Mark T. Steele

Forced Air Speeds Rewarming in Accidental Hypothermia

STUDY OBJECTIVE To compare the rates of rewarming of forced-air and passive insulation as a treatment for accidental hypothermia. METHODS We carried out a prospective, randomized clinical trial in two urban, university-affiliated emergency departments. Our subjects were 16 adult hypothermia victims with core temperatures less than 32 degrees C. A convective cover inflated with air at about 43 degrees C (forced-air group) or cotton blankets (control group) were applied until the patients core temperature reached 35 degrees C. Members of both groups were given IV fluids warmed to 38 degrees C and warmed, humidified oxygen at 40 degrees C by inhalation. RESULTS The mean +/- SD initial temperature was 28.8 degrees +/- 2.5 degrees C (range, 25.5 degrees C to 31.9 degrees C) in the patients who underwent forced-air rewarming and 29.8 degrees +/- 1.5 degrees C (range, 28.2 degrees C to 31.9 degrees C) in those given blankets. Core temperature increased about 1 degree C/hour faster in patients treated with forced-air rewarming (about 2.4 degrees C/hour) than in patients given only cotton blankets (about 1.4 degrees C/hour, P = .01). Core-temperature afterdrop was detected in neither group. CONCLUSION Forced air accelerated the rate of rewarming without producing apparent complications in hypothermic patients.

Trimethoprim–Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess

BACKGROUND U.S. emergency department visits for cutaneous abscess have increased with the emergence of methicillin-resistant Staphylococcus aureus (MRSA). The role of antibiotics for patients with a drained abscess is unclear. METHODS We conducted a randomized trial at five U.S. emergency departments to determine whether trimethoprim-sulfamethoxazole (at doses of 320 mg and 1600 mg, respectively, twice daily, for 7 days) would be superior to placebo in outpatients older than 12 years of age who had an uncomplicated abscess that was being treated with drainage. The primary outcome was clinical cure of the abscess, assessed 7 to 14 days after the end of the treatment period. RESULTS The median age of the participants was 35 years (range, 14 to 73); 45.3% of the participants had wound cultures that were positive for MRSA. In the modified intention-to-treat population, clinical cure of the abscess occurred in 507 of 630 participants (80.5%) in the trimethoprim-sulfamethoxazole group versus 454 of 617 participants (73.6%) in the placebo group (difference, 6.9 percentage points; 95% confidence interval [CI], 2.1 to 11.7; P=0.005). In the per-protocol population, clinical cure occurred in 487 of 524 participants (92.9%) in the trimethoprim-sulfamethoxazole group versus 457 of 533 participants (85.7%) in the placebo group (difference, 7.2 percentage points; 95% CI, 3.2 to 11.2; P<0.001). Trimethoprim-sulfamethoxazole was superior to placebo with respect to most secondary outcomes in the per-protocol population, resulting in lower rates of subsequent surgical drainage procedures (3.4% vs. 8.6%; difference, -5.2 percentage points; 95% CI, -8.2 to -2.2), skin infections at new sites (3.1% vs. 10.3%; difference, -7.2 percentage points; 95% CI, -10.4 to -4.1), and infections in household members (1.7% vs. 4.1%; difference, -2.4 percentage points; 95% CI, -4.6 to -0.2) 7 to 14 days after the treatment period. Trimethoprim-sulfamethoxazole was associated with slightly more gastrointestinal side effects (mostly mild) than placebo. At 7 to 14 days after the treatment period, invasive infections had developed in 2 of 524 participants (0.4%) in the trimethoprim-sulfamethoxazole group and in 2 of 533 participants (0.4%) in the placebo group; at 42 to 56 days after the treatment period, an invasive infection had developed in 1 participant (0.2%) in the trimethoprim-sulfamethoxazole group. CONCLUSIONS In settings in which MRSA was prevalent, trimethoprim-sulfamethoxazole treatment resulted in a higher cure rate among patients with a drained cutaneous abscess than placebo. (Funded by the National Institute of Allergy and Infectious Diseases; ClinicalTrials.gov number, NCT00729937.).

Retained glass foreign bodies in wounds: Predictive value of wound characteristics, patient perception, and wound exploration

A convenience sample of 164 adult patients with 185 glass-caused wounds who presented to an emergency department (ED) and consented to a radiograph was prospectively studied. The purpose was to determine the characteristics of wounds at high risk for foreign body (FB) and the predictive value of patient FB sensation and probing wound exploration for FB retention. Retained glass was located in 28 (15%) wounds. Motor vehicle as a mechanism of injury (P=.003), head as a location (P=.035), and puncture as wound type (P=.002) were more likely to be associated with retained FBs (chi2 analysis). Patients with wounds with glass were more likely to have a positive perception of a foreign body (41%) than those with no glass (17%) (P=.005). The positive predictive value of patient perception was 31%; negative predictive value was 89%. In five cases, wound exploration was negative and subsequent radiograph was positive for FB. In one of these cases, a 4-mm glass FB was removed; in the other four, no FB was found. In conclusion, head wounds resulting from motor vehicle accidents or puncture wounds are more likely to harbor retained glass FBs. Patients with glass FB in wounds are more likely to have a positive perception of FB; however, a positive perception has a low predictive value of glass FB. In this series, a negative wound exploration made the presence of retained FB greater than 2 mm less likely but did not rule out the presence of retained glass.

Opioid toxicity recurrence after an initial response to naloxone

OBJECTIVE To determine the frequency and potential predictors of opioid toxicity recurrence after a response to naloxone in adult Emergency Department patients. METHODS A retrospective case-control study of naloxone-treated patients with opioid toxicity over an 8-year period. Both the patient response to naloxone and recurrence of opioid toxicity was determined by an expert Delphi Panel. The frequency of opioid toxicity recurrence was compared by the duration of opioid effect, the route of opioid exposure, and the presence of other CNS depressant drugs. RESULTS Ninety of 221 (41%) cases with a discharge diagnosis of opioid toxicity were treated with naloxone; six patients were excluded because of a lack of toxicity. There was a response to naloxone in 50% of the 84 cases, and recurrence of toxicity in 31% (95% CI 17-45%) of naloxone responders. The most common opioids were codeine, heroin, propoxyphene, and oxycodone/hydrocodone. Recurrence of toxicity was more common with long-acting opioids (p = 0.04), and was not associated with the route of opioid exposure (p = 0.42), or presence of ethanol and other CNS depressants (p > or = 0.87). CONCLUSION Opioid toxicity recurrence after a response to naloxone occurred in approximately 1/3 of adult Emergency Department opioid overdose cases. Recurrence was more common with long-acting opioids and was not associated with the route of opioid exposure. Other clinically useful predictors of toxicity recurrence were not identified.

Prophylactic penicillin for intraoral wounds

We conducted a prospective, double-blind, placebo-controlled study in adult patients to determine whether prophylactic penicillin prevents infection in intraoral lacerations secondary to minor trauma or seizures. Uninfected full-thickness, mucosal-only, or through-and-through wounds presenting within 24 hours of injury were considered. Management consisted of cleansing, irrigation, debridement, and closure as indicated: no topical antibiotics were applied. Patients were randomly assigned to receive penicillin VK 500 mg or identically appearing placebo four times daily for five days. Home wound care was standardized and patients were followed for a minimum of four or five days. Infection was assessed clinically. Seventy-six patients were enrolled and 62 completed the study. Penicillin (30) and placebo (32) groups were similar in all parameters except wound etiology; assault was more common in the placebo group (P = .02). Two infections occurred in patients receiving penicillin, and six infections were seen among placebo-treated patients (P = .05, beta = 0.17). When patients poorly compliant with therapy were eliminated from analysis, none of the penicillin-treated patients and five of the placebo-treated patients developed infections (P = .027). Our data suggest that patients with intraoral wounds may benefit from prophylactic penicillin if compliant with their therapy. More studies are needed to further delineate the usefulness of prophylactic antibiotics for these wounds.

Prospective analysis of the effect of physician experience with the FAST examination in reducing the use of CT scans

Objective:  The objective of this study was to examine the effect of ultrasound experience level on emergency physicians’ Focused Assessment with Sonography for Trauma (FAST) exam accuracy and emergency physicians’ confidence in using FAST findings to assist in managing patients with blunt trauma.

Foreign body retention in glass-caused wounds

STUDY OBJECTIVE To describe patient and wound characteristics that are clinically useful in identifying wounds that were caused by glass and retained a foreign body. DESIGN Retrospective consecutive case review. SETTING Urban, university-affiliated teaching hospital. TYPE OF PARTICIPANTS Four hundred thirty consecutive patients with a total of 578 evaluable wounds caused by glass during a 12-month period. MEASUREMENTS AND RESULTS Medical records were reviewed to determine patient demographics, primary wound data (eg, location, type, description), mechanism of injury, type of glass involved, and presence of foreign body sensation. Glass was found by examination in 7% of wounds. Eight percent of 137 radiographs were positive. Wounds with the highest prevalence of retained glass were puncture wounds (P < .0005), those caused by stepping on glass or by a motor vehicle accident (P < .005), and those of the head or foot (P < .003). CONCLUSION Characteristics of wounds most likely to retain glass were identified in this retrospective study. The presence of these factors should increase the clinicians suspicion of a retained glass foreign body. The indications for radiography for the detection of retained glass in wounds should be clarified with prospective studies.

Survey of emergency medicine resident debt status and financial planning preparedness

OBJECTIVES Most resident physicians accrue significant financial debt throughout their medical and graduate medical education. The objective of this study was to analyze emergency medicine resident debt status, financial planning actions, and educational experiences for financial planning and debt management. METHODS A 22-item questionnaire was sent to all 123 Accreditation Council on Graduate Medical Education-accredited emergency medicine residency programs in July 2001. Two follow-up mailings were made to increase the response rate. The survey addressed four areas of resident debt and financial planning: 1) accrued debt, 2) moonlighting activity, 3) financial planning/debt management education, and 4) financial planning actions. Descriptive statistics were used to analyze the data. RESULTS Survey responses were obtained from 67.4% (1,707/2,532) of emergency medicine residents in 89 of 123 (72.4%) residency programs. Nearly one half (768/1,707) of respondents have accrued more than 100,000 dollars of debt. Fifty-eight percent (990/1,707) of all residents reported that moonlighting would be necessary to meet their financial needs, and more than 33% (640/1,707) presently moonlight to supplement their income. Nearly one half (832/1,707) of residents actively invested money, of which online trading was the most common method (23.3%). Most residents reported that they received no debt management education during residency (82.1%) or medical school (63.7%). Furthermore, 79.1% (1,351/1,707) of residents reported that they received no financial planning lectures during residency, although 84.2% (1,438/1,707) reported that debt management and financial planning education should be available during residency. CONCLUSIONS Most emergency medicine residency programs do not provide their residents with financial planning education. Most residents have accrued significant debt and believe that more financial planning and debt management education is needed during residency.

A Randomized Trial of Clindamycin Versus Trimethoprim-sulfamethoxazole for Uncomplicated Wound Infection

BACKGROUND With the emergence of community-associated methicillin-resistant Staphylococcus aureus (MRSA) in the United States, visits for skin infections greatly increased. Staphylococci and streptococci are considered predominant causes of wound infections. Clindamycin and trimethoprim-sulfamethoxazole (TMP-SMX) are commonly prescribed, but the efficacy of TMP-SMX has been questioned. METHODS We conducted a randomized, double-blind, superiority trial at 5 US emergency departments. Patients >12 years of age with an uncomplicated wound infection received oral clindamycin 300 mg 4 times daily or TMP-SMX 320 mg/1600 mg twice daily, each for 7 days. We compared the primary outcome, wound infection cure at 7-14 days, and secondary outcomes through 6-8 weeks after treatment, in the per-protocol population. RESULTS Subjects had a median age of 40 years (range, 14-76 years); 40.1% of wound specimens grew MRSA, 25.7% methicillin-susceptible S. aureus, and 5.0% streptococci. The wound infection was cured at 7-14 days in 187 of 203 (92.1%) clindamycin-treated and 182 of 198 (91.9%) TMP-SMX-treated subjects (difference, 0.2%; 95% confidence interval [CI], -5.8% to 6.2%; P = not significant). The clindamycin group had a significantly lower rate of recurrence at 7-14 days (1.5% vs 6.6%; difference, -5.1%; 95% CI, -9.4% to -.8%) and through 6-8 weeks following treatment (2.0% vs 7.1%; difference, -5.1%; 95% CI, -9.7% to -.6%). Other secondary outcomes were statistically similar between groups but tended to favor clindamycin. Adverse event rates were similar. CONCLUSIONS In settings where MRSA is prevalent, clindamycin and TMP-SMX produce similar cure and adverse event rates among patients with an uncomplicated wound infection. Further study evaluating differential effects of antibiotics on recurrent infection may be warranted. CLINICAL TRIALS REGISTRATION NCT00729937.

Screening for stimulant use in adult emergency department seizure patients

Objective: The objective of this study was to determine the prevalence of positive plasma drug screening for cocaine or amphetamine in adult emergency department seizure patients. Methods: This prospective study evaluated consecutive eligible seizure patients who had a plasma sample collected as part of their clinical evaluation. Plasma was tested for amphetamine and the cocaine metabolite benzoylecgonine using enzyme-mediated immunoassay methodology. Plasma samples with benzoylecgonine greater than 150 ng/mL or an amphetamine greater than 500 ng/mL were defined as positive. Patient demographics, history of underlying drug or alcohol-related seizure disorder, estimated time from seizure to sample collection, history or suspicion of cocaine or amphetamine abuse, results of clinical urine testing for drugs of abuse, and assay results were recorded without patient identifiers. Results: Fourteen of 248 (5.6%, 95% CI 2.7%–8.5%) plasma samples were positive by immunoassay testing for benzoylecgonine and no samples (0%, 95% CI0–1.2%) were positive for amphetamine. Positive test results were more common in patient visits where there was a history or suspicion of cocaine or amphetamine abuse (p < 0.0005). Conclusions: During this study period, routine plasma screening for cocaine and amphetamines in adult seizure patients had a low yield. As a result, routine plasma screening would yield few cases of stimulant drug in which there was neither a history nor suspicion of drug abuse in this population.