James Quinn

Abstract

OBJECTIVE: To determine risk factors associated with infection and traumatic lacerations and to see if a relationship exists between infection and time to wound closure after injury. METHODS: Consecutive patients presenting with traumatic lacerations at three diverse emergency departments were prospectively enrolled and 27 variables were collected at the time of treatment. Patients were followed for 30 days to determine the development of a wound infection and desire for scar revision. RESULTS: 2663 patients completed follow-up and 69 (2.6%, 95% CI 2.0% to 3.3%) developed infection. Infected wounds were more likely to receive a worse cosmetic rating and more likely to be considered for scar revision (RR 2.6, 95% CI 1.7 to 3.9). People with diabetes (RR 2.70, 95% CI 1.1 to 6.5), lower extremity lacerations (RR 4.1, 95% CI 2.5 to 6.8), contaminated lacerations (RR 2.0, 95% CI 1.2  to 3.4) and lacerations greater than 5 cm (RR 2.9, 95% CI 1.6 to 5.2) were more likely to develop an infection. There were no differences in the infection rates for lacerations closed before 3% (95% CI 2.3% to 3.8%) or after 1.2% (95% CI 0.03% to 6.4%) 12 h. CONCLUSIONS: Diabetes, wound contamination, length greater than 5 cm and location on the lower extremity are important risk factors for wound infection. Time from injury to wound closure is not as important as previously thought. Improvements in irrigation and decontamination over the past 30 years may have led to this change in outcome.

View details for DOI 10.1136/emermed-2012-202143

View details for PubMedID 23314208

Abstract

To determine if there is a significant difference in the infection rates of wounds irrigated with sterile normal saline (SS) versus tap water (TW), before primary wound closure.Single centre, prospective, randomised, double-blind controlled trial. Wound irrigation solution type was computer randomised and allocation was done on a sequential basis.Stanford University Medical Center Department of Emergency Medicine.Patients older than 1 year of age, who presented to the emergency department with a soft tissue laceration requiring repair, were entered into the study under informed consent. Exclusion criteria included any underlying immunocompromising illness, current use of antibiotics, puncture or bite wounds, underlying tendon or bone involvement, or wounds more than 9 h old.Non-caregivers used a computer generated randomisation code to prepare irrigation basins prior to treatment. Patients had their wounds irrigated either with TW or SS prior to closure, controlling for the volume and irrigation method used. The patient, the treating physician and the physician checking the wound for infection were all blind regarding solution type. Structured follow-up was completed at 48 h and 30 days to determine the presence of infection.The primary outcome measured was the difference in wound infection rates between the two randomised groups.During the 18-month study period, 663 consecutive patients were enrolled. After enrolment, 32 patients were later excluded; 29 patients because they were concurrently on antibiotics; two patients secondary to steroid use and one because of tendon involvement. Of the 631 remaining patients, 318 were randomised into the TW group and 313 into the SS group. Six patients were lost to follow-up (5 SS, 1 TW). A total of 625 patients were included in the statistical analysis. There were no differences in the demographic and clinical characteristics of the two groups. There were 20 infections 6.4% (95% CI 9.1% to 3.7%) in the SS group compared with 11 infections 3.5% (95% CI 5.5% to 1.5%) in the TW group, a difference of 2.9% (95% CI -0.4% to 5.7%).There is no difference in the infection rate of wounds irrigated with either TW or SS solution, with a clinical trend towards fewer wound infections in the TW group, making it a safe and cost-effective alternative to SS for wound irrigation.

View details for DOI 10.1136/bmjopen-2012-001504

View details for Web of Science ID 000315082400012

View details for PubMedID 23325896

Abstract

There is increasing research interest in the risk stratification of emergency department (ED) syncope patients. A major barrier to comparing and synthesizing existing research is wide variation in the conduct and reporting of studies. The authors wanted to create standardized reporting guidelines for ED syncope risk-stratification research using an expert consensus process. In that pursuit, a panel of syncope researchers was convened and a literature review was performed to identify candidate reporting guideline elements. Candidate elements were grouped into four sections: eligibility criteria, outcomes, electrocardiogram (ECG) findings, and predictors. A two-round, modified Delphi consensus process was conducted using an Internet-based survey application. In the first round, candidate elements were rated on a five-point Likert scale. In the second round, panelists rerated items after receiving information about group ratings from the first round. Items that were rated by >80% of the panelists at the two highest levels of the Likert scale were included in the final guidelines. There were 24 panelists from eight countries who represented five clinical specialties. The panel identified an initial set of 183 candidate elements. After two survey rounds, the final reporting guidelines included 92 items that achieved >80% consensus. These included 10 items for study eligibility, 23 items for outcomes, nine items for ECG abnormalities, and 50 items for candidate predictors. Adherence to these guidelines should facilitate comparison of future research in this area.

View details for DOI 10.1111/j.1553-2712.2012.01375.x

View details for Web of Science ID 000305740800011

View details for PubMedID 22687184

Abstract

Clinical trials investigating therapies for acutely and critically ill and injured patients in the earliest phases of treatment often can only be performed under regulations allowing for exception from informed consent (EFIC) for emergency research. Implementation of these regulations in multicenter clinical trials involves special challenges and opportunities. The Rapid Anticonvulsant Medication Prior to Arrival Trial (RAMPART), the first EFIC trial conducted by the Neurological Emergencies Treatment Trials (NETT) network, combined centralized resources and coordination with retention of local control and flexibility to facilitate compliance with the EFIC regulations. Specific methods used by the NETT included common tools for community consultation and public disclosure, sharing of experiences and knowledge, and reporting of aggregate results. Tracking of community consultation and public disclosure activities and feedback facilitates empirical research on EFIC methods in the network and supports quality improvements for future NETT trials. The NETT model used in RAMPART demonstrates how EFIC may be effectively performed in established clinical trial networks.

View details for DOI 10.1111/j.1553-2712.2012.01328.x

View details for Web of Science ID 000302858200011

View details for PubMedID 22506949

Abstract

Early termination of prolonged seizures with intravenous administration of benzodiazepines improves outcomes. For faster and more reliable administration, paramedics increasingly use an intramuscular route.This double-blind, randomized, noninferiority trial compared the efficacy of intramuscular midazolam with that of intravenous lorazepam for children and adults in status epilepticus treated by paramedics. Subjects whose convulsions had persisted for more than 5 minutes and who were still convulsing after paramedics arrived were given the study medication by either intramuscular autoinjector or intravenous infusion. The primary outcome was absence of seizures at the time of arrival in the emergency department without the need for rescue therapy. Secondary outcomes included endotracheal intubation, recurrent seizures, and timing of treatment relative to the cessation of convulsive seizures. This trial tested the hypothesis that intramuscular midazolam was noninferior to intravenous lorazepam by a margin of 10 percentage points.At the time of arrival in the emergency department, seizures were absent without rescue therapy in 329 of 448 subjects (73.4%) in the intramuscular-midazolam group and in 282 of 445 (63.4%) in the intravenous-lorazepam group (absolute difference, 10 percentage points; 95% confidence interval, 4.0 to 16.1; P<0.001 for both noninferiority and superiority). The two treatment groups were similar with respect to need for endotracheal intubation (14.1% of subjects with intramuscular midazolam and 14.4% with intravenous lorazepam) and recurrence of seizures (11.4% and 10.6%, respectively). Among subjects whose seizures ceased before arrival in the emergency department, the median times to active treatment were 1.2 minutes in the intramuscular-midazolam group and 4.8 minutes in the intravenous-lorazepam group, with corresponding median times from active treatment to cessation of convulsions of 3.3 minutes and 1.6 minutes. Adverse-event rates were similar in the two groups.For subjects in status epilepticus, intramuscular midazolam is at least as safe and effective as intravenous lorazepam for prehospital seizure cessation. (Funded by the National Institute of Neurological Disorders and Stroke and others; ClinicalTrials.gov number, ClinicalTrials.gov NCT00809146.).

View details for DOI 10.1056/NEJMoa1107494

View details for Web of Science ID 000300279800004

View details for PubMedID 22335736

Abstract

To determine the sensitivity and specificity of the San Francisco Syncope Rule (SFSR) electrocardiogram (ECG) criteria for determining cardiac outcomes and to define the specific ECG findings that are the most important in patients with syncope.A consecutive cohort of emergency department (ED) patients with syncope or near syncope was considered. The treating emergency physicians assessed 50 predictor variables, including an ECG and rhythm assessment. For the ECG assessment, the physicians were asked to categorize the ECG as normal or abnormal based on any changes that were old or new. They also did a separate rhythm assessment and could use any of the ECGs or available monitoring strips, including prehospital strips, when making this assessment. All patients were followed up to determine a broad composite study outcome. The final ECG criterion for the SFSR was any nonsinus rhythm or new ECG changes. In this specific study, the initial assessments in the database were used to determine only cardiac-related outcomes (arrhythmia, myocardial infarction, structural, sudden death) based on set criteria, and the authors determined the sensitivity and specificity of the ECG criteria for cardiac outcomes only. All ECGs classified as "abnormal" by the study criteria were compared to the official cardiology reading to determine specific findings on the ECG. Univariate and multivariate analysis were used to determine important specific ECG and rhythm findings.A total of 684 consecutive patients were considered, with 218 having positive ECG criteria and 42 (6%) having important cardiac outcomes. ECG criteria predicted 36 of 42 patients with cardiac outcomes, with a sensitivity of 86% (95% confidence interval [CI] = 71% to 94%), a specificity of 70% (95% CI = 66% to 74%), and a negative predictive value of 99% (95% CI = 97% to 99%). Regarding specific ECG findings, any nonsinus rhythm from any source and any left bundle conduction problem (i.e., any left bundle branch block, left anterior fascicular block, left posterior fascicular block, or QRS widening) were 2.5 and 3.5 times more likely associated with significant cardiac outcomes.The ECG criteria from the SFSR are relatively simple, and if used correctly can help predict which patients are at risk of cardiac outcomes. Furthermore, any left bundle branch block conduction problems or any nonsinus rhythms found during the ED stay should be especially concerning for physicians caring for patients presenting with syncope.

View details for DOI 10.1111/j.1553-2712.2011.01120.x

View details for Web of Science ID 000292779900007

View details for PubMedID 21762234

View details for DOI 10.1016/j.annemergmed.2010.06.570

View details for Web of Science ID 000285988500023

View details for PubMedID 20828875

Abstract

The aim of this study was to determine the rate of infection at which it is cost-effective to treat dog bite wounds with antibiotics.Our study was composed of two parts. First we performed a randomized, double-blind controlled trial (RCT) to compare the infection rates of dog bite wounds in patients given amoxicillin-clavulanic acid versus placebo. Subjects were immunocompetent patients presenting to the emergency department (ED) with dog bite wounds less than 12 hours old without suspected neurovascular, tendon, joint or bone injury, and who had structured follow-up after two weeks. Second, we developed a cost model with sensitivity analysis to determine thresholds for treatment.In the RCT, primary outcomes were obtained in 94 patients with dog bites. The overall wound infection rate at two weeks was 2% [95% CI 0 to 7%]. Two of 46 patients (4%) receiving no antibiotics developed infections, while none of the 48 patients (0%) receiving prophylactic antibiotics developed an infection (absolute reduction 4% [95% CI -1.0 to 4.5%]). Using a sensitivity analysis across a rate of infections from 0-10%, our cost model determined that prophylactic antibiotics were cost effective if the risk of wound infection was greater than 5% and antibiotics could decrease that risk by greater than 3%.Our wound infection rate was lower than older studies and more in line with current estimates. Assuming that prophylactic antibiotics could provide an absolute risk reduction (ARR) of 3%, it would not be cost effective to treat wounds with an infection rate of less than 3% and unlikely that the ARR would be achievable unless the baseline rate was greater than 5%, suggesting that only wounds with greater than 5% risk of infection should be treated. Future work should focus on identifying wounds at high-risk of infection that would benefit from antibiotic prophylaxis.

View details for PubMedID 21293762

Abstract

The Institute of Medicine Committee on the Future of Emergency Care in the United States Health System (2003) identified a need to enhance the research base for emergency care. As a result, a National Institutes of Health (NIH) Task Force on Research in Emergency Medicine was formed to enhance NIH support for emergency care research. Members of the NIH Task Force and academic leaders in emergency care participated in 3 Roundtable discussions to prioritize current opportunities for enhancing and conducting emergency care research. We identify key research questions essential to advancing the science of emergency care and discuss the barriers and strategies to advance research by exploring the collaboration between NIH and the emergency care community.Experts from emergency medicine, neurology, psychiatry, and public health assembled to review critical areas in need of investigation, current gaps in knowledge, barriers, and opportunities. Neurologic emergencies included cerebral resuscitation, pain, stroke, syncope, traumatic brain injury, and pregnancy. Mental health topics included suicide, agitation and delirium, substances, posttraumatic stress, violence, and bereavement.Presentations and group discussion firmly established the need for translational research to bring basic science concepts into the clinical arena. A coordinated continuum of the health care system that ensures rapid identification and stabilization and extends through discharge is necessary to maximize overall patient outcomes. There is a paucity of well-designed, focused research on diagnostic testing, clinical decisionmaking, and treatments in the emergency setting. Barriers include the limited number of experienced researchers in emergency medicine, limited dedicated research funding, and difficulties of conducting research in chaotic emergency environments stressed by crowding and limited resources. Several themes emerged during the course of the roundtable discussion, including the need for development of (1) a research infrastructure for the rapid identification, consent, and tracking of research subjects that incorporates innovative informatics technologies, essential for future research; (2) diagnostic strategies and tools necessary to understand key populations and the process of medical decisionmaking, including the investigation of the pathobiology of symptoms and symptom-oriented therapies; (3) collaborative research networks to provide unique opportunities to form partnerships, leverage patient cohorts and clinical and financial resources, and share data; (4) formal research training programs integral for creating new knowledge and advancing the science and practice of emergency medicine; and (5) recognition that emergency care is part of an integrated system from emergency medical services dispatch to discharge. The NIH Roundtable "Opportunities to Advance Research on Neurological and Psychiatric Emergencies" created a framework to guide future emergency medicine-based research initiatives.Emergency departments provide the portal of access to the health care system for most patients with acute neurologic and psychiatric illness. Emergency physicians and colleagues are primed to investigate neurologic and psychiatric emergencies that will directly improve the delivery of care and patient outcomes.

View details for DOI 10.1016/j.annemergmed.2010.06.562

View details for Web of Science ID 000284292800020

View details for PubMedID 21036295

Abstract

The emergency medicine (EM) and prehospital environments are unlike any other clinical environments and require special consideration to allow the successful implementation of clinical trials. This article reviews the specific issues involved in EM clinical trials and provides strategies from EM and non-EM trials to maximize recruitment and retention. While the evidence supporting some of these strategies is deficient, addressing recruitment and retention issues with specific strategies will help researchers deal with these issues in their funding applications and in turn develop the necessary infrastructure to participate in EM clinical trials.

View details for DOI 10.1111/j.1553-2712.2010.00866.x

View details for Web of Science ID 000282877400011

View details for PubMedID 21040112

Abstract

With a careful history, physical examination, and directed investigation, physicians can determine the likely cause of syncope in more than 50% and perhaps up to 80% of patients. Understanding the cause of syncope allows clinicians to determine the disposition of high- and low-risk patients. Patients with a potential malignant cause, such as a cardiac or neurologic condition, should be treated and admitted. Those with benign causes can be safely discharged. This article reviews the diagnosis and ED work-up of syncope, the different classifications of syncope, and prognosis. The use of specific decision rules in risk stratification and syncope in the pediatric population are discussed in another article.

View details for DOI 10.1016/j.emc.2010.03.007

View details for Web of Science ID 000281737700005

View details for PubMedID 20709239

Abstract

During a pandemic, emergency departments (EDs) may be overwhelmed by an increase in patient visits and will foster an environment in which cross-infection can occur. We developed and tested a novel drive-through model to rapidly evaluate patients while they remain in or adjacent to their vehicles. The patient's automobile would provide a social distancing strategy to mitigate the person-to-person spread of infectious diseases.We conducted a full-scale exercise to test the feasibility of a drive-through influenza clinic and measure throughput times of simulated patients and carbon monoxide levels of staff. We also assessed the disposition decisions of the physicians who participated in the exercise. Charts of 38 patients with influenza-like illness who were treated in the Stanford Hospital ED during the initial H1N1 outbreak in April 2009 were used to create 38 patient scenarios for the drive-through influenza clinic.The total median length of stay was 26 minutes. During the exercise, physicians were able to identify those patients who were admitted and discharged during the real ED visit with 100% accuracy (95% confidence interval 91% to 100%). There were no significant increases of carboxyhemoglobin in participants tested.The drive-through model is a feasible alternative to a traditional walk-in ED or clinic and is associated with rapid throughput times. It provides a social distancing strategy, using the patient's vehicle as an isolation compartment to mitigate person-to-person spread of infectious diseases.

View details for DOI 10.1016/j.annemergmed.2009.11.025

View details for Web of Science ID 000275882400008

View details for PubMedID 20079956

Abstract

Event Stream Processing is a computational approach to the problem of how to infer the occurrence of an event from a data stream in real time without reference to a database. This paper describes how we implemented this technology on the STRIDE platform to address the challenge of real time notification of patients presenting in the Emergency Department (ED) who potentially meet eligibility criteria for a clinical study. The system was evaluated against a standalone legacy alerting system and found to perform adequately. While our initial use of this technology was focused on relatively simple alerts, the system is extensible and has the potential to provide enterprise-level research alerting services supporting more complex scenarios.

View details for PubMedID 21347023

Abstract

In the emergency department (ED), adult patients' weights are often crudely estimated before lifesaving interventions. In this study, we evaluate the reliability and accuracy of a method to rapidly calculate patients' weight using readily obtainable anthropometric measurements. We compare this method to visual estimates, patient self-report, and measured weight.A convenience sample of adult ED patients in an academic medical center were prospectively enrolled. Midarm circumference and knee height were measured. These values were input in to equations to calculate patients' weights. A physician and nurse were then independently asked to estimate the patients' weights. Each patient was asked to report his/her own weight before being weighed. Calculated weights using the above equations, visual estimates, and patient reports were compared with actual weights by determining the percentage accurate within 10%. The intraclass correlation coefficient was used to determine the reliability of the estimates with respect to actual weights.Weight was determined within 10% accuracy of actual weight in 69% (95% confidence interval, 63-75) of calculated estimates, 54% (48-61) of physician estimates, 51% (44-57) of nurse estimates, and 86% (81-90) of patient estimates. The weight estimation tool calculated weights more accurately in males (74%, 65-82) than females (65%, 56-73). An analysis of errors revealed that when estimates were inaccurate, approximately half were overestimates and half were underestimates. The correlation coefficient between the calculated estimates and actual weights was 0.89. The correlation coefficient of actual weights with respect to physician estimates, nurse estimates, and doctor's estimates were 0.85, 0.78, and 0.95, respectively.This technique using readily obtainable measurements estimates weight more accurately than ED providers. The technique correlates well with actual patient weights. When available, patient estimates of their own weight are most accurate.

View details for DOI 10.1016/j.ajem.2008.08.018

View details for Web of Science ID 000272403400006

View details for PubMedID 19931751

Abstract

Determination of volume status is crucial in treating acutely ill patients. This study examined bedside ultrasonography of the internal jugular vein (IJV) to predict central venous pressure (CVP). Ultrasonography was performed on 34 nonventilated patients with monitored CVPs. The IJV was measured during the respiratory cycle and with the patient in different positions. Mean IJV diameter in patients with CVP less than 10 cm H2O was 7.0 mm (95% confidence interval [CI], 5.7-8.3) vs 12.5 mm (95% CI, 11.2-13.8) in patients with CVP of 10 cm H2O and greater. Measurement of end expiratory diameter with the patient supine had the highest correlation coefficient: 0.82 (95% CI). There was strong agreement among ultrasonographers: correlation coefficient, 0.92 (95% CI). This pilot study shows promise that ultrasonography of the IJV can be a noninvasive tool to predict CVP. Measurement of end expiratory diameter in supine patients exhibited a high correlation to CVP.

View details for DOI 10.1016/j.ajem.2008.06.005

View details for Web of Science ID 000269311400017

View details for PubMedID 19683116

View details for Web of Science ID 000268798100002

View details for PubMedID 19667295

View details for Web of Science ID 000268373000008

View details for PubMedID 19636032

Abstract

In this study, we compared the skin adhesive 2-octylcyanoacrylate to subcuticular suture for closure of pediatric inguinal hernia incisions to determine if skin adhesive improves wound cosmesis, shortens skin closure time, and lowers operative costs.We prospectively randomized 134 children undergoing inguinal herniorrhaphy at our institution to have skin closure with either skin adhesive (n = 64) or subcuticular closure (n = 70). Data collected included age, sex, weight, type of operation, total operative time, and skin closure time. Digital photographs of healing incisions were taken at the 6-week postoperative visit. The operating surgeon assessed cosmetic outcome of incisions using a previously validated visual analog scale, as well as an ordinate scale. A blinded assessment of cosmetic outcome was then performed by an independent surgeon comparing these photographs to the visual analog scale. Operating room time and resource use (ie, costs) relative to the skin closure were assessed. Comparisons between groups were done using Student's t tests and chi(2) tests.Children enrolled in the study had a mean +/- SE age of 3.7 +/- 0.3 years and weighed 16 +/- 0.8 kg. Patients were predominantly male (82%). Patients underwent 1 of 3 types of open hernia repair as follows: unilateral herniorrhaphy without peritoneoscopy (n = 41; 31%), unilateral herniorrhaphy with peritoneoscopy (n = 55; 41%), and bilateral herniorrhaphy (n = 38; 28%). Skin closure time was significantly shorter in the skin adhesive group (adhesive = 1.4 +/- 0.8 minutes vs suture = 2.4 +/- 1.1 minutes; P = .001). Mean wound cosmesis scores based on the visual analog scale were similar between groups (adhesive = 78 +/- 21; suture=78 +/- 18; P = .50). Material costs related to herniorrhaphy were higher for skin adhesive (adhesive = $22.63 vs suture = $11.70; P < .001), whereas operating room time costs for adhesive skin closure were lower (adhesive = $9.33 +/- 5.33 vs suture = $16.00 +/- 7.33; P < .001). Except for a 7% incidence of erythema in both groups, there were no complications encountered.There is no difference in cosmetic outcome between skin adhesive and suture closure in pediatric inguinal herniorrhaphy. Material costs are increased because of the high cost of adhesive relative to suture. This is partially offset, however, by the cost savings from reduction in operating room time.

View details for DOI 10.1016/j.jpedsurg.2009.02.051

View details for Web of Science ID 000267939600022

View details for PubMedID 19573672

Abstract

We sought to determine the incidence of acute myocardial infarction (AMI) in emergency department (ED) patients with syncope, the characteristics of these AMIs and how helpful the initial electrocardiogram (ECG) was in identifying these cases.In a prospective cohort of consecutive patients with syncope, the initial ECG was found to be abnormal using a prespecified definition (any nonsinus rhythm or any new or age- indeterminate abnormalities). Patients were then followed up to identify an AMI diagnosed within 30 days of presentation.There were 1474 consecutive patient visits for syncope or near-syncope over a 45-month period spanning from Jul. 1, 2000, to Feb. 28, 2002, and Jul. 15, 2002, to Aug. 31, 2004, of which 46 (3.1%) were diagnosed with AMI. The majority of the AMI patients (42) had no ST segment elevation. The initial ECG was abnormal in 37 out of 46 cases. The diagnostic performance of the initial ECG was sensitivity 80% (95% confidence interval [CI] 67%-89%), specificity 64% (95% CI 61%-67%), negative predictive value 99% (95% CI 98%-100%), positive predictive value 7% (95% CI 6%-8%), positive likelihood ratio 2.2 (95% CI 1.6-2.5) and negative likelihood ratio 0.3 (95% CI 0.2-0.5).The incidence of AMI in patients presenting with syncope is low. A normal ECG has a high negative predictive value, although its sensitivity is limited.

View details for Web of Science ID 000272257500010

View details for PubMedID 19272217

Abstract

Syncope is a common condition that is usually benign but occasionally associated with death. This study evaluates the incidence of death after an emergency department (ED) visit for syncope and whether these deaths can be predicted.A prospective cohort study was conducted during a 45-month period. All patients were followed up 1-and-a-half years after their initial ED visit to determine whether they had died. Death certificates were independently reviewed by 2 physicians for the cause and date of death to determine whether the death was possibly related to the initial visit for syncope. Sensitivity and specificity of risk factors (defined by the San Francisco Syncope Rule) or age greater than 65 years was calculated for all-cause mortality and mortality thought possibly related to syncope.There were 1418 consecutive patients with syncope during the study period, representing 1.2% of all ED visits. The all-cause death rate was 1.4% at 30 days, 4.3% at 6 months, and 7.6% at 1 year. It was believed that the death rates from causes possibly related to syncope were 2.3% and 3.8% at 6 months and 1 year. Of the 112 deaths at 1 year, 37% were cardiac related. At 6 months, the risk factors had a sensitivity of 89% (95% confidence interval [CI] 79% to 95%) and specificity of 53% (95% CI 52% to 53%) for all-cause mortality and sensitivity of 100% (95% CI 90% to 100%) and specificity 52% (95% CI 52% to 53%) for predicting deaths likely or possibly related to syncope. Age greater than 65 years had similar sensitivity but much worse specificity compared with the set combined risk factors.Deaths related to syncope after an ED visit are low, especially in the first 6 months and can usually be predicted by risk factors.

View details for DOI 10.1016/j.annemergmed.2007.08.005

View details for Web of Science ID 000255487200006

View details for PubMedID 17889403

Abstract

Each year there are over 7 million lacerations requiring wound closure in the emergency department. Traditionally, most lacerations have been closed with sutures. Topical cyanoacrylate skin adhesives offer many advantages over traditional wound closure devices. Recently, the Food and Drug Administration (FDA) has reclassified the topical skin adhesives. As a result, new topical skin adhesives are expected to enter the market in the near future. This article will review the structure and function of cyanoacrylates as well as their advantages, indications, and usage.

View details for DOI 10.1016/j.ajem.2007.05.015

View details for Web of Science ID 000255262000018

View details for PubMedID 18410821

Abstract

The Broselow pediatric emergency weight estimation tape is an accurate method of estimating children's weights based on height-weight correlations and determining standardized medication dosages and equipment sizes using color-coded zones. The study objective was to determine the accuracy of the Broselow tape in the Indian pediatric population.The authors conducted a 6-week prospective cross-sectional study of 548 children at a government pediatric hospital in Chennai, India, in three weight-based groups: < 10 kg (n = 175), 10-18 kg (n = 197), and > 18 kg (n = 176). Measured weight was compared to Broselow-predicted weight, and the percentage difference was calculated. Accuracy was defined as agreement on Broselow color-coded zones, as well as agreement within 10% between the measured and Broselow-predicted weights. A cross-validated correction factor was also derived.The mean percentage differences were -2.4, -11.3, and -12.9% for each weight-based group. The Broselow color-coded zone agreement was 70.8% in children weighing less than 10 kg, but only 56.3% in the 10- to 18-kg group and 37.5% in the > 18-kg group. Agreement within 10% was 52.6% for the < 10-kg group, but only 44.7% for the 10- to 18-kg group and 33.5% for the > 18-kg group. Application of a 10% weight-correction factor improved the percentages to 77.1% for the 10- to 18-kg group and 63.0% for the >18-kg group.The Broselow tape overestimates weight by more than 10% in Indian children > 10 kg. Weight overestimation increases the risk of medical errors due to incorrect dosing or equipment selection. Applying a 10% weight-correction factor may be advisable.

View details for DOI 10.1111/j.1553-2712.2008.00081.x

View details for Web of Science ID 000255285200005

View details for PubMedID 18439198

Abstract

To determine the accuracy of the online Social Security Death Index (SSDI) for determining death outcomes.We selected 30 patients who were determined to be dead and 90 patients thought to be alive after an ED visit as determined by a web-based searched of the SSDI. For those thought to be dead we requested death certificates. We then had a research coordinator blinded to the results of the SSDI search, complete direct follow-up by contacting the patients, family or primary care physicians to determine vital status. To determine the sensitivity and specificity of the SSDI for death at six months in this cohort, we used direct follow-up as the criterion reference and calculated 95% confidence intervals.Direct follow-up was completed for 90% (108 of 120) of the patients. For those patients 20 were determined to be dead and 88 alive. The dead were more likely to be male (57%) and older [(mean age 83.9 (95% CI 79.1 - 88.7) vs. 60.9 (95% CI 56.4 - 65.4) for those alive]. The sensitivity of the SSDI for those with completed direct follow-up was 100% (95% CI 91 -100%) with specificity of 100% (95% CI 98-100%). Of the 12 patients who were not able to be contacted through direct follow-up, the SSDI indicated that 10 were dead and two were alive.SSDI is an accurate measure of death outcomes and appears to have the advantage of finding deaths among patients lost to follow-up.

View details for PubMedID 19561695

View details for PubMedID 18035161

View details for DOI 10.1016/j.annemergmed.2007.06.476

View details for Web of Science ID 000251440500022

View details for PubMedID 18023761

Abstract

The purpose of this study is to determine the impact of a new rapid admission policy (RAP) on emergency department (ED) length of stay (EDLOS) and time spent on ambulance diversion (AD).The RAP, instituted in January 2005, allows attending emergency physicians to send stable patients, requiring admission to the general medicine service, directly to available inpatient beds. The RAP thereby eliminates 2 conventional preadmission practices: having admitting physicians evaluate the patient in the ED and requiring all diagnostic testing to be complete before admission. We compared patient characteristics, percentage of patients leaving without being seen, EDLOS for admitted patients, time on AD, and total adjusted facility charge for a 3-month period after the RAP implementation to the same period of the prior year.There was a 1.1% increase in census with no difference in patient demographics, acuity, or disposition categories for the 2 periods. The EDLOS decreased on average by 10.1 minutes (95% confidence interval [CI], 3.3-17.0 minutes), resulting in an average of 4.2 hours of extra bed availability per day. Weekly minutes of AD decreased 169 minutes (95% CI, 29-310 minutes). There was also a 3.2% increase (95% CI, 3.1%-3.3%) in adjusted facility charge between these periods in 2005 compared with 2004.The RAP resulted in a small decrease in the EDLOS, which likely decreased AD time. The resulting small increase in ED volume and higher acuity ambulance patients significantly improved ED revenue. Wider implementation of the policy and more uniform use among emergency physicians may further improve these measures.

View details for DOI 10.1016/j.ajem.2006.11.034

View details for Web of Science ID 000247298800012

View details for PubMedID 17543661

View details for PubMedID 17488578

View details for DOI 10.1016/j.annemergmed.2007.02.001

View details for Web of Science ID 000245293700007

View details for PubMedID 17371707

View details for DOI 10.1016/j.annemergmed.2006.06.050

View details for Web of Science ID 000242310700029

View details for PubMedID 17112946

Abstract

We prospectively validate the San Francisco Syncope Rule (history of congestive heart failure, Hematocrit <30%, abnormal ECG result [new changes or non-sinus rhythm], complaint of shortness of breath, and systolic blood pressure <90 mm Hg during triage).In a prospective cohort study, consecutive patients with syncope or near syncope presenting to an emergency department (ED) of a teaching hospital were identified and enrolled from July 15, 2002, to August 31, 2004. Patients with trauma, alcohol, or drug-associated loss of consciousness and definite seizures were excluded. Physicians prospectively applied the San Francisco Syncope Rule after their evaluation, and patients were followed up to determine whether they had had a predefined serious outcome within 30 days of their ED visit.Seven hundred ninety-one consecutive visits were evaluated for syncope, representing 1.2% of all ED visits. The average age was 61 years, 54% of patients were women, and 59% of patients were admitted. Fifty-three visits (6.7%) resulted in patients having serious outcomes that were undeclared during their ED visit. The rule was 98% sensitive (95% confidence interval [CI] 89% to 100%) and 56% specific (95% CI 52% to 60%) to predict these events. In this cohort, the San Francisco Syncope Rule classified 52% of the patients as high risk, potentially decreasing overall admissions by 7%. If the rule had been applied only to the 453 patients admitted, it might have decreased admissions by 24%.The San Francisco Syncope Rule performed with high sensitivity and specificity in this validation cohort and is a valuable tool to help risk stratify patients. It may help with physician decisionmaking and improve the use of hospital admission for syncope.

View details for DOI 10.1016/j.annemergmed.2005.11.019

View details for Web of Science ID 000237162900013

View details for PubMedID 16631985

Abstract

To compare a clinical decision rule (San Francisco Syncope Rule [SFSR]) and physician decision making when predicting serious outcomes in patients with syncope.In a prospective cohort study, physicians evaluated patients presenting with syncope and predicted the chance (0%-100%) of the patient developing a predefined serious outcome. They were then observed to determine their decision to admit the patient. All patients were followed up to determine whether they had a serious outcome within 7 days of their emergency department visit. Analyses included sensitivity and specificity to predict serious outcomes for low-risk patients and comparison of areas under the receiver operating characteristic curve for the decision rule, physician judgment, and admission decisions.During the study period, there were 684 visits for syncope with 79 visits resulting in serious outcomes. The area under the receiver operating characteristic curve was 0.92 (95% confidence interval [CI], 0.88-0.95) for the SFSR compared with physician judgment 0.89 (95% CI, 0.85-0.93) and physician decision making 0.83 (95% CI, 0.81-0.87). Physicians admitted 28% of patients in a low-risk group, with a median length of stay of 1 day (interquartile range, 1-2.5 days). The SFSR had the potential to absolutely decrease admissions by 10% in this low-risk group and still predict all serious outcomes.Physician judgment is good when predicting which patients with syncope will develop serious outcomes, but contrary to their judgment, physicians still admit a large number of low-risk patients. The SFSR performs better than current physician performance and has great potential to aid physician decision making.

View details for DOI 10.1016/j.ajem.2004.11.009

View details for Web of Science ID 000232624900013

View details for PubMedID 16182988

Abstract

Each year, children die from heat stroke after being left unattended in motor vehicles. In 2003, the total was 42, up from a national average of 29 for the past 5 years. Previous studies found that on days when ambient temperatures exceeded 86 degrees F, the internal temperatures of the vehicle quickly reached 134 to 154 degrees F. We were interested to know whether similarly high temperatures occurred on clear sunny days with more moderate temperatures. The objective of this study was to evaluate the degree of temperature rise and rate of rise in similar and lower ambient temperatures. In addition, we evaluated the effect of having windows "cracked" open.In this observational study, temperature rise was measured continuously over a 60-minute period in a dark sedan on 16 different clear sunny days with ambient temperatures ranging from 72 to 96 degrees F. On 2 of these days, additional measurements were made with the windows opened 1.5 inches. Analysis of variance was used to compare how quickly the internal vehicle temperature rose and to compare temperature rise when windows were cracked open 1.5 inches.Regardless of the outside ambient temperature, the rate of temperature rise inside the vehicle was not significantly different. The average mean increase was 3.2 degrees F per 5-minute interval, with 80% of the temperature rise occurring during the first 30 minutes. The final temperature of the vehicle depended on the starting ambient temperature, but even at the coolest ambient temperature, internal temperatures reached 117 degrees F. On average, there was an approximately 40 degrees F increase in internal temperature for ambient temperatures spanning 72 to 96 degrees F. Cracking windows open did not decrease the rate of temperature rise in the vehicle (closed: 3.4 degrees F per 5 minutes; opened: 3.1 degrees F per 5 minutes or the final maximum internal temperature.Even at relatively cool ambient temperatures, the temperature rise in vehicles is significant on clear, sunny days and puts infants at risk for hyperthermia. Vehicles heat up rapidly, with the majority of the temperature rise occurring within the first 15 to 30 minutes. Leaving the windows opened slightly does not significantly slow the heating process or decrease the maximum temperature attained. Increased public awareness and parental education of heat rise in motor vehicles may reduce the incidence of hyperthermia death and improve child passenger safety.

View details for DOI 10.1542/peds.2004-2368

View details for Web of Science ID 000230207500016

View details for PubMedID 15995010

Abstract

Patients who leave without being seen (LWBS) can be an indicator of patient satisfaction and quality for emergency departments (ED). The objective of this study was to develop a model to determine factors associated with patients who LWBS.A modified case-crossover design to determine the transient effects on the risk of acute events was used. Over a four-month period, time intervals when patients LWBS were matched (within two weeks), according to time of day and day of week, with time periods when patients did not LWBS. Factors considered were percentage of ED bed capacity, acuity of ED patients, length of stay of discharged patients in the ED, patients awaiting an admission bed in the ED, inpatient floor capacity, intensive care unit capacity, and the characteristics of the attending physician in charge. McNemar test, Wilcoxon signed-rank test, and conditional logistic regression analyses were used to determine significant variables.Over the study period, there were 11,652 visits, of which 213 (1.8%) resulted in patients who LWBS. Measures of inpatient capacity were not associated with patients who LWBS and ED capacity was only associated when >100%. This association increased with increasing capacity. Other significant factors were older age (p < 0.01) and completion of an emergency medicine residency (p < 0.01) of the physician in charge. When factors were considered in a multivariate model, ED capacity >140% (odds ratio, 1.96; 95% confidence interval = 1.22 to 3.17) and noncompletion of an emergency medicine residency (odds ratio, 1.85; 95% confidence interval = 1.17 to 2.93) were most important.ED capacity >100% is associated with patients who LWBS and is most significant at 140% capacity. ED capacity of 100% may not be a sensitive measure for overcrowding. Physician factors, especially emergency medicine training, also appear to be important when using LWBS as a quality indicator.

View details for DOI 10.1197/j.aem.2004.10.029

View details for Web of Science ID 000227266800008

View details for PubMedID 15741586

Abstract

The authors describe the development of a real-time tracking, notification, and Web-based enrollment system designed specifically to facilitate emergency department research. The system was developed in a cooperative arrangement between an emergency medicine researcher and a medical information software company. The system design and utilization are described as well as the security measures to ensure compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations and database security.

View details for DOI 10.1197/j.aem.2004.08.020

View details for Web of Science ID 000225088900021

View details for PubMedID 15528591

Abstract

This study characterizes the use of complementary and alternative medicines (CAM) among ED patients and demonstrates patterns of healthcare utilization among users and nonusers of CAM therapies. A cross-sectional observational study was performed by administering questionnaires to ED patients at a university teaching hospital. Of the 356 patients surveyed, more than half (55%) had tried at least one complementary and alternative therapy within the past 12 months and 17% had tried CAM for their presenting medical problem. The use of CAM interventions varied significantly among different demographic groups. The number of ED visits over the past year did not differ between the users and nonusers of CAM, but those using alternative therapies did have more visits to outpatient physicians over the past 12 months (7.8 vs. 5.2; 95% confidence interval [CI], 7-4.6; P <.01). After controlling for age, ethnicity, education level, religion, income, and self-report of overall health status, users of CAM had more frequent visits to outpatient physicians (odds ratio [OR], 1.06; 95% CI, 1.02-1.1; P <.01), had no difference in their rates of hospitalization, but trended toward spending fewer days in the hospital when they were admitted (OR,.96; 95% CI,.92-1.0; P =.06). Complementary and alternative medicines are being used by a majority of ED patients with a significant number having used CAM for their presenting complaint before visiting the ED. CAM users do not differ in their utilization of the ED when compared with nonusers, but do have a significantly increased frequency of outpatient physician visits.

View details for Web of Science ID 000221557700009

View details for PubMedID 15138954

Abstract

The causes of syncope are usually benign but are occasionally associated with significant morbidity and mortality. We derive a decision rule that would predict patients at risk for short-term serious outcomes and help guide admission decisions.This prospective cohort study was conducted at a university teaching hospital and used emergency department (ED) patients presenting with syncope or near syncope. Physicians prospectively completed a structured data form when evaluating patients with syncope. Serious outcomes (death, myocardial infarction, arrhythmia, pulmonary embolism, stroke, subarachnoid hemorrhage, significant hemorrhage, or any condition causing a return ED visit and hospitalization for a related event) were defined at the start of the study. All patients were followed up to determine whether they had experienced a serious outcome within 7 days of their ED visit. Univariate analysis was performed with chi2 and nonparametric techniques on all predictor variables. kappa Analysis was performed on variables requiring interpretation. Variables with kappa more than 0.5 and a P value less than.1 were analyzed with recursive partitioning techniques to develop a rule that would maximize the determination of serious outcomes.There were 684 visits for syncope, and 79 of these visits resulted in patients' experiencing serious outcomes. Of the 50 predictor variables considered, 26 were associated with a serious outcome on univariate analysis. A rule that considers patients with an abnormal ECG, a complaint of shortness of breath, hematocrit less than 30%, systolic blood pressure less than 90 mm Hg, or a history of congestive heart failure has 96% (95% confidence interval [CI] 92% to 100%) sensitivity and 62% (95% CI 58% to 66%) specificity. If applied to this cohort, the rule has the potential to decrease the admission rate by 10%.The San Francisco Syncope Rule derived in this cohort of patients appears to be sensitive for identifying patients at risk for short-term serious outcomes. If prospectively validated, it may offer a tool to aid physician decision making.

View details for DOI 10.1016/mem.2004.430

View details for Web of Science ID 000188704300014

View details for PubMedID 14747812

Abstract

To assess the difference in clinical outcome between lacerations of the hand closed with sutures and those treated conservatively.Randomised controlled trial.Emergency department in a tertiary hospital.Consecutive patients presenting between 16 February and 30 November 2000 with uncomplicated lacerations of the hand (full thickness <2 cm; without tendon, joint, fracture, or nerve complications) who would normally require sutures. 154 patients were eligible, 58 refused, and 5 were missed; 91 patients with 95 lacerations were enrolled.Participants were randomised to suturing or conservative treatment.Primary outcome was cosmetic appearance after three months, rated on a previously validated visual analogue scale. Duration of treatment, pain during treatment, patients' assessment of their outcome, and the time for patients to resume normal activities were also measured.Participants treated with sutures and those treated conservatively did not differ significantly in the assessment of cosmetic appearance by independent blinded doctors after three months: 83 mm v 80 mm, (mean difference 3 (95% confidence interval -1 to 8) mm) on the visual analogue scale. The mean time to resume normal activities was the same in both groups (3.4 days). Patients treated conservatively had less pain (difference 18 (12 to 24) mm) and treatment time was 14 (10 to 18) min shorter.Similar cosmetic and functional outcomes result from either conservative treatment or suturing of small uncomplicated lacerations of the hand, but conservative treatment is faster and less painful.

View details for Web of Science ID 000177482500014

View details for PubMedID 12169503

Abstract

The most important outcomes after repair of traumatic lacerations and surgical incisions are their long-term cosmetic appearance and development of infection. However, few studies have attempted to identify patient and wound characteristics associated with increased infection rates and suboptimal scar appearance. The authors determined patient and wound characteristics associated with wound infection or suboptimal appearance after laceration or incision repair. A secondary analysis of data collected from a multicenter randomized clinical trial comparing the outcome of lacerations and incisions closed with tissue adhesive or standard closure methods conducted at 10 clinical inpatient and outpatient sites was performed. The presence of infection and scar appearance were prospectively determined using validated outcomes. Univariate and multivariate analyses were performed to identify patient and wound characteristics associated with poor wound outcome (wound infection at 5 to 10 days or suboptimal appearance at 3 months). Eight hundred fourteen patients with 924 wounds (383 lacerations, 541 incisions) were enrolled. Mean age was 32 years and 47 percent were female. Characteristics associated with suboptimal cosmetic appearance on multivariate analysis were presence of associated tissue trauma [odds ratio (OR), 3.9; 95 percent confidence interval (CI), 1.4 to 10.7], use of electrocautery (OR, 3.4; 95 percent CI, 1.8 to 6.5), incomplete wound edge apposition (OR, 2.9; 95 percent CI, 1.7 to 5.0); extremity location (OR, 2.1; 95 percent CI, 1.2 to 3.7), and wound width (OR, 1.08; 95 percent CI, 1.01 to 1.14). Characteristics associated with wound infection on univariate analysis included associated tissue trauma (8.7 percent versus 1.2 percent, p = 0.04) and incomplete wound apposition (6.6 percent versus 0.5 percent). Suboptimal appearance was more common in infected wounds (relative risk, 3.2; 95 percent CI, 1.8 to 5.6). Suboptimal wound appearance is increased with extremity wounds, wide wounds, incompletely apposed wounds, associated tissue trauma, use of electrocautery, and infection. Type of closure device and use of deep sutures had no effect on infection rates or cosmetic appearance.

View details for Web of Science ID 000177043900008

View details for PubMedID 12142655

Abstract

Most lacerations and surgical incisions are closed with sutures or staples. Octylcyanoacrylate tissue adhesive (OCA) was recently approved for use in the United States. We compared the cosmetic appearance of lacerations and incisions repaired with OCA versus standard wound closure methods (SWC).A multicenter randomized clinical trial including patients with simple lacerations or surgical incisions was conducted at 10 clinical sites. Patients were randomly assigned to treatment with OCA or SWC. Follow-up was performed at 1 week and at 3 months to determine infection rates and cosmetic outcome.Eight hundred fourteen patients with 924 wounds (383 traumatic lacerations, 235 excisions of skin lesions or scar revisions, 208 minimally invasive surgeries, and 98 general surgical procedures) were enrolled. Groups were similar in baseline characteristics. Wound closure with OCA was faster than with SWC (2.9 vs 5.2 minutes, P <.001). At 1 week infection rates were similar (OCA, 2.1% vs SWC, 0.7%; P =.09) and fewer OCA wounds were erythematous (18% vs 36%, P <.001). There were no differences in wound dehiscence rates (OCA, 1.6% vs SWC, 0.9%; P =.35). At 3 months there was no difference in the percent of wounds with optimal appearance (OCA, 82% vs SWC, 83%; P =.67).Repair of traumatic lacerations and surgical incisions with OCA is faster than with SWC, and cosmetic outcome is similar at 3 months.

View details for DOI 10.1067/msy.2002.121377

View details for Web of Science ID 000174528400006

View details for PubMedID 11894031

Abstract

To compare two tissue adhesives, butylcyanoacrylate and octylcyanoacrylate, in the treatment of small (<4 cm) superficial linear traumatic facial lacerations in children.This was a randomized, clinical trial with parallel design. 94 children <18 years of age seen in the ED of a tertiary care pediatric hospital with a facial laceration suitable for tissue adhesive closure underwent laceration closure using either butylcyanoacrylate or octylcyanoacrylate. The primary outcome was the cosmetic result at three months rated from photographs by a plastic surgeon on a visual analog scale (VAS). Secondary outcomes included the time to perform the procedure, the perceived difficulty of the procedure, the pain perceived by the patient, and a wound evaluation score at ten to 14 days and three months.Ninety-four patients were randomized with 47 in each group. The two groups were similar for baseline demographic and clinical characteristics. There was no difference in the three-month cosmesis VAS (median, 70.0 mm for n-butyl-2-cyanoacrylate vs 67.5 mm for octylcyanocrylate, p = 0.84). There was no difference between the groups for time to complete the procedure (p = 0.88), parent/patient-perceived pain of the procedure (p = 0.37), or physician-perceived difficulty of the procedure (p = 0.33). Similarly, there was no difference between the groups for the percentage of early (p = 0.58) or late (p = 0.71) optimal wound evaluation scores.In the closure of small linear pediatric facial lacerations, octylcyanoacrylate is similar to butylcyanoacrylate in ease of use and early and late cosmetic outcomes. The superior physical properties of octylcyanoacrylate appear to add little benefit to the management of these selected lacerations. Physician preference and differing costs may dictate use for these small selected lacerations.

View details for Web of Science ID 000079862700004

View details for PubMedID 10192666

Abstract

To compare the 1-year cosmetic outcome of wounds treated with octylcyanoacrylate tissue adhesive and monofilament sutures and to correlate the early, 3-month, and 1-year cosmetic outcomes.We prospectively randomized 136 cases of traumatic laceration to repair with octylcyanoacrylate tissue adhesive or 5-0 or smaller monofilament suture. A wound score was assigned by a research nurse, and validated by a second nurse blinded to the treatment, at 5 to 10 days after injury (early), 3 months, and 1 year. Standardized photographs were taken at 3 months and 1 year and shown to a cosmetic surgeon blinded to the method of closure, who rated the wounds on a validated cosmesis scale.We were able to examine 77 lacerations at 1 year for follow-up. No differences were found in the demographic or clinical characteristics between groups. Likewise, at 1 year no difference was found in the optimal wound scores (73% versus 68%, P =.60) or in visual analog scale cosmesis scores (69 versus 69 mm, P =.95) for octylcyanoacrylate and sutures, respectively. Agreement was poor between early and 3-month wound scores (kappa=.34; 95% confidence interval [CI],.10 to.58) but a strong association existed between 3-month and 1-year wound scores (kappa=.71; 95% CI,.52 to.90). We noted a moderate correlation between 3-month and 1-year results on the visual analog cosmesis scale (intraclass correlation,.48; 95% CI, .30 to.63).One year after wound repair, no difference is noted in the cosmetic outcomes of traumatic lacerations treated with octylcyanoacrylate tissue adhesive and sutures. The assessment of wounds 3 months after injury and wound repair provides a good measure of long-term cosmetic outcome.

View details for Web of Science ID 000077590700001

View details for PubMedID 9832658

Abstract

Rapid evaluation of the hypotensive patient in the emergency department is essential. The availability of ultrasonography in the ED, performed by emergency physicians and surgeons, has made it easier to evaluate the hypotensive trauma patient. We describe a 44-year-old man transferred to our institution from a community hospital for evaluation of syncope and hypotension with no obvious cause. On arrival the patient began to complain of slight lower abdominal pain. The patient's physical examination revealed minimal abdominal tenderness. A rapid ultrasound examination performed at bedside revealed the presence of intraperitoneal fluid. Examination of the spleen suggested likely rupture. The patient was promptly taken to surgery for splenectomy and discharged home in 4 days.

View details for Web of Science ID 000076785300018

View details for PubMedID 9795331

View details for Web of Science ID 000075126100031

View details for PubMedID 9701322

Abstract

To determine the effectiveness of a new tissue adhesive, 2-Octylcyanoacrylate (2-OCA), for laceration repair, 83 children presenting to T.C. Thompson Children's Hospital Emergency Department with lacerations meeting eligibility requirements between February and June 1996 were randomized to receive 2-OCA or nonabsorbable sutures/staples. The length of time for repair was recorded. The length of time for laceration repair was decreased (2.9 minutes 2-OCA vs 5.8 minutes suture/staple; p < 0.001), the parents' assessment of the pain felt by their children in the 2-OCA group was less, and the wounds closed with tissue adhesive had slightly lower cosmesis scores. 2-OCA is an acceptable alternative to conventional methods of wound repair with comparable cosmetic outcome.

View details for Web of Science ID 000074065100035

View details for PubMedID 9627610

Abstract

To compare 2 clinical wound scales and to determine a minimal clinically important difference (MCID) on the visual analog cosmesis scale.Using data from 2 previously published clinical trials, 91 lacerations and 43 surgical incisions were assessed on the 2 scales; a 100-mm visual analog scale (VAS) (0 = worst possible scar, 100 = best possible scar) and a wound evaluation scale (WES) assessing 6 clinical variables (a score of 6 is considered optimal, while a score of < or =5 suboptimal). All wound assessments on the VAS were done by 2 cosmetic surgeons who rated photographs on 2 occasions. A cohort of wounds on the WES were assessed by a second observer. The difference of the mean optimal and suboptimal VAS scores for each study was used to determine a MCID on the VAS scale.The VAS scale yielded intraobserver agreements of 0.93 and 0.87 (95% CI: 0.89-0.96 and 0.78-0.93) and interobserver agreements of 0.50 and 0.71 (95% CI: 0.32-0.65 and 0.52-0.84) for lacerations and incisions, respectively. Kappa coefficient measuring agreement on the WES was 0.79 (95% CI: 0.57-1.0). The mean (+/-SD) VAS scores of optimal wounds were 72 +/- 12 mm and 65 +/- 20 mm, while the mean scores of suboptimal wounds were 57 +/- 17 mm and 50 +/- 23 mm for lacerations and incisions, respectively.An MCID on the VAS cosmesis scale is 15 mm. Studies should be designed to have a sample size and power to detect this difference.

View details for Web of Science ID 000074112400009

View details for PubMedID 9660284

Abstract

To compare a new tissue adhesive, 2-octylcyanoacrylate, with standard wound closure techniques for the repair of traumatic lacerations.A prospective, randomized, controlled clinical trial enrolled consecutive patients > 1 year of age with non-bite, non-crush-induced lacerations who presented < 6 hours after injury. Structured closed-question data sheets were completed at the time of laceration repair and suture removal. Patients were randomly assigned to treatment with either 2-octylcyanoacrylate or standard wound closure. Infection was determined at the time of suture removal. Long-term cosmetic appearance (> 3 months) was assessed by physicians using a previously validated categorical cosmetic scale and by patients using a 100-mm visual analog scale.There were 63 patients randomized to the octylcyanoacrylate group and 61 patients treated with standard wound closure techniques. The 2 treatment groups were similar with respect to age, gender, race, medical history, and wound characteristics. At the 5-to-10-day follow-up, only 1 wound was infected and only 2 wounds required reclosure due to dehiscence. These 3 patients received treatment with octylcyanoacrylate. At long-term follow-up, the cosmetic appearances were similar according to the patients (octylcyanoacrylate, 83.8 +/- 19.4 mm vs standard techniques, 82.5 +/- 17.6 mm; p = 0.72) and the physicians (optimal cosmetic appearance, 77% vs 80%; p = 0.67).Wounds treated with octylcyanoacrylate and standard wound closure techniques have similar cosmetic appearances 3 months later.

View details for Web of Science ID 000071969400003

View details for PubMedID 9492126

View details for Web of Science ID A1997YA91200007

View details for PubMedID 9329936

Abstract

Octylcyanoacrylate tissue adhesive is a topical wound closure that precludes the need for foreign bodies (sutures) to close wounds. It also has an in vitro antimicrobial effect when standard disc sensitivity tests are used.To determine whether contaminated wounds closed with octylcyanoacrylate tissue adhesive will have a lower infection rate compared with wounds closed with 5-0 monofilament sutures, we designed a randomized, blinded, experimental animal study. Two incisions were made on 20 albino guinea pigs. The wounds were contaminated with 10(5) Staphylococcus aureus ATCC 12600 and randomly assigned to be closed with either topical octylcyanoacrylate tissue adhesive or percutaneous 5-0 polypropylene suture. Five days later the adhesive and sutures were removed, and a section of the wound was given to a histopathologist blinded to the type of wound closure. The wound was determined to be infected if inflammatory cells with intracellular cocci were seen. The rest of the wound was opened and examined for clinical evidence of infection. Quantitative bacteriologic analysis was performed.Five wounds in the tissue adhesive group were sterile on day 5, whereas all sutured wounds had positive cultures (25% versus 0%, p < 0.05). Fewer wounds in the tissue adhesive group were determined to be infected by histologic and clinical criteria (0% versus 55%, p < 0.001, and 20% versus 65%, p < 0.01, respectively). Agreement on the determination of infection by histologic and clinical criteria yielded a kappa coefficient of 0.46 (95% confidence interval [GI], 0.19 to 0.73). An infection criterion of 10(5) colony-forming units/gm of tissue correlated poorly with clinical and histologic infection rates (0.19 [95% CI, -0.06 to 0.44] and 0.13 [95% CI, -0.05 to 0.31], respectively).Contaminated wounds closed with sutures had higher infection rates compared with those reported with topical tissue adhesive. The amount of colonization may not be an accurate method to determine infection.

View details for Web of Science ID A1997XK80800011

View details for PubMedID 9225917

Abstract

To assess the effectiveness of a new tissue adhesive for laceration closure.A prospective, randomized controlled trial.An adult teaching hospital.One hundred thirty patients with 136 lacerations who consented to enrollment during a 5-month period. The lacerations included all eligible nonmucosal facial lacerations, as well as selected extremity and torso lacerations (not on hands, feet, or joints). One hundred six lacerations were available for early follow-up, and 98 were available for 3-month evaluation.Lacerations were randomly allocated to have skin closure with octylcyanoacrylate adhesive or monofilament suture.A 3-month photograph of the wound was assigned a cosmesis score on a previously validated 100-mm visual analog cosmesis scale by a plastic surgeon who was unaware of the method of wound closure.There were no differences in the mean visual analog cosmesis scores (67 mm for octylcyanoacrylate vs 68 mm for sutures; P=.65). Similarly, there was no difference in the percentage of early (80% vs 82%; P=.80) or late (72% vs 75%; P=.74) optimal wound evaluation scores. The tissue adhesive was a faster method of wound repair (3.6 vs 12.4 minutes; P<.001) as well as being less painful (visual analog pain scores, 7.2 vs 18.0 mm; P<.001).Octylcyanoacrylate tissue adhesive effectively closes selected lacerations. This relatively painless and fast method of wound repair can replace the need for suturing several million lacerations each year.

View details for Web of Science ID A1997WY96900030

View details for PubMedID 9153366

Abstract

To compare the tissue adhesive octylcyanoacrylate with subcuticular suture for the closure of head and neck incisions.A prospective comparison with a blinded assessment of cosmetic outcome.Fifty consecutive patients undergoing head and neck procedures at two University of Ottawa teaching hospitals.Twenty-six patients underwent skin closure with monofilament suture and 24 were closed with tissue adhesive. At 4 to 6 weeks the incisions were evaluated with a validated wound scale. Photographs of the incisions were rated using a visual analogue scale by two facial-plastic otolaryngologists who were blinded to the method of skin closure.The adhesive provided faster skin closure (29.7 seconds vs 289.0 seconds, p < .0001), and there were no differences in complications between the two groups. The primary outcome measure was the cosmetic appearance of the incision at 4 to 6 weeks. Although the adhesive group scored higher on both cosmesis scales, the visual analogue scale (octylcyanoacrylate 58.7 mm vs suture 53.2 mm) and the wound evaluation scale (57% vs 50% optimal wound scores), there were no statistical or clinically significant differences on either scale. The two facial-plastic otolaryngologists had good intraobserver and interobserver agreement when rating the cosmetic outcomes (0.87 and 0.71 respectively).Octylcyanoacrylate was found to be an effective method of skin closure in clean head and neck incisions. The practical advantages of tissue adhesives are reviewed.

View details for Web of Science ID A1997WJ57100005

View details for PubMedID 9055170

View details for Web of Science ID A1996UC22300004

View details for PubMedID 8881536

Abstract

To determine whether warming of lidocaine decreases the pain of its injection during digital nerve block.Prospective, randomized, double-blind, controlled trial.Twenty healthy volunteers received bilateral digital nerve blocks of their middle finger. They were first randomly assigned to receive either room-temperature (21 degrees C) or heated (42 degrees C) 2% lidocaine in their first block. They were then randomly assigned to receive the first block in either the right or left hand. The blocks were performed in a standardized fashion by a single physician, who was blinded to which solution was being used. The volunteers rated the pain of each digital block on a 100-mm visual analog scale (VAS). Efficacy of each digital block was tested at 5 minutes.Heating of the lidocaine was associated with a significantly lower median VAS pain score (31.5 versus 25.0; P < .05). There was no difference in pain score between the two solutions in relation to which hand was used (P = .29) or whether the injection was the first or the second (P = .37). When all factors (temperature, order, and hand) were considered in the ANOVA with respect to VAS pain score, the only significant relation found was that between the temperature of the solution and the VAS pain score (P = .028).Heating of lidocaine decreases the pain of injection during digital nerve block.

View details for Web of Science ID A1995TJ27800002

View details for PubMedID 7492035

Abstract

To study: 1) the efficiency of the current use of radiography in acute knee injuries, 2) the judgments and attitudes of experienced clinicians in their use of knee radiography, and 3) the potential for decision rules to improve efficiency.This two-stage study of adults with acute knee injuries involved: 1) a retrospective review of all 1,967 patients seen over a 12-month period in the EDs of one community and two teaching hospital, and 2) a prospective survey of another 1,040 patients seen by attending emergency physicians. The prospective survey assessed each clinician's estimate of the probability of a knee or patella fracture; 120 patients were independently assessed by two physicians.Of the 1,967 patients seen in the first stage, 74.1% underwent radiography but only 5.2% were found to have fractures. Of the 1,727 knee and patella radiographic series ordered, 92.4% were negative for fracture. In the second stage, experienced physicians predicted the probability of fracture to be 0 or 0.1 for 75.6% of the patients. The kappa value for this response was 0.51 (95% CI 0.34 to 0.68). The physicians also indicated that they would have been comfortable or very comfortable in not ordering radiography for 55.5% of the patients. The area under the receiver operating characteristics curve for the physicians' prediction of fracture was 0.87 (95% CI 0.82 to 0.91), reflecting good discrimination between fracture and nonfracture cases. Likelihood ratios for the physicians' prediction ranged from 0.09 at the 0 level to 42.9 at the 0.9-1.0 level.Emergency physicians order radiography for most patients with acute knee injuries, even though they can accurately discriminate between fracture and nonfracture cases and expect most of the radiographs to be normal. These findings suggest great potential for more efficient use of knee radiography, possibly through the use of a clinical decision rule.

View details for Web of Science ID A1995TB33800007

View details for PubMedID 8536122

Abstract

Numerous authors have recommended reusing vials of the tissue adhesive Histoacryl blue, despite the fact that it is manufactured for single use. The purpose of this study is to determine if Histoacryl vials become contaminated during reuse and to determine its inhibitory effects on various microbial pathogens. Ten consecutive vials used multiple times were collected from two hospitals, and the residual adhesive was cultured. The antibacterial effect of n-2-butylcyanoacrylate was then tested against various microbial pathogens. The vials were used an average of eight times and the time between opening and culturing the vials ranged from 2-30 days. There was no growth from any vials. Testing against microbial pathogens showed that the tissue adhesive is particularly effective at inhibiting gram-positive organisms. This study demonstrates that Histoacryl vials do not become contaminated after repeated use and that the tissue adhesive has an antibacterial effect that may be beneficial in the management of wounds.

View details for PubMedID 7594385

Abstract

To determine, from the societal perspective, the most cost efficient of the three methods commonly used to repair pediatric facial lacerations: nondissolving sutures, dissolving sutures, or a tissue adhesive (Histoacryl blue).Cost-minimization analysis and willingness-to-pay survey.Tertiary-care pediatric emergency department.All differential costs relevant to equipment utilization, pharmaceutical use, health care worker time, and parental loss of income for follow-up visits were calculated for each method. On the basis of previous research, our model assumes equal cosmetic outcome for the three methods. In addition, a convenience sample of 30 parents were surveyed in the emergency department to rank their preferences and willingness to pay for the three methods of wound closure.The reduction in cost (in Canadian dollars) per patient of switching from the standard nondissolving sutures was $49.60 for switching to tissue adhesive and $37.90 for dissolving sutures. Sensitivity analyses performed on key variables did not significantly alter our conclusions. Of those parents surveyed; 90% (95% confidence interval, 74% to 98%) chose tissue adhesive and 10% (95% confidence interval, 2% to 26%) chose dissolving sutures as their first choice for wound closure. Nondissolving sutures were ranked third by 29 of 30 parents. Parents were willing to pay a median (25th to 75th percentile) of $40 ($25 to $100) for tissue adhesive and $25 ($10 to $56) for dissolving sutures if only nondissolving sutures provided by the health care system (p = 0.1).Tissue adhesive is the preferred method of closure of pediatric facial lacerations because it results in the most efficient use of resources and is preferred by the majority of parents.

View details for Web of Science ID A1995RC75400007

View details for PubMedID 7776090

Abstract

To develop an appearance scale that will allow the objective and scientific comparison of the cosmetic results of healed lacerations, 33 photographs of healed lacerations and incisions with variable cosmetic results were shown to four plastic surgeons. These plastic surgeons were asked to independently rate the photographs on two separate occasions using two scales, a Visual Analogue Scale and a Categorical Scale. Interobserver and intraobserver agreement were determined for each scale. Comparison of the scales with each other was done to assess consistency. The Visual Analogue Scale showed good interobserver agreement with an Intraclass Correlation Coefficient of 0.75. Intraobserver agreement was also high across the four observers with Pearson correlation coefficients ranging from 0.73 to 0.87. The agreement of the categorical scale was also good with a kappa coefficient for interobserver agreement of 0.53. The kappa coefficient for intraobserver agreement ranged from 0.48 to 0.72. Because the visual analogue scale and categorical scale showed good interobserver and intraobserver agreement, both may be considered good measurement tools in the comparison of alternate methods of laceration care.

View details for Web of Science ID A1995QQ14700025

View details for PubMedID 7893315

View details for Web of Science ID A1994PJ75900013

View details for PubMedID 7922924

Abstract

The authors report the case of a 57-year-old man with a history of ischemic heart disease who presented to the emergency department with an acute myocardial infarction and hypotension. Despite aggressive pharmacotherapy, the patient's heart rate decreased, and he developed pulseless electrical activity within 15 minutes of his arrival. Cardiopulmonary resuscitation (CPR) was begun with an active compression-decompression (ACD) device, and the patient became agitated, making purposeful movements. When ACD-CPR was discontinued for a rhythm check, the patient had no pulse and became motionless. Agitation and purposeful movements occurred on two subsequent occasions with the initiation of ACD-CPR. The patient required physical restraints, sedation, and paralysis for personnel to perform endotracheal intubation and facilitate treatment. The implications of this case are discussed.

View details for PubMedID 7614304

Abstract

The purpose of this experimental study was to compare the effect of a tissue adhesive, N-butyl-2-cyanoacrylate, on the wound's ability to resist infection and gain strength to the effect of percutaneous polypropylene suture. Percutaneous sutures damaged host defenses, inviting the growth of bacteria to a level that was significantly greater than that encountered with the tissue adhesive. Immediately after wound closure, percutaneous sutures provided a more secure closure, as measured by breaking strength, than did tissue adhesives. Seven days later, the breaking strengths of wounds closed by tissue adhesives did not differ significantly from those repaired with percutaneous sutures. Tissue adhesive closure requires less psychomotor skills than suture closure and is accomplished more rapidly than suture closure.

View details for PubMedID 7989692

Abstract

To compare the tissue adhesive Histoacryl Blue with suturing in the repair of pediatric facial lacerations.Prospective, randomized controlled trial.Emergency department of a pediatric teaching hospital.Eighty-one children presenting with clean facial lacerations less than 4 cm in length and 0.5 cm in width.Patients were allocated randomly to have their lacerations repaired with sutures or Histoacryl Blue.The two groups were similar for demographic and clinical characteristics. Photographs taken at three months were rated by two plastic surgeons blinded to the method of closure. There was no difference between groups for appearance scores on a visual analog scale (60.5 mm for Histoacryl Blue versus 57.2 mm for suture, P = .45) or on a categorical scale (Histoacryl Blue versus sutures: unacceptable, 11% versus 13%; acceptable, 59% versus 71%; excellent, 30% versus 16%; P = .76). Measures of observer agreement produced Pearson correlations of .72 and .94 on the visual analog scale and kappa coefficients of .46 and .73 on the categorical scale. Histoacryl Blue was assessed as less painful on a visual analog scale (24.7 versus 43.7 mm, P < .01) and faster (7.9 versus 15.6 minutes, P < .001).Histoacryl Blue is a faster and less painful method of facial laceration repair that has cosmetic results similar to the use of sutures.

View details for Web of Science ID A1993LK28100004

View details for PubMedID 8517562