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Biomedical subjects

D W Steele

Publications and source records attributed to D W Steele.

10 recordsLinked to original sources
PubMed2000

Capnography during sedation/analgesia in the pediatric emergency department.

OBJECTIVE: To measure changes in end-tidal carbon dioxide levels (ETCO2) during sedation/analgesia in pediatric patients and to describe ETCO2 changes associated with different sedation strategies. METHODS: This was a prospective, observational patient series in an urban pediatric emergency department (PED). Participants included 106 children with a mean age of 6.8 years. (range 1.2-16.6 years). Sedation/analgesia was given for fracture reduction (55%), laceration repair (37%), abscess incision and drainage (4%), and lumbar puncture (LP) (4%). Medications included fentanyl, morphine, ketamine, and midazolam. Continuous ETCO2 waveforms were recorded via a Capnogard ETCO2 Monitor. Oxygen saturation was recorded using a Nelcor N-200 pulse oximeter. Recording began prior to sedation and continued until the patient was awake or when it was necessary to remove the patient from the monitor for further medical care. Each record was analyzed for peak ETCO2 and averaged over five consecutive breaths, before and after the administration of medications. The main outcome measure was the change in ETCO2 levels. RESULTS: The mean increase in ETCO2 was 6.7 mmHg (P is included in, 0.00001; range: +0.16 to +22.3). ETCO2 increased by 3.2 mmHg (95% CI = 2.2-4.2) for midazolam alone, 5.4 mmHg (95% CI = 4.5-6.4) for midazolam and ketamine, and 8.8 mmHg (95% CI = 7.4-10.2) for midazolam and opiate. Two patients had transient SpO2 desaturations below 93%, which corrected with stimulation. CONCLUSIONS: Commonly used agents for pediatric sedation result in significant increases in ETCO2. ETCO2 is a useful adjunct in assessing ventilation and may serve as an objective research tool for assessing different sedation strategies.

Adolescent↗
PubMed1998

Pulsus paradoxus: an objective measure of severity in croup.

We used a noninvasive monitor of arterial pressure to determine the utility of pulsus paradoxus (PP) as an objective severity measure in croup. We performed a prospective, blinded comparison of PP in children with croup versus healthy control subjects, analyzed the relationship between PP and Westley croup score (WCS), and observed the effect of racemic epinephrine (RE) on PP and WCS in a subgroup of patients with severe croup. The PP and WCS were measured at presentation and in severe patients after treatment with RE. Mean PP was 6.1 +/- 1.8 (SD) mm Hg (n = 29) in control subjects compared with a mean of 17.8 +/- 11.2 (SD) mm Hg (n = 28) in patients with croup (p < 0.00001). There was significant concordance between baseline WCS and PP (Spearman's rho: 0.68; p = 0.0001). The mean decrease in PP after RE was 7.5 +/- 11.8 (SD) mm Hg (p = 0.05; n = 12). The magnitude of decrease in PP after RE has significant concordance with the concurrent decrease in WCS (Spearman's rho: 0.73; p < 0.007). PP is elevated in children with croup, and the magnitude of elevation correlates with severity as measured by the WCS. PP may have utility as a research tool to objectively measure the severity of upper airway obstruction in croup.

Adolescent↗
PubMed1997

Implementation of a hypertext-based curriculum for emergency medicine on the World Wide Web.

This project reports the publication of a variety of existing curricular resources for emergency medicine on the global Internet in a format that allows hypertext links between related material, timely updates, and end-user feedback. Curricular elements were converted to Hypertext Markup Language with extensive links between related content. The completed document contains instructions for curriculum development, specific curricula for subspecialty areas within a residency, reading lists for subspecialty curricula, banks of images, and board-type questions with answers. Users are provided with a mechanism to provide immediate feedback to section editors with suggestions for changes, including new references. Access to all or part of the document can be controlled via passwords, but is potentially available to anyone with an Internet connection and a World Wide Web browser. The document may by viewed on the World Wide Web at: http:@www.brown.edu@Administration@emergency_Medicine@ curr.html.

Computer Communication Networks↗
PubMed1997

Evaluation of pre- and posttreatment pulse oximetry in acute childhood asthma.

OBJECTIVE: To evaluate the utility of pre- and posttreatment O2 saturation (SpO2) for prediction of admission or relapse after ED release in acute asthma exacerbations using a standardized treatment protocol. DESIGN: A prospective, double-blind, observational study was performed at a pediatric ED. Children with acute asthma were enrolled upon ED presentation. SpO2 was measured prior to treatment and after disposition decision. Two experienced physicians determined disposition based on history and physical examination alone, while blinded to SpO2. Relapse of released patients was determined by telephone follow-up. RESULTS: A pretreatment room-air SpO2 of < or = 91% had a sensitivity of 0.24, a specificity of 0.86, and a likelihood ratio of 1.77 to predict admission/relapse. A posttreatment room-air SpO2 of < or = 91% had a sensitivity of 0.34, a specificity of 0.98, and a likelihood ratio of 16.43 to predict admission/relapse. CONCLUSIONS: As opposed to some previous studies, this study found pretreatment SpO2 to be a relatively poor predictor of admission. A posttreatment SpO2 of < or = 91% occurred in a minority (32%) of patients, but increased the odds of admission 16-fold and may be used as an adjunct to objectively confirm the need for admission.

Adolescent↗
PubMed1996

Continuous, noninvasive measurement of pulsus paradoxus in patients with acute asthma.

OBJECTIVE: To evaluate a continuous, noninvasive measurement technique for pulsus paradoxus (PP) as an objective asthma severity indicator. DESIGN: Prospective, masked assessment of the relationship between PP, peak expiratory flow rate, oxygen saturation, clinical scoring, and admission decisions. SETTING: An urban pediatric emergency department. PATIENTS: Children with acute asthma. INTERVENTIONS: Standardized treatment per National Heart, Lung, and Blood Institute guidelines. MAIN OUTCOME MEASURES: Peak expiratory flow rate, oxygen saturation, pulmonary index score, and masked disposition decision. RESULTS: Significant positive correlations existed between PP and the pulmonary index score at the initial evaluation (r = 0.44; P < .001) and after 30 minutes (r = 0.51; P < .001) and 60 minutes (r = 0.45; P < .001). Significant negative correlations existed between PP and the percent predicted peak expiratory flow rate (r = -0.31; P = .01) and the oxygen saturation (r = -0.30; P = .02). The mean PP was significantly greater in patients who were admitted for further treatment at all time points (P = .003 or P = .002). At 30 minutes after presentation, a PP greater than 15 mm Hg predicted admission for further treatment or relapse; the sensitivity was 0.42, the specificity was 0.89, and the likelihood ratio was 3.86. CONCLUSIONS: Our measurement technique for PP is a useful objective indicator of the severity of asthma. Pulsus paradoxus correlates with clinical score, peak expiratory flow rate, and oxygen saturation. Furthermore, an elevated PP is associated with the decision to admit a patient for further treatment. These results suggest that this technique may represent a useful research tool for the assessment of acute, severe asthma. Further development of the technology may allow for a clinical application.

Acute Disease↗
PubMed1995

Varicella: pediatric genital/rectal vesicular lesions of unclear origin.

Three children who presented with localized vesicular rash in the diaper area were found to have primary varicella-zoster infections. Primary varicella can closely mimic genital herpes simplex virus (HSV 1 or 2), which may be an indicator of sexual abuse. To avoid unfounded investigation for sexual abuse, primary varicella-zoster infection must be included in the differential diagnosis. Direct fluorescent antibody testing is a sensitive and specific diagnostic test that can be used to distinguish HSV 1 or 2 from varicella-zoster.

Chickenpox↗
PubMed1995

Continuous noninvasive determination of pulsus paradoxus: a pilot study.

OBJECTIVE: To evaluate two methods of continuous, noninvasive monitoring of pulsus paradoxus (PP). METHODS: A single-subject, nonblind assessment was conducted of the ability of noninvasive monitoring techniques to measure experimentally induced PP. Variable degrees of PP were induced in a healthy adult breathing through a one-way valve to which a series of external airway resistances were added. Intra-arterial pressure (IAP), finger arterial blood pressure (FINAP), pulse oximeter pulse waveform, and chest wall motion were continuously recorded. For each resistance, PP was calculated from the IAP (PPIAP) and the FINAP (PPFINAP) recordings. PP was measured manually (PPmanual) in the opposite arm. The percentage pulse waveform decrease on inspiration (%PWDpleth) was derived from the oximeter pulse waveform. These measurements were compared with the PPIAP. Bias was assessed as the mean difference between PP measures. RESULTS: PPFINAP was highly correlated with PPIAP (r = 0.96; 95% CI 0.93 to 0.98; p < 0.0001). There was a weak correlation between PPmanual and PPIAP (r = 0.27; 95% CI -0.05 to 0.55; p = 0.0963). The %PWDpleth correlated with PPIAP (r = 0.59, 95% CI 0.32 to 0.78; p = 0.0002). Bias was -1.515 +/- 5.6 mm Hg between PPIAP and PPFINAP; and -4.508 +/- 23.4 mm Hg between PPIAP and PPmanual. CONCLUSION: An accurate and continuous PP can be measured noninvasively using a FINAP monitor. This method has much better agreement with IAP measurements than do manual measurements. The qualitative information provided by the oximeter pulse waveform is less accurate than that provided by the FINAP monitor, but is a potentially useful screening tool for detection of significant PP.

Adult↗
PubMed1994

Are pediatric emergency medicine training programs meeting their goals and objectives? A self-assessment of individuals completing fellowship training in 1993.

The purpose of this study was to evaluate the overall training experience of those individuals completing fellowships in pediatric emergency medicine. Specific attention was given to the technical skills portion of training as set forth by the American Academy of Pediatrics Curriculum Committee on Pediatric Emergency Medicine. We surveyed those individuals completing their second year of fellowship training in pediatric emergency medicine. The questionnaire incorporated a self-assessment of the technical skills portion of the Subcommittee on Pediatric Emergency Medicine's most recent curriculum statement. It also contained several questions designed to evaluate the overall training experience. Eighty percent of respondents completing the self-assessment questionnaire rated their overall experience as favorable, whereas those who rated it unfavorable stressed a lack of training in research and teaching. Ninety-two percent of respondents felt they had a good clinical experience, but 80% expressed a need for further training in administration, 74% in research, and 46% in teaching. Although the majority claimed to be comfortable with most technical skills, several skills, including lifesaving procedures such as external pacing, peritoneal lavage, pericardiocentesis, shunt tap, airway foreign body removal, and needle cricothyrotomy, posed a significant degree of discomfort.

Clinical Competence↗
PubMed1986

Effect of 6-hydroxydopamine on polymerization of tubulin. Protection by superoxide dismutase, catalase, or anaerobic conditions.

Microtubular protein (tubulin) isolated from porcine brain was subjected to selected oxidative stresses, including incubation with the neurotoxin 6-hydroxydopamine (6-OHDA) under aerobic and anaerobic conditions. The functional capacity of the tubulin was determined on the basis of its ability to form microtubules as measured by alterations in the viscosity of the test mixtures, and confirmed by electron microscopy. 6-OHDA completely inhibited formation of microtubules at concentrations as low as 10 mM. Assembled microtubules were half as susceptible to destruction by 6-OHDA as unaggregated tubulin. Anaerobic conditions or the presence of catalase, superoxide dismutase, or a mixture of superoxide dismutase and catalase provided partial protection against 6-OHDA-induced destruction. In control reactions, tubulin-containing solutions incubated for up to 8 hr at ambient oxygen tensions, also showed significant decreases in ability to polymerize. Anaerobic conditions provided partial protection against this loss of function. In contrast, ascorbate accelerated the loss of activity upon standing, while glutathione or dithiothreitol offered no protection.

Anaerobiosis↗