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Biomedical subjects

S G Rothrock

Publications and source records attributed to S G Rothrock.

At least 37 records · Page 2Linked to original sources
PubMed1997

Cranial computed tomography in the emergency evaluation of adult patients without a recent history of head trauma: a prospective analysis.

OBJECTIVES: To examine the pattern of nontrauma cranial CT use in an urban ED, to identify the rate of significant CT abnormalities in this setting, and to develop criteria for restricting the ordering of CT scans. METHODS: A prospective, observational study of a case series of adults who underwent cranial CT scanning for nontraumatic cases was performed at the EDs of an urban teaching hospital and an affiliated community hospital with a combined annual census of 110,000. Clinically significant CT scans were defined as: 1) acute stroke, 2) CNS malignancy, 3) acute hydrocephalus, 4) intracranial bleeding, or 5) intracranial infection. X2 recursive partitioning was used to derive a decision rule to restrict ordering of CT scans. RESULTS: Only 61 (8%) of 806 CT scans revealed clinically significant abnormalities. The presence of any of the following: age > or = 60 years, focal neurologic deficit, headache with vomiting, or altered mental status, was 100% sensitive (95% CI: 94-100%) and 31% specific (95% CI: 28-33%) in detecting clinically significant CT scans. This set of features had positive and negative predictive values of 11% (95% CI: 8-13%) and 100% (95% CI: 98-100%), respectively. If these criteria had been used to restrict cranial CT use, 229 fewer patients (28%) would have had CT scans obtained and no clinically significant abnormalities would have been missed. CONCLUSION: Clinically significant CT abnormalities were uncommon in this study population, suggesting that current criteria for ordering nontrauma cranial CT scans may be too liberal. In this study, a set of clinical criteria was derived that may be useful at separating patients into high- and low-risk categories for clinically significant cranial CT abnormalities. Before these results are applied clinically, these criteria should be validated in larger, prospective studies.

Adult↗
PubMed1997

Do oral antibiotics prevent meningitis and serious bacterial infections in children with Streptococcus pneumoniae occult bacteremia? A meta-analysis.

OBJECTIVE: To determine whether oral antibiotics prevent meningitis and serious bacterial infections in children with Streptococcus pneumoniae occult bacteremia. DATA SOURCES: Using the Medline database, the English-language literature was searched for all publications concerning bacteremia, fever, or S pneumoniae from 1966 to April 1996. STUDY SELECTION: All studies that included a series of children with S pneumoniae occult bacteremia containing orally treated and untreated groups. Children were excluded from individual studies if they were immunocompromised, had a serious bacterial infection, underwent a lumbar puncture, or received parenteral antibiotics. DATA EXTRACTION: Three authors independently reviewed each article to determine the number of eligible children and the outcome of children meeting entry criteria. DATA SYNTHESIS: Eleven of 21 studies were excluded, leaving 10 evaluable studies with 656 total cases of S pneumoniae occult bacteremia identified. Patients who received oral antibiotics had fewer serious bacterial infections than untreated patients (3.3% vs 9.7%; pooled odds ratio, 0.35; 95% confidence interval, 0.17 to 0.73). Meningitis developed in 3 (0.8%) of 399 children in the oral antibiotic group and 7 (2.7%) of 257 untreated children (pooled odds ratio, 0.51; 95% confidence interval, 0.12 to 2.09). CONCLUSION: Although oral antibiotics modestly decreased the risk of serious bacterial infections in children with S pneumoniae occult bacteremia, there was insufficient evidence to conclude that oral antibiotics prevent meningitis. Published recommendations that oral antibiotics be administered to prevent serious bacterial infections in children with possible S pneumoniae occult bacteremia should be reevaluated in light of the lower risk of sequelae from S pneumoniae occult bacteremia and newer data concerning side effects from treatment.

Administration, Oral↗
PubMed1996

Leukocytosis: a new look at an old marker for acute myocardial infarction.

OBJECTIVE: To determine the test performance of leukocytosis for identifying acute myocardial infarction (AMI) in patients with nondiagnostic ECGs, admitted to rule out AMI. METHODS: A retrospective, comparative test performance study was conducted using patients admitted to a university teaching hospital to rule out AMI. Clinical and laboratory information was reviewed and hospital laboratory ranges were used to define threshold elevations: total creatine kinase (CK), 275 U/L; CK-MB, 7.5 micrograms/L ; white blood cell (WBC) count, 11.5 x 10(9)/L; and absolute neutrophil count (ANC), 8.0 x 10(9). Sensitivity, specificity, and predictive values of the total CK, CK-MB, WBC count, and ANC were calculated, and receiver operating characteristic (ROC) curves constructed. Test performances of marker combinations also were determined. RESULTS: The initial WBC count was significantly higher for the subjects who had AMI (11.1 vs 8.8 x 10(9)/L, p < 0.001). For the 688 subjects who had nondiagnostic ECGs, sensitivities for the initial total CK, CK-MB, WBC, and ANC were 39%, 73%, 35%, and 36%, respectively, while the corresponding specificities were 94%, 93%, 85%, and 86%. Logistic regression analysis confirmed leukocytosis as an independent predictor of AMI (adjusted odds ratio 4.08, 95% CI 1.73-9.63). While CK-MB alone was 73% sensitive for AMI, the decision rule of either an elevated CK-MB or an elevated WBC count increased this sensitivity to 88% (corresponding specificity 79%). Similarly, while CK-MB alone was 93% specific for AMI, the combination of an elevated CK-MB and an elevated WBC count increased this specificity to 99% (corresponding sensitivity 20%). CONCLUSIONS: Leukocytosis is significantly associated with AMI, and is a weak but independent laboratory predictor of this condition. In this preliminary study of admitted patients suspected of AMI, the combination of the WBC and the CK-MB may have additional diagnostic value over an isolated CK-MB result. Neither parameter in isolation was satisfactorily sensitive for AMI. Prognostic assessment of the role of the WBC count in clinical decision making should address its complementary role to that of other clinical and ancillary test parameters.

Acute Disease↗
PubMed1996

Ketamine safety profile in the developing world: survey of practitioners.

OBJECTIVE: To evaluate the safety profile of ketamine when used to facilitate surgical procedures in the less controlled setting of developing world, rural hospitals. METHODS: A survey addressing clinical experience with ketamine in the developing world was administered to a convenience sample of missionary physicians. Descriptive statistics are reported. RESULTS: Of the 172 surveyed physicians, 122 (71%) responded; 55 reported experience with ketamine. These physicians estimated a total of 12,844 administrations. The format of one procedural physician and a second trained anesthesiologist/anesthetist was unavailable in the practice of 59% of the responding physicians, and 34% routinely performed procedures while simultaneously supervising ketamine administration and monitoring its clinical effect. Pulse oximetry was used "often" or "always" by only 10% of the physicians. Cardiac monitoring and intermittent vital signs were used in only 19% and 45%, respectively. One unexplained pediatric death occurred during an unmonitored, unobserved ward recovery. An adult suffered cardiac arrest after a failed intubation attempt. Seventeen other complications possibly related to ketamine were apnea (n = 10), laryngospasm (n = 6), and aspiration (n = 1), all of which were transient and without sequelae. Physicians believed that recovery hallucinations and agitation were frequent in adults and unusual in children. CONCLUSIONS: Death and other serious complications were rare in this survey reporting > 12,000 estimated ketamine administrations in the developing world. Although the limitations of survey data are recognized, the margin of safety with ketamine appears to be high, even when administered by non-anesthesiologists in settings lacking basic mechanical monitoring. These findings have important implications for the use of ketamine outside the controlled operating room environment in developed countries.

Adult↗
PubMed1995

Reliability of infrared tympanic thermometry in the detection of rectal fever in children.

STUDY OBJECTIVE: Recently published clinical guidelines for the management of febrile children are based on studies that used rectal temperature data to stratify the risk of bacteremia and septic complications. Appropriate management decisions rely on accurate detection and categorization of fever. Accordingly, this study compared the newer infrared tympanic thermometry (ITT) to rectal thermometry in this regard. DESIGN: Prospective observational study. SETTING: Urban teaching hospital ED with annual census of 60,000. PARTICIPANTS: Consecutive children 6 months to 6 years old who had rectal temperatures measured. INTERVENTIONS: Triage nurses recorded rectal temperatures and bilateral ITT temperatures. Temperatures were correlated by Pearson correlation coefficients and compared using paired t tests with significance set at P < .01. Children were categorized by degree of fever using rectal temperature (afebrile, less than 100.4 degrees F; low fever, 100.4 to 102.9 degrees F; and high fever, more than 102.9 degrees F), and the accuracy of ITT in detecting fever and high fever was determined. RESULTS: Three hundred seventy patients were enrolled in the study. The mean age was 18.4 +/- 11.3 months; boys comprised 56% of patients. The mean temperatures were rectal, 101.0 +/- 2.0 degrees F; right tympanic membrane, 100.4 +/- 1.9 degrees F; and left tympanic membrane, 100.3 +/- 1.9 degrees F. The tympanic membrane temperatures were significantly lower than rectal readings (P << .001 for both right and left versus rectal). Rectal temperatures showed good correlation with both right and left tympanic membrane temperatures (r = .83 and .85, respectively). ITT was 76% sensitive and 92% specific in detecting fever of 100.4 degrees F or more (positive predictive value, 0.92; negative predictive value, 0.76). In the detection of high fever, ITT was only 57% sensitive but 98% specific (positive predictive value, 0.90; negative predictive value, 0.90). Rectal and TM temperatures differed by at least 0.5 degree F in 70% of the patients, 1.0 degree F in 41%, 2.0 degrees F in 12%, and 3.0 degrees F in 3%. CONCLUSION: Despite the statistical correlation between ITT and rectal temperatures, the modalities may yield significantly different temperatures. The poor sensitivity of ITT in detecting fever and high fever may result in clinically important miscategorizations of individual patients. Current clinical management that is based on the presence and height of fever may be adversely affected if ITT is used.

Child↗
PubMed1995

Cerebrospinal fluid shunt complications: an emergency medicine perspective.

Shunt malfunction and shunt infections are the most significant complications associated with cerebrospinal fluid shunts. Most cases of shunt infection are due to S. epidermidis or S. aureus. Seventy percent of all shunt infections present within two months of the shunt surgery. The most common factor associated with shunt infection is age under three months. Even fever may not be a consistent sign of shunt infection. A high index of suspicion for shunt infection or malfunction must be maintained when evaluating the patient with a cerebrospinal fluid shunt. There are many types of shunt systems in use today. An understanding of current shunt systems and their associated problems should allow physicians to promptly diagnose and initiate treatment for patients with cerebrospinal fluid shunts. Prompt neurosurgical consultation is mandatory whenever shunt malfunction or infection is suspected.

Anti-Bacterial Agents↗
PubMed1994

Delayed appendicitis from an ingested foreign body.

An unusual case of acute appendicitis induced by a metal drill bit that was ingested by a 27-year-old man 3 years before presentation is reported. This foreign body lodged in the patient's appendix and developed a fecalith coating. When this fecalith coating enlarged enough to obstruct the appendiceal lumen, the patient presented with classic acute appendicitis. Foreign body-induced appendicitis is reviewed.

Acute Disease↗
PubMed1994

Validation of diphenhydramine as a dermal local anesthetic.

STUDY OBJECTIVE: Although diphenhydramine has been recommended as an alternate local anesthetic for patients claiming allergy to lidocaine, no prior placebo-controlled evaluations of diphenhydramine for dermal anesthesia have been performed. We sought to determine the relative efficacy of diphenhydramine compared to saline placebo and lidocaine. DESIGN: Prospective, randomized, double-blind, placebo-controlled clinical trial. SETTING AND PARTICIPANTS: Twenty-four healthy adult volunteers. INTERVENTIONS: Subjects received intradermal 0.5-mL injections of diphenhydramine 1%, diphenhydramine 2%, lidocaine 1%, and normal saline placebo in a randomized, double-blind fashion. Extent of anesthesia (in mm2) was assessed at one, two, five, ten, 20, and 30 minutes. Pain of initial infiltration was assessed with a visual analog scale. MEASUREMENTS AND MAIN RESULTS: Diphenhydramine 1% produced greater anesthesia than placebo (P < .001) and equivalent anesthesia to lidocaine 1% (P = .889). (Our sample size had 90% power to detect a difference of 30% from the peak anesthesia observed.) Diphenhydramine 2% was less effective than diphenhydramine 1%; however, this difference was not statistically significant (P = .295). Infiltration of either concentration of diphenhydramine was significantly more painful than either lidocaine or saline (P < or = .001) for all comparisons). No clinically important complications were noted. CONCLUSION: In this study of 24 adult volunteers, diphenhydramine 1% was as effective as lidocaine 1% for achieving dermal local anesthesia, although injection was more painful. Although no clinically important complications were noted in our study, the safety of diphenhydramine remains to be established, especially in areas with poor collateral perfusion (eg, digits, pinna, and nose).

Adult↗
PubMed1993

Atropine for the treatment of biliary tract pain: a double-blind, placebo-controlled trial.

STUDY OBJECTIVE: To compare the efficacy of IM atropine with placebo for the treatment of pain caused by biliary tract disease. DESIGN: Prospective randomized, double-blind, crossover study. SETTING: Emergency departments of a university medical center and affiliated county hospital. PARTICIPANTS: Fifty-five adults with biliary tract disease. INTERVENTIONS: Subjects were randomized to receive either 0.6 mg (0.5 mL) IM atropine or normal saline placebo in a double-blinded manner. If pain relief with the initial injection was inadequate, patients received the alternate injection. Pain was assessed by visual analog scale (0 to 100 mm) before the initial injection and 30 to 40 minutes after each subsequent injection. MEASUREMENTS AND MAIN RESULTS: Relief of pain was complete after the initial injection in four of 28 (14%) who received atropine and four of 27 (15%) who received normal saline (P = .956). For subjects who received both injections, atropine and placebo resulted in similar pain relief (-12.0 mm versus -16.0 mm; P = .316). There also was no difference in pain relief between atropine and placebo for the subset of patients with biliary colic receiving both injections (-15.2 mm versus -17.0 mm; P = .658). This study had more than 80% power to detect a 7.5-mm difference in pain relief between atropine and placebo in all patients with biliary tract disease and a 12.5-mm difference in those with biliary colic. CONCLUSION: Atropine is no better than placebo in the treatment of biliary tract pain.

Adult↗
PubMed1993

Successful resuscitation from cardiac arrest using sublingual injection for medication delivery.

A 7-month-old child suffered a cardiopulmonary arrest. After eight minutes of basic CPR by the parents, paramedics arrived and found the child in asystole. Endotracheal intubation and peripheral venous access were unsuccessful, and intraosseous equipment was unavailable in the field. The patient then received 1.5 mg epinephrine and 0.15 mg atropine injected sublingually with prompt return of a sinus rhythm and a palpable pulse. One hour after arrival in the emergency department, the patient again arrested, this time fatally. This case may represent the first report of successful resuscitation from cardiac arrest using sublingually injected medications.

Administration, Sublingual↗
PubMed1993

Tympanometric evaluation of middle ear barotrauma during recreational scuba diving.

We report the first prospective evaluation of middle ear barotrauma in experienced recreational scuba divers. In this pilot study, tympanometric and otoscopic evaluations were performed daily on two experienced scuba divers engaged in multi-day repetitive diving. Middle ear pressures decreased in proportion to diving frequency, demonstrating eustachian tube dysfunction which promptly reversed upon cessation of diving Otoscopic evidence of traumatic injury to the middle ear occurred in proportion to diving frequency, and also readily reversed upon cessation of diving. Tympanic membrane compliance remained normal, often despite pronounced otoscopic abnormalities. Otologic symptoms and impairment of acuity were not observed. Tympanometry appears to be a valuable modality for the verification of middle ear hemorrhage or tympanic membrane rupture. This preliminary data should assist investigators in planning more comprehensive studies of middle ear barotrauma, including clinical trials of treatment and prophylactic interventions for this common condition.

Acoustic Impedance Tests↗
PubMed1993

Cervicofacial and thoracic barotrauma following a minor dental procedure.

A case of cervicofacial subcutaneous emphysema and pneumomediastinum following a seemingly minor dental procedure is described. This dramatic but usually benign complication of dental work is rare and has not been reported in the pediatric emergency medicine literature. A brief review of this entity and an overview of diagnostic considerations and management are presented.

Air Pressure↗
PubMed1993

Can seizures be the sole manifestation of meningitis in febrile children?

OBJECTIVE: It is frequently taught that lumbar puncture is a mandatory procedure in many or all children who have fever and a seizure, because the convulsion may represent the sole manifestation of bacterial meningitis. We attempted to determine the incidence of this occult manifestation of meningitis. DESIGN: Retrospective case series. SETTING AND PATIENTS: 503 consecutive cases of meningitis in children aged 2 months to 15 years seen at two referral hospitals during a 20-year period. MAIN OUTCOME MEASURES: Signs and symptoms of meningitis in patients having associated seizures. RESULTS: Meningitis was associated with seizures in 115 cases (23%), and 105 of these children were either obtunded or comatose at their first visit with a physician after the seizure. The remaining 10 had relatively normal levels of consciousness and either were believed to have viral meningitis (2) or possessed straightforward indications for lumbar puncture: nuchal rigidity (6), prolonged focal seizure (1), or multiple seizures and a petechial rash (1). No cases of occult bacterial meningitis were found. CONCLUSION: In our review of 503 consecutive children with meningitis, none were noted to have bacterial meningitis manifesting solely as a simple seizure. We suspect that this previously described entity is either extremely rare or nonexistent. Commonly taught decision rules requiring lumbar puncture in children with fever and a seizure appear to be unnecessarily restrictive.

Adolescent↗
PubMed1993

Single-dose intramuscular ceftriaxone for acute otitis media in children.

This study evaluated the efficacy of a single dose of intramuscular ceftriaxone for acute otitis media in children, using amoxicillin as a control. (There is currently no established single-dose treatment for this condition.) In a prospective, randomized, double-blind, clinical trial, 233 children, aged 5 months to 5 years, with uncomplicated acute otitis media were randomly assigned to receive either a single intramuscular injection of ceftriaxone (50 mg/kg) plus placebo oral suspension for 10 days, or a placebo injection plus amoxicillin oral suspension (40 mg/kg per day divided three times per day) for 10 days in a double-blind fashion. Demographic and clinical characteristics were similar in both groups. Treatment was successful in 107 of 117 given amoxicillin (91%, 95% confidence interval 86% to 97%) and 105 of 116 given ceftriaxone (91%, 95% confidence interval 85% to 96%). Rates of improvement, failure, relapse, and reinfection were similar in both groups, as were the otoscopic and tympanometric evaluations at the 14- and 60-day follow-up visits. It is concluded that a single intramuscular injection of ceftriaxone (50 mg/kg) is as effective as 10 days of oral amoxicillin for the treatment of uncomplicated acute otitis media in children.

Acoustic Impedance Tests↗
PubMed1992

Plain abdominal radiography in the detection of major disease in children: a prospective analysis.

STUDY OBJECTIVE: To prospectively evaluate previously described high-yield clinical criteria for obtaining plain abdominal radiographs in the emergency evaluation of children. DESIGN: Prospective, observational study. SETTING: Emergency departments of a university medical center and an affiliated county hospital. PARTICIPANTS: Three hundred fifty-four children 15 years old or younger who underwent plain abdominal radiography during a one-year period. METHODS AND MEASUREMENTS: Physicians ordering plain abdominal radiographs completed data forms that included historical and physical examination information before viewing films. At a later date, records of all patients were reviewed for radiologist interpretation and final diagnosis. The data were analyzed to determine the sensitivity, specificity, and predictive values of previously described high-yield criteria (from a retrospective series) in detecting radiographs that were diagnostic or suggestive of "major" abdominal disease. MAIN RESULTS: Sixty-one patients (17%) had major diseases potentially requiring procedural intervention (eg, appendicitis, ingested foreign bodies, and intussusception), whereas 296 patients (83%) had minor diseases not requiring procedural intervention (eg, gastroenteritis and nonabdominal diagnoses). The presence of any of the following features--prior abdominal surgery, foreign body ingestion, abnormal bowel sounds, abdominal distention, or peritoneal signs--was 93% sensitive and 40% specific in detecting diagnostic or suggestive radiographs in patients with major disease. Positive and negative predictive values were 11% and 99%, respectively. If only these criteria had been used to obtain radiographs, 38% of films would have been omitted (at an estimated savings of $20,000) with only two suggestive radiographs missed. CONCLUSION: Our results suggest that restricting abdominal radiographs to patients with at least one of these five high-yield clinical features will detect most diagnostic and suggestive radiographs in children with major abdominal diseases.

Abdomen↗