SAEM (UAEM) 1987 Annual Meeting Program

UniversityAssociationfor EmergencyMedicine

1987Annual Meeting Program and Membership Directory

May 19-21, 1987 Wyndham Franklin PlazaHotel Philadelphia,Pennsylvania

CaII for Abstracts University Associationfor EmergencyMedicine 1987Annual Meeting May 24-26,Cincinnati The 18thAnnual Meeting of the University Association for Emergency Medicine will be held May 24-26, 1988at the Netherland Plaza Hotel in Cincinnati, Ohio.

ProgramChairman, Jerris R. Hedges, MD, is now acceptingabstractsfor review for oral and poster presentationat the 1988Annual Meeting. Becauseof the large number of abstractsubmissions,the Annual Meeting ProgramCommitteehas developeda two-page abstractform to be usedfor all abstractsubmissions.Abstract forms will be mailed to the UA/EM membership and to others upon request. Abstracts not submitted on the official abstractform will be returned to the author for resubmission. In order to be consideredfor the 1988Annual Meeting, all abstractsmust be submittedon the abstractform by the abstractdeadlineof February I !

The deadline for the submission of abstracts for the 1988 Annual Meeting is February 1, 1988. Atl abstractsmust be submitted on the oflicial abstract form and must be postmarked no later than February l. Mail eight copies of the abstract form to: UA/EM 18th Annual Meeting, 9fi) West Ottawa, Lansing, Michigan 48915. Call (517) ,t85-5484 if you have any questions or would like to request an abstract form.

Abstractssubmittedor the resultant manuscripts must not appear in a referred journal prior to publication of the meetingabstractsin the April 1988 issue of Annals of EmergencyMedicine, and must not have been presentedpreviously at a national meeting.

Annalsof EmergencyMedicine is the official journal of the University Association for Emergency Medicine.

UA/EM strongly recommendsthat authors submit their manuscriptsto Annals. Annals will notiff authors of a decisionregarding publication within 90 days of receipt.

Cashawardswill be given for the Best Clinical Paper (Human Subjects),the Best Basic SciencePaper, the BestPoster,and the Best Resident Poster. An award will be given by Annals of EmergencyMedicine for LheBestResidentPaperpublishd in Anrnls. All award winners will be announcedat the 1989Annual Meetins which will be held May 24-26 in San Diego, California.

All abstractsmust be submittedon an official abstractform. Pleaseread the Call for Abstractscarefully for details and instructions.

INDEX Information General

... '.. '..1

U A / E ML e a d e r s h i p

...... '. '.3 . '.......4

V a d eM e c u m

..........6

g verview A n n u aM l eetinO

..... '7

KennedyLecture

..........8

S c h e d uol e f Events

.. ' '16

Abstracts

....'......61

Exhibitors

. . . .63

Constitutionof the University Associationfor EmergencyMedicine for EmergencyMedicine Bylawsof the UniversityAssociation

. '..'...'65 '. '..67

order) .

MembershipDirectory (alphabetical Directory(stateorder) Membership

... ...85 ....89

Membership Application

'....91

Abstract Form.

' . . . .insidebackcover

1987Call for Abstracts

UA/EM-IREM ResearchSymposium EmergencyThrombolytic Therapy

February5-6, 1988 Hotel Intercontinental New Orleans,Louisiana This conferencewill discussthrombolytic therapy for myocardial infarction, stroke, pulmonary embolism,and arterial sions. Further details will be sent to the UA/EM membershipin the upcoming months. Start making plans to attendthis i

GENERAL INT'ORMATION REGISTRATION AND INFORMATION All registrantsmustcheckin at the UA/EM RegistrationDesk to pick up namebadgeswhich are requiredfor admissioninto the Annual Meetingsessions.The RegistrationDesk will be openduring the times listed below.

9:00 am to 5:00 pm T[resday,May 19 7:00 am to 5:00 pm Wednesday,May 20 7:00 am to 4:00 pm Thursday,May 2I

GROIJNDTRANSPORTATION The PhiladelphiaAirport is approximatelya twenty minuteride from theFranklinPlazaHotel. Taxi fare is $15.Limos areavailablefor $5-$7.50.SEPTAhighspeedtrains($3.00peak,$1.75 off-peak) are also available and stop at Market Street West (SuburbanStation)which is only 3 blocks from the Franklin PlazaHotel.

POSTERS The UA/EM AnnualMeetingincludesboth oral andposterpresentations.This year there are 69 posterswhich have been (Red,Yellow, Green).There assigned to threepostersessions during the postersessionsand will be no oral presentations presenterswill be availableduring their scheduledsessionto discusstheir posterwith meetingattendees.However,theposterswill beavailablefor viewingthroughouttheAnnualMeeting.

The postersessionsare scheduledas follows: May20,1:00- 2:00pm Red Session May 20,2:30- 3:30pm Yellow Session May2I,9:30- 10:30am GreenSession

AUSTRALIAN EMERGENCYMEDICINE

UA/EM is pleasedto announcethat AnneF. D'Arcy, MD, of Melbourne,Ausfialia,will addressthe AnnualMeetingon Tiresday,May 19at 5:15pm in theWyndhamA room. Dr. D'Arcy will discussthedevelopmentof academicEmergencyMedicine of the Australain Australia.Dr. D'Arcy is thevice-president sian Collegeof EmergencyMedicine, which is the academic arm of EmergencyMedicinein Australia. Sheis alsothe chairmanof the ResearchCommitteeof the AustralasianCollegeof EmergencyMedicine. All Annual Meeting registrantsare encouragedto attendthis specialpresentation.

UA/EM.STEM MEMBERSHIP FORIJM There will be an open forum on Wednesday,May 20 from noonin the WyndhamA roomto discussoppor11:15-12:00 tunitiesfor a closerworking relationshipbetweenUA/EM and STEM. All membersof STEM and UA/EM are encouraged to aftendand participate.

EMERGENCY MEDICINE RESEARCH FEL. LOWS DIIV\ER The University Association for Emergency Medicine and the Society of Teachersof Emergency Medicine are jointly sponsoring the Emergency Medicine ResearchFellows Dinner on Tuesday, May 19. During the dinner there will be presentations by Dr. Podolsky on the current status of Emergency Medicine fellowships and by Dr. Tintinalli on certification of

fellowships.An opendiscussionwill thenbe held on whether fellowshipprogr:rmsshouldbe certified.

Complimentarytickets are availableto EmergencyMedicine fellows and their directors,however,pre-registrationis required. Otherswishingto attendthedinnercanpurchasetickets for $20 each.All tickets must be purchasedby 3:fi) pm on May 19.

EIVIRA.UA/EMRESIDENTRESBARCHFORT]M The first annualEMRA-UA/EM ResidentResearchForumwill be heldTuesday,May 19, from 6:30-8:00pm. This forumwill be an annualeventdesignedto answerEmergencyMedicine residents'questionsaboutresearch.

The oneandone-halfhour programwill featureDr. Sherman Podolsky of Albert Einstein Medical Center speakingon researchdesign, methodology,and proposaldevelopment.

Following Dr. Podolskywill be Dr. CharlesBrown of Ohio StateUniversitywho will discusshis extensivework on funding sourcesavailableto bothresidentsandfaculty.This Forum residents will serveasa meetingplacefor residentresearchers, in fellowships,andEmergencyMedicinefaculty.All interested registrantsare invited to attend.Thereis no registrationfee.

METHODOLOGY SESSION UA/EM is pleasedto cosponsorthe methodologypaperswith the Societyof Teachersof EmergencyMedicineon Tuesday, of six May 19 from 3:45-5:15pm. This sessionis comprised paperson education/administration.

In additionthereareseveral posters,which alongwith the otherposters,will methodology be availablefor viewing.Thereis no registrationfeeto attend thisjoint session.All registrantsof the UA/EM or STEM Annual Meeting are invited to attend the methodologypaper sessions.

UA/EM.STEM COCKTAIL RECEPTION STEM andUA/EM aresponsoringa cocktailreceptionon Tuesday,May 19from 5:30pm until7:00pm. Thereis no chargefor thereception.Horsd'oeurveswill be servedanda cashbarwill be available.All registrantsandexhibitorsareinvited to attend.

BANQTJET A free ticket to the Annual Meetingbanqueton Thursdayevenor internaing, May 21, is availableto everyactive,associate tionalmemberof UA/EM attendingtheAnnualMeeting.Tickets can also be purchasedfor $35. You must indicate to the UA/EM staff that you will be using your free ticket or purchasingadditional ticketsby 10:fi) am on Wednesday'May 20.

The 1987AnnualAwardsBanquetwill be held at the College in 1787. of Physiciansof Philadelphia,which was established Buseswill be availablefrom 5:30 - 6:00 pm to shuttledinner gueststo the College.A cocktailreceptionwill be heldat 5:45 anddinnerwill be servedat approximately6:30 pm in Mitchell Hall. During the cocktail reception and dinner the Mutter Medical Museum will be open for viewing by the guests.

Following dinner, the annual presentationof the Im-

ago Obscura and James Mackenzie Awards will begin. Last year's winners of the awards will provide the entertainmentas they review this year's entries for the awards and make the presentationsfor 1987. The awards are real, but the presentations are tongue-in-cheek.Expect a hilarious ending to a funfilled evening.

VOLLEYBALL TOIJRNAMENT Dr. Edward Lukawski has made arrangementsfor a volleyball tournamentto be held on May 19,20, and,2l from 5:00-7:00 pm. This tournament is sponsoredby Boehringer Ingelheim and will be held at Clark's Uptown Health Club on the third floor of the Franklin Plaza Hotel. Annual Meeting attendeescan sign up individually or as teams, with a minimum of 6 personsper team. There is no fee to sign-up and all participants will receive a T-shirt. Attendees must sign up for the Volleyball Tournament at the Registration Desk by 3:fi) pm on May 19.

Medical Association. The Annual Meeting has also requested 18 hours of Category 1 credit from the Amercian Collegeof Emergency Physicians.

EXHIBITS Exhibits will be available for viewing on May 19 from 12:30-5:00 pm and on May 20 from 8:00-11:00am and 3:004:00 pm. The exhibits will be located on the samelevel as the poster presentations.All coffee breakson May 19 and May 2O will be held in the exhibit hall. Pleasetake an opportunity to view the exhibits during the scheduledcoffeebreaks and review the exhibitor listing in this program.

MESSAGE BOARD A messageboard will be maintainedat the RegistrationDesk.

Phone messagescan be left at the UA/EM RegistrationDesk by calling the Franklin Plaza Hotel directly at (215) 448-2W0 and requesting the UA/EM Registration Desk.

COMN'ITTEE ON ACADE&IIC DEPARTMENITS There will be a meeting of the ad hoc Committee on Academic Departmentsof Emergency during the lunch hour on Thursday, May 21, 1987 during the UA/EM Annual Meeting in Philadelphia.

Committee members have respondedto an initial request for cornmentsand suggestions.These will be collated and shared at the meeting on May 21. It is anticipatedthat also during this meeting, the committee will set goals and objectives for the next year and the years ahead. Obviously this is one task that will not be accomplishedovernight. Committee membersand interested individuals are encouraged to attend this important

PLACEMENT SERVICB A bulletin board will be maintainednear the RegistrationDesk for person wishing to post positions and physiciansavailable listings.

SPEAKERS' READY ROOM A speakers' ready room will be available for presenterswho wish to check their slides and run through their materialin advance of their presentation. Keys to the ready room will be available at the UA/EM Resistration Desk.

PROCEEDINGS ACADEMIC PROGRAM DIRECTORS' MEETING A meeting of the ad hoc Academic Program Directors' Committee meeting will be held Wednesday, May 20 from 6:30 8:30 pm in the Wyndham B room. The meeting will be chaired

by Bruce Thompson, MD, and all interestedindividuals are invited to attend.

ANNUAL BUSIIYESSMEETING The Association will hold its Annual BusinessMeeting from 4:30-5:00pm on'Thursday,May 21. At the meeting, Richard M. Nowak, MD, will introduceincoming presidentErnestRuiz, MD. Agenda items for the businessmeeting will include the electionof officers, Council and committee members, amendments to the Constitution and Bylaws, officers' reports, and other items of business presented by the membership. All membersof the association are urged to attend.

CONTII\UING BDUCATION The Medical College of Pennsylvania, accreditedby the Accreditation Council for Continuing Medical Education, certifresthat this program meets the criteria for 18 hours of Category I toward the Physicians Recognition Award of the American

Proceeding of the Annual meeting will not be preparedasa separate publication. However, selectedpresentations,scientific papers and pertinent discussionwill be printed in theAnnals of Emergency Medicine, the journal of the AmericanCollege of Emergency Physicians and the University Associationfor Emergency Medicine. In addition, the abstractsfrom the 1987 Annual Meeting have been published in the April 1987issue of Annals of Emergency Medicine.

1988AIINUAL MEETING CALL FOR ABSTRACTS The 1988 Annual Meeting will be held May 24-26in Cincinnati. The Call for Abstracts is publishedon the insidebackcover of this program. Becausethere are changesin this year's abstract submissionprocess,pleaseread the Call for Abstractscarefully and post it in your institution.

UA/EM MEMBERSHIP A membershipapplication is included in this programandadditional copies are availableupon requestto the UA/EM office at 900 West Ottawa, Lansing, Michigan 48915 or call (517) 485-54U. If you are not a member, pleaseconsiderjoining UA/EM. If you are already a member, give this applicationto a colleague. UA/EM needsyour support for the growth and development of academic Emergency Medicine.

UA/EM LEADERSHIP

RichardM. Nowak. MD President

BXECUTIVB COUNCIL

Jerris Hedges,MD Program Chairman

Gail Anderson,MD Louis Binder, MD RichardNowak, MD, President Glenn Hamilton, MD ErnestRuiz, MD, President-Elect Mary Ann Cooper,MD, Secretary/Treas- Ben Honigman,MD RichardLevy, MD urer Harvey Meislin, MD RichardLevy, MD, PastPresident William Robinson,MD JackPeacock,MD, PastPresident John Schriver,MD StevenDavidson,MD, PastPresident David Wagner,MD William Barsan,MD, Councilman MD John Wiegenstein, Arthur Sanders,MD, Councilman JamesNiemann,MD, Councilman ConsensusConference JerrisHedges,MD, ProgramChairman Louis Binder, MD, Co-Chairman JamesWoodburn,MD, EMRA Represen- SheldonJacob$on,MD, Co-Chairman tative Fellowship COMMITTEES CharlesBrown, MD, Chairman ShermanPodolsky,MD Constitution and Bylaws JamesWoodburn,MD RobertJorden,MD, Chairman JamesNiemann, MD Governance DonnaSeger,MD J. DouglasWhite, MD, Chairman Education PeterManingas,MD ThomasStair, MD, Chairman JosephOrnato,MD JamesNiemann,MD ScottSyverud,MD ShermanPodolsky,MD JosephWaeckerle,MD JamesRoberts,MD Blaine White, MD Nominating Governmental Affairs ErnestRuiz, MD, Chairman Richardlrvy, MD, Chairman StevenDavidson,MD StevenBarrett, MD RichardLevy, MD David Wagner,MD G. PatrickLilja, MD J. DouglasWhite, MD BlaineWhite, MD Industrial Relations Program ErnestRuiz, MD, Chairman JerrisHedges,MD, Chairman CharlesBabbs,MD Judith Tintinalli, MD Robert Knopp, MD Michael Callaham,MD Harvey Meislin, MD G. PatrickLilja, MD Arthur Sanders,MD International Affairs StevenDavidson,MD, local arrangements BruceRowat, MD, Chairman HermanDelooz, MD AD HOC COMMITTEES SheldonJacobson,MD Academic Departments of Emergency Wayne Longmore, MD Medicine KennethMattox, MD E. JaclsonAllison. MD. Chairman YasuhiroYamamoto.MD

Membership SteveDronen, MD, Chairman Louis Binder, MD Daniel Cavallaro,NREMT PeterManingas,MD Harlan Sfueven.MD ResidencyDirectors BruceThompson,MD, Chairman 19E7UA/EM-IRIEM Research Symposium Paul Auerbach,MD, Chairman 19E8UA/EM-IRIEI|{ ResearthSymposium William Barsan,MD, Chairman

REPRESENTATIVES American Board of Emergency Medicine Gail Anderson,MD StevenDavidson,MD JudithTintinalli, MD David Wagner,MD ABEM Intraining Examination Committee V. Gail Ray, MD JosephZeccardi,MD AMA Commission on Emergency Medicine Services Paul Pepe,MD, delegate Jack Peacock,MD, alternate ACEP ResearchCommittee PeterManingas,MD Annals of EmergencyMedicine MichaelCallaham,MD, associate editor AAMC Council of Academic Societies MichaelCallaham,MD, delegate ThomasStair, MD, delegate StevenDavidson,alternate RichardLevy, MD, alternate Emergency Medicine Foundation Barry Wolcott, MD

VADE MECT]M BESTBASICSCIENCEPAPER l985-Michelle H. Biros, MD, MS, University of Cincinnati "Post 'Insult Treatment of I schemia-hduc ed Cerebral Inc ti c Acidosisin the Ratt' 1986-Peter A. Maningas,MD, Letterman Army Institute of Research "Use of 7.5VoNaCU6%Dextran 70for Treannentof SevereHemorrlwgic Shockin Swine"

"Effea of Time on Regional Organ Pedusion During Two Methds of Cardiopuhnnary Resuscitation" 1984-Gerard B. Martin, MD, Henry Ford Hospital "Insulin and Glucosekvels During CPRin the CanineModel"

BESTCLIMCAL SCIENCEPAPER

1985-William C. Dalsey, MD, and ScottA. Syverud,MD, University of Cincinnati "Transcutaneous and CardiacPacingFor Transvenaus Early Bradyasytolic Card.iac Arrest"

1985-Harlan Stueven, MD, Medical Collegeof Wisconsin " Bystander/FirstResPonderCPR: Ten YearsExperiencein a Para' medic Systern"

1986- StevenChernow,MD, University of Arizona "Use of the EmergencYDePartHyPertensive ment for Screening"

1986-Stuart A. Malafa, MD, Butterworth Hospital, Grand RaPids "Prehospitalhdex: A Multicenter Tial" and JosephF. Waeckerle,MD, BaPtist Medical Center, KansasCitY "A ProspectiveStudy ldentifYing the Efficacy of Clinical Findings and. Sensitivity of RadiograPhic Findingsin CarpalNaicular Fractures"

BEST SCIENTIFIC POSTER 1986-Mark Howard, DO, Henry Ford Hospital "Improvementin CoronaryPerfusion Pressureslfier OPen Chest Cardiac Massagein Hutnans: A Prelimirnry Report"

BEST RESIDENTPAPER 1983-Jeffrey A. Sharff, MD, Oregon Healttt SciencesUniversitY

Using Flurwrazine, A Calciun Antagonist" 1982-Carl Winegar,MD, WaYneState University "Early Arnelioration of Darnage in Dogs Afier Minutes of CardiacAnest" 1983-CharlesF. Babbs,MD, UniversitY " Improved Cardi,acOutPut Cardiopulmonary with Interposed Compressions" 1984-Charles G. Brown, MD, StateUniversity " Inj uri esAssociatedwiththe cutaneous Placetnent " Transthoracic Pacemalers

BESTPRESBNTATION BEST PAPER t977-Lawrence B. DunlaP, MD, Josephine General HosPital, GrantsPass,Oregon " Percutaneous Transtracheal Ventilation During Car" d.iopulmorwry Resuscitation 1979-Albert E. Cram, MD, University of Iowa "The Effect of PneumaticAntiShock Trouserson Intercranial Pressurein the CanineModel" 1980-Blaine C. White, MD, WaYne state university " Mitochondrial 0" Useand AW Synthesis:Kinetic Effects of Ca"+ and HP@ Modulated by Glucoconicoids" 1981-Blaine C. White, MD, Wayne StateUniversitY "Correction of CanineCerebral Cortical Blood FIow and VascularResistancePost Arrest

1980-Jacek B. Franaszek,MD, HaroldA. Jayne,MD, of Illinois "Medical Preparations for an Mass" door Papal MD, 1981-RobertW. Strauss, Chicago sity of "Expanded Role of the Enerna in the Acute Abdomen

1982-StephenR. Boster,MD, U ty of Louisville "Translaryngeal'4bsorbtion Iidocaine" 1983-SandraH. Ralston,MD, University "Intrapulmonary Epi During

Prolonged.

: diopulmorwryResuscitation proved RegionalBloodFlow Resuscitationin Dogs" 1984-Paul M. Paris,MD, Pittsburgh "The Prehospinl Useof taneous Cardiac Pacing"

IMAGO OBSCT]RAAWARD

MACKENZIE AWARD

1976-Norman E. McSwain,Jr., MD 1977-SungRock Lee, MD 1978-G. Patrick Lilja, MD 1979*StephenKaras, MD 1980-Jack Goldberg, MD 1981-Robert Knopp, MD 1982-Blaine C. White, MD 1983*RichardC. Irvy, MD 1984-Glenn C. Hamilton, MD 1985-Jerris R. Hedges,MD 1986*David DuBois, MD

1976-JamesR. Mackenzie,MD 1977-Cyril T. M. Cameron,MDt 1978-John H. Hughes,MD 1979-JosephF. Waeckerle,MD 1980-KennethL. Mattox, MD 1981-Barry W. Wolcott, MD 1982-Hubert T. Gurley, MD 1983-Ronald L. Krome, MD 1984-CharlesF. Babbs,MD 1985-Blaine C. White, MD 1986-JamesNiemann,MD

PAST PRESIDENTS

KEI\IYEDYLECTT]RERS

HONORARY MEMBERS

1970-197l-Charles Frey, MD l97l-1972-Alan R. Dimick, MD 1972-1973-Robert B. Rutherford, MD I973-I974-Iames R. Mackenzie, MD I974-1975-GeorgeJohnson,Jr., MD I975-t976-Leslie E. Rudolf, MD 1976-L977-DavidK. Wagner,MD 1977-I978-Carl Jelenko,m, MD 1978-1979-RonaldL. Krome, MD 1979-1980-KennethL. Mattox, MD 1980-1981-W.KendallMcNabney,MD l98l-1982-Joseph F. Waeckerle,MD 1982-1983*BarryW. Wolcott, MD 1983-1984-JackB. Peacock,MD 1984-1985-RichardC. Levy, MD 1985-1986*Steven J. Davidson,MD 1986-1987-RichardM. Nowak, MD

1973-Fraser N. Gurd, MD 1974-Oscar P. Hampton,Jr., MD 1975-Curtis P. Artz, MD 1976-John G. Wiegenstein,MD 1977-Peter Safar,MD 1978-SenatorAlan M. Cranston 1980-EugeneL. Nagel, MD 1981-C. ThomasThompson,MD 1982*R AdamsCowley, MD 1984-David K. Wagner,MD 1985-Richard F. Edlich, MD, PhD 1986-Henry D. Mclntosh, MD 1987-Richard D. Sparks,MD

1973-Robert H. Kennedy,MDf FraserN. Gurd, MD C. BarberMueller, MD 1974-John G. Wiegenstein,MD Alexander Walt, MD 1975*OscarP. Hampton,MDf N. H. McNally, MDt Curtis P. Artz, MDt 1976-Anita M. Dorr, RNt EugeneL. Nagel, MD I977-Peter Safar,MD 1978-Eben Alexander,Jr., MD 1979-David R. Boyd, MD, CM 1981-R AdamsCowley,MD 1982-Carl Jelenko,III, MD

PAST ANI\IUAL MEETINGS 1st Annual Meeting May 14-15, t97l Ann Arbor, Michigan

7th Annual Meeting May 15-18,1977 KansasCity, Missouri

13th Annual Meeting June14, 1983 Boston,Massachusefts

2nd Annual Meeting May L2-L3,1972 Washington,D.C.

8th Annual Meeting May 18-20,1978 San Francisco, California

14th Annual Meeting May 22-25,l9M louisville, Kentucky

3rd Annual Meeting May 23-25,1973 Hamilton,Ontario

9th Annud Meeting May ?A-26, t979 Orlando, Florida

15th Annual Meeting May 2I-2t1,1985 KansasCity, Missouri

4th Annual Meeting May 28-JuneL, 1974 Dallas, Texas

lOth Annual Meeting April 20-23, 1980 Tucson, Arizona

l6th Annual Meeting May 13-15,1986 Portland, Oregon

5th Annual Meeting May 20-24, L975 Vancouver,British Columbia

llth Annual Meeting April 13-15,1981 SanAntonio, Texas

17th Annual Meeting I0.f.ay 19-21,1987 Philadelphia,Pennsylvania

6ttr Annual Meeting May lL-15,1976 Philadelphia,Pennsylvania

12th Annual Meeting April 15-17,1982 Salt Lake City, Utah

AI\NUAL MBETING OVERVIEW Tuesday,May 13 9:00- 5:00pm 9:fi) - 12:00noon 9:fi) - 12:00noon 11:00- 12:30pm 12:30- 2:30pm 2:30- 3:15pm 3:45- 5:15pm 5:15- 5:30pm 5:00- 7:00pm 5:30- 7:00pm 6:30- 8:00pm 7:30- 9:30pm

UAJEM Registration, ConferenceCenter Hall Poster Set-Up, ConferenceCenter Ballroom E:rhibitor Set-Up, ConferenceCenter Hall Ancrican Journal of Emugency McdicinctE/litorial Board Meeting' Salon 10 Ctinicst Practice Papers, WyndhamA Kennedy Lecture, WyndhamA Clinical Practice Papers, WyndhamA Education/Administration Papers' WyndhamB Academic Emergency Medicine in Australia' WyndhamA Volleyball Tournament, Clark's Uptown Health Club UA/EM-STEM Cocktail Reception' WyndhamC EMRA-UA/EM Resident ResearchForurn, Salons3 and 4 UA/EM-STEM Fellows Dinner and Program' WyndhamD

Wednesday, May 20 UA/EM Registration, ConferenceCenter Hall 7:00- 8:00am Toxicologr Papers, WyndhamA 8:15- 9:30am 10:00- 1l:00am 11:15- 12:00noon 1:00- 2:00pm 2:30- 3:30pm 3:00- 5:00pm 5:00- 6:30pm 5:00- 7:00pm 6:00- 7:00pm 6:30- 8:30pm 7:00- 11:00pm

CPR Papers, WyndhamB Awards hesentations, WyndhamA UA/EM and STEM Membership Open Forum' WyndhamA Poster Session:Red, ConferenceCenter Ballroom Poster Session:Yellow, ConferenceCenter Ballroom Shock Resuscitation Papers, WyndhamA Trauma Papers, WyndhamB IYIH Panel, WyndhamA Volleyball Tournament, Clark's Uptown Health Club EMRA - EmergencyMedicine Reception' Salon 5 and 6 Ad Hoc AcademicProgram Directors'Meeting' WyndhamB UA/EM Executive Council Meeting' Parlor C

Thursday,May 21 7:00 - 8:00 am 8:00 - 9:00 am

UA/BM Registration, WyndhamFoyer EMS/Trauma Papers, WyndhamC CPR Papers, WyndhamD Poster Session:Green, ConferenceCenterBallroom 9:30 10:30am 11:00- 12:00noon CPR - Pre-Hospital Papers, WyndhamC Cerebral Resuscitation Papers' WyndhamD Committee on Acsdemic Departments of Emergency Medicine Meeting, WyndhamC l2:OO- 1:00pm Diagnostics Papers, WyndhamC l:00 2:30pm Cervicat Spine Iqiury Papers, WyndhamD Cerebral ResuscitationPapers, WyndhamC 3:00 4:00pm Airway/Respiratory Papers' WyndhamD Presidential Addrâ‚Źss, WyndhamC 4:00 4:30 pm UA/EM Annual BusinessMecting, WyndhamC 4a:30- 5:00pm Volleybdl Tournament, Clark's Uptown Health Club 5:00 7:00 pm UA/EM Annual Awards Banquet, College of Physiciansof Philadelphia 6:00 - 10:00pm

KBNNEDY LECTT]RE

Robert D. Sparks, M.D. President and Trustee W.K. Kellogg Foundation, Battle Creek, Michigan

of the specialtyof EmergencyMediTheacademicdevelopment cine will be a key to its future position in the houseof medicine. This developmentmay well be impededby the trendsin the currenthealthcaresystemwhich hasbeenchangingrapidly in the last few years.It hasbeenmy hopeto find a Kennedy lecturerwith the appropriatecredentialsto commenton these issuesduring my year as presidentof the organization.It has beenmy extremegoodfornrnethat throughDr. Kellen andDr. Altnan at theJohnHopkinsUniversitySchoolof Medicinestaff, that we have beenable to invite Dr. Robert D. Sparksto be the 1987Kennedylecturer.

on the Boardof Directorsof the BattleCreekSymphony.Dr. Sparksis a memberof the AmericanMedical Association,and theMichiganStateandCalhounCountyMedicalSocieties.He served on the Board of Educationfor the Lakeview Public SchoolDistrict, BattleCreek, from 1979-83.In 1985he was appointedto PresidentReagan'sBoardof Advisorson Private SectorInitiatives andin 1986waselectedto membershipin the He Instituteof Medicineof theNationalAcademyof Sciences. and internal medicine is the author of articles in the field of healthplanning, and serveson the editorial board of Preventive Medicine.

Dr. Sparksis presidentanda trusteeof theW.K. KelloggFoundationof BattleCreek,Michigan.As president,Dr. Sparksis responsible for disseminationandevaluationof Foundationprograms,communications, andrepresentation to foundationorganizations and other foundations.He was named presidentin 1982.Beforejoining the Foundationstaff in 1976 September as a programdirector in health, Dr. Sparksservedfour years as chancellorof the University of NebraskaMedical Center, Omaha, and vice president of the University of Nebraska System.He also servedin faculty and administrativepositions in the TulaneUniversitySchoolof Medicine,New Orleans, Louisiana,from 1958ta t972. He wasnameddeanof theTulane MedicalSchoolin 1969.Dr. Sparksearnedhis bachelor'sand medicaldegreesfrom theUniversityof Iowa, Iowa City, completinghis graduatemedicaleducationat CharityHospital,New Orleans,andat theTtrlaneUniversitySchoolof Medicinewhere he specializedin internal medicineand gastroenterology.He receivedan honoraryDoctor of HumanitarianServiceDegree from CreightonUniversity, Omaha,Nebraska.Dr. Sparksalso receivedthe OutstandingAchievementAward of the Health EducationMedia Associationand is a DistinguishedService memberof the Associationof AmericanMedicalColleges.Dr. Sparksis a memberand treasurerof the Boardof Directorsof theNationalCouncilon Alcoholism,Inc. He serveson tlte Visiting Committeeof the Harvard Medical School.He also serves

The Kellogg Foundationis amongthe largestprivate philanthropicorganizationsin the world with assetsof about$3 billion andgrantsof approximately$90million annually.Areasof emphasis are adult continuing education;bettermentof health (health promotion/diseaseprevention/public health); communitywide, coordinated,cost-effectivehealth services;a wholesomefood supply;andbroadeningleadershipcapacityof individuals.In Michiganonly, supportis given for economic andopportunitiesfor youth. Foundationprojects development are concentratedin the United States, Latin America, and southernAfrica with limited activity worldwide. of this individual aremerelythe The abovelisted achievements tip of the icebergwhen one hasthe pleasureof reviewing Dr. Sparks'curriculumvitae. His positionsasa deanof a medical schoolanda chancellorof a universityacademicmedicalcenter, an extensivelist of original publicationsin a variety of peer reviewjournals, and his very specialinterestsin the development of other current health care systemsreally do makehim the idealcandidateto commenton academicEmergencyMedicinedevelopmentin our time. Lastly, thepresidentof anorganization grantingapproximately$90 million per year for health relatedimprovementsis certainly an individual that many of us would like to know much better.

Nchard M. Nowak, MD, President

SCIIEDULE OF EVENTS Monday,May lE, 1987 9:fif - 5:lX) pm STEM Educational Forum 2:fi) - 5:l}0 pm Annals of EmergencyMcdbine Editorial Board Meeting' Sfun 9

Tuesday,May 19, 1987 9:fi) - S:fX)pm UA/EM Registration, ConferenceCenter HaIl 9:fi) - 12:f[ noon UA/EM Poster Set-Up, ConferenceCenter Ballroom 9:lXl - 12:l[ noon STEM Educational Forum ll:fi)

- 12:30 pm Ancrican Journal of EmcrgencyMcdicine Editorial Board Meeting' Salon 10

ORAL PRESENTATIONS 12:30 - 2:30 pm Clinical Practice, Wyndlunt A Moderator: ThomasStair, MD, GeorgetownUniversity 1. Prevalenceof UnsuspectedHuman Immunodeficiency Virus (HIV) in Critically Ill EmergencyPatients,Gabor Kelen, MD, JohnsHopkins UniversitY 2. Durationof AntagonisticEffectsof NalmefeneandNaloxone in OpiateInducedSedationfor EmergencyDepartment Procedurcs,William Barsan, MD, University of Cincinruti 3. Appendicitis: Evaluation by Tc-9m Leukocyte Scan, Philip Hennemon,MD, Harbor'UCUI Medical Center 4. A Studyof ChlamydiaTrachomatisPelviceInflammatory Diseasein WomenUndergoingPelvicExaminationin an EmergencyDeparunent Setting, Kristin Jenson, MD, Universiryof lllircis, Peoria 5. ContinuousAntibiotic Therapyof Wounds,Nclnrd Dan, MD, Universityof Arizotw 6. SequentialTreatmentof a SimplePneumothorax,Phyllis Vallee, MD, Henry Ford Hospinl 7. Lung Complianceasa Predicterof HemodynamicChange in TensionPneumothorax,StevenWhite,MD, University of Pittsburgh 8. Observationof HeadTraumaPatientsat Home: A Prosptective Study of Compliancein the Rural South,David Cline, MD, fust Carolina University 2:30 - 3:15 pm Kennedy leture, Wyndhan A Robert D. Sporks, MD, hesident and Trustee, W.K. Kellogg Foundation, Baftle Creek, Michigan "Growing in the lvy: Emergency Medicine in 1987" 3:15 - 3:45 pm Coffee Bretk' ConferenceCcnter Hall

3:45 - 5:15 pm Track A - Clinical Practice, WyndhatnA Moderator: Lynette Doan, MD, University of Chicago 9. Lack of Efficacyof "Weighted" Radiognphsin Diagnosing Acute AcromioclavicularSeparation,Philip Bossart, MD, Universityof Utah 10. The DiagnosticAccuracy and RadiologicEvaluationof Hand/WristandFoot/AnkleInjuries,EdwardSloan,MD, Universityof lllinois 11. Comparisonof Gastric and Closed Thoracic Cavity Lavagein tlie Treatnentof SevereHypothenniain Dogs, Doughs Brunette,MD, HennepinCountyMedical Center 12. Pain Reduction in Local Anesthetic Adminisfration ThroughpH Buffering, Nclard Christoph,MD, University of Virginia 13. Antibiotic Prophylaxisof Oral Wounds,RobertMooney, MD, Harbor-UClll Medical Center 14. Early Fresh Frozen PlasmaProphylaxis of Abnormal CoagulationParametersin the SeverelyHead Injured is not Effective, James Winter, MD, Hennepin County Medical Center

3:45 - 5:15 pm Track B - Education/Administration, Wyndhan B Moderator: ShermanPodolsky,MD, Albert EinstienMedical Center 15. An OrganizedFollow-UpSystemfor Trainingof EmergencyMedicine Residentsand Studentsin a Community HospitalProgram,David Bauer, MD, WilliamBeaumont Hospital 16. EmergencyDepartmentTelephoneAdvice to Patients, Vince Verdile, MD, Universiryof Pinsburgh 17. Decisionto Admit: ObjectiveDRG Criteria VersusClinical Judgement,Inuis Graff, MD, New Britain Gmeral Hospinl 18. EmergencyDepartnent"Dumping" in the Mid South, Anhur Kellermann,MD, MPH, Universityof Tennessee 19. Doesa HelicopterServiceStimulateFinanciallyMotivated Transfers?KennethRhee,MD, Universityof California, Davis 20. A Descriptionof the MassCasualtyPlanfor Paris,France in Response to a TerroristBombing,RobertNorton, MD, OregonHealth SciencesUniversity

5:15 - 5:30 pm AcademicEmergencyMedicine in Australia, WyndhamA, AnneF. D'Arcy, MD, Vice-PresidentandResearchCommitteechairperson,AusftalasianCollegeof EmergencyMedicine,Melbourne, Victoria, Australia.

Sponsoredby Australian Biomedical Corporation, Ltd. S:fi) - 7:fi) pm Volleyball Tournament, Health Club - Third Floor 5:30 - 7:fi) pm UA/EM-STEM Cocktail Reception, Wyndhun C 6:30 - E:fi) pm First Annual EMRA-UA/EM Resident ResearchForum, Sal,ons3 and 4 CharlesBrown, MD, Universityof Ohio, "Sponsorsand InformationSourcesfor ResearchFunding" ShermanPodolsky, MD, Albert Einstein Medical Center, "Guidelines for Writing EmergencyMedicine ResearchProtocols" 7:30 - 9:30 pm UA/EM-STtsM Emergency Medicine ResearchFellows Dinner and Program, WyndhamD ShermanPodolsky,MD, Albert EinsteinMedical Center, "EmergencyMedicineFellowshipsin 1987" Judith Tintinalli, MD, William BeaumontHospital, "Certification of EmergencyMedicine Fellowships"

Wednesday,May 20, 1987 7:fi) - 8:15 am UA/EM Registration (Coffee and Rolls) ConfcrenceCenter Hall 8:15 - 9:30 am Toxicologyl, Wyndhan A Moderator:Lewis Goldfrank, MD, New York University 21. SerumCatecholaminesin CocaineIntoxicated Patients with CardiacSymptoms,StevenKarch, MD, University Medical Center, Lts Vegas 22. Treafinentof CCl4-krducedHepatotoxicity:A Model for Similar Toxins, Sandra Sclmeider,MD, University of Pittsburgh 23. Acute CimetidineOverdosage:An Asessmentof 881 Cases, Edward Krenzel,ok, PhermD, University of Pittsburgh 24. PhenytoinProphylaxisof Cardiotoxicity in Experimental Amitryptiline Poisoning, Henry Schumaker,MD, Universityof Califumia, SanFrancisco 25. Potentiationof Glucagonby Theophylline in the Intact Canine Model with Complete Beta-adrenoreceptor Blockade by Propranolol, Micluel Sugg, CPT, MC, BrookeArmy Medical Center

10:fi) - ll:fi) am Track A - Toxicolog5rII, Wyndlunt A Moderator: SandraSchneider,MD, University of Pittsburgh

26. Efficacyof DelayedAdminishationof Croalid Antivenin, Alan Gold.ner,MD, Universityof Arizoru 27. Efficacy of Charcoalversuslpecac in ReducingSerum Acetaninophenin a SimulatedOverdose,CynthiaAaron, MD, Medical Collegeof Pewtsylvania 28. MethemoglobinLevels Following Inhalation of Amyl Nitrate, John GaWun,MD, Universityof Pittsburgh 29. Specific Treatnent and Quick Diagnosis of Benzodiazepineand Alcohol Overdosesin the Emergency Deparfinent,Roben Askenasi,MD, PhD, Universityof Brussels,Belgiwn

10:f[ - 11:00 am Track B - CPR l, WynilhantB Moderator: CharlesBrown, MD, Ohio StateUniversity

30. Effects of DichloroacetateFollowing CanineAsphyxial CardiacArrest, SusanGin, MD, Universityof Cincinmti

3 1 . Electrical-Mechanical Dissociation in Humans: An EchocardiographicEvaluation, Joseph Boclu, MD, William BeawnontHospital 32. Defining ElectromechanicalDissociation:Morphologic Presentation,Harlan Stueven,MD, Medical Collegeof Wisconsin 33. A Comparisonof Epinephrine and Methoxaminefor ResuscitationFrom ElectromechanicalDissociation:A Studyin HumanSubjects,Lanny Tumer,MD, University of lllinois, Peoria

ll:fi) - 11:15 am Awards hesentations, WyndhamA 19t6 Annual Meeting Best Ctinical SciencePaper "Pre-HospitalIndex: A Multicenter Trial," StuartMalafa, MD, ButterworthHospital,and "A ProspectiveStudyldentiffing theEfficacyof Clinical FindingsandSensitivityof RadiographicFindingsin Carpal Fractures,"JosephWaeckede,MD, BaptistMedical Center The Best Clinical SciencePaperAward is sponsoredby MICROMEDEX, Inc. l9td Annual Meeting Best Bssic SciencePaper "Use of 7 .5% NaCll6% Dextran 70 for Treatmentof SevereHemmorrhagic Shockin Swine," PeterManingas,MD, man Army Institute of Research The Best Basic SciencePaperAward is sponsoredby EmergencyMedicine.

19t6 Annual Meeting Best Scientific Poster "Improvement in Coronary Perfusion PressuresAfter Open ChestCardiac Massagein Humans:A Preliminary Mark Howard, DO, Henry Ford Hospital The BestScientificPosterAward is sponsoredby EmergencyMedicineand AmbulntoryCare NewsandDuPontCritical 19t6 Annual Meeti4g Best Resident Paper "Use of the EmergencyDepartment for HypertensiveScreening,"StevenChernow,MD, Universityof Arizona The Best ResidentPaperAward is sponsoredby Annals of ErnergencyMedicine.

11:15- 12:00noon UA/EM-STEM Membership Open Forum to discussopportunities for a closerworking relationship UA/EM and SIEM, WyndhamA RichardM. Nowak, MD, UA/EM President ThomasO. Stair, MD, STEM ImmediatePastPresident

l:fi) - 2:fi) pm Poster Presentations: Red Session, ConlerenceCenterBallroom 2:fi) - 2:30 CoffeeBrcak, Conference CentcrHall 2:30- 3:30 Poster hesentations:

Yellow Session, Conference CenterBallroom

3:fi) .5:fi) pm Track A - Shock Resuscitation, WyndlunrA Moderator: Peter Maningas,MD, LettermanArmy Institute

3:fi) - 5:fi) pm Track B - Trauma, WyndhamB Moderator: StevenDronen. Universitv of Cincinnati

40. Strategiesfor SelectiveUseof IntravenousSelography (IVP) in BluntRenalTrauma,GaryFleisher,MD, Univer34. Treatrrentof Anaphylaxisin Beta-BlockedRabbits,Peter sity of Pennsylvania Van Ligtm, MD, Universityof Cincinnati 41. RoutinePelvic Radiographyin SevereBlunt Injury: Is It 35. SevenYearsExperiencewith GroupO UnmatchedPacked Necessary?WDNJ/Roben WoodJohnson RedBloodCellsin a RegionalTraumaUnt, Johnlzfebre, 42. EchocardiographyPerformedby EmergencyMedicine MD, Universityof Toronto Physicians: Impact on Diagnosis and Therapy, Ray 36. Resuscitationof Hypovolemic Shock with Cold Blood, Mayron, MD, Hennepin CountyMedical Center StevenSchirk, MD, GeisingerMedical Cmter 43. TraumaScoreChangeDuring Transport:Is It Predictive 37. The Effect of Ethanolon Survival Time in Hemorrhagic of Mortality? Kmneth Rhee,MD, Universityof CalifurShockin an UnanesthetizedSwine Model, Bian Zink, nia, Davis MD, Universityof Cincirvnti 4 . BenefitsandCostsof AdmissionFollowingHeadInjuries 38. Comparison of Peripheral, Central and Intraosseous Mark fuhtla, MD, Tems Routesin Resuscitation of HemorrhagicShocksin Pigs, with Loss of Consciousness, Tech University John Dg NeufeW,Denver GenerqlHospital in a HeadTraumaand lts PsychologicalConsequences 39. Analysis of Growth Plate Abnormalities Following Intraosseous InfusionThroughthe ProximalTibial EpiphyGroupof Adults, Ira Gensemer,MD, GeisingerMedical sis in Pigs, Kis Briclonan, MD, St. VincentMedical Center Cmter/The ToledoHospilal S:fi) - 6:30 pm Panel: "NIH Funding for EmergencyMedicine: Myth or Reality?", WyndharnA Moderator:RichardC. [,evy, MD, Universityof Cincinnati Panelists: JohnR. Marler, MD, Medical Officer, StrokeandTraumaProgram,NationalInstituteof NeurologicalandCommunicative Disorders and Stroke DonaldLeucke,MD, Deputy Director of ResearchGrants,NationalInstitutesof Health NormanAbramson,MD, Universityof Pittsburgh William Barsan,MD, Universityof Cincinnati BlaineC. White, MD, WayneStateUniversity 5:fi) 7:fi) pm Volleyball Tournament, Health Club - Third Floor 6:fi) - 7:fi) pm EMRA-Energency Medicine Reception, Salon 5 and 6 6:30 - 8:30 pm Ad Hoc Academichogram Directors'Meeting, WyndhamB Chairman:BruceThompson,MD, Henry Ford Hospital 7:fi) - ll:fi) pm UA/EM ExecutiveCouncil Meeting, Parlor C

Thursday, May 21, 1987 7:fi) - t:fi) UA/EM Registration (Coffee and Rolls), WyndhonrFoyer 8:ffi - 9:30 am Track A - EMS/Trauma, WyndhamC Moderator:Paul Paris, MD, Universityof Pittsburgh 46. ProspectiveStudyof Morbidity and Cost Effectiveness of Safety Belts, Elizabeth Mueller, MD, University of Illinois 47. Characteristics of Mid-SizedUrbanEMS Systems,Odelia Braun, MD, Universityof Califurnia, San Francisco 48. Mechanismof Injury andAnatomicInjury asPre-Hospital TraumaTriageCriteria,.4nnYanagi,MD, ValleyMedical Center 49. Timely Utilizationof an EmergencyAeromedicalService

by Rural EmergencyDepartmentsto Transfer Trauma Victims, NicholasBauon, MD, fu.rt Carolina University 50. Initial Care and Transportof PediatricTraumaVictims, Miclwel Dick, MSc, Ohio State University 51. A Comparisonof a BiosyntheticSkin Substituteversus 1% Silver SulfadiazeneCreamin the OutpatientTreatmentof SecondDegreeBurns, CharlesEmerman,MD, CaseWesternReserveUniversitv

8:ffi - 9:30 am Track B - CPR II, WyndharnD Moderator:William Barsan,MD, Universityof Cincinnati 52. Optimizing Hemodynamics of Cardiopulmonary Resuscitation

by Varying AMominal CompressionTechniques,JamesChristenson, MD, Universityof Calgary, Alberta MyocardialOxygenDelivery and ConsumptionDuring CPR:A Comparisonof EpinephrineandPhenylephrine, Ronald Taylor, MD, Ohio State Universiry The Effect of MetabolicAcidosison EpinephrineDuring CardiopulmonaryResuscitation, Mark Zwanger,MD, WayneState University Massagein Dogs, 55. Lidocainelrvels During Closed-Chest Patrtce Bartsh, MD, William BeaumantHospital 56. AsynchronousCardioversionof VentricularTachycardia, Edward Michelson, MD, Universityof Pittsburgh 5 7 . A Comparisonof thePerformance of Five Transcutaneous Pacing Devices, Joseph Peterson, MD, University of Pinsburgh

9:30- 10:30am Poster kesentations:

Green Session, Conference CenterBallroom

10:30 - 1l:00 am Cofree Break, Wyndlwn Foyer ll:fi) - 12:00 noon Track A - CPR ltr-he-Hospital, lVyndhan C Moderator: Paul Pepe,MD, Baylor College of Medicine 58. Pre-HospitalAdministrationof Lidocaine:Bolus versus BolusPlusInfusion,JosephNeal, MD, WakeForestUniversity 59. New Perspectiveon Rural EMT Defibrillation, Larry Vulrov,MD, Mayo Clinic 60. Pre-HospitalTrial of EmergentTranscutaneous Cardiac Pacing, Scon Syverud,MD, Universityof Cincinnati 61. A Randomized Studyof EpinephrineversusMethoxomine in PreshospitalVentricular Fibrillation, Ranjan Tahtr, MD, Medical College of Wisconsin

ll:fi) - 12:00 noon Track B - Cerebral Resuscitation I. WyndhanrD Moderator: Bruce Thompson,MD, Henry Ford Hospital Failure of Flunarizineto ProtecttheBrain During fusion Following a 15 Minute CardiacArrest: tion by Markers of MembraneInjury and Morphometry,Blaine llhite, MD, WayneState 63. DeferoxaminePost-TreatnentFollowing Total Ischemia in Dogs, Kevin Kelly, Medical College Wisconsin,Purdue University 64. Brain Enzymelrvels in CSF of DogsAfter Cardiac rest and Resuscitation:Markers of Damageand tors of Outcome, Peter Safar, MD, University Pinsburgh 65. Reversibility of Clinical Deathin Patients:TheMyth the 5 Minute Linit, Paer Safar, MD, University Pittsburgh

12:fi) - l:fi) pm Committee on Academic Departments of Emergency Medicine Meeting, WyndhamC Chairman:E. JacksonAllison, MD, East CarolinaUniversity l:fi) - 2:30 pm Track A Diagnostics,WyndhatnC Moderator: Iouis Ling, MD, HennepinCounty Medical Center 66. Increasing the Diagnostic Power of the Electrocardiogram, Roben Tnlenski, MD, Universityof lllinois 67. How Many MyocardialInfarctionsShouldWe RuleOut? Roben Wears,MD, UniversityHospital of Jaclaonville 68. Clinicalhedictors of BacterialDiarrheain YoungInfants, JonathonFinkelstein,BA, Universityof Pennsylvania 69. Pre-HospitalPredictersof Acute Myocaridal Infarction andUnstableAngina, KathleenHargarten,MD, Medical Collegeof Wisconsin 70. CarboxyhemoglobinLevels in Patientswith Headache, Carey Chisholm,MD, Brooke Army Medical Center 71. Comparisonof Two-DimensionalEchocardiogram and Multigated RadionucleotideAngiographyin the Detection of CardiacInjury Secondaryto Blunt ChestTrauma, StevmDemctropoulos,UniversityHospinl of Jacl<sonville

l:fif - 2:30 pm Thack B - Cervical Spinel4jury, Moderator:RichardBurney, MD, Universityof

72. The Effect of Spinal knmobilization Deviceson monary Function in the Healthy Non-Smoking David Bauer, MD, William BeaumontHospital 7 3 . The Effect of Axial Traction and Oral Intubationon UnstableCervicalSpine,SconFord,MD, Valley Cmter 74. ComputedTomographyin the Initial Evaluationof Cervical Spine,Karen Schleehauf,MD, UMDNI, WoodJohnson 7 5 . SelectiveUse of Cervical Spine Radiographyin Trauma,RobenRntner, MD, WilliantBeaumont 76. Clinical Predictorsof CervicalSpineInjury (CSDin High Energy Transfer Injuries (BHETI), Sreven MD, UMDNJ/RobertWoodJohnson 77. Post-TraumaticNeck Pain: A Prospectiveand up Study, Roben McNamara,MD, Medical Pennsylvania

2:30 - 3:fi) pm Coffee Break, Wyndhan Foyer

3:fi) - 4:fi) pm Track A - Cerebral Resuscitation II WyndhamC Moderator: Gary Krause, MD, Wayne StateUniversity 78. CerebralResuscitation: No Flow versusLow Flow Followedby CardioputnonaryBypass,JackRosenberg, MD, Universityof Missoui 79. Assessment of CanineBrainFunctionUtilizing 31-PNMR Spechoscopy During a 12Minute CardiacArrest, 2 Hours of FemorofemoralBypassReperfusion,andSevenHours of Critical Care Therapy,Gerard Martin, MD, Henry Ford Hospital 80. Early Glucocortocoid Treaftnent Does Not Improve Neurologic Recovery From Global Brain Ischemia, Micluel Jastremski,MD, State Universityof New York 81. The Comparative Effects of Methoxamine versus Epinephrineon Regional Cerebral Blood Flow During CPR, Enc Davis, MD, Ohio State Universiry

3:fi) - 4:fi) pm Track B - Airway/Respiratory Wyndhan D Moderator:RonaldStewart,MD, Universityof Pittsburgh 82. Pre-HospitalUse of NeuromuscularBlocking Agentsin a HelicopterAmbulanceProgram,StephenBorron, MD, University of Cincinnati 83. The Alveolar-Arterial Gradient in Patients with DocumentedPulmonaryEmbolism,David Overton,MD, William BeaumontHospinl 84. Continuous Monitoring of Arterial SaturationDuring PulmonaryResuscitation,Jeffey Jones, MD, Akron GeneralMedical Center 85. ComputerizedPharmacokineticDosing of Theophylline in the EmergencyDepartrnent,E. Gonzalez,Pharm D, Medical Collegeof Virginia

4:fi) - 4:30 pm Presidential Address, WyndharnC RichardM. Nowak, MD, Henry Ford Hospital 4:30 - S:fD pm UA/EM Annual BusinessMeeting, WyndhamC S:ffi - 7:fi) pm Volleyball Tournament, Health Aub - Third FXoor 6:f[ - 10:fi) pm UA/EM Annual Awards Banquet, College of Physiciansof PhiMelphia

POSTER PRESENTATIONS 86. CaseMix and ResourceUse in The EmergencyDepartment, Larry Baraff, MD, UCIA, (Red Session) 87. EmergencyDeparfinentCritical Care Regisuy, David Plummcr, MD, Hennepin County Medical Center, (Yellow Session) 88. Trauma and Aging: Implications for a Philadelphia Trauma Service, Michael lAeingarten,MD, Methodist Hospital, Philadelphia, (Green Session) 89. ComputerizedRadiographicImaging in the Emergency Deparftnent,Inrry Baraff, MD, UCL,/|,(Yellow Session) 90. A Quality AssuranceAssessment of RadiographReading Accuracy by Emergency Medicine Faculty, David Overton, MD, Williatn Beaumont Hospital, (Yellow Session) 91. A Microcomputer-Based Quality AssuranceProgramfor theEmergencyDeparfinent,Williarnlonakin, MD, Elliot Hospital, Manchester,lfl/, (Green Session) 92. Evaluating Clinical Supervision in an Emergency MedicineResidencyProgram:ResidentandStaffPerception of Effective Supervisionand StressManagement, Bruce Thompson,MD, Henry Ford Hospital, (Red Session) 93. Powerand Leadershipin the EmergencyDepartrnent:A Surveyof Nurses,Mark l"angdorf,MD, Universityof Illinois, (Y ellow Session) 94. Time Studyof PatientMovementThroughthe Emergency Department:Sourcesof Delay in Relationto Patient Acuity, Clnrles Sawtd,ers,MD, Vanderbilt University, (GreenSession) 95. EmergencyDepartmentProtocol for the Diagnosisand Evaluationof GeriatricAbuse,Jffiey Jones,MD, ,4kron GeneralMedical Center, (Red Session) 96. Emergency Department Patient Literacy and the Readabilityof Patient-Directed Materials,RobertPowers, MD, Universityof Virginia, (Yellow Session) 97. Allocationof Time in ThreeAcademicSpecialties,Ar-thur Sqnders,MD, Universiryof Arizona, (GreenSession) 98. FactorsInvolved in Selectionof EmergencyMedicine Residents,Ronald Hayden, MD, Universityof lllinois, (RedSession) 99. Development, Implementation, and Evaluation of a MedicalSpanishCurriculumfor an EmergencyMedicine ResidencyProgram, I-ouis Binder, MD, Texas Tech University,(Yellow Session) 100. A Library in Faculty Development for Academic EmergencyMedicine,GlennHamilnn, MD, WrightState University, (Green Session) 101. DiagnosticErrors in EmergencyMedicine, a Consequenceof InadequateKnowledge,Faulty DataInterpretation or CaseType? Tim Alkn, MD, UniversiteLaval, Quebec,(RedSession) 102. Evaluationof a Hospital BasedHelicopter Emergency MedicalService(HHEMS), Carl Boyd, MD, Memorial Medical Center, Savannah,(Yellow Session) 103. ContingencyPlanningDuring an EmergencyMedicalServicesStrike,JosephRyan,MD, Universityof Pittsburgh, (GreenSession)

104. Administation Supportfor ProjectMedicalDirectors:A Profile, RobertSwor, DO, William BeaumontHospital, (RedSession) 105. DiminishingStressin UrbanEmergencyMedicalServices Personnel,Paul Pepe,MD, Baylor Collegeof Medicine, (Yellow Session) 106. A Surveyof EmergencyMedicalService(EMS)Systems in Major CitiesAcrossthe United States,RaymondHart, MD, Universityof lllinois, (Green Session) to7. Guidelinefor Developmentof EMS ReportingForms:A Nationwide Survey, StevenJoyce, MD, Universityof Utah, (Red Session) 108. Developmentof an Optically ScannedEMS Reporting Form andDatabasefor StatewideUse,StevenJoyce,MD, Universityof Unh, (Yellow Session) 109. CephalicVein Cutdownat the Wrist: Comparisonto the StandardSaphenous Ankle Cutdown,David Talan,MD, UCIA,, (Green Session) 1 1 0 .EmergencyIntraosseous Infusionsin Children:A Practical Method of TeachingPre-HospitalPersonnel,C'arfPaul Walter, MD, Michigan State Universi,),,(Red Session) l 1 l . Evaluationof VenousDistensionDevice:Phase II: Cannulation of Non-EmergentPatients,JamesAmsterdam, DMD, MD, Universityof Cincinnati, (Yellow Session) lL2. A Comparisonof Four Techniquesto EstablishIntraosseous Infusion,MichelelAagner,MD, Wigfu Stae University,(GreenSession) I 1 3 . Effect of Clothing and MeasurementTechniqueon Reliability of Blood Pressure Measurements, Jon Krohmer, MD, Wright State University, (RedSession) 1 1 4 .Accuracyof Blood PressureMeasurements MadeAboard' Helicopters,RonaldLow, MD, Universityof Oklnhonw, (Yellow Session) 1 1 5 .The Use of TransthoracicElectrical Bioimpedance in AssessingThoracic Fluid Statusin EmergencyDepartmentPatients,ClwrlesSaunders,MD, VqnderbiltUniversiry, (GreenSession) 1 1 6 .A ComparativeStudy of Intraosseous,Intravenous and Intra-Arterial PH ChangesDuring Hypoventilationin Dogs, Kris Brickman, MD, St. Vincent Medical Center/TheToledoHospital, (Red Session) tt7. Methemoglobinemiain SeverelyDehydratedInfants,/Pachter, TempleUniversity, (Yellow Session) I 1 8 . Comparisonof Intraosseous Infusion in LargeandSmall Swine,JohnSchffitall, MD, MedicalCollegeof Pennsylvania,(GreenSession) tl9. Effect of Splenectomyon HemodynamicPerformancein Fixed-Volume Canine Hemorrhagic Shock, James Hoelcstra,MD, Universityof Cincinrut, (RedSession) 120. BloodPressureEffectsof ThyrotropinReleasing Hormone (TRH) and Epinephrinein AnaphylacticShock,RoDert Muelleman, MD, Truman Medical Center, (Yellow Session) l 2 l . Effectsof DichloroacetateAdministrationDuringSevere HemorrhagicShock, Scott Syverud,MD, University of Cincinnati, (Green Session)

122. Beneficial Effects of a ProstagandinEl Infusion in Experimental Traumatic Shock, M. ,4ndrewlzvitt, DO, ThomasJeffersonUniversity, (Red Session) 123. RapidTreatnent of Patientsin Shockby Paramedicswith Medically Directed Protocols, G. Patrick Lilja, MD, Nonh Memorial Hospital, (Yellow Session) 124. The Utility of Physiologic Scoring for Determining Severityof Injury, Clurles SlwfrIebarger,MD, Allegheny GeneralHospital, (Green Session) 125. PatientOutcomewith Pre-HospitalVentricular Fibrillation: EMT-D vs EMT-P, David Williams, MD, University of Toronto, (Red Session) 126. ElectocardiographicCharacteristicsin EMD, Tom Aufderheide,MD, Medical Collegeof llisconsin, (Yellow Session),(Yellow Session) 127. CarotidArtery CollapseDuring CPR- The Importance of Cardiac versus Thoractic Pump Mechanisms Demonstratedwith Cineangiography,Clwrles Brown, MD, Ohio State Universiry, (Green Session) 128. Pre-HospitalBicarbonateUsein CardiacArrest: A Three Year Experience,Daniel Martin, MD, Medical College of Wisconsin,(Red Session) 129. NonpharmacologicalInterventionsin Therapy of ElectomechanicalDissociation,RanjanThahtr, MD, Medical Collegeof Wisconsin,(Yellow Session) 130. Reversibility of Clinical Death in Animal Ourcome Models: The Myth of the 5 Minute Limit, Peter Safar, MD, Universityof Pittsburgh, (Green Session) 13I . Is Blood GlucoseLevel anIndependentPredictorof Outcomein PatientsResuscitatedFrom CardiacArrest? I/.

Musch, MD, University of Brussels, Belgiurn, (Red Session) 132. Effects of Sodium Dichloroacetateon ATP and Phosphocreatine in Ischemic Rat Brain, Ruth Dmlich, PhD, Universityof Cincinnati, (Yellow Session) 133. Neurologic Progress and Outcome Evaluation for ResuscitationResearch with Canine Models, Mark Angebs,MD, Universityof Pittsburgh,(GreenSession) 134. NeurologicOutcomeAfter 10 MinutesCardiacArrest Plus 10 Minutes CPR, and Resuscitationwith CardiopulmonaryBypass,in Dogs, Mark Angelos,MD, Universityof Pinsburgh, (Red Session) 135. CardiopulmonaryBypassFor holonged CardiacArrest, Eic Brader, MD, AlleghenyGeneralHospital, (Yellow Session) 136. A Modelfor Assessment of CanineBrainFunctionUsing 3l-P NMR SpectroscopyDuring ProlongedCardiopuhnonary Arrest and Bypass Reperfusion, Riclnrd Nowak,MD, Henry Ford Hospital, (GreenSession) 137. IntranasalPhenylephrineas a Causeof Anisocoria, Edward Mlinek, Jr, MD, Hennepin County Medicat Cmter, (Red Session)

138. Succinylcholine AssistedIntubationsin he-Hospital Care, StevenDronen, MD, Universityof Cincinnati, (Yellow Session) 139. Useof a LightedStyletto PositionEndotracheal Tubes, Ronald Stewart,MD, Universityof Pittsburgh, (Green Session) 140. A New Adapter for Fiberoptic Bronchoscopy- Aided TrachealIntubationUnderContolled Ventilation,Makoto Imai, MD, Hoklraido University Hospital, Sapporo, Jqon, (Red Session) 141. The Effect of Scavenging on AmbientLevelsof Nitrous Oxide in Ambulances,WaIt Schrading,MD, University of Pittsburgh, (Yellow Session) 142. Manual Detectionof DecreasedLung Complianceas a Sign of Tension Pneumothorax,Riclwrd Kaplan, MS, Universityof Pittsburgh, (Green Session) 143. Early Treatment of Acute Asthma with Methylprednisolone, Roben McNamara, MD, Medical Collegeof Pennsylvania,(Red Session) 1214.Feasibilityof Pre-HospitalDiagnosisandInterventionin AcuteMyocardialInfarction,PamzlaGrim, MD, (Jniversity of Chicago,(Yellow Session) 145. Useof a SalivaReagentStrip to EstimateBloodAlcohol in EmergencyDeparfrnentPatients,Kenneth Willinms, MD, Universityof Pittsburgh,(Gre,enSession) 146. Cost-Effectiveness of RapidAntigenTestingfor Streptococcal(STREP)Pharyngitisin a PediatricEmergency Deparfinent,Gary Fleisher,MD, Universityof Pennsylvania, (Rd Session) 147. Clinical Presentation of Non-TraumaticThoracicAortic Dissections,Barnet Eskin, MD, PhD, Morristown Memori.alHospital, (Yellow Session) 148. QT Duration and PotassiumConcentrationin Early Myocardial Infarction, Amy Emst, MD, Louisiarn State University, (Green Session) 149. Incidenceof ArrhythmiasDuring Air Transporationof Patient With Acute Myocardial Infarction Who Have Received StreptokinasePrior to Transport, Beverly Ringmberg,MD, Universityof lowa, (Red Session) 150. TheUseof Nifedipinefor theField Managmentof Severe Hypertension,JohnDuda, MD, Universityof Piusburgh, (Yellow Session) 151. SorbitolCatharsisDoesNot EnhanceEfficacyof Charcoal in a SimulatedAcetaminophen Overdose,Robert McNamara, MD, Medical College of Pennsylvania, (GreenSession) I52. A Comparison of Arterial and Venous CarboxyhemoglobinLevels,EuniceSingletary,MD, BrookeArmy Medical Center, (Red Session) 153. TheEffrcacyofan EmergencyDepartrnentScreeningprogram for UnsuspectedCarbon Monoxide Exposure, Timothy Turnbull, MD, University of lllinois, (yellow Session) 154. The Incidenceof Vomiting in ComatosePatientsFollowing the Pre-HospitalAdministrationof Naloxone,paul Pqris, MD, Universityof Pittsburgh,(GreenSession)

Abstracts of the 17th Annual Meeting of the University Association for Emergency Medicine Editorb note: lhg fglJoynng154ab-stractswill be presentedat the Annual Meeting of the university Association or Emergency f Medicine in nhilad-e-lphig,Penlsylvania, May 19-21,1987. Presenterc'names appiar in italics; wherepresenteris notindil,ated, none was specified by the authors.

Oral Presentations I Prevalence of Unsuspected lluman lmmunodeficiency Virus (lttV| in Griticaily ltl Emergency Patients GDKelen, JL Baker, KTSivertson,

T Quinn/ Departmentof EmergencyMedicine,Johns Hopkins Hospital,Baltimore;Laboratoryof lmmunoregulation, National lnstitutesof Allergyand InfectiousDiseases(NIH),Bethesda Implementation of recommended guidelines for prevention ol transmission of the human immunodeficiency virus {HIV) bv emergencypersonnel is not uniform, and in part is basedon a lack of recognition of the extent of asymptomatic and unsuspectedHIV infection in this country. In order to determine the potential risk for emergency personnel of exposure to patients with unsuspectedHIV infection, we prospectivelyexamined for HIV seropositivity, the anonymous sera of 203 consecutive critically ill or injured adult patients without a previous diagnosisof HIV,.presenting to an emergency department of a large urban teachinghospital during a four month period in tSge. Sii l\%l oI the 203 _patients were seropositive for HIV antibody by both enzyme-Iinkedimmunoassay{ELISA)and Westem Blot Analysis, a35O% increaseover that of the population at large.All 6 (16%l seropositivepatients were between the agesof.25-34(n:37), and presentedwith trauma (n:108). These patients represented19% lslL7l oI all penetrating rrauma victims in this age group. All positive patients presentedwith active bleeding,had peripheral venousaccessestablishedboth in the prehospitaland emergency department_setting,and underwent multiple lnvasive pto"edur.r.

Active bleeding,peripheralvenousaccessin the field, and trauma presentation,provedto be statistically discernablefactors lp<.05: Fisher exact test) when compared to the seronegativepatients.

History of IV drug abuseand other traditional risk-factori did not prove to be discriminating in identifying which critically ill patients may posea potential exposurerisk. We conclude that critically ill emergencypatients can be an unsuspectedsourceof HIV infectious exposure,and that young victimJ of penerratrngtrauma presenta particularly high degreeof HIV exposurerisk. These results reinforce the need to implement the establishedrecommended guidelinesfor the prevention of HIV transmissionto emergencypersonnel.

2 Duration of Antagonistic Effects of Nalmefene and Naloxone in Opiate.lnduced Sedation for Emergency Depaitment Procedures WGBarsan, D Seger, DFDanzl, LTLing,

R Bartlett,R Buncher,JT Amsterdam,C Brvan,J Howes/ University of CincinnatiCollegeof Medicine;University of Arizona Collegeof Medicine,Tucson;Universitv of Louisville Schoolof N/edicine; HennepinRegionalPoisoniente( Minneapolis; RichlandMemorialHospital,Columbia,SouthCarolina;Kendle ResearchAssociates,Key Pharmaceuticals, Inc, Cincrnnati Analgesics, including opiate compounds, are frequently given . ln the emergency department prior to painful procedures.Because most procedurestake less than 30 minutes, a patient receiving_anadequateanalgesicdose of opiates -"y tr."d to be observedfor 2-4 hours after the procedure.This long observation time may discouragethe administration of an adequate analgesic dose to avoid prolonged observation. Although naloxone is an e{tective opiate antagonist,its short half-life limits its usefulness iri this situation. Nalmefene is a pure opiate antagonist structurally similarly to naloxone. The serum lialf-life of nalmefene is l0-13 hours, compared to 63 minutes for naloxone. We have completed a controlled, double-blind randomized study companng

l6

the antagonistic effects of nalmefene, naloxone, and placeboin opiate induced sedation to determine acute efficacy,dlurationof action, and adverse effects in patients urrdergoing painful emergency dâ&#x201A;Źpartment procedures.All patients receivid 1.5-3mg/kg meperidine intravenously prior to the procedure. After the procedure, patients received either nalmefene I mg, naloxone I mg, or saline I ml intravenously. Vital signs and alertness assessments were performed for 4 hours after study drug administration. Two-hundredand nine patibnts were studied af{ive centers.

Naloxone significantly reversedsedation compared to placebofor only l5 minutes while nalmefene was significantly effective (P<.05) for up to 210 minutes compared to placebo.Nalmefene was significantly more effective (P<.051than naloxonern reversing sedation at 60, 9O and 120 minutes after administration. The side effects ubserved with nalmefene were similar in type artd number to those seen with naloxone and none were life tirieatening. Nalmefene is an effective, long-lasting opiate antagonist which may be use{ul in reversing the effects of bpiates givin for out-patient procedures.

3 Appendicitis: Evaluation by Tc.99m Leukocyte Scan pL Henneman, CSN/arcus, JABuiler, ESFreedland, RJRothstein, SEWilson / Department of

EmergencyMedicine,Divisionof NuclearMedicine,Department of Surgery,Harbor-UCLA MedicalCenter,Torrance;Department of EmergencyMedicine,SuburbanHospital,Bethesda Diagnosingappendicitismay be difficult. We report a new technetium-99m-albumin colloid white blood cell ITAC-WBCIscan used in the evaluation of appendicitis.In a synthesisrequiring75 m_rngtesrautologous neutrophils and macrophagesfrom 40 cc of whole blood, were labelled with technetium-99m-albumin col.

Ioid (Microlite@)and administered to 100 patiehts with possible appendicitis.Two patients had second scans on separatehospitalizations. TWenty-six patients had appendicitis, thirteen had perforations,five of whom, had an absciis. Seventeenscanswere indeterminant; forty-sevenpercent of these patients had appen. dicitis. Eighty-fivescans were read as either positive or negative for appendicealpathology with a sensitivity of 89%, a specificity of ,92%, and an accuracyoI 92% in diagnosingappendicitis.The value of the TAC-WBC scan in the evaluation of appendicitisappears to be its ability to be used emergently,its hlgh negati;e predictive value for men and women (NpV = 97T.1,ind itJhigh positive predictive value for men {PPV = 93'/,1.The scandoes not appear to be reliable in diagnosing appendicitis in women IPPV : 43%1.

4 Study of Ghlamydia Trachomatis pelvic lnflammatory Disease in Women Undergoing Pelvic Examination in an Emergency Depadment Setting KAJensen, GZHevesy / SaintFrancii Medjcal Center

Residencytn EmergencyMedicine;University of lllinoisCollegeol Medicine,Peoria Current medical literature provides evidence that Chlamydia trachomatis may be the most {requent etiologicalagentresponsi ble for pelvic inflammatory disease (pID). thusfar, no siudies have beenpublished regardingthe incidenceo{ chlamydialpelvic infections rn the emergency department population of wbmen who undergo pelvic exam. From l0/l/85 to 5/31/86, we studied women with complaints warranting pelvic examinationfor proper evaluation.We used an antigen detection method to determine the incidence o{ chlamydial infection, and surveyedhistorical

and physical data we felt might help identify those with the disease.We performed 515 examinations.Patient'schief complaints generally fell into the categories of lower abdominal pain, vaginal discharge/bleeding,sexual abuse/assault/or partner with suspected sexually transmitted disease.A l7% positive detection rate was noted for chlamydia, compared to llo/" Ior gonorrhea (diagnosedby gram smear or culture of cervicai secretions).Of those patients with chlamydia, concurrent infection with gonorrhea was found in 29o/o . One conclusion is therefore,that Centers for Disease Control recommendations that outDatient PID be treated for both of these organisms is justified. Chlamydia was detectedin a total of 90 specimens.Data availableat the time of emergency department visit lead to immediate treatment for Chlamydial PID in only 38% of cases actually positive for chlamydia. When consideredseparatelydifferencesin the incidence of a history of lower abdominal pain, or the findings of a vaginal discharge,adenexal tenderness,or a "chandelier's"sign were not statistically significant between those with chlamydia and those without. By obtaining the antigen detection test, we retrospectively identi{ied 62% of. those patients missed on clinical basis alone, thus allowing us to inform the patient's follow up physician of their need for further treatment. This emphasizes the need for continuing the use of the screeningtest on a routine basis.

5

Gontinuous Antibiotic Therapy of Wounds

RC Dart, M Chvapil/ Sectionof EmergencyMedicine,Division of SurgicalBiology,Departmentof Surgery,Universrtyof Arizona, Tucson A biodegradablecollagenspongeproviding prolongedreleaseof cefoxitin was developed by chemically crosslinking a 2To colIagen slurry in the presenceof an acidic solution of cefoxitin.

This partially binds the cefoxitin to the collagen.In vitro testing, in an aqueoussolution, showed a 60% releaseof cefoxitin from the spongewithin 6 hr. In vivo studiesused l4C-cefoxitin labeled spongesimplanted into a rat excisionalskin wound model. These showeda surge of cefoxitin releaseover 6 hr 1477.3pglg wound tissue).Then as the collagen is degraded,a continuous release was found 133.7p"glgtissue at 14 days). Systemic blood levels showeda small surge (7.1 pglml) followed by lower levels at 14 days(0.2 u.g/ml). Effectsof this delivery system on contaminated and uncontaminated wounds were studied. Wound contraction, adhesionand amount of inflammatory exudate were significantly reduced in cefoxitin sponge treated groups. Quantitative bacteriology showed that the contaminating organisms were obliterated in treated wounds. Skin flora were detected in all wounds; treated wounds had statistically significant lower bacterial counts than did untreated wounds. Approximately 10% of each spongeremained at 14 days. This new system can successfully deliver high local levels of drugs to tissues. It is proposedfor the continuous antibiotic treatment of infected wounds.

0 Sequential Treatment of a Simple Pneumothorax H Richardson, M Sullivan,-P Vallee, BA

Bivins,MC Tomlanovich / Henry Ford Hospital,Detroit In a prospective study of isolated simple pneumothorax, the treatment of 35 patients with a total of 37 pneumothoraceswere studied. A standardized sequential treatment approach was followed for evacuation of the pneumothorax and maintenance of l u n g r e - e x p a n s i o n .T h e p r b t o c o l i n i t i a l l y i n v o l v e d s i m p l e catheter aspiration employing a Seldinger technique and documentation of re-expansion with chest radiography and observation. Reaccumulationof air was treated with Heimlich valve attachment to the catheter at intra-pleural pressure and further observation. Continued air leak was treated with chest catheter suction utilizing a pleurovac at -20 cm H2O pressure. Chest tube thoracostomy was performed for continued failure of re-expansion.ln 22 of the 37 pneumothoraces(61%) simple catheter aspiration maintained lung re-expansion without complications. ln the remaining 15 pneumothoraces{39%), seven 146%Jre-

sponded to Heimlich valve attachment and three i20%l maintained expansion with chest catheter suction. Chest tube thoracostomy was required to maintain expansion in 34o/oof those that failed simple catheter suction or ll% of all pneumothoraces studied. Patienistreated successfullywith simple catheteraspiration were sent home. Patientsrequiring a Heimlich valve, chest catheter suction, or chest tube thoracostomy were hospitalized utilizing these catheter techniques resulted in lower morbidity and shorter hospitalizations than in chest tube thoracostomy.

This study suggeststhat sequential treatment of simple pneumothorax should be considered as a cost effective and therapeutically successfulalternative to immediate chest tube thoracostomv.

7 Lung Compliance as a Predictor of Hemodynamic Change in Tension Pneumothorax SJ White, RMKaplan, K llkhanipour, K Williams,PM Paris,RD Stewart/ Divisionof EmergencyMedicine, Departmentof Surgery,Universityof PittsburghSchoolof Medicine;Centerfor EmergencyMedicineof Western Pennsylvania, Pittsburgh Prompt decompressionreadily reversesthe deleterioushemodynamic effects of tension pneumothorax. Unfortunately, the classicfindings indicating tension pneumothorax can be difficult to detect, especially in the prehospital and emergency department settings.Decreasedlung compliance,subiectivelyperceived as difficulty squeezinga ventilating bag, may be a rapid meansto screenfor tension pneumothorax in an intubated patient. We designed a study in sheep to define the relationship of lung compliance to hemodynamic deterioration in a developing tension pneumothorax. Nine adult sheep were anesthetized,paralyzed, intubated and ventilated by a ventilator that automatically measured lung compliance. A 3-way foley catheter was introduced into either the left (n : 5l or right (n : a).pleural space.Intrapleural air was introduced at either 150 cclmin (CROUP I, n : 7l or 600 cclmin (GROUP 2, n : 21.Mean arterial blood pressure (MAPJ,heart rate, central venous pressure/Iung compliance,and intrapleural pressure were recorded at 30 second intervals for GROUP I and 10 secondintervals for GROUP 2. There were no differencesin these parametersbetween right and left-sidedtension pneumothorax. Creating an intrapleural pressureof 20 cm H2O in both groups produceda compliance of .01 and causedan immediate fall in MAP (Table l). Lung compliance consistently decreasedwith developing tension pneumothorax, and hemodynamic changesoccurred only after marked increasesin intrapleural pressures.Relief of the tension resulted in an increasein compliance and a dramatic return to normal of MAP In this model, hemodynamic changes secondary to tension pneumothorax could be predicted by changesin lung compliance that should be reflectedby compliance changesin a bag/endotracheal tube ventilation. A bench study has confirmed the ability of clinicians to detect changes in compliance well before hemodynamic changes would be expected to occur.

G R O U P 1 IPP (cm HrO) 4 t 21 202 383

G R O U P 2 T

COMP MAP IPP COMP MAP (Ucm HrO) (mm Hg) (cm HrO) (Ucm H2O) (mm Hg) .028 + .005 8 5 + 1 2 .034 + .007 101 + 2 0r .011 + .003 4 4 + 5 202 . 0 1 4+ . 0 0 7 4 2 + 1 8 .008 r .002 3 6 + 8 353 .011 + .007 40 + 4 .O12 ! . 0 0 6 1 5 5 + 6 3 NA4 .021 + .OO7 186 + 30

NA4 .Slow intraoleural iniection air tRapid intrapleuralair injection lBaselrnemeasurementsprior to introductionof intrapleuralair.

2 lntrapleuralpressuresof 20 cm HrO can be generatedduring tension pneumothoraxeven by spontaneouslybreathingpatients.

3 Measurementsimmediatelyprior to intrapleuraldecompression. a Measurements 0.5 min after oleuraldecomoression.

l7

8 Obrervation of Head Trauma Pataents at llome: Prospective in the Study of Gompliance Rutal South DM Cline, T Whrtley/ East CarolinaUniversity School of Medicine,Greenville,North Carolina A prospective study was conducted to test the reliability of home observationof head trauma victims. Over a 4 month period 99 patients were entered and 90 completed the study. Fifty-two percent were male, 50% were age 19 or younger, 3l% were between 20-30 years old and I9"/o were over 30 years old. In all cases a Singleindividual was identified as willing to acceptresponsibility for observing the patient. The observerwas instructed verbally to wake the patient every 4 hours over the next 24 hours, and written instructions were given. Patient and observerdata were collected by the examining physician. Patients were contacted 7-9 days after their infury and questionedas to symptoms and observercompliance.For patients under 15, the observerwas questioned 134 patients). Thirteen percent of observersdid not stay with the patient 24 hours. Sixteenpercentgavethe responsibility of observationto another individual. Seventy-onepercent awoke the patient as instructed. Mothers were chosenas observers for 50% of patients. Non-mother observerswere significantly more likely to abandonthe patient during the 24 hour post-trauma period than patient mothers lKz = 5.67, df = 1, p : < .05).

Patient mothers awoke patients 79"/o of the time while nonmother observerswere compliant in 62Toof cases;while not statistically significant the difference suggeststhat practically, mothers are more reliable observers.Parents as a group l79o/o c o m p l i a n c e )a w o k e p a t i e n t s s i g n i f i c a n t l y m o r e o f t e n t h a n spousesand live-in friends as a group (45% compliancef X2 = 5.138,df = l, p : < .05). Observercompliance fell as patients increasedin age,under 18,89"/owere awakened,18-25yearsold, 74oh werc awakened;over 25, 46%"were awakened.The authors conclude that home observationfor head trauma patients may not be reliable and special attention should be directed towards the care of older patients and when non-parentalobservationis chosen.

I Lack of Eflicacy of "Weighted" Radiographs in Diagnosing Acute Acromioclaviculal Separation P Eossart, SMJoyce,BJManaste( S Packer, MS Linscott/ University of Utah Collegeof Medicine,Sectionof EmergencyMedicine,Departmentof Radiology, Salt Lake City Current literature advocatesthe routine use of radiographs taken with weights addedto the arms (weighted)in order to elucidate the degreeof injury in suspectedacromioclavicular {AC} ioint separation.In addition, sonie authors claim that weights should be suspendedfrom the wrists rather than hand-held, as the latter may obscurethe diagnosisby causing shoulder muscle splinting. However,the use of either method has not been proved to be efficacious,requires additional radiation exposure,and is painful for the patient. Fifty-four pairs of radiographs,taken with and without l0 lb. weights, of patients with suspectedAC injury were studied. The films were read in a randomized and blinded manner by a staff radiologist.Criteria for diagnosisof AC separation were: l" = < 3 mm lor < 50"/oidifferencebetween AC widths with normal coraco-claviculardistance;2' : > 3 mm (or > 5O%l AC width differencewith normal coraco-claviculardistance; 3" : > 5 mm lor > 50"/oldifferencein coraco-clavicular distance,with or without apparentAC ioint disruption. Without weights, thirty-four 1", twelve 2", and eight 3" AC separations were identified. When the readings from weighted films were compared,the diagnosiswas unchangedin forty-five {83%} cases.

The addition of weights causeda changein diagnosisto a higher degreeof separationin four (7%f cases,two from l' to 2'and two from l" to 3". However, adding weights caused the diagnosisto change to a lesser degreeof separationin five {9%) cases,two from 2'to 1",two from 3'to 2', and one from 3'to 1".Reviewof measurementsfrom the latter five casesshows that the addition of weights causedincreasedAC width and coraco-claviculardistance on the uninjured side, while measurementson the iniured

t8

side changedless.In only two cases{4%) did weightedfilms identify 3" AC separationsnot evident on unweighted films. In addition, the use o{ suspendedrather than hand-held weights app e a r e d t o m a k e n o d i f f e r e n c ei n t h e i n c i d e n c e o f c h a n g e d diagnoses.We conclude that the use of weighted radiographs lacks efficacy in elucitlating the degreeof acute AC separation, and recommend that routine use of this technioue be abandoned.

1O Diagnostic Accuracy and Radiologic Evaluation of Hand/Wrist and Foot/Ankle lnjuries EP Sloan,RG Hart,R Goldberg,O Sukavachana, GE Hossfeld,MA Cooper/ University of lllinoisAffiliatedHospitals EmergencyMedicineResidency.

Chicago Orthopedic managementconstitutes a large part of emergency care. Current practice favors the use of radiographicstudiesin evaluatingdistal extremity trauma. Our study was undertakento determine if such evaluation is compulsory in distal extrernity iniuries, regardlessof historical and physical findings. It alsoexamined how accurately resident emergencyphysicianscan predict fractures basedon the clinical exam. l12 patients wereseen in the emergencydepartmentsof two community teachinghospitals by the resident investigators.Included were patientswith the chief complaint of an isolatedhand/wrist or foot/ankleinjury.

Data collection, including the examiner's suspicion of fracture, was completed prior to radiographviewing. Hand/wrist injuries comprised 55.4% of the study group, with a 63.9o/"rate of fracture. In the 44.6% of patients with foot/ankle iniuries, the fracture incidencewas 33.3%. Fracturediagnosisaccuracywas80,0% and 76.5% in the upper and lower extremity groups,respectively.

Noteworthy are the 12 of 51 119.7%)hand/wrist falsenegativediagnoses.Phalanx fractures accounted for 7 of these 12 158.3%) misdiagnoses.In fact, the rate of false negativediagnosisin linger injuries was 7122(31.8%).Falsenegativediagnosiswas lesscom" mon in the lower extremity l4l5l, 7.8%| In the upperextremity, the physical findings which best correlatedwith fracture were, not surprisingly,abnormal position (P : 0.004),grossdeformity (P < 0.0011,bone instability {P = 0.039),and crepitance{P = 0.039|. These all were 100% predictive of fracture. Basedon an odds ratio determination,the most predictivevariablesin the hand/wrist were the clinical impression (22.54),moderateto severe swelling (21.44),diffuse tenderness(10.50),and point tenderness (5.16).Foot/ankle physical findings were overall lesspredictive. The clinical impression(10.57), diffuse(2.52)and compression (2.50)tendernesswere the highest rated. Our data suggests that the diagnosisof fracture is frequently difficult to establish on clinical grounds only. Physical findings such as swellingmay differ in significance dependingon the location of injury. This justifies the liberal use of radiographyin the evaluationof distal extremity trauma, especiallyfinger injuries, becauseof the diffi culty in phalanx fracture diagnosis.Further work is requiredin determining those injuries that would or would not allow a more selectiveuse of radiography.

11 Gomparison of Gastric and Glosed Thoracic Cavity Lavage in the Treatment of Severe l{ypothermia in Dogs DDBrunette, S Sterner, EP Robinson,E Ruiz/ Departmentof EmergencyMedicine, HennepinCountyMedicalCenter,Minneapolis, Minnesota This study was undertakento comparewarm gastricandclosed thoracic cavity lavage {or rewarming severely hypothermic dogs.

Sixteen anesthetized mongrel dogs were monitored by intraarterial catheter, central venous catheter, electrocardiogram, and central venous, esophagealand rectal temperatureprobes.Ani mals were externally cooled to an averageof 21.2 C using ice bags.Eight Group I and eight Group II animals underwent continuous warm saline gastric and closed thoracic cavity Iavagerespectively. The closed lavage system consisted of a high efficiency heat exchanger,a roller pump infusion device and a heat exchange fluid bath. The continuous gastric and thoracic lavage

were accomplishedutilizing af{erentand e{{erentnasogastricand thoracostomytubes. The lavagefluid circulated at a flow rate of 550 cclminute, and a temperature of 30 C. Thoracic lavageanimals were clinically {ollowed for 24 hours, euthanizedand autopsied.The mean time required to rewarm the animals by l0 C was 210.9minutes + 18.6 for the gastric group and 99.3 minutes + 23.Of.or the thoracic group (SE*r - iz : I2.O7l. All of the thoracic lavage animals made an uneventful recovery. Continuous warm saline thoracic cavity lavage for core rewarming of severely hypothermic dogs is more effective than gastric lavage, and appearsto be safe.

12 Pain Reduction in Local Anesthetic Administration Through pl{ Buffering RA Christoph, L Buchanan,K Begalla,S Schwartz/ EmergencyMedical Services,Universityof VirginiaMedicalCenter,Charlottesville Infiltration of local anestheticsis painful; therefore, it would be desirableto develop a less painlul means ol achieving local anesthesiafor wound repair and other minor procedures.The purposeof this study was to investigate the effects of pH buffering on the pain o{ anesthetic administration and anesthetic ellicacy of 3 local anesthetics.Data presentedwas from a prospective/ randomized,double-blindstudy involving 25 adult volunteers.

The 3 local anestheticsused in this study were l7o lidocaine, 1% lidocaine with l:100,000 epinephrine,and l% mepivacaine.Aliquots of these 3 local anestheticswere bufferedwith NaHCO3 (l mEq/ml,) so that a resultant ratio of local anestheticto NaHCOe was l0:1. The pH of the 3 buffered and the 3 non-bufferedIocal anestheticsolutions was measured.Each participant was given a 0.5 cc intradermal iniection of both the bufferedand non-buffered forms of each of the 3 local anesthetics.Each of these six 0.5 cc infections was given over a period of 2/z seconds.The injection sites were located symmetrically over both upper extremities.

Participantsrated the pain of infiltration using a Visual Analogue Scalefrom 0-10, with 0 representingno pain and 10 representing the most pain imaginable.The area of anesthetizedskin surrounding each intradermal wheal was measuredat 6 time intervals from 30 secondsto 4/z minutes. Resultswere analyzedusing the Student'st-test for oaired samoles.

Local Anesthetic '1% lidocaine 1% lidocaine buffered 1ol"lidocaine/epi 1% lidocaine/epi buffered

pH 6.21 7. 2 2 5.58 7. 1 6

Paln Score* (Scale0-10) 4.9 + .40 1 . 1+ . 2 2 5.1 + .41 1 . 8 + . 3 6

1% mepivacaine 6.18 5.1 + .36 l% mepivacaine 7.20 0.9+.22 buffered 'Number representsmean :t standarderror.

Clinical Significance

Paln Reduction

P<10-6

76.40/.

P < 1 0 6

64 1L

P<10-6

8 1. 9 %

No Treatment No. Patients 30 J I No. Injuries patientsi6 Lost To Followup inluries 6 Followed 24 patients/2sinjuries C r u s hI n J U r i e s 2 (0 infections) lvlucosalLacerations 1 4 ( 0 i n f e c t i o n s ) Through-through 9 (3 infections) lip lacerations

Peniclllin 28 30 patients/2 inJuries 2 26 patients/28injuries 2 (0 infections) 14 (0 infections) 12 (1 infection)

The data suggestthat mucosal lacerationsand crush iniuries have a very low infection rate regardlessof antibiotic prophylaxis. Four patients (87ofdevelopedinfections; all were through and through lip lacerations.While 3/25 injuries (12%| treatedwith antibiotics developedinfections, l/28 injuries (3%) treated with penicillin becameinfected.This differenceis not statistically significant. (Significancedeterminedby P < .05 in chi-squareanalysis.I With regardto the through and through lip lacerations,3/e of the non-treatedinfuries (33%) developedinfections, while %zof the infuries treated with penicillin (8%f becameinfected.This is also not a significant difference.

14 Eady Fresh.Frozen Plasma Prophylaxis of Abnormal Goagulation Parameters in the Severely Head Injured ls Not Effective J Winter, D Plumme( T Bottini, D Ray/ Departments of Emergency Medicine andNeurosurgery, Hennepin Medical County Center,

The quantitative estimates of pain for the 3 buffered local anestheticswere significantly reducedcomparedto their non-buffered controls.The onset, extent, and duration of skin anesthesiawas not clinically or statistically altered.The pain of infiltrative local anesthesiacan be reduceddramatically by buffering the local anesthetic prior to its infiltration. This does not compromise efficacy.

| 3

tically following intra-oral soft tissue trauma. 58 patients with intra-oral soft tissue iniuries were treated in a randomizedprospectivestudy with and without penicillin. Woundsincluded lacerations and crush infuries of the labial and buccal mucosa,gingiva, and tongue. Excluded were patients with maxillofacial fractures, wounds older than 24 hours, current antibiotic treatment, congenital heart disease,prosthetic heart valves, and valvular heart disease.All wounds were irrigated with at least 100cc of sterile saline. Muscle and fascia were closedwith polyglycan; mucosa was closed with silk. Every other patient receivedintramuscular benzathine/procainepenicillin G, 1.2 million units for those greaterthan 60 lbs. and 600,000units for those less than 60 lbs. 40 patients received followup through clinic visits between two and ten days following iniury; l0 patients were followed by phone and 8 were Iost to followup. Criteria for infection included oral temperature > 99.5'F or rectal temperature > IOO.1'F,> 2 cm erythema, > 2 cm swelling, and purulent drainage.Results are shown in the table:

Antibiotic Prophylaxis ol Orat Wounds

RP Mooney,RS Hockberge(JT Niemann,SH Inkelis,PL Henneman, LJ Moore/ Harbor-UCLA MedicalCenter,Department of EmergencyMedicine,Torrance Intra-oralsoft tissue iniuries are often treatedwith penicillin in orderto prevent infection by oral flora. The purposeof this study was to investigatethe e{fectivenessof penicillin used prophylac-

L9

Minneapolis Coagulationabnormalitiesare a recognizedcomplication of severe head injury. Coagulopathiesare reportedin as many as 50% of head injured patients. Fresh frozen plasma (FFP|which was formally reservedfor identified coagulopathieshas recently been advocatedas an initial resuscitationfluid as prophylaxisof abnormal coagulationparameters.The benefit of such therapyhas never been established.Head infured patients presenting to our institution since 1981having a Glascow Coma Scale(GCS)of nine or lesswere reviewed{n = 150}.The following data was collected: patient demographics,mechanism of injury, neurologicparameters (serialGCS),daily hematologicparameters(PT APTT HBG, Platelet count, Fibrinogen, FDP) and blood component therapy {FFl pRBC, Whole Blood, Platelet,Cryoprecipitate).The study population included patients who receivedFFPand were without evidenceof unrelated coagulopathies(n : 108)and patients receiving no FFP ln : azl. This population was divided into two groups. Group I received initial FFP within a time from injury (Tlland Group 2 receivedinitial FFPafter time (T2| or not at all.

We assignedeach hour within the first 14 hospital days to Tl and T2. In this way we avoided specific definitions of 'early' and 'late'. Multivariant analysiswas performedwithin the 1015possible groupings. Groups were similar in terms of patient demographics, mechanism of infury, and associatedinjury. There were

no statistical differences in age, presenting GCS or presenting hematologic parameters.Furthermore there were no statistical differences in serial pre-treatment or post-treatment hematologic parameters (P < .051.There were no differences in serial GCS, final Glascow Outcome Scale or mortality. There were no identifiable differences between patients receiving "early" FFI at any given definition of "eatly," as compared to those receiving FFP at some later time/ or not at all. Basedon our study the time of FFP administration did not appear to be critical for effective prophylaxis against coagulopathy.Therefore the use of FFP as an initial resuscitative prophylactic fluid in severe head iniury is not recommended without further study.

the unprotected group. Groups 6-9 received the same CCla dose followed by cimetidine, ranitidine, vitamin C and metronidazole respectively given 4 hours later to simulate a clinical situation.

The animals were sacrificed at 48 hours, liver function tests were obtained and the liver was harvested for histopathology. All control animals lGroups t-4) had normal liver function tests {mean SGPT : 86, 31, 30, 52 respectively|. Group 5, unprotected micg had grossly fatty livers and markedly elevated SGPT levels. Significant protection was afforded by aI a drugs based on reduced SGPT enzyme elevations.

Group

Antidote

5

none

15 Serum Gatecholamines in Gocaine.

Intoxicated Patients with Gardiac Symptoms

6

cimetidine

7

ranitidine

SB Karch / UniversityMedical Center,Las Vegas,Nevada We report a prospective study of the ECG changes,serum electrolytes and catecholamine levels in a group of 6 patients who presented with cardiac symptoms immediately after using "crack." None of the patients had any significant medical history and none were taking any medications. In all but one instance toxicology screening was positive for cocaine and that was the patient who tested positively for metamphetamine.Tests for all other drugs were negative. In all casesnorepinephrine was significantly elevatedwith levels ranging from 345 to 611 ng/l (reference range 0-90 ng/l| and there were similar increasesin epinephrine {135 to 202 ng/\, referencerange 0 to 55 ng/l), while dopamine levels remained essentially unchanged.One patient, who admitted to occasional use of metamphetamine, had a markedly elevated dopamine oI 2OZ ng/l (reference range of 0 to 90 ngll). All of the patients had sinus tachycardia and half had PVC's. One patient presentedwith atrial fibrillation that termi nated spontaneouslyafter two hours. In four patients where additional cardiograms were available, the QTc was seen to decrease as the drug wore off l-2Y", -3o/o, -7yo, - l9%f. Averagepotassium on arrival in the emergencyroom was 3.6 meq/ml. Our findings demonstratethat cocaine use acutely elevatescirculating levels of NE, and also effects adrenal release of epinephrine but has little effect on catecholamine synthesis as reflected by dopamine concentration. The one patient with elevated dopamine may have had changessecondaryto metamphetamineuse.

Prolongationof the QTc, though not expectedto occur with catecholamine elevation, can be explained by cocaine's quinidine like effects. The demonstration that catechol elevation, QT prolongation and relative hypokalemia occurs in these patients may explain why they appear to be vulnerable to arrhythmic sudden death.

8

VitaminC

q

metronidazole

16 Treatment of GGlo.lnduced l{epatotoxicity, A llodel for Similar To*ins SMSchneider, EAMichelson, EP Krenzelok/ Medical EmergencyServices,Departmentof Medlcine,MontefioreHospital,University of Pittsburgh;Pittsburgh PoisonCenter Carbon tetrachloride {CCla) servesas a model for severalimportant toxins and drugs which produces hepatic necrosis in humans by creation of a free radical metabolite in the P450 cytochrome. There is currently no known antidote to modify this effect. We have investigated 4 drugs with potential cytoprotective effects. Cimetidine inhibits the P450 cytochrome and in addition decreaseshepatic blood flow. Ranitidine decreaseshepatic blood flow but has no effect on the P450 cytochrome. Vitamin C is a f r e e r a d i c a l s c a v e n g e r .M e t r o n i d a z o l e i n h i b i t s t h e P 4 5 0 cytochrome. Swiss mice were used since they develop an identical clinical and pathologic picture as humans when exposedto CCl4. All medications were given i.p. 9 groups of l0 mice each were studied. Groups l-4 served as controls and received olive oil plus cimetidine 120 mg/kg, ranitidine 120 mg/kg, Vitamin C 600 mg/kg, and metronidazole 60 mg/kg respectively.Group 5 received CCla 160,000ppm in olive oil plus saline i.p. and servedas

20

SGPT U/L 3372 + 377 1583 + 160 (P = 0,0002) 1780 + 227 (P < 0.002) 1786 + 301 (P = 0,003) 2128 + 503 (P = 0.06)

The hepatotoxicity of CCla and other agents which undergosimilar conversion to a toxic radical may be attenuated by drugs which inhibit P450 cytochrome enzymes,decreasehepaticblood flow, and by free radical scavengers.These drugs, particularly cimetidine, hold promise for therapy in man.

17 Acute Gimetidine Overdosage:An Assessment of 881 Gases EPKrenzelok, T Litovitz, KP Lippold,CF McNally/ PittsburghPoisonCenter,Children's Hospitalof Pittsburgh;NationalCapitalPoisonCenter, GeorgetownUniversityHospital,Washington DC; Smith,Klineand FrenchLaboratories, Philadelphia Cimetidine was introduced into clinical medicine rn 1976.

Since then more than 45 million Datientshave beentreatedwith cimetidine for gastrointestinaldisorders.There are numerousreports in the literature which describe adversereactionsto cimetidine following therapeutic use. However, there are few reports which describethe medical outcome of patientswho ingest acute overdosesof cimetidine alone. This review evaluates881 documented cimetidine overdosesand representsthe largest compilation reported to date. The data was compiled and analyzed retrospectivelyfrom 2,612,236poisoning casesreportedto two nationwide poison surveillance systems from 1978-1985, Only casesof cimetidine exposurewithout coingestantswereincluded. Age, sex, symptom occurrence/ treatment site, reasonand route of exposure/ and medical outcome data were evaluated.All patients were assessedand assignedto one of nine medicaloutcome categories.Eight hundred eighty-one(881)casesmet the criteria and were analyzed. Children between l2 and 35 months of age accounted for 43Y" of the cases and 97% of all exposures were acute. Intentional overdosageaccounted for 2loloof the casesand 767o were accidentalin nature. Gastric emptyingwas per{ormed in 34% of the patients. No symptoms were observed in 79% of the caseswhich included ingestionsof up to 15grams of cimetidine. Only three (3f patients had moderateclinicalmanifestations. No patients had major medical complicationsand there were no fatalities in this series.Even patients in the moderate category experiencedno life-threatening toxic manifestations.

Cimetidine appearsto have a high therapeutic index in both children and adults and demonstrates a remarkable safetv orofile following acute overdosage.

18 Phenytoin Prophylaxis of Cardiotoxicity in Experimental Amitriptyline Poisoning M Callaham, H Schumaker,P Pentel/ Divisionof EmergencyMedicine, Departmentof Medicine,Universityof California,San Francisco; Departmentof Medicine,University of Minnesota Schoolof Medicine,HennepinCountyMedicalCenter,Minneapolis Tiicyclic antidepressant {TCA) overdoseis the third most com-

mon cause of overdosedeath. Phenytoin has been suggestedfor treatment of its cardiovascularcomolications.basedon the belief that phenytoin reducesconduction block and dysrhythmias. To test this hypothesis, twenty dogs were anesthetized with ketamine, intubated, mechanicallv ventilated. and instrumented to monitor blood pressure,ECG, and arterial blood gasses.Ventilation was adiustedto maintain an arterial pH > 7.40 and pCO2 < 40 torr. Ten dogs received prophylactic intravenous loading with 19 mg/kg of phenytoin; all 20 then receivedintravenousamitriptyline at I mg/kg/minute until death, all drug levels were measuredat first toxicity and at death. The differencesin physiologic parametersand weight-adjusteddosesto toxicity and death were examinedby Student'st test and linear regression.There were no significant differences between the control and phenytoin group in any physiologicparameter,plasma levels of amitriptyline or its metabolites at any given toxicity, or the weight-adiusteddoses neededto achieve QRS prolongation, hypotension, or death.

However, animals that received phenytoin had three times as many episodesof ventricular tachycardia {VT) as controls and spent almost three times as much time in Vl which markedly decreasedperfusion. Average and longest episodesof VT were twice as long in the phenytoin group. Animals that manifested VT at any time died with amitryptiline levels 19% lower than thoseof controls (P < .05).This study {ound no benefit of phenytoin prophylaxison TCA-induced toxicity and is the first to report an arrhythmogeniceffect of phenytoin, presumablydue to a prolongation of conduction block conducive to reentrant dysrhythmias. There is no valid indication for the use of phenytoin in TCA overdose.

| 9 Potentiation of Glucagon by Theophylline in the Intact Ganine Model with Complete Beta. adrenoreceptor Bloekade by Propranolol MFSugg, RD Latham,JE Bruce,WJ Ehler,A Galizia/ Departmentof EmergencyMedicineand CardiologyService,BrookeArmy MedicalCenter,Fort Sam Houston,Texas;Departmentof EmergencyMedicine,NortheastBaptistHospital,San Antonio; SurgicalResearchDivision,ClinicalInvestigation Facility,Lackland Air Force Base, Texas;New York City PoisonControl Severebeta-blockerpoisoning is associatedwith markedly impairedmyocardial systolic function and the traditional beta-adrenergicagonists{isoproternol,dopamine and norepinephrine}have all beenrelatively ineffective in treatment. Glucagon is a potent positiveinotropic and chronotropic agent which acts on different myocardialreceptors than those affected by the beta-adrenergic agonists.Although glucagonhas been demonstratedto be effective in treating beta-blocker overdose,Iarge quantities may be neededto obtain therapeutic goals. A study was designedto investigatewhether theophylline potentiatesglucagonin an intacr canine model with complete beta-adrenergicblockage. Tlvelve mongrel dogs were anesthetized with fentanyl and ketamine intravenously,and mechanically ventilated. Invasive indices oI left ventricular function (LV systolic pressure; dp/dt - the slope of the upstroke of the left ventricular pressuretracing; LV end diastolic pressurâ&#x201A;Ź;rnâ&#x201A;Źan aortic pressure;cardiac output; and heart rate) were recorded throughout the study. Propranolol (2 ng/kg IVf was administered to achieve complete beta-adrenergicreceptor blockade. The above indices were comDaredin two treatment regimens,(l) glucagon alone, and iZ) thebphylllne followed by glucagonin each animal. When compared to the glucagon alone treatment group, the group receiving theophylline followed by glucagon demonstrated significantly larger increases in the peak positivedp/dt (P=.005),the mean dp/dt responseover 20 minutes cardiac output (P:.004), and the heart rute lP=.O21. {P.=.01f,,the The LV systolic pressure increased significantly after both glucagonalone (P:.0001) and the theophylline/glucagon combination lP = .OO2l,but there was no difference between the groups. The LV end diastolic pressure demonstrated no significant change after either of the treatment regimens. This study demonstratesthat theophylline is capable of potentiating the ef-

2l

fects of glucagonin the intact canine model. Further studies are neededto delineate what role this combination may have in the treatment of acute beta blocker overdosein humans.

20 An Organized Follow.Up System fol Training of Emergency Medicine Residents and Students in a Community l{ospita! Program DBBauer, JETintinalli, REJackson / Department of Emergency Medicine,WilliamBeaumontHospital,RoyalOak, Michigan; Sectionof EmergencyHealthServices,University of Michigan, Ann Arbor A three component follow-up system for emergencymedicine residents,students and rotating house officers is described.Admission follow-up: Each week, in-house follow-up rounds are conducted on randomly selectedpatients admitted from the emergencydepartment. Casesare presentedto faculty who discuss pathophysiology and emergency management,including a review of charts, radiographs, and initial presentation. These rounds provide an analysis of the impact of emergencydepartment care on final outcome. Dischargefollow-up: Each resident and student is asked to telephone two patients he discharged from the emergencydepartment the previous day. The patients are asked a seriesof questions and a data sheet is completed by the caller. The questionsasked pertain to the course of their illness,problems with medications, compliance with medications, understandingof the dischargeinstructions, and timing and type of follow-up care. Over 100 phone-back sheets are completed monthl)1 with 49"/o by emergency medicine residents, 49% by medical students and 2"/o by rotating house officers. Discharge summaries: Residentsare able to obtain a copy of the discharge summary on selectedpatients they have admitted by filling out a request sheet and attaching it to the patient/s admitting form.

This selectivepolicy is a cost and time efficient teaching mechanism, providing detailed yet succinct information about the course of their admitted patients. A survey of emergencymedicine residentswho have participatedin these activities shows: l) 631" have changed their method of practice due to follow-up rounds, 2) 82"/ofound call-backsto be of educationalbenefit. An organizedapproachto follow-up of emergencypatients is easily accomplishedand perceivedas a beneficialIearningexperienceby the residents.

21 Emergency Depaftment Telephone Advice to Patients V Verdile, PMParis, RDStewart, LAVerdile / Division of Emergency Medicine, University of Pittsburgh; Center for EmergencyMedicineof WesternPennsylvania, Pittsburgh Emergencydepartment personnelare frequently called upon to give advice to patients or kin who telephoneto ask about a wide variety of medical problems. This practice appearsto have wide acceptanceby the public and the emergencydepartmentsoffering such advice. Despite its being common/ few guidelines exist defining such a service,and the legal ramifications of this practice have seldom been addressed.Our study was designedto determine the consistencyand accuracy of directions given to those who telephonedurban or suburbanemergencydepartmentsseeking advice about a medical problem. Thirty-two emergencydepartments were chosenat random and telephonedby a volunteer who was instructed to presenta scenariothat could have reasonably been interpreted as myocardial ischemia. A secondinvestigator monitored the call on another line and transcribedthe conversation. The caller initially stated that her father was having "bad indigestion and heartburn," and asked what she should do. If additional questionswere askedby the emergencydepartment staff person taking the call, the caller was instructed to describethe "indigestion" as a "squeezingsensationin the chest," associated with nauseaand sweating,beginning at rest and lasting for 15 to 20 minutes up to the time of the call. Of the 32 departments contacted, only one {3%) permitted the caller to speak with a physician.Advice in three of the 32 l9%l calls was given by a unit

secretary.The remaining 28 calls (88%)were answeredby a staff nurse.Responseto the scenariopresentedby the caller varied widely among the emergencydepartments polled. Seventeen 159%loI the 32 departments{ailed to ask any further questionsto ascertainmore about the chief comolaint or that would indicate the respondentwas consideringmybcardialischemiaas a possible cause of the pain. Although the further questioning of the caller by 12 ,.37%lof the 32 advisorssuggestedthey were considering myocardial ischemia, only four instructed the caller to dial 9lI, to call the paramedrcsor an ambulanceimmediately and have the patient brought to the emergencydepartment for evaluation. Fourteen 149%l instructed the caller to give the patient antacids,several after receiving a responsefrom the caller that suggestedmyocardial ischemia was likely. Three {9%) refusedto give any information or advice whatever over the telephone.Of the 25 179%lrespondentswho advisedthe caller to bring the patient to the emergencydepartment,none recommendedthat the patient be brought by ambulanceor paramedictransport. Although not possibleto quantify, the directions given by the emergency department personnelwere imprecise and contained technical terms not likely to be understoodby the lay public. These data demonstratethat telephoneadvicegiven by some emergency departmentsis inconsistent and can be inadequateto the point of ieopardizingthe welfareof the recipient of the advice.We believe, basedon the initial results ol this continuing study, that emergency departments should have policies and programs that prevent the dissemination of inadequatemedical directions to callers. Telephoneadvice should be consideredan outreach program of a department,should be guided by medically-soundalgorithms and protocols,and should be subject to a rigorous quality assurancemechanism. Provisionsfor follow-uo when indicated shouldas well bc a part of such a program.

22 Decision to Admit: Objective DRG Criteria Versus Clinical Judgment L Graf|D Mucci/ NewBritain

24 Does a Helicopter Service Stimulate Financially Motivated Transfers? KJRhee,RJ

General Hospital, New Britain, Connecticut Three hundred fifty patients were observed in an observation unit attached to an emergency department for diagnostic workup of eleven critical diagnostic syndromes (abdominal pain, flank pain, CVA/TIA, chest pain, dizziness/vertigo, head injury, headache, syncope, seizure, multiple trauma). The decision for acute care hospitalization after observation for ll.l + 3.9 hours was examined. The obiective DRG criteria for admission were compared to the physician's clinical fudgment of need for hospitalization. Clinical outcome as determined by later events {such as pathology found at surgery or diagnostic procedure, myocardial infarction, development of neurologic defect, documentation of arrhvthmial was used to establish correctness of the decision to admit. The obiective DRC criteria were able to predict the presence of serious pathology necessitating acute care hospitalization with a 74"L sensitivity, 75% specificity, 48% positive predictive value {PPVI and9O"/" negative predictive value {NPV). In contrast, the physician's clinical iudgment was able to correctly predict the presence of serious pathology with a 100% sensitivity, 90% specificity, 8l% PP! and 100% NPV The objective DRG criteria were able to predict the presence of serious pathology found at emergency surgery in 108 cases of abdominal pain or abdomen/chest trauma with a 57% sensitivity, 94% specificity, 77% PPV, 85% NPV The physician's clinical judgment, in contrast, was able to correctly predict the need lor acute care hospitalization with 100% sensitivity, 99% specificity, 95% PP\/, and 100% NPV We conclude that physician's clinical iudgment outperforms DRC objective criteria in identifying which patients with critical diagnostic syndromes need acute care hospitalization for emergency medical or surgical therapy.

23

Tiansfer of emergency department (ED) patients because of inability to pay is a serious and growing problem nationwide. To document the extent and nature of this oractrce in our community, we audited all telephone requests and actual patient transfers from private hospital ED's and affiliated free standing emergency centers to the ED of the Regional Medical Center at Memphis (the MedJ, a publicly subsidized hospital, between fune I and August 31, 1986. Tiansfers to the Med's "special care" areas {burn, high risk obstetrics, neonatal and trauma centers) were assumed to represent tertiary care referrals and were not included. During the 92 day study interval, ED physicians at the Med handled 168 telephone requests for transfer. In 83% of cases, "no money" or "no insurancc" was givcn by requesting physicians as the maior reason for transfer. Over 4OT" of telephone requests were refused; half involved patients who were iudged to be too unstable for transfer or who required an intensive care unit llCU) bed when none was available. Despite telephone screening, the Med ED received a total o{ 286 transfers during the study period. TWo-thirds of these patients arrived without prior telephone authorization, most by private automobile. Almost aIl 197%l were sent for pdmarily economic reasons. Nearly one-third were found to be unstable on arrival by explicit clinical criteria. Eighty six patients (30%) rcquircd cmergency hospitalization and accounted for a total of 634 bed days during a period of extreme inpatient crowding. Threc patients died prior to hospital discharge. Total uncompensated Med ED and hospital charges for care of these patients cxccedcd 350 thousand dollars. During this samc time period, the Mcd ED transferred out a totai of 36 ED patients, includins nine c l i g i b l c f o r V c t e r a n ' s H o s p i t a l c a r c a n d t e n s c n t b e c a u s en o w a r d or ICU bcd was vacant at the Med. Many poor or uninsured paticnts are transferred to crowded public hospitals for non-medical rcasons. Telephone screening is necessary but alone is inadequate to safeguard paticnt welfare. Tough regulations are needed to stop paticnt "dumping."

O ' M a l l e y ,J E T u r n e t N H W i l l i t s , R E W a r d / D i v i s i o n o f E m e r g e n c y M e d i c i n e , D e p a r t m e n t o f I n t e r n a l M e d i c i n e , D i v i s i o no f S t a t i s t i c s ; D e p a r t m e n t o f S u r g e r y ; U n i v e r s i t y o l C a l i f o r n i a ,D a v i s Injurcd paticnts transferred to a trauma center from emergency dcpartmcnts and inpatient hospital units by a new helicopter transport servicc wcre studied to determine if this new service stimulated financially motivated transfers. Ninety-eight injured paticnts were studied over a one year period. Forty-one patients w e r c c l a s s i f i e d a s h e l i c o p t e r d e p e n d e n t , t r a n s f e r r e d b e c a u s eo f t h e new helicoptcr servicc, and 57 patients were classified as helicoptcr indcpendcnt. Chi-square analysis revealed no significant differcncc in location of patient pick up, diagnostic group, or type of insurance between these two groups. The helicopter dependent group's average charge was $30,199, the average collection was $ 2 3 , 9 0 7 , a n d t h e r a t i o o f c o l l e c t i o n s / c h a r g e sw a s 0 . 7 9 4 . T h e h e l i copter indepcndent group's average charge was $34,360, the average collection was $26,174, and the ratio of collections/charges was 0.7(r0. Analysis of variance and the Kruskal-Wallis test revealed no significant difference between groups for these parameters. We found no evidence that a new helicopter service stimulated financially motivated transfers from referring hospitais to a trauma center.

25 Description of the Mass Gasualty Plan for Paris, France, in Response to a Terrorist Bombing R Norton,R Noto,H Julien,H Juniery,S Edelstein / Divisionof EmergencyMedicine,OregonHealthSciences Portland;Brigadede Sapeurs-Pompiers, University, Paris;World Washington Access lnternational, DC The emergencymedical system of Paris consistsprimarily o{ the Brigadede SapeursPompiersde Paris- (FDJFire Department - and the Serviced'Aide M6dicale Urgente {SAMUI, part of the

Emergency Department "Dumping" in the

lfid South AL Kellermann,BB Hackman,R Burns / University of Tennessee.

Memohis

22

national emergencymedical system.The system contains several uniqueospects which allow it to respondoptimally to multiple victim incidents. All of the ambulancesfor both the SAMU and the FD are always staffed with a physician who specializesin emergencymedical care.In the event of mass casualties,this system ensures that qualified physicians are immediately at the scene of the victims. The dispatch and regulation center for SAMU is also staffed24 hours a day by a physician,who in addition to other responsibilities,maintains constantly up dated information about the availability of hospital facilities and services for all hospitals in Paris - intensive care beds, operaring room availability, neurosurgeons,CT scans etc. This system permits rapid transportation to the nearestappropriatefacility. The mass casualtyplan is organizedunder the direction of the FD. Among its other aspectsit allows for on scene triage and initial treatment of less severelyiniured victims. The terrorist bombing of September18, 1986 occurred in the afternoon in front of a crowdeddepartment store.There were 58 injured and 6 deaths5 immediately and I within 6 hours. The time from the onset of the blast to clearing of the scenewas approximately 90 minutes.

The responseof the Mass Casualty PIan is describedin detail.

26 Efficacy of Delayed Administration of Grotalid Antivenin RCDart,APGoldner, D Lindsey / Sectionof EmergencyMedicine,Departmentof Surgery, Universityof Arizona,Tucson A delay of an hour or more is frequently encounteredin the treatment of rattlesnakeenvenomation.Reportssuggestthat this delay may render subsequentantivenin treatment ineffective. A controlled sequential trial using an Armitage restricted plan was used to test the effect of a one hour delay on survival in a new model of rattlesnakeenvenomation.Crotalus atrox venom (25-50 mg/kg) was infected subcutaneouslyinto the hindlimb of 60 groupsof 4 rats. The animals were left untreatedfor one hour and then received one of four treatments. Group I received crotalid antivenin equivalent to 30 vials in a 70 kg human and 09% NaCl solution, 100 ml/kg subcutaneously.Group II receivedantivenin alone. Group III received saline alone. Group IV received no treatment.

tv

Group 12-Hour Mortality

I

tl

0/60 0%

0/60 O"/o

Il 6/60 10.0v"

9/60 1 50 %

24-flour Mortaliiy

10/60 167%

14160 23.3%

21/60 350%

31/60 5 1. 7 1 "

Tieatment with either saline and antivenin lll or antivenin alone (ll) was significantly better than control (P < .01, P < .05, respectively). The decrease in mortality with saline alone was not statistically significant, although it appeared to potentiate the antivenin effect. Antivenin treatment delayed one hour is effective when using large doses in a severe envenomation model.

27 Efficacy of Chalcoal versus lpecac in Reducing Serum Acetaminophen in a Simulated Overdose R McNamara, CK Aaron, M Gemborys, S Davidheiser / Departmentof EmergencyMedicine,Medical Collegeol Pennsylvania, Philadelphia; McNeilPharmaceuticals, FortWashington, Pennsylvania The initial step in overdosemanagement frequently involves induction of emesiswith syrup of ipecac.Certain situatronsarise where emesisis contraindicatedor interfereswith administration of an oral antidote. This study comparesthe effect of ipecac-inducedemesiswith activatedcharcoal-sorbitol(ACSIas the initial step in a simulated acetaminophen(APAP| overdose.Ten volunteers participated in a randomized cross-overstudy with each serving as their own controls. After fasting overnight, the subiects ingested37.5 80mg APAP tablets with l20cc of water.Blood

23

was sampledat 0.5, 1.0, 1.5,2.0,3.0, 4.0, 6.0, and 8.0 hours and analyzed {or APAP by high pressureliquid chromatography.On study days, those taking ipecac received30cc of ipecacfollowed by 24occ of water or 50gm of ACS.solution (RequaCharcoaid 30gm AC/ll0 gm sorbitol).These interventions were done at one hour post-ingestionto simulate clinical conditions. Adequate emesiswas noted in all subiectsat a mean of 25.5+8.9 minutes.

Mean onset to charcoal stools was IO9.l+74 minutes. TWo subjects were hyperemetic {>2 hrsf after ipecac and one required IV rehydration.Profusewatery stools were noted in all subiectswith ACS and three elected IV rehydration. Serum concentration of APAP was analyzedusing analysisof covarianceof areaunder the curve and evaluatedusing a post hoc Tukey-A test. Corrected mean area under the control curve was ll9.4l. Mean area under ipecac and ACS curves were 94.32 and 88.92 respectively.There was a significant difference between control versus ipecac (P < 0.05),and control versusACS {P < 0.051.No significancewas demonstratedbetween ipecac and ACS although blood levels appearedlower with ACS. In this model, ACS solution appearsto be as effective as ipecac in preventingabsorbtionof APAP when used as initial therapy in a simulated APAP ingestion. It may be of benefit as isolated therapy when prolongedemesis is undesirable.

28

Methemoglobin Levels Following Inhalation

of Amyf Nitrite JP Galdun,LD Weiss,PM Paris,RM Kaplan, RD Stewart/ AffiliatedResidencyin EmergencyMedrcine, University of Pittsburgh;Centerfor EmergencyMedicine,Mercy Hospitalof Pittsburgh C u r r e n t t h e r a p y f o r c y a n i d et o x i c i t y e m p l o y s n r t r i t e c o m pounds for the production of methemoglobinemia.Methemoglobin then binds with cyanide,forming the nontoxic compound cyanomethemoglobin.While nitrite administration has been reported to reversethe toxic e{fectsof cyanide,a review of the literature has failed to reveal studies documentins elevatedmethemoglobin levels following nitrite therapy.We chose to study the effectsof amyl nitrite inhalationin an attempt to understandits role in the treatment of cyanide toxicity. Ten volunteers ranging in agefrom 24-32 were recruited for study.All were without history of cardiopulmonarydiseaseand not on medications known to induce methemoglobin formation. EKC and arterial oxygenation were monitored continuously throughout the experiment.

The participants inhaled vapors from a 0.3 cc ampoule of amyl nitrite at 15 secondintervals for a period of five minutes, following the instructions containedin a commercial CyanideAntidote Package.(Eli Lilly and Company, Indianapolis, lnd.) Vital signs and blood for methemoglobinlevelswere obtainedat 0, l, 3, 5, 10, 15,30, and 50 minutes. During the study period no patient exhibited cardiacarrhythmia or arterial desaturation.There was an expected drop in the mean blood pressurewith a compensatory t a c h y c a r d i af o l l o w i n g t h e i n h a l a t i o n o f a m y l n i t r i t e . T h e s e changeswere statistically significant at I and 3 minutes when comparedto baselinemeasurements.Methemoglobin levels rose slightly with statistical significanceat 3, 5, and l5 minures when comparedto baseline.The highest methemoglobin level obtained in any study subiectwas 2.2%.

Time Met-Hb Mean BP

0

1

3

5

10

15

30

60

082

095

1 34'

1 36-

129

136'

121

108

84-

85'

89

93

92

93

95

105-

102'

79

64

65

70

68

98

HR 70 ' P i e s st h a n 0.05

Our results demonstrated that the inhalation of amyl nitrite, as advised by the insert contained in the Cyanide Antidote Package, produces a small elevation in methemoglobin levels. While this elevation is statistically significant when compared with baseline levels, it is unlikely that this would lead to a meaningful clinical effect when binding free cyanide. Despite anecdotal reports of the

T

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:nttlqiii*:ixiilry'":!p"1fi li,i'i:"'::jfi l$ii.':1'f':m u..,o,,,f, 3,r'*:Illln"Hi"t*mechanicarDissociation: rio-*,i.ri'.'a".'::l:,"'168,,:ltSl-A* ilt?:li'..n.,,r ne 2 ,,Jfi Lidocai tdown c u v i a lii,fitt":L il'*-;J""^pii"a :"il#lTll' T,?',lli' "T".5[i''#5i",t'jfii{lffi"TF jnlr:sl'l:.''#,*lli'a 16":#ifiqhili; ilt5.-.

lf ;:nm:t';;#i:*Ti::J'i':i ,"r.ric;1ttJ,ffiilicardissociationtEMPl':T llSL:',':,'#;:';il.'ff iT.T$?'di*,::16.::tr*"rir".:*.H'$.T1tb"1?

Ifi igivi,"(",,*:".::-1ii+I,?lrut*iii,,f

u*T*e*[t:ttii,n *;l

Jt"il,,ffi

o{ morphological comprexes'l^i::: ";i'.i;;jcteristi

ce11 was ivpc-pR rfr^ili :"'J"1J;T#:,::rTllff

cs oi patient s

il+H.j1i:}:*:t"l**lilTiTr+ f:['ll',1*i*:i!*+i:;fil.,1;;3jn*r*l;*+:il:jl fibrillation develoPed'

24

nontraumatic, nonpoisoned/cardiorespiratoryarrest and were determined to be in EMD. The rhythm strips obtained Irom paramedics on all patients were retrospectively reviewed and were arbitrarily categorizedin the following manner: Group 1, isoelectric ST and normal appearing T:waves; Croup 2, abnormal ST and/or T:waves{ST depression,elevation, slurring or T:wave inversion); Group 3, monophasic,slurred RST complex. Becauseof the possibility of prior bundle branch blocks, the width of the QRS was not used in determining the type of complex. The respectiveinitial distribution was Group l, 197 ,39%)rGroup 2, 262 l5l"/.1 and Group 3, 48 {9.4%1.The relative frequency of morphologiespre1.43%1, cedingthe attainment of a pulse was as follows: Group 1 Group 2 {54%},Group 3 14.9%l(P < .011.The morphological frequencyof successfullyresuscitatedpatients prior to admissionto an EmergencyDepartment was as follows: Group I {61%f,Group 2 139%land Group 3 loy.l, (P < .01).The relative frequency o{ patients saved,defined as the patient dischargedalive, were as follows: Group I (63%), Group 2 132%),and Group 3 {5%). We concludethat EMD patients presentedin at least three dif{erent morphologicalgroups and that morphology is indeed related to outcome.

33 Gomparison of Epinephrine and Methoxamine for Resuscitation From Electromechanical Dissociation: A Study in Human Subjects L Turner, M Parsons, R Anderson, J

Ruthman,R Luetkemeyer, J Storm/ Departmentof Emergency Medicine,SaintFrancisMedicalCenter,Universitvof lllinois Collegeof Medicine,Peoria A generousmeasureof discussionhas been generatedrecently regardingpharmacologic resuscitation from electromechanical dissociation.In particulaq,epinephrine,the traditional adrenergic agent/ has been compared in several models to the pure alpha adrenergicagent methoxamine. Redding concluded ihat in-canines, methoxamine was "clearly superior,, to epinephrine. He like others, postulated that the successof this aeent was a function of potent vasoconstriction and increaseddiastolic Dressure which in turn would re-establishcoronaryblood flow. Unlike epinephrine, it would not have the beta lnotropic effect whiih would increasemyocardial oxygen demand, and therefore,make epinephrineless desirable.Severalinvestisatorshave summarized this controversy and suggestedthat whal remained was a controlled human trial comparing epinephrineand methoxamine. A study was there{ore designedwhich was prospective/double blinded, and included eighty human subiects. The ACLS algorithm for EMD was closely followed except that the unknown study drug {either epinephrine or methoxamine} was sent {rom the pharmacyand administeredwhere epinephrinewas called for in the aleorithm. Since clear data were noi available regarding bioequivalency of these two agents/ the Burroughs-Wellcome Company assistedin such studies,and concludedthat one milligram o{ epinephrine was equivalent to l0 mg of methoxamine.

This was a combined study between the Department of Internal Medicine {involving inpatients with this rhythml and the Emergency Department. Data collection sheets were completed on eachof eighty patients and confidential results were sent by the pharmacy to the pro,ect statistician after each twenty patients.

Outcome and conclusion: Survival was evaluated for thoie livins Iessthan one hou1,one to six hours, six to twelve hours, twelv6 to twenty-four hours, and greater than twenty-four hours. Despite recentdebatein which methoxamine has been said to have severaI physiologicadvantagesover epinephrinein resuscitationfrom EMD, no statistically signi{icant dif{erences in survival were observedin this initial study in human subiects.

34

Treatment of Anaphylaxis in Beta.Blocked

Rabbits JC Hunter,PF Van Ligten, JT Molnar,WG Barsan,JR Hedges,RVWDimlich/ Departments of EmergencyMedicrneand Anatomyand Cell Biology,University of CincinnatiCollegeof Medicine

25

There are case reports suggesting that individuals taking betablocking medications may have prolongedanaphylacticreactions and resistanceto epinephrine treatment of anaphylactic shock.

Glucagon has cardiotonic actions which may be use{ul in the treatment of anaphylacticshock. Glucagon'sinotropic activity is independent of adrenergicreceptors and catecholamines.We studied the effects of epinephrine and glucagon treatment for anaphylaxisin beta-blockedrabbits. Forty male New Zealand rabbits were sensitizedwith a 2 mL intravenous(IV) doseof horse serum followed in 48 hours by a2 mL sub-cutaneousdose.After at least 14 days had elapsed,the animals were instrumented under halothane anesthesia.General anesthesiawas discontinued and sedationwas provided with IV diazepam{0.1-0.5mg/kg}. Propranolol IV (2 mg/kg) was given to producebeta-blockade.After a thirty minute recoveryperiod, baselinereadingswere done and a I mL challenge dose of horse serum was given. Shock was denoted by a -i"n arterial pressure : so%-of baseline.The animals were treated after thirty secondsof shock. There were three treatment groupsand one control group {N: l0 per group); treatments were epinephrine{E) IV (0.01mg/kg), glucagon(C) IV {0.5 mg/kg), and epinephrine and glucagon (EC) IV ar rhe same dosages.The controi group (S| received normal saline {0.5 ml/kgf.

Hemodynamic measurementswere made at baseline,at the onset of shock (T:0) and at time intervals up to 60 minutes after shock. There were no differencesbetween the two epinephrine groups (E & EG) for hemodynamics or survival. There were no differencesbetween the two non-epinephrinegroups {G & S) for hemodynamicsor survival. The combined epinephrinegroup had a higher mean arterial pressure atT=2 (P < .001)and a better survival tate at T:5 {P < .005) than the combined non-epinephrine group.In this r_nodel, epinephrineis transiently effective for anaphylactic shock in beta-blockedanimals. Beta-adrenergic activity is not a requirement for improvement of hemodynamics or survival. Glucagon does not effect hemodynamicsor survival in this setting.

35 Se"ett Years Experience with Group O Unmatched Packed Red Blood Gells in a Regional Trauma Unit J Lefebre, BAMclellan, AS Coovadia/ Departmentof EmergencyServices;RegionalTrauma Unit; Departmentof LaboratoryHaematology;Sunnybrook MedicalCentre,Universityof Toronto,Ontario,Canada The introduction of a blood component system has made Group "O" unmatched packed red blood cells (G "O"UPRBCsf availablefor emergencyresuscitationfrom hypovolemic shock. A 7 year retrospectivereview (September1979 to August 1986)is presenteddescribingthe use of 537 units of G "O"UPRBCsfor the resuscitation of 133 trauma patients. A total oI 2214 patients were admitted to the ReSionalTlauma Unit (RTU| during the period of study. Sixty-six percent {1454 patients) received blood transfusionsduring the first 24 hours; 133parients {9.1%of those emergently transfused)received G "O"UPRBCs. The averageage of these 133 patients was 31.6 yearsand the averageInjury Severity Score(ISS)was 37.6. This comparedto an averageage o{ 30.8 years and an averageISS of 26.5 for the 2214 patients. Eighty-two percent of the patients had suffered Class III or IV hemorrhage, requiring an averageof 16.5units of packedred blood cells in the hrst 24 hours. Intra-abdominal bleeding and pelvic fractures were felt to be primarily responsible {or the hemorrhage in 85% of patients. The blood groups of 122 patients were identified; 70 had non "O" blood groups. Ten patients in our study representing L4% of the 70 non-group //O'/ patients availablefor study developed a positive direct antiglobulin test (DAT). Seven o{ these DATs were documented as negative 48 hours after the initial transfusionof C "O"UPRBCs.Sevenof these ten patients had received greater than 8 units of G "O"UPRBCs. No clinical complications were encountered;G"O"UPRBCs are safeand efficient for emergencyresuscitation.Non-group "O" patients receiving 8 or more units of G "O"UPRBCs should not receive type specific blood.

36

Resurcitation of Hypovolemic Shock with

Gold Blood S Schirk,B Bigelow D Dula / GeisingerMedical Center,Danville,Pennsylvania A study was conducted to evaluate the cardiovascularresponsesto a rapid infusion of cold or warmed blood in the resuscitation of shock in dogs. Mean arterial pressure,pulmonary artery pressure, central venous pressure and pulmonary iltety temperaturewere measuredby use of a femoral arterial line and a thermodilution Swan-Ganzcatheter.Becauseof the inherent variable of infusing cold and warm blood, cardiac output was measured by using the cardiac Green dilution method. Core temperaturewas measuredby way of a rectal probe and pulmonary artery temperaturewas measuredby use of the thermal sensoron the thermal dilution Swan-Ganzcatheter.All animals were bled via a femoral artery line over 20 minutes to a total volume of 500 cc of whole blood or approximately 40% of their total blood volumt. Animals were then resuscitatedvia a rapid infusion (50 cc per minute| of the shed blood by way of a ped-iatricfeeding tube placed in the femoral vein. Three groups were studied. A warm blood group with blood at 38 degreescentigradewas infused into the inferior vena cava by way of the pediatric feeding tube. The cold blood group (blood infused at 4" centigrade)was subdivided into seven animals having blood infused into the femoral vein and sevenanimals having the blood infused into the right atrium.

Both cold blood groupsshoweda 3 degreescentrigradedrop in the pulmonary artery temperatureduring the infusion of cold blood, however,all groups had a similar cardiovascularresponsewith respectto cardiac output/ mean arterial pressure,pulmonary artery pressure,central venous pressure.Rectal temperaturesdid not changesignificantly in any of the groups.This study suggests that in the initial resuscitationof shock, a favorablecardiovascular responsecan be anticipated during infusion of warm or cold blood.

ethanol 159.9t 5.9 min) groups.Systolic blood pressurewas signi{icantly lower in the ethanol group after 15 min of hemorrhage l8l + 22 v. 59 * 14 mm Hg, P < .05).Other than this there were no significant differencesin heart rate, systolic, diastolic, or MAP No significant di{{erenceswere found in any of the metabolic parameters.The results o{ this study show that in unanesthetizedswine moderate ethanol intoxication causesincreasedhypotensionearly in hemorrhagicshock, but doesnot significantly affect survival time.

38 Gomparison of Peripherat, Central, and Intraosseous Routes in Resuscitation of Hemorrhagic Shock in Pigs JDG Neufeld,Al Light, of Emergency JA Marx,EE Moore,BC Borlase/ Departments Medicineand Surgery,DenverGeneralHospital Venousaccessis often a clinical dilemma in the severelyhypovolemic child. Collapsedperipheral veins are difficult to cannulate, cutdowns are time-consumingand central lines posesignificant risk. An alternate method of urgent fluid delivery is the intraosseous(lO) route. We comparedfixed rate infusion via peripheral vein {hindlimb), central vein (femoralvein} and IO routes in a hemorrhagicshock model. IO accesswas obtainedwith an 18 gaugespinal needledirected45 degreescaudad,two cm belowthe tibial tuberosity.Twelve Hampshire pigiets (15-21kg) were anesthetized with 2o/ohalothane.Animals were bled sequentiallyover 15 minutes to a mean arterial pressureof 30 mmHg, and maintained at that level of shock for 30 minutes. Resuscitationwas accomplishedwith normal saline deliveredby manual pressureat 50 cclminute for 20 minutes. Four animals were studiedin each group.Bone marrows from two IO animals were harvestedimmediately after the study for histologic examination; at the IO infusion site and in the contralaterallimb. The hemodynamicresDonseto resuscitationis summarized in the followine table.

37 Effect of Ethanol on Suryiyal Time in Hemorrhagic Shock in an Unanesthetized Swine llodef BJ Zink, SA Syverud,SC Dronen,WG Barsan, PV Ligten,BL Timerding/ Departmentol EmergencyMedicine, University ol CincinnatiHospital Controversy exists as to whether ethanol intoxication causes exaggerated hypotensionor increasedmortality during hemorrhagic shock. Previous studies have used anesthetizedanimals.

This limits the interpretation of data since anestheticagents,particularly pentobarbital, have well-documented effects on hemodynamics and may alter ethanol metabolism. We studied the effects of moderate ethanol intoxication on blood pressureand survival time during fatal hemorrhagic shock in unanesthetized swine. Immature female swine, (15-20kg) were splenectomized and instrumented with chronic indwelling aortic catheters,right atrial cathetersand gastrostomytubes. Three to eight days later the awake animals underwent hemorrhagic shock. Thirty minutes prior to the start of hemorrhagethe experimentalgroup, n=8, received3 ml/kg o{ 100% ethanol mixed as a l:3 solution with water via gastrostomy tube. The control group, n = 8, received an equal amount of water. The distal aortic catheter was connectedto a roller pump and blood was removed at a rate of I ml/kg/min until the animal died. Death was defined as apnea with a mean arterial pressureof < 20 mm Hg. Fifteen minutes after the start of hemorrhage an intravenous bolus of 4 ml/kg normal saline was given through the venous line, followed by an infusion of .12 mL/kg/min. Blood pressurewas measuredin the descendingaorta. Arterial pressure, heart rate, lactate and glucose levels, hematocrit, and arterial blood gaseswere measured in both groups at baseline(30 min after gastric ethanol or water instilledf, and every l5 min. thereafter Ethanol levels were measuredin the experimental group at baseline,30 and 60 min.

A mean ethanol level of 1500kg/ml was producedin the experimental group from baseline through 60 min. Data was analyzed using the student'stwo-tailed t test. There was no significant di{ferencein survival time betweenthe control (63.1 * 2.8 min) and

26

Baseline Central vein ,MAP PCWP co N/VO2

Resuscitation

Shock

68 B 369 49

1:4 29 1 2 2.02 0 43 5 3 3

75 8 298 42

:!1 31 1 1 161 0.36 5 2 8

1 1 6 6 10 1 5.29 0 11 3 4 8

t 5 2 0.14 5

68 8 280 48

i1

t0

:!6 2 061 7

I

I

60 1 9 415 0.08 2 4 7

tg 1 0.41 4

Peripheral vein IVAP PCWP co N4VO2 Intraosseous MAP PCWP co MVO2

1 0 34 4 2

30 2 1.62 8

64 1 10 404 012 2 4 6

.MAP,mean arterialpressure(mmHg);PCWPpulmonarycapillarywedgepress u r e ( m m H g ) ;C O , c a r d i a c o u t p u t ( L / m i n ) ;M V O 2 ,m i x e d v e n o u so x y g e n (%). saturation

A two-way analysis of variance with replication revealedno significant differencesamong the three groups.After resuscitation, baselinelevels were almost reachedby MAI attained by PCWB and exceededby CO. MVO2 recoveredto preshocklevels.Marrow'sin which IO fluid was administeredshoweda markedreduc" tion in cellularity similar to changesin asepticnecrosis.We conclude that {or fixed rate infusion. IO crvstalloid resuscitationis as efficaciousas peripheraland central venous routes in correcting hemorrhagic shock as measuredby central circulatory and tissue per{usion parameters.Bone marrow changesmay be the product of high pressuredelivery.Further study is neededto define the rate capacity of IO infusion and its ultimate impact on bone marrow and growth.

39 Analysis of Growth Plate Abnormatities Following Intraosseous Infusion Through the Proximal Tibial Epiphysis in Pigs KRBrickman,

normal IVP may have a limited

P Rega,M Guinnessi The EmergencyMedicineResidencyof St VincentMedicalCenter/The ToledoHospital,Toledo,Ohio Intraosseousinfusion has becomean increasinglypopular technique for vascular accessin critically ill or injured children.

Widespreadacceptanceof this procedure by physicians and potentially prehospitalpersonnelmay lead to inadvertent placement through the immature growth plate. In our study we intentionaily penetratedthe epiphysealplate with the rntraosseous needleand subsequentlyin{used fluids in order to observewhat complications, if any, might arise from this procedure.Twenty pigs at 3-4 weeks of age had a bone marrow aspiration needle introducedinto the medullary cavity through the tibial epiphysis under fluoroscopic visualization. Sodium bicarbonateat Z- mbq/ kS (N : l0) or .9 normal saline at 2 cc/kg (N = l0) were infuse-d through the intraosseousneedle.This was followed by infusion of radiographicdye to confirm intramedullary placement. The animals were then returned to a farm environment and observedfor six months. One animal expired immediatelv after the orocedure from an apparcntanesthesi;complication.Radiographs^of the involved growth plates were taken at two months and six months pos,tinfusion. No growth disturbancesor growth plate abnormalities were detectedclinically or radiographically-throughthe rapid growth phaseof the porcine tibia. This study demonstrates that no growth disturbanceswere induced by the introduction of an intramedullary needle which penctratedthe physeal plate.

Therefore,we feel intraosseousinfusion is a valuable adiunct to pediatricresuscitationthat should be included in vascularaccess p r o t o c o l s ,a n d a l s o s h o u l d b e c o n s i d e r e df o r u s e i n t h e p r e hospitalsetting under selectedcircumstanccs.

40 Strategies for Setectiue Use of Intrayenous Pyelography(lVPl in Blunt Renal Trauma T Lieu,

GR Fleisher, JS Schwartz/ Universityof Pennsylvania, Philadelphia; HarvardMedicalSchool,Boston Children and adolescentsmay sustain blunt trauma from accidents or during sporting events. The evaluation of suspected blunt urinary tract (UT) iniury traditionally has relied on urinalysis{UA) and intravenouspyelograpby{IVP).Wc examined:(l) the yield of IVP; {2) the correlations between IVp and {al hematuria,{b) positive physical findings, (c) mechanism of iniury, and (d) admission to the hospital; and (3) the effect of IVp on patient management.This study analyzedall 78 casestreated between ]an 82 and April 86 who had IVPs for blunt tratma; 77 had either a microscopicor dipstick UA and 69 a microscopicUA. 26 (33%) had abnormal IVPs: 13 isolated congenital anomalies and 13 UT injuries (8 renal contusions,4 renal lacerationswith urinary extravasation,and I bladder rupture). The number {#) of RBCs/hpfon microscopic urrne exam correlatedwith IVp abnormalities (P < .051.Receiveroperating characteristic{ROC) curve analysison the # of RBCs required to predict an injury visible on IVP showed that sensitivity reached 1.0 with a specificity of .55 at a criterion of > 2O RBCs. If only those patients with > 20 RBCs had received IVPs, approximately half of the IVps would havebeen avoidedwhile still detecting all UT injuries. A criterion as low as > l0 RBCs would still derect all casesof UT iniurv on.IVPwhile avoiding 4O% of IVPs. Abnormal IVPs occurredsignificantly more often in patients with flank and pelvic findings on physical exam. Neither the mechanism of iniury nor admiision to the hospital predicted IVP abnormalities (P > .051.In 2 patients,IVP results led to delayedsurgeryfor congenital anomalies {ureteropelviciunction obstruction),and in 3 casesthey altered the management in terms of increased length o{ hospitalization and number of ancillary studies. We conclude: ll IVp hasa substantiallyhigheryield amongpatientswith > 20 RBCs; 2) for patients with < 20 RBCs, IVP still may be required based on clinical findings of flank or pelvic iniury but not based on mechanismof iniury or admission to the hospital; and 3) an ab-

27

influence on managemenr.

41 Routine Pelvic Radiography in Seyere Blunt lnjury: fs it ilecessary/? G Botehto, lD Civit,SERoss, CW Schwab/ CooperHospital/University MedicalCenter,Divisionof Traumaand EmergencyMedicalServices,Departmentof Surgery, UMDNJ- RobertWoodJohnsonMedicalSchoolat Camden, New Jersey Routine pelvic radiographyhas been advised in all victims of severeblunt iniury. However,its value in the awake,unimpaired, asymptomatic patient has not been established.To assessthe importance of pelvic x-rays in detecting occult fractures in unimpaired and asymptomatic victims of severeblunt trauma all patients presentingto a Level I trauma center were evaluated.Over a four month pefiod27I patients presented;150patients suffered blunt trauma with mechanismsof injury suggestiveof high energy transfer.All 150 patients {Av ISS = l4l underwent supine AP x-rays of the pelvis during their initial evaluation.They were further subdividedbased on their level of mentation and oelvic symptoms. Conclusions: l. Pelvic radiographyis essentialin the unconsciousor impaired patient to identify otherwise occult fractures. 2. Pelvic radiographymay not be necessaryin the awake,alert, asymptomaticpatient.

Patients

(N)

(o/.)

P

unconscrous

z1

J

(13.6'l")

NS

Conscious/imparred

61

I

(13.1%)

NS

Unimpaired/symptomatic

11

5

(45.4%)

NS

Unimpaired/asymptomatic

5

0

(0ol")

0 03

No. ot Fractures

6

42 Echocardiography Pedormed by Emergency Physicians: lmpact on,Diagnosis and Thelapy R Mayron,D Plummer,F Gaudio,R Asinger, J Elsperger/ Departments of EmergencyMedicineand Cardiology, HennepinCountyMedicalCenter,Mtnneapolis Over the past three years, echocardiographyhas been performed by emergencyphysicians in our ED. Our experiencehas shown it to be a rapid, non-invasivetest that has improved our approach to diagnosis and therapy in several emergent clinical situations. Through a seriesof lectures,and practical demonstrations, our staff and senior residentshave acquired sufficient expertise to perform echocardiographyon a limited basis.In 1985, scanswere performedby EM staff and chief residentson 156 patients, representingl0% of the patients treated in the critical care area of the ED. Indicationsfor echocardiosraphy fell into three categories.lI Penetratingtrauma, to rule-out pericardial effusion, accounted ior 36% o{ the cases.Four casesoccurred in which the time to diagnosis,with the subsequentperformanceof pericardiocentesisand/or thoracotomy,was dramatically reduced.

2) Non-perfusingcardiacdysrhythmias accountedfior42o/oof.the cases.Echocardiographyis a useful tool in diagnosing electromechanicaldissociation{EMDl. Through echocardiography, EMD can be divided into two categorieswhich have a different prognosis.The first category represents"true" EMD defined as organizedventricular electrical activity at a rate greaterthan 60 in the absenceof visuai evidenceof myocardial contraction. The prognosisis similar to that of asystole.The secondcategoryrepresents"clinical" EMD in which there is myocardialcontractilitv. but no obtainable blood pressure.This carries a more favorabie prognosisbecausea searchcan be initiated for other treatable causesof EMD. A caseinvolving pulmonary embolism, in which the patient successfullyunderwent embolectomy,was identified in this category.Additionally, when a pacemaker induces EKC complexes, but a pulse is still unobtainable, echocardiography can evaluatethe presenceor absenceof myocardial contractility.

3) Unexplained hypotension,particularly in the setting of a high central venous pressure,accountedfor the remaining22% of the

cases.The usuai concern was to ruie out cardiac tamponade A casein this category involved a malignant effusion which was with its potenrapidly diagnosedandtreated.Pericardiocentesis, tlal for moibldity, has been eliminated as a diagnostic modality and is now used only for therapeuticpurposesin our department' We have demonstraied that emergencyphysicians can make effective diagnosticand therapeutic decisionswith echocardiograits use as i standarddiagnostictool in the ED' phy and ad"vocate

43 Trauma Score Ghange During Transport: JE NHWillits, ls lt Predictive of Mortality? KJRhee,

Turner,RE Ward/ Divisionof EmergencyMedicine,Departmentof lnternalMedicine;Divisiono{ Statistics;Departmentof Surgery; Davis of Califbrnra.

University Tiauma Score(TS),a physiologicmeasureof iniury severity,has been used to evaluate prehospital care by comparing the TS-before and after patient transport. To assessthe value of TS when used in this way, we comparedthe changein TS during transport to eventual mortality in a group of iniured patients. Patients transportedby helicopter to the base hospital-during a twentytwo month period had Tiauma Scoresobtained on arrival of the flight crew (TS initial) and again on arrival at the emergencydepart-.nt (TS after transport).Stepwiselogistic regressionwas used to test the predictive power for mortality of TS initial, TS after transport and TS change.There were 387 patients transferred during the study periodr 376 patients had complete information and were included in the analysis.Approximately 75% of patients had no TS change and 25"h of patients experienced iith.. " positive or a negativechange.The best predictor of mortality wai TS after transport (F : 76.98,P < 0.01)with TS change addingsigni{icantly to predictive power {F : 15.OZ,P < 0.01}.We concludethat since TS changeis predictive of survival, it is potentiallv useful as an outcome measureto evaluatethe impact of treatmentduring transport.

44 Benefits and Costs of Admission Following Head lnjuries with Loss of Gonsciousness

BK Nelson.M Zakula,LB Binder,BA Glass,JF Haynes,DA Smith,MP Wainscott/ Divisionof EmergencyMedicine,Texas TechUniversityHealthScienceCenter,El Paso A common problem presentingin the emergencydepartmentis that ol head it"rr-" with loss of consciousness,medically safe yet cost effectivemanagementof the post concussivepatient preienting in apparentgoodhealth remains unsettled.Potential legal of dischargingany post-concussivepatient conconsequences tinue io worry physicians. Studies have concluded the patients who meet the following criteria may be safely dischargedhome: loss o{ consciousness{or no more than five minutes; absenceof a neurologic abnormality; absence of an rmpaired level of consciousnJss;absenceof vomiting or severeheadaches;and normal skull films. Since the advent and widespreadavailability of computerizedtomography,few studies have been published concerning the alert, niurologically intact post-concussivepatient. The pr-r-rpor. of this study was to de{ine bene{itsas well as cost ef{eciiu*.s of admission of the post-concussivepatient as iudgedby the initial assessment.TWohundred fourteen patients agetwo or older admitted for head iniury with loss of consciousnesswithin 48 hours of trauma in calendaryear 1985were retlospectivelyreviewed to compare the patients' initial history and physical to their dischargediagnosis.O{ these, 149 were fully oriented without hemotympanum and neurologicallyintact at presentation, and none had iignificant neurologic complications.One hundred eighty three hospital dayswere rncurred at an expenseof approximately $160,00b.O{ the remaining 64 patients who had an aitered mental status,focal neurologicfindings or clinical evidence of skull fracture, three died and three required long-term nursing home care. Eight others had abnormal CT scans but recovered {uily without iurg.ty. The remaining 50 recovereduneventfully.

Alcohol was involved in 30 of the 64 abnormally presentingpa-

tients. We conclude that ail patients with normal neurologic exam after loss o{ consciousness could have been discharged from the emergency department without consequence. We recommend a larger Jtudy to-determine the cost benefits and any clinical consequences.

Head Trauma and its Psychological 45 Consequences in a Group of Adults lB Gensemer,

JL Smith,JC Walker,D Traugh,FG McMurry,R Burns,M Indeck' JH Blackburn,S Brotman/ Departmentof GeneralSurgery, GeisingerMedicalCenter,Danville,Pennsylvania In order to investigate the relationship between APACHE II, Injury Severity Score-llSS),Glasgow Coma-Score (GCS)and be havioral outcome, a group of 39 patients who had been admitted on an emergency basis with a traumatic head injury were selected from*the i\europsychology Registry for study. Except for subtle personality and cognitive changes,all of the patients were making an apparentgood recovery.The Haldstead-Reitanneuropsychol6gical-tistbattery/which has been shown to be accuratein identilying brain damagedpatients, was utili?ed as the measure of outcome. The age of the subjectsrangesfrom 16 to 49 years {mean 25.6, standaid deviation 9'3)' The educationallevel varied irom elementary school to college (mean 11.6years,standarddeviation 1.Syeari). HalsteadImpairment Indices (HII) rangesfrom .0 to 1.0 (mean .6, standarddeviation .26).APACHE II scoreswere calculatedusing ihe worst valuesduring the |irst 24 hours' These scores ranged from 5 to 35 {mean 16, standard deviation 7)' APACHE Iiwas not found to be significantly correlatedwith the HII ir : O.Zll lP > .05).ISS was calculatedfor each patient and ranged from 5 to 70 lmean 27, standard deviation 13) ISS was found to be significantly correlatedwith the HII ir : 0.38){P < .01).GCS'sran-gedfrom'3 to 15 (mean9.3, standarddeviation3'4)' Of all the corielations, GCS was the most strongly correlated with outcome as measuredbv the HII lt = -}.aa) (P < 0l)' and Cost Study of Morbidity Prospective 46 of Safety Belts E Mueller,T Turnbull, Effectiveness of lllinoisAffiliated M Dunne,J Barrett,P Langenberg/ University TraumaUnit,Cook HospitalsEmergencyMedicineResidency; of lllinois,Chicago,ParkFidge CountyHospital;University Tiauma resultrng from motor vehicle accidents(MVAs)is currently the fourth leading causeof death in the United States' Mandatory safety belt (Sn) use Iegislationin many stateshas stimulated heated debate regarding the merits of SB in MVAs' Few studresindicate the effects of SB usageon outcome data other than fatality rate. We undertook a study to assessthe impact o{ SB usageon the extent of injuries,sustainedin MVAs as well as the health care costs incurred. Thirteen hundred sixty{our patients were prospectrvelyevaluatedover the courseof 6 -o.rth. at 4 Chicago aiea hospitals. Patients were evaluatedin the emergencydepaitment for SB usageand position in the auto' mobile. Charts wire later reviewed by a researchteam member who assignediniury severity scores(ISS)and obtained {inanctal ninety-one,patients data pertrnent to patient care.Sevenhundred ,.42%)were not. The mean (58%l were wearing SB whereas 573 ISSfor SB wearerswas 1.8 + 0.07t as opposedto non-SBwearers who had mean ISSol 4.5I + 0.31 (P < 0.001)'t.Restraineddrivers, front seat passengersand back seat passengersall fared significantly better than their unrestrainedcounterparts.RestrainedoccuDantsincurred mean costs of $534 versus unrestrainedoccupants who incurred costsof $1,583,an almost 3 fold increase(P< Oi patients wearing SB, only 6.8% required admission,as b.OOt1. opposedto I'g.ZU of patients not wearing SB (P < 0.001).There were 5 deathsin this study, aII oi whom were unrestrained.Our findings demonstratethe medical benefit in reducing morbidity as the social bene{it in reducing health care costs in SB 3:J;tt 'standarderroro{ the mean. iTwo-tailed

28

t test.

Front Seat Passenger

Driver N

wirh sB

560

No

295

SB

ISS 183 * 0.09 4.86 + 0.43 P < 0.001

N

ISS

Back Seat Passenger N

ISS

1 7 O 1 . 8 9+ 0 . 1 6 5 0 1 3 4 t 0 . 2 3 160 4.81 + 0.73 109 320 + 038 P < 0.001 P < O.OO2

Characteristics of Mid.Sized Urban EMS 47 Systems O Braun, R McCallion, J Fazackerly / University of C a l i f o r n r a ,S a n F r a n c i s c o ; P a r a m e d i c D i v i s i o n , C i t y a n d C o u n t y o f San Francisco This study describes EMS systems as they currcntly exist in 25 mrd-sized cities (400,000-900,000). Information describing EMS svstems was coilected bv written and nhone survev wrth {ollowups, including city population, primary ambulance provider, number of 24-hour staffed ALS {at least one paramedic) and BLS (2 EMTs) ambulances, annual call volume, use of central dispatch, whether calls are triaged at dispatch, percentage of calls dispatched at each priorrty level, response times, method used for calculation of response times, type of staffing used for ALS and resuscitation calls, use of first responders, their level of training and response times. Responding cities provide eithcr one- or twotier systems. In a one-tier system, an ALS unit responds to and transports all patients in response to 911 cails. Two types of twotier systems are identified: (A) ALS units respond to all cails. An ALS unit on scenc can turn a Datient over to BLS units for transport. (B) ALS units do not rcspond to all calls. An ALS unit on scene can turn a patient over to BLS units for transport. Overall, c i t i c s s t a f f a n a v c r a g e o f I a m b u l a n c c p e r 5 2 , 4 9 ( rp o p u i a t i o n . O n e trcr systems average I ambuiancc pcr 54,882 which is comparable to two-tier systcms which averagc I ambulance per 48,9ltl. A more efficient use of ALS personnel is highlighted by thc two-tier S y s t e m B . I n t h e 3 2 o 1 ,o f c i t i e s t h a t u s e S y s t e m B , o n e A L S u n i t s e r v e sl I B , 9 5 6 p o p u l a t i o n . I n t h e 5 6 % o f c i t i c s t h a t u s e a o n e - t i e r system/ one ALS unit serves 58,336 iP < .00051.Overall, the Code 3 response time for all cities is an average of (;.6 minutes. Thc two-tier system proves more efficient, with an average response time of 6.0 minutes, versus 7.0 minutes for one-tier systems {.05 < 1'< .l).These data suggest that the two-tier System B allows for a more efficient use of ALS resources, while maintainrng a more rapid Code 3 response time.

ity Scores (lSS| were calculated on all deaths and patients admitted to the hospital. A total of 79 oI lO75 17.3%l trauma victims had an ISS of 16 or more. Three hundred thirty-seven o{ 1075 (31.3%)patients had one or more specific MOI or AI associated with their rniury. Positive predictive values (PPV) for each MOI and AI were determined using ISS > 16 as the definition o{ maior trauma: fatality in same vehicle 2/10 120%)r passenger space intrusion ll/65 116.9%); Ial1 of 20 feet or more Il7 |'143%lr extrica,28.6%)) ,,32%), tion of 30 minutes or more 2/7 eiection 16150 auto versus pedestrian 5/35 114.3%);age o{ 65 or more 16ll16 { 1 3 . 8 % ) ' p e n e t r a t i n g t o r s o i n j u r y 2 5 / 3 6 1 6 9 . 4 % ) ;b u r n s a s s o c i a t e d with trauma 2/6 {33.3%lt spinal cord injury 4/4 llo0'/"lr proximal long bonc fracture 4/27 114.8%| Using TS < 14 as criteria for trauma center transport, 2l/79 patients (27%l wrth major traumatic inluries {lSS> l6) wouid be undertriaged. The combinatron of TS < 14, MOI and AI as triage criteria would result in 6/79 p a t i c n t s ( 8 % , )u n d e r t r i a g e d . T h e c o m b i n a t i o n o f s p e c i f i c M O I a n d AI with the TS < 14 markedly restricts the amount of undertriage.

49 Timely Utilization Of An Emergency Aeromedical Service By Rural Emergency Departments To Transfer Trauma Victims H G G a r r i s o n , T W W h i t l e y ,N H B e n s o n / E a s t C a r o l i n a U n i v e r s i t y S c h o o l o f M e d i c i n e / P i t tC o u n t y M e m o r i a l H o s p i t a l , G r e e n v i l l e , North Carolina Tirnc until definrtive intcrvention is a sieni{icant determinate of outcome from serious traumatic injury. Expedited transfer of trauma victims to regional trauma centers is one premise for the g r o w i n g u s e o f e m e r g c n c y a er o m e d i c a l s e r v i c e s . T o a s s e s s whcthcr rural rcferrrng hcrspitals arc taking advantage of the critical timc factor, wc rcvicwcd the rccords of all trauma victims (cxcluding isolatcd CNS trauma) transported by our emergency acromcdical service from rc{erring hospitals to our trauma center ovcr an 1B-month period. Admissron time to the outside ED was comparcd with thc exact time a call for the aeromedical service was reccived from the referring hospital and a "time-to-request'/ was calculatcd. Fifty (78"1') of thc paticnts had blunt trauma and fourtecn 122<'l')pcnctrating. Tcn 116%) <tI the patients were less than l7 ycars of age. The averagc "timc-to-request" for the aerorncdical service was 69.8 mrnutes. "Time-to-request" ranged from I7 minutes bcforc arrival at the referring ED to 337 minutes after a r r i v a l . F o r a l l p a t i c n t s , 2 5 ' k 1 1 6 / 6 4 1o f c a l l s f o r a e r o m e d i c a l transport wcrc made within 30 minutes of referring ED arrival and 58'/u 137l6al of requests were made within (r0 minutes. For children (16 years and younger), 70% 17/10)and9OT" (9/10) of request times were within 30 and fro minutes, respectively. For adults (older than l(r), l7'/,' 19/54) and 52"k l2B/54) of request times were within 30 and (r0 minutes, respectively. There was no corrclation between "time-to-request" and type of trauma (blunt vs pcnetrating), short-term mortahty, need for invasive intervention at the trauma center or distance of referring hospital from the trauma centcr. These observations suggest that, except in children, thcrc frcquently is an excessive delay by rural emergency dcpartments in calling for an emergency aeromedical service to transport trauma vrctlms.

48 Mechanism of lnjury and Anatomic lnjury as Prehospital Trauma Triage Criteria R Knopp, A Yanagi, G Kallsen, A Geide,L Doehring / Department of Emergency Medjcine, ValleyMedicalCenter;Central California Emergency MedicalServices Agency,Fresno Prehospital triage of trauma victims is an essential component of a regional trauma system. The ideal prehospital trauma triage plan would permit accurate identification and rapid transport of patients with critical injuries to trauma centers without changing the flow o{ patients with minor injuries to local hospitais.

Some combination of mechanrsms o{ iniury (MOI), anatomic type of injury (AIJ and physiologic criteria (Tiauma Score {TS), Crams) are used to establish the prehospital trauma triage criteria in most systems. The purpose of our study was to assess the predictive value of speci{ic MOI and AI in detecting serious traumatic injury {lSS > 16). In addition, we compared MOI, AI and Tiauma Score to determine the amount of overtriage and undertriage of trauma victims to a trauma center. All prehospital traumatic deaths, prehospital emergency calls and interfacility transfers involving acute traumatic injury in a county of 550,000 were prospectively reviewed during a two-month period. 1075 trauma victims were included in the study. Prehospital trauma score, MOI, AI and disposition were determined on all patients. Injury Sever-

50 Initial Care and Transport of Pediatric Trauma Victims MRDick,DRKing,SJZuzpan, / G Price Division of Pediatric Surgery, Department of Surgery,Ohio State U n i v e r s i t yC o l l e g e o t M e d i c i n e ; D e p a r t m e n t o f N u r s i n g , C h i l d r e n ' s Hospital; Childrens Hospital Research Foundation,Columbus The prehospital care of 338 consecutive trauma patients admitted to a children's hospital was prospectively evaiuated for compliance to accepted standards of trauma life support. Areas evaluated were: l) control of airway and ventilation, 2) cervical spine protection, 3) control of bleeding, 4J treatment of shock,

29

JM Chrtstenson' Techniques Gompression Abdominal bC Fowett,N Scott-Dbuglas'JV Tyberg / Universityof Calgary' Alberta,Canada To determine the optimal method of applying abdominalcomlevor.r.io.r. during cardiopulmonaryresuscitation{CPR),three #.t. tppii.d to the abdomen'Pressurewas applied !i;;l;r;t;;;. a.td as sbo msec pulsesat ten different phases.dur;;;;iril;;tiy mongreldogs' cycle.In 8 large,anesthetized i;-;h;.;;;tession and right atriaf(RA) pressuresweremeasured ;'h;;;i. ;";iltAo) graand AO-RA pressurecalculatedas the coronary pertuslon dient. A pneumatic piston device provided external chest comventilation ;;;;;t; iaoi-i", l2b lbs for So"/u-ofthe cvcle) and stanitioT' o,,'1l5 cyiles, at 20 mm H2o) which was definedas lf-J cp'n fs-cln1. Another identical device provided abdominal Hgf compression(ACJvia an air filled bladderat low (25 mm contrnumedium [50 mm Hg], and high tl00 mm,Hg] .pressures of o,."s! ; ;;;00 ;t";';ulses- .'{c pulseswhich beganat the end (lACl' AC .hcst compression were defined as interposed-AC applied at progressive !90^y.t:t delavs relative to ;;i;;t;..; inc, r,qc + tdd, IAC + 200, IAC + 300, IAC + 400, IAC +.500, not ie,c + ooo, rAi + 700, IAC + 800, IAC + 900- Low AC did ..r"f, i" any significant hemodynamic change Medium continu" peak ""r aCit"6Aend diastolicAo, mean AQ meanA9-RA and ;o RA Jtsplayi"g a better hemodynamic profile than any medium p,rls"d'Ac. riigtt Iec + 300 demonsiratedthe best overall ..ofif" t"i.i"* cnd iiastolic AO 29 7 mm Hg (P < '001),meanAO il.s'lP . .001i^na p"rL AO-RA t6 6 \P < '01) Continuoushigh We oi".tit. was as effeitive except with respectto peak AO-RA improves significantly + 300 IAC pressure 1) high that: i;;;I".t" a.td is the optimal.method of applvingAC C;it-h;;;Jt"a-ici Jurine CPR and 2) continuous abdominal pressureimprovesCPR anclshould be further investigateddue to the ease ;;;;t"-";i;s of application.

quantilied and 5l fracture immobilization Degree o{ i{gII was patient (MISS)' Three Score Severity Iniury [v the tvtodlfied "i""rr *.i" iJentified: l) EMS: 123 were transporteddirectly by = 9'4]1,21 HOSP: 104were E-.i*.tt.v medical services{x MISS = III ;;;;;f';t.a from anotherhospitallx MISS l0 l), and 3l PAR: : MISS parents by department lx emergenty the to *.i"L"gttt i.i, p I o-"oit.Noncompliance wiih currently acceptedstandards of pediatric trauma care was identified tn 32% of all -patients' *ere characterizedby a high incidence of isolated Fiil;itiia;" ;;;; ;"t;;y; ;"d problems related to lack of C-spine control durFiity-eight EMS and HOSP patients had 78 defii;;1;;;;6'4. in.l.-n.i". in c^re 1ztt"t"l'In patientsin whom-interventionwas most .ornrno., problems were failure to protect the -siiie dicated, the (63%), and ""i"l.lf lzz"t"),.rrot. itt IV administration failure to maintain arrway and ventilation 129%l'Mean age and pffts *.t" not different for EMS and HOSP patients with and without errors in care. The mortality of error and nonerror gto.tp. *"t the same (3.5%).However, the children who died in : ih. irtot group were younger and less-severelyiniured (x age = the nonerror in those than 25) 3.5 month"s,P< 0.01; x l'ttsS except sroup (x age= 8.7 years,x MISS = 4l) ln all areasof care, failure to act a were deficiencies the of 82% iV "i*i"i".,t"tion, rather than incorrect action. These findings support three conclu;;;;;' ii A surprisingly high number of children who mav have parL.".fia.a from pt.h6spita"ltreatment were transportedby utllrzaproper unaware^ot are people many that sugSesting ents, 2) The care delivservic.e.s tion'of i'iailabii .-.tg..iy-medical p.rs"onnelfrequently fell short of currently .r.a lv--.aical acceptedstandards Noncompliance was not related to age or lndeof errorsof omissionsuggests iury severity.3)The prevalence ikillt, or lack of confidencein procedural ii;i.;i ;;.;t;..tt skills.

51 A Gomparison of a B:osynthetic Skin Substitute Vbrsus loloSilver Sulfadiazene Cream in itre 6utpatient Treatment of Second Degree

T Lukens'D Effron gurns B Gdrding C Emerman'R Fratianne, of Surgeryand EmergencyMedicine,Cleveland / Departments GeneralHospital,Case WesternReserveUniverslty' Metropolitan Ohio Cleveland, a bioWe conducteda prospectiverandomizedstudy-comparing svnthetic skin su6stitutewith l% silver sulfadiazenecream ln of outpatient seconddegree.burnsThis studv ;fr;-;;;;g;*"nt healing rate, infection rate.,and pain relief in pa."-pri.i',ft. tienis treated with one of these two methods' Patientsover two -o",lt .f agewith superficialor medium depth-partial thickness burns, less iha.t t*eniy-four hours old, and of appropriatestze and location for outpatient managementwere eligible for.this study. Patients were seen until epitheliazationwas complete' paClinical criteria were used to iudge wound infections' The pain of amount the rated childlen, of case the in ,i".trt, ot parents they expeiienced on a five-po,int scale' Forty-six patients comgroup and 24 in the "i.i.J ,it. studv with 22 in the Biobraner& gioup. Three of the Biobranerqpatients developed 5ii""a.*infeJtions while two of the patients in the Silvadene'" ;;";d gto"p d"u.toped wound infections.This differencewas not signifi.rtri. fh. Biobrane'patientshad an averagehealingtime of ll'4 aryt. ftt. Silvadenedpatients had an averagehealing time of 173 J"vi. rit. differencein healing timj.was significantly shorter {o-r the Biobrane'' patients, (P < .05).The-patients in the Biobraneo gro"p i.p"t,.a significantly less pain than the patients in the Sil'r4"i.o'group offers a sig{p"< .Or}.We conclude that Biobrane@ in the outpatient treatment ol nificant idu"ttt"g. over Silvadene(D oartial thickn.., brrr.tt. The use o{ Biobrane@requires-frequent iiot. oUt.turtion for signs of fluid accumulation or infection'

optimizing HemodYnamics of 52 Gardiopulmonary Resuscitation by Varying

30

OxYgen DeliverY and Myocardial 53 of Durini Gpn: a Gomparison coisumption CG Brown RB Tavior' and Phbnylephrine Epiniptr'iine iA w"rmun T Luu, J Ashton,RL Hamlin/ Divisionof Emergency Medicine'Ohio State Medicine,Departmentof Preventive Coilegeof Medicine,and Departmentof Veterinary University Collegeof Ohio StateUniversity and"Pharmacology, Ff',vrloO6y Medicine,Columbus Veterinary While epinephrine has been shown to improve.myocardial inblooJ flow'(lvtnF)during CPR, its beta adrenergiceffectsmay oxygin consumption lMvor) over mvocardial ;tJrtdial ;;;;; ".yg." ai-iit.ry (IuDdr). Becauseof this pure alpha adrenergic of Jr,1f, t"t"u. been recom;ended for use in CPR The purpose (E), this"study was to compare the effect of epineph-rine a mixed phenylephiine iPE),a pure alpha-l alpha and beta agonrst,versus'during CPR Fifteen swine weigh;;;;;';; ;; Mb62 and MVo2 * = were allocatedto receive 23) (-mean l9.t kg ze.s ii.o iig = 5), or PE l 0 mg/ .ii't.. E 0.2 mgTkg(N : s), PE 0.1 ms/kg (N k;'iN = Ji roir.riiitg t"r, -in,rt.t oiventricular fibrillation and tliree minutes of CPR..MBF {measuredwith radionuclidelabeled arterial and coronary sinus oxygencontents{CaO2 "c";ot; -i.-tott.t"tt, ;sfectively), were measured during normal sinus il tftt,trrn (f.iSn),'Cpn, and during-CPR following,drugadministraMBF ,i,ir. MnO, and tr'tvO, were cllculated using the formula: respectiv;ly' CsOz), , MSr ,.td t- C"O, -Extraction iC^O, .rtior ifnt were calculatedis MVO2/MDO2 Defibrillation was were Outcomes attempted3/z minutes after drug administration' "o-pi."a using an analysisof variance Significantdifferences were followed up using a Neuman-Keulsmultiple comparlson pro..d.lt.. There were"no statistically signi{icant differencesin 'C"O, U.r*..tt the groups during CP\ or-{oliowingdrug adminaiso istraiion, (P > .09).MBE MDO2, MVOz, CsOz-?ndER were followresults > The '47)' ClR, dr.ri.tg lP t"i*".n ;;ii;; sroups ing drug administration are displayedbelow'

E O.2 PE 0.1 PE 1.0 P value 1 6 0 + 0 . 5 1 3 . 9+ 1 . 9 1 3 4 * 2 . 8 0 1 4 2 C s O , ( c c O r / 1 0 0m l ) 3.7+ 1.6 0 8 + 0 . 5 1.3+ 1.2 0.003 M B F ( m l / m i n / 1 0g0m s ) 6 7 2 * 4 9 4 7 . 0* 7 1 3 6 7 * 2 1 1 0009 N / D O 2( c c o ' / m i n / i O Og ) 1 0 6 * 7 5 10 :t 1.2 5 3 * 36 0009 M V O 2( c c o 2 / m i n / i 0 O g) 7 6 * 4 . 4 1 . 0* 1 . 1 4 8 * 3 1 0 0 1 0 ER 7 6 . 6+ 1 0 . 5 9 4 . 6 + 4 . 0 9 0 . 7 + 7 . 5 0 0 1 0 o/.successful 800 0 0 d e fi b r i l l a t i o n C a O , ( c c O r / 1 0 0m l )

Following d,rug administration, there was a significant improve_ ment in CsO2 and ER in the E group comparcd"to both pE gio,rpr, P less than 0.05. Although there was no statisti"aily silrilfi.a'.,t difference in MBF and MDO, between E 0.2 mg/kg nrri pE t.O mg/kg, resuscitation rates *ere significantly ictter in the E group. These data indicate a trend toward improved myocardial oxygen delivery over utilization in those animals treated with 0.2 mg/kg of epincphrine.

The-Effect of Metabotic Acidosis- on 9l During Gardiopulmon;;t-Cartey, lqinenlf1g Resuscitation

ML Zwanger, RD Welcn, GJ tK Todd, BF Bock / Section of Emergency Medicjne, Department of Surgery, Wayne State Unjversity, Detroit Epinephrinc (EPI)is recommended during cardiopulmonary rc_ suscitation (CPR) to increase arterial p.ess.-r.e,to augment coro_ nary perfusion pressure, and to imprbve resuscitabiiity.

Dunng alle,:t, anaerobic mctabolism lcads to the pni :arolopulmonary d u c t r o n . o f l a c _ t i ca c i d ( L A ) . T h e p u r p o s e o f t h i s s t u d y w a s to deter_ minc what cffect metabolic acldoiis has on cpinephrinc during CPR Eightcen dogs werc ancsthctized with pentobarbital, intul D a r c dJ n d p l a c c d o n a v o l u m e v e n t i l a t o r t o m a i n t a i n a n initial pH o f 7 . 3 5 - 7 . 4 0a n d a p C O 2 o f 3 5 - 4 0 t o r r . C a t h e t c r s w c r c inscrted to m e a s u r c a o r t i c s y s t _ o l i c ,d i a s t o h c ( D p ) , a n d r i g h t a t r i a l ( R A ) p r e s surcs;^rrcdn arterial pressure (MApJ and coronary pcrfusion pres_ s u r c I C P P )w c r c c a l c u l a t c d . T w c l v c d o g s r e c c i v c d i n f u s i o n s oi one m o l a r l a c t i c a c i d t o d e c r e a s ct h e p H t o a l e v c l o f Z . t S i * of thcsc twclve dogs thcn had their pH corrected with sodium bicarbonatc (Na Br) while six iJogs_rcmiined acidotic.

Six dogs scrvcd as con_ trols and rcccived no lactic acid. Cardiac arrcst was initiated by an intracardiac electrical dischargc causing ventricular fibrillal tion. Aftcr fivc minutes of fibrillition, sidc to side closcd chest massage was performed at comprcssions per minutc. Thirty *6O seconds after thc start of CpR, I mg o{ epineihrinc was rnjectcd rnto a central linc. Results for thc ihrce gro.rps a.e summarized lmean :t SD mm Hg): Pre Ept

post Ept

pre Ept

post Epl

PE EPI

MAP

MAP

RA DP

RA OP

CPP

Post Epl

CPP 2333i36 4052t136 ti9at5 l 5 8 t 3 . O 3 6 1 1 5 1 4 9 17 6 LA 2 4 2 2 t 3 4 3 8 . 6 4 i6 6 1 2 2 t 1 0 1 6 9 1 2 i 3 5 i 15 1 2 6 r 42 L A + N a B i 2 6 8 1 t 3 . 84 6 1 2 ! 9 2 1 3 6 1 1 6 i 8 3 a t 7 3 9 : :1 5 1 6 8 1 7 5 Control

Using analysis of variance, no differences were noted between the threr groups. Within each group, therc *rr, ,ignifi..nt Increase tl-y+l'lP.< .02), RA diastolic pressure (p < .02),antt Cpp {pl . 0 1 )a f t e r t h e a d m i n i s t r a t i o n o { e p i n e p h r i n e . D u r i n g cardiopujmo_ nary arrest, cven in the presence of a moderate metabolic acido_ srs, eprnephrlne appears to be effective in augmenting arterial and coronary perfusion pressures.

55 Lido_caine Levets During-lackson, Glosed.Ghest llassage in Dogs pA Barish, Re WipeacockI Emergency program, Medicine Residency William Beaumont RoyalOak Mrchigan; Department of Surgery, Wayne !9:?ilgl StateUnrversity Schootof Medicine, Detroit, Michi6an

The pharmacology of lidocaine during closed-chest massage is incompletely understood. Lidocaine levels greater than 510 mcg/ml are considered to be potentially toxic with higher levels known to affect the cardiac ionducting system and i-ryocardiai contractility- The purpose of this study was to determ;ne lidol caine blood levels and pharmacokinetics during closed_chest massage.in dogs. Eleven mongrel dogs were aneJthetized with pentobarbital 25.mg/kg, and-placed on a ventilator. Each dog was given I mg/kg of lidocaine through a peripheral IV line. Arierial lidocaine levels were then drawn at 30 seconds, l, 3, 5, 10, 15,and 20 minutes post-iniection. Three hours after the iniiial bolus, a final_prearrest level was drawn and the dog was placed rn fibrillatory arrest. Standard closed-chert -"rirg" wis started with a l\,lichigan Instruments Thumperri. Eight minutes after onset of complete cardiac arrest,.l_ mgTkg of li"docarne was grven as in the prearrest phase. Arterial lidocaine levels were drain at 1,3, 5, 10, 15, and 20 minutes post injection. pre- and post_arresi lidocaine levels were compaied using the paired t test. The immediatc pre-arrest values were 0.0+e ,t 0.06 pglmL. The I mg/kg dose of lidocaine during closed-chest massagi produced values that significantly higher than the prcarrest values ^wcrc rr()m J to LU mrnures after rniection lp < .001)The levelsat 3 and 5 minutes were 10.5(r + 4.43 and 10.16 :t 2.23 mcg/ml re_ s.pectivcly during closed-chest massage. Time to peak livel was dclaycd and thc initial distributron pliase was prolonged. The VJ in thc control period was 1.0 L/kg whilc duringclosed-chest mas_ sagc Vd was 0. l9 L/Kg. We conclude that d"uring closed-chest m a s s a g c ,t h c c u r r c n t r e c o m m e n d e d d o s e f o r l i d o c a i n e a d m r n _ lstratlon produces potcntially toxic levels in dogs. The phar_ m a c o k i n c t i c s o f l i d o c a i n e a r e s i g n i f i c a n t l y a l t c r e d . ' - F u r t h e rs t u d _ i c s s h o u l d b e d o n c t o u n d e r s t a n < L t h ec l i n i c a l s i g n i f i c a n c e o f t h e s e findings.

-56- l"y4ghronous Gardioversion of Ventricular

Tachycardia EA Michelson, DJ Burkey, RN Fogoros, pM Paris,SM Schneider / Medical Emergency Serviced, Montefiore H o s p i t a l ; D i v i s i o n o f C a r d i o l o g y , p r e s b y t e i i a n - U n i v e r s i t yH o s p i t a l , C e n t e r f o r E m e r g e n c y M e d i c i n e , U n i v e r s i t yo f p i t t s b u r g n T h c l 9 l l 5 N a t i o n a l C l o n f e . r c n c co n C a r d i o p u l m o n a r y R e s u s c i t a _ t i o n a n d . E n - r c r g c n c yC a r d i a c C a r e h a s r e c o m m e n i e d u n s y n chronized countershock for the treatment of hemody""-i.Jtty unstable ventricular tachycardia (VTJ. Conversion of VT tn u..rtricular fibrillation (VF) is a theoretical complication of coun_ t c r s h o c k o c c u r r i n g _a t a c r i t i c a l t i m e d u r i n g c a r d i a c r e p o l a r i z a tion. We cxamined the frequency of VF reJulting from a large scrics of asynchronous patient-countershocks and ihe .orr.lrirJn ot thrs untoward outcome.with timing of the shock during the cardiac cycle. Onc hundred r.u"nty-r.u"., patients studied in our elcctrophysiology lab between fuly l9g2 and December l9g6 had induciblc sustained VT We reviiwed the endocardial tracrnls from the- right ventricular.apex of patients in VT or VF who exp"e_ ricnccd. hemodynamic collapse necessitating cardioversion.

The interval _between the preceding ventriculai depolanzation and countershock impulse {R-shocklwas measured and expressed as a r a t i o o f _t h e p r e c e d i n g R R i n t e r v a l iR-R).patients whose VT deteriorated to VF,prior to cardioversion were excluded. Additionally, we excluded those countcrshocks in which electrical or mechanl ical artifacts made rhythm determination or interval measure_ ment unreliable. One hundred fifty-six asynchronous cardioversrons (73 patientsl werc performed. After excluding episodes of VF, 73 remaining countershocks {46 patients) were for hemo_ dynamrcally unstable VT In only 4 of these Z3 countershocks did VF follow, an incidence of 5.5"/o. A random distribution of R_ shock/R-R ratios was found, with a mean oI O.49 * 0.30. All four episodes of VF following cardioversion occurred with coun_ tershocks that fell close to the ventricular depolarization lR_ shock/R-R - 0:05, 0.06, 0-95 and 0.96), and not during the pre_ sumed critical period of repolarizaiion. We .o.r.l-ud. thrt asynchronous cardioversion of ventricular tachycardia is safe, with a low incidence (5.5%f of inducing ventnc;lar fibrillation.

New PersPectives on Rulal EMT 59 PCo'Brien JWBachman, RDWhite, FeTilriliation Li vukov,

Moreover, there appearsto be no increase in likelihood of fibrillall* ....,iti"g fro; countershocks during the presumed critical cardiac repolarization Period.

/ Mayo Clinic, Rochester,Minnesota Conflicting data exist regarding the impact of basic EMT deliUiilt"tio" ir rural communitiei. To clarify this, 15 rural amin southeastern Minnesota were trained in the ;;lr;;;-;.r"i;es "r" Jirr. H."rt-Aid Model g5@Automatic External Defibrillator.

The communities, varying in size from 5,000to 36,000,wererandomized into two gro.tpJfor a two year cross-over study' Com' -.nci"s Auzust 1,"1984,eight communities were desiqated.to ii.". o"ii."ri *ith'the 'qr,o-while sevenservedas controls'After """ v*r, treatment and control communities crossed over' Deelectrodes were placed in an anterior apical-position iitiiti.ti"g management was standardized The following airway ,tra ittlti"i table demonstr"t., tre"trrr"rrt and control group data as well as data extracted from the largest community'

of Five of Performance 57 Comparison Pacing DevicesrMB Heller,J Peterson, Transcutaheous K llkhanipour,RM Ka$an, PM Paris,Rd Stewart/ Divisionof Emergency Medicin6, University ot Piftsburgh School of Medicine; Center for EmergencyMedicine of Western Pennsylvania,Pittsburgh Transcutaneouspacing is now recognized as a safe and effective "rrr.rr"t"n technique fo-r the treatment o{ pharmacologically-rerirt"f;t Ui"avrrrhythmias. Although currently marketed pacemay differ significantly in the important aspectsof wave' -rk.tt i"i"r of the pacing- stimulus and pad- desig-n,no study has of different units' We studied the per.o-p"t"a the perfor-mance formance of five diflerent transcutaneous pacemakersby-compar; i"*-ift. .rpr"te rate, degreeoi discomfori and capture threshold oi.".ft ,*orrg,"n healt[y volunteers.The five units testedwere: ihe PaceAid';Model 53 ('CardiacResuscitatorCorp), Redi-Pace'" (Medical Data Electronics),TiansPace'" (Micromedical Devices, incl, Zoll NTP {ZMI Corp),and Li{ePak-8'" (PhysioControlCorp)' in-ili, t""ao*, slngle'biind study, each subiect received-pacing stimuli o{ increasingamperagewith each unit until mechanical ."ft"t. was achievei or discomfort becameintolerable' Subiects raied discomfort at severalelecrical output levels and at capture using a visual analogue pain scale. Our.results demonstrate *rrl6d di{ferencesamong the devicesin their ability to achieve caDture and the ,rr.an "a-pt.tt. threshold' Capture rates varied l"i* +Oy' to 80%, significant at the .10level. The capturethreshold varied from 56.5 to more than 104 MA (P < '10)' One subiect who did not capture despite withstanding the maximum output oi on. "nit capiured easily with others. Volunteersconsistently t o*d gt."a.t discomfort with some units as comparedto others but thls was not clearly reflected in the visual analogue pain scaleratings.We would conclude that-important.differencesexist pacing devices,and that these differencesaffect ,*o"g.*t?tnal pacin!'threshold, caprure rates and patient tolerance'

58 Prehospital Administration of Lidocaine goius Versui Bolus Plus lnfusion JM Nea/,SW Medical University / WakeForest LDCase,LWStringer Collins,

Total pts Mean age Witnessed

Contlol Group 68 67.4 40 (59%)

Tieatment GrouP 100 69.8 70 (7O'/")

Treatmenl (Austln) 23 684 18(78%)

27 (677") I (20o/") 5 (13%)

36 (51%) 20 (29"/") 14 (2o%\

10(56%) 4 (22r") 4 (2214

24 (60%|

35 (50./.)

16(90")

32 (46%) 21 (30%)

12 (67"/4 I (507")

Presentingrhythm Bradyasystole PIVR C P R p r i o rt o amDulance Collapseto delib < 10 min Admissions

0 5 (12%)

Discharge -6 (17%) 5 (50%) 1t g%) survivorsfrom VF tlhe controlgroup survlvorexperiencedVF en routeto the hospital .P = 0.053 comparingcontroland treatmentgroups

Center,Winston-Salem,North Carotina TWo protocols for the prehospital administration of lidocaine - bol"l versus bolus plus infulion - were evaluated for their efficacyin producing therapeutic serum-lidocainelevels' Patients lidocaine ior prophylaxis in the setting of acute chest ;;;;i#g oain or for ventricular ectopy were randomized into two treatil.n, gro.tpr. Group A (bolu! protocol; n = I5l receiveda 75 mg iv Uotl"t of lidocaine, followel by repeat 50 mg bolus every l0 : 2l) *in,r,.. during transport. Group B {bolus plus.infusion; n t5 ;g IV lidocaine boius plus immediate institution o{ ;;;;;;;; a 2 mg/min lidoiaine infusion. Persiltent ectopy was treated with re-bolusof 50 mg lidocaine plus increaseof the infui*t-ifi.nitt sion rate to a maxlmum of? mg/min. Serum lidocaine levels *.r. obt"in.d upon arrival in thelmergency department, within l0 minutes of the last bolus. Mean serum lidocaine levels 1'62 : pg/ml l'81 p'g/ml), 1.5'5'0 rr,s/ml Group A {therapeuticlevels did not difier significantly betweenthe two prot-ocols e?";; t(13/211of 1F :'O.A+f 1.Forty percent {AftS} oi Group A and 62"h : broup B paiients'had subtherapeuticlidocaine levels (P 0'194)' There were no differences between the groups in attainment ot J.tit"a therapeutic endpoint {resolutionor prevention of ectopyl' No pati..rtt exhibited ioxic levels of lidocaine' In conclusion, there was no clinically significant differencebetween bolus versus bolus plus infusion o{ prehospital lidocaine with respect to Uao."i"e levels and ittainment of desired therapeutic enda.*p"i.rt. E"ttft.tmore, both protocols resulted in unacceptably high iates of subtherapeutic lidocaine levels.

Ambulance responsetimes in all three groups-weresimilar' Only one unwitnessedarrest was briefly admitted Communities without a 911 system comprised30 percent of the study population, accountedfor 2l percent of all admissions,but had no survlvofs' fo*trs of less than 10,000had 2l percent of all witnessedarrests, achieving 9 percent of all admissions but no survivors' Tleatment fared better than control communities in both ad""r"r"""'itiJ. and -i"rg.neurologically intact survivors When data from ;i;;i;;; wittr 9lI, police first-respondersand .o*-,ittitv d;ii; i; iull-time EMts) are separaiedfrom the treatment group,-however' i[. i.r"ft. suggestadditional considerations' In fact, only one in' year dividual in thi- other 14 communities during the treatment survined a witnessed cardiac arrest in a two year period' The presence of 9ll and a population service area greater than 10,000may of rural EMTD' Potential bene{itsol i" i[.'bt".flt ;;;;-;i; i.tJa fi"- "rrtomrt"d defibrillation may produce significant life. salvase onlv in larger rural communities with EMS systems ul ;hi;fi l";l;'de identi"fiable and essential prerequisites' Successf alter' innovative necesiitate will EMTD rural of "fii;r;i;; natlves to present practrces, including more strategic placement of defibrillators.

32

Prehospital Trial of Emergent 60 SA Trinscutanebus Cardiac Pacing JFIHedges'

Syverud,WC Datsey,S Feero,R Easter,B Shultz/ Department of CincinnatiCollegeof of Etutg"n.y Medicine,University Medicin5;Departmentof EmergencyMedicine,LacktandAir Force Base, San Antonio,Texas;ThurstonCounty Medic l, Olympia,Washington The use of transcutaneous cardiac pacing {or prehospital pati""i. *ittt hemodynamically significant bradycardia or asystole has receivedlimited attention. We used a stand-alonetranscuta-

I

II I

i

I I

i

neouspacemakerin a prospectivecontrolled triai of cardiacpac_ rng for prehospital.paiieniswith bradyasyraoi."na a Grascow Loma 5catescoreof < 12.patientsin the control group(N = ll5) receivedstandardAdvanced_Cardiac Life Support (RCiSj ""re. lri tr.entsin.the.pacinggroup lN : B7) receiv#transcutaneous carorac pacrngln addrtion to standardACLS treatment.

The two groups were comparable i" j...T_r-o! age, sex, presenting rhythm, and mean times to CpR and ACLS. Foi the l+4 patrents in whom the time of arrest could be estimated, the meaf std) ;il;, ;; CPRand ACLS in the totai population *ere S.i t {:: 3.9 and 10.6 + 7.1minutes, respectively.lor ihe OZpa"ed prtrents in whom the time oI arrest could be estimated, tt. -.rl-ii-. frorn ,rr..t-to pacrngwas 21.2 + 10.3minutes (range2-60). tvtultlvrrirte ,rralyl sis of outcome variables(presentatioi ,o .-.ig.""y department admission io the hospitat, *J ai*frirgr?;;;-rh. fnosptratl t,i l,rl:., revealedthat an initial rhythm presentation of ven_ tricular tachycardiaor fibrillation n"d'" ,ho;-;;e to ACLS were correlatedwith a favorableoutcome < O.Oi,-iosistic lp regression analysis).A short time to pace showed a tr.ndlo, admission to the hospital lp : 0.09, logistic,.gr.rrro.r r"rfy.irf.

The use srano-atonetranscutaneouspacing device in the prehospitalof a arresr settlngwas associatedwith generallylong times until pacing not appreciablyimprove outcome. Usleof transcutaneous clnd,did a r o l a cp a c r n g f o r p r e h o s p i t a lb r a d y c a r d i cp a t i e n t s without neurologicalimpairment remains to be evaluaied.

61.. nana_omizedSt_udyof Epinephrine Versus Methoxamine in prehodpitat Vint?iduriar -sir"rlrlE'rhompson, Fibrittation DWotson,-R Thzku; H Hendtey.K Harsarten z rveoiciiCorrege of l,]::P*SE vvrsconstn,

Departmentof EmergencyMedicine,Milwaukee American Heart Association (AHA) recommends the use _The of epinephrineas a vasopressorin the t..";;;;ti.o; of ventricular fibrillation IVF). Experimentaldata *d;;";il;; a pure alpha_ agonist,such as methoxamine,rn"y imf."oue the outcome of pa_ tients in VF.A double-blindrandomizedstudy was conductedin a the use ot *ltn&1-,ne and epi:::"1*.,:y..,,_.m.;omparing nepnnne rn vF, otherwise following the AHA protocols.

One hundredand two.{102Jpatrentsin ventricurar fibrillation who did not respondto the initial defibriliationwith a pulsatit..ty1trn were randomized into two-groups, both containing 5l patients.

Equipressordosesof epinephiine-(.5mg) ,"a -.it o*"_rne l5 mg) were given intravenously and repeateJper AHA luidelinei. fh? mean age,sex ra.tio,and mean paramcdic,"rpoir.

-^t times werc comparablefor the two groups. The mean titi" scene until conversionwas22 + I0 minutes for methoxamine versus I/ + Z minutes for epineohrin" (f = .10).The -etho"aml.re group re_ ceived_3.I* i.4 dbsesor in. ar,.,g'u.r.;r-t.d;^ft dosesfor the epinephrinegroup-{p < .20).conierrio.r rrte, a"ri".a ", ,rr. p..cent of patients who developeda pulse d;;tdr" resuscitation, was 27.5'/" for the methoxamine group versus+O.OU" fo, tie ,[i,group (1)< .02). A s.."c!rsf.rl ,.r"."itril", defined as :fllt]"" rne conveyanceoi a patient to an emergencydepartment with a p:l::. "ld rhythm, wis 17.7% ro, tt. -!it o;,";i;; versus sroup 3-,9.2"/" for the epinephrinegroup {p < .02). Sru. i",", defined as the^percent. of patients dischargedalive after hospitalirrti";;;;; 7.8% for the methoxamine group versus 19.6% {o, the'.pi_

rri"i"r-rr*i"r.r ri,,ai6j, .= ostwec"onctude lf:T'::,*^':lo1l t eprnephrine.results in a significantly

higher rate of suc:l: ?:: cesslul conversionand resuscitation comparedto"methoxamine.

62.

f_"ittlre

of Flunarizine

to protect

the

Brain During Beperfusion foltowing l- is.uinute u_arotacArrest: Evaluation by Markers of Membrane Injury and euantii"ii;;'-'yo.rflometty BCWhite, K.Kumar, NRNayini, GSKrause, SD Aust/ Divjsion of Emeroency

Medicine, WuynZ -Departr"nt, Siut"University Schoolof Medicine,Deiroir; oi elo"hlirrstryand MichiganStateUnrversity Coilegeoir,,le"jic,nefast l:lol"Sy, Lanstno

11has been suggestedthat brain injury {ollowing cardiac arrest ano resuscrtatronrs due to ,,secondaryischemia,,which develops a plogreslive hypoperfusion phenomenon during the Iirst 2 ls_ IoI_towlng nours reperlusion.The calcium antagonistFlunarizine@ ltannsenlnas been shown.to protect against the developmentof post-ischemic.hypoperfusionln the br"ainby multiple t"Uorrtol ries..This_studywas conductedto determin.if ,ti, dr"g h;;;;;_ tective effe_cts-against the developmentof lipid pero"ida'tion,ioss of normal K/Na gradient, and aciumuration of is"hemi. neurons during the first 8 hours of reperfusion]"11l*i"g ,ls-minute cardiac arrest. Data was obta_ined from Z non-isihErii. "orrtrol dog, e animals.sublectedto cardiac,rr.rt ,rrJ ,*t,scrtatron and l\tCt, b nollrs ot stanclardtntensive care {SIC),and 6 dogs which were trcated.with flunarizine (0.1mg/kg iV1 immeaiatai, after resusciranon trom cardracarrest and resuscitatron,then supported by rntensive care for 8 hours. Lipid_peroxidation was .rrairrat.a fy the accumulation of malondiaiaehyde(MDAt;"d i"rs ol unsatu_ ratedlipids (lipid unsaturation index : fUSlt l" tfre parietal cor_ tex. K/Na gradientswere studied by atomic emission specttome_ try o{ parietal brain tissuc afre; disrol"tion-in HNO.. The accumulation of ischemic neurons was evaluatedin th. prrleiai cortex, hippocampus,and cerebellum using light -ic.os.opy arrd quantitative morphometry,with the "o-futi. driven Magiscan tmage analysis system (Nikon). Data were .*^-i.r.a for itatisucar.srgnrtlcancexsrng MANOVA, ANOVA, and Scheffe contrast to pinpoint-significant differencesat It < ..05.Flunanzrne treat_ ment provided no significant protection in cortical U.ri" ,a_pi"s agarnstMDA accumulation (F treated : 490 % NIC), deterioration of LUSI {F treated : 6g% ,.,o, "grinsf K/Na gradient .NIC), rnversion after 8 hours oI reperfusion.Moriiometric anilysis is bctow as perccnt bf neurons d.;;;;,;;;,"s acute is:tb:]:].d c h a n g e s lpyknotic nuclei and deeply eoJinophilic :cytopiasml. i:-,t.

Brain Region Parietal Cortex

SIC Controls 40.0 + 20.8

Flunarizine Treated 3 0 . 0* 1 2 . 6

Hippocampus

293 + 12.1 42 6 + 21.5

1 4 . 8+ 9 6 3 5 . 5+ 1 0 . 8

Cerebellar Purkinge Cells Flunarizine

P NS < .05 NS

cxhibitctl some cvidence of cell sparing cticct

onlv in thc hippoca-.p.gs. concludc tt "t rtunariiin;,:';;;;:ff;.i ryc ,llld peroxidatronand loss of m.embrane integ:lL,,l-. _"r"^r:.-,:l

riry in the cortex during postischemicUrrin ,.p.rfuri;;;'il;;;, rr nas no protectlvc ettcct on quantitatively evaluated tissuemorphology in the cortex ot ..rib.llrlTh;;il;;;ena of brain injury by ischemia and reperfusror,,r..-or! .o-pt.* ,fir"-r"ggcstedby the conccpt of ,,iecondarylsche-ia,il.ri inhibition of rne post-rschemrch_ypoperfusion syndrome by this and other cail clum antagontstsoflers no assuranceoI enhanced tissue salvage.

63 O"t"toxamine po,stfreatment Following Totaf. Cerebrat tschemE jn boll rc",ijty, sr Badytak, W Janas, LAGrore, CFBabbs / Departmint ol iiuuru "no

EmergencyMedicine,MedicalCollegeot Wisconsn Milwaukee; HillenbrandBiomedicalEngineering benter, purOueUnrversity, West Lafayette,Indjana Previousstudies have shown that the iron chelatrng agent deferoxamine decreases,,free,,iron.and ,r"; ;;p;;l;;t rlpiE p*",. idation in postischemicbrain ,t + holrrr. ihir'ri"Ay was designed to examine the long-term functional and histopatfi"l"gi;;iF;;;; of deferoxamineadririnisteredafter total cerebralischemia at the

?#:l ry/yl.

.j^::flju1i9n i1 rackson,s.canine -"J.i lsrrr., ro, ss, LereDta.t lschemra

was produced by balloon "u"."aocclusion oi the ascending thoracic ,ort" ,.rd tir. pori.ro, cava, sufficient to reduce carotid artery pressureio iess than 15 mmHg for 15,min in 25 mongrel dogs. Within e -i" rii", balloon de_ .\z 1o deleroxamrne,_20 mg/kg or 50 mg/kg or saline vehicle was 1?tr9n aomlnlsrered by steady intravenous infusion.

Two of 5 dogs treat_

ed with 50 mg/kg died within one day.All dogs treated with 20 mg/kg survived, but showed no better clinical neurologic scores at 5 days after cerebral ischemia than saline-treated controls (Grandmean : l5% deficit,0"/o : normal, 100% : brain dead).

Quantitative morphologic assessmentof brain pathology by light microscopy in surviving deferoxamine treated dogs revealed mean damagescore of 8.4 ISD = 4.21versus 13.0 {SD : 8.4) for saline treated controls (P > 0.05).More cortical neovascularization was observedin brains of deferoxaminetreated dogs than in those of controls. Deferoxaminepost-treatmentdid not provide a lasting protective bene{it in faclison'scanine model of cerebral rschemiaand reperfusion.

Brain Enzyme Levets in GSF of Dogs After 64 Cardiac Arrest and Resuscitation: llarkets of Damage and Predictors of Outcome P Vaagenes, P Safar,W Diven,J Moossy,G Rao, R Cantadore/ Resuscitation ResearchCenter;Departmentof Anesthesiology/Critical Care Medicine;Presbyterian-University Hospital;University of Pittsburgh This report establishescorrelations ol regional brain enzyme decreaseafter cardiacarrest (CAl and cardiopulmonaryresuscitation (CPRf with cerebrospinalfluid (CSFfcytosolic enzyme increase;and the latter with severity of insult and outcome with neurologicdeficit. Methods: In 63 lightly anesthet\zed,paralyzed dogs,CA was induced either by asphyxiation plus 0-10' CA {AA, n = 321,or by AC shock and l0 min ventricular fibrillation {VF) CA {n = 31).Spontaneous circulationwas restoredwithin 5' by external CPR. IPPV was continued for 20h and intensive care for 96h post-CA, with control of MAI blood sugar,blood gasesand other variables.CSF was collected by cisternal punctures before CA (controls), and at 6, 24,48,72 and 96h post-CA,and analyzed s p e c t r o p h o t o m e t r i c a l l fyo r c r e a t i n e k i n a s e ( C K f , l a c t a t e d e hydrogenase(LD) and aspartateaminotransferase (ASATI.Outcome was evaluatedas overall performancecategories(OPCI l-5; and as neurologicdeficit (NDf scores0-100%.The dogswere killed at 96h with perfusion fixation, and the brains processedfor m i c r o s c o p ya n d s c o r e df o r h i s t o p a t h o l o g i cd a m a g e( H D l .

Enzymes were also analyzedin frozen brain, in 7 regions, in 3 normal dogs,4 dogsat 6h post-CA and in 2 dogsat 72h post-CA. Statistics included Student's t test and Pearsonscorrelation coefficient (r). Results: CSF enzymes peaked at 48h post-CA; the enzyme decreasein the brain precededthe CSF level increase.

The decreasein brain enzymes was most pronouncedin regions with the most severeHD (hippocampus,cerebellum,cortical gray matter, basal ganglia).There was no decreasein regions without HD. After VF-CA, HD was mainly ischemic-neuronal;after AA there were in addition microinfarcts,but the regionaldistribution was mainly as after VF. There were good correlations between ND% (or OPCf and peak CSF-CK.CSF-CK> 80 U/L at 48h was associatedwith a 757o chance o{ poor outcome; norrâ&#x201A;Ź râ&#x201A;Źcovered completely.Conclusions: This "chemical brain biopsy" is an attractive tool for brain resuscitation research,and an adiunctive parameterfor clinically predicting persistent vegetativestate.

65 Reversibility of Glinical Death in Patients: The llyth of the 5.llinute Limit P Safar, H Breivik, N Abramson,K Detre,Brain Resuscitation ClinicalTrialI Study Group/ Resuscitation ResearchCenter,University o{ Pittsburgh Historic clinical perceptionsof the 5' no blood flow limit to the reversibility of primary normothermic cardiacarrest (CAl have been supportedby results with "usual" cardiopulmonaryresuscitation ICPRI and intensive care. Methods: Results o{ a randomized multicenter clinical study {1978-84)of CA, CPR, and "special"post-CA life support "by protocol," have been more encouraging.After CA and restoration of spontaneousnormotension with CPR by AHA standards,patients comatoseat l0' were selectedand receivedstandardizedbrain-orientedextracerebral Iife support,with or without additional thiopental. There were 40 patients of the preliminary study and 262 of the final study. Ar-

34

rest time {AT} (pulselessness without CPR, no blood flow} and CPR time (low flow) were estimated as accuratelyas possibleby immediate retrospectiveinterviews of bystanders,family, ambulance personneland hospital personnel,and by review of records. Progressand outcome were quantitated over 6 mos as Cerebral and Overall PerformanceCategories{CPC,OPC} #l inormal}, #2 (moderately disabled|,#3 (severelydisabled, conscious),#4 {coma),or #5 {brain death, death).Results: 23 of 4O patients of the preliminary study and 93 of 262 patients of the final study had AT ino flow) > 5' (6-30'1.The maiority had in addition CPR times ) l5'. In the preliminary study, the 23 with AT 6-30 min included 9 patients who achieved"completeneurologicrecovery" (CPC I or 2). These included one patient each with myocardial ischemia-relatA e dT s o f l 0 ' , 5 - 1 0 ' 4 , - 7 ' , 3 - 7 ' , 4 - 8 'a, n d > 5 ' ; a n d 2 with exsanguinationcardiac arrest of 22' and > l5', and I with cardiac trauma induced CA of l0' ATs, the last 3 resuscitated with cardiopulmonarybypass.In the Iinal study, the 93 patients with AT of 6-30'includedl8 patientswho achievedgoodcerebral outcome {bestCPC I or 2}. Theseincluded 1 patient after 17' Nf, I after ll' AI I after l0' AT and 15 after 6-9' ATs. Conclusions: Although retrospectrvedetermination of ATs may often not be accurate,27 caseswith "estimated" ATs oI 6-22', followed by resuscitation and good neurologic recovery (CPC l, 2) raise doubts about the 5' limit concept for normothermic CA. Post-CPRprolonged life support by a brain-orientedcombination treatment protocol secms more effective than "usual therapy,"

66

tncreasing the Diagnostic Power of the

Efectrocardiogram R Zalenskr,E Sloan, S Welbel, D C o o k e , K V e r d o n c k , D P r o p p / U n i v e r s i t yo f l l l i n o i s A f f i l i a t e d H o s p i t a l s E m e r g e n c y M e d i c i n e R e s i d e n c y ,C h i c a g o An emergency physician must assess the degree of risk of acute myocardial infarction (AMI) within the frrst hour of the patient's p r e s c n t a t i o n t o t h e c m e r g e n c y d e p a r t m e n t { E D ) .T h e l 2 - l e a d e l e c trocardiogram (EKG) is of limited value because of the frequency of non-specific findings. This may be due to the lack of direct interrogation of the right ventricle and the posterior wall o{ the left ventricle. In this study we tested the hypothesis that the addition of a single right ventricular lead (V4R) and two posterior leads (V8 and V9| would cnhance the sensitivity of the EKG. All paticnts having a possible cardiac complaint who presented to the ED of our emergency medicine residency community teaching hospital were eligible for entry into the study. Whenever a standard l2-lead EKG was performed between 5 a.m. and ll p.m., the three additional leads, V4R, V8 and V9 were obtained if one or more of the following symptoms were present: chest pain, dyspnea, diaphoresis, or weakness suggestive of cardiac ischemia.

Informed consent was obtained. Emergency physrcrans were askcd to interpret the l5-lead EKG and to provide historical data o n a d a t a c o l l e c t i o n s h e e t . I n c a s e so f i n c o m p l e t e d a t a s h e e t s ,t h e additional leads wcre intcrpreted by a third party blinded to the clinical outcome. The study contained 267 patients. Mean age was 6l (range 28-97). Subjects were equally divided by sex. There were 34 cases of ST elevation recorded by emergency physicians.

Nine of these patients 126.4%lhad ST elevation in the posterior or right ventricular leads. A total of six patients had ST elevation exclusively in the additional leads. Three of these sustained proven AMI. One patient had stable angina and two had unstable angina pectoris. In the group of patients with ST elevation on both the l2-lead and the additional leads, V4R, V8, and V9 were found useful because they specified additional areas of ischemic myocardium. Our data suggest that the addition ol V8, V9, and V4R may increase the diagnostic power of the EKC, a particularly important finding in this era of interventional cardiology. Further investigation of this modified technique may lead to redefinition of the "standard" EKG.

67 How Many llyocardial Infarctions Should We Rule Out? Rr Wears, RCLuten, DJVukich, S Li / UniversityHospitalof Jacksonville, Universrty ol Florida

I

+

The proportion of hospital admissions to rule our acute rschemic heart disease(AIHDI in which AIHD is ruled out has attracted considerableattention. Estimates that two-thirds of such admissionsare negativehave producedresearchin techniquesof quantitating patients' risk of AIHD to reduce admissionsof low risk patients. However,no work has been done to estlmate a reasonablenegativeadmission rate. This study provides such an estimate using cost-effectivenessanalysis. Four possibilities were analyzed:intensive care,intermediate care or ward admission,or outpatient follow-up; the goal was to determine a "threshold,, probability of AIHD, below which a lower cost strategywould be more cost effective.Such a threshold could serveas a use{ul decision criterion {or emergency physicians and health planners.

Morbidity, mortality, cost and probabilities were estimated from the published literature and were adiustedto reflect uncertainty in the estimates.The results indicated that at virtually any probability of AIHD, moving {rom a more intensive to a less intensive strategyalways saved money but increasedmorbidity and mortality. However,a reasonable"meta-strategy"was obtained by combining the abovewith an analysisof the relative risk of death Detweenstrategles: Probabilityof AIHD <.13

Strategy Outpatient

. tJ-. to

R o u t i n ea d m i s s i o n

. to- zl

Intermediatecare Intensivecare

> .27

This resulted from using the best strategy available for progressivelylower risk levels until the additional cost per additional life savedreached$1,000,000,then, a cheaperstrategywas selected.Different cutoff values would produce different threshold probabilities (points where strategy changesf.These results suggestthat: l. Assertionsabout the proportion of negativeadmissionsto rule out AIHD basedon subiective opinion should be replacedby explicit,objectiveanalysis.

2. Attempts to rank patients on the basis of risk should concentrate on the range of threshold probabilities estimated by oblecilve analysls.

3. The acceptableproportion of negative admissions may be as high as 70%; lowet rates could indicate excessivelyrestrictive admitting policies.

68 Glinical Predictors of Bacterial Diarrhea in Young lnfants J Finkelstein, S Torrey, JSSchwartz, G Fleisher / University of Pennsylvania Schoolof Medicine,TempleUniversity Schoolof Medicine,Philadelphia; HarvardMedicalSchool,Boston Diarrhea associatedwith bacterial pathogensmay lead, especiallyin young infants, to bacteremiawith sepsisor focal complications.Antibiotic treatment is indicated in selectedcases,vet identrfication of these patients is difficult. Therefore,we undertook a study to evaluatethree clinical criteria commonly used to decidewhether to obtain a stool culture, in infants with diarrhea betweenbirth and twelve months of age. Clinical data {temperatureon presentation,history of blood in the stool, and frequency of stools) and stool cultures were collected on consecutiveinfants 0-12 months old, with diarrhea or a history of blood in the stool, at two hospitals over a one year period. Stool sampleswere cultured by the clinical microbiological laboratory using standardtechniques for bacterial isolation. One thousand two hundred and nine infants were enrolled, with a mean age of 5.3 months; 307 infants were less than twelve weeks of age.Stool culture was positive for bacteria in 119 lI0%) cases,with 97 3 12.5%lShigella,3 {81%)Salmonella,l5 (13%)Campylobacter, {2.5%)Yersinia,and I with both Salmonellaand Campylobacter.

The mean temperatureof infants with negativestool culture was

35

37.9 + .95 (s.d.),comparedto 38.4 + 1.20for infantswho had a bacterial pathogen isolated. The mean number of stools in the previous 24 hours was 6.1 + 4.6 and 7.0 + 3.9 for patients with negativeand positive stool cultures, respectively.A history of blood in the stool was elicited in 98 {ll%f caseswith a negative culture and in 42 (39%) caseswith a positive culture. Clinical factors were evaluatedindividually and in combination to determine their ability to discriminate berween patients with and without a bacterial pathogen.A history of blood in the stool was the best individual predictor: sensitivity (sens)39%, specificity (spec)89%, positive predictive value {ppv) 30%. The presenceof fever greaterthan 38 C had sensof 5l% and specof 67o/o.A history of more than 9 stools in a 24 hour period was the poorestindividual predictor:sens30%, spec 837o,ppv 18%. The combination of fever greaterthan 38 C, and a history of blood in the stool had specof 98% with a ppv of 60%, but a sensof only 20%. We explored a full range of coniunctive and dislunctive combinations, ROC curve analysis, and multivariate analysis, yet were unableto identify any combinationof factorswith both high sensitivity and adequatespecificity.We conclude that approximately l0% of the diarrheain infants less than l, seenin an urban emergency department,is causedby bacterial pathogens,predominantly Salmonella.Those patients with both a history of blood in the stool and a fever greaterthan 38 C are more likely to have a positive culture. However,these three clinical featuresdo not allow for the efficient identification of most patients with bacterial diarrhea,and should not be used alone to determine whether to obtain a stool culture.ROC curveanalysispermitseachclinician to choosecutoff levels, of historical factors and diagnostictests, with sensitivity and specificity appropriateto the clinical situation.

69 Prehospitat Predictors of Acute llyocardial Infarction and Unstable Angina KMHargarten, C Aprahamian,H Stueven,DW Olson,TP Aufderheide, JR Mateer/ MedicalCollegeof Wisconsin,Milwaukee Emergencydepartment studies have attempted to define predictive indicators o{ diagnosisand/or prognosisfor acute myocardial infarction {AMI} and to identify the need for hospital admission in patients with chest pain. Without prehospitalpredictors, dispatchers,paramedicsand basestation physicianscontinue to triage patients basedon patient history. We reviewed401 patients presentingin one year to an urban paramedicsystem with chest pain, normal vital signs,and stable rhythms to identify predictorsof AMI and unstable angina.Thirty-one percent {123)had a diagnosisof AMI, 25% lllil unstableangina, and 43% "other" diagnoses.When comparing symptomatologyof {173) AMI or unstable anginapatients to the "others," 64o/oversus361" had radiation of pain {P < .003), 72"/oversus 28% were diaphoretic{P < .0001).Of the patientswith shortnessof breathas the only associatedsymptom, 30% had AMI or unstable angina while 70% had "other" diagnoses(P < .00021.While electrocardiographicmonitoring is availableto an advancedlife support unit, ST segment elevation on lead 2 was not help{ul in predicting AMI; 29% of.AMI's and 7l% of non-myocardial infarction patients had no ST elevation lP < .0051.All other factors including initial rhythm and vital signs,history of previous myocardial infarction and other associatedsymptoms of ischemic heart diseasedid not contribute to prehospital determination of cardiac chest pain. For stable prehospital patients presentingwith chest pain in which sex, age,radiation of pain, presenceof diaphoresis, and ST elevation are used to discriminate betweenAMI or unstable angina from other diagnoses,the sensitivity is 75% and specificity 54%. Given the consequencesof missing a myocardial infarction, we conclude that prehospitalpersonneland base station physiciansinvolved in the managementand transport of patients are unable to discriminate those with AMI or unstable angina from patients with chest pain from other causes. We recommend that all chest pain patients be transportedby an advanced life support unit and managedas AMI.

Levels in Patients with Garboxyhemoglobin 70 Headache CD Chisholm,J Reilly,B Berejan/ Departmentof EmergencyMedicine,BrookeArmy MedicalCenter,Ft Sam Houston.Texas Occult carbon monoxide (CO) poisoning may be overlookedor misdiagnosed by emergency physicians due to its nonspecific manifestations,and there{ore,a high index of suspicionis needed in order to identify victims of occult CO poisoning. Since headache is a common cornplaint in such patients, a study was designed to investigate the chief complaint of headache.Additionally, the ability of the physician to predict the COHb level based upon history and physical examination was investigated.

Over a ten week period from November 1986- |anuary 1987,I32 adult patients gaveconsentfor participation in this study.FoIIowing a history and physical examination, the physician estimated the COHb level and a venous sample was then drawn for determrnation of the actual COHb level. The mean age was 38.3 yrs {range lB-82 yrs). The mean COHb level for nonsmokerswas 1 . 6 9 7 " f t a n g e 0 . 8 - 1 1 . 6 ) a, n d f o r s m o k e r s w a s 4 . 7 8 % ( r a n g e There was a statistically significant differencebetween 0.9-12.7]r. the 2 groups (P < 0.00I, paired t test).Evaluatorswere inaccurate in their predictions of COHb levei in 15 patients (11.4%),underestimating the COHb level in 5 patients (3.8%)and overestimating it in 10 patients17.5%l.Tfueepatients(2.8%)hadCOHb levels over 10.0%; none of these were predicted by the examiner.

During the study period, 6 patients were evaluatedwith acute CO poisoning ftange2l.5-34.7%l and receivedtreatment with hyperbaricoxygen.None of thesepatients listed headacheas a chie{ complaint. Our results suggestthat there is a low rncidence l2.B%)of signifrcantCOHb levels(> 10.0%)in patientspresenting to the ED with the chief complaint of headache.Clinicians did not suspectthese elevationsbasedon history or physical examination. Smokershad statistically significant higher COHb levels than nonsmokers.Further studies are neededin less temperateclimates to determine the benefit of routine COHb screening in such a patient population.

71 Gomparison of Two.Dimensional Echocardiogram and Multigated Radionucleotide Angiography in the Detection of Gardiac Injury Secondary to Blunt Chest Trauma SL Demetropoulos, KD Keller,DJ Vukich,PS Gilmore/ UniversityHospitalof Jacksonville, University of Florida Cardiacinvolvement secondaryto blunt chest trauma varies in frequency from 6o/oto 76%. There are several noninvasive entities currently availablefor diagnosisof cardiac iniury. Of these,the most promising appearto be two-dimensionalechocard i o g r a p h y ( 2 - D E ) a n d m u l t i g a t e d r a d r o n u c l i d ea n g i o g r a p h y {Muga).Both appearto be accurate in detecting wall motion abnormalities, which are the most common {orm o{ cardiaciniury secondaryto blunt trauma. We attempted to compare these two modalities in patients admitted to the hospital {or blunt trauma to the chest. Using a standardizedset of inclusion criteria rn history, physical exam, chest x-ray and electrocardiogram,we registered patients in our study.We then performed2-DE and Muga on all patients within 48-72 hours of admission.Our first 23 patients were statistically evaluated.Analysis of the untied pairs by the exact binomial test revealeda differencein rate of oositivesat P : .0002level. Muga proved to be far more sensitivethan 2-DE in detectingwall motion abnormalities.Most of the patients suspectedof having cardiactrauma have sustainedother injuries requiring chest tubes, bandages,intubation or traction. Since positionrng and technique are such important parts of echocardiograph;4multiple injuries and their treatment often predisposethe patient to a suboptrmal study. The Muga was not affected by theseproblems.A portable unit was usedwhen patients were unable to be transportedto the nuclear medicine department.2-DE demonstratedtechnical limitation in detecting right ventricular and apical wall motion dysfunction, which are the most common wall motion abnormalities. Musa scan is sensitive in detectine

36

these abnormalities. Cardiac trauma is frequently associated with multiple other serious injuries. These injuries and their treatment can often hinder accurate diagnosis of cardiac damage.

Muga appears to be much more sensitive in detecting wall motion abnormalities than 2-DE and should be the test of choice in evaluating blunt cardiac trauma.

72 The Effect of Spinal lmmobilization Devices on Pulmonary Function in the Healthy Nonsmoking Male D Bauer,R Kowalski/ Departmentof EmergencyMedicine,WilliamBeaumontHospital,RoyalOak, Michigan In the prehospitalmanagementof trauma, a vaiety of devices are utilized {or immobilization of the spinal column during extrication and transport. Two of these commonly used immobilizers, theZee extrication deviceand the long spinal board,employ criss-crossingstraps over the thorax to affix the patient to the device.Our study was designedto determine if these two devices alter pulmonary function in the healthy, non-smoking male. We took 15 healthy, non-smoking male volunteers and tested four pulmonary function parameters:forced vital capacity (FVC|, forced expiratory voiume in one second (FEVI),the ratio , FEF25%-75%1.

A Breon SpiFEVI/FVC, and mid-expiratory flow rometer was used to test these{unctions both beforeand after the volunteers were strapped into the two devices. Three separate trials were given for each parameterand the best scoresusedfor data computation. Strap tension was controlled by placing a sphygmomanometerbeneath each strap and adding tension to produce 10 mmHg pressure.Using Hotelling's T2 multivariate analysis and individual Student t testing for each parameter,we found a significant difference {P < 0.05Jbetween pre-strapping and post-strappingvaluesfor 3 of the 4 functions testedusing the Iong spinal board: FVC lP : O.OO79), FEVI (P : 0.0001),and FEF25%-75%lP : 0.0252).Similarly significant differenceswere found for 3 of the 4 parametersusing the Zee Extrication Device: P F V C ( P : 0 . 0 0 4 0 ) ,F E V I ( P : 0 . 0 0 2 2 ) ,a n d F E F 2 5 % - 7 S ' / " l = 0.0080).These differencesreflect a marked pulmonary restrictive ef{ect. The ratio FEVI/FVC can be normal or even slightly elevated with restrictive airway disease,due to proportional reductions of eachparameter.Correspondingly,we found no significant differencesbetween pre-strappingand post-strappingFEVI/FVC values (P > .051.We conclude from our data that these devices produce a significant restrictive effect on pulmonary function in the healthy, non-smoking ll:.ale.lZee Extrication Device is manufactured by Zee Medical Products,Irvine, Calfornia.)

73 Effect of Axial Traction and Orat Intubation SCFordI on the Unstable Gervical Spine HGBivins, Department of Emergency Medicine, Valley Medical Center, Fresno Application o{ axial (longitudinal) traction during oral intubation is a recommended alternative to nasotracheal or surgical intubation of the alrway in trauma victims with potential c-spine injuries. To our knowledge there are no studies demonstrating the safety of axial traction during oral intubation of actual trauma victims wrth unstable cervical spine injuries. The purpose of this study is to evaluate the effect o{ axial traction during oral intubation of the trauma victim with an unstable cervical spine.

To identifv unstable iniuries c-snine films were taken on all victims (17) of blunt traumatic arrest brought to our emergency department who failed resuscitation. Cross-tabie lateral films were taken during oral intubation with and without 15 pounds of axial traction. Instability was defined as: 1) >3.5 mm of subluxation of adiacent vertebrae; 2f an angle of >ll" between adjacent vertebrae; 3) a predental space >3 mm; 4) intervertebral disc space )5 mm: 5l distance from the dens to basron >5 mm; and 5) displacement of the dens from the basion. Unstable injuries were identified in three lI7-6%l subjects. These injuries included: 1| C5,-7{racture-subluxation; 2} Atlanto-Occupital Dislocation (A-O-

l

+ +

DJ; and 3J Hangman,s{racture. Oral intubation alone resulted in 2.6qm of anterior displacement.t C"." Cr-""a fr"rdno ef{ecton the.Hangman,sfracture. Axial tractiJn;l;. a) 9 mm ;;;;".d: of distraction and 4 mm ot po.t.ri* Jtr;j;;;#;;l"tween c6_7; b) 5 mm of distraction r"a S rn- oa;r"Jr'i* a^irpf"..ment in the a1d c) 4 mm of distraction i" ,t; H;g_an,s fracrure. {-O.-D; Oral intubation with axial traction resulted in: a)"ii mm of ante_ rior displacement and 16 mm of di;;;;";io; i.trv..., Cu-r, of posterior displacementand 3 mm of distraction i) I y in the and c) _4mm oJ distraction i. th. H;;;an,s f-Q-D; fracture.

Axial traction distractsthe unstabie .;.r*d;;i"". ,rra ,"i.., ,f_ plied-in the true axis of the sprnemay result in subluxation. Un_ procedure

1::: lll"

is performldu"J"i r1"r"r""p1iii",."o,,,_.rrd

Data arepresentedberow Arthough certain variables were identified as statistically less rikely-to u"""*o"iriJillh cervical spine infury, notably rear end collisrons ""a p"r"rpi"ous pain only, there_were no independent,variables studiid *hi"h .orrid be use'd to selectivelyexclude a ,"1..t of prti.",.?#^"..rlcal radiogra-

ttt" prr.ii." oi ril.r"i iir.,ri."r spinera_ lP:_Ti:,r.,-"{r.supports orograpny ln blunt trauma patients.

Variable Studied Type of Accident Rollover H i t E i t h e rS i d e Head On Rear End RestraintsUsed

;:'I":T;#J,T',','f l'ryl?H;i:,'.kt;;'*X1J?d1".*:i position without axial tractron.

No

C9-meuted Tomographyin the Initiat !4.

Evatuationof the cerv'icai sipi,is i-sir,f"n"rr

SERoss,I Civit,CWSchwabI Vorf< H6s-piiar,'ylit ,'lennrytuania; MedicatC"r,t!i UH,f oljJ _ Robert 99oq"l Hospitat/University WoodJohnsonMedjcalSchoolCamdun,irf"* J"ir"V Unstableinjury of the cervicalspine(CSI)must be considered in all victims

of blunt high e,nergytransfer. Computed tomog_ taphy (CT) has been advoJatedi"?.-.r"f""ti".-i'of tfr. spine in suchpatients.In order ro evaluate,h" .fil*y;iil_i,.a directed CT of the neck in the work up for CSI, a one yearrevrew of all patients undergoing this study at tfr.

S""tfr..ri fiew fersey Re_ gronal Tiauma Center was un_dertaken.

O"e h""drei i.; ;;-

qf:*tj*.,;:":j*: 1i.:$''"',"".'i:'*1,#::?,T,.",|f

deficitunderwentlimited, direc;eJ-aitl'ii.".#t*l spinedur_ ing the studyperiod.seventy-five "ifrr... p"ri."is had suffered severe headiniury (AIS4 or 5) or ,."tri"v"J- ,tluia. rhe indrfor CT,were: inadequateptji"lrit&r"phs; 2) sus_ :il]:": .l) radiographs; 3) delineatibnof pathoTogic anatomy, l:.j?::.ll:.i" o r 4l perslstent svmDtoms

w i t h n o r m a l p l a i n x _ r a y s .b u r f i n d i n g , s , as well as the sensiiivity and specificiiy ,i. ,fro'*" U"f.*.

Group

No. 1 5 6 2 3 1 3 1 2 4 S Total 104

+/False

+/False

- Sensitivity

Specificity

311 712 5/0

s3/O 2412 7t1

1.0 0.71 0.83 undefined 078

0.98 0.92 1.0 1.0 0.95

oto 15t4

sto B9/3

All inaccuratestudiesinvolved ligamentous iniury at the atlanto_

r:9.

IimiiedJirecteilffi :iii:,ijfj J-:.:^":. ce1v1 caJ,pi ". l!,, il ;p;;;;;j; ;' i;,r'J

t. a tomosra ':;_

;"d;iJii ::,Tf lll -:1.:h. patrents at risk for cervicalspine iniury, p"iti."turty ifii;; are to_rule out injury.CT is alsousefulin 11lioSranhs inadequate,

the anatomic delineation of fractures, U"t i, .ifi_lted value in the evaluation of Iigamentous iniury Irf ,fr."pp", ".rvical spine.

7_5._setectiv-eUse of Gervicat Spine Radiosraphy in Btunr rrauil;; ;;i;;; R Faler,JE Tintinaili, A wilson, J Ratrner, R s;;;. E K.;; ;b;;.rtmentof

EmergencyMedicine,Wjlliamueaumont Hospital,RoyalOak and Troy,Michigan This study was undertaken in an_attempt to identify clinical variablesrarhich would permtt the sel;;;il;tdion of cervical radiographyin infured patients. Bl"";;;;;;;;;",, were prospectively evaluated according to age, mechanism of accident,ctinical siens anj.16;;;;;;;;;'.".r,.rr o1 iniury, type spine ra_ diographic results. Statistica| .i6 idi;;;;;ri.','. r_ ir,.a using a two-tailed Fisher exact t te.t :"t:b-.005). Results - 7o6.patients,aged I to g2 lsTgnrficr;;" imian "g": :ti*"rl evaluated.A total,of24 cervical spine fractureswere notedi 16fracturesresult_ ing from motor vehicle accidents,"il tl;;;lls'and assaults.

37

Fallsand Assaults Falls From a Height Other Falls B l u n tA s s a u l t lvlechanismof Inlury Twisting Hyperflexion/Extension Head Trauma FacialTrauma A x i a lL o a d i n g DirectNeck Trauma Locationof Neck Pain S p i n o u sP a i nO n i y P a r a s p i n o upsa i n O n l y No Pain S p i n o u sa n d Parasprnouspain Locationof Neck Tenderness S p i n o u sT e n d e r n e sO s niy Harasptnous TendernessOnly No Tenderness S p i n o u sa n d ParaspinousTenderness N e u r o l o g i c aFli n d i n a s Paresthestas M o t o rD e f i c i t SensoryDeficit

76

#

7

o

P

0.0436 0.3946 0.0448 0.0074 0.0130 0.0450

Total FracturesFractures Value 2

4

3

tzt

3

208 222

3 2

12.5 41 1.4 0.9

435 157

9 6

2.1 38

3 4 1

14.3 56 2.6

0.030/ 0.2220 0 6254

3 12 3 1 1 1

3.6 2.7 34 2.3 2.9 24

0.5596 0.1298 0.5934 0.5634 0.6/66 0.4708

6 3 9 6

5.3 0.9 4.4 5.6

0.1762 0 0004 0.2423 0 1409

21 7 2 38 B4 445 88 43 34 41

114 330 206 107

100

4

JrJ

5

4.0 1. 6

0 4491 0.0137

244 100

10 5

4.1 5.0

0.2944 0 2439

72 11 19

8 3 6

'1 1.1

272 31.6

0 0015 0.0048 0.00002

Ctinicat predic_torsof_Gervicat Spine Injury ril r r," " sE Ross,KFoMair;y;-wc-Dil.; c?eorn, cw

!99.tl-tt' BIunr Hish.eneis t r;;;;'L; (BHETtl

Schwab/ Djvisionsof TraumaunO Emurgency''VeOicat Services and-orthopaedicsurgerv,UMDNJ/noouliw6oi llhnson schoor of Medicine.Camden,New Jersey all BHETI patients have been said to be at risk .

ATLS coursemandates"ervical .pi". ,raiolr"pfrr"i" for CSI; the "ff ;; ;;tients.,In order to developmore specific"lirri.ri irqr""tors of CSI, and allow a selectiveuse of radiograph;;il;;rrnproved clinical efficiency and cost effectrveness,a prospective study of BHETI was instituted. The g_month study series'in"t"J"J +rO BHETI p;_ tients. A total of 32 CSI,swere identtfleJ ii.7p"rJ.",f, 13 (41per_ ,1.,- withJigamentous or bony instability. patients were :::,],?1 classrrted by mechanism of injury, and five ciinical factors to select patients for risk "f Csf. sig"ifrcance .lfngwn:, of each mechanism of iniury or clinica-lfactor as , pr8ai"to, of CSI was .^"r"lii:j,.r:':,r anatysis. ros oi"ons"iousness (p < :ll-.'qy*

;,1"n' ffi;:i:fflT::!l"i ;lll\'li#D?:ffi: ",:nl,'j;l: ):*:::

predictorsof both stable and "rrrtrUi6 bsl. b"il'ii.r"e rnjuries of the head and neck, fractures "f tfr.-f*i"f t"rr.., _".rAiUt., o, skull were not accuratepredrctors,-i"ifil;i'd nor was any individual mech-

anismof infury Mafor"jor"a tr."f

+ J, sl *r, .,o, "

greater significant risk factor for CSI than simple loss of consciousness(AIS 2). Using only loss of consciousness,tenderness, and neurologic deficit as selection factors for evaluation, all unstable CSI's would have been identified. We conclude that radiographic evaluation of the cervical spine is mandatory in BHETI victims presenting with history of loss of consciousness, depressedlevel of consciousness,tendernessof the neck, or neurologic deficit. Conversely,in the awake, alert BHETI patient without these findings, emergent radiographic examination of the spine may be unnecessary.

77 Post-traumatic Neck Pain: Prospectiye and Follow up Study RMMcNamara, MCO'Brien, S Davidheiser / Departmentof EmergencyMedicine,MedicalCollegeof Pennsylvania, Philadelphia Few studies exist that prospectivelyevaluateand/or follow-up patients with posttraumatic neck pain. We prospectivelystudied 446 emergencydepartment (ED) patients with this complaint. A data collection form was completed in the ED, inpatient records and radiologyreports reviewedand follow-up attempted in all patients not having a fracture or ligament disruption. Data were analyzedusing an unpaired t-test or chi-squaretest when appropriate. Of 351 patients who either had ED cervical radiographyor adequatefollow-up there were 7 , 2.0%l with cervical spine fracture or ligament disruption proven.The immediate onset of neck pain and cervical tendernesshad 100% sensitivity but low speciIicity 165'/'and 48% ).The sensitivity and specificity of headiniury, loss of consciousnessand neurologic findings were: 86% and 70%, 7 l% and 94To, l4o/" and 98%, respectively.Adequatefollowup was obtained in 263 patients of whom IIO 143%)reportedsignificant symptoms {moderateor severeneck pain and/or neurologic symptoms).These patients were more likely female, 67% vs 40o/o{P < 0.00I), involved in a motor vehicle accident (MVA}, 89% vs 78% lP < 0.051,with the mechanism being rear-ended, 62% vs 46% lP < 0.051.A total of 167 163%lsaw another physician with 138(83%)of thesereceivingphysicaltherapy,24 ll4%l havingcervicalCT scansand 19 (ll%) EMGs.Of the 138who did not have an ED cervical radiograph,60 143'/'l later obtained one.

Initially, it was noted that many patients refusedfollow-up as they were in lawsuits. Later, we actively questionedthis and found that 66% of patients were involved in litigation. When comparedto those not in litigation there was no significant differencein age, sex, race or mean contact time. The litigation group,however,were more likely in a MVA, 95% vs 66y' lP, .0OIl, to have seenanother physician,99o/ovs 36'/' |P,.001)or to be still experiencingsignificant pain, 5l% vs 127" (P, .0011.Researchers and ED physicians evaluating these patients should take these findings into consideration.

78 Cerebrat Resuscitation: ilo Flow Versus Low Flow Followed by Gardiopulmonary Bypass JM Rosenberg,MT Steele,JA Salomonelll, M Gratton, CA Soracco,M Rupani/ TrumanMedicalCenter;University of Missouri-Kansas City Schoolof Medicine Cerebral preservationpost cardiac arrest appearsto be related to flow state (low flow vs no flow) prior to resuscitation.Cardiopulmonary bypasshas been suggestedas an adjunct therapy for cardiac arrest. This study comparesthe effects of mechanical chest compressionand ventilation ICPR-lowflow) followed by cardiopulmonarybypassto no flow followed by bypasson canine resuscitationfrom ventricular fibrillation. Twelve fasted mongrel dogswere divided into two groups.After prior anesthesiaand instrumentation, the dogswere fibrillated and either receivedtwenty minutes of CPR followed by two hours of femoral arteryfemoral vein bypassor twenty minutes without resuscitative measuresfollowed by two hours of bypass.Monitored parameters included pupillary responses,respirations,EEG, EKG, mean arterial pressure(MAP), intracranial pressure{lCP),venous electrolytes, glucose,lactate, calcium, SGOI venous and arterial

38

blood gases.Post mortem pathologic studies of the liver, kidney and brain were donb. Speci{icgravity determinations of cerebral cortex, cerebellum and hippocampus were performed to gauge edema Iormation. Baseline analysis showed no significant difIerence between the groups for MAI ICI venous blood chemistries, or blood gas determinations.In the CPR group,4 of 5 ani mals had return of respirationscomparedto 0 of 6 in the no-flow group. This was significant as determined by the Fischer'sexact test (P = .03).Post-arrestarterial and venous pO2b were significantly higher in the CPR group {Mann-Whitney U Test, P < .02).

No other statistical differencesbetween groups were found for MAq ICq venous chemistries, EEG or arterial or venous blood gases.Bromobenzenegradient determined brain specificgravities were not significantly different. Return of spontaneousrespiration using cardiopulmonarybypasssuggestsits utility in resuscitation. This study implies that CPR should not be abandoned prior to using cardiopulmonarybypassas a resuscitativemeasure.

79 Assessment of Ganine Brain Function Utilizing 31-P NllR Spectroscopy During a 12.

Minute Cardiac Arrest, Two Hours of Femoro.

Femoral Bypass Reperfusion, and Seven Hours RMNowak, D of Gritical Gare Therapy GBMartin, / Department Walton,RA Eisiminger, M Smith,MC Tomlanovich Departmentof Neurology; of EmergencyMedicine;NMR Facility, Technology, Perfusion Departmentof Surgery;HenryFord Hospital,Detroit There is little information availabledetailing the perturbations of neuronal pH and energychargeduring prolongedcardiacarrest and total body reperfusion.These changesmay predict the degree of neuronal injury and potential neuronal salvagingtherapies.

This study documents these biochemical alterations in 5 large adult mongrel dogs undergoing 12 minutes of cardiac arrcst,2 hours of femoro-femoralbypassreperfusion,and 7 hours of critical care therapy.The animals were preparedaccordingto methods previously described.During the control period the arterial pH the PaCO2between35-40mrn Hg, was maintainedat 7.35-7.45, and the hematocrit > 35%. Also, durrng reperfusionarterial pH was rapidly normalized and during the critical care periodcardiac output was maximized through fluid and systemic vascularre" sistance manipulations. The following abbreviatedtable details the pH and neuronal energy chargeperturbations recorded. pH

PCr/Pi + PGr

PCr/B-ATP

7 . 0 5 2* 0 . 0 3 8 6 . 1 7 6+ 0 . 1 4 4 '

0.738 + 0.019 0.000'

1.860+ 0.173 0.000'

6854+0209 7 . 0 1 6+ 0 . 0 5 0 7 . 11 0 + 0 . 0 7 1

0.746+0.050 0.716 + 0.074 0.706 + 0.044

2.186 * 0,586 2172 ! 0.369 1 960 t 0.322

7.060 :t 0.092 0.686 * 0.062 7 7 . 0 5 3* 0 . 1 1 1 0.698 + 0.059 ' P < 0 0 5 c o m p a r e dt o c o n t r o l( H o t e l l i n gT s 2) p g 1 = p h o s p h o c r e a t i nP e i, = i n o r g a n i cp h o s p h a t e = B-ATP beta phosphorusof adenosinetriphosphate

2.110 t 0.505 1.800 r 0.389

Conlrol fschemia Bypass (Hrs) .5 1 2 Oft-Bypass (Hrs) 'l

As seen at the end of 12 minutes of ischemia, the brain pH is significantly lower with a total absenceof PCr and B-ATP(P < 0.05).Howevea by 30 minutes of reperfusion,the phosphorus spectrahave returned to a state indistinguishablefrom baseline, and are maintained like this throughout the ensuing 7 hoursof critical care (all P > 0.05).These results indicate that the canine brain becomesvery acidotic afuer12 minutes oi global ischemia with a total depletion of high energy phosphate compounds.

However,with adequatereperfusionthe brain is able to return to an energy state identical to that observedbefore cardiacarrest and remain so for at least t hours. Ongoing studiesin our laboratory are detailing the significanceo{ this in predicting survival neurologic deficrt after 8, 12 and 16 minute cardiac arrest and bypass reperfusion.

_8O earty Glucocortocoid Treatment Does ]lot lmprove Neurologic Recovery From Global Arain

lschemia MS Jastremski, p Vaagen-es, K Sutton, N Abramson, D H e i s e l m a n , T h e B r a i n R e s u s c i t a t i o nC l i n i c a l T r i a l I S t u d y G r o u p / SUNY Health Science Center at Syracuse; Resuscrtatron R e s e a r c h C e n t e r o f t h e U n i v e r s i t yo f p i t t s b u r g h ; A k e r s h u s C e n t r a l H o s p i t a l ,O s i o , N o r w a y Glucocorticoids have enjoyed a long tradition of use rn a vanety of central nervous system insults. However, the rationale for therr use in most CNS insults, particularly brain ischemia and head injury has been based on theoretical considerations and the extrapolation of bencfit as seen in the perifocal edema of intrinsic mass lesions to diffuse insults. Therl is a paucity of carefully collected screntrfic data to support this hypotircsis. ilecently published prospcctrve, controlled studies findrng no benefii from steroid therapy in head injury has promptc.d us to rcassess the utilization of steroids for global brain ischemia. The data base of BRCT I, a multi-institutional study designed to evaluate the effect of thropental on neurologic outcom6 following brain ische_ mir, providcd an opportunity to rcview thc cffeits of stcroid trcatment on neurologic outcome after global brain ischemia.

BRCT I included 262 initially comatose &rdiac arrest survivors who made no purposeful response to pain after restoration of spontaneous circulation.l Neurologic outcomc was scored using a modification of the Glasgow Cerebral performancc catcgorici IC.PC)t.Neurologic recovery was considercd goo<i if , piti".,t achicvcd CPC_l_or 2, with-CpC I indicating normal neuiologic function cir mild dcficit and CpC 2 some dciicit, but able to live indcpendcntly. Since a varicty of diffcrent steroids wcre administcrcd, a conversion table was uscd to standarclizc the doscs into l o w 1 1 2 0 ) ,m e d i u m 1 2 1 - 7 0 1a, n d h i g h ( > Z 0 ) c l o s er c g i m c n s , w h e r e I is cqurvalcnt to I mg of dexamcthasone. Data wcrc analvzcd using univariate techniqucs. Onc hundrcd ninty-two of the Z(t2 patients in BRCT reccived stcroids within thc first eight hours aftcr rcsuscitation, 757" of thc thropcr-rtal group and,7Z%, oI the control group. Thc use of steroids in this study was at thc discrc_ tion of the medical managcment team and tcnded to bc constant within each institution. The results arc summarizcd in thc followinq table:

R B T a y l o r ,R L H a m l i n / O h i o S t a t e U n i v e r s i t y ,C o l u m b u s The improvement in cerebral blood flow (CBF) during cardiopulmonary resuscitation (CpR) following epinephrine adiinistration has been attributed to epinephrine,s llphi adrenergic properties. Methoxamine, a pure alpha-l agonist, has only been sh.own to be comparable to epinephrine in restoring circulation following cardiac arrest in a canine model. This rtrr"dy .o-par.. the effectiveness of varying doses of epinephrine and meihoxamine in improving CBF during CpR following a prolonged car_ diac arrest in a swine model. Twenty-five swine weighiig 15.9"CBp'usins 28.2 kgs. underwent instrumentation for regional tracer microspheres. CBF was determined duiing normal sinui rhythm. Following ten minutes of ventricular fibrillation, CpR was begun with a pneumatic comprcssor. CBF measurements werc again made during CPR. After 3 minutes of CpR the swine wcre randomized to reccive epinephrine 0.02 mg/kg, epinephrine 0.2 mg/kg, methoxamine 0.1 mg/kg, methoxamine-t.O mglkg, or methoxamine 10.0 mg/kg. Five swine werc allocated io Jach group. CBF measuremcnts were determined after drug admin_ istration. CBF measurements werc compared using an analysis of variance. Statistical significancc was consideredat thc p less than 0.05 lcvcl. Thc results of the CBF determinations following drug a d m i n i s t r a t i o n a r e d i s p l a y c d b e l o w { e x p r e s s c di n m l / m i n u t " e / l 0 d grams :t standard devration; cpinephrine : E, methoxamine = M, in rng/kg): E.Oz Left Cortex 04 t 05 Bighi Cortex 04 1 04 Cerebeflum 121 12 M i d b r a i n ' 1 3 il 3 Pons 15t1'1 Medulfa 38 1 3.2 Cervical Cord 6 . 41 5 9

E.2 130 1 37

M..t 0S t

M 1.0

i O 21 t 4A

127 t 40 0.4 1 0.9 2.O! 40 293I 55 1Oa t74i 183 3 1 1t t 2 7 1 7 t 3 i 3 9 1 2 4 3 3 6 1 1 0 01 7 t 9 0 5 1 a 1 0 1 669 a 125 26 x 43 61 t 107 575r88

M 10.0 33 a 31 35 r 69 t 87 !

108 r 159 r

32 60 7.6 100 139

4 1 ! 4 . 0 6 6 : t 9 . 3 1 3 41 9 9

P-value 0001 0001 0001 0001 0001 0001 0001

T h i s s t u d y s u g g e s t st h a t c p i n e p h r i n c i n l a r g c r d o s e s t h a n i s c u r rrntly rccommendcd improvcs regional CBF compared to standard doscs of cpincphrinc, as wcll as gradcd dosis of mcthoxarninc durinc CPR.

Number (o/o)Obtaining Good Neurologic Recovery (CpC 1 or 2) Steroid Regimen [N]

Ail patients

None 70 24 (343) Low 67 25 (373) Medium s8 21 (362) Hrgh 66 19 (28.8) [N] : Numberin entiregroup [n] - Numberin subgroup

Controt Group [n] 12 l3t) (324) 14 [32] (378) 9l21l (42s) 8 [3s] (229)

a2 Prehospital Use of Neuromuscular Blocking Agents in a Helicopter Ambulance

Thiopental croup [n] 1 2 [ 3 3 ] ( 3 64 ) 11 [30] (367) 1 2 [ 3 7 )( 3 24 ) 11 [ 3 1 ] ( 3 ss )

Program S A S y v e r u d , D L S t o r e ( L i B r a u n s t e r n ,S W B o r r o n .

J R H e d g e s , S C D r o n e n / U n i v e r s i t yA i r C a r e , D e p a r t m e n r o r E m e r g e n c y M e d i c i n e U n i v e r s i t yo f C r n c r n n a t iC o l i e g e o f M e d i c i n e Over a ninc-month period, we prospectrvely studied the use of succinylcholinc and pancuronium bromide by the phvsician/ nursc flight team of our hospital based hclicopter icrvice. In order to evaluatc the safety of therr use in the he,cticprehospital setting, patients who rcceived these agents at the sccne of an ac_ c i d e n t ( p r e h o s p i t a lg r o u p , n - 3 9 ) w c r e c o m p a r c d w i t h p a t i e n t s who werc paralyzed by the flight rcam jn thc emcrgency department of.transferring hospitals (control group, n:36i'By protocol, succinylcholine was used primarily foi endotracheal iniubation and pancuronium for prolonged paralysis after endotracheal rntubation. Seventy-fivc patients received one or both asents. The orim a r y t l r a g n o s i sw a s a s l o l l o w s : H e a d i n t u r y , 2 6 ; m u " l t i p l e t r r r - r , 14; combrned head and multiplc trauma, l7; status epilepticus, 7; intracranial bleed, 5; respiratory failure, 3; cardiogenic ihock, Z, overdose, l. Endotracheal intubation was the pririarv indication f t r r p a r a l y s i s i n t h c v a s t m a i o r i t y o f p a t i e n t s 1 7 0 / 7 5 1a, i t h o u g h I C p control, ventilation, agitation control, and seizure control were frequent secondary indications. prior intubation attemnts had failed in 39 of these patients. After paralysis, intubation was successful in 67 of 70 patients 196"/"1.In the three cases where intubation was not successful, one patient requlred a cricothyrotomy, one patient was bagged until spontaneous ventilations .eturned, and one patrent was never paralyzed due to an infiltrated IV Se_ nous complications {i.e. cricothyrotomy, dysrhythmia requiring

Nonc of the three steroid. rcgimens resulted in a significantly grc'ater incidcncc of a good neurologic rccovery than observed in the group that did not receive steroids. Although BRCT was not speci{ically dcsigned to study the effects of sterJids on neurolosic recovery after global brarn ischemra, we believe that the strict protocol governing most aspects of the care of these patlents re_ sulted in a homogenous group of patients except for tire thiopental treatmcnt. Neither steroids alone nor thi combination of steroids and thiopental improved outcome. Thus, we conclude that steroid therapy is not 6eneficial a{ter gtobal brain ischemia.

L BRCT I Study Group: Randomizedclinical study of thiopcntal loading in comatosesurvivors of cardiacarrest. N Engl I Med Lgg63I4:397.

2. JennettB, Bond M: Assessmcntof outcome aftcr severebrain damagc.A p r a c t i c asl c a l e L . a n c e t1 9 8 5 ; 2 : 8 1 .

8l Gomparative Effects of f,lethoxamine versus Epinephrine on Regional Cerebral Blood Ffow During CPR CG Brown,EA Davis,HA Werman

39

drug therapy) occurred in 3 patients but resolved with appropriate therapy in each case. Minor complications (i.e. dysrhythmia not requiring drug therapy, histamine {lush, infiltrated IV} occurred in 16 patients. There was no significant difference in successful intubation or comphcatron rate between the prehospital and control group. The incidence of cricothyrotomy and serious complications observed in this study is lower than that reported in previous studies of the emergency department use of these agents. These results suggest that neuromuscular blocking agents can be used sa{ely and effectively at accident scenes by a physician/nurse team. Paralysis allowed airway stabrhzation in a significant number of criticallv ill oatients who could not otherwise be endotracheally rntubated. Furthcr study of the use of these agents by non-physicians and of thc proper role of drug induced paralysis in the management o{ crrtically ill patients is in order.

83 The Alveolar.Arterial Gradient in Patients With Documented Pulmonary Embolism DTOverton, J Bocka / Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan It has often been stated in the medical literature that the finding of a normal pO2 on arterial blood gases does not exclude the diagnosis of acute pulmonary embolism. We wished to determine whether a more thorough evaluation of the blood gases would provide a better diagnostic test. We asked the question, "Does a normal alveolar-arterial gradient rule out the diagnosis o{ acute pulmonary embolism?" We studied this question in a paticnt population in which the diagnosis was definitiveiy madc. A11 charts of patients undergoing pulmonary arteriography during the twenty year period from February, 1967 until |anuary 1987 were retrospectively evaluated. Excluded were: patients undergoing pulmonary arteriography for reasons other than the diagnosis of pulmonary embolism; patrents in whom medical records were unavailable; patients in whom the arteriogram was negative for pulmonary embolus; and patients in whom room air arterial blood gases were unavailable. Calculations used for the alveolararterial gradient (A-a gradient): A-a gradient : JFIO2 x (barometric pressurc 47mm)l -{PaCO2 x 1.251- PaO2. Locally, barometric prcssure averages 756. Normal A-a gradients were defined as: 4 + (agel4). One hundred nrnty-four pulmonary artenograms werc performed during the study period. 130 cases were excluded: 27 were done for reasons other than the diasnosts of pulmonarv cmbolism; 0 charts werc unavailable for reviiw; 84 weie negative for pulmonary embolism; and 19 (of the remaining 83) did not have room air arterial blood gases available. Thus, 64 patients met all crrteria and werc included. Of these,38 (59.4%l were male, while 26 (40.6%l were {emale. Their ages ranged from lB to 85 (mean 57.6). The A-a gradient ranged from lI.6 to 83.9 (mean - 41.8). In three patients {4.8% ), the gradient was less than thc prcdicted normal for age. One was a 6l year old smoker with a hrstory of COPD, who had a gradicnt of 12.6 (predicted normal - 19.2).This study examined the A-a gradient in patients in whom a definitive diagnosis of pulmonary embolism was made.

We found 3 patients (4.8%) with positive arteriograms in whom the A-a gradrent was less than the predicted normal. We conclude that a normal A-a gradient does not exclude the diagnosis of acute pulmonary embolism.

the skin and utilizes spectrophotoelectric techniques to measure SaO2 on a beat to beat basis. Its accuracy in surgical patients has been well documented under both stable and rapidly changing conditions. However, there is little direct evidence that routine use of SaO2 monitoring in emergency medicine alters short-term morbidity. To determine the rmpact oi SaO2 monitoring on patient management, we conducted a prospective clinical trial on 40 adult patients presenting to the emergency department (ED) with acute respiratory illness, such as emphysema, asthma, or pulmonary cdema. Recorded data included hemograms, pulmonary function tests, artenal gases, subsequent therapy, and response to treatment. Additionally, the 'early warning' capability of SaO2 monitoring was analyzed by recording the severity and outcome of potentially adverse hemodynamic events. Linear correlation analysis revealed good agreement between simultaneous pulse oximeter values and both directly measured SaO2 (r:0.95) and saturations derived from measured arterral PaO2 (r:0.94).

Mean duration of usage for the 40 oximeters in the ED was 1.8 hours; all probes {unctioned reliably over a wide range of systolic pressures (80-206 mm Hgl heart rates {40-lB0 bpm), and hematocrits {20-58%}. The device detected several otherwise unrecognized drops in arterral saturation that were confirmed by laboratory analysis. Continuous measurement of SaO2 improves monitoring of ED patients, facilitates titration oI respiratory therapies, and detects abrupt changes in tissue oxygenation.

Othcr clinical situations in which the ouise oximeter was found uscful in thc ED are rcvicwcd.

85 Gomputerized Pharmacokinetic Dosing of Theophylline in the Emergency Department E R G o n z a l e z , B A V a n d e r h e y d e n ,J P O r n a t o , A B G a r n e t t , T J Comstock / Emergency Medical Services, Medical College of V i r g i n i a ,R i c h m o n d Thc cmcrgcncy dcpartrner-rt is a unique settrng for pharmacokinctic guidcd drug administration bccause of the nced to rapidly optimizc thcrapy. Wc uscd an automated theophylline assay and a computcrizcd Baycsian pharmacokinetic modcl to determine whcthcr computer-assistcd dosing of aminophyllinc in the ED could safcly dccrcasc the number of hospital admissions for asthma. Method: This prospective, randomized study compared outconcs ir-r aclult asthmatics trcatcd in the ED with IV amin o p h y l l i n c d o s c d a c c o r d i r . r gt o i d e a l b o d y w e i g h t ( G r o u p A ) o r acctirding to Baycsian-derrved pharmacokinctrcs (Group B). An IV bolus of aminophylline was followcd by a maintenance infusion in order to achieve a steady statc theophylline concentration {TC) of l5 pglml. Vrtal srgns, peak flow ratc {PFR), and TC were determincd at 0, I, 2, 4, and 6 hours post-load. Results: Fifty-five paticnts (45 + 15 yrs; 74 * 16 kg; 169 + 11cm) were enrolled,20in Croup A and 28 rn Group B, seven patients were excluded. Patient demographics, clinical history and drug therapy did not differ significantly bctween treatment groups. PFR, initial TC, theophylline clearancc {Cl), and volume of drstribution iVd) were similar in both groups. No significant toxicities were observed in cithcr group. Post-load TC's were significantly higher in Group B.

GroupA GroupB

84 Continuous Monitoring of Arterial Saturation During Pulmonary Resuscitation J Jones, D Herselman,L Cannon,R Gradisek/ Departmentsof EmergencyMedicineand CriticalCare Medicine,AkronGeneral MedicalCenter,Northeastern Ohio Universities Collegeof Medicine,Akron Continuous measurementof arterial oxygen saturation {SaO2l usrng pulse oximetry has recently been introduced as a monitoring and management technique in critically ill patients. The pulse oximeter wraps around a finger or toe without penetrating

40

Initial TC 5.4 7.6 (P< 3)

thl

2h.

4hr

TC

TC

12.5

11.4

6hr TC 13.1

TC 125 1 44

1 59

16.7

17.1

(P < 11)

(P < 02)

(P < .02)

(P < .02)

PFR < 100 L/min at l-hour post-load indicated a low nrobabilitv of tlischarge lrom the ED {i - 0.0001). Discharge rri.t.-ong patients with PFR > 100 L/min werc 60"k and 78"/" in groups A and B, respectively (P - .471. TC at 6:hours post-load was the strongest determinant of ED discharge in patients with PFR > 100 L/min (P < .004). Conclusion: In the ED, computer-assisted aminophylline dosing decreased the number of admissions in adult asthmatics with PFR > I00 L/min.

Poster Presentations Gase Mix and Resource Use in the 96 Emergency .Department [t Ei,urr,tlu C"u,"ron, / UCLA Schoots of Medicine andpubtic Health, iL O9rlt:!r3n S Anoeles

We developed a case mix classification system in which emer_ patients were classi{ied'tnto "ti"ic"tty ;;;; ,g::,:I l n g l u t 1:q"f-ent trnancrally homogenous groups. Data were collected ,and r r o m t n r e e c o m m u n i t y a n d _ o - n eu n i v e r s i t y t e a c h i n g hospital from fuly 1983 thru Decem.ber 19g5. Clinic"l i.rfor-"iion and data re_ garding resource consump,tion *ere obtai.reJty ,trtrr"tr.rg _.a_ icalrecords and patient billing informrtio" ioiit and hos_ pital services {oigs,ooo patients. A providerii'mJ fsician study of direct patlent care tlme was undertaken on a sub_group of 2,000 pa_ tients. Cost of care included drrect "ost. orrly.'The cost of emer_

g::Z^q:ry-T-ent suppliesand servicesexclusive-oi.,rrrirrg ;"i.

was determrnedtrom each hospital emergency department"budget. Provider time costs were i functio.r"of totri'dir."t p"tr"", care time, annual income,.productivity and direct patient care fraction. The cost of ancillary service *". J"i.r-i"ed by the chargeby service and the cosi to charge ,",io-to, .r"t hoJpitrl cost center.Two hundred sixteen emergen y department groups paticnts were created. iEDG's) *er. flrst-subla*ii.a i"t" q'rroiii diagnosticcategories:trauma-poisoning, cardiopul-or"ry, glrtrointestinal, genitourinary, o_B_gyrr, rrJrrropry"f,i"tric, eye_ear_ nose,skin-muskuioskeltal,ind rriiscellan.orlr.'il.r. nine maior diagnostic.categories were-further,;b_Ji"ud.a'l"to clinically with different resource consumption by :::::l^cj"l,:lb-sroups dragnoses/patient age, and physician procedure l:/:l:tjl lcriti_ cal careand complexityof lacerationrepairlusing thc Auto_group lnteractive statistical system. Thtse emergei.y a"prrtil"rri groupsexplainedG0% of the variance in totaicosi. Thi correla_ tion coefficientfor the direct costs betweencommunity hospitris and the university iospital was .95 ,"gg""il"g ,hrt there is'little driferencein relative cost between community ,.rd u.rluersitf teachinghospitals.We believe that these EOd, *Jff be useful in oerermrnlngspecrficresourceconsumption as a function of diag_ nosis_ and will thereforeserve as an important management tool for physicians,hospital managers/and as a means of restructurrng rermbursementlor emergencydepartment care.

e-etgency Department Gritical Gare Q7.

Hegtstly

D Ptummer,J Clinton,E Ruiz I Departmentof EmergencyMedicine,HennepinCountyMedi;al a;nrer, Minneapolis Emergencymedical data recording and retrievaj for education and researchis di{{icult. Hospital reJord system, ,.. oft.., poorlf designedfor inpatient data analysis,ignoring the 1:.^.,.^rt_bj:,*d the emergencyand outpatient population.ihese ll.:ir-:] [rob_ lemswereaddressed in our departmentby developmentof a iepa_ rate freestandingcomputer bised EmergencyOJpartment CdtiRegistry. The registry consists of ln emergency :ii :^1i: authored pnyslclan clinically oriented databasesolely f*orre'_ searchand education. Information concerning "".t .rlil""t p" tient is gatheredand entered by a dedicatedr"esearch,r,rrr. "rrd includes:patient,demographics,physician (two-""tri., allowed), nurslngpersonlel, 5 diagnoses,15 procedures etiology,ISS score, eventtiming, disposition,outcome, autopsy,and a ge-neral memo. tntnes are.lnteractivelydeterminedwithin an expanded ICD_9 dragnostrc tormat, which allows for rapid, uniform data entry and recovery.Analysis,using any combinaiion or relation of the data elementsrs possib.le.We have found this to be a practical and system. The 1650 critical casesentered durin! :I:r.,,T:lf T.{ul rne rlrst.year ot operation provide the basis for several typ", oT reports.Accurate documentati.onof successfullymanaged'Jpecil_ ic critical diagnosesand proceduralexperienceis provid"ed to resicents anclstatf. Essentialand up to date informaiion is produced for ongoing ciinical studies. Reports pr";i;;it-;;f;ning depart_

41

mentai trends are examined and used for comparison to other standards. Limited examples include rates of resuscitation, out_ come for a given traumatic ISS score and initial rhythms in car_ diac arrests.. Analysis of frequency and severity of cttlcat pa tients has determined seasonal, m-onthly and daily .-"rg"ri"y department staffing. Other reports have become instrumentai in our departmental and hospital quality assurance data. Documen_ tation and analysis oI experience, which was previously a Iaootlog: undertakrng,. is now accomplished regularly with minimal errort. Inls database is a practical and valuable tool within our emergency_department and will serve as a model fo, the Je_ velopment of future databases for the non_critical .-.r!.".y patient.

qq ftpqqr" and Asins - tmpticarions For a Piiladelphia Traumi S6rvice'HrrS Weinguu"n

ST Wainwright, A Sacchetti/ TraumaServices,Eirergency Services,MethodistHospital,philadelphia, pennsvlvanra With the emergence.oftrauma as a major health problem of ., thrs decade,and with the.increasedlongevity of the population, more.agedpatients are being seen with iiultiple trauma. The establishment of regional trauma centershas facilitated the collec_ tion of data.relating to aging, medical outcome, and demand on tne partlcular center,sresources.Admissionsto the Methodist Hospital Trauma Service,lVlethodist Hospital, phil"dei;h;;; Pennsylvania,were analyzed from Decemb"i fSgS tt.o"gh'J"1;; 1986.An evaluation of 2ll consecutiveadmissions,as recorded on the Methodist Tiauma registry,was done as to length of trospi_ tal stay age,mechanism of rnlury, presentingpre_hoslitaltr",r-" score,grossfinancial chargesfor the stay anj daily .t rrg... U.i"! techniques.of multiple regression,a significant positive associa_ t i o n w a s f o u n d b e t w e e n a g a i n , _l e n g t h o f s t a y , a n d g r o s s financral.charges.

Blunt traumi in ihe agEdindividual was associ_ g:99 yi* thc increasing.lengthof sta| and grosscharges.The r n r r r a t I r a u m a S . c o r ew, t e n p o s i t i v e ,w a s s t r o n g l y r e l a t e d to length ot stay and grosscharges.The pathophysiologicfactors in_ volved tn thc aglng processaccountedfor many of ihese results. l n e l n c r e a s e dl l n a n c i a l d e m a n d so f t h e a g i n gp o p u l a t i o no n a center.achievingtrauma -rrrt*b.".oniidered in the _dcsignation at.locatlonol limited health care resources.

99 Compu_terizedRadiographic tmaging in the Department M;Mrbs.;J-i"[i, nL Scanton lpgr^sencv I UCLA

Schoolof Medicjne.Los Angetes a prototype Fuii FCR l0l Computed Radiographic ,_Y^:,:l"J:1 ,:d lmaglng_{UKtl Sysremin th.eemergencydepartmenrro compare CRI with conventional radiograph!. w. pro.p..i-"ly .u"l,rii.J 42 radiographic examinatio.rJa-orrg S+ emergencyi.pr.t_.rri patients. These evaluations were done with dial imaging usine both conventional radiography and CRI "t id;;"i;;;;;";;;: rameters.Examinations,includ"-d.the cervical spine,ihest, extremities, peivis/hip, skull and abdomen.Six specialists consist ,y. radrorog,ists,two emergency physicians, and two llg 9l orrnopedrc surgeonsindependently analyzedall images. Digital consideredpreferable to convenrional rad"iographtin lTjg._r, 2670ot lere oDservatrons, ol equal quality in 50% of observationsand or lesserqualrty in 22% Emergencyphysicians _ofobservations. found CRI image quality ," U. UEii.. or compara_ fli^d,r:dj?lgs*.,s Dre ln Uzyo ot observations,preferring conventional radiographs in l8% of observations.Orthopedic ,rig.o.r, d.-o"rtrrt"a"" pi"terencefor conventional radiographsln"one thirJoi observatrons.

On.comparing the two im_agrngsystems, conspicuity of abnor_ comparablein l/%if obre.uationr,tnr *", prefera_ ffll?

X1: Dre rn luyo ot observations,and conventional radiographs *ere rated better in lB,'/" of observations. Minification, *"t l.t o""t.ri, on CRI i.mages,.was acceptablein 77% and desiiablein 13% oi I hrs was parricularly true for chest images. The ::::t-ui,!t""r eogeennancement,which is associatedwith the second CRI im_ age, was consideredto be definitely valuable in B5T" and mar_

I

ginally valuable rn 127" of observations.Incorrect processingalgorithms were utilized in 62% of digital exams. Correct processingimproved overall CRI image characteristicsand desirability over conventional studies suggestingthat digital imaging will have greaterapplication in the emergencysetting as processingfeaturesare simplified.

A Quality Assurance Assessment of 90 Radiograph Reading Accuracy by Emergency of Emergency / Department Medicine Faculty DTOverton Medicine, William Beaumont Hospital, Royal Oak, Michigan We sought to determine: the radiograph reading accuracy rate {or emergency medicine residency faculty; how often misread radiographs affected treatment and follow-up; whether certain types of radiographs were more often misread; and whether emergency medicine residency training or board certification aflected radiograph readrng accuracy. A ten-month study comparing all radiograph interpretations by emergency medicine residency faculty and radiologists was performed. Next-day radiologist interpretations were reviewed, and a decision was made as to whether the reported missed findings represented clinically significant missed pathology. This decision was based on specific, pre-established criteria. Radiographs and charts were reviewed to determine the appropriateness of initial treatment and follow-up provided. This, too, was based on pre-established criteria. Erroneous emergency interpretations were categorized according to type of radiograph, physician, treatment and follow-up. Statistical analysis was performed for items 3) and +) using the chi-square and Fisher's exact tests. There were fifteen emergency medicine {aculty during the study period. Ten were residency trained in emergcncy medicine. Of these ten, eight were board certified in emergcncy medicinc. TWo additional physicians were board certified, but not residency trained, in emergency medicine. Six thousand scven hundred and forty sets of radiographs were read by emergency medicine residency faculty during the study period. 361 15.36%) were corrected by the radiologist. 40 10.59%) were, upon review, judged to actually represent clinically significant missed pathology. TWenty-four of these 40 10.36%l warranted a change in immediate treatment, and 24 1036% ) warranted a change in follow-up care provided. No specific types of radiographs proved m o r e l i k e l y t o b e m i s r e a d ( P > . 0 5 ) .E m e r g e n c y m e d i c i n e r c s i d e n cy training and/or board certification did not correlate with improved reading accuracy {P > .05). This study found that a large percentage of radiologist re-reads do not, when assessed by our criteria, represent significant missed pathology. The emergency physician reading accuracy rate, particularly when adjusted for clinical significance, may prove to be a valuable quality assurance tool for assessing emergency departments and individual physicians.

suitable for fCAH review. Criteria can be modified to provide a more facility-specific review. Concurrent screeningis also available using on-screencriteria. Each chart of the requiredrepresenThe tative sample is reviewedand enteredonto the spreadsheet. selectedcliarts for the given time period are then compositely analyzedin a similar manner.Chart deficienciesfor eachprovider as comparedwith his or her peers can be graphically presented.

Statistical analysis of this comparisonis also easily available.A microcomputer can be an invaluable asset to the quality as' suranceprogramof any emergencydepartment.

Evaluating Glinical Supervision in an 92 Emergency Medicine Residency Program: Resident and Staff Perception of Effective Supervision and Stress Managemenl BM Thompson, of / Department LL Baltarowich W Moskal, C Smereka, Fairlane Detroit; HenryFordHospital, Medicine, Emergency mi,c h i g a n Health S e r v i c eB,i r m i n g h aM

Quality Assurance A Microcomputer-Based 91 Program for the Emergency Department Elliot Center, and Trauma Department / Emergency WLJonakin NewHampshire Hospital, Manchester, The Joint Commissionfor the Accreditationof Hospitals qualityassurance {JCAH)requiresa complete,comprehensive programfor the emergency department(EDl.This includesboth concurrent screening as well as chart audits, and problem orrented, occurrence based reviews. Presented is a computer-aided quality assurance program which uses a well known and widely available spreadsheet program (LOTUS 123) and satisfies the requirements in the |CAH Accreditation Manpal for Hospitals. A basic data base is entered lor each patient seen in the ED which can also serve as the JCAH required control registry. From that, charts can be identified which are then audited using one of several templates provided. These templates contain preselected cliteria for a variety of diagnoses or subfects (eg. asthma, antibiotic usage, pharyngitis, chest pain). The LOTUS 123 abilities for analysis and presentation of data are then used for documentation

42

Busy urban emergency departments have o{ten been excellent training facilities for emergency medicine residencies. Even the best of these facilities can become inundated with patients, severely stressing physicians, nurses and the facility itself. A supervising attending physician on duty 24 hours a day in the emergency dcpartment can serve as role-model, knowledge base and as a stress buffer to protect the resident at times of extreme stress.

In an effort to delineate the maior sources of work stress as well as thc optimal approach to supervision of housestaff in our emergency dipartment, we surveyed all l0 full-time attending staff and our 16 residents with an instrument designed to measure perceptions of both groups regarding supervision and stress management. Staff physicians were asked to evaluate their performance against a set of attributes possessed by an ideal supervisor. Using t h e s a m e c r i t e r i a , r e s i d e n t s a s s e s s e dt h e p e r f o r m a n c e o f t h e clinical staff as training supervisors. Whereas, stafl and residents agreed that staff were effective supervisors with regard to knowlcdge base, teaching skills, and as a role model; residents rated the strf{'s overall performance considerably higher than the staff themselves with regard to: 1) knowledge of the supervisory role, 2l encouragement of commitment, 3) ability to inspire confidencc, and 4) ability to deal with problems at the proper level The grcatest discrepancies were in the area of feedback. Staff physicians felt that effcctive feedback was being provided clearly and in a timely fashion. Residents felt that more feedback should be provided, and that which had been grven was not as clear not as timclv as desired. Manv residents felt that most feedback was orovided in the form of recognition of errors or as criticism of pcrformance rather than as iecognition of good performance.

Similarly, staff and resident physicians evaluated the effectiveness of staff management of stress in our busy emergency department. Both groups felt that there was a need to improve their strcss management techniques. The residents again perceived the staff as more effective in reducing stress than the staff themselves. When each group was asked to provide a list of effective techniques for managing stress in the ED, there was remarkable agreement. The following list of ED stress management techniques were developed: l) Timely recognition and prioritization of patients and problems, 2) Understanding of limitations, 3l Fostering departmental teamwork, 4) Eifective communication and prompt feedback to team members, 5) Rapid availability of at' tending and consulting staff to assist in disposition decisions,6) Frequent use of humor, and 7) Daily or periodic review of difficult cases. This survey identified unrecognized deficrency in clinical supervision in our program. In addition it identified and solidified our approach to stress management. Utilization of stmilar survey instruments may enable EM programs to identify other occult problems in clinical supervlsron.

Power and Leadership an the Emergency 93 Departmentl A Survey of Nurses Ml LangdofI

U n i v e r s i t yo f l l l j n o i s A l f i l j a t e d H o s p i t a l s E m e r g e n c y M e d i c i n e R e s i d e n c y ,S k o k i e

of care delivery in the ED, and allows a comparison among pa_ tient subsets.

In no other medical setting must the nursing staff so often assess the competence of a new physician as in ihe emergency de_ partment {ED). Howevel, the mechanisms by which this assess_ ment takes place have not_been investigated. The purpose of this study was to suruey the factors which-emergency nurses iENs) u s e , t o a s s e s s . t h ec o m p e t e n c e o f e m e r g e n c y p l y s i i i a n s ( E f s ) a n d to dlscover their view of the Ep,s basis of power. Twentylnine nurses from three community-hospital EDi affiliated with an emergency medicinc residency were surveyed using rwo lnstru_ ments: rhc Power Peception profile, a mcasure of the seven di{fer_ ent klnds_ot power rclationships, and a survey ol factors which werc rated as pos_itively or ncgatively affecting the EN,s attitudes toward an EP The three most important types of power were those based on the EP,s posscssion of expcrtisc, the authority of his position, and his aciess to important mejical information.

The EP's.power of cocrcion *as,ank.d least potent. On a fivepoint scale, thc nurses rated _the Ep,s compete,ncein handling a critical patient, regardless of outcomc (4.b6* .35 for good oiit_ come vs. 4.25+.97 even if the patient died), his ability to move paticnts quickly 14.75t.44), his willingncss to explainthings to p a t r e n t s a n d f a m i l y 1 ' 4 . 7 5 : : . S Zal n d t o i e a c h n , . , r r . i 1+.fr+*.fii1 ,, t h . ch l g h c s t p o s i t i v e a t t r i b l t e s . - T h c y r a t e d m o s t n e g a t i v e l y t h c E p who has alcohol on his brcath (-'q.65*.35), onc who makes a clcarcrror in judgmcnt (-4.30*.tt2) and one who bccomcs ver_ bafly abusivc to an obnoxious patient l - S . C e * 1 . 2 2 ) .B o a r d c c r _ tification rn cmcrgcncy medicinc had littlc positivc effcct. Ncr_ tncr scx nor mrnority status of the Ep was rcported as an rmportant factor. Almost .hal| la6%l of ENs form ihcir Opinion about an EP within a.singlc shift, although an equally ,ignifilr;i n u m b c r _ ( 4 6 u 1 ,w) a r t t h r e e o r m o r c s h i f t s i o f o r m - a n o p i n i o n . U r - r dcrstanding ENs' pcrceptions of power and leadcrship in the ED can contributc to a tcam effort which opttmizes patlent carc.

94_fi-" Study of patient Movement Through the Emergency_Depa*ment: Sources of Delaj in Relation to Patient Acuity CE Saunders / Department of Surgery, Vanderbilt University Schoolof Medicine, Nashville, Tennessee A continuous obscrvation timc study was uscd to track l5(rg patients through 4 stages of cmcrgcncy departmcnt (ED) carc: l) rcgrstration,2) triagc; 3) waiting for thc physician; and 4) physi: cian evaluation and treatment, in order to idcntify sourccs <tf'clc_ lay in relation to the level o{ paticnt acuity. paticnts were catc_ g o r i z c di n i t i a l l y l A , B , C , o r D l i n o r d c r o f d t , c r c a s i n gs e r i o u s n c s s of thcir problcm, and the flow profilcs for cach category werc comparcd. Patients with the most minor complarnts {b) cxperl_ c n c c d ^ l o n gd c l a y s m o v i n g t h r o u g h t h c f i r s t . l s t a g e s o l c a i c ( l ' 2 , 9 , and l9 min, respectively)despite the fact that thc evaluation anj trcatmcnt stage was relatively bricf (49 min;31 min if no tests were ordered or procedurcs performedJ. By comparison, as thc se_ verity of the illness increased {C and B), thc length of timc spent in each of the first 3 stages of care progressively- decreased (C: 9, 8 , a n d l 5 m i n , r e s p e c t i v e l y ; B : l , 2 , a n d B m i n , r e s p e c t i v e l y ) ,b u i with a progrcssivcly longer evaluation and treatme.t srrse lC. l23..min; B: 142 minl. Tie most critical patienr, J; l;l';;; tually no time in the first three stagesand'a reduced time in thc evaluation and treatmcnt stage (35 mr.,1 a, a result of a rapid dis_ positron from the ED or dcath. Thrs relationship suggeited an emergencysystem onented toward the timely and efficient care of critically.ill patients, but which was less effective at caring expcd.itiously for those with more minor complaints, evei t h o u g h t h c l a t r e r c o m p r i s e d 8 7 - 8 9 oo f t h e t o t a l p a r i e n t c e n s u s , and represents a.group among whom delay is a frequent source of patient dissatislaction. Factors ,.sporrsibl. {or delay included b l o o d t e s . t s ,u r i n a l y s i s , d i a g n o s t i c p r o c e d u r e s , a n d r a d i o g r a p h y .

This study illustrates the use of a iontinuous observatron trme study of patient flow as a technique {or evaluating the efficiency

43

9-5 Emergency Department protocol lor the Diagnosis and Eualuation of Geriatric Abuse

J .Jones, W Cunnrngham, J Dougherty, D Schelble / Department of Emergency Medicine, Akron General Medical Centet N o r t h e a s t e r n O h i o U n i v e r s i t i e sC o l l e g e o J M e d i c i n e , A k r o n As the numbcr of clderly in the United States continues to grow geriatric abuse has become the most recent manifestation of domestic violence secn in the emergcncy department (EDl. Rc_ ccnt data suggest that l -million elderly persons are battered, neglected, or exploitcd each ycar by family members or caretakcrs.

This maltreatment may be more difficuli to identify than child or s p o u s e a b u s c b e c a u s eo f t h e r e l a t i v e i s o l a t i o n o f t h e v i c t i m s , a n d t h c i r r c l u c t a n c e . t o r c p o r t a b u s e . M a n y o f t h e s c c a s e si n v o l v e o n l y subtlc signs and havc a grcat potential to pass undetccted. This papcr summarizes thc current literature on geriatric abusc and dcscribes an cmcrgcncy department protocol for identifying and rcporting suspectcd victims. Wc retrospcctivcly reviewed the mcdical rccords of 36 cldcrly patients hospitalized with documcntcd abusc or neglcct. physical maltreatmcnt was cvidcnt in 8 0 % 1 2 9 )o f - t h e ' c a s e s ,4 4 ' . y "1 1 6 li n v o l v e d p s y c h o l o g i c a l a b u s c . K e y points in thc history, physical cxaminition, and psychosociai evaluation wcrc analyzcd to identify specific criteria uscd in the protocol. This framcwork will aid thc cmcrgency physician in the c r u c i a l f i r s t s t c p s o f i d c n t i f y i n g a b u s c , o b t a i n i n g c : v i d e n c e ,i m m c _ diatc trcatment, and crisis intervention. Wc are currcntlv in the proccss of validating thesc high-yicld criteria in an agc_matchcd control group. Awarcncss that thc problem cxists anJ imprrlvcd dctcction and intervcntion proccdures arc needed tu pi"u"r,t abusc of cldcrly pcrsons fnrm bccoming more widcsprcai.

9..Q -.e-grge.n gy-.gepartment pat ient Li terac y and the Readability of patient.Directed Materials RD Powers / Emergency Medical Servrces, D e p a r t m e n t s o f M e d i c i n e a n d S u r g e r y , U n i v e r s i t yo f V i r g i n i a Schooi of Medicine, Charlottesville Thcrc arc 20 million Amcrican adults who cannot rcatl. Thc demographics of thc illitcratc population suggcst that they rcprc_ s c n t . a : l g n i l i c a n t p r ( r p { r r t i o n6 f p a t i c n t s c a r e d f r r r i n a t c a c h i n g n ( ) s p r r a l L - n t c r g c n c yd e p a r t m e n t ( E D ) . S i n c e m i s u n d e r s t a n d i n g o f wnttcn lnstructlons may caus/j mcdical and/or legal complicatlons tor paticnt or physician, paticnt-directed informition should bc writtcn at an appropriitc comprchcnsion lcvel. This s t u . d y w a s d c s i g n c d t o a s s c s sw h c t h c r r c a d a b i l i t y o f w n t t c n m a r r :rial givcn to paticnts in a Univcrsity Hospital ED matched thc litcracy levcl of these paticnts. Data was gathcred from lll con_ s c - c u t i v ca d u l t E D p a t i e n t s . S i n c c h i g h e s t j t t a i n e d l e v e l o f f o r m a l education corrclatcs with reading ability, this was uscd as a mea_ surc of paticllt literacy. Results of the survey showcd that al_ though thc median schooling levcl of ED patients was l0th gradc, more than 40% could not bc_cxpected t-o rcad at the t3th'grade lcvel, and at lcast 20% could be considercd to bc functionally illitcratc. Readability of ED paticnt-directed materials *". -.rl sured using thc Fry indcx. Hospital and commcrcrally generated paticnt cducation materials regarding care of minor-illncsses rangcd from 7th to l0th grade lcvel; patient-directed brochures from Statc and National ACEp are wiitten at a college reading l e v e l . C o m p r e h e n s r o n o f t h e , , l e a v i n gA M A , , f o r m o r a c o n s e n t f o r surgery_would requrrc at least an llth grade education. The rc_ sults of thrs study show that therc is in alarming discrepancy bctwecn ED patient literacy levels and the reading,"klll, .cqrrr.ed to comprchend im.portant written medical and lelal information.

More than 50% ol ED patients in a teaching hosfital read below t h e l e v e l r e q u i r e d t o u n d e r s t a n d s t a n d a r d d r s c h a r g ei n s t r u c t i o n s .

In addition, understanding the medrco-legally iriportant ,,operative consent" and "leaving AMA,, forms requires i levcl of edu_ cation far beyond that of thc malority of ED parients. If patientdirected written material is to serve iis purpoie, then ED patient

terpersonalskills, required clerkship grades,and the dean'sletter were ranked highesi. The EM residency director (4.88 :! 0.32J and the EM department chair l4.OZt 1.44)were ranked well above other determinors in the final selection process.Our data suggestthat residencydirectors are looking for compatible,-matuiJ candidateswith demonstrated academic prowess,and EM exoerience.Furthermore, residency directors are more likely to select candidatesof whom they have firsthand knowledge.This information should be helpful in channelling the efforts of candidatesas well as residencydirectors,who must be efficient in considering the large number of applications.

populations should be surveyed,and the readinglevel of written material adiusted accordingly.

97 Allocation of Time in Three Academic R Smith, E Criss/ DWSpaite, Specialties ABSanders, Sectionof EmergencyMedicine,Departmentof Surgery, of ArizonaHealthSciencesCenter,Tucson University A survey was done to: 1l characterizethe allocation and distribution of time by tenure track emergencyphysicians,and 2) compare the time distribution o{ emergencyphysicians to two other academicdisciplines.All emergencymedicine residency programs were surveyed by teiephone to determine i{ faculty were eligible for tenure in an affiliated university. Those programs that did have tenure tracks were further questionedregarding hours per week spent on clinical duties, research,and administrative tasks. Similar information was compiled from cardiology and orthopedic faculty at the same universities.Time allocations from each specialty werâ&#x201A;Ź compared using Duncan's Multiple RangeAnalysis with a P < 0.05 consideredsignificant.

Data from the survey revealedthat a tenure track assistantprofessor spends approximately 52 hours per week in emergency medicine. Of theseweekly hours, 23 146%of total time) are spent working clinical shi{ts in the emergency department, 11 hours 120%lare spent doing researchand l8 hours 134%lare spent in administrative tasks.In contrast,cardiologistsspendsignificantly more time in clinical duties (32 hours per week or 55% of total time) and research(18hours per week or 29% of total time). However,cardiologistsspend significantly less time in administrative duties averagingl0 hours per week 116%of total time). Data for othopedic surgeonsshow a similar pattern. Orthopedists spend significantly more time in clinical duties (39 hours per week or 62% ol total time) and significantly less time in administrative tasks (9 hours per week or 16% of total time). Orthopedistsspend a mean of 13 hours per week on research,which is not statistically different from either cardiologistsor emergencyphysicians. Patterns within each academic discipline were also analyzed and a significant difference in research time was found betweenfour tenure track emergencymedicine programsand the other eighteen.Data from thrs survey may help academicemergency physicians evaluatehow they are allocatrng their time in comparisonto other busy ciinical specialties. of Emergency Factors Involved in Selection 98 Medicine Residents E Sloan,R Hayden,MA Cooper, of llltnoisAffiliatedHospitalsEmergency G Strange/ University Chicago MedicineResidency, EmergencyMedicine (EM) is the secondmost sought-afterspecialty training program. The large numbers of applicants attracted each year make it difficult to select the most suitable candidates.We surveyedthe 66 currently approvedEM residency programsto determine the factors that were felt to be most important in applicant evaluation. Sixty-two variableswere divided into four classes:past academicperformanceand experience,letters of recommendation,performanceduring the interuiew, and the written application.Each of these 62 variableswere scoredon a 0-5 scale.In addition the respondentsranked the top five variables that ultimately determined selection. The most highly scaledacademic criteria were: EM clerkship grade14.12+ 0.7311, EM clerkship in the program'sED i4.07 * l.ll), and required clerkship grades(3.84 t 0.961.Letters of recommendationscaled highly were the program's EM residency director 14.46+ 1.06), program'sEM department chair (4.44 * 1.041,and EM residency director from applicant's school |.4.14* 0.83).Highly scaledinterview variableswere the perceivedcompatability with the program (4.70 t 0.51),maturity 14.47* 0.54),and interpersonal skills (4.44 + 0.55).In the application category the quality of the applicant'spersonal statement was scaled highest (3.70 t 1.02).

In the overall ranking of the top five variables, compatability with the program/EM clerkship in the respondent'sprogram,in-

4

and lmplementation' Development, 99 Evaluation of a Medical Spanish Gurriculum Residency Medicine for an Emergency Program LBinder, B Nelson,D Smith,B Glass,J Haynes, of M Wainscott/ Divisionof EmergencyMedicine,Department Surgery,TexasTech UniversityRegionalAcademicHealthCenter, El Paso,Texas Hispanic Americans currently comprise 8% oI the United Statespopulation, and are proiected to become the largestU.S. minoriiy group early in the next century. In many parts of -the U.S. (notably the southwest, southeast,and large ethnic urban areas),largepopulationso{ Spanishspeakingpersonsmay be present. Thus, the need for emergencyphysiciansto be able to communicate in Spanishto Spanishspeakingpatients existsrn many practice settings {especiallywhere translation resourcesare nonexistent or scarce),and is likely to increasein coming years.We present our experiencewith the development,implementation, ind evaluatronof a curriculum in medical Spanishas part of an emergencymedicrneresidencyprogram.This 45 hout coursewas conductedin fifteen three hour weekly sessionsheld on Saturday mornrngswith the emergencydepartment.Teachingresources included an instructor from the loca1community college,a standard medical Spanishtextbook lKatz,Znd ed.),and a department "survival Spanish" monograph preparedby one o{ the authors.

Attendance was strongly encouraged,but not mandatory.The purposeof the coursewas to train departmentpersonnelwith no word initial facility in Spanishto an approximately5,000-10,000 vocabulary level, with orientation to medical applications.Speci{ic educational obiectives included sufficient languagecapabilities {or basic information exchange;ability to take uncomplicated medical histories in Spanish;to conduct an unassisted physical examination; and ability to give common patient discharge instructions. Post-courseevaluations were conductedby interview with both regular attendeesand with personnelwho did not complete the program.Regularparticipation cited significant improvements in vocabulary, syntax/ comprehension,and communication skills; expressedattainment of the educational objectives; and expressedconfidence, eagerness,and improved speedin dealing with Spanishspeakingpatients.Non partictpants cited con{Iicts with other educationaland servicecommitments; trme commitment; timing of lessons;eariy missedsessions {resultingin falling behind}; and lack o{ housestaffinvolvement in the planning processas reasonsfor not completingthe curriculum. We conclude that a curriculum in medical Spanish {or an emergencymedicine residency program can result in attainment oi sulficient communication skills to function effectively in the emergency department setting, and result in improved speedand gratification in dealing with Spanishspeaking patients. However, in the implementation of a similar curriculum, other EmergencyMedicine programsshould considerextent of time commitment, avoidance of con{lict with other educational and service responsibilities, and methods to ensureparticipation prior to implementation.

l OO A Library in Faculty Development fot / Academic Emergency lledicine GCHamilton Departmentof EmergencyMedicine,WrightStateUniversity

School of Medicine, Dayton, Ohio Development of the skills to establish and expand . the academic basis Ior emergency medicine .o",in*, ,o t a high prioritv torchalrs and program directors within this s p e c i a l t y .i " . t , o f t t ! m a i o r _r e p r e s e n t a t i v e s o c i e t i e s i n e m e r g e n c y m e d l i i n e hrrr. dil rected considerable attention to this tJpic.'Still, many faculty have not mastered or even be.r, ."posld-to th"r. skills. The clinical demand of emergency medicine pir"ti".-ott"r, pr""f"a., the opportunity for contempirtiu., -"rrir..a-gio*tt and devel_ opment of academic faculty. without an estabiished network oi mentors/ emergency medicine faculty must turn to textbooks rrom authors outside the fieid for a written source o{ infotmation These books ,r. of ""ryirrg quality and ::_{f{y.d*elopment. apprrcabllrty/and the time to evaluate them in tlre iontext of one's needs is limited. In an,effort to improvc access to quality texlbooks applicable to faculty seeking io lea.r, new academic skills, the author has developei a libraiy i; i;;ity a.u"top_..ri topics. Over sixty books were reviewed, i"r, *"r. selected to torm a useful core library that can serve as tL. str.tmjpoint for iearn_ ing or refreshing skills in management, terChing, research, grantsmanship, interpretation of the medical literaturi, statistics; applications, audiovisual aids, :ompule.r. _writing, ""a prfiirl_gl

To establishand maintain these skills it . "r,tf,oi ,.ti"o."t.ffi the.necessityof sufficient ume, a supporttve environment, and assignmcntthat reinforcestearningthrougir ap_ 1ll^,:f:1.T,91 I hrs lr,brarywas createdto support inrerest,,cc.ss, and lltj1,l3l, contrnuedgrowth tor those servingin academicemergency medicine.

!-O-1 . Diagn^osticErrors in Emergency Medicjne: A Gonsequence of Inadlquate Fautty bata Interfieiiri"" or Case Snoqte_dge, Type?

T Allen,G Bordage/ Sectionde medecined,urgence; pedagogiemedicate (Officeof Medicat Educa'iion), F^r].ir1 9" facuttede medecine,Universit6Laval,eu6bec, Canada Thr5c,sourccso[. diagnosticcrrors were investigated:lack ol , taulty data rnterpretation, and casc types. Forty_five Ll:*l:oC!, vrgnett..s.y",le preparedbasedon actual emergencycases :rt-lnr:al been initiatty_ or found to be partitularly :lll,i:1 -misdiagnosed cjr?ll,engrngSubtects(N:140) were asked to generatea differen_ rral olagnosrstor.each.vignette;they then completeda knowledge rnventory assessingthe essential factual knowledge required io co,lregtdiagnoses.This techniquc has previously fl:::t:,,: :h..to Deenshown distinguishdata interpretationirrorstrom knowi_ erlrors. groups of randomly selectedpracticing physi_ :l-qj trom lour clans the province of euebec participated: certifie*demer_ pengyRhfsicians,non-certifiedemergencyphysicians,certilied ramlry physrcrans,and non_certifiedfamily physicians.

Three typg: 9f casepresentationwere used: 15 "ilti""l_",.." cases,15 misfitting-cue cases,and 15 atypical c^res. Ou.i"ll 44% oI the misdiagn,gs,e.d (averageof 20 errors pcr 45 cases, :T..r,,*..,.. s=r.ll, rne test rs reltablefor group comparisons ialpha coeffi_ c r e n r =0 . 6 9 ) - T h c .m a j o r c a u s c o f m i s d i a g n o s i si s n b t l a c k o f {notlld^g: lzl%1 bur a taulty interpretationof availableclinical d^ta l/9Yol. There is a significant intdraction between physician groupsand.casctypes(F= I0.5, p< .0001);nonetheless differences Detwee_n physrcian groups (F:5.2, p<.OOZland berween case P<-0001)are significant. Certified emergencyphy_ Itli 1t:9;t, betrer iScheffe,stesr, p<.05) than both groups :r,.ilT.p:tt?t-ed ot lamrly physicians,making an averageof 29.g{s:6.gJ c'orrecr oragnoses_as opposedrc 24.21s=5 2l and 23.51s:4.6).Each par_ ticipant obtained proiile of his performance,identifying each I error as a. knowledge or data inteipretation deficiency.The {requency of error types for each case was also co-puied fo, ih. grotlp.oi participants. These results have two rmportant :4/]]:le eo::1!tonal rmplications. First, training programs in emergency meolcrneshould tocus on interpretation of availableclinical data asknowledgealone doesnot guaranteediagnostic*""".., prrtr"_ ularly for certain types of cases.Second,ihe lndividuali;.jJ p;;_ Ille permtts a practicing emergencyphysician to identi{v ,p."ifi"

45

weaknessesin knowledge.and in data interpretation, and to plan hrs continu.ing medrcal education accordingly

7O2 Evaluation of a Hospitat.Based t{eticopter Emerg_encyMedical Servic6 CCe"yJtJierotson /

TiaumaServices,lvlemorial MedicalCenterlnc, Savannah, Georgia The HHEMS has becomea growing and important part of the pre-hospitalcare of the trauma patlent. As rn any aspeit oi medi_ Quality Assurance should be an integrai part of th. :3J__.-r19, HHEMS. Outcome review should be objective,bised tn , .."o!nized standard,and an ongoingpart of the HHEMS program.The TRISSMethod offers such a standardand is describid.the fiscal responsibiiityof the programmust be reviewedbasedon financial data collection and tracked to satisfy the sponsoringhospital,s financial position. A safety program to include nighi decis;s and weather considerationsihoutd be developedprior to imple_ menting service.Methods:.All trau_mapatients i.r.rrport.d by to th-e base_horpitrl *"r. prospectively :l:,HTE#S I.lyt3r:C studred.

The initial Tiauma_Score,the Injury SeveritySiore, ani Patient age were used in the TRISS Meihodology of th" lt"|o, Tiauma Outcome Study to determine probabilitli'of survival. irinancial data to include all charges,.eu..ru., ".rd .o.t, were collected. A safety program _wasdesignedprioi to implementation and revrewedon a monthly basis.Results:Three groups were :o-^pglgg 4ll trauma patients in the hospital trauma regrsrry (n:259a1,HHEMS trauma patients(n: lsli and the Maior"frau_ ma Outcome Group (n:25322). Distribution and survival curves tor the groups reveal the HHEMS group to be more severelyin_ iured.but with improved survival. TRISSmethodologyresults are as follows: N,4ean TraumaScore I 1 . 8 Actual Mortality tg.2% MeanISS 2 8 2 PredictedMortality 26.5% A c t u a lN u m b e ro f D e a t h s 29 % Reductionin Predicted PredictedNumberof Deaths 40.7 N4ortality ZB.B% - 2.34 Z Statlstic 28% reductionin predictedmortalityis significantto the p< .025 level

Multispecialty panel review revealedno preventabledeathsat_ tributable to HHEMS or trauma center care. Financial data ret:*:9.r^.^"^,.1 program cost of g1,246,387including srart up costs or b.ll4luuu.New patrentrevenuewas $1,136,192.

The net effect ot the program consideringonly the new patients was 27,500.

Conclusions:The TRISS Method offers an objective national norm for comparisonof outcome data for trauma patients trans_ ported by HHEMS. This patient population revealeda statis_ tically significant reduction in morlality oI 2g.g%.2) processre_ y-r_._y 9! mortality is a necessarypart o{ outcome review. 3) A HHEMS can be financially feasibleif new patient revenueis considered-in_the, analysis.4) A safety program should be , p"r, of every HHEMS.

_103

Gontingency

planning

Durinq an

Emergency Medical Servicei striidri-*yan,

RD Stewart,R Kennedy,J Overton,A LaRosee/ Divrsronof EmergencyMedicine,University of pittsburgh;Centerfor EmergencyMedicineof Westernpennsylvaiia;City of pittsburgh EmergencyMedicalServicesBureau . Among the problems in disaster management faced by EMS physiciansin their practice of medicine thiorrgh phyrl"ian surro_ perhapsnone presents^ grr^tt challenge ffles.{laraledics), rnan rne malntenance of patient care during withdrawal of service by EMS personnelduring a labor/-manalgement dispute. On the morning of November 2g,19g6,lg0 {ield i-trls p.rso.rnet w.rrt the re-questof the Mayo4 a strike contingencyplan -::^.T11:lA, was developedtor the city that ensured continued provision o{ service without sacrifice of quality of care. The basrc tenets of the plan included: l. That requestsfor servicewould be answered

to meet patient need; 2' Dromptly by a system staffed adequately ac-

apportioned fn"i''ar #rr ,,{'o"ra be answerei and services """i, J R"'po"" times.would equal or be ;ffiil;',;;;;.liu.J would be classiless than current system times, 4' That 9ll calls ambulances that and phvsicians EMs bv ;il ;;;;i;;;o ffio'itv i" oid.' to ensure rapid response.to life;;;ii;;;;sig'n.d of poisonthreateningernergencres;5' Non life-threateningcases ihat turn-around o' center; Poison the to iil;;iJi"-;ria'ged ,. the hospital would be limited to an aver;fi.';i;ilt"tt.?t responseto field ;;;-"i ,." minutes; z. itte iMs physiclan and b' enhanced;8' All clinical ;il";;";;i.;;o,'1a'.o",-"', i".i"ai"g times'o{ intervention' would be recorded il;';ilLi g times would be Uv'ln"'"":riit. ims p}tysi"ians; All dispatch bv'.otpui"t, ^"d *ould be evaluatedeach ;;";;;d;"rrv""a supervisor' l0 Patient destination tii-pt'vti.lt" ;i'i?;;;; facility as determinedby the onclosest'appropriate the ;;"1J6"

iiffifi;i;y;i;i;;.

that on tle as.sumption i'ti" pt," wasbased

oJ EMS as to the the Medical Director *oiriJ advise the Chief that should patient care be and a.ii*ted, ""t.'t.inl "i a"rri,v risk, the"city would seekan immediate iniuncttonto l.i..ii'"J", io work Ambulances during the strike i;#';;;;;''ik*t1;"k asslsteo p"rl"a *at. manned by. 24 non-union EMS supervisors' amhv 60 lav suDervrsorstrom other city departments' These during the rvice se eis of ho"tt ,r.tit /r+ tirr"t# "t.'""a"a *i,r' the normal l,l14 unit hours' In addition' ;;ik;, ;;;;;..J pei'o"'el provided a citv-wide p.ll*-rtJfiie i;:il":it;;i""a Commuiirrt ,..porrr" service to life-threatening emergencies' through marntained was departments emergency with nication rese-rved usuallvnetwork machinc ;i;pho.,.'f".s'l-ili il;-;t;;i had had on;;; P;;;t Center use. Thirtv EMS phvsicians who continued line medic command reiponsibilrtics'in thc' system all 9ll calls triagrngto addition in duties i^ft"rt'TtaO-i..ponse from a recogiiioio"of, for tire triage of all 9ll calls were,adopted into red (lifenized urban EMS system.All calls were classi{ied yellow (urgent)and green(non-urgent)blptltt:]i:i ;;;;-c), at the nosprtar answering-iheEMS 911 line Turn-aroundttme number of sufficient of a m"intenance the in lrou.J ,o'U..rucial of ten average an to reduced was ittis il:**i;;t"r""i... personneland the -ltta". with the cooperationof supervisory amdepartmenfsof the city A strategvof anticipatorv ;;;;;;;.y rereduce to order in implemented was Urrfrri". deployme.rt 'fhis strategically to move to units ALS requi,ed rp""."im6t. and currcnt a'"iig""t.a positions basedon past patternsof service in not having "rilio"a. Thi, .yrt.- ,t"t,,, -"n^gtment resulted calls awaiting available rinits for,a t"lPo11t--9!f:::; ;; q;;; revlewor tion of careby on-sceneEMS physiciansand contrnutng no apparittp tn.Jt #a .-.rg..t.y depaitment recordsrevealed strike ent comDromlr., ,.t ..t.-qt,lity oi care delivered' An EMS provideda and dBase-l1l+' using "t.j,i.d t"pldrv il;"I#'il and guidedtacsensitivereal-time-o.ri,o, of EMs-performance Analvsisof EMS data indicatedthe avcragecall ;i;;j';";r.;i;"s. re;v;,.- fot the 79 hours of the strike to be 505 i;;; fJ,'il period included strike The hours uv.t,1i4unit ti"ii.lJ rp.;;;;, utilization .157resoonsesstatrcoby 714 unit hours Unit hour efficiencv)were calculatedand re;;;";;';;;"*-tllv;ttstrike ro;7.-i".t."t"iievel of svstem performancefor the ;.;ft'; with no sacrifice in accomphshed was ffiiJi i;s';;'s-ofinit strikel This averaqeresponse.,*.,-1ez min presirikevs 6 6 min contingencvplanning-foran urban EMS "xiri"ol.;;;...i.}"t .o..,ia t.tut "t i ptotoivp" of this form of disaster ;;;k"t;d;; strategy. management

to all physiciansat the Na1io1-qlAssociation "M"dical vey was distributed Service Phvsicians (N4PY-s-P) meetins. in ;;'E;;;**;t .rh. s,rru"v was also mailed to all PMD's in Michi;r;;;;;it8;. surveved45 PMD's respondedof the responPMD's the ;;;:ll1 d e n t s T 5 % a r e c o m p e n s a t e d f o r t h e i r t i m e s p e n t a s P M had D,s,ToT'. and 15% had malpracti". .ou.r"g" ioi their PMD duties' Most i" i"gtt aition as a result of their position' il;"';;;i;;d

reili;;;;i;'l"ii""r'"ppoi..,

with office ssu were,provided

The average !;r;;, 65%hada system-wid"d"t" retrievalsystem'PMD'sfrom hours/week 15 is duties their ;i;;!;; o"iioi-i"g i0,000ALS runsper vearweremorerre;'"*;;;il;;;;;;;';#. uv ' gout"''n'ntai so"rce\6e"rovs 22"/o' :l'fiti;;;il;.tt"i.a lt00%vs 74%' 7' :.ijii i; ;it;;;;ce'and"equipment pro'vided P <-'005} 33%' vs svstem data {81% ; ..001ffiJ;-.."irri""a hours duties their. {22'4 periorming week per andspentmoretime than 10'000 il;:i h;J;;;'; ..00;i PMD'srrom areaswith less a hospital by ALS runs/year*".. -o,. ii"quttttly compensated in theperdifference n-o < Thttt'*as 03).

P 15%, vs ,o"i". iOl'i'.

The medi< 83) P l5%, vs iit:onltSU i"g.f .""i"-.'l"t.ft"J1" to requlrea .rt aii..tion of a prehospitaicaresystem..appears

il;r'';;;f i:,h:::,itiT;jfi i:'"r:**:,x',;i'l;,il1X,* most communltresrecer

Stress in Urban EMS / Diminishing -RC 105 NALyle'RBBass deid-onnel PE Pepe Morecock Department

Medicine; bJo.r.i."nLor Medicine,BaylorCollegeoj of Houston PsychologyUnrversity of-EOucationar medical services It is generallyacceptedthat urban emergency

:','Jr::':i.i:l':'; filjfi*iliit?Ts"l;n",lli'*,'mJ;1"'1".'"".ffi undertook thererore we it' i'a"" ;o ;; ;,;;;; ;;;;; ;;';fi ilii;,';,;il;f

(PMR) relaxation tr,. "rl."tt oi piog'"ttiutmuscle a small

group tti.st r'"tt"otdiscussions{GSFD}in ;;il;;;;a iMs p"tto"nel our purpose was to formallv #;i;;;il;fi tt",.'iir'oit-term) and triit llong-term)'indica;;;5;;"-;.;h,ii" or GSFD would alter tors of strcss ".ra to tttlay-*hether PMR c i t h e r o f t h e s e s h o r t - t c r m o r l o n g - t e r m a n x i e t y i n d i c a t o r sarinthis oi medical care pioviders' TWelve-paramedics' ili;;"";;; Houston oJ i;;- p.''o"n'l rosters of the citv ;ii;:;'lu";;i;;i ot rlnls'oiuision, were tested Ior indicators ;ililp;;,;.* sessions' "nd after completion of {our two-hour-long ;;;;JbJf;;.

(STAI)' a standardized ;h;S;te-Trait et"ittv i""t"torv ;-generalanxietv"The long-term and "g'o"ps' titott-tttt ;;;i";;;i"il

il;ffi:il:

1O4 Administration Su-p-portfor ProiectfiJarcai Oirectors: A Profil-e F swor/ williamBeaumont

*.'""J*ii!a-into t*o

r' P.Yhol Group

both PMR and PMR alone was useo, and Group II, in whom that' on initial STAI demonstratejl rt.'tttJts .,r.a.

Cib-;;;; 74th percentileof nortesting, the 12 parameaitt i'"tta at the lor,.reitstressieveland the having mal adults (with first d;;;;;i; 'lc,A;-;;iici-';.itin witiLt there were no significant differences s c o r e s o b s e r v e d b e t w e e n G , o . , p ' I a n d - I l , - t h e r e wsession e r e s i gfor nificant "i1itt end of the fourth "t.tt i"aii'tit il;;I"i'' terms of state)anxtety both groups in terms of trait (but not in to particiIn the nine paramedicswho were available -,tti""gnout indicators. mean trart anxiety scores study' entire the "r,. +l-2 atire-test to 36 1 at post-test{P !nr"g.i ttg;tri"*,ry-rt": .05).Recognirtngtne iimitationi of this small pilot study',we levth"t"t"b"tt EMS personnel do have high stress "iii;;;i;J;J appears to the gtttttal population' and that it ;il^;i,h ;6;cf for decreasingtratt itrr, prtan "io.," -^y bJa useful modality be'further iechniques PMR. that t.";;;t;J anxiety levels. we Ptt"-t-d:t^:y: evaluatedin this specialiitJ gto"p of medical :gt impact on lon that EMS peisonnel stressand its ;i;;;;;;;;.nd in turn, remedialfacand, ciosely .rr-ir.r.d-rr{or. b. oerformance iors be sought.

Hospital,RoYalOak, Michigan Prehosoitaladvancedlifesupport{ALS)providedbynonphysi^Gities, Survey of EllS Svs-tems.in Maior Cooper 106 phystctal / cians is providedunder the-supervistonot a T::]::: M r<o.nigtbutgl R Lee. L Stein' MA E Sloan, Hart, R director to as the proiecirnedical EmergencyMedicine ffi:,;;1;;;;il-;;i";;;d Hospitals Affilia6d ot-tttinois U"it"ititv pMo, the a:, well as ihe PMD' as of the time required. ,tt. time.required. ipitdi'il;.r.

Finrji il ".r.t. ,h.

Y:]1'::L: Chicago ResidencY, a surrisk involved' thi medico-legal

i..ft"i."f supportgivenand

46

rf ti

1J

The emergency medical services (EMS) systems in malor cities across the United States have great variability in both structure and function. A database of this information ls not available. A 24-question survey with 162 variables was designed to obtain baseline information. Questions were devised in the general areas of development, present daily management of the syitem, access and transportation methods within the system, protocols utilized, quality assurance and paramedic discipline. A preliminary mailing with telephone follow-up was used to survey 39 systems s e l e c t e da s t h e l a r g e s t p o p u l a t i o n c e n t e r s b y r e c e n t c e n s u s s t a t i s tics. Preliminary rcsults from 23 respondentsindicate that initial system development ranges from 1953 to 1983 with the present managr)ment gcnerally reflectivc of the originating body. Seventyeight percent of the systems rely on a universal access number, i.e.9ll, while thc rest rely on police, fire, and/or dircct ambulance tclephonc numbers. Air transportation is now incorporated in 82% oI systcms. Forty-three pcrcent of the systems utilize a two-tier system of basic life support (BLS)with advanced life support {ALS) backup as needed. Standing mcdical orders (SMOs)are dcscribed as mandatory by 56% whilc the rcmainder felt they were guidelines. Although 69% rcspondcd that nationally standardized SMOs werc unnecessarv 8(r7o incorooratc the American Heart Association Advanced Cardiac Lifc Support {ACLS) protocols into their system. Sixty perccnt rransporr patients to thc hospital of choice w\th 26% transportins to ahe n c a r c s rh o s p i r a l . O n l y 5 2 ? , a l l o w E M T s t o t . c " i - " n t i l l y irnpaired paticnts without or against conscnt. Althoueh 82y, havc "dead ,,du defined on arrival" critcria, only 57% rccog.rirc nor rcsuscitatc" orders. Twenty-onc pcrcent recognize living wills.

Thr. projcct mcdical dircctor (PMD) has dircct rcsponsibility for q u a l i t y a s s u r a n c c i n 6 5 u 1 ,o f s y s t c m s w h i l c o t h e r s u s c a n E M S committec, fire department official, or othcr mcchanism. Mcdical suspcnsion of personncl fell to the PMD in 6(),1,. Decertification or rcvocation of license was handlcd by a statc rcprcscntativc in 60')r, Lach EMS systcm has dcvcloped diffcrcntly, pcrhaps duc to financial restraints, regulatory influcnces, or a partlcula; originating body.Data obtaincd from studies such as this may contributc not only to the dcvclopmcnt of common standards but to thc incorporation of ncw ideas within cxisting systems.

1O7 Guidelines for Devetopmentof EMS Reporting Forms: Nationwide Survey SMJoyce, E C r i s s / U n i v e r s i t yo f U t a h C o l l e g e o f N / e d i c i n e , S e c t i o n o f E m e r g e n c y M e d i c i n e , S a l t L a k e C i t v ; U n i v e r s i t vo l A r i z o n a C o l l e g e o f l v l e d i c i n e ,S e c t i o n o f E m e r g e n c y M e d r c r n e , T u c s o n

t t

J

Thc Emcrgency Medical Services Systcms Act of l9Z3 cstablishcd a Minimum Data Set (MDS) of 20 elcments to bc reportcd for cach cncounter by an EMS unit. Data elements w.-ri categorized as identification, sociodemographic, chronological, or treatment process descriptions. Since that time, however, regronal data collection and analysis capabilities have developed along widely divergent lines and at variablc rates. As a result, comparison of EMS data from region to region or state to state is virtually impossible. We performed a survey of 22 states known to be using a uniform EMS reporting form on a statewide basis as of 1983. The purpose of the survey was three{old: to summanze EMS data elements currently being collected on a statewide basis, to analyze changes occurring from the original MDS of 1973, and to suggest a more complete list of desirable uni{orm data elements based upon survey results and current EMS research. Fourteen of 22 i64%) states responded, providing examples of current forms, methods of instruction in their use,.and reports generated from data collected. Frequencv disttibutions of data elements from each form were .o-p"r.d to the original MDS. All of the MDS elements are present on over 90% of the forms. MDS eiements most frequentiy omitted include dav of week, time en routc ro scene,CPR and defibrillation information, and most notably, run outcome. Information not included in the MDS but emerging as essential to EMS evaluation and research includes: various trauma scores, times from cardiac arrest to by-

47

standcr CPR, BLS, and ACLS; effrcacy of defibrillation/cardioversion; short term clinical outcorne ; and patient admission number for long-term outcome tracking. Also important are consent for or refusal of care, medical control sourcc, and drug/equipment use documentation. We present a list of 48 data elements which wc consider essentlal to EMS reports. Methodology for data entry and microcomputer processing of this information arc discussed.

We offer this list of data elemcnts as a guideline for states, EMS regions, or other agcncies seeking to incorporate uniform and comprehensive information into their EMS data-gathering systems.

l OB Development of an Opticaly Scanned EMS Reporting Form and Database for Statewide Use SM Joyce, D Witzke, D Brown, E Criss, KJ McGuire / U n i v e r s i t yo f U t a h C o l l e g e o f M e d i c i n e , S e c t i o n o f E m e r g e n c y M e d i c i n e , U n i v e r s i t yo f A r i z o n a C o l l e g e o f M e d i c i n e , O f f i c e o f Medical Education and Section of Emergency Medicine; EMS C o o r d i n a t i n g C o u n c i l o f S o u t h e a s t e r nA r i z o n a , T u c s o n Emergcncy Mcdical ServicesIEMS) rcscarch is an important grncrglng field in emcrgency mcdicinc, but is hindered by the lack of uniformity of types of data gathcred as wcll as proccssing methodology. Wc devclopcd and field-testcd an EMS rcportini form for usc by all elements of the EMS systcm on a statewida basis, using automated optical scanning and microcomputer proccssing. Based on a survey of 22 statcs using statcwide EMS reporting forms, a list of 4x csscntial clemcnis for EMS reporting was devclopcd. This list contains all of thc clemcnts originally d c s c r i b c d i r - rt h c M i n i m u m D a t a S e t r e q u i r c d b y t h e E m e r g e n c y Medical Scrvices Systcms Act of 1973. New additions includc: mcchanism of injury, trauma scoring systcms, CpR data, and c l i n i c a l o u t c o m c . T h c s e c l c m c n t s w c r e i n c o r p o r a t c d i n t o a 1 2 , ,x 17" form with csscntial data containcd on an optrcally-scannable d r : t a c h a b l ep o r t i o r r . A l t c r m r n i m a l t r a i n i n g , 4 , 3 x 0 r c p o r t s w c r c c o m p l c t e d b y E M T ' s , I n t c r m c d i a t c E M T ' s , P a r a m c d i c s ,a n d F l i g h t Nurscs ovcr a 3 mortth study period. An initial form rejection ratc oI l7%' was rcduccd to (5(2, by thc cnd of thc studv without additional training. Computcr analysis of thc data was performed u s i n g t h c S t a t i s t i c a l P a c k a g c f o r t h e S o c i a l S c i c n c e s ( S p S S )p r o gram. Rcports includc basic data such as distribution of number of runs and incidcnt type by EMS unit, company, gcographicarea, date and timc, ctc. In addition, morc complcx analysis involving crosstabulation of scvcral data sets was casily performcd. Examplcs includc: short-tcrm clinrcal outcomL. for iardiac arrest victims according to time clapsed{rom arrest to CpR, type of BLS or A L S c a r c p r o v i d c d , o r s u c c c s so f d c f i b r i l l a t i o n ; o r s h o r t - t e r m o u t comc for trauma victims according to Tiauma Score,rnjury type, or care provtdcd. Rcports also include information required bv statc and local governmcnts, EMS rcgrllalitr* agcncics, hospitali and trauma ccntcrs, and individual providers. We conclude that an optically-scanncd rcporting form containing dctarled clinical inlormation can be effcctively utilized by all levels of EMS oers o n n e l w r t h m i n i m a l t r a r n i n g . T h c d a t a g e n c r a t c dc a n b c a n a lyzed by existing microcomputcr and software systems to provide i n f o r m a t i o n o f u s e t o E M S r e s c a r c h c r sa n d a p e n c i c s . b a s c d u o o n n a t i u n a ll y e s t a b l i s h e t ls t a n d a r d s .

109 Gephalic Vein Gutdown at the Wrist: Gomparison to the Standard Saphenous Ankle Cutdown D A T a l a n ,R R S i m o n , J R H o t f m a n / D e p a r t m e n t o f Medicine, Dlvision of Emergency Medicine, Ollve View and UCLA M e d i c a l C e n t e r s , U C L A S c h o o l o f l v l e d i c i n e ,L o s A n g e i e s Tianscutancous isolation or cutdown of the cephalic vein at t h e w r i s t ( C V - W ) h a s i n f r e q u e n t l y b e e n s u g g e s t e da s a c u t d o w n srte and the technique has not been described in detail or compared to other standard cutdown procedures. We first used fresh cadavers to develop a preferred technique and then conducted a prospectivc cross-over cadaver study comparing the performance by medical students of the CV-W cutdown to the standard cut-

down of the saphenousvein at the ankle {SV-A|.All studentshad a prevrous course in anatomy but had never performed a cut_ down. Before testing they were given written material and a I0_ minute lecture describingboth approaches.A total of 17 students performed 34_cutdowns; 9 {irst attempted the CV-g followed by the SV-A cutdown, while 8 used the reverseorder. The mean tim; (- SD) to isolation of the CV-W was 85 + Z0 seconds,while Ior the SV-A it was 70 + 89 seconds{p = NS). There was I failure {inability to isolate the vein within 5 minutes) in 1Z attempts at the CV-W and 2 failures in 17 attempts at the SV-A (p :'NS).

There were no. complications {nerve, artery, or tendon iniury) with eith-e-rre.!nqr!,The mean externalvein diameter(t'SDi of the CV-W and the SV-A were 3.2 + 1.0mm and 3.6 * 0.7 mm. respectively{P = NS}. We conclude that relatively inexperienced providerscan learn to perform CV-W cutdowns on fresh cavaders with similar speed and successcompared to that for SV-A cutdowns. This technique may provide a usefui alternative to the SV-A cutdown in certain clinical situations.

I i O Emergency Intraosseous tnfusions In Ghildren: A Practical ltlethod Of Teaching Prehospital Personnel Gp Watter, MRCtark/ Slarrow

HospitalEmergencyMedicineResidency, MichiganState Unrversity Affiliated,Lansing Obtaining intravenousaccessin critically ill children is a frustrating experience for emergency personnel. Intraosseousinfusion (IO) is a quick, reliable, and proven technique.Our teaching techniq.ue provides a practical method of insiruction for prel hospital, as well as ED personnel and may be used to t.rch IO iniusion.to anyone_qualifiedto use this life-savingtechnique.

The method uses chicken thighs, l8-gauge spinal ieedles, and methylene blue-dyed saline. The tech;ique ii initiallv demonstrated with an exposed.chicken thigh bone (supermarketgrade) ano tne IU-gsprnalneedle-Atter penetrationof the marrow space, the dyed saline is instilled through the needleand the dye is visualized emanating from the nutrient vesselsat either end o{ the bone. The students are then instructed to try the technique but with the chicken skin intact. This alternative technique ior valcular accessis easily demonstratedand learned. It has been teceived with great enthusiasm by paramedicsand EMTIs in our system.

_111 Evaluation of Venous Distension Device: Phase ll: Cannulation of l{onEmergency Patients JT Amsterdam, JRHedges, E Weinshenker, DJ

Schwytzer/ Departmentof EmergencyMedicine,Northeastern Ohio Universities Collegeof Medicine/Western ReserveCare System,Youngstown, Ohio; Departmentof EmergencyMedicine, Universityof CincinnatiMedicalCenter;procterand GambleCo, WintonHill TechnicalCenter,Cincinnati A device designed to augment venous filling by applying a vacuum to the upper extremity during tourniquet application was evaluatedin patients <65 yearsof ageconsidired to have difficult venous accessand in need of non-emergencyvenipuncture or intravenous cannulation. Patients taking medications which af{ectedplatelet activity or who had venipuncture attemDtswithin one week in the same extremity were excluded. A total of 23 patients iage : 38 + 15 years,weight 166 + 49 lbs) were studied.

The majority were obese l|7%l aid/or did not have prominent veins even when a standardtourniquet cuff was placed (65%).No patients had shock or hypotension. Use of the devrce was successful in 913% ln = 2l) of the patients with a mean rime ro venipuncture a{ter device removal of 35 + 30 sec. In the two casesin which the device was unsuccessful,both patients were IV drug users and required either external jugular or central venotrs line placement. Sevenpatients had unsuicessful attempts at venipuncture or IV cannulation by experiencedemergencynurses on the oppositeextremity immediately prior to use of the device.

In these 7 patients, subsequentuse oi the device was 100% suc-

48

cessful (P : -0003, Fisher,s exact test, assuming all attempts using standardtechniqueswould have been unsuciessful).Wlien conventional tourniquets were unsuccessful for veniDuncture. the use of the venous distensiondevice may obviate the needfoi more invasive forms of venous access.

112 A Gomparison of Foul Techniques to Estabfish lntraosseous Inlusion lvl'vliagner, I McCabe / Department of Emergency Medicine, Wright StateUniversity

Schoolof Medicine,Dayton,Ohio The technique of intraosseousinfusion providesan alternative method for fluid and drug administratioi in infants and small children when other accesssites are unavailable. previous description of the technique has utilized a number of differentneedIes, including bone marrow needles, spinal needles,metal hypodermic needlesand a specializedneedledesignedfor rntraosseous infusion. This study was designedto determineif the successrate in establishing intraosseous infusion varied with four different needle types - standard hypodermic, spinal, bone marrow and Tirrkel intraosseousinfusion needle.The study was also designed to determine the speed with which intraosseous infusion c-ould be established.TWenty-foursecond year residentsfrom various specialties,without prior training or experiencein the technique of intraosseousinfusion participatedin the study.Eachwas given a one pageoutline describingthe technique.Each participant attempted to establishan intraosseousinfusion using four dlifferent needlesin random order in a randomly assignedlimb of an anesthetized piglet. Successwas determined by ihe ability to aspirate bone marrow and infuse fluid within two minutes of the start of the attempt. Successrate with each needle and time to success was determined.The overall successrate was 67.7%. Successrate varied betweenneedles:hypodermic 54%, spinal 7So/o,bonemarrow 75D/o,and Tirrkei 67"/". Howeve4 utilizing Cochrans e-test, there was no statistical differencein successr;te betweenneedle types (P : .25).Eight residentswere success{ulwith all four needles. In these, the time to establisha successfulinfusion varied.

Averagetime was 26.5 secondsfor hypodermic, 22.5 secondsfor spinal, 11 secondsfor bone marrow and 55.5 secondsfor Tirrkel.

Using Freedman two way analysis, these times were significantly different (P = 0.013).We conclude that the techniqui of intraosseousinfusion is easily learned by those without prior experience. A high rate of successcan be obtained even without-soecialized or p.rolongedtraining. Any of a number of readily available needles are appropriate. The bone marrow needle,however may be preferred due to the speed with which intraosseous infusion can be successfullyaccomplished.

Effect of Gtothing and Measurement I 13 Technique on Reliabilityof Blood pressure Measurements JRKrohmer, JB Mcoabe/ Department of

EmergencyMedicine,WrightStateUniversity Schoolof Medicine, Dayton,Ohio The accuracy of-measured blood pressure in the prehospital setting-is affected by clothing worn by patients and equipment available. Cold weather oiten prohibits accurateblood-piessure asse_ssment using standard skin tecbniques.The purposeof this study was to determine if reliable blood pressuremeasuremenrs could be obtained through clothing using automatic and manual methods ot blood pressuremeasurement.Thirty one normotensive adult volunteerswere studied. Multiple blood pressuredeterminations were obtained through several thicknesses of clothins using an automatic blood pressure device (NIBp), auscultation with two different stethoscopes,dnd palpation. The blood pressure.cuf{ used was appropriate size for the extremit}, including clothing. Each subiect served as his own control with contro'i valles simultaneo,uslyobtained using an automatic device applied to the control arm. Statistical anaiysiswas performedusing analysis o{ variance and t test. Clinical significancewas arbitrarily defined as a statistically significant differencein excess

v

of 5 mm Hg. Measurement by palpation significantly underesti_ mated systolic blood pressure., regardlesso{ thickness'of clothing.

Measu,rement.ofsys.tolicblood pressure on skin showed n"o clinrcally significant differenceusing either auscultation method.

There was no clinically significanidif{erence in systolic or di_ astohc tl.loodpressureby auscultation or NIBp through a shirt.

Through a light.coat, there were no clinically signiTicant di{_ terencesin systolic or diastolic biood pressure.Through a heavy coat/ systolic blood pressurewas ovei estimated wit[ NISI!,I t7 mm Hg),but accuratelyobtained by auscultation.Diastoiic biood pressurewas over estimated by auscuitation with one of the two stethoscopes {8.3mm Hg), but accuratelyobtainedwith the other auscultationmethod and NIBP Auscuitation of blood pr.rr.ri. through varying thicknessesof clothing can provide,"firUf" ,yr_ tolic blood pressuremeasurements.biastolic blood pressure measurementsmay be over estimared if taken through heavy clothing_byauscultation. palpation consistently under Jstimates systolic blood pressure.When faced with adveiseenvrronmental conditions,prehospitalcare person-nelcan reliably auscultatesystolic blood pressure through-clothing when ,rrirrg "r, appropri_ ately sized blood pressurecuff. This iray provide a truer assessment of the patientb blood pressurethan palpation.

1_14 Accuracy of Blood pressure Measurements Made Aboard Helicopters RB Low,

D Martin/ Universrty of OklahomaHealthScjencbsCenter, of EmergencyMedicine,Departmentof Surgery; .S.ecligl MediFlight Oklahoma,OklahomaTeachingHospitals,Oklahoma City Unstable_patientswill benefit from aggressivetherapy to con_ trol their blood pressureonly if this prJ."..rr" can be deiermined wlth accuracy.We compared the accuracyof blood pressuremea_ surementstaken aboardhelicopters by palpation, with a doppler device,and with an oscillimetiic device. S'eventeencriticaliy ill p a t i e n r sw h o r e q u i r e da n i n t r a - a r t e r i a l i n e h a d c o n c o m i t a n t Dloodpressuremeasurementstaken invasiveiy and with one or more of the noninvasive techniques.A total o{ 222 comparisons weremade.Error measurementsare reportedas mean * itandard deviation; a high standard deviation implies inaccuracy in indi_ 'lg vidual BP measurements.Mean palpation error was ! ZZ, mean doppler error was B * 17,mean oscillimetric systolic erioi + was 0 33, and mean oscillimetric mean blood pressuremea_ surement error was l0 + 15. A blood pressureundetectableby non-invasivemeanswas no guaranteeofa low arterial blood pres'_ sure:four patients with arterial pressuresfrom 45 to l3g torr had non-palpableb]9od qr999u1es; ihree patients had systolic pres_ suresbetween98 and 143 that were not detectablewith doppler deviceand two patients had systolic pressuresbetween Z0 and ll0 torr that were undetectableby the oscillimetric device. We concludethat someill patientscannothaveaccuratenoninvasive Dtoodpressuremeasurementstaken aboardhelicopterswith pre_ sent technology. | | 5 Use of Transthoracic'Electrical Bioimpedance in Assessing Thoracic

Fluid

Status in Emergency Depa;tmenf pllilnts CESaunders / Department of Surgery, Vanderbrlt Unrversrry

Schoolof Medicine,Nashville

Tiansthoracicelectrical bioimpedancelZl wasmeasuredin 26 se_ riously,ill emergencydepartmint (ED) patients in order to deter_ mlne rne usetu_lness ot this noninvasivemethod of assessingthoracicfluid {TF.}status among this group.patients were dividJd, on the baslsof clinical and radiographicinformation, into one of 3 groups:gr_oupA (11 patients),,with clinically normal TF status; group B. (12 patients), with elevated TF staius; and group C (d patients)/with decreasedTF status. The mean Z valuei meisured in eachgroup were: 26.5 o\-l T group A, 2l.g ohms in group B, and 37.4 ohms in group C {differences signi{icant "t p < .bS}.

49

Absolute ,Z valtes, however, overlapped to some degree limiting the specificity of this measure-eni-as a predictor 6f TF .t"t.rr] Us-ing cutoff Z value of 24.0 ohms would have predicted group B individuals with a sensitivity oI 92y", but a specificity 6f oify 79%. In ll patients, however, impedance measurement would have added information that confiimed diagnosticsuspicionsor suggestedthe diagnosis earlier than would have otherwise oc_ curred. In 5 patients, real-time changes in Z were potentially useful in guiding and monitoring the rEsults of therapeutic intei_ vention,_or changes in clinical condition. this study demonstrates that Z measurement and real-time monitoring can be a useful and noninvasive means o{ assessingTF statusln ED pa_ tients,.althoughwith only a moderatespeci{i"ity.It may be most heipful, however,in those patients whose TF siatus is'changing or unstable. Additional studies over a larger denominator of"paf tients would be useful.

A Gomparative Study of Intraosseous, I I6 Intravenous and Intraaflerial pH Ghanges Du;ing Hypoventilation in Dogs K Briciman, e Rega,

M Guinness/ The EmergencyMedicineResidencybfSt Vincent MedicalCenter/ The ToledoHospital,Toledo,Ohro Severalrecent studies have shown intraosseousinfusion as an effective route of fluid and drug administration. A question re_ mains of whether the marrow cavity supports an active hemo_ dynamic environment or primarily servesas a reservoirfor blood products thereby not accurately reflecting metabolic "h"r,g"s in the central circulation. In addiiion to beiig an effective route of vascularaccess,the medullary cavity may provide a sourceof blood for laboratory analysis when other.orri.r r.. unavailable.

Our study examinedthe effect of hypoventilation on tnrraosseous blood gasescompared to intraarierial and intravenous blood gases.Fourteendogs were subiectedto hypoventilation of two oreatnsper mrnute over twenty minutes. Blood gas sampleswere drawn from tibial intraosseous,femoral arterial,"andcentral venous sites srmultaneouslyat onset, three, six, ten and twenty min_ ure, time intervals. pH determinationsreflected a progressive acloosls trom all sample sites. An analysis of variance revealed that at each time interval there are no significant differencesof pH or pCO2 comparingthe intraosseous,iitravenous and intraar_ t91l"t u1tu19,,asexpected,PO2 values at each interval were signrtrcanrlydtfferentbetweenthe varioussamplesites.Thesedata demonstrate that blood within the medullaiy cavity closely refiects metabolic changesof the central circulation particuiarlv when examining pH and pCO2. This suggeststhat an active ciiculation through the bone m"i.ow p"rriii. despite a progressive acidosisand hypoxemia.

71.7 . Methemogtobinemia in Severety

Dehydrated Infants L pachter,S Torrey,J Greenspan, G Halligan/ St Chrrstophers Hospitalfor Chiidren;Departmentof reorarncs,rempteUniversitySchoolof Medicine,philadelphia The diagnosisand treatment of the severelydehydratedin{ant in the emergencydepartment (ED) may be complicatedby under_ lylng condltrons whtch otten require specific treatment. Methemoslobinemia(metHgb)is one oJ these conditions. Our interest rn thls problem was sparked by severaldehydratedinfants who required treatment for metHgb beforetheir overall clinical status improved. The study was designedto determine whether there are any clinical indicators _wtrichmay help the emergencyphysician.identi{y severely dehydrated infints wlrh ignifiiant metHgb. Infants < 3 months of age who were admitt6d to the hosp,italwith.the diagnosisof dehydrationwere prospectively enrolled. At the time of admrssion,the severity 6I ttte cfrlldt clinical condition was determinedusing the Acute Illness Obser_ vation Score {AIDS) developedat yale which uses six observational items _to quantitate the degreeof apparentillness. A ven_ ous sample for pH and % metHgb was ob,tainedin addition to standardlaboratory tesrs.An elevlted metHgb i f metHgb) was

defined As > 2o/o.Thirteen patients were enrolled in the study.

Three had J metHgb (mean 10.6%).The mean age of these infants was 4 weeks in comparisonto 6.5 weeks in the l0 normal patients. All of the patients with I metHgb were moderately or severelydehydratedl> 6'/.1 whereas only 3 oi the normal infants were this dehydrated.The mean AIDS of the group with f metHgb was higher than the normal group (22.6vs. l2), but the differencewas not statistically significant becauseof small sample size. None of the infants with f metHgb had cyanosis.Although the study population is small, we concludethat I metHgb in dehydratedinfants is primarily a problem of those w h o a r e s e v e r e l yd e h y d r a t e da n d i l l - a p p e a r i n g O . btaining a metHgb level in thesepatients might identify a seriouscondition requlrlngtreatment.

118 Gomparison of Intraosseous tnfusion in Large and Small Swine JM Schotfstail, WHSpivey, CM Lathers,K Jim, S Davidheiser / Departments of Emergency Medicineand Pharmacology, MedicalCollegeof Pennsylvania, Philadelphia Intraosseousinfusion has becomea popular alternativefor venous acccssin recent years,especiallywith regardto pediatric paticnts. Morc information is needed, however, regarding the appropriatesize and type of needle,what flow rates may be expectedand whether this method is appropriatefor initial volume resuscitation.This study examined flow rates {or different size animals and 18 and 13 gaugeneedles.Eight "large"swine (mean weight 14.4kg) and eight "small" swine {meanweight 5.8 kg) of random sex were used.The animals were anesthetizedwith ketamine 25 mg/kg IM and pentobarbital20 mg/kg I! intubatedand ventilatcdon room air. Eighteen-gauge needleswere insertedinto both tibias of four largeswine and four small swine. Thc same procedurewas repeatedwith a l3-gaugeneedleon the other eight swine. Flow ratcs (ml/min) were determinedby measuringthe changein weight of an IV bagafter one-minuteinfusionintervals.

This was done in triplicate for saline and autologousblood at pressurcsof 100cm H2O {gravity}and 300 mmHg pressure.Data were analyzed usrng a four-way ANOVA. The mcan + SD flow rate for salinc in largeswine with a l3-gaugeneedlewas 17.4 + 6.6 vs 5.7 + 2.8 for small swine. Under pressurethe flow increasedto 51.9 + 19.4vs 19.2 * 7.5 ior largeand small animals respectively.The mean * SD flow for blood-in large swrne usrng a l3-gaugcneedlewas 13.6 + 5.7 vs 3.7 + 2.9 in small swine.

Under pressurethe flow rates for biood was 45.9 + 17.3 and 14.4 + 6.0 for largeand small swine respectively.There was no significant differencein flow rate betweenlargeand small swine {P > 0.05)when an l8-gaugeneedlewas used.The maximum {low that could be obtainedwas 21.8 + 7.4 with 300 mmHg pressure.Of the four groups compared;large vs small swine and l8 vs l3gaugeneedle,the only group that was significantly different was the largeswine with a l3-gaugeneedle(P < 05).This groupwas significantly different from the others with saline or blood and with gravity or pressure.This study demonstratesthat the size of the needlein small bones does not play a significant role in volume infusion. In bones with a larger marrow cavity however,a large needle will significantly improve the rate of fluid infusion.

The flow rates achievedin this study suggestthat intraosseous infusion may be used for volume resuscitationin infants and children.

I 19 Effect of Splenectomy on Hemodynamic Performance in Fixed.Volume Canine Hemorrhagic Shock JW Hoekstra, SCDronen, JRHedges / Departmentof EmergencyMedicine,University of Cincinnati Studiesof canine hemorrhagicshock commonly use a splenectomized fixed-pressuremodel. Splenectomyis recommendedin this model to avoid vaiable degrees oI autotranslusion that reduce reliability of mortality estimates and blood volume measurements.The eifects of splenectomyon a non-lethal fixed-vol-

50

ume canine hemorrhagehave not been established.The purpose of this study was to investigate cardiovascularand biochemical effects of splenectomy in fixed-volume canine hemorrhagic shock. Nineteen beaglesof uniform size and weight were bled 5O% oI their estimated blood volumes over one hour and then left without therapeutic intervention for a 9O minute stabilization period. Arterial blood pressure(MAP), central venous pressure, pulmonary artery pressure,heart rate (HR), cardiacoutput, glucose,lactate, arterial and mixed venous blood gases,and hematocrit (HCT) were measuredat regular intervals.Cardiacindex {CI}, stroke volume, and oxygen saturation (02 SAT),delivery i02 DELJ and consumption (02 CON) were calculatedat these intervals. Resultsfrom l0 control animals were comDaredto those from 9 animals that had been splenectomizedtwo weeks prior to hemorrhage.During the hemorrhageperiod, there were no significant differencesobsetved between groups for HR, MAI ot 02 DEL. CI remained higher (P < .O25)and HCT lower 128.9+ 4.7 vs 39.8 + 4.51(P < .00I)in splenectomized animals.Immediately following hemorrhagethere were no significant differencesin the mean valuesfor HR, CI, MAB or serum lactate.02 DEL however, was significantly higher rn control animals {P < .05).Durrng stabilization MAB CI, and 02 DEL rose while HCT fell in both groups.There were no significant differencesbetween groupsin the rates of change of these parametersduring stabiiization. We concludethat the red cell massreleasedbv the canine spleenduring hemorrhageresultsin an increasedHCT and maintenanceof 02 DEL. Splenectomizedanimals maintained 02 DEL by increasing CI during hemorrhage.In the post-hemorrhagicstabilization period, trends in hemodynamic performanceof the two groups were similar, suggestingthat no further autotransfusionoccurred.

12O Blood Pressure Effects of Thyrotropin Releasing Hormone (TRHI and Epinephrine in Anaphylactic Shock RLMuelteman, JPPribbte, JA Salomonelll / TrumanMedicalCenter,KansasCity,Missouri The use of epinephrrne(EPI)in anaphylaxisis empericand may be associatedwith significant cardiactoxicity. Thyrotropin releasinghormone (TRH) has been demonstratedto be effectivein the treatment of anaphylacticshock in animal models. The purpose of this study was to compare the effect of a single dosi of TRH, EPI and normal saline (NS) on mean arterialpressure IMAP) and survival over a one hour period in an animal model of anaphylaxisutilizing a randomized,doubie-blindstudy design.

TWenty New Zealand white rabbits were sensitizedto horse serum. On each study day, animals were anesthetizedwith xyIazine IM, halothaneand nitrous oxide by inhalation. Right atrial and femoral artery catheters were placed. Anaphylaxis was induced, and two minutes post-anaphylaxistreatment was administered with TRH (0.5 mg/ml) 2.0 mg/kg {eight rabbitsJ,EPI (l: 100,000)0.005 mg/kg {eight rabbitsf or NS 4.0 mllkg {four rabbits) IV MAP was determined at baseline and at predetermined intervals. Differencesin MAP were detectedby analysisof variance. If a significant difference was detected,a Bonferronrtest was performed.Differencesin survival between treated(TRH, EPII and control lNSl animals were determinedwith the Fischerexact test. EPI resultedin an increasedMAP over NS and TRH at one minute post treatment {P < .001).TRH resultedin an increasedMAP over NS at two minutes (P < .017)and over EPI at four minutes post treatment (P < .0II). No differencesin MAP were detected after four minutes post treatment. There was no differencein survival between treated and control animals (d < 0.168).These data suggestthat although no differencein survival existed between treated and control animals, TRH had a slower but more sustainedef{ect on MAP than did EPI and NS. 121 Effects of Dichloroacetate Administration Duilng Eevere llemonhagic Shock SA Syverud,WG Barsan,PF Van Ligten,SC Dronen,B Timerding/ Departmentof EmergencyMedicrne,University ol CincinnatiCollegeof Medicine

During hemorrhagic shock, decreased perfusion and poor tissue oxygenation lead to increased lactate production. previous ani_ mal studies .have suggested that sodium dichloroacetate {DCA), an agent which decreases lactate production, can improve hemo'l d _ y n a m i c sa n d s u r v i v a l w h e n a d m i n i s , . r " a ' r i i . r ^ r * e r e hemor_ rhage. We used an unanesthetized porcine he-oirhagic ,ho"k model to assess the effect of DCA on survival tirne when admin_ durinS fatal hemorrhage. Immature female swrne 1_s131ea l14_20 K g Jw e r e s p l e n e c t o m i z e d a n d i n s t r u m e n t e d w i t h chronic in<lwellaorjic and,right atrial catheters one week prior to hemorlrlnl S a g e .u n . t h e d a y o l t h e e x p e r i m e n t , t h e u n a n e s t h e t i z e d animal,s aortic catheter was connect_ed a roller pu-p ,.rd :OO frlf.g .i .to heparin was administered IV All animals ;.r; ;h; bled at a rate o f 1 . 0 c c l k g / m i n u n t i l d e a _ t ho c c u r r e d {defineJ., ,p"., and MAp 20,mm Hg). Experimental animals - gl i...iri.a {N sodium di_ c n l o r o a c e r a t c .{ 2 5 m g / c c d i s t i l l e d w a t e r l 1 0 0 mg/kg IV bolus bc_ Slnnrng l5 mrnutes alter the start of hcmorrhagi followed by a J mg/kg/min constant IV infusion. Controi ";;il"I; (N = 8) re_ ceived an equal volume of normal saline. Arteriai'pr"ss.r.", h.rrt rate,,blood gases, serum lactate, ,.rd ,.ruglrr.5r. *.r. rn."_ sured at baseline and every l5 minutes aurl"g fr.;;.rh"ge. fhei" were.no significant differences in survival ,ifi-r",-ir.,^t" T"u.tr, oi blood, pressures between thc two g-"p, ti i"rl ]l-. i.,.1.o..,,1..,t s a m D l e sl .

Variable S u r v i v at il m e ( m i n ) M A P3 0 m i n ( m m H g ) Lactatebaseine L a c t a t e3 0 m l n Lactate60 min - M e a n( S D )

Controls*

DcA-

63 (2 8) 60 (3 7) 30 (e) 33 (e) 30(r2) 42 (2O) 1 4 8 ( 9 3 ) 1 8 8 ( 1 16 ) 4 4 0 ( 1 30 ) 4 3 . 3 ( 2 1B )

These results suggest that DCA does not dccreasc serum lactatc or improve survival time when admlnistered du.i.rg o.,gorng ,cvere hemorrhagic shock. Further study shoulcl U" aii".t",l ri'tt" an adiunctive treatment aftcr hemorrhage has :ll.:,:^"jt-::",as D e e nc o n t r o l l e d a n d t i s s u c p e r f u s i o n r c s t o r c d .

Beneficiat Effegr.s_ofa prosragtandin Er I?2 Infusion in Experimental Traumatic Siock

MALevitt, AM Lefer/ Departments of physiology and Surgery Medicine),ThomasJeffersonUniu"irityHospital, LEJ^"19,.1.y rnilaoetpnta

The effec.ts of pGEl werc studied in a standardized model of traumatic shock in rats. pcntobarbital ancsthetized rats wcre subjected to standardized drum trauma of 525 revoiutions in a No_ ble-Collip drum. These traumatized ,o,. *.r. cha.acterired by a survival time of 108 + 19 minutes, a fZ-fofJl"..easc in plasma D activity, and a 3-fold increase - pl";;, myocardial :l:!:f:racror activiry. pcEr {t.2 pglkg/min} signifi_ lc:al :n: :u: yi -r: m ! proved IMDFl survrvaltime during traumarii shock {19l = 29 .J9 minutcsl, drug vs vehicle, respectivt,iy {p < 0J}. In : :o, 1o9l r1r o n , a t , G L r s l g n i f i c a n t l y _ a - t t e n u a t c dp l a s m a M D F a c t i v i t y dur_ ing traumatic shock (5g + l0 vs 27 ,t i UZmt_), vehicle us'dr,.,g,

cathepsinD activity wasalsosig_ :::l:ll-:ll retard.ed,it2.l ]p i ;9?l ll,rry :t 1.8vs 1.70* 1.50U/mLf,vehicleis l]l]:r",,y orug/,respectrvely.(P pGEl

< .01). appearsto exert a membrane sraoulzlngettect decreasingplasma cathepsinD and attenuates M D F p r o d u c t i o n .I ' G E 1 r i a y t h e r e f o r " p . o u . to be a useful agentrn acute ischemicdisordersincluding traumat_ :i.^tjry,y,t. lc snock.

!23 !gni{-!rgatme_-nr 9f patienrs in Shock by Paramedic s With Medica rtv oiil6ill-'irLtoco rs p.eliUa,R Robinson, S Dannewitz 7 Department oi Lrn"rg"n"y

Medicineand North TraumaInstitutet',tortnllemorrafVeOicat Center;NorthAmbulanceService,MinneapolL Time to definitive care in the hospital has been identified as a

major determinant in the outcome of patients with traumatic been suggested that additional delays in receiving lll:l: ]l.h* approprrate care occur in prehospital systems using paramedici who initiate intravenous therapy. This study revrews a time course in the prehospital and uiban/suburban/rurat p"rr_.Ji. ambulance system with strong medical control.

Seventy con_ secutive ambulance runs of pitients presenting in traumatic shock were reviewed as ro the-time spent in the lrehospital setting. The number of successful IV staits *., ,".ord.d. ih. ,u.r_ agc response time for p_aramedicsto the scene was 6.27 minutes. . . v e r a g e t l m e s p e n t a t t h e s c e n e w a s 1 0 . 3 5m i n u t e s f o r blunt trau_ ma victims and 8.16 minutes for victims with penetrating trau_ ma. Average time from the scene to the hospital is g.6 minutes.

A total of 87.5 percent of patients arrived ai the hospital with IV access routes established. Medical protocols can be developed to achieve,rapid removal of victims from the scene and still accom_ p.lish advanced medical . p r o c e d u r e s .O u r p r o t o c o l s s p e c i f i e d t h a t lv rnerapy De lnttratcd during transport of patients instead of at_ temptlng IV's while at the scene. How these protocols were de_ velopcd and. implemented are discussed. In addition, su.h pio_ tocols may be use{ul in other shock situations.

The U_ritily9f phy_siotogicScoring for 714 Determining Severity ol i njury-- "i ui " i,", g",.

E.Cottington, D Jehle, R Townsend / Di-vrsroo nf Emergency Medicine, Allegheny General Hospital, pittsburgh, pennsylvania A pcrsrstent problem in the evolution of trauma systems is the . devclopment of criteria for trauma center transfer. frhysrotogic scoring systcms have been used as a mainstay in determining iire nced for such transfer. Unfortunately, these indiccs have'been found to lack rcasonablc sensitivity, allowing as many as rwo_ thirds of scriously injurcd paticnts tir remain unidentificd.

In this we^c_omparedderangcmcnts in individual physiologic signs ;,tudy ("siq1s")(SBP < 90, HR < 50 ot >- t40, RR < l0or > aO,'orCtS <, l2l with a,commonly rccommcnded scoring sysrcm cntcrron, Lnamplon lrauma Scorc{TSl < l2 Othcr TS cutoff lcvels wcre, also testcd. 1095 consecutivc trauma admissions were studied.

Major injury was defined by l n i l r y S e v e r i t y S c o r e ( l S S | ;3 3 % , 25"1,, and.Z0% the patients had isS of > is, > z0', and > zS', .oI rcsptctivcly, indicating significant injury. Rcsulis arc summarized ln thc table: tss > 15 s e n s [v t y s p e c i f i ct y p r o b a b i l i toy f i n l u r y t testis negative ISS - 20 sensIrvrty specrticity p r o b a b i l i toy f i n l u r y rl lest ts negattve

TSs:12

"Signs"

TS<14 41 1 L 5.2"k 5 6 4 x 5 2 % 6 0 3 ! 5 2 % 992 * 07 9 3 . 3: ! 1 . 8 95.1:! 1 6 2 25 * 2 7 186t 2.7 170x2.6

50 7 t 6.0% 983 * 09 14 5 1: 2.3

6 4 1 * 5 8 o / " 67 8 :t 5.6% 90.8 r, 2 0 9 19 * 1 9 '10 1 1 7+ 2 . 2 6 r 2.1

595:! 66% 97.4+ 1.1 9.5 r, 1.9

7 1 . 8* 6 1 . k 7 6 4 , t 5 . 7 % 893* 21 90.3r: 2.0 7 4 +1 8 6.2*16

tss > 25 sens|l|vtly s p e ci fi c i t y p r o b a bi t y o f i n t u r y rl test rs negative

All results reported with 957" confidenceintervals. Although very specrficfor seriousiniury TS < 12 is too insensrrrve as a descriminatorof major versusminor injury to be used fo, trialei has signifrcantlybetter sensitiviiy,with an "...pt"Fl. IS, -:-,,O rn spccificity. Derangementsin individual physiblogic ]"^:i.,,1"r vanablcsottersa more simple system with specificiiyand sJn_ sitivity comparableto TS < 14. Each of these systems fails to a large proportion of patients, makinj ia,tto.,"t tri"!. :9:::1fI crrterla necessary.

L2?- P-atielt Ourcome wilh prehosoital venrricutar Fibriilation: EmT:D "; iMi.i D wittiams,

BA Mclellan / Departmentof EmergencyServices,Emergency Medicine ResidencyProgram,Universityof Toronto,Ontario, Canada Rapid treatment {defibrillation) of prehospital ventricular fibrillation lVFl has been associatedwith imoroved patient survival. Patientsiound in rhythms other than VF are ielt to have little chance for survival irrespective of therapy. A significant number of patients in VF deteriorate to such rhythms after first and second defibrillation attempts by protocol. The impact of additional prehospitalALS procedureson the outcome of these patients was assessed.

A retrospectivereview of 129 patients in VF treatedby metro Toronto paramedics{rom December 1984to December 1985 was undertaken. Defibrillation ^t 2OOI was attempted using a standing protocol and was repeatedonce if unsuccessful.Initial defibrillation was successful in l5 l12%l patients and unsuccessfulin l14 (87%) with 61 147%ldeteriorati n g t o a s y s t o l e , e l e c t r o m e c h a n i c a ld i s s o c i a t i o n ( E M D f o r pulselessidioventricular rhythm {PIVR).Fifty-three (4I%f remained in VF and were given a second countershock which was successfulin 4 patients. Of the 16 successfuloutcomes from defibrillation by protocol 6 l37y.l were dischargedfrom the hospital. Of the ll3 187%lpatients in persistentVF {n = 52), asystole ln : 421,EMD (n = ll) and PIVR {n = 8) after defibrillation by protocol, implementation of further ALS treatment resultedin 26 (22%l successful outcomes of which 9 ,'34%l were dischareed Irom hospital. A correlation was noted between the respoise time and survivability. These data suggestthat while rapid defibrillation of VF is effective,patient survival may be further improved by the availability of further prehospital ALS treatment.

The implications for implementing EMT:defibrillation programs in cities with a tiered resDonseEMS svstem will be discussed.

Electrocardiographic Gharacteristics in 126 EMD IP Aufderheide, H Stueven, R Thakur, C Aprahamian, P Troiano,YR Zhu, D Fark,C Frodermann / MedicalCollegeof Wisconsin,Milwaukee Electromechanicaldissociation{EMD) is a frequent cardiacarrest rhythm, but has a poor responserate to therapy.Little has been written concerning the initial electrocardiographiccharacteristics or EKG changes which occur as the result of treatment in this patient population. The purpose of this retrospective study was to determine predictive indicators of successfulresuscitation in EMD by evaluating various electrocardiographic parameters. During 60 months ending December 31, 1985, there were 5ll non-poisoned,prehospital adult cardiac arrest patients where initial rhythm was EMD. All patients had their initial prehospital EKG rhythm strip evalgdted for rate, the presence of P waves, QT interval, and QRS in{erval. Four hundred and twelve (80.6%)were unsuccessfulresusiitations (Group A|. Ninety-nine 119.4%lpatients were successfulresuscitationsand admitted to an emergency department with a rhythm and palpable pulse.

Their prehospital initial rhythm analysis (Group B) and their rhythm analysis on presentation to the emergency department {Group C) are comparedto Group A in the table below.

GroupA N=412 Group B N=99 GroupC N = 9 9 'P < .01 .'P<.05

Rate 56*27

P Waves

75+45

37.4%

13.60/.

, 115+35

57.7%

OT 55 + .26

oRs .12+ .06

49 t .21 ._

.09 + ,04

4 0+ . 1 1

.09 + .04

Our data would suggestthat successfully resuscitatedpatients (Group B) presenting with EMD have significantly faster initial rates, higher incidence of P waves, and averageQRS and QT in-

52

tervals shorter than patients not respondingto therapy {GroupA).

Furthermore, success{ully resuscitated patients had signif icantly increasedheart rates, developednew onset of P waves, and shortened QT intervals in responseto treatment (Group C vs Group B).

Group B and C patients h4d averageinitial and final QRS complex lengths within normal limits. We believe these observed electrocardiographiccharacteristicsand changesin responseto treatment may have predictive value in evaluating patients with EMD.

127 Garotid Artery Gollapse During CPR The lmportance of Gardiac Versus Thoracic Pump Mechanisms Demonstrated With RBTaylor, HAWerman, Gineangiography CGBrown, T Luu, RL Hamlin/ Divisionof EmergencyMedicine,Ohio State University Collegeof Medicine;Departmentof Veterinary Physiologyand Pharmacology,Ohio State UniversityCollege of Veterinary Medicine,Columbus Large pressure gradients between the aorta and extrathoracic carotid artery during CPR systole in large canines suggest that the intrathoracic segmentof the carotid artery collapses.This occurs becausethe intrathoracic pressure surrounding a collapsible tube {intrathoracic carotid artery),is equal to or greaterthan upstream pressure{left ventricle {LV)pressure)during CPR systole.

This occurs in a large canine model of CPR becausethe pressure transmitted during CPR systole is equally transmitted to all intrathoracic structures. In this model, the cardiac ventricles are not compressed.duringCPR systole (thoracicpump mechanism).

Recent studies in thin chestedhumans undergoingCPR suggest that a positive aortic systolic - right atrial systolic gradientdoes exist during CPR systole (cardiacpump mechanism).This chest configuration more closely simulates the thoracic anatomy of swine. Thus, intrathoracic carotid artery collapsemay not occur in this model. The purpose of this study was to determine the extent to which cardiaccompression(cardiacpump mechanismf or global increasesin intrathoracic pressure (thoracic pump mechanism)contribute to carotid artery collapseduring CPR in a swine and canine model using cineangiography.ln the first part of the experiment swine (weighinggreater than 20 kg) and one canine (weight : 30 kg), were anesthetizedand instrumented for cineangiography.The animals were then fibrillated for ten minutes, after which CPR was begun with a pneumatic compressor.

Right atrial (RA) and aortic (AO) iniections were done during CPR prior to and after epinephrineiniection (0.2 mglkg). Cineangiography of the heart (to document cardiac deformation during CPR systole| and of the intrathoracic and extrathoraciccarotid artery were recorded. Esophageal,LV AO and RA pressureswere recorded. Right atrial dye iniection in the canine model demonstrated no deformation of the ventricles during CPR systolewith up to 120 lbs of compressionforce. During the aortic infection, the intrathoracic portion of the carotid artery was smaller than the extrathoracic portion, which reversed after epinephrine administration. In the swine model, there was significant compression of the ventricles during CPR systole (compressionforce 100 lb). The intrathoracic portion of the carotid artery was similar in size to the extrathoracic segment, prior to and after epinephrine administration. In the swine model, measurementsof intrathoracic pressure(esophageal) were less than LV pressureduring CPR systole. LV pressure was greater than RA pressure during CPR systole. These preliminary studies suggestthat chest configuration has a significant e{fect on the mechanism for blood flow during CPR. Keel-shapedchest configurations in canines may more accurately represent humans with COPD, while swine may more accuratelyrepresentnormal, thin-chestedhumans. Carotid artery collapse and its reversal with epinephrine occurs when the chest configuration prevents cardiac compression during CPR. These differencesin chest configuration and pressuredifferentials help to explain the role of carotid artery collapse in different animal models during CPR and their possible extrapolationto numans.

Prehospitat Bicarbonate Use in Gardiac 128 Arrest: A Three.Year Experience DRMartin, Tp

Atderheicle DW Olson, C Aprahamian, B Thompson, D Birchail, R T h a k u r ,P T r o i a n o ,C F r o d e r m a n n / M e d i c a l C o l l e g e o f W i s c o n s i n ,M i l w a u k e e The AHA no longer recommends the routine use of bicarbo_ nate in cardiac arrests. Reasons cited include the lack of documented effect on clinical outcome and potential adverse effects of metabolic alkalosis and hypernatremii. We reviewed 36 months experience with 625 non-trauma, adult, prehospital cardiac arrest patients to identify 267 successful resuJcitations who had emer_ gency department blood gases and electrolytes performed to determine what complications were associated witir the prehospital use of intravenous bicarb. Fifty-seven patients did not receive bi_ carb and had short resuscitation times (Group l). Two hundred ten patients did receive bicarb and had significantly longer resus_ c i t a t i o n t i m e s ( C r o u p 2 J _B o t h g r o u p s d e m o n s t r a t e d r o u l i n c e a r l y chest compression and hyperventilation as evidenced by no sig_ nificant difference in paramedic response time or rate of suJ_ cesstul rntubation. Despite the greatiy prolonged resuscitation times in Group 2, initial emergency departmeniblood gas results werc not significantly different.

Resuscitation Time

pH pOz pCOz HCO3Na+ Group1 No-Bicarb N = 57 8 .1 + 9 7 . 3 7 +t 4 2 0 6 + 1 5 03 4 . 0 + 1 i . 5 1 8 8 + 4 . 21 3 7 . i + 4 Group2 lV-Bicarb N = 2 1 0 1 8 . 0 + 1 0 - 7 3 5 + . 1 5 2 5 1+ 1 6 5 3 2 . 6 + 9 . 9 1 8 . 2 + 7 . 6 1 3 8 . 2 + 6 ,P < 0001 No patients in_Group I had hypernatremia (Na ts > 1.50),whereas only 4 (2%)-oI Group 2 were hypernatremic. Eight ll4%l oI ti; patients in G.roup I and 36 lI7%) oI the patientsin Group2 werc alkalotic with. pH greater than 7.q9 (p : NS). Sir (10.5% ,yalues ) ot Croup, I and )4 lll.4%l of Group 2 had a metabolic componcnt to the alkalosis as dc.fined by a positivc basc excess valuc (l : NS). We conclude, in a paramedii system with early chest com_ pression and hyperventilation, intravenous bicarbonate can main_ tain physiologic blood gases despite prolonged rcsuscrtatron times. F.urther, the incidence of hypernairemia ind systemic met_ abolic alkalosis in resuscitated patients receiving intravenous bi_ carbonate was not increased when compared iarith non-bicarb patients.

NonpharmacotogicatInterventions in 1?9 Therapyof Electromechanical Di$sociation

RK Thakur,HA Stueven,B Vanags,T Aufderheide,p Trojano, A Evers,C Frodermann / lvountSinaiMedicalCenter;Medical Collegeof Wisconsin,MilwaukeeCountyMedicalComplex Selectedinterventions have been recommendedfor the therapy of electromechanicaldissociation (EMD): p.ric^rdio".rrt.rii fluid chailenge,MAST trousersand thoracentesis.Few studies exist addtessingthe effectivenessof these interventions tn tMD. We retrospectivelyreviewed these interventions in a paramedic system.During a six year period, 5ll adult patients presentedin n o n t r a u m a t i cn, o n p o i s o n i n g c, a r d i o p u l m o n a r ya r i e s t . O f t h e entlregroup/228/5ll 144.6%)patients had 292 interventions.The patients having. interventions were not significantly different Irom thosenot having interuentions in mean age or sex ratio. In t h e i n t e r v e n t i o l g r o u p ( N = 2 2 8 ) ,p e r i c a r d i o c i n t e s r sw a s p e r _ |_o1m5^O^1n".5t'/.

-(N: l16), MAST trousers were applied to 47% (N = 108),fluid challengewas given to 26% (N : 60i and thoracen_ tesiswas performed in 3.5Y" (N:B). Twenty-six patients devel_ opeda pulse after an intervention in the foilowing distribution: MAST trousers(N:10), pericardiocentesis(N: Z),fluid challenge [N = 6l and thoracentesis{N - l). The time interval betweenrnter_ ventionand pulse developmentwas as follows: MAST 4+3 min-

utes, peticardiocentesis 3+4 minutes and fluid challenee 4+4 minutes. In the intervention group that attained a pulsi, 3g% were successfully resuscitated, defined as conveyance bf a patient with a.pulse and rhythm to an emergency depaitment. Save rate, deiined as a patient discharged alive-aftei hoipitalization, as Ojpt in this group. The overall success rate for inierventron Dattents was 13.6% l3I/228) whereas, for those not having an intervention it was 24.03"/" Kr8/289) (p:.O04). The overall iave rate for the rnterventlon patrents was 1.32%" 13/2291 whueas, Ior those not having an intervention it was 7.777" 122/Zg3)r(p: .0OZl. A large humber of patients have nonpharmacologicai interventions f6r EMD in the prehospital system. A small number of these oatients develop a pulse following an intervention, which may be temporally related. The lower success and save rates {or patients undergoing interventions may possibly be attributable to u.rde._ lying disease; however, deleterious effects from the interventions cannot be excluded based on our data.

Reversibitity of Gtinicat Death in Animal ! 30 -Outcome Models: ftre Uyttr of the S.MinutC

Limit P S a f a r / R e s u s c i t a t i o nR e s e a r c h C e n t e r ; D e p a r t m e n t o t Anesthesiology/CriticaC l are Medicine; presbyterian-University H o s p i t a l ; U n i v e r s i t yo f p i t t s b u r g h

The concept that resuscitation from primary normothermic cardiac. arrest (CA) >5' {w.ithout CpR} is inevitably followed by brain damage, has been challenged by the recoveiy of cerebrai neurons after I h ischemia (Hossmann), retinal neurons after 20, anoxia {Ames), and whole brain function after <l5,CA in does and patients. Methods: Our published and new unpublished ri_ sults have been re-examine_djoq thc 5, limit hypotheiis. Monkeys (n>100) were exposed to global head ischemii ol 14-20,bv neck do.gs (n>200) to CA of 2,-20, by ventiicular :9"T,'liql.r,-3Id nonllarron (vf)/ asphyxla or exsanguination. Restoration of spon_ taneous circulation (ROSC) was by tourniquet release, o, ipRALS_,or cardiopulmonary bypass (CpB). Intensive care was to 24 h - 7 d. Outcome evaluation was by overall performance categoization. (OPC I : normal; 2: mod. disabled; 3 : sev dis.; 4:"coma; : d e a t h ) ; 5 deficrt (ND) scoring and histopathologic .neurologic damage {HD) scoring. Results: Many factors in addition to 6A time influenced outcome. Global head ischemia in monkevs of up to l7' was inconsistently followed by OpC l. In dogs, VF_CA of up to 5'and CpR-ALS was consistenily followed Uyb'nC t, oi 15' by no ROSC or OpC 3-5; and oI 7.5,-i2.5, OpC r_4.VF-CA of 15' reversed by CPB was occasionally followed by OpC I, of 2O' by survival with OpC 3-4. Mirigation of post-CA disability was inconsistently achieved by reflow promotion, barbiturate, calcium entry blocker, free radical scavengers, or combination treat_ ments. Asphyxial CA was more injurious to the brain and less injurious to the heart, exsanguination CA seemed less injurious to both. Conclusions: The_5.CA limit concept is outdated. The CA time limit ino flow) for resuscitability bf h.art and brain seems to lie between 15' and 20, of normothermic VF_CA. Reper_ f u s i o n w i t h h y p e r t e n s i v e _h e m o d i l u t i o n a n d h e p a r i n i z a t i o n b y CPB enhances resuscitability. CA (which includis extracerebral anoxia) causes more encephalopathy than the same duration of isolated complete global brain ischemia.

131 ls Blood Glucose Level an Independent Predictor of Outcome in patients Resuscitated from Cardiac Arrest? W Musch, W Buytaert, W Vjncken,

L H u y g h e n s , D L a u w a e r t , L C o r n e / U n i v e r s r t yH o s p i t a l . F r e e U n i v e r s t t yB r u s s e l s , B e l g i u m : U n i v e r s i l y H o s p i t a l . S i a t e U n i v e r s r t y Gent, Belgium

Since it has been demonstrated that high blood glucose level {BCLJ predi_ctspoor neurological outcome in patientl initially re_ suscitated from cardiac arrest/ some authors caution againsi ad_ ministration of glucose-containing fluids after resuJcitation.

Howevel, the BGL in cardiac arrest patients is influenced by a number of factors, such as stress hoimones and exogenous epr_

nephrine. We therefore studied the BGL and the amount of epinephrine given in 184 patients (l16 men, 68 women; age 62+16.4lt,initially successfullyresuscitatedfrom cardiac arrest.

Two groups can be distinguished: group I, 95 patients dying within 14 days,and group II, 89 patients, surviving 14daysafter resuscitation. BGL was significantly higher in group I than in group II {345.9+142 mgldL, versus224.2+ 115.9mg/dl, P < 0.001f.The amount of epinephrineadministeredin group I was significantly higher than in group IIl2.2 + 1.8 mg versus 1.2 + 1.4 mg, P < 0.001).Furthermore, BGL seemed to be directly proportional to the amount of exogenousepinephrine.These data confirm that high BGL is associatedwith poor outcome in patients with cardiac arrest. Rather than being an independentpredictor of outcome high BGL may reflect the amount of epinephrinegiven during resuscitationfrom cardiac arrest and, hence, the intensity of the resuscitation efforts.

132 Effects of Sodium Dichloroacetate on ATP and Phosphocreatine in lschemic Rat BErainRyWDimlich, R Cammenga, PTVanLigten, BL Timerding,J Kaplan/ Departments of EmergencyMedicineand Anatomyand Cell Biology,University of CincinnatiCollegeof Medicine;Departmentol EmergencyMedicine,TempleUniversity, Philadelphia Cortical lactate in fasted or fed rats treated with sodium dichloroacetate(DCA) either prior to or shortly after 30 min of partial global ischemic {PGI), decreasedmore quickly than in untreated ischemic rats. High lactate (ie, low pH) lowers the NAD/NADH pool hence the production of ATP Since ATP is in equilibrium with phosphocreatine(PCr),the goal of presentstudy was to evaluate the effects of postischemic DCA treatment on ATP and PCr levels in fed rats. Fifteen male adult Wistar rats were anesthetized,preparedsurgically,and allowed to equilibrate for 30 min. Eight were made ischemic by a combined insult of bilateral carotid ligation and bleeding to a mean arterial pressure of 50 torr. After 30 min of ischemia, the clamps were removed and shed blood reinfused. Immediately lollowing reinfusion, DCA (25 mg/kg) was administered IV to 4 rrts and 4 received sterile water as a control. Sevenrats were preparedas sham-operated controls. Three receivedsterile water and 4, DCA as treatment control. After 30 min of reperfusion,each rat was sacri{iced by in situ freezing of the brain. Cortical samplesfrom coronal sectionsof frozen brain were analyzedby enzyme fluorometry for lactate,ATI and PCr and data evaluatedby ANOVA. DCA treatment of sham-operatedcontrols had no effect on any metabolite (Mean pM/g t SEM). Lactate was increased125.22t 5.47| and AIP decreased{1.41 t 0.31)in ischemic rats when comparedto controls (3.18 t 0.19 and 2.68 + O.2Orespective).DCA-treated * 2.90) than untreated rats 126.22 rats had lower lactates 1,14.23 ! 5.471andATP levels were lower but not significantly affected 12.45* 0.93 vs. 1.64 * 0.131.However,PCr in rats treated with DCA was significantly higher than in untreated ischemic rats 15.72x. 0.72 vs. 2.00 t 0.54).Since the ATP-PCr equilibrium is pH dependentand will shift to PCr in an alkaline environment, these results indirectly indicate that the decreasein cortical lactate also may induce an alkaline shift in pH in that tissue. Since many of the detrimental effectsof high lactate are thought to be mediatedby a decreasein pH, these data suggestthat DCA treatment is beneficial to cortical tissue after an ischemic eoisode.

133 Neurologic Progress and Outcome Evaluation fot Resuscitation Research with Ganine Models H Reich,M Angelos, P Safar,SW Stezoski, H Alexanderi ResuscitationResearchCenter;Departmentof Anesthesiology/Critical Care Medicine;Centerfor Emergency Medicine;Presbyterian-University Hospital;University of Pittsburgh To evaluate emergencyand long-term resuscitationpotentials after cardiacarrest {CA) or shock, animal models were developed and used in this laboratory in over 500 monkeys and dogs

54

Pre-insult variables, insult, emergency resuscitation 11975-871. and intensive care over 48h-7d were controlled. In order to obtain uniformity in progressand outcome evaluation, neurologic and overall performancedata had to be standardizedand simplified.

Our neurologic deficit (ND) scoring system {ND 100%=brain death, 0%:normall is time-consuming.Our simpler overall performance categorization{OPC I :normal, 2=moderate disability, 3:severe disability,4=coma, 5:death) has shown 100% interobserver reproducibility, but does not examine neurologic disability separately.Methods: We recently deviseda simple Canine Coma Scoring (CCS) system, modified from the Glasgow Coma Score,for neurologic evaluation of dogs. The CCS is divided as follows: 1| eye opening- best= 4, worst = l; 2) motor responsebest= 6, worst: l; 3) responseto voice- best:5, worst: 1. The maximal score is l5 (best);the minimal scoreis 3 {worst}.Using 20 dogs after prolongedventricular fibrillation CA and intensive care for 96 h, we recently comparedour new CCS with our complex ND scoring system and our simple OPC evaluation.Results: All evaluation indices were in excellent agreementwith each other. Data analysis revealeda Pearsoncorelation coefficient of 0.925when comparingOPC with NDS; of -0.967 when comparing OPC with CCS; and of -0.967 when comparing NDS with CCS. The CCS was more highly correlatedto OPC than was NDS correlatedto OPC, however,this differencewas not statistically significant. Conclusion: The new canine coma scoring system is a simple, reliable index for neurologic evaluation that can achievereproducibleendpoints which correlatewell with the simple OPC and the complex ND evaluation systems presently in use. If variou.sresuscitationresearchlaboratorieswere to acquire the same simple CCS and OPC evaluationmethods,consistency and interlaboratorycomparisonof results would be possible.

134 Neurologic Outcome aftet lo.Min Cardiac Arrest Plus lO.Min CPR and Resuscitation with Gardiopulmonary Bypass in Dogs M Angelos, H Reich, P Sa{ar,SW Stezoski.H Alexander/ Resuscitation Research Center;Departmentof Anesthesiology/Critical Care Medicine; ,for Center EmergencyMedicine;Presbyterian-University Hospital; University oJ Pittsburgh Four studies in this laboratory {1983-85fhave shown that after prolongedcardiacarrest {CA), cardiopulmonarybypass(CPB)improvescardiovascularresuscitabilityas comparedto CPR-ALS. Low survivor rates with CPR-ALSobviated evaluationof neurologic deficit {ND). The present study of ND after a clinically relevant insult yielded higher survivor rates.Methods: Lightly anesthetizeddogswere insulted with ventricular fibrillation (VFl CA of l0' {no flow}, followed by CPR-BLSto 15' (low flow}, and then standardized CPR-ALS for restoration of spontaneouscirculation (ROSC)startingat 15'.Defibrillationattlmpts startedat l7'{control group,nl3). In pairedsequence, dogso{ the treatment group {nl4) received CPR-ALS from 15' to 20' (simulating CPB cannulation time), and reperfusion with CPB starting at 20' oI CA. Defibrillation attempts Iollowed at 22'. CPB without thoracotomy (with hemodilution and heparinization,by veno-arterial pumping via membrane oxygenator)was continued for 2 h. Total ischemia time was deliberately longer in the CPB group. Both groupsreceivedstandardizedintensive carcto 96 h. Outcome was measuredas overall performancecategories{OPC)#1 {best}- #5 (worst);neurologic deficit (NDf scores0% (best)- 100% (worst); and canine coma score(CCSI 15 (best)- 3 {worst).Results:There was no significant differencebetweengroups in pre-CA, BLSand post-CA life support variables.In the CPR-ALScontrol group, ROSC attempts failed in 2 of 13. In the CPB group, all t4 had successfulROSC. Ten in each group followed protocol to 96h.

The CPB group {nlO) had a more severeinsult, i.e., mean total ischemia time was 4.6' longer than in the CPR-ALSgroup {nlO) lP < 0.001);and coronary perfusion pressure{CPP)during CPR, before CPB, was by chancelower (P 0.021.ND (14+19 after CPB vs 20 + 20 after CPRf; OPC (#l normal in 6 dogsafter CPBvs in 5

dogs after CPR); and CCS {13,r3 after CpB vs 12+3 after CpR), w e r e n o t , s t a t i s t r c a l l y _d i f f e r e n t b e t w e e n g r o u p s .

Conclusions: Arrer prolonged plus CpR, CpB (vs CpR_ALS) yields better ,CA carolac resuscltabllity and comparable neurologic outcomes de_ sprte longer rschemia times. Resuscitation with good outcome

pn! trZ]rspossibleevenafterCA (noffo*i of iO,if", CpR al;; flow)of I0'.

C?rdioputmonary- Bypass for protonged ! 39 Cardiac Arresi D Jehte,t-Bra'a'er I otvrsiontfErn"rgun.y Medicine, Allegheny pittsburoh General Hospital,

Prolonged external CpR is.associated withln extremely high mortality. Cardiopulmonary bypass iCpBl p;;;;;s onc to resrore clrcutatlon, even alter long periods of arrest.

In this study we

of Cpb'in improvi.g.ria i ;. resusci tabiti

ty ::ilT.::l. :1",:{{icacr ano survrvat tollowing prolongedcardiacarrest and CpR. Eight animalsunder ketamineThalotf,ane/nia.;;;;il; ;"esthesia were arrestedby transthoracicfibrillation. ett ""l."aL'*ere subjecte<l to four minutes of ventricula, fib.ifl"tio" ]ollow.d by five'minutes of standardCpR and.twenty minutes oi"Jr""..a life support without countershocks.During pilot studies cardiac compressionpressureswere chosen thi't'resulted i., -."., arterial pressuresi30-40 mm HgJ comparableto those found in huma.rs receivinggood CpR. Control animals -".. ,t "n i".,,scitated by a modified ACLS_protocol with counie.;h;;k;.'ii. ,t,.,ayg.nup wasstartedon femoro-femoralveno-arterialCpB. Countershocks and drugswere begun one minute after initiation of byprss,-r*J weanrngwas completed by four hours. All animals ,"."iu.a i* tensivemonitoring and rcspiratory support ini Z+-t nr,.r. Cardiac r e s u s c i t a b i l i t y , w aass s e s J e d U , yi o t u t i n g t h " , r r r - b . . . f , r . p i requircd to achicve retuin of sfo.rtrrreousci.icountershocks) culation.Those animals alivc at z+ f,."., ,"a".ui5rrt .rerrulogi"al deficit sco-ring prior to autopsy.Statistical ,"riy.ir-*r, pertormed utilizing Kruskal-WallisANOVA. There was'no statistical differenccin survival betwecn tfr" t*o lrcltrpr...O"" "f four animals in the control group and zcro of ioJ, i.i ifr.'Uvp"r, group was aliveat 24 hours.Mean duration of survival*rr'io, statistically different;ll hoursand 5Z minutcs control ,. fii""" hoursand 24 minutes CPB. There was no significant difference -.rluro.,r.y rn animal mcan arterial irri"g cjpn, p".fuI:1ghts, _pllss,ures slon pressuresduring CpR between g.orp-, Animals i;'tf. ;; slightly fewer counterihocks (3.25control vs. g::p fltt = u.lJ)._AlrhoughcpB has I,l"q"rre.d beenshown to be effec_ .t.," yr-r, uve arrershort perrodsof cardiacarrest.Our findings suggestthat bypassis of timited ,"r""]"li"#ng protongecl _a:j1:p,"]-qrary normothermiccardiacarrest.

_136- A ltlodel for Assessment of Canine Brain Function gging 31.p. NMR Spg.ir"r"-"pi During Prolon_ged Cardiopulmonary Arrest a;T BVp;;; Beperfusion RM Nowak, GBfrrfu-rtin,-O Watil,'in ei.imngu,, M Srnith

MC Tomlanovich /_Departmeni"t f ."rgl..y Medicine; NNIRFaciljty,Departmentof Nzurology;eertrrion"l".nnotogy uepartment of Surgery;Henry Ford Hosprtal,Detroii bypass is able to provide adequateend_organ "-l:T.::::f:-:ral repertuslonaf ter orolonged cardiac arrest.

3llp NMR sp?c_ troscopyallows continuous nonrnvaslvemonitoring of neuronal pH and energy,chargg,potentialry .r".irt -."."r'erlents needed to understandthe pathoohysiologyof brain ischemia and sion. The described-oi.i "o-Ei.,., ,h;;;';;;;eih.,ologt.sreperfu_ ,l_ lowing.uninterrupted neuronrt ..I"r"i- "r.;;;;; u.*?"ri"g cerebralischemia and the reperfusionevent. Large "a"ft -o.rgi"i 9og.,I to 7 daysin advanceof the ischemi. i.,*ft, rindergoexcision of the right temporalis muscle ,"a ,r. ,ffo*.d to recover.

Subsequently the animal ir. r"."th.ti".Jl;;;;;i;,". and pancuronium),.intubated,and placed o" " t.ri7"o5i-i.,i'bir.,k.t i., , custombuilt plastic holding device. It ir -r,..r-.it"d -i.ri.ru.nou., with aortic, Swan-Ganz,arterial bypass,double-lumen r.rO Foleycatheters,and non-ierromagneticECG and deribrillation

55

electrodesare secured in. place. The scalp incisron rs re_opened and skull readiedfor coil placement. rhe dog i, th.n pt"""J ii the 60 cm bore of a Bruker Biospec l.g9 ,.J'" ,rrp.r_"orrductinj magnet system. The Bard CpS s.ystemis primed *itt "utotogo,r! blood and normal saline. This byp_ass unit, the ventitato, (dhio CCV 2), pressuretransducersand-flush bags,polygraph;-d;; {CrassModel ZD), fluid/drug infusors leueit 52t pimps}, cardiac output computer {AmericanEdwards9520),and t}ie heiting/coolEl2 pumpf are.allpositionedoutside, pfry.i"rt 11q.s3urce,(Haake oarrrerand.rn a magncticfield less than 50 gauss.Each is con_ t h e d o g b y s p e c i a l l yd e v e l o p c dl o n g 1 2 3f t . ) l i n e s o r ltubes. e,:tcd^t9 A 4-cm surlacecoil emheddedin plasticis emmobilizedon the cxposedskull and then center positionedln the bore. The homogene.ityis adjustedon the *"ter resonance g0.3 T3gn.t M H z ) a n d t h e n t h e c o i l i s . r c t u n e d t o 3 l _ p h o s p t o r " , {at 1"t .fi.i lpulsc length oi 90 -i.ro_reconds, Illl S.llt;ruousrpectra spectralwrdth of 40O0Hz, and 2 secrelaxationdelay)can now be long as is decmed_scientificallynecessary.Ven:-!li],l"d. {.1,:s rncurar llbr_lilatlon rs precipitatcdby a Z to 3 scc transthoracic Durstot 60 llz currcnt,and during thc predctcrmincdarrest time t n c v c n o u s b y p a s sc a n n u l a i s i n s c r t e du s i n g t i t a n r u m rnstru_ mcnts. Bypass.rcpcrfusion (at lcasr 100 mllkgiminl is initiated ano clcctrodedefrbrrllationattemptcdafter 3 minutes of reflow The fibrillator and defibrillator arc positioned with the other e q u i p m c n r2 3 . f t . a w a yf r o m t h e m i g n e t . T h c a n i m a l c a n b e wcancotrom clrculatorysupportas per protocoland continuous brain 3l-P spcctracan be ind'cfinitely.".ora"a.

In-tranasal phenylephrine as a Cause of fi7 Anisocoria EJMtinek, ODdrunette i nro ll"nnupinCounty

Medical Center, Department of Emergency Medicine, Minneapolis The,usc of a topical sympathomimctic vasoconsrnctor to prep a r c r h c n a s a l p a s s a g e sf o i n a s o t r a c h c a l intubation is a com_ nronly pcrformcd tecirniquc. Thcrc arc ;r";J;rrl rcports in the litcraturc reporting_pupiliary dilation *l-."-pi*r,ion of intra_ ot sympathomimctic solutioni. The purpose of :r jn" rl ]s. 1s:rlul rdr y, , o n was t() dctcrmine w.hcthcr phcnylcphrrnc l%, applied i n t r a n a s a l l y ,c o u l d c a u s c i p s i l a t c r a l p u p i i l a r y ,lilation. A'randomizcd, doublc-blind, prospcctivc "'o.rJ.r.tedutilizing t w c n t y v n l u n t c c r s u b j c c t s . E a c h s u .bsj tcucity s' *cr r, v e d as their own con] rror/ rccclvlng rntranasal instillation of a test solution containing cithcr phenylephrine l% or_normal salinoon a"y i, ,na the other

ll, otl trialswcrc.n"au.t"Jli ir'" .-.ie.'.y

::l1tj:: o c p a r t m c11 n t 9:{ stabrltzation room undcr constant hghting condi_ tions. Thc Roscnbaum pocket Vision Screcner was uttlized for rcfcrcncc rn mcasurrng pupillary.ir" t o t t , . n " " r e s t C t . Sm m . A l l wcrc placcd supine, and after basehnc pupillary size was : :c: ]r:c: r] :m t n c d , o had car(rful intranasal instillation oi 2 ci,s of test size was measu.red at five, t"r,, t*..,ty, ,r,d :lly.,]."1,ryfillary r n r r r y m l n u t e s .R e s u l t s

a r e a s f o l l o w s . F o u r t c e ns u b l e c t sh a d anisocoria{0.5 mm differenceor greater)", ,o-. time durin! their two trials. Five suDlectswerc anlsocoricpre_instillation.

Analysis of thesc five subjectsrevealed"o -.i"rl"a p"plllary ai_ l a t i o n . N i n c s u b j e c t sw e r e .inrtially iso.ori.-r.,d,i.u"tJp"a anisocoria. post-instillatio_n.

Three of ihcse devetopedanisocoria on the side of the instillation of ph.nyi;ph;i;;.'Two of these threc subjcctshad anisocoriaof only OlSii-,'rra rerurnedto minutes rcspectivctfih. lrrt .ut,";; ::::^ll': i,_:*,and.thirty qcveloped markcd ..1mm anisocoriaat twcnty minutes that per_ sisted. Wc conclude that rntranasalinstillation oJ pfr.nyf.pfrii". lo/" ,can cause ipsilatcral pupi.llaryctilation-.Altfro.rgt i., tt l, of subiectsexperiencedlittlc or no anrsocona, :::j,I,:l::ii:rity slgntrrcant. ancls_ustain-ed pupillarydilation can occurin the occal s r o n a lp a t l e n t .u s e o f t h i s t e c h n i q u et o f a c i l i t a t e nasotracheal tube passageshould be avoided i" p"ti*t. ,frose neurologic exam must be carefully followed.

t 3_8 _ Suc-cinytchotine.Assisted Intubations in Prehospitat-Gare Jn Heoges, s i"rLrl]d r""r.o.

SA Syverud,SC Dronen,B Shultz/ Departmentof Emergency Medicine,University of CincinnatiCollegeof Medicine;Thurston CountyMedic One, Olympia,Washington Airway management to ensure proper ventilation and avoidance of aspiration is given first priority in the management oI critically-ill patients. Although endotrachealintubation is considered the optimal technique for airway management, performance of this task in the prehospitalsetting is at times difficult due to increasedmassetermuscle tone, vocal cord spasm,or patient combativeness.Use of short-acting par:,lyzirrgagentsby paramedics in the prehospital setting to facilitate intubation in these situations is an uncommon practice. We report the recent experienceof an EMS system that has used succinylcholine (SUX)for over ten years.We reviewedprehospitalpatient intubations for two lears; 210 patients were intubated by paramedics without the use of SUX and 78 patients were intubated with the use of SUX. The use of SUX to assistintubation was solely at the discretion of the treating paramedics. The patienr group rnrubated with SUX was characterized by a greater percentage o{ women {50% vs 36% j P < 0.05),a smaller percentageof comatose patients upon paramedicarrival {60% vs 90%t P < 0.005),a less frequentneed for CPR (22% vs 82Toi P < .005t and more hospital survivors{58% vs 24%t P < 0.005).The groupswere not different with respectto mean age or frequencyof trauma. Review of hospital records showed no difference between the groups for frequency of either aspirationpneumonia or mechanicalventilation in patients surviving to hospital admission. No patient required emergencycricothyrotomy nor was esophagealintubation noted in either group. Succinylcholine assisted intubation was used safely and selectively by the paramedicsin this EMS system to permit airway control and ventilation of patients with more difficult intubations.

Use of a Lighted Stylet to Position ! 39 Endotracheal Tubes RD Stewart, A LaRosee, A Ati, RM Ka.plan, K llkhanipour/ Divisionof EmergencyMedicine, University of Pittsburgh;Centerfor EmergencyMedicineof WesternPennsylvania,Pittsburgh Although endotrachealintubation is an acceptedmethod of airway control necessaryto the care o{ many critically ill and injured patients, it is not without complications.Among the most seriousof these is misplacement of the endotrachealtube. The most immediately life-threateningis unrecognizedesophagealintubation, which, if not corrected, can lead to death or serious disability due to hypoxia. Intratrachealplacementis no guarantee o{ freedom from complications, for tubes can be displaceddistally and enter a mainstem bronchus,possiblyresulting in atelectasis in the hypoventilatedlung, tension pneumothorax,hypoxia and decreasedsurvival. Correct positioning of an endotracheal tube in the adult is usually defined as placement of the tube within the tracheaapproximately 5 cm {+ 2 cm) superior to the carina.Such a position provides adequateaeration of both lungs while reducing the risk of displacementof the tube distally into one of the mainstem bronchi or proximallv above the cords should the neck be flexed or extendid. Chest i(-ray is considered the most reliable method of detecting incorrect positioning, particularly in patients in intensive care units. It carries with it the disadvantagesof radiation exposure to staff and patients, it is time-consuming and not readily available, and sometimes presents difficulty in interpretation. The lighted stylet (TUBESTAT*, Concept Corporation, Clearwater,FL), a device that allows rapid and reliable intubation of the trachea through transillumination of the soft tissues of the neck, is an alternative to conventionallaryngoscopicintubation. It has been shown effective and safe in the setring of the field, the emergency department and the operating room. We recently demonstrated that transillumination with a flexible lighted stylet can reliably differentiate trachealfrom esophagealintubation. This prompted us to examine whether transillumination could position the endotrachealtube tip consistentlywithin 5 cm {+ 2 cm) of the carina

56

in adults. Five human cadavers of varied weight and body habitus were intubated under direct vision, the head and neck placed in the neutral position, and l0 cc of radiopaque dye wal injected down the tube as a marker for the carina. A flexible lighted stylet was inserted so that the bulb reached the distal end of the tube, and the transilluminated giow was positioned by advancing the tube so that l) the point o{ maximal glow was at the sternal notch, or 2) the glow disappeared beyond the sternal notch. A chest radiograph was taken at each position, and the distance ol the tube tip from the carina was calculated. In each cadaver subject the tube tip could be placed consistently at a point 5 cm ( + 1 cm) superior to the carina by positioning the point of maximal glow at the sternal notch. Posrtioning beyond the sternal notch at a point at which the light disappeared from view resulted also in consistent and acceptable placement, 4 cm {+ I cm) above the carina. We conclude that transillumination of the neck using a flexible lighted stylet can accurately and consistently position an endotracheal tube at an appropriate distance above the carina.

Use of this transillumination method by nurses, paramedical personnel, and physicians would reduce the need for routine X-ray confirmation of the position of endotracheal tubes in intubated patrents. The method could markedly decrease the incidence of tube malposition. Its use would result in increased safety for the patient, a reduction in radiation exposure for staff and patients, and it would prove far less costly than the use of radiographs.

14O A New Adapter for Fiberoptic Bron. choscopy.Aided Tracheal lntubation Under Gontrolled Ventilation M lmai,O Kemmotsu / Department o f A n e s t h e s i o l o g y ,H o k k a i d o U n i v e r s i t y H o s p i t a l , S a p p o r o , J a p a n Flexible fiberoptic laryngoscopy is a method for endotracheal intubation of patients whose tracheas are di{{icult or impossible to intubate with conventional laryngoscopes. This technrque has generally been described in the awake state with toprcal anesthesia and sedation. For many patients, howeveq, this is a stress{ul and unpleasant experience. Patil et alt described the anesthesia mask with diaphragm. And it permits introduction of a fiberoptrc bronchoscope into the airway without the ioss of a seal for positive-pressure ventilation. But Zornow et al2 reported diaphragm fragment aspiration during fiberoptic-assisted intubation with this mask. Our newly developed mask adapter makes fiberoptic-aided tracheal intubation simple and easy, iven in the control ventilating patients. This device is made of vinyl-chloride, measures 7x5x5.5 cm, weighs 42 g. It consists of two parts. (l) rotative disc, which possessesa port, permits introduction of a fiberoptic bronchoscope into the airway without the loss of a seal for positive-pressure ventilation. (2) main part, which attaches to the Laerdal mask, possesses an inclined plane. The characteristics of this adapter are as {ollows. (l) In the parients who don't show difficult intubation preoperatively, the only thing we have to do is changing L joint. We need not change mask. {2} After induction of anesthesia, we can maintain anesthesia with inhaled anesthesia. We need not arouse patients. (3) Because of the transparency of the adapter and Laerdal mask, we can easily find cyanosis and other problems. {4) We can easily handle the tip o{ iiberoptic endoscopy. (5) The rotative inclined plane of this adapter can adjust the angle when intubating endotracheal tube orotrachealy or nasotrachealy. Then we can minimize the damage o{ the nasal and pharyngeal mucous membrane. Use of this mask adapter permits uninterrupted anesthesia and ventilation during the intubation with fiberoptic endoscopy. From our clinical expetiences this adapter is quite helpful for difficult intubation o{ten seen in the ICU and emergency department. rPatil et al: Fibetoptic endoscopyin anesthesia.Chicago, Yeat Book Medical Publication 1983. zZornow et al,'.Anesthesiology 1986i64:303.

141 Effect of Scavenging on Ambient Levets of Nitrous Oxide in Ambulances yVSchradino.

R Kaplan,RD Stewart/ Divisionof EmergencyMedicrne, U.niversity of PittsburgtrSchool of Mediciie; ienter for Emergency Medicineof Westernpennsylvania,pittsburgh The growing use oI nitrous oxide as an inhalation analgesic/ sedativeagent in prehospital care has led to a concern aborit the etiectsoi ambient levels on emergencymedical servlcesperson_ nel. Earlier studies have measured nitrous oxide levels lr, "-_ bulances,but commercially-availablescavengingunits have not beentested.We designeda study to investigati tfre effect of usirrg scavengingdeviceson the ambient level of nitrous oxide in thE patient .compartment of a standard ambulance. Eight healthy male volunteerswere recruited to participate in five trials of single-blindrandomizeddesign.Each volunieer was asked to main_ tain a tight mask seal while breathing a 50:50 nitrous ox_ ide:oxygenmixture for l0 minutes. Nitious oxide levels were first measuredin the ambulance during unscavengedinhalation (NS)by the volunteer subiects.Four trlals were then conducted I l l p - , ! * o s c a v e n g i n gu n i t s [ V i t a l S i g n s ' ' ( V S ) a n d O h m e d a lunrvrlj combrnedwith either a Vital Signs'" {VSM) or Laerdal iLM) facemask.Nitrous oxide levels wereiontinuousiy measured with a Miran-S0 IR analyzer.Mean levels in the presenceand absenceo{ scavengingwere calculatedin ppm/minute. Mean nitrous oxide levels for VSM/OHM (120 ppm/min), VSM/VS (94 ppm/min) LM/]S (9t.ppm/min) and rMlOgpt (ib+ ppmlmin), were statistically dif{erent (p < .05) from conrrol vaiues (726 ppm/min). No significant dif{erence was found between scav_ enger/maskcombinations. The data indicate that nitrous oxide scav-engers are effective in lowering the nitrous oxide ambient levelsin am.bulances, and may meriiconsideration as adiunctsto nitrous oxide delivery systems.

Manuat Detection of Decreased 142 Lung Gompliance as a Sign of Teniion

Pneumothotax SJ White,RM Kaplan, RD Stewart/ Division of EmergencyMedicine,Universityof pittsburghSchoolof Medicine;Centerfor EmergencyMedicineof Western Pennsylvania, Pittsburgh The classicsigns of tension pneumothoraxhave been described as progressive_dyspnea, tachypnea,tracheal deviation, and hypo_ tensionsecondaryto mediastinal shift. These indicatio.r, -ry b" drtircult to detect in the clinical setting, particularly in the field ard emergencydepartment.Followin{the clinicai observation that the complianceof a resuscitatorbag revealedthe presenceof a tensionpneumothoraxin severalpatients in the prehbspitalset_ ting, an animal study from our iaboratory concluded that comphancechangecould be detectedwell beforehemodvnamiccom_ promise. We therefore designed a bench study to investigate wlqlhgl elnergency.personnel of various training br"kg.ou;;, could discriminate differencesin compliance of a iest lurig being ventilatedwith a standardresuscitatorbag. A single_btini stuai designwas used in a group of l0 volunteJrs who"were asked to ventllate a test lung set at seven randomly-sequencedcompliances,rangingfrom .1 to .01 L/cmH2O. Volunteerswere asked to squeezethe resuscitatorbag six ti'mes, in one trial with one hand,and in a secondtrial with two. Each compliance was mea_ suredtwice in each of the two trials. Subiectswere askedto rank compliance,,feel,,as normal to difficult on a scale of I to 5. Vol_ unteerswere consistently able to distinguish compliancesbelow .015,a compliance well above that eipected to^cause hemo_ dynamicchangein,a patient. We have demonstratedthat exped_ encedemergencyclinicians can perceivea decreasedcompliance when venrilating with a baglendotrachealtube. practical skill sessions.demonstrating compliancesusing a test lung should be a part of the.training programs in airway ,rian"gem..rt'of all emer_ gency medicine practitioners. Tension pneuriothorax should be suspected in any intubated patient who is difficult to manually ventilate.Practitionersshould themselvesmanually ventilate p;_ tients during initial resuscitationproceduresand should be alle to detectchangesin compliance oi such patients.

57

743

Early Treatment of Acute Asthma with

Methyfplednisolone BM McNamara,WH Soivev LW Greenspon,S Mangione/ Departments of Emergency-Medicine and PulmonaryMedicine,The MedicalCollegeof pennsylvania, Philadelphia , Corticosteroid_therapyin acute asthma is often reservedfor those patlents refractoryto standardemergencytreatment who are destin-edfor hospital admission.This"study examined the ettlcacy ot early treatment with intravenousmethylprednisolone (125 mg) in 63 adult patients with 74 episodesof-acute bron_ chospasmin a double-blind,placebo-controlled,randomizedtrial.

On_p_resentation subjectshad an initial peak expiratory flow rate measured,followed by bronchodilrtor iher"py. A second {PEFRT) p_eakexpiratory flow rate {pEFR2)and informed "'orr."rrt *".. then obtained.Subjectswere randomizedto either receivemeth_ ylprednisolone (" : _381or placebo (n : 36) intravenously.Further treatment included lntravenous hydration and'bron_ chodilatorsin a standardizediashion. Decision for admissionwas basedupon the clinical assessmentof the treating physician.Dis_ chargedpatients were contacted within l0 daysl Data was ana_ lyzed.usingan.unpairedt-test and Chi-squaretest when "ppropriate. A "P" value of less than 0.05 was considered signiiicant.

There was no significant difference between the group"s 1or age, sex distribution, medications on presentation,duration of the current asthma attack or length of emergencydepaftmenr stay.

The_mean PEFRI for the steroid grorrp w"", tje .S r 64.7L/min while that for placebo was 147.7 * 17.6 L/rnin The pEFR re_ sponse to the initial bronchodiiator therapy (pEFR2-pEFR1) was 87.l + 70.1L/min for the steroidgtoup "nd 66.1 + fi .l L/rrrir fot the placebogroup.These differencls were not statistically signifi.?11 T!9 lu-ber of patients admitted in the steroid group ,i,as6 of 38_116%) comparedwith 16 of 36 laa%l in the placJbogroup (j, < 0..02).Forty-two of SZ IBI%) patients dischargedwere contacted within l0 days. Relapsewas defined as the ne;d to seek medical care in this time frame. Of the steroid group 4 oI 27 IIS%I relapsedversus5 of l5 (33%)in the placeb6group. This difference was-not significant.The ea_rlyuse of intravenousmethylpred_ nisolone in th.e.emergency therapy of acute astirma may heip reclucethe need tor hospitalization.

Feasibitity of prehospirat Diagnosasand 144 lntervention in Acute Myocardial Infirction

P Grim,T Feldman,R Donovan,L Doan-Wiggens, V Nevins, R Childers/ Departmentof EmergencyMedicine,Sectionof Cardiology,Universrty of Chicago Currently only telemetry rhythm strips can be transmitted . from ambulances.Evaluation,,trrage,and rnitiation of tfrerapyfli ambulancepatients with cardiopulmonarycomplaints is limited by the inability to make the specific diagnosisof ,"rrt" myocar_ dial infarction.{AMI). A standard 12 lea6 ECG acquired in the ambulance with immediate hospital basedinterpreiation would overcomethis limitation. To determine the feasibility of pre_hospital therapy for AMI we used a portable system for iZ leid ECC transmission with digitized ECG acquisition connected via modem link to a commercial cellular teiephone.A cardiachisto_ ry and 12lead ECG were acquiredby paramedicsand transmitted to the EmergencyDepartment while the ambulancewas in transit. 50_patientswith cardiovascularcomplaints were studied.Five were.diagnosedas havingAMI by the receivingphysicianbased on hrstoryand transmittedECC. All 5 had AMI substantiated on hospital evaluation.Averagetime from onset of chest pain to par_ amedic evaluationfor AMI patients was 7l minutes. Ti. pre-hospital diagnosis permitted 2 patients to be transferred directiy from ambulance gurney to catheterization table for immediate coronary arteriography.Screeningfor administration of thrombolytlc therapy performed by paramedicsusing a checklist with information transmitted to tle receivingphysiJian resultedin no incorrect decisions either to treat or Gitrtrota therapy.Conclu_ sion:_l) Early diagnosisof AMI may be accuratelymaie using 12 lead ECGs transmitted to the hospital from a moving ambulaice.

2) Decisions to administer or withhold therapy prior to arrival at the hospital can be made basedon information obtained by paramedics and a transmitted 12 lead ECG. 3) Prehospitaldiagnosisof the cardiac patient improves triage and facilitates rapid delivery of inhospital therapy.

145 Use ol a Saliua Reagent Strip to Estimate Blood Alcohol in Emergency Department MBHeller / Patients K Williams, GVAnderson, RMKaplan, AffiliatedResidencyin EmergencyMedicine,Divisionof EmergencyMedicine,University of PittsburghSchoolof Medicine; Grady MemorialHospital,Atlanta The social use of alcohol is ubiquitous in our society,presenting acute hazardswhen intoxication occurs, and chronic health risks with habitual use. The Datient with alcohol intoxication often presentsto the emergencydepartment in a setting where an altered level of consciousnessmav be a direct action of the alcohol or due to associatemedical conditions that may require immediate rntervention. Rapid determination of the blood alcohol concentrationscan assistthe physician in designingfurther evaluation and therapy.Clinical assessmentof alcohol intoxication by the patient or observersis notoriously inaccurate.Laboratory determination of alcohol concentrationis accurate,but often too slow to be of a real immediate use in emergencydecision making. The recent introduction of a reagentstrip {Abusa-Stick'", Chem-Elec Inc, North Webster,Illinoisf that estimates blood alcohol when placedin contact with saliva or serum may offer substantial advantagesin the practice of emergencymedicine. We evaluatedthe accuracyof these plastic strips in 44 patients who presentedto the emergencydepartments of two teaching hospitals. The strips estimate blood alcohol from 0 to 300 mg/dl. All tests were carried out by placing the strip in contact *ith the patient/ssaliva. The mean saliva alcohol level was 139.7* sd 120.3(range-0-300),while the correspondingblood alcohol level was 161.5mg/dl * sd 145.5(range-0-487).The overall correlation between these measurementswas strong. {r: .771.Therc was one falsepositive test and 3 false negatives.We concludethat the saliva reagentstrip is a useful emergencydepartment and field test for estimating the blood alcohol concentration of patients.

Philadelphia; Fleisher, JS Schwartz/ Universityot Pennsylvania, HarvardMedicalSchool,Boston The health benefits, complications, and costs of two strategies using rapid antigen test (t{T) for the dx o{ strep pharyngitis were compared with two traditional strategies.The decision tree includes: the option of using RT either alone or with culture (Cx), the variability in follow-up (f/u) treatment rates, the imperfect sensitivity of Cx and the imperfect effectivenessof Rx. The baseIine analysis uses data from Children's Hospital of Philadelphia to predict acute rheumatic fever (ARF)preventedand severepenicillin reactions for a cohort of 100,000symptomatic pts. Comparedwith Cx alone, RT + Cx prevents 17more RF casesat a marginal cost of $651l/case.Sensitivityanalysesshow: (l) RT+Cx is the best testing strategyfor ARF prevention over the rangeof assumptions; (2) comparing Cx alone vs. RT alone, RT is better at high RT sensitivities while Cx is better at high f/u rates; (3| Cx strategy.Two-way senalone is rarely the most cost-effectiveness sitivity analysis shows that over the range of assumptionsmost

Rx All Cx alone RT alone RT+CX

Cases ARF prevented Pens rxns 77 40 39 57

640 94 136 179

Cosupt $12.00 16 05 11.94 1717

Pen rxns/ CO8UARF preventod ARF prâ&#x201A;Źvented $ 15,540 40,447 30,642 30,164

147 Glinical Presentation of Non-Traumatic JRAllegra, CCV Thoracic Aortic Dissections E Barnet, / Morristown Memorial Hospital Residency L McDonald Grunau, New Jersey;Departmentof in EmergencyMedicine,Morristown, EmergencyMedicine,SomersetMedicalCenter,Somerset,New Jersey;EmergencyMedicalAssociates,Livingston,New Jersey Dissection of the thoracic aorta can be fatal if not treated promptly. Differentiating dissection from other diseaseswith similar presentations,particularly myocardial infarction, is often difficult. We retrospectivelystudied the early presentationof thoracic aortic dissection to determine if there were characteristics which would aid in identifying dissection in the emergencydepartment. One hundred and nine casesof thoracic dissection were found in the admissionsto six hospitals over five years.Up to 180 selectedcharacteristicsof each casewere analyzedusing a spreadsheetprogram on a microcomputer. The frequency of occurrenceof the commonest characteristicswere: pain, 9l%; sudden onset of pain, 3l%; chest pain, Tlo/oiback pain, 6O%i dia p h o r e s i s , 4 5 % ; d y s p n e a , 3 4 o / o ;n a u s â&#x201A;Ź a , 3 2 " / o ih i s t o r y o I hypertension, 737"i history of smoking, 52%; systolic murmur/ 64%"ia neurologic abnormality, 4lo/oi aortic ectasia, 44o/oicar diomegaly,36% ; mediastinalwidening, 34%i ST-Tchanges,49%; mortality was 58%. In 17% of and arrhythmia,34o/o.In-hospital the cases,aortic dissection was not discovereduntil autopsy or was a chance finding on aortography, CT scan, or at surgery.

These "occult" dissectionsdiffered significantly from the others in that they had a higher frequency of cardiac tamponade(56 vs 16%),but a lower frequencyof asymmetry of upper extremity pulses (0 vs 25"/oland mediastinal widening on chest X-ray (0 vs 39% ). This study illustrates that the presentationof thoracic aortic dissectionis diverse.Findings of back pain, neurologicabnormality, systolic murmur, aortic ectasia or mediastinal widening may aid in identifying casesof thoracic aortic dissection,However, absence of mediastinal widening or asymmetry of upper pulses should not be used to exclude the diagnosis.

148 QT Duration and Potassium Goncentration in Early Myocardial Infarction

146 Cost.Effectiveness of Rapid Antigen Testing for Streptococeal (STREPI Pharyngitis in a Pediatrie Emergency Department T Lieu,GR

Strategy

commonly found in the literature, RT alone preventsmore ARF than Cx alone and in many cases,is more cost-effective than RT+ Cx.

8.3 2.4 3.5 3.1

58

AA Ernst,J Lauanis,J Ellis,SB Karch/ CharityHospital-Louisiana New Orleans; StateUniversityEmergencyMedicineResidency, UniversityMedicalCente( Las Vegas;CardiacPathologySection, PaloAlto, California StanfordUniversity, Hypokalemia and QT prolongation have both been implicated as possible causesof ventricular fibrillation (VF) occurring after acute myocardial infarction {AMI}. In order to determinewhether either phenomenon was in fact a reliable predictor of VF we reviewed the records of 138 consecutivepatients presentingwith enzymatically or EKG proven AMI. There were l17 males {84%) with an averageageof 61.7years.Multiple and 28 females 116"/"1 tracings were avarlablefor each patient, though not all were obtained at the same time intervals. Hence an averagevalue for the QTc (Bizet'sformula) was calculatedfor (l) the first hour, (2f hours 2-3, (3) hours 4-17, and {4) hours 18-35.All times were calculated from the time the patients first presentedin the Emergency Department. Fifty-two patients (36%) developedVF,and their averageQTc for the four time periods was .427 ms, .427ms, .424 lms, and .424 ms. Comparable values for the patients not fibrillating were .430 ms, .421 ms, .435 ms, and .426 ms. There are no statistically significant differences between these two groups.Similar results were obtainedfor serum potassium.Initial potassium averaged3.9 meq/l in the patients who fibrillated and 4.0 meq/l in those that did not. These numbers are not significantly different. Of the initial 138 patients there were 20 taking quinidine, and 8 (40%) of them developedVE Comparisonof the QTc in this subgroup with that of the non-VF patients, both

those taking quinidine an_dthose_not taking quinidine, showed no_significant dif{erences.We conclude ,irri, F".-tfr. at least,neither eT duration nor initial potassium first 36 hours concentration haveany value as predictorsof impending u..rtri.utr. fibrillation.

Neither hypotension nor serious arrhythmias were recorded rn any.patient. One patient, in severe f,ul_o"rry edema with marked hypertension,developed,.rp;;;;J;,lrrJ in th. "_.r_ gency department,with the biood p.irrur. ;.;;i;i;g within nor_ mal limits. throughout treatment.A ,..ona prii.nt with metastatic renal cell carcinoma,but with .ro.-rl 6looJpr".ru.. ,ft.. arrival .at the emergencydepartment, ruff.i.a-r'g"neralized sei_ zure without radiographiceuidence(CT MRii"f SJntral systcm drsease.The seizurecould not be attributed nervous ,;;i; p; n?:f]!rt nifedipine. Our data i"ai."t. it "t nifffi;;" is a safeand agent for the prehospital management'oi r.u"r. hyp.r;jt".r::il.

Incidence of Arrhythmias During Air !49 T_ransportationof patienti with A;;i;Itl_yocardialInfarction Who Have "a.r' ie.ei""O S.treptok i nase pri or, rii niniit ii i s" no",s, o 19 Wys\am, MGKienzte, CWWhjte I Uniilersiiy oi towitospitats

and Ciinics,lowa City Patientsrec.eivingintravenousstreptokinase(lV_STK) during acutemyocardialinfarction(AMI) may be at risk'for arrhythmias co_mp.licating transportation a tertiary care center.Emergency .to arr transportation,rcquired in rural ."tiingr, might increasear_ rhythmia risk and complicate therapy.

We"piospJctive.lystudied 40 patients d,uringheliioptc, trrnrport rvrti, ffrghi nurses using continuousHolter monitoring. We io-p.r"J pr?i..,, with AMI to.patrcnts who transportedby air to :1"_::::::9 IV-STK _wcre our tertrary carc center Ior a.variety of other card^iac and noncar_ diac conditions. Duration of ECG ;";;;d;;r';;;gc-d 2t7 min(74.t 6, mean t Sr) arrhyth;;;;;;"*;rded from zr, to as:0 = no ventricula_r-ectopy, I = <.J0 pCVlhr, Z = >13'pCV/hr,3 = - couplets, 4b : self_limiti.l vcntricular Ti:*jT ly,_C,, 1"

TIME

MAP

0

169

3'

tJ/

5'

148

10'

139

15'

129

AMAP

SP

ASP

242

12 21 30 40

DP

ADP

132

226

16

123

I

209

33

117

t3

r96

46

110

187

55

100

22 32

_19f Sorbitot Catharsis Does Not -Enhance Efficacy_of Charcoal in a Simul"i"a over_do;e-i M;;E;;", cK Aaron, M l^1"J.Til"lh9n Uemborys,S Davidheiser

;1"',i,"'il'1'f .["J],.'":x1l:l'$l:r;f,.L11""J,131-'""tcArpa. n

Grade 0

4

O t h e rC a r d i a c

0

14

Non'cardiac

1 2 3 4 a 4b 6 0 0 0 4 1 0 0 0 0 1 1 0 0 0 1 0 0 3 0

9

3

1 0 A l V l( + S T K )

0

4

RecenN t / t( - S T K )

3

8

U n s t a b l eA n g i n a

6

1 0

0

1

Brady 0 1 1 0 0

tachyarrhythmias occurrcd in any Con).:^:I:0,:-+tic l) high-gradc scft-limited. vcntricular".rf,ylfrrnrrr rre common.2) arrhythmras^ arc uncommon. 3) Carcfully moni_ --'-' ,S]_Tjl?-.",t. roredarr transportduring AMI can be accompil.f,"a ,#ty.

;fi :It::;'::D,,ins,;;;;;;;il; ; i ;; .i*"; ;:;' I ilir,f,:",",1,_

!.5^O Use-of Nifedipine for Fietd Managemenr g.f.fevep_ Hypertension MBHeiler, JB orJu, n"rrvurlu PM Paris

RD Stewart/ Divisionof Emergencyfrrf"jo,n.

University of pittsburqhSchoolof tt/edic"he; 6rr"u, ot Emergency MedicalServices,prtlsburgh managcmentof scverehypertensionis limitcd ,_.lh:-Or.hurPital

/ Departmentof EmergencyMedrcine, MedicatCoilegeof pennsytvaniaphiladelphia;-Ifi;Nerl Pharmaceuticals, pennsytvania FortWashington, Rccent work has focusedon the rapidity of transrt time for activatcdcharcoal(AC)with variouscrti,ariics. iimited daraex":,,:l["thcr rapid transit time improvesihe antidotal ac_ :::r_ r^rr (r AL. r,xcesslvecatharsism€y causefluid and electrolyte imbalancc.This study cgmpares.h; "ffi;;;iplain AC versus a c t i v a t c d c h a r c o a l - s o r b r t os.ol l u t i o n ( A C S ) in a simulated ovcrdosc. {ApAp} Erghty healthy-voluntee;s;;r_ :,T:a-liTrophen tlclpatcdin a randomizedcross_over trial. Eachservedas his own ingested32.5 80mg ApAFI;l.t; with t20cc of 13-llrolr.Subiccts water atter an overniaht fast. Blood samples were drawn .i0:, l; 1.5,2,3,4,6, and 8-iroursrna *..r.-".,livr.a"i", arrap by high prcssurcliqurd chromatography-All test jr1;;;;.. separatedby day washout pcriod. All interventronswere done at one l_.::1._" nour post-lngestionto simulate clinical conditions.

On the con_ trol datc, no further intcr_ventrons *"r. u.rd.rirken. On study datcs,subjcctsrcceivedeither a ,turry liSOg;pfrm ac in water (Med Comp Acta-Char,950m2./g.ml, ";50;ff;; iCS solution (Re_ qua Charcoaid30 sm charcoattllclsg ,or'ti"l; lbio_rzg_) *itt l20cc watcr. Tiansii times and side?ffe;t, ,".J ""[a Mean trans i t t i m e f o r A C S w a s 1 . 8+ l . 2 h r s * h i l ; 1 - h ; ; for AC was l7.U+ l0hrs. All subiectsreceivingACS reported frequentwatery charcoalstools (mean lS.S!9.2,tlooir/r"u-Jn"f,""r.f. eff ACS sub_ jccts rcported nausea,two chose to ,.tyai^t. i"iilu..ro.rrly, ,.rd onc requiredan antimotility agentat the conclusi"".i,fr. larav. group, naus.eawas reported by two subiects.

No other ll_,:\jC .tj.:,:.y"re noted,includingconstipation.

Serumconcentra:lu" tron ol APAp was analyzedusing analyiis of covrirance of area under the curve and evaluated;ri;; ,_;; t J.ht.y a ,.r,.

Correctcd mean area under the coniol .uru. *r, 122.79i area under the ACS and AC curves were 90.g5 and g6.5g respectively.

Thgr^e_yas a signrficant diff.re"c. tet*ee;';;;;;i,"^us AC (p < 0.051and control versus_ACS < 0.051.No .ig.,ifl.rn.. *"s lp noted between AC and ACS although;;.*i f"#'lo*., ,.r,r_ levels was demonstrated*itt ec.Toif,";t-rffi ACS demonstrateda significantly rowerarea under the "";;];, as comparedto control. In_this study, ttre aaaition-ofApAp levels sorbitol rn_ creasedtransit time and side .rf.cts 6.,f noi ,h;;;;rd*;i;]i;;; of activatedcharcoal.

j:i :1,i,J#:'r'L:'"itilex'."1,:f:ffi :,i&,;,Xh'l#l"x;j departmcnt,"afii"-r,*p'it"i;,;;s as an effccll,jl..-:,t:lq::cy

uve antlhypcrtensive.

This prospectivestudy was deiigncdto de_ termincthe safetyand cffiiacy'of l"traoirf'"if.ilirne as a field agentrn the treatment of me.dical.o"ditio.r, .hiiaiterir"a by .everei_ypertcnsion.

Fifty adult patrenis"r..por,.a'Uy a busy urban EMS system and who had.s.yst"li; bffi;';;ssures greater than.l80 mm Hg and diastolic blffi;;;;;;ilater than n0 mm Hg were treatedwith l0 mg of nifedipir. i.fir*r"g consulta_ tion with the EMS on-line pliysician i.ftt.iipi". was atlministeredintraorally,either by chewrnga capsulc or by placementof the contenrs of thc caosule sublinlually.

Standari protocols for the treatment of the underlyi"s,;;;;i;"r" ri.iJiilo*.a. stooa pressures were measuredby cuff readingsat 0 minutes and then at 3, 5, l0 and 15 minutes after administration of "rig"r, tfr. a-g. p;tientswere observedfor any .hr"g. i" oit.^iri","f srgnsand symptoms,or adverseeffects._ A marked "ff..t o., .'yrioli; blo;J pressure(SP),diastolic blood pressure(On) and irean arterial b l o o d p r e s s u r ei M A p l b e c a m e e v i d e n i i f s o o n a ft e r nifedipinewas administered.Oecr.asesi" i f J i . i,fei'ig'r"d Dp were significant(P < .0S) for pressuresrecorded after three mlnutes.

Comparison of Arteriat and Venous 75?

G a rb o x yhe m o e Io b i n leyli i- ..7 ;,; " i";' \ shimazu, ;,

-

ered "positives". Con{irmatory carboxyhemoglobin levels were CD Chisholm/ Departmentof EmergencyMedicine,BrookeArmy "positive" patients who consentedto the test' "L,"*'ea from all Fort Sam Research, for Surgical Institute Medical Center; a in" soe p"ti".'tt tested-during this period had F;;;;;;;12.e'"/d Houston,Texas it-rue positiv." CO elevations[breath analysiscon{irmed by carCarbon monoxide is a significant cause of rnorbidity a+4 -T9l: Ulrvft'"mostoUin level). Seven of these were non-smokers (mean (COHbl ,.fd i" ift. United States."Althoughcarboxyhemo.globin : s.ig't" x.2.261 and seven were smokers (mean level : i;"i i;;;ft d" not correlatewell with symptoms and clinical severity n.OeV. t 3.741.We also undertook a retrospâ&#x201A;Źctivereview of carof poisoning, they remain the standard method of confirming COlevels obtained along with arterial blood gas Uo*yirl-ogfobin ooironirrs."i'.rblicationsinconsistently identify the source of "Ui""J ED patients during a similar.time period'-Of on dJne ;;r$"t t"tipi.a for COHb, and no data exist comparing.arterial 532 patients, 15 (2.4%)had carboxyhemoglobin "Oaitio"al" ttr.r6l provide additional "positive"-by-our criteria {>3% levels. While arterial samples ;;;;-;";;;t elevations that were considered ltriot*"tio" in pH and measured 02 saturation, arterial puncture smokers).We feel that ^ Z'8yo inci' >10% for nott-smokers, foi i.-"oi *itfto"t discomlort and potintial morbidity'-Dtl to the dence o{ unsuspectedCO elevationsamong 1,038patients-ts pt"i"- tv-p,oms of CO poisoning, venous COHb levels would rt""fi ""a ih"t"iot" does not warrant/ on a practical basis, the levarterial assistthe-clinician as a scieening tist if they reflect screening of an unselected, urban ED population for Co ;;;ii"; "ir. rtr" study was conductedin 2 phasesand was part of an.oneven during a high risk winter period' exposure/ PhaseI, sheep received loing lnhalation injury study in sh-eep.In i fivE minute exposureto a high CO Concentration(5'27")' SimulIncidence of Vomiting in Comatose 154 arterial'and venous eOHb levels were determined prel*.o"r iaiients Following Prehospital Administration "*ooror. and at regular intervals up to 3 hours post exposure'In SE MBHeller' (range RMKaflan,RDStewart, bf niloxone PM Paris, itil ii tt-pt"d pa"irs,the mean A-V difference was 2'03 Surgery' and the Medicine of throughout difference Departments A-v / Hakala Marini,K l.e-+.01.thire was no significant of PittsburghSchoolof Medicine;Centerfor Emergency University rr-ptittgt""ge {P < .00i, Spearman'sRank Correlation CoeffiCity of PittsburghBureauoi Ha"Oti".j oi Western-Pennsylvania; cieni). ti Phaie II, sheep were administered Iow Co concentraobwere (5 Samples hr)' prolonged time a for EMS ii""r' fioo oot"l i"i""a'pt.-i*porrrr. attd thereifter until 3 hrs post exposure'In Some authorities advocate the routine endotracheal intubation ift. ai tr-pt.d pairs, the mean A-V differencewas l'25 {range, of comatosepatients suspectedof narcotic overdoseprior to the O.a to 2.21.'fheie were no statistically significant differences of the narcotic antagonist naloxone' This opilion "a*i"itttrtlo" ihio"gtto"i the sampling range(P < 0.001,Spearman'sRank Corbelief that these patients have an increasedinir i;ilJ;the i"f"ti6" Coefficienti our rezults show that in the sheep model, "ii"""" "i t"-i,ing and a greaterrisk of aspirationwhen treated in either acute high level or prolonged low level CO expos-ure, s"""t' " beliLf has not been tonfirmed bv clinical ;id-;;bl<";;.

CoHt leve"lscorrelate with aiterial levels' venous CoHb ;;";;; magnitude of this risk, if present,has never been the stuJies and determinations may prove to be an effective screeningtest foJ q*"rtfi.J. w. repo"rthere a retrospectivi.review of all casesof presenting ;ith protean symptoms and risk of Co i"lo*o.r. us. ou.i a 12 month period and the incidence of vomit;;,i.;;t porsonlng.

The Citv.oi Pittsburgh EMS protocol for the il;;;J;.p"",ion. patients wiih an altered consciousnesspossibly of -i-rg.*"'"t due tJ dr,rg overdose includes the use of naloxone prior to any "rt.-ort ai intubation. During a l2-month period naloxonewas Efficacy of an Emergency Dep-artment 153 of Unsuspecte! "a-i""lri"i.J in the field to gl5 patients administeredin doses for Screening Prolram ^Garbon and intraglossal i"tt'-tts"ular, "o,,i, .rrb".tt"t Strange, G ;;iltii.

R Hart, 6;':^t; Monoxide Exposure T Turnbull, irrtr"u"rror.ri routes. Twenty-seven of these patients had.a history MA Cooper,R Lindblad,J Watkins,C Ferraro/ Universityof Residency' Medicine and surrounding circumstances strongly suggestiveot narcotlc Emergency Hospitals Aifiliated lllinois ou"tJot. and refponded to naloxone administration with return Chicago of consciousness.In only one of these cases(4%) vomiting oc' Carbon monoxide (CO) is, reportedly,the most frequent toxnaloxone use and after the patient was able to ""t.Jl"it"*ing sp-ecubeen has and States United in the -be of death icoloeic cause atrway. Aspiration did not occur' Thirty'three own his control particularly responsible for significant morbidity, i;;;d"i; an altered level of consciousnesswere suspatients with other "-orrg lo*er socioeconomicgioups-during. the winter months' of narcotic abuse but the history and team field the """i"a'Un rf"-"iiO.ttoot a study to esti;ate the incidence of unsuspected not permit a definitive diagnosisof nar' did ""loxone i"wo"t.i" emergency urban to an presenting CO exposurein a population "oti" "t.. In these 33 patients there were no incidents of vomitdeoartment {EDl and to assessthe ettlcacy ot screenlngan uni"* ioilot"i"g the adrninistration of naloxone' Of the remaining r.i".t"J ln population for this type of exposure'From November only on. was reported to have vomited, but this 7i? ;;i.";t; were ED our to presenting patients 1987, through 1986 i"ttt"ty trt" concomitant use of ipecac' These data ];ii"*ittg ;;;J;;d Any analyzer' breath hand-held a using screenedfoi Cb exposure administration witho-ut prior endonaloxone that" .;gg"t; ;;;ld eligible was complailt, p"ti."t pt"t""ted to the ED, regardlessof to the initial management approach a safe is iiiubation tracheal exposure iot the itudy. Patients with a history of suspected Co abusesince it does narcotic of patient suspeiied oUt""A"d oiih" were excluded as were those who could not perform the test' the risk of vomiting and aspiration' We lncrease to per not aDDear parts in level CO patient included each Data collected for that field endotracheal intubation may well result i""riJr'*gg.rt millioir (ppm), smoking history, and chief complaint' Any nonof regurgitation, vomiting or aspiration than ;; ;htgh;fi""idence any and .rnot .t ititft " CO leve'i of > l5 ppm (approximately 3% ) naloxone. prompt ot use with a level >48 ppm (ifproximatelv l0%f were consid;;;k;t

EXHIBITORS AircastInc. P.O.Box T 2 WalnutStreet Sunrtrit,NJ 02901

Q0r)273_63sr AircastInc. manufacturespneumaticbraces for the lower leg, knee andelbow'Inflatableaircells provide pneumatic compressionwhich "milk helpto away" swellingandedema.rrr"-"a.;u.t ur" outer shell providesa protectedfunction for earlier mobilization and recoverv.

Annalsof EmergencyMedicine P.O.Box6199ll Dallas,TX 75261-99ll (214)550_0911

Cardiac ResuscitatorCorporation 1224 SouthwestGardenplace Portland,OR97223 (800) 547478r CRC is the innovatorandonly manufacturerof hrlly automaticexternal defibrillators - the HEART* AID@ and of the pACE* AID@ pacerr,aker.

Transcutan@us Theseinstruments,designedfor emergency care, havehelpedto sale mTry lives. We,ll gladly showy* t#;;;; operationof eachdevice when you come by our booth.

Cook Critical Care P.O. Box 489 Bloomington, lN 47402 (812) 339_223s

Annalsof_Emergency Medicineis theofficial journal of the American Collegeof Emergencyphysiciansand tfr" Uni"*rity Associationfor EmergencyMedicine. Editorial Board and staii memuerswill be available to answerquestionsanddiscussyou. ia*, about the ioumal.

High-Flosheathsets*9-Iurr, Check_Floadapterfor ballooncatheters, pneumothorax sets,CVp trays and introducersfor pacingleads.

AustralianBiomedicalCorporation 419Washington Street Gibbstown, NJ 0g027 (ffig)423-s32s

C.V. Mosby Company 11830WestlineIndustrialDrive St. Louis,MO 63146 (800\ 32s4r77

AustralianBiomedicalCorp. will featuretwo innovativeproductsfor Emergency Medicine.The RotalokSurgicalff*Jt"Uf" is designedto meelthed:rynds of surgicalprocedures=including tendonandvascular repairsandplasticandreconstructivesurgery. ih" Don*uy Splint is a lightweight,portablelower extremity traction. The systemincor_ pratesbuilt-intractioncontrol, improved patientcomfort andreduced sideeffects.

Data Consults CharlesFordermann 9028 North 70th Street Milwaukee,Wl53223 (414)354_3518

BardCardiosurgery Division 129ConcordRoad Billerica,MA 01821 (617)663-5353 TheBar! CardiosurgeryCpS.Systemfor emergency cardiopulmonary supportin cardiacarrest and the Bard Infuse-r 37iM Rapid Soilil; AdministrationSet for the management of hypovolemicshock.

CalgonVestalLaboratories Divisionof CalgonCorporation 7501PageAvenue P,O.Box 147 St.Louis,MO 63166 (314)862-2000 Alongwittrits line of Healthcarepersonnerhandwashing andhandrinsforhigh risk areas,CalgonVestallaboratories !_qgdry will feature SHUR-CLENS, the only wound cleanserspecificallf formulated for Emergency Room use.

The purposeof this exhibit is to demonstrate the Milwaukee County Pre-HospitalComputerizedOatanase. fnis l*T"di: databasewas developedby Data Consultsin conjunctionwith the Medical College of Wisconsin.It wasdevelopedfor a microcomputer basedsystemus_ ing a databaseprogram(Revelation)UyCor.ol. in" major program advancemgnt its ability to critically anAyze ttrecomptexcardiacar_ ls rest recordwith its multiple drug interventionsand results.

E.M. AdamsCompany,Inc. l2l West Street Medfield, MA 02052 (617) 769-1799 We will be exhibitinga wide varietyof wound closure[ays, custom suturetrays, and minor proceduretravs.

EmergencyMedicineResidents'Association P . O .B o x 6 1 9 9 1 1 Dallas, TX 75261-9911

(2r4)s5o-o920

California Medicalproducts.Inc. 2841East19thStreet LongBeach,CA 90g04 Qr3)494-717r

Membership opportunities and information job opportunities bulletin board.

TheStitreckryextricationcollar combinesconvenience with an inno_ vativedesignto give betterpatientcare.The collar comesin four adult $zesaswell as a pediatric model. Our newest size, the No_NeckrM will bepresented alongwith our new in_servicevideotapetrainingaid.

Genentech, Inc. P.O. Box 108 Media, PA 19063-0108

(2r5)891-9043

Glaxo,Inc. Suirc 330, 47 PerimeterCenter East Atlanta, GA 303,{6 QM) 6f,8-{/'s7

MICROMEDEX,Inc. 660 BannockStreet, Suite 350 Denver, CO 802044506 (303) 623-8600

You are cordially invited to visit the Glaxo exhibit, where a Glaxo representativewill be availableto answeryour questionsand discuss the latest clinical information on Ventolin Solution, Zantac and Trandate.

Toxicology,clinicalpharmacoloryandtherapeutics, anddisease/trauma orientedclinical information systemsfor the entire hospitalmedical staff. Theseinformation systemsare availableon: CD-ROM for use with personalcomputers,computertapesfor usewith IBM pCsmainframe usersand microfiche.

Hoechst-Roussel Pharmaceuticals.Inc. Route 202-206North Somerville, NJ

PaddockLaboratories,Inc. 3101 LouisianaAvenueNorth Minneapolis, MN 55427 (612\ 5464676

Streptokinasefor acutemyocardial infarction.

PaddockLaboratoriesis pleasedto announcethe availability of two ready-tG'use activatedcharcoalproducts,ACTIDOSEandACTIDOSEAQUA, for poisoningemergencies.paddock,sACTIDOSE and ACTIDOSE-AQUA ready-to-useactivatedcharcoalsuspensions contain a powderedactivatedcarbon with an exceptionallyhigh absorbativecapacity.Seewhy ouncefor ounce,ACTIDOSEis the most effective charcoalproduct you can use in a poisoningemergency.

(20r)23r-2w i

i

I

InternationalMedical Corps 10880Wilshire Boulevard#2008 Los Angeles, CA 9W24 Qr3\ 474-3927

Societyof Teachersof EmergencyMedicine P.O.Box 619911 Dallas,TX 75261-9911

Laerdal Medical Corporation P.O. Box 190 Armonk, NY 10504 (r94) 273-9N4

Qr4)s50-E2r Societyleaderswill be availableto answerquestionsaboutmembership activities. Display items will include the EducationalResources Compendium,GoalsandObjectivesProjectReportandthe Emergency Medicine Core Content.

Heartstart2fi)0 Semi-AutomaticDefibrillator, Airway Management Trainer, RecordingResuscuAnne, DisposableAirways.

SpectrumX-ray Corporation Box 155, Ryan Avenue westville, NJ 08093 (609) 8454944

Marion Laboratories,Inc. 9300 Ward Parkway KansasCity, MO &137 (816)9664000

Spectrum'semergencyandtraumatableis specificallydevelopedfor emergencyandtraumatologymedicine.Designconsidersall problems of traumatizedpatients,eliminatingcomplicationsfrom excessivepatient transferthroughall phasesof critical care.All functionsincluding X-ray, surgery, specialprocedures,orthopedics,traction are readily accomplishedon the table after ambulancereceiving.

Featuredwill be SILVADENE@Cremt (l% silver sulfadiazine) for treatmentof major and minor burns.

Mead JohnsonPharmaceuticalDivision 24(X West PennsylvaniaStreet Evansville, IN 47721 (8r2) 429-7769

Tri-State Hospital Supply P.O. Box 170 Howell,MI48169 800-2484058

You are invited to visit the Mead JohnsonpharmaceuticalDivision exhibit whereour Medical Representatives will be pleasedto discuss productsof interestto you.

Tri StarcManufacturersand distributesa completeline of high quality disposablelacerationtrays designedfor the EmergencyRoom.

U.S. Air Force c/o E.H. Pechanand Associates.Inc. 5537 HempsteadWay Sprhgfield, VA 22151 (703\ 94r44s0

Medex.Inc. 3637LaconRoad Hilliard, OH 43026 (614\ 876-2413 Medex,Inc. will be displayingthe Hi-Flo TraumaSet, C-Fuser,HiPressureStopcocks,Hi-Flo Extension Sets, NovatransDisposable Transducerand also the NCCOM3 which is a Non-Invasive, hemodynamicmonitorgiving conditinuous,real-timedisplayof c.o., a fluid index and contractility index of the myocardism!

U.S. Air Force HealthProfessions.

ZMI Corporation 325 VassarStrept Cambridge,MA 02139 (617) 576-3986 ZMI will demonstratethe Zoll NTp@ Noninvasive Temporary Pacemaker,a new generationcardiacpacemakerthat combinessafety, speedofapplication and easeofuse with clinically proveneffectivenessand documentedpatient tolerance.

Merck Sharpand Dohme WestPoint, PA 19$86 (215)661-5349

62

CONSTITUTION OF THE UMVERSITY ASSOCIATION FOR EMERGENCY MEDICINE ARTICLE I _ NAME

tions to which are deductible under Section 170(c) (2) of the Internal RevenueCode of 1954 (or the correspondingpiovision ^ of any future United State Internal Revenui Law).

The.name^ofthis organization shall be, ..The University ^ Associationfor Emergency Medicine, " hereinafter referred to as, "The Association."

ARTICLE III _ MEMBERSHIP Section l: Classifications. There shall be seven classesof membership:active, associate,emeritus, resident, honorary. and internationalactive and international'associate.

ARTICLE II _ OBJECTIVES Sectionl; The objective of this Association shall be improve_ mentin the quality of me,dicalcare of the acutely ill and injured by operatingas a scientific and educationalorganization as definedin_Section501(c) (3) of the Internal RJvenueCode, as amended.

Sgction2: Quaffications. (l) Candiatesfor active membership shall be (a) physiciansof university or university-affiliated hos_ pitals, who hold medical school faculty appointmentsand who are continuing to participate actively in the f,reldof emergency medicine care and services, have a demonstrated interest in emergencymedicine, whether in an administrative,teaching, or clinical capacity (b) other medical educatorswtrounder+pe__ lm_ +crshipâ&#x201A;Źâ&#x201A;Źmfrittee. ho ld medicat school facul appointment s ry and who are continuing to participate actively ii ine ped oy emergencymedicine care and semices, have a demonstrated interest in emergencymedicine, whether in an administrative. teaching or.clinical capacity and who petition the membership committeefor such active status. (Z) Candidatesfor associafe membershipshallbe any physician,medicalprofessional,edu_ cator, governmentofficial, member of a lay or civic group or any.member of the public at large, who may have an inteiest or desireto participatein pursuingthe purposesand objectives of the Association.(3) Candidatesfor emeritusmembershipshall be (a) active memberswho seeksuch statusand who have given l0 yearsofactive serviceto the Associationand have attiined the age of 60 years (b) other active memberswho under special circumstancesare invited for suchemeritus statusby the Mem_ bership Committee. (4) Candidatesfor residentmembership must be a residentin residencytraining program who have an interestin emergencymedicine. (5) Candidatesfor honorarv membershipshall be individuals who are outstandingmedical or lay contributorsin the field of emergencymedicaftervices.

(6) Candidatesfor internationalactive memb-ershipshall be individuals who meet the qualifications for active members in UA/EM and who reside outsideof the United Statesand Cana_ da. (7) Candidatesfor internationalassociatemembershipshall be individualswho meet the qualificationsfor associatemem_ bershipin UA/EM and who resideoutsideof the United States and Canada.

Section2: The Association shall pursue its objective by sur_ veyingmedicaland scientific articles both publishedand unpub_ lished,andselectingarticlesof note. The Associationshall make available,at cost, to the public copies of the selectedarticles uponrequest.The Associationshall selectmedical and scientific articlesofnote and educatethe physician and the public by pre_ sentingthosearticles at discussiongroups, forumi, paneli, iec_ tures,seminarsand other similar programs. The Association may chooseto sponsor for publication selected medical and scientificarticles of note by treatise, thesis, trade publication or othermedia form in order to make that information, including patents,formulas, medical apparatus and medical systeri designs.,available to the public at large on a nondiscriminatory basis.The Associationmay conductand/or sponsorpublic in_ terest,scientific research in the field of emergency medicine in orderto improve the quality of emergency."ai"it treatment andcare. The Association shall publiih iis research data by treatise,thesis,trade publication or other media form, in order to makethat information, including patents,formulas, medical apparatus and medical system designs, available to the public atlargeon a nondiscriminatorybasii. The Association shill in_ formandeducatethe public, as well as the medical professional, in theresultsof its researchby conductingdiscusiion g.oupr, forums,panels,lectures, seminarsand oth*ersimilar p.o=gru-r.

Section3: A. This corporation is organized exclusively for educational and scientifii pulposes, iricluding, for such pur_ poses,the making of distributions to organizationsthat quiify asexemptorganizationsunder Section501(c) (3) of the tnternal Revenue Codeof 1954(or the corresponding'provisionofany ^ futureUnited StatesInternal Revenue Lawf.

B. No part of the net earnings of the corporation shall inure tothebenefitof, or be distributableto its members,Directors, or_otherprivate persons, except that the corporation 9fT:^ shallbe authorizedand empowered to piy reasonable"o-p"n_ sationfor servicesrenderedand to maki paymentsand distrubu_ tionsin furtheranceof the purpore, ,ei fortfr in paragraph A hereof.No substantialpart of the activities of the corporition shallbethecarrying on of propaganda,or otherwise arempting to influencelegislation,and the cbrporation shall not participatE in, or intervenein (including the publishing or distribution of any political campaign on behalf of any candidare :tateTe_lts) for publicoffice. Notwithstanling any other provision of these articles,the corporation shall noicu..y on uny other activities notpermittedto be carried on (a) by a corpo.ation exempt from FederalIncome tax under Section 501 G) (3) of the Internal Revenue Codeof 1954(or correspondingpiovision of any future UnitedStateRevenueLaw) or 1U;Uy ico.poration, contribu_

Section3: Only active membersshall have voting rights.

Section4: The Associationshall not discriminate,with respect to its membership,on the basis of race, sex, creed, religion or national orisin.

ARTICLE IV _ OFFICERS Section1: The officers of this organizationshall 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 ExecutiveCouncil shall consistof the above officers, the program CommitteeChair_ man, the last +hreerwo presidents, and,*ree four Councilmen_ at-Large.Both activeand associatememberJmay serveon the ExecutiveCouncil, but only active membersmiy be officers of the Council.

63

ARTICLE V - COMMITTEES

Section4: Adoption of a bylaw amendmentshall be by a majorityvoteof the activememberspresentandvotingat any annualor specialmeeting.

The standing committees of the Association shall be: Membership Committee, Norninating Committee, program Committee, Constitution and Bylaws Committee, Education Committee, and Auditing Committee. Additional committees may be created by the Executive Council and ad hoc committees may be created by the Presidentto aid in the Association efforts to achieveand further its goals.

ARTICLE VII - ADOPTION OF TITE AMENDMENTS TO TIIB CONSTITUTION Section1; The constitutionmay be adoptedor amendedat any annualor specialmeetingof the membership.

ARTICLE VI _ AI\NIUAL MEETING

Seaion 2: Proposedamendments to the constitutionshall be submittedin writing to the Secretary/Treasurer by threemembersat least60 daysprior to the meetingat which theyare to be considered.The Secretary/Treasurer shallmail theproposed amendmentsto the membershipat least 30 daysprior to that meeting.

Section1; Thereshallbe an annualmeetingof the Association. This meetingshallconsistof an educational andscientific programand a businesssession.

Section2: TheExecutiveCouncil,by majority vote,maycall, upon30 daysnotice,a specialmeetingof the membershipor standingcommitteeto conductany businessthat the Executive Councilshall placebeforetle membershipor standingcommittee.

Section3; The ExecutiveCouncil may call and conductany specialmeetingby mail. For purposesof notice,the meeting dateshallbe a datesetfor the return of mail ballotsandit shall be calledthevotingdate.Adoptionof anyproposal,resolution or amendmentby mail ballot shall be achievedby affirmative vote of a majority of voting activemembersunlessotherwise providedby anotherprovisionof this constitution.Only those mail ballotsreceivedat the businessoffice of the Association within 30 dayssubsequent to the votingdateshallbe counted.

Section3; TheExecutiveCouncilmay, by resolution,propose amendments to the constitution;providedtheproposedamendmentsare mailed to the membershipat least30 daysprior to the meetingat which they are to be considered.

Section4; Adoption of a constitutionamendmentshallbeby a majority vote of the activememberspresentandvoting at any annualor specialmeeting.

ARTICLE IX - DISSOLUTION Uponthedissolutionof thecorporation,theExecutiveCouncil shall,afterpayingor makingprovisionfor thepaymentof all of the liabilitiesof the corporation,disposeof all of theassets of thecorporationexclusivelyfor the purposes of thecorporation in suchmanner,or to suchorganizationor organizations organizedandoperatedexclusivelyfor charitable,educational, religiousor scientificpurposesas shall at the time qualiff as an exemptorganizationor organizations underSection501(c) (3) ofthe InternalRevenueCodeof 1954(or the corresponding provisionof anyfutureUnit€dStatesInternalRevenue[:w), astheExecutiveCouncilshalldetermine.Any suchassets not sodisposed of shallbedisposed by a Courtof Competent Jurisdictionin the Countyin which the principaloffice of thecorporationis thenlocated,exclusivelyfor suchpurposesor to such organizationor organizations,as said court shall determine, whichareorganizedandoperatedexclusivelyfor suchpurposes.

ARTICLE VII _ BYLAWS Section/'' Bylawsmay be adoptedor amendedat anyannual or specialmeetingof the membership.

Section2; Proposedamendments to thebylawsshallbe submittedin writing to theSecretary/Treasurer by threemembers at least60 days prior to the meetingat which they are to be considered.The Secretary-Treasurer shall mail the proposed amendments to the membershipat least30 daysprior to that meeting.

Seaion3: The ExecutiveCouncilmay, by resolution,propose amendments to thebylaws;providedthe proposedamendments are mailed to the membershipat least 30 days prior to the meetingat which they are to be considered.

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BYLAWS OF THE I.INIVERSITY ASSOCIATION FOR EMERGENCY MEDICINE ARTICLE I - MBMBERSHIP . Section1: Application and Election to Membership Application forms may be obtained from the SecretarylTreasurei of the Association.The Applicant must return the completed application forms and supporting letters to the Secretary/Treasuierof theAssociationat leastone month prior to an Executive Council meetingin order to be consideredfor membership at that time.

The qualifications and recommendations of candidates for membershipwill be reviewed by the Membership Committee at eachmeetingof the Executive Council. Approval of the candidatesby the Council shall constitute election to the membership, effective immediately.

Section2: All membersshall pay dues. Only active members may vote and serve as officers. Associate members mav not vote but may serve on the Executive Council.

ARTICLE II _ OFF'ICERS Sectionl: Election of Officers. The Presidentand Vice-presidentshall be electedfor one year, with automatic succession from Vice-President to President. The Secretary/Treasurer, shallbe electedto a three year term. Councilmen-ai-Large shall eachbe electedto+hre+ fwo year terms, the terms being staggered.{er-+heJat+e+-Councilmen-at-large can be elected for twoconsecutiveterms. Nominees for the above offices shall be selected by the Nominating Committee and must have agreed to standfor election prior to their formal nomination for electionat the businesssessionof the annual meeting. Alternative nominationsfrom the floor shall be solicited. Sirch nominees mustalsoagreeto stand for election. Election shall be by majority voteof the active memberspresentand voting at the businesssessionof the annual meeting.

Section2: Duties of the President. The president shall preside overboththe educationalprogram and businesssessionofthe annualmeetingof the Association, and the meetings of the ExecutiveCouncil. It shall be the duty of the president to see that the rules of order and decorum are properly enforced in all deliberations of the Association, and to sign the approved proceedingsof each meeting. The President shall appoint aciive membersto fill vacanciesand unexpired terms on the Executive Counciland standing and ad hoc Committees. The president shallserveas ex-officio member of all standing committees.

Section3: Duties of the Vice-President.In the absenceor illnessof thePresident,the Vice-Presidentshallpreside.The VicePresidentshall serve as Chairman of the Nominating Committeeand ex-officio member of all standing committees.

Section4: Duties of the Secretary/Treasurer. It shall be the dutyof theSecretary/Treasurer to presidein the absenceof both the Presidentand Vice-President, to keep a true and correct recordof theproceedingsof the meeting, to preserveall books, papena1darticlesbelonging to the Association, to keep an accountof the Association with its members, to keep a iegister of thememberswith the dates of their admission, ind current professional addresses,the latter to be circulated annually to themembershipwithin a month prior to the annaul meeting.

Heshallreportunfinished businessfrom previous meetingsr;quiringaction,and attendto suchother businessas the Associationmaydirect. He shall also superviseand conduct all the correspondence of the Association. He shall collect the duesof the Association,make disbursements of expenses, maintain the

financial accounts and records of the Association and present the hnancial accountsand recordsof the Associationfor review by the Auditing Committee within 24 hours prior to the businesssessionof eachannual meeting, at which time he shall present an annual report ofthe financial condition ofthe Association to the membership. He shall be reimbursed for such expenses as he may incur in the proper execution of his duties. He shall serve as ex-officio member of all standing committees.

ARTICLE III - MEETING Section /; The Association shall be governed by the actions taken by a majority vote of the active members present and voting. Between meetings, within the policies establishedby its membership, the Association shall be governed by the Executive Council. Actions of the Executive Council shall be determined by a majority vote of those of its members present at its meeting, six members constituting a quorum.

Section 2: The annual meeting and any additional meetings of 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. Programsfor the annualmeeting shall be arranged by the Program Committee and approved by the President.A final notice ofthe time, place and program ofeach 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 announcedduring the businesssessionofeach annual meeting. The site of the annual meetings shall be chosen by the Executive Council two years in advance.

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

ARTICLE IV _ FINANCES Section1; The annualmembershipduesfor all membersshall be determinedby the Executive Council. The annual membership will be payable within 30 days of request by the SecretarylTreasurer. The Executive Council may establishprocedures and policies regarding non-payment of dues and assessments.

Section2: The Executive Council shall adopt such membership schedulesas is necessaryto encourageparticipation by the interested public.

ARTICLE V _ PARLIAMENTARY AUTHORITY Rule of order. Any question of order or procedure not specifically delineated or provided for by these bylaws and subsequentamendmentsshall be determined by parliamentary usage as contained in Robert Rules of Order (Revised).

ARTICLE VI _ STANDING COMMITTEES Section1; The Nominating Committee shall consistof the VicePresident,as Chairman,the two most recentpastpresidents,and #tt+three elected members who may not be members of the Executive Council. The latter shall serve staggeredtwo year

terms.It shallbe the taskof this committeeto selecta slateof ofEcersto fill thenaturallyoccuringvacancieson the Executive Council and the standingcommitteesnot otherwisedesignated and providedfor by thesebylaws, and havingobtainedeach candidate'spermissionto do so, placetheir namesin nomination beforetle membership for electionat thebusinesssession of the annualmeeting.

Section2: TheExecutiveCouncilshallconstitutetheMembership Committee.It shallbe the Secretary/Treasurer's duty to review the qualificationsand recommendations of eachappli cant,for presentationandapprovalby the majority of the MembershipCommittee.

Section3; The ProgramCommitteeshall be composedof a Chairman,electedfor threeyears,andthreemembersappointed by thePresidentto staggered threeyearterms.Noneof theappointedmembersof thecommitteecanbe membersof theExecutiveCouncil.Its dutiesshallbe to arrange,in conformitywith instructionsfrom the ExecutiveCouncil, the programfor all meetingsand selectthe formal participants.

Section4: The Auditing Committeeshallconsistof two membersappointedby the Presidentto audit the financial accounts andrecordsof theAssociationat the time of theannualmeeting.

Section5; The ConstitutionandBylawsCommitteeshallconsist of a Chairmanand two othermembers,electedfor staggeredthree year terms so that the memberwith the least remainingtenureshall serveas Chairmanduring his final year

on the Committee. This Committee shall study the potential merits, adverseconsequencesand legal implications of all proposedconstitutional amendmentsor changesin the bylaws and report their findings and recommendations to the President and Executive Council prior to the time of formal considerationof the proposed changesby the membership. In addition, they may themselvessuggestappropriate constitutional amendmentsand bylaws changesto the President and Executive Council upon study of problems arising out of the existing constitution and bylaws.

Section6 The Education Committee shall consist of a chairman, elected for three years, and three other members appointed by the President to staggered three year terms. Neither the Chairman, nor appointed members, can be members of the Executive Council. The Committee shall foster continuing education in emergency medicine.

ARTICLE VII - DISSOLUTION OF THE ASSOCIATION Section,l;Dissolutionof thisAssociation canonly beinitiated by a majorityvoteof all membersof the ExecutiveCounciland mustbe approvedby two+hirdsof the activemembership presentand voting at any annualor specialmeeting.

Section2: Dissolutionshallbe achievedin compliancewith Article IX of the constitution.

University Association for Emergency Medicine 900WestOttawa Lansing, Michigan 48915 (517) 485-5484