Kenneth J. Rhee

Family participation during resuscitation: An option

We began to question the fairness of a policy to exclude close family members from the treatment room during attempted resuscitation of cardiac arrest victims in 1982 after 13 of 18 surviving relatives (72%) who were surveyed about their experiences during the attempted resuscitation of a family member responded that they would have liked to have been present during the resuscitation. We report the results of a program instituted at that time that allowed selected family members to be present during resuscitation efforts. Family members were asked by a chaplain or nurse if they wished to be present in the resuscitation room, and those accepting were accompanied by a supporting emergency staff member who explained the milieu of the code room. None of the participants interfered with resuscitation efforts. Seventy persons who participated were later contacted by one of the chaplains and asked to complete a survey form. Forty-four of 47 respondents (94%) who had been present during resuscitation believed that they would participate again. Thirty-six (76%) thought that adjustment to the death or grieving was facilitated by their witnessing the resuscitation; 30 (64%) felt that their presence was beneficial to the dying family member. We conclude that lay person may wish to be with family members who may be dying even though resuscitation efforts are being made, and that it is reasonable to inquire about this wish. This experience has assisted the grieving process for many and has not interrupted or adversely affected medical efforts at resuscitation.

Patient satisfaction with a nurse practitioner in a university emergency service

STUDY OBJECTIVE To compare the overall satisfaction with emergency department care of patients seen by a nurse practitioner (NP) with that of patients seen in the usual fashion. DESIGN A case-control study comparing responses by means of a five-point scale from a prospectively designed telephone survey. SETTING Midwestern urban university hospital ED in which most patients are seen mainly by fourth-year medical students or house staff and all patients are seen and evaluated by the attending staff. PARTICIPANTS Patients or, for children and incompetent adults, the person who accompanied the patient to the ED. RESULTS Overall satisfaction was good for both groups of patients and was not significantly different: 3.9 (SD, 1.1) for the NP group versus 4.0 (SD, 1.3) for the control group (P = .66 [NS]). CONCLUSIONS This study supports data from earlier studies suggesting that patients are satisfied with ambulatory care delivered by NPs.

The Rapid Acute Physiology Score

The Rapid Acute Physiology Score (RAPS) was developed and tested for use as a severity scale in critical care transports. RAPS is an abbreviated version of the Acute Physiology and Chronic Health Evaluation (APACHE-II) using only parameters routinely available on all transported patients (i.e. pulse, blood pressure, respiratory rate, and Glasgow Coma Scale). RAPS has a range from 0 (normal) to 16. Two hundred eighty-three patients were transported by helicopter; 62 died. Pretransport RAPS was available on 282 of 283 patients (mean, 3.85; median, 3). Because of death, discharge, or transfer, 227 complete APACHE-II scores using least physiologic values for the first 24 hours after transfer were collected (mean, 14.98; median, 13). Stepwise logistic regression showed that when all APACHE-II and RAPS values were available, the best single predictor of mortality was worst value APACHE-II (X2(1) = 57.09, P less than .01). When pretransport RAPS was considered as a single explanatory variable, it too had significant predictive power for mortality (X2(1) = 92.53, P less than .01). Correlation analysis comparing RAPS with APACHE-II values at similar points in time revealed a significant relationship in all cases, with the highest correlation between RAPS worst values and APACHE-II worst values (r = .8472, P less than .01). It was concluded that RAPS can be applied usefully in complement with APACHE-II and may have limited utility when used alone.

Oral intubation in the multiply injured patient: The risk of exacerbating spinal cord damage

The use of oral intubation during the resuscitation of seriously injured patients has been discouraged because of the fear that this technique may lead to cervical cord damage. We report a retrospective study of the 18-month experience of an emergency department in which oral intubation was the usual method of airway control for victims of blunt trauma. There were 237 injured patients intubated in the ED; 21 patients (8.9%) had cervical cord or bone injury. There were no patients in whom a neurologic loss followed an airway maneuver. Oral intubation was the definitive airway maneuver in 213 patients. There was no statistically significant difference in the type of definitive airway maneuver used (eg, oral intubation, nasal intubation, or cricothyrotomy-tracheotomy) between patients with cervical injuries and patients without such injuries. The risk of spinal cord injury secondary to oral intubation in the seriously injured patient was low in our population. Selection of the method for definitive airway control should be based primarily on the operators skills and experience rather than the fear of inflicting cervical cord damage.

Massive verapamil ingestion: A report of two cases and a review of the literature

This report describes two patients who were victims of massive verapamil ingestion and then reviews the available literature. Because verapamil blocks the slow calcium channels of the heart and blood vessels, the use of calcium as a treatment would be logical. In the two cases reported here, calcium was only transiently effective in maintaining cardiac output and blood pressure. Several other agents were then used and most were ineffective. This is similar to experience reported in the literature that suggests that no single agent is capable of reversing verapamils negative inotropic, dromotropic, chronotropic, and vascular smooth muscle effects.

CAN NURSES PERFORM SURGICAL CRICOTHYROTOMY WITH ACCEPTABLE SUCCESS AND COMPLICATION RATES

STUDY OBJECTIVE This study was undertaken to determine whether flight nurses can perform surgical cricothyrotomies with acceptable success and complication rates. METHODS This case series examined the survival, success, and complication rates of surgical cricothyrotomy. A specially trained flight nurse retrospectively reviewed all prehospital, emergency department, inpatient, autopsy, and outpatient follow-up records. RESULTS Fifty-five consecutive patients in whom surgical cricothyrotomy was attempted by a flight nurse during a two-and-one-half-year period were studied. Patients ranged in age from 9 to 76 years. The airway was not cannulated successfully by a flight nurse in two patients. In two patients, the tube was not in the cricothyroid space (one in the upper tracheal rings, and the other in the larynx). In three patients, packing was insufficient to stop bleeding from around the operative site; and in three the tube became occluded by blood in the emergency department. Finally, two patients developed subglottic stenosis. CONCLUSION Surgical cricothyrotomy in the field can be performed reliably by specially trained nurses. Because only the most critically ill or injured patients with unmanageable airways are subjected to this procedure, a significant complication rate can be anticipated.

Double-Blind, Multicenter Trial to Compare the Efficacy of Intramuscular Dihydroergotamine Plus Hydroxyzine Versus Intramuscular Meperidine Plus Hydroxyzine for the Emergency Department Treatment of Acute Migraine Headache☆☆☆★★★

STUDY OBJECTIVE To evaluate intramuscular dihydroergotamine in direct comparison with opioid analgesia in the treatment of acute migraine headache. METHODS This was a prospective, multicenter, double-blind trial performed in the emergency departments of 11 general hospitals in the United States. One hundred seventy-one patients between the ages of 18 and 60 years who presented to the ED with acute migraine headache were enrolled. Patients were randomly assigned to receive either 1 mg dihydroergotamine (DHE) or 1.5 mg/kg meperidine (MEP) by intramuscular injection. The anti-nauseant hydroxyzine (H) was coadministered in both treatment groups. RESULTS One hundred fifty-six patients were evaluable. Treatment groups were comparable in sample size, demographics, and baseline measurements of headache pain. Reduction of headache pain as measured on a 100-mm visual analog scale was 41+/-33 mm (53.5% reduction) for the DHE group, and 45+/-30 mm (55.7% reduction) for the MEP group at 60 minutes after treatment (difference=2.2%; 95% confidence interval [CI] -10%, 14.5%; P=.81). Reduction in the severity of nausea and improvement in functional ability were similar between treatment groups. Central nervous system adverse events were less common in the DHE group (DHE 23.5% versus MEP 37.6%, difference-14.1%: 95% CI -28%, 0%). In particular, dizziness was reported less commonly with DHE than MEP (2% versus 15%, difference=-13%: 95% CI -21%, -5%). CONCLUSION In this prospective, double-blind trial of a convenience sample of ED patients randomly assigned to one of two treatment regimens, DHE and MEP were comparable therapies for acute migraine. The use of DHE avoids several problems associated with opioid analgesia, including dizziness.

The incidence of battery in an urban emergency department

STUDY OBJECTIVE To determine the incidence of battery against emergency department medical staff by patients or visitors. DESIGN Prospective descriptive study over a nine-month period. SETTING A university-affiliated ED Level I trauma center with an annual census of approximately 64,000 located in a major metropolitan area. PARTICIPANTS All staff members who had been punched, kicked, grabbed, pushed, or spat on by a patient or visitor while on duty in the ED. INTERVENTIONS Questionnaire that was completed after the incident. RESULTS During the study period, there were 19 instances of violence against staff by patients. Staff members were punched six times, kicked seven times, grabbed three times, pushed once, and spat on twice. Blows usually were sustained on the face or head (seven) or on the extremities (seven). In only four cases were hospital incident reports filled out, and in no case was there an injury serious enough to require ED treatment or disability leave. The assailant was usually male (15 of 19, 79%) and usually on a psychiatric or substance abuse detainment (15 of 19, 79%). CONCLUSION This study suggests that instances of battery in an urban university hospital ED usually are not serious and are committed by patients on a psychiatric or substance abuse detainment.

Choreoathetoid disorder associated with amphetamine-like drugs

Three cases of an acute choreoathetoid disorder that developed after the use of an amphetamine-like drug are reported. Because of the dramatic improvement in symptoms over a few hours in these cases, we recommend observation, supportive care, and the careful oral administration of activated charcoal.

APACHE II scoring in the injured patient

The purpose of this study was to measure the predictive power of Acute Physiology and Chronic Health Evaluation (APACHE II) with respect to mortality in a group of seriously injured patients and to compare this predictive power with that of the Trauma Score (TS) and the Injury Severity Score (ISS). Six hundred ninety-one helicopter-transported patients were studied. Individual logistic regressions demonstrated that all three scores had significant predictive power when considered individually (TS chi 2 = 136, p less than .0001; APACHE II chi 2 = 171, p less than .0001; ISS chi 2 = 109, p less than .0001). In addition, each severity score added significantly to the predictive power in a stepwise logistic regression (TS chi 2 = 15, p less than .0001; APACHE II chi 2 = 45, p less than .0001; ISS chi 2 = 15, p less than .0001). Areas under the receiver operating curves for the three scores were not significantly different (TS 0.8116, SD 0.0245; APACHE II 0.8515, SD 0.0204; ISS 0.7967; SD 0.0223). APACHE II is a good predictor of mortality, and its predictive power is complemented by TS and ISS.