Benzyl alcohol with epinephrine as an alternative to lidocaine with epinephrine.

A randomized, prospective, double-blind study comparing benzyl alcohol with epinephrine, 1:100,000 (BA), and lidocaine with epinephrine, 1:100,000 (LID), as local anesthetics was carried out on adult patients with simple lacerations. The two study groups were compared for pain of infiltration (100 mm visual analog scale) and need for additional anesthesia. Pain scores were compared by a Mann Whitney Independent Rank Sum test and need for additional anesthesia by a Fishers Exact test. A total of 52 subjects (26 per group) were analyzed. The groups were similar in demographics and wound characteristics. The median pain score for BA, 7.5 mm, was less than for LID, 19.5 mm (p = 0.049). Although more patients receiving BA required additional anesthesia as compared to LID (8/26 versus 2/26), this difference did not reach statistical significance. BA is a reasonable alternative local anesthetic to LID for patients who are allergic to LID.

Home antipyretic use in children brought to the emergency department.

OBJECTIVE: To determine how often children with a complaint of fever receive antipyretics at home and if any demographic factors are associated with correct dosing. METHODS: A prospective, descriptive study of children 3 to 36 months old presenting with complaint of fever was conducted. Caregivers were questioned about demographics and antipyretic given. The ability of demographics to predict proper dosing was tested first individually and then with a regression model. The effect of proper home dosing on presence of fever and height of fever was also analyzed. A total of 138 children were analyzed. RESULTS: Of the 118 (86%) who received antipyretics at home, only 47% had been given a proper dose. No demographic variable predicted proper dosing. CONCLUSION: Reported antipyretic dose at home did not predict presence of fever or height of temperature measured in the emergency department.

Empiric treatment of gonorrhea and chlamydia in the ED.

A retrospective study was conducted on female patients who were screened for Chlamydia trachomatis and Neisseria gonorrhea. The purpose of the study was to determine if any factors predict empiric therapy at the index visit. Of 911 patients enrolled in the study, 100 were found to have positive DNA screens and 54 were given empiric therapy. A logistic regression was used to test the ability of age, ethnicity, DNA probe result and provider type (physician or midlevel provider), to predict empiric treatment. DNA probe result and provider type were the only 2 factors that were found to predict empiric therapy. A subsequent analysis using a Cochran-Mantel-Hanszel test to control for DNA probe result revealed that the provider type remained the only variable that predicted empiric treatment.

Accuracy of estimation of external blood loss by EMS personnel.

BACKGROUND: Emergency Medical Services (EMS) personnel provide care in the out-of-hospital setting. The EMS report, including blood volume estimates, influences hospital management. Our objective was to assess the accuracy of EMS blood volume estimates. METHODS: In this prospective, observational study, EMS providers were asked to view four simulated blood loss scenarios in random order. Each scenario used a specific volume of spilled blood corresponding to the loss likely to cause the four classes of hemorrhagic shock. Estimates are reported using median and interquartile ranges. RESULTS: Ninety-two EMS providers gave 368 estimates. Only 8% were within 20% of the actual volume. Furthermore, only 24% were within 50% of actual volume. There was no correlation between accuracy and any demographic variable, level of training, or years of EMS experience. CONCLUSION: EMS personnel are unable to estimate "blood" volume accurately irrespective of level of training.

Outcomes of admitted geriatric trauma victims.

Conflicting data exist as to the outcome of elderly victims of trauma. With recent improved outcomes for functional recovery, aggressive management of these patients has been advocated. The purpose of this study is to determine outcomes of admitted elderly trauma victims based on initial mechanism of injury and the degree to which other factors affected their overall outcome. A prospective study involving admitted patients > or =65 years was performed at an urban university center from September 15, 1996 until August 31, 1997. Patients sustaining any potentially serious form of trauma were included. Data about mechanism of injury (MOI), comorbid conditions, preinjury medications, types of injuries sustained, length of stay, functional outcome, and ultimate disposition were recorded. Two hundred thirty-nine consecutive patients were enrolled. Mean age was 78.1 +/- 8.1 years. There were 130 women (54%) and 109 men (46%). MOI was as follows: 132 low-mechanism falls (LMFs), 64 high-mechanism motor vehicle crashes (HMMVCs), 22 high-mechanism falls (HMFs), 8 pedestrian versus car (PVCs), and 13 other types. Mean length of stay surviving beyond the ED was 12.9 days. 8 patients were either DOA or died in the ED. There were 19 in-hospital deaths. Deaths were seen in 14% of HMMVCs, 13.6% HMFs, 9.1% LMFs, 25% PVCs, and 7.7% for other mechanisms. Overall outcomes by mechanism were categorized as functional (or baseline), fair, alive but poor, and dead. Functional outcomes were seen in 76.6% of HMMVCs, 81.8% of HMFs, 84.1% of LMFs, 50% of PVCs, and 84.6% for all other injuries. Forty-five percent were discharged home, 26% went to rehabilitation units, 16% went to nursing homes, and 11% died; the remaining 2% were either transferred to a psychiatric facility or to another hospital. Preexisting comorbid conditions did not appear to play a significant role in the ultimate outcomes of these patients. Severity of injury was the leading determinant of death, but severely injured patients often had functional outcomes. Elderly trauma victims most often achieve functional outcomes despite multiple or severe injuries.

Geriatric trauma: outcomes of elderly patients discharged from the ED.

This study was undertaken to investigate which patients 65 years of age or older have adverse outcomes after discharge from the emergency department (ED) after an injury. Patients were enrolled prospectively at an urban university center from September 15, 1996, until August 31, 1997. Patients sustaining any potentially serious form of injury were included. Data about comorbid conditions, preinjury medications, and types of injuries sustained were recorded. Patients were contacted at home at least 30 days after discharge and were questioned about their overall health, need for admission since ED discharge, and whether any complications developed. One hundred five consecutive patients were enrolled, but 5 patients were lost to follow-up. There were 74 low-mechanism falls (LMFs), 11 low-mechanism motor vehicle crashes (LMMVCs), 8 high-mechanism motor vehicle crashes (HMMVCs), 3 high-mechanism falls (HMFs), and 4 other types of injuries. Follow-up ranged from 30 to 147 days, with a mean of 49 days. On follow-up, 88 patients were doing well, 9 were fair, and 3 were doing poorly; of the latter, their poor health was unrelated to their injuries. Complications included 2 extremity infections and 1 poorly healing wound. Eleven patients were seen in an ED within the first 30 days after injury, 6 of whom for problems related to their initial injury or its management. These results show that there is a subset of elderly victims of trauma who may be safely discharged home after appropriate evaluation. Return visits to the ED were just as often related to comorbid conditions as to initial injury.

Nitrous oxide for the treatment of acute migraine headache.

The objective of this study was to determine the efficacy of nitrous oxide in the therapy of acute migraine symptoms in emergency department (ED) patients. This was a prospective, randomized, double blind study of patients presenting to an ED. All eligible patients had a prior diagnosis and symptoms consistent with migraine headache and a normal neurological examination. Patients were randomized to receive either 50% nitrous oxide and 50% oxygen or 100% oxygen over 20 minutes. All patients completed a visual analog pain scale before and immediately after intervention. Initial pain scores and change in pain scores between the two groups were compared. There were 22 patients enrolled, 10 in the nitrous oxide group and 12 in the oxygen group. The groups were similar in age, gender, duration of headache, and initial pain scores. Pain scores decreased significantly in the nitrous oxide group (median change, 69 to 21 mm, P = .02). The oxygen group did not show significant change in pain scores (median change, 78.5 to 72, P = .09). Eighty percent of patients receiving nitrous oxide required no rescue medication at the completion of the intervention, compared with 17% of those receiving 100% oxygen (P = .008). Twenty minutes after termination of intervention, 60% of patients who had received nitrous oxide still required no rescue medication, compared with 8% of those who had received 100% oxygen (P = .02). Nitrous oxide shows efficacy in ED short-term treatment of acute migraine headache.

Outcomes of anticoagulated trauma patients.

Patients on warfarin are at high risk for potentially life-threatening hemorrhage even after relatively minor trauma. Outcomes of these patients and the potential complications of reversing the effects of anticoagulation have received little attention. This study was performed to determine the overall outcome of orally anticoagulated patients who sustained injury as well as to determine any untoward effects of reversing their anticoagulated states. A retrospective study of injured patients on warfarin was conducted on patients admitted to an urban, university, tertiary-referral, level I trauma center between 1/1/93 and 12/31/96. Surviving patients were followed for a period of at least 1 month. Injuries were grouped by anatomic site. Charts were reviewed for degree of anticoagulation on admission (ie, initial international normalized ratio [INR]), survival, adverse effects of reversal of anticoagulation, and reinstitution of warfarin therapy. Discharged patients were contacted at home for follow-up. Thirty-five consecutive patients, 18 men and 17 women, on warfarin therapy at the time of their injuries were reviewed. The mean age was 75 years, with a range of 39 to 96. The mean follow-up period was 12.7 months. Reasons for anticoagulation included atrial fibrillation, prosthetic heart valves, revascularized limb, hypercoagulable state, deep venous thrombosis, pulmonary embolism, phlebitis, and aortic stenosis. Mean admission INR was 3.2, with a range of 1.6 to 10.0. There were 8 in-hospital deaths. Intracranial hemorrhages accounted for the majority of injuries. Ten patients were not given reversal therapy. Four complications were attributable to reversal therapy (upper extremity hemiplegia, transient ischemic attack, deep venous thrombosis, arterial thrombosis). Twenty-one patients had their warfarin reinstituted. Follow-up of surviving patients ranged from 1.5 to 42 months. Patients on warfarin are at high risk for intracranial hemorrhage following trauma. Patients on warfarin may be reversed during the acute period following injury, but transient complications may arise. Further prospective studies need to be conducted to determine which anticoagulated trauma patients may not require reversal therapy.

Accuracy of an enzymatic assay device for serum ethanol measurement.

OBJECTIVE: To determine the accuracy of an enzymatic assay of serum to measure blood ethanol levels in the emergency department. METHODS: A blinded, prospective study of emergency department patients for whom a blood ethanol was ordered and performed. After skin prep with betadine, two blood samples were drawn into separate sodium fluoride-containing vacutainers. One sample was sent to the hospital laboratory for blood ethanol analysis. The other was centrifuged for 5 minutes and the serum was then assayed using the QED A350 Saliva Alcohol Test. Values were then compared by kappa statistic and Pearson's correlation. Sensitivity and specificity calculations were determined for the QED device to detect a blood ethanol > 100 mg/dL. RESULTS: Sixty-six patients were enrolled. The kappa value for QED compared to lab blood ethanol was 0.93. The Pearson's correlation coefficient was 0.94. The QED, in general, tended to overestimate blood ethanol slightly. The QED was 100% sensitive and 82% specific in detecting a blood ethanol > 100 mg/dL. CONCLUSIONS: Analysis of serum using a QED A350' is a sensitive and accurate index of low to moderate increases in blood ethanol appropriate to emergency department, but not legal, interpretation.

Randomized trial of diphenhydramine versus benzyl alcohol with epinephrine as an alternative to lidocaine local anesthesia.

STUDY OBJECTIVES: We compared the pain of infiltration and anesthetic effects of.9% benzyl alcohol with epinephrine, 1% diphenhydramine, and.9% buffered lidocaine. METHODS: A prospective, randomized, double-blind study comparing benzyl alcohol, diphenhydramine, and lidocaine was carried out on adult volunteers. Each subject received all 3 injections in a standardized manner. Pain of infiltration was measured on a 100-mm visual analog pain scale and analyzed with a Kruskal-Wallis test. Duration of anesthesia was assessed at 5-minute intervals for a maximum of 45 minutes and compared with the use of survival analysis techniques by a log-rank test. Return of sensation by 45 minutes was evaluated with an exact chi2 test. All tests were 2-tailed, with significance defined as P <.05. RESULTS: Thirty subjects were enrolled. The diphenhydramine median pain score was 55 mm, compared with 12.5 mm for lidocaine and 5 mm for benzyl alcohol (P =.001). Pairwise comparisons showed that all possible combinations were statistically significant. The 3 anesthetics were different with respect to duration of anesthesia (P <.001). Pairwise comparisons revealed a longer duration of anesthesia for lidocaine than for diphenhydramine or benzyl alcohol, but no significant difference was found between diphenhydramine and benzyl alcohol. Pain sensation returned within the 45-minute study period in only 3 of 30 lidocaine injections, compared with 11 of 30 benzyl alcohol injections and 19 of 30 diphenhydramine injections (P =.001). CONCLUSION: Benzyl alcohol is a better alternative than diphenhydramine as a local anesthetic for lidocaine-allergic patients.

Local anesthesia for lacerations: pain of infiltration inside vs outside the wound.

OBJECTIVE: To compare the pains of infiltration of a local anesthetic for simple lacerations when used from within the wound vs through intact skin. METHODS: A randomized, prospective, single-blind, experimental protocol was conducted on a convenience sample of adults with simple lacerations. Subjects received two 0.5-mL injections of buffered lidocaine in each of the sites being compared. Immediately following each injection, pain was measured using a visual analog pain scale. Pain scores were converted to a numerical score and analyzed by a Wilcoxon signed-rank test. Subjects also were asked which injection hurt more, the first or the second (analyzed by a chi2 test). RESULTS: A total of 63 subjects were enrolled. The first injection was within the wound and the second injection through intact skin (group 1) for 32 patients, and the order was reversed for 31 patients (group 2). Median pain scores for all inside-the-wound injections (14 mm) were lower than those with intact skin injections (37 mm; p < 0.0001). In group 1, 4 subjects reported the first injection (within wound) hurt most, 23 thought the second (intact skin) hurt most, and 5 found no difference. In group 2, 18 subjects reported the first injection (intact skin) hurt most, 5 believed the second injection (within wound) hurt most, and 8 found no difference, p < 0.0001. CONCLUSION: Local anesthesia is less painful when injected from within a laceration as compared with intact skin.

The effect of order on pain of local anesthetic infiltration.

OBJECTIVE: To define the relationship between order of injection and pain of infiltration of buffered lidocaine. METHODS: Volunteers > or = 18 years of age were enrolled in a prospective, double-blind experimental protocol. Subjects received a 0.5-mL intradermal injection of anesthetic in each forearm. All injections were given by the same individual in the same manner. Immediately following each injection, the subjects rated the pain of infiltration on a standardized 100-mm visual analog pain scale. Both the subjects and the individual giving the injections were blinded to the anesthetic being administered. They were told that the injections could be either plain or buffered lidocaine. They were further informed that any individual subject could receive 2 of the same anesthetics or 1 of each in either order. In reality, all injections were buffered lidocaine for all subjects. Pain scores were converted to a numerical score by making measurements to the nearest millimeter and analyzed by a Wilcoxon signed-rank test with p < 0.05 considered significant. RESULTS: Fifty subjects were enrolled. The first injection had a median pain score of 13.5 mm, compared with 23.5 mm for the second (p = 0.007). CONCLUSION: The second injection of buffered lidocaine was found to be statistically more painful than the first in this protocol that controlled for all variables except for order of injection. Future studies involving paired comparisons should take this information into account.

Injuries distracting from intraabdominal injuries after blunt trauma.

While most conscious patients with severe intraabdominal injuries (IAI) will usually present with either abdominal pain or tenderness, there is a small group of awake and alert patients in whom the physical examination will be falsely negative because of the presence of associated extraabdominal ("distracting") injuries. We sought to define the types of extraabdominal injuries that could lead to a false negative physical examination for potentially severe IAI in adult victims of blunt trauma. This study was prospectively performed on consecutive blunt trauma patients over a 14-month period in our level I trauma center. Inclusion criteria were as follows: (1) Glasgow Coma Scale score of 15; (2) age 18 years or older; and (3) computed tomography (CT) of the abdomen or diagnostic peritoneal lavage (DPL) performed regardless of initial physical examination findings. Patients were questioned specifically about the presence of abdominal pain and the initial abdominal examination was documented in addition to other extraabdominal injuries. Abdominal injuries were considered to be present based upon either abdominal CT findings or a positive DPL. Patients with and without abdominal pain or tenderness were compared for the presence of IAI. A total of 350 patients were enrolled. There were 142 patients with neither abdominal pain nor tenderness (group 1) and 208 patients with either or both (group 2). Ten of the 142 patients (7.0%) in group 1 had IAI compared with 44 of the 208 patients (21.2%) in group 2 (P = .0003). Presence of pain and/or tenderness had a sensitivity of 82%, a specificity of 45%, a positive predictive value of 21%, and negative predictive value of 93%. All 10 patients in group 1, and 36 of the 44 group 2 patients, had associated extraabdominal injuries. Although the presence of abdominal pain or tenderness was associated with a significantly higher incidence of IAI, the lack of these findings did not preclude IAI.

Incidence of aspiration after urgent intubation.

This study sought to determine the incidence of aspiration after urgent endotracheal intubation (ET) performed in the emergency department (ED), and to offer a descriptive evaluation of these intubations. In a retrospective review of 133 charts, 87 patients met inclusion criteria. Aspiration occurred in 3 (3.5%) patients (95% confidence interval, 0%, 7.4%). One had witnessed aspiration, and 2 had positive sputum cultures. None of the 87 patients had a positive chest radiograph or unexplained hypoxemia up to 48 hours after ET. Rapid-sequence induction and oral ET was performed in 79 (91%) patients, whereas 4 spontaneously breathing patients were nasally intubated. Seventy percent of patients underwent ET by PGY I or II residents, 29% by PGY III or IV residents, and 1% by ED attending physicians. Seventy-seven patients were intubated on the first attempt, and airway blood or vomitus during ET was noted in 11 patients. This study offers significant descriptive information regarding urgent ET performed in the ED, and shows that aspiration after urgent ET occurs infrequently in ED patients.

The significance of out-of-hospital hypotension in blunt trauma patients.

OBJECTIVE: To determine the significance of a low out-of-hospital systolic blood pressure (SBP) reading in blunt trauma patients who have a normal SBP upon ED arrival. METHODS: A retrospective case-control study compared admitted blunt trauma patients who were hypotensive (SBP < or = 90 mm Hg) in the field and normotensive in the ED (group 1) with those who were normotensive both in the field and in the ED (group 2). The groups were compared for mortality, intensive care unit (ICU) admission, injury severity scale (ISS) score, need for transfusion in the ED, incidence of intra-abdominal injury, and incidence of pelvic or femur fracture. RESULTS: Each group consisted of 52 patients. The groups were similar with respect to age, gender, and initial ED SBP. The group 1 patients had a higher mortality (10 vs 1, p = 0.008), a higher number of ICU admissions (28 vs 12, p = 0.001), more pelvic or femur fractures (16 vs 7, p = 0.03), and a higher ISS score (19.0 vs 10.5, p = 0.01). Although not significant, group 1 also had higher incidences of intra-abdominal injury (10 vs 3, p = 0.07) and transfusion (8 vs 2, p = 0.09). CONCLUSION: The injured patients who were hypotensive in the out-of-hospital setting but normotensive upon ED arrival were more severely injured and had more potential for blood loss than were the patients who were normotensive both in the out-of-hospital setting and in the ED. Out-of-hospital hypotension may be a clinical predictor of severe injury, even in the face of normal ED SBP. Prospective studies are indicated to validate this hypothesis.

Neonatal fever: utility of the Rochester criteria in determining low risk for serious bacterial infections.

The purpose of this study was to test the utility of the Rochester criteria in determining which febrile neonates are at low risk for serious bacterial infections (SBI). This was a retrospective study over a 5-year period of 134 patients younger than 29 days old with fever without a source evaluated in the emergency department. Results of urinalysis, lumbar puncture, peripheral white blood cell count, and cultures of blood, urine, cerebrospinal fluid, and stool were recorded. Of the 134 neonates, 71 were high-risk, 48 low-risk, and 15 were not classifiable by the available data. Nineteen of the 71 high-risk patients (26.8%) had SBI (2 patients had 2 SBI). Three of the 48 low-risk neonates (6.3%) had SBI (1 patient had 2 SBI). None of the 15 nonclassifiable patients had SBI. Employing the Rochester criteria to the fully cultured neonates who could be risk-stratified, the sensitivity, specificity, positive predictive value, and negative predictive value were 86.4%, 46.4%, 26.8%, and 93.8%, respectively. Although outpatient management of febrile neonates may be feasible, a small percentage of neonates meeting low-risk criteria will have a SBI.

Attitude of emergency department patients toward HIV-infected health care workers.

A telephone survey of a random sample of adult emergency department (ED) patients was conducted at a university health science center. The purpose of the study was to determine the opinion of ED patients concerning the risk of human immunodeficiency virus (HIV) transmission and their willingness to be treated by HIV-infected physicians and nurses. Surveys from 107 ED patients were compiled and available for analysis. Ninety percent of the respondents were tolerant of an HIV-infected physician or nurse (HIV + HCW)performing noninvasive procedures. Fifty percent were tolerant of an HIV + HCW performing invasive procedures. Twenty-six percent of the patients said they would leave the department rather than be treated by an HIV + HCW. Patients older than 50 years were less tolerant (P = .004) and more likely to leave the ED (P = .001).

Spontaneous cervicothoracic epidural hematoma following prolonged valsalva secondary to trumpet playing.

Spontaneous spinal epidural hematoma is an uncommon clinical entity. Patients with this disease may present with devastating neurological deficits that can mimic other diseases. Emergency physicians should be familiar with this condition to assure appropriate therapy in a timely manner. A typical case of spontaneous spinal epidural hematoma is presented with review of appropriate differential diagnosis and management.

Topical tetracaine attenuates the pain of infiltration of buffered lidocaine.

OBJECTIVE: To determine whether topical tetracaine attenuates the pain of buffered lidocaine infiltration. METHODS: A prospective, randomized, double-blind trial was conducted involving adults with lacerations being repaired following local anesthesia. Two 0.5-mL injections of buffered lidocaine were given in a standardized manner. Injection 1 was given prior to application of topical study solution. Injection 2 was given on the opposite side of the laceration after topical application of a study solution that was 4 mL of either tetracaine or normal saline. Pain of each infiltration was measured using a visual analog pain scale. Pain score differences (injection 1 - injection 2) were compared for the 2 study solutions using a Wilcoxon 2-sample signed-rank test. RESULTS: Of 57 subjects studied, 29 received tetracaine and 28 received saline. The groups were similar in age, gender, wound length, wound location, and initial pain score. Pain scores decreased significantly in the tetracaine group as compared with the saline group. The median pain score difference for tetracaine was 12.0 mm, with an interquartile range (IQR) of 2 to 43 mm, as compared with 2 mm, with an IQR of - 17 to 21 mm for saline (p = 0.048). CONCLUSION: Topical tetracaine attenuates the pain of infiltration of buffered lidocaine.