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Urine collection from disposable nappies
Abstracts
Abstracts in this issue were prepared by residents in the University of Arizona Emergency Medicine Residency Program.
Richard Dart, MD Co-Editor Section of Emergency Medicine Uaiversity of Arizona College of Medicine Tucson, Arizona
ankle, radiography
epinephrine, cardiac arrest
Ankle injury
Potential complications of high-dose epinephrine therapy in patients resuscitated from cardiac arrest
Anlette AG A JR 157:789-791 Oct 1991 A prosepective study was performed to determine if a physical examination could reduce the frequency of radiologic examination in patients with acute ankle injury. Radiology residents performed a brief examination on all patients (201}. All received a full set of ankle films. Those patients who received radiologic study had either gross deformity, instability or crepitation, focal bony tenderness, severe soft-tissue tenderness, or moderate-to-severe soft-tissue swelling and ecchymosis. Ankle injuries were considered clinically significant if the injury required open or closed reduction and/or long-term immobilization. One hundred one patients (50%) were classified as having inadequate indications for radiographs. 0nly one of the 101 had a fracture (which was clinically insignificant). Of the 151 patients who were examined by a physician before referral, 74 (49%) were classified as having an indication for radiographs. A thorough physical examination may eliminate the overuse of radiographic studies. Ron Widman, Mr?
FEBRUARY1992
2 1 : 2 ANNALS 0F EMERGENCY MEDICINE
Callaham M, Barton C, Kayser S JAMA 265. 1117-1122 Mar6, 1991 Patients resuscitated from nontraumatic cardiac arrest who received high-dose epinephrine and survived at least six hours were evaluated retrospectively for potential complications. These included hypertension, cardiac ischemia, hypokalemia, hyperglycemia, pulmonary edema, arrhythmias, elevated magnesium, and hypocalcemia. Sixty-eight adult patients were enrolled. After all complications data were collected, patients were divided into high-dose epinephrine (bolus of 50 t~g/kg or more, or more than 2.8 lzg/kg per dose) and standard-dose epinephrine. There was no evidence of the expected complications of high-dose epinephrine. The high-dose epinephrine group exhibited a slightly lower serum calcium than the standard-dose epinephrine group. Physician-directed epinephrine dosing (as opposed to random assignment)limited this study. The results support the conclusion that high-dose epinephrine in patients resuscitated from cardiac arrest does not have the same
adverse effects seen in epinephrine overdose. The authors note that if high-dose epinephrine initially resuscitates more patients but does not improve discharge rates, its net impact.will be negative. [Editor's note: This is an important study, but it is limited due to the exclusion of patients who survived less than six hours. This eliminates early lethal complications. Therefore, a randomized trial is needed.] Toni Brophy, MD
urinalysis, pediatric
Urine collection from disposable nappies Ahmad T, VickersO, CampbellS, et al Lancet 338:674-676 Sept 1991 Poor adhesion, contamination by perineal flora, and lengthy time delays complicate the use of traditional sterile adhesive bags for the collection of urine from infants and young children. In search of a more efficacious method, extraction of specimens from disposable diapers (nappies) was investigated. Two methods were studied: a collection bag placed over the perineum after prepping with chlorhexidine; and by compression of the fiber lining of a disposable diaper placed in a 20 ml syringe. Urine specimens were obtained from 45 children (aged 1 to 23 months) by both methods and from 11 older children. Specimens were split for microscopy and •
233/179
ABSTRACTS
culture. Soiled diapers and diapers left on for more than four hours were excludedfrom analysis.Another phase of the investigation involved incubating diapers with prepared cultures of Escherichia coli and Streptoccus faecalis. Delayed extraction and analysis was performed to determine if diapers had an inhibitory effect on bacterial growth. Immediateand delayed post-extractiondetermination of sodium, potassium, blood urea nitrogen, chromium, calcium, and phosphorousalso was performed. The results showed complete agreement of the culture results between the two methods in 32 of 45 specimens. Microscopyreveled no differences in bacterial counts, but did reveal reducedWBC and RBC counts in diaper specimens. Incubationof diapers and delayed extraction revealedno change in numbersof viable organismsover six hours. Lastly, biochemicalanalysis revealed close correlation (r> 0.97} between both methods.The collection of urine specimensfrom disposable diapers is simple, rapid, and effective. Moreover,a cost savings is obvious given that no special steps need to be taken to obtain the specimen. Obtainingspecimens from superabsorbentdiapers with a gel matrix was often impossible, however.
Paul J Sovell, MD
chest pain
Clinical symptoms in young adults with atypical chest pain attending the emergency department Roll M, Kollind M, Theorell T J Intern Med 230.271-277 Sept 1991 This study investigatedthe etiology of atypical chest of pain in young patients presentingto the emergency departmentwith this type of chest pain. The patients were selected from the 445 patients seen during
180/234
eight random weeks in an ED in Stockholm, Sweden. Ninety-five patients less than 40 years old had chest pain, of whom 14 were found to have organic causes. Of the remaining81 patients, 69 agreed to participate in the study. All had a chief complaint of chest pain, were less than 40 years old, had a negative workup in the ED, and had a negative cardiac stress test later. Nine diagnostic categorieswere created into which the patients were distributed. When allowed to selfdiagnosetheir chest pain into one of these nine categories, only one third of the participants agreed with their chart diagnoses.Participants,more often than their doctors, thought that the category"psychologicaletiology" (21% vs 14%) was correct. The largest single group (41%) fell into the category "none," meaningthe final chart diagnosis did not address the complaint of chest pain. Fiftyfour percent of the 69 patients had consulted a doctor for atypical chest pain before. Thesedata and further interviewingsuggestedthat a psychosomatic interpretation, and psychosocial rather than purely medical follow-up, may be an important considerationin young patients with nonorganicchest pain. In general, clues to a psychosomaticinterpretation were intermittent palpitations, with gradual onset and resolution; dyspneathat the patient believed would have not been noticed by a bystander; and associatedsymptoms such as tiredness, anxiety, and tension. Paresthesiaof the left arm (or more limbs), even in the absenceof hyperventilation,did not contradict a psychosomaticinterpretation of the symptoms.
Andrea Graebe, MD
seizures, creatine kinase
pulmonaryembolism
Seizure vs syncope: Measuring serum creatine kinase in the emergency department
Clinical laboratory roentgenographie, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease
Libman MD, Potvin LM, CoupalL, et al J Gen Intern Med 6.408-412 1991 This study prospectivelyevaluated the sensitivity and specificity of serum creatinine kinase (CK)levels in separating seizurefrom other causes of syncope. Subjects consisted of all patients presentingto the emergencydepartment of Montreal General Hospital with any form of transient loss of consciousness. Housestaff were requestedto draw CKsas on all these patients.Patients were subsequentlycategorizedinto two major groups, those with syncope strongly believed to have a seizure etiology and those believed to have other causes of syncope. These groups were distinguished based on history (witnessed seizure postictal states) and subsequent testing (eg, EEG).A total of 312 patients presentedto the ED during the six-month study period. A subset of 96 patients met the criteria for this study as some were lost to follow-up and others did not have CKs drawn. The sensitivity of the CK for determining which patients had seizureswas 0.43, while the specificity was 0.98. When the patient population was subdivided into patients whose CK was drawn before or after three hours, the sensitivity of detecting seizuresrose to 0.80 while the specificity fell slightly to 0.94. The authors note that CK would not be expectedto rise in all forms of seizurebut only in those with tonic clonic activity. The authors concludethat CK may be a useful test for evaluating transient loss of consciousnessdue to seizure. The test appearsto be most sensitive after three hours.
Stephen L Johnson, MD
Stein P, Terrin M, Hales C, et al Chest 100.598-603 1991 This prospectivestudy examined365 patients, without previouscardiac or pulmonarydisease, in whom acute pulmonaryembolismwas of diagnostic concern. Patientswere evaluated by history, physicalexamination, chest radiograph,ECG,and arterial blood gases.Resultswere compared between the groups with or without pulmonaryembolism. Other causesfor symptomatology were not addressed.As expected,no single clinical manifestation allowed for definitive diagnosis of pulmonary embolism. Only a very small percentage of patients with pulmonary embolism did not have a numberof manifestations or combinations thereof. Dyspnea,hemoptysis,or pleuritic chest pain was present in 91%. Chest radiographwas abnormal in 84oYoof those with pulmonary embolism. Dyspnea,tachypnea,or pleuritic chest was present in 97% of patients with pulmonary embolism. Immobilizationdue to surgery was the most prevalent predisposingfactor (56oYo).The diagnosis of pulmonaryembolism remains difficult. As the authors noted, multiple clues are important in the diagnosis or exclusionof pulmonary embolism.Clinical evaluation is of value in the selection of patients in whom further evaluation is required.
David E Compton, MD
ANNALSOF EMERGENCY MEDICINE
21:2
~"
FEBRUARY1992
Abstracts in this issue were prepared by residents in the University of Arizona Emergency Medicine Residency Program.
Richard Dart, MD Co-Editor Section of Emergency Medicine Uaiversity of Arizona College of Medicine Tucson, Arizona
ankle, radiography
epinephrine, cardiac arrest
Ankle injury
Potential complications of high-dose epinephrine therapy in patients resuscitated from cardiac arrest
Anlette AG A JR 157:789-791 Oct 1991 A prosepective study was performed to determine if a physical examination could reduce the frequency of radiologic examination in patients with acute ankle injury. Radiology residents performed a brief examination on all patients (201}. All received a full set of ankle films. Those patients who received radiologic study had either gross deformity, instability or crepitation, focal bony tenderness, severe soft-tissue tenderness, or moderate-to-severe soft-tissue swelling and ecchymosis. Ankle injuries were considered clinically significant if the injury required open or closed reduction and/or long-term immobilization. One hundred one patients (50%) were classified as having inadequate indications for radiographs. 0nly one of the 101 had a fracture (which was clinically insignificant). Of the 151 patients who were examined by a physician before referral, 74 (49%) were classified as having an indication for radiographs. A thorough physical examination may eliminate the overuse of radiographic studies. Ron Widman, Mr?
FEBRUARY1992
2 1 : 2 ANNALS 0F EMERGENCY MEDICINE
Callaham M, Barton C, Kayser S JAMA 265. 1117-1122 Mar6, 1991 Patients resuscitated from nontraumatic cardiac arrest who received high-dose epinephrine and survived at least six hours were evaluated retrospectively for potential complications. These included hypertension, cardiac ischemia, hypokalemia, hyperglycemia, pulmonary edema, arrhythmias, elevated magnesium, and hypocalcemia. Sixty-eight adult patients were enrolled. After all complications data were collected, patients were divided into high-dose epinephrine (bolus of 50 t~g/kg or more, or more than 2.8 lzg/kg per dose) and standard-dose epinephrine. There was no evidence of the expected complications of high-dose epinephrine. The high-dose epinephrine group exhibited a slightly lower serum calcium than the standard-dose epinephrine group. Physician-directed epinephrine dosing (as opposed to random assignment)limited this study. The results support the conclusion that high-dose epinephrine in patients resuscitated from cardiac arrest does not have the same
adverse effects seen in epinephrine overdose. The authors note that if high-dose epinephrine initially resuscitates more patients but does not improve discharge rates, its net impact.will be negative. [Editor's note: This is an important study, but it is limited due to the exclusion of patients who survived less than six hours. This eliminates early lethal complications. Therefore, a randomized trial is needed.] Toni Brophy, MD
urinalysis, pediatric
Urine collection from disposable nappies Ahmad T, VickersO, CampbellS, et al Lancet 338:674-676 Sept 1991 Poor adhesion, contamination by perineal flora, and lengthy time delays complicate the use of traditional sterile adhesive bags for the collection of urine from infants and young children. In search of a more efficacious method, extraction of specimens from disposable diapers (nappies) was investigated. Two methods were studied: a collection bag placed over the perineum after prepping with chlorhexidine; and by compression of the fiber lining of a disposable diaper placed in a 20 ml syringe. Urine specimens were obtained from 45 children (aged 1 to 23 months) by both methods and from 11 older children. Specimens were split for microscopy and •
233/179
ABSTRACTS
culture. Soiled diapers and diapers left on for more than four hours were excludedfrom analysis.Another phase of the investigation involved incubating diapers with prepared cultures of Escherichia coli and Streptoccus faecalis. Delayed extraction and analysis was performed to determine if diapers had an inhibitory effect on bacterial growth. Immediateand delayed post-extractiondetermination of sodium, potassium, blood urea nitrogen, chromium, calcium, and phosphorousalso was performed. The results showed complete agreement of the culture results between the two methods in 32 of 45 specimens. Microscopyreveled no differences in bacterial counts, but did reveal reducedWBC and RBC counts in diaper specimens. Incubationof diapers and delayed extraction revealedno change in numbersof viable organismsover six hours. Lastly, biochemicalanalysis revealed close correlation (r> 0.97} between both methods.The collection of urine specimensfrom disposable diapers is simple, rapid, and effective. Moreover,a cost savings is obvious given that no special steps need to be taken to obtain the specimen. Obtainingspecimens from superabsorbentdiapers with a gel matrix was often impossible, however.
Paul J Sovell, MD
chest pain
Clinical symptoms in young adults with atypical chest pain attending the emergency department Roll M, Kollind M, Theorell T J Intern Med 230.271-277 Sept 1991 This study investigatedthe etiology of atypical chest of pain in young patients presentingto the emergency departmentwith this type of chest pain. The patients were selected from the 445 patients seen during
180/234
eight random weeks in an ED in Stockholm, Sweden. Ninety-five patients less than 40 years old had chest pain, of whom 14 were found to have organic causes. Of the remaining81 patients, 69 agreed to participate in the study. All had a chief complaint of chest pain, were less than 40 years old, had a negative workup in the ED, and had a negative cardiac stress test later. Nine diagnostic categorieswere created into which the patients were distributed. When allowed to selfdiagnosetheir chest pain into one of these nine categories, only one third of the participants agreed with their chart diagnoses.Participants,more often than their doctors, thought that the category"psychologicaletiology" (21% vs 14%) was correct. The largest single group (41%) fell into the category "none," meaningthe final chart diagnosis did not address the complaint of chest pain. Fiftyfour percent of the 69 patients had consulted a doctor for atypical chest pain before. Thesedata and further interviewingsuggestedthat a psychosomatic interpretation, and psychosocial rather than purely medical follow-up, may be an important considerationin young patients with nonorganicchest pain. In general, clues to a psychosomaticinterpretation were intermittent palpitations, with gradual onset and resolution; dyspneathat the patient believed would have not been noticed by a bystander; and associatedsymptoms such as tiredness, anxiety, and tension. Paresthesiaof the left arm (or more limbs), even in the absenceof hyperventilation,did not contradict a psychosomaticinterpretation of the symptoms.
Andrea Graebe, MD
seizures, creatine kinase
pulmonaryembolism
Seizure vs syncope: Measuring serum creatine kinase in the emergency department
Clinical laboratory roentgenographie, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease
Libman MD, Potvin LM, CoupalL, et al J Gen Intern Med 6.408-412 1991 This study prospectivelyevaluated the sensitivity and specificity of serum creatinine kinase (CK)levels in separating seizurefrom other causes of syncope. Subjects consisted of all patients presentingto the emergencydepartment of Montreal General Hospital with any form of transient loss of consciousness. Housestaff were requestedto draw CKsas on all these patients.Patients were subsequentlycategorizedinto two major groups, those with syncope strongly believed to have a seizure etiology and those believed to have other causes of syncope. These groups were distinguished based on history (witnessed seizure postictal states) and subsequent testing (eg, EEG).A total of 312 patients presentedto the ED during the six-month study period. A subset of 96 patients met the criteria for this study as some were lost to follow-up and others did not have CKs drawn. The sensitivity of the CK for determining which patients had seizureswas 0.43, while the specificity was 0.98. When the patient population was subdivided into patients whose CK was drawn before or after three hours, the sensitivity of detecting seizuresrose to 0.80 while the specificity fell slightly to 0.94. The authors note that CK would not be expectedto rise in all forms of seizurebut only in those with tonic clonic activity. The authors concludethat CK may be a useful test for evaluating transient loss of consciousnessdue to seizure. The test appearsto be most sensitive after three hours.
Stephen L Johnson, MD
Stein P, Terrin M, Hales C, et al Chest 100.598-603 1991 This prospectivestudy examined365 patients, without previouscardiac or pulmonarydisease, in whom acute pulmonaryembolismwas of diagnostic concern. Patientswere evaluated by history, physicalexamination, chest radiograph,ECG,and arterial blood gases.Resultswere compared between the groups with or without pulmonaryembolism. Other causesfor symptomatology were not addressed.As expected,no single clinical manifestation allowed for definitive diagnosis of pulmonary embolism. Only a very small percentage of patients with pulmonary embolism did not have a numberof manifestations or combinations thereof. Dyspnea,hemoptysis,or pleuritic chest pain was present in 91%. Chest radiographwas abnormal in 84oYoof those with pulmonary embolism. Dyspnea,tachypnea,or pleuritic chest was present in 97% of patients with pulmonary embolism. Immobilizationdue to surgery was the most prevalent predisposingfactor (56oYo).The diagnosis of pulmonaryembolism remains difficult. As the authors noted, multiple clues are important in the diagnosis or exclusionof pulmonary embolism.Clinical evaluation is of value in the selection of patients in whom further evaluation is required.
David E Compton, MD
ANNALSOF EMERGENCY MEDICINE
21:2
~"
FEBRUARY1992