Sweet 16. Four more leads can let you evaluate parts of the heart traditional 12-lead EKGs miss

There's a growing demand for early prehospital determination of acute ST-segment elevation myocardial infarctions (STEMIs) for fast and efficient transport of patients to hospitals with cardiac catheterization and angioplasty capabilities. Accordingly, EMS responders must be well attuned to the true capabilities of electrocardiography machines. Currently, STEMIs require accurate EKG interpretation in the field to save precious heart muscle and decrease the risk of morbidity and mortality.

[Life-threatening emergencies at the office: implications for medical education and equipment of the primary care physician]

Every medical practitioner is confronted on a daily basis with emergencies. Among these, life-threatening emergencies can have disastrous consequences in term of morbidity and mortality; 22 cardiac arrests and 10 deaths were reported among the 1,650 Swiss practices during a 5 year period. The occurrence of life-threatening emergencies at the office necessitates, according to the type and place of the practice, the skills of the practitioner and the organization of his practice, the implementation of procedures, equipments (for example room equipped with a defibrillator, respiratory nebulizer, splints, emergency drugs) and specific continuous education programs that should be encouraged and made available to the whole medical corporation.

The Six-Item Screener to detect cognitive impairment in older emergency department patients

BACKGROUND

Cognitive impairment due to delirium or dementia is common in older emergency department (ED) patients. To prevent errors, emergency physicians (EPs) should use brief, sensitive tests to evaluate older patient's mental status. Prior studies have shown that the Six-Item Screener (SIS) meets these criteria.

OBJECTIVES

The goal was to verify the performance of the SIS in a large, multicenter sample of older ED patients.

METHODS

A prospective, cross-sectional study was conducted in three urban academic medical center EDs. English-speaking ED patients > or = 65 years old were enrolled. Patients who received medications that could affect cognition, were too ill, were unable to cooperate, were previously enrolled, or refused to participate were excluded. Patients were administered either the SIS or the Mini-Mental State Examination (MMSE), followed by the other test 30 minutes later. An MMSE of 23 or less was the criterion standard for cognitive impairment; the SIS cutoff was 4 or less for cognitive impairment. Standard operator characteristics of diagnostic tests were calculated with 95% confidence intervals (CIs), and a receiver operating characteristic curve was plotted.

RESULTS

The authors enrolled 352 subjects; 111 were cognitively impaired by MMSE (32%, 95% CI = 27% to 37%). The SIS was 63% sensitive (95% CI = 53% to 72%) and 81% specific (95% CI = 75% to 85%). The area under the receiver operating characteristic curve was 0.77 (95% CI = 0.72 to 0.83).

CONCLUSIONS

The sensitivity of the SIS was lower than in prior studies. The reasons for this lower sensitivity are unclear. Further study is needed to clarify the ideal brief mental status test for ED use.

A comparison between clinicians' assessment and the Manchester Self-Harm Rule: a cohort study

As identifying patients at risk of subsequent suicidal behaviour is a key goal of assessment, a cohort study of presentations to five emergency departments following episodes of self-harm was carried out. We compared the accuracy of the prediction of subsequent self-harm within 6 months between global clinical assessments and the Manchester Self-harm Rule. Sensitivity, specificity, and positive and negative predictive values with 95% confidence intervals (CI) were calculated. Global clinical assessments and the rule had a sensitivity of 85% (CI 83 to 87) versus 94% (CI 92% to 95%), specificity of 38% (CI 37% to 39%) versus 26% (CI 24% to 27%), a positive predictive value of 22% (CI 21% to 23%) versus 21% (CI 19% to 21%) and a negative predictive value of 92% (CI 91% to 93%) versus 96% (CI 94% to 96%). The accuracy of predicting short-term repetition of self-harm by clinicians could be improved by incorporating this simple rule into their assessment.

Tracheal intubation by non-anaesthetist physicians using the Airway Scope

OBJECTIVE

To evaluate the performance of the Airway Scope for tracheal intubation by non-anaesthetist physicians.

METHODS

Under supervision by staff anaesthetists, non-anaesthesia residents performed tracheal intubation using either the Airway Scope (n = 100) or Macintosh laryngoscope (n = 100). The time required for airway instrumentation and the success rate at first attempt were investigated.

RESULTS

The time to secure the airway was shorter with the Airway Scope than with the Macintosh laryngoscope (p<0.001). The success rate at first attempt was higher with the Airway Scope than with the Macintosh laryngoscope (p<0.001).

CONCLUSION

The Airway Scope may reduce the time to secure the airway and the incidence of failed tracheal intubation in novice laryngoscopists.

Midazolam or ketamine for procedural sedation of children in the emergency department

A short cut review was carried out to establish whether ketamine or midazolam is superior at providing safe and effective conscious sedation in children in the emergency department. A total of 203 papers were found using the reported searches, of which four presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are summarised in table 1. It is concluded that midazolam and ketamine have similar efficacy and safety profiles but that ketamine is preferred by parents and physicians.

Ultrasound to detect haemothorax after chest injury

A short cut review was carried out to establish whether ultrasonography is as sensitive and specific as chest x ray or computed tomography (CT) scan in detecting haemothorax after chest trauma. Thirty-nine papers were found using the reported searches, of which six presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are shown in table 3. It is concluded that ultrasonography is more sensitive and as specific as chest x ray at detecting haemothorax in patients with chest trauma.

EmerLoc: Location-based services for emergency medical incidents

BACKGROUND

Recent developments in positioning systems and telecommunications have provided the technology needed for the development of location aware medical applications. We developed a system, named EmerLoc, which is based upon this technology and uses a set of sensors that are attached to the patient's body, a micro-computing unit which is responsible for processing the sensor readings and a central monitoring unit, which coordinates the data flow.

OBJECTIVE

To demonstrate that the proposed system is technically feasible and acceptable for the potential users.

METHOD

Transmission speed is assessed mostly by means of transmission of DICOM compliant images in various operational scenarios. The positioning functionality was established both outdoor using GPS and indoor using the UCLA Nibble system. User acceptability was assessed in a hospital setting by 15 physicians who filled in a questionnaire after having used the system in an experimental setting.

RESULTS

Transmission speeds ranged from 88kB/s for a IEEE 802.11 infrastructure to 2.5kB/s for a GSM/GPRS scenario. Positioning accuracy based on GPS was 5-10m. The physicians rated the technical aspects on average above 3 on a 5-point scale. Only the data presentation was assessed to be not satisfactory (2.81 on a 5-point scale).

CONCLUSION

The reported results prove the feasibility of the proposed architecture and its alignment with widely established practices and standards, while the reaction of potential users who evaluated the system is quite positive.

[The doctor's emergency bag must be simple but efficient: manual]

It is extremely difficult to stipulate guidelines for the creation of a specific bag containing emergency material, designed solely for the general practitioner. The purpose of this article is to give each generalist a practical guide to create an emergency bag that meets up to his or her needs and practice purposes. Many factors have to be taken into account. First of all we review the material that is at our disposal in a regular emergency vehicle. All encountered pathologies are analysed following a rigid ABCD system (Airway, Breathing, Circulation, Disability--Diabetes--other). In respect to this system we will present a summary of different pathological changes. The dosage of medication will be specified when indicated for infants. Next we follow with a summary of all material that needs to be in the bag in function of the generalist's purpose. This constitutes all needed medication, legal document and emergency material. We then propose a checklist that can be used by the general practitioner in function of his or her needs.

Initial test of emergency procedure performance in temporary negative pressure isolation by using simulation technologies

Study objective

The potential of infectious disease spread in diseases such as tuberculosis, infectious disease epidemic such as avian flu and the threat of terrorism with agents capable of airborne transmission have focused attention on the need for increased surge capacity for patient isolation. Total negative pressure isolation using portable bioisolation tents may provide a solution. The study assesses the ability of health care workers to perform emergency procedures in this environment.

Methods

Physician performance in completing predetermined critical actions in 5 emergency care scenarios inside and outside of a bioisolation tent (“setting”) was studied in an advanced medical simulation laboratory. By design, no pretraining of subjects about total negative pressure isolation use occurred. Impact of setting on time to completion of predetermined critical actions was the primary outcome measured. Secondary variables studied included impact of study groups, scenarios, and run order (inside or outside of the tent first). Subjective assessments were obtained through questionnaires.

Results

Four teams of 3 physicians completed 5 emergency patient care scenarios during 2 4-hour sessions. Mean time to completion of critical actions was for tent/no tent 298 seconds/284 seconds (P=.69, one way ANOVA), respectively. Mean time to completion for first versus second performance of a scenario in the crossover design was 338 versus 243 (P=.01). The mean score for self-assessed performance did not differ according to setting.

Conclusion

The ability of physicians naive to the total negative pressure isolation environment to perform emergency medical critical actions was not significantly degraded by a simulated bioisolation tent patient care environment.

The Livingston Paediatric Dose Calculator

The Livingston Paediatric Dose Calculator is presented and its use explained. It may be of benefit in emergency departments that do not regularly see large numbers of children requiring drug treatment.

The value of loupe magnification: an underused tool in emergency medicine

STUDY OBJECTIVES

Loupe magnification is widely used in medicine. Hand surgeons, in particular, use magnification for virtually all cases. The physical examination is more effective with magnification including improved tissue and foreign body identification. It is valuable for meticulous debridement of foreign material. Skin closure is much improved with more clearly identified wound edges. The detail and precision is vastly better allowing more ideal surgical repairs. These principles could improve wound care quality for emergency physicians as well. This article will compare wound visualization with the naked eye and 2.5 magnification loupes to determine the relative value for an emergency physician.

MATERIALS AND METHODS

Using a cadaver model, this article will compare relative visualization using no magnification and 2.5 loupe magnification. Comparative photographs will be used for identification of wound edges and anatomical structures.

RESULTS

The photographs presented demonstrate relative visualization with the naked eye and the 2.5 loupes. These photographs demonstrate the advantage of magnification in wound care and closure. The only significant costs are the loupes which should not be a deterrent for emergency physicians.

DISCUSSION

Loupe magnification is the standard for quality wound care and closure in hand surgery. They are also used in many other fields of medicine, including facial and plastic surgery. Magnification is now common and has proven effective. Emergency physicians, in general, have not readily embraced the use of magnification. Hand wounds and facial laceration repairs in the emergency department (ED) are 2 areas magnification could be particularly helpful. This study clearly demonstrates the relative advantage of magnification for tissue identification, debridement, and skin closure. Magnification is a potentially valuable tool in laceration repair in the ED. It greatly enhances results at minimal costs.

Validation of the Simplified Motor Score for the Prediction of Brain Injury Outcomes After Trauma

STUDY OBJECTIVE

The Glasgow Coma Scale (GCS) score is widely used in the initial evaluation of patients with traumatic brain injury. This 15-point score, however, has been criticized as unnecessarily complex. Recently, a 3-point Simplified Motor Score (defined as obeys commands=2; localizes pain=1; withdrawals to pain or worse=0) was developed from the motor component of the GCS and was found to have a similar test performance for predicting outcomes after traumatic brain injury when compared with the GCS score as the criterion standard. The purpose of this study was to validate the Simplified Motor Score in a large heterogeneous trauma population.

METHODS

This was a secondary analysis of a prospectively maintained trauma registry with consecutive trauma patients who presented to a Level I trauma center from 1995 through 2004. Test performance of the GCS and the Simplified Motor Score relative to 4 clinically relevant traumatic brain injury outcomes (emergency intubation, clinically significant brain injury, neurosurgical intervention, and mortality) was evaluated with areas under the receiver operating characteristic curves (AUCs).

RESULTS

Of 21,170 patients included in the analysis, 18% underwent emergency intubation, 14% had clinically significant brain injuries, 7% underwent neurosurgical intervention, and 5% died. The AUCs for the GCS and its components ranged from 0.76 to 0.92 across the 4 outcome measures. The AUCs for the Simplified Motor Score ranged from 0.71 to 0.89, and the relative differences from the GCS AUCs ranged from 3% to 7%, with a median difference of 5%.

CONCLUSION

In this external validation study, the 3-point Simplified Motor Score demonstrated similar test performance when compared with the 15-point GCS score and its components for the prediction of 4 clinically important traumatic brain injury outcomes.

The use of a cardiac output monitor to guide the initial fluid resuscitation in a patient with burns

A case of initial resuscitation of a patient with severe burns is described. Such patients can have hypotension and reduced organ perfusion for a number of reasons, and can remain in the emergency department for many hours while awaiting transfer to specialist centres. The case provides a comparison between resuscitation using traditional burns formulae and a relatively new and simple-to-use cardiac output (CO) monitor--the Vigileo monitor (Edwards Lifesciences, Irvine, California, USA). The case demonstrates that relying on fluid regimes alone can lead to insufficient resuscitation. We suggest that using technologies such as those mentioned in this article, which have the potential to be used in the emergency department, could improve the initial resuscitation of patients with burns.

Mice in the emergency department: vector for infection or technological aid?

OBJECTIVE

To study the type of bacterial flora present on computer mice in an emergency department.

METHODS

Computer mice in the emergency department of a single institution, were swabbed on three separate occasions over a 12-month period. Swabs were plated out on McConkey agar and blood agar. Isolated organisms were identified by senior laboratory personnel using Gram stain, colony morphology and susceptibility testing.

RESULTS

No methicillin-resistant Staphylococcus aureus was identified on the equipment. Two samples cultured methicillin-sensitive coagulase positive staphylococci. A range of other organisms were identified.

CONCLUSIONS

In contrast to studies in other hospital departments, no methicillin-resistant Staphylococcus aureus was identified on computer mice in the emergency department. These results suggest that mouse operated software is not adding to infection control problems in relation to methicillin-resistant Staphylococcus aureus in this environment.

Duplex ultrasound in the emergency department for the diagnostic management of clinically suspected deep vein thrombosis

OBJECTIVES

To evaluate the accuracy and safety of an emergency duplex ultrasound (EDUS) evaluation performed by emergency physicians in the emergency department.

METHODS

Consecutive adult patients suspected of having their first episode of deep vein thrombosis (DVT) presenting to the emergency department were included in the study. All examinations were performed by emergency physicians trained with a 30-hour ultrasound course. Based on EDUS findings, patients were classified into one of three groups: normal, abnormal, and uncertain. Patients with abnormal and uncertain findings were initially treated as having a DVT. Patients with normal EDUS findings were discharged from the emergency department without anticoagulant therapy. A formal duplex ultrasound evaluation was repeated by a radiologist in all patients within 24-48 hours. Patients with normal findings on duplex ultrasound evaluation were followed up for symptomatic venous thromboembolism for up to one month.

RESULTS

A total of 399 patients were studied. The EDUS findings were normal in 301 (75%), abnormal in 90 (23%), and uncertain in eight (2%). All abnormal test results were confirmed by the formal duplex ultrasound evaluation, and three patients (0.8%) with uncertain findings on EDUS examination were subsequently diagnosed as having a distal DVT (positive predictive value, 95% [95% confidence interval, 92% to 95%]; negative predictive value, 100% [95% confidence interval = 99% to 100%]). No patients with normal findings on EDUS examination died or experienced venous thromboembolism at the one-month follow-up.

CONCLUSIONS

EDUS examination yielded a high negative predictive value and good positive predictive value, allowing rapid discharge and avoiding improper anticoagulant treatment.

Novel applications of ultrasound in pediatric emergency medicine

A new field, termed emergency ultrasound (EUS), has recently been established. The past decade saw rapid development in the field of EUS in adult patients, especially as performed by emergency medicine physicians. Ultrasound imaging offers several advantages over traditional radiographic techniques, many of which are especially relevant to patients in the pediatric emergency department. Recent literature has documented increased use of EUS for pediatric patients. This review will examine basic principles of ultrasound relevant to pediatric emergency medicine physicians. Emphasis will be placed on understanding the instrument and its limitations. In addition, we will review recent developments in this field. It is our goal that the reader will gain an understanding of the strengths and limitations of this instrument and will therefore be in a position to plan their own program in EUS in pediatrics. Furthermore, it is hoped that this review will serve as an impetus for innovative research, to refine and extend the indications of this modality to benefit patients in the pediatric emergency department.

Review on the importance of an emergency kit for physicians in out-of-hospital emergencies

The importance of an emergency kit for private use by emergency physicians was evaluated. Self-reporting questionnaires were used to assess the satisfaction of emergency physicians who were given a specially adjusted emergency kit for 3 years. Of 73 emergency physicians, 52.1% used the kit at least once during a 3-year interval. Physicians who already used the emergency kit responded more frequently to the importance of having private emergency equipment than those who did not. The kit's low weight and assortment of equipment including ventilation equipment were given higher ratings by users. The majority of physicians regarded a maintenance interval of 6-12 months as sufficient for the emergency equipment. In conclusion, the private emergency kit was used by more than half of the study participants at least once during a 3-year study period. Emergency physicians who used the emergency kit gave it higher ratings than did non-users.

The ability of Lithuanian ambulance services to provide first medical aid in trauma cases

OBJECTIVE

To evaluate the ability of country ambulance services to provide first medical aid in trauma cases.

MATERIAL AND METHODS

A survey of chiefs of emergency medicine service was performed in October-November 2005, in which 34 of the 59 institutions (58%) were participating. The questionnaire presented questions concerning physical and human resources, performance values, and system configuration. The study has shown that emergency medicine service operates in radius of 23 km, each team providing service for about 40,000 inhabitants. Taking into consideration distance and average on-scene time values, emergency medicine service is capable to render the first medical aid within so-called "golden hour" in case the accident is reported immediately. The physical resources are not quite complete. Not all the cars are equipped with essential first aid measures. Among more rarely found resources are vacuum pumps, intubation sets, defibrillators, vacuum splints, back immobilization devices, and hammock immobilization devices. There are less mentioned resources than working teams and even more than two times less than emergency cars at all. Two-thirds of the operating emergency medicine services do not provide advanced life support procedures. The evaluation of theoretical/practical ability to provide some important medical procedures used in emergency medical care showed that medical staff quite often fails to perform defibrillation, intubation, and pleural cavity drainage.

CONCLUSIONS

Country ambulance service network configuration according to area under service, number of people served, and response frequency comply with the requirement set. The ambulance vehicles lack complete set up as well as some important supplies. Only rarely the staff is skilled enough to perform such advanced life support procedures as intubation, defibrillation, and pleural drainage.