Vincent P Verdile

The syringe aspiration technique to verify endotracheal tube position

This prospective, clinical study was performed to determine the utility of the syringe aspiration technique (SAT) to verify endotracheal tube (ETT) position. Ninety consecutive patients requiring urgent intubation in the emergency department or prehospital setting were enrolled in the study. The SAT correctly identified intratracheal ETT placement in 88 patients and esophageal misplacement in 2 patients. Ultimately, standard detection techniques were used to confirm ETT placement. The SAT was an accurate means of verifying ETT placement.

Torsion of the fallopian tube

Isolated fallopian tube torsion is a rare entity that most frequently occurs during the menstruating years, but has also been reported in premenopausal and postmenopausal women. Diagnosis of this condition is often delayed because of the rarity of its occurrence and prolonged investigations to rule out more common causes of acute abdominal pain. A case of a 13-year-old girl with isolated left fallopian tube torsion is presented. A high index of suspicion must be maintained for adnexal torsion in women with abdominal pain so that an attempt can be made to salvage the adnexal structures.

Anabolic steroid use as the possible precipitant of dilated cardiomyopathy.

Anabolic-androgenic steroid (AAS) use is common among young males, including adolescents. There have been several anecdotal reports of severe cardiovascular events in self-reported young users of AAS, including acute myocardial infarction, sudden cardiac death, and cardiomyopathy. We present an additional case of a young male weight lifter who presented with dyspnea and chest pain attributable to dilated cardiomyopathy (DC), his only known risk factor being the recent use of AAS. The possible role of AAS in the development of DC is discussed.

Physician and patient factors influencing the treatment of low back pain

&NA; Previous retrospective studies have suggested that patient demographics may influence analgesic administration. These studies have not taken physicians’ impression of patient pain into account. This prospective study investigates the influence of (i) physician impression of the degree of pain and (ii) patient demographics on the use of analgesic. A convenience sample of adults with non‐traumatic lower back pain was studied. Possible predictors of analgesic administration included physician pain scores (assessed by visual analogue scale), patient ethnicity, gender, age, and insurance. These variables were tested individually and then using logistic regression. For the total of 91 patients enrolled, only physician pain scale was found to be associated with analgesic use. Median scores were 68 mm (interquartile range=62–80 mm) for those receiving treatment versus 48 mm (interquartile range=30–58 mm) for those who did not (P<0.001). This study therefore suggests that physician impression of patient pain rather than patient demographics influences analgesic use.

Effectiveness of mechanical versus manual chest compressions in out-of-hospital cardiac arrest resuscitation: A pilot study

A prospective, randomized effectiveness trial was undertaken to compare mechanical versus manual chest compressions as measured by end-tidal CO2 (ETCO2) in out-of-hospital cardiac arrest patients receiving advanced cardiac life support (ACLS) resuscitation from a municipal third-service, emergency medical services (EMS) agency. The EMS agency responds to approximately 6,700 emergencies annually, 79 of which were cardiac arrests in 1994, the study year. Following endotracheal intubation, all cardiac arrest patients were placed on 100% oxygen via the ventilator circuit of the mechanical cardiopulmonary resuscitation (CPR) device. Patients were randomized to receive mechanical CPR (TCPR) or human/manual CPR (HCPR) based on an odd/even day basis, with TCPR being performed on odd days. ETCO2 readings were obtained 5 minutes after the initiation of either TCPR or HCPR and again at the initiation of patient transport to the hospital. All patients received standard ACLS pharmacotherapy during the monitoring interval with the exception of sodium bicarbonate. CPR was continued until the patient was delivered to the hospital emergency department. Age, call response interval, initial electrocardiogram (ECG) rhythm, scene time, ETCO2 measurements, and arrest outcome were identified for all patients. Twenty patients were entered into the study, with 10 in each treatment group. Three patients in the TCPR group were excluded. Measurements in the HCPR group revealed a decreasing ETCO2 during the resuscitation in 8 of 10 patients (80%) and an increasing ETCO2 in the remaining 2 patients. No decrease in ETCO2 was noted in the TCPR group, with 4 of 7 patients (57%) actually showing an increased reading and 3 of 7 patients (43%) showing a constant ETCO2 reading. The differences in the ETCO2 measurements between TCPR and HCPR groups were statistically significant. Both groups were similar with regards to call response intervals, patient ages, scene times, and initial ECG rhythms. One patient in the TCPR group was admitted to the hospital but later died, leaving no survivors in the study. TCPR appears to be superior to standard HCPR as measured by ETCO2 in maintaining cardiac output during ACLS resuscitation of out-of-hospital cardiac arrest patients.

Incidence of aspiration after urgent intubation

This study sought to determine the incidence of aspiration after urgent endotracheal intubation (ET) performed in the emergency department (ED), and to offer a descriptive evaluation of these intubations. In a retrospective review of 133 charts, 87 patients met inclusion criteria. Aspiration occurred in 3 (3.5%) patients (95% confidence interval, 0%, 7.4%). One had witnessed aspiration, and 2 had positive sputum cultures. None of the 87 patients had a positive chest radiograph or unexplained hypoxemia up to 48 hours after ET. Rapid-sequence induction and oral ET was performed in 79 (91%) patients, whereas 4 spontaneously breathing patients were nasally intubated. Seventy percent of patients underwent ET by PGY I or II residents, 29% by PGY III or IV residents, and 1% by ED attending physicians. Seventy-seven patients were intubated on the first attempt, and airway blood or vomitus during ET was noted in 11 patients. This study offers significant descriptive information regarding urgent ET performed in the ED, and shows that aspiration after urgent ET occurs infrequently in ED patients.

Agreement between rectal and tympanic membrane temperatures in marathon runners.

STUDY OBJECTIVE To determine the agreement between rectal temperature and infrared tympanic membrane temperatures in marathon runners presenting to a field hospital at the finish line. METHODS The subjects of this prospective, blinded, controlled study were runners 18 years or older who were triaged to the acute care medical area at the finish line for suspected hypothermia, hyperthermia, dehydration, or altered mental status. Rectal and tympanic temperatures were measured simultaneously in all subjects for whom rectal temperature measurement had been deemed necessary and recorded on separate data cards. RESULTS Of the 239 runners treated in the acute care medical area, 37 required rectal temperature measurement and were enrolled in the study. The mean rectal temperature was 38.45 degrees +/- 1.20 degrees C (range, 35.9 degrees to 41.5 degrees C). The mean tympanic membrane temperature was 37.81 degrees +/- 95 degrees C (range, 36.3 degrees to 40.4 degrees C). Pearsons correlation coefficient revealed a moderate correlation (r = .6902, P = .00023). The mean temperature difference between the two thermometers, mean rectal minus mean tympanic membrane, was .64 degrees C (95% confidence interval, .35 degrees to .93 degrees C). Sixty-Two percent of the tympanic membrane readings were within 1 degree C of their rectal counterparts. Agreement ranged from 1.16 degrees (+2 SD) to -2.95 degrees (-2 SD). The 95% confidence interval was 1.67 degrees to -2.95 degrees C. CONCLUSION We were able to demonstrate only a moderate correlation between the two thermometer readings, with a wide spread between the limits of agreement. This spread could be clinically significant and therefore limits the usefulness of tympanic temperature in the marathon race setting. Because of the potentially large and clinically significant differences in rectal and tympanic temperatures and the limitations inherent in our study, we cannot endorse the use of tympanic temperature in the setting of a marathon event.

Out-of-Hospital Deliveries: A Five-Year Experience

INTRODUCTION Prehospital providers regularly encounter patients with obstetrical emergencies. This study determined the frequency and outcome of out-of-hospital deliveries in an urban, all advanced life support (ALS) emergency medical services (EMS) system. METHODS Retrospective review of all out-of-hospital records that involved women delivering babies in the care of prehospital providers from 1984-1988. The EMS system answered an average of 62,000 calls during the study period. The records of these patients were identified through a computer database. RESULTS A total of 81 out-of-hospital deliveries (1.4/month) occurred during the study years. The average age of the mothers was 24 years, and the average gestation period was 30 weeks. The women had an average of three previous pregnancies and two previous deliveries, and 10 were primagravida. Seventy-two (89%) of the deliveries occurred in the home. The paramedics encountered a variety of obstetrical and neonatal complications in 34% of the patient encounters. Nine neonates were delivered prior to the arrival of the paramedic team. Twenty-four neonates had Apgar scores calculated, and the one- and five-minute scores averaged eight and nine respectively. Five of the mothers had no prenatal care. Maternal complications included four patients noted to be hypertensive with the delivery, nine patients had some degree of vaginal bleeding, and in 33 patients, the prehospital providers did not deliver the placenta in the field. An EMS physician was in attendance for only two of the out-of-hospital deliveries. DISCUSSION In this urban EMS system, out-of-hospital deliveries, especially pre-term deliveries, are a common event. There appears to be a significant number of neonatal complications that confront paramedics. Generally, the paramedics were deficient in their documentation of the neonatal assessment. Continuing educational programs for paramedics should include reviewing normal and complicated vaginal deliveries as well as ALS measures for neonates. Protocols for obstetrical emergencies need to be developed and subjected to quality improvement measures. CONCLUSIONS Paramedics, especially those in urban settings, are likely to encounter obstetrical and neonatal emergencies and a significant number of associated complications. Emergency medical services systems and medical directors should have in place continuing educational programs, patient-care protocols, and continuous quality improvement measures to evaluate the care rendered to patients having out-of-hospital deliveries.

A retrospective review of positive chlamydial cultures in emergency department patients

This study evaluated the accuracy of diagnosis and treatment of chlamydial infection based solely on clinical presentation in the emergency department (ED). The signs and symptoms of women with chlamydial infection confirmed by cervical culture were identified and compared between appropriately treated and nontreated groups to determine which clinical features tended to lead to the correct or incorrect diagnosis. The study also determined which signs and symptoms were consistently present in the entire study group. Two hundred thirty-three charts of female ED patients with positive cervical chlamydial cultures were obtained via computerized records from the microbiology lab and reviewed retrospectively. Only 20% of the patients were correctly diagnosed as having a sexually transmitted disease and only 24% were properly treated during their initial ED visit. Although abdominal pain and vaginal discharge were the most frequent symptom and sign, only 70% and 54% of all patients had these clinical manifestations, respectively. Patients with vaginal discharge and cervical motion tenderness were significantly (P < .01) more likely to be treated in the ED. Patients with urinary tract symptoms and pregnancy were significantly (P < .01) less likely to be treated in the ED. Cervical cultures should be performed during all pelvic examinations because of the variability in the clinical presentation of chlamydial infection. A follow-up system must be in place to identify positive cultures and locate patients to ensure appropriate treatment.

PARENTAL REPORT OF CHILD RESTRAINT DEVICE USE IN AN EMERGENCY DEPARTMENT POPULATION

To survey parents regarding use of child restraint devices (CRD) and knowledge of CRD recommendations, parents of children < or = 14 years of age presenting to an emergency department (ED) provided demographic data and answered questions regarding the familys restraint use and their understanding of CRD recommendations. Three hundred thirteen adults completed surveys, providing data on 541 children. Decreasing restraint use was reported with advancing child age. Parental restraint use remained constant. Demographics were similar. Optimal infant CRD position was not identified by 27%. Incorrect answers were associated with single parents, lower income, less education, and older child age. Only 41% identified the age for mandatory car seat use. Most identified the safest vehicle position for any child. No variables were associated with correct answers. In conclusion, CRD use decreases with increasing child age. In this study, many parents were unaware of CRD recommendations.