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8th International Conference on Emergency Medicine, Abstracts 127-144
8th I N T E R N A T I O N A L CONFERENCE ON EMERGENCY M E D I C I N E ABSTRACTS
27 Interpersonal Inpatient and Outpatient Hospital Costs of Young Victims of Violence Zun L/Mount Sinai Hospital, Chicago, IL Study objectives: Young xactuns of violence have varying costs depending on whether they are admitted or discharged from the emergency department. The purpose of the study was to compare the mpatmnt, observational, and outpatmnt hospital costs of those young persons aged 10 to 24 years who are vmtims of interpersonal violence. Methods: The study design was a chart review of consecunve sample of young persons ages 10 to 24 years who were vlcnms of life- or limb-threatemng interpersonal violence in 1998-1999, excluding domestic, sexual assault, and child abuse. The study was exempt from institutional review board The study site is a community, teaching Level I trauma center. The patients' ED presenting vital signs, arrival mode, tNury location, procedures, radiographs, alcohol and drug use, laboratories, prior visits, and
disposition were assessed. The hospital costs were calculated as 50% of charges. The costs did not include the physician, rehabilitation, personal, or societal costs Appropriate statistical analysis and correlations were made usmg SPSS software. Results: Two hundred twenty-eight cases were revmwed; 86.8% were male, 64.9% Afncan Americans, 32.5% Hlspamcs, and 41.2% were brought by ambulance. There were 72.8% gunshots, 16.8% blunt trauma, and 10.4% stabbing; 58 0% were admitted to the hospital, 11% were observed, and 29% were discharged from the ED. The average hospital cost was $14,975 for the patients admitted, $2,904 for those observed, and $1,033 for those who were discharged. Hospital admissions were positively correlated with gender, arnval mode, alcohol and drug use, and negatively correlated to insurance status compared with those discharged (P<.05) and not correlated vnth age, race, vital signs, mechanism, or location (P<.05). The average stay was 5.73 days for patients who were admitted. Gunshot injuries are assocmted with higher costs ($11,495) than other mechanisms of trauma (stab $3,731 and blunt $7,838) but were not statistically significant. The mechanism of injury is correlated with computed tomograph of the head and not correlated with admissions, gender, age, or vital signs (P<.05). Conclusion: There was a significant cost m canng for adolescents who are VlCtZms of interpersonal violence and a large differentml between in and outpatient hospital costs.
It would be desirable for other centers to repeat and, if possible, confirm and expand on these results, as there has been little improvement in efficacy of ACLS since the mid-1900s with new therapeutic approaches.
Table, abstract 128. ROSCSustainedOver Group
Initial ROSC
Group 1 : 1 atm/abs01ute(n=6) Group2:2 atm/abs01ute (n=6) Group 3 : 4 atm/abs01ute (n=6)
129
0/6 0/6 5/6
2-Hour Period
0/6 0/6 4/6
.
The Analysis of Erythrocyte Sedimentation Rate, C-Reactive Protein, White Blood Cell Count, and Temperature in the
Diagnosisof AcuteEndocarditis Chuang R, 01shaker J, Robinson D/University of Texas at Houston, Houston, TX, University of Mar/land, Baltimore, MD
VanMeter I(W, Swanson HT, Sheps SS, Barratt DM, Roycraft EL, Moises J, Killee J, Hatch
Study objective: This study attempts to determine whether the levels of initial erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), WBC count, or temperature tend to correlate with the eventual diagnosis of endocardttis. Methods This prospectwe cohort study was conducted in an urban umversity medical center of all suspected cases of endocardms that presented to the emergency department from August 31, 1998, to March 31, 1999. These included all febrile mtravenous drug abusers, and any other patients with suspected native or artificial valve endocardins who were admitted through the ED. The initial WBC count, ESR, CRP, and highest ED temperatures were recorded on these patients Data were then prospectively collected and are represented as mean ±SD. P values were calculated with the 2-tailed Student's t test. Results: A total of 147 consecutive cases were analyzed vath 14 confirmed cases of endocarditis. The lnitml ESP,s were higher in those with endocardms (56.5±6.1 versus 45.6±14.8, P= 01), as were CRP levels (16.1±10.1 versus 7.2±6 9, P<.001), and WBC counts (16.3±11.7 versus 8 4±5.i, P<.O01). The pauents' maximum temperatures in the ED were similar m both groups (101.7°F versus 101.6°I:, P=.84). Using the normal laboratory limits of ESR for the diagnosis of endocarditis, the sensitivity is 100% and specificity of 9.8%. For CRP, the sensitivity is 100% and specificity is 6%.
PG/Louis4anaState University Health SciencesCenter, New Orleans, LA; Tulane University School of Medmine, New Orleans, LA; Baromedical ResearchInstitute, New Orleans, LA
However, the lowest ESRs and CRP level in the confirmed cases of endocardms were twice the upper level limit of normal for ESR, and 7 times the upper limit for CRP.
Study objective: A previous controlled prospective, randomized study of closedchest cardiopulmonary resuscitation (CPR) in gumea pigs demonstrated advantage of hyperbaric oxygen over normobaric oxygen (after a 1 atm normothermic cardiopulmonary arrest) in affecting lasting return of spontaneous circulation (ROSC). This study investigates a similar approach using open-chest CPR in swine instead,
Using these values, the specificity increases to 25°/0 and 44%, respectively. Conclusion This pilot study demonstrates that none of the eventually confirmed cases of endocardltls had normal initial ESRs or CRPs. These relatively inexpensive tests may prove to be valuable mmal screenmg tests for the exclusion of endocardms in the urban population lacking follow-up.
Methods' This IACUC approved study incorporated the prospective random,zed assignment of 6 swine each to 1, 2, and 4 atm 25 minutes normothermic (37 5°C) cardiopulmonary arrest induced by AC current by catheter apphed directly to the epi-
130
cardmm to produce ventricular fibnllanon. After 25 minutes of cardmpulmonary
Aggarwal P, Wall dP, Smgh 0, Handa R, Dwivedi SN, Wig N, Biswas A/All India Institute of Medmal Sciences, New Delhi, India
28 Oxygen DoseCardiopulmonary Response in 0pen-Chest ACLS in Swine Alter a Arrest 25-Minute
arrest, the animals received cardiac compression by a mechanical ventricular assist device (MVAD) and ventilation by mechanical ventilator with 100% O 2 at the randomly assigned ambient pressures used. Standard American Heart Assocmuon Advanced Cardiac Life Support drug and defibrillation protocols were followed. ROSC was defined as the ability of the ammal to maintain a femoral arterial pressure greater than or equal to 90/50 m m Hg without assistance of an MVAD The ammals were evaluated after inmation of the resuscitative effort for inmal ROSC and sustainable ROSC over the next 2 hours, The animals were sacrificed at 2 hours after initial arrest. A 2-tailed Fisher's exact test was used to analyze study results to obtain a relevant P value, Results: Results are shown m the Table. Conclusion Ventilation vnth oxygen at 4 atm ambient pressure may be more effecrive than with oxygen at 1 and 2 atm of ambient pressure when resuscitating swine after a prolonged normothermic cardiopulmonary arrest of 25 minutes. The results for both mitial ROSC and sustained 2-hour ROSC achieved a level of significance (P<-.0049) by a 2-tailed Flsher's exact test for group 3 over the combined groups 1 and 2 (Table).
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Role of Nebulized Ipratropium in Acute Bronchial Asthma
Study objecuves: Nebulization of ~-agomsts is the first-fine therapy in patients with acute asthma IpratropIum bromide, an anticholinergic, is also being used in pauents with acute asthma. However, its exact role remams to be defined. The present study was aimed at determining the efficacy of ipratropium given alone or in combination with salbutamol compared with salbutamol alone in patients with acute bronchial asthma Methods: The study was conducted at the Department of Emergency Medicine of a tertiary care hospital. To determine the efficacy of ipratropmm and salbutamol, given alone and in combination, a total of 69 patients with acute asthma were studied over an 18-month period (1997-1998) Informed consent was obtained from the subjects before they were randomly assigned into 3 groups Group A patients recmved 5 mg of salbutamol nebuhzed at 0 and 60 minutes. Patients m group B received 500 I.tg of nebulized ipratropium bromide at 0 and 60 minutes, and group C received a combmauon of 5 mg of salbutamol and 500 I.tg of ipratropium bromide at 0 minutes followed by
ANNALS OF EMERGENCY MEDICINE 35:5 MAY 2000
8th I N T E R N A T I O N A L CONFERENCE ON EMERGENCY MEDICINE ABSTRACTS
saline solution at 60 minutes. Patients were blinded to the nature of the treatment. They were monitored for 120 minutes with peak expiratory flow rate and vital signs, Blood gas analysis and electrolytes were obtained at the entry and at 120 minutes. Results: The 3 groups did not differ significantly m age, and basehne vital signs. peak expiratory flow rate, and oxygen saturation The peak expiratory flow rate increased gradually in all groups, but there was no slgmticant difference in the level of bronchodilatation among any group at any time during the study. On analysis of sub
Conclusion. Adenosine is safe and effective in terminating SVT. The most common conversion rhythms are multiform PVCs and nonsustamed ventricular tachycardla.
group of patients with severe asthma (as defined by mttial peak expiratory flow rate below 140 L/min), no significant difference in improvement in peak expiratory" flow rate was found among various subgroups. There were no significant side effects expertenced by patients in any of the groups. Furthermore, the reqmrement of addmonal medications also did not differ in the 3 groups. Only one patient required hospitalization as a result of inadequate response to treatment at the emergency department, Conclusion: We conclude that ipmtropium is an effective bronchodilator in patients with acute asthma. However, there was no slgmficant benefit of combining ipratropium with salbutamol
Study objective: To measure the ability of semiautomatic external defibrillators (SAEDs) to detect and defibrillate unstable cardiac rhythms (ventricular fibrillation [VF], yenmcular tachycardia [VT]) in the out-of-hospital setting. Methods: SATEDperformance data were reviewed for cardiac arrests occurring between January i, 1995, and December 31, 1997. During that period, all Boston emergency medicine services (EMS), fire department, and airport rescue staff used SAEDs to treat cardiac arrest. After every cardiac arrest, data regarding each rhythm analyzed and the subsequent response (shock or no shock) were downloaded from the SAED memory module. The study paramedic and a single study physician independently reviewed each case and interpreted the car&ac rhythms from the downloaded SAED data. A group of EMS physicians independently resolved any d,screpancies. All cases of outof-hospital cardiac arrest in which an SAED was turned on and a rhythm analyzed were included. The primary endpoint was the correct identification and defibrillation of VF or VT. Sensltiwty, specificity, predictive values, and accuracy with 95% confi-
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Nausea and Opioid Use in an Emergency Medicine Setting
GossmanW, DowneyLA, Zun L/Mt. Sinai HospitalMedicalCenter,Chicago,I1_;FinchUniversity of Health Sciences,The ChicagoMedicalSchool,Chicago,IL Study" objectives: To examine the relationship between types of oDoids given for control of pain and the onset of nausea requiring an antiemetic. Methods: Male and nonpregnant females who presented to the Level I trauma center with an acute pain episode and or chronic pain that required the administration of opioid analgesic were eligible for this study. The majority of subjects were given motphine, Demerol, and Vmodin This is a retrospective study, which used data collected over a 3-year period. Of 386 patients who presented at the facility and required the admmlstrauon of optoid analgesm, 78 needed the admimstration of an anuemetic. Using statistical analysis, we examined the relanonshlp between patient's age, race, gender, pain etiology, and/or trauma location, presenting pare scale, first drag used including dosage and route, and requirement for an antiemetic, Results: At the .05 significance level, gender and the administering of morphine showed a slgnffmant relationship. Females were more likely to require an anuemetic when given morphine compared with males.
132 Tachycardia Conversion Rhl/thms From Adenosine in Treating Supraventricular Ooi SBS,CguaBK/NationalUniversityHospital,EmergencyMedicineDepartmentand Cardiac Department, Singapore study objecnves: To study the conversion rhythms, duration to conversion, and adverse outcomes from use of adenosine m treating supraventricular tachycardia (SVT). Methods: This prospective observational study was conducted m the emergency department of a tertiary teaching hospital Consecutive cases of SVT m both adult and pediatric patmnts treated by the first author using intravenous adenosine were studmd. Using a proforma, the doses of adenosine, rime to conversion, side effects, longest rhythm pause after adenosine administration, length of conversion rhythm to resumption of regular sinus rhythm, and the types of conversion rhythm were studmd. Results: Thirteen patients ranging m age from 9 to 71 years were studied during a 2-year period. Only 1 of 13 patients failed to have the SVT converted after the max> mum dose, yielding a success rate of 92.3%. The median time from adenosine administration to start of conversmn was 20 seconds (range 15 to 30 seconds). There was slmving of the rhythm of a median of 2 beats (range 1 to 5 beats) before the start of the conversion rhythm in 9 (75%) of the cases. The median duration from start of conversion rhythm to resumpUon of regular normal smus rhythm was 9.8 seconds (range 3.4 to 32.4 seconds). The longest rhythm pause encountered after adenosine administration was a median of 1.3 seconds (range O 8 to 2 3 seconds) The transient side eftects encountered were chest pare (23.1%), dyspnea (23.1%), flushmg (15.4%), lightheadedness (23.1%), and headache (7.7%). There were no major adverse outcomes, The rhythms encountered were mulnform premature ventricular contractions (PVCs) (75.0%), nonsustained venmcular tachycard~a (41.7%), sinus tachycardm (16.7%), umfocal premature atrial contractions (16.7%), unifocal PVCs (16.7%), and atrioventricular block (8.3%).
MAY 2000 35:5 ANNALS OF EMERGENCY MEDICINE
133
PerformanceAnalysis of Semiautomatic Defibrillators Used in the Out-of-Hospital Setting
MacDonaldRD, Swanson JM, Mottley Jk, Weinstein C/B0ston Medmal Center, Department of EmergencyMedicine, Boston, MA;Boston EmergencyMedicalServices, Boston, MA
deuce nrtervals (Cls) were calculated. Interobserver reliability was computed using statistics to compare the paramedic and physician interpretations with the consensus rhythm determination. Results: During the study penod, 1,079 cardiac arrests with 3,448 rhythms were interpreted by the SAED. Sensitivity and specificity for appropriate management of a shockable (VF or VT) rhythm by the SAED were 81.02% (95% CI 79.71% to 82.33%) and 99 93% (99.84% to 100%), respectively. Positive and negative predictive values were 99 64% (99 44% to 99.84%) and 95.50% (94.81% to 96.19%), respectively The accuracy was 96.17% (95.53% to 96 81%) Interobserver reliabilities, when compared with consensus rhythm interpretation, were 0.876 (paramedic) and 0.988 (physician) Conclusion' The SAED had high specificity but only moderately high sensinvity in detecting and defibrillating unstable cardiac rhythms m the out-of-hospital setting. Further study is under way to identify how sensitivity can be improved.
134
The Use of Herbal Medications Among Pediatric Population at a Large Urban Community Hospital
McRaeA, TsangW, Lee PJ/New YorkMethodistHospital,New York, NY Study objective. The World Health Organization estimates that 4 bdlion people, 80% of the world population, use herbal preparations for some aspect of pnmary health care (1993). Sales of herbal preparations in the United States were estimated to be approximately $8.1 billion and growing annually at a rate of 25% in 1998. There are numerous published literature on adult usage of herbal remedies. To date, there are no studies reported in any peer-reviewed journal on the prevalence of herbal use among the pedtamc populanon, aside from the few single case reports of specific potsomngs among children. The goal of this pilot project was to study the prevalence of the use of herbal remedies in the pediatric population presenting to the pediatric emergency department at New York Methodist Hospital. Methods: A cross-secnonal, convenience sample survey from the pediatric ED at New York Methodist Hospital, an urban, umverslty-affihated mstitution, was administered by the physician to the patient versus caretaker. The survey includes demographic data from patient and caretakers, chmf complaint(s), educanon and insurance status, use of herbal and ahernatwe therapms, and so on. Inclusion criterion was newborns to the age of 20 years. Exclusion critenon was age older than 20 years. The time frame for the project was 1 year with commencement on January 1, 1999. Data were analyzed using descriptive analysis. A sample size of 400 would be reqmred to achmve a 95% confidence interval (CI) with +_5% precision assuming a 20% prevalence. Results: Two hundred fifty-nine surveys were completed with 6 refusals. There were 26 (10%) users of herbal remedies, with a mean age of 9.8 years, and 233 (90%) nonusers, with a mean age of 7.5 years. There were 9 male and 17 female users of herbal remedies compared with 118 male and 113 female nonusers. In terms of racml/ ethmc backgrounds, there were 5 white, 13 black, 8 H~spanic, and 0 Asian users versus 40 white, 90 black, 91 Hlspamc, and 8 As~an nonusers. Twenty-four were from the Umted States. 1 from Russia, and l unknown among the users compared with 182
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8th I N T E R N A T I O N A L CONFERENCE ON E M E R G E N C Y MEDICINE ABSTRACTS
from the United States, 5 Central America, 19 Caribbean, 3 South America, 2 Israel, 1 China, 1 Russia, and 20 unknowns among the nonusers. Rehglous backgrounds include 76% (20) Chnstiantty, 8% (1) Jewish, 8% (1) other (Yoruba), 4% (2) no religion, 4% (2) unknowns among the users versus 54% (128) Chnstlamty, 3% (6) Jewish, 2% (5) other (Mushm, Islam, Buddhlsm), 17% (39) no religion, and 24% (56) unknowns among the nonusers. Parental level of education include the following: 58°£ (15)
hood of psoas abscess is high but with a negative or inconclusive ultrasound finding. Immediate drainage is mandatory after the diagnosis of psoas abscess is estabfished
136
An Epidemic of Heat Stroke Without a Heat Wave
more than high school (college+), 27% (7) less than high school, and 15% (4)
How CK, HsuTF, ChernCH,Wang LM, Lee CH/VeteransGeneralHespital,EmergencyDepartment,
unknowns in the user group compared with 46% (108) more than high school
Taipei, Taiwan, Republic of China
(college+), 43% (100) less than high school, 9% (21) unknowns, and 2% (4) no education in the nonuser group. Insurance status was as follows: private 42% (11), 27% (7) Medicaid, 4% (1) managed care, and 27% (7) unknowns among the user group versus 30% (71) private, 35% (80) Medicaid, 9% (21) managed care, 8% (18) self-pay, and 18% (43) unknowns. Echtnacea is the most commonly used herb among this pediatric population, Conclusion: Ten percent of our pediatric population use herbal remedies. Females were twice as likely to be users of herbs than males. The majority of our pediamc patients are from the United States and are Christians Hlspanics were 30% less likely to be users of herbs than non-Hispanics Black patients were 1.5 times more likely to be users of herbs than nonblacks. There were no associations with white patients, and
Study objective: In Taiwan, a subtropical country without any history of heat waves, heat stroke has been considered a rare disease. However, at the end of the summer of
there were no Asian users of herbs Children of parents with education level greater than high school were twice as likely to be users of herbs than those who completed high school or privately insured were 1 5 times more likely to be users of herbs than those who are publicly insured,
135 The Clinical Manifestations and Diagnosis of Psoas Abscess in the Emergency Department
How CK, HuangYT, ChernCH,Wang LM, Lee OH/VeteransGeneralHospital,Emergency Department, Taipei, Taiwan, Republic of China Study objectwe: Psoas abscess is a rare disease. Misdiagnosis and delayed diagnosis are frequently encountered. Few reports or case studies have addressed the difl~culties in diagnosing psoas abscess in emergency department settings In this report, we present our experiences in making the diagnosis of psoas abscess, Methods: We retrospectively collected the patients with psoas abscess, who were identified by related International Classification oJDiseases (ICD) codes and ED charts at a tertiary care hospital in Tatpei from June 1989 to June 1999. All patients who presented with abscesses involving psoas muscle were enrolled. The diagnosis was based on either the imaging studies, which included ultrasound, computed tomography (CT) scan or gallium scan, or operative procedures. All enrolled cases were either newly diagnosed at our ED or after being admitted to our wards through the ED. Results: In this period, we identified 44 patients with a total of 46 events. The mean age of our patients was 64.56 years, which was much higher than those in the previous hteratures Fever (35 cases, 76.0%) was the most common presentalion. Typical clinical patterns that are specific to psoas abscess occurred only in a small portion of our cases (15 cases, 32 5%) It was noteworthy that 9 (23.9%) cases only presented with fever/sepsis without other symptoms and signs Because of diversified and nonspecific clinical manifestations, only 16 (34.7%) cases had correct initial ED diagnosis. A mixed picture of primary and secondary psoas abscess was found in this area Osteomyelms (7 cases, 15 2%) and urinary tract infection (6 cases, 13 0%) were the most presumptive causes o[ secondary psoas abscess in this region, contrary to those of previous reports The duration of symptomsbefore EDvisits ranged from 1 to 60 days (10.95±10.9E days). Some cases had a prolonged insidious clinical course, while others had a fulmmant course. The duration of the diagnosis made after ED visits ranged from 0 to 44 days (5.23±8.21 days/. The diagnosis of psoas abscess was established by ultrasound in 16 cases (10 performed by emergency physicians and 6 by radiologists), by CT scan In 24 cases, by surgical Intervention in 4 cases, and by gallium scan in 2 cases. The mortality rate was higher in patients without drainage or drainage failure and among those with a shorter duration of symptoms (P<.05). Conclusion: In this study, initial misdiagnosis and delayed diagnosis of psoas abscess were frequently encountered because of the diversified and nonspecific clinical manifestations. Some patients had a fulminant course. Emergency phystcians require the assistance of ultrasound m making the diagnosis and dispostnon of the patients, who usually are admitted through the ED. However, CT scan is indicated when emergency physicians have no adequate experience in ultrasound performance, when the lesion extends beyond the psoas muscle, or when the hkeh-
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1998, after seeing several cases of classic heat stroke, an unusual occurrence in this area, we began to review and collect cases of suspected heat stroke and tried to explore the possible cause of this unusual phenomenon. Methods: We retrospectively collected cases of suspected heat stroke (hyperthermta [>40.6°C]) m the presence of altered mental status and anhidrosls), identified by InternationalCIasslfzcatwnojDtseases codes and emergency department conferences, at a tertiary care hospital in Taipei, Tatwan, from June to August (the hottest months) 1998. In the summer of 1998, daily temperature in Taipei ranged from 22°C to 33°C. The highest temperature occurred on the afternoon of July 19, 1998, when it reached 38.1°C The basic demographic data, laboratory findings, clinical presentation, initial impressions, treatment, and outcome of the patients were recorded. We also tried to understand the lifestyle, living environment, and medical conditions of our patients through interviews of their fam~hes and emergency physicians in charge, tdephone calls, and chart records. Results' Six cases of heat stroke were enrolled in this study; all were classic heat stroke. We found that the most comorbzd conditions were hypertension (4/6) and preexisting mental problems (3/6). All patients lived in the inner part of an urban area, were middle class, and were not socially isolated Most patients felt unhealthy being exposed to the cold and avoided staying in air-conditioned rooms. Laboratory alonormahtms and clinical presentation, except for a high fever and change in conscious status, seemed to be nonspeczflc From the data collected from the local weather bureau, all cases occurred during 2 periods of sustained hotter-than-average weather and, not surprisingly, we found that 3 episodes occurred around the day of the highest weather temperature (38.1°C) Compared with the other study, our patients seemed to have an initial worse outcome--2 died and 1 is In a vegetative state caused by hypoxic encephalopathy, whereas there was a complete recovery in initially diagnosed patients (3/6). A mild disease, no concurrent mfecuon, and early cooling explained the good result of completely recovered patients, whereas misdiagnosls due to absence of experience and delayed cooling seemed to be the most important factor in patients with poor outcome. Conclusion: Because of special environmental and social factors, classic heat stroke may occur occasionally in subtropical regions, without previous history of heat waves and where heat stoke rarely occurs, during periods of the persistently high temperatures, even without reaching the criteria of a heat wave Heat stroke should be consIdered in any patients with hyperthermla and neurologic abnormalities after exposure to high ambient temperatures. Cooling and a search for underlying conditions should be mitiated in parallel. Prevention of heat stroke in an area with a low incidence includes early orgamzatlonal issuing of advlsones or warnings through the media and reminding or teaching emergency physicians about heat stroke during sustained hot weather, especially when record temperatures are set.
137
TheMisdiagnosisofLiverAbscessinthe EmergencyDepartment
ChernCH, How CK,Wang LM, Lee OH/VeteransGeneralHospital.EmergencyDepartment, Taipei, Taiwan, Repubhc of China Study objective" The purpose of this study was to find the mmdiagnosis of liver abscess in the emergency department to delineate the appropriate indications of ultrasonography and computed tomography (CT). Methods: We retrospectively reviewed the cases of liver abscesses, identified by Internanonal Class~ficationof Diseases codes, treated at a tertiary care hospital In Tatpei, the capital of Taiwan, from January 1995 to January 1999. All enrolled cases were newly diagnosed at our ED or after admission to our wards through the ED. Cases diagnosed at other hospitals were excluded from our study. We med to explore the possible cause(s) of misdiagnoses through literature review and our clinical judgment and experience Parameters, such as fever vathout a definite origin lasting more than 3
ANNALS OF EMERGENCYMEDICINE 35:5 MAY 2000
8th I N T E R N A T I O N A L CONFERENCE ON E M E R G E N C Y MEDICINE ABSTRACTS
days, the presence of sepsis,WBC count in excess of 20,000/mm 3 or band form in excess of 6%, the presence of abnormal liver function test reuslts (especially alkaline phosphatase), the presence of epigasmc or right upper quadrant pain or tenderness, and the presence flank pain or flank knocking pain, were indicators for further exam> nation for possible presence of liver abscess. In this hospital, every emergency physician receives a 3-month full-time training in ultrasound before assignment to an attending position, Results: In this period, we collected a total of 160 cases and found 83 (51.9%) cases with initial misdiagnoses Surprisingly, at least 94 (58 8%) patients had visited other clinics and hospitals before coming to our ED, with mlsdiagnoses ranging from upper respiratory tract infection or abdominal pain to fever of unknown origin, sepsis, or meningitis Among the cases with misdiagn . . . . . 3 (1 9°£) were related to atypical presentations, 5 (3.1%) to inadequate laboratory examinations, 41 (25.6°£) to failure to perform ultrasound in the ED, 33 (20.6%) to ultrasound failure to identify the lesions, and 6 (3 8%) to the unavallabifity of ultrasound at mldmght. The possible causes of ultrasound failure to identify a lesion in 33 cases were explored: 12 (36.4°£) cases had small lesions, 8 (24.2%) early lesions, 10 (30.3%) intrahepatic duct stone or dilation, 9 (27 3%) the presence of other diseases (acute cholecystttts, bifiary tract infection, or pancreatitis), 6 (18.2%) peripheral lesions, 12 (36.4%) fatty liver or coarsening of liver, 4 (12.1%) air within abscess or lleus, and i rapid breathing Five (15.2%) cases were due mainly to physician factors (4 reading errors and 1 technical error). However, not any causes of ultrasound failure could be identified in 4 cases, Furthermore, the Immediately diagnosed and initially undiagnosed groups seemed to have no statistical differences in age, the presence of diabetes mellitus, and clinical parameters,
Conclusion: In Talwan, liver abscess is not a rare disease. In this study, mlsdlagnoses occurred in a high portion of cases and most cases were due to failure to order or perform an ultrasound examination and failure of ultrasound to find a lesion, not due to the different clinical presentations. A diagnosis protocol of liver abscess will be presented. Emergency physicians should understand the indications of ordering the appropriate laboratory examinations (liver function tests) and ultrasound in patients with fever of unknown origin or prolonged fever and abdominal pain (especially right upper quadrant pain). From our study, there were many reasons for negative ultrasound findings in liver abscess, so computed tomography may be necessary for cases with prominent physical examination or laboratory abnormalities of some clinical conditIons.
38
12 2% had ngors (P=.056); 26.3% versus 4.4% had recent surgery,; 0% versus 7.8% had distinct margins of erythema (P<.01); 15.8% versus 3.3% had vancose veins; 5.3% versus 18.9% were currently taking antibiotics, 15.8% versus 26.7% had &abetas, 31 6% versus 16.7% had peripheral vascular disease; and 50% versus 21.4% had art elevated WBC count. Conclusion: There are differences in a number of baseline characteristics of "DVT versus celluhtls" patients with positive versus negative duplex scan findings, some of which were statistically significant despite the limited sample size. We plan to con> bine variables into a single clinical prediction model, which will then be prospectively tested to determine its utility m the diagnostic process of these patients.
1~Q
How Do Nurses Train for the Role of Triage In Australasia?
II IIJ~,W Kelly AM, Richardson D/Western Hospital. Department of EmergencyMedicine. Melbourne, Australia, Canberra Hospital, Department of EmergencyMedicine. Canberra, Australia Study objectives: To determine how nurses in Australasia are prepared for the role of triage Methods: We conducted a postal survey of nurse unit managers of emergency departments accredited by the Australasian College for Emergency Medlcme Data collected included the minimum duration of ED expenence required before performing mage, the structure and duration of education activities for the role of triage, and pro cesses used to monitor the quality of triage, both at the level of departments and of individual nurses. Results: Seventy-two responses were received (response rate 90%). All departments were using the Australasian National Triage Scale. Sixty nine departments reported minimum ED experience requirements, with a median requirement of 12 months. Six departments participated in regional triage training courses, and 30 others (42%) conducted formal study programs. Self-learning packages were the most commonly used educational tool, used by 42 departments (58%). Thirty-nine (54%) departments required a period of supervised experience, with the median duration being 2 shifts. Four departments reported that there was no specific training for the triage role. Twenty-nine departments reported that they had no formal process to monitor quality of triage, 24 departments (35%) conducted some form of regular audit, whereas only 8 departments (i2%) analyzed triage category" against presenting complaint or dtagnosis. Conclusion: Preparation of nurses for the role of triage IS highly variable, both m
When the Clinical Impression Is Deep Vein Thrombosis Versus Cellulitis: Do Patient Characteristics Predict the Duplex
duration of previous ED experience required and in the structure of educational programs. Few departments conduct processes to objectively monitor the quality of triage. Future research should focus on identifying core content for training programs for the
Diagnosis?
role of mage and how competency can be assessed and maintained.
RabukaOE,AzoulayLY,KahnSR/McGillUniversity,EmergencyMedicineResidencyProgram, Montreal,Canada;Sir MortimerB. Dav,s-JewishGeneralHospital,Departmentof Clinical Epidemiology,Montreal,Canada
140
Stud}" objectives Differentiating deep vein thrombosis LDVT) from cellulitis is an important emergency department problem, because both are common acute diseases with similar presentations. If a set of clinical parameters were avadable that helped
P0well C, Kelly AM. Williams A/Sunshine Hospital, Department of EmergencyMedicine. Melbourne, Australia; Western Hospital. Department of EmergencyMedicine. Melbourne, Australia; Sunshine Hospital.Department of EmergencyMedicine. Melbourne, Australia
predict the outcome of venous duplex scan in such patients, the process of accurate diagnosis and appropriate therapy would be expedited, while decreasing unnecessary duplex scans The objectives of this study were (1) to determine the proportion of patients who had a final diagnosis of DVT, celluhtls, or both among ED patients in whom the initial clinical impression was "DVT versus cellufitis" and who underwent duplex scanning; and (2) to determine which baseline clinical parameters, if any, predicted the final diagnosis. Methods: This study was a retrospective chart review of patients who presented to the ED of the Sir Mortimer B. Davis-Jewish General Hospital dunng 1995-1998 in whom the initial dlfterential diagnosis was cellulltiS versus DVT, thus leading to referral for duplex scan. Data were collected for several baseline vanables (before duplex scan was performed) such as demographic factors, history, physical examination, and laboratory assessment Patients with positive and negative duplex studies were cornpared on these variables using the Student t test or the X2 test. Results: Of 542 ED patients who were referred for duplex scan, 109 were initially assigned a differential diagnosis of DVT versus celluhtis. Of these, only 19 (17 4%l had positive duplex scan findings. 2 of w h o m were also treated for cellufitis tie, final diagnosis both DVT and cellulttts). Comparing patients with positive versus negative duplex scan findings, 5.3% versus 14.4% had constitutional symptoms; 0% versus
Study objectives: To determine the m i n i m u m clmically significant difference (MCSD) in a visual analog scale (VAS) pain score for children and to determine whether it differs with the age of the child. Methods: This was a prospective, single-group, repeated measures study of children aged between 8 and 15 years in an urban pediatric emergency department On presenladen to the ED, patients marked the level of their pain on a 100-mm, nonhatched VAS. At 20-minute intervals thereafter, they were asked to give a categorical rating of their pain as "a lot better," "a httle better," "much the same," "a little worse," or "much worse" and to mark the level of their pain on a VAS of the same type, blinded to their previous mark. The minimum clinically significant diflerence in VAS pain score was defined as the mean difference between current and preceding scores when the subject reported "a little worse" or "a little better" pain Data were analyzed for the group overall and for the age subgroups 8 to 11 years and i2 to 15 }'ears. Results Seventy-three children were enrolled in the study, yielding 103 evaluable comparisons where pain was rated as "a little better" or "a little worse." The MCSD m VAS pain score in the group overall was 10 mIn (95% confidence interval [CI] 7 to 12 ram). MCSD in VAS score for the 8- to 1 t-year group was 15 inm (95% CI 9 to 22 mm) and for the 12- to 15-year group, 9 m m (95% CI 7 to 12 m m ) These "sTereno{ statistically different (P= 3997l
MAY 2000 35:5 ANNALS OF EMERGENCYMEDICINE
What is the Minimum Clinically Significant Change in Visual Analog Scale Pain Score for Children?
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8th INTERNATIONAL CONFERENCE ON EMERGENCY MEDICINE ABSTRACTS
Conclusion: The MCSD in VAS pain score for children aged 8 to 15 years was found to be 10 mm. Differences of less than this amount, even if statistically different, are unlikely" to be chmcally significant.
141
PrehospitalResuscitationof 0ut-Of-Hospital Cardiac Arrest in Hong Kong
minimally, prepared was 39%, 35%, and 21%, respectively, tor each NBC agent, and less than 1% rated their graduates well prepared Conclusion: This needs assessment is the first phase of a 3-part analysis of the preparedness of emergency physicians to manage medmal aspects of WMD threats.
Programdirectorresponsessuggestthatin a substantialproportionofemergency medlcme residency programs, the traming to manage these threats may be inadequate
Leung LP, Lo CM, Tong HK/QueenMary Hospital,Accidentand EmergencyDepartment,Hong Kong
We suggest that the development of a targeted curriculum and its inclusion m resi-
Study" objectzve: To evaluate the efficacy of out-of-hospital resuscitation tn Hong Kong and identify areas for improvement,
dency programs may" enable emergency medicine physmians to better manage the medmal aspects of weapons of mass destruction
Methods: Ihts was a prospective descriptive study of patients with nontraumatic out-of-hospital cardiac arrest who were transported by the ambulance service to the emergency department for the period March I5, 1999, to September 15, t999. Data
143
Assessmentof Asthma Management Before and After the Introduction of Guidelines in An Accident and Emergency Department in Hong Kong
were recorded m a standard format based on the Utstem style The study- semng was
the ED of a regional hospital m Hong Kong West, serving a populanon of one half
Tsui SH, Sham A, Tong HK, Chan-Yeung M/Queen Mary Hospital, Accident and Emergency
million. A total of 115 cardiac arrest patients older than 18 years were included.
Department and Department of Medicine, Hong K0ng, SAR
Results: There was male predommance (62 6%), mean patient age was 71 4 years. The majonty of cardiac arrests occurred at patients' homes (71 1%), and 54-.8% of cases were unwitnessed The bystander car&opulmonary resuscitation (CPR) rate was 11 3%. In 75.3% of cases, the elevator of the patient's residence did not accommodate
Study objectives: We investigated whether the introduction of gmdelines for asthma management would improve the management of asthma m an accident and emergency" (AGE) department m Hong gong.
a stretcher. The most common ECG rhythm on first contact was asystole (78.4%). Venmcular flbrfllation/pulseless ventricular tachycardia constituted 15.3% of rhythms. The average call to response interval of the ambulance service was 1 02 minutes. The average call to CPR (by ambulance attendants) interval was 9.70 minutes. The average total out-of-hospital interval was 28.31 minutes. Resuscitation in the ED was performed in 52.7% of cases. The overall immediate survival rate was 15 7%. Conclusion: The ambulance service is efficient with quick response time. However, the immediate sunuval rate is low. This seems to be related to the high percentage of unwitnessed arrests and the low rate of bystander CPR. Also, m a modern city like Hong Kong, most residents hve in muhistory buildings. Failure to accommodate a stretcher for patient transport constitutes a significant problem in pcrformmg effective CPR during transport Urgent attention should be paid to public educauon on CPR and future building design.
42 Weapons EmergencyMedicine ResidentPreparednessfor the Threat of of Mass Destruction: Results of A National Residency Program Director Survey Bonucci P, Vuletich M, Smith 6, Johnson M, 8ussow L, Leo M/Oo0k County Hospital,
Methods. An audit was carried out on records of patients with the diagnosis of asthma, older than 2 years of age, seen in the AgzE department between August 18 and November 14, 1998 (88 days). The guidehnes, similar to the one published by the Bntish Thoracm Society but amended to fit the department system, were mtroduced and actively promoted on November 15, 1998. The audit was repeated for patients seen between November 30 and February 10, 1999 (73 day's). The follovang data were collected' asthma history, investigations, treatment, outcome, and medications given on discharge. Results' There were 233 and 337 asthma patients seen during the 2 periods respecuvely, with no differences m gender and age distrtbutmn Their asthma seventy also did not differ as measured by pulse and respiratory rate, arterial oxygen saturation, and peak flow rate before and after bronchodllator treatment. Peak flow rate was measured m 51.5% of patients before and 75% after the introduction of guidelines (P< 01) Significant increases in the use of oxygen (82.8% versus 89%) and systemic steroids (6.4% versus 1 l 9%) were found; 35% and 37 7% of paUents, respecuvely, were admitted to the hospital before and after the mtroducuon of the gmdehnes For those who were discharged, a higher propomon were &scharged wuh a course of oral steroids (25 8% before and 52.7% after, P<.005). Conclusion. Asthma management in the AGE department m~proved after the introduction of guldehncs, but the improvement did not rcsuh m a reduction in the rate of
Department of EmergencyMedicine, Chicago, Ik
hospital admission for asthma
Study objectives The health threat posed by potential exposure to nuclear, biological, or chemical (NBC5 agents, also k . . . . . . . capons of mass destruction (WMD), is receiving significant public attention. The Nunn-Lugar-Domemcz WMD Act of E997
144
was passed by Congress to address the perceived lack of preparedness among emergency personnel. However, training in WMD has not yet become a required part of the curriculum for emergency medmine residency programs. The Investigators believe the first step In addressmg this issue should be a needs assessment to identify current acnw rues and deficiencies. Therefore, we surveyed the program directors of all US emergency medtcme residencms to determme current educational efforts in WMD and their perceplion of the preparedness of their residents to manage these threats, Methods: A 1-page survey of emergency medicine residency program directors was developed which included estimated hours ot didactic instruction on NBC topics and rating of preparedness ot recent graduates to manage incidents m each of these areas using a 5-pomt Llkert scale (l=minimally prepared to 5=well prepared) The snrvey was telefaxed to 116 allopathtc and 26 osteopathic emergency medicine residency programs. Fonow-up telephoning and fa.-dngwas conducted to Increase the rate of response, Results: Ninety-one of 142 program directors completed the sur~'ey, representing a response rate of 6"4%. The estimated training time spent on NBC averaged 11.3 hours/ ?,ear for all programs responding. The average training time for each component was 1.7 hours nuclear exposure/management, 1.7 hours biological weapons, 2.5 hours chemical, and 5 4 hours disaster management. The composition of this time was 51% lecture, 31% drills, 16% external conferences, and 2% other. Twenty-eight percent of residency programs had discussed NBC topics in journal club during the past 3 years, Program directors rated the level of preparedness of their graduates to manage an incident in each NBC agent as follows: nuclear 2.2 points, biologmal 2.3 points, and chemmal 2.7 points. The percentage of program directors who rated their graduates
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FactorsAssociated With Head & Neck Injury in Air Bag-Deployed Crashes
Gregory ME/State University of New York Health ScienceCenterat Syracuse,Syracuse,NY Study objective: To describe the factors associated with the occurrence of head and neck mjuries in serious and fatal car crashes In which air bags are deployed. Methods: This study was a retrospective review of data contained m the Nauonal Highway Traffic Safety Admimstratlon (NHTSA) Special Crash Investigauon Program database. The database includes mformation about senous and fatal car crashes in which air bags were deployed, including patient information, seatbelt usage, the change in velocity experience during the crash (AV), and mjury pattern(s). We compared the frequency' of head and neck mjunes among patients wearing and not wearing seatbehs, as well as for drivers and passengers using %2 analysis or Flsher's exact test. We also compared the mean AV for crashes resulting in head and neck injury and those that did not using t test. Results: The database included 62 serious or fatal crashes occurring over a 9-year period. 56 (90.3%) resulting in a fatahty, and 6 (9.7%) resulting in serious injury. Fifty-five (89%) of the vmtIms were drivers. The frequency of head and neck injury did not differ for VlCUms wearing and not wearing seatbelts (57% versus 45%, Z2 P=.378). The AV did not differ for victims with and without head and neck injury, (12.3 m p h versus 12.6 mph, t test P= 795). Passengers were more fikely to suffer head and neck injury than drivers (100% versus 42.9%, Fisher's exact test P=.0048) Conclusion: Passengers m serious or fatal car crashes in which an mr bag deploys are more likely than drivers to suffer head and neck injuries. Seatbelt usage and AV do not appear to be related to the occurrence of head and neck injury in such crashes.
ANNALS OF EMERGENCYMEDICINE 35'5 MAY 2000
27 Interpersonal Inpatient and Outpatient Hospital Costs of Young Victims of Violence Zun L/Mount Sinai Hospital, Chicago, IL Study objectives: Young xactuns of violence have varying costs depending on whether they are admitted or discharged from the emergency department. The purpose of the study was to compare the mpatmnt, observational, and outpatmnt hospital costs of those young persons aged 10 to 24 years who are vmtims of interpersonal violence. Methods: The study design was a chart review of consecunve sample of young persons ages 10 to 24 years who were vlcnms of life- or limb-threatemng interpersonal violence in 1998-1999, excluding domestic, sexual assault, and child abuse. The study was exempt from institutional review board The study site is a community, teaching Level I trauma center. The patients' ED presenting vital signs, arrival mode, tNury location, procedures, radiographs, alcohol and drug use, laboratories, prior visits, and
disposition were assessed. The hospital costs were calculated as 50% of charges. The costs did not include the physician, rehabilitation, personal, or societal costs Appropriate statistical analysis and correlations were made usmg SPSS software. Results: Two hundred twenty-eight cases were revmwed; 86.8% were male, 64.9% Afncan Americans, 32.5% Hlspamcs, and 41.2% were brought by ambulance. There were 72.8% gunshots, 16.8% blunt trauma, and 10.4% stabbing; 58 0% were admitted to the hospital, 11% were observed, and 29% were discharged from the ED. The average hospital cost was $14,975 for the patients admitted, $2,904 for those observed, and $1,033 for those who were discharged. Hospital admissions were positively correlated with gender, arnval mode, alcohol and drug use, and negatively correlated to insurance status compared with those discharged (P<.05) and not correlated vnth age, race, vital signs, mechanism, or location (P<.05). The average stay was 5.73 days for patients who were admitted. Gunshot injuries are assocmted with higher costs ($11,495) than other mechanisms of trauma (stab $3,731 and blunt $7,838) but were not statistically significant. The mechanism of injury is correlated with computed tomograph of the head and not correlated with admissions, gender, age, or vital signs (P<.05). Conclusion: There was a significant cost m canng for adolescents who are VlCtZms of interpersonal violence and a large differentml between in and outpatient hospital costs.
It would be desirable for other centers to repeat and, if possible, confirm and expand on these results, as there has been little improvement in efficacy of ACLS since the mid-1900s with new therapeutic approaches.
Table, abstract 128. ROSCSustainedOver Group
Initial ROSC
Group 1 : 1 atm/abs01ute(n=6) Group2:2 atm/abs01ute (n=6) Group 3 : 4 atm/abs01ute (n=6)
129
0/6 0/6 5/6
2-Hour Period
0/6 0/6 4/6
.
The Analysis of Erythrocyte Sedimentation Rate, C-Reactive Protein, White Blood Cell Count, and Temperature in the
Diagnosisof AcuteEndocarditis Chuang R, 01shaker J, Robinson D/University of Texas at Houston, Houston, TX, University of Mar/land, Baltimore, MD
VanMeter I(W, Swanson HT, Sheps SS, Barratt DM, Roycraft EL, Moises J, Killee J, Hatch
Study objective: This study attempts to determine whether the levels of initial erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), WBC count, or temperature tend to correlate with the eventual diagnosis of endocardttis. Methods This prospectwe cohort study was conducted in an urban umversity medical center of all suspected cases of endocardms that presented to the emergency department from August 31, 1998, to March 31, 1999. These included all febrile mtravenous drug abusers, and any other patients with suspected native or artificial valve endocardins who were admitted through the ED. The initial WBC count, ESR, CRP, and highest ED temperatures were recorded on these patients Data were then prospectively collected and are represented as mean ±SD. P values were calculated with the 2-tailed Student's t test. Results: A total of 147 consecutive cases were analyzed vath 14 confirmed cases of endocarditis. The lnitml ESP,s were higher in those with endocardms (56.5±6.1 versus 45.6±14.8, P= 01), as were CRP levels (16.1±10.1 versus 7.2±6 9, P<.001), and WBC counts (16.3±11.7 versus 8 4±5.i, P<.O01). The pauents' maximum temperatures in the ED were similar m both groups (101.7°F versus 101.6°I:, P=.84). Using the normal laboratory limits of ESR for the diagnosis of endocarditis, the sensitivity is 100% and specificity of 9.8%. For CRP, the sensitivity is 100% and specificity is 6%.
PG/Louis4anaState University Health SciencesCenter, New Orleans, LA; Tulane University School of Medmine, New Orleans, LA; Baromedical ResearchInstitute, New Orleans, LA
However, the lowest ESRs and CRP level in the confirmed cases of endocardms were twice the upper level limit of normal for ESR, and 7 times the upper limit for CRP.
Study objective: A previous controlled prospective, randomized study of closedchest cardiopulmonary resuscitation (CPR) in gumea pigs demonstrated advantage of hyperbaric oxygen over normobaric oxygen (after a 1 atm normothermic cardiopulmonary arrest) in affecting lasting return of spontaneous circulation (ROSC). This study investigates a similar approach using open-chest CPR in swine instead,
Using these values, the specificity increases to 25°/0 and 44%, respectively. Conclusion This pilot study demonstrates that none of the eventually confirmed cases of endocardltls had normal initial ESRs or CRPs. These relatively inexpensive tests may prove to be valuable mmal screenmg tests for the exclusion of endocardms in the urban population lacking follow-up.
Methods' This IACUC approved study incorporated the prospective random,zed assignment of 6 swine each to 1, 2, and 4 atm 25 minutes normothermic (37 5°C) cardiopulmonary arrest induced by AC current by catheter apphed directly to the epi-
130
cardmm to produce ventricular fibnllanon. After 25 minutes of cardmpulmonary
Aggarwal P, Wall dP, Smgh 0, Handa R, Dwivedi SN, Wig N, Biswas A/All India Institute of Medmal Sciences, New Delhi, India
28 Oxygen DoseCardiopulmonary Response in 0pen-Chest ACLS in Swine Alter a Arrest 25-Minute
arrest, the animals received cardiac compression by a mechanical ventricular assist device (MVAD) and ventilation by mechanical ventilator with 100% O 2 at the randomly assigned ambient pressures used. Standard American Heart Assocmuon Advanced Cardiac Life Support drug and defibrillation protocols were followed. ROSC was defined as the ability of the ammal to maintain a femoral arterial pressure greater than or equal to 90/50 m m Hg without assistance of an MVAD The ammals were evaluated after inmation of the resuscitative effort for inmal ROSC and sustainable ROSC over the next 2 hours, The animals were sacrificed at 2 hours after initial arrest. A 2-tailed Fisher's exact test was used to analyze study results to obtain a relevant P value, Results: Results are shown m the Table. Conclusion Ventilation vnth oxygen at 4 atm ambient pressure may be more effecrive than with oxygen at 1 and 2 atm of ambient pressure when resuscitating swine after a prolonged normothermic cardiopulmonary arrest of 25 minutes. The results for both mitial ROSC and sustained 2-hour ROSC achieved a level of significance (P<-.0049) by a 2-tailed Flsher's exact test for group 3 over the combined groups 1 and 2 (Table).
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Role of Nebulized Ipratropium in Acute Bronchial Asthma
Study objecuves: Nebulization of ~-agomsts is the first-fine therapy in patients with acute asthma IpratropIum bromide, an anticholinergic, is also being used in pauents with acute asthma. However, its exact role remams to be defined. The present study was aimed at determining the efficacy of ipratropium given alone or in combination with salbutamol compared with salbutamol alone in patients with acute bronchial asthma Methods: The study was conducted at the Department of Emergency Medicine of a tertiary care hospital. To determine the efficacy of ipratropmm and salbutamol, given alone and in combination, a total of 69 patients with acute asthma were studied over an 18-month period (1997-1998) Informed consent was obtained from the subjects before they were randomly assigned into 3 groups Group A patients recmved 5 mg of salbutamol nebuhzed at 0 and 60 minutes. Patients m group B received 500 I.tg of nebulized ipratropium bromide at 0 and 60 minutes, and group C received a combmauon of 5 mg of salbutamol and 500 I.tg of ipratropium bromide at 0 minutes followed by
ANNALS OF EMERGENCY MEDICINE 35:5 MAY 2000
8th I N T E R N A T I O N A L CONFERENCE ON EMERGENCY MEDICINE ABSTRACTS
saline solution at 60 minutes. Patients were blinded to the nature of the treatment. They were monitored for 120 minutes with peak expiratory flow rate and vital signs, Blood gas analysis and electrolytes were obtained at the entry and at 120 minutes. Results: The 3 groups did not differ significantly m age, and basehne vital signs. peak expiratory flow rate, and oxygen saturation The peak expiratory flow rate increased gradually in all groups, but there was no slgmticant difference in the level of bronchodilatation among any group at any time during the study. On analysis of sub
Conclusion. Adenosine is safe and effective in terminating SVT. The most common conversion rhythms are multiform PVCs and nonsustamed ventricular tachycardla.
group of patients with severe asthma (as defined by mttial peak expiratory flow rate below 140 L/min), no significant difference in improvement in peak expiratory" flow rate was found among various subgroups. There were no significant side effects expertenced by patients in any of the groups. Furthermore, the reqmrement of addmonal medications also did not differ in the 3 groups. Only one patient required hospitalization as a result of inadequate response to treatment at the emergency department, Conclusion: We conclude that ipmtropium is an effective bronchodilator in patients with acute asthma. However, there was no slgmficant benefit of combining ipratropium with salbutamol
Study objective: To measure the ability of semiautomatic external defibrillators (SAEDs) to detect and defibrillate unstable cardiac rhythms (ventricular fibrillation [VF], yenmcular tachycardia [VT]) in the out-of-hospital setting. Methods: SATEDperformance data were reviewed for cardiac arrests occurring between January i, 1995, and December 31, 1997. During that period, all Boston emergency medicine services (EMS), fire department, and airport rescue staff used SAEDs to treat cardiac arrest. After every cardiac arrest, data regarding each rhythm analyzed and the subsequent response (shock or no shock) were downloaded from the SAED memory module. The study paramedic and a single study physician independently reviewed each case and interpreted the car&ac rhythms from the downloaded SAED data. A group of EMS physicians independently resolved any d,screpancies. All cases of outof-hospital cardiac arrest in which an SAED was turned on and a rhythm analyzed were included. The primary endpoint was the correct identification and defibrillation of VF or VT. Sensltiwty, specificity, predictive values, and accuracy with 95% confi-
31
Nausea and Opioid Use in an Emergency Medicine Setting
GossmanW, DowneyLA, Zun L/Mt. Sinai HospitalMedicalCenter,Chicago,I1_;FinchUniversity of Health Sciences,The ChicagoMedicalSchool,Chicago,IL Study" objectives: To examine the relationship between types of oDoids given for control of pain and the onset of nausea requiring an antiemetic. Methods: Male and nonpregnant females who presented to the Level I trauma center with an acute pain episode and or chronic pain that required the administration of opioid analgesic were eligible for this study. The majority of subjects were given motphine, Demerol, and Vmodin This is a retrospective study, which used data collected over a 3-year period. Of 386 patients who presented at the facility and required the admmlstrauon of optoid analgesm, 78 needed the admimstration of an anuemetic. Using statistical analysis, we examined the relanonshlp between patient's age, race, gender, pain etiology, and/or trauma location, presenting pare scale, first drag used including dosage and route, and requirement for an antiemetic, Results: At the .05 significance level, gender and the administering of morphine showed a slgnffmant relationship. Females were more likely to require an anuemetic when given morphine compared with males.
132 Tachycardia Conversion Rhl/thms From Adenosine in Treating Supraventricular Ooi SBS,CguaBK/NationalUniversityHospital,EmergencyMedicineDepartmentand Cardiac Department, Singapore study objecnves: To study the conversion rhythms, duration to conversion, and adverse outcomes from use of adenosine m treating supraventricular tachycardia (SVT). Methods: This prospective observational study was conducted m the emergency department of a tertiary teaching hospital Consecutive cases of SVT m both adult and pediatric patmnts treated by the first author using intravenous adenosine were studmd. Using a proforma, the doses of adenosine, rime to conversion, side effects, longest rhythm pause after adenosine administration, length of conversion rhythm to resumption of regular sinus rhythm, and the types of conversion rhythm were studmd. Results: Thirteen patients ranging m age from 9 to 71 years were studied during a 2-year period. Only 1 of 13 patients failed to have the SVT converted after the max> mum dose, yielding a success rate of 92.3%. The median time from adenosine administration to start of conversmn was 20 seconds (range 15 to 30 seconds). There was slmving of the rhythm of a median of 2 beats (range 1 to 5 beats) before the start of the conversion rhythm in 9 (75%) of the cases. The median duration from start of conversion rhythm to resumpUon of regular normal smus rhythm was 9.8 seconds (range 3.4 to 32.4 seconds). The longest rhythm pause encountered after adenosine administration was a median of 1.3 seconds (range O 8 to 2 3 seconds) The transient side eftects encountered were chest pare (23.1%), dyspnea (23.1%), flushmg (15.4%), lightheadedness (23.1%), and headache (7.7%). There were no major adverse outcomes, The rhythms encountered were mulnform premature ventricular contractions (PVCs) (75.0%), nonsustained venmcular tachycard~a (41.7%), sinus tachycardm (16.7%), umfocal premature atrial contractions (16.7%), unifocal PVCs (16.7%), and atrioventricular block (8.3%).
MAY 2000 35:5 ANNALS OF EMERGENCY MEDICINE
133
PerformanceAnalysis of Semiautomatic Defibrillators Used in the Out-of-Hospital Setting
MacDonaldRD, Swanson JM, Mottley Jk, Weinstein C/B0ston Medmal Center, Department of EmergencyMedicine, Boston, MA;Boston EmergencyMedicalServices, Boston, MA
deuce nrtervals (Cls) were calculated. Interobserver reliability was computed using statistics to compare the paramedic and physician interpretations with the consensus rhythm determination. Results: During the study penod, 1,079 cardiac arrests with 3,448 rhythms were interpreted by the SAED. Sensitivity and specificity for appropriate management of a shockable (VF or VT) rhythm by the SAED were 81.02% (95% CI 79.71% to 82.33%) and 99 93% (99.84% to 100%), respectively. Positive and negative predictive values were 99 64% (99 44% to 99.84%) and 95.50% (94.81% to 96.19%), respectively The accuracy was 96.17% (95.53% to 96 81%) Interobserver reliabilities, when compared with consensus rhythm interpretation, were 0.876 (paramedic) and 0.988 (physician) Conclusion' The SAED had high specificity but only moderately high sensinvity in detecting and defibrillating unstable cardiac rhythms m the out-of-hospital setting. Further study is under way to identify how sensitivity can be improved.
134
The Use of Herbal Medications Among Pediatric Population at a Large Urban Community Hospital
McRaeA, TsangW, Lee PJ/New YorkMethodistHospital,New York, NY Study objective. The World Health Organization estimates that 4 bdlion people, 80% of the world population, use herbal preparations for some aspect of pnmary health care (1993). Sales of herbal preparations in the United States were estimated to be approximately $8.1 billion and growing annually at a rate of 25% in 1998. There are numerous published literature on adult usage of herbal remedies. To date, there are no studies reported in any peer-reviewed journal on the prevalence of herbal use among the pedtamc populanon, aside from the few single case reports of specific potsomngs among children. The goal of this pilot project was to study the prevalence of the use of herbal remedies in the pediatric population presenting to the pediatric emergency department at New York Methodist Hospital. Methods: A cross-secnonal, convenience sample survey from the pediatric ED at New York Methodist Hospital, an urban, umverslty-affihated mstitution, was administered by the physician to the patient versus caretaker. The survey includes demographic data from patient and caretakers, chmf complaint(s), educanon and insurance status, use of herbal and ahernatwe therapms, and so on. Inclusion criterion was newborns to the age of 20 years. Exclusion critenon was age older than 20 years. The time frame for the project was 1 year with commencement on January 1, 1999. Data were analyzed using descriptive analysis. A sample size of 400 would be reqmred to achmve a 95% confidence interval (CI) with +_5% precision assuming a 20% prevalence. Results: Two hundred fifty-nine surveys were completed with 6 refusals. There were 26 (10%) users of herbal remedies, with a mean age of 9.8 years, and 233 (90%) nonusers, with a mean age of 7.5 years. There were 9 male and 17 female users of herbal remedies compared with 118 male and 113 female nonusers. In terms of racml/ ethmc backgrounds, there were 5 white, 13 black, 8 H~spanic, and 0 Asian users versus 40 white, 90 black, 91 Hlspamc, and 8 As~an nonusers. Twenty-four were from the Umted States. 1 from Russia, and l unknown among the users compared with 182
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8th I N T E R N A T I O N A L CONFERENCE ON E M E R G E N C Y MEDICINE ABSTRACTS
from the United States, 5 Central America, 19 Caribbean, 3 South America, 2 Israel, 1 China, 1 Russia, and 20 unknowns among the nonusers. Rehglous backgrounds include 76% (20) Chnstiantty, 8% (1) Jewish, 8% (1) other (Yoruba), 4% (2) no religion, 4% (2) unknowns among the users versus 54% (128) Chnstlamty, 3% (6) Jewish, 2% (5) other (Mushm, Islam, Buddhlsm), 17% (39) no religion, and 24% (56) unknowns among the nonusers. Parental level of education include the following: 58°£ (15)
hood of psoas abscess is high but with a negative or inconclusive ultrasound finding. Immediate drainage is mandatory after the diagnosis of psoas abscess is estabfished
136
An Epidemic of Heat Stroke Without a Heat Wave
more than high school (college+), 27% (7) less than high school, and 15% (4)
How CK, HsuTF, ChernCH,Wang LM, Lee CH/VeteransGeneralHespital,EmergencyDepartment,
unknowns in the user group compared with 46% (108) more than high school
Taipei, Taiwan, Republic of China
(college+), 43% (100) less than high school, 9% (21) unknowns, and 2% (4) no education in the nonuser group. Insurance status was as follows: private 42% (11), 27% (7) Medicaid, 4% (1) managed care, and 27% (7) unknowns among the user group versus 30% (71) private, 35% (80) Medicaid, 9% (21) managed care, 8% (18) self-pay, and 18% (43) unknowns. Echtnacea is the most commonly used herb among this pediatric population, Conclusion: Ten percent of our pediatric population use herbal remedies. Females were twice as likely to be users of herbs than males. The majority of our pediamc patients are from the United States and are Christians Hlspanics were 30% less likely to be users of herbs than non-Hispanics Black patients were 1.5 times more likely to be users of herbs than nonblacks. There were no associations with white patients, and
Study objective: In Taiwan, a subtropical country without any history of heat waves, heat stroke has been considered a rare disease. However, at the end of the summer of
there were no Asian users of herbs Children of parents with education level greater than high school were twice as likely to be users of herbs than those who completed high school or privately insured were 1 5 times more likely to be users of herbs than those who are publicly insured,
135 The Clinical Manifestations and Diagnosis of Psoas Abscess in the Emergency Department
How CK, HuangYT, ChernCH,Wang LM, Lee OH/VeteransGeneralHospital,Emergency Department, Taipei, Taiwan, Republic of China Study objectwe: Psoas abscess is a rare disease. Misdiagnosis and delayed diagnosis are frequently encountered. Few reports or case studies have addressed the difl~culties in diagnosing psoas abscess in emergency department settings In this report, we present our experiences in making the diagnosis of psoas abscess, Methods: We retrospectively collected the patients with psoas abscess, who were identified by related International Classification oJDiseases (ICD) codes and ED charts at a tertiary care hospital in Tatpei from June 1989 to June 1999. All patients who presented with abscesses involving psoas muscle were enrolled. The diagnosis was based on either the imaging studies, which included ultrasound, computed tomography (CT) scan or gallium scan, or operative procedures. All enrolled cases were either newly diagnosed at our ED or after being admitted to our wards through the ED. Results: In this period, we identified 44 patients with a total of 46 events. The mean age of our patients was 64.56 years, which was much higher than those in the previous hteratures Fever (35 cases, 76.0%) was the most common presentalion. Typical clinical patterns that are specific to psoas abscess occurred only in a small portion of our cases (15 cases, 32 5%) It was noteworthy that 9 (23.9%) cases only presented with fever/sepsis without other symptoms and signs Because of diversified and nonspecific clinical manifestations, only 16 (34.7%) cases had correct initial ED diagnosis. A mixed picture of primary and secondary psoas abscess was found in this area Osteomyelms (7 cases, 15 2%) and urinary tract infection (6 cases, 13 0%) were the most presumptive causes o[ secondary psoas abscess in this region, contrary to those of previous reports The duration of symptomsbefore EDvisits ranged from 1 to 60 days (10.95±10.9E days). Some cases had a prolonged insidious clinical course, while others had a fulmmant course. The duration of the diagnosis made after ED visits ranged from 0 to 44 days (5.23±8.21 days/. The diagnosis of psoas abscess was established by ultrasound in 16 cases (10 performed by emergency physicians and 6 by radiologists), by CT scan In 24 cases, by surgical Intervention in 4 cases, and by gallium scan in 2 cases. The mortality rate was higher in patients without drainage or drainage failure and among those with a shorter duration of symptoms (P<.05). Conclusion: In this study, initial misdiagnosis and delayed diagnosis of psoas abscess were frequently encountered because of the diversified and nonspecific clinical manifestations. Some patients had a fulminant course. Emergency phystcians require the assistance of ultrasound m making the diagnosis and dispostnon of the patients, who usually are admitted through the ED. However, CT scan is indicated when emergency physicians have no adequate experience in ultrasound performance, when the lesion extends beyond the psoas muscle, or when the hkeh-
S36
1998, after seeing several cases of classic heat stroke, an unusual occurrence in this area, we began to review and collect cases of suspected heat stroke and tried to explore the possible cause of this unusual phenomenon. Methods: We retrospectively collected cases of suspected heat stroke (hyperthermta [>40.6°C]) m the presence of altered mental status and anhidrosls), identified by InternationalCIasslfzcatwnojDtseases codes and emergency department conferences, at a tertiary care hospital in Taipei, Tatwan, from June to August (the hottest months) 1998. In the summer of 1998, daily temperature in Taipei ranged from 22°C to 33°C. The highest temperature occurred on the afternoon of July 19, 1998, when it reached 38.1°C The basic demographic data, laboratory findings, clinical presentation, initial impressions, treatment, and outcome of the patients were recorded. We also tried to understand the lifestyle, living environment, and medical conditions of our patients through interviews of their fam~hes and emergency physicians in charge, tdephone calls, and chart records. Results' Six cases of heat stroke were enrolled in this study; all were classic heat stroke. We found that the most comorbzd conditions were hypertension (4/6) and preexisting mental problems (3/6). All patients lived in the inner part of an urban area, were middle class, and were not socially isolated Most patients felt unhealthy being exposed to the cold and avoided staying in air-conditioned rooms. Laboratory alonormahtms and clinical presentation, except for a high fever and change in conscious status, seemed to be nonspeczflc From the data collected from the local weather bureau, all cases occurred during 2 periods of sustained hotter-than-average weather and, not surprisingly, we found that 3 episodes occurred around the day of the highest weather temperature (38.1°C) Compared with the other study, our patients seemed to have an initial worse outcome--2 died and 1 is In a vegetative state caused by hypoxic encephalopathy, whereas there was a complete recovery in initially diagnosed patients (3/6). A mild disease, no concurrent mfecuon, and early cooling explained the good result of completely recovered patients, whereas misdiagnosls due to absence of experience and delayed cooling seemed to be the most important factor in patients with poor outcome. Conclusion: Because of special environmental and social factors, classic heat stroke may occur occasionally in subtropical regions, without previous history of heat waves and where heat stoke rarely occurs, during periods of the persistently high temperatures, even without reaching the criteria of a heat wave Heat stroke should be consIdered in any patients with hyperthermla and neurologic abnormalities after exposure to high ambient temperatures. Cooling and a search for underlying conditions should be mitiated in parallel. Prevention of heat stroke in an area with a low incidence includes early orgamzatlonal issuing of advlsones or warnings through the media and reminding or teaching emergency physicians about heat stroke during sustained hot weather, especially when record temperatures are set.
137
TheMisdiagnosisofLiverAbscessinthe EmergencyDepartment
ChernCH, How CK,Wang LM, Lee OH/VeteransGeneralHospital.EmergencyDepartment, Taipei, Taiwan, Repubhc of China Study objective" The purpose of this study was to find the mmdiagnosis of liver abscess in the emergency department to delineate the appropriate indications of ultrasonography and computed tomography (CT). Methods: We retrospectively reviewed the cases of liver abscesses, identified by Internanonal Class~ficationof Diseases codes, treated at a tertiary care hospital In Tatpei, the capital of Taiwan, from January 1995 to January 1999. All enrolled cases were newly diagnosed at our ED or after admission to our wards through the ED. Cases diagnosed at other hospitals were excluded from our study. We med to explore the possible cause(s) of misdiagnoses through literature review and our clinical judgment and experience Parameters, such as fever vathout a definite origin lasting more than 3
ANNALS OF EMERGENCYMEDICINE 35:5 MAY 2000
8th I N T E R N A T I O N A L CONFERENCE ON E M E R G E N C Y MEDICINE ABSTRACTS
days, the presence of sepsis,WBC count in excess of 20,000/mm 3 or band form in excess of 6%, the presence of abnormal liver function test reuslts (especially alkaline phosphatase), the presence of epigasmc or right upper quadrant pain or tenderness, and the presence flank pain or flank knocking pain, were indicators for further exam> nation for possible presence of liver abscess. In this hospital, every emergency physician receives a 3-month full-time training in ultrasound before assignment to an attending position, Results: In this period, we collected a total of 160 cases and found 83 (51.9%) cases with initial misdiagnoses Surprisingly, at least 94 (58 8%) patients had visited other clinics and hospitals before coming to our ED, with mlsdiagnoses ranging from upper respiratory tract infection or abdominal pain to fever of unknown origin, sepsis, or meningitis Among the cases with misdiagn . . . . . 3 (1 9°£) were related to atypical presentations, 5 (3.1%) to inadequate laboratory examinations, 41 (25.6°£) to failure to perform ultrasound in the ED, 33 (20.6%) to ultrasound failure to identify the lesions, and 6 (3 8%) to the unavallabifity of ultrasound at mldmght. The possible causes of ultrasound failure to identify a lesion in 33 cases were explored: 12 (36.4°£) cases had small lesions, 8 (24.2%) early lesions, 10 (30.3%) intrahepatic duct stone or dilation, 9 (27 3%) the presence of other diseases (acute cholecystttts, bifiary tract infection, or pancreatitis), 6 (18.2%) peripheral lesions, 12 (36.4%) fatty liver or coarsening of liver, 4 (12.1%) air within abscess or lleus, and i rapid breathing Five (15.2%) cases were due mainly to physician factors (4 reading errors and 1 technical error). However, not any causes of ultrasound failure could be identified in 4 cases, Furthermore, the Immediately diagnosed and initially undiagnosed groups seemed to have no statistical differences in age, the presence of diabetes mellitus, and clinical parameters,
Conclusion: In Talwan, liver abscess is not a rare disease. In this study, mlsdlagnoses occurred in a high portion of cases and most cases were due to failure to order or perform an ultrasound examination and failure of ultrasound to find a lesion, not due to the different clinical presentations. A diagnosis protocol of liver abscess will be presented. Emergency physicians should understand the indications of ordering the appropriate laboratory examinations (liver function tests) and ultrasound in patients with fever of unknown origin or prolonged fever and abdominal pain (especially right upper quadrant pain). From our study, there were many reasons for negative ultrasound findings in liver abscess, so computed tomography may be necessary for cases with prominent physical examination or laboratory abnormalities of some clinical conditIons.
38
12 2% had ngors (P=.056); 26.3% versus 4.4% had recent surgery,; 0% versus 7.8% had distinct margins of erythema (P<.01); 15.8% versus 3.3% had vancose veins; 5.3% versus 18.9% were currently taking antibiotics, 15.8% versus 26.7% had &abetas, 31 6% versus 16.7% had peripheral vascular disease; and 50% versus 21.4% had art elevated WBC count. Conclusion: There are differences in a number of baseline characteristics of "DVT versus celluhtls" patients with positive versus negative duplex scan findings, some of which were statistically significant despite the limited sample size. We plan to con> bine variables into a single clinical prediction model, which will then be prospectively tested to determine its utility m the diagnostic process of these patients.
1~Q
How Do Nurses Train for the Role of Triage In Australasia?
II IIJ~,W Kelly AM, Richardson D/Western Hospital. Department of EmergencyMedicine. Melbourne, Australia, Canberra Hospital, Department of EmergencyMedicine. Canberra, Australia Study objectives: To determine how nurses in Australasia are prepared for the role of triage Methods: We conducted a postal survey of nurse unit managers of emergency departments accredited by the Australasian College for Emergency Medlcme Data collected included the minimum duration of ED expenence required before performing mage, the structure and duration of education activities for the role of triage, and pro cesses used to monitor the quality of triage, both at the level of departments and of individual nurses. Results: Seventy-two responses were received (response rate 90%). All departments were using the Australasian National Triage Scale. Sixty nine departments reported minimum ED experience requirements, with a median requirement of 12 months. Six departments participated in regional triage training courses, and 30 others (42%) conducted formal study programs. Self-learning packages were the most commonly used educational tool, used by 42 departments (58%). Thirty-nine (54%) departments required a period of supervised experience, with the median duration being 2 shifts. Four departments reported that there was no specific training for the triage role. Twenty-nine departments reported that they had no formal process to monitor quality of triage, 24 departments (35%) conducted some form of regular audit, whereas only 8 departments (i2%) analyzed triage category" against presenting complaint or dtagnosis. Conclusion: Preparation of nurses for the role of triage IS highly variable, both m
When the Clinical Impression Is Deep Vein Thrombosis Versus Cellulitis: Do Patient Characteristics Predict the Duplex
duration of previous ED experience required and in the structure of educational programs. Few departments conduct processes to objectively monitor the quality of triage. Future research should focus on identifying core content for training programs for the
Diagnosis?
role of mage and how competency can be assessed and maintained.
RabukaOE,AzoulayLY,KahnSR/McGillUniversity,EmergencyMedicineResidencyProgram, Montreal,Canada;Sir MortimerB. Dav,s-JewishGeneralHospital,Departmentof Clinical Epidemiology,Montreal,Canada
140
Stud}" objectives Differentiating deep vein thrombosis LDVT) from cellulitis is an important emergency department problem, because both are common acute diseases with similar presentations. If a set of clinical parameters were avadable that helped
P0well C, Kelly AM. Williams A/Sunshine Hospital, Department of EmergencyMedicine. Melbourne, Australia; Western Hospital. Department of EmergencyMedicine. Melbourne, Australia; Sunshine Hospital.Department of EmergencyMedicine. Melbourne, Australia
predict the outcome of venous duplex scan in such patients, the process of accurate diagnosis and appropriate therapy would be expedited, while decreasing unnecessary duplex scans The objectives of this study were (1) to determine the proportion of patients who had a final diagnosis of DVT, celluhtls, or both among ED patients in whom the initial clinical impression was "DVT versus cellufitis" and who underwent duplex scanning; and (2) to determine which baseline clinical parameters, if any, predicted the final diagnosis. Methods: This study was a retrospective chart review of patients who presented to the ED of the Sir Mortimer B. Davis-Jewish General Hospital dunng 1995-1998 in whom the initial dlfterential diagnosis was cellulltiS versus DVT, thus leading to referral for duplex scan. Data were collected for several baseline vanables (before duplex scan was performed) such as demographic factors, history, physical examination, and laboratory assessment Patients with positive and negative duplex studies were cornpared on these variables using the Student t test or the X2 test. Results: Of 542 ED patients who were referred for duplex scan, 109 were initially assigned a differential diagnosis of DVT versus celluhtis. Of these, only 19 (17 4%l had positive duplex scan findings. 2 of w h o m were also treated for cellufitis tie, final diagnosis both DVT and cellulttts). Comparing patients with positive versus negative duplex scan findings, 5.3% versus 14.4% had constitutional symptoms; 0% versus
Study objectives: To determine the m i n i m u m clmically significant difference (MCSD) in a visual analog scale (VAS) pain score for children and to determine whether it differs with the age of the child. Methods: This was a prospective, single-group, repeated measures study of children aged between 8 and 15 years in an urban pediatric emergency department On presenladen to the ED, patients marked the level of their pain on a 100-mm, nonhatched VAS. At 20-minute intervals thereafter, they were asked to give a categorical rating of their pain as "a lot better," "a httle better," "much the same," "a little worse," or "much worse" and to mark the level of their pain on a VAS of the same type, blinded to their previous mark. The minimum clinically significant diflerence in VAS pain score was defined as the mean difference between current and preceding scores when the subject reported "a little worse" or "a little better" pain Data were analyzed for the group overall and for the age subgroups 8 to 11 years and i2 to 15 }'ears. Results Seventy-three children were enrolled in the study, yielding 103 evaluable comparisons where pain was rated as "a little better" or "a little worse." The MCSD m VAS pain score in the group overall was 10 mIn (95% confidence interval [CI] 7 to 12 ram). MCSD in VAS score for the 8- to 1 t-year group was 15 inm (95% CI 9 to 22 mm) and for the 12- to 15-year group, 9 m m (95% CI 7 to 12 m m ) These "sTereno{ statistically different (P= 3997l
MAY 2000 35:5 ANNALS OF EMERGENCYMEDICINE
What is the Minimum Clinically Significant Change in Visual Analog Scale Pain Score for Children?
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8th INTERNATIONAL CONFERENCE ON EMERGENCY MEDICINE ABSTRACTS
Conclusion: The MCSD in VAS pain score for children aged 8 to 15 years was found to be 10 mm. Differences of less than this amount, even if statistically different, are unlikely" to be chmcally significant.
141
PrehospitalResuscitationof 0ut-Of-Hospital Cardiac Arrest in Hong Kong
minimally, prepared was 39%, 35%, and 21%, respectively, tor each NBC agent, and less than 1% rated their graduates well prepared Conclusion: This needs assessment is the first phase of a 3-part analysis of the preparedness of emergency physicians to manage medmal aspects of WMD threats.
Programdirectorresponsessuggestthatin a substantialproportionofemergency medlcme residency programs, the traming to manage these threats may be inadequate
Leung LP, Lo CM, Tong HK/QueenMary Hospital,Accidentand EmergencyDepartment,Hong Kong
We suggest that the development of a targeted curriculum and its inclusion m resi-
Study" objectzve: To evaluate the efficacy of out-of-hospital resuscitation tn Hong Kong and identify areas for improvement,
dency programs may" enable emergency medicine physmians to better manage the medmal aspects of weapons of mass destruction
Methods: Ihts was a prospective descriptive study of patients with nontraumatic out-of-hospital cardiac arrest who were transported by the ambulance service to the emergency department for the period March I5, 1999, to September 15, t999. Data
143
Assessmentof Asthma Management Before and After the Introduction of Guidelines in An Accident and Emergency Department in Hong Kong
were recorded m a standard format based on the Utstem style The study- semng was
the ED of a regional hospital m Hong Kong West, serving a populanon of one half
Tsui SH, Sham A, Tong HK, Chan-Yeung M/Queen Mary Hospital, Accident and Emergency
million. A total of 115 cardiac arrest patients older than 18 years were included.
Department and Department of Medicine, Hong K0ng, SAR
Results: There was male predommance (62 6%), mean patient age was 71 4 years. The majonty of cardiac arrests occurred at patients' homes (71 1%), and 54-.8% of cases were unwitnessed The bystander car&opulmonary resuscitation (CPR) rate was 11 3%. In 75.3% of cases, the elevator of the patient's residence did not accommodate
Study objectives: We investigated whether the introduction of gmdelines for asthma management would improve the management of asthma m an accident and emergency" (AGE) department m Hong gong.
a stretcher. The most common ECG rhythm on first contact was asystole (78.4%). Venmcular flbrfllation/pulseless ventricular tachycardia constituted 15.3% of rhythms. The average call to response interval of the ambulance service was 1 02 minutes. The average call to CPR (by ambulance attendants) interval was 9.70 minutes. The average total out-of-hospital interval was 28.31 minutes. Resuscitation in the ED was performed in 52.7% of cases. The overall immediate survival rate was 15 7%. Conclusion: The ambulance service is efficient with quick response time. However, the immediate sunuval rate is low. This seems to be related to the high percentage of unwitnessed arrests and the low rate of bystander CPR. Also, m a modern city like Hong Kong, most residents hve in muhistory buildings. Failure to accommodate a stretcher for patient transport constitutes a significant problem in pcrformmg effective CPR during transport Urgent attention should be paid to public educauon on CPR and future building design.
42 Weapons EmergencyMedicine ResidentPreparednessfor the Threat of of Mass Destruction: Results of A National Residency Program Director Survey Bonucci P, Vuletich M, Smith 6, Johnson M, 8ussow L, Leo M/Oo0k County Hospital,
Methods. An audit was carried out on records of patients with the diagnosis of asthma, older than 2 years of age, seen in the AgzE department between August 18 and November 14, 1998 (88 days). The guidehnes, similar to the one published by the Bntish Thoracm Society but amended to fit the department system, were mtroduced and actively promoted on November 15, 1998. The audit was repeated for patients seen between November 30 and February 10, 1999 (73 day's). The follovang data were collected' asthma history, investigations, treatment, outcome, and medications given on discharge. Results' There were 233 and 337 asthma patients seen during the 2 periods respecuvely, with no differences m gender and age distrtbutmn Their asthma seventy also did not differ as measured by pulse and respiratory rate, arterial oxygen saturation, and peak flow rate before and after bronchodllator treatment. Peak flow rate was measured m 51.5% of patients before and 75% after the introduction of guidelines (P< 01) Significant increases in the use of oxygen (82.8% versus 89%) and systemic steroids (6.4% versus 1 l 9%) were found; 35% and 37 7% of paUents, respecuvely, were admitted to the hospital before and after the mtroducuon of the gmdehnes For those who were discharged, a higher propomon were &scharged wuh a course of oral steroids (25 8% before and 52.7% after, P<.005). Conclusion. Asthma management in the AGE department m~proved after the introduction of guldehncs, but the improvement did not rcsuh m a reduction in the rate of
Department of EmergencyMedicine, Chicago, Ik
hospital admission for asthma
Study objectives The health threat posed by potential exposure to nuclear, biological, or chemical (NBC5 agents, also k . . . . . . . capons of mass destruction (WMD), is receiving significant public attention. The Nunn-Lugar-Domemcz WMD Act of E997
144
was passed by Congress to address the perceived lack of preparedness among emergency personnel. However, training in WMD has not yet become a required part of the curriculum for emergency medmine residency programs. The Investigators believe the first step In addressmg this issue should be a needs assessment to identify current acnw rues and deficiencies. Therefore, we surveyed the program directors of all US emergency medtcme residencms to determme current educational efforts in WMD and their perceplion of the preparedness of their residents to manage these threats, Methods: A 1-page survey of emergency medicine residency program directors was developed which included estimated hours ot didactic instruction on NBC topics and rating of preparedness ot recent graduates to manage incidents m each of these areas using a 5-pomt Llkert scale (l=minimally prepared to 5=well prepared) The snrvey was telefaxed to 116 allopathtc and 26 osteopathic emergency medicine residency programs. Fonow-up telephoning and fa.-dngwas conducted to Increase the rate of response, Results: Ninety-one of 142 program directors completed the sur~'ey, representing a response rate of 6"4%. The estimated training time spent on NBC averaged 11.3 hours/ ?,ear for all programs responding. The average training time for each component was 1.7 hours nuclear exposure/management, 1.7 hours biological weapons, 2.5 hours chemical, and 5 4 hours disaster management. The composition of this time was 51% lecture, 31% drills, 16% external conferences, and 2% other. Twenty-eight percent of residency programs had discussed NBC topics in journal club during the past 3 years, Program directors rated the level of preparedness of their graduates to manage an incident in each NBC agent as follows: nuclear 2.2 points, biologmal 2.3 points, and chemmal 2.7 points. The percentage of program directors who rated their graduates
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FactorsAssociated With Head & Neck Injury in Air Bag-Deployed Crashes
Gregory ME/State University of New York Health ScienceCenterat Syracuse,Syracuse,NY Study objective: To describe the factors associated with the occurrence of head and neck mjuries in serious and fatal car crashes In which air bags are deployed. Methods: This study was a retrospective review of data contained m the Nauonal Highway Traffic Safety Admimstratlon (NHTSA) Special Crash Investigauon Program database. The database includes mformation about senous and fatal car crashes in which air bags were deployed, including patient information, seatbelt usage, the change in velocity experience during the crash (AV), and mjury pattern(s). We compared the frequency' of head and neck mjunes among patients wearing and not wearing seatbehs, as well as for drivers and passengers using %2 analysis or Flsher's exact test. We also compared the mean AV for crashes resulting in head and neck injury and those that did not using t test. Results: The database included 62 serious or fatal crashes occurring over a 9-year period. 56 (90.3%) resulting in a fatahty, and 6 (9.7%) resulting in serious injury. Fifty-five (89%) of the vmtIms were drivers. The frequency of head and neck injury did not differ for VlCUms wearing and not wearing seatbelts (57% versus 45%, Z2 P=.378). The AV did not differ for victims with and without head and neck injury, (12.3 m p h versus 12.6 mph, t test P= 795). Passengers were more fikely to suffer head and neck injury than drivers (100% versus 42.9%, Fisher's exact test P=.0048) Conclusion: Passengers m serious or fatal car crashes in which an mr bag deploys are more likely than drivers to suffer head and neck injuries. Seatbelt usage and AV do not appear to be related to the occurrence of head and neck injury in such crashes.
ANNALS OF EMERGENCYMEDICINE 35'5 MAY 2000