Prompt blood-gas analysis consisting of pH, PCO2, and PO2 is now almost universally accessible. PCO2 directly conveys the role of the respiratory mechanism in any acid-base disturbance. The metabolic condition, however, is hidden in a relationship between pH and PCO2 that is most faithfully expressed by the cumbersome Henderson-Hasselbalch equation (HHE). Two methods of quickly determining metabolic status from pH and PCO2, without resorting to the HHE, are discussed. The first method is well known and adjusts pH to represent only metabolic state by quantitatively cancelling the influence of hyper- or hypoventilation. The second method, not previously reported, uses measured pH to estimate the ratio [HCO3-]/PCO2, which, when multiplied by PCO2, equals bicarbonate ion concentration.
All cases received by the Rocky Mountain Poison Center involving over-the-counter (OTC) sleep preparations were studied during an 18-month period to elucidate 1) the range of toxicity; 2) characteristic symptoms, and 3) the time of onset of symptoms. In 155 cases reviewed retrospectively, the three most commonly ingested agents were Sominex, Nytol and Sleepeze. Multiple ingestions were also involved. Symptomatology was equally divided among no symptoms, mild symptoms and possible life-threatening symptoms. The least amount taken to produce possible life-threatening symptoms was 16 Sominex, 18 Nytol and 15 Sleepeze, although the average amount producing the same symptoms was approximately twice that. These symptoms were seen within six hours in all but three of the 39 cases presenting with these symptoms. There were no deaths.
Based on results of studies using high yield criteria to determine the need for skull radiography, the Utilization Review Committee of the University Hospital (UH), University of Washington, Seattle implemented a policy encouraging use of the criteria in ordering skull radiology. The Bureau of Radiologic Health of the FDA supported a project comparing skull radiology use patterns at UH, with the high yield criteria policy, and Harborview Medical Center (HMC), without a policy. Results showed an increase of around 60% at HMC since the 1972--73 academic year. At UH, there was a decrease of 40% since the 1972--73 academic year. At HMC a medical record review showed only 51 positive reports that significantly contributed to patient care, about the same rate observed in 1967. At the UH, only nine positive reports significantly contributed to patient care, with 62% compliance with the high yield criteria. A current demonstration project under the auspices of the Washington State Professional Standards Review Organization and Bureau of Radiologic Health involves implementing the high yield criteria list at both HMC and UH. After three months, out of 6,003 patient visits, skull radiography was deemed necessary in 518 cases. Of this total 181 had high yield criteria checked. There were 37 positive reports out of these and 23 examinations that made a documented significant contribution to patient care. In the group without high yield criteria, 434 cases, there were 22 positive reports but no significant contribution to patient care documented after four weeks.
A 33-year-old man presented with acute nontraumatic cardiac tamponade as a result of pneumococcal pericarditis in association with pneumococcal pneumonia. Hypotension, tachycardia and pulsus paradoxicus, 50 mm Hg, were present. Echocardiographic findings were compatible with cardiac tamponade. Pericardiocentesis was performed. Acute nontraumatic pericardial tamponade in the emergency department presents special problems of diagnosis and management. Diagnosis is based on correlation of data from the history, physical examination, electrocardiogram, chest x-ray films, and a high index of suspicion. Echocardiography to confirm the diagnosis of tamponade and aid in correct placement of the needle in pericardiocentesis is especially helpful.
During 1975, 332 animal bite injuries accounted for 1.2% of all surgical problems treated at the UCLA Hospital Emergency Department. Data on 307 bite injuries were available and analyzed for environmental, animal, human, interaction, and clinical factors. More than half of the dog bites and almost three fourths of the cat bites-scratches happened at or near the victims' homes. Dog bites were almost twice as common among men, while cat bites-scratches were twice as common among women. Of the incidents in which ownership information was available, 85% of dog bites and 80% of cat bites-scratches were from an animal belonging to the victim, his family or friends, or another known person. Forty-three percent of dog bites, and 52% of cat bites-scratches were provoked, that is, happened while the victim was interacting with the animal. Of bites of the head and/or neck, 38% injured the upper lip; 17% of dog bites injured the eye or adjacent tissues; 48% were in children less than ten-years-old. On fifth of cat bites-scratches involved the head and/or neck, 60% of these injured orbital or periorbital tissues. Over 2% of patients were hospitalized. Five percent of dog bite victims and 29% of cat bite-scratch victims returned with complications, mostly cellulitis or lymphangitis. Pasteurella multocida was the most common pathogen cultured, as evidenced by the 50% and 80% culture-positive rates for dog and cat bite-scratches respectively in this series.
Ventilation through a percutaneous needle catheter inserted into the trachea has been advocated for resuscitation in acute upper airway obstruction. However, the customized, prefabricated equipment proposed by others for that use is not always available. We describe a device for percutaneous transtracheal ventilation (PTV) that can be rapidly assembled using available, inexpensive hospital supplies. With this device, moderate inflation pressures and flow rates of oxygen resulted in arterial PaO2 of greater than 300 torr and PaCO2 values of approximately 40 torr in dogs. PTV may be used as a life-saving measure in cases of acute upper airway obstruction when conventional airway management is unsuccessful.
The Glasgow Coma Scale (GCS) is used in central Virginia by emergency medical technicians (EMT's), emergency department personnel and neurosurgical staff to evaluate patients with central nervous system (CNS) trauma. In a series of 406 patients admitted to the neurosurgical services at the University of Virgina Hospital between October 1977 and February 1978, a GCS score was recorded by the neurosurgeon, nurse, and EMT. All 250 data points, including clinical diagnosis and incidence of associated injuries were entered into our information system analysis. The scale can be easily mastered by all members of the emergency medical team giving reproducible results. It also appears to be a valid predictor of the ultimate outcomes of head injury. The GCS has substantial clinical value in the management of the nuerotrauma patient. It is presently being employed in all phases of the emergency medical system to monitor the progression of the neurologic injury. Ultimately, this injury severity scoring system will be used to standardize patient populations in well controlled clinical studies in which different treatment parameters will be assessed.
A patient with complete transection of the common bile duct after blunt trauma from a steering wheel presented with severe right-sided lower chest pain. Based on results of physical examination, blood and urine analysis and chest x-ray films, he was discharged after suture of a lip laceration. Five days later upon his return for suture removal, the appearance of jaundice and mild symptoms of abdominal distention prompted hospitalization and exploratory surgery. At surgery, avulsion of the common bile duct was the only injury. In the few previously reported cases of this injury, jaundice and mild symptoms of abdominal distention appeared three to four days after injury. The minimal findings of a potentially fatal lesion emphasize the need for securing appropriate follow-up medical care for patients with a history of blunt trauma to the chest and/or abdomen.
Many types of trauma may lead to vascular compromise unless treated effectively and promptly. In addition to direct trauma to a major vessel are the crushing injuries, fractures, and burn injuries which give rise to an ischemia-edema cycle and subsequent muscle necrosis and tissue loss. Objective adjuncts to clinical impressions, such as isotope clearance muscle blood flow or the ultrasound Doppler flowmeter are generally not suitable for continuous, uninterrupted monitoring of the degree of vascular compromise. A technique that appears promising in this respect is that of photoplethysmography. This technique uses a small LED infrared emitter/detector array. Blood volume changes in an illuminated vascular bed produce variations in the amount of reflected light sensed by the detector, which after appropriate electronic amplification results in pulsatile blood flow (if present) and its change with time being displayed on the monitor. This technique was used with 25 trauma patients with good results, avoiding unnecessary compartmental decompression in some cases. It has proved to be a simple technique that requires little or no training for interpretation, provides continuous monitoring, is noninvasive and atraumatic in nature, is portable for easy set-up, and is relatively inexpensive.
Emergency department records and patient charts do not provide enough or sufficiently detailed data for audit of quality of care in a high volume emergency department. As a solution, at the Department of Emergency Medicine, University of Southern California School of Medicine, three emergency medical technicians--hospital-based paramedics--were trained as observers of patient process and treatment. In addition to basic identification information, the form completed by observers listed 21 procedural steps and process data such as sequence, time for completion, type of personnel performing, necessary equipment and supplies, and space for comments. Direct observation of patient process was carried out in 442 patients, a total of 3,882 procedures was observed and recorded. The direct observation is perhaps the most accurate method of data collection for auditing purposes because it reflects actual events. This data was used by the Research Peer Review Committee to help rate the quality of patient treatment process.
The use of intravenous glucagon in patients with obstructing esophageal food impaction of at least 24-hours duration has recently been described. Two cases of acute esophageal obstruction were relieved within ten minutes by intravenous infusion of 1 mg of glucagon. Esophagram performed both before and after glucagon administration confirmed the original obstruction and the passage of the food bolus. Therapy for bolus obstruction of the esophagus has classically included proteolytic enzyme digestion, as well as esophagoscopy with manual extraction. Each entails risk of esophageal perforation and mediastinitis. Also, the dose of proteolytic enzymes, such as papain, may take several hours to administer while endoscopic examination is generally not feasible as an outpatient emergency procedure. Intravenous glucagon can dissolve food other than meat and has the further advantage of safety in the patient in which anticholinergics, another occasionally employed therapy, are contraindicated. A protocol for management of these patients is included.
