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Spontaneous
Uterine Rupture As An Unusual Cause Of Abdominal Pain In The Early
Second Trimester Of Pregnancy CASE REPORT: A case of placenta percreta
causing spontaneous uterine rupture is presented. This is a rare condition,
which may present in the antepartum period as abdominal pain, with
or without signs of hemorrhagic shock. This entity can lead to significant
morbidity and mortality if not aggressively managed. A discussion
follows on the pathophysiology, incidence, risk factors, presentation
and management of this condition. Percutaneous
Transcricoid Jet Ventilation Compared With Surgical Cricothyroidotomy
In A Sheep Airway Salvage Model BACKGROUND: We developed a large animal
model of the “cannot intubate/cannot ventilate” (CNI/V)
scenario to compare percutaneous transcricoid manual jet ventilation
(MJV) with surgical cricothyroidotomy (SC). METHODS: Twelve sheep weighing 40-80kg
were assigned to MJV or SC groups. After sedation, intubation, and
line placement, CNI/V was simulated by removing the tracheal tube
and inducing paralysis with vecuronium. When SaO(2) reached 80% (
[Formula: see text] ), MJV catheter insertion or SC was initiated.
Upon successful airway placement, ventilation began using 100% oxygen
at 20 breaths/min. MJV was administered at 50psi. HR, BP, SaO(2),
pH, PCO(2), and PO(2) were recorded at [Formula: see text], 30, 60,
90, 120, 150, 180, 300, 600, and 1200s. Data were reported as [Formula:
see text] over the whole observation period. Baseline values were
compared using Student’s t-tests. Repeated-values ANOVA was used
for post-procedure group comparisons. Statistical tests were two-tailed
and alpha was set at 0.05. RESULTS: Body weights were not significantly
( [Formula: see text] ) different between MJV ( [Formula: see text]
kg) and SC ( [Formula: see text] kg) groups. Baseline respiratory
and hemodynamic variables were also not significantly different. Median
procedure time for MJV (20s) and SC (24s) was not significantly (
[Formula: see text] ) different. Post-procedure values were not significantly
different for SaO(2) ( [Formula: see text] ), pH ( [Formula: see text]
), PCO(2) ( [Formula: see text] ), PO(2) ( [Formula: see text] ),
MAP ( [Formula: see text] ), or HR ( [Formula: see text] ) over the
entire 20min resuscitation period. CONCLUSION: Using a realistic model of
CNI/V we found no difference in respiratory or hemodynamic variables
between MJV and SC. Adequate ventilation and perfusion was maintained
solely by MJV for up to 20min. Severe
Hyperphosphatemia And Hypocalcemia Following The Rectal Administration
Of A Phosphate-containing Fleet Pediatric Enema BACKGROUND: Toxicity secondary to rectally
administered hypertonic phosphate solution in patients with normal
renal function is rarely reported in the literature. We report a case
of electrolyte disturbance and seizure secondary to the rectal administration
of 2 Fleet pediatric enemas. CASE REPORT: A 4-year-old white female
with spinal muscular atrophy and chronic constipation was brought
to the emergency department with complaints of lethargy and difficulty
breathing following the administration of 2 Fleet pediatric enemas.
In the emergency department, physical examination was significant
for a depressed level of consciousness and shallow respirations. A
basic metabolic profile was significant for a calcium of 3.3 mg/dL,
phosphate of 23 mg/dL, and sodium of 153 mEq/L. Arterial blood gases
revealed a pH of 7.24, Pco2 of 38 mm Hg, Po2 of 220 mm Hg. Electrocardiogram
revealed a prolonged QT interval of 340 milliseconds with a corrected
QT interval of 498 milliseconds. Sixteen hours postexposure, she experienced
a generalized seizure unresponsive to multiple doses of lorazepam
and responsive only to 100 mg of intravenous calcium chloride. Two
days after presentation, the patient experienced complete resolution
of symptoms. CONCLUSION: Osmotically acting hypertonic phosphate enemas can result in severe toxicity if retained. This is true even in patients without predisposing risk factors. Emergency
Department Visits For Home Medical Device Failure During The 2003
North America Blackout OBJECTIVES: During a widespread North
American blackout in August 2003, the authors identified a cluster
of patients presenting to their northern Manhattan emergency department
(ED) with complaints related to medical device failure. The characteristics
of this group with respect to presenting complaint, type of device
failure, time spent in the ED, and disposition are described in an
effort to better understand the resource needs of this population. METHODS: This was a retrospective chart
review for all patients evaluated in an urban teaching ED during a
24-hour period spanning the duration of regional power failure. Charts
for patients presenting with medical device failure as part of their
triage complaint were abstracted. RESULTS: Twenty-three of 255 patients
coming to the ED during the 24-hour period presented with medical
device failure. Nineteen of the device failures were due to nonfunctioning
oxygen conservers, three to ventilator failure, and two to airway
suction device failure (one patient had two devices fail). Thirteen
of these patients were admitted to the hospital and accounted for
22% of all admissions during the study interval. Discharged patients
spent a mean of 15.1 hours (range: 3.8-24.4 hours) in the ED. CONCLUSIONS: Patients using electrical
medical devices seek care in the ED when power failure occurs, and
they require significant ED and hospital resources. Effective disaster
planning should anticipate the needs of this population. The
Use Of A Dissected Bovine Heart To Teach Cardiac Sonography OBJECTIVES: To create and test a dissected
bovine heart model (BHM) to facilitate the interpretation of cardiac
sonography (CS). METHODS: After a pretest and an instructional
video on CS, emergency physicians (EPs) were randomized into two groups.
Group 1 viewed two-dimensional (2D) anatomic pictures of human hearts.
Group 2 examined the BHM and the same anatomic pictures as group 1.
The EPs retook the pretest. The differences between the raw pretest
and posttest scores of the groups were compared with an unpaired Student’s
t-test. Multiple linear regression was used to adjust for confounding
by variation in education and initial test scores. EPs with previous
experience in CS were excluded from the analysis. RESULTS: Thirty-five participants met
the inclusion criteria, 16 in group 1 and 19 in group 2. The groups
were well balanced with respect to postgraduate year training. The
EPs in group 1 had a higher average pretest score of 11.6 versus 8.1
in group 2. Compared with the pretest scores, the average improvements
in group 1 and group 2 were 7.6 and 11.3 points, respectively. Group
2 improved an average of 3.7 points (95% confidence interval [95%
CI] = 0.7 to 6.7; p = 0.016) more than group 1. After adjusting for
confounding by the difference in initial scores, group 2 improved
1.8 (95% CI = -1.1 to 4.8; p = 0.22) more points on average than group
1. CONCLUSIONS: A dissected bovine heart
model did not significantly improve the ability of EPs to label structures
on static ultrasounds over inspection of static-labeled anatomic pictures
alone. Extracellular
HMGB1 As A Proinflammatory Cytokine REPORT: High mobility group box-1 protein
(HMGB1, formerly known as HMG-1), a highly conserved ubiquitous protein,
has been for a long time described as a nuclear DNA-binding protein
involved in nucleosome stabilization and gene transcription. Recent
discoveries indicate that HMGB1 is released from activated innate
immune cells or necrotic cells and functions as an important mediator
of endotoxemia, sepsis, arthritis, and local inflammation. Therapeutic
agents that inhibit HMGB1 release or action confer significant protection
against endotoxemia, sepsis, and arthritis in animal models and thus
hold potential for the clinical management of various inflammatory
diseases. Limited
Usefulness Of Initial Blood Cultures In Community Acquired Pneumonia OBJECTIVE: The incidence of community
acquired pneumonia (CAP) is about 4 million cases per year, with a
hospitalisation rate of 20%. In non-immunocompromised patients hospitalised
for CAP the rate of bacteraemia is less than 7% with predictable pathogens.
Despite this, guidelines still recommend use of blood cultures (BCs)
to direct treatment. This study tested the primary hypothesis that
the proportion of false positive BCs would exceed the proportion of
true positives. A secondary aim was to quantify the frequency with
which antibiotic therapy was changed based on BC results. METHOD: Consecutive adults hospitalised
from an urban emergency department (ED) with CAP between January 1999
and March 2001 were assessed retrospectively for study eligibility.
Those with an infiltrate consistent with pneumonia on the admission
chest radiograph and at least one set of and BCs taken in the ED before
antibiotics were given were entered into the study. Patients hospitalised
within the previous two weeks, nursing home residents, and immunosuppressed
patients were excluded. RESULTS: 821 patients were admitted for
CAP and 355 met inclusion criteria. The proportion of false positive
BCs (10%) exceeded the proportion of true positives (9%), by 1% (95%CI
-3.3% to 5.5%). Antibiotic therapy was changed on the basis of BC
results in 5% of patients (95%CI 3% to 8%). CONCLUSION: The rate of false positive
BCs in patients hospitalised with CAP is similar to the rate of true
positives. BCs only infrequently lead to changes in antibiotic therapy,
and in no instance were therapeutic changes driven by detection of
resistant organisms. The results question the utility of routine BCs
in immunocompetent patients with CAP. Antiseptic
Impregnated Endotracheal Tubes For The Prevention Of Bacterial Colonization OBJECTIVE: The effect of endotracheal
tubes (ETTs) impregnated with chlorhexidine (CHX) and silver carbonate
(antiseptic ETTs) against Staphylococcus aureus, methicillin-resistant
S. aureus (MRSA), Pseudomonas aeruginosa, Acinetobacter baumannii,
and Enterobacter aerogenes [organisms associated with ventilator-associated
pneumonia (VAP)], was evaluated in a laboratory airway model. METHODS: Antiseptic ETTs and control
ETTs (unimpregnated) were inserted in culture tubes half-filled with
agar media (airway model) previously contaminated at the surface with
10(8) cfu/mL of the selected test organism. After five days of incubation,
bacterial colony counts on all ETT segments were determined. Swabs
of proximal and distal ends of the agar tract in antiseptic and control
models were subcultured. The initial and residual CHX levels, (five
days post-implantation in the model) were determined. RESULTS: Cultures of antiseptic ETTs
revealed colonization by the tested pathogens ranging from 1-100 cfu/tube,
compared with approximately 10(6) cfu/tube for the control ETTs (P
< 0.001). Subcultures from proximal and distal ends of the agar
tract showed minimal or no growth in the antiseptic ETTs compared
with the control ETTs (P < 0.001). The amount of CHX retained in
the antiseptic ETTs after five days of implantation was an average
of 45% of the initial level. Antiseptic ETTs prevented bacterial colonization
in the airway model and also retained significant amounts of the antiseptic.
CONCLUSION: These results indicate that
the effectiveness of antiseptic-impregnated ETTs in preventing the
growth of bacterial pathogens associated with VAP may vary with different
organisms. War-related
Psychological Sequelae Among Emergency Department Patients In The
Former Republic Of Yugoslavia BACKGROUND: Residents of the Republic
of Serbia faced civil war and a NATO-led bombing campaign in 1999.
We sought to assess the burden of metal health dysfunction among emergency
department (ED) patients presenting for care three years post-war
in Serbia. METHODS: This study was conducted during
July and August 2002 at two sites: a university hospital ED in Belgrade,
Serbia and an ED in a remote district hospital serving a Serbian enclave
in Laplje Selo, Kosovo. Investigators collected data on a systematic
sample of non-acute patients presenting to the ED. All respondents
completed a structured questionnaire assessing demographics and symptoms
of post-traumatic stress disorder (PTSD) (using the Harvard Trauma
Questionnaire), and major depression (using the Center for Epidemiologic
Studies Depression Scale). RESULTS: A total of 562 respondents participated
(310 in Belgrade, 252 in Laplje Selo); the response rate was 83.8%,
43% were female, and mean age was 37.6 years (SD = 13.4). Overall,
73 (13.0%) participants had symptoms consistent with PTSD, and 272
(49.2%) had symptoms consistent with depression. Sixty-six respondents
had both disorders (11.9%). In separate multivariable logistic regression
models, predictors of PTSD were refugee status and residence in Laplje
Selo, and predictors of depression were older age, current unemployment,
and lower social support. CONCLUSIONS: Three years post-war, symptoms
of PTSD and major depression in Serbia remained a significant public
health concern, particularly among refugees, those suffering subsequent
economic instability, and persons living in rural, remote areas. Real-time
B-mode Ultrasound In The ED Saves Time In The Diagnosis Of Deep Vein
Thrombosis (DVT) OBJECTIVE: We hypothesize that EPs can
decrease the time to disposition when performing examinations for
deep venous thrombosis (DVT) compared with disposition times using
imaging specialists (IS). METHODS: We performed a prospective,
single-blind observational study at an academic ED over the course
of 1 year. Patients were enrolled based on study physician availability.
EPs ordered the corroborative ultrasound, then performed their own
examination. EPs recorded patient triage time, ED results, and disposition
times for both EP and IS departments. RESULTS: One hundred fifty-six patients
were enrolled. Thirty-four (22%) were diagnosed with a DVT. Mean time
from triage to EP disposition was 95 minutes and mean time from triage
to radiology disposition was 220 minutes. The difference of 125 minutes
was statistically significant (P <.0001). EPs and ISs had excellent
agreement (kappa = 0.9). CONCLUSION: Compression ultrasound performed
by EPs resulted in a significant decreased time to disposition. Agreement
with ISs was excellent. A
Porcine Epistaxis Model: Hemostatic Effects Of Octylcyanoacrylate OBJECTIVE: To develop a standardized
porcine epistaxis model and evaluate the hemostatic effects of octyl-cyanoacrylate
(OCA). METHODS: Twenty-four standardized full-thickness
wounds were created on the nasal septae of 7 pigs with a 4-mm surgical
punch. Wounds were randomized to no treatment or topical OCA before
and after full heparinization. The rate of hemostasis, time to hemostasis,
and number of applicators of OCA required to achieve complete hemostasis
were determined and groups were compared with t tests and chi2 tests.
RESULTS: Complete and sustained hemostasis
was achieved in all wounds treated with OCA. The time to hemostasis
was significantly shorter in the wounds treated with OCA vs those
left to clot on their own (mean difference, 150 seconds; 95% CI, 92
to 209 seconds, P<0.001). None of the wounds required more than
3 applications of OCA. CONCLUSIONS: We describe a simple and
reproducible animal epistaxis model and demonstrate that OCA is effective
in achieving hemostasis in this model. Utility
Of An Immunization Registry In A Pediatric Emergency Department OBJECTIVES: Determine prevalence of participation
and underimmunization rate in a regional immunization registry (IR)
among patients presenting to a university pediatric emergency department
(PED). Rate of agreement between parental report and documented immunization
status was also measured. METHODS: A convenience sample of parents
of patients younger than 11 years registered in the PED were approached
with a short questionnaire. When informed consent was obtained, the
Central New York (CNY) IR was accessed via computer to see if the
child was in the registry and to ascertain if their immunizations
were up-to-date (UTD). Rate of agreement between parental report and
immunization status documented in the IR was calculated. RESULTS: 698 (97%) of 720 patients consented
to participate. Of these, 235 (34%, 95% CI, 30-37) were enrolled in
the IR. Eighty-five (36%, 95% CI, 30-42) enrolled patients were under
age 2. Sixty-seven (29%, 95% CI, 23-34) were from private group practices,
146 (62%, 95% CI, 56-68) were from university/community health center
clinics and the source of primary care for 22 patients (9%) was unknown.
Only 67 (29%, 95% CI, 23-34) parents of children in the IR were aware
that they were enrolled. Of IR patients, 225 (96%, 95% CI, 93-98)
stated they were UTD, while only 143 (61%, 95% CI, 55-67) were documented
to be so. CONCLUSIONS: A significant number of
patients seen in the PED were in the CNY IR. More than one-half of
the parents of enrolled children did not recall that they had previously
registered their child. Only 61% of patients were UTD, whereas parents
reported that almost all were. In the PED, use of an IR would create
an opportunity for intervention in a large number of patients who
were not UTD. Transient
Ischemic Attack: Review For The Emergency Physician REPORT: In the past few years, the approach
to patients with transient ischemic attacks has undergone a transformation.
To care for these patients, emergency physicians must understand these
changes. They must be comfortable with the diagnosis and treatment
of transient ischemic attacks in their emergency department. To this
end, we ask and answer the following 6 important questions in this
up-to-date review of transient ischemic attacks: (1) How is a transient
ischemic attack defined? (2) Does this patient have a transient ischemic
attack? (3) Once diagnosed, what diagnostic evaluation should be done
(and when)? (4) What treatment should be instituted (and when)? (5)
What is the correct disposition? and (6) What are the current medical
guidelines? A
Rare Ingestion Of The Black Locust Tree BACKGROUND: The Black Locust (Robinia
Pseudoacacia) tree contain toxalbumins, robin and phasin, that exert
their toxic effects by inhibition of protein synthesis. Despite the
potential dangers of Black Locust intoxication, reports of human toxicity
after ingestion are rare. We report the first human intoxication of
Black Locust bark in North America in over one hundred years. CASE REPORT: An eight-year-old male was brought to the emergency department 6 hours after chewing and expelling the Black Locust bark. He presented with emesis, which began approximately 2.5 hours after exposure. His vital signs were as follows: oral temperature, 97.5 degrees F; blood pressure, 128/75 mmHg; heart rate, 114 beats per minute; respiratory rate, 15 breaths per minute. Initial treatment included 4 mg i.v. ondansetron, which resolved the vomiting, one dose of activated charcoal, and intravenous fluids. He was then admitted to the intensive care unit (ICU) for observation of signs of toxicity. Laboratory findings were unremarkable except for a white blood cell of 18.4 K/uL and an elevated alkaline phosphatase of 183 U/L. The patient remained asymptomatic throughout his stay in the ICU and was discharged on the fifth day of admission with a normal white blood cell of 4.1 K/uL and an alkaline phosphatase of 251 U/L. CONCLUSION: Patients with clinical toxicity
following the ingestion of Black Locust are expected to do well with
supportive care and observation. Out-of-hospital
Medication Storage Temperatures: A Review Of The Literature And Directions
For The Future REPORT: The United States Pharmacopeia
(USP) National Formulary prescribes the packaging, storage, and distribution
of medications. Most of the medications commonly used by emergency
medical services (EMS) are intended for storage at “controlled
room temperature.” The USP definition of controlled room temperature
is multifaceted and complex, and cannot be easily described as a simple
range of acceptable temperatures, or even as an average temperature.
The out-of-hospital environment is notoriously uncontrolled, and one
of the uncontrolled aspects of that environment is temperature. This
report reviews and summarizes the past 15 years of published research
relating to out-of-hospital medication temperature exposures. Although
the evidence is clear that EMS medication storage is not consistent
with the USP definition of controlled room temperature, the impact
of EMS medication storage on medication stability and potency remains
unclear. Further research is needed to determine the true extent of
the EMS medication storage problem, and to develop and validate appropriate
solutions. Extremely
Elevated Relative Risk Of Paraffin Lamp Oil Exposures In Orthodox
Jewish Children BACKGROUND: In observance of the Sabbath
and other religious holidays, many Orthodox Jews maintain a burning
lamp that uses paraffin lamp oil as fuel. Unintentional pediatric
exposure to paraffin lamp oil, a hydrocarbon, is typically by ingestion
and carries a risk of aspiration with subsequent pneumonitis. This
investigation was prompted by an apparent increase in paraffin lamp
oil exposures during the Jewish Sabbath, from sunset Friday until
sunset Saturday, noted by the staff of our regional poison control
center. METHODS: In this investigation, we retrospectively
reviewed all exposures to paraffin lamp oil occurring in our large
city in children <18 years old reported to our regional poison
control center between January 1, 2000, and February 1, 2003. Reports
were investigated to ascertain the frequency of occurrence of paraffin
lamp oil exposures on the Jewish Sabbath and Jewish religious holidays.
Caregivers of involved children were surveyed by telephone to determine
the exposed child’s religion and circumstances of exposure. RESULTS: During these 25 months, 45 cases
met inclusion criteria, and all were ingestions. Orthodox Jews accounted
for 32 cases (71%), 4 cases (9%) occurred in children who were not
Orthodox Jews, and demographic data were unavailable in 9 cases (20%).
Twenty-four cases (53%) occurred within 10 hours before or during
the Jewish Sabbath or Jewish religious holidays. The relative risk
of Orthodox Jewish children to ingest paraffin lamp oil, calculated
by using census data, is 374 times that of other children. CONCLUSIONS: Public health authorities and caregivers of Orthodox Jewish children should be cognizant of this phenomenon. Educational efforts directed toward both Orthodox Jews and the general public aimed at preventing paraffin lamp oil exposures are warranted.
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