SAEM 1989 Annual Meeting Program

S

A E M

Societyfor Academic Emergency Medicine

1989Annual MeetingProgram

May 22-25,1989 San Diego, California

Call for Abstracts Societyfor Academic EmergencyMedicine 1990Annual Meeting May 2l-24, Minneapolis,Minnesota The20thAnnualMeetingof the Societyfor AcademicE,mergency Medicinewill be held May 2l-24, lgg} at the Hyatt Hotel in Minneapolis,Minnesota.

ProgramChairman,PaulAuerbach,MD, is now acceptingabstracts fbr reviewfbr oral and posterpresentation at the 1990AnnualMeeting.Because of the largenumberof abstractsubmissions, the AnnualMeeting ProgramCommitteehasdevelopeda two-pageabstractform to be usedfbr all abstractsubmissions.

A copy of theabstract form is publishedin this program.Abstractfbrms will be mailedto the SAEM membership, will be publishedin the Decemberissueof Annalsof'Ernergcnc'y Medicine,and will be senrupon requesr to theSAEM office.Abstractsnot submittedon the official abstractfbrm will be returnedto the authorfor resubmission.

The deadline for the submission of abstracts for the 1990 Annual Meeting is January 19, 1990.

All abstractsmust be submitted on the official abstract form and must be postmarked no later than January 19.

Mail eight copiesof the abstractform to: SAEM Annual MeetingAbstracts 900 West Ottawa Lansing,Michigan48915 Call (517) 485-5484if you haveany questionsor would like to requestan abstractfbrm.

Abstractssubmittedor the resultantmanuscriptsmust not appearin a ref'creedjournal prior to publication of the meetingabstracts in the April 1990issueof Annalsof'Emargent'y Metlit'ine,and must not havebeen presented previouslyat a nationalmeeting.

AnnalsofEmergency Medicineis the officialjournal of the Societyfor AcademicEmergencyMedicine.SAEM stronglyrecommends thatauthorssubmittheir manuscripts to Annals.Annalswill notify authorsof a decision regardingpublicationwithin 90 days of receipt.

Cashawardswill be givenfor the bestabstracts in the followingcategories: ClinicalOral (HumanSubjects), BasicScienceOral, MethodologyOral, ResidentOral, ScientiflcPoster,MethodologyPoster,ResidentPoster, and Oral or PosterPresentation in PediatricAcute Care and Trauma.An award will be given by Annals of Emergency Medicinefor the BestResidentPaperpublishedin Annals.All awarclwinnerswill be announced at the 2lst Annual Meetingwhich will be held in Washington,DC in May 1991.

All abstractsmust be submitted on an official abstract form. Pleaseread the Call for Abstracts carefullv for details and instructions.

PLEASE POST

INTRODUCTION I would like to take this opportunity to welcome you to the inauguralScientific Meeting of the Society for AcademicEmergencyMedicine (SAEM). The program contentreflectsthe goals and o-bjectives of this new Society which include but are not limited to: 1) sponsoringforums for the presentationof scientific investigations,2) promoting the academicmaturationand educationof its membeis, and 3) facilitatinginteractionand dialogue betweenits membersand other organizationsto further researchand patientdare.

It bodeswell that the Society's first meetingwill be the largesttruly scientific assemblyever convened of individualsinvolved in academicemergencymedicine.The Program Committeereviewed473 abstracts and accepted216. Both of thesefiguresare recordswhen comparedto pastUniversityAssociationfor Emergency Medicine meetings.Residentsand fellows were the primary investigatorsin 87 of the studiesto be presented.Registrationand attendanceat the meetingwill alsobe a new high. Attendeeswill havetheoption of attendingseveraltracksdealingwith a specificresearchareaor focus. the Societywill highlightits first "state-of-the-art" presentation,"AIDS Research,"on wednesday,May 24th.

The various committeesand subcommitteesof the Societywill meet during the four daysof the Annual Meeting. Thesemeetingsare open to the membershipand those interestedin becomingmore involvedin committeegoals and tasks are encouragedto attend.

Ample time hasbeenscheduledto allow registrantsto attendthe exhibits. The Sheratonon HarborIsland and the city of San Diego offer a wide variety of attractionsto occupy your sparetime. I encourage you to take advantageof the SouthernCaliforniaclimate.

JamesT. Niemann,MD President

INDEX B a n q u eat n d A i r c r a f tC a r r i e rT o u r .

General Informatiorr K e n n e dLye c t u r e

......,1

2-3 ..........4

State-Of-The-Art:AIDS Research I n t e r n a t i o nSael s s i o n A c a d e m i cE x c e l l e n caen d A c a d e m i cL e a d e r s h iA pw a r d s . . .

Scheduleof Events Posters Abstracts.

E x h i b i t oL r si s t i n g Hotel MeetingRoom Floor Plans.

VadeMecum...

A n n u a lB u s i n e sM s e e t i n gA g e n d a constitution of the Society for Academic EmergencyMedicine . . . .

.......6 .....j

8- 13 .14-16 17-40& 45-68 .........41 . ...42-43 .69-7i .....72-73 77-78

B y l a w so f t h e S o c i e t yf o r A c a d e m i cE m e r g e n c M y e d i c i n e. . . .

....79-81

1 9 9 0A b s t r a c F t orm

.. ..82-83

MembershipApplication 1990Call for Abstracts

. .inside back cover

1989ANNUAL AWARDS BANQUET As always, the Annual Awards Banquetpromisesto be a fine ending to an outstandingeducational experience!All active, associate,and internationalmembersare entitledto one free ticket tolhe Banquet,but advance registration is a must. In order for accuratemeal counts, all banquettickets must be requested

by May 19 in orderto insurea ticket. Only a limited numberof banquetticketswill be availableat theRegistration Desk in San Diego and if you have not pre-registeredyou may not be able to obtain a ticket.

Tickets for residentmembers,presentersand othersare availableat $40 each.Purchasedticketsmust also be reservedby May 19 and additionaltickets may not be availableat the RegistrationDesk.

Thls year's Banquetwill begin with the annual loading of the buseswith a departureof 6:00 pm from the SheratonHotel. The site of this year's Banquetis thi San Diego Wild Animal park which is located 30 miles north of San Diego and the anticipatedbus ride is approiimately 40 minutes.

The Wild Animal Park is a sprawling 1,800 acre sanctuarywhich enablesanimalsto roam freely in settings similar to their nativehomelands.The Wild Animal Park has gainedworld-widerecognitionfor its conservationefforts and offers you the opportunity to experienceits uniqueness.

Upon arrival to the Witd Animal Park, registrantswill journey through animal habitatsof Africa via the WgasasBushLine Monorail. This 50 minutetour will inciudeguid"r de"scribing manyof the2,400animals living together.It will be a specialtreat to view behaviorsoianimals living in entire herdsand flocks.

A cocktail receptionand dinner will follow the tour. The dinner will be held in the Mombasapavilion and will includea delicioustwo-entreebuffet. And of course,the annualImagoObscuraandJames MacKenzie Awards will be presented!

Buseswill leavethe Wild Animal Park at approximatelyl0:fi) pm andarrival at the SheratonHotel shouldn't be laterthan I l:00 pm.

The AnnualAwardsBanquetis a traditionyou won't wantto miss!If you haven'tsignedup for your ticket, call the SAEM office immediatelyat (517) 495-54g4.

AIRCRAFT CARRIER TOUR Thanksto the {.1.S.Navy, the SAEM Annual Meeting registrantshavea rare opportunityto tour the U..S..S. Independence,oneof the 14 aircraft carriersin the U.S. fl"ei. Thesetours will be availableonly on Wednesday, May 24 and rhursday, May 25 and can accommodateonly 75 personseach day.

The tours will take a total of abouttwo hours;from l:00 to 3:00 pm. The tour will beginwith boarding busesfor a departuretime of l:00 pm. A scenicride to the North Islind Naval Stationlocited on CoronadS via the magnificentCoronadoBay Bridge will take approximately30 minutes.A one-hourtour will FlTd follow and will includea tour of the bridge, flight deck, medicaldepartment,hangardeck and ward room.

Buseswill depart at approximately2:30 for a 3:00 pm arrival bac-kat the Shera-ton on Harbor Island.

Sinceonly 75 personsper day will be accommodatedeachday, registrantsmust sign-upon a first come, first servedbasis.Sign-upsheetswill be availableat the SAEM Registition Desk startiig on Sundayevening, May 21.

This is a rare opportunity for our membershipto tour a most impressiveship and SAEM is grateful to the U.S. Navy for its assistance and permission.Dr. Klingelberge.,of the U.S. Naval Hospitalin'SanDiego has been the coordinatorof this event.

GENERAL INFORMATION EMRA RECEPTION EMRA - EmergencyMedicine will host a Receptionon Tuesday,May 23 from 6:30-7:30pm. The highlight of the receptionwill be the presentation of the 1989JeanHollister Award for Excellencein EMS and PrehospitalCare and the 1989EMRA AcademicExcellenceAward.

Hors d'oeurveswill be servedand a cash bar will be available.All interestedEMRA membersand othersare invited to attend.The Reception is sponsoredby Emergency Medicine.

EXHIBITS Exhibits will be availablefor viewing on May 22 from l:00-5:00 pm and on May 23 from 8:00-l l:00 am and l:00-4:00 pm and on May 24 from 8:00-11:00am. The exhibits will be located in the Exhibit Hall and a list of exhibitors is included in this program. All coffee breaksduring exhibit hours will be held in the Exhibit Hall' Registration will also be locatedin the Exhibit Hall. Pleasetake an opportunity to view the exhibits durine the scheduledcoffee breaks.

TECHNOLOGY FORUM An informal TechnologyForum will be held on Tuesday,May 23 from 8:00-11:00am in the SanCarlosRoom.This will includea discussion of the TechnologyAdvisory Board.

EMRA RESIDENT RESEARCH FORUM The annualEMRA ResidentResearchForum will be held on Tuesday, May 23 fromT:30-9:00pm andwill focuson ManuscriptPreparation. Dr. Ronald Krome, Editor Emeritus of the Annals of Emergency Medicine, will begin the forum with a discussionon how to prepare a manuscript for publication. Dr. Krome was the editor of Annals for 15 yearsand brings a wealth of knowledgeand experienceto this topic.

The Forum will continuewith a paneldiscussionby the editorsof the EmergencyMedicinejournals who will describethe generalfocus of their respectivejournals and any aspectsof manuscriptpreparation which are of special interestto them. This will be followed by an open questionand answer period. All Annual Meeting registrantsare invited to attendthis session.

RESEARCH DIRECTORS' LUNCHEON The SecondAnnual ResearchDirectors' Luncheonwill be held Tuesday, May 23 from 1l:30 am to l:00 pm in the Harbor TerraceRoom of the Sheratonon Harbor Island. This year's roundtablediscussion "ResearchDirectors: will focus on the topic, Qualificationsand Expectations."Dr. Gary Krausewill begin the discussionwith a report from a survey on the statusof researchdirectors. Researchdirectors and all othersinterestedin conductingresearchin EmergencyMedicine are welcometo attend.However, spaceis limited and advanceregistration is required. Tickets are $25 and a few tickets may be available at the Registration Desk on May 22.

FELLOWS DINNER AND PROGRAM The Annual Fellows Dinner and Program will be held Monday, May 22 from 7:30 pm to 9:30 pm in the FairbanksBallroom of the Sheraton Grand Hotel. The topic of this year's Fellows Dinner and Program "Fellowship Training Curricula." Dr. Petervan Ligten, Dr' will be, Richard Dart, Dr. Eric Davis, and Dr. Gerard Martin will discusstheir experiencesand recommendationsand this will be followed by a ques-

ls tion and answerperiod. Spaceis limited and advanceregistration required. Tickets are $25 and a few tickets may be availableat the RegistrationDesk on May 22.

OPENING COCKTAIL RECEPTION SAEM is hostingan openingcocktail receptionon Monday,May 22 from 6:00 pm until 7:30 pm in the Bel Aire Ballroom of the Sheraton Grand Hotel. All Annual Meeting registrantsare invited to attendand celebratethe new organizationand toastto its future. Hors d'oeurves will be servedand a cash bar will be available.

PROCEEDINGS Proceedingsof the Annual Meeting will not be preparedasa separate publication. However, selectedpresentations,scientificpapersandper. tinent discussionwill be printed in the Annals of EmergencyMedicine, and thejournal of the AmericanCollegeof EmergencyPhysicians In addition, the Medicine.

Emergency for Academic Society from the 1989Annual Meeting havebeenpublishedin the April issue of Annals of Emergency Medicine.

I99OCALL FOR ABSTRACTS 1990 Annual Meeting will be held May 2l-24 in Minneapolis' Call for Abstracts is publishedin this program. Becausethere changesin this year's abstractsubmissionprocess,pleasereadthe for Abstractscarefullyand post it in your institution.The deadline submissionof abstractsfor the 1990Annual Meeting is January I 990.

SAEM MEMBERSHIP A membershipapplicationis includedin this programand copiesare availableupon requestto the SAEM office at 900West If youare tawa,Lansing,Michigan48915or call (517)485-5484. a member,pleaseconsiderjoining SAEM. If you are alreadya give this applicationto a colleague.SAEM needsyour supportfor growth and developmentof academicEmergencyMedicine.

SAEM BOARD OF DIRECTORS MEETING The SAEM Board of Directors will convenea meetinson Tr May 23 from from 7:00-10:00pm in the CheninRoom.This will be chairedby Arthur B. Sanders,MD, who beginshis term the SAEM presidentat the Annual BusinessMeetingon May 23. interested members and others are invited to attend this, and meetinssof the Board of Directors.

REGISTRATION AND INFORMATION All registrantsmust check in at the SAEM RegistrationDeskto up name badges which are required for admission into the Meeting sessions.The RegistrationDesk will be openduringthe listed below: Sunday Monday Tuesday Wednesday Thursday

pm 7:00-9:00 7:00 am-5:00pm 7:00am-5:00pm 7:00-l1:00am l:00-5:00pm 7:00am-5:00pm

Exhibit Hall Exhibit Hall Exhibit Hall Exhibir Hall Foyer, Grand Foyer, Grand

JAMES MACKENZIE AWARD The James R. Mackenzie Award, named after one of UA/EM's fbundersand first presidentsof the society,was establishedto recognize the importanceof the honest,vigorous, and thoughtfuldiscussionof research papers at a scientific meeting. The Mackenzie Award recognizesthat personwho throughdiscussionof one or more presentationsat the meetingcontributedto the scientificand intellectualquality of the meetingin a significantand meaningfulway. All investigators understand that, in order to havetheir work recognized,they mustpresent it to their peers. The purposesof such presentationsare: to disseminatenew information,to educateothers,to stimulatequestions which will clarify the hypothese, methods,resultsandconclusions of the work presented,and to receiveconstructive criticismwhich will generatenew ideasand improve future work. The MackenzieAward is the embodimentof the belief that thesethingsare important.The award is presentedto encouragemembersto vigorouslyparticipatein the proceedingsof the meeting,becauseit is to promotetheseinteractionsthat the meetingis held.The MackenzieAward hasbegunto be perceivedin an increasinglyinappropriateway. This trend could be turned around and the award placed back in its proper and rightful perspectiveas emblematicof significantcontributionto the annual nrcetlng.

Posterswill bc set-upeachmorningfiom 9:00-12:00noonand must bc disnrantled eachaliern<xrn by -5:00pm. The scheduleis as fbllows: PosterSession I 2:45-5:l-5 pm E,xhibitHall (Sheraton,on Harbor Island) PostcrSession II l:00-3:30 pnr LzrJolla,Monterey,Carmel, Del Mar Rooms(Grand Hotel) PosterSessionIII l:30-4:00 pm (Sameas PosterSessionII)

ANNUAL BUSINESSMEETING The Associatkrn will hold its AnnualBusiness Meetingfrom l:00-2:30 pm on Tuesday.May 23 in the BurgundyBallroom.All membersof theassociation are urgedto attend,however,only activemembersare eligibleto vote.

SPEAKERS'READYROOM A speakers'ready room will be availablefirr thosewho wish to check their slidesin advanceof their presentation.

Keysto the readyroom will be availableat the RegistrationDesk.

22 23 24 2-5-

MEETINGS

Monday, May 22 EMRA Board of Director Meeting 8 : 0 0 a m - 1 2 : 0 0n o o n - R o o m 4 1 4 Annals Editorial Board Meeting 9 : 0 0 a m - 3 : 0 0p m - R o o m s4 l l - 4 1 5 SAEM ResearchCommitteeMeetine l : 0 0 - 3 : 0 0p m - R o o m4 1 8 SAEM UndergraduateCurriculum Committee Meeting 5 : 0 0 - 6 : 0 0p m - R o o m 4 1 8 Tuesday, May 23 SAEM TechnologyAdvisory Board Meeting 8 : 0 0 - l l : 0 0 a m - S a n C a r l o sR o o m SAEM EducationCommittee Meeting 9 : 3 0 - l : 0 0 a m - R o o m5 1 5 SAEM Board of Directors Meetins 7 : 0 0 - 1 0 : 0 0p m - C h e n i nR o r i m Wednesday, }Iay 24

POSTERS

May May May May

ADDITIONAL

Roorn 5l l, Sheratonon Harbor Island Towers II, Sheratonon Harbor Island Towers Lounge, Sheratonon Harbor Island Room I 14, SheratonGrand

MESSAGEBOARD A messageboard will be rnaintainedat the RegistrationDesk. Phone messagescan be left at the SAEM RegistrationDesk by calling the Sheratonon Harbor Island at (619) 692-2269on May 22-24 and at the SheratonGrand on May 25 at (619) 692-2783and requestingthe SAEM RegistrationDesk.

CONTINUING EDUCATION The Universityof California, SanDiego, accreditedby the Accreditation Council for ContinuingMedical Education,certifiesthat this program meetsthe criteria for CategoryI toward the PhysiciansRecognition Award of the American Medical Association.The Annual Meeting has also applied for CategoryI credit from the American College of EmergencyPhysicians.A verificationof CME creditswill be sentto each registrantimmediatelyfollowing the Annual Meeting.

AJEM Editorial Board Meering l2:3o-l:30pm - Room511 SAEM EMS EducatorsCommittee Meetins p m - R o o m4 1 8 3:30-5:00 ResidencyDirectorsMeeting 7:30-9:30pm - White Wines Rooms Thursday, May 25 AcademicChairs Meeting 9 : 3 0 - l l : 3 0a m - R o o m5 1 8

PLACEMENT SERVICE A bulletinboardwill be maintainednearthe RegistrationDesk for personswishingto post positionsand physiciansavailablelistings.

EDUCATIONAL COLLABORATION OF MILITARY AND CIVILIAN TRAINING PROGRAMS A specialsessionwill be held on Tuesday,May 23 from 5:15 to 6:30 pm and will focus on collaborationof military and civilian training programs. Dr. William Dalsey will moderatethis sessionand will discuss,"ResearchConsortiums."Dr. William Bickellwill discuss, "Research Venturesand Funding," Dr. MatthewRice will discuss, "MAST Helicopter Programsand EMS," and Dr. Glenn Hamilton and Dr. RaymondTen Eyck will discuss,"Combined ResidencyPrograms.' ' Additional panelistsfrom all three military serviceswho are actively involved in a wide-rangeof activitieswill also be presentto discuss the possibilitiesand help guide participantsthrough the bureaucracy to avoid some of the pitfalls which can occur in dealing with the military. Theseadditionalpanelistswill include Dr. Gary Lammert, ResidencyDirector at the San Diego Naval Hospital; Dr. Monte Mellon, the Departmentof TransportationConsultantin Emergency Medicine; Dr. John Howell, AssistantChief of EmergencyMedicine at Wilford Hall Medical Center;Dr. Alan Morgan, ResidencyDirector, Darnall Army Medical Center; Dr. John Prescott,Chairman, Departmentof EmergencyMedicine, Fort Bragg; Dr. Tim Coleridge, EmergencyMedicine Consultantto the Army SurgeonGeneral;and Dr. Mitzi Johnson,Chief of EMS, Wright PattersonAir Force Base.

KENNEDYLECTT]RE

D. KaY Clawson,MD Chairman, ExecutiveCouncil, AAMC ExecutiveVice Chancellor University of KansasSchoolof Medicine "The Education of the EmergencyPhysician"

Doctor Clawson is a graduateof Harvard Medical Schooland entered academic medicine after completing his orthopaedic training at Stanford University. He becameone of the youngest department chairmen in the country when he founded the orthopaedic department at the University of Washington' His academic accomplishmentsare impressive. He has authored seventy-fivepapers, five books, and numerousother publications.

Doctor Clawson has focused his career on improving the "My driving force," he said quality of medical education. "is to get enthusiasmback into medicaleducation"' recently, At the University of Washington, he took an innovative, problem-solvingapproachto teaching,presentingstudentswith patients and having them determine how their diseaseshad developed. He was twice awarded the Outstanding Teacher Award there. He was Dean of the University of Kentucky Medical School until he took his present position as the Executive Vice Chancellor of the University of Kansas Medical Center. He founded the Emergency Medicine residency at the University of Kentucky and is now starting an Emergency Medicine program at the University of Kansas'

In recognitionof his commitmentto medicaleducation, has been electedto many leadershiproles in the of American Medical Colleges.He servedas the Chairman the Council of Deans in 1986 and is presentlythe Chai of the Executive Council of the AAMC. Doctor Clawson was chosenas Kennedylecturerthis becausehe has actively and effectively worked to establish separateidentity of EmergencyMedicine in organized medicine. His acceptanceand appreciation of the ability and potential of Emergency Medicine has done to establishits credentialsin the upper echelonsof medical educationin the United States.As Chairmanof ExecutiveCommitteeof the AAMC, his supportfor Medicine continues. The AAMC now has a separate for EmergencyMedicine faculty, and EmergencyMedicino its own listing in the AAMC statisticsand publications' The Society for Academic Emergency Medicine the supportthat Doctor Clawsoncontinuesto giveto EmergencyMedicine. The Societyis honoredthisyearto Doctor D. Kay Clawson presentingthe 1989Kennedy

STATE-OF-THE-ART:AIDS RESEARCH The State-of-the-ArtPresentationwill feature3 areasof AIDS research.Dr. Haseltinewill discussthe pathophysiology of the AIDS virus. He will cover the basic structureof the virus, the history of its discovery by Dr. Gallo, the mechanismof its infectivity, and strategiesfbr drug and vaccinedevelopment.

Dr' Quinn will discussthe epidemiologyof HIV infection in the U.S. He will point out that the disease is spreadingparticularly in the inner cities and amongwomen and drug users.He will cover mechanismsof virus transmission,risk behaviors,and methodsproposed to curb the epidemic.

Dr' Kelen will discussthe nosocomialrisks of HIV focusingon EmergencyMedicine. He will discussthe casesof AIDS among healthcare providers, note the individual casereportsof occupationallyacquiredHIV, and review data from surveillance studies.He will also criticize some of the methodsused on surveillancestudiesand casereportsto attribute HIV to occupationalacquisition.Finally, he will presentdata from his own studieson health care worker risks and health care worker behavior in taking infection control precautionsin the work place.

William A. Haseltine,PhD, is a Professorin the Departmentof Pathologyat Harvard Medical School and Professorand Chief of the Division of Human Retrovirology at the Dana-Farber CancerInstitute.He sits on the AIDS ExecutiveCommitteeof National Institutesof Health and is also on the ExecutiveCommitteeof the Board of Directors for the American Foundationfor AIDS Research(AmFAR). He has receivednumerousawardsfor his researchand has over 200 publications.His major researchinterestsinclude the structureand function of human retroviruses and antiretrovirusdrug and vaccine development.

William A. Haseltine, PhD

Gabor D. Kelen, MD, is the Director of Researchin the Division of EmergencyMedicine and AssistantProfessorof EmergencyMedicine at The Johns Hopkins University School of Medicine. He is a fellow of both the American Collegeof EmergencyPhysiciansand the Royal Collegeof Physiciansand Surgeonsof Canada.Dr. Kelenhasdirecteda numberof epidemiologic projectson AIDS and nosocomialrisk of HIV acquisitionresulting in publicationsin theNew England Journal of Medicine andJAMA. He has receiveda number of awardsincluding the W.M. Keck Career DevelopmentAward and the EMF CareerDevelopmentAward, as well as grants from the Centersfor DiseaseControl and the American Foundationfor AIDS Research.

Gabor D. Kelen, MD

Thomas C. Quinn, MD, is an AssociateProfessorof Medicine in the Division of Infectious Diseasesat the Johns Hopkins University, and has an adjunct appointmentas Associateprofessor of Immunology and Infectious Diseasesin the Johns Hopkins School of public Health and Hygiene. He is alsoa SeniorInvestigatorin the Laboratoryof Immunoregulationat the National Institute of Allergy and Infectious Diseaseat NIH. Dr. Quinn directs the NIAID intramural program on internationalAIDS and has severalongoing studieson AIDS in Africa, the Caribbean, and South America, as well as, severalepidemiologic studieson HIV infection in Baltimore in collaborationwith other Hopkins investigators.He has receivedseveralU.S. Public Health Serviceawardsfor his work in the epidemiologyof internationalAIDS, and haspublishedover 250 articles in the field of infectiousdiseasesand immunology.

Thomas C. Quinn, MD

INTERNATIONAL SESSION Dr. Delooz is the Directorof the EmergencyDepartmentand EmergencyMedicalServicesat the University and Critical CareMedicineat theCatholic aswell as Professorof Anesthesiology HospitalSint-RafaellGasthuisberg, "AcademicEmergenon thetopicof, membership pleased to address the is Belgium SAEM Universityin Leuven, cy Medicinein Europe."

Herman H. Delooz. MD. PhD

1988 Best Paper of the Emergency Medicine Research Society Effect of a mechanical chest compression and ventilation device on arterial and central vehousblood gas values during cardiac arrest in man, David J. Steedman,BSC, MB, ChB, FRCS, Robert Perchick, MD, and Colin E. Robertson, MB, ChB, FRCP, FRCS During cardioplumonaryarrest the differencebetweenarterial and central venouscarbondioxidelevels providesan indicationof pulmonaryblood flow. However the sequentialdeterminationof arterialandcentral hasnot venousgasvaluesin patientsundergoingcardiopulmonaryresuscitationin the emergencydepartment previously been investigated. of centralvenousand Twelve pre-hospitalcardiacarrestpatientshad simultaneousmeasurements blood gasesat lO-minuteintervalsduring CPR with a mechanicalchestcompressionand ventilationdevice.

All patientsreceivedonly basic life supportprior to arrival in the emergencydepartment.

There was a predominantacidosison the basisof both arterial and central venousblood gas asdid Both the mean arterial and central venouspCO2 levels fell during the courseof the resuscitation measurements. these two between difference

Time (minutes) David J. Steedman, MD

a H+(mmol/l) sy I{+(mmol/l) paC02(kPa) pcvC02(kPa)

n=12 0 63.6+6.9 96.3+9.1 4 . 7+ 0 . 8 t l . 2 +1 . 6

n:7 l0 6 3 . 8 t1 5 . 4 86.4+8.2 4.8+1.2 +0.8 10.6

n:5 20 69.2+13.4 103.5+ 12.9 4.3+1.3 8 . 9 +1 . 4

30 5? 5+

78.5t9.i 7 . 8t 1 . 8

The profound difference betweenarterial and central venouspCO2 valuesreflectsthe poor pulmonary flow producedby externalcardiaccompression.Howeverthe decreasein this differenceduringthe tion effort suggeststhe improved flow which can be achievedusing a mechanicaldevice.

Dr. Nowak will addressthe membershipon current activitiesof the InternationalCommitteeincluding presentationto the 1988Annual Meetingof the EmergencyMedicineResearchSociety(EMRS)in the Kingdom, the combinedSAEM and EMRS meetingin 1990,the newly developedBestResident/Fellow PresentationInternational Award, and the 6th World Congresson Emergency and DisasterMedicine. tant dates are found below: 6th World Congress on Emergency and Disaster Medicine EMRS Annual Meeting -

September 10-15' 1989' Hong Kong

November 24-25, 1989, York, United Kingdom

SAEM-EMRS Combined Meeting -

October 18-20' 1990, Edinburgh' Scotland

will be selectedat the 1989SAEM The first recipientof the BestResident/FellowOral Presentation Meeting. The recipientwill receivean expensepaid trip to attendthe 1989EMRS Annual Meetingin on November24 and25. This award is being sponsoredby the EmergencyMedicineResidents'Associ Richard M. Nowak, MD

r

AWARDS 1989 Leadership Award The Societyfbr Academic Emergency Medicine is proud to present its flrst Academic Leadership Award to Dr. Ronald L. Krome. Ron's involvement with academicmedicinebeganwith his rotating internshipin 196l at the old Detroit Receiving Hospital. After two yearswith the Public HealthService,he returnedto Detroit Receivingin 1964for residencyin generalsurgery. He functioned as surgical chief resident in 1968-69and assumeddirectorshipof the emergency department in 1969. The Ronald L. Krome, MD story aboutthat first job is now legend.

When askedto take the position by Dr. Alex Walt, chief of surgeryat Wayne StateUniversity,and himself a fbrmer UAEM president,Ron acceptedwithout a second'shesitation. His surgicalcolleagues,re4lizingwhat a messthe emergency departmentwas in, could only shaketheir headsin amazement.In the middleof the night Ron got a strangephonecall. A voice shouted, " !'l!? hole" and hungup . . . andso beganhis romancewith emergency medicine.

It was all uphill from then. Every day was a new challenge.First the recruitmentof "emergency physicians" in an era beforeany existed.He was mentorto Hal Jayne(WSU classof 1969)thenBrooksBock (WSU classof 1969),thenJudyTintinalliflMSUclassof 1969),andthenBlaine White @SU classof 1972). Many, many go<lcdoctors drifted in and out of Detroit Receiving in those days, all attractedby the energy, charisma,and fiee wheeling environmentcreatedby Ron Krome.

Ron's academiccareerquickly progressed.He was promotedfrom instructorto assistantprofessorin 1969,associateprof'essorin 1972, and achievedfull professorshipat Wayne State University in 1979.

He has publishedmore than 25 articlesin the medicalliterature,l2 book chapters,and is editor of the textbook, EmergencyMedicine:A ComprehensiveStudy Guide.

While his academiccareeradvanced,Ron demonstratedleadership and communityinvolvementon a local level. He was directorol'a methadonemaintenance clinic and a memberof the Mayor's Committee for the Rehabilitationof Narcotic Addicts and on the Governor's Task Force on VictimlessCrime.

On a nationallevel, his leadershipis legendary.He servedas president and vice presidentof the American Collegeof EmergencyPhysicians.He was secretary/treasurer and then presidentofthe University Associationfor EmergencyMedicine in 197-5-78.He was a rrustee of the American Board of EmergencyMedicine from 1979 to 1988 and servedas presidentof ABEM in 1984-85.

He hasdevelopedoutstandingresidencytrainingprogramsat Detroit Receivingand William BeaumontHospital, where he now servesas chief of the Departmentof EmergencyMedicine.

Despitethis outstandingrecord,probablyRon's greatestaccomplishment was his tenure as editor-in-chiefof the Annals oJ'Emergency Medicine. He transformedJACEP (Journalof the American College of EmergencyPhysicians)into the Annals of EmergencyMedicine, a true scientific peer reviewedpublication. The Annals has developed into one of the most respectedscientificjournals in medicine. In so doing it has demonstratedto the medical community the quality of researchand academic developmentof emergency medicine as a specialty.

Beyond Ron Krome's titles, different hats, and involvementwere hoursand hoursof work and miles and miles of travel. His motivation is a deep commitmentto make a significantcontributionto society, to changethings for the better, and to right a systemof emergency medical care that was being done wrong.

Judith E. Tintinalli. MD Arthur B. Sanders, MD

1989 Hal Jayne Academic ExcellenceAward The Societyfbr AcademicExcellence is proud to presentthe 5th annual Hal Jayne Academic ExcellenceAward to Dr. RichardF. Edlich.

Dr. Edlichhasexcelledin emergency medicine as a teacher, scientist, and physician.He is the only activemember of the Universityof Virginia Schoolof Medicinewho hasbeena recipientof the University of Virginia Distinguished Professor Award as master Teacher ( 1 9 8 5 ) . I n M a y , 1 9 8 9 ,t h e V i r g i n i a Councilfor Higher Educationwill honor Richard F. Edlich. him with its OutstandingFacultyAward.

MD, PhD His commitment to medical student educationwas recognizedby the graduatingmedical studentclassof 1987by askinghim to deliverits baccalaureate addressthat was appropriatelytitled "Ret1ections ofa Teacher"and subsequently published in the Annals ol Emergen<'v Medicine.

Dr. Edlichgraduated fiom New York UniversityCollegcof Medicine in 1962.He completeda straightmedicineinternshipin 1963at the Universityof Buffalo,Buffalo GeneralHospitaland a GeneralSurgery Residencyin l97 l at the Universityof Minnes<xaHealthSciences Center.He rcccivedhis PhD in l97l fiom the Universityof Minnesnta wherc his thesiswas, "Studiesin the Management of the Contaminated Wound" in 1973.

For the last25 years,Dr. Edlich hasstudiedthe epidemiology and treatmentol traumaticwounds.He reviewedthis adventureof scien, tilic discoveryin his KennedyLecture"Biology of WoundRepairand Inl'ection: A Personal Odyssey"to UA/EM in 198-5.

His collaborative researchstudicshavebeenpublishedin mure than400 scientificarticlesandsevenbooks,includingCurrcntEmergercvTherupypublished in 1986,Sy^rlarn^r Approachto EmergenL'y Medical Carc publishedin 1983,and,4ManualJbrWoundCkssurein 1980.His researchinvestigations havebeenrecognizedby Awards fiom the Southeastern Society lirr Plasticand Reconstructive Surgerythe VirginiaSurgicalSociety, and the ArnericanSocietytbr Plasticand Reconstructive Surgery.He presentlyserveson the Edikrrial Board of the Annal.soJ'Emergency Medicine.

His clinical interestshavefbcusedon emergencymedicineand burn care. As Directorof EmergencyMedicalServicesof the University of Virginia from 1973until 1982,he was responsible for the coordinationand implementation of a regionalemergencymedicalsystem in CentralVirginia. When he becameDirectorof the Universityof Virginia Burn Centerin 1975,he becamethe championand architect ftrr a lO-bedregionalburn center. He is the recipientof an endowed chair in Plasticand Reconstructive Surgeryand holdsthe academic positionol'DistinguishedProf'essor of PlasticSurgeryand Biomedical Engineeringat the Universityof Virginia Schoolof Medicine.

Raymond Morgan, MD Arthur B. Sanders, MD

SCHEDULE OF EVENTS SUNDAY, MAY 21 Registration, Exhibit Hall

7:00-9:00 pm

All meetings will be held in the Sheraton Hotel on Harbor Island unless otherwise indicated. The Sheraton Grand Hotel is ndxt door to the Sheraton on Harbor Island.

MONDAY, M.AY 22 7:00 am-5:00pm

Registration, Exhibit Hall

8 : 1 5 - 8 : 3a0m

Opening Remarks, Jerris R, Hedges, MD, Program Chairman, ChabLisBallroom

am 8:30-8:50

The Academic Department of Emergency Medicine: What Can it Do?, Chablis Ballroom Glenn C. Hamilton, MD, Professor and Chairman, Department of Emergency Medicine, Wright State University

8 : 5 0 - 9 : 1a0m

How To Obtain Academic Department Status, Chablis Ballroom Alexander Trott, MD, University of Cincinnati

9 : 1 0 - 1 0 : 0a0m

Panef Discussion on Academic Status in Emergency Medicine, Chablis Ballroom E. Jackson Allison, Jr., MD, MPH, East Carolina University Glenn C. Hamilton, MD, Ilright State University Paul Mehne, MD, Associate Dean for Student Affairs, East Carolina University Alexander Trott, MD, University of Cincinnati David llagner, MD, Medical College of Pennsylvania

l 0 : 0 0 - 1 0 : 1a5m

Coffee Break, Ballroom Foyer

10:l5-11:00 am Track A: DevelopingPositiveResidentAttitudes, Chablis Ballroom Michael E. Gallery, PhD, Associate ExecutiveDirector, ACEP

l l : 0 0 - 1 1 : 1a5m

l0: l5-11:00 am Track B: The Impaired Physician, Burgundy Ballroom StephenScheiber, MD, Executive Secretary, American Board of Psychiatry and Neurology

Coffee Break, Ballroom Foyer

I l:15-12:00 noon Track A: Clinical Teaching Skills' Chablis Ballroom Frank T. Stritter, PhD, Professor, SchooLsof Medicine and Education, University of North Carolina at Chapel Hill

I l:15-12:00 noon Track B: Teaching the Non-EmergencyMedicine Rotator, Burgundy Ballroom Margaret M. Barron, MD, Chnirman of Emergency Medicine, Providence Hospital, Washington,DC

l 2 : 0 0 - 1 : 0p0m

Lunch Break

l : 0 0 - 1 : 4p 5m

Manpower Projections: AAMC, SAEM, and ACEP Perspectives, Chablis Ballroom Moderator: Arthur B. Sanders, MD, PresidentElect, Societyfor Academic Emergency Medicine Jacek Franaszek, MD, President, American College of Emergency Physicians Glenn C. Hamilton, MD, Administative Board, Council of Academic Societies, AAMC

l:45-2:00pm

Coffee Break -

Exhibits Open, fuhibit Hall

2:00-2:45pm

Indigent Health Care: The Carrot or the Stick? Chablis Ballroom Michael J. Bresler, MD, Stanford University

pm 2:45-3:00

Coffee Break -

Exhibits Open, Exhibit Hall

pm Track A: 24 Hour Coverage: Ways of Dealing with 3:00-3:45 the Issue, Chablis Ballroom Moderator: Louis Binder, MD, TexasTech University E. Jackson Allison, MD, East Carolina University Glenn Hamilton, MD, Wright State University Daniel Spaite, MD, University of Arizona Robert Prosser, MD, University of Kansas William Robinson, MD, Truman Medical Center

Track B: The Role of EMS in the AcademicSetting' Burgundy Ballroom Moderator: Ron lnw, MD, University of Chicago Kathleen Cline, MD, East Carolina University Paul Pepe, MD, Baylor Collge of Medicine

pm 3:45-4:00

Coffee Break, Exhibit Hall

pm 4:00-5:00

Faculty Development, Institutional Responsibilities, and Strategies, Chablis Ballroom Frank T. Stritter, PhD

5:00-5:30 pm

Awards Presentations, Chablis Ballroom 1989 Hal Jayne Award for Academic Excellence Richard F. Edlich, MD, PhD The Hal Jayne Academic ExcellenceAward is sponsoredby SpectrumEmergencyCare, Inc. 1989 Academic Leadership Award Ronald L. Krome, MD 1988 Best Oral Basic Science "Amanba Phalloides Poisoning: Mechanism of Cimetidine Protection," Sandra M. Schneider,MD, University of Pittsburgh This award is sponsoredby Emergency Medicine 1988 Best Oral Clinical Science "The Inability of PrehospitalTrauma PredictionRules to Classify Trauma PatientsAccurately," William G. Baxt, MD, University of Califurnia, San Diego This award is sponsoredby MICROMEDEX, Inc. 1988 Best Oral Methodology "Attending Coveragein AcademicEmergencyMedicine: A National Survey," Phittip L. Hennemnn,MD, Harbor-IICLA This award is sponsoredby SAEM 1988 Best Scientific Poster *Defining Normal Capillary Refill: Variation with Age, Sex, and Temperature," David L. Schriger, MD, UCLA This award is sponsoredby Emergency Medicine and Ambulatory Care News 1988 Best Methodology Poster "A Computer-AssistedLearning Tool Designedto lmprove Clinical Problem solving Skills," Frank J. papa, DO, Texas College of Osteopathic Medicine This award is sponsoredby SAEM 1988 Best Pediatric Acute Care and Trauma "Endotracheal Intubation of Pediatric Patients by Paramedics," Peter Aijian, MD, Valley Medical Center This award is sponsoredby Pediatric Trauma and Acute Care 1988 Best Resident Poster "Reliability of Clinical Presentationfor PredictingSignificantViper Envenomation," KatherineM. Hurlbut, MD, Ilniversity of Arizona This award is sponsoredby PergamonPress 1988 Annals Best Resident Paper "The Evaluationof SuspectedRenal Colic: UltrasoundScanvs. Excretory Urography," Douglas Sinclair, MD, Victoria General Hospital, Halifax, Nova Scotia This award is sponsoredby Annals of Emergency Medicine

6:00-7:30 pm

Opening Reception, Bel Aire Ballroom (Grand Hotel)

7 : 3 0 - 9 : 3p0m

Emergency Medicine Fellows Dinner and Program, Fairbanks Ballroom (Grand Hotel) "Fellowship Training Curricula" Peter van Ligten, MD, Ohio State Llniversity Richard Dart, MD, University of Arizona Eric Davis, MD, Medical College of Pennsylvania, Allegheny Campus Gerard Martin, MD, Henry Ford Hospital

7:00am-5:00 pm Registration, ExhibitHart

'TUESDAY'

MAY

8:00-12:00 noon

Poster SessionI Set-Up, Exhibit Hall

8:00-8:15 am

Announcements, Jerrts R, Hedges, MD, Chablis Ballroom

8 : 1 5 - 9 : 3a0m

23

Plenary Session, Chablis Ballroom Moderator: John McCabe, MD, State University of New york 132. Emergency Department Diagnosis of Ectopic Pregnancy, Thomas G. Stovall, MD, (Jniversity of Tennessee 133. Mortality and Morbidity Following the 1988 Earthquake in Soviet Armenia, Gabor D. Kelen, MD, Johns Hopkins University 134. Analysis of the Emergency Department Managementof SuspectedBacterial Meningitis, David A. Talan, MD, IlCLtl 135. Ciprofloxacin in the Treatment of Acute Infectious Diarrhea, Martha Neighbor, MD, University of Califurnia, San Francisco 136' Evaluation of Women With Possible Appendicitis Using Technetium-99M Leukocyte Scan, Terri A. Halt, MD, Harbor-UCI-4

9:30-10:00 am

Coffee Break -

Exhibits Open, Exhibit Hall

10:00Track A: Administration, Chablis Ballroom ll:30 am Moderator: Inuis Binder, MD, Texas Tech Universin 137.A MathematicalModel of PsychosomaticSymptoms in the Practice of Emergency Medicine, Raywin R. Huang, MD, Michigan State University 138. RefusingCare to PatientsWho Presentto an Emergency Department, Robert W. Derlet, MD, University of Califurnia, Davis 139.EmergencyDepartmentDiversionof Non-UrgentPatients to an Off-Site Walk-In Facility, Keith T. Sivertson, MD, Johns Hopkins University

10:00Track B: Respiratory, Burgundy Ballroom 11:30 am Moderator: Jerome Hoflman, MD 143.Hypoxic Hazards of Paper Bag Rebreathingin Hyperventilating Patients, Michael Callaham, MD, University of Califurnia, San Francisco 144. Inhaled Sodium BicarbonateTherapy for ChlorineInhalation Injuries, Carey D. Chisholm, MD, Joint Military Medical Command, San Antonio 145.Responseof Bronchial SmoothMuscle to MgCl2 in Yitro, William H. Spivey, MD, Medical College of Pennsylvania

140.Early UnexpectedDeathsFollowing AdmissionFrom the Emergency Department,JosephG. Mueller, MD, Christ Hospital 14l. Use of Autopsy Results in the Emergency Department's Quality AssurancePlan, Mary C. Burke, MD, Univ ersity of Massachusetts 142.DRGs the "Negative" Trauma Work-Up, Catherine M. Dougherry, RN, UMDNJ - Roben WoodJohnson Medical School

146.ProspectiveComparison of Inhaled Atropine and Metaproterenol in the Therapy of Refractory Status Asthmaticus, Gary P. Young,MD, Ponland Veterans Administration Medical Center 147.Adjunctive Use of Ipratropium Bromide in the EmergencyManagementof Acute Asthma, StevenM. Tiernan, MD, Darnall Army Community Hospital 148. The Utility of ExtendedEmergencyDepartmentTreatment of Asthma: An Analysis of Improvementin Peak Expiratory Flow Rate as a Function of Time, Daniel G. Murphy, MD, Cook County Hospital

I I :30 am-I :00 pm Research Directorst Luncheon, Harbor Tercace "Research Directors:

Qualificationsand Expectations" David Cline, MD, East Carolina University Gary Krause, MD, Wayne State University

l:00-2:3p 0m

SAEM Annual Business Meeting, Burgundy Ballroom See agenda,slate of nomineesand proposedConstitutionand Bylaws amendmentsin this program.

pm 2:30-2:45

Coffee Break -

2 : 4 5 - 5 : 1p5m

Poster Sessionl, Exhibit Hall

5 : 1 5 - 6 : 3p0m

Governmental Affairs Committee Session, Chablis Ballroom "Academic EmergencyMedicine's Interface with Federal Agenciesand Research" Moderator: J. Douglas llhite, MD, Georgetown University William kthr, Executive Secretary, Health ServicesResearchStudy Section, National Centerfor Health Services Research John Spiegel, Deputy Director, Health Standards and Quality Bureau, Health Care Financing Administation Richard Cummins, MD, University of Washington Mickey Eisenberg, MD, University of Washington Bonita Singal, MD, University of Cincinnati This panel will explore current programs where federal funding agencieshave developed projects with emergency to investigateselectedtopics of research.Academic emergencyphysiciansactive in theseprograms will presenttheir and representatives of federalagencieswill discusstheir mission,programdevelopment,and attemptto project possible liaisons.

pm 6:30-8:00

"Educational Collaboration of Military and Civilian Training Programs", Burgundy Ballroom Moderator: William C. Dalsey, MD, Iackland Air Force Base William Bickell, MD, University of Oklahoma Glenn Hamihon, MD, Wright State University Matthew Rice, MD, Madigan Army Medical Center Raymond Ten Eyck, MD, Unifurmed Services University of the Health Sciences

pm 7:00-10:00

SAEM Board of Directors Meeting, Chenin Room

6:30-7:30 pm

EMRA - Emergency Medicine Reception, Harbor Terrace During this reception EMRA will presentthe JeanHollister Award and the EMRA Academic Excellence Award. All registrants are invited to attend.

pm 7:30-9:30

EMRA-SAEM Resident Research Forum. Chablis Ballroom "Manuscript Preparation in Emergency Medicine" Ronald L. Krome, MD, Editor Emeritus, Annals of Emergency Medicine John McCabe, MD, Editor, Resuscitation Peter Rosen, MD, Editor, Journal of Emergency Medicine Joseph Waeckerle, MD, Editor, Annals of Emergency Medicine J. Douglns White, MD, Editor, American Journal of Emergency Medicine

Exhibits Open, Exhibit Hall

l0

WEDNESDAY, M.AY 24 7:00-12:00 noon

Registration, Exhibit Hall

8:00-12:00 noon

Poster SessionsII Set-Up, LaJolla, Monterey, Carmel and Del Mar (Grand Hotel)

8:00-8:15 am

Announcements, Jerris R. Hedges, MD, Chablis Ballroom

8:159:45 pm

Track A: Cerebral Resuscitation, Chablis Ballroom Moderator: Gerard Manin, MD, Henry Ford Hospital

8:159'.45 am

149.Evaluation of Brain Edema Using euantitative Magnetic ResonanceImaging, JamesE. Olson, phD, Wright State University 150.Effect of High-Dose Norepinephrine Versus Epinephrine on Cerebral and Mycardial Blood Flow During CPR, James 14. Hoekstra, MD, Ohio State University l5l. CerebrovascularOcclusion:When Do Hemorrhaeic Infarcts Develop? Gabrielle de Counen-Myers, Mb, University of Cincinnati 152. Cerebral Multifocal HypoperfusionAfter Cardiac Arrest in Dogs, Mitigated by Hypertension and Hemodilution, Fritz Sterz, MD, University of Pittsburgh 153. CerebralIschemiaand Reperfusion:Failure of Hyperbaric Oxygen Therapy to Promote IncreasedSurvival or Neurologic Protection, Jeffrey p. Smith, MD, George lVashington Univ er sity 154.A Dose ResponseStudy of an Experimental Iron Chelatorfor Inhibition of DNA Damageby Oxygen Radicals, Debra M. Feldmnn, MD, Wayne State University

9 : 4 5 - 1 0 : 1a5m

Coffee Break -

Track B: Cardiac Arrest/EMS, Burgundy Ballroom Moderator: David Wilcox, MD, IJniversityof Massachusetts 155. The Relative Contributions of Early Defibillation and ACLS Interventionsto Resuscitationand Survival From Prehospital Cardiac Arrest, Judith R. Graves, EMT-P, RN, University of Washington 156. EMT-D Survivors: The Contributionof Defibrillation, Daniel Fark, MD, Medical College of Wisconsin 157.PrehospitalTranscutaneous Cardiacpacing- phase il, William C. Dalsey, MD, Wilfurd Hall Medical Center, Lackland Air Force Base 158.SurvivalPrognosisfor the Elderly Following Out-OfHospitalCardiac Arrest,MarniJ. Bonnin, MD, Baylor College of Medicine 159.Prehospital Prophylactic Lidocaine Does Not Favorably Affect the Outcomeof PatientsWith Chest Pain, Kathleen M. Hargarten, MD, Medical Collese of Wisconsin

Exhibits Open, Exhibit Hall

10:15-12:0 n0 o o n State-of-the-Art Presentation: AIDS Research, Chabtis Bailroom

Moderator: Michael Callaham, MD, Ilniversity of Catifurnia, San Francisco "Pathophysiology of HIV Infection," William Haseltine, PhD, Chief, Division of Human Retrovirology, Dana Farber Cancer Institute, Harvard Medical School "Epidemiology of HIV Infection, " ThomasC. Quinn, MD, Senior Investigator, Narional Institute of Atlergy and Infectious Diseases,National Institutes of Health and AssociateProfessor of Medicine, Johns Hopkins I)niv:ersity 'Risk of Nosocomial Infection with HIV," Gabor D. Kelen, MD, Director of Researchand Asiistant professir of Emergency Medicine, Johns Hopkins IJniversity Lunch Break

12:00-1:00 pm l:00-3:30pm

Poster

3:30-4:00 pm

Coffee Break, Foyer (Grand Hotel)

4:005:30 pm

Session Il,

ln Jolla, Del Mar, Carmel and Monterey (Grand Hotel)

Track A: Pediatrics. Chablis Ballroom Moderator: Dee Hodge, MD, University of Southern Califurnia

4:005:30 pm

160.Comparison of Topical Anesthetic Agents in the Repair of Facial and Scalp Lacerations in Children, David A. Ross, MD, University of Cincinnati 161. TAC vs Cocaine Alone, Lind.aCrabbe, MD. St.Francis Hospital 162. SafetyPracticesand Living Conditionsof l-ow Income Urban Children, Lisa J. Santer, MD, Case Western Reserve University 163' Undiagnosed Abuse in Children Under Three With Femoral Fracture, Heidi J. Dalton, MD, WayneState Univ'ersity 164. Outpatient Management of Febrile Infants 28 to 90 Days of Age With Intramuscular Ceftriaxone, Marc N. Baskin, MD, Children's Hospital, Boston 165' Outcome in Highly Febrile NonbacteremicChildren, Joan Burg, MD, Children's Hospital, Boston

Track B: Infectious Disease, Burgundy Ballroom Moderator: Robert McNamara, MD, Medical College of Pennsylvania 166. Cat Bite Wounds: Risk Factors forlnfection, Daniel J. Dire, MD, Darnall Army Community Hospital 167.The Use of Oral Acyclovir in the Treatment of Herpetic Whitlow, Eric A. Davis, MD, Medical College of Pennsylvania, Allegheny Campus 168. Screeningfor Syphilis in the EmergencyDepartment: RPR's in Patienti wittr Suspecteds"*uully iransmir ted Diseases,Amy Ernst, UO, St. Franiis Hospital 169. HTLV-I Infection in a Inner-City EmergencyDepartment Population: The Next Retrovirus Epidemic?

Gabor D. Kelen, MD, Johns Hopkins Uniiersity 170. Multicenter HIV and Hepatitis B Seroprevalence Sndy, Barbara Wayson,Mb, oregon Heaih Sciences (Jniversity

171. Hepatitis B Infection and Human Immunodeficiency Virus Infection in Emergency Department patients, Keith T. Sivertson, MD, Johns Hopkins Universitv See next page for Track C

ll

4:00-5:30 pm Track C: Cardiac Resuscitation, Palomar Ballroom Moderator: Gary Krause, MD, Wayne State University on Myocardial NecrosisDuring CoronaryArtery Occlusion,TimothyG. Janz,MD, lT2.TheEffects of Fructose-1,6-Diphosphate Wright State University l73.High Energy PhosphateMetabolism During Ventricular Fibrillation, Robert Neumar, Ohio State Universiry 174 Factors lnfluencing Neurologic Recovery After Cardiac Arrest, Norman Abramson, MD, Universiry of Pittsburgh lT5.Improved Resuscitationand Limited Myocardial Infarct Size Following CardiopulmonaryBypass(CPB) Reperfusion,Mark Angelos, MD, Wright State University 176. Comparison of Epinephrine and Dopamine in Cardiopulmonary Resuscitation,Karl H. Lindner, MD, University of Ulm, West Germnny 177.Monitoring End-Tidal Carbon Dioxide as a PrognosticIndex During CardiopulmonaryResuscitationin Humans,Arthur B. Sanders, MD, University of Arizona

pm 5:30-7:00

International Affairs Committee Session, Palomar Ball room ' 'Academic Emergency Medicine in Europe,' ' Herman Dektoz, MD, I)niversity Hospital of St. Rafaell Gasthuisberg,Leuven' Belgium "Report on the EmergencyMedicine ResearchSocietyand the 1990SAEM-EMRS Combined Meeting in Edinburgh, Scotland,'l Richard M. Nowak, MD, Chairman, International Committee presentationof 1988 EMRS Best paper: "Effect of a MechanicalChest Compressionand Ventrilation,Deviceon Arterial and Central VenousBlood Gas Valuesburing Cardiac Arrest," David J. Steedman,MD, Royal Infrmary of Edinburgh,Scotland

pm 7:30-9:30

Emergency Medicine Residency Directors Meeting, Wite WinesRooms: Riesling, Gamay, Colombard, and Chenin "Dual ResidencyTraining Programs" "lmpact of New York Regulationson EmergencyMedicine Training: Staffing, Recruitment,Salaries" "Advancing Medical StudentAwarenessof EmergencyMedicine: Recruitmentof Top Students" "Locked Out of EmergencyMedicine: The Problem of the Flexible ResidentWho Doesn't Match" "Using New Technologiesfor Efficiency and Education:Computer, Videotape,EMail, FAX, Etc." Also, ieports from other organizationsand discussionof organizationof residencydirectors'

THURSDAY, MAY 25 7:00 am-5:00 pm

Registration, Bel Aire Ballroom Foyer (Grand Hotel)

8:00 am-12:00 noonPoster SessionIII Set-Up, Del Mar, La Jolla, Monterey, and Carmel (Grand Hotel)

l5 am 8:00-8:

Announcements, Jerris R. Hed.ges,MD, Bel Aire Ballroom (Grand Hotel)

8 : 1 5 - 9 : 0a0m

Bel Aire Ballroom (Grand Hotel) Lecture, Kennedy "The Eduiation of the Emergency Physician," D. Kay Clawson, MD, Chairman, Executive Council, AssociationoJ Medic1l Colleges and Executive Vice Chancellor, (Jniversity of Kansas School of Medicine

9:00-9:l5 am

Coffee Break. Bel Aire Ballroom Foyer Track B: Clinical, Fairbanks Ballroom (Grand Hotel) Moderator: Phil Henneman, MD, Hcrbor-UCL4 in 183.Comparisonof Cimetidine and Diphenhydramine the Treatment of Acute Urticaria, Ronald Moscati, MD, Darnall Army Community Hospital 184. Cimetidine in the Treatment of Acute Allergic Reactions, Jeffrey W. Runge, MD, Charlotte Memorial Hospital 185. Early Detection of Acute Myocardial Infarction: Immunochemical Determination of CPK-MB Versus Standard Electrophoresis, W. Brian Gbler' MD, Vanderbilt University 186. Use of Indomethacin Suppositoriesin the Treatment of Ureteral Colic, Scott Melanson, MD, Geisinger Medical Center 187. Indomethacionfor Relief of Acute Renal,Colic, Allan B. Wolfson, MD, University of Pittsburgh 188. Stabilization of Unstable Pelvic Ring FracturesWith Military Anti-ShockTrousers:A RadiographicAssessment, Carlos C. Huerta, MD, Mt. Sinai Medical Center of Cleveland

Track A: Trauma-EMS, Bel Aire Ballroom 9: l510:45 am Moderator: RonaM Low, MD, University of Chicago 178.A ProspectiveStudyof Helmet Usageon Motorcycle Trauma, Patrick J. Kelly, MD, University of lllinois 179.Comparison of Different Definitions of Critical Trauma Patients, Michael Smith, MD' Highbnd General Hospital 180.Prehospital Advanced Trauma Life Support for Penetrating Cardiac Wounds, Ben Honigman, MD, University of Colorado l8l . Impactof InterhospitalAir Transporton Mortality in a Rural Trauma System, Robert C. Campbell' MD' Memorial Medical Center, Inc. l82.The Impact of a RegionalizedTrauma System on Trauma Care in San Diego County' David A. Guss, MD, Ilniversity of Califurnia, San Diego

t2

1 0 : 4 5 - l l : 0 a0 m

Coffee Break, Bel Aire Ballroom Foyer

I l:00Track A: Shock-Neurologic Trauma, Bel Aire Ballroom 12:30 pm Moderator: StevenDronen, MD, University of Cincinrnti 189. Neutrophil Medicated Microvascular lnjury, Donna L. Carden, MD, lnusiana State University 190.The Detrimental Effects of IntravenousCrystalloid Following Aortomy in the Swine, William H. Bickell, MD, lztterman Army Institute of Research 19l.An Evaluation of the Diagnostic Capabilities of Magnetic ResonanceImaging with a Comparisonto Computerized Tomography in Acute Spinal Column lnjury, M. Andrew Levitt, DO, Thomns Jefferson University l92.Effect of Hypertonicvs NormotonicResuscitation on Intracranial PressureAfter Combined Head Iniurv and Hemorrhagic Shock, CharleneB. Irvin, MD,"Uiiversity of Cincinnati 193.Effect of ChemicalInterventionson CerebralEdema Formation Following Head Trauma in Rats, Michelle H. Biros, MD, Hennepin County Medical Center 194.Oral Intubationin the Multiply Injured patient: The Risk of ExacerbatingSpinal Cord Damage,Kenneth J. Rhee, MD, University of Califurnia, Davis ll:00-12:30 pm

ll:00Track B: CPR, Fairbanks Ballroom 12:30 pm Moderator: Richard Cummins, MD, [Jniversity of Washington 195.Evaluation of Direct Mechanical Ventricular AssistanceFollowing Fifteen Minutes of Ventricular Fibrillation, Mark P. Anstadr, MD, Ohio State University 196. Coronary PerfusionpressuresDurine CpR are Hisher "Cirin Patientswith EventualReturnof Spontun.ou. culation, Timothy J. Appleton, Henry Ford Hospital l9l.High Dose Epinephrine and Coronary perfusion PressureDuring CardiacArrest in Humans,Norman A. Paradis, MD, Henry Ford Hospital 198.Extreme Systemicand Cerebral Oxygen Extraction During Human CPR, Mark G. Goetting, MD, Henry Ford Hospital 199.Cerebral Lactate Uptake During prolonged Global Ischemiain Humans, Emanuelp. Rivers, MD, Henry Ford Hospital 200. Lidoflazine Administrationto Survivorsof CardiacAr_ rest, Nomnn Abramson, MD, L/niversity of pittsburgh

Track C: Toxicology, Fairbanks Ballroom Moderator: Edward Krenzelok, MD, pinsburgh poison Center 201. Glucagon: PrehospitalTherapy for Hypoglycemia,Rade B. Vukmir, MD, IJniversityof pittsburgh 202. Accurate_Prediction of Tricyclic AntidepressantOverdoseComplicationsUsing ED presentation:A prospectiveStudy, Garritt E. Foulke, MD, IJniversity of Califurnia, Daws 203. Hyperventilationin Tricyclic AntidepressantToxicity, HeetenDesai, MD, Universityof Arizona 204.The Effect of Alpha-l Acid Glycoproteinon Nortriptyline Toxicity in Swine, David C. Seaberg,MD, University piusburgh of 205. The Evaluation of Cocaine Induced Chest Pain, Glenn Tokarski, MD, Henry Ford Hospital 206.SevereOral PhenytoinIntoxication: Lack of CardiovascularMorbidity, Collette D. Wyte, Detroit Receiving Hospital

l 2 : 3 0 - l : 3 0p m

Lunch Break

l:30-4:00pm 4:00-4:15 pm

Poster Session IlI, Oet Mar, La Jolla, Monterey,and Carmel(GrandHotel) Coffee Break, Bel Aire BallroomFoyer

4:155:30 pm

Track A: Trauma. Bel Aire Ballroom Moderator: John Marx, MD, University oJ'Colorado

4:155:30 pm

207. Decreased Inflammatory Reaction (Enhanced Burn Wound Healing) in Non-ionic SurfactantTreatedRats, Paul W. Paustian,Jr., MD, EisenhowqrArmy Medical Center 208. Effect of Povidone-Iodineand Saline Soakins on QuantitativeBacterial Wound Tissue Counts in ,{cute Traumatic ContaminatedWounds, Mark Fourre, MD. Valley Medical Center 209. Tetanus Immunization Status and Immunolosic Responseto a Boosterin an EmergencyDepartmJnt Geriatric Population, Annie Gareau, MD, University of Toronto 210. Utility of ContrastDuodenographyin the Detection of Proximal Small Bowel Injury Following Blunt Trauma, Joanne M. Edney, MD, Denver beneral Hospital 2ll.Computed Tomography (CT) in the Evaluation of Blunt Abdominal Trauma, William C. pevec, (Jniversity of Pittsburgh

6:00-11:00 pm

SAEM Annual Banquet

l3

Track B: Environmental-Toxicology , Fairbanks Ballroom Moderator: Richard Dart, MD, University of Arizona 212..4 Comparative Rewarming Trial of Gastric vs.

PeritonealLavage in a HypothermicModel, M. An_ drew lzvitt, DO, ThomasJffirson llniversity 213. Protocols for the Use of a portable Hyperbaric Chamber for the Treatment of High Altitude Disorders, Robert L. Taber, MD, St.Luke's Hospital 214. A Novel Strategyfor TherapyofAcute Iron poisoning, John R. Mahoney, Jr., phD, Universi\ of Minnesota 215. CombinedTherapy with Cimetidine, penicillin, and Ascorbic Acid for Alpha Amanitin Toxicity in Mice, Sandra M. Schneider, MD, University of pittsburgh 2l6.Contribution of Sorbitol Combined with Activated Charcoal in Preventionof SalicylateAbsorption, Ray E. Keller, MD, Geisinger Medical Center

POSTERPRESENTATIONS Poster SessionI -

Tuesday, May 23

L.)

"Frequent Fliers": A Protocolfbr the Managementof Frequent Visitorsto a Community HospitalEmergencyDepartment,plii B. Fontanarosa, MD, Northeastern Ohio [Jniversitrcs

24

X-Ray Ordering: AgreementBetweenthe Triage Nurse and Physicianin a PediatricEmergencyDepartment.

Z elurulRopp, MD, Children's Hospital of Eastern Ontario

6.

PredictingMyocardialInfarction in the EmergencyDepanment, Charles B. Cairns, MD, Harbor-IJCLA

2 6 . Comparisonof CreatineKinaseand CKMB in EmergencyDepart-

A Dictatedand TranscribedMedical Record Can be Cost Ei'l'ective,Hurlan A. Stueven,MD, Medit'al Collegeof'Wi.sconsin

ment PatientsAdmitted to Rule Out MyocardialInfarction,Gary P. Young,MD, Portlarul VeteransAdministration Medical Center

EmcrgencyDepartmentPatientswith PID: Do They Understand Their Diagnosis'!Elit,ubethA. Cunpbell, RN, Unit,ersityrl Penn.rylvaniu

2 7 . SquamousCells as Predictorsof ContaminatedUrine Culture.

F-rankG. Waltcr, MD, Valley Medical Center

AIDS Educationin the EmergencyDepartment,Duvid Mugid, BS, Univertitt, tl Pcnnsylvaniu

28. Stab Wounds of the Chest: Utiliry of the ExpiratoryChest Radiograph Alone, Sric A. Heine, MD, Medicat Collexeof Pennsylvunitt

ErlcrgcncyPhysicians Responses to FamiliesFollowingpatient Dcath.'[crri Schmidt, MD, Oregon Hrulth St'ience.tUnivcrsitt,

29 Detectionof Sofi TissueForeignBodiesby plain Radiography, Xcrography, ConrputerizedAxial Tomographyand Ultrasonography, Georgc L. Ellis, MD, Universityrl'Pittshurgh

TeachingE,thicsin EmergencyMedicine,Zbigniaw Snxlulski , MI), Butterwtrth Ho.spitul

t0

Problern-Based ACLS Instruction:A Modcl Approach lor UndcrgraduateEntergencyMedical Education, Robcrr F. Polglust, Mcrcer Universit v-

3 1 . PassiveHemagglutinationInhibitionTest filr Diagnosisof Brown

l L .

l3

32. StandardFormulationof NitroglycerinOintmentand Hot packs lirr VenousDilation in PediatricIntravenousAccess.Mark C. Clark, MD, Univcrsitv of Pennsvlvania

An Evaluation of'Pediatric Emergency MedicineEducation: Are The Ncedsol EnrergcncyMedicincand lts ResidcntsBeingMer'/ Ri<'hurdM. Cuntor, MD, State IJnivcrsit,-of New ktrk Paranredic PhysicalAssessment and Interventionin Children.

Nuncy A. Schonleld, MD, Chiltlren's Hospitu! rl ltt"- Angelas

.)-)

The lrnpactof'a DidacticSessionon the Success of FelineEnd<rtrachcal f ntubationby Paranredics,'fhomasE. Tarrulrup,MD, Stutc Uniy,ersit1,tsl New ktrk

34. Inrpactol'the HIV Epidernic:EmergencyDepartment Resource Utilizationby Patientswith Known Human Immunodeficiency Virus (HIV-l) Int'ection, Gary Johnson, MD, Johns Hopkins Universitv

t 4 The Ell'cctol' an Explicit Airway protocol on Flight Nurse Bchaviorand Perfirrmance,KenncthJ. Rhee, MD, Universitv oJ Calilorniu, Duvis

KetanrineSedationProtocolfbr EmergencyPediatricPmcedures, N. Eric Johnson, MD, MPH, ktmu Lirula Univer,sitv

35. Emergency Department Compliance with a Standardfor the Managementol' Patientswith UncomplicatedRecurrentConvulsions, lzrrrl' J. BaralJ', MD, UCLA

1 5 . Developnrent ol'a ComputerModcl to PredictEMS SysterrpertirrnranceAfter Changesin Numbcr, l,ocationand Area of Responsibility of EMS Units, ElizabethCriss, RN, University oJ Arizonu

3 6 Adherenceto UniversalPrecautionsby Health Care providersperfirrming EmergencyInterventionsin an Inner-City Emergency Depaftnrent,ThomnsDiGiovanna, MD, JohnsHopkins lJniversity

1 6 . SequentialClinical Trials in EmergencyMedicine,Roger.l.

Lewis, MD, PhD, Harbor-UCI-4 l7

PortableUltrasoundin Patientswith Suspected Cholecvstitis: Perlirrmanccancl Interpretationby EmergencyDepartmentPhysicians. Lcon Gussow, MD, Cutk County Hospitul Recluse Spider Bite E,nvenomation,StevenM. Burrctt, MD, Universitv ol Oklafutma

I 0 . AnalyzingClinicalCaseDistributions to Improvcan Erlergcney Clerkship, kthcrt A. Dcktren?.o, BS,Albany Mcdicul Colle.qc I I

The Diagnostic Impact of Prehospital l2-Lead Electrocardiography, ktm P. AuJilerheide, MD, Medical College oJ Wisc'onsin

2 5 . A Computer BasedTime-InsensitivePredictiveInstrumentfor

EmergencyDepartmentMedical Record euality - Measurccl by fmplicit and Explicit Methodsin an AcademicSettinc., Amold R. So.sbw,MD, Univer.sityof'Massachusetts 4.

FrequencyAnalysisof the Electrocardiogramin HumansDuring Ventricular Fibrillation, Roger D4wonczyk, pE, Ohio State University

3 1 Preventionof DiseaseTransmissionby Using Mouthto-Mask VentilationsDuring CPR, PatrickJ. Connor,MD, Northwestem University

Effectsof AcuteEthanolIngestionon OrthostaticVital Signs, Christian Tomasz.ew.ski , MD, East Carolina Universtlt

3 8 Incidenceof Reportedand Confirmed Risk of Exposureto Com-

1 8 . Evaluationof the Tilt Test in an Adult EmergencyDepartment Population,Bernard Lopez,MD, ThomasJeffersonUniversity

municableDiseasein an Urban EMS System,Peul E. Pepe,MD, Baybr College of Medicine

1 9 . Probabilityof AppendicitisBefbreand After Observation,ktuis G. GraJf, MD, New Britain General Hospital

3 9 The Persistent Problem of Tetanus, Lisa Grininger, MD, Harbor-UCI-4

20. ThreatenedAbortion: A ProspectiveStudyof Predictorsof Out-

40. A ProspectiveStudy Examining the Need for Coveragefor Vibrio Organismsin Salt Water ContaminatedWounds, JonathanS. Olshaker, MD, Naval Hospital, San Diego

come in an EmergencyDepartmentPopulation,Jean Abbott, MD, University of Colorado

21. Predictorsof Electrolyte Abnormalities in Elderly patients, Bctnita M. Singal, MD, University of Cincinnati

41 . Managementof Pyelonephritisin an OberservationlJnit, George L. H. I&trd, MD, Universiry of Mississippi

22 Symptom Severity in Acute Myocardial Infarction and its Effect on PatientDelay and Use of 9l | , Mary T. Ho, MD, (Jniversity of Washington

12. ObservationUnit Treatmentof Pyelonephritis,ft. ScottIsrael, MD, Capt., USAF, Wilford Hall USAF Medical Center

t4

- ?'o"i

PosterSessionII - Wednesday,l'.4lay24

i ,a

66 Comparisonof Intravenousand IntraosseousAdministrationof

C)J

Epinephrinein a CardiacArrest Model, StevenG. Crespo,MD, Medical College of Pennsylvania

43 Poison Control CentersAre Cost Effective, Robert L. Galli, MD, UCLA 44

67 Comparisonof IntravenousIntraosseous,and IntramuscularAd-

A New Drug ScreeningSystem"Multi-HPLC" by High performance Liquid ChromatographyUsing Multi-Wavelength UV Detector, Shinichiro Suzaki, MD, Nippon Medical School, Tokyo, Japan

ministration of Succinylcholinein Sheep, StevenPace, MD, Madigan Army Medical Center

68 Comparisonof IntraosseousVersusIntravenousLoadingof Phenytoin in Pigs and Effect on Bone Marrow, Paul J. Vinsel,DO, Cpt. MC, Darnall Army Community Hospital

4 5 . Multiple Dose CharcoalTherapyfor SalicylatePoisoning,Milton Tenenbein, MD, University of Manitoba

6 9 . Criticaf lrssons from PrehospitalPediatricCardiac Arrest,Roben

46 In Vitro Absorption Propertiesof Activated Charcoal with

F. Itrvery, BA, MICP, New Jersey Trauma Center

SelectedInorganic Compounds,Rosalind D. Mitchell, MD, University of Southern California

7 0 . CaretakerNeglectand Injury PreventionInstructionfbr Preschool Child Injuries:475 Consecutive Cases,David M. Cline,MD, East Carolina University

4 7 . Role of ActivatedCharcoaland SodiumPolystyreneSulfonate (Kayexalate)in Gastric Decontaminationfor Lithium Intoxication: An Animal Model, James G. Linakis, MD, Chitdren's Hospital, Boston

7 t . Variables Predicting the Need for Major ProceduresDuring PediatricCritical Care Transport, Karin A. McCloskey,MD, Harvard Medical School

4 8 . Rateof Absorptionof Iron From ChewableTablets,JumesP. Winter, MD, Hennepin County Medical Center

7 2 . PediatricRisk of Mortality (PRISM)Score:A Poor Predicrorin Triage of Patientsfbr PediatricTransport(PT), RichardA. Orr, MD, University of Pittsburgh

49 Clonidine Poisoningin Young Children, Jomes F. Wilelt, II, MD, Children's Hospital oJ'Philadelphia

7 3 . The AssociationBetweenSceneTime, PrehospitalProcedures, and Injury SeverityParameters Among SeverelyInjuredPatients, David Tse, MD, UniversityoJ'Arizona

50 Dimethyl-PGE2Prolongs Survival From Alpha Amanitin, Edward A. Michelson, MD, University ofPittsburgh

The Elfect of Alcohol Consumptionon the Outcomeof Motorcycle Accident Victims, Janet Williams, MD, MeelicalCollese rtf Pennsylvania, Allegheny Campu.s

t+.

5 1 . Empiric Useof Naloxonein Patientswith AlteredMentalStatus: A Reappraisal, Jerome R. Hofiman, MD, UCLA

52

Endotracheal Naloxonein Rabbits:No AdverseEffectson Blotxl Gasesand Lung Tissues,StephenC. Rector, MD, We* Virginia University

7 5 . Comparisonof Complicationand Mortality RateBetweenDirect TraumaAdmissionsandTransferTraumaAdmissionsto a Rural TraumaCenter,Dale A. Albright, DO, GeisingerMedicul Center

5 3 PharmocologicInterventionsin Acute CocaineToxicity, Marc

'76.

Smith. MD. Harbor-UCL4

54 Agents Which Protect Against Cocaine-lnducedDeath and

55

Etfect of the 65 MPH SpeedLimit Changeon Mortality and TraumaSeverityin Mokrr VehicleAccidents,David P. Milz.rutn, MD, Eastern Virginia Graduate School of Medicine

Seizures in Animals, Robert W. Derlet, MD, University d' California, Davis

1 7 . Controlling For Severityof Injuries in EmergencyMedicine

Life-ThreateningEventsAfter TheophyllineIntoxication- A ProspectiveAnalysis of 144 Cases, Michael Shanrun, MD, MPH, Children's Hospital, Bostctn

7 8 . E,volutionof Trauma Care, A County Experience,GerardoA.

Research:Iss vs. Triss, C. Gene Cayten,MD, MPH, New York Medical College Gomez,MD, Universityrl'Miami

56. Initial ECG Findingsin 187 Casesof Cyclic Antidepressanr Overdose, Frank W. ktvoie, MD, University ti'ktuisville

7 9 . The Failure of Trauma Systemsin SouthernCalifornia to Affect DeathRatesFrom Mokrr Vehicle Accidents,JosephMorales, MD, University oJ Southern Califurnia

5 7 . China White Epidemic: An EasternUnited StatesEmergency Department Experience, Marcus L. Martin, MD, Medical College of Pennsylvania, Allegheny Campus

8 0 . EMS Field Triage Basedon Tiered Categorizationof Hospital EmergencyDepartmentand Acute In-PatientBed Availability, Barthoktmew J. Tortella, MD, Universitv tf Medicine & Dentistry of New Jersey

5 8 The Effect of Electric Shock Therapy on Local Tissue Reaction to PoisonousSnakeVenom Injection in Rabbits, Cassandra Stroud, MD, Orbndo Regional Medical Center

8l

5 9 . Acute Iron Poisoningsin Children: Evaluationof the predictive Value of Clinical and LaboratoryParameters- lVithdrawn

82. Ef'fectiveness of Cervical SpineStabilizationDevicesMeasured

60 Polymyxin B for ExperimentalShockFrom MeningococcalEn-

by Accelerometry,AhimsaP. Sumchai,MD, Palo Alto Veterans Administration

dotoxin, Greg Baldwin, MD, Children's Hospital, Boston 6 1 . Bacteremiain Children with Otitis Media, SaraA. Schutz.man, MD, Children's Hospital, Boston

TransientNeurologic Deficits Without Cervical Spine Fracture or DislocationFollowing Blunt Trauma, Phil B. Fontanarosa, MD, Maryland Institutefor EmergencyMedical ServicesSystem

6 2 . An Evaluationof the EmergencyDepartmentTreatmentof Status Epilepticus in Children, Steven A. Phillips, MD, Stanford University oJ.

StaplesVersus Sutures for Wound Closure in the Pediatric Population, SusanM. Dunmire, MD, University of Pittsburgh

64

Six Years Experiencein the ED Resuscitationand ICU Treatment of Drowning: PatientCharacteristicsPredictiveof Outcome and Evaluation of Conservative Management, Jane kwelle, MD, Children's Hospital of Philadelphia

FactorsInfluencingthe OperationalSaf'etyof AeromedicalHelicopters, Ronald B. lnw, MD, University of Chicago

84 The Impact of a Cervical Spine RadiographicProtocol on Cost And ProphylacticSpinalImmobilization, RobertJ. Schwartz,MD, MPH, HartJord Hospital

85 Indicationsfor Head CT Scanningin Trauma Patients,John C. Fitzpatrick, MD, UMDNJ-Roben Wood Johnson Medical School 86

6 5 . Comparisonof Serum PhenobarbitalLevels After Single Ver-

ConcomittantFemur Fractureand Head Injury: A ReliableIndicator of Visceral Torso lnjury , ConstantinnPippis, BS, UMDNJRobert lltood Johnsr.tnMedical School

87 The ValueofAlkaline Phosphatase in PeritonealLavage,Stephen

susMultiple Attemptsat Intraosseous Infusion, Michael Choo, MD, St. Vincent Medical Center

M. Megison, MD, University of Texas SouthwesternMedical Center at Dallas

l5

i PosterSessionIII - Thursday, May 25

l

Utility of the Peak Expiratory Flow Rate in the Differentiation of Acute Dyspnea: Pulmonary Edema Versus Obstructive/ BronchospasticDisease,David Cionni, MD, Medical Collegeof Pennsylvania

8 8 . Clinical Comparisonof Resuscitationand Survival Rates for 1980and 1985ACLS Protocolsin Out-of-HospitalVentricular Fibrillation Cardiac Arrests, Ford C. Erickson, MD, Hennepin County Medical Center

Innovations in Aminophylline Monitoring and Therapy, Dr. Russell J. Kino, Australasian College of Emergency Medicine

89. Defibrillation by Intermediate EMTs: The Illinois Prolect, Kathryn L. Mueller, MD, University of Colorado

Impact of PortablePulseOximetry on Arterial Blood GasAnalysis in an Urban Emergency Department, Cynthia A. Cofer, MD, University of Tennessee

90. TranstelephonicDefibrillation, Jay S. Feldstein,DO, Medical Center of Delaware

9l

Aspiration During Manual Low FrequencyJetYentilation,Donald M. Yealy, MD, University of Pittsburgh

Dangersof Defibrillation: Injuries to EmergencyPersonnelDuring Patient Resuscitation,WaruenGibbs, MD, University of Washington

Emergency Intubation in the Uncooperative Trauma Patient, Joseph J. Kuchinski, Jr, DO, Philadelphia College of Osteopathic Medicine

9 2 . Morphology of Myocardial NecrosesAfter 15 or l7 Min VF Cardiac Arrest and Cardiopulmonary Bypass in Dogs, Ann Radovsky, PhD, DVM, University of Pittsburgh

The Value of End-Tidal C02 Measurementin the Detectionof EsophagealIntubation During Cardiac Arrest, AssaadJ. Sayah, MD, William Beaumont Hospital

9 3 . The Effect of BolusInjectionon CirculationTime During CPR, Charles L. Emerman, MD, Cleveland Metropolitan General Hospital

Core TemperatureMeasurementin HypovolemicResuscitation, Robin W. Nicholson, MD, University of Arizona

9 4 . Effects of Arterial and Venous Volume Infusion on Coronary PerfusionPressureDuring Canine CPR, Nina T. Gentile, MD, Henry Ford Hospital

ExsanguinationCardiac Arrest in Dogs: Pathophysiology of Dying, Samuel A. Tisherman, University of Pittsburgh

95 The Effectivenessof BystanderCPR in an Animal Model, James

ExsanguinationVersusVentricularFibrillation CardiacArrestin Dogs: Comparisonof Neurologic Outcome PreliminaryData, Samuel A. Tisherman, University of Pittsburgh

Hoekstra, MD, Ohio State University

96 Left Ventricular Volume and Aortic Flow RelationshipsDuring High-ImpulseCardiopulmonaryResuscitation: Implications RegardingMechanismof Blood Flow , JamesE. Manning, MD, Harbor-UCl,A

Norepinephrinein Hemorrhagic Shock, Peter F. VanLigten,W, Ohio State University (IO) NaCl/6% DextranT0 IsosoluteComparisonof Intraosseous (HSD) to lO 0.9% (NS) in a HemorrhagicShock Model,.Ioftn A. Marx, MD, Denver General Hospital

9 7 . Failureof Fructose-1,6-Diphosphateto PromoteIncreasedSurvival or NeurologicalProtectionFollowing Resuscitationfrom ExperimentalCardiac Arrest, Robett E. Rosenthal,MD, George ll'ashington University

Rapid Correctionof SevereHyponatremiaResultsin Brain ProteinOxidation,and Altered Blood Chemistries, S. Mickel, MD, National Institute of Neurological Disorders Stroke

9 8 No Improved Outcome After Prolonged Cardiac Arrest and TreatmentWith Excitatory NeurotransmitterReceptorBlocker MK-801 in Dogs, Fritz Sterz, MD, University of Pittsburgh

Cardiovascularand NeurohumoralResponsesFollowing Burn

9 9 . Influenceof Epinephrineand Norepinephrineon Arteriovenous

jury, RalphL. Crum,MD, Universityof Califurnia,San

pH and Carbon Dioxide GradientsDuring CPR, Karl H. Lindner, MD, University of Ulm, West Germany

The Significanceof Neutrophilia in Afebrile Elderly Patients, ward A. Michelson, MD, University of Pittsburgh

100. Effectsof Epinephrineand Norepinephrineon CerebralOxygen Defivery and ConsumptionDuring CPR, Karl H. Linder, MD, University of Ulm, West Germany l0l.

Oral Labetalol vs Oral Nifedipine in Hypertensive Alison J. McDonald, MD, University of Pittsburgh

TranscranialDoppler Determinationof Cerebral Perfusionin PatientsUndergoing CardiopulmonaryResuscitation:Methodofogyand PreliminaryFindings,LawrenceM. lzwis, MD, St. Lrtuis University

Cardiovascular Side Effects of Emersencv Intravenous Supraventricular Tachyarrhythmias and Rate-RelatedH sion: Cardiovascular Effects and Efficacy of Intra Verapamil, Bruce E. Haynes, MD, Harbor-UCl,A

102. The PrognosticValue of the Glasgow Coma S,oaleMeasured 24 Hours After Inpatient Single CardiopulmonaryArrest and Resescitation,Bruce M. Thompson,MD, Henry Ford Hospital

Efficacy of Pseudoephedrinein the Prevention of Middle Squeeze,Michael Brown, MD, Butterworth Hospital

103. InadequateAirway ManagementCompromisingEMT-I Automatic Defibrillator Use, Graham Billingham, MD, UCLA

A Safety Assessmentof High-Dose Narcotic Analgesia Emergency Department Procedures, William G. Barsan, Univ ersity of Cincinnati

104. AdequateVentilation Using a Mask and Bag While Maintaining Cervical Neutrality, WendyDelaney, MD, State University of New York - Will be presented on May 23rd

128. Intranasal ButorDhanolfor the Treatment of Moderateto Muscufoskeletal Pain, James Scott, MD, George University

105. AsthmaticCardiac Arrest: An Indicationfor Empiric Bilateral Tube Thoracostomies,Elaine B. Josephson,MD, Henry Ford Hospital 106. Pre-HospitalUse of InhaledBronchodilatorsin ReversibleAirway Disease, Irene Machel, MD, Moristown Memoial Hospital

129. Exposureof EmergencyMedicine Personnelto Ionizing tion During Cervical Spine Radiography, Craig M. Singer, UCLA

107. PrehospitalAdministrationof Inhaled Metaproterenol,David R. Eitel, MD, York Hospital

130. A RadiographicEvaluation of Various Methods of Ankle mobilization, James Scott, MD, George Washington

108. Comparison of Two Delivery Methods of Albuterol in The EmergencyDepartmentManagementof Acute Asthma, Francois R. LtFleche, MD, Eastem Virginia Gradunte School of Medicine

l3l.

t6

Radial Artery Catheterizationof Critically Ill Patients Emergency Department, Gregory F. Bachhuber,MD, County Medical Center

Abstractsof the 1gthAnnualMeetingof the societyfor AcademicEmergencyMedicine .Study done primarily by resident. a Edttor'snote: Thefollowing 276 trbstractswill beltresentecl at the Annual Meetingof the Societyf or Ac ad entic Em ergency Medicine in S-anDiego, May 22-25.Presenters'nirrn", are printcrl in italics; *Lti| pr"rriti, t, not indicated, none was specifiedby the authors.

PosterPresentations

Radiographordering: Triage nurse versus physician

1 'FrequentFliers'- A Protocolfor the Managementof FrequentVisitors to a Community HospitalEmergency Department A Schuckman, PB FontanarosalDepartment of Emergency Medicine, Northeastern OhioUniversities College of Meditine, AkronCityHospital, Akron M o s t e m c r g e n c y d c p a r t m c n t s h a v c p : r t i c r . r t sw h o p r c s c n t f r c _ c l u c n t l y , a c c o u n t f o r a s u b s t a n t i a l n r - r m b c io f r c p c a t v i s i i s , a n d o f t c n h a v r t ' i t h c r r n i n o r c o r l p l a i n t s u r m a j o r d e r n a n i l s .E n c o u n t c r s w i t l . r s u c h " r e g , u l i r r s r" n i r y b t ' d i l f i c u l t , l r u s t r a l i l r g ,a n J t i r r r e - c o n s L r r l i n g t o r t h c c m L . r s c n c yp h y s i c i a n . W c p r c s c n t a m c t h o d f o r m a n : r g c m c n t of paticnts with frcclucnt ED visits, or ,,frcclucr-rtflicrs.,, Tl-rc stcps for.implerncnting thc program incluclc pati"nt iclcntifrcation, cs, tablisl-rrncnt of a con{iclcntial filc, cnsunng thc diagnosis, :lrrangc_ m c n t o f f o l l o w - u p a n d c o n t i n r _ r i t yo f c a r c , p c r i o d i c ' i i l c r c v i c w a n d updatc, and staff cducation. Thc majority oi paticnts havc a history of onc or morc of thc followrng: chronic pain syndrume, bordcrlinc personalrty, psychiatric disordcr, chronic rncdical problcms, drr-rg_ s e c k i n g b c h a v i o r , d r u g z r b r - r soc r, a l c o h o l i s m . p a t i c n i s w i t h f r c q L r c n t ED visits for acute rncdical problcms, such as sicl<lccrll tlisctrse, c h r o n i c o b s t r u c t i v c p u l m o n a r y c l i s c a s c ,o r p o s i t i v c H I V a n t i b o t l y , are also includcd. Thc namcs of all frcclucnt flicrs arc kcpt on'a c o m p u t c r i z c c l l i s t t h a t i s u p c l a t c c lc v c r y t w o m o n t h s . E a c h j r a t i c n t has a confidcntial filc, _availablc only tir tl-rc crrcrgcr-rcy physician, t h a t c o n t a i n s c o p i c s o f t h c r c c o r c l sf r o m p r c v i o u i . E D ' v i s i i s a l o n g with a transcribcd sumrnary of ED diigr-roscs, trcat,.,-,",-,1,",..,J a f t c r c a r c p l a r - r s .I n f o r r n a t i o n c o n c c r n i n g m c c l i c a i , s o c i a l , p s y c h o l o g i c a l , a n c ll c g a l i n t c r v c n t i o n i s a l s o i n c l u d c d . T h c f i l c s a r c r i r a i n taincd by onc.intcrcstod physician who, whcn availablc in tlrc ED, cvaluatcs ancl trcats thosc paticnts. Thc physician also rcvicws p r c v i o u s h o s p i t a l r c c o r d s , c o r u r n u n i c a t c s w i t h t h e p a t i c r - r t sp, r c v i _ ous and currcnt physicians, formulatcs paticnt carc plans, iilcnti_ fics a continuity of carc physician, coirfcrs with familics, ar-rd, whcrc indicatcd, involvcs lcgal authoritics {such as thc narcotics burcar-r.orchild protcctivc scrviccs). Erncrgcncy physrcr:rns, r.rurscs, counscllors, and social workcrs must bc knowlcdgcablc of thc s y s t c m a n d p r c s e n t a r - r n i f i e d a n d c o n s i s t c r - r ta p p i t r a c h t o t h e paticnt. We havc usccl thc frccluent flier prograrn ovir thc past four years, clccreasing the numbcr of paticnti with n-rorc thar-ri0 visits per ycar frorn 30 paticnts in l9B4 to two in 19g7.

-2.

RadiographOrdering:AgreementBetweenthe Triage Nurse and Physicianin a pediatric Emergency Department L Ropp,R Blouin, C Dulberg, M LilChildren's Hospital of Eastern Ontario, andDepartment of Epidemiology, Universrty of Ottawa, Ottawa,Ontario Techniqucs to rcduce paticnt waiting time arc of impurtance in , busy emcrgency departmcnts. Wc hypothcsizccl that thc triagc nurse in a busy pediatric ED could accuratcly ordcr radiographi, thus rcducing patient waiting timc. AII patients registering'aithc ED of thc Children's Hospital of Eastcm Ontario in a onc-wcck period were entered into the study. A study form was attachccl to each chart at rcgistration. It was rcmovcd and cornplctecl by thc triage nurse prior to the physician seeing the chart. Thc triagc nurse doc.umented whethcr thcy would send ihe patient for a radlograph if allowcd-to. If a radiograph would have bccn ordcred, do.r-c.,irtion was donc as to the function deficit, swelling, deformity, and specific.radiograph desired. The radiographs thit wcre aciually ordercd by the physicians wcre subseqt cnily obtaincd. Data werc analyzed for agrecment beyond chanci {kappa), sensitivity, speci-. ficity, and positive (PPV) and negative pridictive values.'Racliographs o_rderedby the emergency physician were uscd as the gold standard.

Allradiographs Ankle Knee Finger Wrist Chest Abdomen

No. 212 '16 17 18 12 24 12

Sensilivity .73 85 .88 .67 .67 .21 .17

PPV .74 '91 .78 100 .80 .50 .50

Kappa .65 87 .83 .79 .72 .?8 .24

Triage nurses showctl good agrccmcnt with physicians in thc o r t l e r i t r go f ( x t I c l l l i t y I i l ( l i r ) A r i t l l l s .

3_Emergency DepartmentMedicalRecord euality Measuredby lmplicit and Explicit Methods in an AcademicSetting AB SoslowlDepartment of Emergency Medicjne, Worcester Memorial Hospital, Worcester, Massachusetts C o n t r o v c r s y s t i l l c x i s t s i r - rt h c f i e l d o f 1 1 r - r a l i o t yf c a r e a s s es s r . n c n r a s t o t h c c o r r e l a t i o n b c t w e u r r t h c a d c t l u , t c y( ) f t l t e r n c d i c a l r c c o r d a n c l p a t i c n t o u t c o l l c s . S t r - r t h c sd r s , r g r e ca s t o t h r t l u a l i t y 0 f c a r c r c n d c r c c l ,b a . s c tol n r c t r o s p c c t i v c c h a r t a u t l i t , c l c p c n d i i t go r r ' w h c t h er i m p l i c i t ( s u b j c c t i v c )o r c x p l i c i t { o b j c c t i v c )c r i i c r i a a r c u s c c l .T h i s s t u ( l y w a s c o n t l u c t c c la t t h c c n c l o f a n a c a c l c r n i cy c a r ( M a r c h t o u n c f l9131a 3 t) a t r a j o r , , 1 3 0 - b c dr - r r b a nt c a c h i r - r ga f f i l i a t c o f t h c U n i v c r s i t y o f M a s s a c h u s c t t sM c d i c a i S c h o o l w h o s c L c v e I U c n r c r g c n c y d c p a r t _ r u r c r . r ts, t a f f c c lb y 2 4 - h o r - r ra t t c n c l i n g p h y s i c i a n s , h o r , r s c s t a i f lcircrg c n c y n r c c l i c i n c a n c l i n t c r n a l n - r e d i c i n c ) ,a n r l n u r s c p r r t c l r l o n c r s / c v a l u a t c s r r r u r cr h a n 3 0 , ( X X )p a t i c n t s a n ' r , r a l l y . T h c s t L i d y . , , , . , . , 1 . , r r . r ' i thc congrucncy bctwccn an cxplicrt ancl :rn ir.nplicit crrt.ria epp n r a c h v i s - ' a - v i s t w o c o n t l l o n a n c ll t o t c n t i a l l y s c r i o t r sp a t t e n t c o l l p l a i n t s - c h c s t p a i n a n c l a b c k r n r i n i l p a i n . E D r c c o r c l s ' o fr a n c l o n r l y sclcctccl paticnts {13 to 89 ycars olil) who prcscntccl with coni_ plitints of chcst pain (142);rnrl rrhtL,rrr1,.,.r' lrrrin {159)ancl wcrc s u b s c c l r - r c r t l yc L s c h a r g c ccl ' ' r p r i s c d t h c s t r t l y p . p r - i l a t i . . . l \ c c . r r l s w c r c g r a d c d b y d i f f c r c n t n o n b l r t r c l c cdl c p a r t n t c n f a l i r t t c n d i n g p h y _ s i c i a n s , a s p a r t o f o u r d c p a r t r n c n t a l e A p r o g r a n r , r , r n a w a r c, l f t h c s t u c l y t l c s i g ' o r i n t c n t / a s t . t h c 1 . , r c s c t ' r ci ,c. ,t h c n - r c d i c a lr c c . r c l s . f s p ec i f i c l - r i s t o r i c i r a l n d c x a m i n a t i o r el c n r c n t s { o b j c c t i v c ) ,a n c i l l a r y l a b o r a t o r y / r a c l i o g r a p h i cu s c , a n d o v c r a l l a d c q u a c y o f t h c h i s t o r y a n r . lc x a m i n a t i o r - r( s r - rjbc c t i v c ) . P h y s i c i a n s d i d d o t s c l f g r a c l c .A 1 0 , 1 , slrbsctof tirc stuclysamplc dcrn..stratccl an intcr.bscrver Dosr.vc c . r r c l a t i . r . r . f 0 . t i 4 . A p o . s i t i v cc . r r c l a t i o n ( r = 0 . 1 3 l , a b r i t r n r i r i r rpl r r i n ; r = 0;78, chcst painl, indcpcnclcnt of thc proviclcrur cithcr clinicai c o n d i t i o n , c x r s t c c lb c t w e c n t h c c x p l i c i t s c o r c a n c l t h c s u b ; c c t i v c s c o r e . . T h c r c w c r c s i g n i f i c a r " r tc l i f f c r c n c c s b c t w c c r - r a n c l a r r o n g a t t c n d i r - r gp h y s i c i a n s , n u r s c p r a c t i t i o n c r s , a n d a l l h o u s c s t a f f l c v c l i a s t o t h c i r n ' r c c l i c a lr c c o r d ' q u a l i t y , " b r - r to v c r a l l , a t t c n c l i n g p h y s i c i a n s s c o r c _ dl - r i g h c rt h a n l - r o u s c s t a faf n d n u r s e p r a c t i t i o n c i s ' w h c n comparcd by thc explicit approach. Thcrc wcrc fcwer but still s i g n i f i c a n t d i f f c r c n c c s i n t h c i r g r a d i n g w h c n a s s c s s c db y t h c s r - r b i e c _ trvc approach.

4 A Dictated and Transcribed Medical Becord Can Be Cost Effective HA Stueven,D Tonsfeldt,E Cisek,K Hargarten,p Aufderheide/ MilwaukeeCountyMedicalComplex,MedicalCollegeof Wisconsin, Milwaukee A dictatcdand transcribcdemcrgencydcpartmentrecordprovides an rmprovcdrncdicai/legal/billing doiurncnt with a more p.rofessional appearance.

A major concernhasbeenraiscdregarding the cost of that transcribcdrncdical record. Our ED Lad an expcrienccwith a computcnzedand dictatcdnredrcalrccordfor a two-y_car pcriod.The Dictaphonc"databank and transcriptronrsts werc locatedrn the ED. The rccordwas transcribcdonto an IBM "AT computerusingMultiMatc- softwarcwith fixcd hcaclinss.

The

t7

I PhysicianResponses to Families 7 Emergency FollowingPatientDeath

mean dictation trme was 2.4 x 1.3 minutes with a record length of 2 1 4 + B B . 6w o r d s . T r a n s c r i p t i o n w a s i n i t i a l l y p r o v i d e d 1 6 h o u r s p e r Our average ED record could be day, seven days per week. completed every eight minutes, with a well-trained transcriptionist producing seven records per hour. In an optimal system the a v e r a g ec o s t p e r r e c o r d w i l l b e a p p r o x i m a t e l y $ 1 . 2 5 . T o e v a l u a t e the effectiveness of the system for reimbursement purposes/ one year of billing data was reviewed for distribution of level of service bcforc and aftcr institution of the dictation system and multiplicd times current charges {or both periods. The avcrage increase in physician charges as a rcsult of dictating was $17.30 per record.

Thc transcrrption cost was easily offset by the increasc in docurncnted level of scrvice. We believe such a system can be cost cffcctive.

PatientsWithPID:DoThey Department 5 Emergency TheirDiagnosis?

Understand Services B Abbuhl,S Stemhagen,E Campbell/Emergency Department, Hospitalof the University of Pennsylvania, Philadelohia Pelvic inflammatory dlsease(PID) is a frcquent problem in cmcrgencydepartmentsand outpatientclinics,with at leastonc million women a year bcing treatedfor PID in the United Statcs. will total $3.5 Thc projectedannual cost of PID and its sccluelae billion by 1990.Formany PID paticnts,thc ED is thcir first contact with medical care. Control of this cpidemic recluiresthat ED pationts understandtheir diagnosisand comply with medical rccommcndations and follow-up.A prospcctivetelephonesurvey of womcn dischargedfrom thc ED with PID was initiated to detcrminc levcl of understandingof the diagnosisand its potential conscclucncos and thc self-reportedcompliancerateswith mcdication and follow-up. Of thc 90 patients contacted,we found that 2L)% did not know that PID was an infection of the female reproductivcorgansand lessthan half knew at leasttwo of the four rnajor cornplicationsof PID. There were no apparentpredictorsof undcrstanding,including levcl of schooling,prior episodesof PID, or using the ED as a primary sourccof medical care.Patients' with undcrstanding of thcir diagnosiswas significantlyassociated knowing the cornplicationsof PID but not associatedwith either short-tcrmcomplianceor satisfactionwith care.We alsoassessed paticnts' understandingof a Pap smear and found that 47% could not dcscribethc test or its function. Even more alarming, 46lo of our paticnts thought they had a Pap test at their recent ED visit, whcn, in fact, they had not. This study points to a significant lack of understandingin ED PID patients regardingtheir diagnosis,its potcntialcomplications,and use of the Papsmear.Possibleintervcntions appropriatefor EDs are discussed.

.6 AIDSEducationin the Emergency Department D Magid, A Behrman, A Stemhagen, S Jacobson/Department of C l i n i c a l E p i d e m i o l o g y ,E m e r g e n c y D e p a r t m e n t , a n d E m e r g e n c y Services Deparlment, Hospital of the University of Pennsylvania, Philadelphia Preventing the further spread of AIDS depends on educating the public to reduce the risk of infection. This study describes AIDS cducation in a unique setting and represents one of the few AIDS education programs that have been validated by controlled testing.

To test the hypothesis that effective community AIDS education can be based in an ED setting, we designed and evaluated two educational interventions in an urban, high-volume ED waiting room. Eight hundred subjects (patients and visitors) completed a preintervention knowledge, attitude/ and behavior survey. The subjects then were assigned to one of three groups: an active group exposed to a videotape, written material, and a preceptor for review and questions; a passive group exposed to a videotape and written material only; and a control group without access to our education program. Long-term knowledge gains and reported risk reduction behavior were evaluated by follow-up testing within a five-week period. Complete follow-up was achieved for 78% of subjects. The cost-benefit of each educational program was evaluated. Significant knowledge gains were found between each of the two intervention groups when compared with the controis {P <. .01). The active group demonstrated greater knowledge gains than the passive group {P < .05). Significant reductions in reported high-risk behavior were found in both intervention groups compared with controls (P < .01). This study demonstrates that an ED-based AIDS educational program can have a significant impact on improving knowledge and on reducing reported AIDS risk behaviors in a highrisk population.

of EmergencyMedicineand T Schnidt, SW Tolle/Departments Portland Medicine,OregonHealthSciencesUniversity, Stressfor physiciansin responseto a patient deathin the emergency departmentis assumedto be great,but there are no studres addressingthis phenomenon.Studiesof the family's responseto an ED deathsuggestthat survivorsareleft with unansweredquestions and unmet needs.We developeda questionnaireto evaluatephysician responsesat the time of patient death and their subsequent interaction with survivors.Questionnaireswere sent to 138 Oregon emergencyphysiciansand completedby 83% {115).Comparisonswere made with a previous study of primary carephysicians in the stateusingmatchingquestionnaireitems. The meannumber of dcathsencounteredby emergencyphysicianswas l7 (SD 1 15) peryear.At one hospital this number was verifiedby an independcnt audit of the number of ED deaths.Emergencyphysicianswere much more likely than primary care physicians(71% vs 29%) to ask survivors to come to the hospital so they could be notified in person{chi-square;P < .0001) and reportedspendinga mean of 15.5 minutes {SD t 10.8)with survivors.Notifying these survivorsis consideredemotionally difficult by most (70%)emergencyphysi cians surveyed.Outreach by all providers was relatively infrequent. Five percent of emergencyphysicians and 7"/oof primary carc providersroutinely sent sympathy cards.Only 3% of emergency physiciansroutinely made a follow-up call versus l9% of primary care physicians, and 7"/oroutinely called with autopsy results versus 77% oI primary care physicians (chi-square;P < .00011.We concludethat survivors and physicianswould benefit from ED bereavementprogramsthat help emergencyphysicians provide outreachto families after a patient death because94% of physiciansreporteda needfor educationin this areabut lessthan half reportedobtaining that training. Instituting these programs might raise emergencyphysician job satisfactionand potentially decreaseliability by increasing the physician-family bond with survivors.

.8 TeachingEthicsin Emergency Medicine oJEmergency J Dougherty/Department Z Srodulski, J Jones, College Hospital, Michigan StateUniversity Medicine, Butterworth of Emergency of HumanMedicine,GrandRapids;Department Medicine,AkronGeneralMedicalCenter,Akron,Ohio Therehasbeena sharpincreasein recentyearsin the varietyand complexity of ethical problems in the practice of emergency medicine. To determine the extent of formaiized training ior emergencymedicine residentsin this area, we surveyedaII US residencyprogramdirectors.The datareceivedfrom the replying69 of 73 residenciesin operationfor more than one year are summarized. Although 6B programdirectorsbelievedthat medical ethics should be part of an emergencymedicine residencycurriculum, only 42 {61%) had any specificteachingdedicatedto this subiect.

The mean number of hours per year spent teachingethical issues was six (range,one to 20|. This time is generally subdivided between didactic lectures(33%|,group discussion(25%), bedside teaching l24o/o),assignedreading llI%1, and case presentations surveyedwithout medical ethics l7%1.Of the 27 139'/"irprograms incorporatedinto their existing curriculum, l4 anticipatedadding this subject to their program in the near future. Specificethical issuesthat were consideredimportant for inclusion into the curriculum were informed consent,confidentiality, resuscitationde' cisions,duty to treat, rights of minors, patient transfers,andorgan donation.Frequentsuggestionsby programdirectorsincludedthe need for more formal teachingin medical ethics, use of problembasedlearning activities/ organizedreading lists, and medicolegal seminars.The data generatedby this study reinforcethe needfor improved training in medical ethics among endorsedemergency medicine residency programs.Innovative teaching methodsare suggested.

A ModelApproach ACLSInstruction: 9 Problem-Based EmergencyMedicalEducation for Undergraduate RF Polglase,DC Parish,RL Buckley,RW Smith,TA Joiner/ Departmentsof InternalMedicineand FamilyPractice,Mercer UniversitySchoolof Medicineand the MedicalCenterof Central Georgia,Macon The optimal {ormat for teachingadvancedcardiaciife support {ACLS) to medical students and others with little emergency medicine experiencehas not been studied extensively.We report an ACLS course taught to sophomoremedical students usinga

l8

problem-based learning model. Thc lecture format was replaced bv a series of clinical problcms emphasizing various portions of the ACLS coursc. Students met weekly with an ACLS instructor who s e r v e da s a t u t o r t o d i s c u s s t h e p r o b l e m . A s e t o f l e a r n i n g o b j e c t i v c s was compiled for the entirc coursc and givcn to students to guidc their studies. Enhanced practlce time t[at includcd teachins statrons and skills laboratories was offered. When tcsrcd, .tr',d.nt, from the problem-based program performecl bcttcr than senior mcdical students from a tradrtional ACLS course that we tausht in thc same timc framc. We concludc that thc rrroblem-based forn-rat i s a n c f f e c t i v e f o r n - r a tf o r t e a c h r n g A C L S t r i t h o s c w h o h a v c h a d l i t r l c p r i o r e x p c r i e n c ei n e m t . r g c n c ym e r l i c i n ea n J / o r r es r r s c i t airo p attempts.

First time pass rates, ACLS testing stations by student group

M e g ac o d e Meanwritten test grade Coursepass rate

Problem-Based (%) (n=11) 90.9

Seniors(%) ( n = 18 ) 50.0

Residents(%) (n=37) 91.9

86.8

83.3

94.6

100

61.1

95.0

ment in pediatric training included incrcased pcdiatric electivcs ( 1 9 % ) , i n c r e a s ed u s e o f c h i l d r c n ' s h o s p i t a l s l 9 % ) , a n d i n c r c a s c d u s c o f p e c L a t r i cf a c u l t y { 9 ' l . ) . O n e h u n d r e d s i x t y n i n c r e c e n t g r a d u a t e s c o n p l e t c d t h e s u r v e y ; 5 7 o / ow e r c b o a r d c e r t i f i c d . T h c y l e l t m o s t uncomfortable with newborn resuscrtation, Vp shunt problcms, a n d . h e m a - t o l o g i co r c a r d i a c c m e r g c n c i e s . p r o b l e n ' r a t i c p r o c c d u r a i skills includcd cricothyrotomy, internal jugular and iubclavian v c i n a c c c s s ,a n d s u p r a p u b i c b l a d d c r a s p i r a t i o n . A n i m a l l a b o r a t o _ r i c s w c r c t h c p r c f e r r e d m e t h o d f o r s l < r l l, i c u . l , , p , - , , c n ti n v e n t i l a t i o n t e c h n i q u e s , c n c l o t r a c h e a lr n t u b a t i u n , a n d v c n i , u s a c c e s s .p c d i a t r i c a d v a n c c d l i f c s r - r p p o r tc e r t i f i c a t i o n w a s u n c o r n m o n l l 2 % 1 . F c w graduatcs{21%) wcrc interestcd in pcdiatric t:mcrgcncy mcdicinc fcllowships. Practicc location was rarcly influcnccd by confidcncc i n . t h c m a n a g c m c n t o f p c c l i a t r i cc m c r g c n c i c s . R e s i d c n c y g r a d u a t c s bclicvc that thcy would bcncfit from incrcascd usc of animal l a b o r a t o r r c sd u r i n g r c s i c l e n c yt r a i n i n g . T h e v o l u m c o f p e d i a t n c p a t i c n t s a n d p r o c c d u r c ss c c n i n r e s i d c n c y c o r r c l a t c s w e l l w i t h t h a i i n a c t u a l p r a c t i c c . P c d i a t r i c a t l v a n c c d l i f c s u p p o r t c ( ) u r s c sm a y p r o viclc a uscful mcchanism for n'rcctingresidcncy training ncccli.

12 ParamedicPhysicalAssessmentand Interventionin Children NA Schonfeld, K Park,R Lev,AJ Haftel/Department of Emergency Medicine, Children's Hospital of LosAngeles

10 AnalyzingClinical Case Distributionsto lmprove an EmergencyMedicineClerkship RA Delorenzo,D Mayer,EC Geehr/Department of Emergency Medicine, AlbanyMedical College, Albany, Newyork Rccommendations for a corc curriculum for unclcrgracluatc emcrgency medicine cducation have bccn publishcd try ACEp;rnrl othcrs. It is expected that a combination of bcdsidc tcachin,: and d i d a c t i c s e s s i o n sw r 1 1c o v c r a l l a s p e c t s o f t h c c u r r i c u l l m r , h u t r h i s has not been dcmonstratcd. This study clcscribcsa mcthod of usir-rg thc distribution o{ clinical cascs to shapc thc rnix of clir-rical anJ didactic learning in an emcrgcncy mctlicinc clcrkship. All scnior students participatc in a four-wcck clnergcncy rncdicinc rotation.

A bricf log describing each clinical oncolrntcr is rnaintainccl by thc stLldents. Data frorn one year w(]rc sortcd int0 32 catcgorics aciaptcd from thc ACEP guidclines and tabulatcd to dctcrrninc thc distribution of cascs seen by each studcnt. A critcrion of u0,2, of stuclcnts cncountering at least ono case in each catcgory was choscn to cnsure a rcasonablc lcvcl of cxposllrc to a particular casc r_rrtr.roic.

O n c h u n d r c d t w c n r y - t h r e e s t uj . n t s w c r c c x p , r r c d t o a n a v c r r r [ c o f 6 3 . 7! ) 7 . 5 ( S D l p a t i e n t s .S c v c n c a t c g o r i c sr n c t t h c c r r t e r i o ni 2 t e s r s i g n i f i c a n t a t 0 . 0 5 ) , i n c l u d i n g m u s c u l o s k c l c t a l i r - r j u r i c s( t j . 0 t 5 . 0 p a t i e n t s p c r s t u d c n t ) a n d a b d o m i n a l p a i n ( 4 . ( r+ 2 . U 1 .T w c n t v - f i v c c a t c g o r i c sf a i l c d r h c c r i t e r i o n , i n c l u d i n g u r i n n r y t r c c t i n f c c t i o n s (2.6 r 2.O) and head trauma (1.7 t 1.5). Rcsults indicatc that exposure to certain categories of patients, with approprratc monitoring, can bc reasonably cnsurcd rn our clinical sctting. C)thcr categories occur with insufficient {rectuency ancl dcmand incrcasctl didactic coverage. The didactic portii)n of the curriculum can bc adjusted so that categorics ndt mccting thc criterior-r will bc cmphasized while those mecting thc cnterion will bc dcemphasized. A method has been described that identifics gaps in thc clinical exposure of students and permits appropriatc idcntification of didactic sessions to crcate a clcrkship cxpericncc morc consistent with recommcnded guidelines.

11 An Evaluationof PediatricEmergencyMedicine Education:Are the Needsof EmergencyMedicineand Its Residents Being Met? RM Cantor, TE Terndrup, M Madden, JB McCabe/Department of Critical CareandEmergency Medicine, SUNYHealthSciences Center, Syracuse

This stucly cvaluatccl paramcclic physical asscssmcnt of cliilc l r c ni r - rt h c f i c l d a n d t h c i m p a c t o f I V l i n c i n s c r t i o n o n s t : r b i l r z a t i o n timc. A. rctrospcctivc rcvicw of paramcrlic and crncrgcncy dcpart_ m c n t c h u r t s o f c h i l d r c n t r a n s p o r t c d b y p a r a m c c i i c so v c r a n l l J month pcriod was pcrforutccl,Four lrundrccl nincty-iivc paticnts {agcs I ntonth to ltl ycars) wcrc transportcd, 194 for ntcdical indications and 301 for trauuttr.Thc rrrosi collnlon ncclical comp l a r n t s w c r c s c i z u r c s a n c l r c s p i r a t o r y d i s t r c s s . T h c r . n c a nr . n o b i l i z a t i o n t i n t c i n t c r v a l ( t i r - r - rocf a l a r m t o t i l n c a t p i t t i c l t t ' s s i c l c )w a s ( r . 5 r n i n L l t c s , m c a r - rs t a b i l i z a t i o n i n t c r v a l { S I ) w a s 1 2 . 5 r r r i n u t e s , a n d rl]can transport tilrc to thc ED was fi.8 lllinutcs. Onc hr.rndrccl s c v c n t c c n p a t i c n t s h a d a n I V l i r . r ca t t c m p t c t l , w i t h 1 0 1 s u c c c s s f u l i n s c r t i o r - r s( f l 6 ' 2 , ) .I V l r r . r c sw c r c a t t c r . n p t c c la n c l s n c c c s s f u l r . n o r c o f t c n i n c h i l c l r c n n t o r c t h a n l 2 m o n t h s o l d { 1 ,< . 0 1) . W h c n a n I V l r n c w a s a t t c m p t c c l , t h c S i i r - r c r c a s c cs li g n i f i c a n t l y t o 1 5 . 5 n t i n r . r t c s{ 1 )< . 0 0 0 1 ) . T h c r c w a s r - r os i g n i f i c a n t c l i f f c r e n c cb c t w c c n t h c o l l t c o l t c of paticnts of sirrilar acuity who did or did not havc an IV linc i n s c r t c t l . F o u r p a r a r . n c c l i cf i c l d p h y s i c a l z l s s c s s m c n t p a r a l r c t c r s wcrc corrparcd with thosc donc by thc rccciving ED physician: l c v c l o f c o n s c i o u s r r c s s{ L O C ) , p u p i l l a r y r c a c t i o n , r c s p i r a t ( ) r y p r r t c r n , a n c ls k i n f i n d i n g s . T I - r cp a r a r r c c l i c sa n c lc m c r g c n c y p h y s i c i a n s , : l s s c s s m c n t sa g r c c d i n m o r c t h a n 5 0 , 2 , o f p a t i c n t s . T h c n r . r r r b c ro f paticnts for whom diffcrcnccs occurrcd, lly p2lranctcr, wcrc LOC (106), pupillary rcaction {13), rcspiratory pattcrn {30), and skin f i n d i n g s { 7 2 ) . W h c n a d i f f e r c n c c o c c u r r c d , t i - r cr r a r a r r c d i c u n c l c r c s tin-ratcdthc scvcrity of the patient s conrlititirr as follows: LOC ( i 3 ' l " ) , p u p i l l a r y r c a c t i o n ( 3 0 7 , ) ,r c s p i r a t o r y p a t t c r n { ( r 0 % , )a, n d s k i n findings (53%). Undcrcstimation of thc scvcrity of thc paticnt,s conclition may rcsult in withholding basic intcrvcntions, such as assistcd vcntilation. Clinical asscssmcnt of thc pccliatric paticnt m _ u s tb c c r n p h a s i z c d i n p a r a m c d i c e d u c a t i o n t o c n s L l r ca p p r o p n a t c lifc-saving intcrvcntion. Paramcdicsarc gcncrally succciifui with I V l i n c i r - r s e r t i o ni n c h i l d r c n m o r c t h a n I y c a r o l d , b u t u s r - r a l l ya t t h c cxpensc of longcr ficld stabilization intervals.

13 The lmpact of a Didactic Session on the Success of Feline Endotracheal Intubation by Paramedics TE Terndrup,RA Cherry,CM Madden,RM Cantor,JB McCabe/ Departments of CriticalCareand EmergencyMedicine,and Pediatrics, and ParamedicEducation, SUNY HealthSciences Center,Syracuse While clinicalreportsof cndotracheal intubation(ETI)of adult patientsby paramcdrcs dcmonstratcmore than 907. succcssrates, reports of prchospitalpcdratric intubation suggestsuboptrmal success rates.Thc small,anesthetizcd cat may be uscdto evaluatc infant ETI performance.Wc hypothcsized that a bricf drdactic scssionwould improve ETI successby paramedrcs.

Thirty-nine certified paramedicswith standard training rn adult ETi were randomizedto control or experimcntalgroups.Thc expcrimental group(201recciveda 40-minutelcctureemphasizing in{antarrway anatomy/equipment,ETI technique,and monitoring for complications. Six small (mean weight, 3.2 kg), young (mean age,5.9 months) cats werc uniformly anesthetizedwith kctamine and accpromazine.Equiprnentwas selectcdfrom standardETI matcrials. Supervisoryphysicians(fivc)wereblinded to groupdcsignation

To ascertain current training of emergency mcdicine rcsidents in pediatric emergency care, we surveyed al1 emergency mcdicine residency programs and recent emergency medrcine graduates for their imprcssions of the quality of pediatric emergency training received. Forty-eight (68%) proâ&#x201A;Źirams returned survcys. They estimated 8.4 pediatric encounters per day pcr resident as compared with 28.6 adult patient encounters (P < .0001 ). Twenty-four perccnt r e q u i r e d p c d i a t r i c c o n s u l r a t i o n p r i o r r o l a r i c n r d i s c h a r g e .T h c most common pediatric electives offered were pcdiatric emctgency department, pediatric ward, and NICU. pediatric curriculum foilowed core content in 54T" ol programs. Animal laboratories were used in 75% of programs to teach pediatric skills. Most program directors believed that the graduates were competent in the management of pediatric emergencies. Suggestions offered for improve-

t9

and evaluated equipment selection, ETI time, tubeplacement, and paramedics were assigned to the expericomplicatrons. i*.nty gto"p and 19 io-the control group. Three were excluded -"niri from the'conirol group a{ter randomization. Control subjects were significantly oldei and had significantiy less estimated ETI experiencc (8.4 i 9.5 ETIs versus 34 + (r2). However, there were no significant differcnces in the percentage of successfully intubated rrtrol and experimental groups, respeccits, 57% and 67"1 . lt, tivciy. Equipment st:i.!.' r, was iudged to be more appropriate in signiilcantly more attempted intubations for the experimental g r o u p , 9 6 % v e r s u s U 2 . 5 % ( P < . 0 5 1 .H o w e v e r , t h e r e w a s n o a p p a r e n t inc."asc in the success rates when the appropriate laryngoscope, ET tube, and stylet werc used. Complications occurred in 50% of att c m p t c d i n t u b a t i o n s . F i f t e e n p e r c e n t o f s u c c e s s f u lE T I e x c e e d e d3 0 .".,-d. of intubation time. TLe corrclation between thc number of = successfullyintubated cats and years as a paramedic (r '24), years = as an EMT (r = .24), and thc number of prcvious ETI (r '31)was p o o r . A l t h o u g h a d i d a c t i c s e s s i o ni m p r o v c s e q u i p m e n t s e l e c t i o n , i t ii,1 not signiiicantly improvo ETI succcss Educational strategies mrrst b" icvcloped'to improvc ETI skills of prehospital providcrs whcn dcaling with infants.

ol previousEMS system models such as the standardset coverage -od.l, totttional'base location model, and queuing model are remedied.Predictionsof responsetimes citywide, in speci{icge.ounit canbe nrrohi. areas,and for eachindividual paramedic-rescue e;til;J fostulating changesin the number of units, location of units, oi changesin serviie area responsibility {eg,contemplated areasof annexition). The model's ability to predict responsetime times Derformancewas comparedwith actual paramedic-rescue i\4odelpredictionswere within 2% of real systemperformanceas determined{rom computerizeddispatchrngrecords' ParamedicResponseTimes - 8 Minutes

System E M SU n i t1 E M SU n i t2 E M SU n i t3

Simulation Prediction(%) 91 92.3 91.3 90.2

True Data (%) 92 92.8 93.2 92.2

In summary, we have developedan EMS system computer model iharallowsplanners to accuratelypredict the effect of a variety of .n^t*.s on responsetimes in an urban paramedic-rescue il;;r.n

14 The Effect of an Explicit Airway Protocol on Flight .16 Sequential Nurse Behavior and Perlormance Medicine ClinicalTrialsin Emergency ot EmergencyMedicineand Clinical KJ Rhee,RJ O'Malley/Divisron of EmergencyMedicine'Los RJ Lewis,HA Bessen/Department Nursing and Medicine, Internal of Department Toxicology, MedicalCenter,Torrance AngelesCountyiHarbor-UCLA of California'Davis,MedicalCenter, Administiition,University tlinical trials in emergencymedicineoften concemthe efficacy Sacramento of critical interventions"in reducing morbidity and mortality' by.physiciansare otten Flight nurscswho arc unaccompanicd Usua1ly,a fixed number of patientsareevaluatedbeforethe dataare great under dccisions management important called'irn to make in^lrlr"A. Unfortunately, more patielts may be enrolled than are explicit an of the cffects tirnc prcssures.This itudy cxamined to obtain a result,and thereforesomemay be unnecessarnecessary transported dccisiirn tree on thc airway managementof patients to a lessef{icacioustreatment ln a sequentialtrial, the iiv *p"t'.a iri,- ttt. sccncof accidentrlr illnesi by comparingthe year preccdaher eachpatient,andthe trial is haltedassoon tr^n^lyzed u" iit^ ing thc institution of this protocol{yearI ) to the yearafter lyear2l' efftcacyor laclithereo{ is demonstrated'Thus, the ""ri-"", ,r Coma Glasgow tree using decision Thc protocol was a.t "xplicit on the out,,rr-be, of patients required is reducedand depe-nds criterionto Scalo{GCS)on arrivalof the flight crcw as.thc'primary The purposeof this study was to trial. duringthe ottt.iu"<l .o-.r dccidcwhcn airway mancuvcri (oraltrachcal/nasotrachcal/cricoof sequeniialtrials over a fixed design' a.rno"taita" the advaritages thyruturt yl wcre rcquircd. fhc fiight nurseshad been trained and W. tl"u" ana\yzedby computer iimulation a trial of trepatitis-B implementation ycars bcforc two mancuvcrs ccitified in all airway a1-di-trial of the MAST ur".in" (rurnll I Me'd r98U 303:833-841) ui th. ptutu.ul,andno specialtrainingotherthan instructionin the In the simula1987iI5:653-658)' (Ann Emerg'Med in tiarrm, s.r,rt protocol's dctailsof the iccision tice was givcn at the time o{ the iionr, prti.ntt are assignedto control and test groups,their out' implcmcntation. .ornJ.'trnaottlly deter"minedaccording-tothe frequencyof out.o-", ob.".u"din the actual studies,and the simulatedsequential Year 2 Year 1 untii the results become statistically signifi .rJv-it-."",inued Patientswith airwaymaneuver/ possible realizationsof eachtrial aresimulated, ( 2 2 .

6 % Y of 1 0 7 t 4 7 4 (5,6%l "rri]rft""*"ds 33t344 Total ""a-tn"t att" distribution of required patient numbers is deterul Patients/AttemPted Successf 96t107(89.7%r 22t33 (66.70/.\ pailenIS -in.O- ftt. risk of type I and type II error is sâ&#x201A;Źt at 0'05' In the first AverageGCS (atlemPted study, *e found thai a sequential trial suf{iciently-sensitiveto 4.6(sD,2.88)t 3.4(sD, 1.03) airway) ;;;;;; , ;"".ne-induced reduction in hepatitis B of 50% would required a median of 150 patients in order to demonstrate have .Year 1 and 2 significantly dif{erentusingchi-square(P< 05) the observedua"iit'. efficacv of 9.2ohrhe actual ;ffi;";t;;l;;; tYear 1 and 2 significantly differentusingStudenl'st test (P < 05) i,"ay "i.ii 1,083patients. The MAST studv used 201 patients'A more sensrtlvesequentialstudy, designed.todetect a 50% reduc' An cxplicit airway managemcnt protocol influcnccd the behavior i-lo"-i"--ott"tity,'wou1d have terminated with a median of 102 and pcrformance of {light nurses. that o",i."a. and also demonstratedlack of efficacy'We conclude i.""""ii"t trials usually require fewer patients than {ixed trials to reach statistically valid conclusions.

15 Development of a Computer Model to Predict EMS Svstem Perlormance After Changes in Number, .17 Eftects of Acute Ethanol Ingestion on Orthostatic Location, and Area of Responsibility of EMS Units V i t a lSigns J Goldberg/ Meislin, HW EA Criss,DW Spaite, TD Vatenzuela, of CA Tomiszewski DM Cline,TW Whitley/Department Center; SeoiJn of EmergencyMedicine,ArizonaHealthScie-nces North Greenville, et"rg.n.y Medicine,EastCarolinaUniversity, O"p"rtt.nt of lridustiialand SystemsEngineering,Collegeol Carolina Tucson Arizona, of University Engineering, There are no acceptedcriteria for orthostatic tilt testingtn in' iinc" tf,.ir inception as experimentsin the prehospitaicare of subiects.W-eper{ormeda prospective,randomized,cro-sshave toxicated (EMS) systems cardiac arrest, emergencymedical services ( g/kgl "".. .*Jy *iih l6 healihv subjectJwho.receivedethanol I i broadenedtheir scopeto copewith a wide variety of illnessesand added'to nonalcoholic beer' orthostatic vital phy*r,.iipt".eboJ providing ". of prri"ienancc capable system, LmS ,n of i"r".. .tg"t, .tt i"ot concentration, and-volume status were checked medical interventions promptly, requiresa significant ;;;;-i";"i planning' ho'"riy fo..ight hours.Peakethanolconcentrationwas 116 5 t 14'5 EMS iacilitate inu.r,-.rr, of community ,esorr.cis.To iini !t one"hour. Analysis of variance {ANOVA) for repeated we developeda computermodel of the EMS system-ina community a significant difference in orthostatic pulse model ;;;r;;.;;;t;aled The miles square covering-144 populafion ot-+OO,OOb group 6r time. Bonferroni'st procedurerevealed either different ;h;;#i;t on (average speeds data engineering ,raffic l".n*otrr"t the dIf{erencebetween the ethanol 122'l t l3'4 beats)and controi tiauel tiries betweenpoints.in the citvJ' and ;oii-ffi;t;;;..red < at two hoursafter relocations' call It-i.i xl .SA.^tsJgroupsto be significant {P '005) EfvfS tj'.t"- performance data (call volume, the ethanolgroup of eight iriteria, clinical By cuirent paramedicingestion. on-scenetimes, transporttimes)from the *ont.ii-"t, "td ^on. in the placebo group were orthostatic at this model The r"'Uj..tt department fire -.rto'pohtan oiir,. ;ffi;;;;;. units ii-!. e, secondANOVA foi repeatedmeasuresshowedsignificant ,".1""t, i". at e effectsof oui-of-servicetime and dispatchof di{ferencesin volume status for either group or time' Bonferroni's limrtations Inherent ito- lolrtlont other than their normal base'

20

t procedurerevcaleda significant fluid deficit {a95 mL) at five, six, and seven hours after ingestion versus nonc in the placebo group.

ANOVAs for repcated measures did not reveal statistical diffei e n c e si n o r t h o s t a t i c b l o o d p r e s s u r ec h a n g e sf o r c i t h e r g r o u p o r t i m c .

Our results show that acute ethanol intoxication causcs an carlv o r t h o s t a t i c p u l s e c h a n g e ,w h i c h r e s o l v c s s p o n t a n c o u s l y a s e t h a n o l c o n c e n t r a t i o n d e c r e a s e sd e s p i t c a d e l a y c d d i u r c s i s .

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Evaluationof the Tilt Test in an Adult Emergency DepartmentPopulation MA Levitt,M Lieberman, B Lopez,M Sutton/Thomas Jefferson pennsylvania University Hospital, Philadelphia.

J Abbott, M Zaccardi, SR Lowenstein/Department of Surgery, D i v i s i o no f E m e r g e n c y M e d i c i n e a n d T r a u m a , E m e r g e n c y M e d i c i n e C l i n i c a l R e s e a r c h C e n t e r , U n i v e r s i t yo f C o l o r a d o H e a l t h S c i e n c e s Center, Denver Altliough, thrcatened abortion is a common problerri in thc cmcrgcncy departmcnt, no prospcctivc studics in an ED sctting havc becn reported. Wc cxamincd prospectivcly the prescnratron, c l i n i c a l c o u r s c ,a n d o u t c o m c o f 7 5 c o n s c c u t i v c t h r e a t c n c d a b o r t i o n paticnts in our urban teaching hospital. All paticnts were in thc f i r s t h a l f o f p r c g n a n c y a n d h a d v a g i n a l b l c c d i n g , a c l o s c c lc c r u i x , a n d a posrtivc prcgnancy tcst. Whilc a 50,2, ratc of fctal loss is oftcn quotccl for thrcatcncd abortron patrcnts, almost thrcc qu:rrtcrs fctal dcmisc; only 2g.1, had a good 1 7 2 " 1 , )o f o u r p a t i c n t s l - r a c 1 olltcomc (prcgnancyviablc at 20 wceks). Two fctal dcmiscs wcrc c c t o p r c . C ) b s t c t r i c h i s t o r y , r a c c , m a t c r n : 1 1a g c , h c r n a t o c n t , v i t a l s i g n s ,p r c s c n c ea n d c l u r a t i o no f c r a n p s , I . ) r c s c n c co f c l o t s o r a b c l o r n i _ nal tcndcrncss on cxamination, anclduration of blccding wcrc not h c l p f u l i n p r c c l i c t i r " r go L l t c o l n c . T h c t i n . r e s i n c c l a s t r n c n s t r u a l p c r i o d w a s h c l p f u l : a v c r a g ct i n r c w a s 9 0 + l l d a y s f o r g o o d o l l t c o n t c paticnts vcrsus (r4 + 3 days for patients with fctal loss { 1 ,= . 0 0 t i ) .

A l s o , p a t i c n t s w i t l . r a c t i v c b l c c d i n g w c r c m o r c l i k c l y t o s u f f c r f et : r l Ioss {RR = 2.3, P = .03). Thc prcsencc of fcr:rl hcart activitv bv u l t r : r s o u n c lw a s a s t r o n g p r c d i c t o r o f g o o c lo u t c o r . r - r{c/ , . . 0 0 1 ) .A l s r i , a quantitativc huuan choriolric gonadotropin {HCG) lcvcl < (r,500 m l U / n L ( / r < . 0 0 1 ) a n d t h c a b s c n c co f a g c s t : t t i o n a ls a c b y u l t r a s o r - r n c( P l < . 0 0 1I w c r c s t r o n g p r c d i c t o r s o f b a d o u t c o m c . F o r t . r a t i c n t s w i t h a n H C G > ( r , 5 0 0 m l U / n i l a r . r dn o f c t a l h c a r t a c t i v i t v . t h u c h a n c c o f a g o o d u u t c o r . r . tw c as only onc tn fivc. All paticnts with an H C C . 6 , 5 0 0 r r r l U / r n L h i r t l t r . r : r tl l t n r i s e.

P a t i e n t s p r c s e n t i n g t o a n u r b a n c m c r g c n c y d c p a r t m c r " r tw i t h cornplaints suggestive of dchydration and/or bloocl loss wcrc cn_ tered into a study to evaluatc thc "tilt tcst,' in an aclult ED population. As part of thcir cvaluation, changcs in hcart ratc and blood pressure frorn lying to standing wcrc obiaincd in a star-rdarclizcd fashion. Body dehydration perccnt was calclllatcd for cach p a t i o n t w i t h p r c v i o u s l y p r _ r b l i s h c dc a l c u l a t i o n s u s i n g n r e a s u r c d serum osmolality and body weight. intcrnal or cxtcrnal Lrlccdinx was recorded if prescnt. Mcan dchydration pcrccntagc for this s a m p l c p o p u l a t i o n ( 2 0 2 ) w a s 3 . 7 2 1 : 2 . t ) .T I - r i ss a m p l c w a s . s u b d i v i d c d i n t o t h o s e p a t i e n t s w i t h a d i a g n o s i so f b l o o d l o s s l g r , r u p I ) a n d t h o s c patients with. a diagnosis of dchydration (group 2). Mcan clchyclra_ t i o n p e r c c n t f o r g r o u p 1 ( 3 6 ) w a s 2 . 7 3 t 2 . 3 8 a n c lg r o u p 2 ( l ( r ( rj w a s 3 94 ! 2.97 lP = .0226). Multiple ANOVA tcsting rcvcalccl syncopc l P = . 0 3 7 ) a n d l a c k o f a x i l l a r y s w e a t ( p = . 0 2 ( r )t o b c s i g n i f i c a n i l y c o r r e l a t c d w i t h d c h y d r a t i o n p c r c e n t a g c . S y r n p t o n - r a t i cr e s p u u s et i ) t h e t i l t t e s t w a s n o n s i g n i f i c a n t ( p : . 9 3 ) .A f o r w a r d s t c p w i s c l i n c a r rcgression modcl was constructod for thc continuoirs variablcs .21 { a g c ,c h a n g c i n h c a r t r a t c [ H R l , c h a n g c i n s y s t o l i c p r c s s u r c l S B p ] , Predictors of Electrolyte Abnormalities in Elderly a n d c h a n g c i n d i a s t d i c p r c s s L r r c[ D p ] ) m c a s u r c d a g a i n s t d c l i y d r , i Patients tion pcrcentage. In thc wholc san-rplc ar-rdin group 2, thc r.nodcls plrtl Singal, JRtledges, PA Succop/Depatrtments of Emergency f o u n d c h a n g c i n H R ( P = . 0 1 6 5 ) a n c i a g c ( 1 ,= . 0 ' 0 4 7 ) ' t od c n r o n s t r a t c M e d i c i n e a n d E n v i r o n m e n t a lH e a l t h , D i v i s r o no f B i o s t a t i s t i c s , a t r u e a s s o c i a t i o n w i t h d c h y d r a t i o n p o r c c n t : 1 g c .N o n c o f t h c s c 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 , O r e g o n f , { e a l t hS c i e n c e s variablcs wcrc significant in thc group I r.nodcl. Thc authurs U n i v e r s i t y ,P o r t l a n d concludc that rn orthostatic mczrsllrcmcnt or-rlyHR ar-rcl:rgc havc a T h c s c r u r l c l c c t r o l y t c p a n c l i s o r . t co f t h c r t r o s t c o m r r . r o n l vn e r _ t r u c a s s o c i a t i o nw i t h l e v c l o f d c h y c l r a t i o n .H o w c v c r , t h c a r n o u r . r o tf f o r r l c d l a b u r a t o r y t c s t s i n t h e c r n c r g c n c y r l c , p a r t n . r c nT t .h . p u r 1 i , , s . v a r i a t i o n i n t i c h v d r n t i o n p c r c e n t o g ee x p l a i n e t l b v H R ; r r r t l i l g e t s n ( ) r o f t h i s s t u d y i s t o v a l i c l a t c I p r c v i o r - r s l yp L r b l i s h c dd e c i s i o n r u l L f o r c l i n i c a l l y t r s c f u l .T h c s c m c a s u r c m c l . l t sd c l l . l ( ) n s t r t t n e():ls\o(,ultlon o r c l c r i n gs t a t s c r l l m c l c c t r , r l y t c s { L o w c e t t l , l . r H 7 ): r n c lt o c v a l u a t c with blood loss. It appoars that thcrc is too rruch individual o t h c r p r c d i c t o r so f a c l i n i c a l l y s i g n i f i c a n tc l e c t r o l y t c a b n o r m a l i t y varration in a paticnt's orthostatic rcsponsc tO clcl-rydratior-rancl ( C S E A )i n o u r s t u d y p o p u l a t i o r . r{ c m c r g c n c y p a t r c n t s > . 5 . 5y c a r s o l d j . blood loss to clctcrminc dcgrcc or prcscncc of dchydration or bkrocl A r c s c a r c h c rs t a t i o n c c li n t h c E D i n t c r v i c w c r l t h e t r c a t i n g fhysiciarr rOSS. i n : r t o t a l o f l , l J l 0 p a t i c r r t c r . r c o u n t c r s .E x t c n s i v c f o l l i r w - i r n w a s c o n c l u c t c c lt o r l c t c n . r . r i r . w r ch c t h c r t h c s c r u m c l c c t n r l v t c n , r , r c l , , . 19 Probability of Appendicitis Before and After d c r c c li n t h c E D r c s u l t c c lr n i r C S E A a n c ii f t l . r o s cp a t i c r . r t sw h o t l i t l n o t Observation h a v c t h c t c s t o r d c r c d o n t h c i n t l u x v i s i t h a r l d \ i r h s t r l L l c n tp h y s i c i a n LG Graff, MJ Radford, C Werne/New Britain General Hospital, New c n c o u n t c r ( < 1 4 d a y s ) i n w h i c l - ra C S E A w a s f o u n c l . S c v c r rh i r n d r c d B r i t a i n ,C o n n e c t i c u t ;U n i v e r s i t yo f C o n n e c t i c u t H e a l t h C e n t e r , n i n t y - s c v c r r p a t i c n t s l - r a dc l c c t r o l y t c s < l r t l c r c col n t h c i n d c x v i s i t .

Farmington O n c I r u n d r c t l t w c n t y - f o u r s h o w c d a C S E A {f r c c l u c n c y= I S . ( r , 2 , T h c ).

The cffect of observatiorl on the probability of appcndicitis wzrs s c n s i t i v . i t y _ a n d - s p c c i f i c i t yo f L o w c ' s c r i t c r i a f o r p r c d i c t i n g C S E A s cxamincd rctrospcctivcly in 252 cclnscclrtivc paii;nts with ab_ w c r c c a l c u l a t c c l - s c n s i t i v i t y , . 9 4 1 t 1 5 , rC, I = . t J t t - . 9 7 ) ;s p c c i f i c i t y , 0 9 dominal pain who underwcnt short-tcrrn obscrvation (10 4 t l.Z I t ) 5 " / ,C ' I = . 0 7- . 1 1) . O f t h c 1 , 0 1 3 p a t i c n t s w h o d i d n o t h a v c a s c n r n r hours) prior to thc decision to opcrate. Alvarado's scoring systclr clcctrolytc pancl on thc inclcx visit, six wcrc found to havc a CSEA was used.to- assign a probability of appcndicitis to cach. pzrticr-rt at a slrbscqucntphysician cltcoluttcr. Lowc,s critcria nrcdictcd all beforc and after observation. Mean scoic of paticnts with appcnclio f t h c s c . T l " r cr c l a t i o n s h i p b c t w c e n t h c f r ec t u c n c y o f C . S E Ae n d t h c c i t r s , i n c r e a s e df o l l o w i n g o b s c r v a t i o n f r o m 6 . U + 0 . 6 t o Z . U1 - 0 . q ( p r e J s o r r t h tec s t w i . l : , r r t l e r . d w e r c l r r i t l v zLei tsl i n A t h , . e h: i. 1 t r ; r r r . t e s t . < .0 1), corresponding to a changc in probability of appcndicitis froin Logistic rcgrcssion analysis w:rs pcrfornted to dctcnninc which 35% to 55%. Mean score of paticnts without ippenciicitis dc_ c l i n i c a l f c a t u r c s w c r c i n d c p c n d c n t l y a n d s i g r - r i f i c a n t l yp r c d i c t i v c o f c r e a s e d f r o m 3 . 8+ 0 . 3 t o 1 . 6 t . O 2 ( p < . 0 1 ) ,c c r r r e s p c , n d i n g t ocah a n g c C S E A . T h c r t o s t c o l r l t l o r t r c a s o n g i v c n f o r c t r d c r i n gc l c c t n r l y t c s i s 'CSte in probability from ti% to 3%. Followrng obscrvation, thc dlffcrto scrccn for an unexpcctccl abr-ronnality. Tlrc frcclucncy of e n c c b e t w c e n m c a n s c o r e so f p a t i e n t s w i t l - r a n d w r t h o u t a p n e n d i c r _ for this group was .11 cornparcd wlth .j0 if thc pliysician ordcrcd trs increascd from 2.6 + 0.6 to 6.2 t .O5 {1, < .01). Twi-Lry_two thc tcst to confirm a suspcctcdabnormality ana .Oj ii thc tcst was contingcncy table analysis showed that observation imnrovcd o r c l c r c db y t h c n u r s c t o c x p c d i t e p a t i c l l t c i l r c . T h e s e t l i f f c r c n c c s a r c m e a n a c c u r a c y f r o m 6 5 Y " t o 8 5 % l p < . 0 1 ) ,m c a n p r o b a b i l i t y o f d i _ s i g n i f i c a n t ( 1 ,< . 0 0 1 ) .L . r p a r t i c u l a r , c t n c r g c l t c y p h y s i c i a n s w h o d o agnos.is(positive predictive valuel fron 70y" to 80o/olp < .0 1 mcan n o t s u s p e c tC S E A i s p r c s c n t a n d c m c r g c n c y n u r s c s w h o d r a w b l o o d ), specificity from 657" to 86% (P < .01], and mean sensitivity from p r i o r t o p h y s i c i a n c v a l u a t i o n r n a y f t n c lt h a t L o w c ' s c r i t c r r a l t r p r o v c 7O"h to B0% (NS). By incorporating change in scorc foliowing d e c i s i o n r n a k i n g . T l - r c ys h o u l d a l s o b c a w a r c t h a t c l d c r l v p n i r " n t , observation as a function of prcobseivation score, sensrtrvity furw i t h a h i s t o r y o f r e n a l d i s c a s c ,a l c o h o l i s n - r ,a n d i r n p a i r c t l a i r i l i , y t , , t h e r i n c r e a s e df r o m 8 0 % t o 9 3 % l p < . 0 1) , a n d p a t i e n t s w r t h a p p e n _ comntunicate may be at incrcasedrisk for CSEA. dicitis could be separated from those without. In this group of patients with an initial intermediate probability of having appen22 Symptom Severity in Acute Myocardial lnfarction and dicitis, observation improved the ability to distinguish pnii."t. its Effect on Patient Delay and Use of 91 1 with and without appendicrtrs.

MT Ho, MS Eisenberg, S Schaeffer, S Damon,p

Litwjn,Mp Larson/Center for Evaluatron of EmergencyMedicalServices,King CountyDepartment of Health,EmergencyMedicalServices Division;Department of Medicine,University of Washington, Seattle Wc studicdwhcther symptom scverityis predictiveof acute myocardialinfarction {AMI) and how it af{ecispatient delay in

20 Threatened Abortion: A Prospective Study of Predictorsol Outcome in an EmergencyDepartment Population

21

seeking care or use o{ the 911 number. For 15 months beginning October 1986, 5,206 patients were admitted to King County, Washington, hospitals for possible AML Patient records were reviewed for patrent delay, mode of transport, and discharge diagnosis. For patients with a discharge diagnosis of AMI, the admission E C C w a i r e v i e w e d . A r e p r c s e n t a t i v es u b s e t o f p a t i e n t s { 2 , 3 8 8 '4 ! % 1 . was interviewed by phone to assesssymptom severity on a sca-leot I (lowest) to 10. Symptoms rated as I to 4 were consideredmild, 5 to 7 moderate, and 8 to 10 scvere. There was no significant correlation betwecn severity and discharge diagnosis o{ AMI no correalso was severe,277".Thete 23ok; moderate, mild,26"ki lation between severity and whether the discharge diagnosis was cardiac rclatcd (AMI, angina, acute pulmonary edema) - mild, 5 5 % ; m o d e r a t c , 5 3 % ; s e v e r e ,5 5 % . O f p a t i c n t s w i t h A M I ( 5 5 2 ) ,S T clevation was present in 55% with mild, 53% with moderate, and 67"1' with t.u".c symptoms. Scvcrity significantly influenced naticnt delav and use oI9ll:57"1, of patients with mild symptoms iclayed moic than two hrrurs, only 32% used 911;51% with rrlud".ute symptoms delayed more than two hours, 427" used 9ll; 46'% with severc symptoms delayed morc than two hours, 4t37o uscd 911. In paticnts with chest pain, efforts to shorten dclay in s c e k i n s c a r c a n d t o j . n c r c a s eu s e o f 9 1 I s h o u l d s t r c s s t h a t s y m p t o m scverity is unimportant.

in Analysisol the Electrocardiogram 23 Frequency Fibrillation HumanBeingsDuringVentricular of Emergency CG Brown,R Neumar,R DzwonczyklDivision The Ohio State of Anesthesiology, Medicineand Department Columbus University, that the initial treatmcntof venRcccntrcportshavcsuggested tricular fibrillation (VF) may be dependenton downtime, thc duration of time betwccn thc onsct of cardiacarrcst and thc initiation of advanccdcardiaclifc support.Howcver, thcrc cxrstsn<r rcliablemethodof cstimatingdowntimc in the prehospitalsetting. thc dynamicsof thc ECG in the Wc havcprcviouslycharactcrizcd frcclucncydomain during VF in a swine rnodeland havc shown that rncdianficqucncy of thc VF ECG can bc usedto accuratelyrlcasurc downtimc during VF. Thc purposcof this study was to charactcrize thc dynar-niccharacteristicsof the VF ECG in human beings-The analcigECG signalwas rccordcdfrom sevcnpcrsonswho developed VF during ambulatory cardiac monitoring The analog-VF ECG signal was digitizcd ^t 128Hz, and cach four secondsof data wcre transformcdinto thc frcqucncy domain using a fast Fouricr transfonn. Thc rncdian frcqucncy thcn was dctcrmined and plotted vcrsusdowntimef or all paticnts.The durationof VF for thesesevcn paticntsrangcdfrom I .53to 1U.27minutes At the onsetof VF thc nu"rag" -cdia.t frccluencywas 4.40 x L2l Hz. The median freurlcniv dccrcascdto 3.38 t l.0B Hz at 3.20 minutes and then incrcascdto a pcak of 4.14 tO.6I Hz at 5.87minutes.The median frcouencv then decreasedover time. Thc averagecoefficient of variation for all seven subiects was 24.737".It appcarsthat thc mcdian frcquencyof the human VF ECG signaldisplaysa dynamic anrl rcpcatallc pattcrn with rcspectto time. It is possibleto modcl thesc iata to cstimatc downtime during VF and thus guide initial therapy.

had the final diagnosis of angina or AMI were mistriaged by paramedics and/or received no advanced life support therapy.

Drehospital ECGs increase diagnostrc sensitivity and specificity, approach congruity with ED diagnoses, and may improve accuracy in triage of chest pain patients.

Group l

Sensitivily

Paramedic clinicaldiagnosis 75.0%

Specificity

-i

-Predictive Value

+ Predictive Value

70.57"

L93.5'l.

133.3%

ur

Base physician c l i n i c a l d i a g n o s i s5 9 . 1 %

I 69.0'l. I

PrehospilalECG 54.2o/o -P=NS.tP<.001

99.2o/a

J

87.O"/"

32.5"/"

r

92.87.

|'

'

92.1"/"

.25 A Computer-Based Predictive Time-lnsensitive Inlarctionin the Myocardial lor Predicting Instrument EmergencyDepartment

CB Cairns,JT Nremann,PL Henneman,lG Mena,MM Laks/The of EmergencyMedicine' UCLASchoolof Medicine,Departments HarborNuclearMedicine,and Medicine,Divisionof Cardiology, UCLAMedicalCenter,Torrance The purposeof this study was to assessthe diagnosticvalue of time-insensitivepredictiveinstrument (TIPI)in a computcr-based, detecting acute myocardial infarction {AMI) in patients whose initial ECG was not diagnosticfor AMI. A TIPI probability scorefor AMI was calculatedusing four clinical variables{age,sex,presence or absenceof chest/left arm pain, and whether chest pain was the primary presenting symptom) and computer interpretatron.of nonspecific ST segment-Twave abnormalitiesusing specifically designcdECG computer language.Forty-ninepatients with chest pain'suggestiveof AMI and nonspecificST-T wave changeswere enrollcd, had thallium-201 and technetium-99m cardiac scans pcrformedand ECCs recordedin the emergencydepartment,and, iollowine admissionhad serial CK-MB determinationsmade and serialEiis obtained.A TIPI probability scorewas computedusing the initial ED ECG. An increasein CK-MB fraction {> 5%) was noted in four of 50 patients.Twenty-four 149'hlhad an abnormal wall motion study, and l3 of thesehad an abnormalthallium scan (scansensitivity ior AMI, 757o;specificity,4O"/oipositive prediciive value, 10%; negativepredictivevalue,95%).Of thosepatients with CK-MB elevation,a TIPI AMI probability scoreof > 37okhad a sensitivity of I00% and a specificity oI 79"/ofor AMI (positive predictive valte, 667oinegativepredictive value, 100%).W-. .91clude that this computer:basedpredictive instrument is highly sensitivein detectingAMI, more accuratethan early radionuclide scanning in detecting AMI, easily accessedin the ED, and of potential value in triage.

of CreatineKinaseand CKMBin 26 Comparison EmergencyDepartmentPatientsAdmittedto RuleOut Infarction Myocardial

VeteransAdministrationMedical GP Young,T Green/Portland Centerand OregonHealthSciencesUniversity,Portland We retrospeitively analyzed total creatine kinase (CK) and CKMB levelsdrawn in the emergencydepartmenton 222 consecutive patientsadmitted to rule out myocardialinfarction to compare 24 The Diagnostic lmpact of Prehospital 12'Lead theii relativeaccuracy.For all o{ the patients,the meanCK was 149 Electrocardiography x7g U lL (normal range,to 2321andthe mean CKMB was i3 t 9 U/ TP Aufderheide.GE Hendley,RK Thakur,FA Laitinen,JR Mateer' L {normal range,to 23).For the a3 (19%lMI patients,the meanCK KC Preuss,RG Hoffman/ HA Stueven,DW Olson,KM Hargarten, was 371 t lStU lL and the mean CKMB was 26 + 13 U/L. For the MedicalCollegeoJWisconsin,MilwaukeeCountyMedicalComplex.

I79 l8l%) nonMl patients,the mean CK was-95!66UlL and the During a ien-month period, i53 blinded prehospital l2-lead meanCKMBwas l0+ 8 U/L. In theED, lTof theMlpatients (40%) ECGs of diagnosticquality were obtained by paramedicson 157 ,34%) had an elevatedCKMB (truehad an elevatedCK and 15 adult patientspresentingwith chestpain. Final hospital diagnoses had positives,P > .05,chi-square).Of the nonMl p-atients,nine (57o-) were classified into thiee groups: group l, acute myocardial an elevated CK and eight {4.5%) had an elevated CKMB {falseinfarction (AMI, 24); group 2, suspected angina (62); group 3, positives, P > .05, chi-square).For the CK values in the ED, the noncardiacchest pain (67).Paramedicand basephysician clinical the positive predicipecificiiy was 94"/o,the sensitivity was-39o/o, diagnoses,and prehospitaland emcrgencydepartmentECGs were tive value was 65%, and the negativepredictivevaiue was 85o/o.For similarly classlfied and compared. ECGs were independently, the CKMB valuesin the ED, the specificitywas967o,the sensitivblindly, and retrospectivelyreadby two cardiologists.For patients ity was 35%, the positive predictive value was 657o, and the with AMI, prehospitalECG alonehad significantly higher specificnegative predictive-valuewis 86%. These results indicate that ity and potiti'tte predictive value than did the paramedicor base p h y s i c i a nc l i n i c a ld i a g n o s i sF. o r p a t i e n t sw i t h s u s p e c t e d - a n g i n a , thJre is nb significant differencebetween the CK and the CKMB when usedin the ED diagnosisof MI. iombining the paramedicclinical diagnosisand the prehospital improvedsensitivityi90 i vs 62.3,P <.O01)and ECG signiTicantiy .27 of Contaminated SquamousCellsas Predictors negativepredictivevalue(88.5vs 70.I, P <.02).Therewas increased between blinded prehospital and ED ECC Cultures a high conc-ordanCe Urine 1 99.3% of California,San Francisco, Ior Ali.1rl,92.8% for anginaJ.Futhermore, ten diagnosis FG Walter,RK Knopp/University San JoaquinValleyMedical prtLntt wiroseprehospitalECGs demonstratedischemiaand who Schoolof Medicine;Fresno-Central

22

E _ d u c a t i oP n r o g r a m ; D e p a r t m e n to f E m e r g e n c y M e d i c i n e , V a l l e y Medical Center, Fresno, California Squamous cclls arc commonly bclieved to indicate a contaminatcd urrnc sample. Howcvrr, no published evidcncc uxist\ ro support this_assumption. Therefore, 105 women with symptoms s u g g e s t i v co f u r i n a r y t r a c t r n f e c t i o n w e r e s t u d i e d p r o s p c c t i v e l y i n o l l r . e m e r g c n c y d c p a r t m e n t . E a c h p a t i e n t h a d t w o u r i n e s a m p l e s ,a midstream clean-catch (MSCC) initially, then a catheterrzcd {CATH). Both samplcs wtrc analyzrd for squarnous cclls and c u l t u r e d . C o n t a m i n a t i o n w a s d e f i n c d a s l e s s t h a n 1 0 , 0 0 0c o l o n i e s / m L o r a u r i n e s a m p l e t h a t g r c w t h r c c o r m o r c s p e c i c so f c o m m e n s a l b a c t e r i a . O f t h e 1 0 5 p a t i e n t s , 2 2 l Z O " / , 1h a d c o n t a m i n a t e d M S C C urine sampies. Although CATH urrne containccl from O to (r0 squamous cclls/low power ficld (LpF, ic, l00x), no CATH sanrplc grew contaminants. For MSCC samples, the positive prcclictivc v a l u e { P P V )o f s q u a m o u s c c l l s f o r c o n i a m r n a t i o n i s s u m n a r i z c c l a s follows, with 90% confidcnce intcrvals: 0 squamous cclls/LRf, 0% P P V { 0 % t o I 0 0 % ) ; L t o l 0 s c l u a m o u sc e l l s / L p F , 2 0 , / . p p v lll.5,t, t - o2 8 . 5 " k ) ; i 0 t o 3 0 s q u a m o u s c e l l s / L p F , I 9 % p p v l 7 . 7 7 " t o 3 ) , . 0 . 1 ) ; 3.0to 60 squamous cells/LPF, 3U% PPV lr).3"1,t<t 65.67o)iand morc t h a n 6 0 s q u a m o u s c c l l s / L P F , 5 0 % , P p V ( O % ,t o 1 0 0 % , ) W . c concluclc t h a t s c l u a m o u sc c l l s i n C A T H u r i n c s a m p l c s a r c n o t p r c c l i c t i v c o f c o n t a m i n a t c d C A T H u r i n e , a n d t h a t t l - r cc l i n i c i a n s h o u l d n o t r . r c c cssarily discard a urine samplc as contamin:ltcd bccar-rscsciLr:lmous ccus arc prescnt.

28 Stab Wounds of the Chest: Utility ol the Expiratory Chest RadiographAlone RMMcNamara, EA HeinelDepartment of Emergency Medicine, The Medical College of Pennsylvania, Philadelphia It is generally rccommcndcd that radiographiccxarnination fur p o t e n t i a l p n c u t n o t h o r a x i n c l u d c s b o t h i n s p i r a t o r y ( I C R ) a n c lc x p i r a t o r y _( E C R ) c h e s t r a d i o g r a p h s . T h i s s t u t l y r c t r o s p o c t r v c l y c x a m incd the uscfulnessof thc ECR alonc in tl0 paticnti sustaining stab wounds of the chest during a two-ycar pcriocl. A board-cciiificd cmcrgency physician indcpcndcntly intcrprctcd only thc ECR in t h c s e p a t i c n t s . T h i s r c a d i n g w a s t h c n c o n - r p a r c dt o a r a d i o l o g i s t ' s intcrprctation of both vicws and, if pcrformcd, a latcral vicw. Disc r c p a n c i c sw e r c r c v i e w c d a n d a n o t h c r r a d i o l o g i s t ' s o p i n i 0 n s o u g h t if nccessary to rcsolvc a diffcrcnce. Finclings wcrc clas,sificdin thicc groups: pneumothorax, cffusion/infiltratc/atclcctasis, ancl Othcr s i g n i f i c a n t f i n c i i n g s .A t o t a l o f 2 1 9 s c t s o f b o t h I C R a n c l E C R w c r c avaiiablc for revicw, and 121 had an includcd latcral vicw. Tl-rcrc w c r e B 7 ( 4 0 % ) p n c u r n o t h o r a c c s w i t h o n c f a l s c - p o s i t i v c { F p )a n d t w o false-negativc {FN) intorprctations by thc cmcrgcncy physrciar-r.

Both false-negative rcadings wcrc a minimal apical pncJmothurax that was dcmonstrable on the ECR. Thcrc wcrc 9g 1.44,,1 i n, s) t a n c c s of eithcr effusion, infiltratc, or atclcctasis with onc falsc-positivc and four falsc-ncgativc intcrprctations by thc cn"rcrgcncy physician. Two of the false-negative rcadings wcrc evicicnt on rorcvicw of thc.ECR, ancl the other two werc small cffusions scen only on the latcral view. Three of the ten other significant findings {hilar rnass, rib fracture, dcnsity) were initially rnrsscd by thc crncrgcncy physician but were obvious on a rcrcview of thc ECR. Scoaratc analysis of the 56 scts of radiographs that wcrc thc initial crncrgcncy department studies revealcd ten (lti%) pncumothoraccs, sevcneffusior-r/infiltrate/atelectasis, andthreeothcrfindinss. Thcrc werc no falsc-positive or false-ncgativc rcadings by thc cmcrgency physician in this group. A propcrly intcrpreted ECR appcars'io bc sufficient in the cvaluation of patients with stab wounds to thc chest.

29 Detection of SoftTissueForeignBodiesby plain Radiography, Xerography, Computerized Axial Tomography, and Ultrasonography G L E l l i s ,M G i n s b u r g , L F l o m / W e s t e r n P e n n s y l v a n i aH 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 ,A f l i l i a t e d R e s i d e n c y i n E m e r g e n c y M e d i c i n e , P i t t s b u r g h ,P e n n s y l v a n i a _ The ourpose oi this study was to detcrmine the reliability of plain.radiography, xerography, computerized axial tomography, and ultrasonography in the detection of soft tissue foreien bodiis of various materials. Fragments of glass and wood measuring 5 mm long by 2 mm wide were placed between two pieces of meat with the preparation submerged under water to prcvent air entrapmcnt at.the inter{ace. The preparation was thin examined by plarn radiography, positive and negative xerography, cornputerized axral tomography, and ultrasonography. The glass foreign bodies were reliably detected by all of the modalitics tested. The wooden and plastic foreign bodies were poorly visualized by plain radiography.

Xcrography and cornputerized axial tomography achicved slight cnhanccment but did not rcliably dif{ercntiatc the foreign bod'ics frorn intrinsic variations of radiodcnsity prescnt tn the soft tissuc r n o c l e l .O n t h c o t h e r h a n d , u l t r a s o n u g r a p h y r c l i a b l y d c t e c t c d t h c forcign bodrescomposcd of plastic and wood. Wc concludcd that u l t r a s o n o g r a _ p hiys t h c m e t h o d o f c h o i c c i n d c t e c t i n g f o r c i g n b o d i e s c o m p o s c c lo f m a t e r r a l t h a t i s n o t s i g n i f i c a n t l y r a d i o d e n s c .

30 PortableUltrasoundin PatientsWith Suspected Cholecystitis:Performanceand Interpretatioiby EmergencyPhysicians L Gussow, R Himmelman, R Zalenski/Deparlment of Emergency Medicine andDivision of Trauma, Department of Surgery, Cook CountyHospital, Chicago, lllinois Altl-rough scvcral studics havc shown thc uscfulncss of ultra_ s o n o g r a p h y p c r f o r r n c c l b y r a c l i o l o g i s t si n t h c c m c r g c n c y d c p a r t mcnt/ nonc havc cxaminccl thc accuracy achicvablc by cn-rcrgcncy p h y s i c i a n s w i t h o u t p r i o r f o r r . n : r lu l t r a s o u n d t r a i n i n g . f h i s . i t u d y was undcrtakcn to cvaluatc cmcrgcncy physician usc of ultrasonography to clctcrminc thc prcscrrcc or abscncc of gallstoncs.

T h r c c c m c r g c n c y p h y s i c i a n s w c r c g i v c r . ra p p r o x i r - n a t c l yc i g h t h o u r s o f t r a i n r n g i n _ g a l l b l a d d c rv i s r - r a l i z a t i o na n d d i a g n o s i s .b y ' a n u l t r a s o u n c lt c c l . r n o l o g i s to n t h c S c a n M a t c I I , p o r t a b l c u l t r a s o u n d s c a n _ n c r l D a m o n C o r p ) . P a t t c n t sc r r t r r u t li r r t o t l r c s t u d y w c r c a l l a d m i t tcd to thc hospital through thc ED with suspcctcdcholccystitrs or ch.olclithtasis.No pilticltt hacl rcccivcd a prcvious sonogram or othcr clcfinitivc tcst fur gallstoncs.Nonc had gallstoncs visiblc on r t h d r r r r r i n ;rr:lr t l r o g r t r p T h .h u i n v c s r i g : r t o sr r r r n n e t tl h ( . f i l t i r . n r i n ( ) n u or two positions (supinc, lcft latcral dccubittrs), took polaroid, p i c t u r c s _o f t h c r n o s t r c p r c s c t l t a t i v c v i e w s , r r n t l i n r r n c d i a t c l y i n t c r p r c t c d t l r c s c : u t i l s l . r o s i t i v cf o r g a l l s t o n c s , n c g a t i v e , o r i n c l c t c r r l i _ natc. This blindcd intcrprctation was comparcd to thc gold stan_ d a r c lo f f o r r n a l u l t r a s o r - r o g r a p h p y crformccl in thc radiology dcpartl . n c n t o r f i r - r c i i n gas t s r l r g c r y . F o r t y - f o u r p t t i c l ' l t s w c r c c n t c r c c l .T h c lrrc:ln :lgc was 39; 6[l'2, wcrc wollclt. Thc prcvalcncc ratc of gallstoncs was 57'2, 125of aa) Twe nty-tw() ica,rs ,"crc rcad as l . r o s i t i v cb y t l - r cc r . n c r g c r . r c|yh y s i c i a r r ; ; r l l l . u t o n c a g r c c d w i t h t l - r c g o l c l s t a n d a r c l ( p o s i t r v c p r c c l i c t i v c v a l u c = 9 5 , 2 , 1 .T h i r t c c n s c a n s w c r c r c a c l a s n c g a t i v c ; a l l b r , r to n c a g r c c c lw i t h t h c g o l d s t a n c l a r c l ( n c g i r t i v cp r c c l i c t i v c v a l L l c= 9 2 , ' l ) . N i n c s c a n s( 2 0 , 2 , ) w c r er c a d a s i n d c t c n . n i n a t c ;o f t h c s c , t h r c c w c r c p o s i t i v c a n t l s i x w c r c n c g a t i v o b y t h c g o l d s t a n c l a r c lW . c c o n c l u d c t h a t c m c r g c n c y p h y s i c i a n 1 r er f r r l l a n c c o f u l t r a s o u n c l s c a n n i n g i s f c a s i b l c a r - r da c c t i r a i c a n d c a n a i d i n c i i a g n o s i sa n c l p a t i c n t d i s p o s i t i o n . T h i s w a r r a n t s f u r t h c r s t u d y .

31 PassiveHemagglutinationInhibitionTest for Diagnosisof Brown RecluseSpider Bite Envenomation SMBarrett, M Romine-Jenkins, JP Campbell/Oklahoma Medical Center, University of Oklahoma Health Sciences Center, Oklahoma City B r o w n r c c l u s c ( F i d d l c b a c k )s p i c l c rb i t c ( B R S B )c n v c n o n r a t i o n i s a c o r n l n o n c a u s c o f n c c r o t i c s k i n l c s i o t - r si n t h c M i d w c s t . H o w c v c r , o t l - r c rc t i o l o g i c s o f s k i n n c c r o s i s c x i s t . P r c s c n t l y , t h c c l i a g n o s i so i B R S Bc n v c n o r n a t i o n i s m a d c c l i n r c a l l y . W c r c p o r t a p a s s i v c h c m a g glutination inhibition (PHAI) tcst to diagnose llRSIl in humin bcings. Thc PHAI assay has bccn usccl succcssfully to idcntifv vcnom frorn BRSB lcsions in guinca pigs, but thc tcsr h;rsntrt yr:t bccn uscd for diagnostic purposcsin human trials. To dcvclop ihc tcst, brown rcclusc spidcrs wcrc captllrcd and disscctcd. Spidcr vcl-lom was poolcd and conccntratcd. Rabbits wcrc inicctcd with vcnom to inducc antibody formation. Finally, human rcd blood c c l l s w c r c c o a t e d w r t h s p i d c r v en o m u s i n g a m i c r o t i t e r p l a t e . T h c P H A I t c s t t h c n w a s s t a n d a r d i z e da g a i n s t c o n t r o l s t o a c h i c v c < t p t i mal concentrations of venom, rabbit antibody, and sensitiZed human rcd cclls. If spider vcnorn is prescnt in rnatcrial from a nccrotic lcsion, this venom will bind with rabbit antrbody so that hcmagglutination does not occur. If venon-r is not prescnt, rabbit antibody is frec to bind with venom, coating red cell membranes so that hernagglutination occurs. Thercfore, hcmagglutination inhib i t i o n i s d i a g n o s t i c o f B R S B c n v e n o m a t i o n . T h c s t a s c so f t h e p H A I test will bc displayedalong with positive and negativc results and control samples. Furthermorc, using venom from other spider s p e c i e sc a p a b l c o f i n d u c i n g n e c r o t i c s k i n l c s i o n s , w e w i l l d i s p l a y the.specificity of the PHAI test for ve nom from thc brown reciuse sploer.

.32 Standard Formulationof NitroglycerinOintmentand Hot Packsfor Venous Dilationin PediatricIntravenous Access

MC Clark, K Shaw, D Schaible, N Mackey/Department.ol University EmergencyMedicine,Children'sHospitaloI Philadelphia, Schooloi Medicine,Philadelphia. of Pennsylvania We siudied the e{{ectivenessof 2% nitroglycerin ointment veins to facilitateIV (NTGI or hot packs in dilating cutaneous. accessin 149 nonacute patrents with stable vital signs from I -onth to 17 yearso{ age. Patients were randomly assignedto ,."r,-".r, groups of NTC (44),hot packs (51),-or control {54J' Oi",-"", #as ,ppli.d for three minutes {rom l-mL syringesbased ,- th. prti..tt't "g" "t follows: 0 to (r months, 0 QQmL; 6 months to 3 years,0.09mi;3 to l3 ycars,0. I(r mL; and olderthan 13,0 25 -i. bo-i".t.iaily'available hot packswere appliedalongwith the ointment but only activated in the hot pack group Placeboointment and inactivatcdhot packswere appliedin the controlSroup' Vcin diameter was measuredby using prccision calipers' Thcre wcre no cliffcrencesamong thc groups in patient weight, age,sex, or prctreatmentmcan vein size Nonc ol the treatmentsalterco vital signs, nor were side effects noted during 30 minutes <lf observaiion.NTG applicationrcsultcd in significantvcin dilation did hot pack "u-prt",l tu placcbo(l = .03210.3Umm SD;P = '041as application(i = O.:+t o.+Amm SD;P = .03).OverallIV succcssrate in successrate werc detectedamong iis75%, and no differences thc sroups.We dcmonstratcda safedosefor a standardformulation ,rt NiC'",r, prcviouslystudiedin thc pediatricpopulationthat dilatcscutancousveins.Hot packs,alsoheretoforcunstudied,werc ..irritv as cffcctivc as NTG in vein dilation Further study to ;"';1";1. ,h" abilitv of thcse tcchniquesto improve the succcssof tV ,.."tt in infantsand childrenwilh smal1veins is warrantcd'

'33 Ketamine Pediatric SedationProtocolfor Emergency Procedures

of Emergency SM Green, NE Johnson,R Nakamura/Department MedicalCenter,LomaLinda' Medicine,Loma LindaUniversrty CaliJornia - -wc rcviewedthe kctaminc litcrature and studicd thc efiicacyof a low-dosc scdativc protocol in childrcn undergoing cmergoncy proccdurcs.

One hundredcight paticntsagesl4 monthsto 13years i:"."lu.J in,tr*uscular racemii kctamine 4 mg/kg with 0 01 mg/ k{ atropinc.Onsct of dissociativesedationwithin five minutes il3'X,of patients;adccluateanalgesia,immobility, and i,!.rit.'Jit r"Jrii,it wcrc achicvcd in 97"1,.No adjunctive rcstraint or local ancrthctic was uscdin 86%. Mcan time from in jection to dischargc pulse ,"". 82 rrrir't,.,t.s irangc,30 to 175).Patientswerc monitoredby ,t-l-.,.y and bedsidenursing, without IV or-intubation' Therc wcrc no'clinicalcomplicationi,althoughone 1fl-month-oldexpericncccl cmesis with transient cyanotic laryngospasm' Emesis occurrcdin (r%. No nightmarcswcrc notcd ln thls age group' Parcntalanclphysician satis{actionwerc high immediately and on {ollow-un intcrvicw. As with all scdative agents,use should be lirnitcd io pcrsonnel capablc and cquipped to manage alrway such as laiyngospasm.Contraindications are dis.nt.i*"n.i". .urt"?. W. concur with 25 yeais of studics documenting.efficacy and safcty of ketamine sedation for outpatient proccdures ln sclectcdpcdiatricPatients.

.34 lmpactof the HIVEpidemic:Emergency Department

by PatientsWithKnownHuman ResourceUtilization Virus(HlV-1)Infection lmmunodeficiency

K Loring,KT Sivertson/ GD Kelen,G Johnson,T DiGiovanna, Diuitionoi EmergencyMedicineand JohnsHopkinsUniversity Maryland Schooloi Medicine,Baltimore, Inner-city emergencydepartmentsare increa.singlybeing used by paiientswith HIV I infeciion. We undertookthis study to assess thc reasons{or emergencyvisits to an inner-city ED by patients HIV infiction. Retrospectivechart review of a four;i[L;;;" month Derlodin 1988revealedthaf 164 patients with known HIV i"i..tio'" accountedfor 256 ll .4%l ED visits Only 27 of the visits clearly unrelatedto HIV infection, and 130visits *.r.]ot..r.nns we.re l5l%) becameadmissions.The most common complalnts 'i.",intE;Il, tever\25"/"l,malaise(I8 % ), and chestpain (I47' ) The (13%)' rno.? "o--'n" diagnosei wete Pneumocystis pneumonia pneumonia ( other l3%), {7%)' disorder neuiological """-i."ri."t and volum-edeplction ((r%)r9j t\t It^:itt from patients rep.is (f,y' l, 'iegular .orrt". oi care,70"/oll27 of-Ilz) occurredduring *t" f-traa (OR)analytimes when tir.re.or....s were unavailable Oddsratio patients HIV that revealed visits 256 the of payor status sis of the were 2.4 iim.t -o.e likely to have inadequateor no lnsurance (95% CI=1 84.ot"p-.d with the generalemergency.population (50)were 3.33,P. .01).Patientswithout a regularsourceof care

more likely to hAveinadequateor no insurancein compari,son^with = = thosewho were regularlyfollowed (OR = 2'I, 95"/oCI I'0-4'9, P .5J.Visits with third-party coverage(187)were more than 3'2 times "r' lik"ty to result in idmissions than visits with inadequate arebased admissions CI: 1.66-6.I;P < .01).Because .o"..r*. 1'95% onlv o"n severity of illness and not payor status, HIV pattents *i,ito"a insurancelikely usethe ED astheir primary sourceof care' We concludethat this dD is soughtwhen other sourcesof careare ""^u^iirlf., but HlV-infected patients are les.sable to pay for serviccsthan others.Adequatelysubsidizedand alternatesources of care are essential to ichieve appropriate use of emergency servicesby these complex patients.

35 EmergencyDepartmentCompliancâ&#x201A;ŹWith a Standard for the Minaglmeirtof PatientsWith Uncomplicated Convulsions Recurrent

LJ Baraff,DL Schriger,S Starkman/TheEmergencyMedicine Center,UCLAMedicalCenter,Los Angeles We conducteda retrospectivestudy to determine if the treatment of uncomplicated iecurrettt convulsions in a university depariment met a minimum standarddefined by the .-.tg*.v ii compliance related to the resident's-specialtyor ^tia fr""iiv o"ri*i'"a"r," year oi training. The standarddescribeditems to be i".l"a"a in the medical reiord and the appropriate diagnostic evaluation. A chart score was defined by the presenceof ten eight desirablehrstory and physical items; a perfect .s""i*i,ta r."i" *rt ioo. only anticonvulsantandethanollevelsweredeemed anoror,tiatefor all patientswhen drawn;a headcomputedtomograo'fi'utirn was deemedappropriateif the patient'sneurologic-status or failed to'retlrn to baselinein one hour' All other i.i"ii-.,.a evaluated individuallv bv the authors' One hundred ;;;;t; .unr".rrtiu. ED patients l8 years or older-who presentedwith a ,""rlrr"n, convuliion and weie not hospitalizedwere the subiects of this study. Patientsrangedin agefrom 18 to 88 years(mean,32 ' t I .2 ISEM]|.ED tirne rattgedfro- 26 to 58I minutes{mean,209 to $1,779 from $0 ranged chirges {ASCsl ffl. nncilla.y service {or testsdeemed f-.arr", $ii6t. only 26.1dof thesechargeswere ,pptopti"t.. There was a significant relationshipbetween the ED i'i?e ind ASCs (Spearmanc6rrelation= 0.4459iP < '0001)'Medical rccordscorcsrangedfrom 8 to 79 (mean,59 t 1 4)'.ASCsf or patients secnby emergenJymedicineresidentswere lessthan for thoseseen were higher!9r [v -"6i"i"" iesidents($82vs $227;P = .003)'A-SCsp'Cy t-Z versusPGY 3-5 residentsi$238 vs $185,P = 16) We concludethat physician documentationdid not meet the detlned resulted in unnecesstandard,exceisive use of ancillary s-ervices ;;; ;;tit and long ED times, and there was.a differencein the o.t'fot-rt". of res'identphysiciansby specialty with emergency physiciansorderingfewer ancillary services'

'36 Adherence

by HealthCare to UniversalPrecautions in an lnterventions Emergency Performing Providers DePartment lnner-CityEmergencY A Stein' E Junkins, L Bisson, D Kalainov, DiGioianni, GDKeten,'T

of EmergencyMedicineand Johns C Scott,ti Sivertson/Division Maryland Schoolof Medicine,Baltimore, University Hopkins -'to "univerdet.rmineif health careworkers (HCws) adhereto sal precautions"we prospectivelyobserved129HCWs performing 1,274 intetventlons on i51 coniecutive patients requiring.rapid intcrventionsin an inner-city emergencydepartmentlocatedin an iIv-ende-ic area. Institution-widi and department-specificinstructional sessionson universalprecautionswere held for HCWs the year prior to the initiation of the study'-Interven' itt.or-,ghor'tt classifiedas maiot 142.5%)or minor ls7'4%l depending ;i;;;;;;; precaunt i}r" pot."tial for exposureas dictated by the universal tions guidelines. Among the interventions observed,residents 473, consuitants 192,attendings 103,nursing staff97' ;.tf";;i housekeeping,32' 76, radiographtechnicians! f ,^.a,nd ,'25'1.%l iri"-.ai". oI ictive bleeding*", p..t.ttt rn 112 174'I%),with 38 ifr.." ff..ai"g"ptofrls.ly. Overall adherencewas adequateduring 16.5% otmai&interventions and 64.8%of minor interventions.(P < .05]. During minor interventions, adherencewes the samefor 0%) andnontraumapresentationsl6T tr""-, pi.t.tit ations162.97o1 pl9f9:: bleeding,adherence fp r .OSi.However, in the prese.nct.of presenduring minor interventionadeclinedto 19'77" ir'ttatmatic i"tio"'t (p < .05) and 07o in nontrauma presentations(P < '05)' During maior procedures,adherencewas 34'0% with traumatic pt.t.""t"tioi-tt and 0'B% with nontraumatic presentations(P< 05J' ihe overall adherencerate for HCWs was residents,58%; attend8%; i"gr,lS "/;r.o"sultants, 43%; nursing staff, 44"k; paramedics,

24

radiograph technicians, l4Y"; and housckccping, gl%. When prcc a u t i o n s w e r e i n a d e q u a t e ,s u r g i c a l m a s k s w e r e u s e d l e a s t ( 2 2 . 4 % 1 , f o l l o w e d b y e y e p r o t e c t i o n ( 4 5 . 0 % ) , g o w n s ( 4 9 . 6 ' l o ) ,a n d g l o v e s 1 7 3 . 7 % 1A. q u e s t i o n n a r r ea d m i n i s t e r e d i m m e d i a t e l y a f t c r t h c s t u d y period revcaled that the most common reasons given lor not adhcring to universal prccautions were lack of timc to put on p r o t e c t i v c m a t e r i a l s 1 4 7 % )a n d i n t e r f e r e n c ei n s k i l l f u l p c r f o r m a n c c o f p r o c c d u r e s ( 3 3 % ) . W c c o n c l u d e t h a t H C W s i n t h i s s et t i n H a r e n o t t a k i n g a d c q u a t ep r e c a u t i o n s d u r i n g c a r c o f c r i t i c a l l y i l l p a t i c n t s a n d t h a t o t h e r s t r a t c g i e s f o r i m p l e m c n t i n g u n i v c r s a l p r c c a L l t l o n sn c c d to bc dcvcloped.

*37

Preventionof DiseaseTransmissionby Using Mouthto-MaskVentilationsDuring CPR RKCydulka, PJ Connor,TF Myerstseclion Medicine, of Emergency Northwestern Memorial Hospital, Northwestern University Medical LoyolaUniversity School; Medical School, Chicago, lllinois

The possibility of diseasc transmission has causccl conccrn among Iaypcrsons and rnedical personncl whilc pcrforn-ring mouthto-nouth vcntilations during CPR. Rcccntly, prcfcrcncc has bccn c x p r c s s e df o r t h c u s c o f p r o t e c t t v e b a r r i c r p r c c a u t i o n s d u r i r - r gC P R .

We asscsscd flows obtainablc whilc usins r-nask or faccshicld barricrs. We also asscsscd thc adccluacy of barricr Fr()tcuri(rns p r o v i d c d b y t h e u s e o f t h c s c d c v i c c s . D u p l i c a t c r . n c a s u r e r n c n t so f f o r c e d v i t a l c a p a c i t y { F V C ) a n d o n c - s c c o n d f o r c c c lc x p i r a t o r y v o l umc {FEV) were obtaincd on two individuals whilc r-rsing l7 diffcrcnt resuscitation dcviccs. Subsccluent to flow tcstir-rg, all t n a s k s w c r c s t c r i l i z e d , a p p l i c c lt o t h o t o s t o r s ' f a c c s : t sd i r c c t c d b y t h c manufacturcrs' instruction, and cr.rlturccl{or oral flora. Eight of thc dcvices were faccshiclds (Microshicld' , Rcsprronics",Resusfacc', Rcsusaid-,Samaritan', Hygicnic-, Mcdicarc-, Portcx'), cight wcrc masks (Dynamed ', Globc ' , LSP 447 ' , Rcs-Q-Onc", MTM-ER ' , R i g h t w a y - ' , M T M - E L V ' , L a c d c r l ' ) a n d o r - r co f t h c c l c v i c c s c l i d n o t mcct critcria for cithcr {accshicldor mask lHudson'). FVC and FEV a c l - r i c v e du s i n g c i t h c r f a c c s h i e l d o r r n a s k t l e v i e e s w c r c s i m i l a r {faccshicld FVC, 90.5'l. prcdictccl; SD 10.3 v; mask FVC, 90.3'2, p r c d i c t e d ; S D 7 . 1 ; 1 ) > . 0 5 1 ; ( f a c c s h i c l dF E V , t 3 1 . 3 ' 2p, r c d i c t c d ; S t ) 2 1 . 2 v ; m a s k F E V , 7 8 9 % p r c d r c t c d ; S D 1 5 . 2 , 1 ) > . 0 5 ) .A l t h o u g h n o significant differcnccs arnong FVC valucs wcrc notccl bctwccn m a n u f a c t u r c r s , a s i g n i f i c a n t l y l o w c r F E V w a s o b t a i n c c lw h i l c u s i n g t h e P o r t e x ' f a c c s h i c l d . N o m a s k d c v i c c s c r - r l t u r c cnl o s i t i v c f o r o r a l { l o r a , w h i l c s i x f a c c s h i c l d d c v i c c s c u l t u r e t l p < r s i t i v e : f o ro r a l f l o r a ( 1 ' <.0071. Onlv thc Microshicld' anclPortcx' faccshicld dcviccs clicl not dcvclop a positivc cultLrrc. In conclusion, wc achicvccl adcquatc f l o w v o l u m c s w i t h a l l m a s k a n c l f a c c s h i c l c ld c v i c c s . H o w c v c r , w c rccomrnend using cithcr a mask dcvicc or the Microshicld' faccsl-ricld for barricr typc protcction whcn pcrforming mouth-to-r-r.routl-r vcntilation.

38 Incidence of Reportedand ConfirmedRiskof Exposureto Communicable Diseasein an UrbanEMS System P E P e p e , M J B o n n i n , G D G r a y / D e p a r t m e n t so f M e d i c i n e a n d S u r g e r y , B a y l o r C o l l e g e o f M e d i c i n e ;C i t y o f H o u s t o n E m e r g e n c y Medical Services, Houston,Texas It is gcncrally agreed that EMS pcrsonnel arc frcquer-rtly cxposcd t o c o m m L r r - r i c a b ldei s e a s e( C D ) d u r i n g t h c c o u r s e o f t h c i r d u t i c s . W c prospectively studicd a1l possible exposurcs rcportcd within zrlarge urban frrc dcpartment-based EMS organizatron durir-rga l2-month period. Using criteria cstablished by the statc hcalth dcpartmcnt, wc invcstigated all reported CD cxposurcs and then delincatcd t h o s c t h a t c o n s t i t u t e d a p o s s i b l c s i g n r f i c a n t r i s k f o r e x p o s u r c ,s u c h as a contaminated needlestick,blood-splattcr on nonintact skin, or aerosolized secretion into the eyes, moLlth, or nosc. Thc rcsults demonstrated that cmployees reported 703 possiblc pcrsonncl exposures to CD during the 12 months studicd. Of these 703 r e p o r t e d e x p o s u r c s ,o n l y 9 9 l l 4 % ) w e r e d e t e r m i n c d t o h a v c h a d a n actual potential for significant cxposure to CD. These 99 cascs involved 24 exposurcs to patients with AIDS or scrologically positive for HIV and to 15 patients with hcpatitis B. Of thc 2(r reported needlesticks, only 20 were determined to be from possibly contaminated nccdies, but two did involve confirmed HIV-positivc paticnts and two involved confirrncd hcpatitis B patients. Thc other 16 nccdlesticks involved patients of unknown scrologrcal status. In relation to the high number of annual rcsponscs madc by EMS personncl, the reported nurnber of CD exposLrresappears to be very low. Furtherrnore, the great majority of claimed cxposurcs do not actually involve significant risk. On the other hand, despite extensrve education and precautionary measlues takcn to prevent

s u c h c x p o s u r e s ,t h e r e s t i l l e x i s t s a n e x t r c m c l y s m a l l b u t f i n i t e r i s k of accidental exposureto lcthal CDs in thc delivery of prehospital meclical carc.

'39 The PersistentProblemof Tetanus L Grininger, F Bongard, Medical S Klein/Harbor-UCLA Center, Torrance.

California A 2 o - y c a r ( 1 9 6 6 1 9 8 6 )r c t r o s p c c t i v e a n a l y s i s w a s c o n d u c t c d o f all casesof tctanus trcatcd at Harbor-UCLA Mcdical Ccntcr to idcntify the contemporary clinrcal profilc and pitfalls in recogntt i o n a n c lt o r e v i e w t h c m a n a g c r n c n t o f c s t a b l i s h c d i n f e c t i o n . E i g h t c a s c sw c r c i d c n t i f i c d , a n d f i v e w e r e a v a r l a b l c f o r r c v i c w , i n c l u d i n g t h r c c m c n a n d t w o w o m c n { a g c r a n g c , 2 l t o 7 t t y c a r s ) .N o p a t i c n t had any frlrrn of systcmic irlmnrrosupprrssion or rcccivcd propcr p r i o r i m m u n i z a t i o n . A l l p a t i c n t s p r c s c n t c c lw i t h j a w p a i n , t r i s r r - r u s , a n d d y s p l - r a g i aT. w o l " r a da h i s t o r y o f t r i v i a l u p p c r c x t r c m i t y l a c er a tions, two had rcccived nccdlcstick injurics, and onc paticnr was a d r n i t t c c lw i t h a g a n g r c n o u sf o o t . T h c t i r n c i n t c r v a l b c t w c c n i n j u r y a n t l o n s c t o f s y m p t o r r r sw a s c i g h t d a y s t o o n c m o n t h . T h c d i a g n o s i s of tctanus was madc on clinical grounds in all cascs,and O tcLani w a s c u l t u r c d f r o r n t h c w o u n c l o f o n c p a t i c r . l t .O n c o f f i v c p a t i c n t s unclcrwcnt wound dcbridclncnt. All Daticntsdcrnonstratcdmr.rsclc s p a s l r s t h a t v a r i c c l i n s c v c r i t y ; t w o F i r t l r n t s r e L l u i r c db a r b i t u r a t c s ancl onc rcrlnircd ncurornuscul;rr par:rlysis t0 achicvc adcquatc v c n t i l a t i o n . T h r c c c l c m o n s t r a t c ccl a r d i o v a s c u l a ri n s t a b i l i t y . F o u r o f fivc survivccl, and all had major in-hospital complications. Wc c o n c l u c l c t h a t t c t a n L l s r c m a i n s a l c t h a l i n f c c t i o u s c l i s c a s cn o t c n trally cumplicating a spcctmrr of clinical problcnrs; [rrevention w i t h a p p r c p r i a t c i r l n . r r . r n i z a t i o ni s m a n c l a t o r y , a n c l a h i g h i n c l c x o f s u s p i c r o n i s r c q u i r c d t u r c c o g n i z c a r r c lt n i t i a t c n c c c s s a r y t h c r a p y .

40 A ProspectiveStudy Examiningthe Needfor Coverage lor Vibrio Organisms in SaltwaterContaminatedWounds JS Olshaker, JF Brown,D Tek/Department of Emergency Medicine, NavalHospital, SanDiego,California E x p c r i c r . r c cg a i n e d i n o u r i n s t i t u t i o t . r h a s s u g g c s t c t lt h a t d c s p i t c p r o p c r i r r i g a t i r ) n / m a n y s a l t w a t c r - c o n t a r . n i n a t c t lw o u n c l s t h a t g c t n o a n t i b i o t i c c o v c r a g cc l c v c l o l .irn f c c t i o n s . T h c s c l c c t i o t . ro f c t . n p i r i c c o v c r : l g c f r l r s a l t w a t c r - c o n t a r . r . r i n a t cw c lo u n d s h a s b c e n c o n r r o v c r s i a l b c c a u s co f u n i q u c r . n i c r o o r g i r n i s r . ri.nr st l r c r r a r i n e el t v i r o l t n l r :n t .

R c c c n t l i t c r a t l r r c l - r a ss p c c i f i c i r l l y c l i s c u s s c ct lh c s p c c t n t r . no f d i s c a s c cruscd by Viltrlo organislns. Wc cxanrinccl in ir plrspcctivu, rrrrrcl<lnrzccl stuciy tl-rc frcclucr-rcyar-rtlclinical effccts of Vllrrio organi s r - r ' r si r . r s a l t w a t c r - c o n t a n r i n a t c t l w o u n d s . T l ' r i r t y p i t tj e n t s w u r r c n t c r c c l i r - rt l - r cs t u c l y o v c r : l o n c - y c i l r p c r i o d . A f t c r i n r t i : r l c v a l u : r t i o r . r i n t h c c u c r g c n c y d c p a r t r n c n t p a t i c n t s w h o l - r a da s o c i a l s c c u r i t y n u r . n b c rc r - r d r n gi r - r: l n c v c n n u r n b c r w c r c p l l t o n : l s c v c n r h y c o u r s c of Vcloccf " 250 rng four tirncs daily. Those whosc social sccurrty n u m b c r c n d c c lr n a n o c l c nl u m b c r w c r c p l l t o n a s c v c n - d a y c o u r s c o f V c l o c c f " 2 5 0 m g f o u r t i m c s d a i l y i n a d c l i t i o n t o a s c v c n - d : r yc o u r s e o f S c p t r a D S " . V c l o c c f ' w a s i n i t r a l l y c h o s c n b e c a u s co f i t s b r o a d c o v c r a g co f m o s t o f t l - r cm u l t i t u d c o f o r g : r n i s n r sc x 1 - r c c t cidn m a r i n c ' c o n t a m i n a t c c l w o u n c l s . S c p t r a w a s p i c k c d a s t h c s c c o n c la n t i b i o t i c s p c c i f i c a l l y t o g i v c a t l d i t i o n a l c o v c r a g cl o r V i b r i o . W o u n c l c u l t u r c s w c r c d o n c o n a l l p a t i c n t s b c f o r c a r - r t i b i o t i ct r c a t r r c n t w : r s b c g u r r .

All paticnts wcrc sccn in follow-up in our wound clrnic in two and scvcn days. Scvcntccn paticnts rcccivcd only Vcloccf'. Tl-rirtccr.r p:lticnts rcccivcd both Vckrccf' ancl Scptra'. No paticnt in cithcr g r o u p c l c v c l o p c da n y s i g n o f c l i n i c a l i n f c c t i o n . O n c o f 3 0 c u l t u r c s (3.3'2,)grcw oLttVibrio alginolytictts. Thc samc culturc also grcw ottt Acntntonos hyclrr4thilia. Sixtccn culturcs {53'lo) grcw out S t a p h y l o c o c t : u sl r u r c l l s . N o o t h c r o r g a n i s r n s g r c w o u t i n c u l t u r c .

Wc c<rnclude that although Villrio organisms do cxlst rn our marinc cnvironmcnti thcy arc rarcly clinically significant. Addit r o n a l c o v e r a g cs p c c i f i c a l l y f o r V i b r i o i s u n n c c c s s a r y ,a d d i n g e x t r a cxpcnsc anclrisl<of rnedication sidc cffccts. ln vitro data suggcst t h a t d i c l o x a c i l l i n i s a c h c a p c r , r c a s o n a b l ea l t c r n a t i v c t o V e l o c c f - o r othcr ccphalosporins in thc cmpiric trcatmcnt of saltwatcr-contaminatcd wounds.

-41 Management Pyelonephritisin of an ObservationUnit GLHWard,RCJorden,HWServerance/Division of Emergency Medicine, University of Mississippi Medical Center, Jackson This study was undcrtakcn to dctcrmine if paticnts with the clinical diagnosis of pyelonephritis could be managed as outpaticnts after receiving thcir initial treatnent in thc cmergency departmcnt obscrvation units. Diagnostic critcria included flank t c n d c r n e s s ,p y u r i a ( > a W B C / h p f ) , a n d b a c t e r i r - r n ag r e a t c r t h a n 1 + .

ZJ

!1 i

I I

Exclusion criteria consisted of septrc shock (BP < 90 mm Hg), age Iessthan I4, male gender,pregnancy, diabetesmellitus, immunocompromise, and debilitation from chronic illness. A11 patients were admitted to the ED observation unit where they received two doses of trimethoprim/sulfamethoxazole {TMP/SMX) IV at a I2hour dosing interval. At the end of this period patients werc either discharged on a ten-day course of oral TMP/SMX double strength or were admitted for additional IV antibiotic therapy. All disc h a r g c dp a t l e n t s w e r e a d v i s e d t o r e t u r n f o r a f o l l o w - u p v i s i t r n t w o weeks. One patient required admission to the hospital, while 59 p a t r e n t sw e r c d i s c h a r g c df r o m t h c o b s e r v a t i o nu n i t . I n c i g h t o f r h e 59 patients urinc cultures were erther lost or not performed; these eight paticnts were excluded from further analysis. An additional nine patients had negativeurine cultures and were eliminated from further study. The remaining 42 patients had positive cultures. One patient whose culturc grew Proteus mfuabilis had recurrent infections and requrred admission for removal of a stag-horn calculus.

Another patient had persistent culture-negatrve pyuria that resolved after an additional ten-day course of oral TMP/SMX. The rcn-rainder of the paticnts, including thre e with Escherichia coli infcctions resistant to TMP/SMX, did we1l. Basedon these data wc c o n c l u d e t h a t p y e l o n e p h r i t i s c a n n o t a l w a y s b e d i a g n o s e ds o l e l y o n clinical grounds; and that paticnts with pyelonephritrs, despite significant fcvcr or nausca and vomiting, can bc trcatcd as outpaticnts after a brief period of observation and antibiotics.

avoidable health care costs.

44 A NewDrugScreening System,"Multi-HPLC," by High-Performance LiquidChromatography UsingMultiwavelengthUV Detector S Suzaki,Y Yamamoto,T Otsuka,M Hayashida,M Nihira,T Watanabe/Departments of Emergencyand CriticalCare Medicine, and LegalMedicine,NipponMedicalSchool,Tokyo,Japan Rapid, accurateanalysisof poisoning is rather difficult, especially in casesof multiple drug ingestion. We present a newly developeddrug screeningsystem.Multi-HPLC, using a microproccssor-controllcd,simultaneous, multiwavelength HPLC detector. The Multi-HPLC systemconsrstsof reversedphaseHPLC with a |ASCO Fine Pak SIL C18 column, a 32-photodiodearray of MULTI-320 multiwavelength (195to 350 nm) UV detector,and a data processor.The data processingprogram, DP-L320, analyzes not only by retention time, but also by the spectrum searchand peak deconvolution method, enabling separationof the superimposedmulticomponent peaks.With the retention time prediction program, thc scparation and identification procedure is nearly automatic. As a standarddrug library, the 47 toxic drugs most frecluentlyencounteredin fapan are registeredin the system.Approximately 945% of the drug poisoningcasesshould be covered.

In the quantitative analysis, each drug can be analyzedat rts optimum wavelength.The sensrtivity(the lowest level of analysis) reaches10 ng. Possibleapplicationsof this system were demonstrated using gastric compounds, sera, and urine specimensof polydrug poison victims. The Multi-HPLC system is considered clinically practical and beneficial.

.42 Observation UnitTreatment of Pyelonephritis HS Israel, JA Marx, SR Lowenstein/Departments of Emergency M e d i c i n e ,W i l f o r d H a l l U S A F M e d i c a l C e n t e r , S a n A n t o n i o , T e x a s ; D e n v e r A f f i l i a t e dR e s i d e n c y i n E m e r g e n c y M e d i c i n e , U n i v e r s i t yo f Colorado Health Sciences Center, Denver Paticnts with pyeloncphritis arc usually admitted to thc hospital for trcatment. To test the hypothcsis that outpatient therapy is c f f i c a c i o u s ,w c r c t r o s p e c t i v e l y r c v i e w e d t h e r e c o r d so f 1 4 7 p a t i c n t s admittcd to thc obscrvation unit of an urban cmcrgcncy dcpartr n en t w i t h a d i a g n o s i so f p y e l o n e p h r i t i s . A 1 l p a t i e n t s w e r e w o m c n , with a mcan agc ol 27 + 9 ycars. Most had frcquency, urgcncy/ dysuria, fcver, nausca,flank pain, fevcr, pyuria, and leukocytosis.

T h c y w c r c t r c a t c d w i t h I V a n t i b i o t i c s , h y d r a t i o n , a n a l g e s i c s ,a n d anticmctics. Therc wcre no trcatmcnt complications. Eighty pcrccnt of thc urinc culturcs grcw morc than 100,000 colonies of a s i n g l c i s o l a t c , w h i c h p r o v c d t < t b e E s c h e r i c h i t tc o l i i n 8 5 % o f c a s e s .

A f t c r a m c a n o b s c r v a t i o n u n i t c o u r s c < t f7 . 4 t 2 . 9 h o u r s t h c o a t i e n t was admittcd to the hospital if clinically unimproved or was discharged on oral antibiotics. Twenty-four patients required admission at the cnd of their obscrvation unit course {19) or r e t u r n e d a f t e r d i s c h a r g e a n d r c q u i r c d a d m i s s i o n ( f i v e J .I n t r a c t a b l e p a i n a n d v o m i t i n g w c r e t h c m o s t c o m m o n r e a s o n sf o r o u t p a t i c n t treatmcnt failurc. No historical data, physical examination findings, or laboratory variable on initial presentation to the ED wcrc predictive of the outcornc of obscrvation unit therapy. The observation unit is an cf{ectivc alternativc to hospitalization for the initial treatmcnt of most cascsof pyclonephritis.

45 Multiple-Dose CharcoalTherapyfor Salicylate Poisoning M Tenenbein,LA Kirshenbaum,DS Sitar/Departments oJ Pediatrics and Pharmacology, University of Manitoba;ManitobaPoison ControlCentre,Winnipeg,Manitoba,Canada Activated charcoal is administeredroutinely to overdosepatients to prevent drug absorption.The administration of multiple doses of charcoal enhances the excretion of already absorbed phenobarbitaland theophylline.This study assesses this intervention for acetylsalicylicacid.Twenty healthy adults participatedin this randomized,controlled,two-limbed crossoverstudy. On two occasions at least one week apart, each volunteer ingesteda solution of 2,880 mg of acetylsalicylicacid in 250 mL of 4 to 5 C water after an eight-hourfast.Fastingwas continuedfor anotherl2 hours. At four, six, eight, and ten hours after ingestion in the experimental1imb,eachvolunteeringested25 g activatedcharcoal in 125mL water. Serialblood sampleswere collectedl4 timesover the first 48 hours, as was all voided urine. Serum salicylic acid concentrationswere measuredby high-performanceliquid chromatographyfrom which pharmacokineticvariableswere derived.

Urine salicylate excretion was quantitated by Trinder's method.

Student'sI test was usedfor statisticalanalyses.The areaunderthe serum concentrationversustime curve from the beginningof the intervention to the end of the study period showed a decrease in bioavailability oI 9./o.Urinary salicylateexcretion was decreased by 18 % . Although statistically significant,they both werequanti. tatively modest and thereforeof questionabletherapeuticimport.

Thus we were unable to demonstrate clinically important enhancedsalicylateexcretiondue to multiple-dosecharcoaltherapy,

43 PoisonControlCentersAre Cost Effective JJ Guterman, G Koehler,RL Galli, BE Haynes,MJ Bayer/UCLA Schoolof Medicine,OliveView MedicalCenter,Department of EmergencyMedicine,Sylmar,California; Los AngelesRegional PoisonControlCenter,Los Angeles;EmergencyMedicalServices Authority,Sacramento, California The California EmergencyMedical ServicesAuthority coordinatesthe regionalpoisoncontrol centersiRPCCs).From December I to 7, 1988,eachcenter surveyedcallerswith regardto what their actions would have been had an RPCC not been available.Eieht hundred frfteen ouestionnaireswere tabulated.Twentv-two oircent of respondentswouid havegoneto an emergencydepartment or private physician. Eight percent would have called 911. Fiftynine percentwould havecalledan ED or private physician.Eightyfive percentof poison exposurecalls from the public are managed

by RPCCs at home without further health care {acility expenditures. For the six centers reporting data, RPCC annual human exposurecall volume from the public is estimated to be 138,315 calls.This estimateis from an eight-monthstudy periodin 1987.

Cost estimatesderivedby the EMS Authority include$153.00for an ED visit, $30.00for an officevisit, and $370.00for a 9I 1 call. The total estimated annualizedcost of care for these Datientshad an RPCC not beenavailablers $8,246,464to $12,341,t65.The annual operatingbudget for the six RPCCs is $4,150,000.The results of this survey suggest savings o{ at least $4,100,000per year in

.

* 46 ln VitroAdsorptionPropertiesof Activated Charcoal WithSelectedInorganicCompounds

26

RD Mitchell,CB Walberg,RC Gupta/Department of Emergency Medicine,University of SouthernCalifornia, Los AngelesCounty MedicalCenter Activated charcoalis a weli-known and often-usedadsorbent in the treatment of acute poisonings.Many referencesrecommend the use of activated charcoal with a number of inorganiccompoundsby listing them in toxin tables.A literature reviewof the adsorptionpropertiesof arsenic,iodine, mercuric chloride,silver, boric acid, and bromide to activatedcharcoalrevealedmisapplication of researchfindings and conflicting recommendations.

Laboratory evidencethat the inorganic compoundsdescribedadsorbto activatedcharcoalin a significantmanner is insufficientor lacking in many instances.The in vitro adsorptionpropertiesof arsenic, iodine, mercuric chloride, silver, boric acid, and bromidewere determinedwith the followine conclusions:toxin adsorbed relates directly to the dosageand specificpreparationof activatedcharcoal; arsenic, boric acid, and potassium bromide do not significantly adsorb to activated charcoal,and mercuric chloride. silver,and

iodine adsorb to activated charcoal. The in vitro findines for arsenic, bromide, and silver have not becn reportcd in the iitcraturc. There is documcnted in vitro analysis of iodine, mercuric chlorrdc, and boric acid with results sunilar to those reDorted in our study. In vitro studies may vary significantly frorn in vivo findings, thereforc, in vivo rcsearch should be uscd to guide clinical practiccs. .Whcn this is no1 possible duc to thc impracticality oi thc toxin bcing studied, current in vitrc.twork should euide oui recom m c n t l a t i o n s{ o r a r . ti v a t t d c h a r c o a l t r s c .

'47

Activated Charcoal and Sodium polystyrene Sulfonate (Kayexalate'D)in Gastric Decontamination for Lithium lntoxication: An Animal Model JG Linakis,PG Lacouture,MS Eisenberg,TJ Maher,WJ Lewander, JL Driscoll, AD Woolf/Division of EmergencyMedicine,The Children's Hospital;Massachusetts PoisonControlSystem; Massachusetts Collegeof Pharmacy,Boston;Department of Pediatrics, RhodelslandHospital; The Rhodelslandpoison Center,Providence To dcterminewhcthcr sodiurnpolystyrcnesulfonatcis cffcctive in clccreasing thc absorptionof lithiurn andto tcst thc :rssumption that lithium is poorlyadsorbecl by activatcdcharcoal,I 2lJrniic wcrc a.dminrstcrcd an orogastricdoscof lithrum chloridc{250mg/ kg)followedimrncdiatelyby orogastricsodiumpolystyrcncsulfonate (10g/kg SPSgroup),activatcdcharcoal(u.6lJ g/kg,AC group),or w.a1eri_nan cquivalcnt volumc (control group).Sr_rbgroups of cach of thc threegroupswcrc sacrificcdat onc, two, four, irnclcight hor_rrs aftcr trcatlncntanclscrum analyzccl for lithiurn concuntration.

Time Atter=LithiumAdministration(hr) 1 2 4 8 2.69 1.75 1.36 1.26

C o n t r o(l L i t h i u m mEq/L) Activatedcharcoal(Lithium mEq/L) 2.51 Sodiumpolystyrenesulfonate ( l i t h i u mm , Eq/L) 1.63 P (SodiumpolystyreneSutfonate v e r s u sc o n t r o l ) <.01 P (Sodiumpolystyrenesulfonate versusactivatedcharcoal) < .01

1.74

1.83

1.06

1.04

0.57

0.76

< .01

< .01

< .01

< .01

< .01

< .05

S t a t i s t i c a l a n a l y s r s r c v c a l c d n o o v c r a l l d i f f c r c r - r c cb c t w c c n t h c A C group and thc control groups, howcvcr, thc SpS gror"rpdilfcrccl fronr both thc control ancl thc AC groups at cach tirnc intcrval, with l i t h i u r n c o n c c n t r ^ t i o n s s i g n i f i c a n t l y l o w c r i n t h c S p Sg r o u p . T h c s c r e s u l t s d c m o n s t r a t c t h a t s o c l i u r np o l y s t y r c n c s u l f o n a t c c f f c c t i v c l y rcduccs thc systcmic absorption of lithium in an rn vivrr n-roclcl,anil that lithium is not cffcctivcly bound by activatcd charcoal.

'48

Rate of Absorption of lron From Chewable Tablets C S H o r n f e l d t ,J P W i n t e r ,L J L i n g / H e n n e p i nR e g i o n a l p o i s o n C e n t e r , D e p a r t m e n t o f E m e r g e n c y M e d r c i n e ,H e n n e p i n C o u n t y M e d i c a l C e n t e r , M i n n e a p o l i s ,M i n n e s o t a The treatmcnt of iron poisonings ( 1 1,t34(r,Z 1%, chcwablc f urr"r-r, l987l is bascd on serurn iron lcvcls. Thc litcraturc offcrs many times for drawing levels, from two to six hours, baset.lrrn adult tablets such as ferrous sulfate. The iron from such tablcts is slowly and erratically absorbed. Becausc the ability to clraw a singlc rron levcl would rnean savings in laboratory tests and cfirergcncy nrrlc/ wc hypothesized that iron from chewablc vitamins is rcadilv absorbed and an optimal drawing time for a single scrum iron lcvel can bc determincd. Hcalthy, fasted adults chcwcd and ingcstcd 10 and 5 mg/kg of iron in a chewablc vitamin form in t-ri s"narat. studics. Iron lcvels wcre drawn serially over cight to l2 hours. At 10 and 5 mg/kg, the averagc peak was 321.2 and24B.4 yrg,ldL,with mean time to pcak at270.0 minutes (4.5hours) and 252.0 minutos {4.2 hours). Student's t test for paired data showcd mean tlmes to p e a k t o n o t b e s i g n i f i c a n t l y d i f f e r e n t { p > . l ) .M e a n i n i t i a l t o t a l i r o n b i n d i n g c a p a c i t i e sw e r e 3 3 4 . 2 a n d 3 3 2 . 4 . I r o n a b s o r b c da f t e r c h c w able vitamin ingcstion reached maxirnum lcvels four to fivc hours after ingestion, and a three-hour level was within 9O7" and L)4,%of peak, rcspectively. Al1 subjectshad modcrate symptoms. A single serum iron lcvel a{tcr four hours gives a strong indication of whether toxicity lnay occur when moderatc amounts of iron have been ingestcd.

-49

ClonidinePoisoningin Young Ghildren JF Wiley/l C Wiley,S Torrey,F Henretig/Departments of Pediatrics, Children's Hospital of Philadelphia andSt Christopher,s Hospital for Children, Philadelphia, Pennsylvania

21

Case rcports of clonidine ingestions suggcstthat such pattents usually need intensive carc. We rcviewcd 4/ consecutrvc cascs.

M e a n a g e o { p a t i e n t s w a s 2 / + l 6 m o n t h s { r a n g c , 9 t o 1 3 4m o n t h s ) .

T h e a v c r a g et i m e f r o m i n g e s t i o n t o s y m p t o m s w a s 5 2 m i n u t c s w i t h 75% of patients displaying symptorns within onc h,)ur of insestion.

Dclayed progrcssion of symptoms did not occur, and durition of symptoms was 9.5 + 5.5 hours. Averagc length of stay was 33 + I I hours. Dcpresscd sensorium occurrcd in 94"k of paticnts. and bradycardia, l-rypotcr"rsion,or hypcrtcnsir)n was secn rn 79"1, of p a t l c n t s . O v c r o n c t h i r d o f p a t r c n t s h a d a p n e a o r d e p r c s s e dr c s p i r a tions. Thcrapy includcd supportive carc {endotrachcalintubation i n _ 1 3 %) ,g a s t r i c . e m p t y i n g { i p ec a c 3 t i % ,) , n a l o x o n c ( 4 0 % ; d o s c r a n g c , . 0 0 U t o . 2 2 m g / k g ) , a t r o p i n c ( 1 5 , / " ) ,a n d d o p a m i n c { 2 , 2 , ) .N a l o x r i n e c : r u s c dt r a n s i c n - ti m p r o v c m c n t i n l 3 o f l 9 p a t i c n t s . T h r c c p a t i c n t s w h o r c s p o n d c d l a t e r r c q u r r c d i r - r t u b a t r o n ,a n d i n t h r c c o t h c r s , n a l o x u n c w : r s a s s o c i a t c dw i t h h y p c r t c n s i o n . C l o n i d r n c c a n c a u s c r . n a j o rn c u r o l o g i c a n d c a r d r o p u l m o n a r y c f f c c t s . I p c c a c i s c u n t r a i n _ d i c a t _ c dc l u c t o r a p i d o n s c t { r f l e t h a r g y . N a l o x o n e i s a p o o r a n t i c l o t c for ckrniclinc ancl may inducc hypcrtcnsiorr. Fcw paiicnts rcquire ventllatory or prcssor sllpport.

50 Dimethyl-PGE,ProlongsSurvival From Alpha Amanitin EA Michelson, SM Schneider/Montefiore Hospital, University of Pittsburgh A l p l ' r a a n - r a n r t i n( A ) i s t h c t o x i n b c l i c v c t l r c s p o n s i b l c f o r d c i r t l , r s f r o r n i n g c s t i O r ro f t h c t o x r e n t u s l t r O t , r . DA r t t , t n i t o p l t a l k t i t l a s . l , l ( t D i m c t h y l - P ( ) E 2 { P G E )i s a p r o s t a g l a n d i nw i t h k n o w n h c p a t i c c v , t o p r o t c c t i v c c f f c c t s a g a l n s t s c v c r a l t o x i r . r s .T l r c p r o t c e t r v e n r c e h a n i s r . ni s L l n c c r t a i n W . c t n v c s t r g a t e dt h c c f f c et , , f i r ( ; E o n t o x i c i t y o f A i n o u r r . n o u s cn t o d c l . S w i s s f c r n a l c r l i c c w c r c d i v i d e d i n t o f r v c g r o L r p s: l n d t r c a t c c l w i t h A 0 . ( r 3 m g / l < g i n t r a p c r i t o n c a l l y . G r o u p I r c c c r v c c ln o f u r t h c r t h c r a p y w h i l c g r o r . r p s2 t l - r r o u g h. 5r c c ei v c d p G E 1 . 5 0g g / l < g i n t r a p c r i t o n c a l l y a f t c r d c l a y s o f o n c a n c l o n c h a l f , t w o , t h r c c , a n d f i v c h o u r s f r o r n A i n j c c t i o n . A s i x t l " rg r o u p r c c c i v c i l o n l y P C E . A n i r - r - r a lws c r c g i v c n f r c c a c c c s st o f o o c la n d w a t c r a n d f o l l o w c i l daily for survival to onc wcck. Survival clata wcrc ana]yzcclbv K a p l a n - M c i c r a n c ll l r c s l o w t c s t s . T h c r c w c r c n o d c a t h s r n i h " f C i c o n t r o l g r o u p , a n c l l l i o f 2 0 1 ' 9 0 " 1t,l)c a t h s i n t h c A c o n t r c l g r o u p .

O r r l y . t h c m i c c i n g r o u p r5 ( f i v c - h o u r d c l a y r - r n t i li n j c c t i o n ) c x p c i i c n c c c la n i n c r c a s c i n s u r v i v a l ( 1 , < . 0 1 ) . p G E f a i l c d t o i n c i c a s c survival whcn givcn within thrcc hours of A; howcvcr, it was c f f c c t i v c i r f t c r a c l c l a y o f f i v c h o u r s . p ( l E p r c s r . r m a b l yl - r a sa s h o r t half-lifc antl is no longcr cffcctivc two to thrce hours aftcr aclnrinistratiolt. Our data suggest A toxicity is dclaycd duc to cithcr d c l a y c d a b s < t r y r t i o no r t i m c n c c c s s a r y f o r t o x t c c o n v c r s r o n . W c conclutlc that a singlc closcof l,l(r-dimcthyl-pGE, prolongs slrrv i v a l a f t c r c x p o s u r c t o a l p h a a r n : r n i t r n i n o u r r n r ) L r s len i l d c l , b u t o n l v if givcn folkrwing a dclay of fivc hor-rrs.

51 Empiric Use of Naloxonein PatientsWith Altered MentalStatus: A Reappraisat JR Hoffman, JS Luo,D Schriger/Emergency Medicine Center, UCLAMedical Center, LosAngeles, California This study was pcrformccl to tcst thc hypothcsrs that thc n ] a j o r i t y o f O p i a t co v c r d o s ep a t i c n t s w i t h a l t c r c d - r n c n t a ls t a t L l sc a n b c i d c n t i f i c d b y c l i n i c a l s i g n s a n d s y m p t o m s , a n d t h a t c r - n p l r l cL r s c of naloxonc in all paticnts with altcred mcntal status is thcreforc unncccssaryias wcll as cxtrcmcly costly. We rcvicwcd rccortls of 2 3 0 p a t i c n t s w h o r c c c i v c c ln a l ( ) x u n cf ( ) r . l c L t t ua l t c r c d m c n t a l s t a t u s .

O n l y 2 5 p a t i c l t t s ( 3 . 4 ' l . ) h a d a c o m p l c t c r e s p o n s ct o t h i s a g c n t ; l 9 1 7 6 % l h a d a { i n a l h o s p i t a l d i a g n o s r so f o p i a t c o v c r d o s c . O f t h c s c 1 9 paticnts, 1il (95%) had rcspiratory ratcs lcss than or etlual to l2; I 7 { 9 0 ' 2 , )h a d c o n s t r i c t c d p u p i l s ; a n d 1 5 1 7 9 , ' 1 h , )a d a k n o w n h i s r , r r y r , f clrug abuse. Thcse numbers wcrc vastly differcnt {p < .01 for all compansons) for thc great majority of paticnts who nerthcr responded to naloxonc nor had an ultir-nate diagnosrs of opiate overdosc. Six "complete rcsponders' provcd not to have opiate o v c r d o s e ; t h c i r a s s u m c d r e s p o n s ew a s f r c q u e n t l y d u e t o s p o n t a n c ous in-rprovcrncnt during a postictal period. partial or questionablc responsc to naloxone also confuscd the diagnosis in 32 patients, nonc of whom proved to have opiate ovcrdose, and onfu ten of whom had any clinical indicators or possibleopiate usc. Selective usc of_naloxone rn paticnts in this serics onihc basrs of easily d c f i n e d c l i n i c a l c h a r a c t e r i s t i c sw o u l d h a v e i d e n t i f i e d v i r t u a l l y a i l responders with opiatc overdosc and decrcased use of thc drug by 8 9 7 _ oE . c o n o r n r c s a v i n g s a s s o c i a t e dw i t h w i d e s p r e a d a d o p t r o n o f such a policy would be enormous with no appaient clinical detri-

'lli t

li Ii' l

Naloxonein Rabbits:No Adverse 52 Endotracheal Effectson BloodGasesand LungTissue

SC Rector, RW Geiss, K Beamer, P LeggiEmergency Service, and Departments of Surgery and Pathology, West Virginia School of Medicine, Morgantown We compaied endotracheal naloxone with normal saline solution to study the effects on arterial blood gases an-dlung tissue in -ihe pulmonary effects of endotracheal naloxone have 16 rabbits. not been studied previously. Eight rabbits received naloxone through an endotracheal tubc, and eight controls received normal saline' Blon,l gas.s were sampled {or 30 minutes. Four subiect rabbits and four controls were killed after two days; the remaining rabbits were i < i l l e da f t e r s i x w e e k s . M i c r o s c o p i c a n a l y s i s o f l u n g t i s s u e w a s d o n c by a pathologist blinded to the identity of thespecimens There was no significa;t diffcrence in blood gasvalues between the naloxone anil iontrol groups. By microscopy, therc was no observed pattern of variance'in iulmonary pathology between the subjcct and control groups. This cxperiment rcvcaled no adverse effects on r a b b l t b l o o d g a s e sa n c l l u n g t i s s u c a f t e r o n e d o s e o f e n d o t r a c h e a l ,rri,,"nt-t" as compared with saline Further study is needcd bcfore cndotrachcal naloxone can be considered safe for human usc'

*53 PharmacologicInterventionsin Acute Cocaine Toxicity of Emergency J NiemanniDepartments D Garner, M Smith, Torrance, Center, Medical Harbor-UOLA andCardiology, Medicine California

Cocainc toxicity is an incrcasing cause oi mortauty among .ro"r!"n.y <lcpartmentpatients. Severalexperimental models of "o.r-" t<ixiciiy in whlih subjcctswere pretrcatedwith pharmacologicagcntshaveappearedin the literature;however,no one has motlcl in *hi.h th" subiectshad cocaineadministered J.r;;t.i; i-r"i-" pt"t"t-rcologic intcrvention. We sought to develop this -ud.l. hrtt werc catheterizedchronically in the iugular vein and ."i,iri,l "t,"ty, had a rcctal tempcraturcprobcplacc4,and had their intra-artcriaiprcssurcsand waveformsrecordedThc LD50 of IV ..r."in. was dcterminedto bc l4 mg/kg, which was confirmedin a control group of ton rats with a 50% mortality. Aftcr cxpcrimentally cnsuring thcir nonlcthality, labetalol, dt'azepam,chlorpromarrnc, clantiolcnc,propranolol, and nitrendipine were adminiaftcr the LD50 dosc of cocainc' Mortality ri.t"J i--"aiatcly ir.."rt.a in the labetalol and propranolol groups (P < '05, chiscluarcwith Yatcs corrcction factor) and was statistically uncha.,gedwith thc other agents.No universalantidotefor cocaine was clctccted.Thcrapy should be dirccted toward treat;;."" mcnt of symptoms.

54 Agents That Protect Against Cocaine'lnduced

Death

and Seizuresin Animals

RW Derlet, TE Albertson/Divisions of Emergency Medicine and C l i n i c a l T o x i c o l o g y , U n i v e r s i t yo f C a l i i o r n i a ,D a v i s , S c h o o l o f Medicine, Sacramento A number of agents were studied to determinc their effectiveness rn protcctlng rats against seizute or death induced by cocaine' In this model, control ritt wete given 70 mg/kg cocaine intraperii."""ffv. Conirol animals developed seizures 94^%"oI the time, and + 0 7 minutes, 82% died in mean times of 6.4 t 0.4 and l0'0 i"rpe.tiuely. Animals were given test agents.intraperitoneally 30 minutes piio. to injection oi cocaine' In this model, significant botit cocaitte-induced seizure and death was af;lii.;;;;ti".i with diazepam, pen-tobarbital, - and the forded'by'pretreatment S K F 10033A {p ' .Oi).Only ]ook oI animals b l o c k e r " p , i i . .

Ce,sA receiving diazepam at the highest dose {2 0 tg/fg) .tested died' a.t'd prop.anolol tended to minimally decrease the iiri"p.iia.l (P > '05)' a.^,tl.^,., but this did not reach statisticalslgnilicance no effect had labetalol and acid, valproic phenytoin, eif'tot"titnia., d."th t"t., th" calcium channel blockers verapamil' r";;il.i;g;h; nifedipine, and diltiazem enhanced toxicity' Agents that enhance the efiect'of the central neurotransmitter gamma-aminobutyric have the greatest e{{icacy in protecting against the ,"ia "pp.r.,o to"i. ei{..ts of cocaine,-while other classic anticonvulsants, catblockers, and calcium channel blockers failed to pro..t'tttr-in. tect.

School,The MassachusettsPoisonControlSystem,Boston of Iife-threateningevents To further characterizethe appearance lLTEsl such as seizuresand severecardiacarrhythmias,following ih.*irvllln. intoxication (serumtheophylline > 30 pg/mL),we folIowed i+4 caseso{ theophyllineporsoningreferredto our poison ""rr*. ou.t a two-and-one-hall'yâ&#x201A;Źarperiod.Fifty-two patientshad acute theophylline intoxication; 64 had-chronic.theophyllineintoxicationiand 28 had acute-on-chronictheophyllineintoxication' Mean ageof patientswas 32 years(range,3 daysto-84years|;me11 level was 59.4pg/ml irange,30 to 211 pC/mU' oeakth"eophviline i...r.irt.h featr,resincluded " me"n potassiumlevel of 3'4 mEq/L 92 to 'iii'istarl, lrange,2.2 to 5.8 mEq/L),mean glucoseof 173mg/dl ltange, and tre-ori in 45 (31%J.Thirtv-nine patients {27%) 13;arrhythmias,27)-Nine patientsdied'Dishad, itE (seizures, tinct featureswere iound when acute and chronic theophyllineintoxicationpatientswere separated.

Peak TheoPhYllineLevel P NO LTE LTE 60.7 < 0001 117.6 Acute NS 48 6 Chronic 48.1

LTE 18 . 1 63.3

Age (Years) P No Lte NS 20j <.0001 31.0

A steowise logistic regressionequation confirmed these correlaexcludrngpotastionswith age,peaktheophyllinelevel,and LTEs., sium and drug Loingestionas significattl sevariibles' On the basis of these dataiwe citnclude thai peak theophylline.levelpredicts LTEs in patientswith acutebut not chronic theophyllineintoxicatrun.re"p..di.ts LTEs in patientswith chronic but not acutetheois indicatedin papt'rvitin.intoxication,hemodialysis-perfusion levii.i.rtt rvith acutc theophyllineintoxicationand theophylline. for indicated is Lemodialysis-perfusion ptciml, and t ioo "irandtheophylnati.nts *hojiave chronictheophyilineintoxication iinc Ievelsof more than 45 pgiml with agemore than 60 years' 56lnitial ECG Findings in 187 Cases of Cyclic

Overdose Antidepressant

of Emergency FW Laioie, GG Gansert,RE WeissiDepartment Louisville' of Louisville, Medicine,Schoolof Medicine'University Kentucky ECG changesassociatedwith cyclic antidepressant{TCA)over' dore h*. been the subjectof many reports in the medical literairrr.. u.rt, tr,e, QRSduration,QT inteival, and most recently/the +o -t qns (T40)axis have been reportedto be valuable i.i-t""t of TCi overdose.To evaluate the discriminant and i;;i;;;;. piedictiue abiiities of these and other ECG-parametersin TCA iu.iaot., we retrospectivelyreviewed the charts,of all overdose Datientsad-itted to intensivecareunits of our facility duringa 30month period.Of 401 patientsreviewed,358 had initial emergency J"o"r,*.n, toxicologic screening,ECGs,and recordsavailablefor analysis,and were iniluded in the study.The study populationwas aiuid.a into t*o groupsbasedon the presenceor absenceof TCA ...?.ttt. The TCA+ group comprised52 2% andthe "r i""t"f"gi. i-e- gro"i+2.8% of the study population Mean^agewas 33 I li 1; wave axis, PR intervai, initial 40^ms QRS axis, and tota^l t;.

T40 bnS a*is were nof statistically different QRS duration,QTc, ixis, and heart rate were all found to be independentlysignificandy different between the two groups by t test (P < '001) Using ..-rno"fy quoted discriminating values i> J99 ryt for QRSduraii"". > f OOl-in for heart tate, ald 130" to 270' for T40 axis),we calculatedthe sensitivities,specificities,andp.ositiveandnegative pi.ai"i*. "^t"es (Tabte).Eacirparametercollld be usedto correctly iirr.itv only 607. to 62oh of Cases,with all-four in combination .o....ily classi{ying only 66/" We conclude,-despiterecentre' althoughhelpfulif present,cannotbe Dorts,that ECG parameters, iJ.i on to include or excludethe diagnosisof TCA overdose' Parameter Heart rate QRS duration T40 axis OTc

Sensitivity(%) 68 44 29

Specificity("/d 59 83 83

PPV 0 64 0 74 0 65

NPV Pearson'sR 0.0895 0.63 0.335'1 0.42 0.2315 0.53 0.2292

An EasternUnitedStates 57 ChinaWhiteEpidemic: ExPerience Department Emergency

Ut Uirtin, J-Hecker,RF Clark,JH Frye, DV Jehle,EJ Lucid/ AlleghenyCampgs,Department MedicalCollegeof Pennsylvania' of EmergencyMedicineand EmergencyMedicineResidency Pennsylvania Proqraml -i:tri"" AlleghenyGeneralHospital,Pittsburgh, whlte (i-methyl fentanyl) (3MF), an extremelypotent of fentanvl, was implicated in a seriesol ;;i;g;. ry";ili;

55 Life-ThreateningEvents After Theophylline lntoxication: A Prolpective Analysis of 144 Cases HarvardMedical Hospital, Children's fH LovejoylThe M Shannon,

28

narcotic deathsin the western United Statesin the period l9B4 to 1985.We report the first outbreakof narcotic overdoiesin the East involving 3MI, which occurredin Allegheny County, pennsylvania, in 1988.Emergencyphysiciansbecamesuspiciousof 3MF use followingan unusualincreasein narcoticou.rdos., presenringto the ED coupledwith screensnegativefor opiates,despitedramltic responsesto naloxone.Speci{ictesting was positive for indicators of fentanyl derivativesin some cases.We reviewedg5.246patient visits to our ED over the 24-month period |anuary l9g7 ro 0...-_ ber l98B for epidemiologicstudy. patients were included if thev met the criteria of a suspectedunintentional narcoticoverdose,bui excludedif not given naloxone.A cluster was definedas a oeriod with a statistically significant increase in overdosesabove the expectednumber for an interval of equal length. Although there were no_significantclinical differencesin casepresentationovcr the study period, there was a statistically significant, I2-fold increasein overdosesduring the Septemberto November 19gg cluster imean, 13 per month ue.s.rs1.05 per month, p <.001 Wilcoxon rank sum test). A dramatic increasein unintentional drug overdosedeathsoccurredin the county during this cluster.

Investigationsfound 3MF presentin street dr.rgr ard parapherna_ lia. A total o{ I8 fentanyl-positive unintentio-naldrug overdose deaths,predominantlymale (89%) and black 156./"), ageiange 19to 44 yearc.(mean, 34.9),were reportedby the county coroner{13 clunng cluster). Narcotic overdosesand unintentional drus over_ dosedeathsdeclinedsharply with confiscationof the clandestine 3MF lab. We conclude that it is important for emergencyphysiciansto recognizeearly that overdosesresponsiveto n;loxonc with inconsistent routine toxicologic screensmay be due to a fentanyl analogue.

provide iron levels on an emergency basis. One hundred hospitals with.24-hour emergency services were surveyed, and only'50% cou_ld provide an iron level in less than six hours. This study evaluated whether certain clinical and laboratory parameters could be used to predict serum iron level and, therefori, the severity of acute iron ingestion in children. The records of childrcn who presented to the Childrens Hospital of Los Angeles emergency department from 1978 to 1985 for acute iron ingestion were rcviewed.

One hundred four children were seen in the ED for acute iron ingestion during that period;94 were included in the study. The age range was I I months to 6.5 years, with a mean of 30 months. peal serum iron levels ranged from 38 to 923 p.gldL, with a mean o1272 pg/dl. Five laboratory or clinical parameterssignificantly (p < .01) correlated with serum iron levels of 300 gg/di or greater: agc on presentation of less than 2years; vomiting; WBC count in excess of 13,000 mL; anion gap greater than l(r mEq/L; or the presenceof radiopaque densities on abdominal flat plate radiograpliy. Of thesc five risk factors, no child in thc study with zero risk-factors had a level of 300 prg/L or more. Conversely, all children with two or morc o f t h e s e r i s k f a c t o r s h a d l e v e l s i n e x c e s so f 3 0 0 p g / L . T h c c l i n i c a l and laboratory parameters of age at prescntation; presence of vomitjng, WBC count, anion gap, and KUB appearance can be used to identify childrcn at risk for toxic serum levels of iron.

'60 Polymyxin B for Experimental ShockFrom Meningococcal Endotoxin G Baldwin,G Caputo,G Alpert,J Parsonett,G Siber,M Baskin,G Fleisher/The Children's Hospital,HarvardMedicalSchool,Boston, Massachusetts One third of childrenwith meningococcemia devclopshockand die.PolymyxinB hasbeenreportcdto ameliorateendotoxicshock due to Escherichittcoli by binding endotoxin.We performeddose titration curveswith mcningococcalcndotoxin and studieclthc cffect on mcningococcalcndotoxin-inducedshock in a rabbit model.Femoralarterialand vcnouslincs wereplaced,and rabbits rc-ceivcd IV saline,cndotoxin(10Ug/kg),or polymyxinB (5 mg/kg) 30 minutes prior to endotoxin.pulsc, rcspiration,mean aricrlJl pressurc,_artcrial blood gases,and levcls of cndotoxinand tumor necrosisfactorweremonitorcd.Rabbitsreceivingcndotoxin(sixof six with sevenof sevenwithout polymyxin B) but not saline{zcro of five) developedshock as indicatedby tachycardia, bradypnea, hypotension,rnetabolicacidosis,and death by 24 hours.

.58 Effectof Electric ShockTherapyon LocalTissue Reactionto PoisonousSnakeVenomInjectionin Rabbits T Wagner, JL Fatk/Department ot Emergency 9.S!g!d,t!_4*ol,

Medicine,OrlandoRegionalMedicalCenier,Orlando,Flori-da; Djvisionof EmergencyMedicine,Departmentof Surgery,University of FloridaCollegeof Medicine,Gainesville This-study evaluatedthe ef{ect of locally applied electric cur_ rent on local tissye damageresulting from snakevenom injection.

FemaleNew ZealandWhite rabbitswereanesthetizedwith 100me intraperitoneal pentobarbital. proximal hind legs were shaved, cleansed,.andinjected subcuraneouslywith I mg]kg fresh venom harvested from Eastern Diamondback rattles'nalieslCrotalus adamant.eous).Animals were randomly assignedto be shocked igroup A) or sham-shocked(groupB). Four tw6-seconddischarges each delivering 1,800 V, 8.18 amps direct current were admilnistered.directly-through the injectibn site at ten-secondintervals, ten mrnutes atter venom iniection. Lesionswere measuredat 12.

24, and48 hoursafter injection by applyingcalipersacrossthe edges of the short_andlong axis o{ the-bulioui lesions by an obse.ver blinded to the randomization scheme. Area o{ the lesions was calculatedand indexedfor body weight. Lesion sizesbetween the groupswere comparedusing the unpairedtwo-tailed t test. Three animals died within 24 hours. Data atereportedas mean + SM. : Group ShortAxis(cm) LongAxis(cm) AreaIndex(cnf/kg)

A B P A B P A B P Time (hr) 12 2 . 4 ! 0 2 . 2 . 9 ! 0 . 4 . 2 9 3 . 1 1 0 . 34 . o l . } . 4 . 1 1 2 . 81 0 . 7 4 . 0 i 1 . 1 . 3 . 1. 3 1 24 2 . 5 1 0 . 43 . 3 1 0 . 3 . 1 3 3 . 5 t 0 . 5 3 . 9 t 0 . 4 . 5 6 3 . 3 t 0 . 8 5 . 3 1 1 . 1 . 1 6. 1 6 48 4.6i0.4 4.610.7 .99 7.2:tO.76.6t0.8 .57 11.grt .5 1 i .512.4.88 .88

Time After Endotoxin (min) 0 Pulse Respirations MAP Pulse Saline 212 228 91 212.

Endotoxin (mg/kg) 224 260 92 305 Binding endotoxin wrth polymyxinB 221 267 92 308

120 Respirations M A P 160.

10 3 108

81

g4

89

The group receivingpolymyxin B did not differ (p > .05)from the one treated with binding endotoxin (Table, .p < .05).Endotoxin and tumor necrosis factor levels were undetectable in controls and peaked at I to 20 ng for endotoxin and 1,100to l,(r00 U for tumor n e c r o s i s f a c t o r { 0 . 1 m L } i n t h e e n d o t o x i n - t r e a t c d g r o u p s .W e d i d n o t show protection by polymyxin B in meningoiocial cndotoxin shock.

'61

In this rabbit modei we were unableto confirm Dreviousanecdotai reports of the efficacy of electric shock therapy in ameliorating local tissue destructionresulting from snake envenomation.Further study of this treatment using technicalvariationsis warranted beforediscardingit as useiess.

59 Acute lron Poisoning in Children: Evaluation of the

PredictiveValueof Clinicaland Laboratoryparameters

NA Schonfeld,AJ Haftel/Childrens HospitpkqfLos Angeles,Los Angeles.California "*t;.M Wm Ingestion of iron-co464rffiW@llri^tions is the fifth most common toxic ingpsXqfuftfthffdien. The clinical severity is usu_ ally correlated tffi ffi&ilnum semm iron level attained within the tlrst srx hoursbfreringestion.Minimal toxicity is found with iron levels below 300 pg/dl. Many hospitals, however, do not

29

Bacteremia in Children With Otitis Media SA Schutzman,S Petrycki,GR FleisherffheChildren'sHosoital.

HarvardMedicalSchool,Boston,Massachusetts Occult bacteremiaoccursin 3 % to 5 % of youngfebrile children with no apparentsourceof infection and carriesa risk of suDDura_ tive complications.Although otitis mediais a frequento.currince, the incidenceof associatedbacteremiahas not beenwell studied.

To quantitate the incidenceof bacteremiain otitis media, charts were reviewedfrom consecutivepatrentsseenNovember l9g7 to March 1988 in The Children,s Hospital emergencydepartment, ages3 to 36 rnonths,who had temperaturesof 39 C or more andwho were diagnosedwith isolatedclinical otitis media.Sevenhundred forty-eight patients were identified. Blood cultures were obtained from 421patients156%1, and,all were treatedwith oral antibiotics.

The meantemperatureof childrenwho had bloodcultureswas39.g C versus39.6 C in thosewho did not (p< .00I ). Mean agesof those with and without blood cultures were l4.l and Il-.6 months. respectively{P< .001).Fourteenof 421 patients(3.3%}who had

rlli blood cultures were bacteremic. These included ten with S pneumoniaet one with H influenzae, two with N meningitidis, and one with Salmonella. An increased incidence of bacteremia occurred at h i g h e r t e m p e r a t u r e s , s i x o I 2 7 6 1 2 . 2 % )w i t h a t e m p e r a t u r e o f 3 9 . 0 t o 3 9 . 9 C w e r e b a c t e r e m i c v e r s u s e i g h t o f 1 4 5 ! , 5 . 5 % )o f c h i l d r e n with temperature above 40 C (P : .07). However, 43o/" oI the bacteremic patients had a temperature lessthan 40 C. We conclude that young febrile children with otitis media had a 3.3% incidence of bacteremia, a comparable rate to those previously reported with no focus; and failure to obtain a blood culture on all children ages 3 to 3(r months with temperatures of 39 C or more and otitis mcdra w i l l r es u l t i n a n i n a b i l i t y t o d e t e c t a l a r g e n u m b e r o f p a t i e n t s w i t h Dacteremla.

In conclusion, scalp and extremity wound closure by stapling was found to be significantly faster and cosmetically equal to suturing in the pediatric population.

.64 Six YearsExperience in Emergency Department Resuscitation and ICUTreatment of Drowning:Patient Characteristics Predictiveof Outcomeand Evaluationof Conservative Management J Lavelle,KN Shaw/Department of EmergencyMedicine,Children's Hospitalof Philadelphia; University of Pennsylvania Schoolof Medicine,Philadelphia Drowning is a major causeof accidentaldeath in children, but controversyexists regardingits treatment and the patient characterrsticsthat prcdict outcome.Most centersadvocatesomeform of cerebralresuscitatrvetherapy iuse of steriods,barbiturate coma, and aggressivetreatment of raised intracranial pressure).At our institution a more conservativeapproachrs practiced,limited to thc support of vital systems.Review of all ICU admissionsfrom fanuary 1982to December1988identified 54 patientswith significant submersioninjury. Forty-four patient recordswere avaiiable for rctrospectiveanalysis.Data were gatheredregardingthe circumstancesof submersionand rescue,condition on arrival in the emergencydcpartment,and hospital treatment and outcome.ICU treatment consistedof modestfluid restriction {75% maintenance} and normalization of blood pressure and arterial blood gases.

Prchospital variables,apnea and asystole,were associatedwith pooroutcomeaswereED characteristics, nonreativepupils,asystole, pH lessthan 7.1, and GlascowComa Scaleof 5 or less(P < .01).

However, in patients with thesepoor predictors,l0% to 24% stilt had intact survrval suggestingthat resuscitativeefforts in the ED must not be withheld from any comatosepatient. On arrival at the ICU, a Glasgow Coma Scaleo{ less than 5 was associatedwith deathor vegetativestate.Improvementin the neurologicexamination from the ED to the ICU was an indicator of sood outcome.

Characteristicsnot useful in prognosticationwer? age under 3 years,submersiontime of five minutes or less,time to resuscitation of ten minutes or more,and cyanosisat the scene.Comparison of outcome in patients who receivedconservativemanagementto outcomewith thosewho receivedaggressive cerebralresuscitation lConn, Canad Anaesth Socl, l98ol, did not demonstratea benefit from thc more complicated therapy. The findings of the present study cmphasizethe role of prevention,prehospitalcare,and ED management in the care of submersion victims. Additionaily, conscrvativcmanagemenr appearsas effectivcas aggressive resuscitation.

.62 An Evaluation of the Emergency Department Treatment of StatusEpilepticus in Children S A P h i l l i p s ,R J S h a n a h a n / D e p a r t m e n to f N e u r o l o g y , S t a n f o r d U n i v e r s i t yM e d i c a l C e n t e r , S t a n f o r d , C a l i f o r n i a ;D e p a r t m e n t o f P e d i a t r i cN e u r o l o g y ,C h i l d r e n ' s H o s p i t a l ,O a k l a n d , C a l i f o r n i a We reviewcd emergency department records of 161 episodes of status cpilcpticus in children from i983 to 1987.Initial treatment was administered in an ED at a community hospital {CH) in 43% of cpisodes, a community medical ccnter (CMC) in 207", and a county hospital (CoH) in [i%, and 29Y" wcre treated at Children's Hospital. Sixty-two pcrccnt were boys and 3U% were girls (age r a n g e , I m o n t h t o 1 7 y e a r s ; a v e r a g e t3 . 1 y e a r s ) .W c c o m p a r e d t h e trcatmcnt rcceived in refcrcncc to three Daramctcrs -- anticonvuls a n t d o s a g ei A D ) , t i m i n g o f a d m i n i s t r a t i o n ( T A ) , a n d a n t i c o n v u l s i v c s c q u c n c e ( A S )- - w i t h r e c c n t l y p u b l i s h e d p r o t o c o l s f o r t h c t r e a t m c n t o f s t a t u s e p i l c p t i c u s i n c h i l d r e n . T h c a v c r a g es e i z u r e d u r a t i o n {ASD) and thc frcqucncy of intubation (FI} werc also reviewed in rcfcrcncc to the abovc Darameters.

AD' AD<' AD>i TA' TA' AS' AS3

CH n = 70 (6hl 38 (54) 30 (43) 2(3) 25(36) 45 (64) 42 (60) 28 (40)

CMC n = 32(ok, 1 8( 5 6 ) 11 (35) 3(9) 14 \44) 18 (56) 19 (59) 13 (41)

CHO n= 46(o/d 46 (100) 0 0 44 (96) 2 (4) 43 (93) 3 (7)

CoH n = 12lohl 7 (59) 4(33) 1(8) 3 (25) 9 (75) 8 (67) 4 (33)

(4 ,P<.05) l R e c o m m e n d e d , ' D e l a y3eN d ,o tr e c o m m e n d e d

FI e4 61 73 50 53f 76' 56 83

ASD (min) 105 163 98 97 139 101, 146.

Wc conclude that by following publishcd protocols {or thc trcatmcnt of status cpilcpticus in childrcn thc average scizure duration a n d t h c i n c i d e n c e o f i n t u b a t r o n a p p e a r st o b e d e c r e a s e d T . his is less likely to occur rn an ED in a CH, a CMC, or a CoH. Undertreatment, cither in thc administration of lessthan thc rccommended anticonvulsant dosagc and/or delayed timing of administration, increases the frequcncy of intubation and scizure duration.

-65

Comparison of Serum Phenobarbital Levels After

SingleVersusMultipleAttemptsat Intraosseous lnfusion K Brickman,P Rega,M Choo,M Guinness/Emergency Medicine

-63 StaplesVersusSuturesfor Wound Residency, St VincentMedicalCenter,and The ToledoHospital, Closurein the Toledo,Ohio PediatricPopulation For nontraumatizedbone, in which a single intraosseousat.

SMDunmire, DMYealy, R Karasic, RDStewartiuniversitytempt was used for drug infusion, serum drug levels have proven S Fuchs, o f P i t t s b u r g hA f l i l i a t e d R e s i d e n c y i n E m e r g e n c y M e d i c i n e ; C e n t e r f o r E m e r g e n c y M e d i c i n e o f W e s t e r n P e n n s y l v a n i a ,P i t t s b u r g h Wound repair with staples has been found to be a raprd and cffcctivc alternative rn suturing in adults, but has not been studicd in the pediatric population. This technique offers the potential advantage of a faster wound closure for the child, resulting in a less emotionally trying experience for the patient/ parents, and physician. We desrgned a prospective, randomized trial to compare suturcs with staples in the pediatric patlent, specifically examining closure trmes and cosmetic results. Thirty-eight children ranging in age frorn 1B months to i6 years with iacerations of the scalp, trunk, and extremities were included. Wound closure by trained housestaff was preceded by a standardized irrrgation and anesthesia protocol. Sutures and staples were removed seven days after closure. Photographs of the wound taken eight to l2 months after repair were revrewed separately by three plastic surgeons blinded to the method of closure. Cosmesis was rated on a scale of 0 to 3, which scored width and discoloratlon of scar. orominence of suture or staple holes, and hair loss. Data were analyied using a two-tailed Wilcoxon rank sum and Student's t test. with the aloha eror set at 0 . 0 5 . T h e m e a n t i m e o f s k i n c l o s u r e w i t h s t a o l e s* r i 0 . 9 7 m i n u t e s c o m p a r e d w i t h 2 0 . 9 m i n u t e s f o r s u t u r e . . p r i r 1 1 ,= . 0 0 0 0 0 1 ) .T h e mean cosmetic score o{ 2.3 for both suture and staole closures was not significant. No significant differences were found between the groups when reviewing age, race, length, and location of laceration.

comparableto those drugsadministeredintravenously. However, in the clinical situation, inexperiencedpersonnel may perform multiple intraosseousattempts. This potentially could allow significant extravasationform multiple intramedullary entrance sites. Our study was designedto compareserumdrug levelsarising from traumatizedbone{multiple intraosseousattempts)with those arrsingfrom nontraumatizedbone (singleintraosseous attempt).

We administered phenobarbitalto 24 dogsrandomly dividedinto traumatized(13)and nontraumatized(lllgroups. In the traumatized group, we createdthree intramedullary insertion sites in a linear fashion and infused only through the central site. In the nontraumatized group, only a single infusion site was created.

Phenobarbitalthen was infusedinto the intramedullaryspace,and central venous phenobarbital samples were collected at one-, three-, six-, and ten-minute intervals. The single-attempt,nontraumatized/groupattainedsignficantlyhigher serum phenobarbi tal levels at each interval comparedwith the multiple-attempt, traumatizedgroup iP < .0001). Therefore,it is critical to achieve single-attempt intraosseousneedle placement for intraosseous infusion to be an effectivemode of therapy.

'66 Comparisonof Intravenousand lntraosseous Administration of Epinephrine in a CardiacArrestModel SG Crespo,WH Spivey,M Scholfstall/Department of Emergency Medicine,Divisionof Research, The MedicalCollegeof

30

P e n n s y l v a n i a ,P h i l a d e l p h i a This study compared serum catccholamine levels and blood p r e s s u r er e s p o n s et o i n t r a o s s e o u sa n d i n t r a v e n o u s ( I V ) e p i n e p h r i n e in a cardiac arrest model. Fifteen swine (10 to 15 kgl were a n e s t h e t i z e dw i t h k e t a m i n e i n t r a m u s c u l a r l y a n d a l p h a - c h i o r a l o s e IV and ventilated with room air. Thc right femoral artery, carotid artery, and external jugular vein wcrc cannulated for blood samp l i n g a n d b l o o d p r e s s u r em e a s u r e m e n t . C a r d i a c a r r e s t w a s i n d u c e d with 50 to 60 Hz current delivcred to thc right vcntriclc by venous pacemaker. Blood pressure and lead II ECG were monitorcd continuously. Blood sarnplcs for epincphrinc were drawn bcfore arrest and every two rninutes thereafter; at fivc minutcs, cardrac compressions were initiatcd with a mechanical rcsuscitator and the animal was vcntilatcd with 100% oxygen. Frvc animals received no furthcr therapy and servcd as contiols; fivc receivccl IV epinephrine 0.0I mg/kg at tcn and 20 minutrs aftt'r arrcst,and fivc r e c e i v e d i n t r a o s s c o u sc p i n e p h r i n e 0 . 0 1 m g / k g . B l o o d s a m p l e s w c r e assaycd for epincphrinc using a Bcckman high-prcssuie liquid c h r o m a t o g r a p h . E p i n e p h r i n ea n d m e a n a r t e r i a l p . " . r u r . ( M A p I a r c l i s t e d f o r c o n t r o l , I V , a n d i n t r a o s s c o l r si n f u s i o n a t b a s c l i n c a n d a t s i x , 1 2 , 2 2 , a n d 3 0 m i n u t c s z r f t c ra r r e s t .

Controls Epinephrine MAP

Epinephrine MAP Epinephrine MAP

Basefine 6 .61.4 76!43 1'16r'1542!14

12 3 81 1 8 3 1! 1 7

22 36114 1815

30 38121 12+3

l V E p i n e p h r i n ea t 1 0 a n d 2 0 M i n 1 . 1r 1 . 8 5 1t 1 8 2 3 51 1 1 8 2 9 2 t 2 1 7 3 8 ! 2 3 '1 16r12 42!13 6 51 1 7 56rB 24+12 IntraosseousEpinephrineat 10 and 20 Min 1.511 951100 291!jZ4Zg7!96 120r38 53111 41r24 34+21

96140 25r14

An ANOVA dcmonstratcd a significant incrcasc in cpincphrit-rc l e v c l s a t 1 2 a n d 2 2 m i n l l t c s f o r t h c I V a n d i n t r a o s s c r ) L l sg r o u p s compared with controls. Thcrc was no diffcrcncc bctwccn thc iV a n d i n t r a o s s c o u sg r o u p s . T h c s c d a t a s u g g c s tc p r n c p h r i n c i s t r a n s portcd to thc central circulation as cffectivcly as front thc bonc during cardiac arrcst.

Thcre has been much recent literaturc supportlng the rcsurgence of use of the intraosseous route of access in Dcdiatrics.

Intraosseous lines providc a timcly noncollapsible rout. to the c r r c u l a t i o n i n r n e d i c a l o r t r a u m a t i c e m c r g e n c i t l sw h c n I V a c c e s si s unobtainablc. Therc has bccn no controlled study comparing IV and intraosscous loading of phenytoin. A 15 mg/kg dose of p - l - r e n y t o i nw a s a d m i n i s t e r e d o v e r l 5 m i n u t e s t o p i g i ' u s i n g e i t h e r the IV (six) or tibial intraosscousroute (six). fcmbral artery blood sarnples were drawn cvery five minutes for 35 minutes aftcr initiation of thc infusion to dctermrnc phenytoin lcvels. There was no statistrcal differcnce between thc two groups using analysis of v a r i a n c c r c p e a t c d m e a s u r e s ( P = . i 0 6 ) . I t h a s b c c n s u g g e s t e dt h a t a l k a l i n e s u b s t a n c c so r t h o s c w i t h h i g h o s m o l a r i t y r n a y i i a m a g c t h e marrow' howevcr, mrcroscopic examination of thc cortei and m a r r o w a t t h c i n t r a o s s e o u ss i t e r n t h e s c p i g s w a s n o n n a l f i v e w c e k s after rnfusion. Wc concludc that the rntraosseous rourc ls an cffectivc altcrnatrvc to IV loading of phenytoin without pernanent dar-nagcttl thc marrow.

69 Critical Lessons From PrehospitalpediatricCardiac Arrest RFLavery, BJ Tortella, CCGriffin/New JerseyTrauma Center, University Emergency Medical Services, NewJersevMedical School; University of Medicine andDentistry of NewJersey, Newark This reportexaminedpediatric(<18yearsold) cardiacarrestoatientsover a t w o - y e apr e r i o d .H i s t o r ym , echantsm o f i n l u r yo. n - s c e n e t i m e s ,a n o p r o c e o u r e attemptsand successeswere obtainedfrom mobileintensivecare unit ambulancerun sheets. Forty-seven patientswere reviewed,representing 3% of all pediatricadvancedlifesupportresponses,and weredividedinto medical ( 6 1 % )a n d s u r g i c a(l3 9 % )c a s e s .M e a no n - s c e n e t i m ef o r a l l a r r e s t sw a s 1 3 . 0 m l n u t e s .M e d i c aal r r e s tm e a no n - s c e n e t i m ew a s 1 5 . 2m i n u t e sw, h i c hw a s s i g n i f i c a n tlloyn g e rt h a nt h a tf o r t r a u m a t iac r r e s t s9, . 9 m i n u t e s( p < . 0 5 ) .M e a n on-scene t r m ef o r u n s u c c e s s f u l Vl l i n ep l a c e m e nwt a s 1 0 . 4m i n u t e sw, h i c h w a s s i g n i f i c a n tsl yh o r t e trh a nt h a tf o r s u c c e s s f ucla s e s ,1 5 . 0m i n u t e s( p < . 0 5 ) . F u r t h edr a t aa n a l y s i sr e v e a l e d t h ef o l l o w i n g : Endotracheal Intubation

Age < l y r > l y r

67 Comparisonof Intravenous,Intraosseous,and IntramuscularAdministrationof Succinylcholinein Sheep GP Moore,SA Pace,W Busby/Emergency Medicine Residency, FortHood,Texas;Emergency Medicine Residency, Madigan Army Medical Center, Tacoma, Washington The intraosscous route of vascular access has bccn ponularizccl rccently for resuscitation in childrcn. Succinylcholin" has [r."n anecdotally_ rcported for airway maltagcrncltt rntraosscously. This drug coulcl bc used for control of thc airway in pcdiatrii burr-rs, status epilepticus, head injury, or combativc paticnts. No scrics quantifying thecfficacy of thc intraosscous rouic has bccn rcportcd for succinylcholine. To accornplish this goa1,six sheep scrvrng as their own controls were ancsthetizcd with halothanc and intubated. Succinylcholinc (1 mg/kg) was givcn, and tl.rc timc to rcspiratory arlest as wc11 as thc loss of the ,'train-of-four" stimulation of the anterior tibial ncrve was notcd. Each shccp was studicd successively using the IV, intraosseous, and intramuscular routcs of administration with a minirnum of seven days scparating trials.

Results werc as follows: Route of Administration

Inlraosseous Intramuscular

Average Time to RespiratoryArrest (sec) 3 0 . 8t 7 . 3 5 7 . 5r 1 0 . 3 2 3 0 . 0: t 1 0 6 . 0

AverageTime to Loss of"Train-of-Four" (sec) 9 3 . 3t 3 4 . 0 100.8!24.2 2 9 1. 0 t 1 0 9 . 0

All groups_were statistically significantly diffferent using thc I test for thc di{ference o{ means {P < .0015). Wc concludc that thc intraosscous route of administration of succinylcholinc in this scries of shcep is comparable to the IV roure and is superior to the intramuscular route.

.68 Comparisonof Intraosseous Versus Intravenous Loading of Phenytoinin Pigs and Effecton Bone Marrow PJ Vinsel, GP Moore,KC O'Hair/Department of Emergency Medicine, Darnall ArmyCommunity Hospital, FortHood,Texas

3l

On-scene lV Line On-scene time (min) time (min) ETI No ETI tV No tV AttemplSuccessAttemptAttemptAtlemplSuccessAttemptAttemDI 88"" 86".

1'./ 5.0 58..

11.7 9.5 30..

96% 820/" 13.2 3.0 93% 78% 13.4 65

This is thc first rcport of on-sccltc timcs ancl succcss ratcs for pcdiatric cardiac arrcst paticnts. Thc data show that paramcdics s p c n c ls i g n i f i c a n t l y l o n g c r a t t h c s c e n cw i t h r n c d i c a l t h a n w i t h t r a u m a t i c a r r o s t s / y c t c l r n o t c l c l a y o n t h c s c c n c w h c n r . r n a b l ct o c s t a b l i s l - ra n I V l i n c o r i n t u b a t c . W h c n c x a m i n i n g t h o s c p a t i c n t s lcss t]ran I ycar old, paramcdics havc a tcnclcncy to 'sciop ancl t r a n s p o r t " a n d f u r g o i n t u b a t i o n a n d f o r g o i n t r - r b a t i o na n d I V l i n c p l a c e t t t t, t t . T l t e r e a : r , n sf o r t h i 5 a r t p r c s c ' n t l yu n d l :r i n v r . s t i l i l i ( ) l t , b u t t l - r c s cd a t a c l o s l r p p o r t c x p a n s i o n o f t h c p c d i a t r i . r c g , - r . , . n t su i p a r a m c c l i c s 'c u r r i c u l u m t o p r o v i d c g r c a t c r c l i n i c a l c o n f i d c n c c a n d t c c h n i c a l s c c u r i t y . T h c s c d a t a a l s o r a i s c t h c c l u c s t i o na s t o w h c t h c r t h i s " s c o o pa n d t r a n s p o r t " t c n d c n c y m a y b c p r o m p t c d b y p a r a m c d i c discornfort with pcdiatric IV and airway managcmcnt.

70 Caretaker Neglect and Injury Prevention Instruction for Preschool Child Injuries:475 Consective Cases DM Cline,T Grant, J King, C Snow, E Katz, A Stewart,E Carrol, T W W h i t l e y / D e p a r t m e n t so f E m e r g e n c y M e d i c i n e , H o m e E c o n o m i c s , P s y c h i a t r y ,a n d P e d i a t r i c s ,E a s t C a r o l i n a U n i v e r s i t v , G r e e n v i l l e ,N o r t h C a r o l i n a Prcschool injury rcduction through instruction has bccn documentcd, but not in thc cmergcncy dcpartmcnt. A pancl from the cmergcncy rnedicine, child dcvcloprnent, psychiatry, and pediatncs dcpartmcnts rctrospcctively rcvicwcd 475 consecutivc injurics i n 3 6 6 c h i l d r e n , a g c s I t o ( r 0 r n o n t h s . G r o u p c o n s c n s u sw a s r e a c h c d conccrning pcrccived caretakcr neglcct leading to injury, child abuse, prcvcntablc injuries, and documentcd instruction. Carctaker neglect was perccived in 40% of injuries: poor supervision, 1 8 . 3 % , ;p o o r c h i l d p r o o f i n g , 7 . 2 o / o m ; ore than 24 hours delay, 2.3%; and multiple typcs, 12.7'k. No significant di{fercnces werc founcl i n n e g l e c t f r e q u e n c i e s f o r c h i l d r e n w i t h o n e ( 2 8 2 ) ,t w o ( ( r 1 ) ,t h r e e l2ll, or four (two) emcrgency vrsits during thc 30-month study p e r i o d . , C h i ' s c l u a r er c v c a l e d t h a t b u r n s a n d p o i s o n r n g s h a d s i g n i f i c a n t l y h i g h e r n c g l e c t f r e q u e n c r e s ,w h i l e i n j u r i e s f r o m { a l l s , l a i e r a t i o n s , a n d s p r a i n sh a d s i g n f i c a n t l y l o w e r n e g l e c t f r e q u e n c i e s .B a s e d on the chart, thc panel recornmended Social Servicc investication for 43 children: physical abuse, five, all rcported; repeated nJglect,

1|i ii i irl

38, 16 reported;14 unreported;and rn eight casesthe chart refuted such need.Thirty-eight percent of injuries were potentially preventable through childproofing 120%)or supervision (18%), but injury preventioninstruction was documentedin only 77o. Examining all documentation,the potential for injury prevention is not being addressedby emergencystaff for this patient population.

score did not reliably identify patients requiring major interventions during pediatric transport who were subsequentlyadmitted to ICU. Risk of mortality indices should not be used for triageo{ pediatric transport. .73 The Association Between Scene Time, Prehospital

Procedures, and IniurySeverityParameters Among SeverelyInjuredPatients

71 Variables Predicting the Need for Major Procedures

D Tse,DW Spaite,TD Valenzuela, EA Criss,HW Meislin,M Mahoney/Section of EmergencyMedicine,Collegeof Medicine, Universityof Arizona;Tucson Fire Department,Tucson, Arizona To evaluatethe relationshipbetween injury severity and time spent at the scene by paramedics,we studied 98 consecutive patientswith Injury SeverityScores(ISS)greaterthan 15broughtto a Level I trauma center by EMS personneifrom a medium-sized metropolitan fire department. Complete hospital records were availablefor eachpatient, and autopsyreportswere obtainedfor all fatalities.Therewere66 men and32 women wrth a meanageof 34.4 years. Thirty-two patients died 132.6%1.Blunt and penetrating trauma accounted for 68.4o/"and 3I.6To of cases,respectively.

Mean scenetirne (ST)was 8.14 min (SD,3.481.ST versusinjury scvcrity parametersrevealedthe following:

DuringPediatricCriticalCareTransport K A M c O l o s k e y ,W K i n g / T h e C h i l d r e n ' s H o s p i t a l , H a r v a r d M e d i c a l S c h o o l , B o s t o n , M a s s a c h u s e t t s ;T h e C h i l d r e n ' s H o s p i t a l o f Alabama Few standards exist for determination of when to use a oediatrrc critical care transport team to transfer an acutely ill child from a nonpediatric hospital to a tertiary care center. This cross-sectional study evaluatedclinical criteria to aid in that determination. Three hundred sixty-nine pediatric transports were evaluated by multiple logistic regression analysis on six variables: age, vital signs, recent seizure activity/ current endotracheal intubation, current respiratory distress, and respiratory diagnosis. The outcome variable was t h c n c e d f o r m a j o r p r o c e d u r e s( c h e s t t u b e i n t u b a t i o n , i n t r a o s s e o u s infusion, umbilical catheter placement) during transport. Maior p r o c e d u r e sw e r e p e r f o r m e d d u r i n g 3 3 o f t h e 3 ( r 9 t r a n s p o r t s ( 8 . 9 % ) .

Patientswith currcnt intubation had 2.I times thc oddsof requiring a m a j o r p r o c e d u r e a s c o m p a r e d w i t h a n o n i n t u b a t e d p a t i e n t l P : . 0 7, a l p h a = . 1 0 ) . P a t i e n t s l e s st h a n 1 y e a r o f a g e w i t h u n s t a b l e v i t a l s i g n s had (r.4 times thc odds of requiring a major procedure compared w i t h p a t i e n t s i n t h a t a g e g r o u p w i t h s t a b l e v i t a l s i g n s ( P = . 0 0 4 ) .I n patients older than or age 1,vital sign stability was not a significant f a c t o r ( P = . 4 1) . I f i n t u b a t i o n , a g e , a n d v i t a l s i g n s t a t u s w e r c u s e d a s above to dctcrminc the use of the transDort team, 113 of thc 369 transports (30% I would have used thc tcam. Thc true-positive rate, t h a t i s , c a s c si n w h i c h t h e p r o c e d u r a l e x p e r t i s e o f t h c t c a m / M D w a s n e c d e d , w o u l d h a v e b e e n 1 8 . 6 % . T h e f a l s e - n e g a t i v er a t e , t h a t i s , cascs in which thc tcam/MD was not uscd but proccdural expcrtisc was nccdcd was 4.9"/".

TraumaScore GCS ISS Fatality Variable 0-12 13-16 3 - 1 2 1 3 - 1 5 2 1 - 7 5 1 6 - 2 0Y e s N o Patients 46 51 60 37 71 27 32 66 (mean) 7.65 8.73 7.80 8.89 7.85 8.93 7.978.23 <.07 <.08 I t e s t( P ) <.08 >.25 Procedures2.26 1.29 2 . 0 0 1. 3 5 1. 8 7 1 . 3 7 2 . 2 51 . 4 9 Itest P <.0005 P < .005 P<.01 P< .0005 'lvlean procedures; numberof prehospital GCS,GlasgowComaScale.

Two frndings were noted. More prehospitalprocedureswere performed on the more severelyinjured cases;and there was a trend toward shorterscenetimes for more severelyinjured patientswith severalcategoriesapproachingstatistical significance.A comparison of concurrentcasesof nontraumatic,adult PCA (145patients) revealeda significantly longer mean scenetime (16.06min) than the severelyinjured group (P <.0001).We concludethat proper training and emphasiscan lead to shorter scenetimes for victims of trauma in a metropolitan EMS system. In addition, the most severelyinjured victims may spendless time at the scenedespite the fact that more proceduresare performedon thesepatients,

72 PediatricRiskof Mortality(PRISM) Score:A Poor Predictorin Triageof Patientsfor PediatricTransport RA Orr, T Venkataraman,CA Singleton/Department of Anesthesiology/Critical Care Medicineand Pediatrics, Children's Hospitalof Pittsburgh, University Pittsburgh, of Pittsburgh, Pennsylvania Risk of mortality indiccs validatedfor intcnsive care{ICU) have bcen uscd to evaluatetriage of patients requiring pediatric transport. Pcdiatric transport patlents admrtted to ICU may require a higher lcvel of care,that rs, major interventions during transport.

The validity of the PRISM score, a risk of mortality index, in identifying pediatric transport patients who require admission to ICU has not becn demonstrated.We studied all patients requrring pediatrictransportto our hospital bctwcen Octoberand Dccember 19U7to test whcther PRISMcan identify patientswho needICU. PRISM was scorcd at initial phone contact and on arrival of the transport team at the referring hospital. Pediatric transport outcomewas defincdasadmissionlocation in our hospital(ICU versus nonICU).PhonecontactPRISMand eight-hourtherapeuticinvervcntion score (TISS)of patients admitted to each locatron were compared.One hundredfifty-six patrentswere studied;77 went to ICU and 79 to nonICU areas.Sixty-nine of 77 ICU patients had a predictedrisk of mortality oI 5%"or less.Of these69 patients,42 16t%1wereintubated,14 l2\%lneededinotropes,13 (I9%) needed drugsfor active seizures,and cight (12% ) neededmore than 20 rl.Ll kg fluids for hypotension.The sensitivity of a phonecontactPRISM scorcgreatcrthan 1 in correctlyclassifyingpatientsgoingto an ICU area was only 64%, decreasingto 137" for phone contact PRISM scoresgreaterthan 10.InIact,25 of 84 i30%)patientswith a phone contact PRISM of 0 requiredICU. Overa11,145of 156patients had a low predictedrisk of mortality (< 5%) basedon phone contact PRISM and age. ICU patients had higher TISS scores120.6r 14.5 versus3.9 + 3.7, ICU versusnonICU, P < .001).TISSfor patients with a predictedrisk of mortality 5% or lesswas also significantly higherfor ICU patients(19.8t 14.8versus3.8 + 3.6 ICU, versus nonlCU, P < .001).Ninety-three percentof patients transportedto our hospitalhad a predictedrisk of mortality of 5 % or less,and48"/o of patrentswith a predictedrisk of mortality of 5% or lessrequired ICU. ICU patients did require a higher level of carebasedon TISS. The sensivity of the phone contact PRISM score in identifying patientsrequiringICU was poor.A particularphonecontactPRISM

PCA Yes No 16 81 7.36 8.38 >.10 2 . 3 81 , 6 3 P < .005

*74 Ellectof AlcoholConsumptionon the Outcomeof MotorcycleAccidentVictims D Jehle/Allegheny J Williams,F Harchelroad, GeneralHospital, Department Pennsylvania of EmergencyMedicine,Pittsburgh, The effectof acutealcohol consumDtionon the outcomeof motorcycle accidentvictims admitted to ;ur trauma centerwasretrospectively reviewed from 1983 through 1987.Alcohol consumption was present in 65% of 182 patients who formed our study group;68% of thesehad blood alcohol levels(BALsfabove100mg/ dL. There was no significant difference in age between those victims of alcohol-relatedand nonalcohol-relatedaccidents.Although the mean length of hospitalization did not differ signifi cantly betweenthe two groups(15.9versus18.3days,P + .054),the mean Injury Severity Scorewas significantly higher in thosepa. tients who had consumedalcohol (20.9versus 17.6,P =.025).The severityof headinjury did not significantly differ betweenthe two groups,but thosevictims with BAL above0 had a greaterincidence of headinjury than those with BAL of 0 (69.5%versus495%, P = .49), and there was no significant differencein mortality between those victims with BAL above 0 and those with BAL of 0 (6.8% versus 10.37o,P = .28}. Those patients with BAL above0 had significantly fewer extremity, pelvic, and rib fracturesthan those with BAL of O 163.9%versus 73.6%, P = .O49).We concludethat there rs no differencein mortality betweenthe two groupsandthat the higher Injury SeverityScoresin ethanol-relatedvictims maybe explainedby the greaterincidenceof headinjury in that group.

-75 Comparison of Complication and MortalityRate BetweenDirectTraumaAdmissionsand Transfer TraumaAdmissions to a RuralTraumaCenter

32

DA Albright,M Indeck/Geisinger MedicalCenter,Danville, Pennsylvania A retrospectivereview of 1,701consecutivetraumapatientsadmitted from October 1986 through |uly 1988was done to determine if a differenceexisted in morbidity and mortality between those patients admitted directly from the scene versus those transferredto a rural trauma center. We excluded331 casesthat

were admitted to thc orthopcdics dcpartment due to minor injuries from falls and stab wounds, that is, sirnple fractures and lacerated t e . n d o n sT . w e n t y - s i x c a s e sw e r e c x c l u d e d d u e t o i n c o m p l e t c c h a r t s .

This left (r03 direct trauma admissions and 240 transfeiadmissions ftom nontrauma centers. The patients wcre matched by age ancl i n j u r y S e v c r i t y S c o r e ( I S S ) .A l l p a t i e n t s ' c h a r t s w c r e r e v i c w e c l f o r r e n a l , . p u l m o n a r y , h e p a t i c , s e p t i a , c a r d i o v a s c u l a r ,a n d h e m a t o l o g i c complications. Comp[cation rates for agc and ISS as indepcndent v a r r a b l c sw c r c e v a l u a t e d f o r b o t h g r o u p s { p = 0 ) . D i r c c t a d m i s s i o n s h a d a n o v e r a l l c o m p l i c a t r o n r a t e o l 2 7 . 5 3 " 1 ,( 1( 1 6o f 6 0 3 ) a n d t r a n s f e r a d m i s s r o n sh a d a n o v e r a l l c o m p l i c a t i o n r a t c o l 2 9 . 7 3 o k l Z 2 Oo f 7 a } l .

T h e r e w a s n o s t a t i s t i c a l d i f f c r e n c c b c t w e e n t h c a c e a n d I S Sm a t c h c d groups {P = .35). When age and ISS matchcd, chrect adrnissron spcci{ic complication ratc was compared with transfcr aclnission speci{ic comphcation rates, only ,rne was sraristrcally significar-rt; p u l m o n a r y ( P = . 0 3 5 5 1 ,r e n a l ( P = . 2 0 0 9 1 ,s o p t i c ( 1 )= . l a r t 6 j ; o t h c r ( P = . , 5 6 1 9 )h, c p a t i c l P = . 5 7 4 6 ) ,c a r d i o v a s c u l a r = . 6 8 9 7 1 ,a n d h c m a lp t o l o g i c ( 1 i= . 9 3 0 8 ) .D i r e c t a d m i s s i o n s h a d a ( r . 4 % n - r o r t a l i r vr a t c . a n d t r a n s f c r p a t i c n t s h a d a 6 . 1 1% m o r t a l i t y r a t c { 1 )= . 9 ) . e o i h a g c a n d ISS are independcnt factors influcncing cor-nplication ratc ir.rrural t r a u r n a p a t i e n t s . W c w c r e u n a b l c t o s h o w a d i f f c r c n c c i r - ro v c r a l l complication or rnortality ratcs in 1,344 pattcnts bctwccn dircct t r a u m a a d m i s s i o n s a n d t r a n s f c r t r a L u l l al d i r i s s r r r n s w l r c n u r a t c h c d by agc ar-rdISS. Thcrc was, howcvcr, a significant cliffcrcncc in tl-rc pulmonary complication ratc betwccn thc two groups.

Mean

Effectof the 65 mph Speed Limit Changeson Mortalityand Trauma Severityin Motor Vehicle Accidents DPMilzman,R LeFleche, J Vargas/Department of Emergency Medicine, Eastern Virginia Graduate Schoolof Medicine, Norfolk, Virginia

77 Controlling for Severity of Injuries in Emergency Medicine Research: ISS Versus TRISS JG Murphy,CG Cayten,WM Stahl/lnstitute for Trauma& Emergency Care,New York MedicalCollege,Valhalla,Our Ladyof MercyMedicalCenter,LincolnMedical& MentalHealthCenter.

Bronx,New York Thc Injury SeverityScorc(ISS)and agecan be usedretrospec, tively to control for trauma severity.Howcvc;, the TRISSmcthod requiresin addition that thc RevisedTrauma Scorc(RTS),using valuesof bloodpressure/ GlasgowComaScalc,andrcspiratoryrate, be takenin the emergencydepartment.Rclationships-betwccn ISS andage,and TRISSwith survivaland hospitallengthof stay{LOS) tor survivorswerecomparcdby causeof in jury: penctrating(pNTR), motor vehrclcaccident(MVA), low fall {LI), or othcr blunt {OB).

Data were collectcdover six months ior 1,367conseclltivcadult patients who died or stayed in four traurna and four nontralllna centcrsfor 48 hours or morc.

LT#:'

to,t

. "no

78 Evolution of Trauma Care, A County Experience GA Gomez, K Vernberg,DJ Kreis, PM Byers, J Yaffa, K Buechter, J D a v i s , L M a r l i n , J E c k e s , E F i n e , R Z e p p a l D e p a r t m e n to l S u r g e r y , U n i v e r s i t yo f M i a m i S c h o o l o f M e d i c i n e A county rrulticcntcr tralllr:r systcl-n (MTS) including onc Lcvcl I and six Lcvcl II traurna ccnters was cstablishcd in l9l.t5.

Aftcr l(r months, fivc Levcl II ccntcrs droppcd out lerviug;r rwuc c n t e r t r a L l n t as y s t c n - r( T T S ) ; p r c s c n t l y t h c L c v c l I t r a u n t a c c n t u r r s t h c o n l y v c r i f i c c l c en t c r i n t h c c o u n t y ( O T S ) . A p p r o x i m a t c l y . 3 5 , 2 , o f a l l r l a j o r t r a u m a p a t i c l l t s w c r c t r : l n s p o r t c c lt o t h c L c v c l I c c n t c r t l r . r r r n gt h _ cM T S p h a s c , 7 0 ' 2 , d u r i n g T T S p h a s c , a n d a p p l r x i n - r a t c l y 9 0 ' 2 , i n t h e O T S p h a s c . T l ' r r s p r c l i r r i n a r y s t r - r c l yc v a l u a t c d p a t r c r - r t o L l t c o r t c a s m c a s u r c d b y r - r o n C N Sp r c v en t a b l c c l c a t h sc l r . r r i n gf o u r n r o n t h p c r i o c l sf r o n r M T S ( l 9 t t 5 t o l g l i ( r )a n d T T S ( 1 9 f i ( rt o 1 9 8 7 )a n d t o c o n t p : t r et h c r c s u l t s w i t h a s i u t r l a r s t u c l y c o n d u c t c d i n I 9 l t 2 w i t h no traLluta systcnt (NTS). A total of l3.l nonCNS dcaths wcrc r c v i c w c r l , ( r , l f r o n t t h c f i r s t p h a s c { M T S ) a r . r dZ 0 f r o r l t h c s c c o n r l p h a s c { T T S ) l i r t h g n r r - r p sw c r c c o r r p a r a b l c w i t h r c s p c c t t o ; r g c , s c x , tnechunisr.ro . rf i n j u r y , a n c l I n j u r y S c v c r i t y S c o r c s .A u t o p s i r s w e r e y r c r k r r n r c t lo n a l l p a t i c n t s . U s i n g t h c p r o c c s s o f g n u p r e v l c w , s l x d c a t h s ( 9 . 5 ' 2 , )w e r c j t r d g c c lt o b c p r c v e n t a b l e d r . r r i n gi h c M T S a n d f i v e { 7 .I ' 2 , ) c l u r i n gt h c T T S . P r c h o s p i t a ld c h y o r n i i s r , , " r ' " g c n r c n t r t c c o u r - r t c cf o l r thrcc of thc I I prcvcntablc dcaths, rnistliagnosis, t l - r r c c ;h o s p i t i r l m i s r l a n a g c m c n t , t w o , d c l a y o r s u r g c r y / t w o , a n d t n o n c t h c _ i n d i c a t c r ls u r g i c a l p n l c c t l l r r c w a s n o t p c r f o r t l c d . C o n t p a r i son of the data rcvcals:

'76

. F i f t c c n y c a r s o f s u c c c s s f u l r c d u c t i o r r s i r - rh i g h w a y f a t a l i t i e s n r a y bc changing sincc thc controvcrsial Surfacc TransDortatron antl Ur-riforrnRclocation Assistancc Act of April lgtiZ |SRURAA) rllowccl strrtcs to rzrisc thc spccd limit Lip to (r5 mph Ort mral i n t c r s t a t o s . I n a r c t r o s p c c t i v c s t u d y , w c a s s c s s c ctl r c i r r p a c t o f t h i s l c g i s l a t i o n o n t h c i n c i d c n c c o f r - r - r o t ovr c h i c l c f a t a l i t i i s a n t l r n y cornpounding factors that may havc prchospital and/()relnurgeney dcpartmcnt trcatmcnt implications. All fatalitics fronr Jtily tir Scptcrnbcr l9llll, on thc 9t3% of Virginia's 253 milcs of iural intcrstatc highways with thc new (r5 rnph limit wcrc corlparcrl w i t h t h c s a m c p c r i o d i n l 9 l . J 7w i t h 5 5 m p h s p c c t l l i r . n i t s . M o t o r v c h i c l c f a t a l i t i c s i n c r c : r s c t l 2 3 . . 5 ' 2 ,o n r u i i r l r n t e r s t a t c s i n l g l l l J .

F a t a l i t i c s r n c r c a s c do n l y 4 . 5 % o r - ra l l o t h c r V i r g i n i a r o a c l s ,r n c l r - r d i r r g a 1 4 . O %i,n c r c a s c o n u r b a n i n t c r s t a t c s t h z r t r n a i n t : l i n c c lt h c . 5 5n t n h spccd limit. It was not possiblc to conlparc initial traurna re,,nirg o f t _ h c { a t a l i t i c sb y s t a t i s t i c a l m c t h o c l s b c c : r u s cm a n y o f t h c r c c o r c l i l a c k c c l s t a n d a r d i z e d a s s e s s r n e n tc r i t c r i a . C r a s h s c v c r r t v . h o w c v c r . w a s s u b j c c t i v c l y i n c r c a s c d a r - r crl c f l c c t c c l b y a 1 3 5 , 2 , i n c r e i r s r i n fatalitics_among thosc wcaring seat belts in l9iil.t cor-nparcclwitl-r I 9U7. Calculated valucs show a 3 lii7nincrcasc in tl-rcin-rp:ictforcc for a 3 , 0 0 0 - 1 bv c h i c l c t r a v c l i n g 6 5 m p h o v c r o n c g o i n g 5 ! m p h . T h c s c data suggcst that therc is an incrcascd fatirlity-ratc zissociatccl directly with spced lirnit incrcasc to (r5 utph. Althougl-r a longcr s t u d y p c r i o d i s n e e d c d t o c s t a b l i s h a l a r g c r d a t a b a s c ,t h c s c p r c l i m i nary results reflcct on possiblc changcs needcd ir-rrural cmcrgcncy m e d i c a l s e r v i c e st o d c a l w i t h a n i n c r c a s c d s c v c r i t y o f r n o t r r r v r h i c l c a c c i d c n t s .T h e n e c d t o r e c v a l u a t c t h e r n c r e a s ci n s p r e t l l i m i t s h o u l d also bc undertaken if futurc rcports continuc to show incrcascd fatality ratcs.

Dearhs

Cause N Age (%l TRTSS' Agef TRTSSAge,.

PNTR 268 29.8 30 (11.2) 0.7811 0.28fi 0.06n o 21il MVA 389 39.5 23 (5.9) 0.54fi 0.21n 0.08n 0.1811 LF 450 75.6 28 (6.2) 0.00 0 . 0 3 n 0 0 3 1 10 . 1 2 1 1 oB 260 40.3 13(5.0) 0.56ft 0.18n 0.16il 0.30rr 'Correlation(12) betweenTRISSand survival/LOS. rRegression(r2)betweenISS and age, and survival/LOS. t t P r< 0 . 0 1 .

For survtval, thc cxplanatory power of TRISS was twicc that of ISS ancl agc in all catcgories; ncither adcquatcly explaincd survival among thosc witl-r LF. ISS and agc wcrc bctter prcdictors of LOS among survivors. l{clationslrips varied by causc of rnjury. Rcs c a r c h c r s s h o u l d c o r - r s i d c trh c I S S w h c n L O S i s s t u d i e d b u t T R I S S w h i c h r c c l u i r c s R T S d a t a c o l l c c t i o n i r - rt h c E D - t o c o n t r o l f o r s c v c r i t y r n s t u c l i c so f s u r v i v a l .

NonCNSDeaths 4 . 1 9 8 2 \ 1 2 m o n t h s()N T S ) B . 1 9 8 5 - 8 6( 4 m o n t h s () M T S ) C . 1 9 8 6 - 8 7( 4 m o n t h s () T T S )

246 63 70

Preventable Oeaths

n 52 6 5

v.

2 1. 1

9.5 7.1

T h i s s t r . r c l ys L U l g c s tas s i g r r i f i c a n t i t . r - r p r o v c r rnet i n c a r c o f m a j o r t r a u n t a v i c t i n t s w i t h a t r a L l n t as y s t c l r ( B a n c l C ) r r s c o n t p a r c c lw i t h n o t r a r u l a s y s t c r r ( A l { 1 ,< . 0 0 5 1 .A l t h o u g h n o t s t : t t i s t i c a l l ys i g n i f i , c a n t , i r k r w c r p c r c c n t a g c o f p r c v c n t a b l c c l c a t l - rw s a s o b s c r v c dd i r r i n s T T S ( 7 .l ' 2 , ) a s c o m p a r c d w r t h M T S ( 9 . 5 , 2 , ) .

79 The Failureof TraumaSystems in SouthernCalifornia to Affect Death RatesFrom Motor VehicleAccidents J Morales, D Rasumoff, A lscovich/Los Angeles County-University of Southern California Medical Center, LosAnqeles; Si Francis

H o s p i t a l ,S a n t a B a r b a r a . C a l i f o r n i a On thc prcmisc that carc of majur traum:l victims would bc i r . n p r o v c d b y t r a n s p o r t i n g t h c m t o s p e c i a l i z c c lc c n t c r s s t a f f c d b y s u r g c o n s , _ C ) r a n gCco u n t y i n 1 9 i i 0 a n d L o s A n g c l e s C o u n t y i n 1 9 t t 3 institutcd trauma systcms. Analysis of motor vchiclc n-rortality s t a t i s t i c s o v c r t h c p a s t t e n y c z r r ss h o w e d t h c f o l l o w i n g : t h c d c c l i n c i n m o t o r v c h i c l c a c c r d c n t { M V A ) m o r t a l i t y i n O r a r - r g cC o u n t y followirrg institution of a trauma systcn thcre was,' in fact, a duplication of a statcwitlc trcnd occurring at thc samc timc; trcnds in rnotor vchicle mortality pcr 100,000population rn the trauma s y s t c l n c o u n t i c s a s c o m p a r c d w i t h t h c r e s t O fC a l i f o r n i a a r e s i m i l a r ; n'rotor vchicle mortalrty per I00,000 population has worsencd in Los Angclcs County sincc the institutiolr of its traurla systeln in 1983, as it has in Orange County and statcwidc during ihc samc pcriod; and thc likelihood of an MVA being fatal is appioximately t h e s a m e i n 1 9 8 7a s i t w a s i n l g Z u b o t h i n t h e c o u n t i c i w i t h t r n . , - " s y s t c r n sa n d i n t h c r e s t o f t h e s t a t c . W c c o n c l u d e t h a t t h c e s t a b l i s h _ ment of organized traurna systems with trauma centcrs staffed bv sllrgcons has had no significant effect on mortality fro- rnotc,, vehicle accidents in thc countics in Southcrn California that have

33

adopted such systems. Basic studies, which so rar have not been done/ are needed to define the factors that influence t.ru_, and to evaluate their relative importance.

T^otilily

TriageBasedon riereOtiiegorization p.O__etvJ!.rjeH of

nospttat Emergency Department and Acute In_patient Bed Availabitity RFLavery, BJ Tortella, CCGriffin/University of Medicine and NgwJers^9y: UniversityHospitai NewJerseyMedical !:ll:lrt,:lNewJersey Dcnoo.t, StateTraumaCenter.Newark

Urban emergency departments have borne thc brunt of an incrcascd demand for cmcrgcncy medical carc prompted hy the in_ creasing patient load, cl,osure of hospital beds, and p.*p..11* payment system shortfalls with indigent ,,patient au_pi"g ; fn l9[33, our state-supported,.tertiary .ri., .,rbnr-, i.r.}rl"l'flolpi,ni w a s r e c c i v i n g a .d i s p r o p o r t i o n a t c a m o u n t ls7.B% [lB,0i6tt "Tiii" cmcrgcncy medica_l systcrn (EMS) paticnt rransports l3I,l92). It .1-: nationaJly that othcr hoipitals hatl aitcrnpicd ro tlcal w l r n l rl ln! .l ,s1c n s l s b y l i m i t t n g s c r v i c c s ,t u r n i n g away ccrtain typcsof p a t r c n r s ,o r s i m p l y c l o s i n g t h c i r E D s . T h c E M S s y s r e mc o n s r t l c r u d r n c s e r e s n o n s c sL r n a c c c n t a b l ca n d i n s t c a d c s t a b l i s h c da D i v c r t / Bypass/Rotation _systcm to morc appropriatcly alr"if,"*'ii4t paticnts.among thc six hospitals in ihe scrvicc area based on the availability of ED and acute in_patient convcntional ""a ,p..i"fty bcds..D.ivert signified that a hospital hJ;;;;;;; rn-patient beds availablc in certain categories, .*, -.ai.rffruigicai/pediatrics B y p a s ss i g n i f i c d t h a t a n E D h a d n o a v a i l a b l c U " a r , - i i g r r a t c r s of thc acutc ln-patient status. A Rotation is institutcd when all t orpitni,

Bypass and.mcans tharEMSrranporrs rtt prii"ni,

1l".lln,D]_y,"lr.,,rr ro alt nosnltals,rcgardlcss 0f their Divcrt/Bypass statlrs,baicdon a prcsctrotationlist. Divcrt statusalk;wcda'hospital to continuctir rcccivepaticntsfor which it h.adheds,. cg, mcdical/surgi."i,*frii" av.iding paticnts who rcquircd,yp., ui rr.a, it ri *ir" dii ;;, ici;.

Thc Bypassstatus recoinir",l ihc fr.t tf,ri-rii, havc finitc re_ sourccsthat can bc temporarilysaturatcd,."grid1.., rif the acutc in-houscbcd status.This systcmrcsultcj iniJniversity Hospital rcccivingrrnly 2 7,k,1110,7.12lt rf EMSpaticnts in I 9Ut{{.19,750).

Usinr.: r a d r r )c ( ) n s u l t a t r ow n i t h t h c m c d i c a lc o t n m a n dp h y s i c i a nw h c r q l appropriatc,transportscan thus be directedto h<xpitals that havc rcsourccsavailablcto bcstcarcfor thc spccificn".a, uf tf," prti.'nt.

UrbanEMS systcmsshoulclconsidc,i"ltiiuiing,*f"r , ti*iJ lrt"_ gorizationsystcmto cnsurcoptimal carcof tt . eUS paticnt.

81 FactorsInfluencing the Operational Safetyof Aeromedical Helicopter nA I,tt!Ounn, G Tagney,.tJ BtumeniUniversity of Chicago !y,

I hc saicty of acromcdical transport has bccn the sub-ject of , ablrndant rccent discussion and ncws coverage by the lny'picr.. invcstigators attcrnpting to understand thi, ph.nn_.nun ln1a: vu ct g u r dcvcropcdtheir knowledge bascfrom studies of iccidents and c x p c r t c o n s en s u s . W c a r e t h _ ef i r s t t o u s c e p i d e r n i o l o g i c methods to safcty of aerometlical irrn.po.. Wc stud_ :,Y*y,f::l,.llperational rcd zo5/.l.JU.ilrghts.rcported by programs listed in thc IgBg Direc_ tory ol A1r Medical Services. The overall ratc of accidents (defincd as pcrsonal injury or ma jor property_danlage)and incidents irigriii_ cant property damagcJ wcre 34 accidents per million ttiglr,, ,;d l n c l o e n t s p e r m r l l r o n f l i e h t s . L e s sa c t i v e h e l i c o p t e r p r o g r a m s (flying flig,hts per yearJ l y irts: n ha r lp, isj o: .were more likely to experience m luU accrdcnts per million; IZ6 incidents per million compared with busier helicopter programs, 22 accidents p* _ii_ lion {? < .005), 65 incidents pe, mittio"" 1F ='.Oif ). ,i-tr".,a was also h , . l i c o p t e r s ,f l o w n b y t h c s i x l a r g e s t i M S h . l i . ; ; i ; ; :v:ej :ndo- lo" ri s t o have a relatrvcly low accident rate, 17 per million,

small.vendors, s3 pel rnilion, ,h;;;il ::Tlli.^d r n r s w a s n11,h..:lrli"* ot statrs_trcally

s i g n i f i c a na r t the alphalevel of.d5. cumptctetycapableof flights under instrument flights ::llC1l,ll: rutcs{all heticopte-rs andall p,ilotslegally_ IFRcapableand, progirrn IFRflishtlhad no arcrdentsdurins r z,SSeflishti. l:lr-.I t.lli,,ing bccause o r t h e r e t a t i v e l ys m a l ln u m b e ro l I F R _ c a p a bI l e ightsJhis improvedsa{ety margin is not sratistically significant at :llrl.l.t, rnc alpnaot .U5tevel.programsin which the pilots wereiFR current Dur.sillr rrmrted by 1aw or practice to VFR flight had the same accrdentand tncidenrratesas programsthat did not require IFR currency training of their pilots.

82 Effectiveness of Cervical Spine Stabilization Devices

Measuredby Accelerometry

EE Sabelman,AP Sumchai,JM-lVartino/Rehabilitation, Research& DevelopmentCenter,palo Alto VeteransnOministrition,palo Alto, uailTornta

34

Accelerometryis the measurementof acceleration and vibration in th.een.vironment and/orthe humanbody,sresponreto it. f ne appilcattonot accelerometry to the measurement of cervicalspine displacementis described.There exist -irir,-"r. ,..elerometers that measureaccelerationsin three ,*.. "o-ro"ty usedin bailis_ tics.testing,aeronauticsresearch,motor vehicle .oitlrio.r, ,na grit The .degreeof stabilization ot " ,"Ui..tb spine can be ilp:l: carculatedrry lntegrarion of the relative three-dimensionalaccel_ erationsof the headand thorax. Accelerometrywas apphedto the evaluationof severalnew stabilizationdevicesiirctuaing the fACn devicc, the Milier backboard,the oi"i. Ul.f.U"r.ilrria , .r.lon7 epoxy compositebackboard.In addition, two rigid i..ur.rl "oli"ir, thc Philadelphraand Stifneck,wereevaluated.-fr.lJrrr"-..,,. *.r. madeusingminiaturc(0.5inch cube),5G r...l"rl-"t..s mounted on a nead bancland strappedto the chest.The difference between rnc accelerauons detectcdby thesesensorsis proportionalto the ratc of changeof displacementacrossthe sub;icil-neck.

Sensors y:lc_c9ll9ctcd_by cablcs,toan amplificr packaget."ai"g in; rn IBM PC/AT,with analog/digirar converterind N6tebooksoftware. tle tlne were synchronizedwith the computer :l:t^",:t^qlt !f pror ot accelcratronin thrce axesto identify events in the recoiding sequence.Mcasurementswere begunwith the subject supineanj

in position."The art,l"."rJJi ^"aii^tyui l:.:1 l::k neutral werc tiacceleratrons gcnerated

during device instaliation, 1ogroll maneuvers,and active and passiveneck movement. Acceieraiions wcre intcgratedfor velocity and displacement.pattern matchint oi accclcrations gcneratcd_ by thc insiallation,na ,ppji.r.ion ot the vanous dcvlces rdcntified comlnon high_riskevents including closure o{ fastcncrs during installationjahuft "o-rrrr., of backbrrardcdgcswith floor,_ and slipping"t',t L i,lfri"*. torro,h.n ,.ru.:not becnadequatelytightcned.The basicpremise on :ll-11: wnlch accclcrornetryis appliedasa researchtool is that the human neadand thorax arecoupledby the neck.The accelerometric evalu_ atlon ot ccrvical immobilization devices has identified events capablcof inducing potentially injurious ..rui."1 .pin. motion.

83Transient Neurologic Deficits Without Cervicalspine Fracture or Distocatioin Fottowing ai, ni ii"r r" pB M

Blanda,CM Dunham, Fontanaroia,H Baython,J Blanda/ MarylandInstitutefor EmergencyMedicaiServi6esbystems, Baltimore;Departmentof EmergencylVeAicine,-Norttreastern Ohio Universities.

Coltegeof Medicind,Akion City Hospitai,nXron Ccrvical spine injury is a prirnary cori.rn in the evaluation of paticnts sustainingblunt trauma. White a substantial ,rumberoi patientswill havecervicalspinefractureor dislocation, eitherwith or without accompanyingrreurologic deficit;, tti"r. i. "'ruUgroup Li patients without cervical fracture or dislocation who ilanliesi transient neurologicsigns and symptoms referabieto the cervical sprnalcord. l he purposeof this study was to identify this subsetof patientswith transientcervicalneuropathy{"tto*i"! li"ritir".., t}e presenting ctinical f.r;;;.r;;"o anatyzethe 1?,:l:.r.:l:'i:e raorog,rapnrc trnclrngs,and to evaluatethe associationwith under. lyrng cervlcal sprne abnormalities. The medical records of 7g5 patientswith blunt cervicalspinetrauma treatedover a three_yeai period were retro.spectively_reviewed. f*."ty prtia"ts with transient neuroiogicde{icitsof the cervicalspinalioid without fracture or dislocation were identified. Fi{ty peicent hrj oth., associated but no patient had maior organinvolrrement.Fourpatients i:t-'.yii::, nad a htstoryof previousspincin juries.Symptomsincludedweak_ ness 170%1, paresthesias ltingling) (507"),numbness(40%),and feeling (I5%). Cervtdipine t.jira"ir*, *"s presenrrn 9::1..r::d /u70. Neurologrc examination revealed motor weakniss in all patients: 40%, ypperextremity onlyi35y",all four extremities;and 2O%o,unilateral. Fifty perceni had absent reflexes-and 60%'had scnsorydeficirsin the involvedextremities.Bladderfunction, anal sph-inctertone, and perianal sensation*.r. "oilff..t.a i,i ,"y of^radio.logicstudies revealea""a"rfyi"f .eiuicit fll-i:", {n3tvs1s aonormatrtres rn 6OTothat included degenerativejoinf disease, Lgamentousinstability, t Er"irt.J at.'",andKlippei 3llf1:::l:11., Twenty five percent of patients were initially :.]1.^o,.l"1Tt?. rrearedwtth Cardner_Wellstongs and steroids,while the remain1ngpatlents were treatedwith a rigid cervical collar and steroids.

All,patients had cornplete resolut"ionof ,y-pio-. and deficits wrtnin r 4 days,wrth deficitsin 75% resolvingin lessthan {ivedays, No patient required surgery The data ,,rgglrt thrr euenthough neurologic deficits not associa6-dwith cervicalspiie :jlTi:l! rracrureor drslocatronarean uncommon sequelaeof blunt cervical their presencemay indicatesigni{icantunderiyingcervical lTlTal spine abnormalities, and consultatio"nwith a spinai s.irgeonis

warranteo.

86 Concomitant FemurFractureand HeadInjury: A ReliableIndicatorof VisceralTorsoInjury

84 The lmpact of a CervicalSpine Radiographicprotocol on Cost and ProphylacticSpinal lmmobilizdtion SGAGabram,RJ Schwartz, LMJacobs/Hartford Hosoital.

Unrversity of Connecticut Schoolof Medicine, Hartford

C Pippis, D Unkle, SE Ross, KF O'Mailey/Divlsion of Trauma and E m e r g e n c y M e d i c a l S e r v i c e s , U M D N J - R o b e r tW o o d J o h n s o n M e d i c a l S c h o o l a t C a m d e n , C o o p e r H o s p i t a l / U n i v e r s i t yM e d i c a l Center, Camden, New Jersev Although major tnjury to the hcad and extrrmltics is usua.llv d i s c o v c r e d _ d u r i n gi n i t i a l a s s c s s m e n t i n t h c f i e l d , i n j u r i e s t o t h c c h c s t o r a b d o m e n a r c m u c h m o r c d i f f i c u l t t o r c c o q n i z ca t t h a t t l m ( ].

Indicators o{ the prcsencc of significant, but rniiially occult, inju_ rics to the chcst or abdomcn arc thus highly useful in thc devclop_ mcnt of trragc systcms. To invcstigatc thc validity of concomitant hcad injury and femoral fracturc as an indicator of thc risk of visceral injury, a 3l-month revicw of all patients adrnitted to a L c v c l I t r a u m a c c n t c r a f t c r s r - r s t a i n i n gh l u n t i n j u r y ( 1 , 9 2 2 ) w a s undcrtaken. Thcrc werc 4til patients with significairt thoracic or a b d o n ' r i n a li n j u r i c s ( A I S > 2 ) f o r a n o v c r a l l i n c i d c n c c o f 2 5 , / u .I n t h c subgrcupof paticnts who had suffcrcdboth a significant hcad injury (AIS > 2) and a fcmur fracture (103),thc incidencc of thoracic or a b d o r n i n a l i n j u r y w a s 4 3 . 7 % 1 4 5o f 1 0 3 ) .T h i s r c r r r c s e n t c da s t a t i s _ t i c a l l y s i g n i f i c a n t i n c r c a s u r li n c r t l e n c u { 1 ' . . O 0 i u s i n g c h i - s c l u a r c a r - r a l y s r sw) h c n c o m p a r c d w i t h p a t i c n t s w i t h h e a d i n l u r y u n a c c o m panicd by fcmoral fracturc (210 of 945, ZZ,l,\, fcrnoral fracture u n a c c o n - r p a n i c db y h c a d i n j u r y ( 1 3 < i 6 8 , 1 9 " 1 , ) ,o r t h c c n t i r e poptrlation.Thc prcscncco{ a hcad injury or frmoral fracturc alonc was not associatcdwith an incrcascd risk of visccral injury. We concludc that paticnts with hcad rnjury in cornbination with f c r . n o r a lf r a c t u r c a r c a t s i g n i f i c a n t r i s k f o r t h ( ) r i r c i c o r a b d o r n i n a l injury. This finding should bc considcrcd for incornorati()n into t r i : r g r g u i t i eJ i n c s .

A prospective cohort study was conducted to determine the impact of a protocol for the radrographic cvaluation of thc cervical spine of blunt-injured paticnts. A1l admitted blunt trauma uatients with suspectcdinjury to the ccrvical spinc were cntered into thc s t u d y . D a t a o n _ p a t i e n t sw e r e c o l l e c t c d t w o m o n t h s p r i o r {25) and t w o m o n t h s a f t e r p r o t o c o l ( 6 8 J .T h c p r o t o c o l e l i m i n a t c d r o u t i n c oblique vicws and instrtutcd earlier computcd tomography (CT) scanning of thc odontoid if open-mouth Watcr's views'werc'unob_ tainable. Data elcments included agc,mcchanism of injury, In jury S c v e r i t y S c o r e{ l S S ) ,G l a s g o w C o m a S c a l e ( G C S ) ,n u m b e r , r f d n y s , i f spinal collar immobilization, diagnosesrclated to cervical spinc i n j u r i e s , r a d i o g r a p h - r e l a t c dc h a r g e s ,a n d r n r t i a l p h y s i c a l c x a m i n a _ t i o n - r e s u l t s .T h e t w o g r o l r p s w c r c n o t s t a t i s t i c a l l y d i f f e r e n t i n a g c , G C S , I S S ,a n d n u m b c r i n t u b a t c d . T h r c c p a t i c n t s i n t h c p r c p r o t o i i r i group had confirmcd (CT scan)spinal injurics; there wcrc nonc in the aftcr protocol group. Thc rangc of days paticnts wcrc immobih z e d w a s o n e t o I I ( m e a n , 1 . t 3 7 f)o r t h e p r i o r g r o u p a n d o n c t o f o u r { m e a n , 1 . 2 )f o r t h c a f t e r g r o u p { p = . 0 0 3 ) .F o r t h o s l p a t i e n t s w h o s c initial physical and radiographic examinatrons wcrc suggcstivcof an injury, thc numbcr of days for cervical collar imrnobilization d c c r e a s c df r o m 5 . 2 d a y s i n t h e p r i o r g r o u l " rt o l . t i d a y s i n t h c a f t c r g r o u p ( P = . 0 1 ) . I n t u b a t c d p a t i c n t s d c c r c a s c df r o r n 4 . 1 d a y s t o 1 . 6 ( P = . 0 0 9 ) .C e r v i c a l s p i n c - r c l a t c d r a d i o g r a p h c h a r g c sc l c c r c a s c d lays t r o m $ 8 , 7 8 2 { m e a n , $ 1 1 7 ) t o $ 6 , 6 7 9 ( m c a n , $ 9 t 3 )l p = . 0 7 ( ) 1T. h c u s c o f a p r c d e t e r m i n e d -p r o t o c o l f o r c v z r l u a t i n g t h c c c r v i c a l s p i n c i n blunt trauma can dccrcasc thc numbcr of clays of ccrvic:rl spinc irnmobilization and dccrease radiograph-rclatcd chargcs.

.87 The Value

of AlkalinePhosphatasein peritoneal Lavage SM Megison, JA Weigelt/The University of TexasSouthwestern Medical Centerat Dallas

'85

Indications For Head CT Scanning in Trauma patients ,1p litzpatrick, SZ Trooskin, L Flancbaum/Department of Surgery, U M D N J - R o b e r tW o o d J o h n s o n M e d i c a l S c h o o l , N e w B r u n s w i c k , New Jersev Thc prccise indications for hcacl computccl tomography (CT) scans rn thc cvaluation of trauma paticnts havc noi ltccn wcll dcfined. Mastcrs et al dcscribcd an aisessrncnt systcm for closcdhcad injurics dividing paticnts into thrcc cat"guri", (low, rnodcratc, and high indcx of suspicron for intracranial injury) basccl on symptoms. The.purposc of this rctrospcctivc study was to idcntify thosc critcria obtaincd prospcctivcly on history and physical cx, amination that would most scnsitivcly idcntify which paticnts would bcnefit from having a hcad CT scan. Wc rcvicwccl thc charts of 166patients fitting thc critcria of Mastcrs ct al for inclusion into a . m o d e r a t ei n d c x o f s u s p i c i o n f o r c l o s c d - h c a ciln j u r y ( M I S ) a n d w h o also had hcad CT scans. Data wcrc collcctccl rclative ro nariunt d c r n o g r a p h i c s { a g e , s c x , r a c e , m o d e o f i n j r " r r y ) ,p r c s c n t a t i o n {vtral signs, Iniury Sevcrity Scorc IISS], Glasgow Corna Scalc), diagnostic workup and results. The l2 factors that placcd patients in thc MIS g r o u p ( 1 ( 1 6C T s c a n s , 3 8 p o s i t i v c ) w c r c t i a n s i c n i l o s s o f c o n s c i o u s ness (LOC), drug or alcohol uso, progrcssivc headachc,unrcliablc history.of injury, age lcss than 2, posi-traur-natic scizurc, arnncsia, multiplc !r1!ma, scrious facial injury, suspectcd basilar fracturc, p o s s i b l e c h i l d a b u s e ,a n d p o s s r b l ep c n e t r a t i n g o r d c p r e s s c df r a c t u r c . lhe factors significantly associated with posrtive scans on chi_ square analysis were LOC, senous facial injury, suspectcd basilar fracture, and possible penctrating or dcpresscd skull fracturc. Stcpwise regression analysis identified the lattcr threc variablcs as in_ dependent predictors of injury, while LOC was depcndent on the presence o{ one of the other three factors for statistiCal sisni{icancc.

The three independent variables identified 33 of thc 31 posirivc scans in the MIS group. The other five positivc scans were analyzed for similarities and were all {ound to shlre a total ISS of I Z or ereater (net ISS of I 3 or greater not including transient LOC in one piiient ).

Of other demographic variables and vital signs collectcd on admlss i o n , o n l y C P R w a s s i g n i f r c a n t l y a s s o c i a t e dw i t h p o s i t i v e C T s c a n s l P : . 0 0 0 2 ) .T h e d a t a s u g g c s rt h a t C T s c a n sa r e i n d i c a t c d w h e n c v e r patient- w.ith MIS presents with a serious facial injury, possible 3 basilar skull fracture, possible penetrating/depressed .kr.ll f."cture, has had CPR, or has sustained trauma with as ISS of 13 or greater, excluding the neurologtc component. Also, it may be possrble to avoid scanning of patients with transient LOC and moderate extracranial trauma {ISS 12 or less) as there were no injuries associated with these criteria alone.

T h c a c c u r a c y o f p c r i t o n c a l l : r v a g c f o r t r : l L l m : 1i s l i m i t c c l b y i t s . rcl:rtivc lack of scnsitivity for hollow viscus injury. pcritoncal lavagc pcrforrncd in thc clogindicatcs that alkalinc rrhosphatasc { A P ) i n l a v a g c f l u i d i s a n c a r l y i n d i c a t o r o f i n t c s t i n a l i n r r . r r v . ' ltfh r : s c rcsults wcrc confirmcd in human paticnts, Ap dctcrinination would improvc lavagcscnsitivrty f,ri hollow viscus injurics. Ap w a s t . n c a s u r c ci rl - r l l I n y n * . s a m p l c s s c n t f o r l a b o r a t u r y a s s a yd u r i n g a o n c - y c a r p c r i o c l . T w o h r " r n d r c dn i n c t y - t w o l a v : r g c s w c r c p c r _ f o n . n c d ;2 5 w c r c p o s i t i v c b y l a b u r a t o r y c r i t c r i a a n d ( 1 6w c r c g r o i s l y positivc. Thcrc wcrc l3 intcstinal injurics; ninc wcrc grossly positivc ancl four wcrc diagnoscd by laboratory rcsults. Tirrcc <if t h c s c f o u r p a t i c n t s w i t h i n t c s t i n a l i n j u r i e s h a d c l c v a t c dl a v a g cA p .

A l l . t h r c c ( l a v a g c df r u r r 3 0 m i n u t c s t o t w o h o u r s a f t c r r n j u r y ) a l s o hacl clcvatcd WBCs or bilc in thc lavagc fluid. Thc rcmaining i n t c s t i n a l i n l u r y w a s c l i a g n o s c db y l a v a g c b i l c b u t l - r a dn o c l c v a t i o n o f A P { l a v a g c d l 5 m i n u t c s a f t c r i n j u r y ) . T w o p a t i c n t s w i t h el c v a t c d AP in othcrwisc ncgativc lavagcs wcrc obscrvcd for at lcast fivc c l a y s .N c i t l - r c r d c r n o n s t r a t c d a n y c v i d c n c c o f i n t r a - a b d o m i n a l i n jury. AP in pcritoncal lavagcis no bcttcr than traditional dctermi_ nants ol intcstinal injury. In fact, in no paticnt was Ap hclpful in d i a g n o s i n ga h o l l o w v i s c u s i n j u r y a n d i t s u s e w o u l d h a v c p r o r n p t c d t w o u n n _ c c c s s a rcyc l i o t o m i c s . T h c s e d a t a c i on o t s u p p o r t i h c u i . , , f l a v a g c a l k a l i n c p h o s p h a t a s c t o i d c r - r t i f yh o l l o w v i s i u s i n l u r i c s .

-88 ClinicalComparison of Hesuscitationand Survival Ratesfor 1980and 1985ACLS Protocolsin Out-ofHospitalVentricularFibrillationCardiacArrests FC Erickson, BDMahoney, KAGriffith/Department of Emergency Medicine, Hennepin CountyMedical Center, Minneapolis, Minnesota

35

T h e I 9 U 5r c v i s i o n o f t h c S t a n d a r c l sa n d G u i d c l i n e s f o r A d v a n c e d Cardiac Life Support (ACLS)for ventricular fibrillation lVFl cardiac arrests is bascd primarily on theorctical laboratory data and previ_ o u s c l i n i c a l e x p e r i e n c c .T h e r c w e r e n o c o n t r o l l e d c l i n i c a l o u r c o m e studies completcd prior to its adoption and promulgation. While intuitivcly and empirically belicved to be better, tt remains clini_ cally unproven. We analyzed all consccutivc out-of-hospital VF cardiac arrests transported by the Hcnnepin Ambulance Service to Henncpin County Mcdical Ccnter during a one-year period before and onc year after our EMS system adopted the l9B5 ACLS revisions. Patients were cxcluded if their arrest was traumatic, hypoth_ ermic/ toxjc/ suicide, elcctrocution, drowning, or they were under I (r ycars of age. One hundred thrrty-nine fiatients were entered into

this retrospective chart study, (r5 ln the first group managed according io the l9B0 protocol and, 74 in the second managed according to the l9B5 tcuitio.t. There werc no statistically significant dif{irences (P < .05) in age, sex, or time to initiation of ACLS treatment betwecn the groups.The first group had a resuscitation r a t c o f 3 3 . 8 % , d i s c h a r g e i a t e - o f 1 8 . 5 o 1 ,a, n d d i s c h a r g e df u n c t i o n a l l y thc samc rate of 13.8%. Thc second group had rates of 41 97", 1 8 . 9 ' / " , a n d 1 4 . 9 7 n ,r e s p c c t i v e l y . W h i l e t h e r c a p p c a r s t o b e a t r e n d tu*rtd high"t rcsuscitition rates with thc new VF protocol, thelc arc no staiistically significant differcnces in any of the rates found' Wc conclude that the new VF protocol is neither rcmarkably bctter n o r w o r s c t h a n t h e o l d p r o t o c o l . A l s o , u s i n g b e t a a n a l y s r s ,g r v e n only an [3'loimprovemcnt in resuscitation ratcs and virtually idcntical dischargerates, it would requirc a massivc study to dcmo.nstrate a stati;tically signi{icant dilfcrencc in outcomcs bctween the two protocols.

89 DefibrillationBy IntermediateEMTs: The lllinois Proiect of of Surgery'Division S Anneken/Department KL Muelter, Clinical Medicine Emergency andTrauma, Medicine Emergency Center, HealthSciences of Colorado University Center, Reseirch lllinois Oaklawn, ChristHospital, Denver; A study was undcrtakcn in Illinois to verify reportsof succcssful cncrgcncy mcdicinc technician-defibrillation (EMT D) programs in Iowa and Seattle. Intcrmcdiate EMTs wcre trained to idcntify vcntricular fibrillation (VF) and opcrate a monitor-dcfibrillator' Monthly tcsting confirmed thc ability of all EMT-ls to defibrillatc a manncquin within 90 scconds of discovcring VF. Six suburban and rurai hospitals wcre involved in thc study. Resuscitation o l l t c o m c s w c r c c o r n p a r e db e t w c c n p h a s c I ( b c f o r c E M T d c f i b r i l l a t i o n t r a i n i n g , ( r 5 )a n d p h a s c 2 ( a f t c r t r a i n i n g , 7 3 ) . P a t i c n t s i n - p h a s c s I and 2 wcil sirnilar-in agc, scx, cardiac history, causc of dcath, c l i s t r i b u t i o n o f c a s c sa m o n g t h c h o s p i t a l s , a n d a i r w a y u s c d d u r i n g t r a n s D o r t . T i m c s f r o m c a l l t o E M T a r r i v a l o n s c c n c w c r c a l s" /o" sirnilir (phasc1, 5.9 min + 0.49;phasc 2, 5'7 r0.39l.Inphasc2,77 o f c a s c sh a d V F w h c n f i r s t r n o n i t o r o d a t t h c s c c n c , i n p h a s c I o n l y 28'/,, hatlVF whcn first monitorcd at thc hospital. This diffcrcncc w a s c x p c c t c d : i n p h a s e 2 t h c a v c r a g ct i m c b c t w c c n o n - s c c n c a r r i v a l a n c lr h y t h r n d c t c r m i n a t i o n a t t h c h o s p i t a l w a s 2 l . 4 t 0 9 7 r n i n u t c s ' I n n h a i c 2 m o r c a r r c s t s w c r c w i t n c s i c d ( 6 t 3 ' 2 v, s 5 i ' 2 , , 1 ) = ' 0 3 )a n d n r < i r cp a t i c n t s r c c c i v c d b y s t a n d c r C P R ] 3 ( r ' 2 ,u s 2 O " l ' , 1 ) =0 4 ) - D c spitc ttvtT-D training and grcatcr numbcrs o{ witncsscd and bys i a n d c r - a s s i s t e dp a t i i n t s i n p h a s c 2 , t h c r c w a s n o d i f f c r c n c c b c twccn thc gtu.,pt in long-tcrm survivors (thrcc of65 in-phasc I vs two of 73 in phase 2). Aiihough arrival timc, numbcr of witncsscd a r r c s t s ,a n d b v s t a n d e r C P R w c r c w i t h i n a c c c p t c d l i m i t s o f a n E M T D program, thcrc was ntl incrcasc in long-tcrm survivors Trarning dcfibrillatc docs not guarantcc highcr ratcs of survival' fl{fs'tu

Delibrillation 90 Transtelephonic

Seattle of Washington, University Othei than one individual casereport and a number of incidental accounts,there have been no studresof the nature or risk to personsprovidingdefibrillatoryshocks.In this study,we reportthe severityand nrtrrie of injuries to prehospitalemergencypersonnel in King County, Washington.In addition, we describethe typesof injuriei o".r.,rtit-tgto defibriliator operatorsvoluntarily reportedto thc Food and Drug Administration. In King County, prehospital cmergcncypcrsonnelreportedeight accidentalshocks One individuai was admittcd tulh. hospital for three days and required lldocainc for premature vcntricular contractions Most injuries were the resuft of accidentaicontact with the patient rather than equipment failurc, although the most serious case was due to cquipmcnt failure.There were l3 injuries reportedto the FDA over . ihi."-rnd-one-ha1f-year pcriod. Most injuries involved a mild shock or burn. Threc patiants were admittcd to the hospital for observation.Two caseJinvolvedmachinefailure.The rateof iniury for oaramcdicswas one pcr 1,700 defibrillatory shocks and for was oneper "-"rg"r-t"y medical technician-defibrillator-personnel 1,000de{i6rillatoryshocks.Thesc ratesprobablyoverestimatethe real risk. Emphasiion safetyand incorporatronof safctyprocedures into resuscitition protocolscan make the ratc of injury evenlower' 92 Morphology of Myocardial Necroses Alter 15 or 17

CardiacArresland Fibrillation Minuteiof Ventricular in Dogs BYPass Cardiopulmonary

Resuscitation A Badoisky, P Safar, FSterz, Y Leonov/lnternational University0f ResearchOenterand Departmentof Anesthesiology, Pittsburgh In st-udicsof normothermic ventricular fibrillation (VF)cardiac arrcst (no flow) of tcn to 20 minutes, dogswith previouslyhealthy hcarts dcvelopedmultifocal myocardial necroses.Cardiacoutput aftcr arrcst is transiently reduced,but recovers.After VF of 30 minutcs, hcartbeatrecovcrcdonly transiently. In this study,-mor' o{ the necroseswere explorea r!ttt!tphology and pathogeneses ilu. airlr wcrc subiectedto VF by externalAC shock (50to 100VJ, with no flow of l5 minutes {ten)or i7 -inut"s (25),reperfusion cardiopulmonarybypass,external defibrillation with DC 200 to 400 f, intcrmittcnt positivc prcssure ventilation to 24 hours, intcnsive carcto 96 h<jurs,and perfusionfixation sacrifice'Grossly, thc hcarts showednecroses/piimariiy involving the subepicardial laycr of thc right ventriculai free wall, of which a mean of l0% (maximum,SfjZ)ot the surfaceareawas necrotic/versusonly l7o of thc lcft vcntricle. There was no correlationbetweenmyocardial and brain histologic damage scores.Myocardial necroseswere most promrnent ;long the pulmonary artery-outflow tract and bcncaih the middle ofihe coionary grooveof the right ventricuiar wa11.Light mrcroscopyshowed necrotic.myofiberswith homogeThe post-VF{noflow) myocardialnecroses noushy'pcreosinophilia. tauscd by'a cornbinaiion of electric iniury andreperfusion may 1-,c iniurv. CPR trauma and coronaryobstruction were ruled out'

J S F e t d s t e i n J, H e n r y , B S i m m o n s , L N i t o w s k i , R O ' C o n n o r / M e d i c a l Center of Delaware T h c p u r p o s c o f t h i s s t u d y w a s t o a s s c s st h c s a f c t y a n d e f f i c a c y Fiftecn of a dcvicc allowing for tianstclcphonic dcfibrillation naticnts wcrc tlcfibriilatcd using thls device. The initial rhythrn *u, .,,urr. vcntricular fibrillation (VF) in tcn patients, fine VF in for.rr, and ventricular tachycardia in onc. -The transtclephonic svstcm consists of a patient unit containing ciectrodes, a mlcropro."rrur, , DC defibdllator, and a microphone. The base station consists of a control panel and ECG display' Opening the paticnt unit and connccting it to a standard telephone iack initiates a dia"ltng sequcnce that automatically dials and pr"p.ugrr--"d the base station wherc a physician can communicatc, ,.tiuttt monitor, and, if necessary, defibrillate from a remote location' Fiftecn patients who prescnted to our cmergency department in car,liac ,rre.t were placed on patient units that activated our base s t a t i o n i n , , . . n o t . i o . r t i o n w i t h i n o u r E D . I n a l l c a s e sv o i c e a n d ECG transmission werc established without difficulty Twcnty asvnchronous defibrillation shocks ranging {rom 200 to 360 J were deiivcred transtelephonically as well. We believe that this system i. n r"t. and ef{icaiious metLod for treating VF and has unlimited

Time 93 TheEffectof BolusInjectionon Circulation DuringCPR

of CL Eierman, A Pinchak,J Hagen,D Hancock/Departments ClevelandMetropolitan EmergencyMedicineand Anesthesiology, Geneial Hbspital,Case WesternReserveUniversity,Cleveland, Ohio Sevcralpreviousstudieshave demonstratedthat peripheralvenous iniection during CPRleadsto prolongedcirculationtimesand io* p.rt drug levelsl Current ACi-S guidelinesrecommendthat a bolus of fiush solution be injectedfollowing peripheraliniectionof medication;however,there is limited evidencethat this technique ir l" tr., effective.The purposeof this study was to investigatethe e{{ect of a bolus iniection-on dye circulation times during CPR' Eight n-rongrcldogsweighing between lB.and 28 kg were instru' minted wiih B-in. "atheiers placedin each of the carotidarteries and a Swan-Ganzcatheterpissed into the pulmonaryartery'The animals were cradledin a dorsalsupportand a modifiedThumper@ was positioned over the lower ventral thorax' Measurementsol end-iidal CO., central venous, and arterial blood pressureswere made througliout the study. Cardiac arrestwas-inducedby 60-Hz Llectrical stinulus applied to a right ventricular wire' Repeated rniectionso{ indocyaninegreendye,2.5 mg in 2 mL of diluentwere made either with (method 1) or without (method2Ja 20 mL saline ilush in a random order. Eight injections were made in eachdog with half of the iniections foliowed by a sahne flush' Dye was withdrawn from the left carotid artery by a motorized syringe through the densitometercell o{ a dye dilution conputer' Dyecir-

prchospital uses.

91 Dangersof Defibrillation: lniuries to Emergency PersonnelDuring PatientResuscitation of for Evaluation S K DamoniCenter M Eisenberg, W Gibbs, KingCourtyHealthDepartment' MedicalServices, Emergency of Medicine, Department Division; Services fmerlencyMedical

36

cuiation time was measured as the time to first appearance of the dye at the densitometer cell. There was no difference in svstolic. diastolic, or coronary perfusion. There was no difference in ETCO. following injection with or without saline flush. The dye circulal tion time with saline flush was SL7 f 20.8 seconds,while the circulation time without saline flush was 86.9 + 43.6 seconds lp < .001). The peak dye concentration following injection with saiine flush was 3.8 t l. t mg/L while the peak dye ioncentratron without s a l i n e f l u s h w a s 2 . 8 t 0 . 9 m g / L ( P < . 0 0 1 ) .W e c o n c l u d e t h a t a 2 0 m L saline flush can enhance circulation times and peak dye levels following peripheral iniection during CpR. Further work remains to be done to establish the optimal volume of flush to be used in clinical situations.

adminstration between the B-CPR and no B-CpR groups {p > .09).

No successful resuscitations were noted in either group foilowing initial defibrillation or following epinephrine therapy. The resulti of this pilot study failed to demonstrate the effectiviness of B-CpR even if started eariy after cardiac arrest. This study suggests that BCPR may only be effective in maintaining critical perfusion to the heart and brain for a relativeiy short duration.

-96 LeftVentricular Volumeand AorticFlow Relationships DuringHigh-lmputse CPR:lmplications Regarding Mechanism of BloodFlow JE Manning,PCD Pelikan,JT Niemann/UCLA Schoolof Medicine, the Departments of EmergencyMedicineand Medicine, (Cardiology), Harbor-UCLA MedicalCenter,Torrance,California: The SaintJohn'sHeartInstitute, SantaMonica,California The purposeof this studywasto assess thc mechanismfor blood flow duringmanualconventionalCPR iCCpR){chestcompression rate,80 to 100/min)and high-impuseCPR (HICPR)(comprcssion rate, I20 to 150/min).Millar catheterswere positionedin thc ascendingaorta{Ao)and left ventriclc{LV)of cight minipigs.Ao and LV pressurcs, LV dp/dt,Ao flow-velocity(AoFl,and changesin LV volume {LW) (conductance methodl were rccordedafter cardiac arrcst and during HICPR and CCPR performedin a randornmanner. CCPR and HICPR were performcdtwicc in each animal.

HICPR significantlyincreased {P < .0001)peakAo prcssure(67+ 6 mm Hg vs 46 ! 41,LV pressure(70 t 3 vs 47 t 5i1,andLV dpI dt l7c)t) + 126 mm Hg/secvs 255 t 471.A decreascin LW occurredUu1 22 ms afterthe onsetof AoF duringCCPR,at 6I + 7 rnsduringHICpR During CCPR,24 + 5% of total lP = NS),and at -3 * 5 ms prearrest.

AoF occurredbeforeonsetof LW decrease,34 +.5% of total AoF occurredbcforca volume changedurrngHICPR (p = NS)and4 t I % prcarrest.In sevenof 1(rHICPR studies,LW increased(r + 3 mL during early CPR systole and AoF. In 30 of 32 studies,LW decrcascd duringlate systolcandin 16(nincCCpR,scvenHICPR), thc lowest LVV wasnotcdto occurti9+ I 7 ms aftcr f orwardf krw had ccased.

We concludethat CCPRandHICPRsharecommonmechanisms for forward flow; the lack of a consistentrelationshin bctwccnLV volumc changesand flow suggests that changcsin LV volume (dimension)during CPR arc not due to vcntricularcompression; andflow prccedingLV volumechangcssupportsintrathoracic pressurcfluctuations as a driving forcc for antegradeblood

*94 Effectsof Arterial and VenousVolumeInfusionon CoronaryPerfusionPressureDuringCanineCpR

NT Gentile,GB Martin,J Moeggenberg,TJ Appleton,NA paradis, RM Nowak/Department of EmergencyMedicine,Henry Ford Hospital,Detroit,Michigan Intra-arterial{IA)infusion hasbeenrcportedto be rnorecffective than IV in{usion in treating cardiacarreit due ro exsangulnarlon.

Computer modeling suggeststhat IA rnfusion, but not IV, may improve coronary perfusionpressure{CPP}during CpR. The purpose of this study was to deterrnineif IA or IV volume infuiion during CPR could augment the effect of epinephrine on Cpp. Fifteenmongrel dogswith mean werght 26.3t 4.4 kg were anesthetized and mechanicallyventilated.Right atrial iRA) and aortic {Ao) catheterswere placed.Additional Ao and centralvenouscatheters were placedfor fluid infusion. Ventricular ftbrillation was induced and Thumper@CPR begunfive minutes later (T = 5). At T = I0 all dogs received0.045 mg/kg epinephrineIV. Group t receivedIV epinephrineonly. Group 2 also receivedan IV bolus of 500 mL saline over three minutes through the central venous cathetcr.

Group 3 received the same volume IA. Resuscitation was attempted at T=18 with standardprotocol.

CPR (Ao-HA diastolic gradient, mm Hg)

Group 1

2 3

T=10 M a xR i s e 12.4!4.2 33.014.4 20.4!4.3 43.2!8.2 11.8t2.4 34.0!4.2

T=13 26.415.0 30.213.8 23.413.8

T=15 25.2r5.1 31.214,9 18.013.6

T=18 20.215.5 29.6!6.7 14.0x3.2

ilow.

The maximum risein CPPwas at T = I 1.6I 1.3.AlthouehCpp increasedsignificantly in all groups (P < .005), there was no differencebetweengroupsin the extent of increase(p > .051.This study failed to demonstratean advantaseto the addition of IA or IV fluid loading to therapeuticepinephrinedosingin dogs.

95 The Effectiveness of Bystander CPR in an Animal Model J Hoekstra,K Rinnert,P Van Ligten,R Neumar,HA Werman,CG Brown/Division of EmergencyMedicine,The Ohio State University, Columbus Severalclinical studieshaveattemptedto discernthe effectiveness of bystanderCPR {B-CPR}.The results of these studies are conflicting but suggestthat B-CPRis effectiveif initiated early and if advancedcardiac life support {ACLS) is instituted within l2 minutes afterthe onsetof cardiacarrest.One problemin comparing thesestudies is the inability to control for variablesthat slsnificantly affect aflect outcome, includ including ischemia time prior to B-CPR, drrration of B-CPR, and paramedic response response time. p.rrpose of time. The The purpose ol

this study wasto determinethe effectiv-eness of B-CpRinan animal model of cardiacarrest and resuscitation.Ten swine were instrumented for aortic pressure{AP}, myocardial (MBF),and cerebral blood flow iCBF) measurementsusing tracer microspheres.Ventricular fibrillation (VFlwasthen induced.After two minutes of VF the animals were assignedto receiveeither B-CPRfor eight minutes ifive) or remain in VF without CPR for an additional eisht minutes (five).Following this, both groupsreceived100%oxygenation and three defibrillationsinitially. If defibrillation was unsuccessful,CPR was continued and epinephrine 0.02 mg/kg was administered.Defibrillation was attempted again threJand one half mlnutes natr minutes atter after eplnephrrne epinephrinead.mlnrstration. administration.AP Ap {mm Hg), MBJ MBF {ml/min/100 g) and CBF {ml/min/100 g) were measured30 sec onds onds and and five five and and one one half half minutes minutes after after beginning beginning B-CPR, B-CPR,and and onr one minute a{ter epinephrineadministration. There were no sisnificant di{ferencesin diastolic AP, MBF, and CBF durine the initial and later stageof B-CPR{P > .14}.There was no differencein the change in diastolic AP, MBF, and CBF following epinephrine

97 Failureof Fructose-1 to Promote ,6-Diphosphate Increased Survivalor Neurological Protection Following Resuscitation FromExperimental CardiacArrest RE Bosenthal, SM Sharpe,GH MarshallJr, JP Smith,RF Shesser/ Department of EmergencyMedicine,The GeorgeWashington University MedicalCenter,Washington, DC Cerebralviability is strictly dependenton the production and use of ATP. Under aerobic condirtions, more than B0% of ATp formation is due to oxidative phosphorylation. Oxidative phosphoryiationceasesrapidly during ischemia and may remarn inhibited following restorationof normal blood flow. Durins thcse periodsthe neuron must rely on glycolysisfor production oJRfp. Although initially increasedduring ischemia,glycolysissoonslows asa result of acidosis-induced inhibition of intermediatcenzymes.

Exogenously adminrstered fructose1,6-diphosphate (FDp)hasbccn shown to increaseglycolytic production of ATp through stimulation of both phosphofructokinaseas well as pyruvate kinase.

Following experimentalhypoxia, FDP has been shown to prolong time to respiratoryarrestas well as to increaseimmediate salvage from hypoxic cardiacarrest.This study was designedto determine th_eutility of FDP for promoting survival and neurologrcrecovery following experimentalcardiacarrestandresuscitation.Male Wistar rats {weighing380 to 445 g), anesthetizedwith an Ip injection of ketamine (36 mgf and xylazine{0.5 mg), were subjectedto controlled ventilation with room air followine midline tracheotomv.

Intracardiacinjectionof 0.4 mL cold I ozo XCI followedby m"nurl thoracic compressionwas used to induce six minutes of cardiac arrest. ROSC was accomplishedusing IACCPR (70 per minute) synchronouswith ventilation with room air. Fifty-four survivors alternatelyreceivedeither FDP i200 mg/kg Ip) or similar volume of salineimmediately on resuscitation.Animal survival wasrecorded daily with neurologicdeficit scores{NDS)beingmeasuredin those animals surviving ten days. There was no differencein survival betweengroupswith l4 of 27 152.k)in eachgroupsurviving the full ten days.NDS of survivorsfor FDP(8.61 14.5)or control{5.8t 12.2) rats were alsonot significantlydifferent{two samplet test, p = .571.

37

KH Lindner, FW Ahnefeld,EG Pfenninger,W Schuermann,lM of Ulm,Ulm, University Clinicof Anesthesiology, Bowdler/Unrversity West Germany Norepinephrine(NE),an alpha l,2l beta-l agonist,seemsto be '98 No lmprovedOutcome After ProlongedCardiac an alternative to epinephrine(E),an alpha l,2ibeta 1,2 agonrstto improvc cerebralblood flow (CBF)duringCPR. E probably stimuArrest and Treatment With Excitatory Neurotransmitter effect' latis cerebraloxygenconsumptionby its beta-2-adrenergic ReceptorBlocker MK-801in Dogs This study compired the effect of E and NE on the balanceof G Shearman/lnternational F Steiz,Y Leonov,P Safar,A Radovsky, cerebraloxygen delivery {CDO,) and consumption (CVO,) durins of Pathology, CenterandDepartment Research Resuscitation CPR. Fourteenpigs weighing 26 to 22 kg were allocatedto receive MerckSharpandDohme of Pittsburgh; University cither 45 pC/ki E {sevenl,or 45 pr/kgNE (seven)following-five d u r i n g i s Excitatory amino acids accumulating in the brain minutes oi v'inlricular fibrillation and three minutes of open-chest c h e m i a m a y c a u s es c l e c t i v e n e u r o n a l d a m a g e a f t e r - i s c h e m i a 'T h i s microspheres)and CPR. CBF (measuredwith radronuclide-labelcd hypothesis was tcsted using MK-801, an N-methyl-D-aspartate sinus oxygen contents (CaO, and Css)r)19ry and sagittal arterial ischcmia We {NMDA) receptor blocker, which can mitigatc focal measuredduring normal sinus rhythm and during open-chestCPR used our dog-model of vcntricular fibrillation-cardiac arrest (VFat 90 secondsand five minutes after drug appliration C?O, beforc, CAI cardiopulmonary bypass (CPB) for four hours, intcrmittcnt werc calculatedusing the formula CBF x CaOr and CBF and CVO. p o s i t i v e p r e i s u r e v e n t i l a t i o n ( I P P V )t o 2 0 h o u r s , i n t e n s i v c c a r c t o 9 6 -'CssO.). Extractionratios(ER)were calculatedasCVO'/ x {CAO. i-to.,.t, ,.td perfusion fixation sacrificc. In study I (ten dogs), VF CDO . ihc Wilcoxon signed-ranktest was used for comparison c a r d i a c a r r c i t w a s I 7 m i n u t e s ; M K - f { O 1 I , 2 0 0 m g / k g ,o r p l a c t b o w a s betwCenprc- and post-applicationof drugs.

Fructose-1,6-dlphosphate did not promote increased survival or neurologic proiection following resuscitation from cardiac arrest in this experimental mode1.

i n f u s e d o v e r 1 2 h o u r s . I n s t u d y 2 { e i g h t d o g s ) ,V F w a s 1 5 m i n u t c s ; MK-801 2,400 mg/kg or placebo was infuscd aftcr arrest ln study 3 ( f o u r d o g s ) ,V F w a s -1 5 m i n u t c s ; M K U 0 1 2 , 4 0 0 m g / k g w a s s t a r t c d 30 minutes beforc VF. MK-UO1plasma levcls pcaked at morc than 5 0 n g / r r l a n c lw c r e 1 5 t o 3 0 n g / m l o v e r l 2 h o u r s M K 8 0 1 d e l a y c d ,"t.,in nf pupillary rcactivity, EEG activity, and wcanrng from IPPV. A1l ZZ ,iugt, MK-U01 or placcbo trcated, survived with scvcre brain damagc. Ncurologic deficit scores, overall performance catcgories, CSF cnzymcs, and brain and heart morphologic damagc scorcs did not differ bctwccn groups. MK-tl0l did not mitigate histologic darnage of the hippocampus. MK-tiO1 alonc docs not sccm t; mitigate brain damage after cardiac arrcst. This does not r u l c o u t t h e p i r s s i b i l i t y o f b e n e fi t f r o m M K - 8 0 1 i n f u t u r c t r i a l s a ft e r shortcr cardiac arrcst in combination with other trcatmcnts/ or aftcr incornplete ischemia.

99 Influenceof Epinephrineand Norepinephrineon ArteriovenouspH and Carbon DioxideGradientsDuring CPR lM W Schuermann, EGPfenninger, KHLindner,FWAhneleld, of Ulm,Ulm' University Clinicof Anesthesiology, Bowdler/University WestGermany DuringCPR artcrialpH and bloodgascsdo not rcflcctthc

rnarked aiidosis and hyp-rcapnia sccn in vcnous blood samplcs' Epincphrinc (EJand noicpincphrinc (NE) lc'ad to an incrcase in myocar<tial biood flow (Mnr) during CPR, but the influence on artcriovcnous carbon dioxide and pH gradients is as yct not known' This study compared the cffects-of E and NE on arterial, mixed venous, ancl coronary venous pH and blood ga-scsduring CPR' Folrrtccn pigs wcighing 20 to22 kg wcrc allocatcd to reccivc cither 4 5 p g / k g L ( s e v c n ) ,o r 4 5 p g / l < g N E ( s e v c n ) f o l l o w i n g f i v e m i n u t e s of ventiicular fibrillation and three tninutcs of open-chest CPR' Blood samples (mean + SD) were obtained duringCPR from aorta, pulmonary artcry, and great cardiac vein be{orc and 90 scconds after irug application. MBF was mcasured with tracer tnicro-sphercs' signed rank test was uscd for comparison between rhc'wlicoxon prc- and post-application of drugs. MBF increasedfrom 71 + 10 to i z 6 t t g m t - / m i n / t o O g a f t e r E a n d f r o m7 4 + 1 l t o 1 0 7 t 3 0 m l / m i n 100 g after NE.

Aorta

E NE

P c o ,( m m H g ) DrugApplication After Before 3 5 1 11 38112 34!4 3816

pH DrugApplication After Before .1 7 . 3 4 t 0 .51 7 . 3 1 1 0 3 7.2810.10 7.2610.08

P u l m o n a r yE NE artery

65112 6 1 1 12

59112 6119

7.17r0.10 7.17L0.07 7.1510.09 7.1010.06

E NE

89i12 78!20

7 3 1 10 68112

7 . 0 01 0 . 0 6 7 . 0 8 1 0 . 0 8 7 . 0 0 + . 0 . 1 7 7 . 0 4 ! 0. 1 1

Great cardiac v e in

UET

E

( m L / m i n / 1 0g0) NE E cDo, ( m L / m i n / 1 0g0) NE E cvo, g) (ml/min/100 NE E ER NE (%)

90 SecondsAfter Before Drug Injection DrugInjection 54x1430x7

Five MlnutesAfter DrugInlection 37x17

3 0 1 11 4 . 3 ! 1, 2

58x227 . 4 t 1. 7 .

45!21 5jt2.4

3 . 7 1 1. 4 1.810.9

7.3t2.72.010.5

5.8t2.7 1.610.8

1.610.7 40!12 41113

1.810.7 ztto

11t0.2 3611I 22t8

26t11'

-P < .05versusopen-chest CPRbeforedruginjection.

In this n.rodcl,E and NE at a doseof 45 prgikgduring open-chestCPR had thc samebeneficialeffect on cerebraloxygenation.

of Cerebral DopplerDetermination 101 Transcranial CPR:Methodology Perfusionin PatientsUndergoing Findings and Preliminary

LM Lewis,C Gomez,B Ruo{{,S Gomez,lS Hall,BM Gasirowski/ Medical-Center Hospital,St LouisUniversity The University during CPR andfrasbeenshown Cerebralperlusionis decreased to dcteriorateconsrstentlyover time. In order to determinei{ any or halt this deterioratronin cerebralperfumaneuverscan decrease sion we undertookthc followingstudy.Any patientbeingresusci' tated for a nontraumatic cardiacarrest was eligible for the study' CPR was carriedout in the usual manner while flow was continu' ously being measuredin the internal carotid artery siphon using window Dopplerultrasound(TCD)by the transo-rbital transcranra"l approach.Vessejldentificationwas basedon the angleanddepthof inionation and the direction of blood flow. Alterations in flow velocity wcre noted and correlatedto variousthâ&#x201A;Źrapeuticintewentions by virtue of a clock on the DoppleJrecorderand the CPRlog she.t. Flow velocrties were consisienily 6O% to 70% of normal during the early phaseof resuscitationbut would deteriorateover flow' Evenearlyin time until there was no evidenceof net forward "systole"with no diastolic CPR flo* *tt nnlv demonstratedduring perfusron.Epinephrineadministrationaugmentssystolicflow rates the time of "diastolic"no flow. TCD appearsto bea and decreases rneasuringcerebralflow in patientsyndergoingCPR way of reliable with resulis consistentwith other describedmethods of cerebral perfusion determination.

102 ThePrognosticValueof the GlasgowComaScale 24 HoursAfterlnpatientSingle Measured Arrestand Resuscitation Cardiopulmonary

Although mixed venous pH and Pco, measutements are more reoreseitative o{ tissue r"ld-brte statG during CPR, they do not adequately reflect the acid-base disturbances seen by the myocardium. Despite an increase in MBF after both catecholamines, Pco, and pH did not change significantly in both groups.

100 Effects of Epinephrineand Norepinephrineon CerebralOxygeriDeliveryand ConsumptionDuring CPR

38

of Emergency RM Nowak,JM HouraniiDepartment BM Tho"mpson, Medicine,HenryFordHospital,Detroit,Michigan;Los Angeles, California Retrospectiveanalysis of out-of-hospitalcardiopulmonaryar' rest (CA) iirectly correlatesthe rapidity of awakeningafterresuscitation to the degreeo{ neurologic outcome. To investrgatea method of predictiig outcomefrom inpatient CA we-prospectively evaluatedthe Glasg5wComa Scale(GCS)24 hours a{tersuccessful measures' resuscitationby stindard advancedcardiaclife support "blue alert"team Our 937-bedteachinghospital with an in-house had2,O7I"bluealertsl'in a14-month period.Therewere1,612CAs, of which 246werc single {mean age,6I.8 yearsJandwere resusci'

t a t e d w i t h c l o s e d - c h c s tC P R a n d c u r r e n t A C L S e u i d e l i n e s . T h c r e w e r c 1 0 6 1 4 2 . 7 % )w h o d i e d p r i o r r o s c o r i n g , l e a v i n g l 4 0 p a t i e n t s 1 43.6%) comprising this report. Sixty-one had a GCS of 9 or lcssand all but one died during hospitalization (this paticnt had a preexi s t i n g i n t r a c e r e b r a l b l e e d a n d d e p r e s s e dG C S p r i o r t o a r r e s t ) .T h e r e m a i n i n g 7 9 ( 5 6 . a % ) h a d a G C S o f t 0 o r m o r e a n d 4 8 ( ( r 0 . 8 % ,w ) ere , 93.8%) d r s c h a r g e d ,o f w h o m 4 5 went homc. Thus, in our study GCS measurcd at 24 hours after rcsuscitation in thcse parieltts was an accluate prcdictor of olrtcome. Paticnts without prccxlsrtng intracranial pathology with a GCS of 9 or less at 24 hour; uniformly died, while approximately one-half wrth a score of l0 or morc s u r v i v e d t o b c d r s c h a r g e d .I f c o n f i r m c d b y o t h e r s t u d i c s , t h c s c g u i d c l i n e s m a y b c u s e d t o g i v c r c a l i s t i c c x p e c t a t r o n st o t h c f a n " r i l y o r t o a i l o c a t e m e d i c a l r e s o L r r c c si n t h c s e t i m c s o f e c o n o m i c a c countability.

103 lnadequate Airway Management Compromising EMT-I Automatic Defibrillator Use FD Pratt, J Potter, G Billingham, JT Niemann/UCLA Schoot of M e d i c i n e , D e p a r t m e n to f E m e r g e n c y M e d i c i n e , H a r b o r - U O L A M e d i c a l C e n t e r , T o r r a n c e , C a l i f o r n i a ;F i r e D e p a r t m e n t ,C o u n t y o f L o s A n g e l e s ; E m e r g e n c y D e p a r t m e n t ,D a n i e l F r e e m a n H o s p i i a l Prior work dcscribing automatic/scmiautomatic dcfibrillator ( A S D ) u s e b y E M T - I p e r s o n n c l e r n p h a s i z c d t h c r - r c c df u r l a y p c r s o n C P R a n d e a r l y a c c c s st o a d v a n c e d r c s c u e r s .H o w c v e r , t h c t ' f f c c t r r f airway managcmcnt by EMT-Is bcforc ancl :rftcr ASD usc or.r s u r v i v a l h a s n o t b e c n a d d r c s s c d .A n A S D p r o g r a m u s i n g E M T - I firefighters was initiated by the Los Ar.rgelci Cirunty Firc'bcpartmcnt in |une 1988. Thc 15 ASDs wcrc usccl on 90 naticnts bv fanuary 1989. Protocol data forms wcrc complctcd try the EMT-I u s i n g t h c A S D , a n d c a s s c t t c - t a p c dd a t a o f E C G r h y t h n " r s a n d o n s c c n c v o i c c r c c o r d i n g s w c r c a n a l y z c d . D u r i n g l 2 ( 1 3 , 2 , )o { o u r defibrillator uscs, tho pattcntrs vcntil:rtion and oxygcnatit)n weru compromiscd by vorniting and subscclucnt aspiration prior to EMTI arrival. A1l of thc pationts with airway compromisc cxpirccl.

Six (50%)of thcsc paticnts wcrc in vcntriclrlar fibrillation, with a p r < l l c c t c csl u r v i v a l o f l 5 % t o 1 9 ' 2 , .I n a c l c q u a t c: r i r w a y l r : r n a g c m c n t

by EMT-I personncl r.rsingdcmancl valvc/mask dcviccs couicl havc diminishcd thc cxpcctcd rcsuscitation ratc from vcntricular fibrill a t i o n . B a s c d o n o u r c a r l y c x p c r i c n c c , w c r c c o r n l l r c n c lt h a t m o r c cmphasis bc placcd on airway managcrncnt whcn initiating ASD p r o g r a m s . A l s o , a d v a n c c d a i r w a y a d j u n c t s ( c s o p h a g c a lo c b t u r a t o r airway, cndotrachcal tubc) should bc considercd for incorporation rnto thc EMT-l scopcof practicc to cnhancc survival aftcr ASD usc.

-104

AdequateVentilationUsing a Mask and Bag While MaintainingCervicalNeutrality W Delaney, REKaiserJriDepartment of Anesthesiology, SUNyat Buffalo Schoolof Medicine andBiomedical Sciences

W e a s s c s s e ctlh c a b i l i t y t o a d c c l , r a t c l yv c n t i l a t c p a t i c n t s i n t h c neutral position with a bag-mask without ccrvrcal Jxtcnsion as is recommended to ficld pcrsonnel for suspcctcd cervical spir-rcinjured patients. We prospectivcly studicd 100 consccr"rtivi paticnts admittecl for clectivc surgery uncler gcncral ancsthcsra. Thc study included analysis of agc, scx, wcigl-rt, hcight, prcscncc of teeth, and ASA status. Fifteen paticnts wcrc cxcludcd duc to deviation from the protocol. Aftcr induction of ancsthcsia, wc could adecluately vcntilatc (r4 paticnts in thc ncutral posrtion { g r o u p 1 ) .T h e o t h e r 2 I p a t i c n t s r e q u i r c d a i r w a y m a n i p u l a t i o n - - j a w thrust, oral pharyngeal airway, or cervical extension to adecluatcly ventilate (group 2). Group 2 patients wcrc olclcr, sicker, zrnd appeared to be hcavier and morc often edcntulous. Four Datj.cnts ( 4 . 7 % ) r c c l u i r e dc c r v i c a l c x t e n s i o n t o v e n t i l a t c . U n d c r i d c j l c o n d i tions, 95% of patients could be ventilatcd maintaining ccrvical neutrality combined with the use of the jaw thrust or oril pharyngeal airway. We concludc that at least 5% of patients in whom cervical ncutrality is maintained arc at risk for inadequatc ventllation and subsequent cerebral hypoxia.

No. Ase (y0 Weight Y. ldeal ASA % withteeth -Student's ttest at 0.02 tChi-squareat 0.02.

G r o u p1 64 36.53 73.27 +7.47 1.578 92

G r o u p2 21 50.680.98 +23.56 2.00f 72

105 Asthmatic CardiacArrest: An Indicationfor Empiric

39

Bilateral Tube Thoracostomies EB Josephson, MG Goetting/Departments of Emergency Medicine a n d P e d i a t r i c s ,H e n r y F o r d H o s p i t a l ,D e t r o i t , M i c h i g a n A s t h m a c a n i n d u c e h i g h i n t r a t h o r a c i c p r c s s u r ea n d a l v c o l a r d i s tention/ placing the patient at risk for barotrauma. pncumothorax (PT) can prccipitatc cardiac arrest (CA) during scvcrc asthma attacks. In addition, assistcd vcntilation during CA may alsct producc PT. This study conparcd the frcquency of pT in asthmatic C A ( A C A ) a n d n o n a s t h m a t i c m e d i c a l C A ( N A C A ) a n d a s s e s s c dt h c rcliability of clinical signs to dctcct PT during ACA. Wc cxanrncd t h c m e d i c a l r e c o r d s a n d r a d i o g r a p h s ,a n d i n t c r v i e w c d t h c t r c a t i n g p . h y s i c i a n _osf e i g h t c o n s c c u t i v e p a t i e n t s w i t h A C A . W c c o m p a r c J thcrn wrth 50 consccutive adult study patients in NACA. pT was diagnoscd if prescnt radiografhically oi discovercd at tubc thoracostomy. Mcdian agcs wcre 14 years (range,12 to 52) in ACA and 6 7 y e a r s ( r a n g e ,3 3 t o 9 2 ) i n N A C A . A l t h o u g h a g e d i f f e r c d b c t w e e n g r o r - r p sb, o d y w c i g h t a n d t h e r a p y w c r c c o m p a r a b l c . p T w a s m o r c f r c c l u e n ti n A C A ( s i x o f c i g h t v s s i x o f 5 0 ; 1 ' . . 0 1 ) . O n l y r i g h t - s i d e d P T u c c u r r c d i n N A C A ( s i t e o f s u b c l a v i a n c a t h c t c r i z a t i o n ) ,w h c r c a s thrcc of six llT in ACA could not bc attriblltcd to nccdlc puncture.

Asthrnatic PT was not dctectcd clinically whilc four of six wcrc c L a g n o s c di n t h c N A C A g r o u p . W c c o n c l u d c t h a t p T i n A C A o c c u r s frccluently,oftcn is unrclatcd to linc placcmcnt. and is clifficult to c l c t c c tc l i n r c a l l y . T h c r c f o r e , er n p i r i c h l l a t c r a l c h L ' s rt u b c p l a c c m c n t should bc an cssential part of rcsuscitation cfforts during ACA.

.106 Prehospital Use of lnhaled Bronchodilatorsin ReversibleAirway Disease I Machel, S Nevins/Department ol Emergency Medicine, Residency in Emergency Medicine, Morristown Memorial Hospital, Morrrstown, NewJersey Sincc thc aclvcnt of mobilc intcnsivc care units, prchosprtal t r c : l t n t c n t o f b l r n c h o s p a s t i c l u n g t l i s c a s ch a s b c c n p u s s i b l c ; h o w c v c r , i t h a s b c c n l i n t i t c d t o a g c n t s h a v i n g c i t l - r c ra h i g h l c v c l o f s i d c c { f c c t s o r l o w c f f i c a c y . N c b u l i z c d b c t a - a g o n i s t sa r c r c c o g n i z c d a s t h c m a i n s t a y o f t r c a t m c n t o f a c u t c r c v c r s i b l c a i r w a y d r s c J s ci n t h c hospital sctting. Our purposc was to invcstigatc thc Lrtility and c o r . n p l i c a t i o r - rosf t h r s t h c r a p y i n t h c f i e l d , a s w c l l a s t h c a c c u r a c y o f d i a g r - r o s i so f b r o n c h o s p a s m i n a p r c h o s p i t a l c a r c s y s t c m w i t h i r u t s t a n c l i r - r og r d c r s . P a r a r n c d i c sw c r c i n s t r u c t c c l b y r c s p i r a t o r y t h c r a l.rists ancl physicians in thc adn-rinistration of isoctharinc and rnctaprotcrcnol witl-r a hand,hcld ncbulizcr, and wc prospcctivcly s t u d i c c l 9 4 p a t i c n t s i n w h i c h t l - r i st h c r a p y w a s g i v c n . O n c p a t r c n t was unablc to comply with thc trcatncnt, onc dcvclopcds.,pravcnt r i c u l a r t a c l - r y c a r d i ao, n c d c v c k r p c c ls c v c r c h y p c r t c n s i , , n , a n . l t l r r . . w c r c j r . r c l g ctdo h a v c b c c n t r c a t c c li n a p p r o p r i a t c l y . A l l o t h c r p a t i c n t s w c r c c o r r c c t l y c l i a g n o s c da s h a v i n g a n c l c m c n t o f r c v c r s i b l c a i r w a y c l i s c a s ca n c l w c r c t r c : l t c d a p p r o p r i a t c l y . F o r t y - s c v c n p a t i c n t s h a d a f i r - r a ld i a g n o s i s o f u n c o m p l i c a t c d b r o n c h o s p a s m . T h c o t h c r s h a c la f i n a l c l i a g r - r o s iosf b r o n c h o s | a s r n a s w c l l i s a t l t l i t i r r n a l d i a g n o s c s rncluding congcstivc hcart failurc, pncumonia, l-ncrastirrii lung c i i s c a s c ,p n c u r n o t h < l r a x , a n d g a s t r o i n t c s t l n a l b l c c d i n g . O v c r a l i , 7 0 ' Z 'o f p a t i c n t s s h o w c d i r n p r o v c m c n t , 2 7 , X ,s h o w c d n o c h a n g c ,a r - r d 2 ( 2 , w o r s c n c d . W c c o n c l u d c t h a t n c b u l i z c c l b c t a - a g o n i s tt h c r a p y i n t h c p r c l - r o s p i t acl a r c s c t t i r . r gi s f c a s i b l c a n d t h a t i n c a r c f u l l y s c l c c t c d p a t i c n t s i t i s b o t h s a f c a r - r dc f f c c t i v c .

107 Prehospital Administration of lnhaled Metaproterenol DR Eitel,SA Meador,R Drawbaugh,D Hess,NK Sabulsky/ Department ol EmergencyMedicine,York Hospital, Yon<, Pennsylvania; Divisionof EmergencyMedicine,The Pennsylvania StateUniversity, The MiltonS HersheyMedicalCenter,Hershey; Schoolof Respiratory Therapy,York Hospital, YorkCollegeof Pennsylvania, York This study evaluatcclthe prchospitaluse of inhaled mctaprotcrcnol.Advancedlifc supportprovidersfrom sevenmedtcunits wcrc traincd using a standarizcdtraining curriculum to idcntify patrentslikely to bcnefit from prehospitaladministratronof inhaledrnctaproterenol.

Candrdatcs for treatmentwcrc thosewith a historyandsymptomssuggestivc of acuteobstructivclungdiscase, those unlikcly to bc rn congestivcheart failure, and thosewith no other contraindicatron for this therapy.Trcatmcntswere administeredby direction of medical command.Unit dosesof metaDroterenolwere uscdin a small volume ncbulizerpowerrdby 8 i/ min 0,. Each treatment was evaluatedby objective(peakflow, respiraloryrate, heart rate)and subjective(dyspnea,wheczing,air entry/ tremor) criteria. Data after admissronwere used to assess field diagnosticaccuracy.We prospectively included122patients

rn the study {71 men, ages 63 + 19 years). Overall, pcak flows rncrcascd(102 t 50 L/rnin bcforc treatmcnt, 139 t l{4 L/rnin after t r e a t m e n t , P < . 0 0 1) , r e s p i r a t o r y r a t e s d c c r c a s e d l 3 4 ! 7 b c f o r c , 2 9 + 7 a f t e r , l ' < . 0 0 1 1 ;a n d h e a r t r a t e s d i d n o t c h a n g c ( 1 1 5 1 2 0 b c f o r e , l14 t 20 aftcr, P = .51). In 62'% c:f paticnts, the increasc in flow c x c c c d e d l 5 % . W h e e z i n g i m p r o v e d i n 5 9 " 1 'o f t h e p a t i e n t s , w o r s cned in 4'%, and did not change in thc others. Air cntry inrprovcd in 59'lo of paticnts. Mild trcrnor occurrcd in 87, of paticnts, mocleratc trcmor occurrcd in l"k, and no tremor occurrcd rn the othcrs. Significant clysrhythmias did not occur. Advanccd life support providcrs corrcctly idcntificd paticnts for this thcrapy, and n o t c c h n i c a l p r o b l c n - r sw c r c c n c o u n t c r c d i n t h c f i e l d w i t h t h i s t r c a t m c n t a p p r o a c h . W c c o n c l u d c t h a t a c l v a n c c dl r f c s u p p o r t p r , ' vidcrs can bc taught to idcntify paticnts likcly to bcncfit fron'r inhalcd metaprotcrcnol, that inhalcd mctaprotcrcnol can bc administcrcd in thc field, and that mctaprotcrcn(tl is both safc ancl cffcctivc whcn uscd in thc prchospital sctting.

PEFR I SD for thc OBLD group was I 10 1 49 L/min versus 225 x97 L / m i n f o r t h e C H F g r o u p i P < . 0 0 0 1 ) .B y c o m b i n r n g t h e m e d i c a t i o n history with the PEFR it was possible to correctly classlfy all c p i s o d e s .P E F R a p p c a r s t o b e a u s e f u l t o o l i n d i f f e r e n t i a t i n g a c u t e dyspnca sccondary to thesc cntlties.

* 1 1 0 I n n o v a t i o n si n A m i n o p h y l l i n eM o n i t o r i n ga n d Therapy College of G Fulde/Australasian BJ Kino,R Day,G Pearce, Australia Hospital, Sydney, Medicine, St Vincent's Emergency

- 108 Comparisonof Two DeliveryMethodsof Albuterol in EmergencyDepartmentManagementof Acute Asthma MJ Bono,J Vargas/Eastern CB Philput, DPMilzman, FRLaFleche, Medicine Emergency Schoolof Medicine, Virginia Graduate Norfolk Medical School, Eastern Virginia Program, Residency In aclltc ashtrna, {1,sytnpathomitnctics l-ravclong l.rccnadr-r-rinis t c r c c lb y h a n d - h c l d n c b u l i z c r s i n c t - n c r g c n c yd c p a r t r - u c n t s .N c w c r s t u d i c s h a v c c l c r n u n s t r a t c dt h e c a s c a n d c l l i c a c y o f u s i n g m c t c r c c l t f t r s ci n h a l c r s w i t h s p : r c c ra t t : r c h t n c n t s i n t h c a m b u l a t o r y c a r c t r c a t r - r . r c ro. rft c l ' r r o n i c o b s t r u c t i v c p u l m o n a r y d i s c a s c a n c l a s t h m a . T h i s s i r - r g l c - b l i n dp, r o s p c c t i v c s t u d y c o m p a r c d t h c c f f i c a c y o f a l b u t c r o l aclministcrcd by hand-hcld ncbr'rlizcr vcrsus a tnctcrcd-closc-inhalcr with an InspirEasc" attachlncttt. Forty-ninc adult paticnts w i t h a c l l t c a s t h r n a p r c s c n t i n g t o t h c E D w c r c r a n d o m l y a s s i g n c ctl o t u r - rocf t w o g r o l l p s . T r c a t m c n t c o n s r s t c c lo f c i t l - r c r2 . 5 m g a l b u t c r o l in.J rrL normal salinc by hand-hcld ncbulizcr (group l)or six puffs o f a l b r . r t c r o (l 0 . ( rm g ) g i v c n a t o l l c - l n i n L l t c i n t c r v : r l s b y m c t c r c c l - c l o s c i n h a l c r w i t h t h c L - r s p i r E a s ca" t t a c h t l c n t ( g r o u p 2 ) r c p c a t c c lc v c r y 3 0 l u l i n L l t c st h r c c t i m c s . T h c g r o u p s w c r c w c l l r n a t c l - r c cflt t r : r g c ,s c x , p r i o r r - n c d i c a t i o n ,a n d s c v c r i t y o f a t t a c k a s d c t c r m i n e d b y a p h y s i c l a n s c v c n t y : l s s c s s l n c n rs c o r c a n c l i n i t i a l p c a k c x p i r a t o r y f l o w r a t c i P E F R ) .T h c r c w a s n o s t a t i s t i c a l c l i f f c r c n c c i n P E F R i m p r o v c l ' n c n t bctwccn thc two groups. Group I (25) had protrcatlncnt PEFRsof 1 6 6 . 5! 6 3 . 2 a n d p o s t - t r c a t m c n t P E F R so f 2 U 0 . 5+ 1 3 9 . (vrc r s r - r s1 5 9 ' 6 + 5 ( r . 5a n d 2 1 1 5 . 0 t 8 u . 0 f o r g r o u p 2 ( 2 4 ) .T h c r c w a s a l s o n o c l t f f e r c n c c in the frcclucncy of adrninistration of aminophylltnc, stcroids, atlmission, or advcrsc sidc cf{ccts. Wc concluclc that albutcrol a c h . n i n i s t c r c dw i t h a r n c t c r c d - d o s c i n h a l c r w i t h t h c I n s p i r E a s c ' attachmcnt is ascffcctivc ashand-hcld ncbulizcrs for thc trcatmcnt o f a c u t c a s t h t . n ai n t h c E D a n d o f f c r s t h c a d v a n t a g ec l fl o w c r c o s t a n d casc of adrninistration.

W c h y p o t h c s i z e d t h a t a n i n d i v i d u a l i z e d c o m p u t e r - b a s c dp r o t o col can improvc accuracyin achicving targetcdtherapeutic plasma theophyllinc lcvcls and lirnit toxicity, as comparcd with standard cInical practicc.Wc prospcctivcly comparcd theophylline conccntrations acl'ricvcd in two sccluct-ttialgroups of crnergency departmcnt paticnts rcquiring IV aminophylline for acute bronchospasm.

Cor-rtrirp l a t i c n t s { 4 ( r )r c c c i v c d a m i n o p h y l l i n c t h c r a p y a c c o r d r n gt o widcly uscd clinical guidclir-res, while tl-re amount of aminophyll i n c g i v c r - rt o c x p c r i m c n t a l g r o u p p a t i c n t s ( 4 3 ) w a s i n d i v i d u a l i z e d accurding to a computcrized modcl. Thc computcr uscd easily d c { i n c d p a t i c n t c h a r a c t c r i s t i c sa n d i n c l u d c d b a s e l i n e t h c o p h y l l i n e l c v c l s m c a s u r c d r a p i d l y b y r c s i d c r - r t si n t h c E D w i t h a m o n o c l o n a l antibody tcst kit.

Percenl of PatientsAchieving Therapeutic,Subtherapeutic,and Toxic PlasmaTheophyllineConcentrationsat One and Six Hours Sixhours one hour Control('/.)Experimental(%) control(%)Experimental(%) 0 10 a 7 Toxic(>20!g/ml) 91 81 37 ( 10to20!g/ml) 26 Therapeutic I 19 53 S u b t h e r a p e u t i c ( < 1 0 L6 r g7/ m l ) W c c o n c l u d c t h a t a c o m p u t c r i z c d d o s a g cp r e d i c t i o n p r o t o c o l t h a t ir-rcorporatcdbasclinc plasrna thcophyllinc conccntrations resulted in drar-r-raticimprovcmcnt in thc ability to achievc therapeutic plasr-r-ra t1-rcophyllinc conccntrations in ED paticnts.

111 lmpact of PortablePulse Oximetryon ArterialBlood Gas Analysis in an Urban EmergencyDepartment of CACofer,BB Hackman/Divisions AL Kellermann, S Joseph, of Tennessee, University andCardiology, Medicine Emergency Memohis Artcrial bloocl gas (ABG) analysis is onc of thc ten most costly cmcrgcncy dcpartmcnt tcsts bascd on cost times frequency ordcrcd. Portablc pulsc oxrmctry offcrs a simplc, noninvasive way to asscss oxygcn saturation, but rts impact on physrcian ABG testing and cluality of carc is unknown. For two months prcceding and two months following introduction of a protable pulsc oximeter in our tcaching ED, rcsidcnt physicians rccorded, for all ABGs, their rcason firr orclcring tht: test, primary patient problem, and planned managcmcnt 1n rcsponse to ABG results. Following introduction of oximctry, rcsidcnts wcrc also rcquired to obtain an oximetry rcading and attach it to each ABG rcquest that did not involve a cardiac or rcspiratory arrest. The only educational intervention offcrccl was a brief {fivc-minute) orientation to the use and limitations of pulsc oximetry. Case records werc subscquently-reviewed by one board-certified physician blindcd to visit date to determine thc perccntage of ABGs ordered during both periods that were indi-ated by explicit clinical criteria. Atotal of 2O,l20patientvisits wcrc notcd duiir-rg the four-month study pcriod. During the two months pnor to introduction of oximetry, ED resident physicrans orclcrcd (r95 ABGs, 436 (63% ) o{ which were indicated by American Collcge of Emergency Physicians or American College oI Physifollowing introduction of cians-criteria. During the two months 1 95% CI = 34% to 52%, P < oximetry, ABG usc decreascd by 43% .001). This differcnce was not explained by differences in total Datient vislts or case mix. Residents decreased their ordering of indicated ABGs by almost as great a degree as they reduced ordering of unindicated tcsts, suggesting they did not reliably distinguish between the two. However, decreased ABG test ordering was not associated with any serious adversc patient outcomcs. Basedon proiected totals, wc estimate that this device (which retails for $2,+so1 will decreasc laboratory charges in our ED by $95,000 per year. We conclude that portable pulse oximetry offers a highly cost effective way to decrease ABG test use without compromistng quality of carc.

109 Utility of Peak ExpiratoryFlow Rate in the Differentiationof Acute Dyspnea: PulmonaryEdema Disease Versus Obstructive/Bronchospastic of Pennsylvania, College D CionnilMedical RMMcNamara, Philadelphia I t o c c : r s i o n a l l yr n a y b c d i f f i c u l t i n t h e p r e h o s p i t a l o r c m o r g c n c y dcpartmcnt setting to distinguish thc ctiology of an acutc episodc o f r c s p i r a t o r y d i s t r e s s .T h i s s t u d y p r o s p c c t i v c l y e x a m i n e d t h c ' u s e f u l n c i s o f t h c a b s o l u t c p c a k e x p i r a t o r y f l o w r a t c ( P E F R )i n t h c c l i f fcrcntiation of acutc, moderatc-to-sevcrc dyspnca due to congestivo hcart failurc {CHF) with pulmonary cdcma from that sccond a r y t o o b s t r u c t i v e / b r o n c h o s p a s t i c l u n g d i s e a s c( O B L D ) . A d u l t E D paticnts, agc 30 or older, wcrc includcd if a PEFR was dctermincd pnor to pharrnacologic intcrvention and a data shcct was complctcd rcgarding their ED cvaluations. Only cprsodcs of dyspnea ihoueht duc to CHF or OBLD alonc at the time of hospital dischargc wcrc subiectcd to anaiysis. Statistical analysis uscd Fishcr's exact test or an unpaired t test when appropriatc. A total of 36 cprsodes ( O B L D , L Z j C H F , l 4 ) o { a c u t e , m o d e r a t e - t o - s e v c r ed y s p n e a i n 3 5 Datients met the entry criteria. Therc was no statistically signifiiant diffcrcnce betwcen the two groups rn agc, sex, race, and the prcsenting respiratory rate, hcart rate, mean artcrial blood pressurc, or thc presencc of diaphoresrs. Thc majority of the OBLD group ( l9 oI 22,86%) prcsented with wheezing; howcver, a 1ar5;epcrce-ntagc of thc CHF group {ten of 14,71%l also prescntedwith somc degrec of whcezing. The OBLD group was more likely to report taking bronchodilitors (91% vs 3(r%, 1' < .001)and less likely on a loop d i u r e t i c a n d / o r d i g o x i n { 1 4 % v s 5 7 % , P < . 0 1 ) .T h e m c a n a b s o l u t e

- 112 AspirationDuringManualLow'Frequency Jet Ventilation 40

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May22,23, and 24 GeneralSessionA: Chablis May22,23, and 24 GeneralSessionB: Burgundy May 24 -

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EMRA ResidentResearch Forum: Chablis

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Sheraton Grand Hotel FairbanksBallroom

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The SheratonGrand Hotelwill be the site of: May 22, OpeningReception:Bel Aire Ballroom May 22, FellowsDinner:FairbanksBallroom May 24and May 25, PosterSessionsll and lll: Del Mar, Monterey,La Jolla' May 25, GeneralSessionA: Bel Aire Ballroom GeneralSessionB: FairbanksBallroom(TerraceA-C) GeneralSessionC: FairbanksBallroom(TerraceD)

and Carmel

D M Y e a l y , M C P l e w a , J J R e e d , R M K a p l a n , K l l k h a n i p o u r ,R D StewarVUniversity of Pittsburgh Affiliated Residency in Emergency M e d i c i n e ;C e n t e r f o r E m e r g e n c y M e d r c i n eo f W e s t e r n P e n n s y l v a n i a ,P i t t s b u r g h High-frequency jet ventilation above 60 cycles/min has previously been demonstrated to protect from aspiration. The recommended O, driving pressure of 50 psi for manual low-frequency (20 cycles/min) jet ventilation commonly cxpels materials from the upper airway; however, the protective effects of manual percutancous translaryngeal jet ventilation against aspiration are unknown.

Seventeen anesthetized adult mongrel dogs (20 to 25 kg) were studied in 36 trials. Group 1 (Control) received no airway protection; group 2 (Tube) received ventilation by a cuffed, 1ow-pressure, high-vo1ume, 8.0-mm cndotracheal tube positroned 2 cm above the carina; group 3 (fet) received manual jet vcntilatron at a ratc oI 2O cycles/min, I:E ratio of 1:2 and O, driving pressureof 50 psi by a percutaneous l3-gauge cannula. Half the trials were performcd at 30 degreesand half at 45 degrees of head elevation. An I BF catheter placed under direct visualization into the proximal airway I to 2 cm below the cords (vet above thc tube cuf{ or cannula tioi was used to instill 250 mg Gastrograffin'" into the trachea over fivi minutes. An anteropostenor chest radiograph was obtaincd to documcnt prcsence and degree of aspiration {on a 0 to 3 scale) and was rcvicwcd by a radiologist blinded to the experimental manipulations. At 30 degreeselevation, none of six fet and none of six Tube anirnals had radiographic evidence of aspiration (scores of 0), while six of six Control animals had moderate-to-scverc aspiration (scores of 2 to 3). At 45 degrees elevation, none of six Tube aminals had evidence of aspiration (score of 0), four of six |et anrmals showcd mild aspiration (scores of 1), and six of six Control anrmals showcd severe aspiration {scores of 3). When compared with thc Control group, both the Tube and the fet groups demonstrated signficantly Iess aspiration at 30 and 45 degrees lP = .0O2).We conclude that in our model standard manual low-frequency jet ventilation at 30 degreeshead elevatron was associated with a low risk of aspiration, comparable to that obserued with a cuffed endotrachcal tubc, with increased risk of aspiration at greater head elevations.

prompt diagnosis and treatment of rnjuries that might otherwise be delayed. However, we conclude that for patients with injuries of low severity treated in this manner, care is more costly and labor intensive than for patients of similar injury severity who are not intubated. These patients, as a group, are younger and more likely to be legally intoxicated.

'114 Value End-Tidal of CO^Measurementin the Detectionof EsophageallfitubationDuring Cardiac Arrest AJ Sayah,WF Peacock, DTOverton/Department of Emergency Medicine, William Beaumont Hospital, RoyalOak,Michigan M c a s u r e m e n t o f e n d - t i d a l C O , ( E T C O -, li nh a s b e e n u s e d t o d e t e c t inadvcrtent esophagealtube placement paticnts with intact hemodynamics, but has not been studied during cardiac arrest.

This study sought to determrne if ETCO, measurement could d r s t i n g u i s h t r a c h c a l f r o m c s o p h a g c a lt u b e p l a c e m e n t d u r i n g c l o s c d c h e s t m a s s a g e .T w e l v e l a r g e d o g s ( a v c r a g ew e i g h t , 2 3 . 5 k g ) w c r c anesthetized using 25 mg/kg pentobarbital. Endotracheal tubes w c r c p l a c e d i n t h e t r a c h e a a n d e s o p h a g u s .P l a c e m e n t w a s v e r i f i e d by fibcroptic cndoscopy. Bilateral femoral artery lincs were inserted.Ventilation was performed during the prearrest phase through the trachcal tube, using a tidal volume of 15 rng/kg. Ventricular fibrillation was induced using a (rO-Hz dischargc through a right vcntricular pacemakcr. After four minutcs of arrcst, closed-chest m a s s a g cw a s i n i t i a t c d a t ( r 0 c / m i n u s i n g a M i c h i g a n I n s t r u m c n t s Thumper-, and continucd for 20 minutes. The dogs wcrc dividcd into two groups. Group A had tracheal ventilation; group B, esophageal ventrlation. Unused tubcs wcrc rcmoved. ETCO, was continuously rccordcd beginnrng two lllinutcs prior to arrcst.

A r t e r i a l b l o o d g a s c sw e r e o b t a i n e d o n c m i n u t c p r i o r t o a r r e s t , a n d o n c , f i v c , a n d 2 0 m i n u t e s a f t e r c l o s e d - c h e s tm a s s a g cw a s i n i t i a t e d .

Groups wcre comparedusing the Mann-Whitney U test.There was no significant differcnce betwcen the groups mean artcrial pressurc, weight, blood loss, IV fluid volume, or prearrcst arterial blood gases.,ETCO, diffcrcds,ignificantly between the groups thro_ughout c l o s c d - c h c s t r n a s s a g e( P < . 0 0 1 ) .I n g r o u p A , E T C O , r a n g e d f r o m l 4 t o 3 4 ( a v c r a g c ,2 I ) . I n g r o u p B , E T C O , r a n g e d f r o m 2 t o l l m m H g { a v c r a g c ,5 ) . M e a s u r e m e n t o f E T C O , c a n r c l i a h l y d i s t i n g u i s h c s o phageal from trachcal tubc placemenl during closed-chcst massage ln oogs.

- 113Emergency Intubationin the Uncooperative Trauma Patient JJ Kuchinski,GH Tinkoff, M Rhodes,JW BecherJrlHospitalof the Philadelphia Medicine,LehighValley Collegeof Osteopathic HospitalCenter,Allentown,Pennsylvania Emergencyintubation for sedationand paralysisof agrtated,uncooperativemultiple trauma patientsis beingusedin many trauma centersand emergencydepartments.The records of all traurna admissionsrequiring emergencyintubation during resuscitation were reviewedfor the l8-month period from fanuary 1987to fune 1988.Patientswith unambiguousdocumentationof intubation for reasonsof agitation and combativenesswere divided into high injury severrty{HIS)and low injury severity {LIS)subgroupsusing admissionTrauma Score(TS)and Injury SeverityScore{ISS).HIS = TS < 13 or ISS) 16 and LIS : TS > 13 and ISS < 16. Fifty-seven patientswere intubatedprimarily for agitationand combativeness; of these,38 |,70%)were classi{iedasHIS and 19 ,.30%las LIS by our criteria.All 38 HIS patientshad significantinjuries diagnosedafter intubation and paralysis,requiring further intervention. The HIS grouphad a meanageof 3 1, meanISSof 25, and meanlength of stay ILOS)of 20.5 days.Mortality was9o/".The mean hospital cost was $24,794,and a mean of 12.7 hours per day in nursing care was required. To determine the rmpact intubation had on trauma paiientswith low injury severityl the LIS subgroupwas compared with a similar group o{ randomly selectedunintubated trauma patientswith TS of more than 13and ISSof lessthan l6 in the same study period. The only mortality in these two groupsoccurredin the intubatedgroup.The causeof deathwas CNS anoxiadue to an esophageal intubation. Thesegroupswere analyzedfor statistically significantdifferences{P < .05)in age,LOS,hospital cost,hours per day of nursing care,and percent of patients with an ETOH level above100 mg%.

- 115CoreTemperature Measurement in Hypovolemic Resuscitation

n rS/,ssli3l,n.o. ill,lilln 8i3llo iJ."ff"

lntubated 19 15/9 Unintubated 32 1617 P < .05by Robuslt test.

P < 0.05by chi-square analysis.

23.4 31.0

6.3 5.6

1O.4 5.9

7,150 3.456

58 19

For the majority of uncooperative,agitatedmultiple trauma patients,emergencyintubation with paralysisand sedational1owsfor

45

RW Nicholson, KV lserson/Section of Emergency Medicine, U n i v e r s i t yo f A r i z o n a , T u c s o n A c c u r a t c c o r c t e m p er a t u r c m c a s u r c m c n t i n s e v e r c l y h y povolcmrc patients can be difficult to achievc.Currcntly, although both tympanic membrane and central venous tempcratures are said to rcflect corc temperature in relatively stable patients, it is unclear whether this is applicable to thc acutely hypovolemic paticnt undergoing rcsuscitation. A dog model was used to determinc a convcnicnt method of measuring core temperature during the rcsuscitativc phasc of hypovolcmia and thc accuracy of multrple sources of temperature measurement. Adult anesthesizcd greyhound dogs had thcrmistor probes placcd for continuous tcmperature monitoring in thc brain, central vcin, tympanic membrane, bladder, rectum, esophagus, and subcutancous tissue.

The dogs were rapidly bled to 65% of thcir initial rntravascular volume. After a period of delay, and in a stepwise manner, they received an autologous transfusion that had bcen cooled to 7 C. Scrial tempcraturc rcadings wcre taken during a baseline and 60minute posttransfusion period. The readings werc analyzed using Pearson's correlation coefficient. Brain temperatures correlated very highly with those in the tympanic membrane throughout the a n r m a l ' s c o u r s e { r = . 9 4 3 i P < . 0 0 0 5 ) .R e c t a l ( r = . 9 O 6 jP < . 0 0 0 5 ) a n d b l a d d e r ( r = . 8 3 6 ; P < . 0 0 0 5 )t e m p e r a t u r e s a l s o c o r r e l a t e d w e l l w i t h brain tempcratures. Central venous system, however, correlated poorly with temperatures at a1l other sites, reflective of the marked swings in intravascular temperature caused by cold transfusions.

These wide variations were damped at the other sites. Because intravascular hypothermra appears to be the source of the arrhythmias and hemostatic abnormalrties often seen during the resuscitation of acutely hypovolemic patients, this may be the most accurate site for core temperature measurement. However, because after the initial resuscitation organ temperatures are of prime importance, tympanic membrane temperatures are the most useful source of core temperature in these patients.

'1 16 Exsanguination CardiacArrestin Doos: Pathophysiotogy of Dying

rate, cardia.c index, mean arterial pressure (MAp), left ventricular stroke.work, heart rate, and systemic vascular resrstance.

Norep_ SA Tisherman,P Safar, F Steiz, y Leonov,K Oku, W Stezoski/ rnepnnne caused a transient increase in systemic blood pressuri.

InternationalResuscitationResearchCenterand Departments At injection, MAP was 51 + 3 mm Hg. MAp peaked of i.O t 0.3 Ane_sthesiology and Surgery,Universityof pittsburgh minutes after iniectron iMAp, l9J ,r 6 mlrr Hg). Duration of action Exsanguination cardiacarrcst/common in trau-ma,hasreceived was bnet, wrth MAp returning to control levels by five . minutes. little attcntion.previousstudiesusedbarbituratcancsthcsia; The group NE showe how_ d a corresponding increrse irr Lmorrhage rate study, N,O-halothaneanesthesiawas used.r" f7 Jogr, with the increase in MAp; ho*.oei, total hemorrhug" :.i.,.1 lTllght ll" anesthesia, u-oirr;. under during spontaneous adjusted for weight was significantly lower in ttre Nf gr6up breathingof air, heill {33 t 2 orrhagewas initiatcd by an aortic catheter.Mean artirial prcssure mL/kg) compared with the controls {42 t 5 ml/kg) (p < .bl ). Survival {MA^PIto 5,! mm Hg in 6Z 145_seconds, and to lessthan 25.;; Fi; time was similar in both groups, (5g t 9 minutes*for controls versus in 100 + 4(rseconds.

Carotidflow decreased . 5 6r I I m i n u t c s f o r N E l . T h e r e w e r e n o s t a t i s t r c a l l y s i g n i f i c a n t rapidly,U"t p"r.i.t"8 dif_ until mcanartcrralpressure waslessthan l0 mm Hg. pulselessness t e r c n c c s t o r c a r d i a c i n d e x , M A p , l e { t v e n t r i c u l a r stroke work, crccurrcd at 6.2 + 3 minutes with blood lossof g0 t S mf,7kg.EfC systemic vascular resistance, or heart rate when compared over bccamedepressedat MAp.50 mm Hg. After brielhyperventilation timc. While NE increased MAp in this model, tt. i,ff.ct *r, in^eightof 14dogs,tidal volume dccrJased,and apneaoccured transitory; no sustained effect on systemic vascular resistance was at 6..5 + 3 minutes,srmultaneous with EEGsilenceandMAf of f Omm Ug notcd._Despite similar survival times, those animals,...i_"! fe or lcss without pulsations(clinical death).Heart ratc initially had a lower total hcmorrhage volume compared *ith "orrtro'i. ,i increased andthen slowedin all dogs.ECGactivity contlnucdwith dcath. This may indicate ihat NE had a'deleterious effect on bradycardia for 30 or more minutes during pulseiessness {electro_ t o l e r a n c c r , h e m o r r h a g i c s h o c k . A d d i t i o n a r s i u J i e s d e l i n e a t i n s mechanicaldissociation)in all dogs;i,nc'ievelopedrpo.rt".r"o.,, thcsc mcchanisms and the effects of continuous inf usions purE of ventricularfibrillation.At pulseleisncss, paO, was aboveS0 mm alpha-adrenergic agonists are needed.

Hg; PaCO,,26 ! tZ mm.Hg; pHa,7.4r 0.1,and BD, ti.3t 4.2 mEq/ L. Hcmatdcritdccreased troi qzx6y" to 38t gZ. in 12of la ;&;; an agonalattcmptat sclf-rcsuscitation (gasps with ticlalvolurne35d to 600,incrcascdECG frequency,no inCicisedMAp) occurrcdafter two to 7.5 minutcs of clinical dcath.Dcath in exsanguination is with clcctomechanical dissociation,rcsultingfrom hypovolcmic hypotcnsion,not hypoventilation,[rypoxc-i", o, acidcmia.

The agonatstatemay explain "miraculous"recovcries.

'1 17 Exsanguination VersusVentricular Fibrillation CardiacArrestin Dogs:Comparison of Neurologic Outcome- preliminalyData

SA Tisherman,P Safar,F Sterz,y Leonov,K Oku, W Stezoski/ InternationalResuscitationResearchCenterand Departments of Anesthesiology and Surgery,Universitv of pittsburoh jrrest is limiicrl by Ncurologic recoveryfrom_cardiac thc postre_ syndromc,includingprolongcdmultifocalccrclr.alhy_ :lscitatign popcrruslonand bl(x)ddcrangcmcnts from stasis.we hypothesizc that bloodlcssischcmia,as in exsanguination (EX),is bciter toler_ atcdthan nonnovolcmicvcntricularfibrillation(VF)cardiacarrcst of the samcduration.In l2 dogs,outcomc*as comparedu.ing ,iui dog modelsof VF cardiacarrest 12.5minutes and EX cardiacarrest (six).EX involvedrapidaortichcmorrhageof two mrnutcs ro mean artcrialprcssurelcssthan 25 mm Hg, andthen VF by electricshock.

Cardiacarrestno flow was 11.5 minutcs lzere 6r I2.5 minutcs (thrcc).Rcsuscitationwas with cardiopulmonary bypass(CpB)for fivc minutosdefibrillation,intcrmittent positivcpressurevcntila_ tion to 20 hours,and intcnsivecare,72 to 96 hnr:ir. Outcomcwas cvaluatcdas<lverallperformance categorics (OpC l, bcst;S,wo.g and ncurotogrcdcficit sc_orcs {NDS 0,.bcst;100,worst).pupillary light reflexrcturnedin l5 minutesor'ressin all animari.continuous EEGactivity returncdcarlicrin thc VF group(36t 20 minutes vs 52 1.12rninutes).All VF dogsachicvedOpC j. One EX dogafter CA no flow of I I ..5minutes wai OpC Z. The other five EX dod;;;; OPC 3. BestNDSs weresimilar 136t2.S% afterVF and 31 1 6.g% after EX).Histologically, the quantity ancldistribution of ischemic neuronalchangeswerc the sarre. The results of this study do not support the hypothesis that EX is better tolerated. N";."l.gi; outcome may not be affectedby the presenccor absenceof blo"od statisduring ischemia.

-118

I

f{qlspinephrine in Hemorrhagic Shock ll Van Ligten,GM Messick,R Neumai J Hoekstra,CG Brown/ Divisionof EmergencyMedicine,The OhioStateUniversity, Columbus A hallmark of irreversible hemorrhagic shock is inabilitv to maintain systemicvascularresistance.Our hypothesiswas that an alpha-adrenergic agonistgiven during he-orihag. would enhance systemic vascularresistance,maintain vital organperfusion,and -oi nrolone survival. We studied the effects nbrepinephrine 1-h_r1q (NE),ql alpha-1,2beta-l-adrenergicagonist,in the early r.rrrr"ir"_ tio-nof hemorrhagicshock. Ten acutely splenectomizedswine g {I to 24 kg)^were hemorrhagedthrough a caroiid artery catheter(l mm ID x 300 mm L). After 25 minutes of uncontrolled continuous hemorrhagg,a singlebolus of IV NE (0.16mg/kg) was given to five animals. The other five animals served ast-'cJntrols.Data were collectedevery ten minutes until death and included hemorrhage

46

119 lsosolute Comparison of Intraosseous NaCl/Golo Dextran 70{, (HSD) to lntraosseous 0.9% Normal Saline in a Hemorrhagic Shock Model J.4 Marx,L Hanson,EE Moore,CE Wade, D Bar-Or/Departments of EmergencyMedicineand Surgery,DenverGeneril Hospital; Universityof ColoradoHealthSciencesCenter,Denver;Letterman Army Institute of Research,Divisionof MilitaryTrauma,San Francisco, California Wc mcasuredthe efficacyof N aCI6% Dextran 20,-, (HSD)deliv_ crcdby the intraosscousroute in the resuscitationof li.-;;rh;i. shock.Hampshirepiglets (20 to 30 kg) were anesthetizedwitht% hatothancby conemask and bled to a meanarterialpressure of30 mm Hg. Intraosseousadministration_was by an 1B-gauge spinal ncedlein a proximal hind iimb tibia. The animalswerJran?omized to rcceive isosolute measurcsof HSD (a mg/kg, n=5) or normai saline(33.3mg/kg,n=5)under300mm Hg pr.ir"?.. Hemodynamic ano lnetabollc parameterswere determinedevery l5 and 30 min_ utes/ respectivelyfor 150 minutes following institution of hemor_ rhage.Data (X 1 SEMwere.analyzedbyunpairedr testsandanalysis of variance.Intraosseousdelivery of HSD'was accomplishedin'6.4 * 1.5 versus37.2 L Z.4 minutes for normal sallni (p < .001).

Hemodynamicvariables,including mean arterial pressure,pulmo_ nary capillary wedgepressure,sysiemic vasculariesistanceindex, cardraclndex/and left ventricularstrokework index (LVSWI),were not statisricallydiffercnt at baselineor during the intervals of h_cmorrhage, rcsuscitation,and observation.LVSWTwas greaterrn the HSD group during the initial B0 minutes of resuscitationbut not to a significant level. Metabolic indices including serumpH and lactate,hematoc.rit,oxygen delivery,and oxygenconsumptron were not^statistically dif{erjnt between the two groups at any Serum sodium (149.6t 2.0 mEqlL), osmoLlitylsil;-i lnjl.url; 4.51,and dexrran 1403.9! 87.0) peaked30 minutes following administration of HSD at 6.0 t 0..3mEq/L, 16.81 0.8 mOsm/Liand 3!2.9 t 30.4 mg/dl abovebaseline,reipectively. f" , h.-o|ih"lt. shock model, intraosseousinfusion of gSO'achieved fr.*oa'y_ namic and metabolic improvement comparableto an isosoluie dellvery of NS. Egressof Dextran,D from the intraosseouscomDartment was unimpeded.

120RapidCorrectionof SevereHyponatremia Resultsin Myelinolysis,BrainproteinOxidaiibn,and AlteredBlood Chemistries HS Mickel,PE Starke-Reed,CN Oliver/Laboratory of Experimental Neuropathology, NationalInstituteof NeurologicaiDisoroersano Stroke;Laboratoryof Biochemistry,NationalFeart, Lung,and Blood Institute,NationalInstitutesof Health,Bethesda,Maryland Biochemicalchangeswere studiedin the brain and blo;d of rats undergoingrapid correctionof severehyponatremia.Myelinolysis has been demonstratedto occur in the lateral corpusstriatum, external capsuie,thalamus, as well as other sites in the rat brain within-four days following rapid correction of severehyponatre_ mia. _Using the rat model oJ electrolyte_inducedmyelinolysis, blood was collectedfrom six hyponatremic rats, 1l rais on d,iy I', five rats on days2 or 3, and_1S,on day 4 following ,rpid correction.

Marked elevarion of blood cholesterol *", ,.I.n Ly day 1 and maintained throughout day 4. By day 4 after coffection, total

protein, albumin, globulin, calcium, phosphorus, uric acid, and creatrnine, were,all significantly elcvaied over thc hypnnrt."rrri. varues, whrle the serum. iron levcl was signtfrcantiy reduced.

Soluble.brain protern oxiclation was studiecl ""ri"! tf.,. i,+ ai"iii"_ phenyl-hydrazine method.for assay uf prnt"in Er.lunyt !r,rupr. oxidation o{ proteins frorn brains *.." rtl.ri.d in rour contror rats, two rats on day l, onc rat on day 2, and four rats on day + "f,"i ."pij correction of hyponatrcn-ria. A significant incrcase in oxidiiccl D r a l np r o t e l n s w a s o b s e r v e da f t e r r a p i d c o r r c c t i o n . C o n t r o l animals h a d 5 . 6 + 0 . 2 ( . S E M )n m o l s c a r b o n y l g r o u p s p e r i n g solublc brarn p r o t e i n . O n e d a y a f t c r c o r r c c t i c t . r ,n . , i n - r " l s h a c l g . q t 2.7 (SEM) protein, | < .03. One animal two days alter corrcction lm,cyls/mS n a . od . z _ n . r r o l s / m gp r o t c r n . A n i r n a l s f o u r d a y s a f t c r correction hacl 9 - I t l . l { S E M ) n r n o l s / m g p r o t c i n , p < . 0 O 6 .A s i g n i f i c a n t oxidativc strcss is demonstrated to occur in the brarn ftillowing thc rapiJ c . r sf r . v c r c h y p o n a t r c m i a . T h c c el l u l a r m . c h r n i r _ s p ' i u _ :o:ul lc: -r.nj lgi l " t h l s ( ) x t d a t t v cs t r e s sa r c n o t y c t c l u c r d a t c d , b u t c u r r c n t work i s f o c u s i r - r go n w h e t h e r t h c a s s o c r a t r t l r n y c l i n o i y s i s rcsults from myelin protcin and lipid oxithtirrn and pe.roxi.laiion.

.121

Cardiovascularand NeurohumoralResponses FollowingBurn lnjury RLCrum.W Dominic, J Hansbrough, MRBrown/Departments of Surgery andMedicine, Unrversity o-fCalifornia, San-biego, Medical Center

Wc reccntly demonstratccl changcs in thc ncurohurnural rc_ sponsc t() bur' inirry that rnay irnpair cartli.vascnlar functi.'.

L a r L l t o v a s c u l a rl u n c t i o n a n c l n c u r o h u m o r a l r c s p o n s c wcrc cvaluatcd in 12 paticnts ovcr a fivc-day pcriod follt,wing,30,Z, to 66,1, burn injury. Hcart r:ltc, r-r-reanaiterial p."rr|-,r. {MAlr), ccntral vcnous prcsslrrc, pulmonary capillary wcdgc prcssurc, cartliac olltplrt/ systcmic vascular rcsist:lncc, and str.lc v.luntc wcre r c c o r c l c d .P l a s m a l c v c l s o f a r - r g i o t c n s i i * I I ( A _ l l ) , a t r i a l natriurctic v a s o p r c s sni , n e u r ( , p c p r i ( l cy { N p y ) , r r , , r q , n i . 1 , hr i n e 1N E ) , al i nl ,ri tdc.p. lr n c p h r i n ( .w c r e I n e i r s L r r e d( ). n . r h c r l l y , r [ [ r L r r rur ] t r r r y ,\ y : _ tcmic vascular rcsistancc was clcvated, anil strokc volr.rmc antl cardiac output wcrc krw. Systcrnic v,rscular rcsistancc, strrkc antl cartliac t,ntput nirrmalizccl by clay a,--.r""..il 1..,y .t,rf I,lJlll.l 5 . w l t n o u t c h a n g c si n c e n t _ r l lv L - n ( ) r t s l ) r e s s t r r co r n t r l r r r o r r ; r rc/r r p i l ' _ lary wcdgc prcssurcr MAp antr hcart rate ditr rot crrangc.vJs.p r c s s r n / ,A - l I , 1 , 1 F ,a n d c p i n e p h r i n c l c v c l s i n p l a s m a w c r c ,Npy, c l c v a t c c lo n d d m l s s i r ) n . v a s . p r c s s i n l c v c l s w c r c c l c v : i t c d 50 ti'rcs normal on admission and rcturncd to normal by clays4 ancl i P l a s m : ra r t c r i a l n a t n u r c t i c p c p t i c l c l c v c l s w c r c n r i r m a l on aclmis_ sion and incrcasccl on clays 3 to 5. Thc rcciproc:rl r"lati,,n.ship bctwccn systcrnic vascular rcsistancc ,r,J-;:;li;. olrtput ancl bctwccn vasoprcssinand atrial natriuroti; p"pii,i"-.,,.."1"tc with r'achother follrwing burn injury a,rd ,cs,-,stiiation.

Wc concludc t n a t i l r c c l c v : t t r o n o f p l a s m a v a s o p r c s s i nl c v c l s m a y contrilllltc to tnc rncrcasc(l systcrtric vascular rcsponsc :rnd clccrc:rscd carcliac output and conrractility aftcr burn injury. Aclministration of an A vl, v I rcccpror antagonist to burn injurcd paticnts will bc uscd to tcst thts hypothcsis.

of Neutrophitia in AfebriteEtderty !2?.TheSignificance Patients EA Michelson, KR Shanabrook, C Moore, M Schneider/Montefiore H o s p i t a l ;U n i v e r s r t yo f p i t t s b u r g h leukocytosis occurs in rcsponse to infcction as ,Ncutrophilic w c l t a s o t h c r p h y s i o J o g i cs t r e s s e s .W h r l c y r r r r n g e r n i l t i r , l r r s( ) l t e r . l n a v c l c v e r a s s o c i a t e dw i t h s i g n i f i c a n t i n f c c t i o n . thi cldcrly rnay r r s p o n s c . F r o m p a t i . . " nt s p r . r . n , i r a , , , u r r ' r r l u n t c a c hing l -o1s. ]p: ll rl 'a: l n cmer$ency department, I00 paticnts ovcr age 65 wcrc prospectivcly idcntified as having tutai WBC above 10k and tcm_ pcraturc less than 50 C. Follow.-up was obtarned from inpaticnt charts of patients and by phone inf"r"i.u{ .li.chrr;;J -admitted patrents. Ninty-six patients had-completc records, thc average agc was 7[3,thc mean WBC was. 13.9; l6 patients had total ncutropliii

than ti,000,and werc"ril.,dc,l fru,r,f.irihe,nrrty.ir. :?:l!: 1:r.p c r c c n r s i r hn c u r r o p h i lw i ae r ea d m i r r e 4 d r, r !t oqt1htcff;I,o*o r a n d 2 o f p a t i c n tw

I a t l m i t t c d o r r r a n s f c r r e di o a n I C U . T w e n r y S r v ( . n { 3 4 % ) h a d a n i n f e c t i o n i d c n t i f i e d , b u t o n i y 5 2 o / ow e r e i d c n t i f t e d i n the ED. In absence of an infectious etiology, -rr-,y pnri"r-,,. still had s i g n i f i c a n t d i s c a s e .T h e s e i n c l u d t d l 4 lI'i"k) witir'acute cardiopul_ monary diseasc, and 19 124%)with other significant known causes or ncutrophrlta; all but one of thesepatients werc admittcd.

Of the I 7 rernaining patients, I I had sevrre pain as the only cause ol thcir neutrophilia and 82% were admittc j. No t tiology lor neutophilia was identificd in six patients; howcver, threJ'were adrnitted.

41

Among paticnts with infection, the diagnosis was apparent on c h e s t r a d r o g r a p hi n 3 0 7 o ; u r i n a l y s i s , ( t 3 , % i i r l o o dc u l t u r c s , ' L t % , Jf; tissuc cxamination, 15,o/.1 sputum a\one, 7ok. Ainong'dis_ ^ a n d charged patients, two (lg%) weie subsequenily iound to have significant pathology; f.ur (3(r%) could not be contactcd aftcr muttlplc attcmpts. Wc concluJc.that nultrophilia in thc cldcrly a f c b r i l c E D p a t i c n t i d e n t r f i r , s a h _ i g h _ r i s kp u p r l r t i u , - , .

Thcsc pa'_ t l e n t s m c r i t c a r c f u l w o r k r - r p{ o r i n f e c t i c l u s a s w c l l a s other serious c l i s c a s c ,i d e a l l y i n a n i n p a t i c n t s c t t i n g .

123 Oral Labetalol Versus Oral Nifedipine in Hypertensive Urgencies lltcOon.a.!a, DM yealy, S Jacobson/Division of Emergency !,1 Medicine,University of pittsburgh AffiliatedResidencyin EmergencyMedicine;Sectionof EmergencyMedicine,Hospital of pittsbuigh the University of Pennsylvania. r nc.pv_rn hypertcnsivcurgencicshasbccn n'ruchdcbatcd ancl cornplicatcd by thc sidccffcctsof availablcagcnts.In a prospcctivc, randor.nizcd, opcn-labclstudy, wc .,,,-,rpnr",i thc usc in thc cncr_ gcncydcpartnrcntof rral labctar.l,an alpha-bcta brockcr,with rlral nifcdipincin hypcrtcnsivcurgcncics.paticntswith diast.lic bloriJ llrcssllrcs{DBP).vcr 120 r.nmHg wh. did n.t havc crrrcrrat.r:r

llV|!rten\rv( cnlLrgenev Wr.rc r-liHihlu.Thc Jrtrgs w U r u g , l v ( n i l . ti l l { r ; l ( l i l l Al ; l s l I ( ' n w t t h r i r r s l 5 - r n . , t r r r r r n g b i r s e J o n thcir rr,5p(.ctiVr phanlacokinctics untrl :t Dllp of I l0 nrg Hg was obtaincd. Eithcr

labctakrl 200.'g initially and a rcpcat a,ir",ii roo t.200 r . n ga t t w . h o u r s . c l c p c n d i n go n t h c D B p , o r n i f " d i p i n " f O n r g f r l t . a r . r cslw a l l o w ev c r y h o u r t o a t o t a l d o s c o f 2 0 n t g w a s g i v c n . A c l c q u a t c control w:ls d c fi n c d a s a I ) l l P . f I I 0 m n r H g a c l l i c v c c i . v . r " lr.riud n,,, "".""ai,ig f o u r . h o u r s .T c n p a t i c n t s w c r e c n r o l l c d i n c a c h g r o t r p ; thcrc was nri signiiicant cliffcrcncc in age, scx, racc, or i..,i.t<iry,,f previous h y p c r t c n s i o n . O f t h c 2 0 p a t i c r - r t r ,l 1 3r c s l - u r r r t l cw d itli no signficairi d i f f c r c _ n c cb c t w c e n g r o L l [ s .T h c n r c a r rt i m c t . c ' r - r t r . l w i t h I:ibctaLrl w l s 6 2 . 5 m i n u t c s , a n d w i t h n i f c d i p i n c w a s ( r 0 . 0n t i n u t c s {p = NS).

T h c n r c a n _ p r r c t r c a t n r c l pt tr c s s l r r ef t l r l a b c t a l o l w a s I 9 5 / I 2 2 , . , . , n , ig a n d f r r r . n i f c d i p i n cw a s j ( ) g l l } g n r m H g {p = NS), which clecrcasci t o J n i ff t c r . t r c J r n t . c n t , p r . e . s s l lfrocr l a b c i a i o l o f l 5 4 l l O { ) nrnt Hg and I o r 1 1 ; . 1 . . 1 | [ rr, r f" 1 6 , 3 / l f X r) r r l H g ( p = N S ) . T h c r . n c a n d c c r c : i s ct n s y s t rr lr c / t l i r r s t o l r eh l o o t l p r c s s r l r cw t r s 4 2 . 6 2 6 . 5 r r r . nH g witI labcta_ f t r ) ti l n d , J 4 . 9 / 2 8 , .n4t n r H g w i t h n i f c d i p i n c ( p = N S ) . M c a n p u l s e ratc ( l u r r e a s c ( ls t x l ) t d t s l)er utiltutc with labctalol and Ono bcat pcr n l i n u t c w i t h n i f c d i p i n c { 1 ,= N S ) . T l r c r l c r n c l o s co f l a b c t a k r l was 2 1 2 n r g .a r r t l l 2 r n g w i t h n i f c d i p i r - r c w , ith thc rlctlian dosc of I i l h c t dt () l h r i . g 2 0 0 ; r r r r ln i f c c l i p i ' c l 0 n t g . N . s i g n r f i c a n t sidc cffccts o c c u r r c t l w j t h c i t h c r d r u g . W c c o n c l . , c i ct h a t r l i a l l u l r " t r , l . , l giu..-. s ' r . . t h r c t l u c t i . r . r i r - rb l . . d p r c s s L r r co v c r : l n a c c c p t a b l c p c r i . d 'f t i r . r cf . r E l ) u s c a ' c l i s a n a r t i r n a t i v c t . . r a l n i f c d i p i n c i'riypcrtcnsivc urgcncics.

'124 CardiovascularSide Effects of Emergency lntravenousPhenytoinAdministration PJ Donovanlleritage Hospital, Tarboro, NorthCaroilna

E r r c r g u n c vI V p h c ' y t . i n a d r r i n i s t r a t i . n i s a w e l r - c s t a b l i s h c d , t n c r : t p y l ( J rp : l t i u l t t s w i t h a c l l t c r c p o t i t t v c s c i z u r c sa n d / o r status cp_ i l c p t i c u s . P r c v i o r . r ss t u d i c s s r - r g g c stth a t c . r r t i n u , , u r ' t V inf.,riun uf p h c r - r y t o i na c h i c . v c sr a p i d t h c r i p c u t i c l c v c l s w i t h m i n i m a l .u.rlpli_ c e t i o n s . R a t e so f p h r . n y t o i n i n f u s i o n v a r y a n d r i s k s t o p a t i c n t s with K n { r w n c : l r L l t o v a s c u l a rd i s c a s c l r a v c n < t t b c c n a s s c s s c c l .

Forty_two w e r e . cvllu;rtctj prospcctivcly to stucly thc carcliclvascular Firtirnts s - l d L ' e t t u c t st r l l 5 m g / l < g o f p h c n y t o i n b y c o n t i n u o u s i V infusion.

P a t i e n t s , w t ' r ut l i v i J , . d ,g r o u p I c o n s i s r U rol I p a t r e n t s j e s s tiran 5(J v c d f s o l d w t t h ( ) u l J l h c f ( r s c l L . r o t ihct . i t f t r l l s t . i t s r . ; F r { , U p2 c r r n s i s t t . r l t h a n 5 0 ,v c a r s o l d . o r a n v i n d i v i i l i i a l w i t h a h i s t o r y : lt a f :t1hlci 'r' ]o"s c1l t' r"or ct i c o h c a r t d i s c a s c .I n f u s i o n r a t c s w e r c 5 0 r n g / m i n a n i 2s ruspccrivlly. paticnts 3 t x / r n 1 1 , e x p e r i c n c i n gb r a c l y c a i d i a ,s e c _ r)nrt- {rr thlrd-d(grr( hcart block, _ hypotcnsion, or aicohol with_ drawal scizurcs wcrc cxcludcd. Cardiac rhythin strips ancl vital s i g r - t sw c r c o b t a i n c d b c f o r e t r e a t m c n t a n c l a t l 5 _ r n i n u t e intcrvals u n t i l o n c h o u r a f t c r i n f u s i o n . N o p a t i e n t i n g r o u p I ( 2 6 )c x p c r i e n c e d bradycardra, hypotcnsion, or.widcnrng ni'qnt ciunng inlusion.

T w o p a t i c n t s i n g r o u p 2 ( 1 ( r )b c c a n r e [ y p o t e n s i v c ( s y s i o l i c blooJ pressurr . 100 nrrn Hg) during infusion, ind one of thesc patient; j u n c t r o n a l c l e v r - l . p c da rhyth'-r at a ratc of 50. Thcse sidc effccts rcsolvedwithin onc hour after infusion. No patients dcvclopcd sei_ zurcs after phcnytoin adrninistration and blood rcvcrs werc therapcutic. Sclectivc administration rates of phenytoin, brr.d orr rgl a n d .h i s t o r y o f a t h e r o s c l e r o t i c h c a r t d i s e a s ca r " . f l i . " . i u r l r , snf., n.d without significant cardiovascularside cffects.

125 SupraventricularTachyarrhythmiasand RateRelatedHypotension:CardiovascularEffectsand Efficacy of Intravenous Verapamil BEHaynes, JT Niemann, KS HaynesiUOLA Schoolof Medicine; theDepartment of Emergency Medicine, Harbor-UCLA Medical Torrance, Center, California

infusion over l5 minutes prior to the painful procedure. Vital signs and alertness scale were performed prior to analgesia, after analgesia, and at 15, 30, 45, 60,90,120, 150, 180, 210, and240 minutes after the procedure. Values from all time intervals were compared with bascline using Duncan's tcst for multiple comparisons. The mean dosc of meperidine was 2.5 rng/kg (173 mg). Although there were statistically significant differences in all parameters between baseline and analgesra, there was little clinical significance in the diffferences. Mean respiratory rate was nevcr lower than l7 breaths per minutc, and mean systolic blood pressure was nevcr below 122 mm Hg. The nadir in pulse rate was 72 bcats per minute. The lowest respirtory rate at any time in any patient was ren, and no patient rcquired ventilatory assistancc or reversal with a narcotic antagonist. No patient required fluids or drug treatment for hypotension or bradycardia. Although paticnts were notably sedated, the lowest l e v e l o f a l e r t n e s si n a n y p a t i e n t w a s l 0 o u t o f 2 5 ( 0 , u n r e s p o n s i v e , 25, totally alert). A11patients wcre safely dischargcd after the fourhour observation, and a follow-up visit in 24 to 72 hours in all patients rcvcalcd no significant late side cffects. We conclude that high-dose narcotic analgesia can be safely givcn in the ED prior to painful procedurcs without untoward stde cffects.

Intravenous vcrapamil is the pre{erred agent for the acutc managcmcnt of supraventricular tachyarrhyhmias lSVT) in the absence of contraindications to its usc. SVT complicated by hypotension has been considered a contraindication; howcver, the efficacy of IV v e r a p a m i l i n t h c m a n a g c m e n t o f r a t e - r e l a t e dh y p o t e n s i o n h a s n o t becn specifically addressedT . he purposeof this study was to assess thc effccts of IV verapamil in patients with SVT and artcrial hypotension. A retrospectivc and prospective study dcsign was used.Inclustion criteria werc SVT (QRS duration < 120 ms, R-R interval r c g u l a r o r i r r e g u l a r ) ;a Q R S r a t e > 1 4 0 / m i n ; s y s t o l i c b l o o d p r e s s u r c (SBP) of 90 mm Hg or lcss; and a normal mental status. We idcntificd 21 cpisodcs of SVT mecting inclusion criteria in l9 paticnts. SVT was duc to AV node reentry in 17, atrial fibrillation in thrcc, and atrial fluttcr in onc. Thcrc wcrc scvcn mcn and 12 women, mcan agc 52 +).7 years lt SDl. SBPprior to vcrapamil was 70 + 2Umm Hg and QRS ratc 192+ l9/minutes. IV calcrum was not adrninistcrcd before verapamil therapy. After IV verapamil (6.5 + 4.3 mg), a positivc rcsponse (conversion to sinus rhythrn or vcnt r i c u l a r r a t c < 1 2 0 ) w a s n o t c d i n l 7 o f 2 1 c p i s o d e s ( t | 0 % , ) .P o s t trcatment SBP incrcascd to 98 t l(r mm Hg {1r..005) and v c n t r i c u l a r r c s p o n s c r a t e d e c r c a s c dt o I 1 2 x 3 9 ( 1 ,< . 0 0 1) { t w o - t a i l c d p a i r ed t t c s t ) . I n o n l y o n c s t u d y c p i s o d c ( 5 % ) w a s v c r a p a m i l t h c r a p y f o l l o w c d b y a d e c r c a s ci n S B Pa n d n o c h a n g c i n v c n t r i c u l a r r c s p o n s e ratc. Wc conclude that IV vcranamil is a safcand cffcctivc drue for t h c r t r a n a g c m c n to f S V T c , r m p l i c a t c d b y r a t c - r e l a t c d a r t c r i a l h y p o tcnslon.

128 Intranasal Butorphanol for the Treatment of Moderate to Severe Musculoskeletal Pain J Scott,M Smith,R Shesser,R Rosenthal, J Smith,J Peterson, K Ghezzi,C Feied,M Hunt,M Bourland,S Sanford/Department of EmergencyMedicine,GeorgeWashington University Medical Center,Washington, DC Sevcremusculoskclctalpain is a problem faced frequently in cmcrgcncycare.Treatmcnt options for such patients are limited and includc oral narcotics,with a relatively slow onsetof action,or parentcralnarcotics that rcquire a physician visit for administration. Aiternativc treatment modalitiesare neededfor the management o{ such patients. We performcd an open label study of the effcctivcncss and safety of intranasal butorphanol for the treatmcnt of pain resulting from musculoskeletalinjury. Thirty adult paticnts with musculoskelctalpain deemedto be severeenoughto warrant parenteral narcotics were administered two intranasal doscs(0.5 mg/dose)of butorphanol.Pain relief was gradedby the patient at regular intervals during a three-hourperiod of observation. Patientswere remedicatedas neededevery 30 minutes to a maximum doseof 3 mg. Ninety-sevenpercentof patientsobtained satisfactorypain reliefwith intranasalbutorphanol53% (I 6)within five minutes and 87"h {26) within 15 minutes of administration.

Onc patient requiredsupplementalintramuscularmeperidine.No major sidc cffectswere noted, but mild sedationoccurredin 70% of thc patients. Intranasal butorphanol appearsto be effective, rapid, and safe when used to relieve moderateto severemusculoskeletalpain. Controlled studiescomparingintranasalbutorphanol to standardparenteralnarcoticsare indicated.

.126 Efficacyof Pseudoephedrinein the Preventionof Middle Ear Squeeze M Brown,J Krohmer, JS Jones/Department of Emergency Medicine, Butterworth Hospital, Michigan StateUniversity College of HumanMedicine, GrandRapids M i d d l c c a r s c l u c c z c{ b a r o t i t i s m c d i a ) i s t h c r n o s t c o m m o n r y p e o f b a r o t r a u m a a m o n g s c u b ad i v c r s . T h c p a i n i s s u b s t a n t i a l a n d m a y causc tympanic mcmbrane hcmorrhagc or rupturo. Prcvious studics havc shown that dccongcstants may rcducc custachian tubc blockage and allow cqualization of middle ear prcssurc.Thc purposc of this study was to dctcrminc thc efficacy and safcty of dccongcstant prophylaxis among first-timc scuba divcrs in thc p r c v c n t i o n o f r n i d d l c c a r s q u e e z c .A p r o s p c c t i v c , d o u b l c - b l i n d t r i a l was ccrmplctcd wrth 24 voluntccr scuba divcrs rccciving cither 60 rng pscudoephcdrinc or placcbo. Following randomization, tablcts wcrc administcred to each subjcct 60 mrnutes prior to diving. Signs and symptorns of middle car squeeze then were recorded. The otoscopic appcarance of the tympanic membrane was graded according to the amount of hemorrhage in the eardrum, with grades running from 0 (symptoms only) to 5 (gross hcmorrhage and rupture). Ear parn, tinnitus, and/or decreased hearing wcre prcscnt i n 1 4 u 1(, t w o o f I 4 ) o f t h o s e r e c e i v i n g p s c u d o e p h e d r i n ev e r s u s 4 0 % (four of ten) of the control group. This diffcrence was statistically s i g n i f i c a n t u s i n g F i s h c r ' s e x a c t t e s t ( P < . O 2 5 ) .O f t h o s e d i v e r s w i t h car pain, t33% (five of six) had evidence of barotrauma to the tyrnpanic membrane (mean score, 1.4). No srde effects were cncountcred. These results suggest that usc of an oral decongestant prtor to diving may decrease the incidence of middle ear squeeze.

'129 Exposureof Emergency MedicinePersonnel to lonizingRadiationDuringCervicalSpineRadiography

127 SafetyAssessmentot High-DoseNarcotic Analgesia for Emergency Department Procedures WG Barsan,D Seger,DF Danzl,LJ Ling, R Bartlett,C Bryan/ University of Cincinnati Collegeof Medicine,Cincinnati, Ohio; University of ArizonaCollegeof Medicine,Tucson;University of Louisville Schoolof Medicine,Louisville, Kenlucky;Hennepin CountyMedicalCenter,Minneapolis, Minnesota; Richland MemorialHospital,Columbia,SouthCarolina;KendleResearch Associate,Cincinnati Despite the availabiltiy of potent opiate compounds for the relief of pain, studiessuggestthat patients are undermedicatedfor the degreeo{ pain experienced.Fearo{ dangerousside effects,such as respiratorydepression,is an important lactor, We per{ormeda prospectivetrial in 70 patients evaluatingthe safety of high-dose narcotic analgesiain emergencydepartmentpatients undergoing painful procedures.Mean patient agewas 3l.l years (range,l8 to 63).Eachpatient receivedmeperidine 1.5 to 3.0 mg/kg by slow IV

48

CM Singer, LJ Baraff,SH Benedict,EL Weiss,BD Singer/The EmergencyMedicineCenter,UCLAMedicalCenter;The UCLA RadiationSafetyOffice;The UCLA Schoolol Medicine,Los Angeles We studied the potential hazardof ionizing radiation exposure to health careworkers (HCWslwho routinely stabilizethe necksof traumapatientsduringcervicalspineradiography.A clinical trauma model was developedusing a RANDO Phantom@ artificial torsoto srmulate an actual patient. A radiation monitor was placedat positions of a simulaled HCW's fingers,hands,arms, and thyroid gland, and standard cervrcal spine radiographswere taken, The exposuresto the finger positions were repeatedwith the monitor inside a 0.5-mm lead equivalentglove.The mean exposureto the finger for a single cross-tablelateral radiographwas 174.5mrem.

The useof leadedglovesreducedthis exposureto 0.3 mrem (99.9%).

For a single seriesof lateral, AP, odontoid, and swimmer'sviews, the total mean measuredunprotectedexposureto the fingerof the hand position nearestthe radiographtube was 581 mrem and230 mrem to the finger of the oppositehandposition.If thesesimulated exposuresare rndicativeof actual patient situations,an HCW who holds the head of a trauma Datient four times each week with unshieldedhandswould receivegreaterthan twice the maximum allowable annual occupationairadiation exposureto the extremities recommendedbv the National Council of RadiationProtection and Measurements.We concludethat HCWs who routinely stabilize the neck of trauma patients during cervical spineradiography

may incur a radlation exposure risk, and that 0.5 mm lcad equrvalent gloves provide an effective barricr to ionizing radration.

ORALPRESENTATIONS 132Emergency Department Diagnosis of Ectopic Pregnancy

130A RadiographicEvaluationof Various Methodsof A n k l el m m o b i l i z a t i o n J Scott, C Martin, E Jacobs, C Miller, R Shesser, R Walls/ Departmenls of Emergency Medicine andRadiology, George Washington University Medical Center, Washington, DC Acute ankle sprarns are among thc most frequently sccn problems rn the emcrgency departmcnt. Although the managcmcnt of thesc injuries is controversial, thc standard o{ care in most cmergcncy settings is immcdiatc irnrnobrhzation, rcst, ice, elevation, and orthopedic refcrral. Several mcchanisrns cxist for irnrnobilizatron of injurcd ankles, and the preferred mcthod varies arnong emcrgencypractitioners. This study was performcd to radiographic a l l y e v a l u a t c a l a y e r e c lb u l k y ( J o n c s )d r c s s i n g , a p l a s t c r p o s t c r i o r splint, and a plastcr sugar tong or stirrup splint for therr abilrty to Iimit thc most lmportant motions of thc injurccl anklc plantar f l e x i o n a n c li n v c r s i o n . T h e s t u d v w a s p c r f o r m c d o n t c n a d u l t r . n a l c v o l u n t c c r s w i t h o u t a n t c c c d c n t a n l < 1 ,p: a t h , r l , t g y .A h a s c l i n c l a t c r a l radiograph of the ankle was obtaincd at rcst and in rnaxir.nal plar"rtar flexion. Aftcr application of cach of thc splints, rcpcat radiographs in r-r-raximalplantar flexion wcrc obtaincd to dctcrminc thc arnount o { m o t i o n a l l o w c d b y c a c h s p l i n t . T h i s p r o c c c l u r cw a s r c p c a t c d i n the antcrior-postcrior planc with maxirnal invcrsion at basclinc and while wcaring cach o{ thc splints. Thc bulky drcssingallowccl 94ok oI plantar flexion and [.i5'2,of invcrsion; thc postcriur splint a l l o w c d 9 0 % o f p l a n t a r f l c x i o n a n c l7 0 % o f r n v c r s i o n ; : r n d t h c s u g a r t o n g s p l i r - r ta l l o w c d 8 0 % o f p l a n t a r f l c x i o n a n c l 5 9 " 1 'o f i n v c r s i o r . r .

Only thc sugar tong splnt dcmonstratcd a statistically significant d c c r c a s ci n a n k l c m o v c m c n t ( P < . 0 0 1) . I f m a x i m a l i m m o b i l i z a t i o n i s d c s i r c df o r t h c m a n a g c m c n t o f a c u t t ' a n k l c s l r a i n s , t h c s u g a rt o n g splint is prcfcrablc to thc postcrior splint or bulky clrcssing.

-131 RadialArtery Catheterizationof

Criticallylll Patients in the EmergencyDepartment G F Bachhuber, D W Plummer, M Lutze,E Ruiz/Department of Emergency Medicine, Hennepin CountyMedical Center, Minneapolis, Minnesota

T h c s u c c c s sa n d c o r n p l i c a t i o n r a t c s o f r a d i a l a r t c r y c r t h c t c r i z a t i o n i n c o n t r o l l c d , c l c c t i v c s c t t i n g s a r c w c l l d o c u m c n t c c l ;h o w c v c r , thcrc is no prospcctivc study cxamining tho olltcomc of cmcrgcncy dcpartmcnt radial artcry cathctcrization in critically ill paticnts.

T h i s s t u d y d c s c r i b c s t h c s l r o c c s sa n d c o r n p l i c a t i o n r a t c s o f r a c l i a l artery cathctcrization in critically ill cmcrgcncy dcpartmcnt pat i c n t s . W c p r o s p c c t i v c l y s t u d i e d 12 6 c o n s c c L l t i v cp a t i c n t s u n c l c r g o ing attcn-rptcd radial artcry cathctt:rization ovcr a onc-ycar pcriocl.

Success ratc and ratcs and naturc of imn-rcdiatc ancl dclayccl comp l i c a t i o n s w e r c d c t e r m i n c d . E a c h p a t i c n t w a s c x a m i n c d c l a i l yu r - r t i l cither cathetcr discontinuation or dcath. Durins thc wcck folkrwing discontinuation, surviving patients undcrwcnt scrial physical c x a m i n a t i o n s . T h o s c w i t h c v i d e n c c o f a r t c r i a l t h r o m b o s i s b a s c do n the Allcn's tcst underwcnt Dopplcr flow str.rdicsfor confirr-nation.

Onc hundred twenty-six patients undcrwcnt attcmptccl artcrial cathetcrization. Six dicd during resuscitationr howcvcr, artcrial c a t h c t c r sw e r e e s t a b l i s h c di n I 1 2 o f t h e r c m a i n i n g 1 2 0 p a t i c n t s f o r ,.34.1)%) a success rate of 931o. Forty-four sustainccl inmcdiatc minor complications, including inability to thread thc wirc ({orthc S e l d i n g e rt e c h n i q u c ) i n 1 6 p a t i e n t s 1 1 2 . 6 " l ' )a n d i n a b i l i t y t o t h r c a d thc catheter in 13 (10.3%). Of the l12 paticnts adr-r-rittcd to thc hospital, 32 survivcd at lcast 24 hours. Dclaycd mir-ror complications included insignifrcant blccding frorn thc punctlrrc sitc in I3 ol 32 1a0.6%) paticnts, ecchymosis in threc (9.3%), and local i n f l a m m a t i o n i n f i v e { 1 5 . ( r % )p a t i c n t s , a n d n i n e 1 2 8 . 1 ' l , ld c v c l o p c d arterial thrornbosrs after cathcter cliscontinuation. No paticnt s u f f e r e d i s c h c m i c t i s s u e 1 o s s . F i v c p a t i e n t s 1 1 5 . 6 ' / " )h a d a r t c r i a l cathcters cultured bascd on clinical suspicion of infection. There were two positive catheter culturcs, but neither patient dcvclopcd catheter-rclated sepsis. No major cornplications occurrcd, thus concluding that radial artery cathctcfization is a useful and safc procedure in the ED resuscitation of critically ill patients.

49

T G S t o v a l l , A L K e l l e r m a n ,F W L i n g , L G r a y / D e p a r t m e n t so f O b s t e t r i c sa n d G y n e c o l o g y , a n d M e d i c i n e , U n i v e r s i t yo f Tennessee, Memphis T h e r a t e o f e c t o p i c p r e g n a n c y ( E P )i n t h c U n i t e d S t a t c s h a s i n c r c a s e d f o u r { o l d s i n c c I 9 7 0 . T o a s s c s st h c a c c u r a c y o f t h c h i s t o r y and physical examination for detection of EP, we identificd all womcn prcscnting to our cmcrgcncy departmcnt with a positrve urinc prcgnancy tcst {UCPI bctween fanuary I and Deccmber 31, I 9 8 8 . A l l p a t i e n t s w c r c i n i t i a l l y s e e nb y t h c E D r e s i d e n t so r f a c u l t y .

Gynccologic consultation was availablc on rcqucst. Serum progcst c r o r - r c( P ) a n d c l u a n t i t a t i v c h u r . n a nc h o r i o n i c g o n a d o t r o p h i n ( h C C ) lcvcls wcrc obtaincd in all cascs whethcr thc Datlcnt was dischargcd homc or admrttcd for furthcr evaluati,in. Results wcrc avarlablc by 2:00 PM thc following day. All dischargcd paticnts wcrc givcn follow-up appointments within two wccks; thosc for-rnd t o h a v c a P l c s s t l - r a n2 5 n g / m l w c r c c a l l c c l t o r c t u r n i m m c d i a t e l y f o r a t r a n s v a g i n a l u l t r a s o u n d a n d / o r l a p a r o s c o p i cc x a m i n a t i o n a n d trcatccl accorcling to :rn cstablishcd protucol. During thc study p c r i r r r l ,l ( r l o f 2 , 1 5 7 E D p a t i c n t s w i t h a p o s i t i v c U C G ( 7 . 5 ' l . )w c r c ultimatcly founcl to havc an EP. All but fivc had P lcss than 25 ng/ rrL {scnsitivity;97 "1);fottr of thcsc fivc had bccn adntittcd for irnm c d i a t c l a p i r r o s c o p y c l u c t o s y n t p t o n - r s .O v c r a l l , E L ) p h y s i c i a n s c l c t e c t c cllJ 9o f l ( rl c a s c s(s c n s i t i v i t y , 5 5 . 3 ' 2 ,) o n i n i t i a l p r c s c n t a t i o n , 5 . 1o f w h i c h ( 6 0 ' 2 , ) w c r c r u p t u r c d a t t h c t i n t c o f s u r g c r y . S c v c n t y t w o E P p a t i c n t s 1 4 4 . 7 " 1 ,w ) crc tholrght to havc bcnign clrnical prcscntation and wcrc scnt homc, including 4l with vaginal blccdi n g t h o r . r g l ' rct l u c t o t h r c a t c n c d a b o r t i o n . N i n c o f t h c s c 4 l h a d b c c n c l c a r c c lb y a g y n c c o k r g y c u n s u l t a n t p r i o r t o d i s c h a r g c . A l l Z 2 w c r c n o t c d t h c f o l l o w i n g d a y t o h a v c a P o f l c s s t h a n 2 5 n g / m L a n c lw c r e askctl to rcturn. Eiglrt of thcsc p:rticnts wcrc found to have a rLlllturccl EP prior to this follow-up cvaluation. EI) physiciar"rs r c c o r c l c d a b s c n c c o f a n a d r . r c x a ll r : l s s o r t c n d c r n c s s i n 9 0 ' X , o f d i s c h a r g c c lc a s c s , a n d t k r c u m c n t a t i o r - ro l c l i n i c a l r i s k f a c t u r s w a s i n c o n r p l e t c i n 5 5 o f 7 2 c a s c s1 7 6 . 4 " 1 ,H ) .o w c v c r , o n l y 9 l o f l ( r l p : l t l c n t s { . 5 6 . 5 ' 2 ,w) i t h E P a c k r - r o w l c c l g codn c o r r l o r c r i s l <f a c t o r s o n follow-up quostioning. Wc conclutlc that thc standardhistury and p h y s i c a l c x a m i n a t i o n ( i n c l u d i n g t h o s c p c r f o r r . n c db y c o n s r . r l t i n g s p c c i a l i s t s )a r c i n s u f f i c r c r - r t l ys c n s i t i v c f o r c a r l y d c t c c t i o n o f u n r u p turcd EP. EDs with high ratcs of EP should strongly consiclcr r - n . t i v c r s aPl s c r c c n i n g : r n c lu s c o f f o l l o w - u p a l g o r i t l - r r nt o d c c r c z r s c L r n n c c c s s a r yp a t i c n t n - r o r b i c l i t ya n d t h c r i s k s o f n t o r t a l i t y c l u ct u u n r l i a g n o s c c ci c t o p i c p r c g n a n c y .

133 Mortalityand MorbidityFollowingthe 1988 Earthquakein Soviet Armenia E K NojilDepartment of Emergency Medicine, TheJohnsHopkins Hospital andSchool Baltimore, of Medicine, Maryland An carthcluakc rcgistcring (r.9 on thc Rrchtcr scalc hit thc northcrn part of thc Armcnian Rcpublic of thc Sovict Union on D c c c m b c r 7 , 1 9 8 8 , r c s u l t i n g i n t h o u s a n c l so f d c a t h s a n d i n j u r i c s .

T h i s s t u d y w a s u n d c r t a k c n t o d c t c r r n i n c c a r t h q u a k c - r c l a t c di n j u r y p a t t c r n s a n d s c v c r i t y ; t o a s s c s sf a c t o r s : r s s o c i a t c cw l ith survival v c r s u s d c a t h ; a n c l t o i d c n t i f y t h c r - n o s ta p p r o p r i a t c t y p c a n d t i r n i n g o f r c s c u c . T h c s t u d y d r c w o r - ra p o p u l a t i o n - b a s c d s u r v c y o f t h r c c t o w n s s c r i o u s l y a f f c c t e d b y t h c c a r t h c l u a k e .D a t a c o l l c c t c d o n s i t c by thc author during thc pcriod immccliatcly aftcr thc carthquakc w c r c o b t a i n c c l f r o m f i c l d s u r v c y s o f t l - r cd c v a s t a t e d t o w n s , d i r c c t intcrvicws with survivors and officials of thc Arrncnian Ministry of Hcalth, and data collcctcd by the Divisron of Informatron Systems, Anncnian Ministry of Health. Dcaths wcrc (r8 trmcs and injury ratcs sevcn tirncs highcr in trapped than in nontrappcd victtms.

T h c p o s s i b i l i t y o f e s c a p ew a s c r u c i a l f o r s u r v i v a l a n d d e p e n d e do n the typc of building and occupant escape behavior. Eighty-nine pcrccnt of pcrsons found alive werc rcscued during the first 24 h o u r s . M o s t o f t h c i n i t i a l r e s c u ew o r k a n d m c d i c a l r c l i e f w a s t o t a l l y disorganizedand carricd out cntrrely by unpreparcd local people.

T h e f i r s t o u t s i d e a s s i s t a n c cf r o m S o v i e t a u t h o r i t i e s d i d n o t a r r i v e for 24 hours. No ir-rternational assistancc was available for several days. Crush syndrome due to limb comprcssion became a major p r o b l c m , w i t h 2 3 p a t i e n t s d e v e l o p i n g a c L r t er e n a l f a r l u r e r e q u i r i n g d i a l y s i s . B c c a u s ea l l h o s p i t a l s r n t h e r e g i o n w c r c s c v e r e l y d a m a g e d , these patients wcrc transfcrred to hospitals in una{fcctcd parts of the country or to ncrghboring Soviet Georgia. Analysis of the data suggcst that the emergency phasc {or medicai care wrth few excep-

with respect to age, duration of symptoms, temperature, .RLQ tenderneis, RLQ rebound, cervical motion tenderness, rectal tenderness, or white blood cel1 count. TAC-WBC scan was indeterminate for appendiceal pathology {abnormal, but nondiagnostic) in 52 women 147"t ), ntne of whom had appendicitis. Fi{ty-eight scans werc read as positive or negative for appendiceal pathology' There wcre I6 true-positives, frve false-posrtives, 36 true-negatives/ and onc false-negative, resulting in a sensitivity oI94"h, aspecifrcity oI 8 8 % , a n a c i r a c y . o f 9 0 % , i p o s i t i v e p r e d i c t i v e v a l u e o f 7 6 " / o ,a n d a negative predictive value of 97"k. Overall, the TAC-WBC scan was abnormal in 96"/" 125oI 26) o{ the women with appendicitis' The rnain value of TAC-WBC scan in women with possible appendicitis is its high negative predictive val'te 197%), and the main oroblem with the TAC-WBC scan is its high indeterminate rate graded compresiql'k). x subgroup of 24 women also underwent sion ultrasound, ten of whom had appendicitis. Eleven of these women l4(t%l had indeterminate TAC-WBC scans and ten had indeterminatc ultrasound (42%). TAC WBC scan was more sensltivc (100% vcrsus 25%, respectively, P = .018), equally sp9!ifi9 =.1), and more acutrate \92"h {80% versus 70%, respectively, P vcrsus 577o, rcspectiv;ly, P = .0481than ultrasound in diagnosing annendicitis in these select women. Further study is needed to de'iermine the role of TAC-WBC scan and ultrasound in women

tions was limited to the three to four days after impact. These results point to the importance of well-organized local disaster preoaredness capabilitieJ because outside assistance will invariably arrive too lati for effective life saving.

134 Analysis ot EmergencyDepartmentManagementof SuspectedBacterialMeningitis B J R Hoffman, C Singer, G D Overturf, D A Talan,JJ Guterman, Medicine, of Emergency Department View-UCLA Lambert/Olive Caliiornia Sylmar, UCLASchooloJMedicine, t

Previous studies of emergency department management of bacterial meningitis have indicated that thcre are often long delays orior to initration of antibiotics. This study was to determine if dclays were related to specific aspects of patient management' We r c t r o s p c c t i v e l y r e v i e w e d { 1 9 8I t o 1 9 8 8 )t h c m e d i c a l . r c c o r d s o f 1 2 2 patie;ts primarily evaluated in the ED and admitted for suspected t r a c t c r i a l ' m c n i . t g i t i t r t a u n i v e r s i t y ( 5 5 ) a n d c o m m u n i t y ( 6 7 )h o s p i tal. The median time from ED registration until initiation of a n t i b i o t i c s { t i m c t o a n t i b i o t i c s ) + S D w a s 3 . 0 t 2 . 5 h o u r s ( r a n g e ,0 5 to l8 hours). The time to antibiotics was not significantly relatcd ( ) 0 " 1 ,o f t h e t o t a l t i m c t o a n t i b i o t i c s to thc time of ED registration; occurrcd following the initial physician cncolrntcr' Timc to antibi' . 0 0 0 0 5 )g r e a t c r f o r c a s e s o t i c s ( m c d i a n t S D ) w a s s i g n i f i c a n t l y ( 1< in wlLich computed tomography scan and/rlr laboratory analysis of ccrcbrospinal fluid preccdcd initiation of antibiotics comparcd w i t h c a s e si n w h i c h a n t i b i o t i c s a d m i n i s t r a t i o n w a s n o t c o n t i n g c n t o n t h c r c s u l t s o f t h c s e p r o c e c l u r c s1 4 . 3! 2 - 8 h o u r s v c r s u s 1 ' 9 t l 9 h o u r s , r e s p c c t i v c l y J .A l s o , t i m e t o a n t i b l o t i c s ( m c d i a n t S D ) w a s s i g n i { i c a n i l y ( P . . 0 0 0 0 5 )g r e a t c r f o r p a t i c n t s i n w h o m a n t i b i o t i c s wcrc initiaicil on the ward as opposed to thc ED (4.5 + 3 2 hours v c r s u s 2 . 2 + 1 . . 5h o u r s , r c s p e c t i v c l y ) ' W e c o n c l u d c t h a t i n t h c E D , krng dclays cxist bcforc initiation of antibiotics for casesof suspcctcd bacterial rncningitis and that in gencral thcsc dclays appcar ll be physician gcncraicd and to a grcat extent potentially avoid-

with possible appendicitis.

Symptomsin ModelofPsychosomatic 137Mathematical the Practiceof EmergencyMedicine

R R Huang,B White/Olficeof MedicalEducationResearchand Collegeof HumanMedicine;Sectionof Emergency Development, HealthCenter' Medicine,DetroitReceivingHospitaland University East Lansing MichiganStateUniversity, Phiysiologicsymptoms such as heartburn, loss of .appetiteand headachearesometimesa result of one'sperceptionof the stressful cnvironment and one's attitude toward his or her career'These syrrrptomsimpair performanceand if the underlyingcausesareleft may progressto evenmore severeproblems .rnati"ndcd,thc su-biect forcing him or her to leavethe professionaltogether'The purpose among a sample of this str"rdywas to investigatethis phenomeno-nof cmergcncyphysiciansand to determinepossiblecausesof these .y-ptn-s in the context of practicingemergencymedicine' Sixtynine physicians from six cmergency departments in the midMichrgan area participated in the s-tudy They were asked to t"rpnnd to a seriesof well-establishedinventoriesthat purport to mcasure strcss symptoms, subiectiveperceptionof stress,-iob satisfaction,tcdium, and feelingsof professionaldemands;the first being categorizedas the somatic dimensionand the last four being categori"ei as the psychologicdime,nsionsfou-ndto be prilcipal mediating variablesin stressresearchstudies.By meansof linear structurai equation rnodelling,otherwise known as causalanalysis, scveralparadigmsihypotheticalrelationalstructures)to exnlain thc rntcractlonbetwccn these varlabieswere empirically tested for goodnessof fit with the actual collected data One paradigmw"asfound to havean adiustedgoodnessof fit of 0'99 {chi.qrr".""= .01, df = l, P = .gB).Essentially,this particular paradigm indicated that subiectivestressplays a major role in determining job satisfaction, feelings of professionaldemands,and tedium' iteclingsof professionaldemandsdetermine job satisfaction,and feclings of professionaidemandsplus tedium,.in turn, determine the piiysioiogic outcomes (symptoms).Stated simply, how one o".".iua, str6ssdetermineshow demandingone perceivesone's lrofession to be and how satisfied one is with one's iob These ielationships affect the final physiologicoutcome' This paradigm contributesto the knowledgeof managingthe well-beingof emergency physiciansin their practices.

able.

of AcuteInfectious in the Treatment 135Ciprofloxacin Diarrhea

ML Neighbor,PT Cohen,D Seigel,M Newman,W Hadley'D Yakjo' O Feigal,H Larkin,MA Sande/SanFranciscoGeneralHospital' San Francisco of California, University Thc cmpirictrcatmcnttlf acutediarrhcarcmainsproblcmaticin that fcw antibioticscradicateall of the commonly encountercd cnteric pathogens.Wc havc comparcd thc cf{icacy and safcty of ciprofloxacinibF), a new quinolonc dcrivativc,with trimethoprirn/ sulfamethoxazolc {TMP/SX)and placcboin the trcatmcntof acute infcctiousdiarrhea.Onc hundrcdthirty-four adults prescntingttl thc San FranciscoGcncral Hospital emcrgcncydepartment complaining of diarrhca *"rc ctttolled in a-prospective,randomizcd, studv. A total of 5tl stool pathogcnswcre obtaincd: ilo.rl-rl"-bhn.tcd 30 Campylobttcter,22 Shigella,three Salmonella, two Yersinia' andt*<','A"romonns.Aftcr four daysof trcatmont, CF successfully cradicatedthe stool pathogcnin 94"k of paticntscomparedwith 60"1,[r:r TMP/SX, and37y" {or placebo.Paticnts kept daily diarics rccorclingthc sevcrity of their diarrhea,nausca, abdominal pain, and fcvcl. Fifty percent of culturc-positive patients were well by clay3 whcn treaied with CF comparedwith-day 4.5 and 5 0 when treatedwith TMP/SX and placebo.CF was also superiorto both in reducingabdominalpain and was well tolerated.These results,as well as'the increasingincidenceof TMP/SX-resistantSfiigella, suggestthat CF shouldbe considcreda drug of choicein the cmpiric treit-"ttt of acute in{ectious diarrhea'

of WomenWithPossibleAppendicitis 136Evaluation LeukocyteScan_ UsingTechnetium'99m

TA Halt,CS Marcus,JA Butler,T Koci' N Worthen, PL He-nneman, of EmergencyMedicine;Divisionol Nuclear ES Wilson/Department Harbor-UCLA of Surgeryand Radiology, Medicine;Departments MedicalCenter,Torrance,California We evaluatedthe use of technetium-99m albumin colloid while blood cell scan (TAC-WBCJin women with possible appendrcitis.One hundred nine women {mean age, 28 5 years; ringe, S to 80)underwent I 10TAC-WBC scans.Twen-ty-sixwomen had'lristologicallyproven appendicitis,ten 139%)of whom had a perforatedalppendiiut sutgery.Women with-appendicitisdi{fered appindicitis only in- the frequencyof pain iro- -o-.tt-*ithout migration from the periumbllical regionto the-right.lowerquadrant (RiQ) (42% versus22Yo,respectively,P = O49land anorexia{88% there were no differences u..t.t.'ZZf , respectiveiy,l' = .OOO:41,

50

138RefusingCareto PatientsWho Presentto an EmergencyDepartment

R W DTrlet,'OruisfiolOivlsionof EmergencyMedicineand Clinical Davis,Schoolo1Medicine' of California, University Toxicology, Sacramento In fuly 1988, the emergencydepartrnent-adopteda policy of refusingio treat patients in the ED if they failed to havewhat was consid&edan emergencycondition. A screeningexaminationwas performedby a triagl ttutseto determineif the patient was eligible io b. seenin the ED. Patientswhosevital signsfell within specific .rt.gotl.. and had one of 50 minor chief compiaintswere refused ""re"in the ED and referredto a number o{ on- and of{-siteclinics' The referralof thesepatientsout of the ED {ollowing a screeningexamination falls within the scopeof legislationgoverningED care

r

and transfer {FederalCOBRA, California SB-12 and Title 22) as determined by thc University of California lcgal counsel. In thc first six months of this new triage system,4,l86 paticnts werc turned away from the ED, representing l9"k of totjl ambulatory patients who presented to the triagc area. Of the 4,I86 patients refused care, 82Yo were referred to off-site nonuniversitv clinics. and 18% wcre referred to clinics within the institution. Of this number, no patients were rctrragedto an ED, and only 54 patients ( 1 . 3 %) c o m p l a i n e d a b o u t t h e i r r c f e r r a l o u t o f t h e E D . I n c o n c l u s i o n , a s e l e c t i v e t r i a g e s y s t c m m a y b e u s e d t o c f f e c t r v c l y d e c o m p r c s sa n ED,

139 EmergencyDepartmentDivision of Nonurgent Patientsto an Off-SiteWalk-lnFacility KT Sivertson, A DiGiovanna, GD Kelen/Division of Emergency Medicine,JohnsHopkinsUniversitySchoolof Medicine,Baltimore, Maryland Studies indicate that onc-thrrd or lnorc of hospital cmcrgcncy dcpartmcnt paticnt vrsits arc for nonurgcnt problcms. A pian to r c c l u i r c h o s p i t a l E D s t o d i v c r t M c d i c a i d p a t i c r " r t sw i t h r r r r r i l r r g e n t problcrns to othcr facilitics is bcing cvaluatcd by ncarly all statc Mcdicaid agencics.A divcrsion plan (dcvclopcd by thc Statc Dc, partmcnt of Health and Mcntal Hygicnc) was r.nodclcdaftcr a p r o j c c t i n i t i a t c d b y t h c c l c p a r t m e n t o { c r n e r g c n c y r n c c l i c i r r co f a n i n n e r - c i t y u n i v c r s i t y h o s p i t a l o n M a r c h l , 1 9 { i 5 .P a t i e n t s l r r s r n r i n g t o t h e E D h a c lp r e v i o u s l y b c c n t r i a g c d a s n e c d i n g p r i m : r r y c a r e , irnrncdiate care/ or critrcal care. Using thc samc triagc critcria, p a t i e n t s i d e r - r t i f i c da s r c c l u i r i n g p r i r n a r y c a r e a r c s c n t t o a n a s s o c i a t c d , b u t g c o g r a p h i c a l l y d i s t a n t ( s e v c n b l o c k s ) , L r r g e n tc a r c c c n t c r .

T h c n u m b e r o f p a t i c n t s r e g i s t c r i n g f o r p r i m a r y c a r c i n t l - r cE D h a s dcclined significantly {1, < .01, chr-squarc)from l4,002 in fiscal 1 9 8 4 l l 9 % , ,< t f7 4 , 1 4 1 t o t a l r c g i s t r a t i o n s ) t o 5 , 2 1 0 i n f r s c a l l g | f t ( 9 , , 2 , o f 5 5 , I 2 l t o t a l r c g i s t r a t i o n s ) .R c g i s t r a t i o r - ras t t h c L l r g c n rc a r c c c n t c r f o r t h c s a r n e p c r j o t l r a n g c d f r o r n 1 7 , 5 0 0 t o l t { , t { 0 0n i l t i c n r \ | c r y ( . i l r .

D c r n o g r a p h r c so f t h c p r r r n a r y c : l r c p a t i c l ' l t s : l t t h c t w o f a c i l i t i c s a r c similar with rcspcct to :rgc/ scx, ancl racc. Thc paticr-rt grollp that c o n t i n l r c s t o r c c c i v c c a r c i n t h c E D i s s i g n i f i c a n t l y ( 1 ,< . 0 1 , c h i s c l u a r c js i c k c r a s i n c l i c a t c d b y t h c p r o p u r t i o n o f c r i t i c a l c a r c c z l s o s i 2 . 5 ' k o f f i s c a l l 9 f l U r c g i s t r a t i o n s { 1 , 3 9 ( rc a s c s )v c r s u s 1 . 5 , 2 ,o f f i s c a l 1 9 1 1 4r c g i s t r a t i o n s ( l , 1 3 t i c a s c s ) ,a n d h o s p i t a l a c h . n i s s i o n s 1 , 4 , 2 ,o f f i s c a l 19 t j Ur c g i s t r a t i o n s ( 7 , ( 1 7 2a d n - r i s s i o n sv)c r s u s l l , Z ,o f f i s c a l I 9 t j 4 r c g i s t r a t r o n s ( ( r , I 5 2 a d n - r i s s i o n s )W . c concludc that nonurgcnt pat i c n t s c a n b c c l i v c r t c c lt o a w a l l < - i n f a c i l i t y w i t h a r c s u l t a n t c h a n g c in carc-sccking bchavior ovcr timc. Thcrc is a currcsl.roncling incrcasc in acuity of thc paticnt group in thc ED.

-140 Early

UnexpectedDeathsFollowingAdmission From the EmergencyDepartment JG Mueller,DJ Fligner,N Wigder/Department of Emergency Medicine,ChristHospitaland MedicalCenter,Oak Lawn, lllinois

Dcath withir-r 24 hours of adrnission has bccn suggestcd as a quality assurance monitor for emergcncy dcpartmcnts. Wc oonductcd a retrospcctivercview o{ al} patrcnts who cxpircd within thc lirst 24 hours after admission frorn our ED during onc yczlr ro d e t e r m i n c t h e v a l i d i t y a n d u t i l i t y o f t h i s r n o n i t o r . E a c h d c a t l - rw a s c l a s s i f i e da s e i t h e r e x p c c t e d o r u n c x p e c t c d . A n u n e x p c c t c d c l c a t h was defined as a patient for whom the final diagnosis was cliffcrcnt from the ED diagnosis, or onc for whom the final and ED dragnoses were the same and none of thc following existcd: tcrminal canccr, severeclementia, CPR performed in thc ED, rncchanical vcnrrlation, appropriatc ICU admission, or a do not rcsuscitatc ordcr. The cluality assurance assessfflent and action also were rcvicwed for each case to determine how often thc cmergency physician was notified of an unexpccted death. During the l 2-monih period thcre were 10,582 admissions througl.r the ED, of which 137 1'I.29%l expired within 24 hours; 23 (0.22%) paticnts were found to havc unexpected mortality. Of thesc 23 patients, the emergcncy physician was officially notified only two 18.7O%ltimes. The mean agc o f p a t i c n t s w i t h u n e x p e c t e d m o r t a l r t y w a s 7 5 . 6 y e a r s ( r a n g c ,4 4 t o 94), and the majority of {ina1 diagnoscs rnvolved cardiac 143.1), v a s c u l a r 1 2 2 % ) ,o r i n f e c t i o u s ( 2 6 % ) p r o c c s s e s .W e c o n c l u d e t h a t a notable number o{ patients admitted through our ED expire carly on and unexpectedly and that the emergcncy physician involved usually is not notified. We suggcst that ED quahty assurance programs notify physicians o{ all early uncxpected mortality.

*141Useof AutopsyResultsin the Emergency Department's QualityAssurancePlan M C B u r k e , R V A g h a b a b i a n , B V B l a c k b o u r n e / D i v i s i o no l E m e r g e n c y M e d i c r n e ,T h e U n i v e r s i t yo f M a s s a c h u s e t t sM e d i c a l C e n t e r , Worcester Thc autopsy is tradrtionally viewed as thc ultrmatc quality a s s u r a n c ei n d i c a t o r i n c l i n i c a l m c d i c i n e , y c t v e r y f c w c l i n i i a l d r i partments actually incorporate autopsy rcsults in thcir formal q u a l i t y a s s u r a n c cp l a n . C o n s c q u e n t l y , t o i n v e s t i g a t e h o w a u t o p s y results could bc included in our emcrgcncy dcpartment plan, ihc clinical and autopsy diagnoscsof 244 patients wcrc comparcd to i d c n t i f y c o n d i t i o n s t h a t w c r e L l n a p p a r c n to r m i s d i a g n o s c d a t t h c tirnc of dcath. Diffcrcnces bctwccn cltnical and autopsy diagnoses w c r e c a t c g o r i z e da s c l a s s I , I I , i l I , o r I V f i n d i n g s . M a j o r u n c x p c c t c d f i n d i n g s ( c l a s s e sI a n d I I ) w e r c f o u n d i n t c n ( 4 , 2 , ) c a s c s ;t h ; m o s t c o m m o n l y m t s s c d d i a g n o s c sw e r c a o r t i c c l i s s c c t i o n{ t h r c c , 1 . 2 % , ) a n d p u l m o n a r y c m b o l u s { t w o , 0 . 8 % , ) .M i n o r u n c x p c c t c d f i n d i n g s { c l a s s c sI I I a n d I V ) w c r c d i s c o v c r c d r n l 4 ( 5 . 8 , / . ) c a s c s . T h c r c s u l t s c l c a r l y i d e n t i f y u n e x p c c t c d f i n d i n g s a n c lp o i n t t o t h c n c c d f o r m o r c a g g r c s s i v cc v a l u a t i o n s o f c c r t a i n c o r - r c l i t i o n sS. y s t c m a t i c r c v i c w o f a l l t o p s y r - l a t ap r c s c n t ec l h a s l c d t o r n c a n i n g f u l c h a n g c sa n d c l el i v c r y ol carc to cmcrgcncy paticnts. Antopsics arc a vital suurcc of olrtcorrc-bascd information that shoulcl be part of cvcry ED,s r l u a l i t y a s s u r a n c ca n d r i s k m a n a g c r r c n t p l a n .

"Negative" 142 DRGs and the Trauma Workup CM Dougherty, L Flancbaum, DN Brotman, J Avedian, SZ Trooskin/ D e p a r t m e n to f S u r g e r y , U M D N J - B o b e r t W o o d J o h n s o n M e d i c a l S c h o o l , R o b e r t W o o d J o h n s o n U n i v e r s i t yH o s p i t a l ,N e w B r u n s w i c k , New Jersey E a r l i c r t l i a g n o s i sa n c lt r c a t n t c n t o f l i f c - t h r e a t c n i n g i n j u r i c s d u c t o r c g i o n a l i z c d t r a l l n t : l c a r e s y s t c l l s l " r a v cr c d u c c d , , p r e v c n t a l t l c c l c : r t h s "d u c t o i r - r j u r y .C o n c u r r c u t l y , c s c a l a t i n g h c a l t h c a r c c x p c n c l i t u r c s h a v c l c c l t o t l - r ci n p l c r . n c n t a t i o n o f p r o g r a m s d c s i g n c d t o c u r t a i l c o s t s . S i r - r c c1 9 7 9 , a l l l - r o s p i t a lc a r c i n N c w f c r s c y h a s b c c n rcintbursccl through a pr(rsPcctivc payntenr systum (DRGs), in w h i c h t l - r c c a s c m i x o f p a t i c r . r t si s s l r p l . r o s c ct lo t v c r a g c o l l t ( i c , "profits" gaincd from thc carc of lcss-ill paticnts offsct ,,losscs,, i r . t c u r r c cflr o r . nc a r i n g f o r s i c k c r p a t i c r l t s ) .T h c p r - r r p o s co f o u r s t u t l y w a s t o c v r l u a t c t h c f i n a r - r c i ailn t p a c t o f D l l G r c i r l b u r s c r . n c n t i n 1 4 0 consccLltivc tr:lulra paticnts with ISS lcss than 9 {nOt scvcrclv i n j u r c c l ) a c l u r i t t c d b c t w c c n ) u l y I a n d D c c c r . n b c r 3 1 , l 9 r , t 7 .T h r a v c r a g c a g c w a s 3 0 y c a r s , a n c l m o t u r v c h i c l c a c c i c l c n tw a s t h c m o s t c o l n l n o l t r . n c c h a n i s n to f i n j r - r r y( ( r ( r ' 2 , )D. i a g n o s t i c s t u d i c s i n c l u d c d 5 1 9 r r r c l o g r a p h s( 3 ( rp o s i t i v c , 7 ' / , , 16, 4 h c a t l c r t r r p u t c d t o m o g r a p h y s c : r r . r s{ l I p o s i t i v c , 1 7 " 1 , ) ,6 0 a b d o n t i n a l c u m p u t c d t o m o g r a p h y sczlnsor diagnostic pcritoncal lavagc (all ncgativcl, cight livcrs p l c c n s c a n s { a l l n c g a t i v e ) ,a n d t h r c c b o n c s c a n s ( a l l n c g a t i v c ) . A l l l r a t i c n t s h a d s c r c c n i n g l a b o r a t o r y t c s t s , a n d 4 8 1 ' 3 4 , k ,h)a d E C G s .

M i n o r o p c r a t i v c p r o c c d u r c s w c r c p c r f o r n t c d i n l 5 p a t i c r - r t s( l l , X , ) ; i r - r t c n s i v cc ; l r c w i l s n c c d c t l f o r 2 2 p a t i c n t s { l ( r , X , )i n c i u d i n g l 5 w i t h l - r c a di n j u r i c s a n d s i x f o r r u l c - o u t c a r d i a c c o r r t u s i o n s .A v c r a { c t o t a l l c r - r g t ho f s t a y w a s 3 . t t d a y s . P a t i e n t s w c r c c o c l c di n t o 4 ( r s c p a r a t c D R C s . O n c h u n d r c d t w c n t y - t h r c c p a t i c n t s{ l l f l , Z , ) w c r ien l i r r s ; t ' n l y t h r c c p a t i c n t s l 2 ' / , ' ) w c r c h i g h - t r i n - ro u t l i c r s . T h i r t y - f r r u r o f t l i r 4 ( r D R C s { / 4 7 , ) w c r c n c t l o s c r s ,a s w c r c 9 4 1 6 7 % ,o1f t h c p a t i c n t s . T o t a l D R G r c i m b r - r r s c m c n tw a s $ 1 7 7, O Q f t r r r r p r r a t i n g c o s i s o f $ 2 5 9 , l 5 Z , y i c l d i n g a n c t n c g a t i v o c o n t r i b u t i o n m a r g i n ( l o s s )o f $ i l 2 , l I 5 { a v e r a g c , $ 5 t 1 7a p a t i c n t ) . T l - r i r t y - c i g h t p c r c c n t o f o p c r a t i n g c o s r s w c r c d u c t o r o o m a n d b o a r d , l ( r ' l u t o r a d i o l o g y f c c s , [ J . t l , Zt,o r n t c n s i v e c a r c , 8 . 6 " 1 ,t o l a b o r a t o r y t c s t s , a n d 6 . 4 ' / , , t r , tp h a r m a c y c o s t s . W e c o n c l u d c t h a t t h c c o s t o f a p p r o p r i a t cd i a g r . t o s t i c v a l u a t i o n a n d c a r c ol trauma patients who arc found to havc only minor injurics {lSS < 9) cxcccds thc DRC rcimburscmcnt. Thc currcnt DRG rcirnb u r s c m c n t s y s t c n - rc l i s c o u r a g c s ,f r o m a f i r - r a n c i a lp e r s p c c t i v e , t h c pcrformancc of a thorough "ncgativc" diagnosticworkup in traulna paticnts.

143 Hypoxic Hazardsof PaperBag Rebreathingin HyperventilatingPatients M CallahamlDivision of Emergency Medicine, Center lor Prehospital Research andTraining, University of California, San Francrsco It rs traditional practice to trcat acute hypervcntilation by having paticnts rebreathc into a papcr bag. This treatment, when crroneously applied to patlents who werc hypoxemic or had myo, c a r d r a l i s c h e m i a , h a s r e s u l t e d i n d e a t h . T h e s e f a t a l c a s e sp r o m p t c d a study of thc effects on oxygenation of papcr bag rcbreathing in

5l

normal volunteers. Sublects deliberately hypcrventilated to an a v e r a g ee n d - t i d a l C O , c o n c c n t r a t i o n o f 2 1 . 6 ( S D , 3 . 2 ) r n m H g - a n d thcn continucd to hyperuentllate into Kraft brown papcr bags containins thc calibraied sensors for a Hewlett-Packard 472104 capnograph and a Teledyne TED (r0| digital oxygcn monittrr' F o u r t c c n m c n a n d s i x w o m e n , a v er a g c a g e o f 3 ( r y c a r s { S D , 6 1J w c r c tcsted. Results, reported as millimetcrs of mercury, wcre idcntical I<'r 2.25-L and 3.0-L papcr bags and are thus combincd After 30 s c c o n d so f r e b r c a t h i n g , m e a n c h a n g e i n O , f r o m r o o m a i r w a s 1 5 9 (6 0) 1 S D ,4 . 6 Ja n d m c a n C C i r ,w a s 3 8 . / ( S D , 6 . 2 ) i a t 6 O s e c o n d s , 2 0 5 ; t 9 0 s e c b n d s ,' 2 2 \ 6 . 8 1 a n d 4 0 . 5 { ( r . 4 Ja; t 1 2 0 s c c o n d s , a n c l ' 4 0 . 2( ( r . 4 ) a - 2 5 . I ( l 2 ) a n d 4 l ( 7 . 3 ) ;a n d 2 3 . 6 ( 6 . 8 lr t r J + 0 . 7 { ( r . 5 )a ; t I 50 seconds, a t l i l O s c c o n c l s , 2 6 . 6 1 8 . 4 Ja n d 4 1 . 3 { 7 . 5 1 A f c w s u b j c c t s a c h i c v c d CO. levcls as high as 50, but many ncver rcached 40 Thc rncan r - n a i i m a l d r o p i n O , w a s 2 6 ( t t . t t f s c v c n - s u bj c c t s t r a d d r t ' p s i n o x y g c n of 2(r r-nm Hg at thrie minLrte s, for:r had drops of 34-mm Hg, and onc hacla drop irf 42 rnm Hg. Thrcc subjccts rcbreathcd into an lll-L p l a s t i c b a g f i l l c d w i t h 1 0 0 ' 2 ,O , , b u t a l t h o u g h C O , r a p i d l y c x c c c c l c c l + 0 , O , l . u . l . r c a c h c c l2 l ' 2 , w i t h i n t w o t o f o u r t n i n u t c s : r n c lc o n t i n u c d t < ic l c c l i n c t o l c s s t h a n l O ' 2 , a t 15 m i n l r t c s . B a g r c b r c a t h i n g d o c s n o t c o n s i s t c n t l y c l c v a t c C O , l c v c l s b u t i t c l r c s c l c c r c : ' r s cF i O , sufficicntly to cndangcr hyptixic paticnts. Additionally, hyp<rxic r c s p i r a t o r y c l r i v c i s d c C r c a s c dl " , yh y p o c a p n i a P a p e rb a g - r c b r c a t h i n g s h r i u l c lr - r c v c rb c u s c d u n l c s s t r y o c a r d i a l i s c h c r n i a c a n b c r u l c d o t t t a n t l o x y g e n a t i o n h a s b c c n d i r e c t l y m c a s u r c c ll l y : r r t c r i a l b l o o c lg a s c s or oulsc oximetrv. Ilccausc tllis cannot bc achicvccl outsidc thc h o i p i t a l , i t s u s c b y p r c h o s p i t a l p c r s o t r n c l. s h o u l db c a b : r n d o n c d ,a r - r d i n - h o s p i t a l u s c p i o i r a b l y i h t , , - , l i lb c g r c a t l y d i m i n i s h c d '

144 InhaledSodium BicarbonateTherapyfor Chlorine I n h a l a t i o nI n i u r i e s PCLanglinais/ CV Okerberg, EMSingletary, CDChisholm, Medical TheJointMilitary Medicine, of Emergency Department - SanAntonio, forSurgical Texas;TheInstitute Command Texas FortSamHouston, Research,

C h l o r i n c g a s l r t r l y c : l t t s c i n h a l a t i o t l i t . t j t t r i c st h r o r - r g hc x p o s t l r c s f r . 1 - r r n r l r - r s t r i i rsl , , u i c c s , h . u r c s w i n r . n i ' g p . . l s , . r : r c l m i x t l t r c s . f blcach and rtcrdicclcarling soltttittns. Victirrls nlay rapidly prcscnt to thc clncrgcltcy clellartlllcnt with dyspnca, chcst plin, notlprot h r c t i v c c , r r - i g l - ltt,r t , t t c h o s p i l s l l l / t a c h y p n c a , a u d c v c n p t l l u r o n a r y cdc'ra. Until rcccrltly, thc p.isindcx" rcc..r'rcnrlccl 5'2,'cStrlizccl NlrHCO, as il trcattllcllt moclality bascd on :rncctlrtal rcp()rt-s/ "it cann.t bc rtlutincly alth.Lrgli thc rrost rcccllt cdition stiltcs that r c c r l ' - r i ' c n c l c c l . " ( ) r - r r s t r . r d yw a s c l c s i g n c c lt o c x a m i n c t h c r . l c . f ncbr:lizccl NaHCO, in thc trcatrllcnt of chlorinc gas inhalatitrn jugular i n j u r y t r s i n g a s h c c f m o d c l . T w c n t y - o n c s h c c p I ' r a di r - r t c r n a l and carotid'artcry cathctcrs placcd by clircct visualization Aftcr b c i n g a n c s t h c t i z c d w i t h p e I r i t ' h a r h i t a l a n d s r ' r c c i n y l c h o l i n c ,c a c h s h c " j . t w " t c n c l o t r a c h e a l l y i n t r - r b a t e dr t n d c x p o s c d t o c h l o r i r - r cg a s Thc atliurals thct.l { 5 0 0 ' p p m Jf o r f o u r u r i n l t t e s b y a c l , t s c d s y s t c l l l , " c r c i . , , l a c c d . n l r B i r c lM a r k 7 v c ' t i l a t o r o n r o o r n a i r . A t 3 0 t - n i l l r t t c s a f t c r c x p r t s u r e, t l " r ca n i r n : r l sw c r c d i v i d c c l i t - t t ot w o g r t t t t p st t ) r t c c i v e a fivc-rirntrtc ncbulizcd trcatlrcllt (8 mL) of normal salinc {Crottp A , t c n ) o r 4 ' 2 , N a H C O , ( G r o r - r pI 3 , 1 l ) . A r t c r i a l b l o o d g a s c s - w c r c s a m p l c d s c r i a l l y a t f i v c , 1 5 , i 3 0 , ( r 0 , a n d 9 0 . n " r i n u t c sa n d 2 4 h o u r s a f t c r t r c a t r n c n t . T h c a n i r l l a l s t h c n w c r c c u t h a n l z c d a n c lt h c o r g a n s ()nc-way ANOVA tal<cn for gross :rnd lllicr(rsc()|ic exrttnin;ttitrt.t r c v ea l c d n < td i f f c r c n c c s o v er t i r - r - rwc i t h i n g r t ' u p s w i t h t h c c x c c p t i o l l i r i t l r c G R a p O , ( f = 6 . 5 7 ) . I - t c s t . f o r u 1 9 u 1 1 l g r ' r r - r p sr c v . c ' r l e ' l diffcrcnccs bciwccir groups with highcr pCO, {P < 001) and lowcr p O , ( / ) < . 0 5 ) v a l u c s f < t tt h c c o n t r o l g r < r u p T h c r c w a s n o d i f f c r c n c c in i-ti,,rtolity ratcs bcforc 24 l-rours for cither group (thrcc) or in microscopic pathology in blindcd comparisorts Thc usc of a singlc inl"ralation troatmcnt of bicarbonatc clocs not apllear to worscn a r t c r i a l b k x r d g a s c so r a l t c r p a t h o l o g y i n t h i s s h c c p r l o d c l a n c lr n a y actually improvc artcrral blood gas valucs.

Zealand rabbits were ancsthetized with kctamrne-xylozine and Nernbutal". The trachea and lungs were removed surgically and placed in oxygenated Tyrode's buffer. Three-millimcter bronchial iir-rg, *.." disiected and placed under 1g passive stretch in a tissue b a i h . M a s n e s i u m c h l o r i d i a d d e d t o t h e t i s s u e b a t h i n d o s e so f 5 , 1 0 , 20, and 5b mM decrcased mcan + SD resting tcnsion by 60 t 23, 10 t i 0 , f r O+ l ( r , a n d 1 0 5 t 4 4 m 8 , r c s p e c t i v e l y . E l e c t r i c a l s t i m u l a t i o n o { 1 0 0 V , 1 0 0 m s t n c r e a s e d m e a n t e n s i o n b y 1 ( r 8I 5 2 m g M a g n e s i u m c h i o r i d c ( 5 , 1 0 , a n d 5 0 m g ) a d d c d t o t h c b a t h d e c r e a s e dt e n s i o n = by 102, 127.5, and i(rt3 rng, respectively. Histamine (n 4) 10 mM incrcascd thc mean + SD tension 49O x 243 mg. Magnesium c h l o r i c l c ( 5 , 1 0 , a n d 5 0 r n M ) d c c r e a s c dt h c h i s t a r n i n e r es p o n s cb y 8 0 t 1 1 3 , 1 7 0 + 1 4 7 , a n d 4 7 5 t 3 I 1 m g . B e t h a n e c o l( n : - 8 ) 5 . m M i n c r c a s c dt - n c a n+ S D t e n s i o n 4 9 5 t 2 ( r ( r n g . M a g n e s i u m c h l o r i d e { 1 0 a n c l5 0 m M l d c c r c a s c dt h c b e t h a n e c o l - i n d u c e dt e n s i o n b y ) ' 3 2 x 1 2 2 ancl 327 t 237 n^rg,,rt:spectivcly. Magncsium chioridc produced a ckrsc-clcpcnclentt"iatntlot-t of bronchial stnooth musclc at rest and whcn siimulatccl by an clcctrical ficld, histamine, and bethanecol' - i n d u c e ds m o o t h T h c s c d a t as u p p o r t i h c h y p o t h e s is t h a t r n a g n e s i t t m musclc rcla"atlon is rcsponsiblcfor thc clinical itnprovemcnt sccn in paticnts who rcccivc nlagncsium for acutc bronchospasm'

146 ProspectiveComparisonof InhaledAtropine and Metaproterenolin the Therapy ol Relractory Status Asthmaticus Medical Administration Veterans GP Young,P Freitas/Portland Highland Portland, University' OlegonHealthSciences Center, at of California University California; Oakland, Hospital, General SanFrancisco

Wc concluctcd a stucly of adults with rcfractory status asthln:rticns to cor-nparc thc rcsportsc to inhalcd anticl-rolincrgic with that to bcta-adrincrgic solutions. Aftcr failing to rcspond to stanclarcl thcrapics, 40 paticr-rts wcrc randontizccl prospcctivcly in a d o t r b l c - b l i n d f a s h i o n t o r c c c i v c c r t h c r 1 . 5r n g a t r o p i n e { A T ) o r l 5 m g lrctaprotcrcnol (MP) by ncbulizcr. Both groups wcrc similar in b a s c l i n c c h a r a c t c r i s t i c s ,i n c l u d i r - r gm c a n F E V , t n c a s u r c m c n t s ( 0 7 0 L AT/0.60 L MP). Comparcd with basclinc,thc-improvcrncnt in thc = FEV. frrr thc MP,troup was statistically srgnificant l3l"/', P '02, r.air..l r tcstl, whercai thc improvcrncnt in thc AT group did not icach significancc (10'2,, P = .15). Comparing thc two groups, statisticzilly sigr-rificant diffcrcnccs favoring MP wcrc found ir-rthc 'h, MPi P < '05, signcd pcrccnt itilprovcrncnt in thc FEV, ( 10'2, AT/3 I i a n k ) a r r d i n t h c p c r c c n t a g e o f p z i t i c n t s i n - r p r o v i n gt h c r r F E V , r n o r c t h a n l 0 ' 2 , a b o v c b a s c l i n c 1 5 6 % ' A T l S ] r " 1 ,M P ; 1 ) < 0 5 , c h i - s q u a r e ) ' No patict-tts in cithcr group suffcrcd any advcrsc outcomos Wc c,urclt cl" tl-rat for thc rlajority of adults with rcfractory bronc l r o s p a s r . i u s t a t l t s a s t h m a t i c l l s , a r - ra d d i t i o n a l b c t a - a d r c n e r g i c inhaiatron trcatmcnt rcsults in tnorc itnprovcmcnt than the addition of an atropinc inhalation.

.147 AdjunctiveUse of lpratropiumBromide in the EmergencyManagementof Acute Asthma of Emergency DJ Dire/Department PKCellucci, SM Tiernan, Army Darnall Program, Residency Medicine Emergency Medicine, FortHood,Texas Hospital, Community

Our stucly was undcrtakcn to dctermine whethcr inhaled ipratropiun-r brrimiclc aclds significantly to thc bronchodilation obtainccl with inhalcd bcta-agonist alonc in the sctting of an acute asthma cxaccrbation. All patict-rtswho presented to our emergency with an acutc asthma attick with an initial FEV, of ,i"pri,-"", 25''/,,to 75n1, <':[prcdictcd were evaluated {or cnro]lment in this cloublc-blinded siudy. Paticnts less than 18 ycars oid or with a i.iriu.y ui glaucoma, urinary tract obstruction, chronic steroid dcpcndencc, crnphysema, chronrc bronchitis, or cigarctte smoking werc cxcluiecl. Ali paticnts rcceivcd 2 mg tcrbutaline with 1 mL sairnc by a n-rinincl-rulizcr at 0, (r0, and 90 mrnutes lmmediately aftcr th{r first dosc of terbutalinc, patients in Group A received four puffs of ipratropiun-r bromide administered by a metcred-dose t a n n i s t c r w i t h a n i n t e r p o s e d s p a c i n g d c v i c e t o s t a n d a r d i z et h e close.Paticnts rn Grtlup B reccived a placebo in thc same manner' was performed on all paticnts immcdiatcly alter Rcpcat sprromctry 'and 9O-minutl terbutaline treatlncnts There were 20 the 6O60-minute, and 90-minute patients ' m e a n in Group A who had an initial, F E V , o l 4 B - . 9 % , 6 3 . 3 % ,a n d 7 3 . 7 % o I p r e d i c t e d , r e s p e c t i v e l y ' Thcre werb l8 patients in Group B who had an initial, 60-minute, prea r . r d9 O - m i n u t e m e a n F E V , o f + 2 5 " k , 5 8 0 % , a n d 6 8 3 % o { respectively. The initial, 60-mrnute, and 90-minute mean -t"f"'.. clicted, for Group A and Group B wcre not statisticaily iEv,

.145 Response of Bronchial Smooth Muscle to MgCl2 'n Vitro of .Emergency MH Spivey,E Skobeloff, R Levin/Department The MedicalCollegeof of Research, Medicine,-Division ol Urology,University the Department Philadelphia; Pennsylvania, PhiladelPhia of Pennsylvania.

Magnesrumhas becn dcmonstratcdto bc an cflective bron' chodilxor when given IV or by IM injection The rnechanismlor ihi, i. .,t.l.rt, lrut it has becn postulated to act directly on thc bronchial smooth muscle. Our study was dcsignedto cxamine cffecton bronchialsmoothmuscle Five-poundNcw magnesiutn's

\')

r-

different lP = .167, two-factor repeated measures ANOVA). Thc concurrent use of inhaled ipratropium and terbutaline does not a greater improvement in FEV, at 60 and 90 minutcs ovcr I.:rl, 1n l n n a t e o t e r b u t a l t n ea l o n e .

'148

The Utility of ExtendedEmergencyDepartment Treatmentof Asthma: An Analysis of lmprovementin Peak Expiratory Flow Rate as a Function of Time RJZalenski, JC Raucci,N Dejneka, S Schabowski, M !.G_Murphy, McDerrnotVDepartment of Emergency Med'icjne, CookCounty Hospital; University of Health Sciences, TheChicago Medicai School; RushMedical College, Chicago, lllinois

Wc studied thc efficacy of cxtendcd cmergcncy department treatment time in achieving a pEFR of S0% predictcd-{pEFR..).

A c h i c v c . m r : n ct _r f P t F R _ , ,w i t h i n t h r c c t i m c f r a m e s * r , . u . l u r r i l J wlthln t()ur, four to cight, and eight to l2 hours of presentation.

Entry into the study commenced when ED treatmcnt was initiatccl.

Thc PEFR was rccorded hourly for up to 12 hours. paticnts wcre categorizcd at presentation by thc ratiir of initial pEFR to prcdictccl P E I R i n t o g r o u p A 1 . 4 0t o . 4 9 1 ,g r o u p B ( . 3 0 t o . 3 9 ) , g r o u p C ( . 2 0 t < r 29), anrJ. group D (lcss than.20). Includcd *"r. pr[i",-rt. "g"d lf, t,, 45 years. Excluded were pregnant worlen, thosc hospitalir"d, thur" wlth an acute comorbid illness,and thosc with initial pEFRof morc than PEFR.,,._Thestudy group was 62"k rnale ancl()0,'/oblack with a m e a n a g e o f 2 [ 3y e a r s .A s s i g n m e n t o { p a t i e n t s i n t o s u v c r i t y g r o u p s y ieldcd,4 I 122%) patients in group A, 42 ;/,,J 123%l in groul.rs, ai eS in group.C, and 36 120%) in group D. Achicvcrncnt oi pffn . reQuircd four to cight hours for 33 I l BZ, pationts ancl rccluircd cigl-r'f ) to.12 hours Jor sevcn (4%l patlcnts. Group A had only onc paticnt who ncedcd more than fuur hours tu ,ihi"u. PEFR GioLrp B ,,. i n c l u d e d3 4 . 1 I I q oI p a ri r - n , rw s h o i r c h i e v c dp E F R . ,w i t h i n i , , u , h , , u r r , tivc {3%)who rccluircdfour to cight hours, anJ'thrcc who nccclcci e i g h t t o l 2 h o u r s . G r o u p C i n c l u c i c d 2 S l l S , ' 1 , )p a t i c n t s w i t h i n f o u r h o u r s , .1 ( r( 9 % ) w i t h i n f o u r t o e i g h t h o u r s , a n d i h r c c r c c l u i r i n g c i g l . r t t o 1 2 h o u r s . G r o u p D h a d 1 2 1 7 , / , )p a t i c n t s w h o a c h i c v c d p E f R ,, within four hours, I I _(6,/olnecding four to cight hours, and , rnly onl paticnt.who rccluircd eight to l2 hours. Ninctccn { 1 0 % , )p a t i c n t s werc discharged from thc ED without having achicvcd^pEFR,,..

Extcnding ED asthma trcatmcnt tlmc in uncomplicatcd asthmal'_ ics for more than four hours yiclds a substantial incrcasc in thc percentagc of patients rcaching thc therapcutio goal of PEFR ,,.

Only a small proportron of paticnts objcitivcly'Lcncfitcct froiil more.than eight hours of ED treatmcnt time in this stucly gror.rp, a n d t h < ; s cw h o d i d s o w c r c n o t p r c d i c t a b l c o n t h c b a s i s J f l n i t i i i PEFR.

+ I

I

d

149 Evaluation of Brain Edema Using euantitative Magnetic Resonance lmaging JE Olson,A Katz-Stein,NV Reo, FA Jolesz,RVW Dimlich/ Departments of EmergencyMedicine,physiologyand Biophysics, and Biochemistryand The Kettering-Scoti tr/agnaticResonance Laboratory, WrightStateUniversity Schoolof Medicine,Dayton, Ohio;Department of Radiology, Brighamand Women,sHospital, MedicalSchool,Boston;Departmentsof Emergency fl_arvald Medicine and Anatomyand Cell Biology,University of Cincinnatj Little is known aboutthe mcchani-sms of brainwater homcosta_ sis.Consequently,current therapiesfor brain edcmaarc limited to nonspccrfic andshort-livcdstcroidal,osmolar,anddiurcticmodali_ tres/trcatmcnts that are contraindicatedin many emurgcncysitLl_ atrons.In our study, wc evaiuatcd an anrmal model irf ccrcbral edema Llslng quantitative proton magnetic resonancc imaging (MRI)techniqucs.T,-weightedNMR images(TE, t30rns;TR, l-sccj were obtained from adult rats. After acquinng a basclineimagc, brain.edemawas producedby Ip injectibn wiih a volurnc (v)'oi drstltledwater equivalentto l5% of the animal,sbody weight.

Sixty minutes later, anrrnalsreceivedI00 g/L NaCl Ip in a voluir-re equalto 0.1 (V).Control animalsdid not ieccivewater or soclium chlorideinjections.Thc mean(t SEM)NMR irnageintcnsityof thc brain_in-creased by 10-7 t f .4% 60 minutes after tiie water lniection {N = 5, P < .00I ) and then fell to control vah-rcs60 minutcs aftcr thc sodium chloride rnjection. The rnean intcnsity of images from control animals did not vary over this two-hour time pcriorl. In paralielstudies,animals were injectedwith cither 5% or 15% waterand were sacrificedfor dcterminationo{ brain warer contcnt by specificgravity rneasurementsor werefixed for electronmrcros_ copy.The mean (+ SEM) cerebralgray matter watcr content in_ creased from 80.9t 0.I % to Ul.B t 0.2%{N = 12,p < .005)(r0mrnutes

53

after a 5"/o water injection. Electron microscopy showed enlarged a s t r o c y t e e n d f e e t a n d e x t r a c e l l u l a r s p a c e s .E n d o t h e l i a l c e l l s , n e u _ ronsi axons, and myelin appeared normal. Brain water content d e c r e a s e dt o c o n t r o l v a l u e s 6 0 m i n u t e s a f t e r a s o d i u m c h l o r i d e injection. We conclude that MRI is a sensitive indicator for measu r i n g s m a l l c h a n g c si n b r a i n w a t e r c o n t e n t i n t h i s a n i m a l m o d e l o f brain edema.This technique may be used to study the time course o f t h e r e m o v a l o f e x c e s sw a t e r d u r i n g b r a i n c d e m a a n t l t o q u a n t i t a _ tively evaluate potential specific treitmc.,ts for brain cdema pres_ cnt during pathological states.

150 Effectof High-DoseNorepinephrineVersus Epinephrineon Cerebraland MyocardialBlood Flow During CPR JW Hoekstra, PFVanLigten, R Neumar, HAWerman, J Anderson, CG Brown/Division of Emergency Medicine andDepanment ot Preventive Medicine, TheOhioStateUniversitv, Columbus

Scveralstudies have dcmonstratcd an impiovcrnent in ccrebral b l r r o d f l o w { C B F Ia n . dm y o c a r d i a l b l o o d f l o w lMnf ) with largc doscs o f r p i n t p h r i n c ( E ) d u r i n g c l o s c d - c h c s tC p R . T h e c f f e c t s o i s i m i l a r d o s e so f . n o r c p i n e p h r i n c { N E ) h a v c n o t b e c n s t u t l i c d . T h c p u r p o s c o f our study *{*t: .orlpr.c thc cffccts of high-dosc e ,reisui high_ dosc NE on CBF and MBF during CpR. Fourtccn swinc wcighing m o r c . t h a n l 5 k g w c r c a n c s t h e t i z e c la n c l i n s t r u m c n t e d f c , , r c g i o n a i b l o o d f l o w a n d h c r n o c l y n a m i c m c a s u r er n c n t s . A f t c r t c n m r n u t e s o f v c n t r i c u l a r f i b r i l l a t i o n C p R w a s l r c g u nu s i n g a r n c c h a n i c a l t h u m p c r .

Aftcr thrcc minutcs of CpR, thc anirnalsrcieivcd cithcr E 0.20 mg/ k g ( s c v c n )o r N E 0 . 2 0 n t g / k g ( s c v c n )t h r o u g h a r i g h t a t r i a l . r t h " t c r .

CPR was continucd for an additronal thrcc rninutcs, and dcfibrilla_ t i o n w a s t h c r . ra. t t c m p t c d . C I } F ( n r L / m i n / 1 0 0 g ) , M B F ( m L / m i n / 1 0 0 g ) , r n y o c a r d i a l o x y g c n d c l i v c r y { M D O , ; r n f - O , / r n i n / f 0 0 g ) ,m y o c a r _ dial oxygcn consurnption (MVO,, mL O,/rnin/l0O 9 1 ,a n d c x t . a c t i o n . r l t i o s ( E R ;M V ( ) . / M D ( ) , 1 w r ' r c m c a s u r c t ld u r i n g n o n n a l s i n u s r l t y t h r n , t l L r r r n gC P R , a n t l a f t e r d r u 3 a d n r i n i s t r i l t t o n .T h c r e \ u l t \ dr-rringCPR and aftcr drug adrninistration, inclucling ratcs of s u c c c s s f u l r c s u s c i t a t i o n ( S R ; , / , , ) ,a r c c l i s p l a y c db c k r w . 1 ) ' v a l u c sf o r E v c r s u s N E w c r c c a l c u l a t c d b y a n a l y s i s o f c o v a r i a n c c ,a d j u s t i n g f o r b a s c l i n c c l i f f c r c r - r c cdsu r i n g C p R . cBF N,4BF MDO, NilVO, ER sR

CPR 1. 0 t 1. 3 4.0!2.9 0 . 6t 0 . 5 0 . 6I 0 . 5 9 3 . 6t 5 . 5

CPH+E 1 0 . 5I 4 . 4 62.2!45.3 9 . 4I 6 . 3 2 . 0t 3 . 8 7 8 . 2x 1 3 . 0 85.7

CpR+NE 1 7 . 31 1 69 118.9r73.1 19 . 91 1 3 . 4 1 1 . 9t 8 . 6 7 7 . Ox 1 3 . 4 57.1

P 0.33 0.04 0.05 0 . 10 0.74 0.56

Whilc NE improvccl MBF and MDO, ovcr E, SR ratcs wcrc lowcr with NE duc to postdcfibrillation airhythmias in thrcc of scvcn a l i r n a l s . F u r t h c r s t L r d yi s r c q u i r c d t o d c l i n c a t c t h c r n c c h a n i s m o f thcsc arrlrythmias with NE.

151 CerebrovascularOcclusion: When Do Hemorrhagic InfarctsDevelop?

GDde Courlen-Myers, M Kleinholz, JA Wolker,KRWagner,RE Myers/University andVAMCof Cincinnati, Ohio W h y h c m o r r h a g i c i n f a r c t s _d c v c k r p i s p o o r l y u n d c r s t o o d c x c c p t . for an association with crnbolic sirokcs. Tircy arc of intcrcst b c c a u s ct h c y m a y c o l r p l i c a t c f i b r i n o l y t i c s t r o k c t r c a t n c n t . O f 1 0 5 p c r m a n e n t a n c l t c m p o r a r y m i d d l c c e r c b r a la r t c r y ( M C A ) o c c l u s i o n s i n c a t s , 8 3 d c v _ c l o p c di n f a r c t s , o f _ w h i c h 2 6 1 3 l % ) w c r e h c m o r r h a g i c w i t h s c a t t c r c dp e t c c h i a l h c m u r r h a g c s o f t c n c o a i c s c i n gt o s m a l l h c _ lnatorras affecting mainly grcy mattcr. Hcrnorrhagii infarcts de_ vrlopcd ovcrwhclrningly in hypcrglyccrnic (20 mM) cornparcd w t t h n c r r r n r r g l y c e m i c{ ( . r n M ) c a t s ( i e , 2 5 o f 5 8 o r 4 5 y o c o m p a r e d w i t h o n c o f 2 5 o r 4 % , ;P < . 0 0 2) . H c r n o r r h a g c s i n t o i n f a r c t s o c c u r r c d r n a x i n ' r a l l y ( 1 0 0 % ) i n h y p c r g l y c c n " r r cc a t s w i t h f o u r a n d c i g l - r th o u r occlusions with rcpcrfusion followed by 26% after pcrmanent o c c l u s i o n . _ T h es i n g l e h c r n o r r h a g i c i n f a r c i i n a n o r m o g l y c c m i c c a t occurred after an cight-hour tcmporary occlusion. The rnean+ SEM i n f a r c t s i z e ( % M C A t c r r i t o r y ) w a s s i g n i f i c a n t l y s r n a l l c r ( p < . 0 5 )i n 3B nonhemorrhagic {32 t 5 %,) than in nine hemorrhagic infarcts i(r2 + 12"k) after pcnrancnt with cvcn grcater diffcrenccs aftc. occiu_ s i o n f o l l o w c d b y r e l e a s e( 2 0 n o n h c r n o r r h a g i c , l 2 + 5 % ; 1 ( r h e m o r _ r h a g i c , t 3 3+ 9 ' %j P < . 0 0 1 ) .T w o f a c t o r s f a v o i i n g t h e d c v e l o p m e n t o f hcmorrhagic infarcts cmergc: hyperglycemii and restored bloocl flow after tcmporary occlusion. Hypeiglyccmia, by enhancing the tissue acidosis of ischemia, apparently c*n."rbni"s both ceiitral nervous systcm parenchymal and vascular damage, leading to

of Emergency BC White, DM Feldman,Ll Grossman/Section Molecular illol.i.L, o"p"rtment oi Surgery,and Department,of Wayne Biology' Molecular for Center and G"netics eiolo;u ;no "'-il;;;;itLrASiite-0niversitySchoolof Medicine Detroit'Michigan t'i" radical-inducedDNA damagemav contrib-152 Cerebral Multifocal Hypoperfusion After Cardiac of brain ce11nuclei during reperfusionafter ",.^,"^ait".gi"irriint-t and lrreit in Dogs, Mitigated by Hypertension is providedby-the for this.sc.heme. support Partial ,*.'., ."rai". inhibHemodilution dcferoxamine chelator iron th" ihat ;;;;;;;;d;;",.,rt.otio" Hecht'K F Sterz,P Safar,Y Leonov,D Johnson,R Latchaw'S injury; however, it does not appearto membrane ..p.if"ti"" i,r Department and ResuscitationResearchCenter damage' Oku/lnternational "r-r,"i'..ff" in adccluatcquantities to prevent.nuclear Pennsylvanra of Pittsburgh, University iron-mediated " Radiology, of examine tb undertaken was ,,.t,iy * ih*.f;, aftcr carthe doseH.-,ffi",ron plus hypcrtcnsionplus heparinization oNn a"-^s' as wcll as t9 ch1r1c13rize ;.;;;;';;et;;i isafar1976)This couldbc the chelator iron {lcliacarrcstin dogsimproJe'cloutcome expcrimental an by protecti;n responscfor DNA arrcstccrcbral,11jl; rcsult of a more homogcncouspost-cardiac EMHP), rvhose chemical t.,yo'o'vpv'ic1'-4-one; J :;i';l-;;;;h;i l l ( r w hl{)otl ll\-Drl s i o n .W e t n o n i t o r t dm u l t i [ r r c a{ll o c a l )c c r t h r a l st improvctlpcnetratton-both o[ cell memhrancs oronertics su,{gr: fibrillaclosedcircular DNA *iifr x"-ci (WolfsonlgfltjJin a'dogmodcl oJvcntricular ;;i ;,i',-h."I.ffi;-brain harricr' Supercorled w'ith arrcst of to or iz s minutes no flow repcriusion breaks One break ii;;-;;;il. strand for syst;m ii,rti[", , ."ntitive deteciion s P B ) e, a r l y . d ei bf r il l a n lt o n a r yl l v p a s -l C ,,"..".rr.r, crR,,r car,li,,pu giving a nickcdtrrcle form that oNe, thc ""."11' il'"ii;;;;,;;;; l f m e a na r t ( r i a lP r c \ s u r e small , ' ' . - . , " j i i ' p v t - , , . i xh , , u r , ,w i t h e t ' n t r ' i o -"i. ,tn*ly nn g"t clectropiioresis Wc used a -ritri"t and tcmperaturc with normal pBS i'i,",J'g"", ;;;;;i damage r1d5ai i.;il"l;,ii,^ hvdroxll studv bpito 2,i00 pBS, pi^lt"ia"ona f (14),thc.rcwas concentra,.'-'"rn"r,".inl prcssurcand hcmatocritafter arrest intracellular normal the to cxposcti ijN,t tzoo ng) was hyp"..-o followcd bv hvpopcrfr'rsionwith rnuliron concentrai;h:;-;,;;;;,.,;, (0 4." ,,ifH,o,'i:0 miciornolar)and variou-s-fer1ou1 itu* (0 to 10.m1/100g/min) and low flow to ;;;i;'i,;;:,,i;i.tl. in I mM Fe2',thereis extensive minutcs l5 Aftcr ,i,r". rt nU 7.'5.

At the low molecuzil -lt, which wcrc not prcscntbcforcarrcst hnmcdiatc l.rostarrcst ir"*t,ir,i,rr, ii,ii.l Jn-ng" n"curs at 50 nM Fe2" l . t t r h o u r s{ m c J nz r t er i r t lp r es s t r r'e thc brain by two in H ; i ; i h I r , , r " p i npeh r i n c l . t r vr e sccn (0 4 rnM) conccnLration iron inirr"igflt u ys p c r i n i n i t i a lh . r ' t n o g c n t o h all the pBSis arrest, 1 5 0t o I . l 0 l n m H g l l t h r t J (rj (l . s u l t c d cardiac I 5-ininute a hours ot rcpcrtusronartcr norru)tcllfollowcclbyno tricklc f low areas;with suhsequcnt cr-nia, t'v I 5 minutes at 3 7.c and is completelv .iitt"t :#;;;l;;;i.'.a norrnovolcmtc of 162and ,i,in, tri"k1" f luw arcasappcarcdHowcvcr,aclditional ir^*t"".r"a frofour hours.EMHP hasa molccularweight (two] of I iiX, to 20,,1,starting with rcpcrfusio' watcr' rhe and iiO'',,, f-r"n",",,rcrit n-octanol bctwccn 5 ;'::;;ii,;;'li,.iil.i""iJtn normalizationof lcBr_pattcrnsand normal sitesmust i.r"ii.a in sustainccl .r.'"i^i,ri .,r*iinr,.. ,, threc sites on iron, and all threc arcashad flows sCllF valuespur,rrr".r.'Ai fivc minutcs,all lxain mctal inactivc in redoxreactions' transition thc r"t.t.t"t t,i fili;A ;; flow low or with no tricklc +ir'"ilroo g/r.r.rin in rcactions :i';,;;.ih*;i.'

Thc EMHP to Fc ratio was varicd from 0:1 to 32:1 was notcd Hy4 mM Fe" and 30 0 in pH '5 "",.t,iitg to six hours' No'ilypopcriusionstatc 7 C, 37 pBS at ng 200 with concluctcd hcr.notlil'tion ,""t-,-,'''tt'bc able to prevcnt post-czlrdiac ;;;.;;t; H,o,. er,"i:o minutcs ind four hours of incubation' ;i;;;;ir (4:1 and 8:1) arrcst r-nultifocalhypopcr{r'rsion ;l.';';BS ;;; ""iti."t.,t to clcctrophorcsis Lowcr showcd somc protcctivc effcct after 30 ",,;";;t";;;.tr'Euip Failure ol by four hours' 153 Cerebral lschemia and Reperfusion: n'linlltcs. Howcvcr, markcd damagc wai. evidcnt comjz't1 EMHP.protectcd Increased of Promote to .u.tttntt't-io"' Therapy a,'t,t iji-rr", lro,l Hvperbaric Oxygen darnage o{ tracc ryas!!il.r i-,i:ti; l;':0 ;;;";"' ;;i,;;;1.';;;.; Suivival or Neurologic Protection bv the32:1 wasachicved J P Smiin,GH Marshall'Jr' RF Shesser/Department l;t;ili; ;; i i; i; 1,;;;;-ple te protcction RE Rosentnat, ratios lower thc seen.at University closc.Howcvcr, in no cascdidthc damage. o'f fmligency lt/edicine,The GeorgeWashington has EMHP alxence complctc its in d"io'gt DC ;ft"ffiP;"Jth" Medicalbenter, Washington, harricr' blood-brain in thc crtrssing n-rortality {or and pr,'p.tiitt notcntiallvsupcrlor Ncurologici.tlury caiitts 'ignif ica.nt.morbrdity is cffectivcin prcventingin vitro DNA is belicvcdto bc a rnaior #;;;;;;i';il,i-Ir,'ErtrHp arrcstsurvivorsLipitl ic'roxitlatitrn cartli:rc rcstor:rtirln thc breali of one sugar-phosphate thc dctccts aftcr tf"t", occurring *.nv tt'r" damagc lttt"g. r-rcurologic causcof ongoing global bond in 5,400. aitcr o' Brcathing ;;;;;;;il;;li,."rniiii.'lnoscf 1.09'z'pcroxidati<ln ccrcbralischcmia has bccn shown to incrcasclipid ot cats ly, hypcrbaricoxygcn.trcatmcnt Paradoxical nnJ t-t-turtrli,y.

155 The Relative Contributions of Early Defibrillation EEGrccovcryand to timc shortens and Survival arrest r.rfri..,a.i,.'airculatory ""0 nCGl"terventionsto Resuscitation studv was ccrcbral spirial flr'ricllactatc prodr-rctionc)ur ;;;;;;;;; Arrest Cardiac FromPrehosPital survival jB K Crump/ to dcten.,rinclh" ;il;.; of hypcrbarrcoxygonon clcsignccl RO Cummins, Gr"ret, S Horan'MP Larsen' arrcst Malc ncr.rroltlgicini.,,y "titti"tt-'scitatitln from cardiac w":hilg-t-ol.center for an<1 niversitv^of U ne, Medici "i ij Jp"it".t (36 'rg) IP.with kctamine County' Wistar rats (3a'0to 460 ;t anesth'-tizcd o1EmergencyMedicalServic,es'.Ktng Lvatuation *lit vcntilatcdwith room air aftcr micllinc Schoolof Services; Medical ^"J -vl"?i.. fo.s tr.,g), Emergency oi Divisio-n W*f'tg;., cold 1"1'KCI foltracheototny.tn,.^.^,ii^"-it'lection of.O-+rnL Washington,Seattle of niversity n"", U f '' ft .Ji.i -w",rtrlvr"d arrcst' cardiac inutc i,r*".l bv thoracic comprcssi(rn in {u19{ r1-r;rn tht arrcst"tnid' oi B2Bconsccutivepeopleresussvnchro;";,,rnpli.h'.J *ith IACCPR {70 pcr rninutcJ iic;G;"; cardiacarrcst {rom 1981through l98T to prehospital fr,rm pc1 citat.d vcntilation (a0 of defibriliation and the addinous with room air vcntilation' Room air contributions relative the clctcrminc (ACLS) interventions of enminute) was corltin.,eJ Lrntil spontancor'rsrespiratioli support life ^lllYl'1, cardiat ;k-;i;;;.d wcrc ptrced ln a -;;t';;f Afi.r "tt.,bntion {(r2t lt3 minutcs),40:nirnals ;J.iv ;'liatrn?c9l9qy to resuscitationand intubation rlotrachcal to assigncd (EMT-D plus t.'vp"'r-,i. lt'n'''bti' and altcrnatclv ;;;il ;ttival. In our t*i titted EMS svstemi;;-;; or rooln patients who regaineda with hypcrbaricoxygen(2 atm absolutcIATAI] groups: ,t."i-"", two rlefined wc ;;-;;i.J; survival was recorded "i, t-ii"f fori.norcthan six hours under the care ii ,cia) for 90 rninutcs Animal i"ri"i".al&rrtt"g;hih''' a"ritii ttuttt mcasurcd.in thosc animals and those who artiy'*iirt'"."-l"gi. of EMTs traincd ,o o.{-i-1."ii1""(EMT I Resus) in survival d.i{{erence surviving threc anclt"" ityt iftt'c w.?sl9 rhyihm uuderthe carcof paramedics p.iiuling tr.toin"d ,.olin.a, (55'l') hypcrw-ithI I of 20 i54%l betweentrcatnent groupsichi-squared) fifiy_oncof the resuscitations r."iir",t*.i iNi;ii;ffi;i. *l n"J ten .{ 20 {50%)room air-treatedrats ;;;i;;;s;"r.r,.i ,.rruttro,, Mosi resuscitatiols (583' 70%) were long-term werc similarly survivors of scores long-term survlvors surviving tcn days.N".tiofogit a"fic.it i;;;irllu;" "."tricular fibril]ation, an! mo11 groups at three days (361,80%) EMT Ds' on the anest showed no signiticant dif{eicncesbetween fibrillation u*trl.nln, ;;; oxvsen= '58 t 8 7' room air = 6.9 x.6,6ti; il = 11111 (hyperbaric beiore arrival of theparamedics' "u.rrg. nf s'i -i""ttt ;;;;.;" = l'3 + 2 8; t' r4l as t^tTl; .i"lit tftvp"rtrtiJo"yg.tt = 2'4 ! 3 2i room air o{ z7;k to achieve \99) ail ventricutq flb-:llti:19,1 were able does ur d' IrTo lrz+l *Jr.rrLatv,rr. t*u_-*-pl. r test. Hyperbaricoxygentherapy survlvors'.ano long-term vors,22"/o(99) of all protcctlon < ) not appcarto promote inircascd survival or ncurologic model for t"i- lrr.vival was significantlybetter]? .0^1 t_orrg resuscitations. to nursing homesl' after cardiac,.r.r, ,,,i "t*ival using this expcrimcntal in the EMT-D Resus group 1797n,wtth 4"/o to nursing global ccrebralischemra' *rift ,n. m.?lt Rt"" gtottp (fov;' ,1th B% ."-pr*J alone de{ibrillation of arrival eirly ttt't r..o"iliil;"..i. dt;;," .154 A Dose-Response Study of an Experimental lron may be processes larserinfarctsand red cell extravasation,and both vcsscls' affected thc in pressure biood ;;;;6;storing

f;lijffii;:il'*:lf,:1 ill:.'";:r',:: ::::]*fjni"J,r:i;r;ti

Cneiatorfor Inhibitionof DNADamageby oxygen Radicals

;;:?;;;';"h;"t

54

closeACLS backup The additionalinterventrons

ol early intubation and IV pharmacology are requirecl to achieve m a x i m u m p r e h o s p i t a ls u r v r v a l .

'156

However, thc out-of-hospital cardiac arrest victim reprcscnrs a drfferen_t population with differcnt prit opt.,y.iotug;r" .patrent uf a r r c s t . W e , . t h e r e f o r e , p r o s p c c t i v e.l y s t u d i e d t h e outcome of all elderly vrctims of out-of-hosprtal cardiac arrest treatcd within a l.tg:, urhan paramedic EMS systcm over a six_month period it T q l : o detcrmrnc thcir overall prognosis and to identi{y any specific survival factors. patient,outcomus were analyzed with iespect tcr m u l t i p l e v a r i a b l c s i n c l u d t n g a g c ,s c x i w h c t h e r m o n i t o . e d, *he thci w i t n e s s . e db , y s t a n d e rC p R , a n d b l o o d p r e s s u r c o r c a r d i a c. i r y , f r - ^ , _ hospital arnval. Outcomes evaluate,i includeJ in f.lnrpitri ,Jrnir_ sron (resuscitatcd) and succcsstul dischargc from the hospiiat ( s u r v i v a l l . F o r t h c p u r p o _ s eos f o u r 5 1 1 i l y ,p a t i e n t s whosc arrest'was injury, hemorrhagc, oi.a'clear rcspiratory ctiolosy 3 : : " : tl o il:!

Tlh l u $ / r c r g l l b o d y a s p i r a t i o n ) w e r c e x c l u d c d . T h e r e s u l t . sd c m o n _ stratcd that of l7Z consecutive cldcrly cardiac arrcst vrctims cvaluated, 39 lzz%,) wcrc successfully ics.,scitatca ,"J Li-tfJt survivcd ovcrall. Of thcsc iZZ paticnti, 59 1 3 3 , 1 ,h) a d v e n t r i c u l a i

EMT-D Survivors: The Contribution of Defibrillation D Fark,J_LaRochelle, DW Olson,G Hendley,Tp Aufderheide,HA Slue-ven/Department of EmergencyMedicin'e',MilwauxeeCounty MedicalComplex,MedicalCottegeof Wisconsin, Milwaukee rncdicaltechnicran__defibrillator programs . Emergency {EMT_D) haveirnprovedsurwivalfrom preh.,spi;i ;;;.li; arrrsr In nrany settings.However,the counrershocksderiveredlly EMT-Ds clonoi appear to contributeto the resuscitation of all survivors.ln Wisconsin,64 rural and suburbanmanual EMT_D serviccsfn.*r.a."pir.i. for rnedicalreview.Thc contributi"" "f a.fiLriiiiriion in the first 4+ srrrvlvorsrs reportcd.The arrest rhythm was ventricular fibrilla_ ,ion clissociation in 11^11survivors{95%)and eleciromechanicai two l.'r7oJ. forty-one vcntricurar fibrillation paticnts rcceivcd countcrshocks and were.divided into two gru.,pr.Group l, 29 patlcnts {66%1,achicvc"da perfusingrhythin tirat pcrsistcj to j]]r11!*^r.hycardia asthcirlnitial"i."rt'.hythm.rh.,.,.,rii:litiy provisionof advancedlifc support(af,3).fhclr final countcrshocl< o r s l r r v r v o r s w e r c f u u n d . i n t h . i s s u h g r o u p , a s 2 5 ( a 2 % ) o f i h c s c wasdelivcredt9.9t 5.5 minutes beforc'ALS.Group 2, cldcrly vcntricular fibrillation/tachyiardia' potl.n., l2 patients wcrc resuscr_ (27"/'),remainedin full arrestat thc time uf aii, d r ] , 1 n i n c { 1 5 ' . / " )s u r v i v c d . A p a r t f r o m h " u , n g u " n t r i . t , l r . it ntrgt.,eight hJ earlicrrcgaincdat lcast transicntpcrfusingor clcctromcchanical r: 1r nt .n. l1l al ,t l { ' l t / r a c h y c a r d i a a s t h c i n i t l a l r h y t h n _ r ,b y s t a n c l e rC p R a l s o dissoc.iation rhythms. Ovcrall,3l paticnts'ictu-.a ,u , appcarcd to contributc t. bcttcr survival ratcs.'During t;;;;;;, thc sarnc neurologicx^ate_(7}%lincluding 2 i frorn grrrupI s t u d y p c r i o d , t h c r e w c r c 3 0 0 t o t a l c a r c l i a ca r r c s t v i c t i m s ilzU,l and scvcn less than tronr group 2lS8%, p = NSJ.Withi,, g.u.,p i, thc 70 ycars old, of whorn 7g 126,l) wcrc rcsuscitatccl paticnts wh. antl ql fii,l returnedto a prcarrcstncurologic_statc'ira,l'a s u r v i v e d .

T h c s c d a t a c o n f i r m t h a t t h c p r o g n o s i sf o i c l d c r l y rigr-,ifi.ontlyshortci victims tirne from trrest to pcrfusingrhythm than thosc who of out-of-hospital cardiac arrcst rs ntrt cntiicly blcak clctcrioratcJ a n c l ,i n f a c t , i s g.(r t,-t.(r vcrsus * lZ.fl id.y minutes, p < .002). In our rcvicw, vcry rc:rsonablcif vcntricular fibrillation/tachycardia i. ifr.l'r": dcfibrillationby EMT-Ds clearly conrib,rt..lii,-r"..,r.rtation scnting rhythrn. fro,' prehcrspital cardiacarrest.in2gtrt 44 survivors(6(r%,, group l) by rcstoringa pcrfusingrhythrn hc{oreALS prtry1.i,,n 159 PrehospitalprophylacticLidocaineDoes Not

FavorablyAffect the

i

patients

Outcomeof With Chest 157 Prehospital Transcutaneous Cardiac pacing _ Pain Phase ll HA Stueven, p EMwaite,JR Mareer, f,Y l,?,s*r, f f Qrrggmln, JH Hedges,S Feero,R Easter,B Shultz,SA Syverud,WC HaecKer, I p Autderheide, Datseyl DW olson/Department of Emergency OregonHealthSciencesUnrversity, portianO;ifrurslon Medicine, Milwaukee County CountyMedical Complex, VeOicat C5ttege ot Medic.One, O^lympia, Washington; University'ot Cirrcinnati; WilforO Wisconsin, Milwaukee HallMedicalCenter,LacklanO nfS, San nnionio,iexas prchospit:tl pararrcclic systcn-rs acLrinistcr prcphylactic Controllcdoutcomestudicsof prchospitaltrr,rr".,,r,-,",,,,, r,,l r,l o:l11". c ' a l n ' jr ( ) a l l | a t i e n r s w h o p r c , s c n tw _ i t h c h c s t p a i n anr_ irf iuspectcd diac pacing(PACE)havc suggcstc,:l thoi "r.ly aJmrnistrati.n .f c a r d i a c _ o r i g i ni n h o p c s o f p r c v c n t i n g m a l i g n a n t u " n t r i . u l n . rr'.1_,yih_ i: nccdcd to improvc survival. Wc pcrforn-rccl n - r i a s .A l t h o u g h m a n y r c p o r t s h a v c b c c n w r i t t c n ,, p.,,rfr".iiu. !.1.1n9 on cfficacy in study of PACE availablc on a daily basii with coni1urisu,l coronary carc units, prchospital data lrc scarcc.

-ir.,. t,, a A randornizctl historical control population of paticnts i.,iii., p r ( ) s p e f t i v c s t l r t l y t . r fp r r p h y l a c t i c l i d o c a i n c sanc EMS . was conductccl.n all systcmwith PACE availablconly-on an altcrnatc-dny s t : i l ) l L ' p i l t l e n t s lrrrir. W" w i t h s t r s p e e t r dc t r r t l i ; r cc h c s t f r d i n p r e \ ( , t l t i n gl o i l hyp.thcsizcd that daily availabiliiy -,r"ia,Li,"li thc ti.rc frou.r s y s t c m ^ f r , ) n rI a n u a r y l 9 l t 4 t h r o u g h fanJary l9lJu. Dur_ lrl1: t1tt,1l |rl 'r"su , . c a r o l a c . d c c o l n p e n s a tui onnr i l p A C E l n d s u b s c r l u c n t l v p c n o t l , 1 , 4 2 7p ; t t i c n t - sw c r c c n t c r c d ; 2 0 4 r c c c i v c d ilrrprovc lidocainc, survival.Estirnateclsurvival probabiliticswcrc falculrrtcd'from , : , i : r , , , : : d l r t n { ) r L ) . i s c h i r r g c . d i a g n o s ii ns c l u d c d 3 1 , 2 , acurc rnyocarlogistic.rcgrcssionrnodelsof iurvivai,,ilr,,rpiLilamissirn ( l r a l i l r l a r c t l ( ) n , , 3 3 ' 2 , ancl uDstablc angina, 7,1,othcr cardiac, uni 2r)%, survivalto hospitaldischargcbascdon historlcalcontrol popula_ n o n c a r c l i a c ,w i t h a n o v c r a l l r n o r t a l i t y o f 7 . 4 , 1 , T h c r c was an cqual tion charactcristics (144wiincsseclarrcsts).Comparisonof actual clistribution of dcaths bctwcc,nthc lidocainc (SZi rra no lidocainc to cxpcctedsurvivalwas maclcwith aZ tcst. Othcr ( 4 { 3g1r o u p s . C ) n l y s i x c a r d i o p u l m o n a r y a r r c s t sp r c l o s p i t a l dichotomous ,,..*.",f variableswcrc comparcdwith chi_sc1"rr",nntv.i.. a n c l I 5 o c c u r r c d i n t l - r cc r n c i g c n c y d c p a r , n - , " n , i l v t n l i g n a n t Continuous vcntncu_ werc comparcd.with,anunpaircdr test. A significancc l a r a r r h y r h r n i a s a s t h c p r c c i p i t a t i n g I11tio,::, ar.cst .hythiii-ii pattcnts with level ot l, < .U5was usedthroughollt. During thc four_r_nonth a c u t c _ r n y o c a r c l i ai nl { a r c t i . ' w c r c s i m i l a r f u r b o t h t h c ' l i d o c a i n c stucly and period, 25 patients with witnesscd carclrac,rc"umpc.,.at,u., .c$roufs.Thc .incidcncc,,i oau"rr" .ii.cts ir.rcluding 3:::ll{yll. during managernenr ol tt,"il. pr"t.l,oftr,rl t r r a d y c a r d l a s , c:rre s c c o n d _ o r t h i r d _ d c g r c c h c a r t b l o c l < s ,t i n n i t u s , a n i i ::'tl{-llci ^J. I nesL.patlents wcrc comparctj with 144 witnessctl1gr,,up a l t c r c d r n c n t a l s t a t L r sw c r e s i m i l a i i n h u t h g r , r r , f r . i r a t r c n t s i n t h c Jrrt.st paticnts from thc control period (groupB). Therc g r o u l h a d .r n o r e s u l . i t c r i v r -. , , n . , p l . i n , r ' , , { . I z z r n c s s wcrc no diffcr_ lll:,*1"" 12.(r,,u enccsln mean times frorn decompensationto advancccllifc sL,pp<,it j I 1 ] , , y . ; ' " r l l ' u . 6 ' x ' 1 4 ) ;P . = - 0 0 2 ) a n d d c v c l o p m e n t o f h y p o t c n s i o n pACL, {ALSJ,decompensation pAaE to or ALS to f,,. gr;;;'; l 4 r { ' / ul i 4 l v e r s u s2 . 4 , / "l l 7 ) r p = . 0 0 f i ) w h c n c o m p a r c dw i i h t h c n o _ versuspaced gror_rp.

B patients. Howcvcr, whcn consideiing all r l d ( ) c a r n cg r o u p . T h e r t ' w e r c n o b e n c f i t s r n a n i f e s i c d f r o m thc usc of group B patients,.thc of conirols paccclwithin tcn p r o p h y l a c t i c l i d o c a i n c i n p a t i c t - r t sw i t h s t a b l e p r u h o s p i t a l _proportion chcst mrnuteswas lessthan for group.A(4% versus30y"j p < pain; thercforc, rolltinc use in thrs sctting appca;s .001l.Thc unwarranted. groupA survival ratc to hospital admissionwas not signiftcar_rtly differentfrom the sroup B ratc (zSZ vcrsus-zi;%;,"u.r, nft", 160 Comparisonof TgOicalAnestheticAgents in the a o t u s t m e nl or r p a r i e n ct h a r a c t e r i s t i cTsh. c g r o u pA s u r v i v a l r a r et o Repairof Facialand Scalp Lacerationsin CnitOren n o s p r t a l ^ d l s c h aw r Sess s r g n r f i c a n t lgyr c a t c rr h a n g r o u p B , s1 2 4 o ^ DS Ross,D Scroggins, J Taylor,G Muskett, 97.; P < .051.This differencewai enhancednii". ".t1urtir,",r, B Singal,S Bernardon, ye1su1 K Gardner, J Fowler/University Ior patlcntarrcstcharacte of Cincinnati Cotteg;ot Medicine; ristics(Z = B.57) p = .0002).Earlyprchos_ William BoothMemorial pital PACE can improve patient long_te; ,"r;l;;.

Hospital.

Florence, KentuZkv158 S.urvival Prognosis for the Elderly After Out_of_ Hospital Cardiac Arrest MJ Bonnin,PE Pepe, p S Clark/Deparlments of Medicineand burgery,BaytorColleqeof Medicine:Cityof HoustonEmergency MedicalServices.Houston,Texas The appropriateness of aggressiveCpR of the eiderly patient (> _^ 70 years)has often been qucstionedin the medical'fitcrature.

55

Topical ancsthetics havc rccently becn used succcssfully in minor wound carc. Their use may be of particular benefit in the pediatric populati.n. wc cornpared three different solutions in a prospcctive, randonrizcd, double-blind study.

Onc solution conrarneoa comblnatron oIO.S"k tetracaine, l:15,000 adrenalinc,and l0-7_o (TAC). The sccond c.ntain ed, I'.g7% iet.acainc _c-o,caine anci l:15,000.adrcnaline (TAJ. Thc third soiution contained 2,k tetra_ caine only (T).One hundred eighty-six childrcn with scalpor facial lacerations were randomized tlo receivc nn. ;f th.-ih;.e solutions in a 2-mL aiiquots on cotton applicators. The soiutrons were

and firearmswere presentin 6%. Additionally, 89okof children 35 to 69 months old and 6% o{ those lessthan 3 vearsold sometimes bathed without adult supervision. These findings indicate the dramatic need for injury prevention programs focused on lowincome urban children. Specific concerns include exposure to hazardoustransportation,chemicals,firearms,burns, and drowning. Lack of information and isolatedcaregiversmay result in poor supervisionand responsesto life-threateninginiuries.

evaluated regarding their effectiveness {complete or partial versus inadequate anesthesia), use of additional injected anesthetics, parental acceptance, occurrence of side effects, and incidence of wound infection. Parameters wete evaluated using chi-square testing with P < .05 denoting significant difference. TAC was found to have no significant difference in effectiveness {87.9%) when compared with TA BO.4%), yet both were more effective than T ( 5 4 . 4 % 1 .A d d i t i o n a l i n j e c t e d a n e s t h e s i a w a s a d m i n i s t e r e d s i g n i f i cantly more often after TA (10.9%) and T (21%) compared with TAC (3.4%). Parents found the technique of topical anesthesia o v e r w h e l m i n g l y s a t i s f a c t o r y 1 9 O . 7 % )T. h e i n c i d e n c e o f i m m c d i a t e side effects was low for all solutions {1.8%, 2.O%, and l8%l without significant differences. The incidencc of wound infection did not show a significant difference; howcver, a definite trend of increased erythema was noted in wounds in which TAC was used.

TA may be a preferable solution because it provides nearly equal effrcacy with a low incidence of infection and adverse reactions, whilc avoiding the high cost and negative public perception associated with cocaine.

'163

Undiagnosed Abuse in Children Less Than 3 Years

Old With FemoralFractures HJ Dalton,T Slovis,RE Helfer,J Comstock,S Scheurer/Wayne Schoolo1Medicine,Detroit,Michigan;Children's StateUniversity Hospitalof Michigan;Departmentsof Radiologyand Pediatrics/ Ypsilanti MichiganStateUniversity, HumanDevelopment, Retrospectiveevaluation of 138 children who presentedconsecutively to an emergencydepartment in one of three ma)or Michigan hospitalswas completed.All hospital recordsand radiographswere reviewed.Initial datawere evaluatedby threepediatriciansto classifythe casesinto one o{ four categories:accident(3I ), abuse(12),underlyingbonepathology(12),and uncertainetiology (83).These 83 uncertain caseswere handled as follows: 36 were referredto Hospital SocialServices,29 of whom were subsequently reportedto ProtectiveServices.Abuse was confirmed in 20 oI 29 169%lof these cases.Thus, a total of 32 casesof femoral fracture were secondaryto confirmed abuse.The remaining l6 of 35 cases

by Hospital SocialServicesand abuseruled out asthe wereassessed cause of the fracture. In the remaining 47 children from the uncertaingroup,no attempt was madeto determinethe etiologyof the fracture. A total of 63 children left the hospital without an etiologic diagnosisof their femoral fracture.A review of the state caseswere registryrevealedthat sevenof 63 {11%)undiagnosed subsccluentlylisted asvictims of abuse.There was no fracturetype characteristicfor any specificetiology.The high incidenceof abuse {32 of 138, 23/ol as the etiology of femoral fracture and of subsecluent abuse in "uncertain etiology" casessuggeststhat _every young child with a femoral fracturewhose causeis not absolutely ccrtain should be admitted to the hospital for an epidemioiogic cvaluation by a multidisciplinary team consistingof medical and socralservicepersonnel.

161TACVersusCocaineAlone A A E r n s t ,L H C r a b b e , D K W i n s e m i u s , R B r a g d o n , R L i n k / S t F r a n c i s H o s p i t a l , H a r t f o r d , C o n n e c t i c u t ; U n i v e r s i t yo f C o n n e c t i c u t , F a r m i n g t o n ;S o u t h L o u i s i a n a M e d i c a l C e n t e r , H o u m a A m i x t u r c o f t e t r a c a i n c , a d r e n a l i n e ,a n d c o c a i n e ( T A C ) h a s b e e n uscd extcnsively in the repair of small lacerations, especially in children. Sevcral studies have tried tctracaine alone or tctracaine and adrenalinc for this purposebut havc found infcrior results.The purpose of our study was to determine if cocaine alone would p r o v i d e a n c s t h e s i ae q u a l t o t h a t o f T A C , e l i m i n a t i n g b o t h t h e r i s k 6f tctracaine toxicity and the theoretical risk of side cffects from the combination of cocaine and adrenalinc and simplifying preparation. Onc hundred thirty-ninc paticnts were cnrolled in a randomizcd doublc-blind comparison study comparing TAC (69 patients) with cocaine alone (70 patients). Effcctivencsswas rated from 0 to 10 by thc cmergency departmcnt staff physician who applicd the solution. Ranks of 0 to 3 wcrc considcrcd poor ancsthe sia; 4 to 7, Iair a n e s t h c s i a ,a n d 8 t o 1 0 , g o o d a n c s t h e s i a .U s i n g t h c W i l c o x o n r a n k sum tcst, TAC was found to provide significantly better ancsthcsia than cocainc alonc (P = .005). Thc perccntagc of paticnts recciving good ancsthesia in the TAC group was approxima tely 72% , which is cquivalent to thc cfficacy found in othcr studics.Good anesthcsia was obtained in 52% of thc cocainc-alone group. No side effccts wcrc rcportcd in either group. No incrcased ratc of infection was f<lund in cithcr group. In summary, TAC was {ound to be a bettcr tooical ancsthctic than cocainc alonc. Neither was associated with s i g n i fi c a n t c o m p l i c a t i o n s .

of FebrileInfants28 to 90 Management 164Outpatient Ceftriaxone DaysOld With Intramuscular

- 162 Safety Practices and Living Conditions of Low' lncome Urban Children of Pediatrics,Case Western LJ Santer,CB Stocking/Department Schoolof Medicine,RainbowBabiesand ReserveUniversity of Medicine, Ohio;Department ChildrensHospital,Cleveland, PritzkerSchoolof Medicine,Centerfor ClinicalMedicalEthics' Chicago.lllinois Iniuries rcmain the leadingcauseof mortality in children. Prior injury prevention efforts have targetedspecific injury modes and primarily private patients, neglectinglow-income urban children. i.r ,n atte-pt to assessthe injury problem in this population, caregrversof indigent children less than 6 yearsold enrolled in an urban pediatric clinic were interviewed regardingliving conditions, transportation,householdconfiguration,and previousiniuries. Of the 133 adults approached,89% agreedto be interviewed.

The median ageof patientsand parentswas 9 months and 25 years, rcspectively. Thirty-eight percent of homes were single-parent homes.The number of injuries or poisoningsper householdaveraged.08 (range,0 to 4), with 40% of householdsexperiencingone or more incidents. Eleven percent oi householdshad a poisoning episode.Eighteenpercentof respondentswere cognizantof ipecac, with ipecacavailablein only 8.5% of homes.Medicine and poison storagewere rnadequatein 427" and5 I % of homes,respectively'If a child ingested something the respondent believed.might be poisonous,5l% would have gone to an emergencydepartment before calling {or advice.While the frequencyof automobile use was low, unrestrainedrides were common with 63% of children usually inappropriatelyrestrained.Match or lighter storagewas inadeouatein 78% of homes.Functional smoke detectorsand fire extinguisherswerepresentin 75% and27% of homes,respectively.

The slorageof knives or scissorswas inadequatein 68% of homes,

56

of Emergency MN Baskin,GR Fleisher,EJ O'Rourke/Division Diseases,HarvardMedicalSchool, Medicineand InJectious Children'sHospital,Boston,Massachusetts A bacterial focus is demonstratedin 3% to 8% of nontoxic febrile infants I to 3 months old despitea benignclinical examination. Traditional managementincludes admissionand parenteral antibiotics pendingbacterial culture results.We conducteda prospcctive study of intramuscular ceftriaxone for the outpatient manasementof febrile in{ants 28 to 90 days old, with fever more than 58 C and no source on physical examination or screening laboratorytests.After blood, cerebralspinal fluid, and urine were obtainedfor culture, if peripheralwhite blood cells were lessthan cerebralspinal{luid white blood cellswere Iessthan lO,and 20,0OO, urine dipstick white blood cells were esterasenegative,febrile infants received50 mg/kg intramuscularceftriaxoneand weresent home. A seconddosewas administered24 hours later, and febrile in{antswere followed-upby telephoneat two and sevendays.Over 20 months, 223 iebrrle infants were enrolled. Fourteen febrile infants (6.3% I had a bacterialfocusidentified (groupI l, and 209did not (group2).There wereno significantdifferencesin meanage(8.4 weelis [gioup 1], 7.4 weeks [group2]), Yale observationscale(6.5 versus6.6),WBC x 103{11.2versus10.6J,or percentpolymorphonuclearceIIs{32versus33).The two groupshad significantdifierences in temperature(39.1versus38.8 C), and percentbandsi9 versus5) and approacheda significant di{{erencein total band count (924 ,rersui 542; P : .06).o{ 79 febrile infants with 6% or more bands, ten (13%l had bacterial {oci eventually identified, whereasonly three 127")of 138febrile infants with lessthan 6% bandseverhad bacterial {oci identified (P = .004).Of the 14 febrile infants with bacterialfoci, four had bacteremia(onecaseeach,Pneumococcus, group B Streptococcus,N meningitid.is, and E co-li).All-feb-rile infants *ere-afebrile with sterile blood cultures obtainedwhen recalled and were well at follow-up. Nine febrile infants had bacterialgastroenteritiswithout bacteremia Eight were followed at home, ind one required hospitaltzatron due to increasingbloody diarrheawithout dehydrationor toxicity. One febrile in{ant had

urinary tract in{ection without bacteremia. Of the 209 febrile infants without bacterial focus, 200 were managed as outpatients and were well at seven-day follow-up. Nrne were admitted to the h o s p i t a l f i v e h o u r s t o t e n d a y s a f t e r s t u d y e n r o l l m e n t . A 1 1w e r e w e l l at follow-up. We conclude that for nontoxic febrile infants 28 to 90 days old, who after a full sepsis workurr do not have an idcntifiable bacterial source by physicil examrnaiion or screeninSl laboratory tests, intramuscular ceftriaxone for two days with telephonc follow-up may be an alternativc to hospital adrnission.

\ P : . O 2 1 . I no u r s t u d y , t h e w o u n d t y p e a n d w o u n d d e p t h w e r e t h e most important factorsin determining the likclihood of developing infection regardlcss of whether the patient was prescribcd prophylactic oral antibiotics.

167 The Use of Oral Acyclovir in the Treatmentof HerpeticWhitlow - Allegheny EADavis,MRSayre/Medical College of Pennsylvania Campus, Pittsburgh

165Outcomein Highly FebrileNonbacteremicChildren J Burg,L Etzwiler, S Petrycki, GR Fleisher/ HarvardMedical School, Boston, Massachuseus Thc incidence and comrrlicatronsof occult bacteremia in children have been well describcd; howevcr, tht're is scant information on similar cohorts of highly fcbrile children who havc ncgatrvc initial blood cultures. We unclertook an investrsation of thc outcomc of thesc nonbacteremic paricnts. Wc studicd 253 childrcn 3 to 3armonths old seen in thi cmergency department betwccn Novembcr 1987 and func lgtltl who were fcbrile to 39 C or hichcr and had no apparent bacterial source of rn{cction. Blood culturcs wcre olltained on all paticnts. Thc children rcccivcd eithcr oral amoxicillin for two days or a singlc dosc of intramuscular ccftriaxonc as part of an ongoing study of thc trcatmcnt for prcsunrptrve bactcremia. A11 nonbactercrnic paticnts wcrc analyzccl. Subscq u e n t i n f e c t i o n s w e r c d o c u m c r - r t c dc l u r i n g t c l c p h o n c f o l k r w - u p o r on repcat examination. Thc mcan agc of thc paticnts was 14 + 8 months, and 47% wcrc boys. Tcmperaturc range was 39.0 to 41.3 C with a mcan of 39.U 1 0.5 C. Tl-ren-rcanYalc obscrvation scorc w:rs 7 . 01 I . U .T h c m c a n w h i t c b l o o d c c l l c o u n t w a s 1 4 , 2 0 0+ ( r , 8 5 0 / m m l ( r a n g c ,2 , 5 0 0 t o 3 t t , 0 0 0 / m m r ) w i t h a m c a n b a n c lc o u n t o [ 7 . 6 ! 6 . 5 , , 1 , .

Ccrcbral spinal {luid was obtainecl in 16%, of paticnts and was n o r m a l i n a l l . P o s i t i v c c u l t u r e r c s u l t s i n c l u d c d t w o o f ( r 2 1 3 , 2),u r i n c lonc E coli, <>ne() vaginalis); thrcc of 12 125,/,)stool {tw(r.S(r1r?rl ne|la, onc Cttmpylobacter); onc throat {group A Streyttococctts).

C h i l d r c n w i t h a b a c t c r i a l i n f c c t i o n o n f o l l o w - r - r pi n c l r - r d c cll4 o l 2 5 3 ( 5 . 5 % ) o t i t i s r n c d i a ; l 4 o f 2 5 3 ( 5 . 5 % , )m i n o r b a c t c r i a l i n f c c t i o n s {throc bactcrial gastrocntcritis, threc urrnary tract infcction, two pharyngitis, four pneumonra, onc sinusitis, onc ir-r-rpctigo).Two paticnts rcquircd hospitalization within 4fi hours, onc for dchyclration and onc with H lnfluenzac B bactercmia.In conclusion, highly febrilcnonbactcrcmic young childrcn rnay dcvclop rninor bactcrial i n f c c t i o n s o r s o r i o u s c o m p l i c a t r o n s o f v i r a l d i s c a s c .I n a d d i t i o n , a singlc ncgatrvc blood culturc docs not clininatc thc possibility of b a c t c r c m i a . U n l i k c t h c i r c o l l n t c r p a r t s w i t h b a c t c r c r . n i a ,h o w c v c r , nonbactcrcmic childrcn appoar to bc at rninirnal risk for subscqllcnt scrious focal bactcrial infcctions such as mcninxitis.

166 Cat Bite Wounds: Risk Factors for Infection D J D i r e l D e p a r l m e n to f E m e r g e n c y M e d i c i n e , 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 yP r o g r a m , D a r n a l l A r m y C o m m u n r t y H o s p i t a l , F o r t H o o d , Texas I n t h c l a s t t c n y c a r s , m a n y c m e r g c n c y m c c l i c i n c s p c c i a l i s t sh a v c studicd anrmal bitc wounds. Most authors' recommcndations for the trcatmcnt of cat bitc wounds havc becn bascd on anccdotal e x p c r i e n c c s ,s t u d i c s o f d o g b i t c w o u n d s , o r o n c s m a l l , c o n t r o l l c d , p r o s p c c t i v e s t u d y o f c a t b i t c s ( w h i c h h a d o n l y 11 p a t i c n t s ) . T o detcrmine risk factors for wound infcction, wc prospcctivcly collccted data on 216 consccutivc cat brte or scratch wounds that o c c u r r e dr n 1 8 5 p a t i e n t s w h o p r e s c n t c d t o o u r c m c r g c n c y d c p a r t m e n t o v c r a t w o - y e a r p e r i o d . O f t h e w o u n d s , 1 5 0 { ( r 9% ,) w c r c p a r t i a l thickncss and 62 129%)wcre full thickness. Twcnty-four {13%,) patients had clinical evidencc of wound infcction on arrival to thc ED. Five (3%) patients developcd clinical cvidcncc of wound infection dcspite ED treatment. None of thc 1a (8%)paticnts with only "claw" injurics developcd a wound infcction. Thc ovcrall patient lnfcctlon ratc {or thosc with cat "bitcs" was I7"1,.Factors a s s o c i a t e dw i t h a n i n c r e a s c d l i k e l i h o o d o f w o u n d i n f c c t i o n s i n c l u d e do l d c r a g e ( P < . 0 0 5j , l o n g e r t i m e i n t e r v a l s u n t i l E D t r c a t m e n t ( P < . 0 5 ) , w o u n d s i n f l i c t e d b y " p e t " c a t s ( P = . 0 0 1 8 ) ,p a t r c n t s w h o attcmpted wound care at home lP = .0041,paticnts having a singlc b i t e w o u n d { P = . 1 9 0 3 ) ,a n d p a t i c n t s h a v i n g m o r c s e v e r ew o u n d s { p = . 0 0 7 7 1o r d c c p e r w o u n d s ( P = . 0 0 0 I ) . D a t a f r o m I 4 { 3 o f t h c s c patients who had only "bite" wounds and did not havc clinical evidencc of infection on prescntation to thc ED were also analyzed for infection risk factors. Wound infections wcre more likcly tcr develop in patients with lower extremity wounds who did not r e c c i v e p r o p h y l a c t i c o r a l a n t i b i o t i c s ( P : . 0 1 8 7 1a n d t h o s e w i t h puncturc wounds who did not reccive prophylactic oral antibiotics

Herpctic whitlow is an rnfcction of thc digit(s)by herpcs simplcx virus type I or II. Thosc at highcst risk rnclude mcdical pcrsonncl. Due to thc infcctious nature of thc diseasc, thosc afflictcd rnust avoid dircct patrent contact until thc lcsions crust ovcr, usually rn two to six weeks. Trcatmcnt has traditionally bccn symptomatic; howcver, rcccntly oral acyclovir has bccn shown to dccrcasc hcaling ttmc in other forms of hcrpetic infcction. The purposc of our study was to cxaminc rhc iffcctivcncss of oral a c y c l o v i r i n d c c r c a s i n gt h c d u r a t i o n o f s y r n p t o m s a n d t h c i n f e c t i v c period of hcrpctrc whitlow. In the first multiplc casc study since 1959, wc retrospcctivcly rcviewcd all cascs of culturc-provcn l " r e r p c t i cw l - r i t l o w p r c s c n t i n g t o t h c c m p l o y c c h c a l t h c l r n i e i n o u r c m c r g c n c y d c p a r t m c n t f r o m M a y 1 9 1 J 3t o M a y l 9 l i l t . T w c n t y - n i n c c a s c s w c r c i d c n t i f i c d , w i t h s c v c n c x c l u s i o n s . T h c r c n " r a i n i n c2 2 paticnts wcrc cvcnly dividcd betwccn thosc rcccrving oral lcyclovir (200 mg fivc tirncs a day for tcn days) and thosc with ncr trcatmcnt. Thc samc physician cxamincd all paticnts at rcgular i n t c r v a l s a n c l ,u s i n g t h c s a m c c r i t c r i a f o r c a c h p a t i c n t , d c t c r r n i n c d whcn thcy coulclrcturn to work. Thc groups wcrc not statistically c l i f f c r c n t i n s c x , a g c , p r c c c d r n g d i g i t a l i r - r j r - r r yo,r c l o m i n a n t h a n c l o r digit involvcd. Data for thc two grollps wcrc analyzcd curnparing tiurcs from initial prcscntation to rctllrn to worl< using thc MannWhitncy tcst. Thc acyckrvir group rcturncd to work carlicr {mcan, I 1 . 3 3 v c r s u s I 7 . 5 ( rd a y s , P = . O O 4 7 l a , nd, subjcctively, thcir syn-rpt o m s w c r c l c s s s c v c r c . W c a l s o f o u n c la h i g h c r ( 1 7 o f 2 2 ) p r o p u r t i o n o f p a t i c n t s w i t h p r c c c c l i n gi n j u r y t h a n p r c v i o u s l y r c p o r t c d . R c c o g n i z i n g t h c r c w c r c l i m i t a t i o n s t o t h i s t y p c o f s t u c l y ,w c r c c o r n r r c n d oral acycluvir as cffcctivc in trc:rting hcrpctic whrtlow.

168Screening for Syphilisin the Emergency Department:RPRsin PatientsWithSuspected Sexually Transmitted Diseases A E r n s t , J D S a m u e l s , D K W i n s e m i u s / S a i n tF r a n c i s H o s o i t a la n d M e d i c a l C e n t e r , H a r t f o r d ,C o n n e c t i c u t ;U n i v e r s i t vo f C o n n e c t i c u t Health Center, Farmington O u r s t r - r c l yw a s i n t c n c l c d t o d c m o n s t r a t c t h c c o s t - c f f c c t i v c n c s s o f s y p h i l i s s c r c c n i n g i n a h i g h - r i s k g r o u p o f c n e r g c n c y r l c p a r t m en t paticnts. Ovcr a four-month pcriod, 2(r0 paticnts with suspccted s c x r - r a l l yt r a n s l l i t t c d d i s c a s c s{ o t h c r t h a n s y p h i l i s ) h a t l r a p i d p l a s n t a r c a g i n s ( R P R s )d r a w n t o d c t c r m i n c t h c i n c i d c n c c o f u r - r s l r s p c c t c d s y p h i l i s .T w c n t y - t w o p a t i c n t s( 1 3 ' 2 , ) h apdo s i t i v c R P R s .O f t h c s c , l ( r ( 6 ' 2 , )a l s o h a c lp o s i t i v c F T A - A B S . O f I 1 ( rp a t i c n t s w i t h p o s i t i v c G C c u l t u r c s , c i g h t a l s o h a d p o s i t i v c R P R s ; o f 2 t l p a t i c r - r t sw i t h p o s i t i v c C h l u n t y d i u a n t i b o d y t c s t s , f i v c h a d p o s i t i v c R P R s .T h c s t u d y g r o u p w a s c o m p a r c c lw i t h t w o s m a l l c r c o n t r o l g r o L r p si n w h o r n s y p h i l i s scrccning is routincly donc at our hospital. In a randomly choscn n - l o n t h c l l r r i n gt h c s t u c l y p c r i o d , 5 5 n c w h o s p i t a l c r n p k r y c c s a n d 9 0 rrcw obstctrics clinic paticnts had bccn scrccncd, and nonc had p o s i t i v c R P R s .T h c d i f f c r c n c c w a s h i g h l y s i g n i f i c a n t l 1 )< . 0 0 1 ) .T h c cost for thc RPR scrccning camc to $104.90for cach patient with a positivc FTA,ABS. Wc concludc that scrccning for syphilis in a h i g h - r i s k p o p u l a t r o n i t - rt h c E D i s c o s t c f f c c t i v c .

169 HTLV-1 Infection in an Inner-City Emergency Department Population: The Next Retrovirus Epidemic?

GD Kelen,T DiGiovanna, L Loty,L Bisson,D Kalainov,KT Sivertson, TC Quinn/Divisions of EmergencyMedicineand Infectious Diseases, The JohnsHopkinsSchoolof Medicine; Johns HopkinsUniversity Schoolof Medicine,Baltimore, Maryland; Laboratory of lmmunoregulation, NlAlD,NlH, Bethesda,Maryland Thc human T-ccll lcukemia virus (HTLV-11rs thc causativc agcntof the adult T-ccll leukcmia (ATL) and HTLV-l associated rnyelopathylHAM). Whilc HTLV-1 is cndemicin ccrtainpartsof thc world,with an cstimatedgcncralpopulationrateof .03%,it has not beenconsidcrcdto be widcly prevalcntin the United Statcs.

Becausccoinfectionwith HIV has beendemonstrated, wc under took this study to examine the epidcmiologyof HTLV-I in a population known to have a high ratc of HIV infcction. OI 2,544 consccutiveserum samplesdrawn from adult patients prcsenting

57

to an inner-city emergency department, 30 ll.2%l were Western Blot seropositiveto HTLV-1. While 152 of the patients (6 0%)were Western Blot seroposrtive to the human immunodeficiency virus {HIV-l}, only three patients (all IV drug users) had concurrent infections. The age distribution of HTLV-1 infected individuals matched that of the patient population in contrast to HIV, whichw a s c o n c e n t r a t e d a m o n g p a t i e n t s 2 5 t o 4 4 y e a r s o l d ( P < . 0 5 ) .H a l f of thc HTLV- 1 infectcd patients were more than 50 years old. Of the 30 seropositive paticnts, 93% l28Jwere black, whereas blacks made up only 77% ol the patient population {P < .05) Only l5 patre-nts {50y.) had an identificd risk factor; ten were IV drug users and five were transfusion recipicnts. Only one patlent's potential sourceof infection was sexual exposure to an HlV-infected partner. All but o n e o f t h e s e r o p o s i t r v ep a t i e n t s l i v e d i n t h e s u r r o u n d i n g n e i g h b o r h o o d , i m p l y i n g t h a t m i g r a t i o n f r o m c n d e m i c a r e a sw a s n o t l i k e l y a principil facior for infection. We conclude that HTLV-1 may be mire pievalent than previously thought among US rcsidents.

Sexual transmission did not seem to play a major roic in HTLV-1 infection. The data support thc hypothcsis that HTLV-1 and HIV a r e i n d c o c n d e n t l v t r a n s m i t t e d d i s e a s c s .W h i l c n o s o c o m i a l i n f e c tion with HTLV-l has not becn demonstratcd, this may bc due to a low lcvcl of surveillancc.

Virusand Humanlmmunodeficiency 170Multicenter StudY HepatitisB Seroprevalence

J Jui, B Wayson,J Schriver,P Stevens,S Modesitt,S Hulman,D MedicineResearchCouncilof Greater Fleming/Emergency OregonStateHealth Portland,OregonHealthSciencesUniversity, Division,Portland Prior singl: institutional invcstigationshavc found unrecogin nized human irnmunodeficicncyvirus (HIV) seroprcvalcncc cmcrgencydcpartmcntpatients to rangefrom 03U% trt 4'k. A prospcctive,anonymousstudy of HIV and hcpatitis B scroprcvalenccwaspcrformcdon cxccssscrumof all ED patientsovertwo 4tl-hour pcri6ds in May and August 19tlti,from scvcn hospitalsin approximatclyonc million)' a majornorthwcsterncity (population, Dcrnographicswcre known for 33ti of 444 {76'2,} paticnts.Forty-six p"rcc.ti wcrc male and U5'X,werc whitc, with a mcdianagcgroup clothesand cquipi,f aOtn 39 ycars.Ambulancetransport-trauma; mcnt contaminatcd with blood; prcscntationsrcquiring ED proccdurc(s); andacuity resultingin intensivccarcadmissionwcrc pr"."nt f<tril"l,,10"1,,7'k,34%, and14% of paticnts,rcspcctivcly' patientswerc HIV positivc,onc previously two of 444 10.45"1'l Fifty-fivc<tfthe 444 ll2'/"1 and threc of 444 10'6%) undiagnoscd. r"-pi.. werc positivcfor hcpatitisB corc antibody(HBcAB)and hepatitisB surfaccantiScn{HBsAC),rcspectivcly.Asscssmcntot risi factorswas possiblcon 180 of 444 l4O%)paticnts.HBcAB corrclatcdwith racc{1'< .001)and IV drug usc (P -< scroprcvalcncc .001l,but thcsecritcriawere sensitivein detectrngonly 14% and l8% of HBcAB-positivepatients,rcspcctivcly.HBcAB was not associatcdwith the following factors: scx, arca of rcsidencc, prescnccof blood on clothing and ecluipmcnt,trauma, acuity of illness,Eo procedures,and mode o{ transport.Thesc data strongly support the usc of universal body fluid precautions.Hepatiti'sB poies a significantand clistinctrisk to all emergencycareproviders that has bcen understatcdbecauseof the HIV exposureconcerns' Henatitis B vaccination should bc strongly advocatcdfor all ED health careworkers. Emergcncymcdicrnc multicenter studlesare of both dcsirablcand fcasiblcio follow trcnds rn the seroprevalence in{ectiousagcntsin the ED. 171 Hepatitis B Infection and Human lmmunodeficiency

Patients Department VirusInlectionin Emergency

KT Sivertson, GD Kelen, TA DiGiovanna, T Brothers, TC Quinn/ D i v i s i o n s o f E m e r g e n c y M e d i c i n e a n d I n f e c t i o u sD i s e a s e s , T h e J o h n s H o p k i n s U n i v e r s i t yS c h o o l o f M e d i c i n e , B a l t i m o r e ,M a r y l a n d ; L a b o r a t o r yo f l m m u n o r e g u l a t i o n ,N a t i o n a l I n s t i t u t eo f A l l e r g y a n d I n f e c t i o u sD i s e a s e , B e t h e s d a , M a r y l a n d Both hcoatitis B virus and human immunodeficiency virus (HIV) have been identified as exposure risks for emergency- health workers. Some municipal emergency medical services stili fail to vaccinate personnel agiinst hepatitis B virus,- arguing that the use of universal precautio;s to auold contact with the blood and body fluids o{ patients wr11 prevent infection with either virus' Sera coilected during a previous study oi HIV infection in emergency department patienti was tested to characterize the prevalence and o{ hepatitis B virus infection' Adequate sera was diitribution available to test 2,i i6 patients by ELISA (Abbott Laboratorres) for

the presence of hepatitis B virus surface antigen. Of the 2,116 patiants, 83 13.9%lwere infected with HIV only -One hundred nine i5.2%l *rre infectious with hepatitis B virus only Frfteen patients i 0 . 7 % ) * . . . i n f e c t i o u s w i t h b o t h v i r u s e s .T h u s , 2 0 7 p a t i e n t s ( 9 . 8 % ) were infectious with one or both viruses. Hepatitis B infection was uniformly distributed across age, sex, and race strata. Statistically signi{icant di{ferences (P < .05, chi-square) existed-between hepatitiJ B and HIV inlection in patients 55 years and older (hepatitis B, 3 2 c a s e so r 2 9 7 o i H I V , { o u r c a s e so r 4 . 8 % ) , f e m a l e s e x ( h e p a t i t i s B , 5 9 c a s e so r 5 4 7 o ; H I V , 2 3 c a s e so r 2 7 . 7 " h ) ,a n d w h i t e r a c e { h e p a t i t i s B, 24 cascs or 22"ki HIV, ten cases or 12"/"1' Arrival by ambulance was the same for both hepatitis B {25 or 22.9%) and HIV {24 or 28.9%)patients. Given the small ovcrlap and the di{{erentdistribution of thcse two infectious viruses in the same ED patient population and the availability of a 1ow-rrsk and highly effective vaccine for hcpatitis B virus, the substitution of unrversal precautions Jor hcpatiiis B immunization is not iustified and increases the probability of emcrgency health workcr infection with infectious blood and body fluid-borne virus.

on 172The Effectsof Fructose'1,6-Diphosphate MyocardialNecrosis During CoronaryArtery Occlusion State JE Olson,GC Hamilton/Wright TGJanz,JE Leasure, Dayton, Ohio Schoolof Medicine, University, to the abilityof fructose-1,6-diphosphate {FDPJ We cvaluated

limit myocardialischemia and necrosisduring acute occlusionof a coronaryartery.Thrombosisof the left antcrior descendingartery was induced in dogsby a closed-chesttechnique.After coronary occlusion producedsignificant S-T segmentelevations,dogswere then injccied intravenously with 90, 175, or 350 mg/kg FDP or normal salinc (controls).Hemodynarnicparameters,ECG changes, anclscrum levcls of creatinckinase,creatinekinase-MB,and lactic dchydrogenascwere evaluatedat baselineand at 30 minutes and foui hours after ECG changes.Four hours after acute coronary occlusron,the animals were sacrificedand cross-sectionalareas and weights o{ ischemic and necrotic myocardial tissue were ouantified in uniform heart sections,using a histologic-staining mcthod. The animals treatedwith FDP demonstrateda significant rcduction in weight and areaof necrotic myocardium compared with control animals (1'< .001);however,there were no significant diflerenccsbctween control and treated animals in biochemical, hemodynamic,or ECG parameters.In control animals, 13,!3% of thc cardiactissue was necrotic by weight and 24 t 4% by crossscctionalarcao{ thc histologic sections.Animals treatedwith FDP had an avcrageol 4 t2% necrosisby weight and l0 t 3% by crossscctionalarei, with the I 75 mg/kg group showing the bestresults' Significant reductions also were seen in the weights and crossscctional areasof ischemrc myocardium of the treated dogsiP < .001).Thesedata suggestthat FDP reducesthe amount-ofmyocardial ischerniaand necrosrsafter acute coronaryartery thrombosis'

During Metabolism Phosphate 173High-Energy Fibrillation Ventricular H Neumar, CG Brown, P Van Ligten, J Hoekstra, R Altschuld/ D i v i s i o n so f E m e r g e n c y M e d i c i n e a n d C a r d i o l o g y ,T h e O h i o S t a t e U n i v e r s i t y ,C o l u m b u s Past studies of mvocardial ischemia have shown an association between high-energy phosphate (HEP) depletion, the on-set of irreversible -yocatdir[ i.tjury, and the degree of myocardial functional recoverv after reper{usion. These studies, however, were of nonfibrillatory regional and global myocardial ischemia Because approximately 50% to 7O% of patients with prehospital.cardlac "ir"rt ^.. found in ventricular fibrillation, we studied the time course of HEP metabolism during ventricular fibrillation' Five immature swine weighing 23.0 t 3.2 kg were studied. After thoracotomy, 4-mm diametei transmural myocardial biopsies were taLe.t in vivo during normal sinus rhythm (NSR) and at designated times durinq ventricular fibrillation. Biopsies were frozen within two secondJ in chilled isopentane and then transferred to liquid nitrogen. Chemical analysii for HEP was done using high-Per{ormance"liquid chromatography The results, expressed in pmol/g proteln, are listed below: Normal Duration of VentricularFibrillation(min) Sinus 30 20 15 10 Hhythm 5 1 8 . 2 t 5 . 9 1 2 . 8 1 3 . 5 1 0 . 7 L 3 . 4 7 . 9 + 2 . 3 3 . 8 1 34 39.0i2.3 ATP 5.4L28 1 0 . 4 ! 2 . 7 1 0 . 8 1 . 2 1 0 j ! 2 . 4 9 . 5 1 1. 8 8 . 2 ! 1. 7 ADP 2.510.3 3.2t0.5 3.611.1 4.7!0.9 9 515.7 O.7tO.4 AMP 4 8 . 1 ! 3 . 2 3 1 . 0 1 8 . 1 2 6 . 8 L 4 . 3 2 4 . 2 ' 1 5 42 2 ' 2 ! 3 4 1 8 8 1 3 5 TAN

58

T A N ,t o t a la d e n i n en u c l e o t i d e(sA T p + A D p + A M p ) Aftcr 20 minutes of ventricular fibrillation, an avcrage 203% ol NS_R myocardial ATP remains. Previous studies of myocardial rschcmia have shown that when ATP is equal to or greatcr than 20o/oof c,rlntrol, myocardial inlury is revcrsible, and the myocardium will ultimately recover function rf adequatcly reperiusecl.

Additional study of ATP rcgeneration and myocardial functional recovery after repcrfusion may help further define the limits of acutemyocardial rcsuscitation aftcr prolongcd ventricular fibrillat1on.

than group 2 during resuscitation. Aortic diastolic and coronary pertuslon prcssures were similar during CpR but signlficantly h i g h c r i n g r o u p 2 a f t e r t h e o n s e t o f C P B . G r o u p I s u r v i v o i s ( n = a )h a d a mcan infarct size of 17.65 X8.26% vcrsus group 2 survivors (n = 6 ) , 5 . 2 4 ! 6 . 0 3 % ( P < . 0 5 ) .T h e r a t i o o f n e c r o t r c t o i s c h c m i c t r s s u c was significantly greatcr in group 2 {p <.05). After lcft antcrior desccnding occlusion, cardropulmonary bypass reperfusion aftcr cardiac arrcst rcsultcd in srgnificantly bettcr resuscitation and sn'rallerinfarct sizcs. Cardiopulmonary bypass rcpcrfusion may lin'rit infarct sizc during thc initial postrcsuscitation phasc.

.176

.174

Comparisonof Epinephrineand Dopaminein CpR KHLindner, FWAhnefeld, lM Bowdler/ Universitv Clinicof Anaestheslology, University of Ulm,Ulm,WestGermany

Evaluation of Direct Mechanical Ventricular Assistance Atter 15 Minutes of Ventricular Fibrillation MP Anstadt, R Neumar, P Van Ligten,HA Werman, GL Anstadt, C G B r o w n / D e p a r t m e n to f S u r g e r y , D u k e U n i v e r s i t yM e d i c a l C e n t e r , D u r h a m , N o r t h C a r o l i n a ; 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 ,T h e O h i o S t a t e U n i v e r s i t y ,C o l u m b u s ; a n d T h e B i o s c i e n c e sC e n t e r , M i a m i ValleyHospital Prcvious studics ustng dircct mcchanical vcntricular assistancc {DMVA) aftcr tcn minlrtcs of vcntricular fibrillation and thrcc m i n l l t c s o f C P R r e s u l t c d i n s u c c e s s f u lm y o c a r d i a l r c s u s c i t ; r t i o n o f four out of scvenaminals. Thc purposc of trur sttrdyw:rsto cv:rluatc t h c c f f e c t i v c r - rses o f D M V A a f t c r l 5 m i n l r t c s o f v c n t r i c u l a r f i b r i l l a tion. Scven immatluc swinc wcighing24.O ! 3.4 l<gwcre instrrrmentcd for rcgional blood flow and hcmoclynarnic rncasurcnrcnts.

A f t c r 1 5 m i n u t c s o f v c n t r i c u l a r f i h r i l l r l t i ( ) n , s t a n r l a r c lr - n c c l " r a n i c a l C P R w a s p c r f o r m c c l f o r t h r c c m i n u t c s . D M V A w a s t h c n a n n l i c c lf o r t h r c c m i n u t c s ( D M V A I ) .A f t c r D M V A I , i n t c r n a l d c fi h r i l l e i i o n w a s a t t c r n p t c d .I f d e f i b r i l l a t i o n d i c l n o t r c s r . r l ti n t h c r c t n r n o f s p o n t a n c , o u s c i r c u l a t i o n , D M V A w a s r c a p p l i c d f o r a n a d c l i t i o n a lt c n m i n u t c s 1 D M V A 2 ) ,a f t c r w h i c h d c f i b r i l l a t i o n w a s a g a i n a t t c m p t c d . R c g i o n a l tissuc blood flow and hcmodynamic mcasurcmcntJ arc displaycd bclow: CPR DMVA] DMVA1-DN,,IVA2 P pt pz n=7 n=7 n=5 n=5 M B F - 2 . 1! 1 . 3 7 8 . 4! 3 2 8 4 . 0r 3 7 . 3 7 6 . 2t 4 7 . g < . 0 0 5 > . 1 .1.4 E N / E P 0 . 21 0 . 1 1 . 2t 0 . 6 t 0.6 0 . 6r 0 . 3 < .005 > .005 c B F 0 . 71 0 . 8 2 . 3 + 2 . 7 1 . 1r 1 . 1 1 . 21 0 . 8 <.05 >.1 MVO, 0.28+0.17 9.4!4.4 10.7!4.6 5.6!2.4 <.005 >.05 ER 8 8 . 91 6 . 7 7 1. 6 t 1 1 . 8 7 7 . 9 t 5 . 9 5 7 . 7 1 1 6 . 6< . 0 1 > . 0 5 A o D P 1 0 . 31 8 . 9 3 1 . 6 r 1 0 . 0 2 7 . 7t 6 . 5 2 6 . 1t . l 1 . 8 < . 0 0 5 > . j -l\,48F m,y o c a r d i abll o o df l o w( m L / m i n / 1 0S0) ;E N / E p ,e n d o c a r d i a l / e p i c a r d i a l b l o o df l o wr a t i o ;C B F ,c e r e b r acl o r t i c abl l o o df l o w( m l / m i n / 1 0 0g ) ; M D O 2 , myocardia o lx y g e nd e l i v e r y( m LO , / m r n / 1 0g0) ; M V O , ,m y o c a r d i aolx y g e n m LO r l m i n1. 0 0g 1 :E R .m y o c a r d i aolx y l e n e x t r a c u o rna r i o : c o n s u m p t i o( n A o D Pa , o r t i cd i a s t o l i pc r e s s u r e( m m H g ) ;p l , c o m p a r i s oonf C p R a n d D M V A It P 2 ,c o m p a r i s oonf D M V A I, ( a n i m a l tsh a ts u b s e q u e n t rl ye c e i v e d DMVA2)and DMVA2.

DMVA providcs MBF and MDO, slrperior to star-rdardCpR aftcr prolongcd vcntriclrl:lr {ibrillation; howevcr, cercbral bloocl fkrws tcmain poor. Aftcr l5 minutcs of vcntricular fibrillation and thrcc minlltcs of CPR, rnyocardial rcsuscitation r:ltc is p(x)r cvcr-r witl-r thrcc to 13 n-rinutcs of DMVA.

E p i n c p h r i n c a n d d o p a r r " r i n ci n d u c c b y a v a s o c o n s t r i c t r o n a n i n c r c a s c dd i a s t o l r c b l o o c ip r c s s u r c a n d h c n c c : r n i m p r o v c c l r n y o c a r d i a l pcrfusion cir-rring C P R . W c h a v c , t h c r c f o r e, c o r n r r a r c dt h c a c t r o n o f c p r n c p h r i n c a n d d o p : u - n i n er n a n a s p h y x r a l a n d e i c c t r i c a l l y i n d u c c d c a r d i a c a r r c s t n - r o c l c lA . sphyxial arrcst was induccd in 2l pigs by c l a r - n p i n gt h c c n d o t r a c h c a l t u b c . A f t c r a t h r c e - r n i n u t e p c l i r l d < i f arrcst/ cxtcrn:ll chcst corlprcssion and vcntilation wcrc applicd.

Scvcn animals rcccivcd 45 pg/kg epincphrinc; a furthcr ievcn a n i r n a l s r c c c i v c d 2 . 5 m g / k g d o p : r r n i n c ;a n d t h c r c m a i n d c r r c c c i v c d no rlrug thcrapy. Twcnty-cight pigs wcrc rcsuscitatcd aftcr a fotrrrrinutc pcriod of vcntricular fibrillation. Scvcn animals wcrc c i c f i b r i l l a t c d w i t l . r o u t c i t h c r r . n c c h a n i c : rm l c a s l r r c so r d r u g t h c r a p y .

Aftcr starting mcchanical mcasllrcs, thc folkrwing du,tcs wcic g i v c n b c f o r c d c f i b r i l l a t i o n t o s c p a r a t cg r o u p s o f s e v c n i r n r m a l s c a c h : a 5 _p g / k g c p i n c p h n n c , 2 . 5 n r g / l < gc l o p a r . r . r i nocr, l 0 n r L p h y s i o l o g i c s a l i n c . A s p h y x i r l a r r c s t r c s u l t e c l .A l l t h c a n i r r a l s g i v c n J p i n c p h r i n c c < r t r l cbl c r c s u s c i t a t c t l t r f t c r 1 7 4 ] 5 3 s c c o n d s . W i t h d o r r a n i i n c . a s p o r . l t : l n c o l l sc i r c u l a t i o r . rc o u l d b c r c s t t l r c d i n 0 n l y t h r c c o f s c v c n a n i n t a l s a f t c r 4 t J Zt ( r 3 s c e r r n d sW . i t h o r - r td r u g t h e r a p y ,n o c i r c u l a t i o n w a s c s t a b l i s h c d .V c n t r i c u l a r f i b r i l l a t i o n o c c u r c c l .I n t h c a b scr.rco c f c i t h c r t l n r g o r r l c c h a n i c a l n t ea s l r r es , o n l y t w o o f s c v c n , a n t l with urcchanical rlcasurcs only, four of scven rnir.nals coulcl bc dcfibrillatcd. In rro casc could a spontancolls circulation bc establ i s h c c lA . f t c r i n i c c t i o n o f c p i n e p h r i n r ,t l c f i b r i l l i r t i o na n d r c s t o r a t i o l . ) o f a s p o n t a n c o u s c i r c u l a t i o r . rw c r e a c h i c v c c li n s i x o f s c v c n a n i m a l s t r l t c r 6 6 7 + 2 l ( r s c c o n c l s ,w h c r c a s w i t h c k r p a m i n c ,a l l a n i m a l s c o u l d b c s r , r c c c srs- fr l l yr c s u s c i t l t c t li n t h e s i g n r fr c a n t l y s h ( ) r t c rt i m c o f I 7 4 1 l l 5 s c c o n d s . A s r . n c a s u r c rbl y t h c r c s u s c i t a t i o n t i n 1 c , c p i n c p h r i n c i s r . n o r cc f f c c t i v c t h a n c k r p a r r r r . r ci n t h c n r a n a g c r n c n t o i a s p h y x i a l a r r c s t . I l t c o n t r z l s t ,a l l a n i r . n a l si r - rw h i c h v c n t r i c u l a r f i b r i l l a t i o n h a d b c c n i n c l u c c t l c o u l c l b c r c s u s c i t : r t c c lw i t h d o p a n - r i n ci n a s i g n i f i c : r n t l y s h o r t c r t i m e , p o s s i b l y b c c a u s ct k r p a m i n c p c n c t r a t c s s y m p a t h c t i c n c r v c c n d i n g s i r n t l c : r t r s c st h c r c l ea s c o f s i o r c c l n , t r " 1 r i . t " p l . r r i n c . S i m i l a r r c s u l t s w c r c o b t a i n c c li n a p r c v i o u s s t u d y r . r s i n gn o r c p i n c p l . r r i n e.

177 MonitoringEnd-TidalCarbon Dioxideas a PrognosticIndex During CPB in Human Beings AB Sanders, KB Kern,CWOtto,MMMilander, GA Ewy/College of Medicine, University of Arizona, Tucson

175lmproved Resuscitationand Limited Myocardial lnfarctSize FollowingCardiopulmonaryBypass Reperfusion M Angelos, M Gaddis, G Gaddis, J Leasure, S Orebaugh/ Department of Emergency Medicine, WrightStateUniversity School of Medicine, Dayton, Ohio R e s u s c i t a t i o n w i t h c a r d r o p u l m o n a r y b y p a s sw a s c o m p a r c d w i t h s t a n d a r dC P R a d v a n c c d l i f e s u p p o r t ( A L S I w i t h a d o g m o d c l o f a c u t c n-ryocardialinfarction followcd by vcntricr"rlar fibnllation. Sixtccn mongrcl dogs were randomly assigncd to reccivc CpR-ALS {group i ; n = f 3 ) o rC P B ( g r o u p 2 ; n : f i ) . A c o i l w a s p l a c c d i n t h e l c f t a n i e r i c x desccnding coronary artery under fluoroscopic gurJancc. Anin"rals werc fibrillated aftcr the appearancc of I mm S-T clcvatron. CpR w a s s t a r t e da f t e r e i g h t m i n u t c s o f v e n t r i c u l a r f i b r i l l a t i o n . E p i n c p h r i n c ( 0 . 0 5 m g / k g ) a n d H C O . ( l m E c 1 / k g )w c r e a d m i r . r i s t e r c da t i c n minutes. Group I reccived initial dcfibrillation attcmpts at l2 minutes. Croup 2 received CPB bcginning at 12 minutes: dcfibrill a t i o n a t 1 4 m i n u t e s a n d b y p a s sf o r o n e h o u r . I s c h e m r c a n d n e c r o t i c areaswcre detcrmined with flourescein and triphenvl tctrazolium histochcmical staining techniques rn survivors. There was no significant difference betwccn prearrest variables {heart rate, mcan arterial prcssure, right atrial pressure, dp/dt, or timc to infarct).

Four of eight group 1 and cight of cight group 2 animals were resuscitated with two of eight and six of eight surviving to four hours, respectively {P < .05). Group I required significanily more eprnephrine, Iidocaine, countcrshocks, and joulcs per kilograrn

T h c c f f c c t i v e n c s so f o n g o i n g C P R c f f o r t s i s d i f f i c u l t t o c v a l u a t e .

Rcccrrt studics sullgcst that carbon dioxidc cxcrctiolt may bc a u s c f u l n o n i n v a s i v e i n t l i c a t o r o f r c s u s c i t a t i o n f r o r n c a r d i a ca r r c s t . A p r o s p c c t i v c c l i n t c a l s t u c l yw a s d o n c t o d c t c r m i n c w h c t h c r c n d - t i c l a l c a r b o n d i o x i d c m o n i t o r i n g d u r i r - r gC P R c o u l d b c u s c c la s a p r o g n o s tic intlicator of rcsuscitation and survival. Thirty-fivJ cardiac a r r c s t s i n 3 4 p : r t i c n t s w c r c r - n o n r t o r c dw i t h c a p n o r n c t r y d u r i n g C p R o v c r a ( ) n c - y c a rp c n o d . N i n c p a t l c n t s w h o w e r c s u c c c s s f u l l y r c s u s citatcd had highcr avcragc cncl-tidal carbon clioxide partial Drcssures {P,,.CO,) during CPR than 2(r paticnts who ci,uld not br r c s u s c i t a t c d( 1 5 + 4 v c r s u s 7 + 5 m m H g , / r . . 0 0 1 ) .T h r e c p a t i c n t s who survivcd to lcave thc hosprtal had a highcr averagep,,CO, t h a n t h c 3 2 n o n s u r v i v o r s{ 1 7 + a )v c r s u s l J + 5 m m H g , p . . 0 5 } . A l 1 ninc paticnts who wcrc succcssfully resuscitatedhad an avcragc f r , 9 0 , v a l u e _o f 1 0 m m H g o r m o r e . N o p a t i c n t w i t h a n r u c r r g .

P r r C O , l e s s t h a n 1 0 m m H g w a s r e s u s c i t a t e d .D a t a f r o m t h i s p r o spectivc clincral trial indicate that cnd-tidal carbon tlioxidc rnirnitoring during CPR is corrclated with resuscitation and survival from cardiac arrest.

-178 A Prospective Study of Helmet Usageon Motorcycle Trauma PJ Kelly,TG Sanson,GR Strange, EMOrsay/Division of Emergency Medicrne, University of lllinois, Chicago; Lutheran General Hospital, ParkRidge,lllinois

59

Trauma resulting from motorcycle accidents accounts for a drsproportionate amount of death and disability in motor vehicle accidents. In our state, from 1982 to l9B5 motor cycle accidents accounted for 1.75"/o of all motor vehicle accidents while they acounted Ior 12.6% of all fatal motor vehicle accrdents. We undertook this study to define the effect of motorcycle helmet usageon the morbidity, mortality, and financial impact associated with m o t o r c y c l e t r a u m a . T h r e e h u n d r e d n i n e t y p a t i e n t s w e r e e n t e r ed i n thc study who wcrc an avcragc agcof 26.5 years old, with 88.7% b c i n g m a l e . F i f t y - s i x 1 1 4 . 4 % lp a t i e n t s w e r e h e l m e t c d v c r s u s 3 3 4 (85.6%) nonhelmeted. Nonhelmeted motorcyclists had signifi' c a n t l y h i g h er I S S( l l . 0 l t 0 . 9 5 v s 6 . 7 3 ! L 4 6 , P = . 0 3 7 ) .P a t i c n t sw h o wcrc not hclmetcd suffcrcd a disproportionatc number of head and ncck injurics (P =.013) and cxtrcmity-pclvic girdle injurics (P = .018). Nonhelmctcd paticnts had a nonsrgnificant trend toward highcr health carc costs {$6,623 vs $5,427,1 = .31). Of thc most severly injured paticnts {lSS, 15),nonhelmeted motorcychsts had significantly longer hospitalizations and incurrcd grcatcr hcalth c a r c c o s t st h a n h c l m e t e d c y c l i s t s { P = . 0 0 0 6 a n d P = . 0 0 0 1 , r c s p c c tivcly). Thcrc wcrc 2(r fatalitics in thc study, of whom 25 wcrc not hclmctcd. Thc rcsults demonstratc that motorcyclc helmcts rcduce the scverity of injury and thc incidence of head and neck injurics as wcll as cxtrcmity-pclvic girdle rnjuries. Further, health c a r c c o s t s a n d l e n g t l " ro f h o s p i t a l s t a y i n t h e r n o r e s c v c r c l y i n j u r c d paticnts arc significantly lowered by thc use of rnotorcylcc hclr-ncts.Finally, our study demonstrated thc nccd of cmcrgcncy physicians to provicle thc public and lcgislators concrctc data t<r sllpport mandatory safcty lcgislation in our casc, thc usc of mutorcyclc hclmets.

cause the risks, benefits, and time required to accomplish it remain unknown. We studied 70 consecutive patients with penetrating cardiac injuries to ascertain the relationships among prehospital procedures, time consumed in the field, and ultimate patient outcomc. Thirty-one patlents sustained gunshot wounds, and 39 sustained stab wounds. The mean Revised Trauma Score was 2.8 t 0 . 5 . P a r a m c d i c ss p e n t a n a v e r a g eo f 1 0 . 7 t 0 . 5 m i n u t e s a t t h e s c e n e .

Scvcnty-one percent o{ patients underwent endotracheal intubation;93Y" had at least one IV line inserted, and57"/" had two IV lines inscrtcd. Twenty-one (30%) survived. There was no correlation bctwccn on-scene time and either the total number of orocedures ( R = . 1 7 , P = . I 7 l o r t h e n u m b e r o f I V l i n e s e s t a b l i s h e d{ R = . 0 6 ; P = .(r).On-scene times did not di{fcr whether endotracheal intubation or pneumatic antishock garment applications were applied. We conclude that well-trained urban paramcdics can perform multiple lrfc support procedures with very shott on-scene times and a high rate of patient survival and that prehospital trauma systcms rcquire a minimum obligatory on-scene time to locate patients and prepare thcm for transport. Endotracheal intubation, IV cannulation, and pncumatic antishock garment application, performed in accordancc with advanced trauma life support protocols, do not add a p p r e c r a b l yt o t h c t i m c e l a p s e di n t h e f i e l d .

- 181 lmpact of InterhospitalAir Transporton Mortalityin a Rural TraumaSystem RC Campbell, K Corse,CR Boyd/Department of Surgery, Memorial Medical Inc,Savannah, Georgia Center, Air transportfor thc seriouslyinjuredpatienthaslong been rccognized as an effective rnode of transportation to get patients to dcfinitivc carc. Fcw studics, however, have examined the rmpact of rntcrhospital air transport on mortality of the rural trauma patient.

Wc rctrospcctively rcvicwcd l(r8 survivablc major trauma patients d c f i n c d a s h a v i n g a n I n j u r y S c v c r i t y S c o r e i I S S Ib c t w c c n l 5 a n d 6 0 ; pcdiatric pationts wcrc cxcluded. Trauma Scorc and ISS wcre obtaincd on cach paticnt. The probability of survival for each paticnt was dcfincd using thc TRISS mcthod of the Major Trauma Outcomc Study. Actual rnortality was compared with predicted mortality. Paticnts wcrc then divided into outcome probability bins to cxaminc thc impact of air transport with respect to the lcvel of injury scvcrity. Our total patient population of l68 had a mean Trauma Scorc of 1 I and a mcan ISS of 29. The mcan probability of survival was 0.697. Fifty deaths were cxpcctcd, with 3l observed.

This 38.9'2, rcduction in mortality was significant to P < .00I lZ = 4.64). Thc grcatest single reduction in mortality occurred in the m o s t s c r r o u s l y i n j u r c d p r o b a b i l i t y b i n ( p s < 0 . 2 5 ) .N i n e t e e n d e a t h s werc obscrvcd in this group with27 expected, a 30% reduction in rnortality (P < .001, Z = 4.76).We conclude that air transport is an cffcctivc componcnt of prehospital care in the survivable, critically injurcd paticnt. Air transport would seem to have its greatest effect on thosc paticnts who are most seriously injured.

179 Comparisonof DifferentDefinitionsof Critical Trauma Patients M Smith,K Cooper, D Morabito, C MayiDivision of Trauma, Highland Hospital, TheBayAreaTraumaRegistry, General Oakland, California T h c o p t i r - n a lc l c f i n i t i o n o f a c r i t i c a l t r a u m a p a t i e n t , f o r c p i d c m i o l o g i c a s w c l l a s q u a l i t y a s s L l r a n c op u r p o s c s / i s u n c l c a r . W c t e s t c d thc following proposcd definitions of critical trauma paticnts on ollr cntirc population of trauma paticnts trcatcd during a l2-month p c r i o d : 1) I S S r n o r e t h a n I 5 o r I S S o f l 0 o r m o r c w i t h a L O S o f m o r c t h a r - rt h r c c c l a y so r p c n c t r a t i n g a n d I S S o f l 0 o r m r ) r c ; 2 ) I S S m o r c t h a r - rl 5 ; 3 ) A I S o f 3 o r r n o r c f o r a n y b o d y r c g r o n ; 4 ) a n y p c n c t r a t i n g traulra proxilrral to clbow or kncc or AIS of 3 or morci 5) probability of survival {POS).90 or lcss {using TRISS rncthodology).

Delinitions

2

3

4

5

1,193 N o .P a t i e n t s 665 381 787 AverageISS 21 28 19 14 AveragePOS (%l 80 66 83 89 142 N o .d e a t h s 142 139 142 (%) l\ilortalty 21 18 12 36 Operatingroom < 24 hours 254 163 271 257 N o .i n t e n s i v e 290 298 care admits 281 206 Averageintensive 1.86 2.91 1.58 1.05 c a r ed a y s B l u n to r penetrating 1.00 1.28 0.59 0.93 Averagehospital h o s p i t adl a y s 7.42 5.28 8.26 9.16 lSS, InjurySeverityScore;AlS, AbbreviatedInjuryScale

A

t

161 36

l Patients Treated 2,180 I

26 121 7 5

94 145 7

57

313

72

343

3.03

0.60

0.53

1.90

6.32

3.48

182 The lmpact of a RegionalizedTraumaSystem on TraumaCare in San Diego County FT Meyer,DAGuss,TS Neuman, WG Baxt,JV Dunford Jr, LD SL Guber/University of California, SanDiego,Medical Griffith, Center Within thc last decade. manv communities across the United Statcs havc introduccd {ormalized systems for the management of trauma victin-rs. Thcsc systems have evolved in part as a consequence of several studies that have identified a high percentage of prcvcntable death among trauma victims in communities without trauma programs. To assess thc impact of the trauma system introduccd in San Diego County in 1984, a review of the autopsy reports on all traumatrc deaths during the I986 calendar year was perf ormed. All deaths occurring before or within one hour of arrival at a hospital werc cxcluded, leavrng 21 1 cases for review. After ail referenccs to hospital name and treating physician were removed from the rccord, a panel of six physrcians analyzed each autopsy rcport to determine if a death was preventable. When five of six reviewers independently concurred that the death was preventable, it was so classified. Results were compared with a study of trauma deaths during the 7979 calendar year that used the same methodology and physician reviewets. In 1986, two of 211 (i%) trauma deaths wcrc classified as preventable compared with 20 ol \77 lII.4%) in 1979 (P < 001). One of 149 10.7%l central nervous system-rclated deaths was assessed as preventable in l9B5 comp a r e d w i t h f o u r o f 9 4 ( 5 % ) i n 1 9 7 9 l P < . 1 0 ) .O f t h e 6 2 n o n - c e n t r a l nervous system-related deaths in 1986, one was believed to be prcventable compared with l6 of 83 non-central nervous system-

Overall mortality for the entirc population w as7 "/"; yetttrunged fuom 7 5'k to 12 % depenciing on the dcfinition used. Also, wide dif ferences in acuity, cntical resourcc (intcnsive care and operating r o o m ) u s c , a n d o v c r a l l t r a u m a a c t i v r t y w i l l b e p e r c e i v c di n t h e s a m e population dependingon the definitions uscd. Concensus needsto bc rcached on a standard definition if meaningful comparisons between trauma centers as well as Datient care standards are to bc made.

180 PrehospitalAdvancedTrauma Life Support for PenetratingCardiacWounds PT Pons/ B Honigman, K Rohweder, EE Moore,SR Lowenstein, Denver HealthSciences Center, Denver; University of Colorado General Hospital Prehospital advanced trauma life support is controversial be-

60

r e l a t e d d e a t h s i n 1 9 7 9 ( P < . 0 0 5 1 .D u r i n g t h e i n t e r v a l b e t w e e n l 9 Z 9 and I986, a formalized system of trrurni care was introduccd in San Diego County. Analysis of traumatic deaths occurring frvc years before the institution of the trauma system compared with deaths occurring two years after the introduction o{ the system revcaled a drop in the preventable death rate from ll.4"k to I.0%.

-183 Comparison of Cimetidineand Diphenhydraminein the Treatment of Acute Urticaria R Moscati, G Moore/Department of Emergency Medicine, Darnall ArmyCommunity Hospital, FortHood,Texas Recent case reports have suggestcd that H, antihrstamines, usccl alone, may be effective in the treatment of acute urticaria, a common emcrgency departmcnt complaint. This contradicts accepted doctrinc on thc treatmcnt of acute urttcaria. Bascd on t h e o r i e s o f H , - a n d H ,- -brleoccckpatdocr i n t c r a c t i o n a t t h e c e l l u l a r l c v e l , i t h a s been stated that H, before H, blockadc may cxaccrbatc s_ymptoms. Thc puiposc rrf our study was t() colnparc diphenhydramine, an H, blocker, and cirnetidine, an H, blocker, rn a iandornizcd, prospcctivc, douhlc-blind clinical trial. Nincty-thrce paticnts prcsenting to thc ED with clinical cvidcncc of acute urtrcarra wcrc treated with cither 50 mg diphcnhydraminc or 300 mg cirnctidinc IM. Patients' signs and symptoms wcrc quantitatcd on a numcrical scalc before rcceiving medication ancl30 minutcs aftcr trcatmcnt.

P a r a m e t e r sm e a s u r e d i n c l u d c d d e g r ec o f i t c h i r - r gr, n t c n s i t y o f w h c a l s , dcgree of sedation, extcnt of whcals, ancl l.rcrception of ovcrali tmprovcment. Usrng analysis of variancc for statistrcal cvaluation, both rncdications provided signifrcant relief of itching and whcai i n t e n s i t y ( P = . 0 0 0 1) . S c d a t i o n w a s c a u s c d b y b o t h d i p h c n h y d r a n - r i n c ( P = . 0 0 0 1 ) a n d c i m c t i d i n c ( 1 , = . 0 0 0 5 1 . H o w c v c r , t l . r cd c g r c c o f s e d a t i o nc a u s c d b y d i p h c n h y d r a m i n c w a s s i g n i f i c a n t l y g r c a t c r t h a n that caused by cimcticlinc {P = .0001). Thc perccption of ovcrall l m p r o v c m c n t w a s g r c a t c r w i t h c i m c t i d i n c ( P = . 0 t t 2 1 ) ,w i t l - r l l Z , Z ,o f t h c s c p a t i c n t s r c p o r t i n g s o m c i m p r o v c m c n t , w h | r c 7 6 , ' 1 ,o f d i p h c n h y draminc-trcatcd paticnts rcportcd imptovcmont. Our results indicatc that cirnctidinc is cfficacious as thc initial trcatmcnt of aclrtc urticaria and has less tcndcncy towarcl scdation. Furthcn.norc, untlcr closc obscrvation, cimctidinc drd not callsc any cxaccrbation of s y m p t o m s o r u n t o w a r d s i c i cc f f c c t s . W c a d v o c a t c c o n s i d c r a t i o n ( ) f c i m c t r d i n c a s a r a p i d , l c s s - s c d a t i n g a n t r h i s t a m i n c f o r u s c i r - rt h c initial trcatmcnt of acutc urticaria. Its usc may cncouragc grcarcr cornpliancc ancllcss rncdicolcgal risk in thc arnbulat()ry parieut.

184Cimetidinein the Treatmentof Acute Allergic Reactions JWRunge, JC Martinez, EMCaravati, SGWilliamson, SC Hartsell/ Department of Emergency Medicine, Charlotte Memorial Hospital andMedical Center, Charlotte, NorthCarolina Cimctidinc, an H, blockcr, has bccn rcportcd to bc an cffcctivc treatmcnt alonc or in combination with dirrhenhvclraminc for ircutc a l l c r g i c r c a c t i o n s . W c s t u d i c t l 3 9 p a t i c n t s i n a r a n d o r n i z c c lc l o u b l c b l i n d p r o t o c o l t o a s s e s st h c c f f i c t c y o { c i n r c t i d i n u c o m p a r c d w i t h diphcnhydramine. Mcdications wcre givcn intravcnously: Group I (N = 14), diphcnhydraminc 50 mg and placcbo; group 2lN = l2), cimctidine 300 mg and placebo; and group 3 (N = lg), dipl.rcnhydrarnine 50 mg and cimetidine 300 mg. Patrcnts ancl examincrs asscsscd symptons and signs of allcrgic reactions using an ll-cm visual analogscale (VAS) be{orc and 30 rninutes aftcr trcatmcnt. Itchins and urticaria occurred with sufficrent frcclucncy for statisrieal evaluation. A significant symptom was dcfiniJ as .l cm or morc on pretreatment VAS and relief as a decrcasc of 2.5 cm or rnorc aftcr treatment. Mean drffcrences in VAS scores wcrc analyzctl usir-rgthc t w o - w a y S t u d e n t ' s f t c s t , a n d p r c s e n c co f r c l i c f w a s t c s t c d u s i n g t h c F i s h e r ' se x a c t t c s t . O f t h c 3 5 p a t i c n t s w i t h i t c h i n g , I 2 o I l Z l I 0 0 % ) receiving diphcnhydramine-placcbo had rclicf cornparcd with six of t e n ( 6 0 . 0 % ) o f t h c p a t i e n t s r c c e i v i n g c i m e t i d i n c - p l i c c L r o ( r t o s t , 1 )= . 0 2 ;F i s l r e r ' s ,1 r= . 0 2 9 ) .A l t h o u g h I 1 o f 1 2 1 9 1 . 7 " 1 , ) r c c e i v i ndgi p h c n h y dramine-cimetidine had rclief, thc differencc betwccn ihis comhination drug group and the single drr-rggroups was not significant { F i s h c r ' s ,P = . I 2 ) . O f 3 3 p a t r e n t s w i t h u r t i c a r i a , f i v c o f 1 l ( 4 5 . 5 % ) receiving diphenhydramine-placebo had relief compared with cight o f t e n ( 8 0 . 0 % ) r e c e i v i n g c i m c t i d i n e - p l a c e b o { N S ; F i s h e r , s ,p = . i 8 ) .

Of those receiving diphenhydramine-cimetidine, ll of 12 (91.7"/,,) had relicf, significantly bctter than diphenhydrarnrnc alone (r tcst, P = . 0 0 6 )F i s h e r ' s ,P = . O 2 7 ) .W e c o n c l u d e t h a t i n p a t i e n t s w i t h a c u t c allergic reactions for itching, cimctidine alone or in cornbrnation with diphenhydramine is no more effective than diphenhydramine alone; and {or urticaria, cimctidine is cffective, and its combination

6l

with diphenhydramine is better than diphenhydramine alone.

185 Early Detection of Acute Myocardial Infarction: lmmunochemical Determination of Creatine Phosphokinase-MB Versus Standard Electrophoresis WB Gibler,LM Lewis,RE Erb,WB Campbell,R Vaughn,AV Biagini,J Blanton/Division of Traumaand EmergencyMedicine, Sectionof SurgicalSciences,Vanderbilt University Schoolof Medicine;Departments of Pathologyand Cardiology, St Thomas Hospital,Nashville, Tennessee Thrcc immunochemrcalmethods for dctcction of creatine phosphokinasc (CPK)-MB andstandard elcctrophorcsis werccvaluatcd for thcir ability to diagnoseacutc rnyoiardialinfarctionin paticntsprcscntingto the emcrgencydepartmcntwith chcstpain.

Serumsamplcswerc analyzcdfor CPK-MBby the four mcthods (CorningMagicLitc- , BaxtcrStratus"f luororrctricinrrnunoassav, HybritcchTandcm-E-,and Hclcna REP-at zero hourslprcsentatior-rto thc ED) and at thrcc hoursaftcr prcscntationon 200 total l ) a t i t . n t sA. [ t c r e x e ] u d i n gr r a n s f e rn n t LE D d i s c h a r g ep l r r e n t s , curnplctcdata wcrc availablcon 90 patrents.Using the hospital dischargcsumn-rary as thc standard,13 of tl-rc90 wcre positivcfor acutcmyocardialrnfarctior"r.

Thc followinc tablc summarizesthc clat:rfor zcro :rnclthrcc hours,witl"rscnsitivitvand spccificitvas notccl: Method Corning Baxter Hybritech Helena

Sensitivity (0 hr) 61.5% 61.5% 53.8% 46.1"k

Specificity (0 ho 97.4k 87.0"k 97A% 98.7"k

Sensitivity (3 hr) 100ak 100% 100% 61.50/"

Specificity (3 hr) 94.80k 85.71" 91.0% 98.7"k

T h c s c n s i t i v i t y o f a l l i r l m u n o c h c m i c a l r n c t h o c l s w a s 1 0 0 , 2 ,a t t h r c c h o u r s c o r " n p a r c dw i t l - r ( r l . 5 " 1 , l o r c l c c t r o p h u r c s t s . A 1 0 0 , 2 , n c g a t i v c p r c c l i c t i v c v a l u c w a s o b t a i r - r c db y t h c t h r c e i n t n l u n r r chcrnical lrcthods at thrcc hours aftcr prcscntation. As thc hospit a l d i s c h a r g c d i a g n o s i s o f a c u t c n . r y o c a r c l i ailn f a r c t i o n w a s b a s c . l on clcctrophorctlc analysis of CPK-Mil, it is possiblc sourc of thc " f a l s c - p o s i t i v c" d c t c r n t i n a t i , r n s b y t h e r r r t r r t is r n s i t r v c l l l m L l n o chcrnical lrcthocls actually dctcctcd srnall infarctions. Rarricl tlctcction of :lcutc uyocardial infarctron offcrs r.nany poteniial a c l v a n t a g c st o t h c c n l c r g c n c y p h y s i c i a n . E a r l y d i a g n o s i s ,w h i l c t h e paticnt is in thc ED, woulcl allow appropriatc dispositiun of thc p a t r c n t w i t h a c u t c n ' r y o c a r c l i a ]i n f a r c t i o n t o t l r c i n t e n s i v u c a r c s c t t i n g . P o t c r - r t i a l l yc, l i a g n < t s i(s} f: r c u t cr l l y o c a r c l i a il n f a r c t i o n w i t h i n a _s i x - h o u r p c r i o c l a f t c r s y u t p t o l n o n s c t r r a y a l l o w t h r o n - r b o l y t i c t h c r a p y t o b c g i v c r - rt o p a t i c n t s w i t l - r a c u t c m y 0 c a r c l i a l i n f a r c t i ( ) r - r n ( ' t h i l v i r ' r gt l i a g n o : t i c F C C s .

-186 Use of Indomethacin Suppositoriesin the Treatmentof UreteralColic S Melanson, S Weitzel, J Gillen, D Kapoor, J Mowad/Departments of Emergency Medicine andUrology, Geisinger Medical Center, Danville, Pennsylvania Urctcral colic can bc a difficult paticnr nan:lgcrrcnt problcm in thc cmcrgcncy clcpartntcnt.Prcscnt trcatlncnt consists of hyclration ancl symptomatic pain control with narcotic analgcsics.

U r c t c r a l o b s t r u c t i o n c a u s c sr c l c a s c o f p r o s t a g l a n d i n st h a t i n c r e a s c rcnal blood flow ancl glorncrular filtration, thcrcby incruasing u r c t e r a l w a l l t c r . t s t o np r o x i m a l t o t h c o b s t r u c t i o n a n d c a u s i n g t h c pain of urctcral colic. By inhibiting prostaglandin synthcsis, indomcthacin blocks this cffcct and has bccn shown to bc cffcctivc i n r c l r c v i n g u r c t c r a l c o l i c w l - r c ng i v c n I V i n E u r o p c a n s t u d i c s . W c condtrctcd a prospoctivc, dt'uhlc-trlind, placch,,-iontrollcd study c x a m i n i n g t h c c f f i c a c y o f i n d o m e t h a c i n s u l . r p o s i t o r i c si n r u l i c v i n g c o l i c s e c o n c l a r yt o r a d i o g r a p h i c a l l y d o c u m c n t c d u r c t c r a l c a l c u l i r n an outpaticnt setting. Patrents wcrc randomized to rcccive surrp o s r t o r i c s { e i t h c r i n d o r n c t h a c i n o r p l a c c b o ) e v c r y c i g h t h t ' 1 1 52 p 6 s u p p l c m c n t a l n a r c o t i c s ( a c e t a r n i n o p h c n - o x y c o d o n c )t o L l s c a s n c c d e d . P a i n c o r - r t r ow l a s a s s e s s e db y t h e n u m b e r o f s u p p l e m e n t a l narcotic tablcts used by cach paticnt each 24 hours. Forty-onc paticnts wcrc entercd into thc study protocol with cornplctc f o l l o w - u p a v a i l a b l c o r - r2 ( r p a t i c n t s . A l l 1 3 p a t i e n t s i n t h e c o n t r o l group had recllrrcnt cpisodcs of colic, nine of thcsc having more t h a n o n c e p i s o d e .F i v e o f t h c l 3 c o n t r o l p a t i e n t s r c q u i r e d h o i p i t a l i z a t r o n f o r p a in c o n t r o l . F o u r o f t h c I 3 p a t i c n t s i n t h c i n d o m c t h a c i n group had recurrcnt colic, witl-r only one having more than one e p i s o d e .N o p a t r e n t i n t h c i n d o m c t h a c i n g r o u p r e q u i r c d h o s p i t a l i -

zation for pain control. Overall, the ratio of supplemental narcotics used by the placebo group versus thc indomethacin group was 7 . 6 : l l P . ' . O O S J . T h e m i a n t i m e t o c a l c u l u s p a s s a g ew a s s l i g h t l y shorter in the indomethacin group (ti2 versus 89 hours), but this dif{crencc was not statistically significant. Our results support the use o{ indomethacin suppositories in the treatment of recurrent colic secondary to ureteral calculi. for Relief of Acute Renal Colic 187 Indomethacin AB Wotfson, DM Yealy/Hospital of the University of Pennsylvania; U n i v e r s i t yo f P i t t s b u r g hA f f i l i a t e d R e s i d e n c y i n E m e r g e n c y Medicine;Center for Emergency Medicine of Western Pennsylvania,Pittsburgh Eaily studies have suggcsted that indomethacin can relieve renal colic by a mcchanism of action different from that of narcotics. If effcctivc, indomethacin would offer the potential advantagc of avoiding narcotic side cffects such as alteratlon of mental status' We prospcctively adrninistcred oral indomcthacin (50 mgJ to 25 nonvomiting patients with acutc renal colic due to a documcnted stonc. Elcven patients (group l) recclved indomethacin in an unblindcd, noniandomized fashion aftcr failure of oral or parenteral narcotics to relicve pain. In I4 additional patients (group 2), indon-rcthacin was givcn as the only initial trcatmcnt. Pain inten-to-10 scalc' sity bcforc and aftei trcatlnent was rcported using a 1 5 .

U 1 2 .

7 t o 3 . ( r t 3 U(1'<02)' p a t i c n t s , p a i n d c c r e a s c d f r o m g r o u p I In Six'of the I 1 paticnts rcportcd a dccrease in pain intensity of 50.o1', or morc, whiih occurrcd within 25 + 1i minutes. In no patient did pain incrcasc. In five of thc six obtaining rclicf, pain dccrcased to a b or 1 lcvcl. Among the I 4 paticnts in group 2, pain decrcascd from 7 . ( r i 1 . 5 t o 4 . 6 + + . 0 ( t ' . . 0 0 S ) .E i g h t o f t h e 1 4 r o p o r t c d a d c c r e a s c + 14 in pain intcnsity of 50'2. or morc, which occurrcd within 40 m i n u t c s . I n f i v c o f t h c e i g h t , p a i n d c c r c a s c dt o a 0 o r 1 l c v c l l n n o n a t i c n t c l i d p a i n i n c r c a s c ; f u r t h c r a n a l g c s i a w a s r c c l u r r c di n t h e s i x nati"nts whosc pain did not rcspond to indomethacin. Paticnts who i c s p , r n c l c dt o i n d o t n c t h a c i n w e r c d i s c h a r g c d o n o r a l i n d o r n c t h a c i n ' Ali wcrc able to continuc with daily activitics; oniy onc had returncd for further pain control at onc wcck follow-up - Two p a t i c n t s s u c c c s s f u l l y t i e a t c d f u r t h e r c p i s o d e so f r c n a l c o l i c a t h o m c with oral indomcthacin. Thcse promrsing preliminary observations suggcst that placcbo-controlled studics arc warrantcd to dcfinc ttLc appropriaic rolc {or indomethacin and similar agcnts in thc managcmcnt of acutc rcnal colic.

-188 Stabilizationof UnstablePelvic Ring FracturesWith MilitaryAnti-ShockTrousers: A Radiographic Assessment Medicine J Shall,J Glauser/Emergency G Polando, CCHuerla, and of Orthopaedic-Research Departments Program, Residency Ohio Centeroi Cleveland, trliSinaiMedical Surgery, Orthopaeiic (MAST)in hcmodytrousers Thebenefitsirf militaryanti-shock

inflated, even extreme manipulative force failed to reproduce fracture end-distraction. At no time during MAST use was the fracture ovcrreduced or did pelvic ring collapse result. The authors find radiographic evidence fo s.tppott the use of MAST in stabilizing the unstable pelvic ring fracture.

189 Neutrophil-Mediated Microvascular Injury of Physiologyand DL Carden,JK Smith,RJ Korthuis/Department MedicalCenter;Clinical LouisianaStateUniversity Biophysics, of EmergencyMedicine,SchumpertMedicalCenter, Department Shreveport,Louisiana Recentstudiesimplicatc polymorphonuclearneutrophilsin the microvascularinjury that occurson reperfusionof ischemictissue' Bcfore tissuc extravasationand microvascularinjury, circulating neutrophils adhcreto the microvascularendothelium and become ,"tivrt d. Thc purposeof our study was to delineatethe role of ncutrophils in producing microvascularinjury in isolated canine The effect of lracilii mrlscl. after a frolonged ischemic insult ncutropenia was examined using specific antisera raised against caninc neutrophils.The antineutiophil serum reducedtheperiphcral white blood cell count to less than 5% of control values' In by adminiaddition,the rolc of neutrophil adherencewasaddressed stcrins a monoclonal aniibody specific for the B-chain o{ the neutrdphilCD18 complex(IB.).Bv binding with the CD18 complcx, IB. interfercswiih ncutrophil adherenceand.extravasation' .fhe'snliret'ttdrag reflection cocfficient (o) was used as an index of the scverity of riiicrovascularinjury and is a sensitivemeasureof changesininicrovascular permeability.The o was determined{or the fJllowlng conditions: control (no ischemia),reperfusionafter four hours oi-ischemia,reperfusiona{ter four hours o{ ischemiain ncutropcnic dogs,and reperfusiona{ter four hours of ischemia in dogstrcated with IBo. Group Control usion(l/R) lschemia/reperf l Pletion) l / R ,( n e u t r o P hdi e

r/R,(rB")

o 0 . 9 9r . 0 8 U,OUf ,UZ

0 . 9 9t . 0 5 1 . 0r . 0 3

Rcpcrfusionaftcr {our hours of ischemia resultedin a significant dcircasc in o, indicating a dramatic increase in microvascular fcrmeability. Neutrophil depletion or preventron o{ neutrophil ndh"..n". preventedihe inciease in microvascularpermeability sccn in untrcated animals. The results of our study indicate that ncutrophils mediate postischemicmicrovascularinjury and that t.ntto-phil adherenceto the microvascuiarendothelium is a prerecluisilefor the production of this injury.

190The DetrimentalEffectsof lv crystalloidAfter Aortotomyin the Swine

SP Bruttig,CE Wade, P Maningas,GA Millnamow/ WH Bickell,LettermanArmy Instituteof Research,Presidiool San Francisco, Tulsa, TraumaService,SaintFrancisHospital, California; Oklahoma ihe obiectiveof our study was to test the hypothesisthat after aortotom, attempting to iapidly replace the estimated blood unl,r-. a.ii"lt *iitt IV crystailoid will increasehemorrhageand decreasesurvival. Sixteen anesthetizedYorkshire swine underwire placementin the antewent splenectomyand statnless-steel rior in{rarenalaoita and were instrumented with Swan-Ganzand carotid artery catheters.The wire was pulled, producinga-S-mm aortotomy and spontaneousintraperitonealhemorrhage'The animals were randomly assignedto tlie untreatedcontrol group(eight) or the lactated Ringer's group (eight),which received80 ml/kg Rinser'sIV. The lactatedhinger's in{usion was initiated 6'5 minutes after aortotomv and infused at a rate o{ 8 ml/kg/min lrom laseline to five minutes after aortotomy,there was a profound decrcasein cardiac output, mean arterial pressure,and mean oulmonarv artery pressurein both groups.The administrationof as response iactatcdRi.tg.t't produccda biphasichemodynam-ic cardiacoutput, meattartetial pressure/and mean.pulmonaryaftery pi.rr".. sign#icantly {P < .05),increased,and then subsequently Fellsrsnific;ntlv (P <'.05]below that of untreatedcontrol animals' ih. ,iolrr-. of'hemorrhage and the mortality rate were signifi! cantly (P < .05)increasedin the Ringer'streatment group12,142 178 veisus 783 t 85 mL, and eight of eight versus zero o{ eight, iespectively).From these data,we concludethat in this model of r,rttcotrtroll.d arterial hemorrhage resulting from abdominal aortotomy, the rapid administrationof IV lactatedRinger'ssignilicantly

rlarnically unstablc paticnts with pclvic ring fracturcs arc wcll du..rrrr"r,t.,1. Howcvcr, this literature and EMS guldclines also advocatc the use of MAST as a skclctal stabilization devicc lt is bclicvcd that MAST imrnobilizes the pclvic ring by acting as a large air splint. No study documcnts, eithcr quantitativcly or- quaiitativcly, evidencc that MAST can adequatcly perform this function' Furthermorc, the potential for creating new darnage, or thc-agg{avation o{ n.gnn "ni soft tissue injurics, has not been asscssed This radiographically- whethcr bonv stability o{ thc .trl,ly "*a-incs n c l v i s i s a c h i c v e d b y M A S T A c a t l a v e r i cm o d c l w a s d c v e l o p c d - a n d Thrcc i.ruu.n ,o sitnulate a human unstable pelvic ring {racture iudaue.s found by radiographic examination to be {rcc of pelvic bone disease o, fiactr.trc-serrred as models. Five types of unstable pelvic ring fractures, simulating worst casc instability, were surgically induccd. For ihe most unstablc fractures, both blunt and obliquc anglc bone cuts were produced. External leg rotation to 90' and abduction to 50'{rom midline were used to represent extremes of expected prehospital motion. Anterior-posterior and inlet views view documented pelvic ring instability' *ith'r.tpp1.-entaioutlet Radiogr'aphic assessment of pelvic ring motion was carried out beforc" and at end-manrpulaiion, both with and without each cadaver in MAST. EMS personnel aided in the application and inflation of MAST to ensure conformity with current protocols' Radiographic evaluation proved MAST was- effective in reducing and siabilizing each unstable pelvic ring fracture With proper MAST inflatio*n, pelvic ring staEility under extreme manipulation was maintained. in every fracture type, bony distraction of up to 6 cm was completely reduced with MAST. In addition, with MAST

62

increases hemorrhage and mortality.

-191

An Evaluationof the DiagnosticCapabilitiesof MagneticResonancelmaging With a Comparisonto ComputerizedTomograpttyin Acute Spinit Column Injury A E Flanders, M A LevitVEmergency Service, ThomasJefferson pennsylvania University Hospital, Philadelphia,

Recently, magnetic resonance (MR) imaging has become a useful adyunct in diagnostic evaluation of suTt t]rr.rc pathology.

Plain radiographic and computed tomographic (Cf) scanning iie thc prcsent standard of care in evaluation of spinal column inlury,.

Where CT scanning demonstrates presence ,rr,l "*terrt of skcletal injury better than plain radiography, both have been limitecl in provldrng rnlormation regarding prcsence and extent of soft tissue injury, primarily concerning the spinal cord and intervertebral discs. Our study_was conducted to evaluate the diagnostic capabili_ ties of MR in the sctting of acutc spinal column injury and to compare these results with those oJ CT scanning. Our study institution is a Lcvel I and regional spinal cord trauma ccnter. The sample population included 49 patie;ts undergoing MR to cvaluate suspected spinal column injury. Thirty-thrce-of th-escpaticnts hacl both MR and CT_cvaluation, and resJlts wcre con-rpaied. Level oi rnjury as imaged by MR and CT scanning ranged from C2 through percent (five) of the injuries -brc ai'C2, Z% !]r.Sgven {fivc) at i3, 2 0 % l l 4 l a t C 4 , 3 7 % 1 2 6 la t C S , 2 3 % l l 7 a t C ( r , a n d S y " o u r ' a t C 7 ' . ) lf I Seventy-one injuries were idcntificd by MR imaging. Thesc injuries were classificd as fracture-dislocation (2 I disc herniation (29), ), and spinal cord cdema-contusion-transection (21). Diagnostii imaging results of patients undergoing CT scanning and MR werc compared. CT scanning dcmonitratcd 22 hactiie_dislocations compared with ten on MR. MR demonstratcd l9 disc protusions compared with seven on CTscanning. Additionally, MR imagcd l3 cord injuries comparcd with zero by CT scanning. f t wcightcd echospin sequcnce imaging provcd'bcst for osscous injury an<i hemorrhage. T2-weighted echospin sequcncc imaging dcrnonsira tcd spinal cord edema best. GRASS imaging p.uu".l-bcst for disc 'MR herniation with its myelogramlikc cfJeci. irnaging provcrl superior in demonstrating spinal cord pathology and intcrvcitcbral dlsc hcrniation. CT scanning was supcrior to MR in dcmonstratins o s s c o u si n j u r y . C T i m a g i n g a n d M R i m a g i n g c a n l r e u s c fu l t o g c t h c : r rn dctcrmining prcscncc and cxtcnt of spinal column iniury.

.192 Effect

of HypertonicVersus Normotonic Resuscitationon Intracranialpressure After Combined Headlnjury and HemorrhagicShock CBlrvin,SA Syverud, SC Dronen,CR Chudnofsky/Department of Emergency Medicine, Universily of Cincinnati Medical Center

-t"

Biros, R Nordness/Department of Emergency Medicine, IrlH H e n n e p i n C o u n t y M e d i c a l C e n t e r , M i n n e a p o l i s ,M i n n e s o t a Morhidity af ter significant head trauma depencls in part on the , degrte ol cerebral edema that develops in the period immediately a{ter the injury. The goal o{ our research was to compare the effects of various chcmical interventions on reduction of ierebral edema aftcr head trauma in the rat. Adult male Spraguc_Dawley rats weighing 350 ro 450 g were anesthetized with kelamine l0b mg/ { kg IP,) and underwcnt right ternporoparietal craniotomy. A 2_cm l . e n g t ho t p o l y e t h y l e n e t u b i n g ( I D , 5 . 8 m m ) w a s p o s i t i o n e d p e r p e n dicular. to the exposcd intact dura through the cranrotorny srte, secured wrth methyLncthacrylate, and filled with normal ialine.

Animals were allowed to stabilize for ten to 15 minutes. Hcad tralrrnawas then producedby a fluid pcrcussion systcm attachcd to the trauma cathcter that delivcred aitandarcl pr".rr,r. wave {prcs_ s u r c , 0 . 5 a t m ) t o t h e u n d e r l y i n g b r a i n t i s s u e . E x p e r i n - r e n t a al n i i n a l s received one o{ thc following drug trcatmcnti: dcxamcthasone (DM), 0.30 rng/kgIV; dichloroacctate (DCA), 25 mg/kg Ip {reduccs t i s s u c l a c t a t e p r o d u c t i o n a n d a c c u m u l a t i o n ) , 1 . . ; - U u t a n e d i o l( B D ) , 4 7 n m l k g , I P ( r c d u c c st i s s u e l a c t a t c p r o d u c t i o n a n d i s o s m o t i c a l l y activc),mannitol, I g/kg IV. Ip and IV injectrons werc delivcred ten m i n u t c s a n d i m m e d i a t e l y b e f o r c t r a u n t a , r e s p c c t t v el y . T h e c x p e r i _ mental treated animals (srx) wcrc "ntop"rid with traumatizcd control animals that reccived thc samc volumc of normal salnc {NS) placebo by the same routc and with nontraumatized control animals that rcccrvcd thc samc study drug or NS. Six hours aftcr h c a d t r a u m a , t h c a n i n - r a l sw c r c k i l i c d , a n d c o r t i c a l t i s s u c w a s harvcstccl for mcasurc of tissuc spccific gravity. Samplcs wcre collcctcd from tl-rctrauma sitc and fiorn a crirrcsp<inding arca of thc oppositc cortex. Nonc of the study drugs affcctcd ihc spccific gravity of cortical tissuc in nontrallmatizcd trcatcd animals. Thc spcciftc gravity of cortical tissuc frorn thc contracoup sitc of traumatizcd animals did not diffcr frorn thc spccific giavity of tissuc from nontraumatizcd trcatcd or control animals.'

ExperimentalCondition With Study Drug (N = 6 for each group) Trauma+ drug intervention

DM 1.035

DCA 1.037

BD 1.039

T r a u m a- d r u gi n t e r v e n t i o n

1.033

1.033

1,033

1.033

Significance(ANOVA) (Nontrauma+NS=1.040)

P=NS

P<.05

P<.05

P<.05

Trauma Site Specilic Gravity (g/mL) Mannitol 1.037

H i g h c r s p c c i f i c g r a v i t y o f c o r t i c a l t i s s u c f r o m a n i n - r a l st r c a t c d w i t h mannitol, DCA, and BD indicatcs lcss watcr contcnt of thcsc tissucs and suggcsts a protcctivc cffcct of thcsc drugs frorn dcvclop_ mcnt of ccrcbral cdcna six hor-rrsaftcr hcad trauma in rats.

Vigorousfluid resuscitationof hemorrhagicshockmay rncreasc 194 Oral lntubationin the Multiptytnjured patient: The cerebralcdema in patients with concomitant closed_he.dir.ryr,.y.

Risk of Exacerbating Spinal Corci Damage Becausehypertonic resuscitation(HTRJresults in fluid shift irom KJ Rhee,W Green, JW Holcroft, JAAMangili/Division of the extravascularto thc intravascularcompartmcnt/ lcss ccrebrai Emergency MedicineiOlinical Toxicology, D,epartments of Internal edemaand lower intracranial prcssurc (fil1 migni be observcd Medicine andSurgery, University of Caiifornia, Davis,Medical when comparedwith normotonic rcsuscitation(Nfn). Immature Center, Sacramento swine(15 to 20 kg) werc instrumented under halothaneancsthcsia Theuseof oralintubation duringtheresuscitation of seriously and splenectomized.Aortic, central venous,and intracranialpres_ i n j u r c d p a t i c n t s h a s b c c n d i s c o u r a g c db c c a u s e o f t h c f e a r t h a t t h i s sureswere monitored. At t : 0, blunt injury to the right cerebral tcchnique may lcad to cervical cord darnagc. Our abstract reports hemisphercwas induced with a fluid percuision dcvice. Simulta_ the. 18-month cxpertcnce of an erncrgency dcprrt-"rrt in which neously,hemorrhagicshock was inducedby rollcr purnp with_ oral intubation was the usual rnethod nf uii."ny.u.rtrol for victims clrawaltrom the arterial catheterof 307" oI blood volume bver 30 of blunt trallma. There were 237 injured paticnts intubated in the minutes. At t : 35, resuscitationwas initiated with 0.9% saline3 E D ; 2 l p a t i c n t s { 8 . 9 %) h a d c c r v i c a l c o r d o i b o n e r n j u r y . T h c r e w e r c ml/k_g/rnin(NTf., n = 4) or Dextran 7O,t' - 7.5"/osaline0.36 mLlkgl no paticnts in whon a neurologic loss followed an airway mancu_ min (HTR,-n= 4) for 20minutes. Both groupswere hypotensiveit ver. Oral intubation was the dcfinitive airway maneuvcr in 213 p . a t i e n t s{ 8 9 . 9 % 1 ,n a s a l i n t u b a t i o n i n I Z p a t i c n t s !!q 9"d of hemorrhage(meanarterial pi.srrr. range,40 to 60 mm 1 7 . 2 % ) ,a n d c r i c o _ Hg)but n-o_rmotensivc by t = 45 (rneanarterial pr.rr'rr" range,90 to thyrotomy or tracheotomy in scven paticnts li.q"/"l. Ot d1c Zl : 45, ten minutes after the siart of resuscitation, mm.Hg) Ar t -t]! patients with cervical injury, oral intubation was the definitrvc ICP in the NTR group (63 I 2l mm Hg) was significantly higher airway maneuvcr in l7 patients (81.0%),nasal intubation in two than.in the HTR group l2Z ! t4 mm Hg) {p < .05, unpaired r Gst). p a t i e n t s 1 9 . 5 % ) ,a n d c r i c o t h y r o t o m y i n t w o p a t i c n t s ( 9 . 5 % ) . T h e s e Cerebralperfusion pressurewas signifiiantly highei in the HTR two cricothyrotomies were performed because nasal and oral intu_ gro-upat t : 45 174t 9 versus 47 ! 17 mm Hg) (p < .051.These bation had failed. The risk of spinai cord injury ,..ondrry tn orrl dif{erences graduallyresolvedduring subsequeniieinfusion of shed intrrbx66l in thc seriously injurcd patient ls low. Selection of the blood. I heseollservationssuggestthat HTR may decreasecerebral mcthod ior dctinitive airway_control should be based primarily on ede.maduring fluid resuscitaiionof combined hemorrhagicshock the operator's particular skills and cxperience rather than the fear and closed-headinjury. of inflicting cervical cord damage.

193Effectof Ghemicalinterventions on CerebralEdema FormationAfter HeadTraumain Rats

195Factorslnfluencing Neurologic Recovery After CardiacArrest 63

N Abramson, P Safar, K Detre, the Brain Resuscitation Clinical Trail (BRCT) ll Study Group/lnternational Resuscitation Research benter, University ot Pittsburgh; 20 hospitals in eight countries Neurologic damage has been reported to occur rn 20y" to 4O"/o of lone-term-cardiac arrest survivors' The recent completion of the seconl ohase of an international randomized clinical trial of brain resuscitation provides additional in{ormatron. Data from 5l(r comatose t.t.uivott of cardiac arrest, including details concerning baseline medical history, brain insult, and the resuscitation process, were analyzed to identify independent predictors of subsequent neurologic recovery. Mortality was,,9}"k 1423 oI 516). Of ihose who survived the entire six-month follow-up perio d' 7 6% 17| of 93) were able to function independently Good neurologic funct i o n w a s r e c o v e r e db y 2 3 % { 1 2 1 o f 5 1 6 ) o f t h e e n t i r e s t u d y p o p u l a t i o n a t s o m e t i m e d u r i n g f o l l o w - u p . A n a d d i t i o n a l 9 % 1 4 7o f 5 1 6 l awakened but never achieved good neurologic function. Thc remaining 667" 1342 o{ 516) never regained consciousness. Factors positiveiy associated with good neurologic recovery/ in both univariate and multivariate analyses, were cardiac cause of arrest, arrest time of less than five minutes, and CPR time of 15 minutes I a I 1P = . 0 1 ) . T h e s e r e s u l t s c o n f i r m t h e f i n d i n g s o f o u r p r e v i o u s clinical trial, parallel reported predictors of mortality after cardiac arrcst, and trlggcst areis for improvement in the treatment of carolac arrcst.

.196 CoronaryPerfusionPressuresDuringCPRAre Higherin PatientsWithEventualReturnof Spontaneous Circulation TJ Appleton,N Paradis,GB Martin,D Bovell,MG Goetting,EP of EmergencyMedicineand Rivers,RM Nowak/Departments HenryFordHospital,Detroit,Michigan Pediatrics, Work in animal models of cardiacarrcsthas demonstratcdthat thc aortic to right atrial pressurcgradicnt during CPR rclaxation phasc (Ao-RAl is the co.unaty perfryr91 pre.ssure.It has been nositivcly corrclatcd with myocirdial blood {low and return of ipunt".t.ir.tt circulation (ROSC).Thc purposeof our study was to measurcAo-RA during cardiacarrestand comparethis in pationts with antl without subicqucnt ROSC.Adult medical cardiacarrcst paticnts((r1J,of a mcan ageof (r3 + 1(ryears,hadaortic arch and right Meaninitial recorded. cathetcrsplaccclandsimultaneousprcssurcs and maximal Ao-RA gradients wcrc mcasurcd and compared Down time avcragcd15t l4 (studcnt'st tcst {or unpiired samplcsJ. minutcs. Timc from arrival to cathctcr placemcntwas 14 + 5 minutes.Fiftv-onepatientshad no ROSC;ten had ROSC' M a x i m a lA o - R A lnitial Ao-RA 9 . 5t 1 1 . 8 0 . 8I 9 . 3 N o R O S C( m m H g ) 26.8! 7.7 1 4 . 5t 1 0 R O S C( m m H g ) ROSCversusno ROSCdifferencesigni{icanlat P < .001.

No natient with a maximal Ao-RA of less than 17 had ROSC' A gradicnt above this did not prcdict ROSC, howcver, as l3 pa-tients *ho fril".i to devclop ROSC had gradients above 17. This substantiates previous animal work and indicates there is a higher mean Ao-RA gradient in patients with ROSC than in those who fail to dcvclop"hcmodynamics. Measurement of Ao-RA may predict outcome and serve as an index for ef{icacy of therapeutic intervcnt1()ns.

- 197 High-Dose Epinephrine and Coronary Perfusion Pressure During Cardiac Arrest in Human Beings NA Paradis,GB Martin,EP Rivers,J Rosenberg,TJ Appleton'RM oJ EmergencyMedicine,Henry Ford Hospital, Nowak/Department Detroit,Michigan Work in inimal models of cardiac arrest indicates that the optimal doseof epinephrinemay be largerthan that usedclinically' Tie aortic to right alrial pressuregradient (Ao-RA) during CPR relaxatronphasei. the coronaryperfusionpressurein the arrested heart and is positively correlated with return of spontaneous circulation (ROSC].The study population was adults in medical cardiopulmonaryarrest who had failed to respond to prolonged standardACLS therapy.Aortic arch and right atrial catheterswere placedand simultaneouspressuresrecorded.The maximum rise in Ao-RA after a standardI -mg doseo{ epinephrineand a high dose-of 0.2 mg/kg (ie, 14 mg in a 70-kgpatient)-weremeasuredduring the five minrites after IV administiation. The protocol was sequential rn that each patient servedas his own control receiving standard dosefollowed by high dose.Patient mean agewas 59 + 16 years' Time from arrival to high dosewas 25 + B minutes. Pressuresarern

millimeters of mercury for patients in whom catheterplacement was con{irmed radiologically(two). BaselineAo-RA was 4.9 + 6 6 beforestandarddose,and 5.6t 8.4beforehigh dose(not statistically di{ferent, P = .54, Student's t test paired samples).The mean maximai increasein thesegradientswas 3.4 + 5 (range,2to l2l after standarddoseand 11.8t 10.7(range,0 to 45)afterthe high dose(P = .001).Four Datientshad ROSC after receivinghigh-dosetherapy.

High-doseepinephrinesignificantly increasesthe Ao-RA gradient duiing CPR in human beings, which may improve myocardial blood flow and ratesof ROSC.

198ExtremeSystemicand CerebralOxygenExtraction DuringHumanCPR

MG Goetting,EP Rivers,NA Paradis,GB Martin,T Appleton/ Departmentiof Pediatricsand EmergencyMedicine,Henry Ford Hospital,Detroit,Michigan We quantified systemic and cerebraloxygen (Or] extra.ctionin 19 adulis undcrgoing CPR for cardiac arrest. fugular bulb, right atrial, and aortii arch catheterswere inserted during CPR with position conlirmed later radiographically.CPR was performed accordingto advancedcardiaclife supportguidelines.Patientswith hemoglo6in of iess than 9.O gldL or arterial hypoxia (SaO,< 0.80) were excluded.O. tensionsand saturationsand hemoglobinwere mcasureddirectly from samplesobtainedsimuitaneouslyfrom all catheters.Systemicand cerebralO, extraction ratios were calculated using standardformulae. Mean age was 67.8 t 15.6 years' Time to CFR averaged7.5minutes in l4 and was unknown in four' Total time of CPR untii blood samplingwas 38'l + 16.1minutes' SaO,was 0.961t 0.043and hemoglobinwas 11.2t 1.6 gldL' Ratio CPR O- Extraction 0.808t0103 Systemic 0.75510.151 Cerebral

Normal 0.23'032 0.28- 0.35

Systemiccxtraction ratio was greaterthan brain extractionratio in systemic ipn ll': .015,pairedt test).Thesedatareflectinadequate and cerebralo*yg.tt delivery during CPR despiteadequatearterial oxygen content. The markedly elevatedextraction ratio suggests thai-delivery-dependentoxygen consumption is occurring.These dataaisoindicat-ethat aerobicmetabolismcontinuesduring severe and prolongedglobal ischemia.The Iower cerebralextractionratio may be due to preferentialbrain per{usionduring CPR' 199 Cerebral Lactate Uptake During Prolonged Global

lschemiain HumanBeings

EP Rivers,NA Paradis,GB Martin,MG Goetting,TJ Appleton,RM of EmergencyMedicine,Surgery,and Nowak/Departments Pediatrics,Henry Ford Hospital,Detroit,Michigan Animal dataindicatethat cerebralmetabolismmay be fueledby lactate during ischemia. We measuredlactate levels acrossthe cerebralcirculation in human beings during cardiacarrest.Fortytwo patients(57t I 5 yearsold) had iugularvenousbulb, aortic arch, and iieht atrial cathetersinsertedduring CPR. Lactatelevelswere drawn immediately after catheterplacement(t = 0) andten minutes {t = l0l later. Patients were managed by advancedcardiac life support guidelines.Lactate was measuredby the Du Pont ACA .tr"y-^ii. "ttry and is reportedin millimeters per liter' Time from arrest until arrival in the emergency department was 20 + 10 minutes. Time {rom arrlval in the ED until sampling was 14 + 5 minutes. Mean lactate levels for aortic arch, iugular venousbulb, and right atrial were 17.Ox 5.6 (t = 0) and 17.7t 5.2 (t = l0), 16'0t , n d 1 5 . 7t 4 . 6 ( t = 0 ) a n d 1 70 1 5 ' 3 4 . 7 l t = 0 l a n d 1 6 . 3t 4 . 3( t = 1 0 ) a (t = 10),respectively.At t = 0, mean aortic arch to iugular venous tulb lactatedifferencewas 1.0x 3 4lP = .03J;at t = 10,the mean = aortic arch to iugular venousbulb differencewas I 46 ! 4'OZlP .018).Of the 4i patients,29 had decreasinglactatelevelsacrossthe brain with differencesas high as 18 4 in one patient' Sixty-nine Dercentof all patients showeddecreasinglactate levels acrossthe train. This is the first evidencesuggestinglactate uptake during prolongedglobal ischemia in human beings.

200 Lidoflazine Administration

Arrest

to Survivors of Cardiac

ClinicalTrial N Abramson,P SaJar,K Detre,the Brain Resuscitation ResuscitationResearch (BRCT) ll Study Groupilnternational benter, Universityot Prttsburgh;20 hospitalsin eightcountries Twenty hospitals in eight countries,participatedin this randomized iti.ri.rt trial testing whether administration of lidoflazine, an experimentalcalciumentry blocker,would improveneurol-

64

ogic recovery after cardiac arrest. Informed consent was obtained from next of kin, usually with a "deferred consent mechanism.

Patrents w5,r1y1doqly assigned to receive placcbo (STD) or hdollazine (LIDO) in addition to protocol_defined standarcl therapy and were followed for six months. Results are available for 505 of the 5 l6 patients entered into thc study. Mean age was 63 yearsj 62o/o l 3 l 1 o f 5 0 5 ) w e r e m a l e ; 6 6 % l 3 B S o i S O S )o f a r r e s t s w e r e c a r d i a c caused;and 60% ,303 oI 505) occurred out of hospital. Mean arrcst time^wa-s4.6 minutes (range, one to 2Z minutcsl. Mean CpR timc w a s 2 3 . 9 m i n u t e s ( r a n g e ,o n e t o 1 8 0 m i n u t e s ) . T r e a t m c n t g r o u p s were,comparable except for greater incidence of history of Jongestrve heart iailure in.STD (p = .05). Comparison of mortality ind ncurologrc rccovery betwcen treatment groups revealed: O.utcomeat 6lvlos (%) LIDO STD (n = 253) ( n = 252) 12.0 12.5

Best Function During Foltow_Up(%) LIDO ST-D (n = 253) (n =2s2) 18.9 18 . 3

factors). The six factors were limb-lead eRS interval of 0.10 seconds or more, altcred.mental status, reipiratory depression, seizures, arrhythmias, and hypotension. Subsequent ciinical course and occurrence of any compiications were th;n evaluatcd. Fortvsevenpatients were entered into the study. All had the p..r.rr.. of a tricyclj c antidepressant con{irmed by toxicologic scrcenrng. None o f t h e l 8 l o w - r i s k a n d n i n e o f t h e 2 9 h i g h _ r i s kp a t i e n t s h " a i o - p f l cations (P < .05 by chi-square).Compiications werc judged life_ threatening (eg, hypotcnsion, arrhythmias) in five f-rigt ?irL pu t i e n t s a n d _s e r i o u s ( e v i d e n c c o f a s p i r a t i o n p n e u m o n i t r s ) i n f o u r .

Review of the data rcvealed that nerther eRS interval nor an isolated clinical finding alonc would havc performcd rd.q,_rat.ly ni risk classification. It was concluded thai combinccl paii.nt ,rrd E C C c v a l u a t t o n f o r t h e p r e s c n c eo f s p c c i f i c f a c t o r s i n t h c E D c a n be u s c d t o a s s e s st r i c y c l i c a n t i d e p r e s s a n t o v e r d o s c p a t i e n t r i s k .

'203

Hyperventilation in Tricyclic Antidepressant Toxicity H Desai, D Seger, A Sanders/Section of Emergency Medicine, C o l l e g e o f 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 , T u c l o n ; - E m e r g e n c y 0.4 5.0 4.7 M e d i c i n e , V a n d e r b i l t U n i v e r s i t y ,N a s h v i l l e ,T e n n e s s e e 1.9 9.3 Sodir-rn-rbicarbonatc is the drug of choicc for the treatment of 8.9 0 66.8 67.7 Q R S - w i d c n i n g c a r d r a cd y s r l - r y t h m i a ss c c o n d a r y t o t r i c y c l r c a n t i d c _ 82.5 prcssant toricity. Altcration of plasma pH with a subsccluenr changc in the protcin binding of the drug is thought to bc thc 2.7 mcchanism of actiun. It is unknown whe thcralkalinization through h y p c r v c n t i l a t i o n r c v c r s c s e R S w i d e n i n g . O u r s t r . r d yw a s c o n c l u c t c d Lidoflazinc has not been shown to excrt a statistically significant in an animal modcl cvaluatrng thc cffect of hypcrventilation brain-bcnefitting effcct on comatose carcliac arrcst survlvors. on r e v c r s i n gQ R S w i t l c n i n g .d u c t o t r i c y c l r c a n t i d e p r c s s a n rt ( l x i e t t y .

-201 p l g s { m c a n w c i g h t , 1 U . 2 1 4 . 3 k g ) w c r c a n c s t h c t i z e dw i t h Glucagon:PrehospitalTherapylor Hypoglycemia .lwctvc halr)tltanc and nrtrous oxide, intubatcd, and rncchanically vcntiRB Vukmir,DMYealy/University ot pittsburgh Afiiiiated-Residency l a t c d .

Nortriptylinc was aclministcrcd intravcnously t,, cach ani pittsburgh in Emergency Medicine, n - r a lu n t i l t h c Q R S c o m p l c x w i d c n c d t o 1 2 0 n - r so r l n o r c . A m c a n o f Wc prospectiv_clystudied the efficacy of glucagon for thc prchos_ .

7 . . 7 5J : | . 1 3 r u g / k g n o r t r i p t y l i n c w a s a d m i n i s t c r c d t o c a c h a n i m a l . pital trr.atment of hypoglycemia whcn IV line ,"i"r, *r, .,r,i,l-,ta,,-r_ T h c Q R S w i d t h i n c r c a s c d f r o r n a b a s c l i n c o I 4 7 . 5 + I 1 . 4 n - r st o t h c a b l c . . . T h es t u d y p o p u l a t i o n c o n s i s t e d o f 5 0 c o n s c c u t i v c p a t i c n t s toxic statc width of 150 1.21.3 ms. Oncc toxicity was achicvcd, cnrolled ovcr a six-month period in a busy urban advanccd lifc v c n t i l a t i o n s w c r c i n c r c a s c d f r o n - r1 0 . ( rt L 7 / r - n i n t , , t q . S t 4 . 5 / m i n . support.system who presented with documcntccl hypoglyccrnia ( < H y p c r v c n t i l a t i o n r c s n l t c d i n a n a r r c w i r . r go f t h c e R S c o m p l c x f r o r n 80 mg/dl by Chcmstrip, BG) and symptoms of dccicasccl cvcl of I 5 0 t 2 1 . 3 t o 9 1 . 6 + I 5 . 1 .m 1 s. This rcprcscntcda significant changc conscrousncss/ s_yncopc/or seizurcs. After a mcan of Ltili failcd IV b y t h c p a i r c d S t u d c n t ' s I t c s t l 1 ). . 0 i J . A r t c r i a l b l o o c lg a s c s. h , r * ! , I w a s a d m i n i s t e r c d cithcr intramuscularly ]i9" 9,jt-O..,.glucagon a rcspiratory alkalosis aftcr hypcrvcntilation. Basciinc pH and { 4 6o f 5 0 ) o r s u b c u t a n c o u s l y ( f o u r o f 5 0 ) .A d o s c o f 1 . 0 , r r g* r , . , r . i pCO, valucs changcd |rorn 7.42 t 0.04 and 35.5 12.3 rnm for adults and 0.5 mg for children 2 ycarsor youngcr. Data collcctcd Hg, r c s p o c t i v o l y , t o p o s t h y p o r v c n t i l a t i o n v a l u c s o f 7. 5 0 X 0 . 0 7 a n < l 1 , 2 7 ' i r n c l u r l c d . p r c t r e a t m e n t ( b y C h c m s t r i p , a n d p o s t _ t r c a u - n c n rs c r l l n r ) t 2 .

6 m m H g , r c s p c c t i v c l y ( 1 ,< . 0 1 ) .S c r r . r mc a t c c h o l a m i n c l c v c l s o f g l u c o s c ( b y i n - h o s p i t a l a s s a y )l e v c l s , a s w c l l a s p r c t r c a t l n o n t and c p i n e l h r i n c a n d n o r . - p i n c p h r i n cw c r c r n c a s u r c da t b a s c l i n c ,p o s t n o r _ post-trcatment assessrrlcnt of lcvcl of c,_rnsciousncssby Glasgow t r i p t y l i n e , , a n d f ( ) s t h y p e r v c n t i l a t i 1 t n ;h g w c v c r , n o s t a t i s t i c a l l y s i g _ C o m a S c o r e( G C S )a n d a 0 t o 3 q u a l i t a t i v c s c a l c .D a t a w c i c a n a l y z c c l nificant changcs in lcvcls wcrc obscrvcd. In a porcinc mocicl irf using two-tailcd rank-sum and Stuclcnts I tcst as wcll as Fishcr,s tricyclic anticlcprcssant toxicity, significant narrowing of wiclc exact tcst. Thc per-cxpcrimcntal alpha crror was sct at 0.05.

Q R S c o m p l c x c s w a s o b s c r v c c lw i t l - r h y p c r v c n t i l a t i o n a n d r c s p i r a _ Twcnty-four malc paticnts and 26 fcrnalc patients wcrc stucliccl, t o r y a l k a l o s i s .F u r t h c r s t u d i c s o n t h c u s i o f h y p c r v c n t i l a t i o n f o ; t h c with a mean agc of 56.8 years (range, 4 months to 92 ycarsl. Tl-rc t r c a t n t c l t t o f w i c l c Q R S c a r c l i a cd y s r h y t h n - r i a sa r e w a r r a n t c d . mean prctreatment blood glucosc was 33.2 t 2.3.3 mg/dl, ancl thc post-trcatment rose to 133.3 t 52.3 rng/dl < .

0 0 0 1 ) .

-?-04 {P er.ralitativc The Effectof Alpha, Acid Glycoproteinon l e v e l o f c o n s c i o u s n es s r o s e f r o m 1. 2 6 t O . 9 6 t o 2 . 4 2 t 0 . O 9 p < . 0 0 0 1 ) NortriptylineToxicity in Swine and GCS rosc from a mean of 9.0 + 4.19 to 13.041 3.6U(p < .0001).

DCSeaberg, The mean time until responsc was B.B rninutcs in thosc who LDWeiss,DMyealy,RMKaplan, Ep Krenzelok/ U,niversity re.spondedby both lcvel of consciousncss criteria of Pittsburgh Affiliated Residency g2%). in Emergency oI 50, -ot l4I Medicine, There was no diffcrence in responsc rate between malc and'fcrnalc Center for Emergency Medjcine Westeri Pennsylvania, patients/ initial level of consciousness scorcs/ or thosc with antl Pittsburgh Tricyclic. antidoprcssant toxicity is a frcclucntly cncountcrccl without a history of diabetes. Headaches occurred in two patlcnts problcr-n in thc. cr-ncrgcncy departmcnt. Wc dciigncci a pruspectivc, l4%| no other sidc effccts were notcd. Wc concludc that gir-rcagon c o n t r o l l c d t r i a l t o . i n v c s t i g a t c t h c c f f c c t o f a l p h a , a c i c lg l y c r i p r o t c i n is a safe and effective trcatmcnt for syn-rptomatic hypoglyien-ria in ' ( A A G . ) ,a n a c u t c p h a s c r c a c t a n t , o n t h c c l i n i C a l a n d p h a i m a c o l o g i c thc prchospital setting when IV line.aciess is diffi;;lt.manifcstations of nortriptyline toxicity. Fourtccn swinc (10 to-i3 k,ll wcrc given a tcn-minutc loading dosefollowcd by a 45_rninutc 202AccuratePredictionof TricyclicAntidepressant l n a i n t e n a n c c i n f u s i o n o f n o r t r i p t y l i n c t o a c h i c v e a l e v c l , b a s e do n presentation: Overdose Complications UsingED A prt'viously p h a r r n a c o l < i n c t i c so,| a p p r o x i m l t e ly 1 , 0 { J 0 Prospective Study .e:rlcuhtcd. n g / d l . A r r h c c n d r r l t h c i n f u s r o n ,s e v c n c o n r r o i r n i r n a l s G E F o u l k e l D i v i s i o n so f E m e r g e n c y M e d i c i n e / C l i n i c aT 1 C )w c r c l oxtcotogy givcn 50 mL 0.9%, salinc and scvcn AAG_trcated animals werc a n d P u l m o n a r y / C r i t i c aC l a r e M e d i c i n e , U n i v e r s i t yo f C a l i f o r n i a i ' grvcn.50 rnl l0%, AAG, both ovcr 15 minutcs. Hcart rate, Davis, Medical Center, Sacramento eRS d u r a t i o n , Q T c i n t e r v a l , b l o o d p r e s s u r e ,a r t c r i a l b l o o d g a s e s , ' a l i u Identifying the subgroup, of tricyclic antideprcssant_ovcrdosc m i n , a n d s e r u m { r c c a n d b o u n d n o r t r i p t y l i n c levcls wcre measured patients who are at rrsk of subsequent complications and therefore at basdinc and cvery hour aftcr for five iours. Data were analyzed warrant use of hospital-critical cat. tcsu.,.c.. is an important but u s i n g l i s h c r ' s c x a c t , t w o - t a i l c d t t c s t s , a n d r e p e a t e d , - n e a s u r e sc r f emergency department task. previous retrospective stucl_ :oTpi:* A N O V A w i t h t h c a l p h a e r r o r s e t a t 0 . 0 5 . O n e d e i t h w a s n o t e c li n t h c resindicate that a constellation of clinical and ECG findings n-right AAG group and none in thc control group be used to identi{y this subgroup. A prospective study of'all such {p = NS). Mean total nortriptylinc levcls after infusion in the control group were 1,240 paticnts presentlng to our ED was peiformed during ihc perio<i of t 498 ng/dl and in the AAG group, 804 t 73 "glar March l987 through April I988. Ali patients *.rc urscss.d fo, thc il = NS). No significant differcnces werc found in the serum fric to iotal nortrip_ presence or absence of six risk factors and classed as high risk tylinc ratios bctwecn groups at any timc intcrval. Howevcr, signifi_ {presence of one or more factors) or low risk {absence of-all six cantly shorter QTc intervals were found during treatment;ith Normal Moderate disability 2 . 7 Severe disability 0 . 4 Coma 0.8 Death 81.5 [,4issing 2.7

65

r i In addition' a trend toward AAG compared with controls (P < '05)' shorter- QRS duration was and press're ftooa i;;#':;t;ot" significant changes were noted during treatment with AAG No

Burn 207DecreasedInllammatoryReaction(Enhanced Rats Surfactant-Treated Nonionii in ivo""a fr""iing) Ward'

RR Haase,.lC McPhersonJr' TH Hguyen'DF PW Paustian, and of ClinicalInvestigation iC U"Fn"rton lll/Department Gordon' Fort Center' ical M ed r.nrmy now'e gv-, Ei t"n i'if'o'io Medicine'Medical Georqia;Departmentor surgeryiEmergency Augusta that Georgia. of and pressure College blood svstolic qRd a"'r;-;, and wounds in ;ici;:;,;;;;r, We havc discovereda oramaticimprovementin burn (F 127)'ln further researchis warranted' Pluronic.I-127 t"tf"t"ttt, nonioni" a with ,".t.i.ri.a (300to 320 g)receiveda thirdrats ^".rtt.,.tir.J-'i" z+ ""?-"a.i, -205 The Evaluation of Cocaine'lnduced Choa"tPain antetior chest wall' 8% bodv by i--"*lott-oithe ilil;;; C Foreback'M G Tokarski,P Paganussr,R Urbanski,D Carden' in a 70 C waterbath' Burn wound area seconds 12 for area, surface Ford Henry of EmergencyMedicine' Tomlanovich/Department after immers.ion'Thirtv minutes later' t--.di^t.iv ;;;;;;;;;;!a Hospital,Detroit,Michigan either g ml/kg body wt salineor F-127 received rrrri "iirr" ,"i-als All animlls were eating'voiding' t"iiu"i" the iit -r"riif uto.,gh rz hours' rhere were no fatalities Animals -r.rli.J the ;;i;;;ilr;;;;it'i" determine To At "t,.*t iniuryor ischemia ;ct i;; ililtii". ^? 48 hours ""a tnt burn wound area measured' *.t.

(CK-I)in this populatioll,Y: animal wounds .re^ti.,ekinaseisocnzymes ;J;;i F-127-treated the of gross "pp.,t^tt"" the autopsy, with chest pain w1th1n in the cvaluated 42 patients presentingto thcID ir'"v !r'"*"J a significant(P < 05) reduction ;;#;t;;U. normal or nondiagnostic 15% was six hours clf cocaine use and liho h^d wound,contraction Tie contraction ;;;"t;; ;i"*;;nd obtained at presentation and Histologicallv-'the degreeof ECGs at presentation. 6r-i*ttt .rli,t"-,t""t.J""i-"tt iil" #;;;;; simultaneIt hn..-'i' l't"t, ECGs wereabtained ti;;;a ;;;r,J llu.it't J"potition, p-erivascularf ibrosis' edema' i,r "il;;;;;";t agc of 28 5 years completcd ously. Forty-twu p",t.rrr, *iiit ^ -""t "*t,"""'"tion in the dermis' submucosa'-and ..ii ;J;;ebi;"d after cocaine use was 135 versus those our study. Mean time tn ptt't"ttt',tion *.r" gr.r,., in the saline-treatedanimal's ;;;;; w" b.li."t thesedata show a p.ositivetherapeutic ;;""*tdF"iti. process 127 on the initial burn-inducedinflammatorv ;;i;;;if healing' wound imProve (1a%) hadeiev-atcd that may lnil"t'on si* patients

shownbetweensroupst*.:{::?'"':"*f :,:ln,"ifi',*}l?""1 ilff d;fi it"illl"f'li'ii'ru;t;;;;;;;;h".rinicarparameters

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208 Effect ol Povidone'lodine

'[.?"i1rt..""*,i[:i,I:'!:tl',^t'# 't:11.1',tffi i*f:*i""'Tf -,:;1':5r' iswcre ri*-r"a 12 hours werc within normal limits'.EC

and Saline Soaking on

woundTissueGountsin Acute a;;iitdi"; Bacterial Wounds iraumaticContaminated

nZFourre,M Callaham,T Boone/ValleyMedical. nl-L"tt"i., of U-niversity i".iJt, o.plttment of Etetgency Medicine',and EmergencyMedicine' 6"iit.i.ii, 5"" Francisco,rr"esno;Divisionof Universityof Cali{ornia,San Francisco wounds in dilute havc It is common pr""t'""-fo soakacutetraumatic -r-',ia.i"inp-thest pain.aftercocaineuseand ;..;;;;;;i;;,t and toilet' The irrigation *ottnd iol.,tio"-befli" *"tti:HilT:fffi; Thisinjurv ECCs' o""iao"'.i"Ji"" ","*"r <irnon<liagnostic jt to determine if s6ught We ""1"o*" efficacv of this practic. infarciion or transient mvoc:rdial.isc il;;J*i p*'ao"t-iodine iolution would dewith reported air"tt been t"t" ;;;;'Id; '"itittt lo.i.ft duc to coronary Ntery;;;;;;, shown ECGs' therecreasequantitativewounJiissuebacterialcounts{previously cocainc usc). Singlc ut ttilinottal-nondiagnostic with no treatcompaned as These infection) wound situation predict ihis ;;;;;;t fore, do not rule nut itti-tt*iu or injury .in iot st1a1{ tl;1 "t t"rflilg *i,ft t'fi"t Patientswere eligible -.* with.acute traumatlc *"i" t"." in ihe emergency department cont"tt tttin ti' hours old that had sienificant ;;t;i;";;d, of CK-I in the ED' clctcrmination weie excludedif Patients ,eq,,i'eJ-i"b'idt-"ttt' and tamination within five davs' ifr'iy #.i" iri.iel"-.-i -ai"t, r"I^dtaken antibiotics *206 SevereOral PhenytoinIntoxication:Lack of bacterialgrowth subsequent no *"t or refusedconsento, tt tlJtt cardiovascular Morbidityv 6 to, l0 mL visibly-contamitreatm-ent, any Before "r.,i,rrr". i'-DetroitReceiving Department, surfaceand subjectedto natedtissuew", ,.-ouJd {'om the wound th.en randomized to wound-was ."ri"*"-it'e ;-.". il;;ri,;il Detroit,Michigan WayneStateUniversity, .-,^r e c e i v e a t e n - m i n u t e s o a k i n l % p o v i d o n e - i o d i nset e , sofatissue line,orno "t Utt:?:|il,T; of hvpotension treatment To facilitatc ,i "ff . afte, the ir"rtment period,,asecond ir."rr*", ;1TJ monitor a in and management cuiture' repeat ,.rtho.iti.t advocate first sites waJtaken for :;fii;;rd;;t-to-the this strategy' {ashion' charts were ,.u.r. ph.ttytuin poisoning'To evaluate il;;;t;h standardized itt a t"'ted ;il;ilil;;1Len recordsof .51 patients admitted to our ;;';';;;-irt.-ti'.aiJti andincidenceo{ wound in{ection reviewedto determine;;;";" levelsof 40 institutlon o,r., ".*u-ylrr perlodwith peak_phenytoinphenvtoin sJ;o""as were enteredinto the study; *iitt patlents Thirty-three peak M',t' irom inge-stion l.t"rtl"s bacterialgrowth' ;;i;;";;;;. three in the salineg,ot'i *Jtt e*cludtd due tono Mean agewas decreased9'19 x 106 tissue illl"t t^, 49.4t 7.7 pg/ml (range,40,to76 us/ml)' gram of per co"ttt historv of seizures'-54 i'h;;;;b""teria'i to"k, 6 a 1 Ip5(1'68x 106)after 44.1 + 1(r.8)ears;56;;;i;;'t (isr) haa a had a isp, i.ii " io;f ,it.t pouiao'".-i"oii"" (95%) were ,rr.i"g ptJtttitta-ptt"i-tvtoi"' and six {11%) x 10' (1.05x 10s)after a saline soak.

3.eg irr"r""r.d ^"a lio-lori., ataxia {36' pitt*ting complaints -r -ttatus included per gram.oftissue iriri.iv oi r't.rtt diri"it Wounds with counts o{ iess than lb, organisms changes' y:i'Y:t:' (tt", s i' 1; ttie"tnl analvsiswas regression Multiple 2,a'/. ),;;;;;;;ir"t. infected' become to ;;";;itk;t gastrointestinalprobafter treatment as a count and visual symptoms (eachnine, l6%Ji and bacterial in changes ;;il;';;"i1he sevencases (f;;, 9't )' Sulcidewas mentioned as a motive in i;t gi""p ""a initial bacterial count' There Iunction of "*p.rl-.ti?l between the-control and povidone;ffi;.ilii:r.ti-oltitt"itt group^had a sienificant trend saline the Howevet, ivttrtvt[,,'i^ requiring.l':1tT""t Twelve-lead ioaj"" sto""p.. treatment 1i"= 'OO0t1'and after il;t;i""t;"^';; count bacterial tn toward increase bacterial contamination initial higher this eftect was greater at traumatic wounds in i1.".f..'rnt """8f"a" tt"t siatti"g acute ptl"ides-no ben'fit in decreasedwound ."i"rii" ;"";d;";-i"i;" may actually increase tissuebacterialcounts and that salinesoaks toxic' while six had increasein p-n intervaitlur, f S t iO -t) when such counts. to nontoxic records'No a decrease(M,17 t l0 ms) in comparison

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ffiH""?:lx'fi l'1r".',Tl*,m*:ln:lff iiilil*j:*i',ft '#i orsurserv' icine,Department Med fi3.yJJf fl"'#E["'n"".,

#ix'i:;""":i l'e1;?"""r?:i'.',"'ff iilni:'::l'#:,ru*;f '''ftn! :.#iiflt[t];ir#:W::.r,';if35:t:3,ffi ii'"!

:i::::tY;1ry:*:.Tfi iilft i:*:#i:t".'":';illl'"ff Statusand lmmunologic i; -209 Tetanuslmmunization -n""pon"Jto i:iSft x.",T:',f :t::;ii*ff:;1."1';?llilliji?l;il,x';ffi EmergencyDepartment in an a Booster complicat"diou"trllar sustained a llp laceratil-r4 tft*t i"*9 t'o casessetr-ele tions and no deaths. wt-'to""f"at that in many ^oral poisoning may be safeiy managedin an unmonltoreo ;[;y.il settinq.

GeriatricPoPulation Toronto' ofroronto' ; c;;";, nieoy, D williams/university Ontario,Canada

66

Although effective procedures for the prevention of tetanus have long been available, serosurvcys done since I97Z dcmonstratc that 49T" to 66T' of the elderly population lacks a protcctive antitoxin level (less than 0.01 IU/mL). Our study was undertakcn t o a s s e s st h e t c t a n u s i m m u n i z a r i o n s t a t u s o f g e r i a t r i c p a t i u n l s presenting to a tertiary care emergency department with a break in the skin barrier and to evaluatc their immunologic responsc to a tetanus booster. From February to Septembcr 1988, 80 patients more than 65 years old wcre enrolled. At cach patient,s initial presentation/ pertinent dernographrc data and tetanlls irnmunization history were recorded, an antitoxin titcr was determined on a serum sample by ELISA, and a booster was administcred if required by the Advisory Con-rmittce of Immunization practiccs (ACIp) criteria. Scrum antitoxin assays were repeatcd on days Z, 14, and 2 I a f t e r t h e i n i t i a l v i s i t u n t i l s e r o c o n v e r s i o n{ t i t c r , m o r c t h a n 0 . 0 1 r u / mL). Forty-four patients (55%) had protcctive levcls at initial presentation and, in 36 las%), the lcvels wcrc unprotcctive. Agc and sex wcre not predictivc of protcction. past n-riliiary scrvicc and a dcfinite history of threc or morc previous ilnrnLrnrzatrons wcrc good predictors of protection. Of thc 36 paticnts who wcrc followcd s.erially for-unprotective initial titers, 19 153"1,)scroconvcrtcd by d a y 1 4 ,w h i l c I 5 1 4 2 % ) d i d n o t s e r o c o n v e r t .T w o p a t r e n t s ( . 5 % )w c r c lost to follow-up at day 7. Patients who did noi seroconvcn wcrc more likely to be oldcr (/r <.05). In conclusion, a considcrablc number of clderly patients lacked an initial protcctivc levcl of tctanus antitoxin in this study. Of these, 42% Iailed to scroconvcrt within l4 days and potentially carried a risk of dcvcloping tctanus despite prophylaxis.

.210 Utility

of Contrast Duodenographyin the Detection of ProximalSmall Bowel Injury Following Blunt Trauma JMEdney,JA Marx,EE Moore/Departments of Emergency Medicine andSurgery, Denver General Hospital andUniversity of Colorado HealthSciences Center, Denver

We comparcd contrast duodenography with a cliagnostrc pcrrroncal lavagc and computed tomography (CT) in thc clctcrminaiion of traumatic small bowel pathology. Contrast duodcnography was performcd on 104 paticnts whri sustaincd major blunt rncchanisrn with midthoracoabdominal impact. Six (5.ti%) truc-posrtivc studics demonstratcd burst jcjunum ln = 2), pcrforation of thc third portion of thc duodcnum, or duodcnal hcmatorna {n = 31. Thc remaining 96 had true-ncgativc contrast duodcnography by clinical outcofire critcria. In patients with hollow viscus pcrforatior-r, laparotomy confirmcd isolatcd injury. Scrum arnylasc was norrnaf in cach. Diagnostic peritoncal lavagc was pcrforrncd within two hours of injury and standard diagnostic pcritoncal lavagc criteria for red blood cclls, whitc blood cclls, and amylasc wcrc not cxcccdcd.

However_,white blood cells wcre equivocal in two of thrcc paticnts, and amylasc ranged from 20 to 56 U/L. CT was obtaincd in two patients and was unrernarkable. In patients with duodcnal hcmatoma, initial serum amylasc was markcdlv c-lcvatcd in two of threc. Diagnostic peritoneal lavage mcasurcmL.ltts wcrc normal.

CT was negativc, not perforrned, and confirmatory of contrast duodenography findings, respcctively. Diagnosis of proximal small bowel injury is problematic. In our expcrience, iontrast duodcnography is a sensitive method of dctcciion when comparecl with diagnostic peritoneal lavage and CT. Subthreshold elevations of whitc blood cclls and amylasc in the immediatc postiniury period may reflect pcrforation of thcsc structurcs.

splcnic injurics were dctected; cight of nine werc successfully managed nonoperattvely, and eight of I I rcquired operation. One splenic injury was mrssed on the initial scan and diasnoscd on a s u b s c q u e n t s c a n . B o t h f a l s e - p o s r t i v es c a n s w e r e r e a d a s s h o w i n g splcnic injurics. Sixteen hepatic lacerations were diagnosed;two wcrc repaired antl 14 wcre managed nonoperatively. Of 20 rcnal i n j u r i e s , t h r c e w e r e r c p a i r e d ,a n d I 7 w e r c m a n a g e d n o n o p e r a t r v e l y .

T w o o f f i v e p a n c r c a t i c i n j u r i c s w e r e n o t d e t e c t e db y t h c i n i t i a l C T scan. Six of ninc laparotomies performed for free peritoneal fluid on CT scan wcre nonthcrapeutic. Conclusions: Thc rate of nontherapeutic laparotomy (33%) bascd on CT was similar to that rcported for pentoncal lavagc; CT cvaluatron of blunt abdon-rrnal injury allowed nonoperativc managcment of splenic, hepatic, and rcnal injurics; CT was unreliablc in thc cvaluation of pancreatic i n j r " r r y ;a n d t h c m a j o r s h o r t c o m i n g s o f C T i n t h e c v a l u a t i o n o f t h e blunt trauma victim wcre its alrsolutc rcliancc trn exoericnced intcrprctation anclthe rcqurred commitmcnt of timc and pcrsc,nncl.

-212

A ComparativeRewarmingTrial of Gastric Versus PeritonealLavagein a HypothermicModel MALevitt,V Kane,J Henderson, M Dryjski/Thomas Jefferson University Hospital, Philadelphia, Pennsylvania

P c r i t o n c a l I a v a g ca n d g a s t r i c l a v a g c z l r ct w o m c t h o d s o f i n t c r n a l rcwarnting that can vcry rapidly bc applicd in thc cmcrgcncy dcpartment. Wc comparcd thcsc two commonly uscd rncthods of rcwartning in thc sctting of a hypothcrmie rahbit modcl. Aftcr obtaining baselinc lrcasurclncnts of rncirn artcrial blood prcssurc. h c a r t _r a t c , t y m p a n i c m c m b r a n c t c n t p c r a t u r c / a n d e s t i p h a g c a ) / rcctal tcrnpcratLlrc, thc cooling phasc was initiatcd. Dialysatc coolcd to 4 C was continually circulatcd through pcritoncal lavagc cathctcrs r-lntil a body corc tcmpcraturc as dctcrntincd by tltc m c m b r a n c t c m p c r a t u r c p r o b c ( ) f2 5 C w a s a c h i c v c d a n d r n a i n t a i n c d for tcn minutcs. Rcwanning was thcn accomplishccl with 40 C; clialysatcby gastric lavagc (N = 5) or pcritoncal lavagc {N = 6).

Rabbits unclcrgoing gastric lavagc hacl continuous rcctal and t r r c m b r a n c t c l n p c r a t u r o m c a s l l r c l n c n t s . R a b b i t s u r - r d c r g o i n gp c r i t o n c a l l a v a g c h a d c o n t i n u o r . r sc s o p h a g c a la n c l m c m b r a n c r c m p c r a t l l r c m c a s l r r c m c n t s . I l o t h g r < t u p sh a d c ( ) n t i n u o u s h c a r t r a t c , r . n c a n artcrial blood prcssurc, and ECG r.nonitoring. Thc mcan cooling t i m c f o r o u r s t u d y w a s 1 i 9 . 0 9t 2 3 . 4 3 m i n u t c s . M c a r - rc o o l i n c t i r n a f r r r t h c p c r i t o n c a l l a v a g c g r o u p s w a s L ) 6 . 6 7! 2 [ i . 0 5 m i n u t c s a n c l f o r t h c g a s t r i c l a v a g c g r o u l . rw a s i l O + 1 4 . 1 4 n - r i n u t c sl P = . 2 4 ) .T h c m c a n r c w a r m i n g t i r . n c f o r t h c p c r i t o n c a l l a v a g c g r o u l . rw a s 1 3 1 . 7 ! 2 7 . 1 ) nlinutcs. Thc mcan rcwarming timc for thc gastric lavagc group w a s 1 3 6 . 0 + 2 5 . 1 m i n u t c s ( n o r - r s i g n i f i c a nbt y r t c s t ) . I n t h i s h y p o t h c r m i c m o d c l , g a s t r i c l a v a g c a n c lp c r i t o n c a l l a v : r g ca c h i c v c d s i i n i l a r rcwarming ratcs that dcmonstratcd no statistical diffcrcncc. Goocl corrclation was found bctwecn tyntpanic mcmbranc tcmpcratLlrc and rcctai tcmpcratllrc (with gastric lavagc)and csophagial tcrnpcraturc (with pcritoncal lavagc).

213Protocolsfor the Useof a PortableHyperbaric Chamberfor the Treatment of High-Altitude Disorders RL TaberlDepartment of Emergency Medicine, St Luke's Hospital, Denver, Colorado _ D c s p i t c a r c c c n t c x p l o s i o r - ri n r c s c a r c h o n h i g h a l t i t u d e i l l n c s s , desccnt rcmains thc dcfinitivc trcatment. Howevcr, in alnrnc s e t t i n g s o f n o r e t h a n 1 0 , 0 0 0 f t w h e r e t h c s e p r o b l c m s a r i s e , r n i r n ed i a t c c v a c u a t i o n r s o f t c n u n p o s s i b l e . R c c c r - r t l y ,a p o r t a b l c , l i g h t weight (7 kg) hypcrbaric bag has been dcvclopcd capablc of withstanding a prcssure of 2 psi. Thc bag's usc has becn reported anecdotally in thc past few yearsas a mcans of sirnulating desccnt and thereby acting as a trcatnent modality. Howevcr, no work has bcen conducted to dcterrnrnc thc optirnal length of trmc of treatmcnt in thc bag to achicve resolution of symptoms and to prevent recurrcncc once thc patient is or-rt of the prcssurized bag and 'rcturns" to altitude. This was cvaluated at the Himalayan Rescue A s s o c r a t i o n ' sa l t i t u d c r c s e a r c hc l i n i c i n P h c r i c h e , N c p a l , a t I 4 , 1 . 5 0 ft. At this altitude, rnflation of the bag to 2 psi effecti a descentof 8 , 2 0 0 f t . B y p r o v i d i n g s u c h d e s c e n t ,d r a m a t i c i m p r o v c m e n t s c o u l d be secn with thc symptoms crf acute -ountrln sickncss, high altitudc pulmonary cdema, and cerebral cdema {HApE and HACE, r e s p e c t i v e l y ) .A t t h c c l i n i c , p a t i e n t s w e r c e v a l u a t c d a n d d i a g n o s e d accordingly and thosc with potcntrally fatal HAPE and HACE were arranged for immediate evacuation. At times, this was not feasible and these patients werc put in thc bag. Repeat serial observation of symptoms and recovery revealed that with l5 acute mountain sickness, nine HAPE, and seven HACE patients, time frames of

-211 ComputedTomography in the Evaluationof Blunt AbdominalTrauma WCPevec,AB Peitzman, AO Udekwu, W Straub/Trauma/ Emergency Services, Presbyterian-University Hospital, University of Pittsburgh Schoolof Medicrne _ . The efficacy of computed tomography {CT) for thc diagnosis of blunt abdominal injury remains controversial. The purpoic of our study was to further define the role of CT in the acuteivaluation of blunt abdominal trauma. Methods: CT scans were performed on 325 consecutive patients sustalning significant blunt abdorninal trauma with these indications: equivocal physical findings, dccreased level of consciousness, spinal cord injury, hematuria, or pelvic fracture. Unstable patients and those with indication for rmmediate surgical exploration were excluded. Results: One hundred twenty scans 137%l revealed abdominal rnjuries; S5 t 20 minutes were requrred to perform the CT scans. Diagnostic accuracy was 97.5%, with two {aise-positrve and thrcc false-negative scans. Thirty patients {9%) underwent laparotomy based on CT findings. Ten laparotomies {33%) were nontherapeutic. Twenty

67

two, {our, and six hours, respectively,were required to provide resolution of the symptoms with no subsequentcomplicationsor deterioration. The author advocatesthe role of the bag as an effectiveadiunctiveand temporizing measurefor the treatment of HAPE and HACE.

214A NovelStrategyfor Therapyof Acutelron Poisoning JR MahoneyJr, PE Hallaway,JW Eaton,BE Hedlund/Departments ol Surgeryand LaboratoryMedicineand Pathology,and Dight Laboratories,UniversityoJ MinnesotaMedicalSchool;Biomedical Minnesota Inc,Minneapolis, Frontiers, Iron poisoningfrom accidentalingestionof iron supplementsis an impoitant form of poisoningin young children and is still lethal in somecases.Presenttherapyinvolves IV and oral administration of deferoxamine.Unfortunately, largeIV dosesof this drug cause profound hypotension, which rs additive with the hypotensive iffect of iron poisoningper se. Thercfore,the maximum IV doseo{ deferoxamineis limited by its toxicity. To circumvent this therapeutic problem, we synthesizeda novel class of high molecular weight derivativeso{ deferoxamineby covalentattachment of the free drug to various polysaccharides.The derivativesused in our experiments were prepared on backbones o{ either dextran or hydroxyethyl starch. Importantly/ these high molecular weight derivativesof deferoxaminemaintain high affinity for iron of the parent drug but lack detectablehypotensive effects. Eighty-one percent of male Swiss-Webstermice {25 to 30 g} given ferrous sulfateby gavageilO;rmol/g body wt and I mL l0% dextranor starch in NaCl, IV) die within 24 hours {n = 16). Immediate IV administration of the maximum tolerabledoseof free deferoxamine (0.15gmol/g in NaCl with 10% dextranor starch)doesnot n = 9). Largerdosesof freedeferoxaminei0.3 reducemortali ty 1'78%; Urnol/g) are lethal even in the absenceof precedent oral iron administration {n = l0}. By contrast, administration of either or starch-deferoxamine(equivalentto 1.25 dextran-deferoxamine or 0.75 gmol free deferoxamine/gbody wt) immediately or 60 minutes after oral iron administration saves100%of iron-poisoned animals(n = 22 and five, respectivelyiP <.001).we concludethat these high molecular weight derivativesof deferoxamineate, in largc doses,much less toxic than free deferoxamine.This greatly dimlnished toxicity, in turn, permits the use of higher and more effectiveIV dosesof iron chelator in casesof acute iron poisoning.

215 Combination Therapy With Cimetidine, Penicillin,

and AscorbicAcidfor AlphaAmanitinToxicityin Mice

of Pittsburgh SM Schneider,GJ Vanscoy,EA Michelson/University Amanitin is the primary toxin of the mushroom Amanita phalloides. High dosesof cimetidine, penicillin, and ascorbicacid assingleagentshavebeenshown to attenuateamanitin toxicity in mice. We looked at this effect using combinationsof theseagents.

Female Swiss mice were divided into nine groups. Croups I through l5 were treated with alpha amanitin 0.6 mg/kg IP and subsequentlytreatedin four hours with saline I mL IP, cimetidine

120mg/kg IP, a combination of cimetidine 120mg/kg and penicillin 250 mg/kg IP, a combination of cimetidine 120mg and ascorbic acid600mg/kg IP, or the combinationof cimetidine,penicillin, and ascorbic acid in above doses,respectively.Groups 6 through 9 receivedsalineand at four hourscimetidine,cimetidine+penicillin, cimetidine+ascorbicacid, or the combination of all three drugsin the dosespreviouslygiven. Half of the animals in eachSroupwere observedsevendaysfor survival.The other animalswere sacrificed at 48 hours, and blood was withdrawn for hepatic enzymes,and liverswasharvestedforhistopathology.AnalysisincludedANOVA, Kaplan-Meier,and lisher's exact tests. Resultsrevealeda lengthenedsurvival in all treatment groups.However,only the combination therapy increasedultimate survival {P < .01).Seven-daysurGroup 2, 36.8%; Group 3,47.5%i vival in Group 1 was 31.6"/o; Group 4, 42.I%; and Group 5, 73.7%. ln the secondhalf of the experiment,three animals from group 1 failed to survive 48 hours.

Mean SGOT (U/L) values (P < .00011of surviving animals were: Group1

Group2

Group3

1 7 , 6 9 3 + 3 , 6 3 9 1 1 , 9 6 2 + 2 , 2 2 2 6 , 9 0 7+ 2 , 6 4 6

Group4

Group5

5 , 1 0 0 +1 , 6 9 7

1'742+846

Control SGOT rangedfrom a mean of 60 to 236UlL. Histopathology resultsparalleledthe enzymaticresults.We concludethat the tliree-drug combination of high-dosecimetidine, penicillin, and ascorbicacid provides significant protection in mice exposedto alpha amanitin in toxic dosages.

.216Contribution WithActivated of SorbitolCombined Charcoalin Preventionof SalicylateAbsorption of Emergency RE Keller,RA Schwab,EP Krenzelol</Department PoisonCenter;GeisingerMedical Medicineand Susquehanna Hospital PoisonCenter,Children's Center,Danville,Pennsylvania oJ Pittsburgh The use of catharticsand activatedcharcoalin toxic ingestions has become a standard treatment modality. Sorbitol has been shown to be the most rapidly acting cathartic,but its therapeutic significancehasbeendebated.Using a previouslydescribedaspirin ovtrdose model, ten healthy volunteersparticipatedin this crossover designstudy, which investigatedthe efiect of activatedchar' coal alone versus activated charcoal and sorbitol in preventing salicylateabsorption.In phaseI of the study, subjectsconsumed2.5 g aspirin followed by 25 gactivatedcharcoalone hour later. Urine waJcollected for 48 hours and analyzedfor quantitative salicylate metabolites.PhaseII was identical to phaseI, exceptthat 1.5 g/kg sorbitol was consumed with the activated charcoal.The mean amount of aspirin absorbedwithout the use of sorbitol was 1.25g {r 0.15),while th mean absorptionwas 0.912g (t 0.18)with the addition of sorbitol.This amounts to a 28T" decreasein absorption of salicyiatesattributable to the use of sorbitol' The differenceis significant at P < .05 using the paired Student's t test. Our study demonstratesthat the addition of sorbitol significantly decreases drug absorption in a simulated drug overdosemodel. Effects on absorption in actual overdosesituations and effects on patient outcome should be the subiectof further study.

68

VADE MECUM BESTORAL BASIC SCIENCE 1988- SandraM. Schneider,MD, University of Pittsburgh, "Amanita Phalloides Poisoning:Mechanismof Cimetidine Protection" 1987- Eric Davis, MD. Ohio State University, "The Comparative Effects of Methoxamineversus Epinephrineon RegionalCerebral Blood Flow During CPR'' 1986- Peter A. Maningas, MD, Letterman Army Institute of Research,"Use of 7.5 % NaCll6 % Dextran 70 for Treatmentof SevereHemorrhaeicShockin Swine" 1985- MichelleH. Biros, MD, MS, University of Cincinnati, "Post Insult Treatment of Ischemia-InducedCerebral Lactic Acidosis in the Rat"

BESTORAL CLINICAL SCIENCE 1988- William G. Baxt, MD, University of California, SanDiego, "The Inability of PrehospitalTrauma PredictionRules to Classify Trauma Patients Accurately'' 1987- RanjanThakur, MD, Medical College of Wisconsin, "A RandomizedStudy of EpinephrineversusMethoxaminein PrehospitalVentricular Fibrillation" 1986- Stuart A. Malafa, MD, Butterworth Hospital,Grand Rapids, "Prehospital Index: A Multicenter Trial" and Joseph F. Waeckerle, MD, Baptist MedicalCenter,KansasCity, "A ProspectiveStudy IdentiS/ing the Efficacy of Clinical Findingsand Sensitivityof Radiographic Findings in Carpal Navicular Fractures" 1985- HarlanA. Stueven,MD, Medical College of Wisconsin, "Bystander/ First ResponderCPR: Ten Years Experience in a Paramedic System"

BEST SCIENTIFIC POSTER 1988- David L. Schriger, MD, UCLA, "Defining Normal Capillary Refill: Variation with Age, Sex, and Temperature" 1987- Ruth Dirnlich, PhD, Universityof Cincinnati, "Effects of SodiumDichloroacetateon ATP and Phosphocreatine in IshchemicRat Brain" 1986- Mark Howard, DO, Henry Ford Hospital, "Improvement in Coronary Perfusion PressuresAfter OpenChestCardiac Massage in Humans: A Preliminary Report"

BEST METHODOLOGY POSTER 1988- Frank J. Papa,DO, Texas Collegeof OstcopathicMedicine, "A ComputerAssistedLraming Tool Designedto ImproveClinicalProblemSolvingSkills"

BEST RESIDENT PAPER 1988- DouglasSinclair,MD, Victoria General Hospital, "The Evaluationof Suspected RenalColic: UltrasoundScanvs. Excretory Urography" 1987- Robert L. Muelleman. MD. Truman Medical Center, "Blood PressureEffects of Thyrotropin-Releasing Hormone and Epinephrine in Anaplylactic Shock."

1987- Gert-PaulWalter, MD, Michigan State University, "Emergency Intraosseous Infusions in Children: A Practical Method of Teaching Prehospital Personnel"

BEST PEDIATRIC ACUTE CARE AND TRALIMA 1988- Peter Arlian, MD, Valley Medical Center, "Endotracheal Intubation of Pediatric Patientsbv Paramedics"

BEST EDUCATIONAL PRESENTATIONS Selected to represent Emergency Medicine ^t the AAMC Annual Meeting.

1988- Frank J. Papa,DO, TexasCollegeof OsteopathicMedicine, "A ComputerAssisted Tool Designed to Improve Clinical Problem Solving Skills" CharlesE. Saunders,MD. Vanderbilt University, "Videotape Reviewof Cardiac Arrest Resuscitation: Analysisof Elements of ResuscitationTeam Performance" 1987- David Plummer,MD, HennepinCounty Medical Center, "Emergency DepartmentCritical Care Registry"

BEST PAPER

1986- StevenChernow, MD, University of Arizona, "Use of the Emergency Department for Hypertensive Screening"

1984- Charles G. Brown, MD. Ohio State University, "Injuries Associatedwith the Percutaneous Placement of Transthoracic Pacemakers"

1985- William C. Dalsey,MD, and ScottA. Syverud,MD, Universityof Cincinnati, "Transcutaneous and TransvenousCardiac Pacing For Early Bradyasytolic Cardiac Arrest"

1983- Charles F. Babbs, MD, Purdue University, "Improved CardiacOutput During CardiopulmonaryResuscitation with InterposedAbdominal Compressions''

1984- Gerard B. Martin, MD, Henry Ford Hospital,"Insulin and GlucoseLevels During CPR in the Canine Model"

1982- Carl D. Winegar, MD, Wayne State University, "Early Amelioration of Brain Damage in Dogs After Fifteen Minutes of Cardiac Arrest"

1983- Jeffrey A. Sharff, MD, Oregon Health SciencesUniversity, "Effect of Time on RegionalOrgan PerfusionDuring Two Methods of Cardiopulmonary Resuscitation"

BESTORAL METHODOLOGY

BEST RESIDENT POSTER

1988- Phillip L. Henneman, MD, HarborUCLA, "Attending Coveragein Academic EmergencyMedicine: A National Survey"

1988- KatherineM. Hurlbut. MD. University of Arizona, "Reliability of Clinical Presentationfor Predicting Significant Viper Envenomation"

69

1981- Blaine C. White, MD, Wayne State University, "Correction of Canine Cerebral Cortical Blood Flow and VascularResistance PostArrest Using Flunarazine,A Calcium Antagonist" 1980- Blaine C. White, MD, Wayne State University, "Mitochondrial 0, Use and ATP Synthesis:Kinetic Effectsof Ca-- and HPO. Modulatedby Glucocorticoids"

1979- Albert E. Cram, MD, University of "The Effect of PneumaticAntiIowa, Shock Trousers on Intercranial Pressurein the Canine Model" 1977- LawrenceB. Dunlap, MD, Josephine General Hospital, Grants Pass, "PercutaneousTranstracheal Oregon, Ventilation During Cardiopulmonary Resuscitation"

BEST PRESENTATION 1984- Paul M. Paris, MD, University of "The PrehospitalUse of Pittsburgh, TranscutaneousCardiac Pacing" 1983- SandraH. Ralston,MD, PurdueUni"IntrapulmonaryEpinephrine versity, During Prolonged Cardiopulmonary ImprovedRegionalBlood Resuscitation: Flow and Resuscitationin Dogs" 1982- StephenR. Boster,MD, Universityof "Translaryngeal AbsorbLouisville, tion of Lidocaine" l98l-

MD, Universityof RobertW. Strauss, "Expanded Role of the Chicago, Barium Enema in the Acute Abdomen"

1980- JacekB. Franaszek,MD, and Harold A. Jayne,MD, UniversitYof Illinois, "Medical Preparationsfor an Outdoor Papal Mass"

KENNEDY LECTURERS 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-Senator Alan M. Cranston 1979-AlexanderJ. Walt, MD 1980-EugeneL. Nagel, MD l98l-C. ThomasThomPson,MD 1982-R Adams CowleY,MD 1983-Ronald L. Krome, MD 1984-David K. Wagner, MD 1985-Richard F. Edlich, MD, PhD 1986-Henry D. Mclntosh, MD 1987-Robert D. Sparks,MD 1988-Gail V. Anderson,MD 1989-D. Kay Clawson,MD

HONORARY MEMBERS 1973-Robert H. KennedY,MDt FraserN. Gurd, MD C. Barber Mueller. MD 1974-John G. Wiegenstein,MD AlexanderJ. Walt, MD 1975-Oscar P. Hampton,MDt N. H. McNally,MDt Curtis P. Artz, MDI 1976-Anita M. Dorr, RNt EugeneL. Nagel, MD 19'77-PeterSafar, MD 1978-Eben Alexander,Jr., MD 1979-David R. Boyd, MD, CM 198l-R Adams CowleY,MD 1982-Carl Jelenko,III, MD

HAL JAYNE ACADEMIC EXCELLENCE AWARD 1985-JamesT. Niemann,MD 1986-Glenn C. Hamilton, MD 1987-CharlesG. Brown, MD 1988-Jerris R. Hedges,MD 1989-Richard F. Edlich, MD, PhD

ACADBMIC LEADERSHIP AWARD 1989-Ronald L. Krome, MD

SILVER TONGUE ORATOR DEBATE AWARD 1979-Ann L. Harwood-Nuss,MD 1980-Peter Rosen, MD l98l-Jerome L. Hoffman, MD 1982-Glenn C. Hamilton, MD 1983-FrederickB. EPstein,MD 1984-Marcus L. Martin, MD 1985-Paul M. Paris,MD 1986-Daniel Danzl, MD 1987-NicholasBenson,MD 1988-Daniel Danzl, MD

PAST PRESIDENTS UA/EM l-Charles FreY, MD l97O-19'1 l97I-1972-Alan R. Dimick, MD 1972-1973-Probert B. Rutherford, MD 1973-1974-JamesR. Mackenzie, MD 1974-19'7s-George Johnson,Jr', MD 1975-19'76-LeslieE. Rudolf, MD 1976-1977-David K. Wagner, MD l9'77-1978-Carl Jelenko,III, MD 1978-1979-RonaldL. Krome, MD 1979-1980-Kenneth L. Mattox, MD 1980-1981-W. Kendall McNabneY,MD F. Waeckerle,MD 1981-1982-Joseph 1982-1983-Barry W. Wolcott, MD 1983-1984-JackB. Peacock,MD 1984-1985-RichardC. LevY, MD 1985-1986-stevenJ. Davidson,MD 1986-1987-RichardM. Nowak, MD 1987-1988-ErnestRuiz, MD

STEM 1975-1976-RobertH. DaileY,MD -Peter Rosen, MD 1976-197'7 C. Roussi,MDt 197'7-19'78-C. 1978-1979-G. Richard Braen, MD 1979-1980-HarveYW. Meislin, MD 1980-1981-FrankJ. Baker, II, MD l98l-1982-John R. LumPkin, MD 1982-1983-HaroldA. JaYne,MDf 1983-1984-KennethV. Iserson,MD 1984-1985-GlennC. Hamilton,MD 1985-1986-DanielSchelble,MD 1986-1987-ThomasO. Stair, MD 1987-1988-MaryAnn CooPer,MD 1988-1989-GaborD. Kelen, MD

SAEM T. Niemann,MD 1988-1989-James

IMAGO OBSCURA AWARD

MACKENZIE AWARD

1976-Norman E. McSwain. Jr.. MD 1977-Sung Rock Lee, MD 1978-G. Patrick Lilja, MD 1979-Stephen Karas, MD 1980-Jack Goldberg, MD l98l-Robert Knopp, MD 1982-Blaine C. White, MD 1983-Richard C. Levy, MD 1984-Glenn C. Hamilton, MD 1985-Jerris R. Hedges,MD 1986-David DuBois, MD 1987-Norman Abramson,MD 1988-CharlesG. Brown, MD

1976-James R. Mackenzie, MD 1977-Cyril T. M. Cameron, MDf 1978-John H. Hughes,MD 1979-Joseph F. Waeckerle, MD 1980-Kenneth L. Mattox, MD 198l-Barry W. Wolcott, MD 1982-Hubert T. Gurley, MD 1983-Ronald L. Krome, MD 1984-CharlesF. Babbs,MD 1985-Blaine C. White, MD 1986-JamesT. Niemann,MD I 987-Arthur Kellermann. MD 1988-Richard E. Burney, MD

PAST ANNUAL MEETINGS CharterMeeting November18, 1970 Denver,Colorado

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

l4th Annual Meeting May 22-25, 1984 Louisville, Kentucky

lst Annual Meeting M a y 1 4 - 1 5 l, 9 7 l Ann Arbor, Michigan

8th Annual Meeting May l8-20, 1978 San Francisco,California

l5th Annual Meeting May 2l-24, 1985 KansasCity, Missouri

2nd Annual Meeting May 12-13, 1972 Washington, D.C.

9th Annual Meeting May 24-26, 1979 Orlando, Florida

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

10th Annual Meeting April 20-23, 1980 Tucson, Arizona

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

l lth Annual Meeting April l3-15,1981 San Antonio, Texas

5th Annual Meeting May 20-24, 1975 Vancouver,British Columbia

l2th Annual Meeting April 15-17, 1982 Salt Lake City, Utah

6th Annual Meeting Mayll-15, 1976 Philadelphia,Pennsylvanra

l3th Annual Meeting June 1-4, 1983 Boston, Massachusetts

16th Annual Meeting M a y 1 3 - 1 5 ,1 9 8 6 Portland, Oregon lTth Annual Meeting May L9-21, 1987 Philadelphia,Pennsylvania l8th Annual Meeting May 24-26, 1988 Cincinnati, Ohio l9th Annual Meeting May 22-25, 1989 San Diego, California

ANNUAL BUSINESSMEETING AGENDA l.

Amendments to the constitution and Bylaws, Louis Ling, MD, Secretary/Treasurer committee and the Board of Directors and The following five amendmentshave been proposed and approved by the constitution and Bylaws The Constitutionand Bylaws (with consideration. for have been submittedto the membershipvii the March isiue of the SAEM newsletter active members of the organization Only program' in this provided is out) crossed proposed deletions the the proposed changesln italics and ure eligible to vote on amendmentsto the Constitutionand Bylaws' the criteria for emeritusmembershipfrom l0 Amendment l: Article III, Section 2,3 (a) of the constitution. This amendmentchanges of 65' an age and years of service 15 years to of 60 age an and the organization to years of service for electionof the vice-presidentposition Amendment 2: Article II, Section2, (a) of the Bylaws. This amendmentwould changethe criteria of Directors' Board the of past member or a so that candidatesfor this position are not required to be a current for election of the program chairman so Amendment 3: Article II, Section 4 of the Bylaws. This amendment would change the criteria This amendmentwould also allow nominaCommittee' Program of the members current be io not required posiiion are for this that candidates tions from the floor for the position of program chairman' for the conveningof Board of Directors Amendment 4: Article II, Section 6 of the Bylaws. This amendmentwould changethe criteria would need to inform membersof the Board of meetings7 days in advance,insteadof requiring meetingsso that the Secretary/Treasurer the SeJretary/Treasurerto inform all members 60 days in advance of Board meetings' establishmentof a quorum at the annual Amendment 5: Article III, Section I of the Bylaws. This amendmentwould make consistentthe This quorum is already establishedfor voting. present and businessmeeting so that a quorum would be a majority of the active members the Constitution' of VIII Article and VII Article in changes Bylaws and the amendmentof Constitution

2. Elections, Louis Ling, MD, Secretary/Treasurer is providedin this program.only activemembers The slateof nomineesis listedbelow andphotosand biographicalinformationon eachcandidate of the organizationare eligible to vote in the elections' Program Committee Chairman-Elect - (one 3-year term to begin May President-Elect- (one l-year position) 1990) Jerris R. Hedges, MD Gary Krause, MD T. Niemann, MD James positions) (three 2-year Board of Directors MD Barsan, William G. Nominating Committee Members - (two 2-year positions) Nicholas H. Benson, MD John A. Marx, MD Louis Binder, MD Paul Pepe, MD Mary Ann Cooper, MD Daniel T. Schelble,MD Daniel Danzl, MD J. Douglas White, MD Lewis R. Goldfrank, MD Richard M. Nowak, MD - (one 3-yearposition) Constitution and Bylaws Committee Member (one 2-year position) Marcus L. Martin, MD Research Committee Chairman JamesD. Woodburn,Jr', MD William H. Spivey, MD

3. Secretary/Treasurer'sReport, Louis Ling, MD, Secretary/Treasurer at APril 28, 1989:1,494 A. Membership Active:902 248 Associate: B. Finance Report - Year Ending December31, 1 9 8 8 Revenues Dues Annual Meeting Symposium EMRA Interest Mailing List Sale EMF Contributions Other TOTAL

r74,599 37,845 16,125 ?5 n?t *

t6,713 1,625 4,465 580 $286,984

Emeritus:l3 Honorary: 12

Expenses Salaries,Wages and PaYroll Taxes Annual Meeting Symposium EMRA Postageand TelePhone Other Administration Committees and RePresentattves TOTAL

83,506 47,441 16,348 20,523* 34,631 29,97l** 16,948r<+* $249,368

*EMRA newsletter and 1989 Job Catalog (profit belongs to EMRA) photocopyingexpenses' **office rent and insurance,newsletterprinting, g"n"J p.iiting, accounting,bank charges,depreciation,computer' and ,r**Annalssubscriptions, AAMC, EMF, AMA Commission on-BUS, EMRA representative,STEM, 6th world congress, EMRS' Committees' and Board exPenses.

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iil tl STEM Annual Business Meeting, Robert Prosser, MD, STEM Secretary/Treasuter process of The active membership of STEM are eligible to vote on the following two resolutions which will complete the nearly two-year amalgamatingthe Society of Teachers of-Emergency Medicine and the University Association for Emergency Medicine into the Society for Academic Emergency Medicine.

BE IT RESOLVED that the Board of Directors of the Society of Teachers of Emergency Medicine is instructed to dissolve the organization as soon as possible after satisfying all legal requirements. Thls amendment supersedesall other provisions of the Constitution and Bylaws of the Society.

BE IT RESOLVED that the Board of Directors of the Society of Teachers of Emergency Medicine will transfer all assetsof the Society and all all debt liability to the Society for Academic Emergency Medicine immediately before dissolving the Society. This amendmentsupersedes of the Society.

Bylaws and provisions of the Constitution other

American Board of Emergency Medicine Report, Judith E. Tintinalli, MD, ABEM President Annals of Emergency Medicine Report, Joseph F' Waeckerle, MD, Editor

President's Address, James T. Nietnann, MD

8' Introduction of New President:Arthur B' sanders' [{dD' rarnes T' Niemann' MD 9. New Business Adjournment ,!c ;*i

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SLATE OF NOMINEES PRESIDENT-ELECT Jerris R. Hedges, MD, MS, is an associate professor of EmergencY Medicine in the Division of Emergency Medicine and the Director of Research Programsat the Oregon Health Sciences University in Portland, Oregon. Dr. Hedgeshas beena member of UA/EM since 1977and a memberof STEM since 1980. He is currently a member of the SAEM Board of Directors (1986-1989) and has served on the UA/EM Long RangePlanningCommittee(1984-1987), the UA/EM Program Committee MD, MS (1985-1989), and as Chairman of the JerrisR. Hedges, Committee Prosram UA/EM (1986-1989).Dr. Hedgeshas servedon the STEM Faculty DevelopmentCommittee(1983-1988).Dr. Hedgeswas a moderatorat the 1988 UA/EM-IRIEM ResearchSymposium.In 1988, Dr. Hedgeswas the recipientof the Harold JayneAcademic ExcellenceAward. Dr. Hedges hasbeenan item writer for the American Board of EmergencyMedicine since 1986. He is a member of the Editorial Board of the Annals of EmergencyMedicine, Joumal of EmergencyMedicine, and Emergency Medicine and Ambulatory Care News. He is a guest reviewer for the American Journal of Emergency Medicine and Resuscitation' He is a 1976graduateof the University of WashingtonSchool of Medicine and he completed his Emergency Medicine Residency in 1979 at the Medical College of Pennsylvania.

BOARD OF DIRECTORS William G. Barsan. MD, is an associate professor at the Department of Emergency Medicine at the University of Cincinnati. Dr. Barsanhas beena member of UA/EM since 1980and was a member ofthe ExecutiveCouncil, from 1985to 1988. Dr. Barsanwas a memberof the STEM Program Committee from 1982-84 and served as chairman in 1983-84.He servedon the UA/EM Program Committeefrom 1982-85and on the Constitutionand Bylaws Committee from 1981-84.He was the chairmanof the 1988UA/EM-IRIEM ResearchSymposium on Emergency ThrombolYtic Emergencies.He has beena moderatorat the 1983, 1984, 1985 and 1987 Annual Meetings. He has been a member of the American Journal of Emergency Medicine editorial board and a guest reviewer of Journal of EmergencyMedicine since 1983and an examinerfor ABEM since 1983.Dr. Barsangraduatedfrom Ohio StateUniversityCollege of Medicine in 1975and completedan EmergencyMedicine residency in 1979 at the University of Cincinnati.

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Nicholas H. Benson, MD, has been a member of UA/EM since 1984 and a memberof STEM since1983.He is currently a member of the STEM Board of Directors having been electedin 1988.

He has been a member of the EMS Educators Committee since 1986 and servedas its chairmanuntil 1988. He has served on the Publications Task Force since 1987. He was a member of the STEM UndergraduateCurriculum Promotion Committee from 1983-87' In 1987 he won the STEM Silver Tongue Orator Award and participated in the

1988 STEM Debates.He serves as a consulting reviewer for the American Journal of EmergencyMedicine and contributing editor of theAero Medical Journal. He graduatedfrom the University of South Dakota School of Medicine and in 1983 completedan emergency medicineresidencyat the University of Illinois Affiliated Hospitals' He is currently an assistantprofessorand Vice Chairmanof the Department of EmergencyMedicine at East Carolina University.

, Louis Binder, MD' is an assistantpro,.ir,' fessor in the Division of Emergency r.,,t Medicine at the Texas Tech University RegionalAcademicHealth Centerat El .

Paso,and is alsothe AssistantDean for ,,,,.., ' GraduateMedical Educationand Student .

Affairs at that institution.He graduated from the Universityof MinnesotaMedical School in 1980 and comPletedan EmergencyMedicine residencyin 1983 at Truman Medical Center. He is the chairmanof the SAEM Undergraduate Committee,was electedto the ConstituLouis Binder, MD tion and BylawsCommitteein 1988,and will be moderatinga paneldiscussionat the 1989 SAEM annual meeting. He is a member of the Education Committee,the Public RelationsCommittee,and the Committeeon AcademicDepartments,and hasbeena memberof SAEM since1982' He was a participantin the STEM Goalsand ObjectivesProject,and was a memberof the UAEM MembershipCommitteein 1986and the Scientific ConsensusCommitteein 1986' He is an examinerfor the American Board of EmergencyMedicine, and a reviewer for Annals of Emergency Medicine and the American Journal of Emergency Medicine.

Mary Ann Cooper, MD, is an assistant professor and director of researchat the Division of EmergencyMedicineat the University of Illinois. She has been a memberof UAEM since 1977, serving on the Constitutionand Bylaws Committee, ProgramCommitteeand the Executive Council where she servedas an atlarge member from 1982 to 1988 and from 1985to 1988. secretary/treasurer She was local arrangementsChairman for the 1984 Annual Meeting in Louisville. Shehasbeena memberof the Mary Ann Cooper,MD Joint AcademicAffairs Task Force since 1986. She has also been an active memberof STEM having servedon its Board of Directorssince1980 as well as newslettereditor from 1983to 1986. She was Presidentof STEM in 1988and was a memberof the AmalgamationTask Force.

She has beenan ABEM examinersince 1982, on the editorialboard of the Journal of Emergency Medicine and a grant reviewer for the Australian ResearchCouncil. The EmergencyMedicine Residents' Associationawardedher its Excellencein TeachingAward in 1988.

Dr. Cooper graduatedfrom Michigan State University Collegeof Human Medicine in 1975 and completed an Emergency Medicine ResidencyProgram at the University of Cincinnati in 1978.

Daniel Danzl, MD, is an associateprofessorin the Departmentof Emergency Medicineat the Universityof Lousiville.

Dr. Danzl has been a member of UA/EM since 1979 and is currently a member of the SAEM Board of Directors, having beenelectedto a one year term in 1988.He was the winnerof the 1986 and 1988 STEM Silver Orator Award. He served on the UA/EM Industrial/GovernmentalRelationsCommittee from 1984-85and a member of the NominatingCommitteeuntil 1988.

Dr. Danzl has been an examiner for ABEM since 1982. He has been an editorialboardmemberof theAmericanJourrutl of EmergencyMer)icine since 1984and a reviewer for Journal oJ Emergency Medicine since 1987.Since l98l he has also servedas a reviewer for Annals oJ Emergency Medic:ine.He was a moderatorat the l9g3 and lggg AnnualMeetings.He was alsoa facultymemberat the t9g7 and lggg UA/EMIIRIEM ResearchSymposiums.He is a 1976graduateof Ohio StateUniversityand he completedhis entergen.y.."di.in. residency in 1979fiom the Universityof Louisville.

Lewis R. Goldfrank, MD, is an associateclinical professorof Internal Medicineat the New York University Schoolof Medicine.He is the Director of the Departments of Emergency Medicine at BellevueHospitalCenter and New York University Medical Center. He is also the Medical Director of the New York City Poison Control Center. Dr. Goldfrank has been a memberof UA/EM since1974.He has beenan Ad Hoc reviewer in toxicology fbr the 1987, 1988, and 1989 Annual Meetings as well as serving as a

RESEARCHCOMMITTEE CHAIRMAN William H. Spivey, MD, is an assistant professorin the Departmentof Emergency Medicine at the Medical College of Pennsylvaniawhere he servesas Assistant Clinical Director and Director of Research.Dr. Spivey is currently the chairmanof the ResearchCommitteeand was appointedchair in 1988.Dr. Spivey has been a member of UA/EM since 1982 and is currently a member of the Constitutionand BylawsCommittee.He will chair the Constitutionand Bylaws Committee 1989-90.He has beenan ad hoc reviewer for the ProgramCommir tee since 1987and was a moderatorduring the 1986Annual Meeting and participatedas a debatorin the l9g6 STEM Debates.He is a reviewer for theAnnals of EmergencyMedicine and a member of theJournal of EmergencyMedicine Editorial Board.

Dr. Spivey graduatedfiom East Carolina University Medical School in l98l andcompletedan emergencymedicineresidencyat the medical collegeof Pennsylvania in 1985.

PROGRAM COMMITTEE CHAIRMAN Gary Krause, MD, is an assistantpro_ fessor in the section of Emergency Medicineat WayneStateUniversity.He has been a member of UA/EM since l98l and is currentlya memberof the Program Committee.He has servedas an ad hoc abstract reviewer and as a moderatorfor the 1987and 1988Annual Meetingsand will be a moderatorat the 1989Annual Meeting. He is a member of the ResuscitationEditorial Board and is a reviewer for Annals of Emergency Medicine. Dr. Krause graduated from Gary Krause,MD Wayne StateUniversity School of Medi_ cine in l98l and completeda residency in emergency medicineat Wayne StateUniversityin 19g4.

tjij rhe UniversityorBruxer res,#:LT['Jr',Ll ?:ti#;, Hilfi:j:

a residency in InternalMedicineat MontefioreHospitaland Meclical Centerin 1973.He hasbeenan examinerfbr ABEM since l9g5 and the AmericanBoard of Medical Toxicology since 19g3. He is a reviewer for the American Journal of Emergenr:yMedicine and an Editorfor the.journalsof Clinicat Toxirnlogy, andMer)ical Toxicrfutgy andAdverse Drug Experience.

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Nowak was a member of the UA/EM Nominating Committee in 1979-8I andchairof theJoint AcademicAffairs Task F:orcesince19g6.

He hasbeenan examinerfor ABEM since 1983and is a reviewerfor JAMA and Annals of Emergency Medicirze, as well as a member of the editorial board of the American Journal of EmergencyMedicine.

He hasbeena moderatorat the 1984,1985,and 1986AnnualMeetinss.

He graduatedfrom the Universityof Toronto Medical Schoolin 1972, completed postgraduatetraining in Internal Medicine at Montreal GeneralHospitalin 1973followedby researchfellowshipin theclinical sciencedivision at the University of Toronto in 1975.

Richard M. Nowak, MD, is the chair of the Department of Emergency Medicine at Henry Ford Hospital and a clinical assistantprofessorin the section of emergency medical services at the Universityof Michigan.Dr. Nowak is a pastpresidentof UA/EM and hasbeen a memberof UA/EM since 1976. Dr. Nowak servedon the ExecutiveCouncil from l98l to 1988and servedon the AmalgamationTask Force. He is currently the chairmanof the International Committee and is collaborating with the Richard M. Nowak, MD 6th World Congresson Emergencyand Disaster Medicine and a co-sponsored meetingwith the EmergencyMedicine ResearchSociety.He was the secretary/treasurer of UA/EM in 1984-85 and has served on the NominatingCommittee.He has beena memberof STEM since 1975 andwasa memberof the STEM Board of Directors in lggl-g3. Dr.

James T. Niemann, MD /J

James T. Niemann, MD, is an associate professor of medicine at UCLA. Dr. Niemannhasservedon the UA/EM Ex_ ecutive Council since 1985 and is the current presidentof SAEM. He hasbeen a member of the Editorial Board of Annals of Emergency Medicine since 1982 and is also a member of the Edi_ torial Board of Critical Care Medicine.

He is a manuscriptconsultant/reviewer for Annals, the American Journal of Emergency Medicine, as well as foi many otherjoumals including./,4M1 and Circulation. He was the first recipientof

the Hal JayneAcademicExcellenceAward in 1985and servedthree yearson the UA/EM Constitutionand Bylaws Committee,servingas chair in 1987-1988.Dr. Niemann servedon the AmalgamationTask Force, the Academic Affairs Task Force, and in 198l-1982 on the STEM Public EducationCommittee, as well as the UA/EM Education Committeein 1984.He has beena memberof STEM since 1980 and a memberof UA/EM since 1981and servedon the STEM Board of Directors in 1981-1982.Dr. Niemanngraduatedfrom the University of California Schoolof Medicine in 1976and completedhis residency in 1979at Los AngelesCounty Harbor-UCLA Medical Center'

NOMINATING COMMITTEE John A. Marx, MD, is an associateProfessor in the Departmentof Surgery, Section of Emergency Medicine and Trauma at the University of Colorado Health SciencesCenter. He is Assistant Director of the Departmentof Emergency Medicineat DenverGeneralHospital and has been ResearchCoordinator for the Denver Affiliated Emergency Medicine ResidencyProgramsince 1980.He attended Stanford Medical School and trained in the Denver Affiliated Residency in EmergencyMedicine from 1978to 1980. Dr. Marx has been a memberof UA/EM since 1981 and has been a moderator at two annual meetings and will be a moderatorat the 1989Annual Meeting. Dr. Marx is the SectionEditor for Original Contributions for the "/ournal of Emergency Medicine. He has been a guest editorial reviewer for JAMA and the American Journal of Emergency Medicine.

Paul Pepe,MD

Paul Pepe, MD, is an associateProfessorof medicineand surgeryat Baylor Collegeof Medicine and director of the Houston EMS system. He has rePresentedUA/EM on the AMA Commission on EMS for the last four yearsand was a moderator at the 1987 Annual Meeting. Dr. Pepehas been a member of UA/EM since 1983. In 1976 he graduatedfrom the University of California Schoolof Medicine, completedan internal medicine residencyin 1979 and then several clinical and research fellowshipsin pulmonary-criticalcare, trauma, and surgical critical care'

Daniel T. Schelble' MD, is an associate professor in Emergency Medicine at NortheasternOhio UniversitiesCollege of Medicine. He is currently a member of the Nominating Committee, having beenelectedto a one year term in 1988' Dr. Schelbleservedon the STEM Board of Directors from 1982-87and was the presidentof STEM in 1985-86.He has also coordinated the Hal Jayne Academic Excellence Award since its inception in 1986. He servedon the Joint Academic Affairs Task Force from 1985-87and Daniel T. Schelble, MD was a member of the Faculty Development Committee. He was the STEM representativeto the AAMC in 1983and hasbeena memberof UAEM since 1984. He graduatedfrom the University of Wisconsin School of Medicine in 1972 and in 1977 completed a residency in Emer-

gency Medicine at Akron General Medical Center.

J. Douglas White, MD' clinical director of Emergency Medicine at :; GeorgetownUniversity Medical Center, is a graduateof Yale University School of Medicine. He completeda residency in internal medicine at Bellevue-New York University, followed bY fellowshipsin clinicalemergencymedicine General Hospital and at Massachusetts researchat Harvard Medical School. Dr. White is currently editor of The American Journal of EmergencY Medicine. He is also Director J. DouglasWhite, MD of Research in the DePartment of Emergency Medicine and is an professorof emergencyand internalmedicineat Georgetown associate University. A memberof UA/EM since 1980, Dr. White was chairman of the GovernanceCommittee from 1986-88,and is currently chairmanof the GovernmentalAffairs Committee.He is currently a member of the Nominating Committee. He representedUA/EM on the Joint AcademicAffairs Task Force, and servedthreeyearson the Constitutionand Bylaws Committee'

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CONSTITUTIONAND BYLAWS COMMITTEE Marcus L. Martin, MD, is an associate professorof EmergencyMedicineat the Medical College of PennsYlvania, Alleghney Campus, EmergencY Medicine Residency Director and AssociateDirector of EmergencyServicesat AlleghenyGeneralHospital'Dr. Martin hasbeena memberof STEM and UAEM since 1984and has participated in the STEM Goalsand Objectivesproiect. He was a member of the STEM Public RelationsCommittee1984-1985.

Dr. Martin was the winner of the 1984 STEM Silver TongueOrator Award, and and alsoparticipatedin the 1988STEM Debate.He has beena reviewer for the Annalsof EmergencyMedicinesince 1985.As a chartermember,Dr' Martin graduatedin 1976from EasternVirginia Medical Schooland completedresidencytraining in EmergencyMedicineat the University of Cincinnatiin 1981.

James D. Woodburn, Jr., MD, MS, was the co-chairman of the 1989 UA/EM-IRIEM ResearchSYmPosium on TechnologyApplications.He was a contributingeditor to the STEM newsletter in 1987and 1988and is currentlya member of the PublicationsTask Force, as well as an ad hoc abstractreviewer for the 1989 Annual Meeting' Dr. Woodburn served as the EMRA rePresentativeto STEM and UA/EM from 1985to 1987.In 1986he coordinatedthe first ResidentResearchForum whiqhis JamesD. Woodburn, held at the Annual Meeting and in 1987 Jr., MD' MS he receivedthe EMRA National Leadership Award. Dr. Woodburn graduatedfrom the University of Wisconsin School of Medicine in 1983and completedan EmergencyMedicine residencyat Hennepin County Medical Center in 1987, which was followed by a fellowship in EmergencyMedicine which was completed in August, 1988.Dr. Woodburn is currently an emergencyphysician at HeilthEast Hospital Corporation in St. Paul and also at the Hennepin County Medical Center.

CONSTITUTION OF THE SOCIETY FOR ACADEMIC EMERGENCY MEDICINE ARTICLE I - NAME

Section 2: Qualifications. (1) Candidates for active membershipshallbe individualswith an advanceddegree(MD, PhD, DO, PharmD, DSc, or equivalent)who hold a medical schoolor universityfaculty appointmentand who activelyparticipatein acute,emergency,or criticalcarein an administrative, teaching, or researchcapacity, (b) individuals with similar degreesin activemilitary service(U.S. or abroad)who actively participate in acute, emergency, or critical care in an administrative,teaching,or researihcapacity.(c) Individualswho otherwisemeetqualificationsfor activemembershipas defined abovebut who do not hold a universityfacultyappointmentmay petition the MembershipCommitteefor considerationfor active membership status,if desired.(2) Candidates for associate membershipshall be healthprofessionals, educators,government officials, membersof lay or civic groups,or members of the public at largewho may havean interestor desireto participatein pursuingthe purposesandobjectivesofthe Association. (3) Candidates for emeritusmembershipshallbe (a) active memberswho seeksuchstatusand who havegiven*&/5 continuousyearsof activeserviceto the Associationand have attainedthe age of6U65 years (b) other active memberswho underspecialcircumstances are invited fbr suchemeritusstatus by the Membership Committee. (4) Candidatesfor resident/fellowmembershipmustbe resident(s) or f-ellowsin residencytrainingprogram(s)who havean interestin emergency medicine.(5) Candidates fbr honorarymembershipshallbe individualswho havemadeoutstandingresearchor educational contributionsto the purposeand objectivesof the Association.(6) Candidatesfor internationalmembershipshall be individuals who resideoutsidethe U.S. and who meet qualiflcationsfbr activeor associate membershipas describedabove.Suchcandidatesmay apply for active,associate, or other membership in the Association.

The name of this organizationshall be, "The Society for AcademicEmergencyMedicine," hereinafterreferred to as, "The " Association.

ARTICLE II - OBJECTIVES Section1: The objectiveof this Associationis to improve the emergency, urgent,or critical careof the acutelyill or injured patientby promoting research,by educatinghealth care professionals andthe public, by fosteringrelationshipswith organizationswith a similar purpose,and by supportingthe specializedor multidisciplinecare of such patientsthrough research andeducation.

The Associationwill functionas a scientificand educational organization as definedin Section501(c)(3) ofthe InternalRevenueCode, as amended.

Section2: The Associationshall pursue its purposeby: l) sponsoring forumsfor the presentationof peer-reviewedscientific andeducationalinvestigations,2) conveningand sponsoringeducational programsfor healthcare professionalsand the laypublic,3) promotingacademicdevelopmentand education of itsmembership throughspecialized programs,4) servingas anacademic, university-based, and/or teachinghospitalrepresentative for the care of the acutely ill or injured patient, 5) developing liaisonwith otherorganizations with a similarpurpose,and 6) publishing researchand educationaldata in the scientific andeducationalliteratureand other mediaavailable to the lay public.

Section 3: A. This corporationis organizedexclusivelyfbr educational and scientificpurposes,including,fbr such purposes, themakingof distributionsto organizations thatqualify asexemptorganizations underSection501(c)(3) of the InternalRevenue Codeof 1954(or the corresponding provisionof anyfuture United StatesInternal RevenueLaw).

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Section3: Member Rightsand Privileges.All membersmay havethe privilegeof the floor and of servingon the committecsof the Association.All membersof the Associationmay serveon the Board of Directorsor as a committeeChairperson. Only activemembersshall have voting rights and shall serveas officersof the Association.

B. No partof the net earningsof the col.poration shall inure tothebenefitof, or be distributable to its members,Directors, Officersor other private persons,except that the corporation shallbeauthorizedand empoweredto pay reasonablecompensation for servicesrenderedand to makepaymentsand distributionsin furtheranceof the purposesset forth in paragraphA hereof.No substantialpart of the activitiesof the corporation shallbethecarryingon of propaganda,or otherwiseattempting to influence legislation,and the corporationshallnot participate in, or intervenein (includingthe publishingor distributionof statements) any political campaignon behalf of any candidate for publicoffice. Notwithstandingany other provisionof these articles,the corporationshall not carry on any other activities notpermittedto be carriedon (a) by a corporationexemptfrom FederalIncome tax under Section501 (c) (3) of the Internal Revenue Codeof 1954(or correspondingprovision ofany future UnitedStateRevenueLaw) or (b) by a corporation,contributionsto which are deductibleunder Section 170(c) (2) of the Internal RevenueCodeof 1954(or the correspondingprovision of any future United State Internal RevenueLaw).

Seoion4; The Associationshallnot discriminate,with respect to its membership,on the basisof race, sex, creed, religion or nationalorigin.

ARTICLE IV _ OFFICERS Section.1:The officersof this organizationshallbe the president, Vice-President, and Secretary-Treasurer.

Section2: Board of Directors shall serve as the governing body of the Association.The Boardof Directorsshallconsist of the aboveofficers, the Program CommitteeChairman,the immediatepastpresident,and five Councilmen-at-Large.

Both activeand associatemembersmay serveon the Boardof Direcbrs, but only activemembersmay be officersof the Association.

ARTICLE V - COMMITTEES

ARTICLE III _ MEMBERSHIP

The standingcommitteesof the Associationshallbe: (l) NominatingCommittee,(2) MembershipCommittee,(3) program Committee,(4) Constitutionand BylawsCommiffee,(5) Education Committee,(6) ResearchCommittee,(7) Liaison Committee

Sectionl: Classifications. There shall be seven classesof membership: active, associate,emeritus,resident/fellow,honorary,and internationalactive and internationalassociate.

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to the Associationof American Medical Colleges,(8) Governmental Affairs Committee, and (9) Committee on International Affairs. Additional committees may be created by the Board of Directors and ad hoc committeesmay be createdby the President to aid in the Association'sefforts to achieveand further its goals.

Section 4: Adoption of a bylaw amendment shall be by a majority vote of the active memberspresentand voting at any annual or specialmeeting.

ARTICLE VI - ANNUAL MEETING

Section 1; The constitution may be adopted or amendedat any annual or special meeting of the membership.

Section 1.' There shall be an annual meeting of the Association. This meetingshallconsistof an educationaland scientific programand a businesssession.

Section2; Proposedamendmentsto the constitution shall be submitted in writing to the Secretary/Treasurerby three members at least 60 days prior to the meeting at which they are to be considered.The Secretary/Treasurershall mail the proposed amendmentsto the membership at least 30 days prior to that meeting.

Section2: The Board of Directors, by majority vote, may call, upon 30 daysnotice,a specialmeetingof the membership or standingcommitteeto conductany businessthat the Board of Directors shall place before the membershipor standing committee.

Section3: The Board of Directorsmay call and conductany specialmeetingby mail. For purposesof notice, the meeting dateshall be a datesetfor the return of mail ballotsand it shall be calledthe voting date. Adoption of any proposal,resolution or amendmentby mail ballot shall be achievedby affirmative vote of a majority of voting active membersunlessotherwise providedby anotherprovision of this constitution.Only those mail ballots receivedat the businessoffice of the Association to the voting date shall be counted. within 30 days subsequent

ARTICLE VII _ BYLAWS Section1: Bylaws may be adoptedor amendedat any annual or specialmeeting of the membership.

Section2; Proposedamendmentsto the bylaws shallbe subby three members mitted in writing to the Secretary/Treasurer at least 60 days prior to the meeting at which they are to be shall mail the proposed considered.The Secretary/Treasurer amendmentsto the membershipat least 30 days prior to that meeting.

Section3; The Board of Directors may, by resolution,proposeamendments to the bylaws; providedthe proposedamendmentsare mailed to the membershipat least 30 days prior to the meetingat which they are to be considered.

ARTICLE VIII - ADOPTION OF THE AMENDMENTS TO THE CONSTITUTION

Section3.:The Board of Directors may, by resolution,propose amendmentsto the constitution; provided the proposedamendmentsare mailed to the membershipat least 30 days prior to the meeting at which they are to be considered.

Section4; Adoption of a constitution amendmentshall be by a majority vote of the active memberspresentand voting at any annual or specialmeeting.

ARTICLE IX _ DISSOLUTION Upon the dissolution of the corporation, the Board of Directors shall, after paying or making provision for the payment of all of the liabilities of the corporation,disposeof all ofthe assetsofthe corporationexclusivelyfor the purposesof the corporation in such manner, or to such organizationor organizationsorganizedand operatedexclusivelyfor charitable, educational,religiousor scientificpurposesas shallat the time qualify as an exemptorganizationor organizationsunder Section 501(c) (3) of the Internal RevenueCode of 1954 (or the corresponding provision of any future United StatesInternal RevenueLaw), as the Boardof Directorsshalldetermine.Any such assetsnot so disposedof shall be disposedby a Court of CompetentJurisdictionin the Council in which the principal office of the corporationis then locatedexclusivelyfor such purposesor to suchorganizationor organizations,as said court shall determine,which are organizedand operatedexclusively for such purposes.

BYLAWS OF THE SOCIETY FOR ACADEMIC EMERGENCY MEDICINE ARTICLE I _ MEMBERSHIP Sectionl: ApplicationProcess.Membershipapplicationforms may be obtained from the Secretary/Treasurerthrough the ExecutiveDirector of the Association.The Applicant must return the completed application forms and supporting letters to the Executive Director of the Association at least one month prior to Board of Directors meeting in order to be considered for membership at that time. The qualifications of applicants for membership will be reviewed by the Membership Committee at each meeting of the Board of Directors. Approval of applicants by the Council Board shall constitute election to one of the membership categories, effective immediately.

Section 2: Dues. Annual dues for active, associate,resident/fellow, and international members will be establishedby the Board of Directors. Honorary and emeritus memberswill not pay dues. Membershipin the Associationmay be terminated for nonpaymentof dues.

Section3: Rightsand privileges. All membershave the privilege of the floor at businessmeetings of the Association and may serve as a committee member, committee chair, or Member-at-Largeof the Board of Directors. Only active members may vote and serve as officers. Any member may submit agenda items for consideration by the Board of Directors.

ARTICLE II BOARD OF DIRECTORS Sectionl: Members.The Board of Directors shall consistof thePresident,Vice-President(President-Elect),the Secretary/ Treasurer,the ImmediatePast president,the program Chair, andfive Members,at-Large.

Section2: Election of Officers. (a) The Vice-president shall beelectedfor a term of one year with automaticsuccessionfrom Vice-President to Presidentthe following year. During this two yearperiod,the electedmemberwill serveas an officer of the Asso_ciation.

Following terms of Vice-president(president_elect) andPresident,this memberwill automaticallyassumethe posi_ tion of ImmediatePast president. Election as Vice-president shallconferBoardof Directorsmembershipfor a minimum of threeyears.Nomineesfor this office will be selectedby the NominatingCommittee, +ne+oar+ofBiteetors, and must have agreed to standfor elec_ tionprior to formal nominationfor electionat the businessses_ sionof the annualmeeting.AlternativenominationsofequaHy @willbe acceptecl from the ilooi.

Suchnomineesmust also agreeto standfor election. Election shallbe by majority vote of the active memberspresentand votingat the businesssessionof the annualmeeting.The Vice_ President may also be electedor appointedas Chair of other standing or ad hoc committees,with the exceptionof the pro_ gramCommittee,and shall be an ex-officio memberof all stand_ ing committees.(b) The Secretary/Treasurershall be elected to a threeyear term. An active member may serve only one termas Secretary/Treasurer.

Nomineesfor this office shall be selected by the Nominating Committeeand must have asreed to standfor electionprior to their formal nominationfbr"elec_ tionat thebusinesssessionof the annualmeeting.Alternative nominations may be offeredfrom the floor. Suchnomineesmust alsoagreeto standfor election. Election shail be by majority voteof the active memberspresentand voting at the buiines.s session of the annualmeeting.The Secretary/Tr"arure, rnuy alsobe electedor appointedas the Chair of standingor ad hol committees, with the exceptionof the Nominatingtommittee andProgramCommittee,and may serveas a memberof all committees.

Section3 : Election of Members-at-lnrRe. Members_at_Larse shallbe electcdro two year rerms.the t-rms being ,tugg.."i.

Members-at-Large may only be electedfor two consecutlve terms.Nomineesfor the aboveoffices shall be selectedby the Nominating Committeeand must haveagreedto standfor elec_ tionprior to their formal nominationfor electionat the business session of the annualmeeting.Alternativenominationsmay be offeredfrom the floor. Suchnomineesmust also agreeto stand for election.Election shall be by majority vote of the active members presentand voting at the businesssessionof the an_ nualmeeting.

Members-at-Large may also be electedas Chairs of standins committees, with the exceptionsof the Nominating and prol gramCommittees,appointedas Chairs of ad hoc committees, or serveas a member of standingor ad hoc committees,with theexceptionof the Nominating Committee.

Section4: Election of Program Committee Chair. The pro_ gramCommitteeChair shall be electedto a three year term.

Norin"es firmberq and must have agreed to stand forilection prior to theirformal nominationfor electionat the businesssessionof theannualmeeting.Alternative nominationswilltstbe accepted from the floor. Such nominees must also agree to ,tond yo,

79

election.Electionshall be by majority vote of the activemembers presentand voting at the businesssessionof the annualmeetins.

The Program Committee Chair shall not be eligible for oth6r electedpositionswithin the Association,but may serveas an appointed member of other standingor ad hoc committees.

Section5: Termsof Office. Terms of office will begin at the conclusionofthe annualbusinessmeeting.The presidentshall appointeligibleAssociationmembersto fill vacanciesandunex_ pired terms on the Board of Directorsand standingand ad hoc committeesuntil the next scheduledelection.

Section 6: Meetings of the Boctrd of Directors. Meetings of the Board of Directors will be convenedat least twice durins the term of the Presidentof the Association.Additionalmeetinei may be convenedat the President'sdiscretionor by petitiJn of six membersof the Boardof Directors.A final noticeof time and placeof suchmeetingsshallbe sentto all membersof the -Asseeiafier+Boa rd by the Secretary/Treasurer at Ieast 5& Z days beforethe meeting.Six membersof the Boardof Directorswill constitutea quorum. Membersof the Association,regardless of membershipcategory,may submitagendaitems.Suchitems mustbe submittedwithin 30 daysof the meetingdate.Meetings of the Boardof Directorsareopento all membersof the Associatron and to the public. Closedmeetingsof the Association's offlcers and ExecutiveDirector may be convenedby order of the President. presidentshall pre_ .Section 7: Duties of the President.The side over both the educationalprogramand businesssession of the annualmeetingof the Association,and the meetinssof the Boardof Directors.It shallbe the duty of the preside-nt to seethat the rulesof order and decorumaie properlyenforced in all deliberationsof the Association,to sign the approved minutesof eachmeeting,and to executeall documentswhich may be requiredfor the Association,unlessthe Boardof Direc_ tors shall haveexpresslyauthorizedsomeother personto per_ fbrm suchexecution.The presidentshallserveas Chair of the Boardof Directorsand shallserveas an ex-officiomemberof all committees.The Presidentshall appointmembersto fill vacanciesand unexpiredtermson the Boardof Directorsand standingand ad hoc Committeesuntil the next scheduled election.

Section8: Duties of the Vice-president(presiclent-Elect).The Vice-President shallpresidein the absenceofthe president.The Vice-President shallserveas Chairmanof the NominatinsCom_ mittee and ex-officio member of all committees.

Section 9: Duties of the Secretary/Treasurer.It shall be the duty ofthe Secretary/Treasurer to presidein the absenceofboth the Presidentand Vice-President.The Secretary/Treasurer shall keepa true andcorrectrecordofthe proceedings ofthe annual business meetingand meetingsof the Boardof birectors, shall preserve documentsbelonging to the Association and issue noticeof the annualbusinessmeetingand meetingsof the Board of Directors 60 days prior to such meetingr. ih" Secretary/ Treasurershallkeepan accountof the Associationwith its mem_ bers and maintaina current registerof memberswith datesof their electionto membershipand preferredmailing address,the latterto be circulatedannuallyto the membershipw;thin 30 days of the annualbusinessmeeting.The SecretaryiTreasurer shall be re^sponsible for reporting unfinishedbusinessrequiring actron from previous meetingsof the membershipoi Boaid of Directors and will be responsiblefor the agendaof the annual businessmeetingand meetingsof the Board of Directors. The Secretary/Treasurer shall collect the dues of the Association. makedisbursements of expenses,and maintainthe financialac_ counts and records of the Association.

The financial record will be presentedto the membershipat the annualbusinessmeeting,biannuallyto the Board of Directors, and at such times as requestedby the Presidentof the Association. The financial recordsof the Associationshall be reviewed annually by two other members of the Board of Directors appointedby the President,or a certified accountantor financial consultant retained by the Board of Directors of the Association.

Section I0: Duties of Board of the Directors, Members-atlnrge. Members-at-Large shall assume whatever duties are assignedby the Officers of the Associationor by Articles in the Bylaws of the Association.

SectionI I: Duties of Program CommitteeChair. Actingunder the auspicesof the Presidentand Board of Directors of the Association, the ProgramCommitteeChair shall be responsiblefor the Association'sannualresearchand educationmeeting,as well as other symposiaor meetingssponsoredor co-sponsoredby the Associationto meet its purpose.The dutiesof the Program CommitteeChair shall includebut not be limited to: (l) selection of committeemembers,(2) selectionof meetingsites, (3) designationof ad hoc committeemembersspecificallyselected for review of materialsto be presentedat the annualmeeting or other Associationmeetings,(4) peer-reviewand selection of papersto be presentedat meetingsor forums sponsoredor co-sponsoredby the Association,(5) publication of call-forabstractnotices,and (6) schedulingactivities at the Association's annual meeting or other meetings sponsoredor cosponsored by the Association.Recommendations from the Program CommiffeeChair must be approvedby the Board of Directors by majority vote.

Sectionl2: Duties ofthe Past President.The PastPresident shall assumewhateverdutiesare assignedby the Presidentor by articlesin the Bylaws of the Association.

SectionI 3: Absenteeism/terminationof ffice. Absencescan be approvedor excusedonly by the President.Two unexcused absences from scheduledBoard of Directors meetings,annual businessmeeting,or specialmeetingsof the Board of Directors during any term as a member of the Board of Directors shall constitutea resignation.Such resignationshall be effective two weeksafter notificationby the President.Any member of the Board of Directors may voluntarily resignand such resignationwill becomeeffective immediately.

Section 14: Special meetings of the Board of Directors.

Special,unscheduled meetingsof the Board of Directorsor the Officersof the Associationmay be convenedby the President, or by any six membersof the Board of Directors. Upon petition by 100or more activemembersof the Association,stating the reason(s)for calling a specialmeetingof the Directors or Officers, the Secretary/Treasurershall call such a meeting within 30 daysof receivingthe petitionto be convenedat a time and place designatedby the President.

ARTICLE III - MEETINGS Sectionl: Annual businessmeeting.An annualbusinessmeeting of the membershipof the Associationshallbe convenedannually and in conjunctionwith the annualscientificand educational meetingof the Association.@ A majoriry of the active and voting members in good standing and in attendanceshall constitutea quorum. Businessitems presentedas informational or for vote by active membersshall include but not be limited to: (1) a financial report from the Secretary/Treasurer, (2) amendmentsto the Constitutionand Bylaws of the Association,(3) electionof officers, members

of the Board of Directors, and the Chairs and membersof standing committees of the Association, (4) reports of committee activities, (5) transactionof other businesswhich may come before the membership,and (6) a "State of the Association" addressby the President. Where dictated by the Constitution and Bylaws, the Association shall be governed by a majority vote of active members in attendanceat the anriual business meeting. The Presidentof the Associationshall presideover the meeting and the Secretary/Treasurerwill circulate agenda items to the membership 30 days before the annual business meeting.The Chairs of the Constitutionand Bylaws Committee and Nominating Committeewill presideover the respective parts of the annualmeeting.The annualbusinessmeeting shall be held at a time and place determinedby the Board of Directors of the Associationapproximatelyone year in advance of the convocation.

Section2: Betweenannualbusinessmeetings,within the policiesestablished by the Association'smembershipand the Constitutionand Bylaws, the Associationshall be governedby the Board of Difectors. Actions of the Board of Directors shallbe determinedby a majority vote of thoseof its memberspresent at its meeting, six membersconstitutinga quorum.

Section 3: Annual scientific and educational assembly. The Associationshall sponsoran annualscientificand educational meetingor assemblyto meet its purposeand objectives.This meetingwill include but not be limited to: (l) presentationof original researchin the sciencesand educationalmethodology, (2) educational/research forums, (3) specialprogramsfor the membershipas determinedby the purposeand objectivesof the Association,and (4) meetingsof the standingand ad hoc committeesof the Association.The researchand educationalprograms of the annual meeting shall be open to the public and the generalmembershipof the Associationin good standing.

All meetingsof standingand ad hoc committeesare open to the public and membersof the Associationin good standing, Programsfor the annualmeetingshall be arrangedby the Program Committeeand approvedby the Board of Directors of the Association.A final noticeof the time, place,and program of the annual assemblyshall be sent to all membersof the Associationby the Secretary/Treasurer at least30 daysbefore the meeting.

Section4: Specialmeetingssponsoredor cosponsoredby the Association.The Associationmay sponsoror cosponsorother scientific or educationalmeetingsof interestte the membership to meet its purposeand objectives.Such meetingsshall be convenedby the President,Board ofDirectors, and Program Committee Chair and publicized 30 days in advanceby the Secretary/Treasurer.

ARTICLE IV - FINANCES Section,/r The annualmembershipduesfor all membersshall be determinedby the Board of Directors. The annualmembership will be payablewithin 30 days of requestby the SecretarylTreasurer.The Board of Directors may establishprocedures and policies regarding non-payment of dues and ASSESSMENTS.

Section2: The Board of Directors shall adopt such membership schedulesas is necessaryto encourageparticipation by the interestedpublic.

ARTICLE V _ PARLIAMENTARY AUTHORITY Rule of order. Any question oforder or procedure not specifically delineatedor provided for by thesebylaws and subse-

quentamendmentsshall be determinedby parliamentary usage as containedin Robert Rules of Order (Revised).

Directors. The Committeeshall foster educationin emergency medicalcareand assumedutiesand tasksas determinedbv the Board of Directors.

ARTICLE VI _ STANDING COMMITTEES

Section 6: Research Committee. The Research Committee shall consist of a Chair, electedto a three year term by the membership,and six other membersappointedby the committee Chair for staggeredtwo year terms. The committeeChair and appointeesmay be membersof the Board of Directors or other Associationcommittees.The chair shall create ad hoc researchsubcommitteeswith the approvalof the Board of Directors. The Committeeshallfosterresearchin emergencymedical cdre and assumedutiesand tasksas determinedby the Board of Directors.

SectionI: Nominating Committee.The Nominating Committeeshallconsistofthe Vice-President,as Chair, the pastpresident,a memberof the Board of Directors electedfor a one year termby the board, and three electedmemberswho may not be membersof the Board of Directors. The latter shall serve staggered two year terms. It shallbe the task of this committee to selecta slateofofficers to fill the naturallyoccuring vacancieson the Boardof Directors and electedpositionson the standingcommittees of the Associationnot otherwisedesignatedand providedfor by thesebylaws. The NominatingCommitteewill seekthe candidatesapproval for formal nominationand shall placetheir namesin nominationbefore the membershipfor election at the business session of the annual meeting The NominatingCommitteewill also provide slatesfor any awards offeredby the Board of Directors.

Section 7: Liaison Committeeto the Association of American Medical Colleges(AAMC). The Committeeshall consistof a Chair, appointedto a five year term by the Board of Directors, and threemembersappointedby the committeeChair for staggered three year terms. The official emergency medicine delegatesto the AAMC will be membersof this committee.The committeeChair and appointeesmay be membersof the Board of Directorsor othercommitteesof the Association.Only current or past membersof the committeewill be nominatedby the NominatingCommitteefor electionto Chair. The Committee shall developprogramsfbr the Associationto be presentedat the annualmeetingof the AAMC and assumeotherdutiesand tasksof similarpurposeasdeterminedby the Boardof Directors.

Section2: Membership Committee. The Board of Directors shallconstitutethe Membership Committee. It shall be the Secretary/Treasurer's duty to review the qualificationsand recommendations of each applicant, for presentationand approvalby the majority of the MembershipCommittee.

Section3: Program Committee.The ProgramCommitteeshall becomposed of a Chair, electedby the membershipfor a three yearterm,two membersappointedby the Presidentto staggered threeyearterms, and two membersappointedby the committeeChair to staggeredthree year terms. The ResearchCommitteechairandthe EducationCommitteechair will be members of the ProgramCommittee. None of the appointedmembers of the committeecan be membersof the Board of Directors.

Thedutiesof the committeeshallbe to arrange,in conformity withinstructionsfrom the Board of Directors, the program for all meetingsand selectthe formal participants.

Section8: GctvernmentalAffairs Committee.The Committee shall consistof a Chair, electedto a three year term by the membership,and threemembersappointedby the committee Chair for staggeredthreeyear terms. The committeeChair and appointeesmay be membersof the Board of Directorsor other committeesof the Association.Only currentor pastmembers of the committeewill be nominatedby the NominatingCommitteefor electionto Chair. The Committeeshallassumeduties and tasksas determinedby the Boardof Directorsto fosterfederal and statesupportof researchand educationin emergency medicalcare.

Section4: Constitutionand Bylaws Committee.The ConstitutionandBylawsCommitteeshall consistof a Chair and two othermembers,electedfor staggeredthree year terms so that thememberwith the leastremainingtenureshallserveas Chair duringtheir final year on the Committee.This Committeeshall studythepotentialmerits, adverseconsequences and legal implications of all proposedconstitutionalamendments or changes in the bylawsand report their findings and recommendations to thePresidentand Board of Directorsprior to the time of formalconsideration of the proposedchangesby the membership.

The membersof the Committee may themselvessuggestappropriate constitutionalamendments and bylawschangesto the President and Board of Directorsupon studyof problemsarising out of the existing constitutionand bylaws.

Section9: Committeeon InternationalAfrttirs. The Committee shallconsistofa Chair, electedto a threeyear term by the membership,and threemembersappointedby the committee Chair for staggeredthreeyear terms.The committeeChair and appointeesmay be membersof the Board of Directorsor other committeesof the Association.The committeeshall assume dutiesandtasksasdeterminedby the Boardof Directorsto foster internationalrecognitionofeducationand researchln emergency medicalcare.

ARTICLE VII - DISSOLUTION OF THE ASSOCIATION

Section5: EducationCommittee.The EducationCommittee shallconsistof a chair, electedto a three year term by the membership, and six other membersappointedby the committeeChair for staggeredtwo year terms. The committeeChair andappointees may be membersof the Board of Directors or otherAssociationcommittees.The Chair shall createad hoc educationsubcommitteeswith the approval of the Board of

Section/: Dissolutionof this Associationcanonly be initiated by a majority vote of all membersof the Board of Directors and must be approvedby two-thirds of the active membership presentand voting at any annualor specialmeeting.

Section2: Dissolutionshallbe achievedin compliancewith Article IX of the constitution.

81

Copiesof this form for additional submissionsare aceptable

SAEMABSTRACTFORM

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Mail To: Societyfor AcademicEmergencyMedicine Annual MeetingAbstracts

900 West Ottawa Lansing,Michigan48915

TITLE:

(Besureto indicatewhich authorwill presentthe paperif accepted)

AUTHOR(S): ( * presenter)

AFFTLTATTON(S):

MAILINGADDRESS:

P H O N EN U M B E R : I will accepteither ORAL or POSTERpresentationof this abstract,but prefer I The work in this projectwas done primarilyby a residentor fellow: I

yes E

Onnl I

pOSfen presentation.

no

I certifythat this abstract(or resultantpaper)will not appearin a refereedjournalprior to publicationof the Abstracts of the SAEM Annual Meeting in the April issue of Annalsof EmergencyMedicineand that this researchmaterialwill not be presentedat a nationalmeetingprior to the SAEM Annual Meeting.

I certifythat this researchhas been approvedby, and complieswith, my institution'sreviewcommitteesfor humanand animalexperimentation where appropriate.

Signatureof PrincipalAuthor Call SAEM at (517) 485-5484 if you have questions.

Date Abstracts mustbe postmarked by the deadlineof January19, 1990.Overto insuretimelyreceipt. nightmailservicesare encouraged

Mark ALL of the followingsubjectcategorieswhich apply to this abstract: L_l arrway

n respiratory LJ cardiopulmonary resuscitation LJ toxicology L--Jradiology n shockresuscitation LJ emergency medicalservices applications I technology

injury n environmental L-l pediatrics L--l neurological LJ cardiovascular Ll pnarmacologrcal I in,fectious disease

tr traumacare

Ll L-l I LJ I I tr

gastrointestinal administrativestudy computermethodologyor modelling educational methodologyreport basic scienceresearch nonlistedresearcharea

of the subrnittors.

Notationof subjectcategoriesis the responsibility 82

SAEMABSTRACTFORM

Copiesof this form for additional submissionsare acceptable

Makeeightseparatecopiesof each page (do not staplecopies)of this form when completed. :..MailTo: Societyfor AcademicEmergencyMedicine ' AnnualMeetingAbstracts

Page 2 ot 2

900 West Ottawa Lansing,Michigan48915

TITLE:

BODYOFABSTRACT: (Theabstractmust be typeddouble-spaced and includeno morethan3OOwords.lt mustbe limitedto the spaceon this pageand be of a typesizeno smallerthanusedon thisform.Do not includereferences, illustrations, or fundingsources.

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Abstracts that do not conformto the instructions will be returnedto the authorwithoutreview.lt wil be the author'sresponsibilityto re-submitthe abstractby the postmarkdeadlineof January19, 1990.Therewill be no extensionof the deadline for re-submissions.

83

APPLICATION SAEM MEMBERSHIP Pleasecompleteand send, with the appropriatedues and initiationpayment,to: o Society for Academic Emergency Medicine . 900 West Ottawa . Lansing, Michigan 48915 (517) 485-5484 (517) 48s-0801FAX Title:DO MD PhD Other

Name Home Address

Address Business PreferredMailingAddress(pleasecircle): Home Business Telephone:

Home (

Sex: M

Birthdate Business: (

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)

lnstitution

FacultyAppointment Positionscurrentlyheld in EmergencyMedicine: 1.

2.

3.

Chairman Department Check the appropriate membership category:

_Active

-Associate

-Resident/Fellow

-lnternational

Active -lnternational

Associate

and who actively Active membership is open to (a) individualswith an advanceddegreewho hold a medicalschoolor universityfacultyappointment teachingor researchcapacity;(b) individualswith similardegreesin activemilitary participatein acute,emergency,or criticalcare in an administrative, petitionthe Membershipcommittee' ,"i"i.J "it.l ihdividualsiho otherwisemeet qualificationsbut who do not hold a tacultyappointmentand who by a curriculumvitae mustbe accompanied The application is submitted.

Annualduesare g195ptusa $15 initiationfee payablewhenthe application off icial SAEMiournal; the Medicine, of Emergency Annals to a subscription include benefits Membership and a letterverifyingtfie facultyappointment. tees to other SAEMeducaa subscriptionto the SAEM newsletter;free SAEMAnnuaiMeetingregistrationand banquetticket;and reducedregistration tional meetings. groups,or membersof the public Associate membership is open to health professionals,educators,governmentofficials,membersof lay or civic payable the applicationis submitted'The when fee plus initiation a $15 at largewho have an interesiin EmergencyMedicine.Annual dues are $175 Medicine,the officialSAEM Emergency of to Annals a subscription include benefits Membership vitae. a curriculum by applicationmust be accompanied journal;a subscriptionto the SAEM newsletter;a free SAEM Annual Meetingregistrationand banquetticket; and reducedregistrationfees to other SAEM educationalmeetings. plusa $15 initiationfee payable Resident/Fellowmembershipis opento all residentsor fellowsinterestedin EmergencyMedicine.Annualduesare $50 is a residentor fellow the applicant that verifying from the director letter by a when the applicationis submitted.The applicationmust be accompanied to Annalsof EmergencyMedicine,lheotticialSAEMjournal;a subscription and the anticipatedgraduationdate.Membershipbenefitsincludea subscription meetings. to the SAEM newsletter;a free SAEM Annual Meeting registration;and reducedregistrationfees to other SAEM educational or associatemembership lnternationalactive and international associate membership is open to individualswho meetthe criteriafor SAEM active is submitted.The appayablewhenthe application but do not residein the united States.Annualdues are $95 plusa 915 (u.S. funds)initiationfee, includea subscription benefits Membership if appropriate. appointment, faculty the veritying a letter vitae and plicationmustbe accompanied by a curriculum and banMedicrL, tne officialSAEMjournal;a subscriptionto the SAEM newsletter;a free SAEMAnnual Meetingregistration to Annalsof Emergency meetings. educational sAEM fees to other quet ticket; and reducedregistration

of my desireto become is correctand is an indication containedin thisapplication My signaturecertifiesthatthe information a SAEM member.

Date

Signatureof apPlicant

This form can be photocopiedif additionalcopies are needed.

April 1989 84

Society for Academic Emergency Medicirre 900 West Ottawa Lansing, Michigan 48915

(s17)48s-s484 FAX number: (517)485-0801