The American journal of emergency medicine
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The authors reviewed the clinical manifestations, complications, and the prognosis affected by Lilly Cyanide Antidote in 21 victims of acute cyanide poisoning over a 10-year period. The clinical signs and symptoms in cyanide poisoning are variable. Among 21 cases, loss of consciousness (15), metabolic acidosis (14), and cardiopulmonary failure (9) were the three leading manifestations of cyanide intoxication. ⋯ Decrease of arteriovenous difference of O2 partial pressure may be a clue for the suspicion of cyanide intoxication. Although the authors cannot show a statistically significant difference (P = .47) for the Lilly cyanide antidote kit in terms of improving the survival rate for victims of cyanide poisoning, the antidote kit was always mandatory in our study in the cases of severely intoxicated victims who survived. Early diagnosis, prompt, intensive therapy with antidote, and supportive care are still the golden rules for the treatment of acute cyanide poisoning, whether in the ED or on the scene.
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Review Case Reports
Delayed tension pneumothorax complicating central venous catheterization and positive pressure ventilation.
Pneumothorax is the most common complication after central venous catheterization. The diagnosis of pneumothorax may be delayed for hours or days, in some instances because of minimal clinical symptoms or radiographic signs on initial evaluation, or in other instances because of late presentation precipitated by positive pressure ventilation. A case is presented in which a patient developed a tension pneumothorax while under general anesthesia 10 days after central venous line placement. ⋯ Supine views, the least sensitive radiographic technique, should be carefully reviewed for evidence of basilar hyperlucency, a deep sulcus sign, or a double diaphragm sign. In patients unable to tolerate the upright position, supine views should be supplemented with lateral decubitus, oblique, or cross-table lateral views. Emergency physicians should be aware of the possibility of delayed pneumothorax, as well as optimal radiographic technique for demonstration of small pneumothoraces, and subtle radiographic findings in supine or semirecumbent patients.
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Comparative Study
Bedside fluoroscopy to screen for simple extremity trauma in the ED.
Portable fluoroscopy units are commonly used by orthopedic surgeons to assist in fracture reduction and immobilization. The purpose of this study was to determine the diagnostic accuracy of bedside fluoroscopy performed by emergency department (ED) physicians to screen for simple extremity trauma. Eligible adult patients presenting to the ED with isolated injuries to distal extremities were evaluated prospectively over a 6-month study period. ⋯ The overall diagnostic accuracy was 0.85, with a 95% confidence interval of .67 to 1.00. There were 11 false-negative fluoroscopic reports, involving the radius (3), distal tibia (3), metacarpals (2), fifth metatarsal (1), phalanx (1), and cuboid (1). These results suggest that bedside fluoroscopy lacks sufficient sensitivity to screen for simple extremity fractures in the ED.
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Comparative Study
Factors affecting ED length-of-stay in surgical critical care patients.
To determine what patient characteristics are associated with prolonged emergency department (ED) length-of-stay (LOS) for surgical critical care patients, the charts of 169 patients admitted from the ED directly to the operating room (OR) or intensive care unit (ICU) during a 6-week period in 1993 were reviewed. The ED record was reviewed for documentation of factors that might be associated with prolonged ED LOS, such as use of computed tomographic (CT), radiology special procedures, and the number of plain radiographs and consultants. ED LOS was considered to be the time from triage until a decision was made to admit the patient. ⋯ Use of a protocol-driven trauma evaluation system was associated with a shorter ED LOS. In addition to external factors that affect ED overcrowding, ED patient management decisions may also be associated with prolonged ED length-of-stay. Such ED-based factors may be more important in surgical critical care patients, whose overall ED LOS is affected more by the length of the ED work-up rather than the time spent waiting for a ICU bed or operating suite.
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The purpose of this study was to determine the percentage of patients perceived by health professionals to be opioid dependent among all patients presenting with pain and specifically among sickle cell patients with pain. Surveys were completed by all staff, residents, and nurses at an urban teaching hospital with an emergency department population consisting primarily of lower socioeconomic patients of African-American origin. ⋯ All health professional groups surveyed estimated opioid dependence in patients with pain far in excess of that shown in previous studies. It is unknown whether pain medication are withheld inappropriately by physicians who perceived patients with pain to be opioid dependent, and that this deserved further study especially among sickle cell patients.