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Study objective: To develop clinical rules for the safe and effective use of flumazenil in suspected benzodiazepine overdose. Methods: We assembled a retrospective series of 35 consecutive comatose patients admitted between October 1992 and July 1993 to a toxicologic ICU with the presumptive diagnosis of drug overdose. These patients were divided into two groups. Group A (low-risk) patients had a clinical picture compatible with uncomplicated benzodiazepine intoxication (calm, without abnormalities in pulse or blood pressure, lateralizing signs, hypertonia, hyperreflexia, or myoclonus) in the absence of predefined electrocardiographic or clinical signs of tricyclic antidepressant or other proconvulsant overdose, and absence of an available history of long-term benzodiazepine treatment or an underlying seizure disorder. Group B (''non-low risk'') comprised all other patients. Efficacy of flumazenil was categorized as complete awakening (with normal level of alertness), partial awakening, or no change in alertness level. The safety of flumazenil was defined on the basis of the absence of seizures or death. Results: In group A (n=4), flumazenil was associated with complete awakening in three patients and partial awakening in one. No seizures were observed. In group B (n=31), flumazenil was associated with complete awakening in 4 patients, partial awakening in 5, and no response in 22. In group B, five seizures occurred. Conclusion: Comatose patients with clinical or ECG criteria thought to contraindicate the use of flumazenil have a reasonably high risk of seizures after administration of this drug. Low-risk patients may be able to receive flumazenil safely, but they may be only a small portion of comatose patients with suspected overdose. [Gueye PN, Hoffman JR, Taboulet P, Vicaut E, Baud FJ: Empiric use of flumazenil in comatose patients: Limited applicability of criteria to define low risk. Ann Emerg Med June 1996;27:730-735.]

Study objective: To determine the effect of cardiology review of ECGs on emergency department practice. Methods: We carried out a prospective cohort study at an urban teaching ED. Our subjects were adult patients undergoing electrocardiography. We prospectively collected 1,000 consecutive ECGs and classified them by severity according to the following system: class 1, normal or minor abnormalities only; class 2, abnormalities with potential to alter case management; and class 3, potentially life-threatening abnormalities. Actual ECG readings by ED physicians (who had access to computerized interpretations at the time of treatment) were compared with those of staff cardiology quality-assurance reviewers; if they were not in agreement, an expert cardiology panel blindly chose the superior interpretation. Subsequently, an expert emergency physician panel reviewed discordant readings for discharged patients to determine the need for further action. Results: Of 1,000 ECGs, the readings for 190 (19%) were significantly discordant. The expert cardiology panel preferred the ED reading in 72 cases (38%) and the staff cardiology reading in 118 (62%). In 30 other cases no ED reading was recorded in the medical record. Of the 148 cases in which the expert cardiology panel agreed with the cardiology reading or there was no ED reading, 102 patients were admitted and 46 discharged. Of the 46 discharges, 8 cardiology readings were categorized as class 1, leaving only 38 cases in which the staff cardiology reading might have affected the ED decision to discharge a patient. All of these readings were in class 2, with the exception of one unclassifiable diagnosis. There were no class 3 readings. On expert emergency physician panel review of these 38 ECGs and interpretations, only 8 (.8%, 95% confidence interval, .3% to 1.6%) were considered sufficiently important to warrant chart review. In actual practice, none of these cases was affected by the ECG quality-assurance (QA) process. Two of these patients died during our 1-year follow-up. In one of these cases, the ECG QA process could have altered the patient's outcome. Conclusion: The existing ECG review process as mandated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will likely have minimal influence on patient outcomes at our institution. We should establish the effectiveness of this mandated QA process before committing scarce resources to its performance. [Todd KH, Hoffman JR, Morgan MT: Effect of cardiologist ECG review on emergency department practice. Ann Emerg Med January 1996;27:16-21.]

Study objective: Patient involvement in medical decisionmaking is accepted as an ethical and a legal imperative. Medical decisions are based in part on individuals' knowledge and acceptance of risk of adverse consequences. It is unclear whether actions taken to protect against low risk of poor outcome reflect patient or physician preferences. We sought to test the hypothesis that emergency department chest pain patients presented with a hypothetical situation involving a low risk of myocardial infarction are more willing than ED physicians to accept the risk associated with discharge from the hospital. Methods: We prospectively surveyed 89 ED patients with chest pain and a cohort of physicians in the ED who had been presented a hypothetical case in which the risk of AMI was quoted as 5% and the risk of death or disability if the patient was discharged was 1% and .2% if the patient was admitted. All the patients had presented to the ED with a chief complaint of chest pain; the 31 physicians, all residents, were approached at a teaching conference separate from their clinical duties. Results: Twenty-eight patients (31%), compared with 2 physicians (6%), chose discharge for the hypothetical patient with chest pain (25% difference; 95% confidence interval [CI], 6% to 41%). Forty-four patients (49%), compared with 30 physicians (97%), correctly identified the risks associated with admission and discharge (46% difference; 95% CI, 29% to 63%). Of the subjects who correctly identified the risks, 19 patients (43%) preferred discharge, compared with 1 physician (3%) (40% difference; 95% CI, 18% to 60%). Conclusion: ED patients with chest pain appear to be more likely than physicians to accept a small risk of poor outcome in a hypothetical circumstance. Many patients cannot identify the risks associated with their decision. [Davis MA, Keerbs A, Hoffman JR, Baraff LJ: Admission decisions in emergency department chest pain patients at low risk for myocardial infarction: Patient versus physician preferences. Ann Emerg Med December 1996;28:606-611.] See related editorial, Shared Decisionmaking: Easier Said Than Done

Study objective:To determine the interrater reliability of previously defined risk criteria for cervical spine injury. Methods: Two emergency physicians independently evaluated patients with blunt trauma to determine whether they exhibited any of four risk criteria: (1) altered neurologic function; (2) evidence of intoxication; (3) spinous process or posterior midline cervical tenderness; or (4) distracting painful injury. Each criterion was explicitly described on study data forms. Physician concordance was measured, and the @k statistic was calculated, for the combined risk criteria (based on the presence of any individual criterion), and for each individual criterion. Results: There were 122 patients evaluated. Physicians agreed on overall classifications for 107 patients (87.7%; @k, .73; confidence interval [CI], .61 to .86). Agreement for individual criteria were as follows: (1) altered neurologic function-102 patients (83.6%; @k, .58; CI, .41 to .74); (2) intoxication-118 patients (96.7%; @k, .86; CI, .72 to .99); (3) posterior midline tenderness-109 patients (89.3%; @k, .77; CI, .65 to .89); (4) distracting injury-112 patients (91.8%; @k, .77; CI, .64 to .91). Conclusion: The combined cervical spine injury criteria have substantial interrater reliability. Individual criteria are slightly less reliable. [Mahadevan S, Mower WR, Hoffman JR, Peeples N, Goldberg W, Sonner R: Interrater reliability of cervical spine injury criteria in patients with blunt trauma. Ann Emerg Med February 1998;31:197-201.]