SAEM 1993 Annual Meeting Program

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INDEX ......."............1

GeneralInformation

........'...............2

Award Leadership of Events..

Schedule

...'........"".....3

K e n n e d yL e c t u r e . . . . .

.'..".'.............6 ........"'.......7

andLuncheons..........

Didactics,Workshops, ScientificPaperSessions

".........13

AnnualBusinessMeetingAgenda.....

-.'...."'20 ......21

Hal JayneAcademicExcellenceAward A w a r dP r e s e n t a t i o n s . . . . . . . . . . . . . .

..'............'.......22

S l a t eo f N o m i n e e s

....-'.......'........23 ...........26

andBylawsAmendments...............

Constitution CORD MeetingAgenda.....

......"31

AACEM MeetingAgenda

"'.....'32

MeetinsRoom Floor P1ans.........

abstracts .........fol1owing

This is SAEM's fifth Annual Meeting.From 1989to 1993,here'show SAEM and emergency medicinehave srown:

1989 413 215 650 1,494 17 7,900 16 3.7 319

1993 682 Number of abstractssubmitted 243 presented Number of abstracts 950 (expected) Number of Annual Meeting attendees 2,574 Numberof SAEM members 98 programs residency Number of approved 11,455 (at 10192) Number of Board-certifiedphysicians 29 Number of EM AcademicDepartments 5.4 (AAMC) VoMedicalStudentsSelectingEM as their certificationplansx 677 Number of EM positions offered through NRMP

GENERAL INFORMATION REGISTRATION AND INFORMATION

IMPORTANT SCHEDULE CHANGES

All registrantsmust check in at the SAEM RegistrationDesk to pick up name badgeswhich are required for admissioninto all Annual Meeting sessions.The RegistrationDesk will be open during the times listed below: pm GrandBallroom Foyer May 16 12:00-7:00 GrandBallroom Foyer noon May 17 7:00am-12:00 pm 1:00-5:00 GrandBallroom B noon May l8 7:00am-12:00 pm 1:00-5:00 GrandBallroom B noon May 19 7:00am-12:00 pm 4:00-5:00 GrandBallroomB 7:00am-12:00 noon May 20 l:00-4:00pm

In orderfor SAEM to take advantageof an importantopportunity to hear Walter Zelman, SeniorAdvisor to the President'sNational Health CareReform Task Forceon Monday, May 17 from 9:15 to 10:15am, the PlenarySessionof ScientificPapershas PlenarySessionA will be held on beensplit into two sessions.

Monday,May 17, from 8:15 to 9:15 am and PlenarySessionB will be held on Tuesday,May 18, from 1:30to 2:30 pm. In addition, the KennedyLecturehasbeenrescheduledto Wednesday, May l9 at 1:30to2:30 pm. Finally,the AnnualBusinessMeeting May 19 from 2:30to 3:30pm. will be heldon Wednesday,

CONTINUING EDUCATION The MinnesotaMedical Associationis accreditedby the Accreditation Council for Continuing Medical Education (ACCME) to sponsorcontinuingmedicaleducationfor physicians.The MMA verifies that this CME activity meetsthe criteria for 34 hours in CategoryI, as definedby the Physician'sRecognitionAward of the American Medical Associationand by the MinnesotaBoard of Medical Practice.One credit hour may be claimed for each hour of participation.A verification of CME creditswill be sent to eachregistrantimmediatelyfollowing the Annual Meeting.

SPEAKERS'READYROOM A speakers'ready room will be availablefor those who wish to check their slides in advanceof their presentation.Keys to the readyroom will be availableat the RegistrationDesk.

BANQUET The Annual Meeting banquetwill be held on Thursday,May 20 at The Empressof China restaurant,which is locatedin the heart of Chinatown.Dressfor the banquetis casual.Buseswill begin loadingat 6:00 pm for the 5-10 minute drive to the restaurant.

The buseswill return to the Hilton at the conclusionof the banquet at approximatelyll:00 pm. Each attendeewill receivetwo complimentarydrink tickets and a cashbar will also be available. of The evening'sentertainmentwill consistof the announcement this year's recipientof the infamousImago ObscuraAward, (Do "missing" afteryour prenot be alarmedif someof your slidesare "collect ensentation.Pastwinnersof the Imago ObscuraAward tries." Slidesare returnedby SAEM staff after the Annual Meeting.) Additional entertainmentwill consistof the SecondAnnual RidiculousAbstractspresentation.After lengthy deliberationand debatefour RidiculousAbstractswere selectedfor presentation: "Differential Effects of Alcohol Intoxication on Head Injury in a Swine/I4edicalStudentModel," RichardJ. Brennan,MD "National Political Aspirationsand EmergencyMedicine Clinical Skills: A Negative Correlation Among EmergencyMedicine "Megagroup"Directors,"RobertM. McNamara,MD "A Prescriptionfor ReducingHealth Care Costsin the EmergencyDepartment,"Lowell W. Gerson,PhD "Validation of the Troy Miller Sign: A Sign of Non-Acuity in the EmergencyDepartment,"ThomasJ. Motycka, MD Banquettickets are $12 for active, associateand international members;$35 for residentand medical studentmembersof SAEM; and $45 for non-members.Membersare entitledto up to two tickets at the discountedrate.There will be a limited number of ticketsavailablefor purchaseon-site.

OPENING COCKTAIL RECEPTION SAEM is hostingan openingcocktail receptionon Monday, May 17 from 5:30 until 7:00 pm in the ContinentalBallroom4 & 5.

A1l Annual Meeting registrantsare invited to attend.Hors d'oeurveswill be servedand a cashbar will be available.

EMRA RECEPTION Residents,faculty and friends are invited to attenda receptionon Tuesday,May 18 from 6:00-7:00pm in the Vista Room. The highlight will be the presentationof two awards:the 1993 Jean Hollister Memorial Award for Excellencein EMS and PrehospiHl Care sponsoredby CoastalEmergencyServicesand the 1993 Academic ExcellenceAward sponsoredby EmCare. Hors d'oeuvreswill be servedanda cashbar provided.

EXHIBITS Exhibits will be availablefor viewing on May 18 and 19 from 9:00-12:00noon and l:30-5:00pm in GrandBallroomB. The poster sessions,Innovationsin Medical Educationexhibits, coffee breaks,and the registrationdesk will also be locatedin the Exhibit Hall. Pleasetake an opportunityto view the exhibitsduring the scheduledcoffeebreaksand exhibit hours.

SAEM BOARD OF DIRECTORSMEETINGS The SAEM Board of Directorswill meet on Sunday,May 16 from 12:00-3:00pm and Wednesday,May 19 from 8:00-10:00 pm. All interestedmembersand othersare invited to attendthis and all meetingsof the Board.

ANNUAL BUSINESSMEETING The Societywill hold its Annual BusinessMeetingon Wednesday, May 19 in GrandBallroomA. At this meetingLouis Ling, MD, will introduceincoming presidentLouis Binder, MD. Agenda items will include election of officers, Board and committee memberspresentationof awards,amendmentsto the Constitution and Bylaws, officers' reports,and other items of businesspresentedby the membership. All membersof the association are urged to attend,however,only active membersare eligible to vote.

PLACEMENT SERVICE A bulletin board will be maintainedin the Exhibit Hall for personswishingto postpositionsandphysiciansavailablelistings.

MESSAGEBOARD A messageboard will be maintainedat the RegistrationDesk.

Phonemessagescan be left at the SAEM RegistrationDesk by calling the San FranciscoHilton and Towersat (415) 111-1400 and requestingthe SAEM RegistrationDesk.

LEADERSHIP AWARD His tife was gentle,and the elementsso mix'd in him that Nature might stand uP, And say to all the world, This was a man!

Shakespeare Julius Caesar William H. Spivey,MD

William Holladay Spivey was born July 23, 1953,in Kinston, North Carolina. After earninghis bachelor's degreein zoology from the University of North Carolina, he enteredthe newly openedEast Carolina School of Medicine in Greenville,North Carolina,and was a member of its first graduatingclass,in 1981.He was the first studentfrom that medical school to enter emergency medicine,then a new specialty.

In his fourth year of medicalschool,Bill Spiveytook an electivecoursein emergencymedicineat the Medical College of Pennsylvania.He returnedthere to complete his residencyprogramin that specialty,and joined the College faculty in 1985. He ascendedthe academic ladderquickly, becomingan associateprofessorof emergency medicinein 1989, having attainedthat rank at an earlierpoint than anyoneelse in his discipline.He was also the Chief of the Division of Researchand the FellowshipDirector.In additionto his faculty responsibilidirectorof the Main Clinical Camties,he was associate pus EmergencyCenterand the Hospital'smedicaldirector for quality assurance.

Centralto his prominencein emergencymedicinewas Dr. Spivey'scontributionto researchin that field. While a first-year faculty member,he demonstratedhow intraosseousinfusioncould be adaptedto cardiacresusitation in infants.That researchwork reachedthe forefront of emergencymedicine,and has helped savethe lives of many childrenworldwide.

Among Dr. Spivey'sotherkey researchinterestswere endotrachealdrug administration,the use of magnesium in sulfatefor asthmaand the role of catecholamines for instituting cardiacarrest.Dr. Spiveywas responsible a researchlaboratoryat the Medical Collegededicatedto work in emergencymedicine.As chief of the research division in the departmentof emergencymedicine,he guidedmany residentsand faculty membersin designing and pursuingsuccessfulresearch.

His accomplishmentsalso were recognizedbeyondhis home campus.He receivedevery significant research award that his specialtyoffers, culminatingin the National Leadershipin ResearchAward presentedfor outby the AmericanColstandingresearchaccomplishments a leaderin many He was Physicians.

Emergency lege of of the emergencymedicineorganizations.At the time of his death he was a member of the SAEM Board of He was also a Directors,servingas secretary/treasurer.

Medthe Emergency of of Trustees Board of the member icine Foundationand a memberof the editorial boardsof the Annals of EmergencyMedicine and the Journal of E m e r g e n c yM e d i c i n e , a s w e l l a s a r e v i e w e r o f t h e American Journal of EmergencyMedicine andPediatric EmergencyCare. He was the SAEM ResearchCommittee chair for three yearsand was the cuffent chair of the ACEP ResearchCommittee,having servedon the committee for many years.He servedon the SAEM Program Committeeand chairedthe Constitutionand Bylaws Committee.He also held many positionswithin the PennsylvaniaChapterof ACEP, including its Board of Directors.At age 39, he had alreadypublishedmore than a dozenbook chapters,40 journal articles and an equal number of abstracts.His presentationsat international medical conferencesand gatheringstook him to Scotland,Hungary,Australiaand China.

"Despite this prodigious array of accomplishments, Bill Spivey was nevermore happy,nor more appreciated, thanwhen he could deliver patientcareat the bedsideand sharethese skills with medical studentsand graduate t r a i n e e s , "s a i d h i s d e p a r t m e n ct h a i r m a n ,D a v i d K .

Wagner,MD. His colleaguesand co-workersremember Dr. Spivey as an honest,down-to-earthand well-loved person,aswell as a devotedfamily man.

Dr. Spivey died on February19, 1993,of a cerebral aneurysm.He is survived by his wife, Linda Inglin Spivey;his daughter,Melissa;and his son, Matthew.

Also surviving are his father,William H. Spivey,Sr., his grandparents, Evelyn and GeorgeHommel, Sr., and Violet B. Spivey;two sisters,anda brother.

SCHEDULEOF EVENTS Sunday,May 16 7:30 am-l:30 pm 8:00 am-5:00pm

8:30am-5:00pm

EMS TaskForcemeeting, TeakwoodRoom(4thfloor, bldg 3) CPC Competitions(4th.floor,bldg 3) CentralRegion,TiburonRoom EasternRegion,BelvedereRoom WesternRegion,SausalitoRoom SouthernRegion,Marin Room

CouncilMeeting and 1I :00am-1:00pm EMRA Representative

pm l2:00-l:30

pm l:30-3:00

AnnaLsEditorialBoardmeeting, TowerRoom(Lobbvlevel) ToyonRoom(4th.floor,bldg 3) SAEM Boardof Directorsmeeting, WalnutRoom(4thfloor, bldg 3)

pm 3:00-6:00

AcademicEmergencyMedicineEditorial Boardmeeting, ToyonRoom,(4thfloor, bldg 3)

ScientificPapers:Toxicology- Clinical, Grand Ballroom A ScientificPapers:Ischemia/Reperfusion Basic,PlazaBallroom A (Lobby level) "An Introductionto the Interpretationand Techniques of Meta-Analysis," SausalitoRoom(4thfloor, bldg 3) "Medical DecisionMaking: From Novice to

pm EMRA Boardof Directorsmeeting, 10:00 am-1:00 l2:00noon3:00pm

Luncheon,Powell Room(6th.floor,bldg 3) "Future ResearchDirectorsLuncheon: Trendsin EM Research" Plaza Ballroom B (lobby level)

Expert," CypressRoom(4thfloor, bld7 3) ABEIWSAEM Officers'meeting, MasonRoom(6thfloor, bldq 3)

pm 3:00-3:15

CoffeeBreak,Grand Ballroom Foyer

pm 3:00-4:30

SAEM EMS Committeemeeting, LombardRoom(6th.floor,bldg 3)

pm 3:00-5:00

Federationof EmergencyMedicinemeeting, CypressRoom(4th.floor, bldg 3)

pm 5:30-6:30

CPC Reception VistaRoom(45thfloor, bldq I )

SAEM UltrasoundTask Forcemeeting, MasonRoom(6thfloor, bldg 3)

pm 5:30-9:30

EMRA Boardof Directorsmeeting, Marin Room(4thfloor, bldq 3)

SAEM 1994AnnualMeetingProgram Committeemeeting, PowellRoom(6thfloor, bldg 3)

Monday,May 17

3 : 1 5 - 4 : 1p 5m

"ScientificMisconductandFraud," SausalitoRoom(4thfloor, bldg 3)

pm 3 :I 5 - 5 : 1 5

ScientificPapers:Toxicology- Basic, Grand BallroomA ScientificPapers:PainManagement Clinical, Plaza Ballroom A (Lobbylevel) "Funding for GraduateMedical Education,"

8 : 0 0 - 8 : 1a5m

Introductoryremarksand Presentationof 1993LeadershipAward, GrandBallroomA (Grand Ballroom Level,bldg 2)

8 : 1 5 - 9 : 1a5m

ScientificPapers:PlenarySessionA, Grand Ballroom A

9:15-10:15am

SpecialSession:Walter Zelman,Senior Advisor, President's Task Force on National Health Care Reform, Grand Ballroom A

4 : 1 5 - 5 : 1p5m

Committeemeeting' SAEM International Mason Room(6thfloor, bldg 3)

pm 5:30-7:00

9:00-12:00noon

CypressRoom(4th.floor,bldg 3) "ComputerSimulationasa Research Tool," SausalitoRoom(4thfloor, bldg 3) SAEM Injury ResearchInterestGroup meeting,SutterRoom(6th.floor,bldg 3) OpeningReception,Continental Ballroom 4 & 5 (BallroomLevel)

ACEP ResearchCommittee, LombardRoom(6thfloor, bldg3) am l0:15-10:30 10:30-1l:30 am noon 10:30-12:00

CoffeeBreak "AlternativeFundingSourcesfor EM Re-

TiresdayMay 18

search,"SausalitoRoom(4thfloor' bldg 3)

am 7:00-8:00

ScientificPapers:Pediatrics, Grand BallroomA Brain InjurY, ScientificPaPers: Plaza Ballroom A (lobbYlevel) "Assessment andRemediationof Clinical

andBiotechnology SAEM Pharmaceutical meeting.

LiaisonCommittee LombardRoom,(6thfloor, bld7 3) am 7:30-9:30

ACEP AcademicAffairs Committee meeting,SutterRoom(6thfloor, bldg 3)

am 8:00-9:30

AC EP/SAEM Officers'meeting.

LombardRoom(6thfloor, bld7 3)

Skills," CypressRoom(4thfloor' bldg 3) noon I 1:00-12:00

SAEM InserviceSurveyTaskForce, SutterRoom(6thfloor, bldg 3)

SAEM Ethics Committeemeeting, Cafeon the SquareCoffeeShop(I'obby level)

am 8:00-10:00

noon 8:00-12:00

9:00am-4:00Pm

am 10:00-10:30

l0:30-12:00noon

pm 12:00-1:30

l:30-2:30pm

"Injury Control Research," Stateof the Art: Grand Ballroom A (Grand Ballroom Level' btdg 2) "EffectiveTeachingWorkshop."

Taylor Room(4thfloor, bldg 3) EMRA/SAEM ResidentLeadershipForum, California Room(BallroomLevel) AACEM Meeting, Mason Room(6thfloor, bldg 3) CoffeeBreak- Visit theExhibits, Grand Ballroom B

pm 5:00-6:30

SAEM ResearchCommitteemeeting' LombardRoom(6thfloor, bldg 3) SAEM AsthmaResearchInterestGroup meeting,MasonRoom(6thfloor, bldg 3)

pm 6:00-7:30

EMRA Awards RecePtion, VistaRoom(45thfloor, bldg I )

MaY 19 WednesdaY, am 8:00-9:00

SAEM BoardandPastPresidents'Breakfast, Van NessRoom(6th.floor,bldg 3)

am 8:00-9:30

ScientificPapers:Geriatrics,Grand BallroomA (Grand Ballroom Level,bldg 2)

ScientificPapers:Pediatrics' Grand Ballroom A ScientificPaPers:InjurY, Plaza Ballroom (LobbYlevel) "The SurveYas a ResearchTool," SausalitoRoom(4thfloor, bldg 3) "TeachingProceduralSkills:BeyondSee One,Do One,TeachOne," BelvedereRoom(4thfloor, bldg 3) EMRA/SAEM William H' Spivey,MD' ResidentResearchForum and Luncheon: "From Conceptto Clinical Trial," California Room(Ballroom level) "The National Injury PreventionLuncheon, Centerfor Injury Preventionand Control: Programsand Prioritiesfor the Year 2000 and BeYond" TeahuoodRoom(4thfloor, bldg 3) CORD MemberLuncheon- ResidencY EducationalModule ProductReview' TowerRoom(LobbYlevel) ScientificPapers:PlenarySessionB, Grand Ballroom A EMRA/SAEM Officers' meeting.

LombardRoom(6thfloor, bldg 3)

l:30-5:30pm

"EffectiveTeachingWorkshop"REPEAT' TaYlorRoom(4thfloor, bldg 3)

2:30-3:30pm

ScientificPapers:EMS, GrandBallroomA ScientificPaPers:RadiologY' Plaza BallroomA (LobbYlevel) ScientificPaPers:Education, California Room(Ballroom Level) "Industry and Pharmaceutical Research," SausalitoRoom(4thfloor, bldg 3)

2:30-6:00pm

CORD Meeting Plaza Ballroom B (LobbYlevel)

3:00-3:30pm

CoffeeBreak- Visit theExhibits' Grand Ballroom B

3:30-4:30pm

"Turning

pm 3:30-5:30

PosterSessionA, Grand Ballroom B

Quality AssuranceInto Quality ReRoom(4thfloor, bldg 3) Sausalito search,"

ScientificPapers: Ischemia./Reperfusion/ CPR,Imperial Ballroom B (Ballroom level) "ABEM Synopsisfor FacultY," Catifurnia Room(BallroomLeveI) "From Academiato Activism: Optionsfor InfluencingChange," FranciscanA (Ballroom Level) "A SystemsApproachto EMS Research," FranciscanB (Ballroom Level) SAEM TechnologyCommitteemeeting' Diabto Room(4thfloor, bldg 3) 9 : 0 0 - 1 0 : 3a0m

CORD Boardof Directorsmeeting' Taylor Room(6thfloor, bldg 3)

am 9:30-10:00

CoffeeBreak - Visit the Exhibits' Grand Ballroom B "The OutcomesMovement:Implications

l:00am 10:00-l

l0:00-11:30am noon 10:00-12:00

11:00-12:00noon

pm 12:00-1:30

for EmergencyMedicineResearch," Calfornia Room(Ballroom Level) "HealthPolicyResearch in Emergency (BallroomLevel) A Franciscan Medicine," ScientificPapers:EMS, GrandBallroomA ScientificPaPers:TechnologY, Imperial Ballroom B (Ballroom level) "Multiple ChoiceItem Writer Session," ToYonRoom(4thJloor, bldg 3) "CollaborativeResearchBetweenPhysiciansandNurses:Friendor Foe?," SutterRoom(6thfloor' bldq 3) "Researchin Cost Effectiveness," FranciscanB (BallroomLevel) Research SAEM Ischemia./Reperfusion meeting, GrouP Interest Diablo Room(4thfloor, bldg 3) "How to Build a Lab," California Room(BallroomLevel) SAEM GeriatricEmergencyMedicine meetinganduPdate, Van NessRoom(6thfloor, bldg 3) "ProEducatorsLuncheon: Undergraduate tectedTime andthe DeveloPmentof AcademicDeParlments," TaYlorRoom(6thfloor, bld7 3)

Debate:"ShouldEM be a Primary Care Specialty?," Calfomia Room(BallroomLevel)

"Geriatric Emergency GeriatricLuncheon: A Model for Collaborative Medicine: Research,"MasonRoom(6thfloor, bldg 3) TechnologyLuncheon, Powell Room(6thfloor, bldg 3)

noon 8:00-12:00

ContinentalParlor 7 (BallroomLevel) "Maximizing Small GroupEffectivenessin Teachingand Administration," SutterRoom(6thfloor, bldg 3) "GrantsmanshipWorkshop," YosemiteA (Ballroom level)

48-Month ResidencyProgrammeeting, Diablo Room(4thfloor, bldg 3)

pm l:00-3:30

EMRA Board of Directorsmeeting, SutterRoom(6thfloor, bldg 3)

pm 1:30-2:30

Kennedy Lecture: Andrew McGuireo ttThe Interface of Injury Prevention, Politics and Emergency Medicine," Grand Ballroom A (bIdS 2)

pm 2:30-3:30 pm 3:30-4:30

SAEM AnnualBusinessMeeting, Grand BallroomA (bldg 2)

1 0 : 0 0 - 1 0 : 1a5m

CoffeeBreak, Grand Ballroom B

l 0 : 0 0 - ll : 3 0 a m

SAEM AAMC Liaison Committeemeeting, Van NessRoom(6thfloor, bldg 3)

1 0 : 1 5 - 1 2 : 0n0o o n

ScientificPapers:Health Care, Grand BallroomA ScientificPapers:Clinical- General, Imperial Ballroom B (Ballroom level) "Real Time Ethics: Practical and Ethical

"CreatingResearchNetworks," California Room(Ballroom Level) SAEM ED Alcohol/Injury Grant Subcommittee, SutterRoom(6thfloor, blde3)

Decision-Makingin the EmergencyDeparlment," ContinentalParlor 8 (Ballroom Level) "Introductionto Clinimetrics,"

SAEM Toxicology InterestGroup meeting, FranciscanB (Ballroom level)

pm 3:30-5:00

SAEM EducationCommitteemeeting, Van NessRoom(6thfloor, bldg 3)

pm 3:30-5:30

PosterSessionB, GrandBallroomB

pm 4:00-6:00

Alumni and CurrentFellows of EMF/ ACEP TeachingFellowshipWine and CheeseReception, VistaRoom(45thfloor, bldg I )

pm 4:30-6:00

"Basic Slide Making Workshop,"

California Room(Ballroom Level)

pm l2:00-1:30

"Alcohol Public PublicHealthLuncheon: Policy and Public Advocacy," TowerRoom(LobbyLevel) Luncheon:"Statusof EmergencyMedicine in China:Presentand Future," VistaRoom(45thfloor, bldg I )

pm 2:00-3:00

SAEM National Databasein EM Subcommitteemeeting, Van NessRoom(6thfloor, bldg 3)

SAEM Public Health and Education Committeemeeting, SutterRoom(6thfloor, bldg 3)

pm 12:00-2:00

SAEM InfectiousDiseaseTaskForce meeting,Van NessRoom(6thfloor, bldg 3)

SAEM GovernmentalAffairs Committee meeting,FranciscanB (Ballroom level)

pm 1:00-5:00

"Slide Making Workshop"REPEAT

SAEM ResidencyAid Committeemeeting, Taylor Room(6thfloor, blde 3)

pm 5:00-6:00

SAEM TraumaResearchInterestGroup, ToyonRoom(4thfloor, blde 3)

pm 6:00-8:00

SpecialSession:Discussionofthe Proposed SpecialRequirements, Califurnia Room(Ballroom level)

pm 8:00-10:00

SAEM Board of Directorsmeeting, ContinentalParlor 7 & 8 (Ballroom level)

ContinentalParlor 7 (BallroomLevel) "Maximizing Small GroupEffectivenessin Teachingand Administration"REPEAT SutterRoom(6thfloor, bldg 3)

pm l:30-3:00

ScientificPapers:Cardiopulmonary, Grand BallroomA ScientificPapers:Clinical - General, Imperial Ballroom B (Ballroom level) "PreceptingMedical StudentandResident Researchers," ContinentalParlor 8 (BallroomLevel)

20 Thursday, JN{I.ay am 8:00-10:00

ScientificPapers:Cardiopulmonary,Grand BallroomA (Grand Ballroom Level,bldg 2) ScientificPapers:InfectiousDisease, Imperial Ballroom B (Ballroom level)

3 : 0 0 - 3 : 1p5m

CoffeeBreak, Grand Ballroom B

3 : 1 5 - 5 : 0p0m

PosterSessionC, GrandBallroomB

6:00-11:00pm

SAEM Banquet

KENNEDY LECTURE

ANDREW McGUIRE ExecutiveDirector TbaumaFoundation SanFranciscoGeneralHospital Andrew McGuire, Executive Director of the Trauma Foundation at SanFranciscoGeneralHospital,is an expertat observing a clinical problem, recognizingits public health context, and working aggressivelytowardsthe implementationof policy which will correctthe problem.As the first directorof Action AgainstBurns,he lobbiedfor a flame resistantsleepwearstandard in Massachusetts and establishedone of the first self-help groupsfor burn survivorsin the nation.

He recognizedthe problem of burns from cigarette-induced home fires and worked with flammability expertsand other scientiststo determinethat a safercigarettecould be made.In 1978,he begana nationalcampaignfor fire-safecigarettes, which led to passageof the federal "Cigarette Safety Action of 1984" and the "Fire SafeCigaretteAction of 1990" which will establishfire safetystandardsfor cigarettesthis year.

Mr. McGuirerecognizedthe problemof tobacco-related health problemsand the problemswith accessto medicalcarein California. He was a leaderin the successfulmovementto tax tobacco,with the revenuesgoing to (amongother places)compensateemergencydepartmentsfor care of the medically indigent, as well as to anti-cigaretteeducationand other important health-related issues.He servedas volunteerchairpersonof the defeatedCalifornia initiative campaignto increasealcohol taxes in 1990.This initiativecalledfor revenuesgoingto health-related purposes.

He servedon the national board of directorsof Mothers AgainstDrunk Drivers (MADD) from 1981-1983and was responsiblefor securingMADD's initial majorfunding,and served as acting executivedirector.He organizedand servedas state-

wide directorof the CaliforniaCoalition to ReduceCar Crash Injuries,which assisted in passage of the mandatoryseatbeltlaw.

He has receiveda John D. and CatherineT. MacArthur prize F e l l o w s h i p ,a W . K . K e l l o g g N a t i o n a lF e l l o w s h i p ,a n d w a s presentedan Emmy Award for his film, "Here's Looking at you, Kid," which portrayedthe rehabilitationof a boy who had suffered a 75Vofull-thicknessburn injury. A ,..oni documentary, "Heroic Measures,"examinedthe ethicalquestionssurrounding theresuscitation of severelyburnedpeople.

He is the nationaldirector of the Campaignfor Fire-Safe Cigarettes,a member of the ACEP PatientTransfer Laws Task Force, and a memberof the Board of Directorsof the American Scald Burn Foundation,Citizens for Reliable and Safe Highways,Civil JusticeFoundation,and Advocatesfor Highwayand Auto Safety.He is a memberof the AdvisoryBoardof theJohns Hopkins Injury PreventionCenter,RemoveIntoxicatedDrivers, Stop TeenageAddiction to Tobacco,and an honoraryBoard memberof Americansfor Nonsmokers'Rights. He is a lecturer at the Departmentof Surgery at the University of California at SanFranciscoand the Departmentof HealthPolicy Management, S c h o o l o f H y g i e n e a n d P u b l i c H e a l t h a t J o h n sH o p k i n s University.

Mr. McGuire has a BA degreein History and English from SonomaStateUniversity and an honoraryDoctor of Humane Lettersfrom the University of New England.

The Societyfor AcademicEmergencyMedicine is pleasedto have Andrew McGuire, a leading injury control expeft, present the 1993 Kennedy Lecture on the topic of, "The Interfaceof Injury Prevention, Politics,andEmergencyMedicine."

DIDACTICS, WORKSHOPS,AND LUNCHEONS t7 Monday,N{{.Iay Alternative Funding Sourcesin EmergencyMedicine Research

( 1 0 : 3 0 - 1 1 : 3a0m ) ScottSyverud,MD, Universityof Virginia, Moderator of monetarysourceswhich Clinicianresearchers often areunawa.re will support small seedprojects and new initiatives in research.

This sessionwill focus on non-traditionalfunding sourcesthat are young investigators,or estabavailableto first-time researchers, lishedinvestigatorswho are looking at specificareasof research.

Severalinvestigatorswill presenttheir experiencewith obtaining funding from private foundations.The specific requirementsand applicationprocessfor eachfoundationwill be outlined.

Assessment and Remediationof (10:30-12:00 noon) Residents' Clinical Skills Paula Stillman, MD, University of Massachusetts;William Burdick,MD, Medical Collegeof Pennsylvania This session,aimedat emergencymedicineresidencydirectorsand faculty, will focus on the clinical skills of residents.Interviewing, physicalexamination,and reasoningskills are often taken for granted,and specificproblemsmay be difficult to identify. In a panel discussionformat, speakerswill addressthe techniquesof assessing theseskills, andremediatingwhennecessary.

ResearchDirectors' Luncheon: Future Tlends in Emergency Medicine Research

(12:00-1:30 pm)

Michelle Biros, MD, HennepinCountyMedical Center;Jerris R. Hedges,MD, OregonHealth SciencesUniversity;JohnMarx, MD, CarolinasMedical Center;Norm Paradis,MD, BellevueHospital Memphis Center;Art Kellermann,MD, Universityof Tennessee, productive panel reIn this session,a of some of the most searchersin our field will be askedto predict what researchin emergencymedicinewill be like in the next decadeand why.

Theseexpertswill alsodiscusswhich currentresearchtrendswill have the most impact on our clinical practice.With the strong and interestingpersonalitiesin our specialty,this discussionis andinformative. boundto be very lively, entertaining

An Introduction to the Interpretation and (1:30-3:00 pm) Techniquesof Meta-Analysis RogerJ. Lewis,MD, PhD, Harbor-UCLA; RobertL. Wears,MD, University of F lorida, Jacksonville Meta-analysis is a group of statisticaltechniquesfor combining the informationfrom multiple clinical trials. Meta-analysisallows valid conclusionsto be drawn from presentlyavailablestudies, even though the individual trials may be too small to give convincing or statisticallysignificantresults.This sessionwill give an introductionto the methodsand interpretationof meta-analyses, allowing thosewith relatively little statisticaltraining to critically Exampleswill be read and interpretpublishedmeta-analyses. pertinentto the drawn from recently-publishedmeta-analyses clinical practiceof emergencymedicine.Although it is not the purposeof this sessionto teachinvestigatorsto perform meta-

analyses,this sessionwould serveas a good startingpoint for thosewishingto learntechniquesfor meta-analysis.

Clinical Judgment and Decision Making -

standingthe DifferenceBetweenthe Noviceand the Expert

Under-

(1:30-3:00 pm)

Arthur S. Elstein, PhD, University of lllinois; Peter Viccellio, MD, State Universityof New Yorh StonyBrook; David Sklar, MD, Universityof NewMexico Dr. Elstein,one of the nation's foremostexpertson clinical reasoningwill discussthe foundationsof expert decisionmaking in clinical practice.The focus of the panelistsand audienceparticipantswill be to presentcasescenarioswheretypical errorsin judgement are committed.Thesecaseswill be analyzed,and variousapproachesfor rec6gnizingand conecting suchproblems will be discussed.Problemswhich typically occur at different levels of training will be emphasized,along with an exploration ofdiffering teachingneedsasa functionoflevel oftraining.

ScientificMisconductand Fraud

(3:15-4:15 pm)

Michelle Biros, MD, HennepinCountyMedical Center Scientific misconductand fraud can occur in the best ofresearch settings,and sometimesbe perpetratedunknowingly.Through the use of casestudiesfrom both clinical and basic sciences,this presentationwill define scientific misconductand fraud, emphasizeits recognition,and discussits implications.Caseswill illustratehow fraud can happen,who it hurts, and how medicalsciencerespondsto it. Basedon advice from expertswho have investigatedallegedor provencases,we will discusswhat can be doneto preventscientificmisconductand fraud.

pm) Fundingof GraduateMedicalEducation(3:15-5:15 Mark Henry, MD, State University of New York, Stony Brook; William Kerr, University of California, San Francisco; Jaclyne Boyden, University of California, San Francisco, David Sklar, MD, Universityof New Mexico This sessionwill explorethe waysin which patientcarerevenues flow throughhospitalsto fund graduatemedicaleducation. Possible changesin the funding formulas basedupon political decisions at a Federallevel and their implications for emergency An overall medicineresidencyprogramswill also be discussed. approachto securingand maintainingadequatefunding for residencytraining througha variety of sourceswill be suggested.

Computer Simulation as a Research Tool (4:15-5:15pm) CharlesE. Saunders,MD, Dept. of Public Health, SanFrancisco This presentationwill be an overviewof the principlesandtechniques of computersimulationin emergencymedicine,with demonstrations.Issuesaddressedwill be the usesof computersimulation in emergencymedicine,the stepsinvolved in creatingcomputer simulationexperimentsfor both real-worldproblemsolving and researchapplications,comparisonsof computersimulation with othermodelingtechniques,andthe useof animation.

Ttresday,May 18 State-of-the-Art on Injury Control

(8:00-10:00 am)

Stephen Hargarten, MD, MPH, Medical College oJ'Wisconsin; Ricardo Martinez, MD, Stanford University; Patricia Salber, MD, University of Califumia, San Francisco; Harvey Meislin, MD, University of Arizona

This sessionis intendedto provide valuableinformation to Academic EmergencyPhysicianswho are consideringinjury control researchas a field of interestas well as to EmergencyPhysicians who are in this researchfield already.This two-hour sessionwill be divided into four parts.The first portion will be dedicatedto

whereinjury control researchhasbeenin the pastand will tracea brief history of injury control researchhighlighting the major contributorsto the science.The next sessionwill hightight the major contributorsto the science.The next sessionwill highlight the current stateof the art of researchas outlined by the Centers for DiseaseControl. Referencesto current researchfunding levels will be outlined.The third sessionwill provide rhe participantswith a stateof the art sessionon an injury problemwith emphasison cuffent and future researchdesignsand translating thoseresultsto advocacy.The fourth and final sessionwill be dedicatedto outlining the injury control researchstrategiesemergency physiciansneed to think about in order to make a significant contributionto this field in the future.The two-hour state of the art sessionwill take a look at the past,the present,and what promisesto be a wide openfuture in injury control.

(8:00-12:00 Effective Teaching Workshop noon) Gerald J. Kelliher, PhD, and Ajit Sachdeva,MD, Medical Collegeof Pennsylvania The workshopwill focus on principlesof oral communication, and group processskills. At the conclusionof the program,participantswill be able to organizeand deliver oral presentationsin a variety of instructionalsettings,use a variety of instructional strategies,identify and use of his/her teachingstyle more effectively, evaluatethe effectivenessof instructionalcommunication, analyzethe communicativeprocessin terms of weaknessesand strengths,identify and demonstrateverbal and non-verbalbehavior which may enhanceor inhibit achievementof group goals, and be able to facilitate discussionamonga group of studentsor colleagues.Participantsare askedto preparea three-minutepresentationprior to this seminarin the mode of their choosing(lecture/discussion, questionand answer,etc) and bring any slides, overheadtransparencies, or smallpiecesof necessary equipment.

Participants must each also bring a 3O-minute blank videotape clearly labelled with their name. Limited to 20 participants per session.

EMRA/SAEM Resident LeadershipForum

(8:00-12:00 noon) RebeccaSmith-Coggins,MD, Stanford University; John Marx, MD, Carolinas Medical Center; WayneGuerra, MD, Denver GeneralHospital; RobertJorden,MD, Maricopa Medical Center This sessionis open to all residentsbut is designedspecifically for residentswho anticipatean active leadershiprole during the courseof their training. The forum will consist of two lectures followed by a panel discussion.The panel is directedtoward chief residents,but anyoneinterestedis encouragedto attend.

Dr. RebeccaSmith-Coggins will teachthe first session.Shewill discusscircadianrhythms and shift work and the resultanteffects on mood and performance.Dr. Smith-Cogginswill conclude with suggestionson schedulingstrategiesand how to best survive shift work. The secondsessionof the forum will deal with residentswho have beenexposedto the humanimmunodeficiency virus throughneedlesticks or splashes.

Dr. John Marx will discuss the impact HIV exposurehas on the resident and whether seroconversionshould affect the resident'sability or right to work. In addition,he will deal with the issueof disability insuranceand whether seroconversionwithout AIDS representsa disability.The speakerswill discussconflict hints, ideasfor motivating residents,and extendedleave/pregnancy policies. Continentalbreakfastcomplimentsof WeatherbyHealthCare.

The Survey as a Research Tool (10:30-12:00 noon) Ted Whitley,PhD, East Carolina University;Arthur B. Sanders, MD, Uniyersityof Arizona The use of survey researchmethodsin emergencymedicine is becoming increasinglywidespread,particularly the distribution of written questionnaires by mail. The purposeof this session will be to introduce the fundamentalsof survey research methodology.Although the focus will be on written questionnaires,many of the principlesto be presentedwill be applicable to surveys conductedin person or by telephone. The importanceof planning and field testing will be emphasized.

Specifictopics will include sampleselection,questionwriting, questionnaireformat, data storageand analysisconsiderations, a n d a d m i n i s t r a t i o np r o c e d u r e sP . a r t i c i p a n t sw i l l h a v e a n opportunity to critique a questionnaireand to interact with the presentersand otherparticipants.

TeachingProceduralSkills: BeyondSeeOne,Do One,TeachOne (10:30-12:00 noon) Dane Chapman, MD, University of Californiri, Davis; Jerris Hedges,MD, Oregon Health SciencesUniversity; Harold Thomas,MD, OregonHealth SciencesUniversity Teaching proceduralskills to house officers and studentsis an important responsibilityof emergencymedicine faculty. However, many faculty feel ill-equippedto do this. This presentation will begin with a discussionby Dr. Thomason teachingprocedural skills at the bedsidewith a focus on maximizingskill developmentand retention.Dr. Hedgeswill then discussthe teaching of severalspecific procedures,again focusing on bedsideapplications.Dr. Chapmanwill presentsome of the newer technologieswhich are availableto teachproceduralskills. There is expectedto be significantaudienceinvolvementanddiscussion.

EMRA/SAEM William H. Spivey MD, Resident Research Forum: From Concept to Clinical Thial

(12:00-l:30 pm)

William Bickell, MD, St.Francis Hospital, Tulsa During this forum, Dr. Bickell will presentthe idea of formulating new conceptsby scrutinizingthe literatureand challengingmedical dogma. He will discussdevelopinglaboratoryand animal models to study theseconcepts,obtaininginstitutionalreview boardapprovalfor controversialprojects,and gainingcooperation of ancillary personnelsuch as paramedicsor nursing staff. Dr. Bickell is well known for his studieswhich have challengedroutine medicalpractices.His studiesof anti-shockgarmentsindicated that they may actually do more harm than good. His current researchindicatesthat the routineuseof fluid resuscitationin posttraumatichypotensionmay increasemorbidity and mortality, and he is currentlyinvolvedin clinical trials to testthis hypothesis.

Injury PreventionLuncheon: The National Center for Injury Preventionand Control: Programsand Prioritiesfor the Year2fi)0 and Beyond (12:00-I :30pm) Art Kellermann, MD, University of Tennessee, Memphis; Elizabeth McLoughlin, Director, San Francisco Injury Center for Research and P revention The issuesduring this luncheon will include: 1) the rationale and significance of the elevation of the Division of Injury Control to Center Status; 2) a brief overview of NCIPC's process for extramural grant review; 3) NCIPC program priorities and research goals; and 4) how academic emergency medicine can help promote the growth and development of the NCIPC.

Industry and Pharmaceutical Research (2:30-3:30pm) Edward A. Panacek,MD, University of Califurnia, Davis; Lala Dunbar, MD, PhD, Louisiana State University; W. Brian Gibler, MD, Universityof Cincinnati T h i s s e s s i o nw i l l p r o v i d e a n i n t r o d u c t i o n t o i n d u s t r y pharmaceuticalsponsoredresearchfor individuals currently not involved in such trials or investigatorswith limited experience who are looking to increasetheir participation.A panel discussion format will be utilized covering opportunitiesin industrysponsoredresearch,a brief review of the mechanicsinvolved in such trials and a recognitionof some of the potentialpitfalls.

Lastly, the anticipatedrole of the pharmaceuticaland biotechnol-

ogy liaison committee in fostering such researchopportunities will be described.

Tlrrning Quality Assuranceinto Quality Research

(3:30-4:30)

David Overton, MD, Michigan State University Kalamazoo Centerfor Medical Studies Maintaining a quality assuranceprogramor developinga quality improvement program can be an onerousresponsibility. With somework, however,this responsibilitycan becomea sourceof quality research. Dr. Overton will sharehis experienceand advicein successfullymaking this transition.

May L9 Wednesday, (8:00-9:30 ABEM Synopsisfor Faculty am) Michael Vance,MD, Presidentand BensonS. Munger, PhD, ExecutiveDirector, AmericanBoard of EmergencyMedicine Dr. Vance and Dr. Munger will outline the changesin Board policies that have taken place during the past 12 months. Many of thesechangeshave direct applicationto programsand faculty.

EmergencyMedicine program faculty and other interestedindividuals are urged to attend.The topics which will be addressed will include ABEM researchprojects,residenttransferpolicies, credit for training in non-EmergencyMedicine programs,the intraining examination,the residenttracking system,and the development of additional subspecialties.Detailed materialswill be availableand time will be allocatedto respondto specific questions abouttheseand otherrelatedtooics.

This sessionwill offer an opportunityfor EMS researchers to gain expertisefrom existingresearchmodels.This will empower them to designinnovativeprojectsfor the much-neededevaluation of EMS systems.Each speakerwill presenta 20-minute didactic sessionleaving time for audienceparticipationat the end of the session. The three topics will be l) A SystemsApproach to EMS Research:Changesfor the Future; 2) The Use of Industrial and OperationalModels for EvaluatingEMS Systems; and 3) The Use of Public Health and EpidemiologicModels for EvaluatingEMS Systems.

From Academiato Activism: Optionsfor Influencing Change

Herb Garrison,MD, Universityof Pittsburgh Dr. Garrisonwill discuss:l) The pros and In this presentation, cons of the outcomesmovementthat is occurring in clinical research;2) The federal Agency for Health Care Policy and Research,the principal funding sourcefor outcomesresearch;3) The scopeof patient outcomesfound in the medical literature; and 4) Implications of the outcomesmovementfor emergency medicineresearch.

(8:00-9:30 am) Andy Sumner,MD, JohnsHopkins University; Gregg Pane,MD, MPA, Paramax/LouisianaMedicaid; Larry Bedard, MD, Marin GeneralHospital; Gary Young,MD, Highland GeneralHospital Academicemergencyphysiciansexperiencethe joys and frustrationsof practicing academicmedicineat the patient's bedside and in the teachingclassroom. Academicianssummarizethe problems of health care in this country and provide theoretical supportfor solutionsto theseproblems,but the argumentsof academicianssometimessuffer from lack of practical experience in with "the system." The panelistshavehad variedexperiences interacting with media, networking with legislators and regulators, electionsto boards and recruitmentto administrative positionswhich influence the day-to-daypractice of emergency medicine,as well as the policy decisionsaffecting the future of emergencymedicine,both academicand clinical. Listeningto the experiencesand recommendationsof role models,the audiencewill learn the art and scienceof "getting involved." The topicsto be discussedwill include how to successfullyinteract with the media, how to get the attention of legislatorsand regulators,how to preparefor importantpositionsboth electorial and administrativeand how to put academictheoriesinto practice on a legislativeand regulatorylevel. The end result will be a renewed enthusiasmfor membersof the audienceto get involved becausetheir understandingof their options for creatingand influencing changewill be expandedand reinforced by the final questionand answerinteractionwith the speakers.

A Systems Approach

to EMS Research:

Changes for the Future

(8:00-9:30 am) Kristi Koenig, MD, Highland Hospital; Dan Spaite, MD, Universityof Arizona; CharlesSaunders,MD, Departmentof Public Health, SanFrancisco;Ron Maio, DO, Universityof Michigan

The OutcomesMovement:Implicationsfor (10:00-u:00 EmergencyMedicineResearch am)

Health Policy Research in EmergencyMedicine

(10:00-11:30 am)

Arthur Kellermann, MD, Univesity of Tennessee,Memphis; Andrew Bindman,MD, Universityof Califurnia, San Francisco; Carl Stevens,MD, ValueHealth Sciences;RobertA. Lowe, MD, MPH, Universityof California, SanFrancisco Ifthe goal ofresearchis to improve patientcare,thenclinical and laboratoryinvestigationsmust be supplemented by studiesof our health care delivery system.These projects are the realm of health servicesresearch.EmergencyMedicine, the barometerof the overall quality of the U.S. medical care delivery system,is the ideal specialtyfor looking at thesequestions.Issuessuch as ED overcrowding,accessto medical care, and cost containment can be studiedwith the samescientific rigor as more traditional researchquestions,and funding for this type of researchis improving. This panel presentationwill begin by defining health servicesresearch.Panelistswill describetheir own research projectsas examples.They will discuss:l) the methodological differencesbetween clinical researchand health services research;2) how to locate the necessaryresourcesto conduct health servicesresearch,including mentorsand funding; 3) pitfalls in research;and 4) how to use the resultsof health servicesresearchto influenceoolicv-makers.

Undergraduate Educators Luncheon: 66Protected Time and the Development of Academic (12:00-l:30 Departments" pm;

Multiple Choice Item Writer Session(10:00-12:00 noon) ConnieGreene,MD, CookCountyHospital;MarcusMartin, MD, Medical College of Pennsylvania,Allegheny Campus; ABEM members This seminaris primarily intendedfor CORD memberswho are parlicipatingin the multiple choicequestiondatabankproject.Becauseit is a working sessionwith eachparticipantbringing questions they haveprepared,the classsize is limited to 30. This session will addressthe "do's" and "don'ts" of multiple choiceitem writing throughcritique of actualquestionspreparedby members of the CORD task force. Each questionwill be analyzedusingthe materials that were distributed to the group as they began this project.Additional materialwill be providedto expandon the basic information.By the end of the seminaritem writers should be ableto write gooditemsthat testvalid conceptsreliably.

William Burdick, MD, Medical College of Pennsylvania; Hal Thomas,MD, Oregon Health SciencesUniversity; Peter Viccellio,MD, StateUniversityof New York,StonyBrook In an evolving academicdepartment,how do faculty obtain and useprotectedtime? What are the pitfalls, problems,and solutions regardingproductivity of nonclinicalpursuits? With departments limited in the amount of protectedtime available,how is such time distributedsuchthat the departmentas a whole is productive and each faculty member has a fair opportunity to progressin his/her career?What are the key behavioursin new faculty that predictsuccess andhappiness?

Collaborative Research: Friend or Foe

Geriatric Luncheon- Geriatric Emergency Medicine: A Model for CollaborativeResearch (12:00-1:30 pm)

(10:00-12:00 noon) Patricia A. Lenaghan, RN, MS, CEN, EmergencyNurses Association;Ronald A. Dieckmann,MD, MPH, Universityof Califurnia, San Francisco; Kristi L. Vaughn,Oregon Health SciencesUniversity;Jane Koziol-Mclain, RN,MS, Universityof Colorado; StevenR. Lowenstein, MD, MPH, University of Colorado;RobertL. Muelleman,MD, Universityof Nebraska This sessionis designedto inform health care team membersof collaborativeresearchmodels.Future researchis aimed in the directionof multi-site,multi-disciplinestudies.This courseis designedto assistresearchersin understandingthe collaborative processwhen working with teammembersfrom other disciplines as well as otheragenciesor departments.The secondpart ofthis sessionwill focus on the panel memberswho have been successfulin workingas researchteams.Theseteamswill consistof physiciansand nurses.Team memberswill discusstheir actual roles in the collaborativeprocessas well as communication, negotiation,and authorship.At the end of this sessionthe participantswill be more informed about the collaborative processand be able to use the processto conductstudieswith otherresearchers and colleasues.

Researchin Cost Effectiveness

Arthur B. Sanders,MD, University of Arizona; Lowell W. Gerson,PhD, NEOUCOM; lnwrence M. Lewis, MD, St. Louis University Researchin geriatric emergencymedicineprovidesan excellent opportunityto make use of collaborationsbetweenemergency medicineand other disciplines.Building collaborativebridges throughresearchallows professionalsto understandthe language and mindsetof other disciplinesand can bring a fresh viewpoint to solveproblems. Issuesin geriatricemergencycarecan only be solvedby collaborativeefforts involving emergencyphysicians,geriatricians, nurses,paramedics, socialworkers,epidemiologists,and other professionals working together.This session will demonstratehow emergencyprofessionalscan build collaborative relationshipswithin medical centersand communitiesto do researchand solveproblemsin geriatricemergencymedicine.

Technology Luncheon ( 1 2 : 0 0 - l : 3p0m ) StevenSeifert, MD, Kino Hospital; Ron Moscati, MD, Erie County Medical Center; William Baxt, MD, University of California, San Diego; Sandra Schneider,MD, University of Pittsburgh;Jim Mateer,MD, Medical Collegeof Wisconsin The following topicswill be discussedduring this session:PET Scanning- State-of-the-Artand ED Applications; Neural Networks: Peeringinto the "Black Box"; PharmacologyUpdate: MonoclonalAntibodiesand Beyond;and An UltrasoundCurriculumfor Emergency Medicine.

(8:00-10:00 am)

Robert Wears,MD, Universityof Florida, Jacksonville Cost-effectiveness has becomean important standardfor assessing aspectsof medicalcare,but many assertionsof cost-effectivenessin medical literature are erroneous.This course will cover the basic principles and commonpitfalls of cost-effectivenessevaluationin emergencymedicalresearch.Participantswill learnto distinguishbetweenchargesand costs,averageand marginal costs,and to recognizeappropriateand inappropriatemethods of determininscost-effectiveness.

Creating ResearchNetworks

(3:30-4:30 pm)

Donald M. Yealy, MD, Scott & White Memorial Hospital and Clinic Clinical and basic researchin emergencymedicinehas advanced rapidly over the last decade.It is often very difficult for a single researcherto keep up with all the technical advancesthat have been made.Clinicianswho do researchoften lack the basic knowledgerequiredto pursuesophisticatedavenuesof research.

In addition, frequently the technologyrequired to pursue a certain line of researchis cost-prohibitiveto a singledepartment.

This conferencewill discussmechanismsby which researchnetworking can be developedto allow clinician researchers accessto a broaderscientificknowledgebaseand advancedtechnolosv.

How to Build a Lab ( l 1 : 0 0 - 1 2 : 0n0o o n ) Michelle Biros, MD, Hennepin County Medical Center; Brian Zink, MD, University of Michigan; Donna Carden, MD, LouisianaStateUniversity Basedon the personalexperiences of establishedinvestigators, this sessionwill discussthe philosophicaland practical steps neededto take a good researchidea and get starteddoing the project in the laboratorysetting.Included will be a discussionof anticipatingspace,equipmentand personnelneeds,as well as how to maintainand managethem oncevou havethem.

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Thursday,May 20 ShouldEmergencyMedicinebe a Primary Care Specialty?

(8:00-12:00 noon) Grantsmanship Workshop PhD, President,Tech-WriteConsultants/ LianeReif-Lehrer.

(8:00-10:00 am)

Erimon-Associates In this workshop,Dr. Reif-Lehrer will discussmany aspectsof writing a good grant proposalfor both private foundationsand federal agencies.She will discussthe review process,with special emphasison writing for the reviewer- that is providing the informationthe reviewerneedsto know. She will also discuss how to deal with the different parts of an application,especially the researchplan. Dr. Reif-Lehrer will detail how to plan, outline, draft, reviseand track the proposaland will also teachsome generalstrategiesfor good expositorywriting. Limited to 50 participants.

Jo Ellen Linder, MD, HennepinCountyMedical Center;Patricia Salber, MD, University of California, San Francisco; Salvatore Vicario, MD, University of Louisville; J. Douglas White, MD, Georgetown University; Art Kellermann, MD, University of Memphis Tennessee, Leadersin emergencymedicine will presentargumentsfrom multiple positions regarding the pros and cons of primary care statusfor the specialty. The ramificationsof changingthe status witl be discussedby a panelfollowing the debate. Dr. White will take the negative position and Dr. Kellermann will take the affirmativeposition.

Computer Slide-Making (8:00-12:00noon/l:00-5:00pmREPEAT) Workshop Mark Langdorf, MD, MHPE, University of Calfornia, Irvine; Carl Schultz,MD; Jeff Jones,MD, Butterworth Hospital; Peter Viccellio,MD, StateUniversityof New York, StonyBrook; Lester Kallus,MD, Fred Schiavone,StateUniversityof New York,Stony Brook This courseis designedfor beginner(morningsession)andintermediate(afternoonsession)computer users with little or no experiencein generating35 mm slides.The morning sessionwill includea basic introductionto the computer,including Windows and DOS.Theafternoonsessionwill deal with slide making hardwareand softwareonly. IBM compatiblecomputersand film recorderswill be used. The coursewill provide an introduction to effectiveslide making, including amount,location and presentationof material.In addition, participantswill gain practical experienceusing the computerand slide making software,with one computerand one tutor for every two students. Total class size will be approximately30 per session.Registrantsare encouragedto bring a text file of a samplelectureoutline. However,a standardsamplelecturewill be provided.This will be usedto create5-10 slidesto illustratehow the designand productionprocessworks. Slideswill be imagedand developed during the workshop.Registrantswill leave the sessionsbelieving that they can, indeed,make excellentquality computer slidesto enhancetheir teaching.Comparisonsof the different hardwareand softwarewill be provided, along with the cost of per session.

Limited to 30 participants the variouspackages.

Maximizing Small Group Effectiveness in Teaching (8:00-12:00noon/ and Administration 1:00-5:00pm REPEAT) Robert Waterman,PhD, University of New Mexico; Stewart Mennin,PhD, Universityof New Mexico This sessionwill addressthe needsof teacherswho work in a small group setting,and the needsof otherswho work with small groupsof peoplewhosegoalis to accomplishspecifictasks(i.e., committeemeetings). The conceptsof feedback,empowerment, ground rules, body language,supportand trust are central to effective small group functioning in any setting, and will be emphasizedduring the workshop. After an initial didactic preLimited to sentation,groupswill practicethe skills demonstrated.

30 parlicipantsper session.

Panel on Real Time Ethics in the Emergency ( 1 0 : 1 5 - 1 2 : 0n0o o n ) Department Lewis Goldfrank,MD, BellevueHospital Center;Robert Knopp, MD, Valley Medical Center; John Moskop, PhD, East Carolina University Emergencyphysiciansare confronted with ethical dilemmas every day while caring for patientsin a busy emergencydepartand the ethment. The panelistswill discusscasepresentations ical decision making that is involved with the care of thesepatients. Subjectsto be discussedinclude resuscitation,overcrowding, and carefor the indigent.Audienceparticipationis welcome andencouraged.Bring your questionsfor this panelofexperts.

Introduction to Clinimetrics

(10:15-12:00 noon)

RaywinR. Huang,MSc, PhD, WayneStateUniversity Clinimetrics is the applicationof measurementtheory to clinical (e.g.blood Medicineis a field filled with measurements sciences. are vital inpressure,WBC, pulse rate). Thesemeasurements formation to physiciansto make diagnosesand to manage are further used in researchto patients.These measurements draw conclusionsthat could have an impact on the practiceof were usedwith the emergencymedicine.Thesemeasurements assumptionthat they were free of errorsand that they were valid measurementsof the clinical phenomenaof interest. Unfortunately,there is not much emphasison the investigationof the Reliability refers reliability and validity of thesemeasurements. to the stability and internalconsistencyof the measureswhen repeatedacrosstime or acrossdifferent measuringinstrumentsor human observers.Validity refers to what the instrumentsor humanobserverspurportsto measure.Hence,it is importantfor clinicians,for purposesofmedical decisionmakingandresearch, to be familiar with clinimetricsso that precisionwill becomepat of theirclinicalactivities.

Public Health Luncheon:

Public Advocacy

Alcohol Public Policy and ( 1 2 : 0 0 - 1 : 3p0m )

James F. Mosher, JD, Marin Institute for the Prevention of Alcohol and Other Drug Problems; Edward Bernstein, MD, Boston City Hospital Alcohol consumption is a major contributing factor to traumatic injuries and deaths, particularly among young people. This presentation will briefly describe the link between alcohol and trauma and its human and economic costs to communities and

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society generally.It will then focus on preventionand early intervention strategies. Particular attention will be given to public policy strategieswhich addressthe role of alcohol in society, such as increasesin alcohol excise taxes, alcohol availability, and measuresto counteractthe aggressivemarketing tactics of the alcoholic beverageindustry. Illustrative case studieswill be included. The presentationwill then discussthe applicationof thesestrategiesin an emergencymedicinesetting and the role of the emergencydepartmentphysicianin promoting preventionand early interventionprograms.

of the initiativesbeing pursuedto establishwestemstyle practice settingsand academicenvironments.Specific referencewill be made to the current five-year program sponsoredby the China Medical Board and China Medical University for the Department of EmergencyMedicine at Wright SrateUniversity Schoolof Medicine. Each participantwill come away with a clearerview of the tremendouspotential of EmergencyMedicine in this large andimportantcountry.

Precepting Medical Student and Resident Researchers

Luncheon:Statusof EmergencyMedicinein China: (12:00-l:30 Presentand Future pm)

(1:30-3:00 pm)

Jerris R. Hedges,MD, OregonHealth SciencesUniversity Preceptingresearchprojectscan be very rewardingor, sometimes,very frustrating. Someprojectscometo fruition and othersseemto consumemuch time and effort, with little ultimate result. Dr. Hedgeswill sharehis experienceand advicein preceptingresidentand medicalstudentprojectswith a focus on maximizingreturns.

GlennHamilton, MD, JiguangLi, MD, Yu Liu, MD, Wright State University For many emergencyphysiciansinterestedin internationalaffairs, the statusof our specialtyin Chinaremainsan enigma. The goals of this luncheonpanel discussionare to detail the current conditionsfor emergencymedicinein China, and explore some

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SCIENTIFIC PAPERSESSIONS Monday, May 1"7 ScientificPapers:Plenary SessionA (8:15-10:15 am)

ScientificPapers:Toxicology-Clinical (1:30-3:00 pm)

Moderator: John Marx, MD, Carolinas Medical Center 1. OutpatientManagementof Low-Risk Febrile Infants Without Antibiotics, M. Douglas Baker, MD, Children's Hospiral of Philadelphia 4. BystanderCardiopulmonaryResuscitation:Is Ventilation Necessary?, RobertA. Berg, MD, Universityof Arizona 5. The Effects of EquivalentSoluteLoadsof l.5Vo Hypertonic Saline/Dextranvs Normal Salineon Survival in SevereUncontrolled Hemorrhagein Swine, SharhabeelM. Jwayyed, MD, Universityof Cincinnati 7. Failure to Validate a PredictiveModel For Refusalof Care to EmergencyDepartmentPatients,Adrienne Birnbaum, MD, Bronx Municipal Hospital Center

Mod,erator: Lewis R. Goldfrank, MD, Bellevue Hospital Center 20. Prevalenceof Recent Cocaine Use in Adult Patientswith UnexplainedSeizures,EdwardA. Panacek,MD, University of California, Davis 21. Cocaethylene,Cocaine and Ethanol Levels in Trauma Patients,Daniel Brookoff,MD, PhD, Universityof Tennessee,Memphis 22. Fow-Year Review of CigaretteIngestionsin Children, ThomasBrabson,DO, Albert Einstein Metabolic Abnormalitiesin Patientswith SevereCarbon M o n o x i d e P o i s o n i n g :I n s i g h t si n t o P a t h o p h y s i o l o g y , Donald A. Chiulli, MD, Henry Ford Hospital MethemogloA ProspectiveStudy of Benzocaine-induced binemia in Humans,Andrew T. Guertler, MD, Madigan Army Medical Center

noon) ScientificPapers:Pediatrics(10:30-12:00 Moderator: Larry Baraff, MD, University of Caffirnia, Los Angeles 9. Utility of Urinary Gram Stain for Detection of Urinary Tract Infection in Young Infants,GR Lockhart,MD, Rhode Island Hospital 10. Epiglottitis in Children 1979-1992:Effects of Haemophilus InfluenzaeType b Immunization,Marc H. Gorelick, MD, Children's H ospital of Philadelphia 11. ExtremelyLow PositiveBlood CultureRatein PediatricAge Group,Dree Daugherty,MD, William BeaumontHospital 12. Effect of Ambient Temperatureon Capillary Refill in Children,Marc H. Gorelick, MD, Children's Hospital of Philadelphia 13. Foley CatheterTechniquefor Removal of Esophageal ForeignBodiesin Children,Jeff E. Schunk,MD, University of Utah

25. A Randomized,Double-Blind,Placebo-Controlled Studyof FluoresceinDetectionin Human Urine, KennethD. Locke, DO. Darnall Army CommunitvHosDital

ScientificPapers: Ischemia/Reperfusion-Basic (1:30-3:00 pm) Moderator: Richard M, Nowak, MD, Henry Ford Hospital 26. The Effect of Global IschemiaandReperfusionon the Plasma Levels of EndogenousVasoactivePeptides,Michael I. Rose,BA, BellevueHospital Center 27. Angiotensin II Improves CerebralBlood Flow in Cardiac Anest, CharlesM. Little, Ohio StateUniyersity

28 The Effects of Vagal Tone on Resuscitationfrom Experimental ElectromechanicaD l i s s o c i a t i o n ,D a n i e l J .

DeBehnke,MD, Medical Collegeof Wisconsin

noon) ScientificPapers:Brain Injury (10:30-12:00

29. Myocardial NecrosisAfter High Dose EpinephrineDuring

Moderator: Willium G. Barsan, MD, University of Michigan 14. Brain Trauma by Epidural Brain Compressionin a Canine OutcomeModel: ProlongedResuscitativeModerate Cerebral Hypothermia,UweEbmeyer,MD, InternationalResuscitation ResearchCenter 15. Hypothermia,Dichloroacetateand Deferoxaminein the Treatmentof CerebralEdema After ExperimentalControlled Cortical Impact in, the Rat, William Heegaard,MD, HennepinCountyMedical Center 16. Traumatic Neuronal Injury in Vitro: SynergisticEffect of the 21-aminosteroidU74500A and the NMDA receptorantagonistMK-801, RaymondF. Regan,MD, Letterman Army Instituteof Research 17. HippocampalNeuronalLoss and NeurologicOutcome After Nimodipine in Fluid PercussionBrain lnjury, Nina T. Gentile,MD, Universityof Connecticut 18. Doesa PerfectGlasgowComaScaleof 15 Obviatethe Need For ComputerizedTomographyof the Head in Traumatic Loss of Consciousness?.

WallaceA. Carter. MD. Bronx Municipal Hospital 19. IntracranialHemorrhageas a Predictor of Occult Cervical SpineFracture,GregoryFrye, MD, ValleyMedical Center

CPR.RobertNeumar,MD, InternationalResuscitationResearchCenter

30. AdenosineMediatesCardiac Tachyphylaxisto Catecholamines,Jffiey W. Runge,MD, CarolinasMedical Center

31. Effects of ContinuousSodium BicarbonateInfusion on EpinephrineVasopressorResponseand SystemicLactate ConcentrationsDuring PorcineCPR,Nina T. Gentile,MD, Universin of Connecticut

(3:15-5:15pm) ScientificPapers:Toxicology-Basic Moderator: Richard C. Dart, MD, PhD, Rocky Mountain Poison & Drug Center 33. Active Extemal Rewarmingof HypothermicCaninesUsing a RadiantHeat Device,ScottA. Syverud,MD, Universityof Virginia The Use of 65 C/ 149 F IntravenousFluid in the Treatment of Hypothermia,Patrick Keogh,MD, Cook CountyHospital 4-MethylpyrazoleBlocks Acetaminophen Hepatoxicityin the Rat, Richnrd J. Brennan,MB, BS,Albany Medical College

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35. Pretreatmentwith PhenobarbitalDecreasesthe Toxicity of

41. Comparisonof Intraoral versusPercutaneousApproachto

Amanita Phalloides,SandraM. Schneider,MD, University of Pittsburgh 36. Treatmentof VerapamilOverdosewith Glucagonin an Intact CanineModel, C. Keith Stone,MD, East Carolina University 31. Hyperinsulinemic-EuglycemicTreatmentImproves Survival During SevereVerapamil Toxicity, Jeffrey A. Kline, MD, CarolinasMedical Center Toxicity in 38. MagnesiumPotentiatesCyclic Antidepressant IsolatedRat Hearls,JeffreyA. Kline, MD, CarolinasMedical Center 39. Effects of Naloxone and Metoclopramide on the Interactions of the MonoamineOxidaseInhibitor Tranylcypromine with Meperidinein an Animal Model, Rajiv Lakhanpal, MD, New York Medical Collese

Mental Nerve Block, Matt Jenkins,Universityof Virginia

42. A Double Blind Comparisonof TAC (Tetracaine,Adrenalin, Cocaine)with TLE (Topical Lidocaine Epinephrine) for Topical Anesthesiawith Cost Comparison,Ken Butler, DO, Michigan StateUniversity 43. 5 mg Droperidol vs 10 mg Haloperidol for Chemical Res t r a i n t o f A g i t a t e d a n d C o m b a t i v eP a t i e n t s ,H a r o l d Thomas,Ir, MD, Bowman Gray 44. Comparisonof Digital Versus MetacarpalBlocks for Repair of Finger Injuries, Kevin Knoop, MD, LCDR, Univer sity of Cincinnati 45. A ProspectiveEvaluationof the Hemodynamic,Respiratory, and OxygenationEffects of Methohexitalin the ED, BenjaminS. Lerman,MD, Highland GeneralHospital

Scientific Papers: Pain Management-Clinical (3:15-5:15pm)

46 Double Blind Comparisonof Dihydroergotaminewith Hy-

Moderator: Robert C. Jorden, MD, Maricopa Medical Center 40. Anatomical Point Injection in the Treatmentof Headaches, B. TomasBrofeldt,MD, Universityof California, Davis

droxyzineversusMeperidinewith Hydroxyzinefor the ED Treatment of Acute Migraine Headache,Robert Shesser, MD, GeorgeWashingtonUniversity

Tuesday,May 18 ScientificPapers:Pediatrics(10:30-12:00 noon)

5 7 . A ProspectiveInvestigationof the Impact of Alcohol Consumption on Helmet Use, Injury Severity, and Medical ResourceUtilization in Bicycle-Related Trauma,David J. Weist,MD, Universityof Arizona 58. Injury PreventionEducationin a PediatricEmergencyDepartment,Lori A. Dandrea, MD, Children's Hospital and Medical Centerof Akron

Moderator: Gary R. Strange, MD, University of lllinois, Chicago 47. Oral vs IntravenousMethylprednisolone in Acute Asthmain Children,PIJ Barnett,MBBS,Children'sHospitalof Boston 48. Metered-DoseInhalers With Spacersvs NebulizersFor Bronchodilator Therapy in a Pediatric Emergency Department,KatherineJ. Chou,MD, Albert Einstein 49. Oxygen SaturationChangesin Acute Exacerbations of Asthmain Children,Jeff A. Finkelstein,MD, Joint Military Medical Centers 50. The Contribution of Routine Pulse Oximetry to Patient Evaluationand Managementin a PediatricEmergencyDepartment,Amy J. Maneker,MD, CaseWesternReserve 51. IntranasalSufentanilfor Sedationand Analgesiain Pediatric Patients,S. Essell,MD, ButterworthHospital 52. Comparisonof IntranasalSufentanil and Midazolam to Meperidine, Promethazine,and Chlorpromazinefor Sedation During LacerationRepair,in Children,Brian A. Bates, MD, Children'sHospital of Boston

B (1:30-2:30pm) ScientificPapers:PlenarySession Moderator: David K. Wagner, MD, Medical College of Pennsylvania 2. ProspectiveValidation of Criteria for On-SceneTermination of ResuscitationEfforts after Out-of-HospitalCardiac Anest,Paul E. Pepe,MD, Baylor Collegeof Medicine 3. A RandomizedProspectiveTrial of Active CompressionDecompression CPR vs. Manual CPR in PrehospitalCardiac Arrest, TheresaM. Schwab,MD, University of California. SanFrancisco 6 . Paramedicsdo not AccelerateTheir Performancein the Presenceof a Skilled Observer,JeffreyD. Bondesson,MD, Denver GeneralHospital 8 . Has the ACEP ChestPain Policy Modified the Evaluation and Managementof PatientPresentingto the ED with ChestPain, LawrenceM. Lewis, MD, St. Louis University Medical Center

noon) ScientificPapers:Injury (10:30-12:00 Moderator: Ernest Raiz, MD, Hennepin County Medical Center 53. The Effects of Heavy Clothing on OccupantResponse, ThomasP. Kuhlmann,MD, Universityof Virginia 5 4 . A C o m p a r i s o nB e t w e e nM a g n e s i u mH e a d f o r m sa n d InstrumentedHuman CadaverHeadsin MeasuringPeak Accelerationof Impact, RoseanneNaunhiem,MD, St. Louis UniversityMedical Center 55. FactorsAffecting Injury Severityto Rear-Seated Occupants in Rural Motor Vehicle Crashes,Charles K. Brown, MD, East Carolina University 56. Law EnforcementTraffic Accident Reportsvs. Emergency DepartmentRecordsfor Motor Vehicle Injury Research, David M. Cline, MD, East Carolina University

ScientificPapers:EMS (2:30-3:30pm) Moderator: Michael Callaham, MD, University of California, San Francisco 59. Measurementof Critical Time Intervalsin a Police Department Early Defibrillation Study, Roger D. White, MD, Mayo Clinic 60. Biologic Variation in Out-of-HospitalCardiacArrest Survival Rates: The Fatal Flaw in Intra- and Inter-system Comparisons?, StanAmbo,MD, Universityof Washington I4

61. Medical Protocolto Reduce"Red Lights and Siren,'Transporl, DouglasF. Kupas,MD, GeisingerMedical Center 62. EmergencyMedicine ServiceSystemsBasedon College/ University Campuses,Brent R. King, MD, Medical College of Pennsylvania

Education 79. The Importanceof Post-ResidencyEvaluations,Judith E. Tintinalli, MD, MS, Universityof North Carolina, ChapelHill 80. An Assessment of Follow-upSystemsin EmergencyMedicine Residencies,Burton Bentley,II, MD, Medical College of Wisconsin 81. DevelopingEmergencyDepartmentManagementin a Residency Curriculum: A PostgraduateSurvey, Louis M. Profeta,MD, Universityof Pittsburgh 82. Use of the American College of Emergencyphysicians' Chest Pain Policy as a TeachingInstrument,Robert W. Wilson,MD, BrookeArmy Medical Center 83. EmergencyMedicine ResidencyFaculty Scheduling:Current Practiceand RecentChanges,Mark T. Steele,MD, University of M issouri-KansasCity 84. Instructionof EmergencyInvasive proceduresUtilizing Human Cadavers,John R. McPherson,MD, University of Florida 85. The Addition of Formal NeonatalResuscitationTraining to the Curriculumof an EmergencyMedicine Residency, William Mallon, MD, LAC/USC 86. Use of a ComputerizedPatientLogbook in Structuringthe Curriculum of an EmergencyMedicine Clerkship,Harry D. Kerr, MD, ColumbiaHospital 87. WellnessRelatedCharacteristics of EmergencyMedicine Residencies:A Resident'sPerspective, AH Nashed,MD, M orr istownM emorial H ospital 88. An EducationalInterventionImprovesFourthyear Medical StudentsEmergencyMedicineTest Utilization and Reduces Costs,S/evenM. Chernow,MD, Universityof Colorado 89. FactorsInfluencing Applicants' Rank Order List for the NRMP Match, Cecile T. David, University of lllinois Affiliated Hospitals 90. Designand Utilizationof an EmergencyDepartmentDatabase, Tom Scaletta,MD, University of Califurnia, San Francisco 91. ComputerAssistedPre-hospitalMedical Control of pediatric Patients,Robert A. Shapiro,MD Children's Hospital Medical Center,Cincinnati 92. PositiveOutcomeBias in the EmergencyMedicineLiterature,Ron Moscati,MD, Erie CountyMedical Center 93. Three Years ExperienceWith a PresentingComplaintOriented Problem Solving Curriculum For Fourth year M e d i c a l S t u d e n t si n E m e r g e n c yM e d i c i n e ,G l e n n C .

Hamilton,MD, Wright StateUniversity 94. The Effectivenessof EmergencyMedicine Residentsin ObtainingFollow-Up Information:A Comparisonof These Methods of OutpatientFollow-Up, Peggy Mair, MD, George WashingtonUniver sity 95. Characteristics of EmergencyMedicineResidentOrientation Programs,Judith C. Brillman, MD, Universityof New Mexico 96. Rule of Two: An InnovativeApproachto Teachingto EmergencyMedicine Residentsat Different Knowledge Levels, GeorgesRamalanjaona,MD, DSc, Brooklyn Hospital Center

ScientificPapers:Radiology(2:30-3:30pm) Moderator: Thomas O. Stair, MD, Georgetown lJniversity 63. The Utility of PrevertebralSoft TissueMeasurements in Identifying Patientswith Cervical SpineFracture,Daniel J. DeBehnke,MD, Medical Collegeof Wisconsin 64. A Field Trial to ImplementDecisionRulesfor Radiography in Ankle Injuries,Ian G. Stiell, MD, Universityof Ottawa 65. Clinical Decision Rule for Knee Radiogruphs,David C. Seaberg,MD, Mercy Hospital of pittsburgh 66. Clinically SignificantCranial ComputedTomographic ScanMisinterpretations at an EmergencyMedicine Residency Program,Dennis Alfaro, MD, Hightand General Hospital

ScientificPapers:Education(2:30-3:30pm) Moderator: Glenn C. Hamilton, MD, Wright State University 67. Documentationof the Need for AttendingSupervisionof R e s i d e n t si n t h e E m e r g e n c yD e p a r t m e n t ,C . J a m e s Holliman, MD, HersheyMedical Center 68. Directing an EmergencyMedicine Residency:The problems and Their Solutions,John V. Weigand,MD, Akron City Hospital 69. Role of EmergencyMedicine Residencyprograms in DeterminingEmergencyMedicineCareerChoice Among Medical Students,E. John Gallagher,MD, Bronx Municipal Hospital Center 70. Report of the Statusof EmergencyMedicine Training in Traditional Academic Centers,E. John Gallagher, MD, Bronx Municipal Hospital Center

PosterSessionA (3:30-5:30pm) Innovationsin Medical EducationBxhibits 71. Utilization of the InstructionalSystemsDevelopment(ISD) Model in EmergencyMedicine, Kelty p. O'Keefe, MD, Joint Military Medical Centers 72. CT/US Computer Atlas, Gregory Spears,MD, Brooke Army Medical Center 73. EmergencyMedicine ResidentProceduresand Resuscitation: Report of a ComputerizedTracking System,Mark I. Longdorf,MD, MHPE, Universityof Calfornia, Irvine 74. Clinical Skills Taught by EmergencyMedicine Faculty: A Model First Year Course,William P. Burdick. MD. Medical Collegeof Pennsylvania 15. An AdministrativePracticumfor EmergencyMedicineResidents,William D. Fales,MD, GeisingerMedical Center 76. The Electronic Suture Lab, Verena Valley, MD, Medical CollegeoJ Wisconsin 7 7 . The Clinical Algorithm ProcessorShell: An Interactive EducationalEnvironmentfor Clinical PracticeGuidelines, JamesC. McClay, MS, MD, Harvard Medical School 7 8 . EmergencyMedicine Residentsand the Acquisition of Expertisein the Diagnosisof Myocardial Infarction, Frank J. Papa,DO, PhD, TexasCollegeof OsteopathicMedicine

Injury 9 7 . T h e R o l e o f E m e r g e n c yM e d i c i n e i n D e v e l o p i n ga n InterdisciplinaryInjury Control Center,Jeffrey H. Coben, MD, Universityof Pittsburgh

t5

102. Moonlighting vs. Attending Pediatric Coverage:An Examination of Admission Rate and Interventions.David J. Treloar,MD, Universityof Michigan 103. Comparisonof Oral Intubation Using a Lighted Stylet Versus Direct Laryngoscopyin Children, SD Berns, MD, George Washington University 104. Use of NeuromuscularBlockade for Pediatric Emergency EndotrachealIntubation, William D. Fales, MD, Geisinger Medical Center 105. Length-BasedResuscitationTape for Pre-Termand Term Newborns,Naghma S. Khan, MD, University of Florida, Jacksonville 106. Can Seizuresbe the Sole Manifestationof Meningitis in Febrile Children?. StevenM. Green, MD, River,side GeneralHospital

9 8 . The Impaired Driver: Hospital and Police Detectionof Alcohol and Other Drugs of Abusein Motor Vehicle Crashes, ElizabethOrsay,MD, Universityof lllinois 99 RetrospectiveAnalysis of the Judicial Outcomeof the Intoxicated Driver, John K. Evett, MD, Eastern Virginia Schoolof Medicine for Bicycle Safety Helmet Use: Do 100 Recommendations EmergencyPhysiciansPracticeInjury Prevention?,Edward Lucci, MD, Madigan Army Medical Center

Pediatrics l0l. Outcomeof a Quality ImprovementProgramfor Electrocardiogramsin a PediatricEmergencyDepartment,Charles J. Graham,MD, Universityof Arkansas

Wednesday lVlay 19 ScientificPapers:Geriatrics(8:00-9:30am)

tzt. Multi-versus Single-tierEMS Systems:A ControlledTrial

Moderator: Judith E. Tintinalli, MD, University of North Carolina 107. MissedDelirium in GeriatricPatientsSeenin the Emergency Department,l-awrenceM. Lewis,MD, St.Inuis University 108. CognitiveImpairmentin Elderly EmergencyDepartment Patients,Lowell W. Gerson,PhD, NortheasternOhio UniversitiesCollegeof Medicine 109. Altitude Travel in the Elderly: Oxygen Saturationand Acute Mountain Sickness,Benjamin Honigman, MD, Universityof Colorado 110. IsolatedClosedHead Injuriesin the Elderly:Clinical Features and Outcome,ThomasJ. Haronian, MD, Akron City Hospital 111. IncidencePatternsof CervicalSpineInjury in Relationto Age,DB Levy,DO, Medical Collegeof Pennsylvania 112. Incidenceof Drug Interactionsin Elderly Patientsin the Emergency Department,Debra L. Holp, MD, Medical Collegeof Georgia

Using ComputerSimulation,Charles E. Saunders,MD, Universityof California, SanFrancisco 122. ProspectiveEvaluationof Field TraumaTriage, William H. Bickell, MD, SaintFrancis Hospital 123.Surviving Relatives'Acceptanceof the Decisionto Terminate Resuscitationin the Field, David E. Fosnocht,MD, Universityof Pittsburgh 124.Comparisonof PrehospitalMonomorphicand Polymorphic Ventricular Tachycardia:Incidenceand Outcome,Stephen Meldon,MD, Medical Collegeof Wisconsin t25. Times of EMS Interventionsas Documentedon Trip Reports Versus On-SceneAudio Recordings,Michael P. Sullivan,MD, Universityof Pittsburgh 126. Use of Automated Defibrillators by Police-First Respondersfor Treatmentof Out-of-HospitalCardiacArrests, VincentN. Mosesso,Jr, MD, Universityof Pittsburgh

ScientificPapers:IschemialReperfusion/CPR (8:00-9:30 am)

Moderator: John B. McCabe,MD, SUNYat Syracuse 127. Lower Transabdominal/Endovaginal Ultrasonographyby EmergencyMedicine Residents,Evelyn Cardenas,MD, Olive View/UCLA t28. UltrasoundEvaluationof Ectopic Pregnancyby Emergency Medicine, JamesMateer, MD, Medical Collegeof Wisconsin t29. Improved Indentification of Ectopic Pregnancywith an EmergencyDepartmentProtocol Utilizing Quantitative HCG and Ultrasonography,Beth C. Kaplan, MD, Boston City Hospital 130.Sensitivity and Specificity of Ultrasoundin the Detection of IntraperitonealFluid, William E. Hilty, Denver General Hospital t 3 l . CentralVenousAccessUsing PortableUltrasoundin the EmergencyDepartment,JosephBurton, DO, WayneState University 132. A One-WayValve ChestWound Dressing:Evaluationin a Canine Model of Open Chest Wounds, Ernest Ruiz, MD, HennepinCountyMedical Center r33. WITHDRAWN t34. SerialElectrocardiograms(SerECGs)are Useful for Identifying PatientsWith PotentialIschemicHeart Diseaseat Rest in the EmergencyDepartment(ED), GarytL. Stewart, BS,Universityof Cincinnati

ScientificPapers:Technology (10:00-12:00 noon)

Moderator: Richard O. Cummins, MD, University of Washington 113. Methodology-Dependent Variationof OutcomePredictors in PrehospitalCardiac Arrest,Gary Lombardi, MD, Bronx Municipal Hospital Center 114. RelationBetweenInitial Post-Resuscitation SystolicBlood Pressureand Neurologic OutcomeFollowing Cardiac Anest,David Persse,MD, Ohio StateUniversity 115. Does Age Affect the Outcomeof PrehospitalResuscitation?,Richard C. Wuerz,MD, HersheyMedical Center 117. Family Responseto Deathin the Field, Terri A. Schmidt, MD, OregonHealth SciencesUniversity 118. Race of the Victim is a Determinantof BystanderCPR, Daniel Brookoff, MD, PhD, University of Tennessee, Memphis

Papers:EMS (10:00-12:00 noon) Moderator: Paul E. Pepe,MD, Baylor 119. On-Line Medical Direction:A ProspectiveStudy,Richard C. Wuerz,MD, HersheyMedical Center 120. Analysis of Interventionsin PrehospitalCare by Standing O r d e r s V e r s u s O n - L i n e M e d i c a l C o m m a n d ,G a s p a r Miguel, MD, HersheyMedical Center Vazquez-de 16

PosterSessionB (3:00-5:00pm) EMS

152. Neuronal Golgi ApparatusUltrastructureDuring Brain Reperfusion,JoseRafols,PhD, WayneStateUniversity

135. Comparisonof Subcutaneous Terbutalineand Nebulized Albuterol During PrehospitalTreatmentof RespiratoryDistressSecondaryto Asthmaor Chronic ObstructivePulmonary Disease,William J. Zehner,Jr, MD, SUNYat Syracuse

153. IncreasedRadical-InducedCell Death After NeuronalDifferentiation,Brian J. O'Neil, MD, WayneStateUniversity 154. Treatmentof NeurochemicalAlterationsCausedby Cortical Impact Injury (CI! in the Rat, Michelle H. Biros, MS, MD, HennepinCountyMedical Center

136. Succinylcholineas an Airway ManagementAdjunct in a SuburbanALS System,ThomasJ. Krisanda, MD, York Hospital

155. The Prevalenceof IntracranialInjuries RequiringOperative Interventionin Mild Head Injuries, StephenA. Schillinger, DO, Akron City Hospital

137. Duration of Immunity to HepatitisB After Immunizationin EMS Personnel,Hansel Ashby, MD, Universityof California, Irvine

156. Lack of Standardsin Animal CPR Research,V. Wenzel, University of F lorida, Gainesville

138. Syphillis Screeningin PrehospitalCare, SJ Weiss,LouisianaState University

157. SelectiveAortic Arch Perfusionwith OxygenatedFlurocarbons Combinedwith Aortic Arch EpinephrineAdministration During CPR,JamesE. Manning, MD, Universityof North Carolina

139. PrehospitalParamedicInterpretationof l2-lead Electrocardiogramsfor Myocardial Ischemia and Infarction, KathleenS. Schrank,MD, Universityof Miami

158. A Comparisonof Effects of CentralVersusPeripheralDrug AdministrationPlus Different Sized PostiqfusionFlushes Upon Drug Delivery to the Aortic Root in a CanineCardiac Arrest Model, Michael Dolister, MD, University of Missouri-KansasCity

140. Cost-Effectiveness of the PrehospitalECG and Thrombolytic Therapy,David J. Magid, MD, Denver GeneralHospital 141. Paramedic-Initiated Non-Transportsand Releasesto BLS Personnel:Is There a Role for On-Line Medical Command?, David T. Kim, MD, Medical College of Pennsylvania

159. The Effect of SupplementalPerfluorochemicalAdministration on HypotensiveResuscitationof SevereUncontrolled Hemorrhage,SusanA. Stern,MD, Universityof Cincinnati

Toxicology

160. EndogenousAngiotensin-IlDuring CardiacArrest and Reperfusion,Michael I. Rose,BA, BellevueHospital Center

142. Flumazenil Induces Siezuresand Death in CocaineDiazepamMixed Intoxications,Robert W. Derlet, MD, Universityof Califurnia, Davis

161. Effect of Compression Durationand Velocity on Resuscitation Hemodynamicsduring High Impulse CPR, Gary L. Swart,MD, Medical Collegeof Wisconsin

143. The Effect of Alpha-AdrenoceptorAgents in Non-Seizure InducedCocaineDeath,Robert W. Derlet, MD, University of California, Davis

162. Changesin RespiratorySystemComplianceduring CardiopulmonaryArrest With and Without ClosedChestCompressions,Ronnie Fuerst, MD, University of Florida, Gainesville

144. Cocaineand Ethanol in CombinationCausesSignificant and ProlongedCardiacToxicity, LanceD. Wilson,MD, Mt Sinai Medical Center

163. The Time Limits of Resuscitation Using Cardiopulmonary Dissociation, Bypassin ExperimentalElectromechanical Daniel l. DeBehnke,MD, Medical Collegeof Wisconsin

145. Evaluation of Cocaine-InducedChest Pain in an Emergency Department(ED) Rapid Diagnosticand Treatment Unit, Dianna M. Hull, BS,Universityof Cincinnati 146. Effective Treatmentof Acute Alkali Injury to the Esophagus by NeutralizationTherapywith OrangeJuice and Cola, CSHoman,MD, SUNYat StonyBrook

164. A Comparisonof Three Non-InvasiveMeasurementsof Coronary Perfusionand Prediction of Return of Spontaneous CirculationDuring CardiopulmonaryResuscitation, RobertF. Grffith, MD, Ohio StateUniversity

147. Is MagnesiumEfficaciousin Tricyclic Antidepressant Overdose?,RandolphO. Maul, MD, Joint Military Medical Command

165. UncontrolledHemorrhagicShock (UHS) OutcomeModel in Rats,Antonio Capone,MD, International Resuscitation ResearchCenter

148. Brown RecluseSpider Envenomationsand the Efficacy of HyperbaricOxygen: A ProspectiveRandomizedTrial Utilizing the Rabbit Model, Michael L. Maynor, MD, Duke University

166. Intestinal Ischemiaand Reperfusion(I/R) is Associated with an Increasein PulmonaryMicrovascularPermeability, Jay A. Young,MD, LouisianaStateUniversity

149. Poloxamer188 as a Treatmentfor Third DegreeBurns, Paul Paustian,MD, Medical Collegeof Georgia

167. IschemicPreconditioningResultsin FacilitatedMitochondrial Function, Charles B. Cairns, MD, Universityof Colorado

150. Alpha-Trinositoland DecreasedFluid BalanceFollowing Thermal Injury, Bo T. Brofeldt, MD, University of CaliJbrnia, Davis

168. High-DoseEpinephrinein CardiacArrest: Resultsof MetaAnalysis, ThomasA. Kunisaki,MD, Universityof Florida, Jacksonville

Ischemia./Reperfusion/CPR

116. Associationof Drug Therapywith Survival in Cardiac Anest,Ian G. Stiell, MD, Universityof Ottawa

151. Correlationof NeurologicDysfunctionand Brain Histologic DamageAfter Asphyxial CardiacArrest in Rats,FengXiao, MD, InternationalResuscitationResearchCenter

221. Acute Changes in Serum Potassium Following S u c c i n y l c h o l i n eU s e i n t h e E m e r g e n c yD e p a r t m e n t , Howard Snyder,MD, Albany Medical College I7

Thursday,N'4ay20 -{rg1ti{c fapers: Cardiopulmonary (8:00-10:00 am) Moderator: Thomas p. Aufderheide, MD, Medical College of Wisconsin 169. An Arrificial Neural Network Trainedto Identify the pres_ enceof MyocardialInfarctionBasesSomeDiagntstic Deci_ sion on Nonlinear RelationshipsBetweenInput Variables, William G. Baxt, MD, University of Catifomii, SanDiego 170. Gender Differences in the Diagnosis of Acute, Non_ traumaticChestpain and ThrombolyticTreatmentof Acute Myocardial Infarction, TerenceD. Valenzuela,MD, Uni_ versityof Arizona 171. Historicaland Electrocardiographic Risk Factorsfor Mor_ tality and SignificantArrhythmia in EmergencyDepart_ ment Patientspresentingwith Syncope,Tp Martin,-MD, Universityof p ittsburgh 172. MulticenterConfirmationof the Value of Serial CK_MB Samplingin the EmergencyDepartment(ED) Evaluation of Chest Pain and Acute Myocardial Infarction (AMI), I4l.

Brian Gibler, MD, (Jniversityof Cincinnati 173. Euly CKMB: predictorof IschemicComplication s. James W. Hoekstra,MD, Ohio StateUniversin 174. Effect of the MenstrualCycle on Asthmapresentations in the-EmergencyDepartment,Emil M. Skobetffi MD, Med_ ical Collegeof pennsylvania 175. MagnesiumAttenuatesNeutrophil Activation in Adult Asthmatic Patients,Charles B. Cairns, MD, Universitv of Colorado

ScientificPapers:InfectiousDisease (8:00-10:00am) Moderator: David Talan, MD, Olive View Medical Center 176. Banier Precautions in TraumaResuscitations: Multivaried Analysisof FactorsAffecting Utilization,pradip Sahdev.

MD, NassauCountyMedical Center 1 7 7 .Hand WashingFrequencyin an EmergencyDeparrment, Michelle R. Meengs,MethodistHospital of Indiana 1 7 8 .Lack of RecognitionandInfectionControlfor Tubercutosis PatientsAdmitted Through the EmergencyDeparrment, GregoryMoran, MD. UCLA 179. PertussisImmune Statusof EmergencyDepartment Staff, SethW. Wright,MD, VanderbittUniveisity I 80. A Mechanismfor the Direct MyocardialDepressantEffects of Endotoxin,CharlesB. Cairns,MD, Univeriityof Colorado 1 8 1 .A RandomizedTrial of a Recombinant EndotoxinNeutralizing ProteinVersusa MonoclonalAntibody to Endotoxin f o r t h e T r e a t m e n to f E . C o l i S e p s i si n a R a t M o d e l , DouglasS. Nelson,MD, Children's Hospital, Boston r82. Doxycyclinevs. Azithromycinin the Treatmentof Women with ChlamydiaInfections:A Cost_effectiveness Analvsis.

David J. Magid, MD Denver GeneralHospital

1 8 5 .P a t i e n t C o m p r e h e n s i o no f D i s c h a r g eD i a g n o s i sa n d Instructionsin an Urban EmergencyDepartment,David J. Karras, MD, TempleUniversityHospid 186. Barriers to Care and Health Behavior in Inner_CityAsthmatics,Jeffrey E. Sterling, MD, MpH, Cook CountyHospital 187. Feasibilityof an ED-BasedRisk_Targeted HIV Screening Program,Gabor D. Kelen,MD, JohnsHopkins University 188. Differencesin clinical outcomesof patientsReleasedfrom the ED After CareAdministeredby SupervisedandUnsuper_ visedHousestaff,Garyp. young,MD, HighlandHospital 1 8 9 .A s s e s s m e not f L i t e r a c y L e v e l s i n S p a n i s hS p e a k i n g Patients,WendyC. Coates,MD, Harbor_UCl,A

Scientific Papers: Ctinical-General (10:15-12:00noon) Moderator: M. Andrew Levitt, DO, University of California, San Francisco 190. Low Voltage ElectricalInjuries in Adults: patterns of Injury, Clinical Features, and AcuteComplications , phit B. Fontanarosa,MD, Akron City Hospitat l 9 l . T h e S y d r o m eo f E x e r c i s eI n d u c e dR h a b d o m y o l y s i s , Richard Sinert,DO, Kings CountyHospital 192. Relationshipof Abstinenceto the presentationand peak Intensity of Signs of Alcohol Withdrawl, William A. Berk, MD, Detroit ReceivingHospital 193. Prospective Evaluationof EmergencyDepartmentMedical Clearance,philip L. Henneman,MD, Haior_IlCl,A 194. Conservative Therapyof plantarpunctureWounds.Robert A. Schwab,MD, Universityof Virginia 195. DetectingEctopicpregnancy:Is Serumprogesterone Screen_ ing Useful?,SusanShepard,MD, universityof pennsylvania 244. Best EMRS Paper: Investigationof the Mechanisms of CardiopulmonaryResuscitationUsing Transoesophageal Echocardiography,ursula M. Guly, Royal Infirmary of Edinburgh

scientiricPap ers:,"rli8:ilrt;flj".t Moderator: W. Brian Gibler, MD, University of Cincinnati 196. EmergencyDepartment(ED) Diagnosisof Acute Myo_ cardial Infarction (AMI) and Ischemia:A Cost Analvsis.

JamesW. Hoekstra,MD, Ohio StateUniversity 197. GenderBias and Thrombolytic Therapy,Raymond E. Jackson,MD, William BeaumontHospitai 198. A Continuouseuality ImprovementApproachApplied to EmergencyDepartmentCare of Asthmipatients, Richard Sinert,DO, Kings CountyHospital 199. Percutaneous Translaryngeal Jet Ventilation(pTV) in the EmergencyDepartment,John W. McGilt, MD, Hennepin CountyMedical Center 200. PulmonaryMechanicsof Dogs During Transtracheal Jet Ventilation,Michqel L. Carl, MD, Universityof Calfornia, Davis 201. Estradiol Withdrawl Alters Rabbit Bronchial Smooth Muscle Response,Emil M. Skobelffi MD, MeclicatCollepe of Pennsylvania

ScientificPapers:Health Care (10:15-12:00 noon) Moderator: Robert A. Lowe, MD, MpH, University of Califo rnia, San F rancisco 183. WITHDRAWN 184. Do-FmergencyDeparlmentsReally Serveas the Medically Indigent's "safety Net"?, Tammyy. Kastre, MD, Uni_ versityofArizona 18

ScientificPapers:Clinical-General(1:30-3:00pm)

222. Ethanol-RelatedHypoglycemia is Uncommon,Andrew Sucov,MD, Brown University

Moderator: Marcus Martin, MD, Medical College of Pennsylvania, Allegheny Campus 202. SplenicTrauma: Correlationof CT Grading SystemsWith Prognosisand Management,M. Sterret, MD, Buttenvorth Hospital 203. A Comparisonof Sinus X-rays with ComputedTomography in Acute Sinusitis,ThomasF. Burke, MD, Madiean Army Medical Center 204. Clinical ScaphoidFracture:Can Day Four Bone ScansAccuratelyPredictthe Presenceor Absenceof ScaphoidFracture?,David Murphy, MD, Universityof WesternOntario 205. Electrocardiographic"Abnormalities" in Patientswith Cocaine AssociatedChest Pain may be due to "Normal" Variations,Judd Hollander,MD, SUNYat StonyBrook 206. Nicroglycerinin the Treatmentof CocaineAssociated ChestPain: Clinical Safety and Efficacy, Judd Hollander, MD, Bronx Municipal Hospital Center 207. SystemicHemodynamicand OxygenTransportResponse t o G r a d e dC a r b o n M o n o x i d e P o i s o n i n g ,H o w a r d A .

Smithline,MD, Henry Ford Hospital

zzJ.

New Onset Seizures:Which PatientsRequireAdmission?, Francis De Roos,MD, Harbor-UCl,A

224. The History of Untreated Vascular Injuries, Eric Hoffer, MD, SUNYat Brooklyn

225.Comparisonof Intralingual,Intravenous,and Intramuscular Administration of Succinylcholinein the Swine Modet, Michael S. Killen, MD, Joint Military Medical Centers

226. Opening of a Less Urgent TreatmentArea in the Emergency Department(ED) Significantly Reducesthe Left Without Treatment(LWT) Rate,Robert O'Connor,MD, St. Francis Hospital 221.E m e r g e n c yD e p a r t m e n tT e l e p h o n eA d v i c e - W h o ' s Calling?,WendyC. Coates,MD, Harbor-UCLA 228.What is an AppropriateED Visit? An Explanationfor the Failure to Agree,RobertA. Lowe,MD, MPH, Universityof Califurnia, San F rancisco

229.E Codes Assignedfrom EmergencyDepartmentRecords: Is the Information There?,Robert J. Schwartz,MD, MPH, Hartford Hospital

230. Tracking the Loss of External Cause-of-InjuryInformation

PosterSessionC (3:15-5:00pm) Clinical Practice/General

From Patientto Physicianto the Medical Record,RobertJ. Schwartz,MD, MPH, Hartford Hospital

208. CosrEffectivenessAnalysesin the EmergencyMedicine Literature:An Assessmentof CurrentMethodologicalPractices,David J. Magid, MD, DenverAffiliated Residency 209. The Health Care Experienceof PatientsWith Low Literacy,WendyC. Coates,MD, Harbor-UCLA 210. Promoting Alertness and Performanceon the Night Shift: An InterventionStudy,RebeccaSmith-Coggins,MD, Stanford University 211. The Incidenceof "Burnout"andIdentificationof High Risk StressorsAmong Graduatesof an EmergencyMedicine ResidencyProgram, Guy M. Newland, MD, Wright State University 272. ChemicalDependencyin EmergencyMedicine Residency Programs:Perspectiveof the ProgramDirectors,RobertM. McNamara,MD, Medical Collegeof Pennsylvania 213. CT ScansAfter Head Trauma:Redefiningthe Low-Risk Patient,C. DeSibour,MD, ButterworthHospital 214. Identificationof Ethanol - IntoxicatedMinor Head Trauma Patients Requiring CT Scans,Laura Staffeld-Cook,MD, Highland GeneralHospital 215. A Comparisonof the ExternalRotationand the Hanging Weight Techniquesfor Anterior ShoulderDislocation Reduction,Daniel J. Dire, MD, Universityof Oklahoma 216. A Radiographic Comparisonof ShortArm CastandPlaster and FiberglassWrist Splints,Kevin T. Jordan,MD, Wilford Hall Medical Center 217. Triage Nurse Use of Decision Rules for Radiographyin Ankle Injuries,Ian G. Stiell, MD, Universityof Ottawa 218. Flexion/ExtensionViews in the EmergencyDepartment Evaluation of Acute Cervical Spine Injury, Juliana Karp, MD, Denver GeneralHospital 219. Misdiagnosis of Appendicitisin Womenof Child-bearing Age, StevenG. Rothrock MD, OrlandoRegionalMedical Center 220. Definrng the PositiveTilt Test: A Study of Healthy Adults with ModerateAcute Blood Loss, Michael Witting, MD, University of F lorida, Jacksonville

231.TargetedScreeningand Empiric Treatmentfor Syphilis in an Urban Inner City EmergencyDepartmentand Related HIV Rates,Amy A. Ernst,MD, LouisianaStateUniversity

233.LidocaineversusDiphenhydraminefor Local Anesthesiain Minor Skin Lacerations,Amy A. Ernst, MD, Louisiana StateUniversity z J z . The Prevalence of PneumococcalVaccinationAmong High Risk Groups Presentingto the EmergencyDepartment, Frederick Yates,MD, BrookeArmy Medical Center z J + . Repairing Skin Lacerations:Glue is Fasterand Just as Effective as Suture,M. Halperin, MD, Universityof Colorado 235.Follow-up of Facial LacerationsSuturedin the Emergency Department,Ilya Chern,MD, St.BarnabasHospital

236.A Surveyof Patients65 Years of Age or Older Discharged From the EmergencyDepartment,William J. Angelos,MD, Universityof Pittsburgh Assessmentof Risk of Death or IncreasedDependencein the Elderly Patient, Drew B. Richardson,MB, BS, Royal BrisbaneHospital 238. Geriatric PatientsWith Fever: Clinical Significance, CatherineA. Marco, MD, JohnsHopkins University 239. ED Immunization of the Elderly with Pneumococcaland InfluenzaVaccine,RobertM. Rodriguez,MD, UCIA 240. Comparisonof Oral and TympanicThermographyas Tools to Screenfor Fever in Adult EmergencyPatients,Edmond A. Hooker,MD, Universityof Inuisville 241. Use of a Magnetic IntubationStylet and MagneticField Sensorfor EndotrachealTube Positioning,StevenJ. White, MD, VanderbiltUniversity ', A"' PulseOximetry is Accuratein Acute Anemia from Hemorrhage, Gregory D. Jay, MD, PhD, University of Massachusetts z+J - The Use of Pulse Oximetry to Predict Hypoxia in Patients with Pneumonia,Mumtaz Husain, MD, Cook County Hospital 15t-

I9

ANNUAL BUSINESSMEETING AGENDA Elections, Louis S. Binder, MD, Chair, NominatingCommittee The slateof nomineesis listed below andbiographicalinformationon eachcandidateis publishedin this program.

President-Elect- (one 1-yearposition) David P. Sklar, MD Secretary/Treasurer- (one3-yearposition) StevenC. Dronen,MD Gary Young, MD Board of Directors - (two 3-yearpositionsand one 2-yearposition) Larry Baraff, MD CareyChisholm,MD Lewis R. Goldfrank,MD Art Kellermann,MD SandraSchneider,MD ScottSyverud,MD Nominating Committee Member - (two 2-yearpositions) JohnGallagher,MD RobertJorden,MD V. Gail Ray,MD JudithE. Tintinalli,MD Constitution and Bylaws Committee Member - (one 3-yearposition) Jeff Jones,MD Brian Zink, MD 2.

Amendments to the Constitution and Bylaws, SandraSchneider,MD, Chair, Constitutionand Bylaws Committee The entireConstitutionand Bylaws and the proposedamendmentsarepublishedin this program.

3 . Awards Presentations,JamesNiemann,MD; Louis Ling, MD; Jeff Jones,MD The list of awardrecipientsis publishedin this program.

4.

Secretary-TreasurertsReport A. Membershipat April 21,1993:2,581 AssociateMembers:278 ActiveMembers:1,235 EmeritusMembers:15 Members:78 International B. FinancialReport- Year EndingDecember31,1992

ResidentMembers:781 HonoraryMembers:12

MedicalStudents:158 Pending:24

Expenses ..$155,827 Salaries, Wages,Taxes............. .................$118,598 A n n u aM l eeting......... ......-..$22,236 Printing......... ..............$45,576 Telephone andPostage... ...................$46,642 OtherAdministration ...............$41,658.

AAMC/Otherorganizations/meetings ......................$9,158'" AnnalsSubscriptions publication .................$28,864 Newsletter ..........$12,300 EMF.............. ........$50,000 PhysioControlFellowship.. .$37,642 ConsultingService

Revenues . . . . . . . . . $ 3, 1 Dues..............

91 92 ...................$153,641 A n n u aM l eeting........

PhysioControlFellowship ............$50,000 . . . . . . . . . .I .1$, 9 5I EMFcontributions..............

Interest Income ........$22,389 Adverlising... ...............$20,360 Newsletter S a l eo f M a i l i n gL i s t . . . . . . . . . . . . .............$3,452 . . . . . . . . . . . . . $19I , 8 Other............. . . . . . . . . . . . . . . .,$52679 C o n s u l t i nSge r v i c e . . . . . . . . . .

......$568,501 TOTAL......... *includesoffice supplies,photocopying,printing, office rent and insurance,accounting,bank charges,president'sdiscretionaryfund. **includes Council of AcademicSocietiesdues,AAMC representatives expenses,staff expensesto attendAAMC Annual Meeting and ACEP Scientific Assembly,SAEM sponsoredposter at the AAMC Annual Meeting, AMA, Iong range planning session,and committeeexpenses.

5. President'sAddress:Louis LingoMD 6. Introduction of New President: Louis Binder, MD 7. New Business 8. Adjournment

20

HAL JAYNE ACADEMIC EXCELLENCE AWARD

Arthur B. Sanders.MD

cardiacresuscitation.He has servedas a presidentof his local AmericanHeart AssociationAffiliate, as a member of the Board of Directors of the Arizona Heart Association,the National Faculty of the American Heart Association'sAdvancedLife SupportCourseand was a contributor to the developmentof the American Heart Association's Standardsand Guidelinesfor CPR and EmergencyCardiac Care. He is currently a member of the AmericanHeart Association'sNationalACLS Subcommittee.

Dr. Sandersgraduatedfrom Cornell University Medical Schoolin 1973.He completed his residencyin internal medicine at the University of Arizona Affiliated Hospitals in 1976 and shortly thereafter was named to the faculty of the University of Arizona Collegeof Medicine in Emergency Medicine and Family and CommunityMedicine.He was promotedto Professorof EmergencyMedicinein 1989.

In 1990 SAEM formed a Task Force to investigatethe impact of the growing needsof the elderly for emergency medical services.Dr. Sandersvolunteeredto chair this Task Force and to serveas Principal Investigatorfor two successfulresearchgrant applicationsto the John A. Hartford Foundation which totalled almost one million dollars.The first grant determinedthe attitudesof health professionals,educatorsand consumersregardingthe emergencycare of the elderly and set priorities for service,researchand educationalneedsin this area.The resultsof this effort were publishedas a monographand as a seriesof articles in Annals of EmergencyMedicine.

The current grant focuseson the developmentof a training model and principals of geriatric emergency care, the developmentof a practice guideline for the emergencymanagementof falls in the elderly, and funds seedgrantsin researchin geriatricemergencymedicine.

Dr. Sanders'contributionsencompassthe teachingof clinical emergencymedicine,leadershipin original scientific researchand selflessserviceto many emergency medicine and related organizations.His primary academic interestsare biomedical ethics in emergency medicine, emergencymedicine education,cardiac arrest and resuscitationand most recently geriatric emergency medicine.Dr, Sanders'first grant was a fellowship for the study of biomedicalethics from the National Endowmentfor the Humanities.He has servedas Chair of the ACEP Ethics Committee,and was the lead author of ACEP's EthicsManualfor which he receivedACEP's ServiceAward. He is a co-authorof the standardtext in "Ethics in EmergencyMedicine." Dr. Sanders this field: also servedon the SAEM Ethics Committee.

Dr. Sandersis the author of over 100 publicationsincluding more than 60 original researchpublicationsin peer reviewedjournals. He is a memberof the Editorial Board of the Journal of EmergencyMedicine and a consultantreviewerfor many other publicationsincluding JAMA, Circulation, Resuscitation,and Annals ef EmergencyMedicine.

Dr. Sanders'dedicationto educationin emergency medicineis attestedto by his continuousinvolvementas a faculty and researchadvisor to medical studentsat the University of Arizona and as course director for the EmergencyMedicine Elective.He is consistentlyratedan outstandingand dedicatedteacher.He has served as coursedirector for over 24 educationalprogramsand has developeda clinical moduleof advancedproblemsolving in emergencymedicine.As chairmanof the,STEM UndergraduateCurriculum PromotionCommitteehe was ins t r u m e n t a l i n t h e d e v e l o p m e n to f C o r e C o n t e n t KnowledgeBase and Skills List for UndergraduateEducation in EmergencyMedicine. In 1989 he receivedthe Vernon and Virginia Furrow Award for Innovations in Medical Educationfor the developmentof a programfor problem solving in emergencymedicine. computer-based He has servedas chair of SAEM's ResidentIn-Service "EmergencyMediSurvey Task Force, and co-authored cine: An Approachto Clinical ProblemSolving." He will begin his term as SAEM's ProgramChair in May.

It's difficult to believethat with all theseactivities,Dr. Sanderswould have time for anything else.However,as many of you know, his quiet but effective leadershiphas been key to the successof many of the organizationsof academicemergencymedicine.He hasbeena memberof the Board of Directors of STEM, UAEM, SAEM, the Arizona Chapterof ACEP, the Associationof Academic Chairs of EmergencyMedicine, and has servedas an officer of severalof theseorsanizations.He was President of SAEM in 1989-90.

SAEM is proud to bestowthis year's Hal JayneAward for Academic Excellenceto Arthur B. Sanders,MD, for his outstandingcontributionsto academicemergency medicine. His hard work, personalintegrity, dedication and unassumingbut effective leadershipstyle serveas a modelfor future leaders.

His researchinterestsin cardiacresuscitationhave included acid base balanceand the role of oxygen-free radicalsin cardiacarrest,and the use of end tidal CO2 in

2l

AWARD PRESENTATIONS The Hal JayneAcademicExcellenceAward and the awardslisted below will be presentedduring the Annual BusinessMeeting.

1993 Physio Control Fellowship David E. Persse, MD Institution:Baylor Collegeof Medicine T h i s $ 5 0 , 0 0 0f e l l o w s h i p i s s p o n s o r e db y P h y s i o C o n t r o l Corporation.

Selectedto be Presentedat the AAMC Annual Meeting "Evaluationof Criteria Usedto SelectApplicantsfor Emergency Medicine Residencies,"Richard Wolfe, MD, Denver General Hospital "Characteristics InfluencingCareerDecisionsof Academicand NonacademicEmergencyPhysicians,"Arthur Sanders,MD, University of Arizona

1993SAEM/EMtr'Innovations in Medical Education Awards "Implementation and Evaluationof ADLS: A Model for Educating Medical Studentsin ED Evaluationand Documentation," JudithA. Linden,MD, GeorgeWashingtonUniversity "Evaluatingthe Medical Literature:A Computer-Based Tutorial," JamesDougherty,MD, Akron GeneralMedical Center "An Emergency MedicineComputer-Based InterestingCase/ RadiographLibrary," David Seaberg,MD, EmergencyMedicine Association of Pittsburgh "Teaching MethodComparisonfor SeniorMedicalStudentEducation in EmergencyMedicine," ColletteWyte, MD, NorthwesternUniversity "InnovativeMethods for Evaluationof EmergencyPhysicians' Competencies in PerformingClinical Skills," Raywin R. Huang, PhD.WayneStateUniversity

Best Oral Methodology Presentation "Prosecution Injured of Alcohol-IntoxicatedDrivers for DWI," Jeff Runge,MD, CarolinasMedical Center

BestOral ResidenUFellow Presentation "A Trial of Multiple ResuscitationRegimensin SevereHemorrhagicShock,"SusanStern,MD, Universityof Cincinnati

Best ResidentPoster "Preventionof NeurologicSequelaeFrom CarbonMonoxideby HyperbaricOxygen in Rats," ChristianTomaszewski,MD, Carolinas MedicalCenter

1992 AnnualMeeting Awards Best Oral Clinical SciencePresentation "Interrater Agreement of ParamedicRhythm Labeling: Implications for Uniform Reporting of Data From Out-of-HospitalCardiacArrest,"Ron Pirrallo,MD, William BeaumontHospital

Best Pediatric Emergency and Critical Care Presentation "A Clinical Trial ComparingN-2-Butyl-Cyanoacrylate With Suturing Facial Lacerationsin Children," Jim Quinn, MD, Universityof Ottawa

Best Oral Basic SciencePresentation "Altered Pattems of CerebralCortex Energy Metabolism and Normalizationby IntravenousAcetyl-L-CarnitineFollowing Cardiac Arrestin Dogs,"GaryFiskum,PhD,GeorgeWashingtonUniversity

Best Medical Student Presentation "In Vitro Effect of Deferoxamineand 2 1 - A m i n o s t e r o i o dn Hyperbaric-InducedLipid Peroxidationin Rat Brain," Kristin Mascotti,BS, Universityof Minnesota

Best Poster "Fluorescent HistochemicalLocalizationof Lipid PeroxidationDuring BrainReperfusion," BlaineWhite,MD, WayneStateUniversity Best Innovations in Medical Education Presentation "A New EducationalProgram for Death Telling: Didactic, Video, and StandarizedFamily Scenarios,"Robert Schwartz, MD, Hartford Hospital

Best Technology Presentation "Comparisonof a Neutral Network Versus Triss for Predicting Survival After Trauma," CharlesShufflebarger,MD, Methodist Hospitalof Indiana

22

1993SLATE OF NOMINEES the SAEM Annual Meetingeveryyearsince1989.At the SAEM Annual Meetingsfrom l99l-93, he hasthe Coordinatorof 3 Panelsessions.He hasparticipatedon the ACEP Editorial Board Home Study Coursefrom 1990-93and he will be its next chairperson.He was President-Electof OregonACEP from l99I-92 and Chair of the OregonACEPEducationandResearch Committeefrom 1989-92.Dr. Young is a reviewerfor Annals of EmergencyMedicine,American Journal of EmergencyMedicine,Jownal of EmergencyMedicine, Joumal of Medical DecisionMaking andthe new SAEM Joumal.

PRESIDENT.ELECT David P. Sklar. MD. is Professor and Vice Chairman of the Department of EmergencyMedicine at the University of New Mexico School of Medicine. He is also the Residency Director of the EmergencyMedicine Residency.He graduatedfrom Stanford University Medical School in 1976 andcompletedan InternalMedi c i n e R e s i d e n c ya n d E m e r g e n c y MedicineFellowshipat Universityof California,San Franciscoin 1980.

David P. Sklar, MD Dr. Sklar has been on the Board of Directorsof SAEM from 1991-1993and has alsobeenPresident of the Council of ResidencyDirectorsfrom 1991-1993.He is a memberof the SAEM Ethics Committee,the ProgramTask Force of the EducationCommitteeand is the Board liaison to the Education Committee,InternationalCommitteeand InserviceSurvey Task Force.He is a reviewer for Annals of EmergencyMedicine andAcademicMedicine and servesas an oral Board Examinerfor the AmericanBoardof EmergencvMedicine.

BOARD OF DIRECTORS Larry J. Baraff, MD, is a professor of EmergencyMedicine and Pediatrics andthe AssociateDirectorof the UCLA EmergencyMedicineCenter.

He graduatedfrom GeorgetownUniversityMedicalSchoolin 1970,comp l e t e d h i s p e d i a t r i c r e s i d e n c ya t GeorgetownUniversityHospitalin 1973 and an infectious diseasefellowship at the Los AngelesCountyU S C M e d i c a l C e n t e ri n 1 9 7 6 .D r .

Baraff is a past memberof the SteerLarry J. Baraff, MD ine Committeeof the NationalCouncil and the Boardof Directorsof the AmericanCollegeof EmergencyPhysicians.Currently,he is a memberof the SAEM Geriatric EmergencyI\{edicineTask Force,the Nominating Committee andthe PublicHealthCommittee.He is alsoa memberof the Annals of EmergencyMedicine Editorial Board and the Executive Committeeof the SouthernCaliforniaInjury PreventionResearch Center.He hasbeena memberof SAEM since1982.

SECRETARY/TREASURER StevenDronen, MD, is an Associate Professorof EmergencyMedicineat the Universityof Cincinnatiand in July will becomethe ResidencyProgram Director at the University of Michigan.He has beena memberof SAEM since 1983,has servedon the Board of Directorssince 1991,and from 1989-1992 he servedas Chairmanof the Residency Aid Committee.

He is currentlythe Chair of the Curriculum Task Force.Since 1991he StevenDronen. MD has been the Director of the SAEM ResidencyConsultingServiceandhe coordinatesthe publicationof the Catalogueof EmergencyMedicineResidencyProgramswhich is now in its third edition.He has beena memberof the CORD Board of Directorssince 1989and has servedas Vice President since 1991.Dr. Dronengraduatedfrom the Universityof Illinois Medical Schoolin 1977and completedan EmergencyMedicine Residency in 1980from HenryFordHospital.

Lewis R. Goldfrank, MD, is an AssociateProfessorof Clinical Medicine at New York UniversitySchool of Medicine and Director of Emergency Servicesat BellevueHospital C e n t e ra n d N e w Y o r k U n i v e r s i t y Medical Center.He is also Medical Director at the New York City Poi* son Control Center.Dr. Goldfrank graduatedfrom University of Bruss e l s ,B e l g i u m M e d i c a l S c h o o li n 1970and completedhis residencyin Lewis Goldfrank, MD InternalMedicine at MontefioreHospital andMedicalCenterin 1913.Dr.Goldfrankwas appointedto the SAEM Board of Directors in 1990 and was electedto the Boardin 1991.He hasbeena memberof SAEM since1974.He has frequentlybeen an Annual Meeting abstractreviewer and sessionmoderator.Dr. Goldfrankis a memberof the Editorial Board of Clinical Toxicology and,Medical Toxicology.He is immediatePast Chairman of the American Board of Medical Toxicology.He waselectedasthe first Chairmanof the American Board of EmergencyMedicine subboardon Medical Toxicology.

Gary P. YoungoMD, graduatedfrom medical schoolat OregonHealth SciencesUniversityin 1979,completed an internshipat OregonHealth SciencesUniversityin 1980,and a Combined EmergencyMedicineand Internal Medicine Residencyat Kern CountyMedicalCenterin 1983.Currently, Dr. Young is the Chairmanof . the Departmentof EmergencyMedi,irir,rrr. ,i '&r cine at HighlandGeneralHotplll._f: .,

Gary P. Young, MD

has been a member of the SAEM Governmental Affairs Committee

"ce 1989andhe hasbeenselected to be its nextchairman.Since 1, he has been a memberof the Pharmaceuticaland Biotechy Liaison Committee.He hasbeenpresentedoral abstractsat L-)

at the 1988 Annual Meeting. She has been a memberof the T e c h n o l o g yC o m m i t t e ef r o m 1 9 8 8 - 1 9 9 3a, m e m b e ro f t h e Constitutionand Bylaws Committeefrom 1990-1993and Chair of that Committee from 1992-1993.Dr. Schneiderhas been Secretaryof the ACEP Section on Toxicology from 199l-1993, has been on the Editorial Board for the Journal of Prehospital and Disaster Medicine, a reviewer for the American Journal of Medicine, and won an SAEM/EMF Medical StudentResearch Award for 1992-1993.Currently, Dr. Schneideris Associate Chief in the Division of EmergencyMedicine, and Associate Professorof Medicine at the University of PittsburghMedical Center.In July she will assumethe position of Professorand Chair of EmergencyMedicine at the University of Rochester.

Carey Chisholm, MD, is the E m e r g e n c yM e d i c i n e R e s i d e n c y Director at Methodist Hospital of Indiana and a Clinical AssociateProfessorof EmergencyMedicine at IndianaUniversitySchoolof Medicine.

He servedon the SAEM EMS Committee from 1986-1991,and on the R e s i d e n c yA i d C o m m i t t e e f r o m 1989-1993,and since 1992has been the Chairmanof the ResidencyAid Committee.Since 1988,he has been Carey Chisholm, MD a soecial site survevor for the RRCEM. Dr. Chisholm is a consultantfor the SAEM Residency Consulting Service, a member of the Program Committee, a member of the ACEP Academic Affairs Committee. and since 1991,has servedon the CORD Board of Directors.He has also been an Editorial reviewer for Annals of EmergencyMedicine since 1989and since 1992 an Editorial reviewerfor AJEM.DT. Chisholm graduatedfrom the Medical College of Virginia in 1 9 8 0 , c o m p l e t e da t r a n s i t i o n a li n t e r n s h i pi n 1 9 8 1 a n d a n EmergencyMedicine Residencyin 1983 from Madigan Army Medical Center.

Scott Syverud, MD, is Research Director and AssociateProfessorin the Division of EmergencyMedicine at the University of Virginia Health SciencesCenter.He was a member o f t h e E M R A E x e c u t i v eC o u n c i l from 1984-1985, an EMRA representative to UAEM ExecutiveCouncil, and the STEM Board of Directors He wasalsoa memfrom 1984-1985. ber of the UAEM GovernmentalAfthe fairs Committeefrom 1986-1987, Scott Syverud, MD UAEM Local ArrangementsChair in 1988,the Chief Residents'ProgramOrganizerin 1990,a member of the SAEM ProgramCommitteefrom 1988-1993,and participatedas a moderatorat the SAEM ResearchSessionsat the 1986 and 1988AnnualMeetings.Dr. Syverudis a reviewerfor Annals of EmergencyMedicine, AJEM, JAMA, and Clinical Chemistry.

He is Co-editor of EmergencyDrug Therapy,and a contributor for the ACLS test, 3rd edition, 1993.Dr. Syverudgraduatedfrom medicalschoolat SUNY Syracusein 1981,completedan Internship and EmergencyMedicine Residencyat the University of Cincinnatiin 1985,a ResearchFellowshipin 1984and a Chief Residencyin 1985.

Arthur L. Kellermann, MD, MPH, graduatedfrom Emory University School of Medicine in 1980,completedan InternalMedicineresidency at the University of Washingtonin 1983,and completedhis mastersof public health followed by a general InternalMedicinefellowshipin 1985.

He joined UA/EM in 1986andis currently a member of SAEM. Dr. Kellermann was the recipient of the Arthur L. Kellermann, JamesMackenzieawardat the 1987 MD. MPH Annual Meeting. He is a reviewerfor the New England Journal of Medicine, Journal of the American Medical Association,Annals of EmergencyMedicine and the American Journal of EmergencyMedicine. Dr. Kellermann servedon the SAEM Nominating Committeein 1991 and 1992 and hasbeena memberof the Programand GovernmentalAffairs Committeessince1991.He is currentlyan AssociateProfessorin the Departmentof Internal Medicine, Chief, Division of Emergency Medicine; and AssociateProfessor,Departmentof Preventive Medicine, at the University of Tennesseeat Memphis. In September1993,Dr. Kellermannwill becomeResearchDirector for the Division of EmergencyMedicine at Emory University and will direct the Emory Centerfor Injury Preventionand Control.

SandraSchneider,MD

NOMINATING COMMITTEE MEMBER E. John Gallagher, MD, has been the Chair of EmergencyMedicine at Bronx Municipal Hospital/Albert Einstein College of Medicine since 7979.Prlorto this, he was directorof the EmergencyMedicine Residency at that institution.He receivedhis MD from the University of Pennsylvania, and was subsequentlyboarded in Medicine and EmergencyMedic i n e . D r . G a l l a g h e rh a s b e e n a n ABEM oral examinerfor ten years, E. John Gallagher,MD and is a reviewer for five medical journals,including theAnnals andJEM. He hasbeena memberof SAEM since 1989and is currently the chair of the SAEM Tradr tional AcademicCentersTask Force.He is currentlyAssocir Professorof Medicine, Epidemiology,and Social Medicin Albert Einstein.

Sandra M. Schneider,MD, graduated from the University of Pittsburgh Medical Schoolin 1975 and completedan Internal Medicine Internshipfrom the PresbyterianUniversity Hospital in 1916,as well an Internal Medicine Residencyat the sameHospitalin 1978.Shehasbeen a memberof UAEM, STEM and S A E M s i n c e 1 9 8 4 .D r . S c h n e i d e r was a moderatorat the 1987 Annual Meeting and was the recipient of the Best Oral Basic SciencePaperAward

.,'^

CONSTITUTION AND BYLAWS COMMITTEE MEMBER

Robert C. Jorden, MD, is Chairman in the Department of Emergency Medicine at Maricopa Medical Center and a Clinical Professorin the Section of EmergencyMedicine at the University of Arizona School of Medicine. He is a member of the SAEM ResidencyAid Committee,a memberof the ResidencyConsulting Serviceand servedon the Task Force on Revisionsof the Core Content from 1989-1990.He has coordinated Robert C. Jorden, MD the National CPC Competitionsfor two years.He was a memberof the STEM ProgramPlanning C o m m i t t e ef r o m 1 9 8 3 - 1 9 8 5a n d a m e m b e r o f t h e U A E M Constitutionand Bylaws Committeefrom 1983-1984.Dr. Jorden has been a memberof SAEM since 1982.He is a reviewerfor JEM and.an AssistantSectionEditor of Case Conferencefor Annals. He is also a member of the ACEP Academic Affairs Committee.Dr. Jordengraduatedfrom Ohio State University in 1973,completeda Surgicalresidencyin 1976at New York University,andcompletedan EmergencyMedicineresidencyin 1980 from DenverGeneral.

Jeffrey S. Jones, MD, graduated from the University of New Mexico Medical School in 1984, completed an Intemshipand Residencyin Emergency Medicine at Akron General Medical Centerin 1987,and completed a Researchfellowship at Akron Generalin 1988. Dr. Joneshas been a member of STEM, UAEM and SAEM since 1984 and has servedon the SAEM Education Committee since 1987.Since 1990 Jeffrey S. Jones,MD he has been a memberof the SAEM Geriatric EmergencyMedicine Task Force, and since 1991,a memberof the Innovationsin EmergencyMedicine Education Subcommittee.

In 1987he was the recepientof the Emergency Medicine Residents'AssociationAcademicExcellenceAward.

Dr. Jonesis the ResearchDirector and an EmergencyMedicine ResidencyProgramstaff physicianat ButterworthHospital.

V. Gail Ray, MD, is a Professorand Chair of the Division of Emergency Medicine at the University of Arkansasfor Medical Sciences.Formerly, she was ResidencyDirector at East CarolinaUniversity and TexasTech University Health SciencesCenterin El Paso.She graduatedfrom the University of Arkansasfor Medical Sciencesin 1977 and completed her EmergencyMedicine Residencyat Truman Medical Center,University V. Gait Ray, MD of Missouri at KansasCitv in 1980.

Dr. Ray servedas Chair of the SAEM MembershipRecruitment and PublicEducationCommitteefrom 1989-1991and hasbeena consultantwith the ResidencyConsultingServicesince 1990.She was also a member of the SAEM Education Committeefrom 1986-1989and a memberof the ResidencyDirectorsCommittee from 1987-1989.Dr. Ray is a guestreviewer for Annals of EmergencyMedicineandhasbeena memberof SAEM since 1981.

Brian J. Zink, MD

Judith Tintinalli, MD, is Professor and Chair of the Departmentof Emergency Medicine at the University of North CarolinaSchool of Medicine.

She becamea member of UAEM in 1971 and has been a member of the SAEM Program Committee from 1984-1989.She was also the Program Chair for the 1984-86Annual Meetings. Dr. Tintinalli was Presidentof CORD from 1989-1991and is currently a memberof the CORD Board Judith Tintinalli, MD of Directors.She is a memberof the AnnalsEditorial Board and was alsothe Presidentof the American Board of EmergencyMedicine from 1988-1989.Dr. Tintinalli raduatedfrom Wayne StateUniversity Medical School in 1969, sitqp1s1"6an Internal Medicine internship at Detroit Receiving l99rital in 1970,and completedan Internal Medicine Residency nolog.Universityof Michigan in 1974.

25

Brian J. Zink, MD, is an Assistant Professorof Surgeryin the Sectionof EmergencyMedicine at the University of MichiganMedicalSchool.He graduatedfrom medical schoolat the Universityof Rochesterin 1984,and completedan EmergencyMedicine Residencyat the University of Cincinnatiin 1988.Dr. Zink hasbeenan SAEM membersince 1986,a member of the ResearchCommitteesince 1989and currently is the Coordinator for the ResearchConsultineService.

may petitionthe MembershipCommitteefor consideration for (2) Candidates activemembershiostatus.+Fdes+red. for associate membershipshall be healthprofessionals, educators,government officials,membersof lay or civic groups,or membersof the publicat largewho may havean interest or desireto participatein pursuingthe purposes and objectives of the Association.

(3)Candidates for emeritusmembership shallbe (a)activememberswho seeksuchstatusand who havegiven 15 continuous yearsof activeserviceto the Associationand haveattainedthe ageof 65 yearsor (b) otheractivememberswho underspecial circumstances are invitedfor suchemeritusstatusby the MembershipCommittee.(4) Candidates for residenVfellow membership mustbe residents trainingprograms or fellowsin residency who havean interestin emergency medicine.(5)Candidates for honorarymembership shallbe individuals who havemadeoutstandingresearchor educationalcontributions to the purpose a n d o b j e c t i v e so f t h e A s s o c i a t i o n(.6 ) C a n d i d a t e fso r i n t e r nationalmembership shallbe individuals who resideoutsidethe for activeor associate U.S.and who meetoualifications memb e r s h i pa s d e s c r i b e da b o v e .S u c hc a n d i d a t e m s a y a p p l yf o r (7) active,associate, or other membershipin the Association.

Candidatesfor medical studentmembershipmust be medical studentswho havean interestin emergencymedicine.

Section3: Member Rightsand Privileges.All membersmay havethe privilegeof the floor and of servingon the committees of the Association.,and servingas committeechairs. Only active and associatemembers may serveon the Boardof Directors@ sea.Only activemembersshallhavevotingrightsandshallmay serveasofficersof the Association.

Section4: The Associationshall not discriminate/wi.th+espeet te-i+s.+embersnrp, on the basisof race, sex, creed,religionor n a t i o n aol r i g i n .

ARTICI.E IV _ OFFICERS Section 7: The officers ei-this-e+geniza+ien shall be the President,\4ee*+esiCe+t{President-Elect), and Secretary-Treasu rer.

Section2; The Boardof Directorsshall serveas the governing body ei+he-aceeeiatiaa.

The Boardof Directorsshallconsistof the aboveofficers,@, the immediate past president,and {i,oesix €€{rq€ilfias+Members-at-Large.

Be+h

CONSTITUTION OF THESOCIETY FOR ACADEMICEMERGENCY MEDICINE A R T I C T IE- N A M E Thenameof thisorganization shallbe,"TheSocietyfor Academic Emergency Medicine,"hereinafter referred to as,"TheAssociation."

ART|CLE Ir OBfECTIVES Section/: The objectiveof this Associationis to improvethe emergency, urgent,or criticalcare of the acutelyill or injured patientby promotingresearch, by educatinghealthcareprofessionalsand the public,by fosteringrelationships with organizationswith a similarpurpose,and by supporting the specialized o r m u l t i d i s c i p l i ncea r eo f s u c h p a t i e n t st h r o u g hr e s e a r c a hn d education.

The Association will functionas a scientificand educationalorganization as definedin Section501 (c) (3) of the InternalRevenue Code,as amended.

S e c t i o n2 : f h e A s s o c i a t i o n s h a l l p u r s u ei t s p u r p o s eb y : 1 ) s p o n s o r i n gf o r u m sf o r t h e p r e s e n t a t i o on f p e e r - r e v i e w e d s c i e n t i f i ca n d e d u c a t i o n ailn v e s t i g a t i o n 2 s ,) s p o n s o r i n ga n d conveningeducationalprogramsfor healthcare professionals a n d t h e l a y p u b l i c ,3 ) p r o m o t i n ga c a d e m i cd e v e l o p m e natn d educationof its membership throughspecializedprograms,4) servingin an academiccapacityto developand promotefurther the mostappropriate measures for the careof the acutelyill or injuredpatient,5) developingliaisonswith otherorganizations w i t h a s i m i l a rp u r p o s e a, n d 6 ) p u b l i s h i n gr e s e a r c ha n d educational data in the scientificand educationalliterature and othermediaavailableto the lay public.

S e c t i o n3 ; A . T h i s c o r p o r a t i o ni s o r g a n i z e de x c l u s i v e l fyo r e d u c a t i o n aal n d s c i e n t i f i cp u r p o s e si,n c l u d i n gf,o r s u c h p u r poses,the makingof distributions to organizations that qualify asexemptorganizations underSection501 (c)(3)of the Internal provisionof any RevenueCode of 1954 (or the corresponding futureUnitedStateslnternalRevenueLaw).

B. No partof the net earningsof the corporationshall inureto the benefitof, or be distributableto its members,Directors,Officersor otherprivatepersons, exceptthat the corporationshall be authorizedand empoweredto pay reasonable compensation for services renderedand to makepaymentsand distributions in furtheranceof the purposesset forth in paragraphA hereof.No part of the activitiesof the corporationshallbe the substantial carryingon of propaganda, or otherwiseattempting to influence legislation, and the corporationshallnot participate in, or intervene in (includingthe publishingor distributionof statements) a n y p o l i t i c a cl a m p a i g no n b e h a l fo f a n y c a n d i d a t e for public office.Notwithstanding any otherprovisionof thesearticles,the corporationshallnot carryon any otheractivitiesnot permitted to be carriedon (a) by a corporationexemptfrom FederalIncometax underSection501 (c) (3)of the InternalRevenue Code provisionof any futureUnitedStates of 1954(or corresponding RevenueLaw)or (b) bv a corporation,contributions to which are deductibleunderSection170(c)(2) of the InternalRevenue C o d e o f 1 9 5 4 ( o r t h e c o r r e s p o n d i npgr o v i s i o no f a n y f u t u r e UnitedStatesInternalRevenue Law).

A R T I C TIEI I M E M B E R S H I P Section1: Classifications.

Thereshallbe sevenclassesof membership:active,associate, emeritus, resident/ellow, honorary, and internationalactiveand international associate, and medicalstudent.

Section2: Qualifications.(1) Candidatesfor active membershipshallbe (a) individualswith an advanceddegree(MD, P h D , D O , P h a r m D ,D S c ,o r e q u i v a l e n tw) h o h o l d a m e d i c a l schoolor universityfacultyappointment and who activelyparticipatein acute,emergency, or criticalcare in an administrative,teaching,or research capacity,or (b) individuals with similar degreesin activemilitaryservice(U.S.or abroad)who activelyparticipatein acute,emergency, or criticalcare in an adm i n i s t r a t i v et e, a c h i n go, r r e s e a r c h c a p a c i t y I. n d i v i d u a l w s ho otherwisemeetqualifications for activemembership as defined abovebut who do not hold a universityfacultv appointment

.

Section3; The Executive Committeeshallconsistof the Presipast-President dent,President-Elect, and Secretary-Treasu rer.

ARTICTE V _ COMMITTEES The standingcommittees€ft+€:A'ss€€iati€'t1 shallbe: (1) Nomi n a t i n gC o m m i t t e e(,2 ) M e m b e r s h i p C o m m i t t e e(,3 ) P r o g r a m Committee,(4) Constitution and BylawsCommittee,(5) Educa(6) Research (7) LiaisonCommittee tion Committee, Committee, to the Association of AmericanMedicalColleges,(B)CovernmentalAffairsCommittee,and (9) Committeeon International Affairs.Additionalcommitteesmay be createdby the Boardof Directorsand ad hoc committeesand task forces may be crea t e d b y t h e P r e s i d e ntto a i d i n t h e A s s o c i a t i o n 'es f f o r t st o achieveand furtheritsgoals.

ARTICTE VI _ ANNUATMEETING Section/; Thereshall be an annualmeetingof the Association. This meetingshallconsistof an educational and scientific programand a business session.

Section2: The Boardof Directors,by majorityvote, may call, upon 30 days notice,a specialmeetingof the membership or standingcommitteeto conductany business thatthe Boardof Directorsshallplacebeforethe membership or standingcommittee.

Section 3; A special meeting can be called by the membershipupon petition by 100 or more active membersstating the reason(s)for the meeting. The Secretary/Treasurer shall call sucha meetingwithin 30 daysof receivingthe petitionat a time and placedesignatedby the President.

Section34: Ihe Boardof Directorsmay call and conductany specialmeetingby mail. For purposesof notice,the meeting zo

Honoraryandemeritus members will not paydues.MemDirectors. maybeterminated for nonpayment of dues. bershipin theAssociation Section3: Rightsand privileges.All membershave the privand ilegeof the floor at businessmeetingsof the Association may serveas a committeemember,committeechairrer.Associof the ate or Active membersmay serveas a Member-at-Large Boardof Directors.Only activemembersmay vote and serveas officers.Any membermay submitagendaitemsfor considerationby the Boardof Directors.

ARTICTE II_ BOARDOF DIRECTORS Sectionl: Members.The Boardof Directorsshall consistof ident-EIect}, the Secrethe President, the Vi€€-+r€€i€h{r+{Pres taryflreasurer, the Immediate PastPresident,tfie*regta+a€lrai+, EMRA,AACEM,and CORD may and {+\€six Members-at-Large. eachappointan ex-officiomemberto the Board.

Section2: Responsibilifies.Members of the Board will meet regularlyto perform the businessof the Association.All scientific and educationalmeetingsof the Associationare to be approvedby the Board.Membersof the Boardmay serveon committeesof the Association,but no Boardmembermay serveasa committeechair, with the exceptionsof the President-Elect servingas Chair of the NominatingCommittee3nd the Secretaryfreasurer servingas Chair of the MembershipCommittee.

The entire Boardservesas the MembershipCommittee.Members of the Board may be appointedto serveas Chairsof Ad hoc Committeesand TaskForces.

S e c t i o n2 3 : E l e c t i o no f O f f i c e r s .( a ) T h e V i e e l r e s i d e n t President-Elect shallbe electedfor a term of one yearwith auto*eln+i€€++e5id€fl+to Presidentthe following matic succession year.Duringthistwo yearperiod,the electedmemberwill serve as an officer of the Association.Followingterms of Vi€€-Pres ident-{President-Elect} and President,this memberwill autoElecmaticallyassumethe positionof lmmediatePastPresident. t i o n a s V i e e P r e s i d e nPt r e s i d e n t - E l escht a l l c o n f e rB o a r do f Directorsmembershipfor a minimum of three years.f,le,minees b)'the Neminating €emmittee; and fer thiseffiee'rvill be seleeted iea

dateshallbe a datesetfor the returnof mail ballotsand it shall be calledthe votingdate.Adoptionof any proposal,resolution or amendmentby mail ballot shall be achievedby affirmative vote of a majorityof voting activemembersunlessotherwise providedby anotherprovisionof this constitution.

Only those mail ballotsreceivedat the businessoffice of the Association within 30 dayssubsequent to the votingdateshallbe counted.

ADOPTION OF AMENDMENTS ARTICLEVII - g+TAIATS Section 7: The constitution and bylaws may be adopted or amendedat any annualor specialmeetingof the membership. to the constitutionand bylaws Section2: Proposedamendments shall be submittedin writing to the Secretaryfireasurer by three members at least60 dayspriorto the meetingat whichtheyareto be considered.

The Secretaryfireasurer shallmailthe proposed amendmentsto themembership at least30 dayspriorto thatmeeting.

Section3: The Boardof Directorsmay, by resolution,propose amendmentsto the constitutionand bylaws;providedthe prooosedamendments are mailedto the membershioat least30 dayspriorto the meetingat which they areto be considered.

Section4: Adoptionof a constitutionand bylawsamendment shall be by a majorityvote of the active memberspresentand votingat any annualor specialmeeting.

ip

prierte the meetint at'rvhieh+he)' arete be eensidered, ma annuat+rspee+a+meeting ART|C|-E tX Vilt - DtSSOLUT|ON Uponthe dissolution o f t h e c o r p o r a t i o nt ,h e B o a r do f D i r ectorsshall,afterpayingor makingprovisionfor the paymentof all of the liabilitiesof the corporation disposeof all of the assets of the corporationexclusivelyfor the purposesof the corporation in such manner,or to such organizations organizedand for charitable, educational, religiousor scioperatedexclusively entificpurposes as shallat the time qualifyas an exemptorganizationor organizations underSection501(c) (3) of the Internal provisionof any RevenueCode of 1954 (or the corresponding futureUnitedStatesInternalRevenueLaw).asthe Boardof Directorsshalldetermine.

Any suchassetsnot so disposedof shall in the Council be disposedby a Courtof Competent Jurisdiction in which the principalofficeof the corporationis then located for suchpurposes or to suchorganization or organiexclusively zations,as saidcourtshalldetermine, which are organizedand for suchpurposes. operatedexclusively

nemineesmuetatsea

(b)The shall be electedto a three year term. An Secretaryflreasurer activemembermay serveonly one term as Secretaryfireasurer.

Nemineesfer this effieeshall be seleetedb)' the Neminating €emmitteeand must have a8reedte standfer eleetienprier te fer eleetienat the business sessien ef the theirfermal-neminatien ie+ memberspresent Eleetienshall be b)' maierity'r'eteef the aeti,o'e

the f ieminating€emmitteeand Pre8ram€ernmittee;and ma)' M Members-at-Large Section34: Electionof Members-at-Large. shall be electedto s'i4ethree-yearterms,the terms being staggered.Members-at-Large may @not servemore than two terms consecutively. seeri+ive+e+ms' Section5: Nomineesfor Election.Nomineesfor this the above and must officesshallbe selected by the NominatingCommittee haveagreedto standfor electionpriorto theirformalnomination for electionat the business session of the annualmeeting.Alternativenominationsmay be offeredfrom the floor. Suchnomineesmustalsoagreeto standfor election.Electionshallbe by majorityvote of the activememberspresentand votingat the business session ofthe annualmeeting.

FORACADEMIC BYLAWS OF THESOCIETY EME R G EN CMYE D IC IN E ARTICTE I - MEMBERSHIP Membershipapplicationforms Section1: ApplicationProcess. may be obtainedfromthe Executive Directorof the Association.

The Applicantmustreturnthe completedapplicationformsand of lettersto the Executive Director.Thequalifications supporting applicantsfor membershipwill be reviewedby the Executive Directorand Secretaryfireasurer.

Approvalof applicantsby the elecExecutive Directorand Secretaryfireasurer shallconstitute tion to one of the membership categories, effectiveimmediately. residenV Section2: Dues.Annual duesfor active,associate, fellow,and international members will be established by the Boardof 27

in€ @as

Section910: Duties of the SecretaryfTreasurer. lt shall be the duty of the Secretaryfireasurer to be the spokesperson of the Associationand to presidein the absenceof both the President and Viee President President-Elect.

The Secretaryfireasurer shallkeep a t r u e a n d c o r r e c tr e c o r do f t h e p r o c e e d i n gos f t h e a n n u a l business meetingand meetingsof the Boardof Directors, shall preserve documentsbelongingto the Association and issuenotice o f t h e a n n u a lb u s i n e sm s e e t i n ga n d m e e t i n g os f t h e B o a r do f Directors.

The Secretaryfreasurer @in€r shallkeepan accountof the Association with its membersand maintaina currentregisterof memberswith datesof theirelection Lo membership and preferredmai Iing address.rthe-{a*te++e*e

€hairsef ^d he€ $mmittees,er

Eeetien 4: Eleetien ef Preqram €emmittee €hai+, The Pretram te standfer eleetienprierte theirfermalneminatienfe- eleetienat the business sessien ef the annualmeetirg,'\lternativeneminatieas 'o'i'ill be aeeeeted frem the fleer,Suehnemineesmustalsea6reete ive membe'spresentand vetirg at the business sessienef the annual meeting,The Pre8ram€emmitbe€ha.i+shallnet be elieibrefer

afirtr€*$rxifi€fsffi+ifit!

The Secretaryflreasurershall be responsible for reportingunfinished business requiringactionfrom previousmeetingsof the membership or Boardof Directorsand in conjunctionwith the Presidentv*ill shall be responsible for the agendaof the annualbusiness meetingand meetings of the Board of Directors.The Secretaryfireasurer shallcollectthe duesof the Association, makedisbursements of expenses, and Fnainta+F overseethe financialaccountsand recordsof the Association.

The Secretary/freasurershallchairthe MembershipCommittee.

The financialrecordwill be presented to the membership at the annualbusiness meeting, biannually to the Boardof Directors, and at suchtimesas requested by the President of the Association.

The financialrecordsof the Association shallbe reviewedannuallyby two other membersof the Boardof Directorsappointedby the President, or a certifiedaccountant or financialconsultantretained by the Boardof Directors.€{+h€+sffi€iati€ft Section 1411: Duties of 8ee44{{he+ti+eeta.? Members-atlarge. Members-at-Large si8ned bi' the effi€ Byfas'€€i+h€k'a+i* shall representthe membershipin conductingthe Association's business, abideby the Constitutionand Bylawsof the Association,and representthe Associationin activitiesrelatedto academicemergencymedicine.

Seetienl1: Dutieref lregram €emrnifteeehair, ,\etint ander t h e a u s p i e e se f t h e P r e s i d e nat n d B e a r de f D i r e e t e r se r t h e

Section56: Termsof Office.Termsof office will begin at the conclusionof the annualbusiness meeting.The President shall appointeligibleAssociation membersto fill vacanciesand unexpiredtermson the Boardof Directorsand standingand ad hoc committees untilthe nextscheduled election, Section67: Meetings.ffi Meetingsof the Boardof Directorsor ExecutiveCommifteewill be conveneda+-leas+ in accordancewith the Policiesand Procedures Manual.AdditieaalSpecial meetingsmay be convenedat the President's discretionor by petitionof six membersof the Boardof Directors.A final noticeof time and placeof suchmeetings shallbe sentto all members of the Boardby the Secretary/ Treasurer at least7 daysbeforethe meeting.

Sixmembers of the Boardof Directors will constitute a quorum.Any Membersof the Associatio@ may submitagendaitems.Suchitemsmustbe submitted within30 daysof the meetingdate.Meetingsof the Boardof Directorsare opento all members of theAssociation andto the public.Closedmeetings of the *'s€€iati€nt€#i€€rs Boardand ExecutiveCommitteeand Executive Directormaybe convenedby orderof the President.

Section78: Dutiesof the PresidentThe Presidentshall serveas the spokesperson for the Associationand presideover beth the programand business educational session of the annualmeetingof the Association, and the meetings of the Boardof Directors.lt shall be the duty of the President to seethat the rulesof orderand decorumare properlyenforcedin all deliberations of the Association, to signthe approvedminutesof each meeting,and to executeall documentswhich may be requiredfor the Association, unlessthe Boardof Directorsshallhaveexpressly authorizedsomeotherpersonto performsuchexecution.

The President shallmakeexecutive decisionsregardingcommittee positions,committeetasks,interorganizationalactivitiesand Boardtasks.The Presidentshalloverseeand take ultimateresponsibilityfor an annualevaluationof the executivedirector.The President shallserveas Chairof the Board of Directorsand with the SecretaryAreasurer shall set the agenda for the Board meetingsand the annual businessmeeting.The Presidentshall serveas an ex-officiomemberof all committees.

The President shallappointmembersto fill vacancies and unexpired termson the Boardof Directorsand standingand ad hoc Committees until the next scheduledelection.The Presidentshall appointa Board liaisonto each committee.The Presidentmay appointtaskforce(s)with limited specificgoals.

Section89: Duties of the r/ke+{esklen+lPresident-Elect).The Viee PresidentPresident-Elect, in the absenceof the Presidentshall be the spokesperson for the Associationand supervisethe Board. ent, The VieePresidentElectshallserveasChairtranof the NominatingCommittee andexofficiomemberof all committees.

The President-Elect shall,in conjunctionwith committeechairs,develop committeetasksfor the presidencyyear, review committeememberperformanceand make committeemembershipappointmentsfor the presidency year.The President-Elect shallalso appoint the Chairsof the nonelectedstandingcommitteesand developthe long-rangeplanning sessionofthe Boardduringthe President-Elect year.

fer the '\sseeiatien'sannual-esearehand edueatienmeetin6;aE 'ovellas ethersympesiaer meetingsspensered er ee spensered b)' the Areeiatien te meet its purpese,The dutie+ef the Pregrarn b{+ fer re,o'ierv ef materialste be presertedat the annualmeetin8er

netiees;an*(6) sehedulintaeti'o'ities at the Asseeiatien's annual ir SectionI 2: Dutiesof the PastPresident.The PastPresidentshall aid the NominatingCommitteein identifyingcandidatesfor special recognitionby the Society.The PastPresident shall assume whateverdutiesare assignedby the Presidentor the PresidentElectand otherwiseserveas a Member of the Boardof Directors. ie+ Section13:Absenteeism/termination of office.Absences can be approvedor excusedonly by the President.

Two unexcusedabsences from scheduled Boardof Directorsmeetings, annualbusiness meeting,or specialmeetings of the Boardof Directors duringanytermas a memberof the Boardof Directorsshallconstitutea resignation.

Suchresignation shallbe effectivetwo weeksafternotificationby the President.

Any memberof the Boardof Directors mayvoluntarilyresignandsuchresignation will becomeeffective immediately.

28

ien fieersithe SeeretarliTreasurer shalleall sueha meetint ,o'o'ithin @ Section1414: Duties of the ExecutiveCommittee:The ExecutiveCommitteeshallconductthe business of the Boardof Directorsand act in lieu of the Boardon routineissues.

All actions by the ExecutiveCommitteeare subjectto reviewand approval by the full Boardof Directorsat theirnextmeeting.

Section 15: Duties of the Committee Liaisons.'Eachof the standingand ad hoc committeesshall be assigned,by the President, a Member of the Boardto serveas a Board Liaison.The Boardliaisonwill serveas a contactfor the committeechair for Board-relatedinformation and direction, assistin the orientation of the commifteemembersin concertwith the committeechair, assistthe committeein the executionof committeefunctions and goals,and assistthe committee chair with budget requests and other administrative dutiesas necessary.

ARTICTE III _ MEETINGS Section1.Annualbusiness meeting.An annualbusiness meetingof the membership of the Association shallbe convenedannuallyand in conjunction with the annualscientific meetingof andeducational theAssociation.

Business items presented as informational or for vote by activemembersshall i n c l u d eb u t n o t b e l i m i t e dt o : ( 1 ) a f i n a n c i a lr e p o r tf r o m t h e (2) amendments Secretaryfireasurer, to the Constitutionand Bylaws of the Association,(3) electionof officers,membersof the Boardof Directors,and the Chairsand membersof the appropriatestanding (4) reportsof committeeactivities,(5) committeesof the Association, transactionof other businesswhich may come beforethe membership,and (6) a "Stateof the Association" addressby the President.

Wheredictatedby the Constitution and Bylaws,theAssociation shall be governedby a majorityvote of activemembersin attendanceat the annualbusiness meeting.The President of the Association shall presideoverthe meetingand the SecretaryAreasurer will circulate agendaitemsto the membership 30 daysbeforethe annualbusiness meeting.

The Chairsof the Constitution and BylawsCommitteeand partsof the NominatingCommittee will presideoverthe respective annualmeeting.

Theannualbusiness meetingshallbe heldat a time and placedeterminedby the Boardof Directorsof the Association approximately one yearin advance.€it+€{€fi\€€a+i€}ft S e c t i o n2 : B e t w e e na n n u a lb u s i n e s sm e e t i n g sw , ithin the guidelinesof the Association'sPolicy and ProceduresManual pelieiesestablished membershipand the by the '\sseeiatien's Constitution and Bylaws,the Association shallbe governedby the Boardof Directors.Actionsof the Boardof Directorsshall be determinedby a majorityvote of thoseof its memberspresentat itsmeeting.@ Section3: Annual scientificand educationalassembly.fhe Association shallsponsoran annualscientificand educational meetingor assembly to meetits purposeand objectives. lts mission shall be to foster researchand educationin academic emergencymedicine.This meetingwill include b++t+e|*e {im+ted+e*(1) presentationof original researchin the sciences (2) educational/research and educationalmethodology, forums, (3) specialprogramsfor the membership as determinedby the purposeand objectivesof the Association,anC (4) meetingsof the standingand ad hoc committees of the Association and (5) a framework to conduct of the Association'sbusiness.The reprograms searchand educational of the annualmeetingshallbe opento the publicand the generalmembership of the Association in€eed-sdan'dirq.g.

All meetingsof standingand ad hoc committeesare open to the public and membersof the Association in+eea+afi+iag. Programsfor the annual meetingshall be arrangedby the ProgramCommitteeand approvedby the Board. €{€i+e€+€+5€4+h€+r€€€r€ia+i€i+ A final notice of the time, place, and programof the annualassemblyshallbe sentto all mem-

at least30 bersof the Associationby the Secretaryfireasurer daysbeforethe meeting.

Section4: Specialmeetingssponsoredor cosponsoredby the may sponsoror cosponsor othersciAssociation.

The Association to meet entificor educational meetings of interest to the membership its purposeand objectives.

Suchmeetings shallbe convenedby the President, Boardof Directors,and ProgramCommitteeChairand publicizedat least30 daysin advanceby theSecretaryfireasurer.

ARTICTE IV _ FINANCES duesfor all members shall Section7.'Theannualmembership be determinedby the Boardof Directors.The annualmembershipwill be payablewithin 30 daysof requestby the Secretary/ procedures Treasurer.

The Boardof Directorsmay establish and policiesregarding nonpayment of duesand assessments.

2:fhe Boardof Directors shalladoptsuchmembership schedules Section participation public. to encourage bytheinterested asisnecessary ARTICLE V - PARTIAMENTARY AUTHORITY Ruleof order.Any questionof order or procedurenot specifically delineatedor providedfor by thesebylawsand subsequentamendments by parliamentary usage shallbe determined as containedin Robert'sRulesof Order(Revised).

ARTICTE VI_ STANDINGCOMMITTEES Section1: Dutiesof Committee Chairs.The Chairs-Electand in deterthe appointedChairs shall assistthe President-Elect miningthe committeegoalsfor the comingyear.TheChairshall submit budget requeststo the ExecutiveDirector for distribution; shallassistthe President-Elect and the Boardliaison in the appointment of committee members;shall assigncommittee goals to committee member(s)and overseetheir completion; shallevaluateeach committeememberon an annualbasisand orient new membersland shall submit a written semi-annual and annual report as outlined in the Policy and Procedures Manual.Chairswill be reviewedannuallyby the Presidentand Boardliaison. All Chairsare responsibleto the Boardand may be removedfor causeprior to completionof term of office by majorityvote of the Board.Vacantpositionswill be filled by the presidentfor the remainderof the term.

Section2: Dutiesof Commiftee Members.Membersshouldproposefuture objectivesto the Chair,carry out assignments givenby the Chair,and aftendthe Commifteemeetingat the annualmeeting.

In general,membersshouldserveon only one committeeat a time, with the exceptionof certainProgramCommitteemembers.

Section3: Terms of Office. Terms of office for Committee Chairsand memberswill beginat the annualbusinessmeeting.

The Presidentshall appointeligibleAssociationmembersto fill vacanciesand unexpiredterms on standingand ad hoc committeesuntil the next scheduledelectionor appointmentdate.

Section14: NominatingCommittee.The NominatingCommittee shallconsistof the\lieePresident-Elect, asChair,the pastpresident, a memberof the Boardof Directorselectedfor a one-yearterm by who maynot be members of the Board,andthreeelectedmembers the Boardof Directors.The lattershall servestaggered two-year terms.lt shallbe the taskof this committeeto selecta slateof officersto fill the naturallyoccurringvacancies on the Boardof Directorsand electedpositionson the standingcommittees of the not otherwisedesignated Association and providedfor by thesebylaws.The NominatingCommittee will seekthe candidates approval for formalnomination and shallplacetheirnamesin nonrination for electionat the business beforethe membership sessionof the will alsoprovideslates annualmeetingThe NominatingCommittee for anyawardsofferedby the Boardof Directors.

Section25: MembershipCommittee.The Boardof Directors shall constitutethe MembershipCommittee.The Secretary/ Treasurershall serveas Chair of the MembershipCommittee. for establishThe membership committeehasthe responsibility for eachmembership classification.

Appliing the qualifications cants reviewedby the ExecutiveDirector and Secretaryfireafor electionto a requested surernot meetingthe qualifications of membershipshall requirepresentation to and classification

29

s+agge+edt've one-yearterms and who may be reappointedfor subsequent terms. eem membersef the Beardef Direeterser etherAsseeiatien subeemmittees mittees'The ehairshall ereatead hee researeh vr'iththe appre,o'al ef the Beardef Direeters,The Committee shall foster researchin emergencymedical care. afid+s€lfl+Ie

approvalby the majorityof the MembershipCommittee,before membership in thatclassification can be granted.

Section36: ProgramCommittee.The ProgramCommitteeshall be composedof a Chair,electedby the membership for a threeyearterm,with the firstyearof the term servedas Chair-Elect; and tr','emembersappointedby the President-Elect with input fro the Board Liaison and the Committee Chair for te++a55e+ed+h+ee one-yeartermsand who may be reappointedfor subsequent terms. memResearch Committeeehai+ @A ber and the Education Committeeehairmemberwill be members of the ProgramCommittee.

Subcommitteesshallbe formedin accordancewith the Policiesand Procedures Manual.

Section710: LiaisonCommitteeto the Associationof American Medical Colleges(AAMC).The Committeeshallconsistof a Chair, appointed to a {ir*e one-year term by the Bee+d+fDiree+e+s President-Elect and who may be reappointedfor up to three consecutiveterms, and th+eemembersappointedby the eemmi*ee with input from the BoardLiaisonand com€hai.rPresident-Elect mifteechair for staggered+h+ee one-yeartermsand who may be reterms.The officialemergencymedicine appointedfor subsequent to the AAMC will be membersof this committee.T-he delegates

The dutiesof the committeeshallbe to arrange,in conformity with instructions from the Boardof Directors,the programfor all meetingsand selectthe formalparticipants.

The dutiesof the Program CommitteeChair shall include:(1) chairingprogramcommittee meetings,(2) overseeingabstractsolicitationand selection, (3) reviewingpoliciesrelatingto abstractsubmission,review and selectionand recommending amendments to the Board,(4) recommendingfuture meetingsites,(5) overseeingeventsand assisting in management issuesat the AnnualMeeting,and (6) reporting feedbackon the successof the annual meetingto the Board, Manual. and otherdutiesasoutlinedin the Policyand Procedures

Direeterser ethereemmitbesef the '\sseeiatien, enl)' eurrenter i+ TheCommitteeshalldevelop @rn programs for the Association to be presented at the annualmeeting of the AAMC. Section811'. GovernmentalAffairs Committee.The Committee shallconsistof a Chair,el€€tedappointedto a th+eeone-yearterm and who may be reappointedfor up to by the President-Elect three consecutiveterms term ser,o'ed as €hair Eleetand tlcreemembersappointedby the with input from the BoardLiaisonand committee President-Elect Chair for sfta55e+e*+h+ee one-yearterms and who may be reapp o i n t e df o r s u b s e q u e ntte r m s .T h e e e m m i t t e e€ h a i r a n d

The committeemembersshall, under the direction of the program chair and with the assistance of the ExecutiveDirectorbe responsiblefor planningand coordinatingthe annualmeetingincluding:(1) determiningthe meeting'scontentand schedule,(2) submissionof a budget,(3) logisticplanningand implementation, (5) planningof (4) on-sitecoordinationand management assistance, (7) soliciting socialactivities,(6) arrangingCMEcreditfor attendees, and evaluatingattendeefeedbaclg(B) recommendingfuture meeting sites,and other dutiesoutlinedin the Policyand Procedures Manual.Recommendations from the ProgramCommitteeChair mustbe approvedby the Boardof Directorsby majorityvote.

the eemmitteel''ill be neminatedby tl'e l'{eminatin6€ernrmittee {e+elee+ie+*e€haic The Committee shalI assume4#ies+red+ fosterfederaland state medicalcare. supportof research andeducationin emergency Section912: Committeeon lnternationalAffairs. The Committeeshallconsistof a Chair,el€€+edappointedto a tfi+eeoneyear term by the President-Elect and who may be reappointed for up to three consecutiveterms W , and threemembersapp o i n t e db y t h e P r e s i d e n t - E l e cwti t h i n p u t f r o m t h e B o a r d liaison and the committeeChair for stags€'r€#h+€eone-year termsand who may be reappointedfor subsequentterms.The

Section47: Constitutionand BylawsCommiftee.The Constitution and BylawsCommitteeshallconsistof a Chairand two other members, three-year termsso thatthe member electedfor staggered withthe leastremaining tenureshallserveasChairduringtheirfinal yearon the Committee.

ThisCommittee shallstudythe potential merits,adverse of all proposed consequences and legalimplications constitutional amendments or changesin the bylawsand reporttheir findingsandrecommendationstotheMBoardofDirecformal considerationof the proposed tors prior 1e the-+irne-e# The membersof the Committeemay changesby the membership. and themselves suggestappropriateconstitutional amendments bylawschangesto the Presidertand Boardof Directors.upen.stt*dy

i€'t+.The Committeeshall €'f4tire€t€rys.+e fosterinternationalrecognitionof educationand research in emergency medicalcare.

Section 13: Liaisonsto other organizations.The President The may appoint liaisonrepresentatives to other organizations. must be a memberof the Associationand liaisonrepresentative be aware of the Association'sorganizationalpositions,missions,policies,and structure.The liaison representativeshall issueat leastbiannualreportsto the Boardof Directorson organizationalactivitiesand issuesrelevantto the Association.

Section5B: EducationCommittee.The EducationCommittee s h a l lc o n s i s to f a C h a i r ,e l e c t e dt o a t h r e e - y e atre r m b y t h e membership, with the firstyearof the termservedasChair-Elect, with and sil<+t*er membersappointedby the President-Elect input from the BoardLiaisonand by the committeeChair for sta€€€red+ve one-yearterms and who may be reappointedfor subsequent terms. membersef the Beardef Direeters er ether'\sseeiatien eemrit 'r'r'ith the appre'o'al ef the Beardef Direeters'The Committee shall fostereducationin emergencymedical care.arad+ssl#+ie

ARTICI.EVII- DISSOTUTION OF THE ASSOCIATION Section /: Dissolutionof this Associationcan only be initiated by a majority vote of all members of the Board of Directorsand must be approved by two-thirds of the active membership presentand voting at any annual or special meeting.

Section 2: Dissolution shall be achieved in compliance with A r t i c l el X o f t h e c o n s t i t u t i o n .

Section 69: ResearchCommittee.The ResearchCommittee s h a l l c o n s i s to f a C h a i r ,e l e c t e dt o a t h r e e - y e atre r m b y t h e membership, with the firstyearof the termservedasChair-Elect, with and six+the+ membersappointedby the President-Elect i n p u t f r o m t h e B o a r d L i a i s o na n d t h e c o m m i t t e eC h a i r f o r JU

COUNCIL OF EMERGENCY MEDICINE RESIDENCYDIRECTORSMEETING May 18, 1993 2:30-6:00pm Plaza Ballroom B (Lobby Level) San Francisco Hilton and Towers 1. Welcome

Dave Sklar, MD

2. Review and approval of September1992meeting minutes

Lanny Turner, MD

3. President'sReport

Dave Sklar, MD

4. Treasurer'sReport

Lanny Turner,MD

5. Bylaws Report

Marcus Martin, MD

6. Election of Officers and Board

Marcus Martin, MD

7. Liaison Reports A. RRC-EM

GlennaCase,PhD

B. ABEM

Mike Vance,MD

C. ACEP President-Elect

JohnMcCabe,MD

D. ACEP Academic Affairs Committee E. SAEM: Curriculum

SteveDronen,MD

F. CAS/AAMC

SteveDronen, MD

Hal Thomas,MD

8. ElectronicResidencyApplication Service

Paul Jolly, MD

9. Slide Bank Report

CareyChisholm,MD

10. Follow-up of ProgramDirector Survey

Gloria Kuhn, DO

11. QuestionBank Report

Marcus Martin, MD

12. PreliminaryResultsof InserviceSurvey

Bob McNamara, MD

13. OvercrowdingSurvey

Nina Mazur, MD

14. Small Group meeting(30 minutes) A. Biorythms

RebeccaSmith-Coggins,MD

B. New Programs

Lanny Turner, MD

C. 2, 3, 4 Match

David Howes,MD

D. AdvancedPlacement

SteveDronen,MD

E. Wellness

Bob McNamara,MD

15. Adiournment

3l

ASSOCIATIONOF ACADEMIC CHAIRS OF EMERGENCY MEDICINE Annual Meeting May L8, L993 Mason Room (6th floor, building 3) San Francisco Hilton and Towers 8:30-9:00 am

Coffee and Welcome

DouglasA. Rund, MD

9:00-9:45 am

Security Issuesin the EmergencyDepartment

Gail V. Anderson,MD

9:45-10:30 am

Academic EmergencyMedicine and the American College of EmergencyPhysicians

John McCabe. MD

10:30-12:00 noon Discussion:SpecialRequirementsfor

DouglasA. Rund, MD

ResidencyEducation in EmergencyMedicine

pm 12:00-1:00

Lunch and Annual BusinessMeetine

DouglasA. Rund, MD Glenn Hamilton, MD

pm 1:00-2:00

Funding Academic Departmentsof EmergencyMedicine: Where Are the Dollars?

SteveStapczynski,MD

pm 2:00-3:00

The Productive Life of an Academic Chair: How Long is Enough?

William Robinson.MD

6:30pm

Annual Banquet

EXHIBITORS (800)s26-878s Aircast, Inc. 92 River Road Summit, NJ 07901 The Air-Stimrp family of braces,the Cryo/Cuff Cold & Compression System,the AircastWalking Brace,andotherfunctionalpneumatic braces.Thesedevicespermit functional managementof many lower extremityinjuries and promoteearly returnto function.

(214)ss0-0911 Annals of Emergency Medicine PO Box 6199ll Dallas. TX7526l-9911 Annals of EmergencyMedicine,cosponsoredby the American College of EmergencyPhysiciansand the Societyfor Academic EmergencyMedicine,is the leadingclinical and scientificjournal in the specialty.

(801)s72-6800 Ballard Medical Products 12050Lone Peak Parkway Draper, UT 84020 EASI-LAV - A closedgastriclavagesystemthat protectsusers, reduceslavagetime and provides a superiorlavagewhile allowing usersmess-freecharcoal administration.SAFETY SHIELD - A one-piecefacial protection mask that provides all around facial protection.

BiositeDiagnostics 11030RoselleStreet SanDiego,CL92l2l

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(800)438-2476 Daniel Stern and Associates 211 North Whitfield Street Pittsburgh, PA 15206 Daniel Stern and Associatesprovidesplacement/recruitment services, billing consulting and medical staff developmenVanalysis nationwide.Our EM Division has successfullyservedhospitals, physicians,and physiciangroupsfor more than 22 years.Please stopby booth #26 to review our services,NationalEM Salaryinformationand availablejob opportunities.

Emergency Medicine Residents'Association (800) 798-1822 1125Executive Circle Irving, TX75038-2522 EMRA is an organizationof medical and osteopathicstudents, residentsand fellows who are being educatedin emergencymedicine. Stop by the booth to get information about EMRA membershipand seeexamplesof EMRA memberbenefits.

(609)848-3817 Emergency Physician Associates,P.A. 307 South Evergreen Avenue Woodbury, NJ 08096 EPA has beencontractingwith hospitalsfor the provision of ED staffing,management, and consultingservicessince 1978.We contractwith hospitalsin the Northeastand offer our physicians competitiveincome, growth potential, and unequaledopportunities. Client hospitalsvary from rural to academicand physician involvementis highly encouraged.

BiositeDiagnosticsis a medicalcompanythat sellsa rapid,noninstrumented,urine drug screencalled TriagerM.Triage is a selfcontained,disposabletestingdevicethe size of a credit card, that simultaneously detectsthe sevenmost commonlyabuseddrugs injust ten (10) minutes.Proceduralcontrolsarebuilt into the test deviceto ensurethat the test is run correctly and that reagentsare active.Triage is packagedin kits of 25 test devicesand is stored at room temperature.

(s13)382-14s1 Ferno 70 Weil Way Wilmington, OH45177 Ferno is the world's leadingmanufacturerof pre-hospitalpatient handling equipment,including cots, stretchers,spinal immobilization devices,etc. - with special interestand involvementin pre-hospitalEMS research.Ferno looks forward to discussing this topic further with SAEM members.

CerenexPharmaceuticals.

(9r9\ 248-2100 Division of Glaxo Inc. 5 Moore Drive ResearchTriangle Park, NC 27709 You are cordially invited to visit the CerenexPharmaceuticals exhibit where our representatives will be availableto answer your questionsand discussthe latestclinical information on subcutaneousIMITREX@ (sumatriptansuccinate)Injection.

(609)243-9300 i-STAT Corporation 303A CollegeRoad East Princeton, NJ 08540 The i-STAT Systemis an easy-to-use, handheld Clinical Blood Analyzer that performsa panel of testsin 90 secondsfrom 2 drops of whole blood. The systemgives emergencystaff immediate blood test resultsthat can lead to faster diagnosisof a patient'scondition.

(901\ 867-0822 Challenger Corporation 70 Belle Meade Cove Eads,TN 38028-9418 MD-Challenger,Clinical Referenceand EducationalSoftwarefor Acute Care and EmergencyMedicine, combinesthe comprehensive coverageof a textbookwith the interactiveteachingand rapid searchcapabilitiesof a computer.Approximately4000 questions and answerscover virtually every key point of emergencymedicine with immediatefeedbackand scoring.Completelyreferenced.

(617)893-sls1 Kurzweil Applied Intelligence, Inc. 411 Waverley Oaks Road Waltham, MA 02154 Kurzweil's VoiceEM gives EmergencyMedicine physiciansthe ability to produce a legible, coded chart simply by speakingwithout handwriting or costly transcription.SupportingRBRVS requirements,VoiceEM prompts you to provide completedocumentation,with the ICD-9 and CPT-4 codesbeing automatically generated.The systemhas a 50,000 word vocabularyand needs no prior voice training.

(8r2\339-223s Cook Critical Care P.O. Box 489 Bloomington, IN 47401-0489 Melker EmergencyCricothyrotomySets,Cook DisposableIntraosseousNeedle,High Volume InfusionSets,PeritonealDialysis Sets,PneumothoraxSets.

(800)431-1Oss Laerdal Medical One Labriola Court Armonk, NY 10504 Resusci@Anne Family of CPR Training Aids and Manikins; Heartstart@AutomatedExternal Defibrillators and Early Defib-

rillation Training Systems;ALS Trainers;Heartsim@2000 Cardiac Rhythm Simulator;Airway Managementproductsincluding Laerdal Silicone Resuscitators,Suction Units, PocetMask, First ResponderAirway Kit; SpinalImmobilizationProducts.

patient safety and managementthroughoutthe hospital, in emergencytransportand in the home.

OP-D-OP Inc. 198 Cirby Way Suite 120 Roseville,CA 95678

(7r4\727-26sr Lasergraphics,Inc. 20 Ada Irvine, CL92718 Lasergraphics,Inc. is demonstratingthe LFRrM family of excellent price/performancedigital film recordersfor professional medical slide production.They offer dramaticspeedincreasefor both Windows and Macintosh environments.Clear, preciseand superiorquality slides are easily producedfrom your favorite professionaldesktopapplication.

(61D320-3000 P.B. Diagnostics 151 University Avenue Westwood,MA 02090 Becausetime is myocardium,PB Diagnosticexhibit will feature advancesin rapid testingfor cardiacmarkers,early diagnosisof AMI throughthe useof serialquantitativemyoglobinandCKMB. Physiciansfor a Violence-FreeSociety Gr't82r-8209 San Francisco General Hospital Room 306, Building One 1001Potrero Avenue San Francisco.CA 94110 Physiciansfor a Violence-FreeSocietyis a non-profrt organization committedto reducingviolencein our societyby providing a forum ofphysicians and healthcareprovidersdedicatedto l) confronting violence as a public health hazard;2) raising public awareness;and 3) supportingphysiciansand providerswho care for victimsof violence.

Marion Merrell Dow fnc.

(816)966-3313 9300 Ward Parkway KansasCity, MO 64114 CARDIZEM@ Injectable(diltiazemhydrochloride)botus and infusion provideshighly selective,rate-dependent temporaryheartratecontrol in atrial fibrillation and flutter.

MICROMEDEX.Inc. 600Grant Street Denver,CO 80203

(.916],783-5741

(303)831-1400

The computerizedClinical Information System (CCIS) from Micromedex,Inc. is a collection of databasesregardingtoxicology, drug therapy,emergencymedicineand patient instructions.

It is availablein a variety of delivery methodsincluding CDROM for PCs,LANs and mainframesapplications.

(4r4)3s4-1600 Mortara Instrument, Inc. 7865North 86th Street Milwaukee, W153224 Mortara Instrument,Inc. designsand manufactures12-lead simultaneousand continuousST segmentmonitors for use in emergencyroom and chestpain evaluationcenters.ST review stationsare availableto review hundredsof ECGs in minutes.ST central stationsallow for viewing ECG waveform of up to 8 patientson one diagnosticquality terminal.

MCW-Mosby/Williams & Wilkins @rs)341-2313 506 E.39th Avenue San Mateo, CA 94403 MCW will featuretitles from Mosby, Churchill and Waverley.

Key titles on display Fleisher-Ludwig/Textbookof Pediatric EmergencyMedicine and Rosen/Emergency Medicine.

Physio Control (206)867-4s69 11811Willows Road,Northeast Redmond, WA 98052 LIFEPAK@ I 0 Defibrillator/Monitor/Pacemaker,LIFEPAK 9P Defibrillator/Monitor/Pacemaker, LIFEPAK 300 Automatic External Defibrillator, Shock Advisory SystemTM, Hands Free Defibrillator System.

(416\626-3233 Spectral DiagnosticsInc 135-2The West Mall Toronton, Ontario NlgC lcz CANADA Spectral'scardiacpanel is a proprietary,in-vitro, rapid format immunodiagnosticpanel test. The cardiac panel simultaneously measuresin a matterof minutes,the level of severalearly-release cardiacproteinsthrougha manualapplicationof a few dropsof a patient's blood. In the emergencysituation,Specral'scardiac panel will for the first time allow a definitive, differentiating diagnosisof patientswith unstableangina and thoseundergoing an evolving myocardial infarction from patientswith simple heartburn.

National EMSC ResourceAlliance (310)328-0720 1001West Carson Street. Suite 5 Torrance, CA 90502 Implementationof emergencymedical servicesfor children (EMSC) can savethe lives of many critically ill and injured children. The staff of the National EmergencyMedicat Servicesfor ChildrenResourceAlliance (NERA) can help you incorporate EMSC into existing EMS systems.NERA can provide comprehensivesupportranging from telephoneand on-siteconsultation to written materialsand other media. Pleasestop by our display and speakwith our representative.

(4ls) 341-9183 W.B. SaundersCo. 284 Shearwater Isle Foster City,CA,94404 Medical Books andJournalsavailabledirect from publisher.

(s10)887-s8s8 Nellcor Inc. 25495Whitesell Street Hayward, CL94545 N e l l c o r I n c o r p o r a t e d m a n u f a c t u r e sa n d m a r k e t s h i g h performancemonitoring equipment,sensorsand accessoriesfor

Weatherby Health Care (203) 866-1144 25 Yan Zant Street Norwalk. CT 06855 Physician SearchFirm specializing in EmergencyMedicine Recruitmentand Consultation.

(3l$ 469-s324 Synergon P.O. Box 419052 St. Louis, MO 63141 Synergon specializesin emergencydepartmentstaffing and management for high-volume,academic,and pediatricfacilities.

34

Abstractsof the 23rd Annual Meetingof the Societyfor AcademicEmergencyMedicine Thcfollmring2l3 abstractswtllbc prcscnud at tlu Annual McctingoJ thc Soaety lor AcadcmicEmcrgcnq Medicinc in San Franciyo, Ca)lfunia, May jl-20, 1gg3.

Prcuntns'namcs are printcAinitalics; whcrc prc*nw is notindicatcd, none was speafcdby tlu authors.

{ OutpatientManagementof low-Risk FebdleInfanS Without I Antibiotics MD BakecLM Bell,JBAvner/Division of GeneralPediatrics.

Sectionof Emergemy Medicine, andDivision of Infectious Diseases, TheChildren's Hospital of Philadelphia, Pennsylvania Studyobjective:To determinewhether febrile l- ro 2-monrh-old infantsidentifiedas low risk for seriousbacterialillness(SBI)can be safelyand efficaciouslymanagedas outpatientswithout antibiotics.

Design:Sixty-monthprospectiveconsecutivecohorr sudy.

Setting:Urban pediatricemergencydepartmentin Pennsylvania.

Participants:Sevenhundred forty-seveninfants29 to 56 daysofage with temperatures2 38.2 C. Interventions:After completehistory, physicalexamination,and sepsisworkup, all infantsreceivedgroup assigr.ment.In-hospitalcontrols (lHC, zt60)were infans wirh either laboraroryor clinical parameterssuggestiveof SBI.Theseinfanrswerehospitalizedand treatedwith antibiotics.The remaining287 well,appearinginfantswith normal lab. oratoryparameterswere randomlyassignedto in,hospital observation without antibiotics(lHO, 148) or outpatienrobservationwirhour antibiotics(OPO, 139). Repeatphysicalexaminationswere performed on all patientsat 24 and 48 hours. Patientoutcome,complications,and chargeswere reviewed.

Results:SBIoccurredin 65 infanrs(8.70,6)and included urirury tract infection(24), gasrroenteriris (13), sepsis(12), meningiris(nine), cellulitis (six), and adeniris(one).Sixty-four of 65 infanrswirh SBIwere identifiedby our admissioncrireria(sensirivity,gg%i95% confidence interval [CU: 92, 100). The negarivepredicrivevaluewas 9906(95obCl: 98, 100). The singleIHO infant misidentifiedsubsequentlywas diagnosedwith ectodermaldysplasiaand had bacreremia.Averagemedical chargeswere$5,5320HC), $3,31I (lHO), and $784 (OpO).

Conclusion:Usingsrrict selecrioncriteria,ir is possiblero manage safelyand efficaciouslyfebrile l- to 2,month-old infanrsas ourparienrj without antibiotics.This method of managementresultsin a sigrificanr reductionin patientchargeswithout increasingrisk to the patient. !l ProspectiveValidationof Criteriafor 0n-SceneTerminationof 4 BesuscitationElfortsAftor 0ut-oFHospitalCardiacArest PEPepe,CGBrown,MJ Bonnin,KTKimball,DRMartin.H Stueven.

R0Cummins, EGonzalez, M Jastremski/Baylor College of Medicine.

Houston, Texas;0hioStateUniversity, Columbus; Emergerny MedicalServices of H0uston, Texas; Columbus, 0hio;Milwaukee, Wisconsin; KingCounty, Washington; Bichmond, Virginia; andSyracuse, NewYork Studyobjective:Recenrsrudiesof our,of-hospitalcardiacarresr (OHCA) havenow derivedspecificcriteria for on-sceneterminationoi resuscitationefforts.Our purposewas to validatethesecriteria prospec. tively in multiple emergencymedicalservices(EMS)sysrems.The examinedcritedastaterhat continuedresuscitationeffortsareuniformly futile when aduh patientswirh normothermic,nonrraumaticOHCA do not regainpulses,eventransiently,after 25 minutes of standard

35

advancedcardiaclife support (ACIS); the lone exceptionsare those with monitored(paramedic-wimessed) arrests,percistentneurologic signs,or persistentventricularlibrillation/tachycardia(VF/V-|).

Design:One-year,blinded study involving a prospectiveevaluation of outcomeconductedto identify whethertherewould be any suwivors amongpatientswho receivedcontinuedresuscitationeffortswhen they did not respondwith pulses(eventransiently)after 25 minutesof sundard ACIS interventions.

Participantsand setting:The aduh nontraumaticOHCA patients from six largeurban EMSsystemsexcludingthosewho immediately achievedspontaneouspulseswith basicCPR,intubation, andlor one to threeinitial countershocks(if needed).

Results:Of I,228 patientsstudied,471 had resuscirarive effortsrerminatedat the scene.Of the remaining757 receivingcontinuedefforts (at the scene,en route, and at the hospital),only 57 ultimarelysurvived to hospiul discharge.Everysuwivor achievedeither rransientor longterm restorationof pulseswithin 25 minutesof paramedicarrival exceptfour patienrswith pe$istentVF/VT, threepatientswith monitoredarests, and one patientwho requireda cricothyrotomyafter inability to perform sundard endorrachealincubation.

Conclusion:The proposedcriteria for on-sceneterminationo[ resuscitationarevalid and do not excludeDotentialsuwivors in EMSsvstems providingsundard ACIS interventiorl.

Conclusion:Preliminaryresultsshow rhat when usedearlyby FRs, ACD CPRincreasedthe rate of hospital admission greatly in one city, subsuntiallyin another,and not at all in the third. Neurologicstatusat hospitaldischargewasimproved.No sigrificant adverseeffectsof ACD CPRwere identified.The varyingresultsalso demonstratethat new intewentionscannotbe introducedwithout regardto the speciliccharacteristicsof an EMSsystem.When usedlate,ACD CPRmay Provide no benefit.

Resuscitation:ls Ventilation /l BystanderCardiopulmonary 't l{ecessary? of HA\erg, KBKsrn,AB Sanders, CW0tto, BWHilwig,GAEwy/University Center, Children's Research Arizona College of Medicine, SteeleMemorial University HeartCenter, Tucson Study objective:Basiclife support with mouth-to'mouth ventilation and chestcompressionsis intimidating, difficult to renrmber, and difficult to perform.Citizensare often reluctantto perforni mouth+omouth ventilation.Our hypothesiswas that initial treatmentof cardiac with or without ventilation,would result arrestby chestcompressions, in comparablerateso[ 24-hour survivaland normal neurologicoutcome in a clinicallyrelevantswine model of wiuressedprehospiul cardiac arrest.

Desigr: Thirty secondsafterventricularfibrillation, domesticswine (I4 to 20 kg) were randomlyassignedto l2 minutesof 1) chestcomProspeAiveTrial of AAive Compression-Deconprecsion pressionsand mechanicalventilation(CC + V), 2) chestcompressions ! A Randomized rf CPRVorsusManual GPRin ProhospitalGardiccArrest only (CC only), or 3) no CPR.Endotrachealtubeswereremovedfrom M Callatram, TSchwab, JJ Shultz, T Utscht, CDMadsen, T Gish.KGLurie/ the CC only group beforechestcompressionsCPR,and the animals 0ivision of Emergency Medicine, University of California, SanFrancisco; were re-intubatedimmediatelybeforeadvancedcardiaclife support Department of Emergency (AC[S). StandardACLSprotocolswere provided at 12.5 minutesof Medicine, ValleyMedical Center, Fresno, California; Division of Cardiology, University of Minnesota arrestto eachgroup. Two hours ofcare in the ICU wereprovided for Studyhypothesis:Previousstudy has shown that activedecompresanimals.Twenty-four-hoursurvivaland neurosuccessfuliyresuscitated sion of the chestduring CPRsigrilicantly improveshemodynamics,bur logic outcomesbetweengroupswere comparedby Fisher'sexacttest. outcomevariableshavenot beenexamined.We conducteda study to A samplesizeof 16 animalsin the CC + V and CC only groupswas determinewhetheractivecompression-decompression (ACD) CPR chosento enabledetectionof a 30% differencein survivalwith a Dower differsfrom manualCPRin ourcomessuchas resuscitationto ICU of ,80, assuming100%survivalin the CC + V group. admissionand hospital discharge.

Results: Desigr: Prospective,blinded study in which first responders(FR) CC+Y CConll ilo CPR were trainedand randomizedto provideeither standardor ACD CPR, surviral 2/8' 24-Hour 16/16 16/16 with crossoverto rhe other techniqueat speciliedtime intervals.

95%Confidence intenals Participants:Four hundred fifty nontraumatic,nonhypothermic, for24-hour surwal 79to 100% 0.3to53% 79to 1ffi96 Normal neurologic 16/16 16/16 r/8' outcome adult prehospitalcardiacarrestvictirnswho were administeredCPR *DilferentfromCC+ V andCConly,P< .Ol under standardizedemergencymedicalservices(EMS)guidelines.

Setting:PrehospitalEMSsystemsof threecities,providing CPR Conclusion:In this clinically relevantswine model of witnessed

by FRswith short responseintewals in SanFrancisco,Califomia,and prehospiul cardiacarrest,I ) CC only is aseffectiveas CC + V, and 2) St Paul,Minnesota,and by paramedicsin Frero, California. both rechniquesof CPRmarkedlyimprove 24-hour survivaland neurolnterventions:ACD CPRby a mechanicalhand-helddevice,the logic outcomecomparedwith no CPR. Ambu CardioPump,or standardmanualCPRaccordingto American HeartAssociationguidelines. f The Ellectsof EquivalentSoluteLoadsol 7.5%Hypeilonic J Saline/DextanVersusilormol Salineon Suwivd in Uncontrolled Results:SeeTable.Poweris low for all variablesar rhis srageof HemonfiagicShockin Swino studyand is not listed.

SM Jwayyed, SAStern,SCDronen/Oepartment Medicine, of Emergency 0rieIlod Admitlodb Universitv of Cincinnati Medical at Hospital Center.

0hio p Location N tCU(%) Di3chlood (%) p Discharlo.l%l Study objective:Studiesof hypertonicsalineusing controlledand CityA uncontrolledhemorrhagemodelsyield oppositeresuls with regardto ACD n 4 l E 21.8 efficacy.Thesedisparateresults rnay reflect the use of models and Standard 38 t3 7.8 0l resuscitationregimensthat werenot comparablebetweenstudies.ln CityB ACD 133 14.4 addition, widely differentamountsof solutewere administeredwithin 5.3 40 Standard tn 99 5.8 43 individual srudies.Wc evaluatedthe effecs of comparableand clinically CityC relevant resuscitationregimens of.7.5oAhypertonic saline/dextran ACD 60 t2 1.7 tm (HT9DEX) and 0.9% saline (NS) on hemorrhageand survival in a nearo Standard 6 5 m t4 5{J 'Equivalent fataluncontrolledhemorrhagemodel. toCPC sco.eof I

Design:Thirty swine (16 to 20 kg) with 4-mm aonic tearswerebled to a pulsepressureof 5 mm Hg (40 to 50 ml/kg) and resuscitated with one of two solutions. lnterventions:Group I received80 mUkg of NS at a rateof 4 mUkg/min. Group 2 received9.6 mlrkg of HTVDEX at a rate of 0.48 mUkg/min. Swine in goup 3 servedas controls and were not resuscitated.In groups I and 2, crystalloidwas followedby infusion of 30 mUkg of shedblood at arate of 2 mUkg/min.

Results:Datawere comparedusing analysisof varianceand Fisher's exacttest.Therewereno sigrificant differencesin hemodynamic parameter betweengroups I and 2.

Group I Gmup2 Goup3 (t = 121 (N.61 It{.121 Mortality' 33% Suruival tirne(minutes)' 5 41 1 1 (mVkg)' Intraperitoneal hemorrhage 34*m 'P< .6 group3 versusI and 2.

$% 58r 3 3 lr 1 3

72% 21x21 5r2

Conclusion:HTS/DEXand NS are equallyefficaciousshockresusc! tation agents.Differencesreportedin previousstudiesreflectthe use of clinicallyinappropriatemodelsand unequalsolureloads.

G ParamsdicsDo Not AccolsratoTheir Performrncein tho Proscnco U ol a Skilled0bsarusr JD fundesson, J Baker,PTPons/Denver AffiliatedResidency in Emergency Medicine; University of Colorado School of Medicine; 0erverGeneral Hospital, Colorado Studybackground:Many prehospitalstudieso[ paramedic(EMT-P) performanceuse direct observationwhile othersreviewtrip sheetor dispatchtimes.Direct obeewarionsrudy validity has beenquestioned on the premise that EMT-PSacceleratetheir performancein the presenceof a skilled observer.

Studyhypothesis:EMT-Pperformanceis not affectedby the presenceof a skilled observer.

Design:Prospectivecomparisonofmean disparchrecordedscene time (MST) of an observedshifr and the nexr previousunobservedshift with the samealtendant,driver, shift period, and day of rhe week.A pairedpower calcularionshowedthat nine shifrswereneededto detect a I5% differencein MST,assumingvarianccof paired differences= 2.25, a = .05, and B = .2. A linear regressionmodel using rnoc clu of the sAsstatisticalprogam wasused for covariatesof attendant,floor, policeand fire assist,call rype,proceduresperformed,age,sex,and number of patients.

Setting:An urban 9l I systemwith 70 EMT-Psand a run volume of 44,000per year.

Participants:EMT-Pswere selectedwhen a supervisorwho was blind to the study scheduledone of rhe skilled observersasa rhird rider. lnterventions:A medicalstudent or emergencymedicineresident observingunder the guiseof a proceduretiming study.

Resuls:FifteenEMT-Pswere obsewedwith a nexr previousunobsewedshift obtainablefor ren. The linear regressionmodel found that attendants,fire assist,I]oor, and medicationsgiven had a sigrificant effecton MST.When the linear regressionmodel was programmedfor fixed obsewer,random attendant,and significantcovariateeffects,there was no sigrificant differencebetween observedshift and next previous unobservedshift MST,wirh a 9506conlidenceinrervalof 0.39 12.00 minutes(P = .70).

Conclusion:EMT-Psdo not acceleratetheir performancein rhe presenceof a skilled observer.

7 Failureto Validatc a Prcdictivc ltlodel for Belusalol Gareto f EmergoncyDepartmcntPaticntr EinsteinCollegeof Medicine, A Birnbaum, M utkewicz/Albert EJ Gallagher, NewYork BronxMunicipal Hospital Center, Study objective: To determine whether triage cdteria developedat the University of Califomia, Davis (UCD) for refusalof care to individuals with nonurgent problems would validate on an independent data se!.

Desigr: Prospectiveobsewationalcohort study.

Setting:Municipal hospiul emergencydepartment.

Participants:A conveniencesampleof 53,t adults presentingto the ED betweenJulyI, 1992,and October15, 1992,who met UCD criteria were enteredinto the srudy. lntervention:The singletargetoutcomevariablewashospitalization.

To optimize the criteria's performance,we required that both the triage nurse and the physician caring for the patient agreethat all UCD criteria for a nonurgentproblemwere specificallymet. No patientw3s refus€d care,nor was their managcmentor dispositioninterferedwith in any way by the investigaton.All patientswere followeduntil admissionor discharge.

Results:Six of 534 patients(l .I %; 9506conlidenccintervai [Cll: 0.4 ro 2.4oA)who met UCD criteria for refusalof carewerehospiulized.

This finding representsa more than 5O-fold difference in incidence of hospitalizationwhen comparedwith that found by the UCD investigpof those tor, who reportedthat only 0.0206(95oACI: 0.0004 to 0.0,10,61 patientswho wererefusedcaresubsequentlyrequiredhospitalization (two-tailed,P < .0000I, Fisher'sexacttest).

Conclusion:We were unableto validatea previouslydeveloped predictivemodel for refusalof carc to patientspresentingto an ED. Our bestestimatesindicatethat if thesecriteria were appliedto 15% of all ED visits-as the original investigatorsindicatedthat it could bethen approximately150,000patienr whoseillnesswarrantedhospiulization would be refusedernergencycare annually in the United States becausethey were mistakenlytriagedasnonurgent.We concludethat refusalof careto patientspresentingto EDsis not a viablesolution to gidlock and overcrowdingand that altemativestrategiesrust be sought. (t Hashe ACEPChostPainPolicyModifiedtho Eyaluationand O Managementol PatientsProsentingto tho EmorgcncyDepartment Wift ChestPain?

LMLewis,LClasater,T Heston/St Missouri LouisUniversity MedicalCenter, Studyhypothesis:The evaluationand managementof patientspresentingto the emergencydepartmentwith acutenontraunutic chest pain hasnot beensignificantlymodified by the publication of ACEFs ChestPain Clinical Policy.

Design:Retrospective, blinded review during two-weekstudy period in eitherAugust 1989 or September1991.All chartswere reviewedin the specificareasof history, physicalexamination,and management.

The degee of adherenceto the rulesand guidelinesasoutlined in ACEP'sChestPain Clinical Policywas comparedwith the ED recordsof 1989 and 1991,and the null hypothesiswas testedusing 1z analysis.

Setting:Ten areaEDsin 1989; eigltrareaEDs (to date)in 1991.

Participants:Men > 35 yearsor women> 45 yearso[agewho presentedto a pailicipatingED with a chief complaint of acute,nontraumaticchestpain. Four hundred fifly chartsmet inclusion criterla and werereviewedfor the 1989study period. To date,219 chartsmet . criteria for reviewfrom the l99l study period.

Results:Adherenceto ACEP'schestpain clinical policy is as follows (Table):

HxlR)

PE(RI

A (nl

AIGI

81% 76% .10

88% 88% .97

65% 61% _s

55% 54% .80

ageincreasedfrom 40 months in the earlier period to 90 months (P = .007). Overall,Hib was identifiedas the causativeorganismin 76% of patients,with 98.2% of theseoccuning before 1990. Elevenpatients l99l P were known to havereceivedHib vaccine.Of these,five (45o,6)had Conclusion:The publicationand disseminationof ACEP'schest blood culture positivefor Hib. Of the eigfrtcasesin 1990 to 1992, three pain clinical policy has not sigrrificanrlyaltercdthe evaluarionand (GABHS)isolated from epiglonis had group A B-hemolytic Strcptococans rrunagementof patients who presentto the ED with acute nontraumatic surfaceculture; threeother casesof GABHSwere identifiedearlier. chestpain.

Thesepatients were sigrificantly older than thosewith Hib disease (l I1.5 monthsversus,10months,P = .006). The following groupsof I Utility of UrinaryGramStain lor Detoctionof UrinaryTract Infec,tion patientswere compared:vaccineversusno vaccine;before 1990versus I in Younglnfants 1990 to 1992;Hib versusGABHSasclusativeorganism.No significant GflLocklpr|WJLewander, DMCimini, SLJosephson, JGLinakis/Departments differencesbetweenany of thesegroupswere found in any of a number of Pediatrics, Emergerry Medicine, andMicrobiology, Rhode lslandHospital, of clinical characteristics, including fever,WBC count, duration of BrownUniversity School of Medicine, Providence, Rhode lsland symptomsbeforepresentation,or duration of endotrachealintubation.

Study objective:To test the hypothesisrhat Gram suin of fresh Conclusion:Acuteepiglottitishas diminishedin frequencysince unspun urine is more reliablethan routine urinalysisin detectinguri1990. Patientsdiagnosedsincethen tend to be olderand nchave nary tract infection run) in young infanrs. diseasecausedby organismsother than Hib (particularlyGABHS).

Design:Prospectivecasâ&#x201A;Źseries.

However,the clinical presentationappearsto be similar to that seen Setting:Urban teachinghospital pediarricemergencydeparrmenr. previously.

Patients:Sixry-eighrinfanr < 6 months old wirh symptomsconsistent witlx UTI (usuallyfever)for whom a suprapubicallyaspiraredor rl I ExtremelyLow PositiveBloodCultureRateIn Pediatic Age catheterizedurine specimenwas obtainedfor culture.

I I Group lnterventions:Gram stain of fresh,unspun urine wasperformed Hospital, Boyal0ak, D Daugtrerty, REJackson, WFPeacockMilliam Eeaumont on all patientsin addition to culture and, if quantity wassufficient, Michigan urinalysis.Usingurine culture resultsas the criterion standard,Gram Study objective:To describethe frequencyofpositive blood cultures stain,pyuria (more than 5 WBCsfhpl), leukocyteesterase, nirrites,and in emergencydepartmentpatients< 6 yearsof age. unstainedmicroscopywere all evaluaredby determiningsensirivity, Setting:A 929-bedcommunity hospiul with 16,000annualpedi specificity,posirivepredictivevalue (PPV),negarivepredictivevalue atric ED visits.

(NPV),and accuracy.Urinalysisdarawere alsocombinedso rhat if any Participants:All patients< 6 yearsof agewithout known immunotestwithin the urinalysiswas positive,rhe urinalysisasa whole was suppressionwho had blood culturesobtainedin the ED from July I 99I consideredpositive(urinalysiscombined).Positiveurine culrure was througfrJuneI992. definedaspure growth of more than 1,000 organismsper millilirer.

Methods:All participatingblood cultureswere reviewed.Samples Results:Therewasa I 3% (nine of 68) prevalenceof positiveurine were drawn usingaseptictechniqueand an "lsolator 1.5" coliection cultures. tube.

Results:One thousandtwo hundred sixty-two cultureswere Toa SsnrilivlV(!61 Sprcificity(%lPPUlil XFV(.A) Accurcfl*l obtained,with 52 (4.2%) interpreredas positive.Forty'five specimens Gram stain 89 47 85 98 85 (860,6)were consideredcontaminants:25 coagulate-negative staph pyuria Urinalysis t 3 $ 88 sl 85 (PSC), (PB),five Pcptostre?tococils epidermis(CNSE),13 Propionobactzr Urinalysis leukocyte esterase 25 88 88 25 80 and threeStreptococats viidans (S9. Sevenpositives(l,10,6)representing Urinalysis nitrites (none 0 t00 +) 87 87 (SP),one pathogenicbacteriawere five Strcptococcus pnanmoniae Urinalysis bacteria 25 8l 17 88 85 (Hl), and one mixed SP/SV.Of the 52 positives, Haemophitus inJlunzac Urinalysis combired 38 75 l9 89 70 22 weretreatedasinpatients,and 30 were discharged.In the Conclusion:Preliminaryresultsof rhis ongoingsrudysuggesrrhar dischargedcohort, five had pathogens,all SP,and 25 had contaminants urinary Gram stain has higfrersensiriviryand predictivevaluesrhan consistingof I I CNSE,eiglrt PB,threePSC,and threeSV. Eighty-three urinalysisin detectingUTI in young infantsand may be more reliable percentofthe dischargedpatients(25) were followedup by telephone, in this agegroup. including all five SPpathogens,and all recovereduneventfully.

Conclusion:Blood cultureswere found to be positive for pathogens | fl Epigfonitisin Childrsn1979to 1992 Etfsctsol Haenmphilus in only sevenof | ,262 ED samples(0.5o6).Therewere five pathogens I V ltrfluenzae Type b lmmunization and 25 contaminantsin the dischargedsubset,all of whom did well MH Gorelick, MD Baker/Oivision of GenoralPediatrics, Emergency Medicine, clinically with five contaminantslost to follow-up. This expensivelaboraTheChildren's Hospital of Philadelphia, Pennsylvania tory test,costing$78 ($96,,+36I2-month total), did not impact clinical Study objective: To examine changesin the clinical presentarionand managenrnt of patients< 6 yearsof agewho were dirturged from the ED. epidemiologyof acureepiglortitisin children sincerhe inrroduction of vaccineagainst Haemophilusinfiuatzae rype b (Hib). ll tF) Design:Retrospective chart review of patientseries.

I Z gf ect ot lmbient Temperarure on CapillaryRelitlin Ghildren Setting:[.arge,urban, tertiary-carepediatrichospital.

MH Gorelick, KNShaw,MD Baker/Division of GeneralPediatrics, Emergency Subjects:One hundred fony-wo children wirh epiglottirisadmirred Medicine, TheChildren's Hospital Pennsylvania of Philadelphia, overa l4-yearperiod(1979to 1992). ambiStudy objective:To assessthe effectof moderatelydecreased Resuls:The averagenumber of casesof epiglottitisdeclinedfrom ent temperatureon capillaryrefill (CR) time in normal children and to 12.2 per yearbefore I 990 to 2.7 per year in I 990 to 1992.The mean rleasurethe reliability of CR measurements betweenobsewers. 't989

Design:Prospectiveinterventionalstudy with crossoverdesigr..

Setting:Urban pediatricemergencydepartment.

Panicipants:Conveniencesampleof 32 children I month to 12 yearsof agepresentingfor careof minor illnessor injury. Exclusion criteriaincluded fever(temperature> 38 C), history or physicalfind' ingsconsistentwith dehydration,or urine specificgavity > 1.020.

Interventions:Participantswere assignedin random order to a 15minute waiting period in eachof two rooms,with and without air conditioning (cool and warm roonr, respectively).Ar rheend of eachwait, ing period, fingertip CR was measuredwith a stopwatch,three timesby eachof one to three trained observers.

Results:MeanCR time was 0.85 t 0.45 secondsin the warm room (meanambienttemperaturc,25.7 C) versus2.39 t 0.76 secondsin the cool room (meantemperature,I9.4 C). The meanoveralldifferencein CR time betweenthe rwo environmenrswas 1.53 seconds(9506confidenceinterval [CI]: 1.31, l.75; P < .00I); the differencewas significanr regardlessof ageor sequenceof exposure.One hundred percentof patientswere corsideredto havenormal CR (< two seconds)in the warm roomr while only 3l% were considerednorrnal in the cool room. ln the l6 patientswith CR measuredby three observers,interobserver reliabilitywas fair, with an intraclasscorrelationcoefficientof .70 (9504Cl:0.56,0.85)and x of .54 (95oACI: 0.33,0.73).

Conclusion:Decreases in ambient temperaturewithin a rangefound in typicaloffice/EDsettingsrruy causesignificantprolongarionof CR time in children with normal circulatory status.Thereis markedinrerobservervariability in the measurementof CR evenwhen performedby experiencedobservers.Thesefindingssuggestlimitarionsto the use of CR in the assessment of ill or injured children.

Foreign I Q FoleyCatheterTechniquefor Removalof Esophageal I rl Bodiesin Ghildrcn JE&hunhAM Harrison, GWNixon/Department of Pediatrics andRadiology, University of Utah,Primary Children's MedicalCenter, Saltl_ake City Study objective:To reviewuse o[ the Foley cathetertechnique (FCT) in removalof esophagealforeigr bodies(EFBs)and ro determine whether age< 21 monrhsor duration of impaction influencesthe successrate.

Design/setting: Ten-yearretrospecrivecharr review;tertiary referral childrens hospital.

Participants:Children (< l6 yearsof age)wirh an EFBwho underwent anemptedFCT removalunder fluoroscopicguidance.

Resulr: Four hundred fifteenepisodeswere reviewed.Children ( 24 months of ageaccounredfor 45%. Children wirh underlying esophageal pathologycomprised14,5%of rheepisodesinvolved.Coins accountedfor76.106of the EFBs.The FCTwassuccessful in 9l.l% of episodes(378), including removal(314), pushedto stomach(,14), spontaneousexpulsion(five), or passageinto the stomach(12) during the procedure,and modified FCT (three).Overall, age524 monrhswas not associated with decreasedsuccess(P > .05). The impacrionduration wasnoted in 290 episodes.When the EFBwas impacredS one day, rhe FCT wassuccessfulin 95% of rhe episodescomparddwirh 6706if impactedlonger(P < .05). Major complicarionsand/or hospitalizarions werenoted in sevenepisodes.One patientreceivedlV antibioticsfor mucosallaceration,one requiredassistancefor transientairwaycompromise,and one sustainedesophagealperforationrequiringsurgery and extendedintubation. Four other Datientswere admitted for observation after operativeEFBremoval.

Conclusion:The FCT successfullyremoved> 90% of pediatric EFBsattempted.Duration of impaction > one day is associated with decreased successrate. Complicationsareuncommon but potentially

serious.Further studiesshould define the Dotentialfor FCT usebv rhe emergencyphysician. rl /l BrainTraumaby EpiduralBrain Gompression in a Ganine0utcomo I rf Modoh ProlongedResuscitativeModeratoCcrcbral Hypothernia U Ebmeyer, PSafur.S Pomeranz, HAlexander/lnternational ffesuscitation andNeurosurgery, Besearch Center andDepartments of Anesthesiology University Pennsylvania of Pittsburgh, Studyhypothesis:In our new caninebmin traumaoutcomemodel, postinsulthypothermiaof 3l C for five hours preventedsecondary intracranialpressure(lCP) rise,but subsequent35 C temperaturedid not preventsubsequentICP rise to brain death.We hypothesizethat hypothermiaof 3l C for,l8 hours can preventbrain death. with Design:After sedationwith ketamine,dogswere anesthetized NrO:Or-halothaneand controlledventilationfor preparation.Under NrO:O, and relaxant,the insult wasby epiduralballoon infl4tion to ICP 62 mm Hg for 90 minutes.After balloon deflation,intermittent positive-pressure ventilation(IPPD with NrO:Or-narcoticwas to 72 hours and intensivecareto 96 hours. Group I (ten) was rnaintained normothermic.Randomizedgroup 2 (I 1) wascooledfrom I5 minutes of balloon inflation to core temperatureof 3l C with surfacecooling and maintainedhypothermicto 48 hours. Rewarmingwas from 48 to 72 hours. lntewention: Postinsulthypothermiaof 3l C for 48 hours.

Results:Nine of ten in group I and eight of I I in group 2 followed protocol.After balloon deflation,meanICP increasedto ) 20 mm Hg in group I at a rrreanof two hours 30 minutesand in group 2 at 22 hours 15 minutes(P = .002). Five of ten group I dogsand I I of I I group 2 dogssuwived IPPVto 72 hours (P = .03). lpsilateralmacroscopically damagedbrain tissuevolume (focus+ penumbra)was 2,094 I I,340 mm3 in group I versus950 t 626 mm3 in goup 2 (P = .08) (2 x 8). The volume o[ the necrotic focus(mean,217 versus220 mm3) and the degreeof cerebellardownwardshift (mean,6.85 versus4.86 mm) werenot sigrificantly differentbetweengroups.ICP rise after 48 hours. bleedingdiathesis,and pulmonary infectionwereworse in group 2.

Conclusion:In this standardizedbrain traumacaninemodel,resuscitativehypothermiao[ 3I C for 48 hours helps keep ICP low and reducesthe volume of damagedbrain tissuebut cannotpreventICP rise during rewarmingand may causeextracerebralcomplication.

Deferoxamine inthe { f Hypoftermia,Dichloroacetate,and I rf Treatmentol CerebralEdemrAfter ExporimentrlControlled Coilical lmpact in thc Rat W Heegaard, MH Biros/Department Medicine,Hennepin County of Emergency Medical Center, Minneapolis, Minnesota Study objective:To investigatethe effectsof hypothermia(hypo) aloneor in combinationwith dichloroaceticacid (DCA) and/or deferoxamine(DFO) in reducingcerebraledemaafter controlledcortical impact (CCI) in the rat, Design:Anesthetizedratswere subjectedto moderatelysevereCCI (impact depth, 1.5 mm; speed,3.5 m/sec)througfra riglrt 6-mm parietalcraniectomy.Sham-operative animals(l l) and untreated traunutized animals(17) were alsoprepared. lnterventions:Immediatelyafter CCl, animalsunderwentselective brain cooling to 33 C (temporalismuscletemperanrre)by exposureof the headto an ice bath (body temperature,37 C). Ten minutesafter CCl, randomizedanimalsalsoreceivedintraperitonealDCA (25 mg4<g, I l), DFO (50 mg/kg,seven),both DCA and DFO (nine), or equivolurne normal saline(ten). Four hours after CCl, animalswere killed, and specificgravity(SpG)at the traumasite was measuredon organic

gradientcolumns.Analysisof variancewasusedto determinegroup differences,with P < .05.

Results:The SpG at the traumasite from all treatmentgroupswas no differentfrom the SpG ofsham-operativecontrols(SpG= 1.040t 0.004).All treatmentprotocolssignificantlyreducedcerebraltissue SpGat the site o[ trauma(pooledSpG = 1.040t 0.002) comparedwith no treatment(SpG= I.033 t 0.00+).

Conclusion:Cerebralhypothermia,DCA, and DFO are effective methodsof reducingpost-CClcerebraledemain the rat. { f, Tnutnatic ileuronal Iniury la lfiro: SynergisticEllect ol the I fl 2l-AminosteriodUTtt5OAand thc ltlMDARoceptorAntagonist MK-801 BFflegan,SSPanter/University of California SanFrarriscoandLetterman Army Institute of Research Studyhypothesis:Secondaryin1uryprocesses after traumaticneuronal injury are mediatedby both membranelipid peroxidationand (NMDA) receptors. excessive activationof N-methyl-o-aspartate Combinationtherapywith the antioxidant2I-aminosteroidU74500A and the NMDA receptorantagonistMK-801 will provide synergistic benefit.

Desigr.:Corticalcell culturespreparedfrom fetalSwiss-Webster micewereusedat 14 to 17 daysin vitro. Traumawas deliveredin a definedmedium by reproduciblytearingthe culture monolayerwith a stylet.Neuronalinjury wasassessed 24 hours later by measurementof lacute dehydrogerusein the culture medium, which is a sensitive markerof cell death. lnterventions:The effectof U74500A and MK-80I, presenrduring and after deliveryof the rraumaticinsult, was quantitariveiyassessed.

Results:Within ten to l5 minutesof injury, neuronsadjacentto a teardevelopedmarkedswellingof cell bodies;most of thesecells degenerated over the subsequent2,t hours. As previouslyobsewed, approximately50% of this injury was prevenredby MK-801 (10 pM).

U74500Aaloneprovidedweakerneuroprorection,reducingneuronal deathby about 2506,with maximum effectat a concentrationof I to 5 pM. U74500Acombinedwith MK-801 wasconsistentlymore effective than eitheragentalone,preventingmore than 75% of neuronaldearh (P < .05, Student-Newman-Keuls rest).

Conclusion:A traumaticinsult to neuronsand glia in culture results in progressiveneuronaldegenerationover the subsequent2,1hours.

This injury is auenuaredby both U74500A and MK-801 and may be due in part to both lipid peroxidationand excessive activationof NMDA receptors.

NeuronalLossand Neurologic0utcomeAfter { ] Hippocampal I f Nimodipinein FluidPercussionBrain Iniury NTGentile,DHSmith,C Burhans, TKMclntosh/Departmert 0f Surgsry (Emergency Medicinel, University of Connecticut HeahhCenter, Farmington; Department of Neurosurgery, University of Pennsylvania, Philadelphia Study objective:Calciumhasbeenimplicatedin the pathogenesis of traunutic brain injury. Nimodipine, a dihydropyridinecalciumchannel blockerhighly selectivefor cerebralvasculanrre,miglrt amelioratethis damageby limiting the influx of calcium into cerebralvascularsmooth muscleand neuronalcells.This study examinedthe effecrsof nimodipine on memory,neurologicdysfunction,and histologicdamageafter fluid percussionlateraltraumaticbrain injury.

Design:The study was randomized,blinded, and placebo controlled.

Methods:Anesthetizedrats underwentlateralcraniotomyand moderatefluid percussionbrain injury (2.5 atm). Shamcontrols(four)

underwentcraniotomywithout injury. Nimodipine (13) or polyethylene glycol (PEG,I3) wasadministercdby intraperitonealinjection (10 pglkp t 5 minutes after injury and by subcutaneouspelles for continuous infusion for 48 hours. Morris Water Mazespatial memory was tested at one week after the injury. Neurologicfunction wasmeasuredusing a five-testcompositeat baseline,24 hours,and one and nrroweek after injury. After behavioral testing, anesthetizedanimals were perfused with 406paraformaldehyde,and the brains were rcmoved. The degree from toluidine blue-stainedl0-pm of CA3 neuronallosswasassessed cryostatsectionswith quantitativeimageanalysis.Plasmanimodipine levelswere measuredat four, 24, and 48 hours.

Results:Therewereno differencesin medianmemory or neurologic function scoresbetweennimodipine- and PEG+reatedanimals (P > .05, Mann-Whitney).Nimodipine-treatedanimalshad significantly lessCA3 hippocampalneuronalstaining(18.I% versus42.6oA)tlwn PEG+reatedanimals(P < .00I, Newman-Keuls).Nimodipine levels were I 9.6 + 1.2, I2.7 t 2.7,and 12.2+ 7.9 nglml at four, 24, and'18 hours, respectively.

Conclusion:Therapeuticnimodipine dosingnot only failedto improvememory and neurologicdysfunctionbut worsenedCA3 hippocampalneuronallossafter fluid percussionbrain injury. Althouglt blockageof NMDA and voluge-sensitivecharmelscan be beneficial after craniocerebraltrauma,nimodipine is probablynot usefuland may be deleteriousfor the treatmentof traumaticbrain injury. { Q Doesa PerlectGlasgoruGomaScaleof 150bviatsComputed I O Tomographyof thc Hoadin TraumaticLossof Consciousness?

Einstein U Gallagher/Albert WACarter, M Davitt,PGennis, G Lombardi, Hospital, NewYork College of Medicine, BroruMunicipal Studyhypothesis:Computedtomograms(CTs) may be unnecessary (LOC) and a Glasgow in patientswith a traumaticlossof consciousness ComaScale(GCS)scoreof 15 becausethe needfor neurosurgicalintervention in thesepatientsis exceedinglyrare.

Design:Prospectiveobservationalcohort study.

Setting:Urban l-evelI traumacenteremergencydepartment.

Participants:Conveniencesampleof 2,48adult patientswith a traumatic LOC and a GCSof 15. ln accordancewith the original designof the GCS,only patientswho were completelyorientedto person,place, and time receiveda perfectscoreof 15. lntervention:With meticulousattentionto orientation,GCSscores were obtainedby trainedresearchassistantsthrough direct interaction with patientsby using a sundardizeddatacollectioninstrumentwith a closed-questionformat.

Results:Forty-two patients(17o,6)were admitted to the hospiul; 206 patientswere dischargedfrom the ED. CTswere obtainedon 47 patients(1906);all werenegarive.Follow-up at a minimum of seven daysafter injury was obuined on all 248 patientsby telephonecontact or by reviewof hospitalrecords.No patient requiredneurosurgical intervention,and therewere no adverseoutcomes(95% confidence intewal [CU: 006to l.5%). This finding is sigrificantly differentfrom the previouslyreportedincidenceof neurosurgicallesionsin patients 95% CI: 1.9%ro 5.4%) with headtraumaand a GCSof l5 (3,30,6: (two-tailedP < .004, Fisher'sexacttest).

Conclusion:l) The necd for neurosurgicalintewention in patients with traumaticLOC and a GCSof 15 may havebeenpreviouslyoverestirnatedbecauseofnonsundardizedapplicationofthe GCS.2) Although CT has been shown to be more cost-effectivethan admission for obsewation,an optirnalstrategyfor selectedheadtraumapatients with a GCSof 15 may be to do neither.This appearsto be a viableclinical altemativeprovided that orientationto person,place,and time is a

scrupulouslyverified prerequisitefor the assigrmentof a perfectGCS scoreof 15. rt Q lntracranial Hemorrhageas a Prodictorof 0ccult GervicalSpino I rf Fracture GFrye,IWolte,B Knopp, R Lesperance, J WlliamsfValley Medical Center, Fresno. hlifornia Studybackground:Kirshenbaumreportedthat occult cervicalspine fracture(OCSF)occurredin 3306of patientswith traumaricintracranial hemorrhage(TICH). He recommendedcomputedtomograms(CT) of the upper cervicalspine in all parientswirh TICH. Studyhypothesis:To determinethe frequencyof OCSFin blunt rraumavicrimswirh TICH. Desigr: A prospectivecross-sectional study.

Setting:Universiry-alliliatedl-evelI traumacenter.

Participants:Ninery-threeblunt traumavictims with a Glasgow ComaScoreS I2. Exclusioni:riteriawere pregnancy,hemodynimic instabilityrequiring immediatesurgery,and incompletecervicalspine senes. lnterventions:Study protocol requiredall patientsto undergoa fiveview cervicalspine traumaseries,headCT, and upper cervicalspine CT. Cervicalspine radiographsand CT were readscparatelyby two radiologistsblinded ro the orher interpretations.OCSFwas definedasa (-) cewicalspine serieswith (+) CT of the upper cervicalspine.The resultswere comparedwith the interpretationof eachpatient'shead CT. Medicalrecordswere reviewedfor demographicinformationand mechanismof injury.

Results:Ninety-rhreeparienrswere enrolled in the srudy.Fifty,six had a TICH noted on CT; two of thesepatientshad an upper cewical spinefracture,but only one was an OCSF.Thirty-sevenparienrshad no TICH; one patientin rhis group had an OCSF.Using a binomial proba, bility calculationro dererminethe likelihood of OCSFin parientswirh TICH, the probability that rhe predicrivepower of TICH is ashigh as I006is .02.

Conclusion:Despirea high percenugeof parienrcwith rraumatic TICH, our study failed ro demonstratethat TICH is a predictorof OCSF. r)fl Prevalencoof RocontCocainoUsein Adult PatiertsWth 4[f UnexplainedSoizuros EAPanacek, A Prescott/Department of Emergency Medicine,University of California DavisMedicalCenter; University Hospitals of Cleveland Studyhypothesis:Adult parienrswirh new-onser,unexplained seizuresmay show a strong associationwith recentcocaineintoxication.

Desigr: Prospecrive,single-blindedprevalencestudy wirh cohort controls.

Setting:Urban universityhospiul emergencydepartment.

Participants:Adult patientswith an unexplainedseizurefromJuly I 989 to December1990. Patientswere excludedif thev had a historv of seizures,apparentmetabolic,infectious,or traumaticetiology,or alcoholwithdrawal. Patientsof samesex and similar age,concurrenrly in the ED, servedascontrols.

Intewentions:In addition to usual evaluations,all study patients had a urinary toxicolory screenperformed.L.aboratorypersonnel performing the tesrswere blinded ro the parienr diagnoses.

Results:During rhe srudy period (1.5 years),532 aduk parientswere seenin the ED for seizures.Of these,92 inirially qualifiedas unexplained,and 72 of rhese(78%) weresuccessfullyenrolledin rhis study. The urine toxicologicscreenwas positivefor cocaine(ie, benzoylecgonine)in 19 of 72 cases(26.4%). Furthcr quesrioningof rhe alerr patientsconoborareda history of cocaineuse within the preceding

three daysin 92% (12 of l3) and within the preceding2,t hours in 69% (nine of I3). The prevalenceof positivecocainescreensin the cgnrol groupwaseigfrtof 7l (l1.3%).

Conclusion:Adult patiens presentingwith unexplainedseizures were found to havea high prevalence(26.40A)of temporallyassociated cocaineuse relativeto controls.The use of toxicologicscreeningof such patientsis recommended.

ttl

4 I Cocaedrylono, Cocaino, andEthanol Levelsin Trauma Patientr DBrookoff, LShaw, ECampbell, ofTennsssee, Memphis; L Fields/University University ofPennsylvania, Philadelphia; Empire Health Services.

Spokane, Washington Study objective:Cocaethylene, a metabolicproduct of the combination of ethanoland cocaine,hassubsuntially gr?z.rer toxicity and a longerserumhalf-life than either of its parentcompounds.To assess the relationshipo[serum levelso[cocaethyleneto levelsofis parent drugs,we obtainedsimultaneousmeasurements of all three from a seriesof traumapatients.

Desigr: Prospectivecaseseries.Serumethanolwasassayedby headspaceBaschromatography,cocaineand cocaethylenewere measuredby high-pressuregaschromatogaphy,and urine was testedfor benzoylecgonine(> 300 nglml) by EMIT-DAU procedures.

Setting:Urban l-evelI traumacenter.

Two hundred eight consecutiveadult victims of major ,rruP#lt.tPr.,r: Results:Fifty-ninepercentof patientswere positivefor cocaine(I2 'r.o727n{mL),55% for ethanol(I2 rc a26m{dL),and.32oAfor cocaethylene(2 to 213 nglml). Fifty-ninepercento[ patientspositive for berzoylecgonineand 306o[ patientswith negativeurine samples had detectableserumlevelso[cocaethylene.Seventy-seven percentof patientspositivefor both cocaineand ethanoland 38% positivefor cocainealonehad detecubleserumlevelsof cocaethylene.

All patients positivefor cocaethylene had detectableserum levelsof cocaine,and 7I% werepositivefor ethanol.Mulcipleregessionanalysisrevealed that serumcocaethylenelevelswere not correlatedwith cocainelevels (r = .02) and only weaklycorrelatedwith ethanollevels(r = .2,1).

Conclusion:The presenceand concentrationofcocaethylenecannot be accuratelydeducedfrom simultaneousserumlevelsof cocaineor ethanol.

LLtow-Year Beviowol Cigareftelngestionsin Childrcn 0 McGee,TErabson, J McCarfry,M Picciotti/Department 0f Emergency Medicine, AlbsrtEinstein MedicalCenter, Philadelphia, Pennsylvania Study objective:To investigatethe demogaphicsof cigaretteproduct ingestionsin children and to assessthe incidence,symptoms,and outconrs of nicotine toxicity.

Desigr: Retrospective databasereview.Becauseo[ the potential for sigrificant toxicity, patientswere referredto the emergencydepanment for ingestionsof more than two cigarettes,six cigarettebutts, an unknown amount! or at the discretionof the poison information specialist.Somepatientswent to the ED on their own. All otherswere managedat home.

Participants:Sevenhundred children under 6 yearsof agewho ingestedcigarettesor cigarettebutts and were reportedto an MPCCcertilied poisoncontrol centerbetween1988 and 1991.

Results:Meanpatientagewas 12 months; medianagewas l0 months.Among 143 symptomaticpatients(2O.4%),vomiting was rhe only symptomin I38 (98.6%)and occurredsponraneously(in lessrhan 20 minutes)in l0l (72.1%).The five remainingpatients(two wirh

Exclusioncriteria:Patientswith known allerg;lto benzocaine, midazolam,or meperidineand patientsreceivinga local anesthetic in addition to benzocaine.

Interventions:Blood for baselineMHb levelswascollected.Patients receiveda countedtwo+econd sprayof.2}obbenzocaineto the oropharynxand then swallowedthe residue.Blood for MHb analysis Conclusion:Significanttoxicity causedby the ingestionof cigarette was collected20, 40, and 60 minutesafterbenzocainedosing.Venous productsin children is rare.Self-limitedsponuneousvomiting is the blood was collectedin lithium-heparinblood gassyringes,agiuted, mostcommon symptom.The absenceof vomiting predictsa favorable placed on ice, and analyzedwithin 30 minutes using a CO oximeter. outcomeevenwhen potentiallytoxic amountsare suspectedto be Resuls:Fifty-sevenmen and 34 women with agesrangingfrom 20 ingested. to 8I years(median,52 years)enteredthe study. Methemoglobinlevels (meanI SD)were0.806+ 0.106,0.906t 0.106,0.9%+ 0.1%,and 0.906t 0.I06 for baseline,20 minutes,40 minutes,and 60 minutes, f ! MetabolicAbnormalitiosin PatientrWth SeveroCarbon 4rl MonoxidePoisoning:InsightsInto Pathophysiology respectively.Dataanalysisusing analysisof variancefor repeatedmeaDAChiulli, EPBivers, S Kristal, HASmithline.

H Blake.E Beiser.

MA Eichenhorn, suresand post hoc testingwith Fisher'sprotectedleast-squares differMCTomlanovich/Henry FordHealthSystems, Detroit, Michigan enceidentifieda signilicantincreasein percentageMHb betweenbaseStudy objective:To examinethe routine laboratorytess performed (P < .05). Therewere line and 20-,40-, and 60-minute measurements in patientswith severecarbonmonoxide(CO) poisoning. no differencesamongthe 2O-,40-, and 60-minute levels.

Participants:Adult patientspresentingro the emergencydeparrmenr Conclusion:A two-secondsprayof 20obbenzocaineapplied to the with severeCO poisoningrequiring hyperbaricoxygenft{BO) therapy. oropharynxof human beingsinducesa statisticallysignilicantbut Desigr: Prospective,consecutivecaseseries.Historicalcontrols. clinically insignificantincreasein percentageMHb at 20,'t0, and 60 Duration,six months. minutesafter dosingwhen comparedwith baselinevalues.

Setting:t-argeurban ED with an HBO chamber.

Methods:Sixty patientsreferredfor HBO therapywith a CO level> Studyof Double-Blind, Placebo-Gontrollod ttr A Randomized, 250,6with neurologicmanifesutionswerestudied.Completeblood 4if Fluorescein Detection in Human Urine count, electrolytes,glucose,and lactic acid levelswere drawn before Medicine, of Emergency KDLocke, JH Ellis,RCOart,WL Manaker/Department and after HBO therapy.

Poison FortHood, Texas; Rocky Mountain Darnall ArmyCommunity Hospital, Results: andDrugCenter, Derver,Colorado Study Study objective:To determinewhether orally ingestedfluorescein dye in concentrationssimilar to that found in antifreezeis detecublein (%l Carboryhemaglobin 4l r 12.5 5.1t4.0 .ml urine samplesusing UV light. Previousinvestigato$haveclaimedthat lacticacid(mM/l) 4.5r3.6 LI r0.4 .001 (mEq/LI Potassium 3.8r0.7 4.310.6 detectionwould be feasiblewith a hand-heldUV light. .001 (g/dLl Hemoglobin 1 4 . 0tr. 7 12.6r.2.0 ,030 Design:Randomized,double-blind,placebo-controlledtrial. (mg/d[) Glucose rqt* I l2 1nt52 .ml Setting:Communityhospitalemergencydepartment.

Conclusion:Patientswirh sigrrificantCO poisoninghavesignificant Participants:Twenty-threehealthyvolunteersbetweenagesI 8 and metabolicderangements.

The hypokalemia,hyperglycemia,and hemo, 40 years(17 men and five women).Exclusionswere pregrancy,renal concentrationseennuy be a result of elevatedcatecholaminelevelsasa disease,or allergyto fluorescein. responseto acutecellularhypoxia.Surfaceoxygenreducedthe CO level lntewentions:Subjectswere randomizedto ingesteither 30 mL of to normal beforeHBO therapyin ,tl % of the parienrs;however,their plain orangejuice or 30 mL of orangejuice containing0.6 mg fluoreslacticacid levelsremainedelevated.Elevatedlactic acid levelsdespitea cein. Urine sampleswere obuined at baselineand one, two, and four normal CO levelreflectevidenceof conrinuedcellularhypoxia. hours. Threeemergencyphysiciansexaminedeachurine samplein a double-blindmannerfor fluorescence using a hand-heldUV lamp.

Methemoglobinenria Resuls: Using an increasein perceived fluorescenceat any time by t I A ProspectiveStrdy of Benzocaino-lnducod 4'l in Humans one or more examinersasa positiveinterpretationgavethe bestsensi AT Guenler,W APearcs/Department of Emergency Medicine and tivity. Therewereseventrue-positivespecimensand five true-negative Gastroenterology Service, Department of Medicine, Madigan ArmyMedical specimensbut six false-positive specimensand five false'negative speci' Center, Tacoma, Washington mens.Sensitivitywas0.45, specificitywas 0.54, positivepredictive Studybackground:Although benzocaineinducesmerhemoglobin valuewas 0.5,t, and negativepredictivevaluewas 0.50. At baseline, (MHb) in animalsand human beings,benzocaine-induced merhemobeforefluorescein,I 5 of the 23 specimenswerejudged fluorescenceglobinemiain human beingshasnot beencritically evaluated. positiveby at leastone examiner.Only one of l2 patientsreceiving Study objective:To determinewherherclinical dosesof benzocaine producedurine that wasjudged to fluoresceby all three appliedto the oropharynxsignificanrlyincreasehuman MHb levels.

HT;J;" Design:Prospectiveconveniencesampleof patientsundergoing Conclusion:Endogenousfluorescence of unknown origin appearsto upper gastrointestinal(UGI) endoscopyduring October 1992. obscurefluorescence producedby lluorescein.Contraryto previous Setting:Gastroenteroloryclinic at an arrny medicalcenterfunctionreports,it is unlikely that the determinationof uilne fluorescence by ing asa community hospiul and referralcenter. hand-heldUV lamp is feasiblein the clinical setting.

Participanrs:Conveniencesampleof 9I patients. lnclusioncriteria:Adults (> l8 yearsof age)undergoingan UGI endoscopicprocedurebeforewhich benzocainewas used. vomiting, threewirhout) developedtransientlethargyor iniubility that completelyresolved.Forty-four of 700 patientsingestedpotentially toxic amountsand were referredto the ED; threewere lost to follow-up. Initially asymptomaticpatientsneverdevelopedsymptoms.

Symptomaticpatientsimprovedwithout sequelae.No patientdeveloped

on the Plasma f f, The Ellectol Globallschemiaand Roperfusion 4lf levels of Endogenous VasoactivoPeptides Ml flose, NAParadis, ML Blucher, S Balter/Department of Surgery, Division of Emergerry MedicalServices, Bellevue Hospital Center, NevvYorkUniversity Medical Center, Brooklyn, NewYork Study objective:Rerum of sponraneouscirculation(ROSC)hasbeen demonstratedto be a function of coronaryperfusionpressure,which is itselfa function of vasomotortone.Vasomotortone,in tum, is determined by the relativestimulationof arterialvasoconstricr.ing and vasorelaxingreceptorsby vasoactivesubstances.We rrrasured the plasma levelsof the endogenousvasoactivepeptidesargininevasopressin (AVP),angiotensinIl (Ang ll), and arrial narriurericpeptide(ANP) during cardiacarrestand resuscitation.

Desigr: A fibrillatory caninemodel of cardiacarresrwasused.

Downtimewas more than ten minutes,duringwhich no therapy, includingbasiclife support,wasgiven. Standardadvancedcardiaclife support(AC[S) wasinitiated ar the end of the downtime with manual extemalchestcompressionstandardizedto an esophageal pulsepressure of 50 mm Hg. Blood sampleswere collecredthrough an aorriccatherer during spontaneouscirculationand threeminutesafter initiation of AC[S. Peptidelevelswere measuredusing standardradioimmunoassay techniques.Resultsare reportedasmeant SD (pglml). Plasmaconcentrationswere comparedusing two-sidedt-tests.

Results:Elevenanimalswere srudiedin the AVP/ANPgroup, and I3 werestudiedin the Ang II group. The arrestinrewal was 15 t 4 minutesin the AVP/ANPgroup and 14 t 4 minutesin the Ang ll group.

AVP Angll ANP

55146 15113 55146

m r73 1 5111 0 5 293r73

.01 <.05 < .01

Conclusion:Thereweresignificanrincreasesin the levelsof these endogenousvasoactivepeptides.This reflectsthe neuroendocrine responseto global ischemiaand CPRreperfusion.Plasmalevelsof these peptidesmay affectthe vital organperfusionpressuresrresponseto exogenousvasopressorsr and outcomeof resuscitative efforts.Future therapiesmay be directedar enhancingor blocking rhe effectof these peptidesto optimizeperfusionpressure,which is one of the principal determinantsof outcomeduring CPR.

,', 4 f Angiotensin ll lmproves Cerebral Blood FlowinCardiac Arrest CMLittle, JCHobson, CGBrown/0hio State University.

Columbus Studyhypothesis:AngiorensinII will improvecerebralblood flow in the settingof cardiacarrest.

Desigr: Swinewere anesthetizedwith halothane,instrumentedfor radiolabeledmicrosphereblood flow measuremenrs (BFM),and rransitioned to cr-chloralose.

A BFM was obtainedin normal sinusrhythm (NSR).Ventricularfibrillation (VF) was induced,and CpR wasbegunat ten minutesof VF. A BFM was performedduring CPRbefore(CpR-pre) and after (CPR-post)angiotensinadministration.Defibrillarionwas attemptedat 16.5minutesof VF, and a BFMwasobtainedif retum of spon[aneouscirculation(ROSC)occurred. lnterventions:Angiorensinll (50 pg/kg wasadminisreredat l3 minutesof VF. Results: CEEF cED02 cFVo2 EXT %

464r 12.0 5.81I5 2.9r 1.4 5l .3r 21.5

CPFpro

CPR-p0.1

6.9x7.2 1.1 01.0 0.8r0.8 8 1 .t59 5

30.8 r 19.7 5.rr1.0

73.9 r39.0 r4.9r9.2

4.0t2.4 7l.0n12.3

7.1t4.2 n9t28

.m4 .009 .m5 .m

CEBFis cerebralblood flow (mUI00 g/min), CEDO, is cerebral oxyen delivery,and CEVO, is cerebraloxygenconsumption(mt400 g/min). EXT 0,6is the cerebraloxygenextractionratio. P is the difference betweenthe CPR-preand CPR-postvalueby paired two-tailedt-test.

Conclusion:Angiotensinll in a doseof 50 pg4<gsigrificantly improvescerebralperfusionduring CPR. lfQ The Ellects of VagalTone on ResuscitationFromExperimental 40 Electromechanical Dissociation Medicine,MedicalCollegeof DJ 0eBehnke/Department of Ernergency Wisconsin, Milwaukee dissociation Studyhypothesis:Many prehospiul electromechanical (EMD) cardiacarrestsare due to bradycardicEMD. Atropine (2 to 3 mg) hasbeenrecommendedasa completevagolyticdosein EMD, but this doseis basedon only two studiesin non-cardiacarrestpatients.

The effectsof completevagotomyin EMD havenot beenstu$ied.We testedthe null hypothesisthat completelossofvagal tone doesnot improve the retum of spontaneouscirculation(ROSC)rate from experimentalEMD. Design:Prospective, controlledlaboratoryinvestigationusing a canineasphyxiationmodel of EMD. Interventions:EMD wasproducedby clampingthe endotracheal tube and wasdefinedas the presenceof ECGcomplexeswith complete absenceof aortic pressurefluctuationsby aortic catheter.Sixteen mongreldogsremainedin untreatedEMD for ten minutesand were randomizedto receivebilateralcervicalvagotomy(eigfrt)or no vagotomy (eight).All animalsreceivedsundard extemalCPRand epinephrine(0.02 mg/kg everyfive minutes)througlroutresuscitation.

Results:ROSCwasanalyzedusing Fisher'sexacttest.Hemodynamic datawere comparedusinganalysisof variance.ROSCwasachievedin I306 of animalswith no vagotomy(one of eigfrt) andT5obo[ animals with vagotomy(six of eiglrt) (P = .02). Survivalto one hour was achievedin I306 of animalswith no vagotomy(one of eight) and 63% of animalswith vagotomy(five of eiglrt) (P = .06). The hemodynamic and arterialblood gasvaluesat five, ten, and l5 minutesduring resuscitation werenot significantlydifferentbetweengroups.During resuscitation, therewas a statislicallyinsignificanttrend toward increasedECG complexrateand coronaryperfusionpressurein the vagotomygroup.

Conclusion:Despitesimilar resuscitationhemodynamicsand ECG complexmte, vagotomizedanimalswith completelossof vagaltone had a sigrificantly improvedrate of ROSCfrom asphyxialEMD comparedwith animalswithout vagotomy.Completelossof vagaltone improvesROSCfrom EMD. Studiesdeterminingthe doseof atropine that producescompletelosso[ vagaltone in EMD cardiacarrestshould be performed. tt/tl tg

r4rf MyocardialNecrosisAfter High-DoseEpinephrine DuringCPR RNeumar, N Bircher, A Badovsky, K Sim,FXiao,L Kau,U Ebmeyer, P Safar/lnternational Resuscitation Besearch Center andCenter for Emargerry Medicine, University of Pinsburgh, Pennsylvania Studyhypothesis:After prolongedcardiacarrest,excessive epinephrine(EPI)dosesduring CPRmay damagzthe heart.

Desigr: Thirty maleras (359 t24 g were studiedin randomized sequence.They wereanesthetized,instrumented,paralyzed,and mechanicallyventilated.Eachrat underwentten minutes of apneic asphyxiaresultingin approximatelysevenminutesof circulatoryarrest.

Resuscitation consistedof intermittent positive-pressure ventilation (lPPVyO,manualextemalCPR,EPI,and 1.0 mEqrtg NaHCOr. Successfully resuscitatedratsunderwentIPPVfor one hour without

pharmacologichemodynamicsupport.Suwivors to 72 hours were killed with pamfornuldehydeperfusionlixation. Myocardial sectionswere stainedwith hematoxylin-eosin-phloxine and examined by liglt microscopyby one blinded investigator.Myocardialnecrosis scoreswere determined(0, none; l, minimal; 2, mild; 3, moderate; 4, severe).

Interventions:At start of CPR,group A (15) received0.01 mg/kg EPI;groupB (i5) received0.1 mg&g EPl. Results:Baselinehemodynamicand metabolicvariablesdid not differ betweengroups(Student'st). Group B developedinitial hypertension(meanarterialpressure> 120 mm Hg) for more than five minutescomparedwith one minute in group A. Group B had more severepostresuscitation metabolicacidemia.Resuscitationrateswere l3 of 15 for group A versus12 of 15 for group B, and survival ratestoT2 hours wereeigfrt of I 5 for goup A versusfive of 15 for goup B (P > .05, Fisher's).Medianmyocardialnecrosisscorewas 0 (range,0 to l) in group A versus2 (range,I to 3) in group B (P - .003,Mann-WhitneyI-I).

Conclusion:In this rat model, 0.I mg/kg EPI during CPRresulted in sigrificantly increasedmyocardialnecrosiscomparedwith 0.01 mg/kg EPLThis may be due to a prolongedduration of EPI effectin the postresuscitation period with higlrer doses. tl/tl

JU larno"ine Mediate: CardiacTachyphylaxis to Catecholamines JW Burye,AA DeStefano, JL Garvey, MEOuinn,BM Faymond/Department of Emergency Medicine, Carolinas MedicalCenter, Charlotte, NorthCarolina Study objective:The mechanismof uchyphylaxisro carecholamines is not known. This study was performedto determinewhethercardiac tachyphylaxisto catecholamines is mediatedby adenosine(ADO) and whetherit can be reversedby aminophylline(AM), an ADO receptor antagonist.

Design:Controlledstudy of rat hearrs(five) in an isolatedbearing heart (l-angendorff)preparationwith rime controls.The AM doseselected had no effecton cardiacfunction basedon prior dose-response studies.Datawere analyzedusing repeated-measures analysisofvariance. interventions:Heartswere perfusedwith Krebs'bufferat a constant cororury flow. Studyheartswereperfusedwirh epinephrine(EPI) I0-o M for ten minutes.Perfusionwas rhenchangedto EPI If M plus AM 18 pglml for ten minutes.Controlswere perfusedwith Krebs'bufferonly.

Measurements: Heart rate,left ventricular peaksystolicpressure (LVP),and +dP/dtasan index ofcontractiliry were measured.Venous effluentwas analyzedfor ADO concenrrarion.CardiacADO production (ADOP)was calculated.

Resuits:EPI causedan increasein LVP and +dP/dt at one minute (P < .05), but tachyphylaxisoccurredby ten minutes.Addition of AM reversedthe uchyphylaxisar one minure (P < .05) and increasedADOP sevenfoldcomparedwith EPI (P < .0001).At ten minuresof EPI plus AM, tac\phylaxis againoccurred,bur ADOP remainedhigh (P < .05).

Resultsarebelow: valuesare meant SEM. wP +dP/dt ADoP HR {mmH0} lmmH0frocl (moumin) Basal EPI(l minute) EPI(10minutes) EPI+ AM(1minute) EPI+ AM(10minutes)

316138 8315.1 312t24 124118 35018 8017.9 328rlS 137 r9.0 376t42 98rtl

1.5S1122 2.W*.401 l.5t5r15l 2.8201479 1.6801262

2.38 *0.35 3.9rr0.33 5.02 + t.I 21.0r2.9 1 1 . 8 *0r

Conclusion:AM reversedtachyphylaxisto EPI in an isolatedheart model,suggestingthar rhe mechanismof uchyphylaxisis mediatedat the ADO receptor.Further studiesare warrantedto clarifo the role of the ADO receptorin this mechanism.

rt I Elfectsol Continuous Infusionon SodiumBicarbonate Lactata Besponse andSystomic Vasoprsssor J I fpineptrrine CPR Concentrations DuringPorcine Medicine, of Emergency EA0'Bangers, CFan,MSSChow/Division NTGentile, School ofMedicine, ofConnecticut Department ofSurgery, University College of Hartford Hospital; ofPharmacy Services, Farmington; Departmsnt Pharmacy, University ofConnecticut Study objective:Acidemiahasbeen linked to hemodynamicinstability responseto epinephrine.However, and depressionof the vasopressor bolus dosingof sodium bicarbonate(NaHCOr) to attenuatemetabolic acidosisduring CPRhasbeenshown to worsenintracellularacidosis the and inducehyperosmolality.This study was desigredto assess impact of continuousNaHCO, infusion on epinephrine-induced changesin coronaryperfusionpressure(CPP)and on systemicsodium, osmolar,and lacute concentrationsduring prolongedporcinecardiac arrest.

Desigr:The studywasrandomized,blinded,and placebocontrolled. lnterventions:Fifteenanimalswereanesthetizedand instrumented with aortic arch, left ventricular,and proximal inferior venacaval catheters.Ventricularfibrillation was induced,and CPRwas begun I 2 minuteslater.At l5 minutes,a NaHCO, (0.I mEq/kg/min)or 0.906 NaCi infusion wasbegun;at 25 minutes,epinephrine(0.02 mglkg) was added.Defibrillationwasattemptedat 28 minures.

Results:Coronaryperfusionpressuresdid not differ between animalsduring CPR(P = .97).The NaHCOT-treated and NaCl-treated rise in CPPafter epinephrineadministrationdid not differ between NaHCO, and NaClgroups(P = .23).Unlike NaCl,infusionof NaHCO, produceda gradualrise in arterialand venouspH and bicarbonate levels(P < .004). Therewereno differencesin Pco2,plasmasodium,ot osmolalitybetweengroups(P > .05). However,systemiclactateconcentrationswere sigrificantly higlrer after NaHCO, than after NaCl treatment (P < .03). Resusciutionwassuccessfulin three of sevenNaHCOTtreatedand two of eiglrt NaCl-treatedanimals.

Conclusion:Correctionof meubolic acidosisby the continuous administracionof NaHCO, during CPRdid not augmentthe epinephrine'inducedrise in CPP.The mechanismthrough which NaHCO, may adverselypromoteanaerobicmetabolismis not clearbut doesnot appearto involve venoushypercarbiaor hyperosmolality. att ol 65C/1f9F lV Fluidin dreTreatmontof Hypothemia JLn"Use P Keogh,C Sheaff,J fildes,J BarreflDepartment of Surgery, [)ivisionof Trauma, Hospital; of lllinoisat Chicago CookCounty University Study objective:To demonstratethe safetyand efficacyol65 A I49 F IV fluid (lVF) comparedwith conventiorwl40 AW4 F IVF in the treatmentof hypothermia.

Design:Ten beagles(9 to 13 kg) were prospectivelyrandomizedto receive65 C (six) or 40 C (four) lVF. The animalswereanesthet2ed, and datawerecollectedat basâ&#x201A;Źline,during hypothermia,and after one and two hours of rewarming.The plasma-free/total hemoglobin (PFHL/THb)was measuredto detecthemolysis.Eachsubjectwas cooledto 30 Cl86 F and then receivedeither 65 C or 40 C IVF througfra specializedcatheterin the superiorvenacavafor two hours.

Conventionalrewarmingtechniqueswere alsoused.All subjects survivedsevendays.A completeautopsywas then performed.

Results:The rewarmingrate was 3.7 C per hour in the 65 C IVF group and 1.75 C per hour in the 40 C IVF goup. Core temperatures were significantlydifferentafter one hour (33.,1t 0.77 versus31.7 t 0.57,P<.0I) and two hours(37 t 1.03versus33.4t 0.89,P < .001).

PFHb/THbwasnot different.Two intimal iniuries occurredin each

group; none at the infusion site.Blindedexaminationby rwo pathologistscould not differentiate*re etiolory of theseinjuries.

Conclusion:65 C IVF is more effectivethan,t0 C IVF in rhe trearment of hypothermia;65 C IVF did not causehemolysis,vascular injury, or organdysfunctionin this model.

QQ Active ExtemalRewarmingol HypothornicCaninesUsinga Urf RadiontHeatDovics LMShecerle,SASyvuud,D Denman/Enthermics MedicalSystems, Inc; Division of Emergency Medicine, University of Virginia, Cfnrlottesville; Division of Badiation 0ncology, University of Cincinnati, Ohio Studybackground:Radiantheat devicesare commonlyusedto warm patientsfor hyperthermiccancertherapy.

Studyhypothesis:A radiantheat devicecan producerapid rewarming in hypothermiccanineswithour inducing hemodynamicinsrability or acidosis.

Desigr: Prospectiveseriesof 20 canineswirh inducedhypothermia: mild (four, temperaturc< 35 C), moderate(seven,remperarure< 32 C) or severe(nine, temperature< 29 C). lnterventions:After anesthesia,intubation,and induction of hypothermia(ice bath), animalswere placedunder a radiant rewarming device(thermalrecoveryunit, TRU). Rewarmingwas continueduntil norTnotherTnia wasachieved.

Methods:Recul temperarure, esophageal temperaturc,subcutaneous temperature,and ECGwere monitored conrinuously.Rigfrtatrial pH, temperature,and aortic pressurewere monitoredin the severegroup.

Rewarmingrateswere calculatedbasedon time for esophagealtemperatureto reach36 C. Results: The TRU producedrapid rewarming:mild, 3.6 C per hour (5D t 0.53);moderate,4.1C per hour (SDf 0.55);severe,3.I C per hour (SDI I.34). ln the severegoup, ventralvenouspH did nor drop during the initial phaseof rewarming(7.29 versus7.25, P = NS). Mean arterialpressureremained> 80 mm Hg in all animalsthrougfrout rewarmlng.

Conclusion:ln this caninemodel, the TRU producedrewarming ratesfasterthan previouslyreportedfor activeextemal techniqueswithout centralacidosisor hemodyramicinstability.Becausedevicesof this typeare in use for cancertreatmentat rnanyhospiuls, their usâ&#x201A;Ź in rewarminghypothermicparienrsmay be worthy of funher investigation.

Hepatotoxicity in | /l {-MethylpyraroleBlocksAcetaminophen rl'f the Rat BJBrenrpn, RFMankes, HLefeyre, N RaccieBobak, HHEaevsky, JA Del Vecchio, BJZink/Departments of Emergency Medicine, Pfnrmacology, and Toxicology, Albarry MedicalCollege, Albany,NewYork Studyobjective:To determinewhether4-methylpyrazoleinhibits thehepatotoxiceffecsof aceuminophenin a rar model.,t-Merhylpyrazole, a potentinhibitor of alcohol dehydrogenase rhat hasbeenusedsafelyin human beings,hasalsobeenshown ro inhibit the cytochromeP4sollEl isozyme.This is one of the two main cytochromePrro isozymes involvedin acetaminophenbioactivarionin human beings.

Design:A prospectivelaboratoryinvestigationusing maleSpragueDawleyras. lnterventions:Animalswere divided into four groups.GroupsI ro 3 receivedacetaminophen(APAP)(2,000 m/kd by gavage;group ,t actedascontrol. At four or eight hours, group 2 received,l-merhylpyrazole(400 mg&g); goup 3 rcceived4-merhylpyrazole (50 mg&g). Serum ASTand ALT levelswere measured.Liverswere removedfor microscopicexaminationand gradingof hepaticnecrosis.

Results:Using the Mann-WhitneyU test,lower AST and ALT Ievels were obtainedwhen borh the 400-mg/kg(group 2, P < .0I) and the 50-mg/kg(group 3, P < .05) dosesof 4-met\lpyrazole wereadministered four hours afterAPAPcomparedwith goup I (APAPoniy). Mean necrosisscoreswere 3.2 for rats receivingonly APAP(group l); 0.83 for thosereceivingAPAPand 4-methylpyrazole(400 mg/kg) (goup Z, P < .05); l0 for thosereceMngAPAP and 4-methylpyrazole(50 mg/tg) (group 3, P < .05); and 0 for controls(group +, P < .05). Althoug! mean AST and ALT levelswere also lower when both +00-mgZkgand 5O-mg/kgdosesof ,t-methylpyrazolewereadministeredeigfrthours afterAPAP,theseresultswere not statisticallysignificant.

Conclusion:When administeredfour hours aftera toxic doseof acetaminophen, 4-methylpyrazolesignificantlyinhibits hepatotoxicity and lesser in the rat, asreflectedby lower levelso[ serumtransaminases degreesof hepaticnecrosis. rlf DecreasesdreToxicityof PreteatnentWith Phenobarbital JJ tu'p,nitaPhalloidcs 0f Pittsburgh, 0f Pittsburgh MedicalCenter; University SM*hneiderlUniversity School of Medicine, Pennsllvania Studyhypothesis:a-Amanitin, the primary toxin of the mushroom Amanitaphalloides, hasnot beenreportedto undergometabolismby the Prro system.lnduction of P*rollBI by phenobarbiul would alter the toxicity o[ a-amanitin if P45ometabolismoccurredat the site.

Desigr: FemaleSwissmice were divided into threegroups.Group I was pretreatedwith phenobarbiral(75 mg&p in peanutoil for two days.On the third day, they received0.4mgkga-amanitin. Group 2 was pretreatedwith peanutoil for two daysand on the third day received0.4 mg/kg a-amanitin.Group 3 receivedphenobarbiul (75 mg/kg) in oil for two daysand receivedan injection of normal salineon the third day. This last group servedasa control. Half of the animals were killed at 48 hours and had serumwithdrawn for hepatic ervymes.

The other half of eachgroup wasmonitored for survival for sevendays.

Results:StatisticalmethodsincludedANOVA, Kaplan-Meier, Mantel-Cox,and Breslowtests.The group pretrcatedwith phenobarbital showeda trend toward improvedsuwival, with Mantel-Cox P = .093andBreslowP = .I I25.

SGOT SGPT

PhemDeriitd + cr-Amelitin

a-Amenilin

P

1.96t 't,st r705tUA I r78g

7,471 tUA I 1,450 9.402 r 1,836

.ml .ml5

A11experimentswere repeatedand verified.

Conclusion:We havepreviouslyshown that 3-MC, which induces P4soIA2, increasestoxicity of a-amanitin.The finding that phenobarbi tal (an inducer of P*rollBl) decreases toxicity stronglysuggeststhat there is metabolismof o-amanitinby the Porosystem.This would explain the observedindividual variation of toxicity, especiallyamong agegroups.lt would alsosupport the reportedtherapeuticeffectof cimetidine(a PrrolA2 inhibitor).

inanIntact Verapamil Overdose WithGlucagon 36[:fifl",fi:of CKStone, WAMay,BCarroll/Department of Emergerf,y Medicine.

East Carolina UniversiW School ofMedicine.

Greenville.

North Carolina Study objective: To evaluate the effect ofglucagon as a treatment for the hemodynamic effects of verapamil overdose in a canine model.

Design: The study was performed in a nonblinded, controlled animal model. Pentobarbiul-anesthetized, instrumented dogs were maintained and observed for 60 minutes or until death. AIl animals

wereoverdosedwith verapamil(15 mg/kg IV) over30 minutes.Mean arterialpressure(MAP), heart rate (HR), ECG,and cardiacoutput (CO) were monitored. lnterventions:The experimentalgroup received2.5 mg glucagonIV bolus and then was placedon a glucagondrip of 2.5 mg/hr. The control group receivedan equivalentvolume of lV normal salinein the same fashion.Analysiswas performedusing the t-testwith crset ar .01 becausemultiple testswere performed.

Results:Therewere eigfrtexperimentaland sevencontrol animals, with mortality of 006and 29%, respectively.The following uble presentsresultsfor MAP (mm Hg), HR, and CO (Umin). fino IVIAP Control 126*.22 '121 Experinentalt24 HR Conkol 155t48 Experirnental 135t37

c0

31t10 32tl5

36113 4 1r l 8

37*.12 5t r19

53tg 5l t12

47r8 70!32

46i9 91t42

control 3.610.9 l.l t0.6 E x p e r i m e n t a l 2 . 7 1 0L. 90 t 0 . 9 . P <. 0 1 .

37116 58123

40r17 53tn

46111 t2tx43'

45r10 124 *41'

L610.6 1.9r0.7 |.9r0.S 2.1tt.2 2.911.8 4.2t2.6 5,6r2.7' 5.9r2.4'

Conclusion:Glucagonappearsro reverseboth the bradycardiaand the depressedCO associatedwith verapamiloverdose.

Treatment lmproves Survival Q ] Hyperinsulinenric-Euglycomic U f DuringSevere Vorapanril Toxicity JA Kline,C Tomaszewski, JD $hroeder,E Leonwa,BM Baymond/Carolinas Medical Center, Charlotte, NorthCarolina Study objective:To examinethe benefitsof varioustreatmentson a continuous-infiisioncaninemodel of verapamiltoxicity.

Desigr: Twenty-four cr-chloralosâ&#x201A;Ź,anesthetized dogswereinstrumentedby left thoracotomyto moniror cardiacoutpur (CO), left ventricular pressure(LVP),cororulryarteryblood flow (CABF),meanarrerial blood pressure(MABP),and arteriallacrate,glucose,and verapamil.

SurfaceECG datawere collected.Toxicity was 0.I mg/kglmin IV verapamil to produce 5006decreasein MABPfor 30 minutes;verapamilrate then decreasedto I.0 mg4<g/hrduring the entire treatmentperiod. lnterventions:Animalswere randomizedto one of four treatments: l) control(C, six), 0.9% NaCl;2) glucagon(GLC,six),O.Z5mglkg bolus, then 150 pglkglhr; 3) epinephrine(EPI,six), 1.0 pg&g/min; or 4) hyperinsulinemia-euglycemia (HlE, six), ,t.0 U/min insulin wirh 20% dextrose(glucose)held * l0 mg/dl of baselinevalue. Infusion ratewas I20 mUhr for all groups.End poinrs were deathor 240 minuresof survivalduring treatment.

Results:Ratesfor survival to 240 minuteswere C, 006;GLC, 50%; EPi, 67%; HIE, I0006 (P < .05 versusconrrol by Fisher'sexacrresr).

MABPand LVP were similar at all rimesfor survivors.HIE consisrently improvedCABFand CO and producedlessectopyon ECG.Epl and GLC producedhyperglycemiafollowed by hypoglycemiain GLC. Verapamiland lactatelevelswere lower for HlE-treateddogsat 240 minutes(P < .05 betweengroups for survivorsby repeated-measures ANOVA).

Conclusion:Comparedwirh EPI and GLC, HIE is a superioranr! dote for continuous,severeverapamiltoxicity in anesthetizeddogs.

Toxicityin 1DO MagnesiumPotontirtcaGyclicAntidepressant r)O lsolatedRatHeailr BM Baymond/Emergency JD Schroeder, JA Kline,M 0e Stefano.LWBerning, Cfurlotte, NorthCarolina Medicine Besearch.

Carolinas Medical Center, Study objective:To comparemagnesium(MAG) with hypematremic toxicity (CAT). alkaline treatment(HAT) for cyclic antidepressant rats were perfused Design:Heartsfrom l8 maleSprague-Dawley retrogradelyby a l-angendorffapparatuswith modified Krebs-Hensleit buffer (KHB). Heartswereinstrumentedfor ECG,left ventricularpressure (LVP),and LV +dP/dt to index contractility.CATwas 2.0 1@mL imipramineHCI (IMIP) in KHB until 2506QRSwidening. lnteryentions:On onsetof CAT, one of three treatments(dissoived in KHB) werebeg:n: l) control (C, six), KHB only; 2) HAT (six), [Na*l 165 mEq/L;pH rirraredto 7.55 wirh NaHCOT;3) MAG (six), [Mg2*] 6.0 mEq/L. All perfusatescontained2.0 pglml- lMlP. Resuls:Dataare reportedas mean* SEat baseline(B).andafter ten minutesof treatment(T). Dau wereequalat B; thereforeone-way ANOVA wasusedto comparevaluesat T; significancewassetat P < .05 ln separatestudies,I5 minutesof perfusionwith [MgLl 6.0 mEq/L in KHB without lMlP producedno significanteffecton any variablelisted below. }IAT

C LVP(mmHgl +dPldt

80t5

57t6

78+6

78t9

MAG

7816

,|,433*1m (mmHg/secl 1.558*971.0101136 1,n0t1571,475tln HR 308+6 248xm 303115 Zfitm 29t12 ORSlmsec) 81t6 10219 64i4 68t557ti 48113 2t1 2t1 %Ectopy 3xZ 813' *Versus tversus tversus C. HAT. CandHAT.

48rllt

590*158J 1n+20t 123t7t 77t1l

Conclusion:MAG and CAT producedsynergisticcardiodepression, QRSwidening, and worsenedbradydysrhythmias.MAG may therefore be harmful in CAT. Elfectsof Neloxonsand iletoclopramideon the Interactionsol !Q rf rf tho Monoamino0xidaseInhibitorTranylcypromine V$th Meperidinein an AnimalModel B Lakhanpal, APA,zar, EWeinstein, B Sabbun, D Sauter/New YorkMedical College, Valhalla Backgound: The inreractionbetweenmepiridineand tranylcypromine(TCN) is known to producea hyperpyrexicresponse.

Study objecrive:To assess and comparethe effectsof the opiate antagonistnaloxoneand the serotoninantagonistmetoclopramide (MET) on this interaction.

Methods:After a four-hour Dretreatmentwith the monoamineoxidaseinhibitor (MAOI) TCN (If mg/kg),maleSprague-Dawley ratswere challengedwith the opiatemepiridine (20 mg/kg).Animalsexhibitinga 2 F increase'intemperaturewere randomlyassignedto receiveinteryentions with eithernaloxone(10 mg&g, MET (15 mg/kd, or normal saline(controls).Rectaltempemtureswere monitoredeveryten minutes over 60 minutes.Analysisof varianceand a pairedSrudent'st-tes!were used to comparethe temperanrreresponse.Valuesof P < .05 were consideredsignificant.

Results:Fifteenpercentof the animalsexhibitedhyperpyrexia.Of these,rats receivingMET had a sigeificant(P < .05) attenuationin temperature,whereasthosereceivingnaloxonehad a temperature potentiationcomparedwith controls (P < .05).

Conclusion:Serotoninappear to mediatethe hyperpyrexic responsebetweenopiatesand MAOL lnterventionswith MET may play a role in attenuationof this response.

A 'llf N

AnatomicalPointIniectionin the Treotmentd Headaches 8TBrofeldt, RWDerlet/Division Toxicology. of Emergency Medicine andClinical University of California, Oavis&hoolof Medicine, Sacramento Study objectives:To evaluatethe potentialusefulnessof pericranial newe blocksby injection of local anestheticsfor treatmentof primary headaches.

Desigr: Open, unblinded,prospectivesrudy.Patientswho presented to the emergencydepartmentwith moderateto severeheadaches were randomlyselected.Thosereceivingpericranialinjectionwerecompared with a rnatchedcohort of headachepatientsreceivingsundard analgesics.

Setting:Universityhospiul ED,Januaryto December1992. lnterventions:lnjection of I to 2 mL of 5U50 mixture of 2% lidocaineand 0.2506bupivacaineinto pericranialnewesin which sensory distributioncorrespondedto the patient'sheadachepattern.

Measurements and results:Thirty-nine patientswere treatedwith a total of 85 inlections.The most frequentlyinjectednervewas the greateroccipital(48) followedby the deeptemporalnerve(3I) . The pre-EDdiagnosesof the patients'headaches werc tensionheadache, 2806;migraine,2606;post-traumatic, l8%; cluster,506;and nine unspecified,2306.lmprovementoccurredin 100%of patiens within five minutes,and headaches were reportedto be toully resolvedin 900,6 of patientsand partially resolvedin I00,6.Twenty-four-to ,l8-hour follow-up datawereavailableon 3I patienrs.Of these,800,6remained symptomfree.In a cohort of 39 parienrstreatedrraditionallywirh analgesicsin the ED, 5I06 had completeand I3% had partial resolutionof headaches, with 4606remainingsymptom freeat 48 hours. Acuteand post-EDheadachepain was sigrilicantly beuer in rhe injecredgroup (P<.05).

Conclusion:Anatomicalnewe block of pericranialnervesis an eflectivemethod o[ treatmentof acuteprimary headaches in the ED. lnjectionof localanesthetics may be more effectivethan oral or parenteral analgesics in certainsubsetsofheadacheparienrs. ol lntraoralVersusPercutaneous Approachto /l { Comparison .l I MentalNerveBlock M Jenkins, S Syverud.

R&hwab, M Lyrrh.KevinKnoop.A Trott/Division of Emergency Medicine, University of Virginia HealthScierresCenter, Charlottesville, Department of Emergency Medicine, University of Cincinnati Medical Center.

0hio Background:Nerveblock are commonly used for anesrhesia before repairof faciallacerations.For anesthesiaof the lower lip and chin, (PER)and intraoral(lO) approachesro rhe menral both percutaneous nerveblock areused.Theseapproacheshavenot beencompared.

Hypothesis:The IO approachro rhe mentalnerveblock is less painful and more effectiverhan the PERapproach.

Design:Prospective,randomized,single-blindwith eachsubject servingashis or her own control.

Setting:Universityhospiul emergencydepartment.

Participants:Ten volunteers,22 to 33 yearso[ age,withour prior experiencewith menul newe blocks, lidocaineallergy,or active oraVfacialinfection. lnterventions:Bilateralmenralnerveblock. lO on one sideand PER on the other.Block were performedwirh 27-gaugeneedlesand 2.5 mL of 206bufferedlidocaineat room temperarureinjectedover 20 seconds.

The order of the blocksand sideo[ the facewere randomized.A blinded investigatoradministereda l0-cm visualanalogpain scaleOAS) after eachblock. Efficacy(anesthesia of lower lip), onset,and durarionwere alsoevaluated.

Results:IO was lesspainful than PERin nine of ten subjects (P = .002,2g2).lO producedlower lip anesthesiain ten of ten subjects versussevenof ten for PER(P = NS). Onsetwas fasterwith lO than PER:0.94I 0.46minutesversus2.06 + 1.33minutes(P = .028,paired t-test).Durationwasnot significantlydifferentbetweenthe two techniques:PER,0.90 i 0.30 hoursversusIO, I.23 t 0.62hours(P = NS)' Conclusion:The IO approachto the menul nerveblock is less painful and at leastaseffectiveas the PERapproach.

Epinephrine, Gonparisonol TAC(Tetracaine, /l ll A Double-Blind t4 CocainelWith TtE (TopicalLidocaineEpinephrinellorTopical AnesthesiaWth Go$ Comparison StateUniversity PABlackburn, K Butler,MHughes, B Biker,M Clark/Michigan College of StateUniversity Besidency;Michigan Affiliated Emergency Medicine Besidency, EastLansing Medicine Emergerry Medicine 0steopathic with lidoStudyobjective:To determinewhether topicalanesthesia caine(506)and epinephrine(l:2,000) (TLE) is equivalenrto topical epinephrine(I:2,000), and cocaine anesthesia with tetracaine(0.50,6), (r0.4.6) (TAC).

Desigr: Prospective,randomized,double-blindtrial from May I992 to August1992.

Setting:Communityemergencydepartmentwith 50,000annual visits,4.606of which havescalpor faciallacerations. as Participants:Patientswith facialor scalplacerationsassessed presentingto the ED when study being suiuble for topicalanesthesia physicianswereon duty. Exclusioncriteria includedalcohol intoxication or agelessthan 2 years. lntervention:Applicationof TAC or TLE to lacerationsbeforesururing. The lacerationwas repaired,and the patient then evaluatedthe painfulnessof the procedureby using a sundardizedvisualpain scale.

Results:Usingthe two-uiled Student'st-test,the meanageswere comparedand found not to be significantlydifferent(P = .40). Pain scores,diameterof tissueblanch around laceration(halo size),and time to lacerationrepair from onsetofapplication ofanestheticwerecomparedusing the Mann-Whitneytest for independentgoups and revealedno sutisticallysigpificantdifferencebetweenTAC and TLE (pain, P = .33; halo sue, P - .82; time, P = .64). Correlationbetween rank correlapain scoresand halo sizewas calculatedusing Spearman's tion methodand revealedthat in the TOE group, the smallerthe halo size,the geater the pain scalescore(r = -.54, P = .037). In the TAC group, this correlationwasnot apparenl(r = -.04, P = .88).

Conclusion:TLE is equivalentto TAC in producingtopicalanesthesia. ln an averagemonth, 4% of our patientvolume has hcial and scalp lacerationsamenableto topicalanesthesia.

The annualcostsavingsto use TLE insteadof TAC would be $ I I 7,700. lt would alsoeliminate somepatients'anxietyregardingrandom occupationaldrug screens by eliminatingthe cocainefrom the topicalanestheticpreparation.

Restraint forChemical Vesus10nq Haloperidol /l 2 5 mSDropeddol 'lrl of AgitatedandGortativePatients Gray H Thamas CarolinaBaptistHospital;Bowman Jr,A Lalor,ESchwartz/North School of Medicine.

Winston-Salem Studyhypothesis:We havepreviouslyreportedthat in equaldoses (5 mg), droperidolis more effectivethan haloperidolfor chemical restraintof agitatedand combativepatients.We hypothesizethat l0 mg haloperidolwill be asellectiveas5 mg droperidol.

Designand setting:A randomized,double-blind,prospectivestudy of adult patientsrequiring physicalrestraintsand presentingto a universityhospiul emergencydepartmentover a 3Gmonth period.

Panicipants:One hundred seventeenviolent or agitatedadult patientswho in the opinion of the attendingphysicianwould benelit from chemicalrestraintto protect the patientor staff and expedite evaluation. lnterventions:Twenty-sixparticipantswere given I0 mg lM haloperidol;5l were given 5 mg lM droperidol; I 2 were given l0 mg IV haloperidol;and 24 received5 mg IV droperidol.

Results:AII patientswere rated on a five-pointcombativeness scale at five, ten, 15, 30, and 60 minuresafrer rhe srudy drug was given.Vital signswerealsorecordedat thesetimes.Therewas a sigtificantly more rapid responseto IM droperidol than ro lM haloperidol(P = .05, ANOVA). Comparisonat eachtime intewal showedIM droperidol to resultin significantlylessagitationar ten (P = .04) and 15 (P = .04) minutes.Therewasno significantdifferencebetweenthe two drugs when given intravenously.Therewere no differencesnoted in any of the viul signs.Two patienlsdevelopedacutedystonicreactionsrequiring treatment;both were in the IM haloperidolgroup.

Conclusion:Droperidol (5 mg IM) resultsin more rapid control of agiuted patientsthan I0 mg haloperidol,without any increasein untowardeffects. ol DigitalVercusMetacarpa!Blocksfor Bepairof /l /l Comparison .frl FingerIniuries K Ktwop,ATotl, S Syverud/Department of Emergency Medicine, University of Cincinnati Medical Center.

0hio Study objective:To compareefficacy,rime ro anesrhesia (TTA), and degreeof discomfortof digiral (DNB) and melacarpalblocks (MCB) for (DA). digital anesthesia Desigr: Randomized,prospective,nonblinded,clinical study conductedfrom April I992 roJanuaryI993. Patientsservedas their own controls.

Setting:lnner city and community hospitalemergencydepartments.

Participants:A conveniencesampleof 30 patients,age> 17 years, with third or fourth finger injuries distal ro/includingthe proxirml interphalangeal joint requiring DA. Exclusioncriteriawere patientswirh known allergiesto anesthetics,severeperipheralvasculardisease,reflex sympatheticdystrophy,drug impairmenr,or inabiliry ro give informed lnterventions:DNB and MCBswere performed(one per side) on all 30 patients(toral of 60 blocks) wirh 206bufferedlidocainewith a Zl-gaugeneedle.The orderwas randomized.

Measurements: lmmediatelyafter eachblock, patienrsrated the pain on a I 0-cm visualanalogscale(VAS).Efficacyof the block wasassessed by both pinprick and requirementfor addirionalanesrhesia.

TEA was assessed everytwo minuies for ten minutes Results:MeanVAS pain scoreswere 2.53 for DNB and 3.38 for MCB (P = . 175I , Studenr'st-resr).MCB failedanesthesiato pinprick in 2306comparedwith 30,6for DNB (P = .0227,?(2).TTA wassignilicantly shorterfor DNB comparedwith MCB, with a meanof 2.82 minutes versus6.35 minures(P < .0001,Srudenlst-rest).

Conclusion:DNB and MCB are equallypainful procedures.DNB, however,is more efficaciousand requiressignilicantlylessTTA. A ProspectiveEvaluationol tre llemodynamic,Respiratory, /l 'lrftr and Oxygenation Etlectsof Methohoxitalin tho Emergency Department BSLernan,D Yoshida, A Levitt,C Clements/Highland General Hospital, 0akland, California Study objective:Methohexital(MI..) is an ultrashort-actingbarbituratewhoseuse in the emergencydepartmenthasgenemtedtrerrpndous controversy.We evaluatedits safetyand efficacy.

Desigr: Prospective.

Setting:Urban county hospitalED. Pailicipants:Fifty-four adult patiens who receivedMTX in the ED. lnterventions:Pulseoxinretry,hemodynamicand ECG monitoring, and GCSscoreswere recordedseriallyfor 30 minutesafter the administration of MTX. Scalesof I to 5 wereused to record the clinician's assessment of the adequaryof sedationand the patient'sassessments of recalland pain of the procedure.

Results:MTX wasusedfor orthopedicprocedures(43 of 54), aswell as LPs,CTs,I6rD ofabscesses, intubations.and one psychiatricinterv1ew.

3 5 1 0 3 0 t Minulsr Basoline ltinut ilinuter MinuGr llimto3 Pulse sBP RR 02sat GCS

84 145 18 9g 15

r0r0,m) 97{0.m1)s3(0.002) 87(0.162) 83(0.361 136(0.0S1 r460.6321r4s{0.2S)144(0.88) r4310.701) r6(o0r5l 16(0,m2) r8(0.974) r8{0.80s,1r8(0.m) s l0.o59l99(0.13) e9(0.347199{0.s{r3l 99{0.s7) 14.9 6.0 9.0 12.5 14.5

P=NScompared withbselrne.

No clinicallysignificantchangeswere obsewedin hemodynamic measurements.

Four patiens (70,6)had transient(lessthan three minutes)apnea;none requiredmore than bag-valve-mask assistance.

The adequacyo[ the sedationasjudged by the clinician was very good (4.6 ! 0.7).Patientsreportedlittle recall(i.4 t 0.9) or pain (1.4 + 0.8).

Conclusion:MTX causesclinicaliy insignifiunt changesin hemodynamics,respirations,or oxygenationasused in the ED. MTX provides excellentsedation,amnesia,and pain relief.

Oouble-Blind Comparison Vuith of Dihydroergotamin.

Hydroxyzine forthe Vonur MeperidineWith Hydroxyzine Emergency Departmant Treilmert 0l AcutoMigraincHeadache S Carleton, R Shesser, M Pietrzak, CChudnofsky, S Starknnn, D Morris,G Johnson, K Bhee,C Barton.

J Chelly, LLTran.

M VanValen/Univsrsity of Cincinnati; George Washington University; Uniformed Health&iences University; University of Massachusetts; University of California, LosAngeles; SUNYHealthScience Center, Syracuse; University of California, Davis; University of California, SanFrancisco; University of Texas, Houston; Sandoz Medical0oerations Studyhypothesis:Theadministrationof dihydroergotaminemesylate (DHE-45) with hydroxyzineis equallyeffectiveas meperidinewith hydroxyzinein the emergencydepartmenttreatmentof acutemigraine headache.

Design: Prospective, randomized,double-blindtreatmentcomparison.

Setting:The EDsof I I generalhospitalsin the United States.

Participants:Establishedmigaineurs with an acutemigraine(vascular scores,4) were studied.Exclusioncriteriawere complicatedor prolongedmigraine,recentor chronic narcotic or analgesicuse, and study drug sensitivity. lntewentions:Baseline[Easurernnts of pain, functiorulperformance, and nauseawere made.Patientswere then randomizedto either the lM combinationof I mg DHE-45with 0.7 mg/kghydroxyzineor 1.5 mg/kg meperidinewith 0.7 mg&g hydroxyzine.Repeatedmeasures were taken30 and 60 minutesafter treatmentwhen the study was terminated for thoseexperiencingadequaterelief.All othersreceivedan lM doseof the sameregimenat reduceddose.Repeatedmeasurements were takenfor 60 minutesafter the seconddose.

Resuls:One hundred forty-fivepatientswere enrolled; 73 received DHE-45 and 72 receivedmeperidine.The two groupshad a similar distribution of age,sex,vascularscore,and baselineseveritymeasures.

The one-hourpain scalereductionwas4l t 32 for DHE and45 + 29 /1f, '?lf

for meperidine(P = .6). Similar improvementsin function and nausea werenoted at one hour for both groups.Twenty-fourDHE patients (32.9%)and 3l meperidineparients(43%) rcquireda secondrrearmenr.

Smallerbut equivalentpain scalereducrions(DHE-45, 7.7 t 0.7; meperidine,6.9 t 3.2) werenoted after the seconddose.The rwo groupswere similar for completeheadacheresolutionin the ED (40 of 73, DHE-a5; 32 of.72,meperidine),2,l-hour headacheretum (I8 of 63, DHE-45; l6 of 57, meperidine),and the need for "rescue"medication (38 of 65, DHE-45; 37 of 59, meperidine).Cenrralnervoussysrem (CNS)sideeffectswere more frequentwtth meperidine(31 of 74) rhan with DHE-45 (four of 74) (P = .05). The frequencyof other side effects was equalin the two goups Conclusion:DHE-45 is highly effecrivefor rhe ED rrearmenrof acutemigraineheadache.Patientstreatedwith DHE-45 experienceless CNS impairmentthan thosetrearedwith meperidine.

n',

rl f 0d Vercus lV Methylprednisolone in AcuteAsthmain Children PLJBarnett, MN Baskin, N Kuppermann, GLCaputo/Division 0f Emergerf,y Medicine, Children's Hospital, Boston, Massachusetts Studyobjective:To determinewhether oral merhylprednisolone (OP) is aseffectiveas lV methylprednisolone(lP) in acuteasrhru in children.

Design:Randomized,double-blind srudy over eight months.

Setting:Emergencydepanmenrin urban children'shospital.

Participants:Forty-sevenchildren (24 lP and 23 OP) berweenI 8 monthsand 17 yearsof agewith moderateto severeasthmaand no steroiduse in the previoustwo weeks.

Interventions:Eachchild was randomlyassignedto receivea single doseof OP or IP (2 mg/kg) with a correspondingplacebo30 minures after their first doseofalburerol, Sundard therapyfor all children consistedof nebulizedalbuterol (0.03 mg/kg every20 minuresx 4, then 0.06 mg&g everyhour x 2) and tV theophylline(5 ro 6 mg/kg) onehour after first doseof albuterol.

MeasurementJresuhs: Children l8 months ro 7 yearsof agewere evaluatedusing the Pulmonarylndex Score(PlS)and children 7 to 17 yearsof ageusing spirometry(including PEFR,FVC, FEV'). Children wereassessed eachhour for vital signs,O, saturation,PlS,or spirometry.

At four hours, an independentphysiciandecidedthe patienr'sdisposition. Groupsweresimilar in age,sex,vital signs,and severitybut not O, saturation(lP, 94% versusOP, 960A;P - .002)at baseline.

Twelve of 24 IP and l l of 23 OP parients(P = .88)wereadmiued.Two parients (one OP and one IP) retumed wirhin ,t8 hours, and one (Op) was admitted.PISand spiromerryimprovedwirhin groupscornparedwith baselineat all timesmeasuredbut were not differentbetweengroups.

O, saturationand vital signswerenot significantlydifferentbetween groupsat two and four hours.

0P tP P 'P<.01.

FVC(% PrcdictedMernl

Beseline

PIS{Usanl 2 Houn

I Hours

Blrslina

2 Houn

I Houn

8.5 8.9 .32

5.4' 5.4' .95

4,0' 3.6. .38

43,3 42,3 .s

75.4' 67.7.9s

88.5' 79.3' .96

Conclusion:OP is at leastaseffectiveas IP in moderarcro severe asthrul.

/l Q Metere&DoscInhalcn Wth SpacersVersusllebulizerslor rlO Bronchodilator Emorgoncy Deparhnent Thrnpy in r Pedaatric (Emergency KJ Chou, of General Pediatrics SJCunningfnm.

EFCrain/Division Medicinel, AlbertEinstein College of Medicine, Bronx, Ne\/ York Study objective:To determinewhether B-agonistsadministeredby metered-dose inhaler with a spacerdevice(MDVspacer)is aseffectiveas nebulizedB-agonists(nebulizer)in the treatmentof acuteasthrnaemcerbationsin children.

Researchdesigr: Randomizedtrial with two arrns.

Setting:Urban pediatricemergencydepartmentin Bronx,New York.

Patients:Conveniencesampleof 87 children > 2 yearsold with a history of two or more episodesof wheezing,presentingwith an acute asthmaexacerbation. lntewentions:Patientswererandomly assignedto receivesundard dosesof B-agonistsby MDVspaceror nebulizer.Dosingintervalsand the use of other medicationswere deternined by the treatingphysician.

MeasurementVmainresults:Baselinecharacteristics and asthma history wererecorded.futhma severityscore,peak {low (children > 5 yearsof age),and O, saturationwere determinedat presentationand beforeadmissionor discharge.The groups did not differ in age,sex, ethnicity, ageof onset,or severityof asthma.Therewere no significant differencesbetweenthe groups in outcomesincluding meanchanges in respirations,asthmaseverityscore,peak flow, O, saturation,number of treatmentsgiven,administrationof steroidsin the ED, and admission rate. Patientsgiven MD7spacersrequiredshorterueatmenttimesin the ED (64 minutesversus93 minutes,P < .001) and fewerpatientsreported sideeffecs(P < .0I).

Conclusion:Thesedatasuggestthat MDVspacersmay be an effective altemativeto nebulizersfor the treatmentof children with acuteasthma exacerbations in the ED. of As$mr in /l (l 0xygenSaturationGhangesin AcuteExacerbations 'lJ Children JA finkelstein, WSJones,KP0'Keefe, GWMitchell, TCMayeslointMilitary Medical Centers, WilfordHallMedicalCenter, Brooke ArnryMedicalCenter, Department of Emergerry Medicine, Department of Pediatrics, &n Antonio, Texas Study objective:To examinethe clinical usefulnessof O, saturation changesafterbronchodilatortherapyasa predictor of relapsein nonhospitalizedchildren with acuteexacerbationsof asthma.

Design:Five-monthprospectiveobservationalstudy during 1992.

Sâ&#x201A;Źtting:tâ&#x201A;Źvel I, miliury traunn center.

Participants:Eigfrty-sevenpatientsaged2 through l7 years(mean, 7 .8 + 5.2 years)who presentedwith a clinical diagnosisof asthmaexacerbation.Ten patientswho were admilted and I I patientswho could not be reachedfor follow-up were excluded Methods:Roomair O, saturationusing a Neilcor oximeterwas carriedout on presentationand 30 minutesafter the last nebulizer treatment.Patientswere treatedin an unrestrictednlanner.An adverse outcomewas definedas any visit within 72 hours to a physicianthat requirednebulizedB-agonisttherapy.

Results:Eiglrt adverseoutcomesoccurredin 66 patients.Outcome was not relatedto steroiduse (P = ,71). Analysisof trend datausing scalecriteria of improvement,no change,or decreasein Oz saturation revealedsignilicancefor trend (P < .004). Risk ratiosrevealedthat a child with a no changevalue for O, saturation(I7) or a decreasein O, saturation(I5) had a 4.4 and I6.5 timesgeater chance,respectively, of havingan advere outcomewhen comparedwith a child showingan improvementin O, saturation.

Conclusion:Nonhospitalizedchildren with asthmawho do not have an increasein their oximetry-measuredO, saturation30 minutesafter treatmentcompletionhavea greaterrisk of havurgan adverseoutcome.

Th: C_ontribution of Routinepulse0ximety to parientEvaluation and Managementin a podiafic Emergency oopartment petrack/Department oipediatrics,Division lJ .Wtrln, SEKrug,EM of Pediatric Emergency Medicine, casewesternBeserve schoorof Medicine, Bainbow Eabies andChildrens Hospital, Cteveland.

Ohio-' Study objective:To determinewhether routine pulse oximetry in . rhe pediarricemergencydepanmenr @ED)idenufiJsparienrswirh nypoxemiaunexpectedon the basisof clinical evaluation.

Desigr:Prospectivecomparisonof a blinded, clinical evaluationof , hypoxemiaby pediarricemergencyphysicianswith subsequenrpulse oximerryreadings.

Setting:pED in an urban, universitymedicalcenter.

Patients:A conveniencesample of it patienrspresenringto the pED with a diagnosisof asthma(andiequiring o.r. o, .lr. aerosoltreat_ ments),bronchioliris,pneumonia,or signsof respiratory distress. of hemoglobinopa'thy, chronic pulmonarydisease L,l.^:,:,:],n |tsrory (omerthanasthma),cyanoticcongenital heartdisease, or severerespl_ ratorl distressrequiring assistedventilationwere not eligible.

Merhods:,physiciansrecordedrhe patienrs,hisrory, p-hysicalexami_ nation,and their treatmentand management plans.Srrld-o'this clini_ cal evaluarion,rhe physicianwas theriasked ,o du,..o'i.," whetherthe patienlwashypoxemic(definedasan oxygen saurarion S 9206).Room_ air pulseoximetry was then obrainedwltir"subsequeni rreatmenr,and rrnnagementplanswere recorded.

Of sevenpariensfound ro be hypoxemicby putse oxime_ ,_.

Y::l-1: try,.rour unexpected, basedon the physician,s clinicalassessment.

-were In thesefour patients,managemenrwasaltired asa resulrof this find_ ing. Hypoxemiawasdelecredwith a sensirivi ty of 43oAand a specificiry of 8006,basedon rhe clinical examinarion,l;., y"l;jr,g a negarive predictivevalueof 900,6 and a positivepredictive'value of 25oA. Conclusion:Clinicalevaluationin apED does not screenadequately of,hypoxemiaand should t. ,uppr.*.n,.d by routine 3::i.^3,.::::l:n putseoxlmerryin all patientswirh respirarory findings.

Ell rrl,

lntranasatSulentanilfor SedationondAnalgesia pediatric I f in rf I Petients J,o.nrs/Emergency program, MedicineResiderrcy Butterworth ffrqdl {l Hospital, Michigan StateUniversity College of Hrr.n iirli.in., GrandBapids Srudy.o_bjecrive: To determinethe efficacy,.,a ,rf.iy of intranasal . sufentanil[or sedationand analSesia in emergencydepartmentpediatric pa.enrs.

Desigr: prospectiveuncontrolledclinical trial.

Setring:A community teachinghospitalwith an ED censusof approximately 19,000pediatricvisirsper year.

Participants:Conveniencesampteof peaiatric ED partents(agesI to 8 years)requiringsedarionand.zor analges"f;;;i"-d;rnor - -"' proce_ dures(eg,lacerationrepair,fracture r"d"ucrio.rj.' hrervenrions:parienrseligible for rhestqdy receivedL5 yrgkgof approximatety20 minuiesU.io..,r,. procedure. *f:.:,,-TlilT'.:Tsally urowslnesswas assessed ar five-minuteintervalsby the treatingphysi_ cun using a four-point sele. Analgesia *rr rrr.rrd Uy ursu"ta'natog scale.Any untoward effectswere noted.

Results: Fortychildrenwereenrolledin the srudy. ^^ At 20 minutes, (95%).receivingsufentanilhad sigrificarit sedationfor rhe ]9^lill."" pruLcuure ano old not requiresupplemenulanalgesia.

The meandura_ tion of sedarionwas 62 minures.Children toleratedthe medication withour.oxygendesaturarion;side effecrs inctuaJ vomiiing isix patients)and pruritus (one patient). t tinety-threepercentof paren$ indicaredthat they would riquest suf.ntanil "g"i.r'fo, ,h"i..f,ila.

Conclusion:Theseresultsindicatethat intranasaladministrationof sufentanilmay be a safe,noninvasivepremedicationfor children under_ going painful proceduresin the ED. Compadson ol IntranaselSufentaniland Midazolamto ff JrC Meperidine,Promethazine, and Chlorpromrzine for Sadation DuringLacerationf,epairin Ghildren GBFleisher/Children,s Hospital.

Boston, Division lA 1ates,SASchutznnn. of Emergency Medicine, Harvard Med'rcal khool. goston Study objective:To comparethe efficacyof intranasal sufentaniTmidazolam (SM) io IM meperidine,promethazine,and chlor_ promazine(MPC) for sedationduring lacerarionrepair.

Design:Single-blind,randomized,controlledstudv.

Serting:Urban children'semergencydepartmenr.

Patientyinterventions.: Children I ro + yearsof agewere randomly assigned ro eitherSM (19) at 0.75 pg&g suienranitaia O.Zmglt<g midazolamor MpC (23) in a 4: I :I ratio-at2.5 mgkgof m"p"idirr". n11lr1:_V_iral signs,O, saruration,anxiety(four_foinr scale;calm, l), . pain (CHEOPS)scoreswere recordedbefore,during, and after medica_ tion. A six-poinrscale(1, good)was usedro assess rlrporrr. to medica_ tion. We assessed levelof alertnessby a l2_point recoveryscore(normal, 12)_atdischargaGroupswere similar in "g.

1rn.rrr, 27.9 monthsSM, 28.5 monthsMPC) and gender(p = NS). Iione had bradycardia, oraaypnea,or hypotension.One patientin eachgroup had an O, satu_ ration< 95oAthat respondedto stimulation.The meanresponse score to medicarion wasSM, 2.2; MpC, 5.3 (p < .001).MeanCI_iEOPS scores were lessduring repair than at baselinewithin eachgroup (SM, I I .l ro p tutpC,I0.9 to 7.3; < .00I); meananxieryscori *.r. reduced 1:7; (SM,2.7 to I.7; MpC,2.6 ro 1.7;p< .O0I).pain andanxrery scores werenot differentberweengoups (p = NS). Time to dischaigewas l_onger in the MPC group (82 minuresfor MpC versus5,1minures for tY:.": .002)-The MpC group had lower meanrecovery scoresar time ot discharge (I0.4) thanthe SM group(l I.5) (p < .O0l).

Conclusion:SM is aseffectiveas IM MpC for sedation in children.

PatientsreceivingSM were more awakeat dischargeand were dischargedsooner.

tr2

Effecrsol HeayyClodringon 0ccupantRasponse :fy, Th" y lssman, Kuhtmann, JBCrandall, ESieveka, WD pilkey, .tl ZCFang, GS Klopp/Univ_ersity of Virginia School of Medicine, Division oiimergency Medicine, Charlottesville, University of Virginia School of ingineering and Applied Science, Charlottesville Study objective:The presenceofseat belt slack potentially increases occupanrinjuries in automobilecollisions.It is known that c'hestin;ury ' ' is directly relatedto chestaccelerarion.

This srudy wasdesigred to determinewherherheavywinter-typeclothing iruroduced seatbelt therebyadverselyaffecteddummy responsein 48 kph :lT:111 (JU mpn) experimental frontaldeceleration sledtests.

Design:Experimentalsled testdecelerations wereconductedusing __ 50th percentileHybrid III anrhropomorphicdummies.

The dummies were instrumenredto analyzeupp.,,rrd lower spinal accelerations wlth resulranrchesraccelerations.

All testswere ionducted at 4g kph (30 mph) and a sleddecelerationo{_20 g. Three-pointshoulderand lap seatbeltsrestrainedthe dummies.Nine'separateiests were conducted: four wirh no slackand no heavyclothing (taseline), rwo wirh 7.6 cm of introducedslackand no heavyclothinglnd rhree with no slackand 7.6-cm-thickheavywinter clorhing.

Results:Chestaccelerations extrapolatedfrom the upper and lower spinalaccelerations showedthat dummieswith no slaci and no heaw

clothing (baseline)averaged49.1 g; dummieswirh 7.6 cm of introducedslackand no heavyclothing averaged59.5 g, a 2006increase over baseline.The heavilyclothed dummiesaveragedchestacceleration of 46.2 g, a 606decreasefrom baselineand a 2306decreasefrom slack conditions.

Conclusion:Among many factors,chesrg (acceleration)is a reliable indicator of restraintsystemperformanceand of potential occupant iqury. This srudy showedrhat heavyclothing increasedbelt peiformancein terms o[ chestacceierations.Chestg decreasedby 6% from baselineandby 23% from introducedslacklivels. Thesefindingsmay haveimplicationsin new restraintsysremsand seatbelt designsl BetweenMagnesiumHeadlormsand tr^A A Comparison rf'l InsfumentedHunun CadaverHeadsin Measuringpeak Accelerationof lmpact LMLewis,RNaunheim, T Pittnnn,J Tricamo.

B Chandel/St LouisUniversity School of Medicine Studybackground:For standardLarion,the AmericanSocietyfor Testingand Materialshas developedspecificationsfor memllic head forms,to be usedin all impact tesring.'Nostudy hasevaluatedwhether metallicheadformtestingyields comparableresuhsto that of human cadaverheads(HCH).

Hypothesis:Accelerarion,in peakg, will not differ significantlyfor identicaldrops,when measuredwith instrumentedHCH, ascomDared wlth standardizedmagresiumheadforms(MgH).

Design:Two HCH fixed in formalin were insrrumentedwirh 750 g uniaxialacceleromerers implantedin rhe right orbit. The HCH and Mg-H were dropped five times onro two differentsurfaces(medium peagriel and rubber marring)from a height of 3.1 m. pre,impactvelocityw-as measured with a smndardvelocirygate.peakacceleiation for the MgH was,alsomeasuredusing a 750 g uniaxial accelerometer.

Velocityarid peakaccelerationwere recordedusing an impact testingsoftwareprogram.Vclocity and peak accelerationwere aviraged for MgH and HCtt for all drops onro.eachimpacredsurfaceand coripared using an unpairedStudent'st-test.

Results:Accelerationand velocity for eachimpactedsurfaceareseen below: t-Test Surlace Gravel Bubber mat

609:5.5m/sec l4lg:5.6m/sec

l00g:5.8m/sec 1689: 5.7m/sec

P < . 0 :1P < . 1 0 P < . 0 5P: > . ' 1 5

Conclusion:lmpacr accelerationdifferedsignificanrlvberweenHCH and MgH, whereasvelocitydid not. Further in-vestigarion,rs necessary to determinewhether MgH are rhe mosrapplicablemodel for prediciing the potentialof injury due to head impacr.

Factors_Affecting IniurySeverityto Rear-Seated 0ccupantsin [[ rfJ RuraiMotorVehicleCrashes CK9rown,0MCline,J Eastman/East Carolina University $hool of Medicine, PittCounty Memorial Hospital, Greenville, NorthCarolina Stu_dy background:lnjury ro rear-seared occupanrs(RSOs)has receivedlittle arrenrionin rhe literaure, with pasi studiesfocusingon pattemsofinjury in emergencydepartmentor hospiulized patien-ts.

Studiesincluding all crashesin a counry populationhavenot been reported.

Hypothesis:RSOsof motor vehiclecrashes(MVCs)sustainless severeinjuries than front-searedoccupants(FSOs).

Setting:Rural North Carolinaemergencypatienrswere seenat the solehospital for the county, a university teniary carecenter.

Desigr: Two-yearretrospecrivereview of all 1988 to 1989 MVCs with RSOs. Participants:All occupantslisted on law enforcementtraffic accident reportsfor multi-occupant MVCsin the countyduring I988 to ]999.

Threehundredsixty-fivecrashesinvolvingI,808 occupanrs (62,3.4% were excludedbecauseof incompleterecords)yielded 237 emergency panents.

Resuls: lnjury severityscoreswere higher for unrestrainedoccupants,occupantsofvehiclesdriven by legallyintoxicateddrivers, occupants betweenrheagesof30 and 59, and FSOs(StudenCs t-test, P < .05). Logisticregressionanalysisconfirmed the abovefindingswirh the exceptionof more severeinjuries for this agerange,which did not predict higher injury sevedtyscoreswhen controlling for other variables.Restraintuse offeredthe greatestprotectiveeffect.Lesserprotectiveeffectswere noted with RSOSand age< l3 years.More seveie injuries were predictedby driver intoxication,impact speed,and age> 60 years,wirh driver intoxicationbeing rhe mosrsignificant.

Conclusion:ln our rural population,RSOssustainlesssevere injuries than FSOs;however,restraintuseand soberdriversprovidea Sreaterprotectiveeffect.Seatlocation doesnot replacerestraintuse.

TralficAccidentReporbVersusEmergency EA !"* Enlorcement rflf Department Recordsfor MotorVehicleIniuryResearch DM Cline, CKBrown, WJ Eastnran/Department of [mergerrcy Medicine.

East Carolina University, Greenvi lle,NorthCarolina Background:The majority of moror vehicleinjury (MVl) studies haverelied on hospital dau, excludingrhosecrashesnot yielding severe injuries or injured occupantswho presentto orher hospitals.

Study objective:To comparethe law enforcementtraffic accident report and the emergencydepartmentrecord (EDR)asa sourcefor MVI research.

Setting:RuralNorth Carolinaemergencypatienrsseenar rhe sole hospital for the county, a university tertiary carecenter.

Design:Two-year(1988to 1989)rerrospective reviewof all multioccupantMVCs,including365 crashes and I,808 ocopants,yielding 237 ED patients.

Participants:All occupantslisted on county law enforcementtraffic accidentreportsand all conespondingED parienrs.

Resuls:Overall,searbeh usewasdocumentedin 93.I06of EDRs, but the EDRagreedwith law enforcementtraffic accidentreportsin only 76.80Aof cases.The EDRconrainedinformarionon seailocationin only 6006of charrsand agreedwith law enforcemenrtraflic accident reportsin 5I.306 of cases.The EDRwas most accuratein documenting the driver of the vehicle(76 of87 cases,91.606)and leastaccurarein identifyingrear-seared (I3 of62 cases,l5.l%). The law occupanrs enforcementrrafficaccidenrreporr sysremof describinginjury rouglrly correlatedwith Mean Injury SeverityScores(MISS)forltre eO parients: killed,MISS= 42; incapacitating injury, MISS= I I.7; nonincapacitaring visibleinjury, MISS= 2.9,compiaint,MISS= 4; no complaint, MISS= I .3. The protectiveeffectof seatbelts wasnot staristically sigrificant for rhe 237 EDRsbur becamesigrificanr when the whole groupof 1,808wasconsidered.

Conclusion:Using EDRsexclusivelyfor MVI researchmay mislead researchers unlessquality control measuresare instituted.physician injury researchers should work with law enforcementto improve data.

systemswhen systenrscompareuniform setsof patientsmeetingthe followingcriteria:witnessed,vcntricular librillation-induced,nontraumatic suddencardiacarrestwith paramedicrâ&#x201A;Źsponsetime < ten minutesfrom collapse.

Setting:A large,suburbanareawirh a population of 900,000,using a two-tieredEMT-D/paramedicsystem.Paramedics were trainedat the sameschooland followed identicalprotocols.

Design:We retrospectivelyreviewedsuwival ratesfor cardiacarrests that met the abovecriteria.We comparcdannualsurvivalratesfor eigfrt paramedicunits in King Counry,Washington,over a ten-yearperiod.

We observedthe survivalratesof a singleparamedicunit over the ten years,and eachyearwe comparedsurvivalratesamongthe eight paramedicunits.

Results:Therewere 6,803 cardiacancstsin lhe ten-vearstudv period. One thousandtwo hundred ten c:rsesmet the study criteria, an averageof I 5 I per paramedicunit. Thirty-eighrpercentof rhese patientssurvivedto hospital discharge.Survivalraresvariedmarkedly amonSthe eight paramedicunits (low, 30%; high, ,12%)and varied markedlyfrom year ro year for individual paramedicunirs (suwival ratescould more than double or fall by 50% from year ro year).

Conclusion:Our hypothesisis invalid. We identifieda greardeal of biologicvariationin survival ratesfor cardiacarrestwithin and among paramedicunits over time, evenwhen paramedicsof uniform skill levelsusedstandardprotocolsto treat;imilar patients.lnrersysrem and intrasystemcomparisonsand qualiry improvementeffore will be invalid if researchersand rnanagersfail to considerthis biologic variation.

A { U I MedicalProtocol

to Reduce'Redlights and Siren'Transport pennsylvania; DFKupas, BJPino,DJDula/Geisinger MedicalCenter, Danville, Citizens' AmbulanceService, Indiana.

Pennsylvania Study objecrive:lt hasbeenesrimaredrhar 12,000emergencymedical vehicleaccidentsannuallyare directly relatedro ,,redlighs and siren"@15) transporr.We proposethat medicalprorocolcan be used to determinewhich patientsmay be transportednon-R[S wirhout adversemedicaloutcome.

Desigr: A protocol basedon specificmedicalcriteria determined transportwith RLSor non-R[S. Darawere obUined prospectivelyfrom emergencycalls over a four-month period and included the patient's condition during transport,mode of transport,and the receivingphys! cian'simpressionof the outcomebenefitof more rapid transport.All non-R[5-transporredpatientswhosecondition worsenedduring transport or who the receivingphysicianbelievednuy havebenefitedfrom a more rapid transportwere reviewed.

Settingand parricipants:CountywideruraVsuburbanemergency medicalservicessystem.Data from 1,625consecutivepanent transDorts wereincluded.

Results:Mosrpariens(92%)did not meerour medicalprotocol and weretransportednon-R[S. Outcomesweie comparedbetweenRIS and non-R[S groupsby 12 analysis.Subsuntially fewerpatienrswere reportedto haveworsenedor died in the non-RlS group (106versus 1806,P < .00I), and rherewereno deathsin the non-R[S goup. When physicianopinion was available,22% of rhe parienrstransponCdwirh RtS may haveimprovedwith more rapid transponversusonly 0.2% of. the non-RlS-transporredparienrs(P < .O0l). Reviewof all casesin rhe abovecategoriesrevealedno morbidity relatedro non-RlS transport.

Conclusion:Medicalcriteria dicraringrhe use of Rl.Srransport resultsin infiequent R[5 transportand no adverseoutcomerelatedto non-R[5 transports.

f,l) EmergencyMcdical Scrvicc Systenr Bascd on ff 4 GollegelJnivar:ityCarpuses BBKing,BS Zachariah, P ClarkfheMedical College of Pennsylvania, Philadelphia; TheUniversity School, Houston ofTexasMedical Background:Many colleges/universities exist in relativeisolation from community-basedemergencymedical servicessystems(EMSS). ln response, some have developedtheir own EMSS. Objective:To determinethe extent of this phenomenonand to delineatethe characteristics of thesesystems.

Design/methods: Questionnaireswere mailed to 1,503collegeJ univenities in the United Statesand Canada.The questionnaireaskedif the institution had an EMSSand included 20 questionsabout the characteristicsof the system.

Results:Nine hundred nineteenresponses(61%) were received.Of institutionsresponding,234 (26%) had an EMSSand 3l (3.,f%)were consideringstartinga system.

Characteristics of the systems:l) Typesof patients:The two most common call typeswere medicaland trauma/surgical.One hundred thirty-four systems(57%) reportedat leastone fourth of calls to be medicaland 91 (39%) reportedat leastone fourth of callsto bâ&#x201A;Ź trauma/ surgical.2) Type of service:One hundred thirty-threeservices(57%) transportpatients.One hundred ninety-five(83%) respondonly to the campusor other universityproperty;the remainderrespondto the community also.One hundred thirty-five (5806)function yearround.

3) Dispatch:One hundred seventy-eight(76ob)aredispatchedby the campuspolice,althoughmost servicesare dispatchedby several sources.Forty-six(20%) use 9I I . ,l) Personnel:Two systems(0.85%) exclusivelyemploy paramedics;I l8 systems(5006)haveat leastone emergencymedicaltechnician.The remainderemploy emergencyclre attendantsand first aid providers.One hundred eighteen(500,6)havea medicaldirector;o[ these,76 (640A)are studenthealth physiciansand 2l (1806)arecommunityphysicians.

Conclusion:A significantnumber of collegeVuniversities have EMSS;half transportpatients.However,personneland medicaldirection rnaybe below the standardof community EMSS.

SoftTissue illeasuroments in f,Q TheUtilityof Prevertsbral lfrJ ldentifying Potionts tYithGewicalSpineFracture DJDeBehnke, C Havel/Department 0f Emergency Medicine, Medical College of Wisconsin.

Milwaukee Study objective:Prevertebralsoft tissuemeasurements > 6 mm at C2 and > 22 mm at C6 havebeenreportedasradiologicevidenceof cervical spineinjury. The objectiveof this study was !o determinethe sensitivity and specificityof thesesoft tissuemeasuremensin patientswith radiographicallyprovencervicalspine fractures.

Desigr: Retrospective cirsecontrol study.

Setting:County hospinl emergencydepartment.

Participants:The study group consistedof patientsadmitted betweenJanuary1989and August l99l with an admitting or dischargc. diagrosisof cervicalspine fracture.The control group wasa sysrernatic samplingof traunu patientsseenin the ED duringJuly l99l who receiveda cervicalspine radiograph.Patienrs< I7 yearsold with penetrating injuries or injuries > 24 hours old were excluded.One hundred thirty-eightstudy and I34 control patientswere identified.Thiny-wo study and 4l control patientswere excludedbecauseo[ inaccessible records.One hundred six study and 93 control patientswere usedfor analysis.

Interventions: Cervical spine radiographswere reviewed, and prevertebralsoft tissuemeasurements were takenat eachcewicallevel.

Results:Study patientswere divided into two groups:thosewith fracn:resat Cl to C4 (49) or C4 to C7 (57). A C2 prevertebralsoft rissue measurement> 6 mm had a sensitivityof 59% and a specificityof 84% for fracturesat CI to C4. AC6 prevertebralsoft tissuemeasurement> 22 mm had a sensitiviryof 7% and a specificityof 95oAfor fracturesat C4 ro C7. When patienlswith NG or ET tubeswere excluded,a C2 prevertebralsoft tissuemeasurement> 6 mm had a sensiriviryof 5506 and a specificityof 8706in CI to C,f fracrures.A C6 prevertebralsoft tissuemeasurement> 22 mm had a sensirivityof 806and a specificityof 95oAin C4 to C7 fractures.

Conclusion:Using prevertebralsoft tissuemeasurements > 6 mm at C2 and > 22 mm at C6 as a marker of cervicalspine injury failsto identlfy a largenumber of patientswith cervicalspine fractures.

64lfiiiiJ,lalto

lmplenrent Decision Rules forRadiosraphy in

lG Stiell,BD McKnight, GHGreenberg, BCNair,I McDowell, CJohns, JBWorthington, AFHenry/Division of Emergency Medicine, University of 0ttawa,0ntario Study objective:Two decisionrules for the use o[ radiographyin acuteankle injuries havebeenpreviouslydeveloped,refined,and validatedon 2,235 patients.This srudy assessed rhe impact on clinical practiceo[ implementingthe refined Otuwa ankle rulesby emergency physicians.

Design:Before-aftercontrolled clinical trial with five-monthcontrol and interventionperiods.

Setting:ED of an 820'bed adult universityhospiral.

Participants: All I,250 adultsseenwith acuteblunt ankletrauma during the study periods. lntervention:The implementationof the Ottawaankle rulesby all ED intems, residents,and attendingstaff physicians.All nonfracrure caseswere followedby telephoneat five to ten days.

Results:Demographicand clinical characteristics, including preva, lenceof fracture,were similar for the two goups. Ratesof referralfor ankleand foot radiogaphy and relativereductionsin usewere: (N= 657) Intervention Rsdiograplry Gontml Roduction lil = 5$ll p Ankleseries Footseries

82.8% 31,l%

59.7% m,8%

<.001 r0

27.9% 13.8%

During the interventionperiod, only threeparientsinsisredon an unnecessary radiograph.Nonfracturepatientsdischargedwithout radiogaphy spenrlessrime in rhe ED rhan thosewho had radiogaphy (80.4versusI 13.9 minutes;P < .0001)and werenot differenrin pro, portionssatisfiedwith ED care(94.7obversus96.406)or proporri;ns havingasubsequent radiograph(5.0%versus4.706).71te ruleswere I0006sensitivefor all 8l malleolarand 20 midfoot fracrures.

Conclusion:Implementationof the Otuwa ankle rules led to a decrease in use of ankle radiographyand waiting timeswithour missed fracturesor patient dissatisfaction.Future studiesshould addressthe generalizabilityof thesedecisionrules in a variety o[hospitals.

FF OC ClinicalDecisionRulelor KneeRadiographs DCSeaberg, B Jackson/Mercy Hospitalof Pinsburgh Study objective:Kneeradiographsare often overusedin the emergencydepartmenr.The objectiveof rhis srudy was to developa decision rule for ordering radiographsin kneeinjuries.

Design:Retrospective chart review of20l consecutivepatients receiving knee radiographs in the ED over nine monrhs (phaseI).

Logisticregressionwas performedon I I clinical indicatorsto develop

a clinical decisionrule. Prospectivestudy on 105 consecutivepatients with kneeinjuries (PhaseIl). All patientsreceivedradiographsto validatethe decisionrule. SensitMty,specificity,and misclassification ratewerecalculated.

Setting:Urban community ED with annualcensusof 38,000.

Results:Logisticregressionanalysisfound that a falVblunt trauma mechanismyieldeda sensitivityol93ob, specificityof.57ob,with a falsenegativerate of 0.9%. The addition of inability to ambulateand.age (< l2 or > 50 yearsofage) yieldeda sensitivityof 9206with a specificity of 6206.The prospectivestudy found the combinationof falVblunt traumawith inability to ambulateor age(< 12 or > 50 yearsof age) was 1000,6 sensitivewith a specificityof 4IoA.Misclassificationratewas 52o6.Usingthe decisionrule, radiogaphscould havebeenreduced37%.

Conc'lusion:The decisionrule of falVblunt traumawith inability to ambulateor age(< I 2 or > 50 yearsof age)was validated.ina prospec' tive study with I00% sensitivity.Clinical decisionrules for kneeradiographscan substantiallyreduceradiographswithout adverseclinical effects.

TomographicScan f f, GlinicallySignificantGranialGomputed MedicineResidency ff lf Misinterpretations at an Emergency Program MA Levitt,DAlfaro,DKEnglish, V Williams, R Eisenburg/Highland General Hospital, 0akland, California; University of California, SanFrarrisco Study objective:The use o[ cranialcomputedtomogaphy (CT) scansis ever increasingin the emergencydepartmentevaluationsof patients.The presentstudy wasconstructedto determinethe accuracy of emergencyphysiciansin interpretingcranial CTs.The effectof confidencelevels,levelof training, and clinical presentationwere additionally correlatedto accuracy.

Desigr: Prospective.

Seuing:Countyhospiul.

Paticipants:Fivehundred forty-four patientsundergoingcranialCT during ED evaluations.

Results:Forty-ninepercent(272) of rhe indicationswere for trauma, l4.ZoA(79) for CVA,25.I% (I39) for HA, I5.I% (8a) for seDure,and I3.7oA(76) for ALOC. Abnormal CTswere interpretedby the radiologist in 288 (52.9oA)of the patiens. The most frequentabnormalities includedscalphematoma,39(l5.2ob);infarction,36 (la.l06); calcification, l6 (6.306);contusion,l6 (6.3%);parenchymal bleed,l3 (5.106); mass,l3 (5.10,6).

Nonconcordance(NC) betweenradiologistand ED evaluationswas found in 206 (38.706)of the cases.NC was decreased by 50o/.at high confidencelevels.Clinically significantmisinterpretations(CSMs)werefoundin I 3l (63.906of NC, 24.I % of totalsample).

TheseCSMsincluded 62 (ll.4oA o[ total sample)caseswith missed major findingsby ED on CT. Theseincluded new infarct, 25 (alo6); rnass,ten (16.1%);edema,eight (12.906);parenchymalbleed,eigfrt (12.906);subarachnoidhemorrhage,four (6.50,6); contusion,Iive (8.106);epidural,one(].6%); and subdural,one(L6o6).

Conclusion:Thirty-nine percentof cranialCTs may be misinterpreted by emergencyphysicians.More imporuntly, I 106of CTs may have major findingsmissedby emergencyphysicians.Structuredtraining in CT interpretationduring residencyandlor 24-hour radiographicinterDretationof CTs is recommended.

Documentation ol thr NeedlorAttendingSuperuision of f,] fl f Rssidentsin tho EmorgoncyDepartnont CJHollimn,BCWuen,MJ Kimak,KKBurkfart.JW Dono,yan.

HLBudnick.

MA 8ates,HAMuller/University Hospital, TheMiltonS Hershey Medical Center.

ThePennsylvania StateUniversity, Hershey Study objective:To determinethe changesin parienrcareby attending emergencyphysicians(AEP)supewisingnonemergencymedicine housestaffftiS) and to comparethesechangeswith a prior study of emergencymedicine(EM) housestaffelsewhere(Ann EmergMed 1992;21:749-752).

Desigr: Prospectivestudy of 1,000consecutiveHS patientcare plans.

Setting:Universityhospiul emergencydepartment;annualcensus, 26,000.

Participants:Thirty-rwo second-and rhird-yearHS and eighrAEPS participatedfrom Octoberto December1992. lnteryentions:HS presentedcaseswith their diagnosesand treatment plans to the AEPs,who then classedany HS errorsor AEPchange of careasmajor, minor, or none, accordingto a predetermined,l0-item datasheetlist.

Results:Therewere I506 major and 35% minor changesin patient careby the AEPs.The mosrcommon major changesby AEpswere orderinglab tests(2.I %) or radiographs(l .7%) thar showeda significant abnormality,finding additional parholory on physicalexaminarion (1.606),and correctionof IV medicationorders(I.I0,6).AEpsprovided direct patientcarein an addirional650 casesduring the srudy period.

Conclusion:AEPspreventedfrequentpatientcltreerrorsand def! cienciesby HS while also providing subsunrialdirecr patientcareand supervisionof studentsand intems. The major error rate for nonemergencymedicinesecond-and third-yearHS was three to four timesthat of EM housestaffreportedin the prior srudy,showingthat AEp supewision is evenmore important in an ED suffed by nonemergencyHS.

68 ?i:::tlffi:;3,,n."*

Medicine Residency: The Probrernt and

JV Waigand, G Kuhn.LWGerson/Northeastern 0hioUniversities College of Medicine, AkronCityHospital; WayneStateUniversity, GraceHospital, Detroit; Department of Epidemiology, Northeastern 0hioUniversitiss College of Medicine.

Akron Study objective:To characterizethe perceivedproblemsfacing emergencymedicineresidencydirectors(EMRDs)and ro determine potentialsolutions" Design:A 72-item quesrionnairewas mailed ro EMRDsof all 93 approvedalloparhicemergencymedicineresidencyprograms,wirh foll.ol-u_pmailingsand telephonecalls to non,respondeis.The survey included a23-item problem list and a lS-item solutionslist construcied by a panel of EMRDs.EMRDswereaskedro rank problemsusing a fivepoint Likert scaleand were askedro indicarewhich of the listed solutions they had usedand had found useful or rhoughrwould be useful.

Results:Eiglrty,sevenof 93 EMRDs(93.5%) compleredrhe suwey.

The respondenrsincluded 88% men and l2% women. The meanage was40 years(range,32 ro 6l); 50% had beenEMRD for lessthan ihree years,and 68.970Aanticiparebeing in the job five yearsor less(62.40A had an associare EMRD; 75.4%had one or more full-time secretaries).

EMRDsworked a medianof 220 hours per monrh including a median of I00 adininisrrariveand 88 clinical hours. Major problemsidentified by respondentsincluded lack of rime for the job (5705),inadequate facultyhelp (3706),lack of communicationwirh faculty(34%), career needsinterferingwith family needs(33%), lack of researchspecialists (3306),irudequatesecretarial support (29%), lack of control overwork

schedule(27'A),lack ofeducationalspecialistsupport (2506),senseof total responsibilityfor the program(25"6),lack of support fromhosp! tal administration(23%), and working with problem residents(22%).

The most frequentlycited solutionsincluded attendingeducational coursessuchas SAEMcourses(9006),the ACEPteachingfellowship (1506),and courseson time management(25oA),personnelrnanagement (3I06), stresstrurugement(2506),self-readingon educational techniques(8506)and rnanagement(6506),discussingproblem/seeking advicefrom emergencydepartmentchairman(9006),ED colleagues (8506),significantothers(80%), and family/personalcounselors(I9%).

Conclusion:EMRDsencounterunique educationaland administrative problems.They believeformai coursesin educationand management would be useful to help solvetheseproblems.

ModicineResidencyProgramsin Deternfning f,Q Roleol Emergency lf J Emergency MedicincCereerGhoiceAmongMedical Studentr EJGallagher, LBGoldfrank, GVAnderson, WG Barsan, RLLevy,ABSanders, GBStrange, ATTrott/Albert Einstein, NewYorkUniversity, Emory University, University of Michigan, University of Cirrcinnati, University of Arizona, University of lllinois,University of Cincinnati Study objective:To characterizethe role o[ emergencymedicine (EM) residencyprogramsin determiningEM careerchoiceamong medicalstudents.

Design:Observational,cross-sectional, descriptivestudy.

Participants:All accreditedEM residencyprograrnsand four-year allopathicmedicalschools. lntewentions:None.

Results:Fifty-two schools(42ob)hada closelyaffiliatedEM residency program,ie, one basedprimarily ar the insriturion'smain teaching hospital(s).This configurationwas associated with a 700,6increasein the medianproportion of studens choosingEM asa careerwhen comparedwith the 73 schoolsthat had no closelyaffiliatedEM residency (5.I06vs 3.006,P < .0001).When institutionsweresrrarifiedby overall commitmentto EM, the medianproportion of studens choosingEM as a careerwas2.9oAfor instirutionswirh a minimal commitment to EM (neitheran academicdepaftmentof EM nor a closelyaffiliatedEM residency),4.Iob for institutionswith a moderatecommitmentro EM (eithera departmentof EM or an EM residencybur nor both),and 5.7% for institutionswith a substantialcommitmentto EM (both a department of EM and an EM residency)(P < .0001). When institutional commitmentto EM wasexaminedin a simple muhivariatemodel, only the presenceofan EM residencywas independentlyassociated with studentcareerchoice(P < .001).

Conclusion:An EM residencyprogramrharis closelyaffiliatedwith a medicalschoolis stronglyand independentlyassociated with a quantitativelyand statisticallysignilicanrincreasein the proportion of studentsfrom that schoolwho choosea careerin EM. lf EM is to meet its manpowershortageneedsby arrmctingstudentsro rhe specialty,it must establishresidencyprogramswithin rhe primary teachinghospital(s)of medicalschools.In the majority of schools,such a configuration doesnot currentlyexist.

Reporton the Strtusof Emergency MedicineTrainingin 7ll f ffTraditional AcademicCsnters EJGallagher, LRGoldfrank, GVAnderson, WG Barsan, RLLevy,AB Sanders, GR Strange, AT TroVAlbertEinstein, NewYorkUniversity, EnroryUniversity, University of Michigan, University of Cirrinnati, University of Arizona, University of lllinois,University of Cincinnati Study objective:To characterizethe statusof emergencymedicine (EM) training in tradirionalacademiccenrers.

Desigr; Observational,cross-sectional, descriptivesuryey.

Participants:All accreditedEM residencyprograms(EMRPs)and four-yearallopathicmedicalschoolsin rhe United Sures lnterventions:None.

Resuls:Sixty-twoinstitutionswere designatedas traditionalacademic centerson the basisof NIH funding. Thesemedicalschools captured9006of all NIH grant moniesawardedin liscalyear 1990.

Twenty-sixof 87 EMRPs(30%) uu"." closelyaffiliatedwith one of these medicalschools.The remaining 70% were eirher freestandingor afliliared with lessresearch-oriented instirutions.Within traditionalacademic centers,thoseinstitutionswith closelyaffiliatedEMRPsreceivedsignif! cantlylower ratingsaccordingto academicdeans'ranking(P < .01I), researchrank (P < .009),and compositeacademicrank (P < .004) when comparedwith'institutionswithout EMRPs.Similarly,when institutional commitmentto EM was measuredaccordingto the presenceof an EMRPor an academicdepartmentof EM, therewasa stronginverse correlationbetweenEM commitmentand academicdeans'ranking (P < .005),research rank (P < .001),and compositeacademicrank (P < .0001), Conclusion:The majority of EMRPs(70%) are not closelyaffiliated with thoseinstitutionswhere the bulk (90%) of linancialresourcesfor the support of academicendeavorarecurrently invested.Within these traditionalacademiccente$, there is a quanriatively and statistically sigrificant inversecorrelationbetweena medicalschool'scommitment to EM and the generallyperceivedacademicstatureof that instinttion. (lSDlModal ] { Utilizationol the lnstructionalSystemsDovelopment f I in Emergency Msdicino KP0'KeafelJoint MilitaryMedicalCenters Emergency Medicine Residency Program, WilfordHallMedicalCenter, SanAntonio Background:The InstructionalSystemsDevelopment(lSD) model hasbeenin usesinceWorld War ll as a scientificmethod of instruction but hasnot beenwidely applied ro medicaleducarion.Our residency programhasadoptedthis model in our emergencymedicineinstruction. We developeda readingschedulefor our PGY-3and PGY-4residents from the text EmcrgmcyMedicine:A ComprchcnsiteSntdyC,uide editedby Tintinalli et al. We crearedgoalsand objectivesfor eachchapter. We then developedmultiple-choicerestquestionsbasedon the statedobjectivesand enteredthem inro a Macintoshcompurerutilizing the LxRTEsrprogram.This allowsus to createa personaltest for each residentbasedon the readingassignment.

Results:lf a poor examscoreis obtained,a differentgroup o[ questions coveringthe samematerialcan be generatedfor retesting.Each month, the residentsevaluatetheir testsand readingassigrments, allowing for improvementof rhe process.This method hasbeenreadily accepted by our residents. lt allowsus to standardize theireducation, givesus direct feedbackof their knowledgebase,and hashelpedus to achieveconsistenrlyhigh resuhson the in-serviceand board cerrification exarns.This programalsoservesas an excellenttool for remedial training for thoseresidentswho encounteracademicdifficulties. t4t

I 2(irrusComputerArlas G Spears, JA Morgan, M Killen/Brooke ArmyMedicalCenter, WilfordHallAir Force Medical Center, Departments of Emergency Medicine, SanAntonio Study objective:To provide an easy-ro-use and updatabledatabase for the teachingof compuredtomographyand ultrasoundanatomyand pathologyrelevantto the practiceof emergencymedicine.

Desigr: Sute-of-the-arrdigital technologyincorporaredinto a pointand-clickgraphicsoperatingenvironmenr.

Results:A self-containedatlascapableof being displayedon any PC or laptop (286/386/486,VGA display)and capableof beingupdatedas CTfuS equipmentimproves.The addition of plain radiogaph aswell as magneticresonanceimagingis possibleshould the user desireto do so.

Conclusion:CTfuS anatomyand pathologyrelevantto emergency medicine can be leamed by viewing labeled imagesas they appear on film.

Emergency MadicincRecidcntProccduresand Resuscitations ]Q f rl Reportof a Computerizod Tleeking Systom of California, lrvine,Emergencl Ml langdof,CSSobel.KASalness^Jniversity Medicine Besiderry, 0range Background:One componentof optimum training in emergency medicalproceduresis the pcrfornnnce of a suflicientnurnber,but there areno dataabout how rnanyarenecessary.

Nonetheless,the Residency ReviewCommitteefor EM requiresprogramsto report the average number of I 8 proceduresand four typesof resuscitations ferformed by seniorresidens.For 2.5 years,we havetrackedresidentcaseexperienceand proceduresby computerboth on and off sewicein our 38,000-visit,lrvel I traumacenter.

Results:This first report of dau from the trackingsystemis the initial stepin describinga sufficientpracticumin EM procedures.The Selected programtracks79 typesof EM proceduresand resuscitations. proceduresper residentfor the EM-2 and EM-3 classesarepresented: EM-3 R.ltr.

Pmcodurc Eltl-z Ran0e TotalDrocedures Totalresuscitations ldult medical l48o/o) Adulttrauma {37%) (l0o/o) rnedical Pediatric Pediatric trauma 150/o) Arterial line Central linefemoral Central lineinternal lugular Central linesubclavian Chesttube Cricothyrotomy rrein Cutdown, saphenous Delivery, wginal Incision anddrainage ofabscess Intmoseous infusion Laceration repair puncture Lumbar Nasotracheal intubatim orotracheal intubation Pericardiocentesis Peritoneal lavage Plaster splintof fracture Beduction ofshoulder Sw?n-Ganz catheterization Ihoracotomv. resuscitative

392 293to 765 ln 37to256 l8 to 9tl 5l 4l I lo 83 6 to 13 9 'l toI 5 27 16to44 14to46 n 12 5 to26 16 8 to26 24 12ro37 0 Otol 4 I toI 11 4 to31 4 to20 II 3 0 toI 43 m to79 m l8 to29 4 I to 7 35 14to73 | 0to3 8 2 to 16 12 4 to45 4 I to5 16 2to21 | 0 to2

335 234t0533 102 54to 125 28 13to52 20 l0 to33 8 3t026 'l 2 to3 14 8t025 22 15to33 7 3tol6 13 5t035 15 7t030 0 0toi 3 | toS 1 3 1 0t o1 5 15 10to23 3 | tos 6 1 3 7t o $ n ll to38 4 0to7 3 1 1 2t o 6 4 I otol 9 7to13 14 3 toa 3 1to4 6 ltolT I 0 to2

we await data from other residenciesto further describethe usual experience.

J /l ClinicalSkills Taughtby EmergencyMedicineFaculty:A Model f rl First-YearCourse Philadelphia U Swisher,WP Burdick/Ihe Medical College of Pennsylvania, Background:A developingtrend in medicaleducationis the introduction of clinical skills in the lirst yearof medicalschool.Our department of emergencymedicineteachesa unique, required,first-year clinical skills coursethat meetsthreehours a week througlroutthe academicyear.

Design:The fall semesteris devotedto the medicalinterview.An initial lectureis presentedon topicssuchas the clinical reasoning

process,interviewingtechniques,merhodsof eliciting a linearhistory, the sexualhistory, substanceabuse,and deliveringinformation to patients.The lectureis followedby a two-hour, srnall-groupworkshop.

In threeworkshops,a total of six standardizedparientspresâ&#x201A;Źntinga varietyof problernsare interviewedby eachsmall group. Studentsalso conduct an individual videotapedinterviewwith a standardizedpatient.

Videotapereviewsessionsare conductedwith six studenrsand a faculty member.Other small group sessionsfocuson papercasesemphasizing the clinical reasoningprocess.In the spring semesterthe sessionsconsist of a brief physicalexaminationlecture,followedby a practicumin which studentdyadsexamineeachother. Interviewingskills are reinforcedby askingstudentsto role-playscenariosconcentratingon that week'sphysicalexaminationsubject.Eachweekly sessionconcludes with a discussionof a relevantpapercase.Usingconceptmaps,the studentsintegratethe case'sclinical datawith basicsciencetheory and generatepotentialdiagroses.Twice a year,studentsobservein the emergencydepartment.The studentsidentify a particularpatient to obseweand then areexpectedto write about selectedaspecsof the case.Clinical skills instruction is receivingmore emphasisand is uking placeearlierin the medicalschoolcurriculum. Many medicalschools areseekinggroups of interestedfaculty to teachin this area.This course can serveasa model for other emergencymedicinedepartmentsto use in offeringclinical skills educationro beginningmedicalstudenrs.

7tr f rf An AdministativePracticumfor Emergencyiledicins Residents WDFales,DMAnderson, JPGillenTDepartment of Emergency Medicine, Geisinger MedicalCenter, Darville, Pennsylvania Background:The developmentof basicmanagementand adminis, trativeskills is an important aspectof emergencymedicineresidency training.Traditional methodsof administrariveskill developmenr include formal didacticsessionsand brief rotarionswith emergency medicinenanagers,often in an observationalcapacity.We describea unique model of a year-long,comprehensiveadministrarivepracticum for seniorresidents.

Design:Our program is dasigrredto developbasicmanagement skills through activeparticipalionin one of sevenadministrariveareas.

We believethat by conductingthe program over a I2-month period the residentsarebetter able to appreciatethe intermediateand long-term aspecso[ administration.Residenrsare challengedro develop,implement, evaluate,and modify new and existingprojectsin their respective areas.In doingso, they gain pracricalexperiencein planning, org,inizing, delegating,communicating,and problem solving.Effectivefacuhy supervisionis balancedwith residentautonomyin the pursuit of esublishedgoalsand objectives.The areasofinvolvement include general departmentaladminisrration(chief resident),emergencymedicalservices,air medicalservices,residencyeducation,continuousquality improvement,residentrecruitment,and traumaseryices.

Conclusion:We believethar rhis approachro administrariveskill developmentresultsin a graduatingresidentbetterable ro meet.the managerialresponsibilities associatedwith a careerin emergency medicine. The deparrment additionally benelirs from the many posirive contributionsmadeby enthusiasticresidents. rtrr /O ff,r ElectronicSuturolab V Valley,YB Zhu,S Harganen/Department of Emergerry Medicine, Medical College of Wsconsin.

Milwaukos The eucrnoNtc suruRr LABis a computer sofrwareprogram designed for medicalstudents.The compurerprogramis targeredfor use in the

emergencydepartmentbut may be usedasa programnredleaming tool.

This softwareprogramfeaturesa'hypertext" approachto the examination, suturedrepair,and generalcareo[ wounds and lacerationsthat typicallypresentto the ED. Actual graphicimagesof a varietyof wounds, instruments,anesthesia(local and nerveblocks),suture materials,and dressingscan be displayedfrom a text prompt within the program.Anatomicaldrawingsare alsousedto enhancethe student's understandingof and approachto wounds and lacerations.The visual displayof actualcasesheigfrtensthe medicalstudent'sleamingexperience.ln addition, the medicalstudentcan refer to the progam for specific topicsas they relateto a patient they may be caring for in the ED. Pediatricwound careand pain managementalsoare illustrated.Followup careis emphasized. 'f -f TheGlinicalAlgori6m ProcessorShell;An Intoractive f f EducationalEnvironmcnt lor GlinicalPracticcGuidelines andWdmen's JCltkClay,RAGreenes/Decision Systems Group, Brigham Hospital, Harvard Medical School, Boston Background:Clinical algorithmsconciselydisplaythe branching logic of diagnosticand therapeuticstrategies.An increasingnumber of practiceguidelineauthorsare using algorithmsto representthe procedural logic in the guideline.We havedevelopedthe Clinical Algorithm ProcessorShell (ceps),an inleractivecomputer tool that supports authoringand disseminationo[ practiceguidelines.Accessto supporting documentationis provided through the use ofDeSvcNln,a set of softwaretoolsalsodevelopedin this laboratory.DrSvcunnoperateson an Apple Macintoshand takesadvantageof the mouse-drivenwindow ing environmentto allow easydirect manipulationauthoringand browsingof content.

Desigr: cers is an authoring shell that enablesdomain expertsto createand modify algorithrnsas a flow chart or seriesof flow charts.

Any portion of the flow chart can be linked to other entitiesin DrSvcNrn(eg, formattedtext, outlines,images,sounds,digitized movies,question-and-answer interactions,or other algorithrns)to create a completeeducationalapplication.

Resuls:We haveusedo{ps to representthe NationalHeart, Lung, and Blood lnstitute Guidelinesfor the Diagrosisand Managementof Asthmain an educationalformat for training studentsand residentsin the rnanagemento[ asthma.We haveimplementeda usefulinteractive educationalenvironmentin which a growing library of algorithrnscan be stored,disseminated,and explored.Developingand updatinga library of clinical practiceguidelinescan be done by contentexperts without the needfor programmingsuppoil. We intend to expandthe role of cepsfor usein quality assuranceinitiativesand for problemspecificcharting.

MedicinoFssidentsanddreAcquisitionof Expeiliso JQ Emergency f O in ttre Diagnosisof Myocordialtnfarction FJPapa,G Kuhnfiexas Medicine,FortWorth;Mount Collegeof 0steopathic Carmel Merc.y Hospital, Detroit Study objective:The objectiveof this investigationwas to describe how emergencymedicine residenr acquire expertise in the diagrosis of myocardialinfarction(MI). In previousinvestigations,the author demonstratedthat an artificial intelligence(Al)-derivedtool (fuzzy setlike expertsystem)could validly model the diagnosticcapabilitiesof medicalstudents,residents,and board-certifiedphysicians(experts).In this study, the Al tool was usedto model and therebydescribethe cognitive markersthat characterizethe acutechestpain (ACPyMI diagnostic strenSthsand deficicnciesof 65 emergencymedicine residentsand 26 ABEM-certifiedpractitioners.

Methods:To characterizethe diagnosticabilitiesof thesesubjecs, the investigatorsfirst neededto createcomputer-basedrepresentations of eachsubject'sconstructor mental imagefor Ml and eigfrtorhercompeting causesof ACP (angina,dissectingaortic aneurysm,pericarditis, upper gastrointestinaldisorders,pneumonia,pneumothorax,musculoskeleul disorders,and pulmonaryembolus).The AI tool rhen used eachsubject'snine diseaseconstmctsto diagnose2l differentand documentedACP/MI testc:rses.Groupsrepresentingvaryinglevelsof residencytrainingwere residenrs,group I, 0 monrhs(la); group 2, one ro four months (25); group 3, five to I2 months (26); experts,group 4, > 36 months(26).

Results:Model validiry was further demonstraredby the superior MI diagrosticaccuracyof experrsover residenrs(t-test;P < .000) and steadyprogressionof Ml diagrosticaccuracyfrom goup i to 4.

Clinical ruturation (ie, transitionfrom goup I to ,1)wascharacterized by l) decreases in the number of Ml testcasesmisdiagrosedasangina, pulmonaryembolus,musculoskeletaldisorders,and pneumorhorax, 2) increasesin the number of MI casesmisdiagnosedasaneurysm,and 3) little to no group differencesin orher misdiagroses.The development o[expertiserequiresrhat subjectsdevelopdiseaseconstrucs capableof correctlydifferentiatingvariousdiseaseclasses.This pilot study suggesrs that Al toolscan identiS diseaseconstructdeficienciesrharmust be conectedin order to acquireACP/MI expertise.Explicit and early instructiontargetedat specificdiseaseconstructrefinementscould produceresidentswith more effectiveACP/MI diagnosticcapabilities. 'tlfl I U ff,r lmportanceof Postresidency Evaluations JE lintirclli/Departmsnt of Emergency Medicine,University of NorthCarolina, Chapel Hill Study objective:To assess residentperformanceafter residency completion.

Desigr: Survey.Evaluationswere requestedsix months aftergraduation from eachresident'sfirst employer.A letter of explanarion,the evaluationform, and a stampedself-addressed retum envelopewere sent.The evaluationrequestedperformanceassessments in two areas, the generalresidencyexperienceand individual attitudesand behaviors.

Setting:Community-hospitalbasedresidencyprogram.

Participants:Employersof 1989and 1990residencygaduates,six monthsafter residenrsbeg3nemployment. lntewentions:None.

Results:Retum responsâ&#x201A;Źrateby employerswas I0006. Insufficient expertisewith pediardcswas reportedby 22% despirerhe fact rhat the programprovided four months of pediatricsand the emergencydeparrment censusincluded 25% pediatrics.The employer'simpressionof individual residentperformanceand attirudesapproximatedthe residencyprogramdirector's.However,problemswith somebehaviors werenoted that could havebeenevaluatedand identifiedin rraining but werenot. This seriesof evaluarionsled to changesin the organiiation and teachingof emergencypediatriccarein the departmentand resultedin changesin the residentevaluationprocess.

Conclusion:A standardizedmethodolory for post-emergency medicineresidencyevaluationsshould be developedto ensurethat the residencyexperiencemeetsthe changing needsoi diff"r..rr ernergency medicipepractices,to monitor the accuracyof the residencyprogram director'sresidentassessmenB, and to improve residentevaluationsin the program.

Ofl An Assessmentol Follow-upSystemsin ErnergencyMedicine lflf Residencies of College of Wisconsin, Departmont B Bmtleyll, D De8ehnke,0J Ma/Medical Milwaukee Emergerry Medicine. of the Residency Studyobjective:The 1990SpecialRequirements ReviewCommitteestipulate that emergencymedicine residencies "must provide a mechanismfor eachresident to obtain information on outcomesof patientsthe residenthasevaluatedin the emergencydepartment." We assessed residencycompliancewith the committee'srequirementsand solicitedproposalsfor implerrrnting mechanismsof followup.

Design:A l6-item questionnairecharacterizingcurrent follow-up sysand satisfaction.A sepatemsand a 5-point linear rale rated effectiveness rate sectionallowed for descriptionof follow-up systens and comments.

Participants:All 84 emergencymedicineresidencydirectorslisted in the I 99 I SAEMResidcncy Handboohwerc polled.

Results:The 72 respondents(86%) representedresidericieswith a had a totalof 138affiliatedteachinghospitals,of which 89 (64.50,6) formal follow-up systemin place.Of those89 hospitalswith systems, 3 I (35of) reportedthat fewerthan half of their residentsuse the system and only 55 (620A)had a mandatorycompliancepolicy; 56 (6306)had the capabilityfor residentsto obtain dischargesummarieson admitted patients,and the samenumber reporteda mechanismfor follow-up of patientsdischargedfrom the ED. Twenty (2206)of the systerr were consideredeffectivewith a rating of,t or higfrer,and only 27 (3006) receiveda high satisfactionrating.

Conclusion:Contraryto ResidencyReviewCommitteerequirements, 3606of emergencymedicineresidency-affiliated hospitalsdo not havea follow-up systemin place;of existingsystemsronly a minority arerated by residencydirectorsas effectiveor satisfactory.Proposalsfor implementingand improving emergencymedicineresidency-based follow-up systemswill be summarized.

Emoruoncy DepailmentManagementin a Residencl Q I Developing lf I Gurriculum:A PostgraduateSuwey LMProfeta, DCSeaberg, M MacLeod/University of Pittsburgh Affiliated Besidency in Emergerry Medicine; MerclHospital of Pittsburgh Study objective:Emergencydepartmentrnanagementis becoming increasinglyimportant in the practiceof emergencymedicine, Residencytraining in this areais often deficient.The objectiveof rhis study was to identify thoseareasof ED managemenrmosr frequently practicedand which areasshould be emphasizedin the curriculum of an emergencymedicineresidency.

Desigr: Mailedsurvey.

Participants: All 63 formerresidentsof an accreditedthree-year residencyin emergencymedicine.

Results:Fifty-oneo[ 63 surveys(8106)were completed.The Table notesthe percentof former residentsinvolvedin eachtopic aswell as a ranking of recommendedimportancefor inclusion in the residency curriculum(1,least;5, most).

Topic % l||volyed Rankin0 Biskmanagement 62 4.65 oualityassurance 70 4.51 Contract negotiation 50 4.24 Malpractice cwerage 32 3.S Billing 56 3.80 Public relations 58 3.69 Physician relations s 3.53 Continuing education 72 3.38 Scheduling 48 3.26 EDbudget n 3.n Recruitrnent bU 3.13 Employee benefih 42 3.11 Nurcing supavision 50 3.52 Committee wo* 10 2.86

Conclusion:The surveyidentified that more than 5006of former residenr participatein billing, contractnegotiation,physicianand public relations,quaiiry assurance,and risk management.Theseareas, in addition to malpracticecoveragetwould bc most impoilant to include in the residency training. Since many graduatesare involved in emergencymedicinenunagement,this subjcctshould be developedas part of the residencycurriculum.

Physicians'Ghert Qll Useol the AmericanCollegeol Emergency O4 paln Policyas a TeachingInstrument EYogel,BW Wilson/Dspartment 0f EmergerryMedicine,BrookeArmyMedical Center, FortSamHouston.

SanAntonio Study objective:To determinewhetherusing the AmericanCollege of EmergencyPhysicians'chest pain policy (ACEP-CPP)as a teaching tool would improve emergencymedicine resident clinical management of chestpain.

Desigr: A chart reviewwas performedof all adult patientswith atraumaticchestpain seenin a one-monthperiod the yearbeforeand one month afteruse of the ACEP-CPPasa teachinginstrument.The CPPwasused to objectivelyevaluateparticipants'nunagernentof chest Paln.

Setting:Urban tertiaryczrrehospitalemergencydepartment.

Participants:PGY2, 3, and 4 emergencymedicineresidents.One hundred ninety-onepatientspresentedin the first study month and 203 presentedin the month after the teaching.All charrswere included in the study. lnterventions:The ACEP-CPPwas reviewedin a one-hourgrand round discussionand mentioneddaily in moming report. A quick form guide waspostedin the ED. Results:ln the yearbefore use of the ACEP-CPP,nine rules(items that ACEPconsidersessential)had < I00% compliance.After teaching, all ruleshad 10006compliance(P < .0005 by 1z). Compliance increasedin 3 I other categoriesand decreasedin eight.

Conclusion:Assumingthat the ACEP-CPPis the gold standardof clinical management,use of the CPPimproved EM residenrs'nurugement of chestpain. Further study needsro be done to determine whetherclinical outcomewas differentand whether the improvements were maintainedover time.

MedicineResidency Faculty Scheduling: Current QQ Emergency thl PncticeandRecent Changes MIStaele,WA Watson/University of Missouri-Kansas CitySchool of Medicine, Truman MedicalCenter, Kansas City Study objective:To assesscurrent emergencymedicinefaculty schedulingpractices.

Design:A mailed questionnaireto the programdirectorsand fulltime facultyof the 93 activeemergencymedicineresidencies.

Resuls:A total of 79 of 93 (850,6)programsand 606 of 949 (6a%) full-time faculty responded.Full-time hculry were 38 t 7 yearsold, had beenin practice8 t 6 years,and.79%were trained in emergency medicine.Facultywork schedulewas randomly generatedin 7306of programsand basedon a set rotarion in the remainder.Twenty-five percen!statedthey used circadianprincipleswhen scheduling.Faculty most commonly (41%) work a combinationof eight- and 12-hour shifts (eighthours during the week, l2 hours on the weekends).Eight-hour shiftswere most common (34%) for thoseworking a single-lengthshifr.

Only 14%worked l2-hour shifts exclusively.Seventy-sixpercentof full-time facultysuted they would prefer to work eiglrr-hourshifs as opposedto other shift lengths.Half of rhe full-time facultywork three or fewernight shifts per month; 60% prefer to work only one to rwo

nights in a row. Over the last five years,30 (40%) of the Programs shortenedshift lengthsand the number of nigfrt shifts worked per month and/or the number of nights in a row worked per faculty decreased to 34"A.lncreasedfacultysizeresultedin fewerniglrt shifs per facultymember.On the other hand, only 6o,6and 5% of programs, respectiveiy,increasedeither shift length or the number of nighs worked per month. Most of the former moved to a longerweekend shift, whereasthe majoriry of the latter were due to the lossof faculty who exclusivelyworked nights.

Conclusion:Our surveyindicatesthat academicfacultyare movlng towardworking shortershifts, fewernigfrt shifts per month, and fewer "isolatnights in a row. This suggeststhat most facultyhavechosenthe ed night shiff stratery to dealwith shiftwork. The majority of the programsdo not usecircadianprincipleswhen scheduling.This suggests that social,family, and administrativeresponsibilitiestake precedence over individual well-being,which would be enhancedby cirladianbasedscheduling. lwasive ProcedurssUtilizingHumon O/l lnstructionof Emergency lf'l Cadavers of FloridaHealth JRMcPherson.

ERlmami,KAKomer,M Martin/University Center, Jacksonville Science Study hypothesis:Residens'speedand skill at performingemergency invasiveproceduresshould improve with formal instructionusing human cadavers.

Methods:Emergencymedicineand generalsurgeryresidents receivedwritten instructiondescribingtechniquesfor performing two emergencyinvasiveprocedures:orotrachealintubation (OTl) and venouscutdowns(VC). Examineesperformedtheseprocedurestwice on the samecadaversupervisedby the sameinstructors.The attempts were timed until the examineeclaimedsuccessfulcompletionor until a predeterminedduration had elapsed.Skill wasevaluatedby objective gradingcriteria.The instruc[or then demonstratedproper technique.

Examineesperformedthe sameprocedures(after instruction) and were subjectiveimprovement similarly evaluated.A questionnaireassessing was completedby all examinees.A paired t-testwasused for data analysis.

Results:Twenty-oneexamineesperformedOTI and l'l performed VC prospectively.The medianpreinstructionand postinstructiontimes were25 t 8.9 (SD)secondsand 17 t 5.8 secondsfor OTI (P < .0003).

Two of 2l examinees(9%) failed the first OTI attempt,but both succeededafter instruction.Four examinees(I9oi) leveredon the incisors on the first attemptand one leveredafter instruction.The medianpreinstruction and postinstructiontimeswere 188 t 80 secondsand 72 ! 49 secondsfor VC (P < .015). Five of l'l examinees(3506)failed the first attemprand two (14%) failed the secondattempt.Eight examinees(56%) causedminor vesselwall damageor did not securethe catheterat the first attempt,and three (21o6)had similar complications after instruction.Fifty-sevenpercentand 75obofexamineesreported subjectiveimpr6vementin OTI and VC skills, resPectively.

Conclusion:Formal teachingofemergencyinvasiveprocedureson human cadaversobjectivelyand subjectivelyimProvesresidentspeed and skill.

Trainingto tho Qf, TheAdditionol Formall{eonatalResuscitation MedicineResidency OU Cuniculumol an Emergency of Emergency Medicine, ENewton,W Mallon,YHa,rrlett/Department MedicalCenter of Southern California LosAngelesCountyUniversity Background:Optimal neonatalrcsuscitationdiffers greatlyfrom Most residenciesoffer little both adult and oediatricresuscitations.

exposureto newbom emergencies in which drug therapies,airway, and vascularproceduresare unique.

Purpose:To demonstrateftat this materialcan be condensedinto a two-weekcurriculum and be successfullyuugirt to emergency medicineresidents.

Methods:All PGYlll EM residentswerescheduledfor a two-week proglam in neonatalresuscitation.During that time, iesidentsreceived traininSthrough didactic and video presentations,casediscussions, and simulatedcodesand functionedas integralmernbersof a neonatal resuscitationteam.All receiveddeliveryroom experiencewith neonatal resuscitations.TheTa<tboh of NconatalRcsnscitntion, published by the AmericanAcademyof Pediatrics,formed the core readingand was given to all residents.Evaluationconsistedof written pretestsand postteststo assess changesin fund of knowledge.Residentsalsoevaluated the rotationusing a visualanalogscale(rating I to I 0, I 0 beingbest).

Results:Sixteenof l7 residentscompleredthe courseand tests.All demonstratedimproved skills and higfrcr post-testscores.Pretestscores rangedfrom 37oAto 63%, with a mcan of 50%. Post-testscoresranged from 83% to I00%, with a meanof 93%. Residentsrated the program asamongtheir mostvaluablerotationsand providedexrensivepositive feedback.The meanvisualanalograting given rhe rotationwas 8.4 (I,l respondents).

Conclusion: Emergencyphysiciansare increasingly facedwith newbom emergencies.

Becauseof lack of exposure,neonatalresuscitation skills tend to be limited. The materialcan be condensedinto a twoweek cuniculum that residentscan absorb.

Qf, Useof a ComputerizedPatient Logbookin Structuringthe lf lf Cuniculumof an Emorgency MedicineCleltship HDKarrlColunbia Hospital, MedicalCollege of Wisconsin, Milwaukee Studyhypothesis:In devisingan organizarionalmodel for a clinical clerkship,a computerizedernergencydepanmentlogbookcan estimate categoricalpatientvolumes.

Design:EachED patient'sprimary diagrosisis codedand recorded in the computerizedlogbook.Foulteenemergencycarecategorieswere createdfrom I l3 ICD-9codesand quantiuted monthly overa 45-month study period. The prevalenceof coding enors wasestimatedusing dispositiondatain unambiguouscategories.Eachsrudentis exposed to 36% of the ED parienrload during rheir one-monrhclerkship.

Setting:Urban community hospital ED. Results:The clinical caregoriestotaled I 3.5% (10,330 of 76,506)of ED volumefor the period, and7O.3%were admittedor died.Admission from thesecategorieswas 3.5 times more likely than from rhe general ED population.ProjectedstudentrEnagementopporrunitiesranged from 12 per month for major rcspiraroryproblemsto six for shockand one for coma.Low patientvolumeswere noted for poisoningand coma groups.The prevalenceof coding errorswas 7.5% (68 of 903).

Conclusion:ED computerizedlogbooksoffer a practicalmeansfor estimatingthe volumesof diagrosticcategoriesimportant in organizing and auditinga clerkship.

Characteristics ol Ernergency Medicine Q7 Wollness-Related ff f Residencies: A BesidonfsPerspective AHNashed, LNelson, M Lozano, PJWhiteman, SRHayden, GpKaplan, M Larson/Monistown Memorial Hosphal Besidency in Emergency Medicine, Nsr/v YorkBethlsraelMedical Center, Bronx Munbipal Hospital, Bellevue Hospital, NewYorkUniversity, SUNY, StonyBrook, Brooklyn Hospital Studyobjective:To examinethecharaccristicsof emergency medicineresidencies with regardro issuesaffectingEM rcsidentwellnessto determinespecilicareaswherefurtherinvestigation is needed.

Design:A 28-question survey was sent to the EMRA rcPresentatives of 102 US EM residenciesto acquireinformationabout their progams and their primary EM training sites. Questionswere asked about factors believedby the investig4torsto aflect the wellnessof EM residents.

Results:Therewere 59 responses(58o6)to the survey.The average number of patientsseenper attendingphysicianhour was 4.8 (range, 2.2 to I J.4). Fifty-sixpercentof respondentshavedaily academic moming rounds.Fifty-six percentperceivedadequatesecurityin their ED. Eighty-threepercentreportedthat moonlightingwas allowed.

Forty-threepercentreporteda set policy for matemiryleaveand 63% for sick days.Stressrelief prograrnswere offeredin 25% of residencies.

Sevenpercentreportedhavinga guaranteedmealbreak,althougb86% felt they were necessary.Therc was no significant differencebetween urban and suburbanprogramsin residenthours or adequatesecuriry.

Conclusion:Therc is a necd for further investigationof issuessuch as EM residenteducation,stressrelief,matemity and sick leavepolicies, ED security,and mealbreaks.Attention to thesear?asm y improve EM residentwellnessand educatron.

Medical Intervontion lmproves Fourth-Ycar OO An Educational andReducsr Emergency illodicine TestUtilizalion OO SuOents' Costs SM ChemowlUniversity of Colorado Health&iencesCenter,Colorado Emergerry Medicine Besearch Center, Denver Studybackground:The failure to improve physicianuse of diagros' tic testshasled to the recommendationof earliereducatioml intervention with medicalstudents.

Objective:To describethe diagrrostictestutilization pattemsof fourth-yearmedicalstudents(MSI$ and to assessthe effectsof an educational intervention.

Design.:Prospective,descriptive.

Seuingand participants:MSIV enrolledin a laboratorymedicine winter electiveduring l99I and 1992.

Methods:A test of five simulatedpatientcasescenailos(AS,asthma; AP, appendicitis;BR,bronchitis;ST, sorethroat; GS,gastroenteritis) and diagnosticorder formswere administeredto all l99l and 1992 students(91). ln 1992, 3l studentsattendeda 90-minuteeducational module on testuseand costcontainmentprinciplesand completeda post-testsevendaysafter the intervention.Recommendeddiagnostic testswerc derived from ACEP Gidelinesfor CostContainmcntin EmcrgarcyMcdicincand a comprehensivereview of the medical literature.

Results:Testperformancewassimilar in t99l and 1992,and both classesoveruseddiagnostictests.The 1992 post-testresultsdemonstrated sigrificant improvement in test ordering for three of the five cases:AS (P = ,002 by the exactbinomial test for paired data),GS(P - .008), and ST (P = .02). Studentsshowedclinically appropriatechanges.For example,studentsorderedfar fewerCBCsbut continuedto order CBCs for AP. Post-testcostswere significantly reduced for three of the five cases:AP (P = .0a8 by repeated-measures ANOVA), AS (P < .00I), and ST (P = .02). The averageexpenditures for all five caseswere sigrificantly decreased afar the intervention($310 t 37 versus$I70 + 28, P < .00I).

Conclusion:A profile of testuseby MSIV showedthat beforeintervention, MSIV spent significantly more and overuseddiagrostic tests.

Educational intervention improves test ordering pattems and reduces costs.

Influencing Applicants' Ronk0rdorlistfor rhattlRMP 89

[i:[f

CTDavid,SEDieboldlUniversity of lllinoisAffiliatedHospitals, Emergerry Medicine Besidency, Chicago Study objective:To determinewhat factorsinfluencedapplicants' rank order list for the NRMP match in emerggncymedicine (EM).

Design:Mail survey.

Participants:All residentswho matchedinto EM in 1992.

Results:Surveyswere refimed from 450 residentsfor a 62oh responsâ&#x201A;Źrate.Respondents rated the importanceof 26 factorson linear (0 to 10) scalesand then chose the five factors that were the most influentialwhen preparingtheir rank order list. Preliminarydau indicatethat location,residentsatisfaction,programreputation,length of program,and traumaexperiencearc the most influential factors.

Correlationsand analysisof variancewill be performedto determine differencesbasedon age,gender,race,and marital status.Additional surveyquestionsinvestigatedsourcesof information re8ardinga program'sreputation,plans to moonliglrt, reasonsfor preferringa three-or four-yearprogram,considerationsin choosinglocation,and whetherfemaleapplicantsdesiredto nreetwith femaleinterviewers.

Conclusion:Dau from this suwey addressthe concemsof EM programdirectorswho wish to know more about the programselection and decision-makingprocessinvolved when applicantspreparetheir rank order list for the NRMP match. attl rflf Designand Utilizationol an EmsrgencyOepartment DataBa$o T ScalanalDepartment of Ernergency Services, SanFrancisco GeneralHospital, University of California Study objective:A microcomputerdatabasethat could be used for researchand qualiry improvementprojectswas designed.

Desigr: Informationcontainedin a hospiul mainframecomputeris retrievedon a monthly basis.The dataare trarsferredinto a FileMaker Pro* databasefile desigmd by the author. Pertinentemergency departmentchart and billing informarionis appendedby a dau entry specialist.In toul, 60 tieldsof demographicand clinical informationare stored.The databaseis nctworked to all ED faculty computersand can be usedsimultaneouslyby multiple users.The databaseis menu-driven, allowing individualswith minimal compurerexperienceto rapidly becomeproficientusers.

Setting:The departmentof emergencyservicesat SanFrancisco GeneralHospitalhasan annualED volunp of 72,000 parienrs.

Participants:All patientsregisreredinro the ED sinceJanuary1992.

Results:The microcomputerdatabaseovercorns the many limitations of the mainframecomputerand eliminatesthe need for an expert programmer.Dataqueriescan be performedimmediatelyat multiple computerterminals.Monthly ED reportsare automaticallygenerated.

Casessatisling speciliedquality improvemenrindicarorsareidentified, and clinical information is reviewed.Most important, the ability to identify specificstudy populationsbasedon diagrostic fields or parient demographicshas facilitatedmany departmentalresearchprojects.

Conclusion:A user-friendly,microcomputerED databasewas designedand is used by faculry members for researchand qualiry improvementprojects.A posterpresentationand hands-ondemonstration of the databasear rheSAEMannualmeetingare planned. g l l

PrchoepitalMedical Contmlol Pediatric Q { Computer-Assisted if I Potisnts HospitalMedicalCerter, flA Shapiro, MEtacher,BM Ruddy7f,hildren's Cincinnati Background:The prehospiul careprovider in many communitiesis Unlike adult inadequatelypreparedto handlepediatricemergencies. intewention, procedurescan be technicallydifficult, and drug doses and equipmentsizescan vary. lmportant differencesexist in illness and treatmentbetweenadults presentation,physiologicalresponses, and children. a computerprogramusedto Desigr: This exhibit demonstrates assistin the prehospitalmanagementof ill or injured children. The prois protocolsfor most emergencies, gram includesagelweight-specific fastenoughto be usedin STATsituations,and can be masteredby the userafter little instruction.The programhasbeenusedby our medical basestationfor more than a yearwith enthusiasmfrom the suff. Futurc applicarionsmight include useby the EMSprovider using a laptop computer.Specificfeaturesof the programinclude l) a user-friendly graphic interface (MicrosoftWindans)that is informative and easyto use with a mouseor touch screen,2) automaticcalculationof drug doses and accessto pop-up windows listing complicationsand contraindications, 3) quick responseto other protocols/proceduresifcomplications develop,4) illustrationsto assistwith intraosseousline placement,nee5) protocolsthat can be dle cricothyrotomy,and needlethoracentesis, edited to conform with local practices,and 6) accessto educational pop-up windows containingsummaryfacs to enhancethe user'sskills. rttt MedicineLiteraturo UZ Positive0utcomaBias in the Emergency Sunyat County MedicalCenter fl Moscati, DJehle,0 Ellis,A Fiorello/Erio Buffalo Backgound: Previousstudieshaveexaminedthe medicaland nonmedicalliteraturefor positiveoutcorre biasin the publication of studies.This study examinesthe emergencymedicine(EM) iiterature for similar biasascomparedwith the generalmedicallterature.

Hypothesis:The EM literaturedoesnot differ from the generalmedical literaturein the percentageof positiveoutcomepaperspublished.

Desigr: Retrospective reviewo[ lirerature.

Medicine Sample:Original contributionsfrom AnnalsoJEmergency andAmericanJatrnal ol Emcrgnq Medicinefor the periodJuly 1990 to June 1992 as well as NeutFnglandJaumaloJMedicincandlovrnal oJthe AmencanMedical Association for the period January I 99 I to December I99l were includedin the sampleand reviewedby two personsindependently.Disagreements in categorizationwere arbitratedby a third independentreviewer.Articlesof a merelydescriptivenature or that had disagreement amongthree reviewerswereexcluded(312). tswas betweengroups,and set at .20 to detecta differencegreaterthan 100,6 a wassetat .05.

Results:A toul of I 77 EM articlesand 2l I generalmedicalarticles were categorizedashavinga positiveoutcome,negativeoutcorne,or demonstratingno di fference.

Lilgralun

Poritiyroucomo

Emergency rnedicine General medicine P<.w,72.

142 169

llegativsoulcomo

l{odiflor.nco

21 33

8 I

Conclusion: The EM literature contains the samebias in publishing positive-outcomepapes as the generalmedicalliterature.

VUitha PresontingGomplaint-0riented QQ ThreeYears'Experience rlrJ Problem-Solving Curriculumlor Fourth-Yoar iledical Studcntsin Emergency Medicine GCHamilton, TGGuttnpn,RLDupper/Oepartment of Energency Medicine, WrightStateUniversity School of Medicine, 0ayton,0hio Background:ln responseto the movementtowardambulatorycare sitesas teachingenvironmentsand the emphasison clinical problem solvingin medicalschools,we designedand implementedin July I 990 a presentingcomplaint-orientedproblem-solvingcurriculum in a one-monthmandatoryemergencymedicinerotation for our fourth-year medicalstudents.

Desigrn: The curriculum focusedon presentingcomplaintsand the stabilization,assessment, and treatmentof undifferentiateddiseaseprocesses.

After a medicalschoolcurriculum review,this inforrnationwas consideredto be valuablefor medicalstudents,wasunder emphasized in the medicalschoolcurriculum, and wasuniquely suitablefor emergencymedicinefacu'kyand residentsto reach.The curriculum includes a singlereferencetext with specificobjectivesfor reading,srudentworkbook, instructorguide, and a 2,200-quesriondatabasederivedfrom rhe objectives.lt offersevaluativecriteria for readingassignments, casediscussions,clinical evaluativeskills, and clinical proceduralskills. The coursework includessupervisedemergencydepartmentexperience, literaturereview,and small group tutorials.Evaluationsarebasedin all threeareas,plusa written final examinationderivedfrom the objectives.

Results:Almost 300 studentshaveuken the course.Their evaluations havebeenmost favorable,as demonstratedby the average responsâ&#x201A;Źof the selectedinformation below.A I to 5 Likert scalewas used;5 representsthe highestscore.I) The objecrivesincreasethe amount of information gained(4.6). 2) Caseload wasappropriatefor levelof training (4.5). 3) Facultyand residentswere preparedfor case (4.8).4) The rextwasappropriarefor MS-IV(4.8). discussions Conclusion:The curriculum hasbeenappreciatedby the instructors as it has decreasedtheir preparationtime/presentationtime ratio to < l. It hasalsoremovedmost of the variationsin our multiple site teachingenvironment.This curriculum may haveapplicationin other emergencymedicineundergraduaterrainingsitesand may assistothers in planningmedicalstudenttraining in ambulatorycaresettings. ol EmergenclMedicineResidentsin Ql1 TheEllectiveness J'l 0btainingFollow-upInfornution:A Compadson of Theso Methodsof 0utpatientFollow-up P Mair,YHaywood, S Sanford, RShesser/George Washington-Georgeto\ /n Emergency Medicine Residency Program, Dspartment of Emergency Medicine, TheGsorge Washington University Medical Center, Washington, DC Study objective:All emergencymedicine(EM) residencyprograms are requiredto nuintain a parientoutcomefollow-up system.This studyexaminesthe role of rheEM residenrin obtainingpatienrfollow-up suweysby comparingthree methodsof ED outpatientfollow-up.

Desigr: Prospective,random assignmentof all eligibleparientsrreared by non-EM residentsto rreatmenigroupsA or B. Group C comprisedeligiblepatientstreatedby an EM residenr.

Participants:Adult parientsdischargedwith diagnosesof post-traurnaticcewicalsprain,normothermicheadache,bronchospasm,nonspecific abdominalpain, and nonspecificchestpain. lnterventions:Group A was given a sumped, addressedoutcome questionnaireat the time of ED dischargeto completeand retum in sevendays.GroupsB and C receiveda structuredphone interview (coveringthe sameinformation asgroup A) sevendaysafter discharge.

Group B wascalledby a quality assurance(eA) suff personand group C by the treatingEM resident.EM residentswere askedto make their

25 monthly, required,follow-up callsbut werenot informed about the study'sresearchhypothesisor desigr..

Results:Group A wascomposedof 70 patients,group B of 8l patients,and group C of 225 patients.Twenty-threegroup A patients (3306),68 group B patients(8406),and 20 goup C patients(90,6) completedthe study. Despitethe sigeificantdifferences(P < .001) in responserates,therewereno differencesamong the $oups in patient age,sex,race,or diagnosis.The degee of improvementamongthe groupswassigrrificantlydifferent(P < .05) with live of 23 (22o/')of groupA, 27 of 68 (a0%)of groupB, and I 2 of 20 (60%) of groupC noting completeimprovement.The cost of collectingthe follow-up informationwas low, with minimal differencesamongthe threegroups.

Conclusion:Outpatientfollow-up suweysare performedmost effectively by designatedQA personnel;solerelianceon EM residentsmay be inadequate.Evidenceexistsfor patientsoverctatingtheir degee of improvementwhen contactedby their treatingphysician.Further study must be directedtoward ways to increaseEM residentcompliancewith follow'up requirements.

ofEmergency Medicine Besident 0rienration 95 ;HLc;rJsrics JC ErillnanlDepartment of Emergemy Medicine,University of NewMexico School of Medicine, Albuquerque Study objective:To determinethe prevalence,duration,compos! tion, and goalsof emergencymedicineresidentorientationprograms.

Design:Eleven-itemdescriptivemail surveysentby the Education Committeeof SAEMto the programdirectorsof all emergency medicineresidencyprogranr approvedby the ResidencyReview CommitteeasofJanuaryI992.

Results:Sixty'nine of 86 surveyinstruments(8006)were retumed.

Orientationprogramswere offeredin 64 residencies, 4l PGYI to 3 programs,five PGYI to 1, and 18 PGY2 to 4 programs.For PGYI to 3 and PGY2 to 4 programs,respectively,meanswith standarddeviations for hours devotedto orientationprogramswere 108 (SD, 92) and 79 (SD,6a); weekswere3.0 (SD,2.3) and2.4 (SD,1.5);percentof didacticinstructionwas45 (SD,5I ) and 23 (SD,26.7);percentof ED clinical time was 19 (SD, 25) and 16 (SD, 26); and percentof rime devotedto specialcourseswere 17 (SD,17) and 16 (SD,l7). Ten differentspecialcourseswere offeredby from one to 54 programs.

The goalsof the programsvariedbetweeninsriutions with 20 or more programspursingeachof six specificgoals.

Conclusion:Residentorientationprogramsare common in emergencymedicine.Orientationprogramsin PGYI to 3 residenciesare longerand devotea greaterpercentageof time to didacticsrhan do PGY2 to ,1residencies.The length of time, composilion,specialcourses offered,and goalsof programsvary greatlybetweeninstirutions.

(1f, Ruleof Two:An InnovativeApproachto Teachingto Emergoncy rf lf MedicineResidents at DilferentKnowledgeLevels G flamalanjaona, N Mazur/Department of Emergency Medicine,TheBrooklyr Hospital Center, NewYork Study objectives:To describean innovativeeducationalapproach designedto improve researchskills amongresidentso[ differentlevels of knowledgeand to hciliure developmentof independentresearch projectsby residents.

Design:Prospectivestudy in a teachinghospitalwith 24 residents.

From a preliminarytesting,we identified two groups of residents, group I and 2, accordingto their level ofresearchknowledge.

Intewentionsand methods:Eachgoup is uugfrt rwo successive hours of the new programeveryfour week by two trainedfaculty

members.For group I , the first hour consistsof conceptualizationof basicaspectsof researchfollowedby anotherhour of integrationof conceptin depth by discussingren preparcdrelevantquestionsfrom the previoushour. For group 2, one hour of didactic teachingof more advancedtopics followedby pracricalexamplesof sâ&#x201A;Źlecredarriclesfrom reputablepeer-reviewedjoumals. The secondhour in both groups allowsan immediateinteractionand feedbackfrom the residents.The researchtopicsfrom group I dealwith researchdesignand basicsof statistics,and themesfor group 2 arechosenfrom titles proposedby researchcommitteeof the SAEMsuch as to provide a continuity of teachingbetweenthe rwo groups.Residentsof the goup I will enter group 2 level oniy afrersuccessfullypassingthe researchquali$ing 'examination.

Resuls:We havedevelopedthe "rule of two" systemof education, which incorporatestwo important factors:level of knowledgeof each residentand teamapproachand continuity of teaching.Eigfrtypercenr of residentssuweyedrated rhenew program ].5 on a 4-poinr scale (i beingexcellent).Compararivetestscoresbetweenrhe previousyear and rheyear of implementationshoweda significantimprovementin meanscoresduring the latter. Early submissionofindependentresearch projectby seniorresidentshas increased,and we are able to double the number of themesto be taugfrtduring this cuniculum year.

Conclusion:Our new educationalapproachhasnot beenreported elsewhere,carriesseveraladvantages(originaliry,simplicity, minimal costof implementation),and could serveasa model of researchteaching to residents.

Modicinoin Developing an QJ lhe Roleof Emergency rf f lfierdisciplinarylniuryControlCenter JH CobenlDivision of Emergency Medicine,Centerfor InjuryReduction and Control.

University of Pittsburgh Background:Effecciveinjury control programsrequirean interdisciplinary approachinvolving variousmembersof the medicaland public healthprofessions.Emergencymedicineand emergencyphysicianscan play a key leadershiprole in establishingtheseprograms,At rhe Universiryof Pittsburglr,an ernergencymedicinefacultymemberwith an interestin injury control devoted20 to 30 hours per week o[ nonclinical time to rhe developmentof an interdisciplinarycenterfor injury reductionand control (CIRCL).

Design:An injury control knowledgebasewas developedfrom reviewof the literatureand attendanceat national conferencesand seminars.A preliminary proposalourlining rhe local need, feasibility,and opportunitiesaffordedby CIRCLwas then developedand rargeredto a senior-levelacademic"constituency"within the university.Tlii, group agreedon the needand desirefor a coordinatedrnjury programand agreedto serveas an advisorycommitteeto help translatethe concept into reality.With recommendationsfrom the advisorycommrttee,a programproposalwas developedand forwardedto senioruniversity administrarion.

Resule:Wirhin 20 months, CIRCI-wasconceptualized,developed, and established.The center,housedin the division ofemergency medicine,involvesrepresentatives of five schoolsand l2 departments of the university.Combined financialresourcesfrom withinrhe university contributedro a first-yearbudger of $l l0,OO0.Thesefunds were usedto recruit core faculryand suppon suff. Activitieshavebeen aimedtoward the problemsof elderly falls,alcohol-relatedinjuries, child unintentionalinjuries, adolescentviolence,and improvld data and surveillancesystenrs.A closeworking relationshiphas beenestablishedwith other local health agencies,and advocacyeffortshavebegun in the legislativeand executive branchesof stategovemment. In rhe

first 6 months of operation,CIRCL facultyhaveobtainedmore than $260,000in extramuralresearchfunding including more than $55,000 retumed to the universityin indirect costs.

Conclusion:This programillustratesthe critical role academicemergencymedicinecan havein injury control effortsand that establishing such a programcan be cost effective.

DriverHospital andPoliceDetection ol Alcohol QQ Thelmpaired Jfl and0therDrugsofAburoin MotorVehicle Crrshos E 0rsay,LDoan-Wiggins, B Lewis/ftogram in Emergency Medicine, University of lllinoisat Chicago; Department of Emergency Medicine, University Loyola Study objectives:To determinethe incidenceof drugs of abuseas well asalcoholuse in driversinvolved in motor vehiclecrashes(MVC) and to determinethe rate of police detectionof impairmentin these motorists.

Desigr: Retrospective charl review of hospltalizeddriven involved in MVC and review of correspondingpolice reporls.

Setting:Two LevelI traumacentersin a largemetropoliun region.

Participants:All MVC driverVmotorcycle operatorsadmitted to the traumasewiceJanuary l, I990, to December31, 1990.

Results:The recordsof 666 injured motoristswere reviewed,of which 200 (3006)were legallydrunk (serumalcohol> 100 mg/dl) and 132 (l9.8of) had positiveurine drug screens.

Cocainewasthe most prevalentdrug of abuseand was presentin 5I (7.7ob).Two hundred ninety-sevenpatients(44.6%)were considered"impaired"(alcohol> 50 mg/dl t or positivedrug screen),representingalmosthalf of all motoristsadmitted.The meaninjury severiryscorefor the entire populationwas9.75 t I5.3. Policereportswereavailablefor ,f70 patients, I39 (29.6"A)of whom were legallydrunk. Driving under the influence (DUI) wassuspectedin 29 patients(6.2ob),baxd on policeassessment of mentalstatus.Alcohol or drug testingwas offeredby policein only 8.I06and 2.8%,respectively.

Thirty-fourpatienrs(7.2%)werecired for DUI. Conclusion:An exceedinglyhigh rate of impairmentexistsin this populationof seriouslyinjuredmotoristsin a metropoliunregion, most of which is not detectedby poiice.Although alcohol is rhe mosr prevalentsourceof driver impairmenr,other drugs of abusearealso importantcontributorsto this problem.

Analysisof tre Judicial 0utcomeof the Q(l Retrospective Jrf lntoxicatedDriYer JK Evett, CJFinley, A Nunez, JS Huff,LDBritt/Eastern Virginia Graduate School of Medicine.

Norfolk Studyhypothesis:The majority of motor vehicleaccidenrs(MVA) with severeinjury arealcohol relared.Our study examinesjudicial outcomesof intoxicateddriverswho enter a regionaltraumasystemasa resultof MVA. Design:A retrospectivereviewof the traunu registryfrom Senura Norfolk GeneralHospital(SNGH)wasconducredfromJanuaryl, I 989, through December3 I , I 990. A lisr of eirherthe socialsecuriry numbersor dateof birth of rhe oatientsas well as the date of the MVA for which the hospiulization occurredwas submittedto the Departmentof Motor Vehicles(DMV). The number of personsfrom the submittedlist who were laterchargedwith driving while intoxicated was requested.Our inquiry to the officialsat the DMV conveyedour interestin numbersalonebecauseof concemsof confidentiality.The investigatorswere thus blinded ro the identity of thoseindividualswho were convicted.

Setting:SNGH is a level I rraumacenterand the primary reaching institution for EastemVirginia GraduateSchoolof Medicine.

Participants:During the study period, 3,36,1patientswereadmitted to the trauma service.The trauma registry was reviewedand inclusion criteriafor entry into our study were definedas identificationof the patientasthe driver involved in a MVA; blood alcoholcontent> 0.lO {dL; and survivaluntil dischargefrom the hospiul.

Resuls:Of the 2,15patientswho met the inclusioncriteria, 12 (1.9%)were convictedof moving violations.

Conclusion:Admissionto a traumasewiceprovidesa refugefrom legalconsequences for the vastmajority of intoxicateddriversinvolved in MVA. for BicycleSafetyHolrmtUse:0o { nn Recommendations I lflf EmergencyPhysiciam Practice Iniury Provention?

ATGuertler, EBLrcc| JB Fusinko/Department of Emergency Medicine, Madigan ArnryMedical Center, Tacoma, Washington Background:Emergencyphysiciansevaluateand treatbicycle accidentvictims and can practiceinjury preventionby recommending bicyclesafetyhelmetuse.

Studyobjectives:The objectiveswere ro determinewherher emergencyphysiciansdocumenthelmetuse and recommendhelmet useupon dischargeand to estimatethe number o[ preventablehead injuries.

Desigr: Retrospective chart reviewand telephonefollow-up of patientsevaluatedfor bicycleaccidenr-associated injuriesbetween May I and October31, 1991.

Setting:LevelIl army emergencydepartmentwith emergency medicineresidencyseeing60,000 patientsper year.

Measurements: Chartswere reviewedfor documenution of helmet use,recommendations for future helmetuse,and injury location.

PatientVguardianswere calledto determinehelmetus€at time of injury (if not documented).

Results:During the study period, 240 of 33,433 parienrvisirswere for bicycle-relatedinjuries. Patienragesrangedfrom 2 to 77 yars, (median,9 years).Telephonefollow-up wasachievedon 152 parients (64%). Helmet useat tinre of injury was documentedon 33 charts (I3.806).Helmetuse documentationwasbetreron Datientswith head rqury (18.5"6of patientswirh, versus5% withour headinjury). Wrirren recommendations for helmetus€were given to ten of 228 patients (4.406)treatedand releasedfrom the ED (12 were admiued),and on follow'up, threepatientyguardiansrecalledrecommendations and four did not (threelost to follow-up). The authorsesrimatedhelmeruse could haveminimized ten and prevenred49 headinjuries,wirh 39 of 240 visits(16.3%)being potentiallyavoidable.All patientsadmiued for headinjury had potentiallyprevenrableinjuries (seven)or injuries that could havebeenmoderated(two) by helmetuse.

Conclusion:Helmet use can Dreventor minimize headtrauma secondaryto bicycleaccidens. dme.gencyphysiciansrarelyask about helmetuseand rarely recommendhelmetuse.in dischargeinstructions.

Studylimitationsinclude rerrospectivenature,dependenceon chart documentation,lack of I00% follow-up, and recallbias.

Programfol I n { 0utcomeol a Oualig lmprovement I ff I Electrocardiognmsin a Pediatric Errrgency Dopaftnont CJGralBm,S Shirm,EFrazier, C Gibson,R Dick/Sections of Emergency Medicine andCardiology, Department of Pediatrics, University of Arkansas for Medical $iencesandArkansas Childron's Hospital, LittleRock Study objective:To determinethe outcomeof a quality improvement (QI) programfor ECGsin a pediarricemergencydepanment.

Desigr: Retrospective review of ECGs,QI records,and hospiul chars.

Setting:PediatricED of a largechildren'shospital.

Participants:Nine hundred fifty-six consecutiveECGSobtainedover a two'year period.

Results:All ECGsin this ED are reviewed by the QI team after cardiolory interpretation.After this review,42 patients(4.3% of all ECGs)were referredto cardiologyclinic for evaluation.Four charts wereunavailablefor review.In 35 cases,cardiologistand emergency physicianinterpretationswere discrepant,with a cardiologyreadingof ventricular hypertrophy and an ED reading of normal being the most common (22 cases).Of the 38 chartsreviewed,l't patientsdid not keeptheir appointment,five patientshad repeatECGsthat werenormal, and 19 patientsweres€enin the cardiolory clinic. Nine Patientsseenin the cardiologyclinic had normal examinations,whereasten patients (I0,6of all ECGs)had conditionsrequiringcontinued follow-up, medication,or surgery.TheseconditionsincludedWolff-Parkinson-White syndrome,cardiomyopathy,pulmonarystenosis,patentdlctus arteilosyncopettwo-degreeAV block, ventricularsepaldefect, sus,vasovagal and coarctationof the aoru. Threepatientswere placedon medication, and one patientunderwentsurgicalligation of patentductusarteriosus.

Conclusion:An ECG QI programin this ED resultedin a changein therapyin I 0,6of patientsand supportsthe use o[ such programsin pediarricEDs. An MoonlightingVorsusAttondingPediatdcCoverage: 4 nt I VZ Examination of AdmissionRateand Intervontions AnnArbor DJ Trelur,B Sowa/University of MichiganHospitals, Study objective:To determinewhether the admissionrateand number of interventions(labs,consultations,procedures,radiographs)in a pediatricemergencydepartment(PED)differsbetweenmoonlighting pediatricians(MPs)and attendingemergencypediatricians@Ps).

Desigl: Retrospective review.

Setting:Inner-cityPEDwith 23,000 visits annuallyand single-staff coverage.

Participants:All children (lessthan 18 yearsold) presentingto the PED during the eveningshift for a consecutivetwo-month period.

Results:Of |,470 children who presentedto the PED during the study period, 516 (35%) were evaluatedby MPsand 954 (650,6)by EPs. There were no statistically significant differencesbetween EP and MP patientgroupswith respectto age,diagnosticcategory,or acuity.There was a sigrilicantly higher hospitalizationrateamongpatientsevaluated

by MPsversusEPs(14.2%versus9.806,P = .04,12).Usingaverage pediatrichospitalizationcharge(basedon avemgelength of stayand per day hospiulizationcost) of $4,080,extrahospiul chargesfor MPs' excessadmissionswereestinuted to be $92,000 for the two-month period. Therewasa tendencyfor MPs to order more labs,radiographs, and consulta[ionsand to perform more procedures;however,this differencedid not achievestatisticalsignificance.

Conclusion:Admissionratesfor MPsare sigrificantly higlrer than for EPs.The higlrer admissionrate,additionalhospiul charges,and tendencytowardmore intewentionsfor MPs should be consideredby ED and hospiul administratorswhen decidingPEDstaffing. ol 0ral IntubationUsinga lighted StyletVenur { n2 Comparison I ffJ DirectLaryngoscopy in Children SD Berns.

RlPatel.JM Chamberlain/Departments of Pediatrics and National Medical Anesthesiology, George Washington University andChildren's Center.

Washington.

DC Study objective:To demonstratethat blind oral incubationover a liglrtedstylet (IJ) is a viablealtemativeto direct laryngoscopy(DL) in children and that the [5 techniquecauseslessneck movementthan DL

Desigr: Randomized,prospectivepatienrseries.

Participantsand serring:Forty-rwochildren berween7 and lg years of ageundergoingelectivesurgeryar an urban children'shospitalwere randomizedro method of incubation ([5 versusDL). All incubatorshad more experiencewith DL than with [S. lnterventions:Patienrswereplacedin a rigid cervical,spinecollar (RC)beforeintubation. An elecrromechanical devicewasattachedto the patientto recordneck movement.If the first attempt failed,the anteriorportion of the RC was removedand in-line tractionwas main_ tainedfor up to two addirionalattempts.

Results:Recordeddau includednumber o[ artemps, duration of eachattempt,and neck flexion and extension.Of 42 patients,36 were successfully intubated(15 of 20 [S versus2l of.22 DL, p = .06).Of Ihosesuccessfullyintubated,therewas a trend toward more arrempr beforesuccessin the L5 group (p = .07); total duration to intubarion waslongerfor L5 (l2I.l secondsverzus68.9 seconds,p < .05);however, duration of intubation for thosesuccessfulon the first arremDtwasnot sigrificant(46.8 seconds,[S, versus55.4 seconds,DL, p = .2'6),and the LSgoup had lessneck movement(10.5 versuslg.6 degees,p < .05).

Conclusion:The LS method moved the neck sigrificantly lessthan DL. ln the handsof an experiencedoperator,rhe G techniquemay be the intubation merhodof choicein the pediatrictraumapatientwith suspectedcervical-spineinjury.

rockadefor podiot.icEmerg ency 1 0 4 lff J,ljh::1ffi.r'*rnB

WDFales, KJHobinson, JJ Skiendzielewski/Department of Emergency pennsylvania Medicine, Geisinger MedicalCenter, Danville, Study objective:The use of neuromuscularblockade(NMB) ro faciliute emergencypediatricendotrachealintubation hasbeenrecom, mendeddespirelimired publishedclinical datasupporringirs use.

The purposeof this study was to investigatecompiicarionand success ratesof NMB-assisted intubationscomparedwith non-NMB-assisted intubations.

Rerrospective cohort srudy of chartsreviewedfromJanuary __-Desi4: 1988to DecemberI992.

Ruralair medicalservicebasedat a tefiiary caremedical ..nf.l,tnt, Participants:The srudy samplewas composedof g7 parients,lg yealsof ageor younger,who underwent emergencyendotrachealintubationby air medicalpersonnel.Infans under I *.ik old w"re excluded. lntewentions:Patienbwere divided inro NMB and non_NMB groupsbasedon the lirst intubation method. Complicationand success ratesweredetermined.

Results:Forty-ninepatiens were intubatedwith NMB and 3g patientswere inrubatedwithout NMB. The groupswerenor found to be differenrin rermsof age,nature of transfer,indication for intubarion, and operalorlevel of training (<r= .OS).Complicationand successrates were.determined,and analysiswas performedusing Fisher'sexacttest (Table). oulcome

NMBGmup

complication mte(o/ol Success rate{%)

Zl49l4.ll 4gl49(l00)

l{on-lrlilBGmup

(39,5) r5138 24ln16!.2l

<.ml <.ml

Conclusion:Our five-yearexperienceindicatesthat pediatric patientsemergentlyinn:batedwith NMB havelower complicationand higher successratesthan thoseincubatedwithout NMB. ihe rerrosDec_ tive naure of the study and small samplesize limir the strengthof our conclusions.

1 05

ten9th-Based Recuscitation Tape forPretorm andTerm

NSKhan.BCLuten,BLWears/Division of Emergency Medicine, University of Florida HealthScience Center-Jacksonville Studyobjective:To developand validatethe accuracyof a "Broselow, type length-basedtape for assessment ofweight and endotrachealtube (EfD sizein newbom infanrs.

Design:Prospecrive, crirerion standard.

Setting:Inner-city,indigent care,teachinghospiral.

Participants:Ninety-eightneonaresadmitted to the neonatailCU. Methods:A lengrh-based weight and ETf tapewas developedusing an initial group of 39 intubatednewbornsand previousstudiescorrelating length,weight, and gesrarionalage.Weiglrtsrangedfrom 500 g ro 4,000 g and ETT sizefrom 2.5 mm to 3.5 mm. The accuracyof rhe rape wasvalidatedusing 96 newboms (48 of whom were intubated)who fell within the weighr range.l[ rhe ETT used for intubation"didnot conelatewith the tapesize,air leak was determinedto assessthe appropriateness of the size.Interobsewervariability wasassessed.

Results:The averagedifferenceberweenthe tapeweigfrrand the actualweight was L3% of weigfrr(SD, I I.I 06)and wasevenly distributed rhroughoutall rhe weighrgroups.Tapeweighrswerewirhin 2006of actualweightsin 9506of cases.The rapepredictedactualETT sizein 96% cases(confidenceinrerval ICU: 86.3% ro 99.5%)and was correctwithin one rubesizein 1000,6 (Cl: 92.9% ro I 0O%).The only error in predicrionof ETT sizewas in underestimation.

Conclusion:A length-basednewbom upe is an accurateand uncomplicatedmerhodof assessing weighrand ETT s2e in prererm and term newbomsand should circumventmedicationand equipment errorcin prehospiul, enrergencyr and deliveryroom resuscitations.

sole Manifestarion otMoninsiris in 1 06 Fff:,ffiffiff;he SM Green, SGRothrock, KJClem,RFZurcher, L Mellick/Departments of Emergency Medicine, Riverside General Hospital, Biverside.

California; 0rlando Begional Medical Center, 0rlando.

Florida; LomaLindaUniversity Medical Center, LomaLinda, California; California Emergency Pfrysicians Medical Group, 0akland Study objective:lr is lrequentlyraugfrtrharlumbar puncrure(Lp) is a mandatoryprocedurein many or all children presentingwith fever and a seizurebecausethe convulsionmay representthe solemanifestation of bacterialmeningitis.We attemptedto determinethe incidence of this occult presentationof meningitis.

Design:Caseseries.

Settingand patients:Five hundred eighty-oneconsecutivecasesof meningitisin children aged0 to l5 yearsseenat two referralhospitals overa 20-yearperiod. lnterventions:Sigrs and sympromsof meningitisin parientspresentingwith associatedseizureswere reviewed.

Resuls: Meningitispresentedwirh associatedseizuresin I25 cases (22oA),and I t 5 (92%) of thesechildren were eirherobtundedor conHtoseat their first physicianvisit after the seizure.The remaining ten presentedwith relativelynormal levelsofconsciousness and either werebelievedto haveviral meningitis(two) or possessed straigfrtforward indicationsfor LP: feverin a neonate(rwo), nuchal rigidity (four), prolongedfocalseizure(one), or multiple seizuresand a petechialrash (one). No caseso[ occultbacrerialmeningitiswere found.

Conclusion:In our reviewof 581 consecutivechildren with menin, gitis, none were noted to havebacterialmeningitispresentingsolelyasa simple seizure.We suspectrhat this previouslydescribedenrity is ;irher extremelyrare or nonexistent.Commonly uught decisionrulesrequiring LP in children with feverand a seizureappearto be unnecessarily restrictive.

101fi;"n13:l',rr

inGeriatric Paticnrs soeninrheEmergcncy

LMLewis,DKMiller,JEMorley,MJ Nork/St. LouisUniversity Medical Center

Study objecrive:To determinewherherthe use of an adaptationof the confusionassessment method (CAM) (lnouye et al: Ann intern Med. 1990)would improve the recogririon of delirium in emergenrydepartment patientsover the conventionalH&p.

Setting:Urban reachinghospital ED. Participants:A conveniencesampleof 250 parients> 65 yearsof age presentingto the ED consciousand able to speak. lnterventions:All patientswere assessed Ly an artendingemergency . physicianin the customaryfashion.ln addition, a geriarncnursespecialist interviewedthe parientusing an adaptationof th" C,qV. thi emergencyphysicianwasuruware of the specificmethodusedor the resultsobuined. All diagnoseslisted by the emergencyphysicianfor patientswirh "definiteor probabledelirium" by the CAM were reviewed to determinewhether delirium, acuteconfusionalstate,or altered menul statuswasincluded among rhem.

Results:Twenty-fourof the patienrsscreened(I006) met criteria for delirium.The ED diagrosisincludeddeliriumor an acceDrable synonymin threeparienrs(13%).In rhe l7 patientsadmitredro rhe hospital(71ol), the most common diagnosesmadein the ED were (rule out sepsis)(five) and fracture(four). The diagnosisof $::,i"" TIA/CVAand delirium/confusionwereeachmadein rhreeDarienrs.

Threeof the sevenparienr dischargedhad fallenand had no evidence of significantinjury.

The diagnosisof delirium may be missedby a routine . _^ !1ncly1io1: H&P in elderlypatienrswho presenrro rhe Eb, parricularlyfor chief complaintsunrelatedto alteredmentalstatus.

1 08 ;:#,f

lmpaimenr inEtderty Emersency Department

SBCounsell, WDSmucker/Northsastern 0hio lW Guson,PBFontanarosa, Universities College of Medicine, Rootstown, Ohio;AkronCityHospital Studyobjecrives:To determinethe feasibilityof a screenngprogram _ for cognirive_ impairment in elderly emergencyd"pr.t-"rrt patienb and to describethe prevalenceof cognitiveimpairmeni in rhoseparients and identify factorsassociatedwith impairment. study.Eligiblepatients _ Design:A three-monrhcross-secrional during 60 randomlyselecredevening,weekend,anjnighi shifts and during weekdayshiftswere given the six-item orientation-memorv_ concentration test.

Setting:Community teachinghospitalwirh annualED censusof 68,000adulrs.

Participants:All patientsolder than 6,1yearswho werephysically ,. ableto communicateand without a prior iiagnosis of dementia were eligible.Five hundred forry-sevenof 95g prti.r,r, (5906)were interviewed;only 95 (1006)refused.othei reasonsfor noninclusion weretoo ill, i l3 (I206);administrarive (sleeping,privacy, reasons repeatvisits,incompleteforms), 99 (i006); known dlmentia, 59 (6%); and communicarionproblems,45 (5%).

Results:One third of parients(lg3 of 547) showedat leasra moder_ arecognirivedeficit (score> l0). The mediantime it took ro administer the testwas 93 seconds.A logisticregressionincluding factors found sigrificant in crude analysesidentifiJd lwo factorsasso"ciated with rmparrmenr:.age over80 years(OR, 3.69;95oAconfidenceinrerval [CIl: 2.21 ro 6.14)and admissionfrom a nursinghonre(OR, 13.8; 95% Cl: 3.79ro 50.2).

Conclusion:Screemngfor cogtitive impairmentin elderly ED patientsis feasible.Very old parienrsand thoseadmirred from a nursing

home have a high likelihood of cognirive impairment rhat may affect clinical evaluation and patients'understanding of and compliance with me dical information and discharge instructions.

theElderl$ 0xysen saturarion and Acure 1 09 il:,frt1|'fl|Jn BHonigrnn, BBoach, GAtkins, CHouston/Universitv ofColorado Health Sciences Center, Colorado Emergerry Medicine Besearch Center.

Denver; Colorado Altitude Research Center, Keystone; Lwelace Medical Foundation Background: Theincidence of acutemounrainsickness (AMS)in the general population armoderare elevations is 2506,but theriskof AMS in elderlypopularions is unknown.It is uncertain whetherarterialoxy-

gen saturarion(SaOro,6) correlateswith AMS in this agegroup.

Hypothesis:Elderlyvisitors,becauseof underlying cardiopulmonary problemsor norrrntive changesof aging,havea higfrerrisk of AMS. ln addition, AMS symptomsin elderlyvisitors to moderateelevationscorrelatewith SaO-o/over a five-davperiod.

Desigr: Profoecrivecohort.

Participantsand setting:Ninety,sevenretired membersand spouses of the 1OthMountain Division attendingtheir 50th reunion in Vail, Colorado(2,824 m).

Measurements: Daily questionruireswere administeredto determine the presenceand severiryofheadache,farigue,dizziness,insomnia,and gastrointestinal symproms.AMS was defined(take l-ouisescoringsys_ tem) asa summatedscoreof ) 3. SupineSaOr%was measuredaftera five-minuterest period. g}yo -Resuls:Of rhe 97 subjects(meanage+ SD, 69.9 t4 years; male),3l% had hypertension,2306had heart disease,and 606had lung " disease.Of the 77 (79%) who residedat sealevel,69 (gOoA)stopped over at I,600 m for rwo days(mean,45 hours). The AMS incidence ratesand meanSaOr%(t SD) are shown for thosewith and without AMS for rhe 77 x.a levelresidents.

DeyI AMSincidence {%)

7.8

Sa0r%withAMS92.3+4.0 gl.gr2.3 Sa0z%withoutAMS

DayZ 11.7

Day3 7. 8

DeyI Ll

Dey5 9.1

90.9r3.9 9t.7tZ.B SZ,9rt.8 gz.j*1.4 n.2fl.6 gl.gx2.2 9t.713.4 92.3130

SaOro6varied only sliglrtly acrossdays(p = . 03 by repearedmeasuresANOVA with group and day effects)but wasnot associated with AMS (P = .84). AMSwas increasedin thosewirh underlyinglung disease(P = .046).

Conclusion:Elderly visitorsto moderateelevationshavea lower incid.enceof AMS-than reporredin youngerpopularions.Sa0206did not differenriatethosewith AMS from thosewirhour AMS.

1 1 0 #fi[:|;:'r:]lead

Iniuries intreEtdedy: Gtinicat Fearuros

TJHaronian.

DBGens,PBFontanarosa/Department 0f EmorgerryMedicine, Northeastern 0hioUniversities College of Medicine, AkronCityHospital; Marylandlnstitutefor EmergerryMedicalServices System,University of Maryland School of Medicine, Baltimore Study objecrive:To evaluatethe impact of isolatedclosed-head m1ury(CHI) in elderly parienrsand to compareclinical characteristics and ourcomeo[ isolatedCHI in elderlyand nonelderlyparienrc.

Desigr: Retrospective reviewof traumaregistrydatacollectedfrom _ July 1987throughJune1990.

Setting:Urban universitylrvel I traumacenter.

Participants:Threethousandone hundred ninery-nineadultswith isolatedCHI associated with lossof consciousness, amnesia,or admis_

sion GlasgowComaScale(GCS). 15. Three thousandsix hundred fourty-four patientswith multisysteminjudes, penetratingtraunu, cardiacarrest,spinal cord injury, major fractures,chestor abdominal trauma,hypotension,or trivial head injury were excluded.

Measurements: Patientswere divided into elderly (age65 yearsor more) and nonelderly(agelessthan 65 years)groups.Datafrom the two groupswere comparedto determinethe nature and outcomefrom acuteCHI using ?(2and t-tests,with significancesetar P < .05. Odds ratios(OR) and 9506confidenceintervals(Cl) were calculatedfor significant variables.

Results:The study population included 206 (6.+a6)elderly patients (meanage,75.2 years;range,65 to 95 years)and 2,993 (93.60A) nonelderlypatients(meanage,30.1 years;range,I5 to 64 years).

Elderlypatientswere more likely to sustainCHI from falls (OR: 6.15; Cl: 4.54,8.32), whereasmotor vehicletraumawas more likely in nonelderlypatients(OR: 1.77;CI: 1.31,2.38).MeanadmissionGCS was 13.8t 2.4 (SD)in the elderlygroup and 13.3i 2.8 in nonelderly patients.Acutecranial CT abnormalirieswere detectedin 67 (32.5oA) elderlyand 505 (17%)nonelderlyparienrs(OR:2.41;Cl: 1.75,3.32).

Craniotomywas requiredin I8 (806)elderly and I54 (5oA)nonelderly patients(OR: 1.77;CI: 1.02,3.01).The moruliry rarewas 14.5oAfor eiderlyand 2.0o6fornonelderlypatiens(OR: 8.19;CI: 5.02, 13.32).

Two thousandtwenty-three(8,106)nonelderlyparienrsand only 105 (5I06)elderlypatientsweredischarged home(OR:5.16;Cl: 3.82,6.97).

Conclusion:Comparedwith head lrauru in youngerparients,isolatedCHI in the elderly is associatedwirh significantlygreatermorraliry and neurologicmorbidity and significantlyreducedlikelihood of func, tionaloutcome.

.l.,tl I I I lncidencePattornsol Cervical-Spino Iniuryin Relationto Age DBLevy, JFLucke, TCEvans, RHDaffner, DPHanlon/Medical College of Pennsylvania.

Allegheny Campus, Pittsburgh Study objectiveand purpose:To study the incidencepattemsof cervical-spineinjuries in the elderly (definedas age> 65 yearsold) and to identif differentincidencepattemscomparedwith a youngerpopulation (ages15 to 65 years).

Materialsand methods:A retrospectivereviewwasconductedo[ all patientsl5 yearsof agesand older susuining cervical-spineor cervical spinalcord injuries without radiographicabnormaliry(SCIWORA) enrolledin the traumaregistryof a Level I traumacenterfor the years 1987 througlr I99l . A log linear analysiswasperformedcomparing the incidencepauerrs of higfr cervical-spineinjuries (Cl to C2) ro low cervical-spineiniuries (C3 to C7) versusage65 yearsor youngerand agemore than 65 years.

Results:A total of 531 parienrswas idenrified.Four hundred rhirryone patientswere lessthan 65 yearsold. This group sustaineda total of 495 cewical-spineinjuries and l7 spinal cord injuries withour apparenr bony abnormalities.One hundred parienrsmore than 65 yearsof age sustainingI20 cervical-spineinjuries were identified.Eight of these patientshad spinal cord injuries wirhour bony abnormaliry. lruvCorvic.l-Spine Iniury P.sred Patienlr< 65Yoarsold HighceMcal-spine injury Absent Present Prtienlr > 65Year! old Highcervical-spine injury Absent Present

3.9% 3t.9%

60.9% 3.20h

7.1% 57.6%

fr.3% s.l%

Conclusion:The log linear analysisyielded the following conclusion: patients3 65 yearsof agehad a pattem of higlr cervical-spine injury-low cervical-spineinjury differentfrom patientsmore than 65 yearsof age(P < .0078) (Table).For patients65 yearsor less,low cew! cal-spineinjury was most prevalent,followedby htgh cewicalspine injury alone.Higfr cewical/lowcewicalin1urycombinationsand SCIWORA were infrequent.For patientsmore than 65 yearsof age,higfr cervical-spineinjury alonewas most prevalent,followedby Iow cervical-spineinjury alone.The prevalenceof highr/lowcervical-spineinjuries and spinalcord injuries without bony involvementwas alsogreater. ll I t Incidenceol DrugInteractionsin ElderlyPatientrin the a a ZEmergency Department of Georgia, Augusta DLHolp,E Hobbs Jr, RCoVMedical College Study objectives:To determinethe incidenceof potentialdrug interactionsoccurringin elderly emergencydepartmentpatientsand the incidenceof additionalpotentialintemctionsthat were causedby medicationsprescribedby emergencyphysicians.

Desigr: Ail medicationsthat patientswere taking beforeevaluation l-errenDnuc were recordedand analyzedusing the MEDICAL INrenecrroNs computerprogram.Additional medicationsprescribedby emergencyphysicianswere then analyzedfor interactionswith existing patientmedications.All drug interactionsobtainedfrom the computer analysiswererated as mild, moderate,or major, basedon the Drug InteractionFact Booh.

Setting:Universityhospital ED. Participants: Sequential seriesof I56 patientsover65 yearsof age, Results: Thestudy populationconsistedof 156 patientson a totalof 68I medications, with theaveragepatienttaking,t.4(SD,2.5) medications. Eigfrtypatientswere on two to four medications,and 6'l patients were on more than four medications.One hundred patientswere identified, with a total of 220 potential drug interactionson pre-existing medications.Of these,35% were ratedasminor, 5106were ratedas moderate,and 14% were ratedas major. T\e averageelderlypatient had 1.4 (SD, 1.7) drug interactions.Eigfrty-eightmedicationswere prescribed.For medicationsprescribedin the ED, therewere I9 patientsidentified,with a total of 30 drug interactions.

Of these,23% were mild, 5606were moderate,and2}oh were major drug interactions. per patientevaluated.

Therewere0.19 (SD,0.7I) drug interactions When medicationswere added,potential drug interactionswerenoted for 34obof the medicationsprescribedand in 29oAof the patientswho had medicationsadded.When medicationswere added,the incidence of potentialmajor drug interactionswas 6.806.

Conclusion:Elderly patientsare typically taking multiple medications, and drug interactionsquite often go unrecognized.Thereis sigrificant potentialfor further drug interactionswhen additiorul medicationsare prescribed.

Vadationol 0utcomePredictorcin I I a M etrodology-DepGndent I I rf PrehospitalCardiacArest Bronx, EJGallagher, P Gennis, G Lombardi/Albert Einstein College of Medicine.

NewYork Study object'ive:To identify variationin outcomepredictorsin prehospiul cardiacarrestassociatedwith differentmethodsof data collectionapplied to a singlecohort of patients.

Desigr: Comparisono[ conventionalmethodsof datacollection using ambulancereportsversusconcurrent,interactive,on-line data collection.

Setting:New York City 9l I system.

Participants:All adults wirh confirmedprehospitalcardiacarrests occurringberween Octoberl, 1990,and March31, 1991,onwhom resuscitationwas attemptedwereeligible for inclusion. lnterventions:Daraextractedfrom 200 randomlyselectedambulancereportsof cardlacanest were comparedwith informanonpreviouslygatheredon the same200 casesrhroughdirect interactionwirh field personnel.The caseswere drawn from a samplingframeof 2,333 consecutiveprehospitalcardiacarrestscausedby primary heart disease collectedduring the study period. The rwo setsof dau were compiled independenrlyby differentindividualsusing the samedau colleciion instrument,which incorporatedthe Utsteintemplate.

Results:Retrospective versusconcurrentmetirodsof dau collection, respectively,showedsignificanrvariationamong the following outcome predictors:bystander-witnessed events(29% versus63% [95% confidenceinterval (Cl) for the difference:25% to 45%1,p < .0001);venrricular fibrillation(VF)as initial rhythm (18%versus2706;Cl: I% ro 1906',P <.03): and wirnessedanesrspresenringin VF (706versuslg06; Cl: 406to 1806;P < .002).

Conclusion:Merhodologicdi[[erencesin collectionof prehospital cardiacarrestdatawere associatedwith significantdifferencesrn outcomepredicrors,most noubly a greaterthan twofold variationin the reportedincidenceofwitnessedcardiacarrestspresentingin VF. Methodology-dependent variationin rhis importani,,denominator"may producesubstanriallydifferentestimatesof predictorsof survivalwithin the samecohort of patients. .l post-Resuscitation SystolicBlood I I RelationBetweonInitial I I 'l Pressureand NourologicOutcomeFollowingCardiacAnost DRMartin,D Persse, pEpepe, CGBrown, M Jastremski, B0 Cummini, EGonzalez, H Stueven/Oepartment 0f Emergency Medicine, The0hioState University; Program in Multidisciplinary Critical Care,SUNy-Health Sciarres Syracuse; Emergency Medicine Services, University 0f Washington; !9*tl 3l Cityof Houston Emergency MedicalServices; Selection of Emergency Medical Services.-Medical College of Virginia; Department of EmergenryMedicine, Medical College of Wisconsin Study objective:To dererminethe relationberweeninitial oostresuscitation(PR)systolicblood pressure(SBp)and neurologic outcomeafter cardiacanest.

Design:Rerrospective study design.

Setting:Six urban emergencymedicalsewicessystems.

Participants:Forty-fivepatienrsresusciratedfrom our-of_hospital cardiacarrestwho survivedto hospital discharge. lnterventions:Patientswere randomizedto receiveeither0.02 mg&g or 0.20 mg/kg epinephrineas rhe firsr pharmacologicinrervention during CPR All orher therapyfollowed standardnLLS gutdelines.

Results:Neurologicgutcomewasassessed using Cp- scoresascer_ tainedfrom hospitalrecords.An analysisof variani (ANOVA) was usedto comparerhebest CpC scoreand initial pR SBp. CPCScolr llo. ot Polieilr SBP(nmH0) I I J

4

l8 I l5 4

111*,57 132r57 I t5r39 10i23

The P value for the ANOVA was .003. Fourreenof the 26 parienrs with CPCscoresof I or 2 (good ourcome)had initial pR SBpsof > 150 mm Hg. Sevenreen of the 19 parienr with CpC scoresof 3 or 4 (poor outcome)had initial pR SBpsof < 150 mm Hg. An initial pR SBpof > I50 mm Hg had a positivepredictivevalueof g7.5%.

Conclusion:A higher SBpin the immediatepR period correlates with a betterneurologicoutcomea[ter out-of_hospitalcardiacarrest.

Whether this is a causalrelation or a marker for other factors that mav affectneurologicoutcorr deservesfurther study. t s ?

I I C Oom lge Affectthc 0utcome of PrehospitalResuscitation?

BCWuerzGVazquez-de Miguel,CJHolliman, SAMeadorGESwope/ University Hospital, TheMiltonS Hershey MedicalCenter, ThePennsylvania StateUniversity, Hershey Studyobjective:To compareresuscitationoutcomesin elderly (> 65 yearsold) and younger(30 to 65 yearsold) prehospitalcardiac arrestvictims.

Design:Retrospective cjrsâ&#x201A;Źseriesover a four-yearperiod.

Setting:Ruraladvancedlife support (Al5) unirs; universiryhospiul.

Participants:Field resuscitarions (563) ofadults; excludedwere patientswith unknown initial rhyrhms(31), noncardiacetiologies,and agelessthan 30 years.

Interventions:Patientsweregroupedby age.Retum o[ spontaneous circulation(ROSC)and survival ro hospiul dischargewere compared by 7z and Fisher'sexacttest.ALS treatmentof cardiacarrestwasby regionalprotocol and on-line physiciancommand.

Results:Sixty percentof patients(320 of 532) wereelderly.The proportion with initial rhythm of ventricularfibrillation (VF) was50% elderlyand ,18odyounger(P - NS).

R0scl%l Surivel(%l Group Elthily Youngar Eldedy Yomoer All(N- 352f vF(N= 258) E M D ( N1 =0 1 1 Asystole{N= 173) P=NSforeachcomparison.

17.8 6j 14.7 7.1

15.8 18.8 23.1 9.3

4.2 8.3 1.3 0

4.9 8.9 0 1.3

'Po,ver - .80fora50%difference and800,6 IR0SC) {survival).

Twelveyoungerand I6 elderlyparienrssurvived;rhe oldesrwas 87 yearsold. ln VF patientswho receivedCPRwithin four minutesand defibrillationwithin eight minures,the elderlyhad beuer ROSC(5006 versusI8.506,P = .008)but thesamesurvival(22.506versusI8.5%, p = NS).

Conclusion:Age more than 65 yearshas lesseffecton resuscitation outcomesthan inirial rhyrhm, earlyCPR,and early defibrillarion.

Analysisof ourcomesusing orher agecutoffsyieldedsimilar results.

Advancedagealoneshould not deterresuscitationattempB. a a F | | O nr.o.irtion ol DrugThenpyWith Survivalin GardiacAnest lG Stieil, GAWells,PCHebert, BM Stark,BNWeitzman/Division of Emergerry Medicine andDepartment of Medicine, University of 0ttawa,Ontario Study objective:To study advancedcardiaclife support (AC[S) drugsgiven during CPRand their associationwith survival.

Design:Observationalcohort study over a two-yearperiod.

Setting:Wards, lCUs,and emergencydeparrmenrof two tertiary carehospitals.

Participants:Five hundred twenty-nineadult patlentswho suffered nontraunutic cardiacarresteither in-hospiul or out-of-hospitaland who requiredepinephrineaccordingro standardACLSguidelines.

Intervention:All drugswere given accordingto ACIS protocols while CPRwasin progress.

Results:The odds ratio and associationwith resuscitationto one hour wereassessed by multivariatelogisticregressionafter adjusting for potentialconloundingvariables.

DnqfVariablo

Itla f,occiYedDrug oddr ndio

9f6 Cl

Procainamide m fi.z 4,7to70.1 .ml tidocaine 210 1.8 t.l t02.9 .t2 ,|.3 Eicarbonate 149 .7 .4to .07 Bretylium 3{l .4 .l to1.2 .10 Atropine l7l .8 .Sto1.3 .39 Calcium E .6 .2to1.9 .39 Bespintorycause 3.5 2.1to6.l .ml Tirne toAcls/minute .9 .gto.9 .ml ouration ofActS/minute ,9 .9t0.g .ml P valuesfor all other variablesenteredinto the model werenor sigrificant:age,gender,location of arrest,wirnessed,rhythm, current diagnosis,pastmedicaldiagnosis,rime ro AC[S, epinephrinedosage.

Further multivariatemodelingsuggestedhigfrersurvivalrareswhen atropine(OR, l.2) and bicarbonare(OR, 1.2) were given late in resuscitation.

Conclusion:Only lidocaineand procainamideappearto be associated with bettersurvivalin cardiacarrest,but timing of drug administration nay be a factor.Largerandomizedtrials ro assessthe effectiveness and timing of srandardACIS drugs arewarranred. ^ i 1 | | I famfy Responsc to Doathin the Feld TA&hmidt,MA Hanahill/Department of Emergerry Medicine,0regon Health Sciences University, Portland Background:Declaringa persondeadin the field and not rranspoiling the personto a hospiul is becomingmore common in prehospiul care.The effectof rhis practiceon surviving family membersis unl(nown, Objective:To betterunderstandthe needsand resDonses of familv membersafter an out-of-hospiraldearh.

Design:Over an l8-month period, telephoneintewiewswereconductedusing a structuredinterviewschedulemodified from a similar study of survivorsof in-patientdeath.

Participants:Thiny-one survivorcof u rban out-of-hospitaldeaths attendedby-oneprivareambulancecompany.Subjectswere eligibleif paramedicshad arrived and deathwas dererminedat the scenewithout transport.Survivorswere interviewedI I to l5 months after the death (mean,l2 monrhs)ro evaluatetheir degrecof coping sincethe death.

Results:Eiglrty-sevenpercentof survivorswerewhite; averageage was 65 years(SD, 13.5 years).Twenty-threepercentof the deaths weresuddenand unexpected,and75% had bcenill for months to years.Although many ofthe survivorssuspectedtheir loved one had died,64% were informed of rhe deathby EUts or lire fighters.Mosr felt the EMTsinformed them in a professional(gI%) and gentle,supportive rnanner(74%). Nonc of the survivorsbelievedtheir loved one shouldbe transporredto a hospital,and only one believedthat something more could havebeendone. ln all exceptone case,when the paramedicsleft the scene,the survivor was not left alone.A year later, 29% still had unansweredquestionsabour the death,but mosr(5g%) wereadjusringwell and no one had a poor adjustment.

Conclusion:Survivorsof out-of-hospiraldeathare sarisfiedwirh the caretheir loved one received.None of our suwivors believedtheir loved one should havebeenrransportedro the hospiral.They also found the paramedicsto be supportiveand to meei their needsat the time of death.Paramedicscan meet the needsof survivorsbv terminat_ ing prehospitalresuscitationof nonsurvivors.

1 1 I Roceol thoVictimlr a Doternfnant of BydandorCPB DBrookoff, A Kellerman, PDobbyns/tJniversity I Hackman. ofTennessee.

Memphis Studyobjective: To determine whetherrhereis anassociation betweenthe raceof the victim and the likelihood of receivingbysrander CPRafter out-of-hospitalcardiacanest.

Design:Prospectivecasâ&#x201A;Źseries.

Setting:Memphis,Tennessee, a ciry of 610,000 inhabitants.

Participants:One thousandnine consecutiveadult victims of nontraumatic,out-of-hospiul cerdiacanest treatedby MemphisEMS betweenJanuary1989and January1992.

Results:Five hundred sixty4hreevictims (5606)wereblack,443 were white (44ob),and.threewere listed as "other" (0.2%).Although black victims were aslikely aswhire victims to havea witnessedarrest (5506versus52o$)and,arrestoutsidethe home (28% versus34%), black victims were sub,stan(ially lesslikely ro receivebysunder CPR than whites (806versus20%; OR, 0.,t3; P < .0001),Logisticregression analysisshowedthat this differencewasnor relatedto other factors, including whether the arrestwaswitnessedor whetherit occu+rsdoutside the home,both of which were independentlyassociated wirh bystanderCPR(OR,2.02;P <.001and 4.45,P <.000I , respectively).

Other demographicvariablessuch as victim ageand sex werenot associated wirh CPR. Conclusion:Blackcardiacanest victims may be substantiallyless likely to receivebystanderCPRrhanwhire vicrims.TargetedCPR training programsand relephoneCPRinstructionshould be adopted to improve ratesof bystanderCPRin minodry populations.

1 I I 0n-Line lledicatoirsction: A Prospective Srudy BCWuerz, CJHolliman, GVazquez-de Miguel/University Hospital, Ihe Mihon SHershey Medical Center.

IhePennsylvania StateUniversity, Hershey Study objectives:To determinehow often on-line medicaldirection (OLMD) alterstherapyin an EMSsysremwith numeroustrearmenr protocolsand to analyzehow time is spentin OLMD. Design:Prospecrive study of OLMD over a four-month period.

Setting:A universityhospitalbasestationin a rural serting.

Participants:Ten emergencyphysicians(EPs)gaveOLMD to 46 paramedics(EMT-P)in 259 consecutivecasâ&#x201A;Źs.Fourreencaseshad incompletedataand wereexcluded,leaving2l5 casesfor analysis. lnterventions:EPsand EMT-Pswereblinded ro rhe srudy. Radios and closed-circuittelevisionswere monitoredby rhird-party observers.

Results:EPsaskedEMT-Psto repeatinformation in 9% of casesand to give further information in 23%. Orders for therapynor requestedby EMT-Psweregiven in 20% of cases.Time intervalsfor the 2,t5 casesare given below TimeInterd EPresponse delay EMT-P report EPquayandorders TotalradiotinE oLMD-treatnent tirne'

llean (minulesl

9t%cl

0.7 .6to ,7 2.2 2.1to2.4 1.2 0.8to 1.7 4.1 3.6to4.5 It.9 I L0 to 12.9 'Hospital anirral tirBminus initidOtIlDcontact.

Time intervalsdid not vary sigriftcandy by EP,EMT-Punir, or call type (trauma,chestpain, other medical).Mean transportinrewal in this systemis I l'9 minutes,rhe sameas rhe OIMD treatnrentinrerval.

Conclusion:PhysicianOLMD changestherapyin 20% of cases, requiresan averagefour-minute time commitment per call, and does not delayhospiul transponwhen combinedwith protocol trearments.

r)fl { I 4lf

Analysisol Interventions in Prehospital CarebyStanding Orderc VercusOn-lineMedicalCommand

G VazquedeMiguel CJ Hollinran, RCWuerz/University Hospital, The MihonS Hershey MedicalCenter, ThePennsylvania StateUniversity, Hershey Study objective:The aim of this study was to comparethe patient clre measuresdoneby paramedicsaccordingto standingordersversus measuresorderedby on-line medicalcommandto determinethe utiliry of medicalcommandorders.

Design:Prospectiveidentilicationof patientcaremeasuresdoneas part of a prehospitalquality assuranceprogram.

Setting:An urban paramedicservicein the nonheastUnited States with on'line medicalcommandfrom threelocal hosoitais.

Participants: All paramedictransporrrepons(5Ii) for Octoberto DecemberI992. lntewentions:All patientcareinterventions,caseby case, were recordedand classifiedif done by sunding ordersor by on-line command orders.

Results:On-linecommandgaveordersin 79 of 515 cases(I5.306); performed in four of thesecases,the orderswere erroneous.Paramedics (92.9%)on srandingoriers.

1,301of the t,399 toul interventions Elevenof 79 commandorderscaseswerejust for additionaldosesof epinephrineor atropinein cardiacarrestcases,and 26 of79 were for interventionsalreadymandatedby standingorders.In only,12 cases (8.206),medicalcommandordereda potentiallybeneficialintervention not specifiedby standingordersor not done by the paramedic.

Conclusion:On-line medicalcommandgaveordersin only I5% of casesin a standingorderssystem,but in almosthalf thesecases,command orden only reiteratedthe standingorders.More selectiveand reduceduse of on-line commandcould be done in this systemwith no changein the typesor number of parienrcareinrerventionsperfoffned. ll Multi- VercusSingle-TierEMSSysternsl A Gontrolled Trial ttl I G I UsingGomputer Simuletion CESaunders, J Pointer/University of California, SanFrancisco; SanFrancisco Department of PublicHeahh;Emergency Services, SanFrancisco General Hosoital Studyobjective:To comparethe operatingcharacreristics and performanceof a multitier EMSsystem(MT, combinedAtS and BLS) with a single-tiersystem(ST,AIJ only) in rhe samecommuniry under similar conditions.

Design:A detaileddiscreteeventcomputersimulationmodel of the current ST systemin SanFranciscowas developedand validatedusing actualsystemdau. A similar MT model was developedbur with an Al5 or Bl5 primary responseoption and a conditionalsecondaryAIS or BI5 responseif needed.Systemperformancevariableswere compared for each.The effecto[ the number and mix of ALS and BIJ resources and the dispatcher"mis-triage"ratewere studiedby sensirivityanalyses.

Results:AIS initial responseintervalwassimilar for ST (ten ALS ambulances)versusMT (sevenA[S: six BtS) ^t7.4 and 7.3 minures, respectively(NS), althougfrthesetimes variedinverselywirh rhenumber and mix of Al5 or BLSresources.The meanMT systemsecondary A[5 responsetime for upgradedBtS calls(mis-triagedAtS) varied directly with the dispatchermis-rriagerare(5%, 34.1 minutes,to 50%, 44.9 minutes),as did primary ALS responserime and AtS and BtS resourceutilization. A[5 servicetime varied inverselywith rhenumber of BIS ambulances,althoug]roverallAtS urilization rateswere minimally affected.

Conclusion:ST and MT systemscan provide similar performance, althougfr they are highly sensitiveto the number and mix of AtS and BLSresources.MT systemsarealsosensitiveto A[5 and BLSmis-rriage

rates,which, if higfr, result in prolongedresponsetimesand reduced ambulanceavailability. a rtttt I LLProspectivo Evaluotionol FieldTnurnaTriagc Francis Hospital, Tulsa,0klahoma WHBickell,JCSacra,CTThornpson/Saint Study objective:The AmericanCollegeof SurgeonsCommitteeon Traumahas proposedthreecriteria for field trauma triage;physiologic (TraumaScore< I2), anatomic(penetratingtruncal injury, flail chest, two or more proximal long bone fractures,pelvic fractures,amputation, and paralysis),and mechanism(motor vehicularcrash [MVC] with significant auto damage,rollover MVC, ejection,MVC with samecar occupant death,falls> 20 ft, auto-pedestrianinjury, and motorcycleacci dent). The objectiveof this study was to determinehow the proposed triagecriteriawould predictsevereinjury.

Desigr: Prospectivesnrdy over a 36-month period.

Setting:Advancedlife support urban EMSsystem.

Participants:Patientsincluded in this study werevictims of blunr or penetratinginjury transportedby gound EMSto a community hospiul Levelll traumacenter.Patientssustainingsevereinjury were identified as thosewith an lnjury gverity Scoreof > ]5.

Resuls:Two thousandninety consecutivepatientswho met entry criteriawere included in this study. The sensitivity,specificity,and relativerisk for the triagecdteriaare as follows:physiologic:4604,9304, 6.6, P < .000i ; anatomic:22%, 9806,I 1.0,P < .0001; mechanismof injury:5406,5306, I.I, P = NS. Conclusion:Both the physiologicand anatomictriagecriteriawere predictiveof severeinjury. However,the mechanismcriterion failed to predictsevereinjury. Moreover,when mechanismof injury was 9206.lnour traumasystem, urilized,the overtriage rateexceeded mechanismof injury was not a useful pammeterfor field triage.

toTerminate oftheDecision Surviving Relatiyes'Acceptance La I t4rJ Resuscitation in thc Feld TEAuble/Division of Emergency DEFosnocht,Ifl 0elbridge, HGGarrison, Medicine, University of Pittsburgh Study objective:Thereis concemthat the public may not accept the decisionto stop resuscitationeffortsin the prehospiul sening.This study determinedwhethersurviving relativeswould accepttermination of refractorycardiacarrestresuscitationin the field.

Desigr: Structuredinterviewone to three monthsafter death.

Setting:Urban, municipal advancedlife support EMSsystem.

Participants:Closestrelative(53) at the sceneof a consecutivesâ&#x201A;Źries of adult patientsin refractorycardiacarrestwhoseresuscitationefforts were terminatedin the home (32) or in the emergencydepartment(21) Follow-up ratewas7 906.

Results:When resuscitationwas terminatedin the home, 960,6of relativesreportedsatisfactionwith this decision.When resuscitation was terminatedin the ED, 82% of relativesreportedsatisfactionwith suggest the decisionto transpoftto the hospital;qualiutive responses that the majority would haveacceptedterminationof resuscitationin the home. In all cases,relativesreportedsatishctionwith the paramedics'careand with the ranner in which they were informed of the oatienfs death. ionclusion: Survivingrelativesacceptthe decisionto terminate refractorycardiacarrestresuscitationin the field.

tlr ol PrehospitalMononnrphicand Polymorphic ll Gomparison I 4-t Venticular Tachycadia:Incidenceand 0utcome W Btady.S Meldon,D DeBehrke/Oepartment of Emorgency Medicine,Medical College of \Msconsin, Milwaukee Studyobjective:Monomorphicvenrricularuchycardia(MW) is the mostcommon form of prehospitalventricularuchycardia(VI). Recent literature suggestsrhat polyrnorphic ventricular uchycardia (PVf) is more common during cardiopulmonaryarrestthan previouslythought but respondspoorly ro advancedcardiaclife supporr (AC[S). We undertookthis srudy to determinerhe incidenceand outcomeof pVT and MVT in the prehospiralserring.

Desigr.:Retrospective prehospiralcharr reviewfrom 1987 to 199I. Setting:Municipal lire department-based muhitiered EMSsystem servinga popularionof approximatelyI million.

Participants:Adult parients> I 8 yearsof ageexperiencingprehospital nontraumaticcardiopulmonaryarrestwith VT occurringat any time during resuscitation.VT was definedas PW if therewasepisodic changingof the elecrricalaxis and/or amplirudeof the ECG or rhe presenceof more than rwo waveformmorphologiesin a singleECGlead.

Outcomewasdefinedas the presenceor absenceof spontaneouscirculation at the end of the prehospitalphaseof care.Four hundredseventysix patientsmet entry criteria,with 28 parientsexcludedbecauseof incompleterecords.Four hundred forty-eigfrtpatientswere usedfor dataanalysis. lntewentions:Sundard ACIS therapy.

Results: MVT occurredin 331 (74%)parienrs, wirh I I8 (36%) achievingretum ofspontaneouscirculation(ROSC).pVT occurredin Il7 (260A)patients,wifi 50 (430,6)having ROSC(P = .21 for ROSC).

VT was the presentingpulselessrhythm in 40 patients;MVT occurred in 28 (7006)patienrs,with 14 (5006)having ROSC.pVT occurredin I2 (3006)patiena, wirh seven(58%) achievingROSC(p = .89 for ROSC).

1z analysiswasusedro analyzeROSCrates.The power to detecta 15% differencein ROSCratesberweengoups was80%.

Conclusion:We concludethat PVT is a common rhythm occurring in prehospitalcardiopulmonaryarest and respondsas well as MW to ACIS therapy.StandardACIS rherapyshould conrinueto be usedin all formsof prehospiul VT. onTrip Repolb I f f Timesol EMSInteryentiontar Documented I 4J VersusOn-Sceno AudioRecordingr VN Mosesso, MPSullivan, EADavis,RECarlin,AVColantoni, MA Sott.

JJ Menegazi/University of Pittsburgh School of Medicine, University of Pittsburgh AffiliatedBesidency in Emergency Medicine, Center for Emergencl Medicine of Western Pennsylvania, Pittsburgh Studyobjective:Accuratedeterminationof timesof occurrenceof prehospiul eventsis essenrialfor both meaningfulresearchand quality management.

We hypothesizedthar times documenredby paramedics for cerraininrerventionsin cardiacarresrcasesnuy nor j:ff:L*" ;: Desigr: Prospective,consecutivecaseseriesfrom Februaryto NovemberI992.

Setting:Threerwo-rieredEMSserviceswirh 24-hour paramedic coverageservinga suburbancommunity.

Participants:Paramedicson cardiacarrestcallsuseda monltordefibrillatorwith continuousaudio and ECG recordingcapability. lntewentions:Timesof selectedinterventionsas recordedon tape werecomparedwith the times listed on trip reportsfor 33 cases.

Recordertimeswere synchronizedwith the dispatchcenter.Times wereanalyzedby two-tailedpaired t-rest.

Results:SeeTable;tirnesare reportedin minutes. ileenTin Dilter€ncer

Frflr oirp.bl Repoil ArrivescerB 6.9 Delibrillation8.6 Intubate 17.8 lVline 15.2 '17.0 Epinephrine Atfopine 2l.7

Trtr

E rlie{

lrlo3l

7.8 9.3 19.7 16.3 18.2 n3

--1.0 -€.7 -9.0 -€.9 -4.2 -5.7

+.7 +4,8 +3.5 +3.4 +2.5 +7.3

Avenge P(twcl,ribdl

|.0 1.4 3.1 2.1 2.2 2I

.tln4 .2 .m .mg .01 .n

Conclusion:Statisticallysignificant dif ferencesexistbetweentimes noted on audio recordingsand timesdocumentedby paramedicsfor certainprehospitalevents.More accuratemethodsof time determination such asreal-timeaudio recordingshould be utilized for purpos€s of researchand quality managementin EMS. for l aC Useol AutomatcdDefibrillatorsby PoliceFirstResponders I 4fl Treatmentof 0ut-of-HospitalGardiacAnestr VNMosesso Jr,EADavis, RECarlin, AVColantoni, MA Scott,M Marquis, JJ Menegazi/University of Pittsburgh &hoolof Medicine, University of Pittsburgh Affiliated Besidency in Emergency Medicine, Center for Emergency Medicine of Western Pennsylvania, Pittsburgh Study objective:lnnovativemethodsto minimize time to defibrillation must be used to improvesurvival from suddencardiacdeath.This study exploresthe useof automateddefibrillationby police,who are often the first to respondin suburbancommunities.

Desigr: Prospective, consecutivecaseseriesfrom Februarythrougfr NovemberI 992.

Setting:Suburbanareawith populaceof 142,000servedby twotieredEMSsystemswith 24-houradvancedlife support (AtS) capability.

Participants:One hundred fifty-sevenofficersfrom sevenpolice deparlmentswere trainedand equippedwith semi'automatedextemal defibrillators(AEDs).All unresponsive,apneic,and pulselessadults wereeligible;excludedwere traunu, immersion,and signsof irreversibledeath. lntewentions:PolicefollowedstandardAmericanHeartAssociation basiclife support guidelines;immediatelyupon detecringpulselessness, padswereapplied,rhythm analysiswas initiated,and up ro rhreeconsecutiveshockswere delivered.Cyclesofanalysis,shock or no shock, one minute of CPR,then re-analysiswere continueduntil EMSanival.

Results:Policeusedan AED in 45 of the 60 casesin which they arrivedbeforeAl5; averagetime of arrival beforeAtS was 3.5 minutes (range,one to nine minutes).Therewere 17 casesof ventricularfibrillation or ventricularuchycardia;all wereshockedwithin threeminutes of policearrival.ROSCoccurredin nine (530,6)of these;four (2306) were discharged,two (12%) without neurologicdelicir. Of rhe 28 patientswho presentedin nonshockablerhythms, ROSCoccuned in five; all five were admitted.One patientwas dischargedintact with pre. sumedrespiratoryarrestonly.

Conclusion:Useof automatedextemaldefibrillationby policeis a viable method to accomplish early defibrillation. Thesefindings support further researchon this promisingapplicariono[ automated defibrillation.

Lower Transabdominal/Endovaginal Ultrasonognphyby 1 t', I L f EmergencyModicinc Besidents E Cardems.

BLGalli/0liveView/UCLA Oepartment of Emergency Medicine Srudy objective: There is increasinginteresr in determining rhe feasi bility and utility of bedsideultrasoundin the emergencydepartmenr.

This study investigatesdegee of agreementbetween emergency

medicine(EM) residentswith introductory training in pelvic ultrasound and radiologistsin detectingthe presenceof an intrauterinepregnancy (lUP), adnexalmass,and hee fluid. EM residents'abilityto correctly diagnosepatientswho haveultrasound lindings suggestiveof ectopic pregnancy(EP) is also evaluated.

Design:Prospectivecohort study.

Setting:A univenity-afliliatedcounty hospital.

Participants:EM residentswith introductory training in pelvicultrasound imaging.

Methods:Study patiens were pregnantwomen requiring pelvic ultrasoundfor evaluationof EP.EM residens independentlyperfornrd the first pelvicultrasound,viewedreal'time images,documentedthe presenceor absenceof IUP, adnexalmass,and free fluid, and recorded a diagnosisand treatmentdecision.The radiolory resident/staffmember then performedthe standardultrasoundexaminationand reportedthe resultsto the EM residentfor definitive care.EM residentfindings (lUP, adnexalmass,freefluid) are comparedwith the radiologist'semergent report. Interobserveragreementis calculatedusing a r coefficient.The sensitivityand specificityo[ EM residents'ability to detectpossible casesof EPare calculatedbasedon the final diagnosisderivedfrom the radiologist'semergentrepon.

Results:Six residentsparticipatedin this snrdy, with one resident completingthe majority of enrries.This is a summaryof 55 casesand representspreliminary data only. Sensiriviryand specificityof EM res! dent ultrasoundat detectingthosecasesin which EPcould nor be ruled out were 9006and 7l%, respectively.Observeragreemenrand x values for documentedfindings (lUP, adnexalmass,and freefluid) were830,6 (r = .66),8606(r = .46),and 88% (r - .66),respectively.

Conclusion:After completingintroductory rrainingin pelvic ultrasound,EM residentswere very good at determiningwhich caseswere suspiciousfor EPbasedon their ultrasound lindings.Therewas fair agreementwith the emergentradiolog;lreport in detectinglUP, adnexal mass,and free fluid. Further study with a largernumber of EM residentsis forthcomingto determinerhe optimum ultrasoundtraining and experiencerequiredto improve this ageementand hencethe safeuse of pelvicultrasoundby EM residentsin rhe evaluationo[ patientswho may haveEP.

lzBilt;}:tl:

Eval ueti onolEctopic Presnancy byEmorsency

J Mateer,EJAiman,M Bro,rrn/Department of Emergency Medicine,Medical College of Wisconsin, Milwaukee Study objective:To determinethe diagnosticaccuracyof tranwaginal ultrasound(TVS)performedby emergencyphysiciansfor ecropic pregnancy(EP).

Desigr and panicipants:This prospecriveconveniencesample included 152 patientsduring a I 2-monrh period, wirh four losr ro follow-up. Suble pregnantpatienrsmore than 18 yearsof agewirh any risk factorsfor EPwere enteredin the study.

Settingand interventions:TVS was performedin an urban emergency departmentby emergencyphysicianswirh initial interpreution and dispositionbasedon predeterminedcriteria.TVS examswere reviewed on video by an obstetrician/Smecologisr (OBG)and inrerprerarions correlatedwith the linal diagrosis.SerumhCG and progesrerone were performedon parienrswith no definitive inrraurerinepregnancy(lUP) on TVS. Resuls:Ultrasounddlagrosesincluded definitive IUP: 87 of 148 (59%); probableabnormal IUP: I7 of la8 (l l%); definitiveecropic: three of l4a (Zoh);and no definiriveIUP: 4l of l,+8 (28%). The OBG agreedwith 9306of the initial interpretationsoverall.fwelve of l6

patientswith the final diagrosisof EP wereadmittedwith this diagnosis.The TVS diagnosisof the other four wasno definitive IUP and no nuss or free fluid. Their serumhCG was < 2,000 mlU/ml (lRP),and they were followedwith serielhCG testing.None of thesehad tubal rupture and/or significanthemoperitoneumat surgery.Upon study completion,meansâ&#x201A;Źrumprogesterone(ng/ml t SD) in Patientswith no definitiveIUP wassignificantlydifferentfor eachfinal diagrosis (P < .05,two-tailedt-test):2,t.3t 14.6,final diagrosisIUP;6.9 t 4.9, ectopic;2.0 t 2.2, spontaneousabortion (SA).A serumprogesterone > I1.0 would havedifferentiatedearly IUP from ED SA (sensitivity, I 0006; specificity,95%).

Conclusion:TVS evaluationby emergencyphysiciansrnay improve diagrosticaccuracyfor EP; further study of the sigr.ificanceof serum progesteronefor identifyingearlyEP is warranted. lmprovedldontificationol EctopicPregnancyWth an { llll I ZJ EmergencyDopartmrntProtocolUtilizing0uantitatiyehGG and Ultrasonography J Schmidt, B Chun, A Kharwadkar, M Moskos, 8Ckplan, RGDart,K Northern, MA Hamid/Boston CityHospital E Kuligor,rrska, Study objective:Delayeddetectionof ectopicpregnancy(EP) (reportedrate, 5006)resuhsin an increasein morbidity. This study evaluatesa protocol designedto identify EP on the initial emergency departmentvisit using quantitativehCG valuesand selectivepelvic ultrasonography(US).

Desigr and setting:ProspectiveI3-month study in urban municipal hospitalED. Participants:Threehundred sixty-fiveconsecutivewomen presenting to the ED complainingof abdominalpain with or without vaginal bleeding,a positivehCG, and uterus< l2 weeksby pelvicexam. lntervention:All positivehCGswere quantified.Patientswith hCG values> I ,000mlU/ml had immediateUS.Patientswith hCG < I,000 either receivedtrarsvaginalUS from Monday througfrFriday from 9,tv to 5 pv or were admittedweekendsand niglrts when US wasunavailable.All patientswere admittedif US did not show definitiveevidence o[ intrauterinepregnancy(lUP).

Resuls:Forty-nineof 365 (I306) had a diagnosisof EPconfirmed by laparoscopyor laparotomy.One hundred seventyof 365 (47oh)were dischargedfrom the ED with conlirmation of IUP. Of I95 admitted, 64 ol 195 (3306)were for D&C basedon US evidenceof abnormallUP, and I3l of I95 (67%)wereadmiuedwith diagnosis of R/O EP.Of R/O EPpatients,49 of l3l (37%)had a diagnosisof EPand only nine of l3l (7%)had finaldiagrosisofnormallUP.Six of 19(l2o/.) EPshad no complaint of abdominalpain, i8 of a9 (]7%) had nontenderpelvic exams,and I8 of 49 (37%)hadhcc < 1,000.Twenty-nineof 49 (59%) EPshad visualizationof EP on US. Sixty-ninepatientswere admitted with indeterminateUS; 14 ol69 (20ob)had EP.Protocolsensitivitywas I0006 for detectingEPat initial ED presentation.

Conclusion:The history and physicalexamareunreliablein the diagrosisof EP.This protocol using quanti:ativehCG and US prevents misdiagrosisand inappropriatedischargeof patientswith EP. t 2n Sensitivityand Spocilicityof Ultrasoundin the Detectionol f Jf, Intraperitoneal Fluid WEHilty,REWolfe,EEMoore,MJ Heinig, MFMestek/Departments of Hospital, Colorado Emergerry Medicine andRadiology, Denver General HeahhSciences Research Center andUniversity of Colorado Center Studybackground:With inexpensiveultrasounddevicesreadily available,emergencyphysiciansand surgeonsnow practicesonogaphy without the benefitof extensivetraining. Althougfrretrospectivestudies

suggestthat ultrasoundis higfrly accuratein detectingintraperitoneal hemorrhage,this hasnot beenesublishedprospecrively.

Studyhypothesis:Bedsidesonographyin the emergencydepartment is higlly specificand sensitivein derecringfluid in the inrraperironeal cavity.

Setting:Municipal ED of a level I traumacenter.

Participants:Attendantsand residentsin radiologyand emergency medicine. Emergencyphysiciansunderwent a two-hour inserviceon sonographicrecognitionof fluid in Monison's pouch. Parienrswith abdominaltraunn wereincluded when hemodynamicallystablewith a negativeperitonealaspirate.

Design:Prospective,blinded, randomizedconveniencesrudy.

Patientsundergoingdiagnosticperitoneallavagewererandomizedinto two groups:group A (no peritonealfluid) and goup B (from 250 to I,000 mL of intraperitonealnormal saline).Sonographywasperformed with the sonographerblinded ro rhe amounr of fluid. The sonogapher then attemptedto visualizefluid at Morrison'spouch (Pie Medical Scanner100,3.5-MHzprobe).

Results:Nineteenpatientswere enteredinto the study. Sonography wasperformedby I3 emergencyphysiciansand by ren radiologists.

Sonogaphywas performed1l times in group A and 32 rimesin group B. In detectingintmperitonealfluid, rhe overallsensirivitywas 8l%, specificitywas64oA,and accuracywas 75%.

Conclusion: Emergencysonographymay have an unacceptablyhigfr incidenceof false-positives and hlse-negarives in derectingintraperitonealfluid. Thesedatasuggesrthar uhrasoundshould not be relied on solelyto determinewhich patientswirh abdominaltraumahave intraperitonealhemonhage.

CentralVenousAccessUsingPortableUltrasoundin the l ai I rJ ! Emergency Depa.tmont G Kuhn,J Eurton,D Zelenka/Grace HospitalEmergerryDepartment, Wayne StateUniversity, Detroit, Michigan Studyobjective:To determinethe uriliry of poruble ultrasound in cannulatingthe intemal jugular vein in the emergencydepartment comparedwith the standardblind percutaneousapproach.We hypothesizedthat physiciansusing ultrasoundguidancefor centralaccess would be able to perform this procedurefasterand with fewercomplicationsrhanwith rheblind approach.

Desigr and setting;Randomized,prospectivestudy conductedover six monthsflanuary 1992 toJune I992) at a universiry-affiliatedteaching hospital.

Participants:All nonarresrpatiens older than I6 yearsrequiring centralvenousaccessfor I) centralvenouspressuremonitoring, 2) venousaccess,3) pacing,or 4) lV medicationswere includedin this study. Seventypatienrswere randomizedinto eithergroup A, blind approach,or group B, ultrasound-guidedapproach.All attemptswere timed and followedfor complications.

Results:Therewasno statisricallysignificantdifferencein the averagetime for cannulationbetweenthe two groups;29 ultrasound-guided cannulationsaveraged40 seconds,and 4l blind approachcannulations averaged,l2seconds(t = .OlO,p = .527). Therewasa significanrdifferencein the number of requiredattempb for successfulcannulation betweenthe two groups.The averagenumber o[ attemprcfor the ultrasound-guidedgroup was 1.2, whereasfor the sundard blind approach, the average numberof arremprswas 1.9 ( = 3.a91,p = .00I). The rares of complicationswerealsosignificantlydifferenr,with no complications for group B and sevencomplicarionsfor goup A (t = 2.890, P = .00I).

Conclusion:Ahhough the ultrasound-guidedapproachwasnor significantlyfasterthan rhe standardblind approach,it significanrly

reducedthe chancesof complicationsand the number of attemptsfor successfulcannulation.

A One-WayValvc GhestWound Dressing:Evaluationin a I tt, l.l(CanineModsl ol ODcnChestWounds Medicine, Hennepin C Perersen/Department of Emergency E Buiz,J Lueders, County Medical Center, Minneapolis, Minnesota Study objective:To testa chestwound dressingincorporatinga lowprofile, one-wayvalvedressing(OWVD) desigredfor use in prehospiul treatmentof pneumothoraxin penefiatingchesttraumaby comparing it with conventionalpetrolarum-impregnated gauzedressings(PGD). breathing Design:Six dogswereusedto developan anesthetized, model using ketamine(40 m/kd, midazolam(200 pgltg), and fentanyl(I0 pglkd maintainedwith an infusion of 600 pglkglmin, 51$k{min, and 0.5 pg&g/min, respecr.ively.

Four dogsxrved asa control group for evaluationof this model on and off the ve4tilator.

Eigfrtdogswith bilateralstandardizedchestwounds were randomized into two goups in a crossover-desigr. study. One group was testedfor the PGDfirst and then the OWVD, both with and without positivepressureventilation(PPV).The secondgoup was testedfor the OWVD, then the PGD.Dogswerestabilizedbetweentestsof each device.Respirations, heart rate,arterialblood gases,and hemoglobin oxygensaruration(qualitative)were monitored.

Results:The control group showedstablevital signsthroughout testing.Animalson PPVmainuined suble viul signsregardlessof the dressingapplied.Dogswithout PPVwereunableto suwive a l5-minute period with the PGD,whereasdogswith the OWVD were able to adequatelymaintainvital signs,The OWVD preventedcollapsein seven of eight tests,whereasthe PGD preventedcollapsein none of eight tests in dogswithout PPV.A probability of .0007 was found when Fisher's exacttestwas appliedto this combineddau.

Conciusion:The OWVD outperformedthe conventionalPGDin preventingseveredecompensation in dogswith bilateralopenchest woundswithout PPV. 1i|i|Wi$drawn

Patients AreUsefulforldentilying I a A SerialElectrocardiogram I lJ't WithPotentiollschenricHeartDisease Anostin the Emergency Departrmnt WBGibler,GLStevtan, RCLevy,MM Nielsen, R Kacich, C Hamilton.

RAWalsh/Department of Emergencl Medicine andDivision of Cardiology, University of Cincinnati Medical Center Study objective:This study evaluatedserialECGsobtainedevery 20 secondsover a nine-hour period on emergencydepanmentpatients Presentingwith chestpain.

Design:Patienswereevaluatedover a nine-hour period in an ED rapid diagnosticand treatrnentunit (Heart ER)by seriall2lead ECGs obtainedevery20 secondsby a computer-baseddevice(Mortara Instruments).A1lECG leadswere independentlyand automatically digitizedfor comparisonwith previousECGsfor ST-segmentdepression/elevation60 msecafter theJ-point.

Setting:University-based ED. Participants:Consecutivepatientswith nontraumaticchestpain; patients< 25 yearsof agewere includedby history of cocaineuse. lntewentions:lf patientsdevelopedST-segmentelevationor depression, they wereadmitted for further evaluation.Patientsunderwent echocardiography and gradedexercisetestingif no ST-segment changes or CK-MBelevationoccurred.

Results:Of 384 patientsevaluated(age:minimum, 2l years,maximum, 89 years;mean,a5; SD, 13.6),86 requiredadmissionfor possi-

ble ischemia/acute myocardialinfarction (AMI). Of theseg6, Ig (20.9"6)had cardiacdiagnosesar discharge:four with AMl, nine with angina/unsubleangina,and five wirh other nonischemiccardiacdiagnoses.SerialECGsdetectedl7 patientswith possibleischemicST,T waveabnormaliries;seven(sensitiviry,39%) ultimately had in_hospiral evaluationsconsisrenrwirh myocardialischemia/AMl(specificity,97%; 366 of376).

Conclusion:ComputerizedserialECGsoffer conrinuousmonitoring of patientsin rhe ED for myocardialischemia/AMl.Early indication of ST-Twaveabnormalitiesmay allow rapid interventionand disposition of theseparientsin the ED. of Subcutaneous Torbutalineand lrlebulizod { t f Comparison t rJrfAlbuterol DuringPrehospitalTroetmentol BespiratoryDistress Secondaryto Asthmr or Chronic0bstructivc pulmonaryDiseasc jf Emergemy WJZelnerJr,JM Scott,PM lannolo, A Ungaro/Department Medicine, SUNYHealthScience Center; Community General Hospitj Study objectives:To determinethe efficacyand saferyof singledoses of subcuraneous terburalineor nebulizedalburerolduring preh&piul treatmentof respiratorydistress.

Design:Double-blind,randomizedrrial.

Setting:Urban, paramedic-based service.

Participants:Eligiblepatientswere > I g yearsof agewith a provi. sionalassessment of respiratorydistressfrom asthmaor chronic obstructive.pulmonarydiseaseand able to give verbalassent.Subjects wereexcludedfor incompletedau collection,allergiesto study -.d1."_ tions,and chestpain of suspectedcardiacorigin.

Measurements and results:Efficacywas assessed with an asthma score(respirations,wheezing,speech,and peakexpiratoryflow rate [PEFRI),and the patient'sdistressscalewasscoredon a I0-cm visual analogscale(VAS).Evaluationwas done at the time of initial paramedic examinationand on arrival in the emergencydepartment.patientswere alsoaskedro ratewherherthey felt subjectivelyimprovedon ED anival.

Safetywas assessed by moniroring for dysrhythmias,nausea,and hemo_ dynamicinsubiliry. Patients.received oxygenplus albuterol(2.5 mg) aerosoland salineinjection (ALB,40) o.*bcuurr"ous terbuuline (-0.25 mg) and salineaerosol(TERB,43). Groupswere similar with respecrro age,sex,initial asrhmascores,pEFR,and distressVAS.Borhgroups showedsigrificant improlement in their asthmascores.TheLIJ group demonstratedsignificantlygrearerasthnu scoreimprovement(2.2 t I.87, meant SD)comparedwirh TERB(l.a t l.6ti; p < .05, rwo_railed Student'st-cesr).The ALB group had a significanrlygreaterrareof sub_ jectiveimprovemenr(83%)versusrheTERBgroup (5ZoA;p . .05,721.

TheALB goup reportedgreatermeanimprovementsin distressrated

by VAS (21 t 15) comparedwirh rhe TET{Bgroup (I4 i I5). There was a grearermeanreducrionin respirationsin the ALB group G.4 !. 5.2) with rhe TERBgroup (3.3 r 4.9), althougfi no significanr lompared qurerences were lound in rhe meanchangein pEFR.Hospiul admission nor significantlydiffereit berweenthe two groups l:.0*l.y:l:r: ,t2%). Seriouscomplicarionswere (overall, not observed,anJ poisible medication-relared sideeffecu of nausea,vomiting, or palpitationswere not demonstrated.

Conclusion:Significantimprovementin asthmasymptomsand .. objectivescoringoccursin adult parientstreatedwith a single doseof ALB comparedwirh TERB.

at an Airway ManagementAdiunct in a { 2A Succinylcholine I rflf SuburbanAIS System TJKrisanda, DBEitel,SDHowells,DRHess/Department of Emergency Medicine, YorkHospital, York,Pennsylvania Studyhypothesis:This study resrsrhe hypothesisthat succinylcholineis a safeand effectiveadjuncr for endotrachealintubation in nonarrestedadult patientsusing nonphysicianAtS providers.

Desigr: Ongoing,prospective,nonrandomized,nonblinded crossovercaseseriesthat beganin August I99 l.

Setting:Predominately suburbanarea(population,100,000)served by a singlehospital-based AIS unir sraffedby RNs and paramedics.

Participants:All nonanestedpatienrsover age 12yearswho had failedone or more conventionalprehospiraloral or nasotracheal intubationattempts(,10). lntewentions:Snrdyparientsreceivedsuccinylcholine(I.5 mg/kg) lV followedby orotrachealinnrbation.

Results:Forty parients(meanage,53.3 years;range,16 to 86) receivedsuccinylcholine.Thirty-nine of theseparienrs(97.506)were successfullyintubatedin the field. This is a sutisricallysignificant improvemenr(P < .01,Z testof proporrions,rwo-tailed)when contrasted with the 7506overallinrubationsuccessrare(209 of 279) documentedin our AIS systemwith a similar patientmix for the threeyearperiodbeforethe introducrionof succinyicholine.

Aftersuccinylcholineadminisrrarion, 30 of the 39 parienrs(7706)were.intubated on the firstattempr;a meanof I.45 intubationarremptsper parienrwas requiredto securethe airway overall(range,one to five). Esophageal intubation occurredin three patienrs(7.506)but was quickly recogrizedand conectedin eachcase.No other significantcomplications werenoted. The solepatientwho was unsuccessfullyintubated waseasilyvenrilatedby conventionalmeans.

Conclusion:The selectiveuse of succinylcholineas a prehospital airwaymanagementadjunct appearsto be a safeand highly effective meansof improving intubation successratesin adult, nonarrested Patients.

Durationof lmmunityto HepatitisB After lmmunization in EMS 1a', I rf f Personnel MJ Burns, HAshby/Dwision of Emergerry Medicine, University of California, lrvine Study objective:It is not known how often or evenwhetherbooster dosesof hepatitisB vaccineareneededamongemergencymedicalser_ vices(EMS)personnel.We invesrigatedthe long-termpersistenceof protectiveanribody to hepatirisB after immunizationin EMSpersonnel.

Desigl: Prospectivecohort study.

Setting:EMSsysremin urban SouthernCalifomia.

Participanrs:The srudy populationconsistedof I I 5 paramedicsand firefighterVEMTswho had beenscreenedfor hepatitisB serologic markersand had beenfound ro haveno evidenceof prior infeciion.All subjects(meanage,35.6 tg.7 years)rhen underweni immunizarion with threedosesof plasma-derivedheparitisB vaccinegiven by deltoid muscleinjection.None receivedboosterdosesof vaccine,Thiiry-nine subjectswere over 40 yearsof ageat time of immunization.

Interventions:Serumantibody to hepatitisB surfaceantigen (anti-HBs)wasmeasuredby enzymeimmunoassayin all subjecrcat a meanof 68 months(range,62 to 77 months)after completionof immunization.

Results:Twenry-ninesubjects(25o6)hadantibody levels> l0 mlU/ml (corxiderednegativeby testcrireria).Absenceof antibody was found more frequentlyin thosesubjectsover 40 yearsof ageattime of immunizationcomparedwith thoseunder 40 yean of age(3606versus

20%, respectively;odds ratio, 2.28), but this differencewasnor sraristically significant(P = .09, 7z;95% conlidencelimirs for odds ratio, 0.88 to 5.91).A study of largersamplesizemight havebeenable to show an agegroup difference.

Conclusion:Five to six yearsafter immunizationagainsthepatitisB, therewassubsranriallossof protecrivelevelsof antibodyamongthis healthygroup of paramedicsand firefighter/EMTs.Further srudiesin this population,especiallyin thoseimmunizedat ageover 40, are neededto determinethe appropriatetiming of boosterdosesof hepar! tis B vaccine.

- aa| I JU SyphilisScreeningin PrehospitalCare SJ Weiss, EMarvez-Valls, AA Ernst, W0 Johnsory'Oepartment of Medicine.

Division of Emergency Medicine; Oepartment of Biometry andGenetics, Louisiana StateUniversity, Metairie Studyobjective:To dererminerhe raresof syphilisinfectionin patientsmanagedby prehospitalproviders.

Desigr: Prospectiveevaluation,threeseparatetwo-weekperiods.

Setting:lnner-city subjecrspresenringro teachingemergency department.

Participants:Two hundred ninety-two subjeca over l8 yearsold consentingto havea venerealdiseaseresearchlab (VDRL)and fluorescent treponerrurlantibody (FTA) measured.

Results:All consentingsubjecrspresenringby ambulanceduring threeseparatetwo-weekperiodshad blood sent for VDRL and FTA titers.A8e,sex,and diagrosticcrtegory (medical,surgicaVtrauma/ obstetric,psychologicaVoverdose, or neurologic)were recorded.

Syphiliswas definedasuntreatedif the FTA was positiveand rhe state syphilisregistrydid nor haverecord o[ past infection.Par.ienrs were excludedif they had pasrinfecrionor if roo litrle blood was drawn ro perform the test.Groupswere comparedwith 262lsrgwith significance at P < .05.Sevenpatientswereexcluded,leavinga roralof 285 parienrs.

Therewere 179males(63%)and 106 females(37%),with 75 (26oA) white and 210 (74oA)black. Thirty-rhreeparienrs(I206, RR= a.0) had untreatedsyphilis,with a sigrificantly higher percenrageof females (I6"6) than males(806)and a significantlyhiglrer percentageof black (170,6)than whites (2.7%). No differencewas derecredin number of new casesof syphilisamong the four diagrosticcategories.

Conclusion:Thereis a high rate of untreatedsyphilisin parienrs transportedby inner-ciryEMS.Rareswere significantlyhigher in blacks and in females;however,the overallratewashigh enoughto warranr screeningofall patients.Sincesyphilis can be passedby contact, screening of prehospiral providersmaybe wananted. of 12-Lead | 2O PrehospitalParamedicInterpretation I rf rf Electrocardiograms lor Myocardiollschemiaand lnfarction KS*hrank,KALittrell, P Farber, D Bosenberg/University 0f Miami&hoolof Medicine, Cityof MiamiFireBescue Studyobjectives:Paramedicsare vital to early recognitionof acute myocardialinfarction(AMl). Educationshould allow them ro accurarely interpret l2-lead ECGsfor AMI evenwithout physicianor computer readings.

Design:An educationalmodule raught I2-lead ECG performance and interpretation,clinical presenrations, and thrombolysiscriteria.

Paramedics then interpretedl2lead ECGs(computerinterpretation disabled)on patienrswith possiblecardiacsympromsand assessed thrombolysiscandidacy.Emergencydepartmentsreceivedparamedic readingbeforeECG transmission.Reviewersread ECGsand then scoredparamedics'readings.

Setting:Universityparamediceducationalfaciliry.Urban EMS. Participants:Paramedics in EMSsystemwith an annualcall volume of 40,000. lnterventions:Twelve-hourcoursewith testing,feedbackover seven-monthfield use.and refreshersâ&#x201A;Źssionsat three and l3 months.

Results:Fifty-fiveparamedicswere trained,370 ECGswere done, and 317 paramedicreadingswerecollected.Reviewersfound 12.806 with QRS> I 20 msec,15.4%significantST elevations,and 19.7% other ischemicchanges.Paramedics correctly read96.8% for QRS duration,95.306for ST elevation,95.3%for ST depression,95.3% for invertedT waves,and 93.8% for Q waves.Errors rarelyaffectedfield treatment.Twenty-sixpercentof ECG transmissionsto EDs failed.

Meanpretestand post testscoreswere 15.80,6 and94.2% (Student's t-test,P < .0005),with retentionscoresix monthsaftercompletionof 90.206(P < .015).

Conclusion:Educationalprogramenabledparamedicstq accurately interpret I2-lead ECGsfor ischemiawith minimal declinein retention.

1 40 f;:l;til'"t.ress

ofthePrehospital EGG andThrombolytic

DJMagid.CBCairns, in PTPons, JS Schwartz/Denver AffiliatedResidency Emergerry Medicine, Medicine Research Center, Denver; Colorado Emergerry Leonard DavisInstitute of HealthEconomics, University of Pennsylvania, Philadelohia Background:Patientswith acutemyocardialinfarction(AMI) receiving thrombolytictherapy(TT) soon after onsetof chestpain (CP)havea greaterreductionin mortality than do patientstreatedlater.Prehospiul ECGdiagnosisof AMI and intiation of TT by paramedicshavebeen shown to reducethe time to treatment.

Study objective:To comparethe cost-effectiveness of threealtemate treatmentstrategiesfor the AMI patientwho activatesthe EMSsystem: I) PHECG:obuin prehospitalECGSbut initiate TT in the ED, 2) PHRX:obuin prehospitalECGsand initiate prehospitalTT; and 3) HOSPM: obtain ECGand initiate TT in the emergencydepartment.

Participants:Patientswith CP of lessthan six houn transportedby paramedics.

Setting:A midsizedurban EMSsystemsewing a population of 7I6,000 with 14 ambulanceunits and an averagecall load per ambu' lanceof 3,900pat'ients per year.

Desigr: Decisionanalyticmodel. Clinical and costestimateswere obtainedfrom GlSSl,lSlS-2,and pooieddata from all availableprehospiral ECGand TT trials. Keybaselineassumptionsincluded l) proportion of TT-eligibleAMI patientsamongall patientswith CP of lessthan six hours was 0.0,1;2) averagetime savedto TT with PHECGwas 30 minutesand with PHRXwas 60 minutes;3) reductionin mortality per hour savedfrom CP to TT was0.015; and 4) increasedrate of unnecessary treatmentusing PHRXwas 0.02.

Results:The incrementalcost-effectiveness ratio of PHECGcomparedwith HOSPRXis $12,826 per yearof life saved(YtS). The incrementalcost-effectiveness of PHRXcomparedwith HOSPRXis $ 19,751lYE. A one-waysensitivityanalysisshowedthat the incremental cost-effectiveness ratiosremain < $50.000/Yl5 for both PHECGand PHRXfor a wide rangeof assumptionsabout risk, benefis, and costs.

For comparison, CCUscost> $100,000m5.

Conclusion:Both prehospiralECGand prehospitalTT are beneficial and cost-effectivetreatmentsfor AMI Datients.

Paramedic-lnitiatcd llontransportrand Beleasosto BIS 1 -l nl I I Personnel: ls Therea Rolefor 0n-LineMedical Command?

DTKin,DCCone,SJ Davidsonpepartment Medicine,Medical of Emâ&#x201A;Źrgency College of Pennsylvania Studyhypothesis:Paramedicscannotreliably identify patientswho do not requireadvancedlife support (Al5) transportto the hospital.

On-line medicalcommand(OLMC) can preventinappropriate paramedic-iniriated non-transports(NT) and basiclife support releases (BR).

Design:BRand NT were retrospectivelyidentified from ambulance cali reports(ACR) and medicalcommandcontrol forms (MCCF) from May 1992 to October 1992. Emergencydepartmentdischargeor admission diagnosiswas obtainedfor transportedpatients.Patientsnot transported to the ED were contactedby telephoneto determineoutcome.

Usingclinicaljudgment, two authorcassessed eachBR/NT for appropri ateness.Appropriateness wasalso correlatedwith ED diagnosis.

Setting:A suburban,hospiul-basedA[5 servicewith 4,200 annual responses.

PolicyrequiresOLMC beforeall NT and BR. ParticipantslTwo hundred sixteenBRand six NT were identified; 28 caseswithout an ACR, MCCF, or follow-up da[awere excluded.One hundred eighty-nineBRand five NT were arnlyzedtogether.

Results:Forty BR/NT (21%) were inappropriate;25 of 40 (63%) had an ED diagrosis(17 admissions)indicatinga need for AIS care.One hundred fifty-four BR/NT(79%) were appropriate;sevenof.154 (4.5oA) had an ED diagnosis(four admissions)indicatinga need for AIJ care (P < .001by 292).

Paramedics appropriatelyidentilied89 of 98 (9t%) traumaBR/NTbut only 65 of 96 (680,6)medicalBR/NT(P < .00I by X2).OLMC was obtainedin lOt (52%) BR/NT.OLMC preventedsix inappropriateBR/NT,authorizedten inappropriateBR/NT,and preventedsevenappropriateBR/NT. Conclusion:Paramedicscannot reliably idenrify medicalparienrs who do not requireA15 transporrro rhe hospiral.OLMC can prevenr inappropriateNT and BR. Further study is neededto oprimizerheuse of OLMC in NT and BR.

pam izuros and0eath incocaine-Diaze 1 4l,llTffi' illl,l;;c"1ffi"3 flW Derlet,TEAlbertson/Division of EmergerryMedicine,University of California.

Davis.

School of Medicine Studyhypothesis:In a mixed cocaine-benzodiazepine intoxication, administrationof the benzodiazepineantagonistflumazenilmay unmaskseizures.

Design:MaleSprague-Dawley rats receivedinrraperironeal(lP) 100 mg/kg cocainealone,diazepamalone,or a combinationof 5 mg/kg diazepamand cocaine.Threeminutes later,groupswerechallenged with vehicleor 5 or I0 mg lP flumazenil.Animal behavior,seizures (time to and incidence),respirations,death(time to and incidence), (EEG)rracingswere recorded.Ten and corticalelectroencephalogram animalswereusedin groups l, 2, 3, 5, and 6 and 20 animalsin group4. lnterventions:Administrationof a benzodiazepineantagonistto animalsafter they had receivedcombination-dosscocaineand diazepam.

Results:ln group l, animalsreceivedcocainefollowedby vehicle.

This resultedin 100%developingseizuresand death.Group 2 received diazepamalone followedby vehicle.Animalsbecamesomnolentand none died. Group 3 rcceived dbzepam followed by 5 mg flumazenil.

Animalsbecamesomnolentafter diazepam,then activeafter flumazenil administration.In goup ,1,a combinationof cocaineand diazepamwas administeredsimultaneously.This resultedin no overt or EEGdetecubleseizuresand a 50% incidenceofdeath. Group 5 receiveda

combinationo[ cocaineand diazepamfollowedlater by 5 mg flumazenil. This resultedin an incidenceof seizuresof 90% (P < .01) and of deathof 10006(P < .0I). Group 6 receivedcocaineand diazepam followedby I0 mg&g flumazenil.In this group, seizuresoccurredin 9006of animals(P < .01) and deathin 90% (P < .05).

Conclusion:Flumazenilcan induceseizuresand increasethe inciintoxications. denceof deathin a model of combinedcocaine-diazepam I 'frl naThe Etlect ol Alphr-AdrenoceptorAgentsin l[onseizureI lnducedCocaincDeath University Medicine, of Emergency RWDerlet, TEAlbertson, J Tseng/Division Davis,$hool of Medicine of California.

Studyhypothesis:Death from cocaineintoxicationresultsfrom mul tiple mechanismsincluding seLures,cardiovascularcoilapse,and apnea.ln the free-movingrat model,continuousseizuresare the Primary we causeof death.To further study the role of o-adrenoceptors, suppressedseizureswith diazepamand investigatedthe effectofseveral cragentsthat affecto, and/or o, recePtors. rats receivedintraperitonealtreatment Desigr: MaleSprague-Dawley (lP) with vehicle,5 mgl<gdiazepamaloneor in combinationwith test agents:0.5 and ).25 mg/kg clonidine, 2.5 and 5.0 mg/tg phentolamine, or 5 and l0 mg&g prazocin.Five minutes after pretreatment,animals receivedI00 mg/tg lP cocaine.Eachtestgoup consistedof ten animalsexceptgroup I (20). Two animalsin groups I, 3, '1,5, and 6 had corticalelectrodesimplantedand EEGsmonitored.

Results: %Deett 2ndIniectiot %Seizurs Group lst Inioclion 'l Vehicle 2 Diazepm 3 Diazepm + clonidine 0.5 4 Oiazepm + clonrdine 1.25 5 Diazepm+ phentolamine 2.5 5 6 Diazepm+ phentolamine + pnzocin5 7 Drazepam 8 Diazepm + pnzain10 -Ps.(E. rP<.01.

Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cocaine Cmaine

rm 0 0 0 0 0 0 0

r00 5 4 5 5 6 0

0 0 0 0 0 ' 10r

Conclusion:Animals protectedfrom behavioraland EEGseizures with diazepamstill havenonseizuredeathsafterhigfr-dosecocaine.The incidenceof deathin theseanimalscan be further decreasedwith the pure c, blocker prazocinbut not other o agentsthat havecombinedc, and c, or soleo, effects.

CauseeSignificantand A i i Cocaineand Ethanolin Combination t trl ProlongedCardiacToxicity of BJHenning, E bvins,C Sutheimer/ Department LDWilson, J Glauser, 0hio TheMountSinaiMedical Center of Clweland, Emergerry Medical Services.

Studybackground:Simultaneouscocaineand ethanolabuseaffects 12 million Americansand is the most common polysubsunceabuse patternin emergencydepartmentpatients.

Hypothesis:Cocaineplus ethanolare more toxic to the heart than either cocaineor ethanolalone.

Design:Prospective,controlled trial. Dogswere randomizedto ethanol(l gkg lV over 20 minutesand then lO-mL NaCl bolus (five); DrW over 20 minutesand then cocaine(7.5 mg4<g)in lO-mL NaCl bolus (six); or ethanol(l g/kd and then cocaine(7.5 mgftg) in lO-ml NaCl bolus (six). lnterventions:Arterial, left ventricular,and pulmonaryartery cathetenwere placedin I7 closed-chest,intubated,anesthetizeddogs (meanweigfrt,20.8 k9. Hemodynamic,ethanol,and cocainemeasurementswere madeat control, afterethanol or DrW bolus every30 min-

utes for one hour, after cocaineor placebobolus everyminute for 15 minutes, and then every hour for five hours.

Results:Statisticswere performedusing ANOVA. Ethanolpeaked at 30 minutes(m = 160 mg%) and cocainepeakedat one minure (m = +,203 ng/ml) after bolus, and eachrapidly declined.Erhanoldid not sigrificantly changethe measuredvariablesover time in comparison with control. Cocainealonesigrificantly increasedheart rate (I50%), PAWP(l9l%), and MPAP(142%)and decreased venrricular contractiliry(,1206),relaxation(40%), SV (27%), and SVo, (17%) from control. Thesevariablesrapidly retumed ro control by 30 minutes.

The ethanol plus cocainegroup showed greaterand more siglificant changes(P < .00I) than either the ethanolor cocainegroup. Ethanol pius cocaineacutelyand significantlyincreasedheart rate (I73%), PAWP(223of), and MPAP(170%) and decreasedcontracriliry(73%), relaxation(8lof), SV (37%), and SVo, (37%). Thesechangesnever retumed to control; at |ive hours, contractility,relaxation,and SV were decreased 27obto 39oAand heart rate was increasedI 3506.

Conclusion:Cocaineplus ethanolin combinationcausedsubstantial and prolongedcardiactoxicity and are morc detrimentalrhan either cocaineor ethanolalone. .l GheotPainin an Emergency lltr Evaluationof Cocaine-lnduced | 'lrf DepailmentRapidDiagnosticrnd Trcatnont Unit WBGibler,DM Hull,BCLwy, RKacich,C Hamilton, BAWalsh/Oepartment of Emergerry Medicine andDivision of Cardiology, University of Cincinnati Medical Center Study objective:Patientspresenringto the emergencydepartment with chestpain after cocaineuse often require admissiondespitea nondiagnosticECG.This srudy evaluaredan ED diagrostic protocol asa safeand cost-effectivealtemative.

Desigl: Prospectivelycollecteddata over one year on patientswith chestpain and possiblemyocardialischemiaor acutemyocardialinfarction (AMI) after recenrcocaineuse.

Setting:Academic,university-based, urban hospital ED. Participants:Thirty-eiglrtconsecutivepatientsaged20yearsor more with chestpain and admittedcocaineusewithin one week beforeED visit. Twelvepatientswith remote(more than one week) cocaineuse wereexcluded.

Interventions:SerialECGswere performed everyZ0 secondsover a nine-hour period; CK-MB determinationswere performedat baseline and at 3, 6, and t hours. lfno ST-segmentelevation/depression or CKMB elevationwas present,the patient underurenttwo-dimensional echocardiography and gradedexerciseresring.Chargesfor parientsin the ED werecomparedwith hospital admissionfor standardrhree-day or lessmyocardialischemiaevaluarions(Srudent'st-resr;significrnce, P < .05).

Results:Only sevenof 38 patientswith recentcocaineuse and chest pain requiredhospitaladmissionfrom the ED (18.4%). ED testabnormalitieswere found in the following number of patients:CK-MB/CK ratio of rhabdomyolysis,thrce; serialECGs,three;echocardiography, two. No patienrhad AMl. The chargesfor parientsreleasedfrom the ED were$1,278(SD,$459)versus$2,810(SD,$1,025)for parienrsunder, goinghospitalevaluarion(P < .0001). Follow-up (one month) revealed no dearhsin patientsreleasedfrom the ED. Conclusion:ED rapid evaluationand releaseof patienrswith chest pain and nondiagr.osticECGsafter cocaineusewere shown to be safe and cost-effective comparcdwith in-hospitalevaluation.

.l Itr ElfectiveTreatmentol Acute Alkali Iniury to the Esophagusby | 'lf, ileutralizationThorapyWth 0range Juicc and Gola CSHonan,SBMaitra,8Pl-ane,HCThodeJr, J Finkelshteyn, GX Brogan/Trauma Research Labwatory, Departments of EmergerryMedicine, Surgery, andPathology. of NewYorkat StonyBrook Sute University Background:Neutralizationof esophageal alkali injuries with weak acid is generallycondemned.Aggressivetissuedestructionsecondaryto liquefactionnecrosisdicutes that treatmentbe early and aimed at blocking this reaction.

Hypothesis:Neutralizationtherapyis effectivein minimizing alkali induced esophageal injury.

Desigr: Prospectivecontrolledin vitro animal model.

Methods:HarvestedSprague-Dawley rat esophagiwere catheterized and placedin an oxygenatedsalinebath (37 C) for 60 minutesand then fixed in 1006formalin. Six groups (ten) were perfusedwith 5006NaOH. Neutralizationwith orangejuice (OJ) or colawas performedat zero, five, and 30 minutesalter injury. Blindedpathologicscoringof 0 (no injury) to 3 (severe)was performedfor six histologiccategories:epithe' lial cell viability (EV), cornified epithelialdifferentiation(CE), granular differentiation(GC), epithelialnuclei (EN), musclecells(MC), and musclenuclei (MN).

Results:Percenugeofesophagealinjury rated 2 or more areshown in the Table.

0J Ev CE GC EIr tC MN Cola EV CE GC EN MC }|ll 0Min l0 l0 40 l0 0 0 OMinl0 m 50 20 2 0 m 5 Min 60 S0 lm 60 70 30 5 Min 60 60 1@ 60 40 40 30Min100100 100 lm lm $ $Min l0 lm lm 80 100 lm Controlsshowedexpectedoutcomes.The Kruskal-Wallistesr showedsignificantdifferences(P < .0I) in all categories.Trend analysis showedgreaterinjury with delayedneutralization(P < .05).

Conclusion:Earlyneutralizationtherapywith OJ or cola reduces acuteesophageal alkali injury and supportsthis form of rherapy. ls MagnesiumEfficaciousin TricyclicAntdepressant 147 B0 Mau| MHMagoon, BASmith,CAButzinlointMilitaryMedical Command Emergency Medicine Besidency Program, SanAnt0ni0, Texas; Clinical Investigation Directorate, WilfordHallMedicalCenter, SanAntonio, Taxas Study objective:To determinethe effectof magresiumsulfateon the cardiovascularparametersin a tricyclic antidepressant(TCA) toxic rabbit model.

Design.:Prospective,randomized,nonblinded, placebo-controlled, two-armedstudy of two groups of ten inrubatedanimals(20). Under continuousECGand arterialpressuremonitoring, eachgroup received parenteralamitriptyline in DrW ar I mghin until ECG QRSduration increasedto 175oAo[ baseline(inrewention point). Arterial pH was controlled.

Intewention:MgSO, (57 mglkg) in DrW (study group) or an equal volume of DrW (control group) was infusedover one minute. Mean arterialpressure(MAP),heart rate (HR), ECG rhythm, QRS,and QT were measuredfor ten minutes.

Results:Eachparametermeanwas comparedbetweentreatmentand control animalsusing two-uiled ftests. Samplesizeprovided power of .8 to statisticallydetectdifferencesin MAP, HR, QRS,and QT of 14, 55, 22, and 35, respectively.QRSand QT changeswerenor sigrificantly differentbetweengroups.MAP decreasedinsignificantly(P = .l 37) and HR decreased significantly(P = .008) at rwo minutesafter MgSOr.Both MAP and HR retumed to control valuesafter four minutes.No consistent differencein grossrhythmscould be derected.

Conclusion:Although magnesiumhasbeensuggested as a therapeutic agentin TCA toxicity in human beings,no basicresearchexiststo validatesuch therapy.We found no beneficialcardiovascular effectsar the dosesgivenwith a TCA toxic animal model using eRS widening of 17506of baselineas rhe interventionpoint. More researchin this areais needed.

Brown BeclusoSpiderEmenomations andthe Elficacyof I nQ I -tIJ HyperbaricOxygen:A Prospectivo, Randomized Trial Utilizing the RabbitModel MLMaynor,BEMoon,B Klitznran, PJFracica, CBGerenfheHyperbaric Center, Departments of Plastic Surgery andPulmonary Medicine, DukeUniversity Medical Center, Durham, NorthCarolina; Departments of ChemistrvBiochemistry.

University of Arkansas, Fayettwi lla Background:LRectusahas achieveda greardeal ofnotoriery in recentyearsfor rhe severityof its dermonecroticenvenomations,often leadingto severecosmeticallydisablinglesionsthat can requireextensivesurgicalrepair.Varioustherapieshavebeensuggestedto be of benefit,includingearly/lateexcision,Dapsone,and antivenin,but all of thesehavedisadvantages.

Severalrecentreportshavesuggested that hyperbaricoxygen(HBO) may be of benefirin healingrheselesions.

Methods:To delineatefurther the role of HBO in the marugemenr of L Reclusa bites,we randomized37 New ZealandWhite rabbitsand 58 injectedlesionsto the following six rrearmentgroups:l) LRulusa venomand no HBO, 2) venom and one immediateHBO rrearmenr (10006O2),3) venomandimmediateHBO for ren rrearmenrs (10006 Or), 4) venom and delayedHBO (48 hours) for ren trearmenrs(100% Or), 5) venomand immediateHBO for ren trearmenrs(9"6 O2), 6) sodium citratebuffer injectionsand immediateHBO for ren rreatments (10006O2).Allvenominjecrionsconsisred of 73 mLof rawvenom extractmixed with physiologicbufferedsaline(Dulbecco'ssolurion), and all HBO trearmenr wereat 2.5 atm (.t8 fsw) for 90 minutes.Daily measurements were madeof the injectedlesiondiametersusingvisuai observationwirh photographyand of rhe local blood flows at the woundcenter,aswell as I to 2 cm out, usinga laserDopplerprobe from day 0 to day i 0.

Results:The Tableshowsthe tabularedmediansfor all six groups for wound diameters.

WoundDhndcn lml 0 Controls Delayed H80'10 lmm€d H80'10 lmm€dH80'1 NaCit'H80'10 lmmed H80''ll0 19%0?l

D|y 5 6

1

2

3

t

0 0 0 0 0

2.5 2.0 1.5 0.87 0

3.0 2.0 1.8 t.5 0

3.5 2.0 1.8 1.1 0

3.5 2.0 1.8 1.6 0

3.5 1.5 t.5 1.6 0

0

2.0

2.5

3.0

3.0

3.5

t

t

9

1

0

4.0 1.2 |.2 1.6 0

4.0 1.1 1.2 1.1 0

4.0 1.1 1.2 1.7 0

4.0 Lr 0.9 1.6 0

4.0 l.l 0.9 1.6 0

3.5

4.0

4.0

4.5

4.5

All groupswere comparedsutisricallywith analysisof variance regardingwound diameer and blood flow. Within all groups,there wassutisticalsignificancebetweenthe controlsand the HBO-treated animalsfor wound diameter(P = .000I). For blood flow, rhe difference betweenthe HBO-trearedlesionsand conrrolswas not statisticallv significant(P = .I905). Histologically,rherewasmore evidenceof lesionhealingin all I00% O, HBO-rreatedgroups than rhe conrrols.

Conclusion:We believerharHBO signifiently improvesthe healing of lesionsin this rabbit model causedby L Raclusa.

Theredoesnot appearto be any major effectby HBO on losl wound blood flow in our studv.

I 49 Poloxamer 188asr TroatmentforThird-Degree Burns PWPaustain.

AHChuang, JCMcPherson lll,JCMcPherson JrAection of Emergerrcy Medicine, 0epartment of Surgery, Medical College of Georgia, Augusta; Department of Clinical Investigation, Eisenhower ArnryMedical Center, FortGordon, Georgia Background:A I 0% solution of poloxamerI 88 in NaCl solution has beenapprovedfor bum therapyin clinical rrials.No reporrsof its ellectivenessin human or aninul bums havebeenoublishedasvet to our knowledge.

Study objective:To study the effecriveness of poloxamerlB8 administrationon the healingof third-degreebums in rars.

Design:Twenty malerats receivedan 806body surfaceareathirddegreebum (I2 secondsin a 70 C warerbath) followed 30 minures later with an lV injection of saline(ten controls)or poloxamerI88 solution(I0 g poloxamer188 in I L of 0.6506NaCl,ten rars).Dose was 8 m[./kg body wt. The poloxamer188 solution wasadministered intraperitoneallyeveryeight hours for 72 hours becauseof its biological half-life of four hours. lmmediatelyafter the bum, the areaof the wound and the wound temperature(thermogram)weremeasured.

Measurements wererepeatedat 48 hours.

Results:The bum areaswerenot significantlydifferent(analysisof variance)initially or 48 hours later:immediate:S = 24.7 t 2.3 cm2 versusP = 25.4*.I.7 cm2;48 hours:S = 16.613.4 cm2versus P = I8.8 t 2.3 cmz,P = NS.Wound skin temperatures wereno! differenrbetweenthe two groupsar any rime.The wounds appeared visuallyidentica'lin both groups.All bums formedescharsthat separated spontaneously,leavingopenwounds through threeweeks,but closedat four weeks,ie, therewasno differencein the rate of healing.

Conclusion:ln our animal model, poloxamer188 treatmentafter the bum appearsto offer little advantageover more conventionalfluid thempy,at leaston the parametersthat we obsewedor measured.

1 50 ilt$liil,.ril"'"'o

Decreased Fluid Balance Following

BTBrofeldt,BAGunther/Division of EmergerryMedicineandDepartment of Surgery, University 0f California, Davis,School of Medicine Studyobjective:o-Myo-I,2,6-inositolrriphosphate (o-Trinositolor u.-T)hasbeenshown to decrease extravasationof Evansblue albumen aftersmall bum injury in ras. In this srudy, the effecrsof o-T on fluid balanceand edemaformationwereevaluatedin a large300,6surface areainjury in 40-kg sheep. lnterventions:Sheepwere surgicallypreparedwith prefemoral lymph fistulasand vascularcatheters.One hour after thermalin1ury, resuscitationwith lactaredRinger's(LR) was iniriared(4 mUkg) along with infusion of a secondblinded solution of eithernormal saline(NS) (six) or 2 mg/kg bolus of o-T followedby conrinuousinfusion ar 3.5 m{kglhr (six). LR infusion ratewas adjustedto retum cardiacoutput (CO) to t I006of baselinewirhin eightto l2 hours.

Results:Dataareexpressedas meant SEM.By one hour, CO droppedfrom 5.2 + 0.1 to 3.5 + 5 Umin in the C groupand from 5.0 + 0.1 to 3.4 + 0.2 Umin in rheo-T group.By 12 hours,CO wasat baseline,berng5.2 t 0.2 in rhe NS group and 5.2 t 0. l7 Umin in the cr-Tgroup. Net fluid balancear 24 hours wirh NS was 3,I90 + &Z nL and wassigrilicantly lesswith c-T, 908 + 508 mL (P < .001), Resusctation volume with NS was4.3 + 0.55 L and was 3.5 t 0.35 L with o-T. Toul urine output was 677 Xl2l mL in rhe NS goup and 1,896+ 415 mL in the c-T group (P < .00I). Afrer 24 hours, rhe lymph flow was 17 timesbaselinein rhe NS group and only 8.5 timesbaselinewirh o-T (P < .001). Plasmavolumewas similar in both groups.

Conclusion:o-T resultedin a lower positivetluid balanceand a reductionin lymph flow. c-T may help resolveposrbum edemaby faciliuting mobilizationand excretionof fluid.

1ltrt Gorrelationof NoumlogicDysfunction andBrain Histologic I rf I DamageAfter Asphyxial Cardirc Amrt in lats FXiao,PSafar.A Badovsky, L Katy'lnternational Resuscitation Research Center, University of Pinsburgh, Pennsylvania Studyobjectives:To examinecorrelationsof neurologicdeficit scores(NDS) and overallperformancecaregories(OPC)in rarsafrer cardiacarrest,with histoparhologicdamagescore(HDS), for reliabiliry of model.

Desigr: After prepararion,l2 ratswere imulted with eight minutes of apneicasphyxia(five minutes of no flow), reversedby exremalCPR, epinephrine(0.01 mgtkg IV), NaHCOufl.O mEq/kg lV), IPPV/O2ro one hour, and ob'servationto 72 hours. They were randomly assigled to two groups:group A, with tympanicmernbranetemperaturemaintainedat 37.5 C throughout;and group B, wirh rympanicrempemrure 34.0 C inducedbeforearrcstand maintainedto one hour after arrest.At one hour, 24 hours, and 72 hours after restorationo[ spontaneouscirculation,NDS (006,besr;100%,worsr;includesconsciousness, respiration, cranialnervereflexes,motor response,sensorycoordination)and OPC (l, best;5, worst; includesreacrionto pain, moving, earing,drinking) were determined.At 72 hours, all ratswere eur.hanized with perfusion fixation,and about 50 coronalseclionswere examinedby light microscopy.The proportion of ischemicneuronswas scoredin I3 brain regionsby a pathologis!who wasunawareof the treatmentprotocol and NDSor OPC. Results:All ratswere resuscitatedand survivedto 72 hours. NDS, OPC,and HDS at 72 hours weresigrrificantlybeuer in goup B than in group A (< .05). The Pearsoncorrelarioncoefficienrof NDS versus totalbrain HDSat 72 hourswas.83 (P < .001)and of OPCversustotal HDSwas.80(P < .001).

Conclusion:Our esublishedasphyxialcardiacanest rat model resultsin functiorul deficit with quantiutive brain morphologiccorrelates.The changesyield ro mild prorecrivehypothermia.Thesefindings enhancethe model'susefulnessfor screeningcerebralresusciution potentials. tlf.t NeuronalGolgiApparetrcUttraEtucfurcDuringBrain a JL Reperlusion J frafols, A Oaya,I White/Departmsnts of Anatonry andCellBiology, Emergerry Medicine, WayneStateUniversity School of Medicine, Detroit, Michigan Studyobjective:Histologicand biochemicalevidenceindicatesthat freeradicalsprimarily damagelipids in selectivelyvulnerableneurons (SVNs)during brain reperfusion.A largeconcenrrarionof lipid peroxidation productsis seenat the baseof the apical dendritewhere the Golgi apparaus is located.This study examinesGolgi ultrasrructurein SVNsduring reperfusion.

Methods:We srudiedthreegoups of rats:normals;ten-minute KCl-inducedcardiacarrest,resuscitation,and 90 minutesof reperfusion; and 360 minuresof reperfusion.Ratswere perfusion-fixedwith cold paraformaldehyde/glutaraldehyde after a salinewashourrhrougfra ventricular catheter, and the brains then werc immersed in cold fixative ovemight.The hippocampalCA zonesand dorsalateralcorrexwerc microdissectedfrom 300-pm vibratomesectionsand examinedby electronmicroscopy.Light microscopic examinationconfirmed adequate fixation.

Results:After 90 minutes of reperfusion,two prominent ultrastruc' tural changeswereseenin SVNs.Althouglr the rough endoplasmic reticulum appearedlargelypreserved,the many polyribosomerosettes ob,sewedin normalshad largelydisaggregated, and numerousfreeribosomeswereseen.The Golgi cistemaewere dilated,and in many instances,cistemalstrucrurehad beenlost, with the Golgi appearingas an agreg te of largevacuoles.Furthermore,both the remainingGolgi cistemaeand the vacuolesweresurroundedby numeroussmall vehicles that appearedto be clathrin coated.In someGolgi, thesevesiclescover the surfaceof the cistemaein multiple layers.Structural damageafter 360 minutesof reperfusionwas enhanced.

Conclusion:Golgi morphologyin SVNsis substantiallyalteredearly during postischemicreperfusion.The appearanceof numerousclathrincoatedvesicleson the Golgi is consistentwith a putativeattempt to recycleperoxidativelydamagedmembraneby endocytosis.Spcha processcould accountfor the concentrationof peroxidationproducts obsewedin this areaof the cell by fluorescencetechnique.

1 53

cellDeath Aftor lrlouronal ,Jfi'.rr1ilfrfil'cal-lnduced

8J 0'Neil,S Chapman, BCWhite/Department of Emergency Medicine, &hool of Medicine, WayneStateUnivsrsity, Detroit, Michigan Studyhypothesis:Freeradicalreactionsprimarily damagelipids in selectivelyvulnerableneuroru during postischemicreperfusion.The capabilityof terminallydillerentiatedneuronsfor early lipid neogenesis or reacylationmay be limited becauseof coregulationof DNA replication and lipid synthesis.We hypothesizethat neuronaldifferenriation increasesvulnerabiliryto radical-inducedcell death.

Methods:NeuroblastomaBI04 cells,which can be differentiated to neuronsin the presenceof dibutryl cyclic AMP (cAMP)and theophylline, weresimultaneouslysubculturedinto mediawith and without I mM cAMPand theophylline!growr 72 hours, and microscopically examinedto confirm neuronaldifferentiation.Addition of I pM cumenehydroperoxideand I pM FeSO,exposeddifferentiatedand undifferentiatedcells to alkoxyl radical.The reactionwasstoppedalong a time coursein I mM DETAPAC,and blinded observersused trypan blue exclusionto assess viability in 500 cells per sample.Triplicate trials that includedcontrolsnot exposedto the radicalwere compared

bvr-resr"t"w

30 Difhronti.ted87tl Undifhrcnlialod 94tl

t5

72xl 65tg 55tB 55*14 37tn 9l *4 81nl0 7915 76t I 76t I

(%viable1SEM) (P<.061

Results:In the presenceof the radicalsystem,viability losswas sigtificantly increasedin the differentiatedcells; therewasno lossof viability without cumenehydroperoxideand iron.

Conclusion:The rateofcell deathafter radicalexposureis increased sigrificantly after Bl04 cellsare diflerentiatedto neurons.Further studies in this systemof the rate of lipid synthesisand reacylationand of mRNA expressionfor the enzymesinvolved in thesereactions may illuminatepotentialcausesfo; this phenomenon. tlE A Treatmentof ilaurochorical Alterationr Cauredby Gortical I rl.t lmpact Iniury in $e Bat MH Biros/Department of Emergency Medicine,Hennepin CountyMedical Center, Minneapolis, Minnesou Studyobjective:To investigatethe effecs of dichloroacetate(DCA) 2l aminosteroidU-74006F tirilazadmesylate(A5), and hyperbaric oxygen(HBO), aloneor in combination,on cerebraleilema,tissuelactic

acidosis,and membranelipid peroxidationaftercontrolledcortical impact injury (CCI) in the rat.

Desigr: Anesthetizedrals were subjectedto moderatelysevere CCI (impact depth, 1.5 mm; speed,3.5 rn/sec)followedby 30 minutes hypoxia (13% oxygen).Nine sham-operative animalsweresimilarly prepared. lnterventions:One hour after CCl, animalswere randomizedto receiveIP DCA (25 mg/kd, AS (5 mg/k&),AS vehicle(r'H), or normal saline,deliveredblindly. At four hours after trauma,animalswere again randomizedto receive60 minutesof HBO (1.5 ATA), 100%O, (100%), or room air. After the final randomization,all groupshad ten to l7 animals.Immediatelyafter exposure,anirnalswere killed, and tissue specificgravity,lacute, and thiobarbiturateproductswere determined from the traumasite.Statisticalsignificancewasdeterminedwith ANOVA and evaluationof 95% confidenceintervals.

Resuits:All animalswith room air exposurehad elevatedlacute unlesspreviouslytreatedwith DCA. One hundred percent02 and HBO loweredlactatein all treatmentgroups ro levelsequal ro shams.Water content(specificgavity) was reducedin DCA-treatedanimalsexposed to 10006O, and HBO, as well as in AS and VH animalsexposedto HBO. Thio6arbiturateswere increasedin all goups exposedto 100% O, and HBO: Treatmentwith AS tendedto lower thiobarbituratesat the traumaslte.

Conclusion:Reductionof elevatedwatercontentand tissuelactate afterCCI may be possibleusing combinedtreatmentwith DCA and HBO or 1000602. DCA alonealsoreduceslactateat rhe rraumasire. { f f The Prevalenceof lntracranialIniurier Requidng0perativa I rlJ Interventionin Mild HeodIniuriot SA fthillinger,A Bodriquez/Department of Emergency Medicine,Northeastern 0hioUniversities, College of Medicine, AkronCityHospital, Akron,0hio; Maryland Institutsfor EmergerryMedicalServices System,University of Maryland School of Medicine, Baltimore, Maryland Study objectives:To determinethe prevalenceof intracranial injuriesrequiring operativeintervenrionin mild closed-headinjury and to correlateGlasgowComaScale(GCS)scoringwith cranialcomputed tomography(CT) findingsand need for surgicalinrervenrion.

Design:Retrospective reviewoftrauma registrydatacollectedfrom July I987 throughJune1991.

Setting:Urban universiryLrvel I traumacenter.

Participants:Threethousandeight hundred four consecutiveadult patientswith closed-headinjury, losso[ consciousness, no evidenceof skull fracrure,absenceo[ focalneurologicdeficirs,and GCSof l3 to l5 in whom cranialCT scanningwas performed. lnterventions:GCSscoringwas performedby the trauma fellow.

Datawereanalyzedto correlateGCSscoreswith posiriveCT findings (definedas intracranialhematoma,cerebralcontusion,cerebraledema, or subarachnoidhemonhage)and the need fot surgicalintervention, Results: Of the 3,804patients,2,578(68%)had cCS of l5; 990 (26%) had GCSof 14; and 23 (6%) had cCS of I 3. Among parienrs with GCSof 15, 157 (6%) had posirivecT findingsand 15 (0.6%) requiredsurgery;for patienrswirh GCSof 14, 188 (I906) had posirive CT scansand 24 (2.4%) requiredsurgery;and amongparienrswith GCSof 13, 66 (28%) had positiveCT findingsand l8 (7.6%) required surgery.Therewasa significant(P < .05) corrclarionwith decreasing GCSscoresand both posiriveCT findingsand the need for surgical intewention.

Conclusion:lntracranialinjuries are common in patientswith closed-headinjury and GCSof l3 ro 15, with the prevalenceof both positiveCT findingsand rhe need for surgicalinrerventiondirectly

conelatingwith decreasingGCSscores.However,a GCSof 15 does not excludethe possibiliryof seriousintracranialinjury.

-

?ra

I 5b leck of Standardein Animal GPRResearch Medicine, of Emorgency D 0rban/Division V Wenzel, A ldris.B fuerst,L Becker, of Department Gainesville; University of Florida College of Medicine, lllinois Medicine, University of Chicago, Emergerny Studyobjective:Therehasbeenrecentinterestin improveduniformity of methodsand reporting for human CPRstudies.The objectiveof publishedanimal CPRsrudiesfor uniformity ol this study was to assess methodsand definitionsregardingsuch important hctors asventilation, chestcompression,coronaryarteryperfusionpressure(CPP),and circulation(ROSC). retum of spontaneous Desigr: We reviewedthe methodologydescribedin 40 articles concemedwith animal CPRresearchpublishedduring the past ten years.Nonresusciutionmodelswere excluded.

Resuls:The experimenulmethodsfor ventilationand perfusion rangedwidely (Table).

Varirble %RoDoiod Rsnge Ventilation Typeofventilator 90 Bare 78 Pressure 35 F,o, 93 35 Tidalvolume Chest compressim 88 Bate IDrcE bJ Depth 4l 0uration ofventricular fibrillation lm Oefinition of CPP 50 oefinition ot RoSC 60 Duration of BoSC 28

l4 Volune-cycled 21Pressure-, 12to 16perminutâ&#x201A;Ź 18to40cmHrO 0.21to 1.0 l0 to30mvkgbodywt perminute 60to 120Compressions 30to 150lb 1 . 5t o3 i n .

0 to 15Minutes definitims 5 Different 22Differentdefinitions defined ROSC l0 Different durations

Conclusion:Imporunt differencesexist in CPRmethodologyamong researchcenters.Failureto defineor report minute ventilation,CPP, and ROSCmadeit diflicult to comparestudies.To makevalid comparisonsof studies,it is essentialto standardizedefinitionsand to report measurements such asminute ventilationand CPP. .lE', SelectiveAortic Arch PedusionWth 0xygonated I rl f Fluorocarbonr Combined YVi$AorticArch Epinephdne AdninistrationDudngCPR JE Manning, DNBatson,CAMurplryJr, SGPenetta,RAMueller,EA NorfleeVDeparments of Emergency Medicine, Anesthesiology, andSurgery, University of NorthCarolina at Chapel HillSchool of Med'rcine Studyobjective:Selectiveaonic arch perfusion(SMP) usesa descendingaortic arch (Ao) balloon catheterto perfusethe heart and brain during CPR.SAAPwith oxygenatedfluorocarbons(O2'FC) plus Ao epinephrine(EP)wasstudied.

Desigr: Randomized,controlled,blinded.

Participants:Twenty-onedogs.

Interventions:Anestherizedanimalswith micromanometerand SMP cathetersunderwent I 5 minutesof ventricular fibrillation, then one minute of CPRfollowedby one of three protocols:group I (seven), 0.0a mg&g EP,peripheralIV; group 2 (seven),0.04mg&gAo EP;or group 3 (seven),0.04 mg/tg Ao EP plus 90 secondsof SAAPwith 15 mUkg O'-FC (perfluorodecalin,the main FC) surting 30 secondsafter EP. Eachgoup had threeminutesof post-EPCPRbeforccountershock and up to 30 minutesof advancedcardiaclife support. CPR-diastolic aortic (dAoP),right atrial (dMP), and coronaryperfusion(Cpp = deop

- dMP) pressureswere analyzed.by ANOVA and t-test.Animalswith retum of spontaneouscirculation (ROSC)had l2 houn of computerized EEGmonitoring.

Ephephinr Group

PrrEP

IlrrcEP

{lrrcEP

ICPP l0i3 l4t4 At8 ?CPP l2n5 34t10.

36*ll' 3CPP 8*4 24tl3.SMP43i9 ldAoP t913 23*7 n*.12 2 dAoP l8 15 45t12' 49*14' 3dAoP 16i3 36112'SMP 6l t3.t 'P<.05versusgroup l. rP<.05versus group 2.

0ata:mmHg,mean tso.

glr.cEp

24t12 40*10' il8*6'r 34rt6 54*13.

66ts't

&rrcEP

nt14 42+11' 47*1' 39120 56113' 6815*t

lOrrcEP

R0SC

35i16 Sotj 43t10 7 otj 45*12 6of7 49121 56+lI 75+4*t

Resulrs:dAoPand CPPincreasedrapidly after Ao EP in goups 2 and 3. SAAPin group 3 markedly increaseddAoPand CPP,bur CPP plateauedas dRAPrise matcheddAoP after 30 secondsof SAAP. ROSCand l2-hour EEGrecoverywere similar in eachgoup.

Conclusion:SAAPwith Or-FC plus Ao EP improved CPRhemodynamicssigrificantly over lV EP but only modesrlyover Ao EPalone.

ROSCwasnot improved. Further srudy wirh refinemenrsin SMP perfusateand infusion parametersis needed. { trO A Gomparisonol Effectsol GentralVersusPeripheralDrug I rflf AdministrationPlur DifferentSizcdPostinlusionFlushoson DrugDeliveryto the Aortic Rootin a CaninoCardiocArrestModel M Dolister, GMGaddis, MLGaddis/Departmonts of Emergency Medicine and Surgery, Truman MedicalCenter, University of Missouri-Kansas City,School of Medicine Background:Centralcircularion drug deliveryduring CPRthrough peripheral(Per)versuscentral(Cen) lV administrationfollowedby differentpostinfusionfluid flush volumeshas nor previouslybeen directiycompared.

Hypothesis:Centralcirculariondrug deliveryduring CPRis not compromisedby Per infusion if an adequateflush volume follows Per drug injection.

Desigr,, methodsand inrervenrions:The deliveryof indocyanine green(lCG) to the aorricroot of an insrrumented,necropsy-verified, 20-kgcaninecardiacarresrmodelwasexamined.ICG (2.-5mg) preceded a 2-mL or l0-ml lluid flush for both Cen and Per roures.Five dogs underwen!three rounds of rhe four Dossibleroutey'flush combinations in stratifiedrandomizedorder. Real-iimedye concentrationve6us rime curvesdocumentedcentraldrug delivery.Systolicand diastolicarterial pressureswere monitorcd. Two-way repeated-measures A.NOVAwith a leastsigrificant difference([SD) test for ANOVA (P < .05) analyzed. data.

Results:Seconds(meant SD) ro onser(ON*c) of dye appearance differedsignificantlyberweenPer/2mL (16I t 76) and Cen/10mL (108 t 35) but not berweenPer/I0 mL (126 * 35) versusCenlI0 mL or versusCen/2mL (123 t 3I) (ANOVA,P = .032;tSD, 43 seconds).

Secondsto peak (PK*") dye concenrrariondid not differ sigrificanrly betweenPerllO mL (230 t 88) versusC-en/10mL (202 t 88) or versus Cer/2ml (215 t 83) bur differedberweenPer/ZmL(316 t I34) versus everyother routey'flush combination(ANOVA, P = .009; LSD,92 seconds).Sixty-oneand 149 would havebcenrequired to achievea power ) 0.8 for the Cen/I0 mL versusPer/I0 mL comparisonso[ ON*. and PI!*, respectively,given our results.Peakdye concentrationand systolicand diastolicpressures(averaging23ll 0 mm Hg for all flusheVroutes)did not differ sigrificantly berweenall routey'flush combinations.

Conclusion:An adequatelysized(0.5 mUkg) postinfusionflush permitsperipherallyadmininistereddrugs to reachthe centralcirculation as quickly, with equivalentconcentration,as centrallyadministered drugs during cardiacresuscita!ion. t trO The Effectof Suppltmontal Perlluorochenical Administration I Ua, on Hypotemiy! Rcruscitationol SoveroUncontrolled Hemonhago RWMillard/ AJ McGoron, SA Stern, SCDronen, X Wang,K Ctnffins, andCell of Emergsncy Medicine,Department of Pharrnacology Department MedicalCenter, 0hio Biophysics, University of Cincinrati Studyobjectives:Althouglrhypotensiveresuscitationof uncontrolled hemorrhagehas beenshown recently to minimize hemorrhagevolurrn and mortality,it is at the expenseof tissueperfusion.Addition of an Orcarryingperfusatemay improve tissue02 deliveryduring hypotensive resuscitation.We comparedhypotensiveresuscitationof severeuncontrolled hemorrhagewith and without supplementationwith an emulsion an Or-carryingperfusate. of perfluorooctylbromide, Design:Fifteenswine (15 to 22 kg) with 4-mm aortic tearswere bled to a pulsepressureof 5 mm Hg and then resusciuted(estimated blood loss,40 to 50 ml^d. lntewentions:All animalswere resuscitatedwith normal saline, (6 mUkg/min), infusedas neededto maintaina meanarterialpressure of 40 mm Hg. Group I alsoreceivedan infusion of 6 m[/kg perfluorooctylbromide.Group 2 sewedascontrolsand receivedan equal volume of placebo(NS). Animalswere observedfor 120 minutesor until death. analysisof Results:Datawere comparedusing repeated-measures variance,the Student'st-test,and Fisher'sexacttest.O, contentand deliverywere significantlygeater in the treatmentgroup. O, content and deliverynadirswere significantlylower in controls.Two-hour mortality rateswere 12.5%and 4306for groups I and 2, respectively (P = .23;950,6confidenceinterval for the difference,-l3ob to74%).

Conclusion:Administrationof an Or-carryingperlluorochemical sigrificantly improvesO, deliveryin hypotensivecrystalloidresuscitation of severeuncontrolledhemorrhage.

160i:illilffi^"giotensin||DuringCardiacArrgstand Ml Eose, NAParadis, M Blucher/Department of Surgery, Division of Emergerry Medical Services, Bslla/ueHospital Center, NewYorkUniversity MedicalCenter Study objective:Retum of spontaneouscirculation during CPRis a function of coronaryperfusionpressure,which is itself a function of arterialvasomotortone.Vasomotortone, in tum, is determinedby the relativestimulationof arterialvasoconstrictingand vasorelaxlngreceptors. We measuredthe plasmalevelsof angiotensinll (ANG II) dunng spontaneouscirculationand CPRto determinethe effectof global ischemiaand CPRreperfusionon this endogenousvasoactivepeptide.

Desigr: A standardcaninefibrillatory model was usedwith down timesof more than ten minutes,during which no therapy,including basiclife support,wasgiven. Micromanometerciltheterswere placed for measurementof perfusionpressures.Advancedcardiaclife support (ACI-S)was initiated at the end of the down time with manual extemal chestcompressionstandardizedto an esophageal pulse pressureof 50 mm Hg. Blood sampleswerc collectedthrough the aortic catheterduring spontaneouscirculationand three minutesafter initiation of AC[S. Peptide levelswere measuredusing sundard radioimmunoassaytechnique. Resultsare reportedas meant SD (pglml). Plasmaconcentrations were comparedusing a two-sidedttest.

Results:Thirteenanimalswere studied.The arrestintervalwas 1,++ 4 minutes.ANG ll levelsincreasedfrom a baselineof 14.7 t 12.9 pglml- during sPontaneouscirculationto 15I t 105 during cardiac arrestand CPR(P < .05).

Conclusion:EndogenousANG ll levelsincreasedduring CPR.This may be the result of aiute renal ischemia andlor sympathetic stimulaAl"lG II augments tion secondaryto elevatedlevelsof catecholamines. the releaseof adrenal catecholaminesand actssynergisticallywith them oncethey havebeenreleased.However,the increasein endogenous levelsappearsinadequateto improve oulcomesigrrificantly.

ExogenouslyadministeredANG II could be elfective'imProvingvital ano resPonseto exogenousvasoPressors' organperfusionPressures! outcomeof resuscitativeeffons.

DurationandVolocityon Resuscitation ^ E ^ Ellectof Comnression

GPR DudngHigh'lmpulse I O I Xrtoavnamics ofEmergerny SJameson/Department DJDeBehnke, JBMateer.

GLSwart.

Milwaukee ofWisconsin, Medical College Medlcine, higfr-impulse whethermechanical To determine Studyobjective: with durationcombined compression CPR,includingshortened hemo-dynamics resuscitation velocity,improves compression increased comparedwith standardmechanicalCPR. Designand interventions:The study was performedin 12 anesthettedswine (20 to 25 kg). The animalswere instrumented (aorticand right atrial Pressurecatheters,aortic llow velocirysensor) waveformrecordingsystem. and monitoredby a computer-based Ventricularfibrillation was induced and continued for threeminutes without interventionand was followedby ten minutes of SCPR:rate, I00; compressionduration, 50%; stroke depth,4 cm; and cylinder driving pressure,50 psi. HICPRwas then appliedwith the following constants:rate, 100; stroke depth, 4 cm; cylinder driving pressure,70 psi (to increasecompressionvelocity).Compressionduration of HICPR wasvariedrandomlyat two-minute intewals for 20% (C20), 3006 (C30), and 4ooh(C4O)of the duty cycle.An SCPRtwo-minute control intervalwas then repeated. were significantlyimproved Results: Hemodynamicmeasurements mean for C20 and C30 comparedwith SCPR,including, resPectively, arterialpressure,45 t I and 43 t 7 versus36 t 7 (mm Hg t SD);and cororury perfusionpressure,2l i 6 and 2l t 8 versus16 f 6 (mm Hg t SD).MAP and CPPduring C40 were not sigrific:ntly differentfrom SCPR,and therewasno differencebetweenC20 and C30. Aortic flow velocitywassignificantlyimproved in C20, C30, and C40 compared 2.3 t0.7.2.1 t 0.9.and 1.95t 0.9 versusI.3 + 0.5 with SCPR: (cm/second1SD). AFV wasnot sigrificantly differentberweenC20, ANOVA C30, and C40 (all comparisonsP < .05, repeated-measures with Bonfenonicorrection).

Conclusion:ln a swine model of HICPR,a shortercompression durationcombinedwith increasedcompressionvelocitysignificantly improvesresuscitationhemodynamicscomparedwith SCPR. '{|Crl, Changesin Respiratory During SystemGomplianco ArrestWth andllUidroutClosed-Chest I U4 Cardiopulmonary Compressions of Emergency V Wenzel, DJ0rban/Division flS Fuerst, AHldris,MJ Banner, Gainesville of Medicine, of Florida College Medicine.

University Study objective:Respiratorysystemcompliance,which is composed of lung complianceand chestwall compliance,is a sigrrilicantfactor affectingventilationduring cardiopulmonaryarrest(tidal volume equals in Co predispose C", timesthe changein airwaypressure).Decreases to hypoventilationduring cardiopulmonaryarrest.No previousstudy

has directly measuredCRSearly in the course of a cardiopulmonary arrest or investigatedthe effectsof closed-chestcompressionson C*, over time. Our obiecdvewas to study the changesin C*, over time during cardiopulmonaryarrestwith and without chestcompressions' We hlpothesized that chestcompressionshave an adverseeffect on C*r' laboratoryinvestigation Oeilgn: We performeda repeated-measures, using a swinecardiopulmonaryarrestmodel' Founeenswinewere studiedin two groups.C", wascomparedwithin and betweengoups for differencesover time uiing the Friedmantwo-wayANOVA, the Wilcoxon signedrank multiple comparisonstest,and the MannWhitney U test.o was setat '05' lnterventions:Ventricularfibrillation was inducedin both groups' and goup B (six) Group A (eig!t) receivedno chestcomPressions minutesafterarrest five beginning compressions receivedclosed-chest with a mechanicaldevicefbr 60 minutes.C", was calculatedfrom an at specilictime intervalsfrom 0 to 60 averageof five measurements minutesin both grouPs. SeeTable.

Results: iltslch 07oup {min} C--(mucmH,0)measured 0 1 0 1 5 m 3 0 f 5 m 2t X6' nr'7 nX6 Nocompressions 29i6 25t41 23!31 21t41 28t3 Co.p,.itlt* + S0. aremean Values 'P < .[Ecomoared at sametirne withothervariable rP< .05compared withsarE\atiaueat tlrâ&#x201A;Ź 0.

C*, decreased significantly more it"lfioio", receiving chest coripressions than in animals not

25X5'r 2515't 25*5't lgt4lt lgt4*t 1814'r

and sooner in animals receiving chest com-

pressions during cardiopulmonary arrest.

UsingCardiopulmonary FllThs TimeLinitg 0l Bosuscitation ElectomechanicalDissociation I OJ avp".t in Experimental of MedicalCollege Medicine, of Emergency DJ DeBehniilDepartment Milwaukee Wisconsin, Studyhypothesis:&rdiopulmonary bypass(CPB)hasbeenshown to be an'effeitivereperfusiontool in animal modelsof prolongedventricular fibrillation, The use of CPBin resuscitationfrom prolonged dissociation(EMD) hasnot beenstudiedextensively' electromechanical Our null hypothesissuted that there is no differencein the rateof retum ofspontaneouscirculationusing CPBafter ten, I5' or 20 minutesof untreatedEMD. Desigr.:ProspectivecontrolledlaboratoryinvestiSationusing a caninemodel of EMD. lnterventions:EMD was producedby ciampingthe endotracheal tube and was definedas the presenceof ECGcomplexeswith complete absenceof aortic Pressureflucnrationsby aortic catheter.Twenty dogs were randomizedto remainin untreatedEMD for ten minutes(group I ' seven),15 minutes(group 2, six), or 20 minutes(goup 3, seven)'After eachinterval,resuscitationwasbegunusing fixed-flow closed-chest CPB(50 mUkg/min) and an epinephrineinfusion (4 mgA<g/min)'After ROSC,animalswereweanedfrom CPBand obsewedfor one hour' Results:ROSCwas analyzedusing Fisher'sexacttest. Hemodynamic datawere comparedusingANOVA. ROSCwasachievedin 100%of group I (sevenof seven),50% of group 2 (threeof six), and 29% of gtoup : animals(two of seven)(P ( .01 goup I versusgoup 3)' Onef,ouisurvival wasachievedin 7l% ofgroup I (five ofseven),17% of group 2 (one of six), and 006of group 3 animals(none of seven) (p <.ot group I vemusgrouP 3). Coronaryperfusionpressure,CPB flow, and arterial blood gasesduring reperfusion were similar between groups. i

Conclusion:CPBis effectiveat restoringspontaneouscirculation when usedearly in this asphyxial EMD cardiacarresrmodel. CPBis lesseffectivewhen used after 15 minutes of EMD with no survivors afrer 20 minutesof arresr.The time limits of rcsuscitationin this model of EMD appearto be approximatelyl5 to 20 minutesof untreatedarrest.

1 Cn A Comparisonol Thrce Noniwasivs Measurenrentsol I ffr| CoronaryPerfusionPressuroand Prcdiction ol Rotrrn of Spontaneous CirculationDudngGPR BFGtiffith.J Hoitink,EDrobny, DEPersse, CGBrorvn/Department of Emergerry Medicine, College of Medicine, The0hioStateUniversity, Columbus Study objective:Threenoninvasivemeasurements (NIM) were correlatedwith coronaryperfusionpressureand retum of spontaneous circulation(ROSC)during CPRin swine.The rechniquesincluded end-tidalCO, medianfrequency(FM) of the EEGsigral, and pulse oximetryGO).

Desigr:Fourteenmixed-breedswineweighing243 X2.6 kg were instrumentedfor CPPand NIM. After ten minutes of venrricular fibrillation and 3.5 minutesof CPR,sequentialcountershockweredelivered.

ROSCwasdefinedassystolicpressureof more than 50 mm Hg for at least oneminute.During CPR,CPPand NIM wereanalped usingANCOVA (overall,P < .05).The final 30 secondsof NIM wereaveraged, and various cutpointswere analyzedfor sensitivityand specificityof predicting ROSC. Results:SeeTable.

FM

.05 .01 .79

Erc0, PO

.$

R0sc

Cutpoint

Sencitivity

FM FICO" P 0 '

7.9Hz 16.7 mmHg 62%

1.00 l.m .80

.55 .10 Spocificity .m .56 .78

Conclusion:BorhFM and ETCO- correlatedwirh Cpp. FM and ETCO, predictedthe successof defi6rillationwirh a sensiriviryof 1.00.

FM has the advantageof higher specificiry.Noninvasivemeasurements may be important adjunctsto CPR. - t a 7

f bI UncontrolledHemonhagicShock0utcomeModel in Rats A Capone, PSafar,A Peitzman, S Tisherman, SWStezoski/lnternational Besuscitation Bessarch Center, Department of Surgery, University of pittsburgh, Pennsylvania Study objective:Recentacuteanimal studieshavechallengedcurrent guidelineslor prehospiul fluid resusciution(FR).Becauserhereis no long-termstudy, we developedan outcomemodel in ratsand compareddifferentFR regimens.

Design:Ratslighrly anesrherized wirh NO2/O2halorhaneand , breathingspontaneouslywere insulted with uncontrolledhemorrhagic shock(UHS)by tail ampuurion (75%). After the rrauma,halothanewas reducedto the leasrpossibleconcenrration(0.2%).After simulatinga prehospiul phaseof UHS (with or wirhour FR lV by lacratedRinger's solution) over one hour, a hospital phasewas begunwith hemostasis and all-out FR, including blood to hematocrit30%. Forry rarswere studiedin randomizedsequencein four treatmentgroups(ten): group I, untreatedcontrols,no FR,no hemostasis;group 2, no FR during the first hour, then hemostasisand all-out FR from one hour; group 3, maximalFR (to meananerial pressure80 to 90 mm Hg) during the first hour (starting15 minutesafter the insult), then hemostasisand all-out FR from one hour; group,l, minimal FR (to MAp 40 mm Hg) during the first hour, then hemostasisand all-out FR from one hour. Anesthesia

was to threehours and observationin cagesto threedays.Analysiswas by one-wayanalysisof varianceand 12 test for mortality Resuls: In group I, all ten ras died at two to l2 hours. ln group 2, nine of ten ratssurvivedto three days,all functionallynormal. In group 3, sevenof ten ratssurvived(five normal, two with disability);in the first hour, FR increasedbleeding volume three times over group 2 and reducedthe hematocritto 5% to 1006.In group 4, ten of ten ratssurvived to threedays,with all normal (P < .05 for normal outcomegroup ,l; NS for survival).

Conclusion:A new UHS rat.survivalmodel givesreproducibleoutcomes.ln prehospiul casesof UHS, FR to normotensionmay not lmProveoutcome. ls AssociatedWifi an { AA Intestinallschsria and Reperfusion I ff lf Increasein PulrmnaryillicrovascularPemeability JA Young.

DLCarden, DNGranger/Departments of Emergency Medicine and Physiology andBioplrysics, Louisiana StateUniversity Medical Center, Shreveoort Background:lntestinalisctremiaand reperfusion(l/R) is a common clinicaleventassociated with local degenerative changesthat may activatea systemicinflammatoryresponseand contribute to disunt organ dysfunction,particularlyin the lung.

Studyobjective:To assess the influenceof intestinalI/R on pulmonary microvascularintegrity.

Desigr: Adult maleSprague-Dawley rats (300 g) were anesthetized with pentobarbiul sodium (30 mg), after which the tracheawas intubatedand a ventralceliotomywas performed.The superiormesenteric arterywas occludedfor 120 minutes,after which the intestinewas reperfusedfor 90 minutes.The sternumwas then excised,cannulas were positionedin the pulmonary arteryand left ventricle,and the heart and lungs wereremoveden bloc. The lungs were suspendedby the tracheafrom a forcetransducerand perfusedwith whole blood.

Changesin pulmonary microvascularpermeabilitywereassessed by measurementof the pulmonarycapillary filtration coefficient(\."). lntewentions:Experimentalgroups included control rats,nonischemic(sham)controls,and VRanimals.Valuesare expressedas mean + SE.Datawere analyzedby comparisonof meansusing one-wayanalysis ofvariancewith Scheffe'sposr-hocrest.

Results:Intestinalischemia(I20 minutes) followedby 90 minutes o[ reperfusionresultedin a significantincreasein pulmonary microvascular permeabilitycomparedwith control or sham-operatedrats(Kr."= 0.287+ 0.02.+,0.i 30 + 0.008,and 0.I 34 + 0.003ml . min-t . srn (P < .05).

HrO-t . I00 g-r lung tissue,respectively) Conclusion:The resultsof this study suggesrthar inresrinalVR is associated a lossof pulmonary microvascularintegrity. Furthermore, this model of pulmonaryinjury after intestirul VR *y provide a means for the developmentof therapeuticinterventionsin the systemicinflamnutory responseand its consequence, multiorgan failure.

Preconditioning Rosults in Facilitated Mitochondrial 167

l.rtff::f

CBCairns, MBMitchell, AHHa*en,A Banerjee/University of Colorado Health Sciences Center, Colorado Emergerry Medicine Research Center, Denver Background:Transientischemia(Tl) protectsagainstsubsequent (lR) injury and resultsin decreasedinfarccardiacischemia-reperfusion tion size,improved function, and enhancedreplenishmentof cellular ATP. Studyhypothesis:Preconditioningwirh TI upregularesmirochondrial function to satis! the increasedcardiacenergydemandsof IR.

Study model: Isolatedrat hearr.ssubjectedto Tl (two minutes)or control followed ten minuteslater by global ischemia(20 minutesar 37 C) and reperfusion(40 minures).

Measurements: We comparedleft ventricularmitochondrialorygen consumption(Vor) for complex I (gluramare/malate) and complexIl (succinate);Vo2 in sute 2 Oasal)ro rhar of srare3 (maximalADP-stimulatedoxidativephosphorylation);mitochondrialfuncrionwirh and without TI beforeirhemia (PRE),afterischemia(ISCH),and afterreperfusion (POST);LV developedpressureafter reperfusion(POST-LVDP).

Results:Therewereno differencesberweenTl and control for complexI ftoth states2 and 3). Complex Il state3 wasaugmenredafter Tl at PRE(2t.0 t l.l ng O/min/mg),ISCH(19.1 t 1.7),and POST (2I.2 t L4) versuscontrolPRE(12.4 t 0.4; P < .05,usingrepeatedmeasuresANOVA with Scheffe'sF-test).Borh complexIl sute 2 (16.9t 1.9)and state3 funcrion(21.2I L4) in rheTl POSTgroup wereaugmented overcontrolPOST(stare2: 10.3+ I.4, P < .05;sute 3: I2.8 + I .0, P < .0I ). POST-LVDP wasenhancedafterTI (80 t 206 initial)venus control(54 t ,to6;P < .01).

Conclusion:Preconditioningwith Tl prorectspost-lRcardiacfunction. Tl preconditioningaugmentscardiacenergericsby selectively upreguiatingmitochondrialsuccinare-consuming oxidativephosphorylation (complexII). The facilitatedmitochondrialcomplex II function is apparentwithin ten minuresafter TI, allowing for the idenrificationof the preconditioned hearrwithout lR insuh.

inCardioc Arrest Ro$U|ts o| 1 68 ff:[?1.".'''#'ephrine RLWears,TAKunisakilUniversity of FloridaHealthScience Center, Jacksonville Study objective:To estimatethe relativeefficacyofhigfr-doseand standard-dose epinephrinein cardiacarrest.

Desigr: Meta-analysis o[ randomizedclinical trials.

Methods:A systemicsearchwas madefor randomizedcontrolled trialshavingprimary outcomemeasuresof retum of spontaneouscirculation (RC),hospiraladmission(HA), or discharge(DC). lnclusion criteriaincludedeffectiverandomization,blinded assessmenr! and welldefinedoutcomes.Pooledodds ratios for eachoutcomewereestiruted (VSD, Mantel-Haenszel by the variance-weighted (MH), DerSimonianLaird (DL), and logistic regressionmerhod(LR), adjustrngfor covariares wherepossible.Quality scoreswereusedin sequentialmeta-analysis to adjust for the quality of rhe componentrrials.

Results:Twenty-sevencandidatesrudieswere idenrified;therewere ten comparativetrials,but only five met inclusioncriteria.The pooled oddsratios and 95% confidenceintervals(CI) for eachmerhodand outcomeareshown (Table).

{ CO An Artilicial Noural ltletworkTrainedto ldentily the Presenco I Uil of Myocardialldarction BasesSomeDiagnoiic Dccisionon l{onlinoarRelationshiprBrtweon InputVodables WGBaxtlUniversity of California, SanDiegoMedicalCenter Backgound: To determinewhethera multilayeranificial neural network trained to recogr.izethe presenceof acutemyocardialinhrction basesdiagrosticdecisionon nonlinearrelationshipsestablished betweenclinical input variables,a linear and nonlinearnetwork with identicalnumbersof input nodeswere trained and then testedon identicalpattemsets.

Methods:The specificuse of nonlinearrelationshipswas further studiedby trendingthe quantiutive effecton network output resulting from the modificationof singleclinical input variablesin 706 specific patternsderivedfrom patientspresentingwith anteriorchestpain. This processallowedfor tracking of the number of pattemsthat generated effectson output of specifiedquantitativerangesaswell as.forthe segregationof the specificpatternsthat generatedtheseoutputs.The ratio of residualvariancesbetweenthe two network was .726.The trained linearand nonlinearnetworksmade2l and nine eilorst respectively, on a 350 testpattem. The output segregationanalysisof specificpattems revealedthat the distribution of the effecton network output was bimodally distributedin eiglrt of the 20 clinical input variablesusedby the network. Analysisof the specificpatterrrsthat segegatedto eachof the two bimodal regionsrevealedthat the basisfor this distribution was,in a sigrificant number of cases,due to the network placing markedlydifferentdiagnosticimportanceon the sarnevariablein differentpattems.

Conclusion:Thesefindingsappearto confirm the suppositionthat the network, unlike other clinical diagnosticmodalities,makesassociative decisionsby establishingnonlinearrelationshipsbetweeninputted information.Specificanalysisof the pattemsthat segregated to the two bimodal regionsalsoreVealedthat, in many instances,theserelationships did not appearalwaysto conform with prior knowledgeabout factorspredictiveof myocardialinfarction.

Dillerencosin the Diagnosisol Acuto,Nontraumatic 1'rnGonder I f fl GhestPain and Thror&olytic Treatmentol Acute Myocardial lnfarction TDValeruuela, DBHampton, LLClark,EFinkel, DWSpaite, EAGearelll/ Arizona Emergency Medicine Besearch Center, College of Medicine, University of Arizona, Tucson; PfrysioControl Corporation, Bedmond, Tucson Washington; FireDepartment, Arizona Study objective:To determinegenderdifferencesin the clinical courseo[ callersto 9I I with acute,nontraumaticchestpain suffering acutemyocardialinfarction(AMl) and in treatmentdecisionintervals.

Desigr: A 29-month prospective,nonrandomizedcaseseriesof B C 1 . 2 7 { 1 . 0 2 t 0 1 . 5 7 ) ' 1 . 2 3 ( l . 0 3 t1o. '417. 5 { 08.)9 0 r 0 2 1 . 3. 2 8 1 ( l . 0 3 r o l . S 8 )adult, acute, '1.14'(0.94t0 nontraumaticchestpain.

HA l.l2'10,92t0 1.37) 1.38) 1.56'10.88t02.75) Lt4.(0.94t0 1.39) Setting: Southwestemcity of 400,000 population and 390-km2area DC l.12{0i4t0 1.68) '1.14(076t0 1.70} l.t4{0.7t rol.B2) l.14(0.76t0 1.70} 'Significant with a two-tier,basiclife support/advanced life support emergency heterogeneity {P<.05}. medicalservicessystem.

Therewas significantheterogeneiryof effectbetweentrials for HA; Participants:Entry criteria:ageolder than I8 years;9II call, ECG adjustingfor dosedid not accountfor the heterogeneity. by paramedics,hospiul dischargediagnosisof AMl. One thousandnro Conclusion:HDE has only a small effecton RC only. No pooled hundred thiileen patients(682 men [5606]; 531 women [,t [%]) were effectwasnoted for HA and DC; the 95% Cl of rhe pooledesrimares are screened.One hundred seventy-nine(I4.8%) had AMI and met entry abour3006n:lrrower than thoseof the largesttrial, reflectingincreased cdteria. power for detectingsmall effects.Heterogeneityof effectaftercontrolResults:The prevalenceof AMI was 123 of 682 in men (I8.1%) ling for dosesuggesrsrharimpoilanr covariatesmodifying the effectof versus56 of 531 in women(10.6%).Forty-seven of 179AMI patients HDE be present.

(27%) were treatedwith thrombolytics.Thirty-eigfrtof 123 men (31.006)with AMI were thrombolyzed;nine of 56 women (16.006)were similarly treated(P < .05). Women with AMI called9l I a meanof 156

minutesafter onsetof chestpain versus56 minutes for men (p < .05).

Women were diaphorericin 22 of 56 cases(39%) versus77 of 123 men (63%) (P < .05). Men and wornendifferedin age(men, 67,l t t2 years; woment72.4 t 12.7 years)but nor in medicalhisrory,nausea,vomiring, pain radiation,or rhe prevalenceof ST-Televation.lntervalsfrom chestpain to thrombolysisand hospitalarrival to thrombolysiswere 132 t 78 minutes and77 t 80 minures,respecrivelyfor men versus 226 t I l0 minuresand 70 t 38 minuresfor wonrn.

Conclusion:The combinationof greaterage,laterand more subrle presenutionto the emergencydepartmentnuy accountfor the lower proportion of women receivingthrombolysis.Effortsto educatewomen to seekmedicalaid more rapidly might increascthe number of women benefitingfrom thrombolytic treatmentof AMl. t ', tl Historicaland ElcctocardiographicBisk Factorcfor Moftality a a a and SignificantArrlrythmiain ErncrgencyDepartnentprlicnts Presenting with Syncope TPMartin,BHHanusa, WN Kapoor/University of pittsburgh, Affiliated pennsylvania Besiderry in Emergency Medicine, Pittsburgh, Hypothesis:Hisroricaland ECG findings from an emâ&#x201A;Źrgency departmentvisit can be used ro identify syncopeparienrs*irt i,lgtr"r risks of moruliry and significanranhyrhmias(SA).

Desigr: Prospectivecohort study. The cohort consistedof253 consecutivesyncopepatientsevaluatedbetweenMarch lggl and December1983 in rhe ED and who underwenta standardizedevaluarion consisringof a hisrory and physicalexaminarion,ECG,laborarory tess, and prolongedelectrophysiologicmoniroring (pEM). All parienis were followed for one year (100% follow-up rare).

Setting:Universityteachinghospiralwith annualcensusof 32,000 adults.

Participanrs: Averageageofparientswas 57.2years(range,l5 to 90 years).Fifry-fivepercentwere female.

Measurements: lnformation from patients'historyand ECG from the ED visit wereused to predict mortality at one yearand SA on subsequentPEMand electrophysiologicstudies.Cox proporrionalhazards modelswereused to identify predictorsof one-yearmortality. Multiple logisticregressionwas usedro identify predictorsofSA. Results:One,yearmortalitywas I5.506(39 of 253). predictorsof one-yearmonality were abnormalECG (relativerisk [RR],4.7;9506 confidenceinterval [CIl, 1.7 to l2.g) and hisrory ofcongestiveheart failure(HxCHF)(RR,2.5;Cl, 1.3 to 5.0). Only 3.6% of-rhei12 patienFwith neirherrisk facrorfor morrality died in the first year, whereas39% of the 39 patientswirh borh *k factorsdied. SAswere found in 24.60Aof.rheparienrs(62 of 253). predicrorsof SA were HxCHF(RR,2.a, CI, 1.03ro 5.6), hisroryof ventricularectopy(RR, 5.3;Cl,2.2ro 12.9),andabnormalEC6 (RR,3.3;CI, 1.5to 7.,1).Only 8.7% of the I 15 patientswith no risk factorsfor SA had SA on larer monitoring,whereas90% of the 20 patientswith all threerisk factors had SA on larer moniroring.

Conclusion:lnformation from ECGand brief history can allow physiciansro identify low- and high-nsk parienrswith iyncope in the ED. Oncevalidared,thesemodelsmay be helpful in rriageofsyncop. patientsfor inpatient or outpatientevaluation. tl-rt MulticenterConfirmation of tho Vrlue of Ssdal GK-M8 | , L Samplingin the EmeryencyDepartmcntEvatuationof Chest Pain and Acute Myocardial Inlarction W! Gibh4JRHedges, JW Hoekstra, Gpyoung,M Bubison, B Christensen/ University of Cincinnati MedicalCenter,Cincinnati.

0hio;University of 0regon Health&iemes Center,Portland; OhioStateUniversity MedicalCenter, Columbus;,Highland Hospital, 0akland, California; Clinirials, lrn,Lexington, Kentucky; Genentech, Inc,SouthSanFrancisco.

Califwnia

Studyhypothesis:SerialCK-MBsamplingimprovesrhe sensitiviryof rapid acutemyocardialinfarcrion(AMl) diagnosisin patienrspresenting to the emergencydepartmentwith chestpain.

Designand participants:Retrospective, cohort analysisof 5,661 patientsfrom the multicenterNational CooperativeCK-MB Project presentingto the ED with chesrpain and subsequentlyadmiued for evaluation.

Sâ&#x201A;Źtting:Eighty-fiveacademicand communiry hospiralEDs. lnterventions:Patientsreceivedan initial ECGand serialCK-MB levelsobtainedon ED presentationand two to threehours later (analyzedby rapid immunochemical rechniques).

Results:Of 5,661 patients,5,596 had known serialCK-MB results.

Of these,784had a dischargediagnosisof AMI (la%). Of the 784AMI patients,523 had ar leastone posiriveCK-MB result (sensirivity,67%); 276 patientswithout AMI had a false-positiveCK-MB level (9406spec! ficity). Forty-threepercenrof patientswith false-positiveelevptionsof CK-MBhad ischemicor other cardiacdiagtoses(angina/unsubleangina, 27.5%; congestiveheart failure/pulmonaryedema,l5.Z%). Of 778 AMI patientswith known ECG resulrs,409 (53oA)had diagnosticECGson ED presentation.Of the 369 AMI parientswith nondiagnosticinitial ECGs,230 (630,6)had posiriveserialCK-MB series,represenringa 30% increasein toul sensitivityfor detectingAMI (from 53% to 8306overall) within two to threehours after ED presentation.

Conclusion:This largemulticenteranalysissupporb earlierwork noring the value of serialCK-MB resultsfor derecringAMI in the ED. SerialCK-MB resultsaid early derectionof rhe ED patientwirh chest pain and AMl. a ' t rra ta | , g EarlyCKMB:Predictorol lschemicGomplications JRHedges, WBGibler, RMBubison, JW Hoekstra, RAChristensen/Department of Emergency Medicine, 0regonHealthSciences University, Portland; Department of Emergency Medicine, University of Ciminnati, Ohio;ClinTrials, Lexington, Kentucky; Department of Emergency Medicine, OhioState University, Columbus; Genentech, lrrc,SanFrancisco.

California Studyhypothesis:PositiveCKMB predictsincreasedrisk for complicationsof myocardialischemia.

Setting:Eighty-liveacademicand communiry hospiralEDs. Designand participants:Retrospective cohort analpis of 5,182 patientswhosepresenringECGwasnegativefor acutemyocardial infarction(AMI). All patienrswereadmitted for evaluationof chestpain in muhicenterNationalCooperariveCK-MB Project.

Measurements: Patienrswere stratiliedby whether or not they had a CKMB greaterthan previouslyesrablishedthresholds.CKMB measurementswere madeon ED presentationand two to threehours later.

Patient medical recordswere reviewed for the following ischemiccom, plications:cardiac-relateddeath,recunenr in-hospiralAMl, significant ventriculararrhythmias,new conductiondefects,congestiveheart failure, and cardiogenicshock.

Results:Threehundred sixty-nineparients(7.3%)had an AMI. The proportion of patientswith a complicationin the AMI group wasZ4olo, whereasthe complicationrate for non-AMI patientswas 0.406.ln all patients,regardlessof final diagnosis,the relativerisk of a complication was 15.7 in thosewirh an early posiriveCKMBversusnegativeCKMB patients(9506confidenceinterval, 10.7 to 23.0). Similarly,in all patients,the RRof dearhwas21.6 (9506Cl, 9.5 to 49.1) in earlypositive versusnegtive CKMB patients.

Conclusion:Muhicenterdau support a prior pilot study indicating that CKMB can help risk-stratifyparienrswirhour ST-segmentelevation on their presentingECG.Early CKMB resultsshould help guide in-hospitaldispositiondecisions.

tl-, 9tting: A referralhospiul for immunologicand respiratorydiseases.

A Eflect of the lllemtrual Cycleon Asthmr Presentationsin dre L 'l EmergencyDspartmont Participants:Five volunteeradult asthmaticpatients.

EMSkobeloff,WH lnterventions:The patients'PMNswere isolated,purified, and Spivey,BASilverman, FPHarkelroad.

W Alessi/Oepartment of Emergency Medicine, Ihe MedicalCollege placedin phosphate-buffered saline(PBS;I pM Ca2*,pH 7.4).The Philadelphia; of Pennsylvania.

Division of Emergency Medicine, LonglslandJewishMedicalCenter.

PMNs(l0z cell.Jml) were then incubatedin PBSwith the following test New HydePark,NewYork;Division of Emergency conditions:0 pM MgC!, I pM MgC! (low), and l0 pM MgCl, (high) Medicine.

Allegheny General Hospita l, Pittsburgh, Pennsylvania both with and without the calcium ionophore423187 (I pM) to Study objective:Adult women are hospiulized three rimesmore increasecation permeabiliry.PMNswere activatedwith FMLP (10 ttM) often and with longerhospitalstaysper admissionthan men. lt has and the production of superoxide(Or) wasmeasuredin 96-well ELISA beenpostulatedthat this may be due to changesin esrrogenand platesby the spectrophotometric reduction of rytochromec. progesterone.

The objectiveof th'isstudy was to determinewhether Results:MagnesiumreducedactivatedPMN 02- production hormorul variations of the menstrual cycle may increasethe likelihood comparedwith no magresium(I.0 t 0.I mmol Oz-/l0s PMN) in both of asthmapresentationsto the emergencydepartmentby adult worlen. low (-0.52 t 0.3) and higlr concentrations(-0.76 t 0.3; P < .05 by Desigr.:Prospectivestudy.

ANOVA with Scheffe'stest).The addition of A23I87 signilicantly Setting:Five urban teachinghospiuls. increasedOr- production in both the high magnesiumgroup (0.53+ 0.02;P < .005)and the low magnesium Participants:Nonpregnant,femaleasrhmaticsagedI3 yearsto group(I.5 i 0.6; menoPause. group(I.2 ! 0.2).

P < .005),with no changein theno magnesium Measurements: Dateof presentation,attack duration, dateof last Conclusion:In clinicallyrelevantconcentrations,magnesiumattenmenstrualperiod, intermenstrualinrerval,age,baselinepeakexpirarory uatesactivatedneutrophil function in adult asthmatics.Magnesium flow rate,and admit versusdischargedecisionwere recorded.The appearsto exer!its PMN effecaby interferingwith extracellular menstrualcyclewasdivided into four phasesbasedon serumestradiol calciuminflux. Magnesiummay havea beneficialanti-inflammatory levels.The four intervalswere preovularory(days5 to I l), periovulaeffectin asthmaticsthat would support its use in the ED management tory (daysl2 to I8), postovulatory(days 19 to 25), and perimenstrual o[ asthma. (days26 to ,1).

Multivariod Results:Datawere analyzedwith a goodness-ot-ftt7,z and StudenCs 1', ABarrier Precautionsin TraurraBesuscitationr: I f ff Analysisol FactorsAllecting Use t. testas applicable.Two hundred rhreewomen (meanf SD age, P Sahdw,MJ Lacqua.

A Vaish/Nassau County Medical Center, N Hanigan, 28.5 t 8.0 years)weresurveyedbetweenJunel99l and May 1992.

EastMeadow.

NewYork Meant SD duration of their asthmaattackswas ]146 t 2.6 days.The Studyobjective:To determinethe relativeimportanceof factors meanintervalbetweenmenseswas 2S !.2.5 days.Forty patienrs(20%) affectinguseof barrierprecrutions(BP)by traumateammembers. reportedhaving irregularmenstrualcycles.Mean+ SD presentingpeak Methods:BPusedby all teammembersduring emergencydepartexpiratoryflow rate for rhegroup was 2I5 188 mUsec.Thirty-eiglrt ment resuscitations were studiedduring three periods:period I: June subjects(I906) wereadmitted; 165 (81%) were discharged.Therewere l99I to August199I, BPusebeforeintewentions;period2: September no significantdifferencesamonggroups for age,length of arrack,interI 991 to JanuaryI 992, educationalseminarsheld and materialaccess val betweenmenses,presentingpeakexpiratoryflow rate,or admiu/ improvedby designated cart;period3: February1992toJune 1992, dischargerates.Presentations by menstrualintervalwere preovulatory, legislationencouragingBPuseintroduced.

4I (20oA);periovulatory,48 (21oA);postovularory,20 (1006);and Resuls:Overall, 1,173contacts(I52 traumaroom resuscitations) perimenstrual, 94 (460A)(P = .0I). werestudied.BPcompliancewas as follows.

Conclusion:Asthmapresentationsare fewestwhen serumestradiol leveisareat a sustainedpeakduring the third week of the menstrual Glover Mrrk/Eyo Protoclion Gowrt cycle.Thereis a nearly fivefold increasein presentationsfor asthma (7%l (91%) I 27 s(24%) 372 341 when serumestradiollevelsdecreasesharply during the sevenperir40{31%) 248(55%) 447 443(99%) menstrualdaysthat follow the sustainedelevation.Thesefindings y,2197%l 354 r84{s2%) mwL%l suggestthat a sustainedincreasein serumestradiolmay decreasethe BPcomplianceimprovedamongall providerssrudied.Regession likelihood of sigrificant exacerbationsof asthmain adult women. coefficientsof factorspotentiallyaffectingcompliancewith BPusewere Conversely,a sharpdecreasein serumestradiolaftera seven-dayelevadeterminedwith gloves,masUeyeprotection,and gownsas dependent tion may increasethe likelihood of signilicanrexacerbations of asthma variables. in adult women. r,', trMa gnesiumAttonuatosNeutrophilAaivation in Adult I f rf AsthmaticPatients CBCairns, M Kraft,L Eorish/Colorado Emergency MedicineBesearch Center, University of Colorado HealthScierresCenter, Denver; National Jatish Center for lmmunology andRespiratory Medicine, Denver, Colorado Studybackground:Intravenousmagnesiumhasbeenproposedas an emergencydepartmenttreatmentfor acuteasthmaexacerbations.

Recentstudies have focusedon the effectsof magr.esiumon bronchial smoothmuscle,yet asthnu is primarily an inflammatorydisease.

Objective:To assessthe effectofmagnesiumon the neutrophil function of adult asthmatics.

Desigr: Prospective,blinded snrdy.

Acco$/ fdrcetiol

Gloves .15 Mask/eye pmteclionr .36 Gow[ .61

logidrlio[

Bi.l

Hour ofDay TS

.04 .sI

.04

.m

GCS ProvidsrProcrdur

05

.02

.m

.m

.m

.01

.59 .r4 .00 .t2 .01 .92 .t2 Conclusion:Useof BPby traumateammemberssigrilicantly correlatedwith education,materialsaccess,and legislation.Introductionof thesemeasureswill improvecompliancewith BP.Other factorsstudied had minimal or no correlationto BPuse.

a -t-l

Interventions: Caseswere identified from rhe mycobacreriolory log.

Demogaphic and historical dau, sire(rriage,ED, or ward) of documented I I I HandWashingFrequencyin an EmcrgencyDopanmom MBMeengs, BKGreene, CDChisholm, WH Cordell,bR Nelsor/Methodist considerationof TB, and IC measures(maskand,/orisolation)were Hospital of Indiana1992StudentSummerBesearch ftogram,University of recorded.The relarionshipof ED presumprivediagnosisof TB and time Michigan School of Medicine; Emergency Medicine andTraunnCentei, to IC measuresand therapywere assessed

by Wilcoxon! rank sum test.

Dopartment of MedicalBesoarch, Methodist Hospital of Indiana, Indianapolis Results:Of 34 TB culture/AFBstain-positivepatients,26 were previStudyobjective:Previousstudiesconductedmainly in intensivecare ously admittedthrough the ED (age,l9 to 88 years,85% men). unirshaveshown low compliancewirh hand washingiecommendations, Waiting room and ED rimes(medianIeR) were rwo (1.5 to three) with failureraresapproaching6006.Hand washingin the emergency hours and six (five ro nine) hours, respecrively.ED physiciandocumen' departmenthas not beensudied. We examinedthe frequencyand tation frequencyof the presenceor absenceof historicaldataand fredurationof hand washingin one ED and the effectsof rhreevariables: quencyof posirivefindingswerecough(960A,gZoA),hemoprysis (73%, levelof trarning,type of patientconracr(clean,dirty, gloved),and years 2306),fever(960A,77%),sweals(6106,38od),weigfrtloss(9206,85%), of staffclinical experience. alcoholism(69ob,l5%), homelessness (42b, 4%), immigrant (23%, Desigr: Observational.

2306),HIV risk (38%, l5%), pastTB (50%, I906),TB exposure(19%, Sâ&#x201A;Źtting:ED of an I ,100 bed rertiaryreferral,centralcity, teaching 006),and pastposirivePPD(23%, l906). Time from ED regisrrarionro _ hospiral. initiation of lC measureswassix and one-half(2.5 ro ten) hours.

Participants:ED nurses,faculty,and residentphysicians.

Isolationfirst occurrcdat tdage,the ED, or ward ln4%,5OoA,and 1606 Participan$were informed that their activitieswereLing monitored of cases,respecrively.Maskswere administeredat triageor the ED in but wereunawareo[ the exactnature of the study.

4oAand 42o$of nonisolatedcases,respectively.ED presumptivediagnolnterventions:An observerrecordedthe nurriberof pattentcontacts sis o[ TB occurredin 65% of casesand, comparedwirh non-TB diagand activitiesfor eachparticipantduring three-hourobservationperiods. noses,wassignificantlyassociatedwith lesstime to lC measures(3.5 Activitieswere,categorized aseither cleanor dirry, accordingto a scale [two to 8.5] versusI5 [8.5 ro 25.5] hours,p < .01)and lessrime ro devisedby Fulkerson.The use of gloveswasnoted, and han"dwashing anti-TBtherapy(I.0 lzero ro onel versusrhree [one to six] days, techniqueand duration were recorded.

P < .05).

Results:Elevenfacuhy, I I residentphysicians,and 13 emergency Conclusion:Among infectiousED TB patients,TB is often unsusnurseswere observed.Of 409 toral contacrs,272 wereclean,+6*dirty, pectedand lC measuresare often not used.ED TB awareness needsto and 9l gloved.Hand washingoccurred after32.3oAof total contacts be improved ro addressthe currenr TB epidemic.

(SD,2.3106).Nurseswashedafter59.2%of 146 contacrs(SD, 4.1%), residents ,a -l]l after18.606of 129 contacts(SD,3.4%),and facultyafter 17.2% of.I3,1 conucts (SD, 3.3%). Nurseshad a significandyhigfrer I lJ Portussis-lnmunrstrtus of EmergencyDopailmontStall hand washingfrequencythan either faculty(p < .OdOt)or residenr SW Wright,KM Edwards, M0 Decker, MM tamberth/Department of Emergerry physicians(P < .000I ). Hand washesoccurred alter 2g.eo6of 272 clean Medicine, Department of Pediatrics, Division of Infectious Diseases.

Vandeibilt contacts(SD, 2.3406),which was significantlyless(p < .0001) than University Medical Center, Nashville, Tennessee dirty contacrs(SD, 7,406)and 64.8% of 9l glovedconracrs Study objective:Becauseadults are not given boosterimmunization 19:0Y y\16 (SD, 5.006).The number of yearsof clinical experiencewas againstpertussis,nuny havewaning pertussisimmunity and aresusnor significantly relaredro hand washingfrequency(p = .g2). Soapand warer ceptibleto infection,Heahhcareworkers may be at particularrisk for wereusedin 126 of the hand washesand an aicohol preparatlonin acquiringand transmittingthe disease.Our purposewas ro document the remainingsix. The averageduration of soapand *ate, hand washes the pertussis-immune sratusof emergencydepairmentemployees. was9.5 seconds.

Desigr: Prospecrive study conductedin Seprember1992. Bloodwas Conclusion:Compliancewith hand washingrecommendarions collectedfrom all availableED personneland assayedfor anribody was low in rhis ED. poor compliancein the ED-maybe due ro the to pertussisroxin (PT) and lilamenroushemagglutinin(FHA). A ques_ large number of patientcontacts!simultaneousnunagementof multiple tionnairecompletedby eachpailicipanr provided demographicdau patienrs,high illnessacuity,and severetimc constraints.Straregies and immunizarionhistory. for improving compliancewirh this fundamentalmerhodof infecrilonconSetting:A largeuniversityhospiul ED. trol need to be explored,as simple educationalinterventionshavebeen Participants:A conveniencesampleof ED facuhyphysiciansand unsuccessfulin other heahhcjtre settings. nursing personnel.All panicipantswere ar leasrI g yearsof age;there wereno other exclusioncriteria. ,,'rA lack of Recognitionand InlsctionControllor Tuberculosis Intewentions:None.

I f lf PatientsAdmittedThroughthe ErnergencyDopaftmont Results:Sevenry-three ED personnelwere studied(about g0% of Moran,Df T1lan,MT Morgan,F McCabe, B Bodriguez/Departmsnt 0f eligiblestaff)including 56 women (76Joh) and l7 men (23.30,6); ! the tmergecny Medicine, 0liveViary/UCIA MedicalCenter, Sylmar, California aver^geagewas 33.4 t 6.8 yean. Geometricnreanrilerswereg.3 t 16.7 Studyhypothesis:The recenrincreasein tubercuiosis(TB) caseswill for PT and 23 + 32.8 for FHA. Theseritersare comparablewith rhose . havegeat impacron emergencydepanmentinfectionconrrol (lC). We previouslyreportedin other adultsnor immunizedsincechildhood, describelC interventionsfor TB patientsadmirnd rhrougfrthe ED and and aresubsrantiallylower than the levelscommonly seenin children hypothesizethat ED suspicionoiTB leadsto more rapid isolarionand or adultsafter immunization. treatment.

Conclusion:Most ED personnelhavelow levelsof antibody to Design:Retrospective chart review. pertussisand may be at risk for acquiring the diseasefrom infected Seuing:Four hundred-bedurban county hospiul. children or adults,with subsequentrisk of transmissionto sureptible Participants:Parientswith TB culrure-positiveand AFB stain_positive patients. Boosterimmunization with an acellular pertussisvaccinehas respiratoryspecimenspreviously admiued througlr the ED during I O9I . beenshown to be safeand immunogenicin adulti and may be appropriate for adult ED personnelro reducetheserisks.

Elfectsof A Mech?nisimfor tho DirectMyocardialDeprossant 1 80 CBCairns.

DDBensard, MBMibhell,AHHarken, A Banerjee/Colorado Emergerry Medicine Besearch University Healttr Sciences Center, of Colorado Center, Denver Backgound: Recentstudieshave demonstratednegativeisotropic effectsof inflammatorymediatorson the hean. Howeyer,the mechanism of this effectfor endotoxin (ETX) remainselusive.

Hypothesis:ETX producesa cardiacmitochondrialdeficit leadingto impairmentof oxygenconsumption,cellularde-energization, and impairedventricularfunction.

Studymodel: Eiglrteenisolated,perfusedrat heartswere infusedfor 20 minuteswith either intracoronaryETX (15 pglmVmin) or saline, and left ventriculardevelopedpressure(LVDP),coronaryflow, and O, consumptionwere measured.ATP, ADP, and AMP levelsweremeasuredfor energychargeusing high-pressureliquid chromatography.

Mitochondrialfunction wasassessed in l2 isolatedhearthomogenates both in the presenceand in the absenceofETX (15 pglml for 15 minutes).MaximalADP-stimulatedrespiration(sute 3) was assessed for complexI (gluumate, malate)and complexll (succinate).Enzyme kinetic studiesfor ETX and mitochondrialrespirationwere determined usingvaryingconcentrationsof ADP (a pM, I0 pM, 50 pM, 200 lrM).

Results:ETX resultedin depressionof LVDP (85.6 I 2.3 mm Hg versusNS, 91.2 t 2.8; P < .05 by ANOVA with Fisher'sprotectedleast squaresdifference),reducedmyocellularenerry charge(0.80 t 0.01 versus0.60t 0.01; P < .05),and increased cororuryflow (16.7t 0.4 mUmin/g versusI3.6 t 0,3; P .05), with no changein O, consumption. Sute 3 mitochondrialfunction was depressedin both complexI (3.4 t 0.2 ng O/mir/mg verus control,5.0 10.4; P < .05 by paired t-test)and complexll (7.9 t 0.,i versusI2.3 t 0.3; P < .05).No changeswereseenin resting(state2) O, consumption.The kineticsof this inhibitory eflect demonstratedmixed competitiveand non'competitive features.

Conclusion:ETX resultsin a rapid decreaseofcardiac function and myocellularenergr charge.ETX impairsADP-stimulatedmitochondrial respirationwithout changingbasalO, consumption.This mitochondr! al deficit may accountfor the myocardialdepressanteffectsofETX. Jl Trial ol a Becombinant EndotoxinNeutalizing Qt A Randomized I ff I ProteinVersusa MonoclonalAmibodyto Endotoxinlor the Treatmentol E coli Sepsisin o Ret Model DSNelson, N Kuppernnnn, BASaladino, J Parsonnet, CMThompson, 8KHammer, FSattler, TJ Novitsky, GRFleisher, GRSiber/Children's Hospital, Boston, Massachusetts; DanaFarber Cancer Instituts, Boston; Harvard Medical School, Boston; Primary Children's MedicalCenter, Saltl"akeCity,utah; Dartmouth Medical School, Hanover, NewHampshire; Association of CapeCod, WoodsHole,Massachusetts Study objective:Gram-negativesepsisstill causeshiglr morbidiry and mortality despiteoptimal antibiotic therapy,primarily becauseof the releaseof endotoxin.We comparedthe effectsof an I1.8-kDa recombinantendotoxinneutralizingprotein (ENP) from Umulus polyphcmtsand a monoclonallgM antiendotoxinantibody (HAIA, Centocor,lnc) in a randomized,blinded, conrrolledsrudyusing a rat model of E coli sepsis.

Designand intervention:Capsulescontaining2.5 to 5 x I0o E coli O I 8ac KI and sterilececalcontentsasan adjuvantwere implantedin the peritoneumof 200- to 225-gmale Wistar rats.One hour later (pre rx), blood bacterialdensitiesand serumendotoxinactivity (measured

by Limuluslysate)were assessed.

Ar rhis tirne, leadacetate(30 mg/kg), which sensitizesrats to the ellecrso[endotoxin, was given intravenously

alongwith blinded dosesof ENP (50 mg&p, HAIA (5 mg&g), or normal saline immediately followed by ceftriaxone (100 rn8&9 and gentamicin (5 mg/kg IM). Serum bacterlal densitiesand endotoxin activity were measuredone hour later (post rx1.

Results:One hour after E coli implantation(pre rx), 9506of ratshad bacteremia,and all had endotoxemia.ENPand HAIA both decreased endotoxemia,but only ENPimproved survival.

EIIP (cfu/mtl 3.2x 1@ pren bacterial 2.1x l@ density Geomean postn bacterial 0 0 dsrsity(cfu/mll Geomean 46.6 pren serum activity endotoxin Geomean {EUlmL)30.3 n.7' postrxserumendotoxin actMty{EU/mL)5 3.

Geomean (%l 50f27(19) 22ot26185Y suryival 24-hour 'P<.01rprsus oren.

2.7x1@ 0 26.7 47.3 3 ot2.l14l

tP<.001 exact test. versus HAIAorsalirE byFisher's

Conclusion:We concludethat ENP,but not HAIA, improvedsurvival in a rat model of.E colisepsiswith higfr mortaliry despiteoptimal antibiotic therapy.This obsewationsuggeststhat ENPmay have thera' peutic benefits for human beingswith Gram-negativesePsis. la Q'tt DoxycyclineVenur Azithromycinin tre Troahent of Womon Analysis I 04 wittr Chtanydialnlcctions:A Cost-Elfectivencss in Emergerry AffiliatedResidency JS Schwarty'Derver DJ Magid,J Douglass, Leonard Besearch Center, 0erwer; Medicine Medicine, Colorado Emergency Philadelphia ofPennsylvania, University DavisInstitute 0f HealthEconomics, Background:Treatmentof women with lower geniul tract (CI) infectionsreducesthe likelihood of developAhmydia trachomatis ing the major complicationsof pelvic inflammatorydisease(PlD), infertility, chronic pelvic pain, and ectopicpregnancy.

Study objective:To comparethe health outcomes,costs,and costtreatment effectiveness of two emergencydepartment-administered strategiesfor women with geniul CT: conventionaltheraPywith doxycycline (DOXY, 100 mg orally, twice daily for sevendays)versus azithromycin(AZl), a new long half-life oral macrolideantibiotic effective asa single I -g dose. adverse Design:Decisionanalyticmodel. Epidemiologicparameters, drug reactions,and managementof complicationswete obtainedfrom costswere from Blue CrosVBlue the literatureand experts;rrurnagement Current wholesaleantibiotic costswereused Shieldreimbursements.

(DOXY,$5.39;AZl, $32.52).Keybaselineassumptions included raresof PID in untreatedpatients(pPID, 0.t5) and overallantibiotic effectiveness incorporatingboth efficacyand compliance:AZI-EFF, 0.96;DOXY-EFF, 0.85.

Results:Known ratesof major and minor antibiotic reactionsand CT sequelaewereusedto calculatenet major and minor complications.

For a hypotheticalcohort of 100,000women with genitalCT, the resultsareas follows.

StraleO AZI DOZY

trior Complicrtiont 856 3,210

ilinol Conplicr$ont t4,t44 23.U0

AYerrga Co.t

$49.82 s55.28

Resultswere sensitiveto pPID and DOXY-EFF.A worst-casescenario sensitivity analysiswas desigred to enhanceDOXY relative to AZI (pPID, 0.10, DOXY-EFF,0.92;25% reductionin the cost of untreated CT infections).Under worst-casescenarioconditions,AZI still results in 500,6fewermajor complicationsbut at a cost of $3,6'+0per additional major complicationpreventedwhen comparedwith DOXY. Conclusion: AZI appearsto provide advantagesin cost-effectiveness over DOXY in the treatmentof women with genitalCT.

1O i Do EmergencyDepailmentsRoallyServeas the Medically I Ot lnOigenfs'saletyNet'?

W Kastre,KVlserson/ArizsuBioethics Program andSectionof Emergency Medicine, University of Arizona of Medicine, Tucson College Studyobjective:Up to 15% of Americanslack the resources!o pay for any medicalcare.This study quantifiesthe willingnessof emergency departmensand privateprimary carepractitionersto seemedically indigent patients.

Design:A self-describedmedicallyindigent woman sougfrtto locate, by telephoneinquiries,where medicalcarewas availablefor threespecific medicalneedscenariosof varying severty. All EDs receivedcalls about all threescenarios,but only the leastseverescenariowasused for privatepractitioners.The timing and order of all callswere randomized.

Settingand participants:All 5,t nonmilitary EDsin Arizoru and 69 randomlychosenprivateprimary c:trepractitionersin the samelocales as the EDs.Callsto EDswere madeduring all time periodsand dayso[ the week;privatepractitionerswere calledweekdayofficehours only.

Results:Virtually all EDswere willing to seemedicallyindigent patients,recommendingthat the caller come to ED immediately760A of the time. This responsedid not vary by geogaphy or the facility's size,althoughED personnelsuggestedinitial home treatmentmore commonlyat smallerhospitals(P = .02) and suggestedcoming to the ED more often on weekends(P < .02). SomeEDs,however,clearlydid not comply with their own telephoneadvicepolicies,and someED personnelfailed to give medicallyappropriateadvice.In contrastto the EDs(P < .00I), 6206of privatepractitioners'staffsclaimedthey were not takingnew patientsor requiredat least$30 in advance.Private practitionersin the largestcommunitieswere sigrificantly more reluctantto seethe medicallyindigent than their peersin smaller communiries(P < .05).

Conclusion:In contrastto most Privateprimary carepractitioners, EDsareat leastwilling to serveasa triagePoint for the medically "safetynet" for the medically indigent and are often the primary care indigent.

,l Otr Gonprehensiond DischargeDiagnosisand Inatructionrin an I OU UrbanErnorgencyDlpuhent Temple Section, Medicine lA Hughes/Emergency DJ knas.JM Spandorfer, Pennsylvania Philadelphia, of Medicine, School Universiw Study objective:To dcterminePatients'undersunding of their emergencydepartmentdischargediagnosisand instructions. suwey. ED staffand patientswere Desigr: lnrerviewer-administered blinded to the purposeof the study.

Setting:An inner-cityuniversityteachinghospitalED' Participants:All patientsdischargedduring three 2't-hour periods were interviewed,yielding a samplesizeof 218. lntewentions: Patientswere interviewed immediately after discharge from the ED and wereaskedto sute their diagnosis,medications'and follow-up instructions.Theywere permittedto referto their written instructions.Patienswereadministereda standardizedtest of reading to surveyquestionswere scoredby two physicians ability. Responses accordingto agreementwith the ED recordand the written discharge instructions.

Results:Fifteenpercento[ study patientshad no understandingor only a vagueundersunding of their dischargediaposis; an additional 8o6had only a Partialunderstanding.Similar resultswere obtained for understandingof medicationand follow-up instructions.The inter-reviewerreliability wasvery high (r = 0.8I to 0.94, P < .00I) ' The meanreadinglevelwas fifth grade;the ED's printed discharge instructionsrequiredan I I th gradereadinglevel. of urban ED patientshavea Conclusion:A sigrificant Percentage poor understandingof their dischargediagnosisand instructions' -

]l^

I Ub Barriersto Caroand HealthBehaviorin Innor-CltyAshmatim of EmergerryMedicine, BJ Rydnun/Department M McDermott, JE Sterling, lllinois Chicago, CookCoungHospital, Background:lnner-cityasthmaticshavebeenidentifiedashavinga higher riik of morbidity and mortality from asthmain part becauseof wilh socio-economicstatus.We soughtto describe barriersassociated our patientpopulationin termsof frequencyof clinical eventsand the existenceand effectsof suchbarriers. suwey was given to Patientswith asth' Methods:A self-administered ma-relatedcomplaintsin an emergencydepartmentduring September 1992.The suwey includedquestionson demographics,asthma-related clinical eventsand clinic attendance,PercePtionsofbarriers,and knowledgeof and behaviorregardingasthma.

Results:Four hundred forty-four surveyswerecompleted.Of respondents,8506wereAfrican-American.Baniersmostcommonly identifiedwere cost o[ care,inconvenienceof clinic hours, prolonged wait for careor clinic appointment,and transportation.Respondents' report of asthmaknowledgewas predictiveof adherenceto medical regimens,clinic attendance,and preventionof crises.Patiensattending clinic reported greaterasthmaknowledge, decreasedsmoking, greater adherenieto medicine,attemPtsat Prevention'and keepingfollow-up appointments.Costand waiting timeswere lessof a banier. Higlr-risk patients had a higfrer ageat onset and were more often seenin clinic'

Participants:Consecutivecohort of 295 (0.6%) patientsover two yearsinitially releasedfrom the ED, then retuming within the next threedaysfor unscheduledre-evaluationin the ED. lntewentions:None. ofanEmergency Risk-Torgeted Depailment-Based, {|O-, Feasibility Results:The majority (166 or 5606)of the casesthat fell out were I O f tttVScreening Program caredfor by UH (P < .05, 12) for an odds ratio of 3.1 as the relativerisk 6DKelen,DAHexter, KNHansen, TCOuinn/Divisions o[ patientsretuming afrcr an UH visit. fu a percentageof toul UH cenESPretorius, PVigilance, ofEmergency Medicine Hopkins andInfectious Oisease. theJohns University, susand asabsolutenumbers,study patientswho wete admitted to hosBaltimore, Maryland; NlH,Bethesda, pital and to critical care beds and deathswere also more common in the laboratory oflmmunoregulation, NlAlD, Marvland UH group.

Studyobjective: Assess feasibility andeffectiveness of anemergency Ptt:l Superired UtruparYired

Conclusion: Oppornrnities existfor decrcasing morbidityandmortalityby decreasing barriersto care.Clinicparticipation appears to be beneficial asanintervention.

department-based, risk'urgetedHIV screening program.

Design:Prospectiveconsecutivecaseenrollmentfor ten-weektrial during 1992.Study patientswere given conlidentialHIV pretestand risk reductioncounseling,with ten- to l,t-day on-siteED follow-up preanangedfor all. Follow-up included post-testcounseling,reinforcement of risk reductionpractices,and $10 incentiveto covertransportation costs.HlV-positivepatientswere refened to the hospitalHIV clinic for further evaluationand treatment.

Setting:ED of largeinner-city university hospiul with hlgh rate of HIV infectionamongpatients.

Participants:Consecutiveconsentingadult IV drug users(lVDUs) not known to haveHIV infection.

Results:SeeTable.

Of the I 7 H lv-positive patientswho retumed for their results,six (3506)kept their hospital HIV clinic relerralappoinrmenr,a rareconsistent with the experienceof that hospitalclinic. Four of 20 activeIVDUs (2506),reachedat a three-monthfollow-up, reportedlyceaseddrug use becauseof the program.Programcost (including resring)was $23,995 ($I I7 per enrolledand $1,000per HIV casederected). % AllIVDU visits 260 Eligible fo.study 205of 2@ '167 Consented/entered 0f205 Seturned forfollow-uo 104of t67 KeptHIVclinicappointrnent 6 of l7 CD4+ cellslessthan200 3 of9

78.8 8r.5 62.3 35.3

ll (HlV+l

% HIV+

8i 32

3i].3 IJ.J

14.3 l

to.z

222

Conclusion:An ED-based,risk-urgeted HIV screeningprogramis feasibleand over the courseo[ one year,could detecta reasonable number o[ new asymptonuticHIV infections,including thosewho should be placedon t''ZT and,prophylacticPCPtherapy(CD4+ < 200).

Associatedcounselingin the ED nuy evenmodifo behavior(at leasr short term) amonga difficult risk group. { OO Differencesin Clinical0utcomesof PatientsRbleasedFrom I OO ttre EmergencyDopartmentAftor GarcAdninisterod by Supervised and Unsuporvised Housestafl GPYoung, W Cimikoski/Highland General Hospital, Oakland.

California; Veterans AffairsMedicalCenter, Portland, 0regOn; 0regonHealth&ierres University, Portland Study objective:Controversypersisrssurroundingthe needto supervisehousestaffin teachinghospitalemergencydepartmentsat nights.We comparedpatienl outcomeswhen housestaffwere supervisedby ED auendingsraff(SH) and unsupervised(UH).

Desigr: Retrospective, blinded analysisby peerreviewersusing criterion standardsfor caseshlling out from a quality ilssuranceindicator.

Setting:ED of a universityhospiral-affiliaredreachinghospiralwirh an annualcensusof 25,000 in which careis supervisedfor more than 7006of patients.

2-Year E0census UHstuq paients admits Subsequent ICUadmits Subsequent deaths

<15.m ls(r.t%l 1r2{0.7s%} l8(0.1%l r%) 16(0

>35,m 129(0.4%) 85{0.2s%} 11(0.m%) l3 {0.04%}

<.ml <.ml <.ml

.m

However,therewereno statisticallysignilicantdlfferenL in rhe percenugeof patientswithin eachstudy group who wereadmittedto hospital(6706versus67%, UH versusSH) and to critical carebeds (I I % versus9o,6)and deaths(10% versusI0%). Nor was thereany statisticaldifferencebetweenthe supervisedand unsupervisedcare asjudged by blinded peer reviewersto be possibly(29% versus33%) or probably(90,6versus8%) in deviationfrom the standardof care.

Conclusion:Unsupewisedhousestaffare more likely to releasâ&#x201A;ŹED patientswho requirean unscheduledretum visit to the ED and who are more likely to subsequentlyexperienceadverseclinical outcomesthan housestaffsupewisedby ED attendingstaff physicians.

in Spanishspeaking Patientr 1 89 Assessment olliteracy Levels BMParker, MVWillians,WCCoatesftlarbor-UClA DWBaker, J Nurss, Medical Grady Hospital, Tonance, California Cefier, Studyobjective:The deliveryof health caredependsheavilyon the written word. Illiteracyis a growing problem in the generalpopulation.

In this study, our objectivewas to determinewhetherilliteracyis present in patientswho speakSpanish.

Desigr: Prospectivesurveyfor a 30-dayperiod.

Setting:Urban county hospital. emergencydepartmentand Participants:Fifty-two Spanish-speaking clinic patients.

Results:The RapidEstimateof Adult Literacyin Medicine a 66-word Englishtestmeasuringmedicallyrelevantliteracy,was translatedinto Spanishand administeredto 52 Spanish-speaking ED patientswith varyinglevelsof education(mean,6.5 * 4 years).The scoreswere 606could not readat all, l806 scored52 to 60, 76% scored 60 to 66. Meanscoresfor lastgradecompletedwere grades0 to 4: 48 (15); 5 to 8: 63 (20); 9 to l7: 65 (16). Thesescoresexceeded expectations basedon English-speaking cohortswho were previouslystudied.

Conclusion:The Spanish-speaking patiens' word recognitionabil! tieswere dichotomous:They could read fairly well or not at all. This differs from English-speaking cohorts.Further testingto assessfunctional ability to follow written medicalinstructionsmay be necessary, especiallyif the healthcareprovidersdo not speakSpanish.The ability to assess the level of literacyin Spanish-speaking patiena is crucial to ensuretheir compliancewith medicaltherapy.

{ On low-Voltage Eloctrical Iniuries in Adults: Patternsol Iniury, I rf lf ClinicalFeatrros,and AcuteCorplicotiom PBFontanarosa, SJAbert,M Chaudhari/Dopartrnnt of Emergency Medicine, Northeastern 0hioUniversities College of Medicine, AkronCityHospital, Akron.Ohio Study objective:To describepattemsof injury, examineclinical features,and characterizeacutecomplicationsin aduls with low-voltage(lessthan I,000 $ elecrricalinjuries.

Desigr: Retrospective chart review.

Setting:N on-bum center,universiry-affiliated,community teaching hospitalwith 68,000 annualadult emergencydeparrmentvisits.

Participants:One hundred elevenadults (meanage,33.7 yeas; range,17 to 7I years)evaluatedin the ED with acutelow-voltage electricalinjuries during a four-yearperiod. Patientswirh high-vohage (> I,000 V) current exposurewere excluded.

Results;Seventy-sixelectricalinjuries (69%) werework-relatedand 28 occurredat home (25%). The most common power sourceswere I10 V (4106)and220V (2,+oA), and the most common deviceswere electricalwires/boxes(29%) and cooking/kitchenappliances (22ob).

The armlhandwas the currenr contactpoinr in 98 patients(8806).The current pathwaywas local in 5506,hand to hand in 2606,andhand to foot in 90,6.Featuresassociatedwith electricshock included tetanic musclecontraction(18%),warer/wersurfaces (I606),and falls(1206).

Entry wounds occurredin 27% and exit wounds in 506.Thirry-seven patients(3306)had acuteECGabnormalities,including dysrhythmias (l 006),conductiondefects(8%), ST-Twavechanges(706),and acure ischemia(306).Neurologiccomplicationsincluded paresr.hesias (27%), neuropraxia(2506),and lossof consciousness (7%). Elevenparienrs (10'6) had elevatedCPK levels,ten (9%) had proteinuria/hemaruria, and one (I06) had myoglobinuria.Ninery-two parients(8306)were dischargedafter ED treatmentand observarion,and I9 (170,6)required admission.Therewere no faulities, and no patientrequiredsurgical intervention.

Conclusion:Although most low-voluge elecrricalinjuries are mild, a substantialnumber oI patientsexperienceclinically significant cardiac,neurologic,and cutaneouscomplications.

1 I 1 TheSyndrome olExercise-lnduced Rhabdorryolysis B Sinen,L Kohl, TScalea/Department ofEmergency Medicine, Health $ierrce Center ofBrooklyn atKings County Hospital Center, Brooklyn, NewYork Study objective:To describethe syndromeo[ exercise-induced rhabdomyolysis(ElR) and ro invesrigarethe relarionshipbetweenEIR and the developmenrof acuterenal failure (ARF).

Desigr: Retrospective chart analysison all patienrswith a prinury dischargediagnosisof rhabdomyolysisfromJanuary 1988 to September t992.

Setting:An urban tertiarycarecenterwith 225,000annualenrrgency departmentvisits.

Participants:Seventy-fivepatienrsmet the designcriteria;35 patientsfit our inclusioncriteria for EIR:a history of strenuousexercise, CPKlevelgreaterthan 500, and urine dipstick posirivefor blood without heman:ria.We excludedparienrswith a history of rrauma,myocardialinfarction,stroke,or documentedsepsis.Chartsalsowere examinedfor the presenceofnephroroxic cofactors(hypotensionor acidosis).

Results:All 35 parientswere male,wirhour significanrmedical history,and an averageageof 24.4 years.Patientspresentedfor treatment an averageof 2.7 days(range,zero to five days)after exerciseand had freeaccessto salt and water after exercise.All patientspresented

with muscularpain and a changein urine color at admission.The averageadmissionCPKwas 30,727 Un-. Blood and urine toxicolory were consistentlynegative.AdmissionBUI{/CREwere within normal limits for all patients.All were treatedwith forcedbicarbonatediuresisbut at a time (average,2.7 daysafter EIR) when this therapyhasnot been shown to be effectivein preventingARF. No patientpresentedwith or developednephrotoxiccofactorsduring hospitalization.None of our study patientsexperiencedARF or any of the commonly described complicationsof rhabdomyolysissuch as hyperkalemia,acidosis, hypocalcemia,or hyperphosphatemia.

Conclusion:EIR is a relativelycommon occurrenceaccountingfor 4706o[ our admissionsfor rhabdomyolysisbut was not responsiblefor a singlecaseofAFR. Previousliteraturehas describedan association betweenEIR and ARF,but all caseswerecomplicatedwith a nephrotoxic cofactor.EiR without complicatingnephrotoxiccofactorsdoesnot leadto ARF. and Peak 1 llljl Relationshio ol Abstinenceto the Presontation 'Signs lJZlntensity of ol AlcoholWthdrawal WA\erk,K Todd/Department Medicine, DetroitEeceiving of Emergency Medicine, Hospitaland University HealthCenter; Department of Emorgency WayneStateUniversity, Michigan Detroit, Study objective:Precisedataabout the timing of onsetof alcohol withdrawal (WD) are lacking.We studiedalcoholicpatientspresenting to an emergencydepartmentto determinethe relationshipof WD signs to duration of abstinence(AB). studyofa cohortof Design,setting,and participants: Prospective I,17 alcoholicpatientspresentingto an urban ED for treatmentof medicalproblems.Patientswith traumaticcomplaintsor AB of more than one week wereexcluded.Age (meant SD) was ,t2.3 + I8,9 yean; I 2I (8206)were male.The presenceand severityof tremor,seizure, anxiety,hallucination,and agitationwere assessed using an accepted scoringsystem.Overallscorewas the sum of individual sigrs. Duration of AB wasdeterminedby interview.Basedon the assumptionthat each sign hasa singlepeakof inrensityover time after AB, the relationshipof the signsto duration of AB was testedusing second-orderpoiynomial regressionequations.Sigrificant correlationwith the best-fitPRequation wasset at P < .05. Meanand SD of time of AB for patientspresenting with eachof the signswasdetermined;time of peakintensityof each sign was takenas the top of the PRcurve againsttime.

Resuls:Ninety patients(6I06) manifestedat leastone sign of WD. The findingsaresummarized(Table).

Number(%l witho.chrign

56{38) 57(39) 7t (48) 14(r0) 55(38) NA 'Fwpatients greater withscore than0.

Tremor Seizure Anxiety Hallucination Agitatim Overall score

Houn (M t SD) ofabrtinence Peeklhoun) Re0re$ionP

iJ3r25 3t r24 27t21 33r25 nxn nt23'

55 55 46 58 40 50

.m3 .03 W

.17 .63 0l

Conclusion:Signsof WD are most likely to peakafter approximately 50 hours of AB and arecommon in patientspresentingto EDswith medicalcomplaints.Agitationis an unreliablesigr of WD in this goup o[ patients,most likely reflectingthe fact that it is alsoa sign of alcohol intoxication.

Eyaluation ofEnrergency Department Medical 1 93 iffi3""".:'J. PLHenneman, B Mendoza, BJ Lewis/Oepartments of Emergenc'y Medicineand Psychiatry, Harbor-UCtA MedicalCenter,Tonarrce, California Studyobjective:To study a sundardizedrnanagement plan evaluating alertadult emergencydepartmenrpatientswith possiblepsychiatric disturbances.

Design:Prospective.

Setting:Urban county hospital.

Participants:One hundred consecutive,alert patients,agedI6 to 65 yearc,seenover nine months,with possiblepsychiatricdisturbances not previouslydiagnosed.Patientswirh obviousalcohol inroxicarionor admitting recreationaldrug use as lhe causeof their alteredbehavior wereexcluded.Psychiatricpatientswith medicalproblemsneeding evaluationwereexcluded. lnterventions:Hisrory,physicalexaminarion,CBC,SMA-7(ytes, BUN, creatinine,glucose),prorhrombin time (PO, calcium,oxygen saturation,CPK if possiblemyoglobinuria,alcohol level,urine drug screen(cocaine,PCP,ampheumine),brain computedromography (CT) scan,lumbar puncture (LP) if febrile,and psychiatricevaluarion, when appropriate.Resultswereconsideredsignificantwhen they resulted in admissionor diagnosedthe causeofthe behavior.

Resuls:Sixty-threemen and 37 women (meanage,38 t l3 years) wereentered.Twenty had previouspsychiatrichistory and 40 had a medicalhistory. Forty-sevenpresenredwirh hallucinarions.Fifty-six weredisoriented.Physicalwassignificanrin three,hemarocritin one, WBC in one,SPA-7in 12, calcium in one, CPK in seven,PT in one, alcoholin six, urine drug screenin 23, CT sc:n in eight, and Lp in three.Sixty-eightpar.ienrs were admiued: 28 ro psychiatryand ,f0 ro medicineor neurology.Primarycausativediagrosiswasneurologicin 25 (seizure,six; infection,three;orher, l6), systemicin 38 (infection, two; meubolic,eighr;roxic,28), and funcrionalin 37. Of the 20 patientswith psychiatrichistory, four were on drugs, onehad DKA, and anotherhad acue renal hilure and seosis.

Conclusion:Altered behaviorin many alert adult patientsis not psychiatricin origin. lf history and physicalexaminariondo not adequatelyguideevaluation,we recommendsendingan SMA-7and alcohol and urine drug screen.When the initial laboratoryresultsdo not explainbehavior,theseresrsshould be followedby a CT scanand Lp.

puncture 1 94 Conservative Tholapy ofplantar Wounds BASchwab, R0Powers/Division ofEmergerry Medicine, University ofVirginia Health &iences Center.

CtErlottesville Background:Thereare no prospecrivestudiesthat definethe complicationrate of plantar puncturewounds. Retrospective seriesrepor! a complicationrate of lessthan 5% for theseinjuries.

Study objective:To define the complicarionrareof plantar puncrure wounds managedwith conservativeinitial therapyin rhe ED. Design:Prospectivec:lseserieswith definedtreatmentprotocol.

Follow-upat 48 hours, one week, four weeks,and six monrhs.

Seuing:Universiryhospiul ED, 58,000 visirs per year.

Participants:Age I8 ro 59 years,presenringwirhin 2,1hours of injury; no history of diabetes,peripheralvasculard.isease, immunosuppression,or anribioticswithin previous48 hours; no rhrough-andthroughwounds,associatedfracture,or evidenceof infectton. . .lntewentions:History and examination,removalof visible foreign body; dilute Betadinesoak;dry dressing;non-weighr-bearingfor 2,1 hours; telephonefollow-up. Radiogaphsat examiningphysician's discretion.

Resuls:Seventy-eiglrt patientsmet entry criteria;six were not enrolled,improperlyenrolled,or refusedto comply with protocol.

Of the remaining72, nine were lost to follow-up, leaving63 available for analysis.Therewere sevencomplications(l 1.9%;95% confidence interval,4.9oAto 22.9%).Therewere four casesof simplecellulitis and one superficialabscess; thesepatientsall presentedwithin one week of injury and respondedto standardtherapy.Therewere two caseso[ retainedforeigr body not detectedat initial evaluation.Only the presenceo[ symptomsat 48 hours after injury was found to be associated with a higher risk of complication(sensitivity,7I%; specificity,85%; P < .05).

Conclusion:The complicationrate for plantarpuncturewounds marugedconservatively appâ&#x201A;Źarsto be l 106.Patientswhosesymptoms persistbeyond24 hours after injury are at higher risk for complication.

Prcsnancv: rsserumProse$e(onc 1 95 H::l,XtrtrTlic FShofer,S Shepard, M Eisinger, RNess/Department of Medicine,University of Pennsylvania School of Medicine, ftriladelphia Study objectives:To assess the accuracyof serumprogesterone(PG) screeningto rule out ectopicpregnancy(EP)in pregnantwomen presentingto the emergencydeparrment.

Desigr: Prospectivecohort study conductedfrom August I 991 to May 1992.

Setting:Largeurban universityhospital.

Participants:All women presentingto the ED with a chief complaint of vaginalbleedingand,/orabdominalpain and who were documented to be pregnantby serumhuman chorionic gonadotrophinftrCG) (I,034) wereincluded.Excludedwere patientswith an insufficient amountof sera(99), for a finalsamplesizeof 935. lnterventions:Datacollectedincludedscreeninghistory, physical examination,serumPG,and quantitativehCG. Everypatientunderwent pelvicultrasoundand/or laparoscopyto evaluatethe possibility of ED. Resuls:Seventy-fourof 935 patients(7.9%) werefound to havean EP.MeanPGwas715 ngldl for womenwith EPs,2,712n{dLtor women with intrauterinepregnancies(lUPs),and 1,773n{dLfor women with spontaneousabortions(F = 46.7, P < .0001). No patient with PG > 2,500 ng/dl had an EP (sensitivity,100%;specificiry,36%).

Other than presenceof cervicalmotion tendemess(22% versus9% for EPand IUP patients,respectively),therewere no statisticallysignificant differencesin presentingsymptomsor screeninghistory between patientswith EPscomparedwith normal IUPs. Conclusion:This study demonstralesthat a PG > 2,500 n{dL excludesthe diagnosisof EP in 100%of patients.Progesterone screening could potentiallyeliminateperformingpelvic ultrasoundson36o6 of patientsfor which PG > 2,500 ngldl.

Oepartment Diagnosisol Acutellyocardial { OA Emergency I arl, Infarctionand lrchemia:A GostAnalysir JW Hoekstra.

WBGibler, BCLwy,M Sayre, W Naber, M Flinn,R Kacich, BWalsh,R Magorien/Departmont of Emergency Medicine andDivision of Cardiology, 0hioStatsUniversity, Columbus; Department of Emergency Medicine andDivision of Cardiology, University of Cirrinnati, Ohio Objective:To assessthe potentialcostsavingsof the emergency departmentdiagrosisof acutemyocardialinfarcrion(AMl) and ischemiausing a nine-hour ED evaluationperiod.

Desigr: One-yearprospectivenonrandomizedstudy with concurrent controls.

Setting:Two Midwesturban universiryhospiul EDs.

Participants:Patients(427) presentingto the ED with chestpain consistentwith myocardialischemia,nondiagr.osticECGs,and suble vital signs.

Interventions:After initial ED evaluation,experimental(EDROMD patientsunderwentnine hours of continuousECGST-segmentmoni toring in the ED with serumCK-MB levelsdrawn atzero,three,six, and nine hours.At center l, patientswith negativeEDROMIeitherunder(echo)and $aded exercisetesting went immediateechocardiography (GXT) followedby ED releaseor wereadmiued to the hospitalfor further testing.At center2, negativeEDROMIpatientswere eitherreleased from the ED for outpatientstressthallium (EDROMI,ED release)or wereadmitted to the hospital for further testing(EDROMI,admitted).

At both centers,positiveEDROMIpatientswith elevatedCK-MB levels, ischemiaby ST monitor, or positiveechoy'GXT wereadmitted to the hospitalfor further testing.Control parientswere admirteddirectly to the hospiul to rule out AMI. Hospitalchargeswere comparedfor EDROMIand controlgroups.

Results:SeeTable(total chargesin dollars;meani SD, Student's t-resr).

EDR0MI Subgmup

EDRoMIChrtler

Corlrcl chsrgor

Center 1{EDR0M|.

EDrelease) 1,358t3iB (n=257} 3,957t2.245ln= 55) C e n t e r l ( E D R O M | . E D r e l1e,a3s6e8)t 3 2 â&#x201A;Ź{ n = 2 5 7 ) 2 . 8 1 0 t 1 , 0 3l7n = 4 1 ) ' Centerl(allpatients) 279i15,788{n=3ili}) 3,95712.245 {n=55) Center2(EDBOM|.EDrelease) 1,212*.319ln=17|1 4,13012,358 {r=15) Center2(EDB0M|,admirted) 4,251t159 ln-7]' 4,t30t2,358In= l5) patientsl (n= 15) Center2(all Zl43*1,463(n=24) 4,13O12.358 'Onlycontrols whodidnotreceive cardiac catheGrization areincluded.

P .0001 .0001 .009 .m6 .85 .0m

Conclusion: At both centerc. this ED evaluation for AMI resulted in sigrificantly lower hospiul charges ro chest pain parienrs. a jt-a -l U /Crnau Bias ondThrontolytic Therapy REJackson,\N Anderson, WFPeacock, AGWilson/,\lVilliam Beaumont Hospital, Royal 0ak,Michigan Studypurpose:To determinewhethergenderis an independent predictorof time to ECGand thrombolyrictherapyin acutemyocardial infarction(AMl).

Design:A retrospectivechart review of emergencydepartment recordson patientswho receivedthrombolyticsin our two departments overa three-year period(1990to 1992).Timeswerenoredby the ED personnelduring the visit. Patientage,sex,shifl ofarrival, mode of arrival,time to ECG,and time to treatmentwereabstracted.The data wereanalyzedusing a multiple linear regression,Cochran-Coxt-test, Yates'corrected, and Mantel-Haenszel 12, sâ&#x201A;Źtringrhe levelof significanceat .05.

Setting:Two suburbancommuniryhospitalEDs,with a total of I 08,000yearlyvisits.

Participants:Patientswith an ECG diagnosticof AMI and receiving thrombolyticswhile in the ED. Results:Of the 252 pariens, 62 were women. Therewereno significant differencesin the proporrion o[women by year,hospiral,shifr, or modeof arrival to the hospital.On average,women were five years older (P = .02). We obseweda gender,relatedeffecron time to rrearment,with women receivingthrombolyticson average25.8 minutes later than men (P = .04) This effectof genderremainedsignificantusing a multivariatelinear regessionand was independentof age,mode of arrival,and hospiral(F = 9.72,P = .002).At 90 minuresafrerarrival,a significantproportion of women experienceddelayin treatment(I2 = 4.2, P <.04). Women alsoreceivedtheir ECG on averageof renminuteslater(P < 0.002).

Conclusion:Genderbiasresultsin a statisticallyand potentially clinicallysignificantdelayto thrombolytictreatmentof AMI. ,l OO A Continuous ApproachAppliedto Oualitylmprovement I JO EmorgencyDoprnmcnt Gereof AsthmaPationtr Medicine,Health of Emergency R Sinert.MAckerman, EFishkiry'0epartmont of Departmsnt Hospital Centsr, Center of Brooklyn at KingsCounty Science NewYork Medicine.

Brooklvn, Study objectives:To determinewhether the principlesof continuous quality improvement(CQI) could significantlyimPacton the careof asthmapatientsin the emergencydepartment. with historicalcontrols.

Design:Prospective Setting:An urban teniary crre centerwith approximately225,000 toral ED visitswith 8,000 asthmavisitsper year.

Participants:A total of I2,964 consecutiveadult patientspresenting to the ED with the diagposisof asthmabetweenFebruaryl9f l and September1992wereenteredinto rhe study.

Interventions:Asthmarelapserate (percentageof total visits that returnedin sevendays)waschosenas the quality of careindicator. lnitially, relapseratewascalculatedfor the precedingyear, 1990, to serveashistoriccontrols.A focusedreviewshowednonrelapsing patientswere givensteroidsmore frequentlyand in higher dosagesthan "asthma relapsingpatients.Beginningin FebruaryI991, we institutedan treatmentprotocol,"which emphasizeda more comprehensivedosing schedulefor steroids.Feedbackof monthly asthmarelapserateand individual physiciancompliancewith the new protocol wasmailedto all careproviders.Physiciantrendingand profilingwere usedby supervisorsto provideadditionalinstruction to noncompliantcareproviders and positivereinforcementto the compliant.

Results:SeeTable.

Asthrn!Rolsps Rrte(%) 1990 Januarv toMarch ApriltoJune JulytoSeptember october to December 'P< .0t bY 12.

12.19 12.45 12.41 I |.89

'lL6l 12.44 10.83' 10.08'

8.86' 8.$' 8.15'

After compliancewith the protocol consistentlyexceeded9006in June l99I, asthmarelapserateshoweda statisticallysigxificantdrop comparedwith the sanrequarterthe previousyear.

Conclusion:We concludethat CQI in combinationwith an asthru protocol emphasizingaggressive use of steroidscan sigrificantly improveasthmapatientoutcome.

199!;fi:ffiilr'nslarvnsodJetventilationinthe JW McGill,G Robinson, of Emergency Medicine, J Clinton/Department Hennepin County Medical Center, Minneapolis, Minnosota Study objective:To evaluatethe use of percutaneoustranslaryngeal jet ventilation(PTV)asa temporaryairwaytechniquein the emergency department.

Design:An I l-year retrospectivestudy of ED and hospitalrecords.

Setting:Regionaltraumacenterwith 85,000 visis per year.

Participants:All patientsidentifiedashaving PTV in the ED. Results:The recordsof 97 patientsundergoingPTV were reviewed.

Agesrangedfrom 3 months to 8I years;the meanagewas40 years.

Fifty-fiveweretrauru-related,,tI werenontrauma.PTV was the first airwaymaneuverin 33 (60%) of trauma'relatedcases.PTV wassuccessfulinTToA of all patients;it wasestablishedin lessthan wo minutesin thesecases.Meanduration (t SD) was 12.2 I I0.3 minutes.Arterial

gaseswere availablein 1l trauma-relatedcasesand five non-trauma (cardiacarrest)patients.In trauma,meanvalues(i SD) for pH, Po, and Po, were7.33 x0.22,37 t 15 mm Hg, 342t154 mm Hg; in nontraumathesevalueswere 7.26 t 0. I 8,,10 t 9 mm Hg, and 743 t 182 mm Hg, respectively.PTV failure resultedfrom inadequateventilation (50%) and inability to placea catheter(,tl%); catheterkinking was cited only twice (9%) but may haveconrriburedto difficultiesin ventilation.Therewere three major complicationsattributableto PTV: bilateraltensionpneumolhoracesin a retardedl6-year-old with upper airway obstruction,bilateral tensionpneumothoraces with pneumoperitoneumin a 7-month-old in cardiacarrestfrom balloon aspiration,and pneumoperitoneumin a 2-year-oldmultiple traumavictim.

Conclusion:PTV is a rapid, effectivetemporaryairway techniquein the managementof critical traumaand nontraumapatients.PTV failuresc:ln be reducedby using designatedcathetenand by using careful placementtechnique.Major complicationsare rare,occur primarily in infants,and may be avoidedby using small catheterswith low ventilatory Pressures.

20 0 i::f; l#1,'

Jst "..hanicsofDogsDurinsTranstracheal

MLCarl,KJ Rhee, E0Schelegle, JFGreen/Departmont of Human Plrysiology, Division of Emergency Medicine, University of California, DavisMedicalCsnter Study objective:To quantiff the deliveredtidal volume and other measurements of pulmonary mechanicsin an animal model during low-frequencytranstrachealjet ventilation(TIIV) and compareit with positive-pressure mechanicalventilation(PPMV)and spontaneous breathing(SB).

Desigr and methods:bboratory study in which sevendogswere anesthetized,paralyzed,, and placedwithin a volume plethysmograph that allowedthe headand neck to be extemalized.Ventilationwas performedusing TIJV (with variableTrrlu ratios) followedby PPMV at 15 mUkg. Tidal volume, trachealpressure,transpulmonarypressure, air flow, CVP,and MAP were measured.

Main results:Tidal volume was 446 t 69 mL during IlfV and 506 t 72 mL during SB(NS, P > .05). TTJV delivereda tidal volume sigrificantly higher than the l5 mUkg volumesuggesredfor PPMVin dogs(P < .05). Trachealpressureduring T-IJV(10.9 cm HrO t 2 cm) was sigrificantly higirer than SB(5.0 cm HrO t 2.8 cm) bur not significantlydifferentthan PPMV(ll.l cm HrO +2.4 cm) (P< .05).

Variationsin T,/Tu ratioshad no significanteffecton tidal volume, trachealpressure,or transpulmonarypressure(P < .05). Minute ventilation increasedsignificantlyand Pco, decreasedsignificantlyas frequency inceasedduring Trrt. ratios of I :I and I :2 (P < .05).

Conclusion:TT]V deliversan effectivetidal volume comparable with both SBand PPMV,with no significantdifferencein measuresof pulmonarymechanicscomparedwith mechanicalventilation.Changing the T,/Tu ratio hasno sigrificant effecron deliveredtidal volume or trachealand transpulmonarypressures.

291;:rs;ll:|.*-trawal

Alters Rabbit Bronchial smooth Muscle

EMSkobelaff,tNH Spivey, C Connolly/Department of Emergency Medicine, Division of Besearch, MedicalCollege of Pennsylvania, Philadelphia Studyobjectives:Acuteexacerbations of asthrm havebeenassociated with the perimenstrualintewal in women. The experimentalhypothesis of this study was that estradiolwithdrawal increasesbronchialsmoorh muscle contraction and relaxation and that this changein responseis maximalwithin sevendaysof the wirhdrawal o[ estradio..

Design:Prospectivecontrolled laboratoryinvestigarion.

lnterventions:Male New Tnalandrabbitswere castratedand allowed to recoverfor 14 daysand then were treateddaily with estradiolfor 14 days(M2), daily for sevendayswith a one-day(Ml + ld), three-day (Ml + 3d), or seven-day(MI + 7d) recoveryperiod. Malecontrols(MC) and castrated,untreatedmalecontrols (CM) did not receiveestradiol' Bronchial rings (3 mm) from each group were placed in a Langendorff apparatusand treatedwith bethanechol(0.5 mM) to induce contraction. Bronchialrinks were then treatedwith isoproterenol(lSO) (10-s, I f , and I0-3 M) and MgCl, to induce relaxation.

Resuls:Changesin muscletension(milligrams)were recordedfor eachinterventionand data analyzedwith an ANOVA and Tukey A post-hoctest.P < .05 wassignificant.Chancesin tensionfor eachgroup areas follows: ill +3d Hl+7d t2 Mt+ld llC Ct Bethanechol

mMl {0.5 ts0 '10-sM 1rM 1G-3M MgCl2 5mM 20mM 50mM

xffi 1,0941272 l.nStl84 1.203t1841.858t2922.777

1,79tn7

-90139 -78132 -li3r58 -246*168-331t107 -220r88 -98*51 -58132 -174188 407+132 -142*60 47t25 -188167 -389*lm -ffiX77 -â&#x201A;Ź411218 -444*137-654r 127 -291t88 --431t110-506r99 -364193 -5851114-3mr1m -ffi2t102 -371x257-296156 -'485186 -5711110-447r$ -2'19!64 -156t48 -102t29 -,|92r40 -&2t97 -nl*.n

Resporseto bethanechol: MI + 3d (< .002)> > MI+ Id (NS)> Mt + 7d (NS) > CM (NS) > CM (NS) > M2. Responseto isoproterenol: M I + 3 d ( N S ) >M I + l d ( N S )> M I + 7 d ( < . 0 0 1 ) > >M 2 ( N S ) > C M (NS)> MC. Response to MgCIr: MI + 3d (< .001)> > MC (NS)> Ml + Id (NS)> Ml + 7d (NS)> CM > M2.

Conclusion:Estradiolwithdrawal after sevendaysof dosingcauses increasedcontractileresponseto bethanecholand increasedrelaxation responseto magnesiumthat is maximalat three daysafter cessationof treatrnent.Estradiolwithdrawalcausesincreasedresponseto isoproterenolat one, three,and sevendaysafter cessationof estradioiinjection. This study has important implicationsfor understandingand of asthma. treatingacuteexacerbations rrn SplenicTrauma:Gorrelationof CTGradingSystemsWith lVZ Prognosisand ilanagement Medicine J Vinen/Emergency M Stenet,JSJones,J Boche, T Harrington, College of Hospital, Michigan StateUniversity Residerry Program, Butterworfr Royal of Badiology, Medicine, Michigan; 0epartment Human GrandRapids, NorthShoreHospital, Sydney, Australia Study objective:fusessthe ability of computedtomographic(CT) gradingsystemsto accuratelypredict the outconr o[ blunt splenic rnJury. blinded casedesign. cross-sectional, Desigr.:Retrospective, Setting:University-affiliatedteachinghospitaland traumacenter.

Participants:Thirty-six consecutiveemergencydepartmentpatients (agerange,5 ro 77 yearc)with blunt splenicinjury who underwentCT scanning. lnterventions:Abdominal CT scanswere reviewedby two radiologistsand two emergencyphysicianswithout knowledgeof any clinical data,treatmentdecisions,or outcome.Eachscanwasevaluatedusing three previouslydescribedCT gradingsystemsfor splenictrauma.Data obtainedfrom eachgradingsystemwas examinedfor interobserver agreement,and correlationsbetweenmeanCT gades and clinical outcomeweredetermined.

Results:Overallinterobseryeragreementbetweenemergencyphysiciansand radiologistswas moderate(r = .62). However,none of the CT gradingsystemsaccuratelypredictedclinical outcome.Twenty-one

patientswith splenicinjury were managedsuccessfullywithout surgery; six (2906)had high CT gradesindicatingearly laparotomy.ln the l5 patientswho underwentsulgery,six CT gradingerrors(400,6)were documented.

Conclusion:Post-traumaticourcomeof the injured spleenis not predictablewith the use of currenr CT gradingsystems.Treatment choicesshould thereforebe basedon rhehemodynamicstatusof the patientand resultsofserial laboratoryand bedsideassessments.

A Gomparison ol SinusRadiographrWth Computed ?n2 C-lJrJ Tomography in AcutoSinusitis TFBurke.

ATGuertler, G Noonburg, J Timmons/Department of Emergsncy Medicine, Officeof Graduate MedicalEducation, andDepartment of Badiology.

Madigan ArnryMedicalCenter, Tacoma.

Washington Backgound: Sinusradiogaph usefulnessin acutesinusitishas neverbeenvalidatedby comparisonwirh computedtomography(CT).

Studyobjective:To determinespecificiryand sensitivityof sinus radiographsin patientswith clinically diagnosedacutesinusitis.

Design:Prospectiveconveniencesampleof patientsclinically diagnosedwith acutesinusitis.

Setting:Emergencydepartmento[ an army medicalcenterfunction'ingasa community hospiul and referralcenter.

Participants:Men and women age> l8 years,clinically diagnosed with acutesinusiris,havingsymptoms( 2 weeks.

Exclusioncriteria:Preguncy, chronic sinusitis,inability to obtain a CT within 72 hours.

Evaluations:Sinusradiographswere obtainedimmediatelyafter entry and sinus CTswirhin 72 hours. Radiologicalcrireda for sinusitis were definedas ) 3 mm of mucoperiostealrhickening,air fluid (A/F) level,or opacification.All films were readin a blinded bshion; CTsby two radiologistsand plain filrns by rwo emergencymedicine(EM) staff and the sameradiologisrs.A third radiologistinterpretedCT scans when the initial radiologissdisagreed.

Results:Thirteenwomen and four men aged25 to 70 years,entered thestudy.Radiologists interpreredI6 of l7 CTsidenrically,with l2 being positivefor sinusitis.Sensirivityand specificityof radiographs were5006and 800,6, 58% and 80ob,77oA and 40%, and 3806and I00% for the two radiologistsand two EM physicians,respectively.Four ethmoid, four frontal, and four spheroidsinusesthat on CT were opacified or had A"/Flevelshad no similar plain film findings.Sensirivityand specificityof maxillarysinus opacificarionor A/F level on radiographs were890,6 and 10006,7806and 100oA,67% and 9606,and 6706and 10006for the two radiologisrsand rwo EM physicians,respecrively.

Conclusion:Sinusradiographshavelow sensitivityand moderate specificityfor diagnosingacuresinusitis.Maxillarysinus opacilications or A,/Flevelsare highly specific.However,up to 330,6of parienrswith normal radiographshad CT evidenceo[ maxillarysinus opacifications or A/F levels.This study is limired by the rime delay from radiographro CT (mean,29 hours).

ClinicalScaphoid Fracture: GanDay-Four BoneScans tnA Gff 'l Accurately PredictthePresence orAbsonco of Scaphoid Fracture?

DGMurphy,MA Eisenhauer, JEPowe,W Pavlosky/Oivision of Emergencl Medicine, University of Western 0ntario,London, 0ntario,Canada Study objective:To evaluatethe accuracyof day-4bone scansin predictingthe presencey'absence of fracrurein parienrswith clinical scaphoidfracrure.

Design:Prospecrivesensitivirystudy of emergencydepartment patientswith clinical scaphoidfractures.All patientswere immobilized

in a thumb spica castand had day-4 bone scansof both wrists and hands.Blindedday-4bone scanresultswereultimately comparedwith the diagrosison day l4 when patientsretumed for repeatclinical exam and rad'iographs.

In casesof equivocalradiographsor clinical examination, a day-14bone scanwas performed.

Setting:Two tertiarycjlre teachinghospitalEDs. Participants:All ED patientsagedl8 to 70 yearswith a diagnosisof clinical scaphoidfracturewere invited to participate.

ResultsiA total of IOOpatientswere enrolledand successfully completedthe study protocol from October 1990 to November1992.

Day-l{ Resull present Scaphoid fracture ScaDhoid frdcture absent

Day-fScan{+} t?

7

Day-{Scrrl-l 0 80

Sensitivity was I00%; specificity,92oA;PPY,65%; NPV, 100'6; accuracy,9306.Numerousother fracnrreswere identified orl the day-,} scans,including ten triquetral,nine distal radius,one capitate,and two eachof the hamate,trapezoid,trapezium,and rnetacarpal.

Conclusion:Day-4 bonesqlns arean accuratemeansof excluding the presenceof scaphoidfracture;however,becauseof a significant number of false-positive scansat day4, rheydo not reliablyrule in the diagrosisof scaphoidfracrure.The bone scansalsoallowed the identification of severalother fracturesof the wist that were not radiographicallyapparent.

?ntr ZVJ

Electrocardiographic Abnormalities' ltVith in Patients Gocaino-Associrtod Chest PainMayBeDucto'llormal'

Variations JEHollander, M Lozano, P Fairweather, EGoldstein, D Cooling, GXBrogan, P Gennis, HCThodeJr,EJGallagher/SUNY StonyBrook, StonyBrook, New York;EronxMunicipal Hospital Bronx, NewYork Center, Study objective:"Abnormal"ECGsare found in 560Aro 84oAof patientswith cocaine-associated chestpain (CCP).We hypothesized that this is due to "normal" variationsin young parients'ECGS. Design:Case-controlseries.

Setting:Municipalhospiul.

Participants:Consecutivepatientswith CCP(cases)agedI8 to 35 yearswerecomparedwith normal controlsmatchedfor age,race,and gender. lntewentions:Fachpatienthad a history and ECG.ECGsunderwent deuiled analysisby two physiciansblinded to the study protocol and hypothesis.

Results:One hundred twelvepatientswere enrolled,56 in each group. lntelphysicianconcordancefor ECGdiagrosiswashigfr (K = .70, P = .0001).ECGswerenot sigrificantly differentbetween casesand controls.The meanfrequencyof ECG diagnosesamongcases and controls,respectively, wasnormal,806,I4%;nondiagnostic, 70oA,75"A;and ischemic,22%,13"A.The early repolarizationvariant was common (36A, 36%). Twelvepercentand 5oAof patientsmet ECG criteria for thrombolyticusc.

Conclusion:"Normal"variations( J point and ST segmentelevations) probablyaccountfor the higfr incidenceof "abnormal"ECGsin young patientswith CCP.Further snrdy is neededto define the prevalenceof these"normal"variationsand to determinewhetherstandardthrombolytic criteriaapply to young patienrs.

ilitroglycerin in dreTroatnsnt ol Cocains-Associated Chest tnC ZW Pain:ClinicalSoletyandElficacy JEHollander, BSHoffrnan, PGennis, PFainveather, M Di$noDSchumb, J Feldman, SFish,S Dyer,CWrelan,E&hwararuald.

PWax/Bronx Municipal Hospital Center, 8ronx, NerrYorkBellevue Hospital, NewYork,Na,rr York; Highland General Hospital, 0akland, California; CityHospital; Oueens Boston Hospital Center, Flushing, NewYork; University NewYork ofBochester, Studyobjective: Theoptimalmedicalregimenfor thetreatment of cocaine-associated ischemic chestpain(CCP)hasnot beendelined.

Whereas animalandhumandatademorstrate therisksof trblockade, studiesin thecardiaccatheterization labsuggest a beneficial roleo[ (NTG).Weevaluated nitroglycerin theclinicalsafetyandeflicacyof NTG in the treatmentof CCP. Desigr: Prospectivemulticenterobservationalstudy of consecutive patientspresentingto the emergencydepartment.

Setting:Six municipal hospital centers.

Patients:Eighty-threeof 246 patienrspresenringwirh CCPwere treatedwilh NTG. Interventions:At the physician'sdiscretion,patientswere treated with NTG. Reliefof chestpain or adversehemodynamicoutcomewere the primary end points.

Results:Patientstreatedwith NTG were older (36 versus32 years, P = .0008), more likely to havean ischemicECG (260Aversus306, P = .0001),be admitted(9,1%versus37%,P -.000I), and havea dischargediagnosisof ischemicheart disease(41% versus906, (,t5o6) P = .0001).NTG wasbeneficialin 4l patients(49%):37 par.ienrs had relief or reductionin the severityofchest pain; four patients(506) had other beneficialeffects.Only one patienthad an adverseoutcome (transienthypotensionin the settingof an RV infarct).

Conclusion:NTG is safeand probablyelTectivein the treatmentof cocaine-associated chestpain.

SystemicHemodynamic and OxygenTranspoftRosponso to tn', LV , GradedCarbonMonoxidePoisoning HASmithline, EPRivers, DAChiulli,MY Rady,LLBaltarowich, HCBlake.

MCTomlanovich/Henry FordHealthSystems, Michigan Detroit, Studyobjective:Systemichemodynamicand oxygenrranspon responseto gradedcarbonmonoxidepoisoningwasexamined.

Desigr: Prospectivecaseseries. lntervention:Five beagles(12 to 20 kg) wereanesrherized, paralyzed,intubated,and instrumentedwirh pulmonaryand femoralartery catheterc.Ventilationwith 0.25% carbon monoxidein air wasused until serumlevelsplateauedand deathensued.Systemichemodynamic and oxygentransportvariableswere measuredevery 15 minutes.

Cardiacindex (CI), systemicoxygendelivery(Dor), sysremicoxygen consumption(Vor), orygen exrmcrionratio (OER),and critical Do, (Dor".o) were recordedand are shown.

Resulu:Seet"O*. ,o* 0bm 20toO l0to 60 60tom >]t Cl(mt/min/kg) Do,{ml,/min/kg) Vo,(mVmin/kg) oER{%) lrctate(mmd^)

166146 t&1r58 T{*n 263168' 175r83 23.316.3 21.0r8.5 19.5r8.3 t4.tx2.4* 5.313.6' 4.4r0.8 4,3it.5 4.6it.4 4.9rl.8 2.4rt.6l9r5 l9rt0 25t6 35tlt. $tll' 2.3+0.5 l.8r0.4 t.9r0.4 3.2t2.0 6.0r1.3' Dozc,* is10.7 t4,0 ml/min/kg.

Values arereantSD. 'P<.05.

Conclusion:ln this model of progessivelethal dosesof CO,Vo, remains constant and is mainuined by increasingCI and OER. A compensatoryincreasein OER is mainuined until dearh.Thereis

no aherationin the Dor-,. l:ctic acidosisappearswhen this Dor-. is reached.Therewasno systemicoxygenutilization defectdemonstrated in this animalmodel of CO poisoning.

r|nQ Cost-Eflectiveness Medicine Amlysesin theEmergency AnAscrgnent of Currenttlethodological ZliJO Literaturo: Practicos Medicine in Emergency DJMagid,SVCantrillflheDerverAffiliatedBesidency Besearch Center andtheColorado Emergerry Medicine whetherpublished cost-effectiveness To determine Studyobjective: analyses haveadhered to necessary basicanalyticprinciples. articles. methodologic reviewof published Design: Structured Intervention:All studieswhoseconclusionsprofessedthe costeffectiveness of a specificprogram,treatnrent,or diagrrostictestwere reviewedto determinewhether an economicanalysiswas performed.

Studiesin which a formal analysiswas done were further reviewedto assessthe useand reportingof five fundamenul principlei of cost-effectivenessanalysis:an explicit statementof l) the perspectiveof the analand 4) ysis,2) the measureof effectiveness, 3) how costswereassessed, a sumrrnry measurementof costand efficacy.The use of sensitivity analysis5) to tesrimportant assumptionswas alsoassessed.

Studysample:Twenty-eiglrtafticlespublishedfrom 1984 to I992 in three peer-reviewedemergencymedicinejoumals.

Results:Overallperformancewas only fair. Forty-sixpercent(I3 of 28) o[articlesperformedno formal analysisdespiteconclusionsthat a treatmentor diagnostictest wascost-effective.Of the studiesusinga formalanalysis,no articlesadheredto all five principles,and the median number of principlesto which articlesadheredwas two. The most common problemsidentified in the formal analyseswerea hilure to makeunderlyingassumptionsexplicit and thereforeverifiableand a failure to testassumptionswith sensitivityanalyses, Conclusion:Greaterattentionshould be devotedto ensuringthe appropriateuse of analyticmethodsfor economicanalyses,and readers should makenote of the methodsusedwhen interpretingthe results of economicanalyses.

WthLowLitency 209 ThoHealth Care Experience olPatienb Medical 0WBaker, RMParker, MVWilliams, WCCoates, KPitkin/llarbor-UCl} Center, Grady Hospital Study objective:To assessthe impact ofilliteracy on the deliveryof health careand to consideraltematemethodsfor providing care.

Design:Patientinterviewsduring a 30-day period.

Setting:Two urban county hospitals.

Participants:Thirty-one patientswhosescoreson the RapidEstirute of Adult Literacy(REALM)test indicatedlow levelsof literacy(English and Spanish).

Results:Many patientswereunwilling to admit to difficulty reading beforethe test.Patientsindicatedthat their inability to readcompromises their carein the following ways: I) they harbor a deepsenseof shamethat is reinforcedby hospiul staff who becomefrustratedor angrywhen they cannotcompleteforms or read instructions;2) access to health careis difficult becausethey cannotread registrationforms and signs;3) health careeducationo[patients, dischargeinstructions, and followup informationare often written to compensatefor the health careprovider'stime pressuresand languagebarriers;4) medication is often taken inconectly; 5) relianceon oral instructions,demonstrationof tasks,and family membersas intermediariesare cornmon coping mechanisms.

Conclusion:Low literacyposesmajor problemsfor patients.

Willingnessto admit readingdifficultiesvarieswidely, so objective testingmay be necessaryto identiry goups needingextraassistance.

Problemareasand coping rnechanismsidenriliedby rhe srudy group may provideinsighr into possibleinterventionsby the health careteam to providehealth careto patientso[ low literacylevels. ,4 nPromoting Alefinoss and Performanccon the ttlightShift An Z aV lnteruentionStudy R Snith-Caggins, MB Bosekind, KRBuccino, W Cole/Stanford University Backgound: Emergencydepartmentshilt work'engenderssleep loss,circadiandisruption,and htigue. ln this study,attendingemergency physiciansuseda rangeof alermessnurvrgementstrategiesto improve day sleepand subsequentalertnessand performanceduring the nigfrt shift.

Methods:Six attendingemergencyphysiciansparriciparedin three conditions(lastingtwo months each)in a randomizedcrossoverdesigl: baseline,experimentalintervention,and activeplacebocontrol. The experimentalinterventioninvolved education(information about sleep, circadianrhythms, and farigue),prevenrionsrraregies (eg,shift scheduling, methodsto improve day sleep),and operationalcounrermeasures (eg,strategicnapping,caffeineuse).The activeplacebo,basedon the 'Jet lag" diet, alteredcarbohydrateand prorein intake. (Thejet lag diet hasno circadianeffect.)Measuremenrs collectedin eachcondition includedambulatoryphysiologicsleeprecordings,psychomotorand cogritive performance,and a self-reporredlog.

Results:Physiciarurated the overalleffectiveness of rhe experimental condition sigrificantly grearerrhan the placeboconrrol (.005) and satisfactionof nigfrt shift alertnessassignificantlygreaterfollowing the intervention(.05). The physiciansworking the night shift (day sleep) reportedsignificantlydecreasedalermess(.05), activiry (.02), morivation (.03), and clearthinkrng (.04). Day sleepwasassociatedwirh significantly decreasedtotal sleeptime (.0007), depth of sleep(.007) and increasedsleepiness(.02). Therewas a rrend during the experimental condition for a reportedincreasein total sleeptime for day sleep(.06) and feelingmore restedduring rhenighr shift (.08). Analysesof rhe physiologicsleepand performancedataare 90% completed.

Conclusion:lnitial analysesshowedthat physiciansreportedbetter sleepand improvedalertnessusing the interventionstrategiescompared with baselineand activeplacebo.The ongoinganalyseswill demonstratewhether thesesignificantself-reporredfindings translateinro improvedphysiologicday sleepand subsequenrimprovemenrsin night shift performanceand alertness. ,lThe Incidenceof 'Burnout'and ldontificarionof High-Risk ttl L a a StressorcAmong GraduatesofanEmorgencyMedicine ResidencyProgram GMNewland,GCHamilton/0epartment of Emergency Medicine, WrightState University School of Medicine, Oayton, Ohio Backgound:The purposeof this studywas ro measurethe incidence o[ "bumout" and to identi] stressorsthar nuy contribute to the experiencein graduatesof an emergencymedicineresidency.euestionnaires weresent to 104 physicianswho graduatedfrom our program from 1982to 1992.

Results:The retum exceeded900,6.Bumout was investigatedusing the threerales of the MaslachBumout Inventory(MBl): emotional exhaustion,depersonalization, and loweredsenseof accomplishment.

Potenlialstressorsweregradedon a standardteikert scalewith respondents indicating the frequency of eachstressorasexperiencedin clinical practice.Stressorswere then groupedinto sevencrEgories including

conflict, clinical uncertainty,administrativeresponsiphysic'ian-patient bilities, institutionalconflict, lifestyleand family conflict, senseof professionalisolation,and societalconflict. Multiple regressionanalysis was usedto correlatebumout indicesto thesestressorcategories.In institutionalmorale, addition, demographics,practicecharacteristics, and the physicians socialsupport strengthweresurveyed.

Conclusion:Our findings demonstratel) bumout ratesin emergency medicineresidency'trainedphysiciansfrom this programarenot as worrisomeas popularly perceived;2) consistentenvironmental elementsand practicecharacteristics correlatewith emotionalexhaustion and depersonalization indicesof bumout. The senseof personal accomplishmentremainshigh in graduates;3) socialsupport strength appear to provide a compcnsatorymechanismthat mitigatesthe impact of occupationalstrcssors;,t) the problem existsto sufficient degreethat continued rcsearchinto origins and prevention is warranted. lr rl itChemi cal Dependenclin EmergencyMedicinen.Slrn"y 4 a Z Prograrm:Perspectiveof the ProgrEmDiroctors College of Pennsylvania, Philadelphia; BMMcNamara, J Margulies/Medical Brooklvn Hospital Center, NewYork Study objective:Chemicaldependencyis an important issuefor residencyprogramdirectors(PDs),and emergencymedicine(EM) has beenidentifiedasa specialtyat risk for this problem. The purposeof this study was to evaluatethe tmininS,knowledge,and experiences regardingchemicaldependencyamong EM programdirectors.

Additionally, the PDs'awareness of substanceuseand chemicaldependencyamongEM residentswasexaminedby comparingtheir estimates with the actualratesreportedby EM residents.

Desigr: An anonymoussuwey mailed in March 1992.

Participants:Surveysweresent to the PDsof all 86 ACGMEapprovedEM residencies.Responses were receivedfrom 67 (78%) of the programs.

Results:The 67 respondingPDsrepresented| ,637 (77oA)of rhe 2,I30 EM residentson duty at the time of the survey.The respondents were in their current position a mean* SD of.4.7! 3.6 years,and 33 (4gob)hadsuspectedchemicaldependencyin a residentat leastonce; 22 (33oA)had identifieda chemicallydependentresident,and nine (13%) hired a residentknown to be in recovery.Regardingfour chemical dependencyissues,the following percentages reportedslight or no knowledge:natural history, 40%; recognitionof impairment,27%; processo[ intervention,46%; re-entryguidelines,60%. Twenty PDs (30%) receivedno training or only informal training regarding physi cian impairment.When comparedwith a February1992 surveyof EM residents,the PDscorrectlyestimatedresidentuse ratesin the pastyear for alcohol,marijuana,benzodiazepines, and [5D but overestimated cocaineand amphetamineuse while underestimatingnarcoticuse. The PDsestimatedthat l6 (1.0%) of their current residentswere impaired by alcohol,whereasthe residentsurveyyielded CAGEscoresconsistent with alcoholismin 4.9% and suspiciousfor alcoholismin an additional 7.606of EM residents.

Conclusion:EM PDsmust be more attentiveto potentialalcohol abuseamongEM residents.Further training regardingchemicaldependencyis desirable.

aa

tt

Zl5 CTScansAfter HeadTrauma:Redefiningdre Low-Riskpatient CDeSibar.JS Jones.C Llrttenton, C Martin/Department 0f Emergency Medicine andBadiology, Buttsrworth Hospital, Michigan StateUniversity College of Human Medicine, GrandEapids, Michigan Study objective:To define thar population of low-risk patientswith headinjurieswho do not requireemergencycomputed.tomogaphy (CT) scanning.

Design:Retrospective analysis.

Setting:University-affiliatedreachinghospitaland LevelI trauma center.

Participants:Six hundred consecutiveemergencydepartment patients(agerange,2 to 95 years)wirh a chief complaint of blunt head traumawho underwentCT scanning.All panicipantshad a normal neurologicexam,maintaineda GlasgowComaScalescoreof at leastI3, and had no clinical evidenceofbasal skull fracrure. lntewenrions:Patientdemographics,mechanismsof injury, and physicalfindingswere analyzedro determinewhich combinationof parients clinical indicatorsbest identifiesan inrracerebraliniury.

-neurologic were followedup by telephoneto dererminesubsequent disabiliry.

Results:Of the 600 patientsstudied,intracerebral inlurieswere documentedin 12 (2oA).Radiologicfindingsincluded inrracerebral hematoma(six patients),corticalconrusion(four),and subarachnoid hemorrhage(two). In this definedpopularion,no clinical ind.icators, aloneor in combination,accuratelyidentifiedall patientswith abnormal CT findings.However,.ron. of rhe l2 patieniswith inrracerebral injuriesdevelopedneurologicsequelaeor requiredsurgicalintewention.

Conclusion:RourineCT scanningis not indicatedfor the patient with blunt headinjury without neurologicabnormalities.

Minor HeadTrauma ti n ldentificationof Ethanol-lntoxicated Z a a PatientsRequiringCTScans MALevitt.B Simon, VWilliams/University of California, SanFrancrsco; Highland General Hospital, 0akland, California Studyobjective:Physicians arremprto identifyintoxicared minor headinjured (MHI) parientsneedingcomputedromography(CT) for suspectedcraniocerebralinjury (CCl) by variousclinical parameters, Recentliterature,however,has demonslratedthe difficulty in identifing which soberMHI parientsneedCT. This study wasdesigredto prospectivelyderermineif clinical guidelinescould be esublishedfor CT usein intoxicatedMHI patienrs.

Design:Prospective,case-control.

Serring:Countyhospital.

Participants:One hundred sevenpatientswith serumethanollevels > 80 mg/dl and havingsustainedminor headtrauma.

Interventions:Eachparientunderwentan abbreviatedneurologic scoringexam(ANSE)at rime of presenrationand one hour later,aiter which the parienrunderwenra cranial CT. Addiriorully, 39 hisrorical and physicalexamination(Fl,/P)variablesused in a previousMHI research designwerecollected.

Results:Nine of I07 patientsenteredhad a CT scanpositivefor CCI (incidence, 8.,106).

Meanserumernanollevelfor the CCi groupwas 0.205+ 0.032and for the noninjuredgroupwas0.249+ 0.0I2 (P = .2132).Therewasno srarisricallysigrificant differencebetweenthe two groupsusing rhe ANSEat rime 0, time one hour, or examiningthe changein scoreduring the one hour. A logistic regressionmodel was constructeddemonstraringno true differencebetweengroups in the 39 H/P variablesstudied.All five patientswith hemorvmpanumand the two parienrswith bilareralperiorbitalecchymosir'f,rdnegativeCT

Conclusion:An 8.4% incidenceof intracranialinjury existsin ethanol'intoxicatedpatientssustainingminor headtrauma.Observation with serialexaminationsbeyond one hour is necessaryto determineCT use.Closefollow-up is recommendedfor thesepatients.

A Comparison of tho ExtornalRotationandthe Hanging t1tr L | ., WeightTechniquos for AnteriorShoulderOislocation Reduction DJ Dire,RG Creath, LBStack,DBFerguson/Section of Emergerf,y Medicine andTrauma.

Department of Surgery, University of Oklahonn HealthSciences Center, 0klahoma City,Department of Emergency Medicine, Darnall Arnry Community Hospital, FortHood, Texas; Department 0f Emergerry Medicine, Brooke ArmyMedical Center, FortSamHouston, Texas Study objective:To determinedifferencesbetweenthe extemal rotation(EXRO)and the hangingweighr(HGW-[) techniquesof anrerior shoulderdislocat'ionreduction.

Design:Prospective,randomized.

Setting:Community hospitalemergencymedicineresidency ProSram.

Participants:Patientsnor pregnanrwirh no history of hepaticor renal disease,headinjury, alteredmenul status,drug or alcoholintoxication,or pain medicationssinceinjury and who had no prereduction lractures. lnterventions:All patientswere given I.5 mg/kg meperidineand 0.5 mg/kg hydroxyzinelM. Threeattemptsfor rhe EXROgroup were allowed;if unsuccessful,the HGWT rechniquewasused.Patientsin the HGWT group had a 10-lb sandbagapplied for up ro 30 minutes;if unsuccessful,the EXROtechniquewas used.Addirional medications wereusedif the firstattemptfailed.Patientsratedthe degreeof pain experiencedfor reduction.Datawere analyzedusing Fisher'sexacttest, Wilcoxontwo-sample test,or a t-testwhereindicated.

Results:Therewere 15 patientsin group EXROand II in group HGWT. Datafrom one HGWT patienrwereeliminaredbecauseof spontaneousreduction.All patientsnot reducedby the initial technique were reducedby one attemptof the altematetechnique.All patientsnot reducedon the first attemptof EXROevenruallyrequiredHGWT. Overall,EXROresultedin reducrionin 6306(ren of I6) and HGWT in 94oA(15 of l6) of patienswho had ir atrempted(P = .083).

Tinel Time2 Timo3 %petients A0o Iniuryb lM Meds Starno Pain Reduced byFint N (years)lt todr to Start Rod|Etio||Sco]o TechliqroUrd EXBO HGwT

23.6 89.| 23.5 87.4 .9597 .S9

3r | 28.0 2.7 60% 35.3 11.2 |.8 90% .2ffi4 .0805 .071 .179 Conclusion:Using this mode of analgesia,anterior dislocationsnor reducedby one attemptof EXROshould haveHGWT performed.

Group HGWT showeda trend toward a shortertime to reductlonwith lesspain and greatersuccess.

P

Comparison ol ShortArm Castand Plasterand ti C A Radiographic a. lV FiberglasWrist Splints KTJordan, JM Howell.

WCLauerman, CAButzin/Clinical lnvestigation Directorate, Department 0f Emergerry Medicine.

WilfordHallMedical Centsr, SanAntonio, Texas; Departmefi of Emsrgency Medicine, Georgetown University Hospital, Washington, DC;Department of 0rthopedic Surgery, University of Pittsburgh Study objective:Prepackaged plasterand fiberglassplints areused in manyemergencydepartments.The purposewas to study the effectivenessof short arm casr(SAC),volar fiberglaswrist splint (FWS),and volar plasterwrist splint (PWS)in limiting rangeof motion.

Design:Unblindedhuman experimenr.

Setting:Military teachinghospiul (1,200 beds).

Participants:Ten malevolunteersbetweenthe agesof 18 and 35 years. lnteryentions:Eachwrist on eachvolunteerwas immobilizedwith SAC,FWS,and PWS.Wrist radiographswere uken with eachappliancein neutral position, flexion, extension,ulnar deviation,and radial deviation.Angular motion was measuredby two radiologisrs.

Results:SeeTable.

MotionTypo

SAC

I1.4r6.5 /.J iD.5 1 8 . 4 1r 1 . 6 n.7*8.0 u.ztzl.t nxm.z 8.716.0 20,1 r il.7 29.9 r8.3 7.9*6.5 9.0r 7.1 14.7 r8.9 Measurements are in degrees,and standarddeviationsarenoted for eachmean.PWSoutperformedFWS in flexion (P < .01), exrension (P < .05),radiaideviation(P < .05),and ulnar deviation(p < .01).pWS wasnot statisticallydifferent than SAC in limiting flexion,extension, or radial deviation,alrhougfrSAC performedbetrerrhan pWS in ulnar deviation(P < .05).

Conclusion:PWSourperformedFWS in limiring wrist flexion, extension,radial deviation,and ulnar deviation.PrefashionedpWSs aremore effectivein limiting wrisr rangeof motion than a similar fiberglasproduct.

Flexion Extension Ulnar deviation Badial deviation

', TriageNurseUseol Docision Rulerlor Radiography in Ankle tt La, Iniuries lG Stiell,G Greenberg, BDMcKniglrt, CJCarterSnell,I McDowell, BCNair,B Aubin,A Cwinn/Division of Emergerrcy Medicine, University of 0ttawa Study objective:To assessthe impacr on patienrcareof the application of clinical decisionrules for ankle radiographyby emergency departmenttriagenurses.

Desigr: Before-aftercontrolled clinical trial with five-monthcontrol (physicianordering radiographywithout rules)and intewention (nurse orderingwith rules)periods.

Setting:ED ofa 550-bedaduh rerriarycarehospital.

Participants: All I,I83 adultsseenwirh acuteblunt ankletrauma duringthe studyperiods. lntewention: After a training sessionand a run-in phase,ED triage nursesused r.heOtuwa ankle rules to selecrpatienrsfor radiography.

All patientswereseenby physiciansbeforedischarge.

Results:Clinical characteristics were similar for the control (633) and intervention(550) goups. During the inrewenrionperiod, use of ankleradiography wasreduced(68.6%versus79.goA,p <.001) but use of foot radiographyincreased (35.I06versus26.7%,p<.01). parienrs spentlesstime in the ED when radiographswere orderedby nurses ratherthanby physicians(92.7versusI15.2 minutes,p < .001).

Eighty-onepercento[ the 84 casesof unnecessaryradiographywere attributedro inappropriateorderingby nurses.The nurseswere less accuratethan physiciansin interpretingboth the ankle (8I.g06 versus 99.606)and the foot (82.5% versus99.0%) rules.Inrerobserveragreement betweennursesand physicianswasgood for lateralmalleolar tendemess(r = .59) and abiliry ro bear weigfrr(r = .6a) bur only fair for naviculartendemess(r = .39).

Conclusion:Implementationof decisionrulesby triagenursesdid not.decrease use of radiographybut did reducewaiting times for ankle injury patients.Further training and experiencewith decisionrules may improvethe efficiencyof nurse orderingof radiography.

irq O Flexion/Extenrion Viowsin theEmergencyDepaftment Z a g Evaluotion ofAcutcGcrvical Spinelniury J Karp,REWoltq MJHeinig, MFMestek, EAJonassen/Denver Affiliated Besidency inEmergerry Medicine, Colorado Emergerry Medicine Besearch Center, Denver General Hospital of Badiology, General 0epartment Derver H0spita I Department of0rthopedics (F/E)viewsin theemerBackground: Theroleof flexion/extension gencydepartment evaluation o[ acutecervicalspine(CS)injuriesis unclear.Previous retrospective studiesdemonstrate a higlr rateof.FlE views:up to 1306of all CSviewsperyearandup to 8%of F/Eviews indicatinginstability.

To safelyperformF/Eviews,strictcriteriamust be met.

Study hypothesis:rvVhenorderedwith appropriateindications,F/E views rarelyyield usefuldiaglostic information in the ED evaluationof acuteCSinjuries.

Design:Prospectivestudy approvedby the institutional review boardovera I5-month period,OctoberI, I99I, througlrDecember31, I992. The radiologylogwas reviewedfor the studyperiod,and all patientsreceivingCSand F/E viewshospitalwidewere noted. Followup consistedo[ telephonecalls and repeatvisits with rhe orrhopedic departmentwhen warrantedby continued pain.

Setting:The ED ofa municipal hospital,a LevelI traurn center.

Participants:Forty-fiveconsecutivepatients> l8 yearsof agewho had FIE views performedafter routine three-viewCSserieswho met entry criteria:normal mentalstatus,absenceof distractingpain, and absenceof neurologicsymptoms.Patientsenteredhad neck pain with CSviewsreadasnormal or with soft tissueswelling,narrowedor widenedinterspace,or abnormalcurvatures.

Results:Duringthe studyperiod,5,280r.oralCSviewswereordered from the ED. Forty-fivepatientsreceivedF/E views from the ED, a rate of 0.906.Of these,15patients,one had an abnormalF/E study: ligamentous insubility betweenCl and C2 requiring cervicalfusion.Follow-up was obtainedin 36 patiens with no indicariono[ any missedCS injuries.

Conclusion:F/E viewsare usedmuch lessoften than generaliy reportedand rarelyyield additionalinformarion.

zlgMisdiagnosis ol Appendicitis in Womenol Chitdbearing Age SGBothrock, SMGreen, M Oobson, SAColucciello, M Simmons/Departments of Emergency Medicine,Orlando Regional Medical Center, Riverside General Hospital, Carolinas Medical Center. andLoma Linda University Medical Center; California Emergency Physicians Medical Group Study objective:To identify the incidenceof misdiagrosisand factorsassociated with misdiagnosisof appendicirisin women aged I5 to 45 years.

Design:Retrospective caseseriesfromJanuary I980 to December 1991.

Setting:TeachinghospiUl with emergencydepartmentcensusof I00,000 patientsper year.

Participants:One hundred seventy-fournonpregnantwomen aged l5 to ,15yearswith a pathologicdiagnosisof appendicitis.

Methods:Using1z analysisand the Studenfs t-test,clinical fearures were comparedbetweenpatientsmisdiagnosed(seenin the prior ten daysand givenan incorrectdiagrosis)and thosewho wereinitially diagnosedcorrectly.

Results:Fifty-eigfrtwomen (33%) with appendiciriswere initially misdiagnosed.

Most common misdiagnoses included pelvicinflammatoin t5 (26%), and urinary infecry diseasein l6 (28%), gastroenreriris tions in seven(12%). Misdiagnosedwomen more frequenrlyexhibited

diffuseand bilaterallower abdominalpain and tendemess,cervical motion, and right adnexaltendemess.Misdiagrosedwomen alsohad a lower incidenceof rigfrt lower quadranrpain and rendemessand peritonealsigns.Misdiagnosiswasalsoassociated with an increasedincidenceof perforation,abscessformation,and an increasein the total length of hospitalization(P < .05 for all comparisons).

Conclusion:The incidenceof misdiagrosisof appendicitisin women of childbearingageis high. Women who are misdiagnosedhaveless typical abdominalcomplainrsand physicallindings and more frequent abnormalpelvic findingsthan thosewho are diagnosedconecrly.

Emergencyphysiciansshould be awarerharatfpical signsand symptoms areassociated with misdiagrosedappendicitisin non pregnantwomen of childbearingage.

Deliningthe PositiveTiltTest A Studyol HealthyAdulrsWrh ,tn ZLV ModerateAcuteBloodLoss MD Witting.BLWears,S LilUniversity of FloridaHealthScience Center, Jacksorville Studyobjective:To define the best crireriafor a positivetih tesrand to determinethe rest'slimiutions in rhe settingof moderateblood loss.

Design:Posturalviul signswere recordedin a standardLedmanner beforeand after 450-mL phlebotomy,and a pairedcomparisonwas done.Criteria for a positivetestwere comparedby areaunder the receiveroperatingcharacteristic(ROC)curve or by comparisonof sensitivityand specificityat a discreetpoint. P < .05 was considered significant.

Settingand parricipants:Healthy,experiencedeuvolemicadulr volunteerblood donors(345)wererestedat two communiryblood donationcentersover a one-yearperiod. Threehundred one donors wereunderage65 years.

Results:Nine patientshad reactionsafterblood withdrawal and wereexcludedfrom viul sigr analysis.The remaining292 donors under age65 yearswere usedto derivecriteria for a positivetilt test.

The areaunder the ROCcurve generatedby pulsechange(a p, .765) wassignificantlygreaterthan both areasgeneratedby systolicblood pressurechange(a s, .552) and diastolicblood pressurechange(a d, 0.513) and was greaterthan rhe areaunder eachof severalROCcurves generatedby combinationof a p and blood pressurechange(a bp).

Criteriabasedon a p alonewerealsosigrificantly betterthan tradirional criteriacombining a p and a bp. SeeTable.

Crilerion ^p 25 300R 18 200R tl moR 3 ^bp ar>?5 ar>20 ... ^d>10 sensitiviry l%)25 (%l96 Specificity

15 96

51 86

47 84

60 80

50 80

94 27

Conclusion: ln diagrrosing moderare bloodlossin heahhyaduhs, criteriabasedon pulsealonearesuperiorto combinations of pulseand bloodpressure.

Changes in SerumPotassium Following tt.lAcute LA a Succinylcholine Usoin theEmergency Department HSnyder, BZink,A Walsh, N Bobak/Department of Emsrgsncy Medicine, Albany Medical College, Albarry, Naru York Studyobjecrive: Hyperkalemia hasbeenreportedaftertheuseof succinylcholine in patientswith severe muscletrauma,bums,spinal cord injuries,and closed-headinjuries.This has occurredweeksto monthsafter rhe inirial injury. This srudy was desigredro idenrify rhe acutechangein serumpotassiumafter succinylcholine-assisted intubation in rhe emergencydepartment

Design:Prospectivenonrandomizedcaseseriesover24 months.

Setting:TertiarycareuniversityhospitalED. Participants:Sevenry-sixconsecutivepatientsrequiringsuccinylcholine-assisted intubationat the discretionof the attendingphysician were identified.Sevenpatientswereexcludedbecauseof late or hemolyzedblood samples.The study population included two bum patientsand 32 blunt traumapatients.

Interventions:Succinylcholine(l mg/kd wasadministeredintravenouslyfor neuromuscularblockade.A serumpotassiumlevelwas drawn five minuteslater and comparedwith the serumpotassiumlevel drawn beforeintubation (a I0.

Results:Serumporassiumincreasedin 3I patients,decreasedin 3I patients,and wasunchangedin sevenpatients.Meanserumpotassium levelst SD were identicalbeforeand aftersuccinylcholine(,1.0+ 0.6 mEq/L).The rangeof serumpotassiumlevelswas 2.8 to 5.8 mEq/L beforeand after succinylcholine.The a K rangedfrom a decrease of I.5 mEq/L to an increaseof l.l mEq/L.No patientexperienceddysrhythmias or cardiovascular collapsein the ED. Conclusion:Serumpotassiumlevelsmay increaseor decrease within Iive minuteswhen succinylcholineis used in the acutesettingbut were not clinicallysignificantin this study.

LLZ Ethanol-Relatod llypoglycemials Uncommon A Sucov, flHWoolard/Division of Emergency Medicine, Brorun University School of Medicine, Department of Emergency Medicine, Rhode lslandHospital Study objective:Many physiciansroutinely evaluatepatientswith alteredmentalstatethat is assumedto be ethanolrelatedfor hypoglycemia.The purposeof this study is to determinewhetherthis practiceaddsvaluableinformation.

Desigr, participants,and setting:Prospective,consecutivecase seriesof 953 patientswho were evaluatedfor ethanolintoxicationin an urban universityhospitalemergencydepartmentover a three-month period. A simultaneousglucosewas performedevenif the physiciandid not suspecthypoglycemia,Glucoselevelswereunavailablein 16 (I.7%).

Of the remainingpatients,353 had no detectableethanol(ethanolnegative), and 58zlpatientshad ethanollevels> 0 (erhanolposirive).Dara were analyzedby Fisher'sR to Z test. intewentions:None.

Resuls:Meanethanollevel in the ethanol-positivegroup was 23I + I I I mgo6;meanglucosewas I05 + 35 mg/dl. The correiation betweenethanoland glucosewas .00I (P = .985). Of thoseparienrs with an ethanol> 99 mg%, meanethanolwas259 t 92 mgo,6, glucose was 106 i 36 mgldl, and the correlationwas-.030 (P = .435).

Hypoglycemia(glucose< 67 m/dL) was observedin five patients (0,906);mild to moderate(50 to 66 mg/dl) in four (0.70,6), and severe (7 mddL) in one (0.2%). Meanethanollevel for thesepatientswas I 61 i 94 mgo6,and the correlationwas-.803 (P = .l I 7). ln the ethanol-negative group, the meanglucosewas I 17 t 58 mg/dl, and therewere four (l.I%) episodesof mild to moderarehypoglycemia.

Conclusion:Hypoglycemiais a rarecauseof alteredmentalstatein an ethanol-positivepopulationand is not more common in the ethanolpositivegroup than in the ethanol-negarive group. Glucoseand ethanol levelsdo not appearto correlate.

a.lra LZJ New-0nset Soizuros:Which patientl RequireAdnrission?

FDe Boos, PLHennernan, RJLa,rris/lepartment of Ernergency Medicine, Harbor-UCIA Medical Center Study objectives:To dererminel) whetherall aduh patientswith new-onsetseizures(NOS) requireadmissionand 2) whetherthosewho requireadmissioncan be detectedin the emcrgencydepartment.

Desigr.:Retrospective chart review during a 36month period.

Setting:Urban county hospital in southem Califomia.

Participanrs:One hundred twenry-sevenpatienrs(39 women, gg men;agerange,16 to 90 years;mean,38 t 17 years)with NOS who underwenra sundardizedworkup including history, physicalexamina_ tion (PE),CBC,SMA-7 (lytes,BUN, crearinine,glucose),calcium,head computedtomography(CT), lumbar puncrure0.P) if clinicallyindicated, ' and admission.Parientsexcluded from study were thosewith acute headtrauma,hypoglyccmiafrom diabetictherapy,and alcohol-or drug-relaredseizuresas determinedin the ED. Resuls:Forry-sevenpercenrof patients(60 of 127) wirh NOS requiredadmissionfor further evaluationor lreatment;thesepatients had new strokes(I,l), masJlesionon CT (12), metabolicabnormalities (six), persistenralreredmentalsratus(five), srarusepilepticus(three), systemicinfection(three),hydrocephalus(rhree),gastroinrestinal bleeding (three),meningiris(rwo), and orher (nine). Thi needfor admission wasobviousin rheED in 98% of parientsrequiringadmission(59 of 60). One parienrhad recurrentseizuresin the hospiul after a normal ED evaluation;this patientalsohad a recurrenrseizurein rhe ED. Fiftvthreepercenrof patientswirh NOS (67 of 127) did not requireadmis_ sion; the ED and hospitalcoursein theseobviouslystablepalienr was uneventful.The number of parientswho underwenteachtestand had a clinicallysignificanrresuh,respecrively, werc:CBC(121, rwo),SMA_7 (126,12),CT (t24,48), Lp (95, four).

Conclusion:One half of patienrswirh NOS requireadmission.

Patientswith NOS who requireadmissionciin accurarelybe detectedbv history,PE,SMA-7,CT scan,idenrificarionof feversouice,and course in the ED. Suble patientswith a negativeevaluationand withour recur_ rent seizurescan be dischargedhome after initiation of appropriate tnerapy.

ttn

ZLa lha Historyof UntreotedVasculerIniuries EHoffer, S Sclafani, T Scalea, S Trooskin/Badiology Department, KingsCounty Hospital Center; Departmont of Emergerry Medicins andSurgery, Stite University of NewYorkat Brooklyn Study objective:To characterizethe naruralhistory ofuntreated vascularinjuries.

Desigr: Thirteen-yearretrospectivechart study.

Sett'ing:Urban lrvel I traumacenter.

Participanrs:All patientswith angiographicallyprovenvascular . injurieswho were not immediatelyexploredor emLohzedbecauseof clinical instabiliry,injury inaccessibility,parientrefusal,or clinical intention.

Intervenrions:All patientswere followedclinicallyand had at leasr one follow-uparreriogramperformed24 hours to four yearsafterinjury.

Resuls:The natural history of rheselesionswas found to b. u.ir._ dicuble, although observationwasassociated with an adverseclinical effectin only one parienr.Similar percentages of pseudoaneurysms healedor expanded.Sixrypercenrof inrimal flapshealed,but rhe remainderdevelopedstenosisor pseudoaneuryJms. One third of rhe cases.ofluminal narrowing,initially rhoughtto be spasm,developed pseudoaneurysrns, stenosis,or thrombosis.One half of the arteriove_

nous fistulaeclosedspontaneously.Two arterialocclusionssubsequently developedarteriovenousfistulae.

Conclusion:Thesedatasugrlesrthat arreriographycannotreliably predict the natural history of vascularinjuries. Operativeexplorationis indicatedfor mostarterialinjuries. However,becausesomeinjuries healedspontaneouslyand clinical deteriorationrarelyoccuned during follow-up, observationof sornearteriographicabnormalitiesis justifiableaslong asintewal angiographyis performed.

Comparisonof lntrclingual, Intravenour,and Intramrscular tttr AL.t Administationof Succinylcholine in dre Swinc Model MS Killen,LBStack/Joint MilitaryMedicalCenters, Brooke ArnryMedical Center/lililford HallUSAFMedicalCenter,SanAntonio,Toxas Study objective:lntralingual(lL) injection of drugshasbeensuggestedto providean altemativeroute of administrationwhen IV access is not readilyavailable,but controlledsrudiesarelacking.Suecinylcholine wasusedas the protorypeagentto evaluarethe time from drug administrationto onsetof clinical effectwhen given intralingually.

Design:Sevenpigs wereanesthetizedwith halothane,inrubated,and placedon a ventilator.A nervestimulatorwas placedover the tibial nerve.Eachanimalwasgivensuccinylcholine(2mg4<g)by the lV, IM, and IL route in random order with 30 minutesbetweeneachtrial. Each animalservedas its own control. The time from drug administrationto Iossof skeletalmuscletwirch was recordedby an obsewerblinded to the routeof administration.

Resuls: IV administrationproducedskeletalmuscleparalysisin 39.4 t7.2 seconds.IM injection resuhedin erraticresponse.Three animalsdid not respondto lM injection,and the remainderrequired two to threeminutesto achieveparalysis.IL injection failed to yield paralysisin any animal.

Conclusion:IV administrationof succinylcholineproducedrapid and reproducibleparalysisasexpecred.IM injection,asexpected,producederraticresults.lL injection,however,did nor produceclinical effectsin any animal.Usingsuccinylcholineat dosesknown to produce a responsein swineby other routes,this study wasunableto support the hypothesisrhat IL administrarioncould provide a suitableahemative when IV accesswas lacking.Further study could be undertaken using differentdoses,a differenrmodel, or differentdruss.

in theEmergency trflOpening ol a lers UrgentTroatmentAroa 'lcft ZLW Dopa.tmsnt Signilicontly Reduces ths Without Treatment'Rate SFSutherland, RE1'ConnorlDepartment of Emergencl Medicine,St Francis Hospital, Wilmington, Delaware; Department of Emergency Medicine, Medical Certerof Delaware, Wilmington "Lefr Studyobjective: without rrearmenr"(LWT) patienrsareusually patientswho aredissatisfiedwith waiting rime and who may posemedicolegalrisk to rheemergencydepartment.This srudywasconductedto determinewhether the openingo[ a sepamtefasttrack (FT) treatment areafor lessurgent parientswithin the ED changesthe LWT rate.lf the LWT ratechanges,what are the linancialimplications?

Desigr.:The retrospectivereviewof ED patientvisitsfrom a sevenmonth periodbeforeand a five-monrhperiodafterimplemenutionof FT. Setting:Generalcommunity hospital.

Participants:All ED parientsduring the study period. lnterventions:ln August 1990,a separatelystaffedFT adjacentro the ED wasimplementedto trearlessurgent patienrsduring peak volume hours of 5 to I I pu.

Measurements and results:Patientcensus,LWT patients,and admissionswere measuredbeforeand after FT. Censuswas 22.622

beforeand I5,441 after; LWT patients\r/ereI ,341 beforeand 522 after; admissiorswere 3,089 beforeand 2,257 after.A total of 2,099 patients were treatedin FT during this period, representing13.6%of the total census.The 5806reduction in LWT patientsis significant(I2 - I Ig, P < .001). The admissionrate remainedconstantat I,1% during both partsof the study. The additionalbilling generatedby the 580,6reduction in LWT patientswas approximatelytwice the FT operatingcost.

FT patientbilling wasapproximarelyseventimes the operatingcost.

Conclusion:Designatinga separateareafor the trearmentof less urgent patienb reducesthe LWT rate, presumablybecauseof decreased waiting times.EDs that reduceLWT ratesmay realizeincreased revenue,increasedpatientsatisfaction,and reducedmedicolegalrisk.

tt', Z-,

EmergencyDepartment TelephoneAdvice- Who'sCalling?

WCCoates, EJLucid, ECottington/Allegherry General Hospital, Pittsburgh, Pennsvlvania Study objective:To caregorizerhe typesof telephoneadvicecallsro the emergencydepartmentand to correlatetheir distributionwith acrual patientdischargediagrosesduring the sametime period.

Study desigr: Prospectivesrudy.

Setting:Urban lrvel I trauma center.

Measurements and main results:Nursesrecordedthe subjectof each telephonecall during a seven-dayperiod. A physiciananalyzedrhe I 66 calls for their urgency.Thirry-rhreepeople(20%) had emergentproblemsincluding chestpain, uncontrolledbleeding,acuteabdominal pain, and acuteasthmaexacerbation.One hundred seventeencallers (7006)requestedinformation on nonurgentmedical'issues, newbom care,public health concems,schoolprojecs, and drug information.

Sixteenpeople(1006)wanredadvicefor self-rrearmenr.

Forty-eight callers,someof whosecomplaintswere serious,askedpermissionto be seen.Eiglrt hundred eigfrrED patienrvisirswere analyzedfor the pri, mary diagrosisduring the test period and werecomparedwith the calls.Using12 analysis,rhe distriburion of callsreflectedthe typesof patientsseenin 78% of cases(P < .05). The remaining2206had orthopedic injuries or lacerationsand tendednot to call the ED beforetheir visits.

Conclusion:Telephonecalls ro our ED reflectedthe typesof patiens actuallyseen.The imporranceof rhe telephoneto patienrwelfarewas demonstratedby the higfr acuity of somecallers.Utilization of the telephoneasa resourcefor patient care,triage,and educationis a promising tool in emergencymedicine.The legal,economic,and logistical implicationsof providing this sewicemerit funher investigation.

What ls an AppropdateEmcrgencyDepailmentVisit?

An ttQ ZLg Explanationlor tho Failureto Agro0 RALowe,AB Bindman, SKUlrich,TAScaletta, G Nornpn,K Grumbach, JM Luce/University of California, SanFrancisco, Prsvention Sciences Group, Division of Emergency Medicine, lnstitute for HealthPolicy Studies; Departments of Emergency Medicine andFamily andComrnunity Medicine, SanFramisco General Hospital Division of General lnternal Medicine Study objective:Third-parry payersare attemptingto control cosrs by withholding paynrenr.for "inappropriare"use of emergencydepartments.The literaturehas reportedthe proportion of inappropriateED visits to rangefrom 38% ro 82%. We hyporhesizedthar rhevariarion betweenstudiesmigfrr be becauseof differencesin how ,,appropriateness"is defined.

Design:Cross-sectional study.

Setting:Urban public reachinghospitalwhoseED servesabour 78,000 parientsannually.

Participants:A11patientsseenduring a one-weekperiod, who were older than I8 years;spokeEnglish,Spanish,or Cantonese;werecoherent; and were not in the higfrest acuity triage categorywere eligible for study. Of the 729 eligible patients,598 (82%) agreedto pailicipate.

Measurements: Sevendifferentindicatorsof inappropriateED visis typical of thosein the literarurewereused.Two could be determined by the patienr:I) willingress to trade the ED visit for a clinic appointof problem seriousment within threedays,and 2) low self-assessment ness.fwo could be determinedby the triagenurse: I) leastacutetriage score,and 2) satis$inga publishedset of triageguidelinesfor refusalof ED care.Threewere determinedretrospectivelyby chart review: l) no physician-orderedtreatment,procedure,or test from a predetermined list of itemssuggestinghigh patient acuity, 2) an emergencyphysician's subjectivereviewconcludingthat the patientwould not havebeen jeopardizedby a 24-hour delayin care,and 3) the patientwas not hospitalizedfrom the ED. All 2l possiblepairs of indicatotswere compared for agreementusing the K statistic.A r score< .,10represents Poor aSreement.

Resuls:The indicatorsclassifiedfrom I006 (patientself-assessment of seriousness) to 90% (hospitalizationfrom the ED) o[ patientvisitsas inappropriate,with the other five indicatorsclassifying210,6to 37% of. visits asinappropriate.More important, there was little overlapbetween indicatorsas to which visits they classifiedas inappropriatebeyond the agreementattributableto chance.K valuesfor agreementbetween indicatorsrangedfrom -.0,1 to .3 L Conclusion:Decisionsas to which ED visits are appropriatedepend heavilyon the criteriaused.ln the absenceof valid, standardizedcriteria for determiningappropriateness of ED visits,effortsto decreaseED utilization nuy createharmful banien to neededcare.

E CodesAssignodFromEmergency Department Records: tr!

ZLat ls the lnformationThoro?

BJ &hwartz,B Juda,LMJacobs/Oepartment of Emergencl Medicine/Traunn, Hartford Hospital, Hartford, Connecticut Study objective:To measureclinicians'documentationsufficientto assignE codes.Emergencydepartmentrecordscomprisean underutilized sourcefor developinginjury preventionstrategies.This study demonstrates a baselinemeasurementto identify areaswhereeducation can enhancedocumentationand thereforeincreasethe assignmentof E codes.

Desigr:Retrospective, randomizeddrart review;two-month duration.

Setting:Urban, high-volumeED with residenttraining programs; chartsarehand-written.

Participants:One hundred randomly selectedED charts(306sample) of patientstreatedand releasedfor an injury inflicted within 2,1 hours o[ presentation.Reviewdone by singleclinician with extensive coding experience.

Results:One hundred chartswere reviewed.All chartshad physician/nursingnotesand clericalinformation.Thiny-three of 45 charts had emergencymedicalseryices(EMS)forms.Seventy-nineof 100 physicianrecords,77 ol 100 nursing notes,30 of I 00 clericalinformation, and 23 of 45 (51%) EMSformshad sufficientinformationto assigrr an E code. Ninety-twochartshad documentationby one or all of the providerssufficientfor coding. Deficienciesidentifiedwere in detail of circumstances resultingin lessspeciliccodes,intention of the injury resultingin errorsof coding intentionality,and omissionsof dau resultingin inability to codeat all.

Conclusion:In a busy urban environment,clinicianswithout knowledgeof E codescollectsufficientinformarionto assigr an E code in a largepercentageof the charts.Educatiorul inrerventio4sshould be

desigredto improve physician,nurse,and clericaldocumentationof causeof injury. Thesemeasurements can sâ&#x201A;Źrveas a baselinefor future documentationstudiesand should be comparedwith orherclinical sites and di fferentchartingtechniques. the Lossol ExternalCauso-oFlniury lnformation ,anTracking LIJIJ FromPatientto Physicianto the Msdical Record BJ *hwartz, D Boiseneau, LMJacobs/Department of Emergency Medicine/Trauma, Hartford Hospital, Hartford, Conneticut Study objective:Cause-of-injuryinformation in the emergency departmentchart is most frequenrlyusedto assigl E codes.The purposeof this study is to measurelossof cause-of-injuryinformation from patientto chart.

Desigr: Prospective,longitudirul observationof history taking and documentation;sevenmonths.

Setting:Urban, 90,000-visitED with residenttraining programs; chartsarehand-written.

Participants:One hundred three patienrsinjured within 24 hours of exam,cooperativeand conversant(conveniencesampling).Attending physicians(25), residenrs(28), physicianassisranrs or nursepracririoners(45), and students(five) uking hisrory were directly obsewedby (MDHis). The researcherthen took derailedhistory @His) researchers (controlgroup). aboutcausarion Intervention:MDHis, abstractedchart (Ch) versusresearcher history taking(RHis).

Results:Total number of cause-of-injuryfactscollected:RHis: 6.2t1.4, MDHis:4.2 t 1.5*,Ch: 2.8 t I.0r. Fourcareqories of causeof-injury facs, what, why, whereand prevention,*ere ised ro measure detailsof information loss.Within eachcategory,significant differencestwere found betweenRHisversusMDHis, MDHis versus Ch, and RHisversusCh. Rarioof MDHiVRHiswas.63 X.22, Chr/MDHis was.62 t .2,1,and CVRHiswas.37 t .18.r Sixty-rhree percentof inforrnationobtainablefrom the patientwasnot recorded on the chart. Factsabout where and pr.u.rriion were omilted most.

Attendingphysicianscollecredrhe mosr lacrsand documentedthe least, and studentscollectedthe leastand documentthe mosr(rp < .05).

Conclusion:Significantdegradarionof information occursin history taking and chartingof cause-of-injuryby ED personnel.Deficiencies were found in all four information categoriesand were most. pronouncedin factsaboutwhere and prevention.Hisrory taking and chart documentationcontributeequallyto the lossof information.

BecauseE codesareusuallyassignedby chan review,significanrhandicap wasidenrifiedin abiliry to assigr E codes.Educarionof ED personnel in cause-of-injuryhisrory raking and dicuting of chars may improvethe ability to assigr E codes.This requiresfurther study.

Screeningend EmpiricTreatmentlor Syphilisin on taiTargeted L., I UrbanInner-CityEmergency0epartmentand RelatedHIVRates AA Ernst, TAFarley,DHMartinAouisiana StateUniversity Department of Medicine.

Divisions of Infectious Diseases andEmergency Medicine; Louisiana StateDepartment of HealthandHospitals, Section of Epidemiology.

New0rleans Studyobjecrive:To esrimarerhe yield of urgeted screeningand empiric treatmentfor syphilis in an urban emergencydepartment.

Design:Screeningof ED parienrsduring scheduledshifts fromJuly l99l toJanuary1992.

Setting:University-affiliatedurban inner-city ED. Participants:Higfr-risk ED parientscomparedwith a group denying , high nsk.

lntervention:ED patiens admitting to drug use or sexualcontact with a drug userwere consideredto be in a high-risk group (HRG)and thosedenyingrisk behaviorswere placedin a control gfoup (CG). All HRG patientsand everyother CG patientwerescreenedin the ED using the rapid plasmarcagin(RPR),and empiric antibiotic treatment was initiatedif RPRpositivewith no previoushistory of syphilis.

Additionally,serumwassubmittedto the routine lab for a VDRLand microhemagglutin treponernapallidum (MHA-TP) testing.The renuinder was frozenfor blinded HIV screening.

Results:A toul of 373 patientswere screenedfor syphilis,with 216 in the HRG and I57 in the CG. The power of the study to detecta fourfold differencein the two.groupswas .8. ?(2with Yates'correctionand Fisher'sexacttestwereusedin statisticalarulysis.No significantdifferencewas found betweenpreviouslyundetectedcasesof syphilis in the HRG (eigfrt,,106)versusCG (four, 20,6)or betweenthe perce;rtwith a positiveMHA-TP(47 122%lversus25 [16o6]).In the HRG,the differencein femaleversusmale ratesof positiveMHA-TP testsapproached statisticalsigrificance(3,1%versusI90,6,with p = ,07). Among females, the MHA-TPwasmore often positivein the HRG than in the CG (34% versusI506,P = .025).PositiveHIV antibodiesweredetectedin l6 of 212 (9oL)of the HRGand five of I55 (306)of the CG (P = .13).Of thosewith positiveHIV antibodies,therealsowere seven(3306) MHA-TP positiveand 14 (6706)MHA-TP negtive.

Conclusion:Thereis a high underlying rate of positivesyphilis serologiesand HIV antibodiesin this inner-city ED population.Syphilis ratesarehigfr in thosedenyingdrug use; therefore,screeningall patientsis warranted.

,at LJL

ThePrevalence of Pneumococcal Vaccination AmongHigF RiskGroups Prcaonting to theEmergency Department

F Yates,B Wilson/Brooke ArmyMedical Center, SanAntonio, Texas Study objective:To estimatethe current prevalenceofpneumococcal vaccination(PneumoVaxo)amonghlgh-risk patientgroupspresenting to the emergencydepartmentof a tertiarycarehospiul.

Design:Overa27-dayperiod,3,337questioilvrires weredistributed to eachconsecutivepatientpresentingto rhe ED. The questionmire identifiedthosepatientswith chronic medicalconditionsplacingthem at increasedrisk for pneumococcalinfectionssuch as emphysema, bronchitis,asthma,asplenia,and cancer.Emergencyphysicianson dury verifiedeachpatient'shistoric information.

Setting:Military tertiarycarehospiul during March I992.

Resuls:9venty-one percent(2,493)of questionnaires wererecovered.

Of these,5l did not note vaccinationstatuseventhough the patient was in a high-risk group. Of the remainingvalid questionnaires, 411 (16.806)were identifiedas higfr-risk,and 74 (18.006)of thesehad prior pneumococcalprophylaxis.This proportion wassignificantlydifferenr (P < .001) from publishedresultsfrom civilian seuingsin 1983 (9.5%) and 1986(8.006).

Conclusion:Althougfrappropriatepneumococcalvaccinarionstatus nay be improvedin this miliury hospitalED serringin 1992,ir is srill well below the 60% prevalencegoal setby rhe US Public Health Service.Differencesbetweenthis study and previousreportsmay reflect improvedpatientand physicianawareness over tirne, samplingproblems, or a differencein health care delivery betweencivilian and miliury systems.

taa L.tJ

lidocaineVorsusDiphenhydramino lor LocalAnestheda in MinorSkinLacorrtions

AA Ernst, E Marvez-Valls, G Mall,J Patterson, X Xie/Department of Medicine, Divisionof Emergency Medicine,Department of Biometry andGenetics, Louisiana StateUniversity, New0rleans Study objective:Our previousstudy demonstratedthat I % diphenhydramine is as effecriveas I % lidocaine for anesthesiain minor laceration repairbut that it is morc painful ro injecr.The purposeof the prcsentstudy is to comparethe effectiveness of 0.5% diphenhydramineto l06 lidocainefor pain of injection and adequacyof local anesthesia.

Desigr: Randomizeddouble-blindedprospectivestudy, December I99I toJune1992.

Setting:Univenity-afliliated urban inner-ciry enrergencydepartrrrnt.

Participants: A toul of 98 adultswith linearskin lacerationswithour end-organinvolvementwere included:,18receivinglidocaineand 50 receivingdiphenhydramine.Two patientswere excludedbeforeanalysis becauseof improper datacollection.

Intewentions:Wounds were anesthetizedwith either diphenhydramine or lidocaine,accordingto a random table.Both patienrsand physiciansrated the pain of injection and suturing accordingro a standard previouslytestedlinear visual analogscale.

Results:Patientand physicianratingswere rankedwithout reggrdto treatmentgroup, and rank sum scoreswere slculated for eachgroup.

Generallinear modelsand multivariateanalysisof variancewereused to analyzethe ranked sum scores.The power of the srudy to detecta rankedsum differenceof l5 was .8 wirh P < .05 consideredstatistically sigrificant. Lidocainewas found to be signilicantlymore effectiveasa local anestheticaccordingto borh patienrs(P < .001) and physicians (P < .004) in faciallacerations.Therewasno sratisticallysignificant differencebetweenI% lidocaineand 0.5% diphenhydraminefor pain of injection or suturing accordingto borh parientsand physiciansfor all other locations.Meanand medianscoresfor injection and suturingwith diphenhydraminecorrespondedto mild pain, accordingro parienrs.

Conclusion:Although nor a replacementfor lidocaine,diphenhydramineis a viable altemative.

Grue rsFasrer and Jusr a8 2341;::1il:r":Tl:Horations: M Halperin, M Yaron,M Weston,CBCairns/Oivision of Emergency Medicine, University of Colorado Health$iernesCenter; Colorado Emergency Medicine Research Center.

0enver Studyhypothesis:Suturingskin lacerationsin rats is not superiorro closurewith butyl-2-cyanoacrylate tissueglue (TG).

Study model: Eiglrt adult rarswere anesrhetized, the dorsalskin was shaved,and an 8-cm, full-thicknessincision was madeon eachside of the midline. In eachanimal, one wound wasclosedwith a singlelayer of intemrpted 5-0 Prolenesururesand one by "spot welding" with TG. The time requiredto closeeachwound was recorded.Sutureswere removedat sevendays,whereasthe TG was allowed to fall off sponuneously.The animalswere killed 20 d.aysafterlacerationrepair,and the woundswerejudged for cosmeticoutconreby an observerblinded to repair technique.

Measurements: Four I x 3-cm strips of skin were excisedfrom each wound. One was used for histologic analysisand three were used for load extensiontestingusing an Instron modcl l0l I tensiometer.

Specimenswere loaded to wound failure while displacement(Dp) and energyabsorption(EA) were recorded.

Results:Pairedt-testswere used to comparethe TG and sutured wounds.Resultsare reponed as meant standardcrror. No statistically sigrificant difference was found in either DP or EA. Time to closurc was

sigrificantly lessusing TG. No histologicdifferenceswere seenregarding cellularity,collagenlibers, proteoglycans,or epithelialresponse.TG wounds were cosmeticallysuperiorin five animals,suturedwounds superiorin one,and judgcd equal in two animals.

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Conclusion:l) Suturesand TG in rat skin repairresult in similar wound strength,stretch,and histolory. 2) Wound closureis accomplishedmuch more rapidly with TG. 3) Cosmeticoutcomemay be superiorwith TG. qttE Follow-upof FaciallacerationsSuturedin tho Emergency t t'tivJ uopanmenl Hospital I Chern,V Markorrchick, S Greissman, D Bar-Or/St Barnabas Medicine, Medicine, NewYork;Emergency Department of Emergency Bronx, Swedish Medical Center, Englamod, Colorado Studyhypothesis:Faciallacerationsrepairedby emergencyphysicianswill havelow complicationratesand higfr patientsatisfaction.

Desigr: All patiens with faciallacerationstreatedin a private community hospiul fromJanuaryl99l to April l99I wereretrospectively identified,and a follow-up telephoneinterviewwasconductedat I2 months.

Results:Therewere a total of 252 patients(males,I7,l; females,78).

Forty-two patientswere unavailablefor interview,and 25 weresutured by a plasticsurgeon.Forty-eigfrtlacerationswere suturedby emergency medicine(EM) residents(PCYll-N) and 179 by the attendingstaff(all residencytrained,board certified in EM); of theselacerations,l7 were not sutured, 122 were suturedwith a one-layerclosure,and 88 were suturedwith a multilayerclosure.Demographicanalpis of etiologies revealedthe following distribution: fall (96), blunt trauma(48), motor vehicleaccident(32),assault(23), sports(23), animalbite (18), other (12). Therewasa total of 291 lacerations:forehead(8+), lip (a8), chin (40), eyebrow(38), periocular(29), cheek(25), eyelid (ten), nasal (nine), under the chin (six), ear (one), intraoral (one). Of the I85 patientswho completedthe interview,only six patientsrelatedproblems during healing, five patients had receivednegativecomnrnts about scarappearance, and five had thought about.scarrevision.The initial impressionof the repair wasrated asvery poor by one patient, poor by three,satishctoryby 13,goodby 15,and excellentby I53. The final impressionof the repair was ratedvery poor by one patient,poor by two, satisfactory by four,goodby I6, and excellentby l6I. Six patientsrated the linal scarappearanceasworsâ&#x201A;Ź than expected,104 as expected,and74 asbetter than expected.The overallED experience was ratedasnegativeby six patientsand positiveby I 78.

Conclusion:To our knowledge,this is the first follow-up of hcial lacerationrepair doneby any specialty.We concludethat EM residency rrainedphysiciansarecompetentat suturing both simpleand complex faciallacerations.

tatr^A Surveyol Patientr05Yean of Ageor 0lderDischarged LrJ|U FromthoEmergcncy Dopartmont WJAngelos,S Krauland/University of Pittsburgh School of Medicine, Centâ&#x201A;Źr for Emergerry Medicine Pennsylvania ofWestern Studyobjective: To determine whetherelderlypatientsdischarged homefromtheemergency department will l) reponneedinghelpin dailyactivities, 2) rerumfrcquentlyto theEDfor care,3) benoncompliantwith follow-up,4) beat risk for deterioration.

Design:Prospective,consecutivecaseseriesof patients65 yearsof. ageor older dischargedhome from the ED over a one-monthperiod (OctoberI992).

Setting:Universityhospitalwith an ED armualcensusof ,t 1,000.

Participants:One hundred eigfrty-nineconsecuriveparienrs dischargedfrom the ED who were 65 yearsof ageor older were placed into two groups(65 to 74, > 7,1).Patiens who were r.rnableto be contactedby telephone(13), refusedro parricipare(eight),or lived out of town (three)were excluded. lntewentions:Telephonesurveycompletedat one and threeweeks afterdischargefrom the ED. Resuls:Therewere 165 completedsurveysfor analysis(87% completed),with a median ageof.74years.Resultsdemonstraredthat 3806of patientslived alone,3,t% required czre,29%were unablero shop, 120,6 had trouble taking medications,33% had either a hearing or visualimpairment,22%werc unablero handlemoney,25% usedan ambulanceasa mode of transportation,40% did not follow up with a physician,i8o6 believedtheir condition wasunchangedor worsened, I606 retumed to the ED, I I % subsequenrlywere admittedro rhehospital, and one died at home. Two-uiled Fisher'sexactrestswith s error setat .05 wereused for comparisono[ groups.Therewereno statistical differencesbetweenthe groups for gender,living alone,trouble taking medications, deterioration in condition,follow-up,or rerumvisits.

Thereweresignificantdifferencesberweengroups(older, higher risk) for subsequentadmissions(P = .046), needingcare(P = .0028),using an ambulance(P = .002),visual or hearingimpaired(P = .00026), unableto shop (P = .00079),and difficulry handlingmoney(P - .0077).

Conclusion:Elderly patients,especiallyover rhe ageof.75years,are at risk for trouble in caring for themselvesat homâ&#x201A;Ź and are at risk to go homewithout assistance or follow-up care.However,our datasuggest that the elderly do not frequentlyretum ro the ED or deteriorate.

237 in:ilx#ltisks

ofDearh orIncrer$od Dependence inthe

DI Bichard sonlloyalBrisbane Hospita l, Herston, 0ueensland.

Austra lia Study objective:Previousresearchhas suggesred that elderly patientsat risk of deathor increaseddependencemay be identifiedat the time of emergencydepartmenrpresentationby simple factors.This study aimed to prospecrivelyassess a raringscaleasa determinantof hospitaloutcomein admittedpatients.

Design.:Patientswere identifiedand enteredby medicalstaffwho completeda one-pageform and were divided into "high" and "low" scoregroupson the basisof a scorecalculatedfrom referral,neurologic disease,cardiacfailure,and socialproblems(range,two to l2; high scoremore than five). The ourcomeof admissionat 28 dayswas determinedfrom hospital records.

Setting:Major public hospiul ED. Participants:One hundred forty-two parientsaged75yearsand over who had 147 admissionsthrougfr rhe ED in a four-weekperiod and wereidentifiedby residentstaff(6Lohof 237 consecuriveeligible admissions). lnterventions:None.

Results:Of 34 high-scoreparienrs,nine (26.5%) died or werenewly admittedto nursing homeson dischargecomparedwirh 13 (12.0%)of 108 low-scorepatienrs(P < .08). Therewasno significantdifferencein total hospitalbed daysor proporrion remainingin hospiul at 28 days.

Havinga socialproblem was rhe singlesrrongestpredictor of dearhor nursinghome admission.

Conclusion:This simplescoreis a predictor of hospital outconn, and its place in clinical assâ&#x201A;Źssrnentrcmains to be determined. As in previousstudies,identifiedsocialproblemsarea major risk hctor. rtrt..l ZrJO GeriatricPaticntsWth Fever:ClinicalSignilicance Hopkins GDKelenruohns CAMarco.CNSchoenfeld, K Hansen, D Stearns, University School of Medicine Studyobjective:To determinethe significanceof feveramong geriatricpatients.

Design:Retrospective study conductedduring a l 2-month period.

Setting:Generalcommunity,university-affiliatedernergency department.

Participants:Patientsover the ageof 65 with a temPeraturein the ED ofat least100.0F orally.

Results:Four hundred cighty-nineeligiblepatientswere identified.

Four hundred twelverecordi were avaih6lefor review.Of these,305 patientswereadmittedto the hospital.Thirty-threepatientsdied within one month of presentation.The most common final diagnoseswere pneumonia(22.8%),urinary tract infection(22.8%),and sepsiJbacteremia(I I.706).Feverwasunexplainedin 13.306of the patients.Risk factorswere identifiedaslisted below for significantdiseaseprocesses (definedas positiveblood culture, deathwithin one month, need for surgery,lV antibioticsfor threeor more days,other sigrificant inpatient therapy,or ED retum within 48 hours).Advancedagewasnot identi fied asa significantrisk factor. t{FY odd!Ratio P Sonritiyity Spcciticity PPV Temp2l0l HR> 120 BP> 90 BR> 30 Nursing home Diabetes wBc > r't,000 Bands > l0 > 1risk > 2 risks

.82 .25 .07 .m .21 .n .66 .49 .96 .65

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.82 .84 .85 .88 .79 .88

.38 .30 .21 .31 .n .n .33 .n .35 ,43

3.08 5.4 7.43 5.7 1.8 2.14 2.72 1.99 5.2 6.07

<.ml <.001 .02 <.ml .m .01 <.ml .03 <.ml <.ml

Conclusion:Febrilegeriatricpatientspresentingto the ED havea high incidenceof sigrificant disease.Thosewith at leastone risk factor shouldbe consideredfor admission.The absenceofany given risk factor is not usefulin ruling out significantdisease.

,2O L.rJ

Emergency Dopartment lmmunization oftheEldedyWith Vaccino Pneumococcal andlnfluenza

RMBodriguez, U Baraff/UCHSchoolof Medicine Study objective:To determinethe percentageof elderlypatients presentingto an emergencydepartmentwho were previouslyimmunized with influenzaand pneumococcalvaccinesand the feasibilityof immunuingunvaccinated patients.

Desigr: Prospectivestudy of a cohor! enrolled over two months.

Setting:An urban universityED. Participants:A conveniencesampleofelderly ED patients.lnclusion criteriawere ED patients) 65 yearsofage. Exclusioncriteriawerecriti cal illness,chestpain, shortnessofbreath, and syncope. lntervention:Eligiblepatientsweregiven an informationsheetand askedabout their immunizationstatus.Patientswho answered'?ro"or "unsure"about prior vaccinatiorswere offeredvaccinationaspart of their ED care and were informed of the chargesfor vaccination. Patients who desiredimmunizationwerescreenedfor contraindications.Those withouccontraindicationswere immunizedas part of their ED care.No attemptswere madeto obuin approvalfrom primary carephysicians.

lmmunizedpatientswere given a record of their ED immunizationsfor their prinary care physicians.

Results:One hundred thirty-threepatientswere askedabout their vaccinationstatus.One hundred nine of 133 (82%) answered'tro" or "unsure'about prior pneumococcalvaccine.

Sixry-eigfrtof 109 (62%) statedthat they desiredpneumococcalvaccinc;63 of I 09 (58%) were immunized.Eighty-four of 133 (6306)answerednno"or "ursure" aboutcurrent influenzavaccinarion.Forty-fiveof.Ba (5a%) suted they desiredinfluenzavaccine;45 of.84(50%) were immunized.The primary reasonsfor refusalwere l) desireto discussvaccinationwith primary physician,2) belief that vaccinesdo not work, 3) fearof reactions.

Conclusion:I ) The majority of ED patientswerenor previously immunizedfor influenzaor pneumococc.,ll pneumoniaas recommended by the CDC; 2) most elderly patientswill acceptimmunizationwith thesevaccinesas part of their ED care;3) thesevaccinescan be effective to elderlypatientsin the ED. of 0ral andTympanicThermography a$ Toolsto t nn Copmparison AalJ Screenfor Feverin Adult EmergoncyPrtients EAHooker, H Houston/Department of Emergency Medicine,University of Louisville School of Medicine, Louisville.

Kentucky Study objective:To compareoral and tympanic thermometersin their ability to screenfor feverin adult emergencyparienrs.

Design:Prospecrive study over a six-weekperiod.patientshad a tympanic temperature(TT) measuredusing the Genius30004 (lnrelligent MedicalSystems)followedby an oral remperarure(OT) using the IVAC 20804 (IVAC Corporation).Nurseswere trained in the proper use of the instruments.lf rheparienthad a fever(OT or TT 2 iOO.Of) ana consentedto a rectaltemperature(RT), the RT was obtainedusing the IVAC 20804.Recul feverwasdefinedas RT > 100.5F. Setting:Universityhospiral.

Participants:A conveniencesampleof 322 patients.patientswho had eaten,drank, or smokedwithin 15 minureswere excluded.Fortvone of 52 patienrswith an elevatedtemperatureby either the oral or tympanicmethodconsentedto RT measurement.

Intewentions:None.

Results:The correlarion(r) of TT ro OT, TT to RT, and OT to RT was .845,.853,and .940,respectively.

Of the4l patientswho had RT measured,24 werefebrile.All 24 weredetectedby the oral thermometer, but only I8 of 24 were detectedby the tympanic thermomerer.The identificationof thesefeversaffectedclinicalevaluation.

Conclusion:In this direct comparisonof oral and tvmDanrc thermography,rhe rympanicthermomererwas lesss..,ritiu. for fever.

Tympanicthermometersshould not replaceoral thermometersas the screeningtool for feverin adult emergencypatients. t Atl Useof a MagneticIntubationStyletand MagneticFieldSensor La I lor Endotracheal TubePositioning White,CM Slovis/Departmont of Emergency Medicine, Vanderbilt University lJ Medical Center, Nasfville.

Tennessee Study objective:Mainstembronchusintubation is a seriousbut avoidablecomplicarionof endotrachealtube (ETI) placement.We hypothesizedrhar rhe rrxagneric field of a magner-rippedinrubarion styletcould be transcutaneously sensedover the suprastemalnotch, thus allowing oprinal positioningof an ETT tip within rhe midtrachea.

Design:Prospecrivetrial.

Participants:Conveniencesampleof 20 intubatedparienrs,age> l g years,unsuccessfullyresuscitatedfrom erdiac arrest.

Seuing:Universityhospiul emergencydepartment.

lnterventions:Upon terminationof resuscitativeeffortsand while the original position of the ETT wasmaintained,a prototypemagnettipped intubation styletwasadvancedthrougfr the previouslyplaced ETT until a light was activatedon the extemalmagneticlield sensor (Mag-probe,Bartol lnd, Mesa,Arizona).The stylet was left in place,and the intratrachealpositionsof both the ETT and the magneticstyletwere documentedwith a singleportableanteroposteriorchestradiograph.

Results:Unrecognizedmainstemintubation occurredin six of 14 patients(4306)intubatedby paramedicsand in two of six patients (3306)intubatedby emergencyphysicians.In an additionalseven patients(five prehospiul, two ED), the ETT was insertedto within 2 cm of the crarina,for an overallrnalpositionrateol75%. Transcutaneous sensingof the magneticfield was possiblein all 20 patients,regardless o[ neck circumferenceor presenceof airwaybleedingor vomitus.The rugnetic styletwas localizedto 8.3 + I.5 cm from the crarina(range, 5.7 to I I.9), and in no cirsewasthe stylettip abovethe levelof the C7 to TI vertebrae.ln all 20 patients,the stylet tip appearedto be in rhe middle third of the trachearelativeto the carinaand C5 body. This would haveresultedin acceptableETT position in all 20 patients(> 2 cm from the carinaand > 5 cm from the glotris;P < .00001,Fisher's exacttest).

Conclusion:A magret-tippedstylet,and in tum an ETT, can be reliablypositionedwithin the midtracheausing an extemalmagneric field sensor.This method may be a cost-effectivemeansto prevent mainstemintubationsduring emergencyair*ay management.

242i:h#ffil"

lr Accurate inAcute Anenria From

GAJay,LHughes, FPRenzi/0epartment of Emergency Medicine, University of Massachusetts Medical Center.

Worcester.

Massachusetts Studyhypothesis:Pulseoximetry is an accuratenoninvaslveassayof oxygensaturation(saor) in patientswith acutesevereanemia (hemoglobinconcentration[Hb] of approximately5 g/dl).

Design:Prospectivepatientswith either acuteupper gastrointestinal bleedingor blunt traumawith hematocrirs< 2006had their Sao, determined by pulseoximetry and arrerialblood gasanalysis.Thesevalues werecomparedasa functionof Hb. Setting:Universityemergencydepartment(kvel I traumacenter).

Participants: Overa six-monthperiod,I6 nonhypoxicadultsof both sexeswere identifiedconsâ&#x201A;Źcurivelywith initial hemarocrirs< 200,6.

All wereencountered within onehour of hemorrhage, and nonehad a recentpreviousHb < l0 g/dL. lntgrventions:Simultaneouscollectionof Sao, by borh pulseoximetry and arterialblood gasanalysiswas a routine part of the emergency careof patientsexperiencingacuteseverehemorrhage.

Resuls:Pulseoximetry resuhedin an average0.33 t 0.2406SE(16) overestimationof Sao. comparedwith arterialblood gaseswithin a rangeof Hb from 3.7 to 8.2 {dL (mean,5.5 gdl). fhis error decreased as the Hb decreased;at3.7 gdL, ir was 00,6.Exrrapolarionby linear regression(y = -1.24 t 0.28 [Hbl) showedthat the (y = Spoz- Saoz) difference would be -0.7 t l.I5% (P < .05) at aHb of 2 {dL. Conclusion:The reliability of the pulse oxirnetrytechnologlzhas beenquestionedin patientswirh severeanemia(Hb < 5 g/dl). This study showedthat this technologyis reliableand accurareat3.7 gdL for nonhypoxicSao, values(Sao, > 9306).The anemicend point where pulse oximetryeither becomesiruccurateor simply failsto work has not beendetermined;however,the presentdata indicatethat pulse oximetry may underestimareSao, by I.806at a Hb of 2 {dL.

oxirnot'y to Prodict llypoxia in Patiantr wth 243;*rrff.::t",* M Husain, RBuckley, B Roberts, R Bydnnn,V Pir*es/Cook CountryEmergencl Medicine Residerry ft ogram, Sricago Studyobjectives:To derribe the relationshipof O, sarurarion measuredby pulse oxirnetry(Spor) and ABG (%OrHb), and compare the sâ&#x201A;Źnsitivity(Se)and specificiry(Sp) of Spo, wirh a new "RespiratoryOximetry Quotient" (ROQ) in predictinghypoxia in pneumonia patients, Methods:Seventy-sixadult patienrswirh clinical and radiographic evidenceof pneumoniahad Spo, and respiralions(RR)prospectively measuredby a physicianblinded ro the ABG results.The ROQ developedbeforepatienrenrollmentwas (100 - Spor) + (RR- l Z2).

AbnormalROQ was 5 or more. The ABG gold srandardfor absolute hypoxiawas Pao, < 70 mm Hg and for compensatedhypoxia was A-aG> 25 or A-aG > 125% of age-adjusted norrnal (2.5 x 0.21 x agein years).

Results:The relation benreen Spo, and %O2Hb on ABG is described asspoz = 15.01+ 0.86 (%OrHb);P < .0076.The Seof spo, < 96% for I) Pao, < 70,2) A-aG> 25, 3) age-adjustedA-aG> l25oh was 70%, 5106,and 4706,respectively.

The5p was72%,82%,and 5906.The Se of ROQ was 9706,95%,and 88%, respecrively.The Sp of ROe was 1606,9%,and 606.

Conclusion:Pulseoximetry lackssufficientdiagnosticaccuracyfor detectinghypoxiato be a subsrirurefor ABG.The ROe has increased sensitivity,and patientswirh an ROG < 5 are unlikely to be hypoxic. An ROGof ) 5 is not specific,and in theseparienrs,an ABG must still be obtained. t A A Investigationol the Mochanirm!of Cardiopulmonary Lln Resuscitation UsingTransesophrgsclEchocardiography UmGuly,ACHPell,P Bloomfield, CEBobertson/ GBSutherland, 0J Steedman, Departments of Accident andEmsrgency Medicine andCardiology, Boyal Infirmary of Edinburgh Study objective:Two opposingtheorieshavebeenadvancedto accountfor the generationo[ blood flow during CPR.To investigate whetherthe cardiacpump or the thoracicpump model predominates, transesophageal echocardiographywas performedduring closed-chest CPRin I 8 patientspresentingin cardiacarrest.

Results:During stemalcompression,therewas markedcompression of the right atrium and rigfrt ventricle.Left ventricularcompressionwas lessprominent,but blood flow occurredfrom the left ventriculareoutflow tract throught the aortic valve.Turbulencewithin the left ventricular outflow tract suggestedobstructionsecondaryto displacementof the interventricularseptumand aortic root compression.Therewas tricuspid regurgiution, antegradepulmonaryanery, and retrogade pulmonaryvein flow. Mitral valvemotion was biphasic,with initial openingfollowedby incompleteclosure.Markedmitral incompetence wasseenin two patients.During stemalrelease,therewas immediate reexpansionand turbulent filling of the rigfrt arrium and ventricule from the venaecavaeand coronarysinus:left atrial filling of the left ventricleoccurredpredominantlyfrom the pulmonary veins.Initially, the mitral valveopend; subsequently,it closedpartially.Transmitul filling of the left ventricle occurredprimarily during stemalrelease.

Therewas retrogradepulmonaryartery flow and aortic valveclosure.

Conclusion:The cardiacpump model is the dominant mechanism during CPR;however,mitral valveclosureappearsto be lessimportant during compressionthan previouslythought. The thoracicpump model may opemtetransientlyduring early stemalcompressionbut produces little forwardblood llow. Thesefindings may allow the developmentof more efficient techniquesof CPR.

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MEDICINE EMERGENCY StudyGuide A Comprehensiue Editedby, JudithE.llntinalli RonaldL. Krome ErnestRuiz May 19 at 4:30 pm Drawing on \il/ednesday, at the Synergoncomplimentary \Wineand CheeseTable at Booth #46 Synergon specializesin staffing and managing academic, pediatric, and high-volume healthcarefacilities.

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