John E. Prescott

A randomized, double-blind, comparative study of the efficacy of ketorolac tromethamine versus meperidine in the treatment of severe migraine

STUDY OBJECTIVE To evaluate the relative efficacy of ketorolac tromethamine and meperidine hydrochloride in the emergency department treatment of severe migraine. DESIGN Prospective, randomized, double-blind trial. SETTING University hospital ED. PARTICIPANTS Patients presenting to the ED with an isolated diagnosis of common or classic migraine. INTERVENTIONS Subjects were randomized to receive a single intramuscular injection of either 30 mg ketorolac or 75 mg meperidine. MEASUREMENTS AND MAIN RESULTS Of the 31 patients completing the trial, 15 received ketorolac and 16 received meperidine. The demographic characteristics of both groups were comparable. At one hour, ketorolac was significantly less effective than meperidine in reducing headache pain (P = .02) and in improving clinical disability (P = .01). Ketorolac also was less effective at reducing nausea, photophobia, and the need for rescue medication (P less than .05). Sustained headache relief was experienced by 44% of the patients treated with meperidine at 12- to 24-hour follow-up, compared with 13% of the patients treated with ketorolac (P = NS). No significant side effects were observed for either group. CONCLUSION IM ketorolac tromethamine is less effective than meperidine in the ED treatment of severe migraine.

Injury Recidivism in a Rural ED

STUDY OBJECTIVE To determine the degree of injury recidivism in our ED population and to identify indicators of injury recidivism. METHODS We conducted a retrospective review in a university-affiliated department of emergency medicine. The study participants were patients who presented for treatment of an injury. An injury recidivist was defined as a patient who presented for treatment of two or more unique injuries during the 1-year study period. The injured population was divided into three categories: (1) those with a single injury visit, (2) those with two to three injury visits, and (3) those with four or more injury visits. Demographics, mechanism of injury, and outcome data were collected and comparative analyses performed. RESULTS Of the 37,360 ED patient visits, 12,075 were injury related. Of the injury visit load, 2,838 of the 12,075 (24%) were injury recidivists. Of injured patients, 1,239 of 10,476 (12%) were recidivists. The sex distribution was similar among the groups, but the mean age decreased as the degree of recidivism increased. The degree of recidivism was higher for patients with Medicaid and for those who were uninsured. Lower mean medical charges per visit were found with increasing degree of recidivism, but the average total charges per patient increased with increasing degree of recidivism. Increasing degree of recidivism was associated with decreasing incidence of transportation-related injury but increased incidence of overexertion or intentional injuries. CONCLUSION A small group of patients account for a significant proportion of ED injury visits. In comparison with injury patients seen once during the year, recidivists represent a younger population of lower socioeconomic status, and they are at increased risk of intentional injury.

Extracorporeal circulation in the management of severe tricyclic antidepressant overdose

Extracorporeal circulation is a technique that provides precise control of circulation, oxygenation, temperature, and blood composition in patients suffering from cardiopulmonary failure. The investigators present the case of a near fatal tricyclic antidepressant overdose that failed to respond to standard therapy but was resuscitated using extracorporeal circulation.

The Emergency Department Log as a Simple Injury-Surveillance Tool

STUDY OBJECTIVE To describe the development of an injury-surveillance system based on the emergency department log. SETTING An ED with 40,000 visits annually, tertiary care center. PARTICIPANTS All patients to our ED during a 6-month period. ED logs are used to collect basic information such as demographics, chief complaint, mode of arrival, and disposition. Our log was modified for collection of injury-related information such as whether the ED visit was because of an injury and, if so, the mechanism of injury. A list of 16 mechanism-of-injury codes was developed on the basis of review of existing literature and on a 1-month review of injuries in our population. The ED log data were entered into a database, and descriptive analysis was performed. RESULTS A list of mechanisms of injury was developed that, when implemented, was successful in coding 93% of injured patients in our ED population. The expansion of the ED log for collection of injury data required minimal training and cost. An example of the data obtained is presented to demonstrate the type of information available. Of the 18,742 patients, the ED log identified 5,067 patients (27%) as having been injured. Most were male (2,972 of 5,067 [59%]), and most were between 15 and 40 years of age (2,857 of 5,067 [61%]). Common mechanisms of injury included falls (907 of 5,067 [19%]), transportation (706 of 5,067 [15%]), cuts or punctures (332 of 5,067 [7%]), sports (323 of 5,067 [7%]), and assaults (245 of 5,067 [5%]). CONCLUSION With minimal training and cost, the ED log can be adapted for collection of injury data on all patients seen in the ED.

Development of an Emergency Department—Based Injury Surveillance System

STUDY OBJECTIVE To describe the development of an emergency department-based injury surveillance system, to describe the problems encountered, and to briefly describe the data output and potential applications. METHODS Within our university-based hospital system and Level I trauma center register, injury data currently exist on all ED patients. Over a 1-year period, these data sets were linked with our ED log using the hospital identification number and date of service as the key merge variables. Elements in our data set included demographic information, ED-related variables, and codes for nature of injury and circumstances of injury. Data files for 1 month were inspected manually to validate the success of the merger. Problems encountered in developing the system were summarized. RESULTS A manual review of 1 month of data files from our hospital system, trauma register, and ED log revealed that the records of more than 97% (2,802) of 2,878 injury patients seen in our ED had additional data attached after the merger. No errors of commission were found, but errors of omission occurred. The barriers that were encountered during the development of this injury surveillance system are described. CONCLUSION Hospital data can be linked to the ED log to create an injury surveillance system that captures valuable information on patients admitted and discharged from the ED.

Polyarteritis nodosa presenting as seizures

A case of polyarteritis nodosa presenting in the emergency department as grand mal seizures is reported. Seizure as a presenting feature of polyarteritis nodosa is unusual. The nature of the patients signs and symptoms led to the diagnosis of polyarteritis nodosa, which was supported by arteriography. Therapy with high-dose corticosteroids and cyclophosphamide resulted in rapid improvement. Standard anticonvulsant therapy proved efficacious during the initial treatment of the patients seizures. The patient died three months later at another facility. Cause of death as determined at autopsy was polyarteritis nodosa.

Poster 019. Work-Related Injuries Among Rural West Virginia Emergency Medical Services Providers

Purpose: To examine hospital hazardous-materials preparedness. Methods: The safety officers of all acute-care hospitals in the five-county Philadelphia metropolitan region received surveys. Questions addressed the ability of EDs to safely decontaminate and treat chemically contaminated patients. Results: Thirty-six of 58 hospitals (62.1%) returned usable surveys. Of these, 25 (69.4%) have a written ED hazmat plan, and 11 (30.6%) conducted a drill of the plan in 1994. Nineteen (52.8%) EDs have a specific treatment area for chemically contaminated patients. A stock of supplies for protecting the ED from secondary contamination is maintained by 16 (44.4%). While 23 (63.9%) EDs store personal protective equipment, most of these involve only gowns, gloves, and surgical masks; only 12 provide any type of respiratory protection. Seven respondents were certain that patients brought in by local EMS would have been decontaminated adequately in the field, eight stated that they believed or felt decontamination would be adequate, and 12 were concerned that field decontamination might not be adequate. Seventeen hospitals (47.2%) reported treating one or more (mean = 2.4) chemically contaminated patients in 1994. We believe the return rate reflects reluctance to commit hospital policies to paper. This was confirmed during telephone follow-up of nonrespondents; for example, one safety officer discussed hazmat principles for 40 minutes, but refused to complete the survey.

Case Report: Utilization of a Phased Response Disaster Plan

The traditional hospital disaster plan is complex and inefficient. Implementation during an actual or perceived crisis usually results in the mobilization of the entire hospital staff and multiple medical resources. This “all or none” phenomenon is costly in terms of manpower and supplies. Furthermore, there is protracted disruption of normal hospital services during disaster plan activation for training or real emergencies.