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Biomedical subjects

C V Pollack

Publications and source records attributed to C V Pollack.

At least 19 recordsLinked to original sources
PubMed2001

The laryngeal mask airway: a comprehensive review for the Emergency Physician.

The Laryngeal Mask Airway (LMA) was developed in the 1980s, but has only recently begun to be used in Emergency Medicine. The LMA affords effective assisted ventilation without requiring endotracheal intubation or visualization of the glottis. In doing so, it is more efficacious than a bag-valve-mask apparatus, although the risk of aspiration of gastric contents persists, particularly if the device is not properly placed. The LMA also has significant potential utility in management of the difficult airway. Most reported clinical experience with the LMA has come from the operating room. This article provides an overview of the extensive potential utility of the LMA in the Emergency Department and prehospital settings as well as a comprehensive review of the pertinent advantages, disadvantages, and complications associated with its use.

Algorithms↗
PubMed2001

Relief by naloxone of morphine-induced spasm of the sphincter of Oddi in a post-cholecystectomy patient.

Spasm of the sphincter of Oddi is a well-recognized effect of the narcotic class of drugs. Although it is usually clinically silent, such spasm occasionally causes debilitating pain that may be mistaken for more serious disorders. We present the case of a patient who had undergone cholecystectomy previously, but in whom morphine given in the Emergency Department precipitated pain consistent with biliary colic; the pain resolved promptly after administration of naloxone. This entity may considered in the differential diagnosis of acute onset of colicky abdominal pain in the patient given narcotics.

Adult↗
PubMed2001

Use of plain radiography to screen for cervical spine injuries.

STUDY OBJECTIVE: Standard radiographic screening may fail to reveal any evidence of injury in some patients with spinal injury. The purposes of this investigation were to document the efficacy of standard radiographic views and to categorize the frequencies and types of injuries missed on plain radiographic screening of the cervical spine. METHODS: All patients with blunt trauma selected for radiographic cervical spine imaging at 21 participating institutions underwent a standard 3-view series (cross-table lateral, anteroposterior, and odontoid views), as well as any other imaging deemed necessary by their physicians. Injuries detected with screening radiography were then compared with final injury status for each patient, as determined by review of all radiographic studies. RESULTS: The study enrolled 34,069 patients with blunt trauma, including 818 patients (2.40% of all patients; 95% confidence interval [CI] 2.40% to 2.40%) having a total of 1,496 distinct cervical spine injuries. Plain radiographs revealed 932 injuries in 498 patients (1.46% of all patients; 95% CI 1.46% to 1.46%) but missed 564 injuries in 320 patients (0.94% of all patients; 95% CI 0.94% to 0.94%). The majority of missed injuries (436 injuries in 237 patients [representing 0.80% of all patients]; 95% CI 0.80% to 0.80%) occurred in cases in which plain radiographs were interpreted as abnormal (but not diagnostic of injury) or inadequate. However, 23 patients (0.07% of all patients; 95% CI 0.05% to 0.09%) had 35 injuries (including 3 potentially unstable injuries) that were not visualized on adequate plain film imaging. These patients represent 2.81% (95% CI 1.89% to 3.63%) of all injured patients with blunt trauma undergoing radiographic evaluation. CONCLUSION: Standard 3-view imaging provides reliable screening for most patients with blunt trauma. However, on rare occasions, such imaging may fail to detect significant unstable injuries. In addition, it is difficult to obtain adequate plain radiographic imaging in a substantial minority of patients.

Adolescent↗
PubMed2001

Use of flexion-extension radiographs of the cervical spine in blunt trauma.

STUDY OBJECTIVE: Flexion-extension (F/E) radiographs of the cervical spine are often used in patients with blunt trauma when the evaluating physician remains concerned about bony or ligamentous injuries despite negative or nondiagnostic standard radiographs. The use of this approach has never been addressed in a large prospective study. We sought to determine the clinical factors associated with ordering F/E views and the incidence of diagnostic F/E films in patients with a normal 3-view cervical spine series. METHODS: Patients with blunt trauma selected for radiographic cervical spine imaging at 21 participating institutions in the National Emergency X-Radiography Utilization Study project underwent standard 3-view (cross-table lateral, anteroposterior, and odontoid views) series, as well as any other imaging deemed necessary by their physicians. Injuries detected by means of screening radiography were then compared with final injury status for each patient, as determined by review of all radiographic studies. Patients who underwent F/E views were analyzed separately. RESULTS: Of 818 patients ultimately found to have cervical spine injury, 86 (10.5%) underwent F/E testing. Two patients sustained stable bony injuries detected only on F/E views. Four other patients had a subluxation detected only on F/E views, but all had other injuries apparent on routine cervical spine imaging. CONCLUSION: F/E imaging adds little to the acute evaluation of patients with blunt trauma. Other approaches, including magnetic resonance imaging, computed tomography, or delayed F/E, in the presence of specific clinical concerns would seem to provide a more reasonable approach to adjunctive imaging.

Cervical Vertebrae↗
PubMed2001

Advances create opportunities: implementing the major tenets of the new unstable angina guidelines in the emergency department.

Of all the clinical syndromes with which emergency physicians must deal, chest pain of coronary cause has benefited from the most striking recent advances both in diagnostic approach (cognitive and technologic) and in therapeutic options. Chest pain evaluation and management have become important foci of research in emergency medicine, and entire units are dedicated to its clinical prosecution in emergency departments and elsewhere in the hospital. New diagnostic tools are proposed and studied on a regular basis. Antiplatelet, antithrombin, and fibrinolytic agents unknown in clinical practice as recently as 5 years ago have secured places in the emergency physician's armamentarium for treating acute coronary syndrome. Many of these diagnostic and therapeutic tools have been developed in the coronary care unit and in the cardiac catheterization laboratory. Although intuitively they may also be useful outside of those settings, they have unreliably been brought to the ED for implementation and resultant appropriate prompt and early care of the coronary patient who does not meet fibrinolytic criteria. As emergency physicians seek to bring accurate chest pain risk stratification into their practice and begin to use new therapeutic agents to minimize myocardial damage before turning the patient's care over to other specialists, it is essential that they are familiar with the data supporting these approaches. In this commentary, we seek to place the American College of Cardiology/American Heart Association unstable angina guidelines into the clinical context of the ED.

Algorithms↗
PubMed2001

2000 ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: a practical summary for emergency physicians.

There have been numerous significant clinical advances in both the diagnosis and therapy of acute coronary syndrome during the past several years. Even the term "acute coronary syndrome" is a recent creation meant to expand clinical attention in patients with chest pain of coronary origin beyond identification of ST-segment elevation myocardial infarction and prompt initiation of reperfusion therapy and to include the evaluation and management of those patients with unstable angina (UA) or myocardial injury that does not cause ST-segment elevation. Many of these advances have been studied and first implemented outside the emergency department, leading some emergency physicians to be slow to embrace them, and leaving others without a viable practical option to use them outside of the cardiac catheterization laboratory or the coronary care unit. In September 2000, the American College of Cardiology and the American Heart Association issued practice guidelines for the care of patients with UA and non-ST-segment elevation myocardial infarction. The guidelines specifically address the diagnosis and management of UA and non-ST-segment elevation myocardial infarction in the ED, suggesting evidence-based standards for risk stratification, for the use of biologic markers of myocardial damage and other adjunctive diagnostic tests, and for the appropriate use of antiplatelet and antithrombin therapeutic agents. This article provides an overview of the ED-pertinent analyses and recommendations from the 93-page document. A commentary on the implementation of these recommendations in the ED follows in a separate article.

Algorithms↗
PubMed2000

Early use of inhaled corticosteroids in the emergency department treatment of acute asthma.

BACKGROUND: Systemic corticosteroids therapy is central to the management of acute asthma The use of inhaled steroids may also be beneficial in this setting. OBJECTIVES: To determine the benefit of ICS for the treatment of patients with acute asthma managed in the emergency department (ED). SEARCH STRATEGY: Randomised controlled trials (RCTs) were identified from the Cochrane Airways Review Group register. Bibliographies from included studies, known reviews, and texts also were searched. SELECTION CRITERIA: Only RCTs or quasi-randomised trials were eligible for inclusion. Studies were included if patients presented with acute asthma to the ED or its equivalent, and were treated with ICS or placebo, in addition to standard therapy. Two reviewers independently selected potentially relevant articles, and then independently selected articles for inclusion. Methodological quality was independently assessed by two reviewers. DATA COLLECTION AND ANALYSIS: Data were extracted independently by two reviewers if the authors were unable to verify the validity of extracted information. Missing data were obtained from the authors or calculated from other data presented in the paper. MAIN RESULTS: Seven trials were selected for inclusion, but data were not available for one of them. In the six usable rials, (4 adult, 2 paediatric), a total of 352 patients were studied (179 ICS, 173 non-ICS treated). Patients treated with ICS were less likely to be admitted to hospital (OR: 0.30; 95% CI: 0.16, 0.57). This benefit was confined to patients not receiving concomitant systemic steroids. Such patients showed the same, but non-significant, trend towards reduced admissions compared to placebo treatment (OR 0.46; 95% CI: 0. 19, 1.11). In children, ICS appeared to be at least as effective as systemic steroids (OR 0.5; 95% CI: 0.24, 1.06). Patients receiving ICS demonstrated small, significant improvements in peak expiratory flows (PEFR WMD: 7%; 95% CI: 3, 13) and forced expiratory volumes (FEV-FEV1 WMD: 5.0%; 95% CI: 0.4, 9.7). The treatment was well tolerated, with few reported adverse side effects. REVIEWER'S CONCLUSIONS: Inhaled steroids reduced admission rates in patients with acute asthma who were not receiving concomitant systemic steroids. In children, inhaled steroids appear to be at least as effective as systemic steroids. Further research is needed to clarify the effect of ICS when used in addition to systemic corticosteroids, and to determine the optimal dose, agent, and frequency of ICS administration.

Acute Disease↗
PubMed2000

Successful cricothyrotomy after thrombolytic therapy for acute myocardial infarction: a report of two cases.

Cricothyrotomy is an emergency airway procedure that is generally performed after failure of primary methods for securing the airway. Coagulopathy has traditionally been considered a relative contraindication to cricothyrotomy, but there is little evidence in the literature to support this. There have been no reports of successful cricothyrotomy in a patient who had received systemic thrombolytic therapy. This report, from the National Emergency Airway Registry, is the first to describe successful cricothyrotomy in this context. We describe 2 patients who received thrombolytic therapy and then had cricothyrotomy performed after failure of other airway measures. The first patient was a 67-year-old man who developed severe pulmonary edema and respiratory failure less than 30 minutes after administration of tissue plasminogen activator using an accelerated regimen. Both intubation and attempts at ventilation using an esophageal/tracheal double-lumen airway (Combitube, Kendall-Sheridan, Argyle, NY) were unsuccessful, and the emergency physician then performed an uneventful cricothyrotomy using a vertical midline incision. There were no complications, and bleeding was minimal. The second patient was a 45-year-old man who developed severe angioedema with respiratory compromise after receiving streptokinase for acute myocardial infarction. Intubation was impossible, and a cricothyrotomy was performed. Significant bleeding was controlled initially with packing and was semielectively explored later in the ICU with ligation of several small bleeding vessels. Prior administration of thrombolytic therapy does not preclude successful cricothyrotomy.

Aged↗
PubMed2000

Traumatic pneumomediastinum caused by isolated blunt facial trauma: a case report.

Traumatic pneumomediastinum is most often identified as an incidental finding in the setting of blunt or penetrating neck, chest, or abdominal trauma. There are only a few cases in the medical literature of a pneumomediastinum following isolated facial trauma. We present a patient who sustained fractures of the lateral and anterior walls of the right maxillary sinus, floor of the right orbit, and right zygomatic arch. Subcutaneous emphysema overlaid the right facial region and extended to the left side of the neck and into the mediastinum. We describe this unusual complication with respect to the anatomic relations of the facial and cervical fascial planes and spaces with the mediastinum.

Adult↗
PubMed2000

Fatal tetanus in a drug abuser with "protective" antitetanus antibodies.

Tetanus is a rare disease in the United States. From 1995-1997, the average annual incidence of tetanus was 0.15/1,000,000 population. Injecting-drug users, particularly those who use heroin, are among the highest risk population for acquiring tetanus. We present a case of an injecting-drug user who was seen in the emergency department with worsening diffuse midthoracic back pain and spasms. He subsequently developed acute respiratory failure and central nervous system hypoxic injury. Serum obtained before administration of tetanus immune globulin showed a tetanus antibody titer greater than 16 times the level considered protective. Because of limited human data on the minimum protective level of neutralizing antibody, as well as reports of tetanus among individuals with "protective" antibody titers, the diagnosis of tetanus should not be excluded solely on the basis of antitetanus titers.

Antibodies, Bacterial↗
PubMed1999

Update on emerging infections from the Centers for Disease Control and Prevention. Outbreak of Vibrio parahaemolyticus infection associated with eating raw oysters and clams harvested from Long Island Sound--Connecticut, New Jersey, and New York, 1998.

This article is part of a regular series on emerging infections from the Centers for Disease Control and Prevention (CDC) and the EMERGEncy ID NET, an emergency department-based and CDC-collaborative surveillance network. Important infectious disease public health information with relevance to emergency physicians is reported. The goal of this series is to advance knowledge about communicable diseases in emergency medicine, and foster cooperation between the front line of clinical medicine and public health agencies.

Animals↗
PubMed1999

Prospective multicenter study of relapse following treatment for acute asthma among adults presenting to the emergency department. MARC investigators. Multicenter Asthma Research Collaboration.

STUDY OBJECTIVE: To identify factors associated with relapse following treatment for acute asthma among adults presenting to the emergency department (ED). DESIGN: Prospective inception cohort study performed during October 1996 to December 1996 and April 1997 to June 1997, as part of the Multicenter Asthma Research Collaboration. SETTING: Thirty-six EDs in 18 states. PATIENTS: ED patients, aged 18 to 54 years, with physician diagnosis of acute asthma. For the present analysis, we restricted the cohort to patients sent home from the ED (n = 971), then further excluded patients with comorbid respiratory conditions (n = 32). This left 939 eligible subjects to have follow-up data. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Two weeks after being sent home from the ED, patients were contacted by telephone. A relapse was defined as an urgent or unscheduled visit to any physician for worsening asthma symptoms during the 14-day follow-up period. Complete follow-up data were available for 641 patients, of whom 17% reported relapse (95% confidence interval, 14 to 20). There was no significant difference in peak expiratory flow rate (PEFR) between patients who suffered relapse and those who did not. In a multivariate logistic regression analysis (controlling for age, gender, race, and primary care provider status), patients who suffered relapse were more likely to have a history of numerous ED (odds ratio [OD] 1.3 per 5 visits) and urgent clinic visits (OR 1.4 per 5 visits) for asthma in the past year, use a home nebulizer (OR 2.2), report multiple triggers of their asthma (OR 1.1 per trigger), and report a longer duration of symptoms (OR 2.5 for 1 to 7 days). CONCLUSION: Among patients sent home from the ED following acute asthma therapy, 17% will have a relapse and PEFR does not predict who will develop this outcome. By contrast, several historical features were associated with increased risk. Further research should focus on ways to decrease the relapse rate among these high-risk patients. The clinician may wish to consider these historical factors when making ED decisions.

Acute Disease↗
PubMed1997

Incision and drainage of cutaneous abscesses is not associated with bacteremia in afebrile adults.

STUDY OBJECTIVE: To determine the prevalence of bacteremia associated with incision and drainage (I&D) of cutaneous abscesses in afebrile adult emergency department patients. Such information has implications for the ED management of immunocompromised patients, patients with history of endocarditis, and patients with prosthetic appliances such as heart valves and artificial joints. METHODS: We conducted a prospective clinical study in the adult ED of an urban tertiary care teaching hospital. Our subjects were afebrile patients aged 18 to 65 years with localized, nondraining, purulent cutaneous abscesses requiring outpatient surgical management. Before I&D, blood for aerobic and anaerobic blood culture was drawn under sterile conditions. The wound was opened and samples for aerobic wound culture were obtained. Two and 10 minutes after I&D, blood was again drawn, from separate venipunctures. All patients were discharged home with ED follow-up scheduled 48 hours later. RESULTS: From the 50 patients who completed the study, 150 blood samples (50 before and 100 after I&D) and 50 wound samples were obtained. No blood culture was positive, but 30 wound cultures (64%) were positive; the most commonly isolated organism was Staphylococcus aureus. CONCLUSION: I&D of localized cutaneous abscesses in afebrile adults is unlikely to result in transient bacteremia. Larger studies are needed to determine whether routine antibiotic prophylaxis is necessary for afebrile patients undergoing I&D.

Abscess↗