The Journal of Emergency Medicine via MedWorm.com

Calendar of Events

The Journal of Emergency Medicine — Mon, 01 Feb 2010 00:00:00 +0100

(Source: The Journal of Emergency Medicine)

Safety of Propofol Sedation for Pediatric Outpatient Procedures: Larsen R, Galloway D, Wadera S, et al. Clin Pediatr 2009;48:819–23

The Journal of Emergency Medicine — Mon, 01 Feb 2010 00:00:00 +0100

Propofol is frequently used for sedation in both inpatient and outpatient pediatric procedures. Most available studies demonstrate its safety when given by Anesthesiology staff. This retrospective study examined the safety of propofol for sedation when administered by pediatric intensivists. In total, 4716 procedures over a 6-year period were included in this study. (Source: The Journal of Emergency Medicine)

Contamination of Portable Radiograph Equipment With Resistant Bacteria in the ICU: Levin PD, Shatz O, Sviri S, et al. Chest 2009;136:426–32

The Journal of Emergency Medicine — Mon, 01 Feb 2010 00:00:00 +0100

Four phases were included in this study to examine infection control procedures, the transfer of resistant bacteria to radiographic equipment, and the effect of improved infection control training on transmission. In the intensive care unit (ICU) at a 750-bed tertiary referral medical center, 14 infection control measures were observed as technicians obtained chest radiographs of ICU patients and then cultures of equipment were obtained by aseptic technique. The 4-month intervention period consisted of daily personal discussions with technicians to reinforce appropriate behaviors. Surveillance of infection control measures were continued for an additional month in the follow-up period. Data from all periods were compared using the Student's t test, and the chi-squared or Fisher's exact tes...

The Association Between Iron Deficiency and Febrile Seizures in Childhood: Hartfield DS, Tan J, Yager JY, et al. Clin Pediatr (Phila) 2009;48:420–6

The Journal of Emergency Medicine — Mon, 01 Feb 2010 00:00:00 +0100

This retrospective case control study analyzed the association between iron deficiency and febrile seizures among children aged 6 to 36 months. The iron status of 361 patients who presented to the emergency department with febrile seizures was compared with 390 otherwise healthy controls who presented with febrile illness without seizure. Iron status was determined by mean corpuscular volume, red blood cell distribution width, and hemoglobin level. The study found that 9% of cases had iron deficiency (ID) and 6% had iron deficiency anemia, compared to 5% and 4% of controls, respectively, with a conditional logistic regression odds ration for ID in febrile seizure patients of 1.84 (95% confidence interval 1.02–3.31). The authors suggest that ID screening should be considered in children p...

Impact of Motorcycle Helmets and State Laws on Society's Burden: A National Study: Croce MA, Zarzaur BL, Magnotti LJ, et al. Ann Surg 2009;250:390–4

The Journal of Emergency Medicine — Mon, 01 Feb 2010 00:00:00 +0100

This study used the National Trauma Data Bank (NTDB) to study multiple aspects of motorcycle collisions (MCC) and helmet use. End points included helmet use in states with mandatory helmet laws, resource utilization of helmeted vs. unhelmeted motorcyclists, and overall mortality of helmeted vs. unhelmeted motorcyclists. Overall in-hospital mortality was the primary study outcome. Data were from the NTDB from 2002–2007, and inclusion criteria were documented MCC, documented helmet use, data to evaluate injury severity score (ISS), resource utilization, and final diagnosis. There were 76,944 patients that qualified for the study. Population means were: age 36 years, admission Glasgow Coma Scale score 13.7, admission ISS 13.5, and 76% helmet use. In the categories of head, face, and cervica...

Predicting Deep Venous Thrombosis in Pregnancy: Out in “Left” Field? Chan WS, Less A, Spencer F, et al. Ann Intern Med 2009;151:85–92

The Journal of Emergency Medicine — Mon, 01 Feb 2010 00:00:00 +0100

Pregnant women are at inherently higher risk for deep venous thrombosis (DVT) but have traditionally been excluded in studies looking at clinical signs and symptoms of DVT. This cross-sectional study enrolled 194 pregnant women suspected of having DVT. Each woman was assessed by a thrombosis expert who assigned a pretest probability (low, moderate, or high) and recorded presence of 11 clinical variables thought to be associated with DVT. Each patient underwent compression ultrasonography (US). If the initial US was negative, the patient had 3 months of clinical follow-up to ensure there was no DVT present; some women with initial negative imaging had repeat US on days 3 and 7, along with 3-month follow-up. Twelve women were diagnosed with DVT on initial imaging. Of the 182 patients with ne...

Natriuretic Peptides and Troponins in Pulmonary Embolism: A Meta-Analysis: Lega JC, Lacasse Y, Lakhal L, et al. Thorax 2009;64:869–75

The Journal of Emergency Medicine — Mon, 01 Feb 2010 00:00:00 +0100

This meta-analysis was designed to evaluate the association of natriuretic peptides with prognosis in acute pulmonary embolus (APE) alone and in conjunction with troponins, as well as their association with right ventricular dysfunction. Search of MEDLINE and EMBASE databases and conference abstracts before February 2008 yielded 222 studies from which 23 studies (enrolling 1127 total patients) were selected for inclusion in the meta-analysis based on ability to construct a 2 × 2 table using natriuretic peptide results and one or more of the outcomes of interest. The final analysis showed significant association of elevated natriuretic peptide levels with all-cause mortality (odds ratio [OR] 6.2; 95% confidence interval [CI] 3.0–12.7), APE-related mortality (OR 5.0; 95% CI 2.2–11.5), a...

Facemasks and Hand Hygiene to Prevent Influenza Transmission in Households: A Cluster Randomized Trial: Cowling BJ, Chan K, Fang VJ, et al. Ann Intern Med 2009;151:437–46

The Journal of Emergency Medicine — Mon, 01 Feb 2010 00:00:00 +0100

Non-pharmaceutical interventions for preventing transmission of the influenza virus have not been well studied. This cluster randomized, controlled trial from Hong Kong investigated the use of hand hygiene and facemasks to prevent household transmission of reverse-transcriptase polymerase chain reaction (RT-PCR)-confirmed influenza. Two hundred fifty-nine households were included in the study; households were randomized to lifestyle education (control, 134 households), hand hygiene among index patients (136 households), or surgical facemasks plus hand hygiene for all household members (137 households). Attack rates among contacts were calculated by RT-PCR or clinical markers after 7 days. Transmission was reduced in 154 households in which interventions were initiated within 36 h of sympto...

Don't Call Me “Mom”: How Parents Want to be Greeted by Their Pediatrician: Amer A, Fischer H. Clin Pediatr (Phila) 2009;48:720–2

The Journal of Emergency Medicine — Mon, 01 Feb 2010 00:00:00 +0100

This study out of Michigan looked at parent and caregiver expectations when being greeted by the child's physician, as well as at how well residents and attendings met those expectations. The study enrolled 100 parents and caregivers at the General Pediatric Clinic at Children's Hospital of Michigan between December 2007 and February 2008. Of the 100 adults who agreed to take part in the study, all were English speaking, 86 were African-American, 81 were the mother of the child. Each individual was asked for his or her expectations concerning shaking hands, being addressed by first name, last name, or both, and physician introducing themselves by first name, last name, or both. Researchers proceeded to ask if the resident and attending (when applicable) met those expectations. Data were an...

Association Between First-Trimester Vaginal Bleeding and Miscarriage: Hasan R, Baird DD, Herring AH, et al. Obstet Gynecol 2009;114:860–7

The Journal of Emergency Medicine — Mon, 01 Feb 2010 00:00:00 +0100

Vaginal bleeding is a common first-trimester complication of many pregnancies. Most studies that address this topic enroll women who present to the emergency department, selecting for more serious cases of bleeding, which may mark the actual miscarriage event. In comparison, this observational cohort study evaluated bleeding episodes that were temporally separate from miscarriage in 4510 pregnant women. Information about the timing, heaviness, color, and duration of vaginal bleeding was gathered via telephone interviews. Additional information about the presence of pain was also collected. In an effort to control for confounders, the authors excluded bleeding within 4 days of miscarriage. The study demonstrated a strong association between “heavy” bleeding (defined as at least 1 day of...

Identification of Children at Very Low Risk of Clinically-Important Brain Injuries After Head Trauma: A Prospective Cohort Study: Kuppermann N, Holmes JF, Dayan PS, et al. Lancet 2009;374:1160–70

The Journal of Emergency Medicine — Mon, 01 Feb 2010 00:00:00 +0100

This prospective cohort study in 25 North American emergency departments (EDs) was designed to derive and validate prediction rules to identify patients < 18 years of age with minor head trauma who are at very low risk for clinically important traumatic brain injury (ciTBI), and in whom computed tomography (CT) may be unwarranted. Investigators identified 42,412 eligible patients with Glasgow Coma Scale scores of 14–15 and conducted standardized assessment in the ED of the enrolled children. At care provider discretion, CT scans were obtained. Study coordinators reviewed records of admitted patients and conducted telephone surveys of released patients to obtain outcome data. By evaluating the injury mechanisms and clinical variables obtained in the initial assessment of the derivation gr...

Biomarkers Improve Mortality Prediction by Prognostic Scales in Community-Acquired Pneumonia: Menendez R, Martinez R, Reyes S, et al. Thorax 2009;64:587–91

The Journal of Emergency Medicine — Mon, 01 Feb 2010 00:00:00 +0100

This prospective cohort study from two hospitals in Spain investigated whether inflammatory markers and cytokine profile measured on admission increase the accuracy of current prognostic scales to predict 30-day mortality from community-acquired pneumonia (CAP). Initial levels of procalcitonin, C-reactive protein (CRP), tumor necrosis factor α, and interleukins IL6, IL8, and IL10 levels were recorded for 453 inpatients. Severity of disease was assessed by the PSI (Pneumonia Severity Index), CURB65 (Confusion, Urea nitrogen, Respiratory rate, Blood pressure, ≥ 65 years of age), and CRB65 (Confusion, Respiratory rate, Blood pressure, ≥ 65 years of age) scales. High levels of CRP and IL6 were found to be independent predictive values for predicting 30-day mortality. Adding CRP to PSI, CU...

Serum Bilirubin Levels on ICU Admission Are Associated With ARDS Development and Mortality in Sepsis: Zhai R, Sheu CC, Su L, et al. Thorax 2009;64:784–90

The Journal of Emergency Medicine — Mon, 01 Feb 2010 00:00:00 +0100

This study out of Massachusetts General Hospital prospectively enrolled a 1006-patient cohort that was admitted to the intensive care unit (ICU) with the diagnosis of sepsis between September 1999 and November 2006. The purpose of the study was to evaluate the relationship between admission total bilirubin and development of sepsis-related acute respiratory distress syndrome (ARDS). Outcomes were ARDS risk and mortality. All patients admitted to the ICU with the diagnosis of sepsis had total bilirubin measured. Those that developed ARDS then had serial total bilirubin (TB) levels measured for a period of 28 days. Additionally, other biomarkers were drawn and DNA analysis performed to identify those individuals with variations of the gene coding for uridine diphosphate glucurosyltransferase...

American Academy of Emergency Medicine

The Journal of Emergency Medicine — Mon, 01 Feb 2010 00:00:00 +0100

(Source: The Journal of Emergency Medicine)

The Journal of Emergency Medicine — Mon, 01 Feb 2010 00:00:00 +0100

(Source: The Journal of Emergency Medicine)

Partial Contents

The Journal of Emergency Medicine — Mon, 01 Feb 2010 00:00:00 +0100

(Source: The Journal of Emergency Medicine)

Issue Highlights

The Journal of Emergency Medicine — Mon, 01 Feb 2010 00:00:00 +0100

(Source: The Journal of Emergency Medicine)

Editorial Board

The Journal of Emergency Medicine — Mon, 01 Feb 2010 00:00:00 +0100

(Source: The Journal of Emergency Medicine)

Calendar of Events

The Journal of Emergency Medicine — Fri, 01 Jan 2010 00:00:00 +0100

(Source: The Journal of Emergency Medicine)

Subarachnoid Hemorrhage as a Cause of Out-of Hospital Cardiac Arrest: A Prospective Computed Tomography Study: Inamasu J, Miyatake S, Tomioka H, et al. Resuscitation 2009;80:977–80

The Journal of Emergency Medicine — Fri, 01 Jan 2010 00:00:00 +0100

In this prospective, single-center study from Japan, 142 survivors of witnessed pre-hospital non-traumatic cardiac arrest from 2004 to 2007 received computed tomography (CT) of the head. Twenty-six (18.3%) of the 142 survivors had CT findings of intracranial hemorrhage, and 88% of these (or 16.2% overall) were found to have subarachnoid hemorrhage (SAH). In those patients with SAH, it was relatively severe, meeting criteria for Fisher grade III (8 patients) or IV (15 patients) classification. Patients with SAH tended to present with pulseless electrical activity (PEA) or asystole (52% and 43%, respectively) as the initial rhythm, whereas patients without SAH presented in either ventricular fibrillation or asystole (43% and 31%, respectively). Patients with SAH were less likely to have posi...

Derivation of a Prognostic Score for Identifying Critically Ill Patients in an Emergency Department Resuscitation Room: Cattermole GN, Mak SKP, Liow CHE, et al. Resuscitation 2009;80:1000–5

The Journal of Emergency Medicine — Fri, 01 Jan 2010 00:00:00 +0100

This prospective observational study conducted in an Emergency Department (ED) in Hong Kong aimed to develop a predictive score to determine which patients were most likely to become critically ill and were at high risk of requiring intensive care unit admission or dying within 7 days of ED presentation. A total of 330 eligible patients over age 18 years triaged to a resuscitation room within a 1-month period were included. Laboratory and physiologic parameters were analyzed using univariate analysis to determine which factors were most associated with a poor outcome. Multivariate analysis was then used to select 6 prognostic factors (systolic blood pressure, Glasgow Coma Scale, serum glucose, serum bicarbonate, white blood cell count, and history of metastatic cancer), each with statistic...

Life after Survival: Long-Term Daily Functioning and Quality of Life after an Out-Of-Hospital Cardiac Arrest: Wachelder EM, Moulaert VRMP, et al. Resuscitation 2009;80:517–22

The Journal of Emergency Medicine — Fri, 01 Jan 2010 00:00:00 +0100

This retrospective cohort study at a Dutch University hospital examined 63 survivors of out-of-hospital cardiac arrest for participation in society and quality of life after their cardiac event. The authors hypothesized that out-of-hospital cardiac arrest survivors functioned at a lower level compared to the rest of the population. More specifically, they looked at physical, cognitive, and emotional impairment, daily functioning, and caregiver strain as secondary outcome measures. Sixty-three survivors and their caregivers, from January 2001 to December 2006, received a questionnaire by mail 3 years after their cardiac event. Two weeks after the first mailing a reminder was sent. The questionnaire to the participants included the New York Heart Association Classification, Fatigue Severity ...

The Presence of a Family Witness Impacts Physician Performance During Simulated Medical Codes: Fernandez R, Compton S, Jones KA, et al. Crit Care Med 2009;37:1956–60

The Journal of Emergency Medicine — Fri, 01 Jan 2010 00:00:00 +0100

This study performed at Wayne State University School of Medicine sought to define the effects of family witnesses in emergency department resuscitation rooms. The study utilized simulated cases to identify the effect of witnesses on overall length of the resuscitation attempt, the time to critical events, such as intubation or defibrillation, and recognition of a drug error. The researchers divided 60 second-year and third-year emergency medicine residents into three simulation groups based on type of family witness: 1) no witness; 2) a quiet witness; 3) an overt reaction witness. All resuscitations were controlled in the simulation laboratory for time of resident entry, time of family witness entry, and time of cardiac rhythm changes regardless of interventions from physicians. The time ...

Yield of Diagnostic Tests in Evaluating Syncopal Episodes in Younger Patients: Mendu LM, McAvay G, Lampert R, et al. Arch Intern Med 2009;169:1299–305

The Journal of Emergency Medicine — Fri, 01 Jan 2010 00:00:00 +0100

In this retrospective review, the authors reviewed the charts of 2106 consecutive patients at a single hospital to determine the diagnostic yield of ancillary testing in the evaluation of syncope. In addition, they determined the cost per test affecting diagnosis and management for commonly performed laboratory and radiographic tests. According to their calculations, the finding of postural hypotension had the greatest diagnostic yield, contributing to the diagnosis 26% of the time. Also high yield were telemetry (11%), electrocardiogram (7%), and the cardiac stress test (10%). Low-yield diagnostic tests included cardiac enzymes (2%), computed tomography (CT) of the head (2%), electroencephalogram (1%), and carotid ultrasound (1%). The authors calculated the cost per test affecting diagnos...

Exposure to Low-Dose Ionizing Radiation for Medical Imaging Procedures: Fazel R, Krumholz HM, Wang Y, et al. N Engl J Med 2009;361:849–57

The Journal of Emergency Medicine — Fri, 01 Jan 2010 00:00:00 +0100

This retrospective cohort study examined claims for 952,420 insured adults between ages 18 and 64 years to determine population-based rates of annual cumulative effective doses of radiation received for radiologic procedures. Of the total number of eligible adults, 655,613 patients underwent a procedure with radiation exposure. Investigators chose to examine the cumulative effective dose of radiation, defined as weighted measures of energy that affect each organ, type of radiation, and potential for future mutagenic degeneration for a given procedure, and these generalized doses were gleaned from the prior radiologic literature. Individual radiation exposure was therefore not measured, only estimated. Based on these data, the overall mean radiation dose was 2.4 ± 6.0 mSv for all included ...

An Unseen Danger: Frequency of Posterior Vessel Wall Penetration by Needles During Attempt to Place Internal Jugular Vein Central Catheters Using Ultrasound Guidance: Blaiva M, Adhikari S. Crit Care Med 2009;37:2345–9

The Journal of Emergency Medicine — Fri, 01 Jan 2010 00:00:00 +0100

This prospective, single-blinded study evaluated for posterior vessel wall penetration during ultrasound-guided internal jugular (IJ) catheter placement. It was conducted at an urban Level I trauma center with emergency medicine residents. The 25 residents that participated in the study had more than 2 years experience in ultrasound, performed more than 100 ultrasound-guided vascular-access procedures before the study, and participated in a 2-day ultrasound-training course. Each resident was asked to place an IJ catheter using ultrasound guidance in the short access view on life-sized torso models. An endocavity transducer was used to observe the placement of the needle. Investigators recorded penetration of more than one wall of the internal jugular, penetration of the adjacent carotid ar...

An Outbreak of Varicella in Elementary School Children with Two-Dose Varicella Vaccine Recipients–Arkansas, 2006: Gould P, Leung J, Scott C, et al. Pediatr Infect Dis J 2009;28:678–81

The Journal of Emergency Medicine — Fri, 01 Jan 2010 00:00:00 +0100

This study investigated the difference between the one- and two-dose vaccine effectiveness after a varicella outbreak at an Arkansas school between September 1 and December 18, 2006. Of the 880 children attending the school, 871 had known vaccination status. Vaccination was defined as receiving the vaccine at least 42 days before rash onset. Ninety-seven percent of these children were vaccinated, of which 58% had one-dose coverage and only 39% had two-dose coverage. Although vaccination status was identified by Arkansas vaccine registry, the number of cases was identified through returned questionnaires (696 returned out of 880). The presence of at least three lesions was necessary in parental diagnosis of disease. Eighty-four children were documented as positive, of which 25 had been vacc...

Adenosine for Wide-Complex Tachycardia: Efficacy and Safety: Marill KA, Sigrid W, deSouza IS, et al. Crit Care Med 2009;37:2512–8

The Journal of Emergency Medicine — Fri, 01 Jan 2010 00:00:00 +0100

In this study, 197 patients received adenosine for wide complex tachycardia, defined as tachycardia with a QRS duration > 120 ms lasting more than 2 min. Nine urban hospitals participated in this multi-center, retrospective, observational study over 15 years, from 1991–2006. Supraventricular tachycardia (SVT) correlated strongly with a response to adenosine (104 [90%] out of 116 patients). Conversely, adenosine had no effect in patients presenting with ventricular tachycardia (VT), with only 2 (2%) of 81 patients demonstrating a response. Response to adenosine increased the likelihood of SVT by a factor of 36, whereas resistance to adenosine increased the likelihood of VT by a factor of 9. Of the group of patients with VT, none had an adverse event, defined as need for emergent electrica...

The Dissociation Between Door-to-Balloon Time Improvement and Improvements in Other Acute Myocardial Infarction Care Processes and Patient Outcomes: Wang TY, Fonarow GC, Hernandez AF, et al. Arch Intern Med 2009;169:1411–9

The Journal of Emergency Medicine — Fri, 01 Jan 2010 00:00:00 +0100

This retrospective observational study examined data from 101 hospitals from 2005 to 2007 to determine whether an improvement in door-to-balloon time was significantly correlated with other measures of improvement in care of patients with acute myocardial infarction. These other measures included the Joint Commission on Accreditation of Healthcare Oragnizations and Centers for Medicare and Medicaid Services core measures such as patients receiving aspirin and beta blockers, as well as in-hospital mortality. In 101 hospitals, a total of 5881 patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention were examined. Of these patients, 3278 were in the early period and 2603 were in the late period. The overall geometric mean door-to-balloo...

Coronary Artery Calcification Screening: Estimated Radiation Dose and Cancer Risk: Kim KP, Einstein AJ, Berrington de Gonzalez A, et al. Arch Intern Med 2009;169:1188–94

The Journal of Emergency Medicine — Fri, 01 Jan 2010 00:00:00 +0100

This collaborative, multi-center study examined the risks of radiation from multidetector computed tomography (CT) used for the screening of coronary artery calcification. There are no current detailed estimates of safe radiation doses for this type of CT scan. Given this fact, the authors used risk models compiled by the National Research Council's Biological Effects of Ionizing Radiation VII committee, as well as databases drawn from the Life Span Study of Japanese atomic bomb survivors and from patients irradiated in the course of medical treatment. This information was used to estimate the risk of cancer against typical incidence according to age or gender. Their goal was to estimate the potential, organ-specific cancer risks from the radiation used in these CT scans. Because the CT sc...

American Academy of Emergency Medicine

The Journal of Emergency Medicine — Fri, 01 Jan 2010 00:00:00 +0100

(Source: The Journal of Emergency Medicine)

The Journal of Emergency Medicine — Fri, 01 Jan 2010 00:00:00 +0100

(Source: The Journal of Emergency Medicine)

Partial Contents

The Journal of Emergency Medicine — Fri, 01 Jan 2010 00:00:00 +0100

(Source: The Journal of Emergency Medicine)

Issue Highlights

The Journal of Emergency Medicine — Fri, 01 Jan 2010 00:00:00 +0100

(Source: The Journal of Emergency Medicine)

Editorial Board

The Journal of Emergency Medicine — Fri, 01 Jan 2010 00:00:00 +0100

(Source: The Journal of Emergency Medicine)

A Nineteen-Year-Old Girl with Palpitations

The Journal of Emergency Medicine — Mon, 28 Dec 2009 00:00:00 +0100

Dr. Diana Felton: Today's case is that of a 19-year-old girl who presented to the Emergency Department (ED) with palpitations for 2 h. She first noticed her “heart racing” 2 h prior, while watching television. She had no chest pain, shortness of breath, or lightheadedness. Before the onset of palpitations, she had been feeling well, without fever, malaise, or recent illness. She had never had palpitations before this episode. There was no drug use. She was a college student currently on semester break. She had no significant medical history and took no prescribed or over-the-counter medications. (Source: The Journal of Emergency Medicine)

Cerebral Venous Sinus Thrombosis in the Emergency Department: Retrospective Analysis of 17 Cases and Review of the Literature

The Journal of Emergency Medicine — Wed, 23 Dec 2009 00:00:00 +0100

Conclusions: CVST is rare, but it can have significant associated morbidity and mortality. Whereas the clinical outcome and functional outcomes of treated patients can vary, prompt recognition of the disease is important. (Source: The Journal of Emergency Medicine)

Response

The Journal of Emergency Medicine — Wed, 18 Nov 2009 00:00:00 +0100

We would like to thank Dr. Almarri for his interest in and valuable contributions to our case report. We are setting out our views below to clarify the points raised by Dr. Almarri. (Source: The Journal of Emergency Medicine)

A Case of Intratracheal Schwannoma Presenting to the Emergency Department With a Diagnosis of Asthmatic Attack: A Clue to Suspect the Cause of Upper Airway Obstruction to Be Other Than Asthma

The Journal of Emergency Medicine — Wed, 18 Nov 2009 00:00:00 +0100

We have read with interest the article by Erol et al. reporting a case of tracheal schwannoma presenting as acute asthmatic attack (). Schwannoma is a rare cause of upper airway obstruction, often misdiagnosed as asthma, that does not respond to therapy and often presents late in its course, with iatrogenic manifestation of excessive steroid use, such as Cushing's syndrome. Schwannoma rarely presents as acute asthma. Recognition of the cause of the upper airway obstruction is essential to preclude affected patients being prescribed lengthy courses of systemic corticosteroids (). Therefore, relevant points regarding this case are presented to provide clues for when to search for alternate causes of obstruction other than asthma (i.e., asthma imitators). (Source: The Journal of Emergency Med...

Keyword Index

The Journal of Emergency Medicine — Sun, 01 Nov 2009 00:00:00 +0100

(Source: The Journal of Emergency Medicine)

Author Index

The Journal of Emergency Medicine — Sun, 01 Nov 2009 00:00:00 +0100

(Source: The Journal of Emergency Medicine)

Contents Index

The Journal of Emergency Medicine — Sun, 01 Nov 2009 00:00:00 +0100

(Source: The Journal of Emergency Medicine)

Calendar of Events

The Journal of Emergency Medicine — Sun, 01 Nov 2009 00:00:00 +0100

(Source: The Journal of Emergency Medicine)

Acute Stroke Symptoms: Comparing Women and Men: Lisabeth LD, Brown DL, Hughes R, Majersik JJ, Morgenstern LB. Stroke 2009;40:2031–6

The Journal of Emergency Medicine — Sun, 01 Nov 2009 00:00:00 +0100

This retrospective study from the University of Michigan Hospital examined the prevalence of traditional vs. non-traditional stroke and transient ischemic attack (TIA) symptoms as they are reported by women vs. men. Over a 3-year period, emergency department and admission logs were tracked and interviews were conducted with each patient or his or her proxy if a patient was unable to participate. Preceding symptom information was collected and classified as traditional or non-traditional based on the American Stroke Association's published stroke warning signs. Traditional symptoms included hemi-body numbness, diplopia, other visual disturbances, aphasia, dysarthria, discoordination/ataxia, hemiparesis, facial weakness, and vertigo. Non-traditional symptoms included pain, mental status chan...

Effect of a Housing and Case Management Program on Emergency Department Visits and Hospitalizations among Chronically Ill Homeless Adults: A Randomized Trial: Sadowski LS, Kee RA, VanderWeele TJ, et al. JAMA 2009;301:1771–8

The Journal of Emergency Medicine — Sun, 01 Nov 2009 00:00:00 +0100

This randomized controlled trial examined the effect of a housing and case management intervention on resource usage among homeless adults with chronic medical illnesses. The primary outcomes were hospitalizations, hospital days, and emergency department visits in an 18-month intervention period. Patients were enrolled on hospital discharge, and randomized to receive either housing and regular case management or usual care, consisting most often of transport to a shelter and general case management services. A sample size of 200 per group was dictated by funding limits. Analysis was based on intention to treat. The primary outcomes were reported as the number of events. The outcomes were reported both with and without adjustment for baseline characteristics. From 455 eligible patients, 407...

Population-Based Study of Risk and Predictors of Stroke in the First Few Hours After a TIA: Chandratheva A, Mehta Z, Geraghty OC, et al. Neurology 2009;72:1941–7

The Journal of Emergency Medicine — Sun, 01 Nov 2009 00:00:00 +0100

The Stroke Prevention Research Unit at Oxford University evaluated 1247 patients who presented with a transient ischemic attach (TIA) or stroke for the first time. These patients were then followed to determine the risk of recurrent stroke within 24 h. The time analyses were performed from two separate points: time of onset of TIA and time from which the patient first called for medical attention. Additionally, the investigators correlated the data with ABCD scores, a validated clinical risk prediction tool for assessment of TIAs. Thirty-five of the 1247 patients had recurrent strokes within 24 h. However, 488 patients had a TIA as an initial event, and 25 of the 35 recurrent stroke patients were in the TIA group. The 6-, 12-, and 24-h stroke risks for the 488 patients presenting with an i...

Utility of D-Dimer Measurement for Screening of Acute Cardiovascular Disease in the Emergency Setting: Tokia Y, Kusama Y, Kodani E, et al. J Cardiol 2009;53:334–40

The Journal of Emergency Medicine — Sun, 01 Nov 2009 00:00:00 +0100

This prospective observational trial from Tokyo studied several questions surrounding the usefulness of rapid D-dimer testing to diagnose acute cardiovascular disease in patients presenting to the emergency department (ED). They classified acute cardiovascular disease (ACVD) as either acute coronary syndromes (ACS) including acute myocardial infarction and unstable angina, or large vessel disease including acute aortic dissection, impending aortic aneurysm rupture, pulmonary thromboembolism, thrombophlebitis, deep venous thrombosis, or arterial occlusion. They first examined D-dimer levels in patients with confirmed acute cardiovascular disease using receiver operating characteristic curve analysis to determine well-balanced cut-off levels for discrimination between ACVD vs. those without,...

Population-Based Study of Risk and Predictors of Stroke in the First Few Hours after a TIA: Chandratheva A, Mehta Z, Geraghty OC, et al. Neurology 2009;72:1941–7

The Journal of Emergency Medicine — Sun, 01 Nov 2009 00:00:00 +0100

Although it is known that the risk of stroke in the week after a transient ischemic attack (TIA) is approximately 10%, this prospective study tracked the incidence of stroke in the first 24 h after TIA. In addition, the authors sought to determine the efficacy of the ABCD2 risk score in predicting stroke recurrence. Over nearly a 5-year period, the Oxford Vascular Study comprising 91,105 individuals was used to track patients presenting with TIA or stroke to Oxford area hospitals, urgent open-access TIA clinics, and accident and emergency departments. Local hospital and private general practitioner office record searches were conducted to screen for patients using billing codes, cranial and carotid imaging study records, and registered death certificates. Two types of initial TIA were defi...

Aspirin vs Anticoagulation in Carotid Artery Dissection: Georgiadis D, Arnold M, von Buedingen HC, et al. Neurology 2009;72:1810–5

The Journal of Emergency Medicine — Sun, 01 Nov 2009 00:00:00 +0100

This prospective, non-randomized cohort study enrolled 298 consecutive patients from 1987 to 2005 with spontaneous internal carotid artery dissection, and compared those treated with systemic anticoagulants to those treated with aspirin alone. The authors assessed the incidences of ischemic events, symptomatic intracranial bleeding, and major extracranial bleeding at 3 months after the dissection. On enrollment, dissection was confirmed by magnetic resonance imaging or digital subtraction angiography. Outcomes were assessed by neurological examination at 3 months in 97% of patients, and by structured telephone interview in 3%. Treatments were chosen by the general practitioner or neurologist caring for the patient, resulting in 202 treated with heparin and warfarin, and 96 treated with asp...

Improved Patient Survival Using a Modified Resuscitation Protocol for Out of Hospital Cardiac Arrest: Graza AG, Gratton MC, Salomone JA, et al. Circulation 2009;119:2597–604

The Journal of Emergency Medicine — Sun, 01 Nov 2009 00:00:00 +0100

The Emergency Medical System in Kansas City, MO implemented a revised cardiac arrest protocol in 2006 after their cardiac arrest survival rates showed no improvement over the past decade in spite of automatic external defibrillators. The revised protocol aimed to improve coronary perfusion pressure through more effective chest compressions. The logic is based on the three-phase time-dependent model for cardiac arrest resuscitation where quality chest compressions can increase the myocardium adenosine triphosphate, reversing the acidic environment created by ischemia that is not favorable to cardioversion. The study used the revised protocol to examine survival rates for out-of hospital, witnessed, cardiac arrest patients with a presumed cardiac origin who were in ventricular fibrillation. ...

Evaluation of the Accuracy of Different Methods Used to Estimate Weights in the Pediatric Population: So TY, Farrington E, Abasher RF. Pediatrics 2009;123:e1045–51

The Journal of Emergency Medicine — Sun, 01 Nov 2009 00:00:00 +0100

In conclusion, the authors stated that the Broselow tape is the most accurate weight-estimation method among most patients aged ≤ 10 years old, but acknowledge that better methods are needed for overweight children, especially in light of increasing rates of childhood obesity. They also concluded that new models, such as the two developed during this study, could be more accurate, but require additional validation. (Source: The Journal of Emergency Medicine)

Corticosteroids in the Treatment of Severe Sepsis and Septic Shock in Adults: A Systematic Review: Annane D, Bellissant E, Bollaert PE, et al. JAMA 2009;301:2362–75

The Journal of Emergency Medicine — Sun, 01 Nov 2009 00:00:00 +0100

The authors of this systematic review evaluated the effects of corticosteroids on 28-day all-cause mortality in patients with severe sepsis and septic shock, and as a secondary objective they investigated the effects of a lower total daily dose of 300 mg or less of hydrocortisone (or equivalent) and a treatment duration of at least 5 days on patients' outcomes. Additional secondary outcomes included intensive care unit length of stay, shock reversal, and serious adverse events (e.g., gastrointestinal bleeding, superinfection, hyperglycemia, hypernatremia, and neuromuscular weakness). Studies were identified from research databases, referenced articles of qualifying studies, unpublished data from trial authors, and proceedings of major meetings. The authors included 17 randomized studies (n...

Do Presenting Symptoms Explain Sex Differences in Emergency Department Delays Among Patients with Acute Stroke? Gargano JW, Wehner S, Reeves MJ. Stroke 2009;40:1114–20

The Journal of Emergency Medicine — Sun, 01 Nov 2009 00:00:00 +0100

This cohort study reviewed 1922 acute stroke cases at 15 different Michigan hospitals, comparing time to physician examination (“door-to-doctor”) and time to computed tomography scan (“door-to-image”) for men and women. Data were abstracted from a statewide stroke registry, and individual symptoms were aggregated into five stroke warning signs: numbness/weakness, confusion/speech, vision, walking/dizziness/balance, and headache. The authors' intent was to test whether different presentations could account for sex differences in time intervals. Suspected strokes were identified by screening for any mention of stroke or transient ischemic attack in the chief complaint field. Cases were limited to emergency department (ED) presentations. Patients were further subgrouped by time from s...

Prediction of Mortality and Major Cardiac Events by Exercise Echocardiography in Patients with Normal Exercise Electrocardiographic Testing: Bouzas-Mosquera A, Peterio J, Alvarez-Garcia N, et al. J Am Coll Cardiol 2009;53:1981–90

The Journal of Emergency Medicine — Sun, 01 Nov 2009 00:00:00 +0100

Given that exercise-induced wall motion abnormalities appear earlier in myocardial ischemia than ST-segment changes, this study evaluated the use of exercise echocardiography (EE) to predict outcomes in patients with known or suspected coronary artery disease (CAD) and normal exercise electrocardiogram (ECG) testing. The study examined 4004 patients with known or suspected CAD and ECG changes at rest who had no evidence of myocardial ischemia during exercise ECG testing. The investigators divided these 4004 patients into two groups: history of CAD and no history of CAD. Among the subgroup of patients with no history of CAD, the pre-test probability of CAD was determined by the Duke score. The EE analysis assigned a wall motion score index (WMSI) to each patient at rest and at peak exercise...

Health Care and Public Service Use and Costs Before and After Provision of Housing for Chronically Homeless Persons with Severe Alcohol Problems: Larimer ME, Malone DK, Garner MD, et al. JAMA 2009;301:1349–57

The Journal of Emergency Medicine — Sun, 01 Nov 2009 00:00:00 +0100

This observational study based in Washington evaluated the impact on public services usage and public cost data over a 1-year period after providing housing to homeless individuals with alcohol abuse problems. It also compared self-reported severity and frequency of alcohol usage for these individuals during this time. There were 126 subjects identified from a rank-ordered list of chronically homeless people that had incurred the highest total costs in 2004 for the area. All identified individuals were offered housing on a first-come-first-served basis in a “Housing First” (HF) program, which provides housing without any regulations requiring subjects to abstain from substance abuse or participate in substance abuse education. Cost data were collected from local Emergency Medical Servi...

American Academy of Emergency Medicine

The Journal of Emergency Medicine — Sun, 01 Nov 2009 00:00:00 +0100

(Source: The Journal of Emergency Medicine)

The Journal of Emergency Medicine — Sun, 01 Nov 2009 00:00:00 +0100

(Source: The Journal of Emergency Medicine)

Partial Contents

The Journal of Emergency Medicine — Sun, 01 Nov 2009 00:00:00 +0100

(Source: The Journal of Emergency Medicine)

Issue Highlights

The Journal of Emergency Medicine — Sun, 01 Nov 2009 00:00:00 +0100

(Source: The Journal of Emergency Medicine)

List of Reviewers for Volumes 36 and 37, 2009

The Journal of Emergency Medicine — Thu, 22 Oct 2009 00:00:00 +0100

Neal Abarbanell, md Fort Pierce, Florida (Source: The Journal of Emergency Medicine)

Reply to Wanda Mohr

The Journal of Emergency Medicine — Mon, 19 Oct 2009 00:00:00 +0100

It was our intention to cite the findings of the Expert Consensus Panel for Behavioral Emergencies as support for our recommendation for “show of force.” This recommendation summarizes the recommendations of emergency psychiatrists throughout the country and is clearly outlined in the report by Allen et al. (). In fact, “show of force” occupies a central position in their algorithm regarding treatment of behavioral emergencies (). In our final editing process, we unintentionally attributed this recommendation to an earlier study authored by Allen et al. regarding the use of medication in treating patients with agitated behavior (). We thank the writer for bringing this to our attention. (Source: The Journal of Emergency Medicine)

Foreign Body Aspiration After High-Velocity Trauma

The Journal of Emergency Medicine — Mon, 19 Oct 2009 00:00:00 +0100

Dr. Susan Wilcox: Today's case is that of a 19-year-old woman who was an unrestrained driver ejected after a high speed motor vehicle crash (MVC). She was traveling approximately 40 mph when her car ran off the road. The Emergency Medical Services crew found her lying on the ground about 15 feet from the car, alert but combative, with obvious facial bruising. Due to a concern for head and facial trauma, the crew performed a rapid sequence intubation at the scene with a 6.0-mm endotracheal tube (ETT). She was hemodynamically stable and easily ventilated during transport to our Level I trauma center Emergency Department (ED). (Source: The Journal of Emergency Medicine)

Clinical Decision Rules for Termination of Resuscitation in Out-of-Hospital Cardiac Arrest

The Journal of Emergency Medicine — Mon, 05 Oct 2009 00:00:00 +0100

Conclusions: The BLS-TOR rule is a simple rule that identifies patients who will not survive OHCA. Further research is required to identify similarly robust CDRs for patients receiving advanced life support care in the setting of OHCA. (Source: The Journal of Emergency Medicine)

No Opiates for Headache—Reply

The Journal of Emergency Medicine — Mon, 05 Oct 2009 00:00:00 +0100

As an emergency physician and hospital administrator, I read with interest Dr. Rosen's well-articulated views regarding the management of opiate-seeking emergency department patients. Dr. Rosen's assertion that each patient should be afforded the best care the physician can deliver devoid of both rote and judgmental thinking is an imperative aspect of professional practice that not only protects the physician's personal well-being, but also protects the patient's best interests. However, the one portion of Dr. Rosen's commentary with which I disagree and that I do not find congruous with the remainder of his argument appears in the second-to-last paragraph, wherein he recommends that physicians use “THEY” to absolve themselves from taking responsibility for the decision to withhold nar...

Calendar of Events

The Journal of Emergency Medicine — Tue, 22 Sep 2009 16:30:40 +0100

(Source: The Journal of Emergency Medicine)

Information Sheets for Patients with Acute Chest Pain: Randomised Controlled Trial: Arnold J, Goodacre S, Bath P, Price J. BMJ 2009;338:b541

The Journal of Emergency Medicine — Tue, 22 Sep 2009 16:30:40 +0100

In this single-center trial from England, 700 consecutive patients with undifferentiated chest pain after diagnostic work-up were randomized to receive verbal advice vs. verbal advice plus a standardized information sheet. The authors noted that patients who received verbal advice plus an information sheet had lower mean anxiety scores as measured by the hospital anxiety and depression scale (7.61 vs. 8.63, difference 1.02; 95% confidence interval 0.20–1.84). The authors also noted a trend toward decreased depression by this same standardized scale. However, addition of a standardized information sheet to standard verbal advice had no effect on patient satisfaction, lifestyle change, or subsequent patient health care utilization. (Source: The Journal of Emergency Medicine)

Impact of Admission Glucose Level and Presence of Diabetes Mellitus on Mortality in Patients with Non-ST-Segment Elevation Acute Coronary Syndrome Treated Conservatively: Dziewierz A, Giszterowicz D, Siudak Z, et al. Am J Cardiol 2009;103:954–8

The Journal of Emergency Medicine — Tue, 22 Sep 2009 16:30:40 +0100

This study out of Poland utilized the Krakow registry of acute coronary syndromes, a prospective, multi-center, observational registry designed to examine epidemiology, in-hospital management, and outcomes of patients with acute coronary syndrome (ACS) in Krakow, Poland, to assess the impact of admission glucose level on the mortality of patients with non-ST-segment elevation ACS. The study includes 763 patients with admission glucose data and non-ST-segment elevation ACS. These patients were stratified into five groups based on blood glucose concentration: 24.2% had admission glucose levels of < 5 mmol/L (90 mg/dL), 50.6% had levels of 5–6.9 mmol/L (90–125 mg/dL), 10.9% had levels of 7–8.9 mmol/L (126–160 mg/dL), 6.7% had levels of 9–10.9 mmol/L (162–196 mg/dL), and 7.6% had l...

A Week-by-Week Analysis of the Low-Risk Criteria for Serious Bacterial Infection in Febrile Neonates: Schwartz S, Raveh D, Toker O, et al. Arch Dis Child 2009;94:287–92

The Journal of Emergency Medicine — Tue, 22 Sep 2009 16:30:40 +0100

In this study, SBI was diagnosed in 87/449 (19%) of febrile neonates, 14 of which qualified as low risk of SBI (low risk criteria [LRC]+); 6.2% of LRC+ neonates were later identified to have SBI. The negative predictive value of the low risk criteria to exclude SBI was 93% (95% confidence interval 90.1–96.4%). Thus, the low risk criteria for SBI may not safely be relied upon to exclude SBI in febrile neonates, and these children should continue to be admitted, cultured, and be given antibiotics. (Source: The Journal of Emergency Medicine)

How (Un)useful is the Pelvic Ring Stability Examination in Diagnosing Mechanically Unstable Pelvic Fractures in Blunt Trauma Patients? Shlamovitz GZ, Mower WR, Bergman J, et al. J Trauma 2009;66:815–20

The Journal of Emergency Medicine — Tue, 22 Sep 2009 16:30:39 +0100

This retrospective chart review study sought to describe test characteristics of pelvic physical examination in detecting pelvic fractures in blunt trauma patients. All blunt trauma patients meeting criteria for trauma team activation between January 2003 and February 2005 were enrolled. Any patient without pelvic imaging was excluded. Charts were reviewed for documentation of pelvic stability, tenderness, or deformity. These results were compared with pelvic X-ray or computed tomography findings. Of 1502 patients, 115 had documented pelvic fractures. Of these, 34 had unstable fractures defined as Tile class B or C. The pelvic ring stability examination had 8% sensitivity (95% confidence interval [CI] 4–14%) and 99% specificity (95% CI 99–100%) for identifying any pelvic fracture. For ...

Effect of Trauma Center Designation on Outcome in Patients with Severe Traumatic Brain Injury: DuBose JJ, Browder T, Inaba K, et al. Arch Surg 2008;143:1213–7

The Journal of Emergency Medicine — Tue, 22 Sep 2009 16:30:39 +0100

This study from Los Angeles County Hospital is a retrospective assessment of the National Trauma Data Bank. It evaluated the effect of American College of Surgeons (ACS) trauma center designation on outcomes in patients with isolated severe brain injury. Patients with a head acute injury score (AIS) ≥ 3 and no other body region AIS ≥ 3 were included in the analysis. A total of 16,035 patients who met the study criteria were admitted to 126 ACS Level I or II trauma centers over a 5-year period. Overall mortality was 9.6% in Level I and 13.9% in Level II facilities (p < 0.001). Overall complication rates were lower in Level I centers (10.6%) than in Level II centers (15.5%) (p < 0.001), and patients in Level I centers also had less progression of their neurologic insult, 1.1% vs. 2.0% (p...

Increasing Prevalence and Associated Risk Factors for Methicillin Resistant Staphylococcus Aureus Bacteriuria: Routh JC, Alt AL, Ashley RA, Kramer SA, Boyce TG. J Urol 2009;181:1694–8

The Journal of Emergency Medicine — Tue, 22 Sep 2009 16:30:39 +0100

This retrospective review from the Mayo Clinic looked at urine culture data from 1997 and 2007 to ascertain prevalence of methicillin-resistant Staphylococcus aureus (MRSA) as a cause of bacteriuria and determine if there are specific risk factors that may predispose patients to MRSA bacteriuria. Hospital charts were reviewed and 7100 and 9985 positive urine cultures were identified from 1997 and 2007, respectively. Patients with urine cultures positive for MRSA in 2007 were compared with two other random cohorts of patients, one with cultures positive for methicillin-sensitive Staphylococcus aureus (MSSA) and another with cultures positive for Escherichia coli to determine differences in patient characteristics and risk factors among groups. It was found that MRSA prevalence, although sti...

Unfractionated Heparin for Treatment of Sepsis: A Randomized Clinical Trial (The HETRASE Study) Jaimes F, De La Rosa G, Morales C, et al. Crit Care Med 2009;37:1185–96

The Journal of Emergency Medicine — Tue, 22 Sep 2009 16:30:39 +0100

This prospective, randomized, double-blind, placebo-controlled single-center study sought to identify differences in mortality, length of stay, and change in multiple organ dysfunction (MOD) score in septic patients treated with low-dose continuous heparin in addition to conventional treatment. The rationale behind this therapeutic trial is that in sepsis, anticoagulant factors such as activated Protein C and antithrombin are depleted; heparin activates antithrombin, resulting in less thrombin and fibrin formation. In 319 patients admitted for sepsis in Columbia, there were no statistically significant differences in length of stay, MOD score change, or 28-day mortality. Although heparin seems to be a safe intervention in septic patients requiring it for other reasons, it offers no additio...

Effect of Topical Alkane Vapocoolant Spray on Pain with Intravenous Cannulation in Patients in Emergency Departments: Randomised Double Blind Placebo Controlled Trial: Hijazi R, Taylor D, Richardson J. BMJ 2009;338:b215

The Journal of Emergency Medicine — Tue, 22 Sep 2009 16:30:39 +0100

This study from Australia randomized 201 emergency department (ED) patients to either water spray or alkane vapocoolant spray to the skin before intravenous (i.v.) cannulation. The main outcome measures were discomfort from the spray and pain from the cannula insertion, both measured on visual analog scales. Exclusion criteria included non-English speaking, moderate to severe pain, skin disease, known allergy, neuropathy, other anesthetics, parenteral analgesia within 4 h, severe illness, and need for urgent i.v. access. Patients received a 2-s spray from a distance of 12 cm after site prep with alcohol wipe. Efforts were made to maintain blinding of patients and data-collecting staff. The principle investigator who applied the sprays could not be blinded due to differences in odor and oth...

The Utility of Early End-Tidal Capnography in Monitoring Ventilation Status After Severe Injury: Warner KJ, Cuschieri J, Garland D, et al. J Trauma 2009;66:26–31

The Journal of Emergency Medicine — Tue, 22 Sep 2009 16:30:39 +0100

In conclusion, the authors noted that capnography is not an appropriate surrogate for blood gas analysis in the trauma setting. (Source: The Journal of Emergency Medicine)

Proximal Humeral Fracture as a Risk Factor for Subsequent Hip Fractures: Clinton J, Franta A, Polissar NL, et al. J Bone Joint Surg Am 2009;91:503–11

The Journal of Emergency Medicine — Tue, 22 Sep 2009 16:30:35 +0100

This study from the University of Washington evaluated the risk of a subsequent hip fracture after a humeral fracture. The authors reviewed data from the Study of Osteoporotic Fractures over a 10-year period. A total of 8049 white women who were age 65 years or older and had no history of hip or humeral fracture were included in the cohort. All were able to walk, were community dwelling, and had not had a bilateral hip replacement. Among this group, 321 women sustained a proximal humeral fracture. Forty-four (13.7%) of them had a subsequent hip fracture. Only 9.6% of women who did not sustain a proximal humeral fracture sustained a hip fracture. After the authors adjusted for bone mineral density and age, those with humeral fractures remained more likely to sustain a subsequent hip fractur...

Treatment of Stable Atrial Fibrillation in the Emergency Department: A Population-Based Comparison of Electrical Direct-Current Versus Pharmacological Cardioversion or Conservative Management: Dankner R, Shahar A, Novikov I, et al. Cardiology 2009;112:270–8

The Journal of Emergency Medicine — Tue, 22 Sep 2009 16:30:35 +0100

This single-center, retrospective comparison analysis of treatment modalities for atrial fibrillation (AF) looked at the success rates and short-term complications of three approaches for the treatment of hemodynamically stable AF in Israel. All AF-related admissions during a 1-year period were reviewed, and 374 patients meeting eligibility criteria were included in the study. The treatment modalities of direct-current cardioversion (DCC), pharmacological, or “wait-and-watch” were compared, and interventions were deemed successful if they resulted in the return to sinus rhythm. Of the 374 patients studied, 85 (22.7%) underwent DCC, of which 78.2% were successfully converted and 52.9% discharged home from the emergency department (ED). Fifty-six (15%) underwent pharmacologic cardioversi...

Predictors for Good Cerebral Performance Among Adult Survivors of Out-of-Hospital Cardiac Arrest: Abe T, Yasuharu T, Ishimatsu S. Resuscitation 2009;80:431–6

The Journal of Emergency Medicine — Tue, 22 Sep 2009 16:30:35 +0100

This study highlights important predictors of neurologic outcomes after cardiac arrest so that in the future, resuscitative efforts can best be targeted toward patients who are most likely to benefit. (Source: The Journal of Emergency Medicine)

Effect of Prehospital Triage on Revascularization Times, Left Ventricular Function, and Survival in Patients with ST-Elevation Myocardial Infarction: Sivagangabalan G, Ong A, Narayan A, et al. Am J Cardiol 2009;103:907–12

The Journal of Emergency Medicine — Tue, 22 Sep 2009 16:30:35 +0100

This prospective study from Australia details outcomes in patients with ST-elevation myocardial infarction (STEMI) depending on triage mode. The modes include direct presentation to a hospital with catheterization facilities, direct presentation to community emergency departments (ED), and ambulance-based triage using transmission of 12-lead electrocardiograms (ECG) to the interventional facility. In the ambulance-based triage group, emergency physicians interpreted the transmitted ECG and when STEMI was identified, the ambulance was routed directly to the hospital with interventional capacity. Only angiographically confirmed STEMI patients were included in the analysis. Between April 2004 and June 2007, 524 patients had confirmed STEMI, and patients were followed-up by telephone at 30 day...

Prehospital Delay in Patients with Acute Coronary Syndromes (from the Global Registry of Acute Coronary Events [GRACE]) Goldberg RJ, Spencer FA, Fox KA, et al. Am J Cardiol 2009;103:598–603

The Journal of Emergency Medicine — Tue, 22 Sep 2009 16:30:35 +0100

It is widely accepted that coronary reperfusion treatment strategies are time dependent. Considerable success has been achieved in decreasing door-to-treatment time; however, less success has been noted in decreasing prehospital delay in patients experiencing acute myocardial infarction (AMI). This retrospective multinational study recruited data from 44,695 patients with acute coronary syndrome (ACS) in 14 countries from 2000 to 2006. ACS was defined as the spectrum of ST-segment elevation AMI, non-ST-segment elevation AMI, and unstable angina. The authors noted significant geographic variation in prehospital delay. Specifically, Australia/New Zealand had a median delay of 2.2 h in those patients with ST-elevation AMI, whereas a similar cohort from Brazil and Argentina delay the longest a...

Effect of Timing and Duration of a Single Chest Compression Pause on Short-Term Survival Following Prolonged Ventricular Fibrillation: Walcott GP, Melnick SB, Walker RG, et al. Resuscitation 2009;80:458–62

The Journal of Emergency Medicine — Tue, 22 Sep 2009 16:30:35 +0100

This study from the University of Alabama evaluated the effect of pauses in chest compressions around the time of defibrillation on resuscitation outcome. Utilizing 48 swine, the authors studied four groups with various pauses and analyzed survival at 4 h post induction of ventricular fibrillation. The first group (G2000) of animals had a 40-s compression pause beginning 20 s before and ending 20 s after defibrillation. The second group (A1) had a 20-s pause just before defibrillation. The third (A2) and fourth (A3) groups had 20- and 10-s pauses, respectively, ending 30 s before defibrillation. The final group (B) did not have a pause in chest compressions. None of the animals in the first group survived. Five animals survived in groups A1, A3, and B, whereas seven animals survived in gro...

The Journal of Emergency Medicine — Tue, 22 Sep 2009 16:30:32 +0100

(Source: The Journal of Emergency Medicine)

Partial Contents

The Journal of Emergency Medicine — Tue, 22 Sep 2009 16:30:32 +0100

(Source: The Journal of Emergency Medicine)

Issue Highlights

The Journal of Emergency Medicine — Tue, 22 Sep 2009 16:30:32 +0100

(Source: The Journal of Emergency Medicine)

Editorial Board

The Journal of Emergency Medicine — Tue, 22 Sep 2009 16:30:32 +0100

(Source: The Journal of Emergency Medicine)

Intravenous Tissue Plasminogen Activator for Stroke: A Review of the ECASS III Results in Relation to Prior Clinical Trials

The Journal of Emergency Medicine — Fri, 18 Sep 2009 00:00:00 +0100

Conclusions: Based on the combined data from all trials, the benefits of thrombolysis with IV tPA for acute ischemic stroke outweigh the risks of treatment for selected patients up to 4.5 h from symptom onset. It is already known that thrombolysis is not beneficial for all stroke patients and strict criteria should be applied before treatment. As time from symptom onset increases, the need for careful patient selection likely also increases. (Source: The Journal of Emergency Medicine)

Reply to Letter to the Editor by Dr. Stamler

The Journal of Emergency Medicine — Thu, 10 Sep 2009 00:00:00 +0100

I regret that Dr. Stamler has misunderstood my joke. Had there been a Republican victory, I would have said Democrat. I think if he reads the article again, he will not apply my descriptions of the patients that I, and probably many other emergency physicians, have found troublesome to be based on their politics. (Source: The Journal of Emergency Medicine)

Re: Peter Rosen's Recent Piece

The Journal of Emergency Medicine — Thu, 10 Sep 2009 00:00:00 +0100

I found the recent Emergency Forum article, “No Opiates for Headache,” by Peter Rosen to be quite memorable, indeed. I was anxious to learn Dr. Rosen's insights into a problem we all deal with, that of opiate use for headaches, a complaint with no objective physical findings. The first half of the article had little, if anything, to do with the subject. Rather, it was a series of interesting reflections upon his long career, and his changing attitudes and responses to the “problem” patients—“the uninsured, the derelicts, and the chronic psychiatric diseases” that are a part of every emergency physician's job. The piece then transitions to the headache-opiate problem. What is the best way to deal with this vexing issue, and its confrontations, power issues, repeat work-ups, an...

Reply to Letter to the Editor on the Management of Headaches without Opiates

The Journal of Emergency Medicine — Thu, 10 Sep 2009 00:00:00 +0100

Thank you, Dr. Lavoie, for your interesting observations concerning my reflections on the management of patients with headaches. I respect your advice about not referring responsibility to administration, but that was not my intent when invoking the “they” rule. My goal is to avoid confrontations with patients: “You want something, and I have the power to say NO!” This leads to more complaints to administration than does citing the more nebulous unnamed authorities. In fact, the only letters of complaint that I have received about pain management over the course of my almost 50 years of practice have been from patients for whom I directly refused pain medications. Moreover, in not one instance of these complaints was I ever supported by the administration. (Source: The Journal of ...

The Measurement of Time to First Antibiotic Dose for Pneumonia in the Emergency Department: A White Paper and Position Statement Prepared for the American Academy of Emergency Medicine

The Journal of Emergency Medicine — Mon, 31 Aug 2009 23:00:00 +0100

Conclusion: Given inconsistent evidence to demonstrate that improving TFAD in CAP improves outcomes or that TFAD is associated with antibiotic overuse, a Class C indication has been assigned (not acceptable/not appropriate) for ED TFAD measurement. The American Academy of Emergency Medicine recommends that measurement of TFAD in CAP be discontinued. (Source: The Journal of Emergency Medicine)

Dyspnea and Multiple Pulmonary Nodules

The Journal of Emergency Medicine — Mon, 31 Aug 2009 23:00:00 +0100

Dr. Adam Levine: Today's case is that of a 67-year-old man, a retired physician of Indian origin, who was referred to the emergency department (ED) by his primary care physician for a 2-day history of increasing shortness of breath and an outpatient computed tomography (CT) scan that showed multiple pulmonary nodules. The patient stated that he was well until 2 months previously, when he acutely developed lower back pain. His primary care physician ordered magnetic resonance imaging (MRI) of the lumbar spine, which showed L2/3 spinal stenosis. The patient subsequently received steroid injections on two occasions. Of note, he reported receiving significant dental work during the same time period. A week after the spinal injections, the patient developed a low grade fever and night sweats. H...

Reply to Maranich and Weisse

The Journal of Emergency Medicine — Mon, 17 Aug 2009 00:00:00 +0100

We appreciate and respect Drs. Maranich and Weisse's critique of our article. We concede that a single, especially retrospective, study should not change patient management. Our conclusions were purposely measured, and include, “seem to be reliable,” “if validated prospectively,” and “may be unnecessary.” (Source: The Journal of Emergency Medicine)

Aggression and a Show of Force

The Journal of Emergency Medicine — Mon, 10 Aug 2009 00:00:00 +0100

During a literature review I came across an article by Rund et al. in the Journal of Emergency Medicine entitled, “The Use of Intramuscular Benzodiazepines and Antipsychotic Agents in the Treatment of Acute Agitation or Violence in the Emergency Department” (). In it, the authors write that, based on a recent study on the management of acute agitation, one of the strategies recommended is a “show of force” by security personnel. The authors include an algorithm in which “show of force” is a strategy recommended for psychiatric patients (as opposed to patients with medical conditions or substance withdrawal or intoxication). (Source: The Journal of Emergency Medicine)

Cellulitis: Infectious or Non-Infectious?

The Journal of Emergency Medicine — Mon, 10 Aug 2009 00:00:00 +0100

We report a case of a rare non-infectious cause of cellulitis that was resistant to antibiotics and improved by steroid therapy. (Source: The Journal of Emergency Medicine)

Positive Cerebral Spinal Fluid Cultures with Normal Cell Count and Gram Stain

The Journal of Emergency Medicine — Mon, 10 Aug 2009 00:00:00 +0100

We read with great interest the article by Boysen et al. regarding cerebral spinal fluid (CSF) culture results (). In the article, the authors conclude that immunocompetent patients evaluated for meningitis with a lumbar puncture do not require follow-up for a positive CSF culture if the cell count and Gram stain are normal. We find this troubling, as such a dismissal of a positive CSF culture could have serious clinical implications. (Source: The Journal of Emergency Medicine)

Calendar of Events