- Email: [email protected]
Hyponatremia in marathon runners: Experience with the inaugural rock'n' roll marathon
RESEARCH FORUM ABSTRACTS
documentation of 19 elements, worsened documentation in 3 dements, and persistently poor documentation in 5 elements in the evaluation of adult female sexual assault vicnms.
50
Use of Percussion as a Screening Tool in the Diagnosis of Occult Hip Fractures
Mohan T, Goh SH, Low BY/Changi General Hospital, Singapore, Republic of Singapore Study objective: We sought to determine the reliability of using percussion as a screening tool for the diagnosis of radiologically occult Garden's type I neck of femur fractures. Methods: A prospective, single-blinded study was performed in the Accident & Emergency Department of an urban teaching hospital over the period of 13 months. A convenience sample of 290 patients with suspected occult femoral neck fractures were enrolled. The investigators were blinded to the side of pain or suspected fracture. The test was performed by percussing the patella and simultaneously auscultating with the bell of the stethoscope over the pubic symphysis. The percussion note was then compared over the contralateral side in a similar fashion. A positive test was one that resulted in diminished percussion note on the side of pain felt. All patients were admitted for further investigation by repeat radiography, bone scintigraphy, computed tomography, or magnetic resonance imaging. Results: Two hundred ninety patients were admitted for further investigation of suspected occult neck of femur fractures. Of thes< 84.5% (n=245) had a positive percussion test and 3.4% (n=10) had a negative test in which a subsequent fracture was demonstrated. In contrast, 10.3% (n=30) had a negative percussion test, whereas 1.7% (n=5) had a positive test when further investigation failed to reveal any fracture of the femoral neck. On further analysis, this translated into a sensitivity of 0.96 (95% confidence interval [CI] 0.87 to 0.99), and specihcity of 0.86 (95% CI 0.49 to 0.98) with a positive predictive value of 0.98 and a negative predictive value of 0.75. The likelihood ratio for a positive test was 6.73 and that for a negative test was 0.75. Conclusion: The use of this simple test of percussion and auscultation to screen patients with occult hip fractures is a useful tool in the emergency department m aiding the physician to risk stratify, before subjecting patients to more expensive and invasive invesngations:
151 Ernst AA, Green E, FergusonMT, Weiss SO, Green W/University of California-Davis Medical Center, Sacramento, CA Study objective: To characterize demographics in male victims of sexual assault and to compare use of anoscopy and colposcopy. Methods: This is a case series of 67 male victims of sexual assault evaluated over an 8-year period by the Sexual Assault Forensic Examination Team (SAFE). The setting is a university-based ED serving as the primary site for examination of sexual assault victims by trained nurse practitioners and physician assistants. Anoscopy was done routinely over the entire study period in all those with any anal penetration or involvement. Colposcopy use started in 1994 Results: Sixty-seven males were evaluated between 1991 and 1998; 55 were from the community, whereas 12 were prisoners. Mean age was 26 years. There were 42 white, 6 Hispanic, and 19 black victims. Eighteen reported a loss of consciousness, 8 threatened the use of a knife, 3 threatened to use a gun, 23 abuse by hands and/or fist, 1 a bottle, and 6 other makeshift weapons. Wood lamp examinations were done in 33 cases, with 12 (36%) positive and 21 (64%) negative. Anoscopy was performed in 61 patients. Of these, 20 (33%) had anoscopic findings in addition to gross examination. Colposcopy was performed in 38 patients. Of these, 3 (8%) had addinonal findings to gross examination. In the 36 with both anoscopy and colposcopy performed, additional findings to gross visual examination were found in 3 (8%) by colposcopy and 17 (47%) by anoscopy (P<.01 nsmg Z2 with Yates' correction; difference=39%; 95% confidence interval 20% to 58%). Conclusion: In male sexual assault victims with anal penetration, anoscopy is a valuable addition to colposcopy for gathering additional evidence of damage.
t ~
| jr_
Comparison of Quality of Medical Documentation for Findings Related to Sexual Assault Prior and Post the Development of a Sexual Assault Forensic Examination Program
Jackson MC. Greleau G. Kimmel C/University of Maryland School of Medicine, Mercy Hospital, Baltimore, MD Study objective: Comparison of medical documentation for findings related to sexual assault before and after the development of a sexual assault forensic examination
S 40
(SAFE) program. Proper documentation is mandatory for effective legal defense for the victim of sexual assault. Methods: This was a retrospective study in an urban teaching hospital. Medical records of 150 sexual assault victims evaluated in the emergency department by multipie health care providers during 1992-1993 (before the SAFE program) were compared with medical records of 150 sexual assault victims evaluated by speciaUy trained SAFE program nurses during 1996-1999. Medical charts were reviewed for appropriate documentation of type of offense, date/time of the examination, narrative content, patient condition, physical and anogenital trauma, diagrams, photographs, evidence collection, and chain of custody. Resuhs: Before the SAFE program, adequate legal documentation occurred in 67% of cases; after the SAFE program adequate documentation was 100%. The patient's condition was documented adequately before the SAFE program in only 5% of the cases, after the SAFE program in 97.5%. Documentation of physical trauma was adequate before the SAFE program in 82.5% of cases, after the SAFE program in 96%. Documentation of anogeintal trauma was adequate before the SAFE program in 55% of cases, after the SAFE program in 94%. Indicated diagrams were charted before the SAFE program in 57% of cases, after the SAFE program in 100%. Indicated photographs were not done before the establishment of the SAFE program. For the cases evaluated by the SAFE program, indicated photographs were done in 98.7% of cases. Documentation of the chain of custody for evidence was found in 8.5% of cases evaluated before the SAFE program and in 100% of cases reviewed after the SAFE program. Conclusion: Appropriate documentation improved after the establishment of the SAFE program.
153 AnImplications Evaluation of an Evidence-Based Renal Colic Algorithm: for Codifying Physician Ordering and Improving Efficiency MacKenzie R. Worrilow C, RichardsonD, Nester B/Lehigh Valley Hospital and Healthcare Network, Allentown. PA Study objectives: Evidence-hased (EB), consensus-driven modifications in clinical practice are difficult to achieve. The challenge for EB medicine is in its applicability to community practice, which has not been welI studied. This study sought to characterize physician ordering patterns and to identify efficiency improvements in response to an EB renal colic (RC) algorithm. Methods: All emergency department patient encounters at a community, tertiary medical center with the diagnosis of RC or renal lithiasis were retrospectively reviewed. The 1997 group (pro-algorithm) represented the control group for established RC practice by emergency physicians. The year 1998 (post) represented the group treated under the EB algorithm that limited the ordering of ."routine" imaging and laboratory studies, and supported helical computed tomography (CT) as the imaging study of choice. Primary outcome measures included utilization of routine laboratory tests, urine analysis, intravenous pyelography, radiographs of the kidney, ureter, and bladder, spiral CT, and uhmsound. Length of stay in the ED was a secondary measure. Results: Physician ordering patterns changed dramatically after the initiation of the new algorithm. Orders for routine laboratory tests decreased from 80% (pro) to 32% (post) (P<.05). Likewise, orders for urinalysis decreased from 73% to 39% (P<.05), respectively. Regarding diagnostic imaging, emergency physicians ordered 20% fewer studies in the postalgorithm period. When a study was indicated, spiral CT was selected in 93% of cases (up from 7% in the pro-algorithm period). The average ED length of stay was also observed to decrease from 4 hours 22 minutes (pro, n=106) to 3 hours 34 minutes (post, n=93) (P<.05). Conclusion: An EB RC algorithm can be implemented and embraced in the ED environment. This EB algorithm significantly reduced utilization of "routine" studies and codified the process for RC evaluations. This reduction in physician practice variation sped the disposition of RC patients in our ED.
54
Hyponatremia in Marathon Runners:Experience With the Inaugural Rock %' Roll Marathon
Davis D, Marina A, Vilke G, DunfordJ, Videen J/University of California-San Diego, San Diego, CA Exercise-induced hyponatremia has been described after extreme events, such as extreme hiking and lronman triathlons, but our understanding of the pathophysiology and treatment of this disease is incomplete. Study objectives: To better define the pathophysiology of exercise-induced hyponatremia in a group of marathon runners presenting to local emergency departments and to derive treatment guidelines for emergency physicians.
ANNALS OF EMERGENCYMEDICINE 34:4 OCTOBER1999, PART 2
RESEARCH FORUM ABSTRACTS
Methods: This study was a retrospective chart review. All participants in the inaugural San Diego Rock 'n' Roll Marathon (June 1998) presenting to 1 of the 12 local EDs were included in the study. Medical records were used to obtain demographic information, presenting complaints, vital signs, physical examination findings, laboratory data, and hospital course. Marathon times were obtained from the Rock 'n' Roll Marathon Web site. Serum sodium values were plotted over rime to identify any trends during sodium correction for patients with initial serum sodium values < 130 mEq/L. The mean times to race completion for patients with initial serum sodium values <125 mEq/L were compared with the mean times for a random sampling of 100 runners who completed the race. Linear regression was used to evaluate initial serum sodium versus postrace time in all patients in whom serum chemistries were obtained. Results: A total of approximately 20,000 runners participated in the event; nearly 50% percent were female, more than for any previous marathon of this size. A total of 74 runners presented to 1 of the 12 EDs; 31 of these were transported by ambulance. Laboratory evaluation was performed in approximately 50% of these patients; nearly half of these were hyponatremic (<135 mEq/L). Nine patients presented with "severe" hyponatremia (<125 mEq/L); 8 of these were female. There was no significant difference between race times for runners with severe hyponatremia (5:24) versus a random sampiing of runners (4:54). A statistically significant correlation between postrace time and serum sodium was observed (r=-0.73, P<.05), with later presentations predicting lower serum sodium values. Difficulty in correcting hyponatremia was observed in patients with initial serum sodium values <125 mEq/L. In several patients, a decrease in serum sodium despite normal saline therapy led to resistant seizures requiring intubarion. Conclusion: Exercise-induced hyponatremia can result in significant morbidity, even in association with relatively common events such as marathons. The pathophysiology of this disease most likely involves a combination of water intoxication and hormonal maladaptations to moderate-to-severe exercise. Females appear to be at higher risk. These results along with the existing literature have led to our recommendations, which include the rapid analysis of serum sodium and the use of hypertonic saline with severe hyponatremia.
55
The Effect of Trendelenburg Position on Subclavian Vein Diameter in Euvolemic and Hypovolemic Volunteers
Gibson GP. Rankins RC, Utecht T/Universib/of California-San Francisco. University Medical Center, Fresno,CA Study objectives: We sought to compare the diameter of the subclavian vein in supine and Trendelenburg positions with both euvolemic and hypovolemic subjects. Our goal was to determine if there was a significant change in the diameter of the vein that would aid in central line placement. Methods: Thirteen volunteers were enrolled and 10 completed the study. All volunteers had subclavian vein measurements made with ultrasound while in the supine and Trendelenburg position in both euvolemic and hypovolemic states. Hypovolemia was accomplished by phlebotomizing 2 units of blood from the volunteers. The films were then read by a radiologist who was blinded to the volunteer's position and volume status. Results: The average change in the diameter of the subclavian vein (Trendelenburg-flat) in euvolemia was -0.02 m m (95% confidence interval [CI], -0.28 to +0.24). In hypovolemic subjects, the average change was +0.09 m m (95% CI, -0.39 to +0.57). Conclusion: Trendelenburg position produces little change in the subclavian vein diameter in euvolemic and hypovolemic patients. These small changes are unlikely to be clinically significant in the placement of a subclavian central venous catheter.
56 The Sexual Assault Examination: A Comparisonof Physical Findings Between an Emergency Department and Freestanding Nurse Examiner Clinic Rossman L, Wynn B, Jones JS/Spectrum Health-Downtown Campus, MSU College of Human Medicine, Grand Rapids, MI Study objective: To compare the documentation of genital trauma in women evaluated for sexual assault between an academic emergency department and a freestanding nurse examiner clinic (NEC). Methods: This was a retrospective cohort analysis of consecutive female patients presenting after alleged sexual assault to either the ED of a university-affiliated urban hospital (n=100 patients) or to a freestanding NEC (n=100). The ED was staffed by board-certified emergency physicians and residents who identified genital trauma using gross visual examination alone. The NEC is located within 1 mile of the hospital and is staffed by registered nurses trained to perform medicolegal examinations using
OCTOBER 1999, PART 2 34:4 ANNALSOF EMERGENCYMEDICINE
colposcopy vclth digital imagang. The 2 patient groups were compared for baseline demographics, assault history, and documentation of genital trauma using a standardized classification system Primary outcome was the frequency and type of documented genital injunes. Results: Case files of 200 patients were reviewed; the mean age was 24.5 years (range 14 to 69 years) with 95% reporting penile-genital contact. The 2 patient groups (NEC, ED) were comparable in terms of demographics, time to examination, assault history, relationship to offender, type, and frequency of nongenital trauma. Genital injuries were documented in 71% of the patients evaluated in the N EC (mean number of genital injuries, 2.1). In companson, 20% of those patients examined in the ED had documented genital trauma (mean number of injuries, 0.3). These differences were statistically significant (;(2=50.4, P<.000I). Trauma types varied in both groups by site--tears appeared most often on the posterior fourchette and fossa, abrasions appeared on the labia, and ecchymosis was seen on the hymen. Conclusion: These results suggest that colposcopy with digital imaging improves detection of genital trauma in female sexual assault victims and may provide valuable medical and legal information.
157 Infectious Do Oiabntic Patients Present to Emergency Departments With Complications at a Higher Rate Than Nondiabctic Patients? Feuer H, ButterfassA, FairweatherP, RichardsonL/Mount Sinai School of Medicine. New York, NY Stud)' objective: Diabetes mellitus is a medical disorder that is recognized to impair the immune system. Diabetic patients are assumed to present to emergency departments with infectious complications at a higher rate than nondiabetic patients. We tested the hypothesis that diabetic patients have a more frequent disposition diagnosis of an infectious etiology than nondiabetic patients. Methods: A retrospective chart review was conducted for two 1-week periods during different seasons at a municipal hospital in the northeastern United States with 70,000 adult ED vasits annually. The charts of all patients who identified themselves as having diabetes mellitus were reviewed; an equal number of nondiabetic patient charts were randomly selected from the same time penods as controls. A precoded data collection instrument for chart review was developed; pertinent demographic and clinical information was abstracted from these ED charts. ED diagnoses were categorized as infectious or noninfectious in etiology Data were analyzed using SPSS 8.0. The Z2 statistic was used to analyze categorical vanables; the Student's t test was used for continuous vanables. Results: A total of 2,585 adult patients presented to our ED during the two 1-week stud)' periods. Data were obtained from 168 diabetics (6.5% of all ED visits) and 148 nondiabetic controls. The mean age of all study patients was 46.1 years of age (range 18 to 103 years) Fifty percent were male, 50% female; 14.3% were white, 17.3% African American, 51.1% Hispanic, 14% Asian, and 5.8% other. There were no statistically significant differences in demographic composition between our diabetic and nondiabetic study groups. In the diabetic group, 34.9% took insulin for glucose control, and 3.5% had other immune-compromising illnesses (H1V or malignancy) versus 5.0% for controls (P=.58). Diabetics were found to have a significantly higher rate of cardiac comorbidiries, 15% versus 6.4% (P=.01). The diabetic group was also found to have significantly higher rates of Medicare and Medicaid coverage. There was no statistical difference bet;veen the 2 groups in the frequency of an infection-based diagnosis: 12.1% of diabetics versus 14.2% of nondiabetics (P=.62). More insulin-dependent diabetics (17.0%) were diagnosed with infection than non-insulin-dependent diabetics (9.3%), although this was not statistically significant (P=. 19). The data also revealed a significantly higher admission rate among diabetic patients: 31.5% versus 181% for nondiabetics (P<.005) Conclusion: The incidence of infectious conditions in patients visiting our ED was not shown to significantly differ between diabetic and nondiabetic populations. Ancillary data gathered portray diabetics using the ED as a more acutely ill population with a significant coincidence of cardiac disease.
58
Empiric Treatment of Gonorrhea and Chlamydia in the Emergency Department
Weist DR. Spear SJ. Bartfield JM/Albany Medical College. Albany. NY Stud)" objectives: This stud)" was conducted to determine how often women screened for Neissena ganorrhoeae (GC) and Chlamydia trachomatis (CT) in an emergency department setting are given proper empinc treatment. Methods: This retrospective chart review was conducted in an urban university
S 41
documentation of 19 elements, worsened documentation in 3 dements, and persistently poor documentation in 5 elements in the evaluation of adult female sexual assault vicnms.
50
Use of Percussion as a Screening Tool in the Diagnosis of Occult Hip Fractures
Mohan T, Goh SH, Low BY/Changi General Hospital, Singapore, Republic of Singapore Study objective: We sought to determine the reliability of using percussion as a screening tool for the diagnosis of radiologically occult Garden's type I neck of femur fractures. Methods: A prospective, single-blinded study was performed in the Accident & Emergency Department of an urban teaching hospital over the period of 13 months. A convenience sample of 290 patients with suspected occult femoral neck fractures were enrolled. The investigators were blinded to the side of pain or suspected fracture. The test was performed by percussing the patella and simultaneously auscultating with the bell of the stethoscope over the pubic symphysis. The percussion note was then compared over the contralateral side in a similar fashion. A positive test was one that resulted in diminished percussion note on the side of pain felt. All patients were admitted for further investigation by repeat radiography, bone scintigraphy, computed tomography, or magnetic resonance imaging. Results: Two hundred ninety patients were admitted for further investigation of suspected occult neck of femur fractures. Of thes< 84.5% (n=245) had a positive percussion test and 3.4% (n=10) had a negative test in which a subsequent fracture was demonstrated. In contrast, 10.3% (n=30) had a negative percussion test, whereas 1.7% (n=5) had a positive test when further investigation failed to reveal any fracture of the femoral neck. On further analysis, this translated into a sensitivity of 0.96 (95% confidence interval [CI] 0.87 to 0.99), and specihcity of 0.86 (95% CI 0.49 to 0.98) with a positive predictive value of 0.98 and a negative predictive value of 0.75. The likelihood ratio for a positive test was 6.73 and that for a negative test was 0.75. Conclusion: The use of this simple test of percussion and auscultation to screen patients with occult hip fractures is a useful tool in the emergency department m aiding the physician to risk stratify, before subjecting patients to more expensive and invasive invesngations:
151 Ernst AA, Green E, FergusonMT, Weiss SO, Green W/University of California-Davis Medical Center, Sacramento, CA Study objective: To characterize demographics in male victims of sexual assault and to compare use of anoscopy and colposcopy. Methods: This is a case series of 67 male victims of sexual assault evaluated over an 8-year period by the Sexual Assault Forensic Examination Team (SAFE). The setting is a university-based ED serving as the primary site for examination of sexual assault victims by trained nurse practitioners and physician assistants. Anoscopy was done routinely over the entire study period in all those with any anal penetration or involvement. Colposcopy use started in 1994 Results: Sixty-seven males were evaluated between 1991 and 1998; 55 were from the community, whereas 12 were prisoners. Mean age was 26 years. There were 42 white, 6 Hispanic, and 19 black victims. Eighteen reported a loss of consciousness, 8 threatened the use of a knife, 3 threatened to use a gun, 23 abuse by hands and/or fist, 1 a bottle, and 6 other makeshift weapons. Wood lamp examinations were done in 33 cases, with 12 (36%) positive and 21 (64%) negative. Anoscopy was performed in 61 patients. Of these, 20 (33%) had anoscopic findings in addition to gross examination. Colposcopy was performed in 38 patients. Of these, 3 (8%) had addinonal findings to gross examination. In the 36 with both anoscopy and colposcopy performed, additional findings to gross visual examination were found in 3 (8%) by colposcopy and 17 (47%) by anoscopy (P<.01 nsmg Z2 with Yates' correction; difference=39%; 95% confidence interval 20% to 58%). Conclusion: In male sexual assault victims with anal penetration, anoscopy is a valuable addition to colposcopy for gathering additional evidence of damage.
t ~
| jr_
Comparison of Quality of Medical Documentation for Findings Related to Sexual Assault Prior and Post the Development of a Sexual Assault Forensic Examination Program
Jackson MC. Greleau G. Kimmel C/University of Maryland School of Medicine, Mercy Hospital, Baltimore, MD Study objective: Comparison of medical documentation for findings related to sexual assault before and after the development of a sexual assault forensic examination
S 40
(SAFE) program. Proper documentation is mandatory for effective legal defense for the victim of sexual assault. Methods: This was a retrospective study in an urban teaching hospital. Medical records of 150 sexual assault victims evaluated in the emergency department by multipie health care providers during 1992-1993 (before the SAFE program) were compared with medical records of 150 sexual assault victims evaluated by speciaUy trained SAFE program nurses during 1996-1999. Medical charts were reviewed for appropriate documentation of type of offense, date/time of the examination, narrative content, patient condition, physical and anogenital trauma, diagrams, photographs, evidence collection, and chain of custody. Resuhs: Before the SAFE program, adequate legal documentation occurred in 67% of cases; after the SAFE program adequate documentation was 100%. The patient's condition was documented adequately before the SAFE program in only 5% of the cases, after the SAFE program in 97.5%. Documentation of physical trauma was adequate before the SAFE program in 82.5% of cases, after the SAFE program in 96%. Documentation of anogeintal trauma was adequate before the SAFE program in 55% of cases, after the SAFE program in 94%. Indicated diagrams were charted before the SAFE program in 57% of cases, after the SAFE program in 100%. Indicated photographs were not done before the establishment of the SAFE program. For the cases evaluated by the SAFE program, indicated photographs were done in 98.7% of cases. Documentation of the chain of custody for evidence was found in 8.5% of cases evaluated before the SAFE program and in 100% of cases reviewed after the SAFE program. Conclusion: Appropriate documentation improved after the establishment of the SAFE program.
153 AnImplications Evaluation of an Evidence-Based Renal Colic Algorithm: for Codifying Physician Ordering and Improving Efficiency MacKenzie R. Worrilow C, RichardsonD, Nester B/Lehigh Valley Hospital and Healthcare Network, Allentown. PA Study objectives: Evidence-hased (EB), consensus-driven modifications in clinical practice are difficult to achieve. The challenge for EB medicine is in its applicability to community practice, which has not been welI studied. This study sought to characterize physician ordering patterns and to identify efficiency improvements in response to an EB renal colic (RC) algorithm. Methods: All emergency department patient encounters at a community, tertiary medical center with the diagnosis of RC or renal lithiasis were retrospectively reviewed. The 1997 group (pro-algorithm) represented the control group for established RC practice by emergency physicians. The year 1998 (post) represented the group treated under the EB algorithm that limited the ordering of ."routine" imaging and laboratory studies, and supported helical computed tomography (CT) as the imaging study of choice. Primary outcome measures included utilization of routine laboratory tests, urine analysis, intravenous pyelography, radiographs of the kidney, ureter, and bladder, spiral CT, and uhmsound. Length of stay in the ED was a secondary measure. Results: Physician ordering patterns changed dramatically after the initiation of the new algorithm. Orders for routine laboratory tests decreased from 80% (pro) to 32% (post) (P<.05). Likewise, orders for urinalysis decreased from 73% to 39% (P<.05), respectively. Regarding diagnostic imaging, emergency physicians ordered 20% fewer studies in the postalgorithm period. When a study was indicated, spiral CT was selected in 93% of cases (up from 7% in the pro-algorithm period). The average ED length of stay was also observed to decrease from 4 hours 22 minutes (pro, n=106) to 3 hours 34 minutes (post, n=93) (P<.05). Conclusion: An EB RC algorithm can be implemented and embraced in the ED environment. This EB algorithm significantly reduced utilization of "routine" studies and codified the process for RC evaluations. This reduction in physician practice variation sped the disposition of RC patients in our ED.
54
Hyponatremia in Marathon Runners:Experience With the Inaugural Rock %' Roll Marathon
Davis D, Marina A, Vilke G, DunfordJ, Videen J/University of California-San Diego, San Diego, CA Exercise-induced hyponatremia has been described after extreme events, such as extreme hiking and lronman triathlons, but our understanding of the pathophysiology and treatment of this disease is incomplete. Study objectives: To better define the pathophysiology of exercise-induced hyponatremia in a group of marathon runners presenting to local emergency departments and to derive treatment guidelines for emergency physicians.
ANNALS OF EMERGENCYMEDICINE 34:4 OCTOBER1999, PART 2
RESEARCH FORUM ABSTRACTS
Methods: This study was a retrospective chart review. All participants in the inaugural San Diego Rock 'n' Roll Marathon (June 1998) presenting to 1 of the 12 local EDs were included in the study. Medical records were used to obtain demographic information, presenting complaints, vital signs, physical examination findings, laboratory data, and hospital course. Marathon times were obtained from the Rock 'n' Roll Marathon Web site. Serum sodium values were plotted over rime to identify any trends during sodium correction for patients with initial serum sodium values < 130 mEq/L. The mean times to race completion for patients with initial serum sodium values <125 mEq/L were compared with the mean times for a random sampling of 100 runners who completed the race. Linear regression was used to evaluate initial serum sodium versus postrace time in all patients in whom serum chemistries were obtained. Results: A total of approximately 20,000 runners participated in the event; nearly 50% percent were female, more than for any previous marathon of this size. A total of 74 runners presented to 1 of the 12 EDs; 31 of these were transported by ambulance. Laboratory evaluation was performed in approximately 50% of these patients; nearly half of these were hyponatremic (<135 mEq/L). Nine patients presented with "severe" hyponatremia (<125 mEq/L); 8 of these were female. There was no significant difference between race times for runners with severe hyponatremia (5:24) versus a random sampiing of runners (4:54). A statistically significant correlation between postrace time and serum sodium was observed (r=-0.73, P<.05), with later presentations predicting lower serum sodium values. Difficulty in correcting hyponatremia was observed in patients with initial serum sodium values <125 mEq/L. In several patients, a decrease in serum sodium despite normal saline therapy led to resistant seizures requiring intubarion. Conclusion: Exercise-induced hyponatremia can result in significant morbidity, even in association with relatively common events such as marathons. The pathophysiology of this disease most likely involves a combination of water intoxication and hormonal maladaptations to moderate-to-severe exercise. Females appear to be at higher risk. These results along with the existing literature have led to our recommendations, which include the rapid analysis of serum sodium and the use of hypertonic saline with severe hyponatremia.
55
The Effect of Trendelenburg Position on Subclavian Vein Diameter in Euvolemic and Hypovolemic Volunteers
Gibson GP. Rankins RC, Utecht T/Universib/of California-San Francisco. University Medical Center, Fresno,CA Study objectives: We sought to compare the diameter of the subclavian vein in supine and Trendelenburg positions with both euvolemic and hypovolemic subjects. Our goal was to determine if there was a significant change in the diameter of the vein that would aid in central line placement. Methods: Thirteen volunteers were enrolled and 10 completed the study. All volunteers had subclavian vein measurements made with ultrasound while in the supine and Trendelenburg position in both euvolemic and hypovolemic states. Hypovolemia was accomplished by phlebotomizing 2 units of blood from the volunteers. The films were then read by a radiologist who was blinded to the volunteer's position and volume status. Results: The average change in the diameter of the subclavian vein (Trendelenburg-flat) in euvolemia was -0.02 m m (95% confidence interval [CI], -0.28 to +0.24). In hypovolemic subjects, the average change was +0.09 m m (95% CI, -0.39 to +0.57). Conclusion: Trendelenburg position produces little change in the subclavian vein diameter in euvolemic and hypovolemic patients. These small changes are unlikely to be clinically significant in the placement of a subclavian central venous catheter.
56 The Sexual Assault Examination: A Comparisonof Physical Findings Between an Emergency Department and Freestanding Nurse Examiner Clinic Rossman L, Wynn B, Jones JS/Spectrum Health-Downtown Campus, MSU College of Human Medicine, Grand Rapids, MI Study objective: To compare the documentation of genital trauma in women evaluated for sexual assault between an academic emergency department and a freestanding nurse examiner clinic (NEC). Methods: This was a retrospective cohort analysis of consecutive female patients presenting after alleged sexual assault to either the ED of a university-affiliated urban hospital (n=100 patients) or to a freestanding NEC (n=100). The ED was staffed by board-certified emergency physicians and residents who identified genital trauma using gross visual examination alone. The NEC is located within 1 mile of the hospital and is staffed by registered nurses trained to perform medicolegal examinations using
OCTOBER 1999, PART 2 34:4 ANNALSOF EMERGENCYMEDICINE
colposcopy vclth digital imagang. The 2 patient groups were compared for baseline demographics, assault history, and documentation of genital trauma using a standardized classification system Primary outcome was the frequency and type of documented genital injunes. Results: Case files of 200 patients were reviewed; the mean age was 24.5 years (range 14 to 69 years) with 95% reporting penile-genital contact. The 2 patient groups (NEC, ED) were comparable in terms of demographics, time to examination, assault history, relationship to offender, type, and frequency of nongenital trauma. Genital injuries were documented in 71% of the patients evaluated in the N EC (mean number of genital injuries, 2.1). In companson, 20% of those patients examined in the ED had documented genital trauma (mean number of injuries, 0.3). These differences were statistically significant (;(2=50.4, P<.000I). Trauma types varied in both groups by site--tears appeared most often on the posterior fourchette and fossa, abrasions appeared on the labia, and ecchymosis was seen on the hymen. Conclusion: These results suggest that colposcopy with digital imaging improves detection of genital trauma in female sexual assault victims and may provide valuable medical and legal information.
157 Infectious Do Oiabntic Patients Present to Emergency Departments With Complications at a Higher Rate Than Nondiabctic Patients? Feuer H, ButterfassA, FairweatherP, RichardsonL/Mount Sinai School of Medicine. New York, NY Stud)' objective: Diabetes mellitus is a medical disorder that is recognized to impair the immune system. Diabetic patients are assumed to present to emergency departments with infectious complications at a higher rate than nondiabetic patients. We tested the hypothesis that diabetic patients have a more frequent disposition diagnosis of an infectious etiology than nondiabetic patients. Methods: A retrospective chart review was conducted for two 1-week periods during different seasons at a municipal hospital in the northeastern United States with 70,000 adult ED vasits annually. The charts of all patients who identified themselves as having diabetes mellitus were reviewed; an equal number of nondiabetic patient charts were randomly selected from the same time penods as controls. A precoded data collection instrument for chart review was developed; pertinent demographic and clinical information was abstracted from these ED charts. ED diagnoses were categorized as infectious or noninfectious in etiology Data were analyzed using SPSS 8.0. The Z2 statistic was used to analyze categorical vanables; the Student's t test was used for continuous vanables. Results: A total of 2,585 adult patients presented to our ED during the two 1-week stud)' periods. Data were obtained from 168 diabetics (6.5% of all ED visits) and 148 nondiabetic controls. The mean age of all study patients was 46.1 years of age (range 18 to 103 years) Fifty percent were male, 50% female; 14.3% were white, 17.3% African American, 51.1% Hispanic, 14% Asian, and 5.8% other. There were no statistically significant differences in demographic composition between our diabetic and nondiabetic study groups. In the diabetic group, 34.9% took insulin for glucose control, and 3.5% had other immune-compromising illnesses (H1V or malignancy) versus 5.0% for controls (P=.58). Diabetics were found to have a significantly higher rate of cardiac comorbidiries, 15% versus 6.4% (P=.01). The diabetic group was also found to have significantly higher rates of Medicare and Medicaid coverage. There was no statistical difference bet;veen the 2 groups in the frequency of an infection-based diagnosis: 12.1% of diabetics versus 14.2% of nondiabetics (P=.62). More insulin-dependent diabetics (17.0%) were diagnosed with infection than non-insulin-dependent diabetics (9.3%), although this was not statistically significant (P=. 19). The data also revealed a significantly higher admission rate among diabetic patients: 31.5% versus 181% for nondiabetics (P<.005) Conclusion: The incidence of infectious conditions in patients visiting our ED was not shown to significantly differ between diabetic and nondiabetic populations. Ancillary data gathered portray diabetics using the ED as a more acutely ill population with a significant coincidence of cardiac disease.
58
Empiric Treatment of Gonorrhea and Chlamydia in the Emergency Department
Weist DR. Spear SJ. Bartfield JM/Albany Medical College. Albany. NY Stud)" objectives: This stud)" was conducted to determine how often women screened for Neissena ganorrhoeae (GC) and Chlamydia trachomatis (CT) in an emergency department setting are given proper empinc treatment. Methods: This retrospective chart review was conducted in an urban university
S 41