The American journal of emergency medicine
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There have been a limited number of studies assessing the impact of attending physician supervision of residents in the emergency department (ED). The objective of this study is to describe the changes in patient care when attending emergency physicians (AEPs) supervise nonemergency medicine residents in a university hospital ED. This was a prospective study including 1,000 patients, 32 second- and third-year nonemergency medicine residents and eight AEPs. ⋯ The most common major changes were ordering laboratory or x-ray tests that showed a clinically significant abnormality, and eliciting important physical exam findings. Potentially limb- or life-threatening errors were averted by the AEP in 17 patients. Supervision of nonemergency medicine residents in the ED resulted in frequent and clinically important changes in patient care.
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Recent animal studies of acute hemorrhage in the presence of a vascular injury have demonstrated improved survival and decreased hemorrhage volume with hypotensive resuscitation, but this has occurred at the expense of tissue perfusion. It was hypothesized that addition of an oxygen-carrying perfusate would improve tissue oxygen delivery during hypotensive resuscitation. Hypotensive resuscitation of severe uncontrolled hemorrhage was compared with and without supplementation with Oxygent HT, an emulsion of perflubron (perfluorooctylbromide; PFOB; Alliance Pharmaceutical Corporation, San Diego, CA), an oxygen-carrying perfusate. ⋯ Two-hour mortality rates were 12.5% and 43% for PFC-treated animals and controls, respectively (P > .05; 95% confidence interval [95% CI] for this difference in mortality is -13% to 74%). Oxygen content and delivery were significantly greater in the treatment group. In conclusion, administration of an oxygen-carrying perfusate significantly improves oxygen delivery in hypotensive crystalloid resuscitation of severe uncontrolled hemorrhage.
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Randomized Controlled Trial Comparative Study Clinical Trial
Comparison of tetracaine-adrenaline-cocaine (TAC) with topical lidocaine-epinephrine (TLE): efficacy and cost.
Topical anesthesia in the form of TAC (tetracaine, adrenaline, cocaine) solution has been used for wound repair. This pilot study was designed to determine if the topical anesthesia achieved using a mixture of lidocaine (5%) and epinephrine (1:2000) (TLE) is equivalent to the topical anesthesia obtained using a solution of tetracaine (0.5%), epinephrine (1: 2000), and cocaine (10.4%) (TAC). A prospective, randomized, double-blind trial was carried out from May 1992 to August 1992 at a community-based teaching hospital Emergency Department (ED) that receives 50,000 annual visits. ⋯ Seventeen patients were in the TLE group; 18 in the TAC group. The mean ages were compared and found to be similar (P = .40) between the two test groups. The pain scale values, the diameter of tissue blanch around laceration (halo size), and the time to laceration repair from the onset of application of anesthetic were compared and no difference was shown between the TAC and TLE groups.(ABSTRACT TRUNCATED AT 250 WORDS)
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Review Case Reports
Removal of a hardened steel ring from an extremely swollen finger.
For several years various authors have discussed the removal of rings from swollen fingers. Removal normally has involved cutting the ring, but nondestructive methods of removal using string frequently have been recommended as well. A case is reported of a patient who presented with a hardened roller bearing on an extremely swollen index finger, which defied all attempts at removal by previously successful methods. ⋯ The blood pressure cuff, which was used while the elastic band was removed, prevented the refill of the tissue while the finger was examined. Four sessions of compression lasting approximately 10 to 15 minutes each with the elastic band were necessary to eliminate the edema and release the ring. The ring was finally removed utilizing a short piece of string to ease it over a small laceration.
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Accurate diagnosis and a clear management approach are the most important considerations in caring for behaviorally disordered emergency department patients. Treating behavioral emergencies often precedes an accurate diagnosis. ⋯ Behavioral emergencies usually requiring minimal pharmacological intervention include adjustment disorder, acute grief, rape and assault, and borderline personality disorder. Behavioral emergencies requiring maximal pharmacological intervention include assault, agitated psychosis, exacerbation of bipolar disorder, exacerbation of schizophrenia, brief reactive psychosis, delirium, dementia, substance withdrawal, and substance intoxication accompanied by violent behavior.