Critical care in an emergency department

A one year review of resuscitation in an emergency department (ED) was conducted. In the stabilization room (SR) within the ED at Hennepin County Medical Center, 852 cases were treated in the year ending July 31, 1978. There were 166 deaths in the SR (19.5%) overall, and 141 (47.9%) and 16 (5.3%) for cardiac and trauma cases, respectively. The 32 fatal cases of blunt trauma (six in the SR, 10 within 24 hours, and 16 late deaths) were reviewed and assigned an injury severity score (ISS). Of these, 12 deaths were unrelated to central nervous system causes. These had an average ISS of 42.8.     

Hate crime violence and its emergency department management

As the 21st century approaches, the United States is moving, toward a more pluralistic society with regard to race, ethnicity, and national origin. With this increase in diversity has come a resurgence of hate crime violence. Scant information is available in the medical literature about hate crime violence, hate groups, hate crime violence legislation, or the physical and psychologic sequelae of hate crime violence on the individual and its effects on the community. Guidelines for the treatment of victims of hate crime violence in the prehospital care setting, ED, and inpatient setting are proposed.     

Ketorolac vs meperidine for the management of pain in the emergency department

OBJECTIVE: To compare the pain relief, sedation, and common side effect profiles of ketorolac tromethamine and meperidine for the management of acute pain in the emergency department (ED). METHODS: A prospective, double-blind, randomized clinical trial was conducted over a 12-month period using consecutive adult patients presenting to a university teaching hospital ED (annual census: 32,000), who required IM analgesia for acute pain. Adult patients with acute pain of various etiologies were randomly assigned to receive a single fixed IM dose of ketorolac (60 mg) or meperidine (100 mg). RESULTS: Ninety-three patients were enrolled in the study; 46 were randomized to meperidine and 47 to ketorolac. Using a visual analog scale, there was no difference in pain relief between the ketorolac and meperidine groups even after adjusting for baseline pain level. Ketorolac caused significantly (p < 0.005) less sedation than did meperidine at one hour. Rescue analgesia was required for seven of the 46 (15.2%) patients receiving meperidine and five of the 47 (10.6%) patients receiving ketorolac (p = NS). Seventeen of 45 (38%) patients receiving meperidine experienced side effects compared with eight of the 47 (17%) patients receiving ketorolac (p = 0.0452). CONCLUSIONS: When used to treat patients who had acute pain states, 60 mg of IM ketorolac produced analgesia similar to that produced by 100 mg of IM meperidine; however, the ketorolac produced fewer subjective side effects and less sedation than did the meperidine.     

Computer-aided-instruction in the emergency department

The Massachusetts General Hospital Laboratory of Computer Science created a library of computer-aided-instruction (CAI) programs in 1972. An experimental network of Cai programs, made possible by National Library of Medicine (NLM) support, was set up in July 1972, operating over commercial communication lines. Programs developed by Massachusetts General, Ohio State University and the University of Illinois Medical College were made available to users with terminals in about 36 cities through a local telephone number. During the first two years of the program over 80 institutions participated. A trial of the Massachusetts General programs, in conjunction with the Continuing Education Committee of the American College of Emergency Physicians, was conducted in five representative community hospitals. The hospitals put up the cost of the terminals and the telephone charges. Results of the study showed that 12 of the 40 (30%) emergency physicians in the target population took 10 or more programs. They gave the programs a favorable overall rating--1.6 on a scale of 1 (strongly positive) to 5 (strongly negative).     

Severe head injury: prehospital and emergency department management

Head trauma causes approximately 75,000 deaths each year in the United States. Both hypoxia and hypovolemia are individual predictors of poor outcome in the patient with severe head trauma. Management begins in the field and is focused on ensuring oxygenation and maintaining a blood pressure that supports cerebral perfusion. In the trauma center, intracranial pressure monitoring may be helpful in guiding the management of increased intracranial pressure. Mannitol, given in intermittent bolus infusions, is the therapy of choice for increased intracranial pressure. Hyperventilation has been shown to decrease cerebral perfusion and should be avoided; it is a temporizing procedure that is reserved for those cases that demonstrate signs of increased intracranial pressure pending initiation of other therapies.     

Quality improvement in the emergency department

A neonate born with a normal heart developed acute myocardial infarction at 12 days of age. Trivial mitral regurgitation secondary to fibrosis of posteromedial papillary muscle progressed to heart failure at 6 months of age. Mitral valve annuloplasty improved her condition.     

Computed tomography in the emergency department

We report a neonatal case of severe, life-threatening Kasabach-Merritt syndrome that was successfully treated with interferon-alpha: This patient had a huge hemangioma of the right leg and a general bleeding tendency. Although the condition initially responded to steroid and radiation therapy, after a relapse, no therapy including steroids, radiation, aspirin, and dipyridamole was effective. Because of severe thrombocytopenia and extension of the hemangioma to the pelvic region, surgical intervention was not indicated. Interferon-alpha therapy was started on day 61 of life. During the therapy the platelet counts increased by more than tenfold and reached the normal level in a month. The size of the hemangioma dramatically decreased. The administration of interferon-alpha might be indicated as a therapy for severe, life-threatening Kasabach-Merritt syndrome, especially when there is resistance to steroid or radiation therapy.     

Radiographic interpretation in the emergency department

This study examined the concordance of radiographic readings between emergency department (ED) attending physicians and radiologists in a community teaching hospital. In addition, the incidents of misinterpretations leading to an alteration in patient care were also reviewed. All radiographs obtained from January through October 1993 were initially interpreted by ED attending physicians with subsequent final review by attending radiology staff. Misread radiographs were placed into one of three categories. The groupings included overread radiographs with no change in treatment, underread radiographs with no change in treatment, and radiograph misinterpretations with a change in treatment. Of 15,585 radiographs obtained during the study period, there were 120 misreads; 12,099 (77.6%) of the 15,585 radiographs had an initial emergency physician interpretation. Radiographic misinterpretations included 7 (5.78%) overreads, 57 (47.1%) underreads, and 57 (47.51%) misreads requiring follow-up (MR-FU). The five most frequently misread radiographs were: abdominal, 12/247 (4.4%); rib, 3/99 (3.0%); foot, 13/621 (2.1%); hip, 3/152 (1.9%); and ankle 11/758 (1.4%). The most frequently obtained radiographs included: chest, 7,012 (0.33% MR-FU); cervical spine, 1,112 (0.18% MR-FU); ankle, 758 (0.66% MR-FU); knee, 633 (0.32% MR-FU); and foot, 621 (0.97% MR-FU). In this study, 99.0% of all emergency department radiographs were read correctly on initial review by ED attending physicians. Of all misread radiographs, less than half (46%) were deemed clinically significant and required a follow-up intervention.     

Violence in the accident and emergency department

We characterized the regression pattern of retinopathy of prematurity (ROP) for 266 infants examined over a 22-month period. Infants were included in the evaluation with a birth weight of less than or equal to 1500 g. Regression of retinopathy was observed in all but 11 infants, who were treated for threshold ROP. ROP limited to the peripheral retina resolved around term (40 weeks postconceptional age). Posterior ROP and/or stage 3 ROP underwent a protracted course of resolution, often not reaching zone 3 until 42 to 45 weeks after conception. Permanent retinal/vascular sequelae of ROP were observed in 10% of infants with ROP. The most common abnormality was failure to completely vascularize the temporal retinal periphery. Overall, retinal morbidity from ROP was an infrequent occurrence (18 of 266 premature infants--6.8%).     

Evaluation of syncope in the emergency department

Treatment of acute myocardial infarction has evolved significantly in the past two decades. Reperfusion therapies of thrombolysis and percutaneous angioplasty are major advances that can be employed to save infarcting myocardium and reduce mortality. When reperfusion therapy is combined with the use of aspirin, beta-blockade, heparin, and nitroglycerin, the emergency management of the patient with myocardial infarction can be completed. Outcomes in patients are determined by what happens in the first few minutes to hours after onset, and any delay in diagnosis or treatment may have significant consequences. This article reviews intervention and treatment strategies for acute myocardial infarction.     

Evaluating chest pain in the emergency department

1. Purification of horse-liver glutathione reductase was obtained by affinity chromatography on N6-(6-aminohexyl)-adenosine-1'5'-bisphosphate Sepharose (N6-2'5'-ADP-Sepharose) and Reactive Red-120-Agarose, and chromatography on DEAE-Sephadex and Sephacryl S-300. 2. The final preparation had 248 U/mg specific activity after 11,174-fold purification with 47% final recovery, and was homogeneous by SDS-electrophoresis. It showed charge heterogeneity in non-denaturing electrophoresis and chromatofocusing, with several peaks of pI between 5.7 and 6.7. 3. The enzyme was homodimeric (107,000 native MW), with S20w = 6.31 S, and 41.22 A of hydrodynamic radius. It showed absorption peaks at 270, 370 and 462 nm, a characteristic of flavoproteins. 4. When NADPH was substituted by deamino-NADPH or NADH the enzyme showed 69 and 8.5% activity, respectively, while with glutathione-CoA mixed disulfide the enzyme had 23% of the activity shown with GSSG. Apparent Km values of 8.8, 680, 59, and 560 microM were measured for NADPH, NADH, GSSG and ferricyanide, respectively.     

Neuromuscular blocking agents in the emergency department

The pbp4 gene of a Staphylococcus aureus strain selected stepwise in vitro for growth on increasing concentrations of penicillin and of its susceptible parent strain showed overall identity except in the promoter region. In the mutant a deletion upstream of the pbp4 structural gene removed 90 nucleotides (nt) that were framed by a 12 nt inverted repeat. This deletion occurred in step 4 of the in vitro selection procedure and was paralleled by a significant increase in the penicillin-binding protein 4 (PBP4) production. The in vitro step selected mutant showed a remarkable increase in the cross-linking of the peptidoglycan compared to its parent. This was linked to morphological changes in the appearance of the cells, which were surrounded by a very thick and fuzzy cell wall.     

Public complaints and the emergency department

The effect of various cytokines including rIL-1, rIL-2, rIL-3, rIL-4, rIL-6, and growth factors including rNGF, rILGF and rEPGF on the post transplant immunodeficiency after allogeneic bone marrow transplantation was explored in 8 patients. The results show that neither cytokine alone was able to increase the proliferative capability in post transplant lymphocytes, however, when added in conjunction a significant increase in PHA driven proliferation was noted. Any significant lack of growth factors is probably not the only cause of immunodeficiency post transplant, since addition of any of these compounds did not have any influence on the lymphocyte proliferation, and so the data presented here suggest that therapeutic application of any of the investigated cytokines or growth factors to such patients is unlikely to be successful in overcoming the defects of T cell function post grafting.     

The management of dental problems presenting to an accident and emergency department

Patients with dental diagnoses, not necessarily traumatic, often present to accident and emergency departments and general medical practitioners. Few doctors have received much, if any, education in the management of these patients. A 6 month prospective study revealed 107 patients (0.3% of new attenders) attending the accident and emergency department of Glasgow Royal Infirmary. Only 19 of these had suffered trauma. Medical staff in the department were only rarely able to make any diagnosis, and management of these patients took place on an empirical, symptomatic basis. Management could be improved by better education of medical students and doctors. Use of an algorithm may be appropriate.     

Caring for Cambodian refugees in the emergency department

BACKGROUND: Platelet utilization has steadily increased throughout the past three decades. At the same time, there has been very little study of the current transfusion practices. STUDY DESIGN AND METHODS: A survey was conducted of institutional members of the American Association of Blood Banks (hospitals) that were actively involved in the care of pediatric and/or adult hematology and/or oncology patients. Inquiries were made relating to the extent of prophylactic versus therapeutic use of platelets, criteria used for prophylactic transfusion of platelets and type, and dose of platelets used. Data were analyzed according to patient age and type of hospital. RESULTS: Of 786 responding hospitals, 630 (80.2%) provided sufficient data for analysis; 126 of that 630 provided care for pediatric patients. The majority (60.9%) of responding hospitals had a minimum of four hematologists and/or oncologists. Eighty-four percent of hospitals reported transfusing some apheresis platelets. The dose of platelet concentrates most frequently used for adults ranged from 6 to 10, with pools of 10 more commonly used in community hospitals. More than 70 percent of hospitals reported transfusing platelets primarily for prophylaxis: 60 percent of hospitals set the threshold platelet count for prophylactic platelet transfusion at 20,000 per microL, with approximately 20 percent each transfusing at higher and lower levels. A platelet count of 50,000 per microL was most frequently required for performance of a minor invasive procedure. CONCLUSION: The data from this study show that the majority of institutions use prophylactic platelet transfusion in both pediatric and adult hematology and/or oncology patients. However, there is considerable variation in platelet transfusion practice.