Douglas A. Rund

Psychiatric Considerations in Patients with Decreased Levels of Consciousness

When patients present to the emergency department with changes in behavior and levels of consciousness, psychiatric causes often move to the top of the list of diagnostic considerations. It is important to thoroughly assess such patients for medical causes. Although it is not common for primary psychiatric conditions to present with altered levels of consciousness, severe cases may present in this fashion. Altered mental states may also be caused by adverse reactions to psychiatric medications. In this article, the authors review some of the psychiatric causes of decreased levels of consciousness, as well as certain adverse drug reactions to psychotropic medications.

Methodology reporting in three acute care journals: Replication and reliability

As the sciences of emergency medicine and acute care medicine develop, it becomes imperative for researchers in these fields to accurately and completely report the methodology of their investigations. It is only through complete reporting that other investigators can critically examine, replicate, or expand on the results of an investigation. The purpose of our study was to compare the completeness of methodology reporting in three acute care journals, Annals of Emergency Medicine, Critical Care Medicine, and Journal of Trauma. Thirty-eight criteria characteristics necessary for the replication of a clinical trial were identified and grouped into ten categories. The categories were experimental design, recruitment and exclusion of subjects, selection of study sample, subject allocation, therapeutic regimen, blindness, outcome criteria, analysis of confounders, withdrawal of subjects, and statistical analysis. All prospective, interventional, controlled trials appearing in these journals from January 1980 to June 1983 were identified. A total of 45 trials were found. Each trial was read independently by two reviewers to determine whether each of the 38 criteria was clearly reported, not clearly reported, or not applicable. Disagreements were resolved by a third reader (adjudicator). The results are reported as the mean proportion of items clearly reported +/- standard deviation: Annals of Emergency Medicine (n = 16), 0.39 +/- 0.10; Journal of Trauma (n = 18), 0.33 +/- 0.14; and Critical Care Medicine (n = 11), 0.32 +/- 0.09. A one-way analysis of variance found no statistically significant difference between journals with respect to these proportions (P = .25).(ABSTRACT TRUNCATED AT 250 WORDS)

Reported alcohol consumption and the serum carbohydrate-deficient transferrin test in third-year medical students

The serum carbohydrate-deficient transferrin (CDT) test was performed on 143 third-year medical students along with questionnaires for the self-reporting of alcohol consumption during the last 2 weeks, the last 6 months, and questions on any alcohol-related untoward events. We found that the CDT test has poor sensitivity for detecting binge drinking in our population of students, despite some likely under-reporting of drinking. Self-reporting of drinking is commonly unreliable, and we found no significant correlation between the CDT concentrations in serum and the magnitude of self-reported alcohol use during 2-week and 6-month periods. Hangover was by far the commonest self-reported untoward event, and there was a highly significant relationship (P < 0.001) between drinking and untoward events. From a small population of non-drinkers, we estimated the reference ranges for CDT to be <27 U/l for men and <35 U/l for women.

Attitudes of the emergency physician toward and diagnostic evaluation of suicide attempters.

The negative attitudes of emergency medical personnel toward suicide attempters are well documented in recent studies. Part of the reason for such negative attitudes may involve the emergency medical professionals lack of knowledge about the variety of psychiatric conditions present in the patient who attempts suicide. Information about such conditions and the emotional reactions certain personalities generate might alter these attitudes. Questioning the patient about the feelings and thoughts experienced during the attempt often provides some of the most helpful data about the patients psychiatric condition, treatment needs, and prognosis. Proper guidelines and education for the emergency physician should help improve the early management of the suicide attempters.

A Review of Medical Response to Disaster Casualties

This chapter summarizes a review of medical response to disaster casualties. The goals are the following: (1) to develop a hypothetical model for investigating the health and medical aspects of disaster preparedness; (2) to determine investigational areas most critical to the health and medical aspects of international disaster care planning; (3) to identify available medical data on specific injuries and illnesses associated with particular types of disasters; (4) to begin collection and analysis of specific disaster plans for the United States and NATO countries.

Acute Frontal Sinus Fracture An Innovative Use of Sonography

Frontal sinus fractures typically occur as a result of direct facial trauma.The fracture may cause signifi cant swelling and hematoma at the site of injury, which makes it difficult for palpation of the bony outer table.The authors describe a patient with a frontal sinus fracture.The sonographic findings were confirmed by facial computed tomography. Following reconstructive surgery, ultrasound demonstrated successful reduction and surgical fixation of the fracture fragment.

Injury Patterns Associated with Earthquakes

Major earthquakes create disaster conditions because the resulting structural collapse causes significant morbidity and mortality. An estimated 15 million deaths have been caused by earthquakes since the beginning of recorded history. (1) Earthquakes have caused an average of 11,250 deaths per year for the last 40 years(2) accounting for 37% of all deaths caused by disaster. (3) In addition to the injury and death caused at the time of the earth movement itself, an earthquake disrupts the community’s capacity to respond effectively. Transportation, communications, and health care systems are typically damaged significantly in the hours and days following the event. As a result, national and international assistance is usually required, since the salvage rate for victims unrescued from a collapsed structure decreases steadily after the first 24 hours after entrapment, international assistance teams and equipment should be on site within one or two days. Unfortunately this kind of response time is rarely possible under present conditions.

Abdominal pain and seizures in a young man

Summary Dr Davis: This case clearly illustrates that the emergency physician must be aware not only of surgical causes of the acute abdomen, but should also be cognizant of treatable medical causes of abdominal pain (Figure 1). The diagnosis of acute intermittent porphyria should be considered in any patient with recurrent episodes of abdominal pain and constipation that begin after the onset of puberty. This is particularly true if neurologie symptoms accompany these complaints. The diagnosis of acute porphyria can be established quickly with the performance of a Watson-Schwartz test on the patients urine. The emergency physician must remember the factors that can precipitate attacks in individuals known to have the disease. In particular, the physician must avoid the use of medications known to exacerbate acute intermittent porphyria (Figure 4). Caution must be exercised in evaluating patients with this disease when viral or bacterial infection are present. Subtle signs of an acute attack must be sought and, if present, admission to the hospital should be consid ered. Patients who are not admitted should be advised tc maintain a high carbohydrate intake. Finally, the emergency physician must be aware of the medications that can be used safely during an acute attack of porphyria. These include meperidine and morphine to control of abdominal pain, chlorpromazine, and other phe nothiazines for nausea and vomiting, and diazepam to reverse acute seizure activity.