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University Associationfor EmergencyMedicine

1986 Annual Meeting Program and Membership Directory

May 13-15,1986 Portland Hilton Hotel Portland, Oregon


Call for Abstracts University Associationfor EmergencyMedicine 1987Annual Meeting, May 20-22;Philadelphia The 17th Annual Meeting of the University Associationfor EmergencyMedicine will be held May 20-22, 1987 in Philadelphia,Pennsylvania. ProgramChairman, Jerris R. Hedges, MD, is now acceptingabstractsfor review for oral and poster presentation at the 1987Annual Meeting. Becauseof the large number of abstractsubmissions,the Annual Meeting Program Committee has developed a two-page abstract form to be used for all abstract submissions.Abstract forms will be mailed to the UA/EM membership and to others upon request. Abstracts not submitted on the official abstract form will be returnedto the author for resubmission.In order to be consideredfor the 1987Annual Meeting, all abstractsmust be submitted on the abstract form by the abstract deadline of February 2. The deadline for the submission of abstracts for the 1987 Annual Meeting is February 2, 1987. All abstracts must be submitted on the official abstract form and must be postmarked no later than February 2. Mail eight copies of the abstract form to: UA/EM 17th Annual Meeting, 900 West Ottawa, Lansing, Michigan 48915. Call (517) 485-5485 if you have any questions or would like to request an abstract form. Abstractssubmittedmust not havebeenpublishedpreviouslyas a manuscript,nor presentedor acceptedfor presentation at a national meeting. Accepted abstractswill be published,in Annals of EmergencyMedicine. Acceptedabstracts must not be published or submittedfor publicationelsewhereprior to publication in Annals. Annalsof EmergencyMedicii,reis the official journal of the University Associationfor EmergencyMedicine. UA/EM strongly recommendsthat authors submit their manuscriptsto Annals. Annals will notify authors of a decision resarding publication within 90 days of receipt. Cashawardsof $1000 will be given for the Best Clinical Paper (Human Subjects)and the Best Basic SciencePaper. An award of $500 will be given by Annals of Emergency Medicine for the Best Resident Paper published in Annals. All award winners will be announcedat the 1988Annual Meeting which will be held May 25-27 in Cincinnati, Ohio.

Important Changein Annual Meeting Abstract Submission All abstractsmust be submittedon an official abstractform. Pleaseread the Call for Abstracts carefully for detailsand instructions.


INDEX ............1

G e n e r aI nl f o r m a t i o n K e n n e dLy e c t u r e

. .. .....3

. .. .. .

......4

UA/EM Leadership

'....4

VadeMecum

......6

A n n u a lM e e t i n gO v e r v i e w

'.....'7

S c h e d u ol ef E v e n t s Abstracts

......'.15

Exhibitors

...'.'.64

Constitutionof the University Associationfor EmergencyMedicine

. . . . . . .66

Bylaws of the UniversityAssociationfor EmergencyMedicine M e m b e r s h iD p i r e c t o r y( a l p h a b e t i coarld e r ) . MembershipDirectory (stateorder) 1 9 8 7R e s e a r cS hy m p o s i u m M e m b e r s h iA pp p l i c a t i o n 1987Call for Abstracts

. . . . .68 .........70 . . . .86 '....90 .......92 .insideback cover


GENERAL INFORMATION REGISTRATION AND INFORMATION

UA/EM-STEM COCKTAIL RECEPTION

All registrants must check in at the UA/EM Registration Desk to pick up name badges which are required for admission into the Annual Meeting sessions.The Registration Desk will be open during the times listed below: Tuesday, May 13 10:00am to 5:00pm Wedneday, May 14 7:00am to 5:00pm Thursday, May 15 7:00am to 3:30pm

STEM and UA/EM are sponsoringa cocktail receptionon Tuesday, May 13 from 5:30 pm until 7:00 pm. The receptionwill beheld in the International Club. There is no charge for the reception. Hors d'oeurveswill be servedand a cashbar will be available. All resistrants and exhibitors are invited to attend.

POSTERS For the first time, the UA/EM Annual Meeting will includeboth oral and poster presentations. All poster presentationswill be held in the Parlors of the Hilton Hotel. Theseparlors are located next to the Rose and State Ballrooms where the oral presentationswill take place. Posterswill be availablefor reviewing during the entire Annual Meeting on May 13,14, and 15. Presentersof posterswill be availableto discuss their presentationson Wednesday,May 14 from 3:15-3:45 pm and Thursday, May 15 from 10:00-10:15 am and 3:15-3:30 pm. All registrants are encouragedto attend the posters presentedduring the 1986 Annual Meeting.

MESSAGE BOARD A messageboard will be maintainedat the RegistrationDesk. Phone messagescan be left at the UA/EM RegistrationDesk by calling the Portland Hilton Hotel directly at (503) 226-16ll and requestingthe UA/EM RegistrationDesk.

PLACEMENT SERVICE A bulletin board will be maintainednear the RegistrationDesk for persons wishing to post positions and physiciansavailablelistings.

CONTINUING MEDICAL EDUCATION Michigan State University College of Human Medicine, accreditedby the Accreditation Council for Continuing Medical Education, certifies that this program meets the criteria for l8 hours of Category I toward the requirement for Michigan relicensureand the PhysiciansRecognition Award of the American Medical Association.The Annual Meeting has also requested18 hours ofCategory I credit from the American Collegeof EmergencyPhysicians.

PROCEEDINGS Proceeding of the Annual meeting will not be prepared as a separate publication. However, selectedpresentations,scientific papersand pertinent discussionswill be printed in theAnnals of EmergencyMedicine. thejournal of the American Collegeof Emergencyphysiciansand the University Association for Emergency Medicine. In addition, the abstractsfrom the 1986Annual meetingwill be publishedin the May 1986 issue of Annals of Emergency Medicine.

EXHIBITS The exhibitswill be availablefor viewing on May 13 from 1:00-4:00 pm and on May 14 from 8:00-11:00am and 3:00-4:30pm. The exhibits will be located in the Galleria Rooms on the same level as the oral presentationsand poster presentations.All coffee breaks on May 13 and May 14 will be held in the Galleria Rooms. Pleasetake an opportunity to view the exhibits during the scheduledcoffee breaks.Please review the exhibitor listing located in this program.

SPEAKERS'READY ROOM A speakers' ready room will be available for presenterswho wish to check their slides and run through their material in advance of their presentation.The speakers'ready room will be located in the Ballroom Check Room and keys will be available at the UA/EM Registration Desk.

BANQUET A free ticket to the Annual Meeting banqueton Thursday evening, May 15, is availableto every active, associateor internationalmember of UA/EM attendingthe Annual Meeting. Tickets can also be purchasedfor $35. You must indicate to the UA/EM staff that you will be using your free ticket or purchasing additional tickets by 10:00 am on Wednesday, May L4. The 1986Annual Awards Banquetwill be held at the World Forestry Center which is only a short distance from the Portland Hilton. Transportation will be provided. The buses will begin shuttling registrantsto the banquetat 6:00 p.m. An Oregan winetasting is being plannedat the Forestry Center prior to dinner. Following dinner, the annualpresentationof the Imago Obscuraand JamesMackenzieAwards will begin. Last year's winner of the Imago ObscuraAwards, Jerris Hedges,MD, and last year's winner of the JamesMackenzieAward, Blaine White, MD, will provide the entertainmentas they review this year's entries for the awards and make the presentationsfor 1986.The awardsare real, but the presentationsare tongue-in-cheek.Expecta hilarious ending to a fun-filled evening.

SPOUSEPROGRAMS Tours of the Portland area sites are being arranged for spousesand otherswho wish to seethe local attractions.A trip to the coastis being plannedfor Wednesday, May 14 and a trip to the ColumbiaRiver Gorge is being plannedfor Thursday, May 15. In addition, on Friday, May 16, two toursare beingarranged.Participantswill havetheir choiceof visiting historic Mt. St. Helensor touring the Oregonwinerys. All tourswill cost approximately$40-$45includinglunch and will last abouteight hours. The UA/EM RegistrationDesk will haveadditional information and sign-up sheets.You must sign-up by May 13.

ANNUAL BUSINESSMEETING The Associationwill hold its AnnualBusinessMeetingfrom l2:00-l:00 pm on Thursday,May 15 in the Stater Ballroom. At the meeting,Steven J. Davidson, MD, will introduce incoming president, Richard M. Nowak, MD. Agenda items for the businessmeetingwill includethe election of officers and Council and committee members,officers' reports,and other itemsof businesspresentedby the membership.All membersof the Associationare urged to attend.

INDUSTRIAL RELATIONS COMMITTEE MEETING The UA/EM IndustrialRelationsCommittee,chairedby ErnestRuiz, MD, is conveninga meetingon Tuesday,May 13 from 7:00-8:30pm in the Council Suite.This meetingis designedto familiarize industrial represenativeswith the scope of EmergencyMedicine, a discussion of academicEmergencyMedicine and UA/EM, how the needsof industry can be met by academicEmergencyMedicine,and mutualconcernsof the investigatorand industryregardingproductdevelopment. Exhibitors representatives are encouragedto attendand participatein this meeting. InterestedAnnual Meeting registrantsare also encouraged to participate.This meeting will be an excellentopportunityfor industry representatives and physiciansto meet and discussinterestsin research,product development,etc.

EMERGENCY MEDICINE RESEARCH FELLOWS DINNER The University Associationfor EmergencyMedicineand the Society of Teachers of Emergency Medicine are jointly sponsoringthe


EmergencyMedicine ResearchFellows Dinner on Tuesday,May 13. During the dinner there will be five to ten minute presentationson the activities of various fellowship programs. The dinner will be held in the Forum Suite from 7:00-8:30 pm. Complimentary tickets are availableto Emergeniy Medicine fellows and their directors, however, pre-registration is required. Others wishing to attend the dinner can purchase tickets for $20 each. Be sure to indicate on the meeting registrationform if you will be attendingthe banquet.All tickets must be purchased by 3:00 pm on May 13.

METHODOLOGY SESSIONS UA/EM is pleasedto cosponsorthe methodologypaperswith the Society of Teachers of Emergency Medicine on Tuesday, May 13 from 1:00-4:45pm in the Rose and StateBallrooms of the Hilton Hotel. A coffee break will be held from 3:00-3:30 pm in the Galleria Rooms and the exhibits and posters will be open during this time. There is no registrationfee to attendthesejoint sessions.All registrants of either the UA/EM or STEM Annual meetings are invited to attend the methodologypaper sessions.

ACADEMIC DEPARTMENTS OF EMERGENCY MEDICINE PANEL

A panel discussion entitled "Academic Departments of Emergency Medicine - What Does it Mean," will be held on Wednesday,May 14 from 12:00-1:00pm in the StateBallroom. RichardC. Levy, MD, Director of the Department of Emergency Medicine at the University of Cincinnati, will moderatethe panel comprisedof other directors of departmentsof Emergency Medicine. The members of this panel are E. JacksonAllison, MD, Gail Anderson, MD, Glenn Hamilton, MD, and David Wagner, MD. Panelmemberswill discussthe value of departmental status and will describe their experience in regards to obtaining departmentalstatusin EmergencyMedicine. All interested registrantsare urged to attendthis panel discussion.There is no fee to attend this meeting.

response,no-code policies, brain death policies, computer tracking, quality assuranceand an update ofthe past year's data gathering.Interestedparticipantsare askedto bring the forms usedin their hospital. There is no fee to attend this meeting.

SCCM LIAISON COMMITTEE ON EMERGENCY MEDICINE On Thursday, May 15, the Society of Critical Care Medicine Liaison Commiftee on Emergency Medicine will meet in the Cabinet Suitefrom 5:15-6:45pm. This meetingwill discussthe plannedcreationof a section of Emergency Medicine in the Society of Critical Care Medicine (SCCM) for the purpose of Emergency Medicine input into SCCM critical care policy and for the exchange of ideas and information relating to the delivery of critical care by emergency physicians.Interested persons are invited to attend.

1987ANNUAL MEETING CALL FOR ABSTRACTS The 1987 Annual Meeting will be held May 20-22 in Philadelphia. The 1987 Call for Abstracts is published on the inside back coverof this program. Becausethere are changes in this year's abstractsub,

missionprocess,pleasereadthe Call for Abstractscarefullyandpost it in your institution.

1987UA/EM.IRIEM RESEARCHS ENVIRONMENTAL EMERGENCIES A schedule for the 1987UA/EM-IRIEM Research Symposium on vironmental Emergencies is included in this program. Please this scheduleand plan to attend the Symposium. The 1987 Symposium will be held February 22-24 at the SheratonSand Resort in Clearwater Beach. Florida. Pleasecontact the UA/EM fice if you would like additional information.

UA/EM MEMBERSHIP

IN-HOSPITAL CPR STUDY GROUPMEETING

A membership application is included in this brochure and additional copies are available upon request to the UA/EM office at 900

On Thursday, May 15 from 5:15-6:00 pm all interestedregistrants are invited to attendthe secondannualmeeting of the In-Hospital CPR Study Group meetingwhich will be held in the Rose Ballroom. The Study Group will discuss code blue evaluation forms, code blue

Ottawa,Lansing,Michigan48915or call (517)485-5484. If you not a member, pleaseconsider joining UA/EM. If you are alreadya member, give this application to a colleague. UA/EM needsyour sup. port for the growth and developmentof academicEmergencyMedicine.


KENNEDYLECTURE

Henry D. Mclntosh is a nativeFloridian; born in 1921in Gainesville, his family moved him at the early ageof 3 to West Palm Beach, Florida. He attendedthe public schoolsof that community and enteredDavidson College in Davidson, North Carolina, in 1939.After being accepted for medicalschool, he requestedthat his acceptancebe postponeduntil terminationof World War II and he volunteeredfor the U.S. Army Infantry in 1943as a Private. He was successfullyacceptedand completed the Infantry Officer Candidate School, the Airborne Parachute Infantry School, the Office of StrategicServices,and finally the Jedburgh Programofthe OSS. He parachutedbehindenemylines in both France and China to train and subsequentlyarm ResistanceForces. After receiving the Silver Star and the French Croix de Guerre with two Bronze Stars, he was dischargeda Captain in December 1945. Dr. Mclntosh graduatedfrom medical school at the University of Pennsylvaniain 1950 and had six years of clinical and researchtraining. He joined the full time faculty of Duke University in 195'7, and organized and directedthe CardiovascularDivision of Duke University. He attainedthe rank of full Professorof Medicine in 1962. In 1970,he was appointedProfessorand Chairmanof the Department of Medicine of Baylor College of Medicine, and Chief of Cardiology of Baylor College of Medicine, as well as Chief of the Medical Service of the Methodist Hospital of Houston, Texas.In 1975, he joined the Watson Clinic in Lakeland, Florida, as a cardiologist. Dr. Mclntosh has been certified by the American Board of Internal Medicineand the AmericanBoard of CardiovascularDiseases.He has servedas a memberof both Boardsas well as being the representative of the American Board of Internal Medicine on the American Board of EmergencyMedicine. He is a memberof numerousscientificsocietiesincludingthe Association of American Physicians,the American Clinical and Climatologic Association,the Associationof Professorsof Medicine, the American College of Physiciansand the American College of Cardiology. He wasthe Presidentof the American Collegeof Cardiology in 1974-75, and he was Chairman of the Council of Clinical Cardioloev of the American Heart Associationin 1975-76. He has servedon the editorial board of numerousscientificjournals including the American Heart AssociationModern Concepts.He is currently the editor of the Baylor College of Medicine Cardiology Series.He has written over 250 scientificarticlesand hasbeena guest lecturer or visiting professor on numerous occasionsto numerous medicalcentersin this country and abroad. Dr. Mclntosh received the DistinguishedAlumni Award of Duke Universityin 1972, the FoundersAward of the SouthernSocietyfor Clinical Investigationin 1982, and was designateda Distinguished Fellow of the American College of Cardiology in 1982, He was elected an HonoraryMember of Rotary Internationalin 1985and was designed a Paul Harris Fellow Rotary Internationalin 1986. Dr. Mclntosh foundedHEARTBEAT INTERNATIONAL in October, 1984.

Henry was the first representativefrom the American Board of Internal Medicine to EmergencyMedicine. He cameon the boardat a time when emergency medicine was attempting to establishits identity and credibility with other boards, as well as with other specialitiesin the medical arena. The representativeson the Board of Emergency Medicine from the emergency medicine organizationswere cautious and suspicious of representativesfrom traditional disciplines, particularlythosemajor fields of medicineand surgery.It took Henry all ofone board meetingto removeour paranoiaand to recognizethe tremendousamount of experience,wisdom, integrity, and common sensethat he brought to this meeting. Shortly thereafter,he was elected to the ExecutiveCommitteeof ABEM and was continuallyre-elected to that position throughouthis entire time on the Board. In his quiet, sometimeslaid-backfashion,Henry alwaysrecognizedthe real issues, and invariably provided a strategy which was both fair and effective in the resolutionof problems. There are multiple Henry Mclntosh vignettesthat have made him a hero of mine, but perhapsnone is more typical than a situationwhich occuredone eveningwhen we were having a late-nightsandwichand a bottleof beer. We had beendiscussingthe valueof bedsidemedicine and complainingabouthow it occuredlessand lessin our currenteducational environment.Henry then askedifany ofus knew what was his blood pressure most usefulbedsideinstrument.After the stethoscope, cuff, ophthalmoscope,percussionhammer, etc. had all beenoffered as choicesrejected, Henry reachedinto his pocket and pulled out a "my "For you large pair of toenail clippers. see," he mentioned, typical patient is elderly, probably arthritic, and needsto talk to me abouthis achesand painsabout which we only havelimited medicinal answers.While he's talking, it is most useful for me to trim his toenails. Trimming toenailsis somethingthat is difficult to do, and bulky toenails provide a common sourceof discomfortto the patient.Finally, it provides for a senseof bonding with the patient which encourageshis free discussionof any problem." I submitto you, that's a real doctor, eminentresearcher,distinguished former departmentchairman, and clinician extraordinaire.It's been a personalprivilege to have been associatedwith him theselast six years on the American Board of EmergencyMedictne.

by David K. Wagner, MD

The University Association for Emergency Medicine is proud to welcome Dr. Mclntosh, and is honored to have speak at our 1986 Annual Meeting. UA/EM gratefully acknowledgesthe sponsorship of the 1986 Kennedy Lecture by Marion Laboratories.


UA/EM LEADERSHIP

StevenJ. Davidson, MD, President

EXECUTIVE COUNCIL StevenDavidson, MD, president Richard Nowak, MD, president-Elect Mary Ann Cooper, MD, Secretaiy/Treasurer Richard Levy, MD, past president Jack Peacock,MD, past president Barry Wolcott, MD, past president William Barson, MD, Councilman Robert Knopp, MD, Councilman Ernest Ruiz, MD, Councilman Judith Tintinalli, MD, program Committee JamesWoodburn, MD, EMRA Representative

COMMITTEES Constitution and Bylaws Patricia Sanner, MD, Charrman Robert Jorden, MD JamesNiemann, MD Education Thomas Stair, MD, Chairman JamesNiemann, MD ShermanPodolsky, MD JamesRoberts, MD Nominating Richard Nowak, MD, Chairman Richard Burney, MD Richard Levy, MD Jack Peacock,MD Blaine White, MD

Judith E. Tintinalli, MD Program Chairman

Program Judith Tintinalli, MD, Chairman Jerris Hedges, MD, Chairman-Elect Michael Callaham, MD G. Patrick Lilja, MD Arthur Sanders,MD Lindsey Horenblas, MD, local arransements John Moorhead, MD, local arrangerients

AD HOC COMMITTEES Governmental Affairs Richard Levy, MD StevenBarrett, MD Kenneth Iserson, MD David Wagner, MD J. Douglas White, MD Industrial Relations Ernest Ruiz, MD, Chairman Charles Babbs, MD Robert Knopp, MD Harvey Meislin, MD International Affairs Bruce Rowat, MD, Chairman Herman Delooz, MD SheldonJacobson,MD Wayne Longmore, MD Kenneth Mattox, MD Yasuhiro Yamamoto, MD 1986 UA/EM-IRIEM Research Symposium Douglas Rund, MD, Chairman Gary Fiskum, PhD

Jerris Hedges, MD Ronald Krome, MD Richard Nowak, MD

REPRESENTATIVES American Board of Emergency Medicine Gail Anderson, MD W. Kendall McNabney, MD Judith Tintinalli, MD

DavidWagner,MD ABEM Intraining Examination V. Gail Ray,MD JosephZeccardi,MD AMA Commissionon EmergencyMedicine Services PaulPepe,MD, delegate JackPeacock,MD, alternate ACEP ResearchCommittee PeterManingas,MD Annals of EmergencyMedicine Michael Callaham, MD, associateeditor AAMC Council of Academic Societies Michael Callaham, MD, delegate Thomas Stair, MD, delegate StevenDavidson, alternate Richard Levy, MD, alternate Emergency Medicine Foundation Barry Wolcott, MD

VADE MECUM PAST PRESIDENTS 1970-197l-Charles Frey, MD l97l-1972-Alan R. Dimick. MD 1972-1973-RobertB. Rutherford,MD 1973-1974-James R. Mackenzie,MD l9'74-197s-GeorgeJohnson,Jr., MD 1975-1976-Lestie E. Rudotf,MD 1976-1977-David K. Wagner,MD 1977-1978-CarlJelenko,III, MD 1978-1979-Ronald L. Krome,MD 1979-1980-Kenneth L. Mattox,MD 1980-1981-W.KendallMcNabnev. MD -MD l98l- 1982-Joseph F. Waeckerle, 1982-1983-BarryW. Wolcott,MD 1983-1984-Jack B. peacock, MD 1984-1985-Richard C. Levv. MD 1985-1986-sreven J. Davidson, MD

KENNEDY LECTURERS 1973-FraserN. Gurd, MD 1974-OscarP. Hampton,Jr., MD 1975-CurtisP. Artz, MD 1976-JohnG. Wiegenstein, MD 1977-Peter Safar,MD 1978-SenatorAlan M. Cranston 1980-EugeneL. Nagel,MD 1981-C. ThomasThompson, MD 1982-R AdamsCowley,MD 1984-DavidK. Wagner,MD 1985-RichardF. Edlich,MD, phD 1986-HenryD. Mclnrosh,MD

HONORARY MEMBERS 1973-RobertH. Kennedy, MDt FraserN. Gurd, MD C. BarberMueller,MD 1974-JohnG. Wiegenstein, MD AlexanderWalt, MD 1975-OscarP. Hampton,MDt N . H . M c N a l l yM , Dt CurtisP. Artz, MDt 1976-AnitaM. Dorr, RNt EugeneL. Nagel,MD 1977-Peter Safar,MD 1978-EbenAlexander, Jr., MD 1979-DavidR. Boyd,MD, CM l98l-R AdamsCowlev.MD 1982-CarlJelenko.III. MD


VADE MECUM BESTBASIC SCIENCEPAPER l985-Michelle H. Biros, MD, MS, University of Cincinnati "Post Insult Treatment of IschemiaInduced Cerebral fuictic Acidosis in the Rat"

BEST CLINICAL SCIENCE PAPER 1985-Harlan Stueven,MD, Medical Collese of Wisconsin " Bystander / First Responder CPR : Ten Years Experience in a Paramedic System"

BEST RESIDENT PAPER 1983-JeffreyA. Sharff,MD, OregonHealth Sciences University "Effect ofTime on RegionalOrganperfusion During Two Methods of CardiopulmonaryResus citation" 1984-GerardB. Martin, MD, Henry Ford Hospital "lnsulin and GlucoseLevels During CPRin the CanineModel" 1985-WilliamC. Dalsey,MD, andScottA. Syverud, MD, Universityof Cincinnati " Transcutaneous and Transvenous Cardiac Pacing For Early Bradyasytolic CardiacArrest"

1983-Charles F. University "lmproved

(Continued)

Babbs, MD,

Purdue

Cardiac Output During Cardiopulmonary Resuscitation with Interposed Abdominal Compressions" 1984-Charles G. Brown, MD, Ohio State University "Injuries Associated with the Percutaneous Placement of Transthoracic Pacemakers"

lst Annual Meeting May 14-15, l97l Ann Arbor, Michigan 2nd Annual Meeting May 12-13, 1972 Washington,D.C. 3rd Annual Meeting May 23-25, 1973 Hamilton, Ontario

BEST PRESENTATION 1980-Jacek B. Franaszek,MD, and Harold A. Jayne, MD, University of Illinois "Medical Preparationsfor an Outdoor Papal Mass" 1981-Robert W. Strauss,MD, Universityof Chicago "Expanded Role ofthe Barium Enema in the Acute Abdomen" 1982-Stephen R. Boster, MD, University of Louisville "Translaryngeal Absorbtion of Lido' caine' 1983-Sandra H. Ralston, MD. Purdue University " lntrapulmonary Epinephrine During Prolonged CardiopulmonaryResuscitation: Improved Regional Blood Flow and Resuscitation in Dogs" 1984-Paul M. Paris, MD, University of Pittsburgh "The Prehospital Use of TranscutaneousCardiac Pacinp "

BEST PAPER L977-Lawrence B. Dunlap, MD, Josephine General Hospital, Grants pass, Oregon " Percutaneous Transtracheal Ventilation During Cardiopulmonary Resuscitation" 1979-Albert E. Cram, MD, University of Iowa "The Effect of Pneumatic Anti-Shock Trousers on Interacranial pressure in the Canine Model" 1980-Blaine C. White, MD, Wayne State University "Mitochondrial 0, [Jse and ATp Synthesis: Kineric Effecrs of Ca'+ ind HPO,: Modulated by Glucocorticoids " 1981-Blaine C. White, MD, Wayne State University ' 'Correction of Canine Cerebral Cortical Blood Flow and Vascular Resistance Post Anest Using Flunarazine, A Calcium Antagonist" 1982-Carl Winegar, MD, Wayne State University, "Early Amelioration of Brain Damage in Dogs Afier Fifieen Minutes of Cardiac Arrest"

PAST ANNUAL MEETINGS

IMAGO OBSCURA AWARD 1976-NormanE. McSwain.Jr.. MD 1977-SungRock Lee, MD 1978-G. PatrickLilja, MD 1979-Stephen Karas,MD 1980-JackGoldberg,MD 1981-RobertKnopp,MD 1982-BlaineC. White,MD 1983-Richard C. Levy, MD 1984-GlennC. Hamilton,MD 1985-JerrisR. Hedges,MD

4th Annual Meeting May 28-Junel, 1974 Dallas, Texas 5th Annual Meeting May 20-24, 1975 Vancouver,British Columbia 6th Annual Meeting May 11-15, 1976 Philadelphia,Pennsylvania 7th Annual Meeting May 15-18, 1977 KansasCity, Missouri 8th Annual Meeting May l8-20, 1978 San Francisco, Californra 9th Annual Meeting May 24-26, 1979 Orlando, Florida 1OthAnnual Meeting April20-23, 1980 Tucson, Arizona l lth Annual Meeting April l3-15, 1981 San Antonio, Texas l2th Annual Meeting A p r i l 1 5 - 1 7 ,1 9 8 2 Salt Lake City, Utah l3th Annual Meeting June l-4, 1983 Boston, Massachusetts

MACKENZIE AWARD 1976-James R. Mackenzie, MD 1977-Cyril T. M. Cameron, MDt 1978-John H. Hughes,MD 1979-Joseph F. Waeckerle, MD 1980-Kenneth L. Mattox, MD l98l-Barry W. Wolcott, MD 1982-Hubert T. Gurley, MD 1983-Ronald L. Krome, MD 1984-Charles F. Babbs, MD 1985-Blaine C. White, MD

l4th Annual Meeting May 22-25, 1984 Louisville,Kentucky l5th Annual Meeting May 21-24, 1985 KansasCity, Missouri l6th Annual Meeting M a y l 3 - 1 5 ,1 9 8 6 Portland, Oregon


ANNUAL MEETING OVERVIEW Tuesday,May 13 9:00 - 12:00noon 10:00am - 5:00pm l:00 - 3:00pm

Annals Editorial Board meeting, Forum Suite UA/EM Registration, Ballroom Foyer Paper Session I, State and Rose Ballrooms

3:00- 3:30pm 3:30- 4:45pm 5:30- 7:00pm

Coffee Break, Galleria Rooms, EXHIBITS AND POSTERS OPEN

7:00- 8:30pm 7 : 0 0- 8 : 3 0p m

Emergency Medicine Research Fellows Dinner, Forum Suite

Paper Session II, State and Rose Ballrooms Cocktail Reception, International Club UA/EM Industrial Relations Committee meeting, Council Suite

Wednesday, May 14 7:00- 8:00am 8:00- 9:00am 9:00- 9:30am 9:30- 10:30am 1 0 : 3 0- 1 1 : 0 0a m l l : 0 0 - l 1 : 1 5a m l l : 1 5 - 1 2 : 0 0n o o n 1 2 : 0 0- l : 0 0 p m l : 0 0 - 3 : 1 5p m 3 : 1 5- 3 : 4 5p m 3 : 4 5- 5 : 1 5p m 5 : 1 5- 7 : 0 0p m 5 : 1 5- 7 : 0 0p m 5 : 1 5- 7 : 0 0p m 7:00- 10:00pm

BallroomFoyer, EXHIBITSAND POSTERSOPEN UA/EM Registration, PaperSessionIII, State and RoseBallrooms CoffeeBreak, Galleria Rooms,EXHIBITS AND POSTERSOPEN PaperSessionIII continued,State and RoseBallrooms CoffeeBreak, Galleria Rooms,EXHIBITS AND POSTERSOPEN State Ballroom Awards Presentations, KennedyLecture,State Ballroom AcademicDepartmentalStatuspanel,State Ballroom PaperSessionIV, State and RoseBallrooms CoffeeBreak,GalleriaRooms,EXHIBITSAND POSTERSOPEN PaperSessionV, State and RoseBallrooms EMRA Boardmeeting,CouncilSuite AmericanJournalof EmergencyMedicineEditorial Boardmeeting,Directors' Suite IRIEM Boardmeeting,Studio Suite UA/EM ExecutiveCouncilmeeting,Forum Suite

Thursday, May t5 7:00- 8:00am 8:00- 10:00am 1 0 : 0 0- 1 0 : 1 5a m l 0 : 1 5- 1 l : 3 0a m 1 l : 3 0- 1 2 : 0 0p m 12:00- l:00 pm

BallroomFoyer' POSTERSOPEN UA/EM Registration, PaperSessionVI, State and RoseBallrooms CoffeeBreak, Ballroom Foyer, POSTERSOPEN PaperSessionVII, State and RoseBallrooms PresidentialAddress,State Ballroom Meeting,StateBallroom UA/EM AnnualBusiness

l : 0 0 - 3 : 1 5p m 3 : 1 5- 3 : 3 0p m 3 : 3 0- 5 : 1 5p m

PaperSessionVIII, State and RoseBallrooms CoffeeBreak, Ballroom Foyer' POSTERSOPEN PaperSessionIX, State and RoseBallrooms

5 : 1 5- 6 : 0 0p m 5 : 1 5- 6 : 4 5p m 6:30- 10:00pm

NAEMSP informationalmeeting,State Ballroom Medicinemeeting,CabinetSuite on Emergency SCCM LiaisonCommittee UA/EM Annual AwardsBanquet,World Forestry Center


University Associationfor EmergencyMedicine SixteenthAnnual Meeting Scheduleof Events May 13-15, 1986

ORAL PRESENTATIONS Tuesday,May 13, 1986 9:00 - 12:00 noon UA/EM Poster Set-Up, Parlor Rooms 9:00 - 12:00 noon Annals of EmergencyMedicine Editorial Board Meeting, Forum Suite 10:00 - 5:00 pm UA/EM Registration, Ballroom Foyer 1:00 - 3:00 pm Paper SessionI Track A - Methodology, State Ballroom

Track B - Methodology, Rose Bsllroom

Moderator: Kenneth Iserson, MD, University of Arizona

Moderator: Michael Callaham, MD, University of Califurnia, San Francisco

l. Teaching Researchin the Emergency Medicine Residency Curriculum, Jffiey Jones, MD, Akron General Medical Center 2. A Geriatric Curriculum for Emergency Medicine Training Programs, J"ffrey Jones, MD, Akron General Medical Center 3. Adaptation of a Three Year Core Curriculum From the New Core Content in EmergencyMedicine, Mark Eilers, MD, Wright State University 4. A Study of Emergency Medicine ResidencyCurricula, Edward Sloan, MD, University of lllinois 5. A Survey of Requirementsfor Emergency Medical Services Experience in Emergency Medicine Residencies, Paul Paris , MD, University of Pittsburgh and the Society of Teachersof Emergency Medicine 6. Development and Evaluation of a One-Month Research Track in Emergency Medicine for Medical Students,Ira Gold, MD, University of lllinois 7. Use of Simulated Patients in a Freshman Emergency Medicine Course, William Burdick, MD, Medical College of Pennsylvania 8. Home Placement of Automatic External Defibrillators Among Survivors of Ventricular Fibrillation, Mickey Eisenberg, MD, PhD, King County Department of Health, Seattle

3:00 - 3:30 pm Coffee Break, GaUeria Rooms Exhibits Open, Galleriu Rooms Posters Open, Parlor Rooms

9. VentilationSkills of EmergencyMedical Technicians:A TeachingChallengefor EmergencyMedicine, Richard Cummins,MD, Universityof Washingtonand King County Emergency Medical Services, Seanle 10. MeasuringValuesand JudgementSkills in Field Performance of Paramedics,Alice Gorgen, RN, Creighton University 11. A MedicalSchool'sRole in EMS Education,Harry Chen, MD, George Washington University 12, Use of a ComputerizedPracticeProfiler for PeerReview and Cost Containment, Stanley Wohl, MD, Stanford University 13. Satisfactionwith Practices:EmergencyPhysiciansversus Internists, Jane Murphy, PhD, University of Pennsylvania 14. Burnout and Emergency Medicine - A Case Study in Michigan, Raywin Huang, PhD, Michigan State Universiry 15. Survey of Emergency Medicine Faculty in Academic Centers, Paul Adler, DO, ThomasJffirson University 16. SabbaticalYear for EmergencyDepartmentFaculty, John Moorhead, MD, Oregon Heahh Sciences University


3:30 - 4:45 pm Paper SessionII Track A - Methodology, State Ballroom

Track B - Administration, RoseBallroom

Moderator: Thomas Stair, MD, Georgetown University

Moderator:Barry Wolcott,MD, WestPointMilitary Academy

17. ReferencingErrors in the Emergency Literature, Gabor Kelen, MD, Johns Hopkins Hospital and Ohio State University 18. An Analysis of the Emergency Medicine Literature: Its Relevanceto the Practitioners,Educatorsand Researchers of Emergency Medicine, Myron Milk, MD, University of Arizona 19. Dynamic Dysrthythmia Recognition: Development and Evaluation of Computer Assisted Instruction System, Gordon Culner, MD, New York Medical College 20. Mega Code Evaluation: The Development of Graded Criteria, Helenka Marcinek, MD, Oregon Health Services Universiry 21. Alcohol and Substance Abuse Prevention: Changing Perceptionsof Riskinessin Drinking, Drugs and Driving, Edward Bernstein, MD, University of New Mexico

2 2 . Informed Consent and Emergency Care: Illusion and Reform, Eugene Boisaubin, MD, Baylor College of Medicine 2 3 . The ObservationGap: The ObservablePatient in the DRG Era, Louis Graff, MD, New Britain General Hospital, Connecticul 24. PatientCompliancein Filling PrescriptionsAfter Discharge,. From the EmergencyDepartment, CharlesSaunders,MD,t Vanderbilt University 2 5 . The Transfer of PatientsBetweenEmergencyDepartments: A Prospective Study, Steven Schwaitzberg, MD, College of Medicine and Ben Taub General Hospital 26. Computer AssistedQuality Assurancein the Department, Edward Luknwski, MD, Johns Hosnital

5:30 - 7:00 pm UA/EM-STEM Cocktail Reception,International Club 7:00 - 8:30 pm UA/EM STEM EmergencyMedicine ResearchFellows Dinner, Forum Suite - all exhibitor 7:00 - 8:30 pm UA/EM Industrial RelationsCommitteemeetingwith Exhibitor Representatives and interestedregistrants are invited to attend. Council Suite

Wednesday,May 1"4 7:00 - 8:00 am UA/EM Registration (Coffee and Rolls), Galleria Rooms Exhibits Open, Galleria Rooms Posters Open, Parlor Rooms 8:00 - 9:00 am Paper SessionIII Track A - Cardiopulmonary Resuscitation, State Ballroom

Track B - EmergencyMedical Services,RoseBallroom

Moderator: Charles Brown, MD, Ohio State University

Moderator: William Bickell, MD, Baylor College of

27. Decline in Systemic Arterial Pressurewith Increasing CPR CompressionRate in Man, Joseph Ornato, MD, Medical College of Virginia 28. Electromechanical Dissociation with Directly MeasureableArterial Blood Pressures,CharlesBerryftnn, MD, University of South Alabama 29. Post-DefibrillationIdioventricular Rhythm: A Salvageable Condition, Jerome Hoflrnan, MD, University of Califurnia at Los Angeles 30. Determinantsof Electro-Mechanical DissociationDuring Cardiac Arrest, Kim Sutton, RN, Universiryof Pittsburgh

9:00 - 9:30 am Coffee Break, Galleria Rooms Exhibits Open, Galleria Rooms Posters Open, Parlor Rooms

31. PrehospitalIndex: A Multicenter Trial, Stuart MD, Butterworth Hospital, Grand Rapids 32. The Ability of Triage Criteria to PredictInjury

in a County-WideTraumaSystem,JeffreySharff, Sl. Vincent Hospital and Oregon Health Sci

University 33. The RelationshipBetween Total PrehospitalTime Outcomein Patientswith PenetratingTrauma,Paul MD, Baylor College of Medicine and Ben Taub Hospital 34. BLS vs. ALS for Trauma in an Urban Setting,C. Cayten, MD, New York Medical College


9:30 - 10:30 am Paper SessionIII continued 35. Femoro-FemoralCardiopulmonaryBypassin the Treatment of Prolonged Canine Cardiopulmonary Arrest, Gerard Martin, MD, Henry Ford Hospital 36. Emergency CardiopulmonaryBypass After prolonged Cardiopulmonary Resuscitation Basic Life Support in Dogs Improves Survival, Robert Levine, MD, University of Pittsburgh 37. The Value of TransthoracicPacing in the Face of Ventricular Asystole,Robin Eisner, MD , Universityof lllinois 38. PresentingCardiac Arrest Rhythms and Their Relationship to SubsequentMortality and Neurologic Recovery, Kim Sutton, RN, University of Pittsburgh

39. Epidemiologyof PediatricPrehospitalCare, Albert Tsai, MD, Valley Medical Center 40. PrehospitalAdvancedLife Supportfor Critically Injured Victims of Blunt Trauma, A. Adam Cwinn, MD, Denver General Hospital 41. PrehospitalCare at a Major International Airport, ,4. Adam Cwinn, MD, Denver General Hospital 42. Bacterial Contamination of Ambulance Oxygen Humidifier Water Reservoirs: A Potential Source of Iatrogenic Infection, Julia Cameron, MD, Medical College of Virginia

10:30 - 11:00 am Coffee Break" Gsllerin Rooms Exhibits Open, Galleria Rooms Posters Open, Parlor Rooms 11:00 - 11:15 Awards Presentation. State Ballroom UA/EM-MICROMEDEX 1985 Annual Meeting Besr Clinical Sciencepaper Bystander/FirstResponderCPR: Ten Years Experiencein a ParamedicSystem,Harlan Stueven,MD, Medicat Cotlegeof Wisconsin uA/EM-Emergency Medicine 1985 Annual Meeting Best Basic Sciencepaper Post-Insult Treatment of Ischemia-Induced Cerebral Lactic Acidosis in the Rat, Michelle Biros, MD, University of Cincinnati Annals of Emergency Medicine 1985 UA/EM Annual Meeting Best Resident paper Transcutaneousand Transvenous Cardiac Pacing for Early Bradyasytolic Cardiac Arrest, Scott A. Syverud, MD, and William C. Dalsey, MD, University of Cincinnati 11:15 - 12:00 noon Kennedy Lecture, Stute Ballroom "The Maturation of a Cardiologistwith Reflectionson the PassingSandsof Time," Henry D. Mclntosh, MD, Sponsoredby Marion Laboratories 12:00 - 1:00 Panel Discussion: Academic Departments of Emergency Medicine - What Does it Mean, State Ballroom, Richard Levy, MD, moderator, Department of Emergency Medicine, University of Cincinnati E. Jackson Allison, MD, Department of Emergency Medicine, East Carolina University Gail Anderson, MD, Department of Emergency Medicine, University of Southern Califurnia Glenn Hamihon, MD, Department of Emergency Medicine, wright state university David Wagner, MD, Department of Emergency Medicine, Medical Cotlege of Pennsylvania 1:00 - 3:15 am Paper SessionIV Track A - Cardiopulmonary Cerebral Resuscitation, State Track B - Shock, Rose Ballroom Ballroom Moderator: James Niemann, MD, Harbor-UCLA 43. Brain Cortex TissueCalcium, Magnesium,Iron, Sodium and PotassiumFollowing ResuscitationFrom a Fifteen Minute Cardiac Arrest in Dogs, Ann Marie Garritano, Michigan State University and Butterworth Hospital 44. Effect of DeferoxamineTherapy on Ultrastructureand BiochemicalMarkers of NeuronalInjury at Eight Hours of ReperfusionFollowing a Fifteen Minute CardiacArrest in Dogs, Mark Goosman, MD, Michigan State University and Butterworth Ho spital 45. Effect of Superoxide Dismutase Therapy on Ultrastructure and BiochemicalMarkers of Neuronal Injury at Eight Hours of Reperfusion Following a Fifteen Minute Cardiac Arrest in Dogs, Gary March, DO, Michigan State Universiry and Mt. Carmel Hospital 46. Natural Courseof Iron Delocalizationand Lipid peroxidationDuring the First Eight Hours Following a Fifteen Minute Cardiac Arrest in Dogs, Gary Krause, MD, Michigan State University and Butterworth Hospital

Moderator: Joseph Clinton, MD, Hennepin County Medical Center 52. Saline ExpandedType O UncrossmatchedPackedRed Blood Cells as an Initial ResuscitationFluid in Severe Shock, Ian Civil, MBCHB, Rutgers Medical School at Camden 53. The Use of 1.5% NaCLl6% Dextran 70 for the Treatmentof SevereHemorrhagicShockin Swine,PeterManingas, MD, Letterman Army Institute of Research 54. Treatment of Hemorrhagic Shock with Interosseous Administrationof CrystalloidFluid, RobertMorcis,MD, Children's Hospital of Los Angeles 55. The HemodynamicEffects of Acute Ethanol in Hemorrhaged Dogs, James Gruber, MD, Denver General Hospital 56. EndotrachealDrug TherapyDuring HypovolemicShock, Sharon Mace, MD, Mt. Sinai Medical Center, Cleveland


Track B - (continued)

Track A - (continued)

57. Transcutaneous Oxygen Tension MeasurementsDuring HemorrhagicHypoperfusionUsing Trendelenburgandthe PneumaticAntishock Garment, WilliamJaffurs, Jr., MD, East Carolina Universiry 58. Usefulnessof Volume-ControlledSevereHemorrhagic Shock Outcome Model in Monkeys, Normnn Abramson, MD, University of Pittsburgh 59. Improved Hemodynamics After Administration of Dichloroacetatein a CanineHemorrhagicShockModel, William Barsan, MD, Universiry of Cincinnati 60. Adequacyof AminoglycosideLoading in Acute Sepsis, Michael Jastremski, MD, State Universiry of New York

47. CerebralIschemiaand Reperfusion:Mitochondrial Injury and Recovery, Robert Rosenthal, MD, George Washington University 48. Brain LactateDynamics During Partial Global Ischemia and Reperfusionin the Rat, Michelle Biros , MD, University of Cincinnati 49. Comparisonof SodiumBicarbonatewith Dichloroacetate Treatment of Serum Lactic Acidosis in the Rat, Ruth Dimlich, PhD, University of Cincinnati 50. Effect of Anoxic Reperfusion-SuperoxideDismutaseDeferoxamine Therapy on Cerebral Blood Flow and Metabolismand Somatosensory Evoked PotentialsAfter Asphyxial CardiacArrest in Dogs, Erga Cerchiari, MD, University of Pittsburgh 51. Serum Glucose Concentration and Brain Pathologic Responseto Circulatory Arrest, Ronald Myers, MD, PhD, VeteransAdministration Medical Center, Cincinnati

3:15 - 3:45 CoffeeBreak, GailertaRooms PostersOpen - presentersavailable for discussion,Parlor Rooms Exhibits Open, Galleria Rooms

3:45 - 5:15 pm Paper SessionV Track A - Cardiopulmonary Resuscitation, Stqte Bullroom

Track B - Medicine, RoseBallroom

Moderator: Harlan Stueven,MD, Medical College of Wisconsin

Moderator:RichardNowak,MD, Henry Ford Hospital 66. ParenteralHaloperidol in CombativePatients:A tive Study, Steven Silverstein, MD, Denver Hospital 67. Haloperidol for Sedationof Disruptive Emergency tients, Joseph Clinton, MD, Hennepin Counry Center 68. PhenytoinLoading in ChronicAlcoholic Patients, Welch, MD, WayneState University and Detoit ing Hospital 69. Prophylaxisof Alcohol Withdrawal Seizures:A tive Study, John Marx, MD, Denver General 7 0 , Developmentof Clinical Criteria for the Rational ing of Serum Electrolytes, Robert Lowe, MD, Vr Medical Center, Group Health Cooperative of Sound and Universiry of Michigan 71. Effectsof Dichloroacetatein SpinalStrokein the William Barsan, MD, University of Cincinnati

61. Neurologic Benefits From the Use of Early Cardiopulmonary Resuscitation, Arthur Sanders, MD, University of Arizona 62. The Comparative Effects of Epinephrine and Phenylephrineon RegionalCerebralBlood Flow During CardiopulmonaryResuscitation,Charles Brown, MD, Ohio State University 63. The Effects of Varying Dosesof Epinephrineon Regional Myocardial Blood Flow During Cardiopulmonary Resuscitationin a Swine Model, Howard Werman,MD, Ohio State University 64. Hypoxic-HypotensiveExposuresin Cats: Early Predictors of Brain and Heart Injury, Gabrielle de CourtenMyers, MD, University of Cincinnati and VeteransAdministation Medical Center 65. DichloroacetateTreatmentof Ischemic Cerebral Lactic Acidosis in the Fed Rat, Justin Kaplan, MD, Universiry of Cincinnati

5:15 - 7:00 pm Emergency Medicine Residents' Association Board meeting, Council Suite 5:15 - 7:00 pm American Journal of Emergency Medicine Editorial Board meeting, Directors' Suite 5:15 - 7:00 pm International Research Institute for Emergency Medicine Board of Directors meeting, Studio Suite 7:00 - 10:00 pm UA/EM Executive Council meeting, Forum Suite

r0


Thursday,May 15 7:00 - 8:00 am UA/EM Registration, (Coffee and Roils), Ballroom Foyer 8:00 - 10:00 am Paper SessionVI Track A - CPR/Cardiology, State Ballroom

Track B - Pediatrics, Rose Bqllroom

Moderator: Peter Maningas, MD, Letterman Army Institute of Research

Moderator: Robert Kowalski, MD, William BeaumontHospital

72. PostcountershockPulseless Rhythms: Hemodynamic Effects of Glucagonin a Canine Model, Kevin Haynes, MD, University of Califurnia at Los Angeles and Harbor-UCLA 73. The Effect of Epinephrine on Cardiovascular Hemodynamics During Metabolic Acidosis, Robert Domeier,MD, WayneState(Jniversityand Detoit Receiving Hospital 74. Selective Venous Hypercarbia During Human Cardiopulmonary Resuscitation: Implications Regarding Blood Flow, Richard Nowak, MD, Henry Ford Hospital 75. Effects of Diltiazem Infusion on Coronary perfusion PressureDuring CanineCardiopulmonaryResuscitation: A Preliminary Report, Mark Howard, DO, Henry Ford Hospital 76. MagnesiumLevels in Cardiac Arrest Victims: Relation to SuccessfulResuscitation,Louis Cannon, MD, Akron General Medical Center 77. SomatosensoryEvoked Potentials During Cardiac Resuscitationin the Dog, Cffion Sheets,MD, Wright State University 78. Use of Cardiac EnzymesIdentifies patients with Acute Myocardial Infarction Otherwise Unrecognizedin the EmergencyDepartment, Jerris Hedges, MD, University of Cincinnati 79. The PredictiveValue of the Initial Emergency Department EKG for Life-Threatening Complications of Myocardial Ischemia,Robert Zalenski, MD, Universin of lllinois

80. Ventilation of Infants During Resuscitation:Mask-Bag versusMouth to Mouth Ventilationby pre-hospitalpersonnel,Robert Kanter, MD, State Universityof New york 81. Comparisonof Arterial and Venous Blood Gasesin Pediatric Resuscitation,Grace Caputo, MD, Children,s Hospital of Philadelphia 82. HypokalemiaComplicatingEmergencyFluid Resuscitation in Children, Daniel Malone, MD, Medical College of Pennsylvaniaand Children's Hospital of philadetphia 83. Evaluationof the "Tilt Test" in Children,SusanFuchs, MD, The Children's Memorial Hospinl and Northwestern University 84. Fluid Resuscitation From Above or Below the Diaphragm in a PediatricAnimal Model of Liver LacerationFrom Blunt AbdominalTrauma,Gary Fleisher,MD, Children's Hospital of Philadelphia and University of pennsvlvania 85. Reflex Bradycardiaand Asystoly Occuring in Response to Fright, Pain, Venipuncture:Diagnosis by Vagal Stimulation Test, Joseph Ramet, MD, IJniversity oJ' Brussels, Belgium Free University, Betgium 86. Relationshipof Bacteremiato AntipyreticTherapy, Leslie Yamamoto,MD, Christ Hospital, Michael ReeseHospitul and West Suburban Hospital, Chicago 87. Acoustic Otoscopy in the Diagnosisof Otitis Media, Dietrich Jehle, MD, Allegheny General Hospiral

10:00- 10:15am Coffee Break, Ballroom Foyer PostersOpen - presentersavailable for discussion,parlor Rooms

10:15- 11:30 pm Paper SessionVII Track A - Radiology, Stste Ballroom

Track B - Techniques,RoseBallroom

Moderator: William Spivey, MD, Medical College of Pennsylvania

Moderator:StevenDronen,MD, Universityof Cincinnati

88. The Accuracy of Interpretationof Head CT Scansby EmergencyPhysicians, Todd Chffin, MD, Butterworth Hospital and St. Francis Hospital 89. High Yield Clinical Criteria for Computerized Tomography(CT) Scansof the Head in pediatric Head Trauma, Derek Taniguchi, BS, Harborview Medical Center, Seattle

93. T h e I n c i d e n c e o f V a s c u l a t u r e a t R i s k D u r i n g Cricothuroidostomy, Charles Little, BA, University rl' OsteopathicMedicine and Health Sciences,Des Moines 94. PlasmaAtropine Concentrationsvia the Intravenous,Endotracheal,and Intraosseous Routesof Administration, Mark Prete, MD, Mctdigan Army Medical Center ll


Track A - (continued)

Track B - (continued) 95. PathologicalEffects of EndotrachealDiazepamin Cats, Michael Rusli,MD, Medical Collegeof Pennsylvaniaand Chester Counry Hospital 96. Intraosseous Infusion Flow Rates in Hypovolemic "Pediatric" Dogs, Dee Hodge, III, MD, Children Hospital of Los Angeles and Children's Hospital Philadelphia 97. ComparativeStudy oflntraosseousversusIntravenous fusion of Phenobarbital, Kris Brickman, MD, St. Medical Center/The Toledo Hospital

90. A ProspectiveStudy Identifying the Efficacy of Clinical Findingsand the Sensitivityof RadiographicFindingsin Carpal Navicular Fractures,Joseph Waeckerle,MD, Baptist Medical Center and University of Missouri 91. Utility of the Chest Radiographin Non-Traumatic Inspiratory Chest Pain, R. Phillip Dellinger, MD, Baylor College of Medicine 92. MeasuredExposureto Ionizing Radiationin the Emergency Department From Commonly Performed Portable Radiographs,Richard Grazer, MD, Universityof Arizona

1l:30 - L2:00 noon Presidential Address. State Ballroom StevenJ. Davidson, MD, Medical College of Pennsylvania 12:00 - 1:00 pm UA/EM Annual Businessmeeting, State Ballroom

1:00 - 3:15 pm Paper SessionVIII Track A - Medicine. State Ballroom

Track B - Techniques/Helicopters, RoseBallroom

Moderator: Jonathan Jui, MD, OreRon Heahh Sciences University

Moderator:ErnestRuiz,MD, HennepinCountyMedical

98. Usefulnessof the Stool Wright's Stainin the Emergency Department,David DuBois, MD, TexasTech Universiry 99. Self-Treatmentwith Antibiotics, Mark Puczynski,MD, Inyola University 100. The Detection and Treatment of Sexually Transmitted Diseasesin the Emergency Department, Ray Mayron, MD, Hennepin Counry Medical Center l0l. SexualAssaultExamination:Medical and Legal Implications, Beth Rambow, BS, University of Minnesota and Hennepin County Medical Center 102. Accuracyof Urine UrobilinogenandBilirubin Assaysin Predicting Liver Function Test Abnormalities, Thomas Kupka, MD, Texas Tech University 103. The Effectiveness of Nalbuphineand Hydroxyzinefor the Treatmentof SevereHeadachein the EmergencyDepartmenr, Deniz Tek, MD, Naval Hospital, San Diego 104. SuicideAssessment in the EmergencyDepartment,Robert Rothstein, MD, Harbor-UCLA 105. Use of the Emergency Department for Hypertensive Screening,StevenChernow,MD, Universityof Arizona 106. The Effects of Naloxone in Patientswith Acute Exacerbation of COPD, David Frommer, MD, Boston City Hospital

IO7. A Comparisonof Intraosseousand IntravenousCBC Astra 8 in Swine, Henry Unger, MD, Medical of Pennsvlvania 1 0 8 .A Comparisonof Bupivacaineand Lidocaineas Anestheticsfor Reducins Pain After Wound William Spivey, MD, Medical College of Pennsyl 109.EffectivenessofPeritoneal Lavasein the Presenceof traabdominalAdhesion, William Gunnar, MD, Uni

siryof lllinois 1 1 0 .Diagnostic PeritonealLavage: Accuracy in NecessaryLaparotomy, Philip Henneman,MD, siry of Califurnia and University of Colorado 1 1 1 The . Efficacy of PneumaticTrousers in the Managementof PenetratingAbdominalInjuries, Bickell, MD, Baylor College of Medicine and Houston-Fire Deoartment 112. EmergencyAeromedicalTransport of Patientswith Myocardial Infarction, Richard Burney,MD, Uni of Michigan I 1 3 . Critical Care Transport of Cardiac Patients: Ground?,SandraSchneider,MD, Universityof t 1 4 . Utilization Prediction for Emergency Medical Heli Services:A Multifactorial Approach, David Wilcox' New England Life Flight and University of l 1 5 . Threshold, Enzymatic, and Pathologic C Associated with Prolonged TranscutaneousPacing Chronic Heart Block Model, Scott Syverud,MD, sity of Cincinnati

3:15 - 3:30 pm CoffeeBreak, BallroomFoyer PostersOpen - presentersavailablefor discussion,Parlor Rooms


3:30 - 5:15 pm paper SessionIX Track A - Toxicology, State Bsllroom Moderator: Scott Syverud, MD, University of Cincinnati 116. Cocaine AssociatedSudden Death Syndrome, Steven Karch, MD, Stanford (Jniversity 117. Indicationsfor IntensiveCareUnit Admission in Tricyclic Overdose, Charles Emerman, MD, Cleveland Metropolitan General Hospital 118. ElectrocardiographjcCriteria for Tricyclic Antidepressant Cardiotoxicity, Howard Bessen, MD, (Jniversity of Califurnia at Los Angeles and Harbor_UCLA ll9. Failure of eRS Interval as a Toxicity predictor in EmergencyDepartmentTricyclic Antidepressant Over_ dosedPatients,Garrett Foulke, MD, University of Califur_ nia, Davis 120. Multiple Dose Activated Charcoal in Intravenous SalicylateIntoxicationin a Dog Model, John Wogan,MD, Denver General Hospital l2l. In Vitro Bindingof fi + Ion Using a ClinicatCationEx_ Resin (KayexalareR;, Jon-Gehrke, MD, Truman :lulg" Medical Center 122. The Evaluarion of the Effect of Cimetidine on the Hepatotoxicityof Amanita phalloidespoisoning, Sandra Schneider,MD, Llniversity of pittsburgh and Fittsburgh Poison Control Center

Track B - Trauma/Environment,

RoseBallroom

Moderator; C. Gene Cayten, MD, New york Medical Coilege 123. Role of Antibiotics in the Treatmentof Extremity Gun_ shot Wounds, paul McCormick, MD, Indiana (Jniversiry 124. El.ectrocardiographic Findings in parientsUnder Forty with RadionuclideDocumentedCardiac Contusion, R. Scott French, MD, Harbor-UCLA and UCLA School of Medicine 125.Nuclear Scanning in the Diagnosis of Acute DiaphragmaticInjury, Sally Coates,MD, arizoro Heatth SciencesCenter and University of Calfornia, Irvine 126. TraumaticAsphyxia Following a Crowd_Crush Disaster: The "Heizel Drama,,, Luc Corne, MD, Free (Jniversity of Brussels, Belgium 127. Rewarmingin Hypothermia:Radio Wave vs Inhalation Therapy in Immersion and Ambient Air Hypothermia Models, J. Douglas Wite, MD, Georgetown (Jniversity 128. Evaporation versus Iced Gastic Lavige Treatment of Heatstroke;ComparativeEfficacy in a ianine Model, -/. Douglas Wite, MD, Georgetown (Jniversry 129. carboxyhemogrobinLevers in patients with Fru-Like Symptoms,Michael Dolan, MD, and T.L. Haltom, MD, Unive rsity of Louisvitte

5:15- 6:00 pm National Associationof EMS Physiciansinformational meeting, state Ballroom 5:15- 6:00 pm In-Hospital CpR Study Group meeting, RoseBallroom 5:15' 6:45pm societyof critical care MedicineLiaison committee on Emergency Medicine, cabinetsuite 6:30- 10:00pm UA/EM Annual Awards Banquet, World ForestryCenter

POSTERPRESENTATIONS l'30' EmergencyDepartmentExperience with suddenDeath: A Survey of Survivors, Gary parrish, MD, Geisinger Medical Center 131, The Literature of Emergency Medicine: A Citation Analysis, Rodney Smith, MD, State University of New York 132. A Computer-AssistedEmergency Department Chart Audit, David Overton, Un, Wittiim Beiumont Hospital 133. Curriculumfor TrainingResidentsin EmergencyMedical Services,Edward Otten, MD, University of Cincinnati 134. A ProspectiveEvaluationof Inflight Medical Emergen_ cieson CommercialAirlines, Cail Speizer, MD, MpH, Harbor-UCLA 135. Profiling Aeromedical Service performance Using TherapeuticIntervention Scoring, Richard Burney, Ui, University of Michigan, Univeisity of Catifornia, and University of Wisconsin 136. Use of the Rapid Accute physiology Score (RApS) to Analyze the physiological Status oi puti.ntr, Kenneth Rhee, MD, University of Califurnia at Davis

137. Methemoglobin LevelsFollowingIntravenous Lidocaine Administration, Michael Helter, MD, IJniversitlt rsf Pittsburgh 138. OxygenEnrichmentof Bag_MaskUnits During positive PressureVentilation, ThomasCempbeil,MD, University of Pinsburgh 139. Role of Hypokalemiain Theophylline Seizures,Zea Borok, MD, University of pittsbuigh 140. OxygenDesaturation in Adults FollowingInhaledBron_ chodilator Therapy, Jerris Heclges, tuti, University of. Cincinnati l4l. Is ContinuousOn-LineMonitoringof Mixed VenousOx_ ygen SaturationBenefical?, Michaet Jastremski, MD, State University of New york 142. Techniquefor Determiningproper Depth of Oral Tracheal Tube Placemenrin the Critically Ill Ad-ultpatient, Mithael Spadafora, MD, University of Cincinnnati 143. ExhaledpCO, as a predictorof Endotracheal Tubeplace_ ment, Keven Mickelson, MD, Hennepin County Medical Center


I J 144. A,ComparativeStudyon Four Designsof Ankle Splints,I Arizona of Gary Halvorson, MD, Universiry 145. The Noninvasive Halo, StephenAmmerman,MD 146. Clinical Use of the Olecranon-ManubriumPercussion Sign in ShoulderTrauma, StephenAdams, MD, Northwestern Universiry 147. HyperbaricOxygen(HBO) in the Treatmentof Cutaneous Necrotic Arachnidism from Brown RecluseEnvenomation, Wendell Pahts, MD, Universiry of Arkansas 148. A Clinical Trial Using Syrup of Ipecac and Activated CharcoalConcurrently, Glenn Freedman,MD, Edward Krenzelok,Pharm. D., Universiryof Pittsburgh 149. The Radiopacityof IngestedMedications,Daniel Savitt, MD, UniversitY of Cincinnati View in Cer150. Clinical Utilizationof the Flexion/Extension vical Trauma, AIan Gravett, MD, Ottumwa Regional Health Center, Iowa and Hennepin Medical Center l5l.

The SpinolaminarLine and Normal Anatomyof the Adult Upper Cervical Spine, Alan Gravett, MD' Ottumwa Regional Heahh Center, Iowa and Hennepin Counry Medical Center

I 52. Evaluationof CervicothoracicJunctionInjury, Constance Nichots. MD, Texas Tech Universiry Criteria for CervicalSpineIn153. High Yield Roentgenophic juries, "/. Douglas Wite, MD, GeorgetownUniversity 154. StabWounds to the Abdomen: Failure of Blunt Probing to PredictPeritonealPenetration,RobertRosenthal,MD, George Washington UniversitY 155. Wound InfectionRateFrom Open PeritonealLavagePerformed in the EmergencyDepartment,Richard Grazer, MD, Universiry of Arizona 156. Mechanismof Farm MachineryInjuries,DeepakKapoor, MD, GeisingerMedical Center 157. Use of PneumaticAntishockTrousersin the Management of PediatricPelvic Fractures,Douglas Brunette,Hennepin County Medical Center 158. Intravenous Fluid Flow Beneath Inflated Antishock Trousers, Mary Muttin, MD, Wright State University 159. Effect of Antishock Trouser Inflation on Oxygen Transport Variables During Hemorrhagic Shock in the Dog, John McCabe, MD, Wright State University 160. Hemodynamic and Metabolic Effect of Ethanol in a Canine Hemorrhagic Shock Model, Brian Zink, MD, University of Cincinnati of HemodynamicStabilityFollowingMepl6l. Preservation tazinol Administration in Canine Graded Hemorrhage, StevenDronen, MD, University of Cincinnati 162. NaloxoneDoes Not Improve HemodynamicsFollowing CanineGradedHemorrhage,SusanGin, MD, Universin of Cincinnati

163. Rapid Bloodwarming by Saline Admixture Technique' Ethan Wilson, MD, University of Arizona of the Manufactureof Intravenous. 164. Non-Standardization Catheters, Kenneth Iserson, MD, University of Arizona 165. The Effect of Timolol Given Five MinutesPostCoronary Occlusion on Plasma Catecholamines,Claire lnthers' PhD, Medical College of Pennsylvania 166. Cardiopulmonary Resuscitation in Children, Arno Tnritsky, MD, George Washington University and Children's Hospital National Medical Center 167. The Effect of IntraosseousNaHCO, on Bone in Swine' Henry Unger, MD, Medical College of Pennsylvania Ad168. The Effect of Different Routesof SodiumBicarbonate Blood pH, and Catecholamines, Plasma ministrationon PressureDuring CardiacArrest in Pigs, WilliamSpivey' MD, Medical College of Pennsylvania 169. RegionalBlood Flow During CardiopulmonaryRes tion in a Swine Model, Ronald Taylor, MD, Ohio University 170. Hyperglycemia and Relative HypoinsulinemiaDu CaiAioputmonaryResuscitationin the CanineModel' lnbadie, MD, HenrY Ford HosPital 171. Hyperkalemia During Human Cardiopulmona Resuscitation:Incidenceand Ramifications,JamesCisr MD, Henry Ford liosPital

After( in CoronaryPerfusionPressures t 7 2 . Improvement Prelimi A Chist CardiacMassagein Humans: Report, Mark Howard, DO, Henry Ford Hospital t 7 3 . Theoretical Effect of Fluid Infusions During Card monary Resuscitationas Demonstratedin a Cot Model of the Circulation, Christian Tomaszewski, sylvania State UniversitY

t74. Emergency Cardiopulmonary Bypass After Cardiac Arrest in Dogs Improves Recovery, Levine, MD, Universiry of Piusburgh

and t 75 . OutcomeTrialsof FreeRadicalScavengers Dog Two in Arrest EntryBlockersAfter Cardiac Erga Cerchiari,MD, Universityof Piusburgh Injury of Post-Ischemic Characteristics 1 7 6 .Ultrastructural the Dog Brain Following a Fifteen Minute Cardiac rest and Eight Hours of Reperfusion,David Webb,' PhD, Michigan State Universityand Butterworth

t77 Inadequacyof Serum and CerebrospinalFluid of Brain Injury during the First Eight Hours ResuscitationFrom a Fifteen Minute CardiacArrest, Koehler, MD, Michigan State Universiryand Hospital 1 7 8 .Cerebral Resuscitation After Cardiac Arrest HetastarchHemodilution, Hyperbaric Oxygenatton Magnesiumlon, Douglas Brunette,MD, Hennepin ty Medical Center


Abstracts of the l6th Annual Meeting of the University Association for Emergency Medicine P49:t note: The-following 178 abstacts will be presented at the Annual Meeting of the University Association for Emergency Medicing in Portland, Oregon,May 13-16,1986.Fresenters' names appear n itailo,'where ptesenter is not naicatea, norZ *o, speciftedby the authors.

Methodology Session I- Teachr3e Researclr in the Emergency lfedicine Residency Gurriculum J Joies,J Dougherty,

D Schelble,L Cannon / Departmentof EmergencyMedicine, AkronGeneralMedical Center,NortheasternOhio Universities Collegeof Medicine,Akron . Researchin emergencymedicine is a necessarycomponent for the growth and developmentof the academii discipline. Although the need exists for competent physician investigators, most graduatesof emergency medicine residencieshave had little structured education in researchdesign and methodology. This is particularly true in community hospital programs with poor funding, limited facilities, and few siaff memlbersactivelv involved in research.Our purpose is to describe a research ".rrri"t'rlum designedto operate within a community based residencv program.This curriculum identifies a detailed set of educational obiectivesin research techniques with the expectation that upon completion of the residency program, the resident will be abli to critically evaluate medical literature and independently design a researchproiect. We have developed a specifii plan for -."iing these obiectives with coordinated seminars, ieadings, lournai clubs, researchprojects or exhibits, and professional conferences. Finally we suggestsome practical methods of motivating residentsand attending staff to pursue clinical investigation.

2 Geriatric Gurriculum for Emergency Medicine J Doughert!, L Cinnon,D lraining Programs J Jones,

Schelble/ Departmentof EmergencyMedicine,Akron General MedicalCenter,NortheasternOhio UniversitiesColleoe of Medicine,Akron The growing number of elderly in the United States will continue to increase the demand for emergency services over the next severaldecades.Although the emergency medicrne core curriculum, as defined by_the American College of Emergency physicians,requires mandatory training in pediatrics, there is no mention of geriatric care. A special body of knowledge regarding normal aging as well as the special presentation of diieasJin thi elderly,is required to provide optim-um care for the aged patient. lhls paper presents an integrated geriatric curriculum designed to operate within_a 3-year emergency medicine residency. this curriculum identifies specific educational obiectives for tiaining in geriatric emergencieswhich can be summarized as follows: l-i Understandand tre-atthe group of diseasespeculiar to the elderly. 2) Recognizethat there are certain diseasesand iniuries that prisent a different cljnical picture in old age.3| psychiatric problims are common in the elderly, and a precise differential diagnosis is vrtal lor proper management. 4) This population is very suscepti_ ble_todrug side-effectsand interactions.5| physical impairments and functional disorders often complicate diagnosis ani therapy. 6|,Diagnostic testing requires an understanling of how phyJlologlc changesin aging affect normal laboratory and radiologic values.These educational obiectives are further defined usinf a specific framework of didactic presentations, ioumal clubs, cise conferen"es,therapeutic audits, formal rotations, and use oi consultants. In addition to improved medical care, this format will providemore valuable educitional experiencesior the emergency medicine resident, and may strengthin positive attitudes tJwari geriatric medicine.

3 Adaptation of a Three.Year Gore Gurriculum from the New Gore Gontent in Emergency Medicine MA Eilers,GC Hamilton/ Departmenlof Emergency Medicine,Wright State UniversitySchool of Medicine,Davtdn, Ohio The secondCore Content of EmergencyMedicine publishedby the American College of EmergencyPhysiciansand the American Boardof EmergencyMedicine is an improved outline of skills and knowledgeareasthat define the specialtyof emergencymedicine. Its publication resulted in a perceivedneed to trlnslate this revised list into a three-yearCore Curriculum for resident training. This curriculum would guide the planning, delivery, and tracking of the didactic component of a graduaie training program in emergencymedicine. AJter reviewing the first Emergency Medicine Core Content published in 1979,the Core Curriculum proposed by Hamilton in l9Bl, and the ACEp Length of Res_idencyTiaining Thsk Force Report for 1983, the subieit list under each of the twenty main categoriesin the Core Content was restructuredinto a seriesof lecture topics that were assigned a specificnrrmber of hours. These assignmentswere basedon the collective experienceof alumni, academicfaculty, and residents with a Core Curriculum used from 1982 to 1985,as well as the recommendationspublished in the Length of ResidencyTiaining Report. The total hours approximates550 hours of didactic presentation.The compiled curriculum has improved lecture orginization, decreasedduplication, and served as the basis for innovative teaching techniques.The Core Content numerical sequencingis incorporatedin the curriculum and has beenadapted for computerizedplanning, scheduling,and tracking of didactic presentations.The Core Curriculum reassembleJthe Core Content into a time-designatedlist of lectures which forms the basis of a formal educational process.Additional applicationsinclude databaseaccounting of materialsplannedand presented,integratedx-ray, slide, and teaching materials recordJ;and a literature filing system. Carefully managed,the curriculum allows the material recommendedin the new Core Content to be taught in a three-year residency.

I { Sludy of Emergency Medacine Residency Curricula EP Sloan, HAJayneI Department of Emergenci

Medicine,Universityof lllinoisCollegeof Medicineat Chicago A phone survey was conductedof 64 of 65 emergencymedicine residenciesto determine both how programs will comply with the ABEM 35-month training requirem-entand to obtain block rotation structures for all training programs.We examined what rotations were consistently found in all residenciesand the occurrence of other rotations. We specifically looked at how progJaqs_ale_rlling rotations to address deficiencies often cited by the RRC/EM: EMS, administration and research.In 1985,27 of 65 141.5%lprcgrams were24 months in length. In fuly of tg}6, 17 of 64 .126.2%lprogramswill continue to b{Zq months in length. pr lulf l, 1987,5l oI 64 (79.9%l programswill be 36 monthi in length. Up to 13 plan a 48 month curriculum for 1987.Sixteen [25.O%lof the 5l three-yearprogramsplan to begin at the pG-II year and include a fourth year. The remaining 5S 1S+.1"/,1wtll begin at the PG-I level. The survey revealed greater than 4b distinct block rotation offerings. Of these, onlyiwo areascould be

t5


found where similar numbers of months were of{eredin all residencies. These were emergency medicine in which all programs identify at least 50% time during the PG-II and PG-III years,and critical care where all programs have at least two months. Our data indicate that block rotations are not being used to address common deficiencies identified by the RRC/EM. Tlventy-four ,37.5V"1 programsoffer no dedicatedEMS rotation time. Another 15 |.23.4%lprogramsoffer less than one month in EMS. Fifty-four 184.4y.1programs have no identified researchtime. Forty-three 167.2%lprograms have no identified administrative time. Furthermore,34 o{ the latter programsdo not specifya chief resident experiencein their block rotations. Considerablechangesare taking place in emergency medicine residenciesin reaction to ABEM's new training requirements.There seemsto be little concurrence of philosophy regardingthe block rotation component of the curriculum. Many residencydirectors are not employing the use of dedicatedrotations to solve the deficienciesnoted bv the RRC/EM in the special requirements.

nity, such exposure should include administration experience.

and in-field

6 Development and Evaluation of a One-Month Research Track in Emergency lledicine for of Medical Students / Go/d,HA Jayne/ Department at Medicine,University of lllinoisCollegeo1Medicine Emergency Chicago We presentour experiencewith the developmentand evalua' tion of a one-month research track in emergency medicine for medical students.The curriculum is set up for the student to do reading and problem-solving in researchmethods, biostatistics and design (80 hours),data collection in one or more of the ongoing studies in the department (usually chart review - 40-60 hours), one major literature searchusing Index Medicus and Sci ence Citation Index (20-40 hours) and participation in all research-relatedmeetings in the Division, as well as the hospital's Institutional Review Board. The activities ale done under the aegis of a tutorial stnrcture where the student meets with a su" pervisor at least weekly to discuss readings and progresson proiects. Evaluation of the student is done by a pre-test and final exam covering the topics of the readings.In addition, eachstudent is evaluatedby the investigatorsof the study in the prolects in which they participate. Finally at the end of the month, the students are interviewed by a non-participatingfaculty member to determine the student'sresponseto the month. Pre-and posttesting demonstratedincreasedunderstandingof basic research conceptsand the use of statistics.Furthermore,the studentswere enthusiastic in their responseand contributed substantiallyto the successof severalresearchproiects. We believe that a successful introduction to research in emergency medicine can be attained in a month of involvement with an investigator,active participation in a researchproiect and independentreading.

Survey of Requirements for EMS Experience 5 in Emergency Medicine Residencaes PM Paris,RD Stewart,EMS EducatorsCommittee/ Departmentsof Medicine and Surgery,Universityof PittsburghSchool of Medicine;the Center for EmergencyMedicineof WesternPennsylvania, Pittsburgh; and the AmericanCollegeol EmergencyPhysicians, Dallas The increasingsophistication of prehospitalcare over the past decadeand the fact that its practice is specificto emergencymedicine make it essentialfor physicians-in-trainingto be exposedto all aspectsof emergencymedical servicessystems.Graduatesof emergencymedicine residenciesare often expectedto direct prehospital care programs in their communities as well as provide leadership in disaster planning and offer medical coveragefor mass gatherings.In an effort to determine the requirements of residencyprograms{or EMS experienceand the content of these elements o{ their curricula, the EMS Educators'Committee of the Society of Teachersof EmergencyMedicine {STEM)designed and distributed a questionnaireto all 66 emergencymedicine residenciesin the country. Forty-two (64%f responseswere retumed. Although the overall pattern showedsome trends in requiredand elective EMS opportunities,differenceswere epparentand show a wide variation in the importance placedby eachprogram on this specialty area.The number of ambulanceservicesdelivering patients to residencyprogramsrangedfrom one to 80, with a median oI 4. The number of radio-directedcases{Medical Commandl ranged from a low of zero to a high of 20,000, with a mean of 4,700. Supervisionof residentsby attending faculty varied from none to faculty supervision of every case. Most residency programsprovide only sporadicon-line faculty supervisionbut make extensiveuse of tape and trip sheet reviews.All but 5 programs make use of ECC telemetry. Eighteen oI the 42 residencies (43%| have helicopter programs and 13 of these 172"/"1routinelyuse residents as part of the flight team. Forty residencies(95%f reported didactic programs in disaster planning and all provide residency participation in disasterdrills. Few programsprovidedany experience for residentsin planning and medical care for mass gatherings. Involvement in administrative aspect of EMS was also found to be unusual, other than occasional trip sheet review. Variety was also seen in the didactic component to EMS curricula, ranging from I to 2 hours of lecture only to a comprehensive base station physician course with monthly conferencesand an extensive required reading list. Other than that provided by air transport service, in-field experiencewas limited to informal "ridealongs" in most programsi with only one program offering regular participation in on-scene care. Tlvelve of the 42 programs indicated interest in an elective opportunity for experience in an urban EMS system other than their own. Our data would suggest that a greater effort must be made to ensure a comprehensive exposure to all aspectsof EMS systems. If residents are to be prepared to assume effective roles in prehospital care in the commu-

7 Patients in a Freshman Use ol Simulated Medicine Course WP Burdick, ES Escovitz/ Emergency Departmentof EmergencyMedicine,Office of Medical Education, The MedicalCollegeof Pennsylvania, Philadelphia Our freshman course in emergencymedicine introducesstudents to the conceptsand techniquesof medical interviewing.To improve our effectivenessin teaching this basic clinical skill, we have expandedour course curriculum to include student inter' views with simulated patients. "Introduction to EmergencyMed" icine" is a required 52-hour coursepresentedto the l14 members of the freshman class.During a fifty-minute lecture on the medical interview, the focus is on the process of leaming the art of taking a history, as well as on general theory and techniquesof patient-doctor communication. Opening questions,open-ended questions, body languageand empathetic Iistening are amongthe techniques discussed.Groups of six students intirviewed two patients in a two-hour period. A faculty member from the Department of Emergency Medicine served as a preceptor for each group. One student initiated the interview, and proceededuntil he or she called for a "time out", indicating that an impassehad been reached. The group then discussed the possible causesfor the impasseuntil "time in" was called and a secondstudentcon' tinued the interview where the first had stopped. At the end of the interview, the "patient" stepped out of character and gave feedback to the students. Simulated patients were trained by one of the authors in a fourteen-hour program that included lectures on interview theory and stnrcture, observation of videotapedinterviews with real patients, and mock interviews with one another. A(ter memorization and discussion of clinical scenarios, the simulated patients were interviewed by the course directorto insure accuracy and validity. Although simulated patients have been in use for over twenty years, this method of instruction has not been widely employed. We feel that use of simulated patients constitutes an effective, non-threatening means of introducing

l6


freshman medical students to the concepts and techniques of medical intewiewing.

I -.1,.-f"

placement of Automatic Exrernal

with the pocket face mask, a reasonably high percentage (67%l met a difficult obiective,tr"ar.a *i"r, "ii"s"ii,J bag valve mask. In this paper we describe the succfssful t."i.riqrr" for bag valve mask ventitation used i" this:;;t;;;;#t objective stan_ dards to be used to measurethe ventilation standardsmust be estabtisheJlo;;;;;;il;;;ry ,lrils of EMTs. Such adjunct that EMTs are permitted to use.

il::i..;#"%:*"nt*:".#, i,gfiii,,,,i,r":,;fi services o'ili"i,"kiig ;"ijLlil;!r'j1ffi"1,ffi13ffi:r{edjcar uummtns,A Hallstrom. I

from venrricular fibrillation ,-Survival determined in fviil, large part by the time fromrollapse i" J.iil.irrr,r.n. Automatic external defibrillators tA,lDl th;i;; i"'r#ra..rrfv detect VF and deliver a countershocknow make i, p*ilf. a train lay per_ sons to provide defibrill ation. si"". _ort.oir-,-oi_;,ospital episodes of VF occur at home the most.likely ,iia*.o'""a therefore po_ operator, is a family_.j_U.i',i I fl,l3| ir.,..,. at riskof rt'.. we 1l? pertormed a study to.dete.mine h;;;;"y patrents at nrghest risk for an eoisode of vF {those ;;; i;;;" already sur_ r-1"1.* eventfarepote"uat.&naiaate,

10 v jl*1131,$fir'" i" Fi" raMeasurino FJii;Iffi ;",#T.,?:*

Department of Famitypractice,Cd;t";-U;;jty,

omanu

Key to patient survival in the field is the applicatronof emergency care proceduresin a timely _"nn.r. ih-iJ."quires not only didactic knowledse,na..rnrt, p-Jrro._;;"'il;',i_," "*"r.,rrng of value judgmenmwhi"h ultimately contributeto the survivabiliry of.the patient. The purpose "r ir,ir ririy';;. ;" evaluaterhe i", ino placement values and ]lT9 sucha devicein tt.iif,-r*.r. fudgment'skills of 29 p"rr_"a'i"r.-ih.se paramedics X?:j:.^.pt*C:f were required to assessand treat "a"r, toutl,y,_y"shington,werescreened iil VF survivorsin p"ii."a, fo. polriUf" enrollmerrt llE covering multiple trauma,*medicrl-"rtei;";-;;j in^trrr"" scenarios studyde_sign randomized p"ti..,t, medicar-respira_ lljl:,r,"dy.TF to one of two tory emergencies.Using Bloom,s condrtrons, AED ptus cpR iraining ;; -p{-r;;";;g ,r_l<"".Ly,', panel of alone.Dur_ iudges ranked actions exhibitin[, rds-;;, rng 1984there were 95,s_u;1ivo^1J."r_"f_fr.rpiial ;kjti;;J;rdlrs to eff iciency VF.in King t nunty.Thirty-two in the field and effect on patient 134%l-o|thess werl;;;i;;"bi;r., survivar for eacn scenarro.A pracement number value was then assigned Fourteenweredrscharged l. """rr- ""ii.". ;".;r.. were then to a nursinghome and ten x|.:? alone. lED In nved as percentagesof valuesand addition,eight were"dee_"a*.a]"?ffy inappropri_ ::]:-1t1,:d a.scale,.the precentages iudgmentsattained.When ate by the personalphvsician #r_;;;;j;ent AEt;h;;;t. :1lj:i:: patrent with the_ The latter Iq, oretrc survival or demise.Res"tt. .t orar"A of pitients *ith ;;;":;;;;.., ," overalllower fll::L.1:i:i.,ed end_stage Kloney in drsease, respiratory anoxicenccphalopathyoi "rfr.r- ".*pir""rj"g managemenrjudgment ,f.ifir. r" addition, :lil,t:C pinpoinred ??: results morbiditv' exact .sixtv-three166%rparieni;';-;;;;.*tal candidates and treatment. Additionalareis of a.ri.i?".1- i"'ii.ld ,rr.rr*.rr, oi the pltients .lisibt.-;;;lle data analysis ,.u!"i.A" f,igher overall l"jj,E?_ot":qment. study 8l% agreed ranking for paramedic, *t o "tro to participate. The reasonscitedior ..irrri'ro participate .i;;;;;d';,ional registry health problemsor philosofhiJ requiring more continui.,g "d,r.rti;, ii:r,rd.d U"iil"i"'*t lliltji:ili"", compared to ich . consid_ paramedics erecl extraordinary maintainine state certificati?,""i"".jnis life_savrn_g eliorts inappropriate.In the present study supports the need for ,.rJl", assessment study,defibrillarorsand training of p"rr_.Ji. values and ii". of "t "rg. "rra participantsknew thev were wer.-pr^ovid.d udgment skills to ide"ntify rh;;;;;;r;oi"ir,i'ilr,,"urng i in"volved;;;;;; proiect.The edu_ extentro which accepiance cation activities to ensure patrent rates*itrri" irr. "oiieii or this st,ray survival.

wrttr8eneralize to a clinical situation-is-o-nii'.,i!j.rt"a

Uy ou.

11 ..1Medicat Schoot,s Rote in EMS Education e venriration ski's.orEmergencv Medica, ;::ry4;1=g*,**i;r16.*1,ri,x,0Ji1,.","""", intb"o..su washingt-on ui,iueisitv '"' schoor orMedicine and Hea,th Fi:+3:sl1il:i!.Et"lH:":m',ti,:i:,t:i science, wasrrinstonl'Dc-' Medicar Services Division. R:jyL 1.E1.'g,.s;;;; il;j%3,ny:t "..o Departmlnl i,iv"ii"i"?,ii,ir"J.'itl, u;l"*'l,,i,ii;irST*::."";[:.,g;il,,1, ;''fi,:[ffi[?l !::Ift the dl'l^i^.:?i:'^".t l::

r;:ttgi4j{i{:iTiiii n#xfu*{ii:':'iii{i*r: cetermine $i{ii'il1$}j'l,jsi.'i::rjr if present EMTskillt.r.rt*i.r,IilTrs urru.-"J FJ{j':-'t',1%H;a fr"i'l:rl::l.,training rn.o.-;;Jfiri:ti,l:IifiliHih:r#1l]

ffi',:1::'Jille7;ii,1,ll".li.l,TXlt;f.:,,T1'"*f,[ffiT T:l; 6d+i;;.Tg;t""ffir#iiJ",;iffL:::'?:ffi,".?L

#';:n:ili's*.-,n:',':,,1x; "oN"lieht.avolume p," #fiti1itrft?:Tr?:qff oirr#i"a r*thasreen r#:*;,'lfi'"jru"":it*lir=pi;i;;;i*. .r s00""-;'io.g". Sio'ir'" h.rrth-;;p;;;jil

lri"r"1-"i ;i.:'ffi:.ir"j#lt.li,ii;t^l_f; lo,u,fH'#.1:il:lH".L*-'ilIfuElJx,l":H3;t 1#;,ff,:f,rff,J,:lJ:i,,...,yi, ',Jffi1'#iil'['i]".f;';":,-{{;.fiiy.:uxilg;.ii :* r#ililii:H,.

pocket tace mask, berore , '.'""."r.,i u.;iir"ii""iz .""r.u, lormal skills assessment t1.t,r11.a-t.1._!;;;;;r;'rl."essful l_; ven-

i",egra, ro,e inproviding #{li:l:tlror,h;;o; pi"yra.* ;fi;"tffirliffi i::;:'j:SX.i;,Lfiii:l,Xi,HKyfr,,*H.f .opoiit"n w"rrri,ist""_;;-io_"ii.r."i' the perceivedneedfor and "tt.,,ffi'"',i.ii#"*r,1"r based prosrarn orrering a) medicini;

io..:$ii:fi1il:'d"".'[:".'-i"i"'J[*$+:** f,f,:#l assessment #ffii,i,, ir thevaveraeed, rd or.#;;;;ffi,"i ven_tilationi ilil,fi5hil,ii:ll::fi::t#llt:r,

u;,-n.s.a.-

{,a iiJie'iu,r, ee.r "t ii,;iil'i #.i,,,,,,,,".o.s responded,,,n:i3,i: ff#i,ii;i1:ll"JiT'ilf:1;lt"t"ru"f;;*i:l;1.:iL"-l+ tended ski, o"""-",t.1. rLaj, "i1.""*i.i?;"ffi:,i.:

mtnutewith the bag valve-mask' ""a s''5-*iii

f,.:,ffi,Tli!{i:i#;iJ;5jni#*ijir:ir;}ir#rl; ptrilosofhy,curricurumdesign,

ii" po"t"t-l'je

describe i*.l-r:*-a

Iil:":il1':ifi:f.T#iff;:il,T$:.*m:r'n"":-.L tni

and.impact and nationar rever ariei year one or :i],*:i"*'*trononarocar

l7


12 Use of a Computerized Practice Profiler for Peer Review and Cost Gontainment S WohlI Heritage Medical Group,San Francisco,California TWelve thousand emergency department encounters in one hospital over a six-month period were analyzed for most common diagrroses,acts performed, costs per diagnosis, charges per diagnosis, and acts per diagrosis. A profile for the practice as a whole was discussed on a weekly basis. The profile of each physician was compared to that of the group in each of the categories.Physicians whose clinical practice was at variance with the habits of the group were readily identified. Findings of sigrrificant variance were found to be the result of excessiveordering of tests for specific diagnoses.In one cese,the most common diagrrosisof a physician's practice was at variance with the group and a review of charts pointed out serious shortcomings in clinical acumen. The profiling procedure resulted in early detection of incompetence, a 20% decreasein total emergency department chargesto patients, and a7"/o increase in physician billings. The bulk of the savings were realized in diagnostic tests. The increasedphysician billing resulted from more appropriate billing per diagrrosisand act performed. The emergency department profiles are easily and economically obtained using encounter documents and a personal computer. If and when the DRG reimbursement format is applied to physicians, the profiling procedure will be a necessity.

13 Satisfaction With Practices: Emergency / Physicians Versus Internists JG Murphy, S Jacobson EmergencyServicesDepartment,Sectionof GeneralMedicine, Philadelphia Departmentof Medicine,Universityof Pennsylvania, While career pattems of emergency medicine, intemal medicine, and surgical residents were compared hy Anwar et al, no comparison has been made of satisfaction with actual practices of emergency physicians vs other specialists. We used a previously tested questionnaire which measuresdifferences between current and preferred practice conditions, and with items regarding training and practice, and intention to changepositions. It was sent to 250 emergency physicians and 250 intemists in a metropolitan area.Ninety-five (38%)emergencyphysiciansand 79 (32%f internists responded. Respondents and nonrespondents were similar with regard to certification status, but respondentstended to have graduated from medical school more recently (1966 + 12.3 yrs vs 196l + l2.l yrsl. Emergency physician and intemist respondents also were similar with regard to certification, with emergency physicians tending to be more recent medical school graduates(1968 * 10.0yrs vs 1964 + l3.l yrsl. Factor and correlation analyses identified six satisfaction indexes: resources, professional autonomy, administrative autonom, patient relationships, academic activities, and professional status. Emergency physicians were less satisfied, ie, reported more diference between current and preferred conditions, than intemists with professional autonomy, patient relations, and status lt-tests: P < 0.fi)l for eachf. Emergency physicians were more satisfied with academic activities (P < 0.0031.Only ,107oof emergency physicians, versus 6O"/"of intemists, reported no intention to leave their present position within the next two years (P < 0.02f. Expectation of position change by emergency physicians was predicted by dissatisfaction with professional autonomy, lack of board certification, recency of graduation from medical school, and belief that monetary compensation would be higher elsewhere (Rz=0.35, F:1I.78; df =4,86r P < 0.011,while variables such as patient load, hours worked per week, and hospital size proved unimportant. We identified significant areasof dissatisfaction among emergency physicians which differed from those among intemists. If verified, educators and administrators may use our results to alter training and practice characteristics in ways that will enhance career satisfaction among emergency physicians.

14 Burnout and Emergency lledicine: A Case Study in llichigan RRHuang,BCWhite/ Officeof Medical Education Research and Development and Section of Emergency Medicine,College of Human Medicine,Michigan State University, East Lansing Bumout is a state of physical, mental and emotional exhaustion and it is an undesirable phenomena in any profession be' cause it curtails the standard and quality of performance of the bumout victim. It is costly to the organizations becauseof lossof trained talents and it is costly to tJre clients becauseof the poor quality of care they receive. Bumout occurs most frequently in highly stressed professions and emergency medicine is ranked among the highfu stressed medical professions. The purposeof this siudy is lo investigate this phenomena in the practiceof emergency medicine and to determine the underlying psychologi' cal and sociological factors that contribute to burnout. This study adopted the Person-Environment Fit research paradigm which essentially stated that stress which resulted in bumout is a result of misfit between the demand of the task and the per' son's abilities and the level of stress is mediated by psychological and sociological factors. The study sample in this researchcon' sisted of sixty-six emergency physicians from six emergencydepartments in the lower Michigan area. Results of the study indiiated that emergency physicians in this area experienceda within "normal" level of bumout, with normality being defined as within the averagelevel as computed from other professions. In other words, emergency medicine is expected to have high level of burnout becauseof its highly stressednature but it is not shown to be the case in this study sample. Further study of the personality traits of this sample show that the physicians tended to be concrete thinkers, calm, assertive, expedient, restrained, self-reliant and self-sufficient, which all are personality traits that are "counter-offensive" to stress as indicated from other studies. In addition, this study found that this sample of physicians received strong social support which is an essentielbuffer to stress, from their colleagues, supervisors and, families and friends in accomplishing their tasks. The personality characteristics and the strong social support of these physicians might help to explain the normal level of burnout as experiencedby these physicians in a highy stressed and expected high bumout profession. Results from this study will provide the information needed for the management of stress for the prevention of bumout in the emergency medical care system.

15 Survey of Emergency tledieine Faculty In of Surgery Academic Genters PMAdler/ Department Philadelphia Hospital, Thomas Jefferson University A survey was done to determine the academic status of emergency medicine in the United States.Questionnaires weresentto all medical school emergency departments as well as non-medi' cal school emergency departments, if they had an emergency medicine residency. One hundred forty-nine surveys were sent out with a 560/o{841responserate. Inlormation obtainedby questionnaire included how many {aculty have academictenure,what is the academic level o( faculty, how many faculty are on an ace' demic or clinical tract, what skills are neededfor promotion, end do they have non-emergency department responsibility. In addi' tion, we studied department status, funding by the university vs independent billing area of the country membership in STEM and salary level. The information obtained was cross correlated with the presence of an emergency medicine residency,mem' bership in STEM and academic versus clinical appointmentsat the university medical school. Analysis of the data revealedthat only 18% of department heads are tenured, but 507" are on en academic tract. Thirty-one percent of medical schools are reluctant to give academic positions to emergency medicine {aculty while l0% of directors do not understand the differencebetweeo an academic and clinical tract at their institution. Eighty-three percent of the tenure takes effect at the associateprofessorlwel,

t8


but 58% of these institutions had years in service as a requirement before tenure is consiaered. iive y."rJt ,"*i". was the mean answer given. Thirty-six ti*. i"a"p""J;;. E;;: mental status, but 2l percent .f _percent fa";iit iiuJ a"ir., outside of the department, e.g., rounding on patient floors oi supervising non_ emergency clinics. Seventy percent were members of STEM, while 59% have emergenry medicine ;.tid;;.r. The maioritv of faculty

salaries *.^* sso,ooo i"lab,ffifiiii; ;;;ns;?;;l $30,000 tg.oyer $e0,000. ih;;;;f,h ffiil l'r i;;;r;;.,";,.,i,1?

gency medicine provides a staius ,"port on the position of emer_ gency medicine in the academic _.ai""i """t"r.

16

This list was then refined and categorized in consultation and by a literature review. Nine separate categories of errors were identi_ fied each with I to r Th. "1;;;;;;.-are as follows: tf ::b,,ryfr. primary reference omitted when required] 2f reterence does not support concept for which.it was cited; Sf misreference;;;;_ ment requires a primary reference tut ,rorrpri_"ry source cited; 4l statemenr or conceDr requires pri+".y *,i"i.""J U"ir.""..rl reviewed source cited; sip.rrd""i .J_il-uii"rtion/personal work: source unverifiabie;,5i.1r""r. r"i"i.""] cited: unavailable f rom or _through normar ;";;;;;;t'il;'.; ", sovernment ,l improperly referenced: manner of rlferencrng unclear ::y_":1 as to what conceDt it refers to; gf referenc. "id;;;;;;;i work likely p."oririg-irrori.-wrrir.'" -not-riad; s) rew texts and ioumal articles have comhent.io" iir" ir.". .f ;;r;;;*; rors in the medical literature, w-ebelieve this;r;;irrr;::;; to systematically characterize these ,.f.rerr"irrg errors. With this ground work, the methodology to "aai"rrlir.'p"r.u"l"rr". of these type_s9f referencing errors in the emergency lit".rtur. ,, "rr._ rentlv being developid. T}t. ".ri si.p..'.,18ill# to what extent these errors in referencinglead to t"utty arsrrmptronsin medical research and the prolifera-tion .f -.Ji"l"f _ir'i#"rmation.

Sabbaticat, r"""rtv-Jn-6Jrii[ry3fiJfi",TBTy,.",L":l.of*;j"*$"",

Medicine, OregonHeatthSciencesu"i"l"itli' iirtf "no The growth and maturationof emergencymedicine _academis has beenmeasuredl" tr"aitio""t-il;;;[."I*portanr -piJ-Jiil"; amons them are lacurty appoint-""r estabrishmentof -r"a medicalschoolemiise.r"y -"a[irr.'ai-priil;;, and solid con_ tributionsto the tea"ching, research;'JI;;;;r. of medicine. The.establishment and piactice of ,abu"ti""T is essentialto the continuingacademic "t o"i-rp*i"riiiwe co*pleted " 1i_tyritr surveyof U.S.University EmcrgencyMidicinJprogramsto idenffr ghich prosramsua'"ru-uri'rr,"i#;;;;i#* programs.we tound that very few faculty have-r-"'t-il accrssto t.rrrr,r.tractsand onlv a handfut have actu alI y,'t"t"" ;;il:;;li;l;.: f ;; monrhsduration.The following pr;;rpilii";; beensuccessful in the establishmentof an orrgoirrg ,"trb"ii""I progr"* "t tlr. oresonHealthsciencesu"i"..fiiiljt proachedon a deoarrme"t"tu"sis' rrr;;;cep, shouldbe ap_ rath;;;i;;r:ila;il;rl fr:ulty; 2f Provideeoualopportunityfo. s"bb"iiJio aII faculty; 3f one yeai ", p1.i'.rr.dl.'";h;;';ftit setection :'-?_blis.h arrangements madewell in ad.vanci;+f Assign-acad"_i" and *ilal ministrativeresponsibilitie.s .f tt. il.ifiy off "ii"ti"a to exist_ ing.faculty;..SJ Use the salaryreducii#Jtt-Ji""r.rr,y on sab_ baticatto offsetthe cost3.$::-.8;;&!;r'trient staiting;and 6| Identifyandcomolv with the parent insiitutions, existingsabguiddlines ""a "p-pri""iio;;;;: llli^.lt .Tt.:, once establrsrr^ed, of a departmeni.with.."[f"ti""f p.ogi";;i. _taculty acceptrng, supportiveand arr.ticipate tt.iio*" Lpportunity ' to furtherthe respectof their f"U"r^;r""a".i.i"ri

.1p An An_atysisof the Emergency iledicine Literaturs tts Retevance to th-e piiciitioneii

jfiffi r"7' ii!:3,'#1r.Tt^?:*.,a'."iH._::

University of Arizona,Tucson .Th-eljterature of emergencymedicineis the database from which the pracritioners."d;""i;r, ;;;;;";;"i,;;, of our special_ ty developnew methods""d ";;ptr iJ.""i'.iirr.i, respective areas.It also reflects the maturation,quality, and generaldirection of our.speciarty. To be.valid,ttr"'ri.i"#. -*"sr be rerevant to the specialty.The obiectiveof this .;;t;;, ,o "rr.r, the for_ mat and extentof coveragein the literaiui.i oi "jr irp..rs of emer_ medicine,including the clinical, ea"l"ri"""l 8-ency. and admin_ rstrative areas.The three maior p..._r.ui"*"Jlournals were analyzed:Annals of EmergencyMidicine liiiy e^"rican four_ nal of EmergencyMedicinr.talH"Il "ij 'ir.iri"i,i.1 Emergency Medicine (lEM,.Analysis.incluiJ ifi;b'fi;il;s over the tast tour years..Allarticres,editorials,""a t.tt*r-*"* incruded.Ab_ stractsand book reviewswere-not includeJ. ffi. f.ff.*i"J drl from eacharticle were enteredi"t" " osMs iiblsp-[l), "rti"t. tide, author,.type instituti"; (r.J;;"-; subiectarea, type article (research,review,.letter,etc.1 ;iffi and f"rif*.ip""iii"* relating.,",ia"*iiir" ,,iala]"i"l rr",ion.rhe l::ff ^:f-i:!ides suDrect areawas classified accordingto the tmergencyMedicine CoreContent.A total of lss3.article'sf;;,h;ilr? joumalswas enteredinto the DBMS.rnitial lenerafi;ii"rfi;y descriptive statisticsare as follows:

1J[,"+f,{?H".,:q.sr,:-TE?","T",i'":$yo,u,.,on of Emergency Medici ne.rne Jotns'riopriiii"riJlpi'llr,Batrimore,

of Emergency Medicine andrhe $y]31{ th".?vision of preventive Medidine, bhio Si;i; Uni-u",.,,y, fp1ff.t uotumbus

The pryposeof referencingis to support . the contentionsand tenets of scientific endeavdrs,""a ti'"r"ait ,Jir""r. It is especially.important in originai;;rk, ;i";;;; fl"rindationsof al_ most all studiesare basedon previous the findings.ofeachstudy """a't. U" "fto.i, or-la""s. Furtheq, "."ril;# hght of what hasoccurredbefore.Erroisi" ,ei.r.n"i"t;t il"d a falseinterpretationsandhencefalseassumptio". tf,"iii"a"iscientific pro-

TABLE 1,

TABLE2. AET

A'ET

Resuscitation

29%

g7%

11%

Toxicotogy

Clinical Research

1g%

11%

19%

14%

Basic Research

10%

16% .t3%

Flâ&#x201A;Źviil

6%

10%

crc

2%

3%

3%

19%

14%

ZO%

5%

14%

14%

25%

10%

6%

Subl.ct

rh!;;,i";; ;?"diJ

fr;,

of referenc-

orcommi tting

;::T :iT;; tlb : literaturein'ord^et,o"rtrlg"i"ria;;f #r.l*'.qttr"::r:?::i:ff I errors and thus be able to oevelop a methodolocv

the,consequence; ;f ,h;; "-; m the original

Trauma

9%

4%

14%

EMS

7%

9%

e%

OB%

General

contribution_s.ctionof Uedicine,Americanloumal .f E^";s";;;' tur;:il;;lr,"1oimat o1nmer_ gencyMedicine, Resuscitation, and lour_ -"cri-tiLotcor|rt":;;;., of !yo"yo,. from fanuary 1980 to o"""-GliSs5 !!1, (or since rnception if after l9g0f were surv-eyed. checkedand all potentiai types"r-i.r"l"".iigetii"f"."rr".s were "rrlr'r'*"r" oo,"a.

19

A'EM

JET

Artcb

2%

29% g%

38%

Education

6%

Editorial

Administrative

7%

6%

5%

Leners

3%

S%

sft

special contributims

Other

fuifiil;il;%jiJ ^arrr'oi-iy-fiergency ;TAT!

AEI lyF

j'##if"T; fiT,'"""ilirry{"#L'J:1*';**:'"**9:#:"#

addressed, tittle atten-tion !."9rre;i;;;; rnt errorsmadeor the srlr"s "$:,|il

JEI

Case Feport

8%

7% t2% 1g%

1%

A/EM publishes a sisnifica-nt amount relating to resuscitarion, AfM^publishes the most .li"i""t-r;;;i;rni j!.r.rr, andIEM oevotes more articles to trauma and-publishes i.i"iiu"ff,;;;;: views. An analysis of the coverege.r'trr. cor. i"itent reveareda paucity oJ articles relating to ey"edisorJerrr;;h;r", contribu_ tions to GI, cutaneous. hr

icardisor-d!r-sl'iil;#ilii::n'T:?..1,0,",:i::?,1L1# :n-;

commonmaiordisorder,", ci rr.-orri"i"^rir?rii, orabetic acid_


and substance abuse, especially among youth. Peck {1985fre' cently reported that the age group (15-l9f represented5.5% of all Califomii licensed drivers in 1983, but accounted lor l6Y" of. all persons killed or iniured in road crashes.Peck attributes the overinvolvement of this age group to impaired risk perception and risk choice. Preventative strategies need to be aimed in this direction. For the last three years, the University of New Mexico School of Medicine/Division of Emergency Medicine has sponsored an Alcohol and Substance Abuse Program {ASAP} within Albuquerque schools. Seventh and 9th graders in small groups visited and interviewed the staff, patients and their families at the emergency department and trauma center. The program'sob'real-life' social and medical iectives were to expose youth to the consequencesof aicohol and substance abuse, especidly drinking, drugs and driving, and to explore altematives and train peer educatois. A pretest/posttest/8-month follow-up evaluationdesign was used to assessthe program's effects. Questionnaires were administered to randomly selected experimental and con' analy' trol groups of seventh graders (n=271. Repeated-measures sis of variance detected a significant experimental-control con' dition X time crossover interaction effect for perception of riskiness,F 12,3ll : 3.2O,p = .O49.The data indicatedthat, over time, the experimental group perceived the riskiness of driving under the influence of drugs or alcohol to be greater, while the control group perceived such behavior to be less risky. Other ef' fects, and implications for the role that emergency physicians and staff can play in prevention are discussed.

osis/coma, intracranial hemorrhage (all typesf, and pulmonary embolism. The specifics of each part of the study are discussed. Recognition: 19 Dynamic Dysrhythmia of a ComputGl. and EYaluation Development Instruction System GJ Cuzner,CG Cayten / Assisted Departmentsol EmergencyServicesand Surgery Our Lady of Mercy Medical Center,Bronx, New York Demand {or basic ECG dysrhythmia recognition skills continues to rise. Cost-effective measuresutilizing new technologies are being sought to improve the acquisition of these skills. We have developed a simple electronic interface linking a personal computer and standard ECG monitor into a complete teaching system. Programming the system required only rudimentary knowledge o{ a computer language. The system goes beyond other computer assistedinstruction (CAI) becausestudents must react to dynamic ECG tracings. Three course modules in dynamic dysrhythmia recognition were developed. Tlventy-four nurses and residents pilot tested the system. Their reactions were tabulated using a 15 Likert scale questionnaire. The scaleswere a continuum from l: most negative to 5: most positive. Three scales measured affective responses;six, responsesto program format; three, responsesto hardwarer and three were subiective measures of knowledge acquisition. The overall mean of the evaluation scales was 4.2i the affective mean: 4.4; the responseto program mean: 4.5; the responseto hardware mean:4.7i and the response to leaming mean: 4.3. The electronics component, the interface construction and various programming techniques are described. The background and problems involved in education evaluation as well as the current state of CAI program evaluation are discussed.

Informed consent and Emergency carel 22 B Mack/ R Dresser, llfusion and Retorm EVBoisaubin, Departmento{ Medicineand Centerfor Ethics Medicineand Public lssues, BaylorCollege of Medicine,Houston The doctrine of informed consent is central to all medical prac' tice but has received little formal analysis in the emergencyset' ting. Although general consent forms are commonly utilized in emirgency centers {EC},we propose that their use is not ethically or legally defensible since most patients do not have life-threatening problems, are capable of making inlormed decisionsabout their care and have a poor understanding of the purpose of the consent form. To test our hypothesis, 83 randomly selectedmedi' cal patients from a general hospital EC were interviewed overtwo months and their charts reviewed. The questionnaire included demographic data and questions about the patients' understand' ing of the consent form, beliefs about patient and physician au' thority and involvement of others in care decisions. Results showed thet 821" signed their own form and 85o/owere alert although 55% were in discomfort, primarily pain. Fifty-sevenper' cent did not know the purpose of the form, 46% thought it a requisite for receiving carc, 267" thought it allowed a physician to operate upon them, 52% would also allow proceduresper' formed they did not want done and 53% would never leavethe hospital against medical advice. In summary, almost all patients were capable of giving consent, although misunderstandingabout the form was common. Patients had a poor awarenessof their rights or options, gave physicians extraordinary authority and commonly acquiesed to treatment out of ignorance, fear or discomfort. In conclusion, the current use of blanket EC consentis inadequate to assist and protect patients or physicians and should be abolished or modified. Modifications include devoting more time to explaining the nature of the consent and giving more specific information about the proposed treatment.

20 ilega Gode Evatuation: Development of ot P Derr/ Departments Graded Griteria H Marcinek, and Hospital StVincent Emergency Services andSurgery Medical Center,Portland,Oregon The obiective of our proiect was to develop an evaluation tool (or grading student's performances in the ACLS mega code. Tlrpically, ACLS instructors do not utilize specific criteria to iudge acceptable performances by the team leader and/or team members. To develop a tool which would provide both consistency and obiectivity, we first accurately delineated both the team leader's and each team member's function. We divided the team leader's function into four distinct areas lf supervision and leadership; 2) rhythm diagrrosis; 3| defibrillator operation, and 4f drugs. Under each of these categories,we defined a certain number of specific tasks to be performed and assigned points. Under rhythm diagnosis, for example, it was felt that the team leader should corrâ&#x201A;Źctly recognize all ECG rhythms presented, wittr at least three rhythms tested. Three points were assignedfor this function. Given all the criteria tested, the maximum point total was filteen (151.Tlvo errors at the maximum were allowed before the team leader failed the mega code. A similar system was developed for each team member. On the basis of these criteria, a check list of specific functions was created into a figure which could then be reproduced as a sticker. This provides a pemanent record of student performancesaccessibleto review by both the instructor and the student. Such a system eliminates the potential conJrontation between student and instructor as both are utilizing the same obiectives. These evaluation tools have been used in our hospital and local area with great success.Instructors enioy using them and students appreciate the obiectivity they provide.

23 The Observation Gap: The Observable MA 21 Alcohol and Subrtance Abu3o Prevention: Patient in the Drug Era LG Graff/V,CSWerne, Medicine, NewBritain / Department Gunning of Emergency Changing Perspectivos of Rliklnc3s In Ddnkingt WGWoodall / Departments General Hospital,NerrrrBritain,Connecticut Drugc, and Dtiving E Bernstein, of EmergencyMedicineand Speech Communication,Universityof New Mexico, Albuquerque Emergency medicine is faced with the consequencesof alcohol

Over a four month period, patients observed for less than 24 hour observation in an obsewation unit administered and at' tached to an Emergency Department, were compared with pa'

20


tients observedfor less 4* ?1 hours in an acute care hospital. 80 of 280 (29%l obsewation Unit pati;;i_td; were appropriate admissions for'the """t" ""r" toririif peer Reli;&'i;ecticut view organization criteria, were sent home after observation

withoutadmission,",

;:t

jz8z"

#"fi i ; appropriate emergency 1}:^.lT-n,!1. hospitaladmissions, that werein the hospitalfor less than24 hours,tould t "u. t"."'o-U..*.a and not admitted to ttre trospita,pi:I"rii" ,lTour.*"rion Unit j# ilj;b,;;;il DiagnosisRelatedGroup.sf*. aift#rr".i,,llr,,,orr.r"_ent for observation in the two^iifi,ere",-riii, iiirr?.r'.,ps was g126,960 p9Lyear.By prospectiv-e p^aymcnt (oiagnosls1;ijt"a drtterence in reimbursementfor observationin the cr.rpJir,. two different sitesof both souos *as $627,24;;; our hospital the ;;;';;; ObservationCap lthe differencein reimbursement emerseniypatientsi" tt. t*o-aUf.i.lilites; for observa_ 11o1 wasgreater rn prospectivepaymentsystemthan in a 9f a cosi r.i_bud;;;l system. 2^!

Patient Gomptiance in Fiiling prescriptions

f rbm th" -;;;;;;;

fllel*oiscrr,als_e_ separtment CE Saunders/ Emergenc! -wadnu-iii",'ienn"r."" Serv'ices, Divisionof Trauma, Vanderbitt University Hospitat] emergency. departmenttrearmenr "-I::t::l,lt., scnptronsgiven to a oatieni upon discharg. consistsof preor, ,r. assumption that they will be filted promptiy-;J;il;il;arions begunas Although

9.'.y,:.a

trreiran e;i;il;",ii?iiai,"

of thisas-

many pa_tienrs. may-be unable (or unwiilingi-i; fijl :l3_pji9", merr prescriptions. We undertook a.study ,o'a.t.i_irr. tfr,! pr.""Ience of and reasons for noncomplir"; i;Jili"g prescrrptions amongpatients discharged.fromtlre .*.rg.";t d.partment, and to determine if differenCesi; ";*;ir;;;;'#;';""s various so. cioeconomicgroups. Ninety_six ^".";;;";*. ;"ii..r,, who had Deengiven prescriptions upon.discharge il;,i; emergency de_ partment were contacted by telephoneih;i;llo;;"g day to determine if th.eir prescriptions had b:;?ilil;il"iinot, tt e reasons tor_not-filling them. patients *.r. ,*iiJilliy p"v., classifica_ uon groupsas follows: by third p^riy-,fi^iu,53 patients; 1nsu19d corered by Medicaid, 19 patients; noninsured',,self_pay,,, 14 patrents; coveredby Medicaie, + p"iie"trr-"J-.irrtiro*r, payer stajll: _6_pr,i.l,r, Th9 percentag.'i" .""ir' gr;,rp**fro fr"a not filled metr,prescriptionsby follow--upthe next"day *.r. ". lollows: insured, 20.8 %, Medicai d, 2 1..f"t", " ".jl_p)r,,,,' ii.'+u, Medicare, 25.07.o; unknown, so.o%.'oiifel;"; b";;;;;ol0, were not as significant. The reasons give-nfg,r not havin!-fiilei prescriptions wereas follows: insufficielnt fu;;, *%;l"c'f oTirl.rrporr",ro' o,

no particu.l",i.r.orr, ie;ii-i"A -+iz"othermis_ T,tt:-,1r..,1q"/:, cellaneous, l8%.of themedicatio", "Jt iili"d, *... *"1_ or se'/" weie iitrli"iiir, *a 15%mis_ !:i1:: musclerelaxants,

cellaneousmedications.We conclude tt"lp..r-"rfu,ions given to , are not {illed in approximately oie-fiftli li:t-.i ,h. percentage of cases, and is not different toi p"ii.rrtr'who have :11 palers third pâ&#x201A;Źrty as opposed to those on Midicaid or who Furrhermore, in one third of ";r;;;;.;edication are self_ lllilj.d not an antibiotic, and omission *itf, pl1."tr"Ily ltjr_11_y* serious consequences.physicians expecting prescriptibns ," i"iiff"j ".i patrentsas a part of their ""i"rg"rriy a.p"r;;;;;;"r. and treatment plan should be alert to p"i.",i"fll""._piiice, and initiate important medications under supervision in the emergency oepartment where warranted.

^59 Transfer of patients Be.tween -io-r"sh,'Kl Emergency oepartments SDSchwadzbers, rriJtto",c ^f Mattese, M Builard / Deoartment oj Surg;ry,b"yioi6orr"g"ot Medicine andtheBenTaubGenerat Ho-spitaf rior.fn

are unable to meet the financial obligations. The definition "true" emergency for non_resourceparients i, oft"rr,"Ul."iio"i.rlof a terpretatron.Hospitals and.physiciansface both fr"rnr"it"li"n and fiscal responsibilitier.rtiir ri"Jy-pr.rp*i*.ry ;;;i;;il ;: tients rransferred from another h";pli;"i, ;;;rgency center or clinic to the hospital emergency ...ri... ftr" p,rrpose was to de_ velop in ter-emerqency department transf er i"ii"rl""r. br"r_g 1983 over 99,000 patients were seen in the"emergencycenter. Dulng the study piriod.(septemb;;;j'o;;;; le83f over 4,500 -oi patrents were seen bv the emergency center "pir".,,, .urgi""l.r"*i.J,

jl-:r.9^0l,.g:rients.were t r.,rf"ir"di.,

weresent trom 60 different hospitals,.ll..clinics iidi i"J e prrurt" physicians ,poor,, offices- Eight patients were in conJitiol'and arrived dead. Despite pri or,.stabilizr.lo";-+ipr.i."t. one patient tifi"Ii._ quired immediate use bt .t " "rr,o.i;;;, ;;ri".rner resuscira_ tion, evaluation or therapy upon arrival. Orre hundrea;il;; patrents were admitted. Of these 40 were t.rrr.pon.a di;;;;iy;; room from ,h.;-me.;;;";;;i.,. jl:.:I.::*r one hundred tnrrty-seven pati ents.were.treated f or-minor ini uries "f t., t."rr-J!i and subsequentlyreleased,Guidelines tor ttrJ proper transferof emergencydepartmentpatients between hospitils will minimize delay of treatment ,"a a"pti.rtior, ffi;;i;"hl;. seryices. 26_Co-puter.Assist_ed euality Assurance in ncy Departmenr EM't,xi*, xi / Department lft:j1r.9 lnf Medicine, or rmergency

Johns Hopkins Hospitit, Baltimore The foint Commission on Accreditation of Hospitalsmandates that quality assurance activities i" , h;;pit;l^-"b";r;-;;;;;;;;; ,,routi.r.-l"ll;;;; departmenr include th. . .'"r rnrormarion

or"-.,e."""v"#.7 ih. r,,"....fuloper;*:, :f f:.:.,"1:.1.ry^:::

dLru' ur a quaury assurance program for the emergency depart_ menr

depends to a large p"ri oi ttr. ."r.-.rrJ-l"fl"liiitv-i_tl which information ma/ be.r.tri.u.Jliol,i"i#.L.rg.r,"y a"p.rrment's control register and its emergency _.ai""r records.The Core Record System is a computer_Ur"r.Air.ai"ri records sysrem which provides the basis f., .;;;ri[;il;ii'if," "ro..g.ncy departmenr of a large, urban, university liosfitJ.-it provides online a,ccessto a minimal essential medical .."ord, pir.rm encounter to^rmscontaining this inlormation o, d._"rr6,'rupports an apsystem/ and_ ffT:l* capture.sysrem. is.integrated with the regiitration a.,i cnarge It also.providesfor a histoilcrf .""o""i., clatabasewhich servesas the baseto,, _""a.-_".nt inlormation system,component.The. core Record systeri is a valuabletool tor quality assuranceactiviries. A, system it can sort the entire set of patientili6i;;i"por,rrrg errcourrt.ri -system, according to a number of different elemenis. Uri"g th.ltD-"9 rt can :-ersency medi cal- recoi?, *i rf,-f ,p".if ic diagnosis l1:lr:? -"-tttime period. It can also sort records :Tj_qiy:: complarnt, certain demographicinformation, "i""rai"i-t"-"f,i.i i.e. age or zip code, and by physician providJr. b".. ,h. ;;;;;?";i'fieai.rl records containing a specilic characteristic fr"u" UE""-ia..rtified, a com_ pu_terprintout listing those patrent encountersis generated.The emers.encymedical records;;t;d, be obtai'ej ::T::l-gldl"E ano,evaluetedaccording to the local starrd"rd'oi-""re or ro standardsset by departmentalpolicy. Th.;t-lrry;;rJ'" "ornpr.rr.r,o screen the entire set of encounters fo, " giu.r, *ek, month, or year facilitates a rapid ""a tt oiough-;iil";1f ;. inlormation describing the evatuation ""J,i."iil"ri;il;;i: in the emergency department.

fil-*:::"^"J

ll:!"mic

pressurewirh Arte_riat

l+:*+:ln9l-fl giTo,e"liiliiiil'i,,=ir.,,.,p ?:::::!Ig,:T:lq,.o^d;;;[,-B-Ki,r:6ilin'i'r[i,1",5 Emergency Medicat services, The medical care of non oep;;;;f iXt;,i1,u"oi.in", pharmacy, gf. 9g Schoot supponedr'",i,i,Jail"il;'it"::'li:l'::::f"t#",'"t$,ti"iff v"oi""l Coii"se'oi viisinia, : Htchmond of

by a stiding,""r" u"r.i'o";;;;. ,,l.lj:^d,.,:'-ined rs râ&#x201A;Źrusedemergencycarebeciuseof fi"r";i;i-:;;;s. patlentspresentingthemselvesto private i"riit",ior*

andno one There are wherethev

frgm Duke University noted improvement ,,Investigators in blood pressure and blood flow in a.g, #iil f"ri.;'6 , 150 bpmf cPR compressionrates. tn theii ffi;'cpR ;;r,ion. _"r,u"lt" )1


no different in 35 patients who received standard ACLS drugs (alone or in combination) to treat post-defibdllation PIVR - in terms ol development of recurrent VF (46%), development,of pulsesin the field {46%1,admission to the hospital (17%f ordisiharge from the hospital alive l9%l - than in 6 patients who sponianeously progreised to another rhythm-before drug therapy cbuld be administered (5O"/",50"/",50%, and t7%, respectively|. These data suggestthat PIVR may be a transient recovery rhyttrm {ollowing defibrillation from prehospital Vl, that it can in this circumsince be associated with good outcome in a reasonable number o{ patients, and that a short trial of CPR only without immediate drug therapy, may be appropriate in these patients.

and the downstroke:upstroke ratio was not controlled. We conducted a prospective study on 12 prehospital arrest patients (7M 5i age 49 + 5 yrsl to determine the efiect of compression rate on radiil arterial'pressure in man when the CPR downstroke: upstroke ratio is held constant. All patients were in VF on arrival oi the paramedic unit and failed standard ACLS therapy. Radial a.tery pressure (reported below as mean t SEMI was monitored througfr a #20 angiocath inserted by cutdown within the first l0 minules after ED arrival. Compression rate was increased from 60 to 140 bpm in 20 bpm increments using a microprocessor controlled CPR Thumpero with a constant 50:50 downstroke: upstroke ratio. Ventilation rate was held constant at l2lmin; inspiratory pressure was 45 cm water. Systolic and diastolic pressures declined slightly as compression rate was increasedfrom 60 bpm (radial artery pressure 49 t 5/32 + 6 mmHg to 120 bprn {ridial artery pressure 4l + 6/24 t 6}, then fell sharply as the rate was increasedto 140bpm (radialartery pressure32 + 6/L7 + 3 mmHgf. Systemicarterial blood pressureduring CPR in man is relatively rate insensitive between the ranges of 60 to 120 bpm when the downstroke:upstrokeratio is held constant.A compression rate above 120 bpm results in a marked fall in systolic and diastolic arterial pressure/probablydue to an inadequatediastolic filling time.

Determinants of Electromechanical 30 E Dissociation During Cardiac Arrest KCSutfon,

Edgren,U Hedstrand,NS Abramson,P Safar/ Resuscitation ResearchCenter,Universityof Pittsburgh ECG pattems observed during cardiac arrest were analyzedin 252 comatose cardiac arrest survivors. At some point after car' diac arrest but before restoration of stable spontaneous circulation, 48 patients (18%fexhibited electro-mechanicaldissociation (Eubf, i.e., ordeily ECG complexes without pulse. In 50% ol ihese patients, EMD was the first rhythm observedwhile the patient was pulseless. Unexpectedly, patients with EMD had a sig' nificantly-shorter mean arrest time than the rest of the study population (4.3 minutes vs. 5.8 minutes, P : .01).CPR times *&. co-p"t"ble between the two goups. EMD patients had a higher l-ylar mortality than study patients who did not exhibit F,rtO 926t" vs 76Yo,P-= .05) and also a lower rate of recoveryof good cerebral function (15% vs. 38"/o,P = .011.Pre-arrestvadibles significantly associated with the occurrence of EMD were older agl, compromised functional cardiopulmonary -status,history of diabetei and history of pulmonary disease.When all prearrest variables were combined in a step-wise logistic regression model, age greater than 70 lP = .05f history of diabetes (P = .051 and history-of pulmonary disease(P : .00U emergedas indepen' dent variaLles predictive of the occurrence of EMD. Reasonsfor increased risk of f,IvlO in these subgroups are unclear, but may include hypercarbia, acidemia, blood glucose and increasedpulmonary vascular resistance.

28 Electromechanical Dissociation With Directly lleasurable Arterial Blood Pressures CR

Berryman/ EmergencyMedical Services,Universityof South Alabama Medical Center,Mobile Patients with electromechanicaldissociation (EMDf are diffi cult to resuscitate and have a very poor prognosis. Various therapeutic regimens have been suggested,but most authors agreethat few if any provide reproduceablebeneficial results' We siudied 22 patients who presented with or developed EMD by placing catheters to directly measure arterial pressure and guide ih.t"py. Sixteen of the 22 were brought to the hospital in EMD by paramedics with resuscitation in progress, two were brought by private vehicle, and four were in the emergency department when EMD developed.After placement of catheters, ll of the 22 patients were noted to have a distinct spontaneous arterial pressure wave form, with systolic pressuresfrom 42 to 104 mm Hg. Six of the patients with measurable arterial pressure were resuscitated to be admitted to the hospital, but only one survived to discharge. It may be reasonableto conclude that there are subsets of paiients with EMD; one Sroup that has directly measur-able arterial pressurebut no palpable spontaneouspulses, and one group that has neither directly measureablearterYl_pressure nor Jponianeous pulses. Further research might be helpful to determine which patients deservea more aggressiveapproach in EMD.

31

29 Post-Defibrillation ldioventricular Rhythm / - A Salvageable Gondition JRHoffman, LWStevenson Deoartmentof Medicine and Divisionof Cardiology,UCLA School of Medicine,Los Angeles While patients with a presenting rhythm of pulseless idioventricular rhythm (PIVR) have a dismal prognosis, PIVR following electrical defibrillation from ventricular fibrillation (VFI may have an entirely different clinical sigrrificance. To evaluate this possibility, we reviewed tapes and typed transcripts of paramedic responses,as well as hospital records, of 100 consecutive patients wiih prehospital ventricular fibrillation. Subsequent development bf field pulses 147"/"1,suwival to hospital admission (277of and hospital discharge(8%l in 49 patients whose initial post-defibrillation rhythm was PIVR was statistically significantly wolge {P < 0.05 by Fisher'sexact testl than for 20 patients successfully defibrillated into any other organized rhythm (757",5O"/" and 30o/orespectively|, but was statistically significantly better than for 25 patients who failed to achieve eny organizedrhythm in the field {0%, 4o/oand 0olo,respectively}. Outcomes were statistically

22

Prehospital Index: A llulticenter Trial

JJ Koehler,SA Malafa,J Hillesland,LJ Baer,NR Navitskas/ Departmentof EmergencyMedicine,ButterworthHospital'Grand Rapids,Michigan Severalprehospital trauma scoring systems have been reported in the liteiature, including the Tlauma Index,Tiiage Index, Tlauma Score, Crams Scale, and Prehospital Index. Their chief purpose being to provide a more obiective and accurate basisfor deci iion making in the prehospital phase of trauma managemâ&#x201A;Źnt.A prospective multicenter trial of the Prehospital Index (PH! was ionducted to determine its applicability and efficacy in different EMS systems. The PHI is a triage-oriented trauma severity scor' ing system comprising four components: systolic blood pressure, pu'ise,respiratory stai.ts, and level of consciousness,each scored b to 5. ei, additional 4 points were assignedfor penetratingabdominal or chest trauma. Prehospital Index was developedto pro' vide an obiective prehospital scoring system for distinguishing those patients who are likely to die within 72 hours after iniury or who require general or neurosurgical operative intervention within 24 hourJ(maior traumaf from all others (minor traumaf' A PHI of 0 to 3 designated minor trauma, and a PHI of 4 to 24 was desigrratedas miior trauma. The PHI was prospectivelyapplied to 2,163 patients at 14 different institutions over varying iime periods from |anuary 1985 through fanuary 1985.Of the 1,946 patients scored as minor trauma in the field, there wesa 0% mortality rate and only a O.O9Y"general or neurosurgicalop' erative rate. Those scored as maior trauma in the field had a mor' tality of 28.1V" IP}{.I 4 to 7, 4.7"/"i PHI 8 to 24, 50.4"/.1andn


gt-t:r^,'l:-r",:of 47.9%(pHr4.to.7,J2;O%,pHr8 to 24, 68.0%1. rnesecata demonstrate the ab.ility pffJ L-p*.iiJ_oJ_ tality.(p.< .0001fand the need;9i of tle il;;.;;; gir.r"r or rosurgical.operative intervention.tp < .obil.'ifr8-pHt t ", neu_ b..r, be a statisrically reliabtetrirg;"-;;i;r.d ir"u_" ,.u"r_ js.f]:wnlo rty scoringsvstemwhenorospectively i&;e;i;;rtiturions on 2,163traumapatienrs.

Relationship B_etweenTotal prehospital 93 Time and Outcome in patienii-Wiir, pe"Jtr"tirrg pE pepe,WHaickellCiWvittl'r"rL's",rey, IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII?"qt KL Mattox / City ot HoustonEmergencyMedicat ";; ;;r; Services; Departments of Mediciie"{q .s"row, aly[itorr"g" or Medicine; BenTaubGeneral Hosp'ital, Hoiston--

Most authorities in the field of trauma recommend that seriously iniryll patientst tr"r,rpoi,.d il;,ry; a regional trau_

macenter{RTCI, even

Tt|e Abitiry of TriageC_riteria ?? to predict tnjury.Severityin a e_ouitv.*ia;'i;;|n" system JA Sharff,K Neetvp oerr

"."rUy

E __rJiy if ot l: l.,q:il: 9rur.ri"l hospitals.The puroose thls.study was to examine the rela_ tionship between th. o,rt"o-. ,"[s"f^of patients with f.""i*riiv I Depart-m""t.J eriig"ncy Medicine presumedhemorrhasic shock due to penetratingrniuries and the Vincenr Ho"piiir a r,,,|"ii"Ii b"iit!, and total prehospital tim-e (Tpr) r.q;it; the Rl9^lrls^:,1_sl Io -"""s."""a j:mgrgency Medicine,Oregon Heatthiciences deriver those lllylslol.ot patrents to a single RTC in a large portland Untversity, urban ,r.". Ou., a B0_month period, 448 consecutiveri:,1T, The ability of triase criteria to predict ;;;;;;;;; ;ury presenting in the field with a svstoli"-tojd ii pressure severity is reviewed for thJfirst ,i* _o'"ih.-oi;ir;';i"r*" of patient infury of"90 mm Hg or less and transported to a single RTC,.,":;;;;p"*iii"ry sysrem in evaluated in a"J--*i ."""iyr,r oregon, I1lilelgr c9u^1? _,suburur" jliT^. -oj,"g..,initial.prehospital with traumai"or. tisi; l"ri"ir", ot 260,2.o0 grea and an scene, "t izi-$iir" miles.Tiauma and transDort times, and.mor.tality. AII patients 1J:l1t:,1* parrents areenteredinto the systemif were managed and transported bv a srngte urban paramedic service which Iowingfield crireria:Dhysioto;ic:;i,i; they meet any of the fol_ ;;;,";;,core ":iform (TSf response < 12 iime (5.3 i .3 _ir,;.st or a Glasgow throughout lr.:r-"-jilltt co-"'s"rrei'16, ;;;;";?;,'iii;r, lrs entlre service area. The_.response "re, is ,pfro*imately 200 wound(excluding extremitierl,';;,;;-;;;i.tron, i,"i,l,il*rii square miles and transport times to the RTC p"rrtyrir, cfr exceed20 minbums> 2oo/",andmai.or.scalping, utes. The TpT was caiculated ", n.-ii*.-.[!sed iechanisi-of t"iiiii Oioii, with a falt > 15feet.uver.iit i-it;il;#';';0 from the ,e_ ceipt of the emersencv minutes, call to the tlme-rf *ii*f MVA with intrusioninto victim,s,p""., la-ire at the RTC. Patients **iif, arbitrarilf .ilJtiorr, MVA with weie categorized into rorri-r,rur.t. according deathin the samevehicte,pedesrril;il;;;;,ii to presenting TS (TS = ll_16, 6_10,2-S,andii p",i"rrr, t..r, andage< were also analyzed in terms of four increm."t"t f0 rgarsstruck by auto.buring ih;;*qr'3h o"rrr.r,r,wereen_ Pj gro.rp.,of ipf (nUt.l. att teredinto the svstem""a trrirpli.J; olltr"-o of the 448 patients were dehvEiiJ'. ;: ten hospitals. ,rr. nrc within a "l: percen_t^of tt. prii,J.,r.'i,"rl i"i.La under physTPT of one.hour.wirite *::? criteria, rotogrc with a 6.5% undei anaromic,^i ii.sy" Ue"a,r.s.,or lower TS, the outcome -or,"tity;;;;A;;'e"xpected, was MoL patientswith a to TpT in .not- signifi""rrtiy-i.i"t.d any of the TS subsets{raUle). sbi"z. "and patients, of ts^.oj l6;;;ii*a eftfrSu;h;h;;: 20.r%.had rias a slight trend a Ts of ls, ro.zy, hadllli';Tffi toward increased mortaliry il ,h;;;;il;r.ri ii-, re.Z%hada "ri,i""r patients Eleven(3.67.) = arrests with were TS transported. 2-5 and TpT greaterthan 40 minuies, IL.i ?-. Averase lJayma mfury severiryscoreIISSf all of the pafor patienrswith a iS df 16 ;;;:;"; tients in this small r.ouo 1"n= Zl h;;-i"ilri"rl"r"j,"i"e 5, with TSof 15wasg.2 x 59, *itf, " the heart, aorh, or hilum. Tlie ,.'r"t,. i"hi.r,;T;;#in,a rT.i rs"; + rq was ll.8 11.7, andwith a TS < t2 was-3i- 20 (p . geographically Iarge .00*0i urban for fSS EMS with system, TS ,h;-,i;;;!,;;"inJo,r,.o < 12compared ,r, _rr,to rsSof Ts 16,ls,;il ? [ ";i;; aging and transportins nenetrating < .osror Ts ro in;u.y rrictirrts directly to a versusTS lB or 14; othe_rc^ompaiisons, RTC does NS1. not appear t6 ,dversely ai,;;,;;;,';;;, the percentof oatients withrss> 16- ^" 7.7%i;,;i{i?j rj"z,j' at reast during the first houi after injury. rj, is' r;: i..;;" i;, TS 13or 14,andt2.So/"for TS < d. Th!;;; patients oi with TABLE.Mortality rutesaccordingto TpT ISS> 16in the whole svsrem anctTS

was Z6%. even[ilength of hospi_ tal stay{Los} (excludinedeathi; th; li;.;A;?;t was3.2 days ror a TS of 16,3.8 davsTorTS-of t5; ,. t;;; f";l' rs or 13or 14, andr5.r daysfor a r's < n(p 2'-.cz'ior;;;;:;[., betweenalr groupsexcepr15 versus15,which is Nsl.-Disp;ition from the emergency departrnsnl,

rPr

20-29 min 30-39 min 40-49 min

y:+tf .ifi;ftu"";,J:":ii!1TjilL:'# -wer" f ,fl:,"8,!: llZ .allectto theOR,anae+.sz

50 + min

rS = 11-15 rs = eit-9t102(s%)

18/128(14yo) ilSS (1gyo) Ot24

16/28(s7%) jst31 (48y") A/7 (43y") ZS goy")

i!':

,;."

7/14 (soy")

rs = 1

1s/j6 (g4o/o)

B/12 (660A)

13/13(to6%)

1/1

6/6 -t-

6/6

air"fiirgj'f,ome.

Witha TSof 15,56.50/o of prii.rrtr. went to the JZoto the oR, and is.s.z"dirch"ig.d;;;;: ward, fri.gn rcthe ICU, t4tifr;TS of 13or 14, 217%wereadmittedto th. w^raiii .i;i;;,il'ici, 26.ty"to the oR, and4.Jo/o wetesenthome;and with sentto the wad,29.5"/"ro t!._icu, ci.i;z a-il-Z-iz,6.gv" n"r, ,.ifrl on and20.5% died.intheED (p < .0Sfor TS 15,";; < ii, N"S;", TS of 13or I4f.Att patientsenrered.4* 16, Mbi;;l'iri "i is""i ,o who went directlyto the oR did so Joran ortt op"ai" ;; ;j;. procedure. AJl,earlydeaths(within tf: first 4C fi;;;l ""Jrir,.a in patients uwttha Ts < 12.Addiriona[v, soy"i{p1;";;;;t"" TS of 15or 16senrto the rcu had rod'_i-+i";ri.tn;;#; field TS ap-is accuratelypredict parient severityand,morbidity 33l_rc,,9 b{ ISS, LOS, and ED-disposirion.Alih;;!h'patients enluog:d tered underMor with rs of rs-oii?.;&';; ,-h. maiority of 1:.., a., significantnumberdo not requiret orpri"ti-""tionor need only briefstay.In this eroup,overtriage(asjudged by ISS,need care,or maiorlifJ-savtng,surgeryf approached9oo/o,while f.. ICU It thesâ&#x201A;Ź.parients were exclude-d, uiaei ,ii"g. *""fa have increased by sr" to royo.M": th;sh;;;J;&# to triasecri_ teriawhich limit excessiveovertriage,yet do-rrot-substantially mcrease undertriage.

23

:qi,r'#,a*n:#?, F:fr+-vlilili%iiff

M_edical College,Valhalla; Department of -CitV eilergencyMedicine, tsellevue Hospitat. Newy91k;_Ney Vorr, Ulliin'ano nospitats Corporation, grr-Evaiuil;'d;;'li:;* Maspeth; EMS york,New

u"lu..,9f advancedlife support (ALSf -._Ih. 'tr""irr"for trauma vi*ims who are within short transit timis of "."ters has been

:,llf5:9

T.6*,t9onlr o,,. r,uiy [;,;;;*j

ALSto basic

in the same urban setting. That study :i::,:llt"ltthat {BtSfprovides concruoes ALS better srabilizaiionl-ihis srrdy "o_pares BLS and ALS in the same geographic ^of the same receiving hospi tals and cont.oili,[-;i;'r;;;fi "r.",riiLirrg in; ury. rhe are on the fouo"wing l;;;;;1 :9-p?:'^r.op -made initiat trauma score lTSf in the field, response gime, scine timg transport trme, and mortality rates. Theparients -sa-pi" iri"r"j", ;lli;_" by the pubtic srs ,na nis ;,;ii, ilio"i r,orpitals :11T!g'!"d in a qenned geographic area for ,"to_ .o_pi"i.-a.ll'roas available durins a 2-month period. Resulti;r;;;i;ti;;.'"


n

PtehosPltal Mean Tlmes (mln) Scene Time Response Time

prolonged Derfusion attained during early resuscitation after TransitTime

Blunt ALS

10

6.60

26.9

7.40

BLS

38

5.82

20 15

8.87

NS Penetrating 24 ALS -18 BLS

P 005

542

19.17

6.42

4.78

11,89

7.78

P O,O5 Field - Trauma Score Groups (Oeaths) 9 -1 3 1-8 NS

Blunt ALS BLS

0 0

2(0) 4(1)

NS 14-16 I (1) 34 (1)

of ffiv plava criticalr-olein tolerance

itts,tltt "ttdthiit

4 (41

s (2)

15 (0)

14 (0) 3 (1) BLS preThe observedmortality was compared to the-mortality rates penetratlng and of blunt series foi TS data ctirmpion's ii.iJU" rt"r. were no statistically significant difLii.i,r""*""ii""iv. #""" the ALS and BLS observed outcomes for "o-iJt ffi;; either blunt or penetrating patients compared to the expected mortality rates. ALS units spent approximately 7, minutes more the ii*" "lift" scene than BLS units; Iio*t"tt, both the ALS and expected survival rates comparable to the paraiili""iit-tt"t. "t"d liy Champion in developing his.initial TS sur*.ai"-""i" ALS may alter survival-probabilitiesfor only a pr"t"Uifities. ,i"ri selectedgroup of trauma patients. It remains to be seenwhether such a gioup-can be defined prospectively' 1 (1)

Femoro.Femoral cardiopulmonary Bypass 35 in the Treatment of Prolonged Ganine Garaioputmonaly Arrest GBMartin'RMNowak'

DL Carden, R Eisiminger,MC Tomlanovich/ Departmentof E*"ig"n"V Medicineind Divisionof ThoracicSurgery'Henry Ford Hospital,Detroit Althoush in vitrc studies have demonstrated functional recov,ii.i ptototte.d ischemia, in vivo experience with "t;';l';;;;;; demonstrates ""h."ii resuscitatedfromiardiopulmonary arrest cerebral resistattce to global ischemia' The il;;i;dt;;.i."*a a.*i". oi ieperfusion attained during resusCitation from cardio;.';.; may plav a criticafrole in determining qhe-de;;i;;;; ,e"ouetv attained after prolonged global is;;';i-ffi;;ion"l itt. p,rtpot. of this investigation was to studv itt"iii :;;;;; ot r.-i,to-remoral veno-arterial cardiopulmo;i;;f.;li";;;s. narv bvpass {CPB) as treatment for prolonged cardiopulmonary in "irJ',. f"" "io"gr"t aog, were electrically fibrillated and left rrre.t-*ithout any therapy (or 12 minutes' Sub""iaiop"t-o""ri (n = 5f r"q""titfv, eithei Cps (n = 5l or closedchest CPR {CC-CPRI a-stanto according attempted resuscitation and *i i"iti"t.a O"rai"iJoto,ocol that included administration of the calcium If initial resuscitation was successful .,liaoit"ri".. "fr""iJfi""t (ie, retum of spontaneous circulationf, the animal was managed care therapy including invasive hemodynamic *iltr-i"i""ti"d ventilatory support for up to ll hours' Neurologic ;;;;ht;td graded using a siandardized neurologic deficit scoril;;i;;"t .yJt"- ", 12 hiurs post insult and daily-for one week i"ijiq*t ot""ittit deaih. Prearresthemodynamic and metabolic parameters in both gro,rpi 1r' > .osl' All cPB animals were ;";;-;;;t"r"ble resuscitated ind itive at 24 hours Post insult as op-*""""t.f"ffv oot"a to none in the CC-CPR group (P < '005)' In addition, 3 of [n-. Cps a.timals were neurologlcaily normal at fina.l grading with NDS ."ot.t of zero. The other two CPB animals had persistent r"u.t. tt"ttologic impairment and a mean NDS score of 5l%' bypiss is more effective than CC-CPR in the b"taiop"t-o"aiy ptoio"lia cardiopulmonary arrest' The degreeof reor ;;;;;;;;

resultant functional recovery'

Emergency Gardiopulmonary/ Bypass After 36 protonqea bardiopulmonary Resusc.itation Basic Lir" sl-pp"rt:n o6gs lmproves Survival / w-Stezoski N Abramson, P Safar, R-i;rfu,-fi Gorayeb, of Anesthesiology/ Department Center, n"*..ii"tion-Res6arin Medicine' forEmergency andCenter Ciiii""iC"r" Medicine, Hospital' Universityof Pittsburghand Presbyterian-University Pittsburgh 4 minutes We srudied a {ield-to-hospitalscenarioin.dogs with by 30 followed (no flowl arrest ""tdi"" fibrillation u.rrtri".,t"t resuscitation cardiopulmonary external ; standard ;;;;;"t life support (low flow)' At the end of this 34-minute "J.J'.p"r-'"'""iv'uvpass i6pnt t"ti.

iiJ.iil,

Penetrating ALS

NS

ll#;iililil1;Jl,t :il;;g;6;rr.h

pumpingbv (cPBl{veno-arterial

pump via'membrane oxygenator' without thorai-rrJ"ettttif"lal bv plasma substitute ""d. ht-p11t.''^11:::) pti-inl ;;;;;;;tr'h' clrculawas uied for iestoration and assistance of spontaneous circulation ;i;; i;; I hour (n= l0)' Restoration of sponianeous after the use of "rrJ-r."tu.tv aftir cps w;ii comp-ared*ith thost = received groups life suppori-(cottttoltl 1tt !9f -sgth -blood 6i,n-"a"""#a pressure.and and heparinization, controlled il'.*oaii"tio" f.r 2o hoirrs, and intensive care for 72 hours' There ;;;;tili;; between groups in prearrest,arrest and BLSvar' aiii"t"nce "o *"t activity and i"bi";. B;;t lif. rrrpport rlsulied in-return of,EEG in [irtrr qroups' Restoration of spontaneouscir' ;;ii't"-";;"y (P < culation succeededrn S 6f Id control and all l0 CPB dogs enerdefibrillation for requirements and time Resuscltation .Oif (P < '0ll' of the * lrra "pin.ph.in. w.relo*er in the CPB group 2 died-from-cardiogenic shock at 4 E'ii;i.-i;;"i.s"tcitrt.d, neurolog' horrr" "nd i+ hourr, arrd 3'suwived to 72 hours; 2 were from cardied 3 resuscitated, dogs l0 CPB tire of ".i*tf. i""ff" to 72 hours survived which a"ll 7 and + ioi tto"tt ffii;il;;; = *"* """-f"gically normal (7 of l0 vs' 2.of tOl {lt 0'025)'-Com' reoarinq compiete tte,rtoiogii recovery of only those initially

ffi;li"..d'it';i10;.t;

theoddsratioin favorof s controlsl,

were 3ls. Hemorrhagic contusions of the myocardium cps-;"t after pro,-".r, ltt both groups. C"onclusions:Emergency CPB cardiovasculai resuscitability and ;ha;;;s i""*"I-Cpn-sis CPBcanl#.by t"*iu"t to 72 hours without neurologicdeficit' R:tHt]'1' damage' myocardial CPR-induced f or "ol "oi"o""t"te rf,er prolonged cardiac arrest or prolonged cPR is ;;-btit ;; ready lor clinical trials'

Value of Transthoracic Pacing in the Face / 37 D Cooke RSBaneca' RFEisner, J-f Venttii"lir Asystole -Medrcine, Mercy

Departmentof Surgery Divisionof Emergency Hospitaland Melical-Center,Chicago; Divisionof Emergency M"di"inu and Cardiac CatheterizationLaboratory'Lutheran General Hospital,Park Ridge, lllinois We investigated the value of transthoracic pacing in u9l"t.*lll patients1tu asvstolein t[e emergencydepartment' Fifteen adult pa".d "si"g the subxiphoidapproachin il;il;;;;;;i;.t; departmeni at two University of Illinois Emergen' l-tt. "-.ig.""y and .u-r"r.a-i"-in. it"tia"n"v ,"."tting hospitals {Mercy Hospital in' Pacemaker Hospital)' itt'etil r"ttt.tr" ^iJ;;-e;;teilnJ given sertion was attempted at the earliest opportunity and.was to tne the highest prioriiy following the patient's.presentatron unwitnessed were (537' patients Lighi l, a"p"tt*""i..-..girr"y ""idi-op,rtirrott"ty "tt.itt ,""4 i patients l47"hl were witnessed' wit' rtt. a6*" time'prioi to the iniiiation of CPR in casesof emergen,r"sr"d ".r"rt *", l"tt than 4 minutes' The time in the + 5'2 min' cy department prior to pacemakerinsertion was 9'4 pacemaker to arrâ&#x201A;Źst cardiopulmonary frorn time ,ri.r. th" total + 4'5 minutes' insertion in the case of witnessed arrest was l2'4 tim; of pacemaker insertion ventricular asystole wls.gon; ;;iit; in 8 iit*"a iv -"ttiple monitoring leads' Capture was successful

24


parients (SB%1.In thisrubset of patients in which capture successful,7 patients was lB7y" I were;i;;il.,i,":; tients in *tr* pa""pi-ur" was successful ,1r. o."t^t^'l^ln.those nessedarrest had retum of pulses-wirh p""ilrrl-t., the 7 patients wno were witnessed cardiopulmon".t;r;;: ",rd had capture,

medications, was in1t11u1edin 16.9 percenr of the calls, utiliza_ tion of ALS procedures increased *irh ;;;; Lom s.l percent in the neonates to 24.g percent i" ,tra ,lof""r",.rrt.. ffr. most common ALS procedure *", _r;;;;rr, ""o.rr. The suclltemnted cessrate of this oroce^dure i.r. r..:,, ii.i;;;:", in the infant to 92.2 percent in-the ,adolescent.The ,i_." .-p".r, on scene was greater in calls involving intravenou-s,.".rrize.z + 16.l min_ utesf compared with thsaverage (18.3l-i;;,mrnutes). Twenty medical and five traumatic "riailp"f_o.rr.i "...r,, were ana_ Iyzed.Therewereno.survivf!;ffi;r;; iiJ"r,rr*.. Sixteen percentf arrests occurred {64 in patienrs ;"d"; l6;o"ths of age. In the arrested patients fiu. oi "1".1-";;;;;. accessartempts were successful. None were successfuri"l"i*"t, L.r;ffiT;; or srx years. This study sho_ws tt "t ,fr. "ppfi*tion in the field is relatively irif.r"q"""t or alS in pedi_ iTtj. Ai:",: and ineffeCtive. ,rne appropriatenessof prolonged ,il;-r;l;, tr o*hospital pediatric emergencies needs further "rr"rl;t::ff

occurred in3 patients (31i1$ilil,A:,.',:lH::iillii:

:f:"1T'J'XTIJ]' 1lld:''op"J"i"' i,,...tio,,wairess

i;:^ ment..successi;];;;;,1i"'i:t.f#.".".#:',,,r:,"fi iJ:"lr?*t,j dependupon CpR initiation time anI-iimelf"p""._"ke,

tron. We concludethat the i.rs.r_ emergencya.prit_.irr, rnsertion transrhoracic pacemaker,reg,;J&;i of a rt is given in F5;;;:r, does

:fl:,T?le;;ilietreatmenr, pr"""nting

not ,lt.,.r,,ilu"l

raresof pa_

Gardiac_

Arrest Rhythms and T_heirRetationsf, io__tos"tr"qi.-""T'iii.rt"litv"rra _38.

eJsi"-"l[,liliiii#o, rc s*on, ilr"Hl"ligf l 'F3":.",","sl vq'o' / Hesuscrtation Research center,University pittsouigi"' ot ECG patterns Z62,comatose ,,,.1i_.^r:l1t"g cardiacarrest sur_ vrvors ,oI were analyzedto evaluate tt.i.i.i"t-"Jip to long_term survivatand neurolosi..le"oyjly. Th. pr;;;;;ilg rcc ,hythrn

40

pretrospital

*[mli,ti:::+t]ihJ;l:i:r.t";*

Dernocoeurroeoartments]9r_"i1ffi ffi.'r_il';."",ilTin{lT;.1"o DenverGeneral Hosoital;,

Departme-nt oi,grn"rg;n"V Medicine, j,l;',tl:,1i"n n-yzl5i;il,",.v.,or. i,,iii i,li?lltr", pita|; andin" Hf,6i" ;T:'.',Hh: F"i","lt" bii JiJX,"b;* ; H;;rh tricur.-t-a;;;;;;ilili ff.. jd;:'J:1,!:T?r:l'rlJ,'#tl*li

have an ECG obtainedd"ri;&p;lr;ja;;r;, fl;.r."trng ECG rnythm was strongly related to .r"ra "nj a,rr-rtion of arrest. pa_ uents presenting with Vl arrested ,il;;;;;;irely from car_ orac causes(96%1.In oar

paramedicsto.achieve ".J!t lfilitt^of uupport (ATLS)in an expedientf"rfri"" AdvancedTraumaLife iri^ii"riis of traumahas oeenstronglychalrensed. In thi; secutivevictims of blu.nttrlym, ;tud), ,rr. ,!i'.ra, of lr4 con_ *ho;"e;-;;;t laparotomvor

ii,'J,i'"i.::,:.;illTffili?1,?"::ff 91qqz..1{ai,Ja#fi l;jft ffi';"T:: r#; [I f; :t*l?tt tss+*.';i."iJ"'.dl'i,';h;;i,,

rng wirh VF had both shorrer arrest times *i-lfro-rr.. CpR tnanpersons times presentine y1i1 g3rtiiffili*yl,r"r., but these cltterenceswere not st-atistica.lll, cesstulresuscitation,mortality significan; .liiJr rnitiattv suc_ during the f_yeaiiollow_up was

j.*r-,.rh;-il''';#;.".i1r.?fi was5.6 + 0.27.The on scene:"r.;1ff":J".T'Hgilj::.,,ff *: time rn""l3.9 i-ti.oz. The time

to hospitalwas 8.0 I o.+. ci" ,L,i. :::li_r:,the ,,_. included hazardsat rlre^-scene, patient .*tri"r-tiL, ffl::.^1ig_ spineimmo_ o lllzatlon {n=991, appli

oTvg'T-F:e+fsplintingoi ir ::i:idlqT,#91?::x1,?-,.!^tl,".t'sF:,.t"f *'::#,.fit individuai iim;J :"Ji':i'1".1,9t ,_'-":h;;f i;t;'b"ti;""il"=:1;,i'"l',',Y;lf

cturingthe follow_upDeiod,-44"/o."f neurologicfunction is compared ;h;+F groii,....ou.r.d good *rirr-ri.z;."j iriltol. p"ti.rrt.

t# rfili rp < .oori rr,i"i,i," ij",. anar yses, ffi1.i,'l;,:j"ii.:, i, related

to outcome,confirmed.thal p.Jr*.;#;ii?y:Jflbles vtf m was independentlvpredictive of mortiliiil;"".1:-lf

i" add iti#,il ;i;#i:Jl::J::X JH :::* ;lg;S j!",t, these patients "lro h";;

ili._1y:,:t., ;;;;i;;;-;:r* survivar. Neurologic recovery rates ru*iuor. ? th.1."p..r.rrti.rg crac arrest rhythms are ^f_o1 ."r_ also low, associated tong rnsult times and .on"u.r.rri p.robablyb;;;#,;, ii.."r.,pr"...I*.,

"f:::.lJ'6".*:Ti:lf:;

per patientf ECG monitorinr (1r=u:i;ffrJil!", testsincludingtype and crois (n=sdiLjlppir."rio., of bloodfor of pASG In=31; On scenerimeswere.an"lyr;A ;;;ifi;to the number or ATLSproceduresperformed: .t 1.03minutes, ,ins'..,i",i "i"#'iv ln=a61,U.8a two rv, pru, intuba_ tron {n=71,l4.O+ 2.94,F: qgl, i4i['b.dr;;.'rv

,':l?,_1"0,tuq'il*r,ffi l"i 1p_aramedics have the cel$"J::ilH;ltFil":ll;;:lf ;m",r,"y-p:.'.J"'fi ";i,",:iil,:"!i""Tl.::i:S?i;*.,X** hadany vital signsin i11_1i3ra,

t3-;ffi;;Tjzf p_atre_nts gz%l hadan increase i" ,yri;li;'#

tt& during their prehosoitalrcourse,.ena

rorty_erght fj"io = 3.68mm

lrediatricPrehospitarcare r.3r?r.=tHi.*tl!xt"J:

n.iit"-it,hi, gro,rp ,urv,ved.Eighteen patienti I sr5iainJa' ; i^ii i; i,ood or.rr,rr" or J4 + 5.32mmHe.of lfwhom _s,21 t3-survived (7i;ii. w" conclude

thc_pediatricp"piiilii"r#fji.,i:#.lTilT: j,:,.#Tf;J.ff :uppog andAdvancedpiaot.ic rite i"o*'iii.ir,rmperative T;ij

ence ontr'. t.t.ail";iJ|?

EmergencyMedicine,varrey Medicatcenter, Fresno, #;*,:t .Very few studies have be,enputlished regarding prehospital or pediatric emergencies. care

nave_ datawhich definethe different ,yp";

q:"a"i"r"I.'-.iii'"i',.1p.*i"ion,can :*:J,:'XTiti,?.:$lilf with #ll?;.and

rivo'abl. inrlu-

to ;? pro"fr._, encoun_

q:Ie at a-maio?Inremarional ;":iffi :i#:|",'jitalcaresettins,"i&,;';.S"ilnroutcomes. t-1^:t:1t"^"?it"! pT Fons,R Martin N Drnerman, flI?9n AA.Cwinn,

#,HX.,l;*Tffi 13i,,.i"t1piil;;,h;.fl'dffi l5ll,ffj

ress_than19 years of aelr^/ere,studied"in r-;;i,.; area with a toralpoputa tion of ssz;.z.oo.Th;;;it ;;i"oir.J.r,unar.a elght-fourforms were ane "r,a

percent or.ar ;;il;i#;'#:: iiT'::ilH.*Jffiifffi? *: tact that the pediatric aer popurationrf,

/ ueparrment of Emersency rvteoicilre rje]i".jr'CllLih Hospirat uepanmenr ; or Emersencyueoicine, t;;"I,'riii riliprrar;andrhe FaramedicDivision,Denver Health anO Hospitafs'-" . .The impact of medical e,mergenciesat Stapleton International

jili{trtrliFft:''"}**t fu;,'

;;;r,"$#_H:i!1,*:::ll,:g::.u:rr,l: prus

centl were more common.than medicai iI*rr.,ili, evrdentin the adolescent. 1

a staric employee oop_ulation .i i_iritil;i:,m0.

rnere were 1,872 ambulance trips to SIA, of which ji"-.-i"o;il;iilil:lll1::,:iLT,Jfwas most rraudulent, .r..t,o""i patient refusals or .r:"..ff"a ::1,.J.",,""1',* .lff"r. 6irfri, trre department was dispatched as first

')<

In 1928, Slo/owere SlTo, the responders tor 49.S7o.The


operatlng expense to send an ambulance and firetruck out on such calls is large. The paramedics were out of service for 827 nours on these non-trensport cases, resulting in increased pres_ sure on the remaining in-service ambulancesiovering the ciry In order to jmprove prehospital services to the airport and Denver proper while exercising fiscal restraint, " p"r" .ii" has been sta_ troned at SIA 16 hours a day since l9g2-He is equippedwith a specially..d:tje:a goff-cart, ACLS drugs, two-way i"aio, "rrJ " monitor/defibrillator. The records for SIA p"ra*edi" services foi the 12 months ending September l9g5 were reviewed. One thousand nine hundred fifty-two patients were seen, of whom 695 were transporlg \35:7.y?l ,!q !gpi,"] by, ambulance, tli li.g;/"| went by private car; 284 114.6/"1 refused any paramedic ."re oi transport; and 837 {49.9%l were released,aftef base statron con_ tact, with instructions to seek definitive care at the final destina_ tion. Presenting complaints were classified into 50 categoriesand th.e frequencies and dispositions are described.patientJwere not tollowed tor outcome. The most common presentations resulting in transport were: chest pain, n= llo li.6%1, syncope, n=5d 17'); psychiatic,^n=57 -i2.9/.1; "Mo-in"t piin, n:iO'12.5U41, [3 tracture,n=31-(1.67.f;and cardiacarrest,n=t9 1t.SoZ ;. ftrb mosi commonly releasedwere: lacerations and abrasions,n:12l (6.2%f;contusion or sprain,n=86 ,'4.4%ltand nauseaand vomitin& n : 8 I (4.47.f. Sixty-four percent of patients triaged by the SIA paramedic 64.40/owere not tiansported (consistent"wi* pr.vio"s experience).Since implementation of this service, distiibution and use of prehospital resources in Denver have become more ernctent and cost eftective.

42 Bacterial Gontamination of Ambulance Oxygen Humidifier Water Reservolrc: A potential WAReese, ::yc9 _oJ^latrogenie Infection JL Cameron, RFClark,Jr,D Kelso, ERGonzatez, Jp Ornato t tp TgVal, Medical-Surgical Emergency Unit,Departments of pnarmacy and

InternalMedicine,Medical College of Virginia,Richmono , The risk and benefit of humidification in the short_term (less than.one_hourfuse of oxygen is unknown. We cultured the water slpply ot humidifiers on 30 randomiy selected area ambulances during November 1985. There were iZ positG lultures. poienl tially pathogenic bacteria (4 pseudomonas iultiphilia, S Pseudomonas aeruginosae, I Klebsiella pneumoniie, and, I rtapnytococcu_sepidermidis) were found in nine samples. As_ suming that the water in ambulance humidifiers stroirta lav. been sterile,.th.efindings are.starisrically silnificant (p < .011. uur results rndicate that ambulance oxygen humidifiers with plastic multi-use bottles can trarbor pot"rriiilly pathogenic organisms and may_be a potential source of iatrogenic diiease. Si"nce there rs no evidence that humidification of orygen for short-term use,in non-intubated patients is beneficial, *r, Juggestrestriction or rne use ot ambulance oxygen humidifiers to intubated patients or to patients with a tracheostomy who require more titan one hour of ventilarion. In such ""."r, " sterile a-isposallehumidifier water reservoir should be used.

43 Brain Corter Tissue Galclum, tagnerlum, lron, Sodium, and postastlum Follbwin-g Resuscitation from a lS.tlnute CadiadArrâ&#x201A;Ź3t an gogs TJHoehner, AMGanitano, ne oiloLnio,-d'JO'ru"ir,r Koehter, NR Nayini, RRHuang, GSKrause, SDAust,BC [yT"r, { wnrte / Section

of Emergency Medicine, Department of Medicine, ano Uepartmentsof Biochemistryand pathology,College of l!T-"1l/"gi"jne, MichiganSrate University,ei6i knsi-ng: anO Uepartment of Emergency Medicine, Butte'nvorthHospita], Grand Rapids, Michigan evidence suggeststhat ultimate neurologic iniury fol,^-1,._":", towlng cardiac arrest and resuscitation may be largely determined by biochemical events occurring d;"t;;rf;;;. To test this hypothesis and further charactjrize tti tili *l^e of some of

26

these-events,we examined tissue samples from the parietal cortex of dogs Jor their total content of calcium, magnisium, iron, sodium, and potassium in five non-ischemic contr6ls ""dirrfiul animals each after l0 minutes, 2 hours, 4 hours, and g hourgieperfusion following a. 15 minute cardiac arrest. Large mongrel dogs were anesthetized with ketamine and Halothane.-fo the fiu, cardiac arrest and reperfusion groups, cardiac arrest was induced with KCl. After 15 minutes cardiai arrest animals were resuscltated by lOOy" Oz ventilation, intemal cardiac massagg administratio-n.of NaHCO3 and epinephrine, and defibrillatioi. In the 4,,and 8 hour groups, the chest was closed with incorporation of!a thoracostomy tube, and the animals were placed on a standard intensive care,protocol. At theappropriate timq a S-Sgm samfle ot the parietal cortex removed. Exactly I gm of the cortex was dissolved in HNO3, and a yttrium standarJadded. Triplicate det.t-illlioT of Ca, Mg, Fe, Na, and K were then made on a fanell Ashe 995-plasmaatomic emission spectrometer.Statistical analy_ sis was done sequentially by MANOVA, ANOVA, and Schefie contrasr. MANOVA yielded p < .0Ol for signilicant differencesin the data pool. Data for Ca, Na, and K all were significant across time at P < .005. There were no significant differinces in Fe and I-vIB.Data are shown as means with,,r/ indicating significant difference from control values at p < .05. GrcuP

C! pil/g

MS r fVS

Fc nf/g

Non lschemic 10 Min. Reperfusion 2 Hr Reperfusion 4 Hr Reperlusion 8 Hr Reperfusion

1.49 1.93. 1.4S 1.45 2.76.

5.63 S.99 S.9S 5.61 4.68

265 3S3 293 299 286

X! FrVC 60.4 70.6. 62. r 60.4 107.4,

Kg i[/g 90.4 83,8 96.3 75.4 48,5.

After I0 minutes of -reperfusionthere were small, but sigrificant, increasesin the total tissu_econtent of Ca and Na, as coripared to non-ischemic controls. All values had returned to nonnal at 2 hours and remained normal at 4 hours of reperfusion. Howeve4,ai 8,hours of-reperfusion, Ca and Na content approximately doubled, and K conrent was reduced by half. We-conclude that between 4 and 8 hours of reperfusion following a 15 minute cardiac arrest, a maior defect occurs in many celli of the cortex with respect.to their ability to control ionic balancesof C4 Na, and K. I h,s migbr be explained either by failure of the energy_dependent ionic pumps or by more generalized damage to thl membrane permeability barrier by a process such as lifid peroxidation.

44 Effect of Defercxamine Therapy on UltrastructurG and Biochemical ta-t*ers of Ne_uronallnjuty at Eight Hourc of Reperfuslon Following a Fifteen.Minute Gardiac Affest ln Doga M Goosman, RADeLorenzo, NRNayini, TJHoehner, AM R Estrada, K Kumar, RRHuang, 3O'Aust, GSKrause, $grgitgno, BCWhite/ Department of Emergency Me-dicine, Buitenrvorth

Hospital,GrandSapids;and Seition-otEmergency Medicine, uepanmentot Medicine, and Departments of Biochemistry and Pathology, Collegeof HumanMeiJicine,MichiganStateUriiversiry EastLansing lipid peroxidation is thought to be a maior con. .Iron-mediated tnbutrng tactor in neurological iniury following cardiacarrest, This study was designedto determine ihe effects"ofdeferoxamine lDtFl. on brain iron and lipid peroxidation after eight hours ol reperfusion, at which tim-e other work in o", t"f,or.iory h., shown severe cellular derangement occurs. Sixteen i;il;;;"sr;i dogs were anesthetized with ketamine and Halothane-and diiided into,three grgu.ps.One group was non-ischemic controls lN = J,. ln- the _remarnrnggroups, a lS-minute cardiac arrest was induced with KCl. The dogs were resuscitated by 5 minutes of internal cardiac massege,epinephrine, bicarbonate, and intemal de. nDnllatton. All dogs we_reresuscita-ted and supported by a standard intensive care ISICf protocol for eight hours. Onj of these groups acted as ischemic controls {N = Sl while the other gr.oup qJ = 6l was treated with DEF immediateiy post-resuscitetion with a loading dose of 2N mg/kgfV followei by fm m/ke/


hr maintenance dose bv tV-drip infusion. A 3 g portion of parietal cerebralcortex was oblined through a 15 mi-trephine hole. In situ fixation was then initiated rrtrir"all,Jyle"Jardiac bypass pump was connected and a3 liter flush i{ci.g;i ]aline was fol_ lowed by 6 liters of Kam219|1,s fil;*;: ii. i.ii,i was prepared

microscopy tnrvrti" th-s"l 3:,1:,1"" were measuredby

;;;;:hrrue

metals

an "to,Tig.emission ,p."il.*","r, low mo_ tecularweightspecies(LMWSI lyit J-Jpi"rianthroline test on an ultrafilteredsamole;""d :rf" tipia p.r*i##;; the thiobar-

(rBAris l r,"a.tit 1irir""1;"# ir npiaao,, P1,ul'", ."g.1I.,.sI ure bonds(LDBf, which waslalcutated

btl;;r#;il the tipids gas,chromatography and then measuringthe doublebondsby in by spectromety q,a zu*_"i"g il,;";.r"rrr. ;.,1.-lanalysis l":,ig" ucal wasdonebv MiNovA- (F= sjE p-. .bozl Statis_ ANovA (nosignificantdifferences i" iro" a"i'i"f"i"ii "firfr.rs p < .01l, Sch,9{{e conrrast test. Dara is reported -""J as means with,.,, 39d: rndicating differencefrom:ronischemic] " i,,-arfference be_ tweentreatmentsat P < .05.

bituric acid test {tseisl ""a.rtJ ,irir".ffi#; ir hpid double bonds(LDB| which was ""t.utrtea by i;";,#;i; the lipids chromarography 8as, and th.r, -.rruri"g'i"lr. i"i,ur. bondsby in each traction by spectrom-et.y"rrd summ'i.rg-iil"r.ruftr. Statis_ tical anatysiswasdoneu, u,,irywe 1r=?.ii p lloo4 ANOVA (no significantdifferencestn calcium,'all i. .021,and the Scheffecontrasttest.Datais,eportei ", ;;;; -""", *i,fr,,*,, indicating differencefrom nonischemic,an4-,;1;;;ff.;;"". between treatmentsatP<.05.

l0n

5

I h soD

Na

l\lorilschemic 999.6

Lg

4&

t h stc

1.A9 SO.9 @.2

1.36

@.6

2.O.t

q.7-t

290.t

2.62 95.4.141.1.1

314.2

0.48.1

9.1.i

27.7.t

4g4t

2.11 il.st

1.221

7.g

7.9 300.61 2.0' 501.41 1.6.

8 h slc

LDB/ palmitater'g

76.71

LDB / palmttate./g

nlwg nlit/1oorng Non-ischemic 399.6

Ltvfws iron ni,?100rng

t h DEF

were measured bv an ,r93i!. emission spectrometâ&#x201A;Źr; Iow molecular weisht species (LMwsl U;il;il;nlthroline test i-; on an ulrrafiltered samnle; ""d tipia p"rJd""i;;;y the thiobar_

,:*:t.."-"!

P"::t

"f

7.U

K ,rl,?s

K Na

â&#x201A;Źo

1.37 59.4 81.6

1.36

4O.7't

290.

2.62 95.4. 41.r.

0.48.

n.7'J

269.

212 U.7

0.93.

5g.8.

::": in the treateddogswerefound to be

J.?",d,l: ,.jil1Ta.:l:f .*":::{.1'F;*;-d;;ftXfi"#:tf ;:l.;;Til *:*llg""::::911_9t;:s9d-;;;d;tis,TTffi " j:*.or, uut i. _"1; J:i.;;.;;': _:**:l

:.^:h:Tl

.

bovenon i s

p,.,"a.i-""'lis,ii,""llil","..,"" '6r'rrcant protectron against j:.:-,thecortexandhippocampusor il"."T',., :::,illil l9D loss of Iipid ao"ur. u..frI

of theX,/Na gradients. ;'ffiffi Tllr"#J,lili EM exeminrri^- ^r ,,-^..^o.r_oegeneration ,"."*t".:":::,::.:!:!;_;d;?,ffi fid "liifi#j"fii',,.1,.j; iy _"A#llj:$ :f^::,a F;;;;;; lL*r1,Ti:'*3:.:::*..,.;;dnFrli'H;"tLTlilil#'l: we co,icrut.',r,;; a;rHil'il:%::"ffi H,:1 : *:.1"^?.:.:i.!s,"."n,J,a""i'#;;;il;'.HjlffiTff T:,Tb"':::.*E1.r"tio"l

3ffm;X,::",*1TT

r"r,"r*ir,","ji;ii::,ia"H:- oegeneration. :i1,^t:-:t:r"ping, :;::::i"l.o5:,i1".ilf_.-"_,..gglilr, jl^1ti,,*Kti,r;;I;i:illii,i",ll',',lH:?",ff

endoptasmi.r. ii""t"*

l.; +il1f i:lj:i,":{^oli.ryjr,"ii"a,*ia",,ii!ii#;itiH,:il:,.J,7 p#r":: ----rvY' ..'s ruuD!4*rar urrrastructural

iniury persists. The effeci on tissue calcium fhis qrrzt,, .\1L^_ r-_-_

i;;"s,i;y''", membrane

46 _ffatr,ral Gourse of lron Delocalization *";;'"il;;#;:.ii";:ffi:ff.'Tl:,# Lipid and peroxidation :[T::ol?:lnlf phosphoIipas" ""ti ", ti or,,;y ; ti" iii"ltigrrt Hours X':H Qg-g #llil di; :il":l ,1r t}lerapy is indeterminate

in

f.-5 lffect of Superoxide Dismutase Therapy on uttrastructure arri

qioci;ilffi;;fers

or

:T,1",":ff"1'i;,i:i*",,1' i:$%$ia5i'i,","$;f,

'e.J Goosman, RADeLorenzo,O,r.l"ii, Ri;lt;il l< Kuma(SD Aust,BCWhite/ Section,or MJ;;iil, Department 5melqgncy of Medicine, andDeoartments.ot p"tnotogy, biocnemistri ""nO Cottege of Human M'eotcine, lai"n,g"" r".t Lansin g; andDepartment Emeffi "vIi"iJ"rJri*r.,ty, r''vv'v"'w' i.", Butterworth ' ]i,rlii" .of Hospital,Grand

[l.*:i:;ni,,l;rt=u:ii.i,iir'ffi pg'i't.rb;ffii;,i.}'ffi ,si"lifl"';"i3"ll,Tgi#1ffi:;, uarntano,REstrada.KK

jlTllt:! -Dt.jt,lr/ichigan; sect"ion cite|.iJi6l,i"v' iiiuo,",n" (uepanment of Medicine)and.Deparrm-;i;; il;l"ristry and e orHumant',teoicine, r,,,| icni-ga-'i"diate univerir ty, H!!i?g#,,|J""s

Iipid peroxidationis thought to be a ._,1::I.9t"l"d ma;or con_ tnDutrngtactorin fofio*i"g;raiac arrest. _neurological.injury rne superoxide radicalcauiestt"'rai,"r"^Ji'i^r.?iro' from fer_

Rapids,MichiganLipid peroxidation is thought to be,.amaior contributing factor ini ury f ollowing cardi.. "]r.rt.'i,r,ce iron avail_ :1, l1::tl_loct""l aDrlrry rs a prerequisite^f9,1 linid peroxidatitn, ifri, .:<p.ri_.", was designed to examine the natural dil;;;;; of iron release Tj:lj.,nl*t.lipidperoxid",i""].ll.'*i""i""*iil_,r,,r,.cardiac arrest rn dogs. Larse mongrel. with ket_ $ogs were ,i".tt.tir.a amine and Halothane "oa fiuia.-a'i.,;ir;il;ps ot five each. In.two groups,_cardiacarrest was induced fiif, rcr. After 15 minutes of cardiac arresr, the d;s;;;;.-;;r;Jiated by 5 minutes of internal cardiac massage, epinephrine and bicarbonate, and internal defibri[ation. Atit;;';;;;;;;! iesuscitated and supported by a standard intensive "".? proro"J until harvest time.,-Specimens which were harvested from the non_ischemic tlogs(N=5| and at 2 hours (N=5f, ";ii;";;;TN::f post_resuscitation consisted of a B g portion'o{ n"rl.rri c.r.brrt cortex ob_ tained through a 15 mm iriphi". t or.l roiJ,ili,r". ,ro' was measured by an atomic emission-ffir;;;r;r;;:"* motecular weight species (LMwsl iron by t-tr'eo_;;;;;?#r"e resr on an lijio peroxidation_ by the thiobarbiruric acid lltl{*tr:{.r"mple; test (TBARS| and the t-issuecontent of lipid double bonds which was calculated by first fractionating ,il 6;;; by gas chro_ matography and then measuring ,h. ,r, .""t trr"_ tion by spectrometryand zumniing A;i"'#ri", tt. ,.r,rrir.'IWilks_larnbda MANPV.4 yielded F=764, p.< .0009. Univariare ANOVA demongatla a{ variables except rissue ii." i" rrir. ,rg,iricance at p < is shown", -&n *1r.. *itrr"";;ili'f,;rs ;2?;^D"j? at alpha significant ortterences < .05 by Scnefe.o"trart]'"-"'

r?;n.g:i:ii,'m*{*rr,,,T; fF"?F:i,iiiir!1ffi

repertusion following a lS-minute ""rAi""-rrr.ri'L'arge mongrel oogswereanesthetized with ketamine;i i;l;;i;. and divid_ groupsof five each:non_ischemic :11i1:S*. "orirotr, lS-minute cardiacarrestwas induced resuscita_ )1ith idil;Ii"rn,ii'uy

$sljffitrf,*:ff il"";nrut,*#i,m:r*ir* "r,rr,

unitsFriedovici, 9t500,ooo "rr"iiiv-r.ri"*li ilrifu,* hr maintenance dose

by IV dri,p'infusio"l fl"-i.gir"*.re tatedby 5 minutesof inte

resuscr-

T?',i;,?iH.:HH.,'ji ::k_1{,",*d;;;;iTf#,ffiH:f

cereD-ral cortexwasobtainedtrr.o."gt,a f S dri ,r"pt _" hole. /n srtutixationwas then initia^tedifr_.alr,Jy]alliai"" Uyp"r. pumpwasconnected.and a,3 tit-e,nuil ol-iib"z, ,"it"" was fol6liters of Kamovsky,st*"r*;. ii," urir,iL, prepared Py:| P tor erectron microscopy(EMl in ttr. "r*r -"rrirJ. rirr,r" -","r,

27


lron nM/g

LMWS ilon nM/1oomg

TBARS nM/1oomg

Lipid Double Bond Content double bonds/ Palmitate/g

430.2 7.34 397.2 12.24' 2m.4' 40.7' 1.98 300.6 t h We conclude that iron is available in LMWS form at two hours post-resuscitation but is resequestered into large molecular weight species at 8 hours. Tissue TBARS levels-have progresiively increased by 8 hours and are accompanied by loss of lipid double bonds. Non-ischemic

399.6

7.90

2 h

341.8

37.U'

47 Gerebral lschemia and Reperfusion: F llitochondriaf lniury and Recovery RERosenthal, ot Emergency / Departments PJVarghese Hamud, G Fiskum, Medicineand BiochemistryDivisionof Cardiology,George WashingtonUniversityMedical Center,Washington,DC Mitochondrial degradation and elevated levels of intracellular calcium are implicated in the pathophysiology of irreversible cell damage that can occur during cerebral ischemia and reperfusionThis Jtudy was designed to measure the effect of ten minutes of total ischemia followed by 100 minutes of reperfusion on dog brain mitochondria (DBMf. Eighteen adult beagles (7.5-17 kgl, anesthetized with biotal and chloralose, were subiected to controlled ventilation on room air. The dogs were then divided into three groups: non-ischemic controls l5l, ten minutes ventricular fibrillition (51,or ten minutes V-fib followed by three minutes of OCCPR, epinephrine, sodium bicarbonate, defibrillation, and spontaneoui ciiculation for 100 minutes (8|. At the end of the appropriate period, a 2-gram sample of left parietal cortex was suigically removed, immediately cooled to 4o C, and processed for mitchondrial studies. Free plus synaptosomal mitochondria were isolated and tested for their capacity to respire and accumulate Ca+ +. Statistical analysis was performed using one-way ANOVA {ollowed by comparison of means by t-test with fifteen degreesof freedom. Oxygen electrode measurements of mitochondrial respiration indicate that there is no significant difference in thC respiratory control ratios for the three groups of animals. There is, however, a marked decrease(35%l in the ADPstimulated rates of respiration for control (170 ng-atoms 0 min-rmg-rl vs arrested animals (l13 ng-atoms 0 min-lmg-\ P<.0Oll. Rates of resting and uncoupled respiration are also depressed after ten minutes of arrest, but to a lesser extent than that observed for ADP-stimulated (State 3) respiration. By 100 minutes after resuscitation State 3 respiration recovers to essentially the same rate obtained with control DBM {165 nt-atoms 0 min-lmglf ln the presenceof ATP plus oxidizable substrates, the mitochondria exhibit a small, but insignificant decline in the ability to sequester6r+ + (as measured by Ca+ + electrodel from control (504 nmoles mg-tf to ten minutes fibrillation (452 nmoles mgll By l0O minutes after resuscitation, there is a significant rise in Ca+ + sequestrationability (712nmoles mg-t| when compared to either control (P<.0251or resuscitated (P<.01f dogs. These findings indicate that: lf l0 minutes of complete cerebral ischemia in the dog causes a substantial decline in the rate at which cortical brain mitochondria can synthesize AIP; 2l mitochondrial damage is completely reversible after 100 minutes of resuscitation; 3l mitochondrial Ca+ + uptake is relatively insensitive to the adverse effects of ischemia and appears to actually improve beyond that of control animals resuscitation.

death. Elevated brain lactate levels following 30 minutes of partial global ischemia (PGI| retum to near normal levels after 60-90 minutes of reperfusion following ischemia, but structural and functional integrity of brain cells may be affected during reperfusion. Cell damige'may depend not only on the absolute level of Iactate that accumulates during ischemia but also on the length of time brain cells are exposed to a high lactate level. Therefore, efforts to rapidly lower elevated lactate levels either during-the ischemic period'or during reperfusion may enhance brain cell re"ouery and protect the cell fiom additional damage after cerebral ischemia. We previously found that both pre-ischemia or postischemia treaiment with dichloroacetate (DCAf significantly Iowers cortical lactate levels at the end of 30 minutes of reperfusion following 30 minutes of PGI in rats. Since these studies did not determinC the effect of DCA during or immediately following ischemia, the goal of the present study was to evaluate the effect o{ pre-ischemia treatmeni with DCA on cortical lactate levels duiing ischemia and the initial period of reperfusion in rats subiected to PGI. Fasted rats were treated with DCA (pretreatedl-or normal saline (untreatedf 15 minutes prior to PGI induced by bi lateral carotid artery occlusion and induced hypotension. AIter 0, 10, and 30 minutes of PGI, cortical lactate levels were measured in groups (n>4| of preffeated or untreated rats at each time period.-Coitical lactate levels also were evaluated from pretreatedor untreated animal groups (n>4f subiected to 30 minutes of PGI followed by 15 or 3b minutes of reperfusion. Serum lactate levels were analyzed simultaneously in each animal group. DCA pretreated and untreated rats had similar rises in cortical lactate levaniels during the ischemic period. During reperfusion, ho-nrever, mals preireated with DCA had lower brain lactate levels than untreited animals, and these differences becamesigrrificant by 30 minutes of reperfusion lP<.0005, ANOVAI. Serum lactate levels also were significantly lower in pretreated animals comparedto untreated animals prior to reperfusion (P<.01) at 15 minutes of reperfusion (P<.051,and at 30 minutes of reperfusion (P_<.051. These results suggestthat pretreetment with DCA does not limit the accumulation of lactate during PGI in the rat, but may promote its clearance during post-ischemic reperfusion. If reperfusion events following ischemia influence the degreeof brain cell iniury DCA may enhance cell recovery by lowering lactate levels early in the period of reperfusion.

49 Gompariron of Sodium Bicarbonate with Dichloroacetate Tteatment of Serum Lactic MHBiros,DWWidman, Acidoris in the Rat AVWDimlich, andAnatomy Medicine / Departments of Emergency J Kaplan and Cell Biology,Universityof CincinnatiCollege of Medicine Serum lactic acidosis is characterized by a blood pH < 7'25 and serum lactate > 5 mEq. Intravenous sodium bicarbonate (NaHCO3) is standard treatment for this condition. However, clinical and experimental studies suggestthat this treatment may be ineffectual, even detrimental, to brain, cardiovascular,and res' piratory function, as well as suwival. Another substance,sodium dichloroacetate IDCAI also has been used successfully to treat clinical and experimentally induced serum lactic acidosis. The present study was designed to compare the effects of NaHCOs with those oi nCe on pH, HCO3, and serum lactate in rats with a low flow-induced (Tlpe A| lactic acidosis. Fasted male Wistar rats (300-4fi) gf were subiected to bilateral carotid ligation and bleeding to a mean arterial blood pressure of 50 torr for 30 min' utes at which time, if the pH or HCO3 tell to 7.2 or l0 respec' tively, the rat was treated intravenously with NaHCO3 10.5 ml,3%f (n=81, DCA (25 mg/kgf In:5f, or remained untreated (n = 61.Blood was collected immediately prior to, as well as 15and 30 minutes following treatment. Over the 30 minutes recirculation period, treatment with NaHCO3 had no effect on serum lac' tate or pH (ANOVAI but HCQ levels increased more than in un- or DCA-treated rats (P < 0.05 Kruskal-Wallisf. DCA treatment had no effect on pH or HCO5 IANOVAI, but serum lactate decreasedmore than in un- or NaHCO3-treated rats (P < 0.05,

48 Braln Lactate Dt/namics Durlng Partlal Global lrchemla and Repeduslon In the Rat MH Br7os,RVW Dimlich / Departments of Emergency Medicine and Anatomy and Cell Biology, Universityof Cincinnati Medical Center lncreasesin brain lactate levels occurring during cerebral ischemia have been associatedwith irreversible brain cell damage and

28


Kruskal-Wallisf.These res mrs experiment. neirher ,J:lj:Xryt-tt

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th3t under conditions of

subiectedthem to 14 minutes of cardiac arrest. After resuscita_ rron, tbese animals showed the same ctini"ai-iiniings as exhib_ rtedby thefedanimars d:jclr!:d: iii *r,l,jl*_infusedani_ mals were killed after 6_Ig hours +;;.. neurologic deterioration leadins to apn-ea because of?".i"a o, be"-"-us"J ;; ;.;;p""yrn8 drosenic shock. wefr,..1:1^uy:1, br"; il;;;;;;neurotogic car_ tenoration in some deBlucose_infused""i_"fr-io".*plore blood_

NaHco3-tieatmentim

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-- --' 'r'*qvuuurar prrt pH; tnerefore, lncrease in HCOe therefore, an an may be In addition' ln addition, since lactate ractate Ievels sirr"e serum levels ;l;J ,.-m :"i.'-11']cntar' of less tL""? th,. ."."11:T_rl.

survivarin*o*r.,trii",i;"",?3Lt-t-jll::rrelatedwithimprovedtreatment with DCA that s^uccessfullycorrects lr[;:"-""""urc th9,ulg.be sll-o-uld be evaluated evaluated turther. fu;tlh*. trupporred in !;;il;';ft [supported' -":cmra Darf r. ,; l'ljlly Medicine ro""a"tiotr-illl searchAwardlil ;d;fii Kaplanf.fi-ersencv

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comatose, develop widespread cicu lations ;;'d;;"iilYtn fasundergo deterioration,.;d;i.";;#tJ-erks', ";t;;l"gi. ot"t" edema and -marked brain stem compres*,ot o', "lr.;;;.'i;;;;;f

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":"""'otr' uu Hrnson'F Tillman'R BellamyI oivision 6i-M1i;1" ,,auril.rrlesearch,retterman LettermanArm) lnstituteof rnsurure Army pro.,1l^'tj'x11 of Reseirc_h,.p_:,, Research. "' oarr san.E::1"n, Francisco' california; rrancrsco' californra; and Department uepanment "iMii,taru'M-#'Y and of Mirira^, ^r^r119-ol .".rn.rl".ll",^,Ul,formed

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29

ServicesUniversiiy rne nealthSciences ot The_choiceof early resySli_111ive.fluid overall prognosisof ihe hypovolemic remainscrucial to the traumapatient. we evalu-


ated the efficacy of small volumes oI 7-5% NaCl in 6ol" Dextran 70 as a treatment modality for a lethal hemorrhage in swine. Sixty chronically instrumented swine were randomized into one of four treatment groups: 0.9% NaCl (n=lSf; 7.5% NaCl (n=l5f; 67o Dextran 70 (n:16},7.5y" NaCl in 67o Dextran 70 (n:141. Each animal was bled 46 mL/kgin 15 minutes. Five minutes after completion of hemorrhage, the animals were infused with their respective treatment in a volume equal to 25% of.the shed blood. 100% of those animals receiving 7.5% NaCl/Dextran 70 survived until euthanized at 96 hours. In comparison, 0.9% NaCl, 7.5% NaCl, and 5% Dextran 70 had 96-hour survival values of l3%, 53%, and 697o, respectively. The percent survival with the 7.5% NaCl/6% Dextran 70 solution was significantly better than 0.91" NaCl (P<0.0011and 7.5% NaCl, {P<0.011.The 7.5% NaCl/6% Dextran 70 solution improved mean aortic pressure, heart rate, serum bicarbonate, and base deficit to a significantly greater extent than 0.9% NaCI alone (P<0.05f. This effect was observed immediately after treatment. At present, the acellular resuscitative fluids used for the treatment of traumatic shock have a suboptimal effect in the volumes infused during transport. Infusion of large volumes of crystalloids may precipitate or aggravate complications, such as dilutional coagulopathies and ARDS. We have demonstrated that small volumes of the 7.5% NaCl/6"/" Dextran 70 solution are superior in their ability to maintain survival and correct the hemodynamic consequencesof shock. This solution may be invaluable in the early resuscitation of the hypovolemic trauma patient.

Moore,J Winkler/ Departmentsof EmergencyMedicine and Surgery Denver General Hospital,Denver,Colorado;and Departmentof EmergencyMedicine,SwedishMedical Center, Englewood,Colorado;and Departmentof EmergencyMedicine, PorterMemorialHospital,Denver The effects of acute ethanol administration on hemodynamic parameters and acid-basebalance were studied in a canine model. Ten mongrel dogs anesthetized and maintained on a volume ventilator underwent splenic artery ligation thirty minutes prior to the study. Group A (N=5| received 2 glKg of ethanol per nasogastrictube. Group B {N:51 servedas controls. Thirty minutes after drug administration the animals underwent a Z0cclKg hemorrhage over 15 minutes. Thirty minutes post-phlebotomy resuscitation was performed with the same volume of homologous blood. Hemodynamic and acid-baseindices were monitored over 3.5 hours. Ethanol levels peaked 60 minutes following administration at 2O7 + 12.6 mg"/". During the entire study, no differences were observed in the heart rate, pulmonary capillary wedge pressure, systemic vascular resistance index, pO2, or pCO2 between the two goups. Following hemorrhage, statistically significant decreasesin mean arterial pressure (MAP), left ventricular stroke work index (LVSWI), cardiac index (CIf, and pH developed in Group A compared with controls. Maximal disparity developedin MAP 167 + ll v ll0 + 9 mm Hg, P<0.01f LVSWI (18.7 * 1.2 v 44.9 + 4.8 gm-meter/M2/beat,P<0.01t CI (1.691 0.24v 2.71 + 0.19L/min/M2, P<0.011, and pH (7.21a 0.05v 7.33 + O.O2,P<0.011 45, 75, 30, and 60 minutes respectively postphlebotomy. In this canine model, ethanol directly or indirectly caused myocardial depressionin the early post-hemorrageperiod.

Tteatment of Hemorhagic Shock with 54 Interosseous Administration of Crystalloid Fluid REMorris,N Schonfeld, AJ Haftel/ Division of Emergency Medicine, Hospital Childrens of LosAngeles

Endotracheal Drug Therapy During 56 Hypovolemic Shock SEMace/ Department of Emergency

Hypotensive inlants frequently require both drugs and a large volume of isotonic fluid to reverse their state of shock. Previous studies have shown that cardiotropic drugs are equally effective whether they are given by the intervenous route or interosseous route. The study reported here was designed to evaluate the e(ficacy of interosseouscrystalloid infusion to reverseacute hemorrhagic shock. Adolescent New Zealand rabbits were anesthetized and rendered hypotensive by removing thirty percent of their blood volume over a ten-minute period. Control animals (n:5f had no further treatment. Immediately following the tenminute bleeding period, the two treatment groups had administered over a ten-minute period a bolus of normal saline equal to three times the volume of blood removed {volume of fluid administered = 67o of body weight). One treatment group received the fluid by central venous line (n=51 and the other by interosseous injection (n=5f. Vital signs were measured at five-minute intervals. At the end of the ten-minute bleeding period, the control, venous, and interosseous groups all had comparable drops in mean blood pressure,respectively55 !6, 60r 12, 53 +5 (mean * SEMf, percent of prebleed [baseline]values. Five minutes later after infusion of one half the crystalloid bolus, the venous and interosseousgroup's mean blood pressurerose to 104+ ll, and 107+4 percent of baseline values respectively.The control group which received no fluid had a mean blood pressureof 70 + 8 percent of baseline values. At the end of the fluid bolus, ie, ten minutes after completion of the bleeding phase,the venous and interosseousgroups had mean blood pressuresequal to 99t8 and 97+3 percent of baseline while the control group's mean pressure was 72+6 percent of baseline. The rise in mean blood pressure seen in both treatment groups was statistically different from the blood pressure of the control group at the 0.05 level when analyzed by the Bonferroni test of multiple comparisons. Thus, we conclude that venous and interosseousfluid administrations were equally effective in reversing mean arterial hypotension due to hemorrhagic shock.

Medicine, Mt Sinai Medical Center,Cleveland During the many emergency situations in which venousaccess is difficult or impossible, endotracheal drug administration is en effective alternative means of delivering life-saving medications. Shock is a commonly encountered emergency situation in which endotracheal drug therapy can and is often used, yet the relative effectivenessof endotracheal drug therapy during shock is not known. Forty-five sets of plasma lidocaine levels drawn at 5, 15, 30, and 60 minutes after the administration of endotracheallido. caine at a dose of 2 or 4 mg/kg were obtained in dogs either in hypovolemic shock or in a normal control group (Group I = "nonshock" or normal control, N = 27; Group II = "shock," N = l8|. Significantly higher plasma lidocaine levels occurred in the shock group in all time periods and with either dose of lidocaine andno matter what the technique of administration (P < 0.001f.Mean plasma lidocaine levels (pglmll at 5 minutes were: 12mg/kg dosef Group I=1.1, Group ll=Z.Oi and (4 mg/Kg dosefGroup I = 2.3, and Group II: 5. l. The dose of lidocaine, the techniqueof administration, and the time at which plasma lidocaine was drawn, as well as whether shock vs nonshock was presentall were highly sigrrificant factors (P < 0.001) in determining plasma lidocaine levels. The degreeof metabolic acidosis as indicatedby the pH and bicarbonate levels were highly correlated (P < 0.001f with the plasma lidocaine levels. The highest plasma lidocainO' levels (up to 12.4 p.glmL in one dog) occurred in the dogswith the. most severemetabolic acidosis (eg, lowest bicarbonate levelsf.Il summary l| endotracheal lidocaine is absorbed during shock;2f with the same dose of endotracheal lidocaine, higher plasmalido. caine levels occur during shock; 3f the higher levels during shock may be related to the degree of metabolic acidosis. This suggests that the dosage of endotracheal medication may need to be ad. iusted for various clinical conditions such as shock.

57 Transcutaneous Oxygen Tension lleasurements Duting Hemorrlragic Hypoperfusion Using Trendelenburg and the Pneumatic Antishock Garment WJatfurs Jr;SSSpicer,

55 Hemodynamic Effectc ol Acute Ethanol in Hemo:rfraged Dog3 JE Gruber, D BarO(JA Marx,EE

30


HLMayo,EJAilisonJ. y $itl"l / Department of Emergency pitt H5"ptt"r !p9i9ine, CountyMernorial J "ni,"oiui!,on ot tsmergency Medicat'Services, e"ri 6iroii*'irfr""irov, Greenvile.

clusions: A monkev,HS model permits simuration of a field_todoes nor causeATN, GI failure, iil;f; il;IiT3tes apparently ARDS, andiiurd resistant hyDorensionoveralI andcerebra

hospitatscenario. frX,.1:i:l,l

Tiends

in transcutan( 1r.I,."".y lrr"rjj povolemia suggestedi;ilffi complicated by ussuei;ilt;r:;rr. ffi :'iX'd,'it5:J"','il;H:#:f,llm.tf adequacy l of resuscitationtu.i"g rr._orrffirjii;"r..

our study wasundertakento compare trendsin ntC"O,d.rriogmoderate hypoperfusion "ri"g-ir,r""iir".i"bJ,ir. liT-11.01*t. modatiries pneumatic ; antishocknirT:lt_(li,sct r0. T1".il;lenburgposi_ ti onins, and com bi n Jq _ c r.. ii,. L"n l',il*l" ^ ".s thet i zed 1ej ventilated. with a 4:t llniTl-9"gr-*,:re anc_ oxygen.Followineai j:litia] r,rUrf mixture-ofnirrousoxide ir"ri.ri pJriod, they were bredover t0 minutes of 25% oLh;il;i;drfi,Llood uolrr_., th: therapeuticinterventionappried Yiil Animals at the onsetof hemor_ rnage. wereobserved mrnurereinfusionperiod,,and1or igmlnutes,-ihln aurins a rsfor.20 _i.r.ri.l iir-Jreafter. ptCo2 wasmeasuredcontinuo,sly and the r"ir,]*jirg.irii"meters were measured serially:cardiacoutpug__."r, "rt"ri?l.pressure(MApf, mrxedvenousoxygenrensio_(Mvori:ri.""i oxygensaturationby a pulseoximete;"C;.;i;;;ilxl"ri"a gases,and (CIfand the oxygenextracrionrate were calculated.p;ilil; resulrssug_ ptco2 fell most rapidlyan;i;d;;l;;flmounr ff::*$ in the rrencelenburg groupdurir

59

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. lmproved Hemodynamics After

#ilIti,i?jig"iiliiiitru"rJT,i""; ,.

"te'"'s""iv"M:iicine,-uniilisii 3"Zlii;"ih',%i'?:i8:lEl'

^__O-::"q.h."lorrhagic_sh-ock,decreasedperfusion and poor tissue oxygenation Iead to increasedfactate p.oarr"iiorr. Since lactic acid is a known cardiov^as""i"ia.pr*r"ri;il"; an agent which decreaseslactate production may.improuJt._Jaynrmics during nemorrhagicshock. We examined ,t. ".. oJ,oiium dichloroace_ an agent which decreases-f""i"i. p"r"a""tion by stim_ :.1::,!D_:ft urarrng the pyruvare metabolic p^tn*iv,-ii1.s6n -[."ii1,.'i" graded canine hemorrhage model. conditi.".il = rif were anestheIV pentobarbitol t2smglkgf...ra'oi.""i."f ::r,.q -yirh f y intubated. an d rns rru m ent ed wi th^Jem o., t "it.ii "i-r-iilr riia ori*"i",",i: "i: tery thermodilution cathete.s at-r;K;ffi;: fZ_minute-inte.vals, llo/o of total blood volume lcalculated as ,.llorr.a from the rapldtall and smallesta-bsolute Hemorrhage.was discontinu.d decreasein ptC,Orwas observed il::r.iiJ "i.or,. l]". Droodvolume tn the Tiendelenbure_ pASG removedland the ""ir"rt. *"rJilowed hour (50% sr9w._Ci.i ;;r;;;tt"" to stabilize confi rmi ng " -inute observatio".p.rioa. err1,ir;il;r. glesetrendswas.obiained*"itf, lurvo, ""i'6i.iir""rio., l::l"g ?0 altowed to ,r,.. Dreatnespontaneouslv rnerewasno differencein MA,p lroom airithro;rt "ii'lt. .b.";.d ;;,.eTgroups. eao2 and stabilization periods.3irial arterial anooxysensaturation,.-ill:d Fmorrhage pr.r:;;, ".".*iiijiiii"ating ;;ac outputs, arstable terial blood gases,serum lactates, ven^tilatory l1;;t functionthroughout. "rrd ,.*_ "ffi Interestingly, "Ct pASG_Tien_ measured !frr.o.. levels were celenburg groupshowedthe greatesta"pr.rrioii the at baseline, "lt1.*h:';Fd;"I, every ls mind,rrirrgth. utes during stabilization..Tieated nypovolemic phaseand ,t.1!.;"a.r.1b.*;1il;e ir, animals ..".iu.i OCe (l00mg/ teast,sus_ gestilg.differingmechanisms Kg rntravenously administered for.maintaini-ng over l0-m]-n-uiJslimm.aiatetv pertri_ atter the completion of f.eripfreral sroir.lheseresultssussesttt"t hemorrhage.Tieated "rri_"l, rvt"n ltcor';: i.d-d upon as an had signifi cantly higher cardiac or:.t1P],1,. rndlcatorof adequacy of resuscitationa"rirrg ir;*.;riage and stroke volumes tnan controls that pe_ at l5 and 30 minutes aft npneralperfusionis better g:r,.T.q in the pASG,

g-.g.'::gd;."'fi ;:.;;.ir,*f HJ:lf"TJfi:"":tli#",'1.,1

or perhapsbet_ ter stlll, combinedpASG-irenoerenburg groups.

58

Usefutness ot

l':md,-h;;i;:si;;!,"3jt[;:"{Ji:',"i"',ffi LL"

p Safar,J u. bar-Joseph, n Saiio,-6-n'.a-ol f lescn, rv {9ssv Aoramson / Resuscitation Re.s9a19h Ceniei anJ'departmentsof Anesthesiotogy/C riticatCare^ j' M"oi"in"-"n - di'rilri!'y, -" -'-v. uniuersttyot rlnsDurgh; andthe University of Munich anesthetized, spontaneouslybreathingCynomolgus *LllSdt

;lllrile'ia;;'ff; T#nsl:l*t i[3tmin' iltrYi;:::'if'fi ln studvI litl, *i

g:",'t,l:J'i*;il;ff T"li":.','3I*'il:*,'.*1TJ3:,*a

ano hrgherbicarbonatelevels, duringifr. ,r"iiiirr,ion period. rreatment wi th DCA t_^o1?u1d d..r.".irrg {.*.ri^"'_i#*hil. glucoseleuels. ru.the,r-si;;;;n. useof DCA :-.Tall:?,..and rn nemorrhagic shockis rn order. lhrhbtâ&#x201A;Ź cO (vmfn) sv (mf) Gfucose trOr

observed,h;;;;i;;',-!!!\s9u".z0

Contro|s DCA endo, hetrbrrhage

Contots OCA 15min

Contotr OCA 30 min

o.ss(.12) o.ss(.12) 0.74(.1s) 0.96(.16f o.7s(.16) 1.1o(.24). 4.5S(1.1) 5.51(0.8) 5.42(1.2) 7.60(.69). s.61(.99) 8.05(1.2). 1u(n) 1fi (27) 153(3s) 1n(17) 142(?7) 113(12). 17.s(2.2) 1B.o (2.7) 16.0(2.1) ls.s(2.2f 16.s(2.0) 19.8(2.3). end ot hemrrhaoe 60 min 90 min 5.so(3.2) 7.06(2.6) 6.96(2.4) 2.ot (0.3), 6.47(z.B) 1.@(0.2).

iti*i*#i#';*r,rr',::,9:'"?ffilT'*#ilfii1:mr#; r.actab

at 145+40

minutei {mec Means continuedii;'ffi ;ii'Hirrli:';.J'J",*;:'1.:fs"::{r.'rT"* (SD)torContots(n=7) & DCA(n=6) .p<0.05(trc lailedt testbr unpaieddata) zn wrth small reinfusions ^ro maintain MAp "i-IO-+O mmHg.

il,#,t"T"l: ffililit,,s.t1.*:,,:l* Fjfl ti fi.: l'f;ffi,Ti'ffi i:ile:?rd*i;i,"f,Hi,,:,iillrru*l,f ..?t,,i?".,."fi x,t?,:T. I,'i, t*?*33fi*t#rgr*,i;t",',.,J,fi iil:T:,1't,:,.$f ilil,H,"F'd#r'LH-;fi 3i;il:jj l_Fi"q*i,lgf.1,i::"fr,,Ji*i.i:lii.#tj*.#r,l,l* Gramnegative sepsis,g_Irj

" with,rppV tcu p.t_rgg erf i,,r."L!"IJresusci tated ,1",r1:?tgroup d-c/5per (NSl,but sFHg*. rrieh.i-ilip^liid ,ep Hr.,o_ pathologicstudies (lieht mrcroscopy| revealedminor multifocal

at Zd in Studies II and tII

percent of deaths bccurring ::*.: " ir*n _riJrr,ry with fifty within tfrJ firri-a-ry. peak amino_glycosidelevels in ttre o-a"rr.g.rJmi;;:ilA"ired to effectrvely conrrol these inlectionsl.It is "-Eidtri".ffective ami_ noglycoside levels be a,

presumptivea*g,,.,i,-.?tiFxtL:T,J"aHff:ir,f itL,i,:

gency department. This study.asked-if-pfji, "]"iir"gf ycoside lev_ ers_obtained after the initial loading alr" .oJJ-L used as an

permanentr""",i""li"ii,,fii-il'":'.,:L"i'J.,',?r:*1".t;.,ff**

tre brain,irrespectiveof the type "r i* n-a-rl"ii'ih"r" neurotosic deficit.A prolong"iior,;a,h;;;;JiT.pianned. *", ,ro Con-

3l

iffi ;11':"1,x'.'.r"ltii'"fi ^':.:h:,"i;s;;;ilibi9ticthe1+1 basedon""..pi.i"ii,,i#':l::#T.[fi :l"Tfi #;i,";;.",il:


prove cerebral blood flow (CBF| following a ten-minute arrest in a swine model. The improvement in CBF has been attributed to epinephrine's alpha adrenergic properties. The purpose of the present study was to measure CBF during CPR, comparing highdose epinephrine to a pure alpha-l agonist, phenylephrine (PEf. Ten swine each weighing greater than l5 kg were instrumented for regional CBF measurements using radioactively labeled tracer microspheres. CBF was measured during normal sinus rhythm {NSR}.Following ten minutes of ventricular fibrillation, CPR was begun and regional CBF was again measured. Following three minutes of CP\ the swine were randomized to receive either epinephrine (0.2 mglkgl, or PE (0.1 me/kgl through a peripheral intravenous line. Regional CBF was again measured one minute after drug administration. Regional CBF following drug administration was compared using an analysis of covariance (covariables = CBF during NSR and CPR!. Statistical sigrrificance was considered at the P < .05 level. Adiusted CBF's are expressedin cclminute/I0O grams for epinephrine and PE respectively: left cerebral cortex 112.5v 2.3, P = .AOL! right cerebral cortex (13.0v 2.8, P = .003|; cerebellum(32.9v 4.1, P = .0041;midbrain {35.7v 2.6, P = .0004f pons (30.3v 2.9, P = .@61;medulla {49.5v 13.4 P : .O2l and cervical spinal cord 149.6v 14.1,P = .0031.In this study 0.2 mg/kg of epinephrine improved regional CBF over that seen with 0.1 mg/kg of PE following a ten minute cardiac arrest. This study suggeststhat PE, a pure alpha-l adrenergic drug may not be as beneficial as epinephrine, a mixed alpha and beta agonist, et ttrese dosages,in improving CBF during CPR following a prolonged arrest.

a 3O-minute continuous loading infusion of 2mg/kg estimated ideal body weight of either gentamicin or tobramicin. Maintenance doses were given according to the Siersbaek-Nielson nomogram. Aminoglycoside levels were determined by fluorescent immunoassay on blood obtained thirty minutes after the loading infusion and thirty minutes before and after the third maintenance dose. Standard statistical techniques were used to analyze t}te results which are expressed as mean + SD. The aminoglycoside level 30 minutes after the loading infusion was 6.14+2.2 pgm/ml. This initial level did not correlate with either the total loading dose or the loading dose expressedin mg/kg {r=0.34 and 0.3 respectively}. Ten patients had levels less than 6 pgm/ml. The peak level after the third maintenance dose was 5.22+1.39 pgm/ml. Only 3 patients had peak maintenance levels > 6 pgm/ml. There was good correlation between the level obtained 30 minutes after the loading infusion end the peak level after the third maintenance dose lr=O.76 P < 0011.Tlvo conclusions and one question can be drawn from this study. Standard Ioading dosesof aminoglycosides produce variable and usually inadequatepeak levels in acutely septic patients. An early peak level obtained 30 minutes after the loading infusion predicts subsequent peak levels after the m'aintenancedosesand can identify those patients who will require larger maintenance doses.Should the third generation cephalosporins, with their equivalent antibacterial spectrum and broader therapeutic to toxic range replace aminoglycosides as the first line antibiotic in presumed GNS?

6l ileurotogic Benefite from the Use of Eady Gatdiopulmonaly Resuscltation AB Sanders, KB Kern, S Bragg, GA Ewy / Sectionsof EmergencyMedicineand Cardiology,Departmentsof Surgeryand InternalMedicine, Universityof Arizona Health Sciences Center, Tucson The efficacy of bystander CPR in resuscitation from cardiac arrest when defibrillation is available within 5-6 minutes has been questioned. Epidemiologic studies from different cities have shown conllicting results. Thus, a study was done to determine the effect of early CPR versus no CPR on resuscitability, 24-hour survival and neurologic deficit in an animal model of cardiac arrest. Tfventy-two mongrel dogs were subiected to 5 minutes of electrically induced ventriculer fibrillation. ln eleven dogs, closed chest massageand ventilation with room air was begun immediately and continued for 5 minutes. The other ll dogs received no CPR. At 5 minutes defibrillation was ettempted and ACLS protocols followed until the animal was resuscitated or died. There was no statistical difference demonstrated in resuscitability or 24-hour survival between the two groups. Eight of ll early CPR animals were resuscitated and survived 24 hours, while 6 of ll "no CPR" dogs were resuscitated and five lived for 24 hours. A significant difference was demonstrated by the Student t test in neurologic deficit and ease of resuscitation. Early CPR dogs had no neurologic deficit while "no CPR" dogs had a 4l% deficit (P < .01|. Early CPR dogs were resuscitated in significantly less time once ACLS was started (29 vs 317 secondsf required less electrical energy {l0O vs 560 ioulesf, fewer countershocks (1.3 vs 4.0f and less epinephrine l0.l vs l.7mgl than did "no CPR" animals. ln this animal model of cardiac arrest, early CPR was shown to be beneficial to neurologic function and ease of resuscitetion even when advanced cardiac life support was provided within 5 minutes.

Effect of Varying Dooes of Epinephdnâ&#x201A;Ź on 63 Regional llyocardial Blood Flow During Cardiopulmonaq/ Resuscitatlon in a Swine f,lodef CG Brown, HAWerman, EADavis, RAHamlin / Division of Emergency Medicine Physiology andDepartment of Veterinary andPharmacology, OhioStateUniversity, Columbus While epinephrine has been shown to improve myocardial blood flow (MBFf during cardiopulmonary resuscitation (CPRf, the effect of standard as well as larger doses of epinephrineon regional MBF has not been studied following a prolonged arrest. This present study compares the effects of varying dosesof epinephrine on regional MBF following a ten-minute arrest in a swine model. Fifteen swine weighing greater than 15 kg were instrumented for regional MBF measurements using tracer microspheres. During normal sinus rhythm (NSR|, regional MBF was measured. Following ten minutes of ventricular fibrillation, CPR was begun. Regional MBF was determined during CPR.Five swine each were then randomized to receive either 0.02, 0.2,or 2.0 mg/kg of epinephrine through a peripheral intravenousline, One minute following epinephrine administration, regionalMBF measurements were made. Regional MBF following epinephrrine administration was compared using an analysis of covariance (covariables = MBF during NSR and CPR|. A multiple com' parison procedure was employed to test for significant dif. ferences. Statistical significance was considered at P < .05.The adiusted regional MBF rates are expressed in cclminute/I00 grams for O.02,0.2 and 2.0 mg/kg of epinephrine respectively:left

atrium {0.9v 67.4v 58.81,right atrium (0.3v 46.2v 38.51, ri ventricle {RVl {0.7 v 82.3 v 66.9} right interventricular (rvsl(1.7v 125.5 v 99.If;left IVS(2.8v 182.8 v l@.51; fVS (16.8v 142.2v 79.21-left ventricle (LVf epicardium119.2 98.5v 108.7f;LV endocardium(2.5v 176.1v 132.91; andLV cardium (22.8 v 135.0 v 115.8|.All comparisons betweeotle and 0.2 mg/kg group were significant (P < 0.051.All comparis between the .02 and 2.0 mg/kg group were signilicant except the RV right-M, left-IVS and mesocardid IVS. There were significant differences between the 0.2 and 2.0 mg/kg group {P .05|. This study suggests that epinephrine in larger doses th currently recommended during CPR is capable of improviag r gional ciond MBF over that seen 'with stendard doses of eoineohri: following a prolonged arrest.

62 Comparatiue Effect3 ot Eplnephdne and Phenylephrlne on Reglonel Gerebral Blood Flow Du:lng Cardiopulmona4/ Reruscltatlon CGBrwtn,

HA Werman, EA Davis,RA Hamlin,F Eirinyi/ Divisionof EmergencyMedicineand Departmentof Veterinary Physiology and Pharmacology, OhioStateUniversity, Columbus Epinephrinein larger dosesthan curently reco-mended during cardiopulmonary resuscitation(CPR|has beenshownto im-

32


=6f,rl"*lgli'Bllix',L:"=Jl,?""ii"*ii"ilHo"

Cgtylen-Mvers,RE Myers./ Departmeni "i p"tnif"-gy, University ot CincinnatiCoilegebt n4eOicine; "n? v"t"r*J'ilministration MedicalCenter,Ci-ncinnati reprcrtedthat exposure to marked hypoxia ,",X. !u"..Oj.viously frruz. = J.47o,mean + SD PaO2 = lT + 3 mmHgf for ZS'minutes in pentobarbital anesthetiZed cats (N=fii jia not cause Draln or heart tniury. Only the 2l cats that also developed hypoa! mmHs mean arterial blood pressure (MAIipl fo; ihe f:jt:i 4 = fI mlnutes rasr were at ri-skfor iniury. Brain damage similar to encephalopathy *", .i,.ri i.,-tiiz\'.^r", of whichZ llTii qreo rn T"l. cardiogenic shock 3 to 12 hours after expoiure (Stroke 1616l:1016/ro2l, l985l. Wg noy report blood a"iCSil"iri"*" magna| compositional and cardiovascnlrt p"u-.iers at B0 minutes after resuscitation that predicted t.rrf""d-fi"tn outcome in these2l hypoxic-hypotensive cats: Hesrt Outcome: Survlvrl '-Shoclq Death BralnOutcome: Intact fn1u,"C Inlurcd Number of animals: 5 9 l PaO2 (100%FiO.),mmHg 4SO+163 3S4+1BO 129+41, FaCOr, mmHg,on respirator 27+g 31+ 19 77+31. Arterial bloodpH 7.19+.09 t.1e+.12 6.73+.8, Serum lactate, mM 3.7+0.9 7.o+2.g 13.0+.1.6serumglucose, mg/dl 131+24# 257+158 379+21g.M A B Bm m H g 12g+2O 112+18 89+12. CSFlactate, mM 10.6+1.8# 16.6+2.g 17.4+1.0 CSFglucose, mg/dl ,,94+77 BO+13 227+:,O2 = mean + S.D., p < 0.05: * = between survival and Jalugs death grou-os(with and withour brain i"t;;;-;. = between death and brain intact survival, # = i.il;"brain intactness and brain iniury (with and without ,"*ir"fi.-iyp"rgly";i. i": sponseto hypoxic srresswas modulated iio, I 6[ z iJy, o?p.ii, food deprivation and strongly air""tfy "##*j *i,f, brain our_ come. We conclude that Eiood gases,pH, ,.*f""t"t{ ""i rt*ificantly between survivors "rra tlo.e ayi.,f in f*:q[.,1 shoct assessed30 minutes following iesuici :-".r,?:t:ltl.Cenrc have no predictive value as to brain iniury. -Howeve4 :?:1:1ou, crsternar,nagna. csF glucose and lactate accurately differentiate Detweenbrain intactness and iniury- AII parameteir "t""i.J-r"_ ody if their 9gr{ins.to. time after exposure ".ri "r" ;;;dfi;; timing is known.

fusion.of shed blo-od,and immediate treatment with either DCA lz5mg/kg, rvf ,or placebo. Thirty minutes later brains were frozen ln situ with liq rid nitrogen for extraction and measurement of tissue glucose, glycogen, and lactate. Blood glucose and serum lacrare were monrtored throughout the experiment. No significant differences were found beiween the tJo fCI gror'rp, in f,rain glucose, brain glycogen, or ischemia-induced elevations in blood grucoseand serum ractate. However, brain lactate levels were sienificantly.lower in DCA treated (mean : lt3 t;;t;iil;ii un-treated (mean = LZ.g pmol/gl pGI animals (ir<.OOf]'Duncan test). In addition, all of the unireated pGl animals n"a leuJ, more than l8 pmoJ/g and, therefore, were at trigh risk fo, neu_ ronal necrosls..Only two of six DCA treated pGI animals had levers hrgher than lg p.mol/g (p..Oq, Fisher,s exact test). DCA immediately after pGI in fed rats reduces exposure of l1:ilT:"t brarn trssue ro critical lactate.levels.This may Iimit su'bsequeni irreversible ischemic brain damage. lt;; [Supporied i" p; Emergency Medicine Foundation lier.rr"h Aw"ra 1Oi Xaptairy.i--

P_arenteratHatoperidot in Combatiye 9q Patients: A prospective Studi s s,ln"rrlr, on

t-rommer,JA Marx, p Rosen./ Departmentof Emergency Medicine and Divisionof EmergencyMedical Services,Denier General Hosprtat;and the Departmentof EmergencyMedicine,Boston City Hospital We studied the efficacy and safety of parenteral haloperidol in eighty-one consecutive adult patienis r.{"i.r"f .-"rgency chem_ ical restraint becauseof combative b"la"ioi i" tfri ,.itirrg-oi psychiatric disease(N=23), or medical illiess L.?"Ti.(\:Tt =9rt.. Ot the_81patienrs, 46 were intoxicated wirh a mean lf ot,26l mg%". Each patient received haloperidol in ?1o9o..:.l"lno, en rnrtral dose ol 5 or l0 milligrams, delivered intravenbusly (IV) (IM), in a randomized, prospective, doublel gliltJalyscuJarly Vrtal signs and combativeness level, usrng e com_ lt-t::-!ashron. scale, wâ&#x201A;Źre assessedat entry and at 2, 5, l0;20, 30, :::t","*::: ans ou mrnutes alter entry Ten mg of IV haloperidol produced more calmnessthan the.oiher 3 relmens at 5,'10, "rrd 20 rrrirr_ utes after entry-(p<0.05). Ten_mg6f rv nAop..ialt 1N=2f oltientsl produced calmness in 5 irinutes, compared with t0-'20 r^n_rnutgl in patients receiving.5 mg IV (N=i3l or l0 mg IM {lJ:16], and 20-30 minutes in p"ii.rrt. ,.".iur.rg 5 mg IM (\= tS1 No adverse hemodynamic, ..ipir",orv,'or acure neu_ rologic effects were noted in'any patient's. iigh', patients devel_

sympto*, iris I r2-+8hiurs'af;; d-s ;:t.j ^::,^'."tyllmidal mrnrstratron that responded

6^5_. Oict toro_,acetateTteatment of lschemic gg^1elrat

LacricAcidoslJin-ih;-Fa frii

",Kaptan, RW.Dimlich, MH BirosI Oepartments "-ie."rdJy Medicine andAnatomy and CellBiology, University of Ci;;in;'ati Medical Center Despiteadvancesin resuscitation,ischemic brain iniury re_ mainsdisastrousand generatty""ti."t"if.. a"jil"f brain.ischemiaassocii'teur"ii r"c-t"t-e-i;;;il ;?;..e studiesof pmol/g with irreversible,r",rrorr"i i"ilry. L;;ng-brain than l8 lactate may,therefore, preventor minimize il;il-i" b-r;ff"ecrosis. Ear_ lier.studies ir,rtlris laboratoryusiogfasiid-rao?ilo.rr,r"red that iJ"i"]iii"tr"io :odium dichtoroacetate(DCA! d;;; t""t t" trommeanvaluesof l0 umol/g to lessthan + rr_ovg when gven eitherbeforeor immediatelyafter partial gf.U"f ir"'t "_ia (pGI|. haveihown thrt f"f,;;i;"I, have more 9:!:1-rnv:sticators anogrycog-en Erur;ose and gâ&#x201A;Źner-ete higher lactate levels by anaerobicmetabolismduringpGr..We""ai"t"Jii" "liiity ribca iL tower.brain ractaterevelsi" fJ-aG-*-i-Jrt'i:"iJii',h-loogt r"upGI. Four groups (n=6f *,"r" ,tuji"al-iir'Li-as q witl rySj placebo ertner or DCA treetment,and control operaied eitherplaceboor DCA treatment. pGI was irrarr"ea rats with for thirty p:111: ty combiningbilateral ""r"rid ;;";-;;lusion with hypotension to a mean arterial blood pressureof l,eS9rrhag:c hlty torr.This wasfollowedby rete"s. oicarotia o"ifirrio"-i"i"JJ

to diphenhydramine. The incidince or Erb was not related to the dose given or the route of drug (P<0.05l. We conclude that ro"ml oi iv-t rtope.,aoi Url _d;-liy:rr srqnll,cantty more rapid effect and is as sa{e as 5 mg iV or 5 or I0 grven to combative parienrs with a wide variety of 3_9,1TIl." pathology. unoerryrng

for Sedation of Dieruprive

9Z_gplej!9t Emergency Patients JE Clinton, S Sterner,A Stelmachers, E Ruiz / Dep_artment of EmergencyMedicine "nd Cri.is InterventionCenter,HennepinCouhty Medical Cenier, Minneapolis ,^lqt,,lTa, .threatening.,.or violenr behavior by a patient often patienr.himself by self-inllicted inyury or by def:-li:o11:t,Ihe rays rn medrcal evaluation and treatment due to the behavioi. We examined the population exhibiting tt is ,yait-e rn our emer_ gency.department. Sedarion usin"gl"foi.iial Uy the intra_ muscular, intravenous, or oral route"wa. ,r'r.Jto *rtrol the benavror lhe salety and efficacy of haloperidol in this setting was ex-amined-One hundred thirty patient, *.i.-"a-inisiered haloperidol for control of their b.'h";i;;. i-ighiyl,frr* received the emergency department, V/B{were critical p"n;i; 9:^t ll:1., tlte drug during resuscitation. Forry-sevenof liJ0 were :T:rvfg cnsrs rntervention center patients. Acute ethanol was involved in Eighteen parienrs had head trauma, 17 of the lg j]],rdu,l"rlA"es. were atso rnebriated. Various other drugs were responsible for the


lowing the first dose were 0.5 + 0.03m9% (n= l87f and were not significantly different between tlose who did and did not sustain AWDS in the phenytoin group. We conclude that prophylaxis with clorazepate is superior to phenytoin and to placebo in the prevention of AWDS during the immediate post-abstinence period.

behavior in 17 patients. Acute psychosis was involved in 35 cases. Thirty-two patients were felt to have a personality disorder. Route of administration was intramuscular in 106,intravenous in 18, and oral in 5 patients. Disruptive behavior was alleviated within 30 minutes in 108/130 patients. Effect was iudged suboptimal in l9l130 and no effect was noted in 3/130 patients. Four complications were noted, 3 minor and I more serious episode of hypotension in a critical patient. Haloperidol is an ef{icacious drug for use with disruptive patients in the emergency setting. It is usually a superior altemative to the use of physical restraint.

70 Development of Clinical Griteria lor the Rationaf Ordering of Serum Electrolytes RA Lowe, ABWood,JR Mackenzie / Department of Emergency Medicine, ValleyMedical Center,Fresno,California;Group Health Cooperative of Puget Sound, Tacoma, Washington;and Section of EmergencyServices,Universityof Michigan Medical Cente( Ann Arbor Serum electrolytes are among the most commonly orderedlaboratory studies in emergency departments, but their value has been questioned. The purpose of this study was to determine the frequency of electrolyte abnormalities in emergency department patients, to assessthe proportion of these abnormalities alfecting patient outcome, and to develop a set of clinical criteria to allow selective ordering of serum electrolytes. This proiect was conducted in the emergency department of the University of Michigan Medicd Center, where 1,031patients on whom the responsible physicians ordered serum electrolytes (Na, K, Cl, and CO2f were studied. The ordering physician completed a questionnaire describing the clinical presentation of each patient. For every patient with electrolyte values outside the laboratory normal range, the chart was reviewed to ascertain whether the abnormality affected patient management, representing a clinically significant electrolyte abnormality (CSEAI. The clinicians' responsesto the questionnaires were used to construct a clinical criterion set predictive of CSEAs. Five hundred forty-five patients 152.9'/"1had one or more abnormal electrolytes, but only 16l patients (15.6%| had CSEAs. A set of 15 clinical criteria detected 98.8% of CSEAs (98.8% sensitivity|. The use of these clinical criteria would have avoided the ordering of electrolytes in 231 cases 126.6%specificityl. At a cost of $20 per set of electrolytes ordered, detection of 159 CSEAs using the clinical criteria would cost $100per CSEA detected. Detection of the additional two CSEAs by ordering electrolytes on all patients in the series would cost an additional $4,660. A receiver operating characteristic curve is presented which allows the clinician to select acceptable tradeoffs of sensitivity and false positive rate. If the accuracy of theseclinical criteria is confirmed in other settings, they will be useful guidelines for reducing laboratory costs without compromising patient

Phenytoin Loading in Ghronic Alcoholic 68 Patients RDWelch, DBSmith, SFDanosi, MLZwanger, BF Bock / Sectionof EmergencyMedicine,Departmentof Surgery WayneState UniversitySchool of Medicineand DetroitReceiving Hospital Chronic alcoholic patients are frequently assumedto have low albumin levels secondary to malnutrition. Phenytoin is bound to albumin; therefore, the usual loading dose of phenytoin might result in a higher percentageof unbound drug and increased toxicity in these patients. The purpose of this study was to administer a loading dose of phenytoin to chronic alcoholic patients to evaluate for signs of phenytoin toxicity. Thirty-six chronic alcoholic patients were given 15 mglkg phenytoin by constant intravenous infusion. Patients were placed on a cardiac monitor with frequent recording of vital signs during tJre infusion. AJter the phenytoin infusion, patients were evaluated for clinical signs o{ toxicity. At one hour post infusion, blood was sent for total phenytoin, free phenytoin, albumin, and total protein. Fifteen patients were hypoalbuminemic, mean 3.4 g/dl. Tkenty-one patients had albumin Ievels within the normal range,mqrn 4.3 E/dl. For all patients, the mean total phenytoin level was 14.8 pglml and the mean free phenytoin level was 1.2 p.g/dl. In the hypoalbuminemic group, the mean free phenytoin level was l.l pglml and the mean total phenytoin level was 13.6 pglml. ln patients with normal albumin levels, the mean free phenytoin level was 1.3g/dl and the mean total phenytoin level was 15.7 pglml. There was no significant difference between these two groups. None of the patients had a post-infusion phenytoin level in the toxic range. This suggeststhat a 15 mg/kg loading dose of phenytoin does not produce toxic levels in chronic alcoholic patients.

69 Prophylaxis of Alcohol Withdrawal Seizures: A Prospective Study JAMarx,J Berne(D Bar-Or, MJGorayeb, MPEarnest, S Silverstein, DAFrommer / Departmentsof EmergencyMedicine,DenverGeneralHospital; St VincentHospital,Green Bay,Wisconsin;SwedishHospital, Englewood,Colorado;PennsylvaniaState Medical Cente( Hershey,Pennsylvania; and Boston City Hospital;and Department of Neurology,DenverGeneral Hospital The efficacy of pharmacologics in the prevention of alcohol withdrawal seizures (AWDSI was evaluated in a prospective and randomized fashion. Eight hundred thirty-one patients (704 male, 127 female) admitted to the Denver Health and Hospitals alcohol detoxification facility for greater than 96 hours weri studied. Patients with prior non-alcohol withdrawal related seizuresor those on confounding medications were excluded. The following study medications were administered orally and begun within 16 hours of admission; phenytoin ln=2671, l0 mg/f,g (maximum l,000mg| day l, ,100mgday 2, 300mg day 3i clorazepatela=289,45 mg day l, 22.5mg day 2,22.5mg day 3; and placebo ln=275!'. AWDS were defined by consistent clinical and laboratory features. Mmission ethanol levels (155 + 6.6m1l"l and the incidence of prior AWDS were not significantly different among the three groups. The incidence of AWDS in patients receiving phenytoin 18/261,3.O%l was not significantly different from those given placebo ll7/275, 6.27"1.Patients administered clorazepate(21289,OJ%l had sigrrificantly fewer AWDS than those in the phenytoin {P<0.05f and placebo {P<0.011groups. Phenytoin levels obtained 24 hours fol-

71 Effects of Dichloroacetate in Spinat Stroke in the Rabbit W Barsan, J Hedges, S Syverud, S Dronen, RVWDimlich / Department of Emergency Medicine, University of CincinnatiMedical Center High levels of brain lactate may contribute to cellular death and dysfunction in acute cerebral ischemia. Although sodiumdi. chloroacetate {DCA} has been shown to lower brain lactate in incomplete cerebral ischemia, functional outcome has not beenassessedwith DCA. We examined the effects of DCA treatment of functional neurologic outcome using a previously developed model for "spinal stroke" in the rabbit. Thirty male New Zealand white rabbits weighing 1.3-2.8kg were studied. All animals were allowed food and water ad libitum. Animals were sedatedwith 50 mg/kg ketamine IM. An intravenous catheter was placed in ah ear vein and the animal was anesthetized with 15-,10mglkg pentobarbital IV A laparotomy was performed and the aorta exposed. A metal clamp was placed on the aorta iust distal to the left renrl artery. The clamp was removed after 2O minutes and the abdomi nal wound closed in two layers. Animals then receivedeither 2cc normal saline (n=l5f or 300 mg/kg DCA in 2cc normal saline In = 15| over l0 minutes. The animals were retumed to their cages when awake and were examined at 24, 48, and 72 hours, and at 7

34


neurologic assessment.The exams were performed by a $1.fs,fo,r Dlrnoedexamrner who was unaware of the treatment given. The neurologic exam was scored on a B-point scale (O:c-an,t walk, l=walk, but no hop, 2:hoppingf. There was also an evaluation lor spontaneousmovement about the room (0=inactive, l=activel. At 24 hours, 67% of.the DCA-treated animals were actively about compared_ to- only 27% of the controls (p=0.03; Toying trsher exact test). Ten of fifteen control animals were unable to walk, -while only five of fifteen DcA-treated animals were unable to walk (.P = .-0,71. 6O/o of the DCA animals were able to hof comparedto 27o/oof contro-ls(p = 0.07l.Theseresulrs ,..gg.ri that DCA can reduce morbidity from spinal cord ischemia ii-the rabbit. Althoug-l-rthis.beneficiai effect ii likely to be secondary to the lowering of post-ischemic intracellular lactate, further siud_ ies are neededto evaluate DCA effects on regional blood flow and cellular energy state in central nervous ,yri.ischemia.

72 postcountelshock pulseless Rhythms: lpqo.dylamic Effects of Gtucagon in-a Canine

Uodel Ks_Haynes,JT Niemann, D Garner,G Jagels, CJ Hennielll / Departmentsof EmergencyMedicinean=dMedicine (urvtstonor Uardiotogy),Harbor_UCLAMedical Center,Tonance . Countershock after prolonged VG without CpR is most often by asystole or EMD. Such an outcome is usually fatal. l9tl?Y.d. h this stud, the effects of glucagon, a known inotrope and chro_ notrope,were assessedduring 19 postcountershock episodesin 9 dogs.W was induced electrilily ana z ,"i" f"iei " 4b0J (current flow 38-45A) rransthoracic shock was giu;.-bo"u""tional CpR with a mechanicaldevice was begun 30-?0 sec aftei countershock and coltinued for 2-3 min. If a ierfusing,tyttaia not follow lPR".gllucagon,I mg was giveniV a"a bpn "onlinued for addi_ tlonal 2-3 min. During,control, postcountershock and CpR, and periods, systolic, and diastolic (diast) ascending aortic f:q":ty (Aol, lett ventricular, pulmonary-arterial, and right atrLl (Ref were recorded, as w.as the instantaneous Ao-RA presl !-ytyf.r sure (coronary.perfusionpressure_ Cppf. Coronary rdrtterence Dlood tlow was measuredwith the coronary sinus flow (CSe) continuousthermodilution.technique. Countershock was alwayi folloqe{ by.asystole (n : 12) or nnrb 1n= 21.--p-il;i;"" never restoreccrrculation after countershock; however, CpR alone ,,con_ verted" asystole to another rhythm in ll/12 episodes. Clucagon administration was associared'with an i"iti"i'i".i.rre in heart retelS4!26 vs 59+29 CpR alone, p <.0051which was followed of spontaneouscirculation in' LaJ9'ilqy"l of study P,::r,r:-*,iqr eprsodes. Glucagon had no significant effect on CpR systolic preplteJ or myocardial perfusion. Myocardial perfusion variables ano UsQ are summarizedin the table {mean*SD; pressuresin q9l-{gr CSQ in ml/min/100 g; differences not significanr _ two tCiled,paired t-testl. Ao Dla3t ilean Ao RA Dlast M6an RA ,ilran Cpp Dtast Cpp gPR gas 25114 97!14 z4!B 1313 22!16 CFR+G 2Btt1 41!14 7!4 2sr9 16r.t3 26a13

CSe 21!11 24!11

$.lyca4n has beenpreviously shown to simulate myocardial ade_ via non-adrenergic mechanisms and independent of }l_.ry_:t:* effect glucose

on metabolism.we co"auae iLi,l" ini, rnoa.t postcountershock asystole/EMD, glucagonhasa direct and fa_ ableeffect upon resuscitation outiomjwhich is noi mediated cbanSesin myocardial blood flow or myocardial perfusion

I Effect of Epinephline on Cardioyascular modynamics During lletabolic Acidosis fYanSglRMDomeier,BF Bock/ Sectionol Emergency l,^.ff ,-?"q"gent .of SurgeryWayneStateUniversiiyS-cnoor and Detroit Receiving Hospital rrine.is usefgl in augmenting cardiovascular hemoin critically ill patients.These patientsfrequentlv have derlying metabolicacidosis. acidosis.The initial Tingmetabolic initi:l oblective nhiecti." ^f of rhi. this was_todetermine the effect of epinephrine on cardiovascuics during moderately sevire levels of acidosis.

35

The second obiective was to correct the pH with either intravenous sodium bicarbonate or hyperventilation end to compare the effects of epinephrine on these rwo groups. Although it is commonplace to correct pH in the hope of improving thi effect of epinephrine on cardiovascularhemodynamiis, the"bestmethod has not been well documented. Ten dogs were anesthetized with pentobarbital, intubated, and placed on-a volume ventilator to maintain an initial pH of 7.BS-7.40and a pCO2 of 35-40 torr. Uatheters were inserted to measure arterial blood pressure and cardiac output. Baseline hemodynamic measurementswere re_ corded, I pglkg of-epinephrine was inlected, and repeat parameters were obtained. One molar lactic acid was infused to simulate acidosis.At pH levels 7.lS-7.20and 7.05-2.10,hemodynamic parameters.were again measuredbeforeand after epinephiine in_ iections. The pH was then correctedwith either sodium bicarbonate. or hyperventilation, epinephrine was given, and repeat hemodynamic parameters were recorded. eardiac output and change in cardiac output after giving epinephrine decreaied with increasing levels of metabolic acidosis. Epinephrine increasedcar_ diac output l28yo, lo6yo, and l0B% at the thiee Ievels of acidosis studied (P<0.0011. Comparing the changein cardiacoutput before and atter pH correction, cardiac output with epinephrine in_ creased fuom 91"/oto 194"/o(p<0.01) irrthe respiraiory group and from ll4"/o to 150% in the bicarbonate group.'We concilude that epinephrineis clearly effective in increaJingcardiacoutput even rn trte tace.ot.moderatelysevereacidosis.This also suggeststhat hyperventilatiol Tay be an acceptableinitial method of pH cor_ rection in metabolic acidosis.

74 Selective Venous Hypercarbia During Hum_anCardiopulmonary Resuscitation: lmplications Regarding Blood Flow GBMarrin, BM

Nowak, DL Carden, MC Tomlanovich/ Departmentof Emergency Medicine,Henry Ford Hospital,Detroit .Although current AHA guidelines emphasizethe importance of correcting acidosis during the tte"t-errt of cardiac "ir.ri, ,r_ terial pH doesnot adequatelyreflect the extent of tissue acidbsis that orcurs during cardiac arrest and resuscitation.We have re_ ported a selective acidosis occurring in venous blood during open-chestcardiopulmonary resuscitalion in the canine model -rne purpose ot thls lnvestigation was to study the relationship between arterial and central-venous gasesduring closed-chestcardiopulmonary resuscitation (CC-CpR.)in humais. fhirty-five la_ tients presentir.rgro the emergency department (EDf in cardiop'ui_ monary arrest had simultaneous meaiurement of central u.rro.r, (cv)and arterial (a)blood gasesduring CC-CPR with a pneumatrc ciest compressor and ventilator. The mean time from arrival in the ED until simultaneous gaseswere obtained was 15.9 + 5.2 minutes. Downtime (time from collapseuntil arrival in the EDf was not availablein all casesbut averaged15.2 + 5 minutes for 25 patients. The mean.pHa of 7.96 + .16 differed significantiy trom the.simultaneously obtained pHcv of 7.05 * .lJ (p<.001i. rne arterral and central venous pCO2 values also differedat 31.3 + l5-2 mmHg and 91.8 + 29.8 mmHE, respectively(p<.0011. Th; g*griove]n:gs pH_gradientwas .31 + .10 with a pCO2 gradientof + 60.5 23.6 mmHg. The CO2 accumulation in the venous cir_ culation rs probably related to the poor perfusion and resultant tactrc acrdosisrhat occursdu-ringCC-CpR. This extensivehydro8pn io1 production overwhelms buffering capacity and causes a shift of the bicarbonate buffer-into free C62 "i-ra HrO. In the presence of minimal systemic blood flow COi2 accuiulates in the trssue and cannot be cleared through the lungs. This phe_ nor been previously rep.-orted in cri"tically ill'fa_ 191enop,h,as trents wrth low cardiac outputs, suggestingthat under conditions of CC-CPR there is compaiativelylr, ,yit"-i"-itlod flow. Mechanrcal and pharmacologic maneuvers during CpR should atincrease_pHcvand decreasepcvCO2 by improving forl:-pt, l" ward blood flow. Thus central venous gases "pp.rr to be b"etter indicators of tissue perfusion than artiial,r"ifi during CCCPR.


75 Effects of Dittiazem lnfusion on Goronary Perfueion Pressure During Canine Gardiopulmonary Resuscitation: A Preliminary

Report GB Martin, MA Howard, RM Norrvak,DL Carden, MJ Yates,EG Rusher,LL Labadie, MC Tomlanovich/ Departmentof EmergencyMedicine,Henry Ford Hospital,Detroit The biochemical cascadesthat result in cellular dysfunction and death appear to be initiated at the onset of reperfusion. Calcium channel blocking drugs have been demonstrated to protect myocardial and cerebral structure and function during ischemic insults. In order to be optimally effective, these agents should be administered at the start of reperfusion (CPRI. Howevet, calcium channel blocking drugs are potent vasodilators and may be contraindicated becauseof a detrimental effect on coronery perfusion pressure (the aortic to right atrial [Ao-RAl pressuregradient). The purpose of this experiment was to investigate the use of the calcium channel blocker diltiazem during closed-chestcardiopulmonary resuscitation (CC-CPR).Twenty-six mongrel dogswere anesthetized with pentobarbital and instrumented with RA Ao, and pulmonary artery catheters. After a 3-minute period of electrically induced cardiopulmonary arrest, CC-CPR was begun using a mechanical chest compressorand ventilator, and the animals were randomly divided into four groups. Group I received no drugs (control|. Group II received an epinephrine infusion at 5 mcg/kg/min. Group III received a continuous infusion of diltiazem et 2O mcg/kg/min, and Group IV received both these epinephrine and diltiazem infusions. CC-CPR was continued for 15 minutes, infusions stopped and defibrillation attempted and repeated if necessary.Resuscitation was consideredsuccessful if there was a mean BP > 50 mmHg within 30 minutes of de{ibrillation that persisted for at least one hour. Successfulresuscitation rates were as follows: Grp I: 3/5, Grp II: 5/7, Grp III: 4/7, Grp I\l: 6/6. There was no sigrrificant difference among the groups (P > .05). Ao-RA gradients were sigrrificantly improved in the group receiving both epinephrine and diltiazem. These results suggest that diltiazem does not have a detrimental effect on the Ao-RA gradient during CC-CPR. ln view of the beneficial effects in reducing myocardial and cerebral iniury further investigation into the early inlusion of calcium channel blockers during CC-CPR is warranted. Grp lV Grp ll Grp lll GrP I Ao-RAgradients (Control) (Epinephrine) (Diltiazem) (EPl+ Dilt) (mmHg) 1 7 . 0+ 9 . 7 9.2 * 9.9 (.P < .01 comparedto control)

17.0+ 9.3

trols were significantly different (P < 0.00U. Hypermagnesemia and hypomagnesemiawere associatedwith no successfulresuscitation. Normomagnesemia directly correlated with successfulresuscitation in cardiac arrest victims (P < 0.011.

77 Somatosensory-Eyoked Potentials Du?ing CA Gardiac Resuscitation in the Dog JB McCabe, Wright Medicine, of Emergency M Mullin/ Department Sheets, State UniversitySchool of Medicine,Dayton,Ohio Assessment of the functional state of the central nervous system during and after cardiac resuscitation is difficult. Recgrding of soniatosensory evoked potentials provides functional information by recording the central nervous system response to a peripheral electrical stimulus. This study was designed to characterize the changes in somatosensory-evokedpotentials during cardiac arrest and resuscitation. Nine mongrel dogs were utilized. The median nerve was stimulated and an evoked responsewas recorded over the peripheral nerve, spinal cord, and contralateral cerebral cortex. Ventricular fibrillation was electrically induced. The animals were allowed to fibrillate for various periods of time and were then subiected to a standardized resuscitation protocol. Total ischemia time ranged from 48 seconds to 23 minutes. Fol' lowing resuscitation, somatosensory evoked potentials were recorded sequentially for periods up to one hour. Somatosensory evoked potentials were graded according to the degreeof abnor' mality, using the potential morphology amplitude, and latency as criteria. Peripheral nerve potentials were well preservedregardless of ischemia time. Spinal cord potentials were abnormal only with prolonged ischemia (greater than 11 minutesl. Cortical potentials became abnormal with any ischemia. The degreeand duration of abnormality was directly related to the length o{ ischemia. Ischemia of Iess than 5 minutes caused alteration in somatosensoryevoked potentials that quickly revertedto normal. Ischemia of 5 to 10 minutes produced a more severeand prolonged abnormality, while ischemia lasting more than ll min' u t e s c a u s e d c o m p l e t e a b s e n c eo f t h e c o r t i c a l p o t e n t i a l s . Somatosensoryevoked potential recording is a useful tool for as' sessing the functional state of the central nervous system during and after resuscitation from cardiac arrest. Current studies are designed to correlate somatosensoryevoked potential changes with long term neurologic outcome.

28.8 ! 7.2'

76 llagnesium Levels in Gardiac Arrest Victims: Relation to Successful Reruocltation

78 Use of Gardiac Enzymet ldentifies Patientc with Acute Myocardial lnfarction Otherwire Unrecognized in the Emergency Departmont JR EAStein/ Departments R Toltzis, B Goldstein, Hedges, G Rouan, of Cardiology; Medicine, Division Inlernal of Emergency Medicine; of Cincinnati Medicine, University Laboratory andfuthology

L Cannon,D Heiselman,J Dougherty/ Departmentsof Internal Medicine, EmergencyMedicine,and CriticalCare Medicine, Akron General Medical Center Multivariate analysis was performed to evaluate significant differences between electrolytes, serum magnesium, and successful resuscitation in cardiac arrest victims in a prospective controlled study. TWenty-two cardiac arrest victims having ventricular fibrillation or tachycardia, electromechanical dissociation, or asystole were compared with 19 matched controls with no ventricular arrhythmias. Of the control group, I was hypermagnesemic l5%1, 17 normomatnesemic (90%|, and I hypomagnesemic (5%). In the arrest group, 9 were hypermagnesemic l4O%1,8 nonnomagnesemic {36%} and 5 hypomagnesemic(33% f. Seventeenout of 22 cardiac arrest victims (66%lhad an abnormal sâ&#x201A;Źrum magnesium level. All hypermagrresemicand hypomagnesemic patients expired. ln the normomagnesemic group, 5 out of 8 were successfully resuscitated /.62"/"1. A positive correlation was seen between normomagnesemiaand successfulresuscitation (P < O.0ll.There was no correlation between other electrolytes and successful resuscitation. Conclusion: Magnesium levels between cardiac arrest victims and coronary care unit con-

Medical Center Recogrrition of an acute myocardial inlarction (AMII in the pa' tient with chest pain frequently challenges the clinician. Pre' vious studies suggestthat cardiac enzymes are of limited valuein identifying patients with AMI in the emergency department{EDl. Such studies have not evaluated the use of cardiac enzyme tests to complement decision making in the population of patients clinically designatedfor ED discharge.We reviewed 773 ED visits by patients aged >30 years presenting with chest pain unex' plained by thoracic trauma or radiographic abnormalities. Disposition of these patients was determined solely by clinicd and electrocardiographic evaluation. Of the 291 admitted patients there were 46 patients with AMI; 22 of the AMI patients hada normal CK level. Of the 482 patients dischargedfrom the ED, l8l patients had an elevated creatine kinase {CKl level. Among the dischargedpatients were five patients with AMI. Four discharged AMI patients were men with a CK level >200 IU/L and threehad an elevated CK-MB fraction l>12 lU/Ll. The one discharged female patient with AMt presented with normal total CK and CK-MB levels. In the population of all males <50 yearsold scheduled for discharge, a total CK >2mfi)lL had a sensitivity, speci

36


positive predictive value for AMI of lOOTo,gS"/", and {!c"1tf, 1a l/7o,, râ&#x201A;Źspâ&#x201A;ŹctlVeJy. In the population of all patients scheduled for qrscnarge,an elevared CK-Inllphad a sensitivity, specificity, and p.ositivepredictive value for AMI of 6OTo,l}Oyo,'ani 60%, rispec_ tively. Although cardiac enzymes can not be uied in isolation to maKeaomrssrondecisions, their selective use for patients otherwise scheduledfor discharge may enhance the iniiial admission -of patients with AMI at rdk for'unintentio;;i al;;h"rg".---

(PaO2 and PACO2,mmHgf. Results are expressedas mean + SD. I

vt

Pico2

F,O,

PACO2

PoOz

MM

24+6

l+6

MB

23+4

37+12 5 5+ 2 3

.20+.01 . 8 0+ . 0 6

3g+20 4 1+ 2 g

106+22 5 1 2+ 6 9

(NS)

(P<r9-e1

0

In all trials MB ventilation -with supplemental 02 provided signi{icantly hiSfrel p-nO2than MIVI veniilation (p<iq6f eACO;';;; similar with borh meth-ods(p>.051.In four trials inaaequaie'ven_ tilation occurred with pnCO2 >ZO. tn these four casesjresulting PaO2 was 47 for MM versus 388, 487 and 493 for MB ventilation] These results.support the use of mask-bagventilation l;;;ilatric prehospital resuscitation to provide*effectiveventilaiion. Even when ventilation is-_su.boptimal,supplemental Oz bf fvfi tends.to prevenrhypoxia. Wide variation in ventilation with both tecnnrques suggeststhe need for further development of training methods to optimize performance.

79 preaictive Value 9f Initiat Emergency Department EKG lor Life.ThreateninqGomntig:rtions ot tfyocardiai i;h;;ia R zarenski, =_, yl9"n^| 9otd/ .Emergency {Ued icineResidency, University of ililnots,

coilege of Medicine,chicago Emergencyphysicians are faceC daily with patients who presenlwith chest pain and are admitted R/O MI. ban the initiai'ED tKU be used to divide these patients into high and low risk .gr.9ull-fgtsubsequentcomplicationsl The studi group included ll0 CCU patients with the ED diagnosis of R/O'fvfi, 50 had Mt as a nnal outcome. The eme_rg_ency physician,s or caidiologist,s interpretationof the initial EKG wai used to classify it as negative

Comparison of Arte?ial and Venous Blood 91 Gases in Pediatric Resuscitatioi aL-Caputo, c

Delgado-Paredes, G Fleisher/ Departmentof pediakics,Section of EmergencyMedicine,Children'sHospitalof philadelphia,and Universityof PennsylvaniaSchool of Medicine,philadeiphia into GroupI (immediatelyiife_thieatMetabolic and respiratory acidosis occurs after anoxic cardioening):ventricularfibrillation or susiainedu.ot.i",rf"i i"*r;;; putmonary arrest in children. ABGs are generally used to guide a,rrest, Mobitz II.or_3_. AV Ufo"t, ,f,o"l-, "rrd CroirpU l1^._"ll]l: bicarbonate therapy and correct metabolii acidosis once ventila: CHF requirins pulmonary artery tion has been established. We compared arterial to venous blood LTl:ilylif le-threateningf cametenzatlon, recurrentchestpain requiringtV vasodiiatorsor mrra-aortrc balloonpump.The initial EKGwashighly associated q":.: Td lactates in a.pediatricrnodgl for CpR. puppies 6_12wks, 4-8 kg were anesthetized, intubated and ventilatid. Femoral arl yl:l-.tlrf !r.."t complications .q l, chiz testf. Fifty-two pa_ ]_p_. terial and sagittal sinus venous catheters were inserted. Anoxic iniriat negative_!KG;eight of theseitS.+Z.fsubse:t_.lj:,-I1d"" cardiac arrest was induced. Alter 5 min, mechanical CpR was MI. No .p:tient (O/S2lin this grouphad -S:T,l y:r: Siagnosed begun. All animals received-epineph.ine'tlie"-were assigred to rf. comptication-(negative 31|T:1t_1!?ry llt-.:,-f.'""J:t{-(.Qrgup value (NPV),of100.0-!.1. I:cer_yeno bicarbonate (Cp 0f br t-meq/kg doses of bicaibonate Six of these 52 had'a L1:9:1iy: ioten_ lGp ll every l0 min. ABGs were obtained at the time of arrest (_5f, ually trte_-threatening (GroupIIf complication(NpV of Sg.Sf at the start of CPR (0) and at B-5 min intervals. WGs and lactates ybyoconhdence l.+otJzl, interval (CIl t g.lo/"1;four of thesesix were measuredat times 0,. +-10,and +20 (prior to NaHCO3 adhad.Ml two hadunstableangina.Fourte"" ot'Sg p"ri.nrs with a at point).. Both gtonps *er. similar i" ;;ighi, positiv_e EKGhadGroupI complications{positive'piedictiveval_ .each T_t-"-t:!."tio" trme unttl anoxic arrest, MAp during CFR, and mean arterial-pFi gs"iocI +^1t.0%1.d;;y_"H; ue fPpVf.of.24.r"/o, of 'SO.O;i, these58 prior. to_arrest. Significant differencis (p < .051 occurred in ar_ gly" Ct + rytigntshad GroupII complications1'feVo,f tenal pH.throughout CpR between the 2 groups. Gp 0 arterial pH indicates_tr,.iutiii rxc "L-t',rr"d to pr"l?:?t:):.Tj:'_,udy worsened as CpR contin,'fdlpH+3:2.15/+ qOS.iil. h Ctt,; incidenceof immediatelylif e-threateningcom_ :i:^,^1 ^"_.^ty..t9* terial pH tended toward alkalosis after NaUCO.r i.x at 0 and l0 the emergency physician could adiit pa_ 1y:9:,r^.,".:9.tirmed, mins (pH + 3:7.54/ + l2:7.Sll anddid not becomeieverety""iaoti" wl1 rnitral negativeEKCs to a lesscostly cardiacmonri:fn1s Differences between arterial and venoui pH were toredunit. :.t1til,.+4011.^21f. srgntrcanrlP < .05)in qoup throughout. However,in com_ _eg!! panng the 2 goups, NaHCO3 had a significant effect in minimizlng the arterial/venous differences seen in our model. We 80_ Ventilation ol Intants Dudng Resuscitation: con_ clude arterial pH does not adequately ..n""iG"1t"te of tissue 1:loosrs.durrng.resuscitation. Bicarbonate Rx during CpR changes the arterial pH and minimizes A,/V differences brit does Departments of pediatrics anopnvsiorogy,'sGi" -'- U,i*Lr.ity "" of Nelv not correct the metabolic acidosis. YorkandUpstate Medical Centea'Syrac"tt;

ornon-specificf positiveiai;s".;i .r*"[oil-a._ !::g:l _or pacedrhylhm,left BBBI.Hospital e way.esr.r$r, 11i1191-l* complrcatrons weredivided

.Ii:11""lHtT;,?;1!"?'fi ,?$x,'r..;;'ii;' ii,xi::Tfl

Performance of mask-bag(MBf-versusmouth_to_mouth(MMl ventilation.byl0 emergeniy'm.iti""t t""t "i"i"rrsls evaluated 'sunngz-mlnute trials on an infant resuscitationmannikin. per_ rcnn:mce wascomparedas the cafulated alveolargascomposi_ tionswhich would haveresultedfr;; th;i;;i"tld ,.r,rr"it"_ tions.-A mannikin the size of a 4 kg i"i""tl"l'r"odified to H20-rand 111ll* 1,.a.1 lung with compliancZ=- I.i ;i;Iesi:t"n::-:_.04 cm-H20ml-r.sec.A 750ml pe:."31.:l-t:-.,:2. qra-tnc resuscttation bag(pMR_21 with 02 enteringthe reserv'oir *s usedfor.MB ventilation'.naJ"3f"-" (v" -ll ::J0rl.Tit

j5tiy_:"!:(f,,rarn-'l*"';a;;;;d;"-;;*;;;,[:dT; :11 g_1e:s:lpneumotach. Gas entering the model lung g9

-..t"t"i. err"-pii.i. "ii"r"a".

was collectei

t""Jy *j-t:99,1 I,ol,*.T" lctatecondi^tions, with physiologic dead spaci = g ml, mask deai productior, = S.S m-l.kg-i.mir-r, an6 g:::_-:_|3 -l,.basal C^O^2 quotient.- 0.8. Alveolar gas volumes w6re converted $Tlt1!o7 ambientconditionsto body tJ-p"i"t"r" ""J-r"t"ur"tiorr. on thesevalues,alveolar gas composition was calculated

J I

Compticaring Emergency 9? Ffuid. Iro"katem-ia Resuscitation ln Ctritaren-on-iiiie, as Malone, GRFleisher, WHSpivey / Department oi Er"rgency

Medicine,MedicalCollegeof funnsylvania, pnitaCetpnta; anO of Emergency Medicine, Chitdren's Hospitat of H:,pa$qlt Hniladetohia Our clinical observations suggestedthat vigorous fluid therapy pubtishii- guid.li;.r, ;?;;;s"lted in hy'_ :1,:lll1*,,following poKalemra. ln order to test this hypothesis, subiects were accu_ mulated by reviewing 3 years "f ;.i;;;; io " o"ai"rri. rcu. ltryJ.y,r ryqydration was defined as more than 20 mVk of nuias rn tne_hrst hour. Basedon admitting diagnosis, the melical rect96 patienrs were reviewed. b"" f,""*i,a ,Lty-fo", "frif:1: _"f. oren were excluded who w^ereilpatients at the time bf rehydration, received less than Z0 mltigfu, n"a i"l.i"ri" porassium_ patholosy, or had_insuffi;";i d;-;;;;;d: Td;; G l!E_"_gpopulation study consisted of 32 children receiving vigorous re_


aphragm (D| in children with blunt abdominal trauma. However, it may be more rapid and/or safer to insert a cetheter below the D. We developed an animal model simulating liver laceration with fluids delivered via the superior (ext iugular - Ef| or inferior (femoral - F| vena cava. Puppies weighing 3-10 kg were given fentanyl/droperidol followed by pancuronium and pentobarbital. Catheters were placed in ttre brachial artery and Ef and F veins. A midline laporatomy incision was made, 5O% of the right median hepatic lobe sharply tesected, and the incision closed. Following a 5b% drop in MAq animals received 30 ml/kg of Ringer's lactate via the EJ (n=61 or F (n=7) veins. At baseline,groups E| and F were similar in regard to weight (5.5 vs 7.0 kgf pulse {205 vs 1951, MAP (77 vs 77 mmHg), CVP l-4.5 vs -3.9 mmHgf and pH {7.38vs 7.32f. Following laceration, immediate decreasesoccurred in pulse (188vs 193f,MAP {40 vs 3lf and Hct (23 vs 2l} but not CVP br pH. After the fluid bolus, pulse (199 vs 2101,MAP 16I vs 49|, attd CVP (-3.2 vs -2.51increased,but Hct (17 vs l8f declinedfurther and pH 17.32vs 7.251began to fall. Subsequently over-3 hours among survivors, pulse, MAI and CVP were stable while pH drifted downward slightly and Hct retumed to baselinelevels. No significant differences were observedbetween the groups.Our data show that fluid resuscitation alone may be sulficient for resuscitation from liver laceration following blunt trauma but re' fute the assertion that fluids given above the D are more e{fective than those administered from below.

hydration as an acute (emergency department| intervention. The diagnoses fell into the general categories of dehydration ('14%f hemorrhagic shock (28%|, and septic shock (28%). Three of these patients received potassium supplementation promptly and were excluded. The remaining 29 ranged in age from 2 weeks to 16 years with a median of 14 months. lrr28 197%1,the serum K* fell, decreasingto < 3.0 mEq/L in ll (38%1,in one child the K+ rose by 0.1 mEq/L. The initial serum K+ ranged from 3.2 to 8.0 {none hemolyzed} with a mean of 4.6, and the post-hydration K* from 1.4 to 5.1 with e mean of 3.3. The magnitude of the decrease varied between 0.4 and 4.0 with a mean of 1.3. The fall in serum K+ levels observedin this study was very significant statistically (P < 0.001 by paired t-testl. Although greater falls to lower levels were observed in the younger (infant| group, this was statistically insignificant. The effect of acidosis and bicarbonate administration was considered, but produced no statistically greater falls in K+ when present. No child developed any documented arrhythmias, but one patient experienced a cardiac arrest presumably due to a post-hydration K+ of 1.4 mEq/L. We conclude that vigorous rehydration of children in the emergency department may lead to potentially deleterious hypokalemia. We recommend early monitoring of K+ levels and prompt supplementation if hypokalemia is detected or as soon as urine output is documented.

83

Evaluation of the "Tilt Test" in Children

S Fuchs,D Jaffe / Divisionof General and EmergencyPediatrics, and the Departmentof EmergencyMedicine,Children'sMemorial Hospital;and NorthwesternUniversityMedical School,Chicago The "tilt test", or assessment of orthostatic pulse and blood pressure is a noninvasive screening test for acute intravascular volume loss with well-accepted utility in emergency evaluation of adults. Its value in children has been questioned because of reports of high false positive rates. We report a prospective study to compare "tilt test" results between children with and without clinical volume depletion in a pediatric emergency setting. Children 4 to 15 years old seeking care at an urban pediatric emergency department were eligible. Children meeting the following criteria were classified as dehydrated: history of vomiting or diarrhea, and a score o( > 4 on a scoring system based on assessment of mucous membranes, ocular turgor, capillary refill, 12hour urine output history and urine specific gravity. The control sample was selected from children with minor complaints (ear recheck, suture removal), and a "volume scote" of <4. Exclusion criteria were selected to remove children whose medical or pharmacologic conditions might affect their response to postural changes.Blood pressureand heart rate were recorded at l-minute intervals by automatic non-invasive blood pressuremonitor, for 4 minutes in the supine position. Subsequently,measurements were taken for 2 minutes in the standing position with the arm supported at heart level. A positive tilt test was defined as a rise in heart rate of > 20 beats per minute (bpm| or a fall in systolic blood pressure of > 20 mm Hg. Preliminary results are available for 7 hlpovolemic and 15 normovolemic chil&en. Six of 7 hypovolemic and only 2 of 15 normovolemic children had elevation of heart rate > 20 bpm. None of the children experienced a drop in systolic blood pressure > 20 mm Hg. The sensitivity and specificity of orthostatic heart rate werc 86"/o and 877o respectively. The predictive values of positive and negative tests were 75% and 93% respectively.These preliminary results support the value of measurement of orthostatic heart rate in children as an adiunct to clinical assessmentof volume status in the emergency setting.

Reflex Bradycardia and Asystole Occurring 85 in Fesponse to Fright, Pain, Venipuncture: L Diagnosis by Vagal Stimulation Test J Ramet,

Sacre,J Marchand/ Emergencyand IntensiveCare Department and NeonatallntensiveCare Unit, UniversityHospitalof the Free University,Brussels,Belgium Children and adolescentswith repetitive syncopespresentfre' quently at emergency departments. Syncopes sometimes occur during ventipuncture or other painful procedures. We report on sixteen inJants who presentedwith syncopessometimes followed by convulsions and iollapse. They were all characterizedby the presenceof documented bradycardia and/or asystole.To deter' mine a possible vagal cause a standardized vagal stimulation test was periormed; o-ular compression during ten secondswith moniloring of heart rate and continuous EEG. Prolongedmax' imal asystole, indicative of an increasedvagal tone were found in these patients. A treatment with atropine was sterted in eleven children. This was associated to clinical improvement and cor' rection of the asystole on control ocular compressions(n=24).A statistically significant difference in duration of the longest asystole was observed between treated and non-treated patients. Wi believe that the natural history of these potentially life' threatening events should not be observedwithout further inves' tigation; an ocular compression not only permits diagnosisbut can be used as a guideline for evaluation of the treatment. Diatnosis of hypervagotony is important because many sufferersre' ceive anti-epileptic medication without need (n=5f. Tieatment with atropine was impressive in reducing both the neturally oc' curring vagotonic reactions and the exaSSeratedresponseto ocular compression.

86

Relationship of Bacteremia to Antlpyretic

Therapy L Yamamoto,HN Wigder,M Jewell,MPH,/ Department of EmergencyMedicine,Christ Hospital,Oak Lawn,lllinois We undertook a prospective study of children from 3'24 months of age with-temperatures of > 40.0 C to determinei{ children whose fevers fail to respond to antipyretic therapyareat greater risk of bacteremia than children whose feversare lowered by antipyretic measures.Children from two clinical settints were studied: primarily black lower-class children at an inner-city hos' pital (n:168f and primarily white middle-class children at a suburban hospital (n=59f. The prevalenceof bacteremia for the two study samples |3.4% and 8.4% respectively| was not statisticelly

84 Fhid Resusc:taffon From Abovc or Betow the Diaphragm In a Pediatrlc Anlmal Hodel of Llver Laceration ftom Blunt Abdomlnal lfauma of / Departments G Fleisher, J Templeton, C Delgado-Paredes fudiatricsandSurgeryUniversity of Pennsylvania Schoolof Medicine,and Departmentof EmergencyMedicine,Children's Hospitalof Philadelphia Current recommendations call for venous accessabove the di-

38


significantamongthetwoâ&#x201A;Źroups.Children to antipyreticswithin two hou-rswerenot who did not respond significantfy"t " fi.ii er risk of bacteremiathan children;i;;;f#;'(p > .05f.we concludstherefore.that lack .ai*;;;;;se iilirtipy.etics is not a clinical markerfor bacteremiain children.

useful ih the detection. of middle ear disease in adults, and that the rangeof normal reflectivity "rl;;;rligltly higher in adults than in children.

9.2.is49",!-"ric Otoscopy in the Diagnosis of otit Media o -renre, birlrsl; ;i'E;"-''""", ;;;:y Medicine,

8_8 lc",r_racy of Interpretation GT Scans_by Emel,senctFirv;i;l;S of Head THcharrin, RNRogers, DDRust/ Departments ol Emergency Medicine, Butterworttr Hospital, GranO RapiOs, Vi"nig"""l';"dSt Francis Hospital,Peoria,

AlleghenyGeneralHospital,pitisOurn6 Acule guppulltive otiris media is the most ear pain in children, and^oneof the -..,Ii.q"."t common cause or pediatric diag_ nosesmade in the emergency department. Unfortunately, current diagnostic instruments, pneumatic *or"opy "rri tympanometry have significant inadequacies.Re"e.rtly "'rr'.ri'.orrogr"plric diag_ nostic method, acoustic otoscopyrh", i;; ;;p;".f, i.. ""ir.-ri[ *il.t, surgical tindings of patie!ts thought to have per_ :,t^"..^._tl srsrent otitis media preoperativelf tn ttri, ao"UTe--bIfte?';,fi; we compareacoustic otoscopy wiih pneumatic otoscopy in identifying acute middle ear prtri.jrosy i;8d "'rriijr." f roo ears)ages7 . 15 years presenting ,""ir,. "*.is;;"|'o"p"r,_.rr, :-:.!:or upper rvi,h ear resDiratory complaints. 1'n. ico"'sti" otoscopy electronically measurestvmpanii membrane i.fj""t*ity utilizing an 80 dB sound source.'vaiying rh. f;il;;;1".i*."r, 2 and 4.5 KHz over 100 m sec. The reflectivity i, _.Jsrr.a on a scale of 0 to 9 units. The hiehest reflectivity iot.J *iiiirr. probe at the extemal auditory Janal is.record.i. R;ii;";;; is a tunction of the effectiveineiasticitv "f th;t;;;;;;'*blr"". Thus higher reflectivities suggesrthe presence oi *iaaf" ."i"ttusion or other pathology{r.u.t.tu-p"rro_r"-l-.r-orr,:;.g",;;anum,tumor). Therewasa significantasso-cration (p <..001, betweenthe presenceof,acut-esuppurative chi_squareanalysisf ';;'si otitis media by pneu_ maric otoscopy and high rerle"riritls ""a for normal earsand low reflectiviti (o thru+1. acu;[atilLgy was found in 84 of 160 ears; there were g3 cases of ,il;;;;;p"r"tive otitis mediaand one

hemotvmf"r"-. uiirj"iii'""riil!.,i"ity greater than4 to indicate,.ri,. p"itoiocy,';il'r';i,i_ty of acoustic otoscopywas 82o/"and tht^specif:At;;Ib;. The positive predictiveaccuracvwas l00fo, ;;;-;i.';s;;iui "".u.""y *". 84%.This deviceis "ri."tiue,'poiil!, :;;r.;1; use, handheld. rapidandreproducible. it doesnt requirea sealand can be used m cryingchitdrenand in kids.wilt ;;;tiJ ;;;." btockageof theexremalcanal.Weconcludethat';;;;,*';r*"opy rs an ac_ curateand.usefuradiunctin.the dffiosilli""",i,."ori.i, mediain crultlren. Acutemiddleeardiseasei. t.r. ""_*"" as a resulr little work t rc U..." a-o""-""rif.iil"rii in adults,and the acoustic otoscope in individuals "s. "i-ri y.;'iri trris study we T:1-11,. compare acousticotoscor

lllinois The development of high resolution computerized axial to_ scans)has revolutionizeJ ii,. ii"gnori, and treat_ ::g:T.hI-lCT ment patients ot with central neurologicdisease;iowev;;i.;;; the ability of emereencyphysicianslffrl to-.or..ctly interpret these scans has not-been *"ir ,tuai.a. uiJ ,J,rir,, ,o answer two questions, (l) how accurately do Efs interpiJt"CT scrns of th. (2f if a patient,r. cf .;;;;'i.si"ni.f'r.,.a by the Ep is 1,.1d, ?ld the patient,s diagnosis andlor outcom. ,au.i*iy "ff..t6af-o*ine a ten month period the Eps readings.(pC pd lt, m, ;it'JndTlfiil? 396 head CT scans were,prospecriiai ^"ilira using eight anatomical components and then compared to the attending radi_ ologists, final impression. Compari"6n-;;il;;;r. ptaced into one of six categoiies depe"atugi; rhe ,;;;;"; of the Ept inter_ pretarion and the patients, clinical course. n id.qy..i"il ,il;i;;, the Ep,s and radioloeists,interpretati;;;;;r; id;"tical, yielding a 77.9%".specificity. n adiotogiJly ;ic",f i.;;;;;ormati ti es were detectedin 4O.07"oI all scais. l"'"f.il" _iri"iJrpreted scansthe maior abnormalitv affectrng the patient,s disposrtion was cor_ rectly identified, but a minoi abnJrm"ii,v-**'-*red. In rwelve other cases the misinterpr;J-6;;; ,,li cit.,i..ily signiri_ cant.to the patient,streaiment ("g, p.;r."". of ai'old non_hemor_ rhagic infarctl. Therefore,in97'.76/"'oftfr. ."*. iir. Ep accurately identified or missed only an i"ris"fi";"iiiiiln yietding a sen_ sitivity of 94.0%.In fourteen casei the r.".r, *.r.,,over read,,by the EP when compared.o tt. i"Jli.gr.ilrp.i,f,.i, y 9a.4%1.Al_ though upon closir anatysrs,our.interpretetion was proven cor_ recr-by additionar diagnostic rt"aiellti-*["-ir ,n"r. cases.of the 5.3% misinteroretEd.scans considered ,adiofapnically significant, less than one-half ;;r;1;;;ii,i!""i?."r,. A further of these patient,s t orpit"i "o"ir;r.r:;il that in no case :yf:': was there an adverseoutcome due to the fpt misinterpr.t"tlon. We conclude that Eps in-our departme"i -t-t frrr. ,ir. "Uility to accu_ rately. interpret mosr CT ,"r"r'oi "- t .rJ tp I .oosf. When the combination of intemretatio" plu. ;li;;;i;irag_.r,, is used,the EP should be able to iorrectly d*g.;;;il-fiffi. patientswith central nervous system dysfuncti'on

(6s;arsr;;ii;?il";;iil,H:,:fi :ffj':h"",:Hod.*ii:l:l[ 99..",tn *irl earcomplaints, lri,it"irr"

3:ll unteers wirhout

o,rriiirirr"#i* heatthyvol_ known.ar pathology.

yietd_.Gtinicl_tCrfteda the ftead in pediarric He-a-i;;;; for GT Scans of i Tanisucni, Fp Rivara, RAparish / Deoartments ofF"O,"t*-i'nj Epidemiotogy, U-niversity of Washington ScnooioJM;;;;;d Haroorview Medical Center,

tormedin the sitting posiiion-in'iif Ac;;;; ;;""py wasper;;,ffi;"""Ir; and in both andsittingno$tie1,__,,l r, p.6l;1.;i;;;r?flecrivity ::!iT and Seaitle oroscopyfindingswerereiordedf;A;i person.Tko *:,:pf,i: Can high-yield criteria be developedfor tnorvtduals were excludedfrom our study du! CT scansin pediatric to complete head trauma? That is. i" th.i" r-#"y-,."lair,,fy',t,.se cerumenimpacti on diagnosgd Uo tf,i "ii"ii'"f f]* ""a f y l..rrg* patients w-ith a histo.ryof ctosedh:T! tr"um,'*h; valuesequalto zero.Alfothq inaiuia*ir-i"j ;;;1. Iikely to have fl"gtlr. greater ana^bnormality found on CT scan? thanor equalto three.Reflectivity I" ";d";;';;;i., ,""1;]r;;d"to th.r. qu"r_ s in the 49 tlons, a retrospectivestudy was done. no-nnaladult ears.{normalin chiliren The t.ipitrf charts of all ilif. rrfi.i" earsdemon_ patients ages 2-12 years who were seen at pa.thotogy: 6 acute ,upp"rltiu.iiitis Haiborvrew Medical ll]1j.l_:gp. media; 3 Center's Tiauma Center from uav t, media; 5 tympanoscleroril, tiaz,irnpiiio, il 1985,with i1;;orympanum. lfl:T_9luir a history of closed head trauma rnere wasa significantcorrelation(p < .0oi;chi_Jquare and abnormal level of con_ an"lysisl sciousness between by history or.physical;;Ji;#*ho the presence of acutesuppurativeotitis mediaand high hrd , cr scan done as part of theii ,,.f,:ilj:IJ.",y;:l^11gnorm"ril;;;;l;iinl?,i.,i,y10,r,_

'6[ ;f Utilizing a rene"ti'ilr,'gr."t". tt"r, i l; ffi'"#::v"]:,ffi: -art-;i. 'purativepathology,

evaluations il.rg."li'l.p"r,#elt were reviewed.A oositive.CT s&n ;r;l;,;';;;ctude one or more of the foilowine: eoidural r,..,,",o,,,r, subarachnoid hemorrhagi, ""r.UJG";;;;iiJil "o"i"riL", "r?"iO."ce of diftuse cerebrat swelling. r.r=inety_eighi ;ilft;;;;;cluded in the

the seniitivity *", 83t" specificity y::-917". There-was no change in reflectiviry with'Valsalva and fltue changâ&#x201A;Ź(.+ l unit in + of-24.rrry ruitr, po'riiion. serous otitis r@edra media tended tended to have have lower.reflecti;"y lowc, ,ofl-^i;,,,.., :--;^:':'. ;;l,;;;';han

did sup_ purativeotitis media,ver higher itran;i"" -We ;;;;;i: lp < .001, analysisof variancef. cJncludetil;;;;;;;'oroscopy is

39

CT sians,u.i. oitrtrr"J _-siiz. J',r,e children. lTjtf'l"l ". abnormality on CT .""rr *r, suUaur"t .r T9:l...ommon t..mr_ toma..l28%l Abnormalities

on CT scan were found to correlate sigaificantly with: Glascow c.-, s""i. t66if ,."r. <I2, altered


mal, related to ICB and mandating treatment other than symp' tomatic, 21 117.5%1,III| abnormal, related to the IC4 and not necessitating treatment, 4 l3.3y.li tVf abnormal, not related to the IC! and affecting management, 8 16.7y"1,V| abnormal, not A related to the ICI and not affecting management, 9 17.5%1. multifactorial analysis of patient databasevariables was done to ascertain a positive or negative association with chest radiograph bene{it (groups II and IIIf. The demographic (actors of previous pulmonaiy disease and the finding of temperature Sreater than 100.0"F. was associatedwith an increased incidence of Group II and III radiographic abnormalities (P<.005 and P<.01, respectivelyl. Afebrile patients less than 30 years old with a respiratory rate of 20 or Iess and no localized chest auscultory findings who reported no history of pulmonary diseaseand no shortnessof breath were noted for a total absence of radiographic abnormalities {P<.0251.The finding of chest wall tendemessfailed to predict absence of significant findings on chest radiograph. We therefore recommend obtaining a chest radiograph in all patients with ICP and fever or past pulmonary history. Our data also would indicate sparing chest radiographs in afebrile non-dyspneic patients less than age30 with respiratory rate of 2O or less and no localizing pulmonary findings on auscultation.

consciousnesson admission, and focal abnormalities on neurologic examination. No clinical finding by itself or in combination accurately identified all patients with abnormal CT scans. 3l% of.the patients with a GCS > 12 and 35o/" of patients who were alert upon admission had an abnormal CT scan. We conclude that there are no clinical criteria, either by history or physical examination, which accurately predict abnormalities on CT scan in children with closed head trauma. A conservative approach - that is, obtaining a CT scan on all children with significant head trauma and abnormal level of consciousnessby history or physical examination - appears warranted. Efficacy of Clinical Findings and Sensitivity 90 Findings in Carpal ilavicular of Radiographic Fractute J Waeckerle/ Departmentof EmergencyMedicine, Baptist Medical Center,KansasCity, Missouri Carpal navicular fracture is the most common wrist bone fracture, with potentially serious complications. Improper diagnosis and inadequate treatment result in delayed fracture union, pseudoarthrosis,avascular nectosis, and wrist instability ultimately leading to deformity and osteoarthritis. To further compound the problem, initial radiographs do not always demonstrate a discerniblefracture line. Due to this lack of sensitivity in the x-ray evaluation, the author conducted a prospective study to test the efficacy of three clinical signs: snuff-box tendemess,pain with supination against resistance, and longitudinal compression of the thumb toward the navicular. Included in the study were 85 period with a patients who presentedto the ED during a SVz-year mechanism of iniury suggesting possible navicular iniury, ie, hyper-dorsiflexion with or without rotation secondary to excessive loading forces. Forty patients ultimately had navicular fractures. Forty-five had no demonstrablefracture or instability on initial follow-up. This study found that snuff-box tendemess had a sensitivity of 100% and a specificity of 987"i supination against resistancehad a sensitivity of 100% and a specificity of98%"i and longitudinal compression of the thumb had a sensitivity oI 98"/" and a specificity ol 98/". Chi-square analysis revealeda P value of < .001 for each of the three clinical maneuvers.This study con' firms the efficacy of the above clinical findings to identify patients with navicular fractures.To better define the frequency of initially negative x-rays associatedwith true navicular fractures, the subgroupof 40 patients with navicular fractureswas studied. Patients who had negative x-rays but positive clinical findings were appropriately immobilized for l0 to 14 days and then reevaluatedand x-rayedagain. Thirty-two had distinctive fracture lines visible on initial x-rays, and eight had lucent fracture lines demonstrated after l0 to 14 days of immobilization. The 2O"/ooccurrence of initially false-negativeradiographs is higher than previously reported. In such ED patients, negative x-ray studies may not exclude navicular fractures and may mislead the emergency physician to improperly diagnoseand treat these patients, resulting in serious complications.

teasured Erposure to lonizing Radiation in 92 the ED from Gommonly Performed Portable of Emergency HWMeislin / Section Radiographs R Grazer, Medicine,Universityof Arizona,Tucson Exposure to ionizing radiation is a hazard experienced by personnel working in an emergency department (EDf or trauma unit' Limited information is available regarding the actual amounts of exposure received within certain distances of radiographic procedures done in the ED. To determine this amount of exposurea series of cross-tablelateral cervical spine {ilms, portable chest x-rays and portable AP films of the pelvis were taken. Measurements were recorded perpendicular to the path of the x-ray beam at the level of the patient with an ion chamber counter. The settings on the portable x-ray machine were calibrated for an average 70-kg patient. A phantom, a simulated patient with realistic tissue density, was utilized. Measurements of the scatter radia' tion were taken at four distances from the phantom, 10,20, 40 and 80 cm, all perpendicular to the beam. Average exposuresfor the cross-table lateral spine {ilms were 0.45 mR, 0.30 mR, 0.19 mR and 0.03 mR at the respective distances. For the chest x-rays, exposure readings of 0.35 mR, 0.21 mR" 0.08 mR and 0.03 mR were recorded. Measurements for the AP pelvis were 2.1 mR at 20 cm, 0.98 at 40 cm and 0.38 at 80 cm. The annual dose from exposure to natural background radiation is in the range of 100-210 mR depending on the geographic location. Using this as a base' line comparison, minimal exposure is received when standing greater than 80 cm, directly perpendicular, from a patient getting i portable chest x-ray or cross-table lateral spine. Although ex' posure increases when AP pelvis films are taken, at 80 cm it is itill minimal compared to background radiation. Therefore, by taking precautions, including standing a reasonable distance away frbm the irradiated field (80 cmf and not directly in the beam, ED personnel need not leave patients unattended during radiographic procedures.

91 Utility of the Chest Radiograph in Nontraumatic Inspiratory Chest Pain FPDellinger, LL Thoi, WH Bickell/ Departmentsof Medicine and Surgery BaylorCollege of Medicine,Houston Although the chest radiograph is often an essential diagrrostic modality for the evaluation of pulmonary disease,its usefulness for the evaluation of inspiratory chest pain (lCPf has not been determined. The obiective of this study was to examine the utility of the chest radiograph in the diagnosis and management of ICP Over a 4 month period 120 non-trauma patients evaluated at a county hospital emergency department with the subfective complaint of chest pain increasing with inspiration were included in this investigation. The study population consisted of 5l% males with a mean ageof 38.1 + 15.5yrs. The results of the radiographic evaluations were classified and distributed as follows: If having no significant abnormalities,77 l64.2y"l,IIf abnor-

Incldence of Va3culatune at Rlrk During 93 / R Tarnopolsky Crlcothyroldortomy CMLittle,MGParker, Medicine of Osteopathic Department University of Otolaryngology, and Health Sciences, Des Moines, lo'va Cricothyroidostomy is advocated as a methd of obuining an airway in both emergency and elective situations. Conllicting de' scriptions of the normal vasculature, and the incidence of hemor' rhage from anomalous structures, are presented in the literature. The generally expressedview is that the only vesselsin this area are the small cricothyroid arteries running medially at the in' ferior margin of the thyroid cartilage and anastamosing in the

40


midline. ln this study, tbe region anterior to the cricothyroid membrane of 34 adulf cad""d;;;;;;;;l;j."visc,rra. patterns, vessel type,.-diameter "J recorded. ;;-iri";;ere T.:J1t.lhe Iwenty-sevencadavers(79y"1had vascuiar structures within this area.-Ifvenry-one cadavlrs ;;; tgzZgt t J-""" vertically oriented

arreriesor veins

r^'o"ia1. j, ,*t aiii*g

"ii cothyroidostomy. Nine of-whi"t eleven ;;i;J;;les and eleven of Iuneteenvertical veins crossedthe medial half of the cricothyroid membrane. The classical vascular p"i,"^ ** f,r"r".r, in onlv thye.e. (9Y-,1 of the cadaverr.Th; p;"'r;;;;-;i;fiil

iliti,;i

within this region ,t - ,"p.i[a in the literis -or" "o111rrro11 may explain why series of "-"rg";,"t".icothyroidos_ ij:t::_llt: tomrestreporta greater_incidenceof bleefin-g complications than t[ose done in a controlled surgical fashion.indivia""f, p.rfo.rning cricothyroidostomy shouljbe p;d;; ioit"rrror.rr"g. ", " complication.

94

plas-a Atropine Concentrations via the

cclkg),endotracheally, followed by five rapid insufflations with a bag_-valve device. The control animals (n=5f receivedsaline 0.i cclkg in a similar fashion. Blood samples'fo; diaz;d;-;;;; drawn at 1,2,..5, 12,30, 50 and 90 minutes "rra """fv'J"rl"" nrgn--pressure-lrqurdchromatography. ABGs were obtained at l0] 20, 30, 60 and 90 minutes. Thi animals were ailowed d;.;;;;; and were sacrificed 48 hours later. The l""gi wer. fixed in for_ maldehyde, sectioned and stained, and evaluiied bv, p"tloll*l-rt

the studyfor gr9s9,"a -i.rrr..pi" ll,:9:1.. I + rE, qrazepamlevels +

Jh;J;: M:';

w_ere 0.4;-0.9 0.6; 0.9 + 0.5; 0.2+ 0.3, _0.d.+ 0.5 +0.2; 0.4+O.Z and 0.3 +0.1 at 1,2,'5-,lS,eO,'00and g-d {."Slrrit1 Til"!",t,,1.rp:ctively.O.5 ng/ml ii a tLerapeutii level in h;;;r. Arrerral Dlood gasesshowed a transient decreasein pH and nO. rn Do.trrgroyps, but a 2-way analysis of variance fail'ea to find a' significant difference berween the two (p > 0.05f. Of the c..;; five animals receiving saline, three ,h;;;e; evidence of in_ and two showed evidence of slight focal intia1111"1"tt9"; areveolar lnllammation. In the six animals receiving diazeoam. one showed no inflammation, one had slighi i"ti""ir"?r".TJii-: mation and four had bronchoprretrmoola. This study d";;;-s-tratesrhat diazepam is rapidllabsorbed by ifr.l"n*r.'ffo*.""r.

f"'li::L'"ii,i?,f,:lEtl?*"T,#T:Lm;:?il

Burkle/ Departmentof EmergencyMedicine inO Clinicaf hvestigation, MadiganArmy Medical Centei iacoma, Washington To d.ate, there have been limited studies on the pharmacokinetics of intravenous atropine, and no pharmacokinetic studies on the endotrache"t o, iritiaorseou, aimfnistration of The purpose of this study "r", to a"i.-i.re tfr" time to ll1oJiq.. concentration of arropine following intravenous, en_ lff-lrr":T" oorracneal,and intraosseous administration in anesthetized using a triple crossoverd..ign. pl;;;; "iropi.r. was asi:$:yr bI a radioreceptor method. Thi time of p.ak :1y:d "o"_ of atropine was shortest with intravJnous if"r_" administra_ 99ntt1ti^o_n gol_(1.37min, SE = O.261while the Utraosseous route was next =

miq SE 0.86tandihe ""d"tr";h;i;;ri"i."t 13.87 tfr"'i".rg*i qE = ? gbl Themeanplasma"o""""rr"rio" of atro_ !1._l ryr, prucaqmrnrstered

rntravenouslywas significantly higher (p < .06fthan-theendotracheal route at 0.7Silin arrai.O min, while compared to the intraosseous groupit wassignilicrr,fy iii,gtLilp .03| gnly at 0.75min. The rieanplar-" "oo"*tr"rion of arro| pine administeredintraosseo"rry;_"9-;grii;;;il' higd (p-< rogte at 5.0 min and wJs greaterthan $un the endotracheal lpl theintravenous and endotrach"agro"pri;._-G 5l to a0.0 min timedsamples. The endotrach""i;J il;;;r.o",rJ rl,r,., provide altemetives to the intravenousadministr;;i"";;;"pine when iTtrevenous. accessis limited.or ";;;;ill;. riirii., rnvestigationsinto thepharmacokinetics of ";r"pi";;G;;tered by difduringgpR, ana aose_r.sp'onse-ilJi; to esrabtish [Tl-1,"]il.r therapeuticdosagefor the endotracheal anJintraosseous 9ll3.l Krute,are needed. a!

Pathglogicat Effects of Endotracheal :t?_D|afepam In Gats M Rusti,WH SpivLV, H-eonn; ntul McNamara, CK Aaron.CM LathersI o6parimentJoi'Er"rg"n"y Medicine and pharmacotogy, [aeoic"icbrreg;oi-elnisyruania, -County PhiladeJphia, and Chester Hospital,il".i Cn"st"r 'Fennsylvania

diazepam. suspended i" p.oiyti'"" !il".r-t(r;;;.;;; u"#""r?rij coholandsodiumbenzoltedoesin"ciease it "'r""ia!"",i ;?;;

ity of bronchopneumonia in cati and ,""y 1""" ,i*il", humans.

"ffe"is in

96 Intraosseous Infusion Flow Rates in ..pediatrG" Doi; ta'r'Jg", c Detsadollvnovotemic

Paredes,G Fleisher/ Divisionof EmergencyMelicine, Childrens Hospitalof Los Angeles,and Emergen-cy Obpartment,Children,s Hospitalof Philadelohia Intraosseousinlusion of fluids is an old technique experiencing rrrew rTylgence in the treatmenr of small children *i,fr-.iil 1 culatory tallure or cardiac arrest when other means o{ vascular accessare difficult to achieve.A recent,t"dy iepo.ted the osseousflow rate for one type of needle in J nolrrovolemicintra"ni_ mal modet. We tested a 26-gauge,2/r-i";l;;i;;l "."di;;;-; l3-gauge, 3lzz-inchbone mairow needle in iitio "rd ,., typo_ volemic puppies to determine: (U *t;t;;. th. nt., n ,",., in vitrc of pedi3slis size bone marrow needl.s, (ti ;l;;r;; yiyo flow rates are achievable in the hypovolemic state,'anJlii *fr* .ff."t a".. needle size have on in'iivg fl.; ;"i;;t'r;"iri, nt* was signifi_ cantly faster than ln vivo flow fortoth "".ai", tp = .OOll. In vivo, mean flow rates were ll cclmin for ttre ZO_lauie needle and 13 for the l3-gauge needle via gravity. ih." rn"* flows for ::lTi" rne same needles werc 24 cclmin and 29 cclmin via 300 _* Hg pressure. While the in vivo flow rates *oe signiiic"rrtly gre"te? for the l3-gauge vs the 20-gauge";i. 6lTi the differences b: were clinically trivial (2 cclmin via graviiy anJi'lclmin,i" iier_ suref..The nearly comparablern "r% ,";", i;,]h. ,*o needles tested indicate that thi rates are a"p."a""t ;;fi;", tir-"gh1l;. bone marrow rather than tt " ,i"" .i.*"-"..d1;. i;. dara suggesr

that whileinrraosseous i"f"sion is a--r"piJr;;Li".-i;;

i;r?i; 1a99ular access,the flow rates ,"hi.u.J'*. noi ,rrlrr"r.rrt to, trr. definitive treatment of severe hypo;;i;;i; ;; h;;;r;h";; shock. The data support th. t."(rr'iqr.ri-"Ji#""ur. adiunct

Previous -animal studies have examined endotracheal admin_ lidocaine and di_ To date,.no.studies lave'been ao",i io a"l"r_ine :0,.,!-.. the ,pulmooarypathologic changes caused by tn1r. "s""t, admin-

whileother-.rns of uarc"t",""...r1rl tiiigT*._p,.a.

,'

igtratiOn $arattonol of eoinenhrine rrr^hina 6-t^-^-^ r:r^--! epinephrine, atro-pine, naloxone,

[r:*:l[rJgute,ltrep,irp"r"oitrri-Jr,"-Jy-ri""J,oexamine pulmonary. histotogiceffecis-"r."a"lriit"htiaiiioirr"r.a irrp.opif6""?y"ol,eth_ f.3fl.,.tliir_::mmerciallydissolved -al99h9l,benzytalcohoi ; J-ili ;H;'":;:: na.s kg| wereanâ&#x201A;Źsthetizedwith pent"UJU"iiJ Et[."en cars eywereintubatedwith a #3 noncuffea*a"ii""frJ s"0Lg/kg Ip tube and

go-oaratiye Study_ofIntraosseouave?ous 9Z_ fntrayenous Infusion ot btrin66aio-iii'i'K Brickman, P.Rega, M Guinness

/ EmergencyMedicine nesiAlncy, -' Sf Vincent Medical Center/The Toledo Hospiiar, fofeJo, Onio Tleatment of pediatric patients requiring urgent intravascular accessfor drug administration remains onJ of ih. _ort pressing facing the emergency physician. fhJ ,.rurgeo"e lite1m.as of popularity of intraosseousinfuiion 't "" pi"ria"a an additional to the physician,s arsenal, Uut to'art. no y:1po" study has ai_ rectly measured serum drug levelj ,"hen cornparing intramedulIary infusion to the peripneral tntravenous route. we admin-

'",*:i,*:%l*:',:HT$'"'ndii:?":ial":H* ililated-u/ith a respirator on room air. An intravenous catheter

femoral artery.six animalsreceiveddiazepam o, -;ili;l 41


istered phenobarbital to 20 dogs randomly assigned to either peripheial IV {n : lOf or tibial intraosseous (n: l0} gr-oups. Central venous drug samples were collected at l-, 3-, 6-, and l0-min intervals. Our resulti confirm thet intraosseous drug infusion will achieve and maintain comparable serum levels to intravenous administration. Intramedulliry placement was usually performed within 30 sec. In our study it was apparent that intraosseous infusion was an effective and efficient altemative for drug administration when peripheral intravenous accesswas impossible. Statistical results reveal that for all time intervals, the interosseous group had higher serum levels of phenybarbitol. Using ANOVA, iepeated meaiutes, comparing the two Sroups, it,was determined that P = .262, indicating no significant difference between the two Sroups.

98

Usefulness of the Stool Wright's Stain

in the ED D DuBois,L Binde( B Nelson/ Divisionof Trauma and EmergencyMedicine,TexasTech University,El Paso A prospective study was conducted to determine if a Wright's stain of stool specimen to detect fecal leukocytes was accurate in predicting the presenceof a bacterial pathogen on stool culture. -Entry criieria were patient age> 3 months and diarrhea > | day. The patient population was drawn from an urban county hospital emergency depirtment on the Texas-Mexico border. A total of 69 patie;ts were evaluated by both routine stool culture and stool Wrlghtt stain. Tlventy-three were evaluated for parasitic pathogeni. There were eighteen cultures positive for bacterial patltogens and 23 positive Wright's stains. Bacterial isolates included Shigella, Salmonella end Campylobacter. Also detected were Giirdia Shistosoma, Blastocystis, and Cryptosporidium. The "â&#x201A;Źt{i(Qijgd1^r't(i^*1(ttgih{b*f ilrre.rrurrra"Jirrednr"yrcsw!f,i il;i, *l,it a specificitv oi esi. for the presence ol a\acteria) These were significintlv correlated with a ;;;h;";; il;lture. fot " br"t..irl patholen by Chi-square analysis-(P '.I".i,ii.'""fi"i. .oif. ift. pi"aictive power of a positive result was 6l% and the preiictive power of a negative result was 94"/o'The Wright's stain for the Jarly presumptive diagnosis of inlectious ir " "t.f"fa"l airitt "" in the emergett"y i"p"ttm.t t, allowing one to evaluate ""tii" i."t.t, risks a"ndiorrrid", instituting empiric antibiotic ih"t"py in a poorly compliant patient population' MS Puczynski' with Antibiotics Seff-Treatment 99 J-G-onzalez,JP O'Keete, JC Mortimer / Departments of Pediatrics "nd M"di"in", LoyolaUniversityMedical Center'Mayrvood'lllinois A study is currently being performed assessingself-treatment paiients who present to a university with antibiotics among "Paiients whose ilnesses were assumedto emerqencv department. physician were requested the examining by origin .il*.J,i-is il io participate. PatiJnts were excluded from the study-if they were ,."'"iuittg antibiotics prescribed for their current illness or reparenterallv -within-the preceding,six weeks' ;;i;;Jii ilicillin Urine specimens were obtained from all patients end tested tor presenceby agar diffusion asiay using Bacillus sub""ii-i"i"Uirt tilis as the test organism. iwo hundred thirty-one patients have been evaluated to dat.. One hundred sixteen pediatric patients [< ie;."ttt and ll5 adults {> 18 yrs) have partiCipatedin t}ris studyhave iniluded fevir (38%f headache(147"f' i""'r.",ilti.v-ptoms

those patients presenting with URI symptoms. A total of 14 bacterial iultures were performed on patients who demonstrated antibiotic activity in their urine. Blood and sputum cultures were more frequentiy performed in the group-with Aa (P < .01 for each).Thii study demonstrates that Aa is found in an emergency department patient population and could pose a significant problem in patients evaluated in an ED. Careless use of antibiotics could hive an impact on bacterial cultures, clinical diagrr'osisor outcome of illness.

l OO Detection and Treatment ol Serually R Klicker' Ilansmitted Diseases in the ED R Mayron,

K Hanson,R Gruninger/ Departmentsol EmergencyMedicine and l%thology,HennepinCounty Medical Center'Minneapolis Patients presenting to the ED of a large county medical center were studied. One-hundred three miles with symptoms of urethritis and 505 females with symptoms of abdominal pain and/or vaginal discharge were consecuiively screened. To evdu' ate differEnt means o-f detecting Neisseila gonorrhoeae lNGl, each patient had a modified Thayer-Martin culture, ELISA technique (Gonozyme, Abbottf, and Gram stain performed. ln addition, tlre prevalence of Chlamydia trachomatis (CTf was deter' mined using direct fluorescent antibody slide test-(MicroTrak, Syvaf. For thle detection of NG, a true positive was defined when ai least two of the three tests agreed.In males, the sensitivity of the culture was 95"/o;Gonozyme, 93Y"; and Gram stain, 9l%.ln females, the sensitivity of the culture was 95"/"i Gonozyme, 91o/oi arrdGram stain, 53%. There were 20 false positives using the Gonozyme in females. In males, the overall incidence of NG was 38% and of Ct 8%. In males with NG, 10% of patients were dssupniriuefru. QI. In,ferndes., tlre.overdl^ incidence of NG was

ff"i..ttaolCl;'l)%.\nternrhsun-rncnruho\S,$*"wusrAl%

rate of Cf The results suSSestthe following recom' "on""*""" for detection and treatment' ln males with urethral ;;;J;il;t is sen' dir-"ttrtg", only a Gram stain need be performed' This test ri,ir., i"p-il ;"a inexpensive.-If p9qiiy9, the patient is treated ;iih ; ;-ci"-dose antibiotic for NG; -iI ne-gative,-with tetracJpresentins with abdominal pain and/or ;ii;; l"; iC i.-al"s should have a thayer-Martin culture and CT r"er""i-aiJ"rge h"'' based on the results of these tests' The ;f;;;'li;;;t; Gram stain in females is not sensitive and representsan unneces' rhe Gonozynietest had an unacceptable numberof *;;;;;t". ii" "ott of routine screening for.cT in femdes is i;iJ";;ti-,i".t. C high incidence and resultant morbidity' Due to-the il;.iiJtt infection, all femal-es treated for NG il;il;;;;i;ott?,rtt.ttt for CT *hen the results of a CT treated irr"""ra f" "-piti""[y epptopriate followup should be arranged "oi'"t"if"ti". ;;;; for all patients.

Sexual Asrault Examlnatlon: iledical end tOl c eokinson,TH Frost'GF B Rambow, rmetEitiona i"lif pei"-tson/ tiepartmentsof Emergencyt!e!i9i19 and Pathology' HlnnepinCornty Meoic"l Centei ani Cnib Abuseand Sexual Office' Team,HennepinCountyAttorney's AssauliProtectioh Minneapolis of our sexud assault-protocol-we To assessthe ef(ectiveness [N = undertooka retrospectivereviewof the sexud assaultcases q9:It'l depanment,during fa2l "t"l""r"a in t"t .-"tg.ncy iniuries,sexudly transmrtteotussoecilicattention to associated le&l ;;dical iollow-up, pregnancv.and il;, ;;;hi;;;;;ith rn;u' = associate<l (N had 9tJ cases percent of all outcome.iifty = tzi were found to have il;:-Nt* il"6"t oi o" women {i'l (N = "*it"t tt".it"a on pelvic examination,althoughonly 29% 31 of th"t. *o-et had complaintsof genital P{1 or bleegllgi iht.e *o-en appearedto havecontracteda sexually treili[utteo ", " ,.tnit of the assault.Thirty percent of the victims ;;;;. trJ "a.q""i" follow-uf as dictatedty o'uf protocol' None of the *o-"n 6ven post-coittl "tttog"tt-qr6rg{ (N =.52} it k"o.T-ll havebecomepregnant.Only 53 of the 182caseshad the potenusr

anddvsuria(15%|' lzod/ol, iJRi;ffi,;;t-1st7"1, GI svmptoms Ni"et6e"'{g7.} oi the patients were found to have antibiotic activity in tiieir'urine. Of the patients with.antibiotic ectivity- in iit.i7 ".1"., ."ly eight {42%l werc from patients who admitted to antibiotics. Data relating to duration of ill,"ff."J-i"ir,r"iioriof ness, age, symptoms, concurrent use of OTC medications and peifoimed were evaluated. Antibiotic abuse {Aa) was ";it"d se"., -oti frequently in patients presenting with URI symptoms ti other piesenting svmptoms (P < '031' in;;i;il";;p"t"d it""t*r which correlate sigrrilicantly with Aa in adult patients include URl symptoms, history of fever, and concurrent use ol en ea ii pediatric paiients was seen most frequently in ""iipn.ti..

A.l


for successfulprosecution, in that there was both a victim willing to-cooperate in prosecution and an identified assailant. Eighteen (34%| of these cases resulted in a conviction. EvidencJof trauma and the presence of male secretions were found in 6lo/o of the casesresulting in successful prosecutions, but were present in o_nly23% of the remaining 35 cases (p < .011.One alleged assailant was cleared by evidence gathered from tLe exam. ihe euthors conclude that medical and evidentiary exams play an essential role in assessingthe medical ramifications of-sexual assault and in providing maximum opportunity for successful prosecutron.

lO2 Accuracy of Urine Urobltinogen and Bilirubin Assays in Predicting Llver Function Test Abnormalities T Kupka, L 6inder, B Netson, M Wainscott, B Glass, D Smith/ Division of Trauma andEmergency

Medicine,TexasTech University,El Paso Comognerrtsof the dipstick urinalysis (urine urobilinogen and urine bilirubinf are often used by emergency physicians to screen for the need to obtain liver function tests in many clinical situations. An ongoing prospective observational study is being conducted to evaluate the sensitivity, specificity, and accuracy of spot urine urobilinogen and urine bilirubin assays(Chemstrip 90| in the ED as screening tests for serum liver function abnormalities_ISGOJ alk phos, bilirubinf. Data (e:rpressedin percentageslcollected on the initial 60 patients are as follows: SGOT Atk 0 Eu AnyLFT Urlnc Udm U'obll

Blll

Bil

UB

B[l

44

41

44

8il1 gO

UB

Scnrltlvlty

UB

65

7t

Bg

36

Spcdncrt

61

82

6t

79

6t

86

67

8it

Acc1lttcy & pE|tdlcdon

56

72

56

67

44

67

76

83

Accuracl hh.dleton

49

55

49

52

83

36

52

@

iZ

57

67

88 g2

34

Aocuncl

SZ

SO

Subgroupsanalyzed(patients with ED diagnosesof hepatitis, biliary tt?9! dicease,and presentation with abdominal painl show urine bilirubin to be: ll 82-lOO%sensitive artd 75-926/"accruate for LFT abnormalities in the setting of hepatitis; 2f 86-10O%specific for LFT abnormalities in the Jettingbf biliary tract disease; 1nd ef .e!-flZ9 specific for LFT abnormai-itiesin patients presenting with abdominal pain. Current data indiiate thai urine bilirubins may be a specific but not sensitive indicator for LFI abnormalities; in contrast, urine urobilinoten appears to have poo.rsensitivity, specificity, and accuracy in predicting LFT abnormalities. Data collected are being subiectedto multiiariate analysis to investigare_thresholdvalues of SGOf, alkaline phosplutase, and serum bilirubin at which the urinary screens einibit the geatest sensitivity, specilicity, and accuracy.

significantly outperformed placebo (P > .051.No clinically signilicant adverse effects were attributed to the study.drugs. These findings are similar to others which showed a lack of efficacy of kappa receptor agonists in classic migraineurs. Nubain appeati to be clinically useful in other types of severeheadache.Thi routine addition of Vistaril for presumed synergistic effect is not supported by this study.

1O4 Suicide Assessment in the ED RJ Rothstein, RSHockberger / Department of Emergency Medicine, HarborUCLA Medical Center,Torrance,California A simple mnemonic, the SAD PERSONS SCALE (SPS),has been described for use in identifying patients at high risk for repeating suicidal behavior. We modified this scale for use in the ED to include the following criteria: Sex (malef Age (< 19 or > previous 45f presenceof Depressionor feelings of hopelessness, suicide attempts or psychiatric care, Excessive drug oialcohol use, Rational thinking loss (organic brain syndrome or psychosisf presently Separated/divorced/widowed,an Organized or serious attempt, No social supports, and a Stated future intent showing a determination to repeat suicidal behavior or ambivalence. T[is scale would be of practical benefit to emergency physicians if certain scoresconsistently correlated with the dispositions made on patients evaluated by psychiatrists following a suicide attempt. Using our modified scale (MSPS)scores obtained by psychiatric and nonpsychiatric housestaff were compared and an attempt was made to correlate the scores with disposition of 100 consecutive patients presenting for evaluation of suicidal behavior. The scores did not predict disposition. However, 4 of I0 criteria were found to be statistically associatedwith the need for hospitalization(p < .C01, chi square|. Those criteria were Depression, Rational thinking loss, Organized or serious attempt, and Stated future intent. Weighting the MSPS, giving 2 points for each of rhese criteria and I each for the other 6, we found that a score of > 6 had a sensitivity oI 94% and a specificity of 7l% in identifying the need for hospitalization, as determined by the psychiatriit. A score of < 5 had a negative predictive value of 95%. When the 2 nonsuicidal patients, admitted for situational reasons only, were eliminated a score of > 6 had a sensitivity of 100% and a score of < 5 had a negative predictive value of l0o7o. Prospective use of the MSPS on 40 additional patients thus far has shown rhat none of the 28 patients with a MSPS < 5 was hospitalized, while 9 of 12 with a score > 6 were admitted. It appears that nonpsychiatrists using our weighted MSPS can quickly and easily obtain the obiective data necessary to accurately assessthe suicide risk of patients in the ED. A score of < 5 will allow confident discharge_ to followup, while a score of > 5 necessitatesemergency consultation and, perhaps, psychiatric admission.

105 lO3 Effectivener3 of ilatbuphine and Hydoxyzine for fleatment of Severo lleadache ln the ED D Tek,M Mellon / Department of Emergency Medicine, Naval Hospital, SanDiego Presenttreatment for acute attacks of headacheis empiric. Intramusc ilar nalbuphine (Nubainf and hydroxyzine (Vistarilf were assessed_ tor pain relief in a prospective double-blind clinical trial. Ninety-four patients were randomly assigned to treatmenr groups rec.9i1l8 Nubain- l0 mg Nubain l0 mg plus Vistaril SOmg; Viitsil 50 Tti or placebo. The treatment groups were founiio be adequatelyhomogeneorrs with regard to age, sex, tyrye and durauon ot headache,and history of prior narcotic use (p > .051.All dala were andyzed by one-way ANOVA. patients who had headachesdiagrosedas other than classic migraine had significantly gr.eaterpain relief with Nubain compared to placeo (p < .OZSi. Ehe combination of Nubain and Visiaril *asnot significantly 6ore effective than other treatment groups {p > .051.In patienti i$th classicmigraine In = 20f nonJof ih.'tte.t-errt rigimens

43

Use of the ED for Hypertensive Screening

S Chernow,K lserson,E Criss / Sectionof EmergencyMedicine, Universityof Arizona,Tucson The ED has been criticized as being an inappropriate site to screen for hypertensive patients. The pain and apprelension associated with many ED visits has been thought to falsely elevate blood pressure readings in this setting. Limited data actually exist conceming subsequent hypertension in patients noted to have an elevated blood pressure in a random ED visit. To evaluate this, all patients admitted to the ED of a university hospitd during a period were prospectively screened{or hypertension. on_e-year Follow-up was attempted for patients who, on admission and dischar,ge,had systolic pressuresgreater than 159 mm Hg or diastolic pressuresgreater than 94 mm Hg. A totd of 239 patients met these criteria, and follow-up was obtained in 477" oI the cases_. Significant hypertension (systolic > 159 or diastolic > 94f was found in 37"/" of these patients on follow-up. Borderline hypertension (systolic 140-159or diastolic 90-941was documented in 33% of the patients. Thirty percent were {ound to be normotensive when evaluated in a follow-up visit. The number of


patients experiencing pain at the time of their initial ED visit was similar among the three groups. On chart review, 4{l% of the significant hypertension group and 42o/" of the borderline hypertension group were found to have a history of hlryertension. A change in treatment occurred in 33% of the significant hyryertensives and in 367" oI the borderline hypertensives. This study supports the usefulness of the ED as a hypertension screening site despite such coexisting factors as pain and apprehension.

of this study was to compare CBCs and routine blood chemistries drawn from the marrow cavity with simultaneous venous samples. Five domestic swine were anesthetized with ketamine 20 mg/kg IM and pentobarbital 20 mg/kg tV Both hindlimbs on each animal were prepped with a povidone-iodine solution and sterilely draped. Eighteen-gaugespinal needleswere inserted into the proximal tibia of each leg. Ten milliliters of blood were aspirated from each site and placed in a tube with EDTA for CBC analysis and plain glass tubes for chemistries. Simultaneous with the intraosseoussampling blood from bilateral femoral veins was obtained by transcutaneousfemoral venipuncture. All CBC samples from the intraosseousneedle clotted immediately, while those drawn from the femoral vein were normal. Blood chemistries were analyzed on a Beckman ASTRA 8. Mean + SE for each group was as follows:

106 Effects of J{aloxone in Patients with Acute Eracerbation of COPD DAFrommer, TL Pefty, JM Wogan,S Silverstein,J LaBrecque/ Departmentof Emergency Medicine,Boston City Hospital;Webb-WaringLung Instituteand Departmentof EmergencyMedicine,Universityol Colorado HealthScience Center; Departmentof EmergencyMedicine, Union MemorialHospital,Baltimore;and NationalJewish Center, Denver Although many opioids depress ventilatory drive, the role of endogenous opioids in central ventilatory regulation is unclear. This study was desigrredto test the hypothesis that endogenous opioids, which are felt to be elevated in stable chronic obstructive pulmonary disease(COPD), might interfere with an otherwise enhanced ventilatory drive during an acute exacerbation of COPD. By reversing these endogenousopioids with the narcotic antagonist naloxone, enhanced ventilation was hypothesized to improve the therapeutic response to an aerosolized beta-agonist. Immediately after obtaining informed consent, 14 eligible patients were randomly assigrredto receive either a naloxone 2 mg bolus or a placebo intravenously in a double-blind fashion. Eligible patients were able to cooperatewith spirometry had an initial forced expiratory volume in I second (FEV-I) < 1.3 L, age > 45 years, and > l0 pack-year smoking history. Vital sigrrs and FEV-I were measured at time = 0, 15, 30, 45, and 50 minutes. Arterial blood gases(ABGs)and serum endorphin levels- were obtained at time = 0 and 30 minutes. {Serum for endorphin levels has been collected and stored, but at time of this writing, has not been performed.) Patients received aerosolizedmetaproterenol 0.3 cc at time = 0 and 30 minutes. Aminophylline and steroids were withheld during this time. Groups were well matched with regard to age, sex, entering aminophylline level, initial vital signs, ABGs, and FEV-I. Statistical analysis by Student's t test revealed significant mean differences between groups at 30 minutes for respiratory rate, blood pressure/pH, and PaCOz.At time 30 minutes the mean (+ SD) respiratoryrates decreasedto24.7 + 2.7 and 30.0 + 4.4 tor the naloxone and control groups respectively {P < .03).The mean systolic and diastolic blood pressuresat 30 minutes were 132 + 19.3/82.3 + l4.2f.or the naloxone group, and 169 + 8.2/95.0 * 7.0 6orthe control group (P < .007 for systolic pressureand P < .14 for diastolic pressuref.Arterial blood gas pH and PaCO2at 30 minutes were 7.44 + 0.04 and 34.3 + 7.7 fiot the naloxone group, and 7.37 + 0.08 and,45.7 + 12.4f.orthe controls (P < .05 and P < .05). No significant differences in FEV-I were present. The differences in vital signs and ABGs between groups suggestsa modulating role for endogenousendorphins in the regulation of ventilation in acute exacerbationsof COPD. The small sample size and absenceof a significant difference in outcomes between groups does not allow a recommendation for clinical usage without further evaluation.

]la lO 141 1 1 lv 140 r 1

K

Cl

5.6 a 0.5 4.8 I 0.2

104 a 2 105 t:t 2

COz 24.7 ! 2.9 26.4 ! 2,2

Glu '176 t 25 163 t 20

BUN

Cr

16.8 ! '1.0

1.0 r 0.1 0.9 I 0.1

17.1 ! 1.0

Cr '10.4r 0.6 10.6 3 0,3

Each group was analyzed using a paired t test. There was no significant difference (p > .05) in any of the groups. Although blood could be drawn from the intraosseous needle in a heparinizedsyringe to prevent clotting the concentration of red and white cells may not be the same as peripheral blood. From this study,it does not appear that a CBC can be reliably obtained from an intraosseous needle. However, intraosseous blood chemistries do reflect those of venous blood and may be used if venous blood cannot be obtained. Knowledge of these data can be of help in the seizing or arrested child who may be suffering from electrolyte abnormalities.

1O8 Gomparison of Bupiuacaine and Lidocaine as Local Anesthetics for Reducing Pain after Wound Repair WHSpivey, RMMcNamara, RS MacKenzie, S Bhat,WPBurdick / Department of Emergency Medicine,Medical College of Pennsylvania, Philadelphia Lidocaine (L) is the drug of choice in most EDs for local anesthesia becauseof its safety and rapid onset of action. However,it wears off shortly after suturing is complete. The purposeof this study was to compare the degree of anesthesia obtained during and after repair of laceration using L lolo versus bupivacaine(Bf 0.257", a long-acting local anesthetic. B or L were administeredin a double-blind, randomized fashion to 100 patients 150B, 50 t). Patients entered in the study were l8 years or older with a laceration greater than 2 cm, not located on the fingers, toes,noseor ears. Exclusion criteria included alcohol or drug abuse,liver disease,psychologic disturbance or allergy to the amide anesthetics. A minimum of 5 cc of drug was administered via local infiltration and the wound was debrided and sutured. Thirty minutes after inliltration of the anesthetic, a blood sample was collected and the serum frozen for assayof B and L levels. Eachpatientwas asked to rate his or her pain on a 0-10 scale (0 = no pain, l0 = severepainf prior to administration of the anesthetic. They then rated pain on the same scaleat 30 minutes, 1,2, 3, 4, 5,6, 12,Lg and 24 hours after completion of suturing. Mean t SE for the two groups were as follows:

1OZ Comparison of lntraosseous and fntravenous CBC and ASTRA 8 In Swine H Unger, WHSpivey, RMMcNamara, CMLathers / Departments of

| L

EmergencyMedicineand Pharmacology,Medical College of Pennsylvania,Philadelphia lnterest in use of the intraosseous route Ior administration of fluids and drugs in the acutely ill child has shown a dramatic increase in recent years. Often it is the only portal of entry into the cardiovascular system. It too may be the only site available from which blood samples may be initially drawn. The purpose

3 . 3 : 0 .r10 . 7 a 0 .r 20 . 8 a 0 ., 2 0 . 9 r 0 . ,2 l . t a 0 . 2, 1 . 3 : 0 .,31 . 1 ! 0 .,31 . 8 a 0,.13. 3 i 0 2 , 1 . 0 t 0 2 30i03 1.9=0.3 | 1 2 . 6 : 0 .132 . 7 r 0 .132 . 8 : 0 .132 . 8 ! 0 .l 3? . 8 ! 0 . 31 2 . 1 s 0l.t3. 7 : 0 . 3 1 1 . 3 ! 0 3

A two-way analysis of variance revealed a sigrr.ificant dilference ( p < .0OU between the two groups. There was no statistical difference (p > .051between the age of the patients, size of laceration, and the amount of drug used. There were no adverseeffectg from the anesthetic in either group in this study. This study shows that patients do experience pain alter a wound is sutured

44


and the anesthetic has ygrn off..It also demonstrates that B signrficandy reducesthe parn a patient may experience arter wound

B

T 673)

A B

ASW (N = 112)

A B

(N :

-airiJii-"i. !9-g^__{g9!iv-ene11_ojperft presence of Intraabd^om on_eatLavaseinrhe

Owntl (N = 785)

A B A;RBC > lOO,OOO/mm3 B:RBC > SO,000/mm3 'Significantatp<.01.

inai rv" Gunnar, uJ Mertotti, Ap Robin,D1-!?IS", / Secrionor Trauma uurgeryCookCountvHospital, JA^Barrett ano oepartmeniJi,surg"ry, unrversity of iltinoisioilege ot veoicin"eltiii""go", of pgrltoneallavagein ,i""fr..".,ce ,"ll:.:1Tbtt,,t1 of prior raparotomy and intraabdominal to evatuate .adhellonsi;'";i;o*rr. tn order this problem to ,1,a'uce i.,,?lf;ao_in"t ,al._ illgaet imaI

,:"*:ll $i.""':ffitrX'fi tt.. p".ttoi,.u--;;'r;;;^i

eo'

a2 a2 88'

spocncry ft) 97

Ae!rey

#.

3;

90 88

86 86 93 93

96 95'

(%)

thisstudysulpg:,^?llasa predictor Il:-:r:k. of of rt is suggested that RBCtr,r"rf,oiJro, BT necessary andASW ;Til#""fJ:

s was deva lp' J.'ri""s,'eldoss

;long midline incision''{t op.t?,i.",

l,f Efficacy of pneumatic Ttousers ! in Prehospital Minagement of peneiraiing the ADdominat gnjurill wu aiix"i i,e-p"p-"lrlLMartox, ML uarrey, cH wyatt/ Deoartr"nt.oisriil",i,'ffii'corr"g" or Ben Taub Memoriat HospitJf; ,j,nJZit"y lt^edicrne; "'.r .ot Houston Fire uepartment Emergency Medical S5riJu."'

ru,bbid.wi th;;i;;;;;# ;ilH;Hil,,*imiik,T*.1 allowed for the abdominal wound.to h;;l;;;;toneal

s.nsfttylty (%) a4

",.,'^Ti rJ[],'il* il#]I,,,p".,,. 'H:,i"T'3'l':i,T"o:f. ",i. :il,jtl,_Ytd;4;;;#"";,"j::",+3:U.:':i.::::f;;*,ffi sronrntherighttowero"r*:1,_r]l.i,J?dqil.;Gt ff I Experimental lavage

of a ravage catheter. Tencclkg of llctated.ringer,s solutioniiilf *r, infused andthe dogwasrolled from.sid. ;.". ro,.eaiil, ;*"'#lf Uuag. nuia

uiooJ ."Ir"Ji_le'',i.ip","a ffiti'",}filgiJ:jff i]l* a"arn-,*itr,inti,.ffi

data I counrerpressu..*"r;;:;"::*f;'"';1:li:,Xff ;innnH::l by,:j"tponade:r{::, ,"q^

;r;;;;ffi;" centrarbrood Illg_. (Bp). pressure However. this h),pothesi, fr", "Ji'U.." evaluated randomizedctinical ,;:r^t_r,. in "b,:.,il #H, study was to evaluate how the orehospital T,i. use.of

j ;:i:i::;^,Tr.jfl :?ftr,1:::#ji*il:l1Ti

actual RBC count was nt"( g) of calculated counts.peritoneallavasefl .: .29 {SE,n .: RBC

containedroii"-i'zriiii;T"l"u:?,::1*,:: jy'ii.J::ffi ["-it

-: "SZl drtlerencebetween the two groups was found (p AII does were reexploredand found to have significant intraabdominal nesrons.our data sussesr ad_ that perito"neaflr;"g;:; reliably de_ tect smatlamountsoi"blood i" th. ,bdomi;;i;"";"y;.rpite --.-', \ prior laparotomyand abdominal adhesions.

the pneumatrc anti_shock garment (pASGl in hypotensive patients *itr, p.rrltr"ting abdom_ rnal rn;uries would affec_tt) the'survival ;;;;rffi 2) the volume

;:.i:?:";'f::'J#:ffif:""

to thesep"ti..,t,' o,,.inga three-year

presenting with penetrating teriorabdominrl1n;.r.1""p1lttnts aninitial prehospitai systolicdp of _=-so --"id;;';,':-::i:n the study'Prehospital .rt. tn", delivereduy ,'rt.rrl" -'.::^lli? emergency medicalse.vicessystem anJ "li il;; #unrcrpal regionalrrrui."' ir., I l"lt;i: :::!-"*tlv transportedto ttt. .ri,-.

jtj,".]'"T1fi1,.;T; ::;r?rdp*;;.;;;:Jjl'.:i."jffi:X[

an altemate day assignmenl o! l4SC ,rr.. fiJ'...utting populatrons {control * study 90,, : 6j}'i.,r. tound to b. I 1gC N

fillf*:#,Ur*m?{#i""r,.ti*ir#"r" jTJnH,j'#*::ff T:li'rii..."rJ; hospiiarph,;.:i;;;ill

X:9:rlg,,Haibor GeneratHospitat,Los Angetes,and Denver uenerat Hospital,Denver The purposeo{ this study was to assessthe accuracy of diagnostrcperironeallavase *-p..at.ij;,;;;r.".y toprt laparotomy. Laparotomies riere .o"ria....J ^frr"i"J rr-..i?*ir" il abdomin al tnlunes required sureical. seven iigh,_five DpLs were retrospectivelireviewed. ^repair.patients in.i"al i" the study werethose receivins DpL for srgnifican;bffi;;;_" (BT) with unexplainedhypotdnsion, "q"iuo""t "iioii""Tii"ai"gs, con_

-in ff lI.f ::"l'f"iil': :; Y. *obabiiitv drco'rlia- *,s.;.;;

rn survival between the and PASG-treatme.ntgroups 169/90vs 60/851.Similari,.t.tlt-t:l signififant. diff.t.ln.. i' the number of or.t"J,?iyi'l1ttt Y," qo

.i16g,pasc'eli'iiii_''.:"L':ll*!':."::T:1'..*ii::,:lil

n39losnitalmanagement of penetrating ,11::.it Jurtes,the PASGprovidesni .i^iii..,i.-:;:.:1::' '#::1ff#:ilta!e aMominalin_

.u-iud o, i.;":i;;;*:ff

in improving

alat 1'i{j1i{tili:?"iilxTii:*,n:fljJ",t#:d*:*:tl:

cluqedfrom the studv were parients _i.f,-rJr,iff. overtpedtonealsigrs,'evisceritio', oiabjom;;l;;;""r, rrargastrointestinal h

l,?1,5,1,I1?1,T,3o4o *i1k"Ef,til"irtT",fi lgrolo-r,nitr,out'dprlilli;lJik#:.';.1il:i.l',..#,: {AMlcal;?;;ffi;;t jf l;yll:g jfr!:!:ixi:::ff#:li 1"1$3jli:=fr',[tili..r*xl'l,ii,*"j:ilm,,:lnlt1*.',,:, careunrtandprohibits vital signs, substan_

Ln ^aptan,DG Watsh,*l*r:ll"r/ Sectionoi ernlrs"n"y Jel/rc_es, University of Michigan,Ann Arbor

. Tiaditional

medical tr

tmersency -.1Jtri"t.if,os;;;i",;r;J., or patients. thromboryric,l:::ry _ry improve Doth survival and caidiac-function, :;g-I"ir;il;; but ".r..rro,-g.rr.r"lly

lurufrff*u*lr*filu'r;m*i:

gr_car repair of intraabdominal iniuries. i;ii'; i"oz" tnrl *a t.lYo IASWI sensitive in oredicting these iniuries. These sensrtrvrties.are less than those reported in the literature. The ac_ curacyot DpL for BT was significantly-grea,.i.-fr"i-io, ASW (ie, elYo.vs86./o,p q .011.Dara were.ree;f;"i.a "iai?i"rent thresh_

aDre. rt persons with AML.. avail_ ,o U.*iii f.#.rir.f, treatment, llgy -jll require emerqency,rransfer *iirri, ii*, to one of the tuyo ot hospitals that provide ,fr... ,._i".r..#...po* here on our experiencewith tie_em:r.g:l.y aeromedicaltreatment and transter for such treatment oJ ib4 g.9l,r.d;;;,ients with sus_ pected AMI. All patients within to or.r, center lor acure cardiac-.r1,. a fSO-_ii. ."ii"r,..f..r.d b, ,n ,"ro_ meolcal team includinx 9"1 b.-;i;;.il;d a, ph)rsician *a "u'rr. on a helicopter wrth rn tensive ca.e caoi bil iiy.' n.trr..., ivtrylcgj;a December tv$4, lO4 patients with suspected were transported for emergency AMI, ZA,men"ia 26 women, cardiac evaluation. Their mean

.fi',',"'"'.? at'ry;ruii:r+#**t,;r*il;i,',r#fi 45


age was 53 years. AMI was confirmed in9a l9o%l and emergency intervention was carried out in 75 of lO4 169"/"1. Ninety patients (87%f survived to be dischargedfrom the hospital. There were no deaths during transport. Complications requiring treatment occurred in 13 ll2%l of the patients during transport, and were associated with an increasedduration of symptoms. Physician skill or iudgment was exercised in 27 oI 104 transports {26%l and did not correlate with Killip classification of physical findings. We conclude that emergency trans{er of patients with AMI, traditionally considered hazardous, may be carried out safely using an aeromedical team. Emergency aeromedical transport expands the availability of regional resourcesfor cardiac care, and potentially allows all patients with AMI to receive the same standard of care regardlessof the site at which they first present with symptoms. Physicians appear to play an important role in safe transport.

1 13 Gritical Gare Transport of Gardiac Patients: Air or Ground? SMSchneider, Z Borax, MB Heller,PM Paris,RD Stewart/ Departmentsof Medicine, MontefioreHospitalof Pittsburghand Universityot Pittsburgh School of Medicine,and the STATTransportProgram,Center for EmergencyMedicineof WesternPennsylvania The transport of critically ill or injured patients has increased in frequency and importance with the trend toward regionalization of trauma centers and the transfer of patients to tertiary care hospitals. Aeromedical transport of these critical patients has been widely endorsed,despite a paucity of data substantiating its effectivenessin other than the seriously iniured patient. The helicopter transport of acute cardiac patients has become increasingly common, although no study has examined solely the effect of such transport on outcome in this subset of patients. Our recent development of a combined air and ground critical care transport service has provided the opportunity for a direct comparison of patients with acute cardiac conditions (myocardial infarction or unstable angina) transported either by our helicopter or by a specially equipped critical care ground vehicle. Both air and ground components were similarly equipped in terms of both personnel(physicianand nurse or paramedic|and medical equipment. Seventy-eight(27 ground, 5l airf transport caseswere studied. Both patient groups were comparable in terms of age, sex, Killip classificationand diagnosis.Total times spent by the transport teams with the patients were significantly greater in the air transport group (53.8 minf than for those transported by ground 127.7 minl (P <.0001f but actual interfacility transport times were similar (16.5vs 17.2min). Seriousuntoward events,defined as arrhythmias, chest pain, hypotension, bradycardia,seizures and cardiacarrest,occurred in 4I% of air transportsand 7.5% of ground transports (P <.002). The overall incidence of untoward events {IV loss, nausea, vomiting and monitoring difficulties) was also significantly greater with air transports 125/51or 49%l than with the ground vehicle (4/27 or l5%)(P <.0031.These data suggest that short ground transport of acute cardiac patients, when performed using a suitably equipped and properly staffed vehicle, is associatedwith fewer untoward events and necessity for emergency intervention. In this subset of patients, ground transport may be preferable to air transport.

periences of established services or accident statistics have been either inaccurate, costly, or difficult to obtain in a relatively short period of time. Utilization of provided services is not always based on patient need alone. Prediction of HEMS utilization requires consideration of many significant, simultaneous factors, in addition to needsbasedon population statistics. This study has analyzed the importance of need as well as some of the many other significant factors that determine prediction of HEMS utilization. Through use of a survey of all hospital-based helicopter emergâ&#x201A;Źncy service programs and published census data, factors relating to helicopter program volume and case mix were analyzed. A 70% response rate was obtained through multiple follow-up letters and phone calls. The following were some of the factors analyzed for ability to predict volume and casemix: standard metropolitan statistical geographicalarea (SMSAI; SMSA population; hospital density; helicopter program density; program age; number of dedicated ICU beds; marketing budget; and time spent educating first responders.Univariate correlations {rl and multivariate regressionanalyses (R| were obtained to provide separate as well as simultaneous explanation of the importance of each of the many factors analyzed. Statistical sigrificance as well as the magnitude of all correlations are provided for all factors. This study provides insight as to why previous methods utilizing total population were inaccurate for predicting utilization of HEMS. A more accurate yet simple and inexpensive method of utilization prediction for HEMS is provided. This information will be vital for medical directors of emergency departments and hospital administratorswho need to estimate utilization pattems for a potential HEMS program.

t

I 15 Threshold, Enzymatic, and Pathotogic Ghanges Associated with Prolonged Transcutaneous Pacing in a Ghronic Heart Block Modef JR Hedges, SA Syverud,WC Dalsey,L Simko, DJ Thomson,J van der Bel-Kahn,M Gabel, PJ Engel / Departments of EmergencyMedicine,InternalMedicine,and Pathologyand LaboratoryMedicine,and Divisionof Cardiology,Universityof Cincinnati Previous studies have shown that brief use of transcutaneous cardiac pacing (TCPf can induce mild, clinically insignificant myocardial damage. Longer use of TCP may cause more severe cardiac damage which might result in an increase in the capture threshold for subsequenttransvenous cardiac pacing (TVP),To assessthis possibility we examined changesinduced by 60 minutes of TCP in a canine chronic heart block model. Heart block was induced in conditioneddogs (n:8f by iniecting 0.1 cc of 37o/"f.ormalin into the AV node under direct visualization after right thoracotomy and pericardiotomy. Sevento l0 days after thoracotomy the animals were anesthetized with pentobarbital, endotracheally intubated, and instrumented with transvenous pacing catheters and femoral arterial lines. Electrodes for TCP and ECG monitoring were applied to each side of the shaved thorax and to the extremities. Six animals were then paced transcutaneously for 60 minutes. TVP and TCP capture thresholds were assessedbefore and after the pacing interval. Serum samples for cardiac enzyme analysis were drawn before pacing and at 4,24, 48, and 72 hours after pacing. Tlvo of the 8 animals (controlsl were treated as above but did not receive pacing. Animals were sacrificed 72 hours after pacing and the hearts were examined for gross and microscopic changes.There was no significant change in TVP or TCP capture threshold after the transcutaneous pacing interval (Thblef.

114 Utilization Prediction for Emergency lledical Helicopter Services: A tlultifactorial Approach ARMacione, DEWilcox / NewEngland LifeFlight and Departmentof Medicine,Universityof MassachusettsMedical School,Worcester As the number of helicopter emergency medical services (HEMSI programs continues rapid expansion, the need for an accurate, readily obtainable,inexpensivemethod of utilization prediction for these services has become apparent. Accurate volume and case mix prediction for these services are critical to resource allocation as health care financial constraints become more severe. All previous methods of utilization prediction basedon ex-

Capture Thresholds TCP TVP

Bolorâ&#x201A;Ź Paclng After Prclng P value 83.3mA(28.8) 85.omA(28.8) .356 042mA(0.18) o.51mA(0.18) .081 Mean(SD)n=6 paired2{aitedt test

Although there was a significant rise in CPK at 4 hours (baseline: 139.7ImU/mL +58.9; four-hour; 383.8 ImU/mL + 212.6i p: .017f there was no detectablerise in the MB fraction in any of

46

I

il


the pacedanimals. There was no elevation of LDH after pacing, although-3of the 6 pacedanimats.d;;;;;;'$;DHI/LDH2 iso_ enzyme flin indicative of the hearts of the pac_ed ^ofrmloca.g,"ft;4;: i.thologic analysis animals revealei subendocardial, subepicardial, and periviscular areas "f U"."pfriji""'degeneration in_ volving less than I% of the m.yocardium^. No evidence of such

";i;il.'ffiJ,,t".,.o.,sp""i,,g ffruf Xn::*rn thecontrof

I

t

tu,.th..,h JJffi iliH;liH:ffi T,:li;::n:g*:* cardialc daml;;; ffi ffi'#lltt,,.ry

fl.,|:l:ll'"'pic Dy

derectable

dynamically significant arrhythmias, or death. rienrs were comarose on admission,';irhei;:;.* All ll of these pa_ coma scale ol < 6. Nine of these ll patients t-rt qRti"i.Lr Level of consciousnesswas a good pr"i;;;;;;'r.nous > 0.10 msec. complica_ rions. An initial Glascow "or* s."i. = s pr"il"r.J il;#i.;; ICU admissionwith a sensitiviiy "f O.Ai l#llp."ifi"ity of 0.89. A eRS inrerval > .10 msec pr"ii"t.J "o_Jfili sitivity of 0.s9 and a specifiiity "a0;;.;fi;;ients iorrc with a sen_ who devet_ oped significant toxicity m".if.;i;';; i;ri;". senous com_ plication within the first two h";;;^;;;r"l in th" ED. We conclude that level of consciousness isl b.ii"i p..ai"tor of risk of,complications and need f- ieU'aJ;rifi'rfr"" is the eRS

rsoenzymeanalvsis d:""if dri;,;?d:;;l[;J#,#i#1'""11+';:i;::l'lril:.;

sale technique.

Sudden Dearh ! I_9 Goc-aine.Associared H r"rul"1-vGil"bi"r]rc stephens :I^l1l9me.s^BKarch, / university' -Ciiv si'noo 3:?1T"it gr. ?atloloev:. r orMed icine, lqntoroorrice, Medicat Examiners a-nJ'countv ot sa-n i,.,llio;l;..0 death syndromeassociared ^_^t^199:l creasrnglycommon,but no myocardialwith cocaineuse is in_ lesion hls ever beenreported.To clarify iis p"tt opr,irioloiy;^#]'#ftd all cocaine_ sudden i:1:1T9 since deathseximinea fy'tt e S"" r*ncisco Medical Examrner mjd_19g3. Thirty_four"".*-*iif, positivetoxrcologywerefound. To control f,;l th. .ff;r';il;;;,G; kalemia,and resuscitatt3l.c_o";ro.ls a groupol 23 patients who had died of 1v.;;;;'f-_

sedative patients were mostly men (g6"/oor_cocarne hyp";;;';";;dose. qr^ogpfS% of controls), with a oft3.e years (controls. : ?z.sl. ou.. iit;i "trhe cocaine :::: iry IV drug users as evidenced'by "","pry fi";i;;;. f1lll -1:r. ;ir; s'oes were examined and graded by three "b#;;r. Microscopic examrnation disclosed that rhe coiaine p"ri*i, ""if.;;1il;";r: onstrated widespread, intense, contractibn band necrosis, while the controls did not {Wilcoxon rwo_tailed,.", ; ; .02).The in_ tensity of necrosis corretared ;;ii ;i;i;"bt;ii,"ii,r.,r,. cocaine concentrations.Becausecocaine p.t."rirr.. J"iicholamine ef_ tects, and becausebeta e

Etecrrocardi g.Sr,aplic_Griteria f or !_1 I Tiicyctic Antidepressanr Gardi-oroll;ft t ;;;ulr"n, I r Niemann, RJRothstein. l{|r4Fks 7 Dep'anrl.'t,"r Emergency Medicine_and Medicine torisionor-cXrl;ffi;j: Laroor-UCLA Medical Center,

Torrance,uatttornta To determine if ECG,fj,"gitgs are oI value in the diagnosis of tricyclic antidepressant.(TCA);;;rJor. r"a .#i.roxrcity 25 pa_ rrents suspectedof TCA overdose *.r; ;;d;;Jaa_iJri6" iil_ nosis of ,,TCA overdose" was based on;;;il;I. iirro.y or medi_ cation vials provided to the emerge".y pt y.i"i"rr. Toxicologic assayslor a TCA were-subsequently positive in ll patients l+TCA, n:ilI. In 14 Datients,toxicologic;il;, were negative tor a TCA (contrors. .Tglt.. ;id-d;;";r;ai a significantly greater.heart rute lrrT +2r/mi" y;lb'J;;;;::tfi eRS duration {toa + 15 msec vs azr ro. pi.oos-i;"d;";r;;;d er interval 1449+38 msec vs al8t36,.p<.Gl ,i;fiij;nrrol patients I - TCAI on admission. +,rca prti.ri,t;';i;;;;;_ore rightward terminal 40 msec frontal plan'e eRS;il;'ii9;* sr. vs s4 * 64', p<.001f than did go"lroJ patients. fhis oisirvation had not oeen reported previouslv.,Onty , ter_i"J-e-n"S"u!",o, of l3O_270" accuratelydiscriminated,between_TCA and +TCA patients lpositive,andne,garivepredictive ""f ". :' rotatron Inormalizationfof the terminal i.gl, io'unterclockwise f.o"i"t pi"rr. eRS vector was noted in +TCA parientsd"";; h;;;;t"lirlrt.,. eI *rce patients had a sinus tachycardia, a correited eT rnterval > 4lg ""j a terminal QRb vectot be,-*.." reo: ""d 220.. usins T::? tnese values as selection criteria, " "o_p.i"r_lia.a ,.rr.fr-o? I5,064 unselectedECGs ...ora.al" o,iir51"* p'".r".*ed. The likelihood of encounrering In thts popula_ tron was 1.0%. When subiected ::-+;;:ECG;;; to Bayesianf--U"^Uifi,y analysis, the posirive and neeative predictive;"I;;i;;ftCG for TCA ingestion,as defined bv oui criteria, nri.iii.-_i'tooz, ,.rp""population'of a zgs overi6r;;i*".1;e llr.Y,^tl efficiency of the Ecc as a diamostic test.was 97%.It r, "tri"i"J.i-,frriifr.

:l?t:.bil;;.;;,"i;"i:d'i;'J',:T:j:T:ruff;:,.*m:f .

lilt-lity i" their.ownright, it "pp."r, tt"iJE"il'r.rults band rh; """L_i"'rrurtrate :o:,:t"".,i9"type necroJis*ppf; mallgnant re-entryarrhythmia.

when for a

3i'.ft lili!,a,.". lj-iiii,;t"ilqi*iilqljh""ffi or putmonary Medicine. an rr,.|etroporitan' de"nl;i ;i"il,!#'"'ston

x il

of ca rdiologv'cleveland

Concernsabout mvocardial and neurological toxicity in tri_ cyclic overdosehave ied to recommendatiois ior intensive care monitoring. ln order to determine ,h;;h;;;ffiics of those pa_ develop signif i cant compli cat-ioi yl: J ;A;i; "s rcU man _ :t-.:r^ agement, we retrosDectivelyanalyzed the-"a.riiri""s for TCA overdosefor the pait ter

srudyi{da-ta;.,J,",i"illir].i.T,i:,i:lf l,f i#.",tt3A,,*i: inSq andlaboratoryverifi-cati-on ,il'd;il;s't"#

depressanrs. Of the 93 oatients,in.the,t,iay, l/

tricyclic anti_ lra seriouscom-

lcc iloi.aragnoiticvalue ,r,. ,.iit"s .ii,r,i'or.o'

or sus_ .in TCA overdose.The e-tectrocargi.s.;ph;r;;;ergency l:::e_d or phy_ slcran, computer can accurately af"grr*r.. i-be_induced ECc contour abnormalities if minimai .ii""iJ-irrf"-r_atron is pro_ Ii!t+#:itat

19

alonemavbea cost-effec,iu. ,o.iil-oaof diagnos-

Faitureof eRS _tntervatas a Toxicity

! iiii:::X?.Tf'T1?i;'3;""."11;;t;;;iliiii'i'J,""tiu",i,.,o"y

Fj{:ii?li{i},i."x*qir*_:IL"m

g:::dl'-'Gffi ':'"'#::lii'i,ii""1l'i;lJl.i':l:ll*.1:r,;; gy Medicine/Ct inicatToxicotogy -rr,l-""ii

comllrcarions. had increases "Jt. ii. .bii a.p*ssion of ilt.*i revelot consciousness 1o< .0011 coma scate andprolongaii.l d.p;;;;i c];l*

"i,i!a$;G;Til".

!.lj;Tr! .orfascom_ pareq to patients without complications., fn the,iZ patients who had TCA levels measured, tle TCA l-e; i."iia'l. be higher in patients with comptications (t,257 ,;7;f;;;r;, 678 ng/ml, p=.121.AII 37 patients with serious ""-;i;,1;;r;equired intu_ i:_ll. department fo;;;G;;; l::"L ot protective :{nersency ;.ntitation or ross airwav reflexes. rt."."-oi'ti-"r-" patients had other complications, incruorng seizures,hypotension, hemo_ 47

:r_ners.qn iil-S;;il or Critical r_;are, Universiry of catiforn ia oauii JitIii"i",s"" r"r"n,o j anddisposi ^-1T1*t""t q?31,p." tion or tricyclicantrdepressant :-ll:11-.n (TCA| -overdosed patients ..;"i;;; common and Admission nlobtep, ""'d ;-;,;;;;'o? :.1tli"ll: toxicity iu p"ti.,,t, fo, supsequenr places,a

tr..rr"ndorrs i.rr?eln J., cntical care resources.Serum drus levels are o"fy f*..fy "lrrJiated ,nd gerrerally too delayed to b. used.as Er; iril;;;r"Ji'ilo.iry. rr,.r"tore various ctinical findings h*;L;;"r;;ij # tonciry indicators. The eRS duratiort*lit-ltce9tlr accurate predictor o1 ,1r. nsk \9n. reported to'be an ol seizures (Szf or ventricular ar_


quantify ion concentrations before and after exposure to resin. Data revealed that Li+ ion was readily adsorbed to the resin.

rhythmias (VAf. In particular, a QRS < 0.10 sec was noted to indicate no risk of subsequent Sz or VA. Previous studies, however, have noted the variability of QRS duration in the acute setting and doubted its reliability as a predictor. To study the performance of QRS duration as a predictor of toxicity in our patient population, we retrospectively reviewed all patients presenting to our ED with TCA overdosage.The charts of 102 patients with quantitative or qualitative confirmation of TCA ingestion were reviewed for ED findings and hospital course. All patients had ECGs in the ED and 57 of these (Group Af revealeda maximal 12lead ECG QRS duration lQnSl of < 0.10 sec. The remaining 45 (Group Bf had QRS > 0.10 sec. There were 3 (5.3%l patients in Group A experiencing VA and 3 |.6.7%lin Group B. There were 4 (7.5%fpatients experiencingSz in Group A and 5 (ll%| in Group B. Chi-square analysis revealed no significant difference lp < .901 in incidence of VA between Groups A and B. Evalation of risk of Sz in the 2 groups revealeda similar lack of significant difference (p < .531.Of note was the fact that 9 {81%l of ll Sz and 5 (62%l of 8 VA occurred in the prehospital or ED setting. We conclude that determination of QRS is not a highly accurate predictor of VA or Sz risk for all TCA-overdosedpopulations. In particulal, risk during the emergency (prehospital and ED) phase of TCA overdose does not appear to be predicted by evaluation of QRS.

%Ll+ Bound $ ! Functlon ot PH KtYgIrlab PH 2.11

0.25 g 62.5%

0.5O 9 742%

2.00 g

7.21

44.8%

60.0%

88.3%

62.0%

74.5%

83.8%

56.4%

69.6%

84.9%

10.8

_ x =

825%

Each gram of resin was found to adsorb 0.452 mEq Li+ ion. pH and competing K+ ion had little or no effect on this binding process.In conclusion, we have demonstrated the ability of Kayexalate to adsorb Li+ ion in a wide pH range and in the presenceof competing cation. It is proposed that cation exchange resins, administered orally in a fashion similar to charcoal, may be clinically useful in the setting of acute lithium intoxication. Clinical trials are presently ongoing to evaluate this concept as a possible adiunct in management of acute lithium intoxication.

Evaluation of the Effect of Gimetidine on 122 the Hepatotoxicity of Amanita Phaffoides / EPKrenzelok D Borochovitz, Poisoning SMSchneider, Medical EmergencyServices,MontefioreHospital,and Pittsburgh PoisonControlCenter,Pittsburgh The ingestion of the mushroom Amanita phalloides is a rare but serious medical event. Over 95% of. deaths attributed to mushroom ingestion are caused by the ingestion of.Amanita phalloides. Clinically, the patient presents after a latent period of 6 to 12 hours with nausea,vomiting, and diarrhea. This resolves but is followed by a rise in SGOT and other liver enzymes over the next 24 hours. Massive hepatonecrosis may lead to death in 4-7 days. The treatment of Amanita phalloides poisoning is Iargely anecdotal and no single therapy has been proven effective. The clinical pattem of poisoning in humans and laboratory animals suggeststhe toxic conversion of amanitin in the liver. This conversion is most likely done in the cytochrome system. Cimetidine is a potent inhibitor of this system and might serve to prevent the hepatotoxicity of Amanita phalloides ingestion in much the same way it does when used in acetaminophen overdose. To test this theory 30 male Swiss mice were divided into 3 groups of I0 mice each. Group I received LD-50 {0.50 mg/kg} of amanitin intraperitoneally plus saline iniections before and after this iniection. This group served as a control. Group II consisted of l0 mice that received the LD-50 dose of amanitin plus a saline iniection pre-toxin and cimetidine 4 hours post-iniection of the toxin. Group III received the LD-50 dose of amanitin intraperitoneally plus cimetidine pretreatment as well as 6 hours posttoxin. AII animals were sacrificed at 48 hours by ether anesthe' sia. Their livers were harvested. Pathologic examination was done under both light and electron microscopy by one of the authors who was not aware of the treatment Sroups. The results show a dif{erence in the 3 groups in the amount of hepatocellular destruction and vacuoles present in the liver. The control group had the most serious destruction, Group II had an intermediate amount of destruction, and Group III showed few vacuoles and little inflammatory response.This suggeststhat the Amanita phalloides toxin may work through a toxic conversion theory and that this conversion may be interrupted by drugs such as cimetidine.

12O ilultiple-Dose Actiyated Charcoal in / K Kulig,DAFrommer Saficylate Poisoning JM Wogan, Departmentof EmergencyMedicine,DenverGeneralHospital, and Rocky Mountain Poison Center, Denver This study examines whether multiple-dose activated charcoal {MDACI can enhance elimination of a toxic dose of intravenously administered salicylate in a dog model. Five mongrel dogs, acting as their own controls, received 175 mg/kg of IV sodium salicylate and then received either no further therapy or MDAC {60 g every hour for two hours, then 30 I every hour for four hoursf. Serial serum salicylate levels were measured. The salicylate dose was toxic, as mani(ested by hyperthermia and respiratory alkalosis. The half-life {t}urlof salicylate elimination was consistently and signi{icantly decreasedfollowing MDAC therapy laverugetrh de' creasewas 397", :.;ange19 to 56/" Iess, P < 0.05).The area under the salicylate elimination cuwe was also reduced by MDAC in all dogs and to a sigrificant degree (average40% decrease,range 2l to 62"/o less, P < 0.05f. The clearance of salicylate was significantly increased by MDAC (averageincrease in clearance 38%, range 2l to 6lT" greater, P < 0.051.Enteral MDAC can enhance elimination of intravenous salicylate in a dog model. [Supported by an American Academy of Clinical Toxicology Research Fellowship Award.l

121 h Yilro Binding ot Li+ lon Using a Glinical Gation Exchange Resin (Kayexalate@l J Gehrke,CW Gehrke/ Departmentof EmergencyHealth Services,TrumanMedical Cente( Kansas City, Missouri,and ExperimentStation,Chemical Laboratories,Universityof Missouri - Columbia Lithium salts are widely used and effective in the management of several psychiatric disorders. They have a low toxic-therapeutic ratio and the incidence of acute Li+ intoxication is increasing. Management of acute lithium overdose should include attempts to prevent absorption. Activated charcoal is ineffective in binding Li+ ion. Currently no satisfactory method of preventing Li+ absorption is available. Proposalsfor the use of cation and anion exchange resins for management of certain intoxications have been made in the past. However, no formal proposals for the use of cation exchange resins in the management of acute lithium intoxication have been published. ln vitro investigations were undertaken to evaluate the ability of a clinical cation excha.ge resin {Kayexalateo} to bind Li+ ion. 0.25 g, 0.50 g; and 2.fi) g amounts of resin were exposed to varying concentrations of Li2CO3 and K3CO3 solution. Flame photometry was employed to

123 Role of Antibioticc in the lleatment of M McCarthy, Ertremity Gunshot Wounds P McCormick, T Broadie, P Yaw J Glorrer/ Department ol Surgery lndiana UniversitySchool of Medicine,Indianapolis The basic principles of treatment for gunshot wounds have evolved from military experience. Selective application of these principles in the civilian arena, with smaller caliber and lower velocity weapons, has produced diverse recommendations for

48


management. The pur e*rcacy of p.ophvla"tft^t-?l lhil studv was t woundsto the extremilt-^" Tibi' i i ": i; i ";-;i:t:;TtJiJ:: *i,t, sr".h"; *";;d;'tl€s' lh€ clinicalrecords.1 zfli,rri"riJ department"r " i** ,l?3e extremitiesseenin emergencv "t";;;tt'T werereviewed.0",,.n-o^1.-11it*1 rlnt ortnopedicsurgicaloro":t .y-i-th i"l "iitt t.q r i ilI";fi:lffr" :i two.pltients fe?zi iiJ"'illttt wereexcluded.o".ir"J.J?'r,il

125

Nuctearf --

uG di:ii'r,iililifl"il9. 1c coates/ secttns

is or 3 .!l': Diasnos

Rappaport, s Lee,S oil"l1'':-t^"{'.ry. ry andrrarma university srib"rv, Ygoi"ine ot niirori.."'.Yl99ncv andSection of Emergency veoicine, iririij ru"ii"fson'.

"il:5#n.* :i :fl k H::'s; rl:*n:riii*', [!]:

tj.F'il::'.,11i**ff t*tl**: i.?"tTj ;:#I *1TTj.tr#.1T#f .j,!HiJ ;jr. ::fil'.:,*,["":*;ru,.h:'. :",:"; Yr:il;.':"

rll;*:ir;".*y*,lli::?H"ff :n

alone. currently there no specific il;;;:":T::1:rocedures is dragnosediaphragmatic sist with ,rr. iir*.riltry iniu"y.-'rt""r] subsequcntlv .ia"".,r,. ilo.iiai,v associated wit; rh"ili"i] ::." tron' a nuclear scanni n-g,..h"tqr;' ;;i developed. s;-;;;;.;t9r ogs^1.1v1slins between25 anct30 kg qrvrded into were 2 groups

ti sti g1l-11signif i cant' most i nfections ;;; ; a r,rr."gi ;'.:" ::l -s1'a (25%l *e'e not apparent until two w.eks o.-r;;;;';",:::1l .th1ee six of the 38 patients fra,cturesa.u.top"a"iirl;:::^"Y"d,t",8' with as did ten of the 128 bull^etfragment's. wi.t r.,.ir,.i d;;;:i? of infection ls.8zo anJ z.s"/" ,.;;i':to_ence for ,tr;;" gr"ilir,

jlii;..T#::",,':,iqif

i,l,,,*i",f ;:::ru:, lllll;; :?itfj:iffi illl,}**iHir rrunlhti:**nd:+jt ,'il:'m*u't%{l;*:",.+,.J":li'S{fi j":i"j:,iffi,: jiHr.,''#: jl:",""u:il*f ;t'"'*'rl,,6{i:ji}lff ;i:}:*;h* :'.,:f$ "rrr* incidence .t r.hqr.*r,.-ai"J i"i"",lo" l.n-tsr'"'

subgroups "r.oi"it.i"loXnatysts oI antibiotic elficagyin these significant benefii. i';ri;;;; with gunshotw;;ffi who had fracures or retainedbullet rt"s*;r,, #,ilt:-.anv ^tftl1-iti"t Irlrt

sulfurcolloidin s -vtg mat satine*;;1;H;j;lTttum "?"".r1 T c the lavagecatheterwas dogswere th.;- -il? removed.The ;fi; uurg for 20 minutes beforJ nuclearr"r*i.,gl J.1"tl:Tot'"n was chosen"r tt. -iapoint to aitia.-?rr".iJyp-ho,rdprocess abdomenduring scanning. control animais;i;; #.:1i1 tn the andchJstco-un$per unir areaweree+i i"i'iii,\:it.t'bdtTt:d

i"il rill

{i9

lllri:ff I i* liy:*#:t - !f{il'J'"Jffi iH'f'r:rtJ:fi liJijf; :ill',:,Jffi Lnft1?"Hii;n;iJ:;fi :H".":""i:l

I

i

I

I

I I I

ff::t'itts",'tutu:^:r$';#i#:9.'ig r*:; gt'H.'1-:*i[#fiffi ifiqJjiiliHinPa'ien's : Ill_*:,,,,*;r;;ii;T;;I:il'#;:;*t1fr1..a.1xi*i'l i" mmal"".;tl;:l'a:n:r#;!*j"t[.:i,:f lllii",.rv ;t#ff:J, smau diaphragma dH JS;|:l tic,."1t' 19:'inr; !-2I

Etecrrocard.

ratro comparing averase *, respectively.A "1r""*'"^i:.1':,:Ju unit arear;. r.ri ..-""r..che-st counts with avera, r nrs.method shows that i

in this animatrnoa"t

aphragmaiic

ot aiil;: I,r"lt-::"t:lv .r."*o."J,.?"i,(EcGIisasen meriti serious;;;il#,,?Jlrcation ,t,1'"1','"H:l parients _ therong_rerrn;ffi .to human trauma_ 11" ::ff :T":11 t " s i ( on trauma' i,*.u.r,], uai Mt I rri t. *i "s [i"* :; Jr'iil.tj'- : : l il:::'.:}ffi Ti:f

investiSated angiography this. nrai"i".rJal fni..iij'rr"iT"i1"e,not traumatii ;;.;,;;;ft;:;.:j:9-" i: bean accuratei"di",toioi

,,ft,,i%,i:ff airiffi

J#.:'r::i,f ;*::llrulr,l.#;a:..":!l!$;l':r?q::fi i $#'i1:f,ffi,""Jii#"l][:it;l'":x?r wasabnormalii-+g tiiili ^"1^ag11ufIe-rins btunttrauma.RNA .A

!c,g

jl1tr'nrnepo..",iilr"+ffi "r:*l#:_tt.t1,rltffJ,f,y:f ;l-f':i,n',ff

Thaumatir

"'"sl{,3:;i:i:ff;:il,;j#[ lri:t:vsei;;#;.T?ll j.ffu.Gi.iiv,"ijr,r"Js[is, unrversity Hospirat of theFree TJ31Tl,:tT#TjiiHilifr'"*u13.*,r,cc,1 eersium

ECG Ftndtngr Non Spec STTA, T wa!€ <.lmv Frearlrate >l0O P wa\e > 25mVor -.07 < mV in Vl PR<12

RBBB QTc>.44 sr ereation r waw inwrsion NormalEcG 'ln patients withHR > lz0. tFisher **,

No]mal RNAil=26 (x) 7 (26) 4 (1s) 0 o o 4 (15) 1 (r 1 gr ,11,1*,

Abnormal FNA N=49 (%) Cht2p Vatuc 15(31) <.0o1 16(33) NS 2 (4) Nsl 6 (12) NSI 4 (8) Nsr t (141 Ns 2(4) Nsr 3 (6) Nsr 15(31) <.os

-.

FoJLoyi-"gsupporter

::lf:T***it:f:l,l,i::H1:H ::1i1h"rd;"iil;;;,blf d:ad

p€oprewereiniured,,r^1{*,h.1 *.r. ;;;i;;J

on rhescene. #H:":rt ;.f#;'"',f "::* ez p"i*"i.'i.,".'l.d-i.,"d,ooul werehospitat;Ji"

wardstor rreatmenr"f -Yi :l:t:'.20

r,i.#i

g:l,Ui:-;'llliilil:r:y3i*'r$ll*.a';:x'J traumatic asphyxia ftom this crowa_

j;t,:x*,t*.,*,.,1: ::*rufif,x***i="i,r,**t1 lau*i:,*i#d:Tiil.fr?3r#:#ntit'iil crush d"isaster.6;';j;rt^"_*

trunk (the "d;;;;hq:i8^:r,nen

i.,o-fthe head,'.*'

i" J"rip?

-4 + 2.s mEq/L,l".ti",.iJl'b T""lt::::tlorsis (biseexcess

'Jj:'1,triX*[:""i;5 TtT*it'1,'lXl"*,*i'*!i.:l"t"f

ilrTTT:";j:Jt?:1J10i.",L0J11.19f ,le:yhohadanormartassium,r,iiil'r"ii.#ilf,1t^_u"tp.",ed andmafi. dfi; ;; '::'::*:l;fi ucedmassive release. "","1[.r"iliJ.

*ilt":,',':#$:i*,n:lix"{l[ir!l-:d','.[:ffi ;";;i .jjl":-t;ttla :,i*?fmo'e ar s-p"r'r.ri,J'f fi il:*li:: fl.:ls"t aresignificantiy iit.. :'"':.;#:.1,1d"',T#,ffi

lv to o""u. i.,-fi#'r:.ffi::

and mechanicalryr"riilated,and ar rJ*ir.ijriile abnomal ,tntubated nNa etlt'Ji5i' plemenrs,. bicarbonate, jl,I:o"ii.,i" !1.1. .*_.I.""jp"*,i'"'*li:i Y'jlji and po_tas,sium j1;tf,:li:.IriyiiltlT:l*y.1*:* r*.p, r..i ;:.:11t-"t'*ho supdeveloped recovered"piJ[y. il;i';::::j' nnos, "rr-p"ii.ii, ***rd.j*li"'iilii:i:I":i#ii:ky;itil flfff:ff::il*' J:: ilil':,H:T$' L:.lg'lfl:,:*"'".,""t-'lT'"i I|XieilfJ,*,i:::*'"*:'*::,::':,ii.il';A*';Til:[','"? 'r3il.l;Llir.i,li ;'*l,tru"H,r,.-,"1'iil._",.,i,,,".,jT1',,xff

myocardial contusion.

ffiffifr#gilr*,l*: ^rrtn atrwey management rs crucial for


Medicine,and EmergencyDepartment,Humana Hospital University,Louisville Subacute carbon monoxide poisoning is commonly misdiagnosed as an influenza-like viral illness. All patients presenting to the triage nurse at University Hospital with flu-like symptoms during February 1985 were asked to give blood samples for carboxyhemoglobin determination. Fifty-five patients with headaches,dizziness, nausea,vomiting, diarrhea, weakness,general malaise, or shortness of breath were enrolled in the study. Carboxyhemoglobin levels ranged from zero to 2l%. Thirteen patients 123.6%l had carboxyhemoglobin levels > l0%. There was no statistically significant difference in carboxyhemoglobin levels between smokers and nonsmokers. Patients using wood heat were more likely to have elevated carboxyhemoglobin levels than were people using any other form of heating (P < .051.No patient with i carboxyhemoglobin level > l0% was diagrrosedas having subacute CO poisoning by emergency department residents or attendings. Funduscopic examination was documented on 6 of 13 patien6 ,.46.1%lwith COHB levels > l0%. Red retinal veins or flame hemorrhages were not seen in any of these patients. We conclude that subacute carbon monoxide poisoning may be a significant cause of flu-like symptoms in an inner-city population during heating months, and should be included in the differential diagnosis of patients presenting with flu-like symptoms. Further studies are warranted to determine the benefit of routine carboxyhemoglobin screening of all patients with flu-like symptomatorogy.

their survival without sequelae.Adequate airway management of victims on the scene might have saved lives.

127 Rewarming in Hypothermia: Radio Wave Versus Inhalation Therapy in lmmereion and AB Ambient Air Hypothermia llodels JD White, of Emergency / Department RCNucci,C Johnson Butterfield, of andSchool Laboratory Experimental Surgery Medicine, UniversityMedical Center,Washington,DC Medicine,Georgetor,vn Anesthetized random source dogs were cooled by refrigeration (3'Cf to a stable core temperature of 25"C, and subsequently rewarmed with warm humidified inhalation {43'C, 450 cc of min ventilation/kg), or radio frequency induction hyperthermia (4-6 watts/kg). The mean time required for core rewarming to 30"C was 231 + 23 min for ventilation and 106 + 32 min for radio wave therapy (P<0.011.There was no tissue damage with either protocol. These data suggestradio wave heating is superior to warm humidified inhalation therapy for core rewarming of accidental hypothermia. Anesthetized random source dogs were cooled by ice water immersion (l'C) to a stable core temperature oI 25'C, and subsequently rewarmed with warm humidified inhalation (43'C, 450 cc of min ventilation/kgf radio wave induction hyperthermia (4-5 watts/kg) or both therapies simultaneously. The mean time required for core rewarming to 30"C was 262 + 29 min for humidified ventilation, 58.5 + 6 min for radio wave therapy(P<0.01[ and74.8 + 12for both therapiescombined {P : .29 versus radio wavel. There was no tissue damage with these protocols. These data suggest radio wave heating alone is the most rapid noninvasive method for core rewarming in immersion hypothermia.

Poster Presentations

128 Evaporation ver$u$ lced Gastric Lavage Tteatment of Heatstroke: Comparative Efficacy R Nucci,C E Riccobene, in a Ganine Model JD White, Johnson,AB Butterfield,R Namath/ Departmentof Emergency Medicine,School of Medicine,and ExperimentalSurgery LaboratoryGeorgetor,vn UniversityMedical Center,Washington, DC This study compared the speedof cooling and efficacy of treatment for evaporative cooling versus iced gastric lavage in a canine heatstroke model. Nine random source mongrel dogs were anesthetized/ shaved, and internally heated until core temperature reached 43.0" C. The animals were then randomly assigned to be cooled by iced (l'C| tap water gastric lavage(n=5, 200 cclmin) through a large (32-F)orogastric tube, or by spraying with tap water (n=4, 15'C, 2 L/minl before a large fan blowing air across the dog 10.5 m/sf. Temperatures were monitored by thermocouples in both tympanic membranes and the pulmonary artery. Blood pressure, pulse, and cardiac output were measured every 5 minutes. Evaporative cooling was over twice as fast as iced gastric lavage (for pulmonic artery 85.8 + 12 min vs 35.5 + 3.5 min, P < .006, for tympanic membrane, 79 + 16 min vs 36.5 + 3.5 min, P < .011.Animals in the treatment group also experienced a quicker and more complete retum to baseline cardiac indices than did the lavege-treatedgroup. Moreover, all animals treated with evaporation survived and were neurologically intact 48 hours later, while only one lavage-treateddog was neurologically intact over the same period. The others in the lavage group died I hour after cooling {n= lf were grosslyataxic (n= lf, or were persistently comatose (n=2). A simple evaporative cooling technique readily available in the emergency department appears to be the most rapid and ef{ective means for cooling and treating heatstroke in the dog.

ED Experience with Sudden Death: 13O JJ KSHoldren, A Survey of Survivoro GA Parrish, OA Lumpkin / Departmentso{ Emergency Skiendzielewski, Medicine and PastoralCare, GeisingerMedical Center,Danville, Pennsylvania The ED encounters victims o( sudden death frequently. The interaction between the ED sta{f and the surviving family members is critical in the subsequent grief response.This study was undertaken to assesssudden death survivors'perceptions and satisfaction with their ED experience, as well as to identify potential weaknessesin their management. Charts of all patients who expired iust prior to arrival or within the ED between fanuary 1980 and March 1985 were reviewed. The closest available relative of each of 56 families was surveyed by telephone interview regarding the care they, as survivors, received while in the ED. Partici' pants were asked to agree or disagree, on a graded scale, with statements regarding their satisfaction with the maior phases of ED care, ie, arrival of the family, the waiting period, notification of death, viewing the body, signing the papers, the concluding process, and follow-up. Overall 47 of 66 l7l%l were satisfied and felt the ED staff did a better than averageiob of managing their grieving family; 19 of 66 |.29%l fek their family received average or worse than averagesupport. Areas of frequent dissatisfaction were identified: lf the family's unawarenessof the patient's condition during the waiting period; 2| the inappropriate manner in which the family was notified; 3f unanswered questions about the patient's emergency care prior to death; 4f lack of appropriate follow-up. 37 of 66 participants (56%| viewed the body in the ED. 32 of the 37 did not regret the procâ&#x201A;Źss; howeve4,only 27 would recommend viewing to someone in the future. Of the 39 who did not view the body, 7 had regrets; 32 did not. When questioned about the attitudes expressedby the ED staft,7O7"of participants felt the staff was reassuring 30% disagreedi 78T" felt they were warm,22o/o disageed; 83% felt they were sympathetic, 17% dis'

129 Carboxyhemoglobin Lerelr In Patlentr GH with Ffu.like Symptom. MC Dolan,TLHaltom, of Emergency Barrows, CSShort,KMFeniell/ Departments Medicine and Pathology,Universityof LouisvilleSchool of

50


agreed;88% felt thev were calm and collected, l2Zo disagreed.We conclude from our ii-it"A gro"p-ifr", -"r,-f"_ilies of sudden death patients were reneralli- r"tirfi.a-"ritl"thJir no experience, impactiig tnuor"tty ."it.'i,rrri"ii"n of lj:t:T-.bly rng process. specific procedural and emotionar their griev_ stiiis ie.a rmprovement.

!9jf -fn"_Lirera_rureof Emersency ilediciner A j 6ipart,i6nt. Gitation Analysis aw smitn orcrirical

Medicine,SUNy Ujstate [redrcat Center, :.9j^"-"ld uyracuse,fferqgncy New york .The development of emergency medicine as a scientific discipline is demonstrated in part'by ifr.-p"Uii"rri."-of several prima_ ry iournals. On the othe; hana, "-irg.""y *;icine remains a multi-disciplinary, specialty, *itit t.re"?"t lr irt*.r, ro emergency physicianspublished in a variety of medicai specialty ;oum1b.

p-::,|9f jT:rf jli1,l*r 3 citation;"ry;i;;I;; source ioumars, Anna6ol Emergencv Medicine, Ameficanlournalof riersiiii

Medicine, lourna! o1 E^"rgency Medicine, Critical Care Medi_ cine, and lournal of Ttauma, *", performJ nfi "i,ril", Ui thesefive journalsduring l98i w"r" i;il;-tA ,rra cited foumals y_._t:1i+.d,by freque-ncy of citation Uy tf,LG [.r-rt.. To com_ pensatetor the size of the iournals,an impact factor was calcu_ latedbydividing the frequency;i;ffi;6ii,i'r,,r_u". of cita_ ble articlesduring 1983i-a t6ei, il;iljil;als wereranked by impactfactor.-To"o-p.rrr"i.'foi ,iil'"iJ "r ,'ioumal, recent citationsof th_e-ioumals weretabulateJ"rrt "" i_i".ai"Jy i"-J"* wascalculatedbv dividing-th"""-U Jr"J.ri^citatiorrs ly tt. numberof citabli articleJdurin! t983aii'ffi;;ira ,t. iournals wererankedby immediacyjndei.The t"p f*" il"-"ls rankedby immediacyindexareAnl EryergM"d, ir;; i;;;Ir";,i Tyr;;;,

Med,Circstock,_fr p"si lm I .Emery "r fu"i,-e"Lrtn A"olsCi, io\owl.Emery M9d, A Ci;:;;;;.". rheselists *,':!!:'frf mrght serve to make decisions

about what ;oumals to incrude in an emergencymedicine library about what'loumals ;-;;;t;;

;filXfl;l;:,and

whatiournals"".;;A;;

piysi"i,,, _ight

Compurer.Assisred ED Charr Audit Dr 132 rtgn./_Departmenr or emergen-y utedi";;;, Witi;, Beaumont !,ve Hospital,

RoyalOak, Michrgan . Computer technology offers.the potential to increase produc_ tivity of quality "ssrri"n"e .rtortr.'!1i.-pt!reit^a'merhod for a micro-computer assistedemergency dlpartment chart audit which numerically and gaphicat"t dei,i"rr?J r"*marizes data. Charts are audited daili aird ""Jpiiir". .itir"#criteria is as_ sessed.Results are tabulated ;;tht ;'" "oirpu,., ^i-tz-a" ,,spreadsheet" using an IBM-pCo "o*prrt.i Lj i*", software. Results are tgbulated according t. gp""ifi" a".ficlncy on the y_ axis, and individual nhvsician"on tff i;;:-T;,"fi.rg ,fr. J"L along the -Y-axissummarizes the performance of the entire department for each criterion. Totaling ;h" ;;t; iiorrg tlr. X_"*i, summarizes the.overall performancJof each physician. Thus a quantitative profile (averige deficiencies p.i "fr'"if i. maintained lor eachphysician and thJentire a.p"rt"i*l iI.'roft**. "o__ bines monthly spreadsheets.to yield'yeaitolJ"*'i",r, and gener_ ates a variety.of gr-ap_hics, allowing uiJ""t ,.pi"rl"t"tion oi p-erformance. Specific deficiencies or irends, "i[t "i-lv i"aividual or cepartment, are thus easily,seen.W-ehave fo,lrrd iire-r,r.eof graptr_ ic peer compalrson.feedbaik luisurrffi-p-"irig iir-. qr.r,, ji1"1iu" pertormanceof each ohvsician to his/her peers on a nionthly arrj

in EMS EJ Otten / Departmentof EmergencyMedicine, Universityof Cincinnati The.most neglected -areaof formal resident education is in the area of emergency medical services. r,r".ry io.-.. residents have echoedthis in requestingassistancei" sJttirrg'up or administer_ ing EMS syst.*j after iompleting ,ir'.iil.ria"""y training. In order to addressthis problern we t i'". i"rtit,rt"o a program start_ ing from day one of resident tt i"i"g-th"t-ori"-"i, tt. resident to the various components of the IME syr,"_ ta over the nexr tour years makes him/her an integral part of that system. During orientation, the first-ye.arresideit is given thiee orre-hou, lec_ tures covering basic conligurations andiyst..n. a.rigrr.. ih" r;_ dent is assigned to one oT 30-paramediJ ";i;; i" our area along with a senior resident who has t*o to ifrr". y"r., .*p.rr.rr"" rs expected ro Fal unit. During the firs.t y""r, tt. i.rij.ir, l,vitl participate in EMT training disaster exercises ,tra ".i,r"L *r* with his unit. The second-yiar ,.rid;";r;;;;"ven an eight_hour course.atthe beginningof the.yearstrerrirrg "3_munrcations and

rear resident i s respon"s i bre f", ;;;;;;;l; lj,ii*-ll :, f ,c!l{ rcremerry cans ln the emergency

department. The third-year iesi_ dent is.assignedto the rmdgenly tirr"ri.iiilrpinse Team at the beginning of the year and is an integal p"rt of?. di."rt.rlUr,_ ning in the area. Borh second_a"dtt ii+ye"i .esia.rrts "r-eie_ quired to attend flight physician ori""t"ti.r'" ""i are.e.rcorrraged to participate in the air ambulance proâ&#x201A;Źram (at least nve runs per monthf. The fourth year contains " f6""*lr.t "ourse director of prehospitai ."r. "rrJ i"J"a.rlr"i"i"g'r.qrr,r._..rt with the fo, EMTs, quality assurance-, research,efrlS fii.i"i"re, administra_ tion, financing rechnical "o*porr.rrir,- "rrJ-tJgi;t"tion with re_ f 11:"lll:^9t1r,,"tplanning-andhazardous"materiatresponse ls also covered. Throughout al] leru years weekly "o"f....""., touching on various "rf."t, of EIvIS "ri" gi"." ,"a residents par_ ticipate with EMT:A ""d EUf=p tr"i"*g i,'rfr. irr,,ue..rty ". *.ll as with their ,,own,, assigned "nit. fh'is c"iii""f"* gr;;;;: quate exposure to the EMS system and ensures that thi resident will become the complete emergency physician.

prospective Evatuation gf Inftight Medical !34 Emergencieb on commeiciir-iiriirilJ ci speizer, cJ prelol / Department ot rmerge;ctii-i,",n",HarborlTnj",.H UCLA Medical

Center,Torrance,Califoriia Over 50 billion passenger-milesare flown each year in the United_States by commercial airlines. elthl"gi ,iu.."f maior airlines.claim approximately 2-j iild*; p* i'irtiir. p.. year,the true incidence, type, and outcome or infiighi-m;aiJ"f .;;;g;;_ cres have not been studied previously Oe$ite the fr.f. the Federal Aviation Administratio" h", ,;;'.;i;'propos.d oia?tr, , ,.g_ 'ro ulation requiring commercial pf;;;;;irji;;; "rrry .r, "*_ tensive emergencymedical kit. To eximine the magnitude of the *.tl as the, pote"ti"l rppi;-;ii;r,.'"r,i pj:lt_.:^T r.q,:ir._.nt, ror â&#x201A;Źny e.mglsgncy medical kit, we have undertaken a study to evaluate inflight medical emergencies.I"nrgfrt ^.ii""f "*.ii""_ cies were evaluated among passengersarrivihg at Los Angeles International Airport (LAX) from Sctober ,f,r'o"g[ December of 1985.Evaluation *"i r".iiit"i.a ty ;h;;ilililil patients re_ quiring more than minor medicar i"r. *"t. tri"g.i to orre Emer-

(EDl.All.Eq LAx first aid st"tior,]-*a p"r"_.ai" 9::^Z records?:f. were examined. The

age, sex, chief compiaint, dluration oi inflight.symptoms, any MD ;s;is6;;; ausr.-,iG and outcome were tabulated. There were 4,400,000 at LAX ;*r;il;;;.vals

,!g.:rydyperiod.rr+

ffi;::#i',*:':L::.1,tru*t#i:*1*.li:::iex$i:

odologyin many of our ou and can easily be amended ,.i -.oi"air]i""i"""*a" emergencydepartments.

133

of various

Gurricutum lor Training Reridentr 5l

d;;;'1"p.;'-.dical

!y'l"g inflight (l:39,000f. i"ss.n!e.i com_ p,laints 5ti patieits h"J .t;;"_s tor more t h9l. Only 9 patients (8%f had infl'ill't physician llt-1i as62 patients required only iirst aid staii,ontreatment :111,": or srgnectout againstmedical advice.52-patients were triaged to the ED; ll were admitted t" the hosfiial;i;h;";;;riti"-r.*ri"i (one a delayed death from a cardiac ,rr..lr"ff.r.Jln the ground at the airport and the other a d.hyJ J;;;-?;;; intracranial bleed with a respiratorv arrest thai ;";;;;; ;Jte to the ED). Nausea and vomiting, chest pain, and loss of consciousnesswere


the most frequent complaints and together accounted for 50% of all inflight emergencies. Only 2 of the ll4 patients would theoreticaliy have bJnefitted from the drugs/equipment likely to be ""iti.a iit a comprehensive emergency medical kit, and then only *ittt ttte pr.t"tti. of a physician.-Weconclude that, while inflight medical iilnesses occui more frequently than believed by airlines, true emergencies are rate. Most bf the illnesses encountered did not requiri advanced medical treatment. The rarity-of tru.e inflieht medical emergencies and low physician availability bring inio question the binefit of any comprehensive medical kit in airliners. Further study is needed.

Profiling Aeromedical Sewice 135 Perlormance Using Therapeutic lntervention JR M Bowman, RGCornell, Scodng KJ Rhee,REBurney,

Phase

Mackenzie/ Divisionof CriticalCare EmergencyMedicine, Deoartmentof Medicine,Universityof California'Davis;Sectionof EmergencyServices,Departmentof Surgeryand Departmentof Biostitistiis, Universityof Michigan' Ann Arbor; and Sectionof EmergencyMedicine, Universityof Wisconsin,Madison There are currently no evaluative measures of hospital based emersencv aeromediial services (AMSf which can be used to examini performance, iudge elficacy, permit comparison, or es' iabish siandards. By'creatlng a therapiutic scoring index and apthat a flying it to three programi, we-tested the hypothesis proprofile of the intensity and complexity ot hosprtal servrces vided patients in the first 24 hours after-transport can be used to evaluale and compare AMS programs. The Therapeutic lntervention Scoring Systim {TISSl,-wiih minor modification, was first used to "otip,tl. intensity of services in the first 24 hours after transport at two university hospital AMS programs on 247 conr""rrii.'" patients during seven flight'months. The, appropriateness of each flight was independently clas-sified,without knowledge of the'fiSS score. Thi statistical techniques of error reductioi, variance reduction and entropy reduction were used to compare the results of these independent assessments,and to "t"ti. " TISS index with three appropriatenessgroups which could be used to compare program operations. AMS transport was aooropriate tor 99Y" of pali.ttts with TISS scores greater than or eqir"l'to 30 (Group I| anh for 670/owith scoresbetween 14 and29 (iroup II|; 7SZ *ittt scores less than 14 lGroup III| were inappropriate."This index was then applied to 715 flights from three hMS ptogt"ms with the following results: AlrS Sorvlce (N)

TISS Apprcprlateness GrouP ll I

ouired for scoring. Values for these factors are proportional to weigh"tsyielding RAPS {rom 0 (n9n9alf to 16' HeliipacuE-Il "oot., tr"nroottid piti.tttt io University Medical Center (UMC) *"-t. t"ot.a Lting inlormation obtained before transfer, on arrival "furur-C, followilng one day of hospitalization a1d worst values obtained during the first 24hrs at UMC. APACHE-II scores were also calculatedexcept when complete data-was unobtainable, ie be{ore transfer. The iverage RAPS score before transport was 8'4 {57 oatientsl for those who died, 2.5 l2l7 patientsl for those who survived to discharge,and 5.7 {13 patients} for tho-sewhose status *"s ,rttkno*tt. (U;;g these groups ANOVA-differs at a value P<0.011.Logistic regreision revlals that RAPS has significant Predi"iiu"'potu.t for riortality. (Chi'square=88.44, df : l, ?<0'0ll Linear rieression demonstrates a sigrrificant relationship between RAPS ani APACHE-II for similar phases of care {Thble}'

lll

UMMC

(203)

45%

36%

18%

ucD

(u7')

46%

30%

24%

uw

(165)

44%

32%

24%

TISS program profiles for these AMS programs were remarkably similar, iespiti marked variation in programs organization and other functional characteristics such as proportion of scene trauma flights. This method of evaluation deservestestinS more tuia"ty""r a means by which AMS programs can be compared and evaluated.

Observatlons

R

R2

P

0.54

.01 01 01

lnitialUMC

236

0]4

Valuesat 24 h

208

0.71

0.51

Worst UMC

225

0.86

0.73

ilethemoglobin Levels Following 137 lntravenous Lidocaine Administration LDWeiss'

T Generalovich, MB Heller, PM Paris' RD Stewart' DR Thompson / Departmentof EmergencyMedicine' Mercy Hospitalof Pittsburgh,and Center for EmergencyMedicineof Western Pennsylvania,Pittsburgh Recent reports have implicated lidocaile and.related local anesthetic agents in the production of methemoglobinemia in patients. Lid"ocaineis noCan oxidant and the proposed mechanism of producing methemoglobinemia in these cases is unknown' Thire aopeais to be a cluse-and-effect relationship between the of these drugs and the appearanceof toxic meth,J*i"ir?i"tio" emoglobinemia. To date tliere is no clinical study that determinJs whether methemoglobinemia should be a cause for con""itr "ftet routine admin'istration of lidocaine' We designed a study to determine the effect of lidocaine loading-and -mainte,r"r". ot the levels of methemoglobinemia found in fifty pati"rr,r, ,o-. of whom were taking nitrates and other drugs known to cause methemoglobinemii. Patients were included in the study who presented to the emergency departmentduring an ischemic episode with an indication for the use of lidocaine, either as prophylaxis or treatment of ventricular ectopy' Any pa' tient who hai been given a prehospital loading dose of lidocaine was excluded from tlhe study' Patients were given a loading dose of lidocaine hydrochloride, 1.0 mg/kg IV bolus, started on a main' tenance infusion at 2.0 mg/min "ttd givett a second IV bolus of liminutes after the initial bolus' The Ildocaine of 0.5 mg/kg-was adiusted according to clinical needs' infusbn -"int"tt.o"" Nfethemoglobin level were drawn et 0, l, and-6 hours,-and lidocaine leve-iswere drawn at I and 6 hours. Lidocaine administration did not significantly change methemoglobin levels in the 50 developed either signs of lidoDatients. No patient in the study'methemoglobin' Routine deteror toxic levels of taine toxicity'methemoglobin levels is not necessary following mination of lidocaine administration.

Oxygcn Endchment of Bag'tlask Units 138 During Positive Pressure Ventilation / R Morton RVDeMichiei, RMKaplan,RDStewart, f Cam[Oett,

Use ol the Rapid Acute Phydology Score 136 (RAPSI to Analyze the Phyelologlc-al Status of of Emergency CJFisher/ Division Patients KJ Rhee,

Center for Emergency Medicine ol Western Fennsylvaniaand Departmentof Surgery Universityof Pittsburgh Bag-valve-mask units are frequently used to provide p-atients with"positive- pressure assisted ventilation. To increase the per"""i"!" of oryg.tt delivered (FpO2f from the bag -supplemental tttntt LI provided via'an orygen inlet nipple attached to ;itg; the ?evice. we studied the effect of sJveral variables on the FpO2 to determine the most effeciive reservoir that ""a "tt"-pr"d *o"n proila. the highest percentage of orygen delivered from

Medicine,Universityot CaliforniaDavis Medical Center, Sacramento The Rapid Acute Physiology Score (RAPSI was developed to quantitatively analyzethe phiiiological status oI patients during diffet.nt phaies of patient iransport and hospital care. RAPS was then compared to patient outcomes and to the Acute Physiology and Chronic Health Evaluation Score (APACHE-III. Only values that are routinely available on all transported patients,-ie pulse, blood pressure, rispiratory rate, and Glasgow Coma Scale, are re-

52


the ventilating port of the bag. Ten volunteers used a standard Laeroalbag-maskunit to ventilate. a test lung under the following conditions: l. a l5 L/min oxygen line withorit ieservoir, 2. a lS Ll min oxygen flow and a l0O cc and 400 cc corrugated t,.rbe-ai tachedto the r.eserv_oir port; 3. a 2.5 L bag,.**ou at l0 and 15 L/mrn oxygen-lln€ilow, 4. a demand valve attached to the reservou lnlet ol the unit. Measurementsand calculations _bag-mask were pertormed tor each technique at the end o{ 2-minute trials at ratesof 12 and 20 ventilationi/minute, compliances of .l and and,slol (4 sec)bag refill time. fi," t ish*, i;d, ;9l"1id yptd lr.uul was reached with use of the 2.5 L reservoir bag and"th6 demandvalve method. Varying the_ventiltory raie caused a significant (P<.0S1difference in- FpO2 at a lOil;in oxygen line !oy.-.FpO2 of .78 at 20 ventilatJrs/ini",-.CTlil;t., of rulrrrtn. Refill time,signific_antlyaffected the FpO2 *h;; ;; reservorr was slow {4 secJrefilling,. .41 during rapid {p<.05). lt^.-l.^1j ,ol"l]g Lorrugated tube reservoirswere found to be more sensitive to variancesin ventilatory technique and oxygen flow rates. Refill_ q*icutarly effect the FpO2 produced by corrugated ::fl^,]T",r tuDes.I h-e-tUUcc tubes produced an FpO2 of .gZ with slow iefillrng and .Jt rvlth rapid. (p<.05) The 400 cc corrugated reservoir an fp02 of 1.00 with.slow refilling and.l0 with rapid. lltoy9g Attaching the demand valve ro the".eservorr port of the lP:..Osl Dagunrt consistently produced FpO2,sof l.@, and had-the added being.easyto.artach, compact, conserving of oxygen :.:Ill_:rq:,"t audible rea^ssurance o{ proper iuncti oning :lLpil-ii1 f,1""iding tnat was rndependent of oxygen flow rates and vlntilation techl nique. On the basis o{ these findings we would recommend that corrugatedtube reservoirsnot be u;d, since they are sensrtive to vanationsin ventilatory technique and cannot aiert clinicians to wrth oxygen flow. While both the 2.5 L bag reservoir llo,o,,.*r ano oemandvalve givc a consistent FpO2 of 1.00, th1 demand advantagesof audible. filling of the ventilating bag :il.:^*"-.-,i:,berng compact and totally independentof ventilitor| ::1l1l.i: recnnlque.

in AdutrsFoilowing !I9 .O5vsenDesa_ruration Inhafed Bronchodilalor

Therapy JR Hedge.s, J cionni, JT Amsterdam, S Embry./Department otEmergenCy Medicine, University of Cincinnati MedicalCenter,and De-partment of InternalMedicine,ChristHospital,Cincinnati Following bronchodilator therapy in asthmatic patients, a fall in arterial olygen concenrration (paO2fhas been atiributed to irrcreased perfusion of persistently underventilated areas. We used continuous noninvasive transcutaneous oximetry to measure oxygen saturation for evaluation of the extent and timing ot 5aO2 decrease.QaO2), We also examined the effect o{ supplemental o.xyggn upon these {actors in adults receiving inhaied bron_ chodilator therlpv fior reactive airway_disease.Baseline ""d ;;;l orop ln sa(Jz atter completion of the first bronchodilator therapy were measured using a time averagedmethod. .fhe perceni change in SaO2was defined as: 100 x (baselineSaO2_peak drop SaO2)/baseline SaO2.A total of 47 patient visits were-siudied;lb patients rec.eivedsupplemental oxygen. Mean age was 3g + lZ.9 yea^rs,baselineSaO2=94.6 ! 2.96/",peak droipSaO2=!1.{ + 3.4"/", and percenrchangein SaOr= 9.4 t Z.SW^. The iean time to peak drop was 24.4 * 15.4minutes in the 40 patients with an observed drop after initial treatment. Comparison of pati."i uir_ its treated with and without oxygen is shown (fablef fhe absolute change in SaO2from baselinE was significant boih *ith "rra without oxy€en (P<.05 and p<.01 respectively).The group recerv_ ing oxygen had a significantly smallir p..".rri drop"and'a larger proportion-of patients showing no drop in SaO2.A simil", tr.lrrd was seen if patients >51 years were eicluded. bhnically signifi_ cant oxyge_ndesaturation can occur within 30 minutes oi infraled bronchodilator the,rapy.Supplemental oxygen 1i_Stlmin; tretps blunt the bronchodilator induced drop in SaO2. wathoutOxygen (N:37) Age 35 2 * 15.5

SaOrb *

95.0 2.7

SaO2t +

91.4 3.3

WithoutOxygen (N: i0)

no_fe^ of H_ypokatemiain Theophyfline -l-3,p_ sefzures Z Borok,

SM Schneider,DS Fraley,S-Adler/ Departments of Medicineand Medical emerg';ncyServices, U.niversity of.Pittsburgh,and RenalanO etectiotyteUnrt, Montefiore Hospital,pittsburgh Theoph,yllineis commonly used for treatment of acute exacer_ , oatronsot asthma.Theophyllinetoxicity may be complicated in *r" and animals by generalized seizures, usually at serum ,o^:l-1greater revejs than.20 pglml. Ivlechanism of seizure production is unclea{, bu-tone theory involves antagonism of brain adenosine receptors.tlowever, toxic levels of thlophylline are associated wltn-hypokalemra_,and. this could also potentiate theophyllinernoucecserzures.In order to evaluate a possible protective effect in theophyttine-i"duced'seizui"i,i. inf"r.a ny:l_\,T:lkl.-tl perkatemrcand normokalemic rats with theophylline through'a centralvein until grand mal seizures o.."rr.d.'iyp.ikalemic"rats werepreparedwith intraperitoneal Amiloride and potassium and naoa meanrnitial potassium5.29 + .47 mEq/I. Control animals recervederther Amiloride or poassium and hid serum potassium levelsof 4.AOx. .L7 and S.6Z = O.SO,l"rp.",i""fy'fp < .00011. Potassiumlevels dter 30 minutes of infuiion were 4.ll + .5g -Iq4l the hyperkalemicrats and 3.42 r 0.20 ane 3.51 + 0.J7 in mrq/I ln the control animals (p < .031.Ten hyperkalemic animals mean theophylline intusion oi';i6.;8-, 46.99 mg/ i..jr.^dj,,.l ? Kg.Amrlonde treated rats seized at Z8.4.SL+ 59.g9 mg/kg an:d potassiumtreated rats at 422.O4 + hO.ZZmg/kg. Ther; *rls ,ro significant difference in the mcan dose of ttEopiyilirr" required to produceseizuresbetween hyperkalemic "rr'Jiorrnok"i.-i" animals.Using regression analysis th.r. *"s ,ro correlation be_ potassium a.nd.m_g/kgof theophylline required to ly-.,..1 :"q* produce serzures.We conclude that although hypokalemia occurs thegnhrlline toxicity it-does not "pp";, ;;t;t a significant 1i! role rn the etlology of theophylline-induced seizures.

53

Age 48.4 I 21.0 -P<.01

SaOrb

SaO2t

93.3 i 3.1 tP<.03

*

91.8 3.6

16 of 37 with y" Drop > S% Time No Drop

Y"Drop 3.9' + 2.3

2 of "/" Drop 1.6" + 1.9

25.2 + 16.0 .t0

3 of 3Zt

with % Drop > S"/" Time No Drop +

19.7 9.0

4 of 10t

-Benificii|? I!1 _ts Gontinuous (rn.Line ilonitoring of Mixed Venous Oxygen Saturation A/s J^astremski, L Chelluri, R Bailly, K Beney / Department of Critical

Care and EmergencyMedicine,Health'sciencesClnter at Syracuse,New York Continuous measurement of mixed venous oxygen saturatron {Sfu2) has recently been introduced as a monitorliri ""a il;A;ment_technique in critical care patients. To determine the impict of Si02 monitoring on patient -*"g"-"rrr ".rJ cost effective_ ness, we_conducteda prospective, randomized clinical trial of nrnety-nrne consecutive patients receiving pulmonary artery catheters in the intensive care unit. The c6n'trol group (n:+d) received a standard Edwards quadruple lumen flowldi.."tla p"tl Tol".y artery catheter. The treatment group (n = SOfreceived'the Oximetrix Opticath; a flow-directed pilmonary "itery ""th.te. reilectrve tiberoptic g-xlme!ry for continuous monitoring L,t:t_1ng ot 5v(J2. Both groups were followed throughout their stay in thE intensive care unit. Data recorded includid ApAcHE ;J Tist scores,duration of stay,-number of catheter days, incidence of catheter problems and changes, number of blood gases (arterial and.v.enousf,and mortality. ^Ldditionally, ,h" ;;li waming,, ca_ pability of S-€2 monitoring ,nas an"lyieJ Uy "rrJpr.irrg tfr. ,"verity,and outcome of potentially adversehemodjrramic events rn Doth groups. Statistical review of data by step-deletion multipte regressio-nanalysis demonstrated that use of-the Opticath did not reduce h-ospital costs by decreasing ttre numUer of blood gases, hemodynamic profiles, length oi rcU .r"v or catheter


stance of miscategorized endotracheal intubation, the cuff on the tube had ruptured and no exhaled pCO2 was detected. It is likely that exhalition occurred around the tube causing this miscategorization. In the second part of the study, 37 patients requiring endotracheal intubation in the Emergency Department were prospectively studied. Immediately following intubation a iudgement of tube position was made by an unbiased respiratory therapist based on presence or absence of exhaled pCOz. There were 37 endotracheal and two esophagealintubations. All intubations were correctly categorized.The clinical part of this study is ongoing. In conclusion, the presenceof exhaled pCO2 accurately predicts endotracheal intubation and its absence predicts esophageal intubation. A small portable capnometer is available which can accurately perform this task in the Emergency Department and which may be well suited for use by paramedics in the field.

changes,and that there was, in [act, a significant increase in the number of problems associatedwith the use of this catheter (P < .05). It also was not associated with a reduction in potentially adversehemodynamic events, or mortality. Although continuous monitoring of S-vO2has been shown to be accurate and a reliable non-specific indicator of respiratory and hemodynamic function, it does not appear to be beneficial in all patients who require pulmonary artery catherization. More study is needed to determine if there is a subset of patients, perhaps those with high initial APACHE scores, that would benefit from this new technology.

142 Technique for Determining Proper Depth ot Oral Tiacheal Tube Placement in the Gritieally / Department of JRRoberts flf Aduft Patient MPSpadafora, EmergencyMedicine, Universityof Cincinnati We studied the position of oral tracheal tubes in eighty-three critically ill adult patients to determine if a distance measurement on the tracheal tube could reasonably assure proper tube placement without the immediate need to assesstube position with a chest x-ray. Fifty-two adult men and thirty-one adult women were included in the study. Data was obtained at the time of intubation by a check list which noted the measurement (cml of the tracheal tube at the corner of the mouth and the relationship of the tip of the tracheal tube to the carina on the post-intubation chest x-ray. The presenceof bilateral breath sounds and the measured distance (cm) from the cricoid cartilage to the tip of the xiphoid process were noted. In addition, brief notation of the patients neck anatomy was obtained. The mean measurement on the tracheal tube at the comer of the mouth was 22.2 cm {SD l.U in females and 23.1 cm {SD 1.5} in males. The mean distance from the tip of the tracheal tube to the carina, as measured on an AP supine chest x-ray was 3.45 cm (SD 2.1| in women and 4.13 cm (SD l.5l in men. Endotracheal tube position was deemed correct if the tip of the tracheal tube was 2 cm or greater cephalad to the carina on post-intubation chest radiograph. Forty-nine men ,96.1%l and twenty-six women (83.8%lhad correct endotracheal tube placement on the initial chest radiograph. If the measurement on the tracheal tube at the comer of the mouth had been corrected to 2l cm in females and 23 cm in males, the tip of the tracheal tube would have been in proper position for bilateral ventilation in 81 of 83 patients 197.6y.,p < .025, Chi-square). This study demonstrates the ability to reasonably assure proper tracheal tube placement in the critically ill adult patient. If the tracheal tube was positioned at 2l cm and 23 cm at the comer of the mouth in adult women and men respectively the tube would have been in proper position for 97.6"/" of the patients regardless of individual differences in extemal anatomy.

144 Comparative Study of Four Designs of of Emergency / Section K lserson Ankfe Spfints G Halvorsen, Medicine,Universityof Arizona,Tucson Ankle iniuries are commonly treated acutely in the emergency department by plaster splint immobilization. These splints do not always retain structural integrity as long as would be expected. Various plaster splint configurations have been suggestedfor the purposebf ankle immobilization, but their relative stabilities have not been tested. This study compared the resistance, provided by four different plaster splint designs, to plantar flexion, the moit powerful movement at the ankle. The designs tested were the: itandard posterior splint, posterior splint with a ridge, modified figure-of-eight splint and stirrup (sugar-tong)splint. Six healthy adult volunteers were immobilized in each of the to plantar splints. AIter a 30 minute drying time they were_asked f[ex, attenrpting to break the splint. Deforming forces were measured by a system utilizing a fluid-containing bag connected to a pressure transducer and monitor. The maximum plantar flexion achieved was measured by a goniometer. In all cases,the stirrup splint resisted breakage while the other designs deformed and broke. The mean maximum plantar flexion achieved by the six subiects was 43 for the standard posterioq,46 for the ridged posterior, 42 for the modified figure-of-eight and 13 for the stirrup. The mean force generated per degree of flexion (mm Hgldegreel was 1.9 for the stindard posterior,3.4 for ridged posterior,3.7for the modified figure-of-eight and 24.8 for the stirrup' The stirrup splint was proved to be significantly more resistant to deformity than the other splint designstested{p<0.0I by Duncan'sMultiple Range Analysis|. Since it provides stronger immobilization than the other designs tested, it should be the preferred splint in cases of ankle iniury needing plaster splinting. Halo SW Anmerman / west The Noninva$ive 145 Lake Village,California The continual search for the ideal cervical spine immobilizer has plagued every emergency trauma system for years. It is very alarming when one realizes that 25"/" of all quadraplegicsbecame neurologically compromised in the intewal between the arrival of the paramedics to the site of the accident until initial evaluation in the ED. There are many devices intended to adequately immobilize the cervical spine, however presently there is no device which allows the patient the protection from possible spinal cord disruption. It is common knowledge that during trauma evaluation multiple devices are utilized with the patient's head always being even to a minor deglee,rotated due to the substitution of one cervical immobilization device for another. By utilizing the sound and proven biomechanical mechanisms of tension band fixation in combination with medial compression the head is held motionless. We have developeda noninvasive Halo which can be applied in any emergency situation in literally seconds. This study was undertaken to establish the overall effectiveness of the noninvasive Halo. It is clear Irom the following data that the biomechanical principles when appropriately applied are su-

Exhaled PcO, as a Predictor of 143 SP Endotracheal Tube Flacement KSMickelson, Sterner,E Ruiz / Departmentof EmergencyMedicine,Hennepin County Medical Center,Minneapolis Unintentional esophagealintubation is a recognized complication of endotracheal intubation. If not recognizedimmediately it can become a life-threatening complication. Recent studies have suggestedthat the presenceof exhaled pCO2 may be an accurate predictor of correct endotracheal tube placement. A two-part study was designedto assessthe accuracy of a portable semiquantitative capnometer (Biochem Tri Med 510 Respiratory Monitor) in predicting esophagealand endotracheal intubations. In the first part of the study, l0l endotracheal and 103 esophageal intubations were randomly performed using direct vision on eight anesthetized, hemodynamically stable mongrel dogs. A blinded observer then iudged the position of the tube using ttre presenceor absenceof exhaled pCO2 as the only criteria. All 103 esophagealintubations were recognizedby the absenceof exhaled pCOz. All endotrachealintubations except one (l0O/lOU (99%l were recognized by the presenceof exhaled pCO2. ln the one in-

54


perior to any of the currently available cervical spine immobilizer devicesor techniques. The noninvasive Halo was compared by goniomitry to the currently most effective combination of devices for maximal cervical immobilization. .

Tapesandbags-Phlladelphla Collar 0.1 + 0.4

Flexion Extension Lateral Rotary

7.4 + 5.5 1.4 + 1.5 4.0 + 3.0

lmprcrrement Halo 96 Comparlson 0.1 + 0.4 0 0.4 + 0.5 375 0.1 + 0.3 1.5 + 0.7

140 267

The data clearly show that biomechanics when properly applied have a predictably superior result.

146 Glinical Use of the olecranon.tlanubrium Percussion Sign in Shoulder Trauma SL Adams I Section of Emergency Medicine, Northwestern University Medical School,Chicago Shoulder trauma constitutes a large proportion of orthopedic iniuries seen in the ED. Evaluation of shoulder iniuries includes the physical examination and often a radiographic series. We evaluatedthe utilization of the olecranon-manubrium percussion test {OMP}to assessits reliability when used in coniunction with the physical examination and radiographic examinatioa. g6 patients were prospectively evaluated by the OMP test. The bell of the stethoscopeis placed over the manubrium, both elbows are flexed at 90 degrees,and the olecranon is percussed.In the normal exam with no disruption of bony conduction, both sides shouldproducean equal crisp sound. ln the event of a dislocation or fracture with disruption of bony conduction, the affected side shouldbe duller in pitch and intensity. In those patients who had radiographicabnormalities, 40/47 l9l.l%d had an abnormal OMP sign. In those patients without radiographic abnormalities (contusions, sprains, Iigamentous iniuriesf, none had an abnormal OMP sign. In assessinganterior shoulder dislocations, ll/13 184.67.|had an abnormal OMP sign (P < 0.021.After relocation 1007ohad a normal OMP sign. TWo of 13 ll5.4o/4 had a false negative OMP sign. Of those with clavicle fractures, 9/9 ll}Oo/"lhad abnormalOMP signs {P < 0.0051.Of those with a fracture of the humerus, 16/20 l81y"l revealedan abnormal OMP (P < 0.011.The test was not significant in assessingacromio-clavicular joint abnormalities. Overall reliability of the OMP sign based on two observerswas 93"/". In the series, the OMP test never resulted in a falsepositive error, but resulted in a 15% false negative error. AIthough the presence of a normal OMP sign does not negate the needfor radiographicstudies, the presenceof an abnormal OMp sigr should suggestthe need for appropriate radiographic studies. We concludethat the OMP sigrr is a helpful adjunct to the physical examination of shoulder iniuries.

Pasternak,EP Krenzelok/ Affiliated Residency in Emergency Medicine and Departmentsof Pharmacyand Medicine,University of Pittsburgh,and PittsburghPoisonCenter We recently described the responseof a group of ten volunteers to a new protocol for the treatment of the nonobtunded overdose patient. This protocol is unique since activated charcoal is administered shortly after the use of syrup of ipecac. Customarily activated charcoal is administered a minimum of one hour after syrup of ipecac. Early results of a clinical trial utilizing this protocol are now reported. Ten overdose patients who fulfilled the entrance criteria for the study were administered syrup of ipecac 60cc via a nasal gastric tube followed immediately by tap warer 500cc. Ten minutes from the initiation of syrup of ipecac administration, an aqueous slurry of activated charcoal 50mg (250cc| was instilled down the nasogastric tube after which the tube was removed. Emetic response and time to emesis were recorded. Thirty minutes after emesis subsided a second dose of activated charcoal 50gm (with sorbitol) was administered orally. Emetic responseswere noted in all ten patients llOO%1.The patients averaged 4.3 emetic episodes. Emesis commenced in an averageof 13.8 minutes from the start of ipecac administration and concluded in an averageof 45.9 minutes. These results are similar to those observed in the earlier volunteer group. This protocol allows the early administration o{ activated charcoal while still preserving the emetic properties of syrup of ipecac in the patients treated. This protocol has been shown to be effective in both a volunteer and patient population.

Radiopacity of lngested Medications 149 DL Savitt, HHHawkins, JRRoberts / Departments of Emergency Medicine and Radiology,Universityof CincinnatiMedical Centei We prospectively investigated the radiopacity of 312 pills found on a university hospital formulary. AII pills were screenedfor potential radiopacity by first x-raying them through 15 and 25 cm of water to duplicate the radiodensity of the human body. The pills that were radiodense through water were studied in a human cadaver model and their density was quantified by computed tomography (CT| scanning. Thirty-five of 312 pills were radiopaque in l5 cm of water or greater and twenty-three of these pills were radiopaque when placed in the stomach of a cadaver. Common mnemonics used to identify radiopaque pills were found to be incomplete and inadequate. Chloral hydrate, iron containing preparations, calcium carbonate, iodinated compounds, acetazolamide, busulfan, and potassium preparations were consistently radiopaque.Antihistamines, phenothiazines,and tricyclic antidepressantsdemonstrated varying radiopacity. There was varying radiopacity among the same medications made by different manufacturers. The presenceof enteric coating did not assurethat the pill would be radiopaque. Merely x-raying a pill that has been placed on a standard x-ray plate will make pills that are actually radiolucent in the body appear radiopaque, and this test can not be used to predict radiopacity in vivo. Visibility when x-rayed through 15 cm of water or greater and a CT radiodensity of greater than 1300 Hounsfield units has prospective predictive value of the radiopacity of a pill in the stomach of a cadaver model on a standard KUB radiograph. Variables, such as the size of the patient, the arrangement of pills in the stomach, air contrast around a pill, the specific make up of the enteric coating, or the pill matrix affect the radiodensity of pills. A routine radiographof the abdomen which is taken in casesof coma or unknown drug overdose will have limited clinical value. A radiograph may be useful in confirming a diagnosis of drug ingestion or assessingthe efficacy of a gastric emptying procedure iI the specific medicarion has been shown to be radiopaque by prospective testing.

147 Use of Hyperbaric Oxygen in the fiieatment of Cutaneous Iectotic Arachnidism ftlom Brown Recluse Envenomation W pahts,J Box. / Department of Emergency Medicine, F Svenson University of Arkansas forMedical Sciences. LittleRock .';Cutaneous necrotic arachnidism due to .Loxosceles reclusa Sveaomation is a common and often disfiguring problem in the south$restemUS. There is currently no safe, effective treatment. .Casereports of 9 patients exhibiting clinical evidence of necrotic #-achnidismtreated with hyperbaric oxygen {HBOf are presented.

Nl rya dramaticimprovemint of lesioni afier fniO tlierapy.No dficant side effects from HBO therapy were noted. Long term ow-up is presented.Further investigation into a possible role HBO in the treatment of cutaneous necrotic arachnidism is

150 Glinical Utilization of the Ftexiou Extension View in Cervical Trauma AWGraveft, SP

Glinical Trial Using Syrup of lpecac and ed Charcoal Goncurrently GEFreedman, S

Sterne( JJ Vieira/ Departmentof EmergencyMedical Services, Ottumwa Regional Health Center, Ottumwa, lolva; and the

))


4

midline there was an average2.5 mm asymmetry in POS, while in those 5 whose SPC2was offset an asymmetry of l'5 mm ever"-. "l<irr.a. Unilateral Cl-C2 facet offsets of l-2 mm occurred in of patients and bilateral offset (medial one side i3 J-ei(ia3y") and lateral the otheil of l-2 mm occurred in 2 patients' We con"i"a" tttrt the utilization of the SLL does not accurately identify p"r["t"Sl. ihe spinolaminar line was devised to be utilized only in cases"of C2-i3 anterior displacement in children and generalization is not correct. We alio conclude that a wide range -of asymmetry can occur in the odontoid view in normal individuals.

Departmentsof EmergencyMedicineand Radiology,Hennepin County Medical Center,Minneapolis,Minnesota Use of flexion/extension motion radiographs (FEMRI of the cervical soine acutely to establish stability is controversial'To esi;Llith'the safety,efficacy and indications for FEMR in the department (EDf we râ&#x201A;Źtrospectively--reviewedI04 ra"-..g"n"y aio"ilottt'oUriined over a 6lmonth period' rEun views were obthe physician had a suspicionof instability, or to tairied^whenever evaluate unusual findings but not routinely. Seventy-sixpoint fiu" o.t".ttt were obtaine-dfor acute iniury (in the ED or at admisiion'to the neurosurgicalfloorl,9.2% for follow-up of recent iniury ann A3% for noritraumatiC proilems or old iniuries' All films o'btained in the ED were done under physician supervision, with the patient self limiting motion if pain or neur.ologic-signq aqo""t.d. General ""t"goii.t of radiographic findings for which itMR *m obtained iicluded localized subluxation (251,degener,tiu. pi"t disease(DJDI (221,fracturesor avulsions(11f,unstable atianio-a*lal ioint [S),artilact (4[ and abnormal position on later"i {zol-I-p.oiter posiiioning (chin tuck or lowering of mandibular position) *"j pres.ttt in a Iarge number of studies (307' of flexi"i, tly" ,reuttal views). Abnormal spine-positionsof kyphosis, reverse lordosis and straightening occurred frequently 145"/"flexion ui.wt, 3l% neutral iiews) [ad no correlation to muscular spasm, limitation of motion, or positioning.. New subluxations detection on t+fSl bn motion occurred at multiple levels and ilEUh altered management in 2 patiCnts by necessitating a Philadelphia collar (PC).The malorityof ED patients requiring PC immo'bilization (bltOl were readily noticeable on routine lateral xrav or bv presenceof neurologic symptoms and their manage-.rrt *tt not affected by FEMR. We conclude that the FEMR can assist proper management of patients with neck iniuries by ideniifyi"j p"tttotogy i"tt " small iubset and ruling out pathology.in The routine lateral view is, by far the most valu-6tl iiti."tt. able siudy but a FEMR should be obtained if any.question of abremains. Indications include casesof abnormal cer"ot*"lity ul""i potitio" (kyphosis,straighteningf,subluxation, presenceof questionableaLnormalities,and noted on routine lateral'

Spinolaminar Line and l{ormal Anatomy 151 SP of the Adult Upper Gervical Spine AWGravett,

Evaluation of cervicothoracic Junction 152 St Center, WRSciiller/ Trauma DHYoung, lniury CGNrcho/s,

.loSeptisHospitaland Medical-Center,Phoenix,Arizona;and Divisionof Traumaand EmergencyMedicine,TexasTech UniversilySchool of Medicine,El Paso Cervical spine iniury has long been recognized as a significant cause of morbidity and mortality in the traumatized patient' of the trauma Iiterature addresses-iniury-to the dt"-;i;.;ity cervicothoracic iunction (Cz Trf We were able to find only two ti"ai.r *fti"ft evaluated ti\e iniidence of C7 T1 iniury' The spinal iniury registry of St |oseph's Hospital and Medical Center and Barrow's Neurological Institute in Phoenix, Arizorta, was examined for cervical ipine iniury patients. Of the 397 patients with cervical spine inluiy 37 l9%l had cervicothora-ciciunction iniury' ifi. t."ota. of thesl patients were evaluated for signs and symptoms of neck iniury. All available lateral C--spineradiographs *.i. "u"tnrt"a for indirect evidence of iniury thiough the level of C7 as curreritly recommended in the trauma literature' Films *!t. r.ui"*"d a{ter being masked at the middle of the body of C7 uii"ril"i"e the C6-C7 luiction. We found the incidence of C7 T1 i;l"ty *i'h" ""*I""i ipine iniured population to be 9%' Nine of our fatients 124%l weie obtunded ind had uninterpretable neuAll of these were diagrrosedby radiographic rolofi" .*"-i"ations. evaliration. It is our recommendation that visualization of the through the cervicothoracic iunction be adopted as ""*i""i.p1"" the standard for trauma care.

Sterner/ Departmen[of EmergencyMedical Services,Ottumwa RegionalHealthCenter,Ottumwa,lowa; and the Departmentof Emlrgency Medicine,HenneprnCounty Medical Center, Minneaoolis,Minnesota TWo signs commonly used by the emergency physician in the evaluatio-nof the upper cervical spine include the spinolaminar line {SLLIand asymmetry of the laieral massesof C-l in reference to ttr. odo"toid'process. Although the SLL is used in the adult cervical spine, thi only reportedieries-arein-children' One-hundred and'seven flexion/eitension and 82 odontoid views were .u"f""t.a to establish normal values. Measurements were obi"itt.a fot the SLL in flexion, extension, and neutral' Odontoid by examining for CI-C2 facet offset and was assessed "rv--.t.V by measuiing the difference in ttre qaraodontoid spaces(POS)'In normal patie;ts 20/l0l {19.8%lof radiographsshowedthe posterior arch bf Cz {peCzl 1.5 mm or more posterior to the SLL in at l."rt orr. view. Ten dt tot (s.srl were more than 2 mm and 2Yo were 2.5 mm. In extension 3 measurements showed the PAC2 to be t mm anterior to the SLL. Of 6 patients with pathology,at the Cl-C2 level, 2 had PAC2 3mm posterior to SLL, one showed PAC2 2.5 mm anterior to SLL, 2 fill within I mm of SLL, and I was within 2 mm of SLL. Measurements of 3 or greater were associated with pathology but these were grossly visible on neutral film, and 3 abnormaliadiographs had PAC2 l-2.mm posteriorto Sii, a t"t g. found in man-y normals. In the odontoid view the spinous process o( C-2 {SPC2}was v.isible in only ll patients, making determination oi rotation dif{icult. X-rays with^knorvn pathol6gy were excluded from this group. Forty-five of 82 154"/"1 of patients had asymmetry of POS ranging frorn I mm to a maximum of 4.5 mm. ln those 5 where ihe SpCz was visible and

High-Yield Roentgenophic Griteria for 153 I JD White Gervical Spine Iniuries CGCadoux, University Georgetown Medicine, oi Emergency Department

MedicineCenter,Washington,DC All trauma patients undergoing cervical radiography -at 9n Yl ban referral teaching hospital emergency department during 12 conr"",rtiue months"ln:i49f were inalyzed for indications and ;;;;t,t of cervical spine x-ray studies. Demographic characteristics of the study "-ea.t Sroup were consistent wrth results ln tne age,26.7 yearsl.-Caseswere reviewed il*i"I".. ts+* -"1.s; accepted indications in the literature for cerioi Cz "o--only vical spine studils undtr these circumstances' The following xwere consideredas positive studies.:fracture, subluxt"v fi"[i"tt "iiotr, tpoidylolisthesis, straighiening spasm, foreign body, compt.rtiott, fuiion, narrowing, or soft tissue.swelling' Seventeen (P = 'Olf i.r""n, of *-r"yr'*"r" positive. Motor vehicle-accidents : of conloss and .Oll, trauma cervical lP I frirtotv of direct scio.rsness(P = .OU cervical tendemess (P = '05t and dru.gin' gestion (P : .081weie associatedwith or suggestiveot, positive xiays. Only 0.2 percent llS/749i, of radiographic examinations reu.rl.d "litti""lty significant findings, and only two criteria (cervical spine t"ttd.*6s., P : .O2,and cervical pain, P - '03| were associated with clinically signiiicant findings' Nevertheless,,.the low incidence of positive findings may have obscured otner nlSnvield criteria in bur statistical analysis. Indeed, stretification analysis indicates a data base of approxi?ately 10,000 patients *orrid b. required to reveal all statistically significant criteria' While our ttndy t.rgg.tts up to 4s oI x'tays could be deferred a clfiically tigttifi"rttt iniury the cost to bâ&#x201A;Źnefit *ui1fto"i -ittini ratio for performing a cervical ipine x-ray study following trauma

56


even under our department,s

current,

broad utihzation

pattems still is at least I in 3.5.and p".il;.;r-ild Jr'i in rr. While it appearsrhat a substantialnumber^of *d;";"pi; studies can be using high-yield, criteria, a liberil "pproa"f, ro cervical :lTlT*d roentgenographs is iustified pending confirmaiion of ou. i.r,rit, in a large,multicenter,prospectivestudy currently under wav.

!p!! _St_"9Woun_ds !_orle Abdomen: Faiture or g plgd i " t pLrit"i-"'iri Fenetrarion ! 31,:lll T:l iJI g nE tiosenthat, Smith,H

Chen, R Shesser,M Smith, R Walls,p Kline/ Departmentof EmergencyMedicine, eeorge -""'. Washington University MedicalCenter,Wasnington, DC' Properevaluation of penetrating abdominal trauma remarns controversial.This study attempti to define the uselulness of blunt probing for evalu.ationoi i"n.*"ii.,g'lUio,'i,rrr trauma. ren adutt beigles (8 to lz kg), ;";".;;;l;;";;ftiotal and chlo_ ralose,were sacrificed by veniricular fiUrifltio" foUowing a stan_ resuscitation protocol. I--.di;;;iy th;reafter, the ab_ 91rjt-"-:d oomen was shaved and. tâ&#x201A;Źn stab wounds '*"i" pfr".a i" tfr. abd,omenof each dog with " ,li ;l;;;.; ,.nar"r. individual probedthe woundsse-ouentiallywi,h;;;;;#; and predicted on the basis of the exam wtrether it" ;;il *rl a."p or super_ ficial. Deep wounds were defineJ ;.;-,i;;;;ating the parietal peritoneum. Following completion .iirr". .,."- the abdomen was.opened by a midline incision ,"d p..r;;;;ilenetratron was visually by two observers.Statistical analysis lgrfiea of data was performedusins the z test for binomial fropoitilis. Fifty_nine of the 100woundJwerefou

Danville,Pennsylvania One hundred sixtv caseswere reviewed, representing a total of five years of farm machinery accidents ,...r'lt our institution. Farm injuries tend to oc.cul.whe-n -r"ti"e.y i,,rsed in a manner thar is not recommen-ded_bythe ;;;-f;;;".. These studies demonstrated that So"/oof tfr" """ia."i, ;;;.r.; ;;;.ili;: ment in which manufacturer-ins-talledsafety snreldrng devices were removed. Further, in 50% of cases,farmers ^."i."pp.a were iniured as they attempted to remove.fo..ig" ."rt..i"f in the ma_ without completely ai.E"grgiil thJa'ilr" "t "i.r. Iniuries ."_li.Z trom.tarm equipment may be devastatiig due to the pr;;;;;

(snaprolls)o. ur"a'.,Jiooster combsl. De_

:iU.1y_,r1:11g._,:.,h tmpalrng, eviscerating,and amputating iniuries tlovlng, were documented in this senes. We ionclude tir"i *"riy fa.m i.r;urie, are due to improper machinery ,r" ""a-"." p..lrUiy p."r""l"Li.l Antishock -F"irr:f Trousers in 157- Use of pneumatic the^ Management ot peJiaiiii, Fractures DD

Brutrcfte,G Fifield,E Ruiz/Oepartmentr-olEr"rg"n"y Medicine and pediatrics,Hennepin'Couniy fr,fJllur Cent"l Minneapolis,Minnesota Pediatric pelvic fractures carr result in significant and mortality The immediate dangerin ","r3.. p.f"i" morbidity fracture is retroperitoneal hemorrhage. Stabilization and -.*'t".._.fy c6ntrol of hemorrhage secondary to a peliic fr""t"r. "r" il. difficult. Measure_s such as surgical .xploratio., arr-Jaiigiogrrptic embo_ lization have met with"varying d.;;;; J';;;..:s. The prolonged of the pneumati" "iti"f,o"k tro"r., for stabiliza_ :,^'IEll tron ot retroperitoneal hemorrhage secondary ipnrf to a pelvic fracture is basedon the principle that eitem"l pr.r!rr.. will ongoing_bleeding within the*peruir. w.'r.iiorplctivery tamponade the application of pediatnc pnf t. fi". y.""g"p".i.",s reviewed who had severepelvic fractures with clinical ,"d/;, ;;A;g."phic evidence of i f ican t retroperi toneal ^sign 19-"iif,"g..' tut?ri"p",,.r,, age was 6..8years.Mean duiation of pAT use *"1 SOtourr. the PAT resulted in stabilizatio" "i Ui.rJ pr.rlur. Utilization oI ".ra pulse in all three of the patients who presentedwitt urrsi"Ute;ttli;i}r;. rl the five patient" aia ,iot ,.t"i..,"v ir""rrrrions. Stable 3:, vrtal signs and hemoglobin appearedto be dependent on conl pAT tinued use of the Th.r..*...;"l."gi;;:;mplications of the use of the pAT in the three survivor"s in this study We describe a,techniquefor long-term maintenance of low pressure within_ the PAT We believe iarly "r. of tt pAi-as " describedto be in the treatment of significanl pediatric pelvic llel{ut ldiunct tractures.Further clinical studiesneed to'be doneio U.tt", i.fi.r. pAT

rx,a-i,,e,sp,eai;;;'#*:.:'.,ilT:T:;i::iT:Tt'dtil,,j:li.:#.

Thirty-eightout of 4l superficiai;il;;;; iorrectly identified;3 wereincorrectlv*rlt.a a."p. i."r]li"iiy":"'sg = t.432, spec,ficity:'.eB (z =-,.ie;," i";'b'oit. si"", lzprobing l_-_.1l an lnaccurate meansof determiningperitonealpenetration is of abdomina.l srabwounds""a ,no"ta'Ul'ffi;l;in coniuncrion with othermethodsof examrnatron!5.9

Wgund Infecrion Rate From Ooen

[il!tr1,t";3?;?i?.fiu::s,..,,s"*"i*uu'

Medicine,Universityof Arizona,Tucson Diagnosticperitoneal lavage(DpL) a procedure often performed "{ the evaluarionot,the trauma patient, is often performed Sflrt underminimal sterile conditions utilizing t# ;op."" ir"n"iq"g wnererhe peritoneumis directly visualiid. rhe-Lck of ,r.iil. techniqu_e would tend to predispose ,fr" p"i*",i., a wound intection. In order to assessthe infection i"t., tients undergoingDpL at,^the Univeiriiylie*."a" ..ui.* of all pa_ -flvo"iurra..d emergency departmentf rom I 9g0-I 9g3-was perform'ea. twelve patients were included in the study_Th;;; p;;;;";J aI had open DPL performed in the emergency depr.tm.l,i.-iir;r. were eight 13.7%linfectionsidentified.-ih.; ;;;;i;il.a ri,i. two sroups. fourpatients tr.szi i".l"i.a"r,,i".iiilr infections Sl: wnose9ry, treatment included locjl measure, Jrriy l*r._ .o"t., stitch removal,cutaneousdrainage). Maior infectiorrr, g.oup t*o (1.9%f,included those oatients *"fro ,"... ir."i.J*i,r, parenteral antibiotics, received a..o dr"i""i. ; ,'h;;;i'and had per_ sistent drainage.Two of'the patrents in Group Tlvo also under_

laparotomy.'Alr ;;;;r-h;ia i.,'uott soups. Xlll -.Tllo'1,o..y uroup one infections resolved usuallyi"G;;il;; irr..E-a"ir. in Group

Ttvo toox up to seven months for complete l^l,S,lf .:11,t_"1tThus, overall, diagnostic peritoneai-lavale performed frn the emergency department carriis to* ,i.t-Ef i"f."iir", (3.8%|and an even iower incidence , --"i.rl.-plications "f technique as performed in ihe emergency |19:/1l.]lus.the department in rrauma conditions has minimai _..UiJi,y.

ot Farm rrachinery

Injuries !99^.|,::l.Ii:T E Kapoor,M Indeck,S Brotman/ Geisinger MediJal Center.

:!-.:{ly"r tractures_

androleof

i" trr. ii."i-.riio?i.autri"

p.rl,i.

!q.8. In_travenousFtuid Ftow Beneath Inftared Antishock Trousers MJMuttin, J K;il;-r.:JB Mccabei Deparrment of Emergency Medicine,' WrijnistiL-in,uers,ty Schoot

of Medicine,bayton, Ohio Antishock trousers are claimed to restrict intravenous access and fluid administration during r.r;;;;;;;;"i" i,._"rrt "gi" shock. This srudy was designed"toa.a.r-i".-ifr" percentageof fluid which enters the "."trit.i..,rt"t,;;'?;iil; infusion in a peripheral vein beneath inflateJ ;;;fi;;k';users. Seven mo_ngreldogs were acutely bled to a ,yr,ofr. nil.a pressure of 50 to.60 mm Hg.,Antishock trouserswere then inllated. microcuries of Technetium 9S labeleJm".-"#.g"*a One to two albumin was infused into a peripherafvein in the hind leg. This was followed by.a t0 mllkg flurd borus. i-rr. ,ru"-'"iarticres which reached the central iirculation ;";;-;rrppJ'ir, 1"t,. p,rt,oo.,r.y capillary bed. Ten minutes followin! il'":;",'; i,rtt boay ,."r, was performed.The percentageof iniected fluid entering the cen_ tral circulation wai catcula'iJ b;-;;;;;;';;" counts to counts localized to the thorax.'Averaie totar body mean arterial was Ilt..mm Hg prior to bleeding,aT iim Hg prior to lJ:r:"1. shock trouser inflation, and 66 mm HE, eI"ierinn"ilo.,."ft," p.r-


rates and lower stroke volumes during the stabilization period. Serum glucose and lactate levels were higher in the ethanol group lThblel.

centage of IV fluid that reached the central circulation ranged from 80.5% to 99.6"/", with a mean ol 91.37". We conclude that a large percentage of IV fluids infused beneath inllated antishock trousers will reach the central circulation. [This research was supported by a Wright State University School of Medicine Research Incentive and ResearchDevelopment Award.l

Parameter

Ethanol

Conitol Baseline

Effect ol Antishock Trouser Inflation on 159 Oxygen Transport Variables During Hemorrhagic JB McCabe / Department of Shock in the Dog ttrtMullin,

sv

.0149(.oos)"

.0158(.0037)

.0039(.0015)

HR

152 (30)

140 (33)

189 (18)

97.5 (12.9)

116 (9.6)

3o4 (88.8)

141.9 (26.5)r

13 7 (6.7)

6.6 (2.8)

Glucose

2.0 (0.86) t ctate 2.3 (0.95) 'Mean values with standard deviations in parenlheses tP < .05 wilh Student two{ailed t test.

EmergencyMedicine,WrightState University,Dayton,Ohio Although antishock trousers have been shown to improve blood pressure during hemorrhagic shock, their effect on many other physiologic abnormalities produced during shock is unknown. The purpose of this study was to characterize the effect of antishock trouser resuscitation on oxygen transport variables during hemorrhagic shock. Eight mongrel dogs were instrumented for hemodynamic monitoring and were bled acutely to a systolic blood pressureof 70 mm Hg. The animals were stabilized at this level for 50 minutes. Antishock trouserswere inflated to 100 mm Hg and remained in place {or 60 minutes. Every 15 minutes during hemorrhage and resuscitation, arterial and venous oxygen content, oxygen delivery oxygen consumption, and oxygen utilization ratio were determined. Arterial blood pressure rose significantly during antishock trouser inflation, due primarily to a rise in systemic vascular resistance. Oxygen delivery fell from 643 to 165 ml/min during the acute hemorrhage, but remained constant throughout the remainder of the experiment. Arterial-venous oxygen content difference intially rose from 2.6 to 5.6 ml/min (P < .051,and remained stable throughout the shock period. Arterial-venous oxygen content rose significantly during the resuscitation period (P < .05f. Finally, oxygen utilization ratio initially rose from 18.4 to 40.7o/o(P < .05). It remained constant throughout the shock period, but rose significantly during resuscitation, reaching 58.5% by the end of the resuscitation phase. Shock trousers do not impair oxygen delivery. Arterialvenous oxygen content difference rose signi{icantly during the trouser inflation. At the same time, oxygen utilization ratio increasedwith shock trouser resuscitation. The antishock trousers may have a detrimental effect on the ability of tissues to utilize delivered oxygen.

Ethlnol Conttol 30 minules Post Hemorrhage .0Os6(.001)t 142 (21')1

Mean arterial pressures(MAP) were significantly lower in the ethanol group during the latter half of the stabilization period. The change from baseline MAP was -27.7"/oin the control group and -50.3% in the ethanol group lP < .05 using Wilcoxon ranked sum testl. These results indicate that ethanol impairs hemodynamics and elevates serum glucose and lactate in dogs during hemorrhagic shock. The effect of ethanol intoxication on the morbidity and mortality of hemorrhagic shock remains to be determined.

161 Preservation ot Hemodynamic Stability Following lleptazinol Administration in Ganine WGBarsan, SASyverud, Graded Hemorrhage SCDronen, SL Gin / Departmentof EmergencyMedicine,Universityof Cincinnati The potential for hemodynamic instability may contraindicate the use of narcotic analgesicsin multiply iniured patients, particularly if hypovolemia is present. Meptazinol, a potent analgesic with opiate antagonist properties, has been shown to improve hemodynamics in rats subiected to hemorrhagic hypotension. Studies have not been performed in other species.The purpose of this study was to evaluate the hemodynamic effects of meptazinol in a canine model of hemorrhagic shock. Conditioned beagles (n = l3l were anesthetized with pentobarbitol (25 mg/kg IVf endotracheally intubated, and instrumented with a femoral arterial line and pulmonary artery thermodilution catheter. Animals were then subjected to an estimated 50% graded hemorrhage (45 ml/kg) over one hour. Following hemorrhage, animals were observed for 90 minutes, then reinfused shed blood over 30 minutes, and finally observed for an additional 50 minutes. Six animals received meptazinol {17 mg/kg IV} 30 minutes after completion of hemorrhage and then 17 mg/kg/hr for the duration of the study. Control animals (n=7) received an equivalent volume of saline. Heart rate, mean arterial pressure, central venous pressure, cardiac output/ arterial and mixed venous blood gases and serum lactates were measuredat regular intervals throughout the study. Cardiac index and systemic vascular resistance index were calculated at the same intervals. Overall there were not sta' tistically significant differences between the groups (P < .05, two-tailed independent t test). We were unable to demonstrate any worsening of hemodynamic parameters in animals receiving meptazinol during any period of the study. Further investigation of meptazinol as an analgesic in multiply iniured patients may be warranted.

160 Hemodynamic and lletabolic Effects of Ethanol in a Ganine Hemorrhagic Shock llodel BJZink,SCDronen, SASyverud / Department of Emergency Medicine,University of Cincinnati Ethanol has been reported to cause myocardial supression, exaggeratedhypotâ&#x201A;Źnsion/ and increasedmortality in various animal models of hemorrhagic shock. Previous studies have not monitored cardiac output or metabolic parameters such as serum glucose and lactate levels. We studied hemodynamic and metabolic changes after administration of ethanol in a 50% graded hemorrhage model in dogs. Conditioned beagles(n=l3f were anesthetized with IV pentobarbital 125mg/kgl, endotracheally intubated, and instrumented with femoral arterial lines and pulmonary artery thermodilution catheters. At l2-minute intervals, l0% of total blood volume {calculated as 9 ml/kgf was withdrawn from the femoral artery cathete4 fior a total of 50% of blood volume at 60 minutes. A 9O-minute stabilization period followed withdrawal. Arterial pressures,cardiac outputs, arterial and venous blood gases,serum ethanol glucose, and lactate levels were measured at baseline,during withdrawal, and during the stabilization period. ln the experimental group In=5! a l:3 solution of 100% ethanol (3 gm/kg) in normal saline was administered as a bolus by orogastric tube 30 minutes prior to the start of hemorrhage.Control animals (n=7) had an identical hemorrhage protocol but did not receive ethanol. Ethanol levels consistently ranged from 2,500 to 3,200 pglml during hemorrhage and stabilization. The ethanol group had significantly higher heart

162

ilabxone Does ilot tmp:ove

Following Canine Graded Hemodynamlcs Hemorhage SL G,n, SC Dronen, SA Syverud, WG Barsan, CA Cunningham/ Departmentol EmergencyMedicine,University ol Cincinnati TWo recent studies have demonstrated no improvement in hemodynamic parameters or survival following naloxone administration in hemorrhagic shock. This is in contrast to earlier studies which consistently demonstrated a beneficial effect. The efficacy of naloxone may be related to the timing of its administration. One study which showed no effect used a canine graded hemorrhage model with naloxone administered prior to hemor-

58


rhage.The purpose of the current study was to evaluate naloxone's ability to improve hemodynamics when administered after a fixed-volumehemorrhage. Conditioned beagles(n:13) were anesthetizedwith pentobarbitol (25 mg/kg IVl, endotracheaily intubated,and instrumented with a femoral arterial line and a pulmonary artery thermodilution catheter. Animals were then subiected to an estimated 50% graded hemorrhage (45 ml/kg|-iorover one hour. Following hemorrhage, animals were observed 90 minutes,_then reinfused shed blood over O0 minutes, and finally observedfor an additional 50 minutes. Six animals received naloxone-(2 mg/kg IV| 30 minutes after completion of hemorrhageand then 2 mg/kg/hr for the duration of ihe study. Control animals {n=7) received an equivalent volume of saline. Heart rate, mean arterial pressure (MApf central venous pressure, cardiac output, arterial and mixed venous blood gases and serum lactateswere measuredat regular intervals throrighout the study. Cardiac.index(CIf and systemic vascular resistanlceindex (SVRif werecalculatedat the same intervals. Overall, there were not statistically significant differencesin the mean data values for MAp CI,SVN.or lactates, although lactates were consistently highei in the naloxonegr-oup{two-tiiled independent Student t iestf."We conclude that naloxone does not significantly improve hemo-hemorrhage. dynamics when administered after a fixed-volume

in size from 12 to 20 gauge. The process included measurements of the intemal and extemal diameter and the wall thickness at the barrel and near the tip of each catheter. The measurements were performed independently using both an electron microscope and the combination of dial calipers and the eye loupe. The results show marked deviations from the labeled sizes, and signifi cant differences between the products of various manufactrirers. The outside diameters, purportedly the site of measurement for labeling varied as much as 87o for l4-gauge (gl, lB% for 16-9' lO% for l8-g, and27% tor 2O-gcatheters. The difference berweei'maximum intemal diameters was l2l" of the mean of all intemal diameters for the l4-g catheters measured, 84"/oior 16-9, and 19% for both l8-g and 20-g. A negligible difference was found between the maximum intemal diameters in the l2-g catheters, although the difference was 33% of the mean for the minimum intemlal diameter. Poiseulle's Law suggests that these differences can greatly affec,tthe intravenous fluid flow rates achieved from these catheters. It is vital to know, especially in hypovolemic resuscitations, the fiow capabilities of intravenous catheters. To make this information more consistent from manulacturer to manu{acture4 it is imperative that industry-wide standardsbe implemented and followed.

165 Effect of Timotot Given Five ltinutes post Goronary Occlusion on Plasma Gatecholamines CM Lathers, N Tumer, WHSpivey / Departments of pharmacology

169 - Rapid Btoodwarming by Satine Admixrure KVlserson / Section of Emergency LeghnaqueEBWilson, Medicine, Arizona Health Sciences Center, Tucson . Severelytraumatized patients often need massive blood transtusion at rates which exceed the capabilities of currently available bloodwarmers. As a result, inadequately warmed blood is olten transfused, with resulting hyp6thermia. Admixture of erythrocytes(packedred blood cellsl ivith heated saline solutions may providj arnore rapid and safe method of bloodwarming and infusion. We developed and tested such a system for easJ and efficacy.This method produces warmed units of erythrocytes, reacy tor transtusion, within 15 seconds. Erythrocyte units, pre_ paredfrom blood which had been collected in CPDA-I, ,.r"i. ai vided into 100-g-to 125-g aliquots. To each aliquot of'blood an equalamount of heated saline, at a temperature bf either 50 C or 60 C, was rapidly added under pressure. Gentle agitation of the eryttuocyteswas performed throughout the lS-second admixture process.Temperaturesof saling erythrocytes, and the resultant mixture were determined by an in-bag temperature probe. Tempâ&#x201A;Ź_retures of the mixture were 34 C ana ZS.t C aftei saline was eddedat temperaturesof 60 C and 50 C, respectively. Sampl.s wereobtainedfor hematocrit and plasma hemoglobin d"t".-irr"tion. We found no significant plisma hemogl6bin elevation in any sample,at.eith_er temperature (p > .05 by Duncan,s Multiple etlg.: AnalysisJ.Ou-r daia indicate that heated saline may'[i 'Japidl.ya!mi1e{ with-erythrocytes without causing significant . hemolysis.-We have demonstrated a technique of iapid bloodi, t{arming which- allows for transfusion at rafts [mit;d only by dhtravenouscatheter size.

l!64 Nonstandardization of the ilanufacture of fintrarcnous Gatheterc KV lserson, CENa,vberg, SB .Glemans / Section of Emergency Medicine, Arizona Health Center;HughesAircraftCompany,Tucson

has been-shown repeatedly that the flow of crystalloids tgh peripheral intravenous catheters of the same size from erent-manufacturers varies significantly. postulated reasons this have included a variation in catheler design, manufac:,:, matenals materials used, used or due to a flaw in experimentd experimentd procedures. Drocedures. assumptionhas always existed that there were indiustry stanis for the manufacture of peripheral intravenous caihet".s lch preventedlarge variations in actual size. These stan&rds not exist. To determine the amount of variation, il any, that between catheters from various manufacturers, peripheral :nous teflon catheters were measured. The cathetirs ianged

59

and EmergencyMedicine,The Medical College of pennsylvanial' Philadelohia This. study determined whether timolol would afford a protective,effect by preventing the coronary occlusion-induced increase in plasma norepinephrine (NE) and epinephrine (E|. Ten anesthetized cats received saline or timolol (5 mg/kg fV1 five minutes after coronary occlusion of the left anterioi descendingcoronary artery,lO to 14 mm below its origin. Coronary occlusion produced arrhythmia in three of the saline cars and in four of thi timolol cats. Three of the saline cats died in cardiogenic shock, two were sacrificed six hours post coronary occlusion. All five of the timolol cats died in CHF post coronary occlusion. PlasmaCatecholamlne Lewls 2 1 5 3 0 ng/mL Control mlnutes mlnutgs mlnutes NE Saline 5.0 + 1.8 5.4 + 1.7 13.6+ 5.0 9.7 + 4.6 Tlmolol 5.3 r 2.1 8,4 + 3.8 5.0 + 1.0 1o.o+ 3.0 E Saline 1.0t 0.4 1.4+ O.4 2.3 + 0.3 2.7 + 1.O Timolol 2.2 + 1.2 4.3 a 3.5 4.6 + 3.1 7.2+ 4.7

Ooalh 76.2a 33.5 43.5+ 22.1 135.7! 78.2 86.3 r 43.9

In summary the data indicate that there was a gradual increasein NE (P_> .05| and E (P < .05) in both groups aftir coronary occlusion. Death produced a significant increase in both NE and E levels. Timolol did not modify the increase in NE and E occurring alter coronary occlusion and at death.

GPR in Ghildren A Zaritsky, 166 V Nadkarnr, P Getson,K Kuehl/ Departments of Anesthesiology, ChildHealth and Development, Research,and PediatricCardiol6gy, George Washington University Schoolof Medicineand Childi6n's Hospital NationalMedicalCenter,Washington, DC This study prospeftivelyl) determinedthe incidence,etiology, agedistribution,andlocationof cardiac(CAland respiratory(RLi arrestsin children;and 2f determinedif any factorsprediciiveof outcomecan be identified.All resuscitationeffortswereprospectively idelti{ied in a children,shospitalfor one year CA-wajdefined as the absenceof a palpablepulse;RA was definedas the absenceof respiratoryeffort-necesiitating assistedventilation. Arrests in the nursery and OR were excluded.Charts were reviewedand completedata recordedby a researchtechnician;all data was independentlyconlirmed by one of the authors.Data includedpatient'sage,sex,locationoi the arrest,presence of un-


derlying disease,duration of CP& tlpes and frequelcy of-medicationi uied during the resuscitation, and initial rhythm, blood gas, and laboratory data. Restoration of spontaneous circulation, survival for 24 hours and survival to discharge (S-DC) were recorded. Results from discriminant analysis desigrred to identify factors which were significantly (p < .051associated with.outcome will be discussed. 93 childtett experienced ll3 arrests (53CA,40RAlt 55% were < 12 mos. In the 93 victims, S-DC occurred in 34% overall, 9.4% survived a CA and 65% a RA- For CA victims, 30 were in-hospital with 13% S-DC, and 23 were ED or out-of-hospital with 4d S-DC. None of the 3l victims receiving > 2 doses of epinephrine S-DC. Underlying chronic diseases.were-present in 7O% oI the CA victims. Other descriptive and predictive data will be presented. Conclusions: Our prospective-study confirms the extrimely poor outcome following CA in children. Mortality in patients receiving > 2 dosesof epinephrine was 100%, suggesting that other pharmacologic therapies may be indicated in this high risk population experiencing CA.

Effect of Intraosseou$ Nal{CO" on Bone 167 / CMLathers RMMcNamara' HDUnger, in Swine WHSpivey, Medical andPharmacology, Medicine o{ Emergency Departments College of Pennsylvania,Philadelphia Previous studies have shown that the intraosseous route is an effective alternative for the administration of NaHCOs in inlants in cardiac arrest. Howeve4 the question of whether the infusion of a hypertonic sclerosing agent such as NaHCO3 permanently damag'eithe bone marrow or cortical structure remains to be answete-d.The purpose of this study was to examine cortical and marrow changesin pigs one month after intraosseous administration of NaH-O3. Five domestic swine weighing 8-12 kg were anesthetized with ketamine 20 mg/kg IM and phenobarbital 20 mg/kg IV The lower hindlimbs were prepped with,a povidineiodine solution and sterily draped. An l8-gauge spinal needle was inserted into the proximal tibia of both the right and left legs. After aspiration of marrow contents to confirm the position of the needle, NaHCO3 I mEq/ cclkg was infused over a 3O-second period into one tibia and an equivalent volume of saline into the opposite tibia. The animals were allowed to recover and four weeks later, AP and lateral roentgenographsand a technetium 99 scan of the tibias were obtained for comparison. Roentgenographs and technetium 99 scans were interpreted by a radiologist blinded to which tibias received saline and NaHCO3. The tibias were fixed in l0% buffered formalin, sectioned and stained for histopathologic examination by a pathologist also blinded to the study. During the study, no animals developed any Srosssigns or symptoms of osteomyelitis. The roentgenographsshowed no evidence of cortical or tiabecular damage from the intraosseousneedle. Technetium 99 scans were identical for both tibias in each animal and failed to demonstrate increased activity associatedwith an inflammatory reaction. As seen in previous histologic studies, there was minimal evidence of an inllammatory reaction in the marrow of these animals. This study demonstrated that NaHCO3 when administered intraosseously has no long-term effect on the bone cortex or marrow in swine and may be safe for use in children.

alnha-chloralose 25 mg/ks, IV and ventilated with a respirator' Catheters were placed in ihe .ight ventricle, left ventricle, and femoral arteries ior MAP recordings and blood pH sampling every 2 minutes. Catecholamine samples were taken from the femoral artery every 2 min. Cardiac ariest was induced by endocardial stimulation with a Grass S 88 stimulator. 5 min post arrest resuscitation was initiated with a mechanical resuscitator. l0 min post arrest NaHCO3 I mEq/kg was administered by the peripheral IV (P;n=61,centrJl 1CE,n=51,or intraosseous(via the tibiaf (I;n=5) ioute. iontrols {C;n = 6} did not receive NaHCO3. MAP {mean t SDf prior to arrest was C 133+43i P 142+33, CE 139t22; and I ndiZe mmHg.5 and 25 min post arrrest it was C 22+8 and 17+8r P 32+12 and20tllr CE27tlO and ll+10; and123!9 and lb*3 mmHg, respectively. A Z-way ANOVA did not reveal anv difference in tUnF values in the four groups (p> .05f. In all groups the blood pH from the femoral artery demonstrated a resiir"to.y alkalosis-that peaked at approximately 7.48 5 min alter initiation of mechanical resuscitation. In the groups receiving NaHCO3, it peaked^t 7.77!0.O9 CE and 7.55t 0.05 P 2 min post infusion and at 7.66+O.03 I 8 min post infusion. ANOVA revealed that the CE and I routes were significantly different (p < .05| from the P group and that all three gtoups were different (p < .05j from the C. Ph;ma E and NE concentrations (nglml) at 0, 6, lO, 12,20, and 30 min post arrest in the C group were: 1.9, 1.3, 13i.5, 309.0' 108.6,271.0, 81.2, 134.7, 29.4, 47.8i and 34.5, 66.5 ng/ml, respectively. All 3 groups receiving N.aHCQa demon' stiated similar pattems and were not significantly different from C (p > 0.05) when compared with a 2-way ANOVA. This study demonstrated a dramatii increase in serum catecholamines with the initiation of mechanical resuscitation followed by a gradual decline. This is reflected in the decreasein MAP during CPR' The route of NaHCO3 administration does not appear to significantly affect the levefof circulating cathecholamines and the associaied MA! but it did significantly influence the blood pH.

Regional Blood Flow During GPR in a 169 T Bridges' HAWerman' CGBrcnvn, Swine lrlodel RBTaylor,

RL Hamlin / Divisionot EmergencyMedicineand Departmentof VeterinaryPhysiologyand Pharmacology,Ohio State University' Columbus Animal models employed to study cardiopulmonary resuscitation {CPR) have been criticized for several reasons. Some species used in these studies, particularly dogs, do not accurately repre' sent human anatomy. ln most studies on resuscitation, cardiac arrest times of less than five minutes have been employed, which are not reflective of the prehospital setting. Finally, regional blood flow measurements lo critical olSans are lacking in these studies. It is the purpose of this study to present an accurate method of regionai blbod flow measurement during CPR after.a prolonged cafui"" arrest using a swine model.,Te-nswine weighing tS-2S.4 kg were instrumented for regional blood flow measuie-ents using radioactive-labeled tracer microspheres. Regional blood flow measurements were made during normal sinus rhythm (NSR). Swine were placed into ventricular fibrillation for ten minutes, and CPR was begun with a pneumatic compresso-r. Measurements of regional blood flow were made again. The following validation studies were performed: l! comparison of paired orgatt flows during CPR to insure uniformity of microsphere-mixin!; 2) comparison of cardiac outputs from ventral and dorsal sailpling siles to determine whether sedimentation of microspheies had occurred during CPR; 3) determination of micro' sph.t. "o,rnt in each tissue sample to insure precision of flow rieasurements; 4) calculation of the arterial-venous shunt during CPR to ensure that microspheres did not bypass the tisiues; and 5l determination of microspheres remaining in the left ventricle ai the end of regional blood flow measurement during CPR. Statistical compariions for paired organ flow and microsphere sedimentation were made using a paired student's test. Statistical sig' nificance was considered at p < .05. The following results were obtained (flows expressedas ml/min/100g|:

Effect of Differcnt Routes of Sodium 168 Bicartonate Administtataon on Plasma Catecholamines, pH, and Blood Pretsure During JM CMLathers, Gardiac Arrest ln Pigs WHSpivey, and Medicine T Tumer / Departments of Emergency Schotfstal,

Philadelphia Pharmacology,Medical Collegeof Pennsylvania, This study compared the effect of different routes of sodium bicarbonate administration on plasma epinephrine (E| and norepinephrine (NEf concentrations, pH, and mean arterial blood pressure (MAPI in a cardiac arrest model. 23 domestic swine (IS-ZO tgl werâ&#x201A;Ź anesthetized with ketamine n mg/kg IM, and

60


!El'F-

I

Rightcerebrum Left cerebrum

NSR 48.9 + 12.4 45.1 + 10.3

Cerebellum

62.2 + 2Oj

Midbrain

49.9 + 10.6 47.1 + 12.O 57.5 + 32.6

Pons Medulla Cervicalcord Left atrium Rightatrium Right venkicle Right IVS MesialIVS Left IVS LV-epicardium LV-mesocardium

39.5 + 22.4 2 3 3 . 0+ 1 5 3 . 9 123.6 + 74.0 '165.7+ 76.6 2 6 3 . 6+ 1 6 6 . 3 306.3+ 177.8 345.7 + 221.9 2 7 9 . 2+ 1 6 6 . 6 287.1 + 237.0

LV-endocardium 345.2 + 2225 Rightkidney 1 7 6 . 1+ 6 7 . 1 Left kidney 177.2 + 76.6 (lVS= interventricular septum,LV : left ventricle)

CPR 2.O + 2.3 ' 1 . 9+ 1.9 1 1 . 9+ 2 3 . 4 4.4 + 5.0 6.3 + 9.5 1 1 . 3+ 1 3 . 4 1 3 . 1+ 1 1 . 3 5.0 + 6.4 3.3 + 4.8 9.1 + 10.8 8.8 + 12.8 1 3 . 6+ 1 8 . 1 14.5+ 21.3 1 1 . 5+ 1 0 . 8 1 9 . 5+ 2 3 . 3 16.1 + 24.7 0.8 + 1.3 1 . 3+ 1 . 5

Comparisonsof paired organ flows, as well as dorsal and ventral samplingsites, riveated n"osisnifi;;;dtff;r;;;'fu > .05).rn no casedidthe remaining "orrrri, i., tt"iv.i"".a iil. of the total number of microspheris iniected. ffr. crf""i"tea-sh.rrrt *"s les, than Z"/oin all caies. This study d"-;;;;;;;;;1iat the micro_ spheretechniquecan be.-proy6t-a"ri";i;;# states (cpRf to measurerenonal blood flow. The resulis confir_ that regiorrlj bloodflow to the hea.t ""a ur"i"-"i.loiu**iiiTi""a"ra external compressionfollowing a ten minute cardiac arrest. There bas._ line regionalflows can"be"r"a ioi "ffi"r."Ti jirr". investiga_ tors to evaluatethe efficacy of variouslnte*..riiorr. used duri?l resuscitation. Finally, tt. u"ii"-Uifity in the pilot 911lionulmongry data presentedcan be used by other in.,e.tig"tors in'a.t"._ilrri.rg samplesizes for future studtes.

-!70 Xypergtycemia and Retatiye H-yp_oinsulinemia During CpR in the Canine G.BMartinltt tioiaii,-ir 6Eii"n, or_ f-9,*f lXylg*"i, uaroen,J Gotdman,

MC Tom,lanorrich / Departmentof Emergency Medicineand Divisionof Endocrinology"riO M"i"bottsm, Henry Ford Hospital,Detroit hru: previouslynoted_anincreasein serum glucose with a ,-Y. decrease in serum insulin levels during closeJ_chist cardiopul_ monary.resuscitation(CC_CpR)in dogsl The purpose vestigationwas to further characterize"thi, pt'"rro'*.rronof this inusing a similar canine model. Ten m"Trc.ii ;;s-r-;.isr,i";';" averageof 2L.4 +.4.5 kg were anesthetizedwith pentobirbital, instru_ mentedwith aortic arch catheterr, ""a-U"l"fj". insulin and glucoselevels obtained. ventricutar filriifi;; ;;, electrically inducedand ventilation rerminated. *t., fir" -i"ites of cardiopulmonaryarest, CC-CPR was initiated using a pneumatic chest compressor and ventilator (Thumper@-f. e "o"t-i".i* epinephrine ",S mcg/kg/min was started at the onset of CC_CpR in :S:ri:l tlve animals while the other five received ,ro .*oi"rror, .r,._ cholamines.Defibrillation_at lO0 watt-se"o"a, *j, atrempted alter l5 minures of CC-CpR *a ,"p."t.A ,. ""J.a ", 200 watt_ seconds._ Serum glucose ,"d i"s"itri i.;;ir-;;;;;;rsured ar in_

ce-cpR ""a Jt.i-..t"r,,-; ;;;;fi !:*rl:(ROSCf. lllp ;."s circulation Glucoserosesignificaniiy a.i"ig tc_bpn irr Uo,t treatment gr.ouFland remainid _eleva,.a"i,.i'nosi-Ct-Cpn 1r"lt.;. et_ thoughinsulin levelsin general aecfineaauring *,i,f, some recovery afterRoscl these"il;;; d;;;i"rea-ch statistical sigrificance. Therewas,however,a significantdecrease in the in-

rariodurins. cGa'pili"diril* "'*i*,re

insurin_ lll:Yfl*.:state (p < .05f. Ischemic cencrency myocaidium depends pri_ marily on glucose as a source "f ""..iji-i""pproJri"t.fy fo*_ 6l

rl.s_ti l1vefs,m,1v furthe.rcompromisedeterioratingmyo-

:::lT, gtucosemetabolism. cardral Additional investigation is neededto rletermine the effects of insulin infusion a"iiig CC-CpR. Since elevated glucose levels have been associateJ-with- wo.sening of neurologic outcome after cerebral ischemic "u""ir, ,a_i.rir"tr"tion of any glucose during cardiac arrest ,horrtd-b. limited to treating verified hypoglycemia. Basollnâ&#x201A;Ź

15 mln CC{?R

15 mln pocr-ROSC

3C mtn pGiROSC

6(, mtn poatROSC

Nm-Epi Gmp

1t2 r 15

298 1 73

3O2 a 113

269 a 99

Epi Gmp

236 t 94

139 1 33

nt

401 t 64

41Ot 47

382 ! 19

! 42

All p < .05 comparedto basetine.

Hyperk4emia During Human GpR: I7-1 Inctoence

and Ramifications GB Manrn, RM Nowak,JE p1sek,DL Carden, MC TomlanovrcnI Oepartmentof Emergency Medicine,Henry Ford Hospital,Detroit Although hypokalemia has been reported after cardiac arrest and successfulresuscitation, extensive "*p"ilrrr.rrt"t data indi_ catesthat potassiumis releasedfrom cells durint ischemia. Since cardiac arrest is a severe form of ischemic i"s"it, tfr. po,rrrit.r_ fluxes that occur during cardiac arrest ,nJ ierus"lt"tion would to produce only hypokale*ir.-rh" p".por"-oi :f,: !: :T"led urrs rnvestrgatlon was_to study serum potassium concentratron iln-1, ourrng closed chest cardiopulmonaryresuscitation(cc_ CPR)in humans. Twenty-two patianrspresentingto tt " ._.ig.rr_ cy department (EDf in cardiopulmon".y "ri!.i lia ,i_.iltr;;?; measurement of central venous_(cvf ind arterial (al ti+l-aJ blood gasesduring CC-CpR utilizing a-p"."-r,i. chest com_ pressorand ventilator (Thumpero).Thi 1f.1 was measuredusine a qlrect samprrngron serectiveelectrode(normal between3.5 tJ 5.0 mEq/L). The mean age of patients was Oa r. 13 years and no patient.had a history of renal insufficiency. The mean time from arrival in the ED until sampling was 14.4 ! +.g--rrrrr,.r. Arterial and central venous [K*l *.r""5.0 t f.a milli and 5.6 + 2.9 m_Eq/Lrespectrvely,with 6 patients having tJ o{ greater than 6 lK mEq/L. In order to control ior changestn"1ii*;'secJnar.y to pfr, values were corrected for pH using ,fr" "o-'-oifv acceptedmethod of Bumell {a .10 changein-pH Jausesan inverse chrnge;lKi1 of .6 mEq/L). Corrected[-Ka+l^was s.0 ;].3-;irh"a corresponding + [Kcv+] of 5.4 3.0. There were no survivors in this stiray.-ell ,loygl hypokalemia may occuruft..,,r"..rrfJ resuscrtation, significant hyp:'I4.g1 does occur; ;;;;;;;;"ts durinf dlac arrest and CC-CpR. Becausepoor tissue perfusion cail dirinr Cc-c?R impairs exchangebetween tt. i"t".itiiiii;;-#;:

iric_reases i" i"t.iriiti"ilirt :T::11-.?-partments, pecreo to be even sreeter.

*."ia u. "._

Interstitial hyperkalemia may play a -of rgle .f.Jir.,rr..ianical dissocia_ i3 the.genesis *ide ..-pf* tion (EMDf after prolongedcardiac;;;;.;;. catcium has ,seen rong Deen known to be beneficial in the treatment of hyperkalemia-induced arrhythmia., th" .,l"".r, oi";l;;_ chloride in wide complex tMO may be-o"-ifr"'U"ri, of this lpnenomenon. y,ating

tmplgvementin coronart/ pertusion -liassa !72 P.ressures_ After Open.GtrestCaiaiac ge in ].fgmans:pretiminiry u e-iiii, i,' tL Labadie, lepon cB Martin, MCTomtanovicn, nrrll'r.f"rar, 7f]"-o"iii"ntor EmergencyMedicine,

Henry Ford r-ro.pir"r.6!t.ii'" to improve ,Efforts _CpR.havebeen directed at developing more etfective methods of cardiac perfusion i" ,t " ,rr.r,"i p"rtierrt. Th,e diastolic aortic-right- at.i"i _prersureJiff.r."". t,fr" coronary perlusion pressure)has been sliown to correlate with survival rrom prolonged arrest in animal modcls and is commonly used as an index of the uficacy of CpR. fn this stlay, ilrri, pr,i.r,,, p.._ senting to the ED in nontraumatic cardiopuimorrrry "rr"r, *.r. instrumented with aortic and right .,""t'."ifr.i.i, for monitor_ ing of the coronary perfusion p;"r;;;l;;;.j.r.a _a "p."


controlled blood pressure and ventilation for 20h, and intensive care for 72h. CPB restored spontaneous heart beat more rapidly and successfully {p < .05[ resulted in more stable circulation (p < .05|, and reduced epinephrine and NaHCO3 requirements (p ( .051. There were fewer life-threatening dysrhythmias and less need for norepinephrine postarrest in the CPB group. CPB improved 72-h survival (7 of l0 vs 2 of l0 control dogs| {p : .025t,, increased recovery of consciousnessin survivors 15of l0 vs 0 of 6 control dogsf lp = .0371.CPB led to less myocardial morphologic damage, ie, no hemorrhagic contusions as induced by extemal CPR, and less extensive ischemic changes(p < .05l.Conclusions: Emergency CPB increases cardiovascular resuscitability and thereby cerebral recovery and should be further explored in clinically realistic scenarios for resuscitation from prolonged total circulatory arrest. Full cerebral recovery after over. l0 min cardiac arrest in dogs requires more than CPB.

chest CPR. Standard CPR was performed by a mechanical compressor and ventilator (Thumperof delivering 2rh to 3 inches sternal deflection. ACLS protocol was followed, though epinephrine was administered by continuous infusion at 5 pglkg/min. After recording pressuresfor 3 minutes during standard CPR, four patients underwent leftlateral thoracotomy and received bimanual, intemal cardiac massagefor l0 minutes. After receiving OCCM, the coronary perfusion pressure rose from 5 t 7 mm Hg during standard CPR, to 36 + 14 (p < .0U. The CPP declined an average of 3 mm Hg between the first and the second halves of the l0minute OCCM period. In this small series, OCCM produced and maintained coronary perfusion pressuresof the magnitude found necessaryto resuscitate animals from prolonged arrest. These preliminary data further support the superiority of OCCM in human cardiopulmonary resuscitation.

173 Theoretical Effects of Fluid Infusions Dudng CPR as Demonstrated In a Computel / SAMeador llodef of the Girculation CA Tomaszewski, MiltonS Hershey Medical Division Medicine, ol Emergency Hershey Cente(funnsylvania StateUniversity,

775 outcome Trials of Free Radical Scavengers and Galcium Entry Blockers After P Gardiac Arrest in Two Dog todels P Vaagenes, W Diven,K Arfors/ Besuscitation E Cerchiari, Safar,R Cantadore, Care of Anesthesiology/Critical Research Center andDepartments and of Pittsburgh; University Medicine andPathology, Pittsburgh Hospital, Presbyterian-University

Recent studies have shown the potential adverseeffects of venous volume loading on blood flow during closed chest cardiopulmonary resuscitation (CPRI.To examine the effect of arterial and venous infusions, we employed a published computer simulation of the circulation during CPR. This model uses computer simuIated electrical networks to model the heart and great vessels. CPR was modeled with compressions at a rate of 80/min and a force of 80 mmHg. Fluid infusions, simulated as current pulses into the abdominal aorta and superior vena cava, were given to measure their effect on myocardial and cranial blood flow. With 6Ct0ml/min infusions into the abdominal aorta, there was a l2lo peak increase in myocardial flow and a 3.8% peak increase in cranial flow. Every 75 ml/min increase in infusion from 0 to 900 ml/min produced a 1.0 ml/min linear increase in myocardial flow and a 3.0 ml/min linear increase in cranial flow. In agreement with previous CPR model studies, simulated vasoconstriction of abdominal and lower extremity vessels resulted in increased myocardial and cranial flows. As resistance of these vessels was increased, abdominal aortic infusions resulted in greater flow augmentations. In contrast to arterial results, infusions at 600 ml/min into the vena cava resulted in a 2.41odecreasein myocardial flow and aO.670/odecreasein cranial flow Rise and fall times for initiation and cessation of flow augmentations were equal to four compression cycles. We conclude that these findings demonstrate the theoretical benefits of rapid arterial infusions during CPR with increases in myocardial and cranial blood flow. This method may provide an early temporary adiunct to myocardial perfusion during CPR.

174 Emergency Gardiopulmonaq/ Bypars After P:olonged Ca;diac Ar?est in Dogr lmproves Recovery E Prefto,P Safa( R Saito,W Stezoski/ Resuscitation ResearchCenterand Departments of Anesthesiology/Critical CareMedicineand Pathology, Universityof Pittsburgh;and Presbyterian-University Hospitaland VeteransAdministration Hospital,Pittsburgh Cerebralneuronscan survive cardiacarrestof 10-20min, but suchan insult cannotbe reliably reversedby extemalcardiopulmonsry resuscitation(CPRf.Emergencycardiopulmonarybypass (CPBI{with veno-arterialpumpingby Bardcentrifugalpump via membraneoxygenator,without thoracotomy,with priming by plasmasubstituteand heparinizationlpermits control of perfusion pressure,flow, temperatureand compositionof blood.CPB (without preliminaryCPR|wasusedfor reperfusionand assisted circulationfor 2h in dogs(n= lOf after normothermicventricular fibrillation cardiacarrest of l2l,t min. Recoverywas compared with that of control dogs(n= lOfin which CPRadvanced life support wasusedto restorespontaneous circulation.Bothgroupshad

62

Testing of brain damage ameliorating therapies after brain ischemia has been done in controlled, clinically relevant animal models with intensive care and long-term (3-7df outcome. Since ventricular fibrillation (VF|, cardiac arrest (CAf and asphyxial CA (AAf account for 90"/" of CPR attempts in humans, our ongoing research program includes both models. In lightly anesthetized dogs, CA was induced either by asphyxiation plus 7 min arrest, or by external DC shock and l0 min VF. Restoration of spontaneous circulation (ROSCIwas by extemal CPR within 5 min, then IPPV for 20h, and intensive care to 96h. MAP and blood gases were controlled. The following therapies were given as IV infusions upon ROSC: l| Lidoflazine (Ll I mg/k& at 0, 8, and 16h (VFl; at 0, 8-72h (AAl. 2| A solution of free radical scavengers(FRSI (mannitol 5%, l-methionine 2% in dextran 4O 3o/ol4 ml/kg plus MgSO4 I mM/kg et},3,7 and llh. 3f Verapamil(V| 0.1 mg/kg, at 0, 5, l0 and l5h. Correction of BE was with NaHCO3 or THAM (FRSI.Concomitant controls received standard intensive care (ST). Outcome was evaluated as neurological deficit (ND| score (0% = normal, 100%= brain deathf and overall performance categories {OPC#I=normal; #2=moderate disability; #3:severe disability; #4=coma-vegetative, #5=brain deathl. Cisternal (CSFf was assayedfor creatine phosphokinase ICPK) (leaks from brain after CAl. The table shows insult and outcome data. The AA model was easier to resuscitate. L improved outcome alter l0 min VF but not after 7 min AA. FRS improved outcome after AA but not after VF. Brain histology showed variable, mainly ischemic-neuronal changes in the VF model and more severe ischemic changes plus microinlarcts in the AA model. Conclusion: The potential brain damage ameliorating effects of FRS and Lido' flazine seem to differ in the 2 dog models. Tlbla: (n) Totalinsuh EEG return time

7 mlnA.phyrl.l CA t0 mln Vbntrlcuh.FlbrfibllonCA q11) FRqs) v(51 sr(e) q5) FRqsl sr(rrl 16'

16'46' 17'3q

20'28" 19'18'

19'?f

V'45' 14'M7'45'

12'45'

11'36'

12'W

15'30

17'45'

CSF€PKU/L 46r26 37+3!' (10) 53i5 (2) 42a14 (4) 84a50 81 149 33r2r' (norrnal< 20) 2717.5 BestNO% 38r8 35!8 25a5t 33!11 18.5r14' 46rll 2--3 Orc range lJ r--3 3-4 24 3-4 2-4 'p < .05. tp < .0O5vs standard (Student'st-test). Meant SD,range.

176 Uftrastructural Cha?acte?istica of Postlschemic Inlury In the Dog Braln Following a Fifteen.tinute Gardiac Arrsrt and Eight Hours of Reperfusion K Kumar, DRWebb,M Goosman, JRTwanmoh,


i Krause, TJftoehner: AMGarritano, It?!."1*l".eS BCWhite, / Deparrments of pathotosiil ffi#; ljT:t!", sectionof Emergencyl\4edicine,and Colleges of Human 'i"1.i,iln.,ns, l,,le-Jic'ine and veterinary Medicine, Michioan si"t; uil;;;,il "no orEmersency-M"di"i;;,

B;i;;;hn'iii$it"r, e,"no

ff591'"",

InM/100 mgJ was determined spectrophotometrically. Data was analysed by_.MANovA and. is shown';;;;;^ ;"ne standard devia.rion. The data showed "o ,ig"iii"""i^ilii.*rr"., between the time groups. Gloup

Ultrastructural

sERUtl

evaluatic . Luws ingars-minuie-;";;il;i*;:*x'"T,."H:nftrrr.Tlnl.,:,".J. illc

reperfusiontime was "h";.;-il;;;;. Is1.o.1.,Thir Lthe, st,rdi.* m ourlaboratories demonstrate. importanr ;;;;;;;* shifts and ongoinslipid peroxidationwith l"'r; ;?';."_;riJi,trrr"t.d f"tty the period berween4,r"d; h;;;'.ir#l1ri." fid:,,." follow_ insult. Largemongreldogsw_ere *.rtt,J".a 5,9it and amrne Halothane.Tissue fr;r" f-ou-r;;;_ir"il*i" with ketconrrol fourcxperimentalanimals *;;lffiil. Tllj:."Trd rn the ex_ penmentalanimals,cardiacarrest was initiated by administration of KCl. Resusciration ;* ff;;"""i., of cardiac anestwith ventilationwithy:r^l^".s"I lood o, i;;;"il;;j"c massase,

24.0

+ 2 1o

CPK

BA

91 a 105

7.5 !4.2

IBAR

csF LUWS CPK 6.0 !3.7

12.3 128.3

4.4 aB.1

4.9 +ta

gg ! 1 2 .I2

7.4 19.8

26j 11.4 t 14.0 a6.2 116.0 6s.4 193.0 a56.7

2.7 t i.s 4.4 t 1.4

2 hr

16.4 +6s

538 a 329

150.2 ! 45.2

4 hr

12.O + 1 4

675 !710

92.4 a 52.0

1. t4g. ]3

gg a4.6

1S.5 t 12.5

714 a970

52.1 r59.4

25.4 !7.1

= 7.3

t hr

TBAR

21.9 a 5.3

99

ss.e 1143.8

10.9 !24.9

14.1 t ta.,

While thereis a trend towardincreasing tarion, there is wide variarionbetwe.i' serumCpK post_resusci_ i"Aiuia""f animalswith r":19;11to. tlese.parameters.rhere-1"r"-r,ie;;;;. reperfusionbrain iniury i" tt ii ,"oa.f] not hetpful 11..T_.f ,of Other studies rn our laborarories showthat tissue_."rui._."ir of iorrr,-iie-n material, and loss of unsatur"t.a fifias-are^iir"frto.. reliable and sensitivemarkersd O:ii: r1r]ryarri"itii'.-fi^t 8 hourspost resuscitation,and theseti

i,tf,',:lifi1,i:l:tdn'l:lnti".""a-N"io,,'#i.i."t.,,,"ra-.r

with incorporation of a thoi'ecostomy ecostomv rrrhc -^r .r_ -- ,"lol.d tube,and theanimals we;ffi'ffi"dffiil'8.hT""; intensive careprotocol. rGu"iii"tio., was",u11t1u^-1-ry1aara 'es-(rrf using a cardiac ;ne0-out usrng cardiac bvpass,pump brroass numn .nnn--.^) connect"a .^ io -_ : r

*

infusion

rhef Ff, :T*?":h:,1:1,":"111"1:l"d;4!in-Juffi;#h,ventricre. ixationp'o".rr.-in-i-t-i-,t-.ffid' ,"1fi fS:;iJ,T:t:,t1,Xt##'f; :';H"fr :#*,rl,"fS:f - used .s1rugturari;td";;;i":ir,fi taneously perfused, to evaluate earlv effects "f ti;;;p;;;;;'r;;il: wasthat ,t-; {,fr iI;#il;"rJr'rl *r, "ro*

serum and

are inad'equate jl:,pjI."d-"h;i;;;pumpinfu_ 31fffi rPR:li?:."j.:,,"d, N"cih2s'il;;i:d,':"";], !i'-l-,lr,i li*Hi5r'*r;: p",,Y':lf*:":l$rjrgqoanti*o*x"-r*'larlci"uiio"arization bythemethod"dv"iiffi terCardiac fi ;i:;.::L;::i:1.fi ,iif:i:"$fl: l7_P..g_",r_*I?,-nesuscilationaf andpreparla r"i .i"-",r'",i',ijJ"jscopy

in tte

f.ffirr:rffi1"*.sted

!,17..t1:oequacv of S-erumand Gerebrospinal

[i:11Hf:rs orarainrnlil dil;'tiT'rirst

CSF markers

and l,gi*i'J Magnesium lon i""'p:rtliJ8l,?'$:?,f,i,*f g::;.llR!!.f1'';iffitllill'."ng",

f,"lv,li;,3|"'f yj"*r,rx;:"pHll:,?eiil;e;iJ"#:#l&.fi 33id,,",

i;l,Ul'1",e":::,:l\4idiq-g;lt;,;"'p;il;i.'Ti",i,li1i:,?,, j'm:,:'":'?,1,*-"r31;tM"#-'il.i;:E:,i["3ffi :ffi 3ji:""1

' ' ' e u r u r r r sd r r u r a l n o l o g y ' S c h o o l o f M e d i c i n e . u n ' u "- - ' ' *-' ' - ' Minnesota; q lru n and Henneptn erlllepln : pnionn Reoional ^-|.:ill"J R egional P o i s o n 1-^^r^Center County Office of irlanning and dnd Devetnnmo.r r,,,ri^^^^llHennepin Development,Minneapolis

tt+i,lii:1"#lT,'"li**tf.:ti"i;,{: amtano,

-H"#;Uiilt orcnzo, MGoosman, ,t r*r.,n-Jn,Lr

This study w_asdone to further invcstigate the effects of hemo_ , i;Ill,,r?i"Iff^"rnyj*:1-?90!n,"".iei#'J,iJ""y e, Butterworth Hospitat, hyperbaric-oxygenation,""d ;?;;;;sulfate c|.;;-Rdd;, il,"iig:X:""t

ne.Departmbnt of raLJicine,ano ,:t":i:g^"TII9d icicorlesd

orxrl"l. r',iloiiiiil

l*l Drare?',*Plittry untversity,East Lansino

}i**t.*":

undertakento see if signilicanr markers of post

flly,l:1, on cere_ Drat resuscitation.Sixteen mongrel a"gJ-*;*'r""sthetized '"*ri"f and monitored via pulmonar/ "rt.ri ""theier, catheter, and ECG. A Ieft latelar thoracotomy was done. ventricular fibrillation by apptication oi " e-uor,'ic;rr!;,. y3.,?!:.1".d Mechanical ventrratron was stopped..Total arrest ,i_. rv*'ii minutes. All oogs were cardiac resuscitated within f-min,li.r'rrrrrrg internal ventilation, bicarbonate,epi"ephri"., m:?$? ,.,d intemal de_ trDnllation. The animals were then ri"aomiz.a-,ioi" tt r".-gr""ir. croup I representedconrrols ""d *;;;;;it.i. cro,rp II aog, received normvoremic hemodilutio;;"'""i1-r",*" t oI 2oo/oto 30% using hetastarch tH.rp""i lo"t&;* ffi;;.sium sulfate G roup rri dogs.received the-abov?--hemodi !.?:939 ^:r-lt t lu tion prus compression in a hypirbaric o*yg.r, ;h;rni., to 2 atmospheres absolute. CriticaL rn""ffi .ilr-"ni rro.rrty r,.u_ rologic scoring was perfor -c,are

;1tTl,',1'*':tl;""-1"^*d,!:-l"sdilJ;rili?)'uringthe l1^Ty'foiloriing,.rur"il",i.",ii,i#""ff-tilli:"::ffi"?; :. Derumandcerebralsoinalfluid-{Csn

.6t"i"J.[iiirt"-"t

for uiqafirterabFi;";";;ii;""i1,thiob",;I:':",T:1T:9 '-5i!_leacfve (rB+Rl ;;;;;ft"

i.lr,"[ir"ilL'11,0,"" ffi i::T::::l,rl1,t_s^.-1"andcsFsaEir"-,i,.,^.*oili".a dividedirto +-gro.rpr: Non ischemr""3l1tlil 1,29_9og: ji"i-",iJ,?,!,,,,"it"_ 1l"Ti.,l5::!llTgdJ:rs,i,i",it.,""", ;;; j;=:r,:,r,TilJ1'.il.l,ilHtrH::i; -",.i.

"and.2-hoursr;fi (i=7ie"iii,"r, ",i.,,iiiijla*iu Li:1':.i.J:*:'-T

ji:*i":?X; :;*,*r*'t;:,f *i.*.rm*i::3,1-aig'i';ilt#':iT.:T'i"l'.11?.'":J, #r+qhTii,,lfi jr1,tJ.my:oz.veltitaiioqt"r-"-rr*ii_aiilil#;:fff romrrustrationof NaHCO3.ano ; eprnephrine, and

defibrilla_ jgM,iursdffi-;;;Jii,,tiit',."a*a tj:'_l,f :::.:f I jg:ytlh::.f"a",a i"t"o,Tu" i"ifiilff f

t tron rruvrrru mlf was lnM/10m.L, wasdetennined

il;:ffii*f;| 'rr,?Ji--

determined'by by o_phenanthroline o_ofr." .. "efri:fii ason.urtrafittered fluid.rotarc35 1.n rdi| afi (ru/dll e determined by a hospitatr"'i;;;;1;i'i?"t"ri"r

study. Data analysis revealed no statistical differelce among the tnree groups with resoect to survival ,il;,-".,;;; tunction parameters, or neurolosic scoring. -of of ;;;;il;;afi.-iir.por,"rr". *,., the finding that one the coritrol ;;;f;;i"r.d fro_ " "o_ matose stare neurolosically intact. Thi, ];"d;;;asts doubt on the usefulnessof the-12_n

:Iess:s;r,.iti.ii""#;i'#i,',::,X?:ff i'JtrT:i:frT:,;Ji

come ln cerebralresuscitatron studv.

63


7 I

EXHIBITORS the Annual Listed below are the exhibitors that have registered to attend registrantsto Meeting as of April ll, 1986. UA/EM encouragesall registravisit theseexhibits on May 13 and May 14 during the morning Galleria in the be displayed will exhibits All tion and coffee breaks. be located will breaks coffee all and Hotel Hilton Portland of the Rooms in the Galleria Rooms. American Medical RePorts 425 Brannan Street, #200 San Francisco, CA 94107 (415) 541-0670 emergency Emergency Medicine Reports is a CME journal that offers pnysiJians a concise, cost-effective way to stay abreastof controverpatients' ,i.r, pltfAtt, and new developmentsin the treatmentof acute Materialsareeditedbytopscholar/practitionersforthecliniciancomI credits mitted to excellence. subscribers can earn 39 Category annually. Booth visitors will receive a free clinical update' Armstrong Industries,Inc. 3660 Commercial Avenue Northbrook, lL 60062

(312)272-s577 Annals of EmergencYMedicine P . O .B o x 6 1 9 9 1 1 Dallas, TX 75261-9911 ( 2 1 4 )5 5 0 - 0 9 1 1 journal of the Annals of Emergency Medicine is the official American College of Emergency Physiciansand the University and staff Association for Emergency Medicine' Editorial Board memberswillbeavailabletoanswerquestionsanddiscussyour ideas about the journal. Bard CardiosurgerYDivision 129 Concord Road Billerica, MA 01821 16rT 663-5353 emergency Display new product for massivefluid resuscitationand an sYstem. bYPass cardiopulmonarY California Medical Products, Inc. 2841 East 19th Street Long Beach. CA 90804 Q13\ 494-' 7r' ll

DuPont Pharmaceuticals Barly Mill Plaza Caverly Building Wilmington, Delaware 19898 (800) 441-7s16 medicine products' DuPont Pharmaceuticalswill display emergency antagonlst' narcotic pure first the Narcan@ , including

E.M. Adams ComPanY,Inc' l2l West Street Medfield, MA 02052 (6r'7) 769-1799 trays' made Suturing, Wound Closure, General Purpose, and Custom possibilities' endless produce with quality products,

Fischer Mangold GrouP P.O. Box 788 24 Happy ValleY Road Pleasanton,CA 94566 (415) 484-1200 staffThe Fischer Mangold Group provides Emergency Department The States' the-United ing and managementfor hoipitals throughout and directors time full for opportunities has and Cioup it expinding paid liability incontract, sub fee_for-service oifers Group The staff. incentive' surance,individualizedschedulingCME, and group

9631-H BusinessCenter Drive Rancho Cucamonga,CA 91730 (714) 980-5s2s where a Glaxo You are cordially invited to visit the Glaxo exhibit' and discuss questions your answer to available will be representative ForZinacefR, TrandateR, the latest clinical information of zantacR, tazR, and VentolinR.

Knoll Pharmaceutical ComPanY 30 North Jefferson Road Whippany, NJ 07981 (201) 887-8300 please visit the Knoll Pharmaceuticalcompany booth, where information on IsoPtin IV is available'

Stifneck Cervical Collars. Cook Critical Care P.O. Box 489 Bloomington, IN 47402 (812\ 339-2235 Christian Hospital NE/NW 11133Dunn Road St. Louis, MO 63136 (314) 355-2300 ChristianHospitalNE/NWisaT28bedacutecarefacilitylocatedin over suburbannortn-St. Louis county. Our emergencydepartmentsees seeking 65,000 casesper year and is a Level II trauma center' We are join our expanding full-time .rn..g.n.y departmentphysicians to which is comsalary excellent an offer emergency department. We package' benefit outstanding plimented by an

Life Support Products, Inc. P.O. Box 19569 Irvine, Californla 92713 body imEMS-related equipment primarily for resuscitation' whole burns. and injuries traumatic and mobilization, close area extrication Mansfield Scientific' Inc. 135 Forbes Boulevard Mansfield, MA 02048 We Mansfield is dedicated to the field of interventional cardiology' and diagnosis for the products offer the latest technologyin innovative (PTCA), Angioplasty coronary involving treatment of heart disease ElecIntra-aortic Balloon Pumping (IABP), Pulmonary Valvuloplasty' trophysiology (EP), and Temporary Pacing'


Laboratories,Inc.

MICROMEDEX, Inc. 660 Bannock Street, Suite 350 Denver, CO 80204 (303) 623-8600

Marion Park Drive City, MO 64137 be featuring SILVADENER (silver sulfadiazine, micronized) our unique topical antimicrobial for serious burns. We are to tell you about its patient benefit features and its unusual action.

pter Corporation Road , PA 19380

Toxicology, clinical pharmacologyand therapeutics,and disease/trauma oriented clinical information systems for the entire hospital medical staff. These information systems are available on: CD_ROM for use with personal computers, computer tapesfor use with IBM pCs mainframe users and microfiche. National Disaster Medical Svstem 5600 Fishers Lane Rockville, MD 20857 (30r) 4434893

f,4150 presentsthe BO 105 and BK l 17 emergencymedical

MBB Helicoptersprovidetwin-enginereliability 19pl:". EMS programsnation-wide.

Pharmaceutical Division PennsylvaniaStreet

The National Disaster Medical System is a federaily coordinated initiative which will augment the Nation's emergency medical response to a major disaster. It wilr assist state and local officials in dealing with a disaster and provide support to the military medical systemii the form of hospital care. Society of Teachers of Emergency Medicine P.O. Box 6l99tl Dallas, TX 75261-9911

IN 47721

7769

(2r4)5s0-092r

Electronics lord Street,Unit 0 91331 lt

STEMis organizedandoperatedexclusivelyfor educational purposes. Someof theSociety'sprimaryobjectives includeimprovingtt. iOu.u_ tion of,teachersof emergencymedicinethroughencouragement of researchin educationalmethodsand clinical procedures,promoting emergency medicine asanacademic discipline,andstrengthening the exchangeof ideasamongemergencymedicineeducators.Society leaderswill be available to answerquestions aboutmembership and activities.

is a noninvasivetemporary pacemakerfor the treat_

cardiacarrest.ThePacepac is anexcellentcom_

rrillation and transvenousendocardial pacing therapy and hospital use.

65


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

ARTICLE I _ NAME

Section I: Classificotlons' There shall be seven classes of membership:active, associate,emeritus,resident,honorary, and internationalactive and internationalassociate.

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

Section2: Qualifications' (l) Candidatesfor active membership shall be (a)-physicians of university or university-affiliated hospitals who hold medical school faculty appointments and who are continuing to participate actively in the field of emergency medicine .u.J and services, have a demonstrated interest in emergency medicine, whether in an administrative, teaching, or clniclal cipacity (b) other medical educators who under special circumstancesare invited for such active status by the Membership Committee. (2) Candidates for associatemembershipshall be any physician, medical professional, educator, government official, member of a lay or civic group or any member of the public at large, who may have an interest or desire to participate in pursuing-the purposes and objectives of the Association. (3) Candidaies foi emeritus membership shall be (a) active memberswho seek such status and who have given 10 years of active serviceto the Association and have attained the age of 60 years (b) other active members who under special circumstances are invited for such emeritus status by the Membership Committee' (4) Candidates for resident membership must be a resident in a residency training program who have an interest in emergencymedicine' (5) Candidites for honorary membership shall be individuals who are outstanding medical or lay contributors in the field of emergency medical r.-i.es. (6) Candidates for international active membership shall be individuals who meet the qualifications for active membership in UA/EM and who reside outside of the United States. (7) Candidates for international associate membership shall be individuals who meet the qualifications for associate membership in UAIEM and who reside outside of the United

ARTICLE II _ OBJECTIVES Section 1.' The objective of this Association shall be improvement in the quality of medical care of the acutely ill and injured by operating as a scientific and educational organization as definei in Section 501(c) (3) of the Internal RevenueCode, as amended. Section 2.' The Association shall pursue its objective by surveying medical and scientific articles both published and unpublished] and selecting articles of note. The Association shall make available, at cost, to the public copiesof the selectedarticles upon request.ihe Association shall selectmedical and scientific articles of note and educate the physician and the public by presenting those articles at discussion groups' forums, panels, Iectures, seminars and other similar programs. The Association may choose to sponsor for publication selectedmedical and scientific articles of note by treatise, thesis, trade publication or other media form in order to make that information, including patents, formulas, medical apparatus and medical system designs, available to the public at large on a nondiscriminatory basis' The Association may conduct and/or sponsor public interest, scientific researchin the field of emergency medicine in order to improve the quality of emergencymedical treatment and care' The Association shall publish its researchdata by treatise,thesis,trade publication or other media form, in order to make that informaiion, including patents, formulas, medical apparatus and medical system designs, available to the public at large on a nondiscriminatorybasis. The Associationshall inform and educate the public, as well as the medicalprofessional,in the resultsof its reseirch by conducting discussiongroups' forums, panels, lectures, seminarsand other similar programs.

States. Section 3.' Only active members shall have voting rights' Section 4r The Association shall not discriminate, with respect to its membership, on the basis of race, sex, creed, religion or national origin.

Section -1.'A. This corporation is organized exclusively for educationaland scientificpurposes,including, for such purposes' the making of distributions to organizations that qualify as exempt organizations under Section 501(c) (3) of the Internal RevenueCode of 1954 (or the correspondingprovision of any future United StatesInternal RevenueLaw).

ARTICLE IV _ OFFICERS Section 1.' The officers of this organization shall be the Presi' dent, Vice-President, and Secretary-Treasurer. Section 2.' The Executive Council shall serve as the Board of Directors of the Association. The Executive Council shall consist of the above officers, the Program Committee Chairman, the la$ three presidents,and three Councilmen-at-Large. Both activeand associatemembers may serve on the Executive Council, but only active members may be officers of the Council.

B. No part of the net earningsof the corporation shall inure to the benefit of. or be distributableto its members,Directors,Officers or other private persons, except that the corporation shall be authorized and empowered to pay reasonable compensation for servicesrendered and to make payments and distributions in furtherance of the purposes set forth in paragraph A hereof' No substantialpart of the activitiesof the corporation shall be the carrying on of propaganda, or otherwise attempting to influence legislatiron,and the corporation shall not participate in, or inteiu.ne in (including the publishing or distribution of statements) any political campaign on behalf of any candidate for public office. Notwithstanding any other provision of these articles, the corporation shall not carry on any other activities not permitted to be carried on (a) by a corporation exempt from Federal Income tax under Section501(c)(3) of the Internal RevenueCode of 1954 (or corresponding provision of any future United StatesRevenue Law) or (b) by a corporation, contributions to which are deductible under Section170(c)(2) of the Internal RevenueCode of 1954 (or the correspondingprovisionof any future United StatesInternal RevenueLaw).

ARTICLE V - COMMITTEES The standing committees of the Association shall be: Membership Committie, Nominating Committee, Program Committee, Constitution and Bylaws Committee, Education Committee, and Auditing Committee. Additional committees may be createdby the Executive Council and ad hoc committees may be createdby the President to aid in the Association efforts to achieveand further its goals.

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ARTICLE VI - ANNUAL MEETING shallbe an annualmeeting

of the Association. l]-t=shall meeting consistof an educati";;i;il';.t;;#f;Handa business session. tion2: The ExecutiveCouncil,by^majority vote, may call,

meet ing ;f i h; ;; b.Jip o.,tan_ ll*n:",,::toconduct I j.ry:iut committee anyuusinEssi;;;;ffi;iiii'u. coun-

tallplacebeforethe membership ;;;dtfi;;_,,,.". etion3: The ExecutiveCouncil may call and conduct any al meetingby mail. For ourposes.of notice, the ...iing Out. bea datesetfor the retuin ot mail u"ff.t, JnAit,iia'tr u. catt_ votingdate.

Maitballots.huilt.;;;;;i.iiid'iu5

0.,", or u"v-p,opo,ui,'*ijiiio" td:otrq. o. J:,1T. 11T., Ltbymail ballotshallU.u.r,i.u.O

t-v-uiti.m-atil.uli. ;;

^_ARTICLEVIII-_ ADOPTIONOF THE AMENDMENTSTO iHN C.OISTITUTION Section1..The constitutio3 "' amendedat any 3aV be adoptedor annualor specialmeetingof tne memier;,;to proposedamendments to the constitutionshallbe leclion 2.. in writing to the Secreta.ti;;;;y threemembers ::?Tiir.-l at.teast60 daysprior to_themeeting ut..ru.ir-it.v are to be considered.The Secretary_t..arur.irt'all #i;;';'r"posed amend_ mentsto the membershipat least30 dayspriorio that meeting. SectionJ.. The ExecutiveCouncilm1y, by resolution, amendmentsto the constitution;provid.Jif,.'propored propose amend_ mentsare mailedto the membership at least meetingat which they are to be considered-30?aysprior to the Sectionl..Adoption of a constitution amendmentshallbe by a majority voteof the activemembersp..r.ni urJ'".ting at anyan_ nual or specialmeeting.

provision :i,:lj:"t^11'lY:1:T1..:i:,"'r'T','h;;;i;;;;"'olaut of thisconstitution. od;;;; il"ji Hii.",: atthebusiness officeof trreessociitiori*1ffi'16 auv, to the votingdateshallbe counted.

ARTICLE VII - BYLAWS

ARTICLE IX - DISSOLUTION

oa,l.'.Bylaws-may be adopted or amended at any annual or meetingof the members-hip.

ion.2;Proposed amendmenJs to the bylawssha' be submitWfitine /ntlng to r- ,i to fhe the Senrp+o,.,/.r-^^^,.-^Secretary,/Treasurer Ly three *.LU.., u, days^priorto the meeiingat which - they are to be con_

Jr,ul-"ii ir,.;; il; ll.n tol11 rhe1.::.j1";rreasurer membership at least30dil;;i;-ri""i,r""ii,.rr,r*. a_ ian3: TheExecutiveCouncilmay, by resolution,propose

provided j: r!.. bytaws; ,ri.ipl.p"*J";;;;j;."" ',"j: r.tothemembership atleast 30aavsp.io,ioiii. _i.,ire they are to be considered.

tion4: ^Ad.optionof a bylaw amendmentshall be by a ma_ voteof theactive --' I .'w'rvv' membirs o presentand votingat any annual gialmeetinJ.

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Upon the dissolution ofthe corporation, the Executive Council

payingor makingp.;;iri;;;;;rliiuvrn.nt :,h"11, {t.l or ail or the liabilities of the.corporation,disposeof-J-tie alr oI rheassets of the corporationexclusivelvfor the puipor., corporationin suchmanner,or to suchorganization o.t.gunirurions organized and operatedexclusivelv, for crraritaUfe,' J,i."iii""r, religiousor scientific purposes ^ as an exempr i!,11-"il1;;.-;r;#; organizationor organizations under Sectioi-iiiii.f fll of the In_ ternalRevenueCode of 1954 *,..1..Jr;;;1i", fo, provisionof any futureUniredStatesInternalRevenu;;;i, ;, rhe Executive Councilshalldetermin". ,u.t, arr.t, noirJ'Oirpor.Uof shail be disposedbv a court ofllvcbmpetenil".rJi.i"" in the county in which the principaroirice ofttre-.-";;;;#j, rhenrocared, rf.h purposesor to.suchorganization y,1c]1si1etV or organiza_ Y trons, as said Court shall determin., *hln ui.' organizedand operatedexclusivelyfor suchpurposes.


BYLAWS OF THE UNIVERSITY ASSOCIATION FOR EMERGENCY MEDICINE ARTICLE III - MEETING

ARTICLE I _ MEMBERSHIP

Section.l: The Associationshall be governedby the actionstaken by a majority vote of the active members presentand voting' Between meetings, within the policies establishedby its membership' the Associition shall be governedby the Executive Council. Actions of the ExecutiveCouncil shall be determinedby a majority vote of those of its memberspresentat its meeting,4rtesl"r membersconstituting

Section 1; Application and Election to Membership Application forms -uy U. obtained from the Secretary/Treasurerof the Association. The Applicant must return the completed application forms and supporting letters to the Secretary/Treasurero.f the Association at least one month prior to an Executive Council meeting in order to be considered for membership at that time' The q-ualifications and recommendations of candidates for membirship will be reviewed by the Membership Committee at each meeting of the Executive Council. Approval of the candidates by the Council shall constitute election to the membership, effective immediatelY. Section 2.' All members shall pay dues. Only active members may vote and serveas officers. Associate members may not vote but may serve on the Executive Council.

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, by its Executive Council. Programs for the annual meeting shall be arranged by the Program Committee and approved by the PresiOeni. A iinal 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 tentative time and place for the next two annual meetingsshall ordinarily be announced during the businesssessionof each annual meeting. The site of the annual meetings shall be chosen by the Executive council two years in advance.

ARTICLE II - OFFICERS Section l: Election of Officers' The President and Vicepresident shall be elected for one year, with automatic succession irom Vice-President to President. The Secretary'/Treasurer,and Councilmen-at-Large shall each be electedto three year terms, the terms being staggeredfor the latter. Nominees for the above offices shall be t.lect.d by the Nominating Committee and must have agreedto stand for election prior to their formal nomination for eleition at the businesssessionof the annual meeting' Alternative nominations from the floor shall be solicited' Such

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

ARTICLE IV - FINANCES

nomineesmustalsoagreetostandforelection.Electionshallbe by majority vote of the active memberspresentand voting at the businesssessionof the annual meeting. Seclion 2: Duties of the President. The President shall preside over both the educational program and businesssessiouof the annual meeting of the Association, and the meetings of the Executive Council. It shall be the duty of the Presidentto seethat the rules of order and decorum are properly enforced in all prodeliberationsof the Association, and to sign the approved ceedings of each meeting. The President shall appoint active membJrs to fill vacanciesand unexpired terms on the Executive CouncilandstandingandadhocCommittees.ThePresidEntshall serveas ex-officio member of all standingcommittees' Section3: Duties of lhe Vice-President.ln the absenceor illness of the President, the Vice-Presidentshall preside' The VicePresiclentshall serveas Chairman of the Nominating Committee and ex-officio member of all standingcommittees' Section 4: Duties of the Secretary/Treasurer' It shall be the duty of the Secretary,/Tieasurerto presidein the absenceof both the Presidentand Vice-President,to keep a true and correct record of the proceedingsof the meeting,to preserveall books, papersand arti;les belonging to the Association' to keep an account of the Association with its members, to keep a register of the members with the dates of their admission, and current professionaladdresses,the latter to be circulated annually to the membership within a month prior to the annual meeting. He shall report unfinished businessfrom previous meetingsrequiring action, and attend to such other business as the Association may direct' He shall also supervise and conduct all the correspondence of the Association. He shall collect the dues of the Association, make disbursementsof expenses,maintain the financial accountsand records of the Association and presentthe financial accounts and recorclsof 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 financiai condition of the Association to the membership' He proshall be reimbursed for such expensesas he may incur in the of member ex-officio as per execution of his duties. He shall serve committees. all standing

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Section 1.' The annual membership dues for all members shall be determinedby the ExecutiveCouncil. The annual membership will be payatle within 30 days of request by the proSecretary/ireasurer. The Executive Council may establish and dues of non-payment policies regarding cedures and assessments. Section2: The ExecutiveCouncil shall adopt such membership inschedulesas is necessaryto encourage participation by the terestedpublic.

ARTICLE V PARLIAMENTARY AUTHORITY Rule of order. Any question of order or procedure not specificaliy delineated or provided for by these.bylawsand subsequent amendmentsshall be determinedby parliamentaryusageas containedin Robert Rules of Order (Revised)'

ARTICLE VI - STANDING COMMITTEES Section /.' The Nominating Committee shall consist of the VicePresident, as Chairman, the two most recent past presidents,and i*o "le.ted members who may not be members of the Executive Council. The latter shall serve staggeredtwo year terms' It shall be the task of this committee to selecta slate of officers to fill the naturally occuring vacancieson the Executive Council and the standing committees not otherwise designatedand provided for by thesJbylaws, and having obtained eachcandidate's permission to do so, ilace their namesin nomination before the membership lor elecrionat the businesssessionof the annual meeting' Section2.'The ExecutiveCouncil shall constitutethe Memberduty to reship Committee. It shall be the Secretary/Treasurer's view the qualifications and recommendations of each applicant' for presentationand approval by the majority of the Membership Committee. Section3: The Program Committee shall be composedof a Chairman, elected for three years, and three members appointed by the President to staggeredthree year terms' None of the applinted 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 for all meetings and select the formal participants.


4: The Auditing Committee shall consist of two appointedby the president to audit the financial acand recordsof the Associationat the time of the annual n J.' The Constitution and BylawsCommittee shall con_ Chairmanand two other memberr,.te.i.Aio."r'tigg...o terms so that the member-with the teast remilning serveas.Chairm-anduring his final year on th;a;r"_

shallstudytf,epotentiir-r.iti uaiJ.r. _cgT1"i,,.: s ano tegetimplications

of all proposedconstituâ&#x201A;Źndmentsor changesin the bylawsana riport ttrelr fina_ recommendations to the presidentand niecutive-Coun_ ;to the time of formal considerationof iir.- prooor.a by the membership.In aaaition, ltrev *uv-tfi.,ii.fu* [opriate constitutional amendmints "na Uuiu*,

and,Execu tiv. c ";;iil :1,:_PT:ld.:I. out of theexisting

po; stiii or

constitution"ra Urf"*l:

69

Section6..The Education Committeeshall consist of a chair_ man, electedfor threevears,and threeother membersuppoiniuA by_thePresidentto staggeredthre. y.-i;r:'N;ither the Chair_ man, nor appointedmembers,can be members of the nr.cuJiue Council. The Committee shall fort., .ontinuiig education in emergencymedicine.

ARTICLE VII _ DISSOLUTION OF THE ASSOCIATION Section1..Dissolutionof this Associationcan only be initiated by a majority vote of all members"iit.-e--.."tive Counciland mrrstbe.approved by two._thirds of the activemsmUership present and voting at any annualor special-.rtini.----' . Section2..Dissolutionshall be achievedin compliancewith Article IX of the constitution.


University Association for Emergency Medicine 900 West Ottawa Lansing, Michigan 48915

(5rD 485-5484

SAEM (UAEM) 1986 Annual Meeting Program