Efficacy and safety of ofloxacin and its combination with dexamethasone in chronic suppurative otitis media. A randomised, double blind, parallel group, comparative study.

The role of corticosteroid in patients of chronic suppurative otitis media (CSOM) is unknown. In the present study, the efficacy and safety of ofloxacin alone (OA) and the ofloxacin + dexamethasone combination (ODC) is compared by studying clinical cure rates and adverse drug reactions in patients with CSOM. After prior permission from the Institutional Review Board and written informed consent from patients, pre-treatment clinical assessment and bacteriology of the middle ear discharge were done. The middle ear was categorised into active, mucoid or inactive according to the type of discharge. Grades of otorrhoea and size of tympanic membrane perforation were noted. CSOM with organisms sensitive to ofloxacin were treated either with OA or ODC eardrops for a period of 15 days. Post-treatment clinical cure (when grade of otorrhoea become 0) was recorded on the 5(th), 10(th) and 15(th) days and bacteriological assessment was recorded at the last visit. All parameters were analysed using Fisher's exact test. A total 110 patients were randomised. The most common microorganism associated with CSOM was Pseudomonas aeruginosa (45.45 %). Clinical improvement was seen in 84.61% and 86.79% of cases, but bacteriological improvement in only 82.69% and 77.35% of cases treated with OA and ODC, respectively. Shift of middle ear discharge from active to inactive was noted in 71.15% and 64.15% patients by the 10th day in the OA and ODC groups, respectively. As there was no difference in clinical or bacteriological improvement, it may be unnecessary to combine steroids with topical antibiotic preparations for management of CSOM.

Anti-urolithiatic effect of cow urine ark on ethylene glycol-induced renal calculi.

PURPOSE: To investigate the anti-urolithiatic effect of cow urine ark (medicinal distilled cow urine) on ethylene glycol (EG) induced renal calculi. MATERIALS AND METHODS: 36 male Wistar rats were randomly divided into 6 equal groups. Group I animals served as vehicle control and received distilled water for 28 days. Group II to VI animals received 1% v/v EG in distilled water for 28 days. Group II served as EG control. Group III and IV (preventive groups) received cow urine ark orally for 28 days in doses of 1 mL/kg and 2 mL/kg, respectively. Group V and VI (treatment groups) received 1 mL/kg and 2 mL/kg cow urine ark orally, respectively from 15th to 28th days. 24-hour urine samples were collected on day 0 and 28. Urine volume and oxalate levels were measured. On day 28, blood was collected for biochemical parameters. Animals were sacrificed and kidneys were harvested, weighed and histopathologically evaluated for calcium oxalate (CaOx) crystals. To calculate the percentage of inhibition of mineralization, simultaneous flow static in-vitro model was used. RESULTS: EG significantly increased urine oxalate, serum creatinine, blood urea level; kidney weight and CaOx deposits. Provision of cow urine ark resulted in significantly lower levels of urine oxalate, serum creatinine, blood urea and CaOx depositions as compared to Group II. (p value < 0.05) It also significantly restored kidney weight. (p value < 0.05) Cow urine ark inhibited 40% and 35% crystallization of CaOx and calcium phosphate, respectively. CONCLUSION: Cow urine ark is effective in prevention and treatment of EG induced urolithiasis in Wistar rats.

Anti-Urolithiatic Effect of Cow Urine Ark on Ethylene Glycol-Induced Renal Calculi

Purpose To investigate the anti-urolithiatic effect of cow urine ark (medicinal distilled cow urine) on ethylene glycol (EG) induced renal calculi. Materials and Methods 36 male Wistar rats were randomly divided into 6 equal groups. Group I animals served as vehicle control and received distilled water for 28 days. Group II to VI animals received 1% v/v EG in distilled water for 28 days. Group II served as EG control. Group III and IV (preventive groups) received cow urine ark orally for 28 days in doses of 1 mL/kg and 2 mL/kg, respectively. Group V and VI (treatment groups) received 1 mL/kg and 2 mL/kg cow urine ark orally, respectively from 15th to 28th days. 24-hour urine samples were collected on day 0 and 28. Urine volume and oxalate levels were measured. On day 28, blood was collected for biochemical parameters. Animals were sacrificed and kidneys were harvested, weighed and histopathologically evaluated for calcium oxalate (CaOx) crystals. To calculate the percentage of inhibition of mineralization, simultaneous flow static in-vitro model was used. Results EG significantly increased urine oxalate, serum creatinine, blood urea level; kidney weight and CaOx deposits. Provision of cow urine ark resulted in significantly lower levels of urine oxalate, serum creatinine, blood urea and CaOx depositions as compared to Group II. (p value < 0.05) It also significantly restored kidney weight. (p value < 0.05) Cow urine ark inhibited 40% and 35% crystallization of CaOx and calcium phosphate, respectively. Conclusion Cow urine ark is effective in prevention and treatment of EG induced urolithiasis in Wistar rats. .

Bedside echocardiography by emergency physicians.

STUDY OBJECTIVE: Timely diagnosis of a pericardial effusion is often critical in the emergency medicine setting, and echocardiography provides the only reliable method of diagnosis at the bedside. We attempt to determine the accuracy of bedside echocardiography as performed by emergency physicians to detect pericardial effusions in a variety of high-risk populations. METHODS: Emergency patients presenting with high-risk criteria for the diagnosis of pericardial effusion underwent emergency bedside 2-dimensional echocardiography by emergency physicians who were trained in ultrasonography. The presence or absence of a pericardial effusion was determined, and all images were captured on video or as thermal images. All emergency echocardiograms were subsequently reviewed by the Department of Cardiology for the presence of a pericardial effusion. RESULTS: During the study period, a total of 515 patients at high risk were enrolled. Of these, 103 patients were ultimately deemed to have a pericardial effusion according to the comparative standard. Emergency physicians detected pericardial effusion with a sensitivity of 96% (95% confidence interval [CI] 90.4% to 98.9%), specificity of 98% (95% CI 95.8% to 99.1%), and overall accuracy of 97.5% (95% CI 95.7% to 98.7%). CONCLUSION: Echocardiography performed by emergency physicians is reliable in evaluating for pericardial effusions; this bedside diagnostic tool may be used to examine specific patients at high risk. Emergency departments incorporating bedside ultrasonography should teach focused echocardiography to evaluate the pericardium.

The importance of serial neurologic examination and repeat cranial tomography in acute evolving epidural hematoma.

Computed tomography (CT) has revolutionized the diagnosis and management of head-injured patients, and its increasing availability has led to its liberal use. CT scanning provides excellent anatomic detail of the brain as fixed static images, but the dynamic nature of human physiology means that many injury patterns will evolve in time. We describe an 8-year-old child who had fallen 8 feet from a tree. He had a brief loss of consciousness but a normal neurologic evaluation on arrival to the emergency department (ED). He underwent expedited cranial CT scanning, which revealed no acute brain injury. Two and one half hours later, the patient had a mild depression in consciousness, prompting a second CT scan in the ED, which revealed an acute epidural hematoma. He had acute surgical evacuation of the hematoma and made a full neurologic recovery. This case illustrates that a single early CT examination may at times provide a false sense of security and underscores the importance of serial neurologic examinations.

The UHP ultrasound protocol: a novel ultrasound approach to the empiric evaluation of the undifferentiated hypotensive patient.

This report describes a novel sonographic protocol for the evaluation of the undifferentiated hypotensive patient. This protocol combines components of 3 sonographic applications: free fluid, cardiac, and abdominal aorta into a single protocol. We believe this protocol and its underlying principles should be a routine part of the empiric evaluation of the patient with undifferentiated hypotension or pulseless electrical activity.

Incidental findings during emergency sonographic examinations: a case series.

The teaching of ultrasonography is rapidly being incorporated into emergency medicine (EM) training programs and clinical practice. Most literature focuses on appropriate indications for the performance of emergency ultrasonography, and most EM-related courses and programs limit their teaching to standard focused indications. Generally this will suffice; however, occasionally, incidental findings, which are beyond the realm of what is taught in these programs, have influenced patient care. In this paper we discuss 7 cases in which incidental findings were discovered during an emergency sonographic examination. In each case the findings changed the patient's disposition, diagnosis and, potentially, outcome.

Ultrasound training for emergency physicians--a prospective study.

OBJECTIVES: Bedside ultrasound examination by emergency physicians (EPs) is being integrated into clinical emergency practice, yet minimum training requirements have not been well defined or evaluated. This study evaluated the accuracy of EP ultrasonography following a 16-hour introductory ultrasound course. METHODS: In phase I of the study, a condensed 16-hour emergency ultrasound curriculum based on Society for Academic Emergency Medicine guidelines was administered to emergency medicine houseofficers, attending staff, medical students, and physician assistants over two days. Lectures with syllabus material were used to cover the following ultrasound topics in eight hours: basic physics, pelvis, right upper quadrant, renal, aorta, trauma, and echo-cardiography. In addition, each student received eight hours of hands-on ultrasound instruction over the two-day period. All participants in this curriculum received a standardized pretest and posttest that included 24 emergency ultrasound images for interpretation. These images included positive, negative, and nondiagnostic scans in each of the above clinical categories. In phase II of the study, ultrasound examinations performed by postgraduate-year-2 (PGY2) houseofficers over a ten-month period were examined and the standardized test was readministered. RESULTS: In phase I, a total of 80 health professionals underwent standardized training and testing. The mean +/- SD pretest score was 15.6 +/- 4.2, 95% CI = 14. 7 to 16.5 (65% of a maximum score of 24), and the mean +/- SD posttest score was 20.2 +/- 1.6, 95% CI = 19.8 to 20.6 (84%) (p < 0. 05). In phase II, a total of 1,138 examinations were performed by 18 PGY2 houseofficers. Sensitivity was 92.4% (95% CI = 89% to 95%), specificity was 96.1% (95% CI = 94% to 98%), and overall accuracy was 94.6% (95% CI = 93% to 96%). The follow-up ultrasound written test showed continued good performance (20.7 +/- 1.2, 95% CI = 20.0 to 21.4). CONCLUSIONS: Emergency physicians can be taught focused ultrasonography with a high degree of accuracy, and a 16-hour course serves as a good introductory foundation.

The comparative accuracy of radiolucent foreign body detection using ultrasonography.

The purpose of this prospective study was to determine the accuracy of ultrasonography in detecting radiolucent foreign bodies and to compare the performance of three newly trained emergency physicians with two experienced ultrasound technologists and one radiologist. One hundred-four chicken thighs were penetrated with a needle-driver, half of them embedded with a 1.5 cm toothpick. An 8.0 MHZ linear array ultrasound probe was used to detect the presence or absence of the foreign body. The overall accuracy (95% confidence interval [CI]) was 82% (79, 85); sensitivity 79% (74, 83), specificity 86% (82, 90), positive predicative value (PPV) 85% (81, 89), and negative predicative value (NPV) 80% (76, 84). The accuracy (95% CI) of the radiologist was 83% (75, 90); of the ultrasound technologists was 85% (80, 90); and of the emergency physicians was 0% (76, 85). The difference in accuracy among the three types of personnel was not statistically significant. Ultrasonography is an accurate modality in detecting radiolucent foreign bodies. Emergency physicians can be trained to provide a degree of accuracy comparable with more experienced ultrasonographers.

Emergency airway management in penetrating neck injury.

STUDY OBJECTIVES: Airway management in the context of penetrating neck injury is a challenging scenario. Management decisionmaking has not been well studied and the initial airway approach remains controversial. We examined various initial emergency airway techniques and their success in the setting of penetrating neck trauma. METHODS: A retrospective study was conducted of emergency department intubations in penetrating neck injury from January 1, 1993, to December 31, 1996, at a Level I trauma center. Cases of out-of-hospital traumatic arrest or out-of-hospital intubation were excluded. Successful airway management was defined as endotracheal tube placement confirmed by clinical evaluation, pulse oximetry, chest radiography, and end-tidal CO(2) detection. RESULTS: During the study period, 748 consecutive patients with penetrating neck injury were evaluated in the ED. Of these, 82 (11%) were deemed to require immediate airway management. Twenty-four of the 82 were excluded because of out-of-hospital traumatic arrest or out-of-hospital intubation, resulting in a study population of 58 patients. Of these 58 patients, 39 had initial rapid sequence intubation using succinylcholine with a 100% success rate. Five comatose patients had successful orotracheal intubation without paralysis, and 2 patients underwent successful emergency tracheostomy. The remaining 12 patients had initial fiberoptic intubation by otolaryngology clinicians, which was unsuccessful in 3 patients. All 3 of these patients were subsequently successfully orotracheally intubated using the rapid sequence intubation technique. Therefore, oral endotracheal intubation was the definitive method of airway management in 47 (81%) of the 58 patients and was successful in all cases. CONCLUSION: Rapid sequence intubation was the most commonly performed initial technique by emergency physicians and was safe and effective in all cases attempted. Furthermore, rapid sequence intubation methodology resulted in successful intubation of the fiberoptic intubation failures. Physicians with airway expertise should consider using rapid sequence intubation as an initial airway technique in managing patients with penetrating neck injury who require airway control.

Serial abdominal ultrasound in the setting of trauma.

Ultrasound is gaining wide acceptance in Emergency Medicine as an inexpensive and accurate examination modality. One of the leading uses of this technology is in the initial assessment of the trauma patient, where the ultrasound examination is often used to determine the need for immediate laparotomy or further diagnostic study. We present a series of four patients, all of whom sustained blunt or penetrating abdominal trauma. In each case, the initial screening abdominal ultrasound was negative for free intraperitoneal (i.p.) fluid but, when repeated by the same practitioner, became positive. These cases demonstrate the need for serial ultrasounds in evaluating the patient with abdominal trauma. Future studies of trauma ultrasound should investigate the utility of serial sonographic examinations.

Ultrasonography of flank pain in the emergency department: renal cell carcinoma as a diagnostic concern.

Acute flank pain is a common emergency department presenting symptom, and bedside ultrasound is being used increasingly in its evaluation. Emergency renal ultrasonography concentrates on the focused presence or absence of hydronephrosis as is often seen in patients with acute flank pain secondary to renal colic. We present three cases in which other abnormal sonographic signs not commonly taught prompted further investigation, revealing renal cell carcinoma. Baseline knowledge of sonographic characteristics of tumors will benefit the occasional emergency patient who has unsuspected renal carcinoma.

The first Australian workshop on bedside ultrasound in the Emergency Department.

AIMS: Bedside ultrasound is not widely practised by emergency physicians in Australasia despite its use in Europe, Asia and North America, and an extensive medical literature on the subject. A workshop was organised at Auckland Hospital, aiming to introduce emergency physicians to the basics of emergency ultrasound. This article summarises the content of the programme, the responses from the participants and the principles that emerged at this workshop. METHODS: A standardised, 16-hour, emergency ultrasound curriculum was offered to 23 participants. Lectures with syllabus material were used to cover the following topics: basic ultrasound physics, pelvis, right upper quadrant, renal, aorta, trauma and echocardiography. Each participant received eight hours of hands-on ultrasound instruction. On completion of the course participants responded anonymously to a course appraisal questionnaire. RESULTS: Twenty-one participants responded to the questionnaire (91% response rate). Delegates found the course informative and the material was considered relevant. Workshop objectives were met and the venue was appropriate. Most participants thought the practical sessions could be improved by decreasing the ratio of delegates to human models. CONCLUSIONS: The first Australasian workshop on bedside ultrasound in the Emergency Department held in Auckland (February 1998) was successful in achieving its objectives. Focused emergency ultrasound can be taught to detect free intraperitoneal or pericardial fluid in trauma patients. There is a need for appropriate quality assurance and credentialling guidelines as more Australasian emergency departments consider the application of focused ultrasound.

Cardioversion of paroxysmal atrial fibrillation in the emergency department.

STUDY OBJECTIVE: Patients presenting to the emergency department with acute atrial fibrillation are traditionally admitted to hospital. The objective of this study was to review the success and safety of ED cardioversion and discharge of patients with acute atrial fibrillation. METHODS: This health records survey included a cohort sample of consecutive patients presenting with acute atrial fibrillation to the ED of a university-affiliated tertiary hospital. Patients who were in unstable condition on presentation, who had a complicating cardiac diagnosis, or those with other medical or surgical conditions requiring admission were excluded from the study analysis. Patient visit information was entered into a database that included demographics and clinical presentation, investigations, ED therapy, complications, consultations, disposition, and follow up. Patient visits were then categorized into the following groups: no ED intervention, spontaneous resolution, heart rate control, attempted chemical cardioversion, or electrical cardioversion. The data were analyzed using descriptive methods. RESULTS: Of the 289 eligible patients seen during an 18-month period, 62% (180) underwent attempted chemical cardioversion with a 50% success rate and 28% (80) had attempted electrical cardioversion with a 89% success rate. Ninety-three percent of electrical cardioversions were performed by emergency physicians. There was an overall 6% (19) complication rate, 95% of which were regarded as minor. One patient had a complication caused by a rate control medication, which necessitated hospital admission. Ninety-seven percent (280) of the patients were discharged home directly from the ED. CONCLUSION: Cardioversion and immediate discharge of patients who present to the ED with acute atrial fibrillation appears to be both safe and effective. This management approach should be prospectively evaluated in multiple settings.

Geriatric trauma.

This article reviews the salient aspects of geriatric trauma, including common injury mechanisms, physiologic differences in elderly patients, and their prehospital and emergency department evaluation. Specific organ injuries and associated mortality are also discussed.