Does the aggressive use of polyvalent antivenin for rattlesnake bites result in serious acute side effects?

OBJECTIVE: To determine the incidence and severity of acute side effects from the use of polyvalent antivenin in victims of rattlesnake bites. DESIGN: We retrospectively reviewed the records of all patients who presented with rattlesnake bites to a university teaching hospital during an 11-year period. From patient medical records, we extracted demographic data, clinical measurements, and outcomes during emergency department evaluation and subsequent hospitalization. Data regarding serum sickness were not collected. OUTCOME MEASURES: Primary outcome variables were the occurrence of immediate hypersensitivity reaction to antivenin, the type of reaction, permanent disability at hospital discharge, and mortality. RESULTS: We identified a total of 73 patients with rattlesnake bites during the study period. Bite envenomation was graded as nonenvenomated, 7 patients (10%); mild, 23 patients (32%); moderate, 32 patients (44%); and severe, 11 patients (15%). We identified 65 patients who received antivenin. Antivenin doses ranged from 1 to 30 vials per patient (mean, 12.0 +/- 6.0), for a total of 777 vials. In 43 patients (66%), 10 or more vials of antivenin were given. The mean number of vials of antivenin given to each snakebite grade were as follows: mild, 8.4 (+/-4.0); moderate, 11.8 (+/-5.7); and severe, 18.7 (+/-6.3). No deaths, amputations, or permanent disability from snakebite occurred in the patients receiving antivenin. Acute side effects of antivenin-occurring within the first 6 hours after administration-were seen in 12 patients (18%; 95% confidence interval, 10%-30%). Acute side effects consisted solely of urticaria in all but 1 patient (2%; 95% confidence interval, 0%-8%). This patient had a history of previous antivenin reaction and required a short course of intravenous epinephrine for blood pressure support. No other complications occurred. CONCLUSION: The administration of polyvalent Crotalidae antivenin is safe. Acute hypersensitivity, when it occurs, consists solely in most cases of urticaria. Serious side effects are uncommon.

Survey of directors of emergency departments in California on overcrowding.

OBJECTIVE: To survey the directors of emergency departments in California on their opinions of the extent and factors associated with overcrowding in emergency departments. METHODS: Surveys were mailed to a random sample of emergency department directors. Questions included estimated magnitude, frequency, causes, and effects of overcrowding. RESULTS: Of 160 directors surveyed, 113 (71%) responded, and 109 (96%) reported overcrowding as a problem. All (n = 21) university or county hospital directors and most (n = 88 [96%]) private or community hospital directors reported overcrowding. The 4 private or community hospital directors reporting no overcrowding serve smaller communities with populations less than 250,000. Thirty-two directors (28%) reported daily overcrowding. The most cited causes were increasing patient acuity and volume, hospital bed shortage, laboratory delays, and nursing shortage. These putative causes were similar between university or county and private or community hospital directors, except for consultant delays, which were more prevalent in university or county hospital emergency departments. CONCLUSIONS: Overcrowding is perceived to be a serious problem by emergency department directors. Many factors may contribute to overcrowding, and most are beyond the control of emergency departments.

Emergency medicine in Belarus.

Belarus is a small eastern European nation between Poland and Russia. Except for the lingering effects of Chernobyl radiation contamination, its system of health care and, in particular, emergency care has received little attention in the world literature. Emergency medical care is organized similarly to that provided in Russia and other European countries. A well-coordinated Emergency Medical Services (EMS) system exists, and many ambulance teams include a physician. Most emergency care is provided in an area of the hospital designated as the reception area, the equivalent of a U. S. emergency department (ED). Unlike the practice in U.S. EDs, many patients have a minimal evaluation after admission to the actual ward or hospital ICU. Emergency Medicine has not been officially organized as a specialty. Opportunities exist for interchange and discussion on the delivery of emergency care.

Overcrowding in the nation's emergency departments: complex causes and disturbing effects.

Ten years ago, serious overcrowding in emergency departments became a national issue. Although temporary improvement of the problem occurred, the issue of ED overcrowding has now resurfaced and threatens to become worse. Overcrowding is caused by a complex web of interrelated issues described in this article. ED overcrowding has multiple effects, including placing the patient at risk for poor outcome, prolonged pain and suffering of some patients, long patient waits, patient dissatisfaction, ambulance diversions in some cities, decreased physician productivity, increased frustration among medical staff, and violence. Solving the problem of overcrowding will not only require a major financial commitment from the federal government and local hospitals, but will also require a cooperation from managed care. Unless the problem is solved in the near future, the general public may no longer be able to rely on EDs for quality and timely emergency care, placing the people of this country at risk.

Methamphetamine abuse and rhabdomyolysis in the ED: a 5-year study.

Patients with methamphetamine toxicity are presenting in greater numbers each year to emergency departments (ED) in the US. These patients are frequently agitated, violent, and often require physical and chemical restraint. The incidence and risk of rhabdomyolysis in this subpopulation is unknown. We conducted a 5-year retrospective review of all ED patients who received the final diagnosis of rhabdomyolysis. Patients with toxicology screens positive for methamphetamine were identified, and demographics, laboratory results, resource utilization, disposition, and outcome were compared to the remaining patients. Of the total 367 patients identified, 166 (43%) were toxicology positive for methamphetamine. Methamphetamine patients differed significantly from nonmethamphetamine patients with regard to demographics and hospital utilization. Methamphetamine patients had significantly higher mean initial creatine phosphokinase (CK), 12,439 U/L versus 5,678 U/L (P = 0.02), and lower mean peak CK, 16,827 U/L versus 19,426 U/L (P = 0.03). The development of acute renal failure was not significantly different between the 2 groups. There were 16 total deaths in the study population, 11 from concomitant infection/sepsis. An association between methamphetamine abuse and rhabdomyolysis may exist, and CK should be measured in the ED as a screen for potential muscle injury in this subpopulation. Patients with rhabdomyolysis with an unclear cause should be screened for methamphetamine or other illicit drugs.

Methamphetamine abuse and emergency department utilization.

Methamphetamine (MAP) abuse continues to increase worldwide, based on morbidity, mortality, drug treatment, and epidemiologic studies and surveys. MAP abuse has become a significant health care, environmental, and law enforcement problem. Acute intoxication often results in agitation, violence, and death. Chronic use may lead to infection, heart failure, malnutrition, and permanent psychiatric illness. MAP users frequently use the emergency department (ED) for their medical care. Over a 6-month period we studied the demographics, type, and frequency of medical and traumatic problems in 461 MAP patients presenting to our ED, which serves an area noted for high levels of MAP production and consumption. Comparison was made to the general ED population to assess use patterns. MAP patients were most commonly Caucasian males who lacked health insurance. Compared to other ED patients during this time, MAP patients used ambulance transport more and were more likely to be admitted to the hospital. There was a significant association between trauma and MAP use in this patient population. Our data suggest MAP users utilize prehospital and hospital resources at levels higher than the average ED population. Based on current trends, we can expect more ED visits by MAP users in the future.

Methamphetamine and the expanding complications of amphetamines.

During the past 10 years, the use of methamphetamine has increased rapidly in the West and throughout the United States. Because of this increase, our attention has focused on methamphetamine's toxicity. Methamphetamine and related compounds generate many of the same toxic effects as cocaine. Because of methamphetamine's widespread use, clinicians should be familiar with its medical effects and toxicity and with treatment options for acute and long-term effects of methamphetamine abuse.

How do prudent laypeople define an emergency medical condition?

To determine the public's perception as to the general definition of an emergency medical condition (EMC), and to compare opinions between the general public and healthcare workers (HCW) on which specific medical conditions require emergency department (ED) care, a survey of people at 12 supermarkets and shopping malls in Northern California was conducted over a 6-month period in 1997. Individuals over age 18 were asked in person to complete a survey sheet. It asked participants to choose one of four definitions of "emergency medical condition." In addition, people were asked to determine which of 30 chief complaints they thought needed care in the ED. Demographic information was also collected. A second set of surveys asking the same questions was conducted among nonemergency healthcare providers at hospitals. Healthcare worker was defined as an MD, RN, LVN, or PA. A total of 1,018 members of the public and 126 healthcare workers completed the survey. EMC definitions selected by the public were: 1) an abbreviated federal EMTALA definition: a condition that may result in death, permanent disability, or severe pain (48.7%); 2) the federal definition plus other conditions preventing work (3.0%); 3) the federal definition plus any other conditions outside business hours (16.5%); and 4) any condition at any time as determined by the patient (31.6%). HCWs selected the following: definition 1 (71%); definitions 2 and 3 (0%); and definition 4 (27%). Definitions 1 and 3 were statistically different when comparisons were made between the public and HCWs. On the question of which of the 30 chief complaints needed care in an ED, agreement was seen between the public and HCWs for severe abdominal pain (94% vs. 99%, respectively) and severe chest pain (96% vs. 99%, respectively). However, the two disagreed on the need for ED care for severe headache (58% vs. 91%, respectively); mild chest pain (51% vs. 79%, respectively); and difficulty breathing (77% vs. 98%, respectively). No significant difference in opinions on the need for ED care was seen for some minor conditions: mild headache, sore throat, cough, flu symptoms, minor foot problems. No significant differences in answers occurred when age groups, occupations, or locations were compared. In conclusion, the public has split views concerning the general definition of an emergency medical condition. Approximately half uses a conservative federal definition, and half uses patient self-determined need as the definition. Data on which specific conditions need ED care provide additional insight on agreement between the public and HCWs on most problems. Both groups agree that many perceived minor medical complaints do not require ED care.

Chemical restraint for the agitated patient in the emergency department: lorazepam versus droperidol.

Patients presenting to the emergency department with acute agitation frequently require physical and chemical restraint. To determine the efficacy of lorazepam vs. droperidol, we conducted a prospective, randomized study of violently agitated patients requiring chemical restraint. Patients were randomized to receive either lorazepam or droperidol i.v. A six-point sedation scale was used. Sedation scores were recorded at time 0, 5, 10, 15, 30, and 60 min. Vital signs were compared at time 0 and at 60 min. Repeat dosages of each drug could be given at 30 min. Toxicology screen, ethanol and creatinine phosphokinase levels were obtained. A total of 202 patients were evaluated. One hundred patients received lorazepam and 102 patients received droperidol. Agitation was attributed to methamphetamine toxicity in 146 patients (72%), cocaine toxicity in 28 (14%), psychiatric illness in 20 (10%), and ethanol withdrawal in 8 (4%). Ethanol intoxication was present in 98 patients (49%). Both drugs had similar sedation profiles at 5 min. Patients receiving droperidol had significantly lower sedation scores at times 10, 15, 30, and 60 than lorazepam. More repeat doses of lorazepam were given (40) than droperidol (8) at 30 min. We conclude that droperidol produces a more rapid and better sedation than lorazepam at the doses used in this study in agitated patients requiring chemical restraint. Lorazepam is more likely to require repeat dosing than droperidol. Methamphetamine toxicity was present in the majority of patients in this study.

Computed tomography for blunt abdominal trauma in the ED: a prospective study.

A study was undertaken to determine the criteria for ordering abdominal computed tomography (CT) in the emergency department (ED) for stable patients who sustained blunt trauma and to identify a patient population at high risk for having intra-abdominal injury (IAI) utilizing physical examination, decrease in hematocrit, and hematuria. Patients in a university ED who had abdominal CT from April 1995 to October 1995 were evaluated prospectively. Before the scan, the examining physician completed an entry form that included physical findings, hematocrit, hematuria, Glasgow Coma Scale score, intoxication, distracting injuries, reasons for obtaining the scan, and planned disposition. Patients were followed until discharge. A total of 196 patients were evaluated. Abdominal tenderness was present in 120 patients. Twenty-two patients had IAI. Eight required surgical intervention, and all 8 had abdominal tenderness. A total of 40 potential trauma admissions were averted by obtaining CT within the ED. The combined abnormal abdomen examination and presence of hematuria had a sensitivity of 64%, specificity of 94%, positive predictive value of 56%, and negative predictive value of 95%. Decrease of > or = 5 in hematocrit was not statistically significant for detection of IAI. CT had no false negatives in this cohort. These results show that early CT scanning of stable patients who have sustained blunt trauma is an effective screen for IAI and may result in fewer total admissions, but has potential for overuse. Patients with abdominal pain and hematuria should be scanned. The benefit of a CT scan for patients without tenderness or with an isolated decrease in hematocrit is questionable.

Managed care and emergency medicine: conflicts, federal law, and California legislation.

The traditional use of the American ED, one of unrestricted access by patients and payment for services by insurers, is being questioned in this era of health care reform. Both primary care physicians and managed care organizations have questioned the use of the ED by patients without obvious problems of an emergency nature. We attempt to address this issue from the emergency medicine and managed care perspectives.