The American journal of emergency medicine
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Review Case Reports
Delayed tension pneumothorax complicating central venous catheterization and positive pressure ventilation.
Pneumothorax is the most common complication after central venous catheterization. The diagnosis of pneumothorax may be delayed for hours or days, in some instances because of minimal clinical symptoms or radiographic signs on initial evaluation, or in other instances because of late presentation precipitated by positive pressure ventilation. A case is presented in which a patient developed a tension pneumothorax while under general anesthesia 10 days after central venous line placement. ⋯ Supine views, the least sensitive radiographic technique, should be carefully reviewed for evidence of basilar hyperlucency, a deep sulcus sign, or a double diaphragm sign. In patients unable to tolerate the upright position, supine views should be supplemented with lateral decubitus, oblique, or cross-table lateral views. Emergency physicians should be aware of the possibility of delayed pneumothorax, as well as optimal radiographic technique for demonstration of small pneumothoraces, and subtle radiographic findings in supine or semirecumbent patients.
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Comparative Study
Bedside fluoroscopy to screen for simple extremity trauma in the ED.
Portable fluoroscopy units are commonly used by orthopedic surgeons to assist in fracture reduction and immobilization. The purpose of this study was to determine the diagnostic accuracy of bedside fluoroscopy performed by emergency department (ED) physicians to screen for simple extremity trauma. Eligible adult patients presenting to the ED with isolated injuries to distal extremities were evaluated prospectively over a 6-month study period. ⋯ The overall diagnostic accuracy was 0.85, with a 95% confidence interval of .67 to 1.00. There were 11 false-negative fluoroscopic reports, involving the radius (3), distal tibia (3), metacarpals (2), fifth metatarsal (1), phalanx (1), and cuboid (1). These results suggest that bedside fluoroscopy lacks sufficient sensitivity to screen for simple extremity fractures in the ED.
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The authors evaluated skill levels of trainees (n = 48) who were taught cardiopulmonary resuscitation (CPR) in "American Red Cross: Adult CPR" classes offered at a work site. The evaluation used a validated skill checklist and a Laerdal Skillmeter mannequin to assess trainee competence. ⋯ All trainees felt confident they could use their CPR skills in an actual emergency; 64% were "very confident." Videotape recordings of the practice sessions showed that instructors overlooked many errors in CPR performance and that trainees provided little corrective feedback to one another. The role of instructors in assisting CPR skill practice and in evaluating skill mastery is questioned.
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The Core Content for Emergency Medicine (EM) recommends that all emergency physicians be trained to manage the airway, including administering paralytic agents for endotracheal intubation. This study analyzed compliance with the recommendations by reviewing airway management practices at EM residencies. All 96 EM residency directors were sent a 10-item survey characterizing airway management practices at residency-affiliated emergency departments (EDs). ⋯ The majority of EM residencies are complying with the Core Content recommendations by actively performing intubations using paralytic agents. Anesthesiologists are infrequently consulted in residency-affiliated EDs. Quality assurance of ED intubations is not rigorously monitored by emergency and anesthesiology departments.
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Comparative Study
Factors affecting ED length-of-stay in surgical critical care patients.
To determine what patient characteristics are associated with prolonged emergency department (ED) length-of-stay (LOS) for surgical critical care patients, the charts of 169 patients admitted from the ED directly to the operating room (OR) or intensive care unit (ICU) during a 6-week period in 1993 were reviewed. The ED record was reviewed for documentation of factors that might be associated with prolonged ED LOS, such as use of computed tomographic (CT), radiology special procedures, and the number of plain radiographs and consultants. ED LOS was considered to be the time from triage until a decision was made to admit the patient. ⋯ Use of a protocol-driven trauma evaluation system was associated with a shorter ED LOS. In addition to external factors that affect ED overcrowding, ED patient management decisions may also be associated with prolonged ED length-of-stay. Such ED-based factors may be more important in surgical critical care patients, whose overall ED LOS is affected more by the length of the ED work-up rather than the time spent waiting for a ICU bed or operating suite.