Tetanus in the emergency department: a current review.

Despite the availability of effective immunization to prevent tetanus, there are still up to one million cases per year worldwide. Although the majority of tetanus cases occur in third world countries, there are still significant numbers of cases occurring in countries such as the United States, where preventive immunization is easily accessible. The Emergency Physician has the opportunity to contribute to the decline of the incidence of tetanus through knowledge of those at greatest risk for inadequate immunization and through providing proper wound care and immunization prophylaxis.

The use of lithium levels in the emergency department.

Most patients on chronic maintenance lithium therapy become toxic at some point during their therapy. Lithium intoxication portends morbidity and mortality. The serum lithium concentration can be used as an adjunct to a physician's clinical acumen in diagnosing and managing the patient with lithium intoxication.

Computerized follow-up of discrepancies in image interpretation between emergency and radiology departments.

Radiographs are ordered and interpreted for immediate clinical decisions 24 hours a day by emergency physicians (EP's). The Joint Commission for Accreditation of Health Care Organizations requires that all these images be reviewed by radiologists and that there be some mechanism for quality improvement (QI) for discrepant readings. There must be a log of discrepancies and documentation of follow up activities, but this alone does not guarantee effective Q.I. Radiologists reviewing images from the previous day and night often must guess at the preliminary interpretation of the EP and whether follow up action is necessary. EP's may remain ignorant of the final reading and falsely assume the initial diagnosis and treatment were correct. Some hospitals use a paper system in which the EP writes a preliminary interpretation on the requisition slip, which will be available when the radiologist dictates the final reading. Some hospitals use a classification of discrepancies based on clinical import and urgency, and communicated to the EP on duty at the time of the official reading, but may not communicate discrepancies to the EP's who initial read the images. Our computerized radiology department and picture archiving and communications system have increased technologist and radiologist productivity, and decreased retakes and lost films. There are fewer face-to-face consultants of radiologists and clinicians, but more communication by telephone and electronic annotation of PACS images. We have integrated the QI process for emergency department (ED) images into the PACS, and gained advantages over the traditional discrepancy log. Requisitions including clinical indications are entered into the Hospital Information System and then appear on the PACS along with images on readings. The initial impression, time of review, and the initials of the EP are available to the radiologist dictating the official report. The radiologist decides if there is a discrepancy, and whether it is category I (potentially serious, needs immediate follow-up), category II (moderate risk, follow-up in one day), or category III (low risk, follow-up in several days). During the working day, the radiologist calls immediately for category I discrepancies. Those noted from the evening, night, or weekend before are called to the EP the next morning. All discrepancies with the preliminary interpretation are communicated to the EP and are kept in a computerized log for review by a radiologist at a weekly ED teaching conference. This system has reduced the need for the radiologist to ask or guess what the impression was in the ED the night before. It has reduced the variability in recording of impressions by EP's, in communication back from radiologists, in the clinical] follow-up made, and in the documentation of the whole QI process. This system ensures that EP's receive notification of their discrepant readings, and provides continuing education to all the EP's on interpreting images on their patients.

Lithium toxicity.

As the emergency physician frequently treats patients on long-term lithium therapy, awareness of the numerous side effects of lithium therapy and the pathogenesis of lithium intoxication is needed to deliver effective treatment. This article reviews the management of lithium intoxication due to acute ingestion or subacute toxicity.

Cranial computed tomography in the emergency department evaluation of HIV-infected patients with neurologic complaints.

STUDY OBJECTIVE: To demonstrate the usefulness of cranial computed tomography (CT) in the emergency department evaluation of HIV-infected patients and patients with risk factors for HIV infection who present with neurologic complaints. DESIGN: Retrospective review of imaging reports and medical records of patients who visited the ED from March 1991 through March 1992. SETTING: Urban university ED. PARTICIPANTS: Patients with HIV infection or risk factors for infection who underwent emergency cranial CT after presenting to the ED with headache, altered mental status, focal deficits, or other neurologic signs or symptoms. RESULTS: One hundred forty-six patients visited the ED 169 times. Of the 169 cranial CTs obtained, 85 (50%) were normal, 49 (29%) showed atrophy only, and 35 (21%) demonstrated focal lesions, with mass effect noted in ten (6%). Enhancing lesions were present in 13 scans. In 21 (12%) cases, CT revealed either an indication for admission, a contraindication to lumbar puncture, or both. In 25 instances, patients with lesions had nonfocal presentations and no papilledema. Two presentations--focal deficit and altered mental status--were each statistically significantly associated with lesions on CT. In seven patients with multiple ED visits, repeat CT showed new findings. Among patients who had risk factors but were of unknown HIV status, there was the same proportion of abnormal scans as in known HIV-infected patients. CONCLUSION: CT detected clinically significant neuropathology among our study patients. Because lesions and mass effect were associated with nonfocal as well as focal presentations, CT is indicated in every neurologically symptomatic patient with HIV infection or risk factors for infection. Because HIV-related diseases can progress rapidly, repeat CT is recommended even in patients with recent scans.

Baseball bat assault injuries.

The baseball bat, according to Baltimore City police crime statistics, is a commonly used weapon. To assess the severity of injuries inflicted by this modern-day club, we retrospectively reviewed 75 charts of patients treated at the University of Maryland Medical Systems Hospital for baseball bat injuries from January 1990 through July 1991. Multisystem trauma was documented, with craniocerebral injury being the most frequent and the most frequent cause of death. Of the victims struck on the head, 26% sustained an intracranial hemorrhage. In our series, the history of loss of consciousness and the Glasgow Coma Scale score failed to reliably identify the patients with serious injuries. Seventeen percent of our patients with intracranial hemorrhages had both a negative or uncertain history of loss of consciousness and a normal Glasgow Coma Scale score on arrival.

Tetanus.

Tetanus causes approximately 50,000 deaths per year worldwide, the incidence being greatest in undeveloped countries. Once tetanus occurs, the risk of death is substantial. Physician attention to the immunization status of patients who present with wounds, chronic and minor, can improve prevention of tetanus. It should be noted that more than 10% of the US population is not properly immunized against tetanus and that those at greatest risk are females of any age, males older than 50, blacks from the rural South, and those without any military experience.

Rabies.

Rabies is usually contracted through wounds and usually causes death in those infected. The major weapon against rabies infection is postexposure immunization, and by virtue of treating numerous animal bites and scratch wounds, emergency physicians play a key role in keeping rabies rare in the United States. Proper management requires knowledge of the changing epidemiology of animal rabies and its impact on postexposure prophylaxis.

The importance of an annual report.

An annual report, by summarizing the emergency department's accomplishments, is an effective means of highlighting the vital role of the emergency department within the hospital system and the community. The report should begin with an Executive Summary and proceed to detail the clinical, educational, research, administrative, financial, and other essential aspects of the status and development of the department.

The electrocardiographic manifestations of cyclic antidepressant therapy and overdose: a review.

Cyclic antidepressants may cause changes in the electrocardiogram at therapeutic or toxic serum levels. The most serious complications of cyclic antidepressant toxicity are dysrhythmias, hypotension, and seizures. It is predominantly the cardiotoxic effects that cause mortality. Once cardiotoxicity is evident, the treatment of choice is serum alkalinization, preferably by sodium bicarbonate therapy. In order to predict which overdose patients are at high risk for complications, electrocardiographic criteria have been identified as reliable screens. For "first generation" tricyclic antidepressants, QRS prolongation (particularly greater than 100 msec) and a terminal 40-ms frontal plane axis greater than 120 degrees are the most sensitive. This article reviews antidepressant pharmacology, electrocardiographic manifestations of antidepressant cardiotoxicity, and approaches to treatment of antidepressant-induced conduction disturbances and dysrhythmias.

Use of a mildly restrictive administrative protocol to reduce orders for manual blood film examination from the emergency department.

In order to conserve laboratory resources, we instituted a mildly restrictive administrative protocol requiring a telephone request by emergency physicians or their designees in order to obtain a manual blood film examination (BFE). This test includes a manual differential leukocyte count (DLC), examination of red cell morphology, and platelet estimate. The protocol resulted in a marked reduction of the number of BFE's performed on emergency department patients from the previous level of one for every complete blood count (CBC). Retrospective chart review of a sample of patients not receiving manual BFEs indicated no apparent adverse effect on patient care. We speculate that the availability of an electronic partial differential count, providing enumeration of lymphocytes and neutrophils along with the CBC, facilitated in part the reduced ordering of manual BFEs.

Application of clinical indicators in the emergency department.

Clinical indicators were developed and used to assess the quality of patient care resulting from the system of shared responsibility between emergency department (ED) and radiology department faculty physicians for interpretation of ED roentgenograms. The first indicator--all discrepancies in roentgenogram interpretation between ED and radiology department faculty--measured an overall discrepancy rate of 3.3% (776 films). Three hundred fifty-two apparent discrepancies were not related to the accuracy with which ED faculty interpreted films, resulting in a revised overall discrepancy rate of 1.8%. The second indicator--undesirable patient care outcomes as a result of delayed accurate radiological diagnosis--measured an occurrence rate of 0 after clinical reevaluation of more than 99% of patients within 24 hours of initial ED evaluation. Aspects of the development and use of clinical indicators are discussed in relationship to the broader monitoring and evaluating process necessary for the continuous improvement of patient care.

The electrocardiographic manifestations of pulmonary embolism.

The electrocardiographic manifestations of pulmonary embolism include rhythm and condition disturbances and changes in the P wave, QRS complex, or T wave. Since these abnormalities are highly variable and frequently transient, they lack the sensitivity necessary to establish the diagnosis of pulmonary embolism. The electrocardiogram may rise the suspicion of pulmonary embolism, but other diagnostic tests are necessary to confirm the diagnosis.

[Taking responsibility and communication : the keys to adolescence.]. / Responsabilisation et communication : les clés de l'adolescence.

The following article focuses on parent-adolescent communication from a perspective of the progressive entrance into adulthood of 12-18 year-olds. The notion of responsibleness is presented here as the learning process towards self-management. The hypothesis of the existence of synchronism between the adolescents' search for autonomy and their parents' delegation of decision-making is drawn and tested using recent results obtained from a sample of Quebec families. The importance of quality communication in parent-adolescent adaptation is discussed in relation with the room given to teens in decisions that concern them. The authors finally suggest that this type of communication is fundamental to the mental health of youth within the family unit.

Echocardiographic diagnosis of acute pericardial effusion in penetrating chest trauma.

Pericardial tamponade persists as a diagnostic challenge to the clinician. The immediate diagnosis is particularly difficult when the patient is well compensated hemodynamically. In contrast to the deceptively stable appearance, the patient is at increased risk due to delayed onset, recognition, and therapy. A case of penetrating thoracic trauma is presented in which the concern about pericardial tamponade was considerable. However, the elements of clinical assessment were inconclusive. Two-dimensional echocardiography was employed in the emergency department to detect a pericardial effusion and thus avoid delayed management. Pericardial tamponade and associated vascular injuries were confirmed at surgery.

Lithium intoxication: manifestations and management.

The clinical diagnosis of lithium intoxication can be elusive because of the slow onset and diversity of toxic manifestations. Mental status and neurologic symptoms often predominate. After the diagnosis is made, management depends on the clinical presentation and serum lithium level. Hemodialysis is the treatment of choice for severe lithium intoxication. Two cases of lithium intoxication are presented that demonstrate that predisposing factors and drug interactions play major roles. A review is given of the pathophysiology, presenting signs, symptoms, and approaches to treatment of lithium intoxication.

Transient acantholytic dermatosis in immunocompromised febrile patients with cancer.

A focal acantholytic dermatosis resembling transient acantholytic dermatosis (TAD) clinically and histologically occurred in four immunocompromised and persistently febrile patients with various malignant neoplasms. No pathologic organism was isolated in cultures from blood or from the actual skin lesions. The rash resolved over several days, coinciding with defervescence. As do authors of other reports of TAD, we believe that the etiology of TAD is related to heat, persistent fever, and/or sweating.

Complete heart block.

Complete heart block (CHB) occurs when atrial impulses are not conducted to the ventricles. It occurs in association with many conditions, including acute myocardial infarction. In the setting of acute myocardial infarction (MI), certain characteristic conduction disturbances tend to precede development of CHB. Knowledge of these disturbances provides rational indications for emergency temporary pacing of acute MI patients.