Earl Schwartz

Droperidol versus haloperidol for chemical restraint of agitated and combative patients.

STUDY OBJECTIVE To compare two related pharmacological agents used for the chemical restraint of agitated and combative patients. DESIGN AND SETTING A randomized, double-blind, prospective study was carried out in patients requiring physical restraint in a university hospital emergency department. PARTICIPANTS Sixty-eight violent or agitated adult patients whom the attending physician believed would benefit from chemical restraint to protect the patient and staff and to expedite evaluation. INTERVENTION Twenty-one participants were administered 5 mg haloperidol IM; 26 were administered 5 mg droperidol IM; 12 were administered haloperidol IV; and nine were administered 5 mg droperidol IV. RESULTS All patients were rated on a five-point combativeness scale at five, ten, 15, 30, and 60 minutes after the study drug was given. Vital signs also were recorded at these times. IM droperidol decreased combativeness significantly more than IM haloperidol at ten (P = .006), 15 (P = .01), and 30 (P = .04) minutes. There was no significant difference between the two drugs when given by the IV route (beta at the 5% confidence level, P = .78). CONCLUSION In equal IM doses (5 mg), droperidol results in more rapid control of agitated patients than haloperidol, without any increase in undesirable side effects.

Emergency medical transport of the elderly: A population-based study☆

Patterns of utilization of emergency medical services transport (EMS) by the elderly are poorly understood. We determined population-based rates of EMS utilization by the elderly and characterized utilization patterns by age, gender, race, and reason for transport. This observational, population-based study was conducted in Forsyth County, NC, a semi-urban county served by one convalescent ambulance service and one EMS service. Using data on all 1990 EMS transports and the 1990 U.S. census data, age-, gender-, and race-specific transport rates for persons aged 60 or older were calculated. Reasons for transport and frequency of repeat users were established. After exclusion of transports because of an address outside the county, a nonhospital destination, a scheduled transport, or missing data, 4,688 transports (78% of total) remained for analysis. The overall rate of transport was 104/1,000 county residents. Transport rates increased for successively older five-year age groups, demonstrating a 5.7-fold stepwise increase from ages 60-65 to 85+ (51/1,000 to 291/1,000). There was no difference in mean age between patients who were frequent EMS users (more than three transports during the year) (n = 66) and other elderly transportees. Reasons for transport differed little between those 60 to 84 years of age and those 85 years of age and older with the exception of chest pain, cardiac arrest, and seizures, all of which were significantly more prevalent in the younger age group.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of emergency services in health care for the elderly: A review

The hospital emergency department (ED) has become an important means of access to health care for the elderly. Inadequacies in the current health care system for the elderly are reflected in their high utilization rates of the ED, continuing questions about the appropriateness of elderly ED patients, differences in the ED care offered the elderly versus the young, and poor coordination of care to and from the ED. Evidence of potential misuse of emergency services exists for both the ED and the emergency medical transport (EMS) systems. The increasing number of nursing home patients sent to the ED with nonemergent problems further emphasizes inadequacies of primary care in the nursing home setting. Economic, legal, and ethical issues that have changed the way medicine is practiced in other settings are finally reaching the sector of emergency services. The current and future roles of emergency medicine services, and the impact these issues will have on the practice of emergency medicine, are discussed.

Community surveillance of falls among the elderly using computerized EMS transport data

Because falls are common among the elderly and are associated with high morbidity and mortality, community surveillance has been recommended. The purpose of this study was to characterize the impact of falls among the elderly on emergency medical transport services (EMS) and to explore the potential for community surveillance of falls through the use of computerized EMS data. Computerized EMS data and United States census data for 1990 for persons aged > or = 65 in Forsyth County, NC, were used to produce EMS transport rates for falls and to make comparisons by age, gender, race, and residence (nursing home vs community). A fall was reported as the cause for EMS summons in 15.1% (613 of 4,058) of cases. Transport rates in 1990 for falls were 7.8 per 1,000, 25.4 per 1,000, and 58.5 per 1,000 for the age groups of 65 to 74 years, 75 to 84 years, and 85 years and older. Rates were higher for females than for males (17.1 per 1,000 v 8.1 per 1,000) and higher for whites than for African-Americans (14.3 per 1,000 v 10.3 per 1,000). Rates for nursing home residents were four times that of community residents (70.6 per 1,000 v 16.0 per 1,000). Over 50% of nursing home fallers were transported between midnight and 0400 compared with 25% of community dwellers. EMS summons for older adults reporting a fall accounts for a significant portion (15%) of all transports in this county. Computerized EMS data demonstrated patterns of falls among the elderly that are consistent with known demographic factors. The potential for using computerized EMS data as a practical means of community surveillance should be further explored.

Effects of isopropyl alcohol, ethanol, and polyethylene glycol/industrial methylated spirits in the treatment of acute phenol burns

STUDY OBJECTIVE To compare the effects of water rinse with those of isopropyl alcohol, polyethylene glycol with industrial methylated spirits, or ethanol on cutaneous phenol burns. DESIGN Controlled trial with all animals receiving all treatments applied to different cutaneous phenol burn sites. TYPE OF PARTICIPANTS Swine weighing 9 to 18 kg. INTERVENTIONS In phase 1, each burn site was treated with water rinse for zero, one, or five minutes combined with either isopropyl alcohol, polyethylene glycol with industrial methylated spirits, ethanol, or no other treatment. Biopsies of treatment sites were done at 30 minutes and at 48 hours. In phase 2, a pilot study, the effect of isopropyl alcohol, polyethylene glycol with industrial methylated spirits, or water treatment on serum phenol levels was noted in animals with 5%, 10%, and 15% body surface area burns. MEASUREMENTS AND MAIN RESULTS In phase 1, on histological examination of biopsy specimens, significant differences in tissue damage occurred among the groups (P < .05). Isopropyl alcohol and polyethylene glycol with industrial methylated spirits were the most efficacious treatments; the duration of water rinse had no significant effect. In phase 2, the systemic absorption of phenol may be greater with water treatment than with isopropyl alcohol treatment. CONCLUSION Isopropyl alcohol and polyethylene glycol with industrial methylated spirits are equally effective in the amelioration of phenol burns of less than 5% total surface area. The wider availability of isopropyl alcohol makes it potentially the most useful treatment for these small burns. Further studies of its risks are needed.

Peripartum cardiomyopathy: A case report

Peripartum cardiomyopathy (PPCM) is a relatively rare form of acute heart failure. Onset is from the last trimester of pregnancy to 5 months postpartum. Diagnosis is made by excluding other causes of acute heart failure, such as infections or toxins, and by determining that the patient does not have an underlying cardiac problem that has been unmasked by pregnancy. Diagnosis in the last trimester is complicated by the fact that the early symptoms of this disorder may mimic the symptoms of normal pregnancy. PPCM must be considered in any patient who presents with new onset peripheral edema, dyspnea on exertion, or paroxysmal nocturnal dyspnea during late pregnancy or up to 5 months postpartum. Limited studies suggest that early and aggressive therapy is associated with a better outcome. Therapy is directed toward decreasing preload and improving cardiac function. Return of cardiac size to normal is associated with a better prognosis than continued cardiomegaly.

Refractory shock secondary to copper sulfate ingestion

Presented is the case of a 62-year-old man with refractory shock secondary to copper sulfate ingestion. The patients history was complicated by the presence of peptic ulcer disease, myocardial disease, and a known abdominal aortic aneurysm. Despite the presence of such characteristic signs and symptoms as hemorrhagic gastroenteritis, hemolytic anemia, and refractory hypotension, the diagnosis of copper sulfate ingestion was delayed for several days after ingestion, when the family first volunteered that the patient had vomited blue-green material the day before his admission to the hospital. This delay contributed significantly to the patients ultimate demise.

Faculty attrition among three specialties

STUDY OBJECTIVES To survey faculty attrition in emergency medicine and compare it with faculty attrition in the specialties of orthopedic surgery and cardiology. DESIGN Chairmen of the three departments were surveyed regarding faculty attrition, work hours, and motivation for leaving. Those emergency physicians having left also were surveyed. MAIN RESULTS Responses were obtained from 67 of 68 emergency medicine programs, 53 of 58 orthopedic programs, and 47 of 54 cardiology programs. Overall, there were 670 total faculty in emergency medicine, of which 67 (10%) left their positions during 1988-38 to enter private practice, 18 to take another academic position, and 11 to do something unidentified. There was no difference in faculty attrition among the three specialties or in what the physicians left to do (P = .75). Both the orthopedists and the cardiologists worked more total hours each week (P = .001) but fewer night hours (P = .03) than the emergency physicians. Among the 67 emergency medicine programs, 28 reported no attrition; 39 reported one or more physicians leaving the program. These two groups of programs did not differ in terms of faculty size, hours worked, or night hours worked.

Acute occlusion of the left renal artery manifested by hypertensive crisis

Because the signs and symptoms of acute renal artery occlusion mimic those of many more common diseases, prompt diagnosis is aided by an awareness that an occlusive renovascular event may have occurred. No routine, noninvasive laboratory test can confirm the diagnosis. Renal arteriography is the procedure of choice after excretory urograms have ruled out an obstructive uropathy. Early assessment of kidney viability is important. The endpoints of emergency treatment are to decrease symptoms, decrease diastolic blood pressure to less than or equal to 105 mm Hg, and to maintain urine output at greater than 50 mL/h. Restoration of a lower blood pressure must not be so prompt that renal perfusion decreases too rapidly. Definitive surgical treatment versus medical management of the renal artery occlusion remains a controversial topic. Where surgery is not feasible, medical management consists of streptokinase acutely followed by heparin and then chronic coumarin therapy.

Axillosubclavian vein thrombosis: Case report

Deep-vein thrombosis of the upper extremity, that is, axillosubclavian vein thrombosis, is a relatively rare and potentially overlooked diagnosis in the emergency department (ED). It can be the cause of significant morbidity and it may be life-threatening. Reported here is the case of a 23-year-old man who presented to the ED with left upper extremity pain and swelling. Venography confirmed the diagnosis of axillosubclavian vein thrombosis. Hospitalization and treatment with intravenous heparin led to a satisfactory recovery. The clinical presentation, predisposing factors, diagnosis, treatment, and complications of this rare entity are discussed.