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Child Car Safety Laws: Knowledge of Caregiver, is More Education Needed?
MEMC V Abstracts Introduction: Contrast-induced nephropathy (CIN) is the third leading cause of acute renal failure in hospitalized patients. We measured the incidence and risk factors for CIN in Emergency Department (ED) patients with normal renal function who had a clinical indication for an intravenous (i.v.) contrast-enhanced abdominal computed tomography (CT) scan. Methods: We conducted a prospective convenience sample of patients who had an i.v. contrast-enhanced CT scan. We studied patients presenting to a university-based urban ED from January 2008 –May 2009. Inclusion criteria: ED patients 18 years of age or older with an initial normal creatinine (Cr) (Cr ⬍ 1.5 mg/dL) who received a contrast-enhanced CT scan in the ED and had a repeat Cr in 48 h. Exclusion criteria: Chronic dialysis patients, pregnant patients, and those refusing consent for study. CIN was defined as a rise in serum Cr of 25% or an increase in Cr ⫽ 0.5 mg/dL from baseline 48 h after contrast. Data were reported as means ⫾ standard deviations. Group comparisons were made by Student’s t-test (a ⫽ 0.0 5, 2 tails). Results: 83 patients (average age 54 ⫾ 18 years [18 – 88 years]; 57% female) were studied. The incidence of CIN was 9.8% (95% confidence interval 4.8 –18.3%). There was no significant (p ⫽ 0.31) difference in age between CIN⫹ (48.4 ⫾ 17.8 years) and CIN⫺ patients (55.1 ⫾ 18.4 years). Patients with CIN had significantly (p ⫽ 0.01) lower initial Cr (0.71 ⫾ 0.14 mg/dL) than those without CIN (1.01 ⫾ 0.31 mg/dL). Glomerular filtration rate (GFR) was significantly (p ⫽ 0.004) higher in CIN⫹ (133.1 ⫾ 55.0 mL/min/1.73 m2) than in CIN⫺ patients (94.0 ⫾ 32.4 mL/min/1.73 m2). Patients with CIN compared to those without did not differ significantly (p ⬎ 0.05) for baseline blood urea nitrogen (BUN), white blood cell count, hematocrit (HCT), bicarbonate (HCO3), systolic or diastolic blood pressure. No patients required renal replacement therapy or died. Conclusion: We found a significant incidence of CIN (9.8%) in patients with an initial normal renal function exposed to intravenous contrast that could not be predicted by age, lower GFR, elevated creatinine, or any differences in BUN, HCT, HCO3, systolic or diastolic blood pressures.
e TOURNIQUET-INDUCED ACUTE ISCHEMIA-REPERFUSION INJURY IS ASSOCIATED WITH OXIDATIVE STRESS AND MITOCHONDRIAL DYSFUNCTION. T.P. Tran, H. Tu, R.L. Muelleman, Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE; H. Albadawi, Massachusetts General Hospital, Harvard Medical School, and the VA Boston Healthcare System, Boston, MA; I. Pipinos, Y. Li, Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE. Up to 10% of preventable combat fatalities are due to hemorrhage from extremity wounds, making emergency tourniquet one of the first-line treatments. Although life saving, prolonged application of tourniquet can cause serious ischemiareperfusion (IR) injury. Using a murine model of tourniquetinduced acute hind limb IR, we investigated acute IR injury, oxidative stress, and mitochondrial dysfunction in skeletal muscle. An IR protocol of 3 h of ischemia and 4 h of reperfusion was achieved by placement and release of a rubber tourniquet at the greater trochanter level around the hind limb of C57/BL6
233 mice. Tourniquet-induced ischemia and subsequent reperfusion were verified by measuring skeletal muscle blood flow (SMBF) in gastrocnemius muscle. SMBF was significantly reduced to ⬍ 10% of baseline during the ischemic period and partially recovered to about 40% of baseline during the reperfusion period. This IR protocol was accompanied by ⬎ 40% necrosis in gastrocnemius muscle. Superoxide production was markedly increased (0.05 ⫾ 0.01 vs. 0.13 ⫾ 0.01 MLU/min/100 g protein, p ⬍ 0.05) and activities of mitochondrial electron transport chain complexes including complex I, II, III, and IV in gastrocnemius muscle decreased in the IR group compared to sham. Activity of manganese superoxide dismutase (MnSOD, the mitochondria-targeted SOD isoform) in gastrocnemius muscle was also reduced in IR, although the protein expression of MnSOD was increased. These results suggest that in a tourniquet-induced IR model, 3 h of ischemia and 4 h of reperfusion results in significant skeletal muscle necrosis and mitochondriopathy. These IR injuries are associated with an elevated superoxide production and reduced antioxidant activity. In the future, this murine IR model can be adapted to mechanistically evaluate anti-ischemic molecules in efforts to minimize morbidity and mortality of tourniquet-induced IR in battlefield injury.
e CHILD CAR SAFETY LAWS: KNOWLEDGE OF CAREGIVER, IS MORE EDUCATION NEEDED? C.J. Martinez-Martinez, C.M. Molins, S.E. Villanueva, Hospital de la Universidad de Puerto Rico, Carolina, PUERTO RICO. Background: As studies have shown, the majority of these deaths could have been prevented by an appropriate use and knowledge of child car seat safety. By determining the level of knowledge among caregivers, more education can help minimize the mortality and morbidity of children due to car accidents. The objective of the study was to determine caregivers’ level of child car seat safety knowledge in subjects presenting to the Emergency Department (ED) in Puerto Rico. Methods: A cross-sectional survey was performed to determine the knowledge of child car safety seats in caregivers presenting to an academic ED in Puerto Rico (PR). The recruitment of subjects took place at the ED in UPR hospital in Carolina, as a convenience sample. Self-administered questionnaires were given to all caregivers. It consisted of 21 questions that included knowledge of car seat safety guidelines, transportation state laws knowledge, and source of education. Statistical analysis was performed using SPSS version 16.0 (SPSS Inc., Chicago, IL). Results: There were 203 subjects enrolled in our study; the range of ages was 14 to 62 years. The mean score of correctly answered knowledge questions was 5.96 out of 12. When asked about the state law limit for a child to be in a car safety seat, 85% were incorrect. Ninety percent of these subjects knew that children under the age of 12 years should be seated in the rear seat. The majority of the subjects correctly identified that a child ⬍ 1 year of age should be rear facing (83%), and that children 1 year or older should be facing the front (83%). Subjects were unable to identify the safest place for a child as the rear middle seat. Statistically significant differences were obtained when analysis of variance was performed to determine the association of knowledge to the level of education (p ⫽ 0.042) and
234 income (p ⫽ 0.012). Conclusion: We concluded that there is a low level of knowledge among caregivers of children ⬍ 13 years old in reference to child car seat safety laws and guidelines in PR. Future efforts should be directed towards improving population knowledge about the correct use of child car safety seats.
e HYPOGLYCEMIA, AN UNCOMMON BUT REAL COMPLICATION OF STANDARD HYPERKALMIA TREATMENT. Y.C. Huang, Department of Emergency Medicine, Chiayi Christian Hospital, Chiayi City, TAIWAN. Introduction: Hyperkalemia is life-threatening and requires immediate treatment. A combination of 25 g glucose and 10 units regular insulin given intravenously over 15–30 min is suggested as part of the standard treatment for hyperkalemia in Advanced Cardiac Life Support (ACLS); however, no precaution has been mentioned for potential side effects. Some patients became hypoglycemic after treatment. We thus investigated our hyperkalemic patients and their response to treatment with insulin and glucose. Methods: This is a tertiary transfer hospital serving over 90,000 emergency visits annually. We treat hyperkalemic patients based on ACLS recommendations. A cross-sectional, cohort, observation study was undertaken from May 2004 to April 2009. We collected data on hyperkalemic patients treated to review their demographics and co-morbidities that may predispose to hypoglycemia. We used multivariable analysis to check potential risks that may predispose to hypoglycemia. Results: There were 160 patients treated for hyperkalemia. Seven cases were excluded and 153 patients were enrolled. There were 76 men and 77 women, with ages ranging from 41 to 96 years (median: 74, interquartile range 65⬃82). About their hyperkalemia: 56 (36.6%) were mild, 63 (41.2%) were moderate, and 34 (22.2%) were severe. Most had multiple systemic illnesses, and renal diseases were the leading co-morbidity: 21(13.7%) received replacemental dialysis, another 86 (56.2%) had documented chronic kidney diseases. Emergency department studies revealed elevated serum creatinine in 133 (86.9%) patients, including 4 (2.6%) with acute renal failure. Seven (4.6%) patients were hypoglycemic 49 –240 (median 79) min after insulin treatment, and 5/7 were symptomatic. No risk factor could be identified that predisposed to the hypoglycemia after insulin and glucose treatment. Conclusion: The risk of hypoglycemia is real after standard ACLS treatment of hyperkalemia with insulin and glucose. Most instances happened 1–2 h after insulin treatment and were symptomatic. We should pay attention to potential hypoglycemia in hyperkalemic patients who receives insulin treatment, especially when their sensorium is impaired.
e A RANDOMIZED, BLINDED, CONTROLLED CLINICAL TRIAL OF 1000 CC VERSUS 500 CC ORAL CONTRAST IN ADULTS UNDERGOING ABDOMINAL CT SCANS. L. Moreno-Walton, Department of Emergency Medicine, Louisiana State University Health Sciences Center, New Orleans, LA; F. Azubiuke, Mt. Sinai Medical Center, Miami, FL; M.S. Radeos, New York Hospital, Queens, NY; A. Baquero, M.T. Ryan, Lincoln Medical and Mental Health Center, Bronx, NY. Objective: To determine if reducing oral contrast volume to 500 cc results in more rapid oral contrast administration with-
The Journal of Emergency Medicine out increasing the percentage of technically inadequate computed tomography (CT) scans of the abdomen. Methods: Prospective randomized blinded study at an urban Level I trauma center. We enrolled subjects ⬎ 18 years of age presenting to the emergency department (ED) who had an abdominal CT scan ordered. Subjects were excluded if they were pregnant or unstable. They were randomized into two groups using numbered envelopes. We diluted 30 cc of oral contrast (diatrizoate meglumine and diatrizoate sodium) in 500 cc (study group) or 1000 cc water (control group). Data were collected by physician questionnaire. Radiologists were blinded to study allocation. Analysis was by chi-squared for categorical and KruskalWallis for non-parametric data. Results: There were 139 patients randomized to each group; 160 (58%) were males. There was no statistical significance between the control and study groups in the median patient age (45 vs. 41 years, p ⫽ 0.12), number of CT scans that answered the clinical question (94% vs. 91%, p ⫽ 0.41), number read as acceptable by radiology (87% vs. 85%, p ⫽ 0.55), number who required subsequent studies (14% vs. 16%, p ⫽ 0.74), total time from beginning contrast to completing CT scan (146 vs. 140 min, p ⫽ 0.70), number of patients who vomited (9.5% vs. 5.7%, p ⫽ 0.26), and number who underwent surgery (8.7% vs. 10.4%, p ⫽ 0.64). The time to consume the 500 cc was significantly less (20 min) than time to consume the 1000 cc (30 min), p ⫽ 0.0001. Patients were more likely to complete the 500-cc volume than the 1000-cc volume (91.2% vs. 73.6%), p ⬍ 0.001; odds ratio 1.41 (95% confidence interval 1.2–1.7) even after adjusting for gender and age. Conclusions: Patients consume the 500-cc solution faster and the resulting CT scans have similar technical acceptability compared with the 1000-cc solution. Future studies should focus on even smaller amounts of oral contrast volume for abdominal CT scans.
e SENSITIVITY OF A NEW DIAGNOSTIC SCALE FOR PULMONARY THROMBOEMBOLISM IN TWO UNIVERSITY-AFFILIATED HOSPITALS. O. Palla´s, M.T. Martı´nez, Department of Emergency Medicine, Hospital del Mar, Barcelona, Catalunya, SPAIN; M. Marin˜osa, M. Paye´s, Hospital Parc Taulı´, Sabadell, SPAIN; F. Del Ban˜o, A. Supervia, E. Skaf, Department of Emergency Medicine, Hospital del Mar, Barcelona, Catalunya, SPAIN; M.L. Iglesias, Hospital Parc Taulı´, Sabadell, SPAIN; J.L. Echarte, Department of Emergency Medicine, Hospital del Mar, Barcelona, Catalunya, SPAIN. Introduction: Validated scales for grading the clinical suspicion of pulmonary thromboembolism (PT) are used in the emergency department setting. The Wells (WS) and the Ginebra (GS) scales have been prospectively validated but have limitations in our environment. Objectives: To compare the sensitivity of a new scale of clinical prediction of PT (Catalan scale) with WS and GS in two hospitals. Methods: There were 194 patients diagnosed with PT between 2004 and 2006. Diagnosis was confirmed by computed chest angiotomography or high-probability ventilationperfusion (V/P) lung scanning. Hospital discharge records and imaging studies were reviewed. The WS, GS, and the Catalan scale (CS), were applied. Data were analyzed with SPSS 13.0
e TOURNIQUET-INDUCED ACUTE ISCHEMIA-REPERFUSION INJURY IS ASSOCIATED WITH OXIDATIVE STRESS AND MITOCHONDRIAL DYSFUNCTION. T.P. Tran, H. Tu, R.L. Muelleman, Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE; H. Albadawi, Massachusetts General Hospital, Harvard Medical School, and the VA Boston Healthcare System, Boston, MA; I. Pipinos, Y. Li, Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE. Up to 10% of preventable combat fatalities are due to hemorrhage from extremity wounds, making emergency tourniquet one of the first-line treatments. Although life saving, prolonged application of tourniquet can cause serious ischemiareperfusion (IR) injury. Using a murine model of tourniquetinduced acute hind limb IR, we investigated acute IR injury, oxidative stress, and mitochondrial dysfunction in skeletal muscle. An IR protocol of 3 h of ischemia and 4 h of reperfusion was achieved by placement and release of a rubber tourniquet at the greater trochanter level around the hind limb of C57/BL6
233 mice. Tourniquet-induced ischemia and subsequent reperfusion were verified by measuring skeletal muscle blood flow (SMBF) in gastrocnemius muscle. SMBF was significantly reduced to ⬍ 10% of baseline during the ischemic period and partially recovered to about 40% of baseline during the reperfusion period. This IR protocol was accompanied by ⬎ 40% necrosis in gastrocnemius muscle. Superoxide production was markedly increased (0.05 ⫾ 0.01 vs. 0.13 ⫾ 0.01 MLU/min/100 g protein, p ⬍ 0.05) and activities of mitochondrial electron transport chain complexes including complex I, II, III, and IV in gastrocnemius muscle decreased in the IR group compared to sham. Activity of manganese superoxide dismutase (MnSOD, the mitochondria-targeted SOD isoform) in gastrocnemius muscle was also reduced in IR, although the protein expression of MnSOD was increased. These results suggest that in a tourniquet-induced IR model, 3 h of ischemia and 4 h of reperfusion results in significant skeletal muscle necrosis and mitochondriopathy. These IR injuries are associated with an elevated superoxide production and reduced antioxidant activity. In the future, this murine IR model can be adapted to mechanistically evaluate anti-ischemic molecules in efforts to minimize morbidity and mortality of tourniquet-induced IR in battlefield injury.
e CHILD CAR SAFETY LAWS: KNOWLEDGE OF CAREGIVER, IS MORE EDUCATION NEEDED? C.J. Martinez-Martinez, C.M. Molins, S.E. Villanueva, Hospital de la Universidad de Puerto Rico, Carolina, PUERTO RICO. Background: As studies have shown, the majority of these deaths could have been prevented by an appropriate use and knowledge of child car seat safety. By determining the level of knowledge among caregivers, more education can help minimize the mortality and morbidity of children due to car accidents. The objective of the study was to determine caregivers’ level of child car seat safety knowledge in subjects presenting to the Emergency Department (ED) in Puerto Rico. Methods: A cross-sectional survey was performed to determine the knowledge of child car safety seats in caregivers presenting to an academic ED in Puerto Rico (PR). The recruitment of subjects took place at the ED in UPR hospital in Carolina, as a convenience sample. Self-administered questionnaires were given to all caregivers. It consisted of 21 questions that included knowledge of car seat safety guidelines, transportation state laws knowledge, and source of education. Statistical analysis was performed using SPSS version 16.0 (SPSS Inc., Chicago, IL). Results: There were 203 subjects enrolled in our study; the range of ages was 14 to 62 years. The mean score of correctly answered knowledge questions was 5.96 out of 12. When asked about the state law limit for a child to be in a car safety seat, 85% were incorrect. Ninety percent of these subjects knew that children under the age of 12 years should be seated in the rear seat. The majority of the subjects correctly identified that a child ⬍ 1 year of age should be rear facing (83%), and that children 1 year or older should be facing the front (83%). Subjects were unable to identify the safest place for a child as the rear middle seat. Statistically significant differences were obtained when analysis of variance was performed to determine the association of knowledge to the level of education (p ⫽ 0.042) and
234 income (p ⫽ 0.012). Conclusion: We concluded that there is a low level of knowledge among caregivers of children ⬍ 13 years old in reference to child car seat safety laws and guidelines in PR. Future efforts should be directed towards improving population knowledge about the correct use of child car safety seats.
e HYPOGLYCEMIA, AN UNCOMMON BUT REAL COMPLICATION OF STANDARD HYPERKALMIA TREATMENT. Y.C. Huang, Department of Emergency Medicine, Chiayi Christian Hospital, Chiayi City, TAIWAN. Introduction: Hyperkalemia is life-threatening and requires immediate treatment. A combination of 25 g glucose and 10 units regular insulin given intravenously over 15–30 min is suggested as part of the standard treatment for hyperkalemia in Advanced Cardiac Life Support (ACLS); however, no precaution has been mentioned for potential side effects. Some patients became hypoglycemic after treatment. We thus investigated our hyperkalemic patients and their response to treatment with insulin and glucose. Methods: This is a tertiary transfer hospital serving over 90,000 emergency visits annually. We treat hyperkalemic patients based on ACLS recommendations. A cross-sectional, cohort, observation study was undertaken from May 2004 to April 2009. We collected data on hyperkalemic patients treated to review their demographics and co-morbidities that may predispose to hypoglycemia. We used multivariable analysis to check potential risks that may predispose to hypoglycemia. Results: There were 160 patients treated for hyperkalemia. Seven cases were excluded and 153 patients were enrolled. There were 76 men and 77 women, with ages ranging from 41 to 96 years (median: 74, interquartile range 65⬃82). About their hyperkalemia: 56 (36.6%) were mild, 63 (41.2%) were moderate, and 34 (22.2%) were severe. Most had multiple systemic illnesses, and renal diseases were the leading co-morbidity: 21(13.7%) received replacemental dialysis, another 86 (56.2%) had documented chronic kidney diseases. Emergency department studies revealed elevated serum creatinine in 133 (86.9%) patients, including 4 (2.6%) with acute renal failure. Seven (4.6%) patients were hypoglycemic 49 –240 (median 79) min after insulin treatment, and 5/7 were symptomatic. No risk factor could be identified that predisposed to the hypoglycemia after insulin and glucose treatment. Conclusion: The risk of hypoglycemia is real after standard ACLS treatment of hyperkalemia with insulin and glucose. Most instances happened 1–2 h after insulin treatment and were symptomatic. We should pay attention to potential hypoglycemia in hyperkalemic patients who receives insulin treatment, especially when their sensorium is impaired.
e A RANDOMIZED, BLINDED, CONTROLLED CLINICAL TRIAL OF 1000 CC VERSUS 500 CC ORAL CONTRAST IN ADULTS UNDERGOING ABDOMINAL CT SCANS. L. Moreno-Walton, Department of Emergency Medicine, Louisiana State University Health Sciences Center, New Orleans, LA; F. Azubiuke, Mt. Sinai Medical Center, Miami, FL; M.S. Radeos, New York Hospital, Queens, NY; A. Baquero, M.T. Ryan, Lincoln Medical and Mental Health Center, Bronx, NY. Objective: To determine if reducing oral contrast volume to 500 cc results in more rapid oral contrast administration with-
The Journal of Emergency Medicine out increasing the percentage of technically inadequate computed tomography (CT) scans of the abdomen. Methods: Prospective randomized blinded study at an urban Level I trauma center. We enrolled subjects ⬎ 18 years of age presenting to the emergency department (ED) who had an abdominal CT scan ordered. Subjects were excluded if they were pregnant or unstable. They were randomized into two groups using numbered envelopes. We diluted 30 cc of oral contrast (diatrizoate meglumine and diatrizoate sodium) in 500 cc (study group) or 1000 cc water (control group). Data were collected by physician questionnaire. Radiologists were blinded to study allocation. Analysis was by chi-squared for categorical and KruskalWallis for non-parametric data. Results: There were 139 patients randomized to each group; 160 (58%) were males. There was no statistical significance between the control and study groups in the median patient age (45 vs. 41 years, p ⫽ 0.12), number of CT scans that answered the clinical question (94% vs. 91%, p ⫽ 0.41), number read as acceptable by radiology (87% vs. 85%, p ⫽ 0.55), number who required subsequent studies (14% vs. 16%, p ⫽ 0.74), total time from beginning contrast to completing CT scan (146 vs. 140 min, p ⫽ 0.70), number of patients who vomited (9.5% vs. 5.7%, p ⫽ 0.26), and number who underwent surgery (8.7% vs. 10.4%, p ⫽ 0.64). The time to consume the 500 cc was significantly less (20 min) than time to consume the 1000 cc (30 min), p ⫽ 0.0001. Patients were more likely to complete the 500-cc volume than the 1000-cc volume (91.2% vs. 73.6%), p ⬍ 0.001; odds ratio 1.41 (95% confidence interval 1.2–1.7) even after adjusting for gender and age. Conclusions: Patients consume the 500-cc solution faster and the resulting CT scans have similar technical acceptability compared with the 1000-cc solution. Future studies should focus on even smaller amounts of oral contrast volume for abdominal CT scans.
e SENSITIVITY OF A NEW DIAGNOSTIC SCALE FOR PULMONARY THROMBOEMBOLISM IN TWO UNIVERSITY-AFFILIATED HOSPITALS. O. Palla´s, M.T. Martı´nez, Department of Emergency Medicine, Hospital del Mar, Barcelona, Catalunya, SPAIN; M. Marin˜osa, M. Paye´s, Hospital Parc Taulı´, Sabadell, SPAIN; F. Del Ban˜o, A. Supervia, E. Skaf, Department of Emergency Medicine, Hospital del Mar, Barcelona, Catalunya, SPAIN; M.L. Iglesias, Hospital Parc Taulı´, Sabadell, SPAIN; J.L. Echarte, Department of Emergency Medicine, Hospital del Mar, Barcelona, Catalunya, SPAIN. Introduction: Validated scales for grading the clinical suspicion of pulmonary thromboembolism (PT) are used in the emergency department setting. The Wells (WS) and the Ginebra (GS) scales have been prospectively validated but have limitations in our environment. Objectives: To compare the sensitivity of a new scale of clinical prediction of PT (Catalan scale) with WS and GS in two hospitals. Methods: There were 194 patients diagnosed with PT between 2004 and 2006. Diagnosis was confirmed by computed chest angiotomography or high-probability ventilationperfusion (V/P) lung scanning. Hospital discharge records and imaging studies were reviewed. The WS, GS, and the Catalan scale (CS), were applied. Data were analyzed with SPSS 13.0