Ernest Ruiz

Emergency department echocardiography improves outcome in penetrating cardiac injury.

STUDY OBJECTIVES To determine the effect of immediate two-dimensional echocardiography on the time to diagnosis, survival rate, and neurologic outcome of patients with penetrating cardiac injury. DESIGN A ten-year retrospective review. SETTING Regional trauma center serving a population base of 1.25 million with 85,000 visits yearly. TYPE OF PARTICIPANTS All patients presenting to the emergency department with penetrating cardiac injury. MEASUREMENTS AND MAIN RESULTS The records of 49 patients with penetrating cardiac injury were reviewed. Of these, 28 received immediate two-dimensional echocardiography in the ED (echo group) and 21 did not (nonecho group). The probability of survival was derived using TRISS methodology. Differences between groups were determined using either the two sample t-test for parametric data or the Mann-Whitney test for nonparametric data. The overall probability of survival was 33.2%, and the actual survival rate was 81.6%. The probability of survival was 34.2% and 31.8% for the echo group and nonecho group, respectively. The actual survival was 100% in the echo group and 57.1% in the nonecho group. The average time to diagnosis and disposition for surgical intervention was 15.5 +/- 11.4 minutes for the echo group and 42.4 +/- 21.7 minutes for the nonecho group (P less than .001). The Glasgow Outcome Score was 5.0 for the echo group and 4.2 for the nonecho group (P = .007). CONCLUSION Since the introduction of immediate ED two-dimensional echocardiography, the time to diagnosis of penetrating cardiac injury has decreased and both the survival rate and neurologic outcome of survivors has improved.

Cricothyrotomy in the Emergency Department

Thirty-eight emergency cricothyrotomies were performed over a 3-year period. This was the first airway control maneuver attempted in 5 patients, 3 of whom had facial and/or neck injury, one apneic with upper airway hemorrhage, and one with aortobronchial fistula. The remaining 33 procedures were performed only after other airway management failed. Five indications were identified among these cases: 1) excessive emesis or hemorrhage (11), 2) possible cervical spine injury with airway compromise (9), 3) technical failure (7), 4) clenched teeth (5), and 5) masseter spasm following succinylcholine administration (1). Fourteen immediate complications occurred in 12 patients (32%). The most frequent was incorrect site of tracheostomy tube placement (5), with 4 of 5 misplaced through the thyrohyoid membrane. Others included execution time greater than 3 minutes (4), unsuccessful tracheostomy tube placement (3), and significant hemorrhage (2). Twelve of the 38 patients were long-term survivors. There was one long-term complication, a longitudinal fracture of the thyroid cartilage during forceful placement of an oversized tube (8 mm inner diameter) through the cricothyroid membrane. This required operative repair and left the patient with severe dysphonia.

Haloperidol for sedation of disruptive emergency patients.

Agitated, threatening, or violent behavior often jeopardizes the patient with self-inflicted injury or delays medical evaluation and treatment. Patient cooperation with therapy can be achieved using haloperidol by the IM, IV, or oral route. The safety and efficacy of haloperidol in the emergency department setting was examined. Haloperidol was administered to 136 patients to control behavior. Eighty-eight received the drug in the ED; 18 of these 88 were critical patients receiving the drug during resuscitation. Forty-eight of the 136 were crisis intervention center patients. Ninety patients were acutely intoxicated with ethanol. Twenty-three patients had head trauma; 20 of these also were inebriated. Various other drugs were responsible for the behavior of 15 patients. Acute psychosis was involved in 40 cases. Thirty-one patients were thought to have a personality disorder. The route of administration of haloperidol was intramuscular in 110, IV in 19, and oral in seven patients. Disruptive behavior was alleviated within 30 minutes in 113 of 136 (83%) patients. Effect was judged suboptimal in 20 of 136 (15%), and no effect was noted in three of 136 (2%) patients. Four complications (3%) were noted, three minor and one more serious episode of hypotension in a critical patient. Haloperidol is a safe and efficacious drug for use with disruptive patients in the emergency setting. It is a useful tool for management of agitation of diverse etiologies.

Cricothyrotomy in the emergency department revisited

Thirty-nine emergency cricothyrotomies were reviewed from the emergency department of Hennepin County Medical Center during the 4-year period ending December 1985. Due to technical changes in airway management and a desire to assess their impact, this experience was compared with a previously reported series of 38 emergency cricothyrotomies from the same department. Technical changes include the use of paralyzing agents, transtracheal needle ventilation, and the use of only vertical skin incisions and #4 Shiley tubes when cricothyrotomy is performed. The presenting problem, indications for cricothyrotomy and complications of the procedure were compared between the two series. Fewer cricothyrotomies were done as a fraction of total surgical and nonsurgical tracheal intubations in the present series (1.7%) compared to the previous series (2.7%). The complication rate decreased from 40% in the previous series to 23% in the present series. Incorrect site of tube placement (10%) and hemorrhage (8%) remain the two leading complications. However, the tube was in the trachea in all cases, and acceptable ventilation was achieved. No patient developed a clinically significant hematoma or hemorrhage from cricothyrotomy. It is concluded that our technical changes in airway management have helped to decrease both the relative frequency of cricothyrotomy and the complication rate.

Neuromuscular blockade for critical patients in the emergency department

This retrospective study examines the indications and the effects of 119 doses of succinylcholine or pancuronium given in the emergency department during a 24-month period to patients considered to have immediately life-threatening emergencies. The most common indication for succinylcholine was to accomplish tracheal intubation (20 of 25 patients). Indications for pancuronium included computerized tomography of the head (60 of 94), control of agitation (40 of 94), facilitation of tracheal intubation (20 of 94), control of ventilation (12 of 94), and control of seizure unresponsive to anticonvulsants (4 of 94). Deterioration following succinylcholine occurred in three cases. These included two involving bradycardia and one involving ventricular tachycardia. Major complications following pancuronium included four incidences of ventricular arrhythmias. Intubation failure requiring surgical airway occurred in one patient given succinylcholine, two patients given pancuronium, and one patient who received both succinylcholine and pancuronium. Inadequate documentation of neurological examination prior to blockade was noted in six of 25 succinylcholine and nine of 94 pancuronium cases. Failure to sedate patients who might be aware of paralysis occurred in three of 25 succinylcholine and eight of 94 pancuronium uses. Neuromuscular blocking agents facilitate expeditious management of selected critical patients in the ED. Their prudent use requires anticipation of potential complications, preparation for surgical airway should intubation fail, documentation of physical examination before paralysis, and prior sedation when the patient responds to pain.

Succinylcholine for Endotracheal Intubation

In the emergency department at Hennepin County Medical Center, succinylcholine has been used to assist difficult intubations since March 1, 1979. In this report, the first 48 cases are reviewed. In these 48 patients, complete relaxation allowing endotracheal intubation was achieved in 42. Forty of the 42 patients intubated suffered no adverse effects. One patient vomited, delaying intubation, and another developed transient asystole. Six of 48 patients were not successfully intubated after succinylcholine; five of these six subsequently required cricothyrotomy. Inadequate dose, improper technique of administration, foreign material obscuring airway, and idiosyncratic reactions were thought to be reasons for failure. When properly administered, succinylcholine can be used to facilitate difficult intubations in the emergency department with an acceptable incidence of adverse effects or failures.

Use of atropine for brady-asystolic prehospital cardiac arrest

The efficacy of atropine in treating prehospital cardiac arrest patients developing asystole slow pulseless idioventricular rhythms (PIVR) was evaluated in a controlled, prospective study. Twenty-one prehospital cardiac-arrested patients developing asystole or PIVR (less than 40) were divided into atropine-treated or non-atropine (control) groups. Control group patients received treatment including bicarbonate, epinephrine, calcium, isoproterenol, dexamethasone, and transthoracic pacing. Atropine-treated patients received 1 mg atropine intravenously with a repeat dose at one minute if no rhythm change occurred. These patients then received the same therapy as the control group. In both groups, rhythm changes were treated as appropriate for the specific circumstances. No differences in mortality or effected rhythm changes were observed. Ten of the 11 controls and eight of 10 atropine patients developed rhythms other than asystole or PIVR less than 40. However, only two patients in each group were successfully resuscitated in the emergency department and only one control group patient was discharged alive. Our findings are not in agreement with those of previous authors who have advocated the use of atropine in cardiac arrest patients with these arrhythmias. We question the usefulness of atropine in this setting. More study is necessary in order to clearly define its role in the resuscitation of patients who have sustained brady-asystolic arrests.

External rotation method of shoulder dislocation reduction

We used the external rotation method for reducing anterior shoulder dislocations on 85 consecutive patients seen in our emergency department during a one-year period. In relatively inexperienced hands, the external rotation method was successful on first attempt in 80% of cases. There were no complications attributable to the technique itself. We feel that it is a successful, easy, and atraumatic method of achieving reduction in both first occurrence and recurrent anterior shoulder dislocations.

Follow-up of 514 consecutive patients with cardiopulmonary arrest outside the hospital

During the years 1974 of 1976, 514 patients with prehospital cardiopulmonary arrest were brought to the Hennepin County Medical Center (HCMC) Emergency Department. Of these, 344 patients (67%) were either dead on arrival or died in the emergency department despite efforts at resuscitation. The remaining 170 patients were admitted to the coronary care unit. Eighty-seven patients (51%) died in the coronary care unit, primarily from uncontrolled rhythm disturbances and/or cardiogenic shock. The remaining 83 patients (16% of the total group, 49% of those admitted to the hospital) were discharged alive from HCMC. In this group, 49 patients of the 83 long-term survivors were ambulatory with full mental function when discharged. The remaining 34 patients were trnasferred to chronic care facilities for medical treatment of on-going problems. Of the 49 ambulatory patients, satisfactory data for follow-up was obtained on 47. Their mortality rate was 15% in the first year and 50% in the second, primarily from sudden death syndrome.

A trial of povidone-iodine in the prevention of infection in sutured lacerations

A prospective, randomized study of 500 consecutive emergency department patients with traumatic lacerations requiring sutures was performed comparing use of topical 1% povidone-iodine (Betadine) and scrubbing with wound management by irrigation with normal saline without scrubbing. A 60-second wound irrigation and scrub with a 1% povidone-iodine solution was the only difference in treatment between the two groups. Data relating to risk factors such as age; degree of contamination; type of closure; ethanol intoxication; mechanism of injury; and bone, joint, or tendon involvement were analyzed. Wounds were classified as clean, infected, or purulent at follow-up examination. One hundred five patients were lost to follow-up. Of the 395 remaining patients, 122 were contacted by phone and were classified based on their description of the wound; 273 were classified at reexamination in the ED. Of 201 povidone-iodine group wounds, 11 became infected; two of them (5.4%) were purulent. Of 194 control wounds, 30 became infected, of which 12 (15.46%) were purulent (P less than .01). These data suggest that use of a topical 1% povidone-iodine solution in traumatic lacerations prior to suturing reduces the incidence of wound infections.