PubMed Health⌕ Search

Biomedical subjects

Steven M Green

Publications and source records attributed to Steven M Green.

33 records · Page 2Linked to original sources
PubMed2004

Clinical practice guideline for emergency department ketamine dissociative sedation in children.

We present an evidence-based clinical practice guideline for the administration of the dissociative agent ketamine for emergency department pediatric procedural sedation and analgesia. Substantial research in recent years has necessitated updates and revisions to the widely disseminated 1990 recommendations. We critically discuss indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, recovery issues, and future research questions for dissociative sedation.

Age Factors↗
PubMed2004

A meta-analysis of the literature on distal radius fractures: review of 615 articles.

A structured meta-analysis of the available literature was performed to evaluate the outcome of the treatment of displaced intra-articular fractures of the distal radius. A comprehensive search of Medline using the key words "radius" and "fracture" revealed over 4,000 articles. After limiting the search to clinical trials in English and excluding pediatric and geriatric age groups as well as biomechanical and animal studies, 615 abstracts were identified in the period from 1976 to May 1998. Thirty-one articles met the inclusion and exclusion criteria. These included two prospective randomized comparative trials, two non-randomized comparative trials, one half prospective case series and half historical control, and 27 papers on case series. Four papers dealt with external fixation versus closed reduction and cast treatment and one paper looked at open reduction internal fixation with or without additional external fixation. There was insufficient data to perform a scientific meta-analysis because of the poor quality of the studies and lack of a uniform method of outcome assessment. However, the data from the comparative trials showed that external fixation was favored over closed reduction and casting. Additionally, comparing the results of the case series showed that external fixation was superior to internal fixation.

Casts, Surgical↗
PubMed2003

One eye but no vision: cave fish with induced eyes do not respond to light.

One of the most intriguing questions in evolutionary biology is the degree to which behavior is a necessary consequence of morphology. We explore this issue by examining phototactic behavior in epigean (eyed surface-dwelling) and troglomorphic (blind cave) forms of the teleost Astyanax fasciatus whose eyes were modified during embryogenesis by removing one or both lens vesicles from the epigean form or by transplanting the lens vesicle from an epigean fish into the optic cup of a blind cave form. Lens removal results in eye degeneration and blindness in adult epigean fish, whereas lens transplantation stimulates growth of the eye, inducing the development of optic tissues in the normally eyeless adult cave fish. Photoresponsiveness was examined by placing fish in an aquarium with one half illuminated and the other half dark and scoring their presence in the illuminated or dark half. Both the eyeless epigean fish and cave fish with induced eyes are indifferent to the illumination whereas the surface forms are scotophilic, suggesting that optic development and phototactic behavior are decoupled.

Animals↗
PubMed2003

A study of the Bispectral Index Monitor during procedural sedation and analgesia in the emergency department.

STUDY OBJECTIVE: The Bispectral Index Monitor has been validated as an objective measure of sedation depth in the operating room; however, its value for states other than general anesthesia remains unclear. We hypothesized that bispectral index monitoring would reliably correlate with traditional definitions of sedation depth in emergency department patients undergoing procedural sedation and analgesia. METHODS: In this prospective observational study we measured the Bispectral Index score and a modified Ramsay Sedation Scale score every 5 minutes in a convenience sample of adult ED patients undergoing procedural sedation and analgesia. Investigators and treating physicians were blinded to Bispectral Index scores, which were later correlated with modified Ramsay Sedation Scale scores. We constructed receiver operating characteristic curves to determine the most discriminatory Bispectral Index score thresholds for sedation depth. RESULTS: Two hundred seventy paired readings were obtained from 37 patients. Despite being statistically significant (P <.0005), the correlation between the Bispectral Index Monitor and modified Ramsay Sedation Scale scores was only moderate (Spearman rho=-0.690) and displayed wide variability. A modified Ramsay Sedation Scale score consistent with mild-to-moderate sedation corresponded to Bispectral Index scores of 34 (general anesthesia) to 98 (fully awake), whereas a modified Ramsay Sedation Scale score consistent with deep sedation corresponded to Bispectral Index scores of 40 to 98. Areas under receiver operating characteristic curves demonstrated moderate (0.83 to 0.86) discriminatory power at all modified Ramsay Sedation Scale thresholds, with the exception of a modified Ramsay Sedation Scale score of 7 or less, which demonstrated high discriminatory power (0.95). A Bispectral Index score of greater than 83 reliably excluded general anesthesia, and a Bispectral Index score of 70 or less reliably identified general anesthesia. CONCLUSION: Bispectral index monitoring reliably predicted patients undergoing procedural sedation and analgesia who were sedated to the point of general anesthesia from those with lesser degrees of sedation but did not discriminate mild-to-moderate sedation or moderate-to-deep sedation, as measured by the Ramsay Sedation Scale score for the patients undergoing procedural sedation and analgesia in our ED.

Adolescent↗
PubMed2003

Can the bispectral index monitor quantify altered level of consciousness in emergency department patients?

OBJECTIVES: A daily part of emergency medicine practice includes assessing patients with altered levels of consciousness (ALOC). The authors hypothesized that a bispectral index monitor (BIS), a processed electroencephalographic monitor traditionally used to monitor patients under anesthesia, would represent an objective quantification of impairment of consciousness. They compared the BIS score with the Glasgow Coma Scale score (GCS) in emergency department (ED) patients with ALOC. METHODS: The authors performed a convenience sampling of ED adults presenting with ALOC (GCS <or= 14). Patients with abnormal baseline mental status were excluded, as were those who were unable to tolerate the forehead BIS leads. The blinded BIS value was recorded after the treating physician assigned a GCS to the patient. The BIS and GCS measurements were then correlated. RESULTS: Data were obtained for 38 patients (20 male, 18 female). The median age was 42 years (range 14 to 93 years). Despite being statistically significant (p = 0.0165), the correlation between the GCS and the BIS score was only moderate (Spearman's rho = 0.387) and displayed wide variability. For example, when the GCS was between 3 and 5, the corresponding BIS scores ranged from 47 to 98. When the GCS was between 12 and 14, the corresponding BIS scores ranged from 56 to 98. Receiver operating characteristic curves for BIS at each GCS threshold demonstrated low discriminatory power (areas under the curve range 0.61 to 0.73). CONCLUSIONS: BIS monitoring does not reliably correlate with GCS in ED patients with ALOC, and does not appear to have potential to accurately quantify impairment of consciousness in this setting.

Adolescent↗
PubMed2003

Ventilatory response during dissociative sedation in children-a pilot study.

OBJECTIVES: It is unclear whether ketamine induces subclinical respiratory depression when administered in dissociative doses intravenously (IV). The authors report a pilot study of capnography in emergency department (ED) pediatric patients receiving ketamine alone for procedural sedation, and describe serial measures of ventilatory response [end-tidal carbon dioxide (EtCO(2)), respiratory rate, pulse oximetry]. METHODS: The authors performed continuous capnography on a convenience sample of 20 ED pediatric patients who received ketamine 1.5 mg/kg IV for procedural sedation. RESULTS: Continuous EtCO(2) and pulse oximetry remained essentially unchanged following ketamine injection, and no EtCO(2) levels > 47 mm Hg were noted at any point throughout sedation. CONCLUSIONS: No hypoventilation was observed in 20 ED pediatric patients receiving ketamine 1.5 mg/kg administered IV over 1 minute. The authors found no evidence of respiratory depressant properties for this dissociative agent.

Anesthetics, Dissociative↗
PubMed2002

High yield criteria for obtaining non-trauma chest radiography in the adult emergency department population.

To develop a clinical decision rule for predicting significant chest radiography abnormalities in adult Emergency Department (ED) patients, a prospective, observational study was conducted of consecutive adults (>or=18 years old) who underwent chest radiography for nontraumatic complaints at an urban ED with an annual census of 85,000. The official radiologist interpretation of the film was used as the gold standard for defining radiographic abnormalities. Using predefined criteria and author consensus, patients were divided into two groups: those with clinically significant abnormalities (CSA) and those with either normal or nonclinically significant abnormalities. Chi square recursive partitioning was used to derive a decision rule. Odds ratios and kappa statistics were calculated for derived criteria. The results showed 284 (17%) of 1650 patients had clinically significant abnormal radiographs. The presence of any of 10 criteria (age >or= 60 years, temperature >or= 38 degrees C, oxygen saturation < 90%, respiratory rate > 24 breaths/min, hemoptysis, rales, diminished breath sounds, a history of alcohol abuse, tuberculosis, or thromboembolic disease) was 95% sensitive (95% CI: 92-98%) and 40% specific (95% CI: 37-43%) in detecting CSA radiographs. Positive and negative predictive values were 25% (95% CI: 23-27%) and 98% (95% CI: 96-99%), respectively. A highly sensitive decision rule for detecting clinically significant abnormalities on chest radiographs in nontraumatized adults has been developed. If prospectively validated, these criteria may permit clinicians to confidently reduce the number of radiographs in this population.

Aged↗
PubMed2002

Crotalidae polyvalent immune Fab (ovine) antivenom is efficacious for envenomations by Southern Pacific rattlesnakes (Crotalus helleri).

STUDY OBJECTIVE: Southern Pacific rattlesnake (Crotalus helleri ) venom is not 1 of the 4 venoms used to produce Crotalidae polyvalent immune Fab (ovine) (CroFab; FabAV). There is currently no published clinical experience regarding the efficacy of this new antivenom for confirmed C helleri envenomation, and animal data suggest greatly diminished efficacy. We assessed the efficacy of FabAV for patients with confirmed C helleri envenomation. METHODS: We conducted a prospective observational study of 23 consecutive rattlesnake envenomations that were treated with FabAV at our center. Patients were excluded if the species of snake could not be confirmed, if FabAV antivenom was not given, or if Antivenin (Crotalidae) polyvalent (equine) was given. We collected serial physical examination and laboratory data over a 24-hour period to serially evaluate the severity score and performed follow-up to evaluate delayed reactions. RESULTS: There were 15 patients who received FabAV and had the species of rattlesnake confirmed (9 C helleri, 4 C scutulatus scutulatus, 1 C mitchellii pyrrhus, 1 C ruber ruber ). C helleri envenomations demonstrated similar improvement in serial snakebite severity scores to those of other species. Three patients treated with scheduled dosing had recurrence of progressive swelling (2 C helleri and 1 C mitchellii pyrrhus ) during the 24-hour study period. CONCLUSION: We observed similar improvement in FabAV-treated patients with C helleri envenomation compared with those of other species and conclude that this treatment in standard doses appears efficacious for bites by this species. Progressive swelling may recur despite scheduled dosing.

Animals↗
PubMed2002

Pulmonary aspiration risk during emergency department procedural sedation--an examination of the role of fasting and sedation depth.

The assessment of pre-procedure fasting and control of sedation depth are prominent elements of widely disseminated procedural sedation guidelines and of the Joint Commission on Accreditation of Healthcare Organizations' standards. Both exist primarily to minimize the risk of pulmonary aspiration of gastric contents. This paper critically examines the literature on pre-procedure fasting and controlling sedation depth in association with pulmonary aspiration, and interprets this evidence in the context of modern emergency medicine practice. The article reviews the pathophysiology of aspiration and changing concepts regarding aspiration risk over the last decade. After reviewing studies on aspiration risk during general anesthesia, the paper reviews the risk of aspiration during labor and delivery as a more appropriate comparison group for aspiration risk during emergency department procedural sedation and analgesia (ED PSA). It is noted that aspiration during ED PSA has not been reported in the medical literature and that aspiration during general anesthesia and labor and delivery is uncommon. The literature provides no compelling evidence to support specific fasting periods for either liquids or solids prior to PSA, and existing guidelines for elective patients are of necessity arbitrary and based upon consensus opinion. The article discusses the implications in the areas of training and preparedness, monitoring, and research for the emergency physician practicing PSA.

Anesthesia, General↗