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Expanded Contents
TABLE of CONTENTS
Annals of Emergency Medicine
Volume , . : April
NEWS AND PERSPECTIVE 17A Rabies Reason: CDC Panel Recommends Reduced Vaccine Dosing for Rabies Exposures M McKenna 20A Distracted Drivers, Safer Cars?: Tech Revolution Provides Some Safety Pluses But Many Minuses for Drivers E Berger PULMONARY 307 Clinical Features From the History and Physical Examination That Predict the Presence or Absence of Pulmonary Embolism in Symptomatic Emergency Department Patients: Results of a Prospective, Multicenter Study (Original Research) DM Courtney, JA Kline, C Kabrhel, CL Moore, HA Smithline, KE Nordenholz, PB Richman, MC Plewa What question this study addressed: When systematically evaluated in a large (n⫽7,940), rigorous, multicenter database, how does an extensive list of clinical variables compare in predicting venous thromboembolism? What this study adds to our knowledge: Seventeen of the 25 variables evaluated were associated with venous thromboembolism and their relative predictive power was ranked. 316 Testing Low-Risk Patients for Suspected Pulmonary Embolism: A Decision Analysis (Original Research) AL Lessler, JA Isserman, R Agarwal, HI Palevsky, JM Pines What question this study addressed: The authors performed a decision analysis to determine whether this 1.8% threshold is reasonable. What this study adds to our knowledge: The testing thresholds in these models averaged 1.4%. 327 Further Illumination of the Test Threshold Approach in the Care of Emergency Department Patients With Symptoms of Pulmonary Embolism (Editorial) JA Kline 331 12-Lead ECG Findings of Pulmonary Hypertension Occur More Frequently in Emergency Department Patients With Pulmonary Embolism Than in Patients Without Pulmonary Embolism (Brief Research Report) MR Marchick, DM Courtney, C Kabrhel, KE Nordenholz, MC Plewa, PB Richman, HA Smithline, JA Kline What question this study addressed: Are these ECG findings more frequent in emergency department (ED) patients with suspected pulmonary embolism, and are they specific enough to be useful in diagnosis or treatment? What this study adds to our knowledge: In this secondary analysis of 6,049 patients in a prospective study on pulmonary embolism, ECG findings of right ventricular dysfunction were more common in those who received a diagnosis of pulmonary embolism. However, findings were insufficiently sensitive and specific to aid in diagnosis or management.
designates free full-text access for nonsubscribers at www.annemergmed.com. designates Continuing Medical Education exam for this article is available at www.ACEP-EMedHome.com. designates that Annals of Emergency Medicine Journal Club answers are now available. indicates a podcast is available at www.annemergmed.com.
Annals of Emergency Medicine (ISSN: 0196-0644) is published monthly by Elsevier Inc., 360 Park Avenue South, New York, NY 10010-1710. Periodicals postage paid at New York, NY, and at additional mailing offices. POSTMASTER: Send address changes to Annals of Emergency Medicine, Elsevier Health Sciences Division, Subscription Customer Service, 3251 Riverport Lane, Maryland Heights, MO 63043.
Volume , . : April
Annals of Emergency Medicine 3A
CONTENTS (continued) PATIENT SAFETY 336 Emergency Physician Perceptions of Patient Safety Risks (Brief Research Report) DP Sklar, CS Crandall, T Zola, R Cunningham What question this study addressed: Emergency physicians’ perceptions of the most important safety problems in their practices were compared with published national patient safety goals. What this study adds to our knowledge: The 2,817 emergency physicians’ (14% of those eligible; 38% of those who opened the e-mail) primary safety concerns were crowding, lack of nursing staff, and unavailability of consultants. None of these were included in national safety goals, and most national goal items were not highly ranked. 341 Confusion About Epinephrine Dosing Leading to Iatrogenic Overdose: A Life-Threatening Problem With a Potential Solution (Concepts) M Kanwar, CB Irvin, JJ Frank, K Weber, H Rosman Epinephrine is indicated for various medical emergencies, including cardiac arrest and anaphylaxis, but the dose and route of administration are different for each indication. For anaphylaxis, it is given intramuscularly at a low dose, whereas for cardiac arrest a higher dose is required intravenously. We describe the clinical problem of inadvertent epinephrine overdose and propose a potential solution. Epinephrine must be clearly packaged and labeled to avoid inappropriate usage and unnecessary, potentially lethal complications in patients with anaphylaxis. TOXICOLOGY 345 Hydroxocobalamin and Sodium Thiosulfate Versus Sodium Nitrite and Sodium Thiosulfate in the Treatment of Acute Cyanide Toxicity in a Swine (Sus scrofa) Model (Original Research) VS Bebarta, DA Tanen, J Lairet, PS Dixon, S Valtier, A Bush What question this study addressed: What is the relative efficacy of sodium nitrite versus hydroxocobalamin, both combined with sodium thiosulfate, in reversing cyanide-induced hypotension and preventing mortality in an animal model? What this study adds to our knowledge: This comparative laboratory trial in 24 swine demonstrated that the hydroxocobalamin-thiosulfate combination was more effective in reversing cyanide-induced hypotension during the 40-minute study period. No difference was observed in cardiac output, blood pH, lactate, or mortality. 352 Intramuscular Cobinamide Sulfite in a Rabbit Model of Sublethal Cyanide Toxicity (Original Research) M Brenner, JG Kim, SB Mahon, J Lee, KA Kreuter, W Blackledge, D Mukai, S Patterson, O Mohammad, VS Sharma, GR Boss What question this study addressed: This 11-rabbit placebo control trial evaluated whether intramuscular cobinamide sulfite, a water-soluble cyanide antidote, reversed the physiologic effects of cyanide poisoning. What this study adds to our knowledge: Using standard physiologic parameters and advanced measurements of hemoglobin function in muscle and brain, cobinamide sulfite resulted in more rapid recovery than placebo. CLINICAL CONTROVERSIES 364 Nasogastric Aspiration: A Useful Tool in Some Patients With Gastrointestinal Bleeding RS Anderson, MD Witting 365 Just Say No: Gastric Aspiration and Lavage Rarely Provide Benefit A Pitera, J Sarko
Volume , . : April
Annals of Emergency Medicine 5A
CONTENTS (continued) TRAUMA 367 Tongue Engorgement Associated With Prolonged Use of the King-LT Laryngeal Tube Device (Case Report) JB Gaither, J Matheson, A Eberhardt, CB Colwell We report a case of massive tongue engorgement associated with the placement of a laryngeal tube device (King Airway-LTS-DT EMS). Our patient developed isolated, massive lingual swelling approximately 3 hours after the out-of-hospital placement of a laryngeal tube. Swelling resolved 2 days later in the ICU after fiberoptic-guided exchange of the laryngeal tube for an endotracheal tube. It is most likely that the observed swelling was due to obstruction of venous drainage from the tongue by the oropharyngeal balloon. Other causes for lingual swelling such as angioedema cannot be definitively ruled out but are less likely to have caused the patient’s tongue engorgement. 370 Pool Chemical Blast Injury (Case Report) BW Shippert Swimming pools are one of the most popular forms of recreation in the United States. Pool-related injuries may produce significant morbidity and mortality, and those related to pool chemicals are of particular importance. The majority of injuries associated with pool chemicals are respiratory, with the remainder composed mainly of dermal exposures. I describe injuries from pool chemicals and the potential for significant injury from blast force. INJURY PREVENTION 373 Special Crash Investigations—A Model for Future Corrective Action: First Generation Frontal Air Bags (NHTSA Notes) 374 Commentary (NHTSA Notes) JW Runge
CHANGE OF SHIFT 378 The Doctor’s Kid LM Yancey
ANNALS OF EMERGENCY MEDICINE JOURNAL CLUB 380 Clinical Prediction Rules TW Barrett, DL Schriger
IMAGES IN EMERGENCY MEDICINE 390 Elderly Woman With Abdominal Pain G Augustin
CORRESPONDENCE 391 Prospective Validation and Head-to-Head Comparison of 3 Ankle Rules in a Pediatric Population K Boutis, S Schuh/J Gravel, S Gouin 393 Insurance Companies Refusing Payment for Patients Who Leave the Emergency Department Against Medical Advice is a Myth HN Wigder, DA Propp, K Leslie, A Mathew Volume , . : April
Annals of Emergency Medicine 7A
CONTENTS (continued) 393 IV versus Oral Acetylcysteine NA Buckley, M Eddleston, Y Li/MC Yarema, DW Johnson, A Nettel-Aguirre, MLA Sivilotti, DA Spyker, BH Rumack 396 POLICY STATEMENTS READER SERVICES 326 Volunteer for a Committee and Lend Your Experience and Expertise 330 American Board of Emergency Medicine 2010 Subspecialty Certification Examination 351 Correction Notice Coppola M. In reply. Ann Emerg Med. 1996;27:530. 23A Manuscript Submission Agreement 24A Information for Readers 25A 2009 Peer Reviewers 35A Calendar for Continuing Education 52A Classified Advertising Rates & Data 53A Classified Advertising
To read our Instructions for Authors, please go to http://www.annemergmed.com/content/instauth
Peer Review and Conflict of Interest in Annals of Emergency Medicine Unless otherwise stated, all original articles published in Annals of Emergency Medicine are peer reviewed by members of the editorial board and expert reviewers. This includes original research, case conferences and reports, concepts and state-of-the-art reviews, special contributions, Clinical Topic Reviews in Evidence-Based Emergency Medicine, and Skills for Evidence-Based Emergency Care. Departments in the journal (Correspondence; Editorials; Brief Commentaries; Health Policy Report; Residents’ Perspective; CDC Update; NHTSA Notes; Evidence-Based Emergency Medicine ‘‘Feedback,’’ ‘‘Updates,’’ and ‘‘Abstracts’’; Change of Shift; and Media and Book Reviews) are peer reviewed by an editorial board member. In all Annals’ peer review, the identity of authors is concealed from reviewers and vice versa. ACEP Policy Statements and Clinical Policies are not peer reviewed by the journal. Annals makes every effort to minimize the opportunity for potential conflicts of interest by authors, reviewers, and editors. Authors are required, on submission of their manuscript, to state in writing whether or not outside funding or other form of support was received and its source, as well as whether or not they have any financial interest in the subject of their study. This information is published with the article. Reviewers are required to declare any potential conflict of interest in their review of a manuscript, and the editor then decides whether it is of a nature that requires they be replaced with another reviewer. Editors who have a conflict of interest regarding a manuscript are required to recuse themselves from the decisionmaking process. The full details of these and other publication ethics policies of this journal are available on the Web at www.annemergmed.com. Select Browse All Issues, select January 2003, and view ‘‘Journal policy on ethics in scientific publication’’ on page 82. Annals’ conflict of interest policy for editors and reviewers can be found at http://www.annemergmed.com/content/instauth/#conflictpolicy.
Volume , . : April
Annals of Emergency Medicine 9A
Annals of Emergency Medicine
Volume , . : April
NEWS AND PERSPECTIVE 17A Rabies Reason: CDC Panel Recommends Reduced Vaccine Dosing for Rabies Exposures M McKenna 20A Distracted Drivers, Safer Cars?: Tech Revolution Provides Some Safety Pluses But Many Minuses for Drivers E Berger PULMONARY 307 Clinical Features From the History and Physical Examination That Predict the Presence or Absence of Pulmonary Embolism in Symptomatic Emergency Department Patients: Results of a Prospective, Multicenter Study (Original Research) DM Courtney, JA Kline, C Kabrhel, CL Moore, HA Smithline, KE Nordenholz, PB Richman, MC Plewa What question this study addressed: When systematically evaluated in a large (n⫽7,940), rigorous, multicenter database, how does an extensive list of clinical variables compare in predicting venous thromboembolism? What this study adds to our knowledge: Seventeen of the 25 variables evaluated were associated with venous thromboembolism and their relative predictive power was ranked. 316 Testing Low-Risk Patients for Suspected Pulmonary Embolism: A Decision Analysis (Original Research) AL Lessler, JA Isserman, R Agarwal, HI Palevsky, JM Pines What question this study addressed: The authors performed a decision analysis to determine whether this 1.8% threshold is reasonable. What this study adds to our knowledge: The testing thresholds in these models averaged 1.4%. 327 Further Illumination of the Test Threshold Approach in the Care of Emergency Department Patients With Symptoms of Pulmonary Embolism (Editorial) JA Kline 331 12-Lead ECG Findings of Pulmonary Hypertension Occur More Frequently in Emergency Department Patients With Pulmonary Embolism Than in Patients Without Pulmonary Embolism (Brief Research Report) MR Marchick, DM Courtney, C Kabrhel, KE Nordenholz, MC Plewa, PB Richman, HA Smithline, JA Kline What question this study addressed: Are these ECG findings more frequent in emergency department (ED) patients with suspected pulmonary embolism, and are they specific enough to be useful in diagnosis or treatment? What this study adds to our knowledge: In this secondary analysis of 6,049 patients in a prospective study on pulmonary embolism, ECG findings of right ventricular dysfunction were more common in those who received a diagnosis of pulmonary embolism. However, findings were insufficiently sensitive and specific to aid in diagnosis or management.
designates free full-text access for nonsubscribers at www.annemergmed.com. designates Continuing Medical Education exam for this article is available at www.ACEP-EMedHome.com. designates that Annals of Emergency Medicine Journal Club answers are now available. indicates a podcast is available at www.annemergmed.com.
Annals of Emergency Medicine (ISSN: 0196-0644) is published monthly by Elsevier Inc., 360 Park Avenue South, New York, NY 10010-1710. Periodicals postage paid at New York, NY, and at additional mailing offices. POSTMASTER: Send address changes to Annals of Emergency Medicine, Elsevier Health Sciences Division, Subscription Customer Service, 3251 Riverport Lane, Maryland Heights, MO 63043.
Volume , . : April
Annals of Emergency Medicine 3A
CONTENTS (continued) PATIENT SAFETY 336 Emergency Physician Perceptions of Patient Safety Risks (Brief Research Report) DP Sklar, CS Crandall, T Zola, R Cunningham What question this study addressed: Emergency physicians’ perceptions of the most important safety problems in their practices were compared with published national patient safety goals. What this study adds to our knowledge: The 2,817 emergency physicians’ (14% of those eligible; 38% of those who opened the e-mail) primary safety concerns were crowding, lack of nursing staff, and unavailability of consultants. None of these were included in national safety goals, and most national goal items were not highly ranked. 341 Confusion About Epinephrine Dosing Leading to Iatrogenic Overdose: A Life-Threatening Problem With a Potential Solution (Concepts) M Kanwar, CB Irvin, JJ Frank, K Weber, H Rosman Epinephrine is indicated for various medical emergencies, including cardiac arrest and anaphylaxis, but the dose and route of administration are different for each indication. For anaphylaxis, it is given intramuscularly at a low dose, whereas for cardiac arrest a higher dose is required intravenously. We describe the clinical problem of inadvertent epinephrine overdose and propose a potential solution. Epinephrine must be clearly packaged and labeled to avoid inappropriate usage and unnecessary, potentially lethal complications in patients with anaphylaxis. TOXICOLOGY 345 Hydroxocobalamin and Sodium Thiosulfate Versus Sodium Nitrite and Sodium Thiosulfate in the Treatment of Acute Cyanide Toxicity in a Swine (Sus scrofa) Model (Original Research) VS Bebarta, DA Tanen, J Lairet, PS Dixon, S Valtier, A Bush What question this study addressed: What is the relative efficacy of sodium nitrite versus hydroxocobalamin, both combined with sodium thiosulfate, in reversing cyanide-induced hypotension and preventing mortality in an animal model? What this study adds to our knowledge: This comparative laboratory trial in 24 swine demonstrated that the hydroxocobalamin-thiosulfate combination was more effective in reversing cyanide-induced hypotension during the 40-minute study period. No difference was observed in cardiac output, blood pH, lactate, or mortality. 352 Intramuscular Cobinamide Sulfite in a Rabbit Model of Sublethal Cyanide Toxicity (Original Research) M Brenner, JG Kim, SB Mahon, J Lee, KA Kreuter, W Blackledge, D Mukai, S Patterson, O Mohammad, VS Sharma, GR Boss What question this study addressed: This 11-rabbit placebo control trial evaluated whether intramuscular cobinamide sulfite, a water-soluble cyanide antidote, reversed the physiologic effects of cyanide poisoning. What this study adds to our knowledge: Using standard physiologic parameters and advanced measurements of hemoglobin function in muscle and brain, cobinamide sulfite resulted in more rapid recovery than placebo. CLINICAL CONTROVERSIES 364 Nasogastric Aspiration: A Useful Tool in Some Patients With Gastrointestinal Bleeding RS Anderson, MD Witting 365 Just Say No: Gastric Aspiration and Lavage Rarely Provide Benefit A Pitera, J Sarko
Volume , . : April
Annals of Emergency Medicine 5A
CONTENTS (continued) TRAUMA 367 Tongue Engorgement Associated With Prolonged Use of the King-LT Laryngeal Tube Device (Case Report) JB Gaither, J Matheson, A Eberhardt, CB Colwell We report a case of massive tongue engorgement associated with the placement of a laryngeal tube device (King Airway-LTS-DT EMS). Our patient developed isolated, massive lingual swelling approximately 3 hours after the out-of-hospital placement of a laryngeal tube. Swelling resolved 2 days later in the ICU after fiberoptic-guided exchange of the laryngeal tube for an endotracheal tube. It is most likely that the observed swelling was due to obstruction of venous drainage from the tongue by the oropharyngeal balloon. Other causes for lingual swelling such as angioedema cannot be definitively ruled out but are less likely to have caused the patient’s tongue engorgement. 370 Pool Chemical Blast Injury (Case Report) BW Shippert Swimming pools are one of the most popular forms of recreation in the United States. Pool-related injuries may produce significant morbidity and mortality, and those related to pool chemicals are of particular importance. The majority of injuries associated with pool chemicals are respiratory, with the remainder composed mainly of dermal exposures. I describe injuries from pool chemicals and the potential for significant injury from blast force. INJURY PREVENTION 373 Special Crash Investigations—A Model for Future Corrective Action: First Generation Frontal Air Bags (NHTSA Notes) 374 Commentary (NHTSA Notes) JW Runge
CHANGE OF SHIFT 378 The Doctor’s Kid LM Yancey
ANNALS OF EMERGENCY MEDICINE JOURNAL CLUB 380 Clinical Prediction Rules TW Barrett, DL Schriger
IMAGES IN EMERGENCY MEDICINE 390 Elderly Woman With Abdominal Pain G Augustin
CORRESPONDENCE 391 Prospective Validation and Head-to-Head Comparison of 3 Ankle Rules in a Pediatric Population K Boutis, S Schuh/J Gravel, S Gouin 393 Insurance Companies Refusing Payment for Patients Who Leave the Emergency Department Against Medical Advice is a Myth HN Wigder, DA Propp, K Leslie, A Mathew Volume , . : April
Annals of Emergency Medicine 7A
CONTENTS (continued) 393 IV versus Oral Acetylcysteine NA Buckley, M Eddleston, Y Li/MC Yarema, DW Johnson, A Nettel-Aguirre, MLA Sivilotti, DA Spyker, BH Rumack 396 POLICY STATEMENTS READER SERVICES 326 Volunteer for a Committee and Lend Your Experience and Expertise 330 American Board of Emergency Medicine 2010 Subspecialty Certification Examination 351 Correction Notice Coppola M. In reply. Ann Emerg Med. 1996;27:530. 23A Manuscript Submission Agreement 24A Information for Readers 25A 2009 Peer Reviewers 35A Calendar for Continuing Education 52A Classified Advertising Rates & Data 53A Classified Advertising
To read our Instructions for Authors, please go to http://www.annemergmed.com/content/instauth
Peer Review and Conflict of Interest in Annals of Emergency Medicine Unless otherwise stated, all original articles published in Annals of Emergency Medicine are peer reviewed by members of the editorial board and expert reviewers. This includes original research, case conferences and reports, concepts and state-of-the-art reviews, special contributions, Clinical Topic Reviews in Evidence-Based Emergency Medicine, and Skills for Evidence-Based Emergency Care. Departments in the journal (Correspondence; Editorials; Brief Commentaries; Health Policy Report; Residents’ Perspective; CDC Update; NHTSA Notes; Evidence-Based Emergency Medicine ‘‘Feedback,’’ ‘‘Updates,’’ and ‘‘Abstracts’’; Change of Shift; and Media and Book Reviews) are peer reviewed by an editorial board member. In all Annals’ peer review, the identity of authors is concealed from reviewers and vice versa. ACEP Policy Statements and Clinical Policies are not peer reviewed by the journal. Annals makes every effort to minimize the opportunity for potential conflicts of interest by authors, reviewers, and editors. Authors are required, on submission of their manuscript, to state in writing whether or not outside funding or other form of support was received and its source, as well as whether or not they have any financial interest in the subject of their study. This information is published with the article. Reviewers are required to declare any potential conflict of interest in their review of a manuscript, and the editor then decides whether it is of a nature that requires they be replaced with another reviewer. Editors who have a conflict of interest regarding a manuscript are required to recuse themselves from the decisionmaking process. The full details of these and other publication ethics policies of this journal are available on the Web at www.annemergmed.com. Select Browse All Issues, select January 2003, and view ‘‘Journal policy on ethics in scientific publication’’ on page 82. Annals’ conflict of interest policy for editors and reviewers can be found at http://www.annemergmed.com/content/instauth/#conflictpolicy.
Volume , . : April
Annals of Emergency Medicine 9A