Annals of emergency medicine
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Knowledge and experience in emergency medical services (EMS) are essential objectives for residency training in emergency medicine (EM). Although a need exists for competent physician EMS leaders, opportunities for educating emergency physicians in this aspect of emergency care have been few. ⋯ The former requires a working knowledge of the local system policies and the ability to respond appropriately to paramedic radio calls. Additional education prepares the resident for a much broader role in EMS, including off-line medical control.
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The records of 333 consecutive alert patients admitted to a trauma service for neurologic observation after sustaining significant blunt head trauma were reviewed. All patients had class I level of consciousness (alert, responds immediately to questions, may be disoriented and confused, follows complex commands); those with significant acute alcohol and/or drug intoxication were excluded from this study. Cervical spine injury did not correlate with the presence of major concomitant injuries, skull fractures, or major intracranial injuries. ⋯ Five of the 42 patients (11%) with signs and/or symptoms of cervical injury had cervical spine fractures. No patient without signs and/or symptoms of cervical injury had a cervical spine injury. These findings suggest that among alert patients with class I level of consciousness who have sustained blunt injury, only those who present with signs and/or symptoms of cervical injury require cervical radiographic evaluation.
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Two case reports of patients with anion gap metabolic lactic acidosis and hypoglycemia are presented. Both patients subsequently died of acute liver failure secondary to acetaminophen hepatotoxicity. The development of type B lactic acidosis with hypoglycemia might have been caused by a deficit in gluconeogenesis secondary to severe hepatic failure and/or a toxic metabolite of acetaminophen. Our findings suggest that acetaminophen toxicity should be considered when lactic acidosis and hypoglycemia are seen.
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Motor vehicle-related trauma deaths in a 21-county rural emergency medical services (EMS) system are reviewed. Injury severity scores (ISS) and Glasgow coma scores (GCS) were recorded to provide baseline data for future comparison as the system progresses. The majority of deaths (67%) were related to CNS injuries. ⋯ Those transferred from community hospitals to the regional tertiary care center had an average ISS of 36.2. Those admitted directly to the tertiary center had an ISS of 38.9. The data suggest that the rural trauma system might improve if there were training programs that promote recognition of significant injury, more aggressive resuscitation, and expeditious transfer of the injured patients.
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A retrospective review was made of fractures for which radiographic manifestations were missed by various physicians working in the ED. It revealed that fractures of three anatomic sites were being missed disproportionately often--fractures of the navicular, elbow, and calcaneus. Fractures of these sites were the most likely to be missed when present. ⋯ The elbow was the only site occurring both on the list of fractures missed disproportionately often and on the list of fractures missed most frequently. Some common fractures were not missed at all (Colle's fracture), and others were missed infrequently (hip fracture, midshaft long bone fracture). Knowledge of those fractures that are most likely to be missed makes possible a more directed educational effort.