Preliminary experience with transluminal laser-induced intrahepatic portacaval shunts

This article outlines the objectives for a resident rotation on a pediatric emergency medicine service that is geographically separate from adult-oriented facilities. In this setting, pediatric emergency department care is considered an off service. However, these objectives incorporate key pediatric knowledge and techniques in a practical format for emergency medicine trainees who have no separate pediatric emergency department experience. The content of the pediatric emergency department educational exposure can be attained in a concentrated 2-month exposure at a pediatric facility or extracted throughout the course of multiple pediatric encounters at a general emergency department. These objectives are a part of a continuing series on the goals and objectives to direct emergency medicine resident training on off-service rotations.     

Unusual headaches

Headache represents one of the most common somatic complaints seen in the emergency department, accounting for 1% to 3% of all emergency department visits. Although most headaches seen in the emergency department are benign, as many as 10% of all headaches are secondary to an underlying pathologic condition. The emergency physician is well-trained to exclude stoke, subarachnoid hemorrhage, and meningitis as potential causes of headache. This article focuses on seven unusual headache syndromes, all of which are associated with significant morbidity and mortality. Particular emphasis is placed on clinical features and diagnostic modalities of choice.     

Effect of dietary administration of oil extracts from rosemary and sage on lipid oxidation in broiler meat

The aim of this study was to propose a method for calculating the costs incurred by the passage of a patient through an emergency department and to show that the scheme for clinical classification of emergency patients known as CCMU (Classification Clinique des Malades des Urgences) can identify groups of patients with different costs and non-medical care loads. All cases seen in the emergency department of a French hospital over an 8-week period were prospectively included. All non-medical and medical procedures, CCMU and GEMSA (Groupe d'Etude Multicentrique des Services d'Accueil) categories were recorded. Accounts for the same period were analysed in order to determine the true cost of each patient's passage through the emergency department. Qualitative data were analysed by ANOVA and logarithmic regression. The median cost of a patient's passage through the emergency department was 322 FF. CCMU identified groups of patients, including those with psychiatric problems, with very different non-medical care loads and costs, the latter varying from 158 FF (CCMU I) up to 1823 FF (CCMU V). This classification could be used as one of the elements defining homogenous groups of emergency department patients in future.     

Beyond the twelve-lead electrocardiogram: diagnostic tests in the evaluation for suspected acute myocardial infarction in the emergency department, part I

On a daily basis the emergency physician is faced with the difficult task of determining whether or not a patient with acute chest pain is sustaining an acute myocardial infarction. In most cases, this is not a straightforward decision. Although observation units are being used more often for chest pain evaluations, many emergency physicians currently admit such patients to an intensive care setting. Because fewer than one-third of emergency department chest pain patients actually suffer an acute myocardial infarction, expensive resources are, in retrospect, used unnecessarily. Conversely, patients who are infarcting, and are inadvertently discharged home from the emergency department, have a worse prognosis than those admitted. This two-part series reviews the newer modalities available that may help the emergency physician arrive at a more accurate diagnosis. The current article, Part I, examines the use of myocardial imaging, computer assisted diagnostic protocols, and newer uses of the electrocardiogram. Part II reviews the use of biochemical assays of cardiac proteins and the Chest Pain Observation Unit.     

Quality development at an emergency unit--an intervention study based on consumer satisfaction

A study among the users of an emergency department was carried out to assess user satisfaction, based upon a questionnaire. The study was split into two periods, before and after a change in procedure in the emergency department, namely that a nurse was to give information about waiting time, make coordinations and fix an order of priority of patients (triage) in the waiting room. Fourteen hundred and twenty-six answers were received, 794 before and 632 after the change. The users questioned after this change of procedure felt that they had been better received, that they had waited for a shorter time and described a better general experience as compared to the users questioned before the change, these differences were significant. There were no difference between the two groups concerning opinions on information about diagnosis, treatment and outcome, whether there was enough time for examination, treatment and information, whether the staff were obliging or whether their expectations had been fulfilled. It is concluded that such changes in procedure in the emergency department are to be recommended.     

Antibiotic use in prosthetic device infections

The incidence of prosthetic infections presenting to the emergency department is constantly increasing as the number of patients with prostheses grows. Our first duty as emergency physicians is to maintain a high index of suspicion for prosthetic infection in patients presenting with prosthetic dysfunction or fever. Optimal cultures must be obtained before instituting antimicrobial therapy. In stable patients, this may preclude starting antibiotics in the emergency department. The diversity of prosthetic infections and the need for accurate treatment in order to reduce the morbidity, mortality, and economic costs requires an in-depth knowledge of the microbiology and pharmacologic management of such infections. Except in the case of prosthetic heart valves, prophylactic antibiotics are rarely indicated and their use should be based on judicious clinical decision making.     

Obstetric and gynecologic emergencies

This article reviews the pearls and pitfalls of obstetric and gynecologic emergencies occurring in women presenting to the emergency department. Some pitfalls include failure to screen for ectopic pregnancy, tachycardia as an unreliable indicator of a ruptured ectopic pregnancy, and the use of serum hCG as a testing procedure during pregnancy. Updates include serologic markers of ectopic pregnancy, ultrasonography in the emergency department, methotrexate treatment of ectopic pregnancy, traumatic placental separation, and fetomaternal hemorrhage.     

Role of technetium-99m sestamibi myocardial imaging in the emergency department evaluation of chest pain

The use of technetium-99m sestamibi myocardial imaging is rapidly becoming a state of the art methodology for the emergency department evaluation of patients with chest pain. The following case report represents the first emergency department sestamibi scan ordered at the University of Mississippi Medical Center and is used to discuss the logistics and indications for such tests. A general guideline for ordering sestamibi scans has been developed for use in the emergency department.     

Stroke: a stranger among the people

INTRODUCTION: Lack of awareness of warning signs of stroke is a factor that contribute to late patient arrival to the emergency department. OBJECTIVE: The goal of this pilot study was to determine the baseline knowledge of stroke among the population (terminology, signs-symptoms, risk factors and attitude) prior to educational campaigns. PATIENTS AND METHODS: A population-based interview using closed-ended questions was conducted by neurologists among 100 users of the Vall d'Hebron's Primary Health Center, randomly sampled. RESULTS: In our population a 9% unknowns totally the disease, of the remainder, 42% has a good knowledge of signs-symptoms and 46% of risk factors. Only 22% of the sample has good global knowledge of the disease. If suffering a stroke this population should seek medical attention through 911 (46.2%) or come directly to the emergency department (50.5%). If symptoms were gone away, transient ischemic attack (TIA), appears a trend to contact primary physicians (59.3%). Respondents aged > 65 years were less likely to recognize symptoms (p = 0.001) and to consider stroke as an emergency. Respondents with an affected relative (50.5%) tend to locate more exactly the disease at the brain (p = 0.05) and to arrive earlier to the emergency department (p = 0.045), than those with non-affected relatives. CONCLUSIONS: Less than a quarter of our population have a good knowledge of the disease. Stroke is considered an emergency unlike TIA. The information about stroke is theoretically associated with early presentation to the emergency department. These results permit a redesign of the questionnaire to conduct a second phase of the study and generalize them for the Spanish population.     

Kojic acid production by Aspergillus flavus using gelatinized and hydrolyzed sago starch as carbon sources

Radiography in an emergency setting is a demanding task, in technical as well as in logistical terms. Rapid acquisition of high quality radiographs under difficult conditions, for example severely injured patients with multi-organ trauma is important. All image data and radiological reports must be transmitted to the trauma surgeon as soon as possible. To meet these needs with the promising means of modern X-ray technology, we decided to implement a completely digital X-ray division inside the new outpatient trauma department. In the setting of an outpatient emergency department digital radiography and PACS cannot be realised without problems. We present our first experience with the installation and 10 month filmless routine in the X-ray division for traumatology outpatients at the university of Innsbruck department of radiology.     

Osteoporosis in men

The study described here is part of an evaluation of a pilot project concerning the implementation of three psychiatric crisis units in general hospitals in Belgium. The purpose was to evaluate the short-term outcome of a multidisciplinary crisis intervention for psychiatric patients referred to the emergency department. Patients were assessed with the General Health Questionnaire (GHQ-28) at the time of referral to the emergency department and again 1 month later. Patients referred for a psychiatric crisis intervention were compared with patients receiving short-term psychiatric inpatient treatment in another hospital. Patients referred to the emergency department showed a considerable degree of psychiatric disturbance. The General Health Questionnaire appeared to be a good measure for assessment of the "state" aspect of a psychiatric disturbance. The state of distress was significantly reduced one month after referral in both treatment conditions. Nevertheless, an important proportion of patients remained in a state of considerable distress. The results indicate that a short hospital-based crisis intervention approach is comparable with more traditional acute inpatient treatment. However, in the case of more severely distressed patients it may be insufficient. Several limitations of this study are also discussed (risk of overestimation of improvement, influence of time or pre-existing differences).     

Relation of out of hours activity by general practice and accident and emergency services with deprivation in Nottingham: longitudinal survey

OBJECTIVES: To investigate the relation between out of hours activity of general practice and accident and emergency services with deprivation and distance from accident and emergency department. DESIGN: Six month longitudinal study. SETTING: Six general practices and the sole accident and emergency department in Nottingham. SUBJECTS: 4745 out of hours contacts generated by 45,182 patients from 23 electoral wards registered with six practices. MAIN OUTCOME MEASURES: Rates of out of hours contacts for general practice and accident and emergency services calculated by electoral ward; Jarman and Townsend deprivation scores and distance from accident and emergency department of electoral wards. RESULTS: Distances of wards from accident and emergency department ranged from 0.8 to 9 km, and Jarman deprivation scores ranged from -23.4 to 51.8. Out of hours contacts varied by ward from 110 to 350 events/1000 patients/year, and 58% of this variation was explained by the Jarman score. General practice and accident and emergency rates were positively correlated (Pearson coefficient 0.50, P = 0.015). Proximity to accident and emergency department was not significantly associated with increased activity when deprivation was included in regression analysis. One practice had substantially higher out of hours activity (B coefficient 124 (95% confidence interval 67 to 181)) even when deprivation was included in regression analysis. CONCLUSIONS: A disproportionate amount of out of hours workload fell on deprived inner city practices. High general practice and high accident and emergency activity occurred in the same areas rather than one service substituting for the other.     

Emergency department visits and hospitalizations for respiratory disease on the island of Hawaii, 1981 to 1991

This study examined trends in and patterns of emergency department visits and hospitalizations for respiratory disease on the island of Hawaii from 1981 to 1991. We found that emergency department visit rates and hospitalization rates for both asthma and COPD for 1987 to 1991 increased in all regions of the island in comparison with such rates for 1981 to 1986. Rates of emergency department visits and hospitalizations for chronic obstructive pulmonary disease or COPD, but not asthma, were significantly higher in the high-exposure Kona side of the island than in the intermittent-exposure Hilo side of the island during 1983 and 1988 to 1990. We also found that during the weeks that winds were from the west, blowing volcanic air pollution toward Hilo, emergency department visits for asthma increased 15%. Some of the results of our study support the hypothesis that volcanic air pollution affects respiratory health on the island of Hawaii, while other results do not. Any future studies should include measurements of air pollutant levels.     

Unnecessary emergency transport and care of grand mal seizures

Every source quoted in this study has clearly refuted the need for emergency transport and care of an uncomplicated grand mal seizure in a managed epileptic patient. This review of a large patient population has determined that 27% of emergency department seizures were uncomplicated and occurred in patients already under care. This represented 0.25% of all emergency department visits and nearly $200,000 in claims to this managed care entity per year. Taking some statistical liberties, a national health care expenditure of $270,000,000 is suggested for this single abuse. It is hoped that further education of the public, medical community, and epileptic patients will produce a comfort level that permits decisions about emergency transport and care of seizures. These savings could translate into basic health insurance for thousands of our medically deprived citizens.     

Golf related head injuries in children: the little tigers

Head injury is a major cause of morbidity in Western society and sport related incidents account for approximately 11% of all head injured patients attending Accident and Emergency Departments. Golf was shown to be one of the sports most commonly associated with head injury requiring referral to a regional neurosurgical centre. Previous studies have demonstrated that it is predominantly children who sustain golf related head injuries which present either to an accident and emergency department or a regional neurosurgical centre. This study examines the number and pattern of golf related head injuries in children presenting to an accident and emergency department or requiring admission to the regional neurosurgical centre, over a three month period.     

Children''s return to school after treatment for cancer: study days for teachers

We present a case of benign paradoxical vocal cord adduction' presenting to the emergency department as acute stridor. This patient received direct laryngoscopy at initial presentation documenting inspiratory vocal cord adduction. The syndrome is not well known to emergency physicians and, because it often mimics life-threatening airway compromise, prompt recognition of the benign nature of this syndrome may avert more aggressive airway interventions such as beta agonists, steroids, endotracheal intubation and tracheostomy. Successful treatment has included relaxation, sedatives and speech therapy to abort the acute attack and prevent further recurrence. As direct flexible laryngoscopy is more readily available in the emergency department, goals for the future are more rapid diagnosis and appropriate treatment of this benign syndrome.     

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.     

Left ventricular aneurysm and peripheral embolism as cause of atypical foot pain

Sudden occlusion of a peripheral artery by embolization or acute thrombosis results in acute ischemia. This is most commonly associated with sudden onset of severe pain, numbness and pallor. Chronic ischemia from peripheral vascular disease results in intermittent claudication. We present a case of peripheral embolization from a left ventricular aneurysm in a previously asymptomatic male who presented to the emergency department complaining of two weeks of pain in his left great toe. Included in the discussion are important diagnostic tests for peripheral thromboembolism and ventricular aneurysm as well as suggestions for emergency department management.     

Accidental hypothermia: a review of 62 cases

A retrospective review of all patients seen in an urban city-county emergency department over a 32-month period with a primary or associated diagnosis of hypothermia was performed using the emergency department encounter form and the inpatient chart of 62 cases (59 patients) with core temperatures of 35 C (95 F) or below. With this relatively large population, a general conclusion was reached about the presentation and natural history of this interesting entity. This permitted a defensible treatment regimen which is currently employed a this institution and which is offered for institutions in similar settings. The variance in clinical signs, laboratory values, electrocardiographic findings and complications encountered in this study are detailed against the background of a review of the findings of the current literature.     

Hysterical emergencies

Most probably common in emergency departments, but still not well studied in this context, the disorders formerly called "hysteria" are now included in the group "Somatization, undifferentiated somatoform, conversion and dissociative disorders" (SSCD disorders) DSM IV. Their common presentation is that of idiopathic somatic symptoms linked with mental disorders. In the emergency department these symptoms confront physicians who generally do not have extensive psychiatric training. The symptoms occur, and disappear, undetermined by the patients, who are genuinely ill and not malingering. Aside from the somatisation disorder, which by definition is chronic, invalidating and rare, the other disorders (SCD) can: be contingent on the picture of another acute, easily recognisable mental disorder; or, on the other hand, be highly reactional and transient; or constitute the "somatic presentation" of an anxious disorder, the panic attack, well known in somatic emergencies. Management is based on diagnostic considerations and by the difficulties of the patient to accept a psychic cause of the symptoms whereas he is experiencing an organic disorder. The possibilities of discussing such psychogenesis in the context of the emergency department are slight, and the best course is often to adopt a pragmatic and prudent medical approach. An essential point is respect of the patient and his ideas. The legal provision, which already exists, for the presence of psychiatrists in emergency departments should lead to physician-psychiatrist cooperation that would be beneficial for these patients.