Annals of emergency medicine
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Randomized Controlled Trial Comparative Study Clinical Trial
A comparison of interposed abdominal compression CPR and standard CPR by monitoring end-tidal PCO2.
Interposed abdominal compression CPR (IAC-CPR) has been demonstrated to significantly improve blood flow compared with standard (S)-CPR in animal and electrical models. Studies with IAC-CPR in human beings have not reported data regarding cardiac output. Animal and clinical studies have correlated end-tidal PCO2 (ETPCO2) with cardiac output produced with precordial compressions. ⋯ In patients arriving in cardiac arrest, return of spontaneous circulation was observed in six patients (30%) during IAC-CPR and in one patient (6%) during S-CPR (P = .07). Our study strongly suggests that cardiac output may be significantly increased in human beings with IAC-CPR as evidenced by the significantly greater increases in ETPCO2 with IAC-CPR compared with S-CPR. In addition, IAC-CPR appeared to demonstrate a trend toward increasing the return of spontaneous circulation.
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Physician involvement in the provision of both direct and indirect medical control to emergency medical providers is critical to the effective operation of an emergency medical services (EMS) system. We conducted a survey of all accredited emergency medicine residency programs in the United States to determine the content of EMS instruction provided to these physicians-in-training. ⋯ The importance placed on EMS during residency training is variable. EMS is the domain of emergency medicine, and adequate training of residents for these responsibilities is imperative.
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Randomized Controlled Trial Clinical Trial
Prophylactic penicillin for intraoral wounds.
We conducted a prospective, double-blind, placebo-controlled study in adult patients to determine whether prophylactic penicillin prevents infection in intraoral lacerations secondary to minor trauma or seizures. Uninfected full-thickness, mucosal-only, or through-and-through wounds presenting within 24 hours of injury were considered. Management consisted of cleansing, irrigation, debridement, and closure as indicated: no topical antibiotics were applied. ⋯ When patients poorly compliant with therapy were eliminated from analysis, none of the penicillin-treated patients and five of the placebo-treated patients developed infections (P = .027). Our data suggest that patients with intraoral wounds may benefit from prophylactic penicillin if compliant with their therapy. More studies are needed to further delineate the usefulness of prophylactic antibiotics for these wounds.
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Review
Accuracy of interpretations of emergency department radiographs: effect of confidence levels.
We conducted a prospective study to assess the relationship between the interpretive agreement rate for emergency department radiographs and the degree of interpretive confidence. We hoped to identify a subset of ED radiographs that did not require mandatory review by a radiologist. For each of the 1,872 plain radiographs studied, emergency physicians assigned a confidence level to the interpretation before comparing it with the radiologist's dictated report. ⋯ No subset of radiographs had 100% agreement. Treatment was potentially altered in 38 patients as a result of the interpretive disagreement that occurred in 2% of studied radiographs. We conclude that the interpretive agreement rate increases in relation to interpretive confidence but that confidence levels cannot safely exclude certain radiographs from mandatory review by a radiologist.
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Previous studies of emergency department management of bacterial meningitis have indicated that there are often long delays before initiation of antibiotics. The purpose of our study was to determine whether these delays were related to specific aspects of patient management. From 1981 through 1988, we retrospectively reviewed the medical records of 122 patients primarily evaluated in the ED and admitted for suspected bacterial meningitis at a university (55) and a community (67) hospital. ⋯ Time to antibiotics was significantly (P less than .00005) longer for patients in whom computed tomography scan and/or laboratory analysis of cerebrospinal fluid preceded initiation of antibiotics compared with patients in whom antibiotic administration was not contingent on the results of these procedures (4.3 [3.2 and 6.0] versus 1.9 [1.2 and 3.4] hours, respectively). Also, time to antibiotics was significantly (P less than .00005) longer for patients in whom antibiotics were initiated on the ward as compared with in the ED (4.5 [3.5 and 6.8] versus 2.2 [1.4 and 3.5] hours, respectively). We conclude that long delays exist in the ED before initiation of antibiotics for cases of suspected bacterial meningitis, and that in general these delays appear to be physician generated and to a great extent potentially avoidable.