On-scene management of trauma patients by paramedics.
Explore the source record for details and available documents.
Allied Health Personnel↗
Biomedical subjects
J R Hedges
Publications and source records attributed to J R Hedges.
Use of abbreviated mental status examination in the initial assessment of overdose patients.
Application of formal mental status testing in the emergency department (ED) to assess cognitive function has been hampered by the lack of a rapidly applied instrument. An Abbreviated Mental Status Examination (AMSE) with 10 test items that can be administered within five minutes by nursing personnel is described. Evaluation of the instrument on 296 ambulatory ED patients with grossly normal neurologic function showed that 93% of patients had a total score of seven or more correct answers and 83% of patients had eight or more correct answers. Application of the AMSE to 375 acute drug overdose patients at the same hospital showed a significant correlation with Glasgow Coma Scale (GCS) score. An AMSE score of seven or less was found to be more sensitive than a GCS score of 13 or less for admission to the intensive care unit (ICU) and complications in the ICU (P less than 0.001). The AMSE score may serve as a useful tool for stratifying cognitive function in acute drug overdose patients and for identifying patients at increased risk for an adverse outcome from their overdose.
Adult↗
Detection of myocardial ischemia/infarction in the emergency department patient with chest discomfort.
Detailed review of the literature for chest discomfort evaluation in the Emergency Department leaves the clinician without a precise guideline as to whom to admit or send home. It is clear that the seasoned physician's instinct (the sum total of the history, physician examination, and ancillary laboratory tests) is as good an indicator as existing statistical decision models. Current decision rules appear most helpful as teaching aids for physicians-in-training and for providing reassurance to seasoned physicians. Although ancillary tests such as echocardiography and rapid myoglobin analysis may play more important roles in the future, emergency physicians must now rely primarily upon their clinical impression to guide admission decisions. Vigorous attempts to minimize the admission of patients without ischemia to the CCU will increase the incidence of infarction patients released from the Emergency Department. The liberal use of intermediate care unit beds may represent one future disposition alternative. Nonetheless, each physician must establish his or her own threshold for admission. Several studies have found a 5 per cent unintentional release of infarction patients from the Emergency Department. Decreasing the admission threshold may lower this rate substantially. Patients with chest discomfort who are released from the Emergency Department require close followup. At urban teaching hospitals, where private physician referral is often limited, the institution may need to establish a clinic specifically for this purpose. Unrecognized myocardial ischemia is one rationale for close followup; however, the pursuit of alternative diagnoses including gastrointestinal and psychiatric (e.g., panic disorders) etiologies may minimize subsequent morbidity in the released population.
Chest Pain↗
Effects of splenectomy on hemodynamic performance in fixed volume canine hemorrhagic shock.
Studies of canine hemorrhagic shock commonly use a splenectomized fixed-pressure model. Splenectomy is recommended in this model to avoid variable degrees of autotransfusion that reduce the reliability of mortality estimates and blood volume measurements. The effects of splenectomy on a non-lethal fixed-volume canine hemorrhage have not been established. The purpose of this study was to investigate cardiovascular and biochemical effects of splenectomy in fixed-volume canine hemorrhagic shock. Nineteen beagles of uniform size and weight were bled 50% of their estimated blood volumes over 1 hr and then left without therapeutic intervention for a 90 min stabilization period. Arterial blood pressure (MAP), central venous pressure, pulmonary artery pressure, heart rate (HR), cardiac output, glucose, lactate, arterial and mixed venous blood gases, and hematocrit (HCT) were measured at regular intervals. Cardiac index (CI), stroke volume, and oxygen saturation (O2SAT), delivery (O2DEL) and consumption (O2CON) were calculated at these intervals. Results from ten control animals were compared to those from nine animals that had been splenectomized 2 wk prior to hemorrhage. During the hemorrhage period, there were no significant differences observed between groups for HR, MAP, or O2DEL. CI remained higher (P less than 0.025) and HCT lower (28.9 +/- 4.7 vs 39.8 +/- 4.5) (P less than 0.001) in splenectomized animals. Immediately following hemorrhage there were no significant differences in the mean values for HR, CI, MAP, or serum lactate. O2DEL however, was significantly higher in control animals (P less than 0.05). During stabilization MAP, CI, and O2DEL rose while HCT fell in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Effects of dichloroacetate in spinal stroke in the rabbit.
High levels of brain lactate may contribute to cellular death and dysfunction in acute cerebral ischemia. Although sodium dichloroacetate (DCA) has been shown to lower brain lactate in incomplete cerebral ischemia, functional outcome has not been assessed with DCA. We examined the effects of DCA treatment on functional neurologic outcome using a previously developed model for "spinal stroke" in the rabbit. Thirty male New Zealand white rabbits weighing 1.3-2.8 kg were studied. After anesthesia with 15-40 mg/kg pentobarbital IV, a laparotomy was performed and the aorta exposed. A metal clamp was placed on the aorta just distal to the left renal artery for 20 minutes and then removed. The abdominal wound was closed in two layers. Animals then received either 2cc normal saline (n = 15) or 300 mg/kg DCA in 2cc normal saline (n = 15) over 10 minutes. The animals were returned to their cages when awake and were examined at 24 hours, 48 hours, and 72 hours for neurologic assessment. The exams were performed by a blinded examiner who was unaware of the treatment given. A three point ambulatory score (0 = can't walk, 1 = walk but not hop, 2 = hopping) and a two point activity score (0 = inactive, 1 = active) were used. At 24 hours, 67% of the DCA-treated animals were actively moving about compared to only 27% of the controls (P = 0.03; Fisher Exact Test). Ten of fifteen control animals were unable to walk, while only five of fifteen DCA-treated animals were unable to walk (P = 0.07). Sixty percent of the DCA animals were able to hop compared to 27% of controls (P = 0.06). These results suggest that DCA can reduce morbidity from spinal cord ischemia in the rabbit.
Acetates↗
Emergency bypass system: analysis of gas transfer.
A portable emergency bypass system using a membrane oxygenator device (CPS) was evaluated. The ability of the CPS to supply the oxygen transfer needs of five anesthetized dogs consistently over six hours and the system's effects on hemoglobin concentration, platelet count, and degree of hemolysis were assessed. The animals maintained spontaneous heart beats, pump flows averaged 100 ml/kg/min; mean arterial pressures were maintained at from 114 to 144 mm Hg. Immediate dilution of hemoglobin and platelet levels occurred in the first 30 minutes. Further hemodilution was limited during the first two hours, although three of the animals required transfusions during the six-hour period to maintain their hematocrits. Plasma free hemoglobin did not significantly increase during the six hours. Baseline oxygen consumption data obtained in three animals ranged from 44.5 to 96 (ml oxygen/min/m2). Oxygen and carbon dioxide transfer measurements during the first hour of bypass were not significantly different from measurements during the last hour of perfusion. The study suggests that optimal use of the CPS could supply much if not all of a patient's basal oxygen transfer requirements for at least six hours.
Animals↗
Correlation of initial amitriptyline concentration reduction with activated charcoal therapy in overdose patients.
Plasma amitriptyline concentrations were measured serially in nine overdose patients and correlated with the timing and amount of each patient's initial activated charcoal therapy. A direct correlation was found between the time to initial charcoal therapy (Tc) and the plasma concentration half-life of amitriptyline (T 1/2) calculated for the first seven to 18 hours of hospitalization; T 1/2 = 2.68 + 0.047 Tc (r = 0.78, P less than 0.05). An inverse trend of T 1/2 with the initial amount of charcoal administered was also noted. Nortriptyline, the major metabolite of amitriptyline, decreased in two of three patients who received greater than or equal to 50 gm of activated charcoal within 60 minutes of presentation. These findings support previous in vitro and human volunteer studies advocating the rapid administration of activated charcoal in acute tricyclic antidepressant overdoses.
Amitriptyline↗
Oxygen saturation as a marker for admission or relapse with acute bronchospasm.
Oxygen saturation (SaO2) as measured by pulse oximetry was evaluated as a means of complementing or supplementing peak expiratory flow rate (PEFR) for early identification of the adult patient needing prolonged therapy for acute bronchospasm. SaO2 was recorded at baseline and at the time of peak drop after initial bronchodilator therapy for 28 patient visits. PEFR was recorded at baseline and at 15 minutes after initial bronchodilator therapy. Potential admission criteria based on these parameters were compared to patients actually admitted or returned within 72 hours (prematurely discharged). Mean patient age was 36 +/- 16.8 years. Mean baseline SaO2 was 95.4 +/- 2.3% (92 to 100%) and SaO2 at the peak drop after the first bronchodilator therapy was 91.9 +/- 3.0% (86 to 97%). Of the criteria evaluated, the following had a significant correlation with admission or premature discharge: baseline PEFR less than or equal to 100 L/min (P = .017); PEFR after first bronchodilator therapy less than or equal to 160 L/min (P less than .0004); the combination of a baseline PEFR less than or equal to 100 L/min with an improvement in PEFR less than or equal to 100 L/min (P less than .0003); and the combination of baseline SaO2 less than or equal to 95% with an improvement in PEFR less than or equal to 100 L/min (P = .0017). As isolated variables, SaO2 at baseline and SaO2 at peak drop following bronchodilator therapy were not useful predictors of outcome, although patients severely hypoxemic at presentation were not evaluated.
Acute Disease↗
Oxygen desaturation in adults following inhaled metaproterenol therapy.
Following bronchodilator therapy in asthmatic patients, a fall in arterial oxygen tension (PaO2) has been attributed to increased perfusion of persistently underventilated alveoli. We used continuous noninvasive pulse oximetry to evaluate the extent and timing of oxygen saturation (SaO2) decrease in adults following metaproterenol inhalation for acute bronchospasm. We also examined the effect of supplemental oxygen upon these factors. Baseline and peak drop in SaO2 after completion of the first bronchodilator therapy were measured and the percent change in SaO2 was calculated. A total of 47 patient visits were studied; 10 patients received supplemental oxygen. Mean age was 38 +/- 17.9 years. Baseline was SaO2 = 94.6 +/- 2.9%, peak drop SaO2 = 91.4 +/- 3.4%, and percent change in SaO2 = -3.4 +/- 2.5%. The mean time to peak drop was 24.4 +/- 15.4 minutes in the 40 patients, with an observed drop after initial treatment. The absolute change in SaO2 from baseline was significant both with and without oxygen (P less than .05 and less than .01, respectively). The group receiving oxygen had a significantly smaller percent drop and a larger proportion of patients showing no drop in SaO2 (P less than 0.01 and less than 0.03, respectively). Clinically significant oxygen desaturation can occur within 30 minutes of inhaled bronchodilator therapy. Supplemental oxygen (2-3 L/min) helps blunt the metaproterenol-induced drop in SaO2.
Acute Disease↗
A comparison of blind nasotracheal and succinylcholine-assisted intubation in the poisoned patient.
In the patient obtunded by drug intoxication, the optimal method of airway protection prior to gastric emptying is not clear. We report a prospective randomized trial of two methods of intubation in this patient population. Fifty-two overdose patients with Glascow Coma Scale scores of 12 or less were intubated either orotracheally after succinylcholine administration or nasotracheally. Success rate, time to intubate, difficulty, and complications of intubation were compared for the two groups. We found a success rate of 100% (23 of 23) for succinylcholine assisted intubation (SAI) versus 65% (19 of 29) success with blind nasotracheal intubation (BNI). Mean time to intubate was 64 seconds and 276 seconds in the SAI and BNI groups, respectively. Eighty-six percent (19 of 22) of patients were intubated successfully in less than 120 seconds in the SAI group versus 37% (10 of 27) in the BNI group (P less than .005). In the SAI group, the mean number of attempts was 1.3 per patient, (range, one to three) with 96% (22 of 23) having two or fewer attempts. No complications were identified. In the BNI group, the mean number of attempts was 3.7 per patient, (range, one to 13) with 45% (13 of 29) having two or fewer attempts (P less than .005). Sixty-nine percent of the BNI group experienced epistaxis, 17% had vomiting, and 10% aspirated. We conclude that SAI is a safe and effective method of airway protection in the obtunded poisoned patient. Complications and difficulty in intubation were significantly less with SAI than with blind nasotracheal intubation.
Adult↗
Use of cardiac enzymes identifies patients with acute myocardial infarction otherwise unrecognized in the emergency department.
Recognition of an acute myocardial infarction in the patient with chest pain is a frequent challenge to the clinician. Previous studies suggest that cardiac enzymes are of limited value in identifying patients with acute MI in the emergency department. Such studies have not evaluated the use of cardiac enzyme tests to complement decision making in the population of patients clinically designated for ED release. We studied 773 ED visits by patients age greater than or equal to 30 years presenting with chest pain unexplained by thoracic trauma or radiographic abnormalities. Cardiac enzyme levels were not available to the clinicians at the time of the initial visit and disposition of these patients was determined solely by clinical and ECG evaluation. Of the 291 admitted patients, 46 had an MI; 22 of the MI patients had a normal creatine kinase (CK) level. Of the 482 patients released from the ED, 181 patients had an elevated CK level. Among the released patients were five patients with MI. Four released MI patients had a CK level greater than or equal to 200 IU/L and three had an elevated CK-MB fraction (greater than or equal to 12 IU/L). In the population of patients scheduled for release, an elevated CK-MB had sensitivity, specificity, and positive predictive value for MI of 60%, 100%, and 60%, respectively. Although cardiac enzymes cannot be used in isolation to make admission decisions, selective use of CK-MB for final screening of patients otherwise scheduled for ED release may enhance the initial admission of patients with MI at risk for unintentional release.
Adult↗
A chest pain clinic to improve the follow-up of patients released from an urban university teaching hospital emergency department.
During a 12-month period, 1,045 of 1,554 patients (67%) over age 30 seen in an urban teaching hospital emergency department with acute chest pain were released based on the clinical judgment of the examining physician. Patients who were released were offered follow-up within 24 to 72 hours in a hospital-based chest pain clinic. Of these 1,045 patients, 772 (74%) returned or were contacted by phone, and 29 were directly admitted; 14 had unstable angina, and eight had new myocardial infarctions. Because of its positive impact on the quality of care at an acceptable cost, the Chest Pain Clinic, which was originally instituted as part of a research protocol, has now become part of the routine spectrum of care provided at the University of Cincinnati Medical Center.
Adult↗
Myoglobin as an early indicator of acute myocardial infarction.
The ECG and the determination of serum enzymes creatine phosphokinase (CPK) and lactate dehydrogenase (LDH) may be falsely normal early in acute myocardial infarction. Myoglobin, an oxygen-carrying protein found in cardiac muscle and striated skeletal muscle, presents an attractive alternative to CPK and LDH in the emergency department setting for identification of acute myocardial infarction. Myoglobin levels may be elevated in the serum within one hour after myocardial cell death with peak levels reached within four to six hours. We report a study of 59 patients presenting to a community hospital with chest pain and subsequent hospitalization. Twenty-one had an acute myocardial infarction. Presenting (0 hour) myoglobin determination was positive in 13 of 21 individuals, while CPK-MB was positive in only three. Serum myoglobin elevation at three hours identified all 21 patients with myocardial infarction with the CPK-MB determination positive in 19. Serum myoglobin elevation may permit early identification of myocardial infarction, with subsequent verification using CPK-MB determination, allowing appropriate intensive care admission for careful monitoring of these patients.
Adult↗
A scoring system for appendicitis and the likelihood ratio.
Explore the source record for details and available documents.
Appendicitis↗
Prehospital trial of emergency transcutaneous cardiac pacing.
A prospective alternate-day controlled trial of prehospital transcutaneous cardiac pacing (PACE) of hemodynamically significant bradycardia and asystole was undertaken. All patients had a Glasgow coma scale score of 12 or less. Patients in the control group (n = 101) received standard advanced cardiac life support (ACLS) care. Patients in the pacing group (n = 101) were to receive PACE in addition to standard ACLS treatment; 89 patients were actually paced. The two groups were comparable in terms of age, sex, presenting rhythm, and mean times to cardiopulmonary resuscitation (CPR) and ACLS. For the 144 patients in whom the time of arrest could be estimated, the mean times to CPR and ACLS were 5.3 +/- 4.0 and 10.9 +/- 7.1 min, respectively. For the 65 paced patients in whom the time of arrest could be estimated, the mean time from arrest to pacing was 21.8 +/- 8.8 min (range 2 to 43). Multivariate analysis of outcome variables (presentation to emergency department with a pulse, admission to the hospital, and discharge from the hospital) revealed that an initial rhythm of ventricular tachycardia or fibrillation and a short time to ACLS were correlated with a favorable outcome (p less than .05; logistic regression analysis). A short time to PACE was associated with admission to the hospital (p = .20; logistic regression analysis). The use of a stand-alone transcutaneous pacing device in the prehospital arrest setting was associated with generally long times until pacing and did not appreciably improve outcome. Use of PACE in patients demonstrating prehospital bradycardia without neurologic impairment remains to be evaluated.
Adult↗
Approach to acute pharyngitis.
The evaluation of the patient with a "sore throat" is deceptively complex. The clinician must first assess the potential for airway compromise. Specific risk factors, reviewed in this article, should be considered, including the presence of a pharyngeal membrane, immunocompromise, potential gonococcal exposure, and prior rheumatic fever.
Acute Disease↗
Hemodynamic effects of naloxone in anaphylactic shock.
Recent reports suggest that endorphins may contribute to hemodynamic depression in septic and hemorrhagic shock. There is also evidence that reversal of endorphin effects with high dose naloxone may improve hemodynamic function and improve survival in shock states. The purpose of this study was to examine the effects of naloxone on hemodynamic parameters in anaphylactic shock. Anaphylactic shock was induced in sensitized rabbits with horse serum. Three minutes after serum challenge, rabbits were treated with a 3 mg/kg bolus of naloxone followed by a 3 mg/kg per h infusion (group I, n = 8), or by injection with an equal volume of saline (group II, n = 8). Cardiac output, blood pressure, heart rate and body temperature were monitored continuously for 60 min and the experiment was terminated. There was a significant increase in cardiac index in group I animals at 10 min (P less than 0.01) and 15 min (P less than 0.01). Stroke volume index was also higher in naloxone treated animals at 10 min and 15 min (P less than 0.05). Although mean blood pressure was higher in group I animals at all time intervals after naloxone was begun, the difference was statistically significant only at 60 min (P less than 0.05). Peripheral vascular resistance index was not significantly different for the two groups.
Anaphylaxis↗
Streptococcal pharyngitis in the emergency department: analysis of therapeutic strategies.
Potential streptococcal pharyngitis represents a common presenting complaint of patients in emergency departments. Studies have shown that therapy within the first 48 hours of presentation hastens the resolution of the infection. A prior analysis of the cost of treatment for potential streptococcal pharyngitis in an outpatient practice suggested that when the likelihood of a positive throat culture is high, therapy is more cost effective without a throat culture. The current analysis evaluates the effects of emergency department charges, incomplete follow-up, and several common screening tests (Gram stain, clinical scoring) upon the cost of treatment and the risk for rheumatic fever. The results of the current analysis support the use of common screening tests to permit immediate oral or parenteral penicillin treatment of selected patients without a throat culture and the use of a throat culture to detect false-negative screen results.
Ambulatory Care↗