Annals of emergency medicine
-
To define a subset of injured children for whom emergency cervical spine radiography may be unnecessary, we performed a retrospective chart and radiologic review. Two entry methods were used: All injured children, from birth through 16 years, who had received cervical spine radiographs at The Children's Memorial Hospital from September 1983, to September 1984, were included. All patients from birth to 16 years with proven or suspected cases of cervical spine injury who had received cervical spine radiographs and who had been treated at either the Children's Memorial Hospital or the Northwestern University Spine Trauma Unit during period 1974 to 1984 also were included. ⋯ Cervical spine radiographs could have been avoided in 79 children (38% of the entire sample). This algorithm performed better than did models derived from logistic regression analysis of the same data. Validation trials are required prior to the implementation of this or other clinical decision algorithms in practice.
-
We tested a 20-gauge, 2 1/2-inch spinal needle and a 13-gauge, 3 1/2-inch bone marrow needle with Ringer's lactate delivered by gravity and 300 mm Hg pressure in vitro and in hypovolemic puppies to ascertain in vivo intraosseous flow rates and to determine the effects of catheter size and anatomic factors on flow rate. In vitro flow was significantly faster than in vivo flow (P = .001). In vivo, mean flow rates were 11 mL/min for the 20-gauge needle and 13 mL/min for the 13-gauge needle by gravity. ⋯ While the in vivo flow rates were significantly greater for the 13-gauge versus the 20-gauge needle, the differences were not clinically significant (2 mL/min difference by gravity and 5 mL/min difference by pressure). The clinically comparable in vivo rates for the two needles tested indicated that the rates are dependent on flow through the bone marrow rather than the size of the needle. The data suggest that while intraosseous infusion is a rapid technique for gaining vascular access, the flow rates achieved may not be sufficient for the definitive treatment of severe hypovolemic or hemorrhagic shock alone.
-
Recent literature has emphasized the relationship between coronary perfusion during CPR and the success of resuscitation from prolonged arrest. In this study, aortic and right atrial pressures were monitored simultaneously during modifications of CPR. Three parameters associated with survival or coronary blood flow during CPR were measured: diastolic arterial pressure (DAP), diastolic arteriovenous difference (DAVD), and mean AV difference (MAVD). ⋯ In the seven autopsied patients, no significant abdominal injury was found. All forms of CPR studies produced DAVD in the majority of patients well below the minimum DAVD needed for resuscitation in animal models of prolonged arrest. Although the interposed abdominal compression seems to offer some advantages over standard CPR, these hemodynamic data suggest that it would be unlikely to improve survival rates appreciably.
-
Recognition of an acute myocardial infarction in the patient with chest pain is a frequent challenge to the clinician. Previous studies suggest that cardiac enzymes are of limited value in identifying patients with acute MI in the emergency department. Such studies have not evaluated the use of cardiac enzyme tests to complement decision making in the population of patients clinically designated for ED release. ⋯ Four released MI patients had a CK level greater than or equal to 200 IU/L and three had an elevated CK-MB fraction (greater than or equal to 12 IU/L). In the population of patients scheduled for release, an elevated CK-MB had sensitivity, specificity, and positive predictive value for MI of 60%, 100%, and 60%, respectively. Although cardiac enzymes cannot be used in isolation to make admission decisions, selective use of CK-MB for final screening of patients otherwise scheduled for ED release may enhance the initial admission of patients with MI at risk for unintentional release.
-
Most authorities in the field of trauma recommend that seriously injured patients be transported directly to a regional trauma center, even if it requires bypassing nearby community hospitals. The purpose of our study was to examine the relationship between the survival rates of patients with presumed hemorrhagic shock due to penetrating injuries and the total prehospital time required to manage and deliver those patients to a single regional trauma center in a large urban area. During a 30-month-period, 498 consecutive victims of penetrating injury, presenting in the field with a systolic blood pressure of 90 mm Hg or less and transported to a single regional trauma center, were prospectively evaluated in terms of age; initial prehospital trauma score; injury severity score (ISS); TRISS probability of survival; response, scene, transport, and total prehospital times; and survival (discharge from hospital). ⋯ The total prehospital time (TPT) was calculated as the time elapsed from the receipt of the emergency call to the time of arrival at the regional trauma center. Patients arbitrarily were categorized into four subsets according to the initial prehospital trauma score (1, 2 to 6, 7 to 11, 12 to 15). Patients also were analyzed in terms of four incremental groups of increasing TPT (0-20, 21-30, 31-40, greater than 40 min).(ABSTRACT TRUNCATED AT 250 WORDS)