Segmental proliferation of the emergency medical system.
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Emergency Medical Services↗
Biomedical subjects
K V Iserson
Publications and source records attributed to K V Iserson.
Diagnosis related groups and emergency medicine.
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Costs and Cost Analysis↗
Failure of dialysis therapy in potassium dichromate poisoning.
A fatal case of oral ingestion of potassium dichromate is presented. Following an initial presentation of abdominal pain and vomiting, the patient had a rapid progression to coma with the development of methemoglobinemia, coagulopathy, gastrointestinal hemorrhage, and respiratory distress syndrome. A blood concentration of chromium on admission was 5,800 mcg/dL, 80% of which was found to be in the intracellular fraction. Supportive treatment was also initiated as a four-hour period of hemodialysis followed by a one-hour period of charcoal hemoperfusion. Neither of these treatment modalities was found to significantly remove chromium from whole blood and neither seemed to affect the progression or outcome of this intoxication. We conclude that the ingestion of potassium dichromate is highly toxic and may rapidly lead to death. Hemodialysis and charcoal hemoperfusion appear to have little role in the management of chromium intoxication.
Adolescent↗
Parenteral chlorpromazine treatment of migraine.
A prospective, uncontrolled clinical trial was conducted to test the safety and efficacy of intramuscular chlorpromazine (1 mg/kg) in the acute, outpatient treatment of migraine. One hundred adult patients were included in the study. There was complete relief of both pain and nausea/emesis symptoms in 96 patients within 55 minutes of the injection. Eighteen patients experienced orthostatic hypotension following injection. All but one responded to noninvasive therapy. The results suggest that chlorpromazine is a safe, effective alternative medication in the outpatient treatment of acute migraine.
Adolescent↗
Airway trauma.
The mechanism of injury, diagnosis, and treatment of maxillofacial, laryngeal, tracheal, and bronchial trauma are considered. Also discussed is pulmonary barotrauma.
Airway Obstruction↗
Blind nasotracheal intubation.
One hundred fifty successive nonapneic patients requiring tracheal intubation had blind nasotracheal intubation performed. The primary indications for intubation were: drug overdose, 54 (36%); head injury, 36 (24%); COPD, 18 (12%); cerebrovascular accident, 15 (10%); congestive heart failure, 11 (7%); and other, 16 (11%). One hundred thirty-eight patients (92%) were successfully intubated using this technique.
Adolescent↗
The emergency amobarbital interview.
Patients infrequently present to the general emergency department with what appears to be a severe psychiatric condition needing rapid differentiation from urgent and emergency medical problems for proper initial disposition and treatment. These include patients with both acute conversion reactions and those in acute catatonic or pseudocatatonic states. Fifteen consecutive patients (11 women and four men ranging in age from 17 to 62) with these symptoms underwent interviews under intravenous amobarbital in the emergency department. Five of these patients presented with acute paralysis of extremities. Ten presented in a state of vigilant awareness similar to, or identical with, catatonia. Using this technique, all 15 patients had the presumptive psychiatric nature of their underlying condition quickly confirmed. The five patients with conversion reactions have no recurrence to date. Four of the 10 catatonia-type patients had resolution of their symptoms without recurrence. All 15 patients responded to 500 mg or less of amobarbital. There were no complications. Two cases are discussed.
Adult↗
Teaching emergency department administration: the in-basket exercise.
Borrowing from formats that have been successfully used in teaching administrators, we developed a limited, time-dependent simulation model, the In-Basket Exercise for teaching emergency department administration. The exercise is designed as an introduction to nonclinical decisions, management communication, and managerial control. Using selected material, and under time constraints, participants are asked to describe the options for several types of administrative items. These options and decisions are then discussed within a group. The In-Basket Exercise has been well received as a simple new tool for teaching emergency department administration where existing methods are generally deficient.
Administrative Personnel↗
A characterization of emergency medicine.
A Medical Specialty Preference Inventory (MSPI) containing 199 items relating to the practice of medicine was developed through ratings by a national sample of over 1,000 board certified physicians in internal medicine, obstetrics-gynecology, pediatrics, psychiatry, surgery, and family practice. Sixty-one emergency physicians completed the MSPI for emergency medicine. Scores on the emergency medicine characterization were compared with those of the six specialties. Results showed emergency medicine most similar to surgery and least similar to psychiatry, although the similarity to surgery was two standard deviations below the mean overall surgery score. A more extensive and systematic effort to characterize emergency medicine using the MSPI rating system could create a national representative factorial characterization of emergency medicine to be used by medical students and physicians when choosing a specialty.
Career Choice↗
Accidental "cranial" defibrillation.
A case of accidental shock to the head, caused by a cardiac defibrillator, is presented. The shock resulted in minor burns and symptoms similar to those of postelectro-convulsive shock therapy (ECT). A physician participating in an advanced life support course, and familiar with the equipment, was the victim. An assumption that the demonstration equipment was not real seems to have been the cause of the accident. Suggestions for prevention of further episodes are discussed.
Accidents↗
J.-F.-B. Charrière: the man behind the "French" gauge.
Joseph-Frédéric-Benoît Charrière, a 19th century Parisian maker of surgical instruments, has by virtue of his ingenuity and advanced thinking, continued to have his presence felt in medicine throughout the 20th century. His most significant accomplishment was the development of a uniform, standard gauge specifically designed for use in medical equipment such as catheters and probes. Unlike the gauge system adopted by the British for measurement of needles and intravenous catheters, Charrière's system has uniform increments between gauge sizes (1/3 of a millimeter), is easily calculated in terms of its metric equivalent, and has no arbitrary upper end point. Today, in the United States, this system is commonly referred to as French (Fr) sizing. In addition to the development of the French gauge, Charrière made significant advances in ether administration, urologic, and other surgical instruments, and the development of the modern syringe.
France↗
Flow characteristics of admixed erythrocytes through medex tubing with a pall filter.
Resuscitation with fluid and blood components is the mainstay of therapy for hypovolemic patients. This study evaluated the flow rate and resultant temperature of 6 degrees C erythrocytes admixed with warmed saline passing through a new commercial large bore tubing. The tubing is 183 cm long and is 0.57 cm in diameter. The effect on the outflow fluid temperature when catheters of various sizes were added to the system distally was also assessed. The admixed solution temperature averaged 36.2 degrees C and the outflow temperature of the mixture from the distal tubing averaged 34.9 degrees C. There was an average drop in temperature over the length of the tube of 1.5 degrees C. The filter in the Medex Hi-Flow Trauma Quad system collapsed, severely restricting fluid flow, after only four units. The problem of filter clogging was overcome by the in-line addition of a Pall filter. Addition of this in-line filter had a negligible effect on the flow rate. The flow rate with the Pall filter in-line averaged 1,150 mL/min. As the catheters that were added distally to the system diminished in size, there was a predictable decrease in the admixed fluid flow rate. A warmed saline-erythrocyte solution may be very rapidly infused through commercial large-bore tubing modified with an in-line filter. The size of the catheters used determines the ultimate flow rate.
Blood Transfusion↗
Emergency burn treatment in Denmark.
Historically, burn treatment in Denmark has included several unique elements. Current Danish treatment includes prolonged tap water irrigation of burns, which largely replaces the use of narcotics for pain control in both the inpatient and outpatient settings. Burns on hands and feet are dressed for maximum mobility. Other burns are left open. Mortality is 10% to 15% below expectations.
Adult↗
Intraosseous infusions in adults.
Intraosseous (IO) access in adults via the distal tibia has never been a widely accepted technique. Yet there have been occasional reports of the successful use of this procedure. This study was done to demonstrate the utility of IO infusions in the adult patient, including those patients in cardiac arrest. Twenty-two patients, aged 36 through 84 (mean 65.1 years), who arrived in the emergency department (ED) in cardiac arrest from nonhypovolemic causes and in whom an intravenous line was not established prior to arrival or was found to be inadequate (nonfunctioning or poorly functioning) upon arrival in the ED, had an IO needle (13-gauge Kormed/Jamshidi, Pharmaseal Division, Baxter Healthcare Corp., Valencia, CA) placed above the medial malleolus. The IO needle was then connected to a standard IV tubing, with a pressure bag or pressure device delivering 300 mm Hg to the solution bag. The resultant flow rate through the IV line ranged from 5 to 12 mL/min. The IO needle was placed and flow established in under one minute in all patients. Temporally related pharmacologic effects were observed after the IO administration of sodium bicarbonate, lidocaine, atropine, and vasopressors. This study shows that I.O. access can be quickly and easily obtained in adults in the medial supramalleolar position during cardiac arrest. This method of drug administration appears to hold promise as another useful modality for adults and older children during nontraumatic resuscitations.
Adult↗
Intravenous equipment: caveat emptor.
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Emergency Medical Services↗
The feasibility of 12-gauge intravenous catheter use in the prehospital setting.
Intravenous fluid therapy is a mainstay in the treatment of trauma and hypovolemia. However, controversy exists as to its effective use by prehospital personnel. We reasoned that 12-gauge catheters, shown to have significantly greater fluid flow than 14- or 16-gauge catheters, might allow prehospital care providers to have a more significant role in patient resuscitation. This study was designed to see if 12-gauge intravenous catheters can successfully be placed and used in the prehospital care arena. During a six-month period, commercial peripheral 12-gauge catheter-over-needle intravenous units were placed in any hypovolemic or potentially hypovolemic patient in whom paramedics thought that rapid fluid therapy was, or might become, necessary. They experienced an overall success rate of 84% and a success-per-attempt rate of 74%. The catheters were placed under normal field conditions. Per preexisting protocols, departure from the scene and transport to the hospital were not delayed for any paramedic interventions, including starting intravenous lines. The 12-gauge catheters can be successfully used by paramedics, both to establish large bore intravenous access prior to arrival at the emergency department and to institute effective fluid therapy where time and circumstances allow.
Allied Health Personnel↗
Confirmation of high blood flow rates through 150 mu filter/high-flow tubing.
Many new products designed to assist in rapid blood infusion are appearing. Some highly touted and routinely used devices for intravenous (IV) infusion have recently been shown to be, at least in part, defective. A tubing with an in-line 150 mu filter (150 mu High-Flow Blood Filter; Saftifilter Blood Administration Sets; Cutter Biological, Berkeley, CA 94710) has recently been introduced to facilitate rapid blood transfusion. It is claimed that at least 8.5 units of blood can be rapidly run through each set before replacement is necessary. To test this under simulated clinical conditions, four sets of ten random units of outdated erythrocytes at 4 to 9 degrees C were each admixed with 250 mL 70 degrees C 0.9 NaCl and infused through the system under a constant 300 mmHg pressure. Two sets infused through unmodified tubing flowed at an average of 25 mL/sec (1500 mL/min) before there was an appreciable slowing of the flow rate. Two sets with 8 Fr catheters attached infused at an average of 22 mL/sec (1320 mL/min) before there was an appreciable slowing of the flow rate. Even after the flow slowed, the 9th and 10th units infused at an average greater than 10 mL/sec (600 mL/min). The tubing/filter exceeded the manufacturer's published claims. This tubing/filter appears to be one element that could be an effective component of a high-flow infusion system.
Blood Transfusion↗
Requiring consent to practice and teach using the recently dead.
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Cadaver↗