Reducing the rate of paramedic needlesticks in emergency medical services: the role of self-capping intravenous catheters.

OBJECTIVE: To determine whether the frequency of unintentional needlesticks can be reduced by replacing conventional i.v. catheters with self-capping ones. METHODS: Retrospective cohort, historically controlled study, conducted in an emergency medical services advanced life support (ALS) service. The ALS service annually transports 12,000 patients, for whom i.v. therapy is attempted in about 65% of cases. The needlestick rate per 1,000 patients receiving attempts at i.v. access was examined during the 2 10-month periods, before and after introduction of a self-capping i.v. catheter. RESULTS: For the 2 periods, the percentage of patients for whom i.v. access was attempted remained constant at 65%. The success rate for i.v. access was statistically unchanged from 88% to 90% (p > 0.5, power = 0.995). During the period prior to use of the new catheter, 44 injuries were reported overall. Of these, 15 were due to unintentional needlesticks, 11 associated with contaminated needles. Following the system-wide introduction of the new catheter, only 1 of 31 reported injuries was due to needlestick (uncontaminated). The extrapolated annual incidence of contaminated needlesticks decreased from 169 (95% CI; 85, 253) to 0 (95% CI; 0, 46) per 100,000 i.v.attempts. The extrapolated incidence for all needlesticks decreased from 231 (95% CI; 132, 330) to 15 (95% CI; 0, 40) per 100,000 i.v. attempts. The absolute number of needlesticks and the proportion of injuries due to needlesticks decreased significantly (p < 0.005). CONCLUSION: The use of i.v. catheters with self-capping needles was associated with a significant reduction in the absolute number of inadvertent needlesticks as well as the proportion of injuries due to needlesticks among ALS providers. The use of self-capping i.v. catheters was feasible and did not appear to be a deterrent to initiating i.v. therapy in the out-of-hospital environment.

Comparison of hydromorphone and meperidine for ureteral colic.

OBJECTIVE: To compare the efficacies of meperidine and hydromorphone in the treatment for ureteral colic in the emergency department (ED). METHODS: A prospective, double-blind, randomized clinical trial was conducted over six months at a tertiary referral center with 93,000 annual ED visits. Seventy-three patients completed the study. The patients received either 1 mg of hydromorphone or 50 mg of meperidine IV at t = 0. Pain intensity was determined using a 10-cm visual analog scale at t = 0, 15, 30, 60, and 120 minutes. A second dose of the study drug could be given between t = 15 and t = 120 minutes when the clinician believed the initial dose was ineffective. Patients requiring more than one additional dose of analgesia were treated as nonresponders and were removed from the study. RESULTS: Thirty-six patients received hydromorphone and 37 received meperidine. The initial pain intensities (hydromorphone group = 8.4 +/- 1.5; meperidine group = 8.5 +/- 2.1), age distributions, sex distributions, and side effects of the two groups were comparable. Pain relief was better (p < 0.05) with hydromorphone at t = 15, 30, 60, and 120 minutes. The hydromorphone group required rescue analgesia less often (31% vs 68%, p < 0.01), had fewer IV pyelographies (IVPs) (28% vs 54%, p < 0.05), and had a lower proportion of hospital admissions (25% vs 49%, p = 0.08). CONCLUSIONS: For the fixed doses used in this study, the adult ureteral colic patients receiving hydromorphone achieved more pain relief, required less rescue medication, underwent fewer IVPs, and avoided hospital admission more frequently than did those receiving meperidine.

Sensitization and exposure to indoor allergens as risk factors for asthma among patients presenting to hospital.

To investigate the role of indoor allergens in adult patients with acute asthma, we conducted a case-controlled study on patients presenting to an emergency room. One hundred and fourteen patients and 114 control subjects were enrolled over a 1-yr period in Wilmington, Delaware. Sera were assayed for total IgE, and for IgE antibodies to dust mites, cat dander, cockroach, grass pollen, and ragweed pollen. Dust was obtained from 186 homes and assayed for dust mite, cat, and cockroach allergens. IgE antibodies to mite, cat, and cockroach were each significantly associated with asthma, and this association was very strong among participants without medical insurance and among African Americans. Among 99 uninsured participants, sensitization to one of the indoor allergens (> 200 RAST units) was present in 28 of 57 asthmatics and in one of 42 control subjects (odds ratio, 39; confidence interval, 9.4 to 166). For cat and cockroach the combination of sensitization and presence of allergen in the house was significantly associated with asthma. Furthermore, there was a strong inverse relationship between IgE antibodies to cat and to cockroach, and the risk of this sensitization was in large part restricted to homes or areas with high levels of allergen. Thirty-eight percent of the asthmatics, but only 8% of the control subjects, were allergic to one of the three indoor allergens, and had high levels of the relevant allergen in their houses (odds ratio, 7.4; confidence interval, 3.3 to 16.5).(ABSTRACT TRUNCATED AT 250 WORDS)

Bolus administration of 5 mg epinephrine as a treatment of last resort for cardiac arrest.

There is some evidence that the dose of epinephrine currently recommended for resuscitation is low. This study examines the effect of bolus administration of 5 mg of epinephrine when given as an agent of last resort for cardiac arrest. The experimental design called for the administration of high-dose epinephrine at the point where resuscitative efforts would have ordinarily been stopped. Resuscitation was then continued for a minimum of five minutes so that any changes in rhythm or return of spontaneous circulation could be noted. Eighty-five consecutive patients undergoing resuscitation in our Emergency Department were enrolled in this study. Twenty-eight (33 percent) exhibited a change in cardiac rhythm. Of these 28 patients, seven (8 percent) developed pulses. Of these seven patients, four expired in the Emergency Department, one survived to admission but expired two days later, and two patients survived to discharge. We conclude that bolus administration of 5 mg of epinephrine may be useful in treating cardiac arrest refractory to conventional therapy.

Tubal pregnancy after total vaginal hysterectomy.

We report the case of a 26-year-old woman who presented to our emergency department for evaluation of abdominal pain 24 days after a vaginal hysterectomy. The patient's serum pregnancy test was positive. An ectopic pregnancy of the right adnexa was diagnosed by ultrasound and confirmed by laparotomy. The patient recovered uneventfully. Ectopic pregnancy after a total hysterectomy can occur if the fertilized ovum is in the fallopian tube at the time of the hysterectomy or if a fistulous tract exists between the vagina and the ovaries, enabling fertilization to occur. The diagnosis of ectopic pregnancy after a total hysterectomy is unusual yet must be considered in the presence of intact ovaries to avoid a delay in treatment.

Shock.

Inevitably, a patient in shock will present to your office. The findings may be obvious, or they may show the more subtle changes of mild tachypnea, tachycardia, and/or changes in mental status. In either event, the perfusion pressure either has already decompensated or will do so momentarily. Whether you initiate therapy then and there might well determine whether your patient will survive. Accordingly, each office should have available for the pre-hospital management of shock those items listed in Table 3. As clinicians, you must be prepared to begin treatment in your office. Although the hospital, particularly the intensive or coronary care unit, is the appropriate setting for the management of shock, therapy must be initiated as soon as and wherever the diagnosis is made. In this situation, an ounce of prevention is indeed worth a pound of cure. Shock, whether it develops insidiously or precipitously, is a state of inadequate tissue perfusion that, if misdiagnosed or treated inadequately, will inevitably result in death.

Thoracentesis in the emergency department.

Presented is a review of thoracentesis, a procedure with which the emergency physician should be familiar. The pathophysiology of pleural effusions is described and is followed by a review of the clinical presentation and diagnosis. Special attention is given to technique and interpretation of results.