Injury prevention and control in children.

Injury is the number one cause of death and life-years lost for children. In children, injury mortality is greater than childhood mortality from all other causes combined. Modern injury prevention and control seeks to prevent and limit or control injuries through the 4 Es of injury prevention: engineering, enforcement, education, and economics. Emergency physicians are often placed in a critical role in the lives of individuals, are respected authorities on the health and safety of children and adults, and have daily exposure to high-risk populations. This gives emergency physicians a unique perspective and an opportunity to take an active role in injury control and prevention. Specific methods or strategies for promulgating injury prevention and control in our emergency medicine practices are suggested, ranging from education (for our patients and health professionals); screening and intervention for domestic violence, child maltreatment, drug-alcohol dependency and abuse; data collection; reporting unsafe products; research; legislation; serving in regulatory and governmental agencies; emergency medical services-community involvement; and violence prevention. Emergency physicians can play a significant role in decreasing pediatric injury and its concomitant morbidity and mortality.

Asthma therapy in the observation unit.

The management of asthma is a commonly encountered clinical problem. There have been major advances in the treatment of asthma, including an increase in the drugs available for treatment, as well as in knowledge of the pathophysiology of the disease. Despite these advances, however, the prevalence, morbidity, and mortality for asthma have shown a disturbing upward trend over the past few decades. Experience with the OU management of asthma has shown many advantages: decreased inpatient hospitalization, better quality of life for patients, higher patient satisfaction, cost-effectiveness, and effective patient care. It is estimated that 60% to 70% of asthmatic patients could be treated in an ED observation unit instead of in an inpatient hospital ward. There is a tremendous opportunity for the OU management of asthma to improve patient care, as well as decrease costs, thereby reducing asthma morbidity and mortality.

Pediatric observation medicine.

Observing pediatric patients in an OU (whether a pediatric or combined or hybrid unit) has many advantages: better patient care, a decrease in missed diagnoses and acuity, better risk management, decreased malpractice liability, cost effectiveness, increased patient and family satisfaction, and psychosocial benefits. Key principles of observation medicine (purpose, time frame, general patient inclusion and exclusion criteria, administration, CQI, and so forth) are equivalent for pediatric and adult observation patients, but there are important differences. Unique characteristics of pediatric observation patients include specific diagnosis, decreased length of stay, less need for cardiac monitoring, a highly variable admission rate, and a decreased percentage or admission rate to the OU from the ED. Whereas the adult OU is primarily a cardiac-monitoring unit, the pediatric OU is a respiratory and infectious disease unit with a frequent need for an i.v. therapy and hydration. Types of pediatric patients commonly treated in an OU include respiratory illnesses (asthma, croup, bronchiolitis, pneumonia), gastrointestinal disorders (gastroenteritis, abdominal pain), dehydration, infections (fever, cellulitis, lymphangitis, pyelonephritis or UTI), overdoses or poisonings, and seizures.

Resuscitations in an observation unit.

The outcome of all resuscitations in a 20-bed observation unit of a large teaching hospital over a 25-month period was reviewed. Resuscitation was defined as a patient receiving one or more of the following: external chest compressions; defibrillation, assisted ventilation (e.g. intubation); and/or advanced cardiac life support drug therapy such as atropine or lidocaine for life threatening dysrhythmias including ventricular tachycardia, ventricular fibrillation, or asystole. There were nine patients out of 10,245 patients admitted to the observation unit (9/10,245 = 0.088% or approximately 0.09%) over the 26-month period from May 1994 to July 1996 who needed resuscitation. Each patient was initially successfully resuscitated. There was only one death (1/10,245 = 0.0098% or approximately 0.01%) in the observation unit. This patient was resuscitated with return of a spontaneous pulse and blood pressure only to expire while awaiting transfer to the Intensive Care Unit (ICU). Eight of the nine patients were admitted to the ICU, four of whom later died, making a total of five deaths (5/10,245 = 0.049% or approximately 0.05%). The other four patients were discharged neurologically intact and at 1 year follow-up were alive and doing well. Compared with resuscitation rates for the prehospital setting, the emergency department, the hospital medical/surgical floors, or the intensive care units, there is a higher successful resuscitation rate for the observation unit.

The impact of paramedics on out-of-hospital cardiac arrests in a rural community.

OBJECTIVE: To determine whether paramedics influence the outcome of cardiac arrest patients in a rural area. METHODS: Retrospective analysis of cardiorespiratory arrest patients in rural southeast Alaska from 1987 to 1996. RESULTS: Paramedics treated 37 patients and advanced life support emergency medical technicians (EMT-IIIs) treated 34 patients. Demographics/CPR variables of the two groups were similar. Return of spontaneous circulation (ROSC) was 46% (17/37) for the paramedic-treated patients and 18% (6/34) for the EMT-III-treated patients (p = 0.01). Intensive care unit (ICU) admission was 38% (14/37) for the paramedic-treated patients and 15% (5/34) for the EMT-III-treated patients (p < 0.03). Discharge from the hospital neurologically intact was 20% (7/35) for the paramedic-treated patients and 9% (3/34) for the EMT-III-treated patients (p = NS). Two patients in the paramedic-treated group had ROSC and survived in the local hospital ICU for several days before being transferred to a tertiary care hospital in another state and were lost to follow-up for the discharge-from-hospital-neurologically-intact category but were included in the ROSC and ICU admission analysis. CONCLUSION: In this rural setting, a paramedic on the scene significantly improved the ROSC (paramedics = 46% vs 18% for EMT-III, p = 0.01) and survival to ICU admission (38% vs 15%, p = 0.03). The presence of a paramedic on the scene increased survival to hospital discharge neurologically intact (20% vs 9%), although this was not statistically significant.

An analysis of patient complaints in an observation unit.

All complaints relating to patients treated in a 20 bed observation unit of a large teaching hospital over a 26-month period are reviewed. From May 1994 to July 1996, 11,042 patients were admitted to the observation unit. During this period there were 28 patient complaints. These complaints consisted of staff attitude/behavior (42.9%), discharge processes (25%), environmental concerns (17.9%), difficulties with diagnostic investigations (10.7%), and miscellaneous issues (3.6%). The type and frequency of complaints were similar to those received in other areas of the hospital, although the profile of complaints was different to those commonly experienced in the emergency department. Observation units are frequently considered to be an extension of the emergency department. Patient complaints received in relation to care received in an observation unit are similar in nature to those recorded in inpatient units as opposed to those received in emergency departments.

The unstable occult cervical spine fracture: a review.

The initial evaluation and management of cervical spine injuries is of critical importance because of the impact of early treatment and management on the patient's eventual outcome. The devastation and cost of missing even one unstable cervical spine fracture is tremendous. The existence of patients with an unsuspected cervical spine fracture who have few, if any, symptoms and/or signs of an injury to the cervical spine is a valid concern and a dilemma for the practicing physician. Thus the principle of the occult unstable cervical spine fracture, which has been established as the standard of care, has major significance and implications. Recently, however, the concept of the occult cervical spine fracture has been challenged. Does the entity of an occult cervical spine fracture exist? If so, how should this affect our indications for obtaining cervical spine radiographs? The author presents the case of an unstable occult cervical spine fracture and a review of the literature.

Unstable occult cervical-spine fracture.

Recognition of injuries to the cervical spine is of critical importance. Such injuries may be difficult to recognize in patients who have an altered level of consciousness or other significant injuries. We present the case of an alert ambulatory patient with no complaint of neck pain, no tenderness of the neck on physical examination, and no history of trauma who, while being evaluated for fever, was found to have an unstable cervical-spine fracture that was not present on radiographs done one year earlier.

Differences in plasma lidocaine levels with endotracheal drug therapy secondary to total volume of diluent administered.

Endotracheal drug therapy provides an effective alternative method for the administration of drugs in the numerous clinical settings in which intravenous access is difficult or impossible to obtain. However, the specific factors affecting endotracheal drug absorption and thus, the drug's plasma levels and effectiveness, has not yet been fully determined. Lidocaine alone or lidocaine mixed with normal saline was given endotracheally in four volumes (Volume I = undiluted with less than or equal to 5.5 cc total volume; Volume II = diluted to 6 cc total volume; Volume III = diluted to 12 cc total volume; Volume IV = diluted to 25 cc total volume) by the same technique of administration and in the same dosage of 4 mg/kg. Each dog served as its own control and received all four volumes of endotracheal lidocaine on different occasions. Plasma lidocaine levels at all four volumes and at all four time periods (5, 15, 30 and 60 min after giving endotracheal lidocaine) were obtained in each of the six dogs for a total of 96 plasma lidocaine levels measured in the study. Mean plasma lidocaine levels (micrograms/ml) at 5 min were: Volume I = 1.9, Volume II = 10.0, Volume III = 3.2 and Volume IV, = 4.3. These results were highly significant (P less than 0.001). The highest plasma lidocaine levels were obtained in the diluted volume, Volume II and the lowest plasma lidocaine levels in the undiluted volume, Volume I, with Volumes III and IV being intermediate.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of hypoxemia on pharmacokinetics of endotracheal lidocaine in dogs.

Endotracheal administration is an effective alternative method for giving drugs in the many clinical situations in which it is difficult or impossible to quickly obtain an intravenous line. Yet whether various clinical conditions such as hypoxemia have any effect on endotracheal drug therapy is not known. Sixteen sets of plasma lidocaine levels were measured at 5, 15, 30, and 60 min after endotracheal lidocaine administration in eight dogs. Each dog was given the same dose of endotracheal lidocaine by the same technique of administration while in both a normal control state (Group I = 'Non-hypoxemia', mean Po2 = 98) and during hypoxemia (Group II = "Hypoxemia", mean Po2 = 36). Significantly higher plasma lidocaine levels occurred in the hypoxemic state (Group II) at time = 5 min while there was no significant difference in plasma lidocaine levels at time = 15, 30, and 60 min. Mean plasma lidocaine levels (micrograms/ml) at 5 min were: Group I = 1.38, Group II = 2.36 (significant at P less than 0.05). Plasma lidocaine levels were: Group I = 1.61 vs. Group II = 1.63 at time = 15 min, Group I = 1.11 vs. Group II = 1.10 at time = 30 min, and Group I = 0.54 vs. Group II = 0.51 at time = 60 min. Thus, there was a higher peak plasma lidocaine level and a shorter time to peak plasma lidocaine levels in the hypoxemic dogs.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma lidocaine levels occurring with endotracheal administration during hemorrhagic shock.

During the many emergency situations in which venous access is difficult or impossible, endotracheal drug administration is an effective alternative means of delivering life-saving medications. Shock is a commonly encountered emergency situation in which endotracheal drug therapy can and is often used. Yet whether a drug given endotracheally during shock can be absorbed from the lungs and pass into the bloodstream is not known. Forty-five sets of plasma lidocaine levels drawn at 5, 15, 30 and 60 min after the administration of endotracheal lidocaine at a dose of 2 or 4 mg/kg were obtained in dogs either in shock or in a normal control group: Group I = "Non-shock" or normal control, N = 27; Group II = "Shock", N = 18. Significantly higher plasma lidocaine levels occurred in the shock group in all time periods and with either dose of lidocaine (P less than 0.001). Mean plasma lidocaine levels (micrograms/ml) at 5 min were: (at 2 mg/kg dose) Group I = 1.1, Group II = 2.0; and (at 4 mg/kg dose) Group I = 2.3, and Group II = 5.1. The dose of lidocaine, the technique of administration, and the time at which the plasma lidocaine level was drawn as well as whether shock vs. non-shock was present were all highly significant factors (P less than 0.001) in determining plasma lidocaine levels. In summary: (1) endotracheal lidocaine is absorbed during shock and (2) higher plasma lidocaine levels occur during shock than during the non-shock control state. This suggests that the dosage of endotracheal medication may need to be adjusted for various clinical conditions such as shock.

Thallium myocardial scanning in the emergency department evaluation of chest pain.

Chest pain is a common complaint of patients seen in the emergency department. The causes are legion, and range from the non-life threatening to the potentially catastrophic. Thallium heart scanning was done prospectively in 20 patients with a "classic" history for myocardial infarction (eight patients) or atypical chest pain and/or associated symptoms plus an abnormal ECG (12 patients) to discern a subset of patients from whom thallium scintography may be indicated in the emergency department. Although further investigation is needed, our preliminary study suggests that myocardial scanning with thallium can be a safe, fairly rapid, and useful objective parameter in the emergency department detection of suspected myocardial infarction, and in differential diagnosis of chest pain when other data such as the history, physical examination, ECG, or enzymes are inconclusive.

Cricothyrotomy.

Cricothyrotomy is a simple and safe method for obtaining airway control during situations in which endotracheal intubation is difficult or contraindicated. Cricothyrotomy can be a lifesaving procedure. It can be done quickly in emergency situations by nonsurgeons with a minimum of necessary equipment and without requiring an operating room. The anatomy, specific techniques or procedure, indications and contraindications, and the advantages and disadvantages are discussed.

The effect of dilution on plasma lidocaine levels with endotracheal administration.

In the many emergency situations in which it is difficult or impossible to obtain venous access rapidly endotracheal drug therapy can be effective and life saving. Yet relatively little is known about endotracheal drug therapy. Plasma lidocaine levels were measured in 23 dogs after the administration of endotracheal lidocaine at a dose of 2 or 4 mg/kg. Endotracheal lidocaine was given either as a dilution with normal saline (1:1 dilution) or undiluted (Group 1, no dilution; Group 2, dilution). Significantly higher plasma lidocaine levels occurred with the dilution group in all the time periods and with either dose of lidocaine (2 or 4 mg/kg) (P less than .001). Mean plasma lidocaine levels (microgram/mL) at five minutes were: (at 2 mg/kg dose) Group 1, 0.64; Group 2, 3.4; and (at 4 mg/kg dose) Group 1, 1.9, Group 2, 4.7 (P less than .001). Arterial blood gases were not significantly different before or after endotracheal drug administration. This study suggests that higher plasma lidocaine levels are achieved and maintained longer when diluted with normal saline than when given undiluted; and higher plasma lidocaine levels can be obtained by dilution without any detrimental effect on respiratory function as measured by arterial blood gases.

Congenital absence of the C1 vertebral arch.

Congenital absence of part of the anterior arch of the atlas, a rare disorder, was observed in two patients. The defect in the C1 cervical vertebrae, caused by congenital nonfusion of the arch of C1, may be confused with a cervical spinal fracture on plain radiographs of the cervical spine. The diagnosis is established by characteristic radiological changes, especially in the CT scan and bone scan. Because congenital anomalies of the cervical spine may predispose to instability of the cervical spine and can be confused with traumatic lesions, thorough evaluation is warranted. Treatment should be based on signs of instability, if present.

Blunt laryngotracheal trauma.

Four cases of acute laryngeal fracture that demonstrate the history and clinical findings characteristic of blunt laryngotracheal trauma are presented. Symptoms in these patients included shortness of breath, neck pain, dysphasia, dysphonia, and hemoptysis. Physical examination findings suggesting acute laryngeal injury included pain on palpation of neck, swelling or edema of the neck, subcutaneous emphysema, and loss of landmarks in the neck. All four patients were admitted to the surgical intensive care unit and had the diagnosis of laryngeal fracture confirmed at laryngoscopy. Airway obstruction is a potential complication in all patients sustaining blunt laryngotracheal trauma. Early diagnosis and management may lead to a good outcome, as with these four patients.

Effect of technique of administration on plasma lidocaine levels.

There are many clinical situations in which IV access is unavailable, and the endotracheal route is a valuable alternative route for drug therapy. The optimal technique of endotracheal drug administration, however, has not been determined. Twenty-nine dogs were divided into five groups and given endotracheal lidocaine at two doses, 2 mg/kg and 4 mg/kg, by differing techniques: control, undiluted lidocaine in a syringe was given as a bolus; needle, the drug was given through a needle attached to the syringe; dilution, lidocaine was diluted approximately 1:1 with normal saline and the entire dilution was given as a bolus; normal saline (NS) followup, lidocaine in a syringe was given as a bolus, followed immediately by an equal bolus of normal saline; and catheter, the drug was given through a catheter that was placed inside and extended just beyond the endotracheal tube. Mean plasma lidocaine levels (microgram/mL) at five minutes were as follows (at a 2-mg/kg endotracheal lidocaine dose): control, 0.64; needle, 0.0; dilution, 3.1; and (at a 4-mg/kg endotracheal lidocaine dose) control, 1.0; needle, 0.6; dilution, 6.2; NS followup, 1.9; and catheter, 1.9. At all time periods with either dose of lidocaine (2 or 4 mg/kg), the highest plasma lidocaine levels occurred with dilution and the lowest with the needle method. These results were highly significant (P less than .001). The highest plasma lidocaine levels may be attained by diluting the drug with normal saline. Higher levels were achieved when the drug was given through a catheter or when the drug was followed with a bolus of normal saline.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute epiglottitis in adults.

Acute infectious epiglottitis, a serious life-threatening disease because of its potential for sudden upper airway obstruction, is most commonly seen in children, although it can occur in adults. Because acute epiglottitis is uncommon in adults, it is often misdiagnosed. Five cases are presented that demonstrate the clinical characteristics of adult epiglottitis. Knowledge of the symptoms and signs of the disease will lead to early diagnosis and appropriate management, thereby reducing morbidity and mortality rates.

Emergency evaluation of cervical spine injuries: CT versus plain radiographs.

The recognition and appropriate initial management of the patient with an acute cervical spine injury in the ED is important because of the devastating and catastrophic effects of spinal cord injury. The use of computed tomography (CT) scan compared with initial plain radiographs in the detection of acute blunt traumatic cervical spine injury was evaluated in 20 patients. There was a disparity between the plain film and the CT scan as read by an attending radiologist in 12 patients (60%). In five patients (25%) the plain radiograph suggested a fracture or dislocation that was confirmed by CT scan. In eight patients (40%) the cervical spine film was read as a fracture, dislocation, or soft tissue widening between the cervical spine vertebrae. CT scan done later after admission was normal. In the remaining seven patients the plain film was read as "normal." CT scan, however, was normal in only three, and in four of these seven patients there was a discrepancy between the plain radiograph and the CT. Thus in four of 20 patients (20%) the plain film was read as "normal," while CT scan showed a fracture in our study. CT scan was superior to plain films in diagnosing cervical spine trauma, and it eliminated the false-positive (40%) and false-negative (20%) results obtained by relying on plain radiographs alone.

Impairment of urate excretion in patients with cardiac disease.

The serum uric acid levels and uric acid clearance rates were evaluated in 28 patients who had congenital heart disease. Based on hemodynamic assessments, the patients were divided into three groups: group 1, with normal cardiac output and normal arterial oxygen saturation; group 2, with hypoxemia (normal cardiac output with a decreased arterial oxygen saturation); and group 3, with cardiomyopathy (decreased cardiac output). The blood levels of uric acid were elevated in group 3. The mean serum uric acid levels were as follows: group 1, 4.2 mg/dL; group 2, 4.8 mg/dL; and group 3, 11.7 mg/dL. All the patients in groups 2 and 3 had decreased uric acid clearance rates. The mean uric acid clearance rates were as follows: group 1, 10.1 mL/min/sq m; group 2, 4.2 mL/min/sq m; and group 3, 1.7 mL/min/sq m. The patients in group 3 had the most severe abnormalities. Patients with congenital heart disease may have marked impairment of their uric acid excretion, which can occur in the absence of significant renal disease, and may be found in acyanotic as well as cyanotic patients.