Biomedical subjects

C L Emerman

Publications and source records attributed to C L Emerman.

At least 55 records · Page 3Linked to original sources

PubMed1993

Evaluation of high-yield criteria for chest radiography in acute exacerbation of chronic obstructive pulmonary disease.

STUDY OBJECTIVES: The objectives of this study were to assess the incidence of abnormal chest radiographs and to test the validity of previously developed high-yield criteria. There is disagreement about the need for chest radiography in acute exacerbation of chronic obstructive pulmonary disease, although high-yield criteria have been developed. DESIGN: Retrospective chart review study. SETTING: County-owned, university-affiliated, urban emergency department. PARTICIPANTS: ED patients seen between January 1988 and July 1991 with chronic obstructive pulmonary disease. RESULTS: Eight hundred forty-seven ED visits were identified; medical records were available for 742. Radiographs were not taken in 8%, leaving 685 ED visits in the study. One hundred nine patients (16%) had significant abnormalities, including 88 new infiltrates, two new lung masses, one pneumothorax, and 20 episodes of pulmonary edema. A history of congestive heart failure and fever was associated with abnormalities, as were findings of rales, pedal edema, and jugular venous distension. There was no association with WBC count, temperature, coronary artery disease, chest pain, or sputum production. Previously published high-yield criteria had a sensitivity of .76; specificity, .41; positive predictive value, 20; negative predictive value, .90; and accuracy, .47. CONCLUSION: Radiographic abnormalities are common findings in acute exacerbation of chronic obstructive pulmonary disease. We found that almost one fourth of radiographic abnormalities are not predictable on the basis of previously developed high-yield criteria. Routine chest radiography should be considered in patients with acute exacerbation of chronic obstructive pulmonary disease to diagnose treatable, radiographically apparent abnormalities.

Aged↗

PubMed1992

Comparative performance of the Baxt Trauma Triage Rule.

New methods of deciding which patients require trauma center transport continue to be devised. Baxt recently published a Trauma Triage Rule (TTR) using anatomic injury, blood pressure, and elements of the Glascow Coma scale which can be used to identify adult major trauma patients. The purpose of this study was to compare the TTR against three previously published trauma triage instruments; the Triage-Revised Trauma Score, the Prehospital Index, and the CRAMS scale. We applied these rules to a data base of trauma patients transported by the Cleveland, Ohio Emergency Medical Services System. All four instruments identified adult trauma patients who either died or required emergent operations with sensitivities of at least .85. The specificity of the TTR exceeded that of the CRAMS. We conclude that the TTR is an effective means of identifying patients who either die or require emergent operation.

Adult↗

PubMed1992

Prehospital pulse oximetry: useful or misused?

STUDY OBJECTIVE: This study evaluated the ability of emergency medical technicians (EMT-As) and emergency medical technicians-paramedics (EMT-Ps) to use pulse oximetry measurements in determining patient oxygen requirements. DESIGN: Prospective case series. SETTING: Cleveland emergency medical services (EMS) system. TYPE OF PARTICIPANTS: Five hundred thirty-two consecutive patients transported to Cleveland area hospitals by the Cleveland EMS system; no exclusions. INTERVENTIONS: EMT-Ps and EMT-As predicted patients' supplemental oxygen requirements based on clinical assessment. Pulse oximetry was performed while patients were breathing room air (RA SpO2). Treatment intervention, including oxygen supplementation and medication given, oxygen saturation after intervention, and oxygen saturation on arrival at the hospital, was also recorded. Therapy guided by the patient's initial RA SpO2 was reviewed to determine the appropriateness of oxygen therapy. RESULTS: Data were analyzed using the chi 2 test and correlation analysis. Eleven percent (59) of patients transported by Cleveland EMS had an initial RA SpO2 of less than 91%. Advanced life support units increased oxygen supplementation on all desaturated patients, whereas basic life support units failed to make appropriate increases in FIO2 in 20% (two) of desaturated patients (P less than .0001). Sixty percent (164) of patients transported by EMT-Ps and 62% (162) of patients transported by EMT-As had an initial RA SpO2 of 97% or greater. EMT-Ps gave supplemental oxygen therapy to all but 7% (11) of these already well-saturated patients, and EMT-As gave supplemental oxygen to all but 6% (nine) of these patients. EMT-Ps administered a higher FIO2 than they had predicted clinically necessary to 2% (four) of patients with an initial RA SpO2 of 97% of greater, whereas EMT-As gave a higher FIO2 than initially predicted to 16% (25) of such patients (P less than .0001). CONCLUSION: EMT-Ps were more likely to appropriately base oxygen therapy on oximetry measurements than were EMT-As. Both groups failed to decrease supplemental oxygen in patients with high explicit protocols for EMS systems contemplating the use of oximetry to guide oxygen therapy. Our results further suggest that pulse oximetry could be used to avoid unnecessary oxygen therapy on a significant number of patients transported by EMS systems because they are already well saturated on room air.

Cost Control↗

PubMed1992

Academic emergency medicine: a national profile with and without emergency medicine residency programs.

STUDY OBJECTIVE: Formal data are lacking regarding emergency departments in academic medical centers, particularly those without an emergency medicine residency program. The Education Committee of the Society for Academic Emergency Medicine conducted a survey to define a national profile of academic emergency medicine. DESIGN: Prospective survey with telephone follow-up. SETTING: Academic medical centers. PARTICIPANTS: One hundred twenty-three academic medical centers as defined by the Association of American Medical Colleges. RESULTS: Results were obtained from 94 (78%) institutions: 27 (29%) had an emergency medicine residency program and 67 (71%) had no emergency medicine residency program. Significant differences were found between those with and without emergency medicine residency programs regarding 24-hour attending coverage (96% versus 73%), mean weekly clinical faculty hours (26 versus 33), the number of emergency medicine board-certified faculty, faculty recruitment difficulties (25% versus 75%), and the presence of a curriculum for housestaff (96% versus 38%). No significant differences were noted regarding the presence of a curriculum for medical students (78% versus 64%). Of the 67 institutions with no emergency medicine residency programs, 42% were actively planning a program, and 42% would consider future development of a program. CONCLUSION: This article provides the first comprehensive profile of emergency medicine in the Association of American Medical Colleges academic medical centers. Programs with emergency medicine residency programs provided more 24-hour attending coverage, had more emergency medicine board-certified faculty, and reported less difficulty recruiting additional faculty than institutions with no emergency medicine residency program. Both need to expand their undergraduate educational activities. Many institutions with no emergency medicine residency program are attempting to develop emergency medicine residency programs.

Academic Medical Centers↗

PubMed1991

A randomized, controlled comparison of isoetharine and albuterol in the treatment of acute asthma.

STUDY OBJECTIVE: To determine whether treatment of acute asthma with repeated doses of nebulized albuterol leads to greater bronchodilation and lower hospital admission rate than treatment with nebulized isoetharine. DESIGN: Randomized, double-blinded, controlled trial of albuterol and isoetharine. TYPE OF PARTICIPANTS: Patients between 18 and 50 years old presenting with acute asthma. Patients were excluded if they had a history of sensitivity to the study drugs, had congestive heart failure or chronic-obstructive pulmonary disease, or were unable to perform spirometry. One hundred three patients were entered into the study. INTERVENTIONS: All patients received oxygen and methylprednisolone in addition to administration of either isoetharine or albuterol. The nebulized aerosol was given at hourly intervals for a total of three doses. MEASUREMENTS AND MAIN RESULTS: Spirometry was performed before treatment and again at 90 and 180 minutes. Initial forced expiratory volume at one minute (FEV1) was 38.1% of predicted normal for the albuterol group and 36.0% of predicted normal for the isoetharine group. At 180 minutes, FEV1 was 55.6% of predicted normal for the albuterol group and 57.1% of predicted for the isoetharine group (NS). Twenty-eight percent of the albuterol group required admission compared with 26% of the isoetharine group (NS). There was no difference in occurrence of side effects between the two groups. CONCLUSION: Repeated doses of albuterol do not lead to a greater improvement in pulmonary function or a lower hospital admission rate than treatment with isoetharine.

Adolescent↗

PubMed1991

Comparison of physician judgment and decision aids for ordering chest radiographs for pneumonia in outpatients.

STUDY OBJECTIVES: To compare physician judgment in the use of chest radiographs for diagnosing pneumonia with decision rules developed by Diehr, Singal, Heckerling, and Gennis. DESIGN: Propsective observational investigation with preradiograph survey of physicians' intent to order chest radiographs for patients presenting with respiratory complaints. All patients had uniform clinical data collected, including chest radiographs and sufficient information to retrospectively apply the four clinical prediction rules. SETTING: The emergency department and medical outpatient clinic of a major urban teaching hospital. PARTICIPANTS: Adult patients presenting with recent history of acute cough or exacerbation of chronic cough plus either fever, sputum production, or hemoptysis. RESULTS: Of 290 patients, 21 (7%) had pneumonia. The sensitivity of physician judgment (0.86) exceeded that of all four decision rules. The specificity of the Diehr (0.67), Heckerling (0.67), and Gennis (0.76) rules exceeded that of physician judgment (0.58). The accuracy of the Gennis (0.76) and Heckerling (0.68) rules also exceeded that of the physicians (0.60). DISCUSSION: Physicians' diagnostic and therapeutic decisions were characterized by high sensitivity but lower specificity for ordering chest radiographs to diagnose pneumonia. The higher specificity and accuracy of two of the decision rules suggest that they may have a role in patient evaluation.

Adult↗

PubMed1991

A comparison of EMT judgment and prehospital trauma triage instruments.

A number of instruments have been devised to aid in the triage of trauma patients. Little work, however, has been done to demonstrate that these triage instruments offer an advantage over the judgment of an emergency medical technician (EMT) in determining which patients require transportation to a trauma center. The purpose of this study was to compare EMT judgment against three scoring systems; the triage-revised Trauma Score, the Prehospital Index, and the CRAMS scale. Data were gathered on trauma victims transported by the City of Cleveland EMS system. The EMTs rated the patient's overall severity on a 4-point scale and estimated the probability of patient mortality. We found that the EMT prediction of mortality was as accurate as the various scores. In a subset of patients, we also found that the EMT assessment performed as well as the scoring systems in identifying patients who either died or required emergent operative intervention. We conclude that EMT judgment is as accurate as these three scoring systems in identifying patients at high risk for death or the need for immediate operative intervention.

Adult↗

PubMed1991

Spirometric criteria for hospital admission of patients with acute exacerbation of COPD.

Recent studies have demonstrated that there is a high relapse rate for patients discharged from the Emergency Department (ED) following treatment of acute exacerbation of chronic obstructive pulmonary disease (COPD). Objective criteria have not been established to determine when to hospitalize these patients. This study evaluated spirometric criteria for that use. Eighty-three patients with an acute exacerbation of COPD were studied; 45 percent were admitted to the hospital while 17 percent of the patients who were discharged suffered a relapse. An FEV1 of less than 40 percent of predicted normal identified patients who required hospital admission or suffered a relapse with a sensitivity of 0.96, specificity of 0.58, and overall accuracy of 0.78. Combining clinical assessment with spirometry led to an improvement in specificity to 0.73 with a minimal decrease in sensitivity. Patients with an FEV1 of 40 percent or greater of predicted normal or no clinical evidence of respiratory distress after treatment may be safely discharged from the hospital. Patients not meeting these criteria are at high risk for relapse and should either be admitted or have further aggressive ED therapy.

Aged↗

PubMed1990

Dye circulation times during cardiac arrest.

Dye dilution curves have been used to calculate cardiac output under conditions of normal circulation. Unfortunately, these curves cannot be integrated easily to determine cardiac output under the low flow states of CPR. The time to initial dye appearance (circulation time), may be useful in judging relative changes in flow when studying experimental resuscitation techniques. The purpose of this study was to investigate the relationship between dye circulation times and other hemodynamic measures during CPR. Repeated measurements of coronary perfusion pressure, dye circulation times, blood gases, and end-tidal CO2 (ETCO2) were made in dogs undergoing CPR. Dye circulation time was significantly associated with the systolic, diastolic, and coronary perfusion pressures. The correlation between circulation time and ETCO2 was -0.70 (P less than 0.0001). There was no correlation with the arterial-venous PO2 gradient. There were significant correlations between the circulation time and both the A-V PCO2 and the A-V pH gradients. We conclude that dye circulation times may be used to gauge relative changes in blood flow during CPR, particularly in laboratory investigations involving repeated measurements.

Animals↗

PubMed1990

Theophylline concentrations in patients with acute exacerbation of COPD.

Patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) frequently report a history of theophylline use prior to arrival in the emergency department. The reliability of using this history to guide aminophylline therapy is, however, unclear. The authors studied patients with an acute exacerbation of COPD to determine the relation between the initial theophylline level and the medication history. Seventy-nine patients with a mean age of 64.3 years were entered into the study. The average theophylline level was 10.8 micrograms/mL. Forty-seven percent of the patients had subtherapeutic levels, 46% had therapeutic levels, and 7% had toxic levels. There were weak although statistically significant correlations between the theophylline level and the interval since the last theophylline dose (r = -.40, P less than .001), as well as with the last recorded outpatient theophylline level (r = .45, P less than .001). However, the theophylline level could not be predicted accurately in a number of patients. The authors conclude, because the prediction rule was often inaccurate, aminophylline therapy in patients with acute exacerbation of COPD should be based on direct measurement of the serum theophylline level.

Aged↗

PubMed1990

A controlled trial of nebulized isoetharine in the prehospital treatment of acute asthma.

Acute asthma is a potentially life-threatening disorder, recognizable to the prehospital care provider. While therapies are available to the prehospital care provider for treating acute asthma, no previous controlled studies have been performed demonstrating the treatment in the field is efficacious and safe. The authors conducted a controlled trial of the prehospital use of nebulized isoetharine in an urban emergency medical services system. Fifty-two patients with acute asthma were studied. Patients were initially evaluated with a peak flow meter. Half of the patients received isoetharine, while the control group received basic life support only. There was no difference in baseline values. Peak expiratory flow increased from 138 L/min to 148 L/min in the control group, while it increased from 149 L/min to 218 L/min in the treatment group (P less than .001). The authors conclude that paramedic treatment of acute asthma with nebulized isoetharine is effective in improving pulmonary function and clinical status during transport.

Acute Disease↗

PubMed1990

The effect of bolus injection on circulation times during cardiac arrest.

Previous investigations have shown that peripheral injection of medication during cardiac arrest leads to prolonged circulation times and low peak drug levels. Current Advanced Cardiac Life Support guidelines suggest that administering a bolus of flush solution after injection of medication may hasten drug delivery, but there is little evidence to support this. The purpose of this study is to investigate the effect of peripheral bolus injection on circulation times during cardiac arrest. Measurements of circulation times were made following injection of indocyanine green dye both with and without a bolus of 20 mL saline flush into a peripheral vein of mongrel dogs. There was no difference in systolic, diastolic, or coronary perfusion pressures during the injections with or without bolus injection. Similarly, there was no difference in end-tidal CO2 or in arterial-venous PO2, PCO2, or pH gradient. The circulation time without bolus injection was 77.7 +/- 42.7 seconds while circulation time with the saline flush was 48.3 +/- 20.9 seconds (P less than .001). Peak dye concentration without saline flush was 3.0 +/- 1.0 mg/L, and peak dye concentration with saline flush was 3.8 +/- 0.9 mg/L (P less than .001). We conclude that a bolus injection of 20 mL of saline enhances dye circulation times and peak levels during cardiac arrest in this animal model. The clinical application of this technique warrants further investigation.

Animals↗

PubMed1990

Outpatient management of partial-thickness burns: Biobrane versus 1% silver sulfadiazine.

A randomized, prospective study comparing the use of Biobrane (group 1) with the use of 1% silver sulfadiazine (group 2) in treating 56 partial-thickness burn wounds was carried out in 52 outpatients with burns that comprised less than 10% of their total body surface area. The two groups were similar in age, gender, race, and extent of burn. Wounds of patients in group 1 (30) were compared with those of group 2 (26) for healing time, pain, compliance with scheduled visits, and costs. Infected and skin-grafted wounds were excluded from healing time analysis. Infection rates of the two groups were similar (three of 30 vs two of 26). One patient in each group underwent skin grafting. Healing times of group 1 wounds were significantly less than those of group 2 (10.6 +/- 0.8 vs 15.0 +/- 1.2 days, P less than .01). Using a pain scale of 1 to 5, Biobrane-treated patients averaged lower pain scores at 24 hours after the burn (1.6 +/- 0.8 vs 3.6 +/- 1.3 P less than .001) and used less pain medication. Compliance with scheduled outpatient visits was also improved in the Biobrane-treated group (88.6% vs 63.2% attendance, P less than .001). Idealized total treatment costs averaged $434 for patients in group 1 compared with $504 for patients in group 2. We conclude that when used on properly selected wounds, Biobrane therapy can significantly decrease pain and total healing time without increasing the cost of outpatient burn care. Improved patient compliance may be an added benefit.

Adolescent↗

PubMed1990

A prospective study of femoral versus subclavian vein catheterization during cardiac arrest.

Femoral vein catheterization has advantages over subclavian vein catheterization during cardiac arrest in that there is minimal interference to ongoing CPR. In addition, risks of subclavian catheterization are not a factor in femoral vein catheterization. Few studies have compared the success rate for catheterization of one site with that of the other during cardiac arrest. We conducted a prospective study to compare the success and complication rates for femoral with those of subclavian vein catheterization. Ninety-four patients undergoing CPR had either femoral or subclavian vein catheters placed during the course of the arrest. Catheter placement was verified by injection of radiopaque contrast material. We found that the success rate for femoral catheterization was 77% compared with a success rate of 94% for subclavian vein catheterization (P less than .05). There were no instances of pneumothorax with subclavian vein catheterization. There was no apparent learning curve leading to an increased success rate during the course of the study. We conclude that femoral vein catheterization should not be used except in those instances where attempts at peripheral and central venous cannulation are unsuccessful.

Aged↗

PubMed1990

Risk of toxicity in patients with elevated theophylline levels.

Toxic side effects of elevated theophylline levels range from minor symptoms to life-threatening complications. We investigated the incidence of life-threatening events in patients with elevated levels in order to identify those at low risk for significant theophylline toxicity. Five hundred ten episodes of elevated levels were reviewed in 214 hospitalized patients. Four seizures occurred in patients with prior seizures, while two had new onset seizures with levels of 27 and 30 micrograms/mL. All eight episodes of ventricular tachycardia occurred in patients who had a history of arrhythmias or who were critically ill. Seven patients had new supraventricular arrhythmias with levels of 21 to 40 micrograms/mL. Life-threatening events may occur in critically ill patients or patients with past seizures or arrhythmias with mildly elevated levels, although the extent to which theophylline toxicity contributes to morbidity or mortality in these patients is unclear. Patients who are otherwise healthy are unlikely to have significant theophylline toxicity with levels less than 25 micrograms/mL.

Aged↗

PubMed1989

Hemodynamic effects of the intra-aortic balloon pump during experimental cardiac arrest.

The low flow states and limited coronary perfusion provided by conventional cardiopulmonary resuscitation (CPR) have prompted investigations into alternative, more invasive, methods of resuscitation. Previous case reports and limited animal evidence have suggested that the intra-aortic balloon pump (IABP) may have a role in resuscitation. We used a canine cardiac arrest model to study the hemodynamic effects of the IABP during closed-chest CPR. A sensor attached to the chest plate of a Thumper was used to time a Datascope Model 3520 ventricular assist console such that the balloon inflated on the upstroke and deflated on the downstroke of the Thumper. There was no increase in systolic blood pressure with the balloon pump. Diastolic blood pressure and coronary perfusion pressure were significantly higher with the IABP. Circulation times were shorter and end-tidal CO2 was higher with the IABP. It was concluded that the IABP improves hemodynamic parameters during experimental cardiac arrest.

Animals↗

PubMed1989

Relationship between arterial blood gases and spirometry in acute exacerbations of chronic obstructive pulmonary disease.

Previous studies have established spirometric criteria for arterial blood gas analysis during acute asthmatic attacks. However, only general guidelines have been available regarding the need for blood gas analysis during an acute exacerbation of chronic obstructive pulmonary disease (COPD). We conducted a study to determine the relationship between arterial blood gases and spirometry in 70 emergency department patients during acute exacerbations of COPD. Arterial blood gas analysis and spirometry were performed on arrival at the emergency department. All of the patients with a pCO2 of more than 45 mm Hg had an FEV1 of less than 35% of the predicted normal. We found patients with a pO2 of less than 60 mm Hg who had an FEV1 as high as 54% of the predicted normal. There was no correlation between the FEV1 and pO2. Because spirometry was not reliable for identifying patients with significant hypoxemia, we conclude that arterial blood gas analysis is indicated for patients presenting to the ED with acute exacerbations of COPD. Spirometric criteria that have been used to eliminate the need for arterial blood gases in asthmatic patients cannot be applied safely to patients with COPD.

Acute Disease↗

PubMed1989

A randomized controlled trial of methylprednisolone in the emergency treatment of acute exacerbations of COPD.

We conducted a randomized, controlled double-blind study to determine whether intravenous administration of methylprednisolone early in the therapy for acute exacerbations of COPD would improve pulmonary function in the Emergency Department and reduce the need for hospitalization. Ninety-six patients completed the study. All were at least 50 years of age and had no history of asthma. Patients received aminophylline and hourly administration of aerosolized isoetharine. Methylprednisolone (100 mg) or physiologic saline solution was given within one-half hour of arrival in the Emergency Department. Spirometry was performed initially and after the third and fifth aerosol treatments. We found no greater improvement in FEV1 in the group receiving the steroid (37 percent) than in the control group (43 percent; NS). There was also no difference in the rate of hospitalization (33 percent in the steroid-treated group vs 30 percent in the control group; NS). We conclude that early administration of methylprednisolone does not affect the emergency phase of treatment for acute exacerbations of COPD.

Aerosols↗