Selective right-lung ventilation during emergency department thoracotomy

Surgeons are occasionally called on to manage patients with penetrating cardiac injuries who arrive at the ED in extremis. Immediate thoracotomy in the ED is associated with good resuscitative results in a select group of such patients, but cardiorrhaphy is often impeded by frequent inflations of the left lung during resuscitation. We investigated a technique for selective right-lung ventilation using a standard single-lumen endotracheal tube in cadaver and animal models. This technique is easily applicable, provides adequate oxygenation and ventilation for up to 60 min, and expedites cardiorrhaphy in the ED.     

Mode of arrival does not predict myocardial infarction in patients who present to the ED with chest pain

Aims

This study aims to determine if patients who arrive by ambulance with a chief complaint of chest pain have a higher risk of myocardial infarction (MI) than those who arrive via alternate transportation.

Methods

All patients ages 18–99 who presented to an urban academic ED between January 2006 and July 2006 with a chief complaint that included “chest pain” were eligible for retrospective analysis. Patients who were transferred or who left without being seen or against medical advice were excluded. Myocardial infarction was defined as patients who were admitted and who had elevated troponin I or went urgently to catheterization laboratory and had >90% occlusion of a vessel, with a final clinical impression of MI.

Results

There were 690 visits for chest pain during the study period, representing 4% of total ED census. A total of 39 visits met exclusion criteria, and 37 patients had 52 repeat visits, leaving 599 unique patients included for analysis. Mean age was 48.8?±?1.4 years (SD 17.7), 44.6% were female, and 35 patients (5.8%) were diagnosed with MI. In all, 157 patients (26.2%) arrived via EMS. Patients who arrived by ambulance did not have a significant difference in rate of MI when compared with alternate transportation [7.0% vs. 5.4%, OR (95% CI) = 1.3 (0.6–2.7), p?=?0.469]. Only 31.4% (11/35) of patients who ultimately were diagnosed with MI arrived by ambulance.

Conclusion

We were unable to show a significant difference in rate of MI between patients who arrived via ambulance or private transportation. Equal consideration and urgency should be given to both types of patients when they arrive at the ED.     

Duplex-guided thrombin injection for the treatment of iatrogenic pseudoaneurysms

This study compares duplex-guided thrombin injection (DGTI) with duplex-guided compression (DGC) for the treatment of iatrogenic pseudoaneurysms. A nonrandomized prospective study, approved by the institutional review board, was performed to evaluate the success rate in DGTI versus DGC (with the use of historical data) in patients who arrive at the vascular surgery service for the treatment of iatrogenic pseudoaneurysm as identified by ultrasound examination. DGTI has been shown to have major advantages over DGC, such as improved patient and operator acceptance, shorter pseudoaneurysm thrombosis times, broader patient applications, and higher success rate.     

The Impact of Longer Consultation Time: A Simulation-Based Approach

Background  Maintaining a sufficient consultation length in primary health care (PHC) is a fundamental part of providing quality care that results in patient safety and satisfaction. Many facilities have limited capacity and increasing consultation time could result in a longer waiting time for patients and longer working hours for physicians. The use of simulation can be practical for quantifying the impact of workflow scenarios and guide the decision-making. Objective  To examine the impact of increasing consultation time on patient waiting time and physician working hours. Methods  Using discrete events simulation, we modeled the existing workflow and tested five different scenarios with a longer consultation time. In each scenario, we examined the impact of consultation time on patient waiting time, physician hours, and rate of staff utilization. Results  At baseline scenarios (5-minute consultation time), the average waiting time was 9.87 minutes and gradually increased to 89.93 minutes in scenario five (10 minutes consultation time). However, the impact of increasing consultation time on patients waiting time did not impact all patients evenly where patients who arrive later tend to wait longer. Scenarios with a longer consultation time were more sensitive to the patients'' order of arrival than those with a shorter consultation time. Conclusion  By using simulation, we assessed the impact of increasing the consultation time in a risk-free environment. The increase in patients waiting time was somewhat gradual, and patients who arrive later in the day are more likely to wait longer than those who arrive earlier in the day. Increasing consultation time was more sensitive to the patients'' order of arrival than those with a shorter consultation time.     

Is emergency department resuscitation of out-of-hospital cardiac arrest victims who arrive pulseless worthwhile?

It is still a common practice to continue unsuccessful field resuscitations in the emergency department (ED) even after prolonged estimated down times. The authors studied patients who arrested in the field and did not regain a pulse before their arrival in the ED to determine if any ever leave the hospital neurologically intact. All cardiac arrests in the urban St Louis area that were brought to our facility over a 2 1/2-year period by advanced life support units (excluding all patients with hypothermia, drug overdose, near drowning, and traumatic cardiac arrest) were reviewed. Of 243 such patients 32 (13%) arrived with a pulse. Twenty-three of these patients were admitted and 10 discharged alive, 7 were neurologically intact. Out of 211 patients who arrived without a pulse, 24 (11%) developed a pulse with further resuscitative efforts in the ED. Eighteen of these patients were admitted but only one was discharged neurologically intact. The only survivor in the group without a pulse arrested while en route to the ED. It is concluded that cardiac arrest victims who arrive in the ED without a pulse on arrival or en route have almost no chance of functional recovery.     

5-Step asthma approach: managing acute asthma in 5 steps or less

Asthma requires immediate and expert care. Definitive therapy can begin in the field with most patients, who will significantly improve by the time they arrive at the ED. Paramedics become expert caregivers when they provide oxygen, administer combined continuous nebulization of beta agonists and anticholinergics, and consider magnesium and epinephrine for asthmatics with severe symptoms.     

Ethics, equipoise, and evidence: when should investigators decide to not test their hypothesis

In an excellent investigation of endotracheal tube cuff pressure assessment, “Endotracheal Tube Cuff Pressures in Patients Intubated Prior to Transport,” Chapman et al measured endotracheal tube cuff pressure in patients who arrive at their emergency department after being intubated in the field. This, the first published American study of this type, presents clear and convincing evidence that patients who undergo endotracheal intubation before transport have endotracheal tube cuff pressures that exceed safe limits.     

The sensitivity of cardiac markers stratified by symptom duration

We compared the sensitivity of three commonly used cardiac markers between two subpopulations, those who came to the Emergency Department (ED) late (6–24 h) after their symptoms began, and those who arrived earlier (<6 h), in a prospective comparative trial. Among all adult patients who presented to our ED with symptoms suggestive of acute myocardial infarction (MI), we drew serum for myoglobin, CK-MB, and troponin I upon arrival (time 0) and 2 h later. Outcomes, including acute MI, were determined. Sensitivities for all three markers between the subpopulations who arrived fewer than 6 h from symptom onset were compared to those who arrived later (6–24 h). We enrolled 346 eligible subjects, 36% of whom described cardiac symptoms as beginning 6 or more hours earlier; 14% suffered acute MIs. For time 0, the sensitivity of all three markers for acute MI was significantly higher among those subjects with symptoms of 6 or more hours’ duration as compared to those with less. For troponin I, the increase in sensitivity between these two subpopulations approached 300%. At the time of the 2-h sample, the differences in sensitivities were much less and were not statistically significant. We conclude that cardiac marker values obtained at time 0 among Emergency Department patients who arrive 6 or more hours after cardiac symptom onset provide significantly higher sensitivities as compared to those obtained in patients who arrive earlier. For troponin I, the increase in sensitivity approaches threefold.     

Beyond the Twelve-Lead Electrocardiogram: Diagnostic Tests in the Evaluation for Suspected Acute Myocardial Infarction in the Emergency Department,Part II

On a daily basis the emergency physician is faced with the difficult task of determining whether or not a patient with acute chest pain is sustaining an acute myocardial infarction. In most cases this is not a straightforward decision. Although observation units are being used more often for chest pain evaluations, many emergency physicians currently admit such patients to an intensive care setting. Because fewer than one-third of emergency department chest pain patients actually suffer an acute myocardial infarction, expensive resources are, in retrospect, used unnecessarily. Conversely, patients who are infarcting, and are inadvertently discharged home from the emergency department, have a worse prognosis than those admitted. This two-part series reviews the newer modalities available that may help the emergency physician arrive at a more accurate diagnosis. This article, Part II, will review the use of biochemical assays of cardiac proteins and discuss the Chest Pain Observation Unit.     

急救网络在危重创伤伤员救治中的作用

目的 研究区域性创伤急救网络在严重创伤伤员救治中的作用.方法 收集2005-03-2007-10问进人我院急诊抢救室的1692例伤员的资料,根据是否为网络内单位伤员,分为网络组和非网络组.比较和分析两组伤后至就诊的时间间隔、致伤原因、送院工具、通讯联络、院前及院内处置.结果 网络组1 h内入院率明显高于非网络组.网络组伤员送院前417例(89%)有预报,非网络组108例(13%)120送院前有预报.结论 区域性创伤急救网络在严重创伤伤员的救治中具有重要作用.     

The use of computerized echoencephalography after recent head injury presenting to the accident and emergency department.

In a review of the records of 874 head-injured patients who had an echoencephalogram in the Accident and Emergency Department, two patients with apparently 'minor' head injury subsequently developed an extradural haematoma. Both would have been diagnosed earlier if the results of the echoencephalogram had been used to influence their referral to the nearest neurosurgical department before the onset of any neurological deterioration. For those patients who arrive in the Department in coma, failure to detect any midline shift should not delay urgent referral for a CT scan. Such patients may be harbouring either bilateral haematomas or a very large single haematoma causing more than the 14-mm maximum shift recordable by the equipment.     

Radiograph use in low back pain: a United States Emergency Department database analysis

We identified factors associated with radiograph evaluation for patients who presented to the Emergency Department (ED) with uncomplicated low back pain (LBP). Using 1998-2000 ED data from the National Hospital Ambulatory Medical Care Survey, a multivariate analysis was performed to assess utilization of radiographs for LBP. Based upon published guidelines, of the over 3 million patients who met our criteria of uncomplicated LBP, 17.8% received an unnecessary radiograph. Patients who arrive via ambulance with moderate pain, who need to be seen within 15 min, and who have 3 or more screening tests ordered are 100% likely to also get a radiograph. There is an increased probability of receiving a radiograph for those patients 40-70 years old, being seen at a metropolitan hospital, having private insurance, and being treated by a resident in training. Multiple factors are associated with the overuse of radiographs for patients presenting with uncomplicated LBP.     

卒中溶栓因流程因素导致院内延迟的研究进展

静脉溶栓是目前治疗急性缺血性脑卒中的有效手段,但受到时间窗限制?院内延迟可能会使部分到院时还在时间窗内的患者失去溶栓治疗的时机?本文通过对患者到院至静脉溶栓流程图进行分析,并查阅相关文献对缺血性脑卒中溶栓患者院内延迟的现状和因诊疗流程相关因素导致院内延迟的原因进行综述。主要目的为缩短院内延迟时间提供参考?     

The incidence of neurogenic shock in patients with isolated spinal cord injury in the emergency department

BACKGROUND: Spinal cord injury (SCI) is recognised to cause hypotension and bradycardia (neurogenic shock). Previous studies have shown that the incidence of this in the emergency department (ED) may be low. However these studies are relatively small and have included a mix of blunt and penetrating injuries with measurements taken over different time frames. The aim was to use a large database to determine the incidence of neurogenic shock in patients with isolated spinal cord injuries. METHODS: The Trauma Audit and Research Network (TARN) collects data on patients attending participating hospitals in England and Wales. The database between 1989 and 2003 was searched for patients aged over 16 who had sustained an isolated spinal cord injury. The heart rate (HR) and systolic blood pressure (SBP) on arrival at the ED were determined as was the number and percentage of patients who had both a SBP<100mm Hg and a HR<80 beats per minute (BPM) (the classic appearance of neurogenic shock). RESULTS: Four hundred and ninety patients had sustained an isolated spinal cord injury (SCI) with no other injury with an abbreviated injury scale (AIS) of greater than 2. The incidence of neurogenic shock in cervical cord injuries was 19.3% (95% CI 14.8-23.7%). The incidence in thoracic and lumbar cord injuries was 7% (3-11.1%) and 3% (0-8.85%). CONCLUSIONS: Fewer than 20% of patients with a cervical cord injury have the classical appearance of neurogenic shock when they arrive in the emergency department. It is uncommon in patients with lower cord injuries. The heart rate and blood pressure changes in patients with a SCI may develop over time and we hypothesise that patients arrive in the ED before neurogenic shock has become manifest.     

Beyond the twelve-lead electrocardiogram: Diagnostic tests in the evaluation for suspected acute myocardial infarction in the emergency department, part I

On a daily basis the emergency physician is faced with the difficult task of determining whether or not a patient with acute chest pain is sustaining an acute myocardial infarction. In most cases, this is not a straightforward decision. Although observation units are being used more often for chest pain evaluations, many emergency physicians currently admit such patients to an intensive care setting. Because fewer than one-third of emergency department chest pain patients actually suffer an acute myocardial infarction, expensive resources are, in retrospect, used unnecessarily. Conversely, patients who are infarcting, and are inadvertently discharged home from the emergency department, have a worse prognosis than those admitted. This two-part series reviews the newer modalities available that may help the emergency physician arrive at a more accurate diagnosis. The current article, Part I, examines the use of myocardial imaging, computer assisted diagnostic protocols, and newer uses of the electrocardiogram. Part II reviews the use of biochemical assays of cardiac proteins and the Chest Pain Observation Unit.     

A nurse goes shopping for a continuing care retirement community

The selection of a continuing care retirement community (CCRC) in which to live is not a matter of flipping a coin. It involves serious and time-consuming investigation. For most people, it is a daunting task. Elderly people who decide on a CCRC for their living arrangement need to follow a selection process to arrive at the appropriate choice--the choice that best meets their particular needs and provides quality of life. This personal account gives insight into one person's experience with the process. Nurses who are knowledgeable about the types of CCRCs available are in a position to help their patients make more informed choices.     

Intrahepatic splenosis: imaging features

We report a patient who presented with asymptomatic focal liver lesions and in whom a diagnosis of intrahepatic splenosis was made. This rare condition mostly occurs in patients who previously underwent splenic trauma or surgery. Magnetic resonance imaging (MRI) characteristics suggesting this diagnosis are described. The lesions were mainly hypointense on T1- and hyperintense on T2-weighted images. After administration of small iron oxide particles (SPIO-Endorem), the lesions remained slightly hyperintense relative to the hypointense liver parenchyma but showed a 50% loss in signal intensity. Knowledge of these MRI characteristics may avoid the use of surgical interventions to arrive at the correct diagnosis of these rare liver lesions. Received: 14 June 1999/Accepted: 14 July 1999     

THE CURRENT MANAGEMENT OF PARACETAMOL OVERDOSAGE

SUMMARY Paracetamol overdosage is a common problem, but severe poisoning occurs in only a small percentage of cases. A patient who has suffered paracetamol overdosage should be monitored carefully to ensure that a specialist liver unit can be contacted at the earliest signs of severe poisoning for optimal management and transfer. Paracetamol overdosage remains the most common cause of fulminant hepatic failure in the UK, with a mortality rate of 90%, but survival rates can be improved dramatically by specialist intensive care management, and with the advent of transplantation a previously untreatable group of patients can be treated successfully. However, a patient who is inadequately monitored and treated in the early stages after an overdose may deteriorate to an extent that renders them unsalvable by the time they arrive at the specialist centre.     

Defining a rational back-up policy for emergency departments

All emergency departments face the possibility of having insufficient personnel to provide adequate care for patients. Such occasions may present an emergency department with several severely injured patients or merely an unusually large number of that emergency department's usual patient profile. When such staffing inadequacies occur, emergency department directors must respond with additional personnel. Since there is no national standard for back-up policies for emergency departments, emergency medicine has a responsibility to examine this question in order to arrive at some possible solutions. In addition, emergency department directors have an obligation to consider their particular staffing and usage patterns in order to try to devise the most efficient back-up policy prior to need. Finally, assessment of the success with which such back-up policies are used is discussed.     

Gatekeepers: A Missed Opportunity for Safe Transport

Abstract. Objective : To assess whether contact with a health care provider or gatekeeper increases the use of an ambulance for patients with acute chest pain. Methods : A convenience sample of adults ≥:40 years of age presenting with a chief complaint of chest pain were interviewed by trained personnel regarding transport used to come to the ED. The study was performed at the ED of an urban university hospital. Patients with hemodynamic instability and those receiving thrombolytics or emergency angio-plasty were excluded. Patients were asked about access to a primary health care provider and contact with a provider regarding this ED visit, including instructions given for transportation. Results : Of the 450 interviewed patients, 42% arrived by ambulance. Those who had contact with a health care provider prior to the ED visit were less likely to come by ambulance than those without contact, 31% vs 51% (p < 0.001). Of the patients who had cardiac enzymes obtained to work up for their chest pain, 34% with health provider contact vs 57% without health provider contact arrived by ambulance (p < 0.001). Of those with acute myocardial infarction, 30% with health provider contact vs 66% without health provider contact came by a mbulance (p < 0.03). Patients who recalled transport instructions from their providers tended to follow those instructions. The majority of patients who recalled no specific transport instructions arrived by personal automobile. Conclusion : Of patients presenting to an ED for evaluation of chest pain, those who made contact with a health care provider were less likely to arrive via ambulance.