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A E M

Societyfor AcademicEmergency Medicine

1990Annual MeetingProgram

May 2l-24, 1990 Minneapolis,Minnesota


INDEX . '.. '..1-2

GeneralInformation

. . . . . . . . ..3

Awards Presentations. . . .

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Kennedylecture

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1 9 9 0L e a d e r s hAi pw a r d . . . .

.....6

1990Hal JayneAcademicExcellenceAward and HonoraryMembers.....

..'....7-13

S c h e d u loef E v e n t s EducationalandSpecialSessions ^Ab.strabts Exhibitors Annual BusinessMeeting Agenda Slate of Nominees Constitution of the Society for Academic Emergency Medicine Bylaws of the Society for Academic EmergencyMedicine vadeMecum"' Membership Application

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.14-16 . !7 15.6.o ' '67-68 ' " """69 '70-73 ' ' ' ' ' '74-75 ' ' ' '75-78 "79-81 . ' "82


GEI\ERAL INFORMATION REGISTRATION

BANQTJET

AI\D INFORMATION

All registrants must check in at the SAEM Registration Desk to pick up name badges which are required for admission into the Annual Meeting sessions. The Registration Desk will be open during the times listed below:

Sunday

7:00-9:00pm

7:00 am-12:00noon 1:00-5:00pm Tuesday 7:00 am-12:00noon 1:00-5:00pm Wednesday7:00-12:fi) noon 3:0G5:00pm Thursday 7:00 am-12:00noon 1:004:00pm Monday

Nicollet Promenade East Nicollet Promenade East Exhibit Hall Exhibit Hall Exhibit Hall

SAEM MEMBERSHIP A membershipapplicationis includedin this programand additional copiesare availableupon requestto the SAEM office at 900 West Ottawa,I:nsing, Michigan48915or call (517) 485-5484.If you are not a member,pleaseconsiderjoining SAEM. If you are alreadya member,give this applicationto a colleague.SAEM needsyour support for the growth and developmentof academicEmergencyMedicine. CONTINT]ING EDUCATION The University of Minnesota,accreditedby the Accreditation Council for Continuing Medical Education,certifies that this programmeetsthe criteria for 32.5 credit hours in Category I toward the PhysiciansRecognitionAward of the American Medical Association.The Annual Meeting has also been approvedfor 35 CategoryI credits from the American College of EmergencyPhysicians.A verification of CME credits will be sent to eachregistrant immediatelyfollowing the Annual Meeting. ANNUAL BUSINESS MEETING The Associationwill hold its Annual BusinessMeeting from 1:3G3:00pm on Wednesday,May 23. At the meetingArthur B. Sanders,MD, will introduceincoming presidentJerris R. Hedges,MD. Agendaitems for the businessmeetingwill includethe electionof officers. Board and committeemembers; to the Constitutionand Bylaws; officers' reports; amendments andother items of businesspresentedby the membership.All membersof the associationare urgedto attend,however,only activemembersare eligible to vote. The agenda,slateof nominees,andConstitutionandBylawsarepublishedin this program. OPEhIING COCKTAIL RECEPTION SAEMis hostinganopeningcocktailreceptionon Monday,May 21 from 6:00 until 7:30 pm. All Annual Meeting registrants areinvited to attend.Hors d'oeurveswill be servedanda cash bar will be available.

This year'sAnnualBanquetwill beheldon NicolletIslandwhich is locatedon the MississippiRiver in downtownMinneapolis. A walkingbridgeleadsto thebanquetsitethroughthehistorical River PlaceShoppingDistrict andSt. AnttronyMain. Someattendeesmay wish to walk the lr/z miles from the Hyatt Regency, but shuttlebuseswill be provided.Dress,as always,is casual. As alwaystheBanquetwill includedinneranddrinks, however, thisyeara uniquecomedyduoof Keith StamlerandBarry Heller of RisusSardonicusProductionswill provide a specialhour of comedywhich is specificto emergencymedicine.This is easy for themsincethey areemergencyphysicians!Their program consistsof five skits, slides,stand-up,andvideotapeandpromisesto setthe moodfor the everpopularBanquet.To addsome seriousness to the evening,the ProgramCommitteewill be announcingthe award winners from the 1990Annual Meeting. A free ticket to the Banquetwhich will be held on Thursday or inevening,May 24, is availableto everyactive,associate ternationalSAEM memberattendingthe Annual Meeting.Additionalticketsare $35each.Advanceregistration is required.

MEETING SITE The Annual Meeting will be held at the Hyatt RegencyMinneapolisHotel and the discountedratesare $90 for singleand $105for doublerooms.TheHyatt Hotel in convenientlylocated in downtown Minneapolis only 20 minutes from the Minneapolis/St.Paul InternationalAirport. The Hyatt offers three restaurantsand a retail mart. In addition, there is the Greenway Athletic Club which is a year-roundfacility featuringracrunnquetball,squash,tennis,nautilusequipment,rnassages, ing tracks,saunas,jaolr;zi,hot tubs,andpro shop.The hotel is alsolocatedon Nicollet Mall, a l2-block long pedistrian-only mall. Major departrnentstores,along with hundredsof other includingthe City Center,are accessishopsand restaurants, ble from the 38 skywaysconnecting33 city blocksin the heart of downtown. Within walking distanceof the Hyatt are the MinneapolisInstituteof Arts, Walker Art Center,andthe Tony-Awardwinning Guthrie Theater,the longestcontinuous-runningtheaterin the country. Adjacentis the MinneapolisSculptureGarden,a 7Vzacreurbangardenfeaturingover40 sculptures,a glassconservatory containing horticultural exhibits, and a whimsical fountainin the form of a giant spoonandcherry. Over 50 performing artstheaters,two world-classart museums,plus dance theaters,musiccompanies,historymuseums,andthe renowned MinnesotaOrchesfiawill satisff every cultural appetite. Within a half hour of downtownMinneapolisare the Canterbury Downs horseracingtrack, the MinnesotaZoo, old Fort Snelling,Valleyfair Family AmusementParkandHistoricMurphy's Landing.Dinner cruisesare availableon both Lake MinnetonkaandtheMississippiRiver. If you'd rathercruiseon land, threerailroadcompaniesfeaturedinnerexcursionsasguestsenjoy a train ride around the Twin Cities area.


EMRA RECEPTION

PLACEMENT SERVICE

EmergancyMedicine and EMRA will host a Reception on Tuesday, May 22 from 6:00-7:00 pm. The highlight of the reception will be presentation of the 1990 Jean Hollister Award for Excellence in EMS and Prehospital Care. Hors d' oeurves will be served and a cash bar will be available. All interested EMRA members and others are invited to attend. The Reception is sponsored by Emergency Medicine.

A bulletin boardwill be maintainednearthe RegistrationDesk for personswishingto postpositionsandphysiciansavailable listings.

FT]TUREMEETINGS May The1991SAEMAnnualMeetingwill beheldonSaturday, 11 through Tuesday, May 14 at the Grand Hyatt Washington Hotel in Washington, D.C. Abstract submissionforms for this meeting will be available in the fall of 1990.

MESSAGE BOARI) Desk. boardwill be maintainedat the Registration A message Deskby canbe left at the SAEM Registration Phonemessages calling the Hyatt RegencyHotel at (6L2) 370-1234andrequestingthe SAEM RegistrationDesk. PROCEEDINGS

The 1992 SAEM Annual Meeting will be held on Monday, May 25 through Thursday, May 28 at the Harbour Castle Westin Hotel in Toronto. Ontario.

of the AnnualMeetingwill not be preparedasa Proceedings scien' separatepublication.However,selectedpresentations, tific papersandpertinentdiscussionwill be printedin theAn' Medicine,theofficialjournalof theSociety nalsof Emergency for AcademicEmergencyMedicine.In addition,theabstracts from the 1990AnnualMeetingwerepublishedin ttreApril 1990 issueof Annalsof EmergencyMedicine.

EXHIBITS

SPEAKERS' READY ROOM

Exhibits will be available for viewing on May 22, 23, and 24 from 8:00-12:00noon and 1:00-5:00 pm in the Exhibit Hall. Postersession,coffee breaks, and the registrationdesk will also be located in the Exhibit hall. Pleasetake an opportunity to view the exhibits during the scheduled coffee breaks.

A speakers'readyroom will be availablefor thosewhowish Keysto to checktheir slidesin advanceof their presentation' the readyroom will be availableat the RegistrationDesk.

SAEM BOARD OF DIRECTORS MEETING The SAEM Board of Directors will convene a meeting on Wednesday, May 23 from 7:00-10:00 pm. This meeting will be chaired by Jerris R. Hedges, MD, who begins his term as the SAEM president at the Annual BusinessMeeting on May 23. Allinterested members and others are invited to attend this, and all meetings of the Board of Directors.

PUBLIC IIEALTH ROI.]NDTABLE DISCUSSIONS On Tuesday,llday22 from l1:30-1:00pm. Dr. Ed on is coordinatingspecialroundtableluncheondiscussions health issues.Theseroundtableswill includethe "AIDS Epidemic""The topics:"Drugs andViolence," "Overcrowding," and "Ethical sured," Allocating Scare Resources."

Implications

All Annual Meeting registrants are invited to participate

these informal discussions.Pleasesign up at the Registration Desk. Box lunches are available for $10.

COMMITTEE MEETINGS Many of the SAEM committees will be meeting during the Annual Meeting. All committee members and interested individuals are urged to attend these meetings:

EducationCommittee EMS EducatorsCommittee TechnologyCommittee ObservationMedicineCommittee ResearchCommittee Membershipand Public EducationCommittee 1991Annual MeetingProgramCommittee AAMC Liaison Committee

pm Is'{day 22 10:30-12:30 5:00-6:30pm lNday22 12:00-1:00pm May 22 4:00-5:00pm May 22 3:00-5:00pm May 23 May 24 9:30-11:30am 1:00-2:30pm May 24 2:30-4:00pm lNday24

Loring ConferenceRoom Loring ConferenceRoom Grant Room Loring ConferenceRoom Loring ConferenceRoom Loring ConferenceRoom


AWARD PRESENTATIONS Each morning during the Annual Meeting, the SAEM awards will be presented. Listed below is the schedule of awards presentations and the award winners. Be sure to attend these presentations each day.

Monday, May 21.r8:fi)-8:30 am 1990Hd Jayne Academic ExcellenceAward Lewis R. Goldfrank,MD This awardis sponsoredby Spectrum,Inc. 1990EMS Fellowship Recipient:Eric A. Davis, MD Institution:Universityof Pittsburgh This $50,000fellowshipis sponsoredby PhysioControl. 1990SAEM-EMF Methodology Grant Recipients "Computer-Based Teachingand Evaluationof Critical Emergency MedicineProceduralSkills," DaneChapman,MD, PhD, University of California,Davis;JohnMarx, MD, DenverGeneralHospital;Ben Honigman,MD, Universityof Colorado "Sequential Bayesian Analysisof ClinicalTrials," RogerLrwis, MD, Harbor-UCLA 1990SAEM-EMF Medical Student ResearchAwards Children'sHospital,Boston Preceptor:Gary Fleisher,MD MethodistHospitalof Indiana Preceptor:William Cordell, MD StanfordUniversity Preceptor:MichaelEliastam,MD Universityof Cincinnati Preceptor:Ruth Dimlich, PhD

Tuesday,Mray22,8:00-8:15am 1989Best Oral Basic SciencePresentation "High EnergyPhosphate MetabolismDuring VentricularFibrillation," RobertNeumar,Ohio StateUniversity This award is sponsoredby EmergencyMedicine. 1989Best Oral Clinical SciencePresentation "PrehospitalProphylactic LidocaineDoesNot FavorablyAffect the Outcomeof Patientswith ChestPains," KathleenHargarten,MD, MedicalCollegeof Wisconsin This awardis sponsored by MICROMEDEX.

19E9 Best Oral Methodology Presentation "Comparison of Different Definitions of Critical Trauma Patients," Michael Smith, MD, Highland General Hospital This award is sponsoredby Weatherby Health Care.

Wednesday,May 23, 8:00-8:15am 19E9Best ScientificPoster "Comparisonof Intravenousand Intraosseous Administrationof Epinephrinein a CardiacArrest Model," StevenG. Crespo,MD, MedicalCollegeof Pennsylvania This awardis sponsored by EmergencyMedicineNews. 1989Best Pediatric Acute Care and Trauma Presentation "Role ofActivatedCharcoalandSodiumPolystyrene Sulfonate(Kayexalate)in GastricDecontamination for Lithium Intoxication:An Animal Model," J. G. Linakis,MD, Children'sHospital,Boston This awardis sponsored by PediatrtcTraumnand Acute Care.

Thursday, May 24r 8:00-8:15am 1989Best ResidentPoster "PharmacologicInterventionsin Acute CocaineToxicity," Marc Smith. MD. Harbor-UCLA This awardis sponsored by PergamonPress. 1989Best Resident/FellowOral hesentation "Effect of Hypertonicvs. Normotonic Resuscitation on Intracranial PressureAfter CombinedHead Injury and HemorrhagicShock," CharleneB, Irvin, MD, Universityof Cincinnati This awardis sponsoredby EMRA. 1989Best ResidentPaper "Contribution of Sorbitol Combined with Activated Charcoalin Preventionof SalicylateAbsorption,"Ray E. Keller, MD, Geisinger MedicalCenter. This awardis sponsored by Annalsof EmergencyMedicine.

Thursday,May 24,11:30-11:45 am 1990LeadershipAward Winners PeterRosen,MD David K. Wagner,MD


KENNEDY LECTT]RE

Arthur L. Caplan' PhD Director, Center for BiomedicalEthics Professor of Philosophy and Professor of Surgery University of Minnesota "Can Money and Morality Mix in Medicine?"

DoctorCaplanis a graduateof ColumbiaUniversityin New York, wherehe receivedhis advanceddegreesin philosophy. At an early age,Dr. Caplanhasdistinguishedhimselfas one of America'smostprominentbioethicists.Formerlyassociate directorof theHastingsCenter,he directsan activeandhighly visible biomedicalethicsprogramat the Universityof Minnesota.His immediateattentionoff campusis directedat the U.S. congressionalresponseto the Oregon health care initiatives. He is author or editor of twelve books, including, Scientific

Controversies,Which BabiesShall Live?, The Sociobiology InSee|chorqEquity: to proEssion:alpurHe trascffiles nals in the fields of philosophy,medicine,and the biological sciences. Doctor Caplan has served as a consultant to many organiza' tions, including the New York Academy of Sciences,the Office of Technology Assessmentof the U.S. Congress, the National Institutes of Health, the National Endowment for the Humanities, and the National Academy of Sciences. He is a frequent guest on such programs as Nightline, ABC's World News Tonighr, the CBS Evening News, and National Public Radio's All Things Considered. He has written for or been interviewed in many newspapers, including the WashingtonPost, New YorkTimes, Philadelphia Inquirer, Los Angeles Times, and Newsday on subjects related to medical ethics. He writes a syn-

dicated newspapercolumn entitled,

"A

Question of

Doctor Caplan was asked to deliver the 1990 Kennedy

of his directandinformedapproachto ethicali turebecause thatwill increasinglyimpactuponall physicians,and physiciansin particular. As American medicineenters of decisionsaboutmatters 1990s,therewill be precedential traordinarycomplexity,such as terminationof life biomedical organprocurementand transplantation, competencyand informed consent, physician rer technological imperatives, cost contaiffnent, and the

of scarceresources.Given the shift to ambulatorymedici theemergencydeparrnentwill becomethe focusof the to situationssuchasindigentcare,trauma response guidelines,innercity drug abuse,acquiredinfectious Dr. Caplan's controversies. andothermedical-societal have writing, organizationalservice,andconsultations ed him uniquely to address these and other ethical The Society for Academic Emergency Medicine is for the opportunity to receive a lecture by Doctor

Becausethis is his first major addressto a largeassembly physicians,it is a sharedopporhrnity.We emergency him to our meetingandanticipatean informativeand KennedvLe.cture. Marion I'aboratories' SAEMgratefully acknowledges sorship of the Kennedylzcture.


1990 LEADERSHIP AWARD After extensivereview and discussion,the Societyfor AcademicEmergencyMedicine Nominatingcommitteedeterminedthat there shouldbe two recipientsof the 1990LeadershipAward. The Societyis proud to announcethat Peter Rosen,M.D. and David K. Wagner, M.D. are this year's recipientsof the lradership Award. Both havedistinguishedthemselvesas foundersand leadersof emergencymedicinetraining programs andorganizations.Their clinical and academiccareershavebeenfull andthey haveservedas role modelsfor new generationsofemergencyphysicians.The following synopsesreview their medicalbackgroundand someof their accomplishments. For thosewho havehadthe honorof personally knowing thesegreat leaders,the limitation of words immediatelycomesto mind. Pleasejoin us during this SAEM Annual Meeting in honoring two of our most valued membersand leaders. After acquiring his medical degree from Washington University Medical School in 1960, Dr. Rosen completed an internship at the University of Chicago Hospitals and Clinics and his surgical residency at Highland County Hospital in Oakland. California. He served as an aftending general surgeon for the U.S. Army from 1%5-1968 and as a bum unit attending surgeonin 1968. After a brief surgical practice in Wyoming, he joined the University of Chicago Hospitals and Clinics as Director of the Division of Peter Rosen, MD Emergency Medicine in 1971. Dr. Rosen also servedas director ofthe Universitv of Chicago Residency Program in Emergency Medicine from l97l1977. He attained the rank of Professor of Emergency Medicine in 1973 and also served as a burn service attending from 197l-1973. ln 1977, Dr. Rosen became the Director of the Division of Emergency Medicine and the Emergency Medicine Residency Program at Denver General Hospital. During the period from 1977-1989, Dr. Rosen guided the development of this premier training program in emergencymedicine. He also served as an emergency medicine medical advisor for the Statâ‚Źof Colorado O9|f.-1985), Colorado ACEP Chapter President(1981), and director of the Denver City Health and Hospital system(1987-1989).During his years in Colorado, Dr. Rosenhas held the rank of Professor of Emergency Medicine both through the Oregon Health SciencesUniversity and the University of Colorado. In 1989, he joined the Department of Emergency Medicine, University of California, San Diego. Dr. Rosbn's accomplishmentsin emergency medicine are legion. He is well known as the Chief Editor of Energency Medicine, the comprehensive textbook of emergency medicine published by Mosby. He is also known for the creation and editing of The Joumal of Emergency Medicine. In addition he was a contributing editor to the Anrnls of Emcrgency Medicine (Formerly JACE\. He has served on the editorial boards of the Emcrgindex Microindex Sertesand the periodical Topics in Emergency Medicine. Dr. Rosen served on the board of directon of the American Board of Emergency Medicine from 197G1986 ard as President of the Society for Teachersof Emergency Mdicfuie (now SAEM) from 19761977. He wasa fourding nunber of the Anrerican Trauma Sociay ard the Colorado Trauma Care ResourceCenter. He also served on the board of directors of the Intemational Research Institute for Emergency Medicine. Dr. Rosen,has served on numerous local and national committees and lectured extensively. However, the strongest measure ofa leader is not the titles one has held, the number of lectures given, nor the committees served, but the accomplishments of those one has taught. Dr. Rosen has trained nine academic emergency medicine directors, eight emergency medicine residency directors, and four assistant or associatedirectors of academic emergency medicine programs. In addition there are nearly 30 graduates of Dr. Rosen's programs who are now directors of private hospital emergency departments, some of which have academic affiliations. Other graduates include Jack Franaszek, MD, the immediate past president of the American College ofEmergency Physicians, and approximately 30 other individuals in full-time academic practice. Leading by example, Dr. Rosen has instilled self-confidence and motivation in his residents, enabling them to rise to leadership roles in emergency medicine. Vince Markovchick, MD Jenis R. Hedges, MD, MS

David K. Wagner, MD

After graduation from St. Louis University Medical School in 1956, Dr. Wagner completed his internship at the Milwaukee General Hospital. After two years of service at the U.S. Indian Service Hospital in SantaFe, New Mexico, he entered a general surgery residency at the USPHS Hospital (University of Washington) in Seattle. Following his general surgery training, he completed a pediatric surgery fellowship at St. Christopher's Hospital (Temple University) in Philadelphia in l9&. In 1965, Dr. Wagner joined the faculty of the Medical College of Pennsylvania (MCP)

in Philadelphia. Among Dr. Wagner's accomplishmentsat MCP are the creation of first an academic Division of Emergency Medicine and subsequently a Departrnent of Emergency Medicine. He also developed the first three year residency progftrm in emergency medicine and one of the first fellowship programs in emergency medicine. Dr. Wagner is a Professor of Emergency Medicine and Professor of Surgery at MCP. On a national level, Dr. Wagner helped found the American Board of Emergency Medicine and has served as its President. He has served on the Council of Medical Specialty Societiesand as President of the University Association for Emergency Medicine (now SAEM) from 1976-1977. He is also known for his co-editorship of the first and second editions of the Principles and Practices of Emergency Medicine, the ftst two volume text in our specialty. He was the first and thus far only chief-editor of the Yearbook of Emergency Medicine, emergency medicine's entry in the well respected"Yearbook" series. More recently he has served as one of the senior contributois and editors in the development of the Advanced Pediatric Life Support Course. Dr. Wagner's many lectures and publications have also furthered the cause of emergency medicine. However, his living tribute to emergency medicine has been the training program which he developed and nurtured. As of June 30, 1989, his commitment to the training of emergency physicians has culminated in 99 graduates of the MCP residency, 22 of thesegraduatesare committed to the full-time academic practice of emergency medicine and another 17 are part-time academicians. Graduatesofhis residency program hae gone on to national positions of leadership (eg, Steven Davidson, MD, Past President, University Association for Emergency Medicine; Jerris Hedges, MD, President-Elect, Society for Academic Emergency.Medicine; Michael Ervin, MD, Past President, American College of Emergency Physicians). While some great leaders may lack personal skills, those who have known Dr. Wagner realize that his most outstanding feature is his personable, down-to-earth nature. His honesty, industriousness, and concern for others exactly fit the picture of the ideal doctor. His selfaffacing manner is rare in a man of his stature. Perhaps this last bit of leadership, that of how one becomes worthy of the title "physician," given by his example is the greatest gift that he has given to his colleagues in emergency medicine. Roben M. McNamara, MD Steven J. Davidson, MD Jerris R. Hedges, MD, MS


1990HAL JAYNE ACADEMIC

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The Society for Academic Emergency Medicine is proud to present the 6th Annual Hal Jayne Academic Excellence Award io Lewis R. Goldfrank, MD. Recipients of the Academic ExcellenceAward are chosenfrom the Society's membership for their contributions to the practice of emergency medicine through education, administration, science, and clinical service' Dr. Goldfrank graduated from the University 'of Brussels Medical School, Brussels,Belgium, in 1970. He interned at Mt. Sinai HosPital (University of Connecticut) Hardord, Connecticut and then comPleted a medicine residency at Montefiore Hospital, Bronx, New York lrr1973. He was an attendingphysician for the Department of Medicine at Montefiore Hospital until 1979. From 19761979 he served as Director of Emergency Services for the North Central Bronx Hospital and simultaneously from 1977-1979he served as Director of Emergency Medical Services for Montefiore Hospital and Medical Center. Sinco 1979, Dr. Goldfrank has served as Director of Emergency Medical Services at Bellevue Hospital Center and New York University Medical Center where he holds the rank of Associate Professor of Clinical Medicine. He has recently accomplishedthe almost impossible task of organizing an em"tg"n"y medicine residency at the New York University School of tr{edicine. To accomplish this formidable task, he has fought and won an eight year political and philosophical battle at his institution, at the City and State Government level, and even in the New York Times. In emergencymedicine, Dr. Goldfrank is best known for his contributions in toxicology. Since 1979 he has served as medical director of the New York City Poison Control Center. He also is the fellowship director of a toxicology fellowship at his institution. He is on the board of directors of the American Board of Medical Toxicology and has served as Secretary/Treasurer and Vice-Chair of that board. Hq is the co-coordinator for the American Board of Medical Toxicology board certification examination. He is an examiner for the American Board of Emergency Medicine, a former toxicology abstract reviewer and ireeting sessionmoderator for the University Association for Emerg6ncy Medicine (now SAEM), and a member of the foxicology/Pharmacology Committee of the American College of Emergency Physicians. Dr. Goldfrank is on the editorial board of Poisindex, Medical Toxicology , and a number of other publications. He is a reviewer for the Journal of American Medical Society, the Ameican Journal of Emergency Medicine, and the AMA Drug Evaluation. Dr. Goldfrank has won numerous academic and humanitarian awards. He has published over thirty scientific articles in peer review journals, contributed to 13 medical textbooks, and is the Senior Editor of Goldfrank's Toxicologic Emergencies a 1,000 page toxicology text now in its fourth edition. Dr. Goldfrank is an extremely socially oriented physician with numerous activities championing the social and medical rights of the homeless,those with drug addiction, and prisoners' He

has given over 150 medical presentationsthroughout the world sou{rtafter as atecfiuer. IIis guidance and and.isfteqpnttl clinical opinion is sought and valued by numerous toxicologists and emergency medicine academiciansthroughout this county' making him perhaps one of the best known emergencyphysicians alive today.

JamesR. Roberts,MD Jerris R. Hedges,MD, MS

HONORARY MEMBERS For the first time in several years, the Society for Emergency Medicine has approved two honorary meml These new honorary members, D. Kay Clawson, MD, Ronald Bellamy, MD, have been important contributorsto the Society and academic emergency medicine. The presentation of theJe honorary members will be made at the Annual Meeting.

EMRS BEST PAPER The Society for Academic Emergency Medicine and the ergency Medicine ResearchSociety (fUnQof tttg Uni$J do-mwork closely together and have establisheda tradition sending one of thlir paper award winners to the other organi

to wel don'sAnnualMeeting.Thisyear,SAEM is pleased Research Injury Western North of the Dr. EmrvsKirknan

tre of the University of Manchester' Dr. Kirkman's pap'r "Potentiation by Ethanol of the Cardio-Inhibitory Response Activation of Cirdiac C-fibre Afferents: Implicationsfor ferers of Myocardial Infarction" will be presentedon day, May 2g. SABI\,I will select a 1990 Best Residel Oial PresentationAward winner who will attend the SAEM in Edinburgh, Scotland.

FIRST ANNUAL PHYSIO EMS FELLOWSHIP The Society for Academic Emergency Medicine is P pleased -Controlto announce the recipient of the First Annual

EMS Fellowship.Dr. Eric A. Davis,MD, has

selected as the recipient and he will complete the at the UniversitY of Pittsburgh.


SCHEDULEOF EVENTS Sunday,May 20 9:f[ am - l2:fi) noon EMRA Board of Directors meeting, RegencyRoom 3:fXF7:15pm Consulting Service Tlaining Session,GreenwayA 7:fi) - 9:f[ pm Registration, Nicollet PromerndeEast

Meeting roonrs are printed in blue

Monday, May 2l 7:f[ am - 5:fi) pm Registration, Nicollet PromenadeEast E:lX)- 8:30 am Opening Remarks and kesentation of Awards: 1990Hal Jayne AcademicExcellenceAward, EMS Fellowship Award winner, SAEM-EMF Methodologr Grant Award, and SAEM-EMF Medical Student Award winners, Nicollet AB

t:30 - 10:fi) am TRACK A, Nicollet C "The Application of Problem-Based Learning in Emergency Medlclne Education" DavidP. Skhr, MD, and W. Daniel Tandberg,MD, Universityof New Mexico

TRACK B. Nicollet D2 "Counselling the hoblem Resident" SusanStephani,S. A. SteplantiandAssociates,andJudithE. Tintirulli, MD, William BeaumontHospital

8:30 - 10:15am - TRACK C: ScientificPapers:Plenary Session,NicolletAB Moderator: Michael Callaham,MD, Universityof Caffimia, SanFrancisco l. Hospital and EmergencyDepartmentOvercrowding: Resultsof a NationalSurvey,Anhur Kellerttunn, MD, MPH, Universityof Tennessee

Films, .Iay M. Goldman,MD, Universityof Pennsylvania 5. Injury SeverityAmongHelmetedandNon-HelmetedBicycliststnvolved in Collisionswith Motor Vehicles,Daniel Spaite,MD, Universityof Arizona

2. The Effect of SodiumBicarbonateon Brain pH and Neurologic Recoveryafter CardiacArrest andReperfusionin Dogs,JackM. Rosenberg,MD, Henry Ford Hospital 3. Withdrawn

6. The Effectof Local Anesthetics on BacterialProliferation:TAC VersusLidocaine,JohnR. Manin, MD, Universityof NewMexico

4. Chest Radiography in the Emergency Department: Lack of Superiorityof PA/Lateral Films Over Single View PortableAP

Robert D. llelch, MD, 7. CocaineAssociatedRhabdomyolysis, WayneSnte University

10:15- 10:30 am Coffee Break. Nicollet PromenadeEast

10:30- 12:f[ noon TRACK h. Nicollet C "The Appllcation of Problem-Based karning in Emergency Medicine Education" DavidP. Sklar,MD, and W. Daniel Tandberg,MD, Universityof New Mexico

TRACK B' Nicollet D2 "Counselling the hoblem Resident" SusanStephani,S. A. StephaniandAssociates,andludith E. Tintinalli, MD, William BeaumontHospital

TRACK C: Scientific Papers:Tfauma/Shock,NicolletAB Moderator: StevenDronen, MD, Universityof Cincinnati 8. CaseControl Study of Injuries Due to the Earthquakein Soviet 11. Will be presentedon Tiresday,May 22, 1:00-2:30pm Armenia, Keith Sivenson,MD, Johns Hopkins University 12. NearFaAl HemorrhagicShockin a PorcineModel: ImprovedOut9. The Use of PackedRed Blood Cells in the Field: Does it Make come with Early Blood Administration, SusanA. Stem, MD, a Difference?Kent N. Hall, MD, University of Cincimati University of Cinciwnti 10. Effectsof 15%SodiumChlorideDuring UncontrolledContinuous Hemorrhage,Peter F. Van Ligten, MD, Ohio State University

13. TrendelenburgPosition and Oxygen Transport in Hypovolemic Shock,RonaA F. Sing,DO, Universityof Pennsylvania

12:fi) - 1:30 pm Emergency Medicine Fellows Luncheon, SkywaySuite "Should Fellowships be Done Only in the Labs of Established/F\nded Researchers" Moderator: Scott Syverud, MD, Universityof Cincinnati Gary Krause, MD, Wayte Snte University Donna Seger,MD, Vanderbilt University 1:30 - 5:30 pm Special Workshop Qlmited registration), 'How to Write a Good Grant Application," Nicollet Dl liane Reif-Izhrer, PhD, President, Tech-lfrite Consultants/ErimonAssociates

7


TRACK A, NicolletAB 1:30 - 3:fi) pm "Achieving Equity in Health Care Access - The Role of Government David U. Himmelstein,MD, Harvard Medical School,and Kenneth W. Kizer, MD, Depanmentof Health Services,Stateof Califumia

TRACK B, Nicollet C "Designing a ResearchStudYr" Norman Hearst, MD, Universityof California, SanFrancisco

3:fi) - 3:30 pm Coffee Break, Nicollet Promenadehst TRACK A, Nicollet C 3:15 - 5:15 pm "Medical Decision Making for the Academic Emergency Physician" Roben Beck, MD, OregonHealth SciencesUniversity; Gary Young' MD, Porttand VeteransAdministrationMedical Center;and Roben A. Lowe, MD, University of Califomia, San Francisco SpeciatNote: The above sessionhas been expandedto two hours

TRACK B. NicolletAB Scientific Papers:EMS Moderator: Ronald B. Iow, MD, University of Chicago 14. Efficacy of Computer Assisted Instruction in the Continuing

tion of Paramedics,RobertS. Poner, MA, NREMT-P,Center EmergencyMedicine of llestem Pennsylvania 15. Reduction of Medications on Paramedic Ambulances, .Ioftn Johnson, MD, Porter Memorial Hospital

16. PrehospitalPacingof AsystoleCardiacArrestBy Paramedics: Controlled Clinical Tial, Jndith Reid Graves, RN, EMT-P, sity of llashington 17. Does Paramedic - Hospital Base Radio Contact Result in

that Deviate from StandardTreatrnentProtocols?,Jerone

Hofrnan,MD, UCI'A l8. MulticenterStudyof End-TidalCarbonDioxidein the Setting,JosephP. Ornato, MD, Medical Collegeof 19. CostBenefitAnalysisof EMS Servicesin theTreatmentof Cardiac Death, Terrence Valenzuela, MD, University of 6:fi) - 7:30 pm Opening Reception, Greenway Ballroom

22 Tuesday, JN{{ay 7:fi) am - 5:fi) pm Registration, Exhibit Hall 8:fi) am - 12:fi) noon Poster I Set'Up, Exhibit Hall 8:fi) am - 12:000noon Exhibits Open, Exhibit Hall g:fi) - g:15 arn presentationof Awards: 1989Oral Basic Science,1989Oral Clinical Science,1989Oral Methodology,NicolletAB "New Antidotes in Toxicologyr" NicolletAB 8:15 - 10:15am State of the Art session, Moderator: JeromeHoflmn, MD, UCI/4 "4 Methyl PyrazoleTherapyand Hydroxycobalamine Therapy," ChantalBismuth,MD, Departrnentof Acute Toxicology,Hospitauxde Paris, Paris, France ..Heavy Metal Poisoning(Mercury)/DMSA/DMPS,"AndrewHeath, MD, PhD, MedicalDirector of Glateo'Sweden ..Immunotherapy and Toxicology, Antidotes:TCA and Digoxin," Paul Pentel,MD, Sectionof ClinicalPharmacology Minneapolis CountyMedical Center, 10:15 - 10:30 am Coffee Break, Exhibit Hall TRACK L, NicolletAB 10:30 - 11:30am Scientific Papers: ToxicologY Moderator: Izwis R. Goldfrank, MD, BellevueHospital Center 20. Failureof AmphetamineAntagoniststo ProtectMethamphetamine Toxicity, Roben W. Derlet, MD, Ilniversityof Caffirnia, Davis 21. ComparativeEfficacy of Different Activated Charcoal Surface Areai in AdsorbingPotassiumCyafide, CarlaM. Goetz,Pl,armD' DuquesneUniversitY 22. The Role of Alcohol Withdrawal in Genesisof Alcohol-Related Seizures,William Berk, MD, l(ayrc State University 23. The ComparativeEfficacy of VariousMultiple DoseActivated Charcoal Regimens, Kaveh ltkhanipour, MD, University of Pinsburgh TRACK C, GreenwaYBC "The Function and Utility of Hurnor in the Emergency Milieur" DouglasLindsey,MD, Universityof Aizona, and ThonwsKuhlnwn, atZ, @ud&

TRACK B, Nicollet CD Disease Infectious Papers: Scientific David A. Talan, MD, Olive View, UCl"4 24. Factors Predictive of Bacteremia in Geriatric Emergency

Moderator:

ment Patients,Phil B. Fonnrnrosa, MD, Akron City 25. Frequencyof EmergencyCare Providers' Contactwith Bl Vinrs (HIV), PatientsInfectedwith HumanImmundeficiency M. BelI, MD, Centersfor Dsease Control 26. Soft TissueInfections in the EmergencyDepartment:The for "Simple" AntibioticlJse,RobenD, Powers,MD, of Virginia Injuriesin Needlestick of Contaminated 27. Under-Reporting cy HealthCareWorkers, W. Daniel Tandberg,MD, of New Mexico


a ^ 1l:30 - l:fi) pm Public Health Roundtable Discussions,Man Suite 5017 (5thfloor) 1l:30 - l:fi) pm EMRA-SAEM Resident ResearchForum: "A Clinician's Approach to Biostatistics'" GreenwayDE Charles G. Brown, MD, Ohio State University 11:30 - 1:f[ pm Annual Meeting of the Association of Academic Chairs in Emergency Medicine, SkywaySuite l:fi) - S:fi) pm Exhibits OWn, Exhibit Hall l:fi) - 2:30 pm TRACK A, GreenwayBC "Ihe Useand Effectivenessof Interactive Video Disc in Emergency Medicine Education" Mark Eilers, MD, and Roben Dupper, MD, Wrtgfu State University

TRACK B, GreenwayA "Improving Your Lecturestt TheodoreW. Whitley, PhD, East Carolina University

TRACK C, NicolletAB Scientific Papers: Trauma Moderator: John A. Marx, MD, Denver GeneralHospital 28. BroadSpectrumCoverageVersusAnti Staphylococcal Prophylaxis Alone ReducesBone Infections After Open Fractures, "/. M. Bergstein,Medical Collegeof Wisconsin 29. Is MaxillofacialInjury an Indicatorof CervicalSpineInjury in Children?,RobenSweeney, DO, Roben WoodJohnsonMedical School 30. Head.Facialand ClavicularTraumaas a Predictorof Cervical Spine Injury, Janet lVilliams, MD, Medical College of Pennsylvania,Allegheny Campus 31.Withdrawn 32. TheEarlyIndentificationof BluntBladderRupturein theMultiply InjuredPatient,ChristinaG. Rehm,MD, RobertWoodJohnson Medical School 33. IntravenousPluronic F-127 ReducesInflammatoryReaction/Enhances Burn WoundHealingin Rats,Paul W. Paustian,MD, Medical Collegeof Georgia 11. QuantitativeEffectsof ExternalCounterpressure on the Work of Breathing,Tdd W. Tnoyer,BS,Universityof Califomin,hn Diego

TRACK D, Nicollet CD Scientific Papers: CPR Moderator: Gerard Martin, MD, Henry Ford Hospital 34. A Comparisonof MechanicalCPR andManualCPRBy Monitoring End-TidalpCO2in HumanCardiacAnest, KevinR. llard, MD, Universityof Pittsburgh 35. The Effectof RapidCompression Rateson EndTidal CarbonDioxide Levels During CardiopulmonaryResuscitation in Humans, Anhur B. Sanders,MD, University of Arizona 36. Comparisonof StandardExternalCPR,Open-Chest CPRandCardiopulmonaryBypassin a CanineMyocardialInfarct Model, Daniel J. DeBehnke,MD, Wright State University 37. The Effectof pH on theChangein CoronaryPerfussion Pressure After EpinephrineDuring CPRin Humans,NormanA. Paradis, MD, Henry Ford Hospital 38. End-TidalCarbonDioxide and CoronaryPerfusionPressurein HumansDuring StandardCPR,EmanuelP. Nvers, MD, Henry Ford Hospital 39. IonizedHypocalcemia DuringProlongedCardiacArrestandCPR in a CanineModel, CharlesB. Cairns,MD, Harbor-UCLA

2:30 - 5:fi) pm FOSTER SESSIONI, Exhibit Hail EMS/hehospital 40. MedicolegalDocumentation of PrehospitalTiage, Brad S. Seden, MD, Hwnana Hospital, ALasl@ 41. The 1989SanFranciscoEarthquake:Impacton EMS Dispatch, Communications, andSystemOperations,CharlesE. Saunders, MD, Universityof Califurnia, San Francisco 42. "IlrcUseof Priority MedicalDisparchto DistinguishBetweenHighRisk and Low-Risk Patients,GeneKallsen,MD, MPA, Valley Medical Center 43. The PrehospialUse of SublingualNifedipinein HypertensiveUrgenciesandEmergencies, LyndaFlilskey,MD, Universityof Florida 44. TheAccuracyof PrehospitalDiagnosisin Patientswith Dyspnea, BruceA. Mackod, MD, University of Pittsburgh 45. ControlledTrial of the PrehospitalUse of Isoetharinefor Acute Asthma, CharlesL. Ernertnan,MD, Case WesternUniversity 46. An Evaluationof PulseOximetryin the Field, David Eitel, MD, YorkHospital 47. Implementationof Rural EMT-Defibrillation: The Utility of MonitoringPatientswith ChestPainandThoseUnresponsive with Vital Signs,PaulJ. Dorwvan,DO, Nonh AdamsRegionalHospinl 48. Identificationof ThoseNon-TraumaticCardiac Arrest Patients for Whom ED ResuscitationEfforts are Futile. Vincent J. Markovchick,MD, Denver GeneralHospital 49. ForcesActing During Transporton PatientsStabilizedby StandardImmobilizationTechniques, RobenSilbergleit,5.8., University of Michigan 50. AmbulanceUse in a CommunitySupportedand a PrivateAmbulanceSystem,EdwardJ. Mlinek, Jr., MD, Universityof Nebraslea 51. TheRoleof Military EmergencyMedicinePhysiciansin Panama: OperationJustCan*,, llilliant H. Dce, MD, Brool<e Amry Medical Center

Trauma 52. A SimulationModelof PrehospitalTraumaCare,RobertWears, MD, University of Florida 53. GlascowComaScoresandRevisedTrauma.Scores from Trauma PatientsAre Not Normally Distributed, Gary M. Gaddis, MD, PhD, TrumanMedical Center 54. ResuscitativeThoracotomy- Trends in Outcome,Grace S. Rozycki,MD, WashingtonHospital Center 55. A Prospective Studyto Identiff High Yield Criteriafor Predicting Acute IntracranialCT Findingsin Head Injured Patients, WolframSchynoll, MD, William BeaumontHospital 56. Adult Minor TraumaPatientsDo Well in SmallHospitals,Jerns R. Hedges,MD, OregonHealth SciencesUniversity 57. Fat Embolizationin TraumaFatalities,Bryce Tanner,MD, Butterworth Hospital 58. ExtendedProtectiveEffect of a Non-ionicSurfactantby MultidoseTreatmentof Third DegreeBums, JamesC. McPherson,Jr, MD, Medical Collegeof Georgia 59. Useof HypertonicSaline/Dextran Versusl,aceratedRinger'sSolution asa Resuscitation Fluid FollowingUncontrolledAortic Hemorrhagein AnesthetizedSwine, WilliarnH, Bickell, MD, Iztterman Army Institute 60. Contributionof PeritonealLavageEnzymeDeterminationsto the Management of IsolatedHollow VisceralAMominal Injuries,Joftn A. Man, MD, Denver GeneralHospital 61. BaseDeficit asa Predictorof SignificantAMominal lnjwy, Jarnes W. Davis, MD, Universityof Califurnia,SanDiego Toxicolog5r 62. Cerebral PhosphateNMR (P-NMR) Spectroscopyas an Objective of CarbonMonoxide(CO)Toxicity: A PilorStudy,KC ftnnn, University of Pittsburgh


63. An Evaluation of Q.E.D., a New, Rapid, Accurate Device for Measuring Saliva Ethanol, Theodore A. Christopher, MD, Thonns Jefferson University 64. Cocaine Rapidly CausesSignificant Myocardial Ischemia and Depression, Philip C. Armado, MD, Mt Sinai Medical Center of Clevel.and. 65. Potentiation of Cocaine Toxicity With Lidocaine, Robert W. Derlet, MD, University of Califurnia, Davis 66. Role of Repetitive Kayexalate in Lowering Serum Lithium Concentration in the Motxe, James G. Linakis, PhD, MD, Rhode Island Poison Center

67. Protective Effects of Felodipine, Nimodipine and Verapamil Against Imipramine - Induced lrthal Cardiac Conduction Disturbances in the Anaesthetized Rat, H. Reynaert, University of Brussels

TRACK A, GreenwaY BC 3:fi) - 4:30 pm ttThe Use and Effectiveness of Interactive Video Disc in Emergency Medicine Education"

TRACK B, Greenway A ttlmproving Your Lecturestt Theodore W. Witley, PhD, East Carolina University

68. PassiveHemagglutination Inhibition Test for Diagnosis of Brown RecluseSpider Envenomation, StevenM. Barrett, MD, University of Oklnhoma 87. A Computerized Patient and Emergency Department Management System, Todd. Greenwald, MD, University of Virginia

Mark Eilers, MD, and Robert Dupper, MD, Wright State University 6:fi) - 7:fi) pm EMRA-Emergency Medicine Reception' Mirage Room 5:fi) - 6:fi) pm ResidencyDirectors Who Participate in PGII Match' GreenwayY 6:30 - 9:30 pm EmergencyMedicine ResidencyDirectors meeting, GreenwayC-E

WBDNESDAY, MAY 23 7:fi) am - S:fi) pm Registration, Exhibit Hall 8:fi) - 12:fi) noon Poster II Set-Up, Exhibil Hall 8:fi) - 12:fi) noon Exhibits Open, Exhibit Hall 8:ffi - 8:15 am Presentationof Awards: 1989ScientificPoster and 1989Pediatric Trauma and Acute Care Award' NicolletAB "Can Money and Morality Mix in Medicine?," Nicollet AB 8:15 - 9:15 am Kennedy Lecture, PhD Arthur Caplan, 9:15 - 9:30 am Coffee Break. Exhibit Hall TRACK B, Nicollet CD Scientific Papers:Toxicology Moderator: Mark A. Eilers, MD, WrightStateUniversity

TRACK A, NicolletAB. 9:30 - 10:45 am Scientific Papers:Resuscitation Moderator: W. Brian Gibler, MD, Universityof Cincinnati Tube(ETT) Position:A Miniaturized 69. Confirmationof Endotracheal Infrared Qualitative CO2 Detector, Ra.deB. Vuktnir, MD, Presbytertan-University Hospital in SurvivalFrom Out-of70. Key Role of PrehospitalResuscitation HospitalCardiac Arrest,Mami J. Bonnin,MD, Baylor College of Medicine 7l . Correlationof CentralArterial BloodGasValuesWith Perfusion During CardiacArrest in a CanineModel, Mark G. Angelos,MD' Wright State University 72. TheEffectof High andLow DoseEpinephrineon MyocardialPerfusion, CardiacOutput,and End-TidalCarbonDioxide During ProlongedCardiopulmonaryResuscitation,Peter B. Chase, Universityof Arizona of "End-of-Life" CarThe Futility of PrehospitalResuscitation 73. diac Arrests,ScottDull, BS, Universityof Washington 7O.45- 17:00 am Coffee Bre*, Exhibit Hall

Activity and 74. AssociationBetweenPlasmaCholinesterase Toxicity, Roben S. Hoflrnan,MD, BellevueHospital 75. Serum Determinationin Toxic IsopropanolIngestion, Jerrard, MD, Universityof Pittsburgh 76. Comparison of Labetalol, Diazepam and Haloperidol for the ment of Cocaine Toxicity in a Swine Model, William H. MD, Medical College of Pennsylvania

77. 1989EMRS Best Paper Award: Potentiationby Ethanolof to Activationof CardiacC-fibre Cardio-InhibitoryResponse ferents:tmplicationsfor Sufferersof MyocardialInfarction, Kirkman,MD, Universityof Manchester 78. Comparison of Epinephrine and Calcium Therapy of

ChannelBlockerToxicity in a ConsciousDog Model,Joftn Schoffstall,MD, Medical Collegeof Pennsylvania

TRACK B, Nicollet CD

TRACK A' Nicollet AB ll:fi) - 12:fi) noon Scientific Papers: CNS Resuscitation Moderator: G. Patrick Lilja, MD, Nonh Memorial Medical Center, Minneapolis 79. Prevention of Cardiac Arrest Induced Neurologic Injury and Us[t5<{@war$(chda[qtolIrono Robert E. Rosenthal,MD, GeorgeWashingtonUniversity 80. Effectsof ChemicalInterventionsof FunctionalRecoveryFollowingC\osnd Kead Trauma in Rats' I1ltchelkI{. Biros" MS^MD, EKl,ttcpua

w*tar!

*kaLLul

Scientific Papers: Cardiology/CPR Moderator: Mark S, Smith, MD, George WashingtonUniversiry 83. An Evaluationof ECG's Pre and PostNitroglycerinTherapyin Patients PresentingWith Chest Pa\n, M. Andrew kvitt, DO,

\ssssS$st\ssssis 84. Comparison of EKG Tests for the Diagnosis of MI in an Setting: Standard vs. Chaos Analysis, Davi'd Justis, MD, Fa

SouthdaleHospitol 85. Do CKMB ResultsAffect ChestPainDecisionMakingin fte

â&#x201A;Źvr+e,

- Super Oxide 81. Effect of Monomethoxypolyethyleneglycol Dismutase(PEC-SOD)on SpinalCordIschemiain a RabbitModel, Kent N. Ilall, MD, Universiryof Cincinnati

lenis R. Hedges, MD, Oregon Health Sciences

86. AMI Detectionin ChestPainPatientswith Nondiagnostic SerialCK-MB Samplingin the ED, W. Bian Gibler,MD, sity of Cincinnati

82. Brain NuclearDNA SurvivesCardiacArrest and Reperfusion, Blaine C. White, MD, llayne State University

l0


f 3d _5'7

CIba

l2:00o- 1:30 pm ResearchDirectors Luncheon: "Roadblocks to the Establishrnent of a Clinical Researchhogram," Moderator: Jerrts R. Hedges,MD, OregonHealth SciencesUniversity David Cline, MD, East Carolina University William Cordell, MD, MethodistHospital of Indiana Gerard Manin, MD, Henry Ford Hospital Scott Syverud,MD, Universityof Cincinnati

Mirage Room

12:fi) - 1:30 pm EMRA RepresentativeCouncil Luncheon, RegencyRoom l:30 - 3:fi) pm SAEM Annual BusinessMeeting: Elections and Constitution and Bylaws amendments,Nicollet AB 2:30 - 4:30 pm Chief ResidentsPrograrn, SlalwaySuite 2:30 - S:fi) pm

POSTER SESSIONII, Exhibit Hall

Clinical Practice

102.Comparison of Morphineby High-DoseIntermittentIntravenous InjectionversusPatientControlledAnalgesiain theEmergency DepartmentTreatmentof Patientswith Sickle Cell Crisis, Edward M. Racht, MD, Medical Collegeof Virginia 103.SafeUse of Nitrous Oxide in PatientsWith COPD, JamesL. McCa,be,MD, Universityof Pittsburgh

87.Will be presented onMay 22. 88 The CardiacPatient'sPerceptionof Carein Relationship to Environment, Daniel Savitt, MD, Rhodehland Hospital 89.The Distributionof OrthostaticVital SignChangesin a Normal Adult Populationandthe Variationof theseChangeswith Age, David L. Schriger, MD, MPH, UCUI 90.FatalTransfusionReactionsin theEmergencyDepartrnent,Affred S. Gervin, MD, Medical Collegeof Virginia

Pediatrics 104.ClinicalFeaturesof MissedAppendicitisin Children,StevenG. Rothrock, MD, lnma Linda University 105.SerumCocaineandTetracaineLevelsFollowingApplicationof TopicalAnesthesia in a SwineLacerationModel, TlamosE. Terndrup, MD, StateUniversityof New York, Syracwe 106.The Utility of AbdominalRadiographs in a PediatricEmergency Department, Kathleen Cronan, MD, Children's Hospital of Philadelphia 107.Length-based Endotracheal TubeSizingfor PediatricResuscitatior4 Roben C. Luten, MD, Universityof Floida, Jaclcsonyille 108.Child Neglectin PediatricPatientsLeavingAgainstMedicalAdvice, Fred Harchelroad,MD, Medical Collegeof Pennsylvania, Allbgheny Campus 109.Screeningfor CocaineIntoxicationin ChildrenWith Unexplained Seizuresin the PediatricEmergencyDepartment,StevenE. Krug, RainbowBabiesand ChildrensHospital I10. Withdrawn 111.The Roleof PostMortemCulturesin PediatricCardiacArrest, L. Pipas, State Universityof New York, Syracuse

91.Treatmentof Subungual Hematomas With Nail Trephination:A ProspgctiveSttrdy, David C. Seaberg,MD, University of Pittsburgh 92.Outcomeof PatientsDischargedFrom the EmergencyDepartment'withNonspecificAbdominalPain,G.R. Cox,MD, George WashingtonUniversity 93.ClinicalComparisonof OcularIrrigationFluidsin ChemicalInjvies, Roben D. Herr, MD, University of Utah 94.RadiologyEvaluationsof EmergencyDepartnentPatients,Marcw L. Manin, MD, Medical College of Pennsylvania,Allegheny Campus 95.FEV I Criteria for Admissionof EmergencyDepartmentPatients with Acute Exacerbation of COPD, CharlesL. Emerman,MD, Casellestern University 96.RecurrentHypoglycemiaafter D50 Administration,Judith J. Detmis, MD, Mt Sinai Medical Center 97.PelvicInflammatoryDiseaseSubsequent to SurgicalSterilization, Mdry Margaret Green, MD, University of louisville 98.TheUtility of RoutineMicrobiologicalAssaysin theInitial Evaluation of Adult SexualAssaultVictims, GabriellaMuscolo,MD, YorkHospital

Technolog;r ll2.The Esophageal DetectorDevice:A RapidandAccurateMethod for Assessing TrachealVersusEsophageal Intubationin a Porcine Model, Mark D. Magelssen,MD, MadiganArmy Medical Center ll3.Evaluation of a PrototypeTube-Value-MaskVentilator for EmergencyArtificial Ventilation, Perry R. Gffin, Jr, BSc, Dalhousie University, Halifax, Nova Scotia l14. The Useof PrehospitalExternalCardiacPacingin Bradycardic Patients,Jeffrey Goldstein,MD, York Hospital l15. Will be presentedonMay 24 116.Prehospital,MultiagencyComparisonof the Pharyngeotracheal Lumen(PTL) Airway Ttbe, SabinaMcMahon,Medical College of Virginia

99.BufferedVersusPlainLidocaineasa Local Anestheticfor Simple,Laceration Repair,Joel M. Bartfield,MD, Brow Municipal Hospital 100.TheEffectof pH Bufferingon Reducingthe PainAssociatedWith Subcutaneous Injectionof Bupivicairc,Paul Cheney,MD, University of New Mexico l0l.InfusionalandSustained-Released Morphinein theTreatmentof Vaso-occlussive Crisis in AdultsWith SickleCellDisease.Daniel Brookoff, MD, University of Pennsylvania l:30 - 5:fi) pm Exhibits OWn, Erhibit Hatt 7:fi) - 10:fi) pm SAEM Board of Directors, RegencyRoom

THURSDAY, MAY 24 7:fi) - 4:fi) pm Registrationt F-xhibitHall E:fi) - l2:f[ noon Poster III Set-Up, Exhibit Halt t:fi) - Ul:fi) noon Exhibits OWn, Exhibit Halt E:fi) - E:15 arn hesentation of Awards: 1989 Resident Poster, 19E9Resident Paper, l9E9 Resident/Fellow Oral hesentation, Nicollet AB

11


8:15 - 9:30 am

TMCK

h, NicolletAB

Scientitic Papers: Resuscitation Moderator: John B. McCabe,MD, SUNY'Syracuse of the Time CourseFrom InfarctionOnsetto 117.Characterization of Delaysand Remedies, IdentificationTherapy: Thrombolytic Robert Woolard, MD, RhodeIsland Hospital 118.Comparisonof CoronaryPerfusionPressureUsing Radialand Cential Aortic PressuresDuring CPR in Humans,JosephInzon, MD, Henry Ford HosPital 119.PotentialAdverseEffectsof High DoseEpinephrinein Human Survivorsof CardiacAnest,MichaelCallaham,MD, University of Caffimia, SanFrancisco 120.Central Aortic PressureDuring Human Electromechanical Dissociation:Identification of a Subset with Aortic Pulse NormanA. Paradis,MD, Henry Ford Hospital Pressures, Bypassin the Treatmentof Cardiopulmonary 121.Femoro-Femoral B. Martin, MD, HenryFord Gerard in Humans, Arrest Cardiac Hospital

TRACK B, Nicollet CD Scientific Papers: CHnical Practice, The Gren Room Moderator: Robert C. Jorden, MD, University of Mississippi l22.The Effect of Varying Lung Complianceon DeliveredTidal Volume and PeakTrachealPressureDuring Low FrequencyJet Ventilation,JamesMenegaui, PhD, universityof Pittsburgh 123.Ability of SpirometryandOximetryto GuideUseof AderialBlood Gaseiin AcuteExacerbationsof ChronicObstructivePulmonary Disease,Gary P' Young,MD, Portland VeteransAffairsMedical Center 124.PerformanceandInterpretationof PelvicUltrasoundby EmergenA EctopicPregnancy: cy Physiciansin Patientswith Suspected ProspectiveStudy,lzon M. Gussow,MD, CookCountyHospital Improvementin Adherenceto UniversalPrecautions 125.Substantial FollowingAdministrativeChanges, in anEmergncyDepartment Gabor D. Kelen, MD, Johns Hopkins University 126.Evaluationof the FebrileAdult in the EmergencyDepartment, J. StephanStapczynski,MD, Ilniversity of Pittsburgh

9:30 - 10:fi) am Coffee Break, Exhibit Hall TRACK !t, Nicollet AB l0:fi) - 1l:30 am Scientific Papers: Pediatrics Hospital Moderator: baniel J. Dire, MD, Darnall Army Community 127.Withdrawn versusIntravascularAc128.Evaluationof PrehospitalIntraosseous cessin Critically Ill Children, SusanFuchs, MD, Children's Hospital of Pittsburgh Ventilationin a PediatricModel, Donald 129.ManualTranlaryngeal M. Yealy,MD, Universityof Pittsburgh 130.InappropriateUseandUnmetNeedin EmeigencyMedicalServicii for Children, Lisa J. Santer, Case WesternReseme University l3l. Validity of a DisposableEnd-TidalCO2 Detectorin Verifying Tube Positionin Infantsand Children,Mananda Endotracheal S. Bhende,MD, Universityof Pittsburgh Can 132.RacemicEpinephrinein theTreatmentof Laryngotracheitis: We Identify Patients for Outpatient Management?,David Hartman, MD, Butterwonh HosPital

TRACK B, Nicollet CDU Trauma/Diagnostlcs L,'z Scientific Papers: -Ernest Ruiz,MD, HennepinCountyMedicalCenter Moderator: I 33. Is theAnteroposteriorRadiographof the CervicalSpineNecessary in the Evaluationof the TraumaPatient?,CJ Holliman,Milnn S. HersheyMedical Center Acutely 134.Value of a SimpleTest of Mental Statusin Screening IntoxicatedPatientsfor SeriousHeadInjuries,Kier Todd,PAC, Wayte State UniversitY 135.Evaluationof the Abdomenin IntoxicatedPatients:Is CT Scan MD' or PeritonealLavageAlwaysIndicated?,Felix Garcia-Perez, Robert WoodJohnsonMedical School Deci' Trauma 136.TheTraumaTriageRule:An AccuratePrehospital sion Rule. GeneJones,Universityof Califurnia,SanDiego 137. Diagnostic Peritoneal Lavage in Abdominal Stab

Analysis of the Red Blood Count via Receiver-Operati CharacteristicCtwe, Michael J. hppa, MD, University Florida, Jacksonville 138. A Prospective Evaluation of Liver Function Tests in S for Intraabdominal Injury, Pradip Sahdev, MD, Hanlord

11:30 - 11:45 am 1,990LeadershipAward Presentation,NicolletAB ..rnternational EmergencyMedicine in an Environment of War," SlqwaySuite,RobertSimon,MD, CookCounty 1l:30 - l:fi) pm ^ .,EmergencyMediciie in Europe,,' SlqrilaySuite,HermanDelooz, MD, Universityof lzuven, Belgium PhD, American ..Undergraduate Educatorsin EmergencyMedicineLuncheon," RegencyRoom,BarbaraBarzanslcy, 1l:30 - l:fi) pm of Pennsylvania College Medical Association,ind WiltiamBurdick, MD, l:fi) - 4:fi) pm Exhibits Opn, Exhibit HalI l:fi) - 2:30 pm

TRACK A, Nicollet AB

Scientific Papers: Administration/Education Moderator: Kenneth V. Iserson, MD, MBA, University of Arizona 139.RefusingCareto Patientsin an EmergencyDepartnent:18Month Experience,Robert W. Derlet, MD, Universityof Califurnia, Davis HaroU Thomas,Jr, 140.FacultyAttrition AmongThreeSpecialties, MD, WakeForest UniversitY l4l.Mechanisms of EmergencyDepartmentPatientFollow-up in EmergencyResidencyPrograms:A National Survey, Tirso Negron, MD, Our Lady of Mercy Medical Center l42.The Useof An Artificial NeuralNetworkfor Decision-Making Under Uncertainty: The Diagnosis of Myocardial Infarction, lYitliam G. Baxt, MD, University of Califumia, San Diego

TRACK B' Nicollet CD Scientific Papers: Clinical Practice Moderator: PhiW L. Henneman,MD, Harbor-UCU 145.AMominal Pain:Thresholdto ObserveAffectsEmergency Inuis G. Graff,MD, New cianDiagnosticPerformance, GeneralHospital 146. Is There a Need for Preventive Health Care in Medicine? Jay M. Goldman, MD, University of 147. Preventive Medicine in the Emergency Department: Vaccine as a Model, Jay M. GoUrnan, MD' Pennsylvania

Career 148.An Analysisof EmergencyPhysicians'Cumulative of HIV Infection. Roben L. Wears,MD, IJniversityof Fl^


0s? l:fi) - 2:30 pm

,^ Q<-t I r z ll u

t

rl

TRACK A (con't)

143. Effect of "Standard Order" Deletion on Emergency Departrnent Coagulation Test Utilization, David S. Groopman, MD, University of Virginia

149.Low Dosesof t-PA as EmergencyTherapyfor AcuteIschemic Stroke(AIS), William G. Barsan,MD, Universityof Cincinnati 150.RealTime Ultrasoundfor the Detectionof DeepVenousThrombosis, JosephF. Chance,MD, Universityof Virginia

144. Comparison of Algorithm-Directed Computerized Triage and Nurse Triage in the Emergency Department, Katherine Lovello, MD, Joint Military Medical Commnnd l:fi) - 3:fi) Synopsis for Faculty: ABEM,

TRACK B (con't)

Greenway AB

2:30 - 5:fi) pm

FOSTER SESSIONlll, Exhibit Hall

Resuscitation

Methodolog5r/Education

151.Prehospital Transcutaneous CardiacPacing:A 2 Year Prospective ControlledClinical Tial, Carolyt J. Kenyon,MD, St.Francis Hospital of Evanston 152.A Comparisonof TranscranialDoppler (Jltrasound(TCD) To Radioactive Microspheres in DeterminingCerebralPerfusionin NormalandLow Flow States,LawrenceM. Izwis, MD, St.futuis University 153.BloodGlucoseand Lengthof CerebralIschemia:Determinants of Brian LactateAccumulationClearance,Ruth V.W. Dimlich, PhD, University of Cinci,tnati ll5.Absence of ThymineGlycol Formationin Brain DNA During Post-Ischemic Reperfusion,Brian J. O'Neil, MD, llayne State University 154.DoesIntravenous AtropineCauseFixedandDilatedPupilsAfter CPR?, Elizabeth Conteras, MD, Henry Ford Hospital 155.Hemodynamic Effectof IncreasingAccelerationof ChestCompessionDuring Cardiopulmonary Resuscitation in Man, Joseph P. Ornato, MD, Medical Collegeof Virginia 156.Lackof CorrelationBetweenEndTidal CarbonDioxideConcentrationandPaC02in CardiacAnest, ChristopherW. Barton,MD, Universityof Caffimia, SanFrancisco 157.Effectof Epinephrine Adminstrationon Ability of End-tidalCarbon Dioxide (EtC02)Readingsto PredictOutcomeof Cardiac Anest, Michael Callaham,MD, Universityof Califurnia, San Fransisco 158.High DoseEpinephrineSignificantlyImprovesResuscitation Rates in HumanVictims of CardiacArrest,Christopher\il. Banon,MD, Universityof Califurnia,SanFrancisco 159.3l-P NMR Spectroscopy in theAssessment of Post-Ishemic Anoxic Encephalopathy After Cardiac Anest, GerardB. Manin, MD, Henry Ford Hospital 160.Effectof High CompressionRatesDuring MechanicalCPR in Humans:Preliminary Results,Asit Gokli, MD, Henry Ford Hospital l6l.Increasesin Coronary PerfusionPressureAfter High Dose Epinephrine Resultin Decreases in End-TidalC02 During CPR in Humans,NormanA. Paradis,MD, Henry Ford Hospital 162.HighDoseEpinephrine TherapyandReturnofSpontaneous CirculationDuring HumanPseudoelectromechanical Dissociation, NormanA. Paradis, MD, Henry Ford Hospital 163.Effectof DirectMechanicalVentricularAssistance VersusOpen ChestMassageon RegionalCerebralBloodFlow in Swrne,Robert F. Grtffith, Ohio State University 164.ClosedThoracicCavityLavagefor the Treatmentof SevereEnvironmentalHypothermia,DouglasD. Brunette,MD, Hennepin CountyMedical Center

165.MassCPR Trainingas a Meansof PromotingCPR Education, Ellen',.J.Weber,MD, Universityof Califurnia, SanFrancisco 166.An Assessment of the Evaluation,Diagnosis,andTreatmentof DermatologicDiseases by EmergencyPhysicians,TheodoreA. Christopher,MD, ThomasJffirson University 167.ProspectiveEvaluationof Flight PhysicianAir MedicalDuties in anEmergencyMedicineResidency Curriculum,K.C. Hutton, MD, Universityof Pittsburgh I 68. Sequential BayesianAnalysisof ClinicalTrials, RogerJ. Izwis , MD, PhD, Harbor-UClr4 169.InformedConsentin Clinical Trials of ThrombolyticTherapy: A Survey of U.S. and InternationalPracticeof Consentin EmergencyResearch, PamelaGrirn,MD, Universityof Chicago 170.Incidenceof InfrequentDiagnoses andthe UnevenDistribution of Clincial StudiesAcross the Core Content in Emergency Medicine,DennisG. Cochrane,MD, Hackensack MedicalCenter 171.CostAwareness in an EmergencyMedicineResidency Program, TerranceP. McHugh, MD, Richland Mernorial Hospital 172.ProcedureDocumentationUsing a ComputerizedDatebase, Carole L. Rothong,MD, HennepinCountyMedical Center 173.TheAccuracyof Computerized Bar Codevs. HandwrittenRecording of TraumaResuscitation Events,RichardV. Chua,MS, Indiana University 174.Preformatted ChartsImproveDocumentation in the Emergency Department,SheHonJacobsen,MD, Universityof Pennsylvanin 175.Designinga ReliableandValid ChartStimulatedRecallExamination, Mary Ann Reinhan, PhD, AmericanBoard of Emergency Medicine 176.JudicialOutcomeof IntoxicatedDrivers Seenin the Emergency Deparfrnent, Nclnrd T. Cook,Jr, MD, Milton S. HersheyMedical Center 177.EmergencyDepartrnent TreafinentofAlcohol Abuse:Impacton Availabilityof EmergencyServices,ErtkaNewton,YaleUniversity 178.Factors AssociatedWith Care.erLongevity in Emergency MedicinePhysicians,KentN. Hall, MD, Universityof Cincinrnti 179.PersonalityTraits andMeasuresof Statesof Physical,Emotional and Mental Exhaustionin PracticingEmergencyMedicine: tmplications for EmergencyMedicine Management,Raywin R. Haung, PhD, Michigan State University 180.LongirudinalStudyof Emergency PhysicianWellness:InitialImpressions,lzslie Zun, MD, Illinois ChnpterACEP

6:lX)- 10:fi) pm Banquet (seepage I for details)

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EDUCATIONAL AI\D SPBCIAL SESSIONS tist. Dr. Reif-Lehrerreceiveda PhD in chemistryfrom

TIIE APPLICATION OF PROBLEM-BASED LEARNING IN EMERGENCY MEDICINE EDUCATION Monday, May 21 (8:30-10:0 am and l0:30-12:fi) noon)

University of California at Berkeley. She is a scientist, veteran writer of grant proposals, and the author of over publications. Dr. Reif-khrer was an associateprofessorat vard Medical School and a Senior Scientist at the Eye Institute of Retina Foundation for many years and servedas member of a National Institutes of Health Study Section. is now president of Tech-Write Consultants/Erimon a consulting firm for proposal writing and related subjects.

Problem-based learning has replaced lecture-based education at several medical schools. In small groups (five or less) of students and faculty, learner-centered education for preclinical studentshas posed a clinical problem to stimulate inquiry about anatomy, biochemistry, pathology or physiology in an appropriate clinical context. The educational experience has been both effective, enjoyable and a good model for continuing education. The implementation of problem-based learning in an Emergency Medicine residency program will be described. After a description of the important elements of problem-based learning the methodology will be demonstratedwith resident volunteers. There will be ample time for discussionand questions following the demonstration. Faculty for this course will be David P. Sklar, MD, and Daniel Tandberg, MD, who are associateprofessors at the Division of Emegency Medicine at the University of New Mexico School of Medicine.

In the Workshop, Dr. Reif-Irhrer will give attendeesan

the i sideview of the review process,emphasizing of providing the information that the reviewers needto She will also discuss the planning, outlining, drafting, revi ing, and finishing stages of proposal preparation, i general strategies for good expository writing. She also dressestracking the application, submitting revised

comments. and using the summarystatement/reviewers DESIGNING A RESEARCH STUDY Monday, }[4ay2l (1:30-3:fi) Duringthis session,NormanHearst,MD, MPH, will

THE PROBLEM COTJNSELING AND DISCPLIMNG RESIDENT: TIIE IMPORTANT FTRST STEPS Monday, D'4ay2l (8:30-10:ffi am and 10:30-12:fi) noon)

the different options in study design for clinical epidemiological researchprojects and will discussthe tages and disadvantagesof each. Dr' Hearst is a member the faculty at the Department of Epidemiology at the Uni ty of California, San Francisco and is also a part-time physician.

The ability to counsel effectively without alienating requires a skillful combination of diplomacy and confrontation. In this session,you will learn how to establishrapport with a variety of personalities. Without rapport, the counseling process is severely hindered. Participants will also learn techniques to assistleading the resident into problem resolution. This session will be taught by SusanStephaniof S.A. Stephaniand Associates and Judith E. Tintinalli, MD. Ms. Stephanihas degreesin clinical social work and psychology, as well as a private practice. She has over ten years of experience presenting keynote speechesand seminars. Judith E. Tintinalli, MD, is the Emergency Medicine Residency Program Director at William Beaumont Hospital in Royal Oak, Michigan.

EMERGENCY

ACHTEVINGEQLITY rN HEALTH CAREACCESS THE ROLE OF GOVERNMENT Monday, May 2l (1:30-3:{X)

This special sessionwill be comprised of a discussion David U. Himmelstein, MD, Assistant Professorof Harvard Medical School and Chief, Division of Social and munity Medicine, Cambridge Hospital, Cambri

andKennethW. Kizer, MD, Director, Massachusetts; ment of Health Services, State of California and Associate fessor, Department of Medicine and Department of ty Health, University of California, Davis. Dr. Kizer will focus on the role of stategovernmentin ing equity in health care access.His premise is that the tiality of reducing the federal budget deficit, the lack of sensuson how to reform our health care system (as by the radically different ways that states are approaching problem), the inherent contradictions in what the public

MEDICINE FELLOWS LI]NCIMON Monday, Mpy 2l (12:fi)-1:30 Pm)

The Annual Emergency Medicine Fellows Luncheon consists of a debate, moderatedby Scott Syverud, MD, of the Univer"Should sity of Cincinnati. The topic of the debate is Fellowships be Done Only in the Labs of Established/Funded Researchers" and the discussantswill be Gary Krause, MD, of Wayne StateUniversrty, and Donna Seger, MD, of Vanderbilt University. Emergency Medicine Fellows, Fellowship Directors and other interested individuals are invited to attend.

to want in the way of a health care system,and the lack political will to markedly change our system in the near all militate against a federal solution to the problem soon - thus leaving it up to the statesfor the next several at least. Dr. Himmelstein will advocate a national healttt i approach to solve the current health care crisis. He will

HOW TO WRITE A GOOD GRANT APPLICATION Monday, May 2l (1:30-5:fi) Pm) Liane Reif-Lehrer, PhD, is the author of the book Writing a Successful Grant Application. She has also had several articles on the subject of grantsmanship published it The Scien'

why a nationalhealthprogramis the only stablesolutionh crisis and will focus on the important lessons of the experience with a national health program.

I4


"The

MEDICAL DECISION MAKING FOR THE ACADEMIC EMERGENCY PHYSICIAN Monday, i[lay 2l (3:30'.5:ffi pm) This sessionwill utilize computervideo technologyto provideon-linemedicaldecisionmakinganalysisof clinical problems and research questions appropriate to Emergency Medicine.The anticipatedclinical and researchexamplesinclude the evaluationof patientswith acute aMominal pain, pulmonaryembolismandblunt abdominaltrauma.The faculty for this sessionwill be Robert Beck, MD, Director of the BiomedicalInformation and CommunicationCenter at the OregonHealth SciencesUniversity and editor of the Journal of MedicalDecisionMaking;RobertA. Lowe, MD, an AssistantClinical Professor,Division of EmergencyMedicineat the Universityof California,SanFrancisco;andGary P. Young, MD, thechiefof EmergencyMedicineat the PortlandVeterans Affairs Medical Center.

Uninsured." Robert Lowe, MD, University of California, San Francisco "Overcrowding," Arthur Kellermann, MD, University of Tennessee "Ethical Implications of Allocating Scarce Resources," V. Gail Ray, MD, and Joyce Mitchell, MD, East Carolina University If your would like to participate in this special sessionplease sign up at the SAEM Registration Desk. Box lunches are available for $10.

IMPROVING YOUR LECTT]RE Tuesday, }[.Iay 22 (1:fi)-2:30 pm and 3:fi)-4:30 pm) During this sessionparticipants will watch a videotapedlecture demonstrating both desirable and undesirable lecturing behaviors. Participants will be askedto identiff as numy of these behaviors as they can, as well as any other behaviors which make an impression on them, either good or bad. This identification process will serve as the basis for a discussion of ways to give more effective lectures. This sessionwill concludewith a brief lecture in which Dr. Whitley will describe other characteristicsof effective lectures and discusssome methods for coping with nervousness.The speakerfor this sessionwill be Theodore W. Whitley, PhD, Clinical Associate Professor and Director of the Division of Researchat the East Carolina University School of Medicine.

THE FI]NCTION AND UTILITY OF HTJMOR IN TIIE EMERGENCY MILIEU Tuesday,iil,{[ay 22 (10:30-11:30am) Humorin EmergencyMedicineis thoughtof asgenerallyinappropriatein contentand target. It is a private and closely guardedsecretthat it is necessaryto the survival and healthy functioningof an emergencycareteamundersfiess.Dr. Lindsey andDr. Kuhlmanhavestudiedhumor in critical medicalsituationsfor over a decadeandhavelecturedinternationallyon this veryserioussubject.DouglasLindsey,MD, DrPH, is Professor Emeritusof EmergencyMedicineat the Universityof Arizona. ThomasKuhlman, PhD, is a Clinical Psychologistin Minneapolis.

TIIE USE AND EFT'ECTIVENESS OF INTERACTTVE VIDEODISCIN EMERGET{CY MEDICINEEDUCATION Tuesday,N[.Iay 22 (1:fi)-2:30pm and 3:fi14:30pm) This sessionwill be of particular interest to educators and administrators interested in a basic orientation and understanding of interactive theory, equipment and courseware as it relates to emergencymedicine education. To answer the questionsof what interactive technology is and what can it do, hardware and software considerations and available courseware will be discussedand demonstrated.In addition, orientation for potential developerswill be addressedand questionswill be answered. Finally, multiple examples of concepts and issues will be presented.The faculty for this sessionwill be Mark A. Eilers, MD, and Robert Dupper, MD, of Wright State University.

EMRA.SAEM RESIDENT RESEARCH FORI]M Tuesday,May 22 (11:30-1:fi)pm) The annualEMRA-SAEM ResidentResearchForum topic will be, "A Clinician's Approachto Biostatistics,"and the speaker will be CharlesG. Brown, MD, AssociateProfessor andResearch andFellowshipDirector, Division of EmergencyMedicine,OhioStateUniversity.All residentsandotherinterestedindividuals are invited to attend. Box lunches are availableduring this session.

PTJBLICIMALTH ROI.]NDTABLE DISCUSSIONS Itresday, Nlay t2 (11:30-1:0 pm)

COMPUTER SOFTWARE DISPLAYS Tuesday, May 22 and Wednesday,May 23 (2:30-5:fi) pm) The ComputerSoftwareDisplayareawill be held in the Exhibit Hall duringPosterSessions I andtr. Therewill be a MacintoshandIBM computerdisplaywhereSAEM memberswill be presenting theirnonommercialsoftrvare.Eachpresenter will have onehourin whichto displayanddescribetheir softrare. A listing of the softwarepresenters will be publistredin theon-siteAnnual Meetingprogram.Individualsint€restedin oomputerapplications in emergencymedicineare encouragedto attendthis special

Sponsored by the Mg-nbershipand Public EducationCommitt€€,Dr. Ed Bernstei#is coordinatingspecialroundtableluncheondiscussions on'public healthissues.Theseroundtables will includethe following topics: "DrugsandViolprrce," EdwardBernstdln,MD, Boston City Hospital "AIDS Epidemic," LewisGoldfrank, MD, BellevueHospital

15


Woodburn' display. This sessionis being coordinated by James Committee' Technology the of MD' Karas, f"fO, -O Steven Among this Year's Presentersare: Irvine Mark Langdorf, MD, MHPE, University of California' Resident :Co-potJti"ed Tracking of Emergency Medicine Procedures" and Clinical Cases Linda McCartney, MD, University of Illinois "Computer-Based Training in Emergency Medicine" Center David Plummer, MD, Hennepin County Medical "Critical Care DatabaseRegistry" Steve Seifert, MD, Tucson, Arizona "Emergency Medicine Utility Programs" Steve Karas, MD, La Jolla, California "HyperCard Applications in Emergency Medicine" RESEARCH DIRECTORS LI.JNCHEON WednesdaY, MaY 23 (12:fi)-1:30 Pm) TheAnnualResearchDirectorsLuncheonwillconsistofapanel "Knocking Down the Barriers to Clinical discussionon the topic of R. Hedges, Research.,, Ttre seision will be moderatedby Jenis Cordell' William MD, and panelists will be David Cline, MD, panelists The fr,fD, Cerara Martin, MD, and Scott Syverud, MD' among will addressthe following ten problems: lack of interest procdata expertise' staff, snrdypatient recruifinent, lack of desigrr poor priorities' clinical essingfailures, lack ofstatistical expertise, and review' board folloi-up, inadequatepatient base, institutional interested and directors lack of interdisciplinesupport. All research individuals are invited to attend. CHIEF RESIDENTS PROGRAM WednesdaY, MaY 23 (2:304:30 Pm) ProThis program will be the First Annual Chief Residents residents chief gru* und iis purpose is to give newly appointed positions' ihe knowledje and skills to be effective in their new residents' chief developing The program will be directed at leadership and scheduling, communication, administration, residents skills, as well as providing an opportunity for chief and issues discuss peers and to meet and network with their residents' chief All face' problems that they commonly interested individuals are invited' iraduating residents and other MD' of ifri, ,".rion is being coordinated by Scott Syverud' are speakers and schedule the University of Cincinnati and the listed below. 2:30

Introduction

2:40

Off Service Residents

3:00

Resolving Conflicts and ScheAufng Hints

3:2O

Time and Stress Management kading and Motivating

3:40

4:00

Reception/Refreshmentsi Meet Your Colleagues

ScottSyverud,MD Universityof Cincinnati William SPiveY, MD Medical College of PennsYlvania Steven Dronen, MD University of Cincinnati Bruce ThomPson, MD Henry Ford HosPital Art Sanders' MD UniversitY of Arizona

EDUCATORS LI.]NCIMON 24 (11:30-l:0 Pm) Thursday, D.4raY DiviBarbara Barzansky, PhD, the AssistantDirector of the the American sion of Undergraduate Medical Education at of the DepartMD' Burdick, William and Association, Medical of Penn' ment of Emergency Medicine at the Medical College Undergraduate Annual First the at speakers the G will sylvania "The Indducators Luncheon. The topic ofdiscussion will be'

I.]NDERGRADUATE

novationProcessinMedicalEducation.',Theabilitytosuc. is encessfully implement change in the medical curriculum inhibit inhance.dLy ond"tttunding the factors that support and level novation. Individual, oiganizational, and environmental revi' factors have all been shown to be important in curriculum suggest sion. This sessionwill describe some key factors and emergency introduce to attempt the in applied be can they how session medicin! into the medical curriculum' The goal of this in medical occured have changes how understand to be will thisin' school curricula and how emergencymedicine can use future of formation to have a greater impact on the education physicians.

INTERNATIONAL SESSION Pm) Thursday, MaY 24 (11:30-1:00 the Robert Simon, MD of Cook County Hospital and "Internat) of International Medical Corps, will discuss Emergency Medicine in an Environment of War'" He p highlight the developmentand implementation of training clinics gr-a-s-of Afghan medics working in underground

ifghanistan,ls well as discussrecentrelief effortswith frle-stitIndiansin Hondurasandeffortsin Africa' Dr' Hen

"Emergency Medicine in Europe' Delooz will then discuss, Dr. Delooz is the Director of the Emergency Department Emergency Medical Services at the University HospitalI

as well as Professorof RafaeilGasthuisberg,

and Critical Care Medicine at the Catholic University in

Belgium.Box lunchesare availableduring this session'

SYNOP$S FOR FACULTY: AMERICAN BOARI) EMERGENCY MEDICINE Thursday, MiaY24 (l:ffi-3:fi) Joseph E. Clinton, MD, President, and Benson S' M PhD, Executive Director, of the American Board of Eme Medicine will outline the changesin board policies thal taken place during the past 18 months' Many of these have direct application to programs and faculty' En medicine ptogiurn faculty and other interested individuals urged to uit"na. The topics which will be addressedwill incl combined training programs with internal medicine pediatrics; credit for training in non-emergencymedicine

of pedi theresidenttrackingsystem;ttresubspecialty ir-t; of additi development I-"rg"n"y medicine; and the subspeciatties.Detailed materials will be available andtime be allocated to respond to specific questions about these

other relatedtoPics.


Abstracts of the Annual Meeting of the Society for Academic Emergency Medicine -Editofs -u"i"i"ii" note: The following 180 abstractswill be prcsented at the AnnuaL Meeting of the Society for Academic -Emetgency Minneapolis,"M.ay21-24.Presenterc'no "t are printed in italics; where presenter is not indicated, none was specifiedby the authors. 'Study done primarily by a resident. tStudy done primarily by a medical student'

Hospital and Emergency Department Overcrowding: Results of a National Survey of Tennessee; / University D Andrulis, B Hackman A Kellermann, Memphis lnstitution, National PublicHealthand Hospital I

I

Emergencydepartmentovercrowdinghas receivedincreasing media attention during the past 18 months, but the nationwide extent and distribution of this problem are unknown. To assess the situation in major US emergencyand trauma care institutions, we survevcdin fall 1988member institutions of the National Associationof Public Hospitals and the Council of Teaching Hospitals (N = 465 total). Two mailings and telephonefollow-up yielded 277 replies(60% responserate).More than half of ,56%l arc privately owned; 44'k are pubrespondinginstitutions lic or veteranshospitals.Medical school affiliation was noted by 86%. Eighty-two support emergencymedicinc residencypro. grams.Overall, 40"/"oI inpatients at these hospitalsare admitted through the ED, although ED patients make up 7oo/oor more of total admissionsat one fourth of public hospitals.Three fourths of respondinghospitals report increasedED use during the past three years.Mean occupancyrates do not suggestcrowding is a problem;only l7 private and nine public hospitalsreportedmean "holding" of admitted occupancyratesof 90"/o<trmore. However, ED patientsdue to periodic crowding is common: more than one fourthof respondinghospitalEDs hold admittedpatientsa mean of four or more hours after they are readyfor transport to a room. Periodicwaits of 12 or more hours were noted by 36% of hospitals; 25o/,,occasionallyhold admitted floor patients for 24 hours or more. Accessto critical care is also di{ficult: one fifth of respondinghospitalsreport mean ICU patient waits of four or more hours,27'h periodically hold ICU patients for 12 or more hours, and l9o/operiodically hold critically ill or injured patients for 24 or more hours. Regardingovercrowding,3oo/oof respondinghospitals refuse interhospital transfers,33% transfer patients to other hospitals,40% divert selectedambulancepatients, and 22% periodicallydivert all ambulances.Despite such efforts, the costof ED crowding is high. At 65% of thesehospitals,ED direcadtors feel that ED overcrowdingis having a moderate-to-severe verseimpact on the quality of their emergencycare.

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The Effect ol Sodium Bicarbonate on Brain pH and l{eurologic Recovery After Gardiac Arrest and Reperfusion in Dogs

GB Martin,NA Paradis,KMA Welch,RM Nowak/ JM Rosenberg, Departments of EmergencyMedicineand Neurology,Henry Ford Hospital, Detroit,Michigan Sodiumbicarbonateis used to reversesystemic acidosisduring cardiacarrest.Use of sodium bicarbonateresulted in more rapid normalizationbrain pH {pH B} when comparedwith the nonCO,-generatingbuffer, tromethamine, in our model of global ischemia followed by cardiopulmonary bypass reperfusion {CPB). This experiment comparedthe pH B and neurologic recovery of dogswith and without sodium bicarbonateafter global ischemia followed by CPB. Adult mongrel dogs were instrumented and placedin the bore 6f a Bruker Biospec 1.89 T superconducting magnetsystem. Ventricular fibrillation was induced, and after 12 minutes, CPB was iditiated and maintained for two hours. The treatment group {N : 5l receivedsodium bicarbonateas neededto correct arteridl pH as rapidly as possible.The control group{N = 5} receivedno sodium bicarbonate.3tPnuclear magnetic resonancespectrawere obtainedat baselineand throughout

ischemia and reperfusion.Inorganicphosphaterelative to the phosphocreatineresonancesignal shift was used to determinepH B. The dogs had neurologic deficit scoring ([NDS] 500, dead; 0, normal) at eight and 30 hours after the insult. During the first l2 minutes of pH recovery,significantly (P < .04 by two-sidedt test) more brain protons l3+.3 * 2.25 x l0s) were neutralizedin the sodium bicarbonategroup than in controls18.56* 10.6 x 10sJ. A{ter one hour, the amount gi protons neutralizedwas the same in both groups.The control group had a significantly better outcome at 30 hours INDS, 278 + 48 vs 425 + lI3; P < .02 by t testl. The initial brain acidosiswas improved with sodium bicarbonate therapy,but this was not reflectedin improved neurologic outcome. The worsening of the NDS with sodium bicarbonate raisesfurther questionsregardingits use during global ischemia.

Outpatient Management of Febrile Infants 28 to 90 Days of Age With Intramuscular Geftriaxone EJ O'Rourke/ Divisionsof Emergency MN Baskin,GR Fleisher, Diseases,The Children'sHospital, Medicineand Infectious Schoolol HarvardUniversity Boston;Departmentof Pediatrics, Medicine,Boston Study hypothesis: Selectedfebrile infants I to 3 months old may be managedas outpatients using IM ceftriaxone. Population:Febrile infants 28 to 90 days old with fever of 38 C or higher and no source on physical or laboratory examination. Methods: Aiter obtaining blood, cerebralspinal fluid, and urine cultures, if the infant was nontoxic, the peripheralWPC was less than 20 x lOs/L,cerebralspinal fluid WBC was.' 1\an l0 x

i$ht:,:,;#lti";":*,t"":Uqrl\ Results: 441 febrile'-1nr. :*4f infants i(r.6%)had ^ t\ I f

-.'tifiedrwent/-nine febrile during follow-up.

::ffi#'",i"l: J"',?ifi [i:l n'r":( \lYr t'""'i 8it?,\N \ ),;:l"ol:,1*iilf i :#J':iil.13il'; -r, B Streptococcus; one each with E coli, N men^ {two witt ! ingitidis,: pneumoniae, S aurcus, andH influenzaType B)' One infant had a urinary tract infection (UTIJ with E coJi bacteremia. Nine had simple UTIs. Ten had bacterial gastroenteritis without bacteremia {eight with Salmonella; one each with Yersinia and Campylobacter). Two febrile infants had pertussis. Four of the eight (50%) bacteremic febrile infants as well as 18 of the 21 185%l iebrile infants with bacterial infections in the absence of bacteremia iulfilled the Rochester criteria for low risk of bacterial infection (normal urinalysis, WBC > 5 and < 15 x lOe/L; band count, < 1.5 x 10e/L). At follow-up, all eight bacteremic infants were afebrile, had sterile cultures, and were given a course of antibiotic therapy. The infant with S aureus bacteremia had osteomyelitis diagnosed one week after initial visit, was hospitalized, and was successfully treated. Of the ten febrile infants with bacterial gastroenteritis without bacteremia, nine were followed at home and one was hospitalized due to bloody diarrhea without dehydration or toxicity. The ten febrile infants with UTIs were well with sterile cultures at follow-up. The two febrile infants with pertussis were admitted six to 15 days after study entry due to severe spells of coughing. Of the remaining 412 febrile infants without a bacterial source, 401 were managed as outpatients and were well at day 7 follow-up. Eleven were admitted

t7


to the hospital five hours to tcn days after study cnrollmcnt and had uncomplicated, less than 72-hour admissions. Conclusion: For nontoxic febrile infants 28 to 90 days old who after a full sepsisworkup do not havc a bactcrial source identified by physical examination or screening laboratory tcsts, lM ccftriaxone for two days with telephonc folkrw-up may be an altcrnativc to hospiral admission.

I4

Population: All bicyclists involved in collisions with motbr vehicles presenting to a Lcvcl I trauma centcr from fanuary 1986 through fanuary 1989. Methods: Paticnt in{ormation was rctricvcd from emergency dcpartment records, inpaticnt records, operativc notes, discharge summarics, and autopsies.Data includcd age, sex, ED and hospital course, body areas rnjurcd, mortality, helmet use or nonuser a n d I n j u r y S e v e r i t y S c o r e ( l S S ) .T h c d a t a w e r e e n t e r e d i n t o a n interactive data basc for analvsis, and statistrcal cvaluation was p c r f o r m e d u s i n g a t w o - t a i l c d , S t u d e n t ' s t t c s t , X 2 , o r F i s h e r ' se x a c t test with P < .05 considcred sisnificant. Results: 29ti paticnts mct study criteria with z$a 195.3%lhaving documcntation of helmet usc or nonusc. One hundred six|'59.1"/"1 t c e n p a t i e n t s ( 4 O . 1 ) ' 1 ,u) s c d a h e l m e t , a n d i ( r 8 did not. T w o h u n d r e d s c v c n p a t i e n t s 1 7 2 . 9 " 1 ' )w e r c m a l c . O n e h u n d r e d n i n e t y - n i n e p a t i c n t s 1 7 0 . 1 " / " h1 a d a n I S S o f l e s s t h a n 1 5 , w h e r e a s 8 5 1 2 9 . 9 % )h a d a n I S S g r c a t e r t h a n 1 5 . S i x o f l 1 6 p a t i e n t s { 5 . 2 % ) who used a hclmct had an ISS of more than 15 comnarcd with 79 o f l ( r t l p a t i c n t s ( a 7 . 0 ' X , )w h o d i d n o t u s c a h c l m e i { f < . 0 0 0 1 ) . Mortality was l-righcr for nonusing patients lten of l(rtl; (r.0%) t h a n h c l m c t - u s i n g p a t i e n t s ( o n c o f l 1 ( r ; 0 . 9 " 1 j, P < . 0 2 5 ) .M e a n I S S f o r h c l m e t u s c r s w a s 3 . { 3c o m p a r e d w i t h l t l . 0 f o r n o n u s c r s l P < . 0 0 1 ) .A s t r i k i n g f i n d i n g o c c u r r c d w h c n t h c p a t i e n t s w i t h o u t h e a d o r n e c k i n i u r i c s ( 2 4 ( r )w c r c a n a l y z c d s c p a r a t c l y . H e l m c t - u s i n g p a ticnts in this group still had a much lower mcan ISS (3.6 vs 12.9; P < . 0 0 1 1a n d w e r c m u c h l c s s l i k e l y t o h a v c a n I S S o f m o r e t h a n 1 5 ( 4 . 4 ' X ' v s 3 2 . 1 ' X ' ; 1 ' < . 0 0 0 1 1t h a n n o n u s e r s . C o n c l u s i o n : N o n u s c o f h c l m c t s w a s s t r o n g l y a s s o c i a t c dw i t h scvcre injuries in this study population; this was truc cvcn whcn thc patients without hcad or ncck injuries wcrc analyzed as a group, a finding not prcviously dcscribcd. Thcrcforc, patients who did not usc hclmcts tcnd to bc in highcr-impact accidcnts than hclmet uscrs bccausc thc injurics suffercd in body areas othcr than thc head and ncck also tcnd to be much morc severe. It is possiblc that thc usc o{ a hclmct is characteristic of a subgroup of cyclists who are lcss likcly to bc in high-impact accidcnts than victims who do not use helmcts.

Ghest Radiography in the Emergency Department: Lack of Superiority of PA/ Lateral Films Over Single-View Portable

AP Films T H u m p h r e y s , J M G o l d m a n , A S t e m h a g e n , F S S h o f e r ,T A C h r i s t o p h e r ,J A B o n a v i t 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 o m a s J e f f e r s o n U n i v e r s i t y H o s p i t a l , P h i l a d e l p h i a ;E m e r g e n c y S e r v i c e s , H o s p i t a l o f t h e U n i v e r s i t y o f P e n n s y l v a n i a ,P h i l a d e l p h i a ; D e p a r t m e n t o f R a d i o l o g y , C r o z e r - C h e s t e rM e d i c a l C e n t e r , U p l a n d , Pennsylvania Hypothesis: Two-vicw posteroantcrior, latcral {PAL) chcst radiographs arc assumcd to bc supcrior to portablc singlc-vicw ant e r o p o s t c r i o r ( p o r t - A P ) c h c s t r a d i o g r a p h s .W c c o m p a r c d t h c a c c u r:rcy of port-APs with that of PALs in cmcrgcncy dcparrmenr paticnts. Population: All adult paticnts who rcccivcd both PALs and port-APs within four hours of cach othcr werc includcd. Paticnts with obvious intcrvcntions bctwccn thc two chcst radiographs (eg, chcst tubc insertion) wcrc cxcludcd. Methods: PALs and port-APs wcrc scparatcd for cach paticnt, placcd in random ordcr, and read by a board-ccrtificd cmcrgency p h y s i c i a n u n a w a r c o f t h c s t u d y ' s p u r p o s c . F o u r v a r i a L r l c sf o u n d on chcst radiographs wcrc notcd for cach film, namcly, congcstivc hcart failurc (CHF), cardiomcgaly ( 1 COR), infiltratc IINFIL), a n d p l c u r a l c f f u s i o n { E F F ) .S c n s i t i v i t y { S E N S ) , s p c c i f i c i t y ( S P E C l , positive and ncgativc prcdictivc valucs {PPV, NPV), and accuracy {ACC) werc calculated for each variablc. All rcadings wcrc comparcd with a radiologist's intcrpretation of cach PAL lthc gold standard). For cach film the rcadcr also rccordcd his confidcncc on a visual analog scale.

Orl""t"it"t;'#l,1airs SINS PAL/AP

of chcstradiographs wcrc rcad.Rcsultsarc *6 SPEC PAL/AP

PPV PAL/AP

NPV PAL/AP

ACC PAL/AP

cHF

0.52tO.47 0.91r/0.95 0.7910.58 0.9210.92 0.91/0.1J9

l COR INFIL

0.r]0/0.tt2 0.9710.84 0.92l0.(ru

o.9Uo.92

0.8510.77 0.68t0.73

0.51/0.55

0.9210.ttu 0.7:l/o.74

EFF

0.7410.66 0.1{]/0.ril

0.6710.53 0.91/0.frtr 0.91/0.iltt

0.t)2t0.84

There were no statistically significant differences bctwccn PAL and port-AP with rcspect to any of the variablcs analyzcd. Confidencc of the PAL rcadings was l6'ln higher than thc port-AP {P : .012). iwhen the radiokrgist's PAL readings were compared with his own port-AP readings, there were no statistically significant differences. I Conclusion: Contrary to expcctation, PALs were not shown to be supcrior to port-APs in ED paticnts, the ED reader's confidence in his readings, however, was greater for the PAL. The reliance on the two-view chest radiograph, with risks associated with transport of patients from the ED, may not be iustified.

*5

lnjury Severity Among Helmeted and Nonhelmeted Bicyclists lnvolved in Gollisions With Motor Vehicles

M Murphy,DW Spaite,EA Criss,TD Valenzuela, HW Meislin/ Sectionof EmergencyMedicine,Collegeof Medicine,University ol Arizona,Tucson Studyhypothesis:Helmet use is associated with lesssevereinjuries among bicyclists involved in collisions with motor vehicles.

l8

The Effect of Local Anesthetics on Bacterial Proliferation: TAC Versus Lidocaine

J R M a r t i n , D D o e z e m a , D T a n d b e r g , E U m l a n d / D i v i s i o no t 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 N e w M e x i c o S c h o o l o f Medicine, Albuquerque For morc than a decade, a topical solution composed of 0.5% tetracaine, l:2,000 adrenalinc, and 1l.8ol' cocaine in normal salinc (TAC) has been used to anesthetize lacerations. Several studies have demonstrated that the anesthetic eflicacy of TAC is cqual to lidocaine infiltration, especially in well-vascularized areas such as the face and scalp. Subsequently, concerns arose that the potent vasoconstrictor effects of TAC may impair host dcfenses ind potentrate wound infection. To address thii controvcrsy, we compared the effect of toprcal TAC with that of l% lidocaine infiltration on bactcrial proliferation in experimental porcine lacerations. Forty-eight incisions of standardized length and depth were made 5 cm from the spine and 7 cm apart on the backs of Hampshrre pigs. The lacerations were then inoculated with infectious doses of Staphy]ococcus auteus by injecting a standardized dose into the entire margin of each wound. Lacerations were paired by location and locally anesthetized. One randomly selected laceration was anesthetized with 3 mL topical TAC while the corresponding paired wound was anesthetized with 3 mL subcutaneouslv iniected lidocaine. Wounds were sutured, and quantitative cultures were obtained by tissue biopsy after 48 hours. The mean log,u bacteria per gram of tissue for wounds anesthetized with TAC was 6.818 (95% confidence interval, 6.O7 to 7.54) compared with 6.820 {95% con{idence interval, 5.9I to 7.75) for those treated with lidocaine; this difference was not significant lP < .05, paired two-tailed t test). The probability


of failing to detect an intergroup differcnce of 0.25 log,,, bactcria/ g was less than 0.01. TAC does not increasc bacterial pioliferation morc than lidocaine infiltration in contaminated expcrimental porcine lacerations.

Gocaine.Associated

insidc a building at the time of thc carthquake comparcd with 13% of thc controlsloddsratio lORl, 34.35;95o1,confidenccinterval lCIl, lti.55 to (13.60). Infurics among thosc in a building having fivc or morc floors werc greaterthan for thosc in smaller buldings lOR, 4.97i 95% Cl, 2.76 to t1.97). Thcrc was also a significant dosc-rcsponscincrcasc in risk for personson successivcly highcrfloorsof a buildingat thc momcnt of thc carthquake.Running out of the building after the first shock of thc carthquake was found to bc a protectivcbehavioriOR, 5.31;957oCI, 2.46 to ll.(rl). A grcaternumbcr of thc conrrols 195.5%lcomparedwith cases(31.2%)wcre rescucdduring thc first hour after impact tP < .05). Conclusion: There wcrc significant differenccsbctween the two groups as to location at thc time of the earthquake,circumstancesof entrapment,and bchavior immcdiately aftcr the impact. Thesc findings will help guidc building construction in carthcluakc-pronc rcgions,suggestoccupantactions to prevent death and injury, and provideinsights that will lead to the improvcmcnt of rcscuc efforts in future earthquakes.

Rhabdomyolysis

RD Welch,K Todd / Departmentof Surgery,Sectionof Emergency Medicine,WayneStateUniversity Schoolol Medicine;Detroit ReceivingHospital,Detroit,Michigan Study hypothesis:Rhabdomyolysisis a common complication of cocaineuse,and muscle symptoms fail to prcdict the dcvelopmcnt of rhabdomyolysis. Population:A prospective,convenicncesampleof patients prcsentingto the emergencydepartmentof a largc inner-city hospital with complaints related to cocaine use were entered in this study. Patientswere excluded who had other potential causesof clcvatedcreatinekinase {CK) levels or rhabdbmyolysis. Thirtyfour patients were enrolled in the cocainestudy group. The control group (34 patients) satisfied the cxclusion criteria and were The Use of Packed Red Blood Gells in the *Cl not cocaincusers. Field: Does lt llake a Difference? -, Methods:History and physical examination were performedon KN Hall,SC Dronen,SA Syverud/ University of Cincinnati Medical all subjects.Initial evaluation included determination of the presCenter,Department of EmergencyMedicine,Cincinnati, Ohio enceof muscle pain or swelling and total CK levels {by oxidized Study hypothcsis: The efficacy of blood administration in the nicotinamide adenine dinucleotide phosphatereductionf. paprehospitalsettingis controversial. We hypothesizethat paticnts tients with a CK level of more than 800 units/L had additional who reccivc packed red blood cells {PRBCs)in the field do not testsperformed,including a urine myoglobin, urine drug screen, have significantly different outcomes from those who do not reand serum phosphorus.Rhabdomyolysiswas identified by a seccive PRBCs. rum CK greaterthan 1,000units/L (> fivefold normalf. CK levels Population:Patientstransportedby air ambulanceto our emerwerecomparedby two-tailed t test. Muscle symptoms were comgency dcpartmentduring a one-yearperiod (fuly I988 through paredwith the developmentof rhabdomyolysisby 1z with Yates' correction, |une 1989)with diagnosesof blunt or penetratingtrauma/ gastrointcstinal bleeding,aortic aneurysm,or vaginal bleedingwere eliResults:The CK level in the cocainegroup was 931 + 3,570 gible for inclusion. units/L {mean + 2 SDs).The CK in the control group was 242 + Mcthods: A retrospectivechart review was performedon 389 336 units/L lP < .024).Of the cocaineusers,24o/o (eight of 34) had patients. Data collected included age, sex, mechanism of iniury, rhabdomyolysis;one developedmultiorgan failure and expired. amount of resuscitationfluids and PRBCsgiven before and durNo patient in the control group had CK greaterthan 1,000units/ ing transport,amount of PRBCsgiven during hospitalization,InL. Only onc cocaine user who developedrhabdomyolysishad j u r y S e v e r i t yS c o r e ,a n d o u t c o m e . P a t i e n t sr e c e i v i n gP R B C s muscle symptoms. Three cocaine users had muscre symproms but did not develop rhabdomyolysis.No patient in the cbntrol {cases}were matched for age and mechanismof injury to two controls. 12 and Student/sf test were used to evaluate the data. grouphad muscle symptoms or developedrhabdomyolysis.MusResults:30 patients receiveda total of 47 units of PRBCsbecle symptoms did not predict the CK level {P > .301. fore hospital arrival. Thesepatients had an ISSof 26.43compared Conclusion:Rhabdomyolysisis a common complication of cowith 22.43for controls and receivedmore PRBCunits in the first cainc use, but muscle symptoms are not a good predictor of the 24 hours 19.8vs 2.21and during their hospital stay (14.4vs 2.8) olsease. than controls. Caseswere significantly more likely to have a severe intra-abdominalinfury {P : .009) and a higher expected mortality than controls. The outcomes (death,dischargedto care Gase.Gontrol Study of Injuries Due to the facility, or dischargedhome) of casesand controls did not differ. Earthquake in Soviet Armenia Conclusion:This study demonstratedsimilar outcomesfor the EK Noji HK Armenian,AP Oganessian/ Departmentof PRBCgroup dcspitea higher incidenceof seriousintra-abdominal Emergency Medicine,The Johns HopkinsSchoolof Medicine; infury and a higher expectedmortality. This suggeststhat early Department of Epidemiology, The Johns HopkinsSchoolof blood administration may be of value; a largeprospectiveevaluaHygieneand PublicHealth,Baltimore, Maryland;Ministryof tion is warranted. Health,SSRof Armenia,USSR. Study hypothesis:Structural factors and victim characteristics werepredictiveof earthquake-related iniuries in the DecemberZ, Effects ot lSVo Sodium Ghloride 1988,earthquakein Soviet Armenia. Dwing Uncontrolled Gontinuous Population:For the case group, 189 personswith hospitalized Hemolrhage injuries were identified through neighborhoodpolyclinics in the PF Van Ligten,CJ Leslie,JW Hoekstra,RF Griffith,CG Brown/ city of Leninakan. Uniniured, matched controls were identified Divisionof EmergencyMedicine,The Ohio State University, from the same neighborhood. Columbus . Methods: Using the retrospectivecase-controlapproach,risk factorsfor iniuries were invesrigated.Both the caseJind controls Study hypothesis: Shock resuscitation during uncontrolled wereinterviewedwith a standardizedquestionnaireas to circumcontinuous hemorrhage (UCHf with a small volume infusion of stancesof entrapment, behavior immediately after the impact, 15% hypertonic saline solution (HTSf is superior to isotonic lacvictim rescueprocess,iniuries sustained,and on-site medical tated Ringer'ssolution ILR). care. Population: 8 swine weighing more than 20 kg receiving LR Results:Casesand controls were similar for many social and (four) or HTS {four). demographiccharacteristics.However, 84% oI the patients were Methods: UCH was initiated in splenectomizedswine. At 25

10

t9


minutes of hemorrhage, the animals were ventilated and randomly treated with 4 ml/kg (l ml/kg/min) of HTS or LR. After receiving the study solution, each group received a constant infusion of LR. Physiological data sets were recorded at ten-minute intervals. Data were analyzed using analyses of variance and Student's t tests. Results: HTS (]llean)

LR (Mean)

Time (minl

20

CI ll/min/Mz) LV stroke work {sAnlutl Orygen extraction {%) Mean arterial pressure {m Hg) Total bleed volumes {mL)

40

30

20

40

30

1.9

1.6

0.8

2.3

3.4

2.5

.01

7.8

4.7

2.0

I1.0

t4.2

9.2

.01

77

80

82

7t

39

70

.006

50

46

3l

s0

49

47

.49

1,160

98{r

.39

Conclusion: The data suggest that 15% HTS significantly improves cardiac performance in shock due to uncontrolled continuous hemorrhage compared with isotonic LR alone. No exacerbation o{ hemorrhage rate was evidenced, presumably because mean arterial pressure was minimally altered.

tl1

Quantitative Effects of External Gounterpressure on the Work of

Breathing TW Zaayer, RC Mackersie / University of California, San Diego School ol Medicine; Department of Surgery, University of California, San Diego Respiratory impairment produced by military antishock trouser {MAST) application, although a theoretical concern, is generally viewed as being a clinically insignificant problem. Pulmonary function tests have been shown to be minimally affected, but no study has assessed changes in the work of breathing imposed by MAST application. The purpose of this study was to quantify these changes. Fifteen normal subiects were studied while supine under three conditions: baseline (MAST applied but not in{lated), MAST inJlated to 30 mm Hg and MAST inflated to 60 mm Hg. To evaluate the effect of decreased chest wall compliance, measurements were repeated after application of a thoracic binder. The subiects were passively ventilated on a volume-cycled ventilator {Bennett MA-l) with tidal volumes of 15 ml/kg and respirations of 15 breaths/min. Pressure and flow were obtained with an in-line pneumotach. Ventilatory work {on the lungs plus chest wall) was calculated using integration of the pressure-flow product over time. Statistical analysis was done using the paired t test with correction for repeateo measures.

'"1::,:lTtl'ff l*"",11"i'#11 i",'"'

MAST Deflated (Baseline)

W i t h o u tb i n d e r

0 . 1 2 9* 0 . 0 1 5

With binder

0 . 1 5 u+ 0 . 0 3 1

'P < .001 compared with baseline.

MAST inflation

MAST 30 mm Hg 0.lf)0 + 0.021' 123.8v,,1 0 . 1 9 0+ 0 . 0 2 . 3 ' 122.r"1,1

MAST 60 mm Hg O . l t l t l+ 0 . 0 6 0 ' (40.1%l o . 2 z z* o . o 8 z ' 134.s"/"1

to pressures o{ 30 and 60 mm Hg sigrificantly

in

creaseswork ol breathing. Normal subjectsare capableof sustaining an estimated 500% to 700% increasein work of breathing without developingacute ventilatory fatigue. T}:le24"/oto 407oincreases in work of breathing observedin this study suggestthat MAST inflation alone is unlikely to precipitate acute respiratory failure in patients whose ventilatory capacity is not compromised.However, the additional work of breathing imposed by MAST application is not trivial, and it may be clinically significant in patients with impending ventilatory failure.

+a 4t I aZ

Near-Fatal Hemorrfragic Shock in a Porcine Model: lmproved Outcome With

Early Blood Administration SA Stern, J Baldursson, SC Dronen, C lrvin / Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati. Ohio Study hypothesis: The timing of blood administration may affect survival and hemodynarnic performance in near fatal hemonhagic shock. Population: 24 immature splenectomized swine {ll to 17 kg}. Methods: After intubation, animals were anesthetized, instrumented, and subsequently bled continuously at a decelerating rate until complete loss of vital sigrrs. One minute later, resuscitatlon was begun by infusing blood or normal saline at 3 ml/kg/min. Group A (eight) received shed blood for ten minutes followed by normal saline for ten minutes. Group B {eightl received the same fluids in reverse order. Controls {eight) received normal saline for 20 minutes. Animals were observed for 30 minutes after resuscitation or until death. Hemodynamic parameters were continuously monitored. Arterial blood gases and hematocrit were measured at fiveminute intervals. Data were compared using a two-tailed t test and x2. Results: Mortality was 25"/", 37 .5% , and lOO7" for groups A and B and controls, respectively. In comparison with group B, group A had significantly greater mean arterial pressure at ten and 15 minutes and significantly higher pH at 20, 25, and 30 minutes into the resuscitation. Controls exhibited significantly greater hypotension and acidosis. Conclusion: ln this study, brief delays in blood admintstration were associated with worse hemodynamic performance, metabolic parameters, and short-term mortality. This suggests that very early blood administration may be indicated in near-fatal hemonhagic shock.

*a

1, f r,

Trendelenburg Position and Oxygen Transport in Hypovolemic Shock

R Srng, M Sawyer, PL Marino i Department of Surgery, The G r a d u a t e H o s p i t a l , U n i v e r s i t yo f P e n n s y l v a n i a ,P h i l a d e l p h i a The Trendelenburg position is a popular maneuver for hypotension, but its effects on tissue oxygenation have not been studied. This study evaluated the effect of body tilt on Or transport in six postoperative adults with hypovolemic hypotension. All patients had indwelling pulmonary artery catheters and hypovolemia was confirmed by a pulmonary artery wedge pressure (PAWP) of 6 mm Hg or lower. The following measurements were recorded in each patient: mean arterial blood pressure (MABP) by radial artery catheters, cardiac index (CI) by thermodilution, arterial hemoglobin (Hbf, and Or saturation in arterial and mixed venous bloJd (Sao" and Svor).b" delivery (Dorf, o" uptake (Vorl, and 02 extraction ratio {O"ER} were calculated as follows: Do, = g1 " ( 1 3 x H b x S a o 2 ) ; V o r : 6 1 x 1 3 x H b x ( S a o 2- S v o r ) ; O r E R -- Yor/Do, x 100. Each variable was obtained with the patient supine and again 15 minutes after placing the patient rn the Trendeleburg position (feet elevated to 30" and head down 15"below the horizontal plane). The results are expressed below as

mean iSD) Variable PAWP MABP CI Doz Vo, o2ER 'P < .01.

Supine 4.8 {0.s} 64.2 19.21 2.1 (0.6) 324.3196.4) 109.6{r8.2) 34.6 19.6)

Trendelenburg 7.2 ll4l' 7r.r

18.41-

r.e l0.s) 3 1 1 . 7( 1 0 9 . 2 ) 103.2 114.9) 36.2

17.41

These results show that the increase in blood pressurefrom Trendelenburgposition is not associatedwith an improvementin tissue oxygenation.

20


14

=,i:[i:iJl i""llTlT;i,=""J,"'l;'

ol Paramedics Education of Western RS Porter/ Centerfor EmergencyMedicine Pittsburgh PennsYlvania, ior the Study hypothesis: Computer-assistedil-t:T::t::,1tAl) acquisiknowledge improves paramedics of ."",i"rlmi'.a"cation lecture and videotape tion and retention *n"" to*ptted with to'#ilrtrrrro", lllTaramedics atThe studv population M** throughdispersed sites training tot'""iio" tending Il continutng out Michigan. M e t h o d s : T h e s i t e s w e r e r a n d o m l y a s s i g n e d t o e i t hsubiects erlecture, cii *.,rtod tv "omp.'t"t-gtttrated -table' "i;i;;'";-^ ":"d-:j-ll:l: to b9 were unaware ot ,n. ,.t"'hld of ittst'"-tiott e,ctt subiect was given a,one.-hourcosnrtrve ;i;;"t;ril;;""i. before, immediatelv afte.r'and 60 davs ;;;;;;i;;"eevaluated inventory Lv a four-point, ten'item-satisfaction ilJiil;;,;;; '.;0:;;;rr'ouJ."tiut"*amination' Pearsoncorrelation coffi and repeated-measures ;i-fi"i.;;, iukey's studentized.rangetest' data {ct = '05)' ,nriv.ir'of uariarrc. were used to analyze "#*i;preference{sigThe satisfactiot-ittuttttory revealeda n i f i c a n t a t P > . 0 5 ) " . o " g * . , r ' o d s , a t t h e . bI'ecture e f o r e , awas fter,and60-pre{ered day a{ter-instru"tion -tii'id-- tu'i""'io"tcAI imtoward feelings the *h"r.r, *l,t ,ir"", ""1 ,"iirr".Jr" and those toward videotape.presentatlons "tJ*i't"ittri"antly

cAI subiectsperih;i' orderof preference'. ffi;ft;':i;;;j;; subvideotape-using. and leciurethan better i."iiiii-riiil?"iiy significant no was There tests' i"ri"*-up ."a bilil;i"tJ ;.;; either immel.li *i* airi.i."". utt*ten licture and video diately or 60 days after instructiot^."" ---^ Tacr Ma4ns Difference Between Test Means SatislactionInventory Means 60 Days 60 DaYs Aftet Before Alter Method After Alter Before Method Lecture

3.20 3.12

Videotape

2.75 2.45'

CAI

2.44 2.75'

3.15

2.ti8'

Basedon Likert scale of 0 (Poor)

CAI and lecture

7.2, 9 . 1 '

ll.5-

CAI and videotape

3.0

10.7'

I l.ti.

Lecture and l '7 4.2 videotape 'Re{lects significance at o

0.3

to 4 {good).

t" h::*19: Conclusion: CAI demonstratesa clear superiority

*q''i'i,i""l"aretention.over]'-tg::*""1*ll,1o:,0:t':X'::':il: while it wasnot the "s'.i"",L'"-"i laramedics' l':iii:':ffifi signifit"rri."t ilJfitiit-towardCAI improved method, m nre{erred prelerred iantly with use and time'

t r I C

a recurent proDmedications and proceduresinlrequently.used,.is. (infrequently used or -"ai""tlotts oi Ellminatiltt medicine' lem in will streamthe current paramedic armamentarium ;;;;;;tii;;*

iil;ffiili;I

16 3:?!,T3'l?1j"?Hu"s::i:1

Glinical Trial^ A Gontrolled MP Larson/ Centerfor Horan, S Cummins, RO Graves, JB Seattle-KingCounty Services' Medical Emergency of Evaluation Medical of Division Healih, .Emergency D;;;;t,";"i of Public Seattle washington' S;ivic;., Universitvof transcutaneouspaclng Study hypothesis:.We tested whether and administration of i"i"itti"n beitit initiated by paramedtcs in primary asyspatients for iv -.ai""ti"'ns can improve survival asystole.' postdefibrillation or tole '"P'";;il;i;;;-ir'. i. patients in tt"av !Jp"i"tlo" comprised,adult paramedics' bv treated were ..iiit" "ttt'tt^who "#i;#;; ;;;';;tttd'.before-and-after evaluaMethods: The studv ;;; trained and authorized to use were ""iit I'i;;'p;;;;JiJ ,i;;. intubation and administration before pra.*"*t" transcutaneou, primary asy-stolicoI postin patients in ;Tlv;;ai""titns gatheredincluded age' "tt"tt'^Data defibrillation asystolic""idi'" alrest/ percent recelv' witnessed in percent tlmes/ response sex, and rates of suwival to ;l;itti;;' ratei"oi cpn, ine bvstander ho-spiialdischarge' R e s u l t s : P a r a m e d i c s t r e a t e d 5 5 4 p a t i e n t s i n p r i m a rcardiac yasystole: according to-advanced 330 of these patients *;;;;;';;

i,id ;;;;;;

inT'l,ui,:'u*'o ,bi;?l ;;iil;;t;;i ';;s" bvparamedici tervention at

Population: 2,459 pateni's'requiringParamedic, -in included in the study the idvancedlife support iel'S)'t"uttittre were excluded' patients "o"el-s population.Non.*",g.t"y''""a' (ambulanceand tip"ti*t,charts Methods:Retrospectrvet*i"* 1989 . calendar for vear J.prrt-etttl -.;;;;;'*y rv therei|[ ot th" patients were monitored' required ii;;il;l the paof percent Thirty-three .py, *a aiJ "* ,.q.tir.^-"di""tion' medication of dosages or *dications tients required oo. o, -* adminisil" to [v therapy' ritty-four percent of the.dosages i;;;i rwo medicaavailable' i+'mediiations. oi'rr'. ii'. i:,t dl;;;il;i medications were used less dons were never used, *i'rf-oirtti the vear' -iit.?irri"t1i'v than *a;;;;,20 times during in retaining knowledge related to

iAaiij

p,o."ol' with no p3-c1's'and224werc

standardACLS protocols No sigtreatedwith irritirt p"t'ig-pl"s -utt*tt"

**;"";iJi nificantdifferences

thepaied:4 ry::::l

percent recelvlng groups in age,sex, percent in witnessedailest/ Time from collapse ty*t"-itiftlte anct CPR, bvstander .times' pacing "u.r"g.a t9 minutes_.In.the paced^group, ;.j i_il;;f whereas3l {9%) in hospitalized' a?d 29 ll3'/.1*.r" ,.rur""J'J p > 'Os)' Survival to (r'rS' the nonpaced gro.r,p*#iJt;"it-"-t'"a and.lolo {four) in the discharse was 37o tt"t"J * 'f" p"gtg^io".n patients in postdefibrillaee additional o; il;;;:; J'."i t*ti *"t. p""ti' ;dt; {20)-;;;9'almitted :dh::tt:{l ili tionasystole patients were not srg+'u"-fi"itti t"^rived' Survival rates for these

liiiJ.i,i""iiri.;;;t-ti"-

or t"i"i""i-ot's foi eitherthepaced

asYstolicPatients' nonpaced " pacminutes after arrestJtranscutaneous i"..itl A;;;ilt;;;, asvstoledoesnot postdefibrillation i"g";;;;;;;trtvt*rt-t"d when used as the first intersignificantly improve survival, even ACLS ,rention in Protocols'

Reduction of lledications on Paramedic Ambulances Indiana

Hospital' ,16 ionnsor,CL p'tnutton/ PorterMemorial Universityof Chicago li.i'lJttiiv-sih"d of Medicine'valparaiso; Chicago Hospitals, types oJ.medicationsavailStudvhvpothesis:The number and

tllryy",Tj IJa""t ta"""ionalneeds proto.cols,

errors' and certarnly continuingl, potentrally reduce medication teplacement on prehospital and tto"tti"J ,o relative costs reduce vehicles.

17

":o'' BffiiiH*""ffifEL':.t.?1""i Deviate From Standard Treatment

Protocols? Medicine JS Luo,o[ S"ntig"t/.UCLAEn]:lS?ncv JR Holfman, california LosAngeles' of Medic-ine' c;il;; UCIASchool and base-

paramedics Study hypothesis: Radio contact between irr thtt'piet not predicted by ;;l; hospital personnell;ty tt"ttd"td brehospital protocols' , "f written and audio records for Design: R"t,o,pt"""J-**tv seizule' syncope/ of complaint chief a with prehospital patients status'. mental Ila.tttit"t pain, or altered patients with one of Population: 659 "t;;;;;i""-p*rt"tpita universitv ho'pital ;;;;;i;;t'l';;it:q chief listed l:; the fbur all runsl' Patients o,f peiod 123/% oltlyear a base'station during were-excluded' trauma oi irimary il;t ;fi; records and scoredeach ifpitrtotpit"r Methods: w. ,.uit*li in standard treatment iisted oittttiapies ioiut" .;t; p";;;;'t

2l


protocols for these complaints (eg, IV line access, oxygen, glucose, and naloxone) as well as therapies not routinely included in such protocols leg, nitroglycerin or dopamine, endotracheal intubation). All charts containing unanticipated therapies were evaluated as to whether simple clinical findings could identify for paramedics the "special cases" who were in need of such action. Los Angeles County statistics were analyzed to assess the costimpact of limiting radio contact between paramedics and basehospitals. Results: Standard modalities were used in the large majority of patients {lV line access, 94T"; oxygen, 9l%; glucose and naloxone, 87o/o of altered mental status cases). Fifteen unanticipated therapies were used in 13 patients ,2.0"/"1;in each case, this was prompted by abnormal vital signs, respiratory distress, profusc diaphoresis, or a second prominent complaint. Conclusion: Almost all patients with these chief complaints could be managed by paramedics using protocols in lieu of basehospital contact. The rare patient who might benefit from radio contact can be identified by obvious clinical characteristics. Proiected annual savings resulting from a 9oo/odecrease in the number of radio contacts in Los Angeles are in the range of $2 to $3 million.

Multicenter Study of End.Tidal Garbon a CD Dioxide in the Prehospital I C, Setting JP Ornato,JB Shipley,EM Racht,CM Slovis,KD Wrenn,PE Pepe, S-L Almeida,VF Ginger,TV Fotre/ MedicalCollegeof VirginiaVirginiaCommonwealth lnternalMedicineSectionof University, EmergencyMedicalServices,Richmond;StrongMemorial Hospital,Universityof RochesterMedical Center,Rochester,New York;BaylorCollegeSchoolof Medicine,City of HoustonCenter for Resuscrtation and EmergencyMedicalServices,Houston;San MateoEmergencyMedicalServicesAgency,San Mateo, California Study hypothesis: To determine the value of end-tidal carbon dioxide {PETco"} monitoring by paramedicsfor assessingintubation in cardiacarrest and nonarrestpatients and for assessing blood flow and prognosisduring CPR. Population: 127 adults 179 cadiac anest, 48 nonarrest)intubated by paramedicsin five major US cities. Methods: Prospective,multicenter design.Inexpensive,disposable PETco, detectorsattached to intubation tubes immediately after insertion into adult patients by paramedicsin the field. The detectorsdisplay the PETco, concentrationon a three-range color scale (A, less than 0.5%; B, 0.5% to 2.OT"iC, more than 2"/"); the device continuously tracks changes in the PETcor. Color was recordedby paramedicssevenbreathsafter intubation, after return of spontaneouscirculation, during manual CPR, and during mechanical CPR. Patient demographicand outcome variables were recorded.Statistical methods were t test, analysis of variance,and Fisher'sexact test. Results: In nonarrest patients, PETco, was I00% accuratein detecting improper tube position {six of six esophagealintubated patients, A; 39 of 39 tracheal intubated patients, Cr P < .0001). In cardiac anest patients, all seven esophagealintubations had a PETco, of A. Seventeenproperly intubated cardiac arrest patients had a PETco" value of A, suggestingthat poor blood flow during CPR can also causea low PETco, value. All cardiacarrest patients who survivedto admissionhad a PETco" of C. Mechanical CPR always produced a PETco, value as high as or higher than that producedby manual CPR. Conclusion:When measuredby a simple, inexpensive,field device, PETco, is extremely accurate in confirming tube position in prehospital nonarrest patients, is useful for tube placement confirmation in cardiacarrest patients but can have low readings due to poor blood flow, has prognostic value in cardiac arrest patients, and suggeststhat mechanical CPR producesas good or better blood flow than manual CPR.

19

Gost-Benefit Analysis ot EMS Services in the Treatment of Sudden Gardiac Death

T Valenzuela, E Criss,D Spaite,H Meislin/ Sectionof Emergency Medione,ArizonaHealthSciencesCenter,University of Arizona, Tucson Study hypothcsis: Thc cost-benefitrelationship per lifc saved from out-of-hospitalsudden cardiac dcath is comparableto that of other rcsourcc-intcnsivc medical intcrventions. Population:All out-of-hospital, nontraumaticcardiopulmonary arrcstsrcquiring advancedlifc support (ALS)intcrventionsin a medium-sizedmetropolitanarca.Paticntswcrc prospectively enrolled over a ten-month period from Octobcr 1988 through July 1989. Methods: Data were obtainedfrom paramedicencounterforms, dispatchlogs,and real-timeevent-reiordingdevicesattachedto all monitor-defibrillator units. Age, witnessed versus unwitnessed,time to basic CPR, time to ALS, status on arrival at emergency department,and survival status were obtained.An estimate of the cost to maintain the emergencymedical services {EMS|system capableof an eight-minute ALS responserime was determined. The cost estimate included training, personnel, equipment, and maintenance.Cost per li{e savedwas compared with that reported for a variety of other medical interventions. Costs were normalized to 1989dollars. Results: 190 cardiopulmonaryarrestswere enrolled.The mean age of victims was 63.9 yearsi 67"k were male, and 33% were female.One hundredten of 190{587'}had witnessedarrests, and 46 of 9O 124"/"1receivedbystander CPR. The initial rhythm of ventricular fibrillation was found in 79 of 190 patients (42%). Fifty-sevenof 190paticnts i30%Jwere {ound in asystole.Thirteen of 190patients(7%)survivedto hospitaldischarge. Over the tenmonth study pcriod, EMS system costsper life savedas compared with other medical intcrventions was as follows: Intervention Cost/LifeSaved(1989$) Bone marrow transplant 24r,000 Breast cancer screening 406,000 Pertussis vaccine program 195,000 Heart transplant 109,000 Liver transplant r49,000 Sudden cardiac death 85,000 Conclusion: Maintenance of an EMS system in a mediumsized metropolitan area capableof successfullyresuscitating deaths due to cardiac dysrhythmias comparesfavorablyin costbenefit terms with a varietv of medical interventions.

20

Failure of Amphetamine Antagonists to Protect llethamphetamine fbricity

RW Derlet,T Albertson,P Rice i Universityof California,Davis, Schoolof Medicine,Sacramento Study hypothesis:Pharmacologicagentsthat antagonized-amphetamine toxicity should also antagonizemethamphetamine toxicity. Population: Male Sprague-Dawleyrats (weight, 200 to 300 g). M e t h o d s : d - a m p h e t a m i n e 7 5 m g / k g { L D 1 0 0 }a n d m e t h amphetamine 50 mg/kg (LD 501and 100 mg/kg (LD 90) wereselected for study and given IP. Animals were first pretreatedintraperitoneal with potential antagonistsbefore stimulant challenge - diazepam12,5, and I0 mg/kgf, haloperidol (5, 10, and 20 mg/ kg), propranolol (5, 10, and 20 mg/kg), and the NMDA antagonist MK 801 {0.5, 1.0,and 2.5 mg/kg). The incidenceand time to both seizureand death were recordedand comparedwith 12 and analysis of variance,respectively. Results: Dtazepam {all doses)provided significant protection against methamphetamine-inducedseizures{P < .5), but not against amphetamine-inducedseizures.MK 801, at all doses,reduced seizures in each group {P < .01). Propranolol and halo-

22


peridol did not alter the incidenceof seizurescomparedwith the controls. Significant protection against amphetamine-induced death was provided by haloperidol(all doses){P < .ll, MK 801 (all doses){P < .l), and propranolol(I0 and 20 mg/kg) {P < .lf. No agent reduced the incidence of methamphetamine(50 or 100 mg/kgf-induceddeath. Conclusion: The failure of d-amphetamineantagoniststo protect against methamphetamine-inducedtoxicity and death suggest that different mechanismsof toxicity may exist between these drugs.

*21

Gomparative Efficacy of Diffelent Activated Gharcoal Surface Areas in

Adsorbing Potassium Gyanide CM Goetz,JD Dricker,EP Krenzelok/ DuquesneUniversity Schoolof Pharmacy;Universityof PittsburghSchoolsof Pharmacy and Medicine;PittsburghPoisonCenter;and Children'sHospital Pittsburgh,Pennsylvania of Pittsburgh, Study hypothesis:Activated charcoalwill interfere with the adsorptionof potassium cyanide (KCNf and its ability to do so increasesparallel to the surfacearea of the activated charcoal. Population: 70 Sprague-Dawleyrats. Methods:The rats were randomizcdinto onc of ninc trcatmcnt groups.The control group consistcd of tcn rats rccciving KCN solution l0 mg/kg by oral lavage.Four groups of tcn animals receivedKCN l0 mg/kg immediatcly followcd by 0.5 g activatcd charcoal{SuperChar'o[SCl 3,150m2lg; Norit Supra'io [NSl 2,000 m2lg; Darco.E[D] 1,500m2lg; USP aal'o'lUSPl 950 m2lg).Thc developmentof morbidity, mortality, and thc timcs of thosc eventswere monitored. Blood CN levels werc obtained from four additionalgroups of five rats each receiving onc of thc four activatedcharcoals. Results:All rats in the control group died. The morbidity, mortality, and serum CN levels were significantly reduced{P < .05) in each of the treatment groups comparedwith controls. There were no statistical differencesamong treatment groups. Control SC NS D USP 7o Symptoms 100 80 70 70 92 7o Mortality 100 67 30 30 30 1.7 7.9 O n s e tS y m p t o m s( m i n ) 8.9 9.9 U.6 Death lmin) 8.0 z5.z 2t .5 26.9 96.8 Level{pglml) 4.0 U.0 2.0 2.5 3.1 Conclusion:The administration of activatedcharcoalstatistically lowers morbidity and mortality following an oral exposure to KCN. However, no statistical differenceswere noted among the different activated charcoal surfaceareas.

22

The Role of Alcohol Withdrawal in Genesis of Alcohol.Related Seizures

W Berk, K Todd, B Bock / EmergencyDepartment,Detroit Receiving Hospital;Sectionof EmergencyMedicine,Department of Surgery,WayneState Universrty, Detroit,Michigan Hypothesis:Alcohol associatedseizuresare not related to alcohol withdrawal. Population:Emergencydepartment patients were interviewed and enrolled if they related a history of alcoholism (drinking habits interfering with normal life patterns), or admitted to drinking daily and had more than one past medical complaint associatedwith alcohol use. Infured and critically ill patients were excluded. Methods: Presentingcomplaints, time since last drink in hours,and blood alcohol level on admission were determined. Patientswere graded{rom 0 to 3 for the following components of a withdrawal score: tremor, anxiety, agitation, hallucinations, bloodpressure,pulse, and temperature.Withdrawal scoreswere comparedusing the Wilcoxon rank-sum test, seizure frequency

was comparedusing the 12 test. Time since last drink and blood alcohol levels were comparedwith the two-tailed unpairedt test. Significancewas taken as P < .05. Results: 153 patients with a mean daily ethanol intake of ,38.6%lpresenting with acute 269 + 227 g were enrolled.The 59 seizureshad signilicantly higher withdrawal scores(P : .009) than others. Seizureswere significantly more frequent in those with any degreeof tremor {P = .0002)or anxiety (P : .048),but not in those with hallucination iP - .07| or agitation (P = .08). Nineteen seizurepatients 132%lhad none of these score-related signs of withdrawal. Patients with seizureshad a longer mean time since last drink {60 vs 46 hours}and lower mean blood alcohol levels (66 vs 105 mg/dl), but in neither casewas the difference signi{icant lP : .6, P : .06, respectively). Conclusion: Alcoholic seizuresare associatedclosely with signs of alcohol withdrawal. The observationthat a large minority o{ seizurepatients have no additional signsof withdrawal suggests that other factors contribute to occurrence.

*;14, 3O

The Gomparative Efficacy of Various Muftiple Dose Activated Charcoal Regimens

K llkhanipour,DM Yealy,EP Krenzelok/ Universityof Pittsburgh AffiliatedResidencyin EmergencyMedicine,Centerfor The Pittsburgh EmergencyMedicineol WesternPennsylvania; Pittsburgh, PoisonCenter;Children'sHospitalof Pittsburgh, Pennsylvania Study hypothesis: Increaseddosing frequency of enteral activated,charcoal (AC) will enhance theophylline clearancein human Derngs. Population:Six healthy, nonsmoking,volunteer adult men taking no other drugs between the agesof 18 and 35. Methods: A prospective,randomized,crossovertrial was performed, with a minimum seven-daywashout betweenphases. Each subject servedas his own control. Subiectsfastedovernight and receivedIV aminophylline (8 mg/kg) over 60 minutes at the start of each phase.During the control phaseno AC was given. All other phasesincluded the administration of an initial doseof 50 g AC. PhaseI subjectsreceived12.5g AC every hour; phaseII, 25 g AC every two hours; phaseIII, 50 g AC every four hours.The total dose o{ AC during each phase was 150 g over the l2-hour study period. All enteral intake was standardized.Serum theophylline levels were obtained and analyzedby high-performance liquid chromatography at times 0.5, l, 1.5,2,3,4,6,8, 10,and 12 hours after the conclusion of the aminophylline infusion. For each data set the area under the curve was calculatedto infinity using the trapezoidalrule. Data were analyzedusing repeated measuresanalysis of variance and Tukey's test, with an alpha error set at 0.05.The designhad a pretrial power of 0.8 to detect a 25"/oor greaterdifferencebetween groups. Results: The AUC {pg x hr/ml-f for each experimentalphase was significantly reduced{P < .0031comparedwith control lcontrol,223 + ll3; ever! hour, 104 + 38; two hours, l2l + 6l; four hours, l12 * 52). However, there was no statistical difference among the three treatment groups. Conclusion: Although each AC treatment regimen significantly enhancedtheophylline elimination comparedwith control, no apparent differencesin theophylline clearanceoccurred by decreasingthe dosing interval of AC.

24

Factors Predictive of Bacteremia in Geriatric Emergency Department Patients

PB Fontanarosa,F Kaeberlein,LW Gerson,RB Thomson/ Departmentsof EmergencyMedicine,CommunityHealth Sciences,and Microbiology/lmmunology, NortheasternOhio UniversitiesCollegeof Medicine,Akron City Hospital;and Akron GeneralMedical Center,Akron, Ohio Hypothesis:The clinical presentationof geriatric patientswith

23


patients. Cloves significantly reduce the risk to emergency care providers of BC during procedures commonly performed in EDs.

sepsis is atypic^l and is an unreliable predictor of the presence of bacteremia. Population: Geriatric patients (aged 65 to 99) hospitalized during a one-year period with a suspected infectious process and who had blood cultures obtained in the emergency department at the time of admission (N : 750) were evaluated. Patients with positive blood cultures (N : 791 comprised the study group and a random sample iN - 136) of patients with sterile blood cultures served as controls. Patients with contaminated blood cultures were excluded. Methods: The ED charts, hospital records, and microbiology reports were reviewed retrospectively to characterize the clinical presentation, hospital course, sources of infection, and causative organisms. Using 12 analysis, data from bacteremic and nonbacteremic patients were compared to determine factors predictive of bacteremia. Results: The incidence of bacteremia was 10.6%. The most commonly isolated organism was Escherichia coli 129%"1.Bacteremic patients had a 23"/" mortality; all nonbacteremic patients survived. Significant (P < .05) factors that predictcd bacteremia {with odds ratio and 95% confidence intervalsJ included age g r e a t e r t h a n 8 4 y e a r s 1 2 . 5 7 ) 1 . 1 3< < 5 . 6 8 ) , a l t e r e d m c n t a l s t a t u s 1 2 . 3 3 i 1 2 7< < 4 . 3 0 ) , v o m i t i n g 1 2 . 5 7 i l . l 3 < < 5 . 9 0 ) ,p u l s e m o r e t h a n IOO 12.12;1.09<< 4.I3), systolic blood pressure lcss than 100 mm H g ( 3 . 2 0 ; 1 . 2 8 < < 8 . 1 1 1 ,W B C c o u n t a b o v e 2 0 , 0 0 0 c e l l s / m m : r l2.O4tl.O2 << 4.12]1,WBC differential with more than 6% band forms 12.64i1.42 << 4.92), total band count more than I,000 1 3 . l l l . 6 7 < < 5 . 8 1 ) , h e m o g l o b i n < l 0 g / d l 1 2 . 3 6 , 0 . 9 7< < 5 . 7 7 1 and BUN greater than 26 rng/dL 12.33i1.27 << 4.30). Among the factors that failed to predict bacteremia were fever, WBC under 20,000, the presence of comorbid disease leg, diabetes, malignancy), and residency in an extended care facility. Conclusion: Bacteremic geriatric patients have an atypical clinical presentation. Except for marked leukocytosis and bandemia, factors commonly associated with infection are unreliable Dredictors of bacteremia in the elderly.

RD Powers / Division ol Emergency Medicine, Department of M e d i c i n e , U n i v e r s i t yo f V i r g i n i a H e a l t h S c i e n c e s C e n t e r , Charlottesville Study hypothesis: Soft tissue infections (STIs) in emergency department patients are caused by predictable pathogens, and do not require newer, broad spectrum/ or more expensive antibiotics for effective treatment. Population: 72 addt University Hospital ED patients with STIs {abscess, cellulitis, wound infection, impetigoJ appropriate for outpatient treatment with oral antibiotics. Methods: Healthy volunteers with STIs were enrolled in a prospective, randomized trial comparing ten days o{ therapy with cephalexin (500 mg two or four times daily) or ofloxacin (300 mg or 400 mg twice daily). Ofloxacin@ is an oral quinolone with a spectrum similar to ciprofloxacin. Microbiology and clinical parameters were assessed in initial and two follow-up visits. Results: 48 167%l of patients had cultures positive for pathogens. Of these, 80% werc staphyloccal or streptococcal species with routine sensitivities. Gram-negative rods were isolated in only iive patients. There was no difierence in outcome between the cephalexin and ofloxacin groups, with clinical response rates exceeding 95%. Patients with no identifiable pathogen responded as well as those with positive cultures. Conclusion: STIs in ED patients are not caused by exotic or multiply resistant llora. The bacteriologic profile and clinical "simple" antibicourse of ED STIs indicate that treatment with a most cases. Empiric otic, such as cephalexin, will be effective in use of broad spectrum, more costly antibiotics for initial therapy of uncomplicated ED STIs cannot be iustified.

25

27

Frequency of Emergency Ca?e Providers'Gontact With Blood of Patients lnfected With Human

Virus lmmunodeficiency R Marcus,DM Bell, DH Culver,CooperativeEmergency DepartmentStudyGroup/ Centersfor DiseaseControl,Atlanta, Georgia Study hypotheses:In inner-city and suburban emergencydepartments patient human immunodeficiency virus (HIV) infections are prevalent; emergencycare provider blood contact (BC) rates are similar; and universal precautionsprevent BCs. Population: ED patients and emergencycare providersin three pairs o{ inner-city and suburban EDs in high AlDS-incidence areasin the US. Methods: Over eight months, blinded HIV antibody testing was per{ormedon a sample of ED patients, and emergencycare providers were observedfor BC {percutaneous,skin, or mucous membrane)and use of infection control precautions. Results: Preliminary analysisof 20,000specimensrevealedpaoI 4.2"/" to 8.9"/" in inner-city EDs and tient HIV seroprevalence 0.47" to 6.4"/oin suburban EDs. Glove use rates were higher in inner-city EDs; eg, during phlebotomy,90% in inner-city, 66"/oin suburbs.BCs were observedin 388 of 9,385 l4%l proceduresobserved; 98% of BCs were skin contacts. BC rates for ungloved versus gloved emergencycare providers were: 16 of 156 (10.3%) versus two of 383 (0.5%) in obtaining an arterial blood sample (relative risk [RR] - 19.6j95% confidenceinterval [CI] : 4.6 to 84.41j76 oI 448 lI7.O"/.)versus 33 of 2,133{1.5%}while starting an IV line (RR : 11.0;95"/",CI : 7.4 to 16.3),33 of 571 (5.8%) versus 22 of 1,820(1.2%)during phlebotomy (RR = 4.8, 95% CI : 2.8 to 8.1). Conclusion: HIV infection is prevalentin inner-city and suburban EDs, indicating the need for universal precautionswith all

26

Soft Tissue Infections in the Emergency Department: The Gase lor "Simple" Antibiotic Use

Under.Reporting ol Gontaminated Needlestick lnjuries in Emergency Health Care Workers

D Tandberg,KK Stewart,D Doezema/ Universityof New Mexico Schoolof Medicine,Divisionof EmergencyMedtcine Study hypothesis:There is considerableunder-reportingof contaminated occupationalneedlestickinjuries among emergency health care workers. Population:A conveniencesample of 259 emergencyphysicians, nurses,and emergencymedical technicians (EMTs). Methods: A survey to elicit demographicand work-relatedfactors was developedand administered.Surveyitems includedage, sex, occupation/years in occupation, the number of procedures performed per week, the number of contaminated needlestick (and other "sharps") iniuries experienced,and the number formally reportedduring the previous five years.Nonsegmentedvisual analog scales were used to assesseight attitudes possibly associatedwith nonreporting.Analysis was by analysis of variance and multiple linear regressionwith stepwisevariableselection. Results:Subjectsexperienced643 contaminatedexposuresdur,35%l were formally ing the five-year study period, but only 228 reported.One or more injuries occurred in 55% of EMTs, comparedwith 72"/oof nursesand 80% of physicians(P < .05).Physicians experienceda mean oi 3.83 contaminatedexposures,while nurses recalled 2.82, and,EMTs only 1.75 lP < .05). Physicians formally reporteda mean of 0.26 exposures,while EMTs reported 0.85 and nurses reported 1.25 lP < .05). Physiciansformally reported only one eighth of their infuries comparedwith EMTs and nurses,who reportedtwo thirds of theseevents (P < .05).Perception of risk, occupation,years in occupation,and concernabout paper work were the most powerful predictors o{ reportingrate (P < .05).

24


Conclusion: Work-related contaminated needlestick inluries are under-reported by emergency health care workers, especially emergencyphysicians.

28

Broad Spectrum Goverage Versus Antistaphylococcal Prophylaxis Alone Reduces Bone Infections After Open Fractules

DH Wittmann,JM Bergstein,C Aprahamian,J Kuchlin/ Departmentof Surgery,Medical Collegeof Wisconsin;Hamburg UniversityMedical School,Altona GeneralHospital,Milwaukee, Wisconsin Study hypothesis: The incidence of bone infection after open fracture can be reduced by the addition of Gram-negative coverage to antistaphylococcal prophylaxis. Population:l14 consecutiveadults admitted to the trauma service with grade II and III open fractures were enrolled in the study.Thirteen patients were excludedbecauseof protocol violations. Methods:In a prospective,double-blind manner patients were randomizedto receive 2 g oxacillin IV {OXAI or a combination of 4 g mezlocillin and oxacillin (M&Ol. Both groups receivedtheir doseimmediately on admission,againat induction of anesthesia, and every eight hours for three days. Patients were evaluated as to age, mechanism of iniury, treatment times {iniury to admission and admission to surgery),associatediniuries, organisms culturedinitially, incidence of bone inJection {OSTITIS),and organismscultured from the bone infection. The two groups were comparedusing the x2 test. Results:The two groups were statistically identical, except for a greater evidence of associated head iniury in the M&O group (40%)versusOXA (16%1.There was significantly lessOSTITIS in the M&O group (four of 52 [8%l vs nine oI 49 lI8%1, P < .051. Therewas no correlation between the bacteria isolated initially and those isolated from the bone infection. In the OXA group, 26 different bacteria were isolated from the infected bone. Fifteen were Gram-positive aerobesand anaerobesand 1l were Cramnegative.There were only seven bacteria isolated in the M&O group. Conclusion: The addition o{ Gram-negative coverage to antistaphylococcalprophylaxis of open fractures is capable of reducing the incidence of postoperative bone in-fections.

llead, Facial' and Clavicular Ttauma as a Predictor ol Gervical-Spine lniury

*aDtl lll,

J Williams,D Jehle, E Cottington/ AlleghenyGeneralHospital; Campus,Pittsburgh Medical Collegeof Pennsylvania-Allegheny Study hypothesis: The American College of Surgeons teaches that "trauma occurring above the clavicle should raise a high suspicion for a potential C-spine iniury." We investigatedthe association of head, facial, and clavicular trauma with cewical-spine and cord iniury. Methods: The recordsof 5,021consecutivetrauma patients admitted to a Level I regional trauma center over three and one-half years were reviewed retrospectively.The incidence of head, facial, clavicle, cervical-spine,and cervical cord infuries were recorded. Glasgow Coma Scores IGCS) were obtained on all patients. Statistical analysis using multiple logistic regressionand 12 analysis was performed to determine the relation between traumatic iniury above the clavicle and cervical spine and cord injury. Results:Head-infuredpatients had no greaterincidenceo{ cervical-spine injury than nonhead-iniured patients 14.76"/ovs 4.37"/o,P : .52)but were found to have significantly fewer spinal cord infuries {1.5%vs 2.3To,P : .0481.There was no dif{erencein incidence of cervical-spine infuries between patients with and without facial iniuries 14.2%vs 4.6Yo,P = .61).However, there were significantly fewer cord iniuries among patients with facial injuries (0.75% vs 2.2%, P = .01).The presenceor absenceof clavicular fracture was not associatedwith a significant increase in cervical spine (6.9%vs 4.4"/o,P : 0.111or cervical cord iniuries vs 2.O%,P : 0.68).A GCS under 14 was associatedwith a 11.6"/" higher incidence of cervical-spineiniury than GCS of 14 or greaterin both head injured 16.7%vs 3.9!", P : .0071and nonhead iniured patients 112.2%vs 5.9"/", P : .002).There was a greater incidence of cervical cord iniury among patients with GCS less than 14 versus GCS of 14 or greaterin both the headvs 1.2%, P = .09) and nonhead-injured groups infured 12.2o/o {8.8%vs 2.7"/',P < .00011. Conclusion: Tiauma to the head,face,and clavicle is not associated with a higher incidence of cervical-spineor cord injury. Physiologicparameterssuch as the GCS appearto be more accurate predictors of cervical-spine or cord injury than mere evidence of "trauma occurring above the clavicle."

Occult

lla

29

ls llarillofacial Injury an Indicator of Gervical-Spine Injury in Ghildren?

KF O'Malley,SE Boss, R Sweeney/ Division of Trauma and EmergencyMedical ServicesUMDNJ; RobertWood Johnson MedicalSchoolat Camden Cooper Hospital;UniversityMedical Center,Camden,New Jersey The incidence of cervical-spine injury has been reported to be increasedin the presenceof significant maxillolacial injury in adults.To investigate the validity of this hypothesis in the pedi atric population, a retrospective review of 580 patients under the ageof 17 admitted to a Level I trauma center between fanuary l, 1986and |une 30, 1989 was perforrned. The mean age was 8.1, mean Inlury Severity Score (ISSfwas 13.7, and there were 29 deaths15%f.There were four patients (0.7%l with cervical-spine iniuries, all considered to be unstable (Abbreviated Injury Scale [AIS]> 3]. Thirty-six patients {6.2%f sufferedmaxillofacial iniuries with an AIS of 2 or greater(17,AIS : 2 and 19 AIS > 2), none of whom was found to have an iniury to the cervical spine. We concludethat significant maxillofacial iniury does not appear to be associatedwith an increasedincidence of injury to the cervical spinein the pediatric age group. Although the possibility of such iniury must be considered, there should be no hesitation in performing definitive airway control maneuvets due to fear of precipitating or aggravating damage to the cewical spinal cord on this basis.

rt

I

Abdominal

llauma

in

Ghitdhood

R Saladino,G Fleisher/ Divisionof EmergencyMedicine,The Children'sHospital,Boston Study hypothesis: Potentially li{e-threatening intra-abdominal injuries occur in the absenceof multisystem trauma in children, and clinical signs and the Pediatric Trauma Score IPTS) are not being helpful in the assessmentof liver or spleen trauma in children.

greaterthan 18.Forty-fourof the 51 186%)patientswith an ISSof i8 or less had a normal pulse (< l2}l, 48 of 51 194"/'lhad normal systolic blood pressure (> 90 mm Hg). A strong negative correla-


treated rats receiving a 30% body surface area burn showed a (34 mm vs 39 small but signi{icant ihift to the right by one hour rn-, p . .0j1. these data substant-iate a positive therapeutic efIect oI F-127 on the initial burn-induced inflammatory process surface activities that improve wound healing' ,rrJ -"-btr.te F-127 appears to preserve the viability of the.tissue immediately and extending into the burn area by reducing inflamrajt".",'to matory damage and providing recovery of underlytng ttssue'

ISS t i o n ( r : - . 8 0 , P : . 0 0 1 Jw a s f o u n d b e t w e e n t h e P T S a n d t h e was ioi "ttitat." with multiple severe iniuries {lSS > lB); there poor correlation {r = - .bq, p >.05} between the PTS and the ISS ior isolated spleen or liver iniury (ISS < l8J'. be Conclusion: We conclude that spleen or liver injury. may De always must and trauma major without in children Dresent nor stro.rgly considered, and neither the initial clinical findings ,tt" ptS reliably predict splecn or liver iniuries in childrcn'

32

The Early ldentification of Blunt Bladder RuPture in the MultiPlY

Iniured Patient SE Ross/ UMDNJ'RobertWood CG Rehm,AJ MJre, KF O'Malley, JohnsonMedicalSchoolat Camden;CooperHospital,University MedicalCenter,Camden,New JerseY Identification of rupture of the urinary bladdcr in thc multiply iniuredpaticnt demandsa high index of suspicton Concomitant i"i".i". -rV leadto a mortality ratc as high x.4.4"1',and delayin Ji"g"otlt ,.rd t..r,-..tt of thc rupturc'dbladdcr will substanmortality. In a rctrospectivcrcvicw of all cascsof ;i;l'tl;;;""t; blunt bladderrupture at a Lcvel I trauma centcrbctwcenfanuary L lgtl(r and March 31, 19U9,the importanceot mrcroscoprcano *r*r h.-",r:ria and the role of rctrogradccystographyand comwas cvalui"*a ,u-"gr"phy (CT) in con{irming this diagnosis !t.a. r*..tiy-one paticnts wcre diagnosedto havc bladdcr rupturcs.All had hcmaturiagreatcrtha; 50 RBCs/highpower field, I 7 g r o s sa n d 4 m i c r o s c o p i cT. w c n t y p a t t c n t su n d c r w c n t r c t r o gr"d" .yr,.,gr^phy,whicti accuratclyidcntificd.bladdcrrupturc' paIn,t o.te wa's found at laparotomy for othci initrrics' Scvcn ,i"t,t ttra CT of the abdomenand pelvis that failcd to identify itt. Ut"aa.t rupturc. We conclude that significant (> 50 RBCs/ lolt f,.-t,"ti" is the principalindicationfor cvaluationfor blunt biaddcriniury and thit rctiogradccystographyis thc diagnostic procedureof choice-.CT scan is neithcr sensitive nor spccltlc enough as primary diagnostic modality'

*33

lntravenous Pluronic F 127 Reduces lnllammatory Feaction and Enhances Burn Wound Healing in Rats

A Gomparison of Mechanical GPR and Manual GPF by Monitoring End'Tidal Pco, in Human Gardiac Arrest in Residency / Affiliated RRZelenak KB Ward,JJ Menegazzi, Centerfor ol Pittsburgh University Medicine, Emergency and Pittsburgh; Pennsylvania, ol Western fmerlencyMedicine Pennsylvanla Untontown, Hospital, Uniontown

)<]) ^ rt't

JC McPhersonlll' RR Runner,KM Plowman'RR PW Paustian, Haase,JC McPhersonJr / Departmentof Surgery/Emergency Medicine,MedicalCollegeof Georgia,Augusta;Departmentof Army Medical Eisenhower and Pathology, ClinicalInvestigation Centet FortGordon,Georgia Early intervention appearsto be the most promising method foii"d""ing the morbi<lity after burns. We treated burn wounds in ,at, .,sirig a daily dose for three consecutivedays with a nonwhich improved wound io.ti" ..tt{""i".tt, Pfuronic F-I27 lF-127l1, it;;li"c ;;t, the 48-hour time period in, -our previous study' Ci."pJ.ii ten anesthetizedrats l-30oto 320 g) receiveda thirdarea-byimmprsion J.gr.. "the b...tt, representing8% of body surface chesi foi 12 secondsin a7o C waterbath At 30 minutes, of iq, ^"a 48 hours the animals received either 8 ml/kg body wt ."fi". ot F-127 ll2 mM/Ll lV. Blood was obtained for red blood cell deformabiliiy using an Ektacytometer and hematocrit' Burn "r"" *r, measuredimmediately; area and histologic samples *.i. ,rt." at 48 and 72 hours and weekly through 28 days' There *ar a signifi"ant (P < .05) reduction in th-edegreeof wound con,tr.rl"irS.so/. I in F'127animals(17.6cm2)comparedwith saline .orrttol. (14.3cm2) at 72 hours. At one week they-were.analogous.Histologically, the degreeof vascularnecrosis,fibrin deposit.lo.t,p.tiurt""rrlar iibrosis,idema, and RBC extravasationin the dermis and cutis were greaterin saline-treatedanlmals compared *i*h f tZZ animals atJ2 hours. RBC deformability was signifi"rrrily d..t."sed in F-I27 versus saline animals from 6 to 48 hours 1O.Ztvs 0.24, P < .001),returned to normal then increased at three and four weeks i0'28 vs 0 25, P < '001)'Herlt*iii"",fv "i saline and F-127animals were not signi{icantly dif;'r;;;;"t ferent at this time (46'8 vs 46.7,P: NSI' Psovalueso{ F-127

S t u d y h y p o t h c s i s : M c c h a n i c a l C P R p r o d u c e s . g r e a t e rc a r d i a c CPR in human be ings, -as dcmonstrated by ttt'"i.t -rnu"l ,,;;;;; cndltidal Pt;or (PETc;o,)valucs (which have bcen shown in both ,,.td lio,lttn bclngs to corrclatc with cardiac output dur;;i-;it ing CPRJ. Fooulation: 15 consccutivc adults 33 to 7tl ycars old prescnting cnt<l a univcrsity hospital in nontraulnatic cardiac arrest wcre rollcd ovcr one month. Mcthods: This was a prospcctivc randomizcd crossover study' I r r r > t o c o l sw c r c b c g u n a f t c r i n i t i a l r c s u s c i t a t i o n a t t e m p t s w e r e trials n n s u c c e s s f u l . P a t i c r - r t sr c c c i v c d f o u r a l t c r n a t i n g f i v c - m i n u t e randomi"cd to begin with eiii*,, ttton"rt and two rncchanical) were ihcr rncchanical or manual CPR. Mechanical compressions by a mcchanical comprcssor (compression depth.' 2 ;;;i.;;;"; at ir.l. s.rih -"ittanical and manual comprcssions were delivcred delivered a ratc o{ 80 pcr minutc with a fixcd ventilatory volume Pcrsons performing manual CPR .fi.i .u"ty ?ifth .u-pr.t.ion. *crc ""p."ic.tccd Amcrican Hcart Association basic life support pcrformcd.manual CPR t.wicc during the fr.r"ia.ii, ,n.l nu ,rn" PETcot It.,r.ly. Ni, NaHCO,, oi cpincphrine was administered' ihosc pcrforming manual compreswas monitorcd cu.tii.tuuuily.'PET(l()r monitor' PETt:c>, values be,iirn, *"rc blintlcd to thc (significance twccn tcchniqucs werc compared using Tukcy's test of /, < .05). 1 36 R c s u l t s : T h c m c a n P E T c : c > ,d u r i n g m c c h a n i c a l C P R w a s (* 242) during mm Hg l* +.ts SD) comparcd with.(r'9 TT Hs pcrformed CPR (P < 001), a di{fcrcncc of 977n Me-"n.,.iiy c- -h-aCn,ircna.li uPtEi nT"t ,x r , w a s h i g h c r i n a l l c a s c - sn; o o n c w a s r c s u s c l t a t e o ' ihi. ttrdy suggcststhat cardiac output durlng CPR mcchanical CPR is signific^tttly high"' than during manual as cvidcnccd by significantly greater PETc:ot'

35

The Effect of FaPid ComPression Rates on End'Tidal Carbon Dioxide Levels During GardioPulmonarY Resuscitation in Human Beings

AB Sanders,KB Kern,J Raife'M Milander,CW Otto' GA Ewy/ of ArizonaHealthScrencesCenter,Tucson University Study hypothcsis: Thcre is no difference in end-tidal carbon when rapidmanualchestcomdioxiticpaitinl prest.,tcs(PETt-cr2) is compa.redwith standardCPR CPR per minute) pi.tti,r" il20 arrest' i80 '- pcr minute) in paticntssufferingcardiac l.5pul"tlnn,23 adults{13men and ten wolner;.meanage'65 hospitals two in arrest cardiac nontraumatic 4 vearsl suffering -perio.i were enteredin the.study'Twenty-two of r+tt-",tt ."irl thc 23 arrestsoccurred in the emergencydepartment' Methods: A crossovertlesign was-usedso each patient seiled control. The PETc-:o,has been correlated-withhemo"r'h;;;; CPR and successfulresuscitationirom cardrac during dvnamics intubation, the capnometerwas attachedto the "i-ri.^-r.rr.*ini endoirachealtube An a"dio tape instructed the resus;;J;i;h. a designatedrate' ei' ;i;;,;; i; performing chest compression-s.at by the alternate followed per minute 120 or pei minute 80 ther

26


rate for one-minute periods. The sequence of the two rates varicd by alternating two tapes every 48 hours. Ventilations wcre kept constant at l(r per minute for both chest compression rates. Thc paired Student's t test was used tq compare PETr:o, values at 60 seconds for the two rates. Results: PETco, levels were significantly greater with the rapid manual {120per minute) chest compression CPR than with s t a n d a r dC P R { 1 5 . 0 + l . B v s 1 3 . 0 + I . 8 m m H g , P < . 0 1 } .T h e u s c of an audio tapc for compression ratc timing significantly inc r e a s e dP E T c ; o z l 8 . 7 * 1 . 2 v s 1 4 . 0 + 1 . 3 m m H g , P < . 0 1 ) r c g a r d less of the initial ratc performed. Conclusion: In this prospective study of cardiac arresr patienrs, rapid manual chest compression CPR at thc rate of 120 per minute rcsulted in incrcased lcvels of exnircd end-tidal carbon dioxide compared with standard chest compression rarcs of 80 per mlnute.

*36

Comparison of Standard External GPR, Open.Chest GPR, and Cardiopulmonary Bypass in a Canine

llyocardial lnfarct Model DJ DeBehnke, MG Angelos,JE Leasure/ WrightStateUniversity Schoolof Medicine,Departmentof EmergencyMedicine,Dayton, Ohio Study hypothesis:Following cardiac arrest,opcn-chcstCPR IOCCPR)and cardiopulmonarybypass{CPBIhavc dcmonstratcd higherrcsuscitation ratcswhen comparedindividuallywith standardexternalCPR (SECPR).We comparedall thrcc tcchniqucsin a myocardialinfarct ventricularfibrillation (VFl modcl. Population:24 mongrcl dogs werc randomly assigncdto receiveSECPR{gradeI, N : 8), closed-chcst CPB igradcII, N = U), or OCCPR{gradeIII, N : 81. Methods:All dogs received lcft anterior descendingcoronary artcry occlusion followed by four minutcs of VF without CPR and {our minutes of Thumper'oCPR. At l2 minutes, dogs rcceivedone of thrcc resuscitationtcchniques.After rcsuscitation, all animals receivedfour hours of intensive care. Croup data wcre comparedusing analysis of variance with a Tukey's posthoc test and exact probability calculations. Results:Eight of eight grade II and six of eight grade III comparedwith two of eight grade I animals were resuscitatediP < ,01|.Three of eight gradc II and III and two of eight gradeI dogs survivedto four hours (NS).Coronary perfusionpressurc(CorPP) two minutes after institution of technique was significantly higherin gradeII 172 ! 39 mm Hg) and grade III 162 + 2(r mm Hg| comparedwith grade I animals (1.5+ 13 mm Hg; P < .02). Epinephrinerequired for resuscitation was significantly less in gradeII (0.01+ 0.02 mg/kg| when comparedwith gradeI lO.Z7* 0.ll mg/kg| and gradeIII animals (0.20 * 0.I2 mg/kg). Conclusion:OCCPR and CPB produce higher CorPP and improvedresuscitationfrom VF when comparedwith SECPR.CPB and OCCPR yielded similar resuscitation results although less epinephrinewas required with CPB.

*37

The Effect of pH on the Ghange in Goronary Perfusion Pressule After Epinephrine During GPB in Human Beings

NA Paradis, MG Goetting,EP Rivers,GB Martin,TJ Appteton,M Calice,RM Nowak/ Departmentol EmergencyMedicine,Henry FordHospital,Detroit,Michigan Acidosisimpairs the pressorresponseto epinephrine(EPI)during spontaneous circulation, and has been suggestedto act similarly during cardiacarrest. The hemodynamic effects of EPI are mediatedthrougha rise in the coronaryperfusionpressure{CPP), the aortic-to-rightatrial pressuregradient during CPR relaxation phase.High-doseEPI IHD-EPI)has been demonstratedto causea significantrise in CPP allowing study of the effect of pH on the

pressor responsc. Study hypothesis: Acid basc status may affcct thc risc in CPP after HD-EPI. Population: 87 adult normothcrmic mcdical cardiac arrcst paticnts. Mcthods: Paticnts had aortic arch and right atrial catheters placed and simultancous prcssurcs rccordcd. Thosc without rqturn of spontancous circulation aftcr prolongcd standard thcrapy werc givcn HD-EPI (.2 mg/kg). A simultaneous aortic artcrial blood gas was obtaincd. Paticnts werc groupcd by artcrial pH and thc changc in CPP was comparcd using the t tcst with significanceatP<.05. Results: The CPP bcforc and after HD-EPI was 3 ,t ll mm Hg a n d 1 3 + 1 3 , r e s p e c t i v e l y { P < . 0 0 0 1 ) .M c a n p H w a s 7 . 2 4 + . 2 5 ( r a n g c ,( r . 7 5 t o 7 . 9 2 1 .P a t i c n t s w i t h a n o r m a l p H h a d a n i n c r c a s c o f 9 + 1 2 . A c i d o t i c ( p H < 7 . 3 t t ) a n d a l k a l o t i c l p H > 7 . a 2 1p a t i c n r s had an increasein thcir CPP of 12 + 9 and 4 + (r, respcctivcly (P < . 0 0 0 1 ) .A c i d o t i c p a t i e n t s w i t h p H l e s s t h a n 7 . 2 6 h a d a n i n c r c a s c in CPP ol 12 + 8 {P - .3 comparcd with NL); thosc with a pH less than 7.0 had an incrcasc of 13 + ll (P - .34 vs NL). Alkalotic p a t i c n t s w i t h a p H a b o v c 7 . ( rh a d a n i n c r c a s c o f 2 + 5 { P = . 0 4 v s NLI. Conclusion: Acidosis, cvcn if it is scvere, docs not impair thc pressor responsc aftcr EPL Alkalosis, as might dcvelop from bicarbonatc therapy, dccreasesthe pressor responsc from EPI. Trcatmcnt of acidosis for the purpose of incrcasing thc cffcctiveness of EPI may not bc indicated.

38

End-Tidal Garbon Dioxide and Goronary Perfusion Pressure in

Human Beings During Standard GPR GB Martin,NA Paradis,EP Rivers,MG Goetting,TJ Appleton,RM Nowak/ Department of EmergencyMedicine,HenryFord Hospital,Detroit,Michigan Study hypothesis:End-tidalcarbondioxidc (ETtn,) corrclatcs with coronarypcrfusionpressurc{CPP = aortic-to-rightatrial rclaxation prcssurc)during CPR in man, and ETr;o, is prcdictivc of return of spontaneous circulation. Population:139adult paticntswith nontraumatlc,normothcrmic cardiacarrest. Methods: Patients were treated accordingto advanccdcardiac life support guidelines.ETc:o, was measuredthroughout the resuscitation.After placementof aortic and right atrial cathetcrs, CPP was measuredand correlatedwith simultaneouslyobtained ETc;or.ETco, was comparedin patientswith and without rcturn of spontaneouscirculation. Pearson'sr correlation and r tests were used. R Value P Value Results: Initial ETr:o, and CPP

0.59

< .0001

Maximum ETrrr, and CPP

0.59

< .0001 < .0001

Mean ETr:o,and CPP 0.56 The initial ETc:o" was I5.8 + 12.l mm Hg in patients with return of spontaneous circulation and 6.7 + 8.9 mm Hg in those without return of spontaneous circulation, P = .002. Conclusion: This study confirms the correlation between ETco, and CPP noted in animal models of CPR and demonstrates the usefulness of ETc:o" in predicting return of spontaneous circulation in human beings. The correlation is lower than that in animal studies, probably reflecting uncontrolled factors in the clinical setting. ETco, provides data that can be used to guide therapy during standird Cpn.

*39

lonized Hypocalcemia During Prolonged Gardiac Arrest and CPB in a Ganine Model

CB Cairns.JT Niemann,CD Pelikan.D Garner J Sharma/ The UCLA Schoolof Medicine;the Departmentsof Emergency Medicineand Medicine(Divisionof Cardiology), Harbor-UCLA Medical Center,Torrance,Californra:and the SaintJohn'sHeart

27


Institute,Santa Monica,California Study purpose:To assesschangesin ionized Ca*2 during proIoneed-vintiicular fibrillation {VF) and CPR' -ffiod"l, Nine anesthetizeddogs subiectedto electrically inVF. duced --Interventions: After sevenand one half minutes of VF, conventional advancedcardiac life support {ACLS) (including counterff d*g th.tapv, "iil..tdittg sod-ium bicarbonate and ;'h";At-;;; calcium chloride) was begun and continued for 20.minutes' Methods: The iollowing variableswere measuredbeforearrest' rnterafter sevenand one half minutes of VF, and at five-minute and ionized pressure, arterial aortic systolic ;;i; il;;;-LS, total CA*i, arterial lactate and pH, and Paor/Paco2' Statisticai Analysis: Analysis of variance, the Newman-Keuls regressionanalvsis were used' Values ""a *utipt. ,d-ii;;;; t SEM. mean the are expressed fr"t"tat, Significant changesin lactate and-ionizedCa+2 wete noted within"five minutes of beginning ACLS {Table)'There.was = correlation between ionized CA+2 and lactate {r "ii*"iii"."t "-".)T-i-2-.ool) during the 20-minute study period' A significant "oir.i*ion between iJnized CA+2 and pH was not demonstrated -.tt,ipt. regressionanalvsis' Total calcium did ;ill;;;t + '8 ""i 8nr"i. during VFTCPR{control 9'2 ! '5 mg/dl vs 8'6 rrrs.lii ^t"zo mini No animal was resuscitatedand the terminal "tvtiol. {N : 7l or pulselessideoventricularrhythm r^h;rh;;;; lN : 2). 5 Min

0 Min Aortrc pressure {mm Hg) lonized Ca + 2 {mg/dl) Lactate {mmol/LJ 'P < .05.

10 lllin

15 Min

20 Min

5 3 * 3

4 7 + 3

+ 4

55 *

4

5 3 r 3 '

5.1 + .l

4.0 t

.l'

3 . t |I . 2 '

1.9 *

3 t'l I

.g

5.4+.4' 6.6+.5^75+.4'

ll9

.2

3.5 + .2' 3.2 + .2'

Conclusion: Ionized hypocalcemiaoccurs during prolongedarrest and CPR and is likely due to CA*2 complexing by lactate as previouslyshown in Yilro.

40

lledicolegat Documentation Prehospital Triage

of

BS Se/den,PG Schnitze(FX Nolan/ EmergencyDepartment' Collegeof Nursingand Nealth Sciences' Hur"n" l-iospital-Alaska; UniversityoJ Alaska,Anchorage;AnchorageFire Department EmergencyMedical Services,Anchorage,Alaska Study obiective: Patients evaluated by paramedics but not ur"tpott.a'to the hospital ("no-patient" runs or NPR) form a irin" or* of the run volume in many emergency medical services Paramedicdocumentation of NPR is o{ten less iefisi t*."-s. lLtt t.golat prehospital .reports and exclude^*,by quality ass-ur'EMS ance review. However, theie patients file 507o to 9O"/" of there Since critical' more even ing documentation -rt f"*t"iit, are no published studies of this important population, we exam-o{ prehospital patient release and refusal of ;;;i efi;;";tion care. P-opulation, Of all EMS runs for 1987 in the system studied' 2,698 l26.lY.l were NPRs. 'MetLods: benerally accepted emergency care documentation criteria {or appropriaie patient release (AR) were applied retrosDecdvelv to- Z,OSSconiecutive NPR reports: history, physical' vital signs, normal mental status, lack of significant impairment Jite't, alcohol or other disease,and for patients refusing f-tr'rt risks of refusing were understood' ;;;; ;;;il;;Jtio" criteria constituted an inappropriately more or one of Omission Jocumented release {IRl. Data analysis was by xzi P 1 '05 was significant. --1".,r1tt, All criteria {or AR were met in 65'20/oof NPRs' Omit,.a-i"-int were risks of refusing understood in 481 (51'37" of IR) ""se., "itals ir 320 134-l"hl,mental status in 188 (20'0%f,no im-

pairment in 120{12.8%),and history-or physical in 19 {2'07'f' Age '0 to 14 and 65 or more yearsand prehospitalassessmentof hyperchoking, infection/fever,- and uentit"tiott, psychiatric "*.rg.ttiy, associatedwith AR' Age 35 to 54, refusal ;dil;;.'tistiliica"tlv ;;; irehospital assessmentof no iniurv/illness, blunt ;;;, head trauma,-seizure,minor trauma, and ethano] use were signifi."*fy "ttoii"ted with IR' There was no significant association RR/IR and patient sex, medical control contact, length il;;" or time of dav. onlv one complication thought due ;i;;;;;;, by EMS computer search' found was IR to --Co"lGio"' The proportion of AR in NPR could be improved ty-rlr,iS ".. oi standardizeddocumentation criteria such as those reri"ai.a, and policies regarding NPR should be examined and fined by all prehospitalcare providers'

41

The 1989 San Francisco Earthquake! lmpact on Emergency lledical Selvices Dispatch, Gommunieations'

and System OPerations

CE Saunders,P Amicti, J Applegarth,J Pointer/ Universityof California,San FranciscoSchoolof Medicine;San Francisco Departmentof Public Health,San Francisco On October 17, lg8g, a 7.1 magnitude-earthquakestruck San Francisco; buildings collapsed,fires brole out,.and power was lost. The 9ll EmergettcyMedical ServiceDispatch Centercontln' power,and.be' ;; ,;;itp",.h ,mi,tlatt"es using diesel-generator dispatched were runs imbulanie 186 e,na, 2:00 and ;t t,0; ;;; io diverse locations, several of which were multicasualty-inci(blunt a.",t. Of the calls received, 44 lo/o were for iniuries ,r"rrrrr", 19.4o/oipenetrating trauma, 6'57o; -motor vehicle acci' iniJry, 5.4'/"1 f all, 4 8% ; bum, -1 6%; and i"ir,* i.|s;i, ""tp'"iiti.a incident, O.sf"l. wltttin the Iirst two hours,the -"iii""t"jfrv ,r.,-U., of ambulancesincreasedfrom 15 to 45 units {31advanced i+ [asic llfe support [BlS]].usingpublic, private'and iif;-r"pp;i resources.Thi jew iadio frequenciesavailablewere ;;i-;i;"";y *itrt "o frequenciesin common betweenmedical ;;;;a;d; alrp"."tt, poiice, fire, out-;f-county, and private BLS units Oni*[ -.iiJ"i control ty telemetry was suspelded,.andparamedics casu' on standing orders.bf 527 earthquake-related il;;r;;J "rii.., ra J""rtt. o"".rrrid (multitrauma, nine; fall, two, -gunshot' o"., f"t", one). Despite the magnitude of the event, the emâ&#x201A;Źr' with sencv medical'servites,.rpontJ was rapid and effective' Medical dispatctr mav becomecomplex i;t;;-learned: il;;; rapid increasesin capacity must-be possible; il';"*Iil;J-radio communication is critical and needs redundancy;inter' by "setcv .oordination is essential;and on-line medical control i-piactical - specialprotocolsand standingorders ;i;;d;; are needed.

42

The Use of Priority lrledical Dispatch to Distinguish Between High'and

Low'Risk Patients G Kallsen,MD Nabors/ Departmentof Health,FresnoCounty; Otputtt"nt ol EmergencyMedicine,ValleyMedical Center' Fresno,California;Departmentof Familyand Community ol fvfuJi"in",Uni"ersityof California,San Francisco;Department California Fresno' County, Fresno Heaith,


one communication center using medical protocols and certified dispatchers. Participants:AII 52,020 requestsfor EMS dispatch in Fresno County in 1988were analyzed.Exclusionsof scheduledrequests, transfers,physician or nurse requests/and nontransportsresulted in 31,026dispatchesreported. Interventions:Dispatcheswere ranked as life threatening (priority l), emergencylpriority 2), or other {priority 3). Outcome was ranked as prehospital arest for patients requiring prehospital CPR,critical condition for patients requiring lights and sirens to hospital, and routine for others. The indications for lights and sirensto hospital are standardizedwith written guidelines. Results:Priority I detectedarrestswith a sensitivity of .90 and specificity of .50. Priority I patients suffered prehospital arrest and critical condition more often than priority 2 patients, who sufferedprehospital arrests and critical condition more often than priority 3 patients lP < .01 by two-tailed analysisof proporrrons). Conclusion: This version of the Clawson model of priority medical dispatch successfullydifferentiatespatients who suffer prehospitalcardiac arrest or critical condition from less critical patlents. A

rlr,

4,

The Prehospital

Use of Sublingual

ilifedipine in Hypertensave urgencies and Emergencies

DJ Vukich,LL Fluskey,JR McPherson,RL Wears/ Divisionof of Florida, Medicine,Departmentof Surgery,University Emergency Jacksonville Study hypothesis:Nifedipine is safe and effective in prehospi' tal treatment of hypertensiveemergenciesand urgenctes. Population:42 symptomatic hypertensiveadults were randomizedinto a control group of ten patients and a drug group of 32 patients.Groupsdid not differ significantly in age,race,or sex. Methods: Inclusion criteria were blood pressureof more than 200 mm Hg systolic or 120 mm Hg diastolic with hypertensive symptoms.Drug group patients received l0 mg sublingual nifedipine,while control patients were simply observed.All patients were monitored during transport and treated in nine area emergencydepartments.ED staff noted efficacyof prehospital treatment,adverseeffects,vital signs,and therapy until disposition. Results: There was a statistically greater decreasein blood pressuresin the treated versus control groups by the one-tailed Student'st test. {Systolicblood pressuretreated22.8o/"+ 16.7vs systolicblood pressurecontrol ll.7o/" ! 7.3 IP <.0031 and diastolic blood pressuretreated 17.3"/o+ 16.7 vs diastolic blood pressurecontrol 3.5% + 2l.l lP < .031f.No adverseeffectsof drug administrationwere noted. There was a trend toward greaterresolution of symptoms in the drug group, but it did not reach statistical significancein this small sample. Conclusion:Nifedipine is a safe and effective drug for treatment of hypertensiveurgenciesand emergenciesin the field. A largersampleand final diagnosisis neededto determine whether outcome is affected.

Xl^Sn l'lt

The Accuracy of Prehospital Diagnosis in Patients With Dyspnea

BA MacLeod,J Lorei,AB Wolfson/ AtliliatedResidencyin EmergencyMedicine,and Divisionof EmergencyMedicine, University of Pittsburgh,Pittsburgh,Pennsylvania Studyhypothesis:Paramedicswith on-Iine physician supervision can conectly diagnoseand treat the cause of dyspnea in prehospital patients. Population:118consecutiveprehospital (PH) patients 12 to 93 yearsoldf presenting with a chief complaint of shortness of breath. Methods:All dyspneicpatients presentingto either of two radio command physicians were enrolled prospectively over one

month. Patient ageand sex, paramedics'severity score(mild : I to severe - 5), physician PH diagnosis(Dx), PH treatment {Rxl/ and ED Dx were recorded.Neither paramedicsnor receivingEDs were aware of the ongoing study. The ED diagnosis was considered the correct one. Accuracy of PH Dx and appropriatenessof treatment were determined. The correlations between the PH and ED, Dx and Rx were evaluated using the contingency coefficient; significanceof P < .05. Results: The averageseverity score was 2.77 ! 1.32.As summarized in the table, when the ED Dx was bronchospasm(56)or congestiveheart lailure {38),the prehospitaldiagnosiswas correct 867" and 82%, respectively.When the ED Dx was bronchospasm or congestiveheart failure, the PH Dx was correct or the ED Dx was consideredand appropriatetreatment was given in 98% and 92"/o, respectively.In 24 patients with other ED Dxs, PH Dx matched ED Dx in 33%, but acceptabletreatment was given in 79%". PH Rx Appropriate PH Dx Same for ED Dx as ED Dx ED Dx 55/56 198'/") Bronchospasm 48/s6 186%l 35/38 192'/.1 3v38 182%l CHF 19/24 1.79%l 8t24 133%) Other Total 87/rr8174%l(P< .0011 109/tt8| 92%l{P < .0011 Conclusion: The cause of dyspnea,particularly bronchospasm and congestiveheart failure, can be correctly diagnosedand treatedin the field by paramedicswith on-line physician supervision.

45

Gontrolled Trial of the Prehospital Use of lsoetharine for Acute Asthma

CL Emerman,B Shade, J Kubincanek/ City of Cleveland EmergencyMedicalServices;Departmentof Emergency Medicine,MetroHealthMedical Center,Case WesternReserve Cleveland, Ohio University, Study hypothesis:Prehospitaladministration of isoetharinefor acute asthma patients will lead to improvement in clinical status and pulmonary function tests (PFT| within the slrort transport times of an urban emergencymedical servicessystem. Population: 52 adult patients less than 50 yearsold with a history of asthma, presentingwith acute dyspnea.Patientswere excluded if they did not have asthma/were unable to perform PFTs, or could not tolerate aerosols. Methods: In this prospective,controlled, nonblinded study, either an advancedlife support or basic life support unit was dispatchedto the scenebasedon proximity. Patients transportedby advancedlife support units received isoetharine,while patients transportedby basic li{e support units receivedoxygen alone. On arrival at the scene,both basic life support and advancedlife support units obtained initial vital signs and a peak expiratory flow rate using a Wright Mini-Peak IIow Meter. The peak expiratory flow rate and vital signs were repeatedon arrival at the hospital. A clinical assessmentwas made to determine whether the patient's respiratorystatus had improved. Results: The initial peak expiratory flow rate for the control group was 138 L/min while it was 148 L/min for the treatment group {NS).There was no differencein initial respiratoryrate or pulse. The transport time was 13.3minutes for the control group and 14.0minutes for the treatment group lNSl. The peak expiratory flow rate increasedto 147.7L/min in the control group while it was 217.5L/min in the treatment group (P < .01f.There was no dif{erencein post-treatment respiratory rate or pulse. Forty-six percent of the patients in the control group had clinical improvement, while 84"/" of the treatment group had clinical improvement {P < .05). Conclusion: We conclude that the prehospital treatment of acute asthma by isoetharine leads to improvement in clinical status and peak expiratory flow rate function within the short transport time associatedwith an urban emergency medical services system.

29


I

in oximetrY orPurse

'''nu' )'3'f '!i."J".I;, n:m"l"J;il a"*l #:Tru;;z'* iit=fi":*ion

46

K!'_.tg Yi" paeh, Harr,Jswap Xg);i?"Jil'" m; 13?ii3; Departmentof EmergencY

"r,"irn'n".1:::::,ll"liibiilitjl'J,::t""jff :}il,:il?#:"; rial oxYgen saturatlon ll

PennsYlvania

"t*urirn",h.:i'r::b,,s^'r3fi "1i:'"'#; #"Tl1:i#Jtr"J',iff tients unresPonsiveto tre menl t":l::t'"tto"'

Denver,Colorado

r"-*i"a^i"e;aless

of emergencv depart

::l;';fiT'x'i:'fiiiit3;Jff: ,"**l*ntil"':,:u' ",f,

": ?il:l:,T?:";''T3::i;..anarvsis"lryjl:'pJ:^rtrip.reports lJl6i :f' r' : Ji *ul.':'! I ,,li##,i:,ittl t,:&r ;r*ili;ilfi'*:1J-{;r*';,a+rl'*lif :X*$".5f"::t""*'*TJ.1','i"".:'tx*;'+f;i!11'I"i; i;; prehospi t aI provi ders :' "*F ; ;l I :: | :f ,":.*;

hospital disPosition, ano

-'il:lf

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*:Ti'L"": ater.$"""8] btooa ar.J1*. "b"'-TJ'J:,:i:f:lttt{,^l-!'{!"::'ll",y: ;;; r.;d'*ice*tfi?'il;,i'l; t",1?::ilHilLt,iX,;;;,;.' iy-,wo pat ient s re r,"na;.a I a i i' cv uated . .we $:T.T: :"r'J r'-'i*. 2%t jl', i;;;' n';; i a were ig" {o\ f ::'1i,". 'nt prttny'irrig*piit wave{orm 68 t7 and Hbo' "i'"'i""a, ;;; ; ?:4 ;x ;lt il^lru;' i;'#:* ,Spo' bv observing analvsis' r, l'ii o'n were comparea -"'i"g. toi"

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also determined'

was0 95 t 0.85%and the mean-metHb

t

911"' *' 1:: i;;;i;,;;;, :S! 5l-*kli|.r*;tlit3';)Ti:"]"'*T'i''il'r"iir'v'ffi Tn" dlii"T,:,fr truii' iJ :l i$l "'on'iJ"'ut"''o"ria'"" {'1,;' thcuse ioalro.?,11r"",Strongconsideration shouldbe givento cessation :I ffl[H;1*.':,.1"i;fi ;:""" :jj*#tii'":'.".'Hnyi*j*'*'i,x$:[?:l?ii'i ;lli:T*'fi.l;'LjrJl*i':l'ni*l'tl;:o*":ft

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Pi91s of unresPonsive pJ Donovan/ North Adamst"Jionui io.pital .Department Adams' Massachusens Liti't"s"*t s"rvices' North and b"tolina established.therules ot,No'tt' state. the ln 1988, mcdical technicians rezulations for detlbrruai;"'Ul-trn"tg91c'y t1"-13"tt{AEDs )' Al -it t"'"i'a"fif"t tE,tur-os ) with automa#'" be used when the EMT-D '*it-itt*-itttv regulations the though patient' no guide"J "t"f*"tting is oresentedwith a purseft"s's with a chief preJented who "nJtit lines addressedttreir use'ii"p;;it;; with vital signs ""t"tponsive ot complaint of chest p""'

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uy tr.i.""iia iniermediateEYlt:, :;";il,;;D ""iultttt"-of "nnlyingAED in -'t" study was doneto tt"'"iit-tttt" complai": gj.frtt:Id1ilrti chief *ttI patients t;;;'uNii;transported sustarn ,t'd to reviewall patientsthattl1-elXereencv departto iti'"tpt'tt"a p"'*ltJ AII monaryarrest' by the local Nout*btr..I9g9 "'"d ment betweenllout'not''fSii8

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with an adult subiect itt*"'Utf-ta

o"

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during experr

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:il'j: ruxq."*#'ffi r:i'''l'*:Ui. *:Iirfi1Jfii ti'['Ji;l:,W,:xtfi{#.i'j" #r::iJ"'*;1*f "i:ru;;ffi""fi ; J;:l i*:*'ti;::iwi:r* tiili:*:; Dosteriora"ls' rnese iii"

t"-ggttt th,'l-hll::1l*r

transportsuD'

tP < .051 patient is which the^b.a1k!'o^arded Conclusion: The forces to direction' bv o'-9

;;;;;.,'.,"ti'ti:::l:1i:n',';::1.1'L-J3:l"J 48 3"",1'i'i'i1'fl.1lu]ii#lTilS"E3 a,,'i"g """p'Jit;il;F subiected

Eflorts Are Futile nesusJitaGve EW P Johnson' pipons' r'rKnight' Sv cJ"t''ri' VJMarkovchict,

measurement ol tnese l

30

1J

?-i"


of immobilization sons.

50

Medicine,Departmentof Surgery,University of Florida;Divisionof Computerand Information Science,University of NorthFlorida, Jacksonville Study hypothesis:A computer simulation model can attain sufficient validity to be used as a tool for experimentationand analysis in prehospitaltrauma care. Methods: We developeda model of the prehospitalcare system incorporating information about degreeof injury, hemodynamic s t a t u s ,O , d e l i v e r y ,a v a i l a b l er e s o u r c e s{ e g ,h o s p i t a l s ,a m b u lances,and helicopters),and field interventions. The model generatespatientsat points in spaceand time and then activatesthe prehospitalresources,which effect interventions that interact with the degreeof injury to produce changesin the physiologic parameters.Patients then are transportedto hospitals according to current protocols {including divert status},where they are assigned an ultimate probability of survival basedon their physiologic status on arrival and the expectedsurvival for that hospital class.This model was implemented in a generalpurposesimulation language(SimScriptII.5|, which can be run on a large number of computer systems.It can be adaptedto reflect different sets of resources,protocols,and patternsof iniury, making it customizable to a particularlocation. Results: Comparing simulation runs to data from the Florida Trauma Registry,no significant differenceswere noted in patient survival, proportion transportedto Level I centers,or prehospital times. Life table analysis was used to compare survival curves; categoricalvariableswere analyzedby x2 tests,and ratio variables by nonparametrictests. Conclusion: Our model successfullyreflects the real world of prehospitaltrauma care with sufficient validity that it can be used as a guide to researchersand plannersto focus direct experimentation on thosc areasin which it is most likcly to be produc-

devices used for the transport of infured per-

Ambulance Use in a Gommunity Supported and a Private Ambulance System

EJ MlinekJr, M Zeiler,RL Muelleman/ Universityof Nebraska MedicalCenter,Sectionof EmergencyMedicine,Departmentof Surgery,Omaha This study was done to evaluateparamedicand patient perception of need for transport in similar socioeconomicpopulations betweena pay and a nonpay prehospitalcare system and between different socioeconomicpopulations within each system. Comparablepopulationswere identified between and within two midwesterncities utilizing cluster analysisof median age,race,number of vearsof education.and income. Paramedicsdocumentedif an advancedlife support transport was warranted.Patients were contactedby mail or phone follow-up. The patient questionnaire included how soon care was neededand if the patient felt his condition required an ambulance.12 analysis was utilized. Four hundredthirty-seven patients were in the free system and 785 patientsin the pay system. Although paramedicsperceivedthat 24'/. 1294of I,222) of the transportsdid not require advancedlife supportservice,there was no statistically significant difference in their perceptionbetween the two systemsin the higher socioeconomicpopulation or in the lower socioeconomicpopulation lP > .05),the two populations within the pay system or the free system(P > .05).Although 26.7% (I3a oi .50I) of the patients perceivedthat their condition did not require an ambulance, there was no statistically significant difference in the patient's perceptionof need for transport between the two systemsin the highersocioeconomicpopulation or in the lower socioeconomic population{P > .05},the two populations within the pay system or the free system {P > .05).There was no differencein the paramedic'sor patient/sperceivedneed for transport betweenpay and nonpaysystemsas well as between different socioeconomic groups.

51

flve.

53

Glasgow Goma Scores and Revased Trauma Scores From Trauma Patients Are Not Normally Distributed

GM Gaddis,ML Gaddis,V Morse/ Departments of Emergency HealthServicesand Surgery,and Divisionof Trauma,Department of Surgery,TrumanMedicalCenter/University of Missouri-Kansas City Schoolof lvledicine Background:The Glasgow Coma Score iGCS) and Revised Trauma Score (RTS) yield ordinal data. Ordinal data are rarely normally distributed.However, GCS and RTS data are frequently analyzedusing statistical methods suitable only for normally distributed data. Misapplied statistical methods can result in erroneous conclusions. Hypothesis: GCS and RTS data from trauma patients are not normally distributed. Design/setting/patients:CCS and RTS lat arrival to the trauma room) for 427 patientswith injuries meriting trauma team activation at a Level I trauma center from October l, 1988,to December 31, 1989,were retrospectivelystudied.RTS data were grouped in incremental O.S-unit ranges.Individual and combined penetrating {P), blunt (B),nonhead {NH}, and head (H) iniury groups were analyzedfor normality and descriptivestatistics. Results:No group exhibited a normal distribution. GCS modes were 15 for all groups, except for the P-H mode of 3. Medians were 15 for all NH groups, 8 for B-H, and 7 for P-H. The modal RTS range was 7.6 to 8.0 for all groups.The median RTS range was 7.5 to 8.0 for all groups except B-H (5.6 to 6.0), P-H 14.5to 5.0),and H (6.6 to 7.01. Conclusion: GCS and RTS data are not normally distributed. Median and mode are appropriatedescriptorsfor GCS and RTS data.Nonparametricinferential statistics are appropriatefor CCS and RTS data. Non-normality causes mean and SD to be improper descriptors o{ GCS and RTS data. Parametric inferential statistical methods are inappropriatefor GCS and RTS data.

The Role of ililitary Emergency Physicians in Panama: Operation Just Cause

WHDice/ Department of EmergencyMedicine,BrookeArmy MedicalCenter,Fort Sam Houston,Texas Operationfust Causeprovided an opportunity to examine the role of emergencymedicine physicians in low-intensity military operations. Emergencymedicine, surgical,and anesthesiaspecialists accompaniedthe assaultforces and establishedcasualty collection points iCCPsI at each target. More than 260 casualties wereresuscitatedand stabilizedat the CCPs.Two casualtiesdied afterreachinga CCP. Casualtieswere flown from each CCP to a joint CCP.Surgicalstabilization was requiredfor 22 casualtiesat the joint CCP. Direct communication between medical teams was difficult but was not essential becauseof well-coordinated standardoperatingprocedures.A team at the ioint CCP coordinatedevacuationof casualtiesto the United States.The first casualtiesarrived at hospitals in Texas within t2 hours of the assault.From the drop zonesthrough hospitalizationin the United States, emergencyphysicianscaredfor combat casualtiesat every Ievelof the evacuationsystem. The successof the medical plan for Operationfust Causesuggeststhat the role of emergencyphysiciansin military operations extends from the front lines to fixedmedicalfacilities in the United States.

A Simulation llodel of Prehospital Eq, Trauma Care -RLWears, CN Winton, S Li, DJ Vukich/ Division of Emergency

3l


54

Resuscitative in Outcome

Thoracotomy

-

Trends

GS Rozycki, C Adams, HR Champion, R Kihn / Trauma Services and Emergency Department,Washington Hospital Center, W a s h i n g t o n ,D C Resuscitative thoracotomy may be successful in select trauma patients presenting in extremis. Recent escalation of urban violence has resulted in an increase in high-velocity multiple penetrating in,uries per patient. This study attempts to relatc those epidemiologic changes to resuscitative thoracotomy outcome c o m p a r e d w i t h d a t a f r o m o u r i n s t i t u t i o n i n 1 9 8 1 - 8 2{ 8 9 p a t i e n t s ) . ' Data wcrc recorded from 73 trauma patients admittcd over an l8month pcriod on whom resuscitative thoracotomy was performcd on admission. In all, c).6o7,' of paticnts survived. Eight paticnts suffcrcd blunt injuries, and all died. Of the (r5 pcnctratinginjurcd patrents, 32 had multiple gunshot or stab wounds; rone survivcd rcgardless of field time, admission vital signs, or wound anatomy. However, 2l% oI single-pcnctrating injurcd patients survived. When comparcd with our data in l98l-82, overall survival ratcs were not statistically significantly differcnt; howcvcr, significant diffcrcnccs in survival were notcd bctwccn multiplcand singlc-penetrating inlury paticnts. Wc conclude that thc blunt and multiplc-pcnctrating inturcd patients in extremis dcfinc a group in which rcsuscitativc thoracotomy is least effcctivc. With these data as a basis, largcr patient populations must bc cxamined to better identify zero prognosis indicators to maximize rcsuscitation efforts and minimize futile resourceconsumptlon. l . D a n n c P D , F i n e l l i F , C h a m p i o n H R : E m c r g c n c yb a y t h o r a c o t o m y ./ Tiaunta 1984;24:796-ttOL

55

A Prospective Study To ldentify HighYield Griteria For Predicting Acute Intracranial GT Findings ln Head

Patients , Injured W Schynoll, D Overton, D Wesolowski, AM Wang, R Krome, A Wilson, R Jackson / William Beaumont Hospital, Boyal Oak, M i c h i g a n ; W i l l i a m B e a u m o n t H o s p i t a l , T r o y ,M i c h i g a n ; S o u t h C h i c a g o H o s p i t a l ,C h i c a g o , l l l i n o i s Study hypothcsis: High-yicld clinical critcria can bc idcntifiecl to prcdict the likclihood of intracranial pathology, as dcfincd by noncnhanccd hcad computcd tomography (CT) in head-iniurcd Datients. Population: All emcrgcncy department paticnts with a history of hcad injury withrn the past two wceks and who underwent ngnenhanced head CT scanning were included. Methods: Head-injured patients from two community hospital EDs from December 2U, l9UU, through fanuary 1, 1990, were studied prospcctively. Nonenhanced head CT scans were ordered at the discrction of the treating clinician. Prior to obtaining the Cl the clinician completed a data form recording 5I variablcs on mechanisms of injury, patient symptoms, and physical findings. Each CT scan was read separately by thc same two neuroradiologists, each blinded to the other's reading. A positive CT was defined by specific radiologic criteria. Data werc analyzed using 1z and Mann-Whitney U test methods. A P < .03 was considered to bc statisticallysignificant. Results: Of the 263 patients entered, 3l ll2%l had positive head CT scans. High-yield variables that were associated with positive CT scans included: G l a s g o wC o m a S c a l e< 1 0 ( P < . 0 0 1 ) Positive Babinski sign {/, < .001) L o s so [ c o n s c i o u s n e s>s J m i n u t c s Racoon's eyes (P <.02J {1' < .0041 Comatosestate lP < .002) Antegradememory loss (P < .008)

Focal motor paralysis {P < .002)

F i x e dp u p i l s ( P < . 0 1 )

Struck pedestrian {P < .01)

Variables such as vomiting, ataxia, seizure, sensory deiicit, reflex

asymmetry, or a history of seat belt or alcohol use were among those that wcre not associated with positive CT findings. Conclusion: In this study, nine clinical criteria were prospectively identified as high yield for predicting acute intracranial CT findings in head-iniured patrents.

56

Adult Minor Trauma Patients Do Well in Small Hospitals

*57

Fat Embolization in Trauma Facilities

JR Hedges, HH Osterud / Divisionof Emergency Medicine and Department of Public Health, Oregon Health Sciences University, Portland Study hypothesis: Adult minor injury trauma admissions farc well in small hospitals. Population: The Iirst 5,000 hospitalized trauma patients from o n e s t a t c d i s c h a r g e dd u r i n g 1 9 8 7 w e r e s t u d i e d . P a t i c n t s u n d e r a g e 18, having an Injury Severity Score ilSS) greatcr than 10, transfcrrcd to another health carc facility, or leaving against medical advicc were excluded. Methods: A rctrospcctive analysis of hospital dischargc information on paticnts meeting inclusion and exclusion critcria was performed. Outcomc mcasurcs werc lcngth of stay in the hospital ( L O S ) f o r p a t i c n t s d i s c h a r g e dh o m e a n d t h c s u r v i v a l r a t i o ( p r o p o r t i o n o f p a t i e n t s d i s c h a r g e dh o m e t o t h c t o t a l o f p a t i e n t s d y i n g i n thc hospital plus thosc dischargcd homc). Predictor variables wcrc spccific hospital, hospital bcd sizc, paticnt age, and trauma ccntcr designation. x2 and analysis of variance werc uscd to test significance (P < .051. Rcsults: Thrcc of 71 hospitals showcd a longcr mean LOS for thc 3,351 study patients {30.tt, 16.0, and l2.l days vs 4.1 to 8.0 days for all others; P < .05). Two hospitals with a longcr LOS w c r c g o v e r n m e n t - s p o n s o r e df a c i l i t i c s a n d t h c t h i r d r c l c a s c d o n l y n i n c p a t i c n t s t o h o m e . T h e r e w c r c 7 2 d c a t h s i n t h i s l o w I S Sp o p ulation. Thc mean age was significantly grcatcr for paticnts who dicd versus thosc discharged homc (74.5 vs 49.4 yr; P < .0011. Ncithcr thc survival ratio nor thc mean paticnt agc at death was found to diffcr by hospital bcd sizc or Levcl I trauma ccntcr dcsignation. Conclusion; Prior studics havc focuscd on thc role of trauma ccntcrs in managcmcnt of maior trdurrld; littlc is known about t h c o u t c o m c o f a d m i t t c d m i n o r t r a u m a p a t i c n t s . W c f < t u n dt h a t small hospitals gcncrally havc a mcan LOS and survival ratio equivalcnt to larger hospitals and Level I trauma centcrs.Despite a l o w I S S ,a d m i t t e d c l d e r l y p a t i e n t s a r e a t i n c r c a s c d r i s k o f d e a t h .

B T a n n e r ,J J o n e s , S C o h l e , P D a v i s o n / E m e r g e n c y M e d i c i n e Residency Program, ButterworthHospital, Michigan State U n i v e r s i t yC o l l e g e o f H u m a n M e d i c i n e ; D e p a r t m e n t o f P a t h o l o g y , Blodgett Memorial Medical Center,Grand Rapids, Michigan Study hypothesis: A postmortem study of trauma victims using a new histologic technique can accuratcly establish the incidencc o{ pulmonary fat cmbolism in relation to the timc of death, and type and the severity of injuries. Population: 9l consecutive blunt trauma victims seen at autopsy in Kent County, Michigan. Mechanisms of injury included motor vehicle accidents, falls, industrial trauma, assault, and strangulation. Methods: Lung sections were postfixcd in osmium tetroxide to detcct the presence of fat emboli. Depending on the number of occluded capillaries per low-power field, three differcnt gradesof fat embolism were distinguished. Hospital and autopsy records were then reviewed to determine time and cause of death and severitv o{ iniuries. Results: Major causes of death were central nervous system related {64), cardiothoracic (38), and abdominal (30). Pulmonary fat embolism was present in 69 cases {76%}. Although 39 victims died at the scene, 62"/" 124 of 39) had evidence of pulmonary em-

32


bolization at autopsy. Of those patients who died within 30 hours of arrival in the emergency department, gS% l2O of 2l) had evidence of moderate to severe fat embolization. Multiple fractures of the long bones, pelvis, and skull were the injuries most commonly associated with embolism. The incidence or severity of fat embolism did not vary with age or sex (P > .05). Conclusion: Our studies show that pulmonary fat embolism occurs vcry rapidly after severe trauma and is followed by !ncreasing numbers of fat emboli depending on the nature of the mortal injuries.

58

Extended Protective Effect of a Nonionic Surfactant by llultidose

Burns of Third.Deglee Treatment JC McPhersonJr RR Runner,KM Plowman,PW Paustian,RR Haase,JC McPhersonlll / EmergencyMedicine,MedicalCollege of ClinicalInvestigation of Georgia,Augusta;and Departments EisenhowerArmy Medical Center,Fort Gordon, and Pathology, Georgra We haveextendedthe treatment period following the acute interventionin burn therapy in which we demonstrateda substanin tissuedamageas evidencedby a significant reductial decrease tion in edema,RBC extravasation,perivascularfibrosis, vascular was necrosis,etc, if a nonionic surfactant,Pluronic F'127 lF-1271, administeredIV soon after the burn iniury {30 minutes after burnl. In this studv anesthetizedadult male rats {300 to 320 gl receiveda third-degreeburn (8% BSA)to the chest by dipping in a 70 C waterbathfor 12seconds.Thirty minutes after burn, the rats wereinjectedlV with salineor F-127solution (12mM/L concentration)at a dosageof ti ml/kg body weight. The same dosewas repeated everyfour daysfor 28 days.Blood sampleswere obtained for measurcmentof RBC deformability using a Technicon Ektacytometerand hematocrit. RBC deformability as measuredby filtrability has been shown by many investigatorsto decreasein burn patients.Likewise, in our burn model, employing an 8% BSAburn, thc saline control rats showed a small but significant in deformability by 72 hours (0.26 vs 0.25, P < .05) decreasc However,thcre was a significant decreasein deformability by 24 hoursin the F-127rats (0.26vs0.24,P < .05).By day 9 there was a small but significant increasein deformability 10.26vs 0.28, P < .051in F-127rats. The increaseddeformability was further elevatedby 12 days (0.26vs 0.32, P < .01)and remainedelevated through28 days{0.26vs 0.31,P < .01).The hematocrit was significantly loweredin the F-127rats by day 5 when comparedwith salinecontrols (35.0 vs 44.6, P < .001) and remained lower through28 days. These data support and extend those we have previouslyreportedshowing that the effectivenessof F-127tteatment of burns is most protective of tissue damagein the early post-burnperiodand by extendingthose {indings to include a significantefiecton the increasedRBC deformability seenhere with the multiple dosesof F-I27 and the right shift of the P., curve, both of which have a significant influence on burn wound healing.

Twenty-{our anesthetized Yorkshire swine underwent splenectomy and stainlesssteel wire placement in the infrarenal aorta and were instrumented with Swan-Ganzand carotid artery catheters. The wire was pulled, producing a 5-mm aortotomy and spontaneousintraperitonealhemorrhage.The animals were randbmly assignedto one of the three study groups: Control; HSD group in which a 4-mL/kg mixture oI 7.5o/oNaCl and 6o/oDex' &an 7Owas given IV; LR group in which 80 ml/kg LR was given IV. The volume of hemorrhageand the mortality rate in the HSDtreated animals were significantly greaterthan in nonresuscitated controls {1,340t 230 mL vs 783 + 85 mL and five of eight versuszero of eight, respectively,P < .05).The volume of hemorrhagein the LR group was signi{icantly greaterthan that in both the HSD and control groups {2,142 + 178 mLi P < .05). From these data, we conclude that in this model of uncontrolled hemorrhageresulting from abdominal aortotomy, the IV administration of HSD significantly increasedthe volume of hemorrhage and mortality. The accentuationof hemorrhagewas not as great as that producedby LR.

60

OJ McAnena,JA Marx, EE Moore/ Departmentsof Surgeryand of EmergencyMedicine,DenverGeneralHospital;The University ColoradoHealthSciencesCenter,Denver Study hypothesis:A limitation of diagnosticperitoneal lavage (DPL) is the early identi{ication of isolated hollow viscus iniury. irevious studies have suggestedelevated lavageamylase {LAM) and alkaline phosphatase(LAP)might prove useful in this identification. Methods: We retrospectivelyevaluated the role of lavageenzvme analvsisin the identification of these iniuries from a consecutive seriesof 158 patients who underwent laparotomyfor hollow visceral organ iniury. Only patients with grosslynegative aspirateand lavagJRBC below thresholdwere included for study. Results:5l patients underwent DPL, of whom 28 were positive basedon aspiiate,LRBC or lavageWBC {LWBC > 500/mm3}criteria. Of the 23 remaining patients,eachof ll with isolatedsmall iniury had LAM bowel iniury and both with pancreaticoduodenal of 20 or more. Six of these had LAP levels of 3 IU/L or more' None had a LWBC above 500/mm3. All six patients with colon iniury and two o{ the patients with gallbladderiniury had LAM less than 20 lUlL and LAP less than 3 IU/L. Conclusion:PreviousLAM criteria fol trauma require revision' LAM of 20 lU/L or more is highly specific for isolated srn'nll bowel injury. Lavageenzyme determinationsappearunhelpful in the detectionof colonic iniuries.

Fa

ta

59

Use of Hypertonic Saline/Dextran Versus Lactated Ringer's Solution as a Resuscitation Fluid Following Uncontrolled Ao*ic Hemorrhage in Anesthetized Swine

WH Bickell,SP Bruttig,CE Wade,J O'Benar,GA Millnamow/ Division of MrlitaryTraumaResearch,LettermanArmy Instituteof Research, Presidioof San Francisco,California;Saint Francis Hospital, Tulsa,Oklahoma Wetestedthe hypothesisthat following aortotomy, the admin r:istrationof hypertonicsaline/dextran(HSDI will increasehemorandmortality. In this study we also comparedthe e{fectsof i .thage IiSD to the administration of lactated Ringer's solution {LR).

Gontribution ol Peritoneal Lavage Enzyme Determinations to the llanagement of lsolated llollow Visceral Abdominal Iniuries

Base Delicit as a Predictor of

IniurY Abdominal Significant f I JW Davis,RC Mackersie,T Holbrook,DB Hoyt / Divisionof Trauma,Universityof CaliforniaSan Diego Medical Center The evaluation of blunt trauma patients for intra-abdominal injury is difficult. Base deficit has been shown to be a reliable indicator of shock and the volume of resuscitation.MiId (-3 to - 5), moderate{- 6 to - 14),and severe(< - l4f categoriesof base deficit were compared with a normal base deficit (2 to 2) to determine if base deficit predicted intra-abdominal.iniury. The records of 3,011 trauma patiettts suffering from blunt iniury admitted between Ianuary 1985and |uly 1988were reviewed.The presenceof intra-abdominal inlury requiring laparotomy was asiertained for each patient. A case-control analysis was performed to assessthe assotiation of base deficit category and intra-ab-

33


dominal injury. Abdominal Iniurv No (2,771) Odds Ratio

Base Deficit Category

P

Yes(240) 4.1,

967"

1.0

Mild

40"/,,

<.00001

43"/,,

rJ.3

< .00001

Severe

t2"/,,

zoy" 8"1 lv" 7"1,

2.7

Modcrate

u.9

<.00001

6.2.

<.00001

Normal

Basedcficit (<

61

32't'

A basc deficit of - (r or worse was significantly associatcd with i n t r a - a b d o m i n a l i n i u r y i n t h i s s t u d y . T h e a b s e n c eo f a s i g n i f i c a n t base deficit docs not excludc the possibility of intra-abdominal injury, but its prcsencc should bc considcrcd a strong indication for obicctive cvaluation of thc abdomen {diagnostic pcritoneal lavage, computcd tomography) in thc blunt trauma paticnt.

t612

Gerebral PhosPhate NMR Spectroscopy as an Obiective of Garbon Monoxide ToxicitY: A Pilot Study

K C H u t t o n , A B W o l f s o n ,J M M e n e g a z z i , J L M c C a b e , D S W i l l i a m s ' E S i m p l a c e a n u / U n i v e r s i t yo f P i t t s b u r g h A l 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 M e d i c i n e ; C a r n e g i e M e l l o n U n i v e r s i t y ,P i t t s b u r g h , Pennsylvania Study hypothcsis: Ccrcbral phosphatc NMR (P-NMRJ spcctroscopy can pr<lvidcan obicctivc corrclatc of carlron monoxidc toxicity, onc ihat, unlikc thc carboxyhcmoglobin (COHb) Icvcl, rcflccis tissuc toxicity and can bc used to cvaluatc thc cfficacy of standard thcrapics. Population: irlinc Flcmish giant rabbits wc'ighing (r.5 to 7.5 kg. Mcth<rds:Animals wcrc scdatcd, paralyzcl, and intubatcd, and artcrial and vcnous lincs wcrc cstablishcd. Thc skull was cxposcd and a surfacc NMR coil was suturcd in placc. Basclinc blood prcssurc, artcrial bltxld gas mcasuremcnts, and ccrcbral P-NMR spcctra wcrc obtaincd. CO cxposttrc was initiatcd with thc animals b r c a t h i n g a m i x t u r c o f 0 . 3 ( X ' C O , z l ' k , C ) , , a n d 7 t i . 7 ' Z 'N ' . P - N M R .o".tra *"tc obtaincd at fivc-minlltc intcrvals for two hours or fntil thc animal dicd; blood prcssurc and artcrial [rlood gas v a l n c s w c r c a l s o f o l l o w c d . A r t c r i a l C O H b l c v c l s w c r c o L r t a i n c da t basclinc and at l5-minutc intcrvals. Animals still alivc aftcr a two-hour cxposurc wcrc sacrificcd. P-NMR spcctra wcrc analyzcd for thc ratio of phosphocrcatinc to inorganic phosphatc {PCr/Pi) and intraccllular pH {ipH). Rcvcrsal of thc normal PCr/Pi to a valuc lcss than l.b was considercd to be clinically significant Rcsults: Of thc ninc animals entered into thc study, threc completcd the cntirc protocol. COHb lcvels rose rapidly, platcauing a l x s v e( t 2 " 1 , . A l l J p c c t r a o b t a i n e d w e r c o f s a t i s f a c t o r y q u a l i t y ' P C r / P i d c c r c a s c d ,6 u t r e m a i n c d a b o v e 1 . 0 e v e n i n t h c p r c s e n c c o f hypotcnsion, sevcrc metabolic acidosis, and transicnt h-ypoxia (mean PCr/Pi - 4.8 at baseline,2.4 at peak). Mean ipH changcd from 7.10 at basclinc to 6.87 at peak. Conclusion: In this model, cerebral P-NMR spcctroscopy may orovidc a clinically useful obiective correlatc of acute carbon monoxide toxicity. Further studies are required to define the value of this tcchnology in this and other models.

63

An Evaluation of O.E.D.' a llew' Rapid' Accurate Device for lleasuring Saliva Ethanol

TA Christopher,MW Timmerman,C Zalesky,JA Zeccardi I Pennsylvania Hospital,Philadelphia, ThomasJeffersonUniversity Hypothesis:Current devicesused to measureblood alcohol leveiJ include standardbreath alcohol analyzersand a semiquantitative saliva alcohol reagentstrip. We evaluatedthe accuracyof the Q.E.D. Saliva Alcohol Test, a new, rapid, inexpensive,easyto-usedevicethat gives a specificquantitative blood alcohol level by measuringsaliva alcohol concentrations.

Population: 42 adults, ages 2l to 45 with no history of recent a l c o h o l i n g e s t i o n , l i v e r d i s c a s e ,i a u n d i c e , a l c o h o l i s m o l o t h e r a d dictions, alcohol intolerance, or pregnancy volunteered for the study. Methods: Subiects wcre asked to drink 4 to 6 ounces of alcohol in thc form of liquor, becr, or winc over a 90-minute period. Blood and saliva samples were obtained for alcohol measurement at 30, (r0, 90, and 120 minutcs following the last drink. Blood samples wcre analyzed within a day by gas chromatography {GC} at a local clinical laboratory. Saliva samples werc tested immediatcly with thc Q.E.D. test. Blood and saliva test rcsults were comparcd using lincar rcgrcssion analysis. Rcsults: All 42 subjects completcd the study yiclding l6ti blood and saliva samplcs. The ra4gc of Q.E.D. saliva alcohol values was 0 to 145 mgidl. The tangc of CC blood alcohol values was 0 to 145 mg/dl. Exccllcnt corrclation was obtained betwcen individual saliva and blood alcohol valucs iCorrclation coefficicnt, r = 0.98; slopc, 1.0; standard less than l5 mg/dl in96o/. of a l l s a m p l c s a n a l y z c d ) .A n a d d i t i o n a l t r i a l c o n d u c t c d i n o u r e m e r gcncy dcpartment with paticnts suspectcd of alcohol ingestion vicldcd statistically similar rcsults. C o n c l u s i o n : T h c Q . E . D . S a l i v a A l c o h o l T e s t i s a n a c c u r a t ed e vicc for spccilic quantitativc mcasurcmcnt of blood alcohol lcvels. As ihc clinical, prchospital, mcdicolegal, and psychosocial aspccts of cmcrgcncy toxicologic screening bccomc bcttcr de' fincd, carly, rapid dctcrmination of blood alcohol lcvcls will be uscful.

*6 4

i?::T'".,:if::lY":?::T.1$'J:"":li

PC Armada,R Henning,I Khalil,J Glauser,M Allen/ Department of EmergencyMedicalServices,The MountSinaiMedicalCenter Ohio Cleveland, of Cleveland, Study hypothcsis:IV cocaincdircctly affcctscoronaryartcries and hcart musclc. Population:7 ancsthctizcddogs. Mcthods:Cocainc,in doscsrtf 0, 2.5,5, 7.5, 10,and I2.5mg/kg, was administcrcdas an IV bolus at 4O-minutcintcrvals.Cardiac rhythm, hcart ratc, ST scgmcntchangcs,R wavc amplitudc,left vcntricular{LV) prcssurc,and thc maximum ratc of LV prcssure risc ldP/dt max) and fall (dP/dt min) werc monitored continu" of variance' ously.Data wcre analyzcdby a multivariatcana-lysis Rcsults:Within 30 sccondsaftcr cachbolus of cocaine,ST seg' mcnt elcvation(1.5mm) occurred(P = .03),LV systolicpressure dccrcascd33%, dP/dT max decrcased467", and dP/dT min de' crcased 37"1, lall P < .001).These changesreturncd to control within 40 minutcs in dogsaftcr low-dosecocainc.Vcntricularfibrillation occurredin two dogs aftcr 7.5 mg/kg, in four dogsafter l0 mg/kg, and in one dog aftcr 12.5 mg/kg of cocaine.Prior !o u..rtti",,rii. fibrillation, maximum changcsoccurredat a dosebf I0 mg/kg in five dogs: ST segmcntsincreasedI.5 mm, R wave 48%, ampliludc decrcased28"1,,LV systolic pressurcdecreased dPidt max dccreased62"/" and dP/dt min dccreased70% lall P < .00r). Conclusion: Cocaine causessignificant cardiac ischemiaand depressionwithin 30 secondsof IV injection

65

Potentiation Lidocaine

of Cocaine Toxicity With

Davis,Schoolof of California, RW Derlet,T Albertsoni University Medicine,Sacramento in Study hypothesis:The toxic cffects of cocaineare enhanced the presenceof lidocaine. Population: Male Sprague-Dawleyrats {weight, 200 to 300 g)' Methods: Animals-reCeivedintraperitonealiniectionsof cocaine (10, 2O,35, ot 50 mg/kg),lidocaine(30 or 40 mg/kgl,ora combinaiion of all dosesof Cocainegiven simultaneouslywith and lidocaine30 and 40 mq/kg. The incidence,time to seizure, time to death were recordedin these groups and were compared

34


by x2 and analysis of variance, respcctivcly. Results: At doses of 30 or 40 mg/kg, lidocainc docs not induce seizures or death. The effect of simultancous injcction of cocainc and lidocaine dramatically increascd thc incidence of both scizures and death above cocaine alonc. Thc incidence of scizurcs in animals receiving 35 mg/kg cocainc alonc was l0%': this increased to 50% and 80% with the addition of lidocaine 30 and 40 mg/kg, respectively {P < .05, P < .01). Dcath did not occur in animals recciving 35 mglkg cocainc alonc: the addition of lidocaine 30 and 40 mg/kg resulted in death of 30'X' and 60"1, of animals, respectively (P < .01 each group). Similarly, in rats rccciving 50 mg/kg cocaine, the incidcnce of death incrcascd from zero to 60% and 80% with lidocaine 30 and 40 mg/kg, respcctivcly lP < .Oil. Conclusion: The overall toxicity of cocainc is significantly increased with the simultancous exDosure to lidocaine in thc rat.

66

Bole of Repetitive Kayexalateo in Lowering Serum Lithium Goncentrations in the Mouse

JG Linakis,PG Lacouture,MS Eisenberg,TJ Maher,WJ Lewander, JL Driscoll,AD Woolf/ RhodelslandPoisonCenter, Departments of EmergencyMedicineand Pediatrics, Rhodelsland Hospital, Providence; Massachusetts PoisonControlSystem, HarvardUniversity; Massachusetts Collegeof Pharmacy,Boston Previouswork has demonstratedthat sodium oolvstvrenesulfonate{Kayexalate@) significantlylowcredsc.u- iithium conccntrationswhen administeredin a singlc oral dqseafter an oral dosc of lithium in a mouse modcl. This effcct was hypothesizedto be the result of decreasedsystemic absorption of lithium. This studywas designedto detcrmine whether repetitive dosesof Kayexalate@ are effectivein enhancingthc climination of lithium. Mice (N = 144)were given orogastriclithium chlorideand thcn dividedinto threegroups:groupC (controls)reccivedwater 0, 30, 90, I80, and 360 minutes after lithium, group K reccivcd KayexaIateo{5 g/kg/dose} at equivalenttimcs, and group E (climination group)receivedwater 0 and 30 minutes after lithium and Kaycxalateoat 90, 180,and 360 minutes after lithium. Scrum was sent from subgroupsof each group at one, two, four, and cight hours after treatmentand analyzedfor lithium concentration.When comparedwith the controls, group K had significantly lowcr serum lithium concentrationsat each of thc timc noints tcstcd. Furthermore,although the controls and thc climination group werenot significantly different at one, two, and four hours after treatment,by eight hours, the elimination group'sserum lithium concentrationwas significantly lower than that of the controls. This suggeststhat over time, repeateddosesof Kayexalate@ actually servedto enhancelithium elimination. This is further supportedby the finding that at one, two, and four hours, the Kayeigroup's serum lithium concentrations were significantly alate@ lower than the elimination group's,but by eight hours, the di{ferencewas no longer significant. These results suggesta possible role for the enhancementof lithium elimination with repetitive dosesof Kayexalateo.

*67

Protective Effects of Felodipine, l{imodipine, and Velapamil Against lmipramine-induced Lethal Gardiac Conduction Disturbances in the Anesthetized Rat

DF Schooks,H Reynaert,H Spapen, L Huyghens,W Vincken,L Corne/ Departmentof Emergencyand IntensiveCare, University Hospital,Brussels,Belgium Toxic concentrationsof tricyclic antidepressantdrugs (TCA) a{ter overdoseare frequently associatedwith seizuresand electrocardiographic(ECG) and hemodynamic changes.We assessedthe effectof verapamil,felodipine, and nimodipine on imipramineinducedcardiactoxicity. In preliminary experiments the minimal

lcthal dosc of imipramine was l0 mg/kg IV. Forty-two male Wistar-Kyoto rats (weight, 352 ! 32 g) werc anesthctizcd with sodium pcntobarbital (40 mg/kg IPI and cquippcd with an intraartcrial cathctcr, allowing continuous rccording of blood pressure. ECG rccording was pcrformcd using thrcc subcutancous nccdlc clcctrodcs. Both jugular vcins wcrc cannulatcd. Thc right jugular vcin was uscd for pcrfusion of salinc {scvcn),verapamil (30 and 100 pg/kg/min; l4), felodipinc 13and (r pgikglmin; l4|, or nimodipinc (1 pglkg/min; sevenI in dosesnot significantly changing blood pressure.Fiftccn minutcs aftcr starting thc infusion, a lO-mg/kg bolus injection of imipraminc was givcn through thc lcft jugular vcin. All rats pretrcatcd with saline dicd within 2.33 + 0.75 minutes. ECG recording showcd sinus bradycardia, followed by atrioventricular and intravcntricular conduction disturbanccs, with marked widcning of QRS (from 0.037 * 0.003 to 0.0U8 + 0.010 seconds; P < .001)and significant incrcasc of the RS hcight (+53.1 * ll.l"l,j P <.01). In contrast,rats prctrcatcd with vcrapamil (30 and 100 pglkg/minJ, fclodipinc (3 pg/kg/min), or nimodipinc (l pglkg/min) survived throughout thc cxpcrimcnt, dcspite an initial fall in blood pressurc, which was lcss pronounccd than aftcr saline. Howevcr, ECC monitoring showed still significant QRS widening and RS height incrcasc. All rats pretreatcd with (r pglkg/min of felodipine survivcd, and imipramine did not induce ECG changcs {QRS width, 0.037 + 0.003 scconds before imipramine vs 0.038 + 0.004 scconds aftcr imipramine; NSI (RS height, + 9.1 * 3.3"1,iNS). Thcsc findings suggcst that pretrcatmcnt with vcrapamil, fclodipinc, and nimodipinc protects against the cardiac cffects of imipraminc, possibly by prcvcnting thc catccholamincrgic action. As far as felodipinc is concerncd, an additional intcraction with thc calmodulin-Ca2t complex could play a role. A randomizcd, doubleblind, placcbo-controllcd clinical trial is currcntly undcr invcstigation in our cmcrgcncy departmcnt.

68

Passive Hemagglutination Inhibition Test for Diagnosis of Brown Recluse

Spider Bite Envenomation KE Blick/ Sectionof Emergency SM Barrett,M Romine-Jenkins, of Medicine,Departments of Surgeryand Pathology, University OklahomaHealthSciencesCenter,OklahomaCity inhibition Our goal was to recreatea passivchcmagglutination (PHAI))tcst to diagnoscbrown rcclusc spidcr (Loxo.sceles reclusal b i t e e n v e n o m a t i o n .R a b b i t s w e r c i m m u n i z e d w i t h u l t r a centrifugedwhole spidervenom to raiseantibody.Group O human RBCswere incubatedwith venom to allow vcnom adsorption to RBC membrancs.If spidcr venom is prcscntin the skin lesionexudatetest sample,this venom will bind with rabbitantibody so that no free antibody rcmains to agglutinatcvcnomc o a t e d R B C s .T w e n t y - s i x s e p a r a t ei n t r a d c r m a l i n f c c t i o n so f brown recluse spider venom {avcragc,24 pgiinjection) were perintradermalinjcctionswere formedin guineapigs.Threeseparate made with venom from Argiope sp. No necrotic lesions resulted Irom intradermal injections with venom from Lycosa.spiwolf spiderJ.Multiple separatecollections from skin lesions were performed from one to three days after inoculations.Thc sensitivity oi our PHAI test preparationfor diagnosisof brown reclusespidcr envenomationin guineapigs is 90.2% {positivetest, 46 of 5l exudate collections). The PHAI test specificityis 100%with venom from other spider speciesin vivo (four test samples)and in vitro (five test samples)and with exudatefrom one nonspiderbite human lesion. Each batch of PHAI tests includes positive and negative controls,and the test proved to be accurateand reproducible.

*69

Gonlirmation of Endotracheal TUbe Position: A lliniaturized lnfrared Qualitative GO, Detector

RB Vukmir,MB Heller,KL Stein / Departmentsof Anesthesiology, CriticalCare Medicine,and EmergencyMedicine,Presbyterian-

35


U n i v e r s i t yH o s p i t a l , P i t t s b u r g h , P e n n s y l v a n t a Study hypothesis: A miniature, infrared, solid.-state CO" detector {vrinicap III) can be used to accurately confirm endotracheal tube placement. Population: 68 consecutive adult patients requiring emergency intubation in the emergency department, ICU, or ward settings' Methods: This prospective clinical trial consisted of 75 cases Di{{iculty of intu'bation and confirmation of endotracheal tube placement were recorded using a linear scale of zero ileast) to l0 exact test (o = imost). Comparisons between groups use Fisher's

.05) R.rrllts'Casesincluded60 (80%)ICU,ninell2"l')ED,andsix

(8%) ward patients.The indication was consideredurgent.in 62 Route of intubation i}z.i"/"1 ^.rd .-.rg..rt (arrest)in 13 117.3%1. nasalin Iive 16J%) and tracheostomyin was oral in 68 1.90.7%1, The mean number of intubation attempts *?t.!:ll two 12.7%). was 6'41,and diffilimg!,'oio". to four); difficulty o{ intubation confirmation was 7.47. Capnometric dctermination of t"f,i endotrachealtube position revealedintratrachealintubation in 72 196%land esophagealintubation in three (47u! cases Thcse were all confirmedby radiographyor direct visualization Scnsitivity and specificity ior endotrachealtubc localization was 1007u lP < .00011. EndotrachealTirbe Position I raencal

Esophageal

Minicap III

Tracheal 72 True-postttve ( loo'2,) 0 F a l s c - p otsi vi e

{0'x, )

Esophageal U Falsc-negative (0'x,l 3 T r u c - n c g avt ic (I ( X ) ' U ),

Conclusion:Corrcct position was dctcrminedin all 75 cascs cardiacor traumaticarrt-st,by usc (100%),including 13(17..i'X,Jin in{raredCO" detector of the miniaturc, s<-rlid-statc,

70

Key Role of Prehospital Resuscitation in Survival From Out'of'HosPital Cardiac Arrest

M J B o n n i n ,P E P e p e , P S C l a r k J r / D e p a r t m e n t o f M e d t c i n e , Baylor College of Medicine; City of Houston Emergency Medical Services, Houston.Texas In view of the inherent hazards of cmcrgency transport/ wc examined the valuc of continued cmergency dcpartment resuscltapative efforts for nontraumatic out-of-hospital cardiac arrest tients (OHCAPS) when prehospital advanccd life support {ALSJ {ailed io achieve restoration of spontaneous circulation' For 16 months, all OHCAPS were pr,rspeitively studied.in terms of multiple {actors including thc timing of ALS procedures, restoratron u{' ronn,^.tao,rs circul-ation, in-patient admission, and successful hospital discharge. Results: Of th; 1,283 OHCAPS studied, 909 did not attain pr'ehospital restoration of spontaneous circulation' Despite further efft-,lts at the ED, only 18 of these {2%) achievedin-patient admission and only two (ri.z%1 werc even-tuallv discharged' Both sur vivors had presented and remained in ventricular fibrillation throughout ihe prehospital phase, and both were left with residual nJurologlcal'deficits. Duiing the study period, the overall discases was abott 20Y", charge rate" for ventricular fibrillation wheieas mean ALS scene and transport times were 27 '8 and 7 I minutes, respectively. Conclusion: With the sole possible exception of refractory ventricular fibrillation cases, the;e data support the validity-of terminatinq resuscitative efforts at the scene when patients do not regain pulses after standard ALS interventions'

71

Gorrelation of Central Arterial Blood Gas Values With Perfusion During Gardiac Arest in a Ganine lilodel

DJ DeBehnke,JE Leasure/ WrightStateUniversity MG Angelos, -of School Medicine,Departmentof EmergencyMedicine,Dayton' Ohio Previousstudieshave shown end-tidal CO, to reflect coronary perfusion pressure{CorPP},which is a key prognostic outcome variable during ventricular fibrillation' Study hypotlesis: Arterial Paco, and pH correlatewith CorPP durins'veniricularfibrillation, therebyprovidingan indirect ass.ss-l.tt of myocardial perfusion. corPopulation: i4 rno.tgt.1dogs with left anterior.descending o.rrry ,r,..y occlusionfollowcd by ventricular.fibrillationwere resuscitatedalter 12 minutes of ventricular fibrillation i""i6-f' *ith ttr.td".,t external CPR and epinephrine(CR I, eight),cardiopulmonary bypass {GR Il, eight), or open-chestCPR (GR III' eightJ. "Methods: Central arterial blood gas and hemodynamicdata *.r" rn""rt:tad at predeterminedtimes during ventricular fibrillation. Group comparisonswere done with I tests and analysis of variancewith a Tukey post-hoctest Correlationwasdctermined using a Pcatsoncorrelationwith a Bonferroniadiustment' R.tultt, Suring Thumper'ECPR and beforeinstitution of technique, there *ete-.to significant differencesin CorPP,Pacor, pH, o,'brr. excess.Two ,n iht." minutes alter technique,Pacot and in CR II pH were significantly higher and lowcr, resp-ec-tively, * 0.12)and GR III (Paco2,34 ! Izi iPr.,,tr., 'ptl,Li'l:t46\ lst pH,7.04 17 t ll; pH, 0.02)when comparedwith GR I {Pat:cr-r, 7.q1 ). o.tz), (P < .05).Survivors(la) had significantlyhigher and lower pH (P = 0llJ tha-n CorPP(P = .03),P"<.,,,,(P = .01.5), = '002) nn.,struiunrt (eight).pif showcd a strong correlation (P a *.iket iorrelation (P = '055)with CorPP' Pac;c>, and Cnrr.lrrt'in.t'Central arterial pH and Paco, may reflect the adequacy of perfusionand predict resuscitationoutcome during ventricular f ibrillation.

The Effect of High- and Low'Dose Perfusion, on Myocardial Epinephrine Gardiac Output, and End'Tidal Garbon Dioxide During Prolonged GPR PB Chase,KB Kern,AB Sanders,CW Otto,GA Ewy / Universtty of Arizona,Collegeof Medicine,Tucson Study hypothesis: There will be no difference in myocardial perfusionpressureimyocardialblood flow, cardiacoutput, or endiiJri cO, partial pressure(P.1co"J after infusion of no-, low;;;, ;;d'tiign aoi. epitteph.Ine during prolonged cPR in the porcine model of cardiac arrest. ' Poprrlation,l0 swine (weight, 20 to 35 kg) were studied Each animal _ t u t o l " served ' o d ' . A fas t e its r t hown r e e mcontrol. inutesofuntreatedventricularfibrilla.

lqa ' I

3

tion, each animal receivedfive minutes of standardCPR without epinephrine,five minutes of CPR after low-doseepinephrine epif 0 . 0 2 ' m g l k g ) ,a n d f i v e m i n u t e s o f C P R a f t e r h i g h - d o s . e ;;hil; {0."i'mglkg), for a total of 15 minutes of closed-chest CpR. Rnimal, i..i ittttr,rmented to obtain aortic and right pr.tt.ttes and for infusion of microspheresfor cardiacout*iu* P"rco, levelswere continuouslymonitored' out detirminations. 'Cardiac outputs and iegional myocardialblood flow were measured with nonradioactive,colored microspheres'Repeated-measures analysis of variance was used to determine statisticalsig.. nificance. n.t"i,t, Myocardial perfusionpressure,was significantly-in+ I creasedover baselinewiih high-doseepinephrine(15 5 vs 32 t 9 mm Hg; P < .01)but not low-doseepinephrine(15 t- 5.vs2l frll Epinephrine's effect on myocardial blood flow was O -+ 12 mLl similar - increasing after high-dose(13 :: 3 vs 60 epinephrine low-dose i13-t 3 vs .tot a{tir < 5rlt -itrltOO g; P .05) 25 + 12 ml/min/100 g). Cardiac output d;cre;sed significantly < after high-doseepinephrine{213 L 30 vs ll4-t 22mLlmini P + .tjii1"f "", lo*idote epinephrine (213 't .30.vs 173 37 mL/ min). Epinephrine'seffect on Putco, paralleledcardiacoutput'

36


Mean Prtco, decreased after high-dose epinephrine (19 + 2 vs 15 + 3 mm Hgt P < .05) but was not a{fected by low-dose epinephrine ll9 ! 2 vs 19 + 2 mm Hg). Conclusion: High-dose epinephrine enhanced myocardial perfusion pressure and myocardial blood flow despite significantly decreasing cardiac output and P.tco" during prolonged CPR.

tzg

The Futility of PrehosPital Resuscitation of trgn6-6f.Lifg" Cardiac Arrests

S Dul/,RO Cummins,JR Graves,MP Larson/ Universityof Washington Schoolof Medicine,Departmentof Medicine, of Washington;Centerlor Evaluationof Emergency University CountyDepartmentof Public MedicalServices;Seattle-King Health,Divisronof EmergencyMedical Services,Seattle Study hypothesis:Our hypothesisis that a significant proportion of out-of-hospitalresuscitationsare attempted against the prearrestwishes of the patient, the family, or the patient'sphysicianor for patientswho have medical conditions that would indicate their arrest was an expected"end-of-life" event. Population:The population consistedof adult patients with nontraumaticcardiac arrestswho were treated by King County, Washington,paramedicsin 1988. Methods:We performed a retrospectivechart review of paramedic incident reports and hospital outcome data. Variablesincludedage,sex, comorbid conditions,prearrestmedications,and no-codestatus as stated by patient {living wills), family, or patient's physician.We defined an arrest as a potentially expected end-ollife event if cancer,renal dialysis, thoracic or abdominal accident,cirrhosis,or AIDS was presaneurysm,cerebrovascular ent or if there was evidence that patient, family, or physician desiredno resuscitationefforts. Results:Overall, 17"/'of 633 patients (108)survived to hospital Twenty-nine percent of the resuscitationattempts discharge. (183)were Ior patients with a potentially end-of-life event; 57o {nine)were success{ullyresuscitatedand survived.Sevenpercent of all cardiacarrests{471had evidencethat a resuscitationeffort was not wanted; 3% (two) of these patients survived to hospital Nursing homes were the site of arrest fot l2T" of all discharge. resuscitationattempts 173l;3"/" (two] of these patients survived. Patientswith an end-of-lifearrest{144)or occurrencein a nursing home (341or both (39) comprised 34% of the resuscitation attempts;5% {ten) of these people survived. Conclusion:In our system, expectedprehospitalarrestsmade up a sizeableproportion of all resuscitationattempts. These attemptswere largelyfutile and often a violation of the principle of death with dignity. Physicians must help families, nursing homes,and patients prepare for anticipated deaths. Emergency medicalservicessystemsshould institute methods to report expecteddeathswithout activation of inappropriateresuscitation attemDts.

*74

Association Between Plasma Gholinesterase Activity and Gocaine Toxicity

RSHoftman,GL Henry,RS Weisman,MA Howland,LR Goldfrank/ Bellevue HospitalAdult EMS; New YorkCity PoisonControl Center;St John'sUniversitySchoolof Pharmacy,New York Studyhypothesis:The severity of cocaine toxicity may be assoplasma cholinesteraseactivity. ciatedwith decreased Population:The study population consisted of 148 consecutive and 24 control Datients. cocaine-intoxicated Methods:Basedon a predeterminedset of criteria, prospective patientswho presentedto the emergency department with signs and symptomsof cocaine intoxication were divided into two goups - life-threateningand nonlife-threatening toxicity. CoI saineuse was confirmed by urine screening for cocaine and benTwenty-four patients with life-threatening criteria : Eoylecgonine.

but negative histories and negative urine screens were chosen as controls. Plasma cholinesterase activity was determined for each patient by a blinded investigator using the Michael method. Plasma cholinesterase activities were compared by analysis of variance. Results: The mean plasma cholinesterase activities of the lifethreatening, nonlife-threatening, and control groups were 682, 904, and 1,058 units/L, respectively. A11 results were significantly diffetent from each other {P < .0001 for life-threatening vs nonlife-threatening, P < .00001 ior life-threatening vs control, and P : .03 for nonlife-threatening vs control). Conclusion: Severe cocaine toxicity is associated with decreased plasma cholinesterase activity. Clinically ill, cocaine-free patients_ have greater plasma cholinestelase activity than either group ot cocalne users.

roxic iH,[-ff51lllTi*'n D Jerrard,VP Verdile,D Yealy,E Krenzelok,J MenegazziI

*7 5

of AffiliatedResidencyin EmergencyMedicine,University ol Divisionof EmergencyMedicine,University Pittsburgh; Centerfor EmergencyMedicineof Western Pittsburgh; PittsburghPoisonCenter,Pittsburgh Pennsylvania; Study hypothesis:An inverse relationship exists between acetone produition and isopropanolmetabolism in the setting of a toxic ingestion oi isopropanolthat is coincident with acidemia. Population: 6 male mongrel dogs (weight, 22 to 24 kg; mean, 22.6 kg). Methods: Each dog was fastedovernight, anesthetizedwith 25 mg/kg IV pentobarbital,and intubated endotracheally.A _nasogastrictube was inserted,and each dog was given a toxic dose {60 mL} of 70% isopropanol.Simultaneous acetone and isopropanol levels as well as arterial blood gaseswere drawn through an indwelling femoral artery catheter at 15 and 30 minutes and one, two, three, four, five, and six hours. Aliquots of serum were harvested,ftozen, and later assayedby gas chromatography. Descriptive statistical analysis was done with means and slandarddeviations,and acetoneand isopropanollevels were correlatedwith Pearson'scorrelationcoefficientwith P < .05 denoting statistical significance. Results: Levels of acetoneand isopropanolcorrelatepositively throughout the study model with an r of .54 iP < .001). Time(hrl 0.25 0.50 Isopropanol(mean) 91.9 99.8 120.9 141.4 169.6 148'0 145.6 143.1 6.8 22.1 32.6 35.5 34.L 23.9 17.2 13.1 lsopropanol{SD) 4.3 6.3 8.3 15.4 2O.5 24.5 284 37 3 A c e t o n el m e a n ) A c e t o n e( S D )

|.2

3.3

4.2

5.8

5.7

69

8.6

5.5

Conclusion: In this model, acetonemia occurs rapidly in the serum {within l5 minutes of ingestion) and continues to rise after the isopropanol level plateaus. Acetone's persistence as a serum marker can be beneficial in identifying isopropanol hours after a suspected ingestion. Significant acidemia was not produced in this animal model.

76

Gomparison of Labetalol' Diazepam' and Haloperidol for the Treatment of Gocaine Toxicity in a Swine llodel

WH Spivey,JM Schoffstall,R Kirkpatrick,L Fuhs/ Departmentof EmergencyMedicine,Divisionof Research,The MedicalCollege Philadelphia of Pennsylvania, Study hypothesis: Drugs that inhibit seizure activity will diminish theioxic effectsof an acute cocaineoverdose.This study compares diazepam,labetalol, and haloperidol {or the control of seizures and hypertension in an acutely cocaine toxic swine model. Population: 19 unanesthetizedswine (weight, l0 to 15 kg) with

37


r if

chronically implanted artcrial and vcnous cathetcrs. Methods: All animals receivcd a cocainc infusion of I mg/kg/ min IV with continuous monitoring of blood pressurc and heart rate. After ten minutes, thc animais received0.2 mg/kg diazcpam {four), 1.5 mg/kg labetalol (five), and 0.1 mg/kg haloperidol (fivc) IV over onc minute; five animals servcd as controls. Cocainc infusion was continued until the animals developed ventricular arrhythmias, status epilepticus, or respiratory compromise. Blood was drawn every five minutes for measurcment of epincphrinc and norepinephrinc levels. Data wete analyzed by analysis of variance with Tukey A post-hoc tests. Results: Blood pressureand heart ratc incrcascd in all animals with the infusion of cocaine. With thc infusion of diazepam, labetalol, or haloperidol, therc was no significant changc in eithcr paramcter at fivc minutes. All animals receiving cocainc, labetalol, or haloperidol dcvclopcd multiplc seizures aftcr a mean of 14.8, 18.2, and 15.7 minutcs, rcspcctivcly. Only two of four animals devcloped scizures in the diazepam group (mean, 35 m i n u t c s ) l P < . 0 5 ) . T h e c o c a i n c i n f u s i o n w a s s t o p p c d b e c a u s eo f toxicity at a mcan (t SD) o{ ZO ! 2,41 + 8, 2l + 3, and 3l + 10 minutcs for the cocainc, diazepam, labetalol, and haloperidol groups, respcctively. There was no significant differcncc for epinephrinc or norepinephrinc among the four groups. Conclusion: Multiple seizures arc a significant factor in thc pathogcnesis of cocainc toxicity. Diazcpam offcrs thc grcatcst protcction for cocainc-induced scizures and toxicity.

77

Potentiation by Ethanol ol the Cardioinhibitory Response to Activation of Gardiac G.Fiber Allerents - lmplications for Sufferers ol Myocardial Infarction

E K i r k m a n , H W M a r s h a l l ,J H e y w o r t h , R A L i t t l e / M e d i c a l R e s e a r c h C o u n c i l S c i e n t i f i cS t a f f ,N o r t h W e s t e r n I n j u r y F e s e a r c h C e n t r e , U n i v e r s i t yo f M a n c h e s t e r ,U K

I

This study was dcsigned to tcst thc hypothcsis that cthanol m o d u l a t e s t h c r e f l c x c a r d i o i n h i b i t o r y r e s p o n s ec l i c i t c d b y a c t i v a t i o n o f c a r d i a c C - f i b e r a f f c r c n t s . E i g h t b c a g l c d o g s l w c i g h t , 1 1 . 5t o t 1y1. 2 3 . 0 k g ) w c r c a n e s t h e t i z e dw i t h a - c h l o r a l o s e( 1 1 0m g ' k g Cardiac C-fibcr afferents wcrc stimulated with vcratridinc injected either into thc left atrium {sixJ or dircctly into thc coronary arterics (two) beforc and during IV infusion of cthanol. Statistical analysis was conducted using a Wilcoxon matchcd-pairs signed-rank tcst with significance at P < .05. In 14 tests in six dogs, left atrial iniection o{ veratridine (0.33 to I.74 pg' kg I) produced a significant bradycardia, with heart rate falling from 146 + 5 to 50 + 3 beats/min imean * SEM) and a significant reduction in mean arterial blood pressure of 43.5 + 2.6 mm Hg from 136.4 + 4.1 mm Hg. During infusion of ethanol (blood alcoh o l l e v e l , 1 3 4 . 8 + 8 . 4 m g % ) t h e c a r d i o i n h i b i t o r y r e s p o n s et o v c ratridine was significantly greater (heart rate falling to 25 + 2 beats/min; mean arterial blood pressure falling by 55.3 + 7.8 mm Hg|. Similarly, the cardioinhibitory response to coronary arterial injections of veratridine was greater during cthanol infusion. In conclusion, ethanol markedly potentiates the reflex cardioinhibition elicited by stimulating cardiac C-{iber afferents. This may suggest a mechanism for unexplained cardiac arrcst and sudden death after small myocardial infarcts (which also activatc these afferents).

78

Gomparison of Epinephrine and Galcium Therapy of Galcium Ghannel Blocker Toxicity in a Gonscious Dog llodel

JM Schoffstall,WH Spivey,L Gambone,SG Crespo,SP Sit, BP Department of Shaw/ The MedicalCollegeof Pennsylvania, Janssen EmergencyMedicine,Divisionof Besearch,Philadelphia; SpringHouse,Pennsylvania ResearchFoundation, Study hypothesis: Calcium and epinephrinediffer in their ef-

fects on thc hcmodynamic consequcnccsof poisoning with calc i u m c h a n n e l - b l o c k i n g a g c n t s n i f e d i p i n c , d i l t i a z c n " r ,a n d v e rapamil. Population: Conscious dogs (weight, l8 to 22 kg; nifedipinc, six; diltiazem, four; verapamil, fivc). Mcthods: Under anesthcsia, dogs wcrc instrumcntcd with an electromagnetic flow probc about thc aortat a pressurc transduccr in thc lcft vcntriclc, a cathetcr in thc thoracic aorta, and flow probcs around the circumflcx coronary, left rcnal, and right iliac arteries. Experimcnts wcrc performcd two to threc wccks after surgcry. Nifedipine, diltiazem, or vcrapamil wcre given by l-mgi kg IV bolus ancl thcn titrated to maintain mcan artcrial pressurc ^t 3O'% bclow baselinc. Aftcr 30 minutcs of hypotcnsion, epinephrine was infuscd by IV bolus (0.1,0.3, and 1.0 mg) tcn minutcs apart, followcd by calcium chloridc (0.1,0.3, and 1.0g) ten minutes apart. Hcmodynamic paramctcrs wcrc mcasured as percent changc from prcinfusion valucs at pcak cffcct of cpincphrinc or calcium and five minutcs after cnd of epincphrinc or calcium infusion. l)ata were analyzcd by analysis of variance with posthoc I tcsts using thc Bonferroni correction; P < .05 (corrected) w a s c o n s i d c r c ds i g n i f i c a n t . Rcsults: Both cpincphrinc and calcium significantly clevatcd mcan artcrial pressurc and cardiac output at peak cffcct. Mean artcrial pressurc was significantly higher at pcak cf{ect for epincphrinc than for calcium in all thrce agents,and thc cffcct was dosc rclatcd. At fivc minutcs after infusion, howcvcr, mcan arterial pressurc was significantly highcr for calcium than for epincphrinc. dP/dt showcd a sirnilar pattcrn. Cardiac output at both pcak cffcct and fivc minutcs aftcr infusion cxhibitcd a dosc-relatcd trcnd for both cpincphrinc and calcium that did not reach significancc. Rcgional blood flows showcd no clcar trcnd favoring cpincphrinc or calcium. Conclusion: Calcium produccs lcss immcdiatc but longcr-lasting improvcmcnt of mean artcrial prcssurc and inotropic statc than cpincphrinc ir-r thc sctting of calcium channcl-blocking agcnt toxicity.

79

Prevention of Gardiac Arrest-lnduced Neurologic Injury and Delaied Mortality by a High Molecular Weight

Ghelator of lron of RE Rosenthal, GH MarshallJr, RF Shesser/ Department Medical University EmergencyMedicine,The GeorgeWashington DC Center,Washington, Study hypothesis:Reactivciron has becn implicatedasan initrator of peroxidative neuronal damageafter resuscitationfrom cardiac arrest. Beneficial effects of postischemiciron chelation with deferoxaminemay be diminished by the hypotensiveeffects of IV deferoxamine.This study tests the hypothesisthat a new high molecular wcight iron chelator IHMWCI without hypotensive cffects will improvc ncurologic outcome and survivalafter. cardiacarrest. Methods: In a nonrandomizcd controlled trial, male Wistar rats were ventilated on room air and underwent 6.5 minutes of, car- ,. diac arrest induced by intracardiac inlection of 0.4 mL cold l7o KCI and thoracic compression. Return of spontaneous circulation' was accomplished with IAC CPR synchronous with 100%02 ventilation. Fifty-six sutvivors altcrnately received IV injections of either HMWC {deferoxamine covalently attached to hydroxyethyl starch, Biomedical Frontiers, Inc) at a dose of 100 mg de' feroxamine/kg or saline. Ventilation with 100% O, was continued for 30 minutes before return to room air. Animal survival was recorded daily. Neurologic deficit scores of survivors were measured at days l, 3, and l0 by blinded observers. Results: Neurologic deiicit scores were significantly less {Wilcoxon rank-sum significance, P < .5) in the treated group at day I (HMWC, I2.O + 13.4; control, 29.1 + 16.9; P : .00061and day3 * 14.7; P = .002) and ap{HMWC, 5.3 t 7.1i control, l9.O proached significance at day 10 (HMWC, 2.8 * 8.7i control, 69 + 14.0; P : .0591.While mortality was similar (Pearson's12 anal-

38


P < .5)during thc first 24 hoursIHMWC, five of ysissignificance, 28; control, four of 28i P : .721,delayed mortality (days I through10)among 24-hour survivorswas significantly reducedin the treatedgroup(13%)comparcdwith controls142%llP - .0281. Conclusion:The covalent attachment of deferoxamineto hydroxyethylstarch permitted safe administration o{ high-doscdefcroxamineaftcr cardiac arrest. There was significant improvcmcnt in neurologic outcome in those animals receiving HMWC after cardiacarrest, thus contributing to decreascddelayedmort a l i t yw i t h H M W C a d m i n i s t r a t i o n .

tBo

Effects of Ghemical lnterventions on Functional Recovery Following Glosed. l{ead Trauma in Rats

MH Biros,W Heegaard/ HennepinCountyMedicalCentet Minnesota of EmergencyMedicine,Minneapolis, Department Studyhypothesis:By reducingcerebraledcmaaftcr closed-hcad traumain rats, l,3-butanediol(BD) and dichloroaceticacid {DCA) will improve functional recovery in animals subiectedto closcdheadtrauma. Population:Adult male Spraguc-Dawlcyrats were pretrainedin avoidance and balancetasks and randomly assignedto cxperimentaltreatmcnt groups (DCA, 25 mg/kg [eight];BD, 47 mM lll]| or controlgroups(equivolumenormal saline lltil). Methods:Beforeexperimentation,animals werc traincd for sevendays to balanceon a thin beam, to swim to a submcrged platform,and to maneuver on an avoidancebcam. Hcad trauma wasdeliveredto surgicallyprcparedrats by a fluid percussiondevicc;at tcn minutcsaftcr thc trauma,an intrapcritoncalinicction of a treatmentdrug or normal saline was dcliveredin a blindcd fashion. Taskperformancewas evaluatedand comparcdbetwccn groupsfur five daysaftcr closed-hcadtrauma. Comparisonsof thc time requircdto perform pretraincdtasks were madc bctwcen groupsand controlsusingStudent'st test with a signiftreatment icanceatP<.05. Results:No experimentalor c<lntrolgroup attaincd prctrauma performance lcvcls on any task at any timc testedaftcr trauma. Bestperformanceof all tasks aftcr trauma occurrcd at thc samc time in all groups.Therc were no statistical differencesnotcd in time requiredfor task performanceof animals receiving either DCA or BD on any task whcn comparcdwith controls, although animalsreceivingBD tended to perform better than untreated anlmals. Conclusion:Although statistically significant improvcment in functionalrecoverywas not seen in animals receiving DCA or BD aftcr closed-headtrauma when compared with controls, trendswere noted that suggestpossible beneiicial effect of BD. Increased numbersof animals in each experimentalgroup are necessary to further evaluatethis observation.

*81

Effect ot llonomethoxypolyethylene. glycohSuperoxide Dismutase (PEG.SODI on Spinal Gord lschemia

in a Rabbit llodel KN Hall,WG Barsan,RVW Dimlich,MS Miller,AErzin I Department of EmergencyMedicine,Universityol Cincinnati Ohio;SterlingDrug, Inc, Rensselaer, Medical Center,Cincinnati, NewYork ,. Studyhypothesis:The use of monomethoxypolyethyleneglycol-superoxide dismutase(PEG-SOD)will produce a 50"/oirnl provementin neurologicoutcome, mortality, and activity level 4[ter spinal cord ischemia in the rabbit

42 New ZealandWhite male rabbits lweight,2.5 to , *. Population:

: B.skg).

,. Methods: The animals were subjected to spinal cord ischemia

clampingthe aorta distal to the left renal artery for 26 minThe rabbits were randomly assignedto three groups: group placebo(16);group 2, 10,000units/kg IV PEG-SODimme-

diately before reperfusion (13); and group 3, 10,000 units/kg IV PEC-SOD 20 minutes after reperfusion (13).The animals werc evaluatcd at one, two, and seven days by a blinded examincr. The subiccts were classified by activity level (active vs inactive, including dead) and presence of hindlimb paralysis (not paralyzed vs paralyzed, including dead). Activity level was deiined as the animal's level of alertness and willingness to move. Death alone was also analyzed as an outcome variable. 12 and Student's t test werc used as appropriate. Results: Rabbits treated with PEG-SOD before reperfusion werc significantly more activc at all evaluation periods than thosc treated 20 minutes after reperfusion ol the control group (r.10).No signi{icant difference in neurologic outlP < .05, x2 come was found. A trend toward more deaths in the control group was found. Activity Level at 24 Hours Group (N) I (l ( r ) 2 (13) 3 (13)

Active 5 l0

Dead

lnactive b

|

)

,

|

6

Conclusion: PEG-SOD had a beneficial effect on activity level aftcr spinal cord ischemia when given before reperfusion. Further study on a larger population is required to evaluate the full cffect of PEG-SOD on neurologic outcome.

82

Brain Nuclear DNA Survives Gardiac Arrest and Repedusion

BC White,Ll Grossman,DJ DeGracia,GS Krause'J Skjaerlund, of EmergencyMedicineand Molecular BJ O'Neil/ Departments Schoolof Medicine, Biologyand Genetics,WayneStateUniversity Detroit,Michigan Study hypothesis: Genomic DNA from the cerebralcortex is damagedby oxygen radicalsduring reperfusionafter a 2O-minute cardiac arrest. Population: 27 large mongrel dogs were anesthetizedwith ketamine and halothani and mechanically ventilated, and central venousand arterial pressuresand ECGs were monitored.The anim a l s w e r e d i v i d e d i n t o f o u r g r o u p s : n o n i s c h e r h i cc o n t r o l s (seven);2O-minutecardiac arrest without resuscitation{six); 20minute cardiac arrest, resuscitation,and two hours' reperfusion (seven);and eight hours'reperfusion {seven)after the same cardiac arrest and resuscitation. Methods: Nuclear DNA was isolated from the cerebralcortex by the method of Cicarelli and Wetterhahn,-modified to include antioxidants.ResidualRNA was removed by RNase digestion and ultracentrifuge sedimentation of the DNA through I lVI NaCl. Radical damagewas modeled in genomic DNA using the Fenton reagentwith Fe2+ concentrationsol O,3.2, 16,80,and 400 pmol/L. DNA damage was characterizedby terminal labeling using four assays.The DNA was labeledon the 3' termini (o-32PdCTF and Klenow polymeraseIf and the 5' termini (I^32P-ATP and polynucleotide kinase); these labeling methods gave appropriaie incorporation on known plasmid restriction digests.Beiause base damage predominates in radical-damagedDNA, we also treated the ONA with exonucleaseIII be{ore3' labeling and with piperidine before 5' labeling. DNA concentrationswere determined by microfluorimetry, and label incorporation was evaluated by multiple analysis of variance and analysis of variance. The size of Iabeled DNA was examined by electrophoresis. Results: In the model, Fenton reagent-damagedgenomic DNA, terminal incorporation after treatment with either exonuclease III or with pipiridine, and shifts in electrophoretic mobility of damagedDNA were proportional to the Fez+ concentrationand thus r"eadilyidentifiei oiyg.n radical damage.The four DNA Iabeling metlods and electrophoresis revealed no sigrrificant dif{erences in the four experimental Sroups. Conclusion: DNA labeling at either the 3' termini after exonucleaseIII or the 5' termidi after piperidine demonstratesradical damage proportional to iron concentration. These techniques do

39


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Studyhypothesis:SerialCK-MB samplingin the emergencydepartment can identify acute myocardial infarction {AMI) in paiients presenting to the ED with chest pain and nondiagnostic ECGs {NDECGs). Population:Patients(more than 30 years)hospitalizedfor chest pain at six dilferent medical center hospitals. Methods:This prospectivestudy assessedserial CK-MB levels using a rapid serum assay (Tandem@ICON QSR CK-MB Assay, Hybritech,Incf for identification of AMI patients with NDECGs. Levels were determined on presentation and hourly for three hours following ED presentation.Patients with rising levels for at least three time intervals or one level above 7 ng/ml were considered to have a positive enzyme study. ECGs showing I mm or more ST-elevation in two contiguous leads were considered to be diagnostic.AMI was determined by the development of new Q-wavesor standardin-hospital enzyme changes. Results:Of the 692 patients, 104 were consideredto have an AMI, 60 of these had NDECGs. Of patients with NDECGs, 52 {87%sensitivity)had a positive enzyme study within three hours following presentation. The predictive value of a negative enzyme study for no AMI was 960/o{specificity,95%)' Combining serialED CK-MB assayresults with diagnostic ECGs yielded a 92% sensitivity for AMI detection. Conclusion:Serial CK-MB determination in the ED can help identify patients with AMI and NDECGs. Becausenearly 50% of patientswith AMI presentto the ED with NDECGs, use of serial CK-MB analysisshould facilitate optimal in-hospital disposition and promisesto help guide therapeutic interventions in patients with suspectedAMI.

*87

A Gomputerized Patient'and Emergeney Department llanagement System

TP Kuhlmann,RD Powers/ EmergencyMedical T Greenwald, of VirginiaHealth Services and Departmentof Medicrne,University SciencesCenter,Charlottesville An information system using personalcomputershas been developedfor a 50,000-visituniversity hospital emergencydepartment. The system servesas a patient and department management tool while providing a data base for health services research.Computerizedviews of the ED floor plan function as a graphicaluser interface to a relational data base.This interface alsoallows for connection to the hospital laboratory and Library InlormationSystemcomputers.The use of a graphicaluser interfaceasa front end has severaladvantages.New userscan learn to use the system in a minimum of time; the accuracy and completeness of data entry are maximized; and EDs in different institutions can contribute to a single data base.Clinicians interact with the work station as they would with a phtient tracking greaseboard. New registrations are captured from the hospital information system and are placed into the computer's waiting room. Through the use of a mouse, a patient can then be movpd into an examining room. A single view of the computerized greaseboarddisplays the demographicsof active patients, the clinicians working with those patients, and brief outlines of their treatmentplans. Unit assistantsenter dischargeinformation after a patient has been released{rom the ED. The demographics;waiting times; medications, laboratory tests, and procedures;diagnoies;and dispositionsthen are automatically appendedto the research data base.Analysis of the data baseassistsin ED managementand gives insights into the quality of patient care, the scopeol resident physicians' experience,and the cost effectivenessot emergencypractrce.

88

ment in which it is delivered. Population: 30 patients presenting to the emergencydepartmeni with acute myocardial inlarction who were admitted to the ICU and subsequently to the step-down unit were enrolled. Methods: A structured questionnaire designed to characterize the effect of the various units on perception of care was used. Responseswere gaded on a scale of I to 10. Results welâ&#x201A;Ź analyzed using ANOVA. Results:Patientsdescribedthe ED as significantly more frightening than either of the other units with regard to risk of imminent death {5.87 vs 1.62, P < .00011,uncertainty of the future (9.37vs 2.34,P <.0001),caregiverlack of concern17.43vs I.22,P < .0001),lack of explanationas to events occurring 14.93vs 9.62, P < .00011,and lack of control on their part 12'07vs 8.02, P < .0001).Comparedwith other units, the ED was most helpful by assuming control of the patient's care (4.60 vs 1.64,P < .00011 and elimination of physical pain 17.77vs 2.37, P < .0001).No significant differenceswere found between the units with regard to physical parameters. Conclusion: Despite advancesin the emergencymanagement of acute myocardial infarction, patients experiencesignificant psychologicalstressin the ED that is not addressedat the same level as in other special care units.

89

The Distribution of Orthostatic Vital Sign Changes an a Normal Adult

1!1f| -tl,

Fatal Tlansfusion Reactions in the EmergencY DePartment

and the Variation of These Population Ghanges With Age DL Schriger,LJ Baraff/ UCLA EmergencyMedicineCenter,UCLA Schoolof Medicine,Los Angeles Purpose:To determine the distribution of orthostatic vital sign changes(OVSCIin a population of healthy adults, thus delineating normal and abnormal {> +2 SD) values. "Hypothesis: The elderly will have a greater increase.iirpulse andlora greaterdecreasein blood pressureon standingthan their younSer counterparts. ' Population: 54 healthy adult volunteer blood donors {prior to donation) and 100 self-sufficientambulatory participantsat a senior citizen's daytime activity center. Methods: Each subject was placedsupine for at least one minute following which pulse was counted for 30 secondsand blood pressurewas auscultatedin an upper extremity. The patient was ihen askedto stand for 30 secondsand the pulse and blood pressure measurementswere repeatedin the same arm. Variation in OVSC with agewas examinedwith linear regression.t tests were used for dichotomous comparisons' Results: Subjectsranged in age from 19 to 94 {mean, 6l; SD, 221.Mean supine pulse and systolic and diastolic blood pressure were 72 and i37 mm Hg and 75 mm Hg respectively.Mean pulse change{PC) was +l (range, -16 to t26i SD, 7). Mean systolic ctranEe{SCIwas +3 (range,-30 to *40; SD, 1l). Mean diastolic change(DC) was +3 {range,-14 to +28; SD, 8). Mean OVSC in patients less than 65 years old were PC, +3; SC, -l; DC, +4i and for thoseaged65 and older were PC, -lr SC, +4iDC, +2. While mean PC and SC differencesbetween adults and elderly were statistically significant (P < .001,P < '0051,and there was evidenceof a linear trend with age for each parameterlP < .O2l1, this study was very powerful {l-B:0.95 to detect a mean pulse or blood pressure difference of 21,the linear trend is weak {R2 < .08 for eachl and the differences are not clinically relevant. Conclusion: Abnormal OVSC, defined as those values more than t2 SD from the mean were: PC more than +15, SC more than - 19, and DC more than - 13. There was no clinically meaningful variation of OVSC with age in this study.

The Gardiac Patient's Perception of Gare in Relationship to Environment

MA Flynn,Dl Savitt/ Departmentof EmergencyMedicine,Rhode lslandHospital,Providence Studyhypothesis: Patients with acute myocardial infarction perceivecare provided differently in relationship to the environ-

AS Gervin/ Medical Collegeof Virginia,Departmentof Surgery, Area of EmergencyMedical Services,Richmond Hypothesis: The emergency department, becauseof the acuity

4l


and intensity of the clinical situation, is a maior site of fatal transfusion reactions resulting from human error. Methods: Under the Freedom of Information Act. reports of Iatal transfusion reactions nationallv from lune 1975 to b...-ber 1985 {most current dataf were obtained and reviewed. Data were analyzed for cause and reaction, clinical area of reaction, and the reason and urgency {or the trans{usion. Results: 328 Iatal transfusion reactions were reDorted with 149 (45%) involving human error during transfusion. Reactions involved mislabelling of blood samples (14%), cross-matching errors in the blood bank {30% f, administration of appropriate blood to wrong patient 1460/0l,and complex {10%). Thirty-five perccnt occurred in the operating room, 27"/o on the ward, 267" in the ICU, and only 77" in the ED (4% undetermined). In the ED, human errors occurred in emergency situations (81%), with 78o/" in trauma. Most fatal transfusion reactions in thc ED involvcd mistakes in the blood bank (64%). Ol 36"/" mistakes involving ED personnel, three fourths involved administration of appropriately cross-matched blood to the wrong patient. Conclusion: Human errors resulting in fatal transfusion reactions in the ED are rare.

*91

E m e r g e n c y M e d i c i n e R e s i d e n c y P r o g r a m , W a s h i n g t o n ,D C Study objective: To determine the subsequent course and outcome of patients discharged from the emergency department with abdominal pain of uncettain etiology. Population: Cohort study of 385 consecutive patients over age 16 seen in an inner-city university hospital ED and discharged with the diagnosis of "nonspecific abdominal pain" or "abdominal pain, uncertain etiology." One hundred eighteen were lost to follow-up, resulting in a final study population oI 267 patients. Methods: Telephone contact two days and two months after thc ED visit to obtain information regarding symptoms, subsequcnt evaluation, and final diagnosis. Results: Two-month {ollow-up was completed on 209 female p a t i e n t s 1 7 8 . 3 % l a n d 5 8 m a l e p a t i e n t s , ' 2 1 . 7 % Jw i t h a m e d i a n a g e o f 3 0 ( r a n g e ,1 6 t o 7 8 ) . T h e m a j o r i t y , 5 8 . 4 % l p r e s e n t e d w i t h l o w e r abdominal pain. Symptoms at two-day follow-up had resolved in l l 5 p a t i e n t s 1 4 3 . 1 % 1a n d d i d n o t r e c u r i n 9 0 o f t h e s e ( 3 3 . 7 % ) .A t two months, pain had resolved in 177 patients 1'66.3%1, continued i n t e r m i t t e n t l y i n 7 8 1 2 9 . 2 % 1a, n d r e m a i n e d c o n s t a n t i n 1 2 1 4 . 5 % ) . Nine paticnts had undergone surgery. No diagnosis was establ i s h e d i n 2 2 5 p a t i e n t s 1 8 4 . 3 ' / " ) .T w e n t y - o n e o f 4 2 p a t i e n t s i n whom a cause for abdominal pain was identified were women with pclvic pathology. Conclusion: Most patients with abdominal pain in whom a diagnosis cannot be established in the ED experience resolution o{ symptoms without sequelae. In the vast majority, a firm diagnosis will not be dctermined despite further evaluation. The most common missed problems are pelvic disorders in women.

Treatment of Subungual Hematomas With Nail Trephination: A Prospective Study

DC Seaberg,PM Paris,WJ Angelos/ University of Pittsburgh AffiliatedResidencyin EmergencyMedicineand the Centerfor EmergencyMedicineof WesternPennsylvania, Pittsburgh Study hypothesis:Treatment of subungualhematomasby nail trephinationalone is without cosmeticor inlcctious complicatlons. _ Population:Consecutivepatients presentingwith subungual hematomasover a two-year study period were cnrolled. Patients with previous nail deformities or with disruption of the nail or nail margin were excluded. Methods: Radiographsof all digits with subungualhematomas were performedto detect fracture. Subungualhematoma size was measuredand nail trephination was performedusing electrocautery. All subungual hematomas were splinted for one week. patients were followed prospectivelyat least six months after injury and examined for nail growth and deformities. Photographs of the nail were taken and a history of infectious complications was obtained during the follow-up. Results:Follow-up was performedin 47 of 5l patients (ages3 to 60 yearsf with a total of 49 subungual hematomas.Averagefollow-up period was l0.l + 4.3 months. All patients reported reduction in pain following nail trephination. Size of Hematoma Relative to Nail Surlace < 25%

2550% '> \OY.

93

RD Herr,GL White,K Bernhisel,N Mamalis,E Swanson/ Division of EmergencyMedicine,Departmentof Surgeryand Department ol Ophthalmology, University of Utah MedicalSchool,Salt Lake City Study hypbthesis:Alternate fluids to normal saline will be associatedwith decreaseddiscomfort during copious.eye irrigation. P o p u l a t i o n :l l c o n s e c u t i v ee m e r g e n c yd e p a r t m e n tp a t i e n t s who required eye irrigation after chemical exposurewere enrolled. Methods: In a prospective,randomized,double-blind manner, each patient had eye(s|irrigated by Morgan lens with 500 mL eachof normal saline,lactatedRinger's,normal saline adiustedto pH 7.4 with sodium bicarbonateiNS + bicarbonate),and Balanced Saline Solution Plus@{BSSPlus, Alcon Laboratoriesf.Overall ranking il, best; 4, worst) and discomfort level {0, none; 10,worst imaginable| were recordedby a blinded observerwho evaluated confunctivalpH and injection. Solutionswere comparedusing analysisof variance and Wilcoxon rank-sum test. .' Results:BSSPlus was given a discomfortrating of 2.0 + L6 lmean * SD) and was ranked1.67 + O.75,whereasnormal saline had a discomfortratingoI 4.9 + 3.5 (P < .05)and was ranked3.17 + O.94lP < .0If. Three patients demandeddiscontinuanceof normal saline or NS + bicarbonateinfusions; eachpreferredBSSPlus. There was equal ability to normalize conjunctival pH and injection. Conclusion: BSSPIus was the only solution with significantly less discomfort than normal saline. Its use should be considered in those patients whose poor tolerance to normal saline threatens to delay or interrupt eye irrigation following a chemical iniury.

SUH With Fractures No

Yes

t2

l

7

4

l(r

9

By patient history, average time for nail to return to normal was 4.0 + 2.6 months. No complications of infection, osteomyelitis, or major nail deformities occurred in any patients. Conclusion: No complications occurred in any of the nails with subungual hematomas treated by nail trephination, regardless of size or presence of fracture. In simple subungual hematomas, regardless o{ size, nail removal with suture repair o{ the nailbed matrix, as suggested in previous studies, is unnecessary. Radiographs may also be unnecessary in these injuries.

*92

Glinical Gomparison of Ocular lrrigation Fluids in Ghemical Injuries

94

Outcome of Patients Discharged From the Emergency Department With l{onspecific Abdominal Pain

ofEmersencv 3:i:",'."f:"iE:i.xH=

K Potts,ML Martin,F Harchelroad/ Divisionof Emergency Medicine,AlleghenyGeneralHospital,Pittsburgh, Pennsylvania Study hypothesis:The number of radiographsmisreadby emergency medicine personnelis not signi{icant in total number; however,an e{ficient quality assurancesysrem may preventpoor

GR Cox, J Scott, S Sanford,D Roselle/ Departmentof EmergencyMedicine,George WashingtonUniversityMedical Center,and the Georgetown/George WashingtonUniversity

42


outcomc in those patients who require alteratrons of managemcnt. Population: All emcrgency department patients evaluated with radiographs ovcr a two-year period in which the formal written interpretation of the radiographs by an attending radiologist was available. This accounted lor 62,282 radiographs. Methods: All charts of ED patients within the study period wcrc rcviewcd within 3(r hours of presentation. Those charts and radiographs in which the final written report of thc attending radiologist was at variancc with the documentation ol the emergcncy physician wcre rcviewed for type of misintcrpretation, age of paticnt, and clinical significance of misinterpretation. Rcsults: A total <tf 62,282 radiographic evaluations were found with complctc chart documentation. Of this total, 139 |,0.22"/"1 dcmonstratcd a variancc in interpretation between the phvsician and thc radiologist. Thc most common radiographs witir varianceswerc: chcst radiograph, 37 126.6%)(infiltrate, 31 122.3%lt ,22.3%) (nasalfracture, l6 m a s s l c s i < r n ,s i x 1 4 . 3 ' 1l ,f; f a c i a l f i l m s , 3 1 o r b i t a l f r a c t u r e , n i n e s i lll.5'l'l; l(r.5%]; nusitis, six 14.3%ll; hand f i l m s , 1 3 ( 9 . 3 % ) ( v o l a r p l a t e f r a c t u r e , 1 1 1 7 . 9 o / " bt u f t f r a c t u r e , t w o l l . 4 ' l ,l ) , a n d a n k l e f i l m s , n i n e 1 6 . 5 % l l l a t e r a l m a l l e o l u s , s i x 1 4 . 3 ' Z , lm ; e d i a l m a l l c o l u s , t w o I l . 4 o l ,l ; p o s t e r i o r m a l l e o l u s , o n e l 0 . t l ' Zl ,) . A l t h o u g h a l l p a t i e n t s i n w h o m v a r i a n c e s o c c u r r e d w e r e notified of the discrepancy, only 5(r of the 139 (40.3%) 10.09% of thc total radiographic cvaluations) required alteration of their carcand wcre fclt to be clinically significant variances.No varia n c c sr e s u l t e d i n p e r m a n e n t d i s a b i l i t y o f t h e p a t i e n t o r l e g a l a c tion against the physician. Conclusion: Radiographic evaluation of patients seeking emergency medical carc are accurately read by the cmergency physician,with fcw discrcpancics noted between the attending radiolo g i s t ' sa n d t h e c m c r g c n c y p h y s i c i a n ' s r e p o r t , a n d e v e n f e w e r c l i n i c a l l y s i g n i f i c a n t v a r i a n c c s . A n e f f i c i e n t q u a l i t y a s s u r a n c es y s t e m prcvcnts thc few variances from progressing to significant morbidity.

95

FEV' Griteria lor Admission of Emergency Department Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease

under the curve of 0.81 + .05. No other spirometric criterion was more accurate than the post-treatment FEV,. Blood gases performed poorly in identifying the need for admission. Conclusion: Patients with a post-treatment FEV, above 40% predicted normal do wcll following discharge. An FEV, less than 40oh of normal identilies patients at high risk for relapse.

*96

ff;,il1:1,:HyposrycemiaArterD5o

JJ Dennis,J Glauser,MK Allen/ ResidencyProgram,Department of EmergencyMedicine,The Mt SinaiMedicalCenter,Cleveland, Ohio Study hypothesis:A significant number of patients presenting with hypoglycemia develop recurrent hypoglycemia after treatment with IV glucose(D50)and oral intake. Population: All patients receiving D50 in the prehospital settings or in the ED for hypoglycemia. Methods: This was a prospective,nonrandomizedstudy conducted from fanuary to fuly 1989in an urban community hospital. Blood sugarswere determincd prior to D50 by both hospital laboratoryand ED glucometer,and at intervals of 20 minutes for one hour, thcn each half hour thereafterby glucometer only. An IV linc of a glucosc-frcesolution was startedand bloodsdrawn by heparin lock insertedin the oppositearm. All patients were given a meal. Additional D50 was given if blood sugarwas 65 mg/dl or less. Results: Of the 2l patients with insulin-dependentdiabetes mellitus (IDDM) lall on NPH insulin),nine (43%)developedrecurrent hypoglycemia.No patient with hypoglycemia from another sourcedid so. Three patients requiredrepeatedD50 boluses. Significant differencesin responsewere not {ound by age, number of NPH units, presentingblood sugar,alcohol use,or history of decrcasedoral intake. But there were significantly more mcn in the group that developedrecurrent hypoglycemra. Conclusion: Blood sugarin hypoglycemicpatients may require ongoing monitoring especiallyin male IDDM patients on NPH insulin.

CL Emerman, D Effron, T Lukens / Depa(ment of Emergency M e d i c i n e ,l v e t r o H e a l t hM e d i c a l C e n t e r . C a s e W e s t e r n R e s e r v e U n i v e r s i t yC, l e v e l a n d ,O h i o

Pelvic Inflammato?y Disease 62 J Subsequent to Surgical Sterilization -, MM Green,SJ Vicario/ Department of EmergencyMedicine, University Schoolof Medicine,Louisville, of Louisville Kentucky Emergencyphysiciansare very cognizant ol the coexistenceol ectopic pregnancyafter surgical sterilization, but the potential for pelvic rnflammatory disease{PID) is thought to be rare. A retrospectivereview was undertaken to see il this entity occurred more frequently than previously reported.Three hundred sixtyfour hospitalizedinpatient charts with a primary dischargediagnosis of PID were reviewedto determine if any had previous surgical sterilization. Patient age,gynecologichistory, diagnoses, and laboratory,clinical, and surgicalfindings were reviewedin all identified cases.Twenty-three casesof PID in 2I surgically sterilized patients were identified. Nine of the caseshad surgical evaluation due to their toxic presentations.All nine casesmet |acobsen'slaparoscopiccriteria for PID. Twenty-two of the 23 casesmet Hager'sclinical criteria for PID. Eighteenof the 23 caseswere admitted from the emergencydepartment.We identified eight previous recent ED/clinic patients for the same complaint in five patients. Statistical characteristicsof the study group were as iollows: estimatedmean interval from sterilization to admission was 4.31 years a 2.84 SDr mean age was 27.26 years a 4.40 SD; a mean WBC on admission of 14,974/mm3+ 5,702 SD, and mean temperatureof 38.0 C + 0.85 SD. A history of PID was noted in 14 of the 2l patients. We conclude that PID occurs more frequently.than previously reported in patients remote from surgical sterilization. We recommend an increased awarenessof this entity and liberal use of laparoscopicexamina-

S t u d y h y p o t h c s i s : S p i r o m e t r i c c r i t e r i a c a n s e p a r a t ep a t i e n t s who require admission or relapse following emergency department treatment for chronic obstructive pulmonary disease from patients who may be discharged successfully. Population: Patients who were morâ&#x201A;Ź than 50 years old with an acute cxacerbation of chronic obstructive pulmonary disease. Patients were excluded ii they had asthma, were unable to perform s p i r o m e t r y ,o r h a d a n o t h e r a c u t e c o n d i t i o n w a r r a n t i n g a d m i s sion. Methods: In this prospective, nonblinded study, patients presentingwith an acute exacerbation of chronic obstructive pulmon a r y d i s e a s eh a d a n i n i t i a l c l i n i c a l e v a l u a t i o n a n d s p i r o m e t r y . The clinical evaluation and spirometry were repeated at the completion of therapy. Patients who were discharged were followed up to determine whether they had suffered a relapse (repeat ED visit or admission within 48 hours). Receiver operating curves were generated to determine the most accurate cut point. The sensitivity of various criteria at their most accurate cut point were compared using McNemar's test. Results: 83 patients with an average age oi 63 years were studied. All patients received nebulized B-agonists, while 34% receivedaminophylline and 2O"/" received steroids. Forty-five percent of the patients were admitted and 17"/" relapsed. A posttreatment FEV, less than 40olo of normal identified the admission/relapsegroup with a sensitivity of O.96, specificity of 0.58, predictive value { + | of 0.73, predictive value ( - ) of 0.92, and an overallaccuracy of 0.78. The receiver operating curve had an area

43


and initiation tions for prompt diagnosis ment.

of approprrate treat-

*1OO *:"lffid:'"!,i{!!i?"lJo *,,r.

Iniection of Subc;ta;eous BuPivicaine / Divjsion b Tandberg G Molzen, 9f.11:t-S,^"1"y P Chenev, 'Me"j;ffi School'ofMedtctnel Mexico New of uliu"itiiv NewMexico Ii#ivt""ii"i ilspiiar nrouquerque' sodiumbibupivicaiT^t^Yith of ft"ift'ing pu Studyhypothetl't subcutaneous local its wlth 'stociatcd paitt tr'e reduces carbonate

*98 l::Jl',':'.;:fi'Il!ilfi'""'?l",.l""?'""' Aduli Sexual Assault V-ictims D Eitel..Dr]e.1sC osden/ iK;;;"' B Suroskv' G Muscoto, "'ili,li:"j':T"?.:$!".,',"Tk1}ittrih'; Obstetrics-Gynecology' o{ EmergencyMedicineand Deoartments PennsYlvania York, voit<UosPitat, assavsa(e not "."d :hl'Tl*:' Study hypothesis:.Gonorrhea ascvaluation o{ the adult sexual tnt'i"ii*f in useful medically

'."ii 'i.ii- r" !!'g"-flsil,.?*i""::;lii;lt';,t,"s initiatlygecn:n All {ema Population: isgl-1988(54)wereincludcdin the Eo'i"rf our suburban/r.,rrr "l*I,f;:tHl .,f the patients andlaboratory',tt^11:t *edical record's

in{iltration.

ceived a 0.5-mL subcutanl

."ilj'l:o' ^i".-i",.,!'^g.':ir -{;r;;ti: IUl'rfri#i"I};fri:i; rir"^"'l "brc bupivicainc rhi "1f il"'i :i:,'h;.,.i, b.:

the same amount of unbu(fered control hand was t'l1t"t"J-*ith iniection us.ing a nonsegmented ,Jr.i"""rr asent. pain was scorcd was for paired measurements test t scalc' Student's '?;;;i ;;;I"*

:q?',ll*,,nburrered [;f *il*",1r"'ru'i":'::*il::*'?|;l',1i?'1;:[if itj H.T';;"i';:"',1,tr.,:u"il..'r:li:i'f b$i.Hii:, y;t.:filr ;;t;:;. Standrrdmcth.dologv chlamvdia. For posit'vc i"ttlit''

wns rtscdI" qt:: tftt rnedical recor-dwas further

;*:-XLt{.,|'Hfl"":JlTff:'f,hhca,threeor54assavs ('557')

:lJl;,fj.::[f"'#fiXl,]ilii,X:?;,'il? rorthecon. HJ';;o;;.. f;;lJ"J:iT: ry,7.1ip' ii?l::i: m c a n d r i l c r c n . "l l , t r l i . t " **r,r' p c r i m c n t a l )w a s 5 9 m m trol. Thc

H.T'.n"ffi:;\n{f fii:l1l6:i,.ii'in','*lxl3:i':l

"'i;,',1:,il,,|l], tobupivicainc bicarbrrnatc {n:"3:'ii"' orsodium

threc Positivc results

t'3:'l:1.i:::T]'

grrhea'al^d rh" i "'i d"nce or positive'so'n

asED cviluation of adult sexual chlamydia assays1n tftt'*iraf was usually u"'v-rn*''l"J''*}ttn *" sault victrms l:-:::"ttd'

with its local inliltratton' reduces thc pain assoctatcd

.;1i-"H:X',H:;i*u"'"' I 01 "l:Hl:ffi' *lyilllf,,y;.5lli:'*'l*,-.':n:"ltl3;xY't'"'lllx our hospital, "ri*i"'iini"t* $61.25Per Paticnt'

*99

of titit ittting results in a savings

asa i:gii1J:J!'$JEl""#;'fine RePair

Grisis in Adults with o""lusitl Disease Gell Sickle ol i5'""1iencv !"lYi"9:^:ld Department , R Polomano D Brookorf Phrladelphta Pennsylvania' oi of tneUn*iversiLy Hospital Nursing, morA rcgimtniti"q :lilt^Tjained-release Studyhvpothcsis: the ircatment of vaso-occlusive

(,"u'7 n:::J' : lil : %E *'.*:: J;[al* ? "H"^' 331'5i # 1! lfl " UiLtlru,l:1":l "i"ip" e1 8,".,H,r, :i:""? Laceration

t""fl

il,fi:: 5"

and Socii EordemrologY Medicine,Bronx,New YorK

nhine is effcctivc "to

"i"

for

i'i'i' r' adultswith ":i:: sickle P1:1"::t^; :;:t"*'".','i* *,,n homozygous Population: uisits tor-va!8-occlusivc six emergency in

} t6ut nouseo{morphine ::*tlffi :1#1i",''il';;;; ;'r'"iipv tnino.',i:fr:'if3',,..

vaso-ocnf -'p"idine in ih'-:':::T'"t or with a were treated

and patients clusive crisis *"' ait"nnii"'utd rnorPhinetl-osnr orotocol that usedrv ttj"t'it"t*l'i"d-t"l"ttt were compareo of thc 'nnnths 'l* fi"t P'?t:::l i;i';;;;iJ;;t'' of tnt period.

;i,i';h;;; of thesamesix-month l":'Jt;'r:iJ:?i;t' "]i:ll*l**:i';"ii,i''il:xl;,i'."*;i":':*l:""'$i'li'":l'u visitsfor'vaso department Results:Emergency ll(r to (r5'rotal hospittuP".,oul", I i n e a r I a c c r a t io n s th i . n , t )I a d u l t p a t i c n t s * i -tlT,p^l^t-

went{roma26to 138.ai'J;ili;;i;;;;"m

m:#t*,.T':,';'Tliil"lll4rr,Lir[*:':"'"":::: ;*'nnm l#,'*lunxafJ#iil;in:r*ff[:'-i"'."":Tl*t;::ti;'lt

r *,il::Fi JiFT: tive :ifiii is} areande{rec -."{l'":;;i .91,1. *ll *:jii:.nX'i}-' l:l':'* l"H:"*"*;:x.:mqq"',6"ur;tif lilifr :',"ft'ff ii:likrlr*t'.:l.s:rril:'l'Tl;},q!:uii?"ry{'!::i 102 3:silfiiil#l-":fi:I"ii':T':l Patient'Gontrolled niilti"iv"tsus Treal1e-nt of Patients o"p"li-""i :li**tt',*l,l?iti*'4i,il;f :'#'!ft:di'Y;:'"Ii tr''"'pr"i"ria"""lTif less.painful "i,..,'; nificantlv -r " ;".0'irfi"it'"Tl

r,"ii"*a iiJ"taine for simplclaccratl:l1:tiT

two-sample test, the Wiit"tcl"

where. modeled n":?l:t:l^in Conclusion: A protocol

control regr-

in the treatment oI vz

test' and matched-pairs sign-ranks

Analgesia in the EmergencY

-

-

With Sickle Gell Grisis-

;;;il;

= osr..I.,:ijji;:',iTil;1 #Tffi;,;; perrective

f#tJ 1"":'i"iii'ltti** %:::tt*#'#j""1ti.*o' to plain lidocaine " ple lacerations'

;;;';;;

iir theanesthetic

that,bu{fered-lidocaineis prelerable

t i""'f

repair of sim' anesthetic agent for the

J,ffn*%ffill"'i. 31"fr 3,"# 5F iuili{ti"i{"1"

Emergency it Pharmaceuticsuno'nt"'nul Medrcine'',S-":]!" Richmond Virginia' ol borr"ge Medical Services,rvrujo-ui {PCAI produces Study hypothe'i'' i"tl""t-"oitrolled--analgesia (Iiv)' iniictions IV better pain contror td;il;";*ent

44


f

Population: 25 adult paticnts with sicklc ccll vaso-occlusive pain crisis were enrolled. Methods: Patients wcre placcd at bed rest and received IV hydration. Lincar analog (10 cmJ pain scale ILAS). verbal pain scale { V P S I , l e v e l o f a l e r t n c s s , a n d v i t a l s i g n s w c r e a s s c s s e dp r i o r t o ih.rapy, every (r0 minutcs thereafter, and at the time of discharge from the cmergency dcpartment. Patients were randomized to liv or PCA. Iiv paticnts rcccivcd morphine sulfate B mg IV evcry 30 to 60 minutes as needcd for an LAS o{ morc than 5 cm. PCA patients reccivcd morphine sulfatc 5 mg bolus and thcn 2.7 mg with a tcn-minutc lock-out. If thc LAS was morc than 5 cm aftcr thrce hours of treatmcnt, the morphine sulfate dosc was incrcased to l0 mg Iiv cvcry 30 to (r0 minutcs as needcd for an LAS of morc than 5 cm, and to 3.3 mg with a ten-minute lock-out by PCA. Data were analyzed by unpaired f test, gencral lincar modcling, and 12. R e s u l t s : l 2 p a t i e n t s r c c ei v e d l i v ( s e v c n w o m c n , f i v e m c n , 2 8 4 + 5.(r years) and 13 patients receivcd PCA (cight women, five mcn, 26.8 + 8.1 yearsl lP - .152 for age). ?rtal doscs administcred by Iiv and PCA wcrc 4.9 + 2 and ll.6 ! 6-2, respcctively l P < . 0 0 0 2 1 .T h e t o t a l d o s c o f m o r p h i n c s u l f a t e d i d n o t d i f f c r s i g -e l(r m8) and the PCA (34.6 :t nificantly betwcen thc Iiv (41 20.9 mg) groups. A dosage incrcasc was recluircd by 35'2, and25"l, o f p a t i C n i s w i t h l i v a n d P C A , r c s p c c t i v c l y l P = . 7 2 6 1 .T r e a t m c n t g r < i u p sd i d n o t d i f f c r s i g n i f i c a n t l y w i t h r c s p c c t t o L A S , V P S , v i t a l iigns, ur lcvel of alcrtncss. LAS and VPS wcrc significantly corrcl a i e d ( r , = . 8 4 , P = . 0 0 0 1 ) .T h c E D d i s c h a r g e r a t c w a s 5 2 " 1 ' a n d ( r 5 ' X ,w i t h l i v a n d P C A , r c s p c c t i v c l y l P - . 6 5 2 ) T h c i n c i d c n c e o f a d v c r s c c f f c c t s w a s ( r 5 ' 2 ,a n d 5 ( r ' 2 ,w i t h l i v a n d P C A , r c s p c c t i v c l y

{P= .7r5t. At thcscdoscsof morphincsul{atc,Iiv and PCA Conclusion: are ccruallvcffcctivc in thc ED trcatmcnt of sicklc ccll crisis.

*103

Safe Use of Nitrous Oxide in Patients With Chronic Obstructive Pulmonary Disease

D M Y e a l y ,J L M c C a b e , G P Y o u n g , F M K a p l a n , J J M e n a g a z z i I 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 P i t t s b u r g h ;T h e C e n t e r f o r E m e r g e n c y M e d i c i n e o f W e s t e r n P e n n s y l v a n i aP , ittsburgh Study hypothcsis: A 50:50 tnixturc of nitrous oxidc and oxygcn can be'uscd safcly in patients with mild to modcratc chronic obstructivc pulmonary discasc (COPD). Populaiion: Paticnts ovcr thc agc of lt3 with COPf) documcntcd by pulmonary function tests, spccifically an FEV,/FVC (r5 mrn r a t i o o f l c s s t h a n 0 . ( r 0 .P a t i c n t s w i t h r e s t i n g P O , l c s s t h a n Hg, rcsting Pcc), grcatcr than 40 mm Hg, or FEV' less than 1.5 L were cxcluded. Mcthods: l0 paticnts undcrgoing routinc pulmonary function tcsting were prospectivcly e.ticrcd into thc study. Each pati6nt b r e a t h e da 5 0 : 5 0 m i x t u r c o f n i t r o u s o x i d e : o x y g e n f o r l 5 m i n u t c s and 50%' oxygen for 15 minutcs with a 3O-minutc washout period. The orier of gas administration was randomized and singlc blinded. Vital signi, heart rhythm, O, saturation, and subjective feeling were monitored continuously. Arterial blood gas samples were 6btaincd at zerot fivc, tcn, and 15 minutcs during inhalation, and ten minutes after the end of gas administration. The data were analyzcd using rcpeatcd mcasures of analysis of variancc in order to detcct differcnces betwecn control and study groups,with the o crror ratc set at 0.05, and a power of 0.80 to detect a 37% diffcrence. R e s u l t s :T h e m e a n F E V r / F V C r a t i o i n t h i s p o p u l a t i o n w a s 0 - 4 7 . There were no statistically significant changes in hcart ratei respiratory rate, blood pressure, pH, and most importantly, Pco' from baseline valucs in cither group during gas administration. One oatient discontinucd inhalaticln of thc nitrous:oxygen mixt u r e d u e t o l i g h t h c a d e d n c s s .N o o t h e r a d v c r s c e f f e c t s w e r c s e e n . Conclusionl A 50:50 nitrous oxidc:oxygen mixture is safe for use in patients with mild to moderatc COPD.

104

Glinical Features ol Missed Appendicitis in Ghildren

105

Serum Gocaine and Tetracaine Levels Following APPlication of Topical Anesthesia in a Swine Laceration Model

SG Rothrock,G Skeoch,J Rush,NE Johnsoni Loma Linda Schoolol Medicine;and Departmentof Emergency University Medicine,Loma Linda UniversityMedicalCenter,Loma Linda, California Study hypothesis:Clinical featuresof pediatric appendicitjs dilfer between casesinitially misdiagnosedand those initially diagnosedcorrectly. Population: l8l patients less than 13 years old with appendicitis seenover a ten-yearperiod were euolled. The study group consistedo{ 50 patients seen by a physician within ten days of the correct diagnosisof appendicitisand misdiagnosed'The control group consistedof 131patients with appendicitisinitially dicorrectly. agnosed -Methods: Charts were reviewedfor 28 clinical features.12 and Student's t tests were used to compare the groups with significanceatP<.05. Results: 50 of 18l casesi28%) were initially misdiagnosed. Most common misdiagnosesincluded gastroenteritisIZI 142%ll and upper respiratoryinfections {nine [18%]).Study group members had a younger mean age{5 yearsvs 7.9 years)and were more likely to have pain duration of more than two days176%vs 4l%1, fever 174"hvs 56%1,vomiting beforepain onset (33% vs 8%), respiratory symptoms l28o/"vs 10%),diarrheal28o/o.vsl0%), and tonstipation {18% vs 5%). Study group patientsalso were more likely-to have temperatureabove 38.3 C 162% vs 26%l' irritability l34o/ovs 6o/ol,lethargy l22o/ovs 3% l, upper respiratoryinfections (30% vs 2%1, and nonright lower quadrant tenderness { 3 0 %v s 8 % ) . Conclusion: Children with appendicitismisdiagnosedhave many atypical clinical featuresthat differ from those initially diagnosedcorrectly.

T E T e r n d r u p ,H C W a l l s , P J M a r i a n i , R M S p e a r s / D e p a r t m e n t s o f C r i t i c a l C a r e & E m e r g e n c y M e d i c i n e , a n d P e d i a t r i c sa n d D i v i s i o n o f C a r d i o l o g y ,S t a t e U n i v e r s i t yo f N e w Y o r k H e a l t h S c i e n c e C e n t e r a t S y r a c u s e ; T o x i c o l o g yL a b o r a t o r y ,O n o n d a g a C o u n t y H e a l t h Department, Syracuse, New York I n t r o d u c t i o n : A m i x t u r c o f t c t r a c a i n e 1 0 . 5 ' 2),, e p i n c p h r i n c ( l : 2 , 0 0 0 ) , a n d c o c a i n e ( 1 1 . 8 % )( T A C ) i s i n c r c a s i n g l y u s c d f o r a n c s thcsia o{ children's lacerations in thc emergcncy dcpartmcnt. Absorption of cocaine or tetracainc may rcsult in scritrus toxicity. Study hypothcsis: There arc no measurablc scrum cocaine or tetracaine lcvels after application of topical anesthesiain a swinc laceration model. Population: Fivc young, hcalthy swinc, wcight 2(r + 3.5 kg {mean * SDl. Mcthods: Following sedation with intramuscular ketamine 22 mg/kg, acepromazine 1.1 mg/kg, and glycopyrolate 0.5 mg/kg, fasted animals underwent trachcostomy, mechanicai ventilation, fcmoral venous, and artcrial cannulation. Maintenancc ancsthcsia with thiopcntal and pancuronium was provided to maintain stagc III ancsthcsia. Hcart ratc, artcrial prcssrlrc,scrum crtcainc, and tetracaine levels were mcasured at baselinc and for 180 minutes. Five mL of TAC was applied for 15 minutes to a standard {acial laceration or the intact sublingual area. Serum samplcs were placcd in vials containing 2'1, NaFl and 1% potassium-oxalate ind rcfrigcrated immediately. Randomly labeled samples wcrc analyzcd for cocaine and tetracaine using gas chromatography and mass spectroscopy. The limit of detection for both assays was ( 2 ng/mi. Polynomial regression (third order) was uscd t<r predict peak levels. Sigirificant changcs in heart ra-te and arterial pr.rsnt", compared with baseline values, were analyzed using rcpeat -easur. ANOVA, with isolation of significant differences

45


bate. Sizes for other resuscitative equipment items were chosen by a panel of experts using a modified Delphi technique Contingency table methods were used to analyze the results. " Results: The tape selected the appropriate endotracheal tube size by pressure criterion 70% ol the time and was within t 0.5 "correct" sizeggo/o of the time. This was significantly -m oi the better iP < .005) than two widely used age-based rules, which gave the correct initial size in only 46% and 57o of cases, and were within + 0.5 mm ior 847" and 50%. The anesthesiologists chose to continue with the tape-sized tube rather than to reintubatc in morc than 90% of cases. Conclusion: The use of a resuscitation tape for length-based sclection of endotracheal tubes may be a significant adfunct to emergency physicians and paramedics who deal with critically ill children.

based on Schcffc's F test. Results: Serum cocainc levcls werc obscrvcd to peak at a mcan <>(79 ns.lmL at 55 minutes and 55 ng/ml at 91 minutcs for mucosal and dcrmal application, rcspcctivcly. Significant decreases in mcan hcart ratc occurrcd from ll0 to 180 minutes {changc,23 + Z.3lmini mcan t SD). No significant changc occurred in systolic artcrial prcssurc, whilc diastolic artcrial prcssurc increascd from 150 to 180 minutcs (mcan changc + l[1.5 + 1.2mm Hg) No tctracainc was mcasurablc. Conclusion: Application of standard TAC solution results in mcasurablc scrum cocainc lcvcls, but not mcasurablc tetracainc lcvcls. No physiologic cffccts wcrc observcd at timcs of pcak lcvcls in this ancsthctizcd swinc model.

.1 06

*:,:Jilh3',f?o3!lii5l'.,"

DePartment EmergencY K Cronan, K Shaw R Bellah / Emergency Medicine, The C h i l d r e n ' s H o s p i t a l o f P h i l a d e l p h i a , P h i l a d e l p h i a ,P e n n s y l v a n t a Study hypothesis: Plain abdominal radiographs are ovcrused in the pediatric cmergency department. Population: 164 children (aged I week to 18 years) receiving abdominal radiographs. Methods: For i ten-month period physicians ordcring abdominal radiographs completed a questionnairc before and after radiographs. All were reviewed by pediatric radiologist.. " Results, Abdominal radiographs were ordered almost cqually to confirm 156"/o)or rulc out a less likely diagnosis. The abdominal radiograph results led to a change in diagnosis (51%|and.in manag"rneni 1460/o);percentages were not altered whethcr a film was oidered to confirm or rule out a diagnosis. Diagnosis change correlated highly with change in management {P < .001). Therc was no diagnostic or management efficacy in 48 cases (30%); this has cost-saiing implications. The most common reason for ordering abdominaf radiographs was to confirm or rule out intestinal ob-struction (46 cases, 28'/"1. Only three proved to have intestinal obstruction (6.5%); two other diagnosesrequiring immediate intervention were made: intussusception and a perforated viscus due to child abusc. Within this subset, four of these five cases requiring immediate action had abdominal radiographs obtained simply to confirm the diagnosis. The next most common reasons for ordering abdominal radiographs were to rule out intussusception, to confirm foreign body and constipation, and to confirm or rule out appendicitis. The most common final diagnoses were constipation and gastroenteritis. Conclusion: Alihough a plain abdominal radiograph can alter diagnosis and management, many films were ordered to rule out diagnoses that were unlikely based on history and-physical examinaiion. We estimate that 30% of all films could be eliminated without compromising the quality of patient care.

1o^7

Length-Based Endotlacheal lube Sizing for Pediatric Resuscitation

RC Luten,RL Wears,J BroselowA Zaritsky/ Divisionof of Florida, EmergencyMedicine,Departmentof Surgery,University of North University Departmentof Pediatrics, Jacksonville; Carolina,Hickory Study hypothesis:Pediatricendotrachealtubes can be accurately selectedby length using a specializedresuscitationtape. Population:Derivaiion set: 205 children undergoingelective r...gery. Validation set: 178 children undergoingelective surgery. Each child servedas his own control. Methods: The length for a given endotrachealtube size was derivedfrom the inteiquartile rangeof patient lengths in the derivation group, these lengths were used to develop a color-coded tape. T[e tipe was validated independentlyby using it to-select eniotracheaf tube size in the validation group. Criteria for acceptablefit included leak pressureswith l0 to 40 mm Hg and the anisthesiologists'decision to accept the tube size or to rerntu-

108

Ghild Neglect in Pediatric Patients Leaving Against lledical Advice

109

Screening lor Gocaine Intoxication in Ghildren With UnerPlained Seizures in the Pediatric Emergency Department

A A n d e r s o n , D S z y m k i e w i c z ,F H a r c h e l r o a d / D i v i s i o n o f Emergency Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania Study hypothesis: Parents who take their children from emetgency medical care against medical advice {AMAJ have had reports of child abuse/neglect filed against them prior to this event. Population: All children iaged 14 years or less) being taken by their parents {rom emergency medical care AMA over a 14month oeriod. Mcthirds: The family of every study population patient was contactcd within two weeks oi evaluation in the cmergency departmcnt to ascertain the reasons for leaving AMA, to define the Louschold population, to determine the Iinal outcome of the problem that caused them to present to the ED, and to verify dcmographic information given during the evaluation. The study population with prior or current investigations for abuse/neglect by the county Children & Youth Services (CYS) organization were determined through a coordinated effort between the ED and CYS. The two groups, those with CYS investigations (+CYS| and those without CYS investigations (- CYS) wete analyzed on several parameters: length o{ stay; single-parent household; total children in household; reasons for leaving AMA; known abnormalities at the time of departure that required treatment of the patient, and insurance tyPe. Results: Oi the patients aged 14 years or less evaluated during the study period, 243 were taken by their parents AMA, of whom complete iecords could be found on 193 {this accounted for 181 different families). Forty-eight patients 1126%lhad been investigated by CYS for child abuse/neglect. The main reason stated for leaving AMA by both groups, + CYS and - CYS, was a prolonged length of stay: however, the mean length of stay was 62 minutes for + CYS, and 143 minutes for - CYS. The only other category that demonstrated a significant difference between the groups was known abnormalities at the time of departure, 62% versus 8% {+CYS vs -CYSJ. Conclusion: A significant percentage oi pediatric patients who are taken by their parents from emergency medical care AMA have prior or ongoing records of child abuse/neglect. This is especially apparent in those patients who are taken after a short period of time and in those in whom an abnormality requiring treatment is known prior to their departure.

SE Krug / Departmentof Pediatrics,Case WesternReserve Schoolof Medicine,RainbowBabiesand Childrens University Ohio Hospital,Cleveland, Study hypothesis:Children with unexplainedconvulsionsmay representa population at risk for cocaine intoxication.

46


tttt

Population: Children between the ages of 0 and 16 years presenting to an urban university hospital emergency department with a history of a convulsion within the preceding 12 hours were considered for enrollment. Children with a known history of epilepsy or prior seizures; an identifiable traumatic, metabolii, or.infcctious precipitant; or presentation consisrent with a typical febrile seizure were excluded. Methods: As part of their ED cvaluation, all cnrollcd children had a urine and blood toxicology screcn performed. All ED charts for the period of the study were reviewed to detcrminc thc comp l e t e n e s so f p a t i e n t e n r o l l m e n t i n t o t h e s t u d y . Results: Ovcr the initial two monrhs of the study, lU children a g e d1 4 m o n t h s t o 1 5 y e a r s w e r c e n t e r e d i n t o t h c s t u d y . B a s e d o n ED chart review, this reprcscnted 9OL oI all potential cnrollces. Further rcview of the enrolled patients eliminated tcn for dcfinablc causes including trauma lonc), metabolic (onc), infection (two), history of epilepsy (two), and febrilc convulsion lfour). Of the remaining cight children with truly unexplained convulsions, two l25o/"1,had positive toxicology screens/ both containing cocaine metabolites. Subsequcnt intcrviews with thcse rwo Datients and their familics confirmed an intcntional {l+-ycar-tildJ and accidental il4-month-old) ingestion. . Conclusion: Thc preliminary data from this study suggcst that children presenting to an ED with an uncxplained convulsion represent a group at risk for cocaine intoxication and warrant considcration for toxicologic screcning.

lro

L Pipas, RM Cantor,JB McCabe / College of Medicine, State University ol New York Health Center at Syracuse; Department of C r i t i c a l C a r e a n d E m e r g e n c y M e d i c i n e , S t a t e U n i v e r s i t yo f N e w York Health Center at Syracuse S t u d y h y p o t h c s i s : O c c u l t i n f e c t i o u s p r o c e s s e sm a y p l a y a r o l e i n t h c p c d i a t r i c c a r d i a ca r r e s tp a t i e n t . Population: A four-year retrospective chart review of pediatric nontraumatic arrcst was ncrformed. Mcthods: Mcdical recoids were examined for specific prearrest historical factors: temperature, change in affect, upper rcspiratory i n f c c t i o n s y m p t o m s , n a u s e a ,v o m i t i n g , o r d i a r r h e a . M i c r o b i o l o g i c rcsults wcrc collectcd when performed, including viral, bacteriil, and fungal invcstigations. Rcsults: 3tl patients were identified, mean age 4 months. Nincty-two pcrcent presentedin asystole.Blood culturcs (periphc r a l o r c a r d i a c ) w c r e o b t a i n e d t n 2 8 1 7 3 % lp a t i e n t s , o f w h o m f i v e ll7%,) grew purc isolatcs of alpha hemolytic Strcptococcus pne1, H influenza (one|, group D Streptococcu.s ionel, Escherichia coli ionc), and Cantlitla albicans ione). Nasopharyngcal and rectal samples wcrc taken for viral isolation in 3I patients {8i%). posit r v c v i r a l r c s u l t s ( l l ) i n c l u d e d p o l i o v i r u s ( s e v e n ) ,a d e n o v i r u s ( t w o ) , r h i n o v i r u s ( o n c ) , a n d p a r a i n f l u c n z a ( o n e ) .T h e m e a n a g e p o s i t i v c for poliovirus was 3.3 months. Tcn patients were testcd for B pertussis, two wcre positive. Both patients had recent histories of cough and uppcr rcspiratory infection symptoms. Review of our paticnts' antccedent conditions dcmonstrated that 55% with cough and uppcr respiratory infection had viral rcspiratory pathogcns; and 36n/. had no antccedent tcmperaturci change in effect, uppcr rcspiratory infection, nausea, vomiting, or diarrhea. Conclusion: No emergcncy departmcnt guidelines currently cxist that highlight pertinent laboratory and historical data worthwhilc in thc postmortem examination of the pediatric paticnt. To assist in an appropriate evaluation wc recommend a full rncdical l-ristory be documcnted, blood and viral cultures be obtaincd, and cxamination for B pcrtussis and rcspiratory syncytial vlrus.

Effect of Intravenous lmmunoglobulin in a Rabbit Model of Meningococcal Endotoxic Shock

R S a l a d i n o ,G B a l d w i n , G A l p e r t , G C a p u t o , J p a r s o n n e t , Z G i l l i s , G S i b e r ,G F l e i s h e rI H a r v a ( d M e d i c a l S c h o o l , B o s t o n , Massachusetts Study hypothesis: IV IgG ameliorates mcningococcal (MC) cndotoxin (ET)-inducedshock in a rabbit model with rcsard to thc physiologic responscs(pulse ratc, mcan artcrial prcssurc lMApl, s e r u m b i c a r b o n a t e ) ,E T l c v e l s , a n d m o r t a l i t y . Population: 22 New Zealand Whitc rabbits wcrc uscd: 12 control rabbits and ten expcrimental rabbits. Methods: Rabbits wcre anesthetizcd and fcmoral venous and arterial catheters were placed. All rabbits rcccivf,r - il0 units/ kgl and wcre observed for "

1l . tN' dose, thc.expe rimen taI .rbbtlrh;ijin'"0, 1400mg/kgl. Results:Pulserate increascd r decreased from baselinet-^fAl--

r\l\ I\\

*112

Ti,*E[

r -,r bicarbonate .rid not diffcr bc-

Geometric Mean

(ng/ml)

(ng/ml)

0

0.02

0 .1 3

60

2.65

l.Oll

I 20

I .l0

0 . 2 5'

ET

IUO

0.5u

0 .I I .

Levels

240

0.411

0 .l 2 '

300

0.35

0.09'

360

0.27

0.rI'

'P < .05

The Esophageal Detector Device: A Rapid and Accurate Method lor Assessing Tracheal Versus Esophageal Intubation in a Porcine Model

R Foutch, MD Magelssen,JG MacMillan/ Madigan Army Medical Center, Departments of Emergency Medicine and Clinical I n v e s t i g a t i o n ,T a c o m a , W a s h i n g t o n

ilHlffi']*'ffi=T::: (min)

The Role Of Postmortem Cultures in Pediatric Gardiac Arrest

Study hypothesis: Thc Esophageal Detector Device (EDD) is a 50 mL syringc attached to an endotracheal tube. When withdrawn it creatcs frce air flow in the trachea and a vacuum in the esophagus. This device will be more rapid and as accurare as capnomctry or clinical methods in determining tracheal versus csophagcal intubation. Population: 30 subiects, including physicians, CNAs, and cmergcncy mcdical technicians-paramedics (EMT-ps) were randomly assigned to thrcc equal groups of "airway managers.,, Croup A used the EDD, group B used clinical methods (CMl, and group C used the FEF end-tidal CO, monitor {ETcor}. Methods: Part I. Under gcneral anesthesia, a hog wis intubated with a standard 7.5 mm endotracheal tube placed in the esophagus or the trachea. Anatomical location was verified by bronchoscopy. Blinded airway managers were asked to identify tube location by one of thc three methods {EDD, CM, or ETco2). Specd and accuracy of the assessment were recorded; comparison by analysis of variance and Fisher's exact test yielded a P < .001. Part II. A second, identical tube was placed, such that both the esophagus and the trachea were intubated. The esophageal tube was ventilated for one minute. An airway manageri using only the EDD, determined placement site of each tube.

Mortality was similar in both groups: eight of lZ $7%l control rabbits and seven of ten 170%l experimental rabbits died. Conclusion: IV IgG {400 mg/kg infused over two hours) in a rabbit model of MC endotoxin-induced shock significantly reduces ET levels and does not lower mortality.

47


I

transcutaneous Results:30 patients {aged49 to 97) received imre.eiued"r,opi-n"prior to pacingwithout clinical rr;'i;-2; pacing; It demonstiated-clinicalimprovement after ;;;;;";;'paceto hospitalization Six receivedtemporarv ;;;';ij-;;*.d permanent pacerequired patients these of three -^r..ir-r"a from the hospital' ;;i.';;; ol the total group-,-tiwere-discharged bradyconclusion: patients *iih he-odynamically,significant prehospitalsetting' ""rii* t"rr"tlt from external pacing in the

placement Results: Part I. The mean time to determine^tu-be seconds' group B (cMl 39 seconds, t3'8 "ctotpt *", i f";';;;;; {eon) A (EDD) and C 3l'5 seconds ,"a"-t"""t-C(Eicor) tube placedetermining in ""t""t" rr"rttl6o'a i#."";i;.; an assessed t.tbl.cts from lioup n {CMl mist?kenly l".*l'irtt* II' rhe EDD remained Part i'r.h.' ,t'. i" ;#h";;;Ti;;.'ri of the and I00% ip""irit despiteprior ventilation ro6li-i*i,l"e

"'3#"*fr^iti*?n. rapid ,oo ,, more th'lin't:,i:l the ptllii; ffiS location tube endotracheal determining in of the .ropr,"g."r i;ri"i-"."iii",i?,n the accuracy of the EDD'

l

* 11 5

Absence of ThYmine GlYcol Formation in Brain DNA During Postischemic RePerfusion

ol EmergencyMedicine' R t o'Neil,GS Krause/ Department

.:',:ffrul[::mli,Hfl,"-lrf\i1""'i.Hl^i' i:#il:J"ffi,".,'."ffJ!3il:::_

tttO

I

tube does not interfere with

reoxvgenatlon Ventilation g-"tg"i"y Artificial pr;;;; syititr"rir, are formed in brain DNA during victoria Anaesthesta ischemia' of iollowing '"'iip"ir"ti""l'iZ'1rrg9 PR GiffenJr, cE Hope / department dogswere anesthetized,instrumented'and racrliy of Medicine, GeneralHospitat;Departmentof Anaesthesia, controls; 20 mintq""ttv aiuiatd into"fouigroups: nonischemic DalhousieUniversity,Halilax' Nova scotia I n r e s p o n s e t o t h e c o n c e r n o v e r t h e a d e q u a c y om-outh f e m c r tog e n c y a r - t i t;;;-;;t"*i"ii""' " ' o i ; ; ; ; ; ; ; ' i t t t i * i t i i oand " i r etwo s u s chours i t a t i oofn ;reperfusion; 2 0 m i n u t e sand o f c20 ardi'" from ;it"J;;il ;i; of rcperhours tificial ventil"'iot' "'i'iit eight and resuscitation, alrest/ cardiac of (rvltn) ventilator ;inutes mouth breathi.,g," p,oio.;i.^;;;.:;"1';-;ask 'h;;;;;A;tc*i ex{usion' ".a ittit'a rhis device is powered bv the DNA (four samtut"ii'od'' In a model experiment' calf thymus (254 nm' 28 8 aâ&#x201A;Źt asan oxygcn reserhaled air of the operator'nt'Jtt"' a tube to UV irradiation bv a"*rged *r' p1.'.i;';;;h;;o"p) -o-p"ri"o. ur"rttr. '1, il;;;;.' voir (1,300 mL), which'ilitil FeSooand 30 pM H2o2); or osirt" i""*,i-i.Ii.n, 1190-ufu studies with mouth-to-morrth,morth-to-mast,'rnJtri-urtu.masktechniquesduringsimulatedtwo-personcPRwerecon-ti"-t"1tt*iie-{3'imlvr)o'amageddNe'isolatedbytwoserial ductedusinglTvolunteerfirst-yearnursingstudentsaSopcratols.,p i " ; " j'ii'i!; ; ; ; ; } ! p h a . t in e x 155 . , c -mM . s o | iN'cl a s p r eand c i pI0 i t amM t e d iNaH'Poo' n 6 T % - e t hpH anol ;; th;;;LJ;i;ed percent ""'t'o'ioio*lat from the cerebral The tidal volume, percent oxvgen' a.nd DNA animals' tlq;;''";tal -o'''thi'snl' i 7 rfit ?s iolbwi r-t"t'deliveredbv each *"tr'oJ*"'" t o - m o u t h l T 6 0 ! 2 g 0 m l ' 1 7 + r % c , 2 ' 3 ' 4 : 0 4 " ! C o ; l ' ' -ioz). m o " t h - t " " l t i *;;dtii;;'i;;iua. " - i t " r l t J i v t h e m e trirtlo*ia^nts. h o d o f b i c a rResidual elliandw RNA e t t ewas r h a removedbv hn' 'l' +l * 8% oz, zs t^o.qJ/"-b-aqto-mask (9r0 r 350 mL, sedimentationof the DNA "nJ.rltr"..tttrifuee o.bs-t'doz% iiNrr?"irg.".n o2,, iio-^r, si-t-3% mask {550 varve-{soft) slv"colswere labeled' using the 'f'ro"gft"'i"l'i'N'Ei ittv-lnt 96^t-3;" O.,, 003^COr); bag-valveirigid] *rr["fSAO'r 300, addingto 8 mM NaBtH* and I li al, !t -.,#i"r's.itlli."u.ii {860 : 290 mL, 9r i.79".C-2. 0.02,/.co)); ancrtuDe-varvc-mask Sorohvdridewas removed Ljnreacted ;'i:s [q DI,l-+t il ffi.ii that i-n ir,. n"na, ,if o.z ! o.zo/. co"). These results indicate relativelyinexpeliencedoperators/-outh,o..n.'th,-*o..th-to-ilv'p1""""r'.'s.TieDNAralasprecipitatedandwashedin6T% incorporam a s k , a n d t u b e - v a l v e - m a s l i t e c h n i c l u e s q r o l l { e ttoi , . ' o dthe . q ucase n . t " u " . ' . " i r ' * J "b; - " J;i"rofluorimetry^prior . i . a i . * r " " d i n P B S . ^ D Nto A cmeasuring o n c e n t r a tlabel ion.w asdeter. -i"tJ This t" with c ANoVA tilation volume (800 mL, t test, P < 0l)' Kruskal-wallis by evaluated were rttt data th"t p'ouitlt ti""' systeri' the of systems' proDunn the by with the bag-valve-mask examined were = comparisorrs varvermask,pp.^ri ,up"_0.05.Group adequatevent'ation ";il;.";h;"irbe are shown as mean * standard Results ipp'opii'tt *r"it ""a"'"t riorln that a higher oxygen and lower carbondioxide'concentradeviation' < 01.)in addition to a ,i"" .t" ,ft" be"obtainli (paircdt tcst' P thvm's DNAs' DNAs, onlv the reaction In the model' calf thvmus operapleasing"Hvrq RtJ;;' aestnetrca'v ano PrLaD'rb intectton verv low ,irt ot t'ot'-'ii-titff;;;;i;;mttit'ttv

tion

U;;:t}:nj*:,.,ii';,h::l,li:,::::tlfil';.f:ff:il'",*1s1"

*'l"T%o''8#ITno "*^ "t"Iilo eeoYeso in tr-'--.t.her-e in [|;.1',"'""g.il;T=Sl:1r=":t:i:"' Y:., were no significan-t-differences label incorporation patients

*114

s D Eiter,w 6r-amer,R Drawbaugh,K Gillespie, J Goldstein, Medicine'York Stein,N Sabulsky/ Departmentof Emergencl M"ditin"

the experimental brain DNAs 2g-Minute

Arrestand

Agest and

t#""T: Nonischemic

"i;ii'Hiii' T{*jfli::t ' ''o '''{ii,1,""-;-*,'fi;:':';"::T",'J'^,;1i3",, y;l#"1";:l*.:1'*:u:'4""T:?;'i:'B;5:'il::iJJ

ot emeis;niv Department York,Pennsvlvania; Hospital, HanoverGeneralnoto't:''.

pennsyrvanra prehospital.patientswith hemodynamicallv

identifies thymine conclusion: Borohydridereduction o{ DNA but there is no'evidence clv-t;h;il;Jtl. :-:::l:,ietroxide'

Study hypothesis: fio- r,r,,r".,,r,,'."j',i;::fii*'o#;*:::l'*3;5;r::,.,:Tt:f;l"lJ'i,,ri,r!^rr9J.1:3tl?'JlilIil:'i:b.r,.frt bradycardias significant glycols' lng. - r r-. external pacerPopulation: We studied patient-s^treated.by

.qil;;;';;;r"".a

s l o rr i s n o t c a u s e d b y t h y m l n e

lii' t"pri"" {ALSJunits in a suburban/rural

L liilifih:rtti:ti*'S:61";.u,'p,,,.,i,"d TlI I- 6ba.se da,a ALS during.l984 to 1988 ALs dl ;;;-g;tit-pts was usedto identifv with r.ii.*Ja - rel.ct only thosc patients ;i;;h;;,;';;ie.th.r' and shects trip ALS bradycardias. srgnificant hemodynamrcarry

il;;il

,? ;;i..1',".8id, werethenreviewed 1::::T'l',:1llj,

initial cardiacrhvthm, useot cal presentation, or ,'"tJ?irli;rltJ'31 admission'th:-'l','9 jl:j-':porarv il,#il;;;;;ing,lospital discharge permanent ,r".rru"t'out

pacing, and hospital

T'"lTl"FillI'*""E""#:L:31, Lumen Airway lub^e

tracheal of ornato.e nacniJ cameron/ Medicalcollege S McMahon,J -Commonweatth Internal.Medicine :,lnri"Tviifrl University:

Virsinia Richmond. Services, ;":ii;; oi'e'"'s"n"y Medicat

glacement the prehospital Hypothesis/p,uryo.:l]o^r.ompare. of the pharvngeotracheal

rate and adequacy oI ."i.t::;;;:';;"d";i.;".;""iveniilation success

48


j

lumen {PTL) airway and the endotracheal tube (ET). Population: 167 adults, aged l6 to 9Z-years, were included if a prehospital provider attempted to intubate with a PTL or an ET airway. Methods: Prospective, multiagency design that included urban and suburban, paid and volunteer, basic life support (BLSf and advanced li{e support (ALS) (cardiac technicran and paramedic) prehospital providers. Patient demographics, provider certification, agency affiliation, indication Ior airway, cstimated time and e a s eo f a i r w a y i n s e r t i o n , a n d e f f e c t i v e n c s s o f v e n t i l a n o n w e r e r e corded by the prehospital provider following cach run in which a PTL or ET airway insertion was attempted. Statistical analysis consisted of analysis of variance and Fishcr's exact test. Results: There were no significant diffcrences in paticnt demographics between PTL and ET groups. PTL airways were inscrted s u c c e s s f u l l ya n d i u d g e d t o r e s u l t i n a d e q u a t e v e n t i l a t i o n i n 8 9 o f 107 (83%) attempts. One quartcr of blind PTL attempts rcsulted i n e n d o t r a c h e a l , r a t h e r t h a n c s o p h a g e a l ,i n s c r t i o n . T h e P T L p h a ryngeal seal was judged to be satisfactory in 78%, of cases. ET airways were inserted successfully in 54 of 63 186%) attcmpts. There was no significant differcncc in succcss rate of eithcr airw a y i n t r a u m a t i c v e r s u s n o n t r a u m a t i c c a s e s ,m a l c v c r s u s f c m a l c patient, volunteer versus paid provider. ALS providers wcrc lcss successlul than BLS providers 178"/"vs 94"k, P < .031 at inserting the PTL airway, probably becauseBLS providcrs uscd the PTL as their pnmary airway in 86"/" <tf cases comparcd with ALS providers who used the PTL as primary airway in 5tl'2, of cascs lP < .00011.ALS providers chose the ET as primary arrway in 4O%, <t( cases. Conclusion: The PTL airway can be inscrtcd by BLS providcrs w i t h a r a t e o l i n s e r t i o n a n d v c n t i l a t i o n s L r c c c s sc o m p a r a b l c t o E T intubation by ALS providers.

*117

minutes. Average time to ECG was 18.9 minutes after rescuearrlval. Conclusion: Delays in initiation of TT can be attributed to several factors including patient recognition of AMI and intrahospital logistics. Paramedic prehospital ECG greatly reduces time ro AMI diagnosis. These data support the development of programs to study the prehospital diagnosis and treatment of AML

* 11 g

E P R i v e r s ,J L o z o n , N A P a r a d i s , M G G o e t t i n g , G B M a r t i n , T J Appleton, RM Nowak / Department of Emergency Medicine, Henry 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 Thc central aortic (Ao)-to-right atrial pressuregradicnts during CPR rclaxation phase is the coronary perfusion pressure {CPP) a n d c o r r e l a t c s w i t h t h e r e t u r n o f s D o n t a n e o u sc i r c u l a t i o n . H y p o t h c s i s R a d i a l a r t e r y { R A D I p r c s s u r cm a y b c a c o n v c n i e n t substitute for Ao pressure in calculating the CPP. Population: l5 normothermic, cardiac arrest patients. Mcthods: Whilc rccciving advanced cardiac life support, right a t r i a l , A o , a n d R A D c a t h e t c r s w e r e i n s e r t e d . P r e s s u r e sw c r c m e a surcd after treatment with standard dose epinephrinc (SD) of I m g a n d a f t c r h i g h d o s c ( H D ) o f 0 . 2 m g / k g . P r e s s u r e sr e p o r t c d r c p rcscnt maximum Ao aftcr treatment and simultaneous RAD in mm Hg. R es u l t s : M a x i m u m R e s p o n s et o S D

Compression 70*ZZ Radial

Gharacterization of the Time Gourse From lnfarction Onset to Thrombolytic Therapy: ldentification of Delays and

Mean

70x23

Relaxation

CCP

Zl*16

| :! l0

ZZ+15

l:l

9

lVlaximumRâ&#x201A;Źsponseto HD Ao R a d i aI

Remedies G R M c K e n d a l l ,M J M c D o n a l d , R W o o l a r d , D O W i l l i a m s / R h o d e l s l a n d H o s p i t a l ; B r o w n U n i v e r s i t y ,P r o v i d e n c e , R h o d e l s l a n d Study hypothesis: Substantral dclays in thc diagnosis and trcatment of myocardial infarction occur using current prehospital and emergency department evaluation procedures. Population: 229 consecutivc confirmed acutc myocardial infarction (AMI) patients. Methods: Each patient was studicd prospcctivcly to charactcrize the delays involved in thc diagnosis and trcatmcnt of AML Times from symptom onset to rcscuc or ED prcscntation, electrocardiogram obtainment, and treatmcnt with thrornbolytic therapy ITT), when appropriate, were recorded. Results: AMI occurred out of hospital in lgU of 229 186.5"1,)i 1 4 0 o f 1 9 8 1 7 0 . 7 " / "p ) r e s e n t e d t o t h e E D b y r e s c u e ( R E S ) ,a n d 5 8 o f 198 129.3%)presented without seeking prehospital assistance INO RES]. Elapsed Time:

Gomparison ol Coronary Pertusion Pressure Using Radial and Gentral Aortic Pressures During CPR in Human Beings

Contpression 103 * 30

Relaxation 36!22

CPP l5 a l2

103 :i 42

3(r + 2l

1 4a l l

Thcre wcrc no significant differencesbctwecn Ao and RAD prcss u r e s i P > . 0 5 1 .T h c c o r r e l a t i o n b c t w e e n A o a n d R A D r c l a x a t i o n pressurcs was 0.97 and 0.98 after SD and HD, respectivcly. Conclusion: RAD correlates with Ao response to vasoprcssor thcrapy during CPR. CPP obtained with RAD rarhcr than Arr is u s c f u l i n m c a s u r i n g r e s p o n s e t o v a s o p r e s s o rt h e r a p y d u r i n g C P R .

Potential Adverse Effects of HighDose Epinephrine in Human Survivors of Gardiac Arrest M Callaham, C Barton,S Kayser/ Division ol Emergency Medicine, Department of Medicine; Division of Clinical Pharmacy, {

f

{

1l| f V

S c h o o l o f P h a r m a c y , U n r v e r s i t yo f C a l i f o r n i a ,S a n F r a n c i s c o S c h o o l of Medicine Study hypothesis: High-dosc epinephrine {HDE} produces no adverse effects in survivors of cardiac arrest comDared with advanced cardiac li{e support iACLS) standard dosesof epinephrine ISDEJ. Population: Prospective series of 6l patients in nontraumatic cardiac arrest at a university hospital who received one to l5 mg IV epinephrine (EPI)boluses at the discretron of the supervising physician werc resuscitated and survived at least six hours. Mcthods: Patients were evaluated Ior alter resuscitation hypertension, arrhythmias, pulmonary status, cardiac enzymes, ECG changes, acidosis, electrolytes, and outcome, using unpaired twotailed r test, contingency analysis, and multiple regression. Measurements and results: The 29 HDE and 32 SDE patients were similar in demographics, site of arrest, bystander CPR, witnessed arrest, presenting rhythm, and joules delivercd. After resuscitation, they did not differ in electrolytes, glucose, pH serum bicarbonate, hours survival {average 184),arrhythmias, ECG

1 SD/Median

t'T,f,tt symptomonset *:::#l rime to to RESor ED Time ECGin ED ECGin ED (min) (min) (min) (min) RES 9 s . 41 9 3 . 9( 5 5 . 5 ) ' 2 i j . 4t I 2 . O o l 1 72l 7 . t ! 2 4 . 9 1 2 ta) ) 5 . 1 7 4 r . t .l 3 ss) N OR E S 1 U 7 .I6 2 t 2 . 0l l 0 3 l 2 9 . 1x 2 t . 9l 2 2 l 7 . 1 . j4 3 8 . ,{1r , 2 ) 'P < .0001 NO RES patients delayed longer than RES patients before secking assistance.Scene and transport time for RES patients was short. All patients had similar substantial delays in time to ECG and treatment; TT was initiated about 1.5 hours after ED atrival. A group of patients {17) with suspected cardiac chest parn had a prehospital l2-lead ECG taken by rescue. Average time from symptom onset to rescue arrival was 50 minutes/ range 2O to 90

49


changes, pulmonary complications, or peak CK. Neither EPI dose per kg nor peak EPI dose correlated with CK-MB. Only one of 18 who received more than l0 mg or more than 0.12 mg/kg EPI was discharged from hospital; she received 105 mg. Standard Dose High Dose (SD) (HD) ? Value Variable Average total EPI, mg

20l24l

Average total EPI,

mg/kglrangel PeakCK-MB% Systolic blood pressure > 150 alter arrest (duration) Serum calcium after anest

.2u1.3)l.0s-1.31 7.75K,.41

17 of 29 (15 min)

r.7(.lJl .03(.01)I.Ol-.Osi 5.6|.4.4)

l0 of 30 {16 minl

.0001 000 I NS

NS

tr.s(.n)

.01I

38 {20)

.031i

3of29

2l ot 112

.025

2of16

l0 of 24

NS

Pco, during arrcst

7.e{.r,r) s2lzel

Discharged alive, all anests Discharged alive, anests < 35 min

Conclusion: HDE even in very large doses causcs no major complications. Survival rates were less, perhaps due to HDE usc late in arrest thar resuscitated sicker patients.

*r20

Gentral Aortic Pressure During Human Electromechanical Dissociation: ldentitication of a Subset With Aortic Pulse Pressures

G B M a r t i n , N A P a r a d i s ,E P R i v e r s , M G G o e t t i n g , J M R o s e n b e r g , TJ Appleton, RM Nowak / Department of Emergency Medicine, Henry Ford Hospital, Detroit,Michigan Hypothesis: Emergency departmcnt cardiopulmonary bypass (CPBIcan rcsuscitatc cardiac arrest patients unrcsponsivc to standard therapy. Population: Witnessed cardiac arrcst patients with short down timcs, aged 14 to 65 years, without severe preexisting illncss, and unresponsive to initial resuscitation. Mcthods: CPB was initiated by an on-call rescarch team. Bypass cathctcrs werc placed in the femoral artery and vcin. A constraincd vortex pump, mcmbrane oxygcnatori and hcat exchanger were uscd in thc CPB circuit. Rcsults: Fivc patients (mean age 43 + 18 years] underwent CPB. Mean timc from cardiac arrest to institution of CPB was 35 t 15 minutcs. Time from arrival in the ED until CPB avcraged 25 ! 12 minutes. Mean timc on CPB was 3.5 + 1.5 hours. Card i a c o u t p u t w i t h C P B a v e r a g e d4 . 4 * l . I L / m i n . A l l f i v c p a t i e n t s h a d r c t u r n o f s p o n t a n e o u sc i r c u l a t i o n w i t h C P B . W i t h i n o n e h o u r of CPB, four of thc five bcgan sustaincd purposcful movements and rcquircd scdation and paralysis.Four of thc fivc werc wcaned from CPB and left the ED; however, all of thcsc patients dicd without regaining consciousncss within 28 hours. Thc cause of dcath was felt to bc sccondary to the postresuscitationsyndrome. Conclusion: This study dcmonstratcs the cfficacy of CPB in achicving rcturn of spontancous circulation in sclcctcd cardiac arrest patients unrcsponsivc to standard therapy. Thc secondary d e t c r i o r a t i o n o f t h c s e p a t i c n t s s u g g c s t st h a t a g e n t s t h a t m i t i g a t e rcperfusion injury may bc ncccssary to gain optimal bencfit from CPB.

122

NA Paradis, MG Goetting, EP Rivers, GB Martin, TJ Appleton, Rl\,4 Nowak / Departmenl of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan Echocardiography has shown that some patients in electromechanical dissociation (EMDI have myocardial wall and valvc motron. Hypothesis: A subset of patients in EMD have central aortic (Ao) pulse pressures that may indicate a better progrrosis. Population: Adult medical cardiac arrest patients. Methods: Standard extemal CPR and advanced cardiac lifc support were performed with the exception o{ administration of highdose epinephrine to some patients late in arrest. Paticnts whose ECC showed regular organized depolarizations but who lacked palpable carotid and femoral pulses were defined to be in EMD. An Ao arch catheter was placed for pressure measurement. Patients found to have regular Ao pressure pulsations were defined to be in pseudo-EMD (P-EMD}, and those without Ao pulscs true-EMD {TEMD). Means were compared by t test and proportions by x2 with significanceatP<.05. Results: Of 187 patients studied, 85 presented with or developed EMD at some time during resuscitation. Of these, 36 142"/")were found to be in P-EMD, with Ao pulse pressures of (r + 3 mm Hg. The resting Ao pressure was 20 + 13 mm Hg in patients with T-EMD, 28 * l0 in those with P-EMD (P : .0031.Duration of the initial ventricular depolarization on the ECG was 0.08 t 0.05 ms in patients with P-EMD, and 0.23 + 0.15 in patients with T-EMD {P = .021. Thirteen of 49 and 23 of 36 patients with T-EMD and P-EMD, respectively had return of spontaneous circulation {P <

.0011.

JJ Menegazzi,M Klain,J Goode,R Molnar/ University DM Yealy, Divisionof EmergencyMedicine;Centerfor of Pittsburgh, Hospital Montefiore EmergencyMedicineof WesternPennsylvania; and DarnallArmy Community Pennsylvania; of Pittsburgh, Hospital,FortHood,Texas Study hypothesis:A dccreasein lung complianccduring lowfrequencyjet vcntilation(LFfV)will lower the deliveredtidal volume and incrcasethc peak trachealpressure. Population:An in vitro model,usinga calibratedMichigantest lung and a computcr software program. Methods: LFJV with a fixed 45-psi driving pressuresource,20breath per minute ratc, and 30% inspiratory time was performed. Both 13 and 14 gaugeiet cannulae{Acutronics AG, Zurich) were studied. Total lung compliance for each trial was varied and mean deliveredtidal volume and peak trachealpressurewere calculated fuorr'64 measurementsat each setting. Data were analyzedusing repeatedmeasuresanalysiso{ varianceand the Pearson produci-moment correlation {r), with a P < .05 considered significant. R e s u l t s :P r e s e n t e db e l o w a r e t h e t a b u l a t e dd a t a f r o m 6 4 0 measurcments. Compliance (L/cm2)

.01 Cannula

Conclusion: Some patients who clinically appear to be in EMD have ventricular contractions with Ao pulse pressures. These patients may have higher rates of retum o{ spontaneous circulation than those without aortic pulses. ECG analysis may help in early identification of patients with P-EMD.

121

The Effect of Varying Lung Gompliance on Delivered Tidal Volume and Peak Tracheal Pressure During Low-Frequency Jet Ventilation

.o2

.05'

.l 0

.l 5 P Value

Iuean DeliveredTidal Volume (mL) I,155 I,ZZ2' 1,343 973

13g

tll3

1 4g

665

794

936

1,079 l,ll5

Correlation r (P Value)

< .001

. 9 s( < . 0 0 1 )

< .001

. 9 3{ < . 0 0 1 1

< .00r < .001

-.82 l< .0011 -.82l< .0011

Mean Peak Tracheal Pressute (cm H"O) l5

l0

o

25 12 45 l4g ' normal lung compliance.

ti

6

l3g

Femoro.Femolal Cardiopulmonary Bypass in the Treatment ol Gardiac Arrest in Human Beings

50

54

3l


Conclusion: In this modcl, dclivcrcd tidal volumcs fall and peak trachcal prcssures increasc as lung compliance is lowcred during LFfV. Dclivcry of adequate tidal volumcs in low complia n c c s i t u a t i o n s m a y b c i m p e d e d a n d a s s o c i a t c dw i t h a n i n c r c a s c d risk of barotrauma as a result of highcr pcak trachcal prcssures.

123

Ability of Spirometry and Oximetry to Guide Use of Arterial Blood Gases in Acute Exacerbations of Ghronic Obstructive Pulmonary

with thc formal scan by radiology or obstetrics. Results: l/ patients were studied; average age,23.4 lears; and average gestational age was 8.1 menstrual weeks. Seven scans wcre read by the emergency physician as dcmonstrating IUP; all of these were confirmed by the formal scan lP < .011.Ten scans were read by the emergency physician as not demonstrating a definite IUP; all of these readings agreed with the formal scan lP < .001). Conclusion: Emergency physrcians can rcliably perform pelvic ultrasound in paticnts with suspected ectopic pregnancy and intcrprct thc rcsults as to thc presencc or absence of definitc IUP.

Disease G P Y o u n g/ P o r t l a n d V e t e r a n s A f f a i r s M e d i c a l C e n t e r , O r e g o n H e a l t hS c i e n c e s U n i v e r s i t y ,L a k e O s w e g o , O r e g o n Study hypothcsis: Spirometry and oximctry arc useful in dctermining which paticnts with acutc cxaccrbations of chronic obstructivc pulmonary discase (COPD) nccd artcrial blood gascs. Population: 100 paticnts abovc agc 50 with a clinical history of chronic obstructivc pulmonary discaseprcscnting to an emerg c n c yd c p a r t m c n t f o r a c u t c r e s p i r a t o r y d i s t r c s s w h o s e t r c a t i n g p h y s i c i a n o b t a i n c d a r t c r i a l b l o o d g a s e s .P a t i e n t s w i t h a h i s t o r y o f asthmaor prcscnting with pncumonia, hcart failure, or pneum o t h < l r a xw c r e c x c l u d c d . Mcthods: C)n prcscntation, cach study patient had arterial b l o o d g a s c sd r a w n , p l u s s p i r o m c t r y ( P E F R ) a n d o x i m c t r y ( S a O " ) p c r f o r n . r c dS. c n s i t i v i t y , s p c c i f i c i t y , a n d p r c d i c t i v c v a l u c s w c r c d e tcrmincd for PEFR with rcspcct to Pr:o, grcatcr than 44 mm Hg and for SaO, with rcspcct to Po, lcss than (rl mm Hg. R c s u l t s :T h c m c a n i n i t i a l r o o m a i r a r t c r i a l b l o o d g a s c s w e r c p H = 7.43 t:0.0(r, Prr>, - 4l + l0 mm Hg, and Po" - (rl + l0 mm Hg. Fifty-thrcc patients had Po, lcss than (rl mm Hg and all of t h c s c p a t i c n t s h a d S a O . l c s s t h i n 9 5 ' 2 , ( s c n s i t i v i t y , 1 0 0 % , ;s p c c i I i c i t y , 4 0 " 1 , ;p o s i t i v c p r c d i c t i v c v a l u c , 6 6 " 1 ' ; n c g a t i v e p r c d i c t i v c v a l u c , 1 0 0 % , )T. w c n t y - s i x p a t i c n t s h a d P r : o , g r c a t c r t h a n 4 4 m m Hg and all but two of thcsc paticnts had PEFR lcss than 200 L / m i n { s c n s i t i v r t y , 9 6 " 1;, s p c c i f i c i t y , 3 ( r ' 2 , ; p o s i t i v c p r c d i c t i v c v a l u c , ( r 0 ' 2 , ;n c g a t i v c p r c d i c t i v c v a l r - r e 9 , 5 o 1 , )E . lcvcn paticnts had pH lcss than 7.36, all of whom had PEFR lcss than 200 L/min and/or Sa(), )c.ss than 9.5')1,. Usitzg thcsc tw,o critcria, 12?1,of study paticnts would not havc had artcrial blood gascs drawn, d e c r c a s i n gt h c p c r c c n t a g c o f p a t i c n t s w i t h o u t p o s i t i v c a r t c r i a l blood gas findings from 3l%, t<':19"1,. Conclusion: Noninvasivc spiromctry and oximctry cnrcna arc uscful in scrccning ED paticnts with acutc cxaccrbations of chronic obstructivc pulmonary discasc for artcrial blood gascs.

124

Performance and Interpretation of Pelvic Ultrasound by Emergency Physicians in Patients With Suspected Ectopic Pregnancy: A Prospective Study

L M G u s s o w ,G A l b e r t o / D e p a r t m e n t o f E m e r g e n c y M e d i c i n e , Cook County Hospitai,Chicago, lllinois Study hypothcsis: Emcrgency physicians can usc ultrasound imaging to reliably cstablish the presence of intrauterinc prcgnancy (lUP) in paticnts with suspected cctopic pregnancy. P o p u l a t i o n :E m c r g c n c y d c p a r t m c n t p a t i c n t s w i t h s u s p e c t c d c c topic prcgnancy. All had bccn schcduled for formal emergcncy pclvic ultrasound in the radiology or obstctrics departmentMcthods: Two cmcrgcncy physicians reccived a maximum of six hours training in pclvic ultrasound supplcmcntcd by individual rcading. Paticnts entered into thc study had thcir bladders fillcd by the tcchniquc indicated for the formal test. In a blinded manner, one of thc two authors performed a transabdominal pelvic scan on each paticnt, using thc ScanMatc IIo portable ultrasoundscanncr (Damon Corp) fittcd with a 3.5 MHz probe. The s c a nw a s r n t c r p r e t c d i m m c d i a t e l y , w i t h d e f i n i t e I U P b e i n g e s t a b lishedby the visualization of a yolk sac, fctal pole, fetal heart movement, or double decidual sign. This readrng was compared

125

Substantial lmprovement in Adherence to Universal

Precautions in an Emergency Department Following Administrative Changes G D K e l e n , G G r e e n , C F o r t e n b e r r y ,E T a y l o r ,D H e x t e r , D F l e e t w o o d , T D i G i o v a n n a , K T S i v e r t s o n/ 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 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 Hypothcsis: Whcn univcrsal prccautions arc institutcd as poli c y w i t h r e p c r c u s s i o n sf o r n o n c o m p l i a n c e , a d h e r e n c e s h o u l d i m provc. Population: Consecutivcly presentingcritically ill or injurcd paticnts of any agc prcscnting to an inner-city cmcrgency dcpartmcnt with high HIV scroprcvalcnce among patients. Methods: During a onc-month period in fuly 1989,exactly onc year aftcr a prcvious study using the samc methodology, health carc workcrs (HCWs) wcrc observcd 24 hours a day in thc ED as thcy pcrformcd proccdurcs on patients rcquiring rapid intervcntions. HCWs wcrc blindcd as to thc purpose of the obscrvation. During thc intcrvcning ycar bctwcen thc two studics, thc institution initiated a policy mandating compliancc with infcction control prccautions. Educational programs wcre unchanged. Expccted precautions wcrc bascd on type of intcrvention and blccding status of thc patrcnt. Intcrvcntions wcrc classificd as maior, minor, or physical cxamination only. Blccding statlrs was dcfined as profusc, activc, or nonc. For major proccduresor profuse blecding all prccautions wcre rcquircd; for minor proccdurcs or activc blccding, at least glovcs werc required. Results: During thc month, 125 HCWs pcrformcd 1,419proccdurcs on 1(r[3paticnts. Ovcrall adherence improvcd t<'t 74.4"1, c o m p a r e d w i t h 4 4 . 0 % i n t h c p r e v i o u s y c a r ( P < . 0 1 ) .M o s t p r o viders improved substantially: residents 58% to 82%, attendings 38% to (r47o, consuitants 43%, to 65"1', nurses 447o to 75"/", radiology 14"/" to 79"/n (cach P < .01). Paramcdics, who are not accountablc to thc institution failed to improve: 8"/" to l4n/,' \P > .2). Adhercncc during major procedures improved from l7% to 55% and in thc facc of profuse bleeding from I9.5% to 47% (P < . 0 1 ) .S p o t c h c c k s c v e r y t w o m o n t h s f o l l o w i n g t h e s t u d y r e v e a l e d adherence to prccautions was maintaincd at 73"1,. Conclusion: As evidenccd by comparing paramedics to othcr providcrs, implcmcnting universal precautions as a policy can dramatically improve provider compliance.

1 26

in fn":'81':il"""'"ll;i""i':,',5"ldurt

yospltal, Emergency J S S l a p c z y n s k l / P r e s b y t e r i a n - U n i v e r s r tH D e p a r t m e n t ; U n i v e r s i t yo f P i t t s b u r g h , C e n t e r f o r E m e r g e n c y Medicrne, Pittsburgh,Pennsylvania

Study hypothcsis: There are definable clinical critcria that arc useful in evaluating febrile adults in the emergency department that will reduce thc use of ancillary tests and bacteriologic cultures. Population: Adult patients seen in an urban univcrsity hospital ED over a l2-month period with a complaint of fcver or oral temperature above 38.0 C.

51


. Me thods: Retrospective review of ED, hospital, and chnical cnarts. , 29%l Results: 26,173 aduk patients seen in thc ED with 7,59O admissions; I,547 16%) patients met entry criteria; 759 la9%) admitted after ED evaluation) 219 ll4%l admitted directly without ,.35%l full ED evaluation; 541 discharged; and 28 l2"k) transferred. Admitted patients werc older and more likely to have ccrmorbid diseases lP < .05 by 2x2 table) than discharged paticnts. Localized signs and symptoms led to ED diagnosis that agreed with discharge diagnosis in92"/" of admitted patients. Bactcremia was seen only in patients with prcdisposing conditions, localized infections, or advanced age. The whitc blood ccll count or differential had no utility in young and middle-aged adults in detecting those patients with bactcrial infection. In the febriie elderly patient, bacterial infections wcrc associated with leukocytosis, pyruia, or radiographic infiltrate. Conclusion; Febrile young and middle-aged adults prcscnting to thc ED can be evaluated using signs and symptoms to guidc the use of ancillary tcsts. In elderly patients, urtnalysis, chest radiography, and white blood cell count arc hclpful. Blood cultures arc useful only in patients with dcfinablc risk factors for bactercmla.

127

Prospective, Randomized, Double. Blind Study Gomparing Racemic Epinephrine and L-Epinephrine in the Treatment ol Group

Y Waisman,BL Klein, DA Boenning, GM Young, R O'Donnell, DW O c h s e n s c h l a g e r / E m e r g e n c y M e d i c a l T r a u m a . C e n t e r ;C h i l d r e n s Hospital National Medical Center; The George Washington U n i v e r s i t y ,D e p a r t m e n t o f P e d i a t r i c s ,W a s h i n g t o n D C Acrosolizcd raccmic epincphrinc (RE) composed of cqual amounts of D and L-isomcrs o{ cpincphrinc is uscd commonly in trcating croup. RE was originally choscn in prefcrencc to thc 30 times more active L-isomcr alone lLEl in thc bclicf that fcwer cardiovasculareffccts would rcsult, but comparativc studies havc not yet becn reportcd. Wc comparcd thc efficacy and advcrsc cffccts of cquivalcnt doscsof thc L-isomer in nebulizei [utions of RE and LE in thc trcatr

Public Safety; Bureau of Emergency Medical Services, Pittsburgh, Pennsylvania Hypothesis: Prehospital intraosseous {lO) infusion is a viable and rapid alternative to IV accessin critically ill chiidren. Population: Children under the age of 6 years in cardiac arrest { 1 1 )o r s t a t u s e p i l e p t i c u s ( t h r e e ) i n w h o m p r e h o s p i t a l I O i n f u s i o n was attemptcd from March 1989 to )anuary 1990. Methods: A prospective study of prchospital vascular access as pcr IO protocol: comparison bctween IV and IO access, number of attempts, success or failure, length of procedure, and location { s c e n eo r e n r o u t e } . P a t i e n t o u t c o m e a n d f o l l o w - u p f o r I O c o m p l i cations was performed. Wilcoxon rank-sum and Fishcr's exact test were used with significance set at P < .05. Results: IV access was attempted in six patients prior to IO infusion; none werc successful, and all requircd more than two minutes imean, 280 scconds).IO infusion was attcmpted in 14 p a t i e n t s , w i t h l l s u c c c s s f u l p l a c e m e n t s v e r s u s I V { P - . 0 0 2 ) ,s i x on the first attempt. Mcan time to IO infusion succcss was 69 s e c o n d s v c r s u s I V ( P - . 0 0 7 1 .T h e r e w e r c f i v c s c c n c s u c c e s s e sa n d n o f a i l u r e s a n d s i x s u c c e s s e sa n d t h r c e f a i l u r e s e n r o u t e l P = . 2 3 ) . M c a n t i m e t o s u c c e s sa t t h e s c e n c w a s 3 5 s e c < l n d sv e r s u s 9 7 s e c o n d s e n r o u t e { P = . 0 ( r ) .O u t c o m e w a s n o t a f f e c t c d b y s u c c c s s f u l IO placement and therc wcrc no IO complications. Conclusion: This study documents the achicvcmcnt of prchosp i t a l v a s c u l a r a c c e s sm o r e r a p i d l y a n d s u c c e s s f u l l y w i t h I O i n f u sion than IV rn critically ill children.

129

Manual Translaryngeal in a Pediatric Model

Ventilation

D M Y e a l y ,J J M e n e g a z z i , R M K a p l a n , T J o n e s , K H W a r d , G P Y o u n g / U n i v e r s i t yo l P i t t s b u r g h , 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 ; Center for Emergency Medicine of Western Pennsylvanra, P i t t s b u r g h , P e n n s y l v a n i a ;D a r n a l l A r m y C o m m u n i t y H o s p i t a l , Emergency Medicine Residency Program, Fort Hood, Texas Study hypothesis: Manual translaryngcal vcntilation with continuous flow (CF) or compressed oxygcn lfET) sourccs is cqually cffcctivc in maintaining normal gas cxchange in an apncic pcdiatric modcl. Population: (r fcmalc piglcts (8.2 to 12.4 l<g; mcan, 9.71 kg). Mcthods: Each animal was studicd in a scoucntial crossover design, with a total of 30 trials and a washout period of tcn minutes bctween trials to normalize mcasurcd variables. Annea was induccd and maintaincd with continuous IV pcntobarLital and pancuronium, and an indwelling {emoral arterial cathetcr was placed. Ventilation at a rate of l2 to l5 breaths per minute through a l4-gaugc laryngeal cannula was performed with 100% oxygen in all trials. The oxygen sources studied wcre (r L/min CF; 15 L/min CF; 5 psi IET; 15 psi fET; and 25 psi fET. Variables measurcd at time zerct, Iive, and ten minutes included heart rate, systolic and diastolic blood pressure, and artcrial pH, Por, and Pcor. Data are rcported as mean values and analyzed using repeated measures analysis of variancc and Tukey's test, with a significanceofP<.05. Results: No significant diffcrcnces were observed between groups with respect to hcart rate, systolic and diastolic blood pressure at any time, as well as with initial arterial pH, Por, and Pc:o". Arterial blood gas results at five and ten minutes are listed with significant changes noted.

ffit+{ss \

ll'illT'"-'r -ucriracc,durationof drseasc ,r prcl\ \I aerosoi -.rents in both groups showcd a significant \\ transier, ! .rrr of thc croup score and respiratory rate followi n g t h e a . u s o l ( P < . 0 0 1 ) ,b u t t h e r e w a s n o d i f f c r e n c e b e t w e e n treatment groups when croup score, heart rate, and blood press u r c w c r c a s s c s s e do v e r t i m e u s i n g r e p e a t e d m c a s u r e s a n a l y s i s o f variance. Rcspiratory rate reduction, however, showed a signific a n t t i m e m u l t i p l i e d b y g r o u p i n t e r a c t i o n ( P < . 0 2 5 1 ,i n d i c a t i n g t h a t w h i l e t h e R E g r o u p ' s r e s p i r a t o r y r a t c i n i t i a l l y d c c r e a s c da n d b e g a n r i s i n g a f t e r 1 5 m i n u t e s t o p r e - a e r o s o ll e v e l s , t h e L E g r o u p ' s respiratory rate decreased aftcr acrosol treatment and remained low {(r0 minutcs). Two patients in the RE group but none in the LE group subsequently required intubation. When delivered by aerosol LE is at least as effective as RE in the treatment of viral croup and does not carry the risk of additional advcrse effects. LE is more rcadily avarlable worldwide, less expensive, and therefore can bc rccommended for this purpose.

128

Evaluation of Prehospital Intraosseous Versus Intravascular Access in Critically lll Children

S Fuchs,D LaCovey,P Paris/ EmergencyDepartment,Children's Hospitalof Pittsburgh;Departmentof Pediatrics, University of PittsburghSchoolof Medicine;City of PittsburghDepartmentof

Source 6 L/min 15 L/min IET s IET 15 IET 25 .P:.OIj.'

pH 5"

pH 10" 7 . 2 4 .. 7 . 2 , 3'' 7. 4 1 7. 3 9 7.39 7.36 7.49 7.49 7.48 7.49 P=.001

PO2 5" 376' ' 477 sOs 525 494

PO2 10" 416 449 495 s29 484

Pco" 5"

s 7. 9 . 40.1 4L.O 29.7' 28.4' '

Pco" 10"

s9.3' 42.1 46.8 31.6' 29.7"

Conclusion: In this apneic, small, pediatric, animal model manual translaryngeal iet ventilation with fET oxygen sources of

52


5 to 25 psi or 15 L/min CF can naintain oxygenation and ventilation for ten minutcs. The use o[ a (. L/rnin CF sourcr' is :rssociated with artcrial hypercarbia a n d a c i d e m i a .

Rcsults: Nonarrest and Respiratory Arrest ETT position Test + {ycllow) (purple) Test

*130

lnappropriate Use and Unmet Need in Emergency Medical Services for Ghildren

L J S a n t e r ,T S Y a m a s h i t a ,S E K r u g / D e p a r t m e n t o f P e d i a t r i c s , C a s e W e s t e r n B e s e r v e U n i v e r s i t vS c h o o l o f M e d i c i n e , R a i n b o w B a b i e sa n d C h i l d r e n s H o s p i t a l , C l e v e l a n d , O h i o S t u d y h y p o t h c s i s : L ' r a p p r o p r i a t cu s c a n d u u r n c t n c c d a r c b o t h s c r i o u sp r o b l c m s f o r c m c r g c n c y r n c d i c a l s c r v i c c s ( E M S ) f o r u r b a n childrcn. P o p u l a t i o n : C h a r t s o f 1 , 2 t 3 (pr a t i c n t s p r c s c n t i n g i n i t i a l l y t o a n urban pcdiatric cmcrgency dcpartmcnt (PED) wcrc revicwcd. M c a n p r t i c n t a g c w a s 5 . . 1 ( 0 t o 3 l ) y e a r s ; [ t l 0 p a t i c n t s ( ( r . 3 ' 2 ,r)e ccivcd public aid. Mcthods: Scvcrc rcspiratory distrcss, shock, n-rultiplc trauma, and acrrtc r.ncntalstatus changcs wcrc luclgcd to nccd EMS, antl paticnts with thesc problcms who did not arrivc by anrbulancc r c p r c s e n t c du n r n c t n c e c l . [ ) a t i en t s w i t h o t h c r p r o b l c m s w h o t r s c d ambulanccsrcprcscntcd in:rppropriatc usc. If the neccl for EMS w a s n o t c c r t a i n , t h c t r a n s p o r t a t i o n a c t u a l l y u s c c l w a s l r r d g c do p t i r n a l . C i r o L t p sw c r c c o m p a r c d b y X l a n a l y s i s w i t h s i g n i f i c a n c e a t 1' < .05. R c s t t l t s : 1 0 6 { t t ' 2 , )a r r i v c t l b y a n r b u l a n c c ; 5 9 " 1 'o f t h r s w a s r n u p p r o p r i a t c r . r s c .E i g h t y - t w o p x t i c n t s ( ( r ' X , )n c c d c d E M S , y c t 4 8 " / , ,o f t h c s cd i d n o t u s c E M S ( L r n m e t n c c d ) . h - ra l l , 1 0 2 t r i ) l r s p ( , r t i l t i r l n d c c i s i o n s{ l t ' X), w c r c s u b o p t i r n a l . [ ) a t i c n t s w i t h i n l p p r r ' 1 . r i i r t t i r n r bullncc usc, whcr] comparctl with patrcnts with lppr,rl.rirrtc trse a n t lp a t i c n t s w i t h u n r r c t n e c t l , w c r c m o r c l i l < c l y t o r e c e i v c p t r b l i c aid and hatl fcwer:rbnorr.nll vitel signs, lcss ltlnrissions, rtntl f c w c r I ) E D p r o c c d r r r c sa n t l r a d i o g r e p h s . l ) a t i c n t s w i t h t r n r n c t n ec t l h a d s i g n i f i c a n t l yr n o r c w a r d l n d i n t c n s i v e c : r r e u n i t a t l m i s s i o n s t h a n p a t i c n t sw i t h e p p r o p r i a t cE M S u s c , b u t w c r c o t h c r w r s c s n n ' i l a r . C h i l d r e n w i t h r c s p i r a t o r y l r r d n c u n r b g i c p r o b l c r . n sh a d s i g nificantly nlorc unmct nccd tlun children with othcr pnrblcn'rs, dcspitcrnorc amlrullncc usc. Conclusi0n: Inappropri:rtcusc and rrrrrnctnccd are rcrnarl<aLrly common in EMS for urban chilclrcn. [)rospcctivcanalysis of tl.rcsc p r o b l c m sr n a y c l r , r c i d a t ct h c i r s o c i o c c o n o r n i c a n d r n c d i c a l c a u s c s .

131

Validity of a Disposable End-Tidal GO, Detector in Verifying Endotracheal Tube Position in

lnfants and Ghildren M S B h e n d e , A E T h o m p s o n , D B C o o k / U n i v e r s i t yo f P i t t s b u r g h S c h o o o f M e d i c i n e ;C h i l d r e n ' sH o s p i t a lo f P i t t s b u r g h ;D i v i s i o n so f E m e r g e n c yP e d i a t r i c s ,C r i t i c a l C a r e , a n d A n e s t h e s i o l o g y , P i t t s b u r g hP , ennsylvania S t u d y h y p o t h e s i s : A c o l o r i m c t r i c , d i s p o s a t r l cc l c v i c c f o r d c t c c t i n g c x p i r e d C O , , a p p r o v c d f o r u s c i n a d r - r l t sb u t n o t i n s m a l l c h i l d r e n ,i s a l s o r e l i a b l e i n i n f a n t s a n d c h i l d r c n f o r c o n f i r m i n g c n d o ' t r a c h e a l( E T J t u b e p l a c c m c n t . P o p u l a t i o n :C h i l d r e n 1 l 2 l ) a g e d 1 d a y t o l / y c a r s , w c i g h i n g 1 . 0 to 70.0 kg 166 of l2l < 15 kg), undergoing ET intubation 1127)tor surgery (52), respiratory support {62), or CPR (I3) wcrc studicd prospectrveiy. Methods: After ET intubation, tubc position was vcrificd by capnometry, artcrial blood gas, Sao", and dircct visualization. T h e d e v i c ew a s a t t a c h e d b e t w e e n t h e E T t u b c I E T T I a n d t h e v e n tilation bag and indicator color was rccorded. A color changc from purple to yellow was defined as positivc. Results were an' alvzed bv Fisher's exact test.

Trachea Esophagus ill 0 0 3 1 < .001

Cardiac Arrest

Trachea Esophagus 9 0 2 2 I' - .07

Conclusion: This device is highly sensitive and specific in vcrifying ETT position in childrcn in the prcscncc of spontancous c i r c u l a t i o r - r .D u r i n g C P R a p o s i t i v c r c s r , r l ti s r c l i a b l c , b u t a n c g a tivc rcsult rcquircs altcrnativc confirmation of tubc placcmcnt. This dcvicc is potentially uscful in thc ficld, during transport, and in tl'rc ED.

*132

Racemic Epinephrine an the Treatment of Lalyngotracheitis: Gan We ldentily Patients For Outpatient Management?

D H a r t m a n , M P r e n d e r g a s t ,J J o n e s / E m e r g e n c y M e d i c i n e R e s i d e n c y P r o g r a m , B u t t e r w o r t hH o s p i t a l , M i c h i g a n S t a t e U n i v e r s i t yC o l l e g e o f H u m a n M e d i c i n e ,G r a n d R a p r d s Stutly hypothcsis: Objcctivc clinical scoring rnay bc uscd trr i d c n t i f y c h i l d r c n w i t h l a r y n g o t r a c h c i t i s l c r o u p ) w h o r . n a yb c safcly dischergcd frorn thc crncrgcncy dcpartmcnt following trc:lturcnt with ncbulizcd raccrnic cpincphrinc and prolongcd Obscrvttlon. l)opulatiolr: All paticnts prcsenting to thc ED bctwecn March :rnrl [)cccrnbcr l9lJ9 with thc diagnosis of laryngotrachcitis wcrc cvaltratcd clinically according to a crollp scoring systcm. Twcntyc i g h t p a t i c n t s ( a g c d ( r t o / l l m o n t l - r s )w i t h p c r s i s t c n t i n s p i r a t o r y stridor et rest aftcr 20 to 30 minutcs of rnist thcrapy reccived n e b t r fi z e t l r a c c r . t - t i c l . r i r . t c p h r i n c( . 0 5 m L / k g o f a 2 . 2 5 ' k ' s o l u t i o n ) : r n t l w c r c en r o l l e d . M c t l ' r o t l s :I ) a t i c n t s w c r c o b s c r v e d i n t h c E D f o r t h r c c h o u r s w h i l e c l i r r i c a l s c ( ) r c s w c r c a s s c s s c da t 1 5 , ( r 0 , 1 2 0 , a n d l l l 0 n ' r i n utcs following trcatmcnt witlr raccrric cpincphrinc. Subsccluent adrnission or dischargc from thc ED was at thc discrction of att c n d i n g p h y s i c i r n s e n d d i d n o t f o l l o w a n y p r c p l a r . r n c dp r o t o c o l . C l i n i c a l v a r i a b l e sw c r c a n a l y z c d ( S t u d c n t ' sI t c s t ) t o i d c n t i f y s i g ' . ischargcd paticnts n i f i c a n t d i f f e r c n c c s b c t w c c n t h c t w o g r o r - r p sD werc followcd up by tclcphonc. R e s r . r l t s :C l i n i c a l s c o r c s w c r c s i g n i f i c a n t l y i m p r o v c d { P ' . . 0 1 ) t l r r o u g h o u t t h c o b s c r v a t i o n p c r i o d i n 2 l p a t i c n t s ( 7 5 ' X , )w h o w e r e dischargcdfrom thc ED. Only onc paticnt rcturncd within 24 hours for furthcr crxrl mist thcrapy. The sevcn paticnts rcquiring : r d n r i s s i u nt o t h c h o s p i t a l w c r c y o u n g c r { 1 4 . 0v s 2 ( r . 2 r n o n t h s ) a n d had highcr prctrcatmcnt croup scorcs ((r.l vs 4.1). Conclusion: Thcsc rcsults idcntify a subsct of chrldrcn with croup who may bc safcly dischargcdfrom thc EI) followrn.qtrcatlrcnt with raccmic cpinephrinc.

133

ls the Anteroposteriol Radiograph of the Gervical Spine Necessary in the Evaluation of the Trauma Patient?

CJ Holliman,JS Mayer,RT Cook Jr JS Smith Jr / University H o s p i t a l , T h e M i l t o n S H e r s h e y M e d i c a l C e n t e r , T h e P e n n s yv a n i a S t a t e U n i v e r s i t y ,H e r s h e y ,P e n n s y l v a n i a S t u d y h y p o t h c s i s : T h c r o l l t i n e a n t e r c t p o s t c r i o rr a d i o g r a p h o f thc ccrvical spinc is not a ncccssary scrcening film to cvaluatc a patient with potcntial ccrvical-spine trauma if thc standardcnrss t a b l e l a t e ' r a la n d o p c n - m o u t h o d o n t o i d v i e w s a r c s a t i s f e c t o r i l y pcrlormeo. Population: The trauma case registry was uscd, and thc charts of all patients with discharge or postmortcm diagnoscsof ccrvical-spine fracture or cervical-spinal cord iniury treated at a Levcl I trauma ccnter during a three-year period were reviewcd. A total

53


o{ 48 patients were studied. Methods: A faculty neuroradiologist who had no knowledge of the original film interpretations examined the cervical-spine films for each case. Sequentially, the crosstable lateral, openmouth odontoid, and anteroposterior films were examined to determine whether additional information about the presence of spine injury was gained from each film. Additional studies obtained (eg, obliques, tomograms) were also reviewed. Resulti: In no case did the anteroposterior view provide useful information or demonstrate an iniury not apparent on the lateral or open-mouth views. Conclusion: The anteroposterior film need not be routine to radiographically evaluate patients with possible cervical spinc trauma.-By not routinely obtaining this view, cfficiency of trauma patient care is improved, less radiation is received by the patient/ and health care costs are reduced.

134

Value of a Simple Test of Mental Status in Screening Acutely lntoxicated Patients for Serious Head Injuries

W B e r k , K T o d d , R W e l c h , J W i l l i a m s ,J F i s h e r ,R W a h l , P C l a p s ' R F a r r e l l ,B B o c k / E m e r g e n c y D e p a r t m e n t , D e t r o i t R e c e i v i n g Hospital,and Section of Emergency Medicine, Department of S u r g e r y , W a y n e S t a t e U n i v e r s i t y ,D e t r o i t , M i c h i g a n Study hypothesis: Sequentially performed mental status scoring facilitates recognition of acutely intoxicated patients with serious head iniuries. Population: 105 emergency department patients with acute alcohol intoxication were prospectively identified by admission breath alcohol of more than 100 mg/dl; ethanol-related impairment necessitating further observation or treatment; and not critically ill, comatose, or with focal neurological signs. Methods: Mental status scores {sums of speci{ic alertness and orientation indices, graded 0 to 3) and breath alcohol levels were determined initially, one hour after arrival, and then cvery two hours until either discharge, admission to the hospital, or to breath alcohol level of 0. Serious head iniury was defined as intracranial hemorrhage by computed head tomography. Patient care was provided independently of the study. Mental status scoring comparisons were made with the Mann-Whitney [./ test with significance set at P < .05. Results: Mean initial blood alcohol level was 305 + 108 mg/ dL. Serious head inluries were diagnosed in four of 105 patients. Mental status scores in these were significantly and increasingly depressed in comparison to others at one lP = .011,three (P -= .005), and five hours (P - .002) after admission. At one hour, the score that identilied all head-iniured patients also included 34 other patients (sensitivity, l00o/"i specificity, ll7"; accutacy, 68%1. At five hours, applying the same mental status score criterion in addition to failure to improve by two units from admission score identified all head-iniured patients and 13 of the other 87 remaining patients isensitivity, 100%; specificity, 24o/o; accurccy, 86"/ol. Conclusion: Lack of improvement in graded mental status of acutely intoxicated patients by {ive hours after admission suggests serious head iniury. Sequential mental status scoring facilitates recognition of traumatic intracranial hemorrhage.

*{ 35

Evaluation of the Abdomen in lntoxicated Patients: ls GT Scan or Peritoneal Lavage Always

lndicated? F Garcia-Perez,KF O'Malley,SE Ross / Divisionof Traumaand EmergencyMedicalServices,UMDNJ,RobertWoodJohnson Medical MedicalSchoolat Camden;CooperHospital,University Center,Camden, New Jersey To investigate the necessityof evaluating the intoxicated pa-

tient with normal mentation (Glasgow Coma Score,I5) for intraabdominal injury with computed tomography (CT) or peritoneal lavage, a retrospective study of patients admitted to a Level I trarr-, ...rt". between February 1, 1986, and December 31, 1989, was conducted. Ninety-two patients wcre admitted with suspccted blunt abdominal injury and serum ethanol of more than 100 mg/dl. Eighty-nine patients underwent CT scans, two had diagnostic peritoneal lavage, and one had both. Of 17 patients complaining of abdominal pain or tenderness upon palpation, six {35.3%) had blood in the peritoneal cavity demonstrated by CT scan or diagnostic peritoneal lavage and underwent celiotomy. All 75 paticnts without abdominal pain or tendcrness had negative CT scans or diagnostic peritoneal lavage, with no instances of misscd iniurv. These results indicate that in the intoxicated patient with normal mentation, the physical examination is a reliable indicator of possible abdominai iniury. Intoxic^tion per se should not bc considcred an absolute indication for performing lavagc or abdominal CT scan.

136

The Trauma Traage Rule: An Accurate Prehospital Trauma Decision Rule

W G B a x t , G J o n e s , D F o r t l a g e / U n i v e r s i t yo f C a l i f o r n r a ,S a n Drego Medical Center All existing major trauma decision rules havc been shown to have low acCuracy in identifying maior trauma victims in thc prehospital setting. This performance has been measured by the I n j u r y S e v c r i t y S c o r e ( l S S )a s t h e d e f i n i t i o n o f m a j o r t r a u m a . B e cause the ISS may not adequately define maior and minor trauma, an alternate definition of maior trauma based on operational criteria was used to determine whether a set of variables that could be collected in the prehospital sctting could be used in a decision rule to accurately predict the presence of operationally defined major trauma. A trauma decision rule based on the operational definition of maior trauma was prospectively derived from "trauma triage 1,004injured adult patients. The rule, termed the i n j u r e d adult patient a s a n y v i c t i m rule," defines a major trauma who has a systolic blood pressure of less than 85 mm Hg, has a Classow motor score of less than 5, or has sustained penetrating traurira of the head, neck, or trunk. The rule had a sensitivity of 927" and a specificity of 92% when tested on the 1,004-patient cohort. The rule accurately identified as maior trauma victims 98% of the patients who died. The rule appears to signi{icantly reduce overtriage while only minimally increasing undertriage but must be prospectively validated.

*137

Diagnostic Peritoneal Lavage in Abdominal Stab Wounds: AnalYsis of the Red Blood Gount bY Receiver Operating Gharacteristic Gurve

MJ Zappa, AL Harwood-Nuss, RL Wears, WF Fallon / Division of E m e r g e n c y M e d i c i n e , D e p a r t m e n t o f S u r g e r y , U n i v e r s i t yo f F l o r i d a , Jacksonville Study hypothesis: The optimal cutoff of RBCs for diagnostic peritoneal lavage in penetrating abdominal trauma can be obiectively determined. Population: 9l consecutive adults with abdominal stab wounds not meeting criteria for immediate laparotomy underwent diagnostic peritoneal lavage. Methods: Patients were identified by retrospective review of the trauma log and registry and separated into two groups. Croup I underwent laparotomy and had findings that required surgical intervention. Group 2 underwent laparotomy but did not require surgical intervention or had no surgery with a benign hospital course and follow-up. Receiver operating characteristic analysis was done on the diagnostic peritoneal lavage RBC count for these two groups. Results: Overlap between the groups was minimal with the

54


25th perccntilc of the RBC count in group I bcing 109,000/mm.r and -the.75th percentile of thc RBC ."ouni in grnti Z icing 478/ mm3. Thc area under the receiver operating jr.r.t"rr.tr. au.ua g e n c r a t c df o r t h i s d a t a w a s 0 . 9 5 , i m p l y i n g t h a t t h c RBC count is a good discriminator. If the probabiiiiy oi having an infury that requircd surgical intcrvention was cqual to that;f having an in_ jury not requiring surgical intervention, the cutoff RBC count for mrnimum misclassification (calculatcd by computing the slopc of thc. fitted curve) would be 5,000 ro t0,000/mmlr. tt/ith the oi_ s e r v e dp r o b a b i l i t y o l Z S . 3 % o f a b d o m i n a l s t a b w o u n d s r c q u i r i n g surgical intcrvcntion, thc cutoff RBC count for maxrmum accuracy is 20,000/mm.r. Conclusion: An RBC count of 20,000/mmr is likcly to bc most discriminating.bctwccn patients requiring surgical lntervcntion a n d t h o s L . n o ti x , . 8 ( r l ; f . . 0 0 1 ) .

.l 38

i"il1,"i""i::e:;i:?:,:l,lJ il;"'

lntra-Abdominal Injury P . S a h d e v ,R J S c h w a r t z , R R G a r r a m o n e l M l a i o O s / D e p a r t m e n t o f E m e r g e n c yM e d i c i n e a n d T r a u m a , H a r t f o r d H o s p i t a r , 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 S c h o o l o f l r . i e d i c i n e , Farmtngton

P u r p o s c :T o d c t c r m i n c t h c s c r c c n i n g v a l u c o f l i v c r f u n c t i o n tests iSGOI SCPT) for intra-abdominni i.rlury in blunt trauma. Mcthods: 30il consccutivc adult blunt trauma paticnts with ad_ mission livcr function rests wcrc- prospectiveli studicd tluring ninc months at a Lcvel I trauma facility. Intra_abdominal injury w a s d i a g n o s e d .b y c o m p u t c . d -tomography (CT) or lopo..,t,rrr",y. Paticnts wcrc followcd until dischaisc. R c - s u l t sA : vcragc paticnt agc ,". J5 y.rr., Trauma Scorc, 14; a n d . l n j u r y . s c v c r i t y . s c o r c ,1 3 . M o r t a l i t y w a s 5 . 3 % . N o p a t i c n t h a d a .m i s s c d a b d o m i n a l i n j u r y . S t a t i s t i c a l a n a l y s i s s h o w c r l l i v c r func_ tion tcsts of 130 IU to havc thc highcst scnsitivity and lowest f a l s c - r r o s i t i v cr a t e . Liver Function Tests (lU/L)

< 30 < 130 > 130

Total Patients

lJs 2s0 sr]

patienrs With CT or Laparotomy (7o)

zz 1261 9(r(38) 4s(78)

Total Liver Iniuries (%)

0 (0) 0 (0) lll {100)

Total Intra-Abdominal Inluries (%)

s {6) 2 I (it) 3 0{ s 2 l

Higher livcr function tcsts valucs had an incrcascd incidcncc of liver injury. Nincty pcrccnt of patients with liver function tcsts of morc than 500 {tcn) had liver injuries. Other intra-abdominal injurics increased significantly at liver function tests of morc t h a n 1 3 0 i T a b l c , P = < . 0 0 1 ) .F o u r p a t i e n t s w i t h l i v e r i n i u r v not r e q u i r i n gr e p a i r u n d e r w e n t . a l a p a r o t o m y b a s e d o n a p o s i t i v e diagn o s t i c p e r i t o n e a l l a v a g e .A l l f o u r h a d l i v e r f u n c t i o n i e s t s o f more than 130 Of l1 patients with intra-abdominal injury and a normal abdominal examination, ten had clevated liver function rests. Conclusion: First, livcr function tests are a marker for signifi_ cant intra-abdominal injury. Second, stable patients withliver tunction tests of more than I30 should havi abdominal injury evaluated _by CT to decrease false-positive diagnostic peritoneal lavages.Third, liver function tests on admissio"n of lesi than I30 IU/L exclude liver iniurv.

{ lyV 21l| r

*140

Faculty Attrition Specialties

Among Three

H Thomas J4 JC Moorhead, AR Magnusson / Bowman Gray S c h o o l o f M e d i c i n e , W i n s t o n - S a l e m ,N o r t h C a r o l i n a ; a n d T h e Oregon Health Sciences University, poriland Study hypothesis: Many emergency physicians perceive that more of their colleagues leave academic medicine than do nhvsi_ cians in other medical disciplines. Population: All institutions with residencies rn emergency medicine. Methods: Questions were asked pertaining to the year l9gg, including size of. faculty, number oi physicia=ns leaving, ,.r.o.r, for leaving, total hours worked, and nighttime hours woiked. Answers were compared with those from the orthopedic and cardiol_ ogy departments from the same institutions. R e s u l t s : _R e p o r t s w e r e r e t u r n e d f t o m 6 7 o f 6 8 ( 9 8 . 5 % ) e m e r gency.medicine, 53 of 58 (9t.4%) orthopedic, and 47 oI 54 187%) cardiology departments. Among 670 emergency physicians iaver: age faculty, tenl, 67 (10%) had left: 38 1it.lV"1'to enter private practice, l8 126.8%l to take another academic position, ind ll 116.4%) to.retire, change specialty, and so on. There were no significant differences (Mantel-Haenzel test, p : .78) between thos"i findingsand data from the orthopedic (total physicians,3Zg; average faculty, 7.Ii 30 17.92'/"1left) and the caidiology deparrments (total physicians, 659i average iaculty, 14; 58 lg.g%l left;. Emer_ gency physicians worked an average of 46 hours a week, signific a n t l y . f e w e r ( P - . 0 0 1 )t h a n t h o s e i n o r t h o p e d i c s { 6 0 . 6 h o u i s ) o r cardiology (56.9 hours), Emergency physiCians worked significantly more_nighttime hours {6.96lwk) versus orthopedics t4.33/ wk) and cardiology {3.33/wk) (P : .03). Conclusion: This comparison of three similar medical disci_ plines failed to show a higher attrition rate for emergency medi_ cine faculty.

Refusing Care to patients in an Emergency Department: lg-Month Erperience

RWDerlet,D Nishio,J SilvaJr / Universityof California,Davrs, Schoolof Medicine,Sacramento Studyhypothesis:Large n-umbersof patients presenrrngro an emergencydepartment can be refused care wittiout resuliins in harm to patients.

- Population: Patients presenting to rhe ED from |uly 1ggg through December 1989. Methods:.Screening examinations were performed by triage nurses.on all,ambulatory patients. patients were refused care"if vrta.lsrgns tell within specific categoriesand they had one of 50 minor chie{ complaints. The referril of these parlents out of the ED after a screening examination conforms to federal legislative stlpulatrons governing ED care and transfer. Results: During the l8 months, 6g,900 patients presented to . ,qe triqg_earea, and 12,108 patients (18%)were refusei care in the ED. Ol the 12,108 patients refused care, 4g7o were referred to p;;vate clinics, 35% to county clinics , and I7"/o to university clinics. Written and telephone follow-up_to-referral clinics, all local EDs, and the coroner,s office identified no patients who had been grossly mistriaged, and no rare advers. o.rtco-es could be identi_ ficd. No written complaints were received from other phyri;;;;, hospitals, or clinics. To follow-up individuals triaged away, a ran_ dom numbcr w-ere given postcards or were teleph6ned; ,"rponr., rndrcated that 65y" were seen in a clinic the same day,25o/o were seen on another day, and l07o never saw a physiciin. The ED passed |oint Commission on Accreditation of healthcare Organi_ zations and Health Care Financing Agency reviews during this period. Conclusion: Large numbers of patients can be selectively tri_ aged out of the ED without adverse outcomes.

141

Mechanisms of Emergency Department Patient Follow.up in Emergency Residency programs:

A ilational Survey HH Osborn, T Negron/ Our Lady of Mercy Medical Center and LincolnHospital,New Yoik Medical College,Bronx,New york . Little if anything has been reportedin the literature describing follow-up mechanisms for emergencydepartment patients. W;

55


T

r I

I i.

addressedthis issue by surveying all American Board of Emergency Medicine-approvedresidenciesin 1984and 1988.Program, ditectors *et. aslied to describethe mechanism for follow-up of patients who were admitted or discharged.We receivedresponses irom 100% of the programsin both 1984and 1988.In 1984,34 of 63 residencyprograms (5a%) had a formal follow-up system for admitted patients.In 1988,this percentageremainedthe same:40 of 73, or 55%. Follow-up mechanisms{or admitted patients that met our criteria as formal consistedof dischargesummaries tollow-up conferencesll2'/"), follow-up rounds (14%),and 125"/"1, use of a iollow-up log (14%).Other findings in our 1988survey showed that 4O"/"of the programshad a formal follow-up system for dischargedpatients. This mechanism consisted primarily of telephone calls and was used in 32% of programs.Nursing was also found to be primarily involved in follow-up of discharged patients {36%). Alihough formal {ollow-up in the ED was highly valued, 50% of the programsdo not have any follow-up in either inpatient or outpatient services.Seventy-onepercent of the residencies reported dissatisfactionwith their present iollow--up methods. We conclude that although the American Board of EmergencyMedicine requires follow-up for determination of qualiry patient care and patient outcomes,there is very low compliance by programs.We feel that the creation of standard and ipecific follow-up guidelineswould enhancecompliance.We desiribe conceptsand follow-up mechanisms that can serve as model programs for emergencymedicine residencyprograms

142

The Use of an Artificial ileural Network for Decision.llaking Under Uncertainty: The Diagnosis ol llyocardial Infarction

San Diego MedicalCenter of California, WG Baxt/ University for Although there exists a largebody of computer-technologies clinical dicision-making, there has been no wide acceptanceof these modalities to aid in clinical diagnosis.The maior reasonis that none of these programs has performed substantially better than clinicians. The following reports on the development of a nonlinear connectionist back propagationnetwork paradigm {or problem-solvingwith uncertainty. The model was testedby meaiuring its abiliry to detect the presenceof-myocardial infarction in paiients presenting to the emergencydepartment with chest pain. .Ilhe nitwork was trained and tested on a retrospectively ierived patient cohort consisting of 356 patients who presented to an ED with anterior chest pain and were admitted to the coronary care unit to rule out myocardial infarction. Two hundred thiity-six patients did not sustain myocardial infarction, and,l20 did sustain myocardial infarction. The network was trained on pattern sets randomly derived from half of the p-atientsin each group and tested on the remaining patients to.whom it had not 6"..r .rpot.d. The process was thett reversed, and the results were averaged.The network per{ormedwith a-sensitivt'tyof 92"/" and a specifictty ol 96%, wliich is substantially better than the 88% sensitivity' and 7l'/" specificity reportedfor clinicians or the 88% sensitivity and 74"/" specificity reported for the best computer-basedapproach.

143

Effect ol "Standard Order" Deletion on EmergencY Department Goagulation Test Utilization

DS Groopman,RD Powers/ Divisionof EmergencyMedicine, of VirginiaHealthSciences Departmentof Medicine,University Center,Charlottesville Economicand political realities mandateimplementation of effective cost-conttinment measuresin the emergencydepartment' Coagglation studies (PT/PTT\ are insensitive- as sc-reeningtests, yet;re widely overordered despite published'"hi8h-yield" criteii". kr "tr attempt to modify physiciin ordering pattems, coagulation studies were deleted from the automated admission order

sets in a university hospital ED. On fuly 1, 1989,coagulation studieswere removedfrom medical admissionlaboratorypro{iles available on the computerizedmedical information system at a university hospital ED. This changewas nei52,000-visit-a-year ther advertisednor concealed,and no special educationalefforts coagulation study use were undertaken. regarding appropriate -of 213 patients admitted from the ED to the ward Tlie chaits medical service before and after July I were examined to assess the effect of coagulationstudy deletion on the frequencyand appropriatenessof coagulationscreening.A 66"/" lP < .000I, x2) reiuition in use was accomplished{or an estimated savingsol $29,000a year.In no casewere the tests omitted when high-yield indication for their use existed. Deletion of low-yield tests from automatedadmissionprofiles can be a rapidly effectivecost-containment measurewithout compromising patient care. Protocol laboratoryprofiles should be reviewed,restrictedto high-yield tests, or omitted entirely.

*144

Comparison of Algorithm.Directed Gomputerized Triage and ilurse Triage in the EmergencY

DePartment KT Lovello,DA Berman,JM Howell,W Beall,WC Dalsey,TA McMurry,ST Coleridge/ Departmentol EmergencyMedicine, JointMilitaryMedicalCommand,San Antonio,Texas Study hypothesis: Efficient use of limited medical resources can be'impioved by triage systems that effectively identily pa-. tients requiring immediale care from those who can be treated less urgently. Algorithm-directedcomputerizedtriage using minimally trained screenersis as safe and effective as nurse triage' Population: Patientspresentingto two foint-Commissionof Accreditation of Healthcare OrganizationsLevel I medical centCIS.

Methods: Algorithm-directed computerized triage by minimally trained screeners has been shown to be effective. We prospectively compared the effectiveness of a nurse triage system with the'algoriihm-directed computerized triage system used by minimally irained screeners. Accuracy of triage was determined by comparing final disposition with trirge category assigned' Mistriage rates were compared by x2 analysis.

Results:

Nurse triage Algorithm-directed triage

Mistriaged

Triaged (N)

Mistriaged

(N)

f/.1

2tl

l3

6.2

2,857

69

The algorithm-directed mistriage rate was significantly lower than the nurse mistriage rate 1y2,9.2i P <.01). There was no morbidity or mortality in either group. significant -Conclusion: Our results indicate algorithm-directedcomputerized triage by minimally trained screenersis safeand effective'

145

Abdominal Pain: Threshold to Observe Affects EmergencY

Performance Diagnostic Physician LG Graff, MJ Radford/ New BritainGeneralHospital,New Britain, of ConnecticutMedicalSchool,Farmington University Connecticut; retrospectivecohort study, to examine the In a Study objective: effects'of observationott .-e.g.ttcy physician diagnosticperformance.

Population: 1,8I3 consecutivepatients in a university-affiliated community hospital who had abdominal pain. The patients were evaluated by nine emergency physicians during a one-year period; 54 had appendicitis by surgical pathology' The mean AIvarado appendiCitis scote-was deterrnirred v\en eac\ ernergency physician decided the patient neededobservation or surgery (thresholdfor observation,N : 16l).

56


Results: Emergency physicians who had a nonzero false-negative rate had a higher mean score at which they observed patients l s c o r e , 5 . l 3 ; 9 5 % c o n f i d e n c e i n t e r v a l 1 C 1 ] 1 , 4 . 6 7 , 5 . 5 9N, = 3 ) t h a n emergency physicians who had a zero false-negative rate {score, 4.56)95% Cl, 3.64,5.51; N - 6|. Emergcncy physicians who had a low mean score at which they rcferred patients iscore, < 4; N - 3) had a lower false-negative rate than emergency physicians who had a high score at which they refcrred patients (score, > 4; N - 6 ) 1 7 . 7 " / "u s l 7 Y " ; a p p r o a c h i n g s i g n i f i c a n c e a t p : . 0 5 ) . T h e paticnt/s rrsk of abscess was proportional to the emcrgency physic i e n ' s f a l s e - n e g a t i v er a t c ( c o r r e l a t i o n c o e f f i c i c n t , . 8 9 , p < - . 0 b 5 ) . Measures of cmergency physician usc of observation services were examined: threshold for observation score inversely correlatcd with falsc-positivc ratc (correlation coefficicnt, .9Zt p <

ment. Access to preventive health-care services by this population is limited. We used influenza vaccination as a model to determine whether these services, if ofiered, would be accepted by patients while visiting the ED. Methods and population: We prospectively of{ered the vaccine to all patients, regardless of chief complaint, aged 65 years or older who presented to the ED or to rhe general medical clinic of a maior urban teaching hospital. House officers staff each site as primary providers, and attending faculty present in each site strongly endorse the use of the influenza vaccine for all eligible patlents. Results: A total of 396 elderly patients wcre offered the influenza vaccine - 195 in the ED and 201 in the clinic. Thirty-four percent of ED patients and 4O7" of clinic patients had already receivcd the prcsent year's vaccine (P : NS). Fifty percent of patients acceptcd and were given the vaccine during their ED viiit, the corresponding acceptance rate in the clinic was 657" Ip <

.00s 1

Conclusion: Usc of obscrvation improvcs crncrgcncy physicians'diagnostic pcrformancc (cspccially scnsitivityj in thc cvaluation of paticnts for appcndicitis.

146

.021.

Conclusion: Although patients were somewhat more likely to accept the influenza vaccine in a traditional clinic than in the !D, thc 507o acceptance rate in the ED had a major impact, doubling thc total number of ED patients vaccinated. This result may undcr-represcnt the magnitudc of thc responsc if preventive serviccs were routinely offered to ED patients. The potential of programs such as this to address the unmct nceds of a largc population of undcrserved patients merits further consideration.

ls There a Need for Preventive Health Care in Emergency Medicine?

JM Goldman, R Feife( A Stemhagen, FS Shofer / Division of E m e r g e n c yM e d i c i n e , T h o m a s J e f f e r s o n U n i v e r s i t y H o s p r r a r ; E m e r g e n c yS e r v i c e s , H o s p i t a l o f t h e U n i v e r s t t yo f . p e n n s y l v a n i a , Philadelphia Study hypothcsis: Paticnts sccking carq in the cmcrgency dcpartmcnt frcquently havc prevcntivc hcalth-carc nceds ihat'havc not bccn mct. Thcse paticnts may bc willing to accept thesc scrviceswhile bcing cvaluatcd and trcatcd for <jthcr conccrns in the ED. . Methods and population: A survcy addrcssing prcvcntlvc hcalth-carc issucs was administcrcd orally to aduit paticnts awaiting carc in a busy inncr-city ED. eucstions includcd dcmog r a p h i c sa n d p a t i c n t s ' k n o w l e d g c , h i s t o r y , a n d a c c c p t a n c c o f t h c following intcrvcntions: blood prcssurc chccks, influcnza and p n c u m o c o c c a lv a c c i n c s ( m o r e t h a n ( r 5 y c a r s o l d ) , b r c a s t c x a m i n a tions and Pap smcars (all womcn), and mammography (women morc than 50 vcars oldl. Rcsults: 550 paticnts complcted thc survcys - (r37nwcrc womcn, and 80%' wcrc black. Twclve pcrccnt of patients dcnicd a recent blood pressure chcck. Fifty-six pcrccnt of cligiblc paricnts had ncvcr rcccivcd influcnza vaccini; 63% had not reccivcd pneumococcal vaccinc; 45% had no recent mammogram; 257o had no recent brcast cxamination; and 19"1, had no reccnt paD s m e a r .F o r t y - f i v c p e r c e n t o f p a t i e n t s r c c e i v e d n o r e g u l a r h e a l t h care. Lack of rcgular health care was associated with a lower incid,enceof-blood pressure checks {P < .001), mammography (,p < .001)a , nd Pap smcar (P < .05).The majority of all patients were willing to acccpt all interventions (exccpt influcnza vaccine) while in thc ED. Conclusion: In general, ED patients receivc inadequate preventive health care. The 45"/" oI ED patients who receive no-regular medical care are even more poorly served. Most patients ,tc *illing to accept preventive health-care intcrventions while in the ED. The appropriateness of the ED for arranging or providing t h e s es c r v i c e s t o t h i s " c a p t i v e a u d i e n c e , , s h o u l d b i e x i l o r e d .

147

Preventive Medicine in the Emergency Department: Influenza Vaccine as a llodel

JM Goldman,A Stemhagen,SB Erban / Drvisionof Ernergency Medicine, ThomasJeffersonUniversityHospital;Emergency pnitadbtpfria; Services, Hospitalof the University of pennsylvanla, Division of GeneralMedicine,University of Massachusetts Medical Center,Worcester Study_hypothesis: For many people, the only significant contact with the medical establishmentis in the emergencydepart-

148

An Analysis of Emergency Physicians' Cumulative Gareer Risk of HMnfection

R L W e a r s , L L F l u s k e y ,S L l , D J V u k i c h / D i v i s i o n o f E m e r g e n c y M e d i c i n e , D e p a r t m e n t o f S u r g e r y , U n i v e r s i t yo f F l o r i o a , Jacksonville Study hypothcsis: Although cmcrgcncy physicians, risks of contracting human immunodeficicncy virus (HIV) infcction from any singlc patient cncountcr arc small, thc cumulative risk during many ycars of practicc is surprisingly large. Population: A simulation analysis consisting of 5,000 instantiations of carccr risk sccnarios. Mcthods: The risk of contracring HIV infection was modeled as a function of thc annual risk of parentcral occupational cxposurc to contaminatcd body fluids, thc probability of transmission givcn cxposure, and an estimatcd rate of increase in the prevalencc of HlV-seropositivity in the paticnt population. The risk of exposurc was modeled by a Poisson distribution (mcan, 0.29 exposurcs per year for the base ycar), and thc probability of transmission was modeled by a beta distribution (mean * SD, 0.005 + 0.004), as was the annual proportional increase in prevale.ncc (0.05 * 0.04); this value was progressively reduced to zero over 15 years. Several thousand simulation runs were madc, allowing estimation of the expected cumulative risk and of the actual distributi<,rn of risk. Results: The mean of the 30-year risk of HIV infection was almost 57", whcreas the range ran from a low of 1.7./" to a high of more than l0%. The magnitude of risk depended on the length of the emergency physician's career, with several decades of exposure, the effect of anti-HIV precautions appeared to be diminished. Conclusion: During their professional lifetimes, emergency physicians may be at substantially greater risk than generally assumed. Although beneficial at all times, the efficacy of anti-HIV precautions diminished with increasing length of active practice.

149

Low Doses ol tPA as Emergency Therapy for Acute lschemic Stroke

WG Barsan,TG Brott, EC HaleyJr, DE Levy,JP Broderick,G Sheppard,JR Marler/ University of Cincrnnati MedicalCenter, Cincinnati, Ohio; University of VirginiaMedicalCenter, Charlottesville; CornellUniversityMedicalCenter,lthaca,New

57


Y o r k ; W i n c h e s t e r ,V i r g i n i a , N a t i o n a l I n s t i t u t e so f H e a l t h , N I N D S , Bethesda, Maryland Study hypothesis: IV tissue-type plasminogen activator (tPA) does not cause excessive bleeding or intracerebral hemorrhage when given to patients with acute ischemic stroke. Population: All patients 80 years old or younger presenting within 90 minutes of onset of acute ischemic stroke were eligiblc. Exclusion criteria were mean blood pressure of more than 134 mm Hg, recent (three months) stroke, or blood on computed tomography {CT) oi the head. Informed consent was obtained in all patients. Methods: Escalating doses of tPA were given: lllaior ICH Patients Infusion (N) Bleeding (N) Time (min) Dose 0.35 mg/kg

60

6

0

0

0.60 mg/kg

60

ll

0

0

0.1t5mg/kg

l0

0

0

32 my,/Mz

60 (r0

0

0

37 mglMz

L)0

2

I

37 mg,lMz

60

2.1 L2 3

I

I

42 mglM2

60

I

0

0

National Institutes of Health INIH) Stroke Scale and vital signs were recorded at baseline, at one, two, and 24 hours, at seven days, and at three months after tPA treatment. Bleeding episodes were classified as minor, maior, or intracerebral hemorrhage (lCH). Patients were classified as showing immediate improvement (during infusion), 24-hour improvement (> 4-point improvement on NIH Stroke Scale), or no improvement. Results: Nine deaths occurred, but none were directly attributable to tPA treatment. Higher doses of tPA i> 32 mg/M2) were associated with significantly more ICH {P : .03, Mann-Whitney U test). Minor bleeding episodes occurred in 12 cases. Of the 74 patients treated, 20 showed immediate improvement, and an additional 34 showed 24-hour improvement. Conclusion: Higher doses of tPA (> 32 rr,g/Mzl are associated with a significantly higher risk of ICH. It seems reasonable to proceed with randomized, double-blind studies with lower doses of tPA given emergently to patients with acute ischemic stroke.

150

Real-Time Ultrasound for the Detection ol Deep Venous Thrombosis

RD Powers,JF Chance, P Abbitt, C Tegtmeyer/ Divisionof of University EmergencyMedicine,Departmentof Radiology, VirginiaHealthSciencesCente( Charlottesville Study hypothesis: Real-time ultrasound can accurately detect deep venous thrombosis of the leg in emergencydepartmentpatients. Population: 70 adults presenting to a university hospital ED with clinical signs and symptoms consistent with deep venous thrombosis. Methods: AII patients had ultrasound of the involved leg followed by contrast venography.Results were sequentially made availableto ED clinicians, who determined the courseof therapy after both test results were known. Results:Ultrasound detecteddeepvenous thrombosis in 14 patients (20%),all involving thigh veins. All were confirmed by venography.Venographydetectedan additional six patients with calf deepvenous thrombosis who had normal ultrasound studies. All 20 patients with deep venous thrombosis were hospitalized for anticoagulation. Reliance on ultrasound alone would have missed six of 20 cases(33%lof deep venous thrombosis but no casesof deepvenous thrombosis involving veins proximal to the knee. Conclusion: As an ED screeningtest for deep venous thrombosis, ultrasound is sensitive for thrombosis in thigh veins but cannot visualize vâ&#x201A;Źnous structures distal to the knee. Clinicians

can use ultrasound to reliably diagnose ol exclude thigh deep venous thrombosis, but venography is necessary to determine whether thrombosis is present in calf veins.

*151

Prehospital Transcutaneous Gardiac Pacing: A Two-Year Prospective Gontrolled Glinical Trial

GE Aldinger, CJ Kenyon / Department of Emergency Medicine, S a i n t F r a n c i s H o s p i t a l o f E v a n s t o n , l l l i n o i s ;D e p a r t m e n t o f F a m i l y P r a c t i c e , M e t h o d i s t M e d i c a l C e n t e r o f l l l i n o i s ,P e o r i a Study hypothesis: Many articles tout the merits of prehospital transcutaneous pacing (PACE) and paramedic systems are adopting it, yet only three studies used comparison groups. None recorded numerically meaningful benefits. We report a two-year prospective controlled trial of PACE in an advanced life support paramedic system with mean response time of 3.9 :t 3.3 minutes to evaluate its use. Population: 604 adults with nontraumatic hemodynamically significant bradycardia, pulseless idioventricular rhythm, or asystole not responsive to initial advanced cardiac life support (ACLS) carc. Based on a systematic allocation ol the pacers, unpaced paticnts served as controls. Methods: l1 pacers rotatcd monthly on 18 ambulances. 12, Fisher's exact test, and analysis of variance were applied with significanceatP<.05. Results: Of 238 patients with pacer availability, 145 were paced. In 85 159%1,capture was noted: 21 114%) had pulses, ten lTokl were admitted, and iour {3%l were discharged.Of the 459 patients not paced, 57 ll2'/.1 regained pulses with standard ACLS iare, 52ll I% l were admitted, and 32 l7'/.1 were discharged. There was no statistically significant difference of outcome variables by rhythm, response time of less than four minutes, or time to ACLS care of less than eight minutes. All groups were comparable for age, sex, witnessed events, response time, and time to ACLS. Conclusion: Given the results of other controlled studies and the absence of any outcome benefit of PACE in bradyasystole in this trial, we believe the advocation of such is premature and possibly ill-advised.

152

A Gomparison of Transcranaal Doppler Ultrasound to Radioactive }licrospheres an Determining Gerebral Perfusion in Normal and Low.Flow States

LM Lewis,JC StothertJr, GE Kraus,CR Gomez, H Goodgold,RM KeltnerJr, K Ashley,JF Fortney/ Departmentol Surgery,University of Emergency of TexasMedicalBranch,Galveston;Departments NuclearMedicine,and Neurology, Medicine,Neurosurgery, Hospital,St Louis,Missouri Surgery,St LouisUniversity Study obiective:We have used transcranialDoppler ultrasound {TCD} to determine cerebralperfusion in patients undergoing CPR. To determine whether TCD reliably measurescerebralperfusion in normal and low-flow states,we undertook the following prospectivestudy. Disign: Six piglets {weight, 10 to 12 kg} were anesthetizedand instrumented.TCD flow velocities in the cerebralcirculation were measuredat baselineand comparedwith baselinecerebral perfusion as determined by the criterion standardof radioactive microsphereinjection. Cardiacarrestwas then induced,and CPR was begun. TCD velocities during CPR were compared with a second injection of radioactive microspheres.The animal was then resuscitated, and a third set of TCD measurements was comparedwith. microspherepcrfusion data. Miasurements and results: Peak systolic and mean systolic TCD velocities fell from baselinelevels to zero within two seconds of cardiac arrest. With CPR, these values avercgedll7% and

58


70% of baseline,respectively,whereasmicrosphereperfusionfell to 36% oI baseline.Postresuscitation,TCD velocities averaged 125%of baseline, with microsphere values averaging 263oh of baseline.Using simple linear regression,peak and mean systolic velocitiesdid not correlatewith microsphereperfusion datalrz .066,P - .36i rz : .O52,P : .41,respectively). Conclusion:In this model, TCD cerebralblood flow velocities during CPR and after resuscitationdid not correlatewith microsphereperfusion.

153

Blood Glucose and Length of Gerebral lschemia: Determinants of Brain Lactate Accumulation and Glearance

RVW Dimlich / Departments of Emergency Medicine, and A n a t o m y a n d C e l l B i o l o g y , U n i v e r s i t yo f C i n c i n n a t i M e d i c a l C e n t e r , CincinnatiO , hio Study hypothesis: The amount o{ brain lactate accumulated during incomplete cerebral ischemia and its subsequent clearance will be affected by the availability of substrate and length of ischemia. Population: 6I adult male Wistar rats, five groups of fed rats, one each fiot zeto, ten, 15, 20, antl 30 minutes of ischemia; and one group of overnight fasted rats given 50% IV glucose 2 mL 15 minutes before ten minutes of ischemia. Methods: Anesthetized rats were made ischemic by bilateral carotid ligation and bleeding to a mean artcrial pressure of +0 1* l0) torr. After ischemia, rats were euthanizcd immediately {30) or after 30 minutes of reperiusion {31) by rn situ freezing of thc brain. Cerebral cortical samples wcrc analyzed by enzymc fluorometry and parametric data by analysis of variance and Duncan's test. Results: Extending the length of ischemia did not significantly increase lactate; giving glucose prior to ischemia did. Howcvcr, both IV glucose and longer pcriods of ischemia slowcd thc clcarance of lactate. o/oClearanceof Lengthof Brain Lactate Generated (pmol,/g) (Mean + SEM) Brain Lactate Ischemia(min) 0 lcontroll(5) l0 l2(rl 15 17) 20(l0l

2.97 t: .30 a-e 18.82* .74 a,f 20.93 + 2.4 b,h I 9 . u t J+ 4 . 1 c , g

N/A

30 15)

2 2 . 1 6* 5 . 7 d , r

27

29.80 + 1.4 e-g,h,i l0 {glucose) {8) Note: a-g = P < .01,h and i - P < .05, Dmcm's test.

7tl 72 52 29

Conclusion: These results can be used to help develop an appropriate treatment plan to control excessive tissue lactate, one {actor that exacerbates irreversible brain damage in cerebral ischemia.

154

Does Intravenous Atropine Gause Fired and Dilated Pupils After CPR?

MG Goetting, E Contreras / Department of Pediatrics, Pediatric C r i t i c a lC a r e M e d i c i n e , 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 Study hypothesis: Systemically administered atropine in conventional doses has minimal effect on pupillary size and reactivity. Population: Two populations of patients were included. Group I included 28 consecutive patients between the ages of I month and 20 years who received atropine prior to endotracheal intubation. Group 2 included 21 consecutive patients who suffered a witnessed arrest between the ages of 3 months and 18 years. No patient had any evidence of brainstem disease and had all four of the following reflexes intact: gag, cough, corneals, and oculocephalics. Methods: In a prospective study, all patients had their right

pupil measured by the same examiner before administration of atropine. Croup 2, median age 3 years, received atropine in doses of O.287 mg/kg :t 0.0032 mg/kg and had the right pupil re-examined 30 minutes after the dose. Croup 2, median age 2 yearc, received atropine in doses ol O.029 mg/kg + 0.014 mg/kg and were re-examined 30 minutes {ollowing return of spontaneous circulatron. Results: Pupillary size in both groups averaged 4.02 t 0.78 mm prior to atropine and 4.75 + .84 mm following atropine {P < . 0 0 1 ) .N o p u p i l s b e c a m e f i x e d . Conclusion: Atropine administered in conventional doses for advanced cardiac lile support failed to produce fixed pupils. Fixed, dilated pupils following CPR cannot be attributed to IV atropine.

155

Hemodynamic Effect of lncreasing Acceleration of Chest Gompression During GPR in llan

RL Levine,JP Ornato, EM Racht, ER Gonzalez / InternalMedicine and Section of Emergency Medical Services, Medical College of V i r g i n i a i V i r g i n i aC o m m o n w e a l t h U n i v e r s i t y ,R i c h m o n d Study hypothesis: Rapid acceleration chest compression produces better systemic arterial pressure than standard chest compression during CPR. Population: I0 adult prehospital cardiac arrest patients. Cardiac arrest from trauma, drowning, or terminal disease were excluded. Mcthods: All patients wcrc in ventricular fibrillation on paramcdic arrival and did not respond to standard advanced cardiac lifc support protocols. Thc patients werc ventilatcd 12 times a minutc at an FIt>, of 0.8. Artcrial pressurc was measurcd with a no. 20 angiocath inscrtcd by radial artcry cutdown. PETt:o" was monitorcd and rccordcd continuously. All patients rcccivcd 1.0 mg of cpincphrinc IV evcry fivc minutes. Patients rcceived microprocessor controllcd mcchanical CPR (Thumper(o; Michigan Instrumcnts) for both standard and rapid acceleration compressions to cnsurc uniformity of comprcssions. During rapid acceleration c o m p r c s s i o n , a n i n c r c a s e d a c c c l e r a t i < l no f d o w n s t r o k e w a s p c r formcd during thc first 50'X, of comprcssion, rcsulting in an incrcascd downstrokc velocity. Thc prcssure sustaincd in the T h u m p c r n Dp i s t o n f o r t h e r e m a i n d c r o f c o m p r e s s i o n w a s i d e n t i c a l in both rapid accelcration and standard compressions. All comparisons bctween techniques werc madc 15 scconds apart. Statistics: General linear modeling, analysis of variance. Results: Rapid acceleration compression produced a higher systolic arterial pressure than did standard compression 192.2 + 8.4 | S E M I v s 7 9 . 9 i : 8 . 7 , P : . 0 0 1 ) .D i a s t o l i c p r e s s u r e w a s a l s o i n creased with rapid acceleration compression {28.t * 7.5 vs 24.7 + 5.1, P = .02). PETco, did not differ significantly between the t w o t e c h n i q u e s ( 0 . 7 t * 0 . 1 3 v s 2 4 . 7 + 0 . 1 3 , P - . 5 5 ) .L a r g e S E M s represent variability of baseline pressures between patients. Conclusion: Rapid acceleration chest compression produces better systemic arterial pressure than standard chest compression during CPR in human beings.

156

Lack of Gorrelation between EndTidal Garbon Dioride Goncentration

Arrest and Paco2 in Gardiac CW Barton, M Callaham / Divisionof Emergency Medicine, U n i v e r s i t yo l C a l i f o r n i a ,S a n F r a n c i s c o Hypothesis: The correlation between end-tidal COr (ETcot) and Paco" previously described in animals does not exist in human victims o{ cardiac arrest. Population: Prospective case series of 48 adult victims of nontraumatic cardiac arrest treated in a university hospital emergency department during calendar years 1987-1989 with simultaneous ETco, and arterial blood gas determinations. Methods: A calibrated capnometer sensor was connected inline to an endotracheal tube in patients ventilated according to advanced cardiac life support guidelines. Readings for ETco"

59


were pairedwith simultaneousarterial blood gases.patients were groupedas +ROP (return of pulsef if they developeda sustained spontaneouspalpablepulse or blood pressure.potentially perfusing rhythm was electromechanical dissociation or ventricular tachycardia. Nonperfusing was asystole or ventricular iibrillation. Differences between means were evaluated with a twotailed t test. Correlations between ETco, and paco, were analyzed using the Pearson correlation coefficient. Results:58 paired measurementswere obtained.There was no differencein mean Paco" betweengroups.ETco, only correlated with Paco, in_patients with + ROP or those with a potentially perfusing rhythm. Group

All

N

58

+ROP

-ROP

Perlusing

Nonperlusing

47

13

45

_.247

ll

ETco" Threshold Sensitivity/Specificity for +ROSC ETco, on anival ETco, before maximum epinepfuine dose

Specilicity

93

45

100

9Z

ETco, alter maximum epinephrine dose

69

Any increasein ETco, after maximum epinephrine

80

ETco" Threshold Sensitivity/Specificity for +ROSC

69

l0 mn Sensitivity Specificity

ETco, on anival

r value lETco2 ETco,

5mm Sensitivity

Pacrl,)

(mm Hg)

zt7

.691

-.2.6

.64

6.6

15.6

4.4

t2.9

P

.0001

Pac<r,lmm Hg) P

57.9

73.7

S4.Z

4.7 .0023

5t].7

.255

57.7

Hypothesis: Epinephrine administration lowers end-tidal CO" {ETcor) levels in cardiac arrest and affects the ability of ETco, to accurately predict outcome. Population: Prospective case series of 5(r paired data readings in 48 patients in nontraumatic cardiac arrest treated in thc emergency department of a 550-bed university teaching hospital during calendar years 1987-1989 who received cpincphrine and had ETco, monitored continuously. Intervention: IV epinephrine at the discretion of thc treating physician, in maximum IV bolus doses ranging from I to 15 mg per panent. Methods and results: Patients were defined as havins a rcrurn of spontaneous circulation (ROSC) if they devcloped aiustained spontaneous palpable pulse or blood pressure. Data were analyzed by two-tailed t test and linear regression. ETcct, is reported in mm Hg.

ETco, before maxlmum epinephrine dose ETco, after maximum epinephrine dose

-ROSC lN - 37)

p

s.5 {SD3.(rt})

.01

4.4 l3.o7l

.003

4.6 ,'3.91

.0o6

8.7 17.11

3.8 (4.s)

.006

t.9 14.61

0 . 1 s( 3 . 2 1

NS

+ROSC {N - lll 8.86 (SD 5.72)

10.2 (5.5)

8.5

{5.4)

Maximum epinephrine dose

lmcJ Lnangern Elco2 after maximum epinephrinedose

46

92

ETco, on anival

15m

ffisfffit-------Speamcit 7

9

8

ETco, before muimum epinephrine dose

l0

100

ETco, after maximum epinephrinedose

l5

9u

AIter epinephrine,ETco, increasedin 44"/o,was unchangedin 337", and decreased in22%. The changein ETco, was not correlated with the size of epinephrinedose(R : .15). Conclusion:High ETco, levels were most predictiveof ROSC when measuredjust beforeepinephrine,but were still useful even after largeepinephrine doses.ETco, sometimesdecreasedafter epinephrine, but more commonly increased,which was a strong predictor of ROSC.

M Callaham, C Barton / Division of Emergency Medicine, U n i v e r s i t yo f C a l i f o r n i a ,S a n F r a n c i s c o

Vadable

9Z

ETco" Threshold Sensitivity/Specificity f or +ROSC

Effect of Epinephrine Administration on Ability of EndTidal Carbon Dioxide Readings to Predict Outcome of Gardiac Arrest

First ETco, on arrival in ED {mm Hgf

40

ETco, alter maximum epinephrine dose

.9s

Conclusion: ETco, was significantly higher, and correlated with Paco_r, in resuscitated patiâ&#x201A;Źnts or patients with a potentially perfusing rhythm. ETco" probably correlates with paco, when iardiac output and, hence, ETco, exceed a threshold level. Below that levef F,Tco, values have no relationship to paco2 and paco, is an unreliable measure of coronary perfusion pressure.

157

88

ETct>, before maximum epinephrinedose

158

High-Dose Epinephrine Significantly lmproves Resuscitation Rates in l{uman Victims of Gardiac Arrest

CW Barton,M Callaham/ Divisionof EmergencyMedicine, Universityof California, San Francisco Hypothesis: High-doseepineph_rine {HDE) improves resuscitarion rates in human victims of cardiac arrest. Population: Prospectivecase series of 49 adult victims of nontraumatic cardiac arrest treated in a university hospital emergency departmentduring calendar yearc 1987-1989 who receivedeither standard-doseepinephrine (SDE)or HDE IV every five minutes. Methods: Patientswere treated accordingto advancedcardiaclife support guidelines.At the discretion of the treating physician, patients receivedepinephrine in bolus dosesranging from I to 15 mg. HDE was an epinephrine dose of at least 0.2 mg/kg; smaller doses were defined as SDE. Patients were grouped as + ROp {retum of pulse) if they developeda sustainedspontaneouspalpablepulse or blood pressure.Potentially perfusing rhythm was electromechanical dissociationor ventricular tachycardia.Nonperfusingrhythm was asystole or ventricular fibrillation. Data were analyzedusing the 1z statistic. Results: The mean epinephrine dose was 2.O7mg {SD 1.6){or SDE and 14.9 lSD, 0.1)for HDE. Sixty percent of patients receiving HDE were resuscitatedversus I5.4% of patients receiving SDE. HDE was significantly better than SDE in resuscitating patients with nonperfusing rhythms, whereas there was no significant difference in patients with a perfusing rhythm.

60


All Patients + ROP ROP Total st)E

a)

,t,l

Nonpcrfusing Rhythms + ROP ROP Total

,19

4

26

HI)E

6

4

L0

4

1

T0trl

12

,\7

49

I

)7

/' , .{X),ll

/,

.(XJt

.lt) 5 .ls

Results:

PerlusingRhyrhms + ROP ROP n)tal 2 2

7 .

4

9 1

l0

5 t,1

1, = .,1tt

3rP NMR Spectroscopy in the Assessment of Postischemic Anoxic Encephalopathy After Gardiac Arrest

Effect of High Compression Rates During Mechanical CpR in Human Beings: preliminary Results

G B N / a r t i n ,A G o k l i , N A p a r a d i s , E p R i v e r s , M G G o e t t i n g , R M N o w a k/ D e p a r t m e n t o f E m e r g e n c y M e d i c i n e , 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

Animal studies. have_suggested that the optimal compression rate in CPR may be higher than the current advanced cardiac lifc support {ACLSJ recommendation of 80 per minute. Hypothesis: Incrcased compression raics during CpR may im_ prove hemodynamics. Population: Five adults with medical cardiac arrcst. Methods: Patients had CpR performed accortling to ACLS g u i d e l i n e sw h i l e i n s t r u m e n t e d w i t h m i c r o m a n o m e t e r _ t i p p e d c a t h e t e r sf o r m e a s u r e m e n t o f a o r t i c ( A o ) a n d r i g h t a t r i a l IRA) pressures.A_computerized pneumatic chest compressu, *r, t.rsed to.perform CPR at 80, I00, lZO, I40, and 160 "b-p.."rror,, p.. minute. Ao and RA pressures ]mm Hg) ,".." -.rirrr.d during compression and relaxation at the end of a one-minute sequence at each CPR rate.

t2O 4l * ll 17 + lZ

140 39 + ll 17 + lZ

RA Compression 4ll + 15

52 + 13 l(r + 14

49 + 13 l(t + 14

47 * 13 45 + 14 17 + t4 lZ + 15

l(r:t 16

160 3tj + l0 lg * 13

There was no slgnificant difference in individual Ao and RA ores_ surcs or gradicnts at any ratc (p > .05). Conclusion: This limited human study supports the current ACLS CPR rate oJ 80 per minutc and fails to provide evidence of improvcd hcmodynamics at higher rates. Further studies are needcd to confirm this findins.

*161

Increases in Goronary perfusion Pressure After High-Dose Epinephrine Result in Decreases in End.Tidal CO, During GpR in Human Beings N.AParadjs, MG Goetting, Ep Rivers, GB Martin, TJ Appleton, RM Nowak/ Department of Emergency Medjcine, HenryFord Hospital, Detroit, Michigan

G B M a r t i n , N A P a r a d i s ,J A H e l p e r n , K M A W e l c h , E p R i v e r s , R M N o w a k/ D e p a r t m e n t s o f E m e r g e n c y M e d i c l n e a n d N e u r o r o g y , HenryFord Hospital, Detroit, Michigan In viuo 3lP NMR spectroscopy enables noninvasive measurc_ mcnt of ccrebral metabohsm. H y p o t h e s i s : C e r e b r a l h i g h - c n e r g.yi np h o s p h a t e ( H E p ) m c t a b o l i s m and brain pH (pHB) are disruptcd paticnts with postischcmic anoxic encephalopathy aftcr cardiac arrcst. Population: Adult survivors of cardiac arrcst without prc_cxlst_ ing neurologic dysfunction and Glasgow Coma Scaic (GCS) s c o r c so f l e s s t h a n 9 a f t c r c a r d i a c a r r c s i . Mcthods: Cercbral NMR spcctroscopywas pcrformcd in a i.9 T magnct as soon as possiblc aftcr resuscitation from cardiac arrcst a n d _ r c p e a t c d2 4 t o 4 8 h o u r s l a t c r . S p c c t r a w c r c o b t a i n c d b i l a t erally from both parictal and/or occinital areas. R e s u l t s :1 3p a t i c n t s , m c a n a g c ( t 6 + 1 2 y e a r s , w c r c s t u r i i c d a t l g + 1 3 a n d 6 3 x 2 0 h < > u r sa f t c r c a r d i a c a r r c s t . M c a n C I C S sw c r c 3 . 6 t I.2,and.3.5 a 1.2,rcspcctivcly, at spcctroscopy.HEP responsc r a n g e dt r ( ) m n o r m a l t < t c o m p l c t c a b s c n c c < l f H E I ) s . I n a l l c a s c s , initial pHB was alkalotic at7.16 + .0/ whcn comparcd with agc.l m a t c h c d c o n r r o l s ( p H 6 . 9 5 + . O 4 , p - . 0 0 0 1 J .d i * p a t i " n t s i c _ maincd alkalotic. on rcpcat spcctroscopy while onc normalizcd a n d a n r ) t h c rd c v c l o p c d s c v c r c a c i d o s i s lpH 6.a\. All paticnts dicd wltnout rmprovcmcnt in ncurologic status. Conclusir)n: A hctcrogencous high-cncrgy rcsponsc occurs in p a t i c n t s _ w . i t hp o s t i s c h e m i c a n o x i c e n c c p h i l n p a t h y . T h c signifi_ canceof this finding is currcntly unclear. Thc consistcnt carly increase in pHB may be a marker of irreversible brain injr.rry as s u g g e s t e di n s t r o k e s t u d i e s . F u r t h e r s t u d i e s t h a t o c c u r e v c n sooner after resuscitation are needed.

{ An r ryry

100 43 + ll 17 + ll

RA Relaxation

Conclusion: HDE significantly improvcs initial resuscrtation rates in human victims of cardiac aricst. Its grcatest effcct is in patients with a nonperfusing rhythm, who probably have the least coronary perfusion prcssurc.

r59

Rate 80 Ao Compression 43 * 14 Ao Relaxation 16 + 9

Coronary pcrfusion prcssurc (Cpp) is aortic minus thc right atrial prcssurcs during relaxation phasc. Cpp has bccn found to Dc hlghty predictivc ()f outc-omc during CpR. High_dose epi_ ncphrinc iHDEPI) has bccn dcmonstrated to increasc Cpp. Al_ though this may rcsult in incrcascs in myocardial perfusion, thc incrcasc . i n a o r t _ i cp r c s s u r c m a y d c c r c a s e c a r d i a c o u t p u t a n d p u l _ monary bkrod flow manifcsting as a drop in the cntl_tidal CO" { E T to ' 1 . . l_1YPt'the. During CPR, incrcascsin thc Cpp aftcr HDEpI wtll decreascbl,xrd fkrw through thc pulmonary circulation, re_ sulting in a dccrcasc in ETc;o,. I)opulation: 47 normothcrrnrc adult paricnts in mcdical cardiac arrcst. Mcthirds: Standard CpR and advanccd cardiac lifc supporr was p c r f < > r m c du n t i l a d m i n i s t r a t i o n o f H D E p l . E T c ; c t , ,w a s m c a s u r c d c o n t i n u o u s l y . A o r t i c a n d r i g h t a t r i a l c a t h c t c r s w e : r cp l a c c d . A f t c r p a t i c n t s f a i l c d t o _ r c s p o n dt o s t a n d a r d t h c r a p y , H D E p i ( 0 . 2 m g / k g l was administcrcd into thc right atrium. Thc-Cpp ,"a'ef.,,rr'iu!i bcforc and thrce minutcs aftcr HDEI)I wcrc comparcd usin-g'thc Wilcoxon rank-sum tcst with significancc at p < .05. Rcsults: Thc CPP bcforc and iftcr HDEpI was 1.5 + 7.2 mm Hg and tt-3 !,l^1.4, rcspectively lp - .002). The ETc:o, decrcascd + ( r . B m m H g t < - 6t . 2 + 4 . 7 d u r i n g t h i s tlql. same timc (p < 101. .0001). Therc was poor correlation betwien the decrcasc in ETc:cr, and the incrcase in Cpp lr - - .221. C o n c l u s i o n ; E T c : c > ,d o e s n o t r c f l e c t i m p r o v e m e n t s i n C p p a f t e r HDEPI during CPR in human bcings. tt ihould not be used as an i n d i c a t o r o f c l i n i c a l s t a t u s o n c e t h i i d o s a g eh a s b e e n u s e d . T h e s e results may indicate a dissociation betwcen systemic organ pcr_ fusion and pulmonary blood flow after HDEpi.

*162

High.Dose Epinephrine Therapy and Return of Spontaneous Circulation During Human Pseudoelectro. mechanical Dissociation

l ) l A P ? r a d l s M G G o e t t i n g , E p R i v e r s ,G B M a r t i n , T J A p p t e t o n , R M Nowak / Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan Echocardiographic studies have shown that patients in clectromechanical dissociation (EMD) may have myocarciial wall and valve motion. We have demonstrated that some patients in EMD have aortic pulse pressures and have termed this pseudo-EMD (PEMD). Studies indicate that high-dose epinephrine (HDEpl) may be more effective than thc standard t-mg dose (SDEplf in the treatment of cardiac arresr. _ Hypothesis: Use of HDEpI in patients with pEMD results in higher rates of return o{ spontaneous circulation (ROSC).

61


Population: Adult medical cardiac arrest patients' Methods: Patients received standald external CPR and adur.".J .".,li^c life support were performed' An aortic arch cathePatients without ROSC -."sJt.-..tt' ,". *"t placed for pt.i*t. aft., rnrlltiple administrations of SDEPI {l mgJ were given HDEP-I ECC 0.2 mg/kg {14 mg in a 70-kg patient} Patients whost palpa.ftn*.E rJgular orlanized depolaiizations bur who lacked {eioral pulses where defined to be in EMD, and Ll" ..-,ia"t"d in those found to have aoriic pulse prcssures were defined to be a f t er R O S C o f r a t e t h e c o m p a r e d r e t r o s p e c t t v e l y w e PEMD. SOfpf ,"a HDEPI. These proportions werc compared by 12, with s i' g i{n e si fui lct sa: n c e a t P < . 0 5 . Of 187 patients studied, 85 presentcd with or developcd EMD ,t so-. time during resuscitation' Of thesc, 36 were fountl to bc in PEMD. Twelve of thet. patients had ROSC after : Sbfpl. Ot 15 patients who received HDEPI, 1l had ROSC {P

021 ionclusion: A significantnumbcrof patientsin EMD are in

pEMD. Some patients in PEMD respond to SDEPL A maiority of paticnts failing to respond to SDEPI have ROSC aftcr HDEPI' 'Earlier use of AoEpt in PEMD may be indicated'

*163

Effect of Direct Mechanical Ventricular Assistance Versus Open-Ghest Gardiac Massage on Regional Gerebral Blood Flow ln Swine

R F G r i f f i t h ,M A n s t a d t , J H o e k s t r a ' P V a n L i g t e n , G A n s t a d t ' L Casto, CG Brown / Division of Emergency Medicine, Department o f S u r g e r y , a n d D e p a r t m e n t o l P r e v e n t i v eM 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 ;B i o s c i e n c e s C e n t e r , M i a m i V a l l e y H o s p i t a l , Columbus, Ohio Study hypothcsis: Prcvious studics have not disccrncd thc bcst m c t h o ; i r i i g c n c r a t i n g r c g i o n a l c c r c b r a l b l o o d f l o w d r ' r r i n go p c n Wc hypothcsizcd that regional ccrcbral .n".tt .oraio. -rttog". iri,.la i.r* gcneratc,Lby a mcchanical method, dircct mcchanical (DMVA), would bc supcrior to manual ".'nrii.uf^i'rtsistancc m a s s agc {MAN). c a r d i a c o 'pt cl i n c h c s t rpnirti,rn, Adult Yucatan minipigs wcighing morc than 44 kg' Mcthods: l2 swinc were instrumcntcd for rcgional ccrcbral vcnbkrod flow using traccr microsphcrcs' Aftcr I5. minutcs of r i c u l a r f i b r i l l a t i o n ( V F J ,s w i n e w e r c r a n d o m i z e d t o r c c e i v e c i t h c r Regional cerebral blood flow was measurcd duri.t,q,N u. ouvA. (VF ine nu.rn^t sinus rhyihm, one minute (VF l) and five minutes -2' )R- a " *f 1t c, tr , i n i t i a t i o n o { o p c n - c h e s t c a r d i a c m a s s a g c ' R c p o r t e d b c l o w a r e r c g i o n a l c e r e b r a l .b l o o d f l o w a s 1 SD in ml/min/100 g. Regional cerebral blood flow was mcan t = '06lr' using a Wilcoxon rank-sum test {- P < '05; P .u-prr.d Tissue

Cortex Ccrebellum Midbrain

Normal Sinus Rhythm ]TIAN DMVA 43 ! 22 42 * ll 45 + 24 50 * 17 30 * 14 32 * 9

vFl MAN DMVA 2 { J *1 6 l l + t J 49 !27 LZ * 13 43 t:26 16 + ll

vF2 MAN DMVA 39* 1l 12*8t 58 :! 1220 + 8' 50 1 15 lu :t 9'

Conclusion: Direct mechanical ventricular assistance produced better regional cerebral blood flow than MAN DMVA is effective regional cerebral flood flow after a prolonged car,i -rlniti"i"g diac arrest.

164

Glosed Thoracic GavitY Lavage for the Treatment of Severe Environmental HyPothermia

DD Brunette,SP Sterner,E Buiz I Departmentof Emergency Medicine,HennepinCountyMedicalCenter,Minneapolls' Minnesota Severeenvironmental hypothermia carries a high mortality ,"* W. hru" previously demonstratedthe e{{ectivenessof closed thoracic lavagi for treaiment of severehypothermia in an animal

been model, but its usefulness in the clinical setting has not intested. We present a small series o{ sevete, envitonmentally duced hypoihermia patients rewarmed using closed thoracic cavThree patients presented with environmentally ini;;1;"^A;. C' a,.i""a tt"vpottt.rmia having-initial corc temperatures o{ 28'3 less was 6 or Score Glasgow.Coma respectively. 24 C, C, ;;d 28.8 in all ihree patients. Associated clinical problems included respiratory deprcssion, cxtremity frostbite, hypotension, and acu.te Closed thoracic cavity lavage was uscd as the "iii"t'tiUritt"tion. method. Thc closed lavage system consisted rewarming ".ir"f"A a li " ftigft efficicncy"heat exchanger, a roller in-fusion pump, and hcat cichangc fluid bath. Thc continuous lavage was accomplished using a{fercnt and efferent thoracostomy tubes The lai,age fluid ciiculatcd at a flow rate of 300 ml/min, with a tcmof 38 to 40 C. The average rewarming ratc was 5 F/hr' p"ir,.,r. 'I.lo pacomplications occurred during rewarmilg, i"q all three tients wcre discharged without sequelae Closed. thoracic cavity lavagc appcars to be an efficient and sa{c mcthod of active interfor patients with severc environmentally induced ,ut i.*rr-l"g is hypothermia."Addifional clinical cxperiencc with this modality ncedcd.

llass GPR Training as a Means of - t^ E Promotins GPR Education I |lC and Research O Braun/ Centerfor Prehospital EJ Weber, San of California, University it"rgun"y Department, Training, Francisco a Objcctivc: To dcterminc what motivatcs citizens to attend mass CPR training cvcnt and whcther such an cvent is an effectivc way to teach and Promotc CPR' Study population: 1,835 pcoplc who attendcd a free mass CPR training cvcnt. pubnnetho.tt, A frcc CPR training cvcnt in San Flancisco was licizcd widcly by mass media. threc one-hour sessionsincluded a vidcotape prescntation and manncquin practice. Aftcr instruccomplcted a survcy consisting of 20 multiple,l,rn, att-".t choicc and fill-in questions. perResults: 1,469 pirticipants complctcd surveys' Forty-fivc. cenr had .tarr., trl".t , CPR .on.t" bcforc' Rcasons for not doing so were did not know how to get a course {96%); had never (54%); ;h.;g;; atout it {54'l.); thought thev might^hurt^somconc a high priority 146%li tear of AIDS (427'); didn't think ir-*r1"'. too ih.y *o"ld ni"d it 137"/")itoo expcnsive 132%li and took out - t , . h t i - . ( 1 6 % ) .F o r t y p e r c e n t s a i d t h c y a t t e n d c d t h e e v e n t ior a'friend or a relative; 29"h said thev saw the ads ;i;;";;; and felt it was time to learn CPR' Less common leasons cnosen game anyway {I87o); c.onvenient loca."-i"g " . uto *.i. " r rbaseball t f r e i (t67. 1, wanted free baseball tickets * " , tii lli't")t l e s s t i m e ( 1 1 7 ' J 'D e [16%i; thought it would be iun {12%); took raised in the literature, after the course 790lo said !pi,.""o"".t""t pari[.y *o"ld do CPR on a stranger' Eighty-five,percent of all said they were now motivated to take a certified CPR ii"ipr".t course. Conclusion: Mass CPR events can attract people who might pubotherwise not learn CPR by creating publicity that increases of conlic awareness. Expense, time, fear of hurting someone or tractins AIDS are not significant obstacles' Even brief training confident-enough to perform CPR on relatives or -"kes"citi"e.ts Enrollment in traditional CPR course.s might also imr,ir"g.tt. prove if massive publicity campaigns were used'

166

An Assessment of the Evaluationt Diagnosis, and Treatment of Dermatologic Diseases bY EmergencY PhYsicians

MA Levitt,T Borkowski,K Kelly,L Urbanskii TA Christopher, Divisionoi Et"tg"n"y Medicine,ThomasJeflersonUniversity Pennsylvania Hospital,Philadelphia, Hypothesis:This study assessedthe spectrum of dermatologic diseaiesin patients presentingto an emergencydepartment,and

62


the accuracy of emergency physicians in evaluating, diagnosing, and treating these patients. Population: 242 consecutive ED patients with dermatologic complaints were prospectively enrolled. Methods: All patients were evaluated initially by a senior emergency physician and soon thereafter by a dermatologist. Both were blinded to each other's assessment, diagnosis, and treatment, and completed identical data sheets that included demographic information, rash description and location, associated symptoms, diagnostic possibilities, and treatment. Frequency data were calculated for descriptive parameters. Concordance of descriptive parameters was judged using either X2 analysis or Fisher's exact test. A Capa analysis was used to compare degree of concordance in diagnosis and treatment. Results: Ol 242 pat\ents evaluated in the ED, 57"/" werc Iemale, Tlok were black, and,26%" were under 16 years of age. Eighty-one percent had no allergies. The most common diagnoses w e r e c o n t a c t d e r m a t i t i s i 1 6 % J ,t i n e a { l l % ) , h e r p e s ( B % ) , c e l l u l i t i s l 8 % ) ,a n d i n s e c t b i t e s { 8 % ) . O n e h u n d r e d s i x t e e n p a t i e n t s s e e n b y a dermatologist were entered into the comparison study. The emergency physician and dermatologist agreement data are presented: diagnosis l6a%), rash classifications and associated sympt o m s 1 5 0 % ) ,a n d r a s h l o c a t i o n i l 0 0 % ) ( P < . 0 5 1 .T h e t h r e e m o s t common therapeutic modalities were topical steroids {emergency physician, 527. I dermatologist, 46% ), systemic antihistamines f e m e r g e n c yp h y s i c i a n , 5 6 7 " / d e r m a t o l o g i s t , 3 9 % j , a n d s y s t e m i c antibiotics (emergency physician, 49"h / dermatologist, 3 l% ). Conclusion: Most dermatologic disease seen in the ED is benign. However, emergency physicians appear to diagnose correctly only 64"/" ol those dermatoses presented to them. They also appear less skilled in providing accurate rash descriptions. These findings suggest that further training in dermatology is n e e d e df o r e m e r g e n c y p h y s i c i a n s .

*167

Prospective Evaluation of Flight Physician Air lledical Duties in an Emergency lledicine Residency Gurriculum

K C H u t t o n , K l l k h a n i p o u t R P o r t e r i U n i v e r s i t yo f P i t t s b u r g h 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 ; C e n t e r f o r E m e r g e n c yM 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 The educational value of flight physician duties in emergency medicine residency training rs presumed to be high; however, prospective evaluation is lacking. Study hypothesis: Duties as a flight physician are of educational value to emergency residents in training, and the educational value varies with flight type and patient severity. Population: 223 flight experiences of 16 emergency medicine residents who shared duties as flight physicians Ior a helicopter air medical service were evaluated from fuly l, 1989, to fanuary l, 1990. Methods: Prospective data were collected, including interventions, demographics, flight type, important medical decisions made, and time away from other duties. The patients' severity and the educational value of the experience were assigned numeric values from 0 (minor/not use{ul) to 4 (high severity/highly usefulf by the residents alter all {lights. Spearman's correlation lrhol was used for statistical analvsis. with a error of 0.05. Results: 223 flights (85o/o interhospital and I57o scene) were recordedfor analysis, an average of 13 total {range, two to 25) and two scene flights per flight physician. Data are summarized below. All rho values showed significant correlations (P < .01) foverall, rho - 0.77). Flight Type

No. (%)

Adult trauma Pediatric trauma Scene trauma Neurologic Cardiac Other

66 45 33 37 58 3l

{.lO) (22) {15) lITj (26) {14)

Severity 2.e 2.6 3.r 2.9 2.7 2.4

Educational Decisions Value f/"1 2.6 3l {471 2.4 18(401 3.0 19(s8l 2.s 18 (491 2.3 29 (sOl 2.2 0 {0}

Interventions f/"1 29 l42l 16{3s} t7 ls)l 18(491 29 (s0l 0 {01

Rho o.74 0.7s 0.71 0.s0 O.74 0.91

Conclusion: Overall duties as a flight physician are educationally valuable to emergency medicine residents in training, and the educational value increases with the severity of the patient. Trauma (scene, adult, and pediatric), cardiac, and neurologic flights were iudged as the most valuable and tended to require more interventions and medical decisions.

.1

68

Anarvsis of *ligitfri"Bavesian

RJ Lewis / Department of Emergency Medicine, Harbor-UCLA 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 Study goals: To develop a method for the planning and analysis of clinical trials using sequential Bayesian methods and to demonstrate the technique by computer simulation. Methods: A sequential Bayesian trial begins with the assumption that virtually nothing is known about the success tates of the control and test treatments. These rates are denoted P^ and P,, respectively. Because of this, all values are considered equally likely, and the probability distributions for P" and Pt are constant from 0.0 to 1.0. As the trial proceeds, patients are randomly assigned to either treatment, their outcomes are determined randomly according to actual treatment efficacies set for each simulated trial, and these data are used with Bayes'theorem ro revise the probability distributions for P. and P,. As data are accumulated, the probability distributions for P. and P, become more narrowly distributed around the true values. From these orobability distributions, the probability distribution for the difference in efficacy, P, - P., is calculated. The two hypotheses to be distinguishedare (P, - P.) > 0and (P, - P.l < 6 where 6 is a predetermined minimum difference in e{ficacy that would be clinically significant. The probability o{ each hypothesis is calculated after every patient and the trial is terminated as soon as one of these hypotheses can be demonstrated with adequate certainty. Unlike statistical methods based on classical hypothesis resting, this method determines the probability that each hypothesis is correct. The tradeoff between sample size and the teliability of the trial result is set by internal algorithm parameters. Results: Numerical simulations o{ 1,000 clinical trials were conducted using 6:0.2 and ten different combi.nations of assumed treatment efficacies. The conclusions of 95.4% of the trials were correct. When P, - P. : 0, the observed rate of type I error was l2o/" and a median of 32 patients was required. When P, - P" = 6, the observed power was 80% and a median oI 37 patients was required. A classical 12 analysis would require 100 patients for the same rate of type I error and power. Conclusion: A technique for the sequential Bayesian analysis of clinical trials has been developed. The method minimizes required sample size and produces true estimates of hypothesis probability.

169

lt'+'ffi*"ff:T;:,:llir!*t-T

of US and lnternational Practice of Gonsent in Emergency Research PS Grim, P Singer,E Hollenback,E Batson,M Siegler/ University of Chicago;PitzkerSchoolof Medicine;AmericanMedical Association, Chicago,lllinois;YaleUniversity, New Haven, Connecticut Obtaining adequateinformed consent during a medical emergency is a fundamentalethical concern to researcherswho study acutely ill patients.To evaluatethe consentprocessin this situation, we reviewed randomizedclinical trials involving thrombolytic therapy for acute myocardial infarction or unstable angina. A searchof literature publishedbetween 1980and 1989identified 55 such studies,2l of which were conductedin the United States. We requested from the authors the informed consent form used in their study, or if none was used,information given to potential researchsubiects.Thirty-eight researchgroups replied, including 14 from the United States.Of the 14US studies,all requiredwrit-

63


i l

i

iii

l

ll I

ri

lii

]i

il

il

ii

ten consent. The studies varied, however, in how they described risks to potential research subjects. In studies involving streptokinase, two listed "allergic reaction" as the only risk, one listed, "bleeding which may require transfusion," one listed "bleeding and allergic reaction," one listed "minor risk of bleeding including internal bleeding and allergic reaction," and one listed "mafor bleeding or stroke." For tPA, one study listed no risks, one listed "bleeding" only, one listed "major bleeding," one listed "bleeding and dysrhythmias," one listed "bleeding at catheter site," two listed "gastrointestinal or intracranial bleeding," and one listed "bleeding and allergic reaction." In contrast, only seven of 24 studies from nine countries other than the US required written consent. Consent procedures varied widely. The Italian GISSI study, involving 11,806 patients, required no informed consent because "the patients' predicament was judged too acute for acceptable applications o{ the procedure." At the other extreme, two German studies carefully detailed the likelihood of side effects in a manner more rigorous than any US studies. Many foreign investigators, in responding to our requests, wondered whether it was possible to obtain truly informed consent in medical emergencies. Although US studies obtain written consent, it is not clear that US subiects are better informed than their foreign counterparts. On an international basis, there is marked variability in the format and content of informed consent procedures {or thrombolytic therapy. This poses two challenges to emergency medicine researchers: determining the best method of conveying risk to patients in emergency circumstances and, through international consensus, determining which risks should be specified.

170

Incidence of Infrequent Diagnoses and the Uneven Distribution of Clinical Studies Across the Gore Content in Emergency Medicine

Study hypothesis: It is often assumed that more experienced physicians possess an increased awareness of the actual financial costs incurred by patients treated within the emergency department. The purpose of this study was to test this hypothesis in an emergency rnedicine residency program and to identify any par ticular areas of difficulty. Population: All members of our emergency medicine residency program were included (seven attending physicians, six senior residents, and ten iunior residentsl. Methods: Members of the department simultaneously completed a questionnaire that required cost estimates for frequently ordered laboratory tests, imaging procedures, medications, and commonly used supply items. Total costs were also estimated for four actual case presentations of varying complexity. The cost estimates made by each group of physicians were compared using an analysis of variance. Ninety-five percent confidence levels were also calculated for the estimated costs. Results: No significant difference {P < .05) in estimates between any group of physicians could be demonstrated. Comparing the 95% confidence levels of the combined estimated costs with the true cost revealed that laboratory tests, imaging procedures, and actual case presentation costs were often signifi,38%, 46%, and 50% of times, respeccantly underestimated r n e cost ications was significantly overestimated r ivelvl. l v e r y l . The c o r of medicati (89% of timesl. Conclusion: This study demonstrated no difference in cost awareness between groups of physicians possessing varying degrees of clinical experience. Educational programs promoting cost awareness should target emergency physicians at all levels.

*a

Procedure Documentation Gomputerized Data Base

Using a

C L R o t h o n g , D P l u m m e r ,A T s a i / 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 Residency Review Committee requires information on procedures performed in emergency medicine residency programs. A noncommercial proprietary data collection and rulebased expert system was designed in which all emergency medicine procedures are logged into a computerized data base. Residents access the system through any touchtone telephone. Data entered included patient name, age and date; procedure performed; hospital rotation; and complications. Each entry is completed in less than 20 seconds. A medical secretary reviews each entry and enters the data into a custom-written data base. Over a three-month interval 20 emergency medicine residents have dictated 1,008 procedures on 770 patients. An audit o{ emergency department procedures revealed 97Yo compliance with the system. Periodic summary reports are distributed to all residents. Ad hoc reports using any number of parameters or group of parameters in multiple logical expressions are available on an electronic password basis. A rule-based system was authored using the data for automatic collection of quality assurance material. This system was easily established and maintained. It has been a costand time-efficient method for documentation necessary for resident education, credentialing, and quality assurance.

DG Cochrane, J Allegra / Hackensack Medical Center, Department ol Emergency Medicine, Hackensack, New Jersey; M o r r i s t o w nM e m o r i a l M e d i c a l C e n t e r R e s i d e n c y i n E m e r g e n c y M e d r c i n e , M o r r i s t o w n ,N e w J e r s e y Study hypothesis: The uneven distribution of clinical studies across the Core Content in Emergency Medicine may be due to a low incidence of many of the Core Content diagnoses. Population: 573,315 patient encounters in nine suburban New |ersey hospitals over a period of 39 months from 1985 to 1988 were studied. Methods: ICD9 diagnostic usage data were summarized and organrzed according to the Core Content in Emergency Medicine. These data then were sorted by decreasing frequency of usage and also were used to derive incidence data for a list of diagnoses published previously by Mills. Mills' list contained topics that were thought to be important but not covered in the thrce major peer-reviewed emergency medicine journals during 1982 to 1985. We arbitrarily chose an incidence of ten per 10,000 as a level of diagnostic usage below which prospective studies would be difficult. Results: A total oi 744 Corc Content diagnoses were needed to summarize the 2,192 di{{erent ICD9 codes that the physicians used. Of the 744 Core Content diagnoses, 547 diagnoses were used less than ten times per 10,000 visits. These included many important areas of the Core Content. We found that many of the conditions listed by Mills were also diagnosed with an incidence of less than ten per 10,000. Conclusion: The uneven distribution of clinical studies across the Core Content may be due to the low incidence of many of these entities.

171

-, lFl a I Z

173

The Accuracy of Computerized Bar Gode Versus Handwritten Recording of Trauma Resuscitation Events

RV Chua, KL Ernsting,WH Cordell,HC Bock, EE Miller/ Indiana Schoolof Medicine;EmergencyMedicineand Trauma University Center,and Departmentof MedicalResearch,MethodistHospital of Indiana,Inc, Indianapolis Study hypothesis:Recordingeventsduring maior trauma resuscitations is more accurateusing a computerizedbar code system than traditional handwritten entries. Population: Four fourth-year undergraduatenursing students servedas subiects.These student nurseshad no previous experience in recordingmaior trauma resuscitations.

Gost Awareness in an Emergency lledicine Residency Program

TP McHugh i Departmentof EmergencyMedicine,Richland MemorialHospital,Columbia,SouthCarolina

g


-F--

four difMethods:Eachof the four nursesviewed videotapesol Each ferentmaior trauma resuscitationsduring a-single session' "rse, by handwritten entrv ind two casesusing the ;;;;;;fi;" randomizc tri .od. method. A Latin squarc dcsign was used to o{ view{t"bi..t, recordingmethod' order i;t;li.;;;;;irbl"t previouslvani;;. ;;;-;t;;.inp..t .ai.). The investigatorshad list of ,riri'trt. "ra."it*Jies,rscitatiotts ani prcpareda.master were coded-records bar and ".i.t.t'handwritten ir'" ;ii;;;;;t. crrors .o-prr..t with the mastcr list and the numbcr of cntry methods' orffii|tlJ Th;-;^rirbili,y among subiccts,rccording a.t.t ,riieotap","*t'". evaluatcd using analvsis of il;;"a;i";i;g, rccording variance.Stuicnt's r test ;as uscd to compare thc -.,ft"a. *l,tt"ut consideringthe othcr threc variablcs' crrors Results:Thcre were no significant differcnccsin cntry was' U.i*.."-t"fi.cts, order of vicwing, or videotapcs There difference (P < 0'll in numbcr of crrors , 'i!"iti"""t ;;;;;;;, tivo recordingmethods.Handwrittcn records(cight) il.i..*',fr" oi8.rt p.t rccord,while.barcodc rec.rds h;;'t";.;;u..o"", count of 4 5 pcr r-ccord' crror mean a had leishtl '''il;.lt;;.,'i;iiii -oa"r, computciizcdbar-coricrcc'rrding.f crlors traumaresuscitationevents had significantly tt'wer entry with handwritten recortli' Bar codc technology offcrs ;;;;J ;;i pot"nti^llv more accuratc mcthod of recording ;;;il;,; rapidlyoccurringivents in cmergencydepartmcnt resuscitations' subiccts ndaitiorr"t studiesare warranted-with larger numbcrs of and in the setting of actual rcsuscitations' ll''a q

S

I r+

Preformatted

Charts

lmProve

Documentation in the Emergency DePartment C Coutifaris' A Stemhagen' F Shofer, T Humpnreys, S Jacobsen, of obstetrics and Department bepartment / Emergency iln;td The of Pennsylvania; of the University unJoin."otogy,Ftospitat Philadelphia Schoolof Medicine, ol P"#nsylvania Uniu.r..ity charts with Hypothesis: Thc usc of program ]prcformattcd) docuncnta.o-pi"int spccific cntry criicria rcsults in improvcd by rcsition^of paticnt cncounters in the emcrgcncy dcpartmcnt in bctr c s u l t s d c t a i l t . a t t e n t i i i n g r c a t e r t h a t ;J staff and ;;t t-e- N r p, iaettiheon<t 1c sa/rpeo. p u l a t i o n : Program charts and blank charts wcrc in thc !Q rhc phvsician evalpi'v'iiians ro. ,r;;;;iy ;.'";J.a with abd()mlnet paln wcrc rew o m c n n o n p r e g n a n t 7 5 o f uations dcsigned t() mcasure. spccific paticnt .ota.a. rottn*-t,p t,i*.yt parameters were administercd by tcle-phone within two outcome ^the ED visit. Using a weighted scalc for information weeks of of total possiblc c h a rts were assigicd ' pitt"nttg" recording, patient outscore. Perccntage scorcs then wcrc correlatcd with parameters. come --n.t,ifit' The use of proglam charts in thc ED rcsulted in a staimprovcment in documentation After comsignlficant tisilJiy ."or. fn. program^charts and blank charts was 'pletion,'the"mc"., 8g% 0001) Wtren correlated with and 74%, respectively (P' : of documentatron was patient outcome parameters, com-pletc-n-ess physiorrel^t.d with patients being referred by their emergency : '009;.odds ratio' s'4)' No (P follow-up"care additional ;i;;;i;; persistcncc statistically significant relationship was found for the quality of oi G .ftt.i coLplaint or the patient's perception of the care that she received in the ED' of paConclusion: The use oi program charts for the recording quality.of the improvcd silnificantly ED tieni encounters in the did resident and staff documentation. Better chait documcntation patrents not demonstrate superior patient care However' more by their physicians for additional follow-up care *.r...f.r..d used' This finding may-indicate *i't.n progt"-'charts'were use greateratt;ntion to certain details of patient care through the of program charts.

175

Designing a Reliable and Valid Ghart Stimulated Recall Eramination

American Board , Wilson' BS Munger, D Solomon / MA ReinhartA U n r v e r s i t yE ' ast Lansing S t a t e M r c h i g i n Medicine; "i rt"tg*;v Studvhvpothcsis:Chart.stimulatedrecalldesignedasaStrucbv a trained examiner is a reli ""J ,a-i"itt"red ,J;;;;#;; clinical performance evaluatron' -able " i ' " " "and i r t 1 .valid ", Emer25 diplomates o{ the American- Board of ieccrti{ication voluntarilv participated in .."r.i"! il";i;i". s.;;; examination {}uly either a field tcst ot tnc oral rccertification (October 1989)' i;ibl ' - l \ , i ; , h.," J the t , {irst administration of the exam as a strucChart-stimulatcd recall was redesigned on physicians'performance mcasure to proccss intervicw tured had subthev that six'cases from ,el.ct.d ;;;;; ;;;d6-lv il;;; During a ," ,t," Amcrican Board o{ Emergency Medicine' -i,,"a to administer a ten-hour training session, examiners were trained based on questions related to eight perfor-,"rvicw ;;;il.J ,l,o wcre^ trained to identify priol to the fh"y -^"*"t*f"g"recall interview the kev concepts of the case' ;;;;; t,i;;fi,cd fn"i of thc case' The kev conccpts formed the ;h;;ttt"r;ilttttJ team leaders ref".ii "f the pcrformancc evaluation' Expericnced and performance ratnotes, examination concepts, kcy afl uic*e.t dev ia tions, ze-ro-order P"t',::l corrciations' -;;. ;;;;;;!tr"Jt'i rcliability was calantl Cronbach's q wcre calculatcd' Intcr-rater c- 'uRl af rt.c, d l t . o, n t h c f i c l d t c s t d a t a ' * '58 (mcan * SD) on-chartCandidates scorcd (r'09 6 ' 3 1 + 0'49 nine,yearseatlier on w i t h c o m p a r e d stimulatcd rccall and inter-rater ih"ir,r."t ccrtification cxamination' The internal recall was correlated rcliabilitics wcre 0.70. Ch"t-'ti-t'lated with their part II exil.+.i *i,ft thcir part I cxamination and 0'37 carlier' years tcn approximatcly amination takcn intervicw Conclusion: Structurcd training and a documented to tof,;. "hart-rtim.,latcd rccali cncounters contributed "t;;';; ial cxamination rcliability and validity'

Judicial Outcome of Intoxicated Drivers Seen in the EmergencY DePartment MiltonS Hospital'.The JS Smith,HA Muller/ University RT Cook, StateUniversity' ThePennsylvania i"r.f,"v MedicalCenter, -. I t

a; |o

Hershey

"per sc" governing drinkThc .statc of Pcnnsylvania has a .law (BAC) o{ I00 mg% or in" r"i Jt*i.s, with'a blood alcohtil lcvel rn our emeruril"t", cunstit-uting an infraction All patients seen c o l l i s i o n s in which u t h i " l " n t o ' :.'*;'.i*;;;"ii.ii,,*l"g

and werc legallv intoxicated would theoiil;t;i'#;;';1;*;; The nursing-and rctically reccivc prosccution by pol"ice'olficers a brief form fill.out to *.'"''"q""'t"d staff ;;;;;ii;s;tysician more than of a BAC with gil'pntients driving werc who un rit was obtainedthrough 100%. Information on iudicial outcr"omc. to the pubiic at the police departmcnt' and district ;"";;t^;;;;; foi five referringcounties'Initial i;r;;; ^JJ ;;"it1f.i[.rrl'es from one of the counties patients 30 of sampling ;;;il;4, level' two ;h;;;,1 that only l1 werc ,""tt "t the county court Four were senic".iu..l iail scntcnces,and three rcceived fines' caseswere i".t".a to advanccdrehabilitativedisposition' Four ol 9+y charges justices.dismissed district iocal p."ar"g. riiii including l8' on charges file to pnli""il.partments failed n.r.. who , " " . t r l l " w h i t h o t h e r c h a r g e sw e r e f i l e d ' M a n y . p a t i e n t s lntoxlcateo should theorcticallybe prosecutedfor driving whtle punof ,hor. -hu ,t..ptn"tu.t+,,Tott receiveminimal ;;";;. d e l a y s ' t r l a l j a i l , s i g n i t i c a n t or i s h m e n t ,n o

ll'a

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I

Emergency

I

Department

Treatment

of Alcbhol Abuse: lmPact On Availability of Emergency Services

Yale-New E Newton,A Weihl/ Yale UniversitySchoolof Medicine; HavenHospital.New Haven'Connecticut of aIStudy hypothesis:The emergencydepartmenttreatment availability "ottli jU"t6 results in a substa-nti'iredluctionin the oi .-.tg.tt"y medical resourcesfor other patients'

65


Population: All 302 patients admitted to the Yale-New Flaven Hospital (Y-NHH) ED in May or fune 1989with a primary diagnosis o{ alcohol abuse or withdrawal were included. Methods: Ambulance and ED recordswere reviewed retrosDectively. Data were abstractedregardingtotal ambulanceuse,dlration of ED stretcher occupancy,and direct costs to Y-NHH and third-party payers.The resultant figures are presentedas percehtagesof estimated total resourcesused by all patients. It is assumed that total resourcesused are a reasonableindex of total available resources,given crisis-level ED overcrowding in the Northeast. Results:This patient population accountedfor 15.7T"of all ambulance runs to Y-NHH during the two-month period, approximately I2"/" of total run time, and l0.4Yo of ED stretcher occupancy. The total ED cost over this period was $80,143,including $19,824billed to the city and $5,808to the state. This cost represents approximately 5"/" of total ED costs for all patients. Conclusion: ED treatment of alcohol abusesubstantiallyreduces the availability of pre- and in-hospital emergencyservices. It is thereforeproposedthat state and municipal funds be reallocated from ED care to treatment at detoxification facilities designed to focus on the specific needsof the alcoholic.

J<a -r O I t C,

Factois Associated With Gareer Longevity in Emergency Physicians

KN Hail, MJA Wakeman,RC Levy / Departmentsof Emergency Medicineand Environmental Health,Universitv of Cincinnati MedicalCenter,Cincinnati, O.hio Hypothesis: Emergencyphysicians whp left the practice of emergencymedicine do not differ significantly from those that continue to practice. Population: 858 emergencyphysicians who graduatedfrom emergencymedicine residenciesfrom 1978 through 1982. Methods: A retrospectivecohort study was performed using a mailed questionnaire.Individuals who did not respondto the first mailing were sent a secondsurvey six weeks later. A sample of l0% of nonrespondentswere contactedby telephoneand compared with respondentson five points. No staristical differences were found. The total responserate was 63.5%. Respondents were divided into those physicians who continue to practice emergencymedicine and those who have elected to leave the practice.The variablesused to comparethe two groups included age, gender, marital status, board certification (in emergency medicine and other specialties), type of emergency medicine practice/ geographiclocation, income level, satisfactionwith original careerchoice, and adequacyof training. 12 and Student's t test were used as appropriate. Results: Twelve percent of respondents left the practice of emergency medicine. Those who had left emergencymedicine were more likely to be unmarried lP : .0251,were less likely to be board certified in emergencymedicine (P < .0011,were more likely to be board certified in anorher field (P : .0011,and were more likely to report annual income of less than $100,000per year lP < .001).Emergencyphysicianswho have left the field were less likely to report being satis{ied or very satisfied with their initial choice of emergencymedicine as a specialty (p : .001).There was no differencein satisfactionwith the quality of emergencymedicine residencytraining (P : .183). Conclusion: Career longevity of residency-trainedemergency physiciansappearsto be greaterthan early projectionspredicted. Previoustraining in other specialties,lower income, single marital status,and lack o{ emergencymedicine board certification are variablesthat are associatedwith a hiSher attrition rare.

179

Personality Traits and lleasures of States of Physical, Emotional, and llental Exhaustion in Practicing Emergency Medicine: lmplications for Emergency lledicine Management

RR Huang, B White / Office of Medical EducatronResearchand Development, Collegeof HumanMedicine,MichiganState University,East Lansing;Sectionof EmergencyMedicine,Detroit ReceivingHospitaland University HealthCenter,Detroit,Michigan The purpose o{ this study was two{old. The first was an attempt to determine the personality traits of emergency physicians who practice in a highly stressfulenvironment. The second was to correlate these traits with measuresof physical, emotional, and mental exhaustion.The first purposewas to answer the questions,What tlpe of personality traits do emergencyphysicians tend to have?And how do these personality traits correlate with physical,emotional, and mental exhaustionthat are common outcomes from working in a stressful environment? Providing answersto these questionsmight assistemergencydepartment directors to identify potenrial medical staff who are at high risk of experiencingthese exhaustivestatesthat curtail human performances,not mentioning the quality of medical services provided. Sixty-nine emergencyphysicians from six emergency departmentsparticipatedin the study. They respondedto a well-establishedpersonality inventory, the I6PF, which is developed by the Institute for Personalityand Ability Testing Inc, and an inventory developedby the University of California at Berkeley to measure these exhaustive states. Results showed that emergencyphysicians tend to be reserved,concrete thinkers, realistic, independent,expedient,cautious, insightful, and self-sufficient. Further discriminant analysisshowed that personality types with attributes of being impetuous,venturesome,apprehensive, and tense tend to experiencemore of these exhaustive states.These results will provide the information neededby the managersof this medical specialty to take preventive measures for the benefit of their staff's well-being. These measuresmight be in the form of support/ both emotional or technical. It could also be in the form of "personalities management," the art of blending personalitiesinto other personalitiesand into the work environment.

180

Longitudinal Study of Emergency Physician Wellness: Initial

lmpressions L Zun, E Chen, DM Carrison,MA Cooper,R Cydulka,L DoanWiggins,C Glushak,D Howes,D Meyers,VK Palys,M Salkin,T Sanson,L Turner,A Vertovec,R Zalenski/ lllinoisChapter, AmericanCollegeof EmergencyPhysicians, Des Plaines Study hypothesis:We suspectthat problemsof burnout and impairment are associatedwith shortened practice lifetimes of emergencyphysicians. Population: Group no. I was all 1989graduatesof emergency medicine residencies;group no. 2 was a random sample of 20% of the diplomatesof the American Boardof EmergencyMedicine. Methods: The survey tool was mailed to both groups.Followup letters were sent six weeks later to nonresponders.The data were analyzedstatistically. Results: Fifty-six percent oI the 1,767surveys were returned. Twenty-five percent of the diplomatesreportedfeeling burned out or impaired,comparedwith 7o/oof the recent graduates.Burnout in the diplomatesis associatedwith prematureattrition, dissatisfactionwith emergcncymedicine, use of medication, social problems,psychiatrictreatment or counseling,and the belief that cmergencymedicine contributed to their problems (P < .05). Twenty-four percentof the diplomatesand 4% of the recent graduatesplan to stop practicing emergencymedicine in the next five years.Anticipated prematureattrition in the diplomatesis significantly associatedwith working in smaller-volumedepartments, s e e i n ga h i g h e r n u m e r o f H M O / P P O p a t i e n t s ,n o t t e a c h i n g housestaff,working fewer hours in emergencymedicine, working more weekends,dissatisfactionwith compensation,and burnout (P < .0s). Conclusion: This study suggestssome disturbing trends and indicatesareasfor further researchto improve the practiceenvironment of emergencyphysicians.

66


EXHIBITORS Abbott Diagnostics AbbottPark AbbottPark, IL M AbbottDiagnosticsis thelargestdiagnosticcompany ,ltff';:?;:i^? provideabuseddrue testingreagentsand initrumentation,STAT chemistry instrumentition, anaViriud f"rt3u"ki.J;fo. sref ,rrun". AdvancedTechnolog5rLaboratories 22100BothellHishwavSE Bothell,wA 98041-3003 Gn) 5:l5_g458 Manufacturer of diagnosticultrasoundimagingequipmentfbr echocar_ diographic imaginglwall motionanalysii ftil;l partsimaging. Annalsof EmergencyMedicine P.O.Box6199ll Dallas,TX 75261-9911 et4) 55}_0gll Anwls is theofficial iournal of the American Collegeof Emergency Ph_ysicians and the 3ociery for e""J"-i"'S--'"Gncy Medicine. EditorialBoardmemberswill be on t anJ t il;;; your questions aboutthejournaland editorialpolicies. Arrow International. Inc. Hill andGeorgeAvenues Reading, PA 19610 (800)233_3187 ArrowInternational featuresa completeline of anesthesia, critical care andcardiovascular kits and.componentsfe";ring ;;r multi_lumen catheter systemwith the uniqueirrow sufety,yrfirge.rM In addition features a completeline of trauma/EDproducts,,i"t ui fugh flow blood Iine, large bore multi-lumen catheters*J p*u_otf,orax and thorocentesis devices. BieMedicus.Inc. 9600West76thStreet EdenPrairie,MN 553,14

Bio-Medicus products areused forprocedur", .*un":u#J;frI# perfu.sion

andlong-termsupport.The complejryrt.'rn "on.irt, of u centrifugal Bio-pump,a Bio-console,un "ni"rg.niy t _dcrank anda flowprobe. BurroughsWellcomeCo. 3030CornwallisRoad Research Trianglepark, NC 27709

(9r9) 248-3ON CaliforniaMedical hoducts. Inc. l90l ObispoAvenue LongBeach,CA 90804 c.arlrornia Medicalproductswill displaythe St*reck ?:l#I::t: vicalimmobilization device(adultand"'hil ;;;;;;v_Vacru hand_ powered suctiondevice(doesn'trequirebatterieqi, fight rigfrt, ""r_ pact,costeffectiveandrequires.noilean_up;, til il;i"p Boardrufor CPR,andthe StifneckrMextrication child sizes, :"[# 6d,;d radiolucent, andprovideseffectiveimmobilization JthJcervical spine). CalgonVestatLaboratories P.O.Box 147 St.Louis,MO 63166

calgon vestat Laboratories wiuexhibititsrineor*ouSo3jl11H

productsandhigh risk skin care.

CherneMedical, Inc. 5710LincolnDrive Edina,MN 55436 TheChernesystemis the first diagnosticinstrument ,|l'fl'.'#:: *To.ry arrerydiseasewhich utlizes ;;ha;,;;;;;_;near :f dynamics to analyzesurfaceelectrocardiographicsignats.' CoastalEmergencyServices, Inc. 2E28Croasdaile Drive P.O.Box15697 Durham, NC 277U (919)383-5055

Coastal Emergency Services, Inc. is the leader in emergency depan_ ment management with,subsidiary corporations locatel near ciient trgslitlls, strong and stable manage-"nt t"*, providing responsive physician recruitment and schedjing, ,i*t.*ug"*ent and quality assuranceconsultation, competitive martetrng assrstance,and a varietv of financial arrangementsto meet y"u. tt"-ptyri;;;;;;r:-'"'t Cook Critical Care. A Division of Cook Incorporated P.O. Box 489 Bloomingron, IN 47402 Gl2) 339-2235 Cook Critical Care will be exhibiting products for Emergency Medi_ cine, inclurling Disposable tntraosseo:usInfuriN""Ot"r, Melker Em_ ergency Cricothyrotomy Catheter Set, pneumothorax Sets, High Volume Infusion Sheath Sets, fafrf_euicf<-Chest Tube Sets, and Peritoneal Lavage Sets. Daniel Stern and Associates The Medical Center East, Suite 240 2ll North Whitfield Street Pittsburgh, pA 15206 GW) 438_2476 Daniel Stern and Associatesproviclesplacement/recruitment billing consulting and medical staff Oevetopmeni/anaysis services, nationwide. our Emergency Medicine Division f,u, ,ui."rrtify ;*Jh;;;t"l;: physicians and physician groups for "*.2dt;;; pleasestop by our booth to review our servicesind availabletppo.tunitier. Emergency Medicine Residents' Association P.O. Box 6199ll Dallas, TX 7526t-99fi (Zt4) 550_OgtI The Emergency Medicine Resrrtents'Association (EMRA) represents over 1,600 "T"rg,"n"y,medicine residents unO rn.ai.ut students to organizations involved i

research.rheBoard,r#H:lS:[r,."TX''.:'ffi #t::f",.lffjldil

SAEM,.ResidencyReviewCornrnitteeanJanifri. fUna leaderswill be availableto answerquestions.

Epic Systems,Inc, P.O. Box 442 LaGrange,IL (fi525 (7O8) 482_3091 TelemetryCommunications equipmentfor the EmetgencyDepartrnent andtheParamedic. CellularandUHF RadioCon.-J", unafield units. y:,_1tf-., 8 MED Frequencies,fZ feaJ, simJonl"u, runs, custom cesrgns. Fenem. Inc. 84 Williams St., Suite 1607 New York, Ny 10038 et2) 248_0220 The FEFrMEnd-Tidal C0, Detector is a disposablecolorimetric devicewhichmeasures rangisof exhaledc0r;;:;;_b_breath for up to 2 hours. It shouldbe usedto veriff pr;;;#;;cheal ----"" intubation and to safelytransportan intubatedpitiJnt. Fujisawa Pharmaceutical Company .401 City Avenue,Suite300 Bala Cynwyd, pA 19004 et5) 668_5170 FujisawaPharmaceutical C^o.mpany will haverepresentatives available to discussCEFIZOXo (ceftizoximel,",hirJg;;";;;, cephalosporin. Glaxo Inc. Glaxo Pharmaceuticals/Allen Hansbury Five Moore Drive P.O. Box 13438 ResearchTriangle park, NC 27709 eD-{/)24g_2l([ The Glaxo Inc. booth will_be hostedby both divisions: Glaxo phar_ maceuticalsandAllen andHansbury.O", f."* *lfft to updateyou on the continuingeducationprogramsavailable for critical care and medicinepersonnel.The latestinformation ;e,T:rgen:y on our respec_ tlve product lines will also be displayed.


Hartwell Medical CorP. 1857DiamondStreet SanMarcos.CA 92069

line of portable the mostcomprehensive Nonin Medicalmanufacturers in relationto unsurpassed are oximeters Nonin's oximetersavailable. smallsize,light weight, easeto use,batterylife, andlow-costreusable sensorsfor neonatesto adults. Nonin oximetersare excellentfor use in the ED, ambulance,or aeromedicaltransport.

(619)47r-UN

Hybritech Incorporated P.O. Box 269006 (619\53s-8462 SanDiego, CA 92126 companythat develops,manufacturers, Hybritechis a research-based andmarketsTANDEMo diagnosticassaysbasedon monoclonalantibody technology. We will be demonstratingthe ICONo QSRo System.The PHoToN@ crrr,is Assayaii the ICoN QSR/Reader tr andPHOTONErao for datareductionandautomationof testresults will alsobe demonstrated.

Paddock Laboratories Inc. 3101 LouisianaAvenueN P.O.Box27286 (612)s464676 Minneapolis,MN 55427-9975 (charcoal,activated)and actidose/actidose-aqua Paddockmanufactures glutose(glucose)and ipecacsyrup,usp for poisoningemergencies, glutoseunit dosefor insulin reactions.

Kurzweil AI 411 WaverleyOaksRoad (617)893-5151 Waltham.MA 02154 Physicianto Medicine Emergency the allows VoiceEM Kurzweil generatelegible reports simply by speaking- without handwriting or costly transcription. Words and phrasesappearon the computer screenastheyare spoken.Typed,legiblereportscanimmediatelybe printedwith a simplevoice command.

Physic'Control Corporation 11811WillowsRoad,NE Redmond.WA 98052

Laerdd Medical CorP. P.O. Box 190 (9r4) 273-94U Armonk. NY 10504 HeartHeartstartrMSemi-Automaticand AutomaticDefibrillators; Training System, startrM

(518)638-6101 Argyle, NY 12809-9684 (ETC): DoubleSheridan'sEsophagealTrachealCOMBITUBETM lumenairway. Ventilationcanbe achievedwhenCombitubeis in either Blind insertionwithout laryngoscope. the tracheaor the esophagus. balloonprovidesuppersealing,anchoringETC strongly Pharyngeal behindhard palate.

Sheridan Catheter CorP. Route 40

Logicare Corporation 1223MenomonieStreet (715)839-0700 EauClaire.WI 54703 Productivityand LogicareCorporationdevelopsRisk Management, Quality Assurancesoftwarefor EmergencyPhysiciansand Nurses. *e arl the developersof the industryleadingCHECKOUT Patient of your DepartInstructionSystem.Look to us alsofor replacement mentRegister,PrescriptionWriting, help with QualityAssuranceor with any departmentinformation needs. Matrix Medical Inc. 145 Mid CountyDrive OrchardPark, NY 14127

Smith Kline Beecham-UpjohnCompany 17609LorenceWay (612)949-252r EdenPrairie, MN 55346 Companyis providinginformation The SmithKline Beecham-Upjohn on thenewthrombolyticagentEminase(APSAC).Pleasestopby and speakwith the rePresentatives. Synergon P.O.Box27352 (3t4) 469-5324 St. Louis,MO 63141 CareStaffing Emergency in Academic,Pediatric,Tertiary Specialists and Management.

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MBB Helicopter CorP. P.O. Box 2349 900 Airport Road (2r5)43r-4rs0 West Chester,PA 19380 Aeromedical and BO105 BK1l7 MBB is the manufacturerof the Helicopters,which rank numberoneandtwo asthe mostpopulartwin enginehelicoptersin EMS use.

Weatherby Health Care 25 Van Zant Street (203)866-ll,l4 Norwalk, CT 06855 WeatherbyHealthCareis a prominentphysicianrecruitingfirm with particularemphasisin emergencymedicine.Visit our boothto exPlore excitingpracticeopportunities. Wilderness Medical Society P.O. Box 397

MICROMEDEX.Inc. 600 Grant Street (303)831-1400 Denver. CO 80203-3527 professionals ; evaluated, Clinical informationsystemsfor healthcare referencedsourceof informationon toxicology(clinicalandindustrial)' drug therapyand emergencymedicine; also availableare patient instruitions, dosingprograms,andmartindale:the extrapharmacopoeia' Deliveryon CD-ROM for usewith personalcomputers,computertapes for mainframes,and microfiche.

Point Reyes Station, CA 94956

(4r5) 663-9107

in the Informationon the goals,activitiesandbenefitsof membership WildernessMedical Society. Wyeth-Ayerst Laboratories P.O. Box 8299 (2rs)97r-561r PA 19101-1245 Philadelphia, Pleasevisit theWyeth-AyerstLaboratoriesexhibitandour representativeswill be happyto discussTubex, Ativan Injectionand other Wyeth-Ayerstproductsand servicesof interestto you.

Miles Inc., Pharmaceutical Division 400 Morgan Lane WestHaven,CT 06516 The displayhighlightsMiles' revolutionarynew antimicrobialCipro (ciproflbxacin) and their new calcium channel blocker Nimotop (nlmodipine).Also coveredare Mezlin, Azlin, andMycelexTroche' Nonin Medical, Inc. 12900Highway 55 Plymouth,MN 55441

(206\ 8674538

Exhibit will include defibrillators, external pacing, ECG and blood pressure monitors for both the hospital and pre-hospital emergency care setting.

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Q: What's the differencebetweena woundirrigation anda wet T-shirt contest?A: The Zerowet Splashshield.This remarkablenew device will redefine your conceptof protection during wound irrigation'

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68


ANNUAL BUSINBSSMEETING AGENDA $. Amendment to the Constitution and Bylaws, lViUiam Spivey, MD, Chairman, Constitution and Bylaws Committee The proposedamendment to the Constitution and Bylaws would establish an Executive Committee to oversee the day-to-day operationsof the Society. The proposed amendmentand the entire Constitution and Bylaws are included in this program. The establishment of the Executive Committee would require the addition of two sections. They are: Article fV, Section 3 of the Constitution: The Executive Committee shall consist of the President, President-elect, Past-President and Secretary-Treasurer. Article II, Section 15 of the Bylaws: Duties of the Executive Committee: The Executive Committee shall conduct the business of the Board of Directors and act in lieu of the Board on routine issues. All actions by the Executive Committee are subject to reviewand approval by the full Board of Directors at their next meeting. 2. Elections, Jerris Hedges, MD, Chairman, Nominating Committee The slateof nominees is listed below and photos and biographical information on each candidate are included in this program.

- (one l-year position) .i President-Elect William G. Barsan. MD

Boardof Directors - (two 2-yearpositions) PaulS. Auerbach,MD LouisS. Binder, MD GlennC. Hamilton,MD GaborD. Kelen, MD GloriaJ. Kuhn, DO JamesJ. Mathews.MD . EducationCommittee Chairman - (one 3-year position) DavidP. Sklar, MD t-. GaryR. Strange,MD

ResearchCommittee Chairman - (one 3-yearterm to begin May 1991:Chair-Electterm to begin 1990) John P. Heggers,PhD Hugh S. Mickel, MD JamesE. Olson, PhD NominatingCommitteeMembers- (one2-yearposition) Arthur L. Kellermann,MD Harlan A. Stueven,MD SuzanneM. Shepherd,MD Constitution and Bylaws Committee Member 3-yearposition) Philip L. Henneman,MD Paul E. Pepe,MD SandraM. Schneider.MD RobertJ. Wilder, MD

(one

CommitteeReports Secretary-Treasurer's Report, Louis Ling, MD, Secretary-Treasurer A.Membership at May 4, 1990:1565 l, ,.

Active Members: 937 InternationalMembers: 56

Associate Members: 190 Emeritus Members: 14

ResidentMembers:316 HonoraryMembers:12

Pending: 40

B. FinanceReport- Year EndingDecember31, L989 Revenues Dues. . .$217,7t7 AnnualMeeting . .$41,951 Symposium .,....$10,124 EMFcontributions.. .....$7,800 Interest. ...$23,796 S T E Ma s s e t s .....$37,249 Saleof Mailing List andnewsletter ads.. ....$4,365 Other. .....$2,216 EMRAnewsletter . .$3,600

Expenses Salaries, Wages,Taxes. ...$103,799 AnnualMeeting .,...$84,869 Symposium ...$15,659 Telephone andPostage. .....$34,528 OtherAdministration .$26,531x AAMC .$14,139x*' AnnalsSubscriptions .$13,775 publication Newsletter ......$13,410 EMF . ..$9.000 STEM ..$4.758 Otherorganizations . .$10,736*t<x TOTAL ..$348,818 TOTAL .....$331.204 *includes office supplies,photocopying,printing,office rentandinsurance,accounting,bankcharges,president'sdiscretionary fund,long rangeplanning. **includes Councilof AcademicSocietiesdues,AAMC representative expenses, staffexpenses to attendAAMC AnnualMeeting, andSAEM sponsoredposterat the AAMC Annual Meeting. EMRA, ACEP ScientificAssembly,AMA, AAMI, EMRS and AMA Committeeon EMS. of Honorary Memberships: Ronald Bellamy, MD, and D. Kay Clawson, l,fD, Arthur B. Sanders, MD

's Address:Arthur B. Sanders.MD of New President:Jerris R. Hedges,MD Business


SLATE OF NOMINEES committee. and is the associate editor for education for of the Academic Emergency Medicine. He was the chairman "Model CurUndergraduate committee that completed the riculum in Emergency Medicine for Undergraduateand Rotating '' Residents, served as chairman on the Ad Hoc Task Force on RegionalResearchSymposis,servedon the Ad Hoc Task Force on the IRIEM symposium, and presentedat SAEM's AAMC presentationon Ambulatory Care Education in 1989. He has beena member of UA/EM since 1982and is currently a SAEM member. Dr. Binder served on the Public Relations Committee (1986-97),the ScientificConsensusCommittee(1986-87)' the Membership Committee (1986-87), the EducationCommittee (1988-present),and was a moderator ofboth a panel discussion and scientific session at the 1989 Annual Meeting. Dr. Binder graduated from the University of Minnesota Medical School in 1980, and completed an Emergency Medicine Residencyin 1983at Truman Medical Center. Since 1987, he has been an examiner for the American Board of Emergency Medicine and a reviewer for Annals of Emergency Medicine and the American Journal of Emergency Medicine.

PRESIDENT.ELECT William G. Barsan, MD, is an associate professor at the Department of Emergency Medicine at the University of Cincinnati. Dr. Barsan has beena member of UAiEM since 1980 and was a member of the ExecutiveCouncil from 1985to 1988. He is currently a member-at-largeon the Board of Directors of SAEM (1988-1990). Dr. Barsan was a member of the STEM Program Committee from 1982-84 and served as chairmanin 1983-84.He served on the UA/EM Program Committee from 1982-85 and on the UA/EM Program Committee from 1982-85 and on the Constitution and Bylaws Committee from 1981-84. He was Program Chairman of the 1988 UA/EMIRIEM Research Symposium on Emergency Thrombolytic Therapies.He has been a moderatorat the 1983, 1984, 1985 and 1987 Annual Meetings. He is a member of the Ameican Journal of EmergencyMedicine editorial board and a reviewer for the Journal of Emergency Medicine and the Annals of Emergency Medicine, and has been an examiner for ABEM since 1983. Dr. Barsan graduated from Ohio State University College of Medicine in 1975 and completed an Emergency Medicine residency in 1979 at the University of Cincinnati.

Glenn C. Hamilton, MD, is professor and chair of the DePartment of Emergency Medicine at Wright StateUniversity School of Medicine. He is currently on sabbaticalat the Sloan Program at Stanford University Graduate School of Business, which he will complete in June. He is a member of the SAEM Board of Directors (1988-1990)and chairsthe AAMC Liaison Committee. He has beena memberof SAEM since 1980 and is a member of the Board of Directors of the Associationof Academic Chairman in EmergencyMedicine' Dr. Hamilton served on the STEM Board of Directors and was president of that organization in 1984-85. He is a member of the Administrative Board of the Council of Academic Societiesof the AAMC. He was an ad hod reviewer of abstractsfor the 1987 and 1988 Annual Meetings and a moderator at the 1984 Annual Meeting. Dr. Hamilton graduated from the University of Michigan Medical School in 1973 and completed his emergency medicine residency at Denver General/St. Anthony's Medical Center in 1979.

BOARD OF DIRECTORS Paul S. Auerbach, MD, MS' is an associateprofessor of surgery and medicine and chief of the division of emergency medicine, Vanderbilt University and is currentlY the Chairman of the 1989-90 SAEM Program Committee. Dr. Aueftach is a member of the Annals of Emergency Medicine editorial board and is co-editor of the Journal of WildernessMedicine. He has been a member of UA/EM-SAEM since MD,MS 1982. He was the Program Chair of PaulS.Auerbach, Rethe 1987 UA/EM-IRIEM search Symposium on Environmental Emergencies. Dr., Auerbach graduated from Duke University School of Medi of Medicine in 1977 and in 1980 completed his Emergency Medicine residency at UCLA. He received his Master of Sciencesin Management degree from the Stanford University Graduate School of Business in 1989.

Louis S. Binder, MD

Louis S. Binder, MD, is an assistant professorand director ofeducation in the Department of Emergency Medicine at the Texas Tech University Health Science Center at El Paso. He is also the Assistant Dean for Graduate Medical Education and StudentAffairs and the Transitional Year Residency Director at that institution. He is currently chairman of the Undergraduate Educational Consulting Service, is chairmanelect of the Constitution and Bylaws

Gabor D. Kelen, MD

70

Gabor D. Kelen, MD' is a former president of STEM and served on the STEM/UAEM amalgamation task force. He has also served on the SAEM Board of Directors since its inception in 1988. Previouslyhe had been the STEM Letter editor from 1985 to 1988 and was a memberof its Faculty Development Committee and chaired the Nominations Committee. He moderated several STEM/UA/EM panel discussions and was among the featured Pre-


in ttreSAEM State-of-theArt Sessionin 1989' Dr' Kelen senters hasbeena member of STEM/UAEM/SAEM since 1984' He is on the Editorial Board of the Ameican Journql of EmergencyMedicineand is a consulting reviewer fot Annals of EmergencyMedicine.Dr. Kelen is an assistantprofessor of Emergency Mrdi"in. at JohnsHopkins University. He graduatedfrom the Universityof Toronto in 1979. He completed his residency in Emergeniy Medicine at the Johns Hopkins University'

Gloria J. Kuhn, DO, is an associate professor, DePartment of Internal Medicine, Section of EmergencY Medicine, Michigan StateUniversity College of Human Medicine, and an associateprofessor, Departmentof Internal Medicine, Sectionof Emergency Medicine, Michigan State University College of Osteopathic Medicine. She was a member of UA/EM since 1980, a member of STEM, and is currentlY a member Gloria J. Kuhn, DO of SAEM. She was the editor of Volumes IV and V of the EducationalResourcesCompendiumin 1986for STEM. She is currently a SAEM representativeto the Core Coptent Task Force' Slnce tggZ Dr. Kuhn has been an oral examiner for the AmericanBoard of Emergency Medicine. Dr. Kuhn graduated from the ChicagoCollege of OsteopathicMedicine in 1970and completedher iesidency in 1979at the Wayne StateUniversity Affiliated Hospitals.

James J. Mathews, IV, MD' is an associate professor of Clinical Medicine, Departmentof Medicine, Northwestern UniversitY Medical School. He graduated from the University of Iowa in 1970and completed his residencY in Internal Medicine at NorthwesternMemorial Hospital in1973. Dr. Mathewswas a member of the STEM Finance Committee (1982-87) and was STEM Secretary-Treasurer(1983-86). He James J. Mathvn,IV' NID was also ttre 1981winner of the Third Annud STEM Silver Tongue Orator Award.Since 1987 Dr. Mathews has been a reviewer for the American Journal of Emergency Medicine; since 1985 a reviewer for Annals of Emergency Medicine; and since 1984 hasbeen a member of the editorial board of the Journal of EmergencyMedicine. Dr. Mathews was a member of UA/EM and STEM and is currently a member of SAEM.

EDUCATION COMMITTEE CHAIRMAN David P. Sklar, MD, is the Associate Director, Division of EmergencyMedicine, and Associate Professor, DePartment of FamilY, Community and EmergencY Medicine, DePartment of Internal Medicine, UniversitY of New Mexico. He is currently a member of the SAEM Education Committee, and was a reviewer of the 1989 EMFSAEM MethodologY Grants this year, and was a Presenter at the David P. Sklar, MD SAEM plenary sessionat the 1989 AAMC Annual Meeting. He has also been an oral board examiner for the American Board of Emergency Medicine since 1989 and a consultattto Annals of EmergencyMedicine since 1988' Dr. Sklar is a 1976graduate of Stanford University Medical School and completed his Internal Medicine residency in 1978 from the University of New Mexico, followed by an emergency medicine fellowship (1978-80)at the University of California, San Francisco' Dr' Sklar has been a member of UA/EM and STEM and is currently a member of SAEM. Gary R. Strange, MD, graduated from the University of KentuckY in 1974 and completed a residencYin Emergency Medicine at the Los Angeles County/UniversitY of SouthernCalifornia Medical Center in 1979. He has been a member of UA/EM since 1982 and a member of STEM and is currentlY a member of SAEM. He is currentlYthe SAEM Education Committee chairman and was appointed to this Position Gary R. Strange' MD for a one year term when the Position became vacant in 1989. Dr. of the STEM Educational Resources was thechairman Strange to the Committee(1982-86)and was the STEM Representative AAMC-CAS. He is also a member of the editorialboardof Annals of Emergency Medicine, an editorial board member and fbr pediatrics for the American Journal of Emer' guest;ditor -gency Medicine, and has been an oral board examiner since iggZ. Or. Strangeis AssociateDirector of EmergencyMedicine at Mercy Hospital and Medical Center, Director of the University of IilinoiJ,q,fntated Hospitals Emergency Medicine Residency, and AssistantProfessorof Clinical EmergencyMedicine at the University of Illinois.

RESEARCH COMMITTEE CHAIRMAN

John P. Hegers' PhD

John P. Heggers, PhD' is a Professor of Surgery/Microbiology and director of Clinical Microbiology at Shriners Burns Institute in Galveston, Texas. He is currentlY a member of the ResearchCommittee and has worked on a Position statement on animal research in emergencY medicine and an editorial on research in emergency medicine. He is also a manuscriptreviewer for the Journal of Wilderness and the


NOMINATING COMMITTEE

Journal of Surgical Research. Dr. Heggers received his Bachelors degree in bacteriology from Montana State University in 1958, his Masters on Microbiology from University of Maryland in 1965, and his PhD on Bacteriology and Public Health from Washington State University in 1972. He joined UA/EM in 1986 and is currently a member of SAEM.

Arthur L. Kellermann, MD, MPH, graduated from Emory University School of Medicine in 1980. completedhis residencyin 1983,and completed his mastersof public health in 1985 at the University of Washington followed by a General Internal Medicine fellowship (1983-85) at the University of Washington. He joined UA/EM in 1986 and is currently a member of SAEM. Dr. Kellermann was the recipient of the James Arthur L. Kellermann Mackenzie award at the 1987 Annual MD, MPH Meeting. He is a reviewer for the New Ensland Journal of Medicine, Arurals of Emergency Medicine, and the American Joumal of EmergencyMedicine. Dr. Kellermann was a panel member at the 1988 UA/EM Annual Meeting. He is currently an Assistant Professor in the Department of Internal Medicine; Chief, Division of Emergency Medicine; and Assistant Professor, Departrnent of Preventive Medicine, at the University of Tennessee.

Hubert S. Mickel, MD, is a clinical associateprofessor at the Uniformed Services University for the Health Sciences,Bethesda,MD, and a faculty member at Washington University and Georgetown University. He is ResearchDirector of the Emergency Deparfinent, Barnes Hospital, St. I-ouis, and a visiting scientist in the hboratory of Biochemisty (LB), National Heart, Lung and Blood Institute OIHLBD, as well as in the laboratory of Experimental Neuropathology (LENP), National Institute of Neurological Disordersand Sroke (NINDS), National hstitutes of Health (NIH). He was a member of UA/EM since 1979 and a member of STEM since 1982 and is currently a member of the Research Commiuee.As a memberof the ResearchCommitteehe hasworked on an ditorial on researchin emergencymedicine and a listing of research priorities in emergency medicine. He is a guest reviewer for the Ameican Joumal of Emergency Medicine and has been an oral examiner for ABEM since 1986. He graduated from Harvard Medical School, interned at the University of Vermont, had a fust-year residency in internal medicine at the Royal Victoria Hospital, Montreal, and servedaresidency in neurolory at the Boston City Hospital.

Harlan A. Stueven, MD, is an associateprofessorand vice chairman of emergencymedicineat the Medical College of Wisconsin. He had been a member of UA/EM since 1981, a memberof STEM since 1983. and is currently a member of SAEM. Dr. Stueven is a member of the editorial board of Resracitation,a reviewer for hmals of Emergmcy Medicine, and an oral examiner for the American Board of Emergency Medicine. He was the recipient of the 1985 UA/EM Best Clinioal Science Paper Award. He had also been a moderator at the 1986 and 1988 UA/EM Annual Meetings and was a member of the UA/EM ad hoc Membership Committee in 1986. A 1977 graduatefrom the University of Minnesota School of Medicine, Dr. Stueven then servedin ttre Air Force (1978-81),before completingan Emergency Medicine ResidencyProgramat the Mdical Collegeof Wisconsin in 1983.

James E. Olson, PN), graduated from Cornell University in 1972 with a Bachelor of Sciencein Engineering Physics and obtained his PhD degree in Biophysics from the University of California at Berkeley. He then completed three years of postdoctoral training at Stanford University Medical Center in the Deparfrnentof Neurology ard sayed on an additional year as a ResearchAssociate. Since 1986he hasbeenat Wright StateUniJamesE. Olson, PhI) versity School of medicine where he holds faculty appointments in Emergency Medicine (Associate Professor) and Physiology and Biophysics (Assistant Profesor). Dr. Olson joined UA/EM in 1987 and is currently a member of SAEM. He has served on the ResearchCommittee since 1988, and has worked on reviewing the EMF-SAEM Mdical Student Grants, selecting research methodology topics for future Annual Meetings, and an editorial on research in emergency medicine.

Suzanne M. Shepherd, MD, graduated from Georgetown University School of Medicine in 1980 and completed her Emergency Medicine Residency in 1983 at the Georgetown/George Washington University. She has been a member of STEM/UAEM/SAEM since 1984 and was a member of the STEM Educational Resources Committee. the Goals and Objectives Committee, and was Subcommittee Chair of the Undergraduate Curriculum Committee. Sheis currently a member of the SAEM Education Committee and the Undergraduate Educational Consulting Service. Dr. Shepherd has been a reviewer for the American Journal of Emergency Medicine, since 1989 and an oral board examiner for the American Board

72


of Emergency Medicine since 1989. Dr. Shepherd is an associateprofessorat Georgetown Universify Department of EmergencyMedicine.

CONSTITUTIONAND BYLAWS COMMITTEE Philip L. Henneman, MD, is an adjunct assistantprofessorof Medicine at UCLA. Dr. Hennemanhas been a moderator at the 1988 and 1989 Annual Meetings. He was a winner of the 1988 Best Oral Methodology Award. Dr. Hennemanis currently a member of SAEM and has also been a member of UA/EM since 1986. He is currently a member of the SAEM ResearchCommittee and the Membership and Public EducaHtilipt. Henneman, MD tion Committee. Dr. Hennemanis a reviewer for Annals of Emergency Medicineand the Journal of EmergencyMedicine and is also an examinerfor the American Board of Emergency Medicine. In 1980he graduatedfrom Harvard Medical Schooland in 1984 completedhis residencyat Presbyterian-St.Luke's Hospital in Denver.

dr&

Paul E. Pepe, MD, is an associate professor of medicine and surgery at Baylor College of Medicine and Director of the Houston emergency medical services system. He is the director of resuscitation and emergency medical servicesresearchand training and he directly overseeesall related post-graduate and undergraduate training programs for the medical school. Dr. Pepe was a memberof UA/EM since 1983 and is currently a member of SAEM. He has representedSAEM on the AMA Commissionon EMS for the last five years and has been a memberof the EMS EducatorsCommittee the last two. He has servedasmoderatorat the 1987Annual Meeting and was Master of Ceremoniesat the 1989 Annual Banquet. In 1976 he graduatedfrom the University of California School of Medicine, completedan internal medicine residency at the University of Washington,Seattle, in 1979 and then several clinical and researchfellowships in pulmonary-critical care, trauma, and surgicalcritical care. Sandra M. Schneider, MD, is an Associate Professor of Medicine at the University of Pittsburgh. Dr. Schneider was a member of UA/EM since 1984 and was a member of STEM and is currently a member of SAEM. She was also a moderatorat the 1987 Annual Meeting and was the recipient of the 1988 Annual Meeting Best Oral Basic Science Paper Award. Dr. Schneiderwas a memberof the UA/EM Technology Committee and of the STEM Cur-

riculum Committee. She is also a member of the editorial oard of Journal of Prehospital and Disaster Medicine. Dr. Schneider is a 1975 graduate of University of Pittsburgh and completed her residency in 1978 at the PresbyterianUniversity Hospital.

Robert J. Wilder, MD, is a professor of Clinical Surgery at the University of Miami and associate director of the emergency care center at the University of Miami/Jackson Memorial Medical Center. He was a consulting reviewer for Annals of Emergency Medicine (1983-87)and since 1984 has been a consulting reviewer for the American Journal of Emergency Medicine. Dr. Wilder was a memRobertJ. Wilder, MD ber of STEM, a member of UA/EM since 1978, and is currently a member of SAEM. He graduated from Columbia University College ofPhysicians and Surgeonsin 1952and then beganhis surgery internship at PresbyterianHospital, Columbus Medical Center (1952-53); starting his residency at Mt. Sinai Hospital, New York (1953-56),and completingat Baltimore City Hospital in 1958. He also completeda one year fellowship (1954-55) with the New York Heart Association.


CONSTITUTION OF THE SOCIETY FOR ACADEMIC EMERGENCY MEDICINE ARTICLE I _ NAME "The Society for The name of this organization shall be, Academic Emergency Medicine," hereinafter referred to as, "The Association."

ARTICLE II _ OBJECTIVES Section1; The objective of this Association is to improve the emergency,urgent, or critical care ofthe acutely ill or injured patient by promoting research, by educating health care professionalsand the public, by fostering relationshipswith organizations with a similar purpose, and by supporting the specialized or multidiscipline care of such patients through research and education.The Association will function as a scientific and educationalorganization as defined in Section 501(c) (3) ofthe Internal Revenue Code, as amended. Section 2: The Association shall pursue its purpose by: l) sponsoringforums for the presentationof peer-reviewedscientific and educationalinvestigations, 2) convening and sponsoring educationalprograms for health care professionalsand the lay public, 3) promoting academicdevelopmentand education of its membershipthrough specializedprograms, 4) serving as an academic,university-based,and/or teaching hospital representative for the care of the acutely ill or injured patient, 5) developing liaison with other organizationswith a similar purpose, and 6) publishing research and educational data in the scientific and educational literature and other media available to the lay public. Section 3; A. This corporation is organized exclusively for educational and scientific purposes, including, for such purposes,the making of distributions to organizationsthat qualify as exempt organizationsunder Section 501(c) (3) of the Internal RevenueCode of 1954 (or the corresponding provision of any future United States Internal Revenue Law). B. No part of the net earnings of the corporation shall inure to the benefit of, or be distributable to its members, Directors, Officers or other private persons, except that the corporation shall be authorized and empoweredto pay reasonablecompensation for services rendered and to make payments and distributions in furtherance of the purposes set forth in paragraph A hereof. No substantialpart of the activities of the corporation' shall be the carrying on of propaganda,or otherwise attempting to influence legislation, and the corporation shall not participate in, or intervene in (including the publishing or distribution of statements)any political campaign on behalf of any candidate for public office. Notwithstanding any other provision of these articles, the corporation shall not carry on any other activities not permitted to be carried on (a) by a corporation exempt from Federal lncome tax under Section 501 (c) (3) of the Internal RevenueCode of 1954 (or corresponding provision of any future United State RevenueLaw) or (b) by a corporation, contributions to which are deductible under Section 170(c) (2) of the Internal RevenueCode of 1954 (or the correspondingprovision of any future United State Internal Revenue Law).

ARTICLE III _ MEMBERSHIP Section l: Classifications. There shall be seven classesof membership: active, associate,emeritus, resident/fellow, honorarv. and international active and international associate.

Section 2: Qualifications. (1) Candidates for active membership shall be individuals with an advanceddegree (MD, PhD, DO, PharmD, DSc, or equivalent) who hold a medical school or university faculty appointmentand who actively participate in acute, emergency, or critical care in an administrative, teaching, or research capacity, (b) individuals with similar degreesin active military service (U.S. or abroad) who actively participate in acute, emergency, or critical care in an administrative, teaching, or research capacity. (c) Individuals who otherwise meet qualifications for active membership as defined above but who do not hold a university faculty appointmentmay petition the Membership Committee for consideration for active membership status, if desired. (2) Candidatesfor associatemembershipshall be health professionals, educators,governmentofficials, membersof lay or civic groups, or members of the public at large who may have an interest or desire to participate in pursuing the purposesand objectives of the Association. (3) Candidatesfor emeritus membership shall be (a) active memberswho seeksuch statusand who have given 15 continuousyearsofactive serviceto the Associationand have attained the age of 65 years @) other active members who under special circumstancesare invited for such emeritus status by the Membership Committee. (4) Candidatesfor resident/fellow membership must be resident(s)or fellows in residency training program(s) who have an interest in emergency medicine. (5) Candidatesfor honorary membership shall be individuals who have made outstanding research or educational contributions to the purpose and objectives of the Association. (6) Candidatesfor internationalmembershipshall be individuals who resideoutsidethe U.S. and who meet qualifications for active or associatemembership as described above. Such candidatesmay apply for active, associate,or other membership in the Association. Section 3: Member Rightsand Privileges. All membersmay have the privilege of the floor and of serving on the committees of the Association. All members of the Association may serve on the Board of Directors or as a committee Chairperson. Only active members shall have voting rights and shall serve as officers of the Association. Section 4; The Association shall not discriminate, with respect to its membership, on the basis of race, sex, creed, religion or national origin.

ARTICLE IV _ OFFICERS Section1: The officers of this organizationshall be the President, Vice-President, and Secretary-Treasurer. Section 2: Board of Directors shall serve as the governing body of the asociation. The Board of Directors shall consist of the above officers, the Program Committee Chairman, the immediatepastpresident,and f,tveCouncilmen-at-I-arge.Both active and associatemembers may serve on the Board of Directors, but only active members may be officers of the Association.

ARTICLE V _ COMMITTEES The standing committees of the Association shall be: (l) Nominating Committee, (2) Membership Committee, (3) Program


Committer,(4) Constitutionand Bylaws Committee, (5) Education Committee,(6) ResearchCommittee, (7) Liaison Committee to the Association of American Medical Colleges, (8) GovernmentalAffairs Committee, and (9) Committee on InternationalAffairs. Additional committees may be created by theBoardof Directors and ad hoc committees may be created by the Presidentto aid in the Association's efforts to achieve and further its goals.

ARTICLE VI - ANNUAL MEETING Section1.' There shall be an annual meeting of the Association. This meetingshall consist ofan educationaland scientific programand a businesssession. Section2: The Board of Directors, by majority vote, may call, upon30 days notice, a specialmeeting of the membership or standingcommitteeto conduct any businessthat the Board of Directors shall place before the membership or standing committee. Section-i; The Board of Directors may call and conduct any specialmeetingby mail. For purposes of notice, the meeting dateshallbe a date set for the return of mail ballots and it shall becalledthe voting date. Adoption of any proposal, resolution or amendmentby mail ballot shall be achieved by affirmative vote of a majority of voting active members unless otherwise providedby anotherprovision of this constitution. Only those mail ballots received at the businessoffice of the Association within 30 days subsequentto the voting date shall be counted.

ARTICLE VII - BYLAWS Section1; Bylaws may be adoptedor amendedat any annual or specialmeeting of the membership. Section2.'Proposedamendmentsto the bylaws shall be submittedin writing to the Secretary/Treasurerby three members at least60 days prior to the meeting at which they are to be considered.The Secretary/Treasurershall mail the proposed amendments to the membership at least 30 days prior to that meeting. Section3; The Board of Directors may, by resolution, proposeamendments to the bylaws; provided the proposedamendmentsare mailed to the membership at least 30 days prior to the meetingat which they are to be considered.

Section 4: Adoption of a bylaw amendment shall be by a majority vote of the active members present and voting at any annual or special meeting.

ARTICLE VIII _ ADOPTION OF THE AMENDMENTS TO THE CONSTITUTION Section 1: The constitution may be adopted or amendedat any annual or special meeting of the membership. 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. Section3.' The Board of Directors may, by resolution,propose amendmentsto the constitution; provided the proposedamendments are mailed to the membership at 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 special meeting.

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 of the assetsofthe corporation exclusively for the purposesofthe corporation in such manner, or to such organizations organized and operatedexclusivelyfor charitable,educational,religious or scientific purposesas shall at the time qualify as an exempt organizationor organizationsunder Section501(c) (3) of the Internal RevenueCode of 1954 (or the correspondingprovision of any future United StatesInternal RevenueLaw), as the Board of Directors shall determine. Any such assetsnot so disposedof shall be disposedby a Court of CompetentJurisdiction in the Council in which the principal office of the corporation is then locatedexclusively for suchpurposesor to such organization or organizations, as said court shall determine, which are organized and operated exclusively for such purposes.

BYLAWS OF THE SOCIETY FOR ACADEMIC EMERGENCY MEDICINE

I

ARTICLE I _ MEMBERSHIP Seaion1: Application Process. Membership application forms maybe obtainedfrom the Secretary/Treasurerthrough the ExecutiveDirector of the Association. The Applicant must return the completedapplication forms and supporting letters to the ExecutiveDirector of the Association at least one month prior to Board of Directors meeting in order to be considered for membershipat that time. The qualifications of applicants for membershipwill be reviewed by the Membership Committee at eachmeeting of the Board of Directors. Approval of applicantsby the Council Board shall constitute election to one of the membershipcategories, 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 members will not pay dues. Membershipin the Associationmay be terminated for nonpayment of dues. Section3: Rights and pivileges. All membershave the privilege of the floor at businessmeetings of the Association and may serve as a committee member, committee chair, or Member-at-Large of 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 TI _ BOARD OF DIRBCTORS Section1: Members. The Board of Directors shall consist of the President, Vice-President (President-Elect),the Secretary/ Treasurer. the Immediate Past President, the Program Chair, and five Members-at-Large. Section2: Election of Officers. (a) The Vice-President shall be elected for a term of one year with automatic successionfrom Vice-Presidentto Presidentthe following year' During this two year period, the electedmember will serve as an officer of the Association. Following terms of Vice-President (President-elect) and President,this member will automatically assumethe position of tmmediate Past President. Election as Vice-President shall confer Board of Directors membership for a minimum of three years. Nominees for this office will be selectedby the Nominating Committee, and must have agreed to stand for election prior lo formal nomination for election at the businesssessionbf the annual meeting. Alternative nominationswill be acceptedfrom the floor. Such nomineesmust also agreeto siand foi election. Election shall be by majority vote of the active members present and voting at the businesssessionof the annual meeting. The Vice-President may also be elected or appointed as Chair of other standing or.ad hoc committees, with of the Program Committee, and shall be an exihe exception -member of all standing committees' (b) The officio Secretary/Treasurershall be elected to a three year term' An active member may serve only one term as Secretary/Treasurer' Nominees for this office shall be selectedby the Nominating Committee and must have agreed to stand for election prior to their formal nomination for election at the businesssessionof the annual meeting. Alternative nominations may be offered from the floor. SuChnominees must also agree to stand for election. Election shall be by majority vote of the active members present and voting at the businesssessionof the annual meeting. The Secretary/Treasurermay also be electedor appointed as the Chair of standingor ad hoc committees, with the exception of the Nominating Committee and Program Committee, and may serve as a member of all committees. Section3 : Election of Members-at-lnrge. Members-at-Large shall be electedto two year terms, the terms being staggered' Members-at-Large may only be elected for two consecutive terms. NomineeJfo. the above offices shall be selectedby the Nominating Committee and must have agreed to stand for election prior to their formal nomination for election at the business sessiottof the annual meeting' Alternative nominationsmay be offered from the floor. Such nomineesmust also agreeto stand for election. Election shall be by majority vote of the active members present and voting at the businesssessionof the annual meeting. Members-at-Large may also be elected as Chairs of standing committees, with the exceptions of the Nominating and Program Committees, appointed as Chairs of ad hoc committees, 5, ,"*" as a membeiof standing or ad hoc committees, with the exception of the Nominating Committee. Section 4: Election of Program Committee Chair' The Program Committee Chair shall be elected to a three year term' I,lomineesmust have agreed to stand for election prior to their formal nomination for election at the business sessionof the annual meeting. Alternative nominations will be accepted from the floor. Suc[ nomineesmust also agree to stand for election' Election shall be by majority vote of the active members present and voting at the 6usinesssessionof the annual meeting' The Program iommittee Chair shall not be eligible for other elected

positions within the Association, but may serve as an appointed member of other standing or ad hoc committees' Section5: Termsof Office' Terms of office will begin at-the conclusion of the annuai businessmeeting. The Presidentshall appoint eligible Association members to fill vacanciesand unexpii"A t"t-i on the Board of Directors and standing and ad hoc iommittees until the next scheduledelection' Section 6: Meetings of the Board of Directors' Meetings of the Board of Directors will be convened at least twice during the term of the President of the Association. Additional meetings may be convened at the President's discretion or by petition of six membersof the Board of Directors. A final notice of time and place of such meetings shall be sent to all members of the noara Uy the Secretary/treasurer at least 7 days before the meeting. Six membersof the Board of Directors will constitute u quoti-. Members of the Association, regardlessof membership category, may submit agendaitems'-Such items must be lO days of the meeting date' Meetings of the ruU-itt"i'*ittrin Board of Directors are open to all membersof the Association and to the public. Closedmeetingsof the Association's officers and Executive Director may be convened by order of the President. Section 7: Duties of the President. The President shall preside over both the educational program and business session of the annual meeting of the Asiociation, and the meetingsof the Board of Directors. It shall be the duty of the Presidentto see that the rules of order and decorum are properly enforced in all deliberations of the Association, to sign the approved minutes of each meeting, and to execute all documentswhich may be required for the Association, unlessthe Board of Directori shall have expressly authorized some other person to P9rform such execution. The President shall serve as Chair ofthe Board of Directors and shall serve as an ex-officio member of all committees. The President shall appoint members to fill vacanciesand unexpired terms on the Board of Directors and standing and ad hbc Committees until the next scheduled election. Section 8: Duties of the Vice-President (Presldent-Elect)' The Vice-Presidentshall presidein the absenceof the President'The Vice-President shall serve as Chairman of the Nominating Committee and ex-officio member of all committees' Section 9: Duties of the Secretary/Treasurer' It shall be the duty of the Secretary/Treasurer to preside in the absenceof bottt the"president and Vice-President. The Secretary/Treasurer shall keep a true and correct record of the proceedingsof the annual businessmeeting and meetingsof the Board of Directors, shall preserve docurnents belonging to the Association and issue notice of the annual businessmeeting and meetings of the Board of Directors 60 days prior to such meetings' The Secretary/Treasurershall heep an account of the Association with its members and maintain a current register of members with datesof their election to membership and preferred mailing address,the latter to be circulated annually to the membershlp within 30 days of the annual business meeting' The Secretary/Treasurershall be responsiblefor reporting unfinished business requiring action from previous meetings of the membershipbr Boird of Directors and will be responsible-for the agendabf the annual businessmeeting and meetingsof the Boari of Directors. The Secretary/Treasurershall collect the dues of the Association, make disbursementsof expenses,and maintain the financial accounts and records of the Association. The financial record will be presentedto the membershipat

76


for vote by active members shall include but not be limited to: (1) a financial report from the Secretary/Treasurer,(2) amendments to the Constitution and Bylaws of the Association, (3) election of officers, members of the Board of Directors, and the Chairs and membersof standingcommitteesof the Association, (4) reports of committeeactivities, (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 attendance at the annual businessmeeting. The President of the Association shall presideover the meeting and the Secretary/Treasurer will circulate agendaitems to the membership 30 days before the annualbusinessmeeting. The Chairs of the Constitutionand Bylaws Committee and Nominating Committee will preside over the respectiveparts ofthe annual meeting. The annualbusiness meeting shall be held at a time and place determined by the Board of Directors of the Association approximately one year in advanceof the convocation.

theannualbusinessmeeting, biannually to the Board of Directors, and at such times as requestedby the President of the Association.The financial records of the Association shall be reviewedannuallyby two other membersof the Board of Directors appointedby the President, or a certified accountant or financialconsultantretained by the Board of Directors of the Association. SectionI0: Duties of Board of the Directors, Members-atLarge. Members-at-Largeshall assume whatever duties are assignedby the Officers of the Association or by Articles in the Bylaws of the Association. SectionI I : Duties of Program Committee Chair. Actingwder theauspices of the Presidentand Board of Directors of the Association,the Program Committee Chair shall be responsiblefor theAssociation'sannualresearchand educationmeeting,as well as other symposiaor meetings sponsoredor co-sponsoredby theAssociationto meet its purpose. The duties of the Program CommitteeChair shall include but not be limited to: (l) selection of committeemembers, (2) selection of meeting sites, (3) of ad hoc committee members specifically selected designation for review of materials to be presentedat the annual meeting or other Association meetings, (4) peer-review and selection of papersto be presentedat meetings or forums sponsoredor by the Association,(5) publication of call-forco-sponsored abstractnotices, and (6) scheduling activities at the Association's annual meeting or other meetings sponsoredor cosponsored by the Association.Recommendationsfrom the ProgramCommitteeChair must be approvedby the Board of Directors by majority vote.

Section2: Betweenannual businessmeetings,within the policies establishedby the Association's membershipand the Constitution and Bylaws, the Association shall be governed by the Board of Directors. Actions of the Board of Directors shall be determinedby a majority vote of those of its memberspresent at its meeting, six members constituting a quorum. Seaion 3: Arvwal sciertific and educationalassembly.The Association shall sponsoran annual scientific and educationalmeeting or assemblyto meet its purpose and objectives. This meeting will includebut not be limited to: (1) presentationof original research in the sciences and educational methodology, (2) educational/ researchforums, (3) specialprogramsfor the membershipas determined by the purpose and objectives of the Association, and (4) meetings of the standing and ad hoc committees of the Association. The researchand educationalprogrann of the arurualmeeting shall be open to the public and the general membership of the Association in good standing.All meetingsof standingand ad hoc committees are open to the public and members of the Association in good standing. Programs for the annual meeting shall be arranged by the Program Committee and approved by the Board of Directorsof the Association.A final noticeof the time, place, and program of the annual assemblyshall be sent to all members of the Association by the Secretary/Treasurer at least 30 days before the meeting.

Section12: Duties of the Past President. The Past President shallassumewhatever duties are assignedby the President or by articles in the Bylaws of the Association. Sectionl3: Absenteeism/terminationof ffice. Absencescan be approvedor excusedonly by the President. Two unexcused absences from scheduledBoard of Directors meetings,annual business meeting,or specialmeetingsof the Board of Directors during any term as a member of the Board of Directors shall constitute a resignation. Such resignation shall be effectivetwo weeks after notification by the President. Any memberof the Board of Directors may voluntarily resign and suchresignationwill become effective immediately. Section14: Special meetings of the Board of Directors. Special,unscheduledmeetingsof the Board of Directors or the Officersof the Association may be convenedby the President, or by any six membersof the Board of Directors. Upon petitionby 100or more active membersof the Association, stating the reason(s)for calling a special meeting of the Directors or Officers, the Secretary/Treasurershall call such a meeting within 30 daysof receiving the petition to be convenedat a time and place designatedby the President.

Section4: Specialmeetingssponsoredor cosponsoredby the Association.The Associationmay sponsoror cosponsorother scientific or educational meetings of interest to the membership to meet its purpose and objectives. Such meetings shall be convenedby the President,Board ofDirectors, and Program Committee Chair and publicized 30 days in advance by the Secretary/Treasurer.

Seaion 15: Dutiesof the ExecutiveCommittee:The Executive shall conductthe businessof the Board of Directors Committee and act in lieu of the Board on routine issues.All actions by theExecutiveCommitteeare subject to review and approval by thefull Board of Directors at their next meeting.

ARTICLE IV _ FINANCES Section 1: The annual membership dues for all members shall be determinedby the Board of Directors. The annual membership will be payablewithin 30 days of requestby the Secretary/ Treasurer. The Board of Directors may establish procedures and policies regarding non-payment of dues and assessments.

ARTICLE III _ MEETINGS SeuionI: Annual businessmeeting. An annual businessmeetingof themembershipof the Association shall be convenedannuallyandin conjunction with the annual scientific and educationalmeetingof the Association. A majority of the active and votingmembersin good standing and in attendanceshall constitutea quorum. Businessitems presentedas informational or

Section2: The Board of Directors shall adopt such membership schedulesas is necessaryto encourageparticipation by the interested public.

77


ARTICLE V _ PARLIAMENTARY AUTHORITY Rule oforder. Any question oforder or procedure not specifically delineatedor provided for by thesebylaws and subsequent amendments shall be determined by parliamentary usage as contained in Robert Rules of Order (Revised).

ARTICLE VI _ STAI\DING COMNIITTEES Section I: Nomirwting Committee. The Nominating Committee shall consist of the Vice-President, as Chair, the past president, a member of the Board of Directors electedfor a one year term by the board, and three elected members who may not be members of the Board of Directors. The latter shall serve staggeredtwo year terms. It shall be the task of this committee to selecta slate ofofficers to fill the naturally occuring vacancies on the Board of Directors and electedpositions on the standing committeesof the Association not otherwise designatedand provided for by thesebylaws. The Nominating Committee will seek the candidatesapproval for formal nomination and shall place their namesin nomination before the membership for election at the business session of the annual meeting The Nominating Committee will also provide slatesfor any awards offered by the Board of Directors.. Section 2: Membership Committee. The Board of Directors shall constitute the Membership Committee. It shall be the Secretary/Treasurer's duty to review the qualifications and recommendationsof each applicant, for presentation and approval by the majority of the Membership Committee. Section3: Program Committee. The Program Committee shall be composedof a Chair, electedby the membershipfor a three year term, two members appointed by the President to staggered three year terms, and two members appointed by the committee Chair to staggeredthree year terms. The ResearchCommittee chair and the Education Committee chair will be members of the Program Committee. None of the appointed members of the committee can be members of the Board of Directors. The duties of the committee shall be to arrange, in conformity with instructions from the Board of Directors, the program for all meetings and select the formal participants. Section 4: Constintion and Bylaws Comrnittee. The Constitution and Bylaws Committee shall consist of a Chair and two other members, elected for staggeredthree year terms so that the member with the least remaining tenure shall serve as Chair during their final year on the Committee. This Committee shall study the potential merits, adverseconsequencesand legal implications of all proposed constitutional amendmentsor changes in the bylaws and report their findings and recommendations to the Presidentand Board of Directors prior to the time of formal considerationof the proposedchangesby the membership. The members of the Committee may themselves suggestappropriate constitutional amendmentsand bylaws changesto the Presidentand Board of Directors upon study of problems arising out of the existing constitution and bylaws. Section5: Mucation Committee. The Education Committee shall consist of a chair, elected to a three year term by the membership, and six other membersappointedby the committee Chair for staggeredtwo year terms. The committee Chair and appointeesmay be members of the Board of Directors or

other Association committees. The Chair shall create ad hoc education subcommittees with the approval of the Board ofDirectors. The Committee shall foster educationin emergency medical care and assumeduties and tasksas determinedby the Board of Directors Section 6: Research Committee. The Research Committee shall consist of a Chair, elected to a three year term by the membership, and six other membersappointedby the committee Chair for staggeredtwo year terms. The committee Chair and appointeesmay be members of the Board of Directors or other Association committees. The chair shall create ad hoc researchsubcommifteeswith the approval of the Board of Directors. The Commiftee shall foster researchin emergency medical care and assumeduties and tasks as determined bv the Board of Directors. Section 7: Liaison Committeeto the Association of American Medical Colleges (AAMC). The Committee shall consist of a Chair, appointedto a five year term by the Board of Directors, and three membersappointedby the committee Chair for staggered three year terms. The official emergency medicine delegatesto the AAMC will be membersof this committee.The committee Chair and appointeesmay be membersof the Board of Directors or other committeesof the Association. Only current or past members of the committee will be nominated by the Nominating Committee for election to Chair. The Committee shall develop programs for the Association to be presentedat the annual meeting of the AAMC and assumeother duties and tasks of similar purpose as determined by the Board of Directors. Section8: GovernmentalAffairs Committee.The Committee shall consist of a Chair, elected to a three year term by the membership, and three members appointed by the committee Chair for staggeredthree year terms. The committeeChair and appointeesmay be membersof the Board of Directors or other committees of the Association. Only current or past members of the committee will be nominated by the Nominating Committee for election to Chair. The Committee shall assumeduties and tasksas determinedby the Board of Directors to foster federal and state support of researchand education in emergency medical care. Section9: Committeeon International Affairs. The Committee shall consist of a Chair, electedto a three year term by the membership, and three members appointed by the committee Chair for staggeredthree year terms. The committeeChair and appointeesmay be membersof the Board of Directors or other committees of the Association. The committee shall assume duties and tasksas determined by the Board of Directors to foster international recognition ofeducation and researchin emergency medical care.

ARTICLE VII _ DISSOLUTION OF THE ASSOCIATION Section1; Dissolution of this Associationcan only be initiated by a majority vote of all members of the Board of Directors and must be approved by two-thirds of the active membership present and voting at any annual or special meeting. Section 2.'Dissolution shall be achieved in compliance with Article IX of the constitution.


VADB MECT]M BEST ORAL METHODOLOGY

ORAL SCMNCE

1989-

989- RobertNeumar,OhioSate University, "High EnergyPhosphate Metabolism DuringVentricularFibrillation" 1988- SandraM. Schneider,MD, University "Amanita Phalloides of Pittsburgh, Poisoning:Mechanism of Cimetidine Protection"

- Eric Davis,MD, Ohio StateUniversity, "The ComparativeEffects of versusEpinephrineon Methoxamine BloodFlow During Cerebral Regional CPR'' PeterA. Maningas,MD, Letterman "Use of Army Instituteof Research, for TreatDextran70 7.5 VoNaCll6 % mentof SevereHemorrhagicShockin Swine" MichelleH. Biros,MD, MS, Univer"Post InsultTreatsityof Cincinnati, Cerebral Ischemia-Induced ment of LacticAcidosisin the Rat"

-

1988- Phillip L. Henneman, MD, Harbor"Attending Coverage in AcaUCLA, Medicine: A NationEmergency demic al Survey"

BEST SCIENTIFIC POSTER 1989- StevenG. Crespo,MD, Medical Col"Comparison of lege of Pennsylvania, Intravenous and IntraosseousAdministration of Epinephrine in a Cardiac Arrest Model" 1988- David L. Schriger, MD, UCLA, "Defining Normal CaPillary Refill: Variation with Age, Sex, and TemPerature" 1987- Ruth Dimlich, PhD, University of Cin"Effects of Sodium Dichlorocinnati, acetateon ATP and Phosphocreatinein Ishchemic Rat Brain" 1986- Mark Howard, DO, Henry Ford Hospital, "lmprovement in Coronary Perfusion hessures After Open Chest Cardiac Massage in Humans: A Preliminary Report"

BESTORAL CLINICALSCIENCE 1989- Kathleen Hargarten, MD,

Michael Smith, MD, Highland General "Comparison of Different Hospital, Definitions of Critical Trauma Patients"

BEST METHODOLOGY POSTER Medical

"Prehospital Collegeof Wisconsin, ProphylacticLidocaine Does Not FavorablyAffect the Outcomeof Patientswith ChestPain"

1988- Frank J. Papa, DO, Texas College of "A ComputerOstcopathicMedicine, Assisted t-earning Tool Designedto Improve Clinical hoblem Solving Skills"

William G. Baxt, MD, UniversitYof "The Inability California,SanDiego, of hehospitalTraumaPredictionRules to ClassifyTrauma PatientsAccurately"

BESTRESIDENTPAPER

RanjanThakur, MD, Medical College "A Randomized StudY of Wisconsin, of Epinephrine versus Methoxamine in PrehospitalVentricular Fibrillation"

StuartA. Malafa, MD, Butterworth "Prehospital Hospital,GrandRapids, Index: A Multicenter Trial" and JosephF. Waeckerle,MD, BaPtist "A ProMedicalCenter,KansasCity, spectiveStudyIdentifyingthe Efficacy of ClinicalFindingsandSensitivityof RadiographicFindings in CarPal NavicularFractures" HarlanA. Stueven.MD, MedicalCol"Bystander/ lege of Wisconsin, Ten YearsExCPR: Responder First perience in a Paramedic Systsm"

Medical 1989- RayE. Keller,MD, Geisinger Center,"Contributionof SorbitalCombined with Activated Charcoal in Preventionof SalicylateAbsorption" 1988- DouglasSinclair,MD, VictoriaGeneral Hospital,"The Evaluationof Suspected RenalColic: UltrasoundScanvs. Excretory UrograPhY" 1987- RobertL. Muelleman,MD, Truman "Blood PressureEfMedical Center, fects of Thyrotropin-ReleasingHormoneand Epinephrinein Anaplylactic Shock." 1986- StevenChernow,MD, Universityof Arizona, "Use of the EmergencY Department for HyPertensive Screening" 1985- William C. Dalsey,MD, andScottA. Syverud,MD, Universityof Cincinnati, "Transcutaneous CarandTransvenous diac Pacing For Early Bradyasytolic CardiacArrest"

79

1984- GerardB. Martin, MD, Henry Ford Hospital, "Insulin andGlucoseLevels During CPR in the CanineModel" 1983- JeffreyA. Shartr,MD, OregonHealth University,"Effect of Timeon Sciences RegionalOrganPerfusionDuring Two Methods of CardioPulmonaryResuscitation"

BESTRESIDENTFOSTER 1989- Marc Smith, MD, Harbor-UCLA, "Pharmacologic Interventions in Acute Cocaine Toxicity" 1988- Katherine M. Hurlbut, MD, Universi"Reliability of Clinical ty of Arizona, Presentation for Predicting Significant Viper Envenomation" 1987- Gert-PaulWalter, MD, Michigan State "Emergency Intraosseous University, Infrrsions in Children: A Practical Method of Teaching PrehosPital Personnel"

BEST PEDIATRIC ACUTE CARB AND TRAT]MA 1989- J. G. Linakis,MD, Children'sHospital, "Role of Activated Charcoal and SodiumPolystyreneSulfanate(Kayexalate) in Gastric Decontaminationfor Lithium Intoxication: An Animal Model" 1988- Peter Aijian, MD, Valley Medical Center, "EndotrachealIntubation of PediatricPatientsby Paramedics"

BEST EDUCATIONAL PRESENTATIONS Selected to represent EmergencY Medicine at the AAMC Annual Meeting 1989- RobertA. Delorenzo, AlbanyMedical College, "Analyzing Clinical Case Distributionsto Improve an Emergency Clerkship" Robert F. Polglase,Mercer UniversiACLS Instruction: ty, "Problem-Based A Model Approachfor Undergraduate EmergencyMedical Education" 1988- FrankJ. Papa,DO, TexasCollegeof "A ComputerOsteopathicMedicine, Assisted Tool Designedto ImProve Clinical ProblemSolving Skills" MD, Vanderbilt CharlesE. Saunders, University,"VideotapeReviewof Cardiac Arrest Resuscitation:Analysisof Elementsof ResuscitationTeam Performance"


David Plummer,MD, HennepinCoun"Emergency ty Medical Center, Care Registry" Critical Department

BEST RESIDENT/FELLOW ORAL PRESENTATION 1989- Charlene B. Irvin, MD, University of "Effect of Hypertonic vs. Cincinnati, Normotonic Resuscitation on Intracranial Pressure After Combined Head Injury and Hemorrhagic Shock"

BEST PAPER 1984- Charles G. Brown, MD, Ohio State "Injuries Associated with University, the Percutaneous Placement of Transthoracic Pacemakers" 1983- Charles F. Babbs, MD, Purdue "Improved Cardiac Output University, During Cardiopulmonary Resuscitation with Interposed Abdominal Compressions" 1982- Carl D. Winegar, MD, Wayne State "Early Amelioration of University, Brain Damage in Dogs After Fifteen Minutes of Cardiac Arrest"

Blaine C. White, MD, Wayne State University, "Correction of Canine Cerebral Cortical Blood Flow and PostArrestUsing VascularResistance Flunarazine,A CalciumAntagonist" 1980- Blaine C. White, MD, Wayne State University, "Mitochondrial 0' Use KineticEffectsof andATP Synthesis: Ca'' andHPO. ModulatedbY Glucocorticoids" Albert E. Cram, MD, UniversitY of "The Effect of PneumaticAntiIowa, Shock Trousers on Intercranial

in theCenineModel" Dressure Lawrence B. Dunlap, MD, Iosephine General Hospital, Grants Pass, Oregon, " Percutaneous Transtracheal Ventilation During Cardiopulmonary Resuscitation"

BEST PRESENTATION Paul M. Paris, MD, University of Pittsburgh,"The PrehospitalUse of CardiacPacing" Transcutaneous 1983- SandraH. Ralston, MD, Purdue Uni"Intrapulmonary Epinephrine versity, During Prolonged CardioPulmonary Resuscitation:Improved Regional Blood Flow and Resuscitation in Dogs" 1982- StephenR. Boster, MD, University of "Translaryngeal AbsorbLouisville, tion of Lidocaine" Robert W. Strauss,MD, University of "Expanded Role of the Chicago, Barium Enema in the Acute Abdomen" 1980- JacekB. Franaszek.MD, and Harold A. Jayne,MD, University of lllinois, "Medical Preparationsfor an Outdoor Papal Mass"

KENI\EDY LECTTTRERS 1973-FraserN. Gurd, MD 1974-OscarP. Hampton,Jr., MD 1975-CurtisP. Artz, MD MD 1976-JohnG. Wiegenstein, 197'7-PeterSafar,MD 1978-SenatorAlan M. Cranston I979-AlexanderJ. Walt, MD 1980-EugeneL. Nagel,MD 1981-C. ThomasThompson,MD 1982-R AdamsCowley,MD 1983-RonaldL. Krome,MD 1984-DavidK. Wagner,MD 1985-RichardF. Edlich,MD, PhD 1986-HenryD. Mclntosh,MD 1987-RobertD. Sparks,MD 1988-Gail V. Anderson,MD 1989-D. Kay Clawson,MD

PhD L, Caplan, 1990-Arthur HONORARY MEMBERS 1973-Robert H. Kennedy, MDf Fraser N. Gurd. MD C. Barber Mueller, MD

1974-John G. Wiegenstein, MD Alexander J. Walt, MD 1975-Oscar P. Hampton, MDf N. H. McNally, MDt Curtis P. Artz, MDt 1976-Anita M. Dorr, RNt Eugene L. Nagel, MD 7977-Peter Safar, MD 1978-Eben Alexander, Jr., MD 1979-David R. Boyd, MD, CM l98l-R Adams Cowley, MD 1982-Carl Jelenko, III, MD 1990-Ronald Bellamy, MD D. Kay Clawson, MD

HAL JAYI\E ACADEMIC EXCELLENCE AWARD 1985-James T. Niemann, MD 1986-Glenn C. Hamilton, MD 1987-Charles G. Brown. MD 1988-Jerris R. Hedges, MD 1989-Richard F. Edlich, MD, PhD 1990-Lewis Goldfrank, MD

ACADEMIC LEADERSHIP AWARD 1989-Ronald L. Krome, MD 1990-Peter Rosen, MD David K. Wagner, MD

SILVER TONGUE ORATOR DEBATE AWARD MD 1979-Ann L. Harwood-Nuss, 1980-PeterRosen,MD 1981-JeromeL. Hoffman,MD 1982-GlennC. Hamilton,MD l983-Ircderjck B. Ep$ein, MD 1984-Marcus L. Martin, MD 1985-PaulM. Paris.MD 1986-DanielDanzl,MD I987-NicholasBenson,MD 1988-DanielDanzl,MD

PAST PRESIDENTS UA/EM 1970-197 l-Charles Frey, MD l97l-1972-AJan R. Dimick, MD 1972-1973-RobertB. Rutherford,MD 1973-1974-James R. Mackenzie,MD 1974-1975-George Johnson,Jr., MD 1975-1976-l-EslieE. Rudolf, MD 1976-1977-DavidK. Wagner,MD 1977-1978-CarlJelenko,m, MD 1978-1979-RonaldL. Krome, MD 1979-1980-Kenneth L. Maftox, MD 1980-1981-W.KendallMcNabney,MD l98l-1982-IosephF. Waeckerle,MD

1982-1983-BarryW. Wolcott, MD B. Peacock,MD 1983-1984-Jack 1984-1985-Richard C. Levy, MD 1985-1986-Steven J. Davidson,MD 1986-1987-Richard M. Nowak,MD Ruiz. MD 1987-1988-Ernest STEM 1975-1976-Robert H. Dailey,MD 1976-1977-Peter Rosen.MD 1977-1978-C.C. Roussi,MDt 1978-1979-G.RichardBraen,MD 1979-1980-Harvey W. Meislin,MD

80

1980-198l-FrankJ. Baker.II. MD 1981-1982-John R. Lumpkin,MD 1982-1983-HaroldA. Jayne,MDt 1983-1984-Kenneth V. Iserson,MD 1984-1985-Glenn C. Hamilton.MD 1985-1986-Daniel Schelble.MD 1986-1987-Thomas O. Stair,MD 1987-1988-MaryAnn Cooper,MD 1988-1989-Gabor D. Kelen,MD SAEM 1988-1989-James T. Niemann,MD 1989-1990-ArthurB. Sanders.MD


IMAGO OBSCURA AWARI) 1976-NormanE. McSwain,Jr'' MD 1977-SungRock Lee, MD 1978-G. PatrickLilja' MD 1979-stephenKaras,MD 1980-JackGoldberg'MD 1981-RobertKnoPP'MD 1982-Blaine C. White' MD 1983-RichardC. LevY,MD 1984-Glenn C. Hamilton' MD 1985-JerrisR. Hedges,MD 1986-David DuBois, MD 1987-NormanAbramson,MD 1988-CharlesG. Brown, MD 1989-Michael Callaham'MD

MACKENZIE AWARI) 1976-JamesR. Mackenzie,MD 1977-CyrrlT. M. Cameron'MDt 1978-JohnH. Hughes,MD 1979-JosePhF. Waeckerle,MD 1980-KennethL. Mattox, MD 198l-Barry W. Wolcott,MD 1982-Hubert T. GurleY,MD 1983-RonaldL. Krome, MD 1984-CharlesF. Babbs,MD 1985-BlaineC. White' MD 1986-JamesT. Niemann,MD 1987-Arthur Kellermann,MD 1988-RichardE. BurneY,MD 1989-RobertMcNamara,MD

PAST ANNUAL MEETINGS November18, 1970 Denver,Colorado

May 15-18,1977 KansasCitY, Missouri

May 22-25,1984 Louisville, KentuckY

May 14-15,1971 Ann Arbor, Michigan

May 18-20,1978 SanFrancisco,California

May 2l-24,1985 KansasCitY, Missouri

May 12-13,1972 D.C. Washington,

May 24-26, 1979 Orlando,Florida

May 13-15,1986 Portland,Oregon

May 23-25,1973 Hamilton,Ontario

April 20-23,1980 Tucson,Arizona

May 19-21,1987 Philadelphia,PennsYlvania

l,1974 May 28-June Dallas,Texas

April 13-15,1981 SanAntonio, Texas

May 24-26,1988 Cincinnati,Ohio

May 2O-24,1975 Vancouver,British Columbia

April 15-17,1982 Salt Lake CitY, Utah

May 22-25, 1989 SanDiego, California

May 11-15,1976 PennsYlvania Philadelphia,

Junel-4, 1983 Boston,Massachusetts

May 2l-24,1990 Minneapolis,Minesota

s

81


SAEMMEMBERSHIP APPLICATION Pleasecompleteand send,withthe appropriate duesand initiation payment,to: societyfor AcademicEmergencyMedicineo 900 west ottawa o Lansing,Michigan48915. (517) 4g5-54g4 (517)48s-0801FAX Name

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Active -lnternational

Associate

Active membership is open to (a) individualswith an advanceddegreewho hold a medicalschool or universityfacultyappointmentand who actively participatein acute,emergency,or criticalcare in an administrative,teaching research or capacity;(b) individualswith similardegreesin activemilitary serviceor (c) individualswho otherwisemeet qualificationsbut who do not hold a facultyappointment and who petitionthe Membershipcommittee. Annualduesare $195plusa $15 initiationfee payablewhen the applicationis submitted.The application mustbe accompanied by a curriculumvitae and a letterverifyingthe facultyappointment'Membershipbenefitsincludea subscriptionto Annals of EmergencyMedicine,lheofficialSAEMjournal; a subscriptionto the SAEM newsletter;a reducedSAEM Annual Meetingregistrationand free banquet ticket; and reducedregistrationfees to other SAEM educationalmeetings. Associate membership is open to health professionals,educators,governmentofficials,members of lay or civic groups,or membersof the public who havean interestin EmergencyMedicine.Annualdues are $175 plus a $15 initiationfee payablewhen ihe applicationis submitted.The application must be accompaniedby a curriculumvitae' Membershipbenefitsincludea subscriptionto Annats of EmergencyMedicine,theofficialsAEM journal; a subscriptionto the SAEM newsletter;a reducedSAEM Annual Meetingregistrationand free banquet ticket; and reducedregistrationfees to other SAEM educationalmeetings. Resident/Fellowmembership is open to all residents,fellows,or medicalstudentsinterestedin EmergencyMedicine.Annual dues are $s0 plus a $15 initiationfee payablewhen the applicationis submitted.The applicationmust be accompaniedby a letterverifying that the applicantis a resident, fellowor medicalstudentand the anticipatedgraduationdate. Membershipbenefitsincludea subscriition toAnnats oiEmergencyMedicine,theofficial SAEM journal;a subscriptionto the SAEM newsletter;a free SAEM Annual Meetingregistration;and reducedregistrationfees to other SAEM educational meetings. International active and international associate membership is open to individualswho meet the criteriafor SAEM activeor associatemembership but do not reside in the United States.Annual dues are $95 plus a $15 (U.S. funds) initiationfee, payable when the applicationis submitted.The ap, plicationmust be accompaniedby a curriculumvitae and a letterverifyingthe faculty appointment,if appropriate.Membershipbenefitsincludea subscription lo Annalsof EmergencyMedicine,lhe officialSAEMjournal;a subscriptionto ttre SREU newsletter; a iree SAEM Annual Meetingregistrationand banquet ticket; and reduced registrationfees to other SAEM educationalmeetings

My signaturecertifiesthat the informationcontainedin this applicationis correctand is an indication of my desireto become a SAEM member.

Signatureof applican May 1990

Date This form can be photocopiedif additionalcopies are needed.


Societyfor AcademicEmergencyMedicine 900 West Ottawa Street Lansing,Michigan 48915 (517) 485-5484 FAX: (517)485-080r


SAEM 1990 Annual Meeting Program