Michael Orlinsky

Pain comparison of unbuffered versus buffered lidocaine in local wound infiltration

The purpose of this study was to compare the pain of infiltration between unbuffered lidocaine and buffered lidocaine in a traumatic laceration. Solutions of unbuffered 1% lidocaine and buffered 1% lidocaine were randomly assigned to Site I or Site II of a single laceration for each subject, with the patient serving as self-control. Pain scores were recorded for each site, and an anesthetic preference was determined for each patient. It was found that buffered lidocaine had a preference ratio of 3.0 over unbuffered lidocaine (95% confidence interval, 1.86 to 4.84; P less than 0.0001). It was also found that Site I was preferred more often than Site II regardless of which medication was used. The conclusion is that buffered lidocaine is preferred over unbuffered lidocaine and that the order of injection is an important factor in trials that involve multiple sequential injections in the same patient.

Use of ocular ultrasound for the evaluation of retinal detachment.

BACKGROUND Retinal detachment is an ocular emergency posing diagnostic difficulty for the emergency practitioner. Direct fundoscopy and visual field testing are difficult to perform and do not completely rule out retinal detachment. Ophthalmologists use ocular ultrasound to enhance their clinical acumen in detecting retinal detachments (RD), and bedside ultrasound capability is readily available to many emergency practitioners (EP). STUDY OBJECTIVE Our study sought to assess whether ocular ultrasound would be a helpful adjunct for the diagnosis of RD for the practicing EP. METHODS This was a prospective observational study with a convenience sample of patients. As part of a general course on emergency ultrasonography, practitioners received a 30-min training session on ocular ultrasound before beginning the study. Trained practitioners submitted ultrasound scans with interpretation on patients with signs and symptoms consistent with retinal detachment. RESULTS Thirty-one of the 72 practitioners trained submitted ocular ultrasound reports on patients presenting to the Emergency Department with concerns for retinal detachments. EPs achieved a 97% sensitivity (95% confidence interval [CI] 82-100%) and 92% specificity (95% CI 82-97%) on 92 examinations (29 retinal detachments). Disc edema and vitreous hemorrhage accounted for false positives, and a subacute retinal detachment accounted for the only false negative. CONCLUSION These data show that trained emergency practitioners can use ocular ultrasound as an adjunct to their clinical assessment for retinal detachment.

Comparative study of intra-articular lidocaine and intravenous meperidine/diazepam for shoulder dislocations

The purpose of this study was to compare the analgesic effectiveness of intra-articular lidocaine versus intravenous meperidine and diazepam during the reduction of anterior shoulder dislocations. Patients were randomized to one of the two methods before the reduction of shoulder dislocations. Patients marked a visual analog pain scale at baseline, after anesthesia just before reduction, and at the time of discharge. Interference with the procedure caused by pain or lack of muscle relaxation, perception of adequacy of analgesia by the patient, adverse effects, and time to discharge from the Emergency Department (ED) were measured. Differences of outcomes, relative risks (RR), and 95% confidence intervals (CIs) were derived. Fifty-four patients with anterior shoulder dislocations presenting from May 21, 1998 through January 21, 1999 were included in this study; 29 were randomly assigned to receive intra-articular lidocaine (IAL) and 25 to receive intravenous meperidine/diazepam (IVMD). IAL was less effective than IVMD in relieving pre-reduction pain (p = 0.045) but equally effective in overall pain relief (p = 0.98). IAL was more effective than IVMD in shortening recovery time (p = 0.025). There was an indication favoring IVMD in terms of physician-perceived muscle relaxation and patients perception of analgesia adequacy. In conclusion, although the IVMD method appears to have some clinically and statistically significant advantages, IAL possesses some favorable features that render it to be an analgesia alternative in shoulder dislocation reduction.

Cost analysis of stapling versus suturing for skin closure

A randomized, prospective study was performed to test the null hypothesis that there is no difference between the cost of stapling and suturing for skin closure of selected linear lacerations. Appropriate wounds were randomly assigned to be closed by staples or sutures. Wound lengths, skin closure times, and the number of staples or the number and types of sutures used were recorded. Costs for materials and labor were calculated. The average total cost per case was

Safety and effectiveness of portable fluoroscopy in the emergency department for the management of distal extremity fractures.

17.69 (with suture kit) and

The validity and reliability of the navicular fat stripe as a screening test for detection of navicular fractures

7.84 (without suture kit) for the staple Group compared with

The comparative accuracy of radiolucent foreign body detection using ultrasonography

21.58 for the suture Group (P = .0001 for each). It is concluded that stapling is less costly than suturing and that the advantage appears to increase as laceration length increases.

A Comparison of Phenytoin‐loading Techniques in the Emergency Department

Abstract [Lee SMK, Orlinsky M, Chan LS: Safety and effectiveness of portable fluoroscopy in the emergency department for the management of distal extremity fractures. Ann Emerg Med October 1994;24:725-730.]

Cost-effectiveness of oral phenytoin, intravenous phenytoin, and intravenous fosphenytoin in the emergency department

STUDY OBJECTIVE The purpose of this study was to determine if the navicular fat stripe (NFS) is a valid and reliable screening tool in assessing potential navicular fractures. DESIGN Retrospective analysis. SETTING Minor trauma section of the Los Angeles County-University of Southern California Medical Center emergency department. TYPE OF PARTICIPANTS Study population included patients seen for wrist injury between January 1987 and December 1988. The individuals who interpreted the radiographs included eight observers with varying degrees of radiographic experience. INTERVENTIONS None MEASUREMENTS AND MAIN RESULTS The positive predictive value averaged 12% or 15% depending on how we counted a straight NFS, and the negative predictive value averaged 93% or 95%, again depending on how we counted a straight NFS. A straight NFS was ten times as likely to occur among normal wrists than among those with navicular fractures. Interobserver reliability was found to be high with a Hoyt reliability coefficient of .79. CONCLUSIONS An abnormal NFS is a poor predictor of a navicular fracture while both a straight and a normal NFS are good predictors of no navicular fracture. A normal NFS may allow less stringent treatment by the emergency physician. Extremes of radiographic experience were found to have no significant effect on NFS interpretation.