Jeffrey Jones

Emergency department protocol for the diagnosis and evaluation of geriatric abuse

As the number of elderly persons in the United States continues to increase, geriatric abuse has become the most recent manifestation of domestic violence seen in the emergency department. Recent data suggest that 1 million elderly persons are battered, neglected, or exploited each year by family members or caretakers. This maltreatment may be more difficult to identify than child or spouse abuse because of the relative isolation of the victims and their reluctance to report abuse. Many of these cases involve only subtle signs and have a great potential to pass undetected. We summarize the current literature on geriatric abuse and describe an ED protocol for identifying and reporting suspected victims. We retrospectively reviewed the medical records of 36 elderly patients hospitalized with documented abuse or neglect. Physical maltreatment was evident in 29 patients (80%), and 16 of the cases (44%) involved psychological abuse. Key points in the history, physical examination, and psychosocial evaluation were analyzed to identify specific criteria used in the development of the protocol. This framework will aid the emergency physician in the crucial first steps of identifying abuse, obtaining evidence, and providing immediate treatment and crisis intervention. Awareness that the problem exists and improved detection and intervention procedures are needed to prevent abuse of elderly persons from becoming more widespread.

Toxic smoke inhalation: Cyanide poisoning in fire victims

The most common cause of death in fires is the inhalation of noxious gases rather than thermal injury. Hydrogen cyanide gas, the most toxic product of combustion, seldom is recognized as a significant hazard in smoke inhalation. During the first four months of 1986, toxic amounts of cyanide were found in four of the six fatalities from house fires in Akron, Ohio. These cases illustrate the increasing frequency of cyanide poisoning in household fires. Sources of cyanide toxicity include the increased use of synthetic polymers in building materials and furnishings. Prompt recognition of and therapy for cyanide intoxication may reduce the morbidity and number of delayed deaths in fire victims. The key point in the diagnosis of cyanide poisoning is a high index of suspicion. The clinical presentation of cyanide intoxication, its diagnosis, and subsequent treatment are discussed. Finally, a prehospital protocol for treating smoke-inhalation victims who may have been exposed to cyanide gas is suggested.

Continuous monitoring of mixed venous oxygen saturation in septic shock

Fiberoptic pulmonary artery catheters provide a practical method for continuously measuring the amount of oxygen in mixed venous blood. To characterize the usefulness of mixed venous oxygen saturation in managing patients with sepsis, we performed serial hemodynamic measurements on 20 patients with documented septic shock. There was a highly significant positive correlation between increases or decreases of 5% or more in mixed venous oxygen saturation and corresponding changes in oxygen delivery (r = 0.95) and oxygen consumption (r = 0.96). Mixed venous oxygen saturation less than 65% was clinically unacceptable in patients with sepsis and was associated with a poor prognosis. In this study, measurement of mixed venous oxygen saturation was a valuable predictor of survival in patients with septic shock and provided a means of continuously monitoring the status of tissue oxygenation.

Diphenhydramine-induced toxic psychosis

A 24-year-old man presented to the emergency department with acute anticholinergic symptoms, hallucinations, and bizarre behavior following a large ingestion of diphenhydramine (Benadryl). Because of the large number of nonprescription preparations containing this antihistamine, similar ingestions are becoming increasingly frequent. Minor anticholinergic side effects associated with diphenhydramine are general medical knowledge. The effects of overdosage are less well known. The clinical presentation of toxic psychosis, its differential diagnosis, and its subsequent treatment are discussed.

Cathartic-induced magnesium toxicity during overdose management

A 39-year-old women was admitted to the hospital following a large ingestion of a tricyclic antidepressant. The administration of magnesium citrate in repeated doses with activated charcoal resulted in a striking increase in serum magnesium levels followed by acute neuromuscular deterioration and respiratory depression. The patient required dialysis for control of hypermagnesemia. Her clinical condition improved slowly without further complication and she was discharged to a rehabilitation center.

Repetitive doses of activated charcoal in the treatment of poisoning

Activated charcoal has found a renewed role in the management of overdosed patients. Routinely administered to reduce the gastrointestinal (GI) absorption of many drugs, growing evidence indicates that repeated doses of charcoal also may enhance drug elimination. Some drugs are excreted into the bile or gastric fluids (phencyclidine, digoxin) and are reabsorbed. Other drugs (theophylline, phenobarbital) can diffuse from the plasma into the lumen of the GI tract. Activated charcoal is administered at regular intervals to sequester these toxins in the GI tract, eventually causing their excretion in feces. This article reviews the evidence for the safety and efficacy of repetitive charcoal therapy. While supportive management remains the mainstay of therapy in poisoned patients, activated charcoal is inexpensive, effective, simple to administer, and may obviate the need for more invasive methods of toxin removal.

Accuracy of prehospital sphygmomanometers

The first requisite for valid blood pressure determination is a correctly calibrated manometer. A total of 125 aneroid sphygmomanometers in prehospital use were calibrated against a mercury manometer standard. A total of 43 (34.4%) aneroid instruments deviated by more than +/- 4 mm Hg tolerance (average of four readings). A deviation of greater than +/- 8 mm Hg was shown by 10.4% (13) of the maeters. These aneroid gauges are easily calibrated by prehospital personnel using a mercury standard and Y-tube connection. Departments with routine maintenance policies had fewer inaccurate instruments. Emergency medical services advisors should ensure periodic maintenance and calibration of sphygmomanometers used in emergency care situations.

Magnesium levels in cardiac arrest victims: Relationship between magnesium levels and successful resuscitation

Multivariate analysis was performed to evaluate significant differences between electrolytes, serum magnesium, and successful resuscitation in cardiac arrest victims in a prospective controlled study. Twenty-two cardiac arrest victims having ventricular fibrillation or tachycardia, electromechanical dissociation, or asystole were compared with 19 matched controls with no ventricular arrhythmias. Of the control group, one was hypermagnesemic (5%), 17 normomagnesemic (90%), and one hypomagnesemic (5%). In the arrest group, eight were hypermagnesemic (36%), nine normomagnesemic (41%), and five hypomagnesemic (23%). Thirteen of 22 cardiac arrest victims (59%) had an abnormal serum magnesium level. All hypermagnesemic and hypomagnesemic patients expired (100%). In the normomagnesemic group, four out of nine (44%) were successfully resuscitated. A positive correlation was identified between normomagnesemia and successful resuscitation (P less than .01). There was no correlation between other electrolytes and successful resuscitation (P greater than .05).

Teaching research in the emergency medicine residency curriculum

Research in emergency medicine is a necessary component for the growth and development of the academic discipline. Although the need exists for competent physician investigators, most graduates of emergency medicine residencies have had little structured education in research design or methodology. This is particularly true in community hospital programs with little funding allocated to research, limited facilities, and few staff members actively involved in research. Our purpose is to describe a research curriculum designed to operate within a community-based residency program. This curriculum identifies a detailed set of educational objectives in research techniques with the expectation that on completion of the residency program, the resident will be able to critically evaluate medical literature and independently design a research project. We have developed a specific plan for meeting these objectives with coordinated seminars, readings, journal clubs, research projects or exhibits, and professional conferences. We suggest some practical methods of motivating residents and attending staff to pursue clinical investigation.

A geriatrics curriculum for emergency medicine training programs

The growing number of elderly in the United States will continue to increase the demand for emergency services. Although the emergency medicine core curriculum, as defined by the American College of Emergency Physicians, requires mandatory training in pediatrics, there is no mention of geriatric care. A special body of knowledge regarding normal aging as well as the special presentation of disease in the elderly is required to provide optimum care for the aged patient. We present an integrated geriatric curriculum designed to operate within a three-year emergency medicine residency program. This curriculum identifies specific educational objectives for training in geriatric emergencies that can be summarized as follows: identify those impairments and functional disorders that often complicate diagnosis and therapy; acquire an understanding of how physiologic changes in aging affect normal laboratory and radiologic values; develop knowledge of drug side effects and interactions in this population; understand and treat the group of disease peculiar to the elderly; recognize diseases and injuries that present a different clinical picture in old age; and differentiate and treat common psychosocial emergencies in the elderly. These educational objectives are further defined using a specific interlinked framework of didactic presentations, journal clubs, case conferences, therapeutic audits, formal rotations, and consultants. This format will provide valuable educational experiences for the emergency medicine resident and may strengthen positive attitudes toward geriatric medicine.