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H A Smithline

Publications and source records attributed to H A Smithline.

16 recordsLinked to original sources
PubMed2001

Social services referral of adolescent trauma patients admitted following alcohol-related injury.

Alcohol screening of severely injured patients should be universal. Hospitalization following alcohol-related injury provides an opportunity for intervention to reduce recidivism. This study examines the frequency of social services referral of an alcohol positive cohort of adolescent trauma patients. This was a retrospective analysis of data collected from 1994 through 1998 by the National Pediatric Trauma Registry. All patients between the ages of 12 and 17 who had a blood alcohol level (BAL) measured were analyzed. Patients receiving referral to the department of social services, family counseling, or addiction services, and those receiving any substance abuse education intervention were considered a positive referral. There were 6006 children age 12 to 17 included in the database during this five-year period, 751 of whom had a BAL measured. Of those screened, 15.5% were positive. Sixty-eight (59%) of the BAL positive patients were referred for intervention through social services. The only statistically significant predictor of referral was whether or not the patient was the operator of a vehicle involved in the motor vehicle collision. Nearly half of the adolescents in this study, who screened positive for alcohol, received no social services support.

Accidents, Traffic↗
PubMed2000

Analgesic administration to patients with an acute abdomen: a survey of emergency medicine physicians.

The objective of this study was to examine current practice patterns of analgesia administration among emergency physicians (EPs) when caring for a patient with an acute abdomen. Cross sectional data were acquired by a survey mailed in October 1997 to 1,000 American College of Emergency Physicians (ACEP) members from a purchased ACEP mailing list which contained 1,000 randomized ACEP members. A repeat survey was sent to nonresponders 2 months later and a random subset of recurrent nonresponders were telephoned. The questionnaire focused on physician demographics, practice patterns, and factors which influenced physician decision of when and whether to administer pain medication, specifically opiates, to patients with an acute abdomen. Forty-four percent of surveys were returned. Seventy-seven percent of respondents were men with an average of 10 years of experience. Fifty-seven percent were residency trained in emergency medicine. Although eighty-five percent felt that the conservative administration of pain medication did not change important physical findings on the physical examination, 76% choose not to give an opiate analgesic until after the examination by a surgeon. Twenty-five percent of patients did not receive any pain medication in the department. In conclusion, although EPs report that the judicious administration of pain medication does not mask important examination findings, the majority wait until after the surgeon has evaluated the patient to deliver analgesics.

Abdomen, Acute↗
PubMed2000

Patient care by physician assistants and by physicians in an emergency department.

OBJECTIVE: Decreasing health care dollars have resulted in increased utilization of so-called midlevel practitioners. We compared emergency physicians with emergency department physician assistants (PAs) to determine whether PAs are an appropriate option for providing services rendered by physicians in this setting. METHODS: We undertook an observational retrospective review of a hospital database (July 1995 to June 1996) from an urban urgent-care facility. Collection of data was restricted to times of single-provider coverage. Every patient who visited the clinic was seen by the sole provider (physician or PA) on duty; no one was turned away. If a patient needed emergency care, he (or she) was transferred to the main emergency department at the hospital, as deemed appropriate by either provider after evaluation. Physicians and PAs were compared in regard to length of visit and total charges in 14 diagnostic groups. Adverse outcomes were not evaluated. Age, sex, race, and multiple diagnoses were controlled for by regression analysis. RESULTS: A total of 9,601 patient encounters were analyzed. PAs and physicians had a similar distribution of diagnostic groups. Respiratory infection and musculoskeletal disorders accounted for approximately 36% of visits; lacerations, gastrointestinal disorders, and otitis each accounted for 5% of visits. Overall, visits were 8 minutes longer and total charges $8 less when a patient was treated by a PA. Patients who had headache, otitis, respiratory infection, asthma, gastrointestinal or genitourinary disorder, cellulitis, laceration, or other musculoskeletal disorder had a longer visit when seen by a PA; the difference ranged from 5 to 32 minutes longer. In no diagnostic group was there a statistically significant greater length of visit or total charge because patients were seen by a PA. CONCLUSION: Despite a few large differences in some diagnostic groups, the two types of provider had, overall, small but clinically insignificant differences in length of visit and total charges. The magnitude of difference in length of visit and total charges strongly suggests that PAs, when compared with physicians, are a viable staffing option in an urgent care facility.

Adolescent↗
PubMed1999

Aminophylline in undifferentiated out-of-hospital asystolic cardiac arrest.

PRIMARY OBJECTIVE: To determine if the introduction of intravenous aminophylline, a nonspecific adenosine receptor antagonist, into the resuscitation algorithm of asystole will increase return of spontaneous circulation when used in undifferentiated prehospital cardiac arrest. METHODS: An urban, prehospital, prospective, randomized, double-blind, placebo-controlled trial of nonpregnant normothermic adults suffering nontraumatic out-of-hospital asystolic cardiac arrest. Subjects were treated in accordance with published advanced cardiac life support guidelines and standard pharmacotherapy. They were randomly assigned to receive either placebo or aminophylline along with the initial boluses of atropine and epinephrine. Cardiac rhythms and carotid pulses were monitored throughout the resuscitation. RESULTS: Eighty-two patients were entered into the trial. Forty-five patients were assigned to the placebo group and 37 received aminophylline. Nine of 45 controls (20%; 95% CI 10-35%) achieved return of spontaneous circulation compared to ten of 37 (27%; 95% CI 14-44%) in the aminophylline group. CONCLUSIONS: We were not able to show a statistically significant improvement in return of spontaneous circulation when aminophylline was given during the early resuscitation phase of undifferentiated asystolic cardiac arrest in the prehospital setting with this sample size.

Aged↗
PubMed1999

Adrenal dysfunction in hemodynamically unstable patients in the emergency department.

OBJECTIVE: Adrenal failure, a treatable condition, can have catastrophic consequences if unrecognized in critically ill ED patients. The authors' objective was to prospectively study adrenal function in a case series of hemodynamically unstable (high-risk) patients from a large, urban ED over a 12-month period. METHODS: In a prospective manner, critically ill adult patients presenting to the ED were enrolled when presenting with a mean arterial blood pressure < or =60 mm Hg requiring vasopressor therapy for more than one hour after receiving fluid resuscitation (central venous pressure of 12-15 mm Hg or a minimum of 40 mL/kg of crystalloid). Patients were excluded if presenting with hemorrhage, trauma, or AIDS, or if steroids were used within the previous six months. An adrenocorticotropic hormone (ACTH) stimulation test was performed and serum cortisol was measured. Treatment for adrenal insufficiency was not instituted. RESULTS: A total of 57 consecutive patients were studied. Of these, eight (14%) had baseline serum cortisol concentrations of <20 microg/dL (<552 nmol/L), which was considered adrenal insufficiency (AI). Three additional patients (5%) had subnormal 60-minute post-ACTH-stimulation cortisol responses (<30 microg/dL) and a delta cortisol < or =9 microg/dL, which is the difference between the baseline and 60-minute levels. This is functional hypoadrenalism (FH). There were no laboratory abnormalities that distinguished patients with AI or FH from those with preserved adrenal function (PAF). Rates of survival to discharge did not differ between the AI group (7 of 8) and PAF patients (21 of 46; p = 0.052). CONCLUSIONS: Adrenal dysfunction is common in high-risk ED patients. Overall, it has a frequency of 19% among a homogeneous population of hemodynamically unstable vasopressor-dependent patients. The effect of physiologic glucocorticoid replacement in this setting remains to be determined.

Adrenal Insufficiency↗
PubMed1999

Do patients with acute medical conditions have the capacity to give informed consent for emergency medicine research?

OBJECTIVE: Because of stress and illness, conscious emergency medicine (EM) patients may be temporarily cognitively impaired and thus incapable of participating in the informed consent process for acute care research. This pilot study sought to assess the mental capacity of ED patients during their evaluation and treatment for acute myocardial infarction (AMI). METHODS: A prospective observational design at a university tertiary referral center. EM patients with AMI from November 1996 to February 1997 were enrolled. While usual care was delivered, patients were administered three subtests of the Wechsler Adult Intelligence Scale-Revised (WAIS-R) test. Subtest scaled scores range from 1 to 19, with abnormal being less than 5. Demographic, historical, and environmental parameters were recorded. Patients assessed how serious they perceived their conditions; and rated their degrees of pain, nausea, breathlessness, and anxiety on 10-cm visual analog scales (VASs). Testing was repeated prior to hospital discharge. RESULTS: Twenty-five patients were enrolled. Of these, two (8%) were suspected by their emergency physicians to have insufficient capacity to give informed consent. However, five (20%) scored less than 5 on all of the WAIS-R subtests (kappa = 0.5) and eight (32%) scored less than 5 on at least one of the subtests (kappa = 0.3). The initial median Digit Span, Comprehension, and Similarities subtest scores were 7, 5, and 6. By discharge, these improved to 8, 7, and 8, respectively. CONCLUSIONS: This pilot study suggests that some patients with AMI may have difficulty processing information necessary to give informed consent for acute care research. Routine clinical evaluation may not detect this cognitive defect.

Acute Disease↗
PubMed1998

Waiver of informed consent: a survey of emergency medicine patients.

Changes to Federal regulations pertaining to waiver of informed consent for acute care research were debated by the research and regulatory communities for more than 2 years before being finalized in October of 1996. Input from the general public was limited. This survey investigated the opinions of emergency medicine patients concerning waiver of informed consent for acute care research. A convenience sample of 212 patients were approached at a tertiary care academic urban emergency department. Seventy-three percent approved of waiver of informed consent if the absolute risks were minimal (50% if the absolute risks were greater than minimal but the incremental risks were minimal). Educational status and certain aspects of the patient's current health status (but not age, race, or gender) significantly affected the results. While most emergency medicine patients would want to be enrolled in a study if they had a serious illness and were unable to give informed consent, a significant percentage of patients would not want to be enrolled regardless of the degree of risk or availability of a family member to speak on their behalf. Waiver of informed consent for emergency research is an ethical dilemma pitting individual rights against societal needs and physician parentalism. A better understanding of what patients consider appropriate may help in resolving this dilemma.

Acute Disease↗
PubMed1996

Orthostatic change in shock index: comparison with traditional tilt test definitions.

OBJECTIVE: To determine whether the orthostatic change in the shock index or published tilt test criteria better discriminated normal individuals from those with moderate acute blood loss. METHODS: Postural vital signs were recorded in a standardized manner before and after an elective 450-mL phlebotomy associated with blood donation in healthy volunteers. Paired comparisons of the sensitivity of each of 3 published tilt test criteria were made against the sensitivity of an orthostatic change in shock index (OCSI) at the threshold for OCSI yielding the same specificity. Subjects were prospectively divided into group 1 (age < 65 years) and group 2 (age > or = 65 years). RESULTS: A total of 336 healthy euvolemic adult blood donors were studied over a 1-year period (group 1 = 292; group 2 = 44). For each published criterion for a positive tilt test (for both groups), OCSI had the same or higher sensitivity for a chosen specificity. No sensitivity difference was statistically significant. An OCSI > or = 0 was 99%/98% sensitive and 10%/10% specific (group 1/group 2) for a 450-mL blood loss; whereas an OCSI > or = 0.25 was 28%/23% sensitive and 92%/100% specific (group 1/group 2). CONCLUSION: The OCSI discriminates normal individuals from those with acute moderate blood loss as well as previously published tilt test definitions do.

Adult↗
PubMed1994

A comparison of the shock index and conventional vital signs to identify acute, critical illness in the emergency department.

STUDY OBJECTIVE: Shock index (SI) (heart rate/systolic blood pressure; normal range, 0.5 to 0.7) and conventional vital signs were compared to identify acute critical illness in the emergency department. DESIGN: Quasi-prospective study. PATIENTS: Two hundred seventy-five consecutive adults who presented for urgent medical care. INTERVENTIONS: Patients had vital signs, SI, and triage priority recorded on arrival in the ED and then their final disposition. RESULTS: Two groups were identified retrospectively by the SI; group 1 (41) had an SI of more than 0.9, and group 2 (234) had an SI of less than 0.9 on arrival in the ED. Although both groups had apparently stable vital signs on arrival, group 1 had a significantly higher proportion of patients who were triaged to a priority requiring immediate treatment (23 versus 45; P < .01) and required admission to the hospital (35 versus 105; P < .01) and continued therapy in an ICU (10 versus 13; P < .01). CONCLUSION: With apparently stable vital signs, an abnormal elevation of the SI to more than 0.9 was associated with an illness that was treated immediately, admission to the hospital, and intensive therapy on admission. The SI may be useful to evaluate acute critical illness in the ED.

Adult↗
PubMed1994

Biphasic extrathoracic pressure CPR. A human pilot study.

HYPOTHESIS: Alternating intrathoracic pressure by means of a chest cuirass can cause perfusion and ventilation equal to or better than standard cardiopulmonary resuscitation (CPR) for humans in cardiac arrest. DESIGN: Nonrandomized, nonblinded, crossover pilot study. SETTING: Large urban emergency department. SUBJECTS: Five adult normothermic, nontraumatic, out-of-hospital cardiac arrest patients unresponsive to standard advanced cardiac life support. METHOD: Right atrial and aortic catheters were inserted for pressure measurement and blood gas analysis while the patient was receiving standard CPR by a pneumatic compression device (Thumper). The Thumper was then replaced by a chest cuirass (Hayek Oscillator). Pressure and blood gas measurements were then repeated. RESULTS: The coronary perfusion pressure increased from -1.2 +/- 8.6 mm Hg to 6.2 +/- 6.9 mm Hg for a mean change of 7.4 +/- 3.1 mm Hg (p = 0.006). The compression phase gradient increased 10.0 +/- 21.9 mm Hg (p = 0.364). The venous to arterial PCO2 gradient decreased 44.5 +/- 32.3 mm Hg (p = 0.070). The oxygen extraction ratio increased 1.6 +/- 9.4 percent (p = 0.761). The mean arterial PO2 and PCO2 changed from 252 to 240 mm Hg (p = 0.836) and from 53 to 66 (p = 0.172) mm Hg, respectively. CONCLUSION: The Hayek Oscillator chest cuirass produced a significant improvement in the coronary perfusion pressure. There was a trend for improved systemic perfusion as indicated by an improved compression phase gradient and venous to arterial PCO2 gradient, although this was not supported by the lack of improvement in the oxygen extraction ratio. The cuirass also adequately oxygenates and ventilates unassisted by positive pressure ventilation.

Cardiopulmonary Resuscitation↗
PubMed1993

A characterization of hypothalamic-pituitary-adrenal axis function during and after human cardiac arrest.

OBJECTIVE: This study characterizes hypothalamic-pituitary-adrenal axis function during cardiopulmonary arrest and after return of spontaneous circulation. DESIGN: Prospective case series. SETTING: A large urban emergency department and intensive care unit over an 8-month period. PATIENTS: Two hundred five adult patients presenting in cardiopulmonary arrest to an urban emergency department. Three patients known to be taking corticosteroids were excluded from the study. MEASUREMENTS AND MAIN RESULTS: Cortisol concentrations were measured before and after advanced cardiac life support and for five consecutive hours after return of spontaneous circulation. Adrenocorticotropic hormone (ACTH) concentrations were measured before advanced cardiac life support and when the cosyntropin stimulation tests were performed 6 and 24 hrs after the return of spontaneous circulation. The mean initial serum cortisol concentration was 32.0 +/- 33.1 micrograms/dL (882.9 +/- 913.2 nmol/L). Fifty-three percent of patients had cortisol concentrations of < 20 micrograms/dL (< 552 nmol/L) at the end of cardiac arrest. Among 44 patients who achieved return of spontaneous circulation, 98% had initial cortisol concentrations of > 10 micrograms/dL (> 276 nmol/L) and 73% of patients had initial cortisol concentrations of > 20 micrograms/dL (> 552 nmol/L). Mean serum cortisol concentrations increased significantly (p = .0001) from 1 to 6 hrs after return of spontaneous circulation and decreased significantly (p = .03) from 6 to 24 hrs. A serum cortisol concentration of < 30 micrograms/dL (< 828 nmol/L) was associated with a 96% and 100% mortality rate at 6 and 24 hrs, respectively. Mean ACTH concentrations were increased without a significant difference between the initial and 6-hr concentrations. Mean ACTH concentrations decreased between 6 and 24 hrs (p = .06). There were no significant responses to the cosyntropin stimulation at 6 and 24 hrs. CONCLUSIONS: Cortisol concentrations after out-of-hospital cardiac arrest are lower than those concentrations reported in other stress states. There is an association between cortisol concentrations and short-term survival after cardiac arrest. Survivors have a significantly greater increase in serum cortisol concentrations than nonsurvivors during the first 24 hrs. Lower than expected cortisol concentrations for the extreme stress of cardiac arrest may have pathologic significance in the hemodynamic instability seen after return of spontaneous circulation. The etiology of the low cortisol concentrations may be primary adrenal dysfunction.

Adrenocorticotropic Hormone↗
PubMed1992

Venous hyperoxia after cardiac arrest. Characterization of a defect in systemic oxygen utilization.

BACKGROUND: Supranormal mixed venous oxygen saturation (mixed venous hyperoxia), although reported, has never been characterized in humans resuscitated from cardiac arrest (postarrest cardiogenic shock). By contrast, cardiogenic shock without cardiopulmonary arrest (primary cardiogenic shock) is accompanied by mixed venous hypoxia under similar conditions of low oxygen delivery (DO2). The appearance of mixed venous hyperoxia indicates an excessive supply relative to demand in perfused tissue or cellular impairment of oxygen utilization, ie, low systemic oxygen consumption (VO2). Failure to improve VO2 has been associated with a poor outcome in other shock states. STUDY OBJECTIVE: This study evaluates the clinical significance of mixed venous hyperoxia and its implications for impaired systemic oxygen utilization. The oxygen transport patterns in surviving and nonsurviving cardiac arrest patients are compared for their prognostic and therapeutic implications. STUDY DESIGN: Consecutive, nonrandomized series. SETTING: Large urban emergency department (ED). PARTICIPANTS: Adult normothermic, nontraumatic out-of-hospital cardiac arrest patients presenting to the ED who develop a return of spontaneous circulation (ROSC). INTERVENTIONS: On arrival to the ED, a fiberoptic catheter was placed in the central venous position for continuous central venous oxygen saturation monitoring (ScvO2). A proximal aortic catheter was placed via the femoral artery for blood pressure monitoring. Upon ROSC, the fiberoptic catheter was advanced to the pulmonary artery. Mean arterial pressure (MAP), cardiac index (CI), VO2, DO2, systemic oxygen extraction ratio (OER), and systemic vascular resistance index (SVRI-dynes.s/cm5.m2) were measured immediately and every 30 min. The duration of cardiac arrest (DCA) in minutes and amount of epinephrine (milligrams) administered during ACLS was recorded. MEASUREMENTS AND RESULTS: Twenty-three patients were entered into the study. Survivors (living more than 24 h) and nonsurvivors (living less than 24 h) were compared. CONCLUSIONS: These findings indicate an impairment of systemic oxygen utilization in postarrest cardiogenic shock patients. In spite of a lower DO2 than survivors, the OER in nonsurvivors remained lower than expected. Venous hyperoxia is a clinical manifestation of this derangement. Epinephrine dose may have a causal relationship. The inability to attain a VO2 of greater than 90 ml/min.m2 after the first 6 h of aggressive therapy was associated with a 100 percent mortality in 24 h.

Aged↗
PubMed1991

Cerebral lactate uptake during cardiopulmonary resuscitation in humans.

Animal studies have shown cerebral lactate uptake under conditions of anoxia and ischemia. Cerebral lactate uptake in humans during cardiopulmonary resuscitation (CPR) has not been previously reported in the literature. Forty-five patients receiving CPR underwent simultaneous sampling through jugular venous bulb, right atrial, and central aortic catheterization. The mean net cerebral lactate uptake (central aortic minus jugular venous bulb) was 0.76 +/- 1.86 and 0.80 +/- 2.03 mM on initial measurement and 10 min later, respectively. Both measurements were statistically significant (p = 0.01) compared to normal controls who have net cerebral output of lactate of -0.18 +/- 0.1 mM. Seventy-one percent of all patients had a cerebral uptake on initial sampling and this gradient persisted upon sampling 10 min later in 68% of the remaining 40 patients who did not have a return of spontaneous circulation. Among multiple variables measured, patients who exhibited a cerebral lactate uptake were 13.2 years younger (p = 0.004), received an additional 7.6 min of CPR (p = 0.05), and had a mean arterial lactate concentration of 4.8 mM higher (p = 0.005) than the nonuptake group. The pathophysiologic explanation of cerebral lactate uptake during CPR is multifactorial and includes utilization and/or diffusion.

Aged↗
PubMedDate not supplied

Hemodynamics of interposed abdominal compression during human cardiopulmonary resuscitation.

OBJECTIVE: Clinical studies of interposed abdominal compression CPR (IAC-CPR) have had diverse outcomes. This study compared the hemodynamics of standard CPR and IAC-CPR in humans. METHODS: A 24-month prospective nonrandomized analysis of hemodynamic parameters was performed in a convenience cohort of 20 adults who had out-of-hospital, nontraumatic, normothermic cardiac arrests. The study took place in the resuscitation unit of a large urban hospital. Thoracic aortic and right atrial catheters were inserted and pressures were recorded during standard CPR and IAC-CPR. Coronary perfusion pressures (CPPs) were determined during standard CPR and IAC-CPR. The patients were separated into two groups based upon their responses to IAC-CPR. Responders had increases in CPP during IAC-CPR; nonresponders had decreases or no change in CPP during IAC-CPR. Aortic relaxation, right atrial relaxation, aortic compression, and right atrial compression phase pressures were compared between the two groups. RESULTS: CPPs increased in 13 patients and decreased in seven patients. The mean change in CPP with IAC-CPR was an increase of 5.8 +/- 15.1 torr. An elevated right atrial compression phase pressure (RaComp) during standard CPR was predictive of an increase in CPP during IAC-CPR (p = 0.047). In those patients who showed improvements in CPP during IAC-CPR, mean aortic relaxation phase pressures (AoRelax) increased by 9.5 +/- 14.2 torr (p = 0.026) and mean right atrial relaxation phase pressures (RaRelax) decreased by 2.6 +/- 6.2 torr (p = 0.099) during IAC-CPR. CONCLUSIONS: The variable effects of IAC-CPR on CPP appear to be multifactorial. The improvement in CPP that occurred in responders to IAC-CPR was secondary to an increase in AoRelax as well as a decrease in RaRelax.

Abdomen↗