Striking the balance.
Explore the source record for details and available documents.
Adaptation, Psychological↗
Biomedical subjects
A B Wolfson
Publications and source records attributed to A B Wolfson.
Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group.
BACKGROUND: Because clinicians fear missing occult cervical-spine injuries, they obtain cervical radiographs for nearly all patients who present with blunt trauma. Previous research suggests that a set of clinical criteria (decision instrument) can identify patients who have an extremely low probability of injury and who consequently have no need for imaging studies. METHODS: We conducted a prospective, observational study of such a decision instrument at 21 centers across the United States. The decision instrument required patients to meet five criteria in order to be classified as having a low probability of injury: no midline cervical tenderness, no focal neurologic deficit, normal alertness, no intoxication, and no painful, distracting injury. We examined the performance of the decision rule in 34,069 patients who underwent radiography of the cervical spine after blunt trauma. RESULTS: The decision instrument identified all but 8 of the 818 patients who had cervical-spine injury (sensitivity, 99.0 percent [95 percent confidence interval, 98.0 to 99.6 percent]). The negative predictive value was 99.8 percent (95 percent confidence interval, 99.6 to 100 percent), the specificity was 12.9 percent, and the positive predictive value was 2.7 percent. Only two of the patients classified as unlikely to have an injury according to the decision instrument met the preset definition of a clinically significant injury (sensitivity, 99.6 percent [95 percent confidence interval, 98.6 to 100 percent]; negative predictive value, 99.9 percent [95 percent confidence interval, 99.8 to 100 percent]; specificity, 12.9 percent; positive predictive value, 1.9 percent), and only one of these two patients received surgical treatment. According to the results of assessment with the decision instrument, radiographic imaging could have been avoided in the cases of 4309 (12.6 percent) of the 34,069 evaluated patients. CONCLUSIONS: A simple decision instrument based on clinical criteria can help physicians to identify reliably the patients who need radiography of the cervical spine after blunt trauma. Application of this instrument could reduce the use of imaging in such patients.
Cervical Vertebrae↗
Diagnosis of acute thoracic aortic dissection in the emergency department.
In this article we try to determine how frequently emergency physicians (EPs) suspected the diagnosis in acute aortic dissection (AD). In this retrospective descriptive study, we identified all patients with the final diagnosis of AD initially evaluated in 1 of 3 emergency departments (EDs) over a 5-year period. Patients were included if AD was not suspected before ED evaluation. Patients undergoing thoracic aorta imaging as the initial ED study were defined as suspected AD. Forty-three patients totaling 44 presentations were identified. EPs suspected AD in 19 of 44 presentations. EPs suspected AD in 12 of 14 (86%) cases of chest and back pain and in 5 of 11 (45%) of chest pain. Thirteen of 39 (33%) painful presentations involved abdominal pain; EPs suspected AD in 1 of 13 (8%). EPs suspected the diagnosis in 43% of acute AD; location of pain was most predictive of a suspected diagnosis.
Acute Disease↗
Planning recommendations for international emergency medicine and out-of-hospital care system development.
OBJECTIVES: To present suggestions on planning for development of emergency medicine (EM) and out-of-hospital care in countries that are in an early phase of this process, and to provide basic background information for planners not already familiar with EM. METHODS: The techniques and programs used by the authors and others in assisting in EM development in other countries to date are described. CONCLUSIONS: Some aspects of EM system development have applicability to most countries, but other aspects must be decided by planners based on country-specific factors. Because of the very recent initiation of many EM system development efforts in other countries, to the authors' knowledge there have not yet been extensive evaluative reports of the efficacy of these efforts. Further studies are needed on the relative effectiveness and cost-benefit of different EM development efforts.
Allied Health Personnel↗
Proposed fellowship training program in international emergency medicine.
Interest in international emergency medicine (EM) has grown steadily over the last ten years. This growth has been fueled by increased demand for emergency services abroad and the proliferation of emergency physicians (EPs) working in international relief and development. As a response, several academic EM programs have developed international EM fellowships for the purpose of providing formal training to EPs interested in international health. Although there have been preliminary articles describing fellowship curricula, to the authors' knowledge no recommendations have been proposed by national consensus that suggest emphasis or required components of a fellowship program. Therefore, a group of EPs interested in fellowship training convened for the purpose of developing goals and objectives for a postgraduate training program in international EM. To that end, this article proposes guidelines for a fellowship training program for international EM.
Curriculum↗
Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS).
Fear of failure to identify cervical spine injury has led to extremely liberal use of radiography in patients with blunt trauma and remotely possible neck injury. A number of previous retrospective and small prospective studies have tried to address the question of whether any clinical criteria can identify patients, from among this group, at sufficiently low risk that cervical spine radiography is unnecessary. The National Emergency X-Radiography Utilization Study (NEXUS) is a very large, federally supported, multicenter, prospective study designed to define the sensitivity, for detecting significant cervical spine injury, of criteria previously shown to have high negative predictive value. Done at 23 different emergency departments across the United States and projected to enroll more than 20 times as many patients with cervical spine injury than any previous study, NEXUS should be able to answer definitively questions about the validity and reliability of clinical criteria used as a preliminary screen for cervical spine injury.
Cervical Vertebrae↗
Guidelines for evaluation of international emergency medicine assistance and development projects.
Interest in the development of the specialty of emergency medicine and of emergency health care systems has greatly increased worldwide in the last few years. The guidelines in this article were developed in an effort to assist others in design and evaluation of all types of emergency medicine projects.
Emergency Medical Services↗
Comparison of intravenous ketorolac, meperidine, and both (balanced analgesia) for renal colic.
STUDY OBJECTIVE: To compare the analgesic efficacy and safety of IV ketorolac, the only nonsteroidal antiinflammatory drug indicated for parenteral use in acute pain in the United States, with IV meperidine and with a combination of the two agents in renal colic. METHODS: We carried out a double-blind, randomized, multicenter clinical trial in the emergency departments of four urban tertiary care teaching hospitals. Our study subjects were 154 patients with suspected renal colic. Each subject received an initial IV dose of ketorolac 60 mg, meperidine 50 mg, or both supplemented as needed beyond 30 minutes with additional doses of meperidine. RESULTS: The main outcome measures were changes in pain-intensity and pain-relief scores, amount of supplemental meperidine required, end-of-study drug tolerability, and adverse events. Analyses of 106 subjects with confirmed renal colic indicated that ketorolac and the combination were significantly better than meperidine alone by all efficacy measures, including pain relief and time elapsed before the need for supplemental meperidine. By 30 minutes, 75% of the ketorolac group and 74% of the combination group had a 50% reduction in pain scores, compared with 23% of the meperidine group (P < .001). The ketorolac and combination groups did not differ significantly in any of the efficacy measures. CONCLUSION: IV ketorolac, alone or in combination with meperidine, was superior to IV meperidine alone in moderate and severe renal colic. Because many subjects in all three treatment groups received supplemental meperidine and because response to ketorolac alone cannot be predicted, clinicians may choose to initiate treatment with a ketorolac-meperidine combination.
Adult↗
The myth of the fecalith.
A radiographically demonstrated fecalith is widely considered a virtually pathognomonic sign of acute appendicitis. This case report describes a patient with a clinical presentation suggestive of appendicitis and a well-defined right lower quadrant fecalith who was found to have a normal appendix at surgery. This case calls into question the venerable dogma surrounding the fecalith and highlights the necessity for the physician to continue to rely on clinical judgment in making the diagnosis of appendicitis.
Aged↗
ECG changes with perforated duodenal ulcer mimicking acute cardiac ischemia.
A 38-year-old man presented to the emergency department with severe epigastric pain. An electrocardiogram (ECG) showed T wave inversions in leads V2 through V4 consistent with myocardial ischemia. The patient had undergone stress thallium testing and cardiac angiography several months prior for recurrent chest pain, and results from both studies were normal. Pneumoperitoneum seen on a chest X-ray prompted emergency laparotomy. A perforated duodenal ulcer was found and repaired. The ECG changes reverted to normal after surgery.
Adult↗
Diagnostic testing: a call for continuing investigation [corrected].
Explore the source record for details and available documents.
Diagnosis↗
Thoracic aortic dissection: ruling in and ruling out.
Explore the source record for details and available documents.
Aortic Dissection↗
Acute hyponatremia in ultra-endurance athletes.
Explore the source record for details and available documents.
Exercise↗
Routine admission electrocardiography in emergency department patients.
STUDY OBJECTIVES: To determine whether routine performance of an ECG could have been safely avoided in a subset of emergency department patients admitted to a university hospital. DESIGN: Retrospective consecutive case series. SETTING: University teaching hospital. TYPE OF PARTICIPANTS: All ED patients admitted to the medical service of the study hospital during a three-month period. METHODS AND INTERVENTIONS: Acceptable indications for an admission ECG were prospectively developed. Charts of all patients were reviewed to determine whether any of these indications were present, whether an admission ECG was performed, and whether an admission ECG resulted in a change in patient management or outcome. An ECG was classified as routine when performed in the absence of documentation of any of these indications. No interventions were performed. MEASUREMENTS AND MAIN RESULTS: There were 636 ED admissions to the medical service during the study period. Of the 631 patients whose chart could be located, 384 (61%) had at least one indication for an ECG and all but one had an ECG performed. No indications for an admission ECG were identified in the remaining 247 patients; of these, 202 (82%) had an ECG performed and 45 (18%) did not. Among the 202 who had a routine admission ECG, the test resulted in a change in management in only three (1.5%) (95% confidence interval [CI], 0.3% to 4.3%) and affected patient outcome in none (95% CI, 0% to 1.5%). Among the 45 without indications who did not have a routine admission ECG, none experienced an identifiable adverse consequence during hospitalization (95% CI, 0% to 6.7%). CONCLUSION: The admission ECG could have been avoided in an identifiable subset of ED patients admitted to the medical service of our hospital, with no adverse effect on patient outcome. This finding, if corroborated in other patient populations, suggests the potential for significant cost savings for the US health care system as a whole.
Aged↗
Hemodynamic effects of 3,4-diaminopyridine in a swine model of verapamil toxicity.
STUDY HYPOTHESIS: 3,4-Diaminopyridine (3,4-DAP) may reverse the hemodynamic effects of severe verapamil toxicity. DESIGN: A nonblinded acute animal preparation. INTERVENTIONS: Eighteen chloralose-anesthetized and instrumented swine were poisoned with verapamil at 10 mg/kg/hr for five minutes and then 5 mg/kg/hr until a systolic blood pressure of 55 mm Hg was achieved. Heart rate, lead II ECG, mean arterial pressure, left ventricular dP/dT max, and cardiac index were monitored. Nine control animals received 0.2 mL/kg/min infusion of normal saline, and nine treatment animals received similar volumes of 1 mg/kg/min 3,4-DAP until systolic blood pressure reached 100 mm Hg, an elapsed time of 30 minutes, or death. RESULTS: Verapamil toxicity was produced in all animals following an average dose of 1.38 +/- 0.44 mg/kg verapamil, and resulted in diminished mean arterial pressure, dP/dT max, cardiac index, and heart rate to average values of 47%, 32%, 46%, and 88% of baseline values, respectively. Transient atrioventricular dissociation was noted in only 22% of cases. 3,4-DAP treatment (with an average dose of 14 +/- 5.6 mg/kg) resulted in significant increases in mean arterial pressure, dP/dT max, cardiac index, and heart rate to 136%, 298%, 149%, and 158% of baseline values, respectively. Mortality was unchanged (22% in both groups). 3,4-DAP treatment was complicated by muscle twitching, tachycardia (rate of more than 180) and hypertension (diastolic blood pressure of more than 110 mm Hg) each in 44% of cases. CONCLUSION: Although 3,4-DAP reversed the hypotensive and negative inotropic effects of verapamil toxicity, it failed to improve survival and resulted in several complications including muscle twitching, tachycardia, and hypertension.
4-Aminopyridine↗
Continuous ambulatory peritoneal dialysis.
Many patients with end-stage renal disease are maintained on continuous ambulatory peritoneal dialysis (CAPD). This technique offers a number of advantages over hemodialysis, but it is associated with certain potential complications. Peritonitis and other infectious complications are the most commonly seen in the emergency department. The evaluation and management of other emergency problems may also need to be modified in patients on CAPD.
Emergencies↗
Perceptions of emergency care by the elderly: results of multicenter focus group interviews.
STUDY OBJECTIVE: To determine the elderly's perception of emergency care and to identify specific problems and solutions. DESIGN: Focus group interviews. SETTING AND TYPE OF PARTICIPANTS: Community senior citizen centers in Boston; Los Angeles; Pittsburgh; Youngstown, Ohio; and Norwalk, Connecticut. Senior citizens who had had emergency care in the past year participated. MEASUREMENT AND RESULTS: Participants were satisfied with their overall medical care. Long waits were a hardship for patients and their families. The elderly are not familiar with the process of emergency care. They were frightened by their injury or illness. Their anxiety was not allayed until they were informed of the nature of their illness and what their treatment and disposition was to be. The emergency department environment frequently made them uncomfortable. There was considerable confusion caused by the billing process. CONCLUSIONS: The elderly would benefit from prior or concurrent education regarding emergency care. Staff should be more sensitive to the anxiety felt by the elderly, should explain the reasons for delays in care, and what to expect. Patients should be informed of the nature and seriousness of their illness as soon as possible. Family and friends may be encouraged to stay with patients. The billing process needs to be clarified and simplified.
Aged↗
Ethical conflicts in the prehospital setting.
STUDY OBJECTIVE: To assess the range of ethical conflicts that confront prehospital care providers. DESIGN: Convenience sample, from October 1989 to January 1990. SETTING: An urban advanced life support emergency medical service that transports approximately 3,000 patients per month. METHODS: Six hundred seven paramedic responses were analyzed by a single observer. An ethical conflict was identified when the paramedic faced a dilemma about what "ought to be done" and the paramedic's values conflicted or potentially conflicted with the patient's. Cases with potential ethical consequence were brought to experts in medical ethics and epidemiology for further analysis and classification. RESULTS: Ethical conflicts arose in 14.4% of paramedic responses (88 of 607 cases). Twenty-seven percent of the conflicts involved issues of informed consent, such as refusal of treatment or transport, conflicts of hospital destination, treatment of minors, and consent for research. Difficulties regarding the duty of the paramedics, usually under threatening circumstances, accounted for 19% of the dilemmas encountered. Requests for limitation of resuscitation accounted for 14%. Other circumstances that presented ethical conflicts involved questions of patient competence (17%), resource allocation (10%), confidentiality (8%), truth telling (3%), and training (1%). CONCLUSION: The data demonstrate a range of ethical conflicts in the prehospital setting and point to areas in which policy needs to be developed. The data also can be used in a prehospital ethics curriculum for paramedics and physicians. Because case sampling was not strictly random, absolute conclusions should not be drawn regarding the frequency of the dilemmas.
Beneficence↗