Ralph B Leonard

Posterior sternoclavicular dislocation: A case report

Posterior sternoclavicular dislocation is a relatively rare form of trauma, but one that must be recognized by the emergency physician. Such a case is presented here. Due to the proximity of the clavicle to critical thoracic outlet structures, serious complications can arise from a posterior dislocation: impingement on and possible trauma to the trachea, pneumothorax, laceration of underlying great vessels, brachial plexus injury, esophageal trauma, and laryngeal trauma that may cause permanent vocal cord changes. Many of these potential complications are life-threatening, and it is important that this injury not be triaged in the emergency department as a minor injury, thereby leading to its improper or delayed treatment.

Blunt carotid artery trauma: A case report

Blunt carotid artery trauma represents only 3% of all carotid artery injuries, but 42% of reported cases have been associated with severe neurologic deficits. We present a case of blunt injury to the right internal carotid artery with subsequent thrombosis and neurologic deficit. Computed tomography (CT) of the head without contrast was normal, a finding that emphasizes the importance of obtaining carotid arteriograms in any patient with a focal neurologic deficit but a normal CT of the head. We review the incidence, mechanism, presentation, and treatment of blunt carotid injuries. We also stress the importance of observing for blunt carotid injuries in the patient with blunt cervical trauma in order to allow earlier intervention, since patient outcome is dependent on that early recognition and intervention.

Patient-Data Collection System Used During Medical Operations After the 1994 San Fernando Valley-Northridge Earthquake

INTRODUCTION In large disasters, such as earthquakes and hurricanes, rapid, adequate, and documented medical care and distribution of patients are essential. METHODS After a major (magnitude 6.7 Richter scale) earthquake occurred in Southern California, nine disaster medical assistance teams and two Veterans Administration (VA) buses with VA personnel responded to staff four medical stations, 19 disaster-assistance centers, and two mobile vans. All were under the supervision of the medical support unit (MSU) and its supervising officer. This article describes the patient-data collection system used. All facilities used the same patient-encounter forms, log sheets, and medical treatment forms. Copies of these records accompanied the patients during every transfer. Centers for Disease Control and Prevention data classifications were used routinely. The MSU collected these forms twice each day so that all facilities had access to updated patient flow information. RESULTS Through the use of these methods, more than 11,000 victims were treated, transferred, and their cases tracked during a 12-day period. CONCLUSIONS Use of this system by all federal responders to a major disaster area led to organized care for a large number of victims. Factors enhancing this care were the simplicity of the forms, the use of the forms by all federal responders, a central data collection point, and accessibility of the data at a known site available to all agencies every 12 hours.

Emergency department radiation accident protocol

Every emergency department faces the potential problem of handling one or more victims of a radiation accident. While emergency departments near nuclear power plants or isotope production laboratories probably have a detailed protocol for such emergencies, a similar protocol is needed for the emergency department that may have to handle an isolated event, such as a vehicular accident that spills radioactive material and contaminates passengers or bystanders. This communication attempts to answer that need, presenting a step-by-step protocol for decontamination of a radiation victim, the rationale on which each step is based, a list of needed supplies, and a short summary of decorporation procedures that should be started in the emergency department.

Effects of isopropyl alcohol, ethanol, and polyethylene glycol/industrial methylated spirits in the treatment of acute phenol burns

STUDY OBJECTIVE To compare the effects of water rinse with those of isopropyl alcohol, polyethylene glycol with industrial methylated spirits, or ethanol on cutaneous phenol burns. DESIGN Controlled trial with all animals receiving all treatments applied to different cutaneous phenol burn sites. TYPE OF PARTICIPANTS Swine weighing 9 to 18 kg. INTERVENTIONS In phase 1, each burn site was treated with water rinse for zero, one, or five minutes combined with either isopropyl alcohol, polyethylene glycol with industrial methylated spirits, ethanol, or no other treatment. Biopsies of treatment sites were done at 30 minutes and at 48 hours. In phase 2, a pilot study, the effect of isopropyl alcohol, polyethylene glycol with industrial methylated spirits, or water treatment on serum phenol levels was noted in animals with 5%, 10%, and 15% body surface area burns. MEASUREMENTS AND MAIN RESULTS In phase 1, on histological examination of biopsy specimens, significant differences in tissue damage occurred among the groups (P < .05). Isopropyl alcohol and polyethylene glycol with industrial methylated spirits were the most efficacious treatments; the duration of water rinse had no significant effect. In phase 2, the systemic absorption of phenol may be greater with water treatment than with isopropyl alcohol treatment. CONCLUSION Isopropyl alcohol and polyethylene glycol with industrial methylated spirits are equally effective in the amelioration of phenol burns of less than 5% total surface area. The wider availability of isopropyl alcohol makes it potentially the most useful treatment for these small burns. Further studies of its risks are needed.

Medical outreach after hurricane Marilyn

INTRODUCTION Many geographical areas are subject to devastating disasters that leave the citizens not only without homes, but also without their local medical systems. Now medical-aid stations consisting of personnel, supplies, and equipment quickly can be deployed when needed to such areas under the aegis of the National Disaster Medical System (NDMS). Such teams can provide emergent medical care as well as daily medical care. However, these aid stations are of no help for the home-bound or nursing home patients too infirm to reach them. Thus, these citizens only can obtain medical care if medical teams make planned outreach excursions to reach them. OBJECTIVE To describe a planned outreach program that was implemented for such patients on St. Thomas Island after it was devastated by Hurricane Marilyn in 1995. RESULTS Over a five-day period, the outreach team provided medical care for 67 patients ranging in age from 11 days to 90 years. Play and art therapy was provided for non-injured children. The most common needs in the elderly were anti-hypertensive medications and insulin-loaded syringes. CONCLUSIONS For outreach efforts of this nature, membership of the team should include a registered nurse, a paramedic, a respiratory therapist, a public health specialist, and a local authority familiar both with the area and its inhabitants. A physician does not need to be assigned to the team, but should be available by radio.

MASS EVACUATION IN DISASTERS

The emergency physician plays an important role in disaster planning and management. Some disasters will require the removal of a segment of the population for their own safety; this removal is referred to as mass evacuation. This aspect of disaster planning is frequently ignored or, at best, given a few short sentences in overall plans for coping with disasters. Very little has been written on this important aspect to permit one to make intelligent evacuation plans. This article summarizes previous studies on the reactions of people to, and their behavior during, actual mass evacuations. The information is used to outline important points that must be addressed by all those involved in disaster plans so that people may be removed from danger quickly, with as few problems as possible.

SARA (Superfund Amendments and Reauthorization Act), Title III: Implications for emergency physicians

Practically every community has one or more industries that use or produce hazardous chemicals. The release of these chemicals into that communitys environment has the potential of causing serious health problems. Previously, physicians have not had information about what hazardous chemicals were in their community or a warning that release of a hazardous chemical had occurred. The Emergency Planning and Community Right-to-Know Act of 1986, known as Title III of the Superfund Amendments and Reauthorization Act (SARA), now mandates that every facility using, storing, or manufacturing hazardous chemicals make public its inventory and report every release of a hazardous chemical to public officials and health personnel. Every facility also must cooperate with physicians who are treating victims of exposure. Emergency physicians, both in their role in their communitys emergency medical services system and as physicians in emergency departments, will soon be involved in many aspects of SARAs numerous ramifications. This report is intended to familiarize the emergency physician with the basic components of Title III of SARA.

Peripartum cardiomyopathy: A case report

Peripartum cardiomyopathy (PPCM) is a relatively rare form of acute heart failure. Onset is from the last trimester of pregnancy to 5 months postpartum. Diagnosis is made by excluding other causes of acute heart failure, such as infections or toxins, and by determining that the patient does not have an underlying cardiac problem that has been unmasked by pregnancy. Diagnosis in the last trimester is complicated by the fact that the early symptoms of this disorder may mimic the symptoms of normal pregnancy. PPCM must be considered in any patient who presents with new onset peripheral edema, dyspnea on exertion, or paroxysmal nocturnal dyspnea during late pregnancy or up to 5 months postpartum. Limited studies suggest that early and aggressive therapy is associated with a better outcome. Therapy is directed toward decreasing preload and improving cardiac function. Return of cardiac size to normal is associated with a better prognosis than continued cardiomegaly.

Emergency Evacuations in Disasters

Some disasters produce circumstances that require the emergency removal of some or all of the citizens from a geographic area. Emergency or mass evacuation can be divided into immediate evacuation, in which the citizens are given no warning of their need to evacuate, and potential evacuation, in which citizens are given time (usually a day or two) to evacuate. The mass evacuation aspect of disaster planning frequently is neglected, but must be planned in detail. An essential ingredient of a plan is the designation of a person who has the authority to order an evacuation and that that person or an authorized alternate, is available instantly 24 hours a day. The plans should identify likely scenarios which could require emergency evacuation for a given community requiring, means of communicating with the citizens, evacuation routes, evacuation mechanisms, and shelter arrangements. All plans need to take into account human behavior during such a stressful situation.