Respiratory effects of spinal immobilization.

OBJECTIVE: To evaluate the effect of whole-body spinal immobilization on respiration. METHODS: This was a randomized, crossover laboratory study with 39 human volunteer subjects (20 males; 19 females) ranging in age from 7 to 85 years. Respiratory function was measured three times: at baseline (seated or lying), immobilized with a Philadelphia collar on a hard wooden backboard, and on a Scandinavian vacuum mattress with a vacuum collar. The comfort levels of each of the two methods were assessed on a forced Likert scale. RESULTS: Both immobilization methods restricted respiration, 15% on the average. The effects were similar under the two immobilization conditions, although the FEV1 was lower on the vacuum mattress. Respiratory restriction was more pronounced at the extremes of age. The vacuum mattress was significantly more comfortable. CONCLUSION: This study confirmed the previously reported respiratory restriction caused by spinal immobilization. Vacuum mattresses are more comfortable than wooden backboards.

Managing ankle injuries in the emergency department.

We review the anatomy and physiology of the ankle joint with attention to the structures most likely to be injured. We discuss the epidemiology of ankle injuries and their physical and radiographic evaluation, including the Ottawa Ankle Rules. Treatment, consultation, and pitfalls are followed by more specific discussions of tendonitis, Achilles tendon injury, tendonous subluxations, tarsal tunnel syndrome, sonovial impingement, and injury to the os trigonum. The references provide a guide for further reading.

Ethics and teaching the art of emergency medicine.

This article discusses the art of medicine as it relates to effective teaching. Valuable contributions to such teaching are made through applying ethical considerations to situations unique to emergency medicine. The author includes several appendices for further information on this vital topic.

Cost-utility of three approaches to the diagnosis of sleep apnea: polysomnography, home testing, and empirical therapy.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) is usually diagnosed with overnight polysomnography in a sleep laboratory. Home sleep studies can be performed at lower cost, but results are somewhat less reliable. Bedside diagnosis of OSAS without any testing has also been discussed. OBJECTIVE: To model the costs and utility of laboratory polysomnography, home study, and no testing during the 5 years after initial evaluation for OSAS. DESIGN: Cost-utility analysis. DATA SOURCES: Published data. TARGET POPULATION: Hypothetical cohort of persons suspected of having OSAS. TIME HORIZON: The 5 years after initial evaluation for OSAS. PERSPECTIVE: Societal. INTERVENTION: Nasal continuous positive airway pressure when OSAS was diagnosed. MEASUREMENTS: Quality of life, survival and charges (as proxies for costs) for each diagnostic method. RESULTS OF BASE-CASE ANALYSIS: Under almost all modeled conditions, polysomnography provided maximal quality-adjusted life-years in the 5 years after the initial diagnostic evaluation. The incremental charges for polysomnography over home study or no testing were about $13,400 and $9200, respectively, per quality-adjusted life-year gained during this period. RESULTS OF SENSITIVITY ANALYSIS: Results were sensitive to the utility of treatment in the absence of OSAS. CONCLUSIONS: The cost-utility of polysomnography instead of home study or no testing in the diagnosis of OSAS compares favorably with that of other procedures for which society judges the added utility per dollar spent to be worthwhile. More precise determination of certain key variables in this model should be a goal of future research.

Propofol bolus facilitates reduction of luxed temporomandibular joints.

"Locked" or dislocated temporomandibular joint (TMJ) is a common problem in emergency medicine. Like many other joint dislocations, the repositioning of the joint can be facilitated by conscious sedation and muscular relaxation. Propofol is a useful agent for use in the emergency department because of its extremely short half-life, its antiemetic properties, and its safety record. We report two cases of locked TMJ that were repositioned under sedation with propofol. We review methods for repositioning the locked TMJ and review appropriate agents for sedation and muscular relaxation.

Neuroleptic malignant syndrome presenting without initial fever: a case report.

Neuroleptic malignant syndrome (NMS) is a rare but potentially fatal complication of the use of neuroleptic medications. It is of interest to emergency physicians because rapid recognition of NMS will improve patient outcome and prevent inappropriate treatment. NMS shares features with malignant hyperthermia, serotonin syndrome, lethal catatonia, and heat stroke. We describe a patient with NMS who presented to our institution without initial fever. We review the literature, the classic presentation of NMS, the risk factors, and the morbidity. We discuss the differential diagnosis and the treatment recommendations from the literature.