The American journal of emergency medicine
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Review Case Reports
Diagnostic difficulties of foreign body aspiration in children.
A case of a 4-year-old child who aspirated a 22-caliber bullet is presented to illustrate the variability of signs and symptoms of foreign body aspiration. Despite the large size of the bullet, cough, dyspnea, and wheezing were absent on presentation. ⋯ A retrospective review of 42 additional children with foreign body aspiration showed 8 (19%) were unwitnessed, 24 (57%) were asymptomatic at presentation, 8 (19%) had normal physical examinations, and 10 (24%) had normal inspiratory/expiratory chest roentgenograms. This demonstrates the importance of considering bronchoscopy for any child who presents with a history of possible foreign body aspiration, but is asymptomatic and has normal roentgenographic findings.
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Randomized Controlled Trial Clinical Trial
A randomized clinical trial of rib belts for simple fractures.
The authors present a pilot study in which 20 patients with simple rib fractures were randomized prospectively into two treatment groups. One group received ibuprofen and the other group ibuprofen plus a rib belt for analgesia. There were no statistically significant differences observed in pulmonary function testing between the groups at initial visit, 48 hours, or 5 days. ⋯ Patients using rib belts uniformly reported a significant amount of additional pain relief. The clinician can use a rib belt to provide additional comfort to the patient with fractured ribs without apparent additional compromise to respiratory parameters. A further study stratifying displaced and nondisplaced fractures has been initiated to clarify the possible contributing roles of displaced rib fractures and the rib belt in patients with displaced fractures.
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Traumatic asphyxia has often been described as a rare syndrome with little prognostic significance. In the authors' series, however, all cases secondary to deceleration injury or compression of the anterior thorax were associated with pulmonary injury. The signs of venous congestion of the face and anterior thorax are not always recognized in the emergency department where they should be most clinically evident. Increased awareness of this syndrome by emergency physicians will result in better reporting and understanding of its clinical implications.
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Percutaneous transtracheal ventilation using a large gauge intravenous-type catheter can be used successfully in the setting of complete upper airway obstruction in animals. In this study, using a large animal model, satisfactory oxygenation and ventilation was achieved by inversely varying the catheter size and the inspiration to expiration ratio (I:E). Specifically, 30 to 63 kg ruminants with an obstructed upper airway were resuscitated for 30 minutes from a hypoxic, hypercarbic, and acidotic state using 12- and 14-gauge catheters connected to a 50 psi oxygen source via a two-way valve with an I:E of 1:4 and 1:9 seconds, respectively. Shorter expiratory time or increased inspiratory time with these intravenous catheters resulted in significant hemodynamic compromise, barotrauma, inadequate carbon dioxide elimination, acidemia, and frequent death.
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Estimates of emergency physician needs traditionally have relied on calculations based on the number of patients seen by the emergency physician (volume formula). We have found this model has not predicted accurately manpower needs in our emergency department as the case mix of services has changed. ⋯ The LIVES formula performed better than the volume formula: a better fit with number of physicians used by chi 2 analysis (chi 2 = 1084 versus 5591), a better correlation with physicians used (regression coefficient 0.98 v 0.21), a higher degree of association with physicians used (correlation coefficient 0.96 versus 0.53 with P less than 0.0001 v 0.06 by Student's t-test), and explained more of the variability in the amount of physicians used (92% v 28%). Changes in types of services provided by the modern emergency department require multifactorial analysis to determine manpower needs.