Thiamine for the treatment of acute decompensated heart failure.
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Aged↗
Biomedical subjects
Howard A Smithline
Publications and source records attributed to Howard A Smithline.
Feasibility of using near-infrared spectroscopy to diagnose testicular torsion: an experimental study in sheep.
STUDY OBJECTIVE: To assess whether near-infrared spectroscopy can detect testicular hypoxia in a sheep model of testicular torsion within 6 hours of experimental torsion. METHODS: This was a randomized, controlled, nonblinded study. Trans-scrotal, near-infrared, spectroscopy-derived testicular tissue saturation of oxygen values were obtained from the posterior hemiscrota of 6 anesthetized sheep at baseline and every 15 minutes for 6 hours after either experimental-side, 720-degree, unilateral, medial testicular torsion and orchidopexy or control-side sham procedure with orchidopexy and then for 75 minutes after reduction of torsion and pexy. Color Doppler ultrasonography was performed every 30 minutes to confirm loss of vascular flow on the experimental side, return of flow after torsion reduction, and preserved flow on the control side. RESULTS: Near infrared spectroscopy detected a prompt, sustained reduction in testicular tissue saturation of oxygen after experimental torsion. Further, it documented a rapid return of these values to pretorsion levels after reduction of torsion. Experimental-side testicular tissue saturation of oxygen fell from a median value of 59% (interquartile range [IQR] 57% to 69%) at baseline to 14% (IQR 11% to 29%) at 2.5 hours of torsion, and postreduction values were approximately 70%. Control-side testicular tissue saturation of oxygen values increased from a median value of 67% (IQR 59% to 68%) at baseline to 77% (IQR 77% to 94%) at 2.5 hours and remained at approximately 80% for the entire protocol. The difference in median testicular tissue saturation of oxygen between experimental and control sides, using the Friedman test, was found to be significant (P=.017). CONCLUSION: This study demonstrates the feasibility, in a sheep model, of using near-infrared spectroscopy for the noninvasive diagnosis of testicular torsion and for quantification of reperfusion after torsion reduction. The applicability of these findings, from an animal model using complete torsion, to the clinical setting remains to be established.
Animals↗
Prospective comparison of helical CT of the abdomen and pelvis without and with oral contrast in assessing acute abdominal pain in adult Emergency Department patients.
PURPOSE: This prospective study compares the agreement of nonenhanced helical computed tomography (NECT) with oral contrast-enhanced computed tomography (CECT) in Emergency Department (ED) patients presenting with acute abdominal pain. MATERIALS AND METHODS: One hundred eighteen patients presenting to the ED with acute abdominal pain undergoing CT were enrolled over a 13-month period using convenience sampling. Exclusion criteria included acute trauma, pregnancy, unstable patients, and patients suspected of having urinary calculi. Patients were scanned helically using 5-mm collimation before and approximately 90 min after oral contrast administration. Both exams were prospectively interpreted by different attending radiologists in a blinded fashion using an explicit data sheet specifying the presence or absence of 28 parameters relating to various common diagnoses. RESULTS: The 118 patients had a mean age of 49 years, a male: female ratio of 7:13, and a median height, weight, and BMI of 166 cm, 80 kg, and 29, respectively. The most common indications for the study included appendicitis (32%) and diverticular disease (12%). Pain maximally localized to the right lower quadrant in 37% and the left lower quadrant in 21%. There were 21 patients that had significant disagreement of interpretations between NECT and CECT resulting in a simple agreement of 79% (95% CI: 70-87%). For specific radiologic parameters, agreement ranged from 77 to 100%. A post hoc agreement analysis was subsequently performed by two radiologists and only five paired scans were identified as discordant between the NECT and CECT. For only one of these patients did both radiologists agree that there was a definite discordant result between the two studies. A final unblinded consensus review demonstrated that much of the disagreement between the interpretations was related to interobserver variation. CONCLUSION: There is 79% simple agreement between NECT and CECT in diagnosing various causes of acute abdominal pain in adult ED patients. Post hoc analysis indicates that a significant portion of the discordance was attributable to interobserver variability. This data suggests that NECT should be considered in adult ED patients presenting with acute abdominal pain.
Abdomen, Acute↗
A descriptive study of heavy emergency department users at an academic emergency department reveals heavy ED users have better access to care than average users.
INTRODUCTION: Emergency department (ED) overcrowding has been a significant problem for the last 10 years. Several studies have shown that a relatively small number of ED patients are responsible for a disproportionate amount of ED visits. This study aims to describe the frequent users of our emergency department. METHODS: This was an institutional review board-approved descriptive study performed by a retrospective review of electronic records. This pilot describes and compares patients who had 12 or more ED visits during the study year with those who visited less. RESULTS: The 234 patients who met criteria for high-frequency use (HFU) of the emergency department were responsible for a total of 4633 visits. Sex, race, and age distribution of HFU patients were similar to those of general ED patients. Eighty-four percent of HF users have insurance and 93% have primary care providers. A relatively small percentage of HFU visits, 4%, were mental health-related visits and 3% were alcohol- and drug-related visits. The HFU visits are socially connected: 93% have their own homes; 94% have relatives or friends; 73% have a religious affiliation. Pain or pain-related conditions are the most common diagnoses. These patients are also frequent users of ambulatory care services. CONCLUSION: The similarities between our HFU and the general ED population are more numerous than their differences. The HFU patients of our emergency department are different in terms of age, employment status, and type of insurance. IMPLICATIONS FOR NURSES: A detailed description of local HFU may help to inform planning and better meet ED patients' needs. As one of many results of this study, the ED chairman met with the Hematology-Oncology team and reviewed the protocol for ED management of sickle cell crisis. The meeting resulted in a revised protocol, including an immediate change in their pain medication from meperidine to either morphine or hydromorphone.
Academic Medical Centers↗
Research opportunities in the management of acute exacerbations of chronic obstructive pulmonary disease.
Acute exacerbations of chronic obstructive pulmonary disease are a common problem in the emergency department. Despite considerable research involving the management of this disease over the past decade, much remains unclear from an emergency medicine perspective. Increased research would better guide the management of these complex patients from the perspectives of the patient, the caregiver, and society. The major areas of research can be divided into diagnosis, therapy, and education. The reliability and validity of different definitions of acute exacerbations of chronic obstructive pulmonary disease need to be assessed. The utility and performance characteristics of diagnostic testing need to be determined for this difficult patient population. Specific diagnostic tests include measures of dyspnea, spirometry and exercise tolerance, measures of gas exchange, airway inflammation, and chest imaging. It remains unclear which patient-specific therapies (oxygen, bronchodilators, corticosteroids, antibiotics, noninvasive positive pressure ventilation, and methylxanthines) should be used and monitored. Finally, the utility of education of both health care providers and patients and how it may be applied to the acute setting need to be addressed.
Adrenal Cortex Hormones↗
A report of dangerously high carbon monoxide levels within the passenger compartment of a snow-obstructed vehicle.
BACKGROUND: We sought to determine how quickly carbon monoxide would accumulate in the passenger compartment of a snow-obstructed vehicle. METHODS: A 1992 sedan was buried in snow to the level of the undercarriage, the ignition was then engaged and carbon monoxide levels recorded at 2.5-minute intervals. The primary outcome was the time at which a lethal carbon monoxide level was detected. Six trials were conducted: windows closed; windows open one inch; windows open 6 inches; windows closed and tailpipe swept clear of snow; windows closed and one cubic foot of snow removed around tailpipe; windows closed and tailpipe completely cleared of snow to ground level in a path 12 inches wide. RESULTS: Lethal levels of carbon monoxide occurred within 2.5 minutes in the vehicle when the windows were closed, within 5 minutes when the widows were opened one inch, and within 7.5 minutes when the widows were opened six inches. Dangerously high levels of carbon monoxide were detected within the vehicle when the tailpipe had been swept clear of snow and when a one cubic foot area had been cleared around the tailpipe. When the tailpipe was completely unobstructed the carbon monoxide level was zero. CONCLUSIONS: Lethal levels of carbon monoxide occurred within minutes in this snow-obstructed vehicle.
Journal Article↗
Beckman Access versus the Bayer ACS:180 and the Abbott AxSYM cardiac Troponin-I real-time immunoassays: an observational prospective study.
BACKGROUND: Reliability of cardiac troponin-I assays under real-time conditions has not been previously well studied. Most large published cTnI trials have utilized protocols which required the freezing of serum (or plasma) for delayed batch cTnI analysis. We sought to correlate the presence of the acute ischemic coronary syndrome (AICS) to troponin-I values obtained in real-time by three random-mode analyzer immunoassay systems: the Beckman ACCESS (BA), the Bayer ACS:180 (CC) and the Abbott AxSYM (AX). METHODS: This was an observational prospective study at a university tertiary referral center. Serum from a convenience sampling of telemetry patients was analyzed in real-time for troponin-I by either the BA-CC (Arm-1) or BA-AX (Arm-2) assay pairs. Presence of the AICS was determined retrospectively and then correlated with troponin-I results. RESULTS: 100 patients were enrolled in Arm-1 (38 with AICS) and 94 in Arm-2 (48 with AICS). The BA system produced 51% false positives in Arm-1, 44% in Arm-2, with negative predictive values of 92% and 100% respectively. In Arm-1, the BA and the CC assays had sensitivities of 97% and 63% and specificities of 18% and 87%. In Arm-2, the BA and the AX assays had sensitivities of 100% and 83% and specificities of 11% and 78%. CONCLUSIONS: In real-time analysis, the performance of the AxSYM and ACS:180 assay systems produced more accurate troponin-I results than the ACCESS system.
Journal Article↗
Patient encounter time intervals in the evaluation of emergency department patients requiring abdominopelvic CT: oral contrast versus no contrast.
The aim of the study was to assess various time intervals during patient encounters involving unenhanced (NECT) versus oral-contrast-enhanced (CECT) abdominopelvic (A/P) CT performed in the emergency department (ED) on adult patients presenting with acute abdominal pain. Computerized patient order entry and administrative data as well as scans themselves were retrospectively evaluated at a high-volume (107,000 visits per annum) regional medical center urban ED for a period of 30 consecutive days. All adult patients who had CT of abdomen and pelvis for abdominal pain during the 30 days of the study period were included. Data collected included demographic information, time of registration, time of first encounter in the ED, time of CT order, clinical indication for scan, time of scan, time of disposition (i.e., discharge or admit), and final disposition. Patients were excluded if they were less than 16 years old, pregnant, or met criteria for major trauma and evaluation in the trauma suite. Patients were also excluded from analysis if they received more than one scan on the same day (3 patients). Of 183 patients, 102 underwent NECT and 81 CECT. Some of the patients who underwent NECT had urinary colic. Among patients who did not have urinary colic there is a statistically significant difference in the median time intervals between: (1) patient arrival in the ED and evaluation by a physician (NECT 57 min, CECT 84 min, P<0.001); (2) patient exam by the physician and the time the A/P CT was ordered (NECT 35 min, CECT 63 min, P<0.01); (3) receipt of the CT order and the time of the scan (NECT 104 min, CECT 172 min, P<0.001); and (4) time of arrival in ED and disposition (NECT 358 min, CECT 599 min, P<0.001). There are significant time interval differences between CECT and NECT during patient encounters involving adults presenting with abdominal pain to the ED. The differences are greater than the amount of time allotted for opacification of small bowel (90 min). Baseline data such as these may prove useful in assessing the efficacy of scan techniques and improving resource utilization.
Abdominal Pain↗
Does morphine change the physical examination in patients with acute appendicitis?
The objective of this study was to determine if judicious dosing of morphine sulfate can provide pain relief without changing important physical examination findings in patients with acute appendicitis. We conducted a prospective, randomized, double-blind crossover design. Patients scheduled for appendectomy were randomized to two groups. Group A received 0.075 mg/kg intravenous morphine sulfate and 30 minutes later received placebo. The sequence of medication was reversed in group B. Patients were examined by a surgical resident and an EM attending before and after receiving medication. Six explicit physical examination findings were documented as absent, indeterminate, or present. Physicians were also asked if they felt overall examination findings had changed after medication. Patient's visual analog scale (VAS) was recorded before each medication and at study completion. Thirty-four patients were enrolled and full data were available for 22 patients. Neither morphine nor placebo caused a significant change in individual examination findings. Three patients in both groups were judged to have a change in their examination after medication. The median change in VAS was 20 mm after morphine and 0 mm after placebo (P =.01). In this pilot study, patients with clinical signs of appendicitis were treated with morphine and had significant improvement of their pain without changes in their physical examination.
Adult↗
The effectiveness of wireless telephone communication technology on ambient noise level reduction within the ED.
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Cell Phone↗
Antipyretic effectiveness of intravenous ketorolac tromethamine.
We assessed the antipyretic effectiveness of intravenously administered ketorolac tromethamine in the febrile adult. A double-blind placebo controlled trial enrolling a convenience sample of febrile (T > 38.0 degrees C, oral) patients (18-65 years old) randomized to receive either 0.5 mg/kg (max 30 mg) intravenous ketorolac or placebo. Oral temperatures were recorded every 15 min during the 1-h study period. There were 20 patients in each group. At 60 min, the temperature decrease was 0.4 degrees C (95% CI: 0.0 degrees, 0.7 degrees ) for the control group and 0.8 degrees C (95% CI: 0.5 degrees, 1.1 degrees ) for the ketorolac group. Logistic regression modeling of afebrile at 60 min, controlling for baseline temperature, yielded an odds ratio for ketorolac of 7.1 (95% CI: 1.3, 39.5). In conclusion, our data support that intravenously administered ketorolac has antipyretic properties.
Adult↗
Errors in a busy emergency department.
STUDY OBJECTIVE: We describe errors occurring in a busy ED. METHODS: This is a prospective, observational study of reported errors at an academic emergency department (ED) with 100000 annual visits. Trained personnel interviewed all ED staff with direct patient contact, during and at the end of every shift, by using standardized data sheets. RESULTS: One thousand nine hundred thirty-five ED patients registered during the 7-day study period in the summer of 2001. Four hundred error reports were generated, identifying 346 nonduplicative errors (18 per 100 registered patients; 95% confidence interval [CI] 15.9 to 20.0). Forty percent of errors were reported by nurses, 25% by providers, 19% by clerical staff, 13% by technicians and orderlies, and 3% multiple reporters. Errors reported for every 100 hours worked were similar for all groups (5.5; 95% CI 5.2 to 5.9). Errors were categorized as 22% diagnostic studies, 16% administrative procedures, 16% pharmacotherapy, 13% documentation, 12% communication, 11% environmental, and 9% other. Patients involved in errors were more likely to be older (P <.0001) and more likely to have higher visit level intensity (P <.0001) than registered ED patients. Ninety-eight percent of errors did not have a significant adverse outcome. Seven errors (0.36 per 100 registered patients; 95% CI 0.14 to 0.72) were associated with an adverse outcome. CONCLUSION: Reported errors occurred in almost every aspect of emergency care. Ninety-eight percent of errors in the ED do not result in adverse outcomes. System changes need to be implemented to reduce ED errors.
Academic Medical Centers↗
Whole body oxygen consumption and critical oxygen delivery in response to prolonged and severe carbon monoxide poisoning.
BACKGROUND: Carbon monoxide (CO) poisoning remains the leading cause of death by poisoning in the world. One of the major proposed mechanisms for CO toxicity is the binding of CO to cytochrome oxidase and interference with cellular oxygen utilization but evidence for this is inconclusive. AIM OF STUDY: This study examined the effects of prolonged CO exposure on the dynamics of whole body oxygen consumption (VO(2)) and oxygen delivery (DO(2)) in an attempt to observe if CO exposure results in a defect of oxygen utilization defect as determined by a reduction in VO(2) during the course of poisoning prior to reaching the point where VO(2) is directly dependent on DO(2). This critical level of DO(2) (DO(2)crit) produced by CO poisoning was compared to historical values produced by other insults, which decrease global body DO(2). METHODS: Five small dogs were ventilated for 2 h with 0.25% CO and room air followed by 0.5% CO until death. Cardiac index (Q), DO(2), VO(2), oxygen extraction ratio (OER), and systemic lactate were measured every 15 min until death. RESULTS: Carboxyhemoglobin (COHb) levels increased linearly over 2.5 h to values above 80% until death. VO(2) remained constant and not significantly different from baseline below a COHb of 80%. At COHb levels above 80%, VO(2) precipitously dropped. Similarly lactate levels were not significantly elevated from baseline until VO(2) dropped. DO(2) decreased by 78% (from 23+/-6 ml/kg/min to 5+/-4 ml/kg/min) over time despite an increase in Q by 58% until levels of COHb were above 80%. OER increased from 19+/-5% to 50+/-11% until death. The calculated DO(2)crit was 10.7+/-4 ml/min/kg, which is not significantly different from values ranging from 7 to 13 ml/min/kg reported in the literature due to other insults, which reduce DO(2). CONCLUSION: In this canine model of prolonged CO exposure, no gradual reduction in VO(2) or increase in systemic lactate prior to reaching DO(2)crit was noted. In addition, CO exposure does not appear to change the DO(2)crit. The combination of these findings does not support the theory that CO produces a whole body intracellular defect in oxygen utilization.
Animals↗
Can CK-MB and cTn-I be detected in the peripheral circulation within the first 10 min of acute coronary ischemia?
There are approximately 4 million patients hospitalized with suspected acute coronary syndromes (ACS) annually. However, the current standard tools for assessing ACS in the Emergency Department are felt to have insufficient sensitivity and specificity. Animal studies have demonstrated that CK-MB and troponin-I are released in a biphasic pattern with an initial transient release which peaks and falls within the first 10 min of ischemia. We hypothesize that transient elevations of CK-MB and troponin-I can be detected in the peripheral circulation within the first 10 min of ischemia in a human model of brief coronary ischemia. We also present results from our pilot study that failed to confirm this hypothesis; however, this pilot studied was insufficiently powered to detect potentially clinically important results.
Creatine Kinase↗
Determining pretest probability of DVT: clinical intuition vs. validated scoring systems.
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Emergency Service, Hospital↗
How reliable are pain scores? A pilot study of 20 healthy volunteers.
INTRODUCTION: Pain scales such as the 100-MM Visual Analog Scale and the 10-point Numeric Rating Scale are used to describe pain intensity. The Visual Analog Scale and the Numeric Rating Scale provide accurate descriptors for a patient's perceived level of pain. But how accurate or reliable is a patient's perception of pain? METHODS: To test the relationship between the intensity of the pain stimulus and pain perception, we devised an experiment using a convenience sample of 20 healthy adult volunteers. A cutaneous nerve stimulator delivered a series of shocks of increasing intensity to the individual via a pediatric EKG electrode. The participants indicated their threshold for "intolerable pain." With use of this same level of stimulus in subsequent shocks, the participants, blinded to the amount of stimulus, were then asked to rate each shock as either "the same," "a little less," or "a little more" than the baseline stimulus. They then recorded their VAS score for each stimulus. RESULTS: "Intolerable pain" varied widely between 8 mm to 73 mm; likewise, the level of stimulus that produced this pain ranged from 4 to 9. Once a person's threshold of "intolerable pain" had been reached, 49% of the subsequent shocks were perceived as different, even though the stimulus was exactly the same. DISCUSSION: This experiment showed that (1) given the same intensity of pain stimulus, different persons have different perceptions of pain; and (2) the same intensity of pain stimulus, given to the same person repeatedly, does not result in the same self-report of pain intensity.
Adult↗
A randomized controlled trial of intravenous aminophylline for atropine-resistant out-of-hospital asystolic cardiac arrest.
OBJECTIVES: Myocardial ischemia, during cardiopulmonary arrest, can lead to atropine-resistant bradyasystole from interstitial accumulation of endogenous adenosine. Aminophylline is a nonspecific adenosine receptor antagonist capable of reversing ischemia-induced bradyasystole in a variety of settings. The hypothesis of this study was that aminophylline improves the rate of return of spontaneous circulation (ROSC) in atropine-resistant asystolic out-of-hospital cardiac arrest when used early in the resuscitation effort. METHODS: This was a prospective, randomized, double-blinded, placebo-controlled trial set in an urban emergency medical services system serving a population of 250,000. All non-pregnant, normothermic adults suffering nontraumatic out-of-hospital cardiac arrest (February 1999 to August 2000) with asystole were eligible. Patients remaining in asystole after initial doses of epinephrine and atropine received either aminophylline 250 mg or matching placebo as a bolus injection through a peripheral intravenous line. All other aspects of the attempted resuscitation proceeded in accordance with standard Advanced Cardiac Life Support (ACLS) guidelines. A sample size of 102 patients was calculated to yield a power of 80% to show an absolute improvement of 25% in ROSC. The aminophylline and control groups were compared by calculating 95% confidence intervals (95% CIs) and the data were modeled using logistic regression. RESULTS: The investigators enrolled 112 consecutive patients. One subject was dropped prior to analysis because of missing data. Data for 111 patients were analyzed on an intention-to-treat basis. Baseline characteristics were similar for the two groups. Comparing the control and aminophylline groups, ROSC was achieved in 15.6% (95% CI = 6% to 29%) and 22.7% (95% CI = 13% to 35%), while reversal of asystole occurred in 26.7% (95% CI = 15% to 42%) and 40.9% (95% CI = 29% to 54%), respectively. Group allocation had an odds ratio of 1.8 (95% CI = 0.6 to 5.3) for ROSC. Witnessed arrest was an independent predictor of outcome with an odds ratio of 3.8 (95% CI = 1.3 to 11.2). CONCLUSIONS: Addition of aminophylline appears to be a promising new intervention in the ACLS treatment of atropine-resistant asystolic out-of-hospital cardiac arrest.
Advanced Cardiac Life Support↗
A randomized controlled trial of intravenous montelukast in acute asthma.
Many patients with acute asthma do not respond adequately to currently accepted therapy, including oxygen, beta-agonists, and corticosteroids. Leukotriene receptor antagonists such as montelukast have demonstrated efficacy in chronic asthma, but their efficacy in acute asthma is unknown. In this randomized, double-blind, parallel-group pilot study, adults with moderate to severe acute asthma received standard therapy plus either intravenous montelukast (7 or 14 mg) or matching placebo. A total of 201 patients were randomized, and 194 had complete data available for analysis. There was no difference in FEV1 response between the 7- and 14-mg montelukast groups. Montelukast improved FEV1 over the first 20 minutes after intravenous administration (mean percentage change from prerandomization baseline, 14.8% versus 3.6% for the pooled montelukast and placebo treatment groups, respectively; p = 0.007). This benefit was observed at 10 minutes and over 2 hours after intravenous therapy. Patients treated with montelukast tended to receive less beta-agonists and have fewer treatment failures than patients receiving placebo. The tolerability profile for montelukast was similar to that observed for placebo, and no unexpected adverse experiences were observed. We conclude that intravenous montelukast in addition to standard therapy causes rapid benefit and is well tolerated in adults with acute asthma.
Acetates↗