The bispectral index monitor: a new tool for air medical personnel.

The bispectral index monitor (BIS) is commonly used in the operating room to help anesthesiologists quantitate the level of anesthesia. The BIS has been shown to reduce the incidence of anesthetic overuse and decrease costs. The device has made its way into critical care areas, where it has proven effective in monitoring sedation levels, specifically in reducing the incidence of oversedation. This article explores the possibility of using the monitor in the air medical environment.

Recent advances in the pharmacologic management of diabetes mellitus.

The importance of glucose control in reducing the complications of diabetes mellitus has been clearly demonstrated. The emergency physician routinely is expected to treat a wide range of problems related to this disease, including making the initial diagnosis of type 2 and occasionally type 1 diabetes. Also common are patients with poorly controlled diabetes. The recent introduction of new classes of agents to lower blood glucose, especially in type 2 diabetes, should improve the control in this category of patient and reduce the complication rate. Some of these agents, such as troglitazone, have potentially fatal complications and require careful monitoring. Emergency physicians should be aware of the common complications of these drugs because patients can present to the ED with them. Hypoglycemia, a common cause of 911 calls and emergency visits, is not a side effect of either metformin or acarbose. Insulin lispro has improved postprandial glycemic control for type 1 and some insulin-requiring type 2 diabetics. Hypoglycemia is less of a risk with insulin lispro, and quality of life is better with this rapidly acting insulin. Newer methods of insulin delivery, such as continuous subcutaneous infusion, have greatly improved glucose control, given greater freedom to patients, and reduced the risks of hypoglycemia.

Prevalence of atypical chest pain descriptions in a population from the southern United States.

INTRODUCTION: The character of chest pain (CP) is a major factor determining triage and admission for patients presenting to the emergency department (ED). Previous studies have found atypical descriptions in as little as 10-15% of patients with true myocardial ischemic pain. Atypical descriptions may be more prevalent in the Deep South of the United States because of cultural differences in the semantic description of pain. METHODS: A retrospective study of patients presenting to the ED of a southern U.S. urban hospital with enzyme-documented myocardial infarction was conducted to determine the prevalence of atypical CP descriptions. A multivariate analysis of those patients with atypical pain descriptions was conducted to determine the independent demographic factors associated with these descriptions. RESULTS: In a total of 77 subjects (56% black; 44% white) meeting the study criteria, 43% were found to have atypical elements in the character of their CP descriptions. Only the black race demographic was found to be significantly correlated with the atypical descriptions. The use of the descriptive term "sharp" accounted for nearly half of the atypical presentations. CONCLUSION: Regional differences in the description of the character of CP may result in misleading portrayals of ischemic heart disease in southern U.S. populations. These differences are associated with a higher prevalence of atypical CP because of semantic distinctions, such as the use of the term "sharp" as a descriptor of acuity rather than character or quality.

Methcathinone intoxication in the rat: abrogation by dextrorphan.

STUDY OBJECTIVE: Methcathinone, a designer drug, has high abuse liability. In this study we characterized acute methcathinone toxicity in rats, attempting to determine whether the excitatory amino acid receptor antagonist dextrorphan can antagonize methcathinone intoxication. METHODS: Intoxication was produced with IV methcathinone infusion (5 mg/kg/minute; 100 mg/mL) in conscious rats. We studied pretreatment, in which dextrorphan or vehicle was injected 30 minutes before methcathinone infusion. In a second protocol, dextrorphan or saline solution was given immediately after the onset of convulsions. RESULTS: Methcathinone caused tachycardia (maximal increase, 131 +/- 10 beats/minute), hyperthermia (+2.3 degrees C), convulsions, and cardiorespiratory collapse in vehicle-pretreated rats (n = 9). Death occurred after 32.0 +/- 1.1 minutes of infusion. Dextrorphan pretreatment (25 mg/kg; n = 7) significantly reduced hyperthermia (+.1 degree +/- .3 degree C) and tachycardia and increased the convulsive (dextrorphan, 134 +/- 9 mg/kg; vehicle, 67 +/- 4 mg/kg) and lethal doses (dextrorphan, 204 +/- 9 mg/kg; vehicle, 160 +/- 5 mg/kg). Dextrorphan, given immediately after the initial methcathinone convulsion, reduced hyperthermic and tachycardic responses but not the lethality of methcathinone. CONCLUSION: Blockade of excitatory amino acid receptors by dextrorphan minimizes acute methcathinone intoxication.

Diagnosis of thoracic outlet syndrome in the emergency department.

The use of the emergency department (ED) as a source for primary care has increased the number of patients seen in this setting with even chronic symptoms such as pain, paresthesias, and weakness in the upper extremity. This group may include individuals with thoracic outlet syndrome (TOS). We were concerned that TOS may be underdiagnosed in the ED because of physician unfamiliarity with the signs and symptoms of TOS. Hence, we retrospectively studied cases of TOS seen at the ED of the University hospital during a 29-year period. We believe this is the first report in the English language literature to reflect the assessment and management of TOS in the ED. The study data include clinical presentation, diagnostic tests, and management of TOS. Lack of thorough evaluation resulted in underdiagnosis of TOS in our ED. We recommend that ED personnel pay close attention to patients with symptoms of long duration and that ED physicians be aware of TOS presentation and its management.

Phenytoin hypersensitivity syndrome.

The purpose of the current manuscript is to familiarize the primary physician with the presentation of phenytoin hypersensitivity syndrome, and to discuss management options. A review of all admissions to the University of Mississippi Medical Center over a five year period revealed 4 cases of phenytoin hypersensitivity syndrome. These cases are presented and the phenytoin hypersensitivity syndrome, characterized most commonly by fever, cutaneous eruption and lymphadenopathy, is described. It is emphasized that the clinician must be aware of the syndrome and must recognize it on presentation. Theories regarding etiology and treatment options are discussed. It is recommended that all patients with symptoms of phenytoin hypersensitivity syndrome be hospitalized and that steroids be initiated.

Heat emergencies.

Heat emergencies occur when the body is unable to adequately dissipate heat. Hyperthermic patients should be cooled immediately with a lukewarm-water spray and cool moving air. Patients with heat exhaustion respond well to administration of intravenous fluids. Patients with heatstroke have a complete loss of thermoregulation, a core temperature greater than 40.5 degrees C (105 degrees F) and impaired mental status. These critically ill patients must be cooled quickly to 39 degrees C (102 degrees F) to avoid devastating complications. Intensive care monitoring and support are indicated. To reduce the risk of heat injury in hot weather, frail and elderly persons must maintain hydration and may need to consider alternate living arrangements. Laborers, athletes and military personnel benefit from gradual acclimation to the heat, increased fluid intake, vapor-permeable clothing and frequent rest periods.

Evaluation of alimentary tract foreign body: clinical and imaging review of 100 consecutive cases.

We investigated the cases of 100 consecutive patients with alimentary tract foreign bodies for clinical findings and use of imaging and compared our findings with those of other reported series. Most of our patients were children, and the alimentary tract foreign body was metal in most cases. There was no undue morbidity or mortality related to either conservative or interventional treatment. Imaging was useful in diagnosis and management of cases. Use of computed tomography and magnetic resonance imaging in evaluation of alimentary tract foreign bodies is discussed.

Gastric emptying in the acutely inebriated patient.

Fifty inebriated emergency department (ED) patients underwent evacuation of gastric contents via a nasogastric tube, in order to determine if a significant amount of ingested ethanol can be removed prior to absorption. Such a result could potentially reduce additional intoxicating effect. The gastric contents were assayed for total ethanol concentration, and a potential (postabsorption) additive blood alcohol level (PABAL) was projected and compared to the actual BAL on arrival. The type of beverage ingested and the time since last drink were recorded. BAL ranged from 108 to 637 mg/dL (mean +/- SD, 290 +/- 104.7). Gastric aspirate volume ranged from 50 to 700 mL (190 +/- 134), and contained alcohol in a range of 87 to 2271 mg/dL (475 +/- 479). Based on the distribution volume for alcohol calculated according to the patient's weight, this corresponded to a PABAL of 3 to 167 mg/dL (mean, 24.3 +/- 29.3). There was no significant correlation between the volume or concentration of gastric aspirate and the patient's stated drinking history. The authors conclude that a significant amount of ingested alcohol may occasionally be removed from absorption by the routine evacuation of gastric contents in intoxicated patients. These patients cannot be identified upon presentation, however, and these data cannot support routine use of gastric emptying in the detoxification of inebriated patients.

Acute carbon monoxide poisoning: emergency management and hyperbaric oxygen therapy.

An ice storm in February 1989 resulted in numerous incidences of carbon monoxide poisoning in central Mississippi secondary to exposure to open fires in unventilated living spaces. Sixteen cases were treated during this period at the University of Mississippi Medical Center and 6 received Hyperbaric Oxygen therapy. These 6 cases and the mechanisms of CO poisoning are discussed and recommendations for emergency management are reviewed.