William C. Dalsey

Clinical Policy for Procedural Sedation and Analgesia in the Emergency Department

[American College of Emergency Physicians: Clinical policy for procedural sedation and analgesia in the emergency department. Ann Emerg Med May 1998;31:663-677.].Abstract [American College of Emergency Physicians: Clinical policy for procedural sedation and analgesia in the emergency department. Ann Emerg Med May 1998;31:663-677.]

Improving Handoffs in the Emergency Department

Patient handoffs at shift change are a ubiquitous and potentially hazardous process in emergency care. As crowding and lengthy evaluations become the standard for an increasing proportion of emergency departments (EDs), the number of patients handed off will likely increase. It is critical now more than ever before to ensure that handoffs supply valid and useful shared understandings between providers at transitions of care. The purpose of this article is to provide the most up-to-date evidence and collective thinking about the process and safety of handoffs between physicians in the ED. It offers perspectives from other disciplines, provides a conceptual framework for handoffs, and categorizes models of existing practices. Legal and risk management issues are also addressed. A proposal for the development of handoff quality measures is outlined. Practical strategies are suggested to improve ED handoffs. Finally, a research agenda is proposed to provide a roadmap to future work that may increase knowledge in this area.

Steroids for the treatment of corrosive esophageal injury: A statistical analysis of past studies

Caustic esophageal injury causes substantial morbidity and mortality. However, the use of corticosteroids to treat this problem has been evaluated in a limited number of studies because adequate sample size is difficult to obtain. We analyzed 361 subjects with corrosive esophageal injury derived from 10 retrospective and three prospective publications. We divided cases into those treated with corticosteroids and antibiotics (T) and those that received neither modality (NT) based on inclusion and exclusion criteria. Forty-one percent of NT cases developed esophageal stricture and 19% of T cases developed this complication (P less than .01). There were no reported strictures among 72 first-degree esophageal burns (combined T and NT cases). The T group contained 54 strictures among 228 patients (24%) with either second- or third-degree burns. The NT group of 25 patients with the same burn severity suffered 13 strictures (52%) (P less than .01). Reports of death and gastrointestinal hemorrhage did not increase among steroid-treated patients. We do not recommend corticosteroid therapy for first-degree esophageal injuries. However, this therapy may be useful in preventing strictures among patients with second- or third-degree corrosive esophageal burns.

Use of Tube Condensation as an Indicator of Endotracheal Tube Placement

STUDY OBJECTIVE To determine whether condensation on the inner surface of the endotracheal tube (vapor trail) is a reliable indicator of intratracheal placement. METHODS Twenty-seven separate experiments were conducted on 10 conditioned, mongrel dogs weighing 15 to 20 kg each. After induction of anesthesia, an endotracheal tube was placed in the trachea under direct visualization. A second, identical endotracheal tube was then placed in the esophagus. An attending emergency physician, blinded to tube placement, then used a bag-valve apparatus to manually ventilate each endotracheal tube in turn. Five ventilations were performed on each tube, and the presence or absence of condensation on the inner surface of the tube was recorded. A second physician, blinded both to tube placement and to the actions of the first assessor, then repeated the ventilation and assessment of both tubes. RESULTS Vapor trail was observed in 27 (100%) of 27 endotracheal tubes correctly placed in the trachea (95% confidence interval [CI], 90% to 100%) and in 23 (83%) of 27 tubes placed in the esophagus (95% CI, 66% to 96%). Physicians concurred in all cases. Absence of vapor trail was 15% sensitive (95% CI, 4% to 34%) for indicating incorrect (esophageal) tube placement. CONCLUSION In this model, condensation on the inner surface of the endotracheal tube was common after placement within the esophagus. If these results are confirmed in human studies, the presence of a vapor trial should not be used as a clinical indicator of correct endotracheal tube placement.

Clinical Policy for the Initial Approach to Adults Presenting With a Chief Complaint of Chest Pain, With No History of Trauma

Abstract American College of Emergency Physicians: Clinical policy for the initial approach to adults presenting with a chief complaint of chest pain, with no history of trauma. Ann Emerg Med 1995;25:274-299.]

Bicarbonate therapy for the cardiovascular toxicity of amitriptyline in an animal model

The beneficial hemodynamic effects of sodium bicarbonate as treatment for tricyclic antidepressant poisoning were investigated in an animal model. Seven adult dogs (17.5 to 20 kg) were poisoned by an intravenous infusion of amitriptyline. Toxicity was defined as a doubling of the initial QRS width. A continuous infusion was used to maintain toxicity for 30 minutes after which 44.5 mEq of sodium bicarbonate was administered intravenously. Five of the animals survived to completion of the experiment. Three of the surviving animals developed dysrhythmias. All dysrhythmias ceased within one minute of administration of sodium bicarbonate. An increase in mean blood pressure (P less than .05) and serum pH (P less than .05) and a decrease in mean QRS width (P less than .05) occurred following administration of sodium bicarbonate. The maintenance of toxicity for 30 minutes suggests that this model can be used for future studies of tricyclic antidepressant poisoning.

Transcutaneous and transvenous cardiac pacing for early bradyasystolic cardiac arrest

Emergency transcutaneous cardiac pacing was studied prospectively in 19 patients presenting to the emergency department with a bradyasystolic cardiopulmonary arrest of 20 minutes duration or less. Pacing was initiated when conventional advanced cardiac life support (including atropine administration) and a fluid challenge failed to restore a pulse. Seventeen patients also had placement of transvenous pacemaker electrodes for cardiac pacing. Transcutaneous cardiac pacing rapidly established a blood pressure in the two patients who for clinical reasons did not receive a transvenous pacemaker. Five patients were transcutaneously paced within five minutes of cardiac arrest (Group 1) and the remaining 14 were paced between five and 20 minutes following cardiac arrest (Group 2). Two of the Group 1 patients were admitted and subsequently recovered full neurological and prearrest cardiac function. Fewer Group 2 patients developed a blood pressure (P = .04), and there were no patients with full neurologic recovery in this group (P = .06). Similar results were found for transvenous cardiac pacing; there was a greater incidence of a palpable pulse and measurable blood pressure (P = .05 for both) in the Group 1 patients than in the Group 2 patients. No difference in clinical outcome was noted between the two pacing techniques. These results support the concept that cardiac pacing must be initiated early if the outcome of bradyasystolic cardiac arrest is to be altered.

Clinical Policy for the Initial Approach to Adolescents and Adults Presenting to the Emergency Department With a Chief Complaint of Headache

Abstract ACEP Clinical Policies committee and the Clinical Policies SubCommittee on Headache [American College of Emergency Physicians: Clinical policy for the initial approach to adolescents and adults presenting to the emergency department with a chief complaint of headache. Ann Emerg Med June 1996;27:821-844.]

Utility of cardiac troponin I, creatine kinase-MBmass, myosin light chain 1, and myoglobin in the early in-hospital triage of “high risk” patients with chest pain

OBJECTIVE To evaluate the use of cardiac troponin I (cTnI), creatine kinase-MBmass (CK-MBmass), myosin light chain 1 (MLC 1), and myoglobin in identifying “high risk” patients with chest pain who will experience serious cardiac events (SCEs) in hospital. DESIGN Prospective study. SETTING University affiliated medical centre in Philadelphia, USA. PATIENTS 208 patients with chest pain, at > 7% risk of acute myocardial infarction (MI), but without new ST segment elevation on their presenting ECG. INTERVENTIONS cTnI, CK-MBmass, MLC 1, and myoglobin concentrations were obtained on admission (0 hour) and at 4, 8, 16, and 24 hours. MAIN OUTCOME MEASURES The sensitivity, specificity, positive and negative predictive value, and pre- and post-test probabilities of patients suffering an SCE in hospital were determined. SCEs included cardiac death, acute MI, cardiac arrest, life threatening cardiac arrhythmia, cardiogenic shock, and urgent coronary revascularisation. RESULTS Admission concentrations of all markers were poor predictors of SCEs in hospital but improved substantially at subsequent timepoints. cTnI and CK-MBmass were consistently the most useful prognostic indicators. If both were negative at 0, 4, and 8 hours, then 99% (95% confidence interval 96% to 100%) of patients remained free from SCEs. The only SCEs not thus predicted were revascularisation procedures and associated complications. Additional tests after 8 hours, or the inclusion of additional markers, did not improve predictive accuracy further. CONCLUSIONS Patients with high risk clinical features on admission who have negative cTnI and CK-MBmass concentrations at 0, 4, and 8 hours later have a favourable in-hospital prognosis and could be considered for early triage out of coronary care units.

Clinical Policy for the Initial Approach to Patients Presenting With a Chief Complaint of Seizure Who Are Not in Status Epilepticus

Abstract [American College of Emergency Physicians: Clinical policy for the initial approach to patients presenting with a chief complaint of seizure who are not in status epilepticus. Ann Emerg Med May 1997;29:706-724.]