Utility of Routine Admission Serum Chemistry Panels in Adult Trauma Patients

Objectives: To determine the frequency of abnormal serum chemistries and whether they provide clinically useful information regarding trauma patients. To identify clinical criteria associated with critical serum chemistry values (CSCVs).
Methods: The records of all trauma patients admitted to one urban, Level I Trauma Center were retrospectively reviewed for the period (July 1-December 31, 1989). All trauma patients who had had serum chemistry determinations at hospital admission and at least once more prior to discharge were studied. The CSCVs were determined by a panel of experts prior to record review. Serum chemistry values, patient demographics, mechanisms of injury, and outcomes were statistically analyzed.
Results: Most (814/913; 89%) trauma patients had abnormal serum chemistry values. However, only 54/913 (6%) had CSCVs and only six of these CSCVs had prompted a change in resuscitation or treatment (therapeutic K⁺ infusions). Age > 50 years, a history of hypertension therapy, and a Glasgow Coma Scale score ± 10 were associated with CSCVs; and CSCVs were correlated with increased mortality and critical care unit admission.
Conclusion: Routine-admission serum chemistry values, while frequently abnormal for major trauma patients, generally do not provide clinically useful information in the resuscitation and treatment of trauma patients. Hypoglycemia and metabolic acidosis were more rapidly determined using bedside glucose determination and arterial blood gas evaluation. The routine-admission serum chemistry panel described in the study lacked utility for most trauma patients. Selective chemistry panel ordering should be used at the time of hospital admission for major trauma patients.     

EMTALA: a clearer road in the future?

The concept of indigent emergency care has been with us since the 1940s. Congress felt that hospitals were avoiding their responsibilities to provide this care, putting patient’s lives at risk. In response, the Emergency Medical Treatment and [Active] Labor Act (EMTALA), a stricter anti-dumping law, was passed in 1986. Subsequent revisions of these rules have extended the reach of the emergency department’s responsibility far beyond its traditional role and have had unintended consequences. Recent modifications of EMTALA may bring the rules more in line with their original intent.     

The Prevalence of Urinary Tract Infections and Sexually Transmitted Disease in Women with Symptoms of a Simple Urinary Tract Infection Stratified by Low Colony Count Criteria

OBJECTIVES: Urinary tract infections (UTIs) and early pelvic infections due to sexually transmitted disease (STD) may cause similar symptoms. Therefore, a simple history and urine dip to establish a diagnosis of UTI may result in overtreatment of UTIs and undertreatment of STDs. The objective of this study was to determine the proportion of women with symptoms suggestive of a UTI who are urine culture positive versus urine culture negative, the prevalence of STDs between groups, and if elements of the history or examination may predict those requiring STD screening. METHODS: This was a prospective cohort study in an urban emergency department. Women 18-55 years of age with urinary frequency, urgency, dysuria, and no new vaginal discharge or change in discharge were enrolled. The following were performed: detailed history; bladder catheterization for urinalysis, urine dip, and urine culture; pelvic examination and cervical samples for gonorrhea and Chlamydia trachomatis DNA ligase; and wet mount examinations. Main outcome measurements were the percentage of women who were urine culture positive (using low count criteria of 10(2) colony-forming units [CFU]/mL), the proportion of STDs between urine culture groups, and univariate analysis and logistic regression of historical and examination elements. RESULTS: Ninety-two patients were enrolled; the mean age was 26 years (range, 18-51 years). All had samples for DNA ligase (one quantity not sufficient) and urinalysis or urine dip, while 75 of 92 had urine cultures performed. A total of 57.3% (43/75) were urine culture positive at 10(2) CFU/mL, while the STD rate for those with urine cultures was 17.3% (13/75). There was no statistically significant difference in the number of STDs between urine culture positive and urine culture negative groups. The only variable on logistic regression predictive of an STD (based on all 91 patients) was more than one sex partner in the past year (p = 0.013). No other element of the history or pelvic examination helped differentiate those who tested positive for an STD. CONCLUSIONS: A total of 17.3% of women with symptoms of a UTI in this study had an STD, while only 57.3% were urine culture positive by catheterization using low count criteria. The proportion of STDs between those with and without a UTI was not significantly different.     

A Randomized, Clinical Trial Comparing Oral Celecoxib 200 mg, Celecoxib 400 mg, and Ibuprofen 600 mg for Acute Pain

OBJECTIVE: Celecoxib is a selective cyclooxygenase-2 (COX-2) inhibitor used to treat pain. The objective of this study was to compare the efficacies of celecoxib and ibuprofen for the treatment of acute pain. The null hypothesis was that no difference between celecoxib and ibuprofen exists. METHODS: The study was a prospective, randomized, double-blind, controlled clinical trial. After consent, patients rated their pain on a 100-mm visual analog scale (VAS) and categorical intensity pain scale. Patients were then randomized to receive 200-mg or 400-mg celecoxib or 600-mg ibuprofen (all orally). Patients were contacted 5 hours after receiving study medication when a second VAS score was recorded, along with categorical pain intensity, pain relief score, side effects, and number of rescue medications taken. The main outcome measures were change in visual analog pain and categorical pain intensity scores, and pain relief scores, at five hours. RESULTS: One hundred ten patients were evaluated and 105 were enrolled. Thirty-four received celecoxib 200 mg, 32 received celecoxib 400 mg, and 39 received ibuprofen 600 mg. Ninety-one were available for the five-hour VAS and 88 for the five-hour categorical pain intensity and pain relief analysis: The two patients who were unable to read a VAS were excluded, and two enrolled patients withdrew prior to medication. One patient was excluded because his injury was a fracture, and therefore did not meet the inclusion criteria. There was no statistical difference among the treatment groups in age, time from injury to medication, initial VAS score, percent lost to follow-up, or treatment with adjunctive therapy. There was no statistical difference in change of VAS among the groups at five hours: ibuprofen 600 mg (-23.8 mm [95% CI = -31.56 mm to -16.1 mm] [n = 32]), celecoxib 200 mg (-16.1 mm [95% CI = -24.3 mm to -7.98 mm] [n = 31]), and celecoxib 400 mg (-12.4 mm [95% CI = -23.1 mm to -1.8 mm] [n = 30]) (p = 0.16). There was no significant difference between the groups, at five hours, in change of categorical pain intensity (p = 0.11) or pain relief scores (p = 0.059), though the pain relief scale approached significance favoring ibuprofen. CONCLUSIONS: No significant difference exists among emergency department (ED) patients treated for acute pain, at five hours, with celecoxib 200 mg, celecoxib 400 mg, or ibuprofen 600 mg, though the power of the study to detect a change was low, 36%. However, the magnitude of pain relief for celecoxib, coupled with the cost of the medication, questions its use in the immediate ED setting.     

Physician Medical Direction and Advanced Life Support in the United States

OBJECTIVE: To determine the specialty training and responsibilities of urban U.S. emergency medical service (EMS) medical directors how these factors relate to the type of service involved (fire, hospital, private, municipal). METHODS: A single mailed survey of training officers--field supervisors of 211 urban advanced life support (ALS) services in the United States. The survey also requested information about medications carried, approved procedures. and who set these standards. Respondents also rated the EMS medical director's involvement in various activities (quality assurance, administrative, executive, run reviews, and in-service/education). RESULTS: Eighty-five percent (n = 179) of the forms were returned. with 165 (78%) usable. The physician EMS medical directors were primarily trained in emergency medicine (77%) and were paiid (75%) for EMS responsibilities. The number of medications carried and the number of approved procedures were not related to either the number of hours the physicians commit weekly to the EMS service or their degree of involvement in ALS activities. The physician EMS medical directors were most often involved in quality assurance and education and were less likely to devote time to executive or other administrative functions of ALS units, with the exception of fire-based EMS physician medical directors, who contributed significantly to executive and administrative functions (p < 0.05). Overall practice standards were established by the medical director (46%), the state department of health (24%), and local/regional health authorities (23%). CONCLUSIONS: EMS training officers believe that urban ALS medical directors in the United States primarily provide quality assurance and educational support. With the exception of fire-based EMS systems. physicians appear to have limited involvement in other EMS administrative and executive functions.     

Storage Temperatures of Out-of-hospital Medications

OBJECTIVES: To determine whether temperatures inside drug boxes used in the out-of-hospital setting are within the U.S. Pharmacopeia recommendations for "controlled room temperature," which is defined as a temperature maintained between 15 degrees C and 30 degrees C with a mean kinetic temperature less than 25 degrees C, and to determine whether time-temperature indicator labels can reliably monitor mean kinetic temperatures. METHODS: Two methods were used to monitor temperatures: miniature electronic temperature recorders and color-changing time-temperature indicator labels. These were placed in drug storage boxes of advanced life support units over three summer months and two winter months. RESULTS: In summer, the electronic recorders logged temperatures exceeding 30 degrees C in all drug storage boxes, ranging from 3% to 29% of the total time. The mean kinetic temperatures by location for the whole period ranged from 21 degrees C to 30 degrees C. In the winter, the electronic recorders logged temperatures exceeding 30 degrees C at one location 2% of the total time. There were significant temperature excursions below 15 degrees C at all locations, ranging from 16% to 90% of the total time. At one location, there were temperature readings below 0 degrees C for 9% of the total time. The mean kinetic temperatures obtained from the electronic recorders and the indicator labels differed by less than 1 degrees C. CONCLUSIONS: This study demonstrates that out-of-hospital medications are subject to temperatures both above and below recommended storage temperatures. Time-temperature indicator labels can reliably monitor exposure to elevated temperatures.     

Epinephrine use by emergency medical technicians for presumed anaphylaxis

Objective

The use of epinephrine for the treatment of anaphylaxis by emergency medical technicians (EMTs) has not been rigorously evaluated. The aim of this study was to determine whether first-tier EMTs use epinephrine safely and appropriately for anaphylactic reactions.

Methods

The study used a case-control design. Cases were persons treated by EMTs with epinephrine for presumed anaphylaxis from January 1, 2000, through January 31, 2003, in King County, Washington (n = 22). Controls were emergency medical services (EMS)-treated persons matched to cases by diagnosis category, patient age, fire department, and year, but who had not been administered epinephrine by EMTs (n = 44). Cases and controls were compared with regard to history, symptoms, and examination characteristics. In a second assessment, physicians blinded to treatment (case/control) status reviewed events to determine whether they would have treated the patient with epinephrine.

Results

When cases were compared with controls, cases were more likely to report a history of anaphylaxis (27% vs. 2%), upper airway symptoms (59% vs. 18%), and shortness of breath (77% vs. 27%). Cases were also more likely to have tachypnea (32% vs. 5%), hypotension (41% vs. 9%), decreased level of consciousness (32% vs. 2%), abnormal breath sounds (46% vs. 16%), and rash (50% vs. 23%) (p ≤ 0.01 for all comparisons). The physicians agreed with the EMTs' decisions regarding epinephrine use (or nonuse) in 86% (57/66) of events: 86% (19/22) in which the EMTs used epinephrine and 86% (38/44) in which the EMTs did not use epinephrine.

Conclusion

In this EMS system, the EMTs used epinephrine for presumed anaphylaxis in a discriminating manner that typically agreed with physician review.