Utility of fever and leukocytosis in acute surgical abdomens in octogenarians and beyond.

BACKGROUND: The study determined the incidence of specific surgical diagnoses in patients age 80 years or older who presented to an emergency department (ED) with acute abdomens and required emergency surgical intervention within 72 hours. The usefulness of an increase in temperature and leukocytosis in the evaluation of each surgical diagnostic group is discussed. METHODS: The study was a retrospective review of ED records and operative reports of patients 80 years or older who were seen from November 1992 to September 1995 at a large midwestern tertiary-care ED with 65,000 annual patient visits. RESULTS: Among the 117 patients who met the inclusion criteria, the most common diagnoses were acute cholecystitis (29 patients), hernia (24), and bowel obstruction (19). The least common diagnoses were Meckel's diverticulum (1 patient), diverticulitis (1), and a carcinoid tumor (1). Temperature increase to more than 37.5 degrees C was statistically more common in patients with acute cholecystitis (13 of 29) and viscus perforation (4 of 11) than in all other patient groups (4 of 77). A leukocyte count of more than 15,500/mm3 was most statistically suggestive of acute cholecystitis (10 of 29 patients), intestinal ischemia (5 of 11), viscus perforation (5 of 11), acute appendicitis (2 of 3), and abscess (1 of 2). Of 115 patients with a recorded temperature and leukocyte count, 35 had a temperature of less than 37.5 degrees C and a leukocyte count of less than 10,500/mm3. CONCLUSION: Acute surgical abdomen in patients 80 years or older has a unique distribution of diagnoses. Although an increase in temperature and marked leukocytosis are not diagnostic of any particular illness, their presence should suggest certain specific surgical illnesses to the practicing clinician. Frequently, elderly patients with acute surgical abdomens present with a normal temperature and leukocyte count.

Use of electron-beam computed tomography in the evaluation of chest pain patients in the emergency department.

STUDY OBJECTIVE: We sought to determine whether electron-beam computed tomography (EBCT) could be used as a triage tool in the emergency department for patients with angina-like chest pain, no known history of coronary disease, normal or indeterminate ECG findings, and normal initial cardiac enzyme concentrations. METHODS: We conducted a prospective observational study of 105 patients admitted between December 1995 and October 1997 to the ED of a large tertiary care hospital with 70,000 annual ED visits. The study group was comprised of women aged 40 to 65 years and men aged 30 to 55 years who presented with angina-like chest pain requiring admission to the hospital or chest pain observation unit. All patients underwent EBCT of the coronary arteries, along with other cardiac testing as deemed necessary by staff physicians. RESULTS: Of the 105 patients, 100 underwent other cardiac testing during hospitalization. Evaluation included treadmill exercise testing in 58, coronary angiography in 25, radionuclide stress testing in 19, and echocardiography in 11. Results of EBCT and cardiac testing were negative for both in 53 patients (53%), positive for both in 14 (14%), positive for tomography and negative for cardiac testing in 32 (32%), and negative for tomography and positive for cardiac testing in only 1 patient. This positive test result, on a treadmill exercise test, was ruled a false positive by an independent staff cardiologist. Two other female patients with normal exercise sestamibi or coronary angiography and EBCT findings also had false-positive treadmill exercise results. The sensitivity of EBCT was 100% (95% confidence interval, 77% to 100%), with a negative predictive value of 100% (95% confidence interval, 94% to 100%). Specificity was 63% (95% confidence interval, 54% to 75%). CONCLUSION: EBCT is a rapid and efficient screening tool for patients admitted to the ED with angina-like chest pain, normal cardiac enzyme concentrations, indeterminate ECG findings, and no history of coronary artery disease. Our study suggests that patients with normal initial cardiac enzyme concentrations, normal or indeterminate ECG findings, and negative results on EBCT may be safely discharged from the ED without further testing or observation. Larger studies are required to confirm this conclusion.

Emergency department evaluation of geriatric patients with acute cholecystitis.

OBJECTIVE: To estimate the frequency of abnormal clinical symptoms, laboratory tests, and diagnostic imaging studies in the ED assessment of elderly (> or = 65 yr) patients with acute cholecystitis, and to compare these factors in young-old (65-74 yr), middle-old (75-84 yr), and old-old (> or = 85 yr) population groups. METHODS: A retrospective, cross-sectional study was performed by review of ED records, hospital charts, and surgical operative reports of consecutive elderly ED patients determined at surgery to have acute cholecystitis. Records were reviewed between April 1990 and April 1995 at a large Midwestern tertiary care facility with 65,000 annual ED patient visits. Clinical signs and symptoms were compared in the young-old, middle-old, and old-old population groups. RESULTS: Of the 168 patients reviewed, 141 (84%) had neither epigastric or right upper quadrant abdominal pain, and 8 (5%) had no pain whatsoever. Only 61 patients (36%) had back or flank pain radiation. Ninety-six (57%) experienced nausea, 64 (38%) had emesis, and 13 (8%) had visible jaundice. Ninety-four (56%) patients were afebrile and 69 (41%) had no increase of white blood cell count. Twenty-two (13%) patients had no fever and all tests were normal. No statistical difference was noted in any symptom or laboratory factor for the 3 age groups, except jaundice was more common among the patients aged > or = 85 years. Ultrasonography was diagnostic for 91%, and CT was beneficial for only 1 patient. Eight patients had normal results on their ultrasonographic and CT studies. CONCLUSION: Classic symptoms and abnormal blood test results are frequently not present in geriatric patients with acute cholecystitis. Increasing age does not appear to affect the clinical and test markers used by clinicians to diagnose this illness. A high degree of awareness is essential for correct diagnosis of acute cholecystitis in geriatric patients.

Abdominal pain in the elderly: use of temperature and laboratory testing to screen for surgical disease.

BACKGROUND AND OBJECTIVES: This study evaluated the usefulness of temperature, leukocyte count, and laboratory screening tests for abdominal pain to distinguish dischargeable from admittable illness and to distinguish admittable, nonsurgical disease from surgical disease in elderly patients (> or = 65 years) who present to the emergency department with acute (< 1 week) nontraumatic abdominal pain. METHODS: A retrospective review was done of emergency department and hospital medical records of these patients from January 1, 1993-December 31, 1993, at a large, Midwestern tertiary care center with 65,000 annual patient visits to the emergency department. RESULTS: Of 231 patients who met the inclusion criteria, 51 were discharged from the emergency department, 94 were admitted without subsequent operation, and 86 were admitted directly for operation or had an operation during hospitalization. For all factors, a statistically significant difference was seen between the patients discharged and those admitted. However, the presence or absence of abnormal test values (hemoglobin, alkaline phosphatase, aspartate aminotransferase, bilirubin, lactate, and the degree of fever and leukocytosis) did not distinguish those who were admitted and did not require operation from those with surgical disease. Surgical diagnoses and prevalence of surgical illness were similar to those observed in prior geriatric studies. A significant number (13%) of surgical patients presented with normal results for all screening tests. CONCLUSIONS: Temperature and laboratory screening tests for evaluation of abdominal pain in the elderly do not differentiate admittable, nonsurgical disease from surgical disease. Physicians who evaluate elderly patients with acute abdominal pain must be aware that their clinical impression of surgical illness is of greater importance than laboratory tests in the decision to request special studies or surgical consultation.

Risk factors for ectopic pregnancy in a rural population.

BACKGROUND AND OBJECTIVES: The study determined the frequency of common risk factors in patients with ectopic pregnancy in a rural-based population (communities with a population less than 60,000). METHODS: The complete medical records were reviewed of all patients with ectopic pregnancy who presented from 1986 through 1992 to the emergency department of a large, rural referral hospital with 65,000 annual visits. RESULTS: Among 126 patients with ectopic pregnancy, the predominant risk factors were a history of infertility in 35% and prior tubal operation in 38%. Pelvic inflammatory disease was a risk factor in 17%, a prior ectopic pregnancy in 16%, and a prior appendectomy or pelvic operation in 13%. No risk factor was identified in 47% of the patients. CONCLUSION: In rural populations, the frequency of common risk factors for ectopic pregnancy is different from that cited in studies of urban populations. Frequently, patients in rural populations have no risk factors whatsoever.

An unusual case of severe griseofulvin-alcohol interaction.

Drug-alcohol interactions in patients who present to emergency departments with a severe "disulfiram-like" illness (including vomiting, diarrhea, flushing, tachycardia, and hypotension) must be recognized and treated appropriately. We report a case of such an interaction caused by oral griseofulvin and alcohol. Emergency physicians should be aware of this potential interaction.

Early defibrillation by police: initial experience with measurement of critical time intervals and patient outcome.

STUDY OBJECTIVE: To assess the feasibility of consistent acquisition of precise and clinically important time intervals in a city police department defibrillation study. DESIGN: On a daily basis, clocks at 911 dispatch were synchronized with those at ambulance dispatch, and all clocks on all defibrillators were synchronized to this time. Times were obtained from recordings at dispatch centers and from defibrillator memory modules. SETTING: City with a population of 70,745 and an area of 30 square miles. PARTICIPANTS: All patients in ventricular fibrillation (VF) treated by police officers using semiautomated defibrillators. INTERVENTIONS: On receipt of a call at 911 dispatch, the nearest squad car was dispatched. If police arrived before the ambulance and a cardiac arrest was confirmed, the closest squad car with a defibrillator was dispatched. Police delivered up to three shocks before ambulance arrival. RESULTS: Of 44 patients in VF, 14 were initially treated by police. Seven of 14 regained a spontaneous circulation with police shocks and seven required additional advanced life support care for restoration of pulses. Ten of the 14 were discharged home. The 911 call-to-shock time interval was 4.9 +/- 1.3 minutes for the seven who regained a spontaneous circulation with police shocks and 6.1 +/- 0.7 minutes for the seven without restoration of pulses by police (P = .035, one-sided, two-sample t-test). CONCLUSION: Acquisition of precise times for determination of time intervals is feasible with a concerted effort to synchronize all clocks from which times are derived. Even small differences in call-to-shock time intervals appear to be critical determinants of restoration of a spontaneous circulation.

Polymyalgia rheumatica and giant cell arteritis in emergency department patients.

Elderly patients with undiagnosed polymyalgia rheumatica and giant cell arteritis are not uncommon, and they may present to the emergency department with nonspecific physical complaints. We describe the cases of two patients who had the "typical" constellation of symptoms. It is important that emergency physicians consider the diagnosis and provide appropriate testing, therapy, and follow-up.

Defining the benefits of rural emergency medical technician-defibrillation.

STUDY OBJECTIVE: To examine the success of rural emergency medical technician-defibrillation (EMT-D) programs in relation to community population size. DESIGN AND SETTING: The four major studies addressing EMT-Ds in communities of fewer than 40,000 persons were reviewed. Additional, unpublished data on community size and neurologic condition of survivors were obtained from the authors. Survivors with prearrest neurologic status in communities with more than 15,000 persons were compared with those in communities of fewer than 15,000 persons. RESULTS: With the exception of the initial rural EMT-D study from Iowa, large communities had a higher rate of prearrest-level neurologic survival than small communities. Control communities appeared to have a slightly lower survival rate than small rural communities. CONCLUSION: Small rural communities cannot expect statistics for prearrest neurologic survival after cardiac arrest to be similar to those from large rural communities. Many emergency medical system factors, such as delay to system access, lack of first-responder CPR, and absence of full-time EMTs, may prevent EMT-D programs in small rural communities from experiencing comparable cardiac arrest survival.

Using regression analysis to predict emergency patient volume at the Indianapolis 500 mile race.

BACKGROUND: Emergency physicians often plan and provide on-site medical care for mass gatherings. Most of the mass gathering literature is descriptive. Only a few studies have looked at factors such as crowd size, event characteristics, or weather in predicting numbers and types of patients at mass gatherings. PURPOSE: We used regression analysis to relate patient volume on Race Day at the Indianapolis Motor Speedway to weather conditions and race characteristics. METHODS: Race Day weather data for the years 1983 to 1989 were obtained from the National Oceanic and Atmospheric Administration. Data regarding patients treated on 1983 to 1989 Race Days were obtained from the facility hospital (Hannah Emergency Medical Center) data base. Regression analysis was performed using weather factors and race characteristics as independent variables and number of patients seen as the dependent variable. Data from 1990 were used to test the validity of the model. RESULTS: There was a significant relationship between dew point (which is calculated from temperature and humidity) and patient load (P less than .01). Dew point, however, failed to predict patient load during the 1990 race. No relationships could be established between humidity, sunshine, wind, or race characteristics and number of patients. CONCLUSION: Although higher dew point was associated with higher patient load during the 1983 to 1989 races, dew point was a poor predictor of patient load during the 1990 race. Regression analysis may be useful in identifying relationships between event characteristics and patient load but is probably inadequate to explain the complexities of crowd behavior and too simplified to use as a prediction tool.

Airway management and air medical transport.

A 5-year retrospective review of airway management by flight nurses was conducted to evaluate airway care and to determine the frequency of surgical cricothyrotomy. Intubation was attempted in 51% of patients, with a success rate of 80%. Oral intubations were attempted in the remaining patients and in those patients in whom initial attempts at nasal intubation failed, with a success rate of 81%. The success rate for intubations was 72% in 1985, 95 % in 1986, 92% in 1987, 97% in 1988, and 76% in 1989. Overall, 87% of patients were successfully intubated and surgical cricothyrotomy was required in only one patient. A greater success rate was achieved when intubations were performed before takeoff than during flight.

Magnetic resonance imaging for calf deep venous thrombophlebitis.

STUDY OBJECTIVE: To compare magnetic resonance imaging (MRI) of the calf with venography for patients with suspected calf deep venous thrombophlebitis (DVT). DESIGN: Ten consecutive adult patients with suspected calf DVT received venography and, within 48 hours, MRI scans. The tests were reviewed blindly by two radiologists, and results of the tests were compared. SETTING: The emergency department of a large teaching hospital with an annual census of 60,000 patients. MAIN RESULTS: All patients with negative venograms had no suggestion of DVT on MRI scan. Two of these patients had other significant demonstrable abnormalities. Four of the five patients with positive venograms had positive calf MRI scans. One patient with a venogram that was difficult to interpret had no DVT on MRI. A thigh DVT was seen on his venogram and was suggested by MRI findings. CONCLUSION: MRI may replace ascending venography as the standard for diagnosis of calf DVT.

Acute abdominal pain in the elderly.

STUDY OBJECTIVES: To determine the incidences of both specific diagnosis and surgical diseases in patients more than 65 years old who present to the emergency department with nontraumatic abdominal pain of less than one week's duration, and to determine the ED staff's ability to diagnose and triage elderly patients with acute abdominal pain. DESIGN: A 12-month retrospective review of all elderly patients who presented to the ED with acute, nontraumatic abdominal pain. SETTING: A regional trauma center serving a predominately rural population in the Midwest. The ED has 55,000 patient visits yearly. MEASUREMENTS AND MAIN RESULTS: Of the 127 patients enrolled, 30 (24%) had no specific diagnosis made in the ED. Biliary tract disease (12%) and small bowel obstruction (12%) were the two most common specific diagnoses. Overall, 53 patients (42%) required surgery, usually during the initial hospitalization. In four cases, the postoperative diagnosis differed significantly from the ED diagnosis. Of the 74 patients (58%) who did not undergo surgery, 51 had follow-up information available. In 14 patients, the follow-up diagnosis differed from the original diagnosis, but most of these changes did not appreciably alter the treatment and outcome. CONCLUSIONS: The incidence of surgical disease is high in elderly patients with acute abdominal pain, and ED staff are able to diagnose and triage these patients accurately.

External transcutaneous pacemakers in interhospital transport of cardiac patients.

From October 1985 to April 1988, 297 patients with presumed unstable angina, acute myocardial infarction, or permanent pacemaker failure were transferred by helicopter from community hospitals to our medical center for tertiary care. Fifty-six patients (19%) experienced treatable bradycardia (heart rate of less than 50) and hypotension (systolic pressure of less than 80 mm Hg); nine patients (16%) improved without treatment, 24 (43%) responded to atropine, and 23 (41%) were unresponsive to atropine. An external transcutaneous pacemaker (EXTP) was applied to patients unresponsive to atropine if a transvenous pacemaker could not be placed. In the atropine-unresponsive group, 11 (48%) had a transvenous pacemaker placed successfully, two (9%) had poor transvenous pacemaker capture (followed by EXTP capture), and ten (43%) were treated with EXTP alone. Eleven patients experienced EXTP capture and improved. Six had profound bradycardia and apnea before EXTP application. Of the 297 patients, 23 (8%) required transvenous or external pacing, and 12 of these patients (52%) survived. The availability of external pacing during interhospital transport of high-risk cardiac patients seems necessary for the management of symptomatic bradycardia and hypotension.

New perspectives on rural EMT defibrillation.

In recent years, several studies have produced contradictory data regarding the impact of emergency medical technicians trained in defibrillation on hospital admission and dismissal survival rates in rural areas. Fourteen communities (service area populations, 4,000 to 36,000) in rural south-eastern Minnesota participated in a two-year crossover study to further define the factors necessary for success. Automatic external defibrillators were used to defibrillate and record patient rhythms in the treatment group and to only record in the control group. Although six of 36 patients (17%) in ventricular fibrillation who experienced a witnessed arrest survived in communities using automatic external defibrillators, compared with one of 27 (4%) in the control group, five of the six survivors were from a single large community with a 911 system, full-time emergency medical technicians, police first-responders, and a well-equipped emergency facility. Our data suggest that certain prerequisites, especially CPR prior to ambulance arrival and collapse to defibrillation times of less than ten minutes, are clearly essential to produce significant benefits from emergency medical technicians trained in defibrillation in rural communities.