J Emerg Med
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An essential feature of the trauma center concept is the rapid delivery of patients with complicated injuries to a regional trauma center directly from the site of injury. A variety of triage instruments have been proposed to aid the prehospital personnel in making this difficult triage decision. We used a combination of prospective and retrospective analysis to evaluate and compare the performance of 11 recommended triage instruments on the same trauma population. ⋯ Of the triage instruments with a sensitivity greater than 70%, the respiratory/systolic pressure/Glasgow Coma Scale (RSG) score provided the largest improvement in odds for needing a trauma center when the triage instrument is positive. Although no triage instrument performed ideally, the patients missed by the triage instruments having a sensitivity greater than 70% were hemodynamically stable. Transfer of such patients to a trauma center following determination of the extent of underlying injury at a referring emergency department should be possible.
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There continues to be a debate on the indications for and value of emergency department thoracotomy, especially with regard to thoracotomies performed by emergency physicians. The current literature does not deal specifically with thoracotomies performed by an emergency physician on trauma patients in full cardiopulmonary arrest in a setting with no immediate surgical backup. This paper reports the results of 6 years of experience by one emergency physician in such a setting involving 80 patients, with a 6% overall survival rate, including two patients who survived blunt traumatic cardiac arrests. This lends support to emergency-physician-performed thoracotomies on trauma patients in "extremis," even in the setting of a hospital with no immediate surgical backup.
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Severe, acute cyanide poisoning is uncommon and can be very difficult to diagnose if a history of exposure is unavailable. Victims of smoke inhalation may have significant cyanide poisoning as well as carbon monoxide toxicity. The Lilly Cyanide Antidote Kit currently available in America unfortunately has its own inherent toxicity. ⋯ Case reports of human cyanide poisoning treated with hydroxycobalamin/sodium thiosulfate have been published only in French. Animal and human data on the use of this antidotal combination are reviewed. Hydroxycobalamin/sodium thiosulfate is an efficacious cyanide antidote with little inherent toxicity.
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Comparative Study Clinical Trial
Performance of disposable needle syringe systems for local anesthesia.
The performance of different disposable needle syringe systems was determined by measuring needle-puncture pain, needle-bending forces, and the fluid dynamics of the systems. Thirty-gauge needles cause less needle-puncture pain than any other needle. The force required to bend the 30-gauge needle irreversibly was lower than that for the other needles. ⋯ On the basis of the results of this study, 30-gauge needles attached to 10-mL syringes are recommended for infiltration anesthesia, and 25-gauge needles with 10-mL syringes are advocated for regional nerve blocks. In infiltration anesthesia, the local anesthetic agent should be injected slowly into the subdermal tissue over a 10-second period. When performing regional nerve blocks, it is also advisable to inject the local anesthetic agent over a 10-second time interval.
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All emergency departments face the possibility of having insufficient personnel to provide adequate care for patients. Such occasions may present an emergency department with several severely injured patients or merely an unusually large number of that emergency department's usual patient profile. ⋯ In addition, emergency department directors have an obligation to consider their particular staffing and usage patterns in order to try to devise the most efficient back-up policy prior to need. Finally, assessment of the success with which such back-up policies are used is discussed.