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Trauma patients frequently have blood drawn for type and crossmatch. The majority of these units are held for 48 hours and never used for that patient. We conducted a retrospective review and followed with a prospective protocol, attempting to identify a variable that would predict the need for blood transfusion, thus decreasing cost and blood waste. In the 180 patients studied retrospectively, we found that 61% of patients with prehospital hypotension (BP < 100 mm Hg) required transfusion, whereas only 11% of patients without prehospital hypotension required transfusion (P < .0001). We prospectively evaluated prehospital hypotension as a predicator of blood usage in 136 patients. Patients with prehospital systolic blood pressure > or = 100 mm Hg had only a type and screen ordered unless clinical judgment dictated otherwise. Of the 136 patients, 109 had no history of prehospital hypotension, and 81 of these were managed with a type and screen. Only 8 patients without prehospital hypotension received a transfusion, 6 because of operative procedures. No patient received uncrossmatched blood, and there were no complications. Implementation of this protocol decreased our units crossmatched for each unit transfused from 3.8 to 2.8. Prehospital blood pressure is a useful adjunct to clinical judgement in identifying major trauma patients who can be initially managed safely without crossmatching.

Respiratory rates are routinely measured in pediatric emergency patients. The normal range has not been established, and commonly reported ranges seem lower than those encountered in clinical practice. This prospective study selected subjects from pediatric patients presenting for care to a suburban emergency department. All respiratory rates were measured for one full minute. Patients with complaints related to the cardiopulmonary system or with an elevated temperature were excluded. A total of 434 patients were entered into the study over a 3-month period of time. Ages ranged from 2 weeks to 18 years. Respiratory rates ranged from a high of 65 breaths/min in a 4-month-old to a low of 12 breaths/min in a 14-year-old. Respiratory rate was inversely related to age, and there was a broad range in every age group. Our study shows that a normal respiratory rate is inversely related to age and is higher than noted in previously published studies. The wide range of "normal" pediatric respiratory rates makes identification of "abnormal" more difficult.

The airway management of 176 consecutive traumatized patients aeromedically transported from the scene of injury was reviewed. In particular, the frequency of performance and time requirements for both blind nasotracheal intubation and cricothyrotomy were analyzed. Airway control was attempted in 70 (39.5%) patients and successful in 67 (95.7%). The average scene Glasgow Coma Scale (GCS) score of these 70 patients was 7.16 (SD = 3.94) and ranged from 3 to 15. For the remaining 106 patients the average GCS was 14.3 (SD = 1.36) and ranged from 6 to 15 (P less than .0005). The scene trauma score (TS) of the two groups was 10.2 (SD = 3.11) and 15.2 (SD = 1.38), respectively (P less than .0005). In the field, blind nasotracheal intubation by an emergency physician (n = 59) or paramedic (n = 3) was successful in 62 of 65 cases (95.1%). The complication rate for this procedure was 4.6%. Cricothyrotomy was performed in two patients. Only three orotracheal intubations were performed. The remaining three patients were nasotracheally intubated in the emergency department. Neuromuscular blockade was not used in either setting. Despite the difference in patient acuity, there was no statistically significant difference in scene or transport times between those patients emergently intubated and those who were not (P greater than .05).

Two cases of acute dystonic reactions associated with diazepam ingestion are reported. This report is a brief review of drug-induced extra-pyramidal syndromes, and a mechanism for diazepam-induced dystonic reactions is proposed. Intravenous diphenhydramine was successful in treating both patients.

The respiratory rate is a sensitive and nonspecific indicator of respiratory dysfunction. Establishing a "normal" respiratory rate has mainly been arbitrary. This study evaluated "normal" respiratory rates in 110 emergency department patients. The mean respiratory rate was 20.1 (+/- 4.0). Women had a more rapid respiratory rate 20.9 (+/- 3.9) than men 19.4 (+/- 4.0) (p less than .04). Smokers had a higher respiratory rate 20.5 (+/- 4.0) than nonsmokers 19.3 (+/- 4.0), but this was not statistically significant (P = 0.124). It was also noted that the respiratory rate measured by the nurse was almost always different from that measured by the medical student (P less than 0.0001). Based on a review of the literature concerning what constitutes a "normal" respiratory rate, we conclude that the "normal" respiratory rate may be higher than that suggested in the medical literature.