Marcus Martin

Emergency department sonography by emergency physicians

A retrospective study was conducted to examine whether emergency physicians can perform accurate ultrasonography that influences the diagnosis and treatment of selected disorders in the emergency department (ED). The physicians acquired a moderate level of expertise in sonography using a series of practical demonstrations and lectures. Patients with symptoms suggestive of cardiac, gynecologic, biliary tract, and abdominal vascular disease periodically underwent ED sonography. The initial interpretation was used as a diagnostic adjunct to subsequent therapy. The accuracy of positive sonographic findings was assessed by confirmatory testing, formal review, or confirmatory clinical course. Emergency physicians were able to diagnose correctly (1) the presence and approximate size of pericardial effusions, (2) the presence or absence of organized cardiac activity in patient with clinical electrical mechanical dissociation, (3) the presence or absence of intrauterine pregnancy in pregnant patients with lower abdominal/pelvic complaints, (4) the position of intrauterine devices in patients with suspected uterine perforation, (5) the presence of gallstones in patients with suspected biliary tract disease, and (6) the presence and size of abdominal aortic aneurysms in patients with pulsatile masses or unexplained abdominal pain. It was concluded that reliable sonography which influences diagnosis and therapy can be performed by emergency physicians and that sonography should become a standard procedure in EDs.

China white epidemic: An eastern united states emergency department experience

STUDY OBJECTIVEnThe purpose of this study was to isolate significant clinical or demographic findings concerning overdose patients treated during a China White (3-methyl fentanyl) epidemic and compare them with data for all unintentional narcotic overdose patients during a 24-month period.nnnDESIGNnWe reviewed charts from 85,246 patient visits to our emergency department during the 24-month period of January 1987 through December 1988 to study this narcotic epidemic. Data from the Allegheny County Coroners Office pertaining to unintentional drug overdose deaths that occurred during this same period also were reviewed.nnnSETTINGnThe first outbreak of narcotic overdoses in the eastern United States involving China White occurred in Allegheny County, Pennsylvania, in 1988.nnnTYPE OF PARTICIPANTSnPatients were included if they met the criteria of a suspected unintentional narcotic overdose, but excluded if they were not given naloxone.nnnINTERVENTIONSnEmergency physicians became suspicious of China White use after an unusual increase in narcotic overdoses presenting to the ED coupled with routine drug of abuse screens negative for opiates despite dramatic patient responses to naloxone. In most of the cases in which specific testing was done, there were positive indicators of fentanyl derivatives. Investigations found China White present in street drugs and paraphernalia.nnnMEASUREMENTS AND MAIN RESULTSnA cluster was defined as a time period with a statistically significant increase in overdoses over the expected number for an interval of equal length. Although there were no significant clinical differences in case presentation during the 24-month period, there was a statistically significant 13-fold increase in overdoses during the September through November 1988 cluster (mean, 13 vs 0.95 per month, P less than .001 by Wilcoxon rank-sum test). A dramatic increase in unintentional drug overdose deaths occurred in the county during this cluster. A total of 18 fentanyl-positive unintentional drug overdose deaths, predominantly male (89%) and black (56%), with an age range of 19 to 44 years (mean, 34.9 years), were reported by the county coroner (13 during the cluster). Narcotic overdoses and unintentional drug overdose deaths declined sharply with confiscation of a clandestine China White laboratory.nnnCONCLUSIONSnChina White was responsible for a dramatic rise in unintentional drug overdose deaths in Allegheny County in 1988. There were no significant clinical differences between China White overdose survivors and other unintentional narcotic overdose victims. Overdoses responsive to naloxone with inconsistent routine toxicologic screens may be due to a fentanyl analogue.

Enalaprilat, an intravenous angiotensin-converting enzyme inhibitor, in hypertensive crises

The effect of enalaprilat (MK‐422), a newly synthesized, intravenous, nonsulfhydryl, angiotensin‐converting enzyme inhibitor, was studied in seven patients with either severe or malignant hypertension. All subjects initially received a 1 mg bolus injection of enalaprilat followed in 30 minutes by 10 mg. Five subjects received an additional 40 mg. Mean (±SE) pretreatment blood pressure for the group was 226 ± 9/141 ± 7 mm Hg. Five minutes after the 1 mg enalaprilat dose, blood pressure decreased to 211 ± 10/131 ± 9 mm Hg and further fell to 201 ± 14/123 ± 11 mm Hg at 30 minutes. The maximal reduction in blood pressure to 169 ± 14/112 ± 10 mm Hg occurred 30 minutes after the 10 mg dose. No further blood pressure reduction was observed in those subjects who received the additional 40 mg dose. Within the entire group, five subjects exhibited sustained blood pressure reduction. No adverse side effects or symptomatic hypotension occurred in any subject.

Emergency Phenytoin Loading by Constant Intravenous Infusion

We evaluated the efficacy of constant intravenous (IV) phenytoin infusion. Thirty-eight patients were evaluated prospectively for complications of continuous-infusion phenytoin loading. A total dose of 18 mg/kg was administered as a solution of 500 mg phenytoin in 50 mL normal saline using a constant infusion pump. The initial delivery rate was 40 mg/min. Cardiac rhythm was monitored by telemetry, and rhythm strips and vital signs were obtained every 15 minutes during infusion. Therapeutic phenytoin blood levels (greater than 10 micrograms/mL) were achieved in 37 patients (97%). Infusion was discontinued in one patient because of IV site irritation shortly after initiation of the infusion. Phenytoin levels in the toxic range were seen immediately postinfusion in 22 patients and in the four-hour postinfusion samples of 16 patients. Thirteen of 18 levels drawn 12 to 24 hours after infusion were therapeutic. Phenytoin levels greater than 20 micrograms/mL were tolerated without significant change in rhythm, QRS interval, or QT interval. A small statistically significant (P less than .05) decrease in systolic and mean arterial pressure was noted during the infusion. Complications included burning at the IV infusion site in four patients; the discomfort was relieved in three cases by reducing the rate of infusion to 20 mg/min. Seizures occurred in two patients during the infusion, requiring the additional use of diazepam or phenobarbital. Administration of a loading phenytoin dose by constant IV infusion is an effective means for achieving therapeutic levels quickly.

Selection of emergency medicine residents

The selection of emergency medicine residents requires review of medical school performance and, usually, an interview in which applicants and program directors exchange important information. Computer technology is available to assist programs in the analysis of information about applicants. Ethnic diversity and minority recruitment should also be considered as 40% of all emergency medicine residencies have no minority residents. Suggestions for developing a valid, humane, and fair selection process are made.

Emergency department echocardiography in the diagnosis and therapy of cardiac tamponade

A 44-year-old male presented to the emergency department in shock with jugular venous distension and upper chest cyanosis. Superior vena cava syndrome was ruled out by computed tomography (CT scan). However, a large pericardial effusion was found on CT scan and confirmed by sonography. Pericardial tamponade was diagnosed by emergency physicians and sonography-guided pericardiocentesis was performed with marked improvement in symptomatology.

Ethnicity and analgesic practice: An editorial

Abstract [Martin ML. Ethnicity and analgesic practice: an editorial. Ann Emergy Med. January 2000;35:77-79.]

Delayed diagnosis of traumatic diaphragmatic hernia during pregnancy

We present a case of delay in diagnosis of diaphragmatic rupture and herniation in a pregnant 25-year-old woman. The diaphragmatic rupture was secondary to trauma sustained five months prior to presentation. Subsequent to her accident, she was provided medical care on multiple occasions for symptoms of intractable nausea, vomiting, and weight loss that were probably related to an expanding uterus and diaphragmatic herniation of abdominal contents. At the time she presented to us the herniation had progressed and she was experiencing severe respiratory difficulty. A nasogastric tube was placed for diagnosis and decompression. A chest radiograph provided the diagnosis of herniation of gastrointestinal contents through the left hemidiaphragm. A healthy 5-lb boy was delivered vaginally and subsequently a left thoracotomy was performed for decompression and repair of the diaphragm. The patients hospital course after hernia repair was uneventful.

Emergency department daily record review: a quality assurance system in a teaching hospital.

A system of daily patient chart review of 11 categories of physician documentation and patient care was implemented over a 36-month period at Allegheny General Hospital in Pittsburgh. A total of 108,317 charts of emergency patients were reviewed. Feedback on errors in all categories were given to the physicians responsible, and necessary corrective actions were taken as soon as possible. All new resident physicians rotated in two-month blocks and received orientation to patient care and chart documentation expectations prior to starting the service. All physicians charts underwent the same thorough chart review. Not only did the percentage of errors decrease from the first months to the second months of the residents rotations, but the yearly percentage of total errors decreased as the study progressed, from 5.47% to 3.57%.

Neuroleptic malignant syndrome

We present the case of a 35-year-old man who developed symptoms of the neuroleptic malignant syndrome (NMS) after taking prescribed, moderately high, therapeutic doses of haloperidol. When brought to the emergency department, he was comatose, hypotensive, and had rigid muscle tone and a core body temperature of 42.2 C. Although initial treatment was supportive, intubation, ventilator support, and further care in the intensive care unit were necessary. Ensuing disseminated intravascular coagulation was treated successfully and the patient was weaned from the ventilator on the third day after admission. He was discharged from the hospital 11 days after admission. Recently recognized drug therapy for NMS, such as bromocriptine mesylate and dantrolene sodium, was not used in this case.