Proposed curriculum for an "observational" international emergency medicine fellowship program.

This article presents information on considerations involved in setting up and conducting fellowship training programs in emergency medicine (EM) for physicians from other countries. General goals for these programs are to assist in providing physicians from other countries with the knowledge and skills needed to further develop EM in their home countries. The authors report their opinions, based on their cumulative extensive experiences, on the necessary and optional structural elements to consider for international EM fellowship programs. Because of U.S. medical licensing restrictions, much of the proposed programs' content would be "observational" rather than involving direct "hands-on" clinical EM training. Due to the very recent initiation of these programs in the United States, there has not yet been reported any scientific evaluation of their structure or efficacy. International EM fellowship programs involving mainly observational EM experience can serve as one method to assist in EM development in other countries. Future studies should assess the impact and efficacy of these programs.

Accuracy of reagent strips in detecting hypoglycemia in the emergency department.

STUDY OBJECTIVE: Although reagent strips are commonly used, their reliability to estimate blood glucose concentration and guide administration of dextrose solutions in the emergency department environment has not been proved. We determined the accuracy of visually interpreted reagent strips (Chemstrip bG, Boehringer Mannheim Corp, Indianapolis, IN) and their ability to identify hypoglycemic patients in the ED. METHODS: We conducted a prospective, nonrandomized blinded clinical study of the visual estimation of blood glucose values by ED personnel using Chemstrip bG reagent strips during a 4-month period. Simultaneously obtained blood samples sent for laboratory glucose determination served as controls. The study was conducted at a large university hospital ED with an urban patient population. A convenience sample of 215 adult ED patients underwent serum glucose determination with data form completion. No study intervention was tested, although timing of administration of dextrose solutions, if given, was recorded. RESULTS: Hypoglycemia was defined as a glucose concentration less than 60 mg/dL on standard laboratory analysis. Reagent strips identified 28 of 29 of these patients (sensitivity=97%), and 171 of 182 patients without hypoglycemia (specificity=94%, negative predictive value=99%) compared with control samples. The 1 false-negative reagent strip reading of 80 mg/dL was obtained from blood stored in a serum separator tube and had a laboratory glucose value of 39 mg/dL. Eighty-seven percent of the reagent strips were within +/-60 mg/dL of the control value for the laboratory glucose reference range less than 350 mg/dL. CONCLUSION: Visually interpreted Chemstrip bG reagent strips provide an acceptable estimation of blood glucose concentration in the ED and are highly sensitive in detecting hypoglycemia.

Epidemiology of adult poisoning at China Medical University.

OBJECTIVE: The objective of this study was to evaluate characteristics of the adult poisoned patient population at a university hospital in the People's Republic of China. METHODS: A prospective observational study was conducted at the Department of Emergency Medicine, China Medical University and included all poisoning cases presenting to the Emergency Department during a one year period. Data collection forms were designed and placed in the Emergency Department. Data were recorded by Emergency Department staff for all poisoned patients presenting during the study period (March 1, 1994 to February 28, 1995). RESULTS: Six hundred ninety-eight poisoned patients were collected in this study. Sedative/hypnotic agents (27.9%) were involved most commonly. The second most frequent toxicologic emergency was carbon monoxide (19%). Food poisoning was the third most common cause of poisoning (5.5%) and was equal to pesticide poisoning. The most common route of exposure was ingestion (71%). Twelve percent of the patients were admitted and 2.4% died. CONCLUSION: This first epidemiological report of adult poisoning from the People's Republic of China offers emergency physicians and toxicologists a preliminary understanding of the most common toxicologic problems seen in adults in a university hospital in China, and will aid in improving the delivery of emergency care to poisoned patients in the People's Republic of China.

Pediatric arsenic ingestion.

Acute arsenic toxicity is rare, and there have been no pediatric cases of acute arsenic poisoning in the recent literature. We report a pediatric case of acute arsenic ingestion treated initially with British antilewisite (BAL) and D-penicillamine (DP), and later with dimercaptosuccinic acid (DMSA). A 22-month-old girl ingested 1 oz 2.27% sodium arsenate and developed immediate vomiting and diarrhea. The patient presented to a community emergency department with the following vital signs: blood pressure 96/72 mm Hg, pulse 160 beats/min, respirations 22 breaths/min. She was pale and lethargic. Gastric lavage was performed, and abdominal X-ray was normal. She continued to have gastrointestinal symptoms and received 3 mg/kg BAL. Sinus tachycardia persisted, with heart rate increasing to 200 beats/min. In 12 hours, she was asymptomatic and was started on oral DP. On day 1, 24-hour urine arsenic was 4,880 micrograms/L. She remained asymptomatic and was discharged on day 6 on oral DP. She did well except for a rash that could have been a side effect of DP. On day 8, when the day 5 24-hour urine arsenic level was returned at 650 micrograms/L, the patient was readmitted and started on DMSA. After 4 days on DMSA, the 24-hour urine arsenic level was 96 micrograms/L. White blood cell count and renal and hepatic function remained normal. The excretion half-life was approximately 2.5 days, which is at least 2 to 3 times faster than the spontaneous excretion half-life expected in adults. Long-term follow-up was unavailable.(ABSTRACT TRUNCATED AT 250 WORDS)

Objectives to direct the training of emergency medicine residents of off-service rotations: toxicology.

Toxicology is an integral component in the training of the emergency physician. This is the 27th article in a continuing series of goals and objectives. The article provides basic guidelines for the organization of the toxicology elective with specific goals and objectives and a list of the contents of the toxicology briefcase. This information should aid in providing a comprehensive experience in toxicology for emergency medicine residents.

Use of amrinone and glucagon in a case of calcium channel blocker overdose.

Hypotension resulting from calcium channel blocker ingestion often is refractory to standard therapeutic modalities. Amrinone and glucagon have been used separately and in combination with other agents in the treatment of calcium channel blocker overdose. We report the successful use of both amrinone and glucagon in the treatment of a 30-year-old woman who ingested 3.6 g of verapamil and presented with refractory hypotension. The use of the two agents together may provide improved inotropic support with minimal increases in myocardial oxygen consumption. In this case, the combination of amrinone and glucagon was safe and effective in the management of the hemodynamic instability associated with calcium channel blocker overdose.

Objectives to direct the training of emergency medicine residents on off-service rotations: hyperbaric medicine.

Objectives for Emergency Medicine residents on Hyperbaric Medicine rotations is the 22nd article in this continuing series of "off-service" goals and objectives. The role of the emergency medicine physician in hyperbaric treatment is evolving as part of a multidisciplinary approach to patients with widely divergent disease states who may benefit from serum hyperoxia and compression. Therefore, emergency residents with interests in this area will benefit from clear goals and objectives during a 2 to 4-week Hyperbaric Medicine Elective.

Pulmonary embolism. Incidence in primary cemented and uncemented total hip arthroplasty using low-dose sodium warfarin prophylaxis.

During a 5 1/2-year period from January 1984 to July 1989, 736 patients between the ages of 50 and 75 with a diagnosis of osteoarthritis had either cemented or uncemented primary total hip arthroplasty. Patients were treated with low-dose sodium warfarin for prophylaxis against pulmonary embolism and had preoperative and postoperative serial lung scanning. The overall incidence of pulmonary embolism was not statistically different between the cemented and uncemented groups (3.87% and 6.19%, respectively; P > .05). Eighty-one percent of the pulmonary emboli were asymptomatic. The incidence of pulmonary embolism was higher in men than in women (7.3% and 2.93%, respectively; P < .05) but did not differ within each individual sex for the cemented and uncemented groups. Of greater significance, when the two initial groups were matched to control for sex and weight differences (564 patients), the incidence of pulmonary embolism narrowed to 4.3% and 5.3% in the cemented and uncemented groups, respectively (P > .55). These data indicate that the use of uncemented total hip arthroplasty does not offer any additional protective value against pulmonary embolism when using low-dose sodium warfarin prophylaxis.

Cinchonism: two case reports and review of acute quinine toxicity and treatment.

Two cases of acute quinine toxicity are presented, one from self-poisoning and the other from an unidentified source. Both patients presented with acute bilateral blindness. They also experienced the classic symptoms of cinchonism, including nausea, vomiting, and tinnitus. Prolongation of the Q-T interval developed in both patients. Serum quinine levels of 5.3 mg/L and 13 mg/L were measured. Although their visual acuity improved, both patients had some residual deficit at follow-up. A review of the literature, including clinical presentation and emergency medicine diagnosis and management, is also presented.

Primary total knee arthroplasty for displaced, acute intraarticular knee fractures. A report of four cases.

Primary total knee arthroplasty was performed in four patients with acute intraarticular fractures. All four were at high risk of failure for standard operative and nonoperative treatment because of severe osteopenia, preexisting intraarticular pathology, or a limited life expectancy. All benefited by early pain relief, functional range of motion, and early ambulation, with no early perioperative morbidity.

Insertional femoral fracture: a biomechanical study of femoral component stability.

A Taperloc femoral component (Biomet Inc, Warsaw, IN) was implanted in seven fresh-frozen cadaver femora. In loads simulating single-leg stance and stair climbing, axial and rotational stability were tested before fracture, after fracture, and after fracture but with the addition of A-O cerclage wire fixation. All fractures were incomplete, began proximally at the anteromedial neck, and extended distally. More than 90% of the components showed decreased axial and rotational stability after fracture. The addition of cerclage wire fixation after femoral fracture provided acceptable axial stability in only three of seven femora and rotational stability in five of seven femora. In order to provide satisfactory initial implant stability after femoral fracture, improved methods of fixation and longer stemmed implants may be necessary.