PrairiEDocs
e-newsletter #16
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Surveying
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Issue #16
"fasten your seat belt and adjust your headrest as this
electronic ed-venture continues" January 19, 2001
In
this issue:
Modify
Placement of Paddles/Pads for Defibrillation?
Trauma
Transfers; Directly to Level I Trauma Centers Versus to Rural
Hospitals and Then on to Level I Centers
Antizol
(Fomepizole) Now Approved for Treatment Of Ethylene Glycol and
Methanol Poisonings
Good
News for Travelers: New Option for Malaria Prevention and Treatment
Worker Dead
at Desk for Five days
100 Years Ago
Cool Web Sites
Quotable Quotes
ERDOCS
listserv
How
to get in Touch With Us
Modify
Placement of Paddles/Pads for Defibrillation?
Placement of Electrodes for Defibrillation--a Review of the Evidence
Moulton C, Dreyer C, Dodds D, Yates DW, Emergency Medicine, University
of Manchester, Bolton Institute, UK. Eur J Emerg Med 2000 Jun;
7(2):135-43
Defibrillation is the only reliable treatment for ventricular
fibrillation. Its success depends on the passage of an adequate
current through the chest rather than on the administration of
a preset energy. The final determinant of both efficacy and cellular
damage is myocardial current density. Therefore, the current should
be evenly distributed with an average value that exceeds the defibrillation
threshold throughout a critical mass of myocardium but does not
cause further local dysfunction. The distribution of current is
altered by the relative positions of the two electrodes. European
guidelines for electrode (paddle) placement during defibrillation
are based on empirical studies and traditional practice. However,
there is increasing evidence to suggest that bi-axillary electrode
placement may be superior to traditional antero-apical and antero-posterior
positions.
Trauma
Transfers; Directly to Level I Trauma Centers Versus to Rural
Hospitals and Then on to Level I Centers
Study of the Outcome of Patients Transferred to a Level I Hospital
after Stabilization at an Outlying Hospital in a Rural Setting
Rodgers FB, Osler, TM, Shackford, SR, et al. Journal of Trauma
1999; 46(3):328-333.
Introduction
The aim of this article was to define the characteristics and
outcomes of trauma patients in a rural setting who are transferred
from an outlying hospital to a Level I trauma center. The authors
hypothesized that given the delay in receiving definitive care,
these patients would have a worse outcome than those admitted
directly to the trauma center.
Materials and Methods
This was a case-control study of all trauma patients admitted
to a Level I trauma center in rural Vermont between January 1993
and July 1996. Data describing patient characteristics and outcome
was collected for a total of 2674 patients; 1061 were transfer
patients (39.4%) and 1608 patients were admitted to the trauma
center directly from the scene of injury (60.6%).
Results
There were some differences in the characteristics of the two
patient groups. Compared to the direct admit group, the transfer
group included more men (65% vs 53%) and consisted of younger
patients (mean age of 35 years vs 44 years). In both groups, 95.5%
of injuries were blunt injuries. On average, the transfer patients
spent 182 ± 138 min during initial stabilization at the outlying
hospital and 72 ± 42 min in transport.
The finding of particular note was that the transfer group had
a significantly longer stay in the intensive care unit (ICU) (5.9
days vs 3.8 days, p=0.001) and total hospital course (9.0 days
vs 6.0 days, p=0.001). The Abbreviated Injury Scale (AIS) scores
revealed that the transfer group had significantly more head and
neck injuries and the direct admit group had more extremity injuries.
Moreover, the trauma scores for the transfer group reflected more
serious injury and more "deranged" physiology than the
direct admits. Overall, transfer patients had higher scores on
the Injury Severity Score (ISS) and the Acute Physiology and Chronic
Health Evaluation, and lower values on the Revised Trauma Score
(RTS). They also had a lower probability of survival Ps). Despite
differences in injury severity, the LD50ISS (the ISS at which
50% mortality occurred) was 35 for both groups.
Multiple analyses failed to show a correlation between transferring
patients to the trauma center and death. Using binary logic regression,
age and ISS were found to be highly significant predictors of
death (p=0.0001) but transfer was not (p=0.47). Even in a subset
of 72 more severely injured patients (PS=0.00-0.9,), age and RTS
were significant predictors of death but transfer was not (p=0.72).
There was no significant difference between the two groups in
time to death from admission.
Conclusions
The authors comment that guidelines for regional trauma centers
were derived from the urban setting, where smaller Level II and
III hospitals may be bypassed for severely injured patients. This
is not applicable in the rural setting, where the site of injury
can be at a great distance from the Level I center.
This study showed no significant differences in mortality between
the transferred patients and the direct admits. This occurred
despite the average interval from injury to arrival at the Level
1 site being 4 hours, with the "golden hour" spent outside
the point of definitive care. The authors suggest that the rural
hospital system, with highly skilled physicians and phone support
from the Level 1 center, is a major factor in patient survival.
Another factor may be that more rural trauma patients die at the
scene of injury, and those who survive the initial accident are
able to withstand delays in definitive care. This results in transfer
patients and direct admits having an equal probability of survival.
These results confirmed the findings of other studies that used
trauma and injury severity scores to predict mortality in rural
trauma patients. Kearney et al. studied patients in Michigan after
initial stabilization at a rural hospital and arrival at a Level
I facility 4 or more hours post-injury. Their predicted survival
for the group was not statistically different from the observed
survival. Veenema and Rodewald also investigated severely injured
trauma patients (trauma score £ 11) who were initially stabilized
in Level III hospitals and eventually transported to a Level 1
center. Again, the predicted number of deaths was not statistically
different than the actual number of deaths.
The authors also commented on two articles critical of rural hospital
trauma management. Martin et al. studied adherence to the Advanced
Trauma Life Support (ATLS) transfer guidelines for 78 rural trauma
patients and noted that errors occurred in 80% of cases. The most
common omission was that in 72% of patients, there was no nasogastric
tube placed prior to transport. However, patient outcome was not
affected by the deficiencies in care. Cone identified three areas
lacking in rural centers: immediate access to surgical subspecialist
and blood bank support, and critical care services (equipment,
nursing, and house staff).
Other results of note from this study include the finding that
out of 143 total deaths, 103 (72%) occurred at the scene. To have
the greatest impact on mortality and outcome, prehospital care
requires greater resource allocation. Helicopter transport was
utilized in only 5.7% of the cases and a multi- disciplinary review
committee found that only 1 of these 55 patients benefited from
air transport. Overtriage, defined as transfer of patients with
an ISS < 9, occurred 37% of the time. The decision by the rural
physician to transfer a patient with major traumatic injury patient
is reasonable, given the limited time and resources available
to him or her. Review authored by Brad Elias, MD, edited by Susan
Kushman, MD
Antizol
(Fomepizole) Now Approved for Treatment of Ethylene Glycol
and Methanol Poisonings
In December 2000, the Food and Drug Administration gave clearance
tomarket Antizol (fomepizole) Injection (Orphan Medical, Inc.)
for the treatment of methanol poisoning, or for use in suspected
methanol ingestion, either alone or in combination with hemodialysis.
This is the second indication granted by the FDA for Antizol and
follows a 1997 approval for the treatment of confirmed or suspected
ethylene glycol poisoning.
Methanol is a common toxic chemical found in many household substances
such as windshield wiper fluid and cleaning solutions. Methanol
poisoning may cause blindness or death. According to the 2000
Annual Report of the American Association of Poison Control Centers
Toxic Exposure Surveillance System, over 1,000 patients in the
United States were treated for methanol poisoning in 1999.
Fomepizole was first approved as an antidote for suspected or
confirmed cases of ethylene glycol poisoning in December of 1997.
Ethylene glycol is the primary ingredient in antifreeze and other
coolants. Ethylene glycol poisoning is characterized by central
nervous system depression, metabolic acidosis, acute renal system
failure, seizures, and severe cardiopulmonary dysfunction. Left
untreated, it will result in kidney failure. Fomepizole both prevents
and reverses accumulation of acids in the body and renal failure
by stopping the accumulation of toxic waste products. Ethylene
glycol poisoning accounted for more than 6,000 exposures and at
least 27 deaths in the US in 1998.
Hemodialysis and ethanol were previous benchmark methods of clinical
treatment in confirmed ethylene glycol poisoning cases, but the
availability of fomepizole has fundamentally changed this. It
can be administered in suspected or confirmed cases.
The most frequent adverse reactions to fomepizole are headache
(14 percent), nausea (11 percent), dizziness, increased drowsiness,
and bad taste/metallic taste (6 percent each).
Good
News for Travelers: New Option for Malaria Prevention and Treatment
With the onset of generally warmer weather globally and increasing
reports of outbreaks of malaria throughout the world recently,
US clinicians now have another choice in prescribing prevention
and treatment for travelers abroad. The CDC now includes Malarone
(atovaquone and proguanil hydrochloride) as another option for
the prevention and treatment of malaria. The drug was approved
by the Food and Drug Administration in July 2000, and available
since mid-August 2000.
The CDC now recommends Malarone as one of three options for the
prevention of Plasmodium falciparum malaria, including those infections
acquired in areas with chloroquine-resistant strains. The CDC
also recommends Malarone as an option for the treatment of uncomplicated
P falciparum malaria including malaria that has been acquired
in areas with chloroquine-resistant or multidrug-resistant strains.
Malarone is a fixed-dose combination of two antimalarial agents,
atovaquone and proguanil. Atovaquone was developed as an antimalarial
agent in the 1980s. In clinical trials at the time, atovaquone
was effective when used alone, but a recurrence of malaria was
eventually seen in some patients. In further clinical trials conducted
in the 1990s, it was shown that, when combined with proguanil,
a cure rate of over 98 percent could be achieved. Malarone is
now
approved for use in more than 35 countries around the world.
Clinical trials leading to U.S. approval of Malarone for prevention
of malaria caused by P falciparum involved more than 400 adults
and children (5 years and older). These studies showed that Malarone
was 98 percent effective in preventing malaria. The most common
attributable adverse events in both adults and children taking
Malarone for prevention of malaria included headache and abdominal
pain and occurred at rates comparable to placebo.
For adults using Malarone for malaria prevention, the recommended
dosage is one tablet daily, starting one or two days prior to
entering a malaria-endemic area, one tablet a day while in the
area and one tablet a day for only seven days after return. For
children who weigh less than 88 pounds, a lower-dose pediatric
tablet is available.
For adult patients with acute malaria, four tablets are administered
as a single dose once daily for three days. Pediatric dosages
for the treatment of malaria are adjusted by body weight. Malarone
is contraindicated in people with known hypersensitivity to atovaquone
or proguanil HCl or any component of the formulation. Patients
with severe malaria are not candidates for oral therapy, and Malarone
has not been evaluated for the treatment of severe malaria, including
cerebral malaria.
Malaria remains "one of the most serious and complex health
problems facing humanity in the 20th century," according
to the World Health Organization (WHO). The WHO estimates that
malaria strikes 300 million to 500 million people per year, resulting
in more than one million deaths, most of which are among children
under the age of five. In the U.S., more than 7 million people,
including business travelers, military personnel, airline employees,
vacationers and missionaries - travel each year to malaria-endemic
areas in sub-Saharan Africa, Southeast Asia, the Amazon area and
the islands of the South Pacific, and more than 1,000 cases of
acute malaria are reported annually in returning U.S. residents.
Worker
Dead at Desk for Five days
From the Birmingham Sunday Mercury on 7th January 2001:
Bosses of a publishing firm are trying to work out why no one
noticed that one of their employees had been sitting dead at his
desk for FIVE DAYS before anyone asked if he was feeling okay.
George Turklebaum, 51, who had been employed as a proof-reader
at a New York firm for 30 years, had a heart attack in the open-plan
office he shared with 23 other workers. He quietly passed away
on Monday, but nobody noticed until Saturday morning when an office
cleaner asked why he was still working during the weekend.
His boss Elliot Wachiaski said: "George was always the first
guy in each morning and the last to leave at night, so no one
found it unusual that he was in the same position all that time
and didn't say anything. He was always absorbed in his work and
kept much to himself."
A post-mortem examination revealed that he had been dead for five
days after suffering a coronary. Ironically, George was proof-reading
manuscripts of medical textbooks when he died.
100
Years Ago
The average life expectancy in the United States was forty-seven.
14 percent of the homes in the United States had a bathtub.
Only 8 percent of the homes had a telephone. A three minute
call from Denver to New York City cost eleven dollars.
There were only 8,000 cars in the US and 144 miles of paved roads.
The maximum speed limit in most cities was ten mph.
Alabama, Mississippi, Iowa, and Tennessee were each more heavily
populated than California. With a mere 1.4 million residents,
California was only the twenty-first most populous state in the
Union.
The average wage in the U.S. was twenty-two cents an hour.
The average U.S. worker made between $200 and $400 per year. More
than 95 percent of all births in the U.S. took place at home.
Sugar cost four cents a pound. Eggs were fourteen cents
a dozen.
Most women only washed their hair once a month and used borax
or egg yolks for shampoo.
The five leading causes of death in the U.S. were:
1. Pneumonia and influenza 2. Tuberculosis
3. Diarrhea 4. Heart disease
5. Stroke
The American flag had 45 stars. Arizona, Oklahoma, New Mexico,
Hawaii and Alaska hadn't been admitted to the Union yet.
Drive-by-shootings -- in which teenage boys galloped down the
street on horses and started randomly shooting at houses, carriages,
or anything else that caught their fancy -- were an ongoing problem
in Denver and other cities in the West.
Plutonium, insulin, scotch tape, crossword puzzles, canned beer,
iced tea and antibiotics hadn't been discovered yet.
There was no Mother's Day or Father's Day.
One in ten U.S. adults couldn't read or write. Only 6 percent
had graduated from high school.
Marijuana, heroin, and morphine were all available over the counter
at corner drugstores. According to one pharmacist, "Heroin
clears the complexion, gives buoyancy to the mind, regulates the
stomach and the bowels, and is, in fact, a perfect guardian of
health."
Cool
Web Sites
The Virtual ER
http://www.virtualer.com/
A nice site that includes a section with a primer on using the
internet for those that are uncomfortable or inexperienced with
it. A variety of medical resources and tutorials, make this a
good addition to bookmarked sites of medical information.
Out of This World
http://liftoff.msfc.nasa.gov/temp/StationLoc.html
Where is the International Space Station? Is it above your head
or above Mongolia? Perhaps it's that bright light at sunset, or
is that Venus? This site takes the guesswork out of locating some
of the larger man-made objects in space. You can locate the space
station, Mir, or Hubble, and many other bits and pieces of space
technology. Three-dimensional images help you track these objects
as they orbit Earth. Download the special NASA software, or follow
the links to other tracking sites. Whether you're an avid sky
watcher or a paranoid, space-junk freak, this site will keep you
abreast of the opportunities or the danger.
Quotable
Quotes
"And
God said: 'Let there be Satan, so people don't
blame everything
on me. And let there be lawyers, so people don't blame everything
on Satan."---George Burns
"What are the three words guaranteed to humiliate men everywhere?
'Hold my purse.' "----Sandra Bullock
"Luge strategy? Lie flat and try not to die." ----Carmen
Boyle (Olympic Luge Gold Medal winner -1996)
"Women might be able to fake orgasms. But men can fake whole
relationships."----Sharon Stone
"I saw a woman wearing a sweatshirt with 'Guess' on it. I
said, 'Thyroid problem?' " ---- Arnold Schwarzenegger
"You have to stay in shape. My grandmother started walking
5 miles a day when she was 60. She's 97 today, and we don't know
where the hell she is." ---- Ellen DeGeneres
ERDOCS
e-mail group (listserv)
As a Clinician
providing acute and emergency medical care, you are invited to
visit and participate in our new ERDOCS group at eGroups, a free,
easy-to-use email group service! You have plenty of experiences
to share, questions to ask, concerns and opinions to voice, suggestions,
news to post, tips to offer, etc.and can do so within this framework.
this is a versatile system for posting things to be sent to a
group to peruse, respond to, or simply be aware of. It eliminates
conventional mail delays and allows you to review and post at
your leisure. (We still have the more open-ended [any visitor
can observe/post] discussion group at the ACUTE CARE, INC. web
site). Our goal is to give you a variety of feedback and communication
tools.
The manager/moderator for this ERDOCS egroup is the webmaster
for the ACUTE CARE, INC. website (www.acutecare.com),
Paul Hudson. You can subscribe by sending an e-mail indicating
your wish to be included to Paul at paul@acutecare.com
As this site grows, it will feature news, calendars, links to
references, resources, and other useful features. We hope you
will support this effort to foster ongoing communication amongst
EM providers.
This
e-newsletter is available through the generous unrestricted
support of
ACUTE CARE,
INC. You can find out more about ACUTE
CARE, INC.
by going online to http://www.acutecare.com
Archived copies of this newsletter are
available at that site.
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