl 3 . 0* 2 3 5.1* 29 3 . 4 + 2 1 - ' 2 . 6* 1 7 2.8 * 2.O 3.5 r. 1.4

Rebound 64 1.4 6.4 8.1

.P < .05 ". P < .005.

$,'#fiil! l#'i5#'.';Jl?lrii,f f;:#':i:x'-lXX'"(B'"'3;::,"f However' in the was a decrease {not signrfrcant) in return visits'

18 3:8,*#i.#,:"3111"":'1?,",=,,, lledicine Emergency Divisionof CG arowi GD Gten, i Rtr'ton,HA Werman/ Medicine' ;;;;;;;"Stut" and Departmentol Prevenlve Departmentol tmergency ColumbLrs; University, Ofrio Medicine,Johns HopkinsHospital,Baltimore may fail to In the analysis of a clinical trial, an investigator outcome between in difierence significant .no*-llt",itiically Failure to demonstratesuch a ;"d';;;;til."?d!ro"ps' #;;"; ^"t"rrtf exists is known a.stvpe II error' and ilff.;;;";-;h;'n-ii beta o{ occurring is termed Ftt'. .Tft,i';" of the i*'ptJ"Ltiv differencethe inthe of magnitude iht p"rt to in related ;;;;i" io d"t""t betwEen.groups and.the sample size ;r;;;;;;", the freThe purpose of this studv-wai to determine ;;;I;;.i quency and degreeto wnrch iht btt" error occurred \n the loutnalci ans (IAC EPt a.nd li',' i-r' i,,iri, rZ i- c ot tr si ir t m er8en cv .P.hv si comparatrve negative All (AEM) Nledicine A"iilt if Emergency l' 1972' ;i;*"1 iii"t, "pp""ri.tgin IACEP andAEM {rom.volume ior inclusion to volume 13, 1984,were surveyed-andwere eligible data were prei" ,ft. t,"an'ftials were excluded if insufficient ',."d controls and historical emploving ii,ii'ts "f ;;;;;rivJ.l as negatrve defined was trial A dcsignswere employed' ;;;;;;t"t no signi{icant if the investrga,o,,p."trr"fliy'stated that there was differenceinoutcomebetweentheexperimentalandcontrol were calgroup. For each negatrvetrial the following parameters the di{ference,.2) obseivid the on U"r.d E"f"i.a, 1) a beta "rro, dif{erence t;. t;[rrir.d to d"t""t " clinicallv-meaningful ;;;i; ;h" authors of this studv, and 3) th.e minimal il;;;;;Tt hau. detected in the trial at a beta could ih;t il{i*;;;; 13 vears surveved,we.found 14 negative the For il;i1;bto o"tv r oi'tt'" trials (7'1%)add-ressed ;;il;;;;;rii^lvr^it"'. ln the the issues of beta erroi and sample size determination error ranged beta calculated tttt tii"it, negatrve 13 rcmaining none of the from 0.4g to ror.""r, oiit" endpoints analyzed, detect a clinically clinical trials had " ,"-pl" tltt suificient to have air{erence.Tfie minimal di{ference that could i-o"i,^"f than the diF was studied sreater ""apoi"tt th. for ;;;;d;;,;a O'2O'given the ferencefound in all casei when beta was set at ir.'"'" results suggest that manv or the ;;;;';;;r"t.J. ;;;;i; ,;i"it ,pp6"'i"g i"-7acEP and.Atm a" not adequatelv ;;;;';;" interventro? "t''J"t tt"dy due to insuf{icient sample the examine of the small samplesizesemplgvgdin the investiga;i;. il;";." of missing a ,i""t-^""fv".d, there *"t " high probability clinically meaningful differenceil one exrsted'

i*,",'*'*g'Tjt*,""1'*tl#$iii1+:f;'l#'[#'it; ntti:Ht}*:rffi:tfrlt:H!:":,'*'o:J;:::'i6i;i:13,"I ioi""...tti"g

,nd treating ai'ilt asthmatics,in the ED -h:tat:l.i:

care patient i''p'ou. .rl,ii."i1'ii:Ili illiffi:ff cniirely by housestaff.It


i:ii;;l";ailn*":;;i,"*:'il};ffi"."J,Hiix:*:""lX"J:'"*; in the ED.

a, a I

Management of Emergencies in the Medical oflice

/ Departmentof EmergencyMedicrne'William Itlk Kobernick BeaumontHospital,RoyalOak, Michigan staff' a As a result o{ requests by members of the medical "Managemeni o{ Emergenciesin the Medical Ofcourse entitled bv-an emergencvphvsician This coursewas i*.;;;;e;;;loped Annual Sciintific-Meeting of the Michigan 1984 tausht at the leci""i.iv. ir'" course was 3 h long' with I h of ;;;;'M;il;I topics t It of "hands-on" station rotations The lecture ;;;;d dysp"tt"priyr"*it, behavioral emergencies' chest pain' i;;i"il of BCLS overview syncop"' shock, t?rliion,'r"i",,ttt, ".rlr"t"rt" EMS svstem' ,"ie,CiS, and how to interact with the prehospital were airway management' simulated oifice ii*-i.iitl."s a review o{ emergencies,equipment needed in lhe office, and physician partici100 theof Forty-two iesuscilAnnie. edis';iitr course The oantsrespondedto a questionnairegiuenduring.the ;;.ruaea zo familv.phvsicians,2 dermatolosists'.5 ft;;;jei;; 6 pedioccuDationalphysicians,L neuioltgist, I generalsurgeon' emergencvphvsi 2 in"ternisis, 3 I il.i;;;; 6tit'"r-oiogi.,, the i gi.,""ologitt."Mo'e thatt 50% stated ttrat each of ;il;;;a more than abovelisted emergencleshad occurredin their o{fices to manage one time. EleveJpercent had adequate equipment BCLS cerp-er-c-enl.were Seventy-one em-rgencies. o{fice "o--on 35% had de{ibrillators' had t9% ".t,11i9a, ACiS ;;a;3;t-;.re questronnarre IV catheters, ar,d 4OT" had laryngoscopes-The that a large percentageof-office phvsicians-1re l;;;;t;;";.; l nls ooorlv preparedto deal with common office emergencles emergency for good opportunity a presents deficiency ii".J,i6t"i positive pfrv.i"lr"t to interaci with their colleaguis' This type oi between the educational experiencemay lead to bitter rapport staff and emergencyPhYsicians'

instne :it:"11''l"i'5t.;ffi I 9 :'SJ,f

Al Wears,DR Kimens / Divisionof MedicalComputer ADolicationsandDepartmentofEmergencyMedicine'Universtty Florida Jacksonville, Hospitalof Jacksonville, patientsJrtr turtner lnselecting (HYC) for criteria High-yield be associatedwith an sometimes may vestisationor treatment ln in the falsenegativerate. The degreeof uncertarnty i.rcre"ase patients ,lr"tt ^" i""t""se frequently is surprisrnglyIarge',Because a with falselvnegativeHYC may suf{erfrom lack ot treatment' decithe to essential is rate negative i"t." o] ,tt. ;:ffii;;il;,-. Presentedis a .ion oi*ft.tfter or not to emplo'yHYC in practice' that enables ,i^"i. *.t.ft.d, suitablefoi use'bynonstatisticians' size in terms sample ll adequate following: the ;;;';;;;;;ine acceptable iicrease in false nesative rute' or 2J ;i^;h" ;;;i;;; given t "r.^t" it' falsenegativerate that ' ggdv of a ;;;;;iil .L-lr lif."fu to detect. Examplesof use are provided'

Durine 31,=*i?'J,ir;::#i 20 i"lH:H:: Dogs in CPR SH Falston,L Showen'A Carter,WA Tacker/ Biomedical


Engineering Center,PurdueUniversity, West Lafayette, Indiana The American Heart Association recommendsendotracheal {ET)delwery oI epinephrineduring cardiopulmonaryresuscira_ tion ICPR)as an alternate to the IV,o,rte. Becarrredose_response relationships _for ET epinephrine are currently unknown, this study was pertormedto comparethe responseto various dosesof epinephrin_e given either IV or endotiacheally in an electro_ mechanicaldissociation(EMD) model. EMD was producedbv subiecting l0 anesthetized dogs to a 2-minute p.iioa of u.* tricular fibrillation (VF).Following defibrillation and confirma_ tion of EMD, mechanical,CpR was begun and a test drug was given. In the. firs-t trial, chest compresiions were adjusteJ to a tevel lncapableof restoring the circulation and were maintained at this level in subsequenttrials. Epinephrine dosagesrequired were I, 3, 10,30, 100 pglkg (IV) or 30, 100,300 pglkg dilrrt.d i., t0 mL salineIET). Tiials were separatedby enoughtime to allow for drug metabolism and animal recovery.R.trrri of pulsatile blood pressurewithin 5 minutes of the onset of VF conitituted a suc_ cessful response.A probit transformation of the percent cumu_ lative responsecurve showedthe IV and ET median effectivedose ( pglkg and I43 pg/kg, respcctively. The potency ratroot 5.5 was significantlydifferentbetweendrug routei. Addi'_ tional variableswere assessedfollowing successfulresuscitation in 4 groups given l0 or 30 p.g/kg I! 1b0 or 300 pglkg ET Th; mean time between drug administration and return of soon_ taneous circulation did not differ significantly between, and it ranged from 96 to ll4 secondi. Mean peak arterial blood pressureswere dose related and ranged from ieZntS mm Hg in the lowdose IV group to 278/Ig9 rim Hg in the high-dose"Ei group rne mean hypertensiveepisodelasted 2l minutes in the hrgh-doseET group, which was significantly ionger than in all other groups.These results show that the dosagefor epinephrine deliveredET must be higher than the IV dosie to achieve the sameresponseduring CpR. Effect of Peripheral Versus Gentral Injeetion of Epinephrine on Ghanges in pressure Aortic Diastolic During Glosed. Ghest Massage in Dogs S Keats,RE Jackson,JW Kosnik,RM iworek. M Zwanger/ Sectionof EmergencyMedicine,Departmentof Surgery,WayneStateUniversfty Schoolof Medicine.Detroit The_purposeof our study was to determine if the site of injcction of epinephrine during closed-chestmassagein dogs is a iac_ tor in the onset and magnitude of changein ihe aortic diastolic pressure.Ten 19-34 kg mongrel dogs were anesthetizedwith pentobarbital,intubatid, and placedon a volume ventilator.They were instrumented to m.rrui. ECG, right atrial, and thoracic aortic pressures.The dogswere placedin {jl cardiac arrestby a low-voltageintracardiac6OHz dischargeby meansof a transvenouspacemaker.Cardiacarrest was maintained for J min_ utes. Side-to-sideclosed-chestmassagewas started at 60 com_ pressronsper minute with an rnterposedventilation every 5th cgmpression(25 cc/kg).After 2 minutes of compression,45 p"g/kg oJ ep_rnephrrne was.injectedeither into the right atrial lC-EN) { N : 5 } , o r t h ^ ep e r i p h e r a (l p E R )( N = 5 } i n t r a v e n o u sa c c e s sf,o l lowed by a 20-cc saline flush. The IV Ine was set at a keep_open rate. Pressureswere monitored for an additional l5 minutes. Frc_ liminary results.are-reportedwith mean plus or minus I SD; all statistics were by the Student t test. Time to onset of rise in aortic,drastolicpressure{in secs)was: pER, 77.2+20.1) CEN, 5i.6t10.4, P < .05. Time to peak aortic pressure(in secs)was: PER,Il4+19.9; CEN, 82+15.6,p < .02.T^here was'no statistical 1*ler9n^ce-in_peak augmentation of aortic diastolic pressure_ PER,6.8:t2.7 mm Hg; CEN, 6.8+3 mm Hg, p >.05. Our conclu_ sron,basedon these prelimrnaryresults,is that penpheraland central .iniec.tionof epinephrineequally augment the aortic diastolrc_btoodpressure.The onset of that effect is delayed,how_ eveq,when the epinephrineis given at a peripheralIV site. D] -




Gomparison of Epinephrine and Phenylephrine for Resuscitation and Neurologic Outcome of Cardaac Arrest in Animals

JC Brillman,AB'Sanders, CW Otto, H Fahmy,S Bragg, G A E w y / 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 e s t h e s l o t o g y ,a n d Cardiology,Arizona Health Sciences Center, Tucson It is uncertain whether epinephrine or a pure alpha agent should. be.thelressor oJ chorce fnr use during cardiop"l-oi"ij resuscitation from cardiac arrest. Theoretical advaniages have been advocated for both agents with respect to myocaiiial and cerebral blood flow. A study was done comparing resuscitability a n d 2 4 - h o u r n e u r o l o g i c o u t c _ o m L i-n f i b r i l l i t i n g " a o g , t t r " t * . i ! treated with either phenylephrine, a pure alphi ago=nist,or epinephrine. Ventricular fibrillation was electrically induced in'lg dogs. After 3 minutes, standard CpR was instituted "ri"g , -._ c h a n i c a l r e s u s c i t a t o r . D o g s w e _ r eg i v c n p h e n y l e p h r i " . i i .pi nephrine at 9 minutes, and delibrillatlon was atiempted at'12 minutes. l)ogs underwent hemodynamic monitoring'and phar_ macologic support, if nccessary, for an additional 90 minutei. At 4, 8, 12, and _24 hours, a standard neurologic cxamination was pcrformed and deficit scores were assigned b! an observer blinded to the drug givcn. Fourteen of thc iA aog, were rcsuscitated. Thcre werc no statistically significant differences in the epi_ ncph,rine-.or phenylephrine-tieated groups with tn'i1 numbcr of animals resuscitated; 2) time and intcrventrons re_ quired for resuscitation; 3) initial cardiac rhythm posttesuscrtation; and 4) occurrcnce of ventricular fibrillaiion during resuscitation. No differences were found in artcrial, central venous, or coronary perfusion pressurcs during CpR. phenylephrine_treate<l oogs rended to have hrgher mean pressures in the critical care perrodl15-30 min), although this was significant only at 25 min_ utes. Total neurologic deficit scores were 127.g + ll3.g for the phenylcphrinc-trcated group and 129.4 + g7 .4 for the cpinephrinc group. No significant differences were found for thc level of con_ scrousness, cranial nerve function, motor skills, or gencral bchavior scores. It was concluded that there is no diffcrence in neu_ rologic or cardiovascular outcome when phenylcphrine is comparcd to epinephrinc in a canine modcl oicardra" ,rr"rt n.,J CPR.


Value of Epinephrine in prehospitat CpR

JS Stapczynski/ St Mary Medical Cente( Long Beach; and D e p a r t m e n t o f M e d i c i n e , U C L A S c h o o l o f M e d - i c i n e ,L o s A n g e l e s A retrospective review_of prehospital CpR done by the Long _ Beach Paramedic System for thc years l9g3 and l9g4 was donc to assessthe value of epinephrine according to clinical outcomc. Fivc-hundrcd sixty-five primary cardiac "rrests were managed dur^rng this period: 3l patients rcsponded to initial defibrillati'on; i n _3 9 p a t i e n t s a n I V c o u l d n o t b C s t a r t e d ; y i e l t l i n g 4 9 5 p a t i e n t s who could be evaluated for the. rolc of epinephrine. .I-he initial dysrhythmias werc ventricular fibrillatlon'{VF) in 247, idto_ ventricular in 79, clectromechanical dissocianon in 49, asystole i n 1 1 2 , .v e n t n c u l a r t a c h y c a r d i a i n l , a n d u n k n o w n i n Z. The clrnrcal outcome evaluated was the ratc of successful resuscita_ tion {SR) rndicated by admittancc to the hospital with a stable .p_u.lscand. btood pressure - arrd thc ratc of hospital discharge. to the rnitral dose of epincphrine 10iri II:i."rly3j..d.according u . . : r - r . um g t v ) , t h e r c w a s n o d i f f e r e n c ei n t h c S R o r h o s p r t a l d i s _ charge,rates. When the prescnting dysrhythmia was Vi ih... *.. a trend towards a higher SR rate l2l.BT"'vs l(r.0%), but thc result was_,no-t,sratistically significant (2x2 chi_squared table, x2 _ .867). Wherr the presenting dysrhythmia was something othcr t h a n V l t h e r e w a s a t r e n d t o w a r d a l o w e r S R r a t e ( 1 3 " . 7 7 "v s 2Z.l%). but again not statistically significant (2x2 chi_squared table xz = 2.894). While an excelienidrug in canine models of cardiac arrest, the role o{ epinephrine as is"currently practiced in human CPR rs not proven.

Lactic Acidosis During Glosed'Ghest 6,A GPR in Dogs 1+ MC Nowak,C Foreback' eB Martin,-RM ilcud"i, ot and Division Emergencylr/edicine of Department / Tomlanovich Detroit Hospltal, HenryFord Chemistry, Clinical

cardiac or neurological outstatistically significant predictor of

CPR{r'o-- }L ;.-;. ih;"ffi;e in cioz {CpnA "i9l)during of ACLS the.number both of pi'di"tot ;;;;;;;;r'i!"'tt"""i hadc-P\ 12dogs of < (P '05), 3-h;NDS the aid -6 ;,;;; it: .0ta1 ,h;..-r',i ecrs steps< 5 andNDS < 63; 5 or X5il; ;o:;il;i >.5 andNDS > 44' steps ACLS e-dlsr'*ith CPRA ciO2< 0 had l2-dogshadcjo2 6 post ROSC; min oo ""a rn*'+i--tt" e,"5"0 { < I00h"d ci-o2 with dogs 6 = ihe sz. Nos ='riio, ,if*iir' )P^s wasa statrs= ++ ii"t O NDS > 63) Ci02at 30 min postROS,C at I min values < (i '05)' i""ffy ttg"tfr.".,ipt ai"toi'of"3-hrNDS

is related to the Survival a{ter out-o{-hospitalcardiacarrest cardiopulinitiation,of the to cardiovascular-"6u"p.. t;;'i;; or downtimg sloq{ lactate levels #;";;il.i,".i.".tcpn), predictor o{ have been shown to ne an"objectiveand reliable trend-s' yet they were and openarrest cardiopulmonary to subjected and 15 min ROSC demonstrated the same i" Jogs i.*""-" at 30 min ROSC or to determine those was as studv ^""tt""y this of prognost* purpose rh" not of the same ;;;;;;;;G,^tio.'. du.rinecPR is a dog-s in cio2 in downtime -""t"6t"t the.change predicting ,rt"t iiJi#a."w. "."ii"8. o{ btood l""t"tJ l"uelt in ;h;;ri;; resuscitabiliiyln addi LrK ^5arre.stand closed-cncst usefulprcdicto,ot ""'ot^L "'a subjcctcdto cardiopulmonary -Sw"n circulaG"'" catheterswere placed in 14 adult il;, iht ;b;"rr""t i"rr"*r"g1tt" ttt"t" of spontaneous aortic and ;;;ail oboutcome' acidsamples.were lactic neurological arterial lr."ri"' nit", iio"' t"fl."t,rllti-^t. ;;;;;;1;;;;. was electricallv induced and the riu'iii"t-" ;i;;?, ;;;:;t;i"i ventilation without "rr-ri ,.-^ in ventricular fibrillation arrest' a contini"r s^t"r""i.t..q'i th. ""a of 5 minutes of cardiac external standard and begun, was oi epl.tepht'ne ;;";;i;t;;; and venMedtcine, / Divisionof Emergency Cpn *rt initiated using a mechanicafchest-compressor minf Ei"O"r, f Cottrngton fi"il" -"t samples were obtained every 5 Pittsburgn Hospital, tt^"*r.. na.tirl lactic icid General Allegheny Cpn, after r,.rhich defibrillation and utes during 30 mrnutes H e m o c o n c e n t l a t i o n a n d h y p e r v i s c o s i t y p l a y p r o m i n e n t r o l e S l nPredewas resuscitation Successful arrest' ",aa-pltd resuscitatton*.r""tl'ty seen af ter cardiac ,h"';;t;;it'.';;" greater pressure blood a systolic occurs rhythm and hemoconcentration il;J;;;p;.tistent that demonstiated' h;ve ;;":"t;e;; of initial counwas studv ci1c,ulatr,o1-lhis it;; "t equal to 80 mm Hg within l0 mrnutes ;''p""taneous ;;;'; i;il#;;il at timed ini.itrt*r.. ii,"rial lactic "cii t"tplts were obtained the degree of hemoconcentration that investigate to undertaken inacid levels light keti"r""it ,fi.t resuscitation Mean arterial lactic d";G ""rdir.'"'itJ-""a"cpn' S-ixdogsunder were ar;;;t with each sampling interval during 30 anesthesia .."tt"i-trs"tficantly endotracheal oxide amine-halothane-nrtrous dogssucto 4 subiected oT'sta.,d"rdexternal CPR {overatlP < 'o5.)'In 8 ;;;;; ffiil ;;';,#ii-,"tt.r. iiuiitlation All dogswere of minutes .n"t" was no significant differencein mean 20 bv folloied ilfrily;t;i,^t"a, minutes ot ventrlcurar ;i;;tll;ii;" acid levels aiter the reiurn of spontaneouscirculawas then restoredwith il;;iil;; Spontan.ottt-"it""t"tion CPR. standard in values were in dogs utilizing open-chestCPR results ;i;;.'il;;;i,ation itrisr,^iv fl"ia,'r"a .o""ttrshocks Hemoglobin cardiacmassage and at 15CPR' durlng t"rlg"ili."", changcsin meatt lactate levelsonce intervals t--ittt'ttt measuredprearrest,", i s i n i t i a t e d . I n c o n t r a s t , c l o s e d . c h e s t C P R i n d o g s d o e s n o t p l o-i""i" following the return of spontaneous r hour) *,".t*rt if.. anaerto halt vide adeuuatcttssucoxygenationand/or perfusion rh"'" *" a sigiificant increase in hemo;;;i;,;;;iRosb1. Iactic acid accumulation' Lactatelevof variance (P? 'oot' analvsis ;;i; ;i;.;;;;'-;;Ji*ii-';' to cardio;i;;iliii;ti .;;t,r"J'a"'i"gcPR by increased concentrations "t-, oi.'no,'prcdictive oi-downtime in dogs subiected Hgb with repeated-""r,,,",i'-fint* rcsDiratoryar.est and closed-chestCPR'


o*' cardiac ed'tration lr',T3,":ffi l:

-"..r i'i; i;;e ;# ;i.i.' :i Uf :"#, $.ii?i*fll;l and I(r.9, after 15 and 2(; ffi^;:: wlth IV {luid and drug therapy;

ccntration subs"qrr.,tttydtciined f u r t h e r i n c r e a s e s o c c u r r e d , h o w e v e r , p e . a k i n g a t 3 0 . 6 0shift mlnutes that there rs-asignificant ;;t,Rose. Th... ti.,aft'g' suggest during space extravascular the intravisculai to the ;iii;i;l;"the return ot and cpR that continues subsequentto il;;;;; spontaneouscirculation'

#1"ftT,:t'T,11?.:i 251'3lffil'"1Tl';:f

Resuscitation Following Outcome ol EmergencyMedicine, / D-ivision D Jehte,iaraoer E Cottington Pittsburgh Hospital, AlleghenyGeneral probabiljty ot Most clinical parametersonly poorly reflect the the arBecause arrest' cardiac following r""i"ttf"f i.t"siitation the internal arises.from coniunctiva ;;'J ;;;ly;;;;;"6.b'rl parallel cerebral "rt,,ila j"&v, "o.,lunciiuai oxygenation should the oxvsenation and brain p.ii".ioti' In this study we.evaluated cardiac predicting in toring moni ";i ;;v;; il;j lci0zl ;.1 il;;;i ;.t"."it"u1tttv. Twelue dogs under light ketamineil ;.;;;;;i were arrestedby fr"i.,ft"".-"iatous oxide eniotracheal ariesthes-ia to 4 min of transthoracicfibrillation. Ai "tinr"lt were subiected standardCPR' of min 20. by (VF) followed ftUrillation ri t.",ri."f {luids' circulation *r. ttt"" resioredwith drugs'-IV i;;;;;;;;"t The dogs were ventilated with 100% oxvsen ;;;';;;;i;^tock. re;he study (exc"eptduring-vF)' Clo.' -values were ,h";;ili and at 15-min CPR' intervalsturing 3-min pr.", at .oia"i

i;;J,-,,]fi'r.ll;;L;;h. ;;;;

(Rosc)' or'po.'t"'"o.'s.circulation

by totaling the number of *1, "*ttitd".-r"r"tcltaEility to achieveRoSC' Neurologicaloutcome was ;e;i;;;;;quired Neurologrc Deficit Scoring (NDS) at.3 hr postarrest' ;r;;;d-[y (cjO2 monitor adHal{ of the dogs *.r. ."t"i""11y hgai iooted Statistical analvCPR' du.ring t"-p.'atuie) ;;; i;t-;;"l"i"ti*'ri analy.ii-*^, o"rfor.ed utilizirig one-tailed-Lltiple regression group f". ih. p.i.ntiallv confoundrng effect of .i',;;;ilii;; steps ransed ecrS of numbe' i"i"r ri. (hJ;6oling). ;il; : and thl e i'iNrjs (0 : normal, 100 brain deadl il;r;;lt, a 20 and 100. The ciO2 at 20 min CPR was not t^t*JU.1**n

and Asystole Postcountershock ldioventricular Pulseless Response to GPB' Bradyarrhythmias: and Glucagon' Agonists, Adrenergic Stimulatol a Nonadlenelgic of AdenYl GYclase K Haynes.JT Niemann D Garner,C Rennie' EmergencyMedicineand Department C "ri6f". i Department.of MedicalCenter' i-larbor-UCLA ot Medicine,Divisionot Cardiol6gy, 'lorrance. California asystole or a Clinically, countershock of VF may result in 30% of attempts The than more in "i;i;;bi;dy;;;r'vti'-i" to assessthe eifects.of immediate arilil;;iffi;;l;;^t drug lhttl.pyl tificial pacing,,rott,i CPR; adrenergic ,"-11 ;;nadrenergic inotropic and chronotropic stimulant ;il;;;";;; of -b;;;vl"tvttor. "!tlas", in the management -postcoun3?--i.iltairird.nyl Briei episodes of vr followed bv coun;;t;h;k 6 dogsanesthetizedwith morphine and in ;;;;'h;;il *.r.'rt,',ai.a cathete^rs N'O. Under f luoroscopicguiiance, transducer-tipped aorta{Ao}and rlght atlru.mlI(Ar' we-renositionedin the ascending was idva"ced to the apex of..the right ;";;r"#;;;il';;ih.;;' measuremento{ coronary ilow icon{or catnetei a ventricle and

G)a, I 1


te 'J.


trnuous thermodilution

technique) was positioned in the coro_

pears to have an adverse .q:.L91 the already minimal dial pcrfusion provided by SE_CpR.

;1ii:::,:$,i'tr1'.'#i***^,"# 6{i:*::l:,'.?,Hyf

ing VF episodes.Countersh..f. *". ?oif";;;;y bradyarrhythmiain all ""i-rir.-i-"i.diate $:l:::


asystoleor a endocardial

j:i,x,: jT,$1*;:*""'*: 29it'"-;fi :;{il3:Htx,,3,1T,'31? .i;ruil*nTl i4i,,-.i,'*i,1.1fl p:'31!!3tiii:J,(T.H#";f ;l,trr:5"nii:_""??tf perfusion in Human Subjects M Howard, M Guinness / Emergency VeJlcine-n"r,o"ncy Program, St Vincent MedicalCinter'anJitr" iof"oo Hospital, Toledo, Ohio

tional CPR was performedfor 2 min ", "",ii'i.r,*ation of sponcirculation (RO-Sg,)During CpR, the Jiastofi. "oroirry


'in"iii,'ot lowed CPR of less than.2-mi., duratlo., VF study epi_ sodes.If ROSCdid not_follow2;i" "iiirn, "pinephrineil mg), rsoproterenol(20 pglk '^1iT-_1X givenrv

Recentliterature has emphasizedthe relationship betweencor_ onary perfusion during CpR and ,""..r.t"i,.rrscrtation. Three parameters of coronary pe_rfusion Ep1were examinedin l4 hu-a" nephrine increased, tie &fi J,in:L :;. .during interp^bsedaudomi"ri-.iri;;;;rro" CpR (rACcsqt;b-sl-i^0e -i)Lirys (l8t16%or"o.,,.or1ir1TfrJS;": llbiects CPR) and standardCpR (St CpR). Th.r" th;;;;rameters are di.05 when comparedto CpL'rto".)- r..,proi.i.riol arte.rl3lpressure(nel1, di"rtoti" azv-aiff"r."". (D;6), d""r."r.a th. 11tgt1c CPR diastolic Ao-RA gradient to l9*10 and mean A/V difference(MAVD).pressures mm Hg and CSe to in the thoracic aorta 02 ml/min/g. Gl"ucagoni"itiafy;;";;;"1 and right atrium were monitored ,i-"tt".r.ot,rty. an increasein 914: Body heart rate, followed bv was_noted and correlated with hemodynr-i.lrrr_.,ers. habitus Standard ACLS protocol was employed, "iifr""Jf, .t J"ropr"r.or, *"r. {lv propranolol0.5 mg/kg)prior to tF, given by continuous infusion. In a series oT 2__i.rrrt. trials, Stit.t.ou.rt...ho"k CPT, high-compressionforce St_Cpn, rna high-com_ l;'"*rltX'pl._^,i:,r,"_,-it,ii:i."d;19;r;JalJnadministration, , s , n u J L . L o n c l u s l o n sl:l e f f c c t i v c !-11,]19 pressron lorce IAC-CpR wereperformed.Eachprii.rrt C p R a l o n em a y f a c i l i t a t er c _ actedas his from postcountershocklr"avl"rvstoi"; 2) own control. Our results..indicatethat, .ompared immediate ::::l.i,iy"alone witf, StCpn, pacrng is of no valuc in the. managementof postcounIAC-CPR producesan 80% improvem.niir-6ei, tershock.brady/asystolc; cpinephri". fp < .001)and HC-IAC-CPR producesa 99.6./.irnpro""-..,ii., l?"fiou". but isopro_ .3J. DAp ip < .0011. myocardial 6tooa ff ,,*-a"ffi high-compressionforce'IACICpii"*ltf, St_CpR, .esuscrtationof llii,T.:l !::l:rscs 9o-0":'j.g there was a 97oL improvement in MAVD (p < .05). bAVD "lro *r, increasedby IA-C-CPR, not to statistical significance.Obese thc managementof postcountershoci .Dut patients had lower arterial ,t y-tt* aiit.rrbances,par_ pllr:y..r a"drrg of CpR (p < ticularly in the setting oi pr.rr..ri .05J. Three b.;_;;;;;*"" blockade. _patientshad a ROSC a"ri"fiigil_;pression force IAC CPR after 54 minutes ol asystolewith St_CpR.In the Z au_ topsied.patients,no significa"t ^*irr"il";"ry^*^, found. The newly discoveredeffeci of elevatedOep "" J""i"ary vascularre_ and the physiological need foruer..s.iiriiu. techniques :lt-,:l_": tnat lncreasevenous return_arediscussed. We concludetfr"i f-nC_ CpR in Xuman -- Beings CPR raises the DAp and the_MAVO, ,"a ^n ^,- . a1! ^Gomnr:ggion ,fr.[iore is probably W lonnston, more effective than standardCpR at ?^2y:!t,,,DLCardenRMNowak. i,"if*_g tlr. human heart. Depa rtment of Emergency Medicine,

:""tJJj,,,kL.;#;il:i:; 1..,:,J;;.*JJH.".#,l,il,:'itffi

#l'#Xffi :::"""i?:H:H:l;lmlrln'i:j;"*;,'il",:i";,ti*

jff:=fffi,3i;lTn 283,T.l'iii:fl's,,*,,i,il Henry

i:y, ilIil,""y:.3rr

:'11,.""'",n:xil"!!1,1;J'-f l"::li'f,:il..iti'""# 3 o F,l"i.lJ#'[?ii?iil]i ::iiii!il-fl itlffff::l,:;" nal cpR (sr-cpR),andit to

.correlate well wi th .oro.rrry blil


rt^.,a.rd .*t.r-

is _, .;;;;;;;,-i.ii?,i,t""", of suc_ cessful cardiac resuscitation.. eftho,igfr-iir.rJ"tlui U..r,r.u"rrt animal.studies

investigatingtt i, gr.Ji."t,-?l; ;;"dr.. have docu_ mented actual Ao-RA gradientsthat occur durln! Sn_Cfn in humans.Seventeenpatienls sustainingout_of-hospiial cardiopulmonary arrestswere instrumented with -nii;;;;."'..".ived thoracic aortic and right atrial catheterson arrival ,t tt " io. only BCLSprior to arrival. CpR was p"rfor_.J tl-iti Eb ,ri.rg , "o-_ puterizedmechanicalchest compressor and ventilator. The mean time from arrival in the "rtt.t.. pir.;;;;;", 16.4+6.9 wijl^' peak systolic"oi.i. ""a iigr,t;,;i;i;;; si111,!r u r e sw e r e 7 2 .!E-9_p1., 2 * 1 7 . 8m m H g a n d 6 9 . 6 + 1 4 . i ; A Hg, respec_ tively. End diastolic aortic lnd ,igt i "triri fi.r.u... ,""r" 28.0*7.1mm Hg and 20.8:.,6.4_; Hs;;;;;"iitvety with an end-diastoticgradient oI 7.2t9.7 il Hc:hi;5"ri, p"rt systolic pressureswere similar in m^ostcases, 3 patients lirdryrtoii. AoRA gradie,ntsof more than 25 -rig, ;hi;il-;r;;;risrent with .",t*r. compression as a mecha"nis_ ll il"*. ft"e patients :?_T., atso had 2-minute trials of simultaneous u."iii;;;." and compressronCPR (SVC-CPR).Ao_RA e"d diastolic gradients de_ creasedin 4 of the 5 during SVC CpR-N;l"i*","i" this study resuscitated.Zero tto* pi"r.ui., in the non_ ff_r,,::::.r:frlly nDnllatlnghearrare estimatedto be Il_I5 i"rn lls ""a would be expected,robe higher in the fibrillati"g t;^r;. ;;"irlce from this study indicates that ED sE CpR p-"'ii", jilif"'IJro.r".y p.rt,"i-'l

i prehospi tat . ;,ii;; ;;; i eiirri,iir, sv i,'^1"f :, - s of c cpR nas been shown to improve carotid blood fto*


t u-rns,

it aD-


Abdominal Wall Binding CE Saunders, JK Heijman,R CotaI OiviJrons of Emergency MedicatServicesand Cardiology,Unir;",t;iC;torado Heatth SciencesCenter,Denver Both traditional and newer methods o{ cardiopulmonaryresus_ crtation {CPR)involve external compression of ihe thorax, either with or without interposed"bd";ili ";;;;Jrrioi ,r,alor rt..,r,ttaneouslung inflation. There i, .;iJ"-"-; t;;;; that the generatron of arterial blood pressure,r,d "aiotid ff",ia-]f,"*'iir?_g CPR results from fluctuitions in i"tr"ifr.r*i" pressurerather than from direct cardiaccompression.To test this hypothesis,we have deviseda method of pr.A".;;;;;,rr,l*".i#.ssure fluctuations without external chest compression by way of high_pres_ telme di at e f requency veniil, tion JJI ir.La,#;;;-h 111;.1,in ; cuttecl endotrachealtube with restriction of chest and ,bdorrii.rai wall motion external bi"di";. A,il;;;;;;.," .by pressures were recordedin 6 anesthetizediogs ,o ".r.rr-pi.rrures in the right atrium (RAf, aortic root (Aop)ianJ ;;; iA| with simultaneous^monitoring of intracranial'pr.rrrr. {i6pi'.arotid blood tlow {CBF},and the ECG. Ventricul;. "ri;;I.;J', induc.d, th. chest and abdomenwere bound-wi,h; ;;!;r.,tr". i".ur.., ventilation was provided at a rate .f 60/-i;-;h;;;;i l'cuffed endo_ tracheal tube with tidal volume;;;J;il;ffiilIn binder pres_ sures varied systematically.pressured";;;; ;;d blood flow were comparable to those seen with standard -pR, with peak

Hg,Ao? RA.e"d_dt"sioii"-gr"a*"i

t0 mm Hg, 19Ymaxlmum 9] lm carotid blood ano flow of 45 cc pir minute. fhe m"i: nitude of arterial pressure ,r,d ""rottd llJ; il;;*as directlv

between HIC and IAC (8.21 or IAC and STD

proportional to tidat volume and binder pressure, the morphology of oressure wave forms were sinusoidal. No barotraumatic complications occurred. We conclude that CPR performed by high-Dressure d o m i n a l intermediate-frequency ventilation with chest and abwall restriction produces blood pressures and carotid fiow that are comparable or superior to standard CPR without the chest wall trauma produced by chest compression. Further study of the technique is warranted.

4ta r, I

Trauma F r a c t u r e dr i b s M y o c a r d i acl o n t u s i o n P u L m o n a rcyo n t u s i o n P u l m o n a r ye d e m a Liver laceration

Vena Gava to Retinal Artery Girculation Time During Mechanical Standard and Modified GPR in Dogs

16 (53%) 16 (53%) 12 (40"/"\ 5 (17v") 4 (131")


4 2 1 2




7 6 1 1


5 4 3 1

No significant correlation was found betwecn the method of CPR and the di{ferent types of trauma. Specifically, IAC did not produce an increase in liver lacerations, nor did HIC produce a significant increase in thoracic or pulmonary injuries. Six of 20 initially resuscitated animals expired during the 24-hour follow-up oeriod due to CPR-induced iniurics. Five of these 6 had extensive pulmonary trauma, inclucling pulmonary hemorrhage or edcma. Livcr lacerations were the second most lethal injury. We conclude that external CPR produces a high incidence of trauma, including serious injury in more than 25"/o oi all recipients. HIC CPR appears to be more traumatic than STD, but no statistical diffcrencc was Iound between HIC and IAC or IAC and STD.

DM Benson, DL Schossow,DR Deavers, RB Hecker / Department o f P h y s i o l o g y a n d P h a r m a c o l o g y ,C o l l e g e o f O s t e o p a t h i c M e d i c i n e a n d S u r g e r y , U n i v e r s i t yo f O s t e o p a t h i c M e d i c i n e a n d Health Sciences, Des Moines, lowa Thc transit time of an IV bolused drug to the arterial circulation is an important consideration during CPR. Inferror vena cava to rctrnal artery circulation time (CT,-.) was determined using retinal fluorcscein photoangiography. Dogs were anesthetized, intubated, paralyzed, fibrillated, and received erther standard CPR {SCPRI ln=7) or modified CPR (MCPR) (n:8). The SCPR group received I ventilation after each fifth compression. In the MCPR group, thc chest was simultaneously compressed and ventilated with the abdomen being bound with a bladder inilated to 40 torr. Chest compressions in both groups were performed by a mechani c a l c h e s t c o m p r e s s o r ( T h u m p e r ( L ! ,M i c h i g a n I n s t r u m e n t s l a t a rate of 66 per minute with a compression depth oI 2-2Vz inches. After 4 minutes o{ ventricular fibrillation and CPR, 0.7 cc oI25% fluorescein solution was injected rapidly into the inferior vena cava, and timed rapid-sequential retinal photography was begun. CT,-. in the MCPR group (3I.5 sec :l 15.3 SD) was less than in thc SCPR group (50.4 sec :t 42.6 SD); however, thrs difference was not statistically significant (P > .l). All tests for significant diffcrenccs were Student's t tests. Aortic (AoP), right ventricular (RVP), and inferior vena cava pressures (IVCP) were also determincd in both groups. During MCPR, mean AoP (72.8 torr t 13.8 SD), RVP (62.5 torr + 7.2 SD),and IVCP (59.3torr * 9.9 SD) were all significantly increased over SCPR values (40.9 t 20.8, 33.4 + 26.9, and 1I.7 + 4.2, respectively) (P < .01). In comparing the CT"-,. observed in this study with an earlier study where chest compressions were performed manually, it appears that mechanically administered chest compressions are superior because CT,,. was'greatly shortened. Thus mechanical chest compression mav bc sunerior to manual CPR.


N o . o f A n i m a l s( N : 3 0 )

41 4t rrrt

Open-Ghest Gardiac ltlassage lor Victims of Medical Gardiac Arrest

tir| 9-

Emergency Bypass System: Analysis of Gas Transfer

EC Geehr PS Auerbach/ EmergencyServices,San Francisco G e n e r aH l o s p i t a lS, a n F r a n c i s c o A ciinical trial was conducted to compare the impact on survrval of open-chestcardiacmassage{OCCPR)versus standard closed-chestcardropulmonaryresuscitation{CCCPR)for victims o{ nontraumatic cardiac arrest. A total of 52 patients suffering out-of-hospitalarrestswere alternately enteredinto the OCCPR or CCCPR groups.Inclusion criteria included witnessedmedical arrests,age between 18 and 70 |ears; and a core temperature greater than 29.4 C. Three patients were excluded due to improper entry into the study. Medical treatment in both groups adheredto AHA guidelines.In the OCCPR group,patients in ventricular fibrillation or ventricular tachycardia were countershockedimmediately and given a trial of antiarrhythmic therapy prror to thoracotomy.All other dysrhythmias were treated with immediate thoracotomy.The mean time for thoracotomy for the OCCPR group was less than 4 minutes (mean, 3.9 min*2.391. There were no differencesbetween study groups with respectto sex,place oI arrest,ventilation device,initiation of CPR, or cause of death as dctermined by chi square analysis (P > . 0 5 ) . D e s p i t e a d i f f e r e n c ei n p r e s e n t i n gf i e l d d y s r h y t h m i a s (P < .051;there was no differencein ED presentingrhythms (P > .081.There also was no differencebetween groups as determined by Student'st test, with respectto age {mean,55 ! 12.4)i downtrme prior to CPR (mean, 5.2 min + 4.6); ambulance responsetime lmean,4.6 min * 2.151;total field CPR time (mean, I9.2 min * 4.38);or arterial blood gases(mean-pH,7.23t '24i PO2, I3l mm Hg * 143;PCOz, 45.8 mm Hg * 21.6).There were 3 admissionsto the hospital from each group,but.there were no survivors. This preliminary trial suggeststhat OCCPR of{ersno advantageover CCCPR in our study population of witnessed medical cardiac arrests.

Gomparison of GPR-lnduced Trauma Among Three Methods of llanual, External GPR in an Animal llodel

KB Kern / Department of InternalMedicine, Arizona Health Sciences Center, Tucson Cardiopulmonary resuscitation {CPR) often results in traumatic infury to the patient. However, differences in CPR-induced trauma among various forms of manual, external CPR are unknown. We compared CPR-induced trauma among manual standard (STD) CPR at 60/min; high impulse compression (HIC) CPR at 120/min, and interyosed abdominal compression (IAC) CPR at 60imin. A large (2a+3 kg) mongrel canine model was used. Ten animals were assigned to each type of CPR. Each animal received 17 min of CPR, which was applied to produce the best possible coronary perfusion pressure without obviously damaging the dog. Defibrillation was attempted at 20 mln. Necropsy was performed at the time of death or after sacrifice at 24 hours. Careful postmortem examination o{ the thorax, lungs, heart, abdomen, and great vessels was performed. A trauma score of a 0-5 was assigned to each area, with a possrble maximal score of 25. The HIC trauma score i10.4) was significantly higher than that of STD {5.31: P < .05. However there was no difference in ttauma scores

JT Amsterdam,JR Hedges,PJ Engel,M Gabel,R Zumwalt/ Departmentsof EmergencyMedicineand Pathology,and Division of CincinnatiHospital,Cincinnati University of Cardiology, Emergency cardiopulmonary bypass has been proposed as an adjunct to cardiac resuscitation in the patient with refractory ventricuiar fibrillation, cardiogenicshock unresponsiveto counterpulsation balloon and/or drug therapy, and profound hypother-



m i a . R e p o r t s o I - e m e r g e n c y b y p a s s h a v e a p p e a r e di n t h e lirerature s r n c e t n e t a t e 1 9 6 0 s /b u t . s u c h d e v i c e s w e r e l a r g e a n d complex to operate. A small, portable, femoral-to_femorallmergency'bypr., system potentially applicable to ED use was evaluated in this ca_ .!rdy The ability to supply the animals, oxygen delivery lt^l., n e e d s w a s a s s e s s e d .F i v e a n e s t h e t i z e d m o n g r e l d o { s ( w e i g h i n g 16-25 kg) were placed on emergency bypass"using i -e-Ira.rE oxygenator. device (,,CpS,,, Bard Company) for O h"ou.s. ,qni-ais maintained spontaneous heart beats. Fump flows averaged l00cc/ kg/min. Mean arterial pressures were maintained from ll4-144 mm Hg,during bypass. Immediate dilution of hemoglobin and ptatelet levels occurred in the Iirst B0 min (p < .001) as*a result of the I liter crystallord prime for the CpS.'Further hemodilution was lrmrted during the first 2 hours, although 3 out of 5 animals required transfusions during the 6-hour pertd to maintain their p l a s i l a f r e e (>30y"1. temogtoUin did not signifi_ f-e1,1tocrits during the 6 hours_B . aseline oxygen consumption :oial :t,aL ] 1 9 * r : 9 o b t a t n e d i n 3 a n i m a l s r a n"the ged from 52_92 (mL oxygenimin). Calc^ulated oxygen transfer by CpS was comprrrLi. 1r""g;,

oxygen/min)1. Oxygentransfermeasuremenrs duriirg 3"6^tl1 t n e r r r slTt t hour ol bypass

were not significantly different from meal surements during the last hour of perfusion. Carbon dioxide transler measurements showed similar stability. The study sug_ gests that optimal use of the CpS could supply much if noj all Jf a patient's basa] oxygen delivery requiremcnts. Further animal and human studies are indicated to assess the role of the CpS in cardiac resuscitation.

eE lyg

Myocardial Tissue lron Delocalization and Evidence for Lipid peroxidation After Two Hours of lschemia

l.f"]t M Gunderson,K Joyce,NR Nayini,GF Eysrer, AM GarrtanoC Zonia,GS krause.SD'Aust BC' White/ Departmentof EmergencyMedicine,Butterworth Hospital, GrandRapids,Michigan;Departmentot RnestfreiiaSinai fiosprtatDetroit;Departmentof Biochemistry, Collegeof Veterinary Medicine,and Sectio^n of EmergehcyMeiicine, College of HumanMedicine,MichiganStateUnivjrsrty,'East Lansing Ischemic tissue injury- has been proposedto be in part due to ,oxygen-radrcal-mediated lipid peroxidation.In vitro studies of such reactionsshow that they are thermodynamically unfavorable,unlesscatalyzedby transitional metals'such as iron in low_ molecular-weightchelates (LMWC ironf; for example, the iron_ $!! complex. This study tested for iron delocahzationinto an LMWC pool.duringmyocardial ischemia,and foi in"reased tiss,re malondraldehyde {MDA), a product of lipid peroxidation.Anes_ tnesrawas rnducedin 8 dogs_(20_25 kg wt) with ketamine,and maintainedby ventilation with t% halothaneafter the a;gr';;; intubated.Arterial pressureand ECG *ere morritoied.e l6ft tho_ racotomywas done and the pericardium was opened.fwerrty rnilligramsxylocaine was given IV The left ,";;;;;;;;...rdirrg "oronary artery,was then ligated in 4 animals, and the circrimflex artery.was ligated in the other 4. Two hours after ligalio;,-th; animals were sacrificed by central venous iniection o'f XCi mEq/kg).Tissue-samples were immediately iaken from the{O.O is_ cnemrczone and lrom the correspondingnonischemic area. The were placed in ice-cold deoxygenatedRinger,s :ls,::r:-specrTens soiuuon, and were then weighed and homogenizedin I mM EDTA. MDA was determined in the t o-og.""'t" Uv the thiobarbi turic acid ;a-s' ultra_filtered lgyy. The re_mainingho-og;;;i; mol wt filter) and the filtrate clearedof protein lAmrcon JU/UUU b_ytrichloracetic acid and o_pr,.,rrr,"analyzedf.; i;;; tfii,. throline assay.Statistical data analysis .,r.J i("--r,ched pair two-tailed t test. LMWC iron was lg.3 nM/100 mg ischemic tissuevs l3.l nM/100 mg nonischemic tissue : 1.t4, p < . 0l). 1t MDA was 0.91 nM/100 mg ischemic tissue versus'0.83 nM/100 mg non-ischemic tissue (t-: 7.27, p < .005).We conclude that rnerels a srgnttrcantincreasein tissue LMWC iron and in MDd arter two hours of myocardial ischemia. This iron mieht be the


catatyst tor maturation of tissue injury during reperfusion as ob_ served b-y other investigators. Iron chelators"such as desferrioxamine should be examined for tissue protection a".i"g ..p.iirrsion following ischemia.

?A lVtU

Nonlinear Transformation of the Resting Electrocardiogram in the Diagnosis of Coronary Artery Disease

D Schreck,L Ng, BS Schreck,D Zacharias,CFV Grunau/ in Emergencyl/edictne.OvertookHospital.potytechnic l,esldelcy tvteotcat Assoctates,Inc. Summit.New Jersey . Despite the common use of the standardl2_ieadECG, its relia_ bility as an indicator of.coronary ,rt.ry air""r. (CAD) is poor. The normal ECG is ialsely negativein more ttrrr'SOZ of angio_ graphically proven CAD. fust"as for othe, physiotogic measrirements, the waveform of the standardECG can ir" -r"tfr.-rtr"rity by signal processingto enhance its rnrerpretatron Ili.1tfo1-5a wlthout altering the data. A computer processthat utifizes non_ lrncar transtormation of the waveform of the standardECG was developed.Using,sucha process,it is possiblethat abnormalities can be identified in ,,normal,,ECGs. Furthermtre, the abnor_ malities may be correlated to CAD. A .";;;il template that rcpresentsgrouped data of normal ECGs foi patients who also nal9 normal coronary angiographywas developed.Unblinded, prâ&#x201A;Źlrmrnary resting of the template versus normal ECCs of t07 whrle patrentswho had normai or abnormalcoronaryangiograms The process identified presenceor absenceof Ilt^p"rlg.T:d. : A U " w r t h U z % s p e c i t i c i r ya n d 7 l y " s e n s i t i v i r yf o r 5 J w o m c n . Spec.ificitywas 82"/oand sensitivity was g6% ?or 54 men. The rcsults are promising, but further ,"fin.-ent of ihe te-plates is rcqurred/and blinded studieswith largernumbers and varieties of patients are needed.

?7 ty f

l_mn1ov9dDiagnostic Accuracy and Acute Management of pelpteiing Tachyarrhythmias with a pill Electrode for Esophageat Electrocardiography

M Shaw,G Zaid, JT Nremann,R Haskeil,VV fit-i-l bepirtments of EmergencyMedicineand Medicine,HarOor_UCLn Medical Center,Torrance,California Esophagealelectrocardiography(E-ECC)can detect atrial elec_ trical activity rn arrhythm[s when p waves ."""oi U. irJentified on the surtaceECG. However,discomfort causedby conventional .electrode.placementand the accurate'interpretation ::o-phig."l cll cardlacsrgnalsagainstbackgroundelectrical ,,noise,,have lim_ lted the use ol E-ECC as a diagnostic aid. Our purpose was to evaluate the utility of a new tJchnique fo, i_fiC in an acute c.aresetting and to determine if uJe o{ E_ECG would affect rhythm dia-gnosis and acUtemanagement.E-ECGswere obtained "pill electrode" Tl"C., .lArzco Medical Electronics,Inc) consist_ rng or a Drpotarelectrode (3 x 20 mm) attached to a pair of 0.5mm-diameter wires contained-in a standaragetatl" capsule. The capsuleswith the enclosed electrodes*.r."r*ritl*ed and the sensing ,electrodeswere positioned posterior to the left atrium. ,l.V are positione_dbehind the left atrium, atrial de-11.1 a tall, spiked ECG deflection, Iarger than l:1.:l1rt9".,produces A preamplifier system with a low_friquency :,r]:^:l:,o:t,:ctron. Iuter and a standardJ-channel ECG recorder *er. ,rr"d. Th. esophagealelectrodeswere connectedto inpuis to sia.rdr.d leJ I, and simultaneousrecordingsof E-ECG l.rf i;"J;"dard lead II were made to facilitate detection of atrial and ventricular depolarizationsand their relationship.E-ECC; *er.'Jlt" from O"lients .wrth perplexingta.hyrr.hyth-ras {ie, ven_ _a-1^Lyik" tncular rate > 100/min and no p wavesevident on the surface ECCJ.In all patients, an E-ECGwas obtainedi" C I ro min with no crscomtort. In 23 of 34 16g%1,the original diagnosisassessed by l2-lead ECG interpretatronwas incorrect based on E_ECG

days) after the initial presentation

Using angiographic findings'


;:ilti!ixlT:il+\'{:ii*:l"T:',:."f$}it"'^+K'*:rx;1n LT,l*i,i#ji'*";'xir;r'i..r*':l'i iii"x,.':iji *:ili:!i:'t'#$.il*1iii',.1%'si*:f,::.'# :ii;#:I,ffi ti1,T","'Tl]'a:';:iiruililiil"*.""f il.ff ( MB ;"^0, lif*,tJ'[.i;".iiiqsJfl-",trr*S*tXilfu ::i:i:'"iT[il; ";;;aK. *#,:"lil.H"; ;|; E+lii]i: il,r,"? il;; s.z ygii';';' *^i i' i,'-Tffi?T3"i3llJ.1lXt';;i i, #Jli,*'"#11n""?if tTi:#il'!i"*1"{l':""-,i*i"':""'ff gemana <1 lHli'-}:;r,3,i,'"";;r.""", :",n:'s::x'"if i:';::*? t:',3li"'iifi?"*ir,,"i", "*1'' aiagnosis an :I*ii''1*':ft ;;;;;;;";;ihdoserV*!:ll,r"n{:tf who werefound to U. "ri-""ffv?"J


of perplexing iachyarrhythmias'

over 30 min -

has been

angiographicaliv l:fTjr11t^1


i:lli*1,""**,th::ilxt"lrlruf;;:"*'i:iie 3$:?H1'"?"."" ll;H:',l Elfl 8 3 :-"" ne' tc Med iu,^,cR-Berrvman; il orcn 'na^ io$,l**-::-..ffi iifftlil"r#i1{:l:r ;::fya::fl,' llili: it th: szx^tizl Ei.ip,' Ix",li'iru;;,i.iav i,*,:::ffi1::l "'l+i[':3."1",{'ni ",y:,o1",'.T'.'nil:ri:iii"i"'?0,:xil;,'.:ff *::[H".'d1i'"":ruxx,w';iq:;'iJi*',tti o{ SouthAlaba UniversitY

e;;i';;wcreplaced-bviJ,',"#'i#'"1'f:l'.J;;,,,0r..""0,,", H

Hs'i?ir*:rrt',:l;*::l'lr1mi6::r?'3i:i :*::,'n:'ax',"1r{tr,:i+!{}, iti*;l#x'l:,'i?,Tfi :li^l#fi x%'Ti"H"ff i 1trn',11""1T'Jilili"ff :?r,fJf iji$'**=ru",,'i"1j:,1'i*lri.l;T;;i[.i:h:lji#"11 siJltliiiYjT[i':fl"?;nffi 'rr*:'"'.'-'.tl*l'l-rd i""r"ai'g.r'" ,"ai 18in otherlocations, lt"?ill,lt#ffT:tJ :ili1i5ileTffixli"T"",r:"'lyy{3iJ'^"'#J. '".'Hil:i :ii::*:;#J#in'#[*'u:lx':"YJl}":'tf; TlrHTih$::1mF$ffi ii:tl{l ti:hffT:l""t :{rsl.**::Ti',Fi',::.1",*.:ii1;l"r$"ffi "::,:H *1#rfl ji,xl#:#il*i"'"ll#?,Tfi :J"il:i**:xh'i.rut*n:'"":,*T:'1,!,"ii, ffitr,,'# defini'ive IHJ i,j,,n;' li:ilimi;;; fi: [j3:TlJi:J.'.TT| ilj.fiir'-"',:xl:?:irii$*:i;!-:ll,'::l':qif #:*# *:',txrrx,:ttryi{"i1'x!}i:Fil!::1,, tiirt*':Ii ",*, ,ll m;ril"r-i;' it',,""' i"i'iI"'r" "a.

PGY II or higher lcvel

riifr [*:*st-[r++;''"'a.rf +[ilil*l'l: in.approxrm: ir-*rn".t, wcrc alteredin some way pl^""-tttt in the ED is cathetcrizationr,*" totttt'idt tft"i t'Av (ate' complication the and docs not increase il;;it;i;i

?"lti"Yllf'J necessarY' ditonal theraPies

39 3:1,1"':i'{".1',1'fi'"i,'#::'i1il.1",,," **n 40 H,li::F::;"i",31iLr,?TliliiJrr,",, cardiac Arrest rreated with -posittttomlolytic

Course in Pati'

,ntravenou":'::"w,3,:,i,T."'*.*u ii"]*]"" i4i{[i']#iffgl:rm+',9"i?3ii#x;3

Acute r,rvo""'i'i'iitiiil'iiiii

g#,5t""i..ll"tll5J')3;;;;'d"i".,tin"nt;rrorioail#i''' rexas 3:11[onio lnstitute,Orlando

?$3?i"1113.;ffi:l:i,'l$il1?#liff ^ffiJ;ryil::: *i*{i**:i:}valt:'":!*il{;Tl?$]il:.:'r'i':#

it*tli$f*t*":'*'lt'."1;11i*ii'';"-.ffi'';3ii lf',i.::#:lf {';*f#;"1"'".p 5 be,ween *"i.p"".a ii",iJ,,ilr -::}q#iif.'i;;: [:::;'f'"*':il:T'#",ii,q1i;;,1;;; i;liii^"{l!xp'ir'"

i'J;ii;;;;i;;csr*tr-"'J?l*:Ti:rilli#"":::;;';e ir*::.r'*iT':H*i,".t'.ff[]:{f,'.:f,'*#li slcns ;r"JiJ "ri,,i"al :ii:rilr|3lil*:i;3'-i'"1; patients

de. rr Group f:t"HiJ"ii; reryer. fil;"1,*:,;..t*hh*r;,s, i:1",":,'."1'1.J10"". -'"i' " gsf[;i"iT]i:,"".x;:;":lxi l"l'%li i|T:,ii:;",ilJ";;a' *.,. .,'i.'1'8o,,, 'tf;:i#ft:'; ::l::"tl;k:Fi-*i iS:)'|'{uTi1".ft""L ffi';; !;il;i;; ;i +i'''i"f" zo ;",t"f:#i:::3r$f',:1"'"lhf1 (*i.t'i"48h),and'ny'iiff"li',fi"ff ;;;;i;'ty '"occrusion

pacins;31T"1i",fl:t'd,::iil:, i[il;lu'i;;;;;;;;;%;'"ardiac

Llkli+Fii:.:i','iTxi':sl*th*it""r*;4fiiq Lq$:.4l]ji".:f#*****r*.*u #;;.il';;:-;ih

" ;;;;



o{ 4 davs(t 4 of angiographv



.,.*l:r f.unnort the concept that cardiac pacrng must be rhe outcome of bradyasystoliccaidiac irrest is to l?,r\r,i..i0.".,t


t=."n:'*HH:1T$:,Ga prehosfital Treatment

of Cardiopulmonary Arrest

p.ital. Misplacement of the pacing catheter tip may contribute to the poor success rate of transvenous pacing iuring CpR.

D,ring 43 #LT:".i'::,',':Ji'g',',""1

rdiacoPac ine

Hypothermic Dogs


R.OConnor,C Reese.A LornbJrdr. J Feldstein, W Wersberg / Departments of EmergencyMedicineand Internal rvreotclne, Wttmtngton MedicaiCentel Wilmington, Delaware Attempts at electrical stimulation of the heart were first reportcd during the mid-lgth century. fr.rt-..rf of b.rdvrw.ioli. arrcst using transcutaneous elect.ricalpacing was i",roaui.a-Uy Zoll in 1952.Recent technrcalretinementshave made availablea number of dcvices for use,rn emergency,.r.rr"uir.r.orrs cardiac patients presenti;g to the ED in b.adyarystoli" Thlr,y-six l:,..11^C_

::l:l:!',rft i?J,"T::f; :Ti11T:1;:fi :lT,*'J:ff :?"ili:" pacing.using the pace- Aido device. On presentatron

:::;1c?T ro rne hIJ, ZU patrentswere asystolic,9 were in completeheart block (CHB),a"a Z naa rcfra^ctoiyfr."iy.rrai"r.'i'lectrical capture was achievcdin 2I of the 36 paticntJ (SSV"t.Captrrre was thus obtaincdin l2 of _20asystolicpatientstOO7.l'iJ'.f 9 with CHB and in 3 of Z with bradycardias 166"/,.'), Eoui patients devel1+ZV"1i, capture.TWo of these ai.a sto.tiy "ft., "a_tr_ :,1._d slon, lilr.:,-irh rhe other two wcre discharged.Both patientj who expired presentedwith bradycardia,wherias o.r" of t'h" s.rruivorspresent_ ed with CHB and the otheq,Ur"ay"rrair.-O.r..iulr., were ob_ tained,the patients receivedtransu..rou, p^..-aiers. Transcutan9o.us11cingfailed to capture in another patient who pr.r.rr,"d with CHB and subsequenily,developed .rpiri" *ltf, p;i;;i;; a transvcnouspacemaker.This_patienrsurvived ""tit ai."frrrg.l Thus asystoleiad a 6oo/.,i,-.^."f:;eil;; ""J r'0.2. p"f re rate with no surVrvors;CHB had a 667o.captuyerate, llo/o prrl.. .rt., ,rrJ 22'% survival,ratc;^bradycardias iad ^ iii"--"ip[.ure rate,4zo/o pulse rate, and a l4%. survival rate. The average time from'onset of arrest to ED arrival was 27.5 min. The transcuraneous was applied as soon as was feasible.The pacing elec_ l_1...-r}". trodesotteilequired repositioning to optimize .rptr-ri. "rrjpulr. generatlon.Tianscutaneor

JP Gillen,M Vogel R Holterman, JJ Skiendzielewskr / Department of EmergencyMedicine,GeisingerMedicalCentei Danviile, Pennsylvania Ventricular fibrillation (VF) has long been described as a complication of orotracheal intubation iri,t* iyp"ifr.r-i. p"ti".ri. Careful review o{ the literature, however,f"iGi; demonstratea true_temporairelationshipbetweenorotracheal intubation and resultant VF in human sub1e.ts.El.v." Jog, ;re anesthetized with pentobarbitalsodium followed Uy .ri.3ifry-tomy {without local anesthesia)and placem."t of ,#riri-J.,J'..ntrrt lines. An thermistor probewas placedorally to lie posterior ::.IJ^rfl",., ro rnc neart. Ihe dogswere then packed in ice withfust orotracheal rnruDatlonand extubation.performedevery2 C starting at27 C. Vcntilator settings were adiustedto mri.,/a- *i*rt pft ;;or;_ ing to arterial blood gasesdrawn every Z. C ""a coirected for tcmperaturc. Of the 42 intubations peiformed during hypotlrei_

gll ontl I episode "r.""'auri"g l2.BB'./.1of Tl1:.1L"^: rnruDatlon. l here were B separate

e p i s o d e so f s p o n t a n e o u s V F i n 5 dogs during cooling unreiatcd to l"trbrtilnllour ot these 5 oogs wtth spontaneous VF were resuscitated successfully with countershock only, further cooled, and reintubated an additlonai ll timcs without episodes of VF. One dog wrs -trrbat.a S sepa_ ratc timcs without arrhythmia until an aiystolic dcath at 14.2 C. ,,19n caused Vf; we would expect one_half of the episodes o r l D n u a t r o n t o b c o h s c r v c dw r t h _ i n t u b a t i o n _ . 035) Our data {p s u g g c s t t h a t t h c i n c i d c n c e ,o f V F d u r i n g i n t u b a t i o n in a'hypothei_ rnrc patrent is much lcss previously described, prouiiiJ ti_,rt adequate gxygcnation and normal pH ;;;;;rined. Further sruolcs wrtl be dlrcctcd toward prctrcatment with bretylium priot to intubation to further reduce arrhythmias auiing intubation-

ationGooIins 4 ! il'""tf#flTffi,o"Tl "",H,'i W-JBarker,JT Amsterdam,SA Syverud,JR H;;g;s,

ii.r,.", t-.,,t J ffi ;:'blfi ,l:jfi : fii:',T', il:.iBl?.:H:?; JS Huff/.Departmentof EmergencyMedicine,F;irf;x Hospital,

of asystoleproduced dismal results ,"J,fr"r'"""firms prior re_ ports- Perhapscarlier intervention during rhe pieiospital phase may hclp circumvent the otherwise air-; pili"osis of asystole.

42F:::*""'*?i::::ffi1!",","f t?;"""" MLHansrrtJ/ bepartments ll_Sf=9tW.! largevJRHedses,

ot LmergencyMedicineand Radiology,Unlversity of Cincinnati Center,Cincinnati;Departmelli"f E;";;;;y Medicine, ]1191!"t LacklandAir ForceBase,San Antonio,Texas an I8-month period we prospectivelystudied 35 ED -p_auents ?lt]"* who had a transvenouspacing catheter placed without

guidance a;;G ;i;;-"fh",, -",,,g..

ll:.",'::.:ll_. _ollcc was assessed \-arneterttp posrtron using postresuscltatronor chest radiographs.pacing cath"eters were fixed in the !91!yor,.* posrtronol electrical capture prior to radiographs; *t." ."pt"i. y,1t.n.I9r achieved,the catheter was fixed ,t gS "- from the pornt ot tnsertion.position of the catheter tip on radiographswas ventricle, t0 of 35; .ishi;ir*;;l/ of 35; and 1i,-f^"-tlly:;,lt*ht u,rnâ&#x201A;Źrrocatlon, 8 ol 35. Ectopic catheter tip locations inciuded caval4),,coronarysinus (l), pulmonary artery (l), in_ llj:t]i',_"j1" ternartugular vein (1].and hepatic v9n ft). Catheter tip position the right veniricte corr.l"ted-wiiil ,;;;f*""tty ylfr1n higher rnc.idenceof electncal capture whe., "omp"areJwlth other catheter tip locations (p < .^004).o"ly i ;it5 ,"", .,r._ cessfullyresuscitared;none lived t" l'.;riii.rr. f-rom the hos_

Fairfax Virginia;Departmentoi er'.rg"nlt r,rrLo[i." university o f C i n c i n n a tC i,incinnati High-frequencyiet ventilation {HF/V) permits gas_ exchangeby , thâ&#x201A;Ź rapid delivery of small tidai volumes. ih;-rilly was undertaken,to evalu.ateHF|V as "n ,dt";;;;;;" .""f1"? of hyperther_ (|,:l-rl-kel patients by enhancement of evaporariveheat fl: russ.r\onexertronalheatstrokewas modelled by paisiveexternal warming oI anesthetizeddogs to 43 C (measuiej i., the prrlmo_ nary artery).control anima[ in:5) were i"t"lriei".ro had their resprratronscontrolled with a volume_cycled respiratorset to maintain their baselinepCO2 level betweeng0 ;0";Hg. Atter reaching their maximum temperature,the control animals were allowed to co_olpassivelywhrle .-p-"*il-i" "iff loorn ,i. {approximately 20 C). HFJVtreatedanimals (n:5)-;;;; heated in an identical manner with the exception that immediately after their peak te-p.r"turef HFfV was iniiirt.a using an :"j.|]T trmersoniet ventilator with a rate of 200, driving pressureof 40 PSI, inspiratory to expiratory ratio of .5, and a fiO, .f .21 (com-

Brain Pulm Art Rectal Skin

Controls [ , 4 e a n( + ^ S t d ) 0 . 0 3 5 1( 0 . 0 0 7 1 ) 0 0386 (0 0082) 0 0358 (0.0077) 0.0594(0 0173)

HFJV M e a n( + t S t d ) 0 0 s 5 1 ( 0 . 0 17 7 ) 0 0674 (0.0245) 0.0624 (0 0204) 0.0890(0 0348)

pressed air). HF|V produced an increase in cooling rate for hyperthermic animals (P < .05) over controls (Thble). Clinical use of HFIV as an adiunct for treatment of hyperthermia should be investigated.

Pharyngeo.Tracheal Lumen Airway: 45 An Assessment of Airway Gontrol in the Setting of Upper Airway Hemorrhage R Bartlett,D Perina,S Martin,J Raymond,J Kareff/ Department of EmergencyMedicine,RichlandMemorialHospital,Columbia, South Caroiina Initial stabilization of the trauma patient begins with airway control. This may be di{{icult to achieve in those patients with m a x i l l o f a c i a l t r a u m a . A s p h y x i a s e c o n d a r yt o u p p e r a i r w a y obstruction by mechanical disruption or obstruction from blood or vomitus is the principal causeo{ death in these patients. Prehospital airway managementvaries widely dependingon the trarning level o{ the ambulancepersonnel.When available,an endotrachealtube provides the most effective ventilation and protection of the lower airway.Becausemaxillofacial trauma olten is associatedwith cervical spine infury, other methods of airway managementmay be selectedin place of the endotrachealtube. One form of airway control that is commonly available is the esophagealobturator airway (EOA).Unfortunatily, the EOA does not provide any protection to the lower airway in the setting of upper airway hemorrhage, and it is di{ficult to consistently achieve an effective seal around the faceplate. The pharyngeotracheal lumen airway {PTL) is an alternative airway device that is simple to use. The PTL airway consistsof 2 tubes of di(ferent diametersarrangedas a tube within a tube. A large low pressure cuff is located at the proximal end of the airway.When inflated, this chamber seals the oropharynx, thereby diverting air down the trachea.It was our hypothesis that this cuff would also protect the lower airway from upper airway hemorrhageand secretions. To test this hypothesis,a postmortem radiographicstudy was designedusing a barium solution to simulate upper airway hemorrhage.Radiographsand xeroradiographywere used to evaluate the ability of the PTL airway to protect the tracheobronchial tree during this simulated hemorrhage.The PTL airway was studied in l0 individuals within the first hour of death. In 9 of 10 cases,the PTL airway provided complete protection of the trachea.In I caseit failed due to a puncture in the proximal balloon. Our findings indicate that the PTL airway provides substantial protection againstaspirationof upper airway secretionsand hemorrhage. It follows that adequate control of airflow in the opposite,outward direction is also obtained.This indicatestwo lifesavingimprovementsover the EOA. The PTL airway representsa highly effective and superior method oI airway control.


Success Rates of Orotracheal Intubation by Transillumination Technique Using a Lighted Stylet

DG Ellis,RD Stewart,RM Kaplan,A Jakymec/ The Centerfor EmergencyMedicine,University of PittsburghAfliliatedResidency in EmergencyMedicine;the Departments of Medicineand Anesthesiology/Critical Care Medicine,Unrversity ol Pittsburgh Schoolof Medicine,Pittsburgh The technique of guided orotrachealintubation using a lighted stylet dependson the transillumination of the soft tissueso{ the neck to direct the tube through the glottis and into the trachea. Two formal studies at the {Jniversity of Pittsburgh have demonstrated the eflicacy of the technique in the operating room as well as in the field and ED settings.Both clinical studiesand our experience to date indicate that this technique can be taught quickly to those skilled in laryngoscopicorotrachealintubation. Our operatingroom study recordedsuccessratesof the technique and times for intubation of 50 patients undergoingelective surgery.All patients were success{ullyintubated, 36 of 50 172"/olon


the first attempt, l1 patients l22Y"l requred a second attempt, and 3 16%) required a third. The average time for intubation was 37 seconds in the 50 patients. The method was refined and improved over the course of the study, and the average time for intubation decreased from an average of 47 seconds in the first 25 patients to 32 seconds in the last 25. A new design of the lighted stylet device resulted from the experience gained. Intubator training and experience influenced initial success rates, and the cadaver lab was of particular value in teaching the technique. In the Pittsburgh studies of this procedure, this technique was found to be o{ particular use in patients with C-spine abnormalities, burns of the mouth, and microstomia; and in poor lighting conditions, and conlined spaces in the field setting. Guided orotracheal intubation using a lighted stylet is a safe and effective method of airway control. This paper reports in detail a description of the refined procedure that has not yet been reported in the medical literature. Further research is warranted as to its wider application in the field of emergency medicine.


Radiographic Diagnosis of Upper Airway Obstruction in lUlaxillolacial Trauma

JF Teichgraebel/ Divisionof Plasticand ReconstructiveSurgery, Departmentof Surgery,Universityof TexasHealthSciences Centerat Houston,Houston Although the examination and diagnosiso{ acute upper airway obstruction is a prime considerationin the managementof maxillofacial trauma, little has beenwritten on the subject.One hundred selectedmaior maxillofacial trauma cases,647" of whom had associatedhead trauma, were analvzedto determine the etiology and subsequentpatterns of acute airway obstruction. A retrospective radiographic analysis was performed to identify anatomic spacesand fractures with potential for obstruction. Most authors have identified the pharynx as the critical point of obstruction in the upper respiratory tract, alter free {luids and foreign bodies.In the series,the most frequent sites of potential airway obstruction included: flail mandible (4); nasopharyngeal hematoma {3}; palatal impaction (2f; posterior pharyngealhematoma i2); and lateral pharyngealhematoma {2). Plain film radiographywas sufficient to document all of thesefindings with the exception of a lateral pharyngealhematoma. Plain film findings were corroboratedby CT scan when it was available.By utilizing conventional roentgenogramsand by understandingthe pattems of obstruction, we have developeda systematic approachto the diagnosiso{ potential airway obstruction in facial trauma.

A O rfCD

J{euromuscular Blockade for Gritical Patients in the Emergency Department

DJ Robert,JE Clinton,E RuizI Departmentof Emergency Medicine,HennepinCountyMedicalCenter,Minneapolis Succinylcholine and pancuronium can be useful adluncts for intubation and other lifesaving procedures in the ED. This study examines the indications and the effects of ll9 doses of either drug given in the ED to 107 patients over a 24-month period. The averageage of the patients was 33.3 years (rangel-81). All were considered to have immediately life-threatening emergencies. The most common indication for succinylcholine was to accomplish tracheal intubation 120oI 251.Indications for pancuronrum included computerizedtomographyof the head 160oI g4lr control of agitation l4O oI 9411facilitation of tracheal intubation {20 of 94); control of ventilation (12 of 9411; and control of seizure unresponsive to anticonvulsants (4 of 94). Deterioration following succinylcholine occurred in 4 cases.These included bradycardia (2),ventricular tachycardia (1f,and failed intubation requiring surgical airway {lf. Possiblecomplications following pancuronium included ventricular tachycardia or fibrillation (21and failed intubation requiring surgical airway (3). Most frequent minor complications of pancuronium included prolonged paralysis of 100 minutes or longer (10),sinus or supraventricular tachycardia {7f


and intubation delay oi 5 minutes or longer {6). Inadequate docu_ menta.tion of neurologic examination priol to blockade^was noted tn 6 oi 25 succinylcholine and 9 of 94 pancuronium cases. Failure to sedate patients who might be awari of paralysis occurred in B of 25 succinylcholine and 8 of 94 pancuroniu-'rrr.r. Neuromuscular,blocking agents facilitate eipeditious management of selected cntlcal pattents in the ED. Their prudent use requrres an_ ticipation of potential complications, preparation foi surglcal airway should intubation fail, documeniatibn of physical eiamination before paralysis and prior sedation when patient responds to pain.

",," 19 i"iffl,t#l"$ilLiltiT,l!.

WAJacobs,MC Gunderson,Sp Holt,BC White,JN Love/ Departmentof EmergencyMedicine,Butierworth Hospital, GrandRapids,Michigan;S-ectioh of EmergencyMedicine, uoilegeot HumanMedicine,MichiganStateUniversitv, East Lansing It is well known that calcium ion influx across the plasma membraneis a necessarystep in mast cell degranulation.Mast cells.w.lll not degranulatein vitro in the absenceof calcium. This has led to a proposedrole for calcium channel blockers, such as verapamil,in the treatment of acute anaphylaxis.The effect of verapamil on anaphylaxiswas studied in-16 albino guinea pigs. lne anrmalswere sensitizedto ovalbumin {OA),later challengid with an IV injection of OA to induce anapirylaxrs,a.rd were ob_ {o,rI hour. The guinea pigs were divided into 4 groupsof 4 leryed each with Croup I beinga control group and receivingno rreat_ ment. Croup 2 received0.2 cc of l:2,00b epinephrineIV 2 min_ utes after the OA iniection. Group 3 ,.""iu.d 5 mg/kg oI ve_ rapamil intraperitoneally 2O minutes prior to OCinlection. Group 4 received I mg/kg of verapamil lV 2 -int.t., after OA rntectlon.Ihe mean times of death,_ in seconds,after OA injec_ {":,\:*fferent groupswere as follows: Croup r, 557 + i4l j l:l :r + 87; and Group I! 713 * -G^t9"p_?,3098 1005;Group 8,429 4u6. Ihe data were analyzedby the Kruskal_Wallisone_way ANOyA The use of epinephrinesignificantly improved survival time in anaphylaxis{p < .02J.There-wasno significantprotective ettect ot verapamil on anaphylaxis in guinea pigs at ihe doses usedin this study (p > .051.

Hemodynamic Effects of Naloxone in t]fa gtV Anaphylactic Shock ,,JRHedges. S Syverud / Department of Emergency YS,B,l::f Meorcrne, University of

CincinnatiMedicalCenter,Cincinnati Recentreports suggestthat endorphins may contribute to hemooynamlcclep.ression in septic and hemorrhagicshock. There is also evrdencethat reversal of endorphin effects with high_dose improve hemodynamic function rrrd-r-prou. rurfflolone,may vrvat ln shock states.The purposeof this study was ro examlne the effects of naloxone on liemodynami. prr"-'.t.r, and survival in anaphylacticshock. A rabbit model of anaphylacticshock was used.Briefly, anaphylactic shock was induced in sensitized rabDlts wlth horse serum. Three minutes after the onset of shock, rabbits were treated with a 3 mg/kg bolus of naloxone followed by a 3 mg/kg/hr.infusion (group1, ,i:S1, o, ly mf."tion with an equal volume of saline (group 2, n=71. Cardiac output, blood pressure,hâ&#x201A;Źart rate, and body temperature were moniiored continuousJyfor 60 minutes, and the experiment was terminated. survrvatm Crguq.l and group 2 was not significantly different. *?: a srgniiicant increasein cardiacindex in group I ani_ l-l:* mals at .IU,mrnutes.{p.<.001)and 15 minutes (p <-.01).Stroke was also higher at l0 minutes and 15 minutes (p < 1o.t1-r15.1n0e1 .U5l..Although mean blood pressurewas higher in group I animals at all time intewals after niloxone was befrrn, th.'differe.rce *as statistically significant only at 60 minute's {p < .05). peripheral vascularresistancewas not significantly different. Althoueh


naloxone treatment does appear to improve hemodynamic functron in anaphylactic shock, there is no apparent beneficial effect on survival in this model.

Central and peripheral Catheter Flow gE { t Rates in ..pediatric" Dogs D Hodge,G Fleisher, C Delgado-paredesT Emergency Department, TheChildren,s philadelphia Hospital of philadelp6ia, Several authorshavereportedflow ratesfor variouscatheters in

vitro, but these studies may not reflect dif{erences in vivo be_ c1u1e venous p,ressure,vaives, and/or venous toituosity partic9f ularly rn the small vessels of the child. We studied flow ratis of 4 sm.all-gauge catheters in a ,,pediatric,,dog model to determine the following: I) whether there is a differenci between rn vitro and in vivo flow rates; 2) whether there is a difference between flow rates of the same catheters placed in central or peripheral veins in the normot,cnsive patient; and 3l whether hypoi'ension affects rrow rnrough the same cathetcr placed in a central vs peripheral a vein. Catheters were inserted inio an ear vein (peripheralf ;J;t; femoral vein {centralf; infusions *.r. -."rrrr"i in'triplicate over a 60-second interval. We found significant differences between in vivo and in vitro flow rates for Z if the larger (2O_gauge) catheters. Th^cse differences wcre greatest when fluld was"delfvered under JUU nr_mHg ol pressure. There was a significant difference in flow ratcs for one of the catheters designedlor central vein use when deljvered through 300 Hg pi"rr,rr" tz I "OSj. Th".e ;;;; -nowever,no significant TT differences between the flow rates of the same catheters.placed e-ither in the central or petipheral vein when dellvered by use of gravity. In hypotensive dogj there were no significant differences in flow for the same catheter rn centrar veins with gravity (4.cclmin), but under 300 mm Hg l: r c!:lph:lrt p s s u r c t h e c l l t t c r e n c ei n c r e a s c d s i g n i f i c a n t l y q l 7 cc/min, p i -05). Our data indicate that the rcsulis of in viiro studies cannot bc cxtrapolated directly to predict ""hi"u"bl. llow rates in clrnlca,l practice. In particular, a small-diameter catheter in the central circulation may allow delivery of fluid under pressure at a taster rate than a catheter of larger diamcter in a peripheral vein. Thus decisions as to site, type, and size of catheier ior fluid re_ suscitation should be based on data obtained in vivo.


Eflicacy of Current Recommendations Bicarbonate Therapy in a pediatric Animal Model for CpR


G Caputo, G Fleisher,C Delgado-paredes / Emergency Department, The Chtidren's phitiadetphia Hbspitatof philadelphia, This study assessedthe adequacyof the recommendeddose , of (2 mEq/kg initially thi" f -EqZf.l .".ry ro min) for Itglrlonltl LrK ln chrldren rn an animal model for pediatric CpR using 6_12 kg dogs.Animals *.t" ".r.rth.i-.a *t,f, i."t'".,yt7 Y_l-:1919;t0 oroperrdol, paralyzedwith pancuronium, intubated orotracheaily and ventilated. Femoralvenousand r.t.ii"l catheterswere rnsert_ ed, and pentobarbital l0 mg/kg was given foi mri.rte.rrrr". of a n e s t h e s i a .S t a n d a r dm o n i t o r i n g w i s p e r f o r m e d .A f t ; r ;i; PaO2stabilizedin the'physiologicrange,the endol laCpz,,and tracheattube was occluded,leadingto cardiacarrest.Five min after cardiac arrest, CpR was belun *lth-" mechanical re_ suscitator at a rate of 80/min, and supplementaloxygen was de_ livered by a volume ventilaror at a riie oi iO/-i". All animals rgc,eive!,a bolus of epinephrineinitially, followed fy an infusion :1 l.lClkq/1nrn..They were assignedconsecutivelyto recerveno r\artLLl.r lGrp u) or a dose^of2 mEq/kg iGrp 2), half beingrepeated after l0 and 20 min. ABGs ""d lactlrie l;r;i, ;;;. ob6ined at (-5J,I min prior toresusciltion (_l),and lh.,,tp:^d:3t{':.^"_rt9rj y, tr, r, tz, t5,'ZtJ,2 5,30,35, and 40 min after the start of bpR. 2 did not.differ significantlyin terms of weight :?Y:1d.ST lo.rv _vs.5.J/kg]; mean blood pressureprior to arrest (gg vsJ6 mm Hg); onset of arrest aJter inoxia lZi2 vs 24g secf; or blood pressureachievedduring CpR (ZOvs i7 mm HgJ.Theie was no

vehiclc {P < .01). Variables approachrng srgnificance include presence of life-threatening problems (CC : .14); abnormal mental status (CC : .14)i arival with neck immobilized {CC : .I7); and t o r t i c o l l i s ( C C - . 1 3 ) .I n o u r s a m p l e o f 1 7 c h i l d r e n w i t h s p i n e injuries, wc could select 14 using the strong variables, and 16 by adding the weaker variables. These variables can be used to develop a log linear or discriminant model that may permit the safe exclusion of unneccssary C-spine films prcsently obtained for child trauma victims.

signi{icant difference between the two groups in pH prior to CPR -5i 6.97 vs 7.20 at -ll. There were, however, statis{6.99 vs 7.06 at tically significant dilferences in pH in these two groups throughout CPR. The pH in Crp 2 was initially alkalotic 17.65at +3 min), but it then approached the physiologic range and remained there until 30 min postarrest, when acidosis was noted lpH,7.2a1. This is in sharp contrast to Grp 0, in which acrdosis was present from the onset of resuscitation and worsened throughout (pH, 7.20 at +3j (r.80at +40). In this model, the current regimen of 2 mEq/kg o{ NaHCO.3 initially, followed by subsequent l-mEqikg doses, may not be optimal because it produces an rnitial alkalosis. A dosage schedule of I mEq/kg initially and subsequently might correct thc acidosis without causing an initial alkalosis, and it might maintarn pH in the physiologic range


Gaustic Ingestions: An ln Vitro Study of the Effects of Buffer, Neutralization, and Dilution

K l M a u l l , A P O s m a n d , C D M a u l l / U n i v e r s i t yo f T e n n e s s e e Memorial Research Center and Hospitai, Knoxville In order to,,dctcrmine relativc changes in pH and temperature o{ solutions of commonly ingestcd liquid caustics (liquid Drano alkali; toilct bowl clcancr-acid) treated by addition of buffer (antacid), diluent (watcr), or neutralizing agent {weak acid), equal increments of cach substance were added to 50 cc of liquid caustic. A Fisher Versamix constant agitator assured immediatc mixing. A Forma scientific LCD digital thcrmometer and a Beckman Expandomatic IV pH mcter were used for instantaneous tcmperaturc and pH readings. Rcsults are shown in Thblcs I and

Diagnosis of Group A Strep Pharyngitis in the Emergency Department in Ten Minutes TexasTech of Surgery, D DuBois,VG Ray,B Nelson/ Department El Paso,Texas University SchooloI Medicine, E e Jg

A l0-minute, rapid test for diagnosing Group A Strep pharyngitis was cvaluatcd usrng positive throat cultures as the marker for disease. Patients prescnting to the ED in a 2-month period with a complaint of sore throat were entered in the study (147 patients). Patients were examined, and a clinical impression of disease was made. A single throat swab was used for culture and thc rapid tcst. Patients were treated initially on the basis of clinical judgment belore laboratory tests wete known. The rapid test had a sensitivity oI 77o/u and a speci{icity of 93%. Clinicai judgment had a sensitivity of 69o/" and a specrficity of 57%. The rapid test was signilicantly better than clinical judgment alone in dctermining the presence of disease (P < .05). The predictive valucs o{ the positive and the negative for the rapid test were 79"/o and 93%, respectively. The predictive values of the positive and thc ncgativc for clinical judgment were 507o and 86"/o, rcspcctivcly. In the ED setting, where adequate follow-up is difficult (14'1, in this study), the rapid test can identify more accuratcly thosc who need theraly when compared to clinical judgment alone, and it will obviate the necd for throat cultures.


A l k a l i( N o O H ) Volume Added Acetic Acid B0cc Caustic



C a u s t l c-

ApH -4.85



N e u t r azl a t i o n YES No

Acid (HCl) volume Added

Developing a Glinical Model to Predict EA G-Spine lnjury in Ghild Trauma Victims arof General M Barthel / Division D Jalfe,H Binns,MA Radkowski, Hospital, Memorial Pediatrics, TheChildren's and Emergency Chicago

T e m pC ' +1.2"

Temp C'

Magnesium aluminum hydroxide

200 cc

+o. I


800 cc






+ 0.5


It is concluded that dilution as a first-aid measure is ineffective in thc managcmcnt of caustlc ingestions bccause even large volurnes of diluent do not appreciably change the pH of the caustic. Neutralization requires rclatively small amounts of solution, causes minimal heat of rcaction, and promptly changes the pH toward neutral. Buffer solutions should be avoided becausc they cause a rapid release of heat (? hcat of formation) without an immediate change in pH of solutron. In vivo studies are needed to conlirm the relative roles of pH extremes and heat in the genesis of trssue iniurv

The child with head or multrple injuries presents difficulties in carly cmergency cervical spine {C-spine) management. By analogy to the adult experience, neck immobilization and C-spine in struggling radiography are routine. Yet neck immobilization children can be technically difficult and obstructive to other essential evaluations. To define a subset of child trauma victims for whom emergency C-spine immobilization and radiography may be unnecessary, we performed a retrospective study of all traumatized children who obtained C-spine radiographs in our children's hospital from September 1983 to September 1984. We also included all cases of C-spine injury from 1973 to 1983. All radiographs were reviewed by a pediatric radiologist, and patients with inadequate studies were excluded. Clinical data included demographics, location and circumstances of injury, initial physical examination, and the Abbreviated Injury Scale {AISJ.Data were analyzed using chi-square and contingency coefficients {CC}. The study sample included 139 children 0-16 years old. Seventeen had spine or cord iniuries, and 122 had normal C-spines. Variables strongly associated with C-spine injuries include the following: complaint of neck pain (P < .001) or limitation of neck motion (P < .0051; neck tenderness {P < .001); abnormalities in re{lexes (P < .005),strength {P < .01) or sensation (P < .01);loss o{ consciousness(P < .05)r AIS score (P < .01);and injury in a motor

E1Q rrlEl

Comparative Effectiveness of Cathartics Used with Activated Gharcoal

EP Krenzelok, R Keller, RD Stewart / School of Medicine, U n i v e r s i t yo f P i t t s b u r g h ; 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 o f W e s t e r n P e n n s y l v a n i a ,P i t t s b u r g h Activated charcoal and a cathartic are routinely used in the management of many poisoning emergencies. The adsorption ol toxins by activated charcoal is not an irreversible process. Therefore, expeditious catharsis of the activated charcoal/toxin complex is critical. This research project was designed to determine which cathartic would produce the most rapid elimination of activated charcoal. In a crossover design, 23 consenting adult human volunteers consumed activated charcoal {50 g) and each ol the following cathartics - magnesium citrate, magnesium sul-




late, and sorbitol - separately at minimum intervals of I week. The time intervai between ingestion oiifr-. l"arrrr,ed charcoal/ cathartic mixture and the "pp.!rr"".^oiir,"iir"

ened QRS or arrhythmia was_attempted. Three showedcrearimthis portion of the experim."t *r, neither blinded l:"_r:i.-:l,lr,

ffi,'.:;'.",Li;[Ti:]fr ilTinl"l:ii#:iry;f*ilrj:*#:*iii,i'..l,;;.}.l*:i ,:'LF:jiy,::;?},l:.,,:'lx,,T induced cardiac conduction abnormalities in some subjectsand that it warrants further investigation.

were.compared to a control of activated charcoal wlthor,i , "rl thartic. A comparison of the average ;;;il;i_.. reveals that the most rapid catharsis is achievJcl *i.t-r;;;

iltu*l; q1*,ff'*r:.ffil.r*'#:iru;t'. . ;":",{,'.'t


"i"'iir. ,.,i*,"d

charcoal/toxr" "._'jrll


more rapid

orAcure X,':l;?ffi,I;,'ffiffi Reversar

RL Norton,H Chen, L Koenig,Jf gucnan, J Kendail/ Divisjonof EmergencyMedicine,oregon HearthSciences poriland University, Mrly case reports in the literature suggest ,tect the antagonist ef_ of naloxonein ethanol intoxication. ffi.i. number of controlled trials in .irfi.iii"_r"ilirg, "r" ""fv a limited o, animals, a_ndthe ,results of these.studies l.rJ ;;;;iliirrg w-e developeda cat model oi a*rr"r-l"a1r;eJ"co.m, .o.r"lrrrio.,r. to evaluate the etfect of hieh-dose_naloxonei" " i""an_i".a, Ufi"J.a, placebo-controitedtrial. Two groufs;? to';;;;;;re given an rv loading dose of 30% ethanol iu.i's_1z:;;;r:'; malntenance d.ose.ofethanol was administe..j tt;;i;;;siv the duration of the studv.Gro"p A;;.;i;;JrViao*o,r. tnfusio' for l2.s mg/ i'.,"ioi;;;..i;;;;;,, was graded 5.q):^9:t^u ll".iy.{,hu. oy spontaneous activity, corneal reflex, ear twitch, and pi'ir, ,._ sponse.The cats were intubated fr.rri ,rt. Irj"..rpr.r.ory .r,. were monitored. Cisternal CSF and ,"rrrb"trl".rd;rphi;*;;; measuredbefore saline or n4l6xsn. "a-l"i.i*-" and at inter_ vals thereafter.A clinical i-p*rri." ""irr.i no response was recordedfor all cats beforethe ,t"ay ..a'" *", known. plas_ ma ethanol levels were not.significan,fy aiif*.",'S lore administration or fnr. thiduraii""'.f-"lr.rr",ion minutes be_ (40 minutcs). cSF and serum endorphi"s weie ;i;tj;;'i;, both groups beforeand aftcr saline or naloxone*r, giu"".-il.r.i rare was slm_ respiratory,i. in Croup A rncreased :l:l:: Tlh ,*^-uo:_Jhe srgnrtrcantly{p < .051within 2 minutes "ft., .rrioiorr., and this differencepcrsisted for 40-minuter.-i;;.i ;; "J.r1"iorr.,"r, i.n_ proved significantty (p < .05)in Gr;;;;i;iri?mrnr,tes or rv naloxone.Severalcats awoke and ."t"U"t.aJt.rnr.tu... fo. gby. of thc cats in both *rorl1 we correctly predicted their assign_ mcnt. to either placebooi natoxonegroups basedon clinical imt*ponse or ,,o ..spo.,sJto ih. Iv soiutions. These 3j"..:il:l l{ antagonist effect of high_dosenaloxone in eth_ ;:t",i,:ilJ_*,r.."Tan

57 r"j,?:txHf:Ellt"j:Hifl lffiHffi,'"o",

|\rAno*linOl lj"* vJr.kpoi.onControl l!:rtne:t, W Longmore,

e*vo rr< U;il;l ;T,%3"*:'.?: i"lyli:l ?;l['"'" i nor"r

Beta blocker overdos-es,11eincreasing in frequency, and they o_ftcnlcad to bradycardia, hypotension, and scizures unresponsrve ro_conventionar,therapy. Animal .tr,di.r ,.rJ ro-e human case

;:'1i'"ii:?:::u:3:in-''X,1ffi fi3ll;i:H*i?""'".J:ffi 3:";

w i t h p e n t o b a r b i t a lf o r i n d u c t i o n -f o l l o w e d by marntenance halothane inhalation """rth.ri". iir-. j;;;';;."ilowed to reach a steadystate.Arterial lines and s*"" Cl.r, "-"ill..r, *... ,.r,ro_ duccd for monitoring "f p"fr", Ul"oa pi#"*"i,if;;;_ ;;;

j,:":1.,1*":*::: ?i?#,',,.%Ti::*;'"a !i::4?13.Jffi

,r",;; ;;;;;ft ;ilL':,iil:j:l ['H:ffT,'fi1,;j ffi: normal pH. A dose resr

given IV Bolus and infus

l"nXo'ii:,1*1ft lHn:*j.1"Ii:;..;.il;;;;;:::i%,1i"lf

Iccts rn the s-mg bolus form..Cardiai output, bi."d pr;;;;;;;l incleaqed dramaticaily with ;h..;;;;;;r,ratron 1,11-s1 of rV

illii'-"".'.iiil1'"?",$';il.:;:r"'il"lf, 5il.',L""'".,$-{osmoderrhe model suggestthat a iir

verery 1l1I-"ft:,! -l' tt- ;;;;:J;'l;1t* ovcrdos"4 1r,-,-n,,


i""i.l'i"'.ffiil*Jiii#!X',1:",';'r?::..Xl'::-T,':l problems to the emersen

ohvsicianrhe problemrequiresrurih;;^;;;;;,;';;:',";1;':"t' optimal doseof glucagonin the nunan propra'orotou.oinlf;e

g?fi,ilffft:,I',1"J.,,". 5 8 Gonduction ---' ili,u',",,'l; 60

Abnormalitiesi R Mayron, E Rujz/ Hennepin Corniv-vlJi"llCenter, Minneapotis

Casereports have describeda beneficial reversingcardiac conduction abnormai*.. effect of phenytoin in by tricyclic"trollld-si,r;i;. l"j"*A ;;;;., been pub_ a suitable ],l;i l[^t:,l,1wins ouestion, *.r. raJ.*r.i'rri.g

Rapid Assay of Serum Theophyiline

"f"","Ji;'"i:3il("'.",iil,,T;J;g".Ji;:??cvlr,4edicin Jf; Many patients with

chronic obstructive airway disease are

,Hfi f.H:H:f Ti,'}*,..ff .tf ,;-f#*[il,?il+T* ".,ii'"'i'llil;,i,:fJ.fl:illJ,"!:;:,l,"f j,jl: li:[:,J,''."'o?,,x regarding appropriate th

doseof amitriprylineb.f"..a.; ll::.11::l l'*her reverse rJ would phenytoin


the cardiotoxic effect oi amrtriptyline is in progr_e_ss? Nineteen ,Jti;;;;;;h.;ized :T:ll were given with ket_ amrne IV amitriptyline and IV phenytoin. I)ata analysrs was conductedon natural'logarithms ;i-;;;;r., basedon the pharmokrneticpropertresot these drugs. The effective rela_


ff,l1;f ,i,k,l;;J.q;;il;'"il;',:H",kH3#',,"1|:'fji]:,l j";$:l#:::

iiit"i,:::,i,?xt",l,:?lill'x,i,tl;**'*;y,fi i*s t"Teterthafa"t"'-i"" serum the-


:i11::*sp.",p.",-.rvi;:'.tt"Jit#::iilTltH:1Tf,llo, f1"r,:::'rffi *ti#?slid't"i?.","3",H *;;.i"i1,"',tff jti["1i.ts,T'::i:i.:;; ;tlii,"':l'^trIll"',$18." J- tl',.-,r'.Hi"'rTT J.i "#:':1 .f qoq"l'"i'-tI'oii fl;t'r;},ffi*t+ iipt{i:,}';:*#3"l,',ffij{J{"fr if#i*:lHfi:ili1,ii$.l,,:,:*:i#l;f

to-,-:".y^9f amitriptyline ir,,.,d,..i.,g'r;;;;;j mance.Similar results were.obtained"*h;iil;;als ii.dir. p.rfo._ were ti_ tratedto a lethal doseof amitriptyline. ffr. .?i..,i* relative po_ tency of amitriptyrine whe"_ph.nyiorr-grr." ,.rirr, " .o.rtrol grouprb: R = 1.35,with 95% .onfid.n..'i.,-t"rurj'.oS to 2.79. With 12 of the animals,phenytoin ,,rescue,i ,i ifr.'ilr". oi a wid-

::',"ffi riT;

mg/kg of E to demonstratt lhi:-9,2 In this model we were,able tli in I 0-m a i"g f-oiigt1 r ^card ad mi ni stercd pe'r pnerat v flow over that seert' f,li"ttl.tjt% ,rifi.rn,fv incieasedbrain blood

jfll;;'J'fJl,'Jil'slli;"i'1"'9,'d1;'ielJT"il:11:1'i ITJ p"'1t'' resnlrlorv rate' and e"ti'o;'i;ii"i Group2 (P < .0011'

**:'J:d,'",T"r.11::'.*T6:il,$'.r:t\f* ;i': *h'1n".'#ilx-il*fi L':BiT:'m lnlil:1,'i"i'"fff #iii:f :i*i:**1.*:';!.x,*l! i:l::nh*

i'l"il; tlilil'i1i'J.*",lflIt:Itrrtgftlifii':'If 621,1'J["J'3J,:TJ$i:'"1J"'i:ff*13'" hospitaf setting'

;';;'Jt ophylline. Placement "'

result S"talyzer in -t-\: Eo will

ffit};'T; :{"{:rjitt:li:i"t::tn'y*jllitr'1il':?"ff bi.ri"n'1oc R'riw' MHB,ros, the Rat


;ff: ;y til :rt:tfllffil; :l Eil:IH

ar and AnatomY Medicine "'1".1"fl'"t clinically signifiischemicinsult is one of damageano brain io-i'i"""ttlblt cant conditio,,' leaalng intracellular P::$ death.Animal 'tuoi" n'il ll'ss'J;9'i^;1;f followins;:t.niltitl; "tidosis severe,b'"in'f"'iE the pH due to

Eii^,i^iiH$L:;J, *:::' :ff 9l ""0 [tili:"i::rm :ir,$Lly,ll*'1l; "'';"#:' 8fi

i',',',",.".x'li'I;:llt''::]'u,?l1:;!li,lgli',i" "SjrXl,brood'ow(.ull#'t;:l"',",::fi :1"::, j,iff*:Ti :ini::litn:lni'i1""'1,"'1,"1:fi'::l,i:il':?F'iv '*#.i;fii#'"t#';â&#x201A;Źi1d::fi }+1ffiqi{itfi;# {;*.c.mpres' F;:it":i'i::?:3*l,sitsif*:*":ff '#l sase {occM)' "'ai' cma-s Depaitmentol Preventive

i'",T:l'i;l"ii |ji; ";. "li r'.'i'

H',ljl'it'i:ix'##'tii"d':t'3" ifi"il',"'lgil:i:Tft ",,';l;'1; ?r* i*fit?fJh]l{:;r; il*iil T"r,:ffi nUii;*laq{11:+i,*':r#"" mor #;i$ ;i;]iiiT*rilxffi mentar e*peri the'i$5'it 'in.ffi; ,,::1'*'*f ffi''Hi:l' ,Ti{ThTi$'*,i'..:'ff


f,":i.,:i.;Ef Ifll:-+tl*i*;:**:lltf ***;1t[:"':",ii,"+r l{; ffi:l***rqi:":r"{+'f'l;ilye;riffi ilffiT,,:t"uf epincphrinepre:ll::"fi.

to determine Durposeof this stuctywas

{''x.H"'-i#ii".t'm frfi*Itrh:ktfxtl.1ltt'f, [[it1"FH;;':lF*l**i*'ri,d'll..r,..iifi {; i1:y"#'j:i*tili;1#l**lt.*:'-""';":":'?iiil oz pIuJo l;':3;?!1,L,1:"1!i#;'io,."*' 'itnii9crn lowing cerebral ischemia'

ilfii*ti*jJnii#.-f1':"J'1q:.'+ii{xliil}!i":. j.?"Ttt'""t':3T;HtlL"""o"oti?t" '.'"":lll'+lr:ili.pilllt1ip::; 63i,",'""3,'", [*:"'l*."'""tr"rTf "tii rt." Badical S91v.9ns31s^ "uling t"aior".ivelvlabeledtracer (or -"r.,rrliinir CBb tor mented ;""t"""-tn",were trJ; srooo .determined microspheres'

*:r'{t il?t'#'n% s=;lt'iliiil;: t1{:#3fr $",*' " tr"jotff:ilg,Xf;;,il;;;,"p"i"*iii;i'*n^I1i"i

flS Kingiton'CAdkinson' E Ruiz,DD Brunette' ry niti*""' / Departments-o'f Emergency MJ Wieland,RI Zerax Snerman and M e d i c i n e a n d S u r g e r y , " e n n " n"i'i"t p i n C oclinrcal u n t y Msciences edica|.C enter. rtt; e'5'ientilation,Pres:)it D"pu'tt"nt5'oi"5t"ii lowingparameters:. Minneapolis; "oB:##J? of Minnesota niversity "si nu"siigution' t -U Diagnostrc Veterinary CountyPoison p"rlr HennePrn *"ii"i;". ';entilation coileqeof Velerinary piunningand Development' ot iiii;;;,';ft Y,T'i 381{1"'1,?'"i'*i""Li"a.Center;Hennepinco'nty"6iii"


'*.oi* ::::i:i"[8il'lf]','1il-:**"'"{ft :[',*x*ff :?': e csrw"'"sli"fmla','red' Jl$;i;. ;;;i";,,n"t,ij,.'1,' between low t"ti *'l "tta to compare

ffji|,y,il1!u5,lfi:{ l'I,'",.?ir::?#ti[H'jil'.'f"'j,,'Jf resus;;.;'"di"r'""n'og'::1 cerebrar

" li"'*XHltr::tlli,'il'T Hij[1tf*t#Jti;t-'"'"];t-'."t1*:?['i:'x1Y:f wilcoxon rank sum



Left cerebralconex Right cerebralcortex Cerebellum Midbrain/Pons Medulla CervicalsPinalcord

% NSR Blood Flow n ' r r i n nC C P R+ E -...:"--= % NSR , 0 02 Blood Flow mg/kg Value mq/k9 n"rinn . vv u u " ! ! Y CCPR -= 01B .Sr ub .04 018 54 '06 o; '018 7a o7 .G 018 1? .75 UJ

o6 I J

20 )\

6s .93

071 038

prepped with ""t't["tued' ;;;;-*t'" citalion' Twelve *""g'"i pressure'aorvenous for-central was sterile techniq''", "nc -i"iio?d la,te'r3.I^lforacotomy A,left tic ptessure,""o tt-t'-,"i't'ngtt' obt-ainedby-applicationof a 6done. Ventricu'"' tot"tiiil"'was Mechanical^ventilation was volt AC current to tn"'"pi""tJi"m' dogswere resuscitatedwithn'U **' epr' stopped. Arrest trme *"t"ii """[t'"!t",i'^l**bonate' itlt"-gt' in 6 min ,t,i"g t"tttt'i were then ranTl: 9:F: nephrine, ",'d ittt""r"d"iilJi"ii""' were treated domized into contror ""i "t"i*""'groups.Six"fogs of 20'l" to 307" ustng a ftt*tt"o"tii iol with rapid hemodilutrori (l g/L) and to"taining ascorbate hetastarch {Hespanl 'ojt"jo''r"r"riniection of alphamagnesium sulfate tlJ50;;;ili-"n



tocopherol acetate {500 mgJ, an<l compression in a hyperbaric oxygenchamberto 2 atmospheresabsolute.Six control d;gr;;;; not treated. All dogs were transferredto an ICU. Critical care managementand neurologic scoring was performed fo, up to i days by blinded observerJ.NeurolJg_ic.;;i;;;;. do.,e'.ve.y hour using a posirive scoring scale.A"ll a"!, ,iifr.ii-e of death autopsiesfor bolh gross andirri.roi.op,. analysis. il^1"_ty""! tvteansurvrval time for thecontrol dogswas 6.5 h ; 8.7, andlor the treateddogsit was 73.9h t: 6s.4 : nbii. Ti.; highest lF totai n-eurologicscore achievedalso was siatisticaliy ,ig"ifi;""t 1p : .021).Three of the treatment dogs awakened'frorr, , .o-",or. state,while none of rhe control ddgsdid. Two of tlre treated dogs We concluie that ihe tr"ri-.", regrmen 9:d_T11,"*-logically. rmproved..survivaltime and appearedto have a beneficial neurologlc



Brood Fj:trf::,*lll""" once,ebrar

Z*11our.,K Koster / Section of Emersency ll]]!li1"ll',,M Medrcrne, WayneState

UniversitySchoolof Medicin-e, Detroit; EmergencyMedicine,witriamBeaumonrHospitat, 3:,?:tngl,.:l HojaruaK Mtchlganisupportfrom DupontLaboratories, vvilmtngton, Lielaware This study was done to_determineif naloxone5 mg/kg IV given to mongrel dogsa{ter cardiacresuscitationresultedrn an rncrease in cerebral blood flow. Eleven mongr.t aog, anesthetized with ketamine, halothane, and atrof,ine. iir"ug-tro"t tfr" ,iuav, pH was maintained at 7.35,--7.4O; pCO2, at 30_a56ir; and systolrc blood pressureat least at 120 mm Hg:M;;;;prra-eters fo. all animals included left femoral ;r,"rt ;;;h;t'.i, prri.iri Richardsonhead bolt; and flow-direct.a ifr"i-oiii"tion catheter (Edwards93A-13l-ZF)for measurementof pulmonary wedgep.essure,cardiacoutput, and core t.-p.rrt.rr.. A thermodilution catneterwas speciallypreparedby dissectrngthe distal 2 cm of rne tnermtstortree from the plastic sheath.After a left frontal was placed,,this theimistor;;;;i";;;";hrough a nick ljT,i",t. ln tne dura onto the left frontal cortex.The left internil carotid artery was exposedand a 22-gaugecatheterwas inserted into the artery iust below the level of-thl craniothyroid artery. prearrest rntraarterialblood pressure,blood g"r.., p.ll*o.r"ry *.ag. pr"._ sure,intracranial-pressure, cardiacorrtp,.rilth.rmodilutloi meth_ oof,and cerebralblood flow were recorded.Cerebral blood ilows were determined according to the single tt.r-iJo, method o{ Hoehneret al by iniecting g cc of 0c l"rm"l"io"irte carotid arrenal catheter,and calculating the cerebralblood flow from the maximal temperaruredrop and the rewarming curve. Cardio_ pregrcarrestwas rnducedwith 0.5 mEq/kg of poiassium chloride inlected into the central venous line. D-o;; i"-"j".a without CPR for 15 min. Resuscitation*", "."o-'*i,f, .rtg;;; "tld.:odilrT bicarbonate;op.n .ardtac massage;and ll-,1^.tfll:t qrrecr cardlacclefibrillation.As soon as hemodynamicswire ble, about,30min postresuscitation,baselinepostarrest sta_ hemo_ oynamlc data were recorded. After baseline determinations, 7 mg/kgnaloxone in the centrat venous li,re; + dJg, 3:::^f::tl.^1 | serveoas controls and received no naloxone. A dopamine infi_ sron was required to maintain a blood pressure of 120 mm Hg systolicin Z of-ll dogs. postarrert ".r"bJ Ltooa no*, *.rE measuredrmmediately after naloxone administration and at 30_ mln Intervals thereafter for 120 min. Baseline cerebral blood flows ranged from 1.35 to 3.60 g/min. C.r"liri^lf""a flows were d.*eased post-cardii" "rr.ri-"rrJ ,"rrr".irtrtio., T:],f:9lt 1i, < .uurJ.l\aloxone had no effect on cerebralblood flow postarrest (p > .05).There was no correlation between """ittooa flow pr. pCO2, rCB,.n!{,. or CO (p > .05). In our stidy :t",1-",r^,:lr:.-,,*ith, naloxonehad no beneficial effect on cerebralblood flow postail rest when measuredby the single-thermistoi -.tfr"a.


the Recovery ol lffecj of _l{ifedipine onphosphates Gerebral High.Energy Aiter

Gardiac Arrest and Resuscitation in the Bat HG Garrison,AR Hansen,GW pailadino,DC Fillipo,HJ Proclor/ EmergencyMedical Services,Departmeniof Surgery, NorthCarolinaMemorialHospital,Chapeti-iitt , We studied the effect of-nifedipine,a calcium entry blocker,on t h e r e c o v e r y o f c e r e b r a l a d e n o s i n et r i p h o s p h a t e iATpl;;; crcarinepho-sgh.a.te lCp) Ievelsfollowing iesusiitationfrom car_ orac arrest. Utrlrzrng_therat model of de Garavilla and Babbs wrrn an arrest tlme of 8 min, 7g% oI the animals arrested were resuscitatedwith an averageintermittent abdominal compres_ sion CPR time of 3.3 min. Rats were randomly assignedto the following groups:prearrestcontrol, .rd-rrr.rf"6ri.ollrrd or. oi 4 treatment groups.Tieatment group animals received either IV normal saline or one o{ three doies of nifedipine (3 pglkg, l0 pgl kg, or 3O^pglks)immediatelypostresuscitati;;.ih"y were sacnnceq at zU and IZU minutes therea{ter.Comparisons of mean valueswere.performedusing an analysis"f ;J;;; with p < .05. As.cxpected,after 8 minutes of cardiacarrest, the levels of ATp and CP dropped to near zero and rebounded''in-allresuscitated animals. B_y120 minutes postresuscitation,rars gi"en the t0 f!7 kg dose of nifedipine had_levels"f ATt;q;i;;f,r,, ,o pr."r..r, control values. Return of Cp values to prearresfilvels was seen only at the 3 pglkg-dose and was independ.r,i oi th. time of measurement. The differences in ATp and Cp levels in these trcated groups,also were significant *h.r, "o-prr"d to 1i{gdinine salrne-treated controls. We concludethat clinically appropriatc doses of nifedipine appearedto have , f.""ii"iri-;ffeit on the recoveryot hlgh-energyphosphatesalter cardiacarrest and resuscltatron.


Brain lron Delocalization and Malo_ndialdehyde production Following Cardiac Arrest

JS Komara,.NRNayini,H_BialekBC White,SD Aust, RJ Indrieri, AT Evans WA Jacobs,RR Huang/ Collegesot luman Medicine and Veterinary Medicineand Department*of Biochemistry, MichiganStateUniversity, East Lansing;Departmentof tmergency Medicine,Mt CarmelMercy Hospital,Detroit; Ct EmergencyMedicine,autterwoiirrHospiral,Grand !:!,illrgi, supportedby grantsfrom the MichiganHeart T1ll9r_^y"n,gan; Assocratlon and the US Army MedrcalResearchand Development Command brain inyury after cardiacarrestmay be due to oxy_ _^l:n!:t:.1 gen radtcatspecles.The availability of a transitional metal, such as lron/ is essentialfor in vitro initiation of this type of reaction. The,brain has,large.stores of iron bound in laige'proteins.This sruoy was conductedto seeif iron availabilityis enhanced in the brain following resuscitationfro- .",dlr;-;r;;;, and wherher rnls rron ts associated with the appearance of productsof radical_ mediated lipid.pcroxidation. Assaysfor brain'tissue rron in row m o l e c u l a rw e i s h r s o e c i e s( L M W S i r o n ) a n d m a l o n d i a i d e h y d e (MDAj were "sea. ihe data were examined statistically using MANOVA. Five nonischemic brain samplesfiom the parietal cor_ tex had LMWS iron levelslin nM/100 -g ti..";1-;f iZ.eiiZ.i}, '"f and MDA levels (in nM/I00 mg tissueJ S.o7.l..JS. Five ani_ mals sublectedto cardiacarrest and open chest resuscitation had brarn _samplestaken after z h of standarJ i;;;;. care (SIC). LMWS iron levels were 32.04:t4.5g (loagrl"ri "tnischemic con_ trols, <.0.11,and MDA levels were 12.i4 : l.g lp againstnon_ rschemic controls, < .0S).Iive other animals were subyectedto ":9 2 h of SrC and were treated witi, sO mg7 ll'"r1,:.1.-r^l-y1-1, Kg.oesreroxamrne by lV infusion immediatelyposrresuscitation. significantly reduced(p < .0s) i:ji :lliT:lll9o-pl^.9{to^slC, uon {24.3+3.38)and MDA (9.40:t0.82i.LMWS i-.^T,ll:,"**s rron levels are rncreasedin the postischemicbrain and appearto be related to lipid peroxidation.rt i, i"i"ry -d;;irls responsrve to treatmentwith desferoxamine.

A-, lED t

Brain lron Delocalization During Various Methods of Artificial Perfusion

KM Joyce, NR Nayini, CL Zonia, AM Garritano,M Probst, TJ Hoehner.GS Krause, SD Aust, BC White / Department of A n e s t h e s i o l o g y ,S i n a i H o s p i t a l o l D e t r o i t , S e c t i o n o f E m e r g e n c y Medicine, Department o{ Medicine, and Department of B i o c h e m i s t r y ,M i c h i g a n S t a t e U n i v e r s i t y ,E a s t L a n s i n g ' s u p p o r t e d by grants from the US Army Medical Research and Development Command and the Michigan Heart Assocaation Tissue rnjury during reper{usron following ischemia is thought to be in part mcdiated by lipid peroxidation. In vitro studies of Iipid peroxidation have shown that the presence of a transitional metal, such as iron, is required for initiation of these reactions by oxygen radical species. The brain has large stores of chemically inert iron. This study examines thc hypothesis that this iron is released {rom tissue stores as a function of the artificial perfusion technique used in resuscrtation. Anesthesia was induced in 25 dogs (weighing 20 - 30 kg) with IV ketamine and maintained with hal,othane after intubatron. The bilateral parietal skull was trephined without removing the bone fragment. Cardiac arrest was induced by central venous iniection o{ KCI (0.75 mEq/kg) and confirmed by the arterial and ECG monitors. Five dogs (group I) served as nonischemic controls; brain specimens were taken from these immediately. Brain samples were taken from 5 dogs alter 45 minutes of arrest (Group 2) without any resuscitation. In the rcmaining l5 dogs, after l5 minutes of cardiac arrest, resuscitation was initiated with 100% 02 and CPR in Group 3, IAC-CPR in Group 4, and internal cardiac massage in Group 5. All resuscitation dogs were given epinephrine, 0.02 mg/kg IV bolus followed by continuous in{usion of 2 pg/kg/min. NaHCOa was given IV {3 mEq/kg for CPR and IAC-CPR, and 8 mEq/kg for internal massagcl "i the beginning o{ resuscitation. After 30 minutes of artiflcial perfusion, brain samples were taken. Malondialdehyde {MDAI was determined bv tlie thiobarbituric acid method. The brain homogenate was ultrafiltered {Amicon 30,000 mol. wt. filter), and the filtrate was analyzed for iron by the o-phenanthroline assay. The data were analyzed by the statistrcal mcthod of muitrvariance. Ultrafiltered iron {nm/100 mg tissuel was 6.2 + I.9, and the MDA (nm/100 mg tissue) was 6.8 + .9 in the nonischemic tissue. There was no significant change in MDA in any of the groups. There was no srgnificant change in the iron during 45 minutei of ischemia, nor with 30 minutes of internal massig. or IAC-CPR after 15 minutes arrest. However, ultra{iltera6lc iron was increased to 14.l + 5.6 with CPR. We conclude that while prolonged internal cardiac massage is not assoctated with delocahzation of iron during artificial perfusion, CPR is. This study did not demonstrate evidence of lipid peroxidation by the presence of MDA during the acute resuscitation phase. Other investigators, however, have shown a 3O-minute lag in the apDearance of MDA a{ter in vivo iron initlated lipid peroxidation.


Drug Overdose Patients Requiring lntensive Gare Admission in the Greater Portland Metropolitan Area: An Analysis

ME Jones. J Jui, L Horenblas,M Albrich, J Herbst, R Eichner, W H u r l e y ,J H o p p o c h , J L i n d b e r g , S B o y e r ,C C h i p m a n / O r e g o n H e a l t h S c i e n c e s U n i v e r s i t ya n d E m e r g e n c y M e d i c i n e R e s e a r c h Council of Greater Portland,Portland A study to determine the epidemiological and clinical {eatures of drug overdose patients requiring ICU admission was conducted by 9 Portland area hospttals from fanuary I, 1984, to |uly l, 1984. Records from 145 patients meeting these criteria were reviewed. Data were collected for patient demographics, psychiatric history, type and source of drug ingested, type of overdose {intentional vs accidental), mortality, and morbidity. Intentional overdoses constituted 87% ol all the overdoses; accidental ingestions comprised the remainder of the overdoses. The median age of the patient with intentional overdose was 32 y, with a {emale-to-male ratio of 1.8:1. In contrast, the median age o{ the accidental over-

dose patient was 73 y with a female-to-male latio of l:I. Ninetyfive pircent o{ the patients were Caucasian, reflecting thâ&#x201A;Ź metropolitin population of Portland. Seventy-four percent of the paiients wire unemployed at the time of overdose. Previous psychiatric illness was noted in72"/o of the patients; 36% of those with prior psychiatric history had history of a previous suicide ati.mnt. Th. source of the drug in 86% of cases was personal prescription. Three deaths were noted in this study: 2 were classified as rngestion ol unknown etiology, and the third was a death from tricyilic antidepressant ITCA) ingestion in a 22-y-old woman. Coronet's records revealed 6 deaths secondary to drug ingestion in the prehospital setting during the period o{ this study. The most common accidental overdose requiring ICU admission was with theonhvlline. TCA overdose was the most frequent and severe typc of intcntional overdose requiring ICU admission. No morbidity was obscrved in 49"1, of patients. These results indicate that significant morbidity occurs among certain portions of thc patients with scvere drug ingestions. Mortality was uncommon. More exact ICU admission criterra are needed to define the paticnt with drug ingestion at high risk fol serious complications in order to utilize scarce ICU lesources more efficiently. Improved education among those prescribing high-risk medicatrons as to both quantity ^nd dose may reduce dramatically the number and sevcrity of these admissions.

1QA 9-t

Treatment ol Polonium Poisoning with Dimercapto Ghelating Agents

BC Dart, KV lserson, HV Aposhian / Section of Emergency Medicine and Department of Cellular and Molecular Biology, Arizona Health Sciences Center,Tucson Polonium-2l0 is a dangerous radioactive decay product of uranium-238. Human bcings have been intermittently exposed to largc amounts of the product (eg, after the Windscale nuclear reactor accidentJ. Toxicity primarily affects the hemopoetic system with rapid deterioration ending in death over a period of days or wecks. Prcvrous rescarch has shown that chelation therapy with British Anti-Lewisite (BAL) must begin early to be effectrve DimercaDtosuccinic acid IDMSAI has been shown to be more effective than BAL. This study evaluates 2 newer chelating agents that are also expected to be more effective than BAL. Thirty-six Spraguc-Dawley rats werc injected with a lethal dose of pololi"- ZtO (a0 pCi/kg). They were then divided into 4 groups The normal saline. The treatment groups recontrol group- o received f the {ollowing treatments: dimercaptopropyl ceived one pthalamidic acid (DMPA), dimercaptopropane sulfonic acid [OmnS), or DMSA. The surviving animals were sacrificed at 106 oays. Resuits Survival Meansurvival

Control Group 219:22.2% 58.1 days



8/9:88 9% 8/9:88 9% 1 0 3 . 4d a V S 1 0 2 . 5d a y s

DMSA 9/9 = 100% 106 days

Comoarison -increascof the survival curves shows a statistically signifiin survival in the treatment groups {P : .003 in all cant groups). Survival differences among the treatment groups- did not ieach statistical significance. It is clear that dimercapto chelating agents greatly improve survival in the rat model. Ii these results aie borne orri i.t l-t, studies, the agents may be useful in the ED treatment of radiation accident victims.

Betrospective Review of Black Widow 7lGI J V Spider Envenomation Medicine, and Emergency of Trauma H Moss,LS Binder/ Division Schoolof Medicine, TexasTechUniversity Department ot Surgery, El Paso,Texas Current literature on the treatmentof black widow spider (Latrodectus mactans) envenomation is largely anecdotal, no re-



cent serres rn elther emergency or generai medicine literature havc been reported on this topic. Thl purpose of this investiga_ tron was to review our experience with 12 patients presenting to the ED berween l97B and l9B4 with Llack widow soilder envenomation severe enough to warrant admission. We sought to establish the frequency of presenting signs and symptoms io the ED, to de{ine the role of laboratory and radiographlc studies in the ED, and to evaluate the effectiveness of d"rug therapies. We found no statistically signi{icant relationship b"etween site of envenomation and presenting symptom complex. Abdominal pain and bite site pain were present in 67% oI patients; 50% had lower extremrty pain. Lesions at the bite site were noted in 25% and abdominal tenderness noted in 67%. ED laboratory and ra_ diographic studies were performed in B of t2 patients with 5 patlcnts havrng normal findings; 3 patients had nonspecific fi;d_ ings. A wide variety of drugs, including calcium gluconate (g3%), muscle (42%), narcotics (42%,), steroidJ{ 17,'/"),and, anti'_ ,rclaxants venom (58%)were used with 2 complications noted: I episodeof nausca and vomiting following excessive calcium gluconate ad_ ministration, and I episode o[ serum sickness. Thlrc was uni_ tormly excellcnt clinical outcome regardless ol the therapies u s e d , a n d s t a r i s t i c a l . a n a l y s i s ( F i s c h e r , si x a c t t e s t ) s h o w e d n o s i g _ n l t l c a n t a s s o c r a t r o nb e t w e e n a n y o f t h e a b o v e t h e r a p i e s a n d c o m p l i c a t i o n s . T h i s r e v i e w s u g g c s r sl ) t h a t t h e r e w a s n o d i f f e r e n c c in prcsentation bctwcen uppcr anrl lower extremity cnvenomation wlth the maiority of oatients presenting with bite site pain, ab_ domrnal parn and tenderness,and lower extremity pain; 2) that lahoratory and radiographic studies do not facilitate ED evaluailon oI black.wrdow spid,er envenomation; and 3) that with uni_ rormly cxccllent cllnical outco_me,only symptomatic therapy would seem justified. The use of antivenom'in-Latrodectus mic_ ldrs cnvenomation did not correlate with improved patient out_ comc, was associated with the complication b{ s.rtrm sickness, and would appear unwarranted.

Evaluation of Emergency 71 Nine.Year Department Personnel Exposure to lonizing Radiation RE Grazer,HW Meislin,BR Westerman, EA Criss/ Sectlonof EmergencyMedicine,University of ArizonaHealthSciences Center.Tucson ED personnelexperiencepotential occupationalhazardsfrom exposureto ionizing radiation. This exposureoccurswhile work_ ing in the ED and/or while supervisingpatients in the x-ray and fluoroscopysuites. To ".sess the risk,"a retrospectivestudy was doneanaly-zingionizing radiation exposureover a 9-year period l o r 1 3 4 E D p e r s o n n e l .T h e g r o u p c o n s i s t e do f 2 l p h y s i c i a n s f ( l q , 0 Z1 . f o r y e a r s t 9 B 2 t g B 4 L 9 2 n r r r s e s| 6 8 . 7 % i f o , y . " r . 1 9 7 5 1 9 B 4 ) ,a n d 2 l a n c i l l a r y p e r s o n n e l i 1 l S . e V " if o , y " r r . 1975-1984). Exposurewas measuredfor both penetratins,.rd ,ro.r_ p e n e t r a t i n gr a d i a t i o n u s i n g s t a n d a r df i l m d o s i m e t ; b a d g e s . Thesebadgeswere collected by the radiation safety departm"ent and read on a_monthly basis;a minimum of 5 mrem dosagewas required to effect a measurablereading. Compliance witL film reading.was66.77o |or physicians, ge.Z:%for nurses,and g6.Z% lor_ancillarypersonnel.Penetratingradiation exposureaveraged 0.iI6 mrem per month for physicians,0.703 mrem per monthJor nurses,.and0 mrem per month for ancillary personnel.Only I personhad any measurablereadingfor nonpenetratingradiation, and that was believedto havebeenlegisterei outside tle ED. The averageannual dosefrom exposureto natural, backgroundradia_ tion is on the order of 100-200mrem. Thus it is conJludedthat l) if standardradiation precautionsare taken, the occupationalrisk trom ionrzing radiation exposureto personnelin thoED is mini_ mal, ancl2) that routine monitoring of radiation exposureof ED personnelis unnecessary.

7 qt J i

TJ Hoehner,AT Evans,RJ Indreri,SD Aust,BC White/ Sectionof EmergencyMedicine,Departments of N4edicine and Biochemistrv Collegeof HumanMedicine,and Collegeof Veterinary Medicine, MichiganStateUniversity, East Lansing;Department of Anesthesiology, SinaiHospitalof Detroit,Detroit It_is our hypothesis that brain iniury after resuscitationfrom cardiac arrest occurs during reperfusionand is in part mediated by iron-dependenrlipid peroxidation.This study wis undertaken to examine the time courseof brain iron delocalizationand lioid peroxidation in an animal model of cardiac arrest and ,.r,,"tion. Assaysfor brain tissue iron in low molecular weight species (LMWS iron) utilized the o-phenanthroline test on a., ultrr_ filtered tissue sample,malondialdehyde(MDAf in brain tissue was assayedby the thiobarbituric acid test. The dara were exam_ ined statistically by the method of multivariance. Samplesof the parietal cortex from 9 nonischemic control dogs {Croup l) had LMWS iron levels(in nm/100 mg tissue)oI 9.6-t 3.9 a;d MDA levels(rn nmilOOmg tissue)of 1.7 + 1.4.Samplesof the parietal cortex taken from 5 dogsa{ter I5 minutes of cardiac"rr.rt *ith_ out resuscitation {Croup 2) had LMWS iron levels of 9.3 + 3.1 and MDA levels of 5.9 + l.I. There is no significant differencein these values between Group I and Group 2l Five dogs were subjected to 15 minutes of cardiac"rt"rt "nd definitive resuscitation by internal cardiac massageand defibrillation {Group 3}. Following resuscitation,the chest was closed and the dogs were given rntensive care for 2 hours. At two hours followins resuscitation. samplesof the parietalcortex had LMWS iron l&els of 37.Ot 4.6,{Pagainstboth Group I and Group 2 < .01)and MDA levelsof 12.2..t (P against both Group I and Group 2 < .0S).We con_ .I.9 clude that.brain lipid peroxidation does not occur during complete global brain ischemia, but it is evident after 2 hourJ of reperfusion.This is associatedwith concomitant increasesin brain LMWS iron levels during reperfusion.Brain LMWS iron levelsare not significantly elevatedduring completeglobal ischemia. Lipid peroxidation and LMWS iron delocalizationin the brain is a reperfusioninjury phenomenonthat may be amenabiero rreatment with an iron chelator such as deferoxamine.

Effect of Deferoxamine on Late Deaths 7.i, t rU Following GpR in Rats SD Kompala, CF Babbs/ Biomedical purdue Engineering Center, University, WestLafayette, lndiana ...Recent work by White et al indicates that free iron radicals, iiberatedintracellularly from bound sites,cataiyzelipid peroxiJal tion reactionsthat are responsiblefor continuing celi inyury days after cardiacarrest and CpR, especiallyin the lipid-rich brain.if iron is the causativefactor, an iron cLelator given after cardiac resuscitationmay reduce subsequentbrain damageand improve outcome. We studied the ef{ectof the iron chelatoi deferoxarnine on survival in rats with experimentally induced cardiac arrest. The experimental model consisted of cold KCI {l% 0.g ml IC) induced cardiac arrest for 6 min in healthy, ketamine_anesthe_ tized rats, followed by I to 4 min of CpR. A single injection o{ deferoxamine{50 mglkg IV) was given 5 min aftei successfulresuscitation.Inour study with 25 rats in the control group and 25 rats in the deferoxamine-treatedgroup, survival wJs similar in both groups up to 48 h after arres"t.Ai'the end of l0 days,however, there was 640/"survival in the deferoxamine-treated'group vs 36To survival in the control group, a statistically signif"icani difference(chi square: B.g}id| J t,p..05). Thus deferixamine preventedlate deaths.This model of complete circulatory arrest and resuscitation in intact animals demonstratesthe potential usefulnessof de{eroxaminein brain resuscitation. Elfects of Garbon Dioxide, Lidoflazine, and Deferoxamine Adminiitered After Gardiorespiratory Arrest and CpR in Rats SF Badylak,CF Babbs/ BiomedicalEngineering Center,purdue University,West Lafayette,Indiana 7 I

Gardiac Arrest and Resuscitation: Brain |ron Delocalization During Reperfusion

GS Krause,KM Joyce,NR Nayinr,CL ZonialAM'Garritano,


A -

We studied the effects of carbon dioxide, lido{lazine, and deferoxamine on the 10-daysurvival rate and subsequentneurologic function of rats initially resuscitated{rom 7 min of cardiorespiratoryarrest.Cardiac arrest was induced by inlection of cold l% KCI into the left ventricles of ketamine-anesthetized rats Dretreated with succinyl choline and positive ptessureventila;ion discontinuedat time zero. CPR was begun at 7 min, and animals with return of spontaneouscirculation enteredthe study.Tieated rats {20) were ventilated for I h with 7"/o CO2 and 937" C2, and were given lidoflazine (2.0mg/kg IV) and deferoxamine(50 mg/kg IV) 5 min after cardiacresuscitation.Control rats {20)were ventiIated for I h with I0O% 02 and given lido{lazine vehicle and deferoxamine vehicle. Lidoflazine treatment (1.0mg/kg), or lido{lazinevehicle for control rats, was repeatedat 8 h. At 2 days, 75% of treatedrats and257o of control rats were alive (chi square : 10.0,df : Ii P < .01).At l0 d,ays,60"/oo{ treatedrats and 25% of control rats were alive {chi sQuare: 5.01, df : 1; P < .05). There was no detectableneurologic deficit among survivors in either group at 15 days. Although administered after return of spontaneouscirculation, the combination of carbon dioxide, lidoflazine,and deferoxaminecan nonethelessimprove the probability of neurologically intact survival in this animal model of cardiorespiratoryarrest and CPR.

2 E I J

Protective Head Gooling During Gardiac Arrest in Dogs

E Brader,D Jehle,P Safar/ Divisionof EmergencyMedicine, AlleghenyGeneralHospital;Resuscitation ResearchCenter, Pittsburgh Prolongedexternal CPR cannot reliably sustain brain viability during cardiacarrest (CAl. A need exists for adiunctsto CPR that are applicablein the field. Preliminary dog studieshave suggested that surface cooling during CA and CPR can, within 10 min, achieve protective levels of brain hypothermia {30 C). Vasoconstriction induced by profound hypothermia of extracranial vasculaturecould redirect CPR-generated blood flow from face to brain. Cooling of the head (in comparison to systemic surface cooling) would minimize afterdrop and increase convenience. Head cooling could thereby be initiated by laymen in the field. TWelvedogs under Iight ketamine-halothane-nitrousoxide endotracheal anesthesiawere arrested by transthoracic fibrillation. The treated group consisted of 6 dogs whose shaven heads were moistened with saline and packed in ice. Six control dogs remained at room temperature.AII 12 dogswere subiectedto 4 min ventricular fibrillation followed bv 20 min standard CPR. Spontaneous circulation was restoredwith drugs and countershoiks. Intensive care was provided for 5 postarrest.Dogs were then returned to their cages and observed {or 24 h. In both the headcooled and control groups, 5 of 6 dogs had spontaneous circulation restored. At the end o{ 20 min of CPR, mean core temperaturedroppedto 35.3 C in the head-cooledgroup and 36.9 C in the control group {P < .05).After I min of spontaneouscirculation, mean core temperature dropped to 34.9 C in the headcooleddogsand 36.5 C in control dogs(P < .001).After 3 h, mean neurologicaldeficit {ND : 100% = brain death; 0% = normal) averaged 37"/" in head-cooled dogs and 62% in control dogs {P < .02). Two of 6 dogs in the head-cooledgroup survived 24 h with neurological deficits of 0% and 97o, respectively.None of the control dogs suwived 24 h. Head cooling for brain protection during prolonged CPR appearspromising and deservesfurther investigation. Afterdrop was noted in head-cooleddogs,but was not of sufficient magnitude that cardiac resuscitation was affected.

7G, f rg

Factors in Sudden Gardiac Death Decision llaking

cardiac Care{ECC) or its termination remains a confusing problem. We reviewed our series of 445 consecutive nontraumatic sudden cardiac deaths seen by paramedics in a tiered urban EMS system and report our experience.ECC was initiated in 319l7o%l and not in 126 (Group A). Eighty-sevenpatients (Group D) were admitted to the ED with a palpable pulse and an organized rhythm. In the remaining 232, ECC was terminated by paramedics in l3l (Group B) and continued in the remaining l0l (Group C). Thirty-two patients were dischargedalive (Group E). An initial rhythm of asystole,unwitnessedarrest,absenceof bystander/firstresponderCPR, onset times greaterthan 15minutes, and final ECG rhythms were evaluated for each group. The table summarizes the results. > 15

Group N A B c D E

126 131 101 8 7 3 2



126 59 21 17 0

11 8 55 36 35 15

85 28 24 3 ' 16

11 9 126 43 98 17 34 1 7 0 3 0

0 JZ

57 0 0


Bystander/First Responder CPRI Ten.Year Erperience in a Paramedic System

HA Stueven,P Troiano,B Thompson,JR Mateer,EH Kastenson, D Tonsfeldt,K Hargarten,R Kowalski,C Aprahamian,J Darin/ Sectionof Traumaand EmergencyMedicine,Medical College of Wisconsin,Milwaukee;Departmentof Emergency Medicrne,WilliamBeaumontHospital,RoyalOak, Michigan The elfectiveness of bystander CPR recently has been chalIenged. We undertook a lO-year retrospective review of our prehospital experience with witnessed cardiorespiratory arrest to ascertain save rates in patients receiving and not receiving CPR before paramedic ALS. Tlaumatic and poisoning arrests and children less than 18 years old were excluded. A total of 1905patients who presented to a paramedic system fuollrrl1/Ol/73 to tO/3tl83 were bystander-witnessedarrests and attempted paramedic resuscitations. Four-hundred-five paramedic-witnessedarrests were excluded. One-hundred-eighty:twoof.1,248 114.6%lwho had CPR initiated before paramedic ALS arrival were saves/as compared to 38 of 252 {15%} who had no CPR initiated until paramedic arrival {P : NSl. A save was defined as a patient discharged from the hospital. The respective save rates for coarseventricular fibrillation were 148of 628 |23.6%lvs 35 of Lsl '23.2y.1,EMD, l1 of 209 {5.3%} vs 0 of 38; asystole,19 of 401 14.7%lvs 3 oI 6l {4.9"/"J;and ventricular tachycardia, a oI n l4l%l vs 0 of 2. In this prehospital system/ bystander/first responder CPR is found not to improve hospital discharge rate.

RF Kowalski,BM Thompson,HA Stueven,C Aprahamian,


0 0 0 32 32

No patients presenting with asystole or whose final rhythm was asystole survived. The probability of survival in unwitnessed arrest and/or absenceo{ CPR and/or onset greater than 15 minutes was evaluated in the ECC-treated patients. Survival was poorest in the combination of all three (P : .0011.The increasedonset time alone (P : .025)or a combination of any of the three factors also was critical (P = .01).We conclude that any patient presenting with asystole and any of the 3 factors need not have ECC initiated. Our data also suggestthat once treatment has beeninitiated, it can be terminated after the rhythm has deteriorated into asystole,especiallyin patients who have an unwitnessedarrestor where there is absenceof CPR and whose onset time is greater than 15 minutes.

Bystander GPR in 78 Professional Prehospital Goarse Ventdcular Fibrillation

C Aprahanian, JC Darin, BM Thompson,JR Mateer,JF Tucker, HA Stueven/ Sectionof Traumaand EmergencyMedicine, MedicalCollegeof Wisconsin,Milwaukee Decision making relative to initiating prehospital emergency


Initial Unwt. Absence lvlin Rhythm Rhythm Rhythm Asyslole Arrest CPR Onset Asyslole E M D Organized


JC Darjn/ Departmentof EmergencyMedicine,William BeaumontHospital,RoyalOak, [rti"t igan; bect,on of Traumaand EmergencyMedicine,MedicalColleg-"of, Milwaukee Recentstudies suggestthat medical professionalsmay perform ,better external CpR than do nonprofesiionalcitizens. professional bystandergpR performed by ilvo ;i;;;;;;;ps was studied retrospectivâ&#x201A;Źly,first with fire department fiist-risponder basic EMTs and then with physicians,nurses,""J o,L", EMTs. These werqcomparedindependentlyto groupsof patrents receiv_ ,C]:ups, rngertnercrtrzenbystanderCpR or no bystander cpR. Four hun_ qreo twenty-oncconsecutive. witnessedcardiopulmonaryarrests presentingwith the initial rhythm of coarse ventriculai fibrillal tron treatedby a regional.paramedicsystem from lanuary l9g0 to fune 1982were anilvzed. i;;;;;;;d poi.o.,ir,!'p"_ _prcdiatric, tients and those receivingIV or endoira"t eri-edications prior to initial defibrillations weie excluded (58).A s;;";sstut aeiit.tttr_ tron occurredif defibrillation prior to administration of medications producedan effectivecardiacrhythm *rtfr-p"fr.r. n"rpr"r. time is definedas the differencebetweenit. ii-i "t call to arriv_ al o{ the paramedicunit. There *r, ,,o ;i;;iii;;;, differencein responsetrme, successfuldefibrillation rate, successfulresusciJtron rate (transportto the_hospitalwith a pulsatile ,frytfr_il"a yve,ratq(lsc,harge alive lrorn the hospital) when comparirrg by_ CPR done by physician, nurse,'and'oth"i fUf to citizen ;ta1de1 bystanderCPR and no bystanderCpR. There was also "" ,rg_ii_ cant differencebetweeniire departmentfirstlrespo"d", Uyrii'"a., bystander CFR. patients ,.""i,irrg fir. a.p"rt_ 9i\t9.citizen ment trrst-responderbystanderCpR had a significaitly faster ie sponsetrme (!.Q mln vs 6.3 min, p <.025land a significantly bettersuccessfulde{ibrillation rate (38% 1zl sij i " zz;t 1+ltztOi, P < .025)than did patienrs receivingno _i bysta.rdeiCpR. patients Uy"r, nurses, and i::.iu:lqlyrjander.CpR.performei other EMTs do not have.better clinicai iesults tha., ao p"ti*i. recervingcitizen_bystanderCpR or no bystander CpR. patients receivingbystander CpR performed by fire J.p"it_""t first re_ sponderswere more likely to have a pulse "ft.i irriti"t defibrilla_ compared patients to yh* .ec.iving no 6yrt".,a., -ln, li::: Du-ta taster responsetime may be a factorln tt.' "tr.ri-.j feSults.

". 7I 3 H!11,L.,"#, ffi,|,:lt'. Hf :1. f,il*, ilew

Strategy in Emergen;y Care -H;il;dr:il WDWeauer, LACobb, quF UnitandDivision orc",oibiosy 5T3rI"1.99r:1"r.y


narDorvtew MedicalCenter,Seattle rates for out-of-hospitalcardiacarrest and ventricular ..Survival fibrillation (VF) have averagedZ(t% oii rt."t-i^*-ff y."rs of oper_ tiered,responseEMS. Uo-.".r, *t.n asystole or :ll::-^.j- Tt erecrromechanrcal dissociationhave been initially recorded,outspite oJ prehospital cari'.'in"a t_year pe:n_ ll-,.j1._b^.-:l_rygr i,ir utl, LtJtz patlents wtth asystolic arrest were treated; ofihese, 7S i5%) were associatedwith rrauma. only zzO1li;if-.r" ,"rrr."r_ tatedand admitted to a hospital; lg (l%) ""*i".a. 'frf..*G; " S-yearsurvey.,ts 16%l oI 247 patient, di;;;;;d *ith electro-

(rhyttrmU"t "" p"fr. Ji pr"rrrr"; ,.rr_ T.::lrl.Sl.ltssociation ,l rnls latter group, suwival

was similar whether the ini1ru,.",. 'al rnythm was thought to be supraventricular or ventricular in origin; only I of 26 patients fou"a in high-a"si". Av' and no pulse survived. Weissessed th. irJl;;;; J"fi"uf hir;";t;;; logistics on survival in 2g5 patient, air"orr.i.J^ii vr. Uri.rg , logistic regressionanalysis," ".."r, ihe importarrce Tu^l:ly"1ir,: ot each tactor,,only delay {rom collapseuntil initiation of chest compressronslP < .OZland the duratibn of CpR before dellvery oi the first shock {p < .0lf significa"tty i"if".r*.il"uicome. for all casesof cardiac arrest and"VF tr.rt.i tro-igia_i9i2, th.r" *", " linear rela^tionshipbetween suwival and tt . ,.rpo."r. time of paramedics. Survival decreasedby 37" Ior.r"t _i""i. required to respond(probability of survivai : o.4o4|_ o.iifis ;;rponse time

w,. predictedthat adding 20 strategicaily :f^t:rl:t:1., .1,^y:. praccd automatrcdetihrillators.for use by the first tier of reipond'_ ing firefighterscould shorten the time f;o;;;l;pr" to defibrilla_ of 12minutes to 8 minutes and, by doing;o, :l::,{1:Tjl lverase slgnrttcantly improve the survival rate for witnessed."ra, of"."il diac arrest and VF

?rehosp*a I I O i::,'*Ttrl'f"Tl",:?:fiin,rhe Gardiac Origin \yl .llarSarten,C Aprahamian,HA Stueven,BM Thompson, JR Mateer,J Darin/ Sectionof Traumaand Emergency Medicine, MedicalCollegeof Wisconsin,Milwaukee . The prophylactic use of lidocaine in the patient with cardiac chest pain has been found by many lnvestilrioi, to reduce the incidence of suddendeath from u"rrt.i",li"r-iyrifrytfr_im i" ifr. '_.J':ilc,butfew studieshaveU.., a.i,. i, the.rrly pi._ l::t::ll phase. A nosprtal randomDed prospectivestudy comparingihe cffects of lidocaine vs no lidocain. i" p"ti.nir'presenting with chest pain,to a pa.ramedic system *rr'.*Ju.1"a to a.t&_in. rne overall mortality, incidence of sudden death (due to ven_ dysrhythmiasl,and mo-rbidity.patient follow_up was ob_ :Ii:ltft ralneo and ttnal dlagnosiswas determined by autopsy, E^CG,andl e l l r m c a n a l y s i s .I n a t - y e a r p e r i o d , ' 4 4 6p a i i c n t s : : - : : I : T , ror the study.of the 222 patients given lidocaine, 5 had Ly11']*i suodendeath due to ventriculardysrhythmiasin the prehospital oj tle 224, patients "oi r"""i"i"g lido"ai.,'., ? :l_9^P^:.-"tllE oevef the samesetting < .{l+1.The over{I)

o-fthe2,groupr *", s:li. and(,.7o2o, respei

:l1l:rn,"J igt^trlIy t1, . .J4e).Oi those.ultimately diagnosedas having ius:lY:lL rarnedan acute.myo_cardialinfarction, 4 of 68 of the lido"caine group devetopedsudden death 1I4.7%overall hospital mortality), compared to 4 of 6l in the no_lidocainegrorrp,'.ith ,r, uu.rrli morta.lity,rateoi 13,ly, fi" =tlt1il11" deueloprnenioi l::1,r] nypotensron,srgniticantdysrhythm.ias {frequentpVCs; VT; bra_ dycardia;2,8" ieart blocks) ,ft., i"iiirllrlii"io'tt. it"Ji ** in,both groups_ofpatienrs. There was no signiiicant !!.ln1ea drtterence. We conclude rhat in the prehospital setting] for pa_ tients presentingwith chest pain of suspected.rrdi". oriein. o'.o_ pnyractrclldocalnehas not becn shown to be beneficiri-ir., pr.venting sudden death or life-threateningdysrhythmias.

f|{ rY I

Prehospital Use of lsoproterenot tol Gomplete lleart Block

EH Kastenson,HA Stueven,D Tonsfeldt,B Thompson, J Darin/ Sectionof Traumaand EmergeniyM"Oi[r", Medical Collegeof Wisconsin,Milwaukee . Isoproterenolhas been recommendedby the Amerrcan Heart Association for ,,immediateconrrol of h;"at;;;r"ally ,rg.rif,_ cant and-atropinerefractory bradycad,iadu6 to-h."ri blJckl, Concern has been raised thai l."prot.r..rol -ly-l"o*., the blood pressurein bradycardiaassociatedwith hypoiension.A retrospectiveanalysis of the prehospitaluse of iioproterenol for atro_ plne retractorycompleteheart blo.ckand hypotension{systolic l91s than 90) Ior a 4-yearperiod reveaiea'it;;..r. !r Twelve of the 25 improved and 6 worsened (p : Nff.-Nrr* ",t z{ieiij showed a mean increase in blood presr"r.''ri,.r'rroproterenol zt to l0l mm Hg systolic.Thr.'.;;t,.;iJr-Ja pulre and,,o !-li pressurepreisoproterenol,and posti;oproterenol averagemean _a increase from 0 to 126 mm Hg. Seven of zs lisv") shJwed no changein,pressure.-Tireeot zs ltii/.i a.ra"pJ , ar.p ::Elf]^"1"_, rn blood pressure.Three oJ ZS ll2%) sustainedcardi".iripli"tori arrest and were not resuscitated.Isoprote.e.roi--)y n.of benefit in improving blood pressure in a. seiective hyp";;;;;; complete heart bloCk patlents, however, a;;;6;f subset may worsen with its use_

of conroom settings.To evaluatethe usefulnessand reliability lirr.ror,r,noiinvasive temperature monitoring, commercially to the availableLCTs {Temptr.ndiI, Biosyttergy,Inc) were applied t"ttdorniv selected, coopelative patients during- prei;;"h";;t; readings hosoital transportatlon. Oral electionic thermometer obtained bv S-minute inte*als' ;;;;';;;;;;J,;;i';'; Sixtv-eieht simultaneous LCT and oral electronic temperature performed in 28 patients' There was a significart ;;i;;;;;; (correla"oii.lition betweenLCT and o,,1 thttrnorntter readinqs applied p was LCT : The . .OOt)' .84, tion coefficient r -easily;;i;trted by ali patients' In I caseno LCT reading-was ;J;il with an visible; this patient was tonfirmed to be hypothermic (6%) in which incidents. 4 were There C. 33.3 o{ ;;;i ;;;;"t"fire could not be seen while the electronic ther;;ET";;Jing readin"gwas within the normal range This was deter-o-"t.t u. a"J to the dif{iculty of visualrzing the color-coded ;i;;J-;; reading in a dimly lit ambulance Liquid crystal i"-o.r"t"t. con;;;il;;;; oiouia".t a reliable and noninvasive means of tinuous moniioring in the prehospitalenvironment'

the Hand'Herd 82


AI rccovich/ EMS Agency, Santa BarbaraCounty;Emergency oEpuit*unt St FranCisHospital,Santa Barbara,California pulPrehospital treatment of asthma and chronic obstructive (coPD) has been difficult due to the inherent -;;;;;-ai;;"t; a'"g ih.'"pv. The initial therapv utilized in ;;;;ii.;ri;;;-oi ;;ne nanalneta ".iotol nebulizer (HHAN) Its effec;;.T;6. t"].iy rtru. been well documented' we performed a ;;;;;;"; in the use of HHAN in the prehospitalsetting ;';r;;G;;dy the i.r Sa.rtaBarbaraCounty, California. Our pur,posewas to test "tliitV oi administration by certified paramedicsorr our advanced i;i;-;,1p;";, ambulances. Paramedics were trained bv 1:tp-t1il? lndltherapisls in its properuse, educatedby physiciansas to rts and compliiations,and testedprior to its.use' Basesta;;i;;t io" ii"rpl."ft *"'t. -"d" awareof the therapy modality available preas c.rtiiied orders to paramedics' The standard HHAN the was sulfate metaproterenol and used was oackagedsystem Standard portable oxygen dispenserswere [i"n ia-i"ittered. "..3 "t " tO L/-ltt flow rate. Thirty patients who met criteria *.r. tr.^t.d with HHAN. Thirty paiients experiencedsubiective and 29 patients improved by clinical criteria No i-pi"".-l", group' Three -Jai."t complications were repoited in the study of the complications were reported in the setup an-dutility w.-"o""i"a. that HHAN is in effective, safe,and ;iH'dN r;;;;. of ,h.t"pv in the prehospital setting Al""ri "fi*,r". ;;;h; discard itro.rsh t"tt}t"r testing is necesiary,this may allow us to "ttd itt accompanving complicapi"t "?t.""Ii"., ;;";;h;lii;; tions, is the primary mode of therapy'

: :l' I 5 F:?:H:L?""";';'*3"Jli'Sffi Field Supetvisols Davidson,DG Faris/ Divisionol Special MH Erder,B Cheney,-SJ fhilad"tphiaHealthManagementCorporation; VeO-nat-dervic"t, Departmentof EmergencyMedicine,MedicalCollegeof Departmentof PublicHeallh F"'i*vr"".i", Philad6lphia Philadelphia on the Field performanceof 120paramedicshas been evaluated April 1984' basisof),650 ALS casestreatedbetweenFebruaryand blse hospiifr. o"i"*"ai.s'field performanceswere evaluatedby Ihrs stuoy supervisors' field system's physicians by-the and tal phvsicians{BPl base the bv evaluation irt. ;##I;;;;t.iur,t'or consistencv ;"i,h';h;;; by the field evaluators{FE),analyzesthe the ol th" ,"..rlti within each gtoup oi evaluatorsand between of the evaluatronmethodolosv uitiaiiv tr'. o" ;";;t,';;;;;poiit patient outi,rhen iested against an objective measurebasedon e;,;. Soimeof the dimensionson which the paramedics ;;;; the scoresgiven by each evaluating group' and *.i"-.*f"",.d, therelationshipbetweenthescoresgivenbythetwogloupsafe reoorted in the table.

Aminophvllinein PrehospitalGare 83

/ EmergencyDepartment'HighlandGeneralHospital' PM Freitas Oakland.California patrents Aminophylline is used in the prehospitaltreatment ot *lth ,tth-, and COPD. There has been considerablecontrover"t. of aminophvlline in patients alreadv,using ;;;;;il;t,ti. aminophvllirie pr.par"tions. Aminophylline Ievelswere collected of 53 ambulince patients.presentingwith i" ,'iiit""p".ir;;;',;Jt patio.r.t o"o.rrtriction. A control population of 34 ambulance in pail.-",t *"i identiiied. IV aminophylline is usually used of patients ii"r,,,s *or. than 40 years old. Inthis age grottp,.44o/o at time of iie;i 3al were already itt"tit 6t Io*iC levels has been previouslv.rehiSher-th^an is rig"t. iitli ;.;;;#"". oorted for ED patrents.A stand"ard250 mg doseof aminophylline an;;;iJ;;,4'; Lio oi so) of patients into a toxic range-with

Evaluative utmenston t t)

reduced ;ffi;4'4% ii;Ji ti u.i"g itt"'.p.utic'-The-susgested of36)of the a"i"g. .r izb *g oi "*i""p'r,vrri"Jwouldput25,%-(9 being D a t l e n t sr n t o x l c , " t t g . * i . h a n o t h e r 3 6 % ( 1 3 o f 3 6 1 emergency the in aminophylline of The efficicy i1t.i"o.",i.. "t Lio".tto"o"ttriction has teen questioned With.a ii."iti,."i amlhieh probability of making patients toxic, -the role ot ".'prrviil* in prehospitalcaie-shouldbe reevaluated'

inthe 4 b[il'i:3il:T?'"1!]:'#"#etrv 8 Slee, SM Joyce,R Dart,HW Meislin/ Sectionof Emergency

Eva uator (2) Score (3)

1 Case management eP Faveragescore ( r a n g e ,1 - 5 )

3 194 3 551

2 Case management BP FE porlronol managed cases Score = 1

0 901= 0 0162

3 Protocolcompliance 99-----jiq9 FE a v e r a g es c o r e S c a l e( 1 ' 5 )

Medicine,Ariiona HealthSciencesCenter,Tucson do not Routrne vital signs in the prehospitalcare environment of means clinical usual The -a"ar,t"-tttt' include temperature temDeratureestimation - feeling the patient's skin, observation of aT"phot..i. or shivering- is unreliable -lvlanytherapeuticmaas Jefibriliation, have an altered response.inthe ;;;;;";,-;;;h hyperthermic patient Therefore, it- mav be imi;;;;;h;';t;;r p6i ""iittr, all p#ents undergo temperaturerecordingas a rouiine vital sig., measrrrementin the prelospital setting' T\: liqilq usecl crystal therinometer (LCT) has been shown.tole an easily andreliableindicatorofcoretemperatuleinEDandopelating


#ol Regresslon Paramedic Pairsin LOWESI Coeiticient 2O7" (5) P= 0.0s(4) 2 s7'

- - ^ 25 -

-0 0246 _+_

---G-1 9 J4t4

00047 BP 4 Proportionot nonFtr-------615justilieddevrations from Protocol 'signiticantat the 95% conlidencelevel

Not available


#al Nlatched Pairs(6) 12




evaluThe relationship between the FE and BP scores has been co",.a Uu-ri ltt. value and significanceof the-linear regression +i ,"a bvil the number of mat-ch!4 pairs at thâ&#x201A;Ź .ir*i"i,l';"i"-" pat"-.di" work{orce (column 6)' The data indii;;;ot;;ilh; cate that one Sroup'sscore is not a good predictor of the second ihi, obt"*"tion raisei thelollowing questions:l) ;;;;;a;";';. --",noaotogy reflecting.the sutiective evaluai; ;'.".ttl;;rfi the ilon within eacligroup?;2) lifat is the relationship between


two group's subiective evaluation?, and 3) which group,s cvalua_ tion better reflects the true measure of the parame?ics,skillsl To answer,these questions, we surveyed the sublective oprnions ol tne evaluators about the top and bottom 20% oI the paramedic

*d comparedthe subjectiverankingof .".f, l.o"p Tfll3^,1",_l wrth.ranklng obtained

from the evaluation. In addition, the"relal the rankrng.from the evaluatio" aai, a"a ifr. *.u.y i^":.[.-,I.:" compared to. the ranking obtained from analysis of an lil-. :..n o,Dtectrve rankrng based on patient outcome data. The results of tnese compansons will be reported, and conclusions about the utility of this evaluation systam wiil be presented.

8 6 *l'si;Jj fl:.Jfi?:""arsarisfaction TW Whitley, DA

Revicki,EJ Allison,SS Landjs/ Deparrments ot EmergencyMedicineand FamilyMedrcine,fasiClror,na University Schoolof Medjcine,Greenville, NorthCLiotina R t ' l a t i o n s h i p sa m o n g d e m o g r a p h i cv a r i a b l e s ,w o r k charac:Ti::1:1 ::cupa,tiona]Jress, and mentat health were rnvestigat_ of 135 emergencymedical technicians iEMis). li.:t^tlj:,-rl-ple rne samplcwas drawn from rescuesquadsand emergency medical servicesproviding prehospital-"ai.rilr..-ln a rural area encompasslllg29 counties. A survey was administerecl to collect aboursupervisorbchavior,work grouprclations,task :ll:,rla,!ron family-social job satisJ:1:,ambtSy'ly, i_upport,locus of crin11s1, as welt as dcmographicdata. Thc sample :1::i:,1,ill.$.pression, ,y comprisedrnal'Iied(74%) white 194%lmcn (756/.1, l:..1"T"-ri wltn an averagcagc ol 33 y (,rengg,19-67y). The majority hai attaineda high school degree(527").Fifty_four p.i"..r, werc ccr_ tified as basic level EMTs, antl the iemainrng qiii'*"r" certific<i a t t h c i n t c r m c d i a t el c v c l . T h c a v e r a g cl e " i t h - o f s e r v i c ca s a n y:,t 4.7 y. The occupational,tr"., ,rb.."i.s, .J,r"ngagcm..,t ll] = .5fJl, coworkcrrclationsft =..49.1, lr and productivltylr = .e), wcre corrclatcdsignificantlywith depression. Thc mcasur"s .rl job -.2t), life . 3 3 ) , s a t i s f a c t i o {nr : i : , I . r t ^ " , : 1 - o , g u- i t y l r .;, 39)' familv-socialsupportlr - - 42),and in{t.= :l::li:uo" ,",r:.,u"ot control lr : -.36) were correiatedsignificantly :.:',t1 wltn, the dcpressionscale. The job satisfaction measure was re_ jl::: :l8jllf:^ntly to .the occupationalstressmeasures,super_ vrsorbchavtorlr - .57),task-rolcambiguity = 1r .461,and work H r o u pt u n c t r o n l n gl r = . 6 1 ) .T h c r e s u r t ss u g g e s t h a t i n c r e a s e d w ( ) r Kg r o u p c o h e s i v e n e s sa n d c l e a r c o m m u n i c a t i o n b e t w c c n EMTsand their supervisors lead to l".r"rr"Jlob,rtistaction and decreased depression.



Riskin urbanEMS

ll PeOe,CL Troisi,D Heiberg,FB Holhnger/ Departments of and Virotosyand E[ioemiotogylaayror'b;irese or l/:91:i!: rvreorone: Urtyot HoustonEmergencyMedicaland Trauma Services, Houston Because,thecity of Houston has large populations of groups ,known to be at high risk for hepatitis n iirus lUnVl infection and an,extremelyhigh .trauma, continually "6;ri;; EMSpersonnelto infected blood, we ,o"gfr, t" a.,ermine the prevalenceof HBV infection in the city,s e"MSp.rro"".l. "*e.. Of the firefighters assignedto th; EMS, J'44 surv.y.d ilO^l^"-:l:l questronnalre, Dy and a blood specimenwas obtained.Each sam-

by RIA or ErAfor r,.priiitr"n ""tibody(anii $:_Xr: r t , , r v l ; n patrtrs ts suriace antigen iHBsAg) and antibodies to

,lg j^o hepatitis.B core#tigen {antr_HBc). or

rLltlntllll:ts'), ne,J44partrcrpants {279 white and 65 nonwhile), all but I were ""o the average yag 29.5 years ftange, 22_57). The anti_ Tll:, lgs nnv prevalence was 16% ll2!" in whites and B5To in nonwhites; P,< .0001).Anti-HAV prevalence *"".ig"rt"rri,lv frigt., in older, white EMS personnel, but was not coirelated witht years of oc_ cupational exposure. Six HBsAg-vaccinated sublects were excluded from H-BV analysis. oi thJs3S""".j .?"f"r,ed for HB

seromarkers, O.6"/" were acutely positive for HBsAg/anti_HBc; 6.8"k werc anti-HBs/anti-HBc positive; 0.9"/o were posltive for anti-HBc aione; and 4.7% of the sera contained only anti_HBs. The 25 individuals 17.4"/") whose sera contained antr-HBc were classrtled as cases of HBV infection._A strong correlation (p < .004) was observed between the prevalence of ftBV infection and of work exposure in the white EMS personnel regardless of ,u-:rt: loD oesc-rrptron (paramedic vs EMT). A similar trend wis seen in tlvls sublects. To exclude a cohort effect based on age, a _Drack Mantel-Haenzel chi-square analysis confirmed the increased risk wltn occupatronal _cxposure in the white, group. A history of hep_ atrtrs. was reported hy 19 persons, lZ of whom had evidence i{ past rnrecrlon lirth HAV (63%l or HBV (37%1. We conclude that Llvl5 persunllel arc at increased risk of hepatitis B intcction. Im_ munization is recommended.


Gomparison of Supraclavicular and lnfraclavicular Approachs for Subclavian Gatheterization

SP Sternel DW Plummer,JE.Clinton/ Departmentof Emergency Medicine,HennepinCountyMedicalCenier,Mrnneapotrs Thc relativc efficacy.oI subclavianvein catheterrzation by the supraclavicularor infraclavicular approachhrs .rot been ad_ dressedin a prospective,randomizedtrit l"". ffri, study was designed to do so in thc emergencysituation. A series of 409 ED subclavian vein catheterization was prospec_ f,i:li:,: i l v er y r a1-.griring n d o m r z c di n t o I o f 2 g r o u p s ,s u p r a c l a v i c u l aori i n _ fraclavicular.When cannulatio.r'wrs li"."i..r.f"f fo, tfr-. ,fp r o a c h d c s i g n a t c db y r a n d o m i z a t i o n , c a n n u l a t r o n via the altcrnateapproachwas attempted.positionof the central venous linc was vcrificd by chest radiographi" gl.q;),-oI cascs.Com_ pneumothorax,arterial puncture, hematoma, llt:,i:l:,it_t".rydcd or KrnKlngsutttclent_to preventpassage of a pacemakerlead.Rano.omlzatlonproduced202 in the supraclaviculargroup and 207 in the,infraclaviculargroup. Twenty_sevenf;i;;; Ttz ey"l occurred grou& w_ith2 malpositionsand 3 complica_ :l^:1" trons..Forty-three lailureslZO.7%)occurredin the infraclavicular g,r^olplwith l7 malpositions and 7 com,plications.ft. .o-ptl"rtron rate was I.5% for the supraclavicularapproach and,B.4il, Iir approach Statistica| ."; ;;;';;;;ea Ied t he onii :ljf":] olrtcrcnccbctwccnthe study groupsto be the higher incidenccof malposition with the inJraclavicularupp.o".h .001).When cannulation by the randomized approachfallejl7-< (ZO"as.s), c".r_ nulation by the alternat" "ppro"ih'*", ,u....rf,rl in all but 2 cases,rcsulting in an overall Cannulation rateof 99.So/o. A signifi_ cantly higher rate of malposition occurs with the infracravicular approachto subclavian_veincannulation. Safety of tfr. Z "p_ proachesis comparable.Failure of r ,nprorll *iii'U" fofio*.aTy successof o.the1.The emcrgencyphysician,sarmamentarrum s n o u t dl n c,th9 t u d cb o t h a p p r o a c h e s .

f|q ryv _

Subclavian Gatheterization in the Emelgency Department: A study of Two Techniques

DE Culhane, KnoOl / Departmentof Emergency !B ,S-chuO, Medicine,ValleyMedical[K Center,'Fresno, C"f,torniu Cuidewire cathetershave been used with increasing frequency last severalyears {or pl;.;;;.;-;il.r,t.rt venous flurinq1h1 rtnes.l\o oata exrst comparing successand complication rates of guidewire {GW) and nonguidewire UVCW)-"rtii.Ierization in the y set trng.^A_ :T^.-19,.1. -prospective,randomized rt.rdy *r, .orr_ p:,::,,o compare,CW and NGW central venouscatheterization Dy tne tLvLl subclavianapproach.The study populationconsist_ ed of 2t0 p_atients(82.trauma, rza mediJ) ;;qffi;; cvC as part ot therr ED care.Catheter placement and complicaiions were de_ termined_byimmediate chest radiograpt, t*o_'ary follo*_.rp, "nd review after discharge.The GW ".ri NGW gro"p. *.r" similar

with respectto patient age, systolic blood pressureand pulse at time of IJVC, presentingcondition, and indication for catheteri,"iior-r. S..c".siful catheterization rates by the subclavianroute *.i. p+.t lI3 (83%){or the GW cathetersandT2oI 97 174%l,Ior ttr" NCW catheters lxz:2.53iP =.11).Pneumothoraxoccurredin 3 GW and 2 NGW patients lvz=.09;P :'77)' Arterial puncture 14)patients Extraoccurre<lin 5 GW rttd t NCW lfl:2.l6iP: ihoi".i. catheter placement occurred in 8 GW and I NGW comlxl:4.02;P -.04) patients. There were no other immediate fii"",io"! en"ou.rteredthat coultl be associatedwith CVC' This ii"Jv r"gg"t,t a tendency,not statistically signi{icant, toward an incrcasediuccess rate using guidewire catheters ln addition, it J"-onr,rr,", a higher t"te o{ io-. complicationswith guidewire catheterscomparedto the nonguidewire catheter'

Gentralr and

ol Intraosseousr Periiheral Routes of Administration of 90 Gomparison Sodium Bicarbonate During CPR in Pigs

WH Spivey, D Malone, HD Unger, S Bhat, RN McNamara, J SchofJstaltN , T u m e r ,C M L a t h e r s / D e p a r t m e n t s o f E m e r g e n c y Medicine and Pharmacology,Medical College of Pennsylvanla' Phrladelphia peTo administer NaHCO.3 during cardiac arrcst, a ccntral or IV must be established.-This is often difficult and time .iph.J cJnsuming, especially in children. One method of drug administration ilrt i"t been examined in recent years is the intrao.r"o..t route. It has been proposed for use in shock and cardiac "ii.rt, ho*"u"r, no studies in ihe cardiac arrest model have been to date. This study compared the intraosseous route of "*"-i.r..l durNaHCO3 administration wiih cenlral and peripheral routes ins cardiac arrest. Fifteen male pigs (15-25 kg) were anesthetized )0 mgi kg IM and alpha-chloralose 25 mg/kg I! *lih k"tr-in" into 4 g,roups. They were.mechanically ventidivi<led and were l"i"a, ,"a their femoral aiterils were cannulatcd for sampling of blood gases every 2 minutes after arrest' Ventricular fibrillation *os l.tiuc.d with an intracardiac pacing electrode at time 0' 9PR was bcgun 5 minutes later with a Michigan Instruments mecnanical resuscitator. NaHCO. (l mg/kg) was administered l0 min,-,1"r ,tr.. arrest through a peripheral IV (n:4), internal iugular central IV (n=3), or iniraosseoui with an l8-gauge.spinal needlc in thc tibia (n'--4). Control animals (n:a) did not receive 4 N"HCO.. Data were analyzed using an analysis of variance All groups exhibited comparable pH values 17 40-7'441 prror to any e*peiimetttal interveniion. Al1 groups demonstrated a respiratory "llialosis that peaked at I0 minutes between 7 48 and 7 '56 after [.i"g pf"."a on the mechanical resuscitator' NaHCO.3 was-then peadministered at minute 10. TWo minutes late1, the central, ripheral, and intraosseous routes demonstrated a mean pH oI7 '74 : t O . 2 8 , 7 . 6 4 + 0 . 1 9 , a n d 7 . 7 1 ! O . O 4 ,r e s p e c t i v e l y ( P < 0 5 J T h e + 0'll The pH value in the control animals was 7 39 "o-pri"bl" in the n"ak"d "t 7.(t4 :t: O.l9 2 minutes post-NaHCO3 infusion pcripheral group and ^t 7.74 + 0.28 in the central group lt p"ri.d ^t )'.8q + 0.ll at 8 minutes postinfusion in the intraLr..or.. group. The intraosseous and central routes were signifi4 .r"iiy gt".rt.t (P < .05) than the peripheral.route and control and throughout the.rerni.trrtei a{ter NaHCOe administiation maindcr of the experiment (20 minutes). Despite reports that blood flow is greatist in the upper extremities during CPR, we that NaHCCi3 infused into the tibia rapidly ttru. a"-ott..iated elevates and maintains an elevated pH. The intraosseous route appears to be a rapid and safe method of administering NaHCO3 during cardiac arrest.

rfta Y I

of Tiaumatic pneumothoraxis a frequent medical.complication "pocket shot" (using fV diug ,busers in Detroit who utilize the patients ih" ".Jtt"t approachto the internal jugular vein).Thirty who sustained a total of 39 traumatic pneumothoraceslseverar I recurrent) were retrospectivelyreviewed' Of these, there was l.pneumomediastiand hemothoraces, 3 pneumothorax, i;;;i;; num. The iniection habits, site of iniection, and presentingsymptoms, as weli as the size of the pneumothorax,treatment, assocrated complications, and follow-up were-reviewed' The sizes tr"g"d ftd- tO% - 100% using siandardized measuring landmriks and nomogram. Of the 39 presentationsof pneumoittor"".t, 2l were lEft-sicted,12 were right-sided,and 6 were bilat.^J-Oi att..., 12 underwent catheter aspiration of their simple or-r.urnothorr*(CASP)[2 bilateral); 27 undcrwent tubc thorareflect 3 i...*v i+ uiLatlrall; and 3 were observed'These figures CASP faiiures that went on to have thoracostomy tubes placed' ihrce patients underwent tetracycline sclerosing therapy' Pa;;;i; ;i,t successfulCASP were observedfor 6 hours in the ED ,r-rd.*bt"qr,"t-ttly {ollowed as outpatientswithout cornplications' CeSn "pp.rtt to b. , safe, efficacious,and-cost-effectivetreat-"tti i"'tt-t. drug abuserpopulation studied Wrth the pressuresof cost containmJnt, this leis invasive approach with outpatient shouid be consideredas primary treatment for sim*4""*.-.", plc prieumothorax.





to Rapid

MAsr Deflation

MR Geer / Departmentof Emergencyand Ambulatory Wn Sicl<ett, Medicineand CardiologyService,BrookeArmy MedicalCenter' Fort Sam Houston,Texas Irreversible hypotension with subsequentcardiovascularcollapse has been ieported as a catastrophicco^mplicationof inappr'opriatcmilitary antishock trouser (MAST) deflation' This clinical investigation was performed to study the mechanism by which rapid td,tSf d.fl"iion produces frYPotension'Five normovolemlc human volunteeri previously sele-ctedfor cardiac catheterizationwere involved in the study' Right and left heart "rthet"ri"rtion with multisensor catheterswas per{ormed External counterpressurewith fobst gladiator MAST was applied sequentiallyup to a maximum of tbOmm Hg, with.a total inflation The MAST was rapidly deflated with serial il;;;l-l'0ii"","t. of the following parameters:mean right-atrial -.r."i.-.",s p..r.rrr" (RAm); mean pulmonary irtery pressure(PAm);left venend diastolic it"ttrrt. iLVEDP);and mean arterial pres[.*il sure (MAP). Comparisonof the-predellationand postdeflationhet"tited in the foliowing observations:a significant -.iv""rnlit decreascin MAP of 37 mm Hg (P < 0l), in conjunction with a ,i-..t*'1"o"'significantdecre"aseinrightandleftheartfilling pressures(ie, deireasein RAm, PAm, and LVEDP oI 8l%' 58%' ;;;81"/"'t" {P <.0ll Analvsisof simultaneousright and le{t pressuresusing'multisensorcathetersdemonstratedthat the fall in MAP pr...?.. the decreasein right and left filling is that the initia.lhypotensiveresponse pressurcs, thus suggesting ie"orrdrry to ^n ^iut. deireasein peripheralvascularresistance' ata



ol Efficacy

of Naloione

in a

Fixed.Volume Hemorhage llodel

SC Dronen,R Foutch,PA Manrngas/ DepartmentolEmergency of Cincinnati;Department01tmergency Medicine,University Medicine,FortRiley,Kansas;Divisionof CombatCasualtyCare' LettermanArmy InstituteResearch,San Francisco Animal studies using a teservoir model of hemorrhagicshock have shown the narcot-icantagonist naloxone-to be ol value in the cardiovascularei{ects of severehemorrhage'This i*.tti"g ""tri.te tiudy was undertaken to evaluate naloxone's e{{icacyin a f*;a-;"I"rn" hemorrhagemodel. Fifteen mongrel.dogswere bled 50% of their estimated-bloodvolumes over one hour' This was icrllow.d by a l-hour stabilization period; reinfusion over a 30-

Alternate Therapy for Traumatic Pneumothorax in "Pocket Shooters"

GB Martin' K Wisdom,RM Nowak,HH Richardson, / Departmentof EmergencyMedicine'Henry MC Tomlanovich Ford Hospital,Detroit



periodr and {inally an additional one-hourmonitoring peTit]"19 riod. Eight dogs,received2 mg/kg IV naloxone 30 minutes pnor to hemorrhage and 2 mg/kg/hr for-the duration o{ the study. Seven control dogs received an equivalent volume of saline without naloxone. Pulmonary capillary wedge pressure, central venous pressure, cardiac output, heart rate, and blood pressure were measuredat 19 intervals throughout the study peiiod. arterial pressure,cardiac index, and systemic vascular resistance were calculatedfor each sampling period. With an isolated exception, there were no significant differences between the narcan and control groups in the mean values calculatedfor each sampling interval {P < .05, two-tailed independent t test). Furthermore, the_changes in hemodynamic parimeters observed during both.the .lremorrhageand stabilization periods were not signifi: cantly dif{erent. Mortality was 2SToin the narcan group versus 0% in the controls. We conclude that in this fixed-volume hemorrhagemodel naloxone does not reversecardiovasculardeterioration. Ef{ects shown in prior studies may reflect the use o{ a model less clinically relevant than that used in this studv.

OA .r-

Empiric Development of a prehospital Approach to ilultiple Victims

BE Haynes,RD Dahlen,FD Pratt/ Departmentof Emergency Medicine,Harbor-UCLA MedicalCenter,Torrance,California' . Most prehospital systems have well-developed protocols for single-victimrescuesand the EMS responseto mass casualtydisasters.Multiple-victim incidents falling between single victims and masscasualtiesin scopehave not beenanalyzediri detail. We reviewed 4I audio tapes bf incidents with 4 b, -or. vrctrms {meannumber of victims:4.9). Two emergencyphysicians and one paramedicliaison nurse critically evaluatedeach tape,listing managementdecisionsthat made the run flow more quicklv and sm.oothly,and tabul.atedproblemsand errors.The moit "o*-o., Ireld errorswere lailing to control the situation by gatheringcasualtleslnto_a compact area and transporting stable victims to a hospitalbeforethe basehospital couldtriage patients. Field physical examinationswere frequently reportA in too much detail, but lung sounds often weie omitted. Confusion during radio transmissionsarose from trouble identifying specific pa1i".rts, overly_detailedindividual reports, and unnecEssarycommunication,of.vital signs. Base hospital errors included iequestrng too much information -from paramedics and requiring transmission of unneededECC rhythm strips. paramedics-shouldcontact base hospitalsearly during multiple victim rescues,giving the base t h e i r l o c a t i o n a n d p o s s i b l ed e s t i n a t i o n s .T h e l n c i d ' e n t c o m _ mandermust consolidatevictims at the sceneand avoid relocating the accident to one ED by uncontrolled load-and-go.Radio transmissionsare most useful in assuring balancedpaiient dis_ tribu-tion, matching the infured to the hoJpitals best able to care tor them. In jurisdictions in which specific orders are required, basehopitals sho,uldgive ,,blanket,,patient care orders, concentrate on patient disp-osition, and avoid requesting detailed information on individual patients. These middle-rangi incidents pro_ vrdean opportunity to test EMS responseto large-scaleincidents, including mass casualty disasters.

(|E atg

Eyaluation ol Major Trauma Gare in a Seyen.Gounty llorthern California

EMS Region RM Riner,W Teufel/ Alpine, Mother Lode, San Joaquin EMS Agencyand Doctors Medical Center,Modesto,Caliiornia The authors conducted a 2-part study of 627 casesof maior trauma -occurringfrom fuly 1980 to fune lggl in the Alpine, Mother Lod.e,San foaquin EMS region. part I, a nonphysicianreview of medical records in 25 hospitals, identified the itudy population, examined perrinent patie;t demographics,ana aevet6pJa Das.elrne data using selected cdteria for subsequent nonphysician audit of trauma care in the region. part II was a physician evaluaaa J I

tion of the medical records and autopsy findings of the 163 patients whose injuries were fatal. It was designed to ascertarn whether the institution of a regional system ;f critical-trauma care commensurate with American College o{ Surgeons Level II Tiauma Center standards might have a favorable impact on morbidity and mortality from malor trauma in the resion. part I identified areas in the region with a larger-than-expecled incidence o{ penetrating trauma, a significant delay in the transfer of nonCNS cases, a S-hour or more interval from patient arrival to transfusion in 40% of the cases, a lack of good documentation of field care in the medical record, a time-atlscene of more than 20 min in more than a third o{ cases, and a death rute o[ Z6yo rn the study population. In Part II, 104 medical records of fatalities were evaluated independently by an emergency physician and a surgeon. The cases were divided into ,,urban triuma,, or ,,rural trauma," "transferred" or nontransferred,,, and ,,CNS death,, or ,,nonCNS-death" groups for analysis of the incidence oI 24 possible deficiencies- in_system organization, provider judgment, and resource availability. The study identified 20 patients ll9.Z%l who were considered "potentially salvageable,,had they been managed ln a trauma care system providing care at ACS Level II Tiauma Center standards. A number of these patients were elderly trauma victims. The most frequent deficiency identified in the study was "delayed or inadequate transfusion,,T and a number o{ deficiencies in care were identified in both potentially salvageable and nonsalvageable patients that could as indicat6rs o{ problems in trauma care management. In an independent review of all 104 cases/ the authors found only 2 cases in.which survival would have depended on surgeon availability in the ED on arrival of the patient; and in both cases transport iime was greater than 15 min.

(|1Q -rL

Special Event iledical Care: The i9g4 Los Angele$ Summer Olympics

WM Baker,BM Simone,JT Niemann,A Dalv/ Deoartmentof EmergencyMedicine,Harbor-UCLA MedicaiCenter,Torrance, California; Departmentof HealthServices,Los AngelesOlympic OrganizingCommittee Anticipating and meeting the health care needs o{ ,,well oersons" attendingor participatingin major athletic, social,or political events is and will continue to be a concern of event organizers.The anticipatedspectrumof requiredmedical ""r. ,t ,.rih eventsis at presentvariableand unpredictable;it crossesthe turf of severalmedical specialties,and medical needsfor such gatherings have not been thoroughly assessedor well-formulatei. The purposeof this study was to review the spectrum of medical illnessesencounteredby health care providersat the maior venues of the 1984Summer Olympics, to determine the utilization pat_ terns of availableservices,and to assessthe role that physicians and other providershave in specialevent mass medicai care.Recordedmedical careprovided at Olympic venueswith a spectator capacity.of 10,000or more {9 of 28 competitive sites) wis retrospectivelyreviewed.Total attendanceat lhese sites during the 15 9_"f1 o{ comperition was 3,447,8O7.Of this populatiori, 5,518 lO.l6y"l were evaluated onsite by advancedmedical personnel {RNs or MDs). Only 3l% requiredphysician evaluation.The maior complaints (recordedusing ICD code)encounteredby physicians were musculoskeletal injury (21%),minor dermal injury {157o),heat-relatedillness lll%1, and minor GI complaints (g%j. OnIy-Z% presented with symptoms of cardiac diseaseand only 9 p^eople.requiredphysician care for alcohol or drug ingestion. Only 100 individuals were referredto hospitals for fuithei evaluationT carei 3lo/o of referrals were {or musculoskeletal iniurv and 2O% were for suspectedcardiac disease.Utilization rates lnumber of patient ylsits pe1 1,000 in attendanceat each site) rangedfrom "higher 0.68-to 6.80,with a mean of 1.60,and were significantly at outdoor events (P : .O24| We conclude that the maioritv o-imedproblems ical likely to be encounteredat maior sports eventsare most likely to be musculoskeletal,cutaneous,or of ,,environmen-

tal" nature, that signi{icant complaints warranting physician evaiuation are most likely to be encountered at outdoor events; that the majority of medical problems encountered in this study were manag'ed by appropriately trained and experienced nonphysician health care providers (in a nonvolunteer setting, this observation should be considered in the assessment of cost-ef{ectiveness); and that many injuries/illnesses could be prevented (eg, heat illness) by lay education and awareness.


RD Stewart, MJ Gorayeb, GH Pelton / The Center for Emergency Medicine and the Departments of Medicine and Anesthesiology/ C r i t i c a i C a r e 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 h , P i t t s b u r g h The usc of nitrous oxide as an anesthetic or analgesic agent {requently raiscs concerns about the possibility of postinhalational di{fusion hypoxemra. With the increasrng usc o{ a mixture of 50% nitrous oxidc - 50% oxygen in emergency medicine, this qucstion is o{ importance to emergency physicians. We undertook a study in 20 healthy adult male voluntecrs to determine whether hypoxemia occurs a{tcr the self-administration by face mask of a 50:50 mixture of nitrous oxidc and oxygcn. An indwclling intraarterial cannula was placcd in thc radial artery of cach subject, and blood gases were mcasurcd bcforc, during and after inhalation of thc mixturc. As a control group, 10 of thcsc subjccts additionally were made to breathc a 50% mixturc of nrtrogcn and oxygen. Baseline blood gascs on room air werc measurcd at time zero. Inhalation of eithcr gas mixture took placc for thc ncxt l5 minutes, with blood gas measurements at times 5, 10, a r - r dl 5 m i n u t e s . A l l s u b j e c t s w e r e t h e n i m m e d i a t e l y m a d e t o breathc room air, with blood gas measurements at 15.5, 16.25, 17.5,20, and 25 minutcs. Thc rcsults rcvcalcd that thc avcragc PaO2 of the nitrous oxidc group was well wrthin two standard deviations ol the control (N2/O2) group at all timcs aftcr timc z c r o ( T h b l e 1 ) ( u s i n g t t e s t w i t h p o o l e d v a r r a n c c s ) .A l s o , c o m p a r i n g a v e r a g e P a O 2 p o s t - N 2 O i n h a l a t i o n w i t h a v c r a g c P a C ) 2p r c N2O inhalation {with cach subjcct scrving as his own control}, wc wcrc unablc to dctcct any significant drop in thc avcragc PaO2 from basclinc values (using paired t test) (Thble 2). ln fact, at t i m c s 1 5 . 5 a n d 1 6 . 2 5 m i n u t e s , t h c a v e r a g cP a O 2 w a s s i g n r f i c a n t l y g r c a t c r t h a r - ra t t i m c z e r o ( P < . 0 1 ) . T h i s s u g g c s t st h a t a s i g n i f i c a n t d r o p i n P a C ) 2d o c s n o t o c c u r w i t h i n t h e f i r s t 1 0 m i n u t c s o f breathing room air aftcr breathing a 50:50 mixture of nitrous oxi t l e- o x y g c n f t r r l 5 m i n u t c s .

Microcomputer.Based Anticipatory Ambulance Deployment Strategy in a Large Urban EMS System

JL Ryan, J Overton, M Wozmak, TF Smith / Department of Emergency Medicine, Truman Medical Center; Metropolitan Ambulance Services Trust;CWI Business Systems, Kansas Crty, Missouri Metropolitan Ambulance Services Trust (MAST) was created by the city council o{ Kansas City, Missouri, in 1979 in thc public intcrest to ensure timely and competent delivery of prchospital care to the citizens. City ordinance requires in part that the provider achieve time-related criteria in response to requests for emergency services. Specifically, an B-minute response time must bc attained tn 9O% of liie-threatening emergencies. Failure to comply is associated with fines and potential breach of contract by the provider. The implementation of a strategy for anticipatory ambulancc deployment has allowed the provider to attain this goal in a cost-effective manner. Known as "system Status Management,/' the plan allows paramedic dispatchers to develop, implcment, and change the geographic locations of advanced lifc support units in the field based on current care demands and the historical likelihood of need for service. This microcomputerbased tool allows immediate rccognition of citywide emcrgency carc capability, makes recommendations for optimum current deployment, records response time parameters for current service, and alcrts the dispatcher to deviations from response criteria. Since implcmentation of this management tool in 1982, the provider has consistently attained the ordinance criteria for response time and has done so with a decreased utilization of ambulance unit hours.

(|a ar|9





1 5 . 5 1 62 5 1 75



Cont PaO2 87.69 222 7 2 3 9 . 8 2 3 9 1 1 7 41 1 1 07 9 5 1 3 8 7 1 9 9 7 1 3


Effect of Technique of Administration on the Endotracheal Absorption of Lidocaine

N2O PaO2 Baselne PaO, P Vaue

SE Mace / Department of Emergency Medicrne, Mt Sinai Medical Center,Cleveland This study was undertaken to determine the optimal technique for the administration of lidocaine by the endotracheal (ET) route. Eight healthy adult mongrel dogs were anesthetized using IV sodium pentobarbital. Each dog was then intubated with an ET tube. Lidocaine was given at a constant dose through the ET tubc as a bolus and with several varrations: with dilution' bv flushing of the lidocaine with normal saline; or by varying the size of the tube or needle through which the lidocaine was given. Blood ievels of lidocarne were drawn at sequential time intervals i5, 15, 30, and 60 minutes after administration of ET lidocaineJ. At all 4 time intervals, higher blood levels of lidocaine were attained by giving lidocaine as a dilution or by flushing of the ET tube with normal saline. Blood levels were less than 2 pglml and not detectable by one-half hour in one group. The other group of dogs attained blood levels greater than 2 pglml, with a maximum of 6.6 pg/mL, and maintained higher levels for a longer period of time {eg, up to I hour). These findings indicate that simple variations in the technique of administration o{ ET lidocaine can maximize blood levels of the drue.



NrO PaO,, 96.94 242.5 2 5 6 . 5 2 3 7 1 1 6 8 3 1 2 8 . 8 9 8 5 4 9 8 . 1 41 0 11

tf, 3

t 6 B3 969 <0.01



1 2 8I 969 <0.01

98.5 96.9 >0 80

20 981 96 9 >0.90

25 101.1 969 >0.50

Fo"owins 1 0 0 s,TiHll""1'fr?ll"lil*

Administration in Human Volunteers PM Paris,RM Kaplan,RD Stewart,LD Weiss/ The University of PittsburghAffiliatedResidencyin EmergencyMedicine;The Centerfor EmergencyMedicine,Departmentof Emergency Medicine,Mercy Hospitalof Pittsburgh;Departments of Medicine and Anesthesiology/Critical Care Medicine,University of PittsburghSchoolof Medicine,Pittsburgh Methemoglobin, hemoglobin with iron in the oxidized (ferric) state, is incapable of transporting oxygen or carbon dioxide. While normally present in the body in levels of less than l%, increasedlevels of methemoglobin may result from overdosesof many drugs or by idiosyncratic reactions from drugs in normal dose; tissue hypoxia may occur. The nitrates have been rmplicated as one of the maior classesof chemicalscausing this reaction. The current medical therapy of pulmonary edemaand myocardial ischemia uses much higher doses than previously of sublingual and IV nitroglycerin. The risk of increasedlevels of methemoglobin in patients so treated should there{orebe greater. We determined levels of methemoglobin in a group of young,

Determination of Arterial Blood Gases Before, During, and After Nitrous Oxide: Oxygen Administration



healthy volunteersfollowing the administration of 4.g ms of ni_ trogiyceringiven over 25 minutes (12 sublingual ,"lf.iE, .r.-f. containing -gt. Elevenmale volunteers"g.i t9_3gy."r, took 91 o.suDrlngual dosesof 0.8 mg (2 tablets)every 5 minutes. Venous blood was.drawn_byheparii iock at 0'and 5 -i.rrrt.., and then every 5 minutes for I hour after the 3-minute sample.Bradycar_ dia and hypotensionin I subject necessitatedhii withdrawal from the protocol. The highest methe-oglobin f*.t ".t i"u.a Uf any subjectwas 1.6%.The results,rrgg"".tthat higher dores i nitroglycerincan be administeredwitlout unduJelevation of methemoglobtnlevels. Idiosyncratic reactions -ry trol""u.i, o"_ yhi.h^.nzyme.deficiency can lead to abnormal sensitivity :_u1,r" to thc_drug. Our results.also would suggestthat nitroglycerin is of little the_prehospitalor hosiital ,.."i-..r. "of cyanide in which the goal is to raisJ quickly methemo;lobin l9"l:try revels.

llit1,:ffi E",liffi :,::T I O1 i"'l:T"?:3ff

S Abbuhl, S Jacobson, JG-Murphy G Gibson / Emergency S e r v i c e sD e p a r t m e n t a n d p h a r m a c y a n d D r u g I n f o r m a t i o n S e r v i c e , H o s p i t a i o f t h e U n i v e r s i t y o f e e n n s y t v " a n i ap, h i i a d e l p h i a We coqrpared mcan serum concentrations of meperidine in s i c k l e c e l l p a t i e n t s i n c r i s i s ( S S )a n d c o n t r o l p a t i e n t s ( C O N ) re_ cciving_meperidine prior to incision and drainage of abscesses. trght SS and 5 CON patients without confounding illnesses cons e n t c d ,r o p a r t i c i p a t e. T h e y r e c e i v e d 1 0 0 m g o f m e p c r i d i n e in thc o c l r o r d o r g . t u t c a lm u s c l e . f o r p a i n . I n d u r a t i o n t h a t m i g h t interfere with the medication,s abso_rption was assessed *itf; ."rp""i-io oI each injection. Blood samples were drawn at baseline, llc ' / u , :it9 1 , l t / t , a n d 2 h postiniection. Serum samples were coded l,.Y:, and blrndedj gas-liquid chromatography was used to quantify meperidine levels. In the SS group,- mean peak concentration of meperidine was 0.324 t .08 pg,/ml ,t ,r, ,u"rrg. of 0.5 + 0.07 h postiniection. Among CON, mean peak concen"tra1on was 0.727 + 0.37 pg/ml at an average of 0.6 * 0.ll h. The difference in peak concentrations of meperidine was signific.antfy aiff..."t 1i = 2.96; df : ll; p < .0I); the difference in imes to peaks was not s r g , n l t l c a n t{ t = 0 . 6 5 ) . D r f f e r e n c e s b e t w e e n g r o u p s f o r s e r u m con_ wcrc significantly different botliat,,.r h lp < .00t)and :at: l , l r : i g " . t I h 11'< .051,Changes within each group between /z h and I h were not significant (p > .30). presencdof induration at the iniec_ tion sire was more frequent among SS than CON, but the Jif_ terencewas not statistically. significant (chi_square : l.lI). We conclude that, given a standard dose, serum concentrations of mepcridine differ between SS patients and CON patients. Further evaluation is needed to explain observed differinces. These re_ sults may suggest reasons-for the relatively pooi pri., control often noted in SS patients.

". I o 2 H:iLr:: l,:'"."3T3,1i iJ,ilT,T3:',"

Response Skills RD Kelley,KC Harrison,SM Lyon,LC Baldwin,CR Hansen/ Quintessentral Mass Casualtybonsultants,San Clemente, California During the years 1980 to 19g4,a series of mass casualty . inci_ dent exercisesinvolving S0 to 4b0 moulaged ,i"ii-, were con_ oucted rn (Jrange County, Cali{ornia. Each series exercised managementtheories and responseconceptsfor a coordinated agencyresponseto a mass casualtyincident (MCIf. The principal goal of these field exerciseswas io decreaseactual MCI victim mortahty and morbidity by increasingMCI responseskills. The casualty responseskills o{ incident scenemanage_ Tt1: Tr:: hospitalpatient care capacityesumarron,pa_ T^T^,,.11:1d,trrage,, nent tteld dtsparchpriority.,and resourcedepletionanticipation presentedprior to eachexercise.Analysisby the respective lere ptannrngcommitteesfor every exercisestressed'the imDortance


of more and effective education oI these skills to all responding agency participants. To meet these needs with comput;r tech: nology an MCI simulation program was developed. ft. o[;..rot the simulation is to decreaie the mortality and morbidity'to all vrctims of the simulation scenario through the choice of ...o-_ mended basic mass casualty response leaching points. These 1ea1:hingpoints reflect established and theoretica"l proced,.rre, foi MCI mitigation. Aithough computer simulation programs have been developed for use during M-Cf operations, this simulation is one of the earliest prototypei for use in disaster medical education. This and more sophisticated revisions of computer MCI srmulation programs can be utilized to maximiz. tt . I""-i.rg experience during field exercises before personnel and materiej arc committed to these large and expensive events. Most impor_ tant, utrlization can enhance and miintain skills a{ter such {ield exercises in the hope of decreasing mortality and morbidity dur_ rng actual mass casualty incidenti.

Disposition of patients Referred from Freestanding Emergency Centers to a _ Hospital Emergency Department L,:5,,1Gold/ Departm.ent of Emergency Medrcine, Hennepin !UountyMedical Center, Minneapolis; Division of Emergency Medicine, MercyHospital and MedjcalCenter, Chicago {

f|l! f rVV

the rapid growth of freestanding emergency centers ,_Y,,h lir.LSJ/ thc're rs somc controversy regarding the severity of illness sccn at these ccnters. This review exrmirres patienis ,.t"rr.J from a network of 8 FECI j.o a hospital OD. during th. .tuJy, 17,387 paticnts werc initially seen at the FECs, oiwhom tOi i0.(r% ) werc transferred to hospitals for further evaluation. Sixty_ threc patients werc referred io our base hospital, of whom y'g 1447n)werc admitted and 6 19.S"l,)were admitted to critical care units. This compares to a 2STo overall admission and 5% critical care admission rate from all ED visits. Four ol the 6 critical care admissions arrived by ambulance, of whom I was unstable and required immediate cardioversion. The other 2 were not sta_ bilized and"arrived by private transport. With telephone follow_ up, none of the, patients discharged directly from the ED who wcre contacted had a missed diagnosis. According to telephone follow-up, 66% oI the discharged p*atients *.r",rtiifi.d *ltil picare and 100% were satisfied with hospital care. Of the admitteJ patients, 87"/" were satisfied with FEC treatment and 100% were satisfied with hospital treatment. For a similar illness in the fu_ ture, 29Y" of all patients would return to an FEC, 297" would p r r v a t e p r a c t i t i o n e r , a n d 4 2 u z ow o u l d g o d i r e c t l y to a lerurn lo,a nosprtal. lt appcars that FEC referrals have a high hospitalization rate, and these patients were satisfied with th6ir "are. Their frr_ ture behavior would be changed so that less than one_third of these patients would return to the FEC for a similar illness.

Needed for I O 4 tT!:"JitlTPhysician

K J R h e e M S t r o z e s k i ,R E B u r n e y , J R M a c k e n z i e , K L a G r e c a _ Reibling/ Section of Emergency Services, Depariment of Surgery, U n i v e r s i t yo f M i c h i g a n , A n n A r b o r Despite the accumulatjon of years of experience with helicopter emergency medical services for transport of critically ill and,injured, patients, the question of whether physiclans'are neeoed tn ilrght remains an unresolved issue of malor lmpor_ tance. We examined the c-osts and benefits of using ligt t pfryri_ clans rn one active HEMS program. During " ,trd=y pErioi of 4 m o n t h s , a l l p h y s i c i a n _ - s p e c i f i cc o n t r i b u t i o n s r o m e d i c a l care were recoroed by,means oi a questio_,nnairethat both flight physician ano nurse tllled out aiter each flight. With the questronnalre as a B , u i d e ,t h e f l i g h t , n u r s e w a s t h e n l n t e r v i e w e d i r i d e t a i l b y o n e o f the authprs, with particular attention to whether the fligLt nurse coulcl have substituted for.the physician and whether tf,e physician's contribution of skill oiludgment clearly led to an im_

for the. p:tt-1"i:Ill proved or potentially improved outcome an important or unrque itigtrt pttysician was found^to have made o{ 174 flights (22%) contribution to the care i ti" p'iit"t in 3-8 was the most tt"dv' oi p"tiod |udgment ;;;T";il;ii"g,t'" skill and nnttt qZ"Z'l nightt iO common contnbutlon, "titJo" ttrgnrs14%f and skill iu",lil;;, *.r"-.o.,,,iut'ted on 7 additronal exer{l% )' ludsment was most.frequentlv ;i#';'.;i;-z-flilrttt treatments' medical critical iir"J rn--"f.1"g diignoses,'initialing to this program of providand determinirrga".ti.rrtiorr.'ifr" .3.t per y9?:'or 7o/" of an ing physicians i, "pp,o*it"tely $85,000 Flight physicians m-illion' Sf'Z rppro"imatelv ot budget annual to patlentcarern contribution important and make a subitantial to difudgment^wiih regard HEMS,.*"t"tJi!';;;;i transports' oI 22"/" in disposition i".ai""l ir."t-"tti. ind]i,, ,*".tlt, proglam o{ this contribution flr outweigh the 7"/" ii. cost.

I motor-vehicle-related traureviewed 126 consecutrve categor) 25 hospi-

tv-iiiJ riigt't helicopterfrom


tals to a regional trauma t"ttttt

i" r*ural Pennsylvania during a 14-

trip dis-oiJi,v *"r t3%. Average.round ff#;;;i;.'ou.i"lt facilitv the'ieferring at times rii--lrtt' ct""ita ;il;#;;^;t communrcatrons a..dedicated in log dispatch the f-m *"r" ,"1"" rrom ffthe. night tea-lnw:re taken ;;;:P;;;A;;;'I"'J;;; facility referring the at tiire Crou"d ohvsicianandnursingnottt' 42'0 minutesoverall Ground ," r'ri3r averaged il"';l;;;;;

#;s# ;i ;;il;'

the flight team

t.qrri.ed^by re133%) iu""ri'"ri"*:l:1,1?,::,lients airway man-

time when no lnteffent;i"*.r.

ouired maior therapeutlc interventions {nrincrnl]I1 ground time' an 84"/o axemcnt).This group av"raged57'4 minuies


(P-: '01)Caregivenbvtt:lt:ir::tjil: b"aseline

delays ate summarized' Recomrr ,"J *tt.q".nt traumavictims requrrrng g'nlr"p*"ii"" of motor-vehicle-related evacuationare established' ,li."!ai"rt

i'lfii"fi3"'i'3I O5 :'J:T,:t:H:':?'"$:":Lli"BiTI'T' 107 lJ:1i."'l'F'i:$T

LJ-Baer/-Departq{ of Emergency xinrc, MS Meindertsma, I"nili[i.i,, grttrworth Hospital, GrandFlapids;Sectionof o"plttmentoi Medicinel\/ichisanState ffiil;;tM;i"t" EastLanslng of HumanMedicine' A s t h e u s e o { h e l i c o p t e r s f o r a i r t r a n s p o r t o f c r i t i c a l physl y i l l p a . Univeisity,'College severity monitor to devices orie-nted.lrauma of triage is a tients increases, the "t;tl";ilit ii. pr" Horpital Index]PI) lt BB pulse' oi 4 "ompottents:sy-stolic a"il"g flight becomes more important "o-prt'"d system i;l;;;";T;;;";t.i, scoring during

HelicoPter TransPort . of / Division M.Martrn t Cottington i o 1"nrc,C Shufflebarge h rs Pittsbu Hospital' Glneral M;oicine,Rtte[rrenv Er;;;;;y

';Ji1*?1"T"'t: nr'jti*;t""#l:;,"#r:",6ii:ff

po2 (Pao2) decreases iee' krrow., ,r,"i'"ii"ii"r iliG ln this-s.tudYwe examflight ;;;;;T.;;;,"d,.no,tp"s'urrzed (ciO2)monitor tor o*ygen ined the use ot the transconiunctiuil helicopter during o*-vge"ation of "tttii"r ;;;;t;i;;;a.quacv Pao2 as compared We volunteers' h;it-hl -arterial ilt;;ff4 with cio2 at gas analvsis blood fv'.""'J",i"Jarterial ;8;:il; Pao2

*"tgrttta after cireful analThese 4 components *.;;;h;;;;"i "tttt' Tie PI was developedto ysis of 3I3 "orrr"",,,'ut^1""t" identifying provide an obiective pr"iiospital scoring system for

ih;;. ;;til'i'r..rv

ro,oooleit altrtudeMean *r"i "i'r"iir, !,ooo i.",, ,"a torr' respectively qT's dropped signiircantly tt"i" (P < .00I, analysrs ot u"ii""""

or i" aJ' 'iiit'i" zz hoiuri-orrequiregeneral trau-

36hours (maio'r neurosurgical operatlve i"tervention within tlat'a PI of 0-3 indicated mal. Using these crrterrafii-*at fo""d while a-i'i'of +-zo tigttifitd maior trauma {penil;";;;;';;, auto-matically classified etrating abdominal o' "h"" iniuries ire 465 consecutrvetrauof analysis Retrospective ;;;i&;;"-a). of 0-3 (mino-r^:TiT:l ma casesrevealed ,it"t Jttttto *ith a. Pr neutosurgrcar mortality ^id ^ 2"/o rate of general^or il;d;-0%

i'" 8l'5 to 58'5 with repeated measures)'Mean

;::1 [:i**]*:lrt;tir:l"ll*:'"'i"']':i;1?':;H:"13f predictor al,a:curate wa.s 02 ci lirl[i'iiiiilt" i"ai"ii""i t"urects, The relationship of PaO2(P < .00I, -"tttpit tlt-gtttsionanalysisJ' coeflicient of a regression with liiear was PaO2 and ciO2 between 02 monitor may be 1.147.We conclude,fr", ,fi" """r"oniunctivil during oxygenation arterial of useful for monltorlng "atq""ty patients' This studv ;;itu"p;;; iiigr'i i" t'."-oJv'""-i'allv. stable oxvgen in all patients subalso supportsthe use J;;;;fi;;t;l transport' iected to helicoPter

Bffil H'rjfiJlTj^xttSJJ;:'.1"?:,Jrl::f :l"J,1'j'rf ;;'';;;;*'s::*;f-':n.:,,llTl,i"T'".ff :'n#.t*;:j ti:'H;lT:il'ffi!' as scored rate' 388 consecutrvetrauma iti" pt *rt then prospeciivelyappliedto

LU lili.ll'illliiil

operative .rhose a o'28o/" tPt4-7' o%l i"-,i. ?ia"r'"a a mortalitvof-27% 4-7' 227"i 8'20'

of 40'57' IPI 8'20,53%land an "p"i'ilt"l"t PI's abilitv to predict morthe a"-""t,rate a"i" Zr;:U:;i;;

i iti'ry 1r',. o9 I O6 +,Ti:i"fti?*ilJ:FTiT,'ilL*",* ":. 1Xl,,T.l ll.: 11Jx;#:*FT TS if?fi "*il nelatei iiauml: ciuses for Delays and i"" "ji "nJiiv* itt' Recommendations GA Parrish' MJ Leicht,DJ Dula,TE Anderson'HW Gessner' V:dl9ii:.1:1 Emergency O.p"itt"ntt-of I Brotman WD Rose, S Danville'Pennsylvanta iiurtu-Srtg"r.y' GeisingeiMedicalCenter' in the United States' There are 65 million iniuries annually the l-40 ase group' of leading'cause is the ,";;;;;; in the US in deaths There were az,ss+ m;i&-vehicle-related occur in rural areas' 1983.Seventyp.r"",tt o1-"it trauma fatalities of auto accidents is 40% to ;;td il. i;;;ii,v t"t. roi-t"i"i-ui"ti^t with comparable iniuries' victims tttbat"t ;'h"., foi A;";;";; start of appropriate The time between o"""itt""" of iniury and survival' Adequate therapv often becomeJiitt f""tot deiermining scene of li{efroir^the far. ;-rten-so il;i?;i;;I"r"-liii;'";;' our rural hospitalunlikelv' is ;;;';;'t tt',i ;h;;;;;fi1;r*v medicine physibasedhelicopt., p,og'"- staffed by emergency victims in our trauma 5% -of cians and fhght nursesadd""tt the by a trauma ":*"i: area requlrlng ,.r,t",v Jili"tt*""tio" victims trauma mafor of preparation ;;;;;T;;pial in delays and inresults ,jf,." aeromedical .,nr"rr",rlrr]-iro*"u"t, retrospectively We facility' creasedground time;;'tftt ttittti"g

5' ;";;;; l"ilf il"f T:lil':'ll ;:l:il;; teverity scoring systems such as the

tt,i"riiitrv'.dtriri"J'ott*" and the CRAMS Trauma Index, Triage t]'J"*-, rt""ta- Scoie' prospectivelv been has Scale ciihus Scale. of these only lrr? in the context ot iield tested. Testing oi t'"tl"'"$ica1 their feasibility, ac' their intended ,rr. ,, "ri,i"rt-i,' d"t"tmj.tittg to be an easily found been has PI iLt ";ii;t' curacy,and ultimate indicator of prehospital l""ttt tigttif fy ""a tt"titii"l'f i-pf "'-""iJ trauma severltY.


TraumaScore SimPlified I OB

University DR Kamens/ Departmentof EmergencyMedicine' Florida Jacksonville' Uotp't"f of Jacksonville, trauma score sys' Tiauma severity scales, exemplified by the encour-

have *#lCisf ?.".i"itJ uv bht-pion and.coworkers' trauma care' To

early aged quantificatlon oi'injury ieverity in assessment'it is es' assurerapid, accurate,and reproduciblefield


sential to use a valid scale that requires no extra tasks beyond stabilization and transport. A s"oiirrg-system'suited for'pi._ *as sgucf using a microcompute, to deuelop'rni l:-T:::'-^t:l: p_r_"f ve,srmplii:f ications. Data elemenrs were uniform Iy ::lltl andig.rr graoed lrmited to objectifiableobservationsroutinely -ade ai trauma scenes;impossible or redundantelement varue combinatlonswererdentifredand excluded.This processproduced a scale,

nearlv.identical {JSJ, to;;;;;;;s l.l,:J':^trywrrn perrormancecompa_rahle

oi uit"r silnr,

to the CTS. BecauseJS contiins only 4 routinely assessiddata elements tr..pri*ory rate, blood pressure,pulse, and neurological),it represents a significant im_ in ppli cability f or prehospital scoring.'High_degree l::l:T::_, -a corretatronbetween the 2 systems was confirmedby impritergeneratedcomparisonso^feachof the 1g,000p.".rbl" bia-J;;; combinationswith its JS counteroart.

trent questronnairewas administered.Of the 54 patients studied, I ll7%),(GroupA), deniedhaving receiveJ *riri.n insrrucions aesprtedocumentation to the contrary in the medical record.Of y.,.r,.,"::, 6,167v")received "o t o-e oUr.rultio" and only I Lh,::: lrrTo/ could recall even I of the g items enumeratedin the mana€ementplan. Of the remaining patients, 17 (GroupB),had the instructions.given directly"to ,t. p.r*"ii"l3l%) be convevedbv rne parrentto the individual responsiblefor the observation.rn 159"/o) received .,o-obseiuatio",' *f,if . 4 di;i :*3r"^tof ]9 i ;;_ cerveoobservatronin concert with the instructions; none, how_ ever,could recall more than 3 of the managemeit rtems. In the remaining 2l cases{39%)]Group C),_the initructions were grven directly to the individr"i ,-.rpL.,.iii. l.i p-"iir"s th;f"_; management.Of these, 167%)were observedas reqiriredin the lBmanagementplan. In addition, g i3g%)recalled 4 or more man_ agement items at follow-up. Of the 54 casesstudied, ;;; ;;_ plication occurredduring h'ome -obr"rurti*, r.qriiring admission to the hospital for intracianial bleeding ""J fr..ii-p" We con_ clude that home observationoi patien-t,a*.fr"#a from the ED following closed-head infury may b; ;;;il;%, particularly when the after-caremanagementinstructions are not given di_ rectly to the individual reslonsible f". p;;;"d];;;ire observation.

","351i?,-" ", LOg iTi.iffi'.;',iJ:H::;:l

B. Eisner,D Howes,T TurnbuilI fmerge;t M;diJne Residency, Universityof liltnois,Chicago; lrtercyFospltai liJ weoicat Center, Chicago . In many institutions it is the standardof care to obtain serum chemistriesas well as serum anticonvulsantlevels part of the as '.ifi"*y ED evaluation.of seizure patients. To determine tfr" "i such a.workup in the ED,.67 seizure ;;il;;-;r.r"nting to an y_l.j,.hing,hospital were studteJ-i" " riandardi,Ja, :::^.:;:l mann€r.AII patients n-: specuve studied had historical and physical examination data obtained, and serum CnC, eiettroly,;, iUN; ql"cose, calcium, magnesium,dilantin, and'phenobarl illiltlll.: perform".d.a"y patienr presentingwith l) ,1::1.::,:.1Tl"atrons nrsr-nme serzure{more than.6 years of age);2} recent h"istory oi significant head trauma; 3) focal .r""rot8ji" i.ii"rt, or 4) focal nature of seizure activiiy underwent CT "scanning of the head. Beforereceiving laboratoiy.r.."tt,,"a "ft.r'"tn"i"i"S historical and physical eximination'", ir,. i'*"riiiriJii .riorogies were

rr,-!" l':::11n.t.',+ed,probability' oecame. avarlabte, the 5 most

eii.r'iir? r"uor".orya"t,

likely etiologies again were listed p€rcentagesof likelihood. CT"scanZf the head was 11,{lssiEea on 4 patients 15.97%1. There were no significant abnor_ l-.1191-.9 rnalues ln serum chemistries noted; there were no seizuresdue nfjmadfl to derangementsin,ry-"oi -"s there any ellect of lab results on diagnosisor dispositioril ioi serum ailantin ,or phenobarbitallevelJ were the piesumeJ'."*., of seizures

alcoholirittJi"*"iin ll, ifutr,.'.,lls reDrrleselzuresin. patients tzL.rr-/ol;

ls patients

4 15.64%lispace_oicupying lesion in 2 pa-tientsl2.BZ%),and.CVA i" Z pjlt.i,t, (2.82,i"i-i; more than 9O"/ooI patients in this study, ,frJ airg"ori, and dis_ position could have beenpredicted basedon hrst ana plysical examrnation alone. Identifying high_yield t'., hi.i*y-;;; physical examination -rv heli air"eci Uforatoiy t"rtirrg by identifying those patients ,, ii.t 16rit ";; ;;;;ilimalities, thus obviatingthe need for a standardseizure ;;.h;;; the ED.

T":il, I ! O ;itn:'"?:-i,if&;'itff::f

CE Saunders,CA Barton.n cota lbiviiio, JEilJ,gLn.y Services,Universityof ColoradoH"ilin S"""n."-r'6Jnt"r, Medical o"nu",. Victims of mild closed-headiniury who_do not require hospifrequently are observeda, io-. ly , ,"ro"".iUle fami_ l-lli1"rro," ly member or other individual guided by a'set oi'written after_ carernstructions. The efficacy ofhome observation for such cases and the extent to which afier_c"..;;;;;;;;ii pr".r, are executed.inthis setting are unknown. To aniwer these issues,we studied_54 .otts.crrti,. victims oJ irr;,rry aircharged.from the ED for home "Ur.*"ri"" ""a.iih. responsibleindividual who had written "f-_"*"1""*ctions "r." of " for managementthat were reinforced verbally bV the EO staff. Fol_ tow-up was performed within 24 hours by t.t"ptio"., and a pa-


| 11


Grireria forEmersency

M.LMills / Departmentof EmergencyMedicine, UniversityHospital of Jacksonville, Jacksonville, Fiorida of this study is to establishhigh_yieldcriteria ,-Il:r LJ putPore ror emerqencvcranial CT. scansin patienti *ho present ln to the ED with aiute neurological disordcr's.i-hi.-i, "r, on_go,.rg, prospective, clinical study. Anticipated Hyc were pubrishe? an'd distributed by,the Depari-"nt oi f-.rg.*y'MJdi.i.,. and the ueparrment ot Neurology to all emergency medicine residents and {aculty.At rhe time 6i each.-.r;;;;t;;r,,-1"t, ,t ".t. .on_ taining detailed clinical findings *.i. "o-pi.i.J-U -data, ,fr" pf,V.i_ cian ordering_the scan. These Ao"g ;itil tlre final inter_ pretation of the CT scan by a neuroiadiologist, were enteredinto a data base_management system (dBASi [t?-'""rivri. and inter_ pretation. Resultswere then correlated*iit tt. pi,iposedcriteria to determine expectedyield for "r"t ".it.ilo".""iv from the first 200 cases,eveal tfrrt "UL"i-Sb%'oi!_".g.rr.y ari" pr_ tients requiring_anemergencyscan fell i"to -"..o"" ^rrrir_"ri""a, of o major areas. Some findings from the preliminary a"t, Presenting Complaints Trauma AlteredMS Seizures Hemiparesis Headache Coma Other

Acute AbnormalCT

CT Scans Indications Urgent Intervention

217" Trauma 197" AlteredMS '17% Seizures

41"/" frauma 24% AlteredMS 38% Seizures

11% l-leadache 9% Coma 11% Other


'127. Hemiparesis

42% Hemrparesis

Headache 47"/" Coma 27o/o Othel

27"/. 8% 187. 2a;i 9"/"

Nineteen percent of all scans indicated the need for urgent rntervention. This study elucidatesthe clinical conditions iirrt.orr.late with HYC in each category,as well as the overall indications for urgent cranial CT scans.

Sutured Wounds in an Urban I a q, Emergency Depadment .) ! D Smirh,M Vortiere,R Sn".s"r,jNaradzay, ItS_Sm/rh, p.Dundas,T Turbiak, R Rosenthat R Au;; F ririn!)-bupartment -u Jr/edicine, The Georgewasninston niversity :j^ll"^ln:::y Mreorcat uenter,Washington, DC largeserialstudiesof woundsand their complications , -Y-or, have examinedinfections in surgicalwounds.No generally

agreed-uponstandardexists as to what constitutes aII acceptable Eb wound infection rate. Our ED is an urban facility that has 41,000 adult patient visits per year. All traumatic wounds are managedby a trained trauma technologistand an attendir-rg-level emergenc! medicine physician.Patientsare referredfor follow-up to the ED Wound Clinic, to the patient'spersonalphysician,or to an appropriate subspecialist(plastic surgery or orthopedics). e standaid approachto wound management is utilized - skin preparationwith povidone iodine, local anesthesia,wound irrigation with normal saline and/or wound cleansing with Pluronic 68, debridement,and layered closure. Primary closure is carried out only i{ repair {ollows injury by iess than 8 hours i16 hours on the face).From August l, 1982, to fuly 31, 1983, 2,522 patients with traumatic wounds were sutured. A total oI 1,255 150%) wounds occurredon the face,neck, or scalp;1,016{40%)wounds occurred on the upper extremity, and 215 (8%)wounds were on the lower extremity. Wound complications were classifiedas infection. suture reaction, or hematoma. OI the 2,522 patients sutured. 2.093 were referred to the ED Wound Clinic for followup; 1,168of these patients kept that appointment. Of these 1,168 patients/ there were 19 wound infections (1 requiring inpatient ireatment),7 suture reactions,and 4 wound hematomas.This representsa wound infection :'ateof I.6"/" and an overall wound complication rate of 2.2o/o.A telephonesurvey was conducted among 687 of the 935 patients referredto the Wound Clinic who soughl foilow-up elsewherei 642 were contacted successfully. Among these 642 patients, there were no infections, no suture reactio;s, and no patients requiring antibiotics. Basedon a total sample of 1,810pitients receiving follow-up, the overall wound infection rate was l.l%. The infection rate varied with the anatomical location of the wound. As expected,wounds on the scalp (0.5%)and Iace lO.7"hlhad the lowest infection rate, and wounds on the knee l5%1,le1 14.4%1,and thigh {2.5%l had the highest infection rates. The iraumatic wound and its follow-up are the

purview of the ED. With careful, consistent technique a wound infection rate of between I and 1.5% can be achieved

a a 4t I f r,

Trial of Povidone.lodine in the Prevention of Inlection in Sutured Lacerations

A G r a v e t t , S S t e r n e r ,E R u i z I D e p a r t m e n t o { E m e r g e n c y M e d i c i n e , Hennepin County Medrcal Center, Minneapolis The value of irrigating solutions in the prevention o{ wound in{ection in traumatic lacerations has not been established. A prospective, randomrzed study of 500 consecuttve ED patients with traumatic lacerations requiring sutures was performed, comparing use of topical l% povidone-iodine (Betadine) with standard wound manigement, including irrigation with normal sahne. A 60-second wound irrigation and scrub with a l% povidone-iodine solution was the only difference in treatment between the two groups. A l% solution of povidone-iodine was chosen based en previous studies ol efficacy and tissue toxicity. Data rclating t6 riik factors such as age, degree of contamination, type of closure, ethanol intoxication, mechanism oi injury, and bone, ioint, or tendon involvement were analyzed. Wounds were classified as clean, infected, or purulent at follow-up examination. One hundred five patients were lost to follow-up' O{ the 395 remaining patients, 122 were contacted by telephone and were classi{ied-bised on therr description of the wound, and 273 patients were classified at reexamination in the ED. Of 201 povidone-iodine group wounds, ll became in{ected, 2 being purulent 15.4%lOf 194 control wounds,30 became infected, 12 being purulent (15.46%). Statistical analysis of the two groups produced a chi-square value of 9.55 and a P value < .01' These data suggest that use of a topical l% povidone-iodine solution in traumatic lacerations prioito suturing reduces the incidence of wound infections.


CONSTITUTION OF THE UNIVERSITY ASSOCIATION FOR EMERGENCY MEDICINE ARTICLE I - NAME The. name- of this orga-niza-tionshall be, ..The University ^ Associationfor Emergency Medicine, " trereinafter referred to as, "The " Association.

ARTICLE II _ OBJECTIVES Section1..The objectiveof this Associationshallbe improve_ mentin the quality of medicalcareof the acutelyill and injured by operatingasa scientificand educationalorlanizafion asdefinedin Section501(c)(3) of the InternalRevenrieCoO", ", amend_ ed. Section2..The Association.shall pursueits objectiveby survey_ ingmedicaland scientificarticlesUothpublishei and unpublish_ .d,..u19selectingarticlesof note. ttre Association shall make available, at cost,to the publiccopiesof the ,.t..t.a articlesupon request. TheAssociationshallselectmedicaland scientificarticles of noteand educatethe physicianand the nuUfi. Uy n..r.nting thosearticlesat discussiongroups, foru-nis,-paneis,] seminarsand other similar programs. The' Association may choose to sponsorfor publication-selected medicaland scientific articlesof note by treatise,thesis,trade publicationor other mediaform in orderto makethat information,inctudingpatents, medical,.apparatus and medicai system designs, l::l^"Jf lto the public avallable at largeon a nondiscriminatory Uasis.fhe A^ssociation may conduct and/or sponsorpublic interest,scientific research in the field of emergency in order to im_ prove.the qualityof emergency mioicat treatmentand care.The Association shallpublish_its rejearchdataby tr.utir., thesis,trade publication or other mediaform, in order io -ur. that information,includingpatents,formulas,medicaluppuiutu, and medical systemdesigns,availableto the public ii turg" on a non_ discriminatory basis.The Associationshall infoim and educate thepublic,aswell as the medicalprofessionar, in irre resultsof its research by conductingdiscussiongroups, forums, panels,lec_ tures,seminars and other similarprograms. Section_3..A. This corporation is organizedexclusively for educational and scientificpurposes,including,for suchpurposes, themakingof distributionsto organizationithat qualify as ex_ empt organizationsunder Section 501(c) (3) of the internal Revenue Code^of 1954(or the corresponiing'p.ouisionof any futureUnitedStatesInternalRevenueLaw). - B. No part of the net earningsof the corporationshallinure to thebenefitof, or be distributableto its memUeis, Directors,Of_ other privatepersons,exceptthat the corporation shall l:. ,?r and empoweredto pay reasonablecompensation l^._1lln9ttr.o ror servlces renderedand to makepaymentsand distributionsin furtherance of the purposesset forih ln purugruphA hereof. No substantial parr of the activitiesof the corflraiion shall be the on of propaganda,or otherwiseatiemfting to influence i.r.tlllg regrslanon,,and the corporationshall not participatein, or in_ tervenein (includingthe publishingor distriLutionof statements) p,"Jlli.?J,..mpaign on behalfof any candidatefor public ofl |,il ilce.Notwlthstanding any other provisionof thesearlicles,the corporation shallnot carry on any other activitiesnot permitted to becarriedon (a) by a corporationexemptfromFederal Income taxunderSection 501(c)t3) of" Codeof 1954 (orcorrespondrng provisionof any future United statesRevenue o,r(bJby.a corporation,contributionsto whichare deducti_ |.,.*) oleunoersecrion (2) of the InternalRevenueCodeof 1954 _170(c) (orrnecorresponding provisionof any futureunited statesInter_ nalRevenue Law).

43 .

ARTICLE III _ MEMBERSHIP section .r: crassifications.There shalr be sevenclassesof membership: active,associate, emeritus,resident, honorary,and international activeand international associate. S9.ct!on 2: Qualifications.(l) Candidatesfor activemembership . shall. be (a) physiciansof university or university-affiliatel hospitalswho hold medicalschoolfacuityappointments and who are.continuingto participateactivelyin ttre tietOof eme.gency medicinecare and services,have i demonstrated interestin emergency medicine,whetherin an administrative,teaching,or (b) other medicaleducatorswho under special :lll::] :o*ity clrcumstances are invited for suchactivestatusby the Member_ shipCommittee.(2) Candidates for associate membership shallbe any physician,medicalprofessional,educator,government ot'ficial, memberof a lay or civicgroupor uny -#b1, of thepublic at.large,who may havean interestor desiieto participate pur_ in s.yi_ng the purposesand objectivesof the Association.(3) i;;_ didatesfor emeritusmembership shallbe (a) activememberswho seeksuchstatusand who havegiven l0 yiars of active serviceto theAssociationand haveattainedthe ageof 60 years(b) otherac_ tive memberswho under specialcircrimstances are invited for by.the_Membership Commiuee.(4) Can:y:1.-.q..irur.starus oroares ror resldentmembership mustbe a residentin a rejidency trainingprogramwho havean interestin emergency medicine.(5) Candida.tes for honorarymembership shallbe i-nJviOuats wt o a.e outstandingmedicalor lay contributorsin the field of emergency medicalservices. (6) candidatesfor internationalactivemembership shall be individualswho meet the qualifications for active membershipin UA/EM and who residsoutsideof the United States.(7) Candidatesfor internationalassociatemembership shall be individualswho meet the qualificationsfor associate membershipin UA/EM and who reiide outsideof the United btates.

Section 3.. Only active members shall have voting rights. Section y'..The Association shall not discriminate, with respect to its_membership,on the basis of race, sex, creed, religion oinational origin.

ARTICLE IV _ OFFICERS Section 1..The officers of this organization shall - - be the presi_ dent, Vice-President, and Secretary_-Tr.urur... Section 2: The Executive Council shall serve as the Board of Directors of the Association. The Executive council shail consist of the above officers, the program Committee Chairman, the last three.presidents,and three Councilmen_at_I-arge. Both active and associatemembers may serve on the Executive"council. but onlv active members may be officers of the Council.

ARTICLE V _ COMMITTEES The standing committees of the Association shar be: . Membership Committee, Nominating Committee, program Committee, Constitution and Bylaws Committee, Education'Committee, and Auditing Committee. Additional committees may be creat;d by the Executive Council and ad hoc committe., -uy be created by the President to aid in the Association efforts to achieveand fur_ ther its goals.

ARTICLE VI _ ANNUAL MEETING Section1.'Thereshallbe an annual meetingof the Association. This meetingshall consist of an educationaland scientific program and a businesssession. Section2.' The ExecutiveCouncil, by majority vote, may call, upon 30 daysnotice, a specialmeetingof the membershipor standing committeeto conduct any businessthat the ExecutiveCouncil shall placebefore the membershipor standingcommittee. Section 3.' The Executive Council may call and conduct any specialmeetingby mail. For purposesof notice, the meetingdate shallbe a date setfor the return of mail ballots and it shallbe called the voting date. Mail ballots shall be sentat least30 daysprior to the voting date. Adoption of any proposal, resolution or amendmentby mail ballot shallbe achievedby affirmative vote of a majority of voting activemembersunlessotherwiseprovidedby anotherprovisionof this constitution.Only thosemail ballots receivedat the businessoffice of the Associationwithin 30 days to the voting date shallbe counted. subsequent

ARTICLE VII _ BYLAWS Section1.'Bylawsmay be adoptedor amendedat any annualor specialmeetingof the membership' to the bylawsshallbe submitSection2.'Proposedamendments ted in writing to the Secretary/Treasurerby three membersat Ieast60 days prior to the meetingat which they are to be conshallmail the proposedamendsidered.The Secretary-Treasurer mentsto the membershipat least30 daysprior to that meeting. Section3.' The ExecutiveCouncil may, by resolution,propose to the bylaws;providedthe proposedamendments amendments are mailedto the membershipat least30 daysprior to the meeting at which they are to be considered. Section4.' Adoption of a bylaw amendmentshall be by a majority voteof the activememberspresentand votingat anyannual or specialmeeting.

ARTICLE VIII - ADOPTION OF THE AMENDMENTS TO THE CONSTITUTION Section1.'The constitutionmay be adoptedor amendedat any annual or specialmeetingof the membership. Section2.' Proposedamendmentsto the constitution shall be by threemembers submittedin writing to the Secretary/Treasurer at least60 daysprior to the meetingat which they are to be conshall mail the proposedamendsidered.The Secretary-Treasurer mentsto the membershipat least 30 days prior to that meeting' Section3.' The ExecutiveCouncil may, by resolution,propose amendmentsto the constitution; provided the proposedamendmentsare mailed to the membershipat least30 daysprior to the meetingat which they are to be considered. Section4.'Adoptionof a constitutionamendmentshallbe by a majority vote of the activememberspresentand voting at any annual or specialmeeting.

ARTICLE IX _ DISSOLUTION Upon the dissolutionof the corporation,the ExecutiveCouncil shali, after paying or making provision for the paymentof all of of the the liabilitiesof the corporation,disposeof all of the assets corporation exclusivelyfor the purposesof the corporation in ,uci, manne., or to suchorganizationor organizationsorganized and operatedexclusivelyfor charitable,educational,religiousor scientific purposesas shall at the time qualify as an exempt underSection501(c)(3) of the Inorganizationor organizations provisionof ter-nalRevenueCode of 1954(or the corresponding any futureUnited StatesInternalRevenueLaw), asthe Executive Councilshalldetermine.Any suchassetsnot so disposedof shall be disposedby a Court of CompetentJurisdictionin the County in which the principaloffice of the corporationis then located, for suchpurposesor to suchorganizationor organizaexclusively tions, as said Court shall determine,which are organizedand operatedexclusivelyfor suchpurposes'



Section 1.. Application and Election to Membership Applica_ . tion forms may be obtained from the Secretary/Treasu..iof the Association.The Applicant must return the completed applica_ tion forms and supporting letters to the Secretary,/Treasurer of theAssociationat least one month prior to an Executive Council meetingin order to be considered ior membership at that time. The qualifications and recommendations of candidates for membershipwill be reviewed by the Membership Committee at e.achmeeting of the Executive Council. Approval of the can_ didatesby the Council shall constitute election to the member_ ship, effective immediately.

Section 1.. The Association shall be governed by the actions taken by a majority vote of the active members present and voting. Between meetings, within the policies establishedby its membership, the Association shall be governed by the Executive Council. Actions of the Executive Council shall be determined by a majority vote of those of its members presentat its meeting, five members constituting a quorum. Section 2..The annual meeting and any additional meetingsof the Association shall be held at times and places fixed by the Association, or in the absenceof action by the Association, ty its Executive Council. Programs for the annual meeting shall be arranged by the Program Committee and approved by the presi_ dent. A final notice of the time, place and program of each meeting shall be sent to all members of the Association by the Secretary/Treasurerat least 30 days before the meeting, but the t_entativetime and place for the next two annual meetingi shail ordinarily be announced during the businesssessionof eich annual meeting. The site of the annual meetings shall be chosen by the Executive council two years in advance.

Section2.. All members shall pay dues. Only active members may vote and serveas officers. Associate members may not vote but may serveon the Executive Council.

ARTICLE II _ OFFICERS Section I: Election of Officers. The president and Vice_ Presidentshall be electedfor one year, with automatic succession from Vice-Presidentto President. The Secretary,/Treasurer,and Counc_ilmen-at-Large shall each be electedto thrle year terms, the termsbeing staggeredfor the latter. Nominees for the above of_ ficesshall be selectedby the Nominating Committee and must haveagreedto stand for Llection prior to tlheirformal nomination for electionat the businesssessionof the annual meeting. Alter_ native nominations from the floor shall be solicited. Such nomineesmust also agree to stand for election. Election shall be by majority vote of the active members present and voting at the businesssessionof the annual meeting. Sec,tion2: Duties of the president. The president shall preside overboth the educational program and businesssessionof the an_ nual meeting of the Association, and the meetings of the Ex_ ecutiveCouncil. It shall be the duty of the president to see that the rules of order and decorum are properly enforced in all deliberationsof the Association, and to sign the approved pro_ ceedingsof each meeting. The president shall appoint aCtive membersto fill vacanciesand unexpired terms on the Executive council and standing and ad hoc committees. The president shalr serveas ex-officio member of all standing committees. Section3: Duties of the Vice-presidenl. In the absence or illness of the President, the Vice-president shall preside. The Vice_ Presidentshall serve as Chairman of the Nominating Committee and ex-officio member of all standing committees. Section4: Duties of the Secretary/Treasurer. lt shall be the du_ ty of the Secretary/Treasurerto presidein the absenceof both the President and Vice-President,to keep a true and correct record of the.proceedings of the meeting, to preserveall books, papers and articlesbelonging to the Association, to keep an account of the Associationwith its members, to keep a register of the members with the dates of their admission, and current professional addresses, the latter to be circulated annually to ihe membership yllhin a month prior to the annual meeting. He shall report un_ finishedbusinessfrom previous meetingsre[uiring action, and at_ tend to such other business as the Associition may direct. He shallalso superviseand conduct all the correspondence of the Association.He shall collect the dues of the Asiociation, make disbursements of expenses,maintain the financial accounts and recordsof the Association and present the financial accounts and recordsof the Association for review by the Auditing Committee within 24 hours prior to the business session of each annual meeting,at which time he shall present an annual report of the financialcondition of the Association to the membirship. He shallbe reimbursedfor such expensesas he may incur in the pro_ perexecutionof his duties. He shall serveas ex_officio member of all standingcommittees.

The educational program of the annual meeting shall be opened to the public.

ARTICLE IV _ FINANCES Section 1.' The annual membership dues for all members shall be_determined by the ExecutiveCouncil. The annual membership will be payable within 30 days of request by th; Secretary/Treasurer. The Executive Council may establish pro_ cedures and policies regarding non-payment of dues and assessments. Section2..The ExecutiveCouncil shall adopt such membership schedulesas is necessaryto encourage participation by the in_ terestedpublic.

ARTICLE V PARLIAMENTARY AUTHORITY Rule oJ' order. Any question of order or procedure not specifically delineatedor provided for by thesebylaws and subse_ quent amendmentsshall be determined by parliamentary usage as containedin Robert Rules of Order (Revised).

ARTICLE VI _ STANDING COMMITTEES Section,l.' The Nominating Committee shall consist of the Vice_ President, as Chairrnan, the two most recent past presidents,and two elected members who may not be membirs of the Executive Council. The latter shall serve staggeredtwo year terms. It shall be the task of this committee to selecta slate oi officers to fiil the naturally occuring vacancieson the Executive Council and the standing committees not otherwise designated and provided for by thesebylaws, and having obtained each candidate,spermission to do so, place their namesin nomination before the membership for election at the businesssessionof the annual meeting. Section 2.' The Executive Council shall constitute the Membership Committee. It shall be the Secretary/Treasurer's duty to re_ view the qualifications and recommendations of each apilicant, for presentation and approval by the majority of the Memtership Committee. ^.Se.ction -3..The Program Committee shall be composed of a Chairman, elected for three years, and three members appointed by.thePresident to staggeredthree year terms. None oi-the ap_ pointed members of the committee can be members of the Executive Council. Its duties shall be to arrange, in conformity with instructions from the Executive Council, the program fbr all meetings and select the formal participants.


^fhe Auditing Committee shall consist of two Section 4: membersappointed by the Presidentto audit the financial accountsand recordsof the Associationat the time of the annuaL meeting. Section5.r.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 tenureshall serveas Chairman during his final year on the Committee. This Committee shdll study the potential merits, adverse and legal implications of all proposed constituconsequences tional amendmentsor changesin the bylawsand report their findings and recommendationsto the Presidentand ExecutiveCouncil prior to the time of formal considerationof the proposed changesby the membership.In addition, they may themselves suggest appropriate constitutional amendments and bylaws changesto the Presidentand ExecutiveCouncil upon study of problemsarising out of the existingconstitution and bylaws.

Section6.' The Education Committee shall consistof a chairman, electedfor threeyears,and three other membersappointed by the Presidentto staggeredthreeyear terms.Neither the Chairman, nor appointedmembers,can be membersof the Executive Council. The Cornmittee shall foster continuing education in emergencymedicine.

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-thirds of the activemembershippresent and voting at any annual or specialmeeting. Section2.'Dissolutionshall be achievedin compliancewith Ar' ticle IX of the constitution.


1986 Annual Meeting Call for Abstracts Program Chairman, Judith E. Tintinalli, M.D., is now accepting abstracts for review for presentation at the 1986 Annual Meeting which will be held May 13-16 in Portland, Oregon. The deadline for submission of abstracts is February 1, 1986. Abstracts must be postmarked no later than February 1 to be considered for presentation. Mail five copies of the abstract to: 1986 UA/EM Annual Meeting 900 West Ottawa Lansing, Michigan 4891 5 Call the UA/EM office at (517) 485-5484 for further details. Abstracts submitted should not have been previously published as a manuscript, nor presented at a national meeting. Cash awards of $1,000 each will be given for the Best Clinical Paper (Human Subjects) and the Best Basic Science Paper. The Best Basic Science Paper is sponsored by UA/EM and the Best Clinical Paper (Human Subjects) is sponsored by MICROMEDEX, Inc. All award winners will be announced at the 1987 Annual Meeting which will be held May 20-23 in Philadelphia.

SAEM (UAEM) 1985 Annual Meeting Program