Amy A. Ernst

Colposcopy in evaluation of the adult sexual assault victim.

Abstract The purpose of this study was to determine if the colposcope improves detection of genital trauma in adult women who are victims of sexual assault compared with gross visual examination alone. A prospective, 1-month pilot study was conducted of 17 women patients who presented consecutively to Charity Hospital New Orleans during April 1994 requesting sexual assault examinations. Use of the colposcope allowed documentation of trauma in 9 of the 17 sexual assault victims (53%), compared with 1 of 17 (6%) by gross visualization alone (statistically significant: χ2 = 0.64, P = .0114). The colposcope improved detection of genital trauma in adult female sexual assault victims as compared with gross visual examination alone at a statistically significant level.

Development of a screen for ongoing intimate partner violence.

A five-question Ongoing Abuse Screen (OAS) was developed to evaluate ongoing intimate partner violence. Our hypothesis was that the OAS was more accurate and more likely to reflect ongoing intimate partner violence than the AAS when compared to the Index of Spouse Abuse (ISA). The survey included the ISA, the OAS, and the AAS. During the busiest emergency department hours, a sampling of 856 patients completed all aspects of the survey tool. Comparisons were made between the two scales and the ISA. The accuracy, positive predictive value, and positive likelihood ratio were 84%, 58%, and 6.0 for the OAS and 59%, 33%, and 2.0 for the AAS. The OAS was more accurate, had a better positive predictive value, and was three times more likely to detect victims of ongoing intimate partner violence than the AAS. Because the OAS was still not accurate enough, we developed a new screen, based on the ISA, titled the Ongoing Violence Assessment Tool (OVAT).

Preflight versus en route success and complications of rapid sequence intubation in an air medical service.

BACKGROUND Maintenance of an airway in the air medically transported patient is of paramount importance. The purpose of this study is to compare preflight versus en route rapid sequence intubation (RSI)-assisted intubations and to determine the value of air medical use of RSI. METHODS This study is a 31-month retrospective review of all patients intubated and transported by a large city air medical service. Subgroup analysis was based on whether patients were transported from a hospital or a scene and whether they were intubated preflight or en route. Information on age, Glasgow Coma Scale score, type of scene, ground time, and previous attempts at intubation was recorded. Complications included failures, multiple attempts at intubation, arrhythmias, and need for repeated paralytic agents. Comparisons were made using a confidence interval analysis. An alpha of 0.05 was considered significant; Bonferroni correction was used for multiple comparisons. RESULTS Three hundred twenty-five patients were intubated and transported by Lifeflight during the study period. Two hundred eighty-eight patients were intubated using RSI (89%). The success rate was 97%. Preflight intubations were performed on 100 hospital calls and 86 scene calls. En route intubations were performed on 40 hospital cases and 62 scene calls. Patients who underwent preflight intubations were significantly younger than those who underwent en route intubations for both the hospital group (34 +/- 11 vs. 44 +/- 24 years, p < 0.05) and the scene group (27 +/- 13 vs. 32 +/- 16 years,p < 0.05). Otherwise, the demographic characteristics of the four groups were similar. Trauma accounted for 60 to 70% of hospital transfers and almost 95 to 100% of scene calls. Compared with preflight intubations, there was a significant decrease in ground time for hospital patients who were intubated en route (26 +/- 10 vs. 34 +/- 11 minutes, p < 0.05) and for scene patients who were intubated en route (11 +/- 8 vs. 18 +/- 9 minutes, p < 0.05). There were no significant differences between the groups for number of failures (9 of 288), arrhythmias (18 of 288), or necessity for repeated paralysis (8 of 288). Multiple intubation attempts were performed in more scene preflight patients (30 of 86, 35%) than scene en route patients (16 of 62, 26%), but this did not reach statistical significance. Even for patients having previous attempts at intubation, the success rate using RSI was 93% (62 of 67). CONCLUSION Air medical intubations, both preflight and en route, for both scene calls and interhospital transports, can be done with a very high success rate. Rapid sequence intubation may improve the success rate. For scene calls, there was a significant decrease in ground time, and there was a trend toward fewer multiple intubation attempts when the patient was intubated en route instead of preflight.

Sex Differences in Analgesia: A Randomized Trial of μ versus κ Opioid Agonists

Objectives We sought to evaluate whether there is a sex difference in the analgesic response to &mgr; versus &kgr; opioids in the management of acute moderate to severe pain of injury in the emergency department. Methods The study was a randomized, double-blind, clinical trial comparing the prototypical &mgr;-receptor agonist, morphine sulfate, to the prototypical &kgr; agonist, butorphanol. The primary endpoints were degree of relief by visual analog scores at 30 and 60 minutes. Statistical analysis was performed using Mann-Whitney U test for nonparametric analysis and repeated-measures analysis of variance. Results Ninety-four patients were entered in the study, with 49 (52%) males and 45 (48%) females. Forty-six received morphine sulfate and 48 received butorphanol. There was no difference in demographics in the two groups. At 60 minutes, females had significantly lower visual analog scores with butorphanol compared with morphine (P = 0.046). At 60 minutes, there was a trend for a difference in response of males versus females to morphine, with males responding better than females (P = 0.06). Conclusion Females had better pain scores with butorphanol than morphine at 60 minutes.

Detecting ongoing intimate partner violence in the emergency department using a simple 4-question screen: the OVAT.

We wanted to prospectively evaluate the use of a brief screening tool for ongoing intimate partner violence (IPV), the OVAT, and to validate this tool against the present Index of Spouse Abuse (ISA). The design was a prospective survey during randomized 4-hour shifts in an urban emergency department setting. The scale consists of four questions developed based on our previous work. The ISA was compared as the gold standard for detection of present (ongoing) IPV. Of 362 eligible patients presenting during 75 randomized 4-hour shifts, 306 (85%) completed the study. The prevalence of ongoing IPV using the OVAT was 31% (95% CI 26% to 36%). For the ISA, the prevalence was 20% (95% CI 16% to 25%). Compared with the ISA, the sensitivity of the OVAT in detecting ongoing IPV was 86%, specificity 83%, negative predictive value 96%, positive predictive value 56%, with an accuracy of 84%. In conclusion, four brief questions can detect ongoing IPV to aid in identifying the victim.

Development of a novel measure of overcrowding in a pediatric emergency department.

Objective: Emergency department (ED) overcrowding has been quantified with a scale that reflects the degree of overcrowding (National ED Overcrowding Scale, or NEDOCS) in general academic EDs. However, validity of the 5-question NEDOCS scale has not been established for a pediatric ED. Our primary objectives were to validate the NEDOCS model in our institutions pediatric ED and explore the possibility of another pediatric ED overcrowding model that would be better than the NEDOCS model. Methods: Objective data were determined by prospectively collecting 20 variables at 42 random site-sampling times in one pediatric ED. Data were obtained by counting patients, determining patients times, and obtaining information from registration, triage, and ancillary services. The 5 questions needed for the NEDOCS scale were among the data collected. Expert consensus (EC) was obtained using a Likert scale completed by the charge nurse and ED physicians who rated the degree of overcrowding. National ED Overcrowding Scale scores were compared with EC score to determine predictive validity of a model for a pediatric ED. Spearman correlation and multivariable linear regression were used to evaluate individual variables. Results: Overcrowding based on EC score was found in 18 (44%) of 41 times in the pediatric ED. In pediatric EDs, high correlations were found between EC score and NEDOCS (0.68), number of patients in the waiting room (0.74), full rooms (0.64), and total registered patients (0.65). In a multivariable analysis, a combination of patients in the waiting room and total registered patients had a high correlation (0.80) with EC score in the pediatric ED. Conclusions: Overcrowding is quantifiable in a pediatric ED. Although the NEDOCS performed well in the pediatric ED, it was outperformed by other variables and other variable combinations. In this pediatric ED, a combination of 2 variables, total registered patients and patients in the waiting room, was a better model than the NEDOCS score for quantifying pediatric ED overcrowding.

1% Lidocaine Versus 0.5% Diphenhydramine for Local Anesthesia in Minor Laceration Repair ☆ ☆☆ ★

STUDY OBJECTIVE Our previous study demonstrated that 1% diphenhydramine is as effective as 1% lidocaine for anesthesia in minor laceration repair, but that it also is more painful to inject. The purpose of this study was to compare 0.5% diphenhydramine to 1% lidocaine for pain of injection and adequacy of local anesthesia. STUDY DESIGN Randomized, double-blinded, prospective study from December 1991 through June 1992. SETTING University-affiliated, urban, inner-city emergency department. PARTICIPANTS Ninety-eight adults with linear skin lacerations without end-organ involvement were included; 48 received lidocaine and 50 received diphenhydramine. INTERVENTIONS Wounds were anesthetized with either diphenhydramine or lidocaine according to a random table. Both patients and physicians rated the pain of injection and suturing according to a standard, previously tested, visual analog scale. MEASUREMENTS AND MAIN RESULTS Patient and physician ratings were ranked without regard to treatment group, and rank sum scores were calculated for each group. General linear models and multivariate analysis of variance were used to analyze the ranked sum scores. The power of the study to detect a ranked sum difference of 15 was 0.8 with P < .05 considered statistically significant. Lidocaine was found to be significantly more effective as a local anesthetic for facial lacerations according to both patients (P < .002) and physicians (P < .004). There was no statistically significant difference between 1% lidocaine and 0.5% diphenhydramine for pain of injection or suturing for all other locations according to both patients and physicians. Overall mean and median scores for injection and suturing with diphenhydramine corresponded to the mild pain category according to patients. CONCLUSION Although not a replacement for lidocaine, diphenhydramine is a viable alternative for anesthesia in the repair of minor lacerations.

Unexpected Cocaine Intoxication Presenting as Seizures in Children

We report four cases of unexpected cocaine intoxication in children manifested by the sudden development of seizures. Each patient presented with seizure activity of unknown etiology. Toxicology screens were positive for cocaine and its metabolites. All four had normal head computed tomography scans and have not required long-term use of anticonvulsants. One infant developed a mild learning disability. Cocaine intoxication should be considered in the differential diagnosis of new onset seizure activity in children. Child protection agencies should be consulted in all cases due to a high probability of abuse or neglect.

Comparison of tetracaine, adrenaline, and cocaine with cocaine alone for topical anesthesia

A mixture of tetracaine, adrenaline, and cocaine (TAC) has been used extensively in the repair of small lacerations, especially in children. The purpose of this study was to determine whether cocaine alone would provide anesthesia equal to that of TAC, thus eliminating the risk of tetracaine toxicity and the theoretic risk of side effects from the combination of cocaine and adrenaline and simplifying preparation. One hundred thirty-nine patients were enrolled in a randomized, double-blind study comparing TAC with cocaine. Effectiveness was rated by the treating physician. Using the Wilcoxon rank-sum test, TAC was found to provide significantly better anesthesia than cocaine alone (P = .005). The percentage of patients having good anesthesia in the TAC-treated group was approximately 72%, which is equivalent to the efficacy found in other studies. Good anesthesia was obtained in 52% of the cocaine-treated group. No side effects or increased rates of infection were reported in either group.

Perpetrators of intimate partner violence use significantly more methamphetamine, cocaine, and alcohol than victims: a report by victims

OBJECTIVES Our objectives were (1) to determine demographic characteristics of intimate partner violence (IPV) victims and perpetrators, as reported by victims in a Victim Assistance Unit where police are called to the scene for IPV, and (2) to compare the relative risk of methamphetamine, cocaine, and alcohol use in perpetrators vs victims of IPV, as reported by victims. METHODS Data from a Victim Assistance Unit intake statistics for the months of January to November 2006 were accessed. For this system in a city of approximately 500,000 population, with a large Hispanic population, police call for an onsite advocate intervention (trained social worker) at their own discretion for the victim and for children involved. Data were collected from the homes visited by police for IPV calls based on victim report on victims, perpetrators, and children in the home and their involvement in IPV. Reports of drug use were self-reported by the victim only. Comparisons were made using chi(2) tests, relative risks (RRs), and 95% confidence intervals (CIs). P < .05 was considered statistically significant. RESULTS Police and advocates visited 1712 homes for IPV calls; males were victims in 141 (8.2%) cases. Nine hundred ninety-seven (58.2%) victims were Hispanic. By victim report, perpetrators were significantly more likely to have witnessed IPV as a child than victims did (48.8% vs 34.3%; RR, 1.4; 95% CI, 1.3-1.6). Of the 2266 children in these homes, 1800 (79.2%) witnessed IPV and 716 (31.6%) were victims themselves. By victim report, the perpetrators were significantly more likely to use methamphetamine (8.9% vs 0.8%; RR, 10.9; 95% CI, 6.4-18.8 ), cocaine (11.8% vs 0.7%; RR, 16.8), and alcohol (53.3% vs 12.9%; RR, 4.1; 95% CI, 3.6-4.7) than victims. CONCLUSION By victim report, perpetrators were more likely to have witnessed IPV as children. By victim report, perpetrators were also more likely to use methamphetamine, cocaine, and alcohol and other drugs. Knowing this correlation may be important to the emergency department physician as screening for drug use, especially methamphetamine, as well as IPV may be useful to identify IPV-related injuries and provide proper referrals for IPV and drug use treatment.