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In 2018, the combination of glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase (UCH-L1) levels became the first US Food and Drug Administration-approved blood test to detect intracranial lesions after mild to moderate traumatic brain injury (MTBI). How this blood test compares with validated clinical decision rules remains unknown.To compare the performance of GFAP and UCH-L1 levels vs 3 validated clinical decision rules for detecting traumatic intracranial lesions on computed tomography (CT) in patients with MTBI and to evaluate combining biomarkers with clinical decision rules.This prospective cohort study from a level I trauma center enrolled adults with suspected MTBI presenting within 4 hours of injury. The clinical decision rules included the Canadian CT Head Rule (CCHR), New Orleans Criteria (NOC), and National Emergency X-Radiography Utilization Study II (NEXUS II) criteria. Emergency physicians prospectively completed data forms for each clinical decision rule before the patients' CT scans. Blood samples for measuring GFAP and UCH-L1 levels were drawn, but laboratory personnel were blinded to clinical results. Of 2274 potential patients screened, 697 met eligibility criteria, 320 declined to participate, and 377 were enrolled. Data were collected from March 16, 2010, to March 5, 2014, and analyzed on August 11, 2021.The presence of acute traumatic intracranial lesions on head CT scan (positive CT finding).Among enrolled patients, 349 (93%) had a CT scan performed and were included in the analysis. The mean (SD) age was 40 (16) years; 230 patients (66%) were men, 314 (90%) had a Glasgow Coma Scale score of 15, and 23 (7%) had positive CT findings. For the CCHR, sensitivity was 100% (95% CI, 82%-100%), specificity was 33% (95% CI, 28%-39%), and negative predictive value (NPV) was 100% (95% CI, 96%-100%). For the NOC, sensitivity was 100% (95% CI, 82%-100%), specificity was 16% (95% CI, 12%-20%), and NPV was 100% (95% CI, 91%-100%). For NEXUS II, sensitivity was 83% (95% CI, 60%-94%), specificity was 52% (95% CI, 47%-58%), and NPV was 98% (95% CI, 94%-99%). For GFAP and UCH-L1 levels combined with cutoffs at 67 and 189 pg/mL, respectively, sensitivity was 100% (95% CI, 82%-100%), specificity was 25% (95% CI, 20%-30%), and NPV was 100%; with cutoffs at 30 and 327 pg/mL, respectively, sensitivity was 91% (95% CI, 70%-98%), specificity was 20% (95% CI, 16%-24%), and NPV was 97%. The area under the receiver operating characteristic curve (AUROC) for GFAP alone was 0.83; for GFAP plus NEXUS II, 0.83; for GFAP plus NOC, 0.85; and for GFAP plus CCHR, 0.88. The AUROC for UCH-L1 alone was 0.72; for UCH-L1 plus NEXUS II, 0.77; for UCH-L1 plus NOC, 0.77; and for UCH-L1 plus CCHR, 0.79. The GFAP biomarker alone (without UCH-L1) contributed the most improvement to the clinical decision rules.In this cohort study, the CCHR, the NOC, and GFAP plus UCH-L1 biomarkers had equally high sensitivities, and the CCHR had the highest specificity. However, using different cutoff values reduced both sensitivity and specificity of GFAP plus UCH-L1. Use of GFAP significantly improved the performance of the clinical decision rules, independently of UCH-L1. Together, the CCHR and GFAP had the highest diagnostic performance.

Exhaled end-tidal carbon dioxide (ETCO(2)) concentration is associated with lactate levels in febrile patients. We assessed the association of ETCO(2) with mortality and lactate levels in patients with suspected sepsis.This was a prospective observational study. We enrolled 201 adult patients presenting with suspected infection and 2 or more systemic inflammatory response syndrome criteria. Lactate and ETCO(2) were measured and analyzed with patient outcomes.The area under the receiver operator characteristics curve (AUC) was 0.75 (confidence interval [CI], 0.65-0.86) for lactate and mortality and 0.73 (CI, 0.61-0.84) for ETCO(2) and mortality. When analyzed across the different categories of sepsis, the AUCs for lactate and mortality were 0.61 (CI, 0.36-0.87) for sepsis, 0.69 (CI, 0.48-0.89) for severe sepsis, and 0.74 (CI, 0.55-0.93) for septic shock. The AUCs for ETCO(2) and mortality were 0.60 (CI, 0.37-0.83) for sepsis, 0.67 (CI, 0.46-0.88) for severe sepsis, and 0.78 (CI, 0.59-0.96) for septic shock. There was a significant inverse relationship between ETCO(2) and lactate in all categories, with correlation coefficients of -0.421 (P.001) in the sepsis group, -0.597 (P.001) in the severe sepsis group, and -0.482 (P = .011), respectively. Adjusted odds ratios were calculated, demonstrating 3 significant predictors of mortality: use of vasopressors 16.4 (95% CI, 1.80-149.2), mechanical ventilation 16.4 (95% CI, 3.13-85.9), and abnormal ETCO(2) levels 6.48 (95% CI, 1.06-39.54).We observed a significant association between ETCO(2) concentration and in-hospital mortality in emergency department patients with suspected sepsis across a range of disease severity.

Prior to 2001 there was no standard for early management of severe sepsis and septic shock in the emergency department. In the presence of standard or usual care, the prevailing mortality was over 40-50 %. In response, a systems-based approach, similar to that in acute myocardial infarction, stroke and trauma, called early goal-directed therapy was compared to standard care and this clinical trial resulted in a significant mortality reduction. Since the publication of that trial, similar outcome benefits have been reported in over 70 observational and randomized controlled studies comprising over 70,000 patients. As a result, early goal-directed therapy was largely incorporated into the first 6 hours of sepsis management (resuscitation bundle) adopted by the Surviving Sepsis Campaign and disseminated internationally as the standard of care for early sepsis management. Recently a trio of trials (ProCESS, ARISE, and ProMISe), while reporting an all-time low sepsis mortality, question the continued need for all of the elements of early goal-directed therapy or the need for protocolized care for patients with severe and septic shock. A review of the early hemodynamic pathogenesis, historical development, and definition of early goal-directed therapy, comparing trial conduction methodology and the changing landscape of sepsis mortality, are essential for an appropriate interpretation of these trials and their conclusions.

OBJECTIVE The reliability of infrared tympanic thermometry (ITT) in children and the effect of acute otitis media (AOM) on ITT are unsettled. This study assessed the effect of AOM on ITT and the utility of ITT in the diagnosis of AOM. METHODS 520 consecutive children, aged 6 months to 6 years, presenting to the ED of an urban teaching hospital were eligible for this prospective observational study. Nurses recorded oral or rectal reference temperatures (RefTs) and bilateral ITT temperatures upon presentation. Emergency physicians were blinded to the ITT temperatures. AOM was diagnosed according to published clinical criteria. RESULTS Among 520 patients, 108 had unilateral AOM and 78 had bilateral AOM. In patients with unilateral AOM, the infected ears were warmer (I = 100.4 +/- 1.8 degrees F) than the uninfected ears (U = 100.3 +/- 1.8 degrees F, p = 0.035). However, the disparity in TM temperatures in infected and uninfected ears with unilateral AOM (I - U = 0.2 +/- 0.9 degrees F) was similar to the difference between right and left ears in those without AOM (R - L = 0.1 +/- 0.8 degrees F, p = 0.60). Compared with patients without AOM, patients with AOM demonstrated no significant elevation of ITT temperatures over RefTs (I - RefT = -0.8 +/- 1.2 degrees F in AOM; ITT - RefT = -0.8 +/- 1.2 degrees F in non-AOM; p = 0.94). This study had >99% power to detect a 1.0 degrees F difference for all groups compared. CONCLUSIONS Infrared tympanic temperature are not helpful in diagnosing AOM in children. AOM has little direct effect on ITT temperatures.

Small, preliminary studies have suggested that capnograms of obstructive lung disease (OD) exhibit a characteristic shape and that this shape may be correlated to changes in forced expiratory volume in 1 s (FEV(1)). We evaluated the association between capnograms and spirometry from subjects with OD with normal and restrictive lung disease (RD) subjects. The study was conducted in a prospective, nonrandomized manner using a convenience sample of 262 subjects presenting to a pulmonary function laboratory. Capnograms were recorded before pulmonary function testing. Subjects with OD had capnograms that were significantly different from normal and RD subjects. These differences were progressive, increasing with disease severity. The average take-off angle of the ascending phase for severe OD was 7.2 degrees less (95% confidence interval [CI]: 4.0, 10.4) than for normals. The average alveolar plateau elevation angle was 0.8 degrees more (95% CI: 0.14, 1.4) for moderate OD than for normals, whereas the average elevation angle was 3.6 degrees more (95% CI: 2.9, 4.3) for severe OD than for normals. Differences between OD capnograms and normal and RD capnograms, correlating to changes in FEV(1), were sufficiently large enough to suggest that the capnogram could be used to discriminate between OD and normal.

Critical care medicine trainees and faculty must acquire and maintain the skills necessary to provide state-of-the art clinical care to critically ill patients, to improve patient outcomes, optimize intensive care unit utilization, and continue to advance the theory and practice of critical care medicine. This should be accomplished in an environment dedicated to compassionate and ethical care.A multidisciplinary panel of professionals with expertise in critical care education and the practice of critical care medicine under the direction of the American College of Critical Care Medicine.Physician education in critical care medicine in the United States should encompass all disciplines that provide care in the intensive care unit and all levels of training: from medical students through all levels of postgraduate training and continuing medical education for all providers of clinical critical care. The scope of this guideline includes physician education in the United States from residency through ongoing practice after subspecialization.Relevant literature was accessed via a systematic Medline search as well as by requesting references from all panel members. Subsequently, the bibliographies of obtained literature were reviewed for additional references. In addition, a search of organization-based published material was conducted via the Internet. This included but was not limited to material published by the American College of Critical Care Medicine, Accreditation Council for Graduate Medical Education, Accreditation Council for Continuing Medical Education, and other primary and specialty organizations. Collaboratively and iteratively, the task force met, by conference call and in person, to construct the tenets and ultimately the substance of this guideline.Guidelines for the continuum of education in critical care medicine from residency through specialty training and ongoing throughout practice will facilitate standardization of physician education in critical care medicine.

Drowning is defined as death by suffocation after submersion in a liquid medium. Near drowning is a term used when a patient recovers, at least temporarily, from the drowning episode. Most authors include loss of consciousness while submerged to complete the criteria of near drowning. In its Guidelines 2000 Conference, the American Heart Association urged that the term near drowning no longer be used and that it be replaced by the term submersion injury.

Acute coronary syndrome (ACS) refers to the spectrum of cardiac disease, from unstable angina to ST-segment-elevation myocardial infarction. In the emergency medical services (EMS) setting, ACS may be more broadly thought to include patients with chest pain or other symptoms believed to have a cardiac origin who have evidence of ischemia or acute myocardial infarction on a 12-lead electrocardiogram, or symptomatic patients with a previous cardiac event or known cardiac disease. Pharmacologic management of these patients is based on the use of three primary classes of drugs: those that affect clotting, those that establish and maintain hemodynamic control, and those that relieve pain. Many of these agents have been evaluated in large clinical trials for in-hospital use, and a number of ongoing studies are assessing their efficacy in the prehospital setting. The appropriateness of prehospital use of specific agents within each class depends on proper patient selection, the necessity of immediate intervention, ease of use in the field, expertise of EMS personnel, and cost-effectiveness of therapy. This consensus group reviewed agents from all three classes (including aspirin, GPIIb/IIIa inhibitors, unfractionated and low-molecular-weight heparins, fibrinolytics, beta-adrenergic blockers, calcium antagonists, nitrates, and morphine) for their overall indication, applicability to the prehospital setting, and current prehospital use.

Objective. To determine whether oral antibiotics prevent meningitis and serious bacterial infections in children with Streptococcus pneumoniae occult bacteremia. Data Sources. Using the Medline database, the English-language literature was searched for all publications concerning bacteremia, fever, or S pneumoniae from 1966 to April 1996. Study Selection. All studies that included a series of children with S pneumoniae occult bacteremia containing orally treated and untreated groups. Children were excluded from individual studies if they were immunocompromised, had a serious bacterial infection, underwent a lumbar puncture, or received parenteral antibiotics. Data Extraction. Three authors independently reviewed each article to determine the number of eligible children and the outcome of children meeting entry criteria. Data Synthesis. Eleven of 21 studies were excluded, leaving 10 evaluable studies with 656 total cases of S pneumoniae occult bacteremia identified. Patients who received oral antibiotics had fewer serious bacterial infections than untreated patients (3.3% vs 9.7%; pooled odds ratio, 0.35; 95% confidence interval, 0.17 to 0.73). Meningitis developed in 3 (0.8%) of 399 children in the oral antibiotic group and 7 (2.7%) of 257 untreated children (pooled odds ratio, 0.51; 95% confidence interval, 0.12 to 2.09). Conclusion. Although oral antibiotics modestly decreased the risk of serious bacterial infections in children with S pneumoniae occult bacteremia, there was insufficient evidence to conclude that oral antibiotics prevent meningitis. Published recommendations that oral antibiotics be administered to prevent serious bacterial infections in children with possible S pneumoniae occult bacteremia should be reevaluated in light of the lower risk of sequelae from S pneumoniae occult bacteremia and newer data concerning side effects from treatment.

Knowledge of the rate of ethanol elimination is essential in the assessment of the intoxicated patient. Surprisingly little literature is available regarding ethanol elimination rates in emergency department (ED) patients; prior studies almost exclusively examined populations of alcoholics or normal controls. Consequently, this prospective observational study was undertaken to assess the rate of ethanol elimination in an ED population. Twenty-four consecutive adult ED patients clinically suspected of intoxication who had serum ethanol determinations drawn were enrolled. Patients underwent serial ethanol determinations via breathalyzer (Intoxilyzer 1400, CMI Inc., Owensboro, KY). Linear regression analysis of the plot of decrease in ethanol level over time was performed to determine the rate of ethanol elimination. Initial ethanol levels in the 24 patients ranged from 58 to 447 mg/dL (mean, 249 +/- 109 [SD] mg/dL). Patients were observed for a minimum of 2 and a maximum of 9 observations (mean, 3.9 +/- 1.7), over a period of 0.5 to 12.1 hours (mean, 4.4 +/-3.5 h). Clinical features of intoxication were poorly correlated with ethanol level (r < .5). The rate of ethanol elimination in the ED population was 19.6 mg/dL/h (r = .83; 95% confidence interval [CI], 16.9 to 22.3 mg/dL/h). Subgroup analysis found differences that were statistically significant but small. Multiple regression analysis showed that time was the major variable useful in predicting changes in ethanol level (P < .001).(ABSTRACT TRUNCATED AT 250 WORDS)

See related editorial, "What's Hot and What's Not: The Gold Standard for Thermometry in Emergency Medicine." Study objective: Recently published clinical guidelines for the management of febrile children are based on studies that used rectal temperature data to stratify the risk of bacteremia and septic complications. Appropriate management decisions rely on accurate detection and categorization of fever. Accordingly, this study compared the newer infrared tympanic thermometry (ITT) to rectal thermometry in this regard. Design: Prospective observational study. Setting: Urban teaching hospital ED with annual census of 60,000. Participants: Consecutive children 6 months to 6 years old who had rectal temperatures measured. Interventions: Triage nurses recorded rectal temperatures and bilateral ITT temperatures. Temperatures were correlated by Pearson correlation coefficients and compared using paired t tests with significance set at P Results: Three hundred seventy patients were enrolled in the study. The mean age was 18.4±11.3 months; boys comprised 56% of patients. The mean temperatures were rectal, 101.0±2.0°F; right tympanic membrane, 100.4±1.9°F; and left tympanic membrane, 100.3±1.9°F. The tympanic membrane temperatures were significantly lower than rectal readings ( P r =.83 and .85, respectively). ITT was 76% sensitive and 92% specific in detecting fever of 100.4°F or more (positive predictive value, 0.92; negative predictive value, 0.76). In the detection of high fever, ITT was only 57% sensitive but 98% specific (positive predictive value, 0.90; negative predictive value, 0.90). Rectal and TM temperatures differed by at least 0.5°F in 70% of the patients, 1.0°F in 41%, 2.0°F in 12%, and 3.0°F in 3%. Conclusion: Despite the statistical correlation between ITT and rectal temperatures, the modalities may yield significantly different temperatures. The poor sensitivity of ITT in detecting fever and high fever may result in clinically important miscategorizations of individual patients. Current clinical management that is based on the presence and height of fever may be adversely affected if ITT is used. [Brennan DF, Falk JL, Rothrock SG, Kerr RB: Reliability of infrared tympanic thermometry in the detection of rectal fever in children. Ann Emerg Med January 1995;25:21-30.]

This study compared early serum levels of ubiquitin C-terminal hydrolase (UCH-L1) from patients with mild and moderate traumatic brain injury (TBI) with uninjured and injured controls and examined their association with traumatic intracranial lesions on computed tomography (CT) scan (CT positive) and the need for neurosurgical intervention (NSI).This prospective cohort study enrolled adult patients presenting to three tertiary care Level I trauma centers after blunt head trauma with loss of consciousness, amnesia, or disorientation and a Glasgow Coma Scale (GCS) score 9 to 15. Control groups included normal uninjured controls and nonhead injured trauma controls presenting to the emergency department with orthopedic injuries or motor vehicle crash without TBI. Blood samples were obtained in all trauma patients within 4 hours of injury and measured by enzyme-linked immunosorbent assay for UCH-L1 (ng/mL ± standard error of the mean).There were 295 patients enrolled, 96 TBI patients (86 with GCS score 13-15 and 10 with GCS score 9-12), and 199 controls (176 uninjured, 16 motor vehicle crash controls, and 7 orthopedic controls). The AUC for distinguishing TBI from uninjured controls was 0.87 (95% confidence interval [CI], 0.82-0.92) and for distinguishing those TBIs with GCS score 15 from controls was AUC 0.87 (95% CI, 0.81-0.93). Mean UCH-L1 levels in patients with CT negative versus CT positive were 0.620 (± 0.254) and 1.618 (± 0.474), respectively (p0.001), and the AUC was 0.73 (95% CI, 0.62-0.84). For patients without and with NSI, levels were 0.627 (0.218) versus 2.568 (0.854; p0.001), and the AUC was 0.85 (95% CI, 0.76-0.94).UCH-L1 is detectable in serum within an hour of injury and is associated with measures of injury severity including the GCS score, CT lesions, and NSI. Further study is required to validate these findings before clinical application.II, prognostic study.

Objectives:To investigate how minute ventilation affects the partial pressure of end-tidal CO2 and arterial and mixed venous pH, Pco2, Po2, and the concentration of bicarbonate during low blood-flow states. We tested the null hypothesis that acid-base conditions during low rates of blood flow are no

Study objective: A number of studies have shown that expired CO 2 concentration is closely related to cardiac output, but that cardiac output was not controlled as an independent variable. In addition, the partial pressure of end-tidal CO 2 (P ET CO 2 ) during extremely low cardioac output has not been reported. The objective of the present study was to measure P ET CO 2 during well-controlled, very low blood flow rates under conditions of constant minute ventilation. Design: Ten anesthetized, intubated, and mechanically ventilated swine (weight, 43 to 102 kg) were placed on two ventricular assist devices in order to control cardiac output. Minute ventilation was measured and kept constant. Ventricular assist device output (measured with an ultrasonic flow probe); P ET CO 2 ; and aortic, pulmonary artery, and central venous pressures were recorded continously. Interventions: After electrical induction of ventricular fibrillation, pump output was decreased in steps. Measurements and main results: Cardiac index ranged from 0 to 5,371 mL/min/m 2 ; 59% of P ET CO 2 measurements were made at cardiac indexes of less than 1,313 mL/min/m 2 (30 mL/min/kg). The relationship of P ET CO 2 levels to cardiac index was determined with linear regression analysis; P ET CO 2 correlated significantly with cardiac index ( P FT CO 2 =4.98+0.012 [cardiac index] ( r 2 =.82). Conclusion: Under conditions of constant minute ventilation, P ET CO 2 correlated closely with cardiac index over a large range of blood flow rates, including extremely low rates.

Study objective This study examines whether serum levels of glial fibrillary acidic protein breakdown products (GFAP-BDP) are elevated in patients with mild and moderate traumatic brain injury compared with controls and whether they are associated with traumatic intracranial lesions on computed tomography (CT) scan (positive CT result) and with having a neurosurgical intervention. Methods This prospective cohort study enrolled adult patients presenting to 3 Level I trauma centers after blunt head trauma with loss of consciousness, amnesia, or disorientation and a Glasgow Coma Scale (GCS) score of 9 to 15. Control groups included normal uninjured controls and trauma controls presenting to the emergency department with orthopedic injuries or a motor vehicle crash without traumatic brain injury. Blood samples were obtained in all patients within 4 hours of injury and measured by enzyme-linked immunosorbent assay for GFAP-BDP (nanograms/milliliter). Results Of the 307 patients enrolled, 108 were patients with traumatic brain injury (97 with GCS score 13 to 15 and 11 with GCS score 9 to 12) and 199 were controls (176 normal controls and 16 motor vehicle crash controls and 7 orthopedic controls). Receiver operating characteristic curves demonstrated that early GFAP-BDP levels were able to distinguish patients with traumatic brain injury from uninjured controls with an area under the curve of 0.90 (95% confidence interval [CI] 0.86 to 0.94) and differentiated traumatic brain injury with a GCS score of 15 with an area under the curve of 0.88 (95% CI 0.82 to 0.93). Thirty-two patients with traumatic brain injury (30%) had lesions on CT. The area under these curves for discriminating patients with CT lesions versus those without CT lesions was 0.79 (95% CI 0.69 to 0.89). Moreover, the receiver operating characteristic curve for distinguishing neurosurgical intervention from no neurosurgical intervention yielded an area under the curve of 0.87 (95% CI 0.77 to 0.96). Conclusion GFAP-BDP is detectable in serum within an hour of injury and is associated with measures of injury severity, including the GCS score, CT lesions, and neurosurgical intervention. Further study is required to validate these findings before clinical application.

To determine the efficacy of dexamethasone as adjuvant therapy to improve pain relief in patients with severe, acute exudative pharyngitis.Prospective, randomized, double-blinded, placebo-controlled clinical trial.Large, urban community hospital emergency department with an emergency medicine residency program.Patients aged 12 to 65 years old with exudative pharyngitis and severe dysphagia/odynophagia. Patients with cancer, AIDS, diabetes mellitus, recent steroid use, pregnancy, or suspicion of peritonsillar abscess were excluded.All patients received oral penicillin (500 mg Pen VK) or erythromycin (333 mg base) three times daily for ten days in addition to either 10 mg single-dose dexamethasone or saline placebo IM injection.Fifty-eight patients graded their initial degree of throat pain on a visual-analog scale that was 15 cm long and scored from 0 to 3.0 in 0.5-cm increments. Follow-up was obtained on 51 patients to determine their condition at 24 hours. At entry, there was no difference in age, weight, antibiotic assignment, or initial pain score between groups. Improvement in pain score (initial versus 24 hours) was 1.8 +/- 0.8 in the 26 patients of the dexamethasone group and 1.2 +/- 0.9 in the 25 patients of the placebo group (P.05). Time to onset of pain relief was also faster in steroid-treated patients who demonstrated relief beginning at 6.3 +/- 5.3 hours, compared with 12.4 +/- 8.5 hours in the placebo group (P.01). Of the 26 patients evaluated at seven days (13 in each group), time to complete lack of pain averaged 15.0 +/- 11.4 hours in the dexamethasone group and 35.4 +/- 17.9 hours in the placebo group (P.02). Complications attributable to dexamethasone were not observed.In patients with severe, acute exudative pharyngitis, single-injection dexamethasone adjuvant compared with placebo resulted in statistically and clinically significant improvement, as evidenced by more rapid onset and greater degree of pain relief.

Fluid resuscitation from traumatic hemorrhagic shock is a critical component of therapy for the critically injured patient. Therapy is aimed at restoring hemodynamic stability and oxygen delivery to tissues. The route and rate of fluid infusion, the temperature of the fluid infused, the type of asanguineous fluids chosen, and the timing of red cell transfusion may all impact substantially on the patient outcome. Complications of fluid therapy, especially edema, may be related to the choice of fluid infused. Identification of hypovolemia and methods to monitor tissue are important aspects of patient care.

Background. ARDSnet standards limit plateau pressure (Pplat) to reduce ventilator induced lung injury (VILI). Transpulmonary pressure (Ptp) [Pplat –pleural pressure (Ppl)], not Pplat, is the distending pressure of the lung. Lung distention can be affected by increased intra-abdominal pressure (IAP) and atelectasis. We hypothesized that the changes in distention caused by increases in IAP and atelectasis would be reflected by Ptp but independent of Pplat. Methods. In Yorkshire pigs, esophageal pressure (Pes) was measured with a balloon catheter as a surrogate for Ppl under two experimental conditions: (1) high IAP group (n[ 5), where IAP was elevated by CO2 insufflation in 5mm Hg steps from 0 to 30mm Hg; and (2) Atelectasis group (n[ 5), where a double lumen endotracheal tube allowed clamping and degassing of either lung by O2 absorption. Lung collapse was estimated by increases in pulmonary shunt fraction. Results. High IAP: Sequential increments in IAP caused a linear increase in Pplat (r 2 [ 0.754, P < 0.0001). Ptp did not increase (r 2 [ 0.014, P[ 0.404) with IAP due to the concomitant increase in Pes (r 2 [ 0.726, P < 0.0001). Partial Lung Collapse: There was no significant difference in Pplat between the atelectatic (21.83 ± 0.63cm H2O) and inflated lung (22.06 ± 0.61 cmH2O, P < 0.05). Partial lung collapse caused a significant decrease in Pes (11.32 ± 1.11mm Hg) compared with inflation (15.89 ± 0.72mm Hg,P < 0.05) resulting in a significant increase in Ptp (inflated[ 5.97 ± 0.72mm Hg; collapsed [ 10.55 ± 1.53mm Hg, P < 0.05). Conclusions. Use of Pplat to set ventilation may under-ventilate patients with intra-abdominal hypertension and over-distend the lungs of patients with atelectasis. Thus, Ptp must be used to accurately set mechanical ventilation in the critically ill. 2010 Elsevier

There are numerous factors that continue to influence the practice of critical care medicine. This article focuses on issues that have significantly impacted critical care practice during the last decade, such as changing socioeconomic factors, the increasing influence of specialty groups and governmental agencies, and the translation of evidence-based medicine into practice.

We evaluate the association between out-of-hospital use of continuous end-tidal carbon dioxide (ETCO2) monitoring and unrecognized misplaced intubations within a regional emergency medical services (EMS) system.This was a prospective, observational study, conducted during a 10-month period, on all patients arriving at a regional Level I trauma center emergency department who underwent out-of-hospital endotracheal intubation. The regional EMS system that serves the trauma service area is composed of multiple countywide systems containing numerous EMS agencies. Some of the EMS agencies had independently implemented continuous ETCO2 monitoring before the start of the study. The main outcome measure was the unrecognized misplaced intubation rate with and without use of continuous ETCO2 monitoring.Two hundred forty-eight patients received out-of-hospital airway management, of whom 153 received intubation. Of the 153 patients, 93 (61%) had continuous ETCO2 monitoring, and 60 (39%) did not. Forty-nine (32%) were medical patients, 104 (68%) were trauma patients, and 51 (33%) were in cardiac arrest. The overall incidence of unrecognized misplaced intubations was 9%. The rate of unrecognized misplaced intubations in the group for whom continuous ETCO2 monitoring was used was zero, and the rate in the group for whom continuous ETCO2 monitoring was not used was 23.3% (95% confidence interval 13.4% to 36.0%).No unrecognized misplaced intubations were found in patients for whom paramedics used continuous ETCO2 monitoring. Failure to use continuous ETCO2 monitoring was associated with a 23% unrecognized misplaced intubation rate.

Study Objective: To determine the incidence of unrecognized, misplaced endotracheal tubes inserted by paramedics in a large urban, decentralized emergency medical services (EMS) system. Methods: We conducted a prospective, observational study of patients intubated in the field by paramedics before emergency department arrival. During an 8-month period, emergency physicians assessed tube position at ED arrival using a combination of auscultation, end-tidal carbon dioxide (ETCO 2 ) monitoring, and direct laryngoscopy. Results: A total of 108 intubated patients were studied. On arrival in the ED, 25% (27/108) of patients were found to have improperly placed endotracheal tubes. Of the misplaced tubes, 67% (18/27) were found to be in the esophagus, whereas in 33% (9/27), the tip of the tube was found to be in the hypopharynx, above the vocal cords. Of the patients with misplaced tubes noted in the hypopharynx, 33% (3/9) died while in the ED. For the patients found to have tubes in the hypopharynx, 56% (5/9) had evidence of ETCO 2 on ED arrival. For the patients found to have esophageal tube placement on ED arrival, 56% (10/18) died in the ED. Esophageal intubation was associated with an absence of expired CO 2 (17/18, 94%) on ED arrival. The singe patient in this subset with a recordable ETCO 2 had been nasotracheally intubated with the tip of the endotracheal tube noted in the esophagus while spontaneous respirations were present. On patient arrival to the ED, 63% (68/108) of the patients had direct laryngoscopy in addition to ETCO 2 determination. All patients had ETCO 2 evaluation performed on arrival. All patients in whom an absence of ETCO 2 was demonstrated on patient arrival underwent direct laryngoscopy. In cases in which direct laryngoscopy was not performed, the attending physician documented the ETCO 2 in conjunction with the presence of bilateral breath sounds. Conclusion: The incidence of out-of-hospital, unrecognized, misplaced endotracheal tubes in our community is excessively high and may be reflective of the incidence occurring in other communities. Data from other communities are needed to clarify the scope of this alarming issue. [Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med. January 2001;37:32-37.]

Proper airway management in the prehospital setting is essential. Recent data from Orange County, Florida, suggest that the problem of misplaced endotracheal tubes may be greater than previous studies have indicated. Strong medical direction, strict protocols, and active continuous quality improvement programs are needed to ensure that paramedics learn the correct techniques of endotracheal intubation, and that they verify tube placement with an end-tidal carbon dioxide monitor, and maintain ongoing monitoring of tube placement during transport.

Drowning and near drowning remain a common cause of childhood death and disability. Toddlers aged one through four drown in private swimming pools. Submersions greater than 10 minutes and lack of CPR at the scene or the need for greater than 20 minutes of resuscitation portends a poor prognosis. Management of respiratory failure without neurologic impairment has the most successful outcome. Prevention of drowning morbidity is dependent on constant parental supervision, and immediate and expert CPR.

Objectives To examine the pattern of nontrauma cranial CT use in an urban ED, to identify the rate of significant CT abnormalities in this setting, and to develop criteria for restricting the ordering of CT scans. Methods A prospective, observational study of a case series of adults who underwent cranial CT scanning for nontraumatic cases was performed at the EDs of an urban teaching hospital and an affiliated community hospital with a combined annual census of 110,000. Clinically significant CT scans were defined as: 1) acute stroke, 2) CNS malignancy, 3) acute hydrocephalus, 4) intracranial bleeding, or 5) intracranial infection. X2 recursive partitioning was used to derive a decision rule to restrict ordering of CT scans. Results Only 61 (8%) of 806 CT scans revealed clinically significant abnormalities. The presence of any of the following: age > or = 60 years, focal neurologic deficit, headache with vomiting, or altered mental status, was 100% sensitive (95% CI: 94-100%) and 31% specific (95% CI: 28-33%) in detecting clinically significant CT scans. This set of features had positive and negative predictive values of 11% (95% CI: 8-13%) and 100% (95% CI: 98-100%), respectively. If these criteria had been used to restrict cranial CT use, 229 fewer patients (28%) would have had CT scans obtained and no clinically significant abnormalities would have been missed. Conclusion Clinically significant CT abnormalities were uncommon in this study population, suggesting that current criteria for ordering nontrauma cranial CT scans may be too liberal. In this study, a set of clinical criteria was derived that may be useful at separating patients into high- and low-risk categories for clinically significant cranial CT abnormalities. Before these results are applied clinically, these criteria should be validated in larger, prospective studies.

Shunt malfunction and shunt infections are the most significant complications associated with cerebrospinal fluid shunts. Most cases of shunt infection are due to S. epidermidis or S. aureus. Seventy percent of all shunt infections present within two months of the shunt surgery. The most common factor associated with shunt infection is age under three months. Even fever may not be a consistent sign of shunt infection. A high index of suspicion for shunt infection or malfunction must be maintained when evaluating the patient with a cerebrospinal fluid shunt. There are many types of shunt systems in use today. An understanding of current shunt systems and their associated problems should allow physicians to promptly diagnose and initiate treatment for patients with cerebrospinal fluid shunts. Prompt neurosurgical consultation is mandatory whenever shunt malfunction or infection is suspected.

Emergency physicians frequently encounter patients with acute urinary retention. Although most common among the elderly, pediatric and young adult patients occasionally may present with this complaint. The differential diagnosis and emergency department work-up must be age specific. We discuss the case of a young man who presented with acute urinary retention, subsequently found to be caused by undiagnosed appendicitis with appendiceal abscess formation. Only nine such cases have been reported in the literature thus far, with only one occurring in the nonpediatric population. This case represents the second such case to be reported. The importance of a thorough history, physical examination, and diagnostic work-up of patients who present with acute urinary retention, particularly those in the younger age group, is emphasized.

Methods Objective End-tidal Carbon Dioxide Levels are Associated with Mortality in Emergency Department Patients with Suspected Sepsis Christopher L Hunter, M.D., Ph.D.1, Salvatore Silvestri, M.D.1, Matthew Dean2, Jay Falk, M.D.1, Linda Papa, M.D.1 Department of Emergency Medicine, Orlando Regional Medical Center1, Orlando, Florida; and The University of Central Florida College of Medicine2, Orlando, Florida

We developed recommendations for antidote stocking at hospitals that provide emergency care.An expert panel representing diverse perspectives (clinical pharmacology, clinical toxicology, critical care medicine, clinical pharmacy, emergency medicine, internal medicine, pediatrics, poison centers, pulmonary medicine, and hospital accreditation) was formed to create recommendations for antidote stocking. Using a standardized summary of the medical literature, the primary reviewer for each antidote proposed guidelines for antidote stocking to the full panel. The panel used a formal iterative process to reach their recommendation for the quantity of an antidote that should be stocked and the acceptable period for delivery of each antidote.The panel recommended consideration of 24 antidotes for stocking. The panel recommended that 12 of the antidotes be available for immediate administration on patient arrival. In most hospitals, this period requires that the antidote be stocked in the emergency department. Another 9 antidotes were recommended for availability within 1 hour of the decision to administer, allowing the antidote to be stocked in the hospital pharmacy if the hospital has a mechanism for prompt delivery of antidotes. The panel identified additional antidotes that should be stocked by the hospital but are not usually needed within the first hour of treatment. The panel recommended that each hospital perform a formal antidote hazard vulnerability assessment to determine the need for antidote stocking in that hospital.The antidote expert recommendations provide a tool to be used in creating practices for appropriate and adequate antidote stocking in hospitals that provide emergency care.

Adenosine, a naturally occurring nucleoside that slows conduction through the atrioventricular node, has recently been approved for the treatment of supraventricular tachycardia. It has been shown to convert patients with supraventricular tachycardia to sinus rhythm in up to 92% of cases. Its intravascular half-life of only 10 seconds and absence of reported serious side effects have made adenosine an attractive antiarrhythmic agent. This report describes two cases in which significant side effects from the administration of adenosine were encountered including: (1) prolonged sinus arrest with syncope, and (2) syncope with prolonged bradycardia and hypotension. Emergency physicians should be cognizant of the potential complications resulting from adenosine administration, and should be prepared to deal with them when using this newly available agent.

We studied the hypothesis that rectal thiopental is an effective agent for emergency department pediatric sedation and may have advantages over a more traditional regimen.Rectal thiopental 25 mg/kg was compared with the combination of meperidine 2 mg/kg, promethazine 1 mg/kg, and chlorpromazine 1 mg/kg in a prospective, randomized, double-blinded study.Children between 18 months and 6 years of age presenting to our teaching hospital ED for laceration repair were entered after the clinical decision was made to sedate. Patients with altered sensorium, medical contraindications to sedation, or medication allergy were excluded.After informed consent, each patient received IM injection (drug combination or placebo) and rectal suspension (rectal thiopental or placebo) simultaneously.Vital signs, pulse oximetry, and pediatric Glasgow Coma Scores were recorded before and every 15 minutes after sedation until discharge. Intradermal lidocaine and suturing began when the patient appeared adequately sedated, and response was numerically scored. Patients were discharged when able to stand. Twenty-nine patients 34 +/- 13 months old were studied. Fifteen patients received rectal thiopental, and 14 received the drug combination. Analysis using the Wilcoxon two-sample test revealed no differences in age, sex, weight, or wound location between groups. The time course of sedation was different for the two treatment regimens. At 15 and 30 minutes after administration, patients who received rectal thiopental were more deeply sedated than those who received the drug combination, as evidenced by significantly lower Glasgow Coma Scores (P less than .05). Accordingly, time from medication administration to suturing was 29 +/- 12 minutes in the thiopental group and 54 +/- 33 minutes (P less than .01) in the drug combination group. Patients in the thiopental group also recovered more quickly and were discharged approximately one-half hour earlier than those in the drug combination group (89 +/- 25 vs 120 +/- 44 minutes, P less than .05). No difference in response to lidocaine injection or suturing was demonstrated between the groups. Laceration repair time was comparable between the groups. There were eight sedation failures (three of 15 in thiopental group and five of 14 in drug combination group, P = NS). Vital signs remained stable, no adverse reactions occurred, and no patient had decreased oxygen saturation to less than 95%.Rectal thiopental is superior to this drug combination for pediatric sedation because it can be administered painlessly, has a more rapid onset and offset of action, and is of equal safety and efficacy at the dosage studied.