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