Annals of emergency medicine
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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.
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The survival rate for patients with prehospital cardiac arrest has improved in some communities with early defibrillation by emergency medical technician-defibrillators (EMT-Ds). In rural areas, previous studies on survival with defibrillation by EMT-Ds have been variable. We conducted an EMT-D study to determine effectiveness in various prehospital settings. ⋯ The neurologic status of survivors at time of hospital discharge was normal in 72%. The average response time, defined as time of emergency medical services activation to the time of EMT-D arrival, was 7.3 +/- 5.8 and 3.7 +/- 2.0 minutes for nonsurvivors and survivors, respectively (P less than .002). There were no survivors when the response time was more than eight minutes.(ABSTRACT TRUNCATED AT 250 WORDS)
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Comparative Study
Comparison of five-view and three-view cervical spine series in the evaluation of patients with cervical trauma.
The three-view trauma series has been the standard screening examination for patients with cervical spine trauma. We conducted a prospective study to determine if the addition of supine oblique views to the three-view series would improve detection of fractures, subluxations, dislocations, or locked facets. All patients over a two-year period with suspected cervical spine injury had a five-view series obtained (three-view series and supine oblique views), and selected high-risk patients underwent thin-section conventional tomography of the cervical spine. ⋯ There were no fractures or dislocations detected on the five-view series that were not detected or suspected on the three-view series. In areas of the cervical spine reported to be better visualized by supine oblique views than three-view series, our results indicate that supine oblique views did not improve detection but did, in certain cases, allow more specific diagnosis of injuries. Our data do not support the routine use of supine oblique views in the initial radiographic evaluation of patients with cervical spine trauma.
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Unstable injury of the cervical spine must be considered in all victims of blunt trauma. To evaluate the role of limited, directed computed tomography (CT) in the initial evaluation of the cervical spine, a one-year study involving 104 high-risk patients was undertaken. ⋯ All false-negative studies involved atlantoaxial rotary subluxation. We conclude that limited, directed CT of the cervical spine is appropriate in the initial evaluation of patients at risk, particularly if plain radiographs are inadequate, but is of limited value in the evaluation of ligamentous injury of the upper cervical spine.
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Although intubation of emergency patients in the field is a routine measure, endotracheal tube misplacement remains a serious problem. Using radiologic criteria, the frequency of undetected endobronchial intubation by physicians was determined retrospectively in 100 (78 traumatized) field-intubated adult patients (72 men and 28 women; age, 18 to 90 years; mean age, 39.1 years) consecutively admitted to the University Hospital of Tuebingen, Tuebingen, Federal Republic of Germany, between January 1987 and February 1988. Position of tube tip relative to carina was evaluated on anteroposterior chest radiographs made on admission. ⋯ While unilateral intubation is not immediately catastrophic, the resulting systemic hypoxemia and hypercapnia are aggravated by potential accompanying injury (eg, lung contusion, hematothorax, pneumothorax, shock, or cerebrocranial trauma), which can lead to secondary damage (eg, acute respiratory insufficiency, ischemic brain damage). Evaluation of the depth of tube insertion with the aid of common clinical techniques is particularly unreliable in the case of thoracic trauma, aspiration, or previously existing pulmonary disease. Suggested measures for prevention of endobronchial intubation are improved and intensified training of emergency staff to increase awareness of and prevent the catastrophic effects of endobronchial malposition of the tube tip, tube shortening before intubation, assessment of insertion depth by checking length scale on the tube, and avoidance of patient head and neck movement.